Every finding on record at Flanagan Rehabilitation and Health Care Center

Based on observation, interview, and record review, the facility failed to provide a clinically qualified Director of Food and Nutrition Services. This failure affects all 41 residents residing in the facility, all of whom consume food prepared in the facility kitchen. Findings include:On 7/14/26 at 10:19 am, V12, Dietary Manager, was actively engaged in food service wares sanitation. V12 was actively managing food preparation and food preparation personnel.On 7/14/26 at 10:19 am, V12 stated she is the dietary manager. V12 stated she has a certification as a Certified Food Protection Manager (CFPM). V12 stated she began working at the facility February of 2026. V12 stated she was planning to speak with the facility's Regional Director of Food Strategy (V8) later in the month to get signed up to take the Certified Dietary Manager (CDM) course. V12 stated V8 only assists in preparation for ordering required food and supplies to fulfill the menus. V12 stated she did not meet the Illinois State requirements for a Dietetic Service Supervisor or Director of Food Services by stating she was not a Registered Dietician. V12 stated she does not have a CDM certificate nor has she completed the course for a CDM certificate. V12 stated her own CFPM course of study did not include clinical and nutritional concerns such as dialysis, gastrostomy tube feedings, or pressure ulcers. V12 stated she had not graduated form any approved clinical school or course of study, the only certificate she had was the CFPM which was basically a cook's certificate in a course for cooking sanitation. V12 stated she had not graduated from any 90 hour approved course prior to 1990. V12 stated she had no military service experience. V12 stated the Registered Dietician is (V9) who comes to the facility one day per month to consult about clinical matters.There were identified food sanitation concerns related to utensil storage and drawer cleanliness. Reference F812. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services form 671) dated 7/15/26 documents 41 residents reside in the facility, all of whom consume food prepared in the facility kitchen.

Based on observation and interview, the facility failed to store food service utensils in a sanitary manner to prevent cross contamination of food. This failure has the potential to affect all 41 residents residing in the facility, all of whom consume food prepared in the facility kitchen.Findings include:On 7/14/26 at 10:40 am, accompanied by V12, Dietary Manager, one of the food service utensil drawers contained a bright metal object with multiple blades and a piece of white food debris stuck between the blades. V12 stated that object was an egg slicer and was used to make egg salad. There was a plastic measuring spoon with a crunchy white flaky substance on the back of the spoon and handle. V12 began to remove all the utensils from the drawer and stated she had been off work the day prior and had planned to examine the utensil drawers. V12 stated the utensils needed to be run through the dishwasher. The bottom of the first utensil drawer had large accumulations of dark brown and black food crumb debris, and dark brown greasy substance approximately two inches in length by one and one half inches in width. V12 remained quiet but began to wipe out the bottom of the utensil drawer.In the facility's second utensil drawer containing food service spoons and ladles, there were large accumulations of light brown, dark brown, and black food crumb debris. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services form 671) dated 7/15/26 documents 41 residents reside in the facility, all of whom consume food prepared in the facility kitchen.

Based on observation, interview and record review the facility failed to ensure the dignity of one (R46) resident by not providing access to a commode causing R46 to wear incontinence briefs for one out of two residents reviewed for dignity in a sample list of 29 residents.Findings include:R46's undated Face Sheet documents R46 admitted to the facility on [DATE]. R46's Brief Interview for Mental Status (BIMS) dated 7/10/26 documents R46 as cognitively intact. R46's Hospital Record dated 7/10/26 documents R46 had a surgical repair of her Right Lower Leg and should be non-weight bearing on her Right Ankle.R46's admission assessment dated [DATE] documents R46 as being continent of bladder and bowel. This same assessment documents R46 requires the assistance of two staff for toileting. On 7/14/26 at 12:15 PM R46 stated she admitted to the facility on [DATE] for short term rehabilitation. R46 stated she 'broke her leg' and is now non-weight bearing on her Right leg. R46 stated she was continent of bladder and bowel prior to admitting to the facility. R46 stated the facility told her that they do not have a commode for her to use and now has to wear incontinence briefs and is incontinent of urine and bowel. R46 stated she has never had to wear incontinence briefs before admitting to this facility. R46 stated she 'feels like a baby wearing a diaper' because she now has to wear incontinence briefs. R46 stated she takes a water pill which makes her urinate 'alot'. R46 stated she has had to wear an incontinence brief since her admission on [DATE] and has been incontinent of urine and bowel every day due to not having a commode in her room. On 7/14/26 at 12:50 PM V3 Certified Nurse Aide (CNA) completed incontinence care for R46. R46 was wearing an incontinence brief that was moderately saturated with urine. R46 did not have a commode in her room. On 7/15/26 at 9:30 AM V1 Administrator stated the facility has extra commodes in storage. V1 Administrator stated the staff should not have told R46 to use an incontinence brief if she was not incontinent. V1 Administrator stated R46 is at the facility for short term rehabilitation, is cognitively intact and able to make safe decisions. V1 Administrator stated she spoke with R46 and a commode has been provided. V1 stated she will educate the staff to ensure all residents are encouraged to stay at their individual highest level of functioning.The facility policy titled Resident Rights Policy dated March 2026 documents each resident will have autonomy and choice, to the maximum extent possible, about how each resident wish to live his/her everyday life and receipt of care, subject to the community's policies and procedures as long as those policies do not violate any requirement.

Based on interview and record review the facility failed to complete a thorough Baseline Careplan for two (R43, R46) residents out of two residents reviewed for careplans in a sample list of 29 residents. Findings include:1. R43's undated Face Sheet documents R43 admitted to the facility on [DATE] and discharged on 4/23/26. R43's Minimum Data Set (MDS) dated [DATE] documents R43 as cognitively intact.R43's Electronic Medical Record (EMR) documents medical diagnoses of Sepsis, Osteomyelitis of Left Ankle and Foot, Vascular Implant and Surgical aftercare following surgery on the circulatory system.R43's Baseline Careplan initiated on 4/16/26 does not include a focus area, goal nor interventions for R43's Peripheral Inserted Central Catheter (PICC) line, use of Intravenous (IV) Antibiotics and Left Groin wound infection which R43 admitted to the facility with. On 7/16/26 at 10:00 AM V1 Administrator stated R43' Baseline Careplan did not include R43's primary reasons for admission, clinical needs such as IV antibiotics, wound infection and isolation precautions. V1 stated all baseline careplans should include the primary reason for admission and any other high priority needs/cares the resident has. 2. R46's undated Face Sheet documents R46 admitted to the facility on [DATE]. R46's Brief Interview for Mental Status (BIMS) dated 7/10/26 documents R46 as cognitively intact. R46's Hospital Record dated 7/10/26 documents R46 had a surgical repair of her Right Lower Leg and should be non-weight bearing on her Right Ankle.R46's Baseline Careplan does not include R46's physician orders for R46's fractured Right Ankle, non-weight bearing status nor transfer status until 7/15/26.On 7/15/26 at 3:30 PM V1 Administrator stated R46's Baseline care plan was incomplete. V1 stated R46's Baseline Care Plan should have included R46's primary reason for being admitted to the facility. V1 state R46 admitted to the facility after being struck by a motor vehicle which resulted in R46's Right Ankle Fracture and being non-weight bearing on her Right Ankle. V1 stated the staff should follow all resident care plans but if the careplans do not include pertinent information for caring for the resident then the resident may not receive the care they need and/or the physician orders may not be followed. V1 Administrator stated she is unable to locate a Baseline Care Plan policy but would expect the staff to enter the appropriate information with 48 hours of the resident's admission to the facility.

Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R46) resident out of one resident reviewed for incontinence care in a sample list of 29 residents.Findings include:R46's undated Face Sheet documents R46 admitted to the facility on [DATE].R46's Electronic Medical Record (EMR) documents medical diagnoses as Fracture of the Right Lower Leg, Morbid (Severe) Obesity, Congestive Heart Failure and Spinal Stenosis.R46's Brief Interview for Mental Status (BIMS) documents R46 is cognitively intact. R46's Care Plan intervention dated 7/15/26 documents R46 requires staff assistance with toileting.On 7/14/26 at 12:50 PM V3 Certified Nurse Aide (CNA) completed incontinence care for R46. R46 was wearing an incontinence brief that was moderately saturated with urine. V3 CNA did not perform hand hygiene or change gloves throughout the procedure. V3 CNA obtained a clean incontinence brief, unfolded it and placed it against the edge of the mattress. V3 CNA used her knees to hold the open incontinence brief up against R46's mattress while waiting for R46 to turn over. On 7/14/26 at 1:00 PM V3 Certified Nurse Aide (CNA) stated she should have washed her hands and changed her gloves after cleansing R46's perineal area prior to placing a new incontinence brief. V3 CNA stated she did not realize she had placed R46's clean incontinence brief against her knees but that 'would not be ok'. V3 CNA stated she 'must have done that by habit'. On 7/15/26 at 9:15 AM V1 Administrator stated staff will be provided education to prevent cross contamination during incontinence care. On 7/15/26 at 11:45 AM V2 Director of Nurses (DON) stated the facility does not have a policy for providing incontinence care but V2 expects staff to prevent cross contamination to reduce the risk of infections. V2 DON stated staff should wash their hands and change gloves when moving from a contaminated area to a clean area. V2 DON stated V3 Certified Nurse Aide (CNA) should have removed her gloves and performed hand hygiene before applying new gloves and then applying a new incontinence brief for R46. The undated facility policy titled Perineal Care Protocol instructs staff to gather supplies, perform hand hygiene and don gloves. This same policy instructs staff to then cleanse the resident front perineal area, perform hand hygiene, cleanse the resident's rear perineal area, perform hand hygiene and then place a new incontinence brief.

Based on interview and record review the facility failed ensure a controlled medication was not stopped abruptly without notifying the physician for one of two residents (R1) reviewed for medication errors in the sample list of three. This failure resulted in R1 becoming unresponsive, falling, and being transferred to the hospital with benzodiazepine withdrawal, delirium, and syncope after R1's Ativan (benzodiazepine) was stopped abruptly.Findings include:R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment. R1's active Care Plan dated 7/18/25 documents the following: R1 has anxiety and intellectual developments. Interventions include give medication as ordered and monitor/document side effects and effectiveness, and to monitor for signs/symptoms of behaviors. The Care Plan documents R1 has diagnoses of Developmental Intellectual Disability, Depression and Anxiety Disorder. R1's July, August and September Medication Administration Record (MAR) documents a physician order from the Hospital dated 7/18/25 for Ativan (Benzodiazepine) 1mg (milligram) three times a day. Pharmacy Records document the pharmacy filled the medication script of 1mg of Ativan on 7/18/25, 8/2/25, 8/14/25, and 8/28/25 for 15 days each refill day with 45 capsules. R1's MAR documents Ativan 1mg three times a day was stopped on 9/6/2025. The Nursing Control Medications sheet dated 9/6/25 documents that 32 Ativan pills were wasted with two nurse witnesses. Nursing Notes dated 9/9/2025 at 9:24AM document facility staff requested a signed prescription for R1's Ativan. The Pharmacy Receipt dated 9/11/25 documents the pharmacy received the signed prescription for 1mg Ativan three times a day. R1's Nursing notes dated 9/11/25 at 2:46pm document Nurse was in next room and heard a thud. Went into residents' room and observed resident on the floor laying supine with her head in the corner of her closet and the wall. Resident unresponsive. Pulse and respirations present. 911 called. MD (Medical Doctor), POA (Power of Attorney), DON (Director of Nurses), and transport notified. Resident put on backboard and neck stabilized. No physical injury observed. VS (vital signs) taken; blood sugar taken. EMS (Emergency Medical Services) arrived 1455 (2:55 PM). Resident slowly began to become more responsive. R1's Medical Record documents R1 was admitted to the hospital on [DATE] with a diagnosis of Benzodiazepine Withdrawal with Delirium and Syncope and Collapse.Nursing Progress Notes dated 9/16/25 at 12:23PM document, The interdisciplinary team met and resident's family and hospital were concerned that resident had a seizure related to Ativan discontinuation, spoke with Medical Director and resident will resume Ativan at current dose and will remain on it indefinitely.On 9/18/25 at 8:17AM, V4 (Registered Nurse), stated V4 was the nurse on duty that day and heard a thud and responded. V4 stated R1 was lying in the corner by the closet, lying flat on her back, her skin was cool and clammy and R1's blood pressure was high. V4 stated she called for the emergency crash cart as R1 was unresponsive and called 911 to send R1 to the Emergency Room. On 9/18/25 at 11:13AM, V5 (Pharmacist) stated a 3mg daily dose of any Benzodiazepine would be considered a high risk medication and should have been decreased gradually continuously for two months. V5 also stated that risk factors include, seizures, cognitive decline, nausea, vomiting, unresponsiveness and harm to a resident if stopped abruptly. On 09/18/25 at 12:05PM, V6 (Registered Nurse) stated V6 noticed the order for R1's Ativan 1mg tablet three times a day had fallen off the MAR and the remainder of the medication was wasted in the sink with another nurse. V6 stated she should have called the Doctor to ask to continue the medication, but did not call and verify with the Doctor or the Power of Attorney or Guardian. On 9/18/25 at 12:43PM, V7 (Medical Director) stated that he was unaware that R1's Ativan 1mg three times a day was stopped, and the nurse should have contacted V7, as any controlled medication needs to be decreased gradually. V7 stated he talked with the hospital and stated R1 was without the 1mg Ativan three times a day from 9/6/2025 to 9/11/25 which caused her to have withdrawal symptoms. V7 states that any decrease of a controlled substance could cause harm if stopped abruptly without tapering and could lead to seizures, altered mental status, dizziness, syncope, and unresponsiveness. V7 stated from his clinical standpoint that stopping R1's Ativan abruptly caused R1 to become unresponsive and fall, resulting in admission into the hospital. The Facilities Medication Administration Policy Documents that Any changes in medication orders must be documented in the resident's medical record and Medication administration records should be maintained for each resident and must be up to date and easily accessible.

Based on interview and record review the facility failed to ensure care plans included problems, goals, and interventions to address diagnoses and medication use for two of three residents (R2, R3) reviewed for medications in the sample list of three. Findings include:1.) R2's active diagnoses list includes epileptic seizures related to external causes, not intractable, without status epilepticus. R2's September 2025 Medication Administration Record (MAR) documents R2 receives Lamotrigine 200 milligrams (mg) by mouth twice daily for seizures since 2/3/24 and Phenytoin Sodium100 mg give two capsules by mouth twice daily for seizures since 5/24/25.R2's active care plan does not include a problem, goal, and interventions for R2's seizure disorder and seizure medications. On 9/18/25 at 12:55 PM V2 Director of Nursing confirmed R2's seizure disorder and seizure medications were not on R2's care plan. V2 stated V2 is responsible for updating the care plans and V2 will update R2's care plan. 2.) R3's September 2025 MAR documents R3 receives Tramadol (opioid) 50 mg one tablet by mouth daily since 4/18/23. R3's active care plan does not have a problem, goal, and interventions for opioid use and monitoring, including risk for constipation. On 9/18/25 at 12:55 PM V2 confirmed R3's care plan does not address Tramadol use, interventions, and risk for constipation. V2 stated V2 will need to update R3's care plan.

Based on interview and record review the facility failed to implement a bowel program for one of three residents (R3) reviewed for medications in the sample list of three. Findings include:R3's August and September 2025 Medication Administration Records document R3 receives Tramadol (opioid) 50 milligrams by mouth daily since 4/18/23 and Milk of Magnesia 30 milliliters daily as needed for constipation. These records document R3 does not receive any scheduled bowel medications and did not receive any doses of Milk of Magnesia. R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment and requires dependence on staff for toileting hygiene. R3's active care plan does not address R3's Tramadol use and monitoring, including risk for constipation. R3's Bowel Tracking Report with date range 8/20/25-9/18/25 documents the following: Large on 8/20/25. None 8/21/25-8/23/25. Large on 8/24/25. None 8/25/25-8/27/25. Large on 8/28/25. None 8/29/25-9/1/25. Large on 9/2/25. None on 9/3/25 and 9/4/25. Large on 9/5/25. Two to three daily 9/6/25-9/8/25. Once on 9/9/25 and 9/10/25. None 9/11/25-9/13/25. Large on 9/16/25. None 9/17/25 and 9/18/25. R3's Nursing Notes with range 8/15/25-9/18/25 do not document R3 was assessed for constipation, offered Milk of Magnesia, or offered any other bowel interventions. On 9/18/25 at 11:29 AM V4 Registered Nurse stated the (electronic medical software) triggers an alert if a resident doesn't have a bowel movement (BM) for three or more days. V4 stated the Certified Nursing Assistants (CNAs) document the residents' BMs. V4 stated R3 has Milk of Magnesia to administer daily as needed. V4 stated R3 has occasional constipation, but nothing frequent. V4 confirmed R3 does not have orders for any other bowel medications. On 9/18/25 at 11:55 AM V3 CNA stated V3 is assigned to R3's care today and R3 has not had a BM today. V3 stated BMs are documented by the CNAs in (electronic medical software) and complaints of constipation are reported to the nurses. V3 stated R3's BMs are generally soft, but R3 has constipation about once per week. On 9/18/25 at 12:55 PM V2 Director of Nursing confirmed R3's care plan does not address opioid use and monitoring, including risk for constipation. V2 stated the facility has a bowel protocol to follow, which V2 will provide. V2 stated the (electronic medical software) sends an alert after three full days have passed with no BM, and continues to alert until addressed/resolved with BM documented. V2 reviewed R3's bowel tracking 30 day report, and confirmed duration of days with no BMs recorded. V2 stated R3 had BMs on day four, so the system would not have prompted an alert. V2 stated V2 will have to see if the system can be changed to alert on day two. V2 stated V2 would expect Milk of Magnesia to be given on day four of no BM. V2 stated V2 might look into getting R3 something scheduled routinely for R3's bowels. V2 confirmed risk of constipation with opioid use. At 2:45 PM V2 stated V2 followed up with corporate staff, and the facility does not have a bowel protocol; it is individually based on each resident's needs and bowel patterns. V2 stated it would also be based on if the resident was experiencing any symptoms such as nausea, vomiting, decreased appetite; which R3 has not had.

Based on observation, interviews and record review the facility failed to address resident's care needs to obtain appointments in a timely manner, resulting in a delay in the removal of a gastrostomy feeding tube and a delay in podiatry services for an infection for (R15). R15 is one of three residents reviewed for infections/ medical devices in the sample list of 27.These delays resulted in R15's transfer to the local hospital, for antibiotic treatment of G-tube infection, and ingrown toenail infection.Findings include:1. R15's current diagnoses list documents the following: Gastrostomy Status (abdominal, surgical G-Tube feeding catheter), Unspecified Severe Protein Calorie Malnutrition.R15's Physician Order Note dated 5/16/25 documents V19, Medical Director/Physician gave the facility a verbal order as follows: Ok for resident to have her enteral (abdominal surgically inserted, Gastrostomy feeding tube) tube removed.R15's Minimum Data Set, dated [DATE] documents R15's Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive impairment.R15's Health Status Note dated 5/28/25 (12 days after the order above to remove the G-tube) documents the following Resident GI (Gastrointestinal) appt (appointment) made for peg tube (type of gastrostomy feeding tube) removal for 8/5/25 (two months and 11 days after V19 MD ordered). Resident aware and appt placed in transportation calendar.R15's Physician Progress note dated 6/14/25, signed by V19, Medical Director/Physician (MD) documents R15 complained of ache and burning at the G-tube site. V19 diagnosed R15 with Cellulitis (bacterial infection of the skin) of the Abdomen. The same Physician Progress note documents an antibiotic medication order to treat the Cellulitis as follows: Ceftin 250 milligrams, Oral, twice daily, for five days.R15's Progress Note date 7/18/25 at 1:22 pm documents R15 was discharged from the facility, to a group home with a group home staff member.R15's Hospital emergency room Note dated 7/18/25 at 4:19 pm (two hours and 57 minutes after discharge from the facility) documents the following: C/O (complaint of) feeding tube infection, infected big toe on right foot, and sore on buttocks. Patient (R15) left (discharged from) (proper name of the facility) Rehab today to go to (Proper name of a group home). Staff there (group home) noted redness around feeding tube. Patient does not use feeding tube anymore and has appointment 8/5 to have it removed. She has had redness 4-5 months. States the sore on her toe and bottom have also been present for months but while she was there, she wanted to have them looked at. Alert to her norm. Patient is a (full mechanical lift) at baseline. Denies any fever, chills, SOB (shortness of breath), or other new illness symptoms. Feeding tube looks like it has mold or other dark substance inside of it. She reports it is supposed to be flushed 2 times daily but that does not always happen. She recently went to the dentist in Chicago to have her teeth pulled and they pushed (administered via G-tube) whatever was in her tube, up inside her. She told them it hurt but they continued.R15's follow -up facility discharge notes dated 7/18/25 at 7:04 pm (five hours and 18 minutes after discharge from the facility), signed by V2, Director of Nursing (DON) confirms R15's left the facility with her G-tube in place, had minimal irritation around g-tube site due to gastric fluids and an ingrown right great toenail. The same note documents The facility had attempted to reach out and schedule an appointment but have not been able to coordinate that, we were awaiting the rounding date for our in house podiatrist to address toe.On 7/23/25 at 8:45 am V5, Group Home Registered Nurse (RN) stated that they completed R15's admission assessment, at the Group home on 7/18/25 after R15 discharged from the long-term care facility. V5 stated V5 found concerns with R15's infected looking great toe, which was red with dried yellow drainage. V5, RN also stated she found R15's g-tube site was red and irritated, and there was what looked like mold inside g-tube. V5, RN said V5 sent R15 to the local Hospital emergency room and the hospital prescribed antibiotics, to treat infected g-tube site and ingrown great toenail. V5 also stated V5, RN was able to get an appointment for R15 to have her G-tube removed today (7/23/25). V5, RN stated We have her scheduled, to see the podiatrist for further treatment of ingrown toenail. On 7/23/25 at 4:43 pm R15 stated I was supposed to get my g-tube out in May. The Speech therapist said I did not need it any longer because I could eat just fine and could swallow. For four weeks they were to leave it in and just do flushes. They did that back in April. Then, I was told by the DON that they couldn't find a doctor that would take the g-tube out because it was stitched into me. I even reminded them I needed an appointment to take it out. They said they found a doctor, who can't take it out until August 5. I just got it out yesterday because the (Group Home) people got me an appointment to take it out right away. I just came back to this group home last week on the 18th. I kept telling the facility nurses my belly hurt around the tube. I even told them when I came back from oral surgery that my stomach hurt when they gave me medicine in my tube (unable to confirm). They did it anyway, that day. The skin around my tube was real red. Some of the nurses would put gauze around it, others would not. I was supposed to have flushes while I had it (G-tube) in my belly. They were supposed to do flushes (insert water to ensure patency and clean) twice a day. I did not get flushes but once a day. Sometimes I did not get flushed once. I never looked to see if there was moldy stuff in my g-tube. I just know the tube area of my belly hurt, and I couldn't get them to do anything, most of the time. (The nursing home) just kept saying I had to wait until August to get the g-tube out. May to August to find somebody to remove it. (The group home) got someone to do it today. It is out and I am thankful to (Group Home) nurses. R15 also stated My big toes were both terribly painful and red when I went to the emergency room the day I discharged . I asked the nurses to look at my toes over and over again. I saw the podiatrist for my ingrown toenails in late May or early June. He clipped them back and said he would see me again if I had any more problems with my ingrown toenails. I am diabetic and have to have the podiatrist do them (clip toenails). The CNA's can't. I talked to the DON(V2), and she said I was on the list to be seen. He (V21, Podiatrist) comes to (long term care facility name). I was in so much pain. The DON said she would put me on the list every time I talked to her. I could not have been on the list; I had to suffer and wait. I would get Tylenol and my tramadol at night, or I would not be able to sleep with my toes hurting. When I went to the emergency room after discharging from the facility, they gave me antibiotics for my toes and my G-tube infections. My toes are feeling better but still hurt. (The Group Home Staff) got me a podiatrist appointment after I finish my antibiotic the end of the week.On 7/24/25 at 7:30 am V2, Director of Nursing stated I had done a full skin assessment on (R15) the day before (7/17/25) she discharged (7/18/25) to the group home. At that time, her (R15's) g-tube site and R15's toes were not infected. They were just a little red and she complained of pain, per her usual. (R15) had no skin breakdown on her buttocks. V2, DON also stated (R15) was scheduled to have her G-tube removed August 5, 2025. That seems like a long time, now that you mention it. It was the first available appointment I could get. I did not tell the doctor (V19, MD) the appointment was that far out. I did not even think to do that. (R15) was on the list to be seen by the podiatrist and had been seen previously by the podiatrist. I will find documentation and provide it.On 7/25/25 at 1:40 pm V10, Certified Nursing Assistant (CNA) stated she provided care for (R15) often. About four or five days prior to (R15's) discharge to the Group home, R15's big toe had green drainage. I notified the nurse (unidentified) at the time. I do not remember if the toe was swollen or red. (R15) did complain it was hurting her. I reported that too. V10, CNA then stated (R15)'s buttocks were always somewhat irritated, especially when she was on her period. She was on her period the week before her discharge. CNAs can't put the zinc paste on residents. We would have to tell the nurse. We often told them (unidentified nurses) (R15's) butt (buttocks) was red and irritated so they would take care of it. (R15) always wanted us (CNAs) to do it when we provided her incontinence care. I know she would complain it was painful for her. I never saw any open areas down there. Her G-tube area was always red and irritated. The nurses would put gauze on that. They would slit two pieces of gauze and put one up and one down, so it made like a hole where the skin got really irritated. The gauze would sometimes come off. You could see some bloody looking drainage on the gauze. Not all the time though. I was scheduled to provide care for R15 the day she discharged . (R15) was complaining her toe hurt, her buttocks hurt, and the g-tube skin was irritated. I didn't really look at the tubing, so I am not sure if there was anything abnormal about the actual tube. I reported to the nurse (unidentified) she was complaining of pain (On the day of discharge 7/18/25).On 7/29/25 at 12:58 pm V19, Medical Director/Physician stated he expects the facility to notify him of a resident change in condition to prevent a delay in treatment. V19 confirmed he had treated R15 for cellulitis of the abdomen 6/14/25. V19 stated the facility should have informed him that there was an issue getting an appointment to remove R15's g-tube. V19 also stated An infection in R15's great toe, he was not made aware of either. We have an in-house podiatrist. The DON should have put (R15) on the list. If he (V21, Podiatrist) was not available, I am in the facility Friday or Saturday. Had I been updated with these issues; I can assure you they would have been taken care of.

Based on observation, interview and record review the facility failed to notify the physician in a timely manner of a delay in the removal of a gastrostomy feeding tube for (R15), a delay in podiatry services for infection for (R15) and a delay in the removal of an Internal Jugular (IJ), Peripherally Inserted Central Catheter (PICC) post the administration of antibiotics for (R30). R15 and R30 are two of three residents reviewed for infection/antibiotics/ surgically implanted devices in the sample list of 27. Findings include:1. 1. R15's current diagnoses list documents the following: Gastrostomy Status (abdominal, surgical G-Tube feeding catheter), Unspecified Severe Protein Calorie Malnutrition .R15's Physician Order Note dated 5/16/25 documents V19, Medical Director/Physician gave the facility a verbal order as follows: Ok for resident to have her enteral tube removed.R15's Minimum Data Set, dated [DATE] documents R15's Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive impairment.R15's Health Status Note dated 5/28/25 documents the following: Resident GI (Gastrointestinal) appt (appointment) made for peg tube (type of gastrostomy feeding tube) removal for 8/5/25 (scheduled two months and 11 days after V19 MD ordered). Resident aware and appt (appointment) placed in transportation calendar. There is no documentation that the physician was notified of the delayed scheduled appointment.R15's Progress Note date 7/18/25 at 1:22 pm documents R15 was discharged from the facility, to a group home with a group home staff member.On 7/23/25 at 8:45 am V5, Group Home Registered Nurse (RN) stated that they completed R15's admission assessment at the Group home on 7/18/25 after R15 had discharged from the long-term care facility. V5 stated she found concerns with R15's infected looking great toe, which was red with dried yellow drainage. V5, RN also stated she found R15's g-tube site was red and irritated, and there was what looked like mold inside the g-tube. V5, RN said V5 sent R15 to the local Hospital emergency room and the hospital prescribed antibiotics, to treat infected g-tube site and ingrown great toenail. V5 also stated V5, RN was able to get an appointment for R15 to have her G-tube removed today. V5, RN stated We have her scheduled, to see the podiatrist for further treatment of ingrown toenail. On 7/23/25 at 4:43 pm R15 stated I was supposed to get my g-tube out in May. The Speech therapist said I did not need it any longer because I could eat just fine and could swallow. For four weeks they were to leave it in and just do flushes. They did that back in April. Then, I was told by the DON that they couldn't find a doctor that would take the g-tube out because it was stitched into me. I even reminded them I needed an appointment to take it out. They said they found a doctor, who can't take it out until August 5. I just got it out yesterday because the (Group Home) people got me an appointment to take it out right away. I just came back (had preciously lived in this group home prior to the long term care facility) to this group home last week on the 18th. I kept telling the facility nurses my belly hurt around the tube. I even told them when I came back from oral surgery that my stomach hurt when they gave me medicine in my tube. They did it anyway that day. The skin around my tube was real red. Some of the nurses would put gauze around it, others would not. I was supposed to have flushes while I had it in my belly. They were supposed to do flushes twice a day. I did not get flushes but once a day. Sometimes I did not get flushed once. I never looked to see if there was moldy stuff in my g-tube. I just know the tube area of my belly hurt and I couldn't get them to do anything, most of the time. (The nursing home staff) just kept saying I had to wait until August to get the g-tube out. May to August to find somebody to remove it. (The group home) got someone to do it today. It is out and I am thankful to (Group Home) nurses.On 7/24/25 at 7:30 am V2, Director of Nursing confirmed she had not notified the physician of these changes in R15's condition.On 7/29/25 at 12:58 pm V19, Medical Director/Physician stated the facility should have informed V19, MD that there was an issue getting an appointment to remove R15's g-tube. V19, MD also stated An infection in R15's great toe, he was not made aware of either. We have an in house podiatrist. The (V2), DON should have put (R15) on the list. If he (V21, Podiatrist) was not available, I am in the facility Friday or Saturday. Had I been updated with these issues, I can assure you they would have been taken care of.2. R30's current Diagnoses sheet documents the following: Other Acute Osteomyelitis (infection in the bone), Right Hand, Acquired Absence of Right Finger (s).R30's current Physician Order Sheet (POS) documents the following orders dated 6/12/25 (on admission): Cefepime (antibiotic) HCI Intravenous Solution 1 GM/50ML (gram per milliliter) , Use 1 gram intravenously in the morning for cellulitis for 10 Administrations (6/23/25 last dose per scheduled). R30's Same POS order dated 6/27/25 documents Resident to be referred for surgical removal of IJ (Internal Jugular) central line (Peripherally Inserted Intravenous Central Catheter). R30's Same POS documents to monitor the central line insertion site for signs of infection, and update md (physician) if needed. R30's Minimum Data Set, dated [DATE] documents R30's Brief Interview of Mental Status score as 14 out of a possible 15, indicating no cognitive impairment.The facility facsimile dated 6/30/25, (three days after the physician order above), documents a referral was sent to a distant hospital for R30's removal of the IJ, Central Intravenous line.The facility facsimile dated 7/11/25, (eleven days after the physician order above), documents a referral was sent to another distant hospital for R30's removal of the IJ, Central Intravenous line. The facility facsimile dated 7/16/25, documents a referral was sent to a local hospital for R30's removal of the IJ, Central Intravenous line.On 7/22/25 at 3:00 pm R30 was awake in bed with a latex glove over her right hand dressings. Fourth digit cotton dressing visible through the gloves. R30's right index finger is not present, recent amputation. A cotton gauze is visible through the latex glove. R30 then pulled the right upper seam of her blouse over and showed the surveyor R30's right subclavian intravenous PICC line dressing. R30 stated The DON (V2, Director of Nursing) said I can not have the PICC line removed until September because it was inserted in (Out of State) Rehab Center. R30 stated I don't see why it takes so long to get an appointment. On 7/24/25 at 7:30 am V2, Director of Nursing (DON) confirmed R30's IJ, PICC line has not been removed after her IV antibiotic was completed. V2, DON stated An appointment is scheduled in September. A hospital in (State) originally placed this and other Illinois providers and hospital declined to remove it. I called (Named three hospitals). None of the hospitals would see her, to remove the PICC line. I probably should have notified the doctor of the delay in getting her an appointment for removing it (R30's PICC). On 7/29/25 at 12:58 pm V19, Medical Director/Physician stated he should have been notified of the delay in R30's PICC line removal. When I was informed last week that State was in the building and asking about the delay in (R30's) PICC line removal, I came in to see her immediately on Friday. I understand the PICC line was put in at a hospital in (Out of State). I looked at it, to see if I could remove this. I could not. I ordered a chest x-ray and have consulted with hospital here in (City Name) to see if they will remove (R30's) PICC line. I should have been notified sooner. She was only on antibiotics a short time after admission to (This LTC facility). The PICC line should have been removed when the antibiotics were complete. I am not sure why the hospital put a PICC line in for such a short duration of antibiotics. I don't usually see this situation. I should have been notified. I could have intervened sooner. I am working at resolving this locally so she does not have to wait until the September appointment that was set up by the DON.The facility undated policy Significant Condition Change and Notification directs staff to notify the medical practitioner for incidents that require the potential for needed medical practitioner interventions.

Based on interview and record review the facility Social Services Director failed to conduct follow up visits following an abuse allegation for one resident (R3) of five residents reviewed for abuse from a sample list of five residents.Findings include:The facility's Abuse policy dated 3/25 documents that Social Service will follow up with any residents after an allegation is made and document the visit in the chart of the resident.R3''s Nursing Note dated 6/4/2025 at 4:45PM documents the Interdisciplinary Team (IDT) met to follow up on R3's recent allegation against a staff member. The investigation was completed, and the allegation was unfounded. R3's reportable dated 5/22/25 stated social service will meet with R3 twice a week for the next four weeks.R3's Quarterly Minimum Data Set, dated [DATE] documents R3 is cognitively intact and R3 reported V7 and V11 Certified Nursing Assistants (CNA's) to the facility. It was noted R3 has a history of Post Traumatic Syndrome Disorder (PTSD) and V4 did not speak with R3 following the incident.On 6/30/2025 at 3:45PM, V4 (Social Service Director) stated she didn't talk to resident after the allegation and she didn't document it as it slipped V4's mind.On 7/1/2025 at 10:15AM, V1 (Administrator) stated V4 did not follow up with R3 and should have along with documenting the interaction in R3's chart as noted in the facilities Abuse policy and the report related to the allegation.

Based on interview and record review, the facility failed to safeguard and account for resident monies held in the resident trust fund cash box. This failure affects 19 residents (R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25) out of 25 reviewed for resident funds on the sample list of 25. Findings include: On 7/2/24 at 9:45 AM, V1, Administrator, stated, (V3) was the Business Office Manager but no longer works here because (V3) wasn't handling the resident trust fund cash according to facility policy. V1 further stated, (V3) was the person who discovered the discrepancy with the funds. The facility's Investigative Final Report dated 6/24/24 documents, On 6/16/24 the BOM (Business Office Manager, V3) noted the trust fund cash on hand was not correct and found the missing amount to be $489.82. The facility's Individual Resident Fund Ledgers document R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25 all have resident trust fund accounts held and managed by the facility. The facility's Resident Roster dated 7/2/24, confirmed by V1, Administrator, documents R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25 reside on the skilled nursing certified part of the facility. On 7/3/24 at 9:15 AM, V1, Administrator, confirmed, (V3) was terminated due to not handling the resident funds according to our facility policy. V1 then clarified, (V3) should not have been handling the cash because (V3) is the person who was doing the reconciliations of the funds. V1 continued, The way it is supposed to go is the Activity Designee (V13) will get a list of desired items from the residents that they want to purchase. Then (V13) will come to (V3) to get the funds from the cash box and have the residents sign for their withdrawals. Then when (V13) comes back from the shopping trip, (V13) will have the residents sign the receipt and sign for the amount of change there is from the shopping. Then (V13) returns the change to (V3) with all the documentation and (V3) was supposed to put the change back into the bank as a deposit. V1 further stated, So (V3) was gathering the money for the shopping trip and handling the money during the shopping trip, then (V3) wasn't having the residents sign for the change they received, and then (V3) was just putting the change back into the cash box. V1 concluded by stating, (V3) was doing things we aren't supposed to be doing just to prevent something like this from happening. The Facility Resident Trust Fund Policy dated 9/2012 documents, The individual responsible for the day to day receipts, disbursements, and recording to the manual ledger should not be the individual inputting this information to the AR (Accounts Receivable) system. The resident fund bank account must be reconciled monthly immediately upon receipt of the bank statement; the reconciliation must be someone other than the person who handles the day to day transactions. On 7/3/24 at 10:44 AM, V1, Administrator, confirmed the amount of the funds that could not be accounted for was $489.82, and that it was V3 who reported the discrepancy.

Based on interview and record review, the facility failed to convey resident funds to a resident's estate or probate within the required 30 days after death. This failure affects one resident (R7) out of 25 reviewed for resident funds on a sample list of 25. Findings include: R7's Electronic Medical Record Resident Listing (undated), Minimum Data Set ([DATE]), and Nurses Notes ([DATE]) all document R7 expired on [DATE]. R7's Individual Resident Trust Fund Ledger provided by V1, Administrator, on [DATE] documents R7 maintained a current balance of $125.00 as of [DATE]. The Facility Resident Trust Fund Policy dated ,d+[DATE] documents, Resident personal funds must be refunded within 30 days of discharge. In the case of resident death, the facility shall convey the residents personal fund balance and any unused room and board with a final accounting of the balance to the resident's estate or the person administering the estate. Release of such funds will require a proof of claim to the funds. If the facility receives no claim for deceased or discharged resident funds then the funds will be sent to the unclaimed property section of the state Secretary of Revenue with information about the resident and next of kin if known. On [DATE] at 10:44 AM, V1, Administrator, stated, (R7) is expired and does still have a balance. (R7) was private pay so I assume the money would go to the POA (Power of Attorney) but I am new to this because I was thrown into it after the termination of our BOM (Business Office Manager) and still trying to figure out how to get it to the appropriate party. V1 then confirmed. (R7) resided on the nursing home certified side.

Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affects three of seven residents (R1, R2, R5) reviewed for abuse in the sample of seven. Findings Include: The facility's Abuse Prevention and Prohibition Policy dated January 2024 documents the facility affirms the right of its residents to be free from abuse and free from mistreatment by anyone. Resident behaviors will be monitored for changes, which could trigger abusive behaviors. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate regardless of whether the individual intended to inflict injury or harm. Physical abuse can include such things as hitting, slapping, punching, and kicking. The Abuse Investigation Summary dated 5/9/24 documents on 5/4/24 staff were wheeling R5 to the dining room and wheeled past R1. Unprovoked, R1 reached out and began punching R5 in the arm. R1 and R5 were separated. After the completion of the facility investigation, the allegation was substantiated. On 6/12/24 at 12:45 PM V6 Certified Nurse's Assistant (CNA) stated she witnessed the incident and observed R1 punch R5 in the arm twice and call him a criminal. V6 stated R1 does not like R5 for some reason. The Abuse Investigation Summary dated 6/3/24 documents on 5/28/24 R2 wheeled up to the table that R1 was sitting at. Unprovoked, R1 yelled that R2 was sitting in her spot and began kicking R2 on the leg. R1 and R2 were separated. After the completion of the facility investigation, the allegation was substantiated. On 6/12/24 at 12:21 PM V5 Certified Nurse's Assistant (CNA) stated she observed R2 wheel up to R1's table and she yelled that it was her seat and R1 kicked R2 in the shin three times. R1's Medical Diagnoses sheet dated June 2024 documents R1 is diagnosed with Dementia with Behavioral Disturbance and Delusional Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment. R1's Psychosocial Evaluation dated 2/26/24 documents R1 has had new behaviors such as physical aggression, accusatory, threatening, anger, frustration, agitation. Staff should monitor R1 more closely when she is out of her room and around others. R2's Medical Diagnoses sheet dated June 2024 documents R2 is diagnosed with Depression, Schizoaffective Disorder, and Anxiety. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has a moderate cognitive impairment. R5's Medical Diagnoses sheet dated June 2024 documents R5 is diagnosed with Cerebral Palsy, Schizoaffective Disorder, Depression, Intellectually Disabled, and Explosive Disorder. R5's Minimum Data Set (MDS) dated [DATE] documents R5 has severe cognitive impairment. On 6/12/24 at 1:50 PM V1 Administrator confirmed R1 punched R5 and kicked R2 and this could be considered physical abuse. V1 confirmed both allegations of abuse were substantiated after the facility investigation.

Based on record review and interview the facility failed to ensure the facility's Medical Director and Director of Nursing attended Quality Assurance meetings. This failure has the potential to affect all 27 residents residing in the facility. FINDINGS INCLUDE: The faciliy's Application for Medicaid and Medicare dated 5/6/24 documents there are 27 residents residing in the facility. The facility's Quality Assurance policy dated 2022, documents, The QAPI (Quality Assurance Preformance Improvment) consists of monthly and quarterly meetings, daily quality assurance activities, QAPI Tasks and Performance Improvement Plans. QAPI sign-in sheets dated 10/26/23 did not include signatures from the Director of Nursing (DON) or Medical Director/ Physician. On 05/06/24 at 01:08 PM, V1 Administrator in Training states that on 10/26/23, the facility did not have a DON at that time and the Medical Director was not in attendance for the QA meeting. V1 stated she was unable to show that facility reviewed the QA meeting with the Medical Director.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions and failed to perform hand hygiene during incontinence care for four (R8, R9, R1 and R24) of 16 residents reviewed for infection control on the sample list of 23. Findings include: The facility's Infection Prevention and Control Manual-Enhanced Barrier Precaution policy dated 12/30/22 documents Enhanced Barrier Precautions are recommended for residents with wounds or an indwelling medical device including urinary catheters. This policy documents a gown and gloves should be worn when providing wound care and caring for or using an indwelling medical device. 1. On 5/06/24 at 10:11 AM, R8 was sitting up in a chair. An indwelling catheter was present. R8 stated he is provided with catheter care every day. R8 stated they wear gloves, but they do not wear a gown. On 5/7/24 at 11:00 AM, V9 Certified Nurse's Assistant (CNA) and V10 CNA entered R8's room to perform catheter care. There was not a sign outside of the door to indicate that R8 required enhanced barrier precautions. V9 and V10 provided catheter care to R8. V9 and V10 were wearing gloves but were not wearing a gown. On 5/8/24 at 1:00 PM, V2 Director of Nursing stated R8 should have an enhanced barrier precautions sign on the door. V2 stated this would include wearing a gown when giving cares to R8. 2. On 5/06/24 at 9:48 AM, R9 was sitting in a chair in her room. R9's left foot was wrapped in gauze wrap. R9 stated R9 has wounds to the left foot. R9 stated she was in the hospital in January 2024 for a wound infection. R9 stated when they do her treatment, they wear gloves but no gown. There was no sign on the door that indicated R9 was in enhanced barrier precautions. R9's Treatment Administration Record dated 4/1/24 through 4/30/24 and R9's Treatment Administration Record dated 5/1/24 through 5/31/24 documents R9 has a venous ulcer to the left foot. R9's electronic health record does not document orders for enhanced barrier precautions until 5/8/24. On 5/8/24 at 1:00 PM, V2 Director of Nursing stated R9 was not in enhanced barrier precautions until 5/8/24. V2 stated R9 should have been in enhanced barrier precautions due to having a chronic wound with a history of a wound infection. 37813 3. R1's physicians orders documents a current physician's order for (petroleum jelly) infused lotion/cream to left buttock every shift for moisture associated skin damage. On 05/08/24 at 10:25 AM V6, Registered Nurse (RN) and V15, Wound Physician applied petroleum jelly to wound on ischial tuberosity Stage II chronic wound. V15 stated (R1) has had a moisture associated wound at this site several times. We have healed it and it opens back up. Neither V6 nor V15 donned gown while completing wound care. A beefy red open wound approximately one half inch by two inches with some serosanguinous drainage was observed. Both V6 and V15 donned gloves and used appropriate hand washing during wound care. On 5/8/24 at 12:00 PM, V2 Director of Nursing stated, We did not put (R1) on enhanced barrier precautions because we thought it was an acute wound. V2 verified the wound had been open several times. 34201 4. On 5/06/24 at 11:08 AM, V10 and V16 CNA's (Certified Nursing Assistant's) transferred R24 from the reclining wheeled chair to the bed and removed R24's incontinence brief. R24 had been incontinent of a bowel movement. R10 performed incontinence care for R24 using disposable wipes. After cares were completed, V10 changed gloves but did not perform hand hygiene. V10 along with V16 then placed a clean brief on R24, and positioned R24 in bed and adjusted the covers. After completion of care, V10 confirmed V10 did not perform hand hygiene after performing incontinence care, and only changed gloves. The facility's Infection Prevention and Control Manual for Hand Hygiene dated 2019 documents hand hygiene continues to be the primary means of preventing the transmission of infection. Hand hygiene consistent with accepted standards of practice such as the use of ABHR (Alcohol Based Hand Rub) instead of soap and water in all clinical situations except when hands are visibly soiled with blood and body fluids or after using the restroom. Staff must perform hand hygiene even if gloves are utilized.

Based on interview and record review the facility failed to identify resident specific targeted behaviors and implement nonpharmacological interventions prior to the use and increase of psychotropic medications for two (R1, R19) of five residents reviewed for psychotropic medications on the sample list of 23 residents. Findings Include: 1. R1's electronic health record documents current orders for Geodon (Antipsychotic) Hydrochloride 60 milligrams (mg)by mouth twice a day and Sertraline (antidepressant) Hydrochloride 100 MG (Sertraline HCl) by mouth one time a day. R1's medical record does not contain resident specific targeted behavior or resident specific interventions or response to interventions. Though the facility did utilize a preprinted behavior tracking. the behaviors/interventions listed were not specific to R1. On 4/8/24 at 12:00 PM, V2 Director of Nursing verified the facility uses the same computer-generated list of behaviors and interventions for all residents who require behavior tracking. 50430 2. R19's undated Facesheet documents R19 has a diagnosis of unspecified dementia with behavioral disturbance. R19's Physician's order sheet dated May 2024 documents that on 3/26/24, R19 had an increase in Risperdal 0.5 milligrams (mg) from once daily to twice daily. R19's progress note dated 2/29/24 documents that R19 was having behaviors. R19's medical record does not document any behaviors after 2/29/24. R19's medical record do not document that nonpharmacological interventions were attempted prior to the increase of psychotropic medication. On 5/7/24 at 10:50 AM, V6 Registered Nurse states that she is very familiar R19 as she cares for her often. V6 states her behaviors aren't consistent and it's normally because a specific resident (unknown) who lives here triggers her. V6 states, Risperdal was increased because of her triggered behavior towards this other resident. On 5/7/24 at 11:15 AM, V2 Director of Nursing confirmed there was no documentation of increased behaviors prior to the medication increase. V2 stated, Psychotropic meds were not being monitored appropriately before the new company took over.

Based on observation and record review, the facility failed to document care plans including resident centered interventions for respiratory care for one of 24 (R29) residents reviewed for care plans in a sample list of 24 residents. R29's MDS (Minimum Data Set) dated 4/2/24 documents R29 is alert and oriented. R29's ongoing Diagnosis Listing documents a diagnosis of Chronic Respiratory Failure with Hypoxia. R29's May 2024 Physician Orders document to use oxygen at 2-4 L (liters) per nasal cannula to keep oxygen saturation levels above 92 % and Albuterol {Bronchodilator} nebulizer every four hours as needed for shortness of breath and wheezing. R29's Care Plan dated 4/9/24 does not document any respiratory problems or needs. On 5/06/24 at 9:19 AM, R29 was sitting up in the wheelchair and was not wearing oxygen. At this time, R29 stated R29 wears oxygen all the time when in bed and uses the nebulizer on average once a day for shortness of breath.

Based on interview and record review the facility failed to provide quarterly statements for one (R9) of sixteen residents reviewed for resident funds on the sample list of 23. Finding include: R9's Quarterly Minimum Data Set assessment dated [DATE] documents R9 is cognitively intact. On 5/06/24 at 9:36 AM, R9 stated the facility manages her money. R9 stated R9 does not get quarterly statements. R9 stated she would be interested in seeing them. On 5/6/24 at 1:15 PM, V4 Business Office Manager stated V4 has not provided quarterly statements to the residents since the company had a data breach in October of 2023. V4 stated this has been since the third quarter of last year and the first and second quarter of this year.

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 12 residents (R13) reviewed for call lights on the sample list of 23. Findings Include: On 5/06/24 at 1:20 PM, R13 was sitting up in the reclining chair in R13's room in front of the television. R13's call light was stretched all the way to the middle of the room and tied to a water jug on the over bed table, which is next to the back of R13's chair. The water jug was on the far end of the table, out of R13's reach. R13 attempted to reach the call light and was not able to. On 5/06/24 at 1:26 PM, V10 CNA (Certified Nursing Assistant) entered R13's room and confirmed that R13 was not able to reach the call light and stated, I wonder why (R13) is like that. R13 care plan dated 3/18/24 documents R13 has impaired physical mobility. This care plan includes an intervention to keep the call light within reach.

Based on observation, interview and record review, the facility failed to follow physician orders for respiratory care including oxygen, BiPAP and C-PAP usage, change oxygen tubing and humidifier bottles as ordered and document resident complaisance/non-compliance of respiratory care for four of four residents (R1, R2, R3, R4) reviewed for respiratory care in the sample list of six. This failure resulted in psychosocial harm of R3. R3 was sent to the hospital after having a panic attack and remains fearful of facility staff's action related to R3's respiratory care. Findings Include: 1. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, change oxygen tubing and humidifier once a week (scheduled for Sundays), and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. R3's ongoing diagnoses list includes the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Chronic Respiratory Failure with Hypoxia, Dependence on Respirator or Ventilator, and Dyspnea. R3's MDS (Minimum Data Set) dated 12/24/24 documents R3 is alert and oriented. On 1/22/24 at 8:50 am, R3 is asleep in bed wearing oxygen but not the BiPAP. Oxygen is running at 3.5 L/NC and the BiPAP machine is sitting on the overbed table. The oxygen tubing and humidifier bottle are not dated. On 1/22/24 at 7:30 pm, R3 was lying awake in bed with oxygen running at 4.5 L/NC. R3 stated since getting the new BiPAP machine on 1/19/24, R3 has only had it on once because you can't find anyone to put it on you correctly. R3 explained, something is not right with it, and it makes my oxygen levels drop. R3 also stated over the weekend, V6 Agency RN (Registered Nurse) cranked R3's oxygen level up to 10 L/NC because R3 was short of breath. R3 reports R3 told V6 to turn the amount of oxygen down but V6 wouldn't. R3 stated, R3 ended up going to the emergency room because of this. R3 started getting real anxious; shaking and increased respirations with the use of accessory muscles when talking about the incident. R3 stated this has happened twice now and because of V6's actions, R3 does not want V6 in R3's room or taking care of R3 without someone else in here to be a witness, he (V6) scares me (R3). R3's January 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) does not document that R3's oxygen tubing or humidifier were changed as ordered on 1/7/24 and 1/14/24. This MAR/TAR also documents R3 has used the BiPAP daily other than 1/14/24 and 1/19/24, it is signed out as refused. On 1/23/24 at 1:24 pm, V6 confirmed R3 had breathing problems on 1/20/24 and V6 turned R3's oxygen up to 10L/NC and sent R3 to the hospital per R3's request. R3's Hospital History and Physical dated 1/20/24 by V27 Hospital Physician documents R3 has a history of COPD is on 3-4 L oxygen at baseline, presents with a chief complaint of feeling short of breath. R3 reports a new male nurse was putting R3's CPAP on and cranked it up to 10L which was very uncomfortable for R3, causing R3 to feel more short of breath however this has since improved. R3 received two breathing treatments per EMS (Emergency Medical Services) in route to the hospital as well as Solu-Medrol {Steroid} 125 mg (milligrams). R3 reports R3 is now breathing at R3's baseline. R3 was not having any of this breathing distress prior to improper management of the CPAP. R3 is upset at this male nurse for cranking up the CPAP to a very high setting, which caused R3 to feel like R3 could not breathe. Symptoms have resolved and the episode was likely related to anxiety after inappropriate CPAP use. 2. R2's ongoing diagnoses listing documents R2 has TBI (Traumatic Brain Injury), Morbid Obesity, Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting Right Dominant Side, Acute and Chronic Respiratory Failure with Hypoxia, and Sleep Apnea. R2's January 2023 Physician Orders document the following orders: BI-PAP wear while sleeping as resident tolerates/allows. Maintain BI-PAP pressures at 20/10 cm (centimeters) H2O (water) and maintain E-PAP (Expiratory Positive Airway Pressure) Rate at 14. Bleed oxygen in at 3L oxygen per minute, oxygen at 2-6 L/minute, document when resident refuses the BiPAP and change oxygen tubing and humidifier weekly (scheduled for Sundays). On 1/22/24 at 8:30 am, R2 was sitting up in bed wearing oxygen running at 3 L/NC. The tubing and humidifier were not dated. The facility's ongoing Grievance Log documents grievances by V10 (R2's POA (Power of Attorney)) on 1/4/24 and 1/10/24 for the facility not applying R2's BiPAP when R2 is sleeping. R2's January 2024 MAR/TAR does not document that the oxygen tubing or humidifier were changed on 1/7/24 or 1/14/24. This MAR/TAR does not document if R2 wore or refused R2's BiPAP on 1/2/24, 1/3/24, 1/14/24 and documents it was refused only on 1/15/24, 1/16/24 and 1/17/24. On 1/22/24 at 11:22 am, V10 stated the facility is not putting R2's machine on R2 at night and when R2 is sleeping. V10 explained, the facility will ask R2 to put it on when R2 is awake, which R2 will not do but that V10 has instructed the facility staff on several occasions to put it on R2 after R2 falls asleep. V10 stated the facility is telling V10 they put it on R2 but V10 has never seen it on R2, even though V10 comes to the facility, at all hours of the day/night. I (V10) fear for (R2's) life because it is nothing but lies. They aren't caring for (R2) as they should. V10 also stated on 1/21/24 around 12:00 am, V10 came to the facility to check on R2 because V10 and R2 had been talking on the phone and R2 was very short of breath. Upon arriving, V10 observed R2's oxygen being unplugged, therefore R2 was not getting any oxygen. R2 was very short of breath and R2's oxygen level was in the 70's. V10 stated that once V6 Agency RN (Registered Nurse) plugged the oxygen in again, R2's oxygen levels began to raise back into the 90's%. V10 explained that during the time without oxygen, R2 was so out of it, (R2) couldn't even tell me (V10) that (R2) wasn't getting oxygen. On 1/22/24 at 4:22 pm, V6 stated R2 is supposed to wear oxygen all the time. V6 confirmed on 1/21/24, R2's oxygen tubing had come disconnect from concentrator so R2 was not getting oxygen. V6 does not know how long R2 had been without the oxygen. On 1/22/24 at 9:15 pm and 10:40 pm, R2 was asleep in bed with oxygen running at 4L/NC but was not wearing the ordered BiPAP. On 1/23/24 at 12:20 pm, 12:45 pm, 1:18 pm, 1:51 pm and 2:08 pm, R2 was asleep in bed without the ordered BiPAP in place. On 1/23/24 at 1:24 pm, V6 confirmed V6 works the night shift on Sunday's when the oxygen tubing and humidifiers are to be changed. V6 stated V6 has never done that but should have, V6 was just too busy. On 1/24/24 at 8:51 am, V10 stated V10 arrived at the facility at 2:15 pm on 1/23/24. V10 explained R2 was asleep in bed at that time without the BiPAP in place. 3. R4's MDS (Minimum Data Set) dated 1/10/24 documents R4 is alert and oriented. R4's ongoing diagnoses listing contains the following diagnoses: Unspecified Asthma with Exacerbation, Acute Respiratory Failure with Hypoxia, Cerebral Palsy, and COPD (Chronic Obstructive Pulmonary Disease). R4's January 2024 Physician Orders document an order for oxygen at 2-5 L/NC as needed to keep SPO2 levels above 90% and to change the oxygen tubing and humidifier bottles weekly (scheduled for Sundays). R4's January 2024 MAR/TAR does not document that the oxygen tubing or humidifier bottle was changed on 1/7/24 and 1/14/24. On 1/22/24 at 8:50 am, R4 was lying in bed with oxygen running at 5L/NC. The tubing and humidifier bottle were not dated. On 1/22/24 at 9:45 am, R4 was sitting up in the wheelchair by the Nurses Station wearing oxygen at 3L/NC. At this time, R4 stated R4 uses oxygen at 3L/NC. When questioned about the oxygen being at 5L/NC earlier this morning, R4 stated that is what happens when V6 Agency RN (Registered Nurse) works. (V6) always turns it way up, saying it will help me (R4). (V6) had it turned up to 10 at one point and I (R4) told him he had to turn it down. R4 explained, R4 has COPD so having oxygen that high doesn't help, it hurts me. R4 said V6 did that a could of days ago too. On 1/22/24 at 4:35 pm, V6 stated when someone has COPD, they aren't supposed to have high oxygen levels but over V6's [AGE] years of being a nurse and practicing, V6 has found that if you bump up the oxygen when someone is having difficulty breathing and give them some breathing treatments then bring the oxygen back down it helps them. V6 stated R4 was having difficulty breathing so V6 bumped R4's oxygen level up. V6 does not recall how high V6 turned it up to, but it could have been up to 10 L. On 1/23/24 at 1:24 pm, V6 confirmed V6 works the night shift on Sunday's when the oxygen tubing and humidifiers are to be changed. V6 stated V6 has never done that but should have. 4. R1's January 2024 Physician Orders document an order for Oxygen at 2 L per nasal cannula to maintain oxygen level above 90%, change oxygen tubing and humidifier bottle weekly (scheduled on Sundays), and CPAP nightly as resident tolerates/allows. Bleed oxygen in at 2 LPM. On 1/22/24 at 8:30 am, R1 was lying in bed with an oxygen concentrator next to the bed. The concentrator was hooked up to the CPAP machine. There was no water in the undated humidifier bottle and the oxygen tubing was not dated. R1 stated R1 uses the CPAP machine every night but doesn't need to use oxygen during the day anymore. R1's January 2024 MAR/TAR does not document the ordered CPAP was worn on 1/2/24 and 1/14/24 or a reason why it wasn't. This MAR/TAR also does not document that the oxygen tubing and humidifier changed were changed on 1/7/24 and 1/14/24. On 1/23/24 at 1:24 pm, V6 confirmed V6 works the night shift on Sunday's when the oxygen tubing and humidifiers are to be changed. V6 stated V6 has never done that but should have. The facility's Oxygen Therapy Policy dated March 2019 documents oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Oxygen may be used provided there is a written order by the physician. The order must state liter flow per minute, mask or cannula, and the time frame to be used. Oxygen tubing/mask/cannula are to be changed weekly. If humidification is indicated, document changes and cleaning of them on the treatment sheet at the time of the occurrence. The facility's undated Nursing Documentation Guidelines documents when a treatment is refused, the staff needs to document: the date and time the treatment was attempted, the residents response and reason for refusal, name of the person attempting to administer the treatment, document that the resident was informed of the purpose of the treatment and the consequences of not receiving the treatment, all pertinent observations, and the date and time the physician was notified, as well as the physicians response.

Based on observation, interview and record review, the facility failed to notify the physician of a pressure ulcer to obtain an appropriate wound treatment, assess and document the pressure ulcer, notify the resident representative of a pressure ulcer and prevent cross contamination of the wound during a treatment for one of three residents (R2) reviewed for wounds in the sample list of six. This failure resulted in R2's MASD (Moisture Associated Skin Damage) progressing to an unstageable pressure ulcer. Findings Include: R2's ongoing diagnoses listing documents R2 has TBI (Traumatic Brain Injury), Morbid Obesity, and Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting Right Dominant Side. On 1/22/23 at 11:22 am, V10 (R2's POA (Power of Attorney) stated R2 was at the hospital on 1/21/23 and the nurse there said R2 has an open area on R2's buttocks. V10 also stated the nurse reported R2 also has another big area that is ready to break open. V10 stated V10 had never been notified by the facility that R2 had any wounds. R2's Hospital Notes dated 1/22/24 at 1:01 am document R2 has a 1 cm (centimeter) open sore to the coccyx, and a reddened area below the coccyx that is not yet open. The facility's ongoing Weekly Wound Tracking Form documents on 1/3/24 and 1/10/24, R2 had MASD to the buttocks but does not document any characteristics of the area. Wound Assessment and Plan Notes by V11 Wound NP (Nurse Practitioner) for R2 document the following: 1/3/24 -Initial visit for MASD to buttocks with onset date of 1/3/24. Peri wound Macerated with Minimal exudate. Treatment Order: cleanse area, pat dry well. Apply an Antifungal powder and a zinc barrier Cream 20% or greater apply every shift and PRN (as needed). This area has a fungal appearance to it with redness, scalloped edges and satellite lesions noted. 1/10/24 - discontinuing the Antifungal powder, new treatment is for zinc barrier cream 20% or greater every shift and PRN. Neither of the Wound Assessment and Plan Notes include measurements of the MASD area. On 1/22/24 at 2:55 pm, V4 and V7 BOM (Business Office Manager)/CNA (Certified Nursing Assistant) entered R2's room to complete the ordered treatment. R2 was rolled to the side and upon removing R2's brief, R2's entire buttocks was caked in a thick white substance with a flaky appearance. V4 attempted to cleanse the area with Normal Saline but the substance would not come off. V4 then had to use a washcloth with soap and warm water to remove the substance and stated, it looks like someone put zinc and Nystatin {Antifungal} on (R2). V4 explained, R2 use to have an order for that but now we are just to use zinc. After the substance was cleansed off, R2 had three different open areas to the buttocks area that V4 measured. The left buttocks had a 0.5 cm by 0.7 and approximately. 0.1 cm deep open area. The wound bed was not visible as it was covered in yellow slough (unstageable). V4 stated that was not there last week so it must have just developed over the last couple of days. R2 also had an area to the left inner buttocks measuring 6.5 cm by 0.6 cm that V4 stated is a self inflicted scratch, that was scabbed over. On the right buttocks, R2 had a 7.2 cm by 4.4 cm superficial open area, in the middle of larger reddened/discolored area, with a beefy red wound base. V4 applied the zinc ointment, which was pink in color, with V4's gloved finger to all three open areas, without changing gloves or performing hand hygiene between wounds. V4 stated V11 will be at the facility on 1/24/24, and that R2's treatment will need changed as zinc is not an appropriate treatment for an unstageable pressure ulcer. At this time, V4 stated the facility don't measure wounds generally, we just go by what the wound provider documents. V4 stated V4 does not know if we are supposed to or not explaining, I'm the only facility nurse and we have no DON, so there is no guidance. As of 1/24/24, R2's Progress Notes do not document V10 was notified of the MASD on 1/3/24 or any changes to R2's skin condition since then. These notes also do not document that V11 Wound NP (Nurse Practitioner) was notified of the MASD progressing to an unstageable pressure ulcer or to get a new treatment order. On 1/24/24 at 1:00 pm, V25 MDS (Minimum Data Set)/Care Plan Coordinator stated when a resident develops a wound or the condition of the wound deteriorates, the staff should be calling the physician to obtain a new treatment order, not wait until they are in the facility. V25 also stated wounds should be monitored and documented on at least once a week and families should be notified of a new and/or worsening wound. The facility's Decubitus Care/Pressure Areas Policy dated May 2007 documents this policy is to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. Upon notification of skin breakdown, a newly acquired skin condition report will be completed and forwarded to the Director of Nursing. The pressure area will be assessed and documented on the Treatment Administration Record. Documentation should include size, stage, site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). Notify the physician for treatment orders. Documentation of the pressure area must occur upon identification and at least once each week on the TAR (Treatment Administration Record). Re-evaluate the treatment for response at least every two to four weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen, contact the physician for a new treatment order. The facility's Dressing Change Policy dated July 2007 documents to apply topical medication per physician's order using an applicator, tongue blade, cotton ball or gauze square. The facility's Notification for Change in Resident Condition or Status documents to promptly notify the appropriate individuals including but not limited to the physician and resident guardian if there is a significant change in the resident's physical/emotional/mental condition and the need to alter the resident's medical treatment.

Based on interview and record review, the facility failed to treat residents with respect, dignity and provide care in a manner that promotes quality of life by not allowing a resident to have a say in medical treatment for one of four residents (R3) reviewed for respiratory care in the sample of six. This failure resulted in R3 being fearful of staff and experiencing ongoing psychosocial harm of R3; which resulted in R3 being sent to the emergency room for an anxiety attack. Findings Include: R3's MDS (Minimum Data Set) dated 12/24/24 documents R3 is alert and oriented. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. R3's ongoing diagnoses list includes the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Chronic Respiratory Failure with Hypoxia, Dependence on Respirator or Ventilator, Dyspnea, On 1/22/24 at 7:30 pm, R3 was lying awake in bed with oxygen running at 4.5 L/NC. R3 stated since getting the new BiPAP machine on 1/19/24, R3 has only had it on once because you can't find anyone to put it on you correctly. R3 explained, something is not right with it, and it makes my oxygen levels drop. R3 also stated over the weekend, R3 was short of breath and had called for the nurse, V6 Agency RN (Registered Nurse) to give R3 a breathing treatment. R3 stated when V6 entered R3's room, V6 cranked R3's oxygen level up to 10 L/NC, then started to check my oxygen level., and was hitting R3 on the back. R3 reports telling V6 to turn the oxygen down but V6 did not do it. R3 stated R3 ended up having to call V5 CNA (Certified Nursing Assistant) into the room and V5 positioned R3 so that R3 could turn the oxygen down by R3's self. R3 stated R3 ended up in the ER (emergency room ) that day, which R3 believes was 1/20/24. R3 stated this has actually happened twice now. Because of V6's actions, I (R3) don't want him (V6) in my room or taking care of me without someone else in here to be a witness, he (V6) scares me (R3). While R3 was talking about this incident, R3 started getting real anxious, shaking and R3's breathing increased, including use of accessory muscles. On 1/22/24 at 8:05 pm, V5 CNA stated V5 has a big concern with V6 and explained V6 has turned R3's, along with other resident's, oxygen up to 10 L several times over the past week. Whenever a resident calls and says they can't breathe, that is what (V6) does. V5 stated, it really stressed R3 out and last week on Thursday, 1/18/24, V17 CNA and V5 were doing our last rounds around 9:15 pm when R3 said R3 couldn't breathe. V5 checked R3's oxygen level and it was in the 50%. V5 reports yelling for V6 Agency RN to come check R3 and V6 immediately turned R3's oxygen up to 10 L/NC. R3 told V6 to stop at least 10-15 times and said, I've told you before that I (R3) don't like that but V6 wouldn't turn it down. V6 started yelling at R3, telling R3 I'm the nurse and you (R3) are going to die. V5 reports that V14 CNA was approximately 100 feet away, and overheard V6 yelling at R3 so V14 came down the hall to see what was going on. V5 stated at that point V5 left the room to report an abuse allegation. After the phone call and on the way back to R3's room, V6 was outside of R3's room throwing things and kicking the medication cart. V6 then came back into R3's room and shoved an inhaler in R3's mouth. R3 told V6 I don't want that; I need a nebulizer but V6 instructed R3 to open R3's mouth. R3 was sitting up on the side of the bed at this point and V6 started hitting R3 on the back 4-5 times, like you would a baby. R3 instructed V6 to stop because V6 was hurting R3 but he continued to do it a couple more times. V5 stated, I'm not sure if that is abuse or not but to me(V5), when you ask to stop being touched and someone continues to do it, that is a problem in my eyes! V5 stated another incident happened on 1/20/24. V5 explained R3 was in respiratory distress with an oxygen level in the 70's and V6 did the same thing and turned the oxygen up to 10 L. R3 was fearful, V6 was not listening to R3. At that point on 1/20/23, R3 was sent to the hospital. V5 reports that R3 asked V5 not to let V6 touch R3 because R3 was not comfortable with how V6 treated R3. V6 made R3 do the inhaler, and nebulizer before V6 would even call to send R3 to the hospital, even though R3 kept requesting to be sent. V5 exclaimed, all I know is I'm very concerned about resident safety due to having a nurse that is doing questionable things. On 1/22/24 at 8:56 pm, V13 CNA stated R3 told V13 that R3 felt unsafe with V6 due to V6 turning R3's oxygen up to 10 L and then walking away, on 1/20/24. V13 explained, it's been over 24 hours now and R3 still feels unsafe and is requesting a CNA in the room with R3 whenever V6 is in there. V13 stated R3 told V13 that V6 was shoving pills down (R3's) throat, inhaler in (R3's) mouth when (R3) wasn't wanting the stuff. On 1/22/24 at 9:34 pm, V14 CNA confirmed V5's above statement of events. V14 also stated R3 reported to V14, that on a different night, R3 was having breathing trouble and had requested a nebulizer but instead V6 turned up R3's oxygen, then told R3, I (V6) told you (R3); you were going to be okay. V14 stated R3 has told V14 that R3 don't like or trust (V6) and has requested a CNA be with R3 anytime V6 has to go into R3's room. On 1/23/24 at 1:24 pm, V6 stated V6 has had a couple incidents with R3 where R3 was having breathing issues and refusing care/treatment. V6 explained, when an oxygen level is in the 50's, without treatment (R3) will die and (R3) wasn't wanting anything other than a nebulizer but I (V6) did both the nebulizer and inhaler, turned up (R3's) oxygen and then (R3) was fine. V6 explained V6 was frustrated. V6 stated after the first incident on 1/18/24, V6 was told the customer is always right and to basically do what they ask so a couple of days later, (R3) was short of breath again and (R3's) {oxygen} levels were again in the 50's and she was wanting to go to the hospital so V6 sent R3 to the hospital after giving R3 an inhaler, nebulizer and increasing R3's oxygen to 10 L. R3's Hospital History and Physical dated 1/20/24 by V27 Hospital Physician documents R3 has a history of COPD is on 3-4 L oxygen at baseline, presents with a chief complaint of feeling short of breath. R3 reports a new male nurse was putting R3's CPAP on and cranked it up to 10L which was very uncomfortable for R3, causing R3 to feel more short of breath however this has since improved. R3 received two breathing treatments per EMS (Emergency Medical Services) in route to the hospital as well as Solu-Medrol {Steroid} 125 mg (milligrams). R3 reports R3 is now breathing at R3's baseline. R3 was not having any of this breathing distress prior to improper management of the CPAP. R3 is upset at this male nurse for cranking up the CPAP to a very high setting, which caused R3 to feel like R3 could not breathe. Symptoms have resolved and the episode was likely related to anxiety after inappropriate CPAP use. The facility's Residents' Rights for People In Long Term Care Facilities dated November 2018 documents; you have a right to make your own decisions, your facility must treat you with dignity and respect and must care for you in a manner that promotes quality of life, you have the right to request, refuse, and/or discontinue any treatment.

Based on observation, interview and record review, the facility failed to protect the residents right to be free from mental and verbal abuse by a staff member for one of five residents (R10) reviewed for abuse in the sample list of 11. This failure resulted in psychosocial harm for R10 as evidenced by R10 being tearful and shaking while talking about the abuse three days later and R10 being fearful of retaliation from the staff member for reporting the abuse. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse is defined as the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s), harassment, humiliation and threats of punishment or deprivation. On 9/3/23 at 6:17 am, V17 CNA stated on 8/31/23 at around 5:15 am, V17 was in the room next to R10's room and providing cares when V17 heard V19 knocking loud and obnoxiously on R10's door. V17 stated it was loud and obnoxious to V17 because R10 has asked staff not to knock on R10's door because it scares R10 when R10 is sleeping. V17 explained after knocking, V19 could be heard asking if R10 needed changed and R10 said yes, I'm wet in the back. V17 stated V17 was not in the room but V17 assumes V19 then pulled the covers back because V19 said, you're not wet, you don't need changed, and R10 continued to say, I'm wet in the back, and do need changed. V17 stated it was at that time, V19 said I (V19) don't need you (R10) to tell me (V19) how to do my job, you (R10) don't need changed. V17 explained V17 then heard V19 tell R10 to roll, then R10 said why would you (V19) put a wet brief in my (R10's) face and V19 replied because you (R10) didn't need changed and I (V19) don't need you to tell me how to do my job. V17 stated R10 could be heard telling V19 that R10 was tired of V19's attitude and being disrespectful and stated, just leave me alone. V17 then stated V19 could be heard saying I'm (expletive) done with you and left the room. V17 stated V17 finished up with the resident V17 was working with and then went to check on R10. V17 explained R10 was visibly upset and crying. The brief was under (R10) but not secured, so I (V17) finished changing (R10) and reported the situation to V18 Agency LPN (Licensed Practical Nurse) on duty, who reported it to V1 AIT (Administrator in Training). V19 was sent home and hasn't been back. R10's ongoing Abuse Investigation dated 8/31/23 documents an Initial report of staff/resident alleged verbal altercation. All parties notified. This investigation contained the following witness statements: V2 BOM (Business Office Manager) documents - V2 doesn't usually work with V19 other than doing rounds with V19 at 6:00 am. V2 documents V19 is short sometimes but V2 doesn't feel like V2 has ever seen V19 be rude or say anything that was abusive to a resident. R11 documents - R11 has wet R11's self in the past waiting on V19 to answer R11's call light and when V19 did answer the light, V19 stated can't you go to the bathroom? and then when R11 said no, V19 acted like V19 was mad but did help R11 get cleaned up. R10 documents - on previous rounds, V19 was banging on the door and R10 has asked V19 so many times not to do that and to be respectful of my roommate. On last rounds, R10 thought R10 was a little bit wet and told V19. V19 started yelling that R10 wasn't wet. R10 told V19 R10 feels like R10's wet and asked to just change me please. V19 then yelled at R10 not to talk to V19 like that. R10 documents that R10 was not being rude but felt like R10 was wet and R10 wanted changed. R10 documents V19 is very disrespectful. V19 took R10's brief off and started shaking it at R10 saying, see it was dry. R10 documents, it's already embarrassing enough without that. R10 documents R10 was laying on R10's side and asked V19 to please stop yelling at R10 and that's when V19 just stomped off, leaving R10 lying naked. R10 documents R10 tried to put the brief on R10's self but then V17 came in and got R10 taken care of. R10 documents when V19 left, V19 said I'm (expletive) done with this. V19 CNA documents - while doing rounds, R10 said R10 needed changed. After turning on the overhead light, V19 told R10 that R10 wasn't wet. R10 started screaming at V19. V19 put the brief under R10 and walked out of R10's room and yelled, I'm (expletive) done. . V18 Agency LPN documents - R10 was upset and crying saying that V19 had yelled at R10 and V18 immediately called V1. R10's MDS (Minimum Data Set) dated 6/4/23 documents R10 is alert and oriented. On 9/3/23 at 9:09 am, V1 AIT stated V1 is still in the process of investigating the allegation but figured it would be considered abuse. On 9/3/23 at 9:30 am, R10 was lying in bed with oxygen on. R10 stated V19 is loud, obnoxious, disrespectful and just plain rude. R10 explained, every time you attempt to talk to V19, V19 says, don't talk to me like that. R10 stated, R10 is not rude to V19 but that R10 had stopped talking to V19 when V19 provided cares because V19 thinks R10 is rude but will then say, what, you aren't going to talk to me, stop being rude. It's like you can't win with (V19). R10 stated last week V19 left me (R10) lying here in bed, naked. How humiliating is that. I (R10) don't care how mad you are, you just don't do that. R10 explained there are men that walk around out in the hallway that could see R10 lying in bed naked and uncovered. R10 stated V19 walked out of here throwing a temper tantrum and left the door wide open. R10 again exclaimed, that's just rude, you don't treat people like that. R10 explained at 5:00 am last week, V19 had banged on the door like the Gestapo while (R10) was sleeping and it scared (R10) to death. R10 stated, R10 wakes up easily and has asked V19 not to knock like that but R10 swears V19 does it louder and longer every time, just to watch (R10) jump. R10 stated after that, V19 asked R10 if R10 needed changed and R10 told V19 yes, that R10 was wet in the back. V19 checked R10 and began yelling at R10 saying that R10 was not wet and did not need changed. R10 stated, R10 explained to V19 that R10 felt like R10 was wet and asked V19 to just please change me (R10) and (V19) continued to yell and scream that I (R10) didn't need changed. R10 began to cry when telling the story. R10 stated V19 then pulled the brief from under of R10 and was waving it around saying see, I (V19) told you that you weren't wet. R10 explained R10 took it until I (R10) just couldn't take it anymore and asked several times for (V19) to please stop yelling at (R10), that I (R10) didn't have to put up with this but (V19) continued. R10 stated V19 finally stormed out, leaving R10 naked, the door open and yelled something like I'm (expletive) done with you. R10 stated this isn't the first time V19 has treated R10 like this but that R10 has never reported it before stating R10 just tried to be nice to V19 but R10 couldn't take it anymore. R10 again started crying, more forcefully this time and stated, V1 told R10 that R10 didn't have to worry about V19 right now until this situation was all figured out but R10 is scared and can only imagine how mad (V19) will be and what (V19) will do when (V19) finds out I (R10) told on (V19). R10, who was still crying at this point started shaking R10's hands back and forth and said, I (R10) don't want to talk about it anymore, it's too upsetting. On 9/3/23 at 11:00 am, V19 confirmed V19 is suspended pending an abuse allegation against V19 in regards to the situation on 8/31/23 with R10. V19 explained the allegation and confessed to saying I'm (expletive) done, while walking out of R10's room, leaving the resident naked, uncovered and with the door open. V19 stated V19 said that because V19 was irritated. V19 stated V19 might have also raised V19's voice and yelled at R10 I'm a loud person in general. (R10) is always telling me to be quiet because (R10) thinks (V19) is talking too loud. V19 also confirmed that R10 has told V19 in the past not to knock on R10's door because R10 feels V19 knocks too loud and it scares R10 and makes R10 jump, but V19 always knocks on the doors because I (V19) don't want to get into trouble for not knocking. On 9/3/23 at 11:45 am, V1 stated V1 feels like staff should still knock but could knock lighter and call out the resident name, if a resident has asked for staff not to knock, that is there right.

Based on observation, interview and record review, the facility failed to prevent the development of a deep tissue injury pressure wound, failed to notify the physician and/or wound practitioner of a newly developed deep tissue injury and obtain treatment orders and document the deep tissue injury for one of two residents (R32) reviewed for pressure injuries on the sample list of 17. This failure resulted in R32 developing a new deep tissue injury to the plantar surface of the right foot. Findings Include: The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcers. Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Conditions will be completed and forwarded to the Director of Nursing. The pressure areas will be assessed and documented on the Treatment Administration Record or the Wound Documentation Record. The physician will be notified for treatment orders. Nursing Personnel are to also notify dietary personnel of any pressure areas to seek nutritional support. When a pressure ulcer is identified, additional interventions must be established and noted on the care plan in an effort to prevent worsening or re-occurring pressure ulcers. R32's Skin Risk assessment dated [DATE] and 6/15/23 both document R32 is at risk for skin breakdown. On 7/16/23 at 8:45 AM, R32 stated R32 has a foot wound on my right foot caused by a screw that R32 stepped on in a walk in shower at R32's house. R32 also stated it was making great progress healing then stopped. On 7/17/23 at 1:23 PM, V22 Agency LPN (Licensed Practical Nurse) entered R32's room to provide the ordered wound treatment. R32 was lying in bed with R32's right foot resting up against the foot board of the bed. V22 removed the intact dressing to reveal a healing surgical wound to the lateral foot, a large surgical wound to the bottom of the foot, with macerated peri wound and a dark purple area to the side/below of the surgical wound. At this time, V22 stated The dark purple area appears to be DTI (Deep Tissue Injury). V22 measured the area of the surgical wound including the dark purple suspected DTI to be a total measurement of 5 cm (centimeters) by 5.7 cm. V22 stated, V22 last saw R32's wound five days prior and the DTI appearing area was not there at that time. As of 7/18/23, R32's Progress Notes do not document the new DTI area or that the physician was notified. R32's July 2023 Physician Orders do not document a treatment for the new DTI area. On 7/18/23 at 12:08 PM, V7 MDS (Minimum Data Set)/Care Plan Coordinator stated nurses change the wound dressings and if the wound has deteriorated, they should notify V18 Wound NP (Nurse Practitioner) that follows R32. V7 also stated that pressure should be off of that area. V7 checked the Progress Notes, Wound Assessments, and Wound Measurement Reports that confirmed that R32's new DTI has not been documented. On 7/18/23 at 3:35 PM, V18 Wound NP stated when V18 first started seeing R32, R32 had a darkened area around to the side of the wound but it was soft at that time and the discoloration had since resolved. When V18 was told that V22 described the area as a DTI, V18 stated R32 pushing R32's foot up against the foot board could most definitely be the cause of the DTI. On 7/19/23 at 10:15 AM, V4 Regional Clinical Nurse stated when a resident comes in with wounds or they develop a wound, nursing should notify V5 DM (Dietary Manager) who would then notify V11 RD (Registered Dietitian) for recommendations for wound healing. On 7/19/23 at 10:32 AM V11 stated, V11 is to be notified of Pressure Ulcers at the time of discovery so nutritional recommendations for wound healing can be given. V11 stated, V11 was notified of R32's surgical wound but not the pressure wound. On 7/19/23 at 11:45 AM, Both V18 and V21 RN (Registered Nurse) entered R32's room to evaluate R32's wound. R32 was lying in bed with bilateral feet pressing up against the foot board. V18 removed the dressing to the right foot and stated, I (V18) see exactly what you {surveyor} were talking about yesterday with the dark spot (pointing to the area next to the surgical wound). V18 stated, V18 think's that is definitely a DTI caused from the pressure from the foot board. V18 measured the DTI area only at 2.6 cm by 2.5 cm and stated V18 should have been notified of the new DTI on Monday (2 days prior when it was first observed).

A. Based on observation, interview and record review, the facility failed to assess a surgical wound weekly, complete dressing changes as ordered to prevent a surgical wound from deteriorating, failed to notify the physician/wound practitioner of the wound decline and failed to implement nutritional interventions for wound healing for one of one residents (R32) reviewed for surgical wounds on the sample list of 17. This failure resulted in delayed wound healing and R32's surgical wound increasing in size. B. Based on observation, interview and record review, the facility failed to apply a splint/brace as ordered for one of two residents (R19) reviewed for splints/braces on the sample list of 17. Findings Include: A.) On 7/16/23 at 8:45 AM, R32 stated R32 has a foot wound on R32's right foot caused by a screw that R32 stepped on at R32's house. R32 explained R32 had surgery for it, but the doctor went too deep and caused more issues. R32 stated it was making great progress healing then stopped. R32's Dietitian Review dated 6/26/23 documents this is an admission assessment for R32, who was admitted to the facility on [DATE]. This Review documents a nutritional recommendation for 30 ml (milliliters) of liquid protein daily for 21 days for wound healing. R32's Dietary Note dated 7/14/23 by V11 RD (Registered Dietician) documents R32's surgical wounds are deteriorating and again recommended 30 ml of liquid protein daily for 21 days for wound healing. R32's Progress Notes document the following: 5/31/23 - Surgical wound. Skin issue location: Right plantar foot - 1 cm (centimeter) by 1.8 cm by 1.5 cm. Wound bed with Granulation tissue. Wound exudate: Serosanguineous. Peri wound condition: WNL (within normal limits). 6/7/23 - Skin Issue: Surgical wound. Skin issue location: Right plantar foot - 1 cm by 1.8 cm by 1.2 cm. Wound bed with Granulation tissue. Wound exudate: None. Peri wound condition: WNL. 6/14/23 - Skin Issue: Surgical wound. Skin issue location: Right plantar foot - 1 cm by 1.5 cm by 0.8 cm. Wound bed with Granulation tissue. Wound exudate: None. Peri wound condition: Maceration. 6/21/23 - Skin Issue: Surgical wound. Skin issue location: Right plantar foot - 0.9 cm by 0.8 cm by 0.4 cm. Wound bed with Slough. Wound exudate: None. Peri wound condition: Maceration. 6/28/23 - Skin Issue: Surgical wound. Skin issue location: Right plantar foot - 1.2 cm by 0.8 Depth by 0.4 cm Wound bed with Slough. Wound exudate: None. Peri wound condition: Maceration. 7/12/23 - Skin Issue: Surgical wound. Skin issue location: Right plantar foot - 1.8 cm by 2 cm by 0.4 cm. Wound bed with Granulation tissue. Wound exudate: None. Peri wound condition: Maceration. There is no wound measurements for 7/5/23 in R32's medical record. R32's June 2023 Physician Orders do not document an order for liquid protein as recommended by V11. R32's July 2023 Physician Orders document an order for the Right plantar foot wound: cleanse with NS (Normal Saline), pat dry, apply skin prep to periwound, lightly pack with Calcium Alginate AG (cut to fit to wound bed), cover with island dressing, change daily until resolved but there is no order for nutritional interventions for wound healing as recommended by V11. R32's June 2023 TAR (Treatment Administration Record) does not document that R32's surgical wound treatment was completed as ordered on the 23rd, 27th, 28th, and the 30th. R32's July 2023 TAR does not document that R32's surgical wound treatment was completed as ordered on the 1st, 3rd, 4th, 5th and 10th. On 7/17/23 at 1:23 PM, V22 Agency LPN (Licensed Practical Nurse) entered R32's room to provide wound care. R32 was lying in bed with the right foot resting up against the foot board of the bed with a dark brown liquid on the bed sheets under the right foot. Nurse removed the island dressing, which had a moderate amount of brownish drainage, to reveal a large wound with a gray wound bed, macerated white tissue surrounding the open area and dark purple tissue extending past the maceration. V22 removed a thin covering of saturated calcium alginate from the large wound. It was not packed with calcium alginate. V22 measured the surgical wound to the right plantar foot and reported measurements of 1.5 cm by 3.5 cm. V22 did not have supplies at the bedside to measure the depth but stated, it appears to be about 3/4 of an inch deep. The open area including the maceration measured 3.2 cm by 5 cm and the area including the open, macerated, and DTI (deep tissue injury) appearing area measured 5 cm by 5.7 cm. V22 cleansed the wound with NS, cut calcium alginate to the size of the wound and applied one layer to the wound bed, applied skin protectant to the periwound and covered the wound with a bordered anti-stick dressing. V22 stated V22 last observed R32's wound five days ago and that it has deteriorated since, she then explained the open area is about the same size however five days ago the wound base was pink, instead of the gray in color as it is now and the macerated area was about half the size it is now and the DTI appearing area was not there at that time. On 7/18/23 at 12:08 PM, V7 MDS (Minimum Data Set)/Care Plan Coordinator stated nurses change the dressings and if the wound had deteriorated, they should notify V18 Wound NP (Nurse Practitioner). V7 stated all wounds are to be measured weekly, and pressure should be removed from R32's foot. V7 checked the Progress Notes, Wound Assessments, and Wound Measurement Reports and stated there is no documentation of the changes in R32's wound or that V18 was notified. On 7/18/23 at 3:35 PM, V18 stated with the decline in R32's wound condition, V18 would have expected a phone call and would have probably changed the treatment order for R32 explaining, calcium alginate is the best thing for the wound, but the dressing might need to be more frequent with the amount of drainage R32 now has. V18 also stated R32 pushing R32's foot up against the foot board could most definitely be the cause of the deterioration of the wound. On 7/19/23 at 10:15 AM, V4 Regional Clinical Nurse stated when a resident comes in with wounds, nursing should notify V5 DM (Dietary Manager) who would then notify V11 Registered Dietician (RD) for recommendations for wound healing. On 7/19/23 at 10:21 AM, V5 DM stated V5 was made aware of R32's surgical wound at the time of R32's admission and V11 RD was notified also at that time, so V5 isn't sure why it took over a month for R32 to be assessed. On 7/19/23 at 10:25 AM, V1 AIT (Administrator in Training) stated after V11 assesses a resident, those recommendations are sent out to the physician and when they are returned, they are given to the nurses. Not sure why R32's nutritional recommendations were not implemented. On 7/19/23 at 10:32 AM, V11 RD stated V11 assessed R32 on 6/26/23 because V11 has 30 days before V11 needs to see new admissions. V11 stated V11 recommended the liquid protein on that day and on again on 7/14/23 due to R32's surgical wound deterioration. V11 stated when a recommendation is made, V11 gives it to V1 AIT (Administrator in Training) and is unsure what V1 does with them. V11 stated protein is needed to build new tissue so not getting the liquid protein could have contributed to the wound not healing. On 7/19/23 at 11:45 AM, V21 RN (Registered Nurse) stated V21 was not aware that the RD had ordered R32 nutritional supplements on two separate occasions and stated that R32 has not received the recommended Protein supplement. V21 explained that V24 Regional Nurse had been handling stuff like that due to the facility not having a DON (Director of Nursing) but that (V24) hasn't been at the facility for sometime due to working at other facility's and now being off work due to an injury. V21 and V18 Wound NP entered R32's room and R32 was lying in bed with bilateral feet pressing up against the foot board. At this time, V18 measured R32's surgical wound at 3.2 cm by 3.3 cm by 0.6 cm and stated the wound continues to deteriorate and get bigger; part of that is due to the macerated skin coming off but explained the pressure from the foot board is also contributing to the wound's deterioration and preventing healing of the wound. V18 also stated the recommended liquid protein from V11 would have helped the surgical wound heal but also thinks R32 needs to have laboratory tests done to see if R32 should be being given any additional wound healing supplements like Vitamin D, iron, zinc, etc. B) R19's July 2023 Physician Orders document an order to wear a splint as tolerated including while sleeping on the left hand. R19's MDS (Minimum Data Set) dated 7/3/23 documents R19 is alert and oriented, has limited range of motion to bilateral lower extremities and one upper extremely, and is on a restorative program for splint/brace seven days a week. R19's Care Plan dated 4/20/23 documents R19 is in a Restorative Nursing Splint/Brace program As evidenced by: impaired mobility of the left hand. R19 can have the splint off during the day and on at night. On 7/16/23 at 9:00 AM, R19 stated the R19's left arm and leg are paralyzed from a stroke. R19's left hand was contracted with fingers curling into the palm of the left hand. R19 did not have a splint on. Also at 10:43 AM, R19 did not have a splint on the left hand. On 7/17/23 at 4:33 PM, R19 was sitting up in a reclining wheeled chair in the Dining Room and did not have a splint to the left hand. At this time, R19 stated, I (R19) haven't worn the splint for over two years, I (R19) don't know where it is. On 7/18/23 at 12:07 PM, V7 MDS/Care Plan Coordinator confirmed R19 should be wearing a splint on the left hand and is unaware that R19 doesn't have one anymore. On 7/18/23 at 12:40 PM, V17 CNA (Certified Nursing Assistant) stated R19 use to have a hard splint for the left hand that curved with R19's hand. V17 also stated V17 hasn't seen it in a really long time. At this time, V17 checked R19's drawers in R19's room and couldn't find the splint. R19 again stated, I (R19) haven't seen it or worn it in years. It's really contracted.

Based on interview and record review the facility failed to assess for the use of an electromechanical lift chair and develop and implement targeted resident centered interventions for one resident (R1) of four residents reviewed for falls in a sample list of six residents. This failure resulted in R1 using the remote control to lift herself and fell to the floor sustaining a fracture of her right femur. Findings include: R1's Physician's Order sheet for May 2021 includes the following diagnoses: History of Falls, General Weakness, and Anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is totally dependant for transfer with the need for the assistance of two or more staff and R1's balance in not steady without staff assistance. R1's Care Plan dated 4/6/21 documents R1 has Potential for Falls. Risk factors include: Unsteady Balance, Increased Weakness, and (R1) has history of falls. R1's Care Plan Intervention dated 4/7/21 documents Insure adaptive devices (Walker/Wheel Chair) are within reach and in good repair. An electric lift chair is not documented in R1's Care Plan. No assessment is documented for the safe use of an electric lift chair. R1's progress note dated 5/20/21 at 8:00AM documents Continues with confusion. Alert X (times) 1 (Alert to self only). Treated for Urinary Tract Infection. R1's progress note dated 5/21/21 at 9:00AM documents Alert X1. Confusion continues. R1's Progress note dated 5/22/21 at 9:00AM documents Alert and Oriented X1 confusion continues. R1's progress note dated 5/23/21 at 10:00PM documents (remote audio) monitor remains in place related to increased confusion. There is no documentation to indicate a fall assessment was completed to address this change in R1's mental status. R1's progress note dated 5/24/21 at 3:15PM documents Heard shuffle on monitor. Resident raised chair to up position. Resident observed on floor in front of chair. No apparent distress. Resident had no initial complaints. Assessed per staff. (Mechanical lift) assisted to bed. External rotation and shortening noted. The progress note goes on to document doctor was notified and an X-ray was performed. R1's X-Ray of right hip dated 5/24/21 at 5:28PM documents Impressions: Displaced Oblique Right Femoral Fracture. R1's progress note dated 5/24/21 at 6:00PM documents Orders received and (R1) sent to (local hospital). A hand written note dated 5/28/21 is documented on R1's care plan stating Observed on floor. Sent to emergency room for evaluation. Hip Fracture. Upon return the following will be implemented: 15-minute checks, Removal of Lift Chair. On 6/7/21 at 10:20AM V3, Registered Nurse (RN) Care Plan Coordinator (CPC) stated. I was the nurse on duty the afternoon (R1) fell . R1 had been experiencing a recent decline. (R1) had been confused for a few days prior to the fall, but (R1) was having a good day that day. (V4, )Certified Nurse's Aide (CNA) and I put (R1) in her electric recliner. We gave (R1) the remote to the chair and her call light. Since (R1) had been having some confusion we even had a baby monitor in (R1's) room. (R1) had been having some respiratory signs and symptoms so she was on the yellow unit for precautions. We went back the room we use to chart and put on personal protective equipment. We heard a shuffling sound on the baby monitor and went in (R1's) room. The lift chair was in the high position and (R1) was lying in front of her chair. She was kind of tangled up in her over the bed tray. We used a (mechanical lift) to get her up. She didn't seem to be in much pain, but her leg was slightly shortened and rotated out. I got an order for an X-Ray and her femur was fractured. (R1) went to the hospital and was seen by the Orthopedic group. The family has decided not to have (R1) return here. On 6/7/21 at 10:30AM V2, Director of Nursing (DON) stated (R1) had been having some issues with respiratory problems recently and had been somewhat more confused than her baseline, but we thought she was improving the day the fall occurred (5/24/21). (R1) had the electric lift chair since she was admitted . It was hers. We do not have an assessment for electric lift chairs. (V3 and V4) are the only witnesses to the fall. On 6/7/21 at 11:40AM V4, CNA verbalized the same chain of events as V3. V4 stated We thought (R1) was better and we gave her the remote to the automatic chair. Then the next thing we knew we were in the charting room and we heard a commotion on the baby monitor and when we went in we found (R1) kind of tangled up in her tray table. We got her up with the lift and (V3) noticed her leg didn't look right and I hear she broke her hip. V5, Orthopedic Surgeon who treated R1 following fall supplied an electronic message to V15, Physician's Assistant (PAC) on 6/9/21 at 11:37AM stating History provided was that (R1) had a mechanical lift chair and lifted to reach a remote and may also have reached forward to reach; This is documented in emergency room Intake Notes/History and Physical and Orthopedic Consult Notes. The resultant fall resulted in a femur fracture and Orthopedics was consulted as a result. The facility's policy Fall Prevention dated December 2009 states 1. Conduct fall assessments on the day of admission, quarterly, and with a change of condition. 2. Identify, on admission, the residents risk for falls. A visual prompt may be placed on the plaque by the entrance to the resident's room. If used any assistive device such as a walker or cane will be identified with the same visual prompt to match the prompt at the entrance to the room.

Based on interview and record review the facility failed to complete wound assessment/treatment per facility policy for one resident (R4) of four residents reviewed for wounds in a sample list of six residents. This failure resulted in R4 developing an abscess and [CONDITION(S)] requiring surgical intervention, treatment and hospitalization . Finding Include: R4's Braden Scale skin risk assessment dated [DATE] documents R4 is at high risk for skin breakdown related to her skin being constantly moist, slightly limited sensory perception, chair fast, potential problems with friction and shear, and very limited mobility. R4's Care Plan documents a problem dated 4/26/21 stating Fragile Skin. Prone to bruising and/or skin tears. R4's High Skin Risk is not otherwise documented as addressed on R4's Care Plan. R4's Care Plan dated 4/26/21 documents Weekly Skin Checks Document Results. The facility's policy Pressure Sore Prevention Guidelines dated January 2018 requires daily skin checks and documentation of skin condition for all residents assessed at high risk for skin breakdown per the Braden scale. R4's Treatment Administration Record (TAR) for April and May 2021 document weekly skin checks, but R4's skin condition is not documented as per facility policy. R4's AIM For Wellness document created by V7, Licensed Practical Nurse (LPN) on 4/30/21 at 12:00PM documents CNA (Certified Nurse's Aide) notified nurse that (R4) had an abrasion to buttocks/Sacral area. (R4) has had this condition before a few times in past. Area assessed/cleaned. Duoderm with [MEDICATION(S)] applied. R4's TAR for April 2021 includes this treatment order which is signed off as completed on 4/30/21 by V7. This same treatment is not documented on R4's TAR for May 2021 and there is no documentation to indicate the treatment was done after 4/30/21. R4's Skilled Progress Notes after 4/30/21 do not include a skin assessment. On 6/8/21 at 1:20PM V8, Certified Nurse's Aide (CNA) stated I took care of (R4) a few times the week she went to the hospital. She had a bruised hip. I've been doing this for almost [AGE] years (CNA work). (R4's) butt did get red at times because she was always wet. She dribbled urine almost constantly. On 6/8/21 at 2:30PM V7 stated I kind of remember 4/30/21. The CNA (can't remember which one) told me (R4) had an open area on her sacrum. V7 pointed to an area above her tail bone in the mid back. I notified the doctor and got treatment orders. I started the treatment. I did not get measurements. It was probably the size of a quarter. It looked red and the top layer of skin was off. I'm not really sure what happened after that. R4's Shower/Abnormal Skin Report dated 5/6/21 by V13, Certified Nurse's Aide (CNA) documents Findings Skin breakdown An anatomical drawing documents the area of abnormality as the coccyx area of the buttocks. V10, Licensed Practical Nurse (LPN) signed off on this form dated 5/6/21. No skin assessment is documented. No treatment is documented as initiated. On 6/9/21 at 10:58AM V13, Certified Nurse's Aide (CNA) stated I did document on (R4's) shower sheet 5/6/21 she had an open area in the middle of her buttocks. It was open, very red, and raw. I gave the shower sheet to (V10) I didn't see the nurse check (R4's) buttocks. R4's AIM For Wellness document created by V10, Licensed Practical Nurse (LPN) on 5/30/21 at 8:45PM documents At 7:30PM (R4) noted to be confused and shaky. incomprehensible speech. Pupils dilated to three millimeters and do not react to light. Unable to follow simple commands. On 6/8/21 at 2:45PM V10 stated Yes that is my signature on the (5/6/21) shower sheet. I honestly don't remember the CNA telling me about an open area or signing the shower sheet. I found (R4) to be unresponsive on 5/30/21. I immediately called the doctor and got her transferred to the hospital. I'm not sure what happened after that. On 6/8/21 at 12:30PM V3, Care Plan Coordinator checked the records of the contracted wound doctor utilized by the facility. V3 stated there is no record that (R4) was ever seen by the wound doctor. On 6/8/21 at 1:00PM V1, Director of Nursing (DON) stated I was aware that we had some failure of staff to follow through with skin documentation for (R4). This was addressed in morning meeting and I am in the process of determining where the breakdown occurred and taking steps to prevent it from happening again. It is being looked at by our Quality Assurance/Quality Assessment committee. R4's nurse's note by V16, emergency room Nurse dated 5/30/21 at 11:00PM documents Black colored wound noted to Right buttocks. [CONDITION(S)] (redness) noted around wound. R4's hospital note by V7, MD (Facility medical Director) documents The patient (R4) comes in with the high fever, acute mental state change and was found to have a Urinary Tract Infection, [CONDITION(S)], and abscess in the right buttock. The patient is a resident of (the facility). She had acute mental state change, most likely metabolic [CONDITION(S)]. Was brought over to ER (emergency room ) where she was found to have a temperature 103.7. Urinary Tract Infection (e-coli positive). We later found she has positive blood cultures (staphylococcus hominus positive) and also an abscess in the right buttock (Methicillin Resistant Staphylococcus Aureus positive). On 6/9/21 at V14, Medical Doctor, the surgeon who incised and drained R4's Right buttock abscess stated The wound on (R4's) buttocks was not new. It definitely had been there at least several days. I removed a lot of pus and dead tissue. The wound was definitely the cause of the [CONDITION(S)]. The Urinary Tract Infection complicated (R4's) condition too. I can't say for sure that this wound was pressure related, the buttocks are a pressure point and pressure would certainly have aggravated it. The wound should have been apparent for some time as it would have caused pain, redness, and the area most likely would have been hard. The facility's policy Pressure Sore Prevention Guidelines dated January 2019 includes a grid that documents daily skin checks for residents identified by a Braden Scale skin risk assessment as high risk. Under Comments this policy states Follow Protocol for coding skin condition C-clear, R-red, O-other, P-pressure, S-skin tear. Any area that doesn't resolve after 30 minutes after pressure is relieved must be documented as Stage I. This policy also states Any resident scoring High or Moderate for skin breakdown will have scheduled skin checks on the Treatment Record. Skin checks will be completed and documented by the nurse.

Based on record review and interview, the facility failed to supervise to one (R10) of five residents reviewed for falls in total sample of ten. This failure resulted in a fall with injuries requiring hospital treatment. The finding includes: According to R10's June's Physician order [REDACTED]. R10's March's POS lists safety devices that include a postioning cushion. The positioning cushion is to be used in the wheelchair and released every 2 hours for 10 minutes and at meals. R10's 2-16-12 Annual Resident Assessment Instrument (RAI) lists R10 as requiring extensive assist of 2 for all activities of daily living (ADLs), including transfers, bed mobility, and bathing. The RAI identifies R10 as a high risk for falls. The 2-17-12 Care Assessment Area (CAA) for falls state that R10 has poor trunk control, leans forward in the wheelchair without the positioning cushion, and will fall out of her wheelchair. R10's 3-22-12 Nurses Notes at 8:20 P.M. state, "CNA (Certified Nurse Assistant) reported that the resident (R10) was on floor in shower room. Resident observed lying on shower room floor on R (right) side. . . . Assessment revealed wounds to R side of forehead above R eye, R side of bridge of nose, {and} R side of chin." Dressings were applied and R10 was transferred to the hospital emergency room . The 3-22-12 emergency room report stated that R10 had "deep 4 centimeter laceration on the forehead" that required 7 sutures to close. R10's 3-22-12 Nurse Notes recorded at 9:00 P.M. state that the CNA, E5 was interviewed regarding the incident. According to the Nurses Notes, E5 "stated that she had transferred resident to shower chair. {Positioning cushion} was out of reach on the counter. She walked several steps to get the {cushion} and resident fell forward out of chair before she could stop her. CNA then opened shower door to call for help." E5 stated on 7-31-12 at 3:28 P.M. that she and E6 (CNA) had transferred R10 from her wheelchair to the shower chair in the shower room. E6 had left the shower room and E5 pushed R10 in the wheeled shower chair into the shower stall. E5 noticed that the positioning cushion was not on R10. E5 turned to get the cushion and E5's back was turned. R10 fell to the floor. E5 stated that R10 was dependent on her for all R10's needs and required supervision at all times. The Director of Nurses (E2) was interviewed on 7-31-12 at 3:35 P.M. and acknowledged that E5 did not supervise R10 and should have.