Every finding on record at Generations at Applewood

Failures at this level required more than one deficient practice statement.A. Based on interview and record review, the facility failed to assess and document resident vital signs for a resident experiencing a change in condition and failed to ensure a resident received timely emergency treatment for one resident reviewed on the sample list of 33. These failures resulted in R7's delay in transferring to a higher level of care to receive emergency care after R7's change in condition.B. Based on observation, interview and record review, the facility failed to implement skin prevention interventions and failed to identify skin integrity impairments for two residents reviewed for skin integrity. These failures affect two residents (R32, R89) reviewed for skin integrity on the sample list of 33.C. Based on observation, interview and record review, the facility failed to ensure medications administered are documented at the time of administration. The facility also failed to ensure that medications were administered timely. These failures affect R47, R69, R73, R104 on the sample list of 33.Findings include: a) R7's face sheet documents R7 admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypoxia, Unspecified Severe Protein-Calorie Malnutrition, Unspecified Asthma, Uncomplicated, Dependence on Respirator [Ventilator] Status, Pressure Ulcer of Sacral Region, Stage 4, Dysphagia, Oropharyngeal Phase, Encounter for Attention to Gastrostomy, Pressure Ulcer of Other Site, Unstageable , Encounterf for Attention to Tracheostomy, Dependence on Renal Dialysis, Hypothyroidism, Unspecified, End Stage Renal Disease, Gastro-Esophageal Reflux Disease Without Esophagitis , Hypotension, Unspecified , Other Specified Symptoms and Signs Involving The Digestive System and Abdomen (Ct Scan [DATE] Suggestive of Contained Perforation, Treated Surgically, Noninfective Gastroenteritis and Colitis, Unspecified, Perforation of Intestine (Nontraumatic) -Treated [DATE] Peritoneal Abscess - Treated with laparotomy and drainage [DATE]. R7's minimum data set ([DATE]) does not document a brief interview of mental status summary score and is marked not assessed. R7 had moderate impairment with cognition regarding decision making and had unclear speech. R7 utilized a feeding tube for nutrition and 51% or more of R7's nutrition was received through the tube feeding. R7's care plan ([DATE]) documents R7 requires tube feeding due to dysphagia, nothing by mouth (NPO) and is ventilator/trach dependent. The goal of care was R7 would be free of aspiration. Interventions to meet this goal include the head of the bed elevated to prevent aspiration, Monitor/document/report as needed any signs/symptoms of aspiration including- fever, shortness of breath, feeding tube dislodged, infection at tube site, self-extubating, feeding tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. R7's pre-admission hospital records document [DATE]: Underwent exploratory laparotomy, drainage of pelvic abscess, and resection of a portion of the uterus due to severe proctocolitis with perforation and intra-abdominal abscess. [DATE]: Extubated but reintubated due to labored breathing and hypercapnic respiratory acidosis. [DATE]: Underwent tracheostomy tube and PEG tube placements for respiratory support and nutritional needs. [DATE]: Transferred to (HOSPITAL) for continued care, including antibiotics, respiratory care, wound care, and rehabilitation. Throughout hospitalization: Treated for septic shock with antibiotics, managed acute kidney injury (which improved), and received empirical Keppra for neurological issues, with EEG showing no seizures. CT scans for CVA were negative. [DATE]: Multiple skin tears and pressure injuries noted, including a deep tissue injury on the right heel and a Stage 4 pressure injury on the sacrum with a drain. Wound care was initiated, including cleansing and application of dressings (e.g., Optifoam, Kerlix, Tegaderm). R7's progress notes document the following: On [DATE] at 12:00 AM, (R7) was observed to be vomiting through R7's trachea. V10, Nurse Practitioner was notified of abdominal distention & vomiting. New orders for one dose of Zofran, enema, check residual, & remove rectal tube. All orders carried out. Report given to incoming nurse to continue to monitor (R7). On [DATE] at 7:50 AM, in nurse-to-nurse report, writer V47, Former Registered Nurse received information regarding (R7's) feeding to be held. Writer (V47) contacted (V10) to verify. Per (V10), (R7) was vomiting and abdomen was distended, recheck residual and if its less than 60cc then restart feeding. Upon assessment, (R7's) right arm was swollen with pitting edema +2, BP 63/39 and HR 102, patient had scheduled 10mg midodrine. Writer notified (V10) and orders were given to give and extra 250cc if residual is within normal range and doppler forearm. Orders were carried out. On [DATE] at 8:20 AM, (V47) rechecked (R7's) blood pressure 76/40, rechecked residual less than 10cc. (V10) notified. Will restart feeding and give extra 250cc and continue to monitor (R7). On [DATE] at 10:30 AM, (R7's) blood pressure was 76/44 despite all interventions. (R7) was not able to go to dialysis d/t hypotension. (R7) was lethargic. Reported to V10, per V10's orders R7 will be sent to (HOSPITAL) via (PRIVATE AMBULANCE COMPANY) for blood pressure and dialysis. ETA of ambulance is 30 mins. Writer notified (FAMILY MEMBER). On [DATE] at 11:40 AM, (R7) left the facility via (PRIVATE AMBULANCE COMPANY) to (HOSPITAL). Review of the ambulance run report ([DATE]) documents the private ambulance company was notified at 11:00 AM and assumed care at the facility on 11:23 AM. The EMS crew arrived and found R7 to be alert and oriented x 1-2 (Person, Time) and lethargic in bed. R7 was laying supine in bed. The EMS crew was informed R7 was hypotensive since approximately 8 AM in the morning. EMS assessed R7's vitals and obtained the following: Blood Pressure: 74/46, Heart Rate 97, Respiratory Rate 12, Blood Glucose 121. R7 was receiving ventilation via a ventilator. EMS started a 20 Gage IV in the upper arm, started IV fluids, and placed the resident in the Trendelenburg position. EMS assessed Revised Trauma Score on arrival and during transport to be between 8 and 10, indicating R7's health status is compromised and requires rapid transport for evaluation. EMS assessed R7's Shock Index (SI) on arrival and throughout transport to be between 1.0 to 1.3, indicating worsening hemodynamic instability and correlates with increased mortality and morbidity. The EMS crew documented R7's primary symptom was severe sepsis with septic shock, and the provider's primary impression of sepsis. R7's acuity was labeled Critical (Red) and R7 was emergently transported to the nearest emergency room with lights and sirens. R7 arrived at the hospital at 11:48 AM and hospital staff assumed care at 11:52 AM. R7's progress notes document: On [DATE] at 8:17 PM, V10 documented: R7 was admitted to ICU at (HOSPITAL). reviewed notes admitted for septic shock, source including intra-abdominal versus urinary versus CLABSI with PermCath versus pneumonia, Chronic respiratory failure requiring mechanical ventilation via tracheostomy, Recent initiation of dialysis with PermCath in place, Chronic Foley for reported urinary retention, Severe protein calorie malnutrition, Diffuse anasarca secondary to poor nutrition. (R7) required Levophed support for septic shock with potential source of infection including intra-abdominal versus urinary. CLABSI given the presence of PermCath and pneumonia are also on the differential. Will cover with antibiotics of Zosyn and vancomycin. Case discussed with general surgery and interventional radiology. Per interventional radiology, there is no safe window and the pocket of fluid collection on the CT appears to be too small to leave a drain. May be able to attempt aspiration for culture and drainage in the morning. General surgery evaluated (R7) given the up trending of pressor requirements organ to discuss possibility of surgical reevaluation. Nephrology has been consulted given hemodialysis history with PermCath in place and at this time do not feel that (R7) requires dialysis. History was obtained from (FAMILY MEMBER) over the phone and confirmed CODE STATUS of DNR/full treatment. Will continue to monitor progress during hospital stay. On [DATE] at 6:47 PM, V10 documented, (R7) passed away at 2:30 PM today ([DATE]) at (HOSPITAL). A review of hospital stay showed she had a CT abdomen with concern for developing abscess in the left lower quadrant. ED noted concern for urosepsis leading to a Foley change which was noted to have a large quantity of purulent drainage followed by 1500 cc of urine output. Patient was given Zosyn, vancomycin, Levophed, 30cc/kg IV fluid bolus. Consulted nephrology, general surgery She was admitted to ICU for further evaluation and management of septic shock. Management included Levophed as needed for pressor support along with Zosyn and vancomycin, later switched to Merrem due to broad possibility of sources, including HD line, urine, ventilator pneumonia. General surgery was consulted as well. They determined that the patient had acute surgical abdomen, but after extensive goals of care discussion with the family, they opted for not undergoing surgery. Overnight 3/2-3, patient's pressor requirements continued to increase and patient continued to be unarousable. It was ultimately determined that the patient will be transitioned to comfort measures at the wishes of her family. At 2:30 PM the RN stated (R7) had passed. Attending (physician) went in room with (R7's) mourning family members, pronouncing (R7's) death at 2:30 PM on [DATE]. R7's death certificate ([DATE]) documents R7 died on [DATE] at 2:30 PM at the hospital. R7's cause of death was septic shock due to an intra-abdominal abscess due to an underlying small bowel obstruction with perforation and severe protein calorie malnutrition. On [DATE] at 1:43 PM, V2 (Director of Nursing) did not recall the events that led to R7's hospitalization and death. R7's electronic health record was reviewed with V2. V2 explained abdominal distention can be signs of constipation, gas, or other dysfunction of the gastrointestinal tract, such as g-tube displacement or infection. When residents vomit through their tracheostomy, they are at increased risk of complications including aspiration. V2 reviewed the electronic health record and confirmed no vital signs were documented on [DATE] at 12:00 AM when R7 experienced a change in condition. V2 affirmed nursing standards of care include taking a full set of vital signs when a resident experiences a change in condition. V2 did not recall R7's blood pressure being 63/39. V2 denied R7's blood pressure being 63/39 or 76/40 was critically low or potentially life threatening and described these values as urgent that require intervention. V2 affirmed R7 received a dose of midodrine, and the blood pressure did not return to normal limits. V2 reviewed the electronic health record and affirmed there was no further documentation of R7's temperature or respirations after 2:51 AM or heart rate (pulse) after 7:50 AM. V2 affirmed it is the expectation that the nurse assesses all vital signs when there is a change in condition. V2 explained sepsis is caused by an infection and can affect multiple body systems to fail. Signs and symptoms of sepsis include mental status changes, lethargy, hyperthermia/hypothermia (fever/low temperature), tachycardia (increased heart rate), tachypnea (increased respirations). V2 affirmed in most cases, sepsis is treatable. When sepsis is not identified or treated residents can develop life-threatening complications. V2 explained untreated sepsis can lead to septic shock which is caused by organ dysfunction/failure as blood volume is shunted to other parts of the body focused on life-saving measures. V2 affirmed V2 would have expected the staff to take all vital signs when R7 developed a change in condition, and affirmed without assessing vital signs, it is difficult to assess for sepsis. V2 denied there was a sepsis protocol for the facility but was working on developing a protocol with V4 (Medical Director). No sepsis protocol or policy was provided to the survey team prior to the exit of the survey. V2 denied the facility tracks sepsis sentinel events as part of a quality assurance process or infection control surveillance monitoring. On [DATE] at 1:18 PM, V48, Former Registered Nurse affirmed V48 no longer works for the facility. V48 explained V48 resigned from working at the facility because there was too much bad s**** going on there, including chronic understaffing and patients not getting care they deserve. V48 affirmed V48 brought these concerns to the management staff multiple times but management wouldn't help and would just sit in their offices. V48 recalled R7's change in condition on [DATE]. V48 explained V48 had worked the 3PM to 11PM shift that night and observed R7 vomiting from R7's tracheostomy site prior to shift change. V48 completed an assessment of R7 and noted R7's abdomen to be distended and hard on palpation, as well as vomiting. V48 stayed over to notify V10 and carry out the orders. V48 recalled taking the vital signs on the vitals machine and was unaware they were not documented in R7's record. V48 could not recall what the vitals were but affirmed if they were abnormal, V48 would have notified V10 and sent R7 to the emergency room. V48 affirmed the vital signs should have been documented in R7's health record and thought vitals automatically transmitted to the chart from the vitals machine. V48 affirmed nurses can send residents out if they are experiencing an emergent change in condition. V48 explained V48 did not send out R7 to the hospital because V10 gave orders to address the change in condition, R7's vitals didn't seem abnormal, and it was the end of V48's shift so V48 endorsed care to V46, Registered Nurse. V48 recalled R7 was sent to the hospital on the following day shift and subsequently died in the hospital. R7's vital signs were reviewed with V48. V48 affirmed 63/39, 76/40, were critically low vital signs and asserted, H*** yeah, with those blood pressures, (R7) should have been sent to the hospital right away. If I would have gotten those vitals, I would have called immediately called 911 and started an IV line right away, that is an emergency. On [DATE] at 1:31 PM, V47, Former Registered Nurse affirmed V47 no longer works for the facility but vaguely recalled the events with R7 on [DATE]. V47 recalled V47 received shift-to-shift report from V46, Registered Nurse but it wasn't very detailed. V46 told V47 that R7 had been vomiting so the tube feeding had been stopped and there were no parameters to restart the tube feeding. V47 denied V46 knew too much about R7's change in condition so V47 assessed R7 herself. R7's abdomen was very distended and R7 was very lethargic. V47 denied palpating R7's abdomen because V47 did not think we (nurses) were supposed to do that if there is a concern with their abdomen. V47 affirmed based on how distended R7's abdomen was it had to have been hard. V47 observed R7's extremities had significant pitting edema, which wasn't R7's baseline. When V47 assessed R7's blood pressure, it was really low like in the 60's (systolic) which was very concerning to V47. V47 noted R7 was due for midodrine, which raises blood pressure. V47 called V10 and reported the low blood pressure to V10 who gave orders, including administering the midodrine and rechecking the vital signs. V47 could not remember the other vital signs on assessment and affirmed she took them using the vitals machine. V47 stated, the vitals should be in the system. V47 affirmed V47 should have documented the vital signs within the progress notes. V47 recalled having to keep calling (V10) over and over about the blood pressure and interventions weren't working. Eventually, (V10) ordered (R7) to be sent out by (PRIVATE AMBULANCE). V47 affirmed V10's order was explicitly to use (PRIVATE AMBULANCE COMPANY), so V47 did not call 911. V47 believed R7 should have been sent out on night shift when R7 began to vomit from the trach and abdomen was distended, as both can be serious changes in condition. Surveyor inquired why V47 did not send R7 out 911 if V47 believed the prior shifts should have sent out 911. V47 explained that V10 tries to do everything V10 can prior to sending out residents. It is the facility's expectation that staff and V10 try interventions prior to sending out residents, and nurses will be reprimanded if they send residents out without a provider's approval. V47 recalled the prior management/ownership of the facility would allow nurses to utilize their clinical judgement, but that isn't allowed unless the providers make their assessment. V47 affirmed nurses would be reprimanded or receive push back if they sent out a resident when a provider did not give them an order. V47 did not think R7 was appropriate for admission to the facility and R7's needs with oxygenation/ventilation exceeded what the facility was equipped to care for. V47 believed many residents that arrive to the facility exceeded the level of care the facility could provide, which is why the facility's residents, especially the tracheostomy patients, have negative outcomes. On [DATE] at 2:31 PM, V10 affirmed V10 is a nurse practitioner and V4 (Medical Director) is V10's supervising physician. V10 explained sepsis is a response to an infectious process in the body. To diagnose sepsis, the patient needs to meet certain criteria such as elevated temperatures, elevated white blood cell counts, elevated heart rate, blood pressure higher or lower, and positive lactic laboratory values. V10 explained if sepsis is not treated promptly, it can be disastrous, it's like an extreme reaction from an infection. It (sepsis) can damage organs, cause tissue death, and can cause death in extreme situations. V10 explained septic shock is a critical stage of sepsis and is a life-threatening emergency. Septic shock causes blood vessels to dilatate (enlarge) which causes blood pressure to drop and fluids to leak from the blood vessels. V10 affirmed septic shock often does not respond to fluid resuscitation, which causes the patient's condition to be more difficult to treat. V10 recalled R7 being admitted to the facility and notified about R7's change in condition. V10 explained R7 was from a rehabilitation hospital and only was at the facility for a few days. V10 recalled R7 admitted towards the end of the week and the facility alerted V10 of R7 vomiting from the trach. V10 was unsure if the secretions were from the ventilator as natural secretions or the secretions were actually tube feeding coming from the trach. V10 affirmed laboratory work was not available for review to see if there were signs of an infection because the facility only has availability for stat labs on the weekends, routine labs wait until Mondays. V10 explained that the hospital providers have asked the facility providers to try 1-2 interventions prior to sending residents to the hospital. When V10 was originally told about the abdominal distention, V10 thought the cause was from constipation which is why V10 ordered to discontinue the rectal tube and give an enema. When V10 was told the resident blood pressure was 63/39, V10 attributed the blood pressure drop to fluid volume depletion, and the pulse elevation was from the abdominal distention/constipation. V10 recalled the resident having blood pressure with systolic in the 90's, which would make the 63/39 less abnormal. V10 could not recall if any other vital signs besides the blood pressures were communicated during follow up phone calls. V10 affirmed the expectation when residents have changes in condition is to assess and report all vital signs and document in the record. V10 recalled having exhausted all interventions and R7's blood pressure was still low, so V10 ordered R7 to be sent out via ambulance. V10 denied V10 stated to use (PRIVATE AMBULANCE COMPANY) when giving the order. V10 stated staff probably should have sent (R7) out via 911. V10 explained V10 called report into the ER and monitored the hospital records while R7 was admitted . While in the hospital, R7 had labs which showed a lactic of 7.1, which affirmed R7 had severe sepsis. V10 recalled R7 was diagnosed with septic shock and there was uncertainty if the infection was from the foley catheter, the permcath, pneumonia. Eventually, they were going to do surgery because R7 was diagnosed with acute surgical abdomen with an abdominal abscess, but there was a goal of care conversation and R7's family opted to choose comfort vs. treatment. V10 confirmed R7 died the following day shortly after comfort care was elected. V10 believed the course of treatment was appropriate for R7, but it was difficult to make good diagnoses about R7's health status because V10 hadn't ever examined R7 and was reliant on what the staff were communicating to V10. V10 denied that the facility gives push back to V10 with sending residents to the hospital but tries to exhaust all interventions prior to sending a resident out. On [DATE] at 10:29 AM, V1 (Administrator) affirmed V1 is the administrator of the facility, is a licensed nursing home administrator but is not clinically licensed. V1 explained sepsis is caused by an infection and causes the body to rapidly decline. V1 denied nurses or V10 get pushback or disciplined if they send residents to the hospital. V1 affirmed nurses have the ability to send any resident to the hospital if they are concerned with their health status. V1 explained the facility tracks their return to hospitalization rate and will debrief with a nurse if they send out and discuss if the hospitalization could have been prevented but denied that a nurse ever gets disciplined. V1 did not recall R7's hospitalization. V1 affirmed V4's role as the medical director is to provide guidance any time there is a physician or practitioner concern and to oversee the medical care provided in the facility. V4 will provide education to providers and other staff as needed. On [DATE] at 2:59 PM, V4 (Medical Director) affirmed V4 is the medical director for the facility and is the supervisory physician for V10. V4 recalled R7's admission to the facility and denied V4 had completed an examination prior to R7's discharge from the facility. V4 explained it is hard for V4 or V10 to treat patients when they haven't examined the patient in person and R7 was not due for a physician visit yet as R7 was recently admitted . V4 affirmed V10 attempted to stabilize R7 at the facility and send out after but would be dependent on what staff told V10 to determine when to send R7 out. V4 could understand why V10 ordered to give the midodrine when R7 was hypotensive, but the midodrine should have increased the blood pressure after administration. V4 explained abdominal distention is signs of changes in condition such as constipation or a bowel obstruction. V4 stated staff should have sent out R7 sooner to the hospital, ideally right when R7 was vomiting from the trach and had abdominal distention at 12:00 AM. Facility policy titled, Making a Transfer or Discharge (3/2016) documents the facility shall make an emergency transfer or discharge when it is in the best interest of the resident. b) R32 re-admitted to the facility on [DATE]. R32's medical diagnoses include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, type two diabetes mellitus, anemia, hypertension, Ogilvie syndrome, benign prostatic hyperplasia without lower urinary tract symptoms, unilateral primary osteoarthritis right hip and hypokalemia. R32's Brief Interview of Mental Status (BIMS) dated [DATE] was 15 indicating R32 is cognitively intact. R32's functional ability document in the Minimum Data Set (MDS) dated [DATE] has upper extremity as no impairment and lower extremity and impairment on both sides. Chair to bed transfer was documented as not applicable. On [DATE] at 10:39 AM R32 was observed with bilateral heel boots in place. R32's skin was observed to be drying and scaling around the toes. Amputation of the left toes with healed scar. R89 is admitted to the facility on [DATE]. R89's medical diagnoses include type two diabetes without complications, muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, anemia, essential hypertension, pain in both knees, hyperlipidemia. R89's Brief Interview of Mental Status (BIMS) dated [DATE] is 12 indicating moderate cognitive impairment. R89's care plan dated [DATE] had a focus area of R89 has the potential for pressure ulcer development related to disease process history of ulcers, Immobility and fecal incontinence. The goal is that R89 will be free from new areas of skin breakdown and have intact skin, free of redness, blisters or discoloration by/through review date. Interventions include following facility policies/protocols for the prevention/treatment of skin breakdown. Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection and wound size. On [DATE] at 9:38 AM R89 described a scratch on the left lower back/upper buttock area Because the CNAs snatch and pull my clothes and the [mechanical] lift sheet out from underneath me. V33 (Certified Nursing Assistant) and surveyor observed R89's backside. A linear scabbed lesion was observed to left lateral hip/low back area. R89 stated It hurts and they pull that sheet out from underneath me which makes it worse. On [DATE] at 9:58 AM V37 (Licensed Practical Nurse) stated V37 was not aware of any alterations in skin integrity with R89. V37 observed R89's wound and described it as a healing stage two pressure ulcer. V37 then stated, It is more of a scratch that is healing. It is scabbed over, so it has been there for a while. V37 stated V37 would ask the wound nurse to see R89. R89's medical record had no documentation of skin/wound issues past or present for R89. On [DATE] at 4 PM V2 (Director of Nursing) stated that R89 and R32's wounds would be assessed and treated by V7 with surveyor present on the morning of [DATE]. On [DATE] at 8:30 AM V7 (Wound Nurse) stated V7 was in the middle of a dressing change and would let surveyor know when R89 and R32's wounds were going to be assessed and treated. On [DATE] at 11:22 AM V7 (Wound Nurse) stated V7 already assessed and treated R89 and R32's wounds. R89 was observed to be sitting up in the wheelchair. V7 stated R89's wound was an abrasion and treated with betadine and a foam dressing three times a week. V7 stated R89's wound was preventable because it may be related to the mechanical lift sheet being pulled out from under R89. To prevent the wound, staff must be more mindful to turn R89 to remove clothing or lift device instead of pulling the clothing or lift device across R89's skin. The staff should not be pulling it out from underneath R89 creating shear to the skin. V7 stated V7 spoke to V3 (Assistant Director of Nursing) and V3 is planning an in-service with the Certified Nursing Assistants to prevent recurrence of this type of skin injury for residents. On [DATE] at 11:45 AM V7 (Wound Nurse) stated she had already assessed R32 earlier this morning and identified a wound to the right foot. V7 described it as a diabetic foot ulcer to the right plantar lateral foot. There was a dressing on the right foot dated [DATE]. The dressing was removed, and a pink open area was observed on the plantar aspect of the right lateral foot. Surveyor asked V7 about the ulceration on the left heel. V7 stated she was unaware of any skin problem with the left heel. I looked at R32 earlier this morning and didn't see anything. Surveyor pointed to R32's left heel where an alteration in skin integrity was observed. R32 stated, That thing on my left heel has been there for a while. A sock on my foot makes it hurt. V7 described the left heel as a one centimeter (1 cm) by one point two centimeter (1.2 cm) pressure point diabetic ulcer. R32 stated, I had complained of the left heel bothering him, but no one has looked at my left or right foot before today. V39 (Wound Certified Nursing Assistant/CNA) stated V39 works on the floor as a CNA and works with wounds. V39 was familiar with R32. V39 stated neither as a CNA working on the floor, or a wound CNA, had V39 previously identified any issue with R32's feet. V39 stated staff are supposed to be looking at residents' skin. If there is a change or concern, it is reported to the nurse who then enters a report in the electronic health record (EHR). The EHR entry becomes the trigger for wound nursing to see the resident. V6 (Wound Nurse Coordinator) stated R32's left heel could be a pressure injury. V6 stated last week, R32 had no skin changes. V6 stated R32's right foot appears to be arterial; the left foot appears to be pressure related. V40 (Wound Nurse Practitioner) stated that R32 had a previous wound to the left foot which resolved on [DATE]. V40 stated R32's left heel is a diabetic foot wound. When surveyor asked how V40 differentiates diabetic foot ulcer from pressure injury, V40 stated because he has diabetes. If he has diabetes, it is a diabetic ulcer. V40 went on to state that R32's left foot could be multifactorial. V40 stated the left foot would not look any different if it was a pressure ulcer, rather than a diabetic ulcer. V40 stated I don't know what R32 looked like before. V40 stated that the risk to R32 is infection and R32 may need a debridement. V40 stated the expectation is that the CNAs are identifying skin and wound concerns and escalating those concerns to the nurse. On [DATE] at 2:04 PM V3 (Assistant Director of Nursing/DON) stated the wound nurse did not discuss R89's alteration in skin integrity with V3. V3 stated no staff in-service is planned regarding R89's alteration in skin integrity and preventing recurrence with R89 or another resident. On [DATE] at 9:15 AM V2 (Director of Nursing) stated V2 was aware of wound on R89's back. V2 stated R89's wound was related to sheer forces of staff pulling the mechanical lift sheet and R89's clothes out from under R89. V2 is developing staff education to prevent additional alterations in skin integrity for R89 or any other resident in the facility. Facility policy titled Wound Assessment with no date stated in part the facility will ensure that all residents with actual or potential skin integrity issues receive a timely, comprehensive, and ongoing wound assessment performed by licensing nursing staff. A full assessment will be completed with any new wound or any significant change in condition of the wound. c) On [DATE] at 11:48am, V14 (Licensed Practical Nurse) was observed administering 9:00am medications. Surveyor also noted that multiple residents were highlighted red (indicating late administration) on the screen displaying the EMAR (Electronic Medication Administration Records). Surveyor inquired why 16 residents were highlighted red on the EMAR V14 stated I (V14) got at least a couple more people to do from this morning, I'm (V4) passing 9:00am medication. Surveyor inquired why R73 was highlighted red on the EMAR. V14 responded, She's (R73) done already and proceeded to document R73's 9:00am medications at this time. Surveyor inquired who else (assigned to V14) had not received prescribed (9:00am) medications today V14 a[

Based upon observations, interviews, and record review the facility failed to implement preventive interventions to maintain skin integrity, failed to ensure that the LALM (Low Air Loss Mattress) as on the correct settings while in use, failed to ensure that multiple linen layers were not beneath the resident while on a LALM, failed to timely identify skin integrity impairments, failed to follow physician orders, and/or failed to document/administer prescribed treatments for 10 of 33 residents (R8, R11, R12, R47, R52, R55, R90, R100, R118, R121, R123) in the sample reviewed for pressure ulcers. These failures resulted in R118 developing a (facility acquired) infected (stage 4) sacral wound on or about 5/5/26 which required hospitalization, antibiotic medication, and surgical debridement. Findings include: R118 was admitted to the facility on [DATE]. R118's diagnoses include type II diabetes mellitus, generalized weakness, and (4/14/26) sacral pressure ulcer - stage 4. R118's (4/10/26) functional assessment affirms the resident is dependent on staff for rolling left and right. R118's (4/14/26) initial sacrum wound assessment states (in-house acquired) stage 3 pressure ulcer injury: Full-thickness skin loss therefore the wound was not identified timely as MASD (Moisture Associated Skin Damage) or stage 1 - as warranted. 3.27cm (centimeters) x 3.91cm x 0cm. Wound bed: 90% granulation. Exudate: serosanguinous: odor after cleaning. R118's (4/14/26) physician wound assessment states per patient, he spends most of the day in his (wheelchair) and when not in the chair is lying on his back in bed. Patient states that he is not able to reposition himself. R118's Physician Order Sheets include (6/16/26) Sacrum: cleanse with wound cleanser, pat dry, skin prep, apply Vaseline gauze and cover with dry dressing PRN (as needed). Apply PRN dressing – if wound vac fails to maintain suction. (6/26/26) Sacrum: cleanse with wound cleanser, pat, apply skin prep to peri wound then adaptic to bone, black foam, and apply wound vac as directed at 125mmhg 3x/week Tuesday, Thursday, Saturday and PRN x 30 days. R118's care plan states (4/14/26) Resident has a stage 4 sacrum pressure ulcer related to immobility and incontinence, interventions: follow facility policies/protocols for the prevention/treatment of skin breakdown. Pressure reducing mattress on bed. Reposition resident every 2 hours. (5/13/26) Resident is on intravenous antibiotic medication related to sacral wound infection. (6/16/26) The resident has a sacral wound requiring wound vac therapy related to impaired skin integrity, interventions: Reposition resident at least every 2 hours and as tolerated to reduce pressure on sacral area. Maintain wound vac at prescribed settings and ensure continuous therapy as ordered by physician. Verify wound vac seal is intact and functioning properly each shift and as needed. R118's (5/5/26) physician wound assessment states (stage 4) sacrum pressure ulcer 8.0 x 5.7 x not measurable cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Peri wound radius: odor. Exudate: heavy purulent. Thick adherent devitalized necrotic tissue: 100%. One or more signs of clinical infection. Surgical excisional debridement procedure: Devitalized tissue and necrotic muscle level tissue were removed at a depth of 2.7cm and healthy tissue was observed. Patient requiring an increase in the level of care. Given decline in wound over 1 week with foul odor, and abscess extending almost to bone under necrosis, recommend patient go to emergency department for workup and treatment above scope of skilled nursing facility. The facility census affirms R118 was transferred to the hospital on 5/5/26 and returned to the facility on 5/11/26 (6 days later). R118's history and physical includes (5/26/26) Assessment/Plan: infected sacral wound systemic inflammatory response syndrome due to infected sacral ulcer. General surgery has been consulted. Will hold anticoagulation in anticipation of surgical debridement of the sacral wound. (5/10/26) The site is bleeding and has a lot of dark red tissue inside, it goes to the bone. The patient has a PICC (Peripherally Inserted Central Catheter) line and will receive antibiotics for six weeks. R118's (4/10/26) BIMS (Brief Interview Mental Status) determined a score of 10 (moderate impairment). On 6/29/26 at 9:56am, R118 was lying atop of a LALM (Low Air Loss Mattress) on his back at this time - the sacrum wound was not offloaded. Surveyor inquired how frequent R118's sacrum dressing is changed. R118 responded, I (R118) don't have no dressings however a wound vac canister (full of blood) was observed next his bed. On 6/29/26 at 10:03am, surveyor inquired about R118's sacrum wound treatment. V14 (LPN/Licensed Practical Nurse) stated, He (R118) has a wound vac. Surveyor inquired who administers facility wound care. V14 responded, It might be wound care, or wound management. V20 (Certified Nursing Assistant) affirmed that she (V20) was assigned to R118 and stated his (R118) incontinence brief was changed before breakfast however it contained a moderate amount of urine and diarrhea at this time. In addition, a dried brown ring was noted on the pad - beneath R118's buttocks. V20 turned R118 to inspect the brief and the wound vac continuously alarmed due to wound vac dressing not adhered to the skin (near the anus). Surveyor inquired about the brown substance covering R118's entire sacral dressing. V14 responded, BM (Bowel Movement) on his (R118) butt and it's here on the tape, it's a dressing. Surveyor inquired about the dried brown ring observed on R118's pad V20 replied, His (R118) wound leaks, it's his drainage from his wound. V14 advised that the wound care nurse would be contacted to change R118's dressing, proceeded to cover resident with the sheet and then left the room. On 6/29/26 at 10:27am, (24 minutes later) surveyor inquired why V14 (LPN) didn't change R118's sacrum dressing - which remained covered with BM. V14 stated, Because when they (facility) have a treatment nurse the treatment nurse does it, not me. On 6/20/26 at 10:33am, V15 (RN/Registered Nurse) approached surveyor and stated, I'm (V15) a floor Nurse, I'm not the wound Nurse. I (V15) was pulled to the floor to do the wounds around 9am. I don't usually do the wound care and affirmed that she (V15) was going to administer R118's sacrum treatment. Surveyor inquired about R118's treatment V15 responded His (R118) wound vac is Tuesday, Thursday, and Saturday. He (R118) gets PRN (as needed) wound cleanser, Vaseline gauze and cover with dry dressing. Surveyor requested that V15 review R118's treatment orders - prior to administration V15 subsequently reviewed the orders (with surveyor) and replied that the wound vac orders are also PRN and affirmed that she (V15) would not be administering R118's wound vac treatment at this time. Surveyor inquired why R118's wound vac would not be administered (as prescribed) V15 stated We (facility) have the wound nurse do the wound vac cause we (facility) have the wound Nurse coming tomorrow with the Doctor as well. I'm going to have um gauze, Vaseline gauze and a dry dressing with wound cleanser. Surveyor inquired about the appearance of R118's sacrum dressing V15 affirmed I (V15) see a wound vac that's attached and some poo that went inside, it looks like its inside the wound. V15 removed R118's transparent film dressing, sprayed the wound dressing (which appeared to be dry) with wound cleanser multiple times, removed the dressing, cleansed the (stage 4) sacrum wound – which was bleeding (after dressing removal), applied Vaseline gauze, dry gauze and bordered dressing at this time (not the wound vac – as ordered). R118's sacrum was not offloaded after treatment administration. R118 was lying on a LALM (Low Air Loss Mattress) covered with a fitted sheet and thick pad, resident was also wearing a disposable brief (3 layers were between the resident and the mattress - impeding air flow). R118's (June 2026) TAR (Treatment Administration Record) affirms sacrum wound vac treatments were not documented (blank entries were noted) on Saturday (6/6/26) and Saturday (6/27/26). On 6/30/26 at 9:42am, surveyor inquired what blank spaces indicate on the TAR. V3 (ADON/Assistant Director of Nursing) replied, It would be like the missing EMR (Electronic Medical Record) documentation for those days. Surveyor inquired how many blank spaces were on R118's (June 2026) TAR. V3 stated, It looks like 2 days that there's missed entries, the wound vac is 3 times a week. Surveyor inquired why blank spaces were on R118's (June 2026) TAR. V3 responded, I'm (V3) not entirely sure. On 7/2/26 at 9:39am, surveyor inquired about R118's sacrum wound V6 (Wound Care Coordinator) stated, I (V6) know it's a sacrum facility acquired pressure stage 3, identified April 14th, 2026. Surveyor inquired when skin integrity impairments should be reported. V6 responded, They should be reported as soon as they're found. The stages are redness, non-blanchable, many stages before it gets to this. Surveyor inquired why R118's (4/14/26) initial sacrum wound assessment was identified as a (stage 3) wound. V6 replied, Really, not reporting that the wound was there. Normally when a wound is found they (staff) have to put it in risk management and there's a weekly assessment that pops up on their MAR (Medication Administration Record) so I'm (V6) not sure why it wasn't reported before it got this bad. If there's a risk management, we (wound care staff) see them (residents) within 24 hours. Surveyor inquired what exudate odor is indicative of. V6 stated, Infection, if there's an odor it normally means that there is some type of infection. Surveyor inquired how R118's sacrum wound could have been prevented. V6 responded, Turning and repositioning, I don't know if he was on an air mattress at that time but that would have helped. Surveyor inquired if R118's sacrum should be offloaded. V6 replied, Yes, maybe he could lie on his side for a little bit. Surveyor inquired if R118's sacrum wound was debrided V6 reviewed the 5/5/26 physician wound assessment and stated, Yeah, it says it was necrosis caused by pressure on the sacrum. It says one or more signs of infection. Surveyor inquired about R118's current sacrum wound treatment. V6 responded, He (R118) gets a wound vac changed 3 times a week. If it comes off, we have orders for the floor nurses to apply Vaseline gauze and cover with a dry dressing, pat it cleanse it dry. Surveyor inquired if R118's wound vac is ordered PRN is it appropriate to place Vaseline gauze, dry dressing? V7 responded Yeah because the floor nurse is unable to place the wound vac. I see the wound vac order does say 3 times a week and PRN. The other order says clean with normal saline/wound cleanser, pat dry, skin prep, apply Vaseline gauze and cover with dry dressing x 30 days - if wound vac fails to maintain suction and affirmed that R118's wound vac is functioning properly and maintains suction. Surveyor inquired what static mode indicates on the LALM V6 replied Basically, its hard. It's not supposed to stay on the static setting; it defeats the purpose of relieving pressure from the wound. Surveyor inquired what's allowed on the LALM while in use. V23 stated, It's supposed to be 2 layers; either a flat sheet and diaper or a flat sheet and pad. On 7/2/26 at 11:44am, surveyor inquired about staff requirements for identified skin integrity impairments V4 (Medical Director) stated They (staff) need to notify the nursing staff and then the nursing staff will reach out to the providers and the wound care. The provider will then integrate care. Surveyor inquired if a resident has a sacrum skin integrity impairment what should be implemented to prevent further breakdown. V4 responded, We (facility) have a set of protocol that we follow, we need to address the nutritional aspect, change the position of the patient, notify the family, involve the wound care services, and see what they (wound care) are recommending. Surveyor inquired if a sacrum wound is not offloaded what's the potential outcome. V4 replied, Its gonna break down. Surveyor inquired what exudate odor is indicative of. V4 stated, It probably means that there is secondary infection of the wound. Surveyor inquired when staff should identify skin integrity impairments. V4 replied, As soon as possible, first of all they (residents) should not have any breakdown, as soon as staff identifies breakdown, they need to notify staff. Surveyor inquired about potential harm to residents if skin integrity impairments are not identified/reported. V4 stated, If we don't take care of it right away, is gonna escalate, turn into stage 4, get worse and can involve the muscles and the bone. R8's diagnoses include anoxic brain damage. R8's (6/10/26) functional assessment affirms the resident is dependent on staff for rolling left and right. R8's (6/4/26) care plan states the resident has impaired skin integrity related to pressure, decreased mobility, and cognitive impairment as evidenced by stage 3 pressure injury to right heel. R8's (6/10/26) BIMS determined that the resident is rarely/never understood. On 6/29/26 at 11:09am, R8 was lying in bed atop of a LALM set on 165 pounds (R8's 6/9/26 weight was 109 pounds – therefore incorrect setting) and static mode (static mode provides a firm surface). On 6/29/26 at 11:21am, V17 (Registered Nurse) affirmed that she's (V17) assigned to R8. Surveyor inquired about R8's LALM settings V17 stated She's (R8) at like 165. Surveyor inquired if 165 is the weight setting V17 responded No, that's just the setting it's on. I (V17) think she weighs a little less than that. Surveyor inquired what mode R8's LALM is on V17 replied It says that the static is on. Surveyor inquired what static mode indicates V17 stated I'm (V17) not really sure what that refers to and failed to adjust the LALM settings at this time. On 6/30/26 at 9:50am, surveyor inquired what static mode indicates on the LALM V3 (ADON) stated It's just static, its continuous - it doesn't alternate. Surveyor inquired what mode the LALM should be on when a resident is lying in bed asleep V3 responded We (staff) would want to have it on alternate, cause it can alternate the pressure for them (residents). Surveyor inquired what the numbers indicate on the LALM settings V3 replied It would be representative to the patients' weight. R90's Face sheet documents in part that R90 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part chronic respiratory failure, dependence on respirator (ventilator), type 2 diabetes, chronic pulmonary embolism, conversion disorder with seizures or convulsions, resistance to multiple antibiotics, and osteomyelitis. R90's Minimum Data Set (MDS) on 4/6/2026 documents in part that Staff Assessment for Mental Status is a 3 indicating that resident is severely cognitively impaired, and that R90 is dependent for all Activities of Daily Living (ADLs). On 6/30/2026 at 10:25AM, R90's low air loss mattress was set on Static Mode. V14 (Licensed Practical Nurse/LPN) states that I (V14) think we use the static button when residents have trach/ventilators so they are not moved too much. On 6/30/2026 at 11:23AM, V7 (Wound Licensed Practical Nurse) stated there is no reason to be on static mode due to having a trach/vent. The only time the static button should be on is if we are performing personal care or turning a resident so that they do not roll off the bed, and then the button should be turned off once the care is complete. R121's Face sheet documents in part that R121 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part Cerebral Infarction, dysphagia, hypertension, tracheostomy, epilepsy, and nontraumatic intracerebral hemorrhage. R121's Minimum Data Set (MDS) on 6/4/2026 documents in part that Staff Assessment for Mental Status is a 3 indicating that resident is severely cognitively impaired, and that R121 is dependent for all Activities of Daily Living (ADLs). On 6/29/2026 at 10:04AM, Surveyor noted that R121's left heel was offloaded from the mattress on pillows, while the right heel was laying directly on the mattress. V52 (Restorative Certified Nursing Assistant/CNA) confirmed this observation and noted that only one heel protector boot is here, I (V52) will look for the other one because he (R121) should have two. On 7/2/2026 at 12:49PM, R121's low air loss mattress was set to static mode. V3 (Assistant Director of Nursing) confirmed the setting and stated it should not be on static mode so that resident gets the benefit of the pressure relief mattress. R11's Face sheet documents in part that R11 is an [AGE] year-old male, admitted to the facility on [DATE]. Diagnoses include in part acute and chronic respiratory failure with hypoxia, dependence on respirator (ventilator), atherosclerotic heart disease, severe sepsis with septic shock, and benign prostatic hyperplasia. R11's Minimum Data Set (MDS) on 6/5/2026 documents in part that Staff Assessment for Mental Status is a 3 indicating that resident is severely cognitively impaired, and that R11 is dependent for all Activities of Daily Living (ADLs). On 6/29/2026 at 09:41AM, Surveyor observed R11 in bed. Adhesive foam dressings were noted on right forearm and left hand, both undated. Heel protector boots were on a table in the corner of the room; R11's heels were resting directly on the mattress. On 6/29/2026 at 01:25PM, V15 (Registered Nurse/RN) stated that she (V15) had changed the dressing on R11's left hand a little while ago but was unaware and did not assess the right arm for a wound. V15 (RN) states she (V15) will call wound doctor for orders after assessing what is under the dressing. R52's Face sheet documents in part that R52 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part acute respiratory failure with hypercapnia, dysphagia, dependence on respirator (ventilator), pulmonary embolism, cardiac arrest, tracheostomy, hypertension, anxiety, obstructive sleep apnea and chronic kidney disease. R52's Minimum Data Set (MDS) on 5/23/2026 documents in part that Staff Assessment for Mental Status is a 3 indicating that resident is severely cognitively impaired, and that R52 is dependent for all Activities of Daily Living (ADLs). On 6/29/2026 at 10:14AM, Surveyor observed R52 laying in bed, regular mattress (no air loss mattress), with heels laying directly against the mattress. On 6/29/2026 at 10:54AM, V54 (daughter of R52) reported there have been issues with CNAs (Certified Nursing Assistants) checking on R52. V54 states that R52 had developed wounds from the pamper because it was put on too tight. V54 (daughter of R52) reports that it is better now because they are not using the pampers anymore. On 6/29/2026 at 1:30PM, Surveyor observed V15 (Registered Nurse) performing wound care to R52's gluteal/sacral area. Area of current breakdown correlates with the lower gluteal area where the diaper previously would lay against the skin. On 6/30/2026 at 10:15AM, V14 (Licensed Practical Nurse/LPN) that R52 affirmed that resident remains on a standard mattress, no offloading of heels nor specialty mattress for preventative measures. V14 (LPN) confirmed that R52 has wounds and remains high risk for wounds, and will follow up. R100's Face sheet documents in part that R100 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis includes in part chronic respiratory failure, dependence on respirator (ventilator), end stage renal disease, dependence on dialysis, bacteremia, type 2 diabetes, epilepsy, vascular dementia, and pressure ulcers. R100's Minimum Data Set (MDS) on 4/30/2026 documents in part that Staff Assessment for Mental Status is a 3 indicating that resident is severely cognitively impaired, and that R100 is dependent for all Activities of Daily Living (ADLs). On 7/2/2026 at 01:04PM, Surveyor observed R100 in bed with only one heel protector on the left foot. Right foot was resting directly on the mattress. V3 (Assistant Director of Nursing) confirmed these findings and could not locate the other heel protector boot in the room. On 6/22/26 at 10:55am, during observation of residents in the Activity/Dining Room, R47 was observed sitting in the wheelchair without pressure relieving cushion/device. Again, at 11:45am, R47 was in the same position in the activity room. At this time, V24(Restorative Director) in the dining room was notified and V24 stated that she(V24) would get a cushion for R47's wheelchair. V47 added that the residents at risk for pressure ulcers should have cushions on wheelchairs to prevent pressure ulcers. On 6/22/26 at 10:15am and 12:45pm, during observation of residents on the unit, the following residents were observed on low air loss mattresses with the machine at the wrong weight settings: R12 weighs 191 pounds LALM weight setting was at 250 pounds. R123 weighs 129 pounds LALM weight setting was at 250 pounds. R55 weighs 177 pounds LALM was not set at any weight. On 6/29/26 at 1:55pm, the surveyor showed all 3 residents' LALM to V15(RN/Wound Nurse). V15 stated that the LALM machine should be set to the nearest weight closest to the resident's weight. V15 explained that it could be that R55's LALM that was not on any weight setting was accidentally knocked off by someone's leg; V15 stated that she(V15) would work on all the LALMs and ensure that they are at the correct weight settings for each resident. R12's Records show the following: Face sheet shows diagnoses which include but are not limited to Dementia, Osteoarthritis of Hip, Disorders of Muscles and Low Back Pain. Pressure Ulcer Risk assessment dated [DATE] shows that R12 is at risk for more pressure ulcers. MDS (Minimum Data Status) section C (BIMS/Basic Interview for Mental Status) dated 6/5/26 for R12 shows a score of 6 out of 15(Severe Cognitive Impairment). MDS section M dated 6/5/26 states that R12 has unhealed stage 4 pressure ulcer and requires pressure reducing devices for chair and bed Care plan dated 2/13/26 states in part: R12 is at risk for alteration in skin integrity, has a sacral pressure injury, receiving Hospice services. Intervention states to provide Pressure relieving mattress, questions, and positioning devices as ordered. R123's Records show the following: Face sheet shows diagnoses which include but are not limited to Dementia, Hemiplegia and Hemiparesis, Pressure Ulcer Risk assessment dated [DATE] shows that R123 is at risk for more pressure ulcers. MDS (Minimum Data Status) section C (BIMS/Basic Interview for Mental Status) dated 3/20/26 for R123 shows a score of 00 out of 15(Severe Cognitive Impairment). MDS section M dated 3/20/26 states that R123 is at risk for pressure ulcers and requires pressure reducing devices for chair and bed. R47's Records show the following: Face sheet shows diagnoses which include but are not limited to Dementia, Alzheimer's Disease, Weakness, And Peripheral Vascular Disease. Pressure Ulcer Risk assessment dated [DATE] shows that R47 is at risk for more pressure ulcers. Care plan Intervention dated 3/3/26 states that R47 should have a pressure reducing cushion in chair. MDS (Minimum Data Status) section C (BIMS/Basic Interview for Mental Status) dated 5/26/26 for R47 shows a score of 6 out of 15(Severe Cognitive Impairment). MDS section M dated 5/27/26 states that R47 is at risk for pressure ulcers and requires pressure reducing devices for chair and bed. R55's Records show the following: R55 stated that she(R55) came to the facility without any pressure ulcers but now has had pressure ulcers two times. Face sheet shows diagnoses which include but are not limited To Weakness, Muscle Wasting and Atrophy, Poorly Neuropathy, Abnormalities of Gait and Mobility, Peripheral Vascular Disease, Type 2 Diabetes, And Disorder of Muscle. Pressure Ulcer Risk assessment dated [DATE] shows that R55 is at risk for more pressure ulcers. Care plan Intervention dated 2/17/25 states that R55 should have a pressure reducing mattress on bed. MDS (Minimum Data Status) section C (BIMS/Basic Interview for Mental Status) dated 5/26/26 for R47 shows a score of 6 out of 15(Severe Cognitive Impairment). MDS section M dated 4/7/26 states that R55 is at risk for pressure ulcers and requires pressure reducing devices for chair and bed. Facility policy Pressure Ulcer Prevention (6/2026) documents in part that All residents will receive timely, individualized risk assessments, appropriate preventative interventions, and ongoing monitoring to ensure skin integrity is preserved to the greatest extent possible and that Skin will be monitored and early changes in skin integrity will be addressed by the licensed nurse. The pressure injury prevention policy (revised 6/2026) states this skilled nursing facility maintains and implements a comprehensive pressure injury prevention program designed to reduce incident, severity, and recurrence of pressure injuries. All residents will receive timely, individualized risk assessments; appropriate preventive interventions; and ongoing monitoring to ensure skin integrity is preserved to the greatest extent possible. All beds in the facility will have pressure reducing mattresses unless pressure relieving, or specialty support surface mattresses are required according to the resident's needs. Interventions to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. Interventions will address as appropriate: repositioning and mobility, support surfaces. The medical provider is notified of changes in skin integrity and treatment orders are obtained and implemented. The (undated) alternating and low air loss pressure relief system policy states the caregiver can select the static function to stop alternating function.

Based on interview and record review, the facility failed to notify R2's attending physician of a scheduled extensive dental extraction procedure. The facility also failed to communicate with the cardiologist and/or attending physician of R2's use of multiple blood thinning medications and request orders related to these medications in relation to R2's scheduled extensive dental extraction procedure. These failures affect one resident (R2) of three residents reviewed for quality of care. These failures caused R2 to experience uncontrolled hemorrhaging from R2's gums/oral cavity after having extensive extraction of ten teeth. R2 required emergent transfer to the local hospital. R2 was admitted from the emergency room to the hospital with a diagnosis of Oral Hemorrhage requiring transfusion of multiple blood products.Findings include:R2's Hospital Record dated 6/1/2026, reads in part: R2 presents to Emergency Department by EMS (Emergency Medical Services) from nursing facility with a chief concern of oral bleeding. Following initial history and physical examination, local pressure was applied to the bleeding area with 4 by 4 gauze and having R2 to clench down with his jaw. This provided some initial relief of the active bleeding and slowed the bleeding down a small amount. With R2's large volume blood loss at the nursing facility described by family and the blood loss witnessed in our emergency department, decision was made to empirically transfuse the patient with a balanced transfusion of 1 unit of blood cells, 1 of platelets, 1 of FFP (Fresh Frozen Plasma). R2's anticoagulation was also reversed with prothrombin complex concentrate, human-[NAME] (Intravenous medication that contains blood clotting factors and used to rapidly reverse the effect of blood-thinning medications.)R2's medical record documents R2 went out of the facility for a dental appointment on 6/1/26 and returned to facility. Staff could not control the bleeding from R2's gums. Emergency Response (911) was called and R2 was admitted to the hospital with a diagnosis of Oral Hemorrhage.On 6/10/2026 at 10:20AM, V13 (Dentist) stated that the dental facility is aware that R2 is on anti-coagulant medications. V13 stated it is the facility's physician that can order to put anticoagulant medication on hold and that it is the physician's decision. V13 stated the dental office did not communicate any recommendation or any pre-procedure guidance or instruction to the facility or R2's physician. V13 stated that the facility already knew the reason for the appointment was for tooth extraction and should have communicated this to R2's physician. V13 stated that R2 consented for new dentures and consented to the extraction of 10 teeth on 6/1/2026.R2's Medical Records document R2's cognition as moderately cognitively impaired.R2's Dental Notes dated 6/1/2026 reads that dental office reviewed medication and that 10 teeth were extracted. These notes also document hemostasis was obtained before R2 was dismissed (back to the skilled nursing facility.)On 6/30/2026 at 12:00PM, V23 (Nurse Practitioner of Cardiology) stated that V23 gave clearance on 1/27/2026 with order to hold Apixaban two days before the procedure and hold Acetylsalicylic Acid 5 days before the procedure. There was no scheduled tooth extraction appointment date at the time of V23's visit on 1/27/2026. V23 also stated that on 2/24/2026, V24 (Nurse Practitioner of R2's Attending Physician) contacted V23 about the clearance for tooth extraction due to R2's Power of Attorney (POA) asking. V23 stated V23 instructed V24 to hold Apixaban for two days and Aspirin for five days prior to the procedure. V23 also stated V23 was made aware of R2 needing a tooth extraction but V23 considered this as low-risk procedure since it was not for multiple teeth extraction, which would have been a high-risk procedure. V23 stated V23 did not receive notification once the dental appointment for the tooth extraction was scheduled. V23 stated no one from the facility informed V23 that there was a set date for the tooth extraction for R2. V23 stated it is V23's expectation that the facility informed V23 of the tooth extraction date. V23 stated, If (I) had known the date of the tooth extraction appointment, (I) would have definitely continue with the order of holding the anticoagulant medication prior to procedure. V23 stated she was only aware of plans to extract a tooth, but not aware of the plan for multiple teeth to be extracted on the same day dental appointment.On 6/30/2026 at 1:00PM, V25 (Attending Physician) stated that V25 was not made aware of the set date for tooth extraction appointment. V25 stated that his expectation is for the facility to inform him of the set date for the tooth extraction procedure. If V25 was made aware, they have protocol such as putting anticoagulant medication on hold prior to the procedure. V25 stated he would have given orders to hold R2's Apixaban for three days and Acetylsalicylic Acid for seven days prior to R2's extraction of multiple teeth. V25 also stated that one tooth extraction is more than enough to cause bleeding, and so it is important to hold blood thinner medication prior to procedure. V25 stated that R2 required at least one or two units of blood transfusion during R2's hospital stay for Oral Hemorrhage.On 6/30/2026 at 1:20PM, V24 (Nurse Practitioner of Attending Physician) stated she was not made aware of the set date appointment for R2's tooth extraction nor made aware of multiple teeth being extracted. V24 stated V24 was aware of possible tooth extraction, but not multiple. V24 stated that the resident received at least one unit of blood and plasma to help reverse R2's oral hemorrhaging. V24 also denied receiving a call from the dental office regarding tooth extraction or receiving written communication informing them/the facility of the plan.On 7/1/2026 at 12PM, V2 Director of Nursing (DON) stated once an appointment is scheduled, the nurses are to notify the resident's family and attending physician. V2 stated this will give the facility/physicians the opportunity to review resident's records and give/receive orders to hold or discontinue anything that is necessary.R2's Physician Order Sheet (POS) does not document an order to hold any medication prior to R2's dental procedure/tooth extraction.The facility's Change in a Resident's Condition or Status policy with a review date of 6/2024, reads in part: Facility shall promptly notify the residents, his or her attending physician and representative of any changes in the resident's condition and/or status. The nurse will notify the residents attending physician or physician extender when there is a need to alter the resident's treatment significantly; and deems necessary or appropriate in the best interest of the residents.

Based on interview and record review, the facility failed to notify family and the attending physician of a dental appointment with procedure scheduled outside of the facility. These failures affects one resident (R2) of three residents reviewed for family and physician notification for changes.Findings include:R2's Face Sheet states V4 and V22 are listed as POA (Power of Attorney) with V22 listed as the first emergency contact.R2's medical record documents R2 went out of the facility for a dental appointment on 6/1/26 and returned to facility. Staff could not control the bleeding from R2's gums. Emergency Response (911) was called and R2 was admitted to the hospital with a diagnosis of Oral Hemorrhage.On 6/9/26 at 11:45AM, V7 (Certified Nursing Assistant (CNA)/Supervisor/Scheduler) stated V7 recalls scheduling the dental appointment for R2 and informing a nurse but V7 could not recall who the nurse was.On 6/9/26 at 12:30PM, V8 (RN) stated it is the scheduler who schedules the appointments that will inform the family. V8 stated most of the time, the staff don't even know that a resident has an appointment until the day of the appointment.On 6/9/26 at 1:30PM, V10 (ADON) stated R2 went to his dental appointment and returned to the facility with bleeding gums. Staff could not control the bleeding and R2 was sent out via 911 to hospital. V10 spoke with V4 and V22 and both verbalized concerns with lack of communication as they stated the facility did not notify them about the dental appointment nor did they receive any communication from the dental facility.On 6/10/26 at 11:35AM, V2 (DON) stated that the chief nurse was in the facility last week along with V10, and they acknowledged the deficiency and initiated corrective action. V2 stated R2's POA was not notified of the dental appointment and tooth extraction for R2.On 6/30/26 at 10AM, V4 (POA-Alternate) stated that V4 was not made aware of a dental appointment on 6/1/26. V4 stated the facility nor dental office contacted V4 to get consent for tooth extraction.On 6/30/26 at 10:25AM, V22 (POA-Emergency contact 1) stated that V22 was not made aware of any dental appointment and stated they would have come and meet R2 for his appointment if they had known. V22 stated the facility nor dental office called V22 to ask for consent for the tooth extraction.The facility's Change in a Resident's Condition or Status policy with a review date of 6/2024, reads in part: Facility shall promptly notify the residents, his or her attending physician and representative of any changes in the resident's condition and/or status. The nurse will notify the residents attending physician or physician extender when there is a need to alter the resident's treatment significantly; and deems necessary or appropriate in the best interest of the residents.

Based on interview and record review the facility failed to follow their fall policy by failing to implement effective fall interventions, failed to thoroughly investigate each fall to determine root cause analysis, failed to conduct fall risk assessments after two falls and failed to conduct neurological checks for one resident (R3) out of three reviewed for falls. These failures resulted in R3 sustaining four unwitnessed falls and being diagnosed with a right femur fracture.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, type II diabetes, heart failure, osteoarthritis of knee unspecified, repeated falls, abnormalities of gait, malignant neoplasm of bronchus or lung and weakness.R3's fall risk evaluation dated 1/26/26 documents: R3 at high risk for falls due to score of 13. A score of 10 or greater, the resident should be considered at high risk for falls.R3 progress note dated 2/23/26 documents: Pain & Vitals: Resident complaints of pain in right shoulder. Refuses to go to the hospital. Hospice was called for recommendations. Hospice nurse suggested pain pill. Vitals are BP 196/61 P 58 R 19 SPO2 98. Hospice nurse will do a follow up. Level of consciousness (LOC) & Orientation: Resident alert and oriented times four. Skin assessment: No changes to skinRange of Motion: No change in all of range of motion. Description: Resident stated she was trying to get in her chair. When standing her ankles gave out and she fell forward. Resident stated she did not hit her head or is in any pain enough to go to the hospital. Resident refused hospital and hospice was called. Intervention: Norco given, resident changed and reposition in bed. Notifications (DON, Family, Provider): Hospice, Family, and DON aware.There was no documentation in R3's medical record following the fall on 2/23/26 for a fall risk assessment, new fall intervention, or investigation with root cause.R3 nursing progress note dated 3/8/26 documents: Around 10am resident was observed sitting on the floor on the mat. She was sitting on her buttocks beside her bed alert and ox3. When asked what had happened, she said she didn't know. Resident assessed for injury before being assisted up per mechanical lift by staff members. Nurse did a body check on resident she denied any pain or discomfort. No injuries were noticed. Notified Nurse Practitioner, family Vital signs monitoring. Neuro. signs stable.R3 nurse practitioner progress note dated 3/9/26 documents: Fall, initial - R3 was found on floor at 10 am she does not remember falling and appears vague when asked any questions in regard to why she was on floor. It is noted that R3 likes to sit on side of bed to help breathe. Patient will be getting a larger floor mat and will also ask pulmonology to evaluate to see if anything else can be done for breathing.R3 progress note dated 3/10/26 documents: Resident refusing a larger floor mat stating I don't want that in my room. Resident was educated on safety and the recent incidents resident stated I would rather fall on the floor. I don't want that large mat in my room.There was no documentation in R3's medical record following the fall on 3/826 for a fall risk assessment, new fall intervention after refusal of floor mat, or fall investigation with root cause.R3 progress note dated 3/20/26 documents: CNA notifies RN at 10:20pm RE unwitnessed/ uninjured fall event. Resident observed sitting on buttocks on top of floor mat perpendicular to bed. Resident had no clothing or socks on; took hospital gown off prior to fall. Mechanical lift used to put resident back to bed, performed full body assessment, and obtained vitals. Range of motion to all four ectremities(ROM x4). No complaints of pain or signs or symptoms of discomfort, or pain. Initiated neurological checks, vitals every 72 Hours, and increased monitoring. Notified daughter at 10:37pm, NP at 10:40pm, and DON at 11:02 for unwitnessed/uninjured fall event. Low bed position with fall precautions in place. Call light within reach.R3's fall risk evaluation dated 3/20/26 documents: R3 at high risk for falls due to score of 16. A score of 10 or greater, the resident should be considered at high risk for falls.R3's neurological assessment dated [DATE] does not documents any response under grips equal and moves all extremities or signature from times 11:35PM to 4:05AM. There was no documentation for 8:05AM and 12:05PM. Day two and day three no documentation for 11-7 shift.There was no documentation in R3's medical record following the fall on 3/20/26 for a fall investigation with root cause. Intervention implemented was medication review.R3 progress notes dated 3/28/26 at 9:48PM documents: Unwitnessed fall in resident's room; heard moaning. Resident observed lying supine on floormat adjacent to bed in hospital gown, no footwear; continued to roll around on floor. Returned resident to bed and performed full body assessment, obtained vitals, and administered 2-5-325mg Norco related to moaning and complaints of right knee pain. Able to perform range of motion (ROM) x4. Low bed position with fall precautions in place: floor mat. Call light within reach.R3's fall risk evaluation dated 3/28/26 documents: R3 at high risk for falls due to score of 23. A score of 10 or greater, the resident should be considered at high risk for falls.There were no neurological checks following the fall on 3/28/26.R3 progress notes dated 3/29/26 at 1:35AM documents: Hospice that the resident had an unwitnessed fall at 9:48PM. The resident is moaning really loud and complaints of severe right knee pain. The resident reported that the Norco administered to her is not helping with the Pain. Writer did ask if the resident wanted to go to the hospital, she declined. Writer requested for Hospice to send a Hospice nurse to reassess to determine if the resident requires diagnostics and additional pain management or to be sent to the hospital for a higher level of care.Facility fall reportable dated 3/31/26 documents under conclusion documents: R3 attempted independent movement or repositioning, resulting in a unwitnessed fall from the bed despite safety interventions being in place. R3 has poor safety awareness related to her functional limitations, muscle weakness and medical comorbidities.Incidents by incident type report for R3 dated 2/1/26 to 5/5/26 documents: Fall on 3/8/26 at 10:00AM; notes R3 refused larger floor mat, education given to R3. Incident 3/20/26 at 10:20 Initiated neurological checks and increased monitoring. Incident on 3/28/26 at 9:48PM. No other falls listed. There was no other information related to investigation (staff interviews) or root cause of the falls. Facility (V2 (DON) and V18 (restorative nurse) ) was asked to provide all information related to all of R3's falls during the survey. No other documentation was presented.On 5/6/26 at 11:44AM, V18 (restorative nurse) said after a fall they will conduct a risk management, fall risk are conducted after the falls, care plans are updated with new interventions. V18 was asked to provide any other information related to R3 falls from February to discharge. V18 was unable to provide any documentation related to the fall investigation, interviews or root cause of falls for R3. V18 said the root cause for all of R3's falls was that she sat at the edge of the bed. V18 said interventions placed after fall on 3/8/26 were larger floor mats; after fall 3/20/26 was medication review; after fall 3/28/26 frequent rounding. V18 said R3 refused larger floor mats. V18 was unable to say how these interventions placed were effective related to the root cause of sitting on edge of the bed. At 12:25PM, V18 provided a note from V36 (NP) about medication change related to trazadone. V18 was informed that R3's trazadone was changed on 2/5/26 and was unable to provide documentation related to medication review.On 5/5/26 at 12:41PM, V2 (DON) said fall risk are completed upon admission, quarterly and after every fall. V2 said fall care plan are updated by V18 (restorative nurse) the following business day if on the weekend or the same day if during the week and present at the facility. V2 said neuro checks are conducted on every resident following an unwitnessed fall. The neuro check form should be completed and signed off by staff. V2 unsure if they had any other neuro checks for R3. V2 said falls are investigated and a root cause of the fall is determined to ensure that the interventions placed are effective to prevent another fall. On 5/6/26 at 3:32PM, V2 (DON) presented a progress note dated 3/26/26 documenting: R3 was started on cipro for possible urinary track infection for medication review after fall on 3/20/26.R3's hospital report dated 3/30/26 documents presents for evaluation of altered mental status. R3 was last well on the March 25th and that since then she has been acting progressively more altered. Under general appearance: musculoskeletal internal rotation to right lower extremity. Under attestation documents: R3 had fall two days ago that has not been yet evaluated. They report R3 has been signaling that she is having pain to the right leg. On exam ill appearing. She does have deformity to her right lower extremity. Hospital x-ray of right femur documents: acute comminuted fracture of the distal femoral metaphysis with posterior displacement and angulation.R3's plan of care dated 1/26/26 risk for falls documents: assist resident with ambulation and transfer, utilizing therapy recommendations; evaluate fall risk on admission and as needed; if fall occurs alert provider, if fall occurs initiate frequent neuro and bleeding evaluation per facility protocol; if resident a fall risk, initiate fall risk precautions. Care plan dated 1/27/25 documents resident is high risk for falls related to gait/balance problems. Interventions documented: anticipate and meet the need of the residents; be sure call light is within reach and encourage resident to use it for assistance as needed; educate the resident/family abut safety reminders dated 10.22.25; frequent rounding dated 3.28.26; larger floor mats dated 3.9.26; medication review dated 1.26.26 and 3.23.26; offer resident to lay down before dinner dated 11.17.25; physical therapy evaluate and treat; review information of past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family as to causes dated 10/22/25; wedges to left side of bed dated 12.1.25.Facility fall prevention and management policy revised documents 12/23: the purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized, person-centered care. The falls prevention and management program provided framework and tools to identify and communicate about a resident's risk for falls. The fall risk assessments is completed quarterly, with significant change in condition or following a fall event. The fall risk assessment is used to identify fall risk factors. Under care planning and interventions: Development of the fall risk care plan is based on results of the fall assessment as well as the investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individual fall risk factors that apply to the resident. The care plan will be revised and reviewed at least quarterly and with any fall event the resident might experience. Staff shall maintain communication with appropriate personnel when situations or resident behaviors suggest that the current intervention is not effective. The facility shall re-evaluate as needed to promote safety.

Based on interview and record review, the facility failed to follow their pain policy and provide effective pain management for one resident experiencing severe right knee pain after a fourth unwitnessed fall. These failures affect one of three residents (R3) reviewed for pain management. These failures resulted in the resident experiencing severe pain, revoking hospice services and being transferred to the hospital with a diagnosis of right femur fracture.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, type II diabetes, heart failure, osteoarthritis of knee unspecified, repeated falls, abnormalities of gait, malignant neoplasm of bronchus or lung and weakness.R3 progress notes dated 3/28/26 at 9:48PM documents: Unwitnessed fall in resident's room; heard moaning. Resident observed lying supine on floormat adjacent to bed in hospital gown, no footwear; continued to roll around on floor. Returned resident to bed and performed full body assessment, obtained vitals, and administered 2-5-325mg Norco related to moaning and complaints of right knee pain. Able to perform range of motion (ROM) x4. Low bed position with fall precautions in place: floor mat. Call light within reach.On 5/5/26 at 3:37PM, V10 (nurse) who was assigned to R3 for falls on 3/28/26 said R3 said she had pain in her right knee cap. V10 said she performed range of motion in all 4 extremities after each fall with no concerns with movement observed. V10 said R3 had norco for pain and did not have any morphine on hand at that time. V10 said they would recheck pain after an hour to see if effective and document. If medication was not effective they would call the doctor. V10 unable to recall if she called the doctor about R3's pain.R3 progress notes dated 3/29/26 at 1:35AM documents: Hospice that the resident had an unwitnessed fall at 9:48PM. The resident is moaning really loud and complaints of severe right knee pain. The resident reported that the Norco administered to her is not helping with the Pain. Writer did ask if the resident wanted to go to the hospital, she declined. Writer requested for Hospice to send a Hospice nurse to reassess to determine if the resident requires diagnostics and additional pain management or to be sent to the hospital for a higher level of care.Hospice nurse visit 3/29/26 at 2:47AM, pain documented 7/10. R3 fell and is complaining of right knee pain. Patient received norco but still moaning and groaning in pain. Under pain worst level of pain in last 24 hours was a nine. Constant severe pain to her right knee after fall. R3 described pain as aching, pressure, shooting sore taut throbbing. Norco was given but pain still extreme morphine and Ativan ordered stat. Facility might do x-ray. Under narrative: facility nurse called at 1:30 on 3/29/26 to report an unwitnessed fall at 9:00 pm on 3/28/26. Facility nurse reported that R3 is in extreme pain and think patient may have fractured her right leg or knee. Facility nurse administrated norco but the pain is still extreme. Comfort kit ordered stat.R3 progress notes dated 3/29/26 at 8:52AM documents: Writer administered 0.25ml Morphine Liquid to the resident. R3 progress notes dated 3/29/26 at 9:00AM documents: Resident is in extreme severe Pain.R3 progress note dated 3/29/26 3:31PM documents: Administered 2-5-325mg Norco at 3:31pm related to moaning out loud; effective. R3 order notes under Norco 5/325 take two tablets every 6 hours as needed severe pain ,moaning.R3 fall follow up note dated 3/29/26 at 5:09PM, vocal moaning, alert to self.R3 order administration note dated 3/29/26 9:31pm documents Norco 5/325 one tab given related to comfort care.Hospice nurse visit dated 3/30/26 documents pain 7/10 as numbness and stabbing. All activities exacerbate her pain. Patient in bed drowsy minimal responsive to writer. R3 post fall over 24 hours ago with complaint of pain to right knee medicated prior to arrival. No visible signs of pain.R3 order administration note dated 3/30/26 at 3:29PM Ativan given for restlessness.R3 progress note dated 3/30/26 at 4:21PM documents: Resident received early am lethargic but responsive to tactile and verbal stimuli. Resident not talking but making sounds noises. Assisted to wash face and give oral mouth care. Resident became more alert later after lunch, she is not eating she was able to take her meds crush with applesauce. Resident complaining of right knee pain and moaning when she received her ADL care and turning. Right knee tender upon touch. Resident remained moaning and became restless only saying the word OH. Lorazepam 0.25cc given PO 2:50 PM. V36 (NP) and ADON made aware of present condition. Warm pack applied to right knee. V36( NP) said she will contact Hospice and family.R3's progress note dated 3/30/26 at 4:30PM by V36(NP) documents: R3 had fall over weekend on 3/29 and was complaining of pain to right knee. Hospice was notified and did ok for x-ray to right knee. Pt was moaning and in alot of pain over weekend even with norco so R3 was given morphine and can have ativan as needed. R3 seen this am sleeping moderately hard to arouse. She does open eyes but is non verbal only moaning when name called. R3 had been given some morphine to help with right knee pain. She took some norco over the weekend but was not strong enough with R3 still having a lot of pain and was given morphine. R3 normally alert and answers questions appropriately. Fall, initial - R3 had a fall on 3/28 per staff they contacted Hospice. The resident was moaning really loud and complaints of severe right knee pain. The resident reported that the Norco administered to her was not helping with the Pain. Writer did ask if the resident wanted to go to the hospital, she declined. Writer requested for Hospice to send a Hospice RN to reassess to determine if the resident requires diagnostics and additional pain management or to be sent to the hospital for a higher level of care. Per staff R3 has refused going to hospital. She is seen in room with ice pack on right knee and moaning hospice did order x-ray awaiting on results.R3's order administration note dated 3/30/26 at 8:29PM documents: Ativan ineffective.R3's nursing note dated 3/30/26 at 8:33PM, R3 transferred to local hospital per family request.On 5/8/26 at 10:29AM, V36 (Nurse practitioner) said she saw R3 on Monday (3/30/26) after the fall over the weekend. V36 said she did see R3 but did not do range on motion on R3's leg due to complaints of pain. V36 said it did not appear to be swollen but difficult to assess due to her size. V36 said she was made aware by staff nurse about getting an x-ray but unsure if it was done. V36 said R3 was not really talking and had been medicated prior to arrival. V36 said she would expect staff to medicate R3 as ordered for pain and reassess pain after administration of medication. V36 said she would expect staff to reassess after an hour and if not effective to contact hospice or physician related to pain not being controlled. V36 said she recall asking staff to administer morphine during visit to keep R3 comfortable. V36 said she spoke to the daughter about changes and that they were monitoring and R3 was declining. Family decided later that day to revoke hospice and she went to the hospital.R3's hospital report dated 3/30/26 documents presents for evaluation of altered mental status. R3 was last well on the March 25th and that since then she has been acting progressively more altered. Under general appearance: musculoskeletal internal rotation to right lower extremity. Under attestation documents: R3 had fall two days ago that has not been yet evaluated. They report R3 has been signaling that she is having pain to the right leg. On exam ill appearing. She does have deformity to her right lower extremity. Hospital x-ray of right femur documents: acute comminuted fracture of the distal femoral metaphysis with posterior displacement and angulation.On 5/8/26 at 12:11PM, V2(DON) said on 3/30/26 R3 was not decisional and would have good and bad days. V2 said they were unsure if R3 was experiencing terminal restlessness. Facility nurse reported that R3 was comfortable that day and no other concerns reported. V2 said not all comfort kits are ordered at admission. V2 said Staff are expected to have ordered pain medication on hand for residents. Staff are expected to administrator pain medication as ordered and evaluate pain at time of administration. Within an hour they are expected to follow up with the resident to ensure medication was effective and reassess pain. They can give verbal pain score and the information would be documented in the medication record. Staff are expected to inform the physician or hospice if pain is not controlled and should administrator medication if available as needed to provide comfort to the resident. Staff should also provide non pharmacologic interventions for pain.R3 controlled drug receipt form dated 3/1/26 for hydrocodone 5/325mg documents: 3/4/26 two tablets given; 3/5/26 one tablet given; 3/7/26 one tablet given, 3/8/26 one tablet given, 3/9/26 one tablet given, 3/11/26 one tablet given, 3/12/26 one tablet given, 3/13/26 one tablet given, 3/15/26 two tablets given; 3/16/26 two tablets given; 3/18/26 two tablets given; 3/19/26 two tablets given; 3/23/26 two tablets given; 3/28/26 at 9:23AM and 9:44PM, two tablets given; 3/29/26 at 2:00AM, two tablets given, at 8:15AM, one tablet given, at 3:31PM two tablets given and at 9:31PM one tablets was given. That was the last dose of medication with zero tablets remaining.R3's medication administration record for march 2026 documents under hydrocodone 5/325mg give two tablets by mouth as needed for severe pain with start date 10/8/25 the following: on 3/28/26 at 9:43PM pain of seven, on 3/29/26 at 2:00AM a pain level of ten and at 3:31PM a pain level of six.R3's medication administration record for march 2026 documents under hydrocodone 5/325mg give one tablets by mouth as needed for pain with start date 10/8/25 the following: on 3/28/26 at 9:24M pain of eight, on 3/29/26 at 8:18AM a pain level of five and at 9:31PM a pain level of two.R3's medication administration record (MAR) for march 2026 documents under morphine sulfate 20mg/ml give 0.25 ML by mouth every one hour as needed for severe pain with start date 3/29/26: given 3/29/26 at 9:00AM a pain level of ten. No other entries documented.R3's physician order sheet dated 3/1/26- 4/30/26 documents: morphine sulfate 20mg/ml give 0.25 ML by mouth every one hour as needed for severe pain with start date 3/29/26.On 5/8/26 at 11:34AM, V41 (pharmacist) said thirty tablets of hydrocodone were delivered on 2/28/26. V41 said no other requests were made or sent for medication. V41 said on 3/29/26 morphine was taken from the emergency medication box for R3 to include two doses. No other requests were made or sent for R3.R3' s plan of care dated 2/14/25 documents: At risk for pain related to osteoarthritis/pain in joints/malignant neoplasm of the lungs. Interventions include; encourage a nap if experiencing fatigue; give pain medications as per physician orders; notify the physician if pain medications are ineffective; vital signs as ordered and as warranted, notify physician of any abnormalitiesFacility pain management policy revised 4/2025 documents: it is the policy of this facility to screen all residents for pain. Identify those who are experiencing pain and assess and develop an effective individualized pain management care plan. Acute pain refers to pain that is usually sudden in onset and time limited with a duration of less than one month and often is caused by trauma or medical treatments such as surgery. Pain assessment is more in -depth evaluation that occurs when residents reports presence of pain. Initial pain includes history of pain, history of addition, characteristics of pain such as intensity, pattern, location, frequency and duration, impact of pain on quality of life (sleeping, appetite, mood, factors such as activities, care or treatment that exacerbate pain as well as those that reduce pain, additional symptoms associated with pain. Physical and psychosocial issues an goals for pain management. Pain reassessment, the patient and resident should be reassessed for pain and side effects, adverse events produced by treatment and the impact of pain on resident. Pain management is a comprehensive approach to the needs of patient who experience problems associated with acute or chronic pain. Comfort goal: this is the goal for pain management that is developed individually with each resident and may include that the patient: verbalizes satisfaction with pain management; verbalizes pain relief; side effects remain minimal; functional status is maintained or improved. A comprehensive pain assessment is done on admission, quarterly and with each report of new or changed pain. The provider will be informed of the resident's initial complaint of pain and review pain management during routine visits. Documentation of the effectiveness of the pain management program can be found on the medication administration record or in the nursing note.

Based on interview and record review the facility failed to follow its ADL ( Activities of Daily Living) policy and provide incontinence care and turning/repositioning for four residents ( R1, R10, R12, and R13) who are totally dependent on two staff for all ADL care, with the potential to affect all 30 residents residing on one nursing unit.Findings include: On 5/6/26 at approximately 3:00 PM, this surveyor and V1 (administrator) observed video surveillance, dated 5/2/2026. At 10:10 PM, the video shows V8 CNA (certified nurse aide) pulling into the facility parking lot. Video shows V8 enter the facility at 11:43 PM. At 1:51 AM, video surveillance shows V8 getting into her vehicle and leaving the facility. Video surveillance shows V8 return and enter the facility at 4:39 AM. At 05:51 AM, video surveillance show V8 leave the facility again and return at 5:59 AM.On 5/5/26 at 2:26 PM, V8 CNA (certified nurse aide) stated that she was scheduled to work a double shift on 5/2/2026 11:00 PM- 5/3/26 3:00PM. V8 stated that it was only her and V38 (nurse) present on side 3 nursing unit during the 11:00 PM-7:00 AM shift due to a CNA call-off.V8 stated that she did not do any checks or changes on any resident during her entire shift on 5/2/2026 11:00 PM-7:00 AM due to the CNA call-off on side 3 nursing unit. V8 stated that she did not provide any incontinence care to any residents that required two-person assistance. V8 said that she waited until 7:00 AM on 5/3/2026 to provide incontinent care for R1. V8 stated that R1 is severely contracted, and she wanted to make sure she provided safe care. V8 stated that the expectation is that all residents are provided ADL (Activities of Daily Living) care every two hours and as needed. V8 stated that she takes her lunch break outside the facility in her car. V8 stated that sometimes she falls asleep in her car and comes back from her lunch break late. V8 stated she is the caregiver for her mom who falls frequently, and she sometimes leaves the facility on her lunch break to go home to check on her mom. V8 stated that her lunch break is thirty minutes. On 5/6/26 at 10:39 AM, V14 CNA stated that she worked 5/3/26 7:00 AM;3:00 PM shift. V14 stated that while she was making her rounds, V8 CNA was providing care to R1 with V21 CNA's assistance. V14 stated that ADL care should be rendered to residents every two hours and as needed. On 5/7/26 at 3:01 PM, V21 CNA stated that on 5/3/2026 at the start of his 7:00 AM-3:00PM shift V8 was standing at the nurses station with her belongings and asked him if he could assist with resident care for R1. V21 said that when they entered R1's room, R1 was visibly soiled and wet. V21 stated that incontinence care should be rendered every two hours and as needed.On 5/7/26 at 9:50 AM, V2 DON (director of nursing) acknowledged that staff should be proving incontinence care and turning/repositioning residents every two hours and as needed.On 5/7/26 at 2:57 PM, V38 stated that she was scheduled to work 5/2/2026 11:00 PM-700 AM shift. V38 stated that two CNAs were scheduled, but there was a CNA call-off leaving V38 and V8 on the unit alone to care for thirty residents. V38 stated that CNAs are expected to make rounds and provide incontinence care every two hours and as needed. V38 stated that V8 told her she was going on break around 1:45 AM. V8's facility timecard shows V8 clocked out for break at 1:51 AM. V38 stated that she received a phone call from V8 around 4:00 AM stating she had an emergency and would be back soon. V38 stated that she took her lunch break outside in her vehicle at 4:00 AM and set her alarm for thirty minutes. V38 stated that she walked back into the facility with V8 around 4:30 AM. V38 stated that she was unaware that V8 left the facility at 1:51 AM and again at 5:51 AM on 5/3/2026 because she was busy providing care to her residents with g-tubes (gastrostomy tubes). V38 stated she answered the call lights but did not provide incontinence care to any resident. V38 said that she informed the residents that V8 the assigned CNA was on break and they would get changed when V8 returned. V38's facility timecard shows she clocked in at 11:15 PM on 5/2/2026. V38's facility timecard shows she clocked out for break on 5/3/2026 at 4:15 AM and clocked back in at 4:41 AM on 5/3/2026. The facilities (ADL) Activities of Daily Living policy, undated, notes in part 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. The facility's protocol for turning and repositioning, dated 07/2018, notes in part residents that cannot assist themselves may be turned every two hours and/or as often as needed.

Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by neglecting to provide the necessary personal care and assistance with ADLs (activities of daily living) to meet the residents needs. This failure affected all 30 residents residing on one nursing unit. Findings include:On 5/6/26 at approximately 3:00 PM, this surveyor and V1 (administrator) observed the facility's video surveillance tape, dated 5/2/2026. At 10:10 PM, the video shows V8 CNA (certified nurse aide) pulling into the facility parking lot. Video shows V8 enter the facility at 11:43 PM. At 1:51 AM, it shows V8 getting into her vehicle and leaving the facility. Video surveillance shows V8 return and enter the facility at 4:39 AM. At 05:51 AM, video surveillance show V8 leave the facility again and return at 5:59 AM.On 5/5/26 at 2:26 PM, V8 CNA stated that she was scheduled to work a double shift on 5/2/2026 11:00 PM- 5/3/26 3:00PM. V8 stated that it was only her and V38 (nurse) present on side 3 nursing unit during the 11:00 PM-7:00 AM shift due to a CNA call-off. V8 stated that she did not do any checks or changes on any resident during her entire shift on 5/2/2026 11:00 PM-7:00 AM due to the CNA call-off. V8 stated that she did not provide any incontinence care to any residents that required two-person assistance. V8 said that she waited until 7:00 AM on 5/3/2026 to provide incontinence care for R1. V8 stated that R1 is severely contracted, and she wanted to make sure she provided safe care. V8 stated that the expectation is that all residents are provided with ADL (Activities of Daily Living) care every two hours and as needed. V8 stated that she takes her lunch break outside the facility in her car. V8 stated that sometimes she falls asleep in her car and comes back from her lunch break late. V8 stated she is the caregiver for her mom who falls frequently, and she sometimes leaves the facility on her lunch break to go home to check on her mom. V8 stated that her lunch break is thirty minutes. On 5/6/26 at 10:39 AM, V14 CNA stated that she worked 5/3/26 7:00 AM-3:00 PM shift. V14 stated that while she was making her rounds at 7:00 AM, V8 CNA was providing care to R1 with V21 CNA's assistance. V14 stated that ADL care should be rendered to residents every two hours and as needed. On 5/7/26 at 3:01 PM, V21 CNA stated that on 5/3/2026 at the start of his 7:00 AM-3:00PM shift V8 was standing at the nurses' station with her belongings and asked him if he could assist with resident care for R1. V21 said that when they entered R1's room, R1 was visibly soiled and wet. V21 stated that incontinence care should be rendered every two hours and as needed.On 5/7/26 at 9:50 AM, V2 DON (director of nursing) acknowledged that staff should be providing incontinence care and turning/repositioning residents every two hours and as needed.On 5/7/26 at 11:40 AM, V34 CNA stated that there are only two CNAs working on side 3 nursing unit today. V34 stated that she is assigned to provide care for 15 residents. V34 stated that of the 15 residents, ten are always incontinent. V34 stated that 12 of her assigned residents require two persons to assist with ADLs; she is able to provide care to three residents by herself. V34 stated that there are currently four residents with tracheostomies, R1, R10, R12, and R13, that always require two persons assist with all ADLs.On 5/7/26 at 2:58 PM, V35 CNA stated that she is assigned to provide care for 15 residents on side 3 nursing unit today. V35 stated that V34 assisted her with providing care to 12 of these residents; the other three residents she was able to provide care by herself.On 5/7/26 at 2:57 PM, V38 stated that she was scheduled to work 5/2/2026 11:00 PM-700 AM shift. V38 stated that two CNAs were scheduled, but there was a CNA call-off leaving V38 and V8 on the unit alone to care for thirty residents. V38 stated that CNAs are expected to make rounds and provide incontinence care every two hours and as needed. V38 stated that V8 told her she was going on break around 1:45 AM. V8's facility timecard shows V8 clocked out for break at 1:51 AM. V38 stated that she received a phone call from V8 around 4:00 AM stating she had an emergency and would be back soon. V38 stated that she took her lunch break outside in her vehicle at 4:00 AM and set her alarm for thirty minutes. V38 stated that she walked back into the facility with V8 around 4:30 AM. V38 stated that she was unaware that V8 left the facility at 1:51 AM and again at 5:51 AM. V38 stated she answered the call lights but did not provide incontinence care to any resident. V38 said that she informed the residents that V8, the assigned CNA, was on break and the residents would get changed when V8 returned. V38's facility timecard shows she clocked in at 11:15 PM on 5/2/2026. V38's facility timecard shows she clocked out for break on 5/3/2026 at 4:15 AM and clocked back in at 4:41 AM on 5/3/2026. The facility's midnight census for 5/1/26 notes there were 124 residents in the facility. On 5/2/26 at 11:00 PM there were 30 residents residing on side 3 nursing unit. The facility's daily assignment sheet, dated 5/2/26, notes there were eight CNAs scheduled to work 11:00 PM-7:00 AM shift. V8 (CNA supervisor) and V42 CNA were scheduled to work on the side 3 nursing unit. V42 CNA called off. V34 CNA is written on schedule to work 4:00 AM-7:00 AM. There were a total of 26 CNAs working on 5/2/26.V34's (CNA) timecard for 5/2/26 does not note V34 worked any part of the 11:00 PM - 7:00 AM; V34 worked day shift. On 5/3/26, V34 clocked in at 6:56 AM and clocked out at 2:57 PM.V8's (CNA) timecard for 5/2/26 notes V8 clocked in at 11:43 PM; clocked out at 1:51 AM. V8 did not clock in upon returning to the facility at 4:39 AM.The facility assessment, updated March 2026, notes in part notes its typical daily staffing pattern, based on the average daily census of 121 residents. It notes the total number of CNAs needed for the average is 28.The facility's abuse prevention guidance policy, dated 10/2022, notes in part neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain. mental anguish or emotional distress. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident including deprivation of goods and services by staff.The facilities (ADL) Activities of Daily Living policy, undated, notes in part 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. The facility's protocol for turning and repositioning, dated 07/2018, notes in part residents that cannot assist themselves may be turned every two hours and/or as often as needed.

Based on interview and record review, the facility failed to follow its fall prevention and management policy and review and revise one resident's care plan after each fall. The facility also failed to implement effective interventions to eliminate or reduce resident's fall risk. This failure affects one resident (R3) out of three reviewed for falls in a sample of 36.Findings include:On 5/6/26 at 11:50 AM, V18 (restorative nurse) stated that she reviews risk management for any resident falls and does rounds asking staff if any resident has fallen in the past 24 hours. V18 stated that V2 DON (director of nursing) will alert her about a resident fall. V18 stated that she investigates each fall. V18 stated that she asks the resident if alert enough, checks for any staff witnesses. V18 stated that during the daily morning meeting IDT (interdisciplinary team) will determine what new interventions should be put in place. V18 stated that she is responsible for updating the resident's falls care plan after each fall. When questioned about what fall interventions were put in place after R3's fall on 2/23/26, V18 responded that she was not aware R3 fell. V18 stated that on 3/9, she placed larger floor mats on side of R3's bed. V18's documentation was reviewed with her. V18 acknowledged that she brought in a larger floor mat but R3 refused it. V18 was unable to verbalize if any other intervention was put in place. V18 stated that after R3's fall on 3/20 medication review was done due to R3's confusion at that time. V18 stated that V36 NP (nurse practitioner) decreased R3's trazodone medication from 50mg (milligrams) daily to 25mg daily. R3's trazodone medication orders were reviewed with V18; on 1/25/26 trazodone 50mg was discontinued and on 2/5 trazodone 25mg was ordered on an as needed basis only. V18 stated that on 3/26 an antibiotic was ordered for UTI (urinary tract infection). V18 was unable to provide any documentation that a urinalysis was done prior to initiating antibiotic. V18 stated that the root cause of R3's falls was due to her sitting up in bed. When questioned what fall prevention interventions should have been put in place, V18 responded frequent rounding was implemented after R3's fourth fall on 3/28. When questioned, V18 is unable to articulate what staff she spoke with after each fall, what were the predisposing factors, when R3 was last seen, and when did R3 last receive any pain medication/sedating medications.On 3/30/26 R3 was transported to the hospital and diagnosed with a right femur fracture.There is no documentation found in R3's medical record noting a root cause analysis was completed after each fall.The facility's comprehensive care plan policy, dated 04/2017, notes in part the comprehensive care plan will include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being while preventing decline; areas of potential risk to the resident with interventions to eliminate or reduce risk. Care plans are revised as changes in the resident's condition dictates.The facility's fall prevention and management policy, revised 12/2023, notes in part the development of the falls risk care plan is based on the results of the falls assessment as well as investigation of all circumstances and related resident outcomes. The falls care plan will be reviewed and revised with any fall event the resident might experience. In the medical record document the event, outcome, and initial and ongoing observations, and update fall risk assessment and care plan.

Based on observations, interviews, and record reviews, this facility failed to follow its call light policy and ensure the call light cord was within reach for 4 residents (R3, R5, R6, and R7) out of 4 residents reviewed for call light accessibility in a sample of 7. Findings include:On 2/13/26 at 9:45 AM, R3 was heard shouting hello from his room. This surveyor asked R3 if he needed assistance, R3 responded that he is uncomfortable sitting in the reclining chair and wants to go back to bed. R3 stated that he has been in this chair since 5:00 AM when he went to his dialysis treatment. R3's call light cord was observed between wall and folded floor mat behind head of bed. When questioned if he was able to use call light for assistance, responded yeah I can't find it. V2 DON (director of nursing) was called to R3's room. When V2 was asked where R3's call light cord was, V2 retrieved it from behind head of bed. V2 stated that the call light cord should be within R3's reach. On 2/13/26 at 11:45 AM, R5 was observed lying in bed. R5's call light cord was observed dangling on R5's wheelchair that was positioned on the right side of R5's bed. R5 stated that R5 does not know where his call light cord is. On 2/13/26 at 11:46 AM, R6 was observed sitting in wheelchair next to her bed. R6's call light cord was observed behind her wheelchair, not within reach. R6 stated that R6 does not know where his call light cord is. On 2/13/26 at 11:47 AM, R7 was observed sitting in wheelchair next to her roommate's bed. R7 stated that she does not know where her call light cord is. R7's call light cord was not within reach. The facility's call light policy, reviewed 06/2024, notes in part functioning call light placed where it is accessible to the resident.

Based on observations, interviews, and record reviews, this facility failed to identify, evaluate and eliminate hazards, and provide adequate supervision to prevent an avoidable accident in accordance with current professional standards of practice for one residents (R4) out of three residents reviewed for avoidable falls in a sample of 7. Findings include:On 2/13/26 at 9:55 AM, R4 was observed lying on his right side on the floor near bathroom. R4's wheelchair was observed on the right side at the head of R4's bed. R4's bedside table was observed positioned in front of wheelchair. R4 was observed wearing regular socks instead of non-skid socks. R4 stated that he slid while walking to bathroom because of the socks he was wearing. This surveyor shouted out for assistance. V11 (nurse) came immediately to R4's room. V11 stated that she is not R4's nurse today but responded to the call for staff assistance. V11 obtained R4's vital signs and performed a head-to-toe assessment, R1 sustained an open area to his right lateral lower leg. V8 CNA (certified nurse aide) and V9 CNA came to R4's room. Both CNAs stated that R4 is not able to walk, he is able to self-transfer to wheelchair, self-propel into the bathroom then self-transfer onto toilet. V11 stated that R4 is not wearing appropriate socks. V11 stated that she was going to get R4's nurse and left R4's room. V11 returned shortly thereafter and stated, I'm his nurse today, I did not know. R4's assigned CNA, V10, came into R4's room. V10 stated that R4 is not able to walk, he is able to self-transfer to wheelchair, self-propel into bathroom then self-transfer onto toilet. V10 stated that she last rounded on R4 when she arrived at work at 7:00 AM.R4's admission fall risk assessment, dated 12/23/25, R4 with a history of falls in the past three months. R4 has intermittent confusion, is chairbound, and incontinent.R4's falls care plan, initiated 1/2/26, notes R4 is at high risk for falls related to gait/balance problems. Interventions identified include, in part, anticipate and meet R4's needs.R4's ADL (activities of daily living) care plan, initiated 12/26/25, notes R4 has an ADL self-care performance deficit related to impaired balance. Interventions identified include, in part, transfers - R4 requires supervision by one staff to move between surfaces. The facility's fall prevention and management policy, revised 12/2023, notes, in part, the fall prevention and management practices include separate activities: universal fall precautions, standardized assessment of fall risk factors, care planning, and post fall response. Universal fall precautions are safety measures that are taken to reduce the chance of falls for all residents, regardless of individual fall risks. The fall risk assessment is used to identify fall risk factors. A fall risk care plan will be implemented to address universal fall precautions and individual risk factors as applies to the resident.

Based on observations, interviews, and record reviews, this facility failed to maintain its call light system in good working condition for one resident (R3) out of four residents reviewed for working call lights in a sample of 7. Findings include:On 2/13/26 at 9:45 AM, R3 was observed sitting in a reclining chair next to the bed closest to the door. R3's call light cord was observed between wall and folded floor mat behind head of bed. When questioned if he was able to use call light for assistance, responded yeah I can't find it. V2 DON (director of nursing) was called to R3's room. When V2 was asked where R3's call light cord was, V2 retrieved it from behind head of bed. V2 handed R3 call light button and R3 was asked to demonstrate how to use it. R3 pressed the call light button; the light did not activate in hallway above R3's door. R3 was asked to press again, the light still did not activate. R3 was given the call light cord for the bed furthest from the door and asked to press call light button, the light was activated in hallway above door. V2 stated that R3's call light does not work, and she will have it replaced. V2 stated that staff should be checking residents' call lights to ensure functioning properly. The facility's call light policy, reviewed 06/2024, notes functioning call light will be placed where it is accessible to the resident.

Based on interview and record review, the facility failed to prevent facility acquired pressure ulcer injury to residents at risk for pressure ulcers. The facility also failed to initiate wound treatment for facility acquired pressure ulcer. These failures affect two residents (R2, R5) of three residents reviewed for pressure ulcer/skin alteration. These failures resulted in R2 developing a facility acquired pressure ulcer injury and R5 developing three facility acquired pressure ulcer injuries.Findings include:1. R2 is a [AGE] year-old female resident. admitted in the facility on 11/27/25 and discharged on 12/12/25. admitted with multiple wounds including surgical site and pressure ulcer injuries.Record reviewed and R2 was assessed to be moderate risk for pressure ulcer. Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated11/27/25, score of 13 (Moderate Risk).On 12/05/25, it is documented that R2 had developed a facility acquired pressure ulcer injury. Location: Rear Left Thigh, with measurements of 4.96cm x 7.46cm x 0 (L x W x D). Wound is not staged and no other description documented with this assessment.On 1/21/26 at 11:20AM. V7 (Wound Nurse) stated that R2 is high risk for pressure ulcer injury and needs to be repositioned. R2 is High Risk due R2's mobility and R2 is dependent and total care. R2 developed a facility acquired pressure ulcer on rear left thigh assessed and documented on 12/5/25. I don't see a (stage) and other descriptions of the wound. I do not see wound treatment order also.On 1/22/26 at 9:30AM, V7 (Wound Nurse) stated that V7 does not know why the nurse who assessed the newly facility acquired pressure ulcer did not put the stage and other description of the wound. V7 stated that when assessing a wound, V7 will assess and document location site, measurement, staging and the wound bed (eschar, slough, granulation, epithelial, drainage and what type and amount). V7 stated looking at the picture taken by the nurse, V7 would stage the wound as unstageable.On 1/21/26 at 11:30AM, Treatment Administration Record and Physician Order Sheet reviewed with V7 and V7 confirmed that there is no treatment order for this sire: rear left thigh pressure ulcer. No treatment order and non-rendered from initial date for this acquired pressure ulcer wound on 12/5/25 until discharged date of 12/12/25.On 1/22/26 at 11:45AM, V19 (Wound Physician) stated that V19 can recall seeing R2 twice during R2 stay in the facility. V19 stated V19 is having problem pulling wound documents for the R2. V19 stated IT department already contacted to help V19 track down V19's wound notes for R2.V19 also stated that R2 has multiple wounds present upon admission. V19 does not recall the specific wound location site. V19 stated it is important to have a treatment for a wound as soon as it is identified. Needs treatment to take proper care of the wound. Although there is no order under physician order, it doesn't mean the resident was not getting treatment.2. R5 is a [AGE] year-old female admitted in the facility on 11/7/2024, she was sent out to the hospital on [DATE]. R5 receives dialysis at the facility every Monday, Wednesday, and Friday and requires assistance with activities of daily living. R5 is transferred to a reclining chair when she is transported for dialysis.On 1/21/2026 at 11:40 AM, V7 (Wound care coordinator), was interviewed and stated that R5 was admitted to the facility with intact skin. R5's Braden Scale for predicting pressure sore risk showed a score of 17 on 6/11/2025 and a score of 17 on 9/1/2025, both of which were interpreted as at risk for pressure injury. V7 stated that R5 developed three (3) facility-acquired pressure injuries during R5's stays in the facility. R5's Skin and Wound evaluation was reviewed with V7. Wound #1 - Right heel Pressure injuryInitially identified on 11/12/2025 as a new ulcer/wound documented as a Diabetic ulcer; re-assessed on 11/19/2025 and classified as a Stage 4 pressure injuryWound measurements: 3.81 cm x 2.9 cm (surface area: 9.09 cm^2)Wound bed composition: Granulation tissue: 10%, Slough: 10%, Eschar: 80%Wound #2 - Coccyx/Sacrum Pressure injury Initially identified 12/9/2025 as a new Unstageable pressure ulcer in the CoccyxWound measurements: 4.96x 6.97 cm (surface area: Area31.23 cm^2)Classified as Unstageable pressure injury to coccyx and the site/wound location was changed to Sacrum on 12/9/2025Unstageable ulcer due to Slough and/or escharWound #3 - Rear Left thigh Pressure injury (Ischium)Initially identified on 12/17/2025 as a new Unstageable ulcerWound measurements: 3.97 cm x 2.68 cm (surface area: 7.91 cm^2)Classified and Described as an unstageable pressure injury presenting as a deep tissue injuryV7 was asked how she became aware of the wound on R5's right heel wound. V7 stated that a floor nurse reported to her that R5 had a wound on the right heel; however, she could not recall the name of the nurse who reported it. V7 further stated that she assessed the wound herself and identified it as a diabetic ulcer then classified as a Stage 4 pressure injury after re-assessment.V7 stated that certified nursing assistants (CNAs) check residents' skin while providing care, such as during showers. If they observe any wounds or changes in skin condition, they report their findings to the nurse for assessment and, if necessary, referral to the wound care team. However, V7 confirmed that there was no documentation showing R5's skin alteration prior to the identification of multiple facility-acquired pressure injuries.R5 was referred to V19 (Wound physician) for wound evaluation. V19 confirmed via phone call on 1/22/2026 at 11:52 AM that he saw and evaluated R5's pressure wounds.11/25/2025 seen for Right heel wound; wound report stated that the wound is Stage 4 pressure injury measuring 5.5x4.4 cm and depth is unmeasurable due to presence of nonviable tissue and necrosis12/9/2025 seen for Sacrum wound; wound report stated that the wound is Unstageable Necrosis measuring 5.0x7.0 cm and depth is unmeasurable due to presence of nonviable tissue and necrosis12/16/2025 seen for Left ischium: wound report stated that the wound is Unstageable Deep Tissue Injury (DTI) with intact skin measuring 4.0x2.7On 1/21/2026 at 1:46 PM, V15 (Registered Nurse/RN) stated that nurses complete weekly skin assessments, including head-to-toe assessments. V15 stated that assessments are often performed while CNAs are changing or bathing residents to allow for better visualization of the skin. V15 reported that nurses inspect the skin by removing garments to check for redness or open areas that are not being treated. V15 stated that findings are documented on a form that is completed and submitted to the wound care team, with the affected areas circled and signed by the nurse. V15 further stated that CNAs also report skin concerns to nursing staff. V15 said that even mild changes in skin condition are reported to the wound care team, which then provides treatment orders. V15 stated that any redness or skin changes should be reported promptly to prevent progression to more severe conditions, including Stage 4 pressure injuries, and that wounds should be treated immediately.On 1/22/2026 at 8:52 AM, V17 (RN) stated that certified nursing assistants check residents' skin during showers and while providing care. If any skin alterations are observed, they are reported to the nurse for assessment, and the nurse then relays the information to the wound care team. V17 further stated that regular skin assessments are important to identify wounds early, noting that pressure injuries typically begin with redness and can be addressed before progressing to a more severe stage like into a stage 4 pressure ulcer.On 1/22/2026 at 12:30 PM. V2 (Director of Nursing/DON) was interviewed regarding R5. V2 was asked why there were no shower sheets documenting that R5 had skin conditions prior to the discovery of Stage 4 pressure injury to the right heel and unstageable wounds to Sacrum and Left ischium. V2 responded that CNAs may have assumed that nurses were already aware of R5's wounds and failed to notify the wound care team about it. V2 stated that reporting the wound earlier would have allowed proper treatment and believed the wound could not have worsened if reported sooner. V2 acknowledged that there was a lapse in reporting skin conditions and V2 emphasized that if a wound is pressure-related, it should be treated immediately or appropriately dressed to prevent progression and infection. V2 also agreed that a stage 4 pressure ulcer could not develop overnight, and therefore there should have been observable signs of skin alteration prior to the ulcer's development that was reported to the wound care team.V21's NP (Nurse Practitioner) note dated 12/15/2025 that the NP saw R5 due to ESBL (Extended-Spectrum Beta-Lactamase) infection of the right heel. Wound was swabbed (tested) on 12/9/2025 and final culture and sensitivity report came out positive for ESBL on 12/13/2025, R5 was referred to infectious disease doctor. The record further showed that R5 was started on intravenous (IV) antibiotics on 12/15/2025, for an infection of the right heel pressure injury, specifically Invanz (ertapenem) IV 1 gram daily for 10 days. The record also showed that R5 received intravenous antibiotic therapy with Unasyn 1.5 grams every 12 hours on November 14, 2025, for a right heel wound infection.According to nurse interviews, nurses reported performing complete weekly skin assessments, including head-to-toe assessments, which are often conducted while CNAs are changing or bathing residents to allow for better visualization of the skin. However, review of documentation revealed no shower sheets or assessment records indicating that R5's skin was assessed during showers or while care was being provided prior to discovering the wounds.The failure to identify early detection of skin conditions and alterations led to one (1) stage 4 and two (2) unstageable pressure injuries. Proper treatment and interventions were not put in place to possibly prevent wound worsening and infection. The lapse in reporting led to failure in providing treatment.POLICIES:Pressure Ulcer Treatment and Management Policy with a revised date of 5/2022, reads in part: Residents will receive treatment for pressure injuries.Residents with pressure ulcers will have a physician's order for treatment.A description of the wound will be maintained on a weekly basis.The licensed nurse will the document treatment as given on Treatment Administration Record.Pressure Ulcer Prevention Protocol with a revision date of 5/2018, reads in part: Resident will be assessed to determine their risk factor(s) for pressure ulcer development, upon admission and at least quarterly thereafter.Newly admitted or readmitted residents will have a Pressure Ulcer Risk Assessment completed upon admission, weekly thereafter for the next 3 weeks after admission.Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each residence individual needs and risk, which may include:Daily skin checks conducted by either the CNA or licensed Nurse to ensure early identification of potential problem areas.Plan of care to address mobility status and ability to reposition self.Use of Pressure Reducing Devices, such as pressure reducing mattresses, mattress overlays, w/c cushioning devices if needed.Determination of need for supplemental skin care such as barrier care or moisturizing lotion.Any other factor identified on the risk assessment including but not limited to nutritional support, positioning support devices or medication review.The resident care plan will indicate the resident's risk factor(s) and include individualized interventions as needed for a comprehensive pressure ulcer prevention program.Residents will have their skin checked and documented utilizing the Treatment Administration Record. This skin check will be performed at a minimum of weekly.Documentation:Pressure Sore Risk Assessment (Braden Scale)Skin Check DocumentationCare PlanPressure Ulcer Treatment and Management with a revised date of 5/2017, reads in part:Residents with pressure ulcers will have a physician's order for treatment.A description of the wound will be maintained on a weekly basis.The licensed nurse will document the treatment as given on the Treatment Administration Record.A Skin Risk Assessment will be completed quarterly on all residents.The clinical record will indicate whether the resident was admitted with a pressure ulcer, or the ulcer was acquired in the facility.The plan of care will include the presence of the pressure ulcer and include the individual description of the treatment plan including pressure relief, turning and repositioning, additional nutritional measures, need for assistance with mobility and range of motion.The physician will be notified when the assessment indicates a lack of progress in healing.Residents with pressure ulcers will be determined to be high risk for pressure ulcer prevention and all components of the At-Risk protocol will include Pressure relieving devices, nutritional support, assistance with mobility including repositioning and ROM as outlined in the At Risk Procotol.The licensed nurse will perform the treatment utilizing standard precautions for infection control. Any wound drainage cultured wound necessitates the need to follow the CDC guidelines for isolation precaution as necessary.Documentation:Physician Order SheetSkin Risk AssessmentTreatment Administration RecordCare PlanWound Dressing Policy with a revised date of 5/2017, reads in part:Objectives: To provide an appropriate type of protective wound covering that facilitate the healing process.Procedure: Change dressing using clean technique according to physician orders. Frequency of wound dressing changes and the type of wound dressing will be specified in the physician's order.

Based on interview and record review, the facility failed to ensure a resident was properly secured while being transported using the facility's private transport vehicle. This failure affects one of three residents (R3) reviewed for falls. R3 fell forward inside the facility's private trasnport vehicle and sustained a right intertrochanteric femur fracture requiring surgical repair of Intramedullary nailing of the right proximal femur.Findings include:R3 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis and muscle wasting and atrophy.The Facility Reported Incident dated 11/11/25 reads in part: R3 experienced a fall from wheelchair during transport while in route back to the facility after an appointment. Upon returning to facility, R3 was assessed and complained of severe pain in right leg. Nurse practitioner present in the facility and ordered to send R3 out to emergency department via 911 (emergency transfer). R3 was transferred to local hospital. Hospital records indicate R3 sustained a right intertrochanter femur fracture.Summary of Investigation: R3 alert and oriented x 3 with periods of forgetfulness. R3 scored 13 on Brief Interview for Mental Status (BIMS) assessment and is able to make her needs known. V10 (CNA) stated R3's wheelchair was locked in place with seatbelt secured around R3. V10 verbalized while V10 was transporting the resident back to facility, V10 approached a red light and applied breaks. V10 stated in the rearview mirror, V10 observed R3 slide out of R3's wheelchair and onto the floor of the vehicle, landing on R3's buttocks. V10 immediately stopped and tended to R3. V10 verbalized R3 denied pain and assisted back R3 into the wheelchair. Upon arrival back in the facility, R3 reported leg pain. V10 said V10 promptly assisted R3 to bed and notified the nurse of the incident and complaints of pain. Nurse immediately assessed R3.Nurse (V8) stated V10 notified V8 that R3 slid out of R3's wheelchair during transport and onto the floor of the vehicle. V8 verbalized V10 stated R3 was back in bed and verbalized right leg pain. V8 assessed R3 and observed external rotation and shortening of resident right lower extremity.Per R3, once R3 arrived back to the facility, R3 started to feel severe pain in her right lower extremity and was assisted back to bed by V10.Conclusion: The facility determined R3 fall likely occurred from force applied to the vehicle breaks.On 1/20/26 at 2:45PM, R3 stated that V10 (CNA) was the driver of the vehicle. On their drive back in the facility, V10 abruptly pressed the break and R3 fell forward and landed on the vehicle floor. R3 stated R3's wheelchair was not strapped or properly secured. R3 also denied the seatbelt was applied on R3. R3 stated that R3 was sure that the wheelchair was not strapped and properly secured because as R3 fell forward, the wheelchair also moved and tipped over, landed and hit R3 on the head. V10 stopped the vehicle and asked R3 if R3 is okay and if there is any pain. R3 denied pain at the time, and V10 assisted R3 back onto the wheelchair. Upon arrival in the facility, R3 reported to V10 that R3 had right leg pain. V10 continued to take R3 in her room and transfer R3 back to bed. R3 then reported the nurse came in to assess her pain. R3 then reported to the nurse about the incident that happened during transport.Nurse Practitioner notes dated 11/10/25 at 1530, reads in part: R3 said R3 went to appointment with R3's physician and that R3 slipped out of her wheelchair and hit R3's head. R3 denies any headache but does have right hip pain. Upon assessment right hip looks shortened and externally rotated. R3 admits to pain when right hip assessed with abduction and adduction.On 1/20/26 at 12:30PM, V8 (RN) stated that R3 went for appointment and transported by V10 using the private facility vehicle. Denied getting a phone call from V10 regarding the accident during transport. V8 stated she was not even made aware that R3 had returned to the facility. It was just reported to V8 that R3 is complaining of pain, but V8 does not recall who the staff member was that reported the pain to V8. V8 stated she does not recall upon entering R3's room if R3 was already in bed. But recalls assessing R3's right leg. V8 stated V8 observed swelling on right hip and all the way to right thigh. Also observed right leg shortening and external rotation. V8 reported it to the nurse practitioner who was in the facility at the time and went to see R3 also in her room and ordered to call 911.On 1/21/26 at 2:05PM, V2 (Director of Nursing) stated that V2 investigated the incident and reported it to State Survey Agency. V2's expectation is for V10 to pull over on the side of the road, and call the facility, or as soon as they arrived in the facility to report it to V2 and nurse. For the V10 (CNA) to report to the nurse and have the nurse assess the resident before moving and transferring the R3 back to bed, after the fall incident, especially if the resident was complaining of pain. V2 also stated that facility policy for fall incidents would say to report the fall and not to move the resident without assessment.Clinical Guideline Falls Management with a revised date of 3/2022, reads in part:Post Fall Response: Resident who fall require observation and ongoing monitoring.Immediate Post Fall Care: Prior to moving the resident, assess for injury (e.g., abrasion, laceration, fracture, head injury, bleeding). If resident fell forward and hit chin, consider neck injury and handle resident to assure this until physician notification. Activate appropriate emergency response (Code Blue, 911) as required for serious injury.Perform verbal assessment to the cause of the fall and potential for injury.Perform physical assessment including:Cognition, range of motion/mobility, skin evaluation, pain assessment.Vital signs: Temperature, Pulse, Respiratory Rate, Pulse Ox, Blood Pressure, painNeurological assessments should be performed for unwitnessed falls or fall with potential head injury.

Based on interviews and record reviews, the facility failed to follow its abuse prevention policy and notify the State Survey Agency within the required two-hour timeframe of allegations of abuse and injury of unknown origin for six residents (R1, R2, R3, R4, R5, and R9) out of seven residents reviewed for abuse in a sample of 10.Findings include:On 9/18/25 at 3:00 PM, V1 (administrator) reviewed the date and time allegations of abuse were known and the date and time the initial reports were sent to the State Survey Agency. V1 acknowledged that the initial reports for an allegation of abuse or an injury of unknown origin must be reported immediately but not more than two hours after allegation is known.1. R1's family member on 7/21/25 at 2:00 PM reported he observed bruising on R1's arm. When R1 was questioned, R1 stated that V4 CNA (certified nurse aide) had been rough during care for R1. An abuse investigation was initiated. The initial report was not sent to the State Survey Agency until 7/21/25 at 6:06 PM.2. On 9/18/25 at 11:23 AM, V5 RN (registered nurse) stated that she recalls the conversation she had with R2's family member on 7/25/25. V5 stated that R2's family member alleged a male resident came into R2's room during the night and got in bed with R2. V5 stated that this allegation that was made would be something facility would investigate as allegation of abuse. V5 stated that V5 shared this information with the ADON (assistant director of nursing) shortly after speaking with R2's family member at 6:03 PM.R2's medical record, dated 7/25/25 at 6:03 PM, V5 RN (registered nurse) noted V5 spoke to R2's family member over the phone as R2's family member was unable to come by today (7/25). V5 relayed details of the conversation with R2. R2's family member stated that R2 told her a man came into R2's room and got into bed with R2.R2's medical record notes the incident occurred overnight 7/24 into 7/25.The initial allegation of abuse report was not sent to the State Survey Agency until 7/27/25 at 3:32 PM.3. On 7/3/25 at 9:30 AM, R3 alleged V12 CNA, overnight CNA, was rough while changing R3 and ignored R3's care preferences. An abuse investigation was initiated. The initial report was not sent to the State Survey Agency until 7/3/25 at 12:32 PM.4. On 9/18/25 at 10:45 AM, V8 (nurse) stated that V8 provided care for R4 on 8/15/25. When questioned when V8 notified V1 (administrator), V8 scrolled through her text messages on her phone and stated at 8:01am on 8/15/25 she started notifying management. V8 stated that when V8 was entering R4's room she observed a purple discoloration left lower face/chin area. V8 stated that when she assessed R4 she observed bruising in various stages on R4's face, R4's left cheek was yellowish green. V8 stated that R4 swings her right arm most of the time; R4's right side is hyperactive. V8 stated that V8 was informed that the day prior, R4 shifted herself around in bed.R4's medical record, dated 8/15/25 at 8:30 AM, V8 (nurse) noted bruising on R4's left side of face. An injury of unknown origin investigation was initiated on 8/15/25. The initial report was not sent to the State Survey Agency until 8/15/25 at 3:18 PM.5. On a facility grievance/concern form, dated 7/15/25, R5's family member reported to V1 (administrator) that a nurse allegedly gave R5 a medicine that was not ordered for R5 (melatonin). The initial report was not sent to the State Survey Agency until 7/17/25 at 3:44 PM.6. On 9/11/25 at 2:30 PM, R9 reported that a male staff member touched R9 inappropriately during care earlier in the day. The initial report was not sent to the State Survey Agency until 9/11/25 at 5:34 PM.The facility's abuse prevention policy, revised 10/2022, any allegation of abuse will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. The Illinois Department of Public Health will be notified of injuries of unknown origin. Time frames for reporting and investigating abuse will be followed.

Based on interview and record review, the facility failed to develop a person-centered care plans for four residents (R1, R2, R3, and R4) identified as at risk for abuse out of four residents reviewed for abuse in a sample of 10. Findings include:On 9/18/25 at 1:00 PM, V9 SSD (social services director) stated that social services is responsible for initiating/updating care plans related to resident behaviors, mood, and cognitive status. V9 stated that social services is not responsible for completing an abuse care plan for residents. V9 stated that V9 does not know who is responsible for initiating/updating the abuse risk care plan.On 9/18/25 at 1:23 PM, V2 DON (interim director of nursing) stated that the nurses are responsible for initiating/updating nursing related care plans, such as resident diagnosis. V2 reviewed the abuse risk assessment completed for R2. V2 stated that social service did R2's abuse risk assessment. V2 stated that care planning required that appears next to the abuse risk assessment indicates a care plan needs to be done for that resident. V2 stated that V2 thinks social services is responsible for initiating an abuse risk care plan for the resident.On 9/18/25 at 2:19 PM, V10 (social service assistant) stated that V10 and V9 complete abuse risk assessments on all residents. V10 stated that they do not initiate an abuse care plan rather document under the resident's cognition, mood, or behaviors care plan. V10 stated that they would note the allegation of abuse under the resident's behaviors care plan. 1. R1:R1's abuse risk assessment, dated 6/5/25, notes R1 is at risk for abuse/neglect evidenced by him being physically and mentally dependent on staff to make decisions and complete basic ADLs. It also notes care planning required.R1's medical record does not note an at risk for abuse care plan was initiated. 2. R2:R2's abuse risk assessment, 7/10/25, notes resident is at risk for abuse/neglect evidenced by her being physically dependent on others to complete basic ADL care. It also notes care planning required.R2's medical record does not note an at risk for abuse care plan was initiated. 3. R3:R3's abuse risk assessment, dated 8/14/25, notes R3 is at risk of abuse attributed to complications of her diagnosed chronic medical health conditions, exhibited impaired mobility status and exhibited lack of safety awareness. It also notes care planning required.R3's medical record does not note an at risk for abuse care plan was initiated. 4. R4:R4's abuse risk assessment, dated 7/14/25,notes R4 is at risk for abuse attributed to her exhibited non-verbal communication deficit, exhibited fluctuations in her cognitive functioning status and exhibited impaired mobility status. It also notes care planning required.R4's medical record does not note an at risk for abuse care plan was initiated.

Based on observation, interview and record review, the facility failed to identify causes of resident weight loss; failed to identify that a resident had AIDS (acquired immunodeficiency syndrome); failed to monitor R3's HIV diagnosis according to professional standards; failed to develop a plan of care to address known weight loss and refusals of care; failed to notify providers of abnormal lab results; failed to notify providers of severe weight loss; failed to follow physician orders for lab work; failed to notify the provider/implement dietician recommendations timely. These failures affect 1 resident (R3) reviewed for quality of care. These failures caused harm to R3 as evidenced by a 5.5% weight loss in 6 days, an 8.2% weight loss within a month and a 16% weight loss within 3 months.Findings include:R3's face sheet documents in part a diagnosis of HIV (Human Immunodeficiency Virus) hemiplegia and hemiparesis of the right side, memory deficit following unspecified cerebrovascular disease, and schizoaffective disorder. R3's significant change MDS (minimum data set) (6/6/2025) documents R3 has a brief interview of mental status (BIMS) summary score of 10, indicating that R3 has moderate cognitive impairment and R3 has had weight loss that was not prescribed by the physician. On 6/30/2025, an additional BIMS assessment was completed for R3 with a summary score of 6, indicating new cognitive decline and severe cognitive impairment. R3's laboratory testing indicates on 5/17/25, R3 had abnormally low CD4 (Cluster of Differentiation 4) levels of 151 uL (microliter.) No laboratory values for R3's HIV viral load were noted within the medical record and were not provided by the facility prior to the end of the survey. R3's medication administration record (MAR) dated June 2025 documents R3 refused medications for HIV treatment 14 times in 1 month. R3's documentation of R3's weights is as follows:-12/5/2024 106 lbs (pounds) -1/3/2025 105 lbs-3/3/2025 105.6 lbs-4/4/2025 106.4 lbs-5/7/2025 101.8 lbs (-4.3% weight change from comparison weight 4/4/2025) -5/26/25 97.6 lbs (-4.1% change from 5/7/2025; -7.6% change from 3/3/2025) -6/5/2025 97.8 lbs (-8.1% change from 4/4/2025) -6/11/2025 95.2 lbs (-10.6% change from 4/4/2025, -10.4% change from 12/5/2024)-6/17/2025 90 lbs (-5.5% change 6/11/2025, -8.2% from 5/26/2025, -15.4% from 4/4/2025)-6/24/2025 89.4 lbs ( -16% from 4/4/2025, -9.2% from 5/26/2025, -15.2% from 1/3/2025)R3's progress notes document V9 (Infectious Disease (ID) Nurse Practitioner (NP)) visited R3 on 5/13/2025 for R3's diagnosis of HIV and gave the following orders: .-Order CD4 and viral load, -Monitor CBC (Complete Blood Count), CD4 and viral load, -Staff to continue to monitor, -Inform PCP (Primary Care Physician)/PCNP (Primary Care Nurse Practitioner) or ID if acute change in condition or fever . There is no evidence the viral load order was carried out by the nursing staff. On 5/16/2025, V14 (Registered Nurse) reached out to V7 (Physician) and notified V7 of a change in condition described as functional decline including refusals of medications, decreased appetite, refusing food/drink. V7 responded to V14 and stated that V7 would come visit the R3 and to follow up with Infectious Disease MD (medical doctor). On 5/20/2025, V7 was notified by V14 of R3's change in condition described as decrease in appetite, refusing meds, not wanting to get out of bed and a general change in mental status. V7 reviewed the abnormal CD4 lab values and assessed the resident and ordered the resident to be sent to the hospital for further assessment for altered mental status. The abnormal CD4 laboratory results or diagnosis of acquired immune deficiency syndrome (AIDS) was not identified by V7. R3 was hospitalized from [DATE] until 5/23/2025 for a urinary tract infection. On 5/27/2025, V9 (Infectious Disease Nurse Practitioner) visited R3 and did not review the abnormal CD4 lab. On 6/6/2025, a significant change was identified by the facility and a significant change MDS was completed by the facility's interdisciplinary team. On 6/6/2025, V8 (Physician) assumed care from V7 and completed a visit with R3. During this visit, V8 did not identify the abnormal CD4 values resulted on 5/17/2025 and did not identify that R3 had AIDS. On 6/10/2025, V6 (Registered Dietician) identified that R3 had weight decline, was concerned with adequate by mouth intake and recommended an appetite stimulant if not contraindicated. There is no documentation that this recommendation was communicated to a provider. On 6/20/2025 (documented on 6/25/25), V8 examined R3 and identified significant weight loss, failure to thrive, HIV and ordered in response: (unknown medication) Consider starting dose: 7.5 mg at bedtime Can be titrated based on response and tolerability, usually in 7.5?15 mg/day range for appetite. There is no documentation in the progress notes that indicates that the significant weight loss warnings from 5/7/2025, 5/26/2025, 6/5/2025, 6/11/2025, 6/17/2025, and 6/24/2025 were communicated to a provider. On 6/25/2025 at 1:15 PM, R3 was observed lying in bed and appeared cachexic. R3 had unintelligible speech at this time while trying to conversate.On 6/25/2025 at 1:49 PM, V5 (Restorative Nurse, Licensed Practical Nurse) affirmed that V5 is responsible for monitoring weights within the facility and addressing weight loss. V5 explained that R3 has had significant weight loss since May of 2025 and that the dietician was aware. R3 has been refusing meals and the facility does not know the cause of R3's decreased appetite. V5 stated, nothing seems to be working. We don't really know why. V5 affirmed that R3 has had significant decline. On 6/26/2025 at 10:15 AM, V2 (Director of Nursing) stated that V2 was aware that R3 had weight loss but was unsure of the cause of the weight loss. Surveyor reviewed the abnormal CD4 result (5/17/2025) with V2 (Director of Nursing) and V2 affirmed that V7 (Physician) reviewed the laboratory result. V2 denied knowledge of the result, affirmed that the resident could have AIDS, and was unsure if V7 had identified the abnormal CD4 level. V2 denied any knowledge that R3 was ever diagnosed with AIDS or if AIDS had ever been identified for R3. V2 affirmed that AIDS is life-threatening, can cause weight loss, and patients with AIDS have unique care needs in comparison with a resident with HIV. V2 stated that notifications of changes in a resident's health status made to the provider and family should be noted within a resident's progress notes. V2 was unsure of how often the facility was monitoring R3's CD4/HIV viral load. V2 affirmed that the last time R3 had lab work related to R3's HIV diagnosis was 1/28/2024. The facility was unable to provide additional documentation for lab monitoring prior to the exit. R3's physician orders do not document any active standing orders for regular monitoring of R3's CD4 and HIV viral load. On 6/26/2025 at 11:38 AM, V10 (Infection Preventionist, Licensed Practical Nurse) affirmed that V10 was aware of R3's HIV diagnosis. V10 reviewed R3's medical record and affirmed there was no active orders to monitor CD4 counts or Viral Load and that the 5/17/25 lab was abnormal for CD4. V10 reviewed R3's progress notes and providers documentation including but not limited to, V7 (Physician), V8 (Physician), V9 (Infectious Disease Nurse Practitioner) and V17 (Nurse Practitioner) and affirmed that the lab value was not addressed and that AIDS was not identified by any of R3's practitioners. V10 stated that AIDS can cause weight loss, increases their risk of opportunistic infections and places them at risk for death. On 6/26/2025 at 11:25 AM, R3 was observed lying in bed and V11 (MDS Nurse, Registered Nurse) affirmed that R3 had sunken in cheek bones, visible ribs, and sunken in areas around R3's collarbones (symptoms of cachexia, muscle wasting). When R3 was asked if R3 had lost any weight, R3 shook R3's head indicating yes. V11 affirmed that the facility is aware of R3's significant weight loss but was not sure the cause of the weight loss. On 6/26/2025 at 12:01 PM, V6 (Registered Dietician) affirmed that V6 is the dietician contracted to the facility. V6 stated that V6 was familiar with R3 and has a history of weight loss. V6 explained that R3 continues to lose weight despite having as many supplements as we (the facility) can provide. V6 had been told from staff that R3's appetite was poor so V6 recommended an appetite stimulant on 6/10/2025 to address the weight loss if the medication was not contraindicated. V6 stated that the facility needed to review that recommendation with a medical provider and that V6 expects when recommendations are made that they are communicated timely. V6 believed that R3 could have greatly benefited from an appetite stimulant to address R3's weight loss. Surveyor reviewed R3's lab work with V6 and V6 stated I (V6) had no idea that R3 had AIDS. I don't look at labs like that (CD4), I only look at labs like electrolytes. I rely on nursing or the providers to communicate information to me like that. AIDS can cause significant weight loss and cause decreased appetite. (R3) having AIDS would make perfect sense as the cause of his weight loss and lack of appetite! Now that I know (R3) has AIDS, I would say the root cause of (R3's) weight loss is the AIDS. R3's weights were reviewed with V6 and V6 affirmed that R3 has had severe, unintended weight loss.On 6/26/2025 at 12:54 PM, V8 (Physician) affirmed that V8 is the primary care provider for R3 and assumed care after V7 (Physician) on 6/1/2025. V8 stated that a CD4 <200 units/liter indicates that a patient has AIDS. V8 affirmed that treatment for AIDS vs. HIV differs, that AIDS can cause weight loss, and that AIDS is a life-threatening condition. V8 affirmed that V8 was aware that R3 had a diagnosis of HIV but was unsure of who was following/treating R3's HIV. V8 explained that V8 defers to an infectious disease consult to manage HIV. R3's CD4 laboratory testing was reviewed with V8 and V8 affirmed that the CD4 level indicated that R3 had AIDS. V8 denied any knowledge of R3's CD4 levels prior to the interview and was never told that R3 had AIDS. V8 stated R3's weight loss certainly could be caused by AIDS and that AIDS would cause the lack of appetite and changes in condition that R3 had been experiencing. V8 stated that V8 was not notified of the dietician recommendation of an appetite stimulant until V8's visit with R3 on 6/20/2025 (the medication was not administered until 6/30/2025). V8 stated that the facility should be notifying V8 with weight loss and dietician recommendations. V8 explained that R3 frequently refuses medications/care and that this can place R3 at risk for AIDS and HIV-resistant infections. V8 affirmed that a plan of care should have been developed in response to R3's weight loss and refusals of HIV medication. V8 explained that the standard of care for monitoring a patient with HIV is a CD4/HIV viral load no longer than every 6 months. When the surveyor notified the physician that the last time the facility had documentation the CD4 was tested was 1/2024, V8 replied (R3) is lucky to be alive if (R3) had had AIDS this whole time. V8 explained that V8 has reviewed hospice care with R3 and stated, I (V8) think (R3) is even more appropriate for hospice care now that I know (R3's) failure to thrive is caused by AIDS. Review of R3's care plan does not document any identification, goals or interventions related to R3's identified weight loss and does not document any interventions of weight monitoring in R3's HIV care plan. A refusal of care and weight loss care plan was added on 6/27/2025 (after the start of the survey). On 6/26/2025 at 1:08 PM, V12 (MDS Nurse, Registered Nurse) reviewed R3's medical record, affirmed that there was not a weight loss care plan in place for R3, no monitoring of weight related to R3's HIV diagnosis, and that R3's care plan should have addressed R3's significant weight loss. V12 stated that the purpose of the care plan and the resident assessment process is to identify resident needs and have a plan in place to address their problems. V12 reviewed R3's weights and affirmed that R3 has had significant weight loss. V12 stated when weight loss is identified, the provider should be immediately notified to address the weight loss and a plan should be put in place. On 6/26/2025 at 3:01 PM, V1 (Administrator) stated that V7 no longer has a relationship at the facility due to care concerns. V7 was attempted to be reached via phone on 6/25/2025 and 6/26/2025 and was unable to be reached. On 6/30/2025, R3's MAR documents an appetite stimulant (Mirtazapine 7.5 mg (milligrams)) was started (20 days after V6 gave the recommendation). On 6/30/2025 at 9:31 AM, V9 (Infectious Disease Nurse Practitioner) affirmed that V9 is the rounding infectious disease provider at the facility and that V9 sometimes rounds on HIV positive patients or they go to the specialized center. V9 recalled seeing R3 during rounds in May and asked V10 (Infection Preventionist, Licensed Practical Nurse) which provider was managing R3's HIV diagnosis. V10 told V9 that V10 was unsure and that V9 could follow so V10 put in labs. V10 stated that the standard of care for HIV positive patient lab work is a CD4 and viral load is drawn every 3 months but may need more lab work if they are unstable, maybe monthly. V9 denied that any staff member of the facility has communicated any concerns with R3's HIV diagnosis or results of the ordered lab work V9 had ordered. V9 stated, If the labs were abnormal or not collected, I would have expected the facility to call me. V9 explained that when a patient has a CD4 of less than 200 units/liter, the patient is considered to have AIDS. V9 stated that AIDS can cause weight loss, loss of appetite, opportunistic infections and is life threatening. Surveyor reviewed the lab work provided with V9 and V9 affirmed that R3 had AIDS. V9 stated, I had no idea of these lab results. The facility never told me that (R3's) CD4 was that low. I did not review the CD4 lab results when I visited (R3) on (5/27/25), I am not sure if the results were even available for me to view. I haven't had any calls or concerns about (R3's) HIV diagnosis or refusal of medications from the facility. They (the facility) should have told me, I could have changed his orders, like I would have also made sure psych was on board to manage the refusals of care. Refusing HIV meds can also put the resident at risk of developing AIDS. I wasn't made aware and didn't know the facility didn't follow my order for a viral load either. (V7) did not make me aware of the results either.On 6/30/2025 at 10:00 AM, V14 (Registered Nurse) stated that V14 is regularly assigned to care for R3 and was assigned to care for R3 today. V14 described that R3 has had a change in condition in June and explained that R3 has had very poor appetite, non-compliant with medications at times, and doesn't like to get up out of bed. V14 recalled reporting these symptoms to R3's physician (V7) and recalled that R3 was admitted for a UTI at the end of May (2025). V14 stated, (R3) is really declining. I have noticed that R3 has lost a little weight but restorative handles that. (R3) seems appropriate for hospice now due to the decline, (R3's) providers have been discussing it with (R3) lately. V14 stated that when a resident refuses care the provider needs to be notified immediately, especially if education doesn't work. V14 affirmed that restorative notifies the provider of weight changes but the nurses are responsible for communicating lab results to the providers immediately if they are abnormal. V14 stated that V14 was unaware of R3 having AIDS until the end of last week. V14 stated that AIDS can cause weight loss and is life threatening. V14 affirmed that if the facility was addressing the refusals of care or weight loss a plan would be developed in the care plan.On 6/30/2025 at 10:32 AM, V3 (Assistant Director of Nursing) affirmed that V2 (Director of Nursing) was not in the facility and that V3 is the acting director of nursing in V2's absence. V3 stated that the standard of care is that if weight loss identifies or triggers that the physician and dietician are notified, and that the documentation of this notification is made in the resident's progress notes. V3 reviewed R3's progress notes and affirmed that there is no documentation that any provider was notified about R3's weight loss. V3 stated that the facility should be notifying and documenting to the provider about R3's weight loss. V3 stated that the standard of care is that when weight loss is identified that a care plan is put into place to prevent further weight loss. V3 reviewed R3's care plan and affirmed that a care plan was created on 6/27/25 to address R3's weight loss and should have been created earlier when the weight loss was first identified. V3 stated that the standard of care for lab work is that the provider should be reviewing their lab work and abnormal lab values should be communicated to the provider for follow up. After, the notification should be documented within the resident's progress notes. V3 reviewed R3's progress notes and affirmed that V9 (Infectious Disease Nurse Practitioner) did not review R3's CD4 and the expectation is that V9 should be monitoring and following up on labs that V9 orders. V3 reviewed R3's records and V3 affirmed that there was no documentation that a provider was notified about R3's abnormal CD4 level that indicated AIDS and that the provider, should have been notified right away. V3 reviewed R3's progress notes and orders and affirmed that the dietician's recommendations for an appetite stimulant were not carried out until 6/30/2025. V3 stated that the recommendation should have been communicated to the provider right away and affirmed that R3 experienced a delay in care. V3 reviewed R3's orders and affirmed that V9's viral load lab order for R3 was not completed and that when providers give orders, they should be carried out. V3 stated, we should have known (related to the AIDS). R3's lab work documents on 7/1/2025 that R3's CD4 count was 75 uL (further decline from 5/17/2025). Facility policy titled, Weight Management (3/2022) documents in part, . It is the policy of this facility to monitor the nutritional status of all residents including all significant trending patterns of weight change to maintain acceptable standards of nutritional status . All significant, unplanned or trending weight changes must be investigated by the facility . In the case of significant or trending weight change, the following steps will be taken: A. Determine Possible Cause B. Determine Plan of Action C. Notify the Physician and responsible party . The Registered Dietician will assess each resident with a significant weight change and make appropriate recommendations to the physician . The Director of Nursing will refer all concerns and recommendations to the appropriate department for action. The Director of Nursing or designee will ensure physicians and resident representatives are informed of significant or trending weight fluctuations or concerns regarding a change in resident's nutritional status . Facility policy titled, Change in a Resident's Condition or Status (2/2025) documents in part, The Nurse will notify the resident's attending physician or physician extender when: .b. There is a significant change in the resident's physical, mental or psychosocial status c. There is a need to alter treatment significantly d. The resident repeatedly refuses treatment or medications .On 7/8/2025 at 12:00 PM, V2 (Director of Nursing) affirmed there is no facility policy for following physician orders.

Based on interview, observation and record review, the facility failed to develop and implement pressure ulcer prevention intervenctions for three of 12 residents (R49, R24, R120) reviewed for pressure ulcers. Findings include: 1. On 05/07/25 at 9:53 AM V4, LPN, said R49 has pressure wounds on her sacrum and legs. R49 said I can't move my legs, they stay like this. R49's legs contracted and knees touching with dressing on left and right knee. Pillow between legs, but knees still touching. On 5/8/25 at 1:41PM V2, Director of Nursing (DON) and V9, Wound Nurse, were interviewed together. R49 has a stage 4 pressure ulcer to her left knee that developed in house on 4/3/25. V9 stated all of R49's skin impairment locations. V2 said R49 is at high risk for skin breakdown they put a pillow between her knees and use wedges for positioning. Repositioning is done every 2 hours, we do that for everyone. V9 said R49 is not able to reposition herself. The surveyor asked for documentation of the skin prevention interventions used to prevent pressure on R49's knees. V2 said I will check the Treatment Administration Record (TAR) for documentation. The surveyor asked if the facility has avoidable/unavoidable risk assessment for pressure ulcers. V2 said I am not aware that we have those. V2 said the purpose of the avoidable/unavoidable risk assessment would be to ensure the facility has implemented all interventions possible to prevent further breakdown. On 5/8/25 when the TAR for R49 was presented the surveyor notified V2 that there is no treatment for the left knee until 4/11/25. On 5/9/25 at 9:30am V2 said the purpose of MAR/TAR is to make sure meds are passed and doing treatments. V2 said if not signed off then it was not done. On 5/9/25 at 11:16 AM V7, Nurse Practitioner, said R49 is generally declining, she had blood work, we have a consult going on for her workup to rule out cancer. V7 said they have measures such as using pillows and repositioning every 2 hours. V7 said 2 hours is the standard for repositioning for the facility. R49's diagnosis include but are not limited to Alzheimer's Disease, Chronic Kidney Disease, Venous Insufficiency, Convulsions, Diabetes, and Peripheral Vascular Disease. On 3/4/25 a wound evaluation completed states Blister front left knee, lateral, in house acquired. 6.28 x 2.96 Centimeters (cm). treatment identifies heel suspension/protective devices and mattress with pump. (Nothing written to treat the knee.) On 4/29/25 Focused Wound Exam for R49 states stage 4 pressure wound of the left knee full thickness, 5.2 x 3.6 cm. Treatment Administration Record for April 2025 does not have a treatment for the left knee impairment until 4/11/25. (Per interview and documentation, the impairment was found on 3/4/25.) Care plan does not address left knee pressure ulcer. There are no interventions included to address her knees. The physician pressure ulcer treatment policy dated 5/17 states residents with pressure ulcers will have a physician's order for treatment. The nurse will documents the treatment as given on the TAR. 41758 2. R24 had the diagnosis of pressure ulcer of sacral region stage three (3), pressure ulcer of right elbow stage four (4) and functional quadriplegia. Physician order sheet dated 1/24/25 documents: low air loss mattress. Vital report dated 5/8/25 documents: weight 125.8 pounds. On 5/8/25 at 11:59am, R24 was observed in bed, on an air loss mattress with the setting on four hundred (400) pounds. V4 (nurse) said, R24's air mattress was set on four hundred pounds. V4 said, R24 is not four hundred pounds. A white plastic medical bracelet was observed wrapped around the air loss mattress control panel. On 5/8/25 at 1:16pm, V16 Assistant Director of Nursing (ADON) said, the air loss mattress should be set based on the resident's weight to prevent and treat pressure ulcers from getting worst. If the air mattress is set to high above or too low below the resident actual weight it will not help prevent pressure ulcers/wound from getting worst. On 5/8/25 at 1:37pm, V9 (treatment nurse) said, a medical band with the resident weight is place on the air mattress control panel. The facility's in-service dated 5/5/25 documents: Air bed settings are based on the resident's weight which can be found in the system. There are also wristbands located on the base of the board with weights. 3. On 5/7/25 at 1:15pm, R120 was observed on a regular pressure reducing mattress. V8 (nurse) said, R120 is on a regular mattress. R120 was not on an air mattress. On 5/8/25 at 2:36pm, V2, Director of Nursing (DON) said, if the wound doctor's make a recommendation for a low air loss mattress, it must be followed. On 5/9/25 at 12:39pm, V2 said, an air loss mattress is a pressure relieving mattress. Progress note dated 4/5/25 documents: spoke to R120's family who requested that patient have a consultation to be placed on an air mattress for bed sore prevention. She stated that R120 was on an air mattress in the previous facility she stayed in as well as in the hospital. Wound doctor note dated 4/8/2025 documents: Recommendation: Low Air Loss Mattress Pressure Ulcer Prevention Protocol dated 5/18/25 documents: All bed in the facility will have pressure reducing mattresses unless pressure relieving mattresses are required according to the resident's needs.

Based on observation, interview and record review, the facility failed to develop and implement a plan of care for one resident who was diagnosed with urinary retention requiring a urinary catheter. This failure affects one of two residents (R118) reviewed for urinary catheter care. Findings include: R118 was admitted to the facility on [DATE] with a diagnosis of retention of urine. On 5/6/25 and 5/8/25, during the survey R118 was observed with urinary catheter in place. R118's plan of care did not document any information related to R118's urinary catheter. On 5/8/25 at 4:18PM, V16 (Assistant director of nursing, ADON) said any resident with an indwelling urinary catheter should have a plan of care in place. V16 said she was unable to find any documentation in R118's care plan related to the urinary catheter. V16 said V16 is unsure why she does not. Facility policy titled Comprehensive Care Plans undated documents: to develop a comprehensive person-centered care plan, consistent with the resident's rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing and mental and psychosocial needs. The comprehensive care plan will include areas of potential risk to the resident with interventions to eliminate or reduce risk.

Based on interview and record review, the facility failed to ensure residents receiving psychotropic medications have a gradual dose reduction attempt or documented clinical contraindication for not attempting. This failure affects one resident (R77) of three reviewed for psychotropic medications. Findings include: R77's POS (physician order sheet), notes an order for Escitalopram (Antidepressant) 10mg (milligrams) oral daily for major depressive disorder, recurrent, moderate. R77 was admitted to this facility on 8/23/24. R77 transferred from another long term care facility. Those medical records note R77 was receiving escitalopram 10mg daily for major depressive disorder. On 5/8/25 at 5:10 PM, V2 DON (Director of Nursing) stated that V2 is unable to find any documentation in R77's medical record noting a GDR (gradual dose reduction) was done for Escitalopram medication. V2 stated that the purpose of GDR is to find optimal dose and to determine if the medication is helping resident. This facility's psychotropic and anti-psychotic medication policy, revised 04/2025, notes anti-psychotic medication is to be administered at the lowest possible dosage for the shortest period of time and will be subject to GDR (gradual dose reduction) requirements. This facility's gradual dose reduction policy, reviewed 08/2023, notes residents who use psychotropic drugs shall receive gradual dose reductions and behavioral interventions. The facility will attempt a GDR on a resident in two separate quarters (with at least one month in between) within the first year in which a resident is admitted on a psychotropic medication.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent development of a pressure ulcer; failed to promote wound healing and prevent infection for a dependent resident who was assessed as being at risk for pressure ulcer; and failed to perform weekly skin assessments as ordered. These failures applied to one (R1) of three residents reviewed for pressure ulcers and resulted in R1 developing a stage 4 facility acquired pressure ulcer to her sacrum, which required hospitalization for treatment of infection and surgical wound debridement. Findings include: R1 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her past medical history includes, but not limited to Local infection of the skin and subcutaneous tissue, dysphagia, peripheral vascular disease, pressure ulcer of sacral region stage 3, pressure ulcer of right elbow stage 4, venous insufficiency, hypothyroidism, hyperlipidemia, gastro esophageal reflux disease without esophagitis, chronic kidney disease stage 3, etc. Pressure ulcer list provided by the facility documented that R1 has 3 facility acquired pressure ulcers, stage 3 to the right elbow, stage 4 to the left leg and stage 4 to the sacrum. Wound note dated 11/5/2024 documented the following: stage 4 pressure wound sacrum full thickness, duration >2 days, wound size 8.0 x 15.5 x not measurable c. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Hospital record dated 11/11/2024 documented in part, [AGE] year-old female presented from nursing home with pressure ulcer on the right elbow and worsening of sacral decubitus ulcer with foul smell draining pus. Same hospital records documented empiric treatment with IV (intravenous) Vancomycin and IV Zosyn, general surgery consulted, planning for surgical debridement. The record also documented that based on clinical assessment at admission, patient will require more than 2 medically necessary midnights of in-hospital care because of sacral decubitus ulcer infection. Infectious disease section of the hospital record documented that R1 will be de-escalated to Unasyn 3 grams every 8 hours to be continued at the nursing home for a total of 6 weeks. Minimum data set (MDS) assessment dated [DATE] section C (cognitive patterns) scored R1 as a 7 for brief interview for mental status (BIMS). Section GG (functional status) of the same assessment documented that R1 is dependent on staff for all activities of daily living (ADLS). Section H (bowel and bladder) documented that R1 is always incontinent of bowel and bladder. R1 has an order for weekly skin checks dated 8/30/2024, and there is no documentation of any skin checks in her medical record. 1/13/2025 at 9:40AM, R1 was observed in her bed, awake and alert and stated that she is doing okay. R1 said that she has not been changed today, she was last changed yesterday and feels like she is wet. R1 also said that no one has changed her wound dressing yet, she does not know who is her assigned certified nurse assistant (C.N.A) for today. At 9:46AM, V4 (C.N.A) was observed in the hallway and stated that she is assigned to R1, she has not changed R1 or her roommate yet, she was going to get them next after she finished with the resident she is helping right now. 1/13/2025 at 10:10AM, V4 (C.N.A) and V5 (restorative) were observed coming out of R1's room, holding a bag of dirty linen, V4 said that they just changed resident, her roommate is okay and does not need to be changed. Surveyor asked to see resident's dirty incontinence brief and noted a large area of reddish stain that saturated the brief. V4 stated that R1 was not wet, the stain is from her wounds. Surveyor asked to see resident's wounds and noted a large area of deep wound on resident's sacrum that looks red, with lots of drainage. V4 and V5 applied a clean incontinence brief on R1 with no dressing covering the wound and said that they will inform wound care nurse that resident's wound does not have any cover. 1/13/2025 at 1:05PM, R1 was observed still lying on her back and stated that no one has come to turn her or put a dressing on her wound. 1/13/2025 at 2:00PM, Observed wound care for R1 with V3 (DON) and V11 (Wound Tech). When V3 removed resident's incontinence brief, it was soaked with wound drainage and there was no dressing covering resident's wounds. Surveyor presented this observation to V3 and she said that she was not aware that R1 did not have any dressing to her wounds, no one informed her. She added that the wound should not be left without dressing because it will be losing hemostasis. 1/15/2025 at 11:58AM, V13 (LPN-Licensed Practical Nurse/Wound Care) said that she is familiar with R1 and has been treating her wounds since she was admitted to the facility. V13 said that she first became aware of resident's sacral wound on 11/4/2024, the wound team was just treating residents leg wound that was present on admission and were not aware of anything going on in resident's sacrum. V13 added that the wound care team did not do another skin assessment apart from the one done upon admission. As for the resident's order for weekly skin assessment, the floor nurses are supposed to do that in conjunction with the C.N.A's during ADL care and notify wound care of any skin alterations. V13 added that the facility dropped the ball this time, there was a gap in communication, resident's wound could have been identified earlier. Facility pressure injury prevention protocol (undated) stated in part: 1. Residents will be assessed to determine their risk factor(s) for pressure injury development, upon admission; weekly x 4 weeks following admission/readmission and at least quarterly thereafter. 4. Residents will have their skin checked and documented utilizing the Treatment Administration Record. This skin check will be performed at a minimum of weekly. Skin Assessment Policy and Procedure (undated) documented the following: Intact, healthy skin is the body's first line of defense. It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. Upon admission to the facility the following will be assessed: (1) Risk for developing pressure injuries using valid assessment of pressure injury risk; (2) General skin condition; (3) Current injuries. Under procedures, the policy documented in part: All resident's, regardless of risk, will have a documented weekly review of skin condition.

Based on interview and record review the facility failed to perform a safe transfer by not using the mechanical lift for 1 resident (R2) dependent on staff for transfers. This failure affected one of three residents reviewed for injury. This failure resulted in R2 sustaining an acute mildly displaced fracture of the distal femoral diaphysis on the left leg. This past non-compliance occurred from 11/7/24 to 12/4/24. The findings include: The facility reported to IDPH (Illinois Department of Public Health) that on 11/7/24 while R2 was being transferred to dialysis chair by CNA (Certified Nurses Assistant), R2 slid down and had an assisted fall. Shortly after, R2 complained of pain to left knee. Small bump noted to left knee. R2 sent to the hospital for evaluation. Imaging received from the hospital identified distal femur fracture. R2's diagnosis include but are not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease, Atherosclerosis of Native Arteries of Left Leg with Ulceration of Other Part of Foot, Peripheral Vascular Disease, Anxiety Disorder, Depression, Polyneuropathy, Fracture of Lower End of Left Femur, Dependence on Renal Dialysis, and Weakness. Physical Therapy record includes diagnosis of Right Above the Knee Amputation. General Order dated 8/8/24 for R2 notes transfers: mechanical lift x 2 assist. On 12/12/24 at 12:00PM R2 said the day I fell I asked V9, Certified Nursing Assistant (CNA), for the mechanical lift and the dialysis chair. R2 said V9 said there was no time for that. R2 said V9 said I am not walking all the way down the hall to dialysis to get the chair. R2 said I fell as V9 and some other aid were transferring me into the chair in the dialysis room. R2 said I fell on to my knee, and it hurt. R2 said I told them I needed to go to the hospital. R2 said I went to the hospital, and I have a fracture. R2 said I did not get dialysis on that day. R2 said before the fall staff were not always using 2 people to transfer me. The surveyor observed R2 has left leg and old/healed right leg amputation. A lift pad was observed hanging on the back of R2's door. On 12/13/24 at 9:52AM V9 said I had taken care of R2 before. V9 said I got R2 ready, meaning I got her dressed for dialysis and gave patient care. V9 said I put a clean gown on her. V9 said I didn't have the proper stuff to work with R2 on that day. V9 said I got help from another CNA and put R2 in a wheelchair by lifting her in. V9 said we have done mechanical lift and manual lift transfers with R2. V9 said R2 don't stand at all, we have to completely lift R2. V9 said R2 didn't say anything about the transfer. V9 said this was not the first time R2 didn't have a lift pad in the room. V9 said if there is not a lift pad, then we are supposed to look for one. V9 said we couldn't find one. V9 said pads are hanging on the mechanical lift or they have they their own in the room. V9 said they (the facility) don't have a stock of pads. V9 said we took R2 to dialysis around 6:15-6:40AM. V9 said in the dialysis room as we were taking R2 out of the wheelchair she got twitching and wiggly. V9 said R2 was lowered to the floor. V9 said another aid helped me, I don't know her name. On 12/13/24 at 10:27AM V10, CNA, said a CNA was passing me by and asked me to help her. V10 said I didn't know R2. V10 said when we got to dialysis, I saw R2 had 1 leg. V10 said we tried to lift R2 into the chair and R2 could not hold herself up and we lowered R2 to the ground. V10 said in lowering her, R2 bent her leg. V10 said I never worked with R2 and didn't know she required a mechanical lift. On 12/12/24 at 1:14PM V2, Licensed Practical Nurse/LPN, said I wasn't there for R2's fall. V2 said I heard they needed help and came on the dialysis unit. V2 said I saw R2 was on the floor, she was crying out noises, sort of pain. V2 said we got her up and into a dialysis chair. V2 said R2 said she wanted to go to the hospital. V2 said R2's knee was visible. V2 said R2 expressed pain and according to the statement I looked and she may have had a bump. (The surveyor provided V2 with her witness statement during the interview.) On 12/13/24 V12, Restorative Nurse, said the staff have a sheet that tells them what level of assistance a resident requires. V12 said on admission I see the patient and identify the transfer status for them. V12 said on the care plan and resident profile sheet I include level of transfer assist needed for the resident. V12 said on hire I tell staff about the transfer status. V12 said R2 has been a mechanical lift since July 2024. V12 said on assessment R2 was weak and not able to use 2 person lift due to pain and shortness of breath. V12 said on 11/7/24 R2 was identified to require a full body mechanical lift. V12 said R2 usually has a lift pad hanging behind the door. V12 said when I spoke to R2 she said she asked the CNA to use the lift. V12 said the cause of the fall was that the staff did not use the lift to transfer R2. V12 said I have not received reports of lift pads or lifts not available for resident transfer. V12 said the lift pads are kept in the room behind the door, in the laundry room, and in my office. V12 said if I am not here the unit 3 nurse has the key to my office, so they can get a lift pad. V12 said R2 is alert. V12 said the practice to get a patient up for dialysis is to obtain the weight before getting out of mechanical lift. V12 said we have 3 full body mechanical lifts. V12 said the practice is to get the wheeled dialysis chair to the resident room, use the lift pad to transfer with the mechanical lift and place the residents into the dialysis chair and then bring the resident in the chair to the dialysis room. V12 said we usually don't place the resident into a regular wheelchair when preparing for dialysis. V12 said the staff needs to get the chair from dialysis. V12 said R2 did not have her prosthesis on the day of the fall, it is not even in the room. On 12/13/24 at 11:51AM V6, Assistant Director of Nursing, said I called the hospital to follow up on R2 and I was notified she had a fracture. V6 said R2 returned and she had the immobilizer on to her left leg. V6 said I started my investigation by asking R2 and the CNA what happened. R2 said while being transferred she slid and her left leg was unable to hold her body weight and she slid forward. V6 said the staff performed an improper transfer, R2 was supposed to be transferred with a mechanical lift. V6 said V9 transferred R2 with assistance from V15, CNA, from her bed into a wheelchair in her room. V9 then took R2 to dialysis room. V6 said then V9 attempted a second transfer to get R2 into the dialysis chair with assistance from V10. V6 said R2 was new to both V10 and V15. V6 said V9 performed two improper transfers with R2. V6 said the transfer procedure for R2 should have been to bring the dialysis chair to the room and then wheel R2 to dialysis in the chair. V6 said at dialysis the mechanical lift can be brought into the room and used to assist the resident into the chair. V6 said V9 said that R2 did not tell her that there was a lift pad in the room. V6 said V9 said she has gotten R2 up in the past without the use of the mechanical lift. V6 said R2 was working with therapy, but we had not gotten the ok from therapy to discontinue the mechanical lift. V6 said for the improper transfer I gave V9 disciplinary actions. V6 said V9 claimed there were no lift pads. V6 said each resident has 2 lift pads in the room, 1 for use and an extra one if soiled. V9 said if there is no lift pad, then the staff should look for another lift pad, if not found then they should notify the on call person that no lift pad can be found. V6 said I was not notified that they could not find a lift pad before the incident. V6 said R2 said she told V9 the pad was there. V6 was asked asked if the CNA should make the decision to not use a lift for transfers. V6 replied no. V6 said R2 has not had previous falls. V6 said R2 had an order in the old computer system (facility began a new electronic charting system in November 2024) stating she was a two person transfer with mechanical lift. V6 said the order was not discontinued. R2's MDS (Minimum Data Set) assessment for Cognitive Patterns assessment dated [DATE] notes a score of 15, intact. MDS Functional Ability assessment for R2 dated 10/21/24 documents impairments to range of motion to both sides of lower extremity. R2 is documented dependent on staff for toileting hygiene, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Dependent- helper does all of the effort. Resident does none of the effort to complete the activity. Functional Abilities assessment dated [DATE] identifies R2 is dependent for transfers. Restorative assessment dated [DATE] identifies R2 is dependent for transfers. R2 is non-weight bearing. R2 uses no splint, braces, or prostheses. R2's Fall Risk Assessment identifies R2 is at high risk for falls. Order Summary Report notes R2 has dialysis ordered Tuesday, Thursday, and Saturday. Incident occurred on 11/7/24, Thursday. Order Summary Report includes an order dated 11/13/24 for immobilizer to left knee at all times. R2's hospital record dated 11/7/24 CT of left knee findings states comminuted, mildly displaced fracture of the distal femoral diaphysis. Small knee joint effusion and mild surrounding soft tissue edema. X-ray of the left knee dated 11/7/24 states acute mildly displaced fracture of the distal femoral diaphysis. R2's hospital orthopedic consult dated 11/7/24 states she was being transferred to her dialysis chair and was accidentally dropped by a staff member, she reports her leg was bent back and was very painful. She complains of pain in the left knee, left ankle and has spasms going down her left leg. States she does not walk and has not walked in two years. She uses a mechanical lift for transfers and does not put weight through her left leg. Plan includes R2 is a poor surgical candidate due to bone quality and medical history. The facility did not provide a seperate incident/accident report than the facility IDPH reportable. The facility Limited Lift / Resident Handling policy dated 5/17 states It is the intention of this facility to provide safest environment as possible for our residents. Residents are assessed periodically for safety in transferring. Staff will use safety devices to assist in the transferring of our residents that have been assessed that the resident is no longer safe to be independent in this area. These devices may include gait belts and mechanical lifts. The facility Mechanical Lift policy dated 2/17 states A mechanical lift assist staff to lift and move a resident as safely and as easily as possible. Prior to the survey date of 12/18/24, the facility had taken the following action to correct the noncompliance: 1. Inservices for safer transfers began at the facility on 11/7/24-11/9/24. More inservices done 11/21/24 and 12/4/24. 2. Competency by return demonstration of safe transfer training. 3. Safe transfer audits are being completed, started 11/15/24; 11/16/24; 11/19; 11/25; 11/26; 12/3; 12/5 .and is ongoing during my survey. 4. QA meeting held 11/19 with administrator, DON, and medical director to discuss improvement plan. 5. Interviews with staff regarding transfer status knowledge. I have no concerns. 6. DON said there was 90% staff training completed on initial inservicing. As of Friday 12/13/24, there were 4 CNAs left to train. They are PRN (as needed) staff. 7. The CNA who performed the improper transfer had not returned to work because she refused to come to the facility for training. Observation of transfers during the survey completed, no concerns. Observation of mechanical lift pad equipment available to staff.

Based on observation, interview, and record review the facility failed to implement and ensure effective interventions were in place to reduce the risk of falls/falls with injury for three of three residents (R58, R69 and R80) in the sample of 22 reviewed for fall prevention program. This failure resulted in R80 being sent to the local hospital sustaining a left femoral fracture. Findings include: On 6/26/2024 at 9:40am R80 was observed in bed with one floor mat on the right side of the bed only. On 6/26/2024 9:45am V13 (Licensed Practical Nurse-LPN) observed with surveyor R80 with one floor mat and said R80 is a high fall risk and should have two floor mats, one each side of the bed. On 6/26/2024 at 10:10am V2 (Director of Nursing-DON) said R80 is a high fall risk and should always have bilateral floor mats down while in bed. A face sheet indicated R80 was admitted to the facility on [DATE] and has a diagnosis of repeated falls, syncope and collapse. An initial fall risk assessment dated , 3/12/2024 had a score of 7 that indicated R80 was low risk. Admission care-plan dated 3/13/2024 problem: History of falls. On 3/13/2024 a BIMS (Brief interview of Mental status) score was documented of 99-no resident was unable to complete interview. On 3/13/2024 a fall intervention was put in place, bed in a low position while in bed. On 3/17/2024 R80 had a fall, complained of hitting the back of his head and right wrist pain. An intervention of bilateral floor mats while in bed was put in place. On 3/23/2024 R80 had an unwitnessed fall and complained of left shoulder pain, an intervention of bed bolsters was put in place. On 4/5/2024 R80 was found on the floor with wheelchair turned over. No fall intervention was in place. On 4/14/2024 R80 had an unwitnessed fall, found lying on the floor next to his bed on his left side. R80 was unable to verbalize what happened. No fall intervention was put in place. On 4/14/2024 an x-ray of left humerus anatomic neck and multiple left ribs were observed. A portable x-ray dated on 4/26/2024 for pain and guarding, indicates R80 sustained a faint lucent line across the neck of the left femur, a subtle shortening of the femoral neck noted. Impression acute nondisplaced left intertrochanteric femur fracture. On 5/20/2024, most recent, R80 had a BIMS-score 99-no resident unable to complete interview. A physician order sheet dated 5/27/2024, no fall orders. On 5/29/2024 R80 had a fall, was observed on the floor in front of his wheelchair. R80 said he slid out of his wheelchair and was observed guarding his left lower extremity near his hip. No fall intervention was put in place. On 6/12/2024 R80 was observed on the floor in a laying position next to bed, could not verbalize what happened. A fall intervention was put in place for a safety appliance to elevate heel while in bed with a cushion. 39781 2. On 6/26/24 at 10:48AM, With V14 Registered Nurse (Registered Nurse-RN) R69 was observed in bed in semi-Fowler's position leaning to the right side of the bed with her head hanging from the bed. V14 repositioned R69. R69 is alert and responsive but confused. No floor mat on the right side of the bed, only on the left side. R69's bed is not in the lowest position. V14 took the bed control on top of bedside drawer and placed R69's bed in the lowest position. V14 said that R69 is at high risk for falls. R69 should have a floor mat on both sides of the bed and the bed should be in the lowest position when in bed. V17 (Certified Nurse Assistant-CNA) said that she is the assigned CNA for R69. V17 said that she received R69 with only one floor mat on the left side of the bed when she came to work this morning. V17 said that R69 should have a floor mat on both sides of the bed and R69's bed should be in the lowest position. On 6/26/24 at 10:55AM, Informed V4 (Assistant Director of Nursing-ADON) of above observation. V4 said that R69 should have bilateral floor mats on each side of the bed and the bed should be in the lowest position while in bed. On 6/26/24 at 12:30PM, Informed V2 (DON) of above observation. V2 said that R69 is at risk for falls. She should have a floor mat on both sides of the bed and the bed should be in the lowest position while in bed. V2 added that they should implement fall preventive interventions in place. R69 is readmitted on [DATE] with a diagnosis listed in part but not limited to repeated falls, history of falling, abnormalities of gait and mobility, unsteadiness of feet, muscle wasting and atrophy, osteoarthritis. Fall assessment done on 4/20/24 indicated she is at high risk for falls. Fall care plan indicated that she is at risk for falls related to impaired cognitive status, impaired functional status, weakness/deconditioning cellulitis of left lower limb. Intervention: Keep bed in lowest position with brakes locked. 3. On 6/26/24 at 11:56AM, R58 was observed with V10 (Concierge/CNA unit manager) lying in bed not in lowest position with only 1 floor mat on right side of the bed. V10 took the bed control located on top of his bedside drawer and placed R58's bed in the lowest position. V10 said that R58's should have bilateral floor mats on each side of the bed and bed should be in the lowest position when resident is in bed. On 6/26/24 at 12:30PM, Informed V2 (DON) of above observation. V2 said that R58 is at risk for falls and on a fall prevention program. He should have floor mats on both sides of the bed and the bed should be in the lowest position while in bed. V2 added that they should implement fall preventive interventions in place. R58 is readmitted on [DATE] with diagnosis listed in part but not limited to history of falling, cognitive communication deficit, muscle weakness, osteoarthritis. Fall assessment done on 4/16/24 indicated he is at high risk for falls. R58's fall care plan indicates that he is at risk for falls related to difficulty with balance and gait, dependent on assistive device for locomotion, requires assist for toileting, use of medications that can cause weakness or lethargy, history of falls, and diagnosis including cardiac, vision impairment, incontinence, acute and chronic medication conditions. Interventions: Provide resident with safety device/appliance: Bilateral floor mats when in bed. Fall prevention program protocol. Keep bed in low position with brakes locked. Facility Policy: Fall Prevention and Management revised 2/2023 Purpose: The purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person-centered care. The falls prevention and management program provide a framework and tools to identify and communicate about a resident's risk for fall. Additionally, the program addresses a safe process to follow for supporting a resident who has experienced a fall event. Fall prevention Practices: Fall prevention and management practices include separate activities. . universal fall precautions Universal fall precaution: . universal fall precautions are safety measures that are taken to reduce the chance of falls for all residents regardless of individual fall risks.

Based on observation, interview, and record review the facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit (F), failed to ensure a resident was positioned safely while providing direct resident care, and failed to develop fall prevention interventions to include monitoring for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. This failure affected 3 of 3 residents (R1, R3, R2) and resulted in R1 spilling coffee sustaining full thickness burns to the right posterior thigh measuring 13.9x6.3x0.1cm (centimeters) and to the left thigh measuring 4.8x18.5x0.1cm. This failure also resulted in R3 rolling out of the bed sustaining a laceration to left eyebrow, subarachnoid hemorrhage, and a nondisplaced patella (knee) fracture. Findings include: 1) R's latest admitted to the facility is 4/18/24 with a diagnosis of multiple sclerosis. Alzheimer's disease with late onset, major depressive disorder and anxiety. R1's Minimum Data Set (MDS) dated [DATE] documents a brief interview for mental status score of 5/15 which indicates severe impairment. Under section GG functional abilities and goals under eating documents a score of five. Five indicates setup or clean-up assistance- Helper sets up or cleans up. Resident completes activity. Helper assists only prior to or following the activity. R1's physician progress note dated 1/18/24 documents: R1 is alert with periods of forgetfulness. She is able to follow simple commands but with frequent redirection and reorientation. Under psych exam: attention/concentration: attends to tasks with staff assistance, easily distracted; Judgement: impaired; insight: impaired; impulse control: impaired. Facility reportable dated 2/24/24 documents: R1 was in the dining room for breakfast and activities. After breakfast, R1 attended the activity taking place in the dining room. R1 requested for a cup of coffee from V5 (Activity aide). V5 said she placed a plastic coffee mug with coffee in front of R1 before returning to her tasks. R1 immediately grabbed the mug. Before staff could respond, she spilled the coffee on her lap. Under conclusion: Upon investigation the facility determined that the resident accidentally spilled coffee on herself. Staff responded immediately and provided first aide. Facility has reviewed and ensured all coffee machines are properly calibrated regarding temperatures. Staff was re-educated on assisting residents with hot items. On 5/22/24 at 10:48AM, V5 said she was preparing an activity in the common dining room when R1 requested coffee. V5 said she got coffee from the machine in the dining room and placed it in front of R1. V5 said she informed R1 the coffee was hot when she placed it on the table. V5 said she went on to continue the activity and heard R1 screaming out, It burns. V5 said she observed R1 with spilled coffee on R1 and the floor. V5 said R1 threw the coffee cup on the floor. V5 said R1 can be confused at times. V5 said after the incident she was told to let the coffee cool down before giving it to R1 or any residents. On 5/23/24 at 1:35PM, V9 (Nurse) was the assigned nurse to R1 on day of the incident. V9 said she did not witness incident but performed a skin assessment after the incident. V9 said R1's skin was red and blistering on both thighs. V9 said R1 is alert to self and has behaviors of throwing items when upset. V9 said she would not give R1 any hot liquids because of her behaviors of being impulsive and the possibility of injury occurring to R1 or other residents or staff. On 5/23/24 at 2:49PM, V20 (Nurse) said R1 is alert to self. R1 has behaviors of throwing things when upset and it is not a new behavior. V20 said she would not give R1 hot liquids due to this behavior. R1's progress notes dated 2/24/24 documents: Resident was observed in bed with redness and blistering to bilateral inner thighs. Writer was informed that resident was drinking coffee and spilled it on herself. PCP made aware, orders received and carried out. R1's wound doctor evaluation dated 2/27/24 documents: Patient spilled hot liquid on inner thighs. Under wound site one documents burn to the right posterior thigh full thickness measuring 13.9x6.3x0.1cm. Thirty percent of skin is fluid filled blister. Under wound site two documents: burn wound of the left thigh full thickness measuring 4.8x18.5x0.1cm On 5/22/24 at 9:56AM, V7 (Dietary Manager) said coffee should have a temperature of 130-140 degrees F when served. 140 degrees F would be the highest temperature because it may cause a burn. V7 said they check coffee temperatures weekly but do not have a log of the temperatures. On 5/28/24 at 1:31PM, V2 (Director of Nurses/DON) said R1 has a history of behaviors of throwing food and yelling out. V2 was asked how do staff determine who is safe to consume hot beverages. V2 said she was not able to answer that question. V2 said staff should wait a few minutes before serving any residents coffee. V2 was asked if the incident with R1 could have been avoided and V2 said probably not based on R1's impulsive behaviors, R1 would of spilled the coffee either way. Facility hot beverage policy dated 1/16 documents: Facility will ensure that residents are served hot beverages at a temperature that allows palatability while decreasing the risk of inadvertent burns. Hot beverages will include coffee. Dietary staff will take temperature of all hot beverages prior to each meal and record the results on the temperature log for coffee prior to service to resident. The logs will be maintained for one year by the food service supervisor. Those residents determined to be unsafe with hot beverages by the interdisciplinary team will be offered assistance when consuming hot beverages. 41758 2) R3 was diagnosed with generalized muscle weakness and osteoarthritis. Brief interview for mental status dated 05/09/24 documents a score of fourteen which indicated cognitively intact. Section GG (functional abilities) dated 10/28/23 documents: R3 needed partial/moderated assistance (helper does less than half the effort. Helper lifts, hold or support trunk or limb but provides less than half the effort) to roll left and right. On 5/21/24 at 2:33PM, V4 (Certified Nurses Assistant/CNA) said he was changing R3's linen (bed sheet/cover). R3's sheets were wet. R3's linen was half on the bed. V4 said, R3 was on his side but does not recall which side. R3 was not close to the edge. R3 was alert. R3 was able to help turn and reposition. V4 said, before he could walk around to the other side of R3's bed to complete making the bed. R3 fell face down on the floor. R3 sustained a cut above eyebrow which was bleeding. V4 said, he called V6 (Nurse). V6 assessed R3. V4 said, him and V6 got R3 off the floor using a bed sheet. 911 was called. R3 said he was not okay. On 5/21/24 at 2:49PM, V3 (Assistant Director of Nurses/ADON) said, R3 was alert and oriented times person, place and time. V4 was providing care for R3. R3 required one person physical assist for bed mobility. R3 had a bed support safety rail located on the right side of his bed. R3's right side was his strong side. R3 didn't grab the bed support safety rail when being turned. V4 pulled the draw sheet to assist with turning R3. R3 usually grabs the bed support safety rail to help with turning onto his side when requested. R3 rolled out of the bed onto the floor. R3 sustained a laceration to the left eye and knee. R3 was diagnosed with a subdural hematoma and left knee fracture. On 5/21/24 at 3:04PM, V3 said, the bed support safety rail is used to aide with bed mobility. Verbal cues were given to R3 to remind R3 to grab the bed support safety rail. R3 only needs prompting. V4 informed R3, that they were going to turn. R3 was awake but could have still been a little sleepy. V4 should have made sure R3 grabbed the bed support safety rail before proceeding to the next step of turning. On 5/21/24 at 3:10PM, V6 (Nurse) said, R3 was being changed by V4. R3 has a habit of not cooperating and being stiff. It might take a minute for R3 to relax his body. R3 may cooperate but on occasions additional staff is needed. V4 told R3 to turn on his side, which R3 can do with help. R3 was seen on the floor. R3 was on his left side facing his bed. R3 hit his forehead on the wheel of the bed. R3 complained of knee and back pain. R3 said he fell , he couldn't believe it and he was dazed. On 5/21/24 at 3:52PM, surveyor observed a bed support safety rail on the left upper side of R3's bed. R3 was assessed to be alert and oriented to person, place, and time. R3 said he was half asleep while being changed by V4. It was a routine activities of daily living (ADL) care. R3 said he was too close to the edge of the bed. R3 said, V4 pushed him to the right side resulting in a fall onto the floor. R3 said, at the time of the incident, he did not have a bed support safety rail on the right side. R3 said, he was holding the mattress. There was nothing else to hold on to. There were no floor mats on the floor. R3 said, his left side/left upper extremity was weaker than the right. R3 said, he did not have anything to assist him when he was turning on his right side. R3 said, V4 pushed him and he ended up on the floor. On 5/23/24 at 12:40PM, V17 (Physical Therapy Assistant) said R3 has a bed support safety rail on the left side of his bed. R3 did not have a bed support safety rail on the right. R3 has bilateral weakness to the upper extremities. A bed support safety rail is used for poor trunk control. It aides with turning right or left. R3's bed support safety rail on the left side can only assist with turning towards the left side. Nursing note dated 01/24/2024 documents: Writer called to resident room by CNA (V4) status post (s/p) witnessed fall, resident (R3) observed on floor, vitals performed, and neuro check performed. Resident assisted by two staff back to bed. Noted left brow bleeding, bruising and lacerations to left knee. 911 called. Facility fall occurrence dated 01/24/24 documents: General Information: Fall, Cognition prior to occurrence: oriented times two, Injuries: Laceration to left brow. Laceration and bruising to left knee. Notes: CNA was performing AM care and was rolling the resident to the side in order to change the bed sheets. When the CNA pulled the sheet to make the bed while resident was on his side, the resident rolled off the bed. Fall type: Falling to ground. Laying on right side, mattress on the floor: no. Facility final reportable incident dated 01/29/24 documents: V4 stated that he was providing ADL care to the resident (R3), during which he instructed the resident to turn to his right side. V4 states, that the resident has a bed support safety rail on the right side of his bed for mobility but did not grab it. V4 states that the resident turned with more force that normal and fell out of the bed at approximately 5:30AM. Hospital paperwork dated 1/24/24 document: Patient (R3) presented to the emergency department for evaluation of head injury after mechanical fall. Per emergency medical service (EMS), patient was turning in bed when he fell out of bed. Patient fell with head strike hitting the left portion of his forehead on the ground. Patient complained of left-sided knee pain (multiple abrasions noted to the left knee), left shoulder pain and pain associated with facial laceration to the left eyebrow (with bleeding) measuring four centimeters in length and depth requiring five sutures. CT (computed tomography scan) of the head demonstrated subarachnoid hemorrhage near the right frontal lobe. Left knee x-ray: Nondisplaced patella fracture. Patient placed in left-sided knee immobilizer. 3) R2 was diagnosed with Dementia with behavior disturbance, restlessness, agitation, weakness and generalized anxiety. Hospice referral package dated 2/19/24 documents: Family was looking for respite care 2/28/24 - 3/8/24. R2 has a history of falls. R2 has had three falls since admission. R2 needs standby assist with transfers. R2 continues to have progressive weakness. R2 does not ambulate at most times and the seat of the roller walker is used to move her about the home. On 5/22/24 at 12:34PM, V12 (Nurse) said, R2 had behavior issues. R2 attempted to get out of the chair and bed. Medications and distractions were not working. R2 would scoot to the end of her chair or sit sideways, putting legs over the chair arm and get out of the chair on her knees. R2 was able to move body and climb. On 5/22/24 at 1:50PM, V3 (ADON) said, R2 kept trying to get out bed on to the floor. R2 had a fall upon admission. The second incident was not a fall, R2 was on the floor in a praying position. R2 got herself out of the bed to pray. On 5/22/24 at 2:40PM, V45 (CNA) said, R2 was in a room away from the nursing station then she was moved across from the nursing station. Nursing note dated 2/28/24 documents: writer observed resident sitting on floor near bed. Nursing note dated 3/5/25 documents: resident (R2) climbed out of chair and sat on floor in a praying position. Fall report dated 2/28/24 documents: R2 was alert to self. BIMS (Brief Interview for Mental Status) 4 (severe cognitive impairment). Visually observed on the floor near bed, sitting on buttock. R2 demonstrated poor safety awareness and was unable to be redirected. R2 also had wandering behaviors with an unsteady gait. R2's fall care plan dated 2/28/24 documents: Resident has history of falling related to weakness, unsteady gait, and cognition. Interventions dated 2/28/24: Place resident in a fall prevention program; Provide resident an environment free of clutter; Keep call light in reach at all times. Intervention dated 3/29/24: Observe frequently and place in supervised area when out of bed. Falls prevention and management policy revised 2/2023 documents: The purpose of this policy is to suppose the prevention of fall by implementation of a preventive program that promotes the safety of residents based on care processed that represent the best way we currently know of preventing falls. The fall prevention and management program is designed to assist staff in providing individualized person-centered care. Fall refers to unintentionally coming to rest on the found, (sic) floor or other lower level. A fall without injury is still a fall. When a resident is found on the floor, a fall is considered to have occurred.

Based on observation, interview and record review, the facility failed to provide feeding assistance for residents with visual deficits that were identified as needing assistance which resulted in an unplanned serve weight loss. This affected two of three residents (R8, R9) reviewed for unplanned weight loss. This failure resulted in R8 having a weight loss of 8.99% in one month and R9 having a weight loss of 10.6% in four months. Findings Include: 1) R8 has a diagnosis with Dementia. On 05/24/24 at 12:21PM and 12:33PM, R8 was observed with her head tilted to the ceiling with a non-focusing blank stare while eating in the dining room with no feeding assistance. R8 was observed scooping pureed food off her plate onto the tray, putting the spoon in her mouth with no food on it. R8 dropped the spoon on the tray. R8 was observed tapping around on the tray with her hand, putting her fingers in food then licking food off her fingers for twelve minutes until she touched the spoon and preceded to feed self with small amounts of food. On 05/24/24 at 12:51PM, V3 (Assistant Director of Nurses) said, R8 required set up assistance only. R8 refuses help with feeding assistance. R8 has vision impairment. R8 was asked by the surveyor, if she would like some help with eating. R8 nodded head up and down in a yes motion. V3 said, R8 nodded head in a yes motion. V3 assisted feeding R8. R8 took two small portions of food from the tip of the spoon. On 5/24/24 at 2:30PM, V2 (Director of Nurses) said, R8 has had weight loss in last six months. V2 said, she expects staff to assist with feeding for R8 as recommended by the dietitian. Care plan dated 9/26/23 documents: R8 is alert with confusion and exhibits impaired cognitive functioning status. R8 is unable to visually track objects or people. Receive mechanically altered diet with puree meat and vegetables related to edentulous (no teeth): approach 1:1 feeding assist. R8's dietary note dated 05/08/2024 documents: weight: 79 pounds, down 9% and 10.9% x 1 and 6 months respectively. This is the lowest weight recorded over the past six months of reviewed data. Diet order dated 05/08/2024 documents: Patient (R8) must be fed by staff. Will need to continue to encourage by mouth intake at all meals. Recommendation: give much encouragement to eat. R8's vital report documents: May: 79 lbs (pounds), April: 86.8 lbs, March: 87.8 lbs, February: 84.6 lbs and January: 91 lbs. Facility weight maintenance policy revised 03/22 documents: It is the policy of this facility to monitor the nutritional status of all residents, including all the significant or trending patterns of weight change to maintain acceptable parameters of nutritional status. All significant, unplanned, or trending weight changes must be investigated by the facility. Suggested parameters for evaluating significance of unplanned and weight loss are: interval one month, significant loss of 5% or severe loss of greater than 5%; interval three months significant loss of 7.5% percent or severe loss of greater than 7.5%; interval six months significant loss of 10% percent or severe loss of greater than 10%. In the case of a significant weight or trending weight change the following steps will be taken; determine the possible cause; determine plan of action; notify the physician and responsible party. 2) R9 has a diagnosis of Dementia, Glaucoma, Intraocular Lens (tiny artificial lens for eye) and Multiple sclerosis. Brief interview for mental status dated 4/4/24 documents a score of fourteen which indicates cognitively intact. On 5/24/24 at 12:56PM, R9 was observed with a lunch tray on the bed side table directly in front of R9. R9 was trying to feed herself string beans with a spoon that she held backwards in her hand. R9 who was assessed to be alerted and oriented to person, place and time, said I can't feed myself. On 5/24/24 at 1:06PM and 1:15PM, While surveyors were observing R9's room, V34 (Guest Services-Certified Nurses Assistant/CNA) went into R9's room to assist with feeding R9. V34 said, she had never fed R9 before and she was just helping out. R9 said, V34 has never fed her before and she does not receive feeding assistance from any staff. V34 stop feeding R9. V34 said, R9 didn't eat much. On 5/24/24 at 1:50PM, V26 (Occupational Therapist/OT) said, R9 needs assistance with meals due to visual impairment and impaired coordination related to multiple sclerosis. V28 (OT) said, R9 was having difficulty getting food in her mouth. R9's coordination has gotten worst. On 5/24/24 at 2:30PM, V2 (DON) said, R9 is not on a weight loss program. Care plan edited 04/05/2024 documents: R9 requires assist with ADL's (activities of daily living) related to weakness, lack coordination and impaired mobility in regards to multiple sclerosis. Approach dated (7/7/2020) documents: R9 can eat in room and be monitored from hallway during rounds, (edited 1/11/24) documents: eating: supervision and set up help. R9's vital report dated 01/2024 - 05/2024 documents: May 179.8 pounds (lbs), April 186 lbs, March 187 lbs and January 198 lbs. Physician note dated 4/25/24 documents: R9 reports good appetite. Dietary note dated 5/8/24 documents: weight (WT): 180 pounds, down 11.2% x 6 months. Weight decline each month noted since 3/4. By mouth (po) intake does not appear to be meeting needs for weight maintenance. Some slow/steady weight decline may be beneficial as patient has a high body mass index (bmi) 29.9, however rapid loss is not desired. Facility weight maintenance policy revised 03/22 documents: It is the policy of this facility to monitor the nutritional status of all residents, including all the significant or trending patterns of weight change to maintain acceptable parameters of nutritional status. All significant, unplanned, or trending weight changes must be investigated by the facility. Suggested parameters for evaluating significance of unplanned and weight loss are: interval one month, significant loss of 5% or severe loss of greater than 5%; interval three months significant loss of 7.5% percent or severe loss of greater than 7.5%; interval six months significant loss of 10% percent or severe loss of greater than 10%. In the case of a significant weight or trending weight change the following steps will be taken; determine the possible cause; determine plan of action; notify the physician and responsible party.

Based on interviews and observations the facility failed to supervise an impulsive, confused resident, with unsteady gait from getting into bed with another resident. This affected two of three (R1, R2) residents reviewed for supervison/monitoring. This failure resulted in R1 screaming, crying, and feeling nervous after R2 climbed into her bed. A reasonable person would have been scared and terrified. Findings include: R1's diagnosis includes but is not limited to Dementia, Anxiety, Adjustment Disorder with Mixed Anxiety, Weakness, History of Transient Ischemic Attack, and Osteoporosis. R2's diagnosis includes but is not limited to Diabetes mellitus, Heart Failure, Vascular Dementia, and Major Depressive Disorder. Progress notes dated 12/10/23 at 5:25AM state R1 was heard yelling for help and upon entering the room staff observed her roommate (R2) in her bed. Resident (R1) was observed gripping a butter knife but was not aiming it towards R2. R1 unsure why R2 was in her bed. On 4/6/24 at 12:16PM V3, Certified Nursing Assistant (CNA), said when she walked past the room she saw one resident on the floor and one resident on the bed. V3 said R1 was crying. V3 said R2 had a behavior of crawling on the floor. On 4/6/24 at 12:29PM V5, CNA, said in general R2 was very aggressive she needed redirection and sometimes staff would stay with R2. V5 said R2 would get out of bed and she could walk a few steps. V5 said R2 would sometimes hit staff. V5 said if R2 was in a bad mood she would start hitting. V5 said R2 would sundown and show these behaviors more in the evening time. V5 said we had to check on R2 often. V5 said R2 was alert and confused at times, she fluctuated. V5 said R1 is cooperative, keeps to herself and is not like her to be aggressive. On 4/6/24 at 12:43PM V1, Licensed Practical Nurse (LPN), said on 12/10/23 I was informed that the CNA saw R2 in R1's bed. V1 said I was told R2 was near R1's bed. V1 said I was told R2 was hovering over R1. V1 said R2 is not fully oriented. V1 said the CNA tried to redirect R2 to her bed. V1 said R1 was confused and I was told she had a butter knife that she grabbed from under the bed sheet. V1 said this happened around 6:00am. V1 said when I walked in the room I saw R1 in the bed and R2 was on the floor, scooting around the bed. V1 said R1 is alert times 2- 3. V1 said R1 said she did not feel comfortable with R2 in the room. V1 said R1 gave me the butter knife, it was a facility butter knife. V1 said this is new behavior for R1. V1 said I was not told there was anything going on with R1. V1 said R2's baseline is always moving around. V1 said R2 was someone who needed frequent checking on. V1 said V2, CNA, was the first staff in the room. On 4/6/24 V2, LPN, was the CNA assigned to R1 and R2 on 12/10/23. V2 said on night shift, I heard yelling and screaming, I immediately went into the room. R1 was calling out help repeatedly. V2 said I was in the room across changing a resident. V2 said when I got there I saw R2 on top of R1, in R1's bed. V1 said R1 was laying flat facing up and R2 was laying flat on R1 facing her. V1 said R1 had the butter knife. V1 said I don't know where R1 got it from. V1 said R1 and R2 had been rounded and changed. V1 said I had checked on R1 and R2 2 or 3 times before this. V1 said I don't know how R1 got in R2's bed. V1 said usually R2 can walk, but her balance is not steady. V1 said neither was awake on last round. V1 said I checked and changed them and they woke up. V1 said I was in the other room about 15 minutes. V1 said I asked R2 what she was doing and R2 was just confused and had no answer. V1 said R1 was nervous afterwards. V1 said R2 had slept most of the shift and it was unusual that she sleep the entire night. V1 said I did not see R2 crawling around the floor. V1 said R1 is not capable of getting out of bed, she does not get up on her own. On 4/6/24 at 1:50PM V8, CNA, said usually R2 could walk but unsteady. V8 said we watched her often, I would keep her near us. V8 said R2 just wanted to get up and walk, she could not sit. V8 said R2 could not retain information. V8 said R2 would get in other residents' face and curse them out. V8 said R2 was verbally aggressive and physically aggressive with staff. V8 said we would move R2 to keep others safe. V8 said in the past, R1 said R2 would get into her bed or get into her belongings. V8 said R2 would be on R1's side of the room. V8 said they were not roommates for long. V8 said R1 didn't like that R2 was in her things. On 4/6/24 at 2:24PM V9, Social Service Director, said I was not notified that R1 and R2 were not getting along. I was not made aware that R2 was rummaging in R1's things or on R1's side of the room. On 4/6/24 at 2:45PM V4, Director of Nursing, said R2 has been confused since admission. V4 said she was not aware that R2 was verbal or physically aggressive to staff or residents. V4 said I was not told R1 was upset that R2 was on her side of the room and in her things. We would have spoken to R1 and investigated. At 3:31PM V4 said Vulnerable is anyone who could be taken advantage of or manipulated. The surveyor asked V4 can an aggressive person take advantage of a vulnerable resident, V4 said sure. V4 said per the nurse practitioner note R2 was impulsive and refused to answer her questions. V4 said staff documented R2 was impulsive and hard to redirect from safety awareness. The surveyor reviewed R2's progress notes from 10/5/23; 11/4/23 aggressive behavior; 11/7 combative & aggressive with staff; 11/16 verbal aggression; and 12/7 refused medication with V4. V4 said I was not aware of those behaviors. V4 said R2 saw the psych nurse practitioner three times during that time. V4 said the nurse practitioner is not here every day. R2's Progress Notes dated 10/5/24 shows R2 requires 1 on 1 supervision, very impulsive behaviors. R2's care plan dated 12/15/23 states R2 exhibits abnormal behavioral symptoms, choosing to crawl on the floor at times. Interventions include seat R2 where constant/near constant observation is possible. Care plan dated 11/9/23 R2 exhibits verbally/physically aggressive behaviors towards staff. Care plan dated 9/26/23 states R2 exhibited decline in her status and exhibited lack of safety awareness. R2 exhibits impaired cognitive function due to diagnosis of Vascular Dementia with a BIMS score of 4. R1 care plan dated 12/27/23 states R1 has impaired vision and cognitive decline.

Based on interview and record review, the facility failed to follow their change in condition policy, and to provide emergency life sustaining measures for one (R8) of five residents reviewed for change in condition and emergency life sustaining measures in a sample of 17. This failure resulted in an Immediate Jeopardy when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. The Immediate Jeopardy began on [DATE] when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. V1 (Administrator) was notified on [DATE] at 11:46 am. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but the non-compliance remains at level Two because time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: Resident face sheet indicates that R8 was a [AGE] year old female, admitted on [DATE] with diagnosis not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (Primary, Admission), Dysphagia following cerebral infarction. Peripheral vascular disease, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, aphasia following cerebral infarction, and hypertension. On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work on R8 until R8's DNR paperwork is provided to them. When V8 provided the DNR form, the paramedics verified the name and then stopped the resuscitation. V8 said that she realized that the DNR was for R9 and not for R8. V8 said there was a mix up of beds between R8 and R9. V8 said that R8 did not have a wrist band and she had no other way to identify the resident other than what was in the computer. V8 was asked, how do you identify the residents? V8 response was Name, Date of Birth, Pictures, and social security number. V8 said that she called V2 (Director of Nursing/DON) and told V2 that R9 expired, but called back later and informed V2 that R8 was the person that expired and not R9. V8 said that V2 told her to call 911 and initiate cardiopulmonary resuscitation (CPR). V8 said that V8 did not provide any emergency care to R8 prior to calling V2. V8 said she did not notify the physician of the change in R8's condition. On [DATE] at 3:59 PM, V12 (Certified Nurses Assistance/CNA) said that R8 told her that R9 was having difficulty breathing. V12 said that V8 (Nurse) told her to go and clean R8 up when she has time. V12 said that by the time she could make it to R8's room, the paramedics were already in the room. V12 said that she observed thick yellow mucus coming out of R8's mouth. V12 said that R8's tongue was sticking out, and the resident's mouth was swollen. V12 said that V8 thought that R8 was R9. V12 said that everyone knows who R9 is. V12 said that when V8 realized the mix up 30 minutes after the paramedics had left, V8 rushed to R8's room with the resuscitation cart and initiated cardiopulmonary resuscitation (CPR). V12 said that R8 didn't appear to be breathing at this time because 30 minutes had passed since the paramedics left. On [DATE] at 09:45 AM, V2 (Director of Nursing/DON) said that the advance directives are in the computer. V2 said that there is a resident profile sheet that hangs at the back of the door which contains the resident code status. V2 said that if the resident has a Do Not Resuscitate (DNR), the DNR form (orange copy) is kept behind the profile sheet that is hanging behind the door. V2 said that this will be the place staff will refer to for residents' code status in an emergency. V2 also said that the facility also tries to keep the same staff on the same unit. On [DATE] at 1:30 PM, V2 (DON) said that V8 (Nurse) called and notified her that R9 (R8's roommate) had expired and family was notified. V2 said shortly after, V8 called V2 again and informed V2 that it was R8 and not R9 that passed. V2 said that she instructed V8 to call 911 and start CPR. V2 said that V8 originally thought that it was R9 who is a DNR that expired. V2 said everyone knows who R9 is. On [DATE] at 4:15 PM, V2 said that as a nurse, if a resident is having difficulty breathing, V2 would attend to that resident regardless of code status. V2 also said that residents' photos are uploaded in the matrix computer system for identification purposes. On [DATE] at 10:40 AM, V14 (R8's Physician) said that R8 was a full code. V14 said that he was not on call on the day R8 expired. V14 said that V15 was covering for him. V14 said that if he was notified of the change in R8's condition, most likely he would have sent R8 out to the hospital for further evaluation. On [DATE] at 11:25 AM, V15 (Nurse Practitioner) said that she was on call on the day that R8 expired. V15 said that V8 did not notify V15 about R8's change in condition. V15 said that she would have absolutely sent R8 out to the hospital for evaluation depending on her condition. [NAME] Fire Department Run Report dated [DATE] at 6:01:00 AM, had R9's name on this run report and documented that I/S was dispatched to a location for the 78 y/o female with difficulty breathing. U/A NH staff at door advised crew the pt. was breathing. Upon making pt. contact in pts. Room pts. Was found sitting up in the bed unresponsive and apneic with a faint carotid pulse. Pt. was placed supine in bed and airway was suctioned by NH staff and cleared of mucus. Pt. was ventilated with BVM. Patient became pulseless and CPR was initiated. Crew asked NH staff if the pt. had a valid DNR. NH staff advised that the pt., has a valid DNR and provided the crew with a paperwork which did not include pts. Valid DNR. Crew requested that NH staff locate and provide DNR for crew. CPR was continued by crew. Pt. placed on cardiac monitor with multi-use pads and rhythm check was performed. Pt. was asystole on cardiac monitor and CPR and ventilations were performed. NH staff came back to pt. room and handed crew a copy of the pts. DNR. Crew confirmed that the name on the provided paperwork from the NH staff and the DNR were for the same pt. and the DNR was valid. CPR was stopped by the crew for a rhythm check. Pt. was asystole on the monitor. (Local Hospital) was contacted via cell and pts. death was confirmed by (Doctor) at 0616 hrs. MPD officers were on Scene. Scene was turned over to MPD w/o incident. All times approx. EOR [NAME] Fire Department Run Report R8 dated [DATE] documents: In summary, [NAME] dispatched to above location for CPR in progress. Upon arrival, crew found 76 y/o/f unconscious not breathing with no pulse. Crew notes staff is not performing CPR on patient. Crew member that was directly involved with this patient on previous call states this patient was confirmed deceased by (Local Hospital) ER by alternate EMS crew. Per staff, this patient was pronounced dead with a valid DNR form by previous EMS crew earlier this morning. Staff states that paperwork and identification of patient was mixed up with alternate patient residing in the same room. Nursing home admitted the identification error. Crew took over CPR momentary and when information was gathered, crew discontinued CPR. Contacted (Local Hospital) ER for confirmation of crew's decision to not render deceased patient confirmed by (Doctor). Scene was turned over to [NAME] Police. Medical Emergencies Facility Policy: It is the policy of the facility to provide emergency care to a resident in need of it. Basic life support, including CPR will be provided until the arrival of Emergency Medical personnel in accordance with physician's order and a resident's Advance Directives. Emergency Care Procedure: Nurse in charge of resident will evaluate resident's condition. If help is needed and there is more than one nurse available, the nurse assigned to the resident will stay with the resident and will send a nurse's aide to go call the other nurse. The nurse's aide will also bring emergency equipment if needed. Second nurse will notify DON, resident's physician, and follow his/her orders. Call ambulance, notify family, and fill out transfer form. Call emergency room and let them know resident is on the way. During extreme emergency, call rescue squad, and call physician and follow above procedures. If only one nurse available, he/she will instruct one nurse's aide to stay with the resident after the emergency measures have been taken, and the nurse will call physician, or ambulance. Notify family and fill out transfer form. Documentation of treatment and resident's response during emergency must be done in the clinical record. Respiratory Distress, Treatment: 3. Check oxygen saturation. Administer oxygen when signs of air hunger are present. Medical Emergency Response Policy, Objective: 1. It is the policy of the facility to provide each resident with necessary emergency treatment. This includes the facility providing basic life support including CPR, to a resident requiring emergency care until the arrival of Emergency Medical personnel in accordance with physician's orders and resident's Advance Directives. Licensed personnel will assess the resident, determine interventions, notified the resident's physician, and document the event in the medical record. Procedure: 3. Nursing interventions will include following CPR guidelines, establishing an airway, support breathing and circulation until paramedic assistance arrives, at which time paramedics will direct the care of the resident. Facility Guidance on Advance Directives, Objective: A resident has a right to make decisions about the health care they receive now and in the future. An advance directive is a written statement prepared by the resident about how these medical decisions are made in the future, if the resident is no longer able to make them for themselves. The residents' choice about advance directives will be respected. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following steps to remove the immediacy verified by the survey team during an onsite review. The DON and Nursing Supervisor initiated an in-service for all Licensed Nursing staff on Medical Emergency Response and Change in a Resident's Condition. Licensed staff who were unable to attend face-to face training due to scheduling will receive in-service education before working their next shift. In-servicing was completed for licensed nurses on [DATE]. No licensed nurses are on vacation. Licensed nurses on LOA were sent communication that they must complete in-service education before starting their next shift. Completed [DATE]. Education related to emergency medical response and change in resident condition will be incorporated into new hire orientation effective [DATE]. Ongoing education for medical emergency response and change in resident's condition will be conducted quarterly for 6 months then incorporated into annual staff education and training. The DON and Nursing Supervisor initiated an in-service for all Licensed nurses on management of respiratory distress. This training included review of facility procedure for management of respiratory distress. Staff knowledge was evaluated using a knowledge test. Staff who were unable to come to the building for face-to-face in-services due to scheduling will complete in-service education prior to working their next shift. In-servicing for licensed nurses was completed [DATE]. No licensed nurses are on vacation. Licensed nurses on LOA were sent communication that they must complete in-service education before starting their next shift completed [DATE]. Education related to management of respiratory distress will be incorporated into new hire orientation effective [DATE]. Ongoing education for management of respiratory distress will be conducted quarterly for 6 months then incorporated into annual staff education and training. DON and Nursing Supervisor initiated an in-service for nursing staff to review emergency medical response policy and staff response. Understanding of the in-service content was evaluated at the time of in-service through question and answer. Staff who were unable to come to the building for face-to-face in-services due to scheduling will complete in-service education prior to working their next shift. Nursing staff on off-duty, on vacation or LOA will receive communication that they must complete in-service education before starting their next shift Completed [DATE]. Education related to emergency medical response and staff response will be incorporated into new hire orientation effective [DATE]. Ongoing education for management of respiratory distress will be conducted quarterly for 6 months then incorporated into annual staff education and training. On [DATE] the Social Service Director initiated a facility wide audit of records for all residents to assure POLST form, EHR banner and profile matched resident code status. The Social Service Director is responsible for updating the POLST form, EHR banner and resident profile. The DON initiated an in-service for all nursing staff regarding the location of code status information. Understanding of the in-service content was evaluated at the time of in-service through question and answer. Staff who were unable to come to the building for face-to-face in-services due to scheduling will complete in-service education prior to working their next shift. Nursing staff on off-duty, on vacation or LOA will receive communication that they must complete in-service education before starting their next shift. completed [DATE]. Education related to the location of code status information will be incorporated into the new hire orientation effective [DATE]. Ongoing education for location of code status will be conducted quarterly for 6 months then incorporated into annual staff education and training. The Facility conducted an audit of all in-house residents to assure the resident bed and placement match with computer entry. Any discrepancies were immediately corrected in the computer. Completed [DATE]. The facility implemented a system to identify bed or window placement immediately upon entry to the resident room. Completed [DATE]. The facility has reviewed and revised the resident identification policy. Completed [DATE]. The Administrator completed an audit to ensure all residents in house have a photo uploaded to the EHR for resident identification. Completed [DATE]. The Administrator and Nursing Supervisor initiated an in-service for licensed nurses on the revised policy for resident identification. Understanding of the in-service content was evaluated at the time of in-service through question and answer. Staff who were unable to come to the building for face-to-face in-services due to scheduling will complete in-service education prior to working their next shift. Nursing staff on off-duty, on vacation or LOA will receive communication that they must complete in-service education before starting their next shift Completed [DATE]. Education related to the resident identification policy will be incorporated into new hire orientation effective [DATE]. Ongoing education related to the resident identification policy will be conducted quarterly for 6 months then incorporated into annual staff education and training. An emergency ad-hoc meeting of the facility QAA committee which included the Medical Director, was convened and the interventions and response was reviewed and approved. Completed [DATE]. Ongoing Quality Auditing: The DON or designee will conduct a weekly random audit starting on [DATE] x 8 weeks using a QA tool to assure all nursing staff are aware of medical emergency response and change in condition and can describe the steps to take in a medical emergency and where code status information is located. The Social Service Director will conduct an audit weekly using a QA tool to verify code status matches on banner, profile and POLST form weekly for residents with code status changes and new admissions. The Admissions Director will conduct an audit using a QA tool 2x/week for 8 weeks to verify resident bed assignment is consistent with computer census documentation. The DON or designee will conduct a random audit using a QA tool 2x/week for 8 weeks to verify staff knowledge of resident identification policy and procedures.

Based on interview, and record review, the facility failed to follow their policy in notifying a physician of a change in condition for one (R8) of five residents reviewed for change in condition notification in a sample of 17. This failure resulted in R8 being unresponsive, apneic with a faint pulse and expiring. Findings Include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work on R8 until R8's DNR paperwork is provided to them. When V8 provided the DNR form, the paramedics verified the name and then stopped the resuscitation. V8 said that she realized that the DNR was for R9 and not for R8. V8 said there was a mix up of beds between R8 and R9. V8 said that R8 did not have a wrist band and she had no other way to identify the resident other than what was in the computer. V8 was asked, how do you identify the residents? V8 response was Name, Date of Birth, Pictures, and social security number. V8 said that she called V2 (Director of Nursing/DON) and told V2 that R9 expired, but called back later and informed V2 that R8 was the person that expired and not R9. V8 said that V2 told her to call 911 and initiate cardiopulmonary resuscitation (CPR). V8 said that V8 did not provide any emergency care to R8 prior to calling V2. V8 said she did not notify the physician of the change in R8's condition. On [DATE] at 4:15 PM, V2 said that as a nurse, if a resident is having difficulty breathing, V2 would attend to that resident regardless of code status. On [DATE] at 2:00 PM, V2 said that staff are expected to administer any amount of oxygen to a resident in an emergency if the resident is showing signs of air hunger and notify the physician. On [DATE] at 10:40 AM, V14 (R8 Physician) said that R8 was a full code. V14 said that he was not on call on the day R8 expired. V14 said that V15 was covering for him. V14 said that if he was notified of the change in R8's condition, he most likely would have sent R8 out to the hospital for further evaluation. On [DATE] at 11:25 AM, V15 (Nurse Practitioner) said that V15 was on call on the day that R8 expired. V15 said that V8 did not notify V15 about R8's change in condition. V15 said that she would have absolutely sent R8 out to the hospital for evaluation depending on her condition. Facility Policy: Change in a Resident's Condition Status. Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status.

Based on interview and record review the facility failed to ensure that oxygen was administered to a resident with labored breathing and failed to notify the physician of the change in condition for one of five residents (R8) reviewed for accommodation of needs in a total sample of 17. This failure resulted in R8 becoming unresponsive and apneic with a faint carotid pulse and expiring in the facility. Findings include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work on R8 until R8's DNR paperwork is provided to them. When V8 provided the DNR form, the paramedics verified the name and then stopped the resuscitation. V8 said that she realized that the DNR was for R9 and not for R8. V8 said there was a mix up of beds between R8 and R9. V8 said that R8 did not have a wrist band and she had no other way to identify the resident other than what was in the computer. V8 was asked, how do you identify the residents? V8 response was Name, Date of Birth, Pictures, and social security number. V8 said that she called V2 (Director of Nursing/DON) and told V2 that R9 expired, but called back later and informed V2 that R8 was the person that expired and not R9. V8 said that V2 told her to call 911 and initiate cardiopulmonary resuscitation (CPR). V8 said that V8 did not provide any emergency care to R8 prior to calling V2. V8 said she did not notify the physician of the change in R8's condition. On [DATE] at 4:15 PM, V2 said that as a nurse, if a resident is having difficulty breathing, V2 would attend to that resident regardless of code status. On [DATE] at 2:00 PM, V2 said that staff are expected to administer any amount of oxygen to a resident in an emergency if the resident is showing signs of air hunger and notify the physician. On [DATE] at 10:40 AM, V14 (R8's Physician) said that R8 was a full code. V14 said that he was not on call on the day R8 expired. V14 said that V15 was covering for him. V14 said that if he was notified of the change in R8's condition, most likely he would have sent R8 out to the hospital for further evaluation. On [DATE] at 11:25 AM, V15 (Nurse Practitioner) said that V15 was on call on the day that R8 expired. V15 said that V8 did not notify V15 about R8's change in condition. V15 said that she would have absolutely sent R8 out to the hospital for evaluation depending on her condition. Resident face sheet indicates that R8 was a [AGE] year old female, admitted on [DATE] with diagnosis not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (Primary, Admission), Dysphagia following cerebral infarction. Peripheral vascular disease, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, aphasia following cerebral infarction, and hypertension. [NAME] Fire Department Run Report dated [DATE] at 6:01:00 AM, had R9 name on this run report and documented that I/S was dispatched to a location for the 78 y/o female with difficulty breathing. U/A NH staff at door advised crew the pt. was breathing. Upon making pt. contact in pts. Room pts. Was found sitting up in the bed unresponsive and apneic with a faint carotid pulse. Pt. was placed supine in bed and airway was suctioned by NH staff and cleared of mucus. Pt. was ventilated with BVM. Patient became pulseless and CPR was initiated. Crew asked NH staff if the pt. had a valid DNR. NH staff advised that the pt., have a valid DNR and provided the crew with a paperwork which did not include pts. Valid DNR. Crew requested that NH staff locate and provide DNR for crew. CPR was continued by crew. Pt. placed on cardiac monitor with multi-use pads and rhythm check was performed. Pt. was asystole on cardiac monitor and CPR and ventilations were performed. NH staff came back to pt. room and handed crew a copy of the pts. DNR. Crew confirmed that the name on the provided paperwork from the NH staff and the DNR were for the same pt. and the DNR was valid. CPR was stopped by the crew for a rhythm check. Pt. was asystole on the monitor. (Local Hospital) was contacted via cell and pts. death was confirmed by (Doctor) at 0616 hrs. MPD officers were on Scene. Scene was turned over to MPD w/o incident. Medical Emergencies, Facility Policy: It is the policy of the facility to provide emergency care to a resident in need of it. Basic life support, including CPR will be provided until the arrival of Emergency Medical personnel in accordance with physician's order and a resident's Advance Directives. Emergency Care Procedure: M. Respiratory Distress, Treatment: 2. Check oxygen saturation. Administer oxygen when signs of air hunger are present. Medical Emergency Response Policy, Objective: 1. It is the policy of the facility to provide each resident with necessary emergency treatment. This includes the providing basic life support including CPR, to a resident requiring emergency care until the arrival of Emergency Medical personnel in accordance with physician's orders and resident's Advance Directives. Licensed personnel will assess the resident, determine interventions, notified the resident's physician, and document the event in the medical record. Change in a Resident's Condition or Status Policy, Objective: Our facility shall promptly notify the resident, his or her attending physician, and representative of change in the resident's condition and/or status. Procedures: 1. The nurse will notify the resident's attending physician or physician extender when: b) There is a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 1 of 3 residents (R13) reviewed for safety, this deficiency resulted in R13 falling out of bed on 11/26/2023 and being sent to the local emergency hospital, sustaining an acute intraparenchymal hemorrhage. Findings include: On 12/8/2023 at 2:31pm V22 (Certified Nursing Assistant-CNA) said on 11/26/2023 between 4:00pm and 4:30pm she rounded and observed R13's head on the metal bar underneath the bedside table on the floor. V22 said that it looked like R13 hit her head on the metal bars of the wheels of the bedside table. V22 said that R13 did not have any floor mats at the bedside, and she is a high risk for falls. On 12/13/2023 at 3:45pm, V21(Registered Nurse-RN) said on 11/26/2023 at about 4:30pm, V22 notified her that R13 was on the floor and her head was lying on the metal part of the bedside table. V21 said R13 is a high risk for falls and assessed her and sent her to the hospital. On 12/14/2023 at 10:35am V2 (Director of Nursing-DON) said that as the fall coordinator if a resident is a high fall risk, she expects all fall interventions to be in place, there should have been fall mats at R13's bedside. R13's resident face sheet indicated that R13 has a diagnosis of Functional quadriplegia, hemiplegia and hemiparesis and cognitive functions. A care plan dated 11/24/2023 with a problem of history of falls and intervention approach to provide resident safety device, floor mats to bilateral sides of the bed. A fall incident report dated 11/26/2023 and a final report dated 11/27/2023 of R13 fall interventions, did not include bilateral fall mats being in place and the report also documents that R13 sustained an acute intraparenchymal hemorrhage. Facility Policy: Reviewed 2/2023 Falls Prevention and Management, Purpose: The purpose of this policy is to support the prevention of falls by implementation of preventive program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. The falls prevention and management program are designed to assist staff in providing individualized, person-centered care. Fall prevention practices: Care planning and interventions to address fall risk factors: A fall risk care plan will be implemented as part of the baseline care plan to address universal fall precautions and as part of the comprehensive care plan utilizing information from the fall risk assessment. The care plan will be reviewed and revised as least quarterly and with any fall event the resident might experience.

Based on interview and record review, the facility failed to ensure outpatient hemodialysis was in place prior to discharging a resident home. This affected one of three (R1) residents reviewed for safe discharges. This failure resulted in R1 missing approximately four treatments and being admitted to the local hospital with an elevated potassium level requiring emergency hemodialysis. Findings Include: R1 is an [AGE] year old with the following diagnosis: end stage renal disease with dependence on renal dialysis, type two diabetes, peripheral vascular disease, and chronic heart failure. A Nursing note dated 9/28/23 documents R1 admitted from the hospital. R1 is alert and oriented times three. R1 receives dialysis on a Tuesday, Thursday, and Saturday schedule to a right upper chest port/permacath. A Physician note dated 10/5/23 documents R1 was admitted to the hospital previously for generalized weakness and frequent mechanical falls. R1 was started on dialysis on 9/21/23. A permanent catheter was placed on 9/25/23. Plan is to continue current dialysis. A Social service note dated 10/12/23 documents R1 plans to discharge from the facility with recommended medical equipment that was ordered being a wheelchair to R1's family member's house out of state. Social services will continue to follow up appropriately on R1's anticipated discharge date . A Discharge note dated 10/18/23 documents R1's family is at the facility to pick up R1 for discharge. Essential medications and education were given to the family. Discharge instructions were given to the family to follow up with a primary care doctor chosen by the family upon discharge. The Hospital Records dated 10/26/23 documents R1 was told to come to the emergency department by the nephrologist because of abnormal labs. R1 has kidney failure and was getting hemodialysis while in rehab but has not had dialysis since 10/17/23. R1 had no other complaints. R1's lab values are as follows: potassium 5.8 mEq/L (elevated), BUN 84 mg/dl (elevated), and creatinine, 7.6 mg/dl (critically elevated). R1 was found to have a high potassium level which was checked outside the facility due to not receiving dialysis over the last two weeks. R1 had a dialysis catheter placed during the last hospitalization and received dialysis at the rehab facility. R1 was discharged from the rehab facility nine days ago and has not had dialysis performed since then. Nephrology was consulted and placed orders for R1 to receive STAT dialysis. R1 was admitted to the hospital with planning for outpatient dialysis prior to a safe discharge. On 11/7/23 at 12:07PM, V3 (R1 Family Member) stated V3 is now in charge of R1's care and came in from out of state to help care for R1. V3 endorsed being present for R1's discharge and no follow up appointments or dialysis was scheduled after discharge. V3 denied telling the facility they were leaving for a new state the day of discharge. V3 stated the plan was to follow up with all R1's physicians here before making plans to leave to another state. V3 stated V3 called a physician and had labs ordered on R1. V3 endorsed since the labs were elevated, they sent R1 to the hospital for dialysis. V3 endorsed R1's last dialysis session was nine days before being admitted to the hospital. V3 denied giving the facility an exact date of leaving for out of state. On 11/7/23 at 2:31PM, V4 (Nurse) stated V4 was the nurse that discharged R1. V4 reported the plan was for R1 to go straight to another state but V4 was unsure of the exact day R1, and family would be leaving. V4 endorsed R1's family member did not have any further questions about R1's care when they left the facility. V4 reported the facility will normally set up all after care a resident needs in a discharge but R1's family member requested to set it all up in the new state. On 11/7/23 at 2:49PM, V5 (Social Services) stated R1's family member requested R1 be discharged as quickly as possible due to traveling to another state. V5 reported the only thing R1's family requested was a wheelchair to wheel R1 through the airport. V5 stated R1 was supposed to be discharged from the facility and leave directly to the airport. V5 endorsed the facility will normally set up follow up appointments and care when a resident is discharged . V5 reported no post-discharge care was set up for R1 based on R1's family's request. V5 stated, R1's family member acted like she knew what do to and who to call if she had a problem. On 11/8/23 at 12:58PM, V11 (Nephrologist) stated V11 followed R1 while R1 was a resident in the facility. V11 endorsed being aware the family wanted to take R1 to another state but denied knowing when R1 was traveling to the new state. V11 stated usually social services and the nursing team work together to coordinator dialysis care for a resident after they are discharged . V11 endorsed the responsibility of setting up chair time for dialysis and admitting to a new facility should not fall on family members. V11 stated the facility should have done due process to make sure all post discharge care is scheduled. V11 reported being aware R1 missed dialysis session but was not sure of how many were missed. V11 stated a resident runs the risk of having elevated labs levels and should get to the hospital as soon as one session is missed. The Discharge and Transfer Plan of Care dated 10/18/23 documents R1 had a tentative discharge date of [DATE]. The rest of the form is not completed. There are no discharge medications, follow up appointments, referrals, or facility contact information documented. The Physician Order Sheet documents R1 should receive dialysis three times a week on Tuesday, Thursday, and Saturday. This order was placed on 9/28/23. The Care Plan dated 9/29/23 documents R1 is an anticipated short term stay. R1 expects to discharge back into the community when medically appropriate. An Intervention is documented as nursing will arrange PCP and all other necessary appointments for R1 prior to the tentative discharge date . The Care Plan dated 9/29/23 documents R1 requires hemodialysis secondary to renal failure and is at risk for complications. An intervention is documented as hemodialysis is ordered three times weekly by the physician. The Minimum data Set Section O dated 10/5/23 documents R1 receives hemodialysis. The policy titled, Post-Discharge Plan, dated 03/2016 documents, .1. When the facility anticipates a resident's discharged to a private residence or to another nursing care facility, a post discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The post discharge plan will be developed by the care plan team with the assistance of the resident and his or her family. 3. The resident or representative should provide the facility with a minimum of a 72 hour notice of an anticipated discharge date to ensure that an adequate discharge plan can be developed. Failure to comply with this rule could result in the facility being unable to develop a discharge plan and make appropriate discharge arrangements. 4. As a minimum, the post discharge plan will include: a. A description of the residence and families, preferences for care; b. A description of how the resident and family will access and pay for such services; c. A description of how the care should be coordinated, if continuing treatment involves multiple caregivers; d. The identity of specific residence needs after discharge (I.e., personal care, sterile dressings, physical therapy, etc.); and e. A description of how the resident and family need to prepare for the discharge.

Based on interview and record review the facility failed to ensure the safety of a resident during a wheelchair transport for 1 of 3 residents (R2) reviewed for safety in the sample of 9. This failure resulted in R2's foot getting stuck under her wheelchair and causing a right tibial fracture (near her right knee) and experiencing subsequent leg pain. The findings include: R2's face sheet showed she was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include osteoarthritis of knee, osteoarthritis of hip, chronic pain, polyneuropathy, dementia, psychotic disturbance, anxiety disorder, chronic kidney disease, muscle wasting and atrophy, muscle weakness, and abnormal gait and mobility. R2's facility assessment dated [DATE] showed she had no cognitive deficits and required extensive assistance of staff for most cares. R2's 4/27/23 nursing note entered at 3:26 PM showed, Resident complained to POA (Power of Attorney) that she has pain in her vaginal area. POA made aware of resident's complaint. Writer assessed resident's complaint and made NP (nurse practitioner) aware, and NP ordered an x-ray of resident's right side from hip to foot . R2's 4/27/23 nursing note entered at 6:40 PM showed, X-ray completed and awaiting result. R2's 4/28/23 nursing note entered at 1:36 AM showed, Received x rays results acute non disclose fracture to right tibial . At 3:23 AM another nursing note was entered showing . order to send resident to [acute care hospital] . R2's 4/29/23 nursing note entered at 7:00 PM showed, Resident readmitted . Resident diagnoses: Right Fracture of Tibia Shaft (closed non surgery). Wearing immobilizer to leg. Patient will be non weight bearing . R2's eMAR (electronic Medication Administration Record) showed on 4/29/23 (readmitted to facility) R2 reported pain at a 10 out of 10 on the pain scale. R2's 5/19/23 nurse practitioner note showed, Patient is a [AGE] year old female with past medical history of dementia and hypertension is seen for follow up on her fracture . Patient has complaints noted to her right leg, but no numbness is noted. Continue present management with all medications continue Norco (narcotic pain medication) for pain management . Continue hinge brace to RLE (right lower extremity), circulation checks every shift . R2's 5/24/23 nurse practitioner visit note showed, . She is reporting right leg pain today, which has been present since her recent fracture . R2's acute care hospital paperwork showed she was admitted to the hospital on 4/28/23 for a fracture of her right tibial shaft and discharged back to the skilled nursing facility on 4/29/23. This same paperwork showed she was to be non weight bearing to the right lower extremity and was to wear a hinged knee brace . On 6/25/23 at 9:35 AM, R2 was lying in bed covered with a blanket. R2 said she was having pain to her feet and her right leg. R2 said she had injured her leg a little while back when someone was pushing her wheelchair in the hallway. R2 said, The girl told me to hold her papers. I had her papers on my legs and she was pushing my chair. The papers started to slide off my lap and when I tried to catch them because I told her I wouldn't let them fall. Part of my knee broke. I pulled my left foot up but didn't get my right one up, so it went up under the wheelchair . I had footrests before this happened, but they stayed in here (her room) all the time. Now they aren't allowed to take me out of the room without them. On 6/25/23 at 11:46 AM, V11 (Activity Aide) said, About a month ago R2 was at the nursing station when I asked her if she wanted to go to the activity. She did not have footrests on her wheelchair. I didn't really pay attention that she didn't have footrests. Her feet were up, and everything was good. It looked like she lost her balance, and she dropped her foot down. Her foot got caught up under her chair. I reported it to the nurse. [R2] said 'ouch my foot' so I had the nurse take a look at her. They tell us that if you see a patient that is pushing themselves, we should let them do it and if we push the resident in the wheelchair, we should have foot pedals. On 6/25/23 at 1:28 PM, V8 LPN (Licensed Practical Nurse) said R2 complains of pain to her right leg. V8 said usually therapy does an assessment and they determine if the resident needs foot pedals on their wheelchair. On 6/25/23 at 1:55 PM, V9 CNA (Certified Nursing Assistant) said the Restorative Aides determine if a resident needs foot pedals. V9 said the way the staff know what the residents needs are is by looking at the falling star that is posted on their door or they could ask the nurse. V9 said R2 can propel her wheelchair around her room with her arms now. V9 said if residents are being assisted in their wheelchair, they need to have foot pedals on. V9 said some residents propel themselves at times so they don't have foot pedals. V9 said if a resident propels their own wheelchair at times they would not have foot pedals on. On 6/25/23 at 2:30 PM, V2 DON (Director of Nursing) said R2 had worked with therapy on the day the incident occurred. V2 said when R2 was done in therapy they put her next to the nursing station in her wheelchair. V2 said R2 could propel her own wheelchair but she needed enough time to do it and it was difficult for her to maneuver the corners. V2 said V11 was going down the hall asking residents if they wanted to attend the activity. V2 said V11 got R2 straightened out in the hall so she could propel herself and then continued down the hall asking other residents if they wanted to go. V2 said when V11 came back down the hall she started pushing R2 around the corner. When she was pushing R2 her foot fell down and went up under the wheelchair. They had wheelchair pedals in the room but since therapy was working with her, they didn't have them on her chair. V2 said R2 does not necessarily need the foot pedals and she can tell you if she wants them. On 6/25/23 at 3:11 PM, V19 CNA said, Usually if the patient is in the wheelchair, they sometimes have footrests. We sometimes know what the resident needs from checking the care plan or asking the nurse. We are told we are supposed to have foot pedals on the chairs. We had an inservice about that. They said we can look on the back of the door or ask the nurse if the resident needs foot pedals. A policy addressing the use of foot pedals when transporting residents in wheelchairs was requested and not received.

Based on observations, interviews, and records reviewed the facility failed to assist a dependent resident back to bed, failed to ensure to provide assistance to a resident with impaired balance, failed to ensure fall prevention interventions were implemented and a fall risk assessment was completed per policy and procedures. These failures affected 3 of 3 residents (R1-R3) reviewed for fall preventions. This failure resulted in R1 falling asleep in the wheelchair and falling to the floor and sustaining a laceration with suture repair. Finding include: A. R1 is [AGE] years old with diagnosis including, but not limited to [CONDITION(S)], Diabetes mellitus, Chronic [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following Cerebral Vascular Infarction affecting Left Dominant Side. R1 sustained a fall on 8/13/22. According to his cognitive assessment, R1 is noted to be cognitively intact. On 9/16/22 at 10:10AM R1 observed in bed. No star on R1's doorway. R1 noted alert. R1 said when I fell , I was sitting here in my chair. R1 indicated to center of the room, between the beds. R1 said I was watching TV and fell asleep. R1 said I had a knot on my head pointed to top of his left temple, along hairline. R1 said they gave me stitches. On 9/16/22 at 11:49AM R1 observed in bed, top half leaning to right side, head of bed elevated, call light and sheet on the floor. R1 is not able to reach his light for assistance. R1 said his wheelchair is in the bathroom. The surveyor observed a seat cushion in place, but no nonslip device placed on or under the cushion. On 9/16/22 at 12:12PM V4, CNA, said a star on the door or a light bulb means to check the resident when walking by. V4 said all residents who use a wheelchair cushion should have a grippy device on the cushion. V4 said safety interventions are listed on the sheet in the resident closets. V4 presented R1's closet list that includes his transfer status, but no fall risk or safety interventions are listed on the sheet. V4 said, if the interventions are new they may not be on the list yet. V4 said she is not aware that R1 has fallen. R1's call light remains on the floor while the surveyor and V4 discussing the care sheet and fall interventions. V4 left the room and did not place R1's call light in his reach. On 9/16/22 at 12:44PM, during a phone interview, V5, CNA, said on 8/13/22 she was assigned to R1. V5 said she had asked R1 if he was ready for bed, and he said no. V5 said she left R1 sitting in his wheelchair with the bedside table in front of him. V5 said about 45 minutes later R1 was seen on the floor. V5 said there was blood on R1's face and the floor. V5 said she thought R1 may have fallen asleep in his wheelchair and fell . V5 said she had not known R1 to have fallen before. V5 said residents at risk for falls have stars on their door. On 9/16/22 at 2:36PM V11, Restorative Nurse, said regarding R1's fall on 8/13/22, I know R3, and he was ready to get back to bed. V11 said R1 had told the nurse working that he fell asleep in the chair. V11 said when I spoke to him, he said he was trying to get back in the bed. V11 said I know R1, he was ready to get back to bed. V11 said it was unusual for R1 to be out of bed at that time on the day of the fall. V11 said the papers in the closet doors show the residents' transfer status, but do not include safety interventions. On 9/20/22 at 9:45AM V12, MDS Nurse, was asked if the care plan reads call light in reach, should it be in reach? V12 said yes. The surveyor asked what is the purpose of having the light in reach? V12 said so the patient can call for assistance, if they need to use the bathroom or reach for an item not in reach. V12 said whatever they need they can use the call light to ask for assistance. Fall Record provided by the facility dated 8/13/22 initiated by V17, Agency Nurse, notes a fall occurred at 7:35PM with a laceration and hematoma to the left forehead. V17's phone number was requested, but not provided. The report notes R1 was observed lying prone next to wheelchair. R1 stated he fell asleep in his chair and fell . The conclusion written by V11 states R1 attempted to self transfer from the wheelchair to bed without staff assistance. Review of R1's progress notes dated 8/13/22 note R1 was transferred to the hospital following his fall for evaluation. Progress note dated 8/14/22 note R1 returned to the facility with 1 suture to his scalp. Progress notes dated 8/22/22 note 2 sutures were removed. R1's Fall Risk assessment dated [DATE] notes R1 has intermittent confusion and is a High Risk for falls. The facility provided 2 fall risk assessments for R1 dated 10/25/21 and 6/30/22. No fall risk assessment provided following fall on 8/13/22. R1's hospital record dated 8/13/22 notes a 4 x 3 x 2 cm left parietal hematoma with abrasion. Additionally, Frontal scalp contusion. Assessment notes scalp hematoma and underlying laceration. Laceration repair performed with 1 suture to the left parietal region. Review of R1's Orders do not include fall prevention orders. R1's Cognitive Patterns assessment dated [DATE] notes a score of 14, intact. R1's Functional assessment dated [DATE] notes he required extensive assistance with bed mobility and transfers of 2 persons. R1's Fall care plan start date 10/25/21 note R1 is at risk for falling related to [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting Left Dominant Side and unsteadiness on feet. Interventions include, start date 7/11/22, provide with safety device to wheelchair to prevent sliding; start date 10/25/21 keep call light in reach at all times. Risk factors on care plan do not include the contributing factors listed on the fall risk assessment, intermittent confusion, and medications. B. R2 is [AGE] years old with diagnosis including, but not limited to Dementia and [CONDITION(S)]. On 9/16/22 at 10:17AM, the surveyor observed R2 walking independently in the room from reclining chair into the bathroom. V14, Staffing Coordinator, walked past while he was up and walking and V14 did not intervene. No staff is present in the room. No star or light bulb symbol outside of R2's door. On 9/16/22 at 10:27AM R2 observed to walk out of his bathroom and ambulate in the room. V1, Certified Nursing Assistant (CNA), walked past and did not stop to intervene. V1 interviewed outside of R2's room where R2 is visible. V1 said she is checking on people at least every 2 hours and when walking by for safety. V1 said when I check people I am looking to see if they need to use the bathroom, they have what they need, call lights in reach, water in reach, and that everything is in reach. These things need to be in reach, so the residents don't fall trying to get to them. No staff in R2's room as he continues to walk in his room. On 9/16/22 at 10:34AM, the surveyor observed R2 kneeling on the floor between the bed and recliner chair on his knees looking for something behind the recliner chair. On 9/16/22 at 2:04PM V9, CNA, said R2 can participate in cares. V9 said R2 is not independent, he can feed himself, needs help with dressing, and he can toilet himself. V9 said R2 would not change his clothes. V9 said R2 needs direction from staff. V9 said R2 can ambulate independently, he comes out for meals. V9 said stars or wrist bands are used to identify fall risk. On 9/20/22 at 9:45AM V12, MDS Nurse, was asked if a resident care plan states give resident verbal reminders not to ambulate/transfer without assistance, should they be ambulating or transferring independently? V12 said no, they should not walk independently. V12 was asked if this intervention is specific to the room or anywhere? V12 said the intervention applies in general. R2's Fall Risk assessment dated [DATE] notes R2 has balance problems while standing and walking. On 9/16/22 the surveyor requested a copy of R2's Fall Risk Assessment. The assessment dated [DATE] was provided. [This greater than 100 days since last assessed for fall risk.] R2's care plan start date 5/25/22 notes R2 experiences wandering (moves with no rational purpose, seemingly oblivious to needs to or safety). Start date 5/17/22 notes R2 is at risk for falling related to unspecified Dementia. Interventions include give verbal reminders not to ambulate/transfer without assistance. Place in fall prevention program. R2's cognitive Pattern assessment dated [DATE] notes a score of 2, severely impaired. C. R3 is [AGE] years old with diagnosis including but not limited to Polyarthritis, Presence of Artificial Knee Joint, and Chronic Obstructive Pulmonary Disease. R3 was admitted to the facility on [DATE]. On 9/16/22 at 11:35AM the surveyor observed R3 in her room at the end of the hallway, last room from the nurses' station. R3 sleeping in the side chair, door open to her room. R3 did not verbally respond to the surveyor. No star observed on the resident doorway. On 9/16/22 at 11:59AM V3, CNA, said residents at risk for falls are identified by the care plan posted in each residents' closet. V3 accompanied the surveyor to show the care plan. V3 showed the surveyor a document posted in a random resident closet Transfer Sheet. V3 said this sheet will include the resident transfer status and if they are in the fall program. V3 said there is also a binder with safety interventions at the desk. V3 did not present the surveyor with a binder when asked. Transfer sheet reviewed and there is no safety intervention listed on sheet. On 9/16/22 at 1:05PM V7, Registered Nurse, said on 9/15/22 the CNAs got R3 up in the morning, because she has a history of falling and R3 was sitting in her wheelchair at the nurse's station. V7 said I was in another resident's room and when I came out, I saw R3 on the floor. V7 said R3 fell in front of the nurses' station. V7 said R3 said she was trying to get to the phone. V7 said no staff was with her when R3 fell , but they heard her fall, and they came out of the rooms. V7 said any resident sitting at the nurse's station is a fall risk and are there to be watched. V7 said we might have an icon, but I am not 100% sure, to identify residents at risk for falls. V7 said fall prevention interventions are on the care plans and some are orders. On 9/16/22 at 1:32PM V6, CNA, said he was assigned to R3 on the evening shift of 9/14/22. V6 said R3 sat with me most of the day yesterday because she was active. V6 said R3 was trying to walk, and she had said she didn't want to be alone. V6 said after dinner, R3 went to bed, then she got back up and was walking in the hallway. V6 said I don't know if R3 has ever fallen, she is pretty new. On 9/16/22 at 1:50PM V8, CNA, said on 9/15/22 she saw R3 at the nurse's station trying to get up. V8 said R3 said she was hungry and V8 said she told R3 breakfast is on the way. V8 said then the trays arrived on the unit. V8 said V9 and V16, both CNAs, were passing trays and V8 said she left to do her rounds, walking with her back to the nurse's station and R3. V8 said then V9 told her we need a nurse. V8 said she then saw R3 on the floor. V8 said following R3's fall she has not been told what the new fall prevention intervention is for R3. V8 said the residents have a care plan behind the doors that include safety interventions. On 9/16/22 at 2:04PM V9, CNA, said she was on the unit passing meal trays on 9/15/22. V9 said the night shift had gotten R3 out of bed and into her wheelchair because R3 was a fall risk. V9 said she was told R3 was trying to get up and walk so they put R3 at the nurses' station. V9 said she was in a resident room and heard a boom and someone said there was a fall. V9 said she came out of the room and saw R3 on the floor. V9 said she had seen R3 standing up about 10 minutes before R3 fell . V9 said R3 thinks she has to make a call and go to work. V9 said when R3 gets restless she moves around and tries to use the phone. V9 said V8, CNA, was on a different unit when R3 fell . V9 said V7 and V16 were in resident rooms and nobody was at the nurses station. The surveyor clarified with V9 if there was no one at nurses' station with R3? V9 said correct, she (R3) was the only one there. On 9/16/22 at 2:36PM V11, Restorative Nurse, said when a new resident is admitted we complete a restorative assessment. The assessment includes how the resident transfers, range of motion ability, their walking ability, and any assistive or fall prevention devices needed. V11 said if a resident is admitted with a fall history, confusion, or attempting to ambulate when needing assistance, we will consider the resident a high fall risk and they will be placed on the fall prevention program. V11 said staff is notified of high fall risk residents with a blue star on the door. V11 said staff is notified of the fall program at orientation. V11 said residents at the desk require frequent observation or to be in sight of staff. V11 said observation at the desk was not effective for R3. V11 said before 9/15/22, R3 was a fall risk because she gets up without assistance. V11 said staff would know R3 is a fall risk by having her. V11 said R3 was a new admit so we were in the process of getting her care plan in place. V11 said I have not done any of the fall interventions for R3, yet. V11 said after the fall risk assessment, if the resident is at risk, I put in the fall care plan and the interventions. On 9/20/22 at 9:45AM V12, MDS Nurse, said the Interim care plan should be in place in 48 -72 hours, from admission. V12 said the purpose of the interim care plan is so that care will be delivered, especially if there are risks involved. V12 said if a resident is at risk for falls then the care plan will be implemented for falls. R3's Fall Record provided by the facility dated 9/15/22 notes R3 had an unwitnessed fall without injury. Fall Risk Assessment completed on 9/15/22 at 9:09AM notes R3 has balance problems while walking, decreased motor coordination, and no history of falls in the last 3 months. R3 is noted to be a High Risk for falls. There is no fall risk assessment completed on admission, 9/10/22. Initial Baseline Care Plan dated 9/10/22 notes R3 will be free of injury. Assess for risk factors, Orient to room and call light use, and assess history of falls. Review of further Care Plans, 6 pages provided, does not include interventions to prevent falls. Care plans do not include interventions when R3 attempts to get up unassisted. R3's care plan does not include the contributing factors identified on her fall risk assessment. A facility provided hospital record with a printed date 8/24/22 notes R3's family concerned about R3's memory loss and complaints of fall in house several weeks to month ago. Record states legs gave out. On 9/20/22 at 10:51AM, the surveyor asked V11 what score she used to determine to place stars on the resident doorways. V11 said it depends on the fall risk assessment score and if they have fallen. The surveyor asked V11, do you have a documented consistent plan to follow stating when the stars will be put on the door? V11 responded, no. On 9/20/22 at 11:18AM V13, Director of Nursing was interviewed. V13 said the star is used to let staff and family know that the resident is a high fall risk. V13 said if we know the patient is trying to get up alone, when they are newly admitted , then they have them at the nurses' station, or in activity to see what interventions will be put in place. V13 said residents are placed at nurses' station to closely monitor. V13 said I wasn't here (in the facility) when R3 fell . V13 said we are not going to prevent all falls. The surveyor provided V13 with R3's Interim care plan for review. V13 said we probably need to add more to it, this is a corporate form. The surveyor asked V13 how the staff know if a new admission is at risk for falls? V13 said the CNAs will do room to room report. V13 said this is a verbal report. The surveyor asked what protocol is used to identify fall risk residents to the staff. V13 said I don't have an answer. V13 said when a resident is admitted the computer interventions are put in place by the nurses within 7 days. V13 said the light bulb symbol is used if the resident is not able to use their call light. On 9/20/22 after the 11:18AM interview with V13, DON, the surveyor requested copes of R1's and R3's Transfer Sheets. These were not provided to the surveyor. On 9/20/22 at 12:46 PM V12, MDS Nurse, said quarterly is defined per Resident Assessment Instrument (RAI) Manual as every 90 days or earlier. V12 said if an assessment is done in October, the next one is due in January, then April, then July, and then in October. V12 said in 1 year the resident should have at least 4 assessments completed. The facility Falls Prevention and Management policy revised 3/2022 notes the purpose of this policy is to support the prevention of falls by implementation of a preventive program that promotes the safety of residents based on care process that represent the best ways we currently know of preventing falls. The falls prevention and management program is designed to assist staff in providing individualized, person centered care. The falls prevention and management program provides a framework and tools to identify and communicate about a residents risk of fall. Fall Prevention Practices includes: universal fall precautions, standardized assessment of fall risk factors, care planning and interventions to address risk factors. The fall risk assessment is completed quarterly, with significant change in condition, and following a fall.

Based on interview and record review the facility failed to protect a resident from misappropriation of property by staff resulting in a resident experiencing financial and identity theft and financial hardship leading to psychosocial harm. This failure applies to one resident (R1) in a total sample of 3 residents reviewed for theft. Findings include: On 01/04/2022 from 2:58PM - 4:00PM V1 (Administrator) stated that R1's belongings were secure in her room in her stand next to her bed and clothes in the closet when she was transferred to the hospital on 11/24/2021. V1 stated the facility maintains the cleanliness of resident's rooms when they are temporarily out of the facility. V1 stated the facility was notified on a Saturday morning that R1's belongings would be picked up by family so V10 (Housekeeping Supervisor) asked V8 (Housekeeper) to pack up R1's room on a Saturday to prepare her belongings for pickup. V1 stated R1 notified V13 (Licensed Practical Nurse) that Saturday evening her debit card was used by someone at the facility. V1 stated, V13 reported that R1 called again and reported that her daughter picked up her purse and used the debit card at a restaurant. V1 stated that the next day V13 informed her that the police were at the facility and stated R1 reported to the police that her card was stolen and that she did not have a daughter. V1 stated the local police reviewed video footage from local businesses showing V9 (Dietary Aide/Maintenance Staff) using R1's cards. V1 stated she believes it's possible when V8 (Housekeeper) packed up R1's room she found R1's purse and gave it to V9. V1 stated V9 was arrested and charged with felony identity theft. V1 stated initially V8 was arrested then V9 took responsibility for the theft and was charged. V1 stated the following Monday another housekeeper found a wallet in the dumpster at the facility near the soiled utility room. V1 stated she observed the wallet to contain R1's ID and other cards. V1 stated the wallet may have been placed there to mislead authorities. V1 stated she speculates that V9 may have brought the wallet back and placed it there. V1 stated V9 reported that he placed the wallet back in the resident's drawer but had not been at the facility during the time of the ordeal to do so. V1 stated the facility's video footage only showed V8 going into R1's room and performing cleaning procedures and likely packing her belongings but didn't indicate what she was doing inside the room. V1 stated housekeeping staff are typically responsible for packing up resident's belongings for discharge. V1 stated normally housekeeping staff reports any valuable items found while cleaning rooms of residents who are out of the facility and turn it in to management. V1 stated V9 was officially terminated because of the incident of R1's purse being stolen. On 01/05/2022 at 11:42AM R1 stated she was reluctant to take the surveyor's call for fear of retaliation from the facility and because they had already made a false report to law enforcement on her behalf, and she wasn't sure if the surveyor's attempt to reach her was another attempt by the facility to trick her. R1 stated she has been going through hell as a result of having her purse stolen by staff at the facility. R1 stated because of the incident she didn't have her driver's license and had to replace all of her financial and identification cards. R1 stated her church had to provide her with financial assistance because she wasn't able to acquire items she needed. R1 stated staff stole her entire purse that contained her expensive earbuds, prescription medication, identification cards as well as every credit card she had, and she can't afford to replace any of these items. R1 stated she is still being victimized because last week the offenders attempted to use the card again to purchase a game console subscription. R1 stated, the staff who stole her purse made purchases at a restaurant, a smoke shop, and a gas station. R1 stated the offenders tried to use her cash app and chime bank card account but it was declined because those accounts had no money in them. R1 stated while all this is going on, she is in the middle of trying to learn to walk again. R1 stated she feels mistreated by the facility and because she was in fear for her safety she refused to return to the facility. R1 stated the facility called the police right after she informed them her cards were stolen by staff and lied to the police that she reported to them that her daughter had her purse and cards. R1 stated the police then called and asked if she had a daughter and she said no. R1 stated the police informed her that the facility reported that she notified them that her daughter had her cards; but that was false. R1 stated she only has a son. R1 stated this situation made her very angry and upset her significantly. She is the victim and the facility tried to make it appear to the police that she was not in her right mind; making up an imaginary daughter to cover up what had been done. Abuse investigation report dated 12/12/21 documents R1 reported to V1 (Administrator) that her debit card was not in her possession and there were unauthorized charges on her account; local police department was notified; Administrator, Director of Nursing, Family and Physician were notified; V13 (Licensed Practical Nurse) was interviewed and reported she received a call from R1 stating her daughter picked up her purse and used the debit cards and V8 (Housekeeper) was likely not involved with the missing purse; V10 (Housekeeping Supervisor) was interviewed and reported observing a black backpack style purse on R1's night stand prior to asking V8 to pack up R1's belongings, V8 stopped for lunch at local restaurant the day of the incident; V8 was interviewed and stated she did not see R1's purse and put all R1's belongings in the closet; V8 and V9 (Maintenance Staff) were related and were both suspended pending investigation; Police investigation revealed V8 did remove R1's purse from her room and V9 obtained the cards and used them; both employees were terminated as a result of the offense; R1 was reimbursed for the incident; Police Department formal request for video camera footage attached to investigation report. Police report dated 12/11/21 documents V8 acknowledged she was assigned to R1's room to pack up her belongings and clean her room; V8 reported that her son V9 used R1's debit cards; video footage of V9 using R1's debit card at multiple locations was observed by law enforcement; V9 turned himself in to law enforcement and stated on 12/11/21 that V8 informed him that she found a wallet that she would try to bring it home to him, they both went through R1's wallet, and he used the cards in the wallet to make purchases. The facility's Abuse Policy reviewed 01/04/2022 states: The facility prohibits mistreatment, misappropriation of resident property by: Establishing an environment that promotes resident security and prevention of mistreatment. The facility is committed to protecting our residents from misappropriation of property by anyone including, but not limited to, facility staff. Misappropriation of Resident Property: is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.

Based on observation, record review and interviews the facility failed to monitor a resident with a history of swallowing problems closely during meal time to immediately intervene when and if the resident showed difficulty swallowing and or aspiration. This applied to one (R1) of three residents reviewed for supervision. As a result R1 was found by a housekeeper unresponsive and later noted with food in mouth by paramedics and pronounced dead. Findings include: According to R1's face sheet, R1 has [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] shows R1's Brief Interview for Mental Status (BIMS) score was 12, with disorganized thought behavior present and fluctuates. R1 had impairment to one upper extremity. Facility initial report to state agency dated [DATE] indicated R1 had [DIAGNOSES REDACTED]. V1 (Administrator) notified that resident noted unresponsive in her room. Code called. Staff responded and initiated CPR. 911 responded to the facility and took over CPR. Resident expired in the facility and EMT's left. Responding officer, when leaving facility mentioned to V1 that the EMT had removed a piece of beef. Initial review of resident's plan of care indicate that she was on a regular diet. Investigation initiated and full report to follow. The local police department report dated [DATE] shows in-part offense code, death investigation. Reported at 1:57pm. Responding officer was dispatched to Generations at Applewood to assist Fire Department with a non-responsive resident, not breathing. Responding officer and paramedics arrived on scene and observed V8 (Certified Nursing Assistant/CNA) performing chest compressions on R1, who was laying on her bed in R1's room. Paramedics took over CPR efforts on R1 who was still not breathing nor responding. Local paramedics observed pieces of food (meat) in R1's throat, which they removed in effort to clear R1's airway. Paramedics advised R1 had no pulse. Responding officer spoke to R1's CNA (V6) who advised that she last saw R1 responsive at approximately 1:30pm when she brought her food tray containing soft roast beef, cut potatoes and cobbler. V6 stated R1 can feed herself so she left the food tray with R1 and left the room. At 2:39pm responding officer spoke to the medical examiner to discuss the facts of the incident. At 2:56pm Medical Examiner contacted responding officer and opened a Medical examiner case for R1. Medical examiner said a case was opened due to the fact pieces of food were found in R1's throat. In respond to the officer's report, on [DATE] at 2:10p.m V1 stated that the responding police officer only mentioned that R1 had food particles around her mouth. R1's MDS assesment dated [DATE] indicated R1 required extensive assistance with one person physical assist with eating. R1's plan of care with last review date [DATE] shows R1 requires assist with ADL (Activity of Daily Living) related [MEDICAL CONDITION](stroke), history of falls and anxiety. The approach for ADL assist includes: bed mobility - extensive x 2 staff assist; eating - supervision and set up for meals; transfers - mechanical lift x 2 staff; toileting - extensive x 1 staff; 2 for bed mobility, incontinent; dressing/grooming - extensive x 1 staff; bathing - extensive x 1 staff, 2 with showers; and positioning - unable to ambulate. Needs assist with initiating and completing meals. R1 has swallowing problems related to history of dysphagia; goal shows that R1 will not choke. The approach is assess for dehydration, regular diet thin liquids, no tomatoes, baked potatoes, spinach, citrus products or orange juice, monitor for signs and symptoms of aspiration pneumonia, monitor for signs and symptoms of malnutrition, observe resident closely for signs of difficulty swallowing and/or aspiration. Use aspiration precautions. R1's plan of care does not mention what aspiration precautions that will be utilized for R1. R1's plan of care does not mention how the facility will monitor R1 during meals times and does not show how the facility will observe for difficulty with swallowing and aspiration. According to the above information, R1's plan of care and MDS assessment does not reflect the same information for assistance with eating. R1's progress notes dated [DATE] at 2:44pm documented by V4 (Nurse) show housekeeper entered residents room and witnessed resident unresponsive; when writer was made aware by the nursing assistant writer assessed resident for vitals, non-present, crash cart was obtained, HOB (head of bed) was lowered, board was placed under resident, mattress was deflated, airway was checked, CPR was initiated and 911 was called. Supervisor and MD made aware. Writer also contacted R1's daughter and updated; daughter stated she would call back to let facility know what her next plans are. Will endorse to next shift nurse. On [DATE] at 12:44pm during interview, V6 (CNA) said when she was summoned to R1's room because R1 was not breathing, V6 saw food on the upper part of R1's gown. V6 said it look like beef that R1 was eating. On [DATE] at 3:45p.m V12 (Assistant Director of Nursing/ADON) said V9 (Nurse) mentioned to her that the paramedics pulled 2 food particles out of R1's mouth. On [DATE] at 10:58a.mp.m V9 denied saying to V12 that the paramedics pulled food particles from R1's mouth. V9 said she did see food on R1's gown when she responded to R1 being unresponsive. On [DATE] at 10:58a.m V4 (Nurse) said she was the nurse responsible for R1's care on [DATE] and R1 does not need assistant with meals, just set up only. V4 said when she responded to R1's room she observed food on R1's clothing around her neck. On [DATE] at 12:44pm V6 (CNA) said she was the aide responsible for R1's care on [DATE] for the 7:00a.m - 3:00p.m shift. V6 said around 1:30pm on [DATE] she took R1's lunch tray to her. R1 was awake and alert. V6 said she set R1 up for lunch by raising the head of the bed and placing pillows behind R1's back. V6 said she set the lunch tray on the table, she cut up the roast beef and opened the beverages for R1 to eat. V6 said she cut R1's roast beef up into pieces. V6 said she set the tray up and left the room because R1 does not require assistance with meals, just set up only. V6 said she knows what assistance R1 requires because she always works with R1 and she knows her residents. V6 said she did not look at R1's kardex that day. V6 said the kardex shows what type of assistance the residents need for ADLs (Activities of Daily Living). V6 said she did not check R1's electronic record either to see what kind of assistance R1 required. On [DATE] at 12:44p.m V6 said R1 was contracted at the left elbow and did not have full range of motion to the left upper extremity, but she used her right hand to eat. V6 stated R1 would have to use her right hand to activate the call system as needed. On [DATE] at 11:32a.m V9 (Speech Pathologist) described aspiration precaution as oral care, cleaning the mouth, make sure resident's head of bed is elevated between ,[DATE] degrees when eating, which allows for optimal digestion, prepping the food tray, cutting the food up in bite size pieces and offering a drink in between bites, sometimes offering after every bite, and cueing the residents. V9 said after the resident takes the last bite or swallow make sure that the resident is sitting up for at least 30 minutes after the meal; this allows for digestion because as you get older food travels slower. V9 said she would suggest to use aspiration precautions at all times. V9 said someone must be present to give cueing and encouragement. R1's Physician order [REDACTED]. R1's kardex that was presented by V4 (Nurse) on [DATE] with a run date of [DATE] shows ADL functional Rehabilitation, eating: supervision and set up for meals. Needs assist with initiating and completing meals. On [DATE] at 1:54p.m V3 (Restorative Nurse) said R1's baseline for meal assist is supervision with set up only; R1 does not need assistance with meals. V3 said supervision means the aide can check on the resident whenever they get a chance, but the nurse should determine how often the CNA checks on the resident during meal times. On [DATE] at 12:58p.m V2 ( MDS Coordinator) said she completed R1's MDS section G for ADLs for [DATE] and R1's status of requiring extensive assist with one person physical assist with eating was based on the data gathered by the program ( electronic records). The program pulls over the information based on the staff documentation over the past 7 days. V2 said R1 must have required a higher level of assistance at least 2 to 3 times in that 7 day look back period. V2 said she did not make an observation of R1's eating ability. V2 said she does not usually complete section G of the MDS. V2 said she did not mention to anyone that R1's eating assist changed because it was not a significant change in condition. A review of R1's point of care charting 7 days prior to R1's MDS assessment date of [DATE] shows R1 had episodes of requiring total assistance and one person physical assistance with meals. On [DATE] at 2:14p.m V11 (Physician) said the facility informed him that R1 was eating and later she passed out. V11 said he was not made aware that the paramedics pulled food from R1's throat. V11 said if the care plan shows R1 needs supervision with eating then the facility should provide supervision. Facility policy titled Comprehensive Care Plans dated ,[DATE] shows to develop a comprehensive, person centered plan of care, consistent with the residents rights, that includes measurable objectives and time frames to meet the resident's medical, nursing and mental psychological needs. The comprehensive care plan will include services that are to be furnished to attain or maintain the resident's practicable physical, mental psychological well-being while preventing decline when possible. Areas of potential risk to the resident with interventions to eliminate or reduce risk. The identity of the professional services that are possible for each element of care. Measurable objectives and time frames. To achieve desired outcomes and fulfill the person centered ace approach the facility will provide the services and or items included in the plan of care. Care plans are revised as changes in the resident condition dictates but no less than on a quarterly basis.

Based on observation, interview and record review the facility failed to provide an adequate amount of staff assistance for safety during the provision of care. This applies to 2 of 3 residents (R1, R2) reviewed for falls in a sample of 7. This failure resulted in R1 falling off the side of the bed and incurring a fractured right hip requiring hospitalization and surgery. Findings include: 1. R1's Resident Face Sheet dated (MONTH) 4, (YEAR) documents R1 with [DIAGNOSES REDACTED]. Minimum Data Set, dated dated dated (MONTH) 5, (YEAR) documents R1 requiring the extensive assistance of two staff for bed mobility. R1's Event Report dated (MONTH) 17, (YEAR) at 5:45pm, completed by V14 (Nurse), documents R1 fell out of bed at 5:40pm. On (MONTH) 4, (YEAR) at 11:18am, V14 stated V16 (Former Nursing Assistant) yelled for V14 to come help in R1's room. V14 stated when V14 entered R1's room R1 was on the floor between the bed and the wall with the bed in a partially elevated position. V14 stated V16 reported R1 fell when V16 was providing incontinence care; V16 had rolled R1 onto her side facing away from V16 and V16 told R1 not to move. R1 then reached out for something causing R1 to fall off of the bed onto the floor on the side which was unattended by staff. V14 stated R1 would reach for items and V14 should have had a second person on the other side of the bed to assist during care of R1. V14 demonstrated R1's position in the bed right before the fall as described by V16. On (MONTH) 4, (YEAR) at 12:58pm, V17 (Nurse Practitioner) stated she was informed by V14 that R1 had fallen out of bed when a nursing assistant was cleaning R1. V17 stated it was reported to her only one nursing assistant was providing care to R1 and while providing care R1 reached for an item and fell from bed. V17 stated R1 requires the assistance of two staff persons, one on each side of the bed for safety. V17 confirmed this was a preventable injury. V17 stated as a result of this fall R1 was admitted to the hospital where R1 was diagnosed with [REDACTED]. R1's Resident Progress Notes dated (MONTH) 18, (YEAR) documents R1 admitted to the hospital with [REDACTED]. 2. R2's Resident Face Sheet dated (MONTH) 4, (YEAR) documents R2 with [DIAGNOSES REDACTED]. On (MONTH) 31, (YEAR) at 11:28am,V20 (Nursing Assistant) raised R2's bed with a scooped air mattress to an elevated position and began to provide care to R2. During this care V20 turned R2 onto her right side away from V20 and cleansed R2's buttock area without staff support on the other side of R2. V20 then left the bedside to go to R2's closet for more wipes. V20 then rolled R2 onto her left side without staff support on R2's other side and cleansed R2's posterior buttock area further. On (MONTH) 31, (YEAR) at 3:00pm, V1 (Administrator) stated for safety two staff members should have been providing care to R2. R2's Minimum Data Set, dated dated dated (MONTH) 24, (YEAR) documents R2 as requiring the extensive assistance of 2 staff for bed mobility. The Fall Reduction Program dated (MONTH) (YEAR) documents the facility will implement appropriate interventions to provide necessary supervision and assistive devices as necessary.

Based on interview and record review the facility failed to provide physician ordered dosing and monitoring of anti-coagulant medication. This applies to 1 of 3 residents (R2) reviewed for anti-coagulant use in a sample of 7. This failure resulted in R2 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: R2's Laboratory Report for INR and PT ([MEDICATION NAME] Time) dated (MONTH) 18, (YEAR) documents R2 with an elevated PT of 34 (normal range 12.5-15.1 seconds) and an elevated INR of 3.4 (normal 0.8-3.0 Ratio). There is no evidence in the clinical record of any further PT or INR test results between (MONTH) 19, (YEAR) through (MONTH) 1, (YEAR) at the facility. R2's Order History Report from (MONTH) 1, (YEAR) to (MONTH) 4, (YEAR) documents no medication changes or PT and INR tests were ordered between (MONTH) 19, (YEAR) to (MONTH) 1, (YEAR). Resident Progress Notes dated (MONTH) 2, (YEAR), completed by V17 (Nurse Practitioner), documents R2 having bloody stools and to be sent to the hospital for evaluation of a potential [MEDICAL CONDITION]. On (MONTH) 4, (YEAR) at 12:58pm, V17 (Nurse Practitioner) stated V17 was called regarding R2's elevated PT and INR test on (MONTH) 18, (YEAR). V17 stated a verbal order was provided to an unknown evening shift nurse to hold R2's [MEDICATION NAME] and repeat the PT and INR test on (MONTH) 20, (YEAR). V17 stated that was not done and R2 continued to receive the same dose of [MEDICATION NAME] up until R2 was hospitalized on (MONTH) 2, (YEAR). R2's (MONTH) and (MONTH) (YEAR) Medication Administration History reports documents R2 received [MEDICATION NAME] 4 milligrams daily (MONTH) 5, (YEAR) through (MONTH) 1, (YEAR). On (MONTH) 5, (YEAR) at 8:25am, V21 (Physician) stated an elevated INR can be problematic causing bleeding for residents with a weak supply of blood to the gastric tract. V21 confirmed R2 was hospitalized with gastric bleeding and a significantly elevated INR which occurred after verbal orders given by V17 to facility staff were not followed. V21 stated residents receiving [MEDICATION NAME] are monitored individually based on the test results. V21 stated if residents are receiving [MEDICATION NAME], PT and INR's are completed minimally every 72 hours if levels are not therapeutic and every 2 weeks if therapeutic. R2's Hospital emergency room Report dated (MONTH) 2, (YEAR) documents R2 presenting to the emergency room with blood in stools. This report documents R2 being admitted with a [DIAGNOSES REDACTED]. This report further documents due to the elevated INR Vitamin K and 2 units of blood was being administered for treatment. The facility policy Anticoagulant Therapy dated (MONTH) (YEAR) documents anticoagulant medications and monitoring are to be administered per physician orders.

Based on observation, interview, and record review the facility failed to prevent, identify and treat pressure ulcers for one resident (R12) of two residents reviewed for pressure ulcers in the sample of 18. This failure resulted in R12 developing multiple deep tissue injuries to the left lower leg and right foot. Findings include: The facility's, undated, Pressure Ulcer Prevention Protocol, documents 4. Residents who are assessed as being at High Risk will have a plan of care that will include: A. Daily skin checks conducted by either the CNA or Licensed Nurse to ensure early identification of potential problem areas. B. Plan of Care to address mobility status and ability to reposition self. C. Use of Pressure Reducing Devices, such as pressure reducing mattresses, mattress overlays, w/c (wheel chair) cushioning devices, if needed. D. Determination of need for supplemental skin care such as barrier cream or moisturizing lotion. E. Any other factor identified on the risk assessment including but not limited to nutritional support, positioning/support devices, or medication review. The physician's orders [REDACTED]. The Medication Administration History for R12, dated 5/1/17 through 5/24/17 documents Skin assessment twice weekly on shower days on 3-11pm on Wednesday and 7:30am - 3:30 pm on Saturday. This form documents that in May 2017, R12's skin was assessed on the following six days; 5/3/17, 5/6/17, 5/10/17, 5/13/17, 5/17/17, and 5/20/17 with either no findings or old findings. R12's Current Care Plan, dated 5/24/17, documents Problem as (R12) is at risk for skin breakdown R/T (related to) Dementia and incontinence and HX (history) of [MEDICAL CONDITION] and HX of closed pressure areas. This Care Plan also documents an approach to Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Report any signs of skin breakdown (sore, tender, red, or broken areas). This Care Plan documents the Goal as (R12's) skin will remain intact thru next review. The Braden Scale (pressure ulcer risk assessment), dated 4/7/17 documents R12 as a High Risk for skin breakdown. The Quarterly MDS (Minimum Data Set) for R12, dated 4/10/17, documents yes in Section M0150 that R12 is at risk of developing pressure ulcers. The Wound Care Specialist Evaluation for R12, dated 4/26/17, documented by Z3 Facility Wound Doctor, documents R12's left sacral wound Resolved on 4/26/17 with no other wounds identified. The Resident Progress Notes for R12, dated 5/3/17 through 5/23/17, do not include any documentation of R12 having any pressure ulcers. On 5/24/17 at 9:40am, 10:30am, 12:00pm, 1:00pm, 2:00pm, and 2:15pm, R12 was positioned lying in bed on (R12's) right side. At no time did R12 have any pressure reducing interventions present to bilateral feet or legs. On 5/24/17 at 9:40am, E16 and E20 CNA's (Certified Nursing Assistants) provided care for R12. During cares, R12 hollered out as E16 and E20 removed (R12's) bed sheet and pulled R12 up in the bed. E16 pulled R12's right and left legs apart at which time a deep reddish purple fluid filled blister was noted to R12's left inner leg. R12 hollered out again as E20 was applying a sock to R12's right foot where there was a dark reddish purple fluid filled blister to R12's right lateral bunion area, a large oval shaped clear fluid filled blister to R12's right lateral foot, and a dark reddish purple fluid filled blister to R12's right lateral heel. E16 and E20 CNA's turned R12 to R12's right side and exited R12's room. On 5/24/17 at 9:45am, E16 CNA stated R12's left leg wound and right foot wounds have been there awhile, at least the two months that (E16) has been working at the facility. E16 stated she did not report R12's wounds to anyone because they are not new. E16 also stated E20 CNA is new and is in orientation so (E20) would not have reported it. On 5/24/17 at 2:15pm, E5 LPN (Licensed Practical Nurse) stated R12 only had a sacral wound and is unaware of any other wounds to R12 and no one has reported any new wounds. On 5/24/17 at 2:45pm, E2 DON (Director of Nursing) stated she is unaware of any wounds to R12 other than R12's resolved sacral wound. On 5/24/17 at 10:05 am, E17 Wound Nurse stated pressure ulcers are assessed weekly and skin assessments are done twice a week on shower days for high risk residents. E17 stated R12's sacral wound has closed, R12 remains a high risk for pressure ulcers, R12 should be turned and repositioned every two hours, have boots on and pillows used for positioning. E17 also stated she is unaware of R12 having any other pressure ulcers and no one has reported any. On 5/24/17 at 3:00 pm, E2 DON (Director of Nursing) and E17 Wound Nurse performed a skin check of R12's body, acknowledged the new wounds to R12's left inner leg, and R12's right foot with the following measurements: dark reddened area to left inner leg measuring 3.0cm (centimeters) x 0.7cm x 0.2 cm; DTI (deep tissue injury) to right lateral foot measuring at 3.0cm x 2.5cm x DTI; Fluid filled blister to right medial foot measuring 4.0cm x 3.0cm and Fluid filled blister to right to right lateral heel measuring 5.0cm x 4.0cm. On 5/25/17 at 10:52 am, Z3 Facility Wound Doctor stated she is familiar with R12, stated R12 is a high risk for developing pressure ulcers, she would expect the staff to turn and reposition R12 every two hours, provide R12 with off-loading and support for pressure areas. Z3 also stated she has not seen R12 for a few weeks and was not aware of any other wounds on R12.

Based on observation, interview and record review, the facility failed to follow their policy and provide adequate supervision for 4 of 6 residents (R1,R3,R4,R6) reviewed for falls in the sample of 8. This failure resulted in R1 falling from the wheelchair, sustaining a laceration to the head and bleeding in the brain. Findings include: On 9/23/14 at 11am, R3 sat leaning forward in the wheelchair with a chair alarm in place in the hallway across from the nurse station on side 1. There were no staff members in the hallway for 6 minutes. R3 had a fall on 8/8/14. On 9/23/14 at 11:15am, R6 sat up in the wheelchair with a chair alarm in place in the hallway across from the nurse station on side 2. E3(Nurse) was at the desk but left several times within a 5 minute period. There was no one else at the nurse station when E3 left. At 11:20am, E3 stated R6 is brought out to the nurse's station because staff does not like to leave her unattended. The chair alarm will sound if R6 moves around or tries to get out of the chair. On 9/23/14 at 11:25am, R4 sat in a wheelchair with a chair alarm attached, across from the nurse station on side 3. R4 had a fall on 9/4/14. E4(Nurse) stated R4 gets up when she's not supposed to, so staff does not leave her alone, R4 is brought to sit in her wheelchair out at the nurse's station. Closed record documents R1 was assessed as a high risk for falls on admission due to previous falls at home. Minimum Data Set (MDS) 8/6/14 documents R1 had a fall with major injury prior to admission to the facility and was not appropriate for the mental status interview due to cognitive deficits. R1 does not have a fall care plan. Nurse Notes for 8/2/14, 8/3/14, 8/4/14, and 8/6/14, R1 was brought out to the nurse's station on the 11pm-7am shift for close monitoring due to the bed alarm being activated by the resident. On 8/6/14 at 6:50am, R1 fell from the wheelchair while sitting at the nurse's station. Fall Investigation 8/6/14 documents staff was in other rooms or down at the end of the hallways, not near R1. R1 was transferred to the hospital and was diagnosed with [REDACTED]. Hospital radiology report 8/6/14 documents an acute on chronic right subdural hematoma measuring 7 millimeters(mm) in width causing a 5 mm midline shift. emergency room History 8/6/14, R1 was alert and oriented to person, which is a normal assessment for her. R1's Glasgow Coma Scale (GCS) 8/6/14, which assesses neurological response, score R1 13 out of 15. R1 opened her eyes spontaneously, verbal response was confused, and motor response localized pain. Physician Certification 8/6/14 documents qualified clinical personnel or service unavailable; hospital resources unavailable; R1 needs to be transferred to another hospital to receive appropriate medical treatment. Nurse Certification 8/6/14, R1 is being transferred to a trauma hospital due to bleeding in the brain and possible surgical intervention by a neurosurgeon. No return phone calls from messages left on 9/23/14 for Z4(emergency room Physician), Z5(Trauma Surgeon, and Z6(Neurosurgeon). Transfer emergency room Records 8/6/14 document R1 now has a GCS of 7 out of 15, shallow breathing, and low oxygenation. R1 does not open her eyes, does not respond verbally, and still localizes pain. History and Physical 8/6/14 on arrival R1 breathing is compromised due to the altered mental status. R1 was placed on a ventilator to help her breathe; due to the poor prognosis, family withdrew life support and placed R1 on hospice. On 9/23/14 at 1:40pm, E6(Nurse) stated R1 had a chair alarm. E6 heard the alarm and turned to see R1 on the ground. E6 stated R1 gets restless at night. She brings R1 out to the nurse's station to "keep an eye on her" and prevent falls. On 9/24/14 at 1pm, E5(Restorative Nurse) stated residents assessed as high risk for falls have interventions of chair and bed alarms, low beds, floor mats, supervision, don't leave resident alone in the room, and bring them out to the nurse's station to monitor. E5 stated supervision means have more people watch the resident. On 9/24/14 at 1:10pm, E2(Director of Nursing) stated the residents are assessed for fall risk on admission, interventions are put into place, and a care plan is initiated. Staff moved R1 to the nurse's station at night to monitor her more closely, R1 was getting out of bed, staff wanted to prevent a fall from the bed. E2 stated there isn't as much staff at night, so they put R1 out at the nurse's station to watch her. E2 confirmed that R1 did not have a care plan for falls and did not have floor mats ordered. On 9/24/14 at 1:25pm, Z2(Trauma Surgeon) stated R1 had a new area of bleeding in the brain over the old area. This new area caused the brain to be pushed over to the side, creating pressure inside the skull. It was this pressure that caused R1's condition to deteriorate during the transfer from the first hospital. Z2 stated this injury is associated with R1's head trauma from the fall. On 9/25/14 at 1:20pm, Z1(Physician) stated that it would have been better if someone was there to watch R1. An intervention could be to have someone stay at the desk to watch those residents that are put there. Fall Reduction Policy - The program will include measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. All assigned nursing personnel are responsible for ensuring ongoing precaution are put into place and consistently maintained. Post Fall Investigation policy - Any new information and/or interventions will be reflected on the resident's care plan at the conclusion of the investigation. Comprehensive Care Plans policy - A preliminary plan is developed upon the resident's admission.

Based on observation, interview, and record review, the facility failed to follow the pain prevention protocol, assess for pain, and offer to administer prescribed pain medication during wound care for 1 of 6 residents in a sample of 20. This failure resulted in R2 complaining of pain, and facial grimacing continuously throughout the wound treatment. Findings include: According to the facilities pain management policy the facility shall identify residents that are experiencing pain and develop a pain management plan of care. Residents are to be assessed utilizing the pain scale, verbal descriptor, or numeric rating scale. The policy also indicates that a pain screen will be completed if the resident experiences a new onset of pain. On 5/10/12 at 10:00am while observing R2's wound treatment, E24 and E25 both were noted to be performing the treatment. R2 was observed with a large open wound to the coccyx area without a dressing in place. E24 was observed squirting normal saline into R2's open area as prescribed, and R2 was noted as yelling out in pain. E24 did not stop the treatment to assess R2's pain. E24 continued by patting R2's open area with dry gauze, and again R2 was observed yelling out in pain. R2 said that it was hurting. E24 continued to pack R2's wound with calcium alginate as prescribed and again R2 was observed yelling out that she was in pain. E24 was observed applying a foam padding and dry dressing to R2's open area, as E24 applied the dressing R2 complained of pain. On 5/10/12 at 10:10am E24 said that she did not ask if she required pain medication before administering the wound treatment, and said that she didn't inform R2's primary nurse to administer R2's as needed prescribed medication. E24 didn't reply when asked why she didn't assess or perform a pain scale while R2 was complaining of pain. E24 said that she was aware of both the facilities pain prevention protocol, and pressure ulcer protocol. E24 was asked when are measurements done on wounds? E24 replied that they are done weekly and should have been done today. E24 proceeded to remove R2's newly applied dressing and R2 was again observed as yelling out in pain as E24 removed the dressing. After measuring R2's wound, E24 again cleaned the wound by squirting normal saline into the open area and R2 yelled out in pain. E24 was observed patting the wound with dry gauze and R2 again yelled out in pain. E24 proceeded to pack the open wound with calcium alginate once again and R2 was observed with facial grimacing and grunting noises. E24 applied the foam padding and dry dressing and R2 was observed with facial grimacing and grunting noises. During the entire time of R2 having the wound treatment re-done, E24 failed to assess R2's pain, no pain scale was done and R2 was not offered any prescribed pain medication.

Based on observation, interview and record review the facility failed to assess and administer prescribed pain medication during a wound treatment observation for 1 of 6 residents (R2) identified for pressure ulcers in a total sample of 20. This failure resulted in R2 yelling out in pain, and displaying facial grimacing during the wound treatment. Findings include: On 5/10/12 at 10:00am while observing R2's wound treatment, E24 and E25 both were noted to be performing the treatment. R2 was observed with a large open wound to the coccyx area without a dressing in place. E24 was observed squirting normal saline into R2's open area as prescribed, however R2 was noted as yelling out in pain. E24 didn't stop the treatment to assess R2's pain. E24 continued to pat R2's open area with dry gauze and again R2 was observed yelling out in pain. R2 said that it was hurting. E24 continued to pack R2's wound with calcium alginate as prescribed and again R2 was observed yelling out that she was in pain. E24 was observed applying a foam padding and dry dressing to R2's open area as E24 applied the dressing R2 complained of pain. On 5/10/12 at 10:00am E24 said that she didn't'ask if she required pain medication before administering the wound treatment and said that she didn't inform R2's primary nurse to administer R2's as needed prescribed medication. E24 didn't reply when asked why she didn't assess or perform a pain scale while R2 was complaining of pain. E24 said that she was aware of both the facilities pain prevention protocol, and pressure ulcer protocol. E24 was asked when are measurements done on wounds? E24 replied that they are done weekly and should have been done today. E24 proceeded to remove R2's newly applied dressing and R2 was again observed as yelling out in pain as E24 removed the dressing. After measuring the R2's wound E24 again cleaned the wound by squirting normal saline into the open area and R2 yelled out in pain. E24 was observed patting the wound with a clean gauze and R2 again yelled out in pain. E24 proceeded to pack the open wound with calcium alginate once again and R2 was observed with facial grimacing and grunting noises. E24 applied the foam padding and dry dressing and R2 was observed with facial grimacing and grunting noises. During the entire time of R2 having the wound treatment re-done, E24 failed to assess R2's pain, no pain scale was done, and R2 was not offered any prescribed pain medication. On 5/15/12 during the daily status meeting the E2 (Director of Nursing), said that the wound nurse should assess for pain prior to initiating wound care, and administer the appropriate medication accordingly. According to the facilities pain management policy the facility shall identify resident that are experiencing pain and develop pain management plan of care. Residents are to assessed utilizing the pain scale, verbal descriptor, or numeric rating scale. The policy also indicates that a pain screen will be completed if the resident experience a new onset of pain.