Every finding on record at Fair Oaks Rehab & Healthcare

Based on interview and record review, the facility failed to ensure a medical record was complete/accurate for 1 of 3 residents (R4) reviewed in the sample of 6.The findings include:R4's Death Certificate indicated R4 died on [DATE] at 3:55 AM at the facility.R4's progress notes, dated [DATE], indicated R4 was found unresponsive on the floor, 911 was called, six rounds of CPR (cardiopulmonary resuscitation) were provided, and paramedics arrived. The progress note ended with the paramedics arriving and providing CPR. There was no indication in R4's medical record what happened after the paramedics took over CPR such as pronouncing R4 dead or what happened to R4's body.On [DATE] at 9:17 AM, V2 (Director of Nursing) said she was involved when R4 was found unresponsive on [DATE]. V2 said she helped provide CPR to R4 until paramedics arrived. V2 said eventually the paramedics pronounced R4 dead. V2 added the corner came and removed R4's body from the facility. At 1:03 PM, V2 reviewed R4's progress note/medical record and confirmed there was no documentation that indicated R4 died or what happened to R4's body.On [DATE] at 1:36 PM, V1 (Administrator) said there should be documentation of R4 being pronounced dead and what happened to R4's body. On [DATE] at 1:36 PM, documentation regarding what happened to R4 after the paramedics arrived and what happened to R4's body was requested. The facility could not provide the documentation.

Based on observation, interview, and record review, the facility failed to ensure a resident's insulin was administered as ordered for 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include:On 7/20/26 at 10:20 AM, R1 was in bed resting. R1 said he is a diabetic and does receive insulin multiple times a day. R1's Medication Administration Record for May 2026 shows R1 was receiving Tresiba Subcutaneous Solution 100 unit/ml (insulin degludec) Inject 72 units subcutaneously one time a day for diabetes scheduled at 9:00 AM from 4/15/26 to 5/26/26. This same MAR shows R1's Tresiba order was changed on 5/27/26 to Tresiba Subcutaneous Solution 100 unit/ml (insulin degludec) Inject 75 units subcutaneously one time a day for diabetes scheduled at 12:00 PM. R1's New Prescription Summary, dated 5/25/26, shows an order Insulin degludec (Tresiba Flextouch U-100 unit/ml Subcutaneous insulin pen. Inject 72 units under skin daily at noon. Do not skip dose, can be taken with or without food, can be taken along with rapid acting insulin. On 7/20/26 at 12:30 PM, V8, Pharmacist for R1's Endocrinologist, said he manages the insulin prescriptions for the doctor and sends the orders to the facility for R1. V8 said he faxed the order for R1 on 5/25/26 and the dose of the Tresiba was not supposed to change just the time of the administration was to be changed to noon. On 7/20/26 at 2:25 PM, V2, Director of Nursing, said medication orders should be transcribed at ordered and administered according to the order. The facility's Drug Administration-General Guidelines Policy, dated 7/25, shows, Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to ensure a resident experiencing nausea and loose stools during a salmonella outbreak was considered for salmonella infection. This failure resulted in R6 experiencing loose stools with nausea for a week before being sent to the local hospital for salmonella and sepsis. This applies to 1 of 6 residents reviewed for infection control in the sample of 6.The findings include:Per email communications with V1 (Administrator) on 4/7/26, V1 stated R4 and R6 were roommates from 2/14/26 until 3/21/26, when R6 was discharged to the local hospital. R4's hospital records from 10/21/25 show R4 was positive for salmonella before discharging to the facility on [DATE].R6's progress note from 3/14/26 shows R6 presented with nausea and loose stools during the morning shift. R6's progress note from 3/14/26 shows R6 continued to experience loose stools during the evening shift. R6's progress note from 3/17/26 from V13 (Nurse Practitioner) states R6 was seen for poor appetite and loose stool for three days. Oral intake poor despite staff encouragement. Intravenous fluids were ordered and started. R6's progress note from 3/21/26 shows R6's condition worsened resulting in V18 (Registered Nurse/RN) sending R6 out to the emergency department at the local hospital. R6's hospital paperwork shows R6 was admitted to the local hospital on 3/21/26 with a positive salmonella stool sample and treated for sepsis. On 4/2/26 at 10:28 AM, V2 (Director of Nursing) said if the facility had no additional new cases of salmonella before 3/20/26, the facility would have no longer been in outbreak status. When R6 started experiencing loose stool and nausea, V2 didn't immediately think R6 could have salmonella due to R4 being positive in November of 2025 and R5 being positive in January of 2026. V2 did say since R6's positive test of salmonella on 3/21/26, any new symptoms of diarrhea would be treated as a potential positive salmonella case to prevent any further transmission. On 4/2/26 at 2:25 PM, V13 (Nurse Practitioner) said V13 has been servicing the facility since about October 2025. V13 said V13 was aware there were prior positive cases of salmonella but was unaware R4 was the first resident to have a positive case of salmonella in the facility. V13 said if V13 does not see the resident, V13 is unable to access their records. Had V13 known R4 was the original case of salmonella, V13 would have sent R6 out sooner to be tested for salmonella. V13 said from 3/14/26 until being sent to the hospital on 3/21/26, no staff made any indications R6 could possibly have salmonella. V13 said the first week back at the facility following the hospital stay, R6's function was affected, noting R6 had experienced three falls within the first week. On 4/6/26 at 10:23 AM, V6 (Regional Infection Control Coordinator) said it was recently confirmed after sample analysis that all four samples of the positive cases at the facility were identical organisms.

Based on observation, interview, and record review, the facility failed to protect a cognitively impaired resident (R7) from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. R8 was observed with his hand on R7's thigh moving towards her genital area. This failure applies to two of three residents (R7, R8) reviewed for abuse in the sample of 8 and resulted in Immediate Jeopardy.The Immediate Jeopardy began on 3/2/2026 when R8 was observed with his hand on R7's lap moving up towards her private area. V1 (Administrator) was notified of the Immediate Jeopardy on 3/5/2026 at 3:18 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/6/2026, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:The facility face sheet shows R7 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (paralysis) of the right side, aphasia (inability to speak), cerebral infarction (stroke) and dysphagia (difficulty with swallowing). The facility assessment, dated 2/26/2026, for R7 shows her to have no speech, is rarely understood, and has memory impairment. R7 uses a wheelchair to self-propel and requires maximum assistance from staff for her activities of daily living. The care plan for R7, dated 2/28/2026, shows her to have severely impaired decision making and is non-verbal due to history of multiple strokes. The care plan does not show any behaviors for R7.A facility state report dated 3/2/2026 shows R7 was observed by staff in the resident common area and at approximately 6:30 PM. Another male resident (R8) was observed touching R7 in an inappropriate manner.On 3/3/2026 at 3:00 PM, V1 (Administrator) said she was notified of the incident at approximately 6:40 PM by V17 (Agency Nurse). V1 said V17 told her she saw R8 touching R7's thigh and working his way up towards R7's private area. V17 then told V1 that R8 stated R7 was teasing him. V1 said the police and the families of both residents were called as well as the physician. V1 said she told the families the staff were able to stop it before it became inappropriate. V1 said she does not feel it was abuse as it was not willful and R8 did not seek out R7. V1 said R7 has a history of wanting to hold hands with others and will wheel herself over to other people and grab their hands. V1 said R7's family are pressing legal charges against R8. V1 said R7 and R8 have been placed on 15-minute checks. On 3/4/2026 at 7:45 AM, V1 said the police came back the night before and served R8 with papers to appear in court. V1 said he is being charged with criminal sexual abuse.The notice to appear signed by R8 on 3/3/2026 shows he is to appear in court for the charges of criminal sexual abuse.On 3/4/2026 at 9:03 AM, this surveyor was in the hall near the resident common area and saw R7 and R8 holding hands. There were numerous staff present near the area, walking by and standing at the nursing station talking. No staff intervened until V1 saw this surveyor standing near the situation and was alerted to R7 and R8 holding hands. V1 said she was placing R8 on a 1:1 observation.On 3/4/2026 at 10:54 AM, V17 (Licensed Practical Nurse-LPN, Agency Nurse) said she was the nurse assigned to R8 that night. V17 said she was at the nursing station across from the residents' common area and she looked up and saw R8 with his hand on R7's thigh and he was moving his hand up to her private area. V17 said she immediately separated the residents, called for the nurse for R7, and asked R8 to leave the common area. V17 said R8 was yelling and cursing at her and said R7 was teasing him. V17 said when R7's nurse came to get the resident, he told her that earlier in the shift, R8 wanted R7 brought closer to him, and he took R7 to the other end of the building away from R8. V17 said if she had known this, she certainly would have kept a closer eye on the situation and kept female residents away from R8. V17 said the police responded right away and spoke with R8. On 3/3/2026 at 3:30 PM, V11 (Registered Nurse-RN) said on 3/2/2026 at around 5:00 PM, he was near the resident common area and heard R8 yell out to staff to bring R7 over to him and he would help calm her down. V11 said R7 was trying to stand up on her own. V11 said he took R7 to the other nursing unit to keep her away from R8 due to the history R8 has with female residents. V11 said R7 likes to hold hands with anyone and will roll up to them and grab their hands. V11 said R8 has a history of inappropriate behavior with other female residents. V11 said he has been caught touching and kissing other female residents. On 3/4/2026 at 12:30 PM, V22 (Social Services) said R8 likes to chat up the ladies. V22 said R8 does not social distance and likes to hold hands with another female resident (R6) who has dementia and has a history of hand holding with male residents and staff. V22 said R8 has had other incidents of kissing R6. V22 said R7 is new to the facility and likes to hold hands with other staff and residents. V22 said R7 would be the one to go up to R8 and grab his hands. V22 said he has spoken with R8's son and he said his father has always been a ladies' man and liked to frequent bars and chase the ladies. On 3/4/26 at 12:46 PM, V14 (R7's Daughter) said, My mom's nurse called me that night to let me know. He said there was an incident with one of the other residents and my mom, that he was trying to get into her pants and that one of the nurses had seen what was happening and split them up. She has only been at the facility for about two and a half weeks. She can move her wheelchair with her feet. My mom doesn't speak; she has global aphasia so she can't tell you how she is feeling. Before she had her medical issues, she would have yelled and screamed about this happening to her. She had a stroke, so her right side is weak. If she didn't have any of that, she would have jumped up and gotten away from him. They said they are going to keep him away from her and that they would be checking on him every 15 minutes to see where he is, because my mom can't be in her room by herself, due to her fall risk, they put her in that little tv room next to the nurses' desk. I told them I don't want that guy there anymore; I don't need to be worrying that my mom is going to be harmed. It makes me feel bad because I feel like I put her in a place to be harmed. A call was placed to V31 (the responding police officer) with no return call. A Freedom of Information Act request was made for the police report, and a redacted copy was obtained. The report written by V31 was dated 3/2/2026 at 7:19 PM. V31 documented he was called to the facility for a disorderly resident. V31 interviewed the nurse who told him she witnessed a male resident's hand on a female resident's lap, inside her pants and around the area of her vagina. The report shows the nurse said he did not touch the vagina but was close to it and she stopped it from happening. The nurse stated the male resident became verbally aggressive with her and when she took him to his room, he told her the other resident had aroused him. The nurse stated the female resident cannot speak or move very well so there is no way she would have given consent. The report then shows an interview with the male resident saying he was aware of why the police were there, but he did not do anything. The male resident understood what was being said and was coherent. At first the male resident said he was sitting across from the female resident, and she placed her hand on his hand. The male resident understood the female resident could not speak and he stated she is new to the building. The male resident then changes his story and stated he reached over and grabbed her hand and had his hand placed on her lap. He added he would never touch anyone in their private area. He said all he did was rub around her thigh and lap, but nothing sexual happened. V31 then spoke with a witness; a resident of the facility who said he was watching TV and the male and female resident were behind him. The resident said he turned his head back and saw the female resident swat away the hand of the male resident. He then heard a nurse yell, and he knew something was wrong. He then heard the male resident and the nurse argue. The resident stated this is not the first time the male resident has done this, he has touched other female residents in inappropriate areas. When they are sitting in the TV room watching TV, and the male resident see's something on TV, like a woman, he begins to talk dirty. V31 then spoke with a second nurse who said this is not the first time this has happened, a few weeks ago he made out with another female resident who suffers with dementia. The nurse said he feels the male resident is aware of what he is doing and earlier that night the male resident wanted me to bring the female resident to him, he added this was unusual but did not take the female near the male resident. V31 then spoke with a CNA (Certified Nursing Assistant) who said she has seen the male resident engage in multiple instances of inappropriate touching with other residents. She had observed the male resident touch female residents around their breasts and mentioned kissing another resident on the mouth. On 3/5/2026 at 9:59 AM, a return call to V17 was made to clarify her statement. V17 said R8's hands were not inside R7's pants. His hands were on the outside of her clothing. V17 said R7 was wearing black pants and an incontinence brief. V17 said she did not tell the police his hands were inside her clothing. Review of R8's clinical record shows he was started on Depo-Provera (a hormonal medication of the progestin type) on 8/1/2025 for abnormal sexual behavior. The injection was ordered to be given to R8 every 3 months. On 3/5/2026 at 8:10AM, V2 (Director of Nurses-DON) said she was not aware of why R8 was started on Depo-Provera. On 3/5/2026 at 8:20 AM, V22 (Social Services) said he was not aware of when or why the Depo-Provera was started. V22 said he does not know who ordered it or why. A Physician progress note, dated 7/14/2025, shows V16, (R8's Primary Care Physician), ordered the Depo-Provera due to staff stating inappropriate sexual behavior towards female residents.On 3/5/2026 at 11:40 AM, V16 (R8's Physician) said he is not too familiar with him, but name sounds familiar. I don't remember any specifics. Given the history they gave me, I don't remember what happened, but if there is abnormal sexual behavior, Depo-Provera is the first go-to medication to stunt those very heavy, abnormal hormone surges in hopes to decrease the urge for him to go into those kinds of behaviors. After some time if it is not working, you would also have to consider psychiatric behaviors and add antipsychotics as a last resort because they are risky medications. I don't remember the patient or the details of what happened, but this is a routine medication for taking care of patients with these kinds of problems. If they described behaviors that were unwanted, no matter what it is, sexually inappropriate is sexually inappropriate, it doesn't matter how they describe it. Rubbing of legs and hands is inappropriate, and you would need to do something, and that would be the first medication that you would give. I would expect them to have closer supervision of those patients until the behaviors are all done, and they responded well to the treatment. They need to keep an eye on these patients until they don't pose a risk to other residents. A review of progress notes for R8 shows on 8/5/2025, R8 was observed by family touching the abdomen of a female resident. On 1/7/2026, R8 was observed kissing the hand of another female resident. A progress note, dated 1/10/2026, shows R8 was observed following a female resident around the front room, the female tried to move multiple times but R8 continued to follow her and was trying to hold her hands and rub her arms. On 2/6/2026, a note was written by V22 (Social Service Director) stating R8's son was notified of R8 kissing a female resident on the mouth. A review of the nursing progress notes for R6 shows on 3/14/2025, R6 and R8 were observed in R8's room and were being Sexually inappropriate. Nurse V11 was contacted and he said he does not remember the incident, it was last year. The facility face sheet for R8 shows he was admitted to the facility with diagnoses to include congestive heart failure, chronic pulmonary disease, osteoarthritis and depression. The facility assessment, dated 1/21/2026, shows him to have mild cognitive impairment, shows no behaviors and requires supervision with his activities of daily living. The care plan for R8 shows he may be socially inappropriate with other residents, dated 2/27/2025. On 3/20/2025, an intervention was added stating do not allow him to be unsupervised with female residents. On 2/27/2025, an intervention to intervene to protect the rights and safety of others, remove from the situation and take to alternate location as needed. The facility face sheet for R6 shows she was admitted to the facility with the diagnosis of Alzheimer's Disease. The facility assessment, dated 2/10/2026, shows her to have severe cognitive impairment and requires moderate assistance from staff for her activities of daily living. A care plan, with a revision date of 2/12/2026, for may make sexual inappropriate comments of advances towards male staff and residents. Interventions include if found making inappropriate physical advances, remove her from the situation immediately. The behavior monitoring tool used by the facility shows no behaviors were observed for R6, R7, or R8 for the last 30 days. The undated facility abuse policy shows each resident has the right to be free from abuse. Definitions of sexual abuse is sexual behavior exhibited by one person or another without consent or the capacity to consent. This includes kissing and hugging. Resident behaviors are monitored for changes that trigger abuse behaviors. Our facility will reassess care plan interventions on a regular basis. Intervention strategies based on resident screenings will be implemented to prevent occurrences of abuse. Our facility will remove any alleged perpetrator from any further contact with any resident. The facility presented an abatement plan on 3/5/2026 at 3:46 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove immediacy. The abatement plan was returned to the Administrator for revisions. The facility presented a revised abatement plan on 3/5/2026 and the survey team accepted the revised plan on 3/5/2026 at 4:00 PM. The Immediate Jeopardy that began on 3/2/2026 was removed on 3/6/2026 when the facility took the following actions to remove the immediacy:Identification of residents that have the potential to be affected by the deficient practice:Female residents with a cognitive deficiency have the potential to be affected by this deficient practice. Immediate actions implemented to decrease resident risk:*R8 has been placed on one-on-one care until his discharge on [DATE]. *The female residents that gravitate to him have been identified and are being closely monitored to ensure staff are following care plans for interventions. *The DON or Designee has educated nursing staff regarding R8's one-on-one status as well as the need re-direct females from his vicinity while he remains in the facility. All staff will be educated prior to working their next shift. *The Social Service Director or Designee will educate all staff on the abuse policy and procedure including how to identify inappropriate sexual behavior with a focus on residents that don't have the cognitive ability to consent. All staff will be educated prior to working their next shift. *The DON or Designee has educated nursing staff on where to find the care plan of residents to include any interventions for behaviors. All staff will be educated prior to working their next shift. *Beginning 3/6/26, all behaviors will be reviewed in the morning clinical meeting to ensure proper interventions are put into place and the care plan is updated to reflect such. The DON or Designee will then make sure any changes to either are communicated to the staff.*Ad Hoc QAPI meeting will be held on 3/6/2026 with QAPI team members in person and Medical Director (V16) via phone. The abuse policy and procedure as well as the state regulation was reviewed and the measures being put in place to ensure this deficient practice doesn't happen again.

Based on observation, interview, and record review, the facility failed to have isolation signs on the doors of two residents on isolation. This applies to 2 of 3 residents (R2,R3) reviewed for infection control in the sample of 8.The findings include: The facility face sheet for R2 shows she was admitted to the facility with diagnoses to include Parkinson's, surgical site aftercare and urinary tract infection. The facility assessment, dated 12/17/2025, shows R2 to be cognitively intact and requires moderate assistance with her activities of daily living. A Physician order dated 12/12/2025 shows an order for enhanced barrier precautions.The facility face sheet for R3 shows he was admitted to the facility with diagnoses to include surgical aftercare, pressure ulcers, type 2 Diabetes, and wound infections. The facility assessment, dated 1/22/2026, shows him to be cognitively intact and requires partial assistance with his activities of daily living. A Physician order, dated 11/4/2025, shows R3 is to be on contact isolation. A care plan, dated 11/6/2025 with a revision date of 12/19/2025, shows R3 requires strict isolation precautions.On 3/3/2026 at 1:00 PM, no signs for isolation were observed on the doors of R2 or R3.On 3/3/2026 at 1:30 PM, V2 (Director of Nursing) said R2 and R3 both have orders for Enhanced Barrier Precautions (EBP) and should have signs on their doors to alert staff to use personal protective equipment (PPE) to prevent spread of infections. R3 is no longer having diarrhea, and his contact isolation was changed to EBP. V2 said, That's my bad, the signs should have been moved with the residents when they switched rooms.The undated facility policy for infection prevention and control manual-enhanced barrier precautions shows EBP are an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms in nursing homes. EBP involves the use of a gown and gloves during high contact resident care.

Based on observation, interview, and record review, the facility failed to perform incontinence care for a dependent resident (R3). This applies to 1 of 3 residents reviewed for incontinence care in the sample of 7.The findings include:R3's electronic face sheet, printed on 12/12/25, showed R3 has diagnoses including but not limited to Lennox-Gastaut Syndrome, Epilepsy, autistic disorder, and severe intellectual disabilities.R3's facility assessment, dated 11/24/25, showed R3 has severe cognitive impairment, incontinence of urine and bowel, and dependent on staff for personal hygiene.R3's care plan, dated 8/19/25, showed, (R3) has bladder incontinence due to cognitive impairment and impaired mobility .provide perineal care after each incontinent episode, check frequently for incontinence .On 12/12/25 at 10:10AM, V4 (Certified Nursing Assistant-CNA), V6 (CNA), and V5 (Licensed Practical Nurse-LPN) provided incontinence care for V3. V4 removed R3's toy off his lap and revealed a large wet area on the front of R3's pants. V4 stated R3 got up around 6:30AM and has not been changed since then. R3 was transferred into his bed and rolled to his left side. R3's lift sling was soiled as well as the back of his pants. R3's incontinence brief had a strong urine odor and was saturated with urine. V7 (R1's father) was in the room and confirmed he was in early today, and R3 hasn't been changed since he has been here. V4 and V5 stated residents should be checked at least every 2 hours for incontinence. V5 stated R3 would be high risk for skin breakdown due to incontinence and inability to reposition. On 12/12/25 at 12:25PM, V2 (Director of Nursing) and V1 (Administrator) stated residents should be checked for incontinence at least every 2 hours, if not more often. V1 stated she is shocked R3 was soiled as staff are very attentive to him at all times, as well as his parents when they are visiting. V2 stated R3 is definitely a risk for skin breakdown and should be checked for incontinence often and any refusals should be documented.The facility's policy titled, Pressure Injury Assessment and Treatment, dated 01/2025, showed, F. Risk Factor-Bowel/bladder Incontinence. a. check resident for incontinence as per personalized care plan and clean skin when soiled .The facility stated they do not have an incontinence care policy as of 12/12/25.

Based on observation, interview, and record review, the facility failed to assess a resident's need for siderails for positioning/bed mobility before removing them for 4 of 16 residents (R47, R42, R26 and R23) reviewed for accommodation of need in the sample of 16. The findings include:1.On 9/8/25 at 10:00 AM, R42 was lying in bed. R42 did not have siderails or assist bars on his bed. V26 (R42's Father) said he is upset the facility came in about a week or so ago and took his siderails off. V26 said R42 would use his siderails to help turn in bed, and it was good therapy for him. R42's Rehab Data Report, dated 8/18/25, shows diagnosis of: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R42 requires substantial/maximal assistance to roll from left to right while in bed. On 9/9/25 at 3:01 PM, V2 (Director of Nursing) said everyone in the whole building had siderails, and they went around and removed all of them due to risk for entrapment. V2 said their plan is to have therapy assess each resident to determine their need for siderails for positioning, but they have not done that yet. V2 said she knows for sure R42 needs siderails to help with positioning and mobility. 2. On 9/8/25 at 10:03 AM, R47 was sitting in a wheelchair in his room. R47's bed did not have siderails or assist bars on it. R47 said they took his siderails off and told him he could not have them. R47 said now he has nothing to assist him in turning in bed. R47's Functional Abilities and Goals Assessment, dated 8/20/25, shows he requires partial/moderate assistance to roll from left to right in bed. On 9/10/25 at 9:28 AM, V2 (Director of Nursing) said R47 is able to use his siderails for bed mobility. 3. On 9/8/2025 at 10:27 AM, R26 said she is going to complain because they took the siderails off her bed. R26 said now she cannot use them to roll herself in the bed. R26 had no bedrails on her bed. R26's Functional Abilities and Goals Attestation, dated 9/4/25, shows R26 has no functional limitations to her upper or lower extremities for range of motion and requires substantial/maximal assistance to roll left and right. R26's Resident Bed Rail/Enabler Consent Form, dated 3/25/25, was signed by R26, and shows the request was prepared by R26 while being mentally capable of participation in her own health care decisions. It shows R26 consents to the utilization of bed rails/enablers for her care. 4. On 9/9/25 at 8:46 AM, R23 said she had a different bed a week or so ago and they came in and removed all the side rails. R23 said she was not given the option to keep her siderails on her bed and she needs them to turn or raise up in bed. R23's Functional Abilities and Goals Attestation, dated 2/9/25, shows R23 has no functional limitations to her upper or lower extremities for range of motion and requires supervision or touching assistance to roll left and right. On 9/9/25 at 3:01 PM, V2, Director of Nursing (DON), said everyone in the whole building had bed rails. They went through and removed all of them, and the plan is for therapy and herself to assess each resident to see if the siderails are truly needed for positioning purposes. The facility's Bed Rails Policy (approved 12/2024) shows when a bed has a pre-installed rail, the facility must determine whether disabling the rail would pose a risk to the resident.

Based on observation, interview, and record review, the facility failed to ensure the pureed meal was prepared in a smooth consistency. This applies to 6 of 6 residents (R49, R56, R65, R20, R33, R42) reviewed for therapeutic diets in the sample of 16. The findings include: On 09/08/25 at 10:08 AM, V6 (Cook) placed seven hamburger patties in the food processor, added seven scoops of thick processed cheese product, and blended. V6 then added three additional hamburger buns and three scoops of liquid broth, blended, and then added four more buns and several additional scoops of liquid broth. The food processor was full to the brim of the puree cheeseburger. V6 and V5 (Dietary Manager) sampled the pureed cheeseburger and V5 stated, I think a little more blending and maybe blend half of it at a time. V6 did not remove 1/2 of the puree meal from the food processor and continued to blend the pureed cheeseburger approximately 30 more seconds and then sampled the puree and said, it's good and placed it in the steam tray. On 09/08/25 at 12:15 PM, a sample tray of the pureed meal was provided. The cheeseburger puree appeared thick and lumpy on the plate. This surveyor sampled the pureed cheeseburger; it was thick, pasty, with bits present, using the tongue to remove the lumpy puree stuck on the upper palate of the mouth. The puree cheeseburger was not a smooth consistency. At 12:30 PM, V5 sampled the puree cheeseburger and said there are nibbles and it's not smooth as pudding. V5 said V6 was following the recipe and was nervous. V5 said he instructed her to separate the amount being pureeing; it was too much at one time. The facility's undated list provided on 9/9/25 shows R49, R56, R65, R20, R33, R42 receive a puree therapeutic diet. The facility's Burger Cheeseburger on Bun [NAME] puree recipe shows prepare products separately if possible in a food processor, bun product until smooth.gradually add stock in a thin stream to bun mixture and blend until thoroughly pureed, no lumps or bits.prepare meat product.blend meat product in a food processor until finely ground.gradually add beef stock in a thin stream to finely ground meat in food processor and continue to process product until the product is completely pureed (smooth no lumps or bits).combine milk and margarine, gradually add milk and margarine in a thin stream to cheese mixture and blend until thoroughly combined.Pureed Food Preparation undated Policy undated states, Pureed food will be prepared using standardized recipes to ensure quality, flavor, palatability and maximum value.pureed foods will be the consistency of applesauce or smooth, mashed potatoes.

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to be able to self-administer medications. This applies to 1 of 16 residents (R50) reviewed for medication self-administration in a sample of 16.The findings include:On 9/8/25 at 9:35 AM, R50 was talking with a visitor. R50 used an inhaler and placed the inhaler in a lock box on their nightstand. R50 stated she had been storing it in the box for a while.R50's Physician Orders showed an order for Albuterol-Budesonide Inhalation Aerosol 90-80 to be given 1 puff inhaled orally every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease. There is no physician order for R50 to self-administer the inhaler.R50's medical record showed no assessment or care plan pertaining to self-administering medications at the time of the survey.On 9/10/25 at 8:30 AM, V2, Director of Nursing, stated residents need to be assessed, care planned, and have a physician order to self-administer medications.The facility's Self-Administration of Medication Policy, dated 04/2021, showed the facility's interdisciplinary team will assess the resident for the ability to take the medication correctly, obtain a physician's order for the resident to self-administer specific medications, and place appropriate documentation in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure a Stage III pressure wound was assessed for 1 of 4 residents (R1) reviewed for pressure wounds in the sample of 16.The findings include:On 9/8/25 at 9:55 AM, R1 was observed to have dressing to her right posterior thigh. R1 said it was not caused by her accident; her skin splits there sometimes.On 9/9/25 at 10:10 AM, V4, Wound Care Nurse, said if there a new skin condition, the CNA (Certified Nursing Assistant) will notify the nurse, and the nurse will assess it and notify her. V4 said she will assess it as soon as she is informed, usually the same day, sometimes the next day, but within 24 hours. V4 said she is aware of R1's right posterior thigh wound. V4 said she did not do an assessment and did not document the wound measurements. On 9/9/25 at 11:34 AM, V25, said R1's right posterior thigh wound is a pressure ulcer. V25 said it goes from open to healed frequently, and was closed for a long time. V25 said every time is reopens, it remains a Stage III pressure ulcer. R1's Skin Check Weekly & PRN form, dated 9/4/25, shows R1 has a new area of skin impairment to her right thigh denoted and open area of site 35) Right thigh (rear). The facility was not able to provide an assessment from their wound care nurse complete with measurements for the wound as of 9/9/25 at 2:00 PM after it was identified on 9/4/25. A document provided by the facility on 9/8/25 listing all the residents with wounds in the facility (undated) does not show any wound(s) to R1's right thigh. R1's Progress Note from V25 from her weekly visit conducted on 9/2/25 does not include any right thigh wound(s).

Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident who is underweight for 1 of 5 residents (R12) reviewed for nutrition in the sample of 16. The findings include: R12's Face Sheet shows that she admitted to the facility on [DATE], with a diagnosis of moderate protein-calorie malnutrition and dementia. R12's Weights and Vitals Summary shows a weight of 77 pounds on 8/17/25. R12's Dietitian Note dated 8/19/25 shows, Resident screened for malnutrition, at risk per MNA score.Varied intake at meals, consuming 25-100% per chart review. Current weight: 77#. BMI (Body Mass Index): 14.1, underweight.REC (recommendations): MedPass 60 mL (milliliters) TID (three times a day) between meals for varied PO (oral) intake / underweight.R12's Nutrition Diagnosis Criteria Form, dated 8/19/25, show 2 Cal Med Pass of 60 mL three times a day is recommended as a nutritional intervention. This recommendation was signed as approved by the provider. R12's Physician's Order Sheet does not document an order for MedPass three times a day. R12's September Medication Administration Record does not show that MedPass was given. On 9/8/25 at 12:00 PM, R12 was in the dining room. R12 appeared very thin. R12 ate one cookie from her meal tray and then said she is no longer hungry and was done eating. On 9/9/25 at 8:15 AM, R12 was in the dining room. R12 breakfast tray was in front of her, but she was sleeping. R12 was approached multiple times to try and wake her up, but she would not wake up and eat. At 8:30 AM, R12 was brought out of the dining room and did not eat breakfast. On 9/10/2025 at 10:08 AM, V27 (Dietitian) said she did R12's initial assessment when she was admitted . V27 said she gave the recommendation for a supplement due to R12's low weight and history of a decreased appetite. V27 said =with any recommendations, she completes a form, and it is sent to the team and if they agree, the facility puts the orders into the computer.On 9/10/25 at 9:28 AM, V2 (Director of Nursing) said she does not know what happened with R12's nutritional supplement. V2 said they received the recommendation form, it was signed by the provider, and then scanned into R12's chart, but the order did not get placed into the system. The facility's undated Nutritional Assessment and Monitoring Policy shows, The Dietary Manager or RD (Registered Dietitian) will complete a comprehensive nutritional assessment according to the admission date and MDS schedule. The Individualized plan of care will be written and reviewed regularly when changes are noted.

Based on observation, interview, and record review, the facility failed to ensure a resident received pain medication as ordered to achieve adequate pain control for 1 of 16 residents (R60) reviewed for pain management in the sample of 16. The findings include: R60's Face Sheet shows diagnoses of: chronic pain, pain in left foot, ankle and joints, bone transplant, osteoarthritis of left foot and ankle, dislocation of tarsal joint of left foot, contracture of left foot, non-pressure chronic ulcer of left foot, joint disorder of left ankle and foot, and aftercare following joint replacement surgery.R60's September Medication Administration Record shows an order for oxycodone 5 mg (milligrams)-1-2 tablets every 4 hours as needed for pain, 1 tablet for pain from 1-5, 2 tablets for pain 6-10. R60's Oxycodone Controlled Substance Sheet shows from 9/3-9/6, R60 took 10 tablets of oxycodone daily. The sheet shows on 9/7 at 4:20 PM, she had only 7 pills left. R60's Care Plan shows she has pain due to: status post left achilles Tenotomy, presence of external fixator, left ankle contracture and chronic pain. The interventions show, Administer analgesia as per orders.On 9/8/2025 at 10:45 AM, R60 was lying in bed. R60 said she had pain in her right lower extremity that she rated at a 9 out of 10. R60 said they constantly run out of her pain medications and say they are waiting on a prescription from her doctor. R60 said she is not due for more pain medication until 1:00 PM. On 9/8/25 at 2:54 PM, R60 said she got half of her dose of pain medication due to them running low. R60 said the nurse came in and told her that her pain medication was running low, and he was going to give her one pill and some Tylenol instead of the two she is supposed to have. R60 said she really wanted the two due to her severe pain, but she agreed. R60 said her pain is still at a 9 out of 10 in her right leg. R60 was wincing and grimacing in pain throughout the conversation. On 9/8/25 at 2:58 PM, V30 (Registered Nurse) said R60 was due for her oxycodone and he had heard that the night nurse sent in a request for a refill, but he had not received it yet. V30 said he went to R60 and told her she only had three pills left and offered one pill along with some extra Tylenol, and she was ok with the plan. V30 said she was rating her pain at a 7 out of 10 at that time. On 9/9/25 at 2:29 PM, V2 (Director of Nursing) said controlled substances require the prescriber to send in a new prescription with every refill. V2 said when a resident has about 7 pills left, the staff should re-order the medication. V2 said if the medication is ordered in the morning, they will get it from pharmacy that same day. V2 said if they run out of a medication that is needed before the refill has arrived, they can get the medications from the convenience box or call pharmacy for a stat delivery. V2 said if either of those options do not work out, they can pick up the prescription from the local pharmacy. V2 said the resident should never have to go without pain medications or have to choose one pill or two due to running low. The facility's Pain Management Policy shows, It is the policy of this facility to respect and support the resident's rights to optimal pain assessment and management.

Based on observation, interview, and record review, the facility failed to ensure 1 of 16 residents (R46) ingested their medications in the sample of 16 residents reviewed for pharmacy services.The findings include:On 9/8/25 at 10:36 AM, R46 was lying in bed on his left side. Two pills were on his bed covers. On 9/8/25 at 10:42 AM, V24, Registered Nurse (RN), said the nurse should always watch to make sure a patient swallows their medications. V24 approached R46's bed and removed the two pills from his linens. The facility's Medication Administration Policy for Senior Living (undated) shows staff members must ensure that residents have swallowed or otherwise received the medication properly.

Based on observation, interview, and record review, the facility failed to ensure pharmacy recommendations were addressed and/or implemented for 1 of 5 (R23) residents reviewed for monthly medication review in the sample of 16. The findings include: The findings include:On 9/9/25 during the morning medication pass which began at 8:23 AM, V31, Licensed Practical Nurse/LPN administered R23 Trelegy Ellipta via inhalation. V31 did not instruct or encourage R23 to rinse her mouth following the inhaled medication.R23's Pharmacy Medication Regimen Review, dated 7/20/25, shows the following: Resident has an order for the following inhaled corticosteroid: Trelegy Ellipta. To prevent oral candidiasis (thrush) caused by the inhaled corticosteroid, ensure the resident rinses their mouth with water (swish and spit) after each inhalation. Please consider adding this to the order on the MAR (Medication Administration Record). On 9/10/25 at 11:05 AM, V2, Director of Nursing (DON), said once the pharmacy reviews the residents medications, they get the recommendations the next day. They present the recommendations to the Nurse Practitioner (NP); V32/NP, addresses the recommendations within a couple days, and the facility processes them and implements any changes, as appropriate right away, meaning within a day or two.The facility's Pharmacist Consultant Policy and Procedure (revised 04/21) shows the pharmacist recommendation(s) will be reported to the DON, attending physician, and/or nurse on duty immediately that day. It is the facility's responsibility to assure that every pharmacist recommendation is responded to as mandated by the current regulations. If the recommendation is declined, rationale must be documented as to the reason.

Based on observation, interview, and record review, the facility failed to administer medications as ordered at the correct time and the correct location. There were 47 opportunities with 7 errors resulting in a 14.89% error rate. This applies to 2 of 4 residents (R23 and R64) observed in the medication pass.1.R64's Face Sheet shows diagnoses of: generalized osteoarthritis, diabetes mellitus, and hypertension. R64's September Medication Administration Record shows orders for: Lidocaine External Patch 4%-Apply to right elbow one time a day for right elbow pain to be applied at 8:00 AM, Vitamin D3 10 MCG (micrograms)-2 tablets by mouth one time daily at 8:00 AM, labetalol 100 MG (milligrams)-1 tablet by mouth twice daily at 8:00 AM and 8:00 PM for hypertension, and Insulin Lispro-inject per sliding scale subcutaneously with meals at 8:00 AM, 12:00 PM and 5:00 PM for diabetes mellitus. On 9/9/25 at 8:59 AM, V29 (Registered Nurse) started preparing R64's 8:00 AM medications. V29 omitted R64's 8:00 AM dose of labetalol and Vitamin D. At 9:23 AM, R64 was sitting in his chair in his room. R64's breakfast tray was on his bedside table, uneaten. R64 said he was finished with his tray and was not going to eat anything. V29 checked R64's blood sugar and it was 207. At 9:30 AM, V29 administered R64's insulin, provided R64 his prepared oral medications, and put his lidocaine patch on his left elbow. 2. On 9/9/2025, observation of R23's morning medication administration began at 8:23 AM. V31, Licensed Practical Nurse (LPN), prepared and administered R23's medications, however, three medications were omitted (Biotin 5 mg (milligrams), Pantoprazole sodium delayed release 40 mg, and Venlafaxine HCL extended release). V31 said each of the three medications named above were gone and would need to be reordered. R23's Order Summary Report, dated 9/10/25, shows current, active orders for Biotin oral capsule 5 mg give one time a day, Protonix (pantoprazole sodium) 40 mg give my mouth one time a day, and Venlafaxine HCL ER oral tablet extended release 24 hour 75 mg give two tablets by mouth one time a day. R23's Medication Administration Record (MAR) for September 2025 shows the three medications described above were each scheduled to be given at 8:00 AM each morning. On 9/10/25 at 11:57 AM, V2 (Director of Nursing) said when nurses are preparing medications, they should ensure the right dose, right medication, right time, right route, and right resident are followed. V2 said the nurse should give all ordered medications at the time they are ordered but can be given one hour before and up to one hour after the ordered time. V2 said if the nurse is out of a medication, they should check to medication room if it is a stock medication, or the convenience box if it is a prescription medication. V2 said the ordered location should always be followed for pain patches. V2 said insulin should be given at the time they get their meal, or right before they eat. The facility's Medication Administration Policy for Senior Living (undated) shows medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose, and the right route.

Based on observation, interview, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was used when providing care to residents on contact isolation or enhanced barrier precautions to prevent the spread of infections for 2 of 16 residents (R8 and R63) reviewed for infection control in the sample of 16. The findings include: 1.R8's Physician's Order Sheet shows he is on Contact Isolation for Carbapenem-Resistant Acinetobacter Baumannii (CRAB). On 9/8/25 at 9:08 AM, R8 had a sign on his door that showed he was on contact isolation. V18 (Certified Nursing Assistant) entered the room with no PPE on. At 9:10 AM, V18 exited the room holding unbagged soiled linens in his hand and arm, and disposed of them in a cart in the shower room. On 9/8/25 at 2:08 PM, V2 (Director of Nursing) said if a resident is on contact isolation, the staff should wear gloves and a gown when entering the room, and should dispose of all linen in the linen container in the room. The facility's Infection Prevention and Control Manual-Transmission-Based Precautions Policy shows, Procedure for Contact Precautions.Wear gloves whenever touching the resident's intact skin or surfaces and articles near the resident.Don gloves upon entry into the room or cubicle.Don gown prior to entry into the room or cubicle.After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganisms to other residents or environmental surfaces. 2. On 9/8/25 at 10:45 AM, R63's catheter bag was hanging on the side of the bed. R63 stated they had the catheter for few weeks to help decrease skin irritation. R63's room was not identified with an Enhanced Barrier Precautions (EBP) sign. When asked if the staff wear isolation gowns when they come in the room to perform care takes (hygiene, catheter care, repositioning), R63 stated, Not since I had the catheter. The staff have just been wearing gloves. On 9/9/25 at 9:20 AM, V17, Licensed Practical Nurse (LPN), entered R63's room with no isolation gown on. V17 had to adjust R63's gown and bedding to access R63's arm. V17 then administered R63's insulin dose. On 9/9/25 at 9:30 AM, V17 stated R63 should be on EBP for having a catheter. V17 stated the personal protective equipment (PPE) for EBP is a gown and gloves when performing cares with a resident. V17 stated they should have worn a gown when the gave R63's insulin. V17 verified R63's room did not have an EBP sign. R63's physician orders, printed on 9/9/25, showed R63 has an order for EBP initiated on 4/6/25 regarding wounds. R63 physician orders showed R63 has an order for a urine catheter, with a start date of 7/25/25. On 9/9/25 at 1:00 PM, V2, Director of Nursing, stated PPE used for EBP isolation is gown and gloves for direct care. The facility's undated EBP policy showed on of the reasons a resident should be placed on EBP isolation is when they have a medical device which includes urinary catheters.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 4. The findings include: 1. On 6/9/25 at 11:38 AM, R2 was observed in his room sitting in his wheelchair. There were several snacks on his bedside table. R2 said he eats those when his blood sugar is low. On 6/9/25 at 12:11 PM, V6 (Licensed Practical Nurse-LPN) said R2 is a brittle diabetic, and his blood sugars are all over the place. R2 gets long-acting insulin twice a day, and short acting before meals. V6 said she waits to check his blood sugar before meals. V6 stated, (R2's) blood sugar was 133, it's below 150, so he does not get insulin. V6 said she follows the physician orders on how much insulin to administer. On 6/9/25 at 2:41 PM, V9 (R2's Guardian/family member) said R2 is a brittle diabetic, and she does not believe the nurses are giving him the correct insulin doses and the facility is not following the physician orders. V9 said she has expressed her concerns with V1 (Administrator). R2's Endocrinology After Visit Summary, dated 5/15/25, shows orders to increase Tresiba (Long-Acting Insulin) to 70 units at 8:00 AM and decrease Tresiba bedtime dose to 50 units. No need to give the fixed dose of Novolog (short acting insulin). Revise the Novolog scale as follows: (The same report shows it was noted by nursing dated 5/15/25). Blood Sugar Novolog Dose <150 None 151-200 6 units 201-250 8 units 251-300 12 units 301-350 14 units 351-400 18 units >400 22 units R2's Medication Administration Record (MAR), dated May 2025 and June 2025, shows orders including Novolog Solution 100 Unit/ML (Milliliters) Inject as per sliding scale: If 151-200= 4 units 201-250= 6 units 251-300= 8 units 301-350= 10 units 351-400 = 12 units 401+ = 14 units, notify POA and MD if over 500. (Start date 4/8/25; DC date 6/7/25). (The MAR does not shows the revised sliding scale orders from 5/15/25). On 6/9/25 at 3:00 PM, V3 (Asssistant Director of Nursing/ADON) said nursing should verify all orders are carried out, and confirmed R2's sliding scale orders did not get changed from 5/15/25. 2. R1's face sheet shows she is an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, COPD, cirrhosis of liver, cognitive communication deficit, acidosis, anxiety, hypertension, occlusion and stenosis of the carotid artery. R1's Medication Administration Record for April 2025 shows orders including Rifaximin (antibiotic) oral tablet 550 mg (milligrams) one tablet twice a day for hepatic encephalopathy. The MAR shows on 4/16/25, R1 did not receive both doses. On 6/9/25 at 1:30 PM, V3 (ADON) said they received a ten day supply of R1's antibiotic (Rifaximin), and the medication was not given on 4/16/25 because they did not have the medication. Nursing should re-order medications at least a few days prior before the last dose. The facility's undated Medication Administration Policy for Senior Living states, All medication orders must be prescribed by a licensed healthcare professional and documented accurately in the residents' medical records .Any changes in medication orders must be documented in the resident's medical record .Medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose and the right route .

Based on interview and record review, the facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R9) found not breathing and pulseless whose physician's order showed the resident was a Full Code. This failure led to a delay in R9 receiving CPR and R9 dying in the facility. This applies to 1 of 3 residents (R9) reviewed for death in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM, when facility staff failed to immediately initiate CPR on R9 when she was found unresponsive and pulseless. This failure resulted in R9 receiving CPR 42 minutes after being found unresponsive and pulseless, which resulted in R9 dying in the facility on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:13 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past Noncompliance. The findings include: R9's Physician's Order Sheet shows an order dated [DATE] for Full Code. R9's Care Plan, dated [DATE], shows, [R9] does not have a completed POLST (Physician Orders for Life-Sustaining Treatment). She is a FULL CODE .Ensure resident's wishes are honored in regard to any advanced directive. R9's Health Status Note, dated [DATE] at 11:29, PM shows, 1740 Today this writer went into patients room to check on resident get her blood sugar and offer her medication, patient was cold to touch body limp checked patients vitals no bp (blood pressure), no pulse, no respiration, had [V25] also check vitals. Patient had mottling on left side of body. Patient was laying on left side. per CNA (Certified Nursing Assistant) patient was checked at 3 pm MOD (Manager on Duty) called at 1745 DON (Director of Nursing) called at 1746. Called POA (Power of Attorney)? .1750 Notified #2 emergency contact. Called 911 report given arrived at 1815 patient assessed for any vitals started CPR and did CPR for 20 minutes patient was asystole the whole time. 1835 coroner was called On [DATE] at 11:25 AM, V22, Registered Nurse (RN) said she went into R9's room at 5:40 PM, and she had no respirations, no pulse, and no blood pressure, and was mottled from her chest onto her left side. V22 said she checked a temperature and it was around 96 degrees Fahrenheit. V22 said she did not know the policy for finding someone passed away, so she called V2 (Director of Nursing). V22 said she did not know if R9 was a full code or DNR (Do Not Resuscitate). but found out she was a full code about ,d+[DATE] minutes after leaving her room when she looked in the computer. V22 said a resident's code status can be found on the computer or on the crash cart. V22 said it took her a long time to figure out if she was a full code because she got another nurse to verify that she did not have any vitals and was trying to get the CNA in there to help her. V22 said after the other nurse came in and verified she did not have any vitals, she called V24 (Manager On Duty) and told her R9 had expired. V22 said she does not remember what V24 had told her, but she then called V2 (DON) and V2 told her to start CPR. V22 stated, [V2] told me to start CPR but I didn't, because she was mottled and draining fluids from her mouth, so I did not do it. It was right after supper time and I didn't have any help at that time. V22 said after speaking to V2, she called 911 and went down to R9's room and about a minute later, 911 arrived and started CPR. V22 said she should have started CPR immediately because she was a full code. On [DATE] at 12:47 PM, V23 (CNA) said around 3:00 PM, R9 was laying in bed on her left side and appeared to be sleeping. V23 said around dinner time, V22 came out of R9's room and said she had passed away and she needed to clean her up. V23 said she went to the dining room and spoke with the other CNAs, and told them R9 had passed away. V23 said she then went back into the room and after about 10 minutes, V22 came in and told her she needed to clean her up. V23 said she proceeded to provide incontinence care to R9. V23 said R9 had a little bluish color under both of her breasts and the left side of her head (where you would lay your head on a pillow) that was light blue and it was the size of a half of a hand. V23 said she was able to see all of R9's body when she cleaned her up, and she did not have any other discolorations seen on her body. V23 said after she was done cleaning R9 up, the parametics arrived and started CPR. On [DATE] at 9:30 AM, V25 (RN) said she was at her medication cart right before supper on [DATE] when V22 came walking down the hall and said, I think my patient died . V25 asked V22 if she wanted her to verify, and she said yes, so they walked down to R9's room and she listened for an apical pulse for one minute and listened for respirations and there was none. V25 said R9's face was pale and her lips were normal color. V25 said R9 had a gown and blankets on, so she was unable to see her full body. V25 said she then told V22, Yes, she has passed on. V25 said her and V22 then walked down the hallway and she went to her medication cart, and V22 went to sit at the nurse's station computer, which is about 5 feet from her cart. V25 said she heard V22 say, Oh my God, this patient is a full code. I am going to call [V2]. V25 said she heard V22 on the phone with someone and she hung up the phone and said, [V2] wants me to code her. V25 said she responded with ok, and then V22 responded with, I am not doing CPR, I am calling 911. V25 said a code was never called and no compressions were ever started by her or V22. V25 said, It was [V22's] patient and she was pretty strict about not doing CPR, so I did not do anything. V25 said that a code blue should have been called and CPR started. On [DATE] at 11:19 AM, V24 (MOD) said she received a call from V22 at 5:47 PM on [DATE]. V24 said V22 said her resident had passed away. V24 said she responded with, I'm sorry, was she hospice? V24 said V22 responded with, No, she was a full code. V24 said she immediately told her to get off the phone and initiated compressions and have someone call 911. V24 said V22 responded with, No, she is already mottled and dead, I'm calling [V2]. V24 said she then told her again she needs to immediately start compressions, and V22 hung up the phone on her. V24 said there is no reason that anyone should not do CPR on a resident if they are a full code. V24 said CPR should be initiated right away. On [DATE] at 11:51 AM, V2 (DON) said V22 called her at 5:49 PM on [DATE] and said R9 had passed away and started telling her who she had called (on call phone and POA). V2 said she asked V22 what R9's code status was and she said, Let me check. V2 said V22 responded that R9 was a full code. V2 said she told her that she should have started CPR right away, and needed to start a code. V2 said said ok and hung up the phone. V2 said she called the facility back after notifying the Administrator and corporate nurse about what was happening, and V22 answered the phone. V2 said she asked her if she started a code and she said, no. V2 said she again told her she needs to start CPR and call 911 and V22 responded with, She's gone, it looks like she has been gone for a little while. V2 said even if R9 had mottling to her left side, V22 still should have started CPR immediately and continued CPR until the paramedics arrived. V2 said if a resident is found unresponsive with no pulse or respirations, the staff should immediately check their code status in the medical record or on the crash cart and start CPR right away if they are a full code. On [DATE] at 2:33 PM, V8 (Nurse Practitioner) said she was surprised to hear R9 had passed away because she had just seen R9 a few days prior and she was doing ok. V8 said she would expect that if a staff member found a resident unresponsive with no pulse and respirations, they should immediately check their code status and if they are a full code, immediately start resuscitation efforts. V8 said she is not aware of any situations were a nurse would not perform CPR if a resident is a full code. V8 said they should initiate CPR immediately and continue until a physician/provider or EMS (Emergency Management Services) are at the bedside. V8 said mottling in a resident does not always mean that they are deceased . V8 said a resident can have mottling for various reasons including hypoxia, change in heart rhythm, or change in vitals. V8 said a code is still warranted even if the resident has mottling present. On [DATE] at 12:33 PM, V27 (Local Fire Department-Deputy Chief) said he responded to the call on [DATE]. V27 said thatwhen they arrived, they asked if R9 was a DNR or full code, in which the nurse responded she was a full code. V27 said they immediately initiated CPR. V27 said R9's face was pale, lips were pink and her core and arms were still warm to touch. V27 said the facility staff were not doing CPR upon their arrival. The Local Fire Department Narrative, dated [DATE], shows, Staff stated patient was last seen at 17:40, and at that time, the staff noted that the patient was not breathing and was possibly deceased and called 911 at 18:06, [First Crew Members to arrive at the scene] stated to [Second Crew Members to arrive at the scene] that no one was performing CPR upon their arrival and that their CPR was the first CPR initiated at approximately 18:22. [Crew Member] asked the staff if the patient had a valid DNR, to which the staff stated no, the patient was a full code, and they were not aware that she was a full code. V22's CPR Certification Card shows she was certified in performing CPR on [DATE] and expired ,d+[DATE]. The facility's Cardiopulmonary Resuscitation Policy, dated ,d+[DATE], shows, The goal of early delivery of CPR is to try and maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). If a resident is found unresponsive and not breathing normally, a clinical staff member will verify code status using the medical records. If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate CPR. The facility presented an abatement plan to remove the immediacy on [DATE]. The survey team reviewed the abatement plan and accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility: 1. On [DATE], the Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse or Designee educated clinical staff regarding the CPR policy and procedure and Advanced Directive policy and procedure including identification of when CPR is needed. All additional staff will be educated prior to working their next scheduled shift and new hires will be educated during the orientation process. 2. On [DATE], current resident orders were reviewed by the regional nurse to confirm resident preferences aligned with code status. 3. On [DATE], the facility nurse management team started auditing certified and licensed nursing staff on appropriate action if a resident is found unresponsive with no pulse or blood pressure and not breathing. This will be done four times a week for six weeks. A mock code was conducted on [DATE] and [DATE] on all three shifts to ensure understanding of the CPR policy and procedure. The Director of Nursing or designee will conduct a mock code with clinical staff once per month for 6 weeks to verify understanding of CPR policy and procedure, including identification of when CPR is needed. Any noted issues will be addressed and will be discussed during the QAPI (Quality Assurance and Performance Improvement) process. 4. On [DATE], an emergency QAPI meeting with the QAPI team members and Medical Director was held to discuss the deficient practice and review the policies. The CPR policy was reviewed, and no changes were needed to the current policy. The Advance Directive policy was reviewed, and no changes were needed to the current policy.

Based on interview and record review, the facility failed to assess and monitor a change of condition for a resident following surgical repair of left humerus fracture. This failure resulted in R1 sustaining a new fracture to her left distal humerus shaft discovered on her outpatient appointment on 1/29/25 (nine days after admission) and requiring new surgical intervention. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 14. The findings include: R1's face sheet shows she is an [AGE] year old female admitted to the facility on [DATE], with diagnoses included unspecified fracture of shaft of humerus left arm, orthopedic aftercare, cognitive communication deficit, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and primary osteoarthritis. R1's Final Incident Report, dated 1/31/25, documents (R1) was admitted on [DATE], post fall with left humerus fracture status post nailing on 1/14/25. R1 had an ortho follow up appointment on 1/30/25. Facility received a phone call that R1 had a fracture to her distal humeral shaft that had been missed during her hospital stay and that would require surgery V19 (R1's Orthopedic Surgeon) stated the fracture was new and was a torsional injury . On 2/10/25 at 4:45 PM, V19 said absolutely not R1's fractures was not missed during her hospital stay. On 1/20/25, R1's dressing was changed at the hospital with an ace (elastic) bandage in place. R1 was able to move her left arm as a unit. R1 was discharged to the facility with weight bearing as tolerated. At her post op appointment on 1/29/25, R1's left arm was in a sling, and she was not able to move her left arm with increased swelling. R1 did not have an order for a sling, and was not wearing a sling when she was discharged from the hospital. An X-ray was done and showed a new spiral fracture to the left distal humerus. This was a torsional injury caused by twisting movement, pressure, force, and rotation. The facility did not report any changes regarding R1. He would expect the staff to assess the post-surgical extremity every shift, monitor for swelling, edema and change in range of motion. Staff should call and obtain an order for the use of sling. On 2/10/25 at 11:36 AM, V16 (Occupational Therapist) said she did R1's evaluation for OT on admission. R1 did not come with a sling. She placed the sling on R1's left arm and removed the ace bandage because R1 was having a hard time keeping her arm positioned and placed the sling on for comfort. Nursing usually gets the order for the use of a sling, it was for protection. The next time she saw R1 was on 1/25/25, R1 was lying in bed with her left arm behind her and in significant pain, she would cry out with movement. She said she reported to nursing regarding her pain. On 2/10/25 at 10:17 AM, V17 (COTA-Certified Occupational Therapist Assistant) said she was working with R1 the next three days after her evaluation. On 1/21/25, R1 had no pain, her left arm was in a sling for positioning and edema. On 1/23/25 she noticed increased pain and edema to her left arm. She could only use her left hand and she did not do therapy with her left elbow or shoulder, she did not attempt therapy because of the increased pain. She stated she reported the pain to nursing. On 2/10/25 at 8:44 AM, V13 (Physical Therapist) said normally if a resident has a sling it comes with them on admission and should have orders for the use of a sling. On 2/6/25 at 11:19 AM, V14 (PTA-Physical Therapy Assistant) said during physical therapy, the sling was in place because R1 would attempt to use her left hand for pulling. R1 was able to use the walker one time with her left arm resting on walker. She said R1 was non-weight bearing to her left arm and she did not want her to use her arm to push off. The sling was used for safety, when she did not have the sling on her arm was externally rotated and in downward hanging position. She never did any exercises with her elbow, and reported to nursing R1 would act out in pain and had increased swelling to her left arm. On 2/6/25 at 2:17 PM, V21 (Registered Nurse/RN) said R1 was alert to self, dependent on staff for cares. R1 did not complain of pain. R1's left arm had no edema and had a sling in place. When she received report, they told me she had a sling. There should be a physician's order for a sling. Staff should assess the surgical extremity site every shift. She does not recall therapy reporting R1 having increased pain or swelling. On 2/6/25 at 2:37 PM, V18 (RN) said she was R1's nurse on 1/23/25 and the day she went out for her follow up appointment on 1/29/24. She reported R1 had no pain or swelling to her left arm. R1 had a sling on with gray tape, she never saw her arm out of sling. Usually there is an order for the use of a sling. She did not know there was no order for a sling. The surgical extremity should be assessed every shift and monitored for swelling and pain. She does not recall therapy reporting R1 having increase pain or swelling. On 2/10/25 at 2:15 PM, V30 (Certified Nursing Assistant-CNA) said R1 did have not have the will to get up and do anything, her left arm was tender to the touch and sore. She was not motivated to get up. Her left arm was in a sling and was one person transfer. She could not communicate her needs. On 2/10/25 at 2:46 PM, V29 (RN) said she does not recall R1 or if therapy staff reported R1 having increased pain and edema. Assessments should be done every shift, and any changes of condition should be reported. On 2/10/25 at 12:07 PM, V2 (Director of Nursing/DON) said she is not sure how R1 sustained a new spiral fracture while at the facility. They were notified about R1's fracture during her outpatient appointment. The staff reported it was a fracture they missed. She followed up with V19, and he confirmed it was a new fracture caused by a twisting force. R1 was admitted to the facility on [DATE], there was no physician order to use a sling. Nursing should do a daily assessment of the extremity site and report any changes. She would expect staff to identify a change in the resident's extremity and notify the physician. Nursing is responsible for entering the physician orders and verifying all orders are carried out. R1's Xray report, dated 1/15/25, documents left humerus xray unremarkable appearance of open reduction internal fixation hardware. Anatomic post fixation fracture alignment. No unexpected postprocedural finding. R1's Ortho Discharge Summary report, dated 1/20/25, document left humerus closed reduction with insertion of humeral nail on 1/14/25 .left upper extremity skin warm and dry, left hand edema improving. Left arm elevated on pillow .able to wiggle all fingers and make a loose fist elbow wrist and hand ROM (range of motion) grossly intact .weight bearing as tolerated to left upper extremity, may use left upper extremity to help balance while using walker, continue left hand elevation, lymphedema glove, and ace bandage for swelling. Surgical Site Care: meplilex border post op dressing, leave dressings in place until outpatient ortho postop visit, two weeks from date of surgery on 1/29/25. R1's Physician Orders Sheets, dated January 2025, did not show orders for weight bearing as tolerated to left upper extremity, continue left hand elevation, lymphedema glove and elastic bandage for swelling, and did not show orders to use a sling. The P.O.S. shows orders entered on 1/24/25 for surgical site care. R1's Nursing Admission assessment, dated 1/21/25, documents left shoulder surgical incision, color normal, temperature warm and moist .and documents no pain. R1's Occupation Therapy Treatment Encounter notes, dated 1/20/25, documents, (R1) given sling for left upper extremity support as her arm is hanging to the side and complaints of significant pain. On 1/21/25 right arm shoulder flex, sling repositioned and hand squeezes. On 1/22/25, right arm shoulder flex, left support put under elbow . nursing notified and aware of pain. On 1/25/25, (R1) very lethargic, difficulty waking up, crying unable to verbalize needs, nursing notified indicating pain in left upper extremity (LUE) .left upper extremity in bad position upon therapist arrival, (R1) on right side with left arm behind her; hand down with increased edema. On 1/28/25, positioning for edema management in left upper extremity. R1's Physical Therapy Encounter Notes, dated 1/21/25, 1/22/25 and 1/23/25, documents R1 bed mobility, sit to stand mobility and bilateral lower extremity and trunk strengthening performed and responding well to treatment. On 1/24/25 working on upper extremity sling management and positioning on edema management. On 1/27/25, exercises with lateral weight shift and one hand support. Sling on LUE (left upper extremity). R1's electronic health record does not show daily assessments were performed on her left upper extremity on 1/20/25, 1/22/25, 1/23/25, 1/24/25, 1/26/25-1/28/25. R1's daily skilled nurses note, dated 1/25/25, documents R1 has the following skin issues: left arm surgery; grasp is equal, upper extremity movement: left side has decreased movement, left arm sling. R1's Medication Administration Record, dated for January 2025, shows to assess pain every shift. Pain scale 0-1 no pain, 2-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-9 very severe pain and 10 worst possible pain. R1's M.A.R. shows no pain recorded on 1/20/25 and 1/21/25. On 1/22/25 and 1/23/25 shows a pain level of 4 recorded. On 1/28/25 shows a pain score of 8 (severe pain). R1's Current care plan, initiated on 2/3/25 (after R1's discharge), showed she was admitted with left arm surgical incision, with interventions to observe extremities for signs and symptoms of tissue perfusion touch, report significant findings to physician. R1's Orthopedic Progress note, dated 1/29/25, documents, (R1) presenting for her first postoperative visit status post left proximal humerus closed reduction with insertion of humeral nail performed on 1/14/25 .grimaces when left arm is examined. (R1's) left arm is in a sling, which was not discharged from hospital with. X-rays obtained today demonstrate left proximal humerus CRIF hardware intact .new fracture noted to the distal 1/3 shaft when compared to 1/15 Xray the humerus distal to the stem in a spiral fashion .Left Upper Extremity: left arm in sling .severe non-pitting edema to left hand .pain with palpation of hand .unable to flex/extend wrist or wiggle fingers. Shoulder ROM (range of mortion): deferred due to pain. The facility's Significant Condition Change and notification Policy stated, To ensure that the resident's family and/or representative and medical practitioner are notified of resident condition changes as those listed below .a significant change in the resident's physical, mental, or psychosocial status .mobility changes, onset of swelling .other abnormal findings .a need to significantly alter treatment .the licensed nurse will contact the resident's representative and their medical practitioner .

Based on interview and record review, the facility failed to maintain reconciliation of a controlled narcotic medication. This failure has the potential to affect all 14 residents (R1-R14) that reside in the facility and have a current order for the narcotic. This past non compliance occured from October 25, 2024-November 5, 2024. The findings include: The Order Listing Report, dated November 12, 2024, shows R1-R14 have current orders for hydrocodone/Norco either scheduled or as needed. The facility's State Report, dated October 29, 2024, shows, It was reported to the ADON (Assistant Director of Nursing) that eight tablets of hydrocodone (Norco) that were sent for the stat safe (emergency backup storage) were missing. The hydrocodone was delivered on Friday evening October 25, 2024 and signed for by the nurse working in the front of the building. She then took the delivery to the nurse in the back to drop it into the stat safe. To put medications in the stat safe, there must be two nurses with log in access from the pharmacy. The nurse that was working with her did not have access. The package was placed in the locked med room .On Monday morning another nurse was notified by the pharmacy that the medication had not yet been dropped into the safe. The nurse notified the ADON. On November 12, 2024 at 8:38 AM, V1, Administrator, said the pharmacy delivered a Norco pack for the facility's stat safe on October 25, 2024. V5, LPN (Licensed Practical Nurse), signed for the Norco/accepted the delivery and took it to V6, RN (Registered Nurse), that was working the back hall and near the stat safe. V6 went to drop the Norco and realized she needed two nurses to drop it, and the other nurse on duty did not have access, so V6 left the Norco on top of the stat safe. Pharmacy called the facility the following Monday on October 28, 2024 and said they had noticed it was not dropped into the safe. V3, ADON, began an investigation. V1 said staff searched everywhere for the narcotic and could not find it. V1 said as of November 12, 2024, the narcotic is still unaccounted for. V1 said all staff present were drug tested and the facility was still waiting on three drug test results. V1 said all nursing staff now have access to the stat safe and inservices were provided November 5, 2024. On November 12, 2024 at 9:25 AM, V5, LPN, said she signed for the narcotic when pharmacy delivered it on October 25, 2024. V5 said she did not have access for the stat safe, so she brought the narcotic to V6, RN, to drop it into the stat safe. V5 said that V6 was administering medications to a resident, so V5 gave the narcotic to V6 and then went to finish her assignment. On November 12, 2024 at 9:45 AM, V6, RN, said on Friday evening, October 25, 2024, V5 brought V6 eight Norco and V6 placed the narcotic on top of the stat safe. V6 said neither nurse she was working with had access to the stat safe, so she just put it on top of the stat safe. V6 said she worked PM'S and night shift on Friday. V6 said she forgot to ask the day nurse on Saturday to place the narcotic into the stat safe with her. V6 said she did not work Saturday at all, and she believes she worked the night shift Sunday October 27, 2024. V6 said the narcotic was still on top of the safe on Sunday October 27, 2024. V6 said she received a call from V3, ADON, around 10:00 AM asking where the Norco was because it was missing. V6 said if a medication is for the stat safe, then it should go into the stat safe right away. V6 said she had forgotten about the Norco after Friday. V6 said the other nurses, Did not offer to put the medication in the stat safe with me. On November 12, 2024 at 10:29 AM, V8, RN, said she saw the Norco narcotics setting on top of the stat safe. V8 said V6 came into the facility to receive report from V8. V8 told V6 the narcotic needed to be placed into the stat safe right away, and V6 asked V8 to wait until after nurse to nurse report. V8 said after V8 and V6 were done giving report, V8 said she forgot about the Norco, and then went home. On November 12, 2024 at 10:43 AM, V7, LPN, said the narcotic Norco came into the facility on a Friday evening (October 25, 2024). V7 said V5 gave the narcotic to V6. V7 said V6 did not drop the narcotic in the stat safe. V7 said V6 set the narcotic on top of the stat safe. V7 said he was working the night shift Sunday into Monday (October 28, 2024). V7 said he went into the medication room to find steri strips for his resident that had fallen. V7 said he went into the medication room at about 4:30 AM on October 28, 2024. V7 said he saw a card of medications on top of the stat safe at that time. V7 said that narcotic medication should be dropped into the stat safe right away. The facility's Stat Safe Delivery-Nursing policy, dated September 21, 2024 shows, All narcotics will be reconciled against the manifest at the time of delivery. The nurse should immediately take the stat safe deliver to the machine to restock. For narcotics, a witness should be present as these are added to the machine. Prior to the survey date of November 12, 2024, the facility had taken the following actions to correct the noncompliance: 1. A QAPI meeting was held on November 5, 2024 2. Current licensed associates were re-educated by the Director of Nursing or designee on controlled substance procedure for the STAT safe, controlled substance policy, controlled substance destruction policy, and proper documentation of controlled substances. 3. The Director of Nursing or designee will review the controlled substance documentation of 10 residents per week to verify compliance with appropriate practice per policy and nursing standards of practice. 4. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent.

Based on observation, interview, and record review, the facility failed to ensure pressure injury prevention interventions were in place for two of five residents (R32, R47) reviewed for pressure injuries in the sample of 14. This failure resulted in R32's pressure injury worsening. The findings include: 1. R32's Braden Scale for Predicting Pressure Sore Risk, dated 4/28/22, shows R32 is at risk for developing pressure injuries. R32's Care plan, revised on 5/3/22, shows R32 was admitted with impaired skin integrity related to poor surgical healing, and remains at risk related to impaired mobility, comorbidities including: hypertension, [CONDITION(S)], and [CONDITION(S)]. History of skin implantation site to wound bed right skull and skin graft site to right anterior scalp scar tissue. Pressure area to left heel. R32's Care Plan, initiated 4/27/22, shows air mattress in place to alleviate pressure, float heels while in bed as tolerated, offloading boots to be on at all times except during bathing or cares. R32's Care Plan, revised on 4/11/22, shows R32 has actual impairment to skin integrity related to moisture and related to incontinence, impaired mobility, decreased sensory perception, nutrition, friction & shear, and disease process. Administer treatments as ordered and monitor for effectiveness. R32's Order Summary Report, dated 7/11/22, shows R32 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Order for heel boots on all times *No Shoes* was ordered on 3/24/22. Order to check low air loss mattress for functionality every shift was ordered on 4/11/22. Orders to clean the left heel with normal saline, or soap and water, or wound cleanser. Pat dry. Apply calcium alginate silver and cover with foam every day shift and as needed was ordered 5/10/22. On 7/11/22 at 8:50 AM, R32 was in bed lying on his back. There were heel protector boots on R32's chair next to his bed. R32's heels were directly on the mattress. There was a pump noted to the foot of R32's bed that controlled R32's air mattress. The pump was shut off. On 7/11/22 at 2:37 PM, R32's heels were directly on the bed and the air mattress pump was still off. R32's protective heel boots were still on R32's chair next to his bed. V23, CNA (Certified Nursing Assistant), removed R32's sock from his left foot. R32 said, OW! when V23 removed his sock. R32 said his heel is painful. There was no dressing noted to R32's pressure injury to his left heel. V24, CNA, said R32's heels should be elevated off of the bed. V23 said R32's heel boots should be on his feet. On 7/12/22 at 1:30 PM, V14, ADON (Assistant Director of Nursing)/Wound care nurse, said the pump at the end of R32's bed was off, but should be on. V14 said she wasn't sure if R32 is supposed to have shoes on or not. (R32 was in the facility's television room sitting in his wheelchair with shoes on both of his feet.) R32's Treatment Administration Record, dated 7/1/22-7/31/22, shows the dressing to R32's left heel was not documented as completed on 7/8/22 and 7/10/22. R32's weekly skin check was not performed on 7/7/22. R32's low air loss mattress was not documented as checked on 7/7/22 in the evening, and 7/8/22 on the day shift and evening shift. The wound care physician's note, dated 6/16/22, shows R32's pressure injury to his left heal is a stage IV pressure injury. Post debridement measurements were 1.2 cm (centimeters) in length X 2 cm in width X 1.3 cm in depth. R32's Skin and Wound Evaluation, dated 6/28/22, shows R32's pressure injury to his left heel measured 2.5 cm X 1.0 cm X 0.4 CM. R32's Skin and Wound Evaluation, dated 7/12/22, shows R32's pressure injury to his left heel measured 1.0 cm X 1.6 cm (depth was documented as not applicable). The facility's documentation that V14 ADON (Assisted Director of Nursing)/Wound Care Nurse provided, dated 7/13/22, shows R32's left heel wound measures 1.5 cm in length X 2.2 cm in width X 1.3 cm depth. On 7/12/22 at 9:35 AM, V14 said the purpose of dressings to pressure injuries are to promote healing and prevent infection. On 7/13/22 at 8:23 AM, V17, CNA, said R32 uses heels boots for pressure injury prevention interventions. V17 also said the pump at the end of R32's bed should be on. At 9:12 AM, V20, LPN (Licensed Practical Nurse), said R32 should have a dressing on his left foot, heel boots on while he is in bed, and the left heel boot should be on when he is in the chair. V20 said the air mattress pump at the foot of R32's bed should be on. V20 said the treatment to R32's left heel is done every other day. V20 said heel boots and dressing treatments help to prevent pressure on areas. V20 said if dressings are not in place, heel boots are not in place, and air mattresses are not on, then the pressure injury will get worse. On 7/13/22 at 9:08 AM, V14 said if pressure is not relieved from pressure injuries, then the pressure injury could get worse. The facility's Pressure Ulcer/Pressure Injury Prevention Policy revised 3/2021 shows, A facility must implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and if a pressure injury is present, provide treatment to heal it and prevent the development of additional pressure injuries. 2. R47's Physician Orders, dated 3/15/22, shows, float both heels while in bed an wear waffle boots. R47's Care Plan, dated 5/5/22, shows, impairment to skin integrity related to pressure to heels while in wheelchair and bed Heel protectors on when in bed. On 7/11/22 at 9:00 AM, R47 was in bed, with both heels flat on the mattress. R47 had no heel boots on. On 7/12/22 at 9:55 AM, R47 was in bed with his heels flat on mattress, without heel boots. R47 stated, I have heel boots. They just don't have them on me right now. I don't know why not. On 7/12/22 at 12:10 PM, V19, Registered Nurse, said R47 has a blister on his right heel, and he is supposed to have the heel boots on when he is in bed for protection.

Based on interview and record review, the facility failed to obtain and monitor a resident's weights, failed to identify a resident to be at risk for weight loss, failed to develop a care plan for a resident at risk for weight loss, and failed to identify a resident's repeated significant weight loss and report the resident's weight loss to the Registered Dietician and physician. These failures resulted in R13 sustaining a significant weight loss of 22.56 % (46.7 pounds) in 3 months. This applies to 1 of 7 residents (R13) reviewed for weight loss in the sample of 14. The findings include: R13's Admission Record, printed 7/11/22, showed R13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's admission Dietician Nutrition Assessment, dated 4/13/22, showed, High nutritional risk at this time due to dementia and depression. Continue to encourage fluids and intakes. Continue to monitor weight, labs, meds, skin integrity, and PO (oral) intake. Registered Dietician to follow PRN (as needed). R13's medical records dated 4/13/22-7/11/22 were reviewed and showed no additional Dietician Nutrition assessments were completed on R13. R13's admission care plan and current care plan were reviewed, and showed R13 was severely cognitively impaired and primarily nonverbal due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's care plans showed no documentation identifying R13 as being at risk for weight loss or compromised nutritional status. R13's Weights and Vitals Summary Report, printed 7/11/22, showed R13's admission weight on 4/8/22 was 207 pounds (lbs) and had decreased to 199.6 lbs on 4/20/22 (12 days later). The report showed no weights were obtained for the second and fourth week of R13's admission from 4/11-4/15/22 or 4/25-4/29/22. The report showed R13's weight decreased to 186.3 lbs on 5/11/22, and decreased again to 160.3 lbs on 7/11/22. The report showed three significant weight losses for R13 including 10% in one month (20.7 lbs) from 4/8/22-5/11/22; 10.75% in one month (19.3 lbs) from 6/1/22-7/11/22, and 22.56% in three months (46.7 lbs) from 4/8/22-7/11/22. On 7/11/22 at 2:10 PM, V2, Director of Nursing (DON), stated, Residents are weighed by our CNA's (Certified Nursing Assistants). If there is a discrepancy in weight, the CNA should reweigh the resident. If the discrepancy remains, the CNA should report the weight loss immediately to me or the nurse. We would then notify the physician and Dietician . On 7/11/22 at 3:19 PM, V2, DON, reviewed R13's weight report and stated, I see (R13) has not been weighed for July (2022) yet. I will make sure it is done. I wasn't aware she was losing weight and it had become significant. I run a monthly report on all residents to look for weight loss. The computer report system never flagged (R13) for weight loss. No one ever told me she was losing weight. I am not sure if her weight loss was ever reported to (R13's) physician or the Registered Dietician. On 7/11/22 at 12:38 PM, R19 (R13's husband/roommate) stated, I know she has lost some weight but I don't know how much. She doesn't eat much. She needs to be fed. Some staff are good about feeding her. Some staff just drop off the food, and then pick it back up even if she hasn't eaten any of it. They give her egg salad almost every day, like they did today. She ate her egg salad, but she really didn't eat much of her mashed potatoes and gravy. I can help but think if they had just offered her a slice of meatloaf today, she would have eaten it. They don't really offer her options or ask her what she wants to eat. She isn't big dessert eater but likes canned fruit. They don't give her fruit very often. On 7/11/22 at 12:10 PM, V3, Registered Nurse, stated, I don't know if (R13) has lost weight or not. I know she is not on any supplements or fortified foods. On 7/11/22 at 2:42 PM, V11, Registered Dietician (RD), stated, I come to the facility on ce a month to see residents. Any newly admitted resident should be weighed once a week for the first four weeks and then once a month. I run monthly weight loss reports, remotely via my computer, for every resident in the facility and put interventions in place for weight loss as needed. I saw (R13) on 4/13/22, upon admission, and have not seen her since. I have never put her fortified foods or supplements because she didn't need them in April (2022) when I saw her. I see here in the computer she has only 4 weights recorded (4/8/22-6/1/22). I don't see a weight yet for July (2022). I had no idea she had lost so much weight. Her weight loss never showed up in my monthly reports and no one has called me from the facility to notify me. Someone should have called me after (R13) was weighed on 5/11/22 and made sure I knew about her weight loss. I had no clue. Had I known about her weight loss, I would have reassessed her. I know she didn't like to eat breakfast, but I would have added double food portions to lunch and dinner, and would have had her intake monitored. If she wasn't eating, I would have figured out what she likes to eat and also added a liquid supplement. I don't know how her weight loss was missed. On 7/12/22 at 9:25 AM, V12, Nurse Practitioner (NP), stated, Myself or the physician should be notified if a resident loses 3-5 pounds in one month. I was not notified of (R13's) weight loss from 4/8-5/11/22. I actually saw (R13) on 5/12/22 in the facility, and saw no documentation on R13's weight loss. No one in the facility reported her weight loss to me. Had I known about (R13's) weight loss in May, I would have started her on a supplement and added fortified ice cream. I see her physician started her on an appetite stimulant medication on 6/9/22. Despite the medication, I see yesterday's weight shows she is down to 160 lbs. No one has called me as to notify me of yesterday's weight either. Even with (R13's) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/22 at 10:49 AM, V11, Registered Dietician (RD), stated, No one from the facility has called me to notify me that (R13's) weight from yesterday (7/11/22) is down to 160 lbs. She has dementia, but this amount of significant weight loss could have been prevented. R13's physician orders, dated 4/8/22-6/8/22 showed no orders for liquid supplements, fortified foods, appetite stimulant medications, and/or physician prescribed weight loss interventions for R13. The facility's Weight Assessment and Intervention policy, dated 2/2021 showed, 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly. The facility's Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol policy, dated 2/2021, showed, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time.

Based on observation, interview, and record review, the facility failed to protect a resident from sexual and physical abuse. This applies to one of three residents (R1) reviewed for abuse in the sample of 8. This failure resulted in R1 being sexually abused on 12/25/21 by a family member and physically abused by a staff member on 3/6/2022. R1 remains fearful the male nurse will return to R1's room and is combative with care. The findings include: The facility face sheet for R1 shows R1 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment, dated 12/1/2021, shows R1 to have moderate cognitive impairment and R1 is dependent on 1-2 staff for activities of daily living. 1.On 3/9/2022 at 10:15 AM, R1 could be heard behind a closed-door yelling stop it, leave me alone, get out of here, don't touch me, don't touch my leg. V1, Administrator, was present with the surveyor outside the door and said R1 has experienced sexual abuse from R1's son in December. V1 said R1 has these behaviors of yelling out with any care R1 receives from staff. Observation of the care showed the resident pleading for help for the staff to leave R1 alone, and to stop being touched. (R1 was being assisted to R1's wheelchair to go see the dentist) On 3/10/2022 at 9:00 AM, V1 and V3, Social Service Director, said there was an incident on 12/25/2021, in which R1 was receiving a visit from R1's son, V14. V14 was observed leaning over R1 fondling her breasts and open mouth kissing R1. V1 said the Certified Nursing Assistant (CNA) who witnessed this happening immediately got the nurse, and V14 was escorted out of the building. On 3/10/2022 at 9:45 AM, V6, CNA, said V6 was working on 12/25/2021, and was in the hall near R1's room and V6 saw V4, CNA, in the hall outside R1's room. V6 said V4 was visibly shaken, and told V6 V4 had just seen V14 kissing R1 on the mouth. V6 said V6 went to get the nurse, and the nurse came to the room and told V14 he had to leave the facility. On 3/10/2022 at 11:00 AM, V4, CNA, said V4 answered R1's call light on 12/25/2021, and observed a man visiting with R1. R1 was on the phone, and the man told her they were fine. V4 said V4 shut off the light, but remained in the hall because V4 had a weird feeling about him. V4 said soon after, the call light came on again and V4 entered R1's room, and found V14 with V14's hands under R1's shirt, fondling R1's breast, and V14's tongue down (R1's) throat. V4 said V4 entered the room and said, excuse me, and V14 immediately stood up and almost fell to the floor. V4 said V4 asked R1 if R1 was OK, and R1 said yes. V4 said V4 stayed in the doorway, but looked around in the halls for help. V4 yelled for the nurse, but the nurse was with another resident. V4 then saw V6, CNA, and told V6 what V4 saw, and told her to get some help. V4 said V4 did not know V14 was R1's son, but the look on (R1's) face made me feel like something was wrong. V4 said V14 appeared drunk. On 3/10/2022 at 2:00 PM, V5, Registered Nurse (RN), said V5 was the nurse working that night. V5 said V5 was notified of the incident by V6, and went directly to R1's room and told V14 he had to leave now. V5 said V14 appeared drunk, and V14's shirt was undone. V5 said after V14 left the facility, V5 made sure R1 was OK, and then V5 called the Administrator and the Director of Nursing (DON). V5 said R1 was assessed, and later sent to the emergency room for an examination. V5 said the police came to the facility to talk to the staff and the resident. V5 said, (R1) has always had behaviors of yelling when we provide care and now, I know why. On 3/10/2022 at 12:10 PM, V2, DON, said R1's POA was notified of the sexual abuse witnessed by staff, and that the police had been called. V2 said V2 told the POA R1 was being sent to the emergency room to be examined as the police had instructed them to do. 2. On 3/9/2022 at 8:40 AM, V1 and V2, DON, said on 3/6/2022, R1 was being transferred into bed by V10, Registered Nurse/RN, V11, CNA, and V7, Nursing Assistant (NA), and R1's catheter was accidently pulled out. V1 and V2 said they were notified by facility staff that physical abuse had happened during this transfer, and with the replacement of the foley catheter. V2 said the abuse was reported to V6, CNA, by V7, and V6 reported to V2. V1 said V1 received a call from V10 stating R1's foley catheter had been pulled out accidently. On 3/9/2022 at 9:00 AM, R1 said V10 was rough with R1 on Sunday night (3/6/2022). R1 said V10 slapped R1's arm and put the catheter up in R1's face and was waving it around. He was yelling at me. If he ever comes in my room again, I feel like I would have to protect myself from him. I'd hit him. On 3/9/2022 at 9:15 AM, V6, CNA, said V6 received a call from V7 telling V6 that V7 had been helping with the transfer of R1 with V10 and V11. V6 said V10 was rough with R1, and was rushing the care. V6 said she was told by V11 that V10 had slapped R1 and was flapping the foley catheter in R1's face. V6 said she called V1 right away. On 3/9/2022 at 9:40 AM, V7 said V7 was in the room helping with the transfer with R1. V7 said R1 was yelling at the staff saying, Don't touch me and V10 was yelling back at R1. V7 said as the transfer was happening, the catheter bag fell to the floor. V7 said V7 told V10 the bag fell to the floor, and V10 told V7 to just get R1 in the bed. As R1 was being turned to the bed, V10 stepped on R1's catheter bag. As the lift moved, the catheter was pulled out of R1 as R1 was lowered into the bed. V7 said V7 then turned V7's back and was helping R1's roommate get ready for bed, but V7 heard continued yelling to R1 from V10. V7 said V7 was told by V11 that V10 had slapped R1's arm and waved the catheter in R1's face. On 10/9/2022 at 10:20 AM, R1 was being assisted out of her bed to go see the dentist. R1 was struggling with the staff and yelling at them to stop touching her, don't touch my foot, don't touch me and not that black guy (Meaning the male nurse V10). On 3/9/2022 at 1:20 PM, V10 said V10 would never slap a resident; V10 was reinserting the catheter, and R1 was trying to grab V10's hands, so V10 pushed R1's hands away. V10 said V10 did not wave or put the foley catheter in R1's mouth or R1's face. V10 said V10 called V1 in case there were complaints from the residents that medications were late. On 3/9/2022 at 1:50 PM, V11, CNA, said during the transfer of R1 back to bed, the process was rushed, and V10 was pushing and pulling roughly on R1 during the transfer. V11 said as V10 was reinserting the catheter, R1 was yelling out stop don't touch me. V10 took the rubber end of the catheter and flipped it towards R1's face and said to R1 repeatedly, Shut up, why are you screaming. V10 then purposefully slapped R1's arm as R1 was trying to grab V10's arm. V11 said V11 took hold of R1's hands while the catheter was being put back into place, because she was afraid V10 would hurt R1. V11 said R1 was screaming out the whole time that R1 was in pain and to stop touching R1. On 3/10/2022 at 2:15 PM, V1 said after the incident on 12/25/2021, the staff were educated on abuse including reporting, protecting the resident, and the types of abuse. V1 said after this incident, R1 has been offered and is receiving services with a social worker. V1 said V1 did not feel V1 could educate the staff on caring for a victim of sexual assault without announcing R1 was sexually abused. V1 said R1's behaviors could be because of the abuse R1 has suffered in the past. V1 said since the incident on 12/25/2021 they have been learning more of R1's past. The care plan, with a revision date of 12/28/2021, for risk of decline in mood related to experiencing sexual abuse shows an intervention, dated 9/21/2021, for behaviors of scream/yelling out during cares, but no interventions on how to care for the resident while having these behaviors. There was no care plan for risk of abuse for a resident with behaviors related to care behaviors. The social services history and comprehensive assessment, dated 9/17/2021, shows R1 answered yes to the question willing to answer questions regarding certain traumatic events, and denied a history of sexual assault. The same assessment shows behaviors of screaming and verbally threatening others, screaming at others, and cursing at others daily. The facility policy for abuse, with a revision date of 1/2017, shows, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians' friends or other individuals.

Based on observation, interview, and record review, the facility failed to safely transfer a resident. This applies to one of three residents (R2) reviewed for transfers in the sample of 8. This failure resulted in R2 having extensive bruising to R2's breasts, under arms, to R2's back. R2 also had pain and a decrease in range of motion. The findings include: On 3/9/2022 at 10:45AM, R2 said two staff members put the gait belt around R2's breasts to transfer R2 to the bed. R2 said R2 told the staff the belt was too high on R2's chest and should be around R2's abdomen. R2 said the staff told R2 that was the only way they knew how to put the gait belt on. R2 said as R2 was being assisted into R2's bed, R2 screamed out in pain because it hurt so bad. R2 showed the surveyor R2's bruising. Both breasts were black and blue, as well under R2's left arm and onto R2's left back. R2 said they were very swollen at first, and looked like two big bowling balls. R2 said it was hard to move R2's arms due to the pain, and R2 was afraid of falling because R2 wasn't sure how they would get R2 up. R2 said R2 could not remember when it happened, or who the staff were that did it. On 3/9/2022 at 12:00 PM, V2, Director of Nursing (DON), said the bruising was first brought to V2's attention on Monday 3/7/2022, by the therapy department. V2 said it was very apparent the bruising was caused by improper placement of a gait belt. V2 said V2 was unsure of when it happened and who was responsible for the transfer. V2 said a gait belt should be applied around the abdomen and not the chest. On 3/9/2022 at 12:10 PM, V7, Nursing Assistant (NA), said V7 was helping R2 get dressed for bed on Sunday night, 3/6/2022, and noticed the bruising to R2's breasts. V7 said V7 did not tell anyone because V7 figured someone already knew about it. On 3/9/2022 at 1:50 PM, V11, Certified Nursing Assistant (CNA), said V11 first noticed the bruises to R2's chest and back on Wednesday, 3/2/2022. V11 said V11 did not tell anyone because V11 figured the nurses already know about it. V11 said R2 was having a hard time moving R2's arms. On 3/10/2022 at 10:55 AM, V12, Occupational Therapy Assistant (OTA), said V12 was working with R2 on 3/4/2022, and R2 was having a hard time moving R2's arms. V12 said when V12 asked R2 if R2 was in pain, V2 showed V12 the bruising to R2's breasts, arm, and back. V12 said V12 had to stop therapy that day because of the pain. V12 said V12 went and told the DON right away about the bruising. The OTA progress note, dated 3/4/2022, shows R2 complained of an increase in pain to R2's left side and breast area. V12 also documented the nurse was informed. The nursing progress note, dated 3/7/2022 by V2, shows R2 has purple bruising to R2's bilateral breasts, left upper inside arm and left side of R2's back. Brusing is consistent with improper placement of gait belt during a transfer. R2 changed to a mechanical left transfer. The facility face sheet shows R2 has diagnosis to include muscle weakness, difficulty in walking and COVID-19. The facility assessment, dated 1/27/2022, shows R2 requires extensive assistance of two staff for transfers. R2's skin check, dated 3/8/2022, shows bruising to left and right breasts and under bilateral arms. The facility policy, reviewed on 9/28/2020, for gait belts shows, Gait belts are used to promote safety during treatment related to activities especially during transfer . Gait belts should be secured around the residents trunk with care to preserved skin integrity

Based on observation, interview, and record review, the facility failed to ensure a gait belt was used to safely ambulate a resident. This failure resulted in R1 falling while ambulating with therapy, and sustaining a left [CONDITION(S)]. R1's left [CONDITION(S)] required surgical intervention. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: R1's Face Sheet, dated 2/8/22, showed diagnoses to include, but not limited to: left [CONDITION(S)]; diabetes; hypothyroidism; mild cognitive impairment; repeated falls; dizziness and giddiness; dementia without behavioral disturbance; macular degeneration; peripheral vertigo; generalized muscle weakness; difficulty walking; and lack of coordination. R1's Facility Assessment, dated 10/24/21 (before the fall), showed R1 was cognitively intact; required extensive assistance of one staff member for bed mobility, transfers, and walking in the corridor; was not steady during transitions and walking; and experienced occasional pain. R1's Fall Risk Assessment, completed 1/20/22, showed R1 was a High Risk for falls. R1's Progress Note, dated 1/20/22 at 10:51 AM, showed .Resident walking with therapy at 0920. Heard the sound of a fall. Therapist stated that she just fell over and did not hit her head. Resident complaining of pain in left hip and stated that she thinks it is broken . R1's Fall Risk Care Plan, revised on 1/21/22, showed R1 was at risk for falls and a gait belt should be used with all walking activities and transfers. The Facility's Final Report, dated 1/25/22, showed, R1 . was ambulating in the hallway with a Certified Occupational Therapy Assistant (COTA). She became unsteady and fell to the floor, landing on her left hip . Upon nursing assessment, her left leg appeared shorter than the other and rotated outward. Resident complained of pain . R1 was sent to the emergency room at the local hospital for evaluation and treatment. She was admitted with a left [CONDITION(S)] . Conclusion: R1 had a witnessed fall during therapy while ambulating with therapist. R1 had surgery on her left [CONDITION(S)] and returned to the facility on [DATE] . R1's Facility Assessment, dated 2/1/22 (after the fall), showed R1 had moderate cognitive impairment; was totally dependent on 2 or more staff for transfers; did not walk in the corridor; and experienced frequent pain. On 2/8/22 at 9:37 AM, V4 (COTA) said V4 was walking with R1 when R1 fell (1/20/22). V4 said they were walking down the hall, back to R1's room. V4 said V4 did not have a gait belt on R1. V4 stated, (R1) should have had the the gait belt on for a security belt because she was unsteady. I should have had the gait belt on her. I don't know why I didn't use one. V4 said R1 was getting tired and was going to sit back in the wheelchair. V4 said R1 reached back with R1's left hand to sit in the wheelchair and R1 just fell . V4 said R1 landed on R1's left hip. V4 said V5 (Registered Nurse - RN) and V6 (Nurse Practitioner - NP) were at the desk when R1 fell and they came to help immediately. On 2/8/22 at 10:52 AM, V5 (RN) said V5 was working when R1 fell . V5 said V5 was sitting at the nurses' station with V6 (NP). V5 said V5 looked up and saw V4 (COTA) and R1 walking toward the nurses' station. V5 said R1 did not have a gait belt on. V5 said the last time she looked, it was like V4 was just strolling down the hall with R1 and didn't appear to be paying attention. V5 said V5 looked down and then V5 heard the thump. V5 said R1 was on the floor on R1's left side. V5 said R1 said R1 thought she broke her hip. V5 said R1 said R1 knew what it felt like because R1 broke R1's right hip before. V5 said R1's blood pressure was elevated, and R1's left leg was shorter and rotated out. V5 said R1 was sent to the hospital within 15 minutes of the fall. V5 said R1 sustained a left [CONDITION(S)] from the fall and had to have surgery. On 2/8/22 at 12:41 PM, V6 (NP) said V6 did not witness R1's fall, but heard the thud. V6 said therapy was walking R1, and then R1 was on the floor. V6 said R1 was on the floor on R1's left side. V6 said R1 was in pain and R1's left leg appeared shorter than R1's right leg. V6 said the fall caused R1's left [CONDITION(S)]. V6 said the staff should be using a gait belt on R1. On 2/8/22 at 12:56 PM, R1 was sitting in R1's wheelchair with a lift sling underneath of R1. R1 said R1 was walking in the hall with therapy when R1 fell (1/20/22). R1 said the therapist did not have the belt around R1. R1 stated, They are supposed to have that on. I'm not sure what happened. I just went down and fell on my left side. I had to have surgery and have quite a bit of pain. Now they have to use the machine (total lift) to get me up and down. I used to be able to get up with the help of the staff. On 2/8/22 at 11;06 AM, V7 (Director of Rehab) said a gait belt should always be used when ambulating or transferring residents, in case they have a loss of balance. V7 said gait belts are also used to assist with proper mobility and gait pattern. V7 said there is an entire drawer of gait belts in the therapy department. V7 said R1 had a history of falls. The facility's Fall Policy (revised 9/17/19) showed, Purpose: The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention, and education of both Staff and residents. Policy: The facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety . Program: . Residents found to be at high risk for falls are placed on the Fall Program, and Interventions are implemented to meet individual needs . The facility's Gait Belt Policy (reviewed 9/28/20) showed, Policy Statement: Gait belts are used to promote patient safety during treatment related activities especially during transfer, ambulation, and balance activities. Gait belts should be used during any treatment activity that may place a patient at risk. Therapist must be within close proximity to be able to reach the gait belt to assist the patient if needed .

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering Person Under Investigation (PUI) resident rooms, having PPE available outside the resident rooms to prevent exposure COVID-19; failed to ensure staff were using PPE when entering a resident room on contact precautions; failed to disinfect a multi use glucometer; and failed to ensure staff performed glove exchange and hand hygiene between resident care. This has the potential to effect 9 of 18 residents (R40, R199, R200, R201, R17, R37, R46, R4, R6) reviewed for transmission based precautions. This failure has the potential to infect high risk residents with COVID-19, and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on April 12, 2021 at 12:40 PM, when V8, Certified Nursing Assistant (CNA), entered R199's room without donning full PPE (droplet precautions), exited the room, and entered R200's room without donning full PPE (droplet precautions). The Immediate Jeopardy was identified on April 12, 2021 at 12:40 PM. V1, Administrator, was informed of the Immediate Jeopardy on April 13, 2021 at 2:10 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on April 14, 2021 at 8:55 AM; 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.) R40's Face sheet, printed on April 13, 2021, showed R40 was readmitted to the facility on [DATE]. R199's Face sheet, printed on April 13, 2021, showed R199 was admitted to the facility on [DATE]. R200's Face sheet, printed on April 13, 2021, showed R200 was admitted to the facility on [DATE]. R201's Face sheet, printed on April 13, 2021, showed R201 was admitted to the facility on [DATE]. The Centers for Disease Control Preparing for COVID-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions, updated 11/20/2020, shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory, eye protection, gloves, and gown when caring for new admissions and readmissions. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. The facility's vaccination tracking list, printed on April 12, 202,1 showed R40 and R199-R201 have not been vaccinated for COVID-19. On April 12, 2021 at 9:10 AM, R40 and R199-R201 had Droplet Precaution signs posted on their doors. R200 had no Personal Protective Equipment (PPE) cart outside their room; R199 and R201's PPE carts were empty, and R40's cart was empty and kept inside R40's room. On April 12, 2021 at 12:40 PM, V8, Certified Nursing Assistant (CNA), entered R199's room without donning PPE (gown, gloves, new surgical mask over N95), retrieved R199's lunch plate from the bedside table, and exited the room V8 then entered R200's room without donning PPE (gown, gloves, or new surgical mask over N95), retrieved R200's lunch plate from the bedside table, and exited the room. Upon entering both rooms, V8 had on the same surgical mask over her N95. On April 12, 2021 at 12:50 PM, V8 stated she should have put on PPE prior to entering R199 and R200's rooms. V8 stated correct PPE for droplet precaution (COVID quarantine) rooms is gloves, gown, eye protection, N95 mask, and surgical mask over the N95. On April 12, 2021 at 12:55 PM, V7, Registered Nurse (RN), stated if a resident is on droplet precaution COVID/PUI) you should wear a N95 mask, gown, gloves, eye protection, and a new surgical mask over N95 when in the resident's room. The surgical mask should be taken off with the other PPE when exiting the room. On April 12, 2021 at 1:10 PM, V3, Assistant Director of Nursing (ADON), stated staff should not be entering the COVID quarantine rooms unless they have on the correct PPE which includes N95, surgical mask, gown, gloves, and eye protection. On April 12, 2021 at 2:00 PM, V3 verified R40's PPE cart should not be placed inside the room, and R199-R201's PPE carts were missing and/or not stocked with PPE supplies. On April 13, 2021 at 8:30 AM, V3 stated we have supplies of gowns, gloves, surgical masks, hand sanitizer, and disinfection wipes. V3 stated, I believe it was laziness why the carts were not stocked. When you take the last of something you replace it. On April 13, 2021 at 11:30 AM, V9, CNA, stated when you go into a COVID-19/quarantine room, We are supposed to wear gown, gloves, masks, goggles/face shield. V9 stated, If the cart was empty I would go get more PPE. I would not go into the room without proper PPE. On April 13, 2021 at 11:50 AM, V14, CNA, opened the PPE storage area. Inside the storage area there were multiple boxes of gloves, gowns, and surgical masks. V14 stated there was another box of gowns and other PPE supplies in the beauty shop. V14 stated she was out with COVID-19, but was able to work with maintenance to order more PPE while she was out. V14 stated the facility started running low while we had COVID in the building, but we never ran out, and were always able to order more PPE. V14 stated she did not know why the quarantine hall PPE carts were not stocked. The facility's PPE guidance for COVID-19 is the Illinois Department of Public Health (IDPH) guidelines, dated June 22, 2020. The guidance for admission/readmission residents showed required PPE includes N95 usage, gloves, eye protection, and gowns. The facility's COVID-19 Positive Result Tracking, printed on April 13, 2021, showed facility's current outbreak status, started on March 18, 2021. The Immediate Jeopardy began on April 12, 2021 and was removed on April 14, 2021, when the facility took the following actions to remove the immediacy: 1. Staff education began on April 12, 2021, and will be completed on April 14, 2021, prior to the start of the employees' shift. Staff have been educated by Director of Nursing and Assistant Director of Nursing regarding isolation of PUIs, wearing PPE while providing resident care to the PUIs to prevent the spread of COVID-19, and ensuring that there is adequate PPE available in isolation carts. 2. Staff education prior to shift on April 13, 2021, and all remaining PRN/Casual staff will be educated via phone by end of day April 13, 2021. 100% of the staff to be in-serviced as of 4/13/2021. All employees and contracted employees that received education via telephone and verbally confirmed they acknowledge the education will be asked to sign the formal education during all staff testing. 3. To ensure compliance, the Director of Nursing (DON) or designee will perform audits on the isolation status of PUI residents ensuring correct PPE is worn. The time frame will be 3 times per week for 4 weeks, and weekly thereafter to ensure policy and procedures are being followed. The DON or designee will audit the isolation bins 5 times weekly for 4 weeks, and 3 times weekly thereafter to ensure sufficient PPE is available for use prior to entering any isolation room. 4. The QA committee will review this plan of correction until such time consistent substantial compliance has been met as determined by the QA committee. Audit findings will be discussed by the QA committee and monitoring will be adjusted as determined by the QA committee. 5. An emergency QA meeting was held with the facility Medical Director (via Telephone), Regional Nurse, facility Administrator, Director of Nursing, Assistant Director of Nursing (Infection Preventionist), and Nurse Practitioner to review and/or modify abatement plan as needed. 2.) R17's 2/11/2021 Minimum Data Set (MDS) shows she has a cognitive impairment, requires extensive assistance from staff for her Activities of Daily Living (ADL's), and is always incontinent of bowel elimination. A laboratory report in R17's electronic medical record shows she tested positive for [CONDITION(S)] (C-Diff) (bacteria in the colon causing diarrhea) on 1/28/2021. R17's current care plan shows on 1/28/2021 interventions were added to place R17 on contact isolation for [CONDITION(S)] infection. The same care plan shows R17 has a history of smearing feces and touching other objects. The Center for Disease Control (CDC) contact precaution isolation requirements signage, for outside of resident rooms, provided by the facility, says staff should clean their hands, including before entering, and when leaving the room. And also states providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. On 4/12/2021 at 11:45 AM, R17 was sitting up in a wheelchair in her room. There was a clear 3 drawer plastic isolation cart outside of her doorway. No visible sign was posted on the door to the room or on the cart, to indicate what PPE (Personal Protective Equipment) was required to enter R17's room. On 4/12/2021 at 12:02 PM, V19 (Activity Aide) was in the hallway assisting to pass out noon meal trays. V19 walked into R17's room; she did not put on a gown or gloves. V19 sat R17's tray down in front of her on the over bed table, and assisted R17 to set up the tray and take off the covering so she could eat. V19 then exited the room without washing her hands. The surveyor asked V19 if she was aware that R17 was on isolation. V19 said she was told since she wasn't providing care to R17, she did not need to put on a isolation gowns or gloves. On 4/12/2021 at 12:12 PM, V28 (CNA) said she was aware R17 was on isolation for C-Diff, but she was told staff did not need to put a gown or gloves on to enter her room if they are not doing care. On 4/12/2021 at 12:19 PM, V29 and V30 (Dietary Aides) were outside of R17's room in the hallway passing juices and waters out to residents. Both entered R17's room without washing their hands, putting on gloves or a gown, and did not wash hands or use hand sanitizer exiting the room. V29 took a glass of juice in for R17 and placed it on the table. V30 entered the room and was talking with R17 about items on her tray. V29 and V30 exited her room and continued down the hallway passing water and juice to other residents. On 4/13/2021 at 8:25 AM, V13 (CNA) said R17 is on isolation, and everyone who enters the room should wash their hands and also put on gowns, gloves, face shield, masks, and wear shoe coverings. On 4/13/2021 at 8:35 AM, V3, Assistant Director of Nursing (ADON), said R17 has been on contact isolation since she tested positive for C Diff. V3 said all staff should wear gowns, gloves, masks, and eye wear to enter the room. V3 also said what the staff indicated to the surveyor about not needing PPE to enter R17's room is absolutely not true. She said all staff should have had PPE on to enter her room even if just to drop off a tray. V3 also said R17 does have a history of smearing feces in the room. 3.) On April 12, 2021 at 11:43 AM, V7 (RN) performed a blood sugar check for R37 with a glucometer. V7 wiped the front and the back of the glucometer quickly using a disinfecting wipe (red top) and threw away the wipe. At 11:51 AM, V7 performed another blood sugar check using the same glucometer on R46. V7 cleansed the glucometer wiping the front and back then threw away the wipe. V7 said the glucometers are multi-use, and there is not a certain amount of time needed to cleanse with the disinfectant wipe; just wipe down and air dry. The Infection Prevention and Control Manual for Cleaning and Disinfecting Blood Glucose Meters states, It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident to resident transmission of blood-borne pathogens is a well-known risk when using lancets, needles and syringes. Blood glucose monitors that are shares must be cleansed and disinfectant must be cleansed and disinfected between each use 9. Follow manufracture's guidelines for cleaning and disinfecting of glucose meters The manufacturer's label instructions for disinfection states, Thoroughly wet pre-cleaned, hard non-porous surface with a wipe, keep wet for 2 minutes and allow to air dry. Use as many wipes as needed for the treated surface to remain wet for the entire contact time 4.) On April 12, 21 at 9:31 AM, V12 (CNA) assisted R4 to the bathroom. V12 cleansed R4's bottom of stool, and with the same contaminated gloves applied barrier cream. V12 then pulled up R4's pants and removed her gloves. V12 then assisted R4 to her wheelchair and gathered her toothbrush and toothpaste. V12 then went to R6 (R4's roommate) without washing her hands and applied gloves, checked her incontinent brief, and removed her gloves and left the room without washing her hands or hand sanitizing. On April 13, 2021 at 12:33 PM, V13 (CNA) said handwashing should be done before and after patient care. Gloves should be changed after cleansing a resident and before applying barrier cream. 5.) On April 12, 10:14 AM, V12 (CNA) removed R6's saturated incontinent brief then removed her gloves and pulled down her face mask to talk to the resident. V12 then left the room without washing her hands. V12 returned back to the room and provided care to R4 without washing her hands or hand sanitizing. The facility's Infection and Control Manual states, Appropriate hand hygiene is essential in preventing transmission of infectious agents .

Based on interview and record review, the facility failed to provide pain management to a resident (R1), failed to provide nursing services to a resident (R1), and failed to ensure a resident (R1) was free from social isolation. These failures resulted in R1 experiencing prolonged pain without medication intervention, and being isolated in a shower room for an extended period of time. These failures also resulted in R1 not receiving a nursing assessment and experiencing emotional instability. The findings include: The facility's admission and discharge log, printed on 2/5/21, showed R1 was admitted to the facility on [DATE] and discharged from the facility on 2/1/21. A review of R1's electronic medical record showed no diagnosis, medication, progress notes, care plan or assessments were entered for R1 during his time at the facility from 2/1/21 at 2:30PM thru 2/1/21 at 7:30PM. On 2/9/21 at 9:24AM, V8 (Registered Nurse) stated, (R1's) admission was awful. He was an anticipated admission coming from a local facility to be closer to his family. He came to the building and I told (V9-Certified Nursing Assistant, CNA) to complete her part of his admission. (V9) then alerted me that (R1) had bed bugs. I notified (V2 Director of Nursing) and she went to (R1's) room. (V2) told me that (R1) could not stay in the facility. R1's roommate was then moved to an alternate room (creating a private room for R1). R1 was then taken to the shower room and kept in there until we were able to get him transported to the hospital. We had to attempt to feed him dinner in the shower room because his room had been sprayed for bed bugs and we didn't have anywhere else to put him because of COVID restrictions. (R1) arrived at the facility between 2:30PM-3:00PM and the transportation company finally arrived somewhere between 6:30PM-7:30PM. (R1) received a change of clothes but I could not provide any nursing services to him or chart anything in his records because I was told by (V2) that he was not our resident. On 2/9/21 at 9:33AM, V9 (CNA) stated, (R1) came to the facility at the beginning of my shift around 2:30PM-3:00PM. We took him to his room and transferred him into a recliner. When we stood him up I saw bugs crawling on his back. We gave (R1) a meal tray in the shower room and propped the door open. He wouldn't eat dinner because he was so upset and kept yelling and swearing and telling us he didn't bring the bugs into the facility. I felt so bad for him because there wasn't anything I could do for him. We didn't transfer him again until right before he left for the hospital. On 2/9/21 at 9:40AM, V2 (Director of Nursing) stated, (R1) arrived to the facility sometime around 3PM. (V9) came and got me because he had beg bugs on him. We did not have a private room to put (R1) in. We took his clothes off and bagged up his belongings and set them outside. The next thing I knew he was going to the emergency room for back pain which didn't surprise me because he was sitting for so long. I think he left the facility around 6:30PM-7:00PM. He wasn't with us long and no meals were provided to him. We didn't consider him our admission so no medications were given to him. His room was to be closed for 1 hour and then inspected for further bed bug infestation. As long as the room is cleared, residents can be moved back into the room. The maintenance department cleared the room the next morning and got rid of the recliner (R1) was using. There is no documentation in (R1's) medical record because the nurse on duty did not perform any nursing services because he wasn't our resident. On 2/9/21 at 10:31AM, V10 (R1's power of attorney) stated, My brother called me from the facility and told me that (V7) told him that my Dad couldn't stay at the facility and we needed to pick him up because he had beg bugs. My Dad was very upset about this incident and in pain from being up in a wheelchair for 5+ hours. My Dad was so confused about what was going on and angry that the local emergency room staff let us in just to calm him down and help explain the situation. When my Dad arrived at the emergency room there were no bed bugs or bites on him. (V7) told me that there was not a room available at the facility for my Dad to return to so my Dad sat in the emergency room for almost 24 hours waiting for alternative placement. On 2/5/21 at 1:10PM, V7 (Community Relations Coordinator) stated, I think (V10-R1's daughter) called his primary physician and had him sent to the local emergency room for back pain. (V10) refused to have (R1) sent back to the facility he came from. I greeted (R1) in his room around 2:30PM and he was checked in, transferred to his wheelchair then the staff took him to the shower room, and removed his clothes and belongings from the facility. (R1) was offered hydration but no meals were provided to him. I left to go home for the day after that because I thought everything was arranged. On 2/5/21 at 1:10PM, V1 (Administrator) stated, (R1) had bugs and bites all over his body. I get it that we accepted him but we did not have a private room to admit him to. R1's records from a local hospital, dated 2/1/21, showed, (R1) was transferred to a facility to be closer to family on 2/1/21. He was never actually admitted and personnel there refused to take the patient stating he had bedbugs. On evaluation there is no evidence of bedbugs. It is very difficult to accurately reconcile his medications with our limited information. R1's records from a local hospital, dated 2/1/21, showed, (R1) states his primary concern is his back pain, which he states is constant and worsened after transfer and is primarily located to his lumbar spine. Denies itchiness, no new rashes. Skin warm and no clearly visualized bite marks on initial examination. R1's electronic medical record at the facility showed no skin assessment or medication administration for 2/1/21.

Based on observation, interview, and record review the facility neglected to follow their fall prevention policy and pain management policy by not peforming an assessment and not reporting a resident fall. This failure resulted in a delay in treatment and R1 experiencing untreated pain. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 7. The findings include: The facility's Fall Prevention Policy revised (MONTH) 2014 shows following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported and potential causal factors identified and investigated. The facility's Significant Condition Change and Notification policy undated, shows the resident's family and/or representative and medical practitioner are notified when an accident or incident, with or without injury, that has the potential for needed medical practitioner intervention occur. The facility's Pain-Clinical Protocol revised (MONTH) 2013 shows the physician and staff will identify individuals who have pain or who are at risk for having pain .the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. R1's Electronic Medical Record shows R1 was admitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) dated (MONTH) 14, (YEAR), shows R1 was cognitively intact. On (MONTH) 5, (YEAR) at 12:10 PM, V7 (R1's Power of Attorney/Spouse) stated, R1 fell in the bathroom. I did not know he fell . They did not call me when he fell . V7 visited R1 on the evening of (MONTH) 9, (YEAR) after lunchtime and stated, R1 was hollering out with pain. He was sent to the emergency roiagnom on (MONTH) 10, (YEAR) and the surgeon called me and said he broke three ribs and had to have surgery. He suffered. He should have had [MEDICATION NAME] a long time ago. R1's Health Status Note that was created on (MONTH) 16, (YEAR) (8 Days after the incident) by V4 RN (Registered Nurse), shows on (MONTH) 8, (YEAR) at 3:36 AM, R1 was observed on his buttock in his bathroom. R1 was incontinent of a bowel movement. R1 was assisted to standing position with two staff. R1 was assisted to the toilet and a CNA (Certified Nursing Assistant) completed cleaning the resident and changing his incontinence brief. On (MONTH) 5, (YEAR) at 2:42 PM, V4 (worked (MONTH) 8, (YEAR) 10:00 PM-6:00 AM) said, If a resident falls, we take vital signs and document it. We report the fall, notify family and doctor, and perform neurological checks. It should be documented with in the shift. V4 said R1 fell early in the morning about 3:30 AM, but could not remember what day. V4 said V5 Wound Care Nurse came in to work for me about 4:00 AM. V5 said I did not tell her about R1's fall. I forgot to fill out a fall report and I did not do vital signs. I should have stayed to finish. I don't remember if V5 called the medical doctor and family. I did not call the medical doctor or family. I was off the weekend and I filled out the occurence report a few days after the fall. V5 Wound Care Nurse's Time Card dated (MONTH) 9, (YEAR) shows V5 punched in at 4:50 AM to relieve V4. V4 punched out nine minutes later at 4:59 AM. On (MONTH) 9, (YEAR) at 1:15 PM, V5 Wound Care Nurse (Worked (MONTH) 9, (YEAR) 6:00 AM-10:00 PM) said she asked V13 Medical Doctor to assess R1 because he was acting strange. R1 complained of pain everywhere. R1 could not reach for his own water. R1 was kept in bed that day, he would not use his call light and he screamed for help. This was a fall that was not reported. I am not aware that anyone called R1's family or doctor. R1's behavior got worse as the day went on. V13 went to assess R1 and said that R1 had bruising on his side. V5 said she did not know of any falls so she told V14 (Administrator during this time). I told him an investigation needed to be started. V5 said she saw bruising on R1's front and back side. V5 said if residents fall the nurse does an assessment, vital signs, and neurological checks. The doctor and power of attorney is notified. On (MONTH) 10, (YEAR) at 8:00 AM, V10 CNA (Certified Nursing Assistant) (Worked (MONTH) 8, (YEAR) 10:00 PM-6:00 AM) said R1 fell in his bathroom. It took the nurse a long time to look at him. It was shocking to me. I quit working there because of the fall (the way it was handled by the nurse.) R1's Health Status Note dated (MONTH) 10, (YEAR) at 4:00 AM, entered by V12 RN, shows R1 X-ray reports received, call to nurse practitioner. Resident sent to emergency room for evaluation. R1's X-ray (performed at the facility) report dated (MONTH) 10, (YEAR) at 2:36 AM, shows R1 had a prominent lateral pneumothorax (collapsed lung) present. R1's local hospital History and Physical dated (MONTH) 10, (YEAR) at 11:44 AM, shows R1 had [DIAGNOSES REDACTED]. R1's Emergency Department Progress Notes dated (MONTH) 10, (YEAR) at 6:06 AM shows, patients presents with left ribcage bruising for the past two days. Patient states he fell in the bathroom though his facility states they were unaware of how this happened but obtained a chest X-ray when the bruising was noted yesterday. Pain in ribs are moderate and sharp with deep breaths. On (MONTH) 5, (YEAR) at 3:25 PM, V3 ADON/RN (Assistant Director of Nursing/Registered Nurse) stated, R1 was sent out to the hospital after an X-ray showed he had a pneumothorax. If a resident falls, the staff nurse calls the nurse manager, performs a head to toe assessment, neuro checks if the fall was unwitnessed or they hit their head, vital signs are taken with neuro checks. Neuro checks are performed every 15 minutes for two hours, then every 30 minutes for two hours, the every hour for four hours, and then every shift. Staff should call the doctor and notify the power of attorney. There is post fall charting that is done. (MONTH) 9, (YEAR) at 1:00 PM, V3 said R1 was more agitated and more confused on (MONTH) 9, (YEAR). He was not normal. We found out about his fall after he was sent to the hospital. The director of nursing was doing an investigation regarding the pneumothorax and that's when V4 told her about R1's fall. On (MONTH) 10, (YEAR) at 11:00 AM, V11 RN (Registered Nurse) stated, I remember being surprised hearing about R1's fall and condition. R1 was generally pretty ambulatory. The fall was reported late. R1 doesn't typically complain of pain. On (MONTH) 5, (YEAR) at 3:12 PM, V2 DON (Director of Nursing) said if a resident falls, the nurse does a skin assessment, neuro checks, vita signs and notify the doctor and family. The fall is documented in the progress notes/nurse notes. Charting should be done during that shift. There were no neurological checks documented. There were no vital signs documented after R1's fall until (MONTH) 10, (YEAR).

Based on observation, interview, and record review, the facility failed to assess a residents change in behavior and complaints of pain following a fall. This contributed to R1 experiencing prolonged unrelieved pain for a period of 24 hours. R1 sustained a pneumothorax (collapsed lung) from a fall early morning on (MONTH) 9, (YEAR). This applies to 1 of 3 residents (R1) reviewed for pain in the sample of 7. The findings include: R1's Minimum Data Set (MDS) dated (MONTH) 14, (YEAR), shows R1 was cognitively intact. The facility's Occurrence Report that was entered on (MONTH) 16, (YEAR) (entered 7 days after R1's fall), shows R1 fell in his bathroom while ambulating on (MONTH) 8, (YEAR). On (MONTH) 5, (YEAR) at 2:42 PM, V4 RN (Registered Nurse) said R1 fell early in the morning at about 3:30 AM, but couldn't remember what day. The facility's schedule shows V4 worked the night shift on (MONTH) 8, (YEAR) 10:00 PM-6:00 AM (March 9, (YEAR)). V5 Wound Care nurse worked (MONTH) 9, (YEAR) 6:00 AM-10:00 PM. V12 RN worked the night shift (MONTH) 9, (YEAR) 10:00 PM-6:00 AM (March 10, (YEAR)) and (MONTH) 10, (YEAR) 6:00 AM-2:00 PM. On (MONTH) 5, (YEAR) at 12:10 PM, V7 (R1's Power of Attorney) said she went to visit R1 on (MONTH) 9, (YEAR) after lunch sometime. R1 was hollering in pain. He suffered. He should have had [MEDICATION NAME] a long time ago. On (MONTH) 10, (YEAR) at 8:00 AM, V10 CNA (Certified Nursing Assistant) (worked (MONTH) 8, (YEAR) 10:00 PM-6:00 AM) said R1 fell in (MONTH) (YEAR). He had redness by his ribs. R1 said he was in pain. He could not sit up in bed. I told his nurse, but it took them a long time to come see him. On (MONTH) 9, (YEAR) at 1:15 PM, V5 (Wound Care Nurse) (worked (MONTH) 9, (YEAR) 6:00 AM-10:00 PM) said when she came in Friday (March 9, (YEAR)), R1 was acting strange and complained of pain everywhere, he couldn't reach for his own water. We kept him in bed that shift. He wouldn't use his call light and he would scream for help. I asked the doctor to see him. The doctor said there was bruising on his side. I did not know of any falls. I am not aware that anyone medicated R1 for pain. His behavior got worse as the day went on. V5 assessed R1's skin and their were scattered bruises on his side that were purple. R1's physician progress notes [REDACTED]. R1 was seen today for concerns of changes in behaviors. R1 was cooperative but not his usual self. Prior to entering patient's room, I could hear him yelling for someone to come help him. The patient reported back pain and upon assessment bruising noted to left side of ribs. Patient stated that he had a fall a couple of nights ago. Order placed for left rib X-rays. Staff RN notified of X-ray order as well as patient complaint of pain and she will administer as needed pain medication. Will await x ray report. R1 X-Ray report dated (MONTH) 10, (YEAR) at 2:36 AM, shows R1 had a priminent lateral pneumothorax (Collapsed Lung) present. On (MONTH) 9, (YEAR) at 9:05 AM, V6 CNA (Worked (MONTH) 9, (YEAR) 6:00 AM-2:00 PM) said she was informed in report that R1 was yelling on third shift. R1 was not as mobile as usual and she reported it to the nurse. The were no vital signs documented after the fall that occured early morning (MONTH) 9, (YEAR) until (MONTH) 10, (YEAR). On (MONTH) 10, (YEAR) at 12:54 PM, V12 RN (Registered Nurse) (Worked (MONTH) 9, (YEAR) 10:00 PM-6:00 AM and (MONTH) 10, (YEAR) 6:00 AM-2:00 PM) said she was told they were doing X-rays on R1. R1 did not complain of pain before this fall. V12 stated, I'm not sure if he had pain and do not remember medicating him for pain. R1's Health Status Note dated (MONTH) 10, (YEAR) at 4:00 AM shows V12 entered a note that says, R1 awake, complains of pain in back and left rib area, with coughing. Medicated for pain. R1's Medication Administration Record [REDACTED]. R1's MAR indicated [REDACTED]. (These medications were ordered for pain). R1's Controlled Substances Proof of Use form for [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 shows 30 [MEDICATION NAME] were received on (MONTH) 18, (YEAR) and 30 [MEDICATION NAME] were disposed of on (MONTH) 26, (YEAR). No [MEDICATION NAME] were signed out for R1. On (MONTH) 10, (YEAR) at 11:00 AM, V11 RN said if a pain medication is given, the nurse documents it in the MAR. The MAR makes the nurse enter in a progress note. V11 was not sure why pain medication was not signed out for R1. On (MONTH) 9, (YEAR) at 10:30 AM, V2 DON (Director of Nursing) said if a resident complains of pain, the staff should assess them and treat with medications or notify the physician to obtain orders.

Based on interview, and record review the facility failed to ensure a resident at risk for choking, did not have access to and did not consume nectar consistency liquids. These failures contributed to R1 being given nectar consistency liquids and aspirating on [DATE]. R1 expired on [DATE]. The Immediate Jeopardy began on [DATE] when R1 had a choking episode which resulted in aspiration after the CNA (Certified Nursing Assistant) gave R1 a nutritional supplement that was left on the dining table by the nurse. On [DATE], E1 Administrator was informed of the Immediate Jeopardy related to R1 aspirating and expiring. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of revised policies, procedures, and staff education. This applies to 1 of 3 residents (R1) reviewed for risk of choking in a sample of 8. The findings include: During this survey, R1 was unavailable for observation or interview. R1's Progress Note dated [DATE], showed R1 expired at 11:15 AM. R1's Hospice Patient Information Sheet dated February 12, 2016 showed R1's primary hospice medical [DIAGNOSES REDACTED]. On [DATE] at 10:00 AM, E6 CNA stated that she assisted R1 with eating dinner on the evening of [DATE]. E6 CNA stated, (R1) had pretty much finished his dinner of pureed spaghetti with no episodes of choking. He also had a thickened drink that was red, it looked like fruit juice. A plastic cup of Med Pass (nutritional supplement) was right next to (R1's) fruit juice on the table. I handed the cup of nutritional supplement to (R1) and he took a drink. He started choking right away after he took a drink . We got the nurse right away and she did the Heimlich maneuver on (R1). A white substance started coming out of (R1's) mouth. I don't know where the nutritional supplement came from. I just assumed it (nutritional supplement) was (R1's) because it was right next to his plate and fruit drink. I didn't know at the time that the nutritional supplement wasn't honey thickened consistency. On [DATE] at 10:30 AM, E2 Director of Nursing (DON) stated that she received a call from E4 Licensed Practical Nurse (LPN) on the evening of [DATE] stating that R1 had a choking episode at dinner. E2 DON stated, (R1) did not have a physician order [REDACTED]. That nutritional supplement is nectar thick consistency, not honey thick consistency . I have no idea who put the nutritional supplement on (R1's) table. The nurses administer the nutritional supplements to residents. Nutritional supplements should never be left for a resident to finish. The nurse is to wait and watch as the resident consumes the supplement. I also just inserviced the CNA's (including E6) on checking the residents' diet tickets for food and fluid consistency prior to serving the residents. E2 also stated she had interviewed numerous staff in an attempt to find out where the nutritional supplement had come from on the evening of [DATE]. E2 stated that all of the staff interviewed denied any knowledge of where the nutritional supplement had come from. On [DATE] at 3:30 PM, E10 (Food Service Director) stated, The difference between honey thick fluids and nectar thick fluids is the consistency. Honey thick fluids are thicker in consistency than nectar thick fluids. The label on the container (undated) of the nutritional supplement used by the facility showed, Suitable for nectar consistency diets. On [DATE] at 12:15 PM, E4 LPN stated, I put the Med Pass (nutritional supplement) on the table that evening by the spot where (R2) sat. (R2) sat next to (R1) in the dining room. (R1) must have gotten a hold of (R2's) nutritional supplement . I handed the nutritional supplement to (R2) in the dining room and left it with him. I can't really verify if (R2) drank any of his nutritional supplement. I was called into the dining room that evening ([DATE]) by staff because (R1) was choking. I gave him the Heimlich and he coughed up a milky substance. We immediately wheeled him to the nurse's station and put him on oxygen. I could hear audible rattles coming from (R1's) lungs. E4 stated she called the hospice nurse and physician immediately after the event. On [DATE] at 1:45 PM, E1 (Administrator) denied that R1 had any history of reaching for food on the table or taking food from other resident's plates. E1 stated that R1 needed assistance to eat. On [DATE] at 11:05 AM, Z1 (Hospice Nurse) stated that the on-call hospice nurse notified R1's son at 7:31 PM on [DATE] of R1's choking episode and the son did not want R1 sent to the hospital. Z1 said she updated R1's son at 11:00 AM on [DATE] on R1's condition and the son stated again that he did not want R1 sent to the hospital . Z1 stated, R1's official [DIAGNOSES REDACTED]. R1 became hospice in February 2016. Over the last six months, he had been on increased aspiration precautions due to two episodes of aspiration pneumonia. The last two times he was treated for [REDACTED]. He had an order for [REDACTED]. He has never had an order for [REDACTED]. Med Pass is not honey thick. We expected him to pass from something related to his dysphagia . On [DATE] at 1:50 PM, Z2 (Hospice Physician) stated he was notified that R1 had a choking episode on the evening of [DATE] by the on-call hospice nurse. Z2 stated, I don't recall being told that (R1) had received the wrong fluids. (R1) had been on increased aspiration precautions such as sitting up-right in the chair in the dining room and the pureed diet. I believe (R1's) cause of death was aspiration but I would have to check. R1's Care Plan, Minimum Data Set (MDS), Physician Orders, Progress Notes, Hospice Notes, Incident Report (dated [DATE]), and Comprehensive Diet Assessments were reviewed. R1's Physician order [REDACTED]. No order for a nutritional supplement (Med Pass) was found in R1's Physician order [REDACTED]. The facility's Resident Nutrition Services Policy dated [DATE] showed, 3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's orders [REDACTED].>Through observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. Reviewed the Choking Policy, Assessment and Documentation with all nursing staff on [DATE]. 2. Educated all nursing staff on ensuring resident's are provided with their prescribed diet including correct fluid consistency. As of [DATE], 100% of all CNAs, including PRN's, were educated. 3. Educated all nurses on ensuring medications, including supplements, are not to be left with a resident and that when providing fluids, to enure the correct consistency is provided according to the resident's orders. As of [DATE], 100% of all nurses were educated. 4. All new nursing staff will have the same information reviewed with them at the time of orientation. 5. The facility will complete random daily audits to monitor for correct diet and fluid consistency with meals. 6. The facility will complete random daily audits to monitor for compliance with supplement administration.

Based on observation, interview, and record review the facility failed to apply a physician ordered protective skin barrier wipe (skin prep) to a blister. The facility failed to follow a physician order [REDACTED]. The facility failed to change a pressure injury dressing every third day as ordered by a physician. The facility failed to update care plan interventions when pressure injuries were discovered. These failures contributed to R8's suspected deep tissue injury increasing in size. These failures contributed to one of R9's closed deep tissue injury turning into an unstageable wound filled with slough. These failures contributed to R9's stage II pressure injury turning into an unstageable wound with slough and drainage. This applies to 2 of 3 residents (R8 and R9) reviewed for pressure injury in the sample of 15. The findings include: 1. R8's initial Minimum Data Set (MDS) for September 16, 2016, shows he was at risk for pressure injuries and did not have any unhealed pressure injuries when he entered the facility. R8's Braden Scale for Predicting Pressure Sore Risk dated September 10, 2016, shows R8 to be at low risk for developing pressure injuries. On September 27, 2016 at 8:15 AM, E10 Certified Nursing Assistant (CNA) removed R8's left protective boot and sock. R8 had a blister on his left heel that was intact with a discolored purple center that extended to the outer edges of the blister. The diameter of the blister was the size of a baseball. R8's paper chart shows a physician order [REDACTED]. On September 28, 2016 at 7:58 AM, R8 was in the dining room with a shoe on his left foot. On September 28, 2016 at 8:30 AM, E11 Dietary Aide confirmed R8 had a left shoe on while eating in the dining room. On September 28, 2016 at 11:04 AM, E12 Certified Nursing Aide (CNA) said R8 should not have shoes on because he has a blister on his left foot and having a shoe on puts pressure on the blister. On September 27, 2016 at 11:10 AM, E4 Registered Nurse (RN) said R8 developed the blister from resting his heel on his mattress and skin prep is part of R8's blister treatment plan. E4 said the application of the skin prep should be documented in R8's Treatment Adminstration Record (TAR). E4 could not find documentation that skin prep was applied to R8's blister. E4 said the skin prep was not on R8's TAR. E4 opened R8's electronic medical record and modified R8's September 15, 2016, skin prep order to appear on R8's TAR. On September 27, 2016 at 1:45 AM, E2 Director of Nursing said the skin prep application should be on R8's TAR and if it is not on the TAR nurses would not know to apply the skin prep. E2 expected the physician orders [REDACTED]. R8's TAR printed on September 28, 2016, shows the first day skin prep was applied to his blister was September 27, 2016 (12 days after it was ordered). On September 28, 2016 at 11:03 AM, E2 said by not using skin prep and by not keeping R8's shoes off his blister (the wound) could worsen and increase in size. R8's Health Status Note dated September 15, 2016, shows, Patient has 4.5cm x 4cm fluid filled blister on left heel. Family, (E2), (nurse practitioner) notified R8's Pressure Ulcer Weekly Wound Evaluation sheet dated September 21, 2016, shows a suspected deep tissue injury to the left heel measuring 6.2 cm x 6 cm (increase in size). The pressure injury was acquired at the facility. The same sheet indicated the care plan was updated. On September 27, 2016 at 11:03 AM, E2 said the wound nurse or herself updates the resident's care plan when a wound is found or on the next day. R8's Care Plan printed on September 27,2016, shows interventions for his blister were entered September 27, 2016 (12 days after the wound was found). 2. R9's Order Summary Report for September 2016, shows R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R9's Nursing Admission Data Collection dated August 25, 2016, shows R9 did not have impaired skin integrity. R9's first Braden Scale for Predicting Pressure Sore Risk was done on September 1, 2016, and it shows R9 was low risk. Another Braden Scale for Predicting Pressure Sore Risk was done on September 15, 2016, R9 remained a low risk for pressure injury development. R9's Order Summary Report for September 2016, shows an order was written on September 15, 2016 to apply a foam pad to the left buttock every three days for pressure injury and suspected deep tissue injury. On September 26, 2016 at 1:40 PM, E4 removed a visibly soiled dressing from R9's left upper buttocks near his coccyx that was dated September 21, 2016. This dressing was covering two different pressure injuries, one on the upper left buttock and one near the coccyx. The dressing had a moderate amount of brownish colored drainage on it with a slight odor. E4 stated, The drainage is brownish green and a moderate amount, considering it is five days old. The pressure injury on R9's left buttock was approximately the size of a dime and filled with slough (dead tissue). The pressure injury on R9's coccyx was the size of a pencil eraser and was also filled with slough. E4 then reached in her pocket for a marker and wrote the date on the new dressing. E4 cleansed the wound bed and placed the new dressing on, without changing her gloves. R9 also had a blackened unstageable pressure injury to his left heel which was larger than a half dollar. E4 placed skin prep to this area. On September 27, 2016 at 1:00 PM, E4 stated R9's dressing should be changed every three days. Gloves should be changed after taking off a soiled dressing and placing a new clean dressing. If gloves are not changed, then the risk of infection increases and if infection is present on the dressing then you could reinfect the wound. R9's Treatment Administration Record for September 2016, shows E4 signed off the ordered treatment on September 23, 2016 and September 26, 2016. On September 28, 2016, during the daily conference, E2 stated she was aware that the dressing change was signed off by E4 but not sure why since it was not done. R9's Weekly Skin Check dated September 1, 2016, shows R9 had slight redness to his left heel. R9's Pressure Ulcer Weekly Wound Evaluation shows that a suspected deep tissue injury was found on his left heel on September 21, 2016. There was no drainage and the wound was closed. This was the only Weekly Wound Evaluation found for this wound. R9's Daily Skilled Nurse's Note dated September 20, 2016, shows R9 had a blackish, four centimeter circular blister on his left heel. The Daily Skilled Nurse's Note dated September 22, 2016 at 1:26 AM, showed R9 had no skin issues, however at 6:26 PM the Daily Skilled Nurse's Note showed R9 had a blackish blister on his left heel. R9's Pressure Ulcer Weekly Wound Evaluation dated September 14, 2016, shows R9 had a closed suspected deep tissue injury and a non draining stage 2 pressure injury to his left buttock. R9's Pressure Ulcer Weekly Wound Evaluation dated September 21, 2016, shows R9's pressure injuries were now unstageable, filled with slough, and draining. (Wound deteriorated in seven days) There was no change in treatment orders R9's Minimum Data Set, dated dated dated [DATE], shows R9 had two unstageable/deep tissue injuries and one stage two pressure injury. On September 27, 2016 at 1:10 PM, E2 stated gloves should be changed after taking off a soiled dressing because you could introduce something that wasn't in the wound. E2 stated she expected the nurses to check the wound dressing daily. If a dressing is due to be changed every three days, it would be an expectation to do so. If a dressing is left on longer than ordered and there is drainage present, the resident could develop an infection. R9's care plan initiated September 14, 2016, shows to administer treatments as ordered, monitor for effectiveness, and monitor dressing frequently. There were no other interventions added to R9's care plan after the discovery of the pressure injury to his buttocks or heel. The facility's policy on Clean Treatment Technique revised on August 2015, shows to wash hands and apply gloves before cleansing the wound and applying a clean dressing. The facility's policy on Pressure Ulcer Prevention revised on August 2015, shows a Braden Scale risk assessment will be completed upon admission, weekly for four weeks, quarterly, and when a significant change in the resident's condition is noted. An individual plan of prevention will be developed to meet the needs of the resident. Protect heels, float if possible, skin checks weekly, and relieve pressure to heels by using pillows or other devices.

Based on observation, interview and record review the facility failed to identify and provide treatment to prevent pressure ulcer from developing and worsening, failed to routinely assess and monitor resident pressure wounds. These failures resulted in three residents (R2, R3, R11) developing pressure wounds which progressed to unstageable wounds. The facility failed to ensure a resident's (R1) dressing was in place to promote healing of a pressure wound. This applies to 4 of 9 (R1, R2, R3, R11) residents reviewed for pressure ulcers in the sample of 16. The findings include: 1. The (undated) facility face sheet for R2 shows an admission date of [DATE]. The 7/16/14 quarterly Minimum Data Set (MDS) shows R2 required extensive assist with bed mobility and needs assist of one staff for repositioning. The MDS ambulation assessment showed R2 ambulated in her room and the corridor with limited assist of 1 staff. The 8/5/14 Braden Skin assessment to predict pressure ulcer risk documents R2 at low risk for developing pressure ulcer. The 7/29/14 weekly skin check form show R2 had no new areas of concern. The 8/5/14 weekly skin check shows " slight redness noted under breasts and ulcer areas to the residents heels. " There are no measurements or description of the heels. The 8/5/14 Weekly Pressure Ulcer Assessment documents a facility acquired left outer heel wound identified on 8/5/14. The wound measured 2.5cmx4.5cm (length x width). The wound was classified as unstageable with slough/Eschar tissue over 100% the wound. The right outer heel had a wound identified on 8/5/14 at 2cmx3.5cm and is a suspected deep tissue injury. The wound is described as discolored and blue/purple. On 10/8/14 at 11:00 AM, E2 DON (Director of Nursing) stated she had looked at the prior skin assessments for R2 and could not find a previous nursing note; the measurements of 8/5/14 are the initial assessment of the wounds. On 10/8/14 at 12:15 PM, E5 (Certified Restorative Assistant) stated when R2 would ambulate with a wheel walker as staff followed her with wheelchair. E5 stated R2 would have her tennis shoes on and ambulate to all of her meal every day. On 10/7/14 at 9:05 AM, E4 LPN (Licensed Practical Nurse) stated R2 was ambulatory until the pressure sores on her heels were found. E4 stated R2 was then put in a wheelchair and (protective) boots were put on her feet and she cannot have her tennis shoes on or walk to meals. On 10/8/14 at 11:00 AM, E4 stated the nurses are required to perform weekly skin assessments for their assigned residents. E4 stated the CNA ' s (Certified Nursing Assistants) will report any abnormal finding to them or they will put the information into the computer as an alert for the nurse to assess an area of concern. E4 stated she had first noticed R2 ' s heels when she was assisting her to move and noted blood on the sheet. E4 stated it looked as though a blister had broken open. E4 stated R2 was wearing tennis shoes up until that day. E4 stated R2 probably developed the sores while she was in bed because she did not move all that well when she was in bed. E4 stated there were no interventions in place to prevent the blisters from forming. On 10/8/14 at 11:00 AM, E2 stated the CNA ' s are trained to report any skin issues to the nurse by either verbal report or by placing an alert in the point of care computer system. E2 stated she had checked R2 ' s documentation in the alert system and found no notes to the nurse to let her know R2 was having issues with her heels. E2 stated the heels should have been noted as breaking down before they were found on 8/5/14. E2 stated she was at a low risk for skin breakdown so she did not have any special mattress and nothing was done to protect her heels. E2 stated R2 ' s skin sores were probably from not being positioned properly and not getting turned every two hours. On 10/7/14 at 1:00 PM, R2 is observed sitting in a wheelchair in her room with both feet in protective boots to both feet. R2 stated when she arrived at the facility in January she was wearing her own shoes and walking to her meals. R2 could not recall how she developed the sores on her heels, but stated she does not like the boots she has on and would like to just wear her shoes again. The 8/13/14 Restorative note by E12 RN (Registered Nurse), documents R2 has shown a significant decline, requires increased assist to complete ADL ' s (Activities of Daily Living). Occupational Therapy working with her and she is not participating in active range of motion exercises or walk to dine program. (R2) has developed deep tissue damage and unstageable pressure ulcers to both of her heels, has increased pain and confusion. The 1/19/14 care plan for R2 states she has potential for pressure ulcer development. The intervention listed is to follow facility policies and protocols for the prevention and treatment of [REDACTED]. The facility ' s November 2010 Pressure Ulcer Prevention shows residents that are at a mild or low risk for pressure ulcers are to have frequent turning, reminders or assistance with turning at night and protect the heels. Skin checks weekly by a licensed nurse and daily observation of skin during care given by the CNA ' s. 2. The Undated facility resident profile shows R3 has the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) of 08/01/2014 shows R3 requires extensive assist of 1 staff with bed mobility and extensive assist of 2 staff with transfers. On 10/08/2014 at 10:45 AM, E9 (LPN) provided wound care to R3's pressure ulcers on her coccyx and her right ischium. R3 had one large pressure ulcer over her coccyx. There was a quarter sized area on the right side of the coccyx that was covered with 90% slough and 10% granulation tissue. There was a nickel sized area on the left side of the coccyx with 90% slough and 10% granulation tissue. There was an area in between the sloughed areas to the left and right of the coccyx with 100% granulation tissue. There was a dime-sized open area on the right ischium that was 100% granulation tissue. There was a third open area located superior and slightly to the right of the coccyx measuring 0.7cm x 0.6 cm that was 100% slough. All the open areas were moist with no drainage noted. The skin surrounding all of the open areas on R3's buttocks was reddened. R3's 09/25/1014 Weekly Pressure Ulcer Assessment shows an unstageable pressure ulcer over her coccyx measuring 8.3 x 5.7 centimeters (cm) with eschar and a moderate amount of opaque exudate. The document shows the peri wound area is as red and macerated. The 09/25/2014 documents show a stage III pressure ulcer on R3's right ischium measuring 1.5cm x 1.2cm x less than 0.1 cm depth with 90% granulation tissue and 10% necrotic tissue with small amount of exudate. There was no documentation of the open area superior and slightly to the right of R3's coccyx including, onset of pressure ulcer, the size of the wound bed, healing or decline of pressure ulcer. On 10/09/2014 at 11:10 AM, E2, Director of Nursing (DON) stated "Oh, I didn't know there was another open area." On 10/09/2014 at 11:30 AM, E2 stated "There were no nurses notes charting the pressure ulcer above and to the right of R3's coccyx. I have looked everywhere and have not found any documentation." On 10/8/14 at 10:20 AM, E11 and E16 (CNA) provided incontinence care to R3 in preparation for the wound care treatment. After cleaning and drying R3's sacral and ischial pressure ulcers, E11 applied a thick layer of dimethicone skin barrier over the pressure sores. E11 said " I think I'm supposed to put this on, the nurse can take it off if she needs too". On 10/8/14 at 10:50 AM, E9 (Registered Nurse) said R3 does not have an order to have dimethicone skin protectent applied to her pressure sores. 3. R11's 9/24/14 revised Pressure Ulcer Care Plan shows R11 has [DIAGNOSES REDACTED]. R11's MDS of 10/3/14 shows R11 is cognitively intact and requires extensive assistance from staff with dressing, transfers, bed mobility, and activities of daily living. On 10/9/14 at 12:15 PM, R11 was sitting in a wheelchair in his room. R11 had gauze wrapped around his right calf, his left upper calf (below his knee), and a gauze dressing to his right heel. R11's 7/15/14 skin assessment shows a score of 15, identifying R11 as low risk for breakdown. The 7/29/14 skin assessment shows R11 is at moderate risk for skin breakdown. R11's 7/9/14 Weekly Pressure Ulcer assessment dated [DATE] shows R11 was also admitted with a "100% [MEDICATION NAME] tissue, closed but red area to R11's Right Heel, measuring 0.3cm x 0.2cm." R11's Weekly Pressure Ulcer assessment dated [DATE] shows the Right Heel Pressure Ulcer was resolved. R11's Weekly Pressure Ulcer Assessment dated 9/18/14 shows a "facility acquired re-opened" Pressure Ulcer to R11's Right Heel. This initial assessment shows the pressure ulcer was identified on 9/15/14 measuring 0.5 cm x 0.4 cm, unstageable with slough/eschar and 90% necrotic tissue. There is no evidence of ongoing assessments to show monitoring of the heel until 9/18/14 when the wound re-opened as unstageable with 90% necrotic tissue. R11's Skin/Wound Progress note dated 9/18/14 shows "When repositioning legs and checking dressing placement, noted new area to left outer calf". R11's initial Weekly Pressure Ulcer assessment dated [DATE] shows a facility acquired "Unstageable" Pressure Ulcer to R11's Left Calf. This document shows the pressure ulcer measured 1.1cm x 0.8cm, 0.1cm with 75% necrotic tissue and slough when first identified. On 10/9/14 at 12:15 PM, R11 said when he first arrived to the facility he had an air mattress with "restraints on the sides" so he wouldn't fall out of bed. R11 said the bed was comfortable but he could not use the air mattress because he could not go from lying in the bed to a sitting position because of the sides of the mattress. R11 said the raised sides caused "horrible pain" to his legs when he tried sit up and get out of the bed. R11 said the facility then had to put a basic mattress on his bed that did not have raised sides at the bottom. R11 said now "they were able to get me a better air mattress that does not have those uncomfortable sides like the first one". R11's Weekly Assessment shows he was admitted on [DATE], with multiple Pressure Ulcers but did not have an air mattress placed until 7/24/14. R11's Weekly Pressure Ulcer assessment dated [DATE] shows R11 had a change from an air mattress to a "pressure-reducing" mattress in place. R11's Weekly Skin Note dated 9/2/14 shows "continues on regular pressure reducing mattress at this time...". R11's Physician order [REDACTED]. On 10/10/14 at 12:30 PM, E2 said she talked with R11 and his wife on 9/12/14 and told them he (R11) could have an air mattress that did not have bolsters on the sides. E2 said this mattress would be less restrictive for R11. E2 also said the air mattress is better than the pressure reducing mattress at relieving pressure and due to R11's existing skin issues, he (R11) should have been on an air mattress the whole time. On 10/9/14 at 12:15 PM, R11 also said he thinks the pressure ulcer to his left leg started from sitting in his wheelchair and resting his leg on the side of the chair. R11 said he noticed a sore spot to his left leg and " I said what's happening down here and they checked it". R11 said that is when they found the sore to his left calf. R11 relaxed his left leg and demonstrated how it rests on the bottom left side of the wheelchair. R11 said "we were not aware my leg was resting on the chair and causing a problem. My leg is stronger now and I can keep it off the chair myself". On 10/9/14 at 12:00 PM, E2 said a full body skin assessment should be completed weekly by the nursing staff. In addition, E2 said the Certified Nurse Assistants - CNA's do a daily assessment and are instructed to notify the nurse of any skin changes or concerns. E2 said the CNA's also have a shower skin check sheet that is completed at least twice a week with showers. E2 said the nurse has to visibly look at the resident's skin shower during the shower and sign the shower skin check sheet with the CNA every time a shower is given. E2 said if daily skin checks are being completed, and weekly skin checks are being completed, a pressure sore should be found before it is Unstageable, with slough and necrotic tissue present. E2 said there should be a progression of decline with the wound, not first identifying it as Unstageable. The 2010 facility "Pressure Ulcer Prevention" policy states "Skin Checks weekly by License Nurse, Daily observation of skin during care given by CNA's..." 4. On 10/07/14 at 1:08 PM, E7 and E8 (Certified Nursing Assistants-CNAs) provided perineal care to R1. When R1 was turned towards her left side, R1 ' s healing stage IV pressure ulcer on the coccyx was open to air; no treatment/dressing was in place. A scant amount of yellowish drainage was noticeable on R1 ' s draw sheet from the wound bed. E8 and E7 both stated that no dressing was in place earlier this morning when they did an incontinence check on R1. E7 and E8 did not report their findings to the charge nurse. On 10/07/14 at 1:52 PM, E9 (Licensed Practical Nurse-LPN) said that the nurses assigned in each hall or the wound care nurse are responsible to do the wound treatment for [REDACTED]. " The wound treatment order for R1 dated 08/01/14 shows the treatment order written as follows: " Cleanse wound bed to coccyx with NS and pat dry, apply [MEDICATION NAME] every day shift everyday. " The progress notes dated 10/07/14 at 2:14 PM shows an entry by E9 written as " ...notified second shift nurse dressing change not done, resident up in wheel chair " On 10/09/14 at 11:20 AM, E2 (DON) said that the staff is expected to follow the doctor ' s order as it is written. E2 stated " whatever is written in the treatment record should be followed and if the CNAs find a wound without a dressing, they have to report that to the nurse right away. "