Every finding on record at Evervella of Swansea

Based on interview and record review, the Facility failed to answer call lights timely for 2 of 6 residents (R1, R3) reviewed for resident rights in the sample of 6. Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and age-related physical debility. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact. On 6/11/26 at 1:50 PM, R1 stated it usually takes about 30 minutes for staff to respond after pressing the call light. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and heart disease. R3's MDS dated [DATE] documented R3 was cognitively intact. On 6/11/26 at 12:55 PM, R3 stated sometimes call light waits take a long time, and it is usually worse on weekends due to short staffing. On 6/11/26 at 12:34 PM, V5, Ombudsman, stated residents have been complaining that call lights are not being answered in a timely manner. The Facility's Resident Council Meeting Minutes dated 3/31/26 document staff response time getting ready for bed as an issue. The Facility's Resident Council Meeting Minutes dated 4/30/26 document long call light response time as an issue. On 6/16/26 at 7:40 AM, V1, Administrator, stated call light response time has been an issue, so all staff were in-serviced on 6/15/26 regarding call light policy, timeliness, and resident requests. The Facility's Call Light Policy documents staff will respond to residents' requests and needs in a timely and courteous manner.

Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner in 1 of 7 residents (R20) when reviewed for accommodation of needs in the sample of 16.Findings Include: On 2/17/26 at 1:54 PM, R20 was observed in her room in the wheelchair. R20 stated she filed a grievance because it takes too long to get her call light answered and needs met. R20 stated it also depends on who is working, the agency staff are the worst, and it is worse during the night and on the weekends. R20 stated she has had diarrhea and when she needs to go, she needs to go and worries that the staff will not get to her in time and she will have an accident in her pants. R20 stated since filing the grievance, things have not improved and are the same. On 2/18/26 from 11:33 AM until 1:10 PM, R22 was observed in her room with her call light on and stated she turned her call light on at 12:00 PM because she needs to use the bathroom. R22 stated the CNAs (Certified Nursing Assistants) were passing meal trays and the wait time for her call light to be answered depends on what they are doing. R22's call light was answered at 12:25 PM.R20's Face Sheet, undated, documents R20 has, in part, the following diagnoses: Heart Failure, Malignant Neoplasm of the Bladder, Enterocolitis due to Clostridium Difficile, Muscle Wasting, Abnormalities of Gait and Mobility, and Muscle Weakness.R20's Care Plan, dated 2/10/26, documents R20 has Clostridium Difficile.R20's OBRA (Omnibus Budget Reconciliation Act) Interim GG Assessment, dated 2/11/26, documents R20 requires supervision/touch assist with toileting and partial/moderate assist with transfers.A Grievance, dated 2/11/26, documents R20 filed a grievance due to long call light wait times.On 2/18/26 at 1:33 PM, V1, Acting Administrator/Regional Director of Operations, stated call lights should be answered as soon as possible.The Call Light Policy, undated, documents the purpose of the policy is to respond to a residents requests and needs in a timely and courteous manner. Resident call lights will be answered in a timely manner.

Based on observation, interview and record review, the facility failed to ensure working call lights for 2 of 2 residents (R1, R3) reviewed for call lights in the sample of 6. Findings include:R1's admission Record documented an admission Date of 11/20/25 and listed Diagnoses including Hypertension, Prediabetes, and Postpolio Syndrome. R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition and requires substantial/maximal assistance for toileting. R1's Care Plan dated 11/20/25 documented a problem area, Resident has an ADL (Activities of Daily Living) self-care performance deficit related to Musculoskeletal impairment /Postpolio Syndrome.On 1/14/26 at 12:15pm, R1 was alert and oriented to person, place, time, and purpose. R1 stated he was discharged home from the facility on12/30/25. R1 stated the care he received at the facility was 'terrible.' R1 stated twice during his stay, he was incontinent and left to sit in feces and was told by staff they were too busy serving supper, and he would have to wait, which took over two hours on both occasions. R1 stated he found it humiliating to be a grown man sitting in his own feces. R1 stated he had been left on bedpan more than an hour on more than one occasion. R1 stated call lights were very slow, up to an hour, and then if you needed the nurse, it might be another hour before she got there. R1 stated more than once staff would come in turn off the call light and never come back.R3's admission Record documented an admission Date of 11/21/25 and listed Diagnoses including Diabetes Type 2 and Fractures of the Left Tibia and Fibula. R3's Minimum Data Set, dated [DATE] documented that R3 has no deficits in cognition and requires partial to moderate assistance for toileting. R3's Care Plan dated 12/12/25 documented that R3 has an activity of daily living self-care performance deficit related to leg fractures.On 1/14/26 at 10:20am, R3 was alert and oriented to person, place, time, and purpose. R3 stated her call light has not been working for 3-4 days now. R3 pushed the button and the light did not come on outside the door. R3 stated staff are supposed to be checking on her more frequently because of this. R3 stated day shift is good about checking on her frequently but night shift doesn't, and she has had to yell for help during the night shift. R3 stated a couple nights ago nobody came to check on her and she hollered for help for about 30 minutes until somebody came. R3 stated she could hear staff talking nearby so she knows they could hear her. R3's call light was pressed and it was observed to not come on. R3 stated she has been left in her own urine for an extended period of time in an undignified manner. On 1/14/26 at10:30am, V3, Licensed Practical Nurse, stated today they will be moving R3 to a different room because the call light isn't working. V3 stated she is not sure how long the call light has been out, but V3 worked 1/13/26 and it wasn't working, so staff were checking on R3 at least every hour.On 1/14/26 at 2:40pm, V2, Director of Nurses, stated she was made aware that morning that R3's call light was not working, and it was her understanding it stopped working today. When asked about the above interviews in which residents complained of long call wait times, V2 stated she does not believe this is accurate and represents inaccurate resident perception. V2 stated it is her expectation that staff answer call lights within a 10-minute time frame. On 1/14/26 at 1:45pm, V7, Corporate Maintenance Supervisor, stated the facility is currently looking to hire a full time Maintenance Supervisor. V7 stated he was aware R3's call light wasn't working and that he is not sure how long it has been out, but he did replace a battery in part of the unit on 1/12/26. On 1/14/26 at 3:15pm, V6, Activity Director, stated she is the staff member responsible for scheduling Resident Council meetings. V6 stated in the past 90 days residents have complained about call lights taking up to an hour.A Call Light Policy documented, Purpose: To respond to residents requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. 3. Bathroom lights should be viewed as emergencies and immediate attention will be given.

Based on interview, observation, and record review, the facility failed to maintain a working call light system for one resident (R3) of 5 residents reviewed for call lights in the sample of 6. Findings include:R3's admission Record documented an admission Date of 11/21/25 and listed Diagnoses including Diabetes Type 2 and Fractures of the Left Tibia and Fibula. R3's Minimum Data Set, dated [DATE] documented that R3 has no deficits in cognition and requires partial to moderate assistance for toileting. R Care Plan dated 12/12/25 documented that R3 has an activities of daily living self-care performance deficit related to right leg fractures.On 1/14/26 at 10:20am, R3 was alert and oriented to person, place, time, and purpose. R3 stated her call light has not been working for 3-4 days now. R3 pushed the button and the light did not come on outside the door. R3 stated it is her understanding that the facility does not currently have a Maintenance Supervisor. R3 stated staff are supposed to be checking on her more frequently because of this. R3 stated day shift is good about checking on her frequently but night shift doesn't, and she has had to yell for help during the night shift.On 1/14/26 at10:30am, V3, Licensed Practical Nurse, stated today they will be moving R3 to a different room because the call light isn't working. V3 stated she is not sure how long the call light has been out, but V3 worked 1/13/26 and it wasn't working, so staff were checking on R3 at least every hour.On 1/14/26 at 2:40pm, V2, Director of Nurses, stated she was made aware that morning that R3's call light was not working and it was her understanding it stopped working today.On 1/14/26 at 1:45pm, V7, Corporate Maintenance Supervisor, stated the facility is currently looking to hire a full time Maintenance Supervisor. V7 stated he was aware R3's call light wasn't working and that he is not sure how long it has been out but he did replace a battery in part of the unit on 1/12/26. V7 stated he is not sure what the issue is but the contracted security company responsible for the system will be working on it today. V7 stated there had been issues last week with call lights in other areas of the building not working, and knows there are some in empty rooms currently not working. An undated Call Light Policy documented, 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 5. Hand bells will be provided for alert dependent residents when positioned out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. A. Room checks will occur hourly until system is repaired.

Based on interview and record review the facility failed to answer call lights in a timely manner for 6 (R1, R2, R3, R4, R5, and R6) of 6 residents reviewed for timely assistance in a sample of six. Findings include:1.R1's admission record documents an admission date of 111/21/25 with diagnoses including: nondisplaced comminuted fracture of shaft of right fibula, nondisplaced [NAME] fracture of right tibia, type two diabetes mellitus, hyperlipidemia, bell's palsy, and acute kidney failure. R1's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 15 indicating cognitively intact. R1's toilet transfer ability was documented as not attempted due to medical condition or safety concerns and chair to bed transfer as: partial/moderate assistance, and walk 10 feet as not attempted due to medical condition or safety concernsOn 12/12/25 at 12:48 PM R1 stated, the facility to the cushion out of her wheelchair and she had been up sitting in her chair for a while and her bottom hurt so she wanted to lay down so she would not be in pain and it took the staff over an hour before they would help her to bed. R1 stated, a few weeks ago she had to wait about three hours for a bed pan so she couldn't wait and soiled herself and had to stay like that for over an hour before someone came to assist her. R1 stated, there are other times she has waited 30 minutes to an hour before anyone would come. R1 stated, sometimes she will see the staff walk by her room when she has her call light on and they do not stop.2.R4's admission record documents an admission date of 11/26/25 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure, peripheral vascular disease, muscle wasting and atrophy, and asthma. R4's MDS dated [DATE] documents a BIMS score of 14 indicating cognitively intact.On 12/12/25 at 12:53 PM R4 stated, sometimes she feels they do not have enough people to help. R4 stated, there are times it will take them a while to get to come assist them. R4 stated, she has put her call light on before so hopefully they would come assist R1 faster. R4 stated, the call light is on and they (the staff) just keep going on by (the room). 3.R2's admission record documents an admission date of 12/10/25 with diagnoses including: chronic diastolic heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic chronic kidney disease, persistent atrial fibrillation, obstructive sleep apnea, morbid obesity, abdominal aortic aneurysm, muscle wasting and atrophy, chronic kidney disease, and restless legs syndrome. R2 was alert to person, place and time at time of interview.R2's care plan documents a focus area of: the resident has an ADL (activities of daily living) self care performance deficit related to impaired balance and obesity with an intervention of encourage the resident to use bell to call for assistance with no date listed.On 12/12/25 at 12:56 PM R2 stated, the other night he put his call light on and he had to wait too long and had an accident and had to sit in it for a bit. R2 stated, he tried to hold it but he just could not wait any longer.4.R5's admission record documents an admission date of 07/03/25 with diagnoses including: stable burst fracture of T11-T12 vertebra, chronic kidney disease stage 4, atrial flutter, rheumatoid arthritis, obesity, cardiomegaly, diabetes mellitus, and reflex neuropathic bladder. R5's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact. R5's functional abilities document the ability to transfer from chair to bed and to transfer to the toilet is supervision or touching assistance. R5 toileting hygiene is documented as substantial/maximal assistance is needed.On 12/12/25 at 1:04 PM R5 stated, there are times she has had to wait a while for staff to answer her call light before usually it is more at night or the weekends. R5 stated, sometimes they will walk by and not acknowledge the light, depending of the staff member.5.R6's admission record documents an admission date of 10/14/25 with diagnoses including: cerebral infarction, middle cerebral artery syndrome, chronic kidney disease, type 2 diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. R6's MDS dated [DATE] documents a BIMS score of 15 indicating cognitively intact.R6's care plan documents a focus area of: impaired physical mobility with an undated intervention of assist resident in performing movement/tasks. This same care plan documents a focus area of: the resident had a cerebral vascular accident with an undated intervention listed as: monitor/document residents abilities for ADLs and assist resident as needed. Encourage resident to do what he/she is capable of doing for self.On 12/12/25 at 1:42 PM R6 stated, there are times in the nights he has had to wait over 30 minutes before they have come to assist him and there are other times that he has had to wait over an hour for someone to came and assist him at night.6.R3's admission record documents an admission date of 12/19/24 with diagnoses including: atherosclerotic heart disease of native coronary artery, diabetes mellitus due to underlying condition with diabetic nephropathy, atrial fibrillation, acute respiratory failure, acute and chronic respiratory failure, and overactive bladder. R3's MDS dated [DATE] documents a BIMS score 15 indicating cognitively intact. R3's functional abilities include: sit to stand as dependent, chair to bed transfer and toilet transfer as substantial/maximal assistance.R3's care plan documents a focus area of: the resident is at risk for falls relating to gait/balance problems, incontinence and amputation with undated interventions listed as: anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 12/12/25 at 2:03 PM R3 stated, she has to go to the bathroom and she has already asked three CNAs (Certified Nurse Aides) for assistance and she has been told they will be back but she is still waiting and you can only wait so long. R3 stated, this (having to wait) happens all the time. R3 stated, it is not uncommon that she will have to wait 30 minutes or more before someone comes to assist her. She has had accidents because she just could not hold it anymore. R3 stated, there are some CNAs that could be more pleasant when they (the residents) need help. R3 stated, she can not help it that she can not just wait that long. R3 stated, there are times staff have walked by her room and not acknowledged her call light. R3 stated, she understands they are busy but they have to understand the residents including herself can not wait that long. R3 stated, sometimes they staff are on their phones in the hallway and they are waiting. R3 stated, she has brought this up in resident council several times because it never used to be this bad.On 12/13/25 at 11:56 PM V3 (Certified Nurse Aide (CNA)) stated, there is one CNA per hall for the night shift. V3 stated, he has approximately seven residents that require two persons to assist them on his hall. V3 stated, if he is already assisting another resident a different resident may have to wait 20 - 45 minutes depending on the care needed and how soon someone can assist him. V3 stated he has not walked by a resident's room with the call light on without telling them he will be back.On 12/14/25 at 12:08 AM V4 (CNA) stated, the hall she works at night usually has approximately 5 - 6 residents requiring two persons to assist. V4 stated, depending on the shift, it could be 25-30 minutes before she can get to the next resident if she is assisting a resident, depending on the care needed and depending on how many are waiting. V4 stated, she has had residents have an accident before she could get there with a bedpan.On 12/14/25 at 12:18 AM V5 (CNA) stated, the hall she typically works at night has approximately 10 - 12 two person assist residents. V5 stated, she assists those individuals that their call lights have been on the longest and will assist them first then go to the next resident. V5 stated, she believes she has seen a 22 minute call light time before. Sometimes she may have to wait for someone to assist her. V5 stated, if the resident has their call light on, she will stop by the room and tell them she will be back when she can, she will not ignore it. V5 stated, she has had residents that have had accidents because she could not get there quick enough with a bed pan.On 12/14/25 at 7:43 PM V1 (Administrator) stated, her expectation is for call lights to be answered by all staff, if that staff member can not take care of that need then she would expect them to get the staff member that can. V1 stated, it would be her expectation for the call lights to be answered in approximately 5 minutes.The resident council minutes dated 10/28/25 documents a section titled, compliments/concerns/comments/suggestions: with a complaint listed as: there was a complaint about the CNAs not being helpful enough. These same minutes document a complaint of CNAs care for the residents they like and don't care for others and a complaint of: after meals there is no one on the halls to take residents to the restroom.The resident council minutes dated 10/28/25 document a section titled, compliments/concerns/comments/suggestions: with a complaint listed as: there was a complaint about the CNAs not being helpful enough.The undated facility policy titled, call light documents: to respond to residents' requests and needs in a timely and courteous manner.

Based on observation, interview, and record review, the facility failed to continue intravenous antibiotics to 1 resident (R1) of 1 resident reviewed for antibiotic use in the sample of 5. This failure resulted in R2 being re-diagnosed with osteomyelitis and having a peripherally inserted central catheter (PICC) reinserted. During the onsite survey, past noncompliance was cited after the facility implemented actions to correct the noncompliance which included in services and quality assurance checks. The deficient practice occurred on 10/10/2025 and was corrected on 11/11/2025 prior to the start of this survey and was therefore Past Noncompliance. The facility was able to demonstrate monitoring of the corrective action and sustained compliance. Findings include: R2's face sheet documents an admission date of 7/5/2018. Diagnoses include Osteomyelitis, Chronic Kidney Disease, Cerebral Infarction, Peripheral Vascular Disease, Dementia. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is severely cognitively impaired, is dependent for all activities of daily living, and requires substantial/maximum assist with turning and transfers. R2's care plan dated 5/6/2025 documents Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk. Interventions include educate Resident / Representative about proper skin care to prevent skin breakdown. Educate Resident / Representative about the proper usage of pressure reducing devices. Educate Resident / Representative on importance of keeping skin clean and moisturized. Evaluate skin integrity. R2's progress notes dated 9/30/2025 at 1:56PM documents R2 arrived back to the facility by way of ambulance at 1:30PM and was readmitted to room. R2 is alert and mood is stable, dependent on staff for all care needs. R2 has a diagnosis of osteomyelitis and per report from hospital nurse, R2 has a midline to left upper arm and will continue intravenous, IV, antibiotic until 10/10/25. No complaints of pain or discomfort upon arrival. R2 was assessed. R2 has midline to left upper arm, dressing is intact. scattered bruising to left lower and upper arm. scratch noted to face on right cheek. Callus noted to right side of right foot. Tip and nail to 2nd toe on right foot is detached from toe and rest of toe is dark in color. R2 needs assist of 2 with mechanical lift for transfers. R2 is currently lying in bed with call light in reach.R2's discharge paperwork dated 9/30/2025 at 12:24PM documents Ceftriaxone 2 gram in sodium chloride 0.9. 1/o Solution 70 milliliters, ml, start taking on October 1, 2025, inject 2 grams into the vein daily. End of treatment, EOT, 11/10/2025. R2's medication administration sheets (MARS) document Ceftriaxone Sodium Solution Reconstituted 2 gram intravenously every 24 hours for infection until10/10/2025. Start Date-10/01/2025 at 11:00AM.R2's progress notes document PICC line discontinued 10/17/2025 at 3:25PM.R2's progress notes dated 11/10/2025 at 2:25PM document During the telehealth visit with Infectious Disease, ID, today. Nurse discovered that the intravenous, IV, antibiotic order entered upon R2's return from hospital on 9/30/25 was entered incorrectly. The stop date was supposed to be 11/10/25, but the stop date was entered as 10/10/25. IV antibiotics ended on 10/10/25. Infectious Disease states that her labs have looked ok and that it would be up to the family if they wanted to restart the IV antibiotics. Nurse was instructed to call back to ID and tell them that they need to decide the next plan of action and fax orders to the facility. Nurse called ID who stated their recommendation is to send R2 to the hospital for culture/x-rays and new orders on if antibiotics were still necessary. ID called and notified power of attorney, POA, of such so R2 is being sent to hospital for evaluation. Consultation with ID doctor and R2 sent to hospital per their recommendation. R2's progress notes dated 11/10/2025 at 4:09PM document Received order from Physician to send R2 to hospital for evaluation and treatment related to osteomyelitis to right foot. Family made aware. R2 will be sent to hospital, awaiting emergency medical services, EMS, for transporting. R2 is alert and mood is stable, no complaints of pain or discomfort at this time. R2's progress notes dated 11/12/2025 at 1:16PM documents R2 arrived at the facility at 11:40AM by way of EMS accompanied by two emergency medical attendants, EMT, attendants. R2 was readmitted and was reorientated to room. R2 is alert with confusion; mood is stable and dependent on staff for all care needs. Per hospital nurse R2's diagnosis is osteomyelitis and R2 will be on IV and by mouth antibiotics until 12/24/25. R2 had no complaints of pain or discomfort upon return. R2 has a peripherally inserted central catheter (PICC) reinserted. PICC line to left upper arm which is intact. Hardened knot near left elbow. No open areas to buttocks, old scar tissue in between left and right buttocks. Old scar tissue under left buttocks. Heels are intact, toenail to 2nd toe on right foot is hanging and toe has a scab. Appetite was good during lunch. R2 is currently lying in bed with call light in reach.R2's hospital discharge paperwork dated 11/12/2025 documents R2 had external catheter placed on 11/12/2025 at 9:00AM. On 11/20/2025 at 12:00PM R2 was resting in bed with eyes open. V3, Assistant Director of Nursing, ADON, and V4, wound nurse performed skin check on R2. R2's second great toe appears calloused and darkened. On 11/19/2025 at 3:05PM V2 stated R2 came back from the hospital on 9/30/2025. The nurse that took the orders transcribed the discontinue date of her antibiotics as 10/10/2025 and it was supposed to be 11/10/2025. We realized the error when R2 was in a telehealth meeting with the infectious disease specialist and the nurse that had incorrectly transcribed the orders was in the meeting with R2. R2's labs had been normal, and her white blood cell count had returned to normal. The Dr even said it was up to the family if they wanted to restart the antibiotic. We didn't feel it was fair to put that decision on the family, so we sent R2 out to the hospital and there she was restarted on the antibiotic. We did some education, training, and quality assurance on all residents on an antibiotic and the stop dates. On 11/21/2025 at 8:50AM V11, Pharmacist, stated Discontinuing the antibiotic early for osteomyelitis is a big deal. That would be a significant medication error. That could lead to all sorts of problems.On 11/21/2025 at 9:35AM V12, Nurse Practitioner, NP, stated The incorrect transcription of the antibiotic for (R2)'s osteomyelitis definitely contributed to her being re-diagnosed with osteomyelitis and needing further antibiotics. I would expect the orders to be transcribed correctly.Facility's medication administration policy dated 6/1/2025 states To provide practice standards for safe administration of education for residents in the facility. Medications will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner or as a consistent state law. The licensed nurse must know the following information about any medications they are administering the drug's name, route of administration, action, indication for use and desired outcome, usual dosage and side effects.

Based on observation, interview, and record review the facility failed to perform adequate incontinence care to 1(R1) of 4 residents reviewed for incontinence care in the sample of 5. Findings include:R1's face sheet documents an admission date of 10/8/2025. Diagnoses include Chronic Diastolic Congestive Heart Failure, Hepatic Failure, Nonalcoholic Steatohepatitis, Chronic Respiratory Failure, Pneumonia.R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive deficits. R1 requires maximum assist with rolling side to side and transfers. R1's care plan dated 10/23/2025 documents R1 has a venous/stasis ulcer related to peripheral vascular disease, to left and right lower extremities. R1 picks and scratches at skin. Interventions include administer and monitor treatments as ordered. Give medications for pain and minimize skin exposure to moisture from incontinence, wound drainage or perspiration. On 11/20/2025 at 8:06AM R1 lying flat in bed. R1 stated, I need to get up. I should've gotten up 2 hours ago. I know I am wet, and I need to get up. Surveyor asked R1 if R1 had pushed call light. R1 stated, It won't do any good. It doesn't work. Surveyor tested R1's call light and call light did not light up above R1's room door. On 11/20/2025 at 8:19AM V6, Certified Nursing Assistant, CNA, entered R1's room. V6 assisted R1 with rolling side to side and removing R1's wet incontinence pad and adult pull up. Pad was very yellowed and soiled. V6 then assisted R1 with a new adult pull up without performing any incontinence care. On 11/20/2025 at 8:25AM V6, stated, I do not usually work this hall, so I am unfamiliar with the residents.On 11/20/2025 at 3:20PM V2, Director of Nursing stated, I expect rounding to be done every 2 hours or sooner, so the residents needs are met.On 11/20/2024 at 3:30PM V1, Administrator, stated, V6 is a new employee. We just had orientation with her, and we go over and over incontinent care with all new employees. Facility's Incontinent Care policy updated 6/17/2025 states Purpose is to prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every 2 hours and provided perineal and genital care after each episode.

Based on interview and record review, the facility failed to ensure there was an adequate number of CNAs (Certified Nursing Assistants) working to provide care to the residents. This failure has the potential to affect all 85 residents residing in the facility.Findings Include:On 9/23/25 at 9:24 AM, R35 stated that the facility is short staffed. On 9/23/25 at 9:40 AM, R28 stated that the facility is short staffed for CNAs. She stated that sometimes R28 has to wait 2 hours for her call light to be answered.On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they have cut down on staff. R75 stated within the past 2 weeks, unsure of exact date, he had to wait 3 hours to get his call light answered because they don't have enough.The Facility Assessment, with a review date of 1/16/25, documents the following staffing plan for the number of licensed nurses and CNAs per shift per day: Licensed nurses - 4/4/3 and CNAs 8-10/8-10/5-7. The CNA/Nurse Schedules document the following: 9/6/25 - 3 nurses and 3 CNAs; 9/7/25 - 1 nurse and 4 CNAs; and 9/13/25 - 3 nurses and 3 CNAs.On 6/30/25 R20 filed a grievance due to the new company works the employees too hard and the facility is short staffed. Staffing Policy, undated, documents it is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. 09/25/2025 12:20 PM V1 (Administrator) stated the residents always think we need more staff but according to the numbers, they aren't. V1 stated they run with the 4 nurses and 8 CNAs on day shift, 4 nurses and 7 CNAs on evening shift, and 2 nurses and 4 CNAs on night sift. V1 stated they fill any vacancies or call offs with agency staff. The CMS (Centers for Medicare & Medicaid Services) form 671, dated 9/23/25, documents there are 85 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to offer snacks to the residents. This failure has the potential to affect all 85 residents residing in the facility.Findings Include:On 9/23/25 at 9:18 AM R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. R68's MDS (Minimum Data Set), dated 8/19/25, documents he has moderate cognitive impairment. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they cut out their soda, fruit drinks at breakfast and evening snacks. R75 stated they don't offer any snacks. R75 stated about the only thing he likes is the hot dogs and he is getting tired of hot dogs. R75's MDS, dated [DATE], documents R75 is cognitively intact. On 9/23/25 at 9:40 AM, R16 stated the food tastes horrible, they took away our soda and snacks. R16 stated they don't offer any snacks throughout the day or in the evening time. R16 stated sometimes she gets so hungry, she has to eat the food even though it tastes bad. R16's MDS, dated [DATE], documents R16 is cognitively intact. On 9/23/25 at 9:35 AM, R1 stated the facility does not offer snacks, her daughter has to provide her snacks. R1's MDS, dated [DATE], documents R1 is cognitively intact. On 9/24/25 at 11:14 AM, R45, President of Resident Council stated, since the new owners took over there have been a lot of changes, especially in the food department. The new owners took away hot chocolate, soda and snacks. They no longer give out any snacks. They said they don't have to give out any snacks anymore. If I lived at home and wanted a snack I could go and get a snack. Now, we have no snacks. Why is that and is that any fair. I used to get a hot chocolate at night and now they tell me there is no more hot chocolate. At first, I thought they just ran out, and but no, they said they can't get any more hot chocolate. R45's MDS, dated [DATE], documents R45 is cognitively intact. On 9/24/25 at 11:18 AM, R74 stated he gets hungry, especially at nighttime, and the facility has never offered him any snacks at night, and he has never seen any snacks at night available for him to just take and/or eat. I think they should offer snacks because sometimes I am just not hungry at dinner but then I am hungry later and I have to wait for breakfast unless my family brings me something and I know not everyone here is lucky enough to have family bring them stuff. R74's MDS, dated [DATE], documents R74 is cognitively intact. On 9/24/25 at 11:22 AM, R35 stated they have never offered her snacks and/or told her she could get any snacks since she has been here, and she has been here since July. R35's MDS, dated [DATE], documents R35 is cognitively intact. On 9/24/25 at 8:32 AM, no snacks were observed in the dry storage area. There were no cookies, no pudding, no graham crackers, no fruit cups, no fresh fruit, no peanut butter, no bread. On 9/24/25 at 8:33 AM, the refrigerator did not contain any fresh fruit, there were 9 cups of yogurt, no other snacks were observed in the refrigerator. On 9/24/25 at 8:34 AM, there was one loaf of bread near the toaster in the kitchen. On 9/25/25 at 3:39 PM, a tour of the medication storage room was completed with 2 bags of potatoes chips, 6 prewrapped cookies, 6 puddings, and 12 small cartons of juice. On 9/24/25 at 8:35 AM, V4 (Dietary Manager) stated, I was not working last night so you will have to ask (V5, Dietary Aid), she was the one working last night. It is what it is. I am on a strict budget, and I just don't have the budget for snacks, and I order things, but they get removed and I have no control of the food anymore. On 9/24/25 at 8:38 AM, V5 (Dietary Aid) stated, I did work last night, but I did not send out any snacks because honestly, we don't have anything here to give out as snacks. There are no snacks to pass out. 09/25/2025 1:33 PM V1 (Administrator) stated we don't have a policy on snacks, we aren't required to offer a snack unless they have an order for it, if they want something, they have stuff at the nurse's station. On 9/25/25 at 3:32 PM, V7 (Licensed Practical Nurse/LPN), stated they used to bring a cart out from the kitchen with snacks, but I am not sure why, but they no longer do that. I do not have any snacks here at the nurse's station for residents. On 9/25/25 at 3:34 PM, V6 (LPN) stated I keep a few snacks in the locked medication room because I need the pudding and applesauce for medication pass. There is not a lot in there. The CMS (Centers for Medicare & Medicaid Services) form 671,dated 9/23/25, documents there are 85 residents residing in the facility.

Based on observation, interview, and record review the facility failed to maintain a resident's dignity in 1 of 1 residents (R104) reviewed for resident rights in the sample of 34.Findings Include:On 9/24/25 at 7:52 AM and 8:02 AM, R104 was observed in bed, uncovered with the blankets at the bottom of the bed, incontinent brief on, shirt pulled up under her breasts, privacy curtain pulled, resident not visible from door but once in the room, able to see around the curtain from bed one. R104's Minimum Data Set, dated [DATE], documents R104 has severe cognitive impairment and requires assistance with activities of daily living. R104's Care Plan, dated 9/19/25, documents R104 requires assistance with activities of daily living. On 9/25/25 at 1:33 PM V1 (Administrator) stated she would expect residents to be treated with dignity. The Resident Rights Policy, dated 6/1/25, documents the purpose of the policy is to promote the exercise of rights for each resident.

Based on interview and record review the Facility failed to ensure the POA (power of attorney) was notified for change of condition for 1 of 3 residents (R19) reviewed for notification in the sample of 34. Findings include: R19's Physician Order Sheet for September 2025 documents a diagnosis of acute respiratory failure, unspecified whether with hypoxia or hypercapnia, sepsis, unspecified protein-calorie malnutrition, vitamin deficiency; hypo-osmolality and hyponatremia; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; unspecified chronic conjunctivitis, right eye; non-st elevation myocardial infarction; pneumonia, pneumonitis due to inhalation of food and vomit; acute respiratory distress syndrome; repeated falls, urinary tract infection.R19's Minimum Data Set (MDS) quarterly assessment dated [DATE] document R2's cognition was not assessed. R19 MDS document R19 needs assistance with most ADL's (activities of daily living); she has impairments on both her upper and lower extremities and uses a wheelchair. R19's Care Plan with a revision date of 8/23/2025 documents (R19) is dependent on staff for meeting emotional, intellectual, physical, and social needs. (R19) has immobility and physical limitations. R19's Face sheet documents V12 is the POA (Power of Attorney) and V13 is the alternate contact. On 9/23/2025 at 2:32 PM, V12 (Family of R19/POA) I just met with the (Facility) yesterday and we had a Care Plan Meeting. I told them I was the POA and if there are any issues, please make sure I am notified. Back in June when my mom fell, they did not even notify me that she fell. They notified my brother, and he is the alternate contact. I am the POA and I am the one that makes decisions for my mom's care. If they could not get ahold of me, I would understand but they never contacted me.R19's Progress Notes dated 5/31/2025 at 6:12 AM, Resident was found on the floor and this nurse per nursing judgement is sending resident for further evaluation and treatment. The resident is nonverbal and cannot let nurse know if she has any pain. Resident has no visible injuries, EMS (emergency medical services) has been called and to transport with lights and sirens. POA was notified and he said to send to hospital. Awaiting for EMS to arrive.R19's Progress Notes dated 5/31/2025 at 8:32 AM, Note Text: POA/daughter called this nurse and voiced her concerns as to how her mom fell out of bed and if mom had any injuries. Daughter also informed this nurse that she was upset because she was not informed. This nurse informed daughter that resident did not have any injuries but was sent to hospital for precautions because resident is nonverbal. This nurse apologized to daughter about not being notified. This nurse informed daughter that her brother was informed about the fall and brother stated to send her to hospital. POA would like this nurse to report to other nurses that she's to be contacted first. Nurse will remind all nurse to call daughter first with any updates about resident.On 9/24/2025 at 3:01 PM, V14 (MDS/Care Plan Coordinator) stated, We did have a Care Plan meeting over the phone yesterday. The POA did not mention anything related to notification. I would expect all POA's to be notified for any change of condition. For (R19) V12 is listed for her POA and should always be notified first. If they cannot reach V12, then they should be notifying the alternate contact V13.The Change of Condition Policy dated 7/1/2025 documents, To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, effective manner.

Based on observation, interview and record review the Facility failed to ensure abuse did not occur for 2 of 3 residents (R5 and R23) reviewed for abuse in the sample of 34. Findings include: 1-R23's Physician Order Sheet (POS) dated December 2024 documents a diagnosis of depression, acute on chronic heart disease, heart failure, acute respiratory failure with hypoxia. R23's Minimum Data Set (MDS) dated [DATE] document she was cognitively intact for decision making of activities of daily living. R23 uses a wheelchair and has impairments on both sides of her lower extremities. For sitting to standing she needs substantial to maximal assistance from staff. The Facility failed to provide a Care Plan for R19 that addresses abuse. On 9/25/2025 at 9:42 AM, R23 stated she did get into it with another resident over the remote and she scratched him because he grabbed the remote out of her hands.R23's Initial Report dated 12/9/2024 documents, Resident (R23) was watching television in main dining room. Resident (R5) came over to her and wanted the remote. He grabbed for the remote and sustained a skin tear to his arm from (R23's) fingernail. (R23's) finger was swollen but x-ray revealed no fracture. Residents separated and treated accordingly. Investigation started. Final summary to follow. 2-R5's POS for December 2024 documents a diagnosis of heart failure, arthritis, chronic atrial fibrillation, type 2 diabetes mellitus, pain, anemia, essential hypertension, and bradycardia.R5's MDS dated [DATE] document R5 was cognitively intact for decision making of activities of daily living. He is in a wheelchair, has no impairments and requires substantial/maximal assistance with most activities.R5's Care Plan with a revision date of 5/17/2025 documents, The resident is/has potential to be verbally aggressive r/t (related to) Poor impulse control, resident yells at staff, cusses at staff, yells at residents, resident made statement that I wish I wish I was dead but stated that he had no plan to harm self.R23 and R5's Final Report documents, On 12/9/2024 at approximately 6:10 PM, (R23) was sitting in the dining/activity area watching television. (R5) had been sitting there previously but had moved away. (R5) came back to the area and requested (R23) turn the television off. When she refused (R5) attempted to snatch the remote control from the table in front of her. In the process of trying to get control of the remote (R5) grabbed (R23's) right hand, squeezing it. (R23) then reached out and scratched (R5's) left hand causing a skin tear. Investigation initiated and concluded. (R23) has swelling and pain to her right hand 2nd digit. An x-ray was completed in house and results determined osteopenia and moderate arthritis changes without acute fractures.On 9/25/2025 at 9:41 AM, R5 was sitting in the dining room having breakfast. On 9/5/2025 at 9:42 AM, R5 stated, I did get into with another resident because I wanted the TV on and she would not turn it on so I tried to grab the remote and she dug her nails into me because she did not want me to turn on the TV and I grabbed her hand to get the remote.On 9/5/2025 at 9:43 AM, R5's left arm near the wrist has a scar on it in a strange shape approximately 6 cm (centimeters) x 3 cm.On 9/26/2025 at 1:11 PM, V1 (Administrator) stated (R5) and (R23) got into an argument over the remote but nobody was hurt, and it was not anything serious and no resident was injured. The Facility's Abuse Prevention and Prohibition Program reviewed 6/1/2025, document's purpose: to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to protect residents and to ensure a standardized methodology for the prevention of abuse. Resident to resident altercations must be reported if the altercation is caused by a willful action that results in physical injury, mental anguish or pain. The facility protects residents from any harm that could result from abuse.

Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for an indwelling catheter for 1 of 3 (R7) residents investigated for a catheter in a sample of 34.Findings include:R7's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R7's EMR dated 7/11/25 documents a diagnosis of obstructive and reflux uropathy, unspecified.R7's MDS (Minimum Data Set) dated 7/6/25 documents a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident has an indwelling catheter.R7's Physician Order dated 7/15/25 documents Foley catheter: 18Fr/10ml balloon: change monthly; every night shift starting on the 15th and ending on the 15th every month.There was no care plan noted for the Catheter.The facility was unable to provide a care plan for the catheter.On 9/24/25 at 11:55 AM, R7 stated that he does have an indwelling catheter.On 9/25/25 at 2:15 PM, V14 (MDS/Care Plan Coordinator) stated she is new to the MDS/Care Planning position, started in June 2025 and is still learning. Facility's policy Care Planning dated 9/2/25 documents To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.

Based on observation, interview, and record review, the facility failed to clean and maintain a C-Pap (Continuous Positive Airway Pressure) and change oxygen tubing/humidifier in 2 of 2 residents (R16, R35) reviewed for respiratory care in the sample of 34.Findings Include: 1.) On 9/23/25 at 9:40 AM, R16 was observed with oxygen on at 3.5 liters/minute/nasal cannula. The oxygen tubing/cannula was not dated when it had last been changed. R16's Face Sheet, undated, documents R16 has a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). R16's Care Plan, dated 9/24/25, documents R16 has impaired gas exchange. There was no documentation in R16's record as to when the oxygen tubing/cannula had been changed last. On 9/25/25 at 11:05 AM V2 (Director of Nurses) stated they are to change the oxygen tubing and humidifiers weekly. The Oxygen Administration Policy, dated 8/1/25, documents all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly. 2.) R35's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R35's EMR dated 7/8/25 documents a diagnosis of obstructive sleep apnea. R35's Physician Order dated 7/9/25 documents BiPap (Bilevel Positive Airway Pressure) at night for sleep apnea; at bedtime. R35's MDS (Minimum Data Set) dated 8/6/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident that uses a CPAP. No care plan noted for R35's CPAP. The facility was unable to provide a care plan for R35's CPAP. Manufacture's Manual dated 4/4/22 documents that the water tank should be hand washed daily to prevent mold and bacteria growth. The hose should be washed weekly. The mask should be wiped off daily and cleaned with water and mild detergent weekly. On 9/23/25 at 9:24 AM, R35 stated that no one has cleaned her CPAP equipment since she was admitted in July. She stated that at home she cleans her own equipment but did not even think about since she has been at the facility. On 9/24/25 at 8:43 AM, V6 (Licensed Practical Nurse) stated that nurse that takes the resident's CPAP/BiPAP off is supposed to clean it. She stated that the facility has no set schedule for cleaning resident's CPAP/BiPAP. On 9/25/25 at 11:06 AM, V2 (Director of Nursing) stated that the nurse should wipe the mask and replace the hose if they have extras. She stated that all respiratory equipment is taken care of on Wednesdays. On 9/25/25 at 11:22 AM, observation of (name brand) CPAP machine sitting on R35's nightstand with hose and mask attached and lying on nightstand uncovered. Facility's policy CPAP Therapy dated 9/1/25 documents Continuous Positive Airway Pressure is used to treat obstructive sleep apnea. The goals of this therapy include; improve ventilation, improve quality of sleep, decrease hospitalizations, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing, and improve lung compliance. Cleaning and Maintenance 1.b. remove the headgear from the mask or nasal pillows shell. Disconnect the mask or shell, swivel, and tubing. C. With a soft cloth, gently wash the mask or pillows with a solution of warm water, and a mild clear liquid detergent. D. Rinse thoroughly. If the mask still feels oily, repeat step C. E. Allow the mask or pillows to air dry. Do not place any supplies in the dryer. Once air dried place in plastic bag. F. Washing tubing as necessary with a solution of warm water, and a mild clear liquid detergent. Rinse thoroughly, and allow to air dry.

Based on observation, interview and record review the facility failed to ensure insulin pens and stock medication have legible expiration dates for 2 (R35 and R32) residents in a sample of 34. Findings include: 1.)R35's Physician's Order Sheet (POS) dated 9/2025 documents Humalog KwikPen, inject 10 units subcutaneously three times a day for DM (diabetes) and Glargine insulin, inject 42 units subcutaneously at bedtime for DM. On [DATE] at 12:45 PM R35's Humalog Kwik insulin pen was not dated. R35's Glargine insulin pen was also not dated. 2.)R32's POS, dated 9/2025 documents insulin Aspart, inject per sliding scale three times a day for diabetes. On [DATE] at 12:48 PM R32's Aspart insulin pen wasn't dated. 3.)On [DATE] at 12:50 PM the 400 hall medication cart had a stock medication, sodium chloride 1,000 mg bottle, the expiration month was not readable and the year was 2025. On [DATE] at 12:53 PM V6 (Licensed Practical Nurse) opened the 400 hall medication cart. V6 stated all the insulin pens should be dated with the date they are opened so staff know when they are to throw them away because they expire 30 days after opening. On [DATE] at 1:18 PM V2 (Director of Nurses) stated all insulin pens should be dated with the date of expiration, so staff know when they are to throw away the insulin pens. Some insulin pens expire in 30 days and some expire in 45 days. V2 also stated she expected staff to be able to read the expiration dates on all stock medications and if the stock medication date is not readable or rubbed off the nurse should throw that medication away. The Facility's Medication Storage Policy, revised [DATE] documents purpose: to ensure proper labeling and expiration dates of medications. Facility should ensure that medications have an expired date on the label.

Based on interview and record review, the facility failed to serve palatable, timely meals to 3 of 4 residents (R16, R68, R75) reviewed for nutritive value/appearance/palatable/preferred temperature in the sample of 34.Findings Include:On 9/23/25 at 9:40 AM, R16 stated the food tastes horrible, they took away our soda and snacks. R16 stated they don't offer any snacks throughout the day or in the evening time. R16 stated sometimes she gets so hungry, she has to eat the food even though it tastes bad. R16's MDS (Minimum Data Set), dated 9/10/25, documents R16 is cognitively intact. On 9/23/25 at 9:18 AM, R68 stated since the new company took over the place isn't worth a s***, they used to give us soda, candy, cookies for snacks, now they don't even offer snacks. the food is worse than it was before, you get smaller portions. Breakfast is late, it should have been served at 8:00 AM today but it wasn't served until 8:45AM. R68's MDS, dated [DATE], documents R68 has moderate cognitive impairment. On 9/23/25 at 9:55 AM, R75 stated since the new company took over, they cut out their soda, fruit drinks at breakfast and evening snacks. R75 stated about the only thing he likes is the hot dogs and he is getting tired of hot dogs. R75's MDS, dated [DATE], documents R75 is cognitively intact. The Resident Council Minutes, dated 9/26/24, 10/28/24, 12/20/24, and 8/26/25 document complaints of the meals being served late. On 9/25/25 at 1:33 PM V1 (Administrator) stated they don't have the smorgasbord of food like we had before, but the quality hasn't changed. This is one of the biggest complaints I have from the residents. The Food Preparation: Taste Testing Policy, undated, documents food items will not be served unless palatable and pleasing to the eye.

Based on interview and record review the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics for 3 out of 5 residents (R106, R55 and R34) sampled for antibiotic use. Findings include:1. R106's Hospital After Visit Summary, dated 6/24/2025 documents R106 was diagnosed with a urinary tract infection (UTI) and prescribed an antibiotic Levofloxacin. The Facility's Infection Surveillance Log, dated 6/24/2025 documented R106 symptoms decreased level of consciousness and confusion and treatment an antibiotic levofloxacin. No organism was documented on the log. R106's Hospital Records, dated 6/26/2025 urine culture documents multiple organisms present, probable contamination, suggest repeat culture. R106's Physician's Order Sheet (POS) dated 6/24/2025 Levofloxacin 750 mg 1 tablet by mouth every other day for 10 days. R106's Medication Administration Record (MAR) dated 6/2025 staff documented Levofloxacin was administered per physician's orders. R106's Electronic Medical Record (EMR) no documentation of organism for urine. 2. R55's Hospital After Visit Summary, dated 9/15/2025 documents R55 was diagnosed with a UTI and prescribed an antibiotic Cephalexin. The Facility's Infection Surveillance Log, dated 9/15/2025, documented R55 symptoms not eating, lethargic and weak and treatment an antibiotic Cephalexin. No organism was documented on the log. R55'a POS, dated 9/15/2025 documents a physician order for Cephalexin 250 mg 1 tablet by mouth 4 times a day for infection until 9/22/2025. R55's Hospital Paperwork no documentation of a urine culture completed. R55's MAR dated 9/2025 staff documented Cephalexin was administered per physician's orders. R55's EMR no documentation of what organism for the UTI. 3. R34's Hospital After Visit Summary dated 6/8/2025, documents R34 was diagnosed altered mental status. The Facility's Infection Surveillance Log, dated 6/9/2025, documented R34 symptoms behaviors and treatment an antibiotic Cefdinir. No organism was documented on log. R34's POS, dated 6/8/2025 documents a physician's order for Cefdinir 300 mg by mouth two times a day for 6 doses. R34's MAR dated 6/2025 staff documented Cephalexin was administered per physician's orders for UTI. R34's Hospital Paperwork dated 6/8/2025 documents urine culture final report: growth indicates contamination with mixed bacterial flora. Please submit a new specimen with special attention given to the collections process and to prompt transport to the laboratory.R34's EMR no documentation of what organism for the UTI. On 9/25/2025 at 12:30 PM V3 (Assistant Director of Nursing) stated she is also the facility's Infection Control Preventionist (ICP) at the facility and is responsible for ensuring all residents on antibiotics for UTIs have a urine culture in their medical record, so the facility knows what organisms are in the facility at all times. V3 stated she called the hospital today to inquire about resident's urine cultures and she was waiting for the medical records to be sent over. On 9/26/2025 at 10:15 AM V2 (Director of Nurses) stated she knows the facility's infection surveillance log doesn't have the residents with UTIs organisms documented on there. V2 stated when a resident is readmitted to the facility with a physician's order for an antibiotic for a UTI she immediately contacts the medical records department at the hospital and requests the resident's urine culture be sent to the facility as soon as possible. V2 stated it is very challenging to get the hospital to send medical records including the urine culture and she requests it because she knows she needs it because she needs to know what organisms are in the building and if the antibiotic is resistant or sensitive to the prescribed antibiotic. V2 stated she is very frustrated because although she requests the urine cultures from the hospital she doesn't receive them and she knows she will receive a citation for not having the proper medical records. The Facility's Antibiotic Stewardship Program, updated 3/13/2025 documents this facility is dedicated to implementing an antibiotic/antimicrobial stewardship program to reduce the unnecessary use of antibiotics. This program help ensure that our residents get the right antibiotics at the right time for the right duration and can improve individual patient outcomes, slow antibiotic resistance and reduce healthcare costs. Laboratory will provide data on microbiology reports. Review the clinical record for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotic used to identify patterns of use and determine the impact of new stewardship interventions. The Facility's Long-Term Care Facility Application for Medicare and Medicaid documents a total of 85 residents.

Based on observation and interview the facility failed to promote resident's dignity by answering call lights and addressing resident's needs for 4 of 4 residents (R1, R2, R3, R6) reviewed for Resident Rights in the sample of 6.Findings include: 1.R6's Face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, dementia, hypothyroidism, and zoster ocular disease.R6's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact and required supervision or touching assistance from staff for toileting hygiene and toileting transfers as well as needing partial/moderate assistance with lower body dressing. R6's Care Plan dated 10/18/22 documented he is at risk for falls with an intervention added on 9/26/24 to keep nurse call light within easy reach and instruct resident to use call light for assistance. R6's Care Plan dated 10/18/22 documented a plan for ADLs (activities of daily living) with an intervention added 9/26/24 to assist to toilet as needed and assist with hygiene after voiding/bowel movements to prevent skin breakdown. On 7/15/2025 at 5:13 AM, R6's room call light is lighted up and on above his door. On 7/15/2025 at 5:14 AM, at the nurse's station the call light is beeping and is audible and flashing in red. The computer documents R6's call light was turned on and has been on for 32 minutes. The computer documents the room number and the amount of time the call lights have been on.On 7/15/2025 at 5:30 AM, at the nurse's station the lights are flashing, and the computer is beeping. On the computer R6's room was identified and documented the light had been activated for 44 minutes. On 7/15/2025 at 5:42 AM, R6's call light is still on and beeping at the nurse's station and lighting up. On 7/15/2025 at 5:43 AM, the computer at the nurse' station document the call light for R6's room was on for 50 minutes.On 7/15/2025 at 5:48 AM, on the V8 (Licensed Practical Nurse/LPN) stated, I am working the 200 and 300 halls. Usually during the night shift, we have two halls that we are responsible for, and we have a CNA working on each hall. We can always use more help. It's hard if a staff goes on break because sometimes, I can't even take a break because of the load we have. The computer tells us what call lights have been turned on and how long the response is before they are answered. I see Room (R6's) call light has been going off for 50 minutes now and has not been answered.On 7/15/2025 at 5:50 AM, V8 (LPN) opened R6's door and asked him what he needed. R6 was in the bathroom sitting on the toilet and could be observed from the hallway. On 7/15/225 at 5:51 AM, V8 stated R6 needed a pull up/adult diaper.On 7/15/2025 at 5:58 AM, R6 stated he had been on the toilet for almost an hour waiting for staff to answer his call light and bring him a (adult pull up diaper) as he was out. I think they need more staff to answer the call lights at night.2.R2's Face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, displaced fracture of upper end of left humerus, morbid obesity, acute pain, overactive bladder, and type two diabetes mellitus.R2's MDS dated [DATE] documented he was cognitively intact and was dependent on staff for toileting hygiene and required substantial/maximal assistance from staff for toileting transfers.R2's Care Plan dated 4/26/25 documented a plan for medical management of diabetes mellitus with an intervention dated 4/26/25 for staff to serve diet as ordered, off HS (hour of sleep) snack unless contraindicated. R2's Care Plan dated 4/26/25 continued to document he required assistance with ADLs (activities of daily living) with an intervention dated 4/26/25 for staff to assist x (times) 1-2 with personal hygiene, toileting, dressing, and bathing. R2's ADL Care Plan also included an intervention for staff to shower 2x (times) weekly or as needed.On 7/14/25 at 10:20 AM, R2 stated the average wait time at night is an hour because they just can't keep up. R2 stated he's been left on the toilet 3 times for over an hour with the call light on and after the first time, he took his cell phone with him and called the front desk to let them know he needed help off the toilet. R2 stated his buttocks and legs get numb and uncomfortable from being left on the toilet for so long. R2 stated he isn't a priority; they just do what needs to be done.3. R1's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, displaced bicondylar fracture of left tibia, benign neoplasm of meninges, major depressive disorder, and generalized anxiety disorder. R1's MDS dated [DATE] documented she was cognitively intact and required partial/moderate assistance of staff for toileting hygiene and toilet transfers.R1's Care Plan dated 2/10/25 documented she requires assistance with ADLs (activities of daily living) with an intervention dated 2/10/25 for staff to assist x(times) 1-2 with personal hygiene, toileting, dressing, and bathing. R1's Care Plan dated 2/10/25 documented she was at risk for falls with an intervention added on 2/10/25 to keep nurse call light within easy reach and instruct R1 to use the call light for assistance.On 7/14/25 at 9:55 AM, R1 stated since she's been here, she's had to wear diapers because she needs help getting to the restroom and she's soiled herself to where it's leaked on to the floor from waiting too long; it's humiliating. R1 stated she has been left on a bedpan for 45 minutes. R1 stated it was very uncomfortable to be left on the bed pan. R1 stated, I understand they want to make money but at what cost for human dignity and respect?4.R3's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, malignant neoplasm of the colon, secondary malignant neoplasm of liver and intrahepatic bile duct, and abdominal pain.R3's MDS dated [DATE] documented she was cognitively intact and required substantial/maximal assistance from staff for toileting hygiene and toileting transfers were not attempted due to medical condition or safety concerns.R3's Care Plan dated 6/27/25 documented she required assistance with ADLs and is ask risk for falls with an intervention added the same date for call light to be in reach.On 7/14/25 at 9:45 AM, R3 stated the call lights take about 45 minutes to be answered. R3 stated she will soil herself from having to wait too long for assistance with the bed pan and feels it is embarrassing; the owners are pitiful for this.On 7/14/25 at 2:08 PM, V3 (Certified Nursing Assistant/CNA) stated call lights have been on for extended amounts of time.On 7/14/25 at 2:14 PM, V4 (CNA) stated R2 was left on the toilet for a long time because the call light wasn't working, and he had to start yelling to get someone's attention. On 7/16/25 at 12:22 PM, V1 (Administrator) stated she expects staff to answer call lights as soon as possible and to prioritize. The facility's Call Light Policy, undated, documented that resident call lights will be answered in a timely manner. It continued to document all staff should assist in answering call lights and bathroom lights should be viewed as emergencies with immediate attention to be given.

Based on interview and record review the Facility failed to seek medical interventions in a timely manner for 1 of 5 residents (R39) reviewed for medical interventions in the sample of 37. This failure resulted in R39 having a fall and not being sent out to the hospital for 2 hours and 34 minutes and sustaining a fracture of her left ankle. Findings include: R39's Physician Order Sheet (POS) July 2024, documents a diagnosis of Pneumonia, unspecified organism; Unspecified severe protein-calorie malnutrition; Hypertensive encephalopathy; Memory deficit following unspecified cerebrovascular disease; Unspecified osteoarthritis, unspecified site; Essential (primary) hypertension; Other specified nutritional anemias; dry eye syndrome of unspecified lacrimal gland; Polyarthritis, unspecified; Gastro-esophageal reflux disease without esophagitis; Anxiety disorder, unspecified; Hyperlipidemia, unspecified; Overactive bladder; Pain, unspecified; Allergy, unspecified, subsequent encounter; Major depressive disorder, recurrent, unspecified; Constipation, unspecified; Alzheimer's disease, unspecified; Personal history of COVID-19; Acute cough; Urinary tract infection, site not specified (History of); Constipation, unspecified; Pneumonia due to other specified infectious organisms; Deficiency of other vitamins; Other chronic pain; Opioid use, unspecified, uncomplicated; Unspecified fracture of left lower leg, subsequent encounter for closed fracture with routine healing; Dyspnea, unspecified; Other pancytopenia; Encounter for desensitization to allergens; Unspecified dementia, unspecified severity, with other behavioral disturbance; Hypokalemia; Altered mental status, unspecified; Unspecified open-angle glaucoma, stage unspecified; Encounter for prophylactic measures, unspecified; Vitamin D deficiency, unspecified; Vitamin deficiency, unspecified. R39's Minimum Data Set (MDS) dated [DATE] documents R39 was moderately impaired for cognition for activities of daily living. R39's Care Plan documents, Requires assistance with ADL's (activities of daily living) due to decreased strength and balance, decreased activity tolerance, decreased safety, impulsive, impaired cognition. Category: ADLs Functional Status/Rehabilitation Potential Start Date: 3/15/2024. R39's Care Plan: Problem: At risk for falls due to history of falls, dementia, poor safety awareness, behaviors of refusing care, medications, high blood pressure, pain, arthritis, left knee problems (gives out), poor vision, abnormal labs. 6/9/23 Fall, 7/28/2023 Fall, 03/05/2024 Fall. Resident will be free from injury/harm over the next 90 days. Target Date: 06/15/2024 (Long Term Goal). R39's Progress Notes dated 3/5/2024 at 2:50 AM, Resident found on floor beside bed, resident assessed and noted to have small lump on internal LL (left leg). Resident has complaints of pain. No other complaints of pain or injuries noted elsewhere. Resident stated when asked what occurred my legs became twisted, and I fell out of bed Neuro checks WNL (within normal limits) resident assisted back to bed per 2 staff with a gait belt. Resident continued to complain of LL leg pain, call placed to POA (Power of Attorney) who stated, it was too late in the night to send to emergency room , I want STAT (immediately) x-rays done. (V19 Nurse Practitioner) notified and ordered stat L ankle and L tib/fib x-rays. (X-ray company) notified of stat x-ray order, on call nurse notified. R39's Progress Notes dated 3/5/2024 at 2:52 AM, This nurse spoke with (V22 POA) and explained to her that (X-ray company) does not perform stat x-ray services overnight anymore and that they start x-ray services again at 8:00 AM, in the morning, and couldn't guarantee when (x-ray company) would arrive at the facility and (V22 POA) stated that's fine. This nurse explained to (V22) that resident had a small bulge in her left lower extremity and that resident was holding her leg and repeatedly stating that her leg hurt. (V22) again stated that she wanted stat x-rays done that it was too late in the night to send her to the hospital. R39's Progress Notes dated 3/5/2024 at 5:24 AM, Resident has continued to hold her left leg and scream out in pain, resident is screaming I don't care what my daughter said, I want to go to the hospital. DON notified. Left voicemail for (V22) to return call. Ambulance notified of need for transport. R39's Progress Notes dated 3/5/2024 at 10:49 AM, Resident returned to the facility via ambulance at 10:50 a.m. and was transferred to bed by EMT's. Resident is alert and oriented. Resident has a fractured L (left) ankle with a standard order for (acetaminophen). On 7/25/2024 at 9:24 AM, V18 (Certified Nursing Assistant/CNA) placed the gait belt around R39's waist and as she was placing the gait belt around R39, V18's foot was touching R39's left foot, R39 yelled out, ouch you hurt my leg, I broke my leg, be careful, V18 stated, you did not break your leg. On 7/25/2024 at 9:28 AM, V18 was asked if she was positive R39 had never broke her leg and she stated she was agency and did not know anything and was not aware R39 had broken her ankle previously. R39's Final Fall Report documents, (R39) is a [AGE] year-old female that admitted to the facility on [DATE] with the following diagnosis: Alzheimer disease, unspecified dementia with Behavioral disturbances, hypertensive encephalopathy, unspecified osteoarthritis, essential hypertension, polyarthritis, generalized anxiety disorder, hyperlipidemia, pain, vitamin D deficiency, unspecified severe protein-Calorie Malnutrition, and Major depression disorder. According to her most recent MDS, (R39) has a BIM (Brief Interview of Mental Status) score of 8 (moderately impaired for cognition). (R39) resides in the facility long term with no plans to discharge. On 3/5/2024 at approximately 2:50 AM, (R39) was in her room in the bed. (R39) had pulled all the linen away from the mattress and her bilateral lower extremities became tangled in the sheets. She rolled over in the bed and fell to the floor twisting her left leg and foot. The charge nurse completed an assessment and palpated an abnormal raised area to left shin/ankle. (R39) did have complaints of pain with tactile stimuli. The charge nurse proceeded to notify the doctor and POA (Power of Attorney). The POA requested to have a STAT x-ray performed in house and refused transfer to the ER (emergency room ). When scheduling the x-ray, the charge nurse was notified the STAT x-rays were no longer offered overnight, and exam would have to be scheduled for after 8:00 AM. The exam was scheduled, and the charge nurse informed the POA. The POA continued to refuse transfer to the ER at that time. At approximately 5:15 AM. (R39) continued to exhibit symptoms of pain and informed the DON (Director of Nursing). It was decided that she be transferred to the ER (emergency room ) for treatment. The following was completed immediately: skin pain evaluation, PROM (Passive Range of Motion) to extremities (Medications evaluated), Care Plan reviewed, most recent labs reviewed, MD/POS/DON notifications, Transfer to ER (emergency room ). Investigations completed. (R39) returned from the ER with a diagnosis of Closed fracture of Distal end of Fibula, unspecified fracture, Morphology, initial encounter. During record review and staff interviews, it was reported that (R39) often uses profanity and can be verbally aggressive at time. She had an increase in behavior over a short period. (R39) required more redirection, verbal cueing, and one-on-one care with staff including family phone calls. (R39) had been refusing to seek assistance, yelling out, making false allegations towards peers and staff, and attempting to propel herself in the wheelchair when asked to remain in common areas. (R39) reported that she wrapped in bed covers and rolled from the bed. However, it is believed that due to her cognition and poor safety awareness, (R39) was attempting to turn and position herself in the bed and was lying close to the edge when she rolled and fell . (R39) has a history of falls and bone/joint issues. It has been determined that she is at an increased risk for fractures due to a decreased bone density. R39's Initial Serious Injury Incident Report, with incident date of 3/5/2024 documents, Resident observed on floor from bed wrapped in sheet and cover. Stated that she got tangled and rolled out of bed. Sent to ER for x-ray. Fracture of distal end of fibula. Investigation started immediately. Final/Summary to follow. R39's Hospital Records dated 3/5/2024 at 6:24 AM, documents, (R39) [AGE] year-old female presenting to the ED (emergency department) from (Facility) complaining of left knee and foot pain. Patient states she fell out of bed. Episode occurred around 2:30 AM, given Tylenol. Still complained of pain. R39's Hospital records document she was given 5-325 mg (milligrams) tablet of hydrocodone-acetamonophen (Norco) (narcotic) and was given an splint/Brace immobilizer to wear as directed with no weight bearing for her fractured distal end of fibula. R39's Hospital Records dated 3/5/2024 at 6:24 AM, documents XR (x-ray ankle) left 3 or more views, XR knee left 1 of 2 views: Diagnosis: Closed fracture of distal end of fibula, unspecified fracture morphology, initial encounter. Clinical fracture of distal end of fibula, unspecified fracture morphology, initial encounter. Findings: Mildly displaced fracture of the distal left fibular shaft. On 7/25/2024 at 4:39 PM, V19 (Nurse Practitioner) stated, I was contacted by the facility on 3/5/2024 regarding (R39) having a fall and ordered a STAT x-ray. The facility never contacted me again telling me the STAT x-rays were no longer be performed overnight and or they would not be available until 8:00 AM the following morning. I normally give them a four-hour window. If the resident was still in pain and if they would have contacted me and the resident was yelling and screaming, I would know there was not much else we could do for her and would have had her sent out to the emergency room right away and would not wait. On 7/26/2024 at 5:15 PM, V2 (Director of Nursing) (R39) was trying to get herself out of bed and got caught up tangled in the sheets. (R39) was complaining of pain and when we contacted her daughter, she told them not to send her out to the hospital and to get an x-ray in house. I was not present for the conversation. I was told that later (R39) was still complaining of pain and I was contacted by the nurse, and I told her to send her out. On 7/26/2024 at 9:32 AM, V31 (Registered Nurse) stated, I remember (R39) falling. I was at the nurse's station, and I heard her scream. When I went to her room, I found her sitting Indian style on the floor on her mat. Her leg had a bulge to it, and she was in pain. I called the daughter (V22) and told her I wanted to send her out and she was adamant about not wanting to send her out to the hospital and to get a STAT x-ray in the facility. I told her it would be better for her to be seen in the ED, but she refused. I do not remember much else except (R39) was screaming and was in a lot of pain and we finally sent her out. I do not remember one way or the other about calling the doctor again. The Change of Condition Reporting Policy with a revision date of 2/2018 documents, (Facility) will notify the resident's physician and the resident's representative whenever, there is a significant change in the resident's health, mental or psychosocial status. Assess the resident condition as warranted which may include, but is not limited to checking vital signs, completing a physical assessment as indicated speaking with the resident about the symptoms and noting the presence or absence of pain. Notify the physician of the change/incident/accident There is an accident (incident or unusual occurrence). Notify the physician of the change of condition/incidents/accidents/unusual occurrences and accident findings. may be reported to the physician. (Changes of condition/incidents/accidents/unusual occurrences may be reported to the physician.

Based on interview and record review the Facility failed to ensure there was a RN (Registered Nurse) working in the facility for 8 consecutive hours a day, 7 days a week. This has the potential to affect all 82 residents living in the facility. Findings include: On 7/23/2024 at 9:00 AM, Schedules were requested for the past 14 days, including Registered Nurse (RN). The schedule coverage did not document any RN working on 7/13/2024 and 7/14/2024. The PBJ (payroll-based journal) Report for the second quarter (January 1- March 31) of 2024 documents concerns for RN coverage and one star rating for fiscal quarter 2, 2024 for the facility. On 7/23/2024 at 10:11 AM, V3 (Assistant Director of Nursing) stated, I am a Registered Nurse along with the Director of Nursing. I know we are currently trying to hire more RNs and we struggle on the weekends. I know we are supposed to have a RN on duty every day for 8 consecutive hours every day. On 7/23/24 at 11:34 AM V1 (Administrator) stated I am going to be honest we did not have a Registered Nurse (RN) for 7/13/2024 and 7/14/2024. We are in the process of attempting to hire more Registered Nurses. I hired two RNs, and they did not even last a day. I am not going to lie I know the weekends are where we are getting hit. I am just having issues finding staff. The Facility assessment dated [DATE] documents, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Nursing Services, RN. Great need for RN's and continued struggle. Areas Facility Assessment Informed, Action to be taken/already taken this year, Need RNs to stabilize nursing department. On 7/24/2024 at 4:18 PM, V2, Director of Nursing stated there was no staffing policy. The 672 Long Term Care Facility Application for Medicare and Medicaid form dated 7/24/2024 documents, there are 82 residents living in the facility.

Based on interview and record review, the facility failed to properly care for a hospice resident with Dementia residing at the facility for Respite Care, including Activities of Daily Living (ADLs) and Medication Administration for 1 of 1 resident (R2) reviewed for proper nursing care. This failure resulted in R2 having significant behaviors resulting in R2 obtaining a leg injury. Findings include: R2's Face Sheet, undated, documents R2 was admitted to the facility on [DATE] for a 5-day Respite stay and was discharged on [DATE]. R2's diagnosis include Dementia and Parkinsonism. R2's Care Plan and Minimum Data Set (MDS) was not completed due to short stay at the facility. R2's Admission Functional Ability Assessment, dated 5/2/24, documented that R2 was dependent on staff for all ADLs, and mobility. On 5/9/24 at 9:53 AM, V5 (R2's Daughter) stated (R2) went to the facility last Thursday (5/2/24) for Respite Care for five days as I had to go out of town. When he got there, the Hospice Nurse did a Tuck-In assessment on him, and he was fine and without injuries. On Friday (5/3/24), the Hospice bath lady went and gave (R2) a bath, and she didn't notice anything wrong with him either. The facility called me on Saturday (5/4/24) and said that (R2) scratched his leg, which I told them he does that when he is anxious and to give him his anxiety medication. On Sunday (5/5/24), my aunt visited (R2) and told me that he had a bandage covering the lower left shin and when I called the facility to ask about it, they told me he was banging his legs against the rail and caused a scratch. I told them to put something on the rails to avoid him hurting himself. Then on Monday (5/6/24), the Hospice bath lady noticed bruising and the wound on his legs. I sent all his medications with him to the facility and only one medication was given the entire time he was there. They gave him his Seroquel every day, but they did not give any of his anxiety medications. He has Clonazepam and Lorazepam for his restlessness and anxiety. The Director of Nursing (DON) called me yesterday (5/8/24) after they spoke with the Hospice team about (R2), and she told me she did an investigation and afterwards, fired one Certified Nursing Assistant (CNA) and suspended two nurses. On 5/9/24 at 12:15 PM, V1 (Administrator) stated that R2 was admitted for a five-day Respite stay and the family brought scheduled and as needed (PRN) medications with him. V1 stated that R2 was discharged in the morning of Tuesday (5/7/24) and his daughter (V5) called them later that day and herself and V2 (Director of Nursing/DON) talked to her about her concerns. V1 stated that R2 wasn't in the same condition going home as he was when admitted . V1 stated R2 had multiple areas of bruising/injury to his legs and was not clean when he was discharged . V1 stated that the nurse had called V5 and told her that R2 had a scratch on his leg and when R2 got home, his leg wound was much more extensive than a scratch. V1 stated that V5 did state that R2 scratches himself when he is anxious, but this was much worse than a scratch. V1 stated that they reviewed R2's Medication Administration Record (MAR) and that R2 did not receive any of his PRN anxiety medications while he was in the facility. V1 stated that V5 was very unhappy about R2's condition and V1 stated she understands why and that R2's care was unacceptable. V1 stated that she talked to the CNA who was responsible for cleaning R2 prior to discharge and ended up terminating his employment because of R2's condition at discharge. V1 stated she then disciplined the nurses, one nurse for documenting R2's wound as a scratch, when it was much worse, and the other nurse who was responsible for R2 the day of his discharge. V1 stated that they also talked to the Hospice Nurse about R2's stay and they concurred with V5's description of R2's leg wound. V1 stated that best practice was not followed, and she was embarrassed about the situation. V1 stated that this was not what she would expect from her nurses and CNAs. On 5/9/24 at 11:15 AM, V2 (DON) stated that she spoke with the Hospice Nurse who explained the concerns with R2's condition at discharge. V2 stated that the daughter was told of a scratch on R2's leg and was not told of the extent of the injury. V2 stated she called V5 yesterday (5/8/24) and V5 described things to her that she felt was not best practice and not what a normal nurse would do. V2 stated that the bedrails go halfway down the bed, so R2 was able to bend his legs up and, being restless, was able to hit his legs on the siderails, causing his injury. V2 stated that she suspended the two nurses and will be reeducating them, and all staff, when they return. On 5/9/24 at 1:10 PM, R8 (R2's previous roommate) stated that R2 was always talking, yelling, and was restless in his bed. On 5/9/24 at 1:18 PM, V7 (CNA) stated that she took care of R2, and he would only answer questions with a one-word answer. V7 stated that R2 would yell while in his bed and it was usually about pancakes. On 5/9/24 at 3:08 PM, V6 (Hospice Nurse) stated (R2) arrived at the facility on Thursday (5/2/24) and I went in to do an assessment on him. (R2) was in good spirits, was calm, in no distress, and had no skin issues. I went over his orders for his Respite stay with the nurse. On Monday (5/6/24) V5 (R2's daughter) came home from out of town early because she received a phone call from the nurse at the facility that (R2) had scratched his leg. (V5) called me and asked me if I would go see (R2) so I did. When I got to the facility, (R2) had an area to his left leg that was reddened, he was very anxious and restless, so I asked the nurse to give him a dose of his PRN medication, so she did, and I called (V5) and updated her. His order was for Ativan 0.5 MG every four hours PRN, and normally gets Ativan three times per day at home. (R2) got back home on Tuesday (5/7/24) and (V5) notified me that he got home and had dried stool on him and had marks on his legs. The facility was given a case of (nutritional supplement drink) to give to (R2) because he usually drinks five to six of them a day, there was only two of them missing out of the case. (V5) asked me to follow-up on what happened at the facility, so I called the facility and spoke with V2 (DON), who looked in (R2's) chart and said that (R2) hit his leg on a bedrail. I updated (V5), my managers, and let (R2's) Practitioner know and received orders to treat (R2's) leg. (R2) had several scabs on his right leg from his knee down to his ankle and had a large, reddened area to his right knee and hip. (R2's) right leg had an 8 CM long reddened area to his left shin with open areas of blood and Serosanguineous fluid, it appeared similar to a sheering injury where a few layers of skin were sheared off. We are cleaning the wound and applying (name brand of a dressing) and wrapping with (gauze wrap) every two to three days and PRN. R2's Braden Scale Assessment, dated 5/2/24, documented that R2 was a High Risk for skin impairments. R2's Skilled Nursing Assessment, dated 5/7/24, documented, Behavioral Symptoms-Short tempered/easily annoyed: Yes, and Behavioral Symptoms-Fidgety or restless: Yes. R2's Nursing Note, dated 5/2/24 at 10:22 AM, documented, admitted to facility from home for five-day Respite Care. Transported by ambulance from home. Remains on service with (Hospice Company). Bedbound, reported by EMT's (Emergency Medical Technician) resident has not been in w/c (wheelchair) since February. Non-weight bearing. Alert and oriented to self. May respond with yes or no, but no conversation. Inc. (incontinent) of B&B (bowel and bladder). Total care needed. Meds brought by EMT's. Dr. notified of respite admit. R2's Nursing Note, dated 5/4/24 at 11:48 PM, documented, Skin check complete. Upper extremities and body are clear of any concerns. BLE (bilateral lower extremity) have abrasions and discoloration. Left shin has a clean, dry, and intact dressing. 2nd left toe have (sic) 2 scabs. Right greater toe have (sic) one small scab. Right malleolus have (sic) a old scab noted. R2's Nursing Note, dated 5/4/24 at 12:09 PM, documented, This nurse noted resident's leg was rubbing against bed rails causing skin abrasion measuring 8.5 CM (centimeter) x 6 CM; no bleeding noted; area was cleansed and tx (treatment) in place; made aware to hospice nurse and resident's daughter. R2's Physician Order (PO), dated 5/2/24, documented, Lorazepam 0.5 MG (milligram) Q (every) 4 hrs (hours) PRN. R2's PO, dated 5/2/24, documented, Clonazepam 0.5 MG Q 6 hrs PRN. R2's PO, dated 5/2/24, documented, Quetiapine 50 MG BID (twice daily) 8:00 AM and 4:00 PM. R2's PO, dated 5/2/24, documented, Olopatadine 1 drop to each affected eye Q 6 hrs PRN. R2's PO, dated 5/6/24, documented, Cleanse left leg shin with wound cleanser, then apply double layer (name brand of a dressing) then wrap with (gauze wrap); change daily and PRN. R2's Event Report, dated 5/4/24, documented, Description: Skin abrasion. Event Details: Skin Tear/Laceration. Activity during skin tear/laceration occurrence: Friction in bedrails. Interventions: Cleansed with wound cleanser, apply (name brand of a dressing) or hydrogel and wrap with (gauze wrap) (no skin flap). Evaluation: Event still open. The facility's investigation into R2, dated 5/9/24, documented, During our investigation, (V5) called the Administrator and talked about concerns. She stated that the nurse who called about the abrasions on the legs did not adequately describe what she witnessed upon the resident returning home. She also stated that when she spoke with the nurse, (V16), she let her know that (R2) gets anxious and that there were medications ordered to take care of anxiety. Upon reviewing the MAR (Medication Administration Record), it was noted that one dose of Lorazepam was given throughout his stay for anxiety. (V16) stated that when she took care of him, that he did not appear in any distress and that she did not feel he was displaying signs of anxiety. (V5) also stated that (R2) now had pink eye and that his PRN medications for eyes were not given. In reviewing the progress notes and orders, it appears that (R2) has order for Natural Tears and an antihistamine eye drop. There is no indication in the notes that the resident required this PRN medication during his stay. (V5) alleged that (R2) was soiled upon return home. Resident was incontinent of bowel and bladder, and we feel it would be difficult to determine when this incontinence occurred. The progress notes revealed skin assessments and events. A treatment was put into place and the measurements were documented. It is also noted that sheets were applied to the bedrail and pillows were placed between the rail and mattress to attempt prevention of skin issues. While reviewing documentation, (R2) did not have any decreases in cognition during stay and he had no symptoms of pain or distress. Administrator, DON, and ADON (Assistant Director of Nurses), interviewed CNA (V17), LPN (V16), and LPN (V18). Disciplinary actions were taken at the discretion of the facility. Because (V5) felt as if the expectation of her father's care was not met, the facility determined disciplinary action was necessary to stress the importance of customer satisfaction. The Facility's Respite Care Policy, dated 11/2023, documented, 1. It is the facility's responsibility to provide medical care when needed in the absence of family. It continues, 6. The residents may bring in their own medications to be used during their stay at (the facility) if the stay is for 14 days or less. Respite stays beyond 14 days will require medications be ordered from (the facility's) pharmacy. The Nursing staff at (the facility) will dispense all medications.

Based on interview and record review, the facility failed to prevent abuse by a staff member for 1 of 3 (R5) residents reviewed for abuse. A reasonable person would feel angry, intimidated, and fearful of staff from being hit and cursed at by a staff member. The findings include: R5's Care Plan, dated 03/10/2023, documents Problem: Cognitive skills for daily decision making moderately impaired - decisions poor; cues/supervision required d/t (due to) Dementia. It continues Approach: Engage in activities that do not require frequent decisions; observe for signs of frustration. Provide assistance as needed. It also documents Problem: Short-Term memory impaired - unable to recall after 5 minutes d/t Dementia, New Environment. It continues Approach: Re-orient to time, location, events, and activities as needed. Approach: Provide direct guidance when resident is unable to follow through with instructions. Approach: Maintain consistent routine; introduce change slowly to reduce confusion. R5's Progress Notes, dated 4/13/2023 at 7:20 AM, documents CNA (Certified Nursing Assistant) came and made me aware that resident had slid off the sliding board while trying to transfer. The writer came into the room to see resident lying on the floor. Resident said, nothing hurts at this time and has no bumps or bruising at this time. VS (Vital Signs), WNL (within normal limits). Resident is currently in dining room waiting on breakfast. NP (Nurse Practitioner) notified, family notified, and DON (Director of Nursing). R5's Progress Notes, dated 4/13/2023 at 7:31 AM, documents Administrator and DON made aware of Incident. The facility's Final Report of Alleged Physical and Verbal Abuse, not dated, documents on 4/13/2023 V7 (Licensed Practical Nurse/LPN) and V17 (CNA) were called to the room of resident R5, age 79, by V18 (CNA) to assess and assist in getting R5 off the floor, due to a fall while doing a sliding board transfer with V18. All staff members assisted the resident bask into his wheelchair. Almost immediately, V18 pushed and slapped, R5 and called him a Mother Fxxxxx as witnessed by the 2 other staff in the room. V18 was removed from the facility immediately. Resident was assessed for injury, and none noted. Resident did not voice any complaints of pain. (Local Police) was called. Physician, Administrator, DON, and family contacted. V19 (Officer from Local Police Department) arrived at facility to investigate. Staff who witnessed were interviewed and resident was also interviewed. Resident told (V19) that he remembered the fall but does not remember being struck by an employee. V19's report is (XXXX-XXXXX). Report was still in progress as of 4/17/23 at 2p.m. Several other residents who were assigned to V18 were interviewed by the V2 (DON). No resident mentioned being hurt by V18, but a few said he was 'rough' when pulling them up in bed with draw sheet. No one interviewed has been hit or cursed at by V18. Nurse Practitioner/NP assessed and interviewed resident on 4/14/23. No injuries noted. Resident unable to recall event for NP. V18 was interviewed by V2 on 4/13/23 by phone. V18 was asked what happened with R5. V18 talked about the fall and stated without being asked I didn't say anything disrespectful but, did not say anything about the physical altercation. V18 was terminated at that time. Facility does substantiate the physical and verbal abuse. The facility's Patient and staff interviews as it relates to Abuse allegations: 4/13/23 documents the following: 1. V7 (LPN) stated that she was called into patient's room, (R5), due to a fall. While trying to get him off the floor, with assistance of V17 and V18, V18 slapped the patient on the head twice and called him a Big Mother Fxxxxx. She also stated that she smelt alcohol on his breath. After that she asked, (V18) to leave the building, notified the Administrator, called the Police, and notified DON. 2. V17 stated, around 6am her co-worker, (V18) asked for assistance with getting (R5) off the floor. She stated, when she entered the room, she saw the patient lying on his back on the floor. She then told (V18) he should get the nurse to make sure he was okay before they moved him. After the nurse assessed him, they (V18, V17, and V7) assisted him into the w/c (wheelchair), using the (full body), lift pad. Once (R5) was in the w/c, he (R5), leaned forward and asked if they needed to remove the (full body lift), pad and V7 responded it was fine. She then stated, that (V18) pushed him back in the chair and told him to behave, then called him a Big Fxxxxx. On 5/1/2023 at 2:30 PM V1 stated that she did do an investigation on the incident that occurred with (R5) and a staff member. V1 stated that she was notified that (V18) physically and verbally abused (R5). V1 stated that she was proud of her staff for being advocates for the resident. V1 stated that the nurse was able to get the employee out of the facility and assessed the resident. V1 stated that she was notified that R5 did not have any injuries. V1 stated that the Police were called, and the incident was reported. V1 stated that an officer came out to the facility and interviewed the resident and the staff members. V1 stated that she has followed up with the police and as of current the report hasn't been completed. V1 stated,that she has also been in contact with the family, and they are upset and wanting to file a complaint as well. V1 stated that V2 performed the interviews with the staff and residents and did not find any other residents that had been abused by V18. V1 stated that some of the residents felt he was rough but not abusive. V1 stated that they were able to substantiate the abuse because they had witnesses that were vocal about what happened. On 5/2/2023 at 9:39 AM V7 (LPN) stated that she was the nurse the night of the incident. V7 stated that V18 told her that R5 had fallen and V7 needed help getting R5 off the floor. V7 stated that she (V7) and V17 went to room to help V18. V7 stated that once entering the room she observed R5 on the floor and assessed him. V7 stated that initially they attempted to transfer R5 manually but R5 would not move his legs. V7 stated that at that time V18 stated to R5 all you had to do was move your legs. V7 stated that they then transferred R5 using the full body lift. V7 stated that once in the wheelchair V18 called R5 a fat Mxxxxx Fxxxxx and hit R5 in the head twice. V7 stated that V18 then said all you had to do was move your legs. You are ruining my morning you big Mother Fxxxxx. V7 stated that R5 did not say anything but you could see that he wanted to but V18 was standing over him and stated What. You are ruining Morning you big Mxxxxx Fxxxxx. V7 stated that V18 was posturing over R5 trying to intimidate R5. V7 stated that she told V18 that he needed to leave the facility. V7 stated that V18 became aggressive with her and would not leave initially asking what he did. V7 stated that she had to tell V18 to leave multiple times before he would leave the building. V7 stated that she was able to get V18 to leave. On 5/2/2023 at 10 am R5 stated that he has had a fall, but it was the staff fault because they put him to close to the edge of the bed. R5 stated that he did not remember the employee and did not remember being cursed at or hit. R5 stated that he would not like to be hit. R5 stated that he would not have been ok with that. R5 stated that he would be angry and wanting to fight back. R5 stated that he isn't in any condition to fight back. R5 stated that not being able to fight back is scary. On 5/2/2023 at 157 PM V13 (R5's Sister) stated that she was made aware of the incident with her brother and the staff member. V13 stated that R5 has dementia and has short-term memory problems. V13 stated that R5 would have never tolerated being hit or cursed at. V13 stated that R5 would have felt like anyone else in that situation. V13 stated he would have been angry, intimidated and scared all at the same time. V13 stated that how would you feel if this was done to you? V13 stated that they are thankful that the staff spoke up about the situation with her brother but what about the times they were not there and what about the other residents that were cared for. On 5/3/2023 at 2:15 PM V2 stated, that she interviewed V18 by phone. V2 stated, that she asked V18 what happened with R5. V18 stated, that R5 had fallen. V2 stated that she asked is that all that happened and V18 responded I didn't say anything wrong. V2 stated, that she asked again if that was all that happened with R5 and V18 stated, that he didn't know what she was talking about. V2 stated, that informed V18 that his services were no longer needed. The facility's Abuse Prevention Policy, dated 8/2016, documents The facility believes that each resident has the right to be free from abuse, neglect, corporal punishment, misappropriation of their property, involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other Residents residing at (facility), consultants, volunteers, staff of outside agencies providing services at (facility), family members, legal guardians, and individuals visiting our facility.

Based on interview, record review, and observation the facility failed to provide safe transfers for 2 of 3 residents (R1, R2) reviewed for transfers in the sample of 3. This failure resulted in R1 and R2 receiving severe skin tears. Findings Include: 1. R2's MDS dated [DATE] documents R2 is an extensive assist of one person for bed mobility, and total dependence of two staff members for transfers. R2 is moderately cognitively impaired. R2's Skin Integrity Care Plan dated 1/10/23 documents use mechanical lift for all transfers, and a avoid shearing residents' skin during transfers, positioning and training. R2's Transfer Care Plan dated 9/30/22 documents Problem: Transfers from bed, chair and wheelchair was last reviewed on 1/7/23 documents resident (R2) will be assisted by 2 staff with mechanical lift. Staff to follow resident care card located in the closet. R2 sitting in her wheelchair in her room both of her legs are wrapped in gauze below her knee. She also was wearing pressure relieving boots on both feet. R2 stated, I do not know how my legs was injured. R2's Event Report/ Investigation dated 12/10/22 documents V12 (an agency Certified Nurse Assistant/CNA) was caring for R2. V12 assisted R2 into her wheelchair. V12 observed that the resident's right shin was bleeding. She went to get V11 (Licensed Practical Nurse/LPN) and reported R2's leg was bleeding. V11 observed a skin tear R2's right shin and applied a pressure dressing. The resident denied any pain. V11 called the physician and the POA. The resident was transferred to (a local hospital.) The resident returned to the facility with sutures and an order for antibiotics. Upon investigation of the incident V12 stated that she had transferred the resident to the chair by herself, despite the care card indicating that the resident required the assistance of two staff for transfer. The agency was contacted and informed of the situation. It was requested by (the facility) that this CNA not return to the facility for any further shifts. The use of a mechanical lift will now be used for any transfers for R2. All direct care staff were in serviced that R2 requires (a mechanical lift) for transfers. V12 left the facility and did not write her statement, because she didn't know what happened. R2's Progress Note dated 12/10/22 at 6:40 AM documents (V12) came up to nurse's station and stated, I was transferring resident (R2) and she started bleeding and it's a lot. This nurse ran down to resident's room and witnessed a large amount of blood coming from resident left lower leg. Left lower leg had a 5-inch laceration noted. This nurse immediately applied pressure with a clean towel to site. This nurse stayed at bedside applying pressure to site, when another nurse came in and applied a pressure dressing to site. Resident (R2) had no s/s (signs and symptoms) of shock. Resident (R2) denies any pain. As other nurse stayed at bedside this nurse called EMS. EMS arrived at site. POA (V23) was contacted and was understanding. EMS transferred resident to (a local hospital). This nurse asked V12 how she transferred resident. V12 stated she self-transferred resident from bed to wheelchair. This nurse reminded V12 to check care card in resident's room that states resident is a 2-assist transfer not one. Nurse asked V12 to make a statement. On call nurse was contacted. DON (director of nursing) contacted. R2's Progress Note dated 12/10/22 at 4:30 PM resident (R2) arrived at the facility by EMS from (a local hospital). Two EMS staff transferred resident into bed from stretcher lift. Resident came back with 12 sutures on the 5-inch laceration with a dressing wrap. Dressing should stay in place for 24hrs and not get wet. Change dressing as needed after 24hr. Hospital gave a referral to have a follow up appointment with V14 (Physician) in one week r/t (related to) laceration. New order for cephalexin 500mg capsule (by mouth twice daily) for 5 days. NP (Nurse Practitioner) informed. POA (Power of attorney) informed, DON contacted. R2's Progress Note dated 12/13/22 documents (R2) seen on wound rounds today by V19 (NP), and she didn't like to look of bilateral heels. Decline seen since last week. R2 complaining of increase pain to legs. Resident doesn't have an appointment with V22 (Physician) until 12/22/22. V19 spoke with Physician office (V22) about concerns and possibility of no blood flow to bilateral lower extremities. V22's office agreed that she needs to be evaluated at the ER (emergency room ). V19 spoke with V23 (POA). He also agreed to and wants his mom to be evaluated. A local Emergency Medical Service (EMS) was called to arrange the non-urgent transport. Called report to the local hospital. The local arrived at facility for transport. V23 was notified R2 on her way to the hospital. On 1/10/23 at 8:53 AM V11 (LPN) stated, So that day I was the nurse on the hall. The night shift CNA (certified nursing assistant) from the agency ran down the hallway to state the resident was bleeding. She was the night shift, and I was the day shift nurse. I ran down the hallway and applied pressure to the injury. I could see she would need to be sent out. Another nurse held pressure on the injury, and I called the EMS (emergency medical services) and the family. I asked the CNA to write a statement, but she really didn't know what happened to make the residents leg bleed. On 1/10/23 at 11:19 AM V12 (CNA) stated, I do remember that a resident hurt her leg on the XXX hall, but it was not my patient. I remember the CNA telling the nurse. No, I don't remember the CNA's name. On 1/10/23 at 11:00 AM V1 (Administrator) stated we asked the agency not to return V12 to the facility, because she transferred R2 by herself. She did not look at the care card. 2. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired. She is a limited assist of one staff for bed mobility and an extensive assist of one plus staff for transfers. R1's Skin Care Plan dated 10/5/22 documents Skin will be free from irritation redness and break down for the next 90 days. Sheep skin to bilateral side rails and use a draw sheet to turn the (R1). A. R1's Event Report dated 12/27/22 documents The resident (R1) has extremely fragile skin that tears even when being turned. The residents(R1) recent tear resulted from transfer. From the bed to the wheelchair. Resident stated she didn't hit anything, nothing was bumped. In the past has refused to be (mechanical) lifted into the wheelchair. Staff talked to resident about changing to (mechanical lift). R1 is willing to do a try of mechanical lift. R1 is alert and responsive, and able to make her own decisions. Attempted both mechanical lift and (protective sleeves) resident R1 refused both, care card in place. Resident continues to be a 2 person assist if she gets up. Resident prefers to stay in bed. R1 obtained a 5.3-centimeter skin tear to the top of her right hand. R1's treatment is applied (brand name dressing) or hydrogel and wrap with (gauze wrapping). R1's Progress Note dated 12/27/22 documents R1 obtained skin tear to top of right hand; area 5.3 cm; area cleansed with wound cleanser and (brand name dressing) and dry dressing applied; CNA informed this nurse while transferring resident she hit hand and obtained skin tear; NP notified; (V10) POA, notified; this nurse spoke with resident (R1) about changing transfer status to (mechanical lift) to prevent further injuries while transferring resident stated that she will try mechanical lift just not today; resident informed this nurse that we could attempt tomorrow after breakfast, nurse will do trial of mechanical lift with resident R1 tomorrow. B. R1's Final Investigation Report dated 8/8/22 documents the initial report was sent to your office (IDPH Office) on August 4, 2022, when R1 sustained a skin tear during repositioning. R1 was transferred to a local hospital for follow up care. Staff at the hospital cleaned and dressed the skin tear, no stitches or staples were needed. Upon return to the facility, our physician wrote orders for wound nurse practitioner to follow up with care. Nursing staff at facility were all given in servicing on proper repositioning techniques to ensure resident R1 safety and wellness to prevent any future occurrences. V3 and V4 (CNA) were given an Employee Counseling Records dated 8/4/22 and it documents while transferring a resident always make sure that all limbs' legs and arms are in a safe place to avoid injury. V3's written statement dated 8/4/22 documents V4 and V3 were transferring the R1 from the bed to wheelchair once the resident R1 was in the wheelchair. We decided to pull her back a little more but didn't realize her arm was between the arm rest of the chair and her body. We grabbed the gait belt and moved her back, and afterwards realized she had a skin tear. We immediately told the nurse. During the whole transfer, the R1 was pulling away. We kept having to remind her she did not need to resist. V4's Written Statement dated 8/4/22 documents V3 and V4 were transferring R1 from bed to chair using a gait belt. R1 needed to be pulled back into the chair so we did use a gait belt. We didn't notice her arm was in between the chair and her body. After we moved her back, we realized she had a skin tear. We told the nurse right away. During the entire transfer R1 was resistant we kept reminding her she was okay, and she wasn't going to fall. On 1/10/23 at 3:42 PM V4 stated, (R1) always leans back in her chair when you try to transfer her, and we were pulling her forward so we can transfer her, so when we sat her back down her arm got stuck between the arm rest and the chair. She got a skin tear we told the nurse. On 1/10/23 at 3:35 PM V3 stated, We (V3 & V4) were trying to pull her (R1) up in the chair when her arm got caught between the wheelchair bar and the chair. The Facility Policy Skin Tears dated 3/2003 documents in order to limit the skin tears and adequately monitor residents skin tears. We will identify, document, treat, and investigate all skin tears. The (DON) Director of Nursing will initiate preventative measures. The Facility Policy Resident Transfer dated 7/2017 The facility will assess the resident to determine the safest method of physical transfer as a component of activities of daily living.

Based on interview and record review the facility failed to ensure an environment free from accident hazards to prevent injuries for 3 of 4 residents (R2, R3, and R4) reviewed for injuries in the sample of 3. This failure resulted in R2 sustaining a laceration to right lower leg that required 14 sutures. Finding include: R2 R2's Physician Order Sheet, (POS) dated 12/13/21, documents diagnose of ST elevation [CONDITION(S)], Gastro-[CONDITION(S)] Reflux disease, hypertension, and protein-caloric malnutrition. POS dated 12/14/21 documents Physical Therapy to evaluate and treat and Occupational Therapy to evaluate and treat. R2's Nursing Note dated 12/20/21 at 10:01 AM documents This nurse was called to resident room and observe skin tear to right shin; skin tear assessed by other nursing staff; small amt of blood noted from skin tear; area cleansed, treatment in place; offer PRN pain med, resident refused to take and stated she is not in pain; made aware to (V7) DON (Director of Nursing) and resident's daughter (V6). R2's Nursing Note dated 12/20/21 at 10:15 AM documents Site examined. Bleeding had stopped. Skin flap remaining partial, irregular. Unable to reapproximate at this time. CNA reported that while transfer resident's right leg went under the wheelchair and torn on the side where the leg rest are applied to the wheelchair. Sheepskin was applied to the area. R2's Nursing Note dated 12/20/21 at 1:47 PM documents This nurse help resident out from toilet and notice gross blood in the drsg from skin tear; resident stated she just came from therapy; this nurse change resident drsg and notice increase in bleeding; resident refuse to take pain med and stated she is not in pain; resident also on Eliquis; offered resident to lay her in bed but resident's daughter want resident to eat her lunch first then go to bed; resident did go back to bed after lunch; made aware to (V7) and received order to apply pressure drsg and send resident to ER to eval and treat; apply pressure drsg as per order; resident family at bed side; call (local EMS); send resident to ER (local hospital) at Belleville; report given to nurse; vitals BP=124/79, Temp= 97.7; P=80, Resp=20, Oxygen=96 @ RA. R2's Hospital Report dated 12/20/21 documents 1:48 PM (R2) presenting to the ED, (emergency department), c/o, (complaint of), a laceration to (R2) right shin that occurred at 0730 this morning. Patient is at (facility) SNF. (R2) has lived there for the past 1 week. Today RLE (right lower extremity) hit an open bar on the wheelchair and caused the laceration. (R2) is on a blood thinning medication. Laceration repair dated 12/20/21 at 4:31 PM Right lower leg. 3.5 cm (centimeter) x 4.0 cm V shaped laceration. 14 sutures. R2's Minimum Data Set (MDS) dated [DATE] documents that R2 has no cognitive impairment. MDS dated [DATE] documents that resident requires extensive assistance of two plus persons for transfers. Resident is not steady, only able to stabilize during surface-to-surface transfer. R2's Care plan dated 12/13/21 documents R2 requires assist with ADL's related to impaired mobility. Interventions: Assist of blank for bathing. Scheduled bathing. Encourage assist with bathing/dressing. PT referral. OT referral. 12/14/21 - (mechanical) lift for transfers. 12/20/21 D/C (mechanical lift). R2's Physician order dated 12/14/21 and d/c 12/20/21 documents (mechanical) lift used for transfers. Every shift. On 12/23/21 at 12:12 PM, V1 (Administrator) stated, (R2's) daughter came into the facility right after the incident occurred. The daughter is very high stung. The CNA was transferring (R2) with a gait belt in place and (R2) got hung up on (R2's) wheelchair and got a skin tear. (R2) is on blood thinners and (R2) was bleeding and (staff) from Rehab applied some steri-strips and (R2) went out to the hospital. I believe (R2) got sutures. We placed sheepskin over the wheelchair. I talked with the daughter and did follow up with her. On 12/23/21 at 1:15 PM, V3 (Wound Nurse) stated, The CNA was transferring (R2) from the bed to the wheelchair. (R2's) right leg went under the wheelchair. (R2's) leg got cut on a something where the legs attach to the wheelchair. I tried to use steri-strips, but it kept bleeding. We then sent (R2) to the hospital. On 12/23/21 at 2:15 PM, V8 (Certified Nursing Aide/CNA) stated, She doesn't remember anything being wrong with the wheelchair. We usually transfer (R2) with two people because (R2) is so skittish. R3 R3's Physician Order Sheet (POS) dated December 21, document, a diagnosis of Alzheimer disease, [CONDITION(S)], anxiety disorder, and contracture right, contracture of left foot. R3's POS documents, (Skin protectors) to bilateral lower extremities at all times 10/23/21 open ended. No discontinued date was documented. R3's Care Plan with a problem start date of 12/15/17 document R3 is at risk for skin breakdown for Pressure Sore Risk 12/22/21 has a skin tear to right mid-shin while transferring from wheelchair to bed. R3's MDS dated [DATE] document R3 was severely impaired for cognition. Bed mobility extensive assist of 2 plus staff, transfer extensive assist of two plus staff members and has impairment on both sides of her lower extremities. R3's Progress Notes dated 12/20/21 at 7:45 PM, Resident acquired a laceration to right lower leg while x2 assist transfer to the bed after supper. Cleansed the area with wound cleanser, applied Calcium Alginate and a dry dressing. Resting in bed with eyes closed. No Signs or symptoms of infection noted. Will continue to observe. R3's Incident Report dated 12/20/2021 at 7:30 PM, Skin tear was investigated. (Skin protectors) not present during transfer. Staff to be counseled regarding resident not wearing (skin protectors). On 12/23/2021 at 2:24 PM, V2 (Director of Nursing) stated (R3) is to have R3's (skin protectors) on (R3's) lower extremities on at all times. The Certified Nursing assistant were in a hurry and they were not paying attention to (R3's) care and I wrote them up for it. It was (V5). On 12/23/2021 at 3:00 PM, V5 (CNA) stated, I was taking care of (R3) and I remember when (R3) got the skin tear a few days ago. I did not check anything and (R3) was calm and everything during the transfer but I saw the skin tear on (R3's) leg you could not miss it; I immediately went and got the nurse. (R3) caught (R3's) leg on something. R4 R4's POS document unspecified dementia without behavioral disturbances, and heart failure. R4's MDS dated [DATE] document R4 was severely impaired for cognition of decision of daily living, bed mobility extensive assist with two plus staff, for bed mobility and transfer. R4 was no steady from moving from seated to standing position and only able to stabilize with staff assistance. R4's Incident Report dated 11/5/21 at 12:53 PM, Resident sat up in bed and hit right eyebrow on mechanical scale Intervention: Resident hospice and being weighed daily still as previously ordered. Spoke to hospice regarding changing resident to monthly, Investigation with staff, 2 staff present during weight check. Resident was told by staff to lay still but sat up in bed when the mechanical bar was down, resulted in resident hitting head on bar. R4's Progress Notes dated 11/5/21 at 12:59 PM, Resident was being weighed with mechanical scale and resident was lowered down and after CNA detached mechanical pad resident sat up in bed and hit right eyebrow on mechanical scale; area purple in color 3 centimeters in length, call placed to notify Power of Attorney, no concerns noted at this time. R4's Care Plan with a Problem start date of 3/13/19 document on 11/5/21 has a bruise to the right eyebrow after weight obtained via mechanical lift scale, resident sat up in bed and hit (R4's) face on mechanical scale. No complaint of pain, has discolored area to right eye. On 12/23/21 V2 (Director of Nursing/DON) stated, I would expect staff to be alert and assure that (R4) did not hit (R4's) head with the mechanical scale and everything was clear. There were 2 staff members present but (R4) was confused and would not always listen to commands. I would expect staff to be aware of (R4's) behaviors and try to the best of their abilities keep (R4) safe. On 12/28/21 at 8:42 AM, V10 (CNA) stated, We were weighing (R4) with (mechanical lift). We weren't moving (R4) or anything. When we lowered (R4) down to the bed, (R4) trying to sit up. We were trying to get (R4) unhooked from (mechanical lift) when (R4) sat up and hit the side of head on the (mechanical lift). I don't remember who was helping me but there was two of us. I reported it to the nurse. Facility policy revised 1/18 documents (Facility) will take every precaution to prevent the occurrence of accidents. When an incident/accident does occur, the facility will document it on the Incident Accident Report form and in the Nurse's Notes. An incident may be defined as, but is not limited to falls, resident injuries of known or unknown origin, or any occurrence of an unusual nature that requires investigation.

Based on observation, interview, and record review, the facility failed to appropriately perform wound care and notify the surgeon timely for appropriate treatment of [REDACTED]. This failure resulted in R3 having increased pain, opening of R3's surgical incision, severe bleeding and increased drainage with signs of infection requiring hospitalization and surgical removal of the hip-replacement hardware. Findings include: 1. R3's Hospital Discharge Note, dated 7/25/19, document R3 was to be admitted to the facility following surgery for [REDACTED]. R3's Progress Note, dated 7/26/19, documents R3 had a left [MEDICAL CONDITION] with several staples that were to be removed on 8/10/19. R3's Progress Note, dated 7/28/19 at 6:23 AM documents: Left hip dressing saturated with serosanguineous (fluid that is yellow with small amounts of blood) drainage. Changed this AM. Staples c/d/i (clean, dry, intact), [MEDICAL CONDITION] to hip noted. The Note documented R3 was given Tylenol for pain with relief noted. There was no documentation V9, R3's Orthopedic Surgeon, was notified of the drainage to R3's left hip surgical wound. R3's Progress Notes, dated 7/29/19 at 6:11 AM, 8/1/19 at 6:09 AM, and 8/4/19 at 2:13 AM document R3's hip incision dressing needed to be changed because they were saturated with serosanguineous drainage. There was no documentation V9 was notified of R3's wound drainage. A Note, dated 8/5/19, written by V6, Nurse Practitioner (NP) documents R3's left lower extremity was swollen and bruised from recent [MEDICAL CONDITION] with surgery. The Note documented staples were noted to R3's incision site with no signs/symptoms of infection noted to the area. R3's Progress Note, dated 8/7/19 at 4:02 AM, documents R3 was given [MEDICATION NAME] (narcotic to treat moderate to severe pain) and Tylenol for complaints of left leg pain. R3's Progress Note, dated 8/11/19 at 1:32 AM, documented R3 continued to have dressings which were saturated with drainage. R3's Progress Note, dated 8/13/19 at 8:47 PM, written by V12, LPN, documents 11 staples from posterior left hip, 4 staples from the distal left hip and 29 staples from the middle hip surgical site were removed with steri strips applied. V12 documented all areas were reddened but not warm to touch, steri strips applied, areas noted to be reddened but not warm to touch and had purulent-sanguineous (thick, grayish or yellow to green drainage which is usually signs of infection or not normal to wound) coming from the surgical site. There was no documentationV9, Surgeon, was notified of the purulent drainage. On 9/17/19 at 2:50 PM,V12 stated R3's sutures lines were three different incision lines, two small ones with a longer one in the middle. V3 stated there was one area on the longer line that was open with drainage when she removed the staples and put on steri strips on it to keep it closed. V12 stated she had taken care of R3 prior to this time and that the longer suture line had small open area then too so that wasn't much different. V12 stated she removed the staples because the order on the TAR said they were to be removed. She stated she did not contact any physician including R3's surgeon regarding the open area of the suture line or the purulent drainage at the time or previously before removing the staples. V12 stated the incisional line was red but had no warmth, had odorless purulent drainage but no more than any other time. R3's Progress Note, dated 8/15/19 at 11:06 AM, written by V7 LPN/Wound nurse, documents she was requested to look at R3's left hip incision. V7 documented R3's main incision line measured 12.5 centimeter (cm) in length with site surrounding firm to touch, warmth, but not excessive, redness seen to incision line with moderate green drainage on dressing with significant amount of blood present. V7 also documented regarding R3's two smaller incision sites, one proximal to main site and the other is distal. The distal incision had green odorous drainage. V7 documented the areas were cultured. V7 documented R3 had a follow up visit with V9, Surgeon, on 8/26/19 and that they were trying to get her into a closer one. V7 documented she notified V8, Primary Care Physician. The Note documented V8 ordered antibiotic for possible hip infection. There was no documentation that V9 was informed in the green drainage with odor or the blood at the incision site. A Note, dated 8/15/19, entered by V6, Nurse Practitioner, documents R3's pain in left hip had worsened. V6 documented area noted to be warm and red with increased pain. V6 documented R3 had signs and symptom of infection, was being treated with an antibiotic twice daily for 7 days and was receiving [MEDICATION NAME] (narcotic) 5/325 twice daily. V6 documented call surgeon for f/u (follow up) apt and call with any changes to resident condition. There was no documentation that V9 was informed of R3's increased pain with the incision being red and warm. R3's Progress Note, dated 8/16/19 at 3:23 AM, documents there was a scant amount of green drainage noted with redness to R3's incisional line. R3's Progress Note, dated 8/16/19 at 10:23 AM, by V7, Wound nurse, documents R3's wound: Continues to have moderate amount of greenish/bloody drainage on dressing. Resident in great deal of pain. V7 documented that V6, Nurse Practitioner and V8, Primary Physician were notified with a new order for [MEDICATION NAME]. There was no documentation V9 was notified of R3's wounds status or R3's increased level of pain. R3's Progress Note, dated 8/17/19 documented R3's wound continued to have light and dark green drainage. R3's Progress Note, dated 8/18/19, documented R3's laboratory results were in and she was seen by V8, Primary Care Physician. The Note documented V8 wanted R3 to be seen by a wound specialist. R3's Physician's Progress Note, dated 8/18/18, written by V8 stated he examined R3 for new admission, history and physical, and left [MEDICAL CONDITION] post-surgery with complaints of pain. There was no information in V8's note regarding R3's surgical wound. R3's Progress Note, dated 8/19/19 at 2:46 PM written by V7 documented R3 was seen on wound rounds and R3's incision showed moderate amounts of green drainage with odor detected, site warm, some redness but improved. V7 documented that V6 and V8 were notified but not the Surgeon, V9. The note continues that the partial results from the culture swabs from the prior week were returned with new orders to discontinue the [MEDICATION NAME] and change [MEDICATION NAME] sensitivity to organism. The Note documents R3's pending appointment with the surgeon on 8/26/19. On 8/20/19, the Culture Report for R3's left hip incision site was infected with heavy growth of bacteria Pseudomonas Aeruginosa and [MEDICATION NAME] Faecalis. R3's Progress Note, dated 8/20/19 at 2:23 PM, documents the results of the culture were received with notification made to V6 and V8 and new orders received for [MEDICATION NAME] 500 milligrams (mg) bid (twice daily) for 7 days. The Wound Consultant Note, dated 8/20/19, written by V13, Wound Specialist documents R3 to have unspecified open wound measuring 10.9 cm (centimeters) x width 0.2 x depth 0.7cm, firm peri wound, moderate green drainage with facial grimacing and moaning with dressing change. A note dated 8/20/19 documented by V6, Nurse Practitioner, states the reason for the visit as R3's left hip incision had opened with severe increased bleeding from R3's wound since removing staples and R3 was currently on Eliquis (blood thinner). R3's Progress Note, dated 8/21/19 at 2:39 PM, documented Resident had copious amount of bleeding today. NP (Nurse Practitioner) in house pressure dressing applied. New order received to D/C (discontinue) Eliquis (blood thinner). The plan of care documented was infection as the cultures were back,[MEDICATION NAME], advised to call Surgeon with update and culture report, left hip bleeding has stopped at this time, advised if bleeding starts again, to send resident out to emergency department, and call with any changes to condition. R3's Progress Note, dated 8/21/19 at 4:16 PM, V7 LPN documents V9 Surgeon's office was called and given update regarding all current situations and R3's left hip. The Note documented that the office was notified R3 had green drainage and odor from incision and that the incision was cultured and notified them of what was cultured. V7 documented the facility would continue to monitor and notify the office of any changes, started having a fever, WBC (white blood cells) becomes elevated. The note also documents V9's office was informed of increase bleeding and that the blood thinner was stopped with dressing changes being done every shift. R3's Progress Note, dated 8/22/19 at 11:31 AM, documented Therapy informed this writer that this resident began bleeding as she was transferring this resident back to bed. The note continues that a pressure dressing was applied to stop the bleeding. The Note documented This writer called to inform MD (V8, Medical Doctor of resident's current status as resident wound appears to be dehiscing (opening) and per the Nurse practitioner, if the bleeding continues, send her to the hospital. There was no documentation V9, R3's Orthopedic Surgeon, was notified. R3's Progress Note, dated 8/22/19, at 1:02 PM documented R3 was now bleeding through the second layer of the pressure dressing. Resident expressed she was in extreme pain. The Note documented when asked (R3) to rate her pain on a scale of 1-10, R3 responded Can I say 20?' The Note documented R3 was transported to the local emergency room . There was no documentation V9 was notified of R3 being sent to the hospital with a dehisced incision site. R3's progress note, dated 8/22/19 at 8:49 PM, documented R3's return from the hospital as she was seen for a Hematoma. Orders included continue present medication regime and keep dressing on area of wound dehiscence. The emergency room visit report dated 8/22/19 documents R3 was seen for intermittent bleeding from an incision mark on left hip. Under exam, the note documents 10 cm incision with .5cm of the incision is bleeding on the left hip; small amount of 'cheesy' sebaceous material; 100cc of blood expressed wound was tight with pressure with 100cc blood expressed but is now soft. An ultra sound was performed with the findings heterogeneous fluids collection at the area of interest 3.0 x3.0 x 1.2cm. R3's Progress Note, dated 8/23/19 at 5:56 PM, documented that a call was placed to V9, Surgeon, office regarding R3 being sent to the emergency room the prior night for excessive bleeding and that the wound had dehiscence to the distal portion of the incision. V7 informed V9's office that R3's WBC now showed an elevated white count and the x-ray could not rule out osteo[DIAGNOSES REDACTED]. V7 documented a return call was received to continue to monitor over the weekend and if resident started to run a temperature, transfer her to (out of state hospital where hip surgery was performed) for evaluation and they will see her on Monday (8/26/19). R3's Progress Notes from 8/23 and 8/26/19 at 9:37 AM, document R3 to receive pain medication as ordered for complaints of pain upon movement and position changes. R3's Progress Note, dated 8/26/19 at 11:36 AM, documents that R3 went out for appointment and the facility was notified by the doctor's office (V9's office) that the resident was going to be admitted to Hospital due to left hip surgical site. The Hospital Detail of Stay, documented R3 was admitted on [DATE] with left hip wound drainage. The [DIAGNOSES REDACTED]. The Hospital's Summary of Consultation documented R3 was admitted , underwent surgery for [REDACTED]. R3's Medication Administration Records (MAR) for (MONTH) and (MONTH) documented R3 to have experienced an increase in pain following admission. On admission, R3 received Tylenol 500mg 2 tabs every 6 hours PRN (as needed) for pain along with [MEDICATION NAME] 2.5-325mg every six hours prn. The MAR for (MONTH) 2019 show R3 receiving three doses of Tylenol and doses of [MEDICATION NAME] from 7/25/19 to 7/29/19. On 7/29/19, R3 was documented as having 4 [MEDICATION NAME] and an order change to include scheduled [MEDICATION NAME] HCL 50mg with 650mg Tylenol every six hours with the [MEDICATION NAME]. On 8/16/19, an order for [REDACTED]. There was no documentation V9 was notified of R3's increased pain. On 9/17/19 at 1:58 PM, V14, V9's Medical Assistant, stated they were initially contacted on 7/26/19 regarding treatments to keep R3's suture line clean and dry. V14 stated they were not notified again until 8/21/19 when V7 contacted their office reporting R3 to have the staples removed and the suture line open. V14 stated V9's Office Notes document V7 stated that R3 [MEDICATION NAME], was afebrile and the drainage was clear. V14 stated you may remove sutures if the incision is clean dry and intact but it's never recommended to remove staples/sutures if any drainage is present as it will definitely open up then. V14 stated she recalled discussing this with the nurse that took the note on 8/21/19 and stated she was under the impression that R3 had started the antibiotic and was getting better. V14 stated (V9) would have wanted to have been informed of any systemic systems failure such as fever, chills, redness and/or warmth in the incision area, or a general feeling of unwellness. V14 stated an increase in pain would also be an indicator of something not being right as well as refusal to do activities of daily life. V14 stated their office does not have any further calls recorded nor does she recall any additional conversations with the nursing home staff. V14 stated R3 was not good when she came in and was by herself. V14 stated R3 had copious amounts of drainage saturating chuck after chuck (disposable pads) while she was in the office. V14 stated the ultrasound and X-ray results dated 8/23/19 from her ED visit along with the signs of systemic failure prompted V9 into taking R3 back to surgery again. V14 stated V9 reported R3 to have a surgical systemic event that was a threat to life. V14 stated it is impossible to determine if the hardware failure caused the infection, but they certainly could have prevented it from becoming as severe had they been adequately informed with a clearer picture of R3's condition including the amount and type of drainage she'd been having along with the increased pain earlier. On 9/18/19 at 1:12 PM, V6 NP stated she saw R3 several times with the first being over the severe swelling of her leg. V6 said it is not unusual to have some oozing from the incisional line right after the surgery but when she started to have a large amount of drainage, she told them to contact R3's surgeon and documented it in her notes. V6 stated standards of practice would always be to contact the surgeon before any other physician. V6 also stated she realized they removed the staples on the incision which was open afterward and you do not remove staples from an open incision line and again referred them to the surgeon. V6 also stated she was there when R3's wound started bleeding and gave the order to send her to the Emergency department as it started again. On 9/17/19 at 12:59 PM, V7, facility wound nurse, stated R3 had a lot of drainage and swelling when she first came in to the facility. V7 stated she did call and leave messages for V9. V7 stated she was told by V9's office they would wait until R3's follow-up appointment on 8/26/19 not seeing an urgency at the time of the conversation. V7 stated R3's pain level did increase as her stay extended which required several changes in pain medication due to the facility not wanting her on narcotics. On 9/17/19 at 12:45 PM, V13 Wound Specialist stated she saw R3 one time and gave a verbal order to change treatments once. V13 stated she thought the facility was keeping the surgeon well informed of R3's condition. On 9/18/19 at 2:13 PM, V8, Medical Director/Primary Physician stated he saw R3 only one time on 8/18/19 but was not aware of any complications at the time. V8 stated he doesn't recall looking at R3's suture line during his one visit. V8 stated the facility calls the exchange and the Nurse Practitioner picks up the call for him. V8 stated he did not know about R3's increased drainage, dehisced incision and/or excessive bleeding but would have definitely referred her back to the surgeon had he known. V9's, R3's Orthopedic Surgeon, written responses to surveyor's questions regarding R3, dated 9/23/19, documented V9 would have wanted to be notified of the large amount of drainage from R3's incision site. V9 documented that no one on her team was informed that R3's incision was open prior to removal of R3's staples. V9 documented, I don't think staple removal was appropriate for an open wound. V9 documented she was not aware that R3 had been transferred to a local ER with severe bleeding from her incision site on 8/21/19. V9 documented Yes, we would have wanted to know and yes we would have wanted the facility to contact us because we would have asked to send her here. Regarding the question, Had you been notified of (R3's) issues as they occurred, rather than at her regular follow-up appointment, would it have altered her outcome for her overall condition? V9 responded Yes, we may have been able to clean and clear the infection before it caused the fracture collapse & joint destruction. The policy entitled Skin Care, Pressure Ulcer/Wound Management dated 2/13 documents the facility policy is To promote healing of pressure ulcers, stasis ulcers, and other wounds, the facility will use standardized protocols or follow physician's specific orders for wound care. Treatment objectives include cleaning the wound bed of necrotic tissue (if present), treat infection (if present,) protect healthy tissue, and treat consistently with appropriate products. The policy documents standardized protocols are based on currently accepted standards of practice, utilized consistently whenever possible, and present to physician's when obtaining orders for wound care. The facility's policy entitled Change of Condition Reporting dated 2/13 documents in part the facility will notify the resident's physician whenever there is a significant change in resident's health, need to alter treatment or discontinue treatment, and when the resident is to be transferred. 2. R2's Wound Consultant Notes, dated 9/17/19 documents R2 had a bilateral above knee amputation (BKA) on 8/15/19. R2's Initial Wound Sheets document R2's order at the time of admission was to clean the incision with wound cleanser and apply dry gauze, then wrap with gauze wrap then ace wrap. R2's Progress notes entered on 9/9/19 at 1:43 PM document: Upon dressing change to left BKA noted to have small amount of dehiscing (opening) and small amount of green drainage. No odor or redness or warmth noted. The physician was notified and a new order for Santyl ([MEDICATION NAME] agent) and dry dressing daily to be followed by wound management was received. On 9/18/19, V7 Wound nurse documents R2 's wound to be 0.5 cm length, 4.5 width with 100% slough and moderate exudate. A Specialized Wound assessment dated [DATE] describes the wound as decline. On 9/18/19 at 11:30 AM, V10 LPN donned gloves and removed R2's dressing which had a small amount of greenish drainage on it. V10 then saturated some gauze pads with wound cleanser and gently patted the width of R2's wound. The incision line was dehisced, the wound bed had 100% slough and was oozing clear serosanguineous drainage which was dripping down the outside of his leg onto the floor as he held his leg up. No clean field was set for supplies nor was R2's leg supported during the treatment. V10 then applied a huge amount of Santyl over the wound bed then applied the dry dressing then wrapped it. V10 did not cleanse the wound appropriately nor did she change her gloves between the dirty and clean phase of the treatment.

Based on interview and record review, the facility failed to provide wheelchair foot pedals to prevent falls for 1 of 4 residents (R18) reviewed for falls in the sample of 42. This failure resulted in R18 sustaining a laceration to the forehead requiring 3 stitches and a right nondisplaced distal radial fracture. Finding includes: R18's Fall Report, dated 3/11/2018, documents, in part, Fall Summary: Fall to floor. What was this resident doing during or just prior to the fall? Pushed in wheelchair and put feet down and fell forward The Report documented Assessment: Laceration forehead area. Pain: Nonverbal grimacing. The Report documented Resident put feet down while moving. Foot pedals not on wheelchair. Resident fell forward out of wheelchair and hit forehead which caused a laceration with 3 stitches. The Fall Investigation documented R18's [DIAGNOSES REDACTED]. The Report documented Interventions put into place after this incident as leg rests staff education. The Report documented Witness statement I (V21, Certified Nurse's Aide/CNA) was handed (R18) by a (V20, Licensed Practical Nurse/LPN). She told me (R18) was dropping her feet down off and on. She told me to be careful so I did. Next thing (R18) planted her feet firmly on the ground as I pushed her she fell forward onto the floor. The Report documented Why do you think the resident fell : She didn't have foot pedals. R18's Incident Follow up, dated 3/11/18, documents, in part, Ambulance arrived at 8:25 AM and transferred resident via gurney to local hospital. R18's Nurse's Note, dated 3/11/18, documents, Resident arrived back from local hospital bandage on resident forehead. 3 sutures were placed at the hospital for the laceration. R18's Nurse's Note, dated 3/12/18, documents Went to change resident's forehead dressing and noticed swelling to the right wrist/forearm. Resident c/o (complained of) pain when touching and ROM (range of motion) of right hand. Called doctors office and ordered a 2 view X-ray on the right wrist/forearm. R18's Nurse's Note, dated 3/12/18, documents, in part, X-ray result back shows a nondisclosure distal fx (fracture) new order to apply ace wrap and sling to right arm. R18's X-RAY report, dated 3/12/18, documents, in part, Right forearm: 2 views Impression: Nondisplaced distal radial fracture is seen. R18's Minimum Data Set (MDS), dated [DATE], documents R18 has a Brief Interview of Mental Status (BIMS) of 3 indicating R18 is severely cognitively impaired. R18's MDS documents R18 requires extensive assistance of 1 staff member for locomotion on the unit utilizing a wheelchair. R18's Fall Risk Assessment, dated 2/5/18, documents, Resident is at significant risk for falls. Rationale: decreased strength and balance, impaired cognition, unaware of safety. On 07/12/2018 at 12:14 PM, V22, Physician, stated that they should have stopped and reassessed for the need of wheel chair footrests for safety since she was putting her feet down already. 07/11/18 03:15 PM, V2, Director of Nurses (DON), stated, Yes, the wheelchair foot pedals were not on the wheelchair and they should have been at the time of the fall. The intervention for that fall was to reeducate staff about foot pedals. The facility INCIDENT/ACCIDENT policy and procedure, dated 01/2018, documents, The facility will take every precaution to prevent the occurrence of accidents.

Based on interview and record review the facility failed to immediately report allegations of potential abuse to the Administrator, failed to thoroughly investigate allegations of abuse, and failed to timely report allegations of abuse to the Department. This has the potential to affect all 66 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 5/22/14, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding allegations of abuse. Findings include: 1. R34's physician's orders [REDACTED]. R34's Admission Minimum Data Set 4/2014, documented R34 is severely cognitively impaired, and is a 2 staff assist with all Activities of Daily Living, showers, and transfers. The Facility's Follow up Report for Alleged Abuse, Neglect and/or Theft, dated 5/21/14, documented the following: On 5/12/14 at 7:30 PM, during R34's shower, E27 Certified Nurses Aide (CNA), was overheard cursing several times at R34 telling him to sit down because he was refusing his shower. E27 took R34 to his bedroom. E28, CNA, witnessed E27 put R34 onto his bed and then roll him over hard. On 5/21/14 at 12:50 PM, in a phone interview, E1, Administrator, stated although R34's abuse occurred on 5/12/14, it was not reported to him until 5/16/14 between 2:00 PM and 3:00 PM. He was aware staff had not reported it immediately to him and did not know why they did not. E1 stated E27 continued to work on 5/12 and worked an evening shift on 5/15/2014. E28's Statement, dated 5/16/2014, documented on 5/12/14 at 7:30 PM, E27 was in the shower room and told R34 to "Sit The F***k down several times." E27 told R34 "Oh my F***king God why do I always get your shower." E28 documented she helped E27 transfer R34 to bed. E27 rolled R34 onto his side so hard that he almost fell out the other side of the bed. E28 documented that she left the room to get E29, Licensed Practical Nurse (LPN). E28 told E29 what had happened to R34 then left the area. E28 documented a few days later she also told E30, Registered Nurse (RN), what had happened to R34. In an interview with E28 on 5/21/14 at 8:15 PM, she confirmed the above statements. E28 stated she helped E27 put R34 onto the side of his bed, but then went to help R34's roommate. E28 stated once E27 had R34 laid down on the bed, E27 rolled R34 over onto his side so hard he almost fell off the side of the bed. E28 stated E27 had to grab him and pull him back. E28 stated she thought when she told E29 what had happened, E29 would intervene and take care of R34, but E29 did nothing. E28 stated when she came back to work on 5/16/14 she sought out E30 and told her. E30 said she would tell E1. E29's Statement, dated 5/16/14, documented that on the evening of 5/12/14, E28 told her that E27 had rolled R34 so hard in his bed that he almost fell on the floor. E29 documented "I did not think this held any merit because these two CNA's have been sniping and sniping at each other for the better part of three weeks. R34 can be resistive to care and can at times be combative. He requires 2 people to take care of him." On 5/21/14 at 8:15 PM, E29 stated "I was not told that( E27) had been cursing at (R34). (E28) did say that (E27) had rolled (R34) too hard when putting him to bed. (E27) and (E28) were upset and arguing with each other about who was supposed to help who with resident care. It is common knowledge that these two girls argue. ( E28) did not say anything about (E27) cursing at (R34) in the shower. I did go and look at (R34) that evening after he was in bed and he seemed fine. I did not think anything happened to (R34) that should be reported as abuse or otherwise." E30's Statement, dated 5/16/14, documented: "On 5/15/14, (E28) came to me at about 5:30 PM and asked to talk to me. She said that on a evening that I was not working, another CNA (E27) was overly rough with (R34) and was cursing at him and nearly rolled him out of the bed. (E28) said she told the other nurses that night but nothing happened." On 5/21/14, at 7:50 PM, E30 stated "I did not work on 5/12/14. On the evening of 5/15/14, (E28) told me about the event with (E27) and (R34). I am a new nurse here, and I knew this had to be reported, but there was no one from the office here at the time, and so I reported it the next day, 5/16/14 to E3, Assistant Director of Nursing (ADON) and E1. 2. On 5/13/14 at 9:45 AM, during the Survey Entrance Interview, E1 stated that he did not have any reportable investigations to be reviewed. He stated no staff, residents or family members had made any abuse allegations in the past year. 3. On 5/13/14, at 1:45 PM, R6 stated that one day near the end of April, he was leaving Physical Therapy, and a staff member came up to him and kissed him on both cheeks and his forehead. After kissing him, the staff then stated "I really, really love you." The staff was in street clothes, and was a lady. R6 stated he was shocked by this behavior, and although he could not remember the staff face or name, he felt very uncomfortable being touched in this manner. R6 stated he told Z4, his wife, about this incident, and Z4 had spoken to E1 but no one from the facility had talked to him about this event. R6 stated repeatedly that this event made him uncomfortable even to speak of it now. On 5/14/14 at 11:15 AM, E1 stated "Around 5/2/14, (Z4) did come and tell me that a staff member had kissed (R6) and told him she loved him. (Z4) was not happy about this incident and said it had made (R6) uncomfortable. I went to the Physical Therapy Dept and asked 3 or 4 staff there if they had seen or witnessed this event. They all said they had not seen anyone kissing (R6) at any time. Because I could not find anyone that had witnessed (R6) being kissed, and figured (R6) just made the story up. I did not talk or interview (R6) about the event. I did not do an incident report, write down any of this information, or send anything to the Department. I didn't see what the need to report this event as I did not think it was abuse. I couldn't verify anything had happened, and there was nothing to document." On 5/15/14, in an interview with E2, Director of Nursing (DON), she stated she was not in the building at the time of this event, but had heard about it. E2 stated E1 is the Facility Abuse Coordinator and handles these types of complaints. E2 stated at this time there is only one female resident in the building who wanders, and she would not kiss anyone as she is more withdrawn and does not readily approach other residents. E2 stated that R6 was an alert resident, and she had not heard of him making up stories about staff in the past. 4. A review of the Facility Follow up Report for Alleged Abuse, Neglect and/or Theft dated 12/30/13 documented "R28 was missing two rings. R28 was seen wearing the rings on 12/26/13, but on 12/27/13 the rings were reported missing by a family member. The search continues." On 5/16/14 at 11:00 AM, E1 stated "At the time R28's gold rings went missing, he was on hospice and dying. Several family members had been coming in and out to see R28 over the holiday. R28's family told the staff on 12/27/13 about the missing rings. No one told E1 of the problem until 12/30/13. E1 stated he did call the police and they did file a report. E1 stated he is aware that this event should have been reported immediately. E1 stated he does not know why staff failed to report this to him sooner, but thinks because it was a holiday weekend, they waited until the following Monday. E1 stated he did report it to the department, but it was 3 days later on 12/30/13. 5. The Resident Census and Conditions of Residents, CMS 672 dated 5/14/14, documents that the facility has 66 residents living in the facility. 6. The Immediate Jeopardy situation was identified and determined to have begun on 5/12/2014 when E27 verbally abused R34. E1, E2, E3, and E4, Facility RN Consultant were notified of the Immediate Jeopardy on 5/21/14 at 4:51 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. E27 alleged to have abused R34 on 5/12/14, was terminated from service on 5/21/14. 2. On 5/21/14, E4, immediately re-inserviced and instructed E1, E2, and E3 on the Facility Abuse Policy including Reporting, Investigating, Documenting and Reporting to the Department all alleged, suspected, and potential abuse of residents. 3. On 5/21/14, E4 instructed E1, E2, and E3 on the Facility Policy for investigation, documentation and reporting of Injuries of Unknown Origin. 4. On 5/21/14, Facility staff were re-inserviced on the Facility Abuse Policy and protocols for immediate notification of allegations of suspected abuse. Facility staff were not allowed to work until they received this in-service. 5. The facility began a review of it's Abuse Policy and made changes in the policy language to reflect staff's reporting immediately to the Administrator any and all allegations of abuse or suspected abuse. E4 stated that the Facility will continue to review and update the Abuse Policy to meet current regulations. .

Based on interview and record review the Facility failed to operationalize its Abuse Prevention Policy to ensure that the Administrator was notified immediately of all allegations of abuse, neglect, mistreatment, and misappropriation of resident ' s property. The Facility failed to operationalize its Abuse Policy by not conducting a timely and thorough investigation, allowing a Certified Nurse's Aide (CNA) to have direct contact with residents after potential incidents of abuse. The Facility failed to operationalize its Abuse Policy by not notifying the Department immediately of allegations of abuse. This has the potential to affect all of the 66 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 5/22/14, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding allegations of abuse. Findings include: 1. The Facility Follow up Report for Alleged Abuse, Neglect and/or Theft, dated 5/21/14, documented the following: On 5/12/14 at 7:30 PM, during R34's shower, E27 Certified Nurses Aide (CNA), was overheard cursing several times at R34 telling him to sit down because he was refusing his shower. E27 took R34 to his bedroom where E28, CNA, witnessed E27 put R34 onto his bed and then roll him over hard. On 5/21/14 at 12:50 PM, in a phone interview, E1, Administrator, stated although R34's abuse occurred on 5/12/14, it was not reported to him until 5/16/14 between 2:00 PM and 3:00 PM. In an interview with E28 on 5/21/14 at 8:15 PM, she stated "I told E29, Licensed Practical Nurse (LPN), on 5/12/14 when this happened. I thought when I told E29 she would intervene and take care of R34, but E29 did nothing." E28 stated she did not realize she should report this allegation to E1. On 5/21/14 at 8:15 PM, E29 stated E28 did not say anything about E27 cursing at R34 in the shower. I did go and look at R34 that evening after he was in bed and he seemed fine. E29 stated "I did not think anything happened to R34 that should be reported as abuse or otherwise." On 5/21/14 at 7:50 PM E30 stated "On the evening of 5/15/14, (E28) told me about the event with (E27) and (R34). I am a new nurse here, and I knew this had to be reported, but there was no one from the office here at the time to ask what to do, and so I reported it the next day, 5/16/14 to (E3, Assistant Director of Nursing, ADON) and (E1)." 2. On 5/13/14, at 1:45 PM, R6 stated that one day near the end of April, he was leaving Physical Therapy, and a staff member came up to him and kissed him on both cheeks and his forehead. After kissing him, the staff then stated "I really, really love you." The staff was in street clothes, and was a lady. R6 stated he was shocked by this behavior, and although he could not remember the staff face or name, he felt very uncomfortable being touched in this manner. R6 stated he told Z4, his wife, about this incident, and Z4 had spoken to E1 but no one from the facility had talked to him about this event. R6 stated repeatedly that this event made him uncomfortable even to speak of it now. On 5/14/14 at 11:15 AM, E1 stated "Around 5/2/14, (Z4) did come and tell me that a staff member had kissed (R6) and told him she loved him. Z4 was not happy about this incident and said it had made (R6) uncomfortable. I went to the Physical Therapy Dept and asked 3 or 4 staff there if they had seen or witnessed this event. They all said they had not seen anyone kissing (R6) at any time. Because I could not find anyone that had witnessed (R6) being kissed, and figured (R6) just made the story up. I did not talk or interview (R6) about the event. I did not do an incident report, write down any of this information, or send anything to the Department. I didn't see what the need to report this event as I did not think it was abuse. I couldn't verify anything had happened, and there was nothing to document." 3. The Facility's Follow up Report for Alleged Abuse, Neglect and/or Theft, dated 12/30/13, documented "R28 was missing two rings. R28 was seen wearing the rings on 12/26/13, but on 12/27/13 the rings were reported missing by a family member. The search continues." On 5/16/14 at 11:00 AM, E1 stated he was not made aware of R28's missing rings until 12/30/2013. E1 stated he did report it to the Department, but it was 3 days later on 12/30/13. 4. The Facility's Abuse Investigation Policy, Revised 05-2013, documented: Policy - Any employee alleged to the Abuse Prevention Coordinator to have perpetrated Resident abuse will be immediately barred from further contact with all Residents until the matter is properly resolved. The Abuse Prevention Coordinator will render a decision regarding the validity of the allegation based on analytical judgement. All allegations of abuse will be reported in a timely manner to the State Agency in accordance with current regulations. 2. Timely Reporting - Abuse allegations must be initially reported by the Administrator to the State Agency within 24 hours of occurrence except in cases of serious bodily injury resulting from a suspected crime. Procedure - 1. Employee as Perpetrator of Abuse: When an investigation of a report of suspected abuse of a resident indicates, based on credible evidence, that an employee of a long-term care facility is the perpetrator of the abuse, that employee shall be barred from further contact..... #4 - Upon receipt of the Notification of Suspected or Witnessed Abuse, the Abuse Prevention Coordinator or Designee will notify the Resident or Resident's representative of the alleged incident and of the progress of the investigation by telephone and/or in writing unless otherwise provided by law. #6. The Abuse Prevention Coordinator will notify the Illinois Department of Public Health via facsimile, or telephone on holidays or weekends, of the alleged abuse incident within 24 hours of the receipt of the allegation, unless serious bodily injury is present... a 2 hour time limit for reporting must be followed. Page 5 - If You See Abuse, You Must Report It: Any employee who has actual knowledge of the abuse of neglect of a resident shall immediately submit a complaint to the Abuse Prevention Coordinator. 5. The Resident Census and Conditions of Residents, CMS 672 dated 5/14/14, documents that the facility has 66 residents living in the facility. 6. The Immediate Jeopardy situation was identified and determined to have begun on 5/12/2014 when E27 verbally abused R34. E1, E2, E3, and E4, Facility RN Consultant were notified of the Immediate Jeopardy on 5/21/14 at 4:51 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Staff alleged to have abused R34 on 5/12/14, was terminated from service on 5/21/14. 2. On 5/21/14, E4 immediately re-inserviced and instructed E1 E2, and E3 on the Facility Abuse Policy including Reporting, Investigating, Documenting and Reporting to the Department all alleged, suspected, and potential abuse of residents. 3. On 5/21/14, E4 instructed E1, E2, and E3 on the Facility Policy for investigation, documentation and reporting of Injuries of Unknown Origin. 4. On 5/21/14, Facility staff were re-inserviced on the Facility Abuse Policy and protocols for immediate notification of allegations of suspected abuse. Facility staff were not allowed to work until they received this in-service. 5. The facility began a review of its Abuse Policy and made changes in the policy language to reflect staff's reporting immediately to the Administrator any and all allegations of abuse or suspected abuse. E4 stated the Facility will continue to review and update the Abuse Policy to meet current regulations.

Based on record review and interview the facility repeatedly failed to protect residents from physical, mental, and verbal abuse for one resident (R6) reviewed for abuse in the sample of 15 and one resident (R34) in the supplemental sample. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 5/22/14, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding allegations of abuse. Findings include: 1. R34's physician's orders [REDACTED]. R34's Admission Minimum Data Set 4/2014, documented R34 is severely cognitively impaired, and is a 2 staff assist with all Activities of Daily Living, showers, and transfers. The Facility Follow up Report for Alleged Abuse, Neglect and/or Theft, dated 5/21/14, documented the following: On 5/12/14 at 7:30 PM, during R34's shower, E27 Certified Nurse's Aide (CNA), was overheard cursing several times at R34 telling him to sit down because he was refusing his shower. E27 took R34 to his bedroom. E28, CNA, witnessed E27 put R34 onto his bed and then roll him over hard. On 5/21/14 at 12:50 PM, in a phone interview, E1, Administrator, stated although R34's abuse occurred on 5/12/14, it was not reported to him until 5/16/14 between 2:00 PM and 3:00 PM. He was aware staff had not reported it immediately to him and did not know why they did not. E1 stated E27 continued to work on 5/12 and worked an evening shift on 5/15/2014. E28's Statement, dated 5/16/14, documented on 5/12/14 at 7:30 PM, E27 was in the shower room and told R34 to "Sit the F***k down several times." E27 then told R34 "Oh my F***king God why do I always get your shower." E28 documented she helped E27 transfer R34 to bed. E27 rolled R34 onto his side so hard that he almost fell out the other side of the bed. In an interview with E28 on 5/21/14 at 8:15 PM, E28 stated that she did help E27 put R34 onto the side of his bed, but then went to help R34's roommate. E28 stated that once E27 had R34 laid down on the bed, E27 rolled R34 over onto his side so hard he almost fell off the side of the bed. E27 had to grab him and pull him back. E29's Statement, dated 5/16/2014,E29, she documented that on the evening of 5/12/14, E28 did tell her that E27 had rolled R34 so hard in his bed that he almost fell on the floor." 2. On 5/13/14, at 1:45 PM, R6 stated that one day near the end of April, he was leaving Physical Therapy, and a staff member came up to him and kissed him on both cheeks and his forehead. After kissing him, the staff then stated "I really, really love you." The staff was in street clothes, and was a lady. R6 stated he was shocked by this behavior, and although he could not remember the staff face or name, he felt very uncomfortable being touched in this manner. R6 stated he Z4, his wife, about this incident, and Z4 had spoken to E1 but no one from the facility had talked to him about this event. R6 stated repeatedly that this event made him uncomfortable even to speak of it now. On 5/14/14 at 11:15 AM, E1, stated "Around 5/2/14, (Z4)did come and tell me that a staff member had kissed R6 and told him she loved him. (Z4)was not happy about this incident and said it had made R6 uncomfortable. I went to the Physical Therapy Dept and asked 3 or 4 staff there if they had seen or witnessed this event. They all said they had not seen anyone kissing R6 at any time. Because I could not find anyone that had witnessed R6 being kissed, and figured (R6) just made the story up. I did not talk or interview R6 about the event." 3. The Facility's Abuse Prevention Policy, dated 3-2011, documented "This facility believes that each resident has the right to be free from abuse, neglect, corporal punishment, misappropriation of their property, and involuntary seclusion. Resident must not be subjected to abuse by anyone, including but not be limited to: facility staff, other Resident residing at (Facility), consultants, volunteers, staff of outside agencies providing services at (Facility), family members, legal guardians, and individuals visiting our facility." 4. The Immediate Jeopardy situation was identified and determined to have begun on 5/12/2014 when E27 verbally abused R34. E1, E2, Director of Nursing, E3, Assistant Director of Nursing, and E4, Facility RN Consultant were notified of the Immediate Jeopardy on 5/21/14 at 4:51 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. E27 allegedly abused R34 on 5/12/14 and was terminated from service on 5/21/14. 2. On 5/21/14, E4, immediately re-inserviced and instructed E1, E2 and E3 on the Facility Abuse Policy including Reporting, Investigating, Documenting and Reporting to the Department all alleged, suspected, and potential abuse of residents. 3. On 5/21/14, E4, instructed E1, E2, and E3 on the Facility Policy for investigation, documentation and reporting of Injuries of Unknown Origin. 4. On 5/21/14, Facility staff were re-inserviced on the Facility Abuse Policy and protocols for immediate notification of allegations of suspected abuse. Facility staff were not allowed to work until they received this in-service. 5. The facility began a review of it's Abuse Policy and made changes in the policy language to reflect staff's reporting immediately to the Administrator any and all allegations of abuse or suspected abuse. E4, stated that the Facility will continue to review and update the Abuse Policy to meet current regulations.

Based on record review and interview, the facility failed to provide safe transfer techniques to prevent injury for one of four residents (R2) reviewed for falls in the sample of 10. This failure resulted in R2 fracturing the right tibia and right fibula on 10/26/11. Findings include: The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documents R2 requires extensive assistance with transfers and is moderately impaired with cognition. The facility's Fracture of Unknown Origin form, not dated "CNA's (Certified Nurse's Aides) transferred guest just prior to c/o (complaints of ) pain had heard crack." The form documented staff were educated on (mechanical lift) transfers after this incident. The facility's Incident/Accident Report , dated 10/26/11, documented "Noted yelling out when gotten up this am. Narrowed site to R (Right) ankle. Guest unable to tell us. Also noted L (Left) leg edematous to thigh area." The X-Ray report, dated 10/26/11 documented "There are acute mildly displaced fractures of both the distal tibial and fibula diaphyses." R2's Fall Prevention Measures form, revised on 9/5/10, documented "(Mechanical lift) for transfers." R2's Care Plan, dated 10/19/11, documented "At Risk for Falls related to h/o (history of) left distal femur fracture, muscle weakness, leans to the left side, slides forward in w/c (wheelchair) at times." The interventions for this problem documented " (mechanical) lift for transfers." On 6/26/12, at 4:30 PM, an interview with E2, Director of Nurse's was conducted. E2 stated "They transferred her with 2 assist to the (geriatric) chair and heard a pop. They thought it was the (geriatric) chair and told nurse when she (R2) complained of pain. They did not follow the plan of care which was a (mechanical lift)."