Every finding on record at Fair Oaks Health Care Center

Based on observation, interview, and record review the facility failed to ensure a resident was transferred with a mechanical lift in a safe manner which applies to 1 of 5 residents (R1) reviewed for safe transfers in a sample of 5. This failure resulted in R1 falling from a mechanical lift sling sustaining a subdural hematoma. This past compliance occurred from 1/23/26 to 1/29/25.The findings include:R1's undated Facesheet showed R1 is a [AGE] year-old female admitted to the facility on [DATE]. This Factsheet showed R1 was readmitted to the facility on [DATE] with a new diagnosis of traumatic subdural hematoma.The facility's State Agency Serious Injury Report dated 1/23/26 showed R1 was hospitalized after falling from a mechanical lift sling. This report showed the cause was from an improper sling attachment for the sling loops.R1's Hospital Discharge Report dated 1/27/26 showed R1 was admitted to the hospital with an admission diagnoses which included a subdural hematoma (brain bleed) and a hematoma of the scalp (bruising). This Report's cat scan reading showed R1 sustained a 3-millimeter subdural hematoma.On 2/2/26 at 9:45 AM, V1 Administrator stated after interviewing V14 and V15 Certified Nursing Assistants (CNAs) they were able to determine and recreate the sling loop coming off the lift hook. When the loop strap was wrapped around the end of the transfer bracket it caused tension which popped the loop off the hook.On 2/2/26 at 10:45 AM, V14 stated V15 and V14 were getting R1 up to their wheelchair. V15 had hooked their side of the mechanical lift sling then wrapped the rest of the strap around the end of the lift bar. When R1 was being move over the wheelchair the sling came off the lift, and R1 fell to the floor.On 2/2/26 at 10:55 AM, V15 stated R14 and R15 were going to transfer R1. R15 stated they hooked the loop of the sling on the lift bar and wrapped the rest around the outer hook of the bar. When R1 was lifted and moved toward the wheelchair the sling came undone and R1 fell to the floor.The facility's Safe Resident Handling/Transfers Policy dated 1/7/26, at time of R1's injury, showed Staff members are expected to maintain compliance with safe handling/transfer practices.Prior to the survey date of 2/2/26, the facility had taken the following action to correct the noncompliance:1. On 1/23/26 V14 and V15 received formal training on mechanical lift equipment use and safe mechanical lift transfers. 2. On 1/23/26 - 1/29/26 facility staff were educated by video, in-services, and in person return demonstrations for mechanical lift equipment use and safe mechanical lift transfers.3. On 1/27/26 and 1/29/26 the facility Quality Assurance Performance Improvement (QAPI) Committee developed a plan of correction for the 1/23/26 mechanical lift fall. The QAPI Committee wrote and implemented an addendum to the facility's Safe Resident Handling/Transfers Policy which was initiated on 1/27/26. The all-staff in-service of 1/29/26 includes the addendum to the education of the in-service.4. The facility has an agreement with the agency used for 3rd party scheduling to have their staff complete the online video and quiz prior to working their first/next shift at the facility. A return demonstration with the facility's Physical Therapy department or designated nursing personnel is required prior to working on the floor of the facility.5. The new hire on-boarding training for care staff includes this new policy.

Based on observation, interview, and record review the facility failed to perform a safe wheelchair transport for a high fall risk resident for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in R1 falling forward from the wheelchair and sustaining a broken nose and a laceration to his forehead that required sutures.Findings Include:On 10/9/25 at 10:10 AM, V9 (Certified Nursing Assistant -CNA/Restorative Aide) pushed R1 in his wheelchair from the dining room to a seating room without footrests in place. R1's shoes came in contact with the floor four times during the transport of approximately 25 feet. R1 was well groomed with a bandage on the middle of his forehead. R1 had a privacy bag for his indwelling catheter directly under the seat of his chair. The surveyor asked R1 how he hurt his head. R1 replied, He (V6 - CNA) was giving me a ride from the dining room to my room and suddenly this (touching his wheelchair) stopped, and I kept going. I hit my head on the floor. The surveyor asked R1 if he had footrests on his wheelchair. R1 said there were footrests, but they haven't used them on his chair in a while. R1 said he usually tries to pick up his feet, but the footrests do keep his feet from hitting the floor. R1 said his feet might have fallen and that could have stopped the chair. R1 denied refusing footrests to be placed on his wheelchair when staff propel him.R1's Face sheet dated 10/9/25 showed diagnoses to include, but not limited to diabetes; asthma; neuromuscular dysfunction of the bladder; dysphagia (difficulty swallowing); dementia; CHF (congestive heart failure); anemia; CKD (chronic kidney disease - Stage 3); muscle wasting and atrophy; abnormalities of gait and mobility; need for assistance with personal care; atrial fibrillation; and generalized osteoarthritis. R1's facility assessment dated [DATE] showed he was cognitively intact. R1's Final Incident Report dated 10/8/25 showed, on 10/5/25 at approximately 8:30 PM, a CNA (V6) was transporting R1 back to his room, in his wheelchair. R1 appeared to reach down for an item, which caused a forward shift in weight resulting in a fall from the wheelchair, striking his face on the floor. R1 sustained a laceration to his forehead and was bleeding from his nose. R1 was transferred to the hospital and returned to the facility on [DATE], following an overnight stay. R1 had sutures to the laceration on his forehead and had mild swelling and discoloration of the nose when he returned. R1's hospital evaluation revealed an acute nasal bone fracture with no intervention required and a laceration repaired with sutures to his forehead. This report showed that Nursing and CNAs were re-educated on safe transport procedures.R1's Fall Risk assessment dated [DATE] showed he was a high fall risk.R1's Fall Risk Care Plan updated 10/8/25 showed on 10/5/25 while CNA attempting to propel wheelchair, R1 reach for supposed item off the floor and fell out of wheelchair. R1's EMR (Electronic Medical Record) did not show that R1 had refused use of footrests on his wheelchair when being propelled by staff. R1's Hospital Records dated 10/6/25 showed R1 fell out of his wheelchair and fell on his face. R1 had a nosebleed and forehead laceration that was sutured in the emergency department. R1's (CT/Computed Tomography) of his brain/cervical spine/facial bone showed he had an acute on chronic nasal bone fractures and the potential for SDH (Subdural Hematoma), therefore R1 was admitted to the Neuro ICU (Intensive Care Unit) stepdown for observation and repeat CT.On 10/9/25 at 9:28 AM, V4 (Registered Nurse - RN) said she was working 10/5/25 when R1 fell from his wheelchair. V4 said she didn't witness the fall because she was administering medications to another resident. V4 said V5 (Agency Licensed Practical Nurse - LPN) notified her of the fall. V4 said when she went to the dining room, R1 was lying on the floor bleeding from his forehead and nose. V4 said V5 had a towel on R1's forehead to stop the bleeding and V6 (CNA) was obtaining vital signs. V4 said she called 911 and R1 was sent to the hospital. V4 said R1 returned to the facility on [DATE] with a broken nose and sutures to his forehead. V4 said V6 (CNA) reported that R1 was reaching for something on the floor and fell. V4 stated, It was so strange because I've never seen him (R1) reach for anything like that. V4 said V6 (CNA) said he was going to get R1 to bed, and he fell right in front of him. I'm not sure exactly how that happened. V4 said R1 was alert and oriented and was able to make his needs known. V4 said R1 would be able to tell you what happened. V4 said R1 usually had good trunk control when he was sitting up in the wheelchair and normally asks for assistance and she was so surprised by the fall. On 10/9/25 at 10:45 AM, V5 (Agency LPN) said she was preparing meds when she heard a loud sound, as if someone fell and she heard R1 scream. V5 said she ran to the dining room and R1 was face down on the floor and V6 (CNA) was there. V5 said R1 was bleeding from his nose and forehead. V5 said she noticed R1's catheter was trapped under his leg and assumed the resident may have been trying to get the catheter out, when he fell forward. V5 said V6 (CNA) told her that R1 was reaching for something.On 10/9/25 at 11:15 AM, V7 (CNA) said he was working 10/5/25, but did not witness R1's fall. V7 said he was assisting another resident and noticed the ambulance lights. V7 said he went to the dining room and saw R1 on the floor. V7 said he's familiar with R1 and he was alert, oriented, and was able to let the staff know what he needs. V7 said he had never seen R1 reach down from the wheelchair, especially when staff were pushing him. V7 stated, To be honest with you, I don't think he was trying to reach over for something. If someone was pushing him, then why would he try to pick something up? V7 said V6 told him he didn't know what happened. V7 said V6 told him he was pushing R1 and all the sudden R1 was falling forward. On 10/9/25 at 1:40 PM, V6 (CNA) said he was working on 10/5/25 and around 8:40 PM he went to get R1 ready for bed. V6 said R1 gathered his puzzle book and glasses case with pens inside. V6 said he released R1's brakes and started pushing R1's wheelchair. V6 said he turned R1 from the table and pushed the wheelchair 3-4 feet from the table when suddenly it looked like R1 was reaching down for something on the floor. V6 said R1 fell from the wheelchair and landed face first. V6 said R1 had no reason to reach, it didn't make sense. V6 said R1 never had footrests on his wheelchair. V6 said we push R1's wheelchair and he always lifts up his feet. V6 said there was nothing in front of us that would have blocked the wheels. V6 said he was holding the chair and R1 just went all the way forward. V6 said he doesn't know if R1 would have fallen if the foot pedals were in place. V6 said R1 still could have fall because he was reaching. V6 said the staff try to use foot pedals on resident's wheelchairs just in case they can't lift their feet because they could get tired, and their feet could fall down. On 10/9/25 at 12:18 PM, V3 (Director of Nursing - DON) said she was notified by V4 (RN) on 10/5/25 that V6 (CNA) was in the process of moving R1 in his wheelchair when R1 reached for something and fell. V3 said R1 was hospitalized 24-30 hours and had sustained broken nose and sutures to a forehead laceration from the fall. V3 said whenever staff are propelling a resident in the wheelchair, they should be using footrests. V3 said this was an important safety measure because feet can get stuck, and accidents can happen. The surveyor asked V3 if R1 had footrests for his wheelchair. At 12:32 PM, V3 walked to the dining room. R1 was seated in his wheelchair at the table and there were no footrests in place. V3 asked V9 (CNA/Restorative Aide) and V9 said R1 refuses the footrests. V3 went to R1's room and there were two footrests on a table and one footrest in the closet. V3 said she wasn't sure if the footrests were for R1's wheelchair. V3 stated, I'd like to think if he was refusing footrests that we would have it documented somewhere. At 3:04 PM, V3 said she was unable to find any documentation that R1 had refused the footrests. V3 said she could see how having the footrests in place could have reduced R1's risk of falling. V3 said residents have the right to fall, but we should be doing everything we can to keep them safe. On 10/9/25 at 1:33 PM, V11 (Certified Occupational Therapy Assistant - COTA) said the proper way to propel a resident in a wheelchair included ensuring the resident is properly positioned, unlocking the brakes, and pushing slowly with the footrests in place. V11 said the footrests keep the resident's legs safe from dangling or getting run over from the wheelchair. V11 said the footrests are important for the resident's safety. V11 said even if a resident can self-propel, staff should still use footrests when they propel the resident. On 10/9/25 at 2:11 PM, V13 (Therapy Director/ Physical Therapist) said the purpose of footrests while pushing a resident was for safety. V13 said you never know if they can hold up their legs, they could wear out. V13 said if a resident was properly positioned in a wheelchair with the leg rests on, then they should remain safely in the wheelchair. V13 said using the leg rests should alleviate the risk a bit of falling forward out of the chair. The surveyor requested a wheelchair transport policy, but none was received. The facility's Safe Lifting and Movement of Residents Policy dated 2017 showed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to live and move residents. Policy Interpretation and Implementation: 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents.

Based on interview and record review the facility failed to notify the physician of resident's rash on the day it was identified. This applies to 1 of 4 (R1) in the sample of 4 reviewed for notification. The findings include: On 3/10/2025 at 9:44AM, V6 Physical Therapy Assistant (PTA) stated she worked with [R1] on 2/21/2025 and [R1] mentioned she had a rash on her neck. V6 stated she did see a blotchy red area on her neck and believes she reported to the nurse but was unsure who she reported it to. On 3/10/2025 at 10:39AM, V8 Registered Nurse (RN) stated she vaguely remembers [R1]. V8 stated nobody mentioned a rash to her that day. V8 stated she would have called the doctor if the resident did in fact have a rash. On 3/10/2025 at 12:17AM, V11 Nurse Practitioner (NP) stated she was not notified of [R1's] rash until 2/25/2025 right before [R1] was being discharged . On 3/10/2025 at 1:30PM, V1 Administrator stated the facility did not have documentation of a provider notification for [R1] on 2/21/2025. The facility failed to provide documentation a physician or provider was notified of [R1's] rash that was identified on 2/21/2025. The facility provided Acute Condition Changes - Clinical Protocol policy revised 3/2018 states, . Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, . changes in skin color or condition) and how to communicate these changes to the Nurse. the nursing staff will contact the physician based on the urgency of the situation . the nurse and physician will discuss and evaluate the situation.

Based on interview and record review the facility failed to assess a resident after a rash was observed by staff. This applies to 1 of 4 (R1) in the sample of 4 reviewed for assessments. The findings include: On 3/10/2025 at 9:44AM, V6 Physical Therapy Assistant (PTA) stated she worked with [R1] on 2/21/2025 and [R1] mentioned she had a rash on her neck. V6 stated she did see a blotchy red area on her neck and believes she reported to the nurse but was unsure who she reported it to. On 3/10/2025 at 10:39AM, V8 Registered Nurse (RN) stated she vaguely remembers [R1]. V8 stated nobody mentioned a rash to her that day. V8 stated she would assess the resident if someone told her about a rash and call the doctor if the resident did in fact have a rash. On 3/10/2025 at 10:19AM, V7 Infection Control Preventionist stated if a resident has a rash it is reported to her by the nurse, and she would follow up. V7 stated the physician should be involved so they can assess it as well and see what treatments is needed for it. V7 said assessment and notification should happen on the same day. On 3/10/2025 at 1:30PM, V1 Administrator stated the facility did not have documentation of a skin assessment for [R1] on 2/21/2025. The facility failed to provide documentation an assessment was completed after the rash was identified on 2/21/2025. The facility provided Acute Condition Changes - Clinical Protocol policy revised 3/2018 states, . Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, . changes in skin color or condition) and how to communicate these changes to the Nurse.

Based on observation, interview, and record review the facility failed to provide the correct portion of vegetables. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample. The findings include: On 6/4/24 at 11:50 AM, V4 [NAME] began the noon lunch service for the dining room nearest the kitchen. V4 served sloppy joes, peas with onions, sweet potato, and cake. V4 used a green handled ice cream scoop to serve the peas and the portion appeared inadequate. On 6/4/24 at 12:18 PM, V4 completed the lunch service for the dining room adjacent to the kitchen. V4 stated the green handled ice cream scoop was 2.66 ounces. V4 stated the grey scoop is 4 ounces. V4 stated he always used the green scoop for vegetables. The facility's menu and recipe for peas showed the portion size should be 4 ounces. On 6/05/24 at 9:54 AM, V3 Dietary Manager stated the residents in the dining room adjacent to the kitchen only received 2 and 2/3 ounce of peas and they should have been served 4 ounces. (More than a 30 percent deficit.) V3 stated, The dietitian reviews the menu, and the portions are sized to ensure the residents receives the correct amount of nutrition and nutrients for a healthy diet and healing. The facility provided list of residents who dined in the dining room adjacent to the kitchen, and were a regular diet, included R16, R1, R17, R21, R4, R11, R6, and R80.

Based on observation, interview, and record review the facility failed to measure food temperature on the steam table in a manner to prevent cross-contamination. This applies to 5 of 5 residents (R17, R21, R4, R6, & R11) reviewed for menus in the sample of 12 and 3 residents (R16, R1, & R80) outside the sample. The findings include: On 6/4/24 at 11:50 AM, V4 began the lunch service for the dining room adjacent to the kitchen. V4 stated he had already measured the temperature of the sloppy joe meat; however, it was requested he check the temperature again. V4 removed a thermometer from a cup that contained numerous writing utensils. V4 then stuck the thermometer probe into the sloppy joe meat without sanitizing the thermometer. V4 then continued with the lunch service. On 6/05/24 at 9:54 AM, V3 Dietary Manger stated .He (V4) should have cleaned the thermometer then temped the sloppy joe. The purpose of cleaning the thermometer first is to prevent any cross contamination to make sure it's clean before it goes in the food and to make sure there is no debris from its previous use. The facility provided list of residents who dined in the dining room adjacent to the kitchen, and were a regular diet, included R16, R1, R17, R21, R4, R11, R6, and R80.

Based on interview and record review the facility failed to immediately initiate potential lifesaving interventions for 1 of 1 resident (R27) reviewed for quality of care in the sample 12. The findings include: R27's Face Sheet showed a recent admitted [DATE] with diagnoses to include dysphagia (difficulty swallowing), dementia, and communication deficit. R27's Nursing Note from [DATE] at 3:36 PM, (note authored by V2 Director of Nursing) stated At approx. 12:30 (PM), [V6 Registered Nurse] approached this writer and asked if I could come help with [R27]. This writer asked what was going on and [V6] stated he (R27) appeared to be choking. We ran into the dining room and this writer witnessed [R27] sitting at his table with [V7 and V8 Certified Nursing Assistants] two CNAs next to him trying to get him to respond to them. Cyanosis (blue/purple color of the skin caused by lack of oxygen) could be seen on all his fingers and around his lips at first glance . The note showed, I asked if the Heimlich (abdominal thrust use to dislodge food stuck in a person's airway) had been done. [V6] responded that it had not been. [V6] started to do the Heimlich, and I went to call EMS (Emergency Medical Services). The note showed CPR (Cardiopulmonary Resuscitation) was started and an attempt to clear his airway was done. The note showed, during CPR, pureed food debris was removed from his mouth. The note showed EMS suctioned R27, placed a breathing tube, and no food was observed blocking his airway. The note showed life saving measures were unsuccessful and R27 was pronounced dead at 1:04 PM. R27's Nursing Note from [DATE] at 12:29 PM, (note authored by V6) stated, Called into dining room by CNA staff. Resident non-responsive making gurgling noises, spitting out some of his lunch. Went and grabbed nursing supervisor and came back. Resident brought from dining room toward nursing station. CNA staff stood resident up and this nurse attempted Heimlich maneuver. Heimlich maneuver was not effective. Nursing supervisor called 911 at this time. Resident lowered to floor and CPR was started until paramedics arrived. On [DATE] at 2:49 PM, V6 stated I was his (R27's) nurse that day. I was sitting at nursing station charting. CNA called me over because he was not responding while eating. I noticed he was making gagging noises. So, I went down and grabbed the DON (Director of Nursing). I grabbed her and she came over and then we pulled him by the nurse's station. The Heimlich wasn't effective, so we put him on the floor and the DON called 911 and we started CPR. V6 stated V2 was in her office which was approximately 100 feet away. V6 stated, My initial instinct, when the CNA's grabbed me, was that he was choking. V6 stated he did not immediately start the Heimlich maneuver because At that moment I thought it would be better to have an extra nurse to help if he would need CPR. V6 stated, he believed R27 was sitting at the table alone and the food that was removed from R27's mouth appeared to be his pureed lunch. On [DATE] at 7:50 AM, V7 stated he was in the dining room with R27 during lunch on [DATE]. V7 stated R27 was able to feed himself. V7 stated he was at a table next to R27 and V8 was seated at a table across from R27. V7 stated he was first alerted to R27 having issues when he was making noises as if he was trying to clear his throat. V7 stated R27 was also not able to verbally respond, which was not normal for R27. V7 stated he could not recall who went to get V2; however, the Heimlich maneuver was not started until V2 arrived at the dining room. V7 stated he believed the amount of time from the onset of R27's issue and until the Heimlich was started was less than a minute. V7 stated, based on R27 not being able to talk, he had just been eating, and the noises R27 was making; the symptoms were consistent with choking. V7 stated he had CPR and Heimlich training. Multiple attempts to contact V8 CNA were made on [DATE]. V8 did not return phone calls. On [DATE] at 10:13 AM, V2 DON stated the Heimlich should have been started immediately upon onset of R27's symptoms. V2 stated V6 should have started the Heimlich himself and sent a CNA to get her. V2 stated, The longer you wait the worse the situation can get; time is of the essence. I was down on one of the hallways, he came to the office to get me. He (V6) stated I think [R27] is choking. V2 stated, food was removed from R27's mouth during CPR and it appeared to be his pureed lunch. V2 stated paramedics used a camera scope to insert the breathing tube and there was not food visible in his airway. R27's Death Certificate showed the cause of death to be Alzheimer's (dementia). The facility's Emergency Procedure-Choking policy (Revision ,d+[DATE]) showed, Trained staff will assist the resident who is choking by attempting to expel the foreign body from the airway .Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. Ask the resident to cough or speak, if at all possible, to determine if his or her airway is obstructed. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign object. Call for help but stay with the resident. Quickly assure the resident that you are going to stay and assist him or her. If the resident cannot cough, only then should abdominal thrust be performed .

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with pressure ulcers for 1 of 4 residents (R18) reviewed for pressure in the sample of 12. The findings include: R18's undated face sheet showed an admitted [DATE] and diagnoses including but not limited to gangrene, methicillin resistant staphylococcus aureus infection, acute myeloblastic leukemia, not having achieved remission, diabetes mellitus with foot ulcer, chronic ulcer of left foot, right leg below knee amputation, elevated white blood cell count, colostomy use, and colon cancer. R18's facility assessment dated [DATE] showed no cognitive impairment and requiring staff assistance with bed mobility, transfers, toileting, and personal hygiene. The same assessment showed R18 had one or more pressure ulcers. R18's weekly wound round report dated 6/4/24 showed an unstageable pressure ulcer to the coccyx with current measurements at 2.5 x 2 centimeters. The report showed an unstageable right buttock pressure ulcer with current measurements at 2.5 x 2 centimeters. The report showed an unstageable left posterior ankle pressure ulcer with current measurements at 0.8 x 1 centimeters. Attached to the report was a handwritten note (unknown author) with directions: ORDER AIR MATTRESS and heel boots at all times while in bed. On 6/4/24 at 3:01 PM, R18 was lying in bed on a low air loss pressure ulcer mattress. R18 was thin and weak in appearance. R18 was a female resident with an almost bald head. R18 stated her buttock had been sore for days and her new air mattress has been a lifesaver. R18 stated she had just got the special air mattress and her back side was killing me before then. R18 had a nephrostomy bag and colostomy bag visible from under her gown. R18 was missing her right lower leg and her left foot was lying directly on a pillow. R18 refused to allow any observations for her buttock or coccyx wounds. On 6/5/24 at 9:31 AM, R18 stated she had the buttock wound when she came to the facility. Staff have been treating it daily with a cream and finally got her the special air mattress. R18 stated the wound doctor sees her every week but was unsure of which day. R18 refused any observations of her dressing changes or wounds. R18's left foot was still lying directly on a pillow. On 6/6/24 at 11:23 AM, V9 (Wound Care Nurse) stated she became the wound care nurse this week and just started doing wound rounds with the doctor. V9 stated R18 had an unstageable coccyx wound at admission, a right buttock wound at a stage two, a left ankle wound, and several left toes amputated. V9 stated R18 is at high risk for more skin breakdown. She eats very little, has been on chemotherapy for cancer, is refusing hospice, and is very immunocompromised. V9 reviewed R18's wound prevention orders and stated she just received a low air loss mattress just this week. It should have come in last week but didn't for some reason. V9 stated she could not say why the pressure reducing mattress was not on her bed at the time of admission. R18 needs the special mattress to relieve pressure on certain areas like her coccyx, buttocks, heel, and elbows. V9 stated the heel protector should be on whenever she is in bed. V9 stated her care plan should be reflecting the same interventions. It is important to follow the interventions, so staff know how to help her progress and heal. Without any interventions, she is at risk for her current wounds to worsen and develop new ones. On 6/6/24 at 11:36 AM, V2 (Director of Nurses) stated the prior assistant director of nurses was in charge of ordering pressure ulcer mattresses. V2 stated she quit abruptly last week so V2 could not say why she never ordered one for R18 at admission. V2 stated she recently realized R18 was not on the correct mattress. V2 stated the care plan should show the pressure reducing interventions needed. They help reduce pain and prevent further break down. V2 stated the interventions should be in place shortly after admission, typically within 24 hours. V2 reviewed R18's electronic medical record and said there is no care plan related to R18's wounds. On 6/6/24 at 11:40 AM, V10 (Care Plan/MDS minimum data set coordinator) stated residents are assessed at admission and she puts care plan interventions in place shortly after that. V10 stated they are put in resident charts the next morning if she is not here the day of admission. V10 stated the interventions are important to ensure staff know how to care for the resident. There are care plans on the door of resident rooms too. That gets updated as needed by nursing or therapy staff. V10 reviewed R18's medical record and said there should be a care plan for her pressure ulcers. The prior wound care nurse was doing care plans for skin issues, and I guess she did not do one for R18. V10 stated it should have been caught when the MDS was completed but it wasn't. It was overlooked and I guess all the care plans need to be reviewed. V10 stated she was sure there are other residents missing care plan interventions. The facility's Pressure Ulcers/Skin Breakdown policy revision dated 3/2014 states under the monitoring section: 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. R18's care plan had no focus area related to her wounds. The care plan did have one approach area start dated 10/31/23 (prior stay) related to skin concerns. The area was not completed and risks, skin condition, wounds, pressure reducing interventions were blank. The care plan on the door of R18's room was reviewed and did not show any pressure reducing interventions.

Based on observation, interview, and record review, the facility failed to ensure interventions were put in place for a resident with a history of falls, failed to ensure the resident's fall risk assessment was reassessed after a fall with injuries, and failed to develop a care plan showing he was a fall risk and identify interventions to prevent further falls for 1 of 1 resident (R11) reviewed for falls in the sample of 12. The findings include: R11's Face Sheet, provided by the facility on 6/6/24, showed he was admitted to the facility on [DATE], with diagnoses including vascular dementia with agitation, muscle wasting and atrophy, abnormalities of gait and mobility, cognitive communication deficit, anxiety disorder, bilateral ankle effusion (a buildup of fluid in the soft tissues around the ankle joint), major depressive disorder, osteoarthritis, and chronic heart failure. R11's care plan, with a start date of 5/16/24, showed Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). R11's care plan with a start date of 5/8/24 showed he had a memory/recall deficit. On 6/4/24 at 11:00 AM, R11 was observed in the dining room during the activity, sitting at a table looking around the room. R11 had an arm sleeve covering his left lower arm. R11 stated the sleeve was on his arm because he hurt his arm. When asked how he hurt his arm, R11 stated he bumped it on something. R11's Event Report dated 5/18/24 at 5:29 PM showed Resident found on floor in room with chair alarm sounding by CNA (Certified Nursing Assistant). Writer notified and noted resident laying on his right side on the floor with the wheelchair near his head. ROM (range of motion) checked-WNL (within normal limits). Noted 4 skin tears to left arm .Resident stated (he) was trying to walk to the bathroom and ended up on the floor . The report showed the skin tears on R11's left arm measured 5.5 cm (centimeters) x 4 cm, 1.5 cm x 1 cm, 1 cm x 1 cm, and 5.5 cm x 1 cm. The report showed the last time prior to the fall that R11 last used the bathroom or received incontinent care was at 1:30 PM (almost four hours earlier). The report also showed resident was receiving diuretics (medications that cause increased production of urine to help clear extra fluid out of the body). On 6/5/24 at 3:30 PM, R11 was in his room sitting in a wheelchair. The Care Plan Information sheet on R11's bathroom door did not identify R11 as a fall risk and no interventions were circled under the safety section to identify any interventions that were in place. R11's electronic medical record did not have a care plan showing R11 was at risk for falls and list interventions to prevent further falls. R11's Fall Risk assessment dated [DATE] showed he was a high fall risk. The assessment showed R11 had had a fall in the six months leading up to his admission, was incontinent, had a lack of understanding of one's physical and cognitive limitations, and required assistance or supervision for mobility, transfers, or ambulation. On 6/6/24 at 9:05 AM, V2 (Director of Nursing-DON) stated R11 has had a fall and he is a fall risk. V2 stated R11 does have a chair alarm, but they are put on any resident with confusion or cognitive deficits. V2 stated there should have been a falls risk care plan in place for R11, with interventions in place. V2 stated a fall risk assessment was done for R11 on 5/8/24 when he was first admitted . V2 stated there has not been another one done since then. V2 stated the facility's policy is if someone has a fall, another fall risk assessment should be completed, and interventions should be put in place on their care plan. On 6/06/24 at 10:12 AM, V10 (MDS/Care Plan Coordinator) stated there was not a care plan in place for R11's fall risk and interventions. V10 stated it is important to make sure a risk assessment is done, and a care plan is put in place to try to prevent further falls. V10 stated R11 is a fall risk. R11's Physician Order Report, provided by the facility on 6/6/24, showed he was receiving skilled physical therapy to include therapeutic exercises, therapeutic activities, gait training, neuromuscular re-education, and patient education. The report showed R11 was also receiving speech therapy to address deficits in orientation, memory, problem solving, and overall cognition for safety and to prevent further regression. The facility's policy and procedure titled Fall Risk Assessment, with a revision date of March 2018, showed The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The policy showed 1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. 2. The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 3. The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension .5. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. 6. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). 7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, Activities of Daily Living (ADL) capabilities, activity tolerance, continence, and cognition .9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences for risk factors that are not modifiable. The facility's Falls-Clinical Protocol, with a revision date of March 2018, showed 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record .4. The physician will identify medical conditions affecting fall risk .and the risk for significant complications of falls . The protocol showed Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The protocol showed Monitoring and Follow-Up .2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The facility's policy and procedure titled Care Plans-Baseline, with a revision date of March 2022, showed A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident .2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. 3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment.

Based on observation, interview, and record review the facility failed to ensure a resident with an indwelling urinary catheter had physician care orders in place for 1 of 5 residents (R25) reviewed for catheters in the sample of 12. The findings include: R25's undated face sheet showed an admitted [DATE] and diagnoses including but not limited to arthritis due to other bacteria of the left shoulder (at admission), methicillin susceptible staphylococcus aureus infection, sepsis, stage three kidney disease, prostate cancer, and retention of urine. R25's facility assessment dated [DATE] showed no cognitive impairment and the use of a urinary catheter. The same assessment showed the use of an antibiotic medication. R25's order history report dated 5/6/24 to 6/6/24 showed the use of intravenous cefazolin (antibiotic) from admission to 5/11/24. The same report showed an order to chart on use of the antibiotic for left should joint sepsis. On 6/4/24 at 2:31 PM, R25 was seated in a wheelchair in his room. R25 had a catheter bag hanging from the side of the wheelchair and dark yellow urine was in the tubing. R25 stated he was on an antibiotic when he arrived at the facility (cefazolin). R25 stated he has been weak from prostate cancer treatments and recently fell at home. The fall caused a shoulder injury that was operated on, and it became infected with a staph infection. R25 stated he came to the facility about one month ago while still on the antibiotic. The PICC line (peripherally inserted central catheter-long, thin tube inserted through a vein in the arm) was just taken out a day ago. R25 stated he has had the urinary catheter since the hospital stay and had it when he arrived at the facility. R25's physician order report for June 2024 was reviewed. There were no orders for the use of an indwelling catheter. R25's care plan was reviewed and there was no evidence of the use of an indwelling catheter. There were no care orders or interventions related to the urinary catheter located in R25's electronic chart. On 6/6/24 at 9:47 AM, V2 (Director of Nurses) stated physician orders should be in place for all residents with indwelling catheters at the time of admission. The order should include the size, when to change it, how or if it needs to be flushed, and any urology appointments coming up. V2 stated she was not sure exactly what the care plan should include but would expect the same type of information. Care interventions are needed to ensure the resident stays safe and is healing. Catheters are a common cause of urinary tract infections. V2 stated (R25) is at an even greater risk of infection based on his past medical history and recent shoulder infection. V2 reviewed R25's electronic medical record and verified there were no care orders or interventions related to the indwelling catheter. The facility's Urinary Catheter Care policy revision dated 9/2014 states: The purpose of the procedure is to prevent catheter-associated urinary tract infections .1. Review the resident's care plan to assess for any special needs of the resident. The facility's Care Plans policy revision dated 3/2022 states: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .and must include the minimum healthcare information necessary to properly care for the resident .b. physician orders .

Based on interview and record review the facility failed to maintain an accurate reconciliation of controlled substances. This applies to 1 of 1 resident (R18) reviewed for controlled substances in the sample of 12. The findings include: R18's hydrocodone/acetaminophen (a combination narcotic opioid pain medication and an over-the-counter pain medication) Controlled Drug Receipt/Record/Disposition form (Controlled Substance Count Sheet) showed the order was for the medication to be given every 6 hours as needed for pain. The reconciliation form showed on 5/16/24, one tablet was dispensed, and 18 tablets remained. The next two entries on the form were lined out and error was written next to the entries. The errors were signed by only one nurse. The next entry, on 5/24/24, showed one tablet was removed and 16 tablets remained. The two stricken entries between 5/16/24 and 5/24/24 did not indicate the medication was wasted or destroyed. The form did not show an entry indicating when the 18th tablet was dispensed. On 6/06/24 at 12:21 PM, V2 stated, while reviewing R18's-controlled substance count sheet, V2 was unable to determine the disposition R18's 18th hydrocodone/acetaminophen tablet. V2 stated if the medication was wasted, the record should reflect this, and it should be signed by two nurses. V2 stated the two stricken entries appear to be documentation errors and not entries showing the medication was wasted. V2 stated nursing staff are expected to do a count of all controlled substances at the start/end of every shift. V2 stated if the cause of the discrepancy cannot be quickly determined and corrected; the nurses should notify herself or the Administrator. V2 stated she was not aware of this missing narcotic, and it should have been caught at shift change. V2 stated narcotic medications are more likely to be diverted. V2 stated the purpose of the count sheets is to ensure an accurate count of controlled substances and to inhibit diversion of controlled substances. The facility's Controlled Substances policy (Revision April 2019) showed, any wasted controlled substances should be disposed of in the presence of a witness and signed by both nurses. The policy showed, controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing immediately .

Based on observation, interview, and record review, the facility failed to prevent cross-contamination when assisting a resident with their toileting needs, and failed to ensure staff wore the proper PPE (personal protective equipment) while providing direct care to a resident on enhanced-barrier precautions for 1 of 2 residents (R18) reviewed for infection control in the sample of 12, and 1 resident (R83) outside the sample. The findings include: 1. R83's Face Sheet, provided by the facility on 6/6/24, showed she had diagnoses including displaced fracture of upper end of the left humerus (the long bone that extends from the shoulder to the elbow), osteoarthritis, obesity, and glaucoma. R83's facility assessment dated [DATE] showed she is dependent on staff for toileting and lower body dressing and requires substantial/maximal assist with upper body dressing and getting on and off the toilet. On 6/4/24 at 1:46 PM, V15 (Certified Nursing Assistant-CNA) was assisting R83 with her toileting needs. R83 had a bowel movement. V15 wiped the stool from R83, then folded the toilet paper, using only her left gloved-hand, and wiped again. V15 repeated this process two more times, then wiped the stool from the toilet seat with toilet paper. V15 left the same gloves on used to clean R83's stool to pull R83's brief and pants up. V15 pulled R83's shirt down and readjusted the gait belt around R83. V15 touched the gait belt in several areas while walking R83 back to her wheelchair. V15 touched both brakes on the wheelchair with her left gloved-hand and the left handle on the wheelchair before removing the soiled glove and washing her hands. On 6/6/24 at 9:32 AM, V2 (Director of Nursing-DON) stated after cleaning a resident who had a bowel movement, she would expect the CNA to remove the gloves, wash or sanitize her hands and put clean gloves on, before touching the resident or anything in the environment to prevent cross-contamination. R83's skin integrity care plan, with a start date of 6/6/24 (last day of survey) showed R83 has the potential for further skin breakdown related to impaired mobility. The care plan showed Assist with toileting. The facility's policy and procedure titled Personal Protective Equipment-Glove Use, with a revision date of September 2010, showed When to Use Gloves: 1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin .3. When cleaning up spills or splashes of blood or body fluids. The facility's policy and procedure titled Handwashing/Hand Hygiene, with a revision date of August 2019, showed The facility considers hand hygiene the primary means to prevent the spread of infection .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .h. Before moving from a contaminated body site to a clean body site during resident care .j. After contact with blood or bodily fluids .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used .b. When anticipating contact with blood or body fluids . 34891 2. R18's undated face sheet showed an admitted [DATE] and diagnoses including but not limited to gangrene, methicillin resistant staphylococcus aureus infection, acute myeloblastic leukemia, not having achieved remission, diabetes mellitus with foot ulcer, chronic ulcer of left foot, right leg below knee amputation, elevated white blood cell count, colostomy use, and colon cancer. R18's facility assessment dated [DATE] showed no cognitive impairment and requiring staff assistance with bed mobility, transfers, toileting, and personal hygiene. The same assessment showed R18 had one or more pressure ulcers. On 6/4/24 at 2:56 PM, V11 (Physical Therapist) and V12 (Director of Physical Therapy) transferred R18 using a slide board from the bed to a wheelchair in her room. V11 and V12 wore gloves but did not have gowns on. R18's nephrostomy and colostomy bags were visible from under her shirt. V12 stated they were just about to do a second transfer from the wheelchair to the upright recliner. R18 requested to rest for a minute. V11 and V12 stated they would return shortly and continue with the transfer. R18 requested this surveyor return later for any interviewing. This surveyor exited R18's room and noted the signage on the door clearly stating R18 was on enhanced barrier precautions. The sign showed staff must wear gloves and a gown for high-contact resident care activities. Those care activities were listed and included: transferring, the use of invasive tubing devices, and the presence of wounds. A stocked bin of PPE (Personal Protective Equipment) was next to the doorway. On 6/4/24 at 3:12 PM, V11 and V12 donned gloves outside of R18's room and closed the door to do the second transfer. V11 and V12 did not don a gown prior to entering the room. On 6/4/24 at 11:06 AM, V13 (Registered Nurse) stated the facility policy states PPE is needed in enhanced barrier precaution rooms if care is being provided. A gown and gloves are necessary anytime staff are providing any of the care activities shown on the isolation precaution door sign. On 6/6/24 at 9:39 AM, V2 (Director of Nurses) stated enhance barrier precautions are put in place for residents with wounds, catheters, ostomies, feeding tubes and such. The gown and gloves are an extra precaution to protect the resident from outside germs getting introduced into the open areas of the body. All staff need gowns and gloves during care. April 1st was our big day and we started requiring the PPE then. That includes the therapists too. Only wearing gloves is not enough. Gowns are required too to reduce the risk of infection. The facility's Enhanced Barrier Precautions policy revision dated 12/19/22 states: Enhanced Barrier Precautions are defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of MDROs in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregivers.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported for 1 of 3 residents (R1) reviewed for abuse in the sample of 5. The findings include: On 2/15/24 at 1:32 PM, V6, Licensed Practical Nurse (LPN), said she cared for R1 on 2/9/24. V6 said when she was giving R1 her noon medications that day, R1 told her that someone in the middle of the night grabbed her by her hair and was dragging her and calling her names and mocked her. V6 said she told V8, LPN that R1 alleged she was being dragged around on the floor by her hair in her room. V6 said V7 told her R1 had made those kinds of statements before. V6 said she would be expected to inform the administrator about any abuse allegations as soon as possible. V6 said did not report R1's abuse allegations to the Administrator. On 2/15/24 at 3:02 PM, V7, Certified Nursing Assistant (CNA), said R1 said she was trying to get out of bed at night and the night lady was yelling at her, and someone was pulling her hair, then someone said just leave her there. On 2/20/24 at 9:05 AM, V8, LPN, said if she ever heard of any allegations of abuse, she would notify V1, Administrator/Abuse Coordinator immediately because she is the abuse coordinator. V8 said if V1 was not available, she would notify the Director of Nursing (DON) or a supervisor. On 2/20/24 at 9:37 AM, V9, LPN, said if any resident reported any allegations of abuse, she would definitely call the DON, the family, and probably the police too. On 2/20/24 at 10:13 AM, V1 said when she reviewed the staff interviews, she came across one from V12, CNA, which said R1 would become confused and say night shift had dragged her by her hair, kicked her, and they don't change her. V1 said she was never informed of the allegations, or she would have done an investigation. A written interview from V12 dated 2/13 shows R1 told V12 several times that night shift has dragged her by her hair and they kick her, and they don't change her. The facility's Abuse Prevention Program Policy and Procedure (updated 7/1/22) shows employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor who must then immediately report it to the administrator.

Based on interview and record review, the facility failed to ensure a high fall risk resident was transferred with a gait belt for 1 of 5 residents (R1) in the sample of 5 reviewed for safety. The findings include: On 2/15/24 at 1:32 PM, V6, Licensed Practical Nurse (LPN), stated on 2/9/24 around 7:30 AM, V7, Certified Nursing Assistant (CNA), came to get her and brought her to R1's room where R1 was on the floor in her bathroom. V6 stated V7 told her R1's legs went out and she had to assist R1 to the floor. V6 stated R1 did not have a gait belt on her person. On 2/15/24 at 3:02 PM, V7, CNA, stated she was caring for R1 on 2/9/24. V7 stated she took R1 to the bathroom and was pulling up R1's pants and R1's legs went out and she just collapsed. V7 stated she was able to catch R1 by her pants and lower her to the floor in the bathroom. V7 stated R1 did not have a gait belt on when she went down. On 2/20/24 at 9:05 AM, V8, LPN, stated R1 transferred with a 1-2 person assist and a gait belt. On 2/20/24 at 10:13 AM, V1, Administrator, stated they moved R1 closer to the nurse's station because she is a high fall risk and is restless at night. On 2/20/24 at 12:01 PM, V13, Physical Therapy Assistant (PTA), stated she worked with R1 on several occasions. V13 stated R1 needed someone with her at all times for transfers and she needed a gait belt. V13 state R1 was not safe without a gait belt. R1's Fall Risk assessment dated [DATE] shows R1 is a High Fall Risk. R1's current Face Sheet provided by the facility (undated), shows R1's diagnoses include, but are not limited to, muscle wasting and atrophy, syncope and collapse, diabetes, sick sinus syndrome (a group of heart rhythm problems), anxiety, anemia, cerebral infarction (stroke), and atrial fibrillation (heart arrhythmia). R1's Minimum Data Set, dated dated dated [DATE] shows R1 requires substantial/maximal assistance with toilet transfers. The facility's Bathroom, Assisting a Resident to Policy (revised February 2018) shows a gait belt should be used for safety and support.

Based on interview and record review, the facility failed to protect 4 residents (R1, R2, R3, R5) from misappropriation of narcotic medications. This applies to 4 of 5 residents reviewed for misappropriation in the sample of 11. The findings include: 1) R1's physician's orders dated 5/22/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 4 hours as needed for pain. R1's-controlled drug receipt/record/disposition form showed on 6/10/23 R1 had 4 Hydrocodone tabs remaining. On 6/11/23, R1 had 3 Hydrocodone tabs remaining in his medication card with no documentation of R1 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 1 of R1's Hydrocodone tablets. 2) R2's physician's orders dated 6/7/23 showed, Hydrocodone-Acetaminophen 5-325mg 1 tablet every 4 hours as needed for pain. R2's-controlled drug receipt/record/disposition form showed on 6/10/23 R2 had 20 Hydrocodone tabs remaining. On 6/11/23, R2 had 19 Hydrocodone tabs remaining in her medication card with no documentation of R2 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 1 of R2's Hydrocodone tablets. 3) R3's physician's orders dated 4/29/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 6 hours as needed. R3's-controlled drug receipt/record/disposition form showed on 6/8/23 R3 had 15 Hydrocodone tabs remaining. On 6/11/23, R3 had 13 tabs remaining in her medication card with no documentation of R3 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 2 of R3's Hydrocodone tablets. 4) R5's physician's orders dated 5/15/23 showed, Oxycodone 5mg take 1/2 tablet every 4 hours as needed for pain. R5's-controlled drug receipt/record/disposition form showed on 6/11/23 R5 had 25 Oxycodone tabs remaining. On 6/11/23, R5 had 24 Oxycodone tabs remaining in her medication card with no documentation of R5 receiving a second dose of Oxycodone on 6/11/23. The facility was unable to account for 1 of R5's Oxycodone tabs. On 6/29/23 at 11:37AM, V1 (Administrator) and V2 (Director of Nursing) stated V3 (Assistant Director of Nursing-ADON) spoke to V4 (Registered Nurse) about an hour and a half before shift change and she was fine. V8 (Licensed Practical Nurse-LPN) notified V3 that V4 wasn't acting right, and they couldn't complete narcotic count so V3 took V4 to the human resources office and they called me (V1) and I came right in. We notified the local police department and I thought she would get drug tested at the emergency room but since she was not going to the emergency room , I drug tested her. Her drug test showed positive for opiates. She was very calm and sleepy and could hardly stay awake during this whole process. The police interviewed her while she was still at the facility and interviewed her a few days later and she couldn't recall the events of that day. The aides on that day were agency and the other one was new so they didn't know her and couldn't have been able to tell if she wasn't acting right. A narcotic count was completed with V9 and V3 so that the count could be corrected. We never did find any of the missing medications in the facility, so we are assuming that V4 ingested all of them during her shift that day. On 6/29/23 at 12:35PM, V9 (LPN) stated he came to work at approximately 3:00PM on 6/11/23 and began counting narcotics with V4 (Registered Nurse). V9 stated the count started off wrong and he thought maybe it was just a mistake and then when they kept counting the narcotics, the counts remained off for several residents and V4 appeared impaired, slurring her words, and couldn't give an explanation as to why the medication count was incorrect. V9 stated V4 did not sign out on any narcotics for several residents on their narcotic count form and on the electronic medication administration record. V9 then stated he alerted V3 (ADON) who was the manager on duty that day and she came and removed V4 from the nursing cart and took her to the human resources office. V9 and V3 then corrected the narcotic count so that V9 could begin passing evening medications to residents. On 6/29/23 at 12:44PM, V6 (Local Police Detective) stated an officer came to the facility on [DATE] at approximately 3:35pm for reports of an intoxicated nurse and narcotic counts were off. (V3-ADON) reported she suspected (V4-Registered Nurse-RN) had ingested medications and was intoxicated. (V9 LPN) reported that (V4-RN) was not acting right, appeared under the influence, and was swaying at the nurse's cart. (V4) stated she did not take any medications from the medication cart, but the officer stated (V4's) pupils were constricted, she had slow speech and slow reactions. Another officer checked (V4) for medications and her vehicle as well as the staff lounge and there were no medications present. (V4) then consented to a toxicology test and it tested positive for opiates .I met with her a few days later and she told me that she was intoxicated while she was working all day and doesn't recall anything from the entire day until the police showed up at the facility. The facility's policy titled, Abuse Prevention Program (Facility) Policy and Procedure dated 7/1/22 showed, .IV. Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment . The facility's policy titled, Controlled Drug Policy and Procedure dated 1/1/13 showed, The narcotic count and inventory- 2. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count.

Based on interview and record review, the facility failed to document administration of narcotic medications to ensure accurate reconciliation for 4 of 5 residents (R1, R2, R3, R5) reviewed for pharmacy services in the sample of 11. The findings include: 1) R1's physician's orders dated 5/22/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 4 hours as needed for pain. R1's Controlled Drug Receipt/Record/Disposition Form showed R1 received a dose of Hydrocodone on 6/1/23, 6/2/23, 6/5/23, and 6/9/23. R1's MAR for June 2023 contained no documentation of R1 receiving Hydrocodone on these dates. R1's June 2023 MAR showed R1 received a dose of Norco on 6/10/23; however, there was no documentation on R1's Controlled Drug Record form. 2) R2's physician's orders dated 6/7/23 showed, Hydrocodone-Acetaminophen 5-325mg 1 tablet every 4 hours as needed for pain. R2's Controlled Drug Receipt/Record/Disposition Form showed R2 received a dose of Hydrocodone on 6/7/23 and one dose daily from 6/13/23-6/16/23. R2's Medication Administration Record (MAR) for June 2023 contained no documentation of R2 receiving Hydrocodone on these dates. 4) R5's physician's orders dated 5/15/23 showed, Oxycodone 5mg take 1/2 tablet every 4 hours as needed for pain. R5's Controlled Drug Receipt/Record/Disposition Form showed R5 received one dose of Oxycodone on 6/12/23 and 6/14/23. R5's June 2023 MAR showed no documentation of R5 receiving Oxycodone on these dates. On 6/29/23 at 9:48AM, V7 (Agency Licensed Practical Nurse) stated anytime a narcotic is administered to a resident the nurse would then sign that narcotic out in the resident's Controlled Drug Form and on the MAR. V7 stated there would be no reason why a nurse would not sign the narcotic out in both places. V7 stated if a medication is not signed out on the MAR, then a resident could get a dose of narcotic medication before the time it is scheduled for because the system will not know that the resident already received the medication. On 6/29/23 at 12:10PM, V2 (Director of Nursing) stated that all narcotic medications are signed off on the residents Controlled Drug Form and the resident's MAR. V2 stated this is unacceptable for nurse's not to be signing it out in both places and not doing so could lead to a medication error and potential overdose of narcotics. We also use the documentation if there is a discrepancy during the shift-to-shift count of narcotics. If a nurse forgets to document in either place, then we can check the MAR or Controlled Form to see if they charted it there then that would resolve the discrepancy. The facility's policy titled, Controlled Drug Policy and Procedure dated 1/1/13 showed, Objective: To provide physical facilities and method of operation for the administration and control of narcotics, depressants, and stimulant drugs, which will meet the requirement of State and Federal narcotic enforcement agencies .The Narcotic Count and Inventory: 2. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count.

Based on interview and record review, the facility failed to report an allegation of theft to Illinois Department of Public Health (IDPH) within the required timeframes. The findings include: The Illinois Department of Public Health Long Term Care Facility Serious Injury Incident and Communicable Disease Report dated 6/26/23 showed, During the change of shift on June 11, 2023, at approximately 2:55PM it was observed that the narcotic count was off on 5 residents-controlled drug receipt/record/disposition form. A total of 7 narcotics were missing during the change of shift, nurse to nurse handoff . The facility did not submit an initial report to IDPH and did not submit a final report to IDPH within 5 business days. The facility submitted a final report to IDPH on 6/26/23. (15 days after the incident occurred) On 6/29/23 at 11:07AM, V1 (Administrator) stated, I had no idea that I had to report this to IDPH. I wasn't going to report it either until the police came back to the facility on [DATE] and told me it was possibly neglect. Once I started filling out the serious injury incident report, I saw that there was a box to check by medication diversion and I immediately knew I didn't report it when I was supposed to. The facility's policy titled, Abuse Prevention Program (facility) Policy and Procedure dated 7/1/22 showed, VIII. External Reporting .this report shall be made immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury .2. Five-day Final Investigation Report. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health .

Based on observation, interview, and record review the facility failed to ensure the call light was within the reach of a resident to call staff for assistance for 1 of 1 resident (R5) reviewed for call light accessibility in a sample of 12. The findings include: R5's Face Sheet printed 5/9/23 showed diagnoses to include but not limited to Type 2 diabetes mellitus without complications, hypertension, muscle wasting, cognitive communication deficit, and benign prostatic hyperplasia with lower urinary tract symptoms. R5's MDS (Minimum Data Set) dated 4/15/23 showed he is severely cognitively impaired. R5 requires extensive assist of one person with bed mobility and toileting and requires total physical assistance of two or more persons with transfers. R5's Care Plan last reviewed/revised on 3/2023 showed R5 was re-educated on using his call light to alert staff of needing assistance with activities of daily living (ADL's) and that his call light was to be within his reach. On 5/8/23 at 9:48 AM, R5 was observed sitting in his wheelchair on the right side of the bed. R5's call was on the left side of his bed. R5 was unable to reach the call light when asked if he could reach the call light. On 5/9/23 at 10:47 AM, R5 was lying in bed, but his call light was lying on the floor on the right side of the bed and out of his reach. On 5/8/23 at 9:51 AM, V10 (Registered Nurse) RN came into R5's room and stated they placed R5's call light too far away from him. On 5/8/23 at 10:01 AM, V8 (Certified Nursing Assistant) CNA stated the call lights should be in reach of the residents because it is important for them to call when they need help. The facility's policy titled Call System, Resident, dated September 2022 states, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/ bathing facilities and from the floor.

Based on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents requiring assistance with incontinence care for 2 of 12 residents (R21, R281) reviewed for activities of daily living in the sample of 12. The findings include: 1. R21's care plan dated January 24, 2023, showed R21 required the extensive assistance of staff for toileting and transfers. R21's care plan states R21is incontinent of bowel and bladder with a history of urinary tract infections and to provide incontinence care after each incontinent episode. On May 8, 2023, at 8:47 AM, V8 Certified Nursing Assistant (CNA) entered R21's room to provide care. As V8 CNA pulled down R21's bedding, it was noted that R21 was wearing two incontinence briefs. The incontinence brief, that was closest to R21's body, was saturated with urine. This surveyor observed urine that leaked onto the second incontinence brief. R21's buttocks and scrotum were reddened in color. V8 CNA stated, This is the first time I have changed him today. I am not sure when he was last changed on nights. They know they are not to put two incontinence briefs on residents. 2. R281's resident assessment dated [DATE], showed R281 required the extensive assistance of two staff for toileting and repositioning. The assessment showed R281 was always incontinent of stool. On May 8, 2023, at 9:27 AM, V9 Certified Nursing Assistant (CNA) repositioned R281 on his right side. R281 was incontinent of stool. R281's incontinence brief was soiled with stool. V9 CNA then repositioned R281 on his back, per R281's request, and then left the room. At no time did V9 CNA provide any perineal care to R281 or remove R281's soiled incontinence brief. On May 9, 2023, at 10:10 AM, V2 Director of Nursing stated, Residents should be rounded on every 2 hours and provided with incontinence care during those rounds, as needed. Staff should never put two incontinence briefs on a resident. That puts a resident at a huge risk for infection and skin breakdown. The facility's Activities of Daily Living (ADL) policy dated March 2018 showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .c. Elimination (toileting) .

Based on observation, interview, and record review the facility failed to ensure pressure injury treatments were in place for 2 of 4 residents (R281, R21) reviewed for pressure injuries in the sample of 12. The findings include: 1. R281's Face Sheet printed May 9, 2023, showed R281 was admitted to the facility on [DATE], with diagnoses including a Stage IV sacral pressure injury, Stage III pressure injuries to his left and right buttocks, osteomyelitis to his sacral pressure injury, and Type 2 Diabetes Mellitus. R281's initial wound assessment dated [DATE], showed R281 had a Stage IV pressure injury to his sacrum that measured 10 cm (centimeters) x 14 cm x 4 cm with bone, muscle, and tendon exposed. The note showed, There is a medium amount of necrotic tissue within the wound bed including adherent slough, necrosis of muscle and necrosis of bone. The note also showed R281 had Stage III pressure injuries to his right and left gluteus (buttocks). R281's physician order dated May 8, 2023, showed R281's Stage IV sacral pressure injury was to be cleansed, packed with gauze, and covered with a gauze dressing, that was to be taped in place, twice a day and as needed. R281's physician order dated May 3, 2023, showed a foam dressing was to be in place over R281's Stage III pressure injury to his left buttock. R281's physician order dated April 27, 2023, showed, Check for placement of dressings to bilateral buttocks and coccyx every shift. On May 8, 2023, at 9:27 AM, V9 Certified Nursing Assistant (CNA) repositioned R281 on his right side. R281 was incontinent of stool. No dressing was noted over R281's pressure injury to his left buttock. No dressing was noted over R281's sacral pressure injury. A fist-sized open wound was noted to R281's sacral area. A 4-inch (in) x 4 in gauze dressing that was soiled with stool, was noted inside of R281's sacral wound. A soiled square gauze dressing was noted, lying loosely, in R281's soiled incontinence brief. V9 CNA repositioned R281 on his back, per R281's request, and then left the room. At no time did V9 CNA provide any perineal care to R281 or remove R281's soiled incontinence brief. On May 8, 2023, at 12:40 PM, V6 Wound Nurse stated, (R281) was just admitted here with pressure injuries to his buttocks and a large wound to his sacral area with bone exposure noted in the wound. He is to have foam dressings to his buttock wounds and a gauze dressing to his sacral wound. He had a rectal tube in the hospital because he was having frequent stools. He was on IV (intravenous) antibiotics due to his sacral wound . He is still having frequent stools, so staff need to be checking on him frequently and providing incontinence care as soon as possible. They are to let the nurse know if dressings are missing from the pressure injuries. On May 10, 2023, at 9:50 AM, V6 Wound Nurse stated, (V9 CNA) should have at least placed a clean pad under (R281) (on May 8, 2023) before she repositioned him on his back. That would have gotten him off the soiled incontinence brief. 2. R21's Face Sheet printed May 9, 2023, showed R21 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, dementia, a pressure injury to his right foot, and chronic osteomyelitis to his right ankle/foot. R21's Wound Management Report dated May 3, 2023, showed R21 had a Stage III (pressure injury), measuring 2 cm x 2 cm x 0.2 cm, to the bottom or R21's right foot, below his right pinky (5th) toe. R21's physician orders dated March 22, 2023, showed a foam dressing was to be applied to R21's right plantar foot wound. The foam dressing was then to be secure to R21's foot with a gauze dressing. The orders showed a foam boot was to be on R21's right foot, at all times. On May 8, 2023, at 8:38 AM, R21 was observed in bed. R21 wore socks, with his feet directly on the mattress of his bed. No foam boot was noted to R21's right foot. A circular brown stain was noted to the bottom of R21's right sock, directly below his fifth toe. On May 8, 2023, at 8:47 AM, R21's socks were removed from R21's feet. A nickel-sized open wound was noted to bottom of R21's right foot, directly below his fifth toe. No dressing was noted to the wound. No dressing was found in R21's sock. A small amount of dried blood was noted around the wound. On May 8, 2023, at 12:40 PM, V6 Wound Nurse stated, (R21) has had a Stage III (pressure injury) to his right foot for months with a history of osteomyelitis to the wound. He should have a foam dressing in place over the wound. He should wear a foam boot on his right foot and/or at least make sure his heels are off loaded. The facility's Policy/Procedure for Pressure Ulcers (undated) showed, STANDARD: To ensure that a resident who is admitted to the facility without a pressure ulcer does not develop a pressure ulcer unless clinically unavoidable. A resident who has been admitted with a pressure area receives services to promote healing, prevent infection, and any additional ulcers from developing .

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers for Disease Control (CDC) regarding isolation of COVID-19 residents in regards to cohorting of COVID-19 residents. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to 4 of 9 residents (R1, R2, R3, R4) reviewed for infection control in the sample of 9. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on November 3, 2020 when R4's COVID-19 test results were positive. The Immediate Jeopardy was identified on November 23, 2020. V1 Administrator was informed of the Immediate Jeopardy on November 30, 2020. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on November 30, 2020; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. The facility's COVID-19 line list provided on November 23, 2020 shows 6 residents in contact/droplet isolation for positive COVID-19 test results. On November 23, 2020 at 9:10 AM, R1 and R2 were observed in the same room as each other. R1 was sitting up in her wheelchair watching television. R2 was lying in bed watching television. The bedside curtain was pulled between the residents. R1's COVID-19 laboratory test form shows the test was collected on November 9, 2020 and reported to the facility on [DATE] as detected. A detected test shows that a resident is positive for having COVID-19. R1's progress notes dated November 11, 2020 show, Obtained tympanic (ear) temperature of 101 (degrees Fahrenheit) at approximately 4:00pm, informed V3 Assistant Director of Nursing (ADON) of elevated temperature, floor nurse also made aware. Rapid COVID test collected. The same progress notes continue to show, Rapid COVID test positive . R2's COVID-19 laboratory test forms show, the test was collected on November 3, 2020 and reported to the facility on [DATE] as not detected. A not detected COVID-19 test shows that a resident is negative for having COVID-19. Another laboratory test for COVID-19 collected on November 9, 2020 and reported to the facility on [DATE] shows, not detected. The most recent laboratory COVID-19 test collected on November 16 and reported to the facility on [DATE] continues to show, not detected. (R1 and R2 remained roommates for 13 days following R1's positive COVID-19 test results). The facility's resident roster provided on November 23, 2020 showed R1 and R2 are roommates. On November 23, 2020 at 9:10 AM, V5 Registered Nurse stated, We are treating everyone as if they were positive for COVID-19. She stated, R1 was the only positive resident for COVID-19 in that room and her roommate R2 was negative. On November 23, 2020 at 1:56 PM, V2 DON stated, they didn't have anywhere to move the positive residents so they left the residents where they were. They do not have a COVID-19 unit. On November 24, 2020 at 9:39 AM, V3 ADON stated, they didn't have anywhere to move the positive residents so they left them where they were. They were advised to close the privacy curtain and wear different PPE (personal protective equipment) for each resident. On November 25, 2020 at 3:12 PM, V12 Facility's Medical Director stated, When they test positive (residents), isolate them and hope for the best. That is all we can do. On November 30, 2020 at 9:22 AM, V11 Nurse at local Health Department stated, best practice is to separate the positive residents and cohort them together. They should have a plan for this. The Centers for Disease Control and Prevention (CDC) website entitled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes states, If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents . The facility's Coronavirus (COVID-19) policy dated May 1, 2020 shows, Policy: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical features and an Epidemiologic Risk for the COVID-19 and to adhere to Federal and State/Local recommendations . In the event of a facility outbreak, institute outbreak management protocols: . Place residents in private rooms on standard, contact, droplet (airborne if available) precautions. Cohort residents identified with same symptoms/COVID-19 confirmation . The facility's COVID-19 policy dated May 1, 2020 shows, What to do if there is active COVID-19 in facility: 1. Isolation for all residents: Infected Resident (s), Known or Suspected: Single room: if possible, place resident in private room with their own bathroom and the door to their room closed. Cohort with other COVID-19 residents: May need to share rooms with other COVID-19 positive or suspected residents. 2. On November 23, 2020 at 9:10 AM, R3 and R4 were both lying in bed. The bedside curtain was pulled between the residents. R4's COVID-19 laboratory test form shows the test was collected on November 3, 2020 and reported to the facility on [DATE] as detected. R4's progress notes show he developed symptoms of a fever and congestion starting on November 3, 2020. R4's electronic medical record (EMR) shows R4 passed away in the facility on November 23, 2020. R3's COVID-19 laboratory test form shows the test was collected on November 3, 2020 and reported to the facility on [DATE] as not detected. Another laboratory test for COVID-19 collected on November 9, 2020 and reported to the facility on [DATE] as not detected. The most recent laboratory COVID-19 test collected on November 16, 2020 and reported to the facility on [DATE] as detected. (R3 remained roommates with R4 the entire time R4 was positive for COVID 19. R3 tested positive for COVID-19 13 days after R4's COVID-19 positive result). R3's EMR shows he was sent out to a local hospital on November 23, 2020. Patient noted to be more lethargic and confused this morning. Oxygen (O2) saturations (sats) noted to be 86% at room air. O2 applied at 3L (liters) and sats increased to 88%. O2 increased to 5L with sats increasing to 91%. Continues with congested, non-productive cough . Another progress note for the same day shows, 911 called and arrived to transport patient to local hospital. R3 was admitted to the local hospital with a [DIAGNOSES REDACTED]. On November 30, 2020 at 12:45 PM, V2 DON stated, R3 remained in the hospital and was inpatient hospice now. The facility resident roster provided on November 23, 2020 showed R3 and R4 are roommates. The Immediate Jeopardy that began on November 3, 2020 was removed on November 30, 2020 when the facility took the following actions to remove the immediacy. 1. On November 27, 2020, the facility dedicated the 4 rooms for residents who tested positive for COVID-19. 2. On November 27, 2020, all 5 residents who tested positive for COVID-19 were moved to the rooms listed above. 3. On November 27, 2020, a temporary plastic barrier wall was constructed to separate the COVID-19 unit from the PUI (persons under investigation) unit. 4. If more residents become positive, the facility will dedicate additional rooms and move the temporary wall, as needed. 5. If a resident's roommate tests positive, but the resident is negative, the negative resident will be isolated to a private room, if a private room is available, for 14 days. If private room is not available, the negative resident will room share with other exposed residents, per CDC guidance. 6. If a resident is symptomatic, with results pending, they will be isolated to a private room. 7. If COVID unit is full and there are more positive cases, facility will temporarily halt admissions and utilize the Acorn unit for COVID-19 negative/asymptomatic residents. 8. On November 27, 2020, facility informed staff of separate COVID-19 unit and positive residents would reside on that unit. On November 30, 2020, facility began formal education of all staff on plan for separating COVID-19 positive residents from COVID-19 negative residents and the plan to cohort positive COVID-19 residents. All staff education will be complete by December 1, 2020, prior to working their shift.

Based on observation, interview and record review, the facility failed to train and educate the nursing staff on how to stage a pressure ulcer and to correctly identify the site of the wound and failed to demonstrate the accurate way of measuring wounds. The facility also failed to develop and implement specific and individualized interventions to promote healing. This applies to four (R 2, R 1, R 7 and R6) of five residents (R1,R2, R5, R6 and R7) reviewed for pressure ulcers in the sample of 12. These failures contributed to the worsening of R2's pressure ulcer. R2's left heel and right ankle progressed to unstageable pressure ulcers. The findings include: (1) R2's Admission Body Audit dated 03-21-14 showed R 2 was admitted with the following: 1. Location # 8 - right (ankle) foot - identified as (pressure) ulcer. 2. Location # 13 - left heel - open area. R2's weekly skin charting dated 03-21-14 for the right lateral ankle (# 8) showed this was identified as pressure ulcer, described, and measured at 1.5 cm X 2.0 cm pink with black areas, surrounded by a ring of yellow, no measurable depth; surrounding skin is red. The stage was not identified. R 2's weekly skin charting for the left heel dated 03-21-14 identified as open area to left heel. Description: 1.8 cm X 2.0 cm superficial pink wound. R 2 ' s weekly skin charting dated 04-21-14 reads " left heel healing well. " The pressure ulcer list dated 04-22-14 showed R 2 has only 2 areas of admitted pressure ulcer (1) coccyx and (2) Right lateral ankle with comments that these ulcers are " better. " On 04-24-14 at 11:00 AM, E 5, LPN (licensed practical nurse) was observed during R2's pressure ulcer treatment; E 5 measured and describes the wounds as follows: 1. Right ankle - with moderate amount of brownish drainage, very tender to touch, wound is 100% covered with thick greenish slough, measured at 2.0 cm X 2.0 cm. " I don ' t know how and what to stage this is. " 2. Left heel (area # 13) - with brownish/black discolored area, very tender to touch, no dressing noted and measured at 2.0 cm X 2.0 cm. The NPUAP- National Pressure Ulcer Advisory Panel categorizes this wound as Unstageable. A full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 04-23-14 at 1:55 PM, E 6/ Medicare Nurse stated, " We don't usually stage the wounds. No, we do not have a comprehensive assessment. We only use the Braden Scale for Predicting Pressure Sore Risk Assessment (which E 6 was unable to locate in R2's clinical record). We use the weekly skin charting (which does not identify the Stage) and the care plan. E 6 reviewed and presented 21 pages of R2's plan of care and E6 stated, " There's no skin or ulcer care plan in here. " On 04-24-14 at 11:30 AM, R 2 was observed in bed with no off-loading device in place. (2) On 04-22-14 at 1:30 PM, E 2 (Director of Nursing) presented the facility's pressure ulcer list. The list showed four (R 2, 7, 15 and R 16) residents admitted with pressure ulcers. This list does not identify the stages of the pressure ulcers. E 2 also presented the weekly skin charting for the identified residents, which also does not identify the Stages. E 2 explained (showing the weekly skin charting) " if you read the description then, you can figure out what stage the wound is. " E 2 agreed the facility has not been identifying the stages of the wound in their wound assessment, progress notes or tracking sheet. E 2 said, " The afternoon shift nurses do the treatment for [REDACTED]. E2 also expressed the Medicare Nurse (E 6) will do the initial assessment and recommends the treatment modalities. " On 04-23-14 at 1:55 PM, E 6 stated, " I really don't have formal wound training but we have computer training (on wounds) yearly. R7 was admitted to the facility on [DATE] with a documented Stage III coccyx wound. The physician order [REDACTED]. On 4/23/14 at 1:30 pm, E5 (licensed practical nurse, LPN) changed R7's dressing. There were 2 brownish spongy dressings ([MEDICATION NAME]), there was a a small scabbed wound on the left buttock. E5 described this as, reddish brown in color and closed. E5 stated " I wouldn't stage this wound but if I had to I would call it a stage 1. " E5 described the coccyx wound as " pink in color with a whitish color tissue inside the wound covering 100% of the area. " E5 stated this was not exudates but didn't know what to call it. E5 proceeded to measure the area at 1.0 cm X 0.8cm with a 1.0cm induration and a depth of 0.3cm. The surrounding compromised tissue that surrounds the wound and brownish in color was not measured. E5 stated that was not part of the wound and that is how she measures the wound but was not sure how everyone else does. Wounds were cleaned and dressed per physician orders. R7 reports there is pain there if she sits too long or lays on it too long. On 4/23/14 at 1:30 pm E5 stated she has not had any formal training on wounds or wound care and the facility requires an annual computer in-service on wounds to be done and that is where they learn about staging and measuring wounds. E5 stated wound care and dressing recommendations were done by the medicare nurse that is here 5 days a week during the day shift. E5 is not aware of any trained wound nurse in the facility but states, " I don't usually take care of wounds because they are done on the 3pm-11pm shift. On 4/23/14, R7 was noted to have an 18lb weight loss in one month. A hydration risk evaluation of 8 (8 or higher places the resident at high risk). R7's Braden score on 4/8/14 was 18 and on 4/15/14 it was also 18 (a score of 12 or less places the resident at high risk). The weekly skin charting for the right buttock on 4/15/14 documents the wound to be an abrasion/open area with measurements of 1cm x 0.75cmwith no depth and superficial. The coccyx weekly skin charting documents that wound to be 1.0cm x 0.5cm x 0.2cm open area, with scant yellow drainage. There is no staging involved in the weekly skin charting or tracking, improving or worsening of wounds. Also, it is unknown if the measured areas are consistent with all staff as there is no formal education provided. There was no physician assessment of the R7 ' s wounds. On 4/24/14 at 11:00am, E9 (registered nurse, RN) was changing the dressing on R1's Posterior upper thigh/gluteal fold area. E9 stated this was friction created from sitting in the wheelchair. E9 has a medical [DIAGNOSES REDACTED]. R1 has redness to both posterior gluteal folds and open abraised areas on the left posterior thigh. E9 stated she would stage this as a stage 1 pressure sore but is not comfortable with staging because she usually doesn't take care of wounds they are done on the 3pm-11pm shift. E9 stated she recently took the computer annual in-service on pressure sores on the computer and that is how she knows how to stage this wound. E9 stated she was unaware if there was a wound nurse in the facility but didn't think so and that the medicare nurse usually made dressing recommendations to the physician if needed. There were no physician assessments of R1's wounds. No sting barrier and transparent dressing applied to both areas. R1's careplan for skin integrity originally dated 8/2013, with updated goals to continue to 5/2/2014 , documented in handwriting on careplan the following: 12/23 [MEDICATION NAME] to left upper extremity twice a day for 3 days. 12/26 keflex 500mg three tab daily three times a day for 7days, Risaquad one tab daily for 14 days. 4/20 [MEDICATION NAME] to left antecubital for redness. There is no specific problem initiated for R1's gluteal fold redness. There is an intervention listed for no sting barrier and transparent dressing to left posterior thigh until healed that was entered 8/2013 but not specifically care planned. The other interventions were to check for incontinence every 2 hours and turn and reposition every 2 hours. R1 stated he does go back to his bed about every 2 to 2 ? hours to be changed but is physically unable to reposition himself in his wheelchair. There is no assessment or documentation on how the facility decided two hours was the appropriate length of time for R1 to be sitting. On 4/24/14 E1 provided a copy of the facilities policy and procedure on pressure sores. This policy is documented to be updated on 6/2013. The policy states a stage 1 pressure sore is a persistent area of redness (with no break in the skin) that does not disappear when pressure is relieved. Stage 2 is described as a partial thickness loss of skin layers that presents clinically as an abrasion, blister, scab or shallow crater. R1's weekly skin charting for the left gluteal fold on 4/1/14 documents a scabbed over 1 cm x 2 cm area. The dressing change observed on 4/24/14 at 11:00am showed open abrasion areas on the left posterior gluteal folds and redness to both areas that did not disappear after repositioning. On 4/24/14 at 3:00pm E1 and E2 both stated R1 friction and shearing on the gluteal folds was not a pressure sore. According to R6 ' s TAR (Treatment Administration Record) for February 2014, states resident is to have heels off-loaded while in bed and [MEDICATION NAME] of [MEDICATION NAME] to bilateral heels every night for boggy heels. According to R6 ' s TAR for March 2014, states resident has treatments to areas on right and left heel and to keep heels off loaded while in bed. According to same MAR indicated [REDACTED]. According to R6 ' s TAR for April 2014 has received treatments of: [MEDICATION NAME] to left and right heel daily until resolved, off-loading of heels while in bed, [MEDICATION NAME] to left butt change every seven days and as needed until heeled, Laniseptic cream to reddened buttock area every shift until healed. According to R6's weekly skin charting for left and right heels on 4/8, 15 & 22/14 resident ' s heels were " boggy " According to R6 ' s weekly skin charting for left buttock, on3/24/14, resident has area described as 2cm x 1cm non-blancable purple area surrounded by blanchable [DIAGNOSES REDACTED] with [MEDICATION NAME] dressings. On 03/31/14 area to left buttock is 2cm x 1cm non-blanchable purple area surrounded by blanchable [DIAGNOSES REDACTED] with [MEDICATION NAME] treatments cont. On 4/8/14 area on left buttock is pink/reddish. On 04/15/14 area on left buttock is pink and red. On 4/22/14 area on left buttock is pink and red. 04/23/14 at 9:00am E10 RN stated she did not know why the area on R6 ' s buttock was being treated and was not sure if it was pressure or not. At that time R6 had a 6 x 5 x 0cm reddened area on left buttock and redness did not dissipate when pressure was relieved. E10 also stated R6 ' s heels were both " Mushy " feeling at heels, red and tender to touch at times and R6 is to have heels off-loaded while in bed. E10 was unable to state what the area on the heels was classified as but stated it could possibly be pressure areas. On 04/24/14 at 2:15pm E9, RN stated pressure ulcers were staged 0-3 and was unable to describe how to measure depth of a wound. E9 stated she had never heard of an un-stageable pressure area. On 4/24/14 E2 DON provide a manual entitled "Chronic Wound Care" that she designated as what staff has to use to address, measure, assess and stage pressure areas. On page 228 under stage I pressure ulcer: Non-blanchable [DIAGNOSES REDACTED] of intact skin; Discoloration of the skin, warmth, [MEDICAL CONDITION], induration or hardness may also be used as indicators. On page 229 in box 14.1 it states a stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one of more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red blue or purple hues.

Based on observation, record review and interview the facility failed to: (1) Develop and implement specific and individualized interventions to monitor a resident from falling. (2) Conduct a comprehensive assessment of contributing risk factors for falling for a residents (R1) who had a history of [REDACTED]. (3) Evaluate assistive device (raised toilet seat chair) was appropriate for R1. As a result: R1 had fallen on two consecutive days unwitnessed by staff. On [DATE] at 4:00 pm in the bath room; and on [DATE] at 11:25 am in the bath room. Both times R1 lost her balance while pulling up her clothing. On [DATE] when R1 fell , per hospital record, she sustained fracture to her right hip. R1 expired in the hospital due to pulmonary embolism. This is for one of three residents (R1) in the sample of three who are at risk for falling. Findings include: R1's Nurses Notes documented an incident of her falling on [DATE] at 4:00 pm indicating a Certified Nurse Aide (CNA) found R1 lying on floor on bath room on her left side with her left arm underneath her body and upper torso. She complained of pain to right shoulder and knee. On [DATE] at 10:15, she am complained of not feeling well at all, Her pulse oxygen saturation measured 91% which was below the parameter (92%) set for her. On [DATE] at 11:25 Physical Therapist (PT) found R1 lying on bath room floor on her right side, right arm under torso of body, complaining of pain to right hip and right knee. R1 was admitted to the hospital with [REDACTED]. The facility also documented in R1's Nurses Notes from [DATE] to [DATE] she complained of being tired and weak and was walking with walker with staff supervision. The facility reported an incident on [DATE] 11:25 am involving R1 who had fallen in bath room and sustained right hip fracture. The facility did not conduct a thorough investigation of the incident to develop specific interventions to prevent further incidents of falling. The investigation of the incident work sheet for [DATE] and [DATE] noted, "resident was pulling up under garment and pants at the same time, lost balance." The facility did not evaluate why she was tired and weak or if she could be independent, ambulating her self with walker to toilet her self. The only intervention that was added in the fall investigation work sheet for both incidents was, "re-educated on pulling one item up at time." The incident investigation also did not include environmental risk factors; such as use of a chair that has a raised toilet seat. On [DATE] observation of R1's bath room indicated there was a chair over the toilet with a raised seat. This chair was not secured to the toilet. It was easily tipped over to the side with a little unevenly distributed weight on the chair. E4, the Nurse who was with surveyor, verified R1 used to use the chair. On [DATE] E5, the Physical Therapist stated R1 had improved since she was admitted to the facility. R1 was using a wheel chair when she came to the facility where as she was now able to ambulate with standby assistance. E5 also stated on [DATE] morning R1 complained of being weak and cold after breakfast and went to her room. E5 went to check on R1. She found R1 on the floor in bath room near toilet. E5 indicated the only way the incidents could have been prevented if R1 called for help, which she did not do. R1's [DATE] fall risk evaluation scored '10'. A score of 10 or above represents high risk. The risk factor noted in the evaluation were history of falls, uses wheel chair, gait / balance, medication use and predisposing diseases. These risk factors were not further evaluated to develop specific and individualized intervention to prevent her from falling. For Example: (1) R1 has [DIAGNOSES REDACTED]. There is no evaluation to show if the facility ruled out orthostatic hypotension. (2) R1 was using a wheel chair upon admission. At the time of fall incidents she ambulated with rolling walker with supervision. There is no evaluation to indicate if she was safe to ambulate with rolling walker independently. (3) R1 had fallen at home prior to her admission to the facility. There is no information to indicate the circumstances of her falling. R1's [DATE] fall care plan intervention are not specific. For Example: (1) remind resident need assistance with transfer / ambulation. It is not clear how the facility will ensure implementation of this intervention, when R1 has the tendency of not calling for help. . On [DATE] interview from staff (E3, CNA; E4, Nurse; E5, PT) indicated R1 was alert and oriented. She would do whatever she wanted to do. She ambulates with walker a without calling for help. No interventions were developed to monitor R1 when she was not calling for help ambulating in an unsafe manner.

Based on interview and record review, the facility failed to provide supervision and plan preventive measures to ensure safety of the residents for 2 of 3 sampled residents.(R1 and R10) The incidents resulted in an injury to R1 receiving bruises, scrapes and abrasion. R10's incident resulted in abrasion on the left side of back. Findings include: 1) R1 has [DIAGNOSES REDACTED]. Review of R1's incident reports documents the following: - On 01/17/11 at 10 AM per R1's roommate R1 fell in room onto R1's knees. Incident Report Documentation showed the following: Safety Alarm recommend per care plan: Yes Safety Alarm: On, Safety alarms started this AM (morning) Items/Factors contributing to incident: Dementia, refusing to use walker and wear glasses. Change in mental status in the last 90 days? Yes, more confused. Activity at time of fall or what was resident attempting to do? In the bathroom. Was resident using an assistive device? No Wearing glasses? No Cognitive: Decline in cognitive skills Recommendations/Interventions: Did not have glasses on or using walker. Told staff her doctor told her she didn't need them. Unable to re-educate on this issue. Had her talk on the phone to an employee who told her he was her doctor and needed to use the walker. She agreed also bed alarm added. Review of R1's care plan showed no update on the recommendations identified for further prevention of fall. - On 01/24/11 at 1:30 AM R1 was found lying on her back on the floor by her bed. R1 sustained bruise on right upper back and left hip. Incident Report Documentation showed the following: Change in mental status in the last 90 days? More confused. Activity at time of fall or what was resident attempting to do? Going to bathroom. Recommendations/Interventions: Was trying to get up to bathroom and fall. Alarm on. Night light put in bathroom and staff instructed to ask her (R1) on rounds if she needs to use the bathroom. Again care plan was not updated to prevent further falls. R1 was not wearing glasses and did not use walker. Recommendation "staff instructed to ask her on rounds if she needs to use the bathroom" Again preventive measures were not in place and recommendation not in care plan. R1 had bruises on the back and left hip. - On 01/26/11 at 12:40 PM, CNA ( Certified Nursing Assistant) found R1 sitting on the floor in between chair and roommates bed. R1 states she hit her head on the floor but thinks she hit it on the wall due to position. R1 was sitting in could have hit it on the floor. Soft raised area noted to left side of head. Incident report documentation showed the following: Safety alarm recommended per care plan: NO Safety alarm: left blank Equipment involved: Walker about 3 feet from resident. Items/factors contributing to incident to incident: R1 did not have glasses on "don't need them anymore." Recommendations/Interventions: Was walking without walker and no glasses. Tried to reeducate her (R1) on the use of walker and glasses no success. R1 needs to use her walker but at this time doesn't understand. Will keep trying to reeducate her (R1). There was no update on R1's care plan to prevent further falls. - On 01/27/11 at 7:40 AM R1 was found in resident's room trying to sit and slid to the floor. R1 sustained abrasion to mid spine. Incident report documentation showed the following: Safety alarm recommended per care plan: left blank Safety alarm : left blank Equipment involved: left blank Recommendations/Interventions: Chair had been moved. R1 was used to her chair being next to the bed but instead her night stand was there. R1 did not have her glasses on. Chair put back next to bed. Again R1's care plan was not updated. - On 04/22/11 at 8:05 AM R1 was found on the floor sitting on her buttocks in bathroom doorway. R1 sustained 2 scrapes to center of back and lower back. Incident report documentation showed the following under, Activity at time of fall or what was resident attempting to do? Getting out of bed Did resident require supervision? YES Wearing glasses? NO Recommendations/Interventions: Tab alarm pulled off of top. Given a new tab alarm. - On 04/28/11 at 5 PM R1 was found on the floor infront of chair in R1's room. Incident report documentation showed the following under: Activity at time of fall or what was resident attempting to do? Unknown Did resident require supervision? YES Recommendations/Interventions: Unknown what she (R1) was trying to do. Most likely going to the bathroom. Will have 3-11 shift take R1 to bathroom when they arrive. E3 Assistant Director of Nursing/Care Plan/ MDS (Minimum Data Sheet ) coordinator was informed on 05/16/11 regarding R1's falls and care plan not being updated to prevent further falls. Assessments such as MDS on 11/15/10 and 02/15/11 reflect that R1 needs supervision in transfer and extensive assistance on toileting. R1 has blood test done showing Urinary Tract Infection identified on 01/17/11. Per nurses notes documents that R1 was lethargic on 01/17/11. Resident is confused and most of her falls occurred in her room. R1 continued to have falls with bruises with no change of plan or proper supervision. 2. R10 has [DIAGNOSES REDACTED]. Review of R10's incident reports documents the following: - On 09/02/10 at 10 AM R10 was noted sitting on the floor on her buttocks. Incident report documentation showed the following under, Safety alarm recommended per care plan: NO Safety alarm: left blank Recommendations/Interventions: Resident non complaint. Remind resident to always ask for assistance Care plan was not updated per recommendation. - On 09/13/10 at 2:50 PM, R10 was found on the floor on R10's bathroom sitting in front of the toilet with wheelchair in the doorway. R10's indicated that she was trying to pull her pants down to go to the bathroom. R10 was identified to have unsteady gait but there were no preventive measures implemented on the care plan. - R10 again fell on the hallway on 09/17/10 at 1:25 PM and had abrasion on the side of her back. R10 has poor balance but no preventive measures and no assessment to see if alternative means such as therapy or assistance in mobility is needed. Nurse's note dated 09/17/10 recommended application of chair alarm to wheelchair for lack of safety awareness but was not added to approaches on care plan. - R10 again fell on [DATE] at 10 AM when she slipped out of wheelchair into her buttocks. Wheelchair was not locked per resident. Incident report documentation showed the following under: Safety alarm recommended per care plan; NO The safety alarm recommended for R10 was not applied. Recommendation was to place a pressure release brakes on the wheelchair. This was not added to the care plan. - R10 again fell on [DATE] at 2:40 PM. R10 was found sitting on the floor next to bed trying to transfer to bed and wheel chair moved. Incident report document showed the following: Safety alarm recommendation per care plan: NO Safety chair alarm was not applied. Recommendation/Interventions: Was standing to transfer from bed to wheelchair and lost balance. Wheelchair was locked. Care plan was not updated. - R10 was found sitting on the floor in room between bed and window on 11/26/11. Again safety alarm is marked "no" and not applied. Recommendation: Not appropriate for alarm due to dignity issue. No preventive measures identified and care plan was not updated. - R10 again found on 11/26/11 at 1:30 PM sitting on the floor between bed and window facing bathroom door with wheel chair at her feet .This time the facility had recommendation to start ambulating her two times a day. There was no rehabilative assessment on her ambulatory needs and recommendation was not added to care plan