Every finding on record at Franciscan Village

Based on observations, interviews, and record reviews, the facility failed to provide assistance with activities of daily living (ADLs) to four residents at least every two hours and failed to provide requested transfers from bed to wheelchair. This affected six residents (R1-R6) in the sample who were reviewed for assistance with incontinence care and/or transfers. Findings include:On 8/1/26 at 10:25 AM, R1 stated that she does not like to get up into wheelchair because she has to wait two hours, after requesting assistance, to get back into bed. R1 stated that by the time staff get her in bed she has a lot of low back and buttocks pain from sitting in the same position. R1 stated that two weeks ago her family came to visit around 3:00 PM, R1 was transferred via mechanical lift device into wheelchair then went outside with family. R1 stated that she came back in at dinnertime and ate in the dining room. R1 stated that she requested to get back in bed about 6:00 PM; staff brought R1 to her room. R1 stated that it takes two staff members to transfer her with the mechanical lift device. R1 stated that staff did not assist her into bed until 8:00 PM. On 8/2/26 at 10:16 AM, R2 was heard informing V6 CNA (certified nurse aide) he wanted to go to the bathroom. V6 responded that R2 needs a mechanical lift device to transfer. V6 offered a bedpan but R2 refused. V8 CNA was observed entering R2's room and informed R2 that they will help him get up in a few minutes, R2 responded 'more like one hour'. V8 assured R2 it would only be a few minutes not one hour. V6 and V8 exited R2's room then exit the nursing unit. V6 and V8 returned to the nursing unit at 10:55 AM. At 11:49 AM, V8 was observed bringing the mechanical lift device into R2's room. At 12:02 PM, R2 was observed being transported to the dining room. On 8/2/26 at 12:50 PM, R3 and R4 stated that their briefs were wet. On 8/2/26 at 12:52 PM, this surveyor observed V4 CNA and V5 CNA transfer R6 from wheelchair to bed via a mechanical lift device and provide incontinence care. R6's buttocks was observed to be reddened and with deep indentations from the sling. R6's brief was saturated. On 8/2/26 at 12:57 PM, V4 stated that he doesn't recall when R6's brief was last changed. On 8/2/26 at 1:05 PM, this surveyor observed V7 CNA and V8 CNA provide incontinence care for R3. V7 and V8 stated that they just transferred R3 from wheelchair to bed using the mechanical lift device. R3's pants covering buttocks were wet. R3's brief was saturated. R3's buttocks was reddened with deep indentations from the sling. A small puddle of liquid was observed on R3's wheelchair. On 8/2/26 at 1:15 PM, this surveyor observed V4 CNA and V6 CNA transfer R4 from wheelchair to bed via a mechanical lift device and provide incontinence care. R4's buttocks was observed to be reddened and with deep indentations from the sling. R4's brief was saturated. R4 was observed to have an open area on right buttock and a second open area on lower left buttock. V9 (nurse supervisor) was called to room to assess R4's skin and wound. V6 stated that R4's brief was last changed at 8:00 AM. On 8/2/26 at 1:27 PM, this surveyor observed V7 CNA and V8 CNA transfer R5 from wheelchair to bed via a mechanical lift device and provide incontinence care. R5's brief was saturated. R5's buttocks was reddened with deep indentations from the sling. R5 was observed to have an open area on left buttock. V9 (nurse supervisor) was called to room to assess R5's skin and wound. V7 stated that she did not observe any skin breakdown when she provided incontinence care for R5 this morning. On 8/1/26 at 2:15 PM, V4 CNA stated that residents are checked and changed every two hours. On 8/1/26 at 2:17 PM, V5 CNA stated that residents are checked and changed every two hours. On 8/2/26 at 10:18 AM, V7 CNA stated that residents are checked and changed every two hours. On 8/2/26 at 2:30 PM, V2 DON (director of nursing) stated that staff are expected to check and change residents every two hours to protect the resident's skin integrity to prevent any skin breakdown. V2 stated that residents should not be sitting in soiled briefs. V2 acknowledged that residents should not have to wait more than a few minutes to receive assistance with transferring into or out of wheelchair. The facility's activities of daily living (ADLs) policy, dated 12/1/23, notes in part appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with hygiene, transfers, and elimination (toileting).

Based on observations, interviews, and record reviews, the facility failed to follow its infection control hand hygiene policy and perform hand hygiene before and after resident contacts. This failure affected four residents (R1, R2, R4, and R7) out of seven reviewed for infection control in a sample of 7.Findings include:On 8/1/26 from 12:15 PM until 1:15 PM, lunch meal service was observed.On 8/1/26 at 12:54 PM, V5 CNA (certified nurse aide) was observed wiping face on multiple occasions while feeding R2. No hand hygiene was performed after touching face and hair.On 8/1/26 at 1:00 PM, V4 CNA was observed picking up R4's sandwich with his right hand to feed R4. No hand hygiene performed before or after touching R4's food.On 8/1/26 at 1:03 PM, V5 CNA was observed assisting another resident, R7, no hand hygiene performed before or after assisting R7 and before continuing to feed R2.On 8/1/26 at 1:10 PM, V6 CNA was observed passing lunch to residents in their rooms. V6 was using a small cart on wheels. There were two plates with covers and one cover turned over with discarded food on the top and drinks on the middle shelf; bottom shelf was empty. V6 brought R1 her lunch; no hand hygiene performed after exiting R1's room. V6 was observed emptying the cover with discarded food into the garbage can in room [ROOM NUMBER], taking the bag out of can and placing it on the bottom shelf of cart. V6 then proceeded to bring lunch into room [ROOM NUMBER]. No hand hygiene performed.On 8/2/26 at 2:30 PM, V2 DON (director of nursing) stated that staff are expected to perform hand hygiene before and after resident care, and in between each meal passed to residents. V2 stated that staff are expected to cut up resident's sandwich and use a fork to feed the resident. V2 stated that staff absolutely must perform hand hygiene after touching their face.The facility's infection control hand hygiene policy, dated 9/1/23, notes in part hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, between resident contacts, before performing resident care procedures, after sneezing, coughing, and/or blowing or wiping nose, and when in doubt.

Based on observations, interviews, and record reviews, this facility failed to provide the necessary care and services to prevent new pressure wounds from developing for two residents (R4 and R5) out of six residents at risk for developing wounds in a sample of 7. Findings include:On 8/2/26 at 1:15 PM, this surveyor observed V4 CNA and V6 CNA transfer R4 from wheelchair to bed via a mechanical lift device and provide incontinence care. R4's buttocks was observed to be reddened and with deep indentations from the sling. R4's brief was saturated. R4 was observed to have an open area on right buttock and a second open area on lower left buttock. V9 (nurse supervisor) was called to room to assess R4's skin and wound. V9 stated that R4's left buttocks wound is not new. V6 stated that R4's brief was last changed at 8:00 AM. On 8/2/26 at 1:27 PM, this surveyor observed V7 CNA and V8 CNA transfer R5 from wheelchair to bed via a mechanical lift device and provide incontinence care. R5's brief was saturated. R5's buttocks was reddened with deep indentations from the sling. R5 was observed to have an open area on left buttock. V9 (nurse supervisor) was called to room to assess R5's skin and wound. V7 stated that she did not observe any skin breakdown when she provided incontinence care for R5 this morning. On 8/1/26 at 2:15 PM, V4 CNA stated that residents are checked and changed every two hours. V4 stated that residents' skin is assessed when care is provided. On 8/1/26 at 2:17 PM, V5 CNA stated that residents are checked and changed every two hours. V5 stated that residents' skin is assessed when care is provided. On 8/2/26 at 10:18 AM, V7 CNA stated that residents are checked and changed every two hours. V7 stated that residents' skin is assessed when care is provided. On 8/2/26 at 2:30 PM, V2 DON (director of nursing) stated that staff are expected to check and change residents every two hours to protect the resident's skin integrity to prevent any skin breakdown. V2 stated that residents should not be sitting in soiled briefs. V2 stated that the nurses are contacting R4 and R5's physicians to obtain wound treatment orders. Per R4's most recent MDS (minimum data set), R4 is dependent on staff for toileting.R4's care plan, initiated 5/12/21, notes R4 is at risk for impaired skin integrity/skin breakdown related to incontinence, weakness, decreased mobility/ADL function, and aged/fragile skin. Interventions include but not limited to check and change after each incontinence, evaluate skin for rednessPer R5's most recent MDS, R5 is dependent on staff for toileting.R5's care plan, initiated 7/22/24, notes R5 has potential for impairment to skin integrity related to incontinence, muscle weakness, compromised skin condition, and decreased mobility. Interventions include but not limited to keep skin clean and dry.

Based on interview and record review, the facility failed to ensure a resident was provided adequate assistance during bed mobility to prevent injury. This failure resulted in R1 requiring hospitalization for treatment of a femur fracture. This applies to 1 of 3 residents reviewed for skin impairments in the sample of 5.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, morbid obesity, right hip osteoarthritis, dementia, and fracture of right fibula. The EMR continued to show R1 was transferred to the local hospital on March 27, 2026, and had not returned to the facility. R1's MDS (Minimum Data Set) dated January 13, 2026, showed R1 had moderate cognitive impairment. The MDS continued to show R1 required supervision from facility staffing with eating, R1 was dependent on facility staff for transfers to and from a bed to a chair and required substantial assistance from facility staff for rolling side to side in the bed. R1's self-care care plan dated October 13, 2022, showed Decrease self-care deficit: bathing, dressing, feeding, transfer/mobility. The care plan continued to show multiple interventions dated February 20, 2026, including [Mechanical lift] transfer times two; toilet hygiene: dependent; shower/bathing: dependent; roll left and right: substantial/maximal assistance; chair/bed-to-chair transfer: dependent. On April 9, 2026, at 2:36 PM, V11 (RN/Registered Nurse) said on March 23, 2026, close to 10:00 PM, the CNA (Certified Nursing Assistant) called V11 and reported a skin tear on R1's right leg. V11 said the CNA thought it happened when she was trying to pull a sheet out from underneath R1's leg. V11 said when he went to treat R1's skin tear, he noticed bruising by the skin tear and under R1's right knee. On April 9, 2026, at 4:13 PM, V8 (CNA/Certified Nursing Assistant) said she was changing R1 and R1's bed sheets by herself and R1 sustained a skin tear. V8 said she was standing on the right side of R1's bed, R1 was lying away from V8 and V8 pulled the sheets out from under R1's legs. V8 said that is when she saw the skin tear on R1's right shin, below her knee. V8 said there was bruising present as well. V8 said she also used the mechanical lift by herself to reposition R1 in bed. V8 said she would always utilize the mechanical lift by herself to reposition residents in bed who could not assist her with repositioning. V8 said she thought it was okay to use the mechanical lift by herself because she used the mechanical lift by herself at other nursing home facilities she has worked at. V8 said she did not have anyone help her with R1's bed mobility and repositioning. On April 9, 2026, at 2:08 PM, V7 (LPN/Licensed Practical Nurse) said on March 26, 2026, she went to see R1 and R1 was moaning and groaning in pain. V7 said R1's pain was located by the dressing of her skin tear. V7 said R1 also had a blister behind her knee and bruising around the bister and the skin tear. V7 said she received orders for an x-ray and administered R1's as needed acetaminophen. On April 9, 2026, at 2:24 PM, V6 (R1's NP/Nurse Practitioner) said she saw R1 on March 24, 2026, due to a skin tear she experienced the day before. V6 said on March 24, there was some slight bruising around R1's skin tear visible around the dressing. V6 said on March 26, 2026, V10 (R1's Family) reached out to V6 about the bruising. V6 said she told V10 some bruising is expected from the skin tear, but V10 sent a picture of the bruising. V6 said the bruising was significantly extensive since March 24, much more than would be expected. V6 said she ordered an x-ray of R1's right leg to rule out a fracture, and the results showed a right femur fracture. V6 said fractures are not typically idiopathic. On April 9, 2026, at 1:34 PM, V3 (ADON/Assistant Director of Nursing) said he completed the investigation of R1's femur fracture. V3 said on March 27, 2026, an x-ray showed R1 had a femur fracture and R1 was sent to the hospital via emergency medical services. V3 said R1 had experienced a skin tear on her right shin below her knee a few days before and had extensive bruising below and above her knee. V3 said there was also a blister behind R1's right knee. R1's x-ray results dated March 27, 2026, showed .Findings: There is a fracture involving the proximal femur with 2.3 cm (centimeter) displacement. The remainder of the femur is intact. There is osteopenia. On April 9, 2026, at 3:46 PM, V3 said V8 used the mechanical lift by herself to reposition R1 in bed. V3 said staff are to use two staff members anytime they are using the mechanical lift. On April 9, 2026, at 3:36 PM, V12 (R1's Doctor) said there was suggestion R1 had bone loss, but R1 had not had a formal bone density scan. V12 said R1's femur fracture could have been caused from being moved in bed by one staff member. V12 said she doesn't think staff would be able to safely perform R1's bed mobility by themselves due to R1's obesity and inability to assist with care. V12 said there should be two staff members when utilizing a mechanical lift. On April 13, 2026, at 1:17 PM, V2 (DON/Director of Nursing) said R1 required two staff members for bed mobility. V2 said V8 should have had a second staff member present to assist V8 with R1's bed mobility and changing R1's linens. V2 said staff are to use two people when operating the mechanical lift, including with bed mobility. V2 said the purpose of two staff members assisting with the mechanical lift is for resident and staff safety and to prevent injury to the resident and staff. V2 said the facility does not train staff they can use the mechanical lift by themselves. The facility's undated final report showed Details of the Incident/Initial: On March 26, 2026, an x-ray was ordered to follow up with pain and bruising to the right knee above an area where a skin tear had occurred a few days prior. On March 27, 2026, x-ray results indicated an acute right femur fracture with osteopenia. The NP (Nurse Practitioner) and POA (Power of Attorney) were notified and the resident was transferred to [local hospital] via [Emergency Services] transport. The resident denies falling and does not remember any events that lead to the fracture. There is no evidence or report of a recent fall. An investigation has started. The final investigation is pending. Resident Details: [R1] is a [AGE] year-old long-term resident at [the facility]. She was admitted on [DATE]. [R1] is alert and oriented times one to two, with frequent confusion and is a poor historian. She is able to make her basic needs known. She has a historical BIMS (Brief Interview for Mental Status) score range of 6 to 12, with her last documented BIMS score being 11 (moderate cognitive impairment). [R1] is incontinent of bowel and bladder, requires maximum assistance for all ADLs (Activities of Daily Living), and is dependent for all transfers. [R1] is unable to ambulate, self-propel in a wheelchair, and reposition herself in bed. She is a set-up for meals. Investigation: Corresponding factors: The resident has general weakness, joint stiffness, and a history of osteoarthritis to the right hip. [R1] has had poor physical therapy performance in the past with the inability to perform adequately related to morbid obesity, physical limitations, and impaired cognitive function. [R1] prefers to spend the majority of her time in bed and often refuses to be transferred to her recliner chair. She is not a fall risk and has had no falls in the last four years. Interviewing was conducted with multiple nursing staff who had worked with the resident in the last several days of the noted right hip fracture. None of the nurses or aides had reported a fall or a transfer from bed to chair during this period. The resident had remained in bed, per her preference at the time, in the days preceding the notification of the fracture. There was a skin tear incident that occurred on March 23, 2026, during the evening shift. A shear type, skin tear to the right upper shin of the resident was caused when the assigned aide has attempted to reposition the resident up in the using the bed sheet as support. There was no bruising immediately after the skin tear. However, the next day and in the following days, bruising and blistering had appeared over the superior portion of the skin tear up to the lateral aspect of the right knee. The resident is alert and oriented times one to two at baseline and is a poor historian. At no point in time, did she ever report a fall/impact trauma, and she denied knowing how or when her right hip became fractured. The resident's typical behavior was present with a smile and deny pain. The resident reported mild pain with the highest level being 5 out of 10 in the days prior to the X-ray, with as needed acetaminophen being provided. The resident has a history of chronic pain to her lower legs and especially her right knee. She had orders for as needed diclofenac and acetaminophen in relation to this chronic pain. The nursing staff interviews had concluded that the resident would rarely display signs or symptoms of pain and usually denied significant pain when asked. However, it was noted by the aides that during patient care the resident would make a 'grunting noise' when being turned over to her side. This was considered normal for her baseline due to her stiffness and chronic pain. According to the aide interviews, there was a brief period when two aides were turning over to her left side and she screamed out in pain to her left side. Once she was laid on her back she was unable to describe where the pain came from and denied further pain. The aides notified the nurse of the situation. The X-ray was ordered of the whole right leg by V6 (NP) in relation to the increased bruising to the right knee. On March 27, 2026, the mobile x-ray results showed as reads, 'Findings: there is a fracture involving the proximal femur with a 2.3 cm (centimeter) displacement. The remainder of the femur is intact. There is osteopenia. Conclusion: Acute appearing right femur fracture as described.' The x-ray report has also indicated that the right tibia and fibula were negative for acute fracture and that there was evidence of degenerative and erosive changes to the bones. After the notification of the right femur fracture, the resident was immediately assessed and found to be laying in bed in a comfortable position and denying any pain. As needed acetaminophen was provided for comfort. The NP and POA were notified, and the resident was then sent out via emergency services to [local hospital] emergency room. The resident was admitted with a diagnosis of pain and swelling. Per hospital report, follow-up x-rays and a CT (Computerized Tomography) scan confirmed the right femoral head fracture, and surgical intervention was not recommended. Interviews: Staff interviews were conducted by multiple nurses and CNA's that had worked from March 22, 2026, to March 27, 2026. In the interviews, the majority of the staff reported they did not notice or observe abnormalities n her behavior or pain levels. The resident has been known to have chronic pain in both legs and receives as needed pain medication. On March 23, 2026, the resident sustained a skin tear during ADL care from [V8]. Then on March 26, 2026, [V7] was asked by the resident's son about the bruise to the right knee. It was explained to him that this was related to the skin tear that happened days prior. [R1] was displaying facial grimacing and complaining of pain when the right leg was touched. As needed pain medication was provided, and the NP was notified. The NP then ordered x-rays of the right leg. The x-rays became available on March 27, 2026, which indicated a right hip fracture and an order was received to send the resident to the hospital. [V12]: Per phone conversation with Primary Care Physician [V12]. She is suggestive this fracture may have happened due to friction/shearing of resident being moved across the bed during care. The resident x-ray results at the hospital revealed she has advanced osteoarthritis. The doctor does not believe there was a fall involved and due to the weight of the resident, if there was a fall there would need to be multiple staff to assist with the resident getting up off the floor. The resident could not get herself up and one staff member would not be able to get the resident up off the floor. [V12] stated that with the advanced osteoarthritis that there is possible bone loss and fragility of the resident's bones which aided in the fracture. The facility's policy titled Lifting Machine, Using a Mechanical dated July 2017, showed Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At lest two nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: a. Lifting a resident from the floor; b. Transferring a resident from bed to chair; c. Lateral transfers; d. Lifting limbs; e. Toileting or bathing; or f. Repositioning.

Based on observation, interview, and record review, the facility failed to ensure safe transfer mobility for a resident who is dependent on staff for transfer assistance. This failure resulted to R118 falling from her wheelchair and sustaining fracture injury. In addition, the facility also failed to follow recommended transfer assistance and appropriate use of assistive devices for residents who are identified as high-risk for falls. This applies to 4 of 4 residents (R10, R43, R52, R118) reviewed for accidents and supervision in the sample of 19.The findings include:1. R118’s face sheet showed that R118 was admitted to the facility on [DATE], with diagnosis that included urinary tract infection, toxic encephalopathy, personal history of transient ischemic attack with cerebral infarction, cognitive communication deficit, rheumatoid arthritis, unsteadiness on feet, and lack of coordination. R118’s Minimum Data Set, dated [DATE] showed R118 had lower extremity impairment on the left side and is dependent on staff for transfers and mobility. Dependent means helper does all of the effort R118’s progress notes dated August 12, 2025 and written by V24 (Registered Nurse) showed the following: At around 12:50 PM writer answered call light to assist resident to the bed. While transferring the resident to the bed the resident lost her balance in the wheelchair and fell on her side. The resident hit her head on a small cabinet. No bleeding or injury noted. Provider notified with no new orders given. The facility’s incident report dated August 16, 2025 showed the following: R118 had diagnoses that included toxic encephalopathy, cerebral infarction with affected left side. R118 was alert and oriented to self, and time and required a 2 person assist with transfers. On August 12, 2025, R118 was being transferred by the registered nurse when R118 lost her balance, fell, and hit her head on a cabinet. On August 14, 2025, R118 was noted to have left hip pain and was guarding during positioning. The provider was notified and an x-ray of R118’s left hip was ordered. R118’s x-ray results of her hip showed a fracture and R118 was sent to the emergency room for evaluation and treatment. “Conclusion: education for registered nurse provided for proper transfer of patients. Documented coaching given to the registered nurse, and all staff to be in-serviced on proper resident transfers.” R118’s x -ray results ordered on August 14, 2025 showed a fracture of the left femoral neck with displacement of the distal fragment. On August 20, 2025, at 1:19PM, V24 (Registered Nurse) stated that around 12:50PM on August 12, 2025, V24 was passing medications when R118’s call light went on. V24 answered the call and asked R118 if she would like to get into bed. V24 asked R118 if she was able to stand up and assist V24 with repositioning the wheelchair. V24 stated she began to reposition the wheelchair when she stopped the wheelchair it was facing the bed and R118 slid out of the chair. R118 slid onto her left side hitting her head and shoulder on the dresser and then landing on the floor. V24 stated that R118 had left sided weakness and required two staff members for transfers. V24 noted three family members were present in room at time of incident. V24 stated she told the resident not to move then she left the room and found V25 (Certified Nursing Assistant) in hallway and asked for assistance with resident. On August 20, 2025, at 2:02PM, V32 (Family Member 1) stated that R118’s left leg has not been functional since her stroke, and her left leg tends to curl inward behind right leg. V32 stated that R118’s left leg needs to be well positioned before movement. V32 stated that R118 was complaining of pain in groin and leg on Wednesday, Thursday, and Friday. On August 20, 2025, at 2:30PM, V33 (family member) stated she was in the room at the time of R118’s fall. V33 stated that around 11:15 AM on August 12, 2025. V33 stated that R118 was sitting up in a wheelchair and R118 wanted to go back to bed. V24 came to R118 room and said she would come back after meal to assist R118 back to bed. V24 walked in and asked R118 If I help you stand will you be able to get into bed. V33 told V24 that R118 has not been walking, is post stroke, and has left sided weakness. V33 stated V24 did not respond. V33 stated she told V24 multiple times that R118 has left side weakness. V33 stated V24 started to move wheelchair into position to near the bed. When V24 started moving the wheelchair back and she lifted and turned it at the same time to angle it into position. V33 said screamed in pain and V24 said pick your legs up. V33 was tried to explain that R118 cannot pick her leg up but V24 did not acknowledge it. R118's left leg was dragging and it got stuck behind her the right leg. R118 was leaning towards her left side. When V24 lifted the back of the chair to help turn it more, R118 fell out of the chair, hitting her head and shoulder on the table and landed on the ground on her left side. On August 21, 2025, at 2:10 PM, V35 (Family member) stated that he visited R118 on August 12, 2025, along with two other family members. V24 came in and gave R118 some medications and came back later to assist R118 into bed. V24 began moving objects in room to assist prepare for transfer. V35 stated the family began to inform V24 that R118 is unable to walk. V24 started to turn wheelchair, and he noticed that R118 legs were not moving with the wheelchair. V35 stated it happened really fast when V24 continued to move R118, V24 lifted the back of the wheelchair. The lifting the back of the wheelchair caused R118 to hit her head and shoulder on the dresser as she fell to the ground. On August 20, 2025, at 4:09 PM, V3 (Assistant Director of Nursing) was notified by V24 on 08/12/2025 regarding incident with R118. V3 stated that an order for an x-ray of the left hip was obtained on August 15, 2025, when a nurse noted R118 reported new onset guarding to left leg. V3 stated the family requested ice packs during this time. The facility was later notified of R118’s acute fracture. V3 stated that if residents hit their head during a fall the nurse on duty performs neuro-checks, pain assessments, fall assessments and ROM (Range of Motion) exercises. An investigation was completed with nurses and CNAs. The day of the incident V3 was called to the room by V24. According to V3, there were family members present in the room when the resident fell. V3 stated repositioning R118 in the wheelchair would require two staff assistance. V3 stated Incident reports are completed immediately, and a morning meeting is held the next day discuss interventions. In this instance a meeting was held the next day and the intervention was to perform staff education. V3 stated V24 had attempted to transfer resident alone. V3 stated that R118 had left sided weakness. On August 20, 2025 at 11:06 AM, V26 (Nurse Practitioner) stated that she just happened to look through R118’s medical record on August 15, 2025 and noticed that R118 x-ray results showed a fracture. V26 called the facility and told them to send R118 out to hospital. V26 stated that the fracture was a result of the fall. V26 said R118 could not stand up on her own. The expectation is that the provider is notified right away in instances of head injuries. With a head injury the patient would need to go out to the hospital for a evaluation. V26 stated she nor the doctor were aware that R118 hit her head during the fall. V26 stated that had the provider’s been aware of the head injury they would have sent R118 to the emergency room immediately. R118’s care plan dated August 11, 2025 showed R118 was at risk for falls due to decreased mobility, weakness, left sided weakness and had ADL (Activities of Daily Living) self-care and mobility deficit. R118’s fall care plan showed the following intervention dated August 12, 2025: Re-educate staff related to transfer status. R118 was seen by physical therapy and occupational therapy between August 12, 2025, an August 15, 2025. Therapy progress notes showed R118 required maximum assistance for transfers and bed mobility. R118’s 72 hour post fall monitor dated August 14, 2025 at 3:47 PM showed the following: R118 “verbalized pain on left hip, guarding during positioning.” R118’s progress note dated August 14, 2025 at 10:59 PM showed the following: Resident complained of left hip pain and guarding her side during positioning. The doctor was notified and gave an order for a left hip x-ray to rule-out fracture. R118’s had and order dated August 14, 2025 at 10:44 PM for an X-ray of the left hip. 2. Face sheet shows that R52 is 93 years-old who has multiple medical diagnoses including dementia, generalized muscle weakness, unsteadiness on feet, lack of coordination, and repeated falls. On August 18, 2025, at 11:33 AM, R52 was in the dining room eating lunch, sitting on her wheelchair, she had a wound on her forehead that was almost healed. A staff member stated that R32 fell 2 to 3 weeks ago. On August 19, 2025, at 12:59 PM, V19 (Certified Nursing Assistant/CNA) assisted R52 in the bathroom for toileting. R52 was assisted to stand and pivot for transfer from wheelchair to toilet seat. After R52 voided, V19 assisted R52 to stand up and instructed R52 to stay still while V19 provided peri-care. Afterwards V19 assisted R52 back to the wheelchair. This process was all done without using a gait belt. R52's Morse Fall Scale dated May 28, 2025, shows R52 is high risk for fall. R52's Minimum Data Sheet (MDS) dated [DATE], shows R52 is cognitively impaired and dependent with sit to stand position and toilet transfer care. Fall incident log and progress notes from April to August 2025 showed that R52 has history of multiple fall incidents. R52’s active care plan shows she is at risk/active for falls. R52 has altered safety awareness. R52 overestimates her abilities related to previous CVA (cerebrovascular accident), history of falls, decrease balance/mobility/ADL skills. Decrease cognitive function and decrease thought process due to dementia. This same care plan shows multiple interventions including two staff assistance with use of gait belt for transfers. 3. Face sheet shows that R43 is 97 years-old with multiple medical diagnoses including vascular dementia, poly-osteoarthritis, generalized muscle weakness, history of fall, history of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. On August 19, 2025, at 1:25 PM, V20 and V21 (Both CNA) transferred R43 from reclining wheelchair to bed via mechanical lift. R43 was positioned in the middle lower half of the sling with the lower part of her buttocks and lower extremities off the sling and not supported. R43 was screaming that her back was hurting. V21 stated the sling was sliding while she was in the reclining chair. V20 placed her arms under R43’s legs during transfer, while R43 was screaming all throughout that her back was hurting. 4. Face sheet shows R10 is R100 years-old who has multiple medical diagnoses including spinal stenosis, generalized muscle weakness, lack of coordination, and unspecified dementia. On August 20, 2025, around 12:20 PM, V23 and V29 (Both CAN) transferred R10 from bed to wheelchair using a gait belt. R10 appeared afraid and hesitant to transfer. R10's knees were bent/folded and was not fully standing. There was no non-skid wheelchair pad on her wheelchair seat. R10 Morse Fall Scale dated 8/13/25 shows, R10 is a high risk for fall. Facility's fall log from February to August 2025 shows that R10 has had multiple fall incidents. R10's Fall Care Plan shows: R10 is at risk/actual falls related to diagnoses of orthostatic hypotension, history of falls, incontinence, muscle weakness, joint stiffness, and dementia. This same care plan shows interventions which include ensuring non-skid mat on the wheelchair seat. On August 20, 2025, at 3:36 PM, V2 (Director of Nursing/DON) stated that staff must follow all fall prevention interventions especially for residents who are identified as high-risk for fall. Ensure that staff use assistive device as recommended to prevent fall incidents.

Based on observations, interview and record review, the facility failed to prepare food, clean dishes and store pots and pans in sanitary conditions. This applies to all 97 residents that receive food prepared in the facility kitchen. The findings include:Facility's CMS Application Form for Medicare/Medicaid dated August 18, 2025, showed that the facility census was 97 residents. Facility provided information that there are no residents on NPO (nothing by mouth) status.On August 18, 2025, at 9:25 AM, during the initial tour of the kitchen the following observations were made: The food processor had orange colored debris on the inside of the lid. V10 (Cook) stated that the food processor is used to prepare mechanically soft foods. The shelving under the prep area that stored silver foil and clear wrap, pan liners, sandwich bags and other miscellaneous items had food particles and dust and grime. The deep fryer was noted with oil that had blackened substance and food remnants in deep frying area with food debris and spills on sides of the oven near fryer. Under the stoves there was extensive food spills and debris. V10 stated that the deep fryer was last used on Friday (August 15, 2025) and that the utility person cleans it out twice weekly. V10 added that he is due to clean it out on Tuesday (August 19, 2025). In the dish room, two of the shelving's on a free-standing rack that had pots and pans inverted on it was noted to have brownish colored substance on it that had the appearance of rust. In the walk in Cooler there were two cases each of orange and apple juice's stored on the floor of cooler under the shelving. V9 (Executive Chef) stated that these cases of juices were frozen and were temporarily placed in the cooler due to issue with the fan motor in the walk in Freezer. On August 18, 2025, at 11:27 AM, V11 (Cook) was seen preparing mechanical soft chicken in the same food processor seen earlier with the lid of the food processor with orange colored substance on it. When asked what the orange substance was, V11 removed the rubber lining and stated that it looks like remnants of pureed carrots. V11 added that the lid is old and needs to be replaced. The ceiling tiles above the pureed meal prep area and other meal prep counters had extensive blackish substance and dust bunnies. On August 18, 2025, at 9:44 AM, and at 11:33 AM, V5 (Director of Dining Services) stated that she had just done an inspection and saw rust on the shelving and that the facility needs to get a new rack. V5 stated that the food processor should have been cleaned and sanitized prior to use in preparing the mechanical soft chicken. On August 20, 2025, at 3:10 PM, the kitchen was visited again and noted that the deep fryer its surrounding areas were still with food debris and spills. The ceiling tiles seen earlier had extensive blackish substance and dust bunnies above food prep areas. V6 was notified of the same. On August 20, 2025, at 3:12 PM, V9 (Executive Chef) stated that the dishes for the first floor are washed by the servers in the Assisted Living side dish room, as the facility dish room on the first floor is under construction for the past month. This dish room was noted located across the hallway from the facility kitchen. On request, V9 started the dish machine, and after running it for a few minutes, the Wash gauge showed 140 degrees Fahrenheit, and Rinse gauge showed 160 degrees Fahrenheit. V9 stated that it is a high temperature machine and normally the Rinse should be at 180 degrees' Fahrenheit. When asked if they have test strips to verify for sanitation, V9 was seen looking for the same and unable to locate the same. V9 pointed to an area in the wall and stated that they use a digital monitor and its normally placed on the wall. V27 (Dishwasher) from Assisted Living came into the area and stated that the digital monitor has not been available for the last two months. V27 stated that he only does the dishes for dinner at the Assisted Living side and fills the logs and for the dinner meal and that no one else fills logs for other meals. The Dish Machine Temperature Log posted on the wall showed a range of 155-175 degrees Fahrenheit for the Rinse for most of the recordings in the month of July and August 2025 logged only for one meal. On August 20, 2025, at 12:09 PM, V19 (Registered Dietitian) stated that the fryer grease spills should be cleaned immediately after use as it's a fire hazard. Facility policy and procedure titled Cleaning and Sanitizing (effective October 25, 2022) included, Purpose: The [facility] dietary department should follow the cleaning and sanitizing guidance to ensure food contact surfaces are cleaned and sanitized correctly. The policy's procedure included, 1.) Food contact services must be cleaned and sanitized after every use and in between each task. If items are in contact use, they must be cleaned and sanitized every four hours.Facility policy and procedure titled Food Storage (effective October 25, 2022)) included, Purpose: The [facility] dietary department should ensure all perishable, non-perishable, and chemicals are stored safely and accordance to the local and state requirements. The policy's procedure included, 4.) All foods should be stored away from the walls and at least six inches off the floor.Facility policy and procedure titled Dish Machine Monitoring (effective October 25, 2022)) included, Procedure: 1.) Dish machine temperatures logs should be easily visible and posted near all ware washing equipment. This would include but not limited to the main kitchen, satellite kitchen, bistro, cafe, memory care pantry, etc. 2.) Dish machine temperatures should be checked and documented at the start of breakfast, lunch, and dinner each day. 3.) High temperature dish machines required the wash temperature and final rinse temperature to be observed and documented. Wash temperatures should be reading a minimum of 160 F and final rinse should be reading a minimum of 180F.

Based on observation, interview, and record review, the facility failed to ensure that their controlled substance medications were completely sealed in their packaging. This applies to 7 of 7 residents (R8, R10, R35, R44, R50, R60, R65) reviewed for medication storage in the sample of 19. The findings include: On August 19, 2025, from 3:40 PM to 4:20 PM medication room and cart observations were conducted from the 3rd floor to the first floor of the facility with V13, V14, and V15 (All Nurses). The following were observed: 1. R35's Lorazepam 0.5 mg (milligram) number18 tablet's packaging was broken and was taped over.2. R50's Lorazepam 0.5 mg number 27 tablet's packaging was broken and was taped over.3. R10's Triazolam 0.25 mg number 1 and 5 tablets' packaging were broken and taped over.4. R60's Hydrocodone/APAP 5-325 mg number 20 tablet's packaging was broken and taped over.5. R65's Tramadol 50 mg number 12's tablet's packaging was broken and was taped over.6. R44's Lorazepam 0.5 mg number 16 tablet's packaging was broken and was taped over.7. R8's Oxycodone HCL 5mg number 29 capsules packaging was broken and was taped over. On August 20, 2025, at 10:14 AM, V2 (Director of Nursing/DON) stated that staff must ensure that controlled substance medications are in their original packaging and completely sealed, to ensure that they have complete accountability of each tablet or capsule. Policy regarding medication storage in the facility dated March 2021 stated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. In addition, the controlled substance storage policy stated, Medications included the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations.

Based on observation, interview and record review, the facility failed to provide fortified foods for residents that had a recommendation for the same. This applies to 6 of 6 residents (R18, R35, R45, R64, R78, R95) reviewed for fortified foods in the sample of 19. The findings include: On August 19, 2025, starting at 11:44 AM, the meal service was observed in the 2nd floor dining room with V7 (Server) at the steam table. R18 and R95's meal tickets showed 'fortified pudding', and they did not receive the same. R78's meal ticket showed 'magic cup', and she did not receive the same. On August 19, 2025, starting at 12:21 PM, the meal service was observed in the 3rd floor dining room with V8 (Server) at the steam table. R35, R45 and R64's meal ticket showed 'fortified pudding', and they did not receive the same. On August 20, 2025, at 11:31 AM, V17 (Registered Dietitian) stated that she when she makes a recommendation for fortified foods, she uses the kitchen platform for the facility meal tickets to enter her recommendations. V17 stated that the fortified foods will not appear on the diet order on the Physician Order Sheet but will show up on the meal tickets. V17 stated that she made above recommendations for R45 and R78 as they have had a past history of significant weight loss, but weights have stabilized in the recent months. V17 stated that R18, R35, R64 and R95's weights are stable and that she recommended fortified pudding or magic cup as they all had inconsistent intake. V17 added that if the meal tickets show a fortified food item, the resident should receive it. On August 20, 2025, at 3:22 PM, V6 (Assistant Dining Service Director) stated that the facility does not have magic cup as it has been discontinued and the residents are to receive fortified pudding instead. V6 added that the facility makes the fortified pudding and that the servers are supposed to plate them in bowls and put it on the tray along with the rest of the meal for each resident. R18's care plan (revised June 11,2025) showed that R18 is at increased nutritional risk related to advanced age, impaired cognition and variable intake. Interventions included to provide fortified foods.R35's care plan (revised August 21, 2024) included that R35 has history of inadequate nutrient intake related to impaired cognition as evidenced by recent history of weight loss. Interventions included to provide fortified foods. R45's care plan (revised September 21, 2024) included that R45 has a history of inadequate nutrient intake related to decrease intake as evidenced by weight loss. Interventions included to provide fortified foods. R64's care plan (revised September 21, 2024) showed that R64 has a history of inadequate intake related to decrease appetite as evidenced by significant weight loss. Interventions included to provide fortified foods. R78's care plan (revised June 10, 2025) showed that R78 had inadequate intake related to early satiety as evidenced by weight loss over time and observed 50% meal consumed. Interventions included to provide fortified foods. R95's care plan (revised June 5, 2025) showed that R95 is at risk or unintentional weight loss related to variable intake, impaired cognition as evidenced by observed meals 50% or less consumed. Interventions included to provide fortified foods.

Based on observation, interview and record review, the facility failed to follow menu spreadsheets to serve portions for main entree for residents receiving mechanical soft diets. This applies to 4 of 4 residents (R73, R96, R117 and R119) reviewed for dining in the sample of 19. The findings include:Diet menu spread sheet for Tuesday (week 2) included 4 oz (ounce) portion of Bacon Wrapped Beef. The same menu spreadsheet showed to use #8 scoop of ground chopped beef steak with gravy for dental soft (mechanical soft) diets. Facility color coded scoop size equivalents showed that #8 (gray scoop) =4 oz and #12 (green scoop) =3 oz. On August 19, 2025, at 11:34 AM, the meal service was observed in the facility kitchen with V16 (Server) at the steam table. V16 used a #12 green colored scoop to serve the ground chopped beef steak and R73, R96, R117 and R119 received the same. On August 20, at 12:03 PM, V17 (Registered Dietitian) stated that V16 should have used the scoop as shown on the menu as the scoop is utilized to serve the correct portions to meet the appropriate calories and nutrition needs for the resident from the planned menu. Facility Diet Roster printed on August 18, 2025, showed that R73, R96, R117 and R119 were on Dental Soft (Mechanical Soft) diet.

Based on observation, interview and record review, the facility failed to follow diet guidance for mechanical soft diets.This applies to 6 of 6 residents (R20, R23, R47, R52 and R84) reviewed for mechanical soft diets in the sample of 19.The findings include:On August 19, 2025, at 10:00 AM, the meal service was observed in the 2nd floor dining room with V7 (Server) at the steam table. R23, R47, R52 and R84 received a serving of corn. These residents diet orders on meal tickets showed Dental Soft (Mechanical Soft) and they had circled soft and chopped green beans as a vegetable option. R20 also received a cup (4 oz/portion) of chopped fruit that included chunks of raw pineapple. On August 20, 2025, at 11:50 AM, V17 (Dietitian) stated that residents on mechanical soft diets are allowed chopped canned fruits only and soft, cooked vegetables. On August 19, 2025, at 11:59 AM and 12:32 PM, V6 (Assistant Director of Dining Services) stated that if the green beans were circled, these residents should have received the same. V6 added that pineapple chunks are not served on mechanical soft diet. Facility policy titled Mechanical Altered Diets and Thicken Liquids included as follows: Purpose: Mechanically altered diet is prepared and served at each ministry as prescribed by the Physician. Procedure: 2. The menu that has been approved and signed off by the consulting RD (Registered Dietitian) contains diet spreadsheets and recipes that reflect the modifications needed for Mechanical Soft and puree diets. General Principles and Guidelines:6. Vegetables are cooked soft, moist and fork tender with no large chunks or pieces. 9. Soft, peeled fresh fruits such as peaches, nectarines, melon without seeds and sliced banana are allowed.

Based on observation, interview, and record review, the facility failed to provide assistance to residents requiring staff assistance with ADLs (Activities of Daily Living).This applies to 2 of 3 residents (R22 and R117) reviewed for ADL care in the sample of 19.The findings include: 1. R22's EMR (Electronic Medical Record) showed R22 was admitted to the facility on [DATE], with diagnoses that included Parkinson's without dyskinesia and dysphagia (difficulty swallowing), oropharyngeal phase. R22's MDS (Minimum Data Set) dated June 10, 2025, showed R22 was cognitively intact and required set-up or touching assistance. R22's Physician Progress note dated July 18, 2025, showed, [R22] having difficulty feeding himself with Parkinson's so staff will now feed him. R22's care plan showed R22 had a self-care performance and functional mobility deficit related to Parkinson's disease and dementia. R22 had inadequate oral intake related to disliking diet texture and decreased appetite.interventions included, provide dining assistance as necessary. On August 18, 2025, at 12:27 PM, staff passed R22 his lunch tray in the dining room. At 12:46 PM, R22 said he was done eating. Staff did not provide R22 assistance or encouragement with the meal. On August 19, 2025, at 12:24 PM, R22 was in the dining room for lunch. R22's tray consisted of ground meat, mashed potatoes, corn, and canned peaches. R22 ate only the corn and the peaches. At 12:30 PM, R22 told staff he was done eating. No one assisted R22 or encouraged him to eat. On August 20, 2025, at 8:38 AM, V34 (CNA /Certified Nurse Assistant) was passing breakfast trays. V34 took R22's tray into his room. He was given a disposable bowl with dry cereal, glass of orange juice, and milk for the cereal. R22 was in bed. V34 left the room while R22 to eat. Later, R22 was noted to eat only 25% of cereal, and spilled most of the juice down the front of his gown. V34 said at this time that R22 does not need assistance. On August 20, 2025, at 12:08 PM, V17 (Registered Dietician) said there is an order for R22 to be a 1:1 feed either in room or dining room. V17 also added that R22 should be fed in the dining room to encourage intake. V17 also stated that. R22 has been in the hospital a couple of times and has lost some weight. On August 20, 2025, at 12:29 PM, V5 (Director of Dining) said the resident's meal ticket will have a note showing the resident requires assistance with feeding. R22's diet ticket was provided, and it showed no straws. On August 20, 2025, at 12:53 PM V5 (Director of Dining Services) said the staff look at the resident's meal ticket and it will show at the bottom if they need assistance with eating. On August 20, 2025, at 12:57 PM, V5, V17, and V6 (Assistant Dining Service Director) said that when a diet order is entered into the system and they add an intervention like no straws, it will carry over to the diet ticket, but if there is a physician order for a resident to be 1:1 feed, the nurse will enter it and then let dietary know and let the CNAs know that there is a change or a new order for the resident to be assisted with eating. 2. R117 is a [AGE] year-old female with a history of Dementia, Leg Fracture, Neuropathy, and Pain in Left Hip who was admitted to the facility 08/11/2025. On 08/18/2025 at 10:25 AM Observed R117 lying in her room in her bed wearing a gown, with a strong bowel odor, observed her bedside table with multiple cups of red colored beverages a few feet away from her bed. On 08/18/2025 at 11:45 AM Observed R117 still with a strong bowel odor and with flies flying around her, observed her bedside table positioned over her bed. On 08/18/2025 at 12:00 PM, V30 (Certified Nursing Assistant) stated approximately 8:30 or 9AM this morning was the last time that R117 was provided personal care and changed. R117's current care plan initiated 08/11/2025 documents she has bowel incontinence with interventions including check the resident every two hours. On 08/20/2025 at 10:21 AM V30 (Certified Nursing Assistant) stated R117 doesn't use the call light to call for assistance. V30 added that for residents who don't use the call light for assistance she usually checks them for incontinence care at the beginning of her shift, around breakfast and lunch time during her shift and every 2 and a half to 3 hours. On 08/20/2025 at 12:02 PM V2 (Director of Nursing) stated residents should be checked for incontinence care every two hours and as needed. The facilities Grievance Logs and Grievance Forms from April, May, and July 2025 and Resident Council Meeting Reports and Grievances from February – April and July 2025 document multiple concerns regarding activities of daily living. The facility's Activities of Daily Living Policy received August 21, 2025, documents: Residents with be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs)l Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Elimination (toileting) Dining (meals and snacks). The facility's Incontinence Care Policy received August 21, 2025, states: Incontinence care is provided based on individual resident's needs and as per service plan.

Based on observations, interviews and record reviews the facility failed to assess and provide interventions for a resident exhibiting pain during care.This failure applies to 1 of 3 (R117) reviewed for pain management from a total sample of 19The findings include: R117 is a [AGE] year-old female with a history of Dementia, Leg Fracture, Neuropathy, and Pain in Left Hip who was admitted to the facility 08/11/2025. R117's admission progress note dated 08/11/2025 documents she was admitted from the Hospital with a diagnosis of Left femur (thigh bone) fracture and post fracture surgical care; Feels pain when turning. R117's practitioner progress note dated 08/13/2025 documents she was seen on 08/13/2025 with chief complaints including mobility dysfunction secondary to fall, left proximal femur (thigh bone) fracture, and pain. R117 was admitted to the facility for skilled nursing and rehab and asked to be seen by primary team to optimize therapy and for pain control; she complained of left hip pain with movement.On 08/18/2025 at 12:08 PM V30 (Certified Nursing Assistant) stated R117 can be changed by one staff with no issue however R117 does scream and yell when touched. Observed R117 screaming and yelling in pain and yelling for help throughout the course of receiving incontinence care from V30 (Certified Nursing Assistant). On 08/18/2025 at 12:35 PM Observed R117's meal tray still sitting in her room untouched. V30 (Certified Nursing Assistant) asked R117 if she could raise her bed so she can eat, R117 stated she couldn't handle that and preferred not to be moved. V30 then stated when she asked the nurse for pain medication for R117, the nurse (V24) told V30 that she did not know if R117 had any orders for medication. On 08/18/2025 at 12:49 PM V24 (Registered Nurse) stated she was waiting for V30 (Certified Nursing Assistant) to finish providing incontinence care to R117 to administer pain medication and R117 does have a prescribed Tylenol medication that can be administered. R117's current physician orders include active orders effective 08/11/2025 to monitor her Pain Level and Location each shift; effective 08/12/2025 for one 500mg Acetaminophen (analgesic) Extra Strength Tablet by mouth every 6 hours as needed for Pain may give with hydrocodone/Acetaminophen; effective 08/13/2025 for two 325mg Hydrocodone-Acetaminophen Oral Tablets by mouth every 4 hours as needed for severe pain and one tablet by mouth every 4 hours as needed for moderate pain; and effective 08/18/2025 for two 325mg Acetaminophen 325 tablets by mouth every 6 hours for pain. R117's Current care plan initiated 08/11 documents she is on pain medication therapy (Hydrocodone/Acetaminophen) related to Pain with interventions including Administer analgesic medications as ordered by physician.On 08/20/2025 at 10:21 AM V30 (Certified Nursing Assistant) stated R117 can't get out of bed and doesn't like to move because it hurts. V30 stated on 08/18/2025 she had started providing R117 with incontinence care and R117 began screaming, V24 (Registered Nurse) overheard R117 screaming. V30 stated V24 said she could not give R117 anything for pain because she was waiting for R117 to finish receiving incontinence care; V30 stated when R117 expresses pain and begins screaming she handles her gently, rubs her back and reassures her that she will be gentle but had to continue performing incontinence care for R117 on Monday 08/18/2025 because she had feces on her.On 08/20/2025 at 12:02 PM V2 (Director of Nursing) stated that if a resident is exhibiting significant pain during incontinence care the nurse should assess them for pain, determine the source of pain and the resident should be medicated prior to initiating care, if the resident cannot tolerate incontinence care even if they have stool on them they should be medicated if they have pain medication and made comfortable before proceeding with care, if the resident doesn't want to be touched until the pain goes away the staff should wait and reapproach.The facility's Activities of Daily Living Policy received August 21, 2025, states: Appropriate care and services will be provided for residents who are unable to carry out ADL's (Activities of Daily Living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. The facility's Pain Management Policy received August 21, 2025, states: The community to the extent possible, to prevent or manage pain will:Recognize when the resident is experiencing pain and identified circumstances when the pain can be anticipated.Evaluate the existing pain and the cause(s) andManage or prevent pain, consistent with the plan of care, current professional standards of practice, and the resident's preferences. Assessment:The nursing staff will evaluate each individual for pain when there is worsening of existing pain.The nursing staff will identify any situations where an increase in the resident's pain may be anticipated; for example, repositioning and if possible, pre-medicate prior to the activity.

Based on observation, interview, and record review, the facility failed to follow physician orders for medication administration. There were 28 medication opportunities with 2 errors resulting in 7.14% error rate. This applies to 1 of 6 residents (R100) reviewed for medication pass in the sample of 19. The findings include: On August 19, 2025, at 9:28 AM, V4 (Nurse) administered medications to R100 including Metoprolol Succinate ER (Extended Release) 50 mg tablet. V4 crushed the Metoprolol ER and gave it to R100. During medication reconciliation and review of Medication Administration Record (MAR), it was observed that R100 has an order of Polyethylene Glycol 3350 17 Grams Powder for Oral Solution (Miralax). V4 did not administered this medication. On August 19, 2025, at 11:09 AM, V4 stated that whatever medications that was observed that she administered for the morning were the only medications R100 has. On August 20, 2025, at 9:30 AM, V2 (Director of Nursing/DON) stated that staff must follow physician order when administering medications. Give medications according to the time it's supposed to be given. Follow right patient, route, time, dose, and medication. Staff must follow the medication recommendation including not to crushed extended-release medications. Facility's Medication administration Policy and Procedure dated June 1, 2023, shows: Policy: To provide documentation on the process of administering medications within the healthcare community. Medication Administration: Medications are administered in accordance with written orders of the prescriber. Medication Crushing Guidelines with revised date of January 2018 shows: Time Release Tablets are designed to release medications over sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication actions in other cases. In either case these tablets should not be crushed.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of activities of daily living (ADL) care. This applies to 3 of 4 residents (R36, R43, R52), reviewed for infection control in the sample of 19. The findings include: 1. On August 19, 2025, at 12:59 PM, V19 (Certified Nursing Assistant/CNA) assisted R52 in the bathroom for toileting. After R52 finished voiding, V19 assisted R52 to stand up and proceeded to provide peri care. V19 cleaned R43 from front to back of the perineum, applied new incontinence brief, and pulled R52's pants back on while wearing same soiled gloves.2. On August 19, 2025, at 1:31 PM, V21 (CNA) provided incontinence care to R43 who had a bowel movement. R21 removed pants and soiled incontinence brief, cleaned R43 from front to back, applied barrier cream, and applied new incontinence brief, while wearing same gloves all throughout the care. Then V21 removed his gloves and without hand hygiene continued to straighten R43's beddings and adjusted the bed.3. On August 20, 2025, at 11:22 AM, V23 (CNA) assisted R36 to put her clothes on. V23 touched the catheter bag while sliding R26's left thigh through the pants with the catheter bag, assisted R36 to put on her sweater, and placed the shoes on to R36, while R36's feet were still in bed. This pair of shoes were used by R36 while propelling her wheelchair. The sole of the shoes was dirty. V23 touched different surfaces during this ADL care, from dirty to clean to dirty to clean tasks without changing her gloves. On August 20, 2025, at 3:44 PM, V2 (Director of Nursing/DON) stated staff must perform hand hygiene and change gloves from dirty to clean tasks during provisions of ADL care for infection control.Infection Control policy regarding Standard Precautions dated June 1, 2023, stated, Policy: It is Franciscan Ministries' policy to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services and therefore the community applies the Standard Precautions infection control practices outlined below: . 2.) Perform Hand Hygiene: . B.) After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. C.) After contact with a resident's intact skin (e.g., when taking a pulse or blood pressure, or lifting a resident). D.) If hands will be moving from a contaminated-body site to a clean-body site during resident care. E.) After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. 5.) Using Gloves: . G.) Changes gloves during resident care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face).

Based on observation, interview, and record review, the facility failed to obtain monthly weights/reweights and recognize significant weight loss for a resident. This failure resulted in R82's weight loss not being recognized until R82 sustained a 12.47% weight loss in 90 days. This applies to 1 resident (R82) reviewed for weight loss in a sample of 34 residents. The findings include: On 8/6/24 at 11:57 AM, R82 said she does not like the facility food. R82 said the food is bland and I don't eat much because the food doesn't look good. R82 said she doesn't like her meat chopped up. R82 said she weighed 150 pounds when she was admitted a year ago and the last time they weighed her she was 120 pounds. R82 said she does not receive any supplements. No supplements were seen in R82's room. R82's Face sheet shows an initial admitted [DATE]. R82's POS (Physician Order Sheet) shows order dated 12/22/23 for monthly weights, an order dated 10/24/23 for general diet mechanical soft texture, thin liquid consistency, and does not show a hospice order. V2's (DON's) weight change note written on 5/13/24 states R82 had poor appetite and weight loss and speech therapy to see R82 for possible upgrade of diet. Since 5/13/24, R82 did not have any notes written by V21 (Clinical Nutrition Manager/Dietician) or speech therapy. R82's 'Weights and Vitals Summary' shows her initial admission weight on 8/21/23 was 152 pounds. R82's weight on 5/9/24 is documented as 143.6 pounds. On 6/17/24 R82's weight was documented as 133 pounds, this weight was struck out by V21 (Clinical Nutrition Manager/Dietician) with a note showing reweight requested. R82 was not reweighed in June. R82's weight was not documented in the month of July 2024. R82's weight was not documented again until 8/6/24 as 120.8 pounds. This weight was again struck out by V21 with a note requesting reweight. As of 8/7/24 at 2:30 PM, R82 did not have an accepted weight documented since 5/9/24. At 2:30PM on 8/7/24, surveyor requested from V1 (Administrator) that R82 be weighed. On 8/7/24 at 4:28 PM V2 (DON/Director of Nursing) verbally notified surveyor that R82 was just weighed and the result was 125.7 pounds. On 8/7/24 at 4:28PM, V2 (DON) said she notified V21 (Clinical Nutrition Manager/Dietician) of R82's weight of 125.7 pounds and he was aware it was a significant weight loss. The weight change from 5/9/24 of 143.6 pounds to 125.7 pounds on 8/7/24 is a 12.47% weight loss in 90 days. As of 8/8/24 at 11:31 AM, R28's weight of 125.7 pounds verbalized to surveyor on 8/7/24 had still not been documented in her medical record. On 8/8/24 at 1:16 PM, V21 (Clinical Nutrition Manager/Dietician) said the facility's current policy is that every resident gets weighed at least monthly by the 5th of the month. V21 said if a resident's monthly weight is documented and it is 5 pounds more or less than the previous weight, he will strike it out and request a reweight. V21 said he requests a reweight by sending an email list of all residents who need to be reweighed to V2 (DON) and V4 (Wound Care Nurse). V21 verified that he emailed V2 and V4 that R82 needed to be weighed/reweighed on 6/17/24, 6/21/24, 7/8/24, 7/11/24, 7/17/24, and 8/6/24. V21 said if the resident's weight has not been entered by the 5th of the month it becomes an urgent priority. V21 said accurate weights are important because it is the first step in an accurate nutritional assessment. V21 said we don't want significant weight loss ever and R82 fell through the cracks. V21 said R82 should be evaluated by speech therapy. On 8/8/24 at 1:37 PM, V2 (DON) said she did not know why R82 was not reweighed after V21 requested reweights. V2 said she will take responsibility for R82's weight not being recorded on 8/7/24 when it was taken because she was handed the written weight. V2 said she did not communicate to V21 on 8/7/24 that R82 was reweighed or what her weight was, contradicting what she had told surveyor on 8/7/24. V2 said speech therapy has never seen R82. V2 said she could not remember if she had ever talked to R82's nurse about obtaining an order for speech therapy after she wrote her weight change note in May of 2024. On 8/8/24 at 8:38 AM V2 said they used to have a restorative aide that was responsible for obtaining resident weights/reweights, but the aide had been gone for 2-3 months so they had put V4 (Wound Care Nurse) in charge of obtaining resident reweights. V2 said she wished V21 had been more vocal and communicated to her verbally that reweights were needed instead of sending email. V2 said R82's reweights fell through the cracks because her weights were struck out so she did not trigger as weight loss. On 8/8/24 at 12:21 PM, V4 (Wound Care Nurse) said V21 may have notified her that R82 needed a weight/reweight. V4 said when she receives the email from V21 she notifies the nursing staff to obtain the weight and she tries to make sure the staff get it done. V4 said, but I am not going to lie, I don't always catch a weight that is missed. On 8/8/24 at 2:41 PM, V24 (RN/Registered Nurse) said all residents require a monthly weight, she was not aware that her resident, R82, had not had a weight accepted since 5/9/24, and V4 (Wound Care Nurse) is responsible for notifying the nursing staff when a weight is needed. V24 said monitoring resident weights is important because they need to pay attention if a resident is not eating because of decreased appetite or if something else medically is going on with the resident. On 8/8/24 at 2:47 PM, V25 (CNA/Certified Nurse Assistant) said all residents need to be weighed once a month. V25 said monitoring resident weights is important because they want to make sure residents are maintaining their weights, and if they are losing weight, they want to make sure the resident is eating enough. V25 said V4 notifies them when a reweight is needed. V25 said she has fed R82 in the past and her appetite varies, sometimes R82 eats dinner and sometimes she says she doesn't want to eat dinner. R82's Care Plan dated 8/22/23 shows she is at risk for altered nutritional status related to advanced age. Interventions include honor resident's food preferences and monitor weight monthly. The facility's policy titled, Weight Management dated 3/1/21 states, Community nursing and dietary staff will cooperate to prevent, monitor, and intervene for undesirable weight loss or gain for our residents. Weight Measurements: The nursing staff will measure resident's weight on admission, and monthly thereafter . Monthly weights are to be completed and documented in the electronic medical record between the 1st and the 5th of each month as assigned. Communication: Any weight change as below will be retaken for confirmation. If the weight is verified, nursing or the dietician will notify the physician. Significant Changes are defined as more .than . 7.5% .within 90 days .Undesirable Weight Loss: Interventions for undesirable weight loss or gain should focus first on food .Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician may order tests, appetite stimulants, or medications as appropriate.

Based on observation, interview, and record review, the facility failed to discard expired food items from the dry storage and failed to properly store food items in the freezer by building ice on food packages, the walk-in freezer door side, and the floor. This applies to all 98 residents consuming food from the kitchen. The Findings Include: On [DATE] at 9:42 AM, during an initial kitchen tour with the dietary manager (V5), the kitchen dry storage was observed with one-quarter of 32-ounce (oz) peanuts expired on [DATE], one pound of opened Pistachio bag expired on [DATE], an opened almond bag with two pounds of almonds expired on [DATE], and an unopened white chocolate designer dessert sauce 16 oz expired on ,d+[DATE]. On [DATE] at 9:45 AM, V5 stated, Everyone, especially the stock person, is responsible for checking for expired food items, which should be discarded. On [DATE] at 9:50 AM, the freezer was observed with 2.5 pounds (lbs) of provolone cheese, opened but without a date or label. On [DATE] at 9:52 AM, V5 added, Opened food items should have a date/label. I will throw those out. On [DATE] at 9:55 AM, the walk-in cooler to walk-in freezer was observed with ice built up around the door sides (walk-in cooler to walk-in freezer), floor, and food packages, including two 20 pounds of meat rolls and 10-pound white fish. On [DATE] at 10:00 AM V6 (Chef) stated, We are contracted workers, and we notified the maintenance, and they notified the contractor ,d+[DATE] weeks ago. It seems like nobody wants to do anything with the condensation issues with the freezer. They said they placed the work order. The facility presented the Food and Supply Storage policy revised on ,d+[DATE] document: Procedures Cover, label, and date unused portions and open packages. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. On [DATE] at 02:21 PM, V2(Director of Nursing/DON) stated, We have no residents with a gastrostomy tube (GT) or nothing per oral (NPO). Hence all of our 98 residents are eating from the Kitchen.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents dependent on staff for personal hygiene and grooming. This applies to 10 of 10 residents (R12, R26, R30, R42, R44, R45, R49, R51, R59, and R68) reviewed for ADL's in a sample of 34. The findings include: 1. On 08/06/24 at 12:00 PM R44 was in the dining room eating lunch. R44 had long chin hairs. R44 said she wanted the chin hairs removed, but the staff does not help her remove them. On 08/07/24 at 11:33 AM R44 was sitting in the dining room. R44 still had long chin hairs. She stated she still wanted them removed. R44's face sheet showed multiple diagnoses which included hypertensive chronic kidney disease, primary generalized osteoarthritis, dementia, hypertension, lack of coordination, muscle weakness, osteoporosis, and adult failure to thrive. R44's MDS (MDS/Minimum Data Set) dated 05/08/24 showed R44 had moderate cognitive impairment. The same MDS showed R44 required substantial/maximal assistance with personal hygiene. R44's Personalized Care & ADL Deficit care plan revised on 12/20/23 showed a goal of considering R44's preferences when providing care and will complete ADL's with staff assistance. Interventions: substantial/maximal assistance with personal hygiene. 2. On 08/06/24 at 12:14 PM R51 was sitting in a wheelchair in the dining room. R51's fingernails had a dark colored substance underneath on both hands. On 08/07/24 at 4:22 PM R51's fingernails on both hands continued to have a dark colored substance underneath. R51's face sheet showed multiple diagnoses which included hypertensive heart and chronic kidney disease, diabetes, heart failure, muscle weakness, vascular dementia, anemia, hypertension, and peripheral vascular disease. R51's MDS dated [DATE] showed R51 had severe cognitive impairment. The same MDS showed R51 required substantial/maximal assistance with personal hygiene. R51's Alteration in ADL/Mobility performance care plan revised on 03/18/24 showed a goal of considering R51's preferences when providing care and completing ADL's. Interventions: substantial/maximal assistance with personal hygiene. 3. On 08/06/24 at 11:17 AM R59 was sitting in recliner chair. R59's fingernails on her right hand had a dark colored substance underneath. On 08/07/24 at 10:50 AM R59's right hand fingernails continued to have a dark colored substance underneath. R59 stated she would like to have her nails cut and cleaned. R59's face sheet showed multiple diagnoses which included hypertensive chronic kidney disease, polyosteoarthritis, dementia, muscle weakness, vascular dementia, psychosis, hypertension, unsteadiness on feet, and hypothyroidism. R59's MDS dated [DATE] showed R59 had severe cognitive impairment. The same MDS showed R59 was dependent with personal hygiene. R59's ADL self-care performance deficit are plan revised on 02/21/24 showed a goal of R59 receiving assistance from staff to complete ADL and functional mobility task. Progress notes from 07/09/24-08/09/24 showed no documentation of R59 refusing care. On 08/07/24 at 11:15 AM V19 (CNA/Certified Nursing Assistant) said the residents nails should not be dirty. V19 said it is my responsibility to clean and trim the residents nails. All nails should be trimmed and cleaned after a shower and as needed. On 08/07/24 at 11:18 AM V22 (Registered Nurse) said residents nails should not be long or dirty. Nails should be cleaned and trimmed as needed. Residents could scratch themselves or put dirty fingernails in their mouth and get an infection from the bacteria. On 08/07/24 V22 said female residents should not have chin hairs. [NAME] hairs should be removed as needed. It is a dignity issue for a woman to have chin hairs. On 08/08/24 at 11:59 AM V2 (Director of Nursing) said residents should not have long, dirty fingernails. Nail care should be done as needed and on the shower days. Residents should be properly groomed on the shower days which includes nail care. If residents have dirty fingernails, they could get an infection. Women should not have chin hairs. [NAME] hairs should be removed when they are visible. [NAME] hairs are a dignity issue for women. It is expected that the CNA's and nurses properly groom the residents to maintain their dignity. The facility's Activities of Daily Living Policy effective date 12/01/23 showed- Policy: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Procedure: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 41384 4. On 08/06/24 at 01:33 PM, R26 was observed with long jagged nails with a brown substance under the nails. R26 said that she was unable to remember the last time she was provided nail care and she would like for someone to provide it. R46's 7/11/24 care plan showed, The resident has an ADL (activities of daily living) self-care and mobility usual performance deficit related to weakness, decrease mobility ADL function, decrease balance/strength. The resident will participate in performing her ADLs with staff assistance. Intervention - Personal Hygiene: Substantial/Maximal Assistance. R26's 8/1/24 MDS (minimum data set) showed in section GG under Personal Hygiene - R26 needs substantial maximal assistance. 5. On 08/06/24 at 11:59 AM, R30 was observed with his left hand contracted and his fingernails were not visible. R30's nails on his right hand were observed long, jagged and with a brown substance under the nails. R30's 7/6/24 Care Plan showed that R30 is at risk for Functional/ADL Status decline related to weakness, aging process, left hemiplegia related to CVA (cerebral vascular accident). Personal Hygiene: Substantial/Maximal Assistance. R30's 6/23/24 MDS section GG under personal hygiene showed R30 needs substantial/maximal assistance. 6. On 08/06/24 at 01:28 PM, R42 was observed with long jagged nails, with a brown substance under the nails. R42's 8/1/24 care plan showed, Resident has an ADL self-care and mobility usual performance deficit related to weakness, decreased mobility, recent fall, fracture of right femur. R42's care plan interventions showed, Personal Hygiene Assistance substantial/maximal assistance. R42's 5/9/24 MDS section GG under Personal Hygiene showed R42 needs substantial/maximal assistance. 7. On 08/06/24 at 12:14 PM, R45 was observed with long jagged nails with a brown substance under the nails. R45 said that she doesn't know the last time she was provided nail care and that it bothers her that it has not been done. R45's 7/15/24 care plan showed R45 has a risk for Self-Care Deficit. Provide assistance with ADLs as needed. R45's 7/1/24 MDS section GG under personal hygiene showed that R45 needs substantial maximal assistance. 8. On 08/06/24 at 01:25 PM, R49 was observed with long jagged fingernails with chipped nail polish on them. R49 said that staff does not do a good job providing nail care for her. R49's 5/18/24 MDS section GG under personal hygiene showed that R49 is dependent for care. 9. On 08/06/24 at 12:14 PM and on 08/08/24 at 10:52 AM, R68 was observed with long jagged fingernails with a brown substance under them. R68's 6/27/24 MDS section GG under personal hygiene showed that R68 needs substantial/maximal assistance. R68's 8/7/24 care plan showed, resident has an ADL self-care and mobility usual performance deficit related to weakness, hearth failure, coronary artery disease and dementia. The goal showed, will maintain current ADL function and participate in ADLs with staff through the review date. The Intervention showed, Personal Hygiene Assistance Level: Substantial/maximal assistance. 46409 10. On August 6, 2024 at 1:35 PM, R12 was in the dining room had had facial hair, which was approximately 1.5 inches long on her chin. On August 8, 2024 at 10:11 AM, R12 still had facial hair 1.5 inches long on her chin. On August 8, 2024 at 1:19 PM, V16 (CNA/Certified Nurse Assistant) said the staff shave residents as needed or on shower days. V16 said female residents should not have facial hair, and they should be shaved. At 1:24 PM, V17 (CNA) said female residents should be shaved for dignity reasons. At 1:34 PM, V19 (CNA) said the facial hair should be removed for female residents, unless it was their preference to keep it on. At 1:41 PM, V14 (CNA) said the female residents should be shaved for dignity reasons. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said it was her expectation for the staff to shave female residents. V2 said she had also bought tweezers for the staff to remove facial hair. R12's face sheet showed she was admitted to the facility for palliative care, Alzheimer's disease, congestive heart failure, polyosteoarthritis, anxiety disorder, hypertension, and repeated falls. R12's MDS (Minimum Data Set) dated June 14, 2024 showed R12 had severe cognitive impairment and was dependent on staff for personal hygiene. R12's care plan dated March 8, 2024 showed R12 had an ADL [Activities of Daily Living] self-care and mobility usual performance deficit. The facility's Activities of Daily Living policy dated November 14, 2023 showed Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to do hand hygiene and glove change during incontinence care, wound care, and during the meal service. The facility also failed to use proper PPE (Personal Protective Equipment) for residents who were under EBP (Enhanced Barrier Precautions) during wound care. This applies to 6 residents (R45, R92, R68, R60, R14, and R96) reviewed for infection control in a sample of 34. The findings include: 1. On 08/06/24 at 12:28 PM V9 CNA (Certified Nurse's Assistant) was observed delivering lunch to residents that were in their rooms. V9, with ungloved hands, brought R45 her lunch plate, set it on her bedside table, moved R45's personal items that were on her bedside table around to make room for the plate, then opened the container of ice cream, opened the cloth napkin and handed R45 her utensils. V9 then went back into the hall, did not clean her hands, picked up R68's plate and brought the plate to R68's bedside table, adjusted R68's personal items on her bedside table, opened the ice cream, opened the napkin and gave the utensils, and then adjusted R68's bed using the bed control. V9 then left the room and did not clean her hands and came back with coffee and peaches off the food cart and gave the coffee and peaches to R68. Then V9 went into the bathroom and put on gloves but did not clean her hands and adjusted R68's bed again and provided her with water and cut up her food. R45 then asked V9 to cut up her food also. V9 removed her gloves, did not clean her hands, and put on new gloves and cut up R45's food. Then V9 removed her gloves, picked up R92's plate and brought it into R92's room. V9 did not clean her hands after removing her gloves. V9 then picked up R92's personal bottle of olive oil and poured the olive oil in R92's cup of coffee with her uncleansed hands. 2. On 08/08/24 at 09:22 AM V4 (Wound Care Nurse) was providing wound care for R60. V9 CNA (Certified Nurse's Assistant) was assisting with wound care, she was observed touching R60's bare skin while turning her and holding her in a sideline position while wound care was being provided. V9 was observed with gloves on her hands but did not have a gown on. V4 cleaned R60's sacral wound removed her gloves, did not clean her hands and did not remove her gown, and left the room to go to her medication cart to get another vial of normal saline and then came back into the room, did not clean her hands and put on new gloves and continued to clean R60's wound. Then after wound care was completed V10 CNA came into the room to assist V9 in incontinence care for R60. V9 then left out of the room, touching the door handle with her dirty gloved hands to get some washcloths from the hall. V4 returned to the room and was observed then putting on a gown. V9 then proceeded to clean R60's perineal and rectal/buttock area. Then V9 with same dirty gloved hands applied skin barrier protection to R60 buttocks and then removed her gloves and went into the bathroom. V9 then came out of the bathroom put on new gloves, touched R60's colostomy bag that was full of stool, and then opened and applied barrier cream to R60's perineal area. V9 then removed her gloves and put on a new pair of gloves but did not clean her hands. V9 then pulled the new brief between R60's legs and attached the brief on the left side. V4 then pulled out the soil brief from under R60 and then pulled out the new brief and attached it on the right side. V4 did not remove her gloves and clean her hands after touching the soil brief and before touching and attaching the new brief. Then V4 went into the bathroom and got 2 clean washcloths with her dirty gloved hands and gave one of them to V9. Then both V4 and V9 then clean R60's arm pits at the same time with those washcloths. Then both V9 and V4 with the same dirty gloved hands pulled R60 up in the bed, and V9 used the bed control to adjust the bed while still wearing the dirty gloves, and V4 was observed touching R60's bedrails with her dirty gloved hands. On 08/08/24 at 02:28 PM, V1 (Administrator) said that V4 should have had a gown on because R60 was on EBP. V1 said that the nurse should have removed her gown and washed her hands before going to the medication cart, and V4 should have removed her gloves and cleaned her hands before touching the door and getting clean wash clothes. V1 said that staff should have removed their gloves, cleaned their hands and put on new gloves before going to a clean area for infection control issues and cross contamination. 3. On 08/08/24 at 09:55 AM, V4 was observed providing wound care for R68. V4 cleaned the wound and then applied a new dressing to the wound. V4 did not remove her gloves and clean her hands before applying the new dressing. V4 then with dirty gloved hands, pulled up and attached R68's brief and then pulled up R68's blanket. V4 then used the bed control to adjust the bed and put R68's call light in reach. V4 then removed her gloves and cleaned her hands. On 08/08/24 at 10:07, V4 said that she should have removed her gloves and cleaned her hands after cleaning R68's wound and after finishing wound care and before touching R68's personal items. On 08/08/24 at 02:20 PM, V1 said that V4 should have removed her gloves and clean hands after cleaning the wound. The facility's Hand Hygiene policy dated 9/1/23 showed, staff in direct contact with resident will perform proper hand hygiene procedures to prevent the spread of infection to others . Hand Hygiene Table showed hand hygiene should be done: between resident contacts, after handling contaminated objects, before performing invasive procedures, after removal of protective equipment PPE including gloves, before and after handling clean or soiled dressings, linens, etcetera, before performing resident care procedures, after handling items potentially contaminated with blood body fluid secretions or excretions, and during resident care moving from a contaminated body site to a clean body site. 46409 4. On August 7, 2024 at 10:46 AM, V4 (Wound Care Nurse) provided wound care for R14. V4 removed R14's old dressing, removed her gloves, used ABHS (Alcohol Based Hand Sanitizer) and applied new gloves. V4 then used normal saline and gauze to clean V4's wound and grabbed the new dressing without glove change or hand hygiene and applied the new dressing to R14's wound. On August 8, 2024 at 1:50 PM, V4 said her gloves should have been changed and hand hygiene should have been done prior to handling the new dressing because the wound was dirty and she would want to make sure her gloves were clean prior to handling a new dressing. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said gloves should be changed and hand hygiene should be done when going from dirty to clean procedures, such as after cleaning the wound, prior to applying the new dressing. R14's face sheet showed she was admitted to the facility with diagnoses including stage 4 pressure ulcer, atrial fibrillation, generalized osteoarthritis, muscle wasting and atrophy, lack of coordination, low back pain, unsteadiness on feet, dementia, gastro-esophageal reflux disease, and hammer toes to the right and left foot. R14's POS (Physician Order Set) showed Enhanced barrier precautions (EBP) related to a wound/(indwelling urinary catheter). PPE to be utilized during high contact resident care activities. R14's MDS (Minimum Data Sheet) dated July 16, 2024 showed R14 was cognitively intact. R14's care plan dated August 7, 2024 showed Enhanced Barrier Precautions to be maintained. The facility's Hand Hygiene policy dated August 21, 2023 showed ABHS should be done when, during resident care, moving from a contaminated body site to a clean body site and Before applying and after removing personal protective equipment (PPE), including gloves. 34410 5.R96 is a [AGE] year-old female admitted on [DATE] with an admitting diagnosis, including an infected leg wound. On 08/07/24 at 11:20 AM, V4 (Wound Care Nurse) provided wound care to R96's left lower leg open wounds without wearing a gown. On 08/07/24 at 11:31 AM, V3(Registered Nurse/RN) stated, R96 is done with her antibiotics and is on enhanced barrier precaution due to her lower extremity wounds. Staff should wear gowns and gloves when providing care to residents. On 08/07/24 at 11:30 AM, V4 (Wound Care Nurse) stated that she should have worn the gown to provide wound care to R96 as she is on enhanced barrier precaution; I forgot. The facility presented the Enhanced Barrier Precaution policy dated 4/1/24 document: Guidelines. 3. Implementation of Enhanced Barrier Precaution: b. Personal Protective Equipment (PPE) for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room 4. High-contact resident care activities include: h. Wound Care: Any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to put call lights within reach for residents. This applies to 3 of 3 resident (R52, R54, R56) reviewed for accommodation of needs in a sample of 34. The findings include: 1. On August 6, 2024 at 11:27 AM, V14 (CNA/Certified Nurse Assistant) and V15 (CNA) had finished providing incontinence care for R52. After completing incontinence care, V14 and V15 left R52's room. R52's call light was out of reach of the resident. R52 said he did not know where his call light was and would not know how to call for help without it. R52's face sheet showed he was admitted to the facility with diagnoses including type 2 diabetes mellitus, dementia, depression, seizures, difficulty in walking, muscle weakness, fracture of the lumbar vertebra, and subdural hemorrhage. R52's MDS (Minimum Data Set) showed R52 had moderate cognitive impairment and required substantial assistance from staff for eating, oral hygiene, and personal hygiene, and was dependent on staff for toileting, shower/bed baths, upper and lower body dressing, and putting on/taking off footwear. R52's care plan dated October 5, 2022 showed R52 was at risk for falls related to weakness, decrease balance/strength/mobility/ADL (Activities of Daily Living) function, history of falls with injury .with intervention including Ensure call light is available to resident. 2. On August 6, 2024 at 1:13 PM, R54 was sitting in his wheelchair. R54's bed was made, and his call light was seen underneath the blankets, out of reach of the resident. R54 also said he did not have a room phone to call for help either. R54's face sheet showed he was admitted to the facility with diagnoses including congestive heart failure, chronic kidney disease, anemia, polyosteoarthritis, depression, hypertension, and gastro esophageal reflux disease. R54's MDS showed R54 had moderate cognitive impairment, and he needed substantial assistance from staff for eating, oral hygiene, upper body dressing, and was dependent on staff for toileting hygiene, shower/bed baths, lower body dressing, putting on/taking off footwear, and personal hygiene. R54's care plan dated February 26, 2024 showed R54 was at risk for falls related to gait/balance problems, incontinence, weakness, decrease balance/mobility/ADL skills/strength, and history of falls, with an intervention including Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 3. On August 6, 2024 at 11:36 AM, R56 was being settled into her bed for a nap by a CNA, then left the room. R56's call light was hanging off the side of the bed. R56 said she would call for help by pressing the call button. R56's face sheet showed she was admitted to the facility with diagnoses including hyperlipidemia, muscle weakness, osteoporosis, difficulty in walking, lack of coordination, and dysphagia. R56's MDS dated [DATE] showed R56 was cognitively intact and showed R56 required substantial assistance from staff for eating and oral hygiene, and was dependent on staff for toileting hygiene, shower/bath, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. R56's care plan dated July 15, 2021 showed R56 was at risk for falls related to decreased balance/mobility/ADL function, weakness, and disease process, with an intervention including Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On August 8, 2024 at 1:19 PM, V16 (CNA) said the call lights should be clipped to the blanket in front of the resident so they could see it and could reach for it. V16 said if the resident was in the wheelchair, it should still be within reach to the resident. On August 8, 2024 at 1:24 PM, V17 (CNA) said the staff should give the call lights to the resident before leaving the room because the call light should always be placed within reach to the resident. V17 said if the resident was in the chair, she would bring it close to the chair or loop it around the chair, or clip it to the sheets. On August 8, 2024 at 1:30 PM, V18 (CNA) said the call lights need to be within reach of the resident, and if they are in the chair, to clip it to their shirt or onto the chair. On August 8, 2024 at 1:38 PM, V20 (LPN/Licensed Practical Nurse) said the call lights should always be where the resident can reach it, whether that be in their hands or clipped in front of their hands. On August 8, 2024 at 2:06 PM, V2 (DON/Director of Nursing) said the call lights should be within reach of the residents. V2 said if the resident was in the chair, the call light should still be reachable to the resident. The facility's Answering Call lights policy dated September 1, 2023 showed When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to invite 2 residents (R45, and R68) to their care plan meetings that were reviewed for care plans, in a sample of 34. Findings include: 1. On 08/06/24 at 12:14 PM, R45 said that she has not attended a care plan meeting, nor had she been invited to one since she has been admitted to the facility. R45's electronic health record showed that she was admitted to the facility on [DATE]. 2. On 08/06/24 at 12:14 PM, R68 said that she has not attended, nor has she been invited to a care plan meeting since she was admitted . 08/08/24 at 11:09 AM R68 was in her room with V8 (R68's son) and R68 again said that she has never attended or has been invited to a care plan meeting. Then V8 said that he comes and visits his mother twice a week and he receives notices from the facility about his mother's care but he has never received any invitation or notice for her care plan meetings. R68's electronic health records showed that she was admitted on [DATE]. On 08/08/24 at 02:37 PM, V1 (Administrator) said that the residents and representatives are to be invited to their care plan meetings so that the residents have a choice in their care and their family will know and are able to contribute to the resident's plan of care. V1 said that the facility should document in a progress note that the resident and representative was invited and if they attended. A record review was conducted during this survey from 8/6/24 - 8/8/24 and no documentation could be found showing R45, R68, and their representatives, were invited to and attended any care plan meetings for the past year. The facility was unable to provide any documentation showing that R45, R68, or their representatives were invited or attended their care plan meetings. The facility's Resident Comprehensive Care Plan policy with review date 03/21/2024 showed, To ensure the timeliness of each resident's personal centered baseline and comprehensive plan and to ensure that these care plans are reviewed and revised by and disciplinary team composed of individuals who have knowledge of the resident his or her needs each resident and resident representative if applicable is involved and developing the care plan and making decisions about his or her care. Care plan is to include participation of the resident and the resident's representative and explanation must be included in the residence medical records if participation of the resident and their resident representative is determined not practical for the development of the residence care plan.

Based on interviews and record review the facility failed to ensure that a resident's narcotic medication ([MEDICATION(S)]) was administered as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for narcotic medications. This failure resulted in R1 being hospitalized with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: R1 was admitted to the facility on [DATE], from home under hospice care with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission baseline care plan dated June 24, 2022, showed under summary that the resident was alert and oriented x 3 and was receiving hospice care. The same admission baseline care plan summary showed in-part, She is here for respite care x 5 days. R1's progress notes dated June 24, 2022 (12:00 PM) created by V4 (Nurse) showed in-part, All orders from hospice verified with MD/NP (Medical Doctor/Nurse Practitioner), with no new orders. All medications and treatment to be continued. All admission procedures completed. R1's progress notes dated June 25, 2022 (2:39 PM) created by V5 (Nurse) showed in-part, with complaints of pain 7/10, vital signs stable. 8 AM pain meds administered as ordered. Husband noticed patient easily arousable but easily goes back to sleep. Patient stated she feels warm, sweating, and flushed face. Encouraged fluids, patient able to consume 1 liter of ice water, ice pack placed on patient's armpit and groins. Upon checking the order, patient had overdosage of pain meds. Informed husband, hospice, and MD regarding the medication overdose. 11:45 AM patient picked up by ambulance transportation and transferred to (hospital) ER (emergency room ). R1's progress notes dated June 25, 2022 (8:48 PM) showed, Pt admitted at (hospital) due to [MEDICATION(S)] poisoning per (hospital) ED (emergency department) staff. R1's incident report submitted to the State Agency on June 25, 2022, as the initial and final report showed in-part, On June 25, 2022 at 11 AM resident is usually alert and oriented x 3 and was noted to be sleepy but arousable and able to respond to name. Resident with order for [MEDICATION(S)] 30 mg TID (three times a day). Medication error noted. Resident medication was entered in the system as 30 ml. Family, MD and hospice were notified. Review of R1's medication profile sent to the facility by the hospice company on June 24, 2022, at (1:37 PM) showed multiple medication orders which included, [MEDICATION(S)] 10 mg/ml (milligrams/milliliter) oral concentrate; Administer 30 milligrams oral 3 times a day; (3 ml); pain management. R1's facility electronic order summary report showed an order dated June 24, 2022, [MEDICATION(S)] HCl ([MEDICATION(S)]) Concentrate 10 mg/ml, give 30 ml by mouth three times a day for Pain Management. R1's MAR (medication administration record) for the month of June 2022 showed that in the evening of June 24, 2022, V6 (Nurse) administered [MEDICATION(S)] HCL Concentrate 10 mg/ml, 30 ml by mouth to the resident and in the morning of June 25, 2022, V5 (Nurse) administered [MEDICATION(S)] HCL Concentrate 10 mg/ml, 30 ml by mouth to the resident. Based on the hospice medication profile order, facility electronic order summary and MAR, R1 received 30 ml of the [MEDICATION(S)] medication, which was equivalent to 300 mg, instead of the ordered 3 ml which was equivalent to 30 mg. Along with the prescribed amount, R1 received an additional nine dosages in a single medication administration on two separate occasions. On July 6, 2022, at 1:44 PM, V3 (Assistant Director of Nursing) stated that during admission of a resident, the facility follows an admission check list which included medication verification and reconciliation to make sure that all orders transcribed in the electronic system are correct and accurate. According to V3, on June 24, 2022, when R1 was admitted to the facility, R1's admission check list was not fully completed because only the admitting nurse (V4) documented her initials that the medications were reconciled and that all the orders were correct. However, there was a second step which was for the night nursing supervisor to initial that everything in the admission check list, including medication reconciliation of all ordered medications, are properly transcribed in the electronic system to ensure correctness. According to V3, the second step of double checking the transcribed medication orders in the electronic system was not completed because the night shift nursing supervisor was off that day and when the said night shift nursing supervisor came to work the next day (June 25, 2022), R1 was already at the hospital due to overdose of the [MEDICATION(S)] medication. Review of R1's admission check list, dated June 24, 2022, showed that V4 (Nurse) had initialed the said check list indicating that she completed multiple admission tasks which included, medication reconciliation and all correct orders into [electronic system]. However, the column which indicated Double Check, was blank. On July 6, 2022,at 3:04 PM, V4 (Nurse) stated that she was the nurse who admitted R1 on June 24, 2022. According to V4, when R1 was admitted at the facility, the hospice nurse (does not know the name) who was present at the time of admission had the hospice company faxed R1's medication profile to the facility. The same hospice nurse who was present called their hospice Nurse Practitioner to verify the orders and the hospice Nurse Practitioner gave the order to continue all the orders written on the hospice medication profile, including the [MEDICATION(S)] which she had placed a check mark on the medication profile list. According to V4, R1's facility physician was also notified of R1's admission at the facility including the hospice medication profile orders to which the physician agreed. V4 stated that she then faxed a copy of the hospice medication profile orders to the facility pharmacy who would input the orders into the electronic system. According to V4 after the pharmacy puts in the orders, the orders would remain inactive or pending until the nurse activates the specific order. V4 stated that after seeing that all of R1's medication orders were in the electronic system, she individually activated each ordered medication one at a time based on the hospice medication profile orders. However, V4 admitted that she made a mistake and that she was not familiar with the [MEDICATION(S)] medication and the dosage. V4 stated that she got confused and activated the 30 ml [MEDICATION(S)] order that was put in by the pharmacy, instead of correcting it to 30 mg as ordered (by the hospice Nurse Practitioner with the approval of the facility Physician) and written on the medication profile orders. V4 added that she followed the resident's (R1) admission check list and initialed that she completed the medication reconciliation and had verified that all orders entered in the electronic system were correct. However, V4 stated that another nurse was supposed to double check R1's admission check list, including the medication reconciliation and verify that the orders in the electronic system are correct. On July 6, 2022, at 3:43 PM, V6 (Nurse) stated that she was the nurse who gave R1 [MEDICATION(S)] 30 ml on June 24, 2022 sometime after dinner. V6 stated that she was not familiar with the said medication and its normal/usual dosage. V6 added, since the order in the electronic system was to give [MEDICATION(S)] 30 ml, I followed the order, and I gave the 30 ml. On July 7, 2022, at 10:20 AM, V5 (Nurse) stated that she was the nurse who gave R1 [MEDICATION(S)] 30 ml on June 25, 2022 during the morning medication pass between 8:30 AM and 9:00 AM. V5 stated that she was not familiar with the said medication and its usual dosage because she have never given this medication before. According to V5, I trusted that the nurse who activated the [MEDICATION(S)] order had verified that it was the correct order including the correct dosage. V5 stated that on June 25, 2022, at approximately 9:15 AM, R1's husband came to visit the resident. R1's husband asked, what medications were given to the resident because according to the husband, R1 was sleepy and was not her usual self. According to V5 she told R1's husband what medications were given to the resident and per R1's husband, she is taking the same medications, but she never felt so sleepy, warm, sweaty and flushed before. V5 stated that she went to check on R1 and noticed that the resident felt hot, sweaty, and flushed as described by the husband. According to V5, R1 had an ongoing continuous oxygen and the resident's vital signs were within normal limits, including the temperature when she checked R1. V5 stated that she offered R1 ice water and encouraged the resident to drink. V5 stated that because of R1's change in condition she located the hospice medication profile orders and compared it with the orders in the facility's electronic system. It was only during this time that she discovered that R1 had overdosed on the [MEDICATION(S)] because the order on the hospice medication profile was to give 30 mg and not 30 ml. According to V5 the available [MEDICATION(S)] for R1 was 10 mg/ml and only 30 mg should be given to R1 which was equivalent to 3 ml. V5 stated that she immediately informed R1's husband, the Director of Nursing, hospice and the Physician about the medication error. The hospice ordered to send R1 to the emergency room for evaluation and treatment and V7 (Physician) agreed with the hospice. On July 7, 2022, at 11:45 AM, V8 (Hospice Clinical Director) stated that R1 has been receiving hospice care at home since July 3, 2021. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated that R1 was ordered to receive 3 ml of [MEDICATION(S)] 10 mg/ml, since June 16, 2022, for management of generalized pain. According to V8, based on the hospice physician notes dated June 16, 2022, R1 has chronic pain syndrome and was no longer tolerating the IV (intravenous) [MEDICATION(S)] (narcotic) which was why the [MEDICATION(S)] was started. V8 stated that the facility should follow and administer R1's medications as written and verified in the resident's medication profile which was also approved by the resident's Physician. On July 7, 2022, at 11:00 AM, V7 (Physician) stated that since R1 was admitted at the facility for respite stay under the hospice care she agreed for the resident to continue all her medications from home, including the [MEDICATION(S)]. V7 stated that she agreed for R1 to receive 3 ml and not 30 ml of the [MEDICATION(S)] medication. According to V7 she was informed on June 25, 2022, around noon that R1 was given overdosages of the [MEDICATION(S)] and ordered to send R1 to the hospital for evaluation and treatment as long as the hospice agreed. V7 stated that she expects the facility to follow the resident's medication orders and for the facility to ensure that all the orders are transcribed correctly. V7 stated that she followed R1's care at the hospital after the resident was sent to the ER (emergency room ). According to V7, she spoke to the ER physician and was informed that R1 was hypertensive, confused, very flushed, with breath sounds diminished on both sides and with temperature of 36.9 (equivalent to 98.42 degrees Fahrenheit) when assessed at the ER. V7 stated that [MEDICATION(S)] suppresses respiration and because of the significant overdose of the medication, R1 could have gone into respiratory coma and die.

Based on observation, interview and record review, the facility failed to safely transfer R1 between surfaces. The facility also failed to provide supervision to R2 during the use of the restroom. This failure resulted in R1 sustaining a clavicle fracture and shoulder separation following an unsafe transfer, and R2 sustaining a left frontal traumatic subarachnoid hemorrhage/contusion. This applies to 2 of 3 residents (R1, R2) reviewed for falls with major injury in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged from the facility on June 16, 2021. R1 had multiple diagnoses including, [CONDITION(S)], [CONDITION(S)], hypertension, hip fracture, chronic kidney disease, history of falling, urine retention, dementia, and diabetes. R1's MDS (Minimum Data Set) dated April 14, 2021 shows R1 had moderate cognitive impairment, required supervision with eating, and extensive assistance with all other ADLs (Activities of Daily Living). R1 was frequently incontinent of bowel and bladder. R1's MDS continues to show R1 had a fall during the prior two to six months resulting in a fracture and one fall since admission to the facility resulting in injury. On May 27, 2021 at 9:15 AM, V9 (RN-Registered Nurse) documented, CNA reported that since Tuesday [5/25/21], resident has been weaker with her transfers. [R1] requiring [body sling] mechanical lift . The facility's IDPH (Illinois Department of Public Health) Reportable Final Report dated June 15, 2021 for R1 shows: On 6/9/2021 in the AM while providing ADL care, CNA (Certified Nursing Assistant) noted skin discoloration to right shoulder. Nurse on duty assessed [R1] and noted pain. CMS (Circulation, Motion, Sensation) to right arm was WNL (Within Normal Limits). MD was notified and orders received for X-ray. X-ray showed fractured right clavicle. On 6/10/2021, [V8] (NP-Nurse Practitioner) evaluated [R1] and asked her to be sent to hospital for further evaluation. Investigation showed that on June 3, while toileting resident that after being placed on toilet [R1] had difficulty using sit to stand [lift] and was weak to properly hold hand grasps and CNAs had to get a third person to assist them in getting [R1] back to bed. Investigation showed no fall, but they did have arm to arm placement under arms while third person used gait belt during transfer. On July 7, 2021 at 11:42 AM, V3 (RN) said, The CNAs had [R1] on a sit to stand mechanical lift from the toilet. They were having a hard time and called me in to help. The resident could not grasp the handrails on the sit to stand mechanical lift. The CNAs tried twice, and the second time, they lowered [R1] down to the toilet riser. She was totally asleep and unable to assist with the use of the sit to stand mechanical lift. We lifted the resident using the toilet riser to move her from the toilet towards her bed. We couldn't use the [body sling] mechanical lift because that lift would not fit through the bathroom doorway. Once we got next to [R1's] bed, each CNAs grabbed the resident under each arm, and I was holding [R1's] legs. She was very weak. Had we known she needed the [body sling] mechanical lift, we never would have put her on the toilet using the sit to stand mechanical lift. I talked to the family right away and they said they were surprised we used a sit to stand mechanical lift because they did not think [R1] could use that device. This all happened before breakfast on June 3, 2021. On July 7, 2021 at 11:54 AM, V6 (Director of Therapy) said, Every time a resident is transferred between surfaces, the resident needs to be assessed to see if the resident can tolerate being transferred and what is the most appropriate type of transfer device. This can change from day to day. If the resident is too weak to transfer, then the staff should use a [body sling] mechanical lift where a sling is placed under the resident's entire body and cradles the resident as they are lifted for the transfer between surfaces. This is the type of mechanical lift device we recommended for [R1] when she was discharged from physical therapy in late May 2021. [R1] was very inconsistent with transferring between surfaces at that time. I was never notified by facility staff that she had become increasingly weak the week prior to her injury and was consistently requiring the [body sling] mechanical lift for most transfers. On July 8, 2021 at 11:27 AM, V8 (NP-Nurse Practitioner) said, The nurse told me they lifted [R1] without the mechanical lift device and then the resident had bruising to her shoulder area a few days later. I ordered an X-ray that showed there was a fracture of her clavicle and possibly a shoulder separation. I ordered to send the resident to the emergency room . On July 8, 2021 at 5:06 PM V18 (NP) and V19 (Orthopedic Surgeon) said, the mechanism of injury for R1's clavicle fracture and shoulder separation were directly related to R1's improper transfer and being improperly lifted under the arms. 2. On July 6, 2021 at 10:30 AM, R2 was self-propelling his wheelchair in his room. R2 could not recall his fall incident in April 2021. R2's left hand was curled inwards towards his abdomen and he was unable to use his hand. R2 appeared weak on his left side while self-propelling his wheelchair. The EMR shows R2 was admitted to the facility in April 2016 with multiple diagnoses including [CONDITION(S)] disease, traumatic hemorrhage of the cerebrum, left-sided [CONDITION(S)], [CONDITION(S)], major depressive disorder, heart disease, right arm biceps injury, repeated falls, dementia with behaviors, [CONDITION(S)], dysphagia, cognitive communication deficit, [CONDITION(S)], [CONDITION(S)], and shortness of breath. R2's MDS dated [DATE] shows R2 is cognitively intact, requires supervision with eating, limited assistance with locomotion on the unit and personal hygiene, and extensive assistance with all other ADLs. R2 is frequently incontinent of urine and always continent of stool. R2's MDS further shows R2 has had one fall since admission/entry or reentry or prior assessment. Facility documentation shows R2 has sustained falls at the facility on April 28, 2021, May 5, 2021, May 13, 2021, and June 5, 2021. The facility's IDPH Reportable Final Report dated May 3, 2021 for R2 shows: On 4/28/21, [R2] was transferred to the toilet in his room. CNA was outside room door and heard a loud noise. [R2] was on floor in the bathroom next to the toilet.After getting [R2] into chair, [R2] vomited yellow. At this time 911 was called.[R2] was sent to [local hospital[ diagnosed with left frontal lobe favored to reflect a combination of subarachnoid blood and possible small hemorrhagic cerebral contusion. Hospital documentation dated April 29, 2021 shows, Presents .following a fall at his nursing home, found to have a small L (Left) frontal TSAH/contusion (Traumatic Sub-Arachnoid Hemorrhage/contusion). On July 8, 2021 at 12:39 PM, V16 (RN) said, [R2's] fall happened at 6:30 AM. [R2] is very impulsive. He has behaviors where he intentionally tries to hurt himself. The DON (Director of Nursing) told us not to leave him alone in the bathroom, that he's a two person assist. He's not supposed to be alone in the bathroom. That's something that has been in place for a long time. Obviously, the staff wasn't doing what they were supposed to be doing when they left him alone in there. He has fallen a lot, and it's usually because he doesn't follow directions, or being non-compliant. He has been difficult for the CNAs especially. He can only use one arm and one leg. He won't want to use a bedpan so it's tricky. On July 12, 2021 at 11:40 AM, V20 (CNA) said, I take care of [R2] all the time. During that incident on April 28, 2021, I had placed R2 on the toilet and left the bathroom. I was standing outside the door. I could not see the resident from where I was standing. I heard a thud that sounded like a potato sack hitting the floor. I ran to the bathroom and found him on the floor. He couldn't answer any questions I was asking him. He lost control of his bladder and had liquid stool after he fell on the floor. I had been told that a few days earlier he had a fall when he threw himself on the floor. I had taken care of him all the time. I left the bathroom just to give him some privacy. He didn't ask me to leave the bathroom. I just stepped out for his privacy. I did not see him fall off the toilet. He was lying on his left side when I found him. On July 12, 2021 at 3:12 PM, V2 (DON) said, Fall risk assessments were done for [R2] on March 4, 2021, and two times in April 2021. On March 4, April 14, and April 27, 2021, [R2] was assessed to be a high fall risk. He was being evaluated numerous times because he was having behaviors of banging his head on things like a lamp, and throwing himself on the floor during that time frame. He was expressing interest in assisted suicide and started trying to harm himself by throwing himself on the floor. The facility's Incident Report Details for R2, dated April 28, 2021 shows: During nursing report CNA called RN to resident's bathroom. Resident had apparently fallen from the toilet. Resident was unable to answer any questions re: pain or whether or not he had hit his head. There was no apparent injury seen. Upon getting him back to his WC (Wheelchair) he began vomiting. He is on [MEDICATION(S)] (blood thinner). 911 called immediately. Cause Codes: Lack of/inappropriate supervision. Investigative Findings: Upon investigation resident was left alone on the toilet. He fell forward striking his head, resident was sent to ER for further evaluation.

Based on interview and record review, the facility failed to provide ongoing assessments and dressing changes for a resident with known pressure ulcer. As a result, R36 was admitted to the hospital with [REDACTED]. This applies to 1 resident (R36) reviewed for pressure ulcer in the supplemental sample. The findings include: R36's progress notes on [DATE] at 5:00 PM showed R36 was transferred to hospital for low hemoglobin. emergency room reports showed R36 was transferred to the medical floor with a request for a podiatry consult due to R36 having a stage 3 pressure ulcer on the right foot with readily exposed bone and facia. R36's podiatry note completed on [DATE] at 7:19 AM showed lateral foot ulcer moist with [MEDICAL CONDITION] drainage. Hospital records showed an excisional ulcer debridement was performed on [DATE] on the right foot and R36 was diagnosed with [REDACTED]. According to the EHR (Electronic Health Record) R36 received wound care assessments and evaluations performed by V5 (wound doctor) from [DATE] through [DATE]. Included in the documentation was the assessment of stable eschar. Patient to continue current treatment and PCP (primary care provider) to manage stable, chronic wound. Please reconsult if necessary. Attached dressing treatment plan showed to continue with [MEDICATION NAME], apply dry dressing for 30 days. V5's assessment and evaluation showed 2 wounds on the right foot, one being the ankle and the other as right, distal lateral foot. R36's care plan showed admitted with skin/tissue integrity concerns including the right outer foot with unstageable pressure wound with measurements of 4.0 X (by) 3.6 X unmeasurable due to 100 % eschar. The intervention was treatments as ordered. R36's (MDS) Minimum Data Set quarterly assessment on [DATE] showed BIMS (brief interview for mental status) score of 15 which meant R36 is cognitively intact On [DATE] at 11:25 AM, R36's progress note showed V3's (Assistant Director of Nursing) assessment indicated wound to right lateral foot which has previously stable eschar had deteriorated .physician was informed, Santyl ointment was ordered . Measurement showed 3.2 X 2.0. V23's (PCP) encounter notes showed R36 was seen by V23 on: ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE] and ,[DATE] failed to show descriptions or assessments of the right lateral foot. V23's encounter notes showed on ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; ,[DATE]; V23 documented foot wound - improving. On [DATE] at 5:19 PM, V3's progress note showed unstageable pressure ulcer to right lateral distal foot. Measures 3.0 X 2.0 but not measurable due to 80% devitalized slough tissue, 10% eschar and 10% pink granulation R36's (MONTH) POS (physician order [REDACTED]. R36's (MONTH) POS showed the same R36's (MONTH) POS showed no orders for medication or dressing changes for the right lateral distal foot. R36's (MONTH) POS showed to apply topical ointment to wound bed daily X 30 days, cover with dry dressing daily X thirty days starting on [DATE]. R36's April's TAR (Treatment Administration Record) showed the topical ointment was applied and dressing was changed on R36's right lateral distal foot daily from [DATE] to [DATE]. R36's May's TAR showed the topical ointment was applied and dressing was changed on R36's right lateral distal foot daily from [DATE] to [DATE]. R36's June's TAR showed R36 did not receive any ointment nor was the dressing changed on the right lateral distal foot daily from [DATE] to [DATE]. R36's July's TAR showed the topical ointment was applied and dressing was changed to R36's right lateral distal foot daily from [DATE] to [DATE]. On [DATE] at 6:36 AM, V27 (nurse) noted R36's right lateral foot with odor. On [DATE] at 10:19 PM, V3's wound assessment noted slough and serosanguinous drainage On [DATE] at 1:34 PM, R36 voiced concerns to V7 (nurse) about dressing changes not being done every day. On [DATE] at 12:36 PM, R36 and family member expressed continued concerns about dressing changes not being done daily. On [DATE] at 11:08 AM, V3 (ADON) stated R36 has not been seen by a wound doctor since (MONTH) 2019. V3 added, R36's wound was stable after V5 stopped seeing R36 and described the wound with eschar, black in color, dry, without redness, drainage or pain. V3 stated the Attending physician has never seen the wound and there was no need for the Attending physician to see the wound, because V3 is a certified wound nurse. In addition, V3 stated the wound changed from partial eschar to slough in April. V3 stated eschar totally disappeared in June. On [DATE] at 12:38 PM, V5 (Wound doctor) stated she has not seen the resident since (MONTH) 2019 and if there was a deterioration in the condition of the wound, she probably wouldn't have been notified because her agency only sees Medicare patients. She added that however, a physician should have been notified and followed R36 for wound care. On [DATE] at 1:24 PM, V7 (nurse) reviewed her progress note dated [DATE] and clarified that the resident (R36) and (V9) resident's brother questioned dressing changes and making sure they are done daily. V7 stated the dressing was dated from a few days previously. V7 checked the computer and discovered there was no orders for dressing changes. V7 stated she spoke with V3 (ADON/wound nurse) who said dressing changes should occur daily. V7 informed V3 that the previous order had expired on [DATE], for Santyl 250 mg once daily. V7 stated V3 would renew the order. V7 stated that without a current order, the night nurse would not know to change the dressing, because it would not pop up. V7 stated on [DATE], the family and resident approached her again, and V9 was pretty upset because the same dated dressing had not been changed. V7 spoke with V3 who stated the order had not been placed and would do so immediately and change the dressing. On [DATE] at 1:50PM, V7 reviewed the electronic POS and verified orders for dressing change to R36's lateral foot was only in place for periods [DATE] to [DATE] and [DATE] to [DATE] prior to R36 being hospitalized . Policy provided by the facility titled Pressure Ulcers/Skin Breakdown - Clinical Protocol effective ,[DATE] showed: The physician will authorize pertinent orders related to wound treatments . The physician will help staff characterize the likelihood of wound healing . Policy provided by the facility titled Pressure Ulcer Treatment effective ,[DATE] showed the purpose as: .to provide guidelines for the care of existing pressure ulcers .; when eschar or slough is present, a pressure ulcer cannot be accurately staged until the eschar is removed .; Pressure ulcers require a comprehensive approach .;

Based on observation, interview, and record review the facility failed to ensure pressure ulcer treatment orders were obtained, a turning and repositioning program was initiated, and a pressure ulcer prevention device was in place for two of seven residents (R210, R22) reviewed for pressure ulcers in a sample of 16. These failure resulted in R210 developing two unstageable pressure ulcers; one on the right and left ischium (the back lower portion of the hip bone at the base of the buttocks). Findings include: A Prevention of Pressure Ulcers policy dated 10/1/2012 states, Review the resident's care plan to assess for any special needs of the resident. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition. For a person in a chair: Change position at least every hour. Use foam, gel, or air cushion as indicated to redirect pressure. Monitor nutrition and hydration status. The care process should include efforts to stabilize, reduce, or remove underlying risk factors, to monitor the impact of the interventions; and to modify the interventions as appropriate. 1. R210's admission nursing assessment dated [DATE] documents that at the time of admission to the facility R210 had a stage II pressure ulcer to the coccyx, non-pressure wounds to both feet, and required assistance of 1-2 people for transfers and activities of daily living. R210's Braden Scale Risk assessment dated [DATE] documents that R210 is at high risk for the development of pressure ulcers because R210 has very limited sensory perception, is occasionally moist requiring an extra linen change per day, is chairfast, has very limited mobility, and rarely eats a complete meal making R210 at risk for poor nutrition. R210's physician's orders [REDACTED]. two times daily and as needed. There were still no orders for R210's stage II pressure ulcer to the coccyx. R210's treatment orders on 8/17/18 also document for R210 to be turned and repositioned every two hours and to have R210 lay down after meals. R210's Medication Administration Record/ Treatment Administration Record (MAR/TAR) does not document any treatments were applied to R210's stage II coccyx pressure ulcer. R210's nurse's note dated 8/17/18 at 2:24p.m., documents, Was called by staff and observed left perineum with redness, warm to touch, hardness of skin with excoriation and small bluish discoloration on the surrounding area. The coccyx has an excoriation which is new. At 6:13p.m. R210's nurse's note entered by V3 (Assistant Director of Nurses/ Wound Nurse) states, Coccyx with maceration and excoriation, superficial maceration present measuring 1.0cm (centimeters) long x 1.0cm wide x 0.1cm deep. Resident needs help with transfers, ADL's (Activities of Daily Living) and incontinence care. Left Buttock noted with non-open skin injury measuring 2.0cm long x 2.0cm wide x 0.1cm deep with surrounding area that is red and warm. Left inner buttock noted with non-open skin injury measuring 2.0 cm long x 2.0cm wide not measureable. Persistent non-blanchable deep maroon/purple discoloration intact skin. Surrounding area of the skin is red and warm to touch and hard to touch on palpation. This note also states, Staff was aware to reposition resident side to side and limit sitting for long periods of time on her wheelchair. R210's nurse's notes dated 8/18/1/8 to 8/21/18 document that R210 continued to require the assistance of two people for ADL's and transfer. R210's nurse's notes dated 8/14/18 to 8/21/18 also document only once that R210 was, turned and repositioned routinely but not on an every one hour basis as instructed in the pressure ulcer policy or every two hours as ordered by R210's physician. R210's Certified Nurse Aide (CNA) Care Card dated 8/14/18 documents for R210 to be repositioned but does not include specific turning instructions. R210's medical record does not include documentation by CNA's that R210 was being turned every one hour or every two hours between 8/14/18 to 8/21/18. R210's Initial Wound Evaluation and Management Summary dated 8/21/18 documented by V12(Wound Physician) documents that R210 had developed a stage three pressure wound to the coccyx which measured 2.3cm long x 2.4cm wide x 0.2cm deep resulting from pressure, an unstageable (due to necrosis) wound of the left ischium measuring 2.3cm long x 2.5cm wide resulting from pressure, and an unstageable (due to necrosis) wound of the right ischium measuring 1.3cm long x 0.7cm wide. The summary further documents that R210's right and left ischiumn wounds required surgical debridement to remove devitalized tissue, slough, biofilm and necrotic, non-viable subcutaneous fat and surrounding connective tissues until healthy tissue was observed. R210's Nutritional assessment dated [DATE] documents R210 had a stage 2 pressure ulcer to the coccyx and recommended R210 be weighed weekly for four weeks then monthly. On 8/30/18 R210's Weight worksheet log documented that R210's admitted was on 8/14/18. The weight log also shows that R210 has been weighed only once on 8/14/18. On 8/30/18 at 11:21a.m. V3, V7 (Registered Nurse), and V9 (Certified Nurse Aide) were positioning R210 in bed so V3 could change R210's pressure ulcer dressings. V3 verified that R210 was admitted to the facility on [DATE] at which time R210 had only one pressure ulcer which was on R210's coccyx. V7 verified that R210 is wheelchair bound and requires assistance for turning and repositioning. V3 removed R210's soiled dressings which exposed a deeply reddened area encompassing a large round wound to the left ischium, which was approximately 3cm long x 2.5cm wide. The depth of the wound could not be visualized because of a thick white gel-like tissue protruding from the wound. V3 used a cotton swab to insert a medicated ointment into the wound, demonstrating that the wound had tunneling surrounding the wound opening. R210's right ischium wound was approximately 1.5cm long x .5cm wide with a thick whitish gel-like substance inside the wound bed and with the wound surrounded by deep red tissue. R210's coccyx wound was a round hole which was approximately the size of a pea and which was partially hidden by a flap of skin. Within the wound was a thick yellowish slough covering the wound bed. V3 stated that all three of R210's pressure ulcers had deteriorated since she last examined them on 8/24/18. Despite stating that R210's wounds deteriorating, V3 did not take measurements of R210's wounds. V3 and V7 verified that R210 is not on an hourly turning schedule but instead is supposed to be turned about every two hours. 2. R22's Braden Scale Risk assessment dated [DATE] documents that R22 is at risk for the development of pressure ulcers. R22's care plan instructs to provide appropriate pressure relieving devices. A Pressure Ulcer report dated 8/24/18 documents that R22 developed a Deep Tissue Injury (DTI)/ Unstageable pressure ulcer to the sacrum measuring 7cm (centimeters/cm) long x 6cm wide on 8/20/18. R22's nurse's note dated 8/21/18 at 5:57p.m. documents that R22, Sat in his chair most of the morning. This same note also documents that R22 began using a specialized high backed wheelchair on that date. On 8/28/18 at 8:00a.m. R22 was eating breakfast in the dining room while seated in a specialized high backed wheelchair without a pressure relieving cushion in place. On that same date at 11:30a.m. R22 was eating lunch in the dining room while seated in a specialized high backed wheelchair without a pressure relieving cushion in place. On 8/29/18 at 8:00a.m. R22 was eating breakfast in the dining room while seated in a specialized high backed wheelchair without a pressure relieving cushion in place. On 8/29/18 at 10:49a.m. V3 (Assistant Director of Nurses), V11 (hospice nurse), V7 (Registered Nurse), and V8(Certified Nurse Aide) entered R22's room in order to change R22's pressure ulcer dressings. V3 removed R22's soiled dressing covering R22's sacral wound. R22's sacral pressure ulcer was approximately 7.0cm (centimeters) long x 6.0cm wide with brown necrotic tissue partially covering the wound bed. R22's specialized high backed wheelchair was near the end of R22's bed and did not have a pressure relieving cushion in place. V7 stated that R22 had a pressure relief cushion in his old wheelchair but when it was replaced with the specialized wheelchair on 8/21/18 the cushion was not moved to the new wheelchair.