Every finding on record at Gilman Healthcare Center

Based on observation, interview, and record review the facility failed to implement pressure relieving interventions, transcribe treatment orders, and complete skin assessments for two (R4, R32) of three residents reviewed for pressure ulcers in the sample list of 44 residents. These failures resulted in R4's stage one pressure ulcer deteriorating to an unstageable pressure ulcer and R32 developing a facility acquired unstageable pressure ulcer that deteriorated to a stage three. Findings include: The facility's Prevention of Pressure Ulcers policy dated 10/1/2025 documents preventative measures include identifying risk factors, position changes at least every two hours when in bed or chair, routinely assessing and documenting skin condition, and reporting signs of developing pressure ulcers to the nurse. This policy documents the care plan should include efforts to stabilize, reduce, or remove underlying risk factors and monitoring and modifying these interventions. This policy includes using tools such as pressure ulcer risk assessment form to assess pressure ulcer risk. 1.) On 08/17/2026 at 1:16 PM, V22 (R4's) Guardian, stated R4 has a pressure ulcer on R4's left side that started as a blister within a couple months of admitting to the facility; R4 resided in a group home and never had any wounds prior. V22 stated R4 prefers to lay on R4's left side and the wound required debridement (mechanical removal of dead tissue) and antibiotic treatment. On 8/18/2026 at 3:35 PM, V7 Infection Preventionist/Registered Nurse (IP/RN) administered R4's left hip pressure ulcer treatment, which consisted of applying 1/4 strength bleach solution and packing the wound with medicated honey coated wound packing. R4's wound bed was pink, and V7 measured the depth with the end of a cotton tipped applicator, approximately 0.6 cm (centimeters). R4 was lying in bed on a low air loss mattress, leaning to R4's left side with a U shaped cushion under R4's left side. R4 required V7's assistance to turn and reposition during this treatment administration. V7 RN/IP stated R4 favors the left side which is why the wound has been hard to resolve. V7 RN/IP stated the wound started as a reddened area, then once debrided it was stageable then deteriorated due to infection but is now showing healing/improvement with significantly less drainage. R4's Census documents R4 was admitted to the facility on [DATE]. R4's Diagnoses list includes Epilepsy, Profound Intellectual Disabilities, and Psychosis. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively impaired and severely impaired with decision making. This MDS documents R4 had no behaviors or pressure ulcers during the review period. This MDS documents R4 requires partial/moderate staff assistance for bed mobility and transfers. R4's MDS dated [DATE] documents R4 has one facility acquired pressure ulcer and requires partial/moderate staff assistance for bed mobility and transfers. R4's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 4/1/26 and 5/16/26, document R4 has no limitations in mobility, makes major and frequent position changes; and has no apparent problem with friction/shearing as R4 moves in bed and chair independently and has sufficient muscle strength to lift up completely; which does not match R4's mobility status as listed on R4's MDS assessments, resulting in an incorrect score of 20, low risk. These evaluations do not document any pressure relieving interventions or goals as prompted. R4's active Care Plan documents a problem dated 2/9/26, for potential skin impairment related to limited mobility, incontinence, fragile skin, and diuretics; and includes interventions to include good nutrition/hydration, inspect environment for sharp edges, keep skin clean/dry, use of lotions as part of daily skin care, bathing as scheduled, trim/file R4's fingernails, and to use caution during transfers and bed mobility to prevent striking arms, legs, and hands. This care plan does not include being at risk for pressure ulcer development or any pressure relieving interventions prior to 5/25/26. This care plan documents a problem dated 5/25/26, R4 has an unstageable pressure injury to left hip and R4 tends to lay on R4's left side. This care plan includes interventions to administer treatments as ordered, apply barrier cream after incontinence cares, encourage R4 to comply with plan of care and refer to the interdisciplinary team if R4 is non-compliant, notify the nurse and physician of any changes in skin condition, low air loss mattress (5/28/26), utilize pillows in positioning to maintain body alignment, encourage R4 to change positions at least every two hours and as needed when in bed/chair to improve circulation, promote wound healing, and prevent further development of pressure injuries. R4's May 2026 Treatment Administration Record (TAR) documents weekly skin assessments every Monday and to record a progress note to indicate any skin impairments or if skin is intact. This TAR indicates skin assessments were completed but there are no corresponding skin assessments documented in R4's Electronic Medical Record. R4's May 2026 Shower Sheets, provided by V25 Medical Records on 8/18/26, document there were no skin issues noted on 5/8/26, 5/15/26, 5/22/26, and 5/26/26. V29 Certified Nursing Assistant (CNA) and V30 License Practical Nurse (LPN) signed R4's 5/19/26 shower sheet, which identifies two areas of abnormal skin on R4's right side (verified to be R4's left side). There is no documentation in R4's Electronic Medical Record that R4's skin change noted on 5/19/26 was documented and assessed by a nurse, reported to a provider, and treatments/interventions initiated prior to 5/25/26. R4's Wound Assessments and Plans, completed by V23 Wound Physician, document the following: On 5/25/26 R4's left hip unstageable pressure ulcer measured 1.8 centimeters (cm) long by 1.5 cm wide, and unmeasurable depth due to 100% slough (built up dead tissue) covering the wound, which required debridement. On 6/15/26, R4's unstageable pressure was now a stage three pressure ulcer that measured 1.5 cm x 1.0 cm and undetermined depth, with post debridement depth as 1 cm. On 6/22/26 this wound was measured to be 1.4cm. by 0.9 cm x 1 cm, with 0.8 cm tunneling at four o'clock. On 7/6/26 this wound measured 1 cm x 0.8 cm x 2.5 cm. On 8/17/26 this wound measured 0.4 cm x 0.4 cm x 0.6 cm. On 8/20/26 at 8:16 AM, V29 CNA confirmed V29 signed R4's 5/19/26 shower sheet. V29 CNA stated R4 had purple areas to R4's left side, which is the same area where R4's current wound is. V29 CNA stated at that time the wound was not open or V29 would have noted that on the shower sheet, and V29 reported R4's skin change to the agency nurse (V30). V29 CNA stated the wound looked like it was ready to open and V29 used pillows to relieve pressure on that side, which R4 was compliant with. On 8/19/26 at 10:05 AM, V13 Wound Nurse confirmed R4's wound treatment was initiated on 5/25/26 and confirmed skin assessments should be documented in a progress note weekly and when changes in skin integrity are identified. V13 Wound Nurse stated the wound started as an abscess that was debrided, then got deeper with tunnelling and drainage requiring two rounds of antibiotics due to infection and has recently been healing. V13 Wound Nurse stated R4 doesn't allow pillows or wedges and likes to lay on R4's left side, and currently a U shaped pillow is being used to offload pressure from the wound, which has been helpful. V13 Wound Nurse stated a low air loss mattress is implemented when the resident currently has or a history of having at least a stage three pressure ulcer or if the resident doesn't move. V13 Wound Nurse reviewed R4's Braden Evaluations, completed by V13, and confirmed these evaluations do not document R4's mobility needs according to R4's MDS. V13 Wound Nurse stated V13 does not assess for mobility, and couldn't speak to R4's MDS, as that is done by therapy staff. V13 Wound Nurse confirmed the facility uses the Braden Evaluation to determine a resident's risk level for developing pressure ulcers. On 8/19/26 at 12:25 PM, V2 Director of Nursing (DON) stated V2 was unable to locate any documented weekly skin assessments in May 2026 prior to R4's unstageable pressure ulcer. V2 DON confirmed there were no documented wound assessments or treatments for this wound between 5/19/26 and 5/24/26. On 8/20/26 at 10:30 AM, V2 DON confirmed there were no documented pressure relieving interventions developed and implemented prior to R4's pressure ulcer. V2 DON provided R4's care planned problem, goals, and interventions dated 2/9/26, as noted above, as R4's pressure ulcer preventative interventions. V2 DON stated R4 was ambulatory at that time. V2 DON stated turning and repositioning interventions aren't implemented unless the resident is extensive assist with bed mobility and is not based on the resident's Braden risk score. On 08/19/2026 at 12:53 PM, V23 Wound Physician stated R4's unstageable pressure ulcer deteriorated to a stage three but R4 is noncompliant and has been a challenge with offloading and repositioning despite using different devices due to R4's cognitive deficits. V23 Wound Physician stated this has caused delayed healing, but it is almost closed. V23 Wound Physician stated V23 cannot speak as to the events that led up to R4's wound but generally speaking the facility should follow its policy regarding pressure ulcer prevention and generally implement turning and repositioning. V23 Wound Physician stated in general we want to identify pressure ulcers when stage one or two as they can turn into unstageable or open up pretty quickly.2.) On 08/17/2026 at 3:32 PM, R32 was in bed on R32's back with an orthotic boot on the left foot and pressure relieving boot on right foot. R32's bed contained a standard foam mattress and R32 did not have (foam device) underneath R32's feet to float R32's heels off the bed. R32 stated R32 does need some assistance from staff with bed mobility. R32 stated the facility added pressure relieving boots and the foam device after R32's heel wound developed. On 8/17/26 at 3:41 PM, V16 CNA stated R32 should have R32's heels floated when in bed. V16 CNA entered R32's room and confirmed R32's heels were not floated. V16 C found R32's foam device in R32's roommate's (R49) bed with R49. V16 CNA stated R32 just recently started using the foam device to float heels which was shortly after R32 developed the wound. V16 CNA stated prior to that we floated R32's heels with a pillow and at that time R32 only used a pressure relieving boot for the right foot. On 08/18/2026 at 11:15 AM, V7 Infection Preventionist (IP) administered R32's left heel wound treatment as ordered. R32's heel wound was approximately pea sized, red/pink in color with some white slough and surrounding macerated peri wound. V7 IP stated R32's pressure ulcer was facility acquired, initially presenting as redness on admission. R32's Hospital Discharge summary dated [DATE] documents orders for heel lift boot to left leg and treatment to cleanse left heel, apply bordered foam dressing every five to seven days and as needed, and peel back to assess skin every shift. This order was transcribed onto R32's Treatment Administration Record (TAR) through 6/28/26, however there are no documented assessments of this wound prior to 8/1/26 when R32 had an unstageable pressure ulcer. There are no documented weekly skin assessments in R32's Electronic Medical Record as prompted by R32's TAR. R32's admission MDS dated [DATE] documents R32 as cognitively intact, requiring substantial/maximal staff assistance for lower body dressing and bed mobility, and R32 had no pressure ulcers. R32's MDS dated [DATE] documents R32 requires partial/moderate staff assistance with lower body dressing and bed mobility, and R32 has no pressure ulcers. R32's Braden Scale for Predicting Pressure Ulcer Risk Evaluation documents R32's mobility is slightly limited, R32 makes frequent, slight changes in body/extremity positioning independently (which is incorrect according to R32's MDS). This same evaluation documents R32 as having friction/shear problem related to requiring moderate to maximum assistance with moving, complete lifting without sliding against sheets is impossible, and R32 frequently slides down in bed or chair requiring frequent repositioning with maximum assistance. R32's Braden documents R32 is at moderate risk for developing pressure ulcers. R32's active Care Plan initiated 6/20/26, documents R32 has impaired musculoskeletal status related to fractured right tibia and a diagnosis of Diabetes Mellitus. This Care Plan includes an intervention to check all of R32's body for breaks in skin and treat promptly as ordered. This Care Plan documents R32 has skin alterations, including left heel, with interventions including administering treatments as ordered and refer to wound specialist and/or podiatrist for consultation. This Care Plan does not include any pressure relieving interventions such as turning/repositioning or offloading heel pressure prior to 8/1/26. R32's Physician Order dated 8/1/26 documents to wear orthotic boot to left heel at all times, heel protector to right heel, and ensure heels are floated when in bed utilizing (foam device). R32's Nursing Note dated 8/1/26 at 11:41 AM documents R32 has an unstageable pressure ulcer to left heel, R32 has a history of Diabetes Mellitus and limited mobility which places R32 at increased risk for impaired skin integrity. The wound measured approximately 4.5 cm x 5.0 cm x 0.1 cm. Treatment orders were initiated and R32's care plan was updated with the wound and interventions. R32 was fitted with a heel offloading boot and (foam device) was implemented to offload pressure from heels and promote wound healing. R32 was scheduled to be seen by V23 Wound Physician on 8/3/26. R32's Wound Assessments and Plan, recorded by V23 Wound Physician, document the following: On 8/3/26 the unstageable pressure ulcer was 100% slough covered, (this is the first documented assessment by V23). On 8/10/26 R32's wound measured 2.3 cm x 2.6 cm and was 80% slough. The treatment order is listed as cleansing with wound cleaner or Normal Saline, pat dry, apply skin protectant wipe/spray to periwound, apply thin layer of medicated honey, followed by calcium alginate, and covered with a dry clean dressing three times weekly and as needed (which was not transcribed onto R32's TAR until 8/17/26). On 8/17/26 R32's wound measured 2.3 cm x 2.5 cm with 75% slough, and debridement was attempted but stopped due to R32's complaints of pain. On 8/19/26 at 10:05 AM, V13 Wound Nurse stated R32's hospital referral noted a left heel stage one pressure ulcer, which was present on admission, and was red/intact. V13 Wound Nurse thought a skin protectant treatment was in place, which would be documented on the TAR, and heel protectors were implemented. V13 Wound Nurse confirmed R32's physician's order for heel floating and protective boots is dated 8/1/26. V13 Wound Nurse stated R32 is compliant with wearing heel protectors and floating heels but doesn't always like to lay down. At 11:35 AM, V13 Wound Nurse stated V13 rounds with V23 Wound Physician and enters V23's orders. V13 Wound Nurse stated V23 Wound Physician gives orders verbally and also provides V23's progress notes the same day as V23's visits, but V13 does not always review V23's notes. V13 Wound Nurse stated V13 thought V23 Wound Physician gave verbal orders for R32's treatment to continue daily on 8/10/26. V13 Wound Nurse reviewed V23 Wound Physicians 8/10/26 notes and confirmed these orders were not implemented until 8/17/26.On 8/19/26 at 12:25 PM, V2 DON stated R32 had a preventative treatment for left heel that was discontinued on 6/28/26 and was never implemented in July 2026. V2 DON stated V2, nor V13 Wound Nurse knew why the treatment was stopped. V2 DON stated V2 was unable to find any documented weekly skin assessments or heel wound assessments during that time, prior to R32's wound being unstageable. On 8/19/26 at 1:16 PM, V2 DON stated V2 was unable to locate any documentation of any pressure relieving interventions for heel pressure prior to 8/1/26. On 8/19/26 at 12:53 PM, V23 Wound Physician stated R32's pressure ulcer was first identified as unstageable and is showing improvement and healing, and V23 has attempted debridement but had to stop due to R32's pain and low tolerance. V23 Wound Physician stated V23 did not recall what was verbally said on 8/10/26 regarding R32's treatment orders, but V23 expects the facility to implement treatments as listed in V23's notes. V23 Wound Physician stated V23 cannot speak as to the events that led up to R32's unstageable pressure ulcer but generally speaking the facility should follow its policy regarding pressure ulcer prevention and generally implement turning and repositioning. V23 Wound Physician stated in general we want to identify pressure ulcers when stage one or two as they can turn into unstageable or open up pretty quickly. V23 Wound Physician stated in general V23 recommends pressure relieving boots or offloading devices for stage one and stage two pressure ulcers.

Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to provide supervision for one (R4) resident with a known history of taking food from other trays resulting in R4 choking requiring the Heimlich maneuver. R4 is one of four residents reviewed for accidents in the sample list of 44 residents.B. Based on observation, interview, and record review the facility failed to document elopement attempts, reassess for elopement risk, implement interventions and revise care planned interventions to prevent elopement for one (R49) of four residents reviewed for accidents in the sample list of 44 residents.C. Based on observation, interview, and record review the facility failed to provide proper transfer assistance for one (R32) of four residents reviewed for accidents in the sample list of 44 residents.Findings include: A.) On 8/17/2026 at V22 (R4's) Guardian, stated a nurse called V22 in April 2026 to report R4 had choked on food that R4 had grabbed from another resident's table in the dining room, the Heimlich maneuver was done and R4 was sent to the hospital. V22 Guardian stated R4 doesn't have any teeth, R4 has always been on a pureed diet, and R4 has a diagnosis of PICA (an eating disorder with urges to eat inedible items). V22 Guardian stated V22 had a history of choking on a cinnamon roll prior to being admitted to the facility.On 8/18/26 between 8:00 AM and 8:30 AM, R4 was sitting in the dining room eating pureed texture food feeding R4's self.R4's Minimum Data Set (MDS) dated [DATE] documents R4 has cognitive impairment, is severely impaired with decision making, and requires partial/moderate staff assistance with eating and supervision/touch assistance with walking.R4's Care Plan dated 2/25/26 documents R4 has a behavior problem of seeking food off other residents' trays due to PICA and includes interventions to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, and seat R4 at a table where R4 can be monitored more closely. R4's Care Plan dated 2/11/26 documents R4 has no teeth, requires a pureed texture diet, and a history of food seeking; and includes interventions for using small spoons to encourage small bites, and staff to redirect R4 back to R4's table when food seeking. R4's Care Plan dated 4/8/26 documents R4 had a choking incident and includes interventions for R4 to sit with other residents during meals who all eat pureed texture diet and staff to ensure R4 does not leave the dining area with food or other ingestible for each meal. R4's Nursing Note dated 4/7/26 at 9:32 AM documents the following: R4 was walking out of the dining room from breakfast when a Certified Nursing Assistant (CNA) called for the nurse. R4 was attempting to sit and wouldn't walk much further. R4 was turning cyanotic (blue, indicating lack of Oxygen) and R4 was clammy. R4 was moved to a room where the Heimlich was performed which was able to move what was obstructing R4's airway. R4 was able to breathe on R4's own, coughing and trying to get something out of R4's throat. Emergency Services were called and R4 was transferred to the local emergency room.R4's emergency room Note dated 4/8/26 at 9:49 AM documents R4 has Profound Intellectual Disabilities and history of [NAME] presenting for assessment following a choking incident on a non-food item.On 08/18/2026 at 10:10 AM, V4 CNA stated: V4 was bringing an identified resident down the hallway and was not in the dining room when R4 choked at breakfast. V15 CNA was in the dining room at the time. V14 Registered Nurse (RN) witnessed the incident and said R4 grabbed a piece of cake off another resident's tray and V14 performed the Heimlich Maneuver on R4. V13 Wound Nurse was doing wound rounds at the time. R4 had a prior history of seeking food from other residents' food trays, staff would try to give R4 extra food to meet R4's needs, and now staff have to transport R4 to and from the dining room and make sure staff stays with R4 while R4 is in the dining room. On 08/18/2026 at 10:36 AM, V15 CNA stated: R4 was walking out of the dining room and took something off another resident's tray and then the Heimlich Maneuver was done, but R4 didn't witness this. V15 was unsure what R4 choked on. If someone is not sitting with R4, R4 will try to take things off other's plates, and we now provide one to one supervision of R4 during meals.On 08/18/2026 at 11:40 AM, V6 Dietary Manager stated: V6 was not in the dining room during R4's choking incident and did not know if any dietary staff were in the dining room during R4's choking incident. R4 was food seeking and believed R4 choked on scrambled eggs as this was discussed in the morning management meeting. At that time R4 was on a pureed diet and sitting at a table with unidentified residents with regular and mechanical textured diets at the time, near the entrance to the dining room. After the incident R4 was moved to a table with only residents who also have pureed texture diets.On 08/19/2026 at 8:57 AM, V19 CNA stated: In April around 8:00 AM, R4 came out of the dining room and started walking down the [NAME] South Hall toward V19 and R4 looked like R4 was looking for someone. V19 directed R4 to the East side and as they passed the reception desk R4 was not making any noise and had a worried facial expression, which was unusual for R4. V19 CNA tried to look in R4's mouth but couldn't see any object and didn't see R4 chewing. V19 CNA grabbed V13 Wound Nurse and R4 was taken into a resident room. There were unidentified staff in the dining room when V19 CNA had left there just a few minutes prior. R4 had a history of taking food from other plates prior to this and when R4 gets up R4 is quick and tries to reach for food. Prior to the incident R4 was just being taken to R4's table but now staff have to take R4 directly out when R4 is done eating.On 8/19/26 at 10:05 AM, V13 Wound Nurse stated: V13 was walking down the hallway when a CNA alerted V13 to R4, who was by the reception desk. As R4 was walking R4's lips turned blue. V15 CNA and V14 RN were also present, and the Heimlich Maneuver was administered but unable to clear so R4 was placed on the floor and did Heimlich. R4 coughed and cleared R4's airway. No food or objects came out or was seen. V13 did not know what R4 choked on. V13 Wound Nurse thought staff was with R4 in the dining room and when R4 walked out. R4's group home reported R4 had [NAME] but R4 had no history of that in the facility but did grab at other's food prior to the incident.On 8/19/26 at 10:55 AM, V14 RN stated: V14 didn't recall much about R4's choking incident. R4 was in the middle of the hallway having trouble breathing and V13 Wound Nurse thought R4 was probably choking on something but not sure what. V14 RN administered the Heimlich on the floor and whatever it was cleared. V14 RN didn't recall seeing any food or object in R4's mouth/airway. R4 had come from the dining room prior, and V14 RN couldn't recall if staff was in the dining room when this happened or if any staff seen R4 put something in R4's mouth prior to leaving the dining room. On 8/19/26 at 11:12 AM, V17 Assistant Director of Nursing (ADON) stated V17 didn't witness R4's choking incident but was working that day. V17 ADON stated the root cause of R4's choking was R4 seeking food that was not appropriate texture for R4. V17 stated after the incident R4 was moved to sit at a table in the dining room only with residents who are also on pureed diet and to be escorted by staff to and from the dining room. V17 ADON didn't know what R4 choked on. V17 confirmed R4's care plan noted a history of food seeking and [NAME] prior to this incident with interventions for monitoring during meals. V13 Wound Nurse stated V13 believes if there was a staff monitor at the dining room entrance to ensure residents don't leave with food in their mouth it could avoid things like this.On 8/19/26 at 11:56 AM, V1 Administrator provided the incident report dated 4/8/26 for R4's choking incident. V1 stated there were no documented staff interviews for this investigation. V1 Administrator stated V1 didn't know what R4 choked on as V1 was not present during the incident.B.) On 8/17/26 at 3:53 PM, V16 CNA stated R49 wanders into resident rooms and has sounded exit doors. V16 CNA stated that about a week and a half ago around 4:30/5:00 AM while V16 CNA was giving an unidentified resident a shower, R49 wandered over to the [NAME] Hall (R49 resides on East Hall) and went out an exit door. V16 CNA stated V16 believes staff saw R49 leave since unidentified staff brought R49 back into the facility but V16 didn't recall who this staff person was.R49's Minimum Data Set (MDS) dated [DATE] documents R49 has cognitive impairment, is severely impaired with daily decision making and wandered daily during the review period.R49's last documented Elopement Evaluation (risk assessment) was completed on 3/7/26. This assessment documents R4 doesn't have a history of elopement or attempts of elopement and R4 wanders aimlessly.R49's Care Plan dated 3/14/25 documents R49 is at risk for wandering/elopement with only one intervention dated 3/14/25 to clearly identify R49's room and bathroom.On 08/17/2026 at 3:31 PM, R49 was lying in bed, which was low to the floor with a fall mat in place. There were no signs posted near R49's room or bathroom to identify these locations. On 8/19/26 at 8:23 AM, there were no signs posted near R49's room or bathroom to identify these locations.On 8/19/26 8:09 AM, V33 CNA stated V33 works night shift and R49 does walk over to the [NAME] Hall but V33 was not aware that R49 has sounded any exit doors or has gotten out of the building.On 08/19/2026 at 8:30 AM, V20 Social Services Director (SSD) stated elopement risk assessments are completed on admission, quarterly and with any changes, and typically V20 completes these assessments. V20 SSD stated nursing should report any changes in wandering behaviors to V20 and document these behaviors in the nursing notes. V20 SSD stated V20 reviews the last 72 hours of nursing notes to identify any behaviors. V20 SSD confirmed R49's last elopement risk assessment was on 3/7/26 and no new elopement interventions since 3/14/26. V20 SSD stated V20 is fast but doesn't have a history of trying to go through exit doors, and no one had reported that R49 had gotten out an exit door. V20 SSD stated the nursing staff should have notified V20 and V20 would have done a new elopement risk assessment and updated R49's care plan. No one reported that R49 had gotten out an exit door. R49 is fast but doesn't have a history of trying to go out exit doors. At 8:43 AM, V20 SSD confirmed there were no signs posted to identify R49's room and bathroom, as care planned. The facility's Elopements and Wandering Residents policy dated 11/25/25 documents the facility will use a systematic approach to monitor and manage residents at risk for elopement, including assessing risk and implementing interventions to reduce hazards and risks, monitoring for effectiveness and modifying as needed. This policy documents residents will be assessed for risk for elopement/unsafe wandering throughout their stay and interventions will be care planned. This policy documents nursing and unit managers will document interventions and response to interventions.C.) On 08/17/2026 at 10:23 AM, R32 was in a wheelchair in R32's room. R32 stated a female CNA transferred R32 out of R32's wheelchair without using R32's wheeled walker or gait belt, which should be used. R32 stated this hurt R32's ribs and has caused pain when R32 breathes. R32 held R32's right rib cage.R32's Minimum Data Set (MDS) dated [DATE] documents R32 as cognitively intact and requiring partial/moderate staff assistance for transfers. R32's active Care Plan documents R32 has alteration in musculoskeletal status related to right tibia fracture. This care plan does not include R32's transfer status.R32's Physician Order dated 6/22/26 documents non-weight bearing to right leg.R32's Nursing Note dated 8/18/2026 at 12:24 PM documents that R32 voiced right rib pain with onset Saturday during a transfer from wheelchair to bed. R32 described the pain as intermittent and rated a four on 1-10 scale. A chest x-ray was ordered.The facility's CNA and Nursing Information Sheets dated 8/14/26 document R32's transfer status as two assist, with a wheeled walker, and gait belt.On 08/19/26 at 8:23 AM, R32 stated R32's chest x-ray came back negative.On 08/17/26 at 3:41 PM, V16 CNA assisted R32 out of bed to standing position with wheeled walker but no gait belt. V16 provided incontinence care and pulled up R32's pants. Midway through these cares, V34 Agency CNA entered the room and began assisting in gathering supplies for R32's incontinence care. At 3:59 PM, V16 CNA confirmed V16 transferred R32 with one assist. V16 stated V16 doesn't always use a gait belt for R32's transfers as R32 doesn't really need one.On 8/18/26 at 10:10 AM, V4 CNA stated the CNAs refer to papers in the communication book at the nurse's stations that identify resident care needs and transfer status. This book was reviewed with V4 CNA who confirmed R32's transfer status is listed as two assist, gait belt and wheeled walker. V4 CNA stated this form was just updated on 8/14/26.On 8/18/26 at 11:32 AM, V7 Infection Preventionist (IP) and V4 CNA transferred R32 from bed to wheelchair. R32 complained of right rib pain during this transfer and reported the same alleged incident to V7 IP that R32 voiced on 8/17/26. V7 IP assessed R32's chest and there were no signs of injury or bruising. V7 IP stated R32 is accurate/credible and R32 transfers with two staff assist, wheeled walker, and gait belt.The facility's Safe Resident Handling policy dated 7/1/26 documents handling aids may include gait belts and resident transfers will be performed in accordance with the resident's plan of care.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of resident dishes. This failure has the potential to affect all 65 residents in the facility. Findings include:On 8/17/2026 at 11:08AM, V6 Dietary Manager reported the food prepared in the kitchen is available for all residents to eat. On 8/17/2026 at 11:17AM, a fruit fly was present flying around and resting on the bucket of sanitizer located beneath the kitchen mechanical sanitizing dishwasher.On 8/17/2026 at 11:22AM, the mop closet attached to the facility kitchen was infested with fruit flies. The closet shared a wall with the adjacent kitchen walk-in cooler. The cooler condensation drainpipe discharged through the wall and was leaking condensate continuously onto the floor surface below. The leak formed a stagnant puddle of water soiled with debris black in coloration. Thirty or more fruit flies were flying around the closet area between the puddle and other surfaces inside of the closet. The door between the mop closet and the main kitchen area where food is prepared was open which allowed the flies to readily enter the kitchen areas. V6 Dietary Manager was present and reported the mop basin sewer drain probably needed cleaned with enzymatic cleaner. On 8/18/2026 at 11:50AM, the floor surfaces beneath the three-basin sink were soiled. Seven or more fruit flies were present at the three-basin sink and flying between the soiled floor surfaces onto clean dishes stored on shelving immediately adjacent to the sink. On 8/18/2026 at 11:52AM, a house fly was resting directly on a tub of peanut butter located in the kitchen walk-in cooler. On 8/18/2026 at 11:55AM, 23 or more fruit flies remained in the mop closet area. On 8/19/2026 at 1:50PM, 17 or more fruit flies remained in the mop closet area.The facility Long-Term Care Facility Application for Medicare and Medicaid dated 8/17/2026 documents 65 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure the kitchen mechanical dishwasher was free from plumbing leaks and failed to maintain sanitary dishwasher and floor surface areas. These failures have the potential to affect all 65 residents residing in the facility.Findings include:1. On 8/17/2026 at 11:17AM, a solid chemical dispenser that dispenses a pre-soak chemical was located directly above the drainboard leading to the mechanical dishwasher in the facility kitchen. Water was continuously leaking from the dispenser and puddling onto the floor surface below the dishwasher. A pre-rinse spray valve and nozzle were located immediately beside the above chemical dispenser and were also leaking a continuous drip of water onto the flooring surface below. On 8/18/2026 at 11:49AM, the dishwasher water leaks remained as above. On 8/19/2026 at 1:50PM, the dishwasher water leaks remained as above.2. On 8/17/2026 at 11:17AM, the equipment surfaces of the dishwasher and attached drainboards were heavily soiled with food debris and mineral deposits. The floor surfaces beneath the dishwasher and three-basin sink were excessively soiled with heavy accumulations of food debris and soiling. A pile of dark, rotting food debris approximately six by six inches in area and one inch in thickness was present beneath the dishwasher drainboards at the corner of the adjoining walls and completely obscured the tiled floor surface below the debris. Four plastic cups and a spoon were present scattered on the floor surface below the dishwasher. On 8/17/2026 at 11:20AM, the walk-in cooler floor surface was soiled throughout with food debris, broken eggs, spilled liquids (unidentified), cardboard, single use margarine packets, and a carton of milk. The evaporator/condenser condensation drain line was actively dripping water onto the cooler floor. On 8/18/2026 at 11:49AM, the dishwasher and the floor surfaces beneath the dishwasher and three-basin sink remained as above.On 8/18/2026 at 11:50AM, the floor surfaces beneath the three-basin sink remained soiled.On 8/18/2026 at 11:59AM, the walk-in cooler floor surfaces and condensation drain line remained as above. On 8/19/2026 at 1:50PM, the dishwasher, floor surfaces beneath the dishwasher and three-basin sink, walk-in cooler floor surfaces, and the walk-in cooler condensate drain line remained as above. On 8/19/2026 at 1:55PM, V6 Dietary Manager stated yeah when asked if the walk-in cooler floor surfaces need cleaned. On 8/19/2026 at 2:10PM, V6 Dietary Manager stated yeah, they do when asked if the flooring and equipment surfaces above need cleaned.On 8/17/2026 at 11:08AM, V6 Dietary Manager reported the food prepared in the kitchen is available for all residents to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 8/17/2026 documents 65 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure the dignity of two (R7, R29) out of two residents reviewed for dignity in a sample list of 44 residents. Findings include: 1.R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. This same MDS documents that R29 requires maximum assistance of staff for toileting, personal hygiene, and dressing and is dependent on staff for assistance with transfers. R29's Care Plan dated 10/03/2023 documents R29 is incontinent of bladder and bowel. This same care plan intervention dated 5/18/2021 instructs staff to provide skin care per facility guidelines and as needed. On 8/19/26 at 9:40 AM, V21 Certified Nurse Aides (CNA), and V28 CNA completed incontinence care for R29. R29 was thoroughly saturated with urine which had soaked through R29's pants, wheelchair cushion and socks. After completing incontinence care V28 CNA applied the same urine-soaked pants back on R29. V21 CNA removed R29's socks but did not cleanse R29's feet. V21 CNA and V28 CNA left R29's room with R29 wearing urine-soaked pants and urine on R29's feet. On 8/19/26 at 9:45 AM, V21 CNA stated V21 did not know where R29's clean pants were so V21 put R29's soiled pants back on R29. V21CNA stated V21 would have changed R29's pants when R29 was assisted up for lunch. On 8/19/26 at 9:55 AM, V28 CNA stated V28 saw that R29's socks were saturated with urine. V28 CNA stated V28 could see the wetness on V28's glove when V28 wiped V28's glove over R29's socks. V28 CNA stated V28 should have washed the urine off R29's feet and legs instead of leaving R29 laying with urine on R29's feet and legs. On 8/19/26 at 10:05 AM, R29 stated R29 likes to have good hygiene. R29 stated R29 did not understand why the staff (V21 and V28) would leave R29 in clothing that was soaked in urine and not wipe off R29's feet. R29 stated that is gross when asked how R29 felt about the care R29 received. On 8/20/26 at 11:00 AM, V2 Director of Nurses (DON) stated residents should be provided with incontinence care every two hours and as needed. V2 DON stated no resident should be left in urine-soaked clothing or with urine on their skin. V2 DON stated this could cause skin breakdown and make the residents feel bad about themselves. 2. R7 Current Diagnoses list documents the following: Cerebral Infarction Due to Thrombosis of Left Middle Cerebral Artery, Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Dominant Side, and Unspecified Fracture of the Lower End of Right Radius, Subsequent Encounter for Closed Fracture with Routine Healing and Local Infection of the Skin and Subcutaneous Tissue Unspecified, and Cellulitis of Right Upper Limb. R7's Minimum Data Set, dated [DATE] documents R7 has severe cognitive impairment and is dependent on substantial to maximum assistance of staff for activities of daily living. R7 Current Care Plan documents the following: (R7) likes to lay in bed between meals. The same current Care Plan documents: Due to facility Abuse and Neglect assessment (R7) scored at an increased risk for Abuse or Neglect. The assessment shows concern for (R7) in the following areas: exhibit depressive symptoms/tendencies, engages in isolative/withdrawn (sic), experiences periods of confusion/forgetfulness, requires a high degree of care, sensory deficits and a communication barriers. (R7) will be treated with respect, dignity, and reside in the facility free of mistreatment from others through the next review. On 8/17/26 at 1:20 pm, R7 was not in R7's room. R7's bed was unmade. R7's bedroom had an odor of bowel incontinence that permeated the room. The middle-left side of R7 's bottom sheet was soiled with dried feces-like material that spanned approximately six inches long, by four inches wide. The same soiled bottom sheet had numerous (too many to count), red and brown, blood-like spots that were scattered on the bedsheet. The area of the scattered blood-like spots measured approximately twelve inches long by twelve-inches wide, on the right upper side of the bed sheet. The soiled bedsheet area scattered with brown and red blood-like spots was distal to R7's bed pillow. The bottom right corner of R7's pillowcase was also soiled with numerous scattered blood-like spots that covered approximately a four inch long by four-inch-wide part of the pillowcase. On 8/18/26 at 9:15 am, R7 was lying in bed, covered up and asleep. The bedsheet was not visible on this observation. R7 's pillowcase was observed to be the same as the observation noted above the day before (8/17/26). On 8/18/26 at 1:10 pm, R7 was seated in a wheelchair, just outside the dining room across from the nurse's station. R7's lower arm was in a soft type of cast. R7 was actively scratching R7's right neck and shoulder. R7 had numerous, scabbed, pinpoint and pencil eraser sized areas, visible where R7 was scratching. R7 also had brown build-up of debris under R7's left hand fingernails. R7 was nonverbal, pleasantly confused and unable to communicate. R7 scratched scabbed skin, and soiled fingernails were in clear view of residents' staff and visitors as R7 sat in a wheelchair across from the nurse's station. This surveyor walked down to R7's room. R7 's bed was unmade. R7's bed linen remained soiled with the same pattern of feces and blood-like debris noted on 8/17/26 at 1:20 pm, documented above. Therefore, R7 was presumed to be laid in the soiled bed sheets, repeatedly. On 8/18/26 at 1:15 pm, V32 Certified Nursing Assistant (CNA) confirmed V32 CNA is R7's caregiver today. V32 CNA stated V32 did not see R7's bed linen this morning. V32 CNA stated Night shift got (R7) up this morning, and (V15 CNA) laid (R7) down after breakfast. I (V32 CNA) didn't know who got (R7) up for lunch. We (unidentified CNAs) were all helping each other. V32 CNA also stated Me (V32 CNA) and (V21 CNA) are going to lay (R7) down in a few minutes. We automatically change (provide incontinence care) the residents when we lay them down or get them up. V32 CNA and V21 CNA entered R7's room. V32 CNA stated I (V32) saw (R7) in bed after (V15 CNA) laid (R7) down. I (V32) did not see (R7's) sheets until now. That is disgusting. I (V32) would never lay a resident in a dirty bed. I (V32) don't know why (V15 CNA) did not say something, and (R7) is mine (a resident V32 CNA provides care for today). The sheets had to be that way from night shift. I (V32) will change them now before we lay (R7) down. V21 CNA was present and stated This is pitiful, absolutely, pitiful. No one should ever have to lay in a nasty bed like this. On 8/18/26 at 1:55 pm, V15 CNA said V15 CNA was just helping with putting residents to bed after breakfast. V15 CNA also stated I (V15) saw (R7's) bedsheet were dirty when I (V15) laid (R7) down after breakfast, but I (V15) figured who ever (R7 's) CNA (V32 CNA was identified above as R7's caregiver) was, would be changing (R7) and would give (R7) clean sheets then. I (V15) did not change (R7). I (V15) just laid (R7) down after breakfast. On 8/18/26 at 2:15 pm, V7 Registered Nurse/Infection Control Preventionist (RN/IP) stated (R7) has a treatment for skin. (R7) scratches (R7's) self so we try to keep (R7's) nails short. V7 RN/IP also stated (R7) should never have been laid in a soiled bed. Yes, this is a dignity issue. Linens, are to be changed when soiled, without delay. The facility policy Promoting/Maintaining Resident Dignity dated 01/01/26 documents the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1.All staff members are involved in providing care to residents to promote and maintain resident dignity and respect for residents' rights. The same policy further documents: 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications and document nonpharmacological interventions attempted for two (R49, R66) of five residents reviewed for unnecessary medications in the sample list of 44 residents. Findings include: The facility's Behavior Monitoring policy dated 5/6/26 documents behaviors and interventions will be monitored. The facility's Use of Psychotropics policy dated 5/6/26 documents: The policy is to ensure residents only receive psychotropic medications when nonpharmacological interventions are contraindicated, and these medications should only be used to treat symptoms and not for staff convenience. Nonpharmacological interventions must be attempted to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 1.) R49's Minimum Data Set (MDS) dated [DATE] documents R49 has cognitive impairment and no behaviors during the review period besides daily wandering. This MDS documents R49 receives antipsychotic medication, and no gradual dose reduction (GDR) was attempted. R49's active care plan does not identify R49's psychotic behaviors that warrant the use of Risperidone (antipsychotic medication). R49's Care Plan lists R49's behaviors as refusal behaviors by placing R49's self on the floor when R49 does not want to engage in tasks, wandering/elopement risk, and pushing/shoving/grabbing/kicking at staff. R49's June-August 2026 Medication Administration Records document orders for Risperidone (antipsychotic) two milligrams (mg) by mouth twice daily since 10/3/25 and Lorazepam (antianxiety) 0.5 MG one tablet by mouth every two hours PRN (as needed) for restlessness/anxiety. Lorazepam was administered four times in July 2026. R49's Electronic Medical Record does not identify what behaviors R49 has to warrant the use of Risperdal or what behaviors, and nonpharmacological interventions were attempted prior to Lorazepam administration. R49's Psychiatry Note dated 8/12/26 documents: R49 has Major Depressive Disorder with Psychotic Features, Generalized Anxiety Disorder, Moderate Intellectual Disability, Severe Dementia and Alzheimer's Disease. R49 is doing well, R49 is calm and cooperative, and staff report no concerns. R49's mood is okay with depressive symptoms controlled, no significant anxiety, sleep/appetite stable, and no hallucinations, paranoia, delusions or other psychotic features. Continue Risperidone for psychotic features related to Major Depressive Disorder. Last GDR (05/28/26) was contraindicated for Risperidone due to an acute escalation of agitation and physical aggression including attempts to hit staff that immediately manifested upon the previous taper attempt. On 08/18/2026 at 9:45 AM, V4 Certified Nursing Assistant (CNA) stated the only behavior R49 has is slouching down when walking and putting R49's self on the floor. On 08/18/2026 at 10:05 AM, V26 Registered Nurse (RN) stated R49 doesn't really have any behaviors just that R49 is a high fall risk and has to be watched because R49 will walk without assistance. R49 has to be watched because R49 will walk without asking for assistance. On 08/19/2026 at 3:30 PM, V17 Assistant Director of Nursing (ADON) stated R49 is nonverbal and would scream out of nowhere inconsolably and unprovoked, then go back to having a flat affect. V17 ADON stated R49 was sleeping more, not eating well and admitted to hospice, which V17 was surprised hospice didn't adjust R49's Risperidone since R49's dementia has progressed and R49 doesn't have behaviors like R49 used to. V17 ADON stated R49 had agitation, gets up and moves and has mood swings which is why the Lorazepam is ordered. V17 ADON stated staff try to redirect R49 by offering activities and toileting. V17 ADON confirmed the nurses should document behaviors and nonpharmacological interventions in the nursing notes prior to giving PRN (as needed) Lorazepam. On 8/20/26 at 9:25 AM, V17 ADON stated R49's last Risperidone GDR was on 2/27/25 when it was reduced to two mg twice daily (current order), and one has not been attempted since then since psychiatry documents it as clinically contraindicated. V17 ADON stated V17 has not been able to find documentation of behaviors to support the use of Risperidone. V17 ADON confirmed there were no documented behaviors and attempted nonpharmacological interventions for R49's Lorazepam administrations in July 2026. 2. R66's Electronic Medical Record (EMR) documents R66's medical diagnoses as Anxiety, Depression, Bipolar Disorder, Borderline Personality Disorder and Drug Induced Subacute Dyskinesia. R66's Minimum Data Set (MDS) dated [DATE] documents R66 as severely cognitively impaired. R66's Care Plan documents an intervention dated 11/23/2025 that instructs staff to monitor/document/report as needed any adverse reactions of Psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. R66's Physician Order Sheet (POS) dated August 2026 documents a physician order starting 1/3/26 to administer Lorazepam (anxiety medication) one milligram (mg) four times daily for Anxiety. This same POS documents a physician order starting 12/16/25 to administer Haloperidol (antipsychotic medication) two mg every six hours as needed for Bipolar Disorder. This same POS documents a physician order starting 12/01/2025 to administer Risperdal two mg twice daily for Bipolar Disorder. This same POS documents a physician order starting 1/03/2026 to administer Trazadone 100 mg every bedtime for Depression R66's Medication Administration Record (MAR) dated July 2026 documents R66 was administered Haloperidol two milligrams (mg) on July 3, 5, 6, 7, 8, 18, 19 and 20 on an as needed basis. This same MAR documents R66 had no behaviors on the same dates listed. R66's Behavioral Tracking form dated 7/22/26 through 8/19/26 documents R66 has had no behaviors. R66's Nurse Progress Notes dated 07/01/2026 - 8/20/2026 does not document any non-pharmacological interventions attempted for R66 prior to administering Psychotropic medications. R66's Nurse Progress Note dated 8/4/2026 at 6:32 PM documents R66 left with Emergency Medical Services (EMS) on stretcher to go to a planned Psychiatric Hospital admission. This same note documents R66 left with R66's suitcase of clothes, comforter, medications, face sheet, orders, advanced directive paperwork, and Power of Attorney (POA) papers. R66's Electronic Medical Record (EMR) documents R66 was hospitalized from [DATE] -8/15/26. On 8/20/26 at 9:00 AM, V2 Director of Nurses (DON) stated R66 has had 'almost daily' behaviors including yelling out, attempting to stand repeatedly once resulting in a fall with major injury, repeatedly making phone calls to outside agencies and family for unnecessary requests, increased lethargy resulting in increased risk of falls/injury, decreased appetite and general behaviors that R66 does not normally have. V2 DON stated R66's inpatient stay was to adjust R66's Psychotropic medications due to so many uncontrolled behaviors. V2 DON stated the staff are not documenting correctly and will educate the staff on documenting appropriately. On 8/20/26 at 9:45 AM, V17 Assistant Director of Nurses (ADON) stated R66 has had multiple behaviors which constituted R66's planned inpatient hospital stay from 8/4/26 -8/15/26. V17 ADON stated the staff are supposed to document behaviors for any resident prescribed psychotropic medications. V17 ADON confirmed R66's Behavioral Tracking only shows that R66 had not had any behaviors and is inaccurate. V17 ADON stated V17 will be educating staff on the importance of documenting resident behaviors appropriately. V17 ADON stated staff should always attempt non-pharmacological interventions prior to administering Psychotropic medications. V17 ADON stated this is an important part of managing a resident's medications to ensure the least amount of medication is ordered and/or given.

Based on observations interviews and record reviews, the facility repeatedly failed to follow their policy to complete oxygen humidifier and oxygen administration equipment refills/ replacement (R22 and R63), failed to enter weekly oxygen equipment care and replacement on the treatment administration sheet/physician order sheet and care plan (R22), failed by initialing that oxygen equipment had been replaced when it had not occurred (R63). These failures affected two of three residents (R22 and R63) reviewed for respiratory/oxygen administration on the sample list of 44 residents.Findings include:1. R22's current Diagnoses sheet documents the following: Acute Respiratory Failure with Hypoxia.R22's current Physician Order Sheet (POS) documents the following: PRN (as needed) 02 (oxygen) at 1-2 L (one to two liters per minute) to keep 02 above 90% (90 percent blood oxygen saturation level). This physician order is incomplete for the delivery device to administer R22's oxygen. The same POS does not document an order to replace the oxygen equipment.R22's current Medication Administration and Treatment Administration (MAR/TAR) record documents: Oxygen per Nasal Cannula/Face Mask at 2 L/min continuous (without interruption) or PRN to keep Sats > (greater than) 90 % (blood oxygen saturation) every shift for SOB (Shortness of Breath). R22's MAR/TAR do not document replacement or refill humidifier bottle as the facility policy below directs.R22's current care plan does not document R22's oxygen equipment replacement or refills for the care of R22's respiratory therapy care.On 08/17/2026 at 1:50 PM, R22 was lying in bed. R22's bedside oxygen concentrator was actively dispensing oxygen at two litter per minute via R22's nasal cannula. R22 had a disposable oxygen humidifier water bottle attached to the nipple of the bedside oxygen concentrator. There was no water in R22's oxygen humidifier bottle. Both R22's humidifier water bottle and oxygen tubing were dated 7/07/26. R22 stated the oxygen dispensing without water makes R22's nasal passages dry and sore at times. On 8/17/26 at 1:55 pm, V3 Licensed Practical Nurse (LPN) confirmed R22's oxygen concentrator humidifier water bottle was empty. V3 LPN also confirmed the dates on both R22's nasal cannula/tubing and humidifier water bottle were dated 07/07/26. V3 LPN stated it was obvious that R22's humidifier and oxygen bottle was not changed weekly as the facility policy directs.On 8/17/26 at 4:00 pm, V2 Director of Nursing (DON), stated V2's expectations include the following: The nurses should not be signing off the changing of the oxygen equipment since they did not provide them, the care plans and physician orders should be complete and accurate, and the nurses are expected to follow the facility oxygen administration policy.2. R63's current Diagnoses sheet documents the following: Acute and Chronic Respiratory Failure with Hypoxia.R63's current Physician Order Sheet (POS) and corresponding Medication /Treatment Administration Record (MAR/TAR) dated August 1-31, 2026, documents the following: Oxygen 2-3 L per nc (nasal canula) prn to keep 02 sat > 90 during sleep, and every 12 hours as needed for wheezing.The same POS and MAR/TAR documents Change 02 (Oxygen) tubing every Monday night, every night shifts every Mon (sic) (Monday) for tubing. This was signed off by nurses' initials as completed every Monday in August, though the dates (7/07/26) on the tubing and humidifier bottle do not reflect this documentation was accurate.On 8/17/26 at 1:53 pm, R63 (R22's roommate) was asleep in bed with an oxygen concentrator bedside. R63's oxygen was not actively dispensing oxygen. R63's oxygen tubing was wrapped around the top of the concentrator. R63's O2 tubing/nasal cannula, and empty disposable oxygen humidifier water bottle, attached to the nipple of R63's concentrator, were both dated 7/07/26.On 8/17/26 at 1:55 pm, V3 Licensed Practical Nurse (LPN) confirmed R63's (R22's roommate) oxygen concentrator humidifier water bottle was empty. V3 LPN also confirmed the dates on R63's nasal cannula/tubing and humidifier water bottle were dated 07/07/26. V3 stated it was obvious that R63's humidifier and oxygen bottle were not changed weekly as the facility policy directs.On 8/17/26 at 4:00 pm, V2 Director of Nursing (DON) stated V2's expectations include the following: The nurses should not be signing off on the changing of the oxygen equipment since they did not provide those tasks, the care plans and physician orders should be complete and accurate, and the nurses are expected to follow the facility oxygen administration policy.The facility policy Oxygen Concentrator dated 10/01/25 documents the following: Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.Definition: An oxygen concentrator is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. The oxygen passes through a filter system and is then stored within the device for delivery based on the flow meter setting.Procedure: 3. Use of the Concentrator: I. Keep delivery devices covered in a plastic bag when not in use. 4. Care of the Concentrator: c. Nurse responsibilities:1. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.11. Change the prefilled humidifier bottle when almost empty.

Based on observation, interview and record review the facility failed to properly store medications for two (R69, R70) residents, failed to maintain medication storage keys under the supervision of a licensed nurse and failed to ensure a medication cart filled with medications was properly locked out of three residents reviewed for medication storage in sample list of 44 residents. Findings include: 1.R69's Brief Interview for Mental Status dated 8/14/26 documents R69 as cognitively intact. R69's undated Face Sheet documents R69 admitted to the facility on [DATE]. R69's Physician Order Sheet (POS) dated August 2026 does not document a physician order for R69 to self-administer medications. R69's Physician Order Sheet (POS) dated August 2026 does not document a physician order for R69's Chlorhexidine medicated mouthwash. On 8/17/26 at 1:40 PM, R69 had an open bottle of Chlorhexidine medicated mouthwash sitting on top of R69's bedside dresser. R69 stated the hospital gave the mouthwash to R69. R69 stated R69 is supposed to be using it but the staff do not help R69 with it. On 8/18/26 at 11:00 AM, R69 had an open bottle of Chlorhexidine medicated mouthwash sitting on top of R69's bedside dresser. On 8/18/2026 at 11:30 AM, V2 Director of Nurses (DON) stated R69 should not have any medications left at R69's bedside. V2 DON stated R69 has not been assessed to self-administer medications. V2 DON stated R69 admitted from the hospital with the Chlorhexidine and should have an order and the medicated mouthwash should be kept in the locked medication cart. 2. On 8/17/26 at 11:50 AM, V4 Certified Nurse Aide (CNA) asked V5 Licensed Practical Nurse (LPN) for a key to the public restroom. V5 LPN gave V4 CNA a blue and white key ring with multiple keys on it. V4 CNA walked down the hall out of the line of site of V5 LPN to attempt to unlock the restroom. V4 CNA returned the keys to V5 LPN stating the keys didn't work for the restroom. On 8/17/26 at 11:55 AM, V5 LPN stated the key set V5 gave to V4 CNA was the keys to the medication storage room. V5 LPN stated V5 has been a licensed nurse for 20 years. V5 LPN stated a nurse should never surrender the keys to the medication room to anyone other than another nurse. V5 LPN stated V5 did not watch where V4 CNA was going but trusts that V4 CNA would not do anything wrong with the keys to the medication room. The facility policy titled Medication Storage dated 10/01/2025 documents only authorized personnel will have access to the keys to locked compartments. The facility is to ensure all medications are stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations, in sufficient quantities to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. 2.) On 08/17/2026 at 4:40 PM, V18 Registered Nurse (RN) transported R29 into the [NAME] South Hall shower room to administer R29's Novolog insulin while leaving both [NAME] Hall medication carts unlocked and out of V18's view. R29's insulin vial was left on top of the cart and these carts were located near the entrance of the dining room with staff and residents walking past due to approaching mealtime. At 4:49 PM, V18 RN returned to the carts and confirmed V18 left R29's insulin vial on top of the cart and that both carts were left unlocked and out of V18's view. V18 RN confirmed the medication carts should have been locked. 3.) On 08/18/2026 at 2:06 PM, the [NAME] North medication cart was reviewed with V7 Infection Preventionist (IP). R7's opened Insulin Glargine-yfgn pen with dispensed date 6/2/26 was not labeled with an opened date to indicate expiration. R5's opened Lantus insulin pen with dispensed date 6/26/26 was not labeled with an opened date to indicate expiration. V7 IP confirmed these pens were not labeled with opened dates. V7 IP stated insulin pens are considered opened once placed in the medication cart and should be labeled with opened dates. R7's August 2026 Medication Administration Record (MAR) documents R7 receives Insulin Glargine-yfgn daily since 4/20/26. The Manufacturer's Guidelines for Insulin Glargine-yfgn dated July 2021 documents the medication is good for 28 days after opening or at room temperature. R5's Physician Order dated 8/20/26 documents to administer Lantus pen-injector 100 units/milliliter (u/ml) 35 units daily and 40 units at bedtime. The Manufacturer's Guidelines for Lantus dated May 2025 documents the medication is good for 28 days after opening or at room temperature. The facility's Medication Storage policy dated 10/1/25 documents all medications will be stored in locked compartments; and during medication pass, medications must be under the direct observation of the nurse administering the medications or locked in the medication storage or cart. The facility's Labeling of Medications and Biologicals policy dated 10/1/25 documents multi-use vials must include opened dates and should be discarded within 28 days unless otherwise specified by the manufacturer.

Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for two (R16, R29) residents and failed to wear the appropriate Personal Protective Equipment (PPE) when providing care for one (R32) resident out of three residents reviewed for Infection Control in a sample list of 44 residents. Findings include: 1. R16's Minimum Data Set (MDS) dated [DATE] documents R16 as severely cognitively impaired. R16 requires the maximum assistance from staff for toileting, bathing, dressing, personal hygiene and is dependent on staff for transfers using a total body mechanical lift. R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. R29 requires maximum assistance of staff for toileting, personal hygiene, dressing and is dependent on staff for assistance with transfers. On 8/19/26 at 9:10 AM, V28 Certified Nurse Aide (CNA) and V29 CNA completed incontinence care for R16. R16 was incontinent of urine. V29 CNA wore gloves while placing both hands over R16's buttocks that had not been cleansed yet when V29 CNA walked over to R33 (R16's roommate) during the middle of providing incontinence care for R16 without removing V29's gloves to assist R33 with removing R33's Nebulizer mask. V29 CNA removed R33's Nebulizer mask, touching R29's forehead and hair. V29 CNA then returned to R16 wearing the same contaminated gloves to continue incontinence care for R16. On 8/19/26 at 9:28 AM, V29 Certified Nurse Aide (CNA) stated V29 should have removed the contaminated gloves prior to assisting R33 with removing the Nebulizer mask and then again when moving from R33 back to R16 to continue incontinence care. On 8/20/26 at 10:10 AM, V2 Director of Nurses (DON) stated staff should change gloves and perform hand hygiene between caring for residents. V2 DON stated V2 does not believe the facility has a specific policy for this situation but would expect staff to maintain Standard Precautions. 2. On 08/17/2026 at 3:32 PM, there was a sign indicating Enhanced Barrier Precautions (EBP) posted at R32's room doorway entrance. R32 had an orthotic boot on R32's left foot. R32 stated R32 sees the wound doctor and receives wound treatments to left heel. On 08/17/26 at 3:41 PM, V16 Certified Nursing Assistant (CNA) entered R32's room and transferred R32 out of bed to standing position and provided incontinence cares and dressing assistance. V34 CNA entered R32's room and assisted V16 CNA with R32's cares, neither V16 nor V34 wore a gown during these cares. At 3:59 PM V16 CNA stated gloves are worn at all times, and gowns are worn if V16 feels unsafe or for contact precautions. V16 CNA confirmed V16, and V34 CNA did not wear gowns during R32's observed cares. R32's EBP sign was reviewed with V16. V16 CNA stated V16 was unsure if the sign was for R32 or R32's roommate (R49). V16 CNA stated V16 did not realize a gown needed to be worn for the high contact care listed on the EBP sign. On 08/18/2026 at 11:15 AM, V7 Infection Preventionist (IP) stated R32 is on EBP for a chronic draining wound and staff should wear gown and gloves for all high contact care activities. The facility's EBP policy dated 10/1/25 documents EBP is an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) through use of gown and gloves during high-contact resident care activities, including assistance with transfers, dressing, and incontinence cares. EBP is used for residents with colonized MDROs, indwelling medical devices, and chronic wounds.

Based on observation, interview and record review the facility failed to ensure three (R18, R33, R52) residents were provided with a homelike environment out of three residents reviewed for clean, homelike environment in a sample list of 44 residents.Findings include:1. R33's Minimum Data Set (MDS) dated [DATE] documents R33 as cognitively intact. On 8/18/26 at 12:05 PM, R33's wall in R33's room was missing paint on a two foot long by one foot wide scraped off paint and another area approximately six inches long by six inches wide area of scattered missing paint areas. R33's window blinds are missing pieces and are broken in other areas. On 8/18/26 at 12:07 PM, R33 stated R33's room would look much better if the paint and broken blinds were fixed. R33 stated R33 did not break the blinds or chip the paint off the walls. R33 stated R33's room was in this condition when R33 was moved into this same room. 2. R52's Brief Interview for Mental Status (BIMS) dated 8/04/2026 documents R52 as cognitively intact. On 8/17/26 at 1:50 PM, R52's window blinds are missing several broken blinds and missing pieces showing a clear view of the outside. On 8/17/26 at 1:55 PM, R52 stated R52 expected a room with functioning window blinds. R52 stated R52 would like to have R52's blinds replaced with ones that cover the window. 3. R18's Minimum Data Set (MDS) dated [DATE] documents R18 as cognitively intact. On 8/17/26 at 1:00 PM, R18's window blinds were torn and/or missing in several places. On 8/17/26 at 1:05 PM, R18 stated it would be very nice if R18's blinds were fixed so that no one could see through R18's window. R18 stated replacing the window blinds in R18's room would make R18's room look better. On 8/18/26 at 10:00 AM, V27 Maintenance Director stated V27 is the only maintenance person for the facility. V27 stated there is a list of things that need fixed and V27 buys supplies as the maintenance budget allows. The facility policy titled Promoting/Maintaining Resident Dignity dated 01/01/2026 documents the facility will protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on interview and record review the facility failed to ensure a resident's right to make treatment decisions was honored for one (R49) of five residents reviewed for unnecessary medications in the sample list of 44 residents. Findings include: R49's Minimum Data Set (MDS) dated [DATE] documents R49 has cognitive impairment. R49's Electronic Medical Record documents V31 as R49's Guardian. R49's July 2026 Medication Administration Record (MAR) documents Lorazepam (antianxiety medication) 0.5 milligrams one tablet by mouth every two hours as needed for restlessness/anxiety, with four administrations recorded. R49's Electronic Medical Record does not include documentation that R49's Lorazepam order was reviewed with V31 (R49's Guardian) or that V31 gave consent to use this medication. On 8/20/26 at 9:25 AM, V17 Assistant Director of Nursing (ADON) stated V17 was unable to find documentation for consent for use of Lorazepam for R49. V17 ADON stated the facility communicates a lot with V31 Guardian through electronic mail, and V17 ADON has reached out to see if V31 could provide documentation that V31 was notified and gave consent for Lorazepam use. The facility's Use of Psychotropic Medication Policy dated 5/6/26 documents Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on observation, interview and record review the facility failed to provide a comfortable mattress for one (R69) resident out of one resident reviewed for accommodation of needs in a sample list of 44 residents.Findings include:R69's undated Face Sheet documents R69 admitted to the facility on [DATE].R69's Brief Interview for Mental Status dated 8/14/26 documents R69 as cognitively intact. On 8/17/26 at 1:30 PM, R69's bed was sunken in the middle section about the depth of two bricks. R69's mattress was not a contour mattress nor a mattress with built up edges.On 8/17/26 at 1:35 PM, R69 stated R69 has trouble sleeping on R69's mattress due to the middle of the mattress is so indented and uncomfortable. R69 stated R69 admitted to the facility from the hospital several days ago. R69 stated R69 has had the same mattress since admission. R69 stated R69 had mentioned to staff that R69's mattress was very uncomfortable, but nothing had been done.On 8/17/26 at 1:38 PM, V3 Licensed Practical Nurse (LPN) assessed R69's mattress and confirmed R69's mattress is not a contour or specialty mattress. V3 LPN stated R69's mattress is 'worn out' and will get it replaced. On 8/18/2026 at 11:30 AM, V2 Director of Nurses (DON) stated all residents should have a comfortable mattress. V2 DON stated a good night's sleep is very important to a resident's overall health. V2 DON stated the facility should have changed this mattress before admitting anyone to that room.The undated policy titled Resident Rights documents residents have the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on interview and record review the facility failed to provide quarterly statements for trust fund accounts for one (R49) of one resident reviewed for resident trust funds in the sample list of 44 residents. Findings include: On 08/17/2026 at 1:23 PM, V22 (R4's) Guardian stated V22 has not received any trust fund statements from the facility for R4's account, but V22 has asked for statements. V22 Guardian stated V22 believes R4 had money transferred to the facility from the group home R4 was living in prior to admitting to the facility in February 2026. V22 stated the facility has Rep Payee for R4's social security benefit checks, but the facility should be sending R4's trust fund account quarterly statements to V22. On 08/18/2026 at 9:15 AM, V12 Business Office Manager stated R4 admitted to the facility in February 2026 and received one social security income deposit at that time. V12 confirmed R4 has a resident trust fund account. V12 stated V12 mails quarterly statements to V22 but does not document this information. V12 stated V12 was unsure when R4's statements were mailed to V22. R4's Resident Statement Landscape dated 2/27/26 through 8/18/26 documents an accounting record and current balance of R4's resident trust fund. The facility's Quarterly Resident Trust Fund Statements Policy dated November 2025 documents the facility will provide a written, itemized resident trust fund statement at least quarterly and upon request to the resident or resident representative, and will document the distribution of these statements.

Based on observation, interview, and record review, the facility failed to ensure contractures and range of motion interventions were care planned and implement interventions to prevent reduction in range of motion for one (R34) of three resident reviewed for range of motion in the sample list of 44 residents. Findings include: R34's Physician's Order dated 1/1/26 documents bilateral knee hinge braces up to six hours a day to prevent further knee contractures. Apply in the morning. R34's Occupational Therapy Discharge summary dated [DATE] documents R34's left hand contracture and use of two rolled washcloths. R34's Care Plan dated 2/16/25 documents R34 has restorative programs due to limited physical mobility and weakness, with interventions including customized wheelchair (7/13/26), monitoring and reporting contractures forming/worsening, provide gentle range of motion with daily care as tolerated, provide supportive care, assistance with mobility as needed and document assistance, and therapy referrals as ordered as needed. This care plan documents R34's diagnoses include left knee contracture. This care plan does not address R34's left hand contracture, use of washcloths for left palm, or use of knee braces.The facility's Certified Nursing Assistant and Nursing Information Sheets dated 8/14/26 document to apply R34's knee brace at 4:00 AM and remove at 11:00 AM. R34's information does not include use of washcloths to left palm. On 08/17/2026 at 11:04 AM, R34 was in a reclining wheelchair in the East Hallway. R34's left hand and wrist were contracted, and there were no washcloths in R34's palm. On 08/18/2026 at 3:56 PM, R34 was in bed and there were no washcloths in R34's left hand. V7 Infection Preventionist (IP) entered R34's room and confirmed this. V7 IP stated R34 admitted with these contractures which have not gotten any worse. On 08/19/26 at 9:15 AM, V21 Restorative Certified Nursing Assistant stated R34 is supposed to have washcloths in R34's left palm, which has been in place for a long time and was ordered by therapy. V21 stated V21 updates the resident care sheets that are in the communication binders located at the nurse's stations, which is where staff look for resident information. V21 confirmed R34's information included knee braces, but not washcloth for left hand. V21 stated V21 will need to update the sheet to include washcloths to left palm. At 11:55 AM, V21 reviewed R34's care plan and confirmed it did not include R34's left hand contracture, knee brace, or rolled washcloths for left palm. On 08/19/2026 at 9:47 AM, V9 Director of Therapy stated R34 was on therapy for contractures, R34 did not tolerate an orthotic device but was tolerating two rolled washcloths to left palm to maintain skin integrity and to prevent further contracture. V9 stated this was recommended upon discharge from therapy and reported to V21 Restorative CNA, who is responsible for ensuring staff are aware and implementation.

Based on observation, interview and record review the facility failed to prevent cross contamination during incontinence care, failed to provide timely and complete incontinence care and failed to perform hand hygiene during incontinence care for two (R16, R29) residents reviewed for incontinence care in a sample list of 44 residents.Findings include:1. R16's undated Face Sheet documents medical diagnoses as Dementia, Anxiety, Depression, History of Urinary Tract Infections (UTI) and General Weakness.R16's Minimum Data Set (MDS) dated [DATE] documents R16 as severely cognitively impaired. R16 requires the maximum assistance from staff for toileting, bathing, dressing, personal hygiene and is dependent on staff for transfers using a total body mechanical lift.R16's Care Plan intervention dated 06/15/2023 documents R16 has a history of Multi Drug Resistant Organism (MDRO) due to Extended Spectrum Beta Lactamase in the urine.On 8/19/26 at 9:15 AM, V28 Certified Nurse Aide (CNA) and V29 CNA completed incontinence care for R16. R16's incontinence brief was moderately saturated with urine. R16's front and rear perineal area skin was reddened. V28 CNA used one washcloth each to wash, rinse and dry R16's front perineal area, then repositioned R16 and used the same contaminated washcloths to wash, rinse and dry R16's rear perineal area. V28 CNA and V29 CNA did not change gloves or perform hand hygiene throughout entire incontinence care. V28 CNA did not wash, rinse or dry R16's buttocks. V28 CNA nor V29 CNA applied barrier cream after completing R16's incontinence care. On 8/19/2026 at 9:30 AM, V28 Certified Nurse Aide (CNA) stated V28 started V28's shift at 7:00 AM and saw that R16 was already up and sitting at the dining room table. V28 CNA stated night shift assisted R16 out of bed and provided incontinence care with R16's morning Activities of Daily Living (ADL) at 6:00 AM. V28 CNA stated V28 did not realize R16 was a resident in V28's assigned group. V28 CNA stated R16 had not been provided with incontinence care since R16 was assisted up at 6:00 AM. V28 CNA stated V28 should have changed V28's gloves, used clean washcloths, washed R16's entire perineal area including R16's buttocks and applied barrier cream. V28 CNA stated V28 normally provides incontinence care for incontinent, dependent residents every four hours but stated V28 CNA should have provided toileting assistance for R16 before breakfast instead of waiting so long.2. R29's undated Face Sheet documents R29's medical diagnoses as Diabetes Mellitus Type II, Dementia, Morbid Obesity, Chronic Kidney Disease and Urinary Incontinence.R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. R29 requires maximum assistance of staff for toileting, personal hygiene, dressing and is dependent on staff for assistance with transfers. R29's Care Plan dated 10/03/2023 documents R29 is incontinent of bladder and bowel. This same care plan intervention dated 5/18/2021 instructs staff to provide skin care per facility guidelines and as needed, provide incontinence care after each incontinent episode and clean perineal area with each incontinence episode. This same care plan includes an intervention dated 10/24/2024 to check R29 as required for incontinence.On 8/19/26 at 9:25 AM, V21 Certified Nurse Aide (CNA) and V28 CNA completed incontinence care for R29. R29's incontinence brief, pants and socks were fully saturated with urine. R29's wheelchair cushion was saturated with urine. V28 CNA transferred R29 from R29's wheelchair to R29's bed using a mechanical lift stand aid. V28 CNA then assisted R29 to a lying position in R29's bed lying fully clothed, and directly on top of the incontinence pad. V28 CNA did not change gloves or perform hand hygiene during the entire incontinence care. R29's front and rear perineal area skin was reddened. R29 was incontinent of urine and bowel. V28 CNA used one washcloth each to cleanse, rinse and dry R29's front perineal area and then repositioned R29 to use the same contaminated washcloths to wash, rinse and dry R29's rear perineal area. V28 CNA did not wash R29's buttocks. V28 CNA used a contaminated washcloth to remove a moderate amount of bowel movement from between R29's buttocks without opening R29's buttocks to visualize the area to see if R29's skin was thoroughly cleansed. V28 CNA had three small areas of brown stool on the top of V28's gloved Left hand. V28 CNA wore the same contaminated gloves to open and reach inside R29's bedside dresser drawer to retrieve barrier cream. V28 CNA wore the same contaminated gloves to apply barrier cream to R29's abdominal fold. V28 CNA did not apply barrier cream to R29's buttocks area. On 8/19/26 at 9:37 AM, V28 Certified Nurse Aide (CNA) stated V28 did not think about changing R29's incontinence pad. V28 CNA stated V28 should have changed gloves and performed hand hygiene. V28 CNA stated V28 was not able to see R29's perianal area but should have ensured R29 was provided thorough cleaning. V28 CNA stated applying barrier cream is a standard but V28 forgot to apply it to R29's buttocks. V28 CNA stated V28 did not know that R29 was in V28's resident assignment. V28 CNA stated R29 was assisted up by night shift staff at 6:00 AM. V28 CNA stated R29 had not been provided with incontinence care since 6:00 AM. On 8/19/26 at 9:40 AM, V21 Certified Nurse Aide (CNA) stated V21 assisted V28 CNA in providing R29 incontinence care. V21 CNA stated V21 used warm water to wet a washcloth but could not find any soap so V21 handed V28 CNA warm, wet washcloths that did not have any soap on them. V21 CNA stated V21 should have left R29's room to find soap so that R29 could be cleansed properly. On 8/19/26 at 9:50 AM, R29 stated the staff should have provided complete incontinence care. R29 stated R29 does not like to wait too long for staff to assist R29 due to R29 is prescribed a 'water pill' and urinates frequently. R29 stated R29 had to wait 'too long' for toileting assistance this morning (8/19/26). On 8/20/26 at 11:00 AM, V2 Director of Nurses (DON) stated residents should be provided incontinence care every two hours and as needed. V2 DON stated incontinence care includes washing with soap, rinsing and drying all affected perineal areas. V2 DON stated the facility has a policy for incontinence care, but staff should know to prevent cross contamination, use soap and wash all affected areas completely. V2 DON stated V2 and other nurse managers will educate the staff on incontinence care. The facility policy titled Incontinent Perineal Care dated 10/01/2025 documents incontinence care must be provided at least every two hours and as needed. Perineal care is completed whenever the perineal area is soiled with urine or feces. The staff providing perineal care should maintain Standard Precautions unless otherwise indicated.

Based on observation and interview, the facility failed to serve timely lunch meals to two residents (R21, R60) of ten reviewed for mealtimes on the sample list of 44 residents. On 8/17/2026 at 11:08AM, V6 Dietary Manager reported the following resident mealtimes in the facility dining room: breakfast at 7:30AM, lunch at 11:30AM, and supper at 5:30PM. On 8/17/2026 at 12:10PM, Resident Mealtimes (undated) was posted in the hallway immediately outside of the facility dining room. The sign listed the following mealtimes for residents: Breakfast at 7:30AM, Lunch at 11:30AM, and Supper at 5:30PM.On 8/17/2024 at 12:14PM, facility staff were assembling resident lunch meal trays at a steam table located in the corner of the facility dining room. On 8/17/2026 at 12:14PM, R60 was seated at a dining room table waiting for lunch to arrive. R60 reported breakfast meals are often one hour late being served to R60, and lunch meals are often one-half hour late. R60 reported food often does not arrive from the kitchen to the dining room steam table on time for staff to be able to serve residents meals timely. R60 reported R60 was hungry. On 8/17/2026 at 12:15PM, only nine of twenty-one tables in the dining room had been served lunch meal trays. On 8/17/2026 at 12:19PM, R21 was seated at a dining room table waiting for staff to serve R21's lunch meal. R21 reported meals are often late to be served and stated this makes R21 feel sad. On 8/17/2026 at 12:30PM, staff provided meals to the last table in the dining room, one hour after the designated lunch mealtime.

Based on observation, interviews, and record review the facility failed to provide assistive eating devices for one (R9) of 29 residents reviewed for dining in the sample list of 44 residents. Findings include: R9's Physician Order dated 12/22/25 documents the use of adaptive cups at meals to increase independence with eating. R9's Minimum Data Set, dated [DATE] documents R9 has cognitive impairment and requires partial/moderate staff assistance with eating. On 08/17/26 at 12:24 PM, V4 Certified Nursing Assistant (CNA) fed R9 lunch and was giving R9 drinks from a regular drinking cup, not an adaptive cup as ordered. At 12:28 PM, R9's meal ticket documented use of adaptive cup for meals. V4 CNA confirmed R9 is supposed to have adaptive cups used for meals, but the kitchen doesn't have any clean right now. V4 CNA stated R9 is able to hold the adaptive cups and take drinks independently.

Failures at this level required more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident who fell from a wheelchair while being transported by a staff member was assessed for potential head, cervical spine, or other injuries prior to being moved and failed to ensure the resident was safely transported in a wheelchair with required foot pedals for two (R2, R7) of ten residents reviewed for accident hazards and supervision on the sample list of 11. These failures resulted in R2 sustaining two acute C1 cervical spine fractures and left facial fractures. R2 expired at the hospital after the fall. R2's death certificate documents a contributing factor as Fall at Nursing Home and the manner of death as Accident. The Immediate Jeopardy began on [DATE], when R2 was wheeled out of the dining room by staff and fell forward from the wheelchair onto the floor. V1 Administrator, V2 Director of Nurses, and V19 Assistant Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 10:59 AM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. B. Based on interview and record review the facility failed to lock the wheelchair after transport for one of ten residents (R11) reviewed for falls on the sample list of 11. This failure resulted in R11 sustaining a scalp hematoma and closed head injury. Findings Include: a. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as moderately cognitively impaired and dependent for wheelchair mobility and all activities of daily living. R2's Care Plan dated [DATE] identifies R2 as being at risk for falls due to current medical condition and being unaware of safety needs. Following an actual fall on [DATE] with facial injury, interventions included ensuring R2 was sitting properly in the wheelchair with proper posture and providing staff assistance with transfers and activities of daily living. The Facility's Accident and Supervision Policy, revised [DATE], requires the resident environment to remain as free of accident hazards as possible and requires each resident to receive adequate supervision and assistive devices to prevent accidents. The policy further requires the facility to identify hazards, evaluate risks, monitor interventions for effectiveness, and modify interventions as necessary. The facility's Head Injury Policy, revised [DATE], requires staff to assess residents following a known or suspected head injury, including vital signs, neurological evaluation, assessment of the head, neck, eyes, ears, nose, face, pain assessment, stabilization of the resident's condition, and activation of EMS (Emergency Medical Services) when indicated. The Facility Reported Incident documents on [DATE] at 1:00 PM, R2 was being wheeled out of the dining room when R2 fell forward from the wheelchair onto the floor. The facility Risk assessment dated [DATE] at 1:00 PM documents the fall was witnessed and R2 was sent to the emergency department. On [DATE] at 2:02 PM, V8, Certified Nursing Assistant (CNA), stated V8 was pushing R2 out of the dining room when R2 leaned forward and fell face first onto the floor. V8 stated there were no foot pedals on R2's wheelchair at the time of transport. V8 stated R2 was unconscious after the fall and yelled for help. V8 further stated foot pedals would have helped prevent R2 from falling forward onto the floor. On [DATE] at 10:05 AM, V4, Registered Nurse (RN), stated R2 was lying on the floor on the stomach, was flaccid, and was not responding. V4 stated staff turned R2 onto the back and moved R2 from the dining room to the nearest available room before completing an assessment because other residents were present in the dining room and R2 was lying near the doorway. V4 stated six staff members, identified as V17 CNA, V9 CNA, V8, V14 CNA, V2 Director of Nursing, and V11 Licensed Practical Nurse, assisted with rolling and transferring R2 before an assessment was completed. On [DATE] at 2:00 PM, V19 Licensed Practical Nurse (LPN), stated upon arrival R2 was lying on the back, unconscious, and not responding. V19 stated no assessment was completed in the dining room because other residents were present and R2 was lying near the doorway. V19 instructed Certified Nursing Assistants to obtain a mechanical lift and move R2 to a nearby room before an assessment was completed. V19 stated R2 began opening the eyes after being moved but was unable to move. V19 further stated wheelchair foot pedals should be on wheelchairs while transporting residents. On [DATE] at 8:36 AM, V18 (Crossroads Director) stated V8 was observed pushing R2 in the wheelchair when R2 leaned forward and fell and stated foot pedals would have helped prevent the fall. On [DATE] at 8:25 AM, V2 (Director of Nursing) stated R2 was moved because the nurse in charge directed staff to move the resident. V2 confirmed residents who are dependent in wheelchair mobility should have foot pedals unless doing so would create a greater risk. On [DATE] at 8:13 AM, V5 (Therapy Director) stated residents who are dependent for care require wheelchair foot pedals while transporting any residents. On [DATE] at 8:35 AM, V3 (CNA) transported R7 without foot pedals while R7's feet intermittently struck the floor. The Emergency Department documentation dated [DATE] states facility staff reported R2 was wheelchair-bound, fell face first to the floor, and became unconscious basically after staff returned R2 to the wheelchair. The Emergency Department History and Physical documented R2 sustained a forehead contusion, facial injuries, neck pain, hypotension, and required placement of a cervical collar. CT (Computed Tomography) imaging identified two acute C1 cervical spine fractures and left facial fractures. Hospital documentation dated [DATE] at 9:17 PM documents R2 became unresponsive while undergoing MRI (Magnetic Resonance Imaging), developed bradycardia, became apneic, cardiopulmonary resuscitation was initiated, and R2 expired. R2's Death Certificate dated [DATE] documents the contributing factor as Fall at Nursing Home and the manner of death as Accident. On [DATE] at 9:12 AM, V20, Medical Director, stated the C1 cervical spine fractures could result in paralysis. On [DATE] at 9:44 AM, V21, Deputy Coroner, stated the case was referred to the coroner because it involved an accident and confirmed R2's death was caused by the fall at the nursing home. On [DATE] at 8:22PM, V25 emergency room Physician, stated R2 came into the emergency room, hypotensive and complaining of pain. V25 also stated that R2 went to receive Magnetic Resonance Imaging (MRI) due to R2 possibly having a spinal cord compression and became unresponsive. V25 stated V25 believes that R2's fall and moving R2 from the floor without an assessment completed at the nursing home contributed to R2's death. The facility presented an abatement plan to remove the immediacy on [DATE] at 10:59AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE], and the survey team accepted the abatement plan on [DATE]. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. All current residents with wheelchairs and need of leg pedals have been assessed to ensure safe transport within the facility by therapy designee on [DATE]. 2. On [DATE] All Licensed Nursing staff were educated by V2, DON on safety and fall risk assessments with emphasis on Head Injury Policy, Accidents and Supervision, and Fall prevention program. Nursing staff were in serviced on documenting for a fall that include, at a minimum Vital signs, General condition and appearance, Neurological evaluation for changes in: a. Physical functioning b. Behavior c. Cognition d. Level of consciousness e. Dizziness f. Nausea g. Irritability h. Slurred speech or slow to answer questions i. Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell or bleeding. Any injuries to head, neck, eyes, or face, including lacerations, abrasions, or bruises. j. Pain Assessment 3. On [DATE] All Licensed Nursing staff were educated by V2, DON. Training/Education included: Parameters for if/when a nurse can move a resident. Post fall if residents are alert, upon licensed nurse assessment if no injury noted resident can be moved. Post fall potential injury or deformity send out to emergency department for further evaluation. Post fall unresponsive send out to emergency department for further evaluation and/or treatment. Fall Guideline Informative Sheet. 4. All residents' accidents will be reviewed by V2 Director of Nursing or V19 Assistive Director of Nursing within 24 hours to ensure appropriate implementation of safety intervention including updating the residents' plan of care. 5. All residents were re-evaluated for a fall risk level. This was completed on [DATE], by V2, DON, and V19, ADON. 6. Facility residents have been assessed for the necessity of wheelchair and or leg pedal/s by V5 Director of Therapy on [DATE]. In the future, residents will receive a Wheelchair Screen by therapy upon admission and upon significant change of condition. 7. Facility will continue QAA process to ensure ongoing monitoring and evaluation of nursing assessments following a resident fall. This will continue to occur daily during QA meetings. Any deficiencies will continue to be monitored monthly until resolved. This is ongoing. 8. V2 Director of Nursing and V19 Assistive Director of Nursing will review each incident report upon occurrence within 24 hours to ensure appropriate interventions are implemented and updated plan of care is complete. V2 Director of Nursing or designee will complete random daily chart audits for 14 days and weekly audits of fall interventions for 6 weeks. Review all fall incident reports to ensure that appropriate interventions have been put in place to reduce the risk of resident falls/accidents and that care plans have been updated to reflect these interventions. This is ongoing. 9. Compliance will be monitored through daily floor audits by charge nurses, random IDT team spot checks, and direct observations by shift-to-shift report. 10. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. This is ongoing. b. R11's Care Plan dated [DATE] documents R11 is diagnosed with a history of falling, Dementia, Major Depressive Disorder, Lack of Coordination, Muscle Weakness, and Legal Blindness. The same Care Plan also documents R11 is at risk for falls related to a history of falls, gait and balance problems, and poor safety awareness. R11 had an actual fall on [DATE]. The new intervention the facility implemented related to this fall was to ensure R11's wheelchair is in the locked position at the dining table. R11's Minimum Data Set, dated [DATE] documents R11 is severely cognitively impaired, requires a wheelchair for mobility, requires substantial/maximum assistance from staff for transfers, and is dependent on staff for wheelchair mobility. R11's Fall Incident Report dated [DATE] documents R11 was in the dining room after the evening meal and around 5:40 PM, R11 fell out of her wheelchair. R11 was found by V24 Dietary Aide. R11 was on the floor on her side with her head by her stomach and a big bump on her left side of her head. R11 was sent to the emergency room for evaluation and treatment. The root cause for the fall was she fell from her wheelchair and the new intervention was that staff are to ensure the wheelchair wheels are locked while sitting at a table. R11's Hospital Records dated [DATE] documents R11 was transported to the emergency room after a fall at the facility. R11 was in the dining room and attempted to stand on her own and fell. R11 complained of pain to the left side of R11's head. R11 had a 'goose egg' bump to the left side of R11's head upon arrival to the hospital. R11 was diagnosed with a small left scalp hematoma and closed head injury. On [DATE] at 1:45 PM V2 Director of Nurses (DON) confirmed R11 cannot propel herself in the wheelchair. R11 requires staff assistance for wheelchair mobility. Staff should have locked R11's wheelchair when sitting R11 at the dining table. V2 confirmed staff did not lock R11's wheelchair and R11 attempted to get up and fell to the floor. V2 confirmed R11 was sent to the hospital after the fall and sustained a hematoma. V2 stated the facility implemented a new intervention in R11's fall care plan for staff to always make sure a resident's wheelchair is locked when sitting at the dining table.

Based on interview and record review, the facility failed to adequately assess and supervise a cognitively impaired resident for the use of an electric assisted standing recliner for one (R1) of three residents reviewed for accidents on the sample list of five. This failure resulted in R1 falling and receiving a left subdural hematoma and a nondisplaced fracture of the left frontal bone. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needed substantial assistance with Activities of Daily Living (ADL), wheelchair bound and dependent on staff to and unable to ambulate. R1's Fall Risk Evaluation dated 11/16/24 documents R1 was at risk for falls. R1's Care Plan dated 11/26/24 documents; Fall Risk: R1 has the potential for falls due to current medical conditions and Gait/Balance problems, Restorative: R1 has limited physical mobility related to weakness. R1's Chair/bed-to-chair transfer Task dated 12/13/24 at 6:18am documents: R1's ability to transfer from bed to wheelchair. V7 (Certified Nursing Assistant/CNA) documented R1 dependent-Helper does all the of the effort. R1 does none of the effort to complete the activity, or the assistance of 2 or more helps is required for the resident to complete the activity. On 1/4/25 at 11:50am, V7 (CNA) said, on 12/13/24 V7 was working the 6:00am - 2:30pm shift and that R1 was in V7's group. V7 said, R1 is a 2-person mechanical lift transfer, or a 2-person gait belt transfer. V7 said, V7 would have last changed R1 between 1:00 and 2:00pm due to V7 always conducting rounds after lunch. V7 said, R1 was in R1's electric assisted standing recliner when V7 left work at 2:30pm on 12/13/24. V7 said, R1's electric assisted standing recliner did have a remote to use to assist with standing, and V7 would use it sometimes to assist with getting the mechanical lift hooked up to transfer R1. V7 said, V7 would than pin the remote not in reach of R1, so that R1 would not have access to the remote to lift the chair in an upright position. On 1/4/25 at 12:12pm, V8 (Occupational Therapy) said, R1 was on therapies case load, and on 12/13/24 R1 was either a 2 person stand pivot transfer using a gait belt, or a 2-person mechanical lift transfer. V8 stated that R1's family brought R1's electric assisted standing recliner in from home, due to R1 slept and sat in it at home. V8 stated, R1's electric assisted standing recliner had a remote that when activated it would assist with standing R1 into an upright position. V8 stated when V8 was done providing therapy to R1, V8 would not place the electric assisted standing recliner remote in eye contact of R1's vision, due to R1 liked to fidget with things, such as the television remote, call lights and anything that R1 could reach. V8 stated that therapy did not attempt to educate R1 in using the remote for the electric assisted standing recliner, due to R1 being a 2-person assist with transfers, and R1's cognitive impairment. On 1/4/25 at 12:41pm, V6 (CNA) stated that on 12/13/24, V6 was working the 2:00pm-10:30pm shift, and R1 was not in V6's group. V6 stated that at 3:30pm, V6 was told that R1 was on the floor in R1's room. V6 stated when V6 got to R1's room, R1 was laying on the floor in front of R1's electric assisted standing recliner on R1's left side, and that recliner was lifted all the way up in a standing position. On 1/4/25 at 1:13pm, V5 (Restorative Assistant) stated that V5 had conducted therapy with R1 and that R1 was a 2-person assist with a gait belt or 2 assist mechanical lift. V5 stated that on 12/13/24 at 3:30pm, V5 was walking down the hallway and heard R1 calling for help. V5 stated upon entering R1's room, V5 observed R1 laying in front of R1's electric assisted standing recliner which was in the up position. The up position would make R1 stand. V5 stated that V5 went and notified V3 (Registered Nurse/RN) that R1 had fallen. On 1/4/25 at 1:40pm, V2 (Director of Nursing) stated that V2 conducted the investigation regarding R1's fall. V2 stated that V2 attempted to interview R1 after returning from the hospital and R1 was unable to provide any details of the fall. V2 stated after interviewing staff, V2 learned that on 12/13/24 at 3:30pm, V5 heard R1 calling for assistance from R1's room. Upon V5 entering R1's room, V5 observed R1 on the floor on R1's left side, and R1's electric assisted standing recliner was in the upright standing position. V2 stated that V6 (CNA) confirmed that R1 was observed on the floor in front of R1's electric assisted standing recliner in an upright standing position. V2 stated that V3 (RN) also confirmed that upon entering R1's room, V3 observed R1 laying on R1's left side in front of R1's electric assisted standing recliner, which was in the up position, and that R1 had a hematoma to the left side of R1's forehead. V2 stated that V3 obtained orders and sent R1 to the emergency room for evaluation, and the facility was informed by the hospital that R1 had sustained a left subdural hematoma and a nondisplaced fracture of the left frontal bone. On 1/4/25 at 2:10pm, V3 (RN) stated that on 12/13/24 at 3:30pm, V5 informed V3 that R1 had fallen in R1's room. V3 stated that V3 immediately went to R1's room and upon entering observed R1 laying on the floor on R1's left side, and R1's electric standing assisted recliner was in a standing upright position. V3 stated V2 assessed R1 and noted a hematoma to the left side of R1's forehead. V3 stated that R1 was unable to provide any information on how R1 had fallen. V3 stated V3 called the facility physician and got an order to send R1 to the emergency room for evaluation. R1's Facility Census documents R1 was admitted to the facility on [DATE] and was discharged on [DATE] and had the following medical diagnoses; Encounter for Palliative Care, Traumatic Subarachnoid Hemorrhage, Displaced Spiral Fracture of Shaft of Left Femur, Encounter for Orthopedic Aftercare, Multiple Fractures of Ribs Right Side, Atrial Fibrillation, Atherosclerotic Heart Disease, Sjogren syndrome, Dysphagia Oropharyngeal, Cognitive Communication Deficit, Lack of Coordination, Weakness, Long Term Use of Non-Steroidal Anti-Inflammatories (NSAID), Abnormalities of Gait and Mobility, Muscle Weakness, Person Injures in Motor-Vehicle Accident, Presence of Coronary Angioplasty Implant and Graft, Hyperlipidemia, HTN, Osteitis Deformans of Multiple Sites and Peptic Ulcer. R1's Post Fall Evaluation Dated 12/13/24 at 3:30pm documents; Fall Details: Date/Time of Fall: 12/13/24 at 3:25pm, Fall was not witnessed. Fall occurred in R1's room. Activity at the time of fall: R1 was using R1's remote to get up out of R1's recliner chair. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: R1 had a hematoma to the left side of R1's forehead. Did fall result in emergency room (ER) visit/hospitalization . R1's Hospital Medical Imaging Report dated 12/13/24 documents CT scan head without contrast. Findings: The visualized base of skull structures appear intact. A scalp hematoma in the left frontal scalp is noted. This hematoma in the frontal scalp measures 8 millimeters in thickness. A subtle fracture of the left frontal bone is noted. This appears nondisplaced in the nature is appreciated best on coronal imaging. A moderately large subdural hematoma along the left parietal region is seen, measuring 10.5 millimeters in thickness. The midline of the cerebral falx is displaced towards the right by as much as 4.8 millimeters. Chronic appearing decreased attenuation in the left frontal deep white matter is seen, suggesting an area of encephalomalacia and probable prior white matter. This area of encephalomalacia was seen on 11/18/24. The left subdural hematoma represents new findings. Impression: Scalp hematoma in the left frontal area is seen. A nondisplaced fracture of the left frontal bone is suspected on this exam. Slight shift of the midline towards the right is seen, as described above. Chronic periventricular white matter small-vessel disease changes suggesting microvascular angiopathy changes and an area of encephalomalacia in the left frontal area is seen but appears unchanged since 11/18/24.

Based on record review and interview the facility repeatedly failed to ensure that a designated key member (Infection Control Preventionist) of the committee was present at their quarterly Quality Assurance (QA) meeting. This has the potential to affect all 56 residents that reside in the facility. Findings include: On 5/21/24 at 3:25 pm the facility provided an undated facility Quality Assurance and Performance Improvement Program (QAPI) policy that documents the following: The facility Administration is responsible to oversee that the facility to ensure Quality Assurance and Performance Improvement Committee (QAPI) , meet monthly at minimum and includes the following key members: The facility Director of Nursing, Medical Director or other designated Physician, Infection Control Preventionist, Staff responsible for the facility plant and three additional staff member responsible for direct patient care and services. The facility provided the attendance sign-in sheets with the QAPI policy noted above. The sign in sheets included all QA committee meetings held since last annual 7/14/24. The facility QA meeting sign-in sheets were dated 7/28/23, 9/15/23, 11/03/23, 12/08/23, 1/26/24, 2/23/24, 3/22/24, and 4/26/24. The signatures on the QA meeting sign-in sheets, did not include the required (V3, Registered Nurse) Infection Control Preventionist. On 05/22/24 at 09:20 am V3, Registered Nurse/Infection Control Preventionist stated V3 has been the Infection Control Preventionist for one year. V3 provided V3's Nursing Home Infection Preventionist Training Course Certificate dated 6/21/23. V3 stated she has not attended the QA committee meetings, because she did not know she was required to do so. On 5/22/24 at 9:25 am V1, Administrator acknowledged V3, Infection Control Preventionist did not attend any QA committee meeting in the past year as required. The facility Long-Term Care Facility Application for Medicare and Medicaid dated 5/21/24 documents the facially total resident census as 56.

Based on observation, interview, and record review the facility failed to ensure all mechanical lift slings were routinely assessed and replaced in accordance with manufacturer's instructions and facility policy. This failure resulted in a mechanical lift sling breaking during R1's transfer which caused R1 to fall from the mechanical lift and sustain head lacerations that required staple closure. This failure has the potential to affect seven additional residents (R2, R3, R4, R5, R6, R7, R8) of eight residents reviewed for mechanical lift transfers in the sample list of eight. Findings include: The facility's Safe Resident Handling/Transfers policy dated December 2023 documents residents require safe handling during transfers to prevent/minimize risk for injury and staff will inspect equipment prior to use. This policy documents if equipment is damaged, broken, or not functioning properly the equipment will be removed from further use. This policy documents manufacturer's instructions on proper sling sizing and tracking of service times will be followed, slings will be assessed/inspected for damage, and damaged, broken, or unsafe slings will be removed from service and replaced. The Full Body Sling manufacturer's instructions for use dated 2023, provided by V1 Administrator, documents Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use. Recommended to replace slings at minimum every six months. R1's Care Plan revised 1/23/24 documents R1 is at risk for falls and injury, R1 slipped out of mechanical lift sling on 12/29/23, R1 had a laceration, and R1 returned to the facility with staples to be removed in 10-14 days. R1's Provider's Progress Note dated 1/3/24 at 9:01 AM, recorded by V9 Nurse Practitioner, documents Patient is a poor historian due to cognitive/psychiatric impairment Chief Complaint/Reason for this Visit S/p (status post) fall with laceration to head. (R1) seen for follow up S/p fall with laceration to head. Per staff, on 12/29/2023, CNA (Certified Nursing Assistant) and Nurse was transferring resident to bed when he slid out of the (full mechanical lift) sling. Resident was lowered to the bed when he slipped out of the bottom of the (full mechanical lift) sling on to his bed and hit his head during transfer. He was then transferred to ED (emergency department) for eval (evaluation), CT (computed tomography) scan showed no fracture or intercranial bleed. Lacerations to scalp were closed with staples. 3 staples to the left side of his head and 2 on top of his head. Staples to be removed in 10-14 days. The facility's Final Investigation Report dated 1/5/24 documents on 12/29/23 R1 had lacerations to the left side and front/top middle of head and based on the investigation R1's left lower leg slid out of the full mechanical lift sling during R1's transfer which caused R1 to shift forward and hit R1's head on the mechanical lift. This report documents R1 was transferred to the emergency room and returned to the facility with staples to the lacerations. V3 Licensed Practical Nurse (LPN) written statement dated 12/29/23 documents a CNA asked V3 to assist in transferring R1 to bed and the CNA had R1 already prepared for the transfer. This statement documents R1 was positioned over top of the bed, R1 slid out of the bottom part of the sling, R1 was bleeding from R1's head and appeared to have hit R1's head while sliding out of the sling. This statement documents R1 was startled and crying, the sling appeared to have ripped during transfer, the sling was destroyed to ensure discontinued use and all staff were in-serviced on the full mechanical lift slings. V4 CNA's written statement dated 12/29/23 documents V4 asked the nurse (V3) to assist with R1's chair to bed mechanical lift transfer, V4 was the one who prepared R1 for the transfer, and R1 slipped out of the bottom of the sling while R1 was positioned over top of the bed. This statement documents R1's head was bleeding and V4 thought R1's head hit the bar on the full mechanical lift. R1's emergency room Summary dated 12/29/23 documents R1 was evaluated for a scalp laceration and these lacerations were closed with staples. The Inservice Sign in Sheet dated 9/21/23 documents V6 Restorative CNA instructed nursing staff to check mechanical lift slings prior to use. The (Full Mechanical Lift) Sling Monitor logs dated 12/8/23-12/31/23 document mechanical lift sling inspections with 27 entries of slings that are not coded with a number. These logs document to identify the sling model inspected, asks if the sling was functioning properly, and if not functioning properly describe the steps taken. The 12/29/23 QAPI (Quality Assurance Performance Improvement) Review on the Use of the Slings for the Mechanical Lift Machine lists slings numbered 1-50 and asks if any tears, rips, or holes were observed on the sling fabric, if the stitching on the sling fabric was observed for signs of fraying, if the sling loops had any fraying or signs of damage, and if the safe working load label was visible. This log documents actions that were taken to address concerns found from the audit and eight slings were discarded. There is no documentation prior to 12/29/23 that all slings were labeled to ensure all slings were routinely inspected and tracked. There is no documentation to show when these slings were purchased and how often they are replaced. The Midnight Census Report dated 1/22/24 documents eight residents (R1-R8) use full mechanical lifts for transfers. On 1/23/24 at 8:40 AM V5 and V10 CNAs transferred R2 from the chair to the bed with a full mechanical lift. At 8:49 AM V13 and V14 CNAs transferred R1 from the chair into the bed with a full mechanical lift. At 9:07 AM V5 and V11 CNAs transferred R3 from the chair to the bed with a full mechanical lift. On 1/23/24 at 8:08 AM V3 LPN stated V3 assisted V4 with R1's mechanical lift transfer on 12/29/23, V3 heard a pop sound, and R1 slid out of the full mechanical lift sling onto the bed. V3 stated R1's forehead was bleeding and V3 assumes R1 hit R1's head on the bar of the full mechanical lift. V3 stated the bottom left looped strap of the sling, that attaches to the lift, broke causing the popping sound. V3 stated laundry staff are responsible for inspecting the slings and the CNAs should inspect the sling before use. V3 confirmed V3 did not inspect the sling as V4 already had R1 setup for the transfer. On 1/23/24 at 10:14 AM V4 CNA stated V4 had R1 set up for the mechanical lift transfer, V4 did not check the sling prior to use/transfer and V4 should have. V3 assisted V4 with R1's transfer, the sling leg strap snapped, and V4 assumes R1 hit R1's head when R1 fell from the lift onto the bed. V4 stated the next day the facility purchased new mechanical lifts and slings, which could have prevented this incident since there were prior concerns with the facility's full mechanical lift slings being unsafe. On 1/23/24 at 9:22 AM V6 Restorative CNA stated V6 is responsible for checking mechanical lift slings weekly for signs of wear and tear such as rips and fraying, and if signs of wear/tear are noted then the sling is taken out of use. V6 stated laundry staff also inspects the lifts and they are the ones who keep a log of this. V6 stated when new slings are purchased, they are numbered for tracking and when we are low on supply of slings more are purchased. V6 confirmed there is no specific frequency for how often the slings should be replaced. V6 stated V6 was unsure what number sling was used for R1's transfer and V6 was told that the sling strap broke and it was discarded due to being faulty. At 9:46 AM V6 stated V6 has a master list of all of the facility's slings and this list was completed two weeks ago. At 11:53 AM V6 confirmed V6 did not have a master list for all slings and there was no tracking system in place for slings prior to 12/29/23. V6 stated it was difficult to track and ensure all slings were routinely inspected since V6 did not have a master list prior to 12/29/23. On 1/23/24 at 9:35 AM V12 Laundry Aide stated laundry staff document sling inspections and these forms recently changed. V12 stated the slings are numbered and are inspected for signs of wear/tear, rips and fraying each time they come through the laundry. V12 stated if there are concerns with the slings they are taken out of use and turned into V6 or V8 Housekeeping/Laundry Supervisor. On 1/23/24 at 9:39 AM V8 stated we recently switched to a different form to document sling inspections that is easier to understand and asks additional questions that the prior forms did not. V8 stated these forms were implemented about two weeks ago. V8 stated V6 is responsible for labeling and tracking all of the slings. V8 confirmed there was no master list of slings until after R1's incident on 12/29/23. V8 stated prior to that not all of the slings were numbered and this was noted on our logs. On 1/23/24 at 12:05 PM V2 Director of Nursing stated V2 conducted the investigation of R1's 12/29/23 incident and V2 was aware that the sling strap broke during R1's transfer. V2 stated after the incident all of the full mechanical lifts and slings were inspected and a few slings were replaced, and prior to that the slings were being replaced on an as needed basis. V2 stated V2 is responsible for ordering mechanical lift slings and V2 confirmed there was no set frequency for replacing the slings. V2 stated laundry staff was responsible for checking the slings and the CNAs should inspect the slings for signs of wear when applying the sling and prior to transfers. V2 stated after R1's incident we in-serviced the nurses and CNAs on full mechanical lift transfers/slings, the facility's policy, and to check the slings prior to use.

Based on observation, interview and record review, the facility failed to develop care plans and implement fall prevention interventions for residents at risk for falls and failed to thoroughly investigate a fall and implement appropriate post fall interventions for three of three residents (R5, R6 and R7) reviewed for falls on the sample list of 10. These failures resulted in R5 having multiple falls resulting in a compression fracture of L5. Findings Include: The facility Fall Prevention Program dated June 2023 documents the fall prevention program will be implemented to ensure all resident's safety in the facility whenever possible. This program should include a measure that determines each resident's needs by assessing the risks for falls and implementing appropriate interventions to provide the necessary supervision, and assistive devices are utilized as necessary. As part of the initial assessment, identify with a history of falls and risk factors for subsequent falling. Risk factors causing the fall should be identified. Identify the root causes of the fall incident, which could be related to the resident's current or declining medical condition or worsening behavior. For an individual who has fallen, staff will attempt to define possible root cause(s) of the fall. Contributing fractures can include but not limited to resident's gait, balance, and current medications that may be associated with dizziness or falling. Collect and evaluate any information until either the cause of the falling is identified or can be speculated as to what was the resident trying to do causing the fall, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Based on the preceding assessment, the staff and or physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If the underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment until falling reduces or stops or until a reason is identified for its continuation. If the resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 1) R5's ongoing Census documents R5 was admitted to the facility on [DATE]. R5's undated Profile Sheet document the following diagnoses: Orthostatic Hypotension, Abnormalities of Gait and Mobility, Osteoarthritis, and Mild Cognitive Impairment. R5's MDS (Minimum Data Set) dated 9/28/23 documents R5 has Moderately Impaired Cognition, is non-ambulatory and requires extensive assistance of one staff for bed mobility, transfers and locomotion. R5's Fall Risk Assessments dated 9/22/23, 9/23/23, 9/26/23 and 9/27/23 all document R5 is at risk for falls. R5's Care Plan dated 9/22/23 documents R5 is at risk for falls with interventions including: evaluate fall risk, determine ability to transfer, assist resident with transfers and ambulation. R5's updated Care Plan dated 9/26/23 documents R5 has had an actual fall with minor injury due to Poor Balance, Unsteady gait, and confusion with interventions to continue interventions on the at-risk plan, dump wheelchair, encourage to sit in more visual area, remove foot pedals, and send to ER (emergency room ) for further evaluation. On 10/11/23 at 11:32 am, hanging on the wall in R5's room, at the head of the bed were two signs. One documents Call don't fall. The second sign, which was hanging upside down in the same location documents If you need help, please push the red button on your call light and wait for help. R5's Progress Notes document the following: 9/23/23 - Housekeeping staff alerted RN (Registered Nurse) that R5 was on the floor. Upon getting to R5, R5 was noted lying on the floor. R5 stated that R5 was attempting to get up to go look for her husband. R5 is weak and ended up sliding out of the wheelchair. 9/26/23 - noted to be on floor by DON (Director of Nursing) and CNA (Certified Nursing Assistant). R5 was did not have footwear on, call light was within reach. 9/27/23 two entries, both by V6 RN - 1) notified by another resident that R5 was on the floor. When leaving dining room and looking down hall, noticed R5 sitting on the floor, against the wheelchair with R5's right leg bent up on leg rest and 2) was notified by another resident that R5 fell out of the wheelchair in the dining room. Upon entering, R5 was noted to be on the floor, leaning up against the wheelchair with R5's head resting on the seat. R5 did not have shoes on. Other staff members assisted R5 back into the wheelchair and R5 was placed near nurses station. R5 denies pain and hitting R5's head. Given order to send to the hospital. On 10/12/23 at 11:30 am, V2 DON stated R5 was originally admitted to the facility due to falling at home and R5's husband not being able to take care of her. V2 explained R5 is very impulsive and thinks R5 can do things for herself because R5 is wanting to go back home to her husband. V2 provided more details related to the above falls. V2 explained on 9/23/23, R5 was on the floor near the hallway bathroom, after sliding out of R5's wheelchair while looking for her husband. V2 stated a new intervention was implemented to sit in a more visual area. V2 confirmed the intervention was not appropriate as sitting in a more visualized area would not prevent R5 from sliding out of the chair. V2 explained on 9/26/23, R5 was attempting to get out of bed by R5's self and was found on the floor. V2 stated V2 is unsure why R5 was trying to get up out of bed because V2 didn't investigate the fall or talk to the resident about the fall but instead just went off of the witness statement which documented that she was wanting to get dressed. V2 stated a new intervention of visual cues were posted in R5's room to call for assistance. V2 confirmed that the visual cues should be some place that R5 can see them, other than being behind R5's head, and positioned so R5 can read them. V2 stated V2 is only aware of one fall on 9/27/23 and that is the one where (R5) sustained the fracture and it was reported to IDPH (Illinois Department of Public Health. V2 stated V2 only has one incident report from that day, and it was for the fall that occurred at 7:15 pm, in the hallway, when R5 slipped out of the wheelchair. V2 believes R5 was trying to get the foot pedals off of the wheelchair so the new intervention was to remove the foot pedals and dump the seat of the wheelchair. V2 stated no interventions were implemented for the other fall that day, as V2 was not aware of a second fall. R5's Emergency Department Adult Provider Note dated 9/28/23 by V9 Hospital Physician documents R5 was brought to the emergency roiagnom on [DATE] after trying to lift R5's self up from a wheelchair, slipped and fell to the floor from the wheelchair. R5 is complaining of pain to the lower back. This note documents R5 has an acute L5 compression fracture. R5's Radiology Results dated 9/27/23 documents there is minimal height loss and a faintly visible fracture line through the superior endplate of L5 consistent with an acute compression fracture. 2) On 10/11/23 at 1:30 pm, R6 was lying in bed with a seated walker next to the bed. R6 stated the last time R6 fell , R6 had bent down to pick something up off the floor and R6's knee gave out, explaining R6 has two bad knees that give out at times. R6's October 2023 Physician Orders document an order on 10/2/23 to wear a soft knee brace for pain. R6's MDS (Minimum Data Set) dated 9/12/23 documents R6 has moderately impaired cognition and requires supervision with transfers and ambulation. R6's Progress Notes dated 10/6/23 documents R6 sitting on buttocks on the floor in the dining room. R6 stated R6's right knee gave out. Fall was witnessed by other residents in the dining room. On 10/12/23 at 10:52 am, V2 DON (Director of Nursing) stated R6's fall was not investigated, and no new post fall interventions were implemented. 3) R7's ongoing Census documents R7 was admitted to the facility on [DATE]. R7's Fall Risk Assessments dated 9/18/23 documents R7 is at risk for falls. R7's Care Plan dated 10/2/23 does not contain an at risk for falls care plan or any fall prevention interventions. On 10/12/23 at 11:12 am, V2 DON (Director of Nursing) confirmed R7 does not have an at risk care plan for falls and did not have any fall prevention interventions put into place at the time of admission, even though R7 was at risk for falls at the time of admission to the facility. V2 stated R7 should have had one in place with standard fall prevention interventions.

Based on interview and record review, the facility failed to prevent two episodes of physical abuse between residents for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10. This resulted in R1 hitting R2 on top of the head with a metal cane then R1 throwing a cup and eating utensils at R2, hitting R2 in the arm, causing psychosocial harm for R2 and R9, along with a hematoma to the top of R2's head. Findings Include: The facility's Abuse, Neglect and Exploitation Policy dated 2/28/23 documents, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse include, but is not limited to hitting, slapping, punching, biting and kicking. The facility's Final Incident Report dated 9/22/23 documents on 9/17/23, it was reported that R1 and R2 were sitting in the dining room when R1 went over to R2 and struck R2 on the head with R1's cane. An investigation has been completed and staff interviews confirm that R1 struck R2 with R1's cane. R1 was not exhibiting any threatening behavior prior to R1's action and did not appear to even know why R1 had done so. R2 stated R1 hit R2 in the head with R1's cane. R2 does not know why R1 did this and reported that there was no altercation between them prior to this. R1 stated R1 doesn't know why R1 hit R1's peer (R2) and had no intention of hurting R2. Other residents present during this incident confirmed this incident, but none had any idea why R1 took this action. On 10/12/23 at 9:05 am, R2 stated R2 was sitting in the dining room at dinner time when R1, who was at a different table but near R2, stood up and hit R2 on top of the head with R1's cane. R2 stated R2 had a large lump on R2's head and a headache after it happened. R2 explained the nurse put ice on it and sent R2 to the hospital for evaluation. R2 stated the lump went down with ice but that R2 had a headache for a couple of days. R2 also stated that after that happened, a couple weeks later, R1 threw R1's cup at R2 hitting R2 in the arm. R2 explained the facility then moved R1 to a different table, away from R2, but it was too late, (R1) already had hit me (R2) a second time. R2 stated R2 was afraid of R1 explaining, I (R2) don't want (R1) around me, I (R2) don't know what (R1) will do. On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was not present when R1 hit R2 with R1's cane however R1 told V12 about it saying R1 did it because R2 wouldn't talk to R1. V12 stated V12 explained that R2 was hard of hearing and that is probably why R2 didn't respond to R1. V12 then stated that after the first incident, V12 was told by V8 Activity Aide/CNA (Certified Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm. V12 stated R2 is now afraid of R1. On 10/12/23 at 12:39 pm, V8 stated V8 was in the dining room and when V8 walked by R2, who was sitting at the table along with R8, R9 and R10, R2 reported that R1 just threw a glass and silverware at (R2) that hit R2 in the arm. V8 explained R8, R9 and R10 all seen R1 throw items at R2, and thought it was wrong of R2 to throw the items. V8 stated V8 considers R1's actions to be abusive toward R2. R9's MDS (Minimum Data Set) dated 9/20/23 documents R9 is alert and oriented. On 10/12/23 at 1:47 pm, R9 stated R9, R2, R8 and R10 were all eating lunch when R1 threw a pop can at R2, hitting R2 in the upper arm, then a cup, that was not full was thrown and hit R2, then a knife that didn't hit R2 but instead landed on the floor, sliding under the table and then the rest of R2's utensils, which also hit the floor. R9 explained, this isn't the first incident with (R1) either. A couple of weeks prior, (R1) was walking past (R2) and hit (R2) on top of (R2's) head with (R1's) metal cane. R2 ended up getting a big knot on the top of R2's head and instantly complained of a headache. R9 stated R2 is scared of R1 now and every time R1 walks past R2 at the table, R1 taunts R2 by telling R2 to look at something that isn't there. V9 explained V9 thinks R1 is trying to be funny but that isn't funny after hitting (R2). (R1) could easily walk a different way but (R1) always walks right by (R2) and it's intimidating to (R2). R9 stated we {R8, R9 and R10} all sit there and wonder if it's going to be our turn next and that scares me (R9) because I'm in this wheelchair due to a broken ankle, I (R9) just can't get up and walk away from (R1). On 10/16/23 at 9:00 am, R1 confirmed R1 hit R2 over the head with R1's cane while in the dining room and stated R1 was upset, not necessarily at R2 but in general, and that is why R1 did it. R1 also confirmed R1 hit R2 with a cup in the dining room explaining that R1 did not throw the cup at R2 but instead swiped the table with his hand, pushing a cup and utensils off the table in R2's direction and was trying to hit R2 with them.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to develop a care plan and interventions for a resident (R4) who is at high risk for developing pressure ulcers and has a history of pressure ulcers. The facility failed to implement pressure relieving interventions, routinely assess resident's skin, identify a pressure ulcer, assess a pressure ulcer upon identification, report a pressure ulcer to the wound nurse and physician, implement a treatment, and ensure open wounds were covered for one (R4) of five residents reviewed for pressure ulcers and repositioning in the sample list of five. These failures resulted in R4 developing a pressure ulcer of the right buttock that deteriorated into a Stage 4 pressure ulcer without treatment nor interventions. The Immediate Jeopardy began on (8/17/23) when R4 developed a pressure ulcer that was not identified, evaluated, and treated. V1 (Administrator) was notified of the Immediate Jeopardy on 8/30/23 at 4:16 PM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 8/31/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and Quality Assurance reviews. Findings include: a.) The facility's Wound Report dated 8/22/23 documents R4 admitted to the facility with a left hip wound on 6/29/23 that measures 1.4 centimeters (cm) long by 1.2 cm wide by 0.1 cm deep, and R4 has a left inner knee facility acquired Stage 2 Pressure Ulcer that measures 0.8 cm by 1 cm by 0.1 cm. On 8/29/23 at 9:59 AM, 11:35 AM, 1:15 PM, 1:21 PM, 1:53 PM, and 2:31 PM, R4 was sitting in a reclining back wheelchair in R4's room. R4's legs were contracted with R4's knees near R4's chest and R4's heels/feet against R4's buttocks. There was a cushion in R4's wheelchair and an air mattress on R4's bed. At 9:59 AM, R4 stated R4 has a wound on R4's buttocks that has been there a few days and the wound does not receive daily treatments. At 1:53 PM, V10 (Certified Nursing Assistant/CNA) positioned R4 onto R4's right side in the wheelchair, removed the wedge cushion between R4's knees, and placed the cushion between R4's right leg and the armrest of the wheelchair. V10 did not replace a pillow or wedge cushion between R4's knees prior to leaving R4's room. At 2:31 PM, R4 did not have a pillow or wedge cushion between R4's knees. On 8/29/23 at 3:32 PM, R4 was lying in bed on R4's right side. R4's legs were contracted and R4's heels were near R4's buttocks. R4 was not wearing any pressure relieving boots and R4's heels were not floated. V5 (Registered Nurse/RN) removed a dressing from R4's left hip. There was a large pink, scarred area, approximately the size of a softball, with a small open area near the center. R4's left inner knee had an open red wound that was not covered with a dressing. V5 stated the wound treatment is barrier cream and V5 does not cover it with a dressing. R4's right buttock had an uncovered deep, open wound, approximately quarter size, that contained yellow and red wound tissue. V5 (RN) and V6 (Certified Nursing Assistant/CNA) had to reposition R4's legs in order to observe the wound. V5 and V6 stated they were not aware of this wound and were unsure how long R4 has had the wound. R4's Diagnoses List dated 8/29/23 documents R4 has Multiple Sclerosis, Multiple Muscle Contractures, and Severe Protein Calorie Malnutrition. R4's Admission Minimum Data Set, dated dated dated [DATE] documents R4 is cognitively intact, requires extensive assistance of at least two staff for bed mobility/transfers/toileting, is dependent on two staff for bathing, is frequently incontinent of bowel, has impaired range of motion to bilateral upper and lower extremities, and admitted to the facility with a Stage 4 pressure ulcer. R4's Braden Assessments dated 7/4/23, 8/15/23, and 8/22/23 document a score of 11, indicating R4 is at high risk for developing pressure ulcers. R4's Care Plan dated 7/4/23 documents a problem Wound Management and interventions to monitor for signs of infection, and administer wound treatment as ordered, but does not identify the type or location of these wounds. This care plan does not document a problem area, goals, or interventions identifying that R4 is high risk for developing pressure ulcers or any pressure relieving interventions. R4's Order Summary Report dated 8/30/23 documents orders for pressure-relieving boots when in bed, turn/reposition every 2 hours, float heels when in bed, and a low air loss mattress initiated on 6/29/23, apply barrier cream to bilateral buttocks every shift initiated on 8/8/23, and a wound treatment for the left knee including use of a pillow between knees initiated on 8/23/23. There are no other documented pressure-relieving interventions in R4's medical record. There is no documentation in R4's medical record that the orders for floating heels and the use of pressure-relieving boots were implemented routinely or that R4 refuses these interventions. R4's Treatment Administration Record documents the nurses signed out the treatment for barrier cream to R4's buttocks every shift as ordered. R4's Wound Assessment and Plans recorded by V4 (Wound Physician) document: On 7/4/23 recorded by V4 (Wound Physician) documents R4's left hip Stage 4 Pressure Ulcer measured 6.5 cm by 4.8 cm by 0.1 cm. On 7/18/23, R4 had a left buttock Stage 2 Pressure Ulcer that measured 0.9 cm by 2.6 cm by less than 0.1 cm deep and notes that R4 has limited positioning options due to severe bilateral hip and knee joint contractures and current difficult-to heal ulcer left lateral hip (greater trochanter.) On 8/8/23 R4's left buttock wound healed. On 8/22/23, R4's left medial knee Stage 2 Pressure Ulcer measured 0.8 cm by 1.3 cm by less than 0.1 cm and includes orders to use a pillow between R4's knees and a daily treatment for a barrier cream covered with a foam dressing. R4's left hip pressure ulcer measured 1.4 cm by 1.2 cm by 0.1 cm. There is no documentation in R4's medical record that routine skin assessments are completed (besides wound assessments), or that R4's right buttock wound was identified, assessed, reported to V3 (RN/Wound Nurse) and V4 (Wound Physician), and treatment orders were administered prior to 8/29/23. R4's Skin Evaluation Note dated 8/29/2023 at 8:21 AM recorded by V3 documents assessment of R4's left hip and left inner knee pressure ulcers. This note does not document that a full skin assessment was conducted and does not identify that R4 has a right buttock wound. Interventions listed are encouraging R4 to frequently shift weight, raise buttocks when sitting in chair, treatments as ordered, and turn/move R4 at least every two hours. R4's Nursing Note dated 8/29/2023 at 5:05 PM documents R4's right medial buttock wound was assessed and measured 4 cm by 3 cm by 2 cm with undermining from 7 to 12 o'clock, and the deepest part measured 4 cm. The wound contained black eschar (dead tissue) and yellow slough. The wound was cleansed, and a calcium alginate treatment was applied. V3 (RN/Wound Nurse) was notified and will assess R4 in the morning. On 8/29/23 at 1:21 PM, V10 (Certified Nursing Assistant/CNA) stated R4 is supposed to be repositioned every two hours and V10 lays R4 down towards the end of dayshift. V10 stated V10 uses a drawsheet and wedge cushion and reclines the back of the wheelchair to reposition R4 in R4's chair. V10 confirmed R4 has been in the wheelchair since around 10:00 AM. On 8/29/23 at 3:26 PM, V11 (Regional Clinical Nurse) confirmed care plans should be updated to include current pressure ulcers, pressure ulcer risk, and pressure relieving interventions. V11 stated R4's care plan will be updated today. On 8/29/23 at 3:46 PM, V5 (RN) stated, I'm embarrassed by that referring to R4's right buttock wound. At 4:14 PM, V5 stated V5 did not apply the barrier cream or assess R4's buttocks yesterday, because R4's left buttock wound had healed. V5 stated no one had reported R4's wound to V5. On 8/29/23 at 4:11 PM, V9 (Registered Nurse/RN) stated R4 has an air mattress, and we turn and reposition R4. V9 confirmed no pressure-relieving interventions for bilateral lower extremities, and stated we tried to use a roll to prevent pressure at one time. V9 stated V9 was not aware of R4's right buttock wound. V9 confirmed V9 worked 8/26/23 and 8/27/23 and did not assess R4's buttocks. On 8/29/23 at 4:30 PM, V7 (Certified Nursing Assistant/CNA) stated V7 works on R4's hallway and provided care for R4 over the weekend (8/26/23-8/27/23). V7 stated R4 had an open wound to R4's right buttock that was not covered with a dressing. V7 stated the wound should have been covered and V7 had previously reported the wound to the nurses. V7 stated the wound had been there for a few weeks. V7 stated the nurses tell V7 they don't have a treatment for R4's buttock wound, only a treatment for R4's hip wound. V7 stated R4 primarily lays on R4's right side and R4 has never had or used pressure-relieving boots. On 8/29/23 at 4:38 PM, V8 (Certified Nursing Assistant/CNA) stated V8 provides care for R4 on evenings and night shifts and last cared for R4 this past weekend. V8 stated that over the weekend R4 had a wound on R4's bottom and hip. V8 described the wound as being a hole on R4's right buttock, that was not covered with a dressing. V8 stated we had been applying barrier cream, and V8 was not sure how long the wound had been there. V8 stated there was a sore there a week ago Thursday (8/17/23), but it was not as bad. V8 stated V8 has told the nurses about R4's wound, but they just give cream to apply. V8 confirmed R4 has never had or used pressure-relieving boots. On 8/29/23 at 3:51 PM, V2 (Director of Nursing/DON) stated skin assessments are to be completed on shower days and documented on the shower sheets which are not part of the resident's Electronic Medical Record. V2 stated the CNAs are to immediately report any skin issues to the nurses. At 4:01 PM, V2 confirmed V2 was unaware of R4's right buttock wound. V2 stated R4 was listed on today's wound report and confirmed it does not document a right buttock wound. At 4:26 PM, V2 provided R4's bath sheet dated 8/29/23 and stated that is the only documented shower/skin sheet V2 could find. V2 stated V2 is going to assess R4's wound and implement treatment orders. On 8/29/23 at 4:04 PM, V3 (RN/ Wound Nurse) stated R4 had a wound to the left buttock that healed approximately two weeks ago and V3 was not aware that R4 currently has a right buttock wound. V3 stated V3 looked at R4's bottom on Monday 8/28/23 and could have missed the wound, because V3 rolled R4 by herself. V3 stated R4 admitted with an order and still has an active order to wear pressure-relieving boots, but R4 refuses to wear them. V3 stated there is no documentation that heel pressure relieving interventions are implemented. V3 stated R4 has an order for a wedge or pillow between R4's knees. On 8/30/23 at 8:09 AM, V3 stated V3 did not document R4's refusal to wear pressure relieving boots, and V3 assumed the order was transcribed to R4's Medication Administration Record (MAR) for the nurses to implement and document. V3 stated staff should have documented refusals in the nursing note or MAR. V3 stated R4 only admitted to the facility with the left hip wound, R4 has a long-standing history of wounds, and has very fragile skin. V3 stated the staff should have told V3 about R4's right buttock wound. V3 stated the nurses should report new wounds to V3 and the physician and measure the wound. V3 stated V3 notifies V4 (Wound Physician) to obtain wound orders, or the primary physician if unable to reach V4. V3 stated the CNAs should be showering the residents and reporting the skin issues. V3 documents in a progress note when a full body skin sweep is done by V3/V4. V3 confirmed V3 did not conduct a full body skin check on R4 on 8/29/23. V3 stated a treatment order was initiated yesterday for R4's right buttock wound and previously the treatment was for barrier cream, but that would have changed once it was identified to be open. V3 stated R4 is contracted and R4's feet rest there (referring to the location of R4's buttock wound) and refusing to wear the boots. V3 stated R4 likes to wear shoes when sitting in the wheelchair, so it is uncertain if the wound was caused from a shoe or heel. V3 confirmed R4's left knee wound should be covered with a dry dressing. On 8/30/23 at 10:25 AM, V1 (Administrator) stated V1 was not aware of R4's right buttock wound prior to 8/29/23. On 8/30/23 at 9:30 AM, V4 (Wound Physician), V3 (RN/ Wound Nurse), and with assistance of V12 (CNA) turned R4 in bed to assess R4's skin and wounds. V4 measured R4's left hip wound and V3 administered the treatment. V4 measured R4's open right buttock wound and stated R4's right buttock wound measures 2.5 cm by 2.7 cm by 1.1 cm deep, with undermining 0.7 cm at 1 o'clock and 3 o'clock. Silver calcium alginate and two by two gauze was packed into the wound and covered with a bordered adhesive dressing. V4 stated R4's right buttock wound is a Stage 4 pressure ulcer since V4 could feel bone. During R4's full body skin check, R4 had scarring from previous wounds to the penis, right heel, right outer foot, sacrum, right hip, and right/left buttocks. R4's right knee wound was not covered with a dressing. On 8/30/23 at 9:26 AM, V4 (Wound Physician) stated V4 has been treating R4 since October 2022 when R4 resided at a former facility. V4 stated R4's muscle volume is very low and due to R4's contractures R4's skin is stretched over R4's buttocks. Wounds can progress quickly for R4. At 10:02 AM V4 stated if R4 had been wearing pressure-relieving boots it may have prevented R4's right buttock wound from developing. V4 stated V4 is not sure if the wound was caused from R4's heel pressure or the chair. V4 last assessed R4 on 8/22/23 when the left knee wound was discovered, and the buttock wound was not there at that time. V4 stated V4 was ashamed that the wound was missed during that assessment and V4 should have done a more thorough skin assessment. It would take probably less than a week for R4 to develop that kind of wound. R4's shoes could have caused pressure to the area as well, and it absolutely would have been better for R4 not to wear shoes. V4 stated therapy could have also helped with R4's mobility and joint flexion. V4 stated V3 and V4 depend on the CNAs to assess skin and report when wounds are found. V4 stated the barrier cream is more for prevention and confirmed this treatment would not be appropriate for open wounds. V4 stated R4's wound being left open puts it at risk for contamination. V4 stated it concerns V4 that the nurses documenting the barrier cream administration should have been looking at and assessing the area. V4 confirmed that if R4's wound had been reported and assessed immediately, monitored, and a treatment implemented it could have prevented R4's wound from deteriorating to a Stage 4. V4 stated in hindsight this wound could have been prevented. R4's Physician Order dated 8/31/23 documents administer Keflex (antibiotic) 500 milligrams one capsule via gastrostomy tube three times daily for 15 days for wound. The facility's undated Pressure Ulcer/Skin Breakdown-Clinical Protocol documents the following: Significant risk factors for developing pressure ulcers such as immobility, weight loss, and a history of pressure ulcers need to be identified. Pressure ulcers will be assessed and documented and include wound characteristics and measurements. Treatments and support surfaces will be documented. The physician will order wound treatments including pressure reduction surfaces and the application of topical agents; will help identify medical interventions for wound management; and help staff alter the care plan as appropriate including when new wounds develop despite current interventions. The facility's undated Pressure Ulcer Risk Assessment documents the following: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 5. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e. (for example), perspiration, feces, urine, wound discharge, soap residue, etc. (etcetera), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 6. Once a pressure ulcer develops, it can be extremely difficult to heal. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches. Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 5. Any change in the resident's condition. 6. The condition of the resident's skin (i.e. (for example), the size and location of any red or tender areas). The Immediate Jeopardy that began on 8/17/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: 1a. R4's physician and family were notified of R4's new wound to the right ischium on 8/29/23. 1b. A treatment order was obtained from the physician and implemented to R4 on 8/29/23. 1c. R4 received a skin assessment on 8/29/23, a Braden scale assessment (pressure ulcer risk assessment) on 8/29/23, and R4's care plan was updated on 8/30/23. 2a. A full body skin assessment was conducted for every resident residing in the facility, completed on 8/30/23. 2b. Newly identified skin alterations were reported to respective physicians, and treatment orders were obtained and implemented on 8/30/23. 2c. Newly obtained physician orders were transcribed into the Physician Order Sheet and Treatment Administration Record. Resident's care plans were updated to reflect the new skin conditions, monitoring, assessments, education, and orders on 8/30/23. 3a. An in-service training was completed for the Director of Nursing and Wound Care Nurse for pressure ulcer prevention, interventions, skin assessments, identification, reporting, and treatments on 8/30/23. 3b. An in-service training was completed for licensed nursing staff for pressure ulcer prevention, interventions, skin assessments, physician notifications, obtaining treatments orders, transcribing orders, and monitoring wounds on 8/30/23. 3c. An in-service training was conducted for certified nursing staff for completing and documenting shower sheets and reporting to licensed nurses any skin conditions and skin issues without a dressing on 8/30/23. 3d. V1 confirmed facility staff nor agency staff will be allowed to work until these required in-service trainings are completed on 8/30/23. On 9/1/23 at 10:17 am, V1 (Administrator) stated all facility staff had received the in-service trainings. V1 stated the facility only works with one agency and has conducted the in-service trainings with the agency staff who have worked in the facility, and scanned the in-service trainings to the agency who will require any additional staff to complete the in-service training prior to being sent to the facility. 3e. The facility policies for pressure injury prevention, preventative skin care, nutrition and hydration, repositioning, and pressure relieving devices were reviewed and revised on 8/30/23. 3f. In-service training was completed for all direct care staff regarding identification of high-risk residents and how the direct care staff are informed of these residents on 8/31/23. 4a. i. ii. iii. iv. v. While the facility began the monitoring and auditing procedures on 8/30/23, these measures will be ongoing for 4 weeks, then a minimum of 3 months, and reviewed and evaluated weekly by the facility Quality Assurance program and facility administration. B. Based on observation, interview, and record review, the facility failed to develop and update care plans to include pressure ulcer risk, interventions, and pressure ulcers, complete pressure ulcer risk assessments, implement pressure relieving interventions and preventative treatments for four (R1, R2, R3, R5) of five residents reviewed for repositioning/pressure ulcers in the sample list of five. Findings include: The facility's undated Pressure Ulcer Risk Assessment policy documents to complete pressure ulcer risk assessments on admission, quarterly, annually, and with significant changes. b.1) R1's MDS dated [DATE] documents R1 is cognitively intact, requires assistance of one staff person for transfers and bed mobility, and is at risk for developing pressure ulcers. R1's Care Plan dated 1/18/23 documents R1 has impaired skin integrity of the right heel and includes interventions to follow facility protocol for treatment and apply pressure relieving boots. R1's Physician Order dated 2/22/23 documents to wear a pressure-relieving boot to the left foot when in wheelchair and offload heel in bed. R1's Physician Order dated 5/17/23 documents to cleanse R1's right heel and apply a skin protectant daily. R1's August 2023 Medication Administration Record (MAR) does not document R1's right heel skin protectant was administered on 5 days and R1's left heel boot is documented as applied three times daily except for 6 refusals. The skin protectant entries for 8/1/23 and 8/5/23 refers to the nursing notes. R1's Order Administration Notes document: On 8/5/2023 at 2:49, out of time. On 8/1/2023 at 2:27 PM, shift over out of time. There is no documentation R1's treatments were administered on the next shift. On 8/29/23 at 12:39 PM, 1:08 PM and 2:32 PM, R1 was sitting in a wheelchair in R1's room and was not wearing a pressure relieving boot. At 12:39 PM, R1 stated R1 used to wear a pressure-relieving boot, but the wounds on R1's feet have healed, and staff told R1 that R1 no longer has to wear the boot. At 2:32 PM, R1 stated they no longer apply the skin protectant to my heels since R1's wounds have healed. On 8/29/23 at 10:08 AM, V19 (Licensed Practical Nurse/LPN) reviewed R1's order administration notes and stated V19 did not have time to administer R1's skin protectant treatments on 8/1/23 and 8/5/23, so it fell on to the next shift to administer. At 3:14 PM, V19 stated R1 refuses to wear the pressure relieving boot because R1's wound has healed. b.2) On 8/29/23 at 8:11 AM, R2 was sitting on R2's bed wearing a walking boot on the left foot. R2's Diagnoses List dated 8/30/23 includes Diabetes Mellitus. R2's Care Plan dated 6/8/22 documents R2 is at risk for skin breakdown and includes interventions to assist with toileting and repositioning. R2's Physician Order dated 8/16/23 documents to wear a short walking boot due to an ankle sprain. There are no documented Braden Assessments in R2's electronic medical record after 9/8/22. R2's Census Report documents R2 admitted to the facility on [DATE]. b.3) On 8/29/23 at 8:14 AM, 9:52 AM, 10:43 AM, and 1:58 PM, R3 was sitting in a wheelchair in R3's room. R3's Diagnoses List dated 8/30/23 includes Conversion Disorder with seizures/convulsions, Diabetes Mellitus, COVID-19 (8/21/23) and Dementia. R3's MDS dated [DATE] documents R3 has short- and long-term memory impairment, requires extensive assistance of one person for bed mobility, transfers, and toileting, is always incontinent of bowel and bladder, and is at risk for developing pressure ulcers. R3's Care Plan dated 6/18/23 documents R3 is at risk for developing pressure ulcers due to decreased mobility, lethargy, and moisture; and includes pressure relieving interventions and monitoring. R3's electronic medical record documents R3's last Braden Assessment was completed on 4/9/23. This assessment documents a score of 13, indicating R3 is at moderate risk for developing pressure ulcers. b.4) On 8/29/23 at 9:26 AM, R5 was lying in bed with R5's right foot on a foot cradle. R5 states R5 has a wound to R5's right heel. At 11:00 AM, R5 was sitting in the hallway and had a pressure-relieving boot on the right foot. On 8/29/23 at 1:45 PM, V3 (Wound Nurse) administered R5's right heel wound treatment. There was a golf ball sized red/open wound to R5's right heel. The facility's Wound Report dated 8/22/23 documents R5 has a right heel unstageable pressure ulcer that developed on 8/1/23 and measured 1.8 centimeters (cm) long by 3.2 cm wide by 0.1 cm deep. R5's MDS dated [DATE] documents R5 is cognitively intact, requires extensive assistance of two for transfers/bed mobility/toileting, and is at risk for developing pressure ulcers. R5's Physician Order dated 12/28/22 documents to wear pressure relieving boots at all times. R5's Physician Order dated 8/23/23 documents to cleanse the right heel wound and apply silver calcium alginate and cover with a dry dressing daily. R5's Care Plan revised on 4/10/23 documents R5 is at risk for pressure ulcers and includes interventions for skin assessments weekly, provide incontinence care, use pressure relieving cushion and mattress, and float heels under calves when in bed. This care plan has not been updated to include R5's right heel pressure ulcer, foot cradle, and pressure relieving boots. There are no documented Braden Assessments in R5's electronic medical record after 1/4/23 until 8/1/23. R5's Braden score was 20 on 1/4/23. On 8/1/23 R5's Braden score was 16, indicating R5 was at risk of developing pressure ulcers. On 8/29/23 at 11:26 AM, V3 (Wound Nurse) stated pressure ulcer risk is determined by the Braden Assessment, which is done quarterly by V3 and the MDS Coordinator. V3 stated interventions and risk are documented on the care plan. V3 stated R5 is noncompliant with floating R5's heels and wearing pressure relieving boots. On 8/29/23 at 3:26 PM, V11 (Regional Clinical Nurse) confirmed care plans should be updated to include current pressure ulcers, pressure ulcer risk, and pressure relieving interventions.

Based on interview and record review the facility staff failed to provide safety for one resident (R21) when using the mechanical lift for transfer for one (R21) of four residents reviewed for accidents in a sample of 23. This failure resulted in R21 falling onto the floor out of of a mechanical lift sling during a transfer requiring a emergency department evaluation and sustaining a facial laceration. Findings include: The Physician's Orders dated July 2023 list the following diagnosis for R21: Obstructive Hydrocephalus, Unspecified Dementia with Behavior Disturbance, Bipolar and Seizures. Facility incident report dated 6/19/2023 documents R21 was being transferred with a mechanical lift by V7, CNA (Certified Nursing Assistant). R21 was up in the air above the bed in the mechanical sling and the strap broke which caused R21 to fall out of the sling and was assisted to the floor by V7. R21 hit his head, left temple area on the leg of the mechanical lift and received a laceration to left eyebrow and skin tear to left hand along with a large area of bruising the the left hand and arm. R21's progress notes dated 6/19/23 documents the ambulance was called and transferred R21 to the Emergency Department and R1 returned to the facility at 6:30 AM on 6/20/23. R21's Emergency Department provider notes dated 6/19/23 documents presenting to ED for evaluation of fall, head trauma. Staff was assisting patient with a (Mechanical lift transfer) and patient fell off (mechanical lift) and hit his head. Physical exam: Skin- 2 centimeter jagged laceration noted lateral to the left eyebrow, skin tear to dorsum left hand. Laceration repair: Repair method- Tissue adhesive. V7, CNA stated in interview at 2:48 PM One of the straps that was on the the mechanical lift hooks broke which caused (R21) to fall out of the sling and V7 assisted (R21) to the floor and (R21) hit his head on the leg of the mechanical lift. V7 stated (R21) was still in the sling above the bed in the air and this is when the sling's strap broke causing ( R21) to fall and hit his head. V2, DON (Director of Nurses) stated in interview on 7/14/23 at 10:05 AM. The CNA V7 hooked the sling up wrong when transferring (R21). We have two slings one is complete full body sling for transfers and the other sling is one that covers the body under the buttocks area. V2 stated this sling you have to criss cross the sling straps in order to use it correctly. V7 did not have the sling applied appropriately and V7 was educated on the proper placement of sling usage, also always have 2 staff when using mechanical lift for transferring residents. The care plan for R 21 dated 5/21/23 states R21 must be transferred with 2 staff and a mechanical lift. The facility policy titled Safe Lifting and Movement of Residents revision date October 2009, documents The Policy Statement is In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview, and record review, the facility failed to ensure nurses were trained in peritoneal dialysis, monitor and record weights and dialysis volume intake/output, and communicate with the dialysis center to coordinate care for two (R1, R2) of two residents reviewed for peritoneal dialysis in the sample list of four. This failure resulted in R1 experiencing an 18-pound weight gain in 4 days and being hospitalized for fluid volume overload. Findings include: The facility's Peritoneal Dialysis (Continuous Ambulatory) policy dated as revised October 2010 documents: This procedure must be performed by a nurse who has been specifically trained in peritoneal dialysis procedures, complications, and infection control for dialysis. Observe for signs and symptoms of fluid volume overload (hypervolemia) including, labored breathing, increased blood pressure, edema, and neck vein distension. Verify the dialysate solution/concentration, number of exchanges and infusion, dwell, and drain times. Dwell times are generally three to six hours during the day. Obtain and record the resident's weight and vital signs before and after administering peritoneal dialysis. Record the amount of dialysate infused and drained, drained peritoneal fluid characteristics, start and stop time of the infusion, and communication with physician/dialysis center. Notify the physician of any discrepancies between the fluid intake and output. The facility's Facility Assessment Tool dated 10/4/22 documents the facility provides dialysis services and has an average of 3 residents who receive dialysis. The dialysis In-Service Sign In Sheets dated 3/25/22, 4/6/22, 9/9/22, and 12/23/22 does not document V5 and V17 Licensed Practical Nurses (LPNs) were in attendance. 1.) R1's Order Summary Reports dated 4/10/22 and 4/16/22 document: R1's diagnoses include Chronic Kidney Disease Stage 3, End Stage Renal Disease (ESRD), and Dependence on Renal Dialysis. R1's orders dated 4/6/22 and 4/26/22 document peritoneal dialysis administration - use three 2.5 % (dialysis solution) bags at night with cycler for 10.5 hours, 3000 milliliters (ml) times 4 bags (for a total of 12,000 ml), and a last fill of 2800 ml twice daily on at 6:00 PM and off at 4:30 AM, and to obtain daily weights. The order dated 4/16/22 documents peritoneal dialysis daily Manual drain; fill with 2500 cc (cubic centimeters/milliliters) with 2.5% solution, dwell. This order does not indicate duration for the dwell time. R1's April 2022 Medication Administration Record (MAR) does not document R1's dialysis volume output after peritoneal dialysis administrations, and the dialysis administration is not signed out as stopped at 4:30 AM as ordered on 4/8, 4/9, and 4/10/22. This MAR documents to obtain R1's weight daily, but the entries are blank and do not document R1's weight was obtained. R1's dialysis volume intake/output is not recorded in R1's medical record. There are only two weights recorded in R1's medical record, an admission weight of 205 pounds (lbs) on 4/6/22 and 223 lbs on 4/10/22 (an 18-lb weight gain in 4 days.) R1's Nursing Notes document: On 4/9/22 at 3:28 AM and on 4/10/22 at 3:19 AM R1 had an expiratory wheeze, R1's abdomen was firm/distended, and R1 had no urinary output so far on this shift. On 4/10/22 at 9:07 AM, R1 had shortness of breath and was tired, and attempts were made to contact peritoneal dialysis provider with no feedback. R1's primary provider was notified, and orders received for CBC (complete blood count) and CMP (complete metabolic panel). On 4/10/22 at 10:39 AM ,V8 (Registered Nurse/RN) and an unidentified Certified Nursing Assistant were transferring R1 back to bed after obtaining R1's weight, and R1 became unresponsive. R1's carotid pulse was very weak and thready. Emergency transport services were notified. R1 was assisted to bed and regained consciousness. R1's breathing was labored, R1 had an expiratory wheeze, R1's blood pressure was 72/40 and pulse was 101 beats per minute. Weight gain was also noted. R1 was transferred to the local hospital. R1 was readmitted to the facility on the evening of 4/15/22. There is no documentation that the facility communicated with R1's dialysis center or Nephrologist upon R1's return to the facility on [DATE] to coordinate R1's care/orders. On 4/16/22 at 1:21 AM, R1's family informed the nurse that the dialysis cycler was alarming low drain, and the family contacted the company who instructed the family to disconnect R1's dialysis and notify the dialysis center in the morning. The nurse notified the dialysis center and the dialysis nurse instructed to administer dialysis at next scheduled time and last night's dialysis will be considered a missed dialysis. On 4/16/22 at 2:57 PM, R1's inhaler was administered for wheezing, and R1 had 3 cc output from R1's noon dialysis exchange. There is no documentation that the dialysis center or Nephrologist were notified of R1's 3 cc output after 2500 ml solution was administered. On 4/17/22 at 8:21 PM, R1 was transferred to the hospital per the request of R1's family and dialysis center, and due to excess fluid and dialysis complications. R1's Chest x-ray dated 4/10/22 documents Findings: Moderate cardiomegaly. Minimal perihilar pulmonary vascular congestion. Mild interstitial edema. No pneumothorax. Mild degenerative changes. Impression: Changes suggestive of volume overload. R1's Hospital Discharge Summary Report dated 4/15/22 documents R1 hospital course diagnoses include acute heart failure with preserved ejection fraction, atrial fibrillation, and elevated troponin, likely from ESRD. R1's Emergency Department Physician Report dated 4/17/22 documents: R1 presented with shortness of breath and weight gain since discharged two days previously. R1 reported increased edema, discomfort, and shortness of breath. R1 had pitting edema throughout R1's extremities. Primary Impression: ESRD on peritoneal dialysis Additional Impressions: Shortness of breath, Elevated troponin, Elevated brain natriuretic peptide (BNP) level, Edema, Volume Overload. R1's History and Physical dated 4/18/22 documents R1 had issues with receiving peritoneal dialysis at the nursing home and R1's family reported that the nursing home staff were not trained to handle peritoneal dialysis. On 1/17/23 at 11:48 AM, V3 (Registered Nurse/RN) stated daily weights are recorded on the Medication Administration Record (MAR) or the vitals section of the electronic medical record. On 1/17/23 at 2:03 PM, V8 (RN) stated: Peritoneal dialysis input/output volumes are recorded on the resident's dialysis logs kept in a binder in their room. R1 became unresponsive (on 4/10/22) during a transfer after R1's weight was obtained, R1 had a weight gain and was transferred to the hospital. Weights should be recorded daily on the MAR, and we would notify the physician and dialysis for the same weight parameters for Congestive Heart Failure, greater than 3 lbs in 1 day or greater than 5 lbs in one week. Notify the physician and dialysis of complications/changes in condition and record in the nursing notes. On 1/17/23 at 1:04 PM, V2 (Director of Nursing/DON) stated V2 was unable to locate R1's dialysis logs. On 1/17/23 at 2:43 PM, V16 (Dialysis Center Registered Nurse) stated the nurses should be monitoring residents on peritoneal dialysis for fluid retention by monitoring daily weights, blood pressures, assessing for swelling/edema and shortness of breath. V16 stated signs of fluid volume overload would include weight gain and increase in blood pressure, and V16 expects the facility to notify the dialysis center with any changes or signs of fluid volume overload, including a weight gain of 2 lbs or more in 24 hours. The facility should have been monitoring R1's weight daily, notified us of R1's weight gain, and we would have ordered a different type of dialysis solution of 4.5 % to help treat and reduce R1's fluid retention. On 1/18/23 at 9:22 AM, V16 stated the facility should have reviewed/clarified R1's peritoneal dialysis orders with R1's Nephrologist when R1 readmitted from the hospital. On 1/18/23 at 8:54 AM, V17 (LPN) stated V17 has not had any formal training on peritoneal dialysis, and V2 had ran through peritoneal dialysis training with V17 a few years ago. V17 stated V17 vaguely recalls R1 and V17 had to contact an unidentified nurse who formerly worked for the facility to guide V17 and another unidentified nurse on how to administer R1's peritoneal dialysis. Neither V17 nor the unidentified nurse working night shift knew how to do R1's peritoneal dialysis. V17 remembers when R1 went to the hospital (4/17/22) and stated R1 was swollen. V17 confirmed R1 was sent in for excess fluid and dialysis complications per V17's nursing note. On 1/18/23 at 10:36 AM, V1 (Administrator) stated R1's weights and peritoneal dialysis solution volume intakes/outputs should have been recorded on R1's dialysis logs, and R1's family may have taken the logs home when R1 was discharged . At 11:38 AM, V1 (Administrator) stated V2 had provided peritoneal dialysis training for V17 (LPN), but V1 has no documentation of that training. 2.) R2's Order Summary Report dated 1/17/23 documents R2's diagnoses include End Stage Renal Disease with dependence on Renal Dialysis. R2's orders include peritoneal dialysis exchanges two times daily - dwell 12 hours, use 7.5% extraneal 2000 ml at 6:00 PM and 2.5 % dianeal at 6:00 am. Fill and drain every 12 hours. R2's December 2022 and January 2023 MAR and nursing notes document V5 (LPN) administered R2's peritoneal dialysis. On 1/17/23 at 10:01 AM, R2 had an abdominal peritoneal dialysis catheter. R2 stated R2 receives peritoneal dialysis 7.5 % 2000 ml at night and 2.5 % 2000 ml in the morning. R2 stated the nurses tell R2 they have been doing dialysis for years if R2 asks questions such as draining the dialysis line. On 1/18/23 at 8:54 AM, V17 (LPN) stated: V17 has administered R2's peritoneal dialysis, and R2 explains the procedure step by step to V17. V17 has not had any formal training on peritoneal dialysis, and V2 had ran through peritoneal dialysis training with V17 a few years ago. On 1/17/23 at 3:09 PM, V2 (DON) stated V2 was unable to locate documentation that V5 (LPN) had received peritoneal dialysis training.

Based on observation, interview, and record review the facility failed to follow the established plan of care related to transfers for one (R1) of three residents reviewed for accidents in the sample of three. This failure resulted in an improper transfer, where R1 hit R1's leg on a tilt back wheelchair sustaining a 10-centimeter laceration to the lower left leg requiring 12 sutures. Findings include: R1's Admitting Diagnoses; Non-traumatic Subdural Hemorrhage, [CONDITION(S)], Lack of Coordination and Muscle Weakness. R1's Facility Referral/Screen to Rehab services dated 10/21/21 documents R1's transfer status as mechanical lift. R1's Care Plan dated 10/20/21 documents R1's transfer status as requiring a mechanical lift. R1's Minimum Data Set (MDS) dated [DATE] documents R1 Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet), total dependance 2-person physical assist. R1 is severely cognitively impaired. R1's Nursing Progress Notes dated 8/17/22 at 6:40pm document V4 (Licensed Practical Nurse/LPN) was called to R1's room. V3 (Certified Nursing Assistant/CNA) and V5 (Agency Certified Nursing Assistant/ Agency CNA) stated that V3 and V5 observed a skin tear on R1's left lower leg. While assessing R1, V3 and V5 stated that V3 and V5 2 person transferred R1 from tilt back chair to R1's bed. V3(CNA) and V5 (Agency CNA) were re-educated on mechanical lift transfers and slings. V4 (LPN) explained that the mechanical lift sling should have been placed under the resident, and then lifted with a mechanical lift. V3 and V5 shook their heads nodding yes they understood. V4 notified Hospice, V6 (R1's Physician), V1 (Administrator) and V7 (R1's Power of Attorney/POA). V6 and Hospice stated to send R1 to the emergency room for evaluation and treatment. R1 was sent to Hospital emergency room for treatment. V5's (CNA) Facility Investigation Witness Statement dated 8/17/22 at 7:30pm documents upon entering (V5 and V3, CNA) realized the patient R1 did not have a sling, V5 and V3 attempted to transfer R1 to the bed and upon doing so R1 obtained a skin tear on the lower left leg. V4 (LPN) was notified and followed protocol. V3's (CNA) Facility Investigation Witness Statement dated 8/18/22 no time documents V5 (Agency CNA) and V3, 2-person assist transferred R1 into bed. At this time there wasn't a mechanical lift sling under R1. V5 was on the inside near the bed, V3 was on the outside. When V3 and V5 got R1 to the bed that's when it was noticed there was blood. That's when V3 noticed the skin tear. V5 stayed with R1, and V3 went and got V4 (LPN). That evening V3 was working on the other side of the hallway, V5 had asked V3 for assist. R1's Nursing Notes dated 8/18/21 at 2:26 pm document R1 has 12 stitches to the left lower leg, is wrapped in bandage for 24 hours, minimal drainage noted on dressing. R1 was at baseline today. R1's Hospital Discharge Summary date 8/18/22 document R1 having a 10-centimeter laceration to the left lower leg, received 12 sutures and antibiotic ointment and non-adhesive dressing applied. On 9/2/22 at 10:28 am, V3 (CNA) said on 8/17/22 at 6:40pm V5 (Agency CNA) asked V3 for assistance transferring R1 from tilt back wheelchair to bed. V3 said, V3 was working the opposite hallway and went to R1's room to assist. V3 said, V5 informed V3 that R1 was a 2-person assist, and V3 didn't observe a sling under R1. V3 said, V3 took the outside arm and V5 took the inside which was closest to the bed and transferred R1 to the bed. V3 said, R1 appeared to hit R1's lower left leg on the tilt back wheelchair. V3 said, after getting R1 into bed, V3 observed that R1 was bleeding on R1's lower left leg. V3 (CNA) said, V5 stood with R1 and V3 went and got V4 (LPN) who came to R1's room and assessed R1. V3 said, V4 informed V3 and V5 that R1 was a 2 person mechanical lift transfer, and that they should have placed a sling under R1 and used the mechanical lift. V3 said, V3 didn't know R1 was a 2-person mechanical lift resident, and V5 didn't tell V3 that R1 was a mechanical lift transfer. V3 said, R1 was sent to the emergency room for evaluation. V3 said, V3(CNA) was educated by V4 on where and how to obtain the transfer status of residents. On 9/2/22 at 11:50am, V4 (LPN) said, on 8/17/22 at 6:40pm, V3 (CNA) informed V4 that R1 had received a skin tear when R1 was transferred to bed. V4 said, V4 went to R1's room and conducted a head-to-toe assessment of R1 and noted a skin tear to R1's lower left leg. V4 said, V4 contacted Hospice, V6 (R1's Physician) and V7 (R1's Power of Attorney/POA) and informed them of the incident. V4 said, V4 received new orders to send R1 to the emergency room for evaluation and treatment. V4 said, the ambulance arrived and transported R1 to the hospital. V4 said, V4 asked V3 (CNA) and V5 (Agency CNA) how R1 was transferred and V3 and V5 informed V4 that they used 2-person stand and pivot. V4 said, V4 informed V3 and V5 that R1 is not a 2-person stand and pivot but is a 2-person mechanical lift. V4 said, V4 educated V3 and V4 on where/and how to obtain the transfer status of residents. V4 said, V4 later learned that R4 received 12 sutures to the left lower leg. On 9/2/22 at 2:25pm, V2 Director of Nursing (DON) said, on 8/17/22 at 6:40pm V3 and V5 transferred R1 using a 2-person stand and pivot transfer. V1 said, during the transfer R1 hit R1's left lower leg on the tilt back wheelchair causing a laceration. V1 said, R1 was assessed by V4 (LPN) and was sent to the emergency room were R1 received 12 sutures to the left lower leg. V1 said, V3 and V4 should of transferred R1 using 2-person assist, a sling and a mechanical lift, per R1's plan of care. Facility Using the Care Plan (no date); Highlights Policy Statement: The care plan shall be used and developing the resident's daily care routine and will be available to staff personnel who have the responsibility for providing care or services to the resident. Completed care plans are places in the resident's chart and/or in a striped folder located at each nurses' station. Care plans are available on each (Brand) computer and (System Brand/Type) data storage system. CNAs are responsible for responding to the Nurse/DON and change in the residents' condition and care plan goals and objectivities that have not been met or expected outcomes that have not been achieved. Other facility staff noting a change in a resident's condition must also report those changes to the DON. Changes in the resident's condition must be reported to the DON so that a review of the resident's assessment and care plan can be made. Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy.

Based on observation, interview, and record review the facility failed to ensure a resident (R1) was transferred per the resident's assessment and facility policy and failed to ensure R1 was wearing physician ordered compression stockings. These failures resulted in R1 being sent to the local emergency room with a right lower leg laceration that required 17 sutures to close the laceration. The facility also failed to prevent a resident (R3) injury by failing to replace a broken toilet tank lid resulting in R3 being sent to the local emergency room with a left index finger laceration that required 4 sutures to close the laceration. R1 and R3 are two of three residents reviewed for injuries in the sample list of three. Findings include: The facility's Safe Lifting and Movement of Residents policy revised October 2009 documents: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 1. The facility's Final Investigation Report dated 10/22/21 documents: On 10/18/21 at 8:30 AM R1 was transferred from the wheelchair to the bed by attending aide (V6 Agency Certified Nursing Assistant (CNA)), and R1's right lower leg bumped against the wheelchair causing a laceration. R1 was sent to the local emergency room and received 17 sutures to close the laceration. The clinical record confirm that this resident (R1) has bilateral 4 + pitting [CONDITION(S)] (indicating a deep indentation [MEDICATION(S)] more than 20 seconds). R1's Hospital Discharge Summary dated 10/18/21 documents R1 was evaluated for a laceration of the right lower leg and R1 received 17 stitches to close the laceration. R1's Diagnosis List dated 11/1/21 documents R1 has diagnoses of [CONDITION(S)], Anxiety, and Unspecified Intellectual Disabilities. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment and requires extensive assistance of at least two staff for transfers. The MDS documents for chair/bed to chair transfers. R1 is dependent, meaning the helper does all of the effort and the resident does no effort in completing the activity, or the assistance of 2 or more staff is required to complete the activity. R1's Care Plan dated 6/30/21 documents R1 requires assistance with Activities of Daily Living (ADLs) including transfers. This care plan documents an intervention dated 10/20/21 to transfer R1 with a full mechanical lift. R1's Care Plan dated 10/21/21 documents R1 is dependent on two staff and a full mechanical lift for transfers. R1's Care Plan does not document R1's transfer status or the amount of assistance R1 needed with transfers prior to 10/20/21. R1's Nursing Notes document on 10/8/21, 10/11/21, 10/12/21, 10/14/21, and 10/15/21 document R1 requires total care for ADLs and uses a full mechanical lift for transfers. R1's Restorative Nurse Screener Evaluation dated 10/6/21 documents R1 requires substantial/maximal assistance for chair/bed to chair transfers. R1's Order Summary Report dated 11/1/21 documents an order started on 8/10/21 to apply compression stockings to bilateral lower extremities in the morning and remove at night to reduce [CONDITION(S)]. R1's Wound Evaluation & Management Summary by V29 Wound Physician dated 10/21/21 documents R1's right, anterior, lateral leg laceration with stitches measured 10 cm (centimeters) long by 5 cm wide and an order to apply a nonadherent dressing covered with a gauze sponge daily. There is no documentation in R1's medical record that R1 refused to wear R1's compression stockings on 10/18/21. V6's Witness Statement dated 10/21/21 documents on 10/18/21 (R1) was sitting in (R1's) w/c (wheelchair). I (V6) put (R1's) pedals to the sides, positioned (R1's) legs between mine. (V6) put (V6's) arms underneath of (R1's) arms and stood (R1) up and transferred (R1) to the bed. Rolled w/c back, noticed that (R1's) (R) (Right) LE (Lower Extremity) was bleeding. (V6) asked housekeeper to call for help. (V6) lifted (R1's) legs onto bed. Nurse arrived. V6's Just-In-Time Training dated 10/18/21 documents V6 received training to follow the resident's care plan when transferring residents. The care plan can be viewed in (Electronic Medical Record System) or ask the nurse or CNAs. V6 is expected to ask if V6 is unsure how to transfer a resident. On 11/1/21 at 8:47 AM V6 and V7 CNA's transferred R1 from the wheelchair to the bed with a full mechanical lift. R1's lower legs were swollen, and R1 was not wearing compression stockings. R1 had a dressing covering R1's right lower leg laceration that was saturated with blood-tinged drainage, and the drainage had seeped onto R1's right lower pant leg. V7 confirmed R1 was not wearing compression stockings. V7 stated night shift had gotten R1 dressed and into the wheelchair. On 11/1/21 at 10:14 AM V9 Licensed Practical Nurse (LPN) changed R1's right lower leg laceration dressing. R1's sutures were intact, and the surrounding skin was red and black. On 11/1/21 at 8:39 AM V6 Agency CNA stated: On the day of R1's injury, V6 transferred R1 from the wheelchair to the bed. V6 locked the wheelchair and pushed the foot pedals to the side. V6 used a gait belt to stand R1 and pivot R1 to the bed. R1 partially stood during the transfer. When V6 lifted R1's legs into bed V6 noticed blood and a cut on R1's leg. R1 was wearing really tight jeans and did not have on compression stockings. R1 is supposed to wear compression stockings, but night shift had already gotten R1 dressed and in the wheelchair that morning. V6 was told that R1 was supposed to be transferred with a full mechanical lift, and V6 should check the resident's care plan or ask a nurse for transfer status prior to transferring a resident. V6 does not work on R1's hallway often, so V6 did not know R1 was to be transferred with a full mechanical lift. V6 was told that R1 bumped R1's leg on part of the wheelchair during the transfer causing the laceration. On 11/1/21 at 12:20 PM V2 Director of Nursing (DON) stated a full mechanical lift for transfers is the new intervention implemented after R1's injury. V2 believes R1's leg hit the wheelchair during the stand and pivot transfer causing the laceration. The CNAs were educated on how to locate the Kardex and resident transfer status, the facility is still adjusting to the new (Electronic Medical Record) system. V3 Assistant DON stated prior to R1's injury at times two staff were used to transfer R1, and staff can always downgrade a resident to use a full mechanical lift if the resident is having difficulty with transfers. V3 stated, I believe we are all on the same page now and (R1) is to use a (full mechanical lift) for transfers. On 11/1/21 at 12:41 PM V2 and V3 confirmed R1's care plan does not document R1's transfer status prior to 10/20/21 when it was updated to use a full mechanical lift for transfers. V2 stated: R1's Care Plan documented to assist with transfers but did not document the amount of assistance R1 needed. The Care plan is where staff look to determine a resident's transfer status. On 11/1/21 at 2:33 PM V11 LPN/Restorative Nurse stated: V11 completes transfer, ADL, and restorative assessments that transfer to the MDS. V11 viewed R1's Restorative Nursing Screener dated 10/6/21 and MDS dated [DATE]. V11 stated at the time V11 completed the evaluation, V11 gathered information from the CNAs. An unidentified CNA told V11 that R1 was substantial/maximal assistance for transfers, which means R1 needed two staff to complete the transfer. V11 stated R1's MDS documents for chair/bed to chair transfer R1 is dependent, which means R1 was totally dependent on staff and a full mechanical lift is used. On 11/1/21 at 2:52 PM V16 Nurse Practitioner stated: R1's right leg laceration would be consistent with R1 bumping R1's leg on the wheelchair during a stand and pivot transfer. R1 had to have a bunch of stitches to close the laceration. Compression stockings would have provided an extra layer of protection for R1's skin. If the facility has the staff, they should be using two staff to transfer R1, and the injury probably could have been avoided. 2. The facility's Final Investigation Report dated 11/1/21 documents: On 10/23/21 at 12:30 PM R3 was observed in another resident's room with blood on R3's clothing. R3 had a cut to the left greater finger and was sent to the local emergency room where R3 received 4 sutures. The lid of R3's toilet was found chipped. Resident (R3) has a history of impulsiveness and is unaware of safety measures. Resident (R3) is believed to have cut (R3's) finger on the toilet lid and walked to other resident's room. The toilet lid was replaced immediately. R3's Hospital Nursing Notes dated 10/23/21 document R3 arrived at the emergency room with a 2 cm (centimeter) laceration to the crease of the left index finger. The laceration was closed with 4 stitches. R3's Diagnosis List dated 11/1/21 documents R3 has diagnoses including [CONDITION(S)], Deaf, and [CONDITION(S)]. R3's MDS dated [DATE] documents R3 has highly impaired hearing and severely impaired vision and requires extensive assistance of one staff person for transfers and walking in R3's room. R3's Care Plan dated 10/21/21 documents: R3 transfers with assistance/supervision of one staff person related to hearing and vision deficits. R3 wanders into other resident rooms looking for a place to go to the bathroom. Redirect R3 back to R3's room, wheelchair, or bed. On 11/1/21 at 10:06 AM R3's left index finger was observed with V9 LPN. There were no stitches in place. V9 stated R3's stitches were removed on 10/31/21. On 11/1/21 at 10:31 AM V17 Maintenance stated: Staff notified V17 last week that R3 had a cracked toilet tank lid. The lid appeared as though it had been dropped and cracked. V17 replaced R3's toilet tank lid the same day it was reported to V17. On 11/1/21 at 10:44 AM V17 stated: V17 was notified on 10/25/21 about R3's cracked toilet lid. Prior to that day, no one had reported to V17 that R3's toilet lid was broken. On 11/11/21 at 10:36 AM V8 CNA stated: V8 found R3 lying in another resident's bed. there was blood all over the room and on the bed. V8 noticed a cut on R3's finger and notified the nurse. On 11/1/21 at 12:45 PM V5 CNA stated: There was a crack to the top of R3's toilet tank lid. V5 was not sure when V5 noticed it. It was there before R3 cut R3's finger on 10/23/21. V5 didn't report the broken toilet lid to anyone. V5 didn't feel any sharp edges. V5 does not work all of the time and V5 thought someone else may have reported it. On 11/1/21 at 3:25 PM V1 Administrator stated: R3 has poor safety awareness and the facility believes R3 cut R3's finger on the top of the toilet tank lid that was cracked. On 11/1/21 at 2:52 PM V16 Nurse Practitioner stated: If the toilet lid was ceramic and cracked, it could have caused R3's cut. It could have been prevented if the CNA (V5) had reported the broken lid to V17 Maintenance. V17 would have prioritized replacing the lid to prevent any potential injury. The CNA dropped the ball on that one. They could have taken another toilet lid from another room to replace the broken one until V17 was notified.

Based on record review, observation and interview the facility failed to secure R32 while R32 was left in bed unattended by direct care nursing staff. This failure resulted in an unwitnessed fall to the floor from an elevated bed, which caused a laceration to R32's left posterior scalp that required emergency medical treatment of [REDACTED]. Findings include: On 3/23/21 at 10:50 am, R32 was positioned in a right side lying, fetal position. R32 was laying on a low-flow air mattress. The mattress was on a bed frame, lowered to 18 inches off the floor. R32 had a speciality call light placed on R32's pillow, five (5) inches from R32's right cheek. R32 had nine staples on the left posterior aspect of his head, two inches behind R32's left ear. R32 stated R32 fell from R32's bed causing the injury to R32's head. R32's speech was garbled as R32 continued to speak unintelligibly. No other details of the fall could be understood from R32. On 3/23/21 at 12:30 pm V2, Director of Nursing (DON) stated (R32) had a reportable (notification requirement to State Agency of a fall with injury) fall on 3/18/21 and an investigation is in progress. V2 also stated We (the facility) added a new fall intervention immediately to maintain (R32's) bed in the lowest position. R32's Minimum Data Set ((MDS) dated [DATE] documents R32 has a Brief Interview Of Mental Status score of 2 out of 15 (severe cognitive impairment). The same MDS documents R32 is totally dependent on physical staff assistance with bed mobility, transfers, personal hygiene, locomotion on and off unit via wheel chair and does not ambulate. The same MDS documents R32's primary [DIAGNOSES REDACTED]. The same MDS documents R32 has one, unhealed Stage IV Pressure Ulcer and has a pressure reducing device on R32's bed and chair. R32's Nurse Progress Note dated 3/18/21 at 4:51 pm, signed by V11 Registered Nurse (RN) documents the following: RN (V11,) called by the CNA (Certified Nursing Assistant, V12) stating that resident (R32) is on the floor, upon getting to the resident's room, resident noted on the floor, lying on his left side, and facing his (R32's) bed, and moderate amount of bloody drainage noted under resident's head. Resident is not able to give a full description of what he was doing prior to the incident, spinal alignment maintained and resident turned to his right side, resident noted to have a 7 cm (seven centimeter) moderately deep laceration to his (R32's) left occipital, resident denied pain to the site, site cleansed with soap and water and pressure dressing applied to site, and bleeding controlled. pupils PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation), resident did not lose consciousness, resident denied headache and/or dizziness, MD (Physician, unidentified) called with assessment findings and notified of incident, and resident transferred to the ED (Emergency Department) at (regional hospital) for eval (evaluation) and treatment, resident's POA (Power of Attorney, unidentified)called and notified of incident per protocol (fall) , DON (V2, Director of Nursing) and administrator (V1, Administrator) notified of incident (R32's Fall) per facility protocol, EMTs (Emergency Medical Technician's) called and resident transferred to the ED. will follow-up. R32's Safety Events-Fall Incident-Accident Event/ Report dated 3/18/21 document the following Diagnoses: [REDACTED]. The same Safety Events-Fall Incident-Accident Event/ Report documents R32 had an unwitnessed fall at 4:45 pm. The same report documents Description of the fall incident: Resident found lying on the floor in his room facing his bed, and on his left side. R32's (local acute care) Medical Center, After Visit Summary Report dated 3/18/21 documents the following: Reason for (the) Visit, [MEDICAL CONDITION]. [DIAGNOSES REDACTED].* Laceration of scalp, initial encounter. Imaging Tests, CT (computed axial tomography) brain including bone windows for trauma, (and) CT cervical spine without contrast. Done Today, Laceration Repair. R32's Care Plan dated 3/2/21 documents the following fall intervention updated on 3/18/21 (the same date of R32's unwitnessed fall with injury): Category: Falls, (R32) is at risk for falls and injuries related to ID (Intellectual Disability), impaired mobility, incontinence, [MEDICAL CONDITION] d/o (disorder) and medication use. He has a history of falls. Long Term Goal Target Date: 02/18/2021 ( typo, 5/18/21 per updated categories on the same care plan) Falls and significant injuries will be minimized through (by) interventions through next review date. Approach Start Date: 03/18/2021 (same day as R32's fall with injury) Keep bed in lowest position. Nursing (discipline responsibility). On 3/24/21 at 2:20 pm, V3, RN / Assistant Director of Nursing (ADON) / Wound Nurse, and V9, CNA entered R32's room to provide R32's incontinence care and wound care. V9, CNA raised R32's bed level up to three feet off the floor to perform incontinence care. R32 laid on a low-flow air mattress. V3 and V9 provided total assistance to repositioning R32 in bed. R32 was repositioned from a right side lying position to R32's back, then to a back lying position onto R32's left side position. R32 did not assist with repositioning. After V9 provided incontinence care and V3 provided pressure ulcer treatment, V3 cleansed R32's left posterior occipital region wound. R32 had nine staples present that closed the left posterior scalp wound. While V3 cleansed the wound, R32 stated he had a fall from bed. R32's also stated My bed was way off the floor. V3 stated R32's scalp staples were due to R32's fall on 3/18/21. V3, RN/ADON/Wound Nurse, V9, CNA and R32 confirmed R32 can not move himself in bed. V3 also stated (R32) has the low air- flow mattress that shifts according to (R32's) weight, because (R32) has history of pressure ulcers and can't position himself in bed. On 3/24/21 at 2:45 V12, CNA stated the following: I (V12) was providing (R32's) care when (R32) fell and hit his (R32) head 3/18/21. V12, CNA also stated I was getting (R32) up for supper. I got him (R32) all cleaned up and dressed and (then) left him for a few seconds to get the (mechanical lift) sling. The (mechanical lift) sling was in the hall, on the railing. I got the sling and told (V10, CNA) that I (V12, CNA) needed help transferring (R32). In those few seconds, (R32) had fallen to the floor from (R32's) bed. The bed was up off the floor about two and a half or three feet. The bed was up because I had been providing his incontinence care and getting him dressed and so I could transfer (R32) by (mechanical lift). I (V12) should have put the bed down all the way in the lowest position before I (V12) left (R32's) room. (R32) can't really move on his own. I (V12) may have had him (R32) off center in his bed. I don't know how his weight shifted. I (V12) feel really bad that he (R32) fell . On 3/25/21 9:00 am, V2, Director of Nursing stated the following: I completed the fall investigation for (R32's) fall 3/18/21. The root cause of (R32's) fall was that (R32) was too close to the edge of the bed when the CNA (V12) left the room, leaving (R32) unattended with (R32's) bed still in the elevated position after (R32's) cares had been provided. (R32) has a birth anomaly with a larger than normal head. (R32) does move his head back and forth and must have shifted his weight enough, resulting in (R32's) fall with injury.

Based on observation, interview, and record review the facility failed to provide supervision as outlined in R1's plan of care and failed to initiate targeted resident centered interventions to prevent falls for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in R1 sustaining a dislocated right shoulder and a fractured right humeral head. Findings include: R1's physician's orders [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 is severely cognitively impaired and not able to communicate verbally. R1's most recent Fall Risk assessment dated [DATE] documents that R1 is at high risk for falls due to history of one or more previous falls, takes high fall risk drugs, has an unsteady gait, and lack of understanding of R1's own physical and cognitive limitations. R1's 4-20-19 Care Plan lists a problem statement related to potential for falls and injuries related to disease process of [MEDICAL CONDITION], weakness, incontinence, unsteady gait/balance, and medication use. One intervention listed includes to keep resident in supervised area while awake. R1's Care Plan entry dated 4/20/19 documents (R1) has limitation in transfer ability related to weakness, unsteady balance and severe Intellectual Delay. (R1) has been noted transferring himself to/from bed, wheelchair and recliner without assist from staff. (R1) has impaired safety awareness and not easily redirected. A progress note for R1 dated 5-29-19 3:30 p.m. documents R1 is unsteady and leans forward when walking, that R1 is constantly walking and wandering on the unit, and that R1 does not follow directions. A progress note for R1 dated 5-29-19 11:40 p.m. states that R1 needs 1:1 (one to one) supervision, that R1 wanders about the facility ad lib into inappropriate areas, and that R1 needs close supervision. R1's Medication Administration Record [REDACTED]. On 7/2/19 at 3:00PM V2, Director of Nurses verbalized Any resident who is given a PRN [MEDICATION NAME] should be monitored for side effects. V2 stated that a side effect associated with [MEDICATION NAME] is increased risk of falls. The manufacurers package insert for [MEDICATION NAME] states The most common side effects of [MEDICATION NAME] include: sedation, dizziness, weakness, unsteadiness. R1's progress note by V6, Licensed Practical Nurse (LPN) dated 06/22/2019 at 02:05 AM Documents (V6) walked behind the resident (R1) on South East hallway when (R1) fell . (R1) was out of reach to prevent this fall. The progress note goes on to document that following the fall R1 was placed in the recliner chair in the East hall living room, with no other interventions documented. R1's next progress note by V6, Licensed Practical Nurse (LPN) dated 06/22/2019 at 02:09 AM (4 minutes following R1's fall) documents (R4) called for help, went to the room and observed (R1) sitting on floor by the (R4's) recliner. R1's progress note by V7, Licensed Practical Nurse (LPN) dated 06/23/2019 at 09:18 PM documents During HS (evening) care, CNA alerted (V7) to a bruise to the anterior right shoulder. (R1) assessed; dark red, with light purple bruising noted to anterior and posterior right shoulder. (R1) had decreased ROM to right shoulder and appeared to be guarding right arm. Increased swelling also noted to right arm. (V8, Medical Doctor) paged. Upon return call (V8) gave orders for (R1) to be sent to ED (Emergency Department) for evaluation and treatment. R1's progress note by V9, Licensed Practical Nurse (LPN) dated 06/24/2019 at 01:43 AM documents (R1) returned to facility via ambulance transport from (Local hospital) . Returned with [DIAGNOSES REDACTED]. Returned with orders to call (V10) Medical Doctor in 2 days for Orthopedic follow up. Currently resident is alert, non-verbal, but if shoulder is touched resident will lean more to that side. ER (emergency room ) nurse also endorsed that resident is sedated from medication given at ER. (R1) also is wearing a shoulder immobilizer. On 7/2/19 V9 Licensed Practical Nurse stated I do remember readmitting (R1) after (R1's) right shoulder dislocation. (R1) had an immobilizer on. (R1) kept pulling at it, so we left it off. I'm not sure where the brace went. I haven't seen it since that day. R1's Care Plan entry dated 06/24/2019 documents (R1) required to wear a sling on his right arm r/t (related to) a recent shoulder dislocation. R1's progress note by V11, Registered Nurse (RN) dated 06/25/2019 at 02:45 PM states (R1) right arm continues to have hard non-[MEDICAL CONDITION], with warmth, and resident has become guarded with extremity. NP (Nurse Practitioner) here to evaluate and ordered resident be sent back to (local hospital) ED (Emergency Department) for further evaluate to rule out [DIAGNOSES REDACTED]. R1's progress note by V11, Registered Nurse (RN) dated 06/25/2019 at 07:36 PM documents (R1) admitted to (local hospital) due to blood clot to the right arm. On 7/1/19 at 9:30AM and 2:45PM and on 7/2/19 at 9:00AM, 1:40PM, and 3:00PM R1 was in the common area sitting in recliner. Other residents were present in the common area, but staff were not in visual control of R1. R1 did not have an immobilizer present to right shoulder as ordered. R1's hospital history and physical dated 6/25/19 by V12, Nurse Practitioner documents (R1) suffered a right anterior shoulder dislocation on 6/23/19 and was subsequently brought to the Emergency Department. The dislocation was reduced and repeat imaging indicated a proximal humeral head fracture. Patient was discharged back to the nursing home with a shoulder immobilizer. Patient has not been wearing shoulder immobilizer at the nursing home and was brought in for swelling of the right upper extremity. Subsequent exam and ultrasound revealed and confirmed the deep venous thrombus of the right brachial vein. On 7/2/19 at 1:40PM V12, Nurse Practitioner stated (R1's) right shoulder dislocation and humeral head fracture is consistent with the two falls 6/22/19 at the facility. It is highly likely the Deep Venous Thrombus ([MEDICAL CONDITION]) to (R1's) right brachial vein was also a consequence of the right shoulder injury. The [MEDICAL CONDITION] required inpatient hospitalization to treat. The lack of immobilization as ordered in the Emergency Department but not followed by the nursing home would have caused increased pain and increased likelihood of complications such as the [MEDICAL CONDITION]. On 7/2/19 at 3:00PM V2, Director of Nurses stated (R1) came back to the facility with an immobilizer in place 6/23/19. I think (R1) kept taking it off. The transfer sheet from the hospital stated (R1) had an immobilizer. Maybe since it was documented in the discharge sheet from the hospital we didn't realize it was a physician's orders [REDACTED]. The facility's policy Falls and Fall Risk Managing revised 12/07 states If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on interview and record review the facility failed to administer [MEDICAL CONDITION] medications as ordered for one resident (R1). This failure resulted in R1 experiencing [MEDICAL CONDITION] for three days and being hospitalized in the Intensive Care Unit with uncontrolled [MEDICAL CONDITION]. The facility also failed to give an IV (intravenous) antibiotic as ordered for R1. R1 was one of three residents reviewed for medications in the sample of three. Findings include: The facility's Controlled Substance Prescriptions policy dated 10/25/14 documents, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. This policy also documents, New Controlled Substance Prescriptions: For emergency controlled substance orders, the nurse will review the Emergency Kit list for available medications prior to contacting the prescriber. The nurse will communicate to the prescriber the emergency medication available to provide appropriate care to the patient. This policy goes on to document, If the medication is not available in the emergency kit, the nurse contacts the pharmacy using the after-hours emergency number(s) if necessary.Also, Emergency/STAT (immediate) Medication order (Medication not contained in Emergency Medication Supply). a. An emergency/STAT order is placed and validated with (pharmacy provider) and the medication is scheduled to be given as soon as received or within four (4) hours, whichever is sooner. Subsequent doses are scheduled according to facility policy. The facility's Admission Criteria policy dated (MONTH) 2012 documents, Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: a. type of diet, b. medication orders, c. routine care orders. The facility's Medication Error Event for R1 with a recorded date of 3/20/19 documents, R1 admitted to the facility with orders for [MEDICATION NAME] (anticonvulsant/controlled substance) and Onfi (benzodiazepine used to treat [MEDICAL CONDITION]/controlled substance) which both require a prescription. Scripts (prescriptions) were not (obtained) (R1) did not receive (R1's) medication. This report documents the error began on 3/16/19 and ended on 3/18/19. According to R1's Resident Face Sheet, R1 was admitted to the facility on [DATE] at 5:59 PM. R1's Medication Administration History dated 3/1/19 through 3/25/19 documents R1 received one medication on 3/15/19 which was calcium. No other medications were given on 3/15/19. This Administration History documents R1 was admitted with [DIAGNOSES REDACTED]. R1's POS dated 2/25/19 through 3/25/19 documents orders for Onfi tablet 20mg (milligrams), two tablets twice a day at 8:00 AM and 8:00 PM and [MEDICATION NAME] 150mg two tablets twice a day at 8:00 AM and 6:00 PM. The order start date for these medications is 3/16/19. R1 was admitted to the facility on [DATE]. The medications were ordered on discharge from the hospital on [DATE]. R1's Medication Administration History dated 3/1/19 to 3/25/19 documents: Onfi 20 mg(milligram) give two tablets twice a day was not given on 3/15/19, 3/16/19, 3/17/19, or 3/18/19 with the reason documented on the Medication Administration History as drug/item unavailable; [MEDICATION NAME] 150 mg give two tablets twice a day was not given on 3/15/19 at 6:00 PM, on 3/16/19 and 3/17/19 at 8:00 AM and 6:00 PM and on 3/18/19 at 8:00 AM with the reason documented as drug/item unavailable. R1's Nurses Progress Note dated 3/16/19 at 12:24 PM by V3 Registered Nurse (RN) documents, X (times) 2 1 minute [MEDICAL CONDITION] noted during the shift. R1's Nurses Progress Note dated 3/17/19 at 10:51 AM by V5 documents, (R1) had [MEDICAL CONDITION] episode while in w/c (wheelchair) by the nurses station for about 2 (minutes). R1's Nurses Progress Note dated 3/17/19 at 10:48 PM by V18 LPN documents, (R1) had 3 [MEDICAL CONDITION] between 4:30p(PM)-5:30p. R1's Nurses Progress Note dated 3/18/19 at 8:30 AM by V6 Assistant Director of Nursing documents, Called MD (Medical Doctor) office regarding narcotic script request and asked if MD had received them. Secretary stated they were sorting through 50 (plus) faxes they had received over the weekend. Reported to secretary that (R1) was having [MEDICAL CONDITION] and it was very important that MD signs and faxes the narc (narcotic) scripts back ASAP (as soon as possible). She stated she would get them over as soon as she could and that MD wasn't going to be in the office until 10:45 AM. R1's Nurses Progress Note dated 3/18/19 at 1:02 PM by V7 Registered Nurse documents, Several attempts made to contact (V4) (R1's facility Physician) regarding (R1's) change in condition, no call back as of yet. VS (vital signs) are as follows BP (blood pressure) 98/71, HR (heart rate) 80, RR (respiratory rate) 16, T (temperature) 97.9. No oral intake tolerated, (R1) unable to eat or be assessed by ST (speech therapy). (R1) has had several [MEDICAL CONDITION] throughout shift. This note also documents, Messages left for (V4). (R1) has been sent to the (hospital) via ambulance. R1's Nurses Progress Note dated 3/18/19 at 1:33 PM by V7 documents, Spoke to (V4) on telephone regarding (R1's) [MEDICATION NAME] and Onfi orders. (V4) stated that (V4) is not comfortable signing for said medication because they are not (V4's) orders. Orders originally given per (hospital physician) prior to admission to this facility. R1's Nurses Progress Note dated 3/18/19 at 2:26 PM by V7 documents, (Hospital) called to verify that (R1) has not received [MEDICATION NAME] or Onfi medications since (R1's) arrival. (R1) was admitted to this facility from the (hospital) without the hard copy for those medications and this facility was unable to obtain said medications. R1's Emergency Department Course/Medical Decision Making documentation dated 3/18/19 at 1:53 PM by V12 hospital Physician, documents, It has been found that (R1) has not had any of (R1's) IV (intravenous) antibiotics or [MEDICAL CONDITION] medication for at least the last 48 to 72 hours. At this time, (R1) requires (R1's) medication to get (R1's) [MEDICAL CONDITION] under control and make sure (R1's) infection is under control. R1's Nurses Progress Note dated 3/18/19 at 2:26 PM by V7 Registered Nurse (RN) documents, (Hospital) called to verify that (R1) has not received ([MEDICATION NAME]) or Onfi medications since (R1's) arrival. (R1) was admitted to this facility from (Hospital) without the hard copy for those medications and this facility was unable to obtain said medications. This writer (V7) notified RN calling from ED (Emergency Department) of this situation. R1's hospital History and Physical dated 3/19/19 at 9:39 AM by V13 hospital Physician documents, Apparently over the weekend (R1) could not get (R1's) [MEDICAL CONDITION] medication so (R1) started having [MEDICAL CONDITION] yesterday at the (nursing facility) so (R1) was sent to the emergency room and was admitted to the floor. (R1) was transferred to ICU (Intensive Care Unit) where (R1) has been intubated, having IV (intravenous) sedatives also. R1's EEG (Electroencephalogram) dated 3/19/19 by V14 hospital Physician documents, This is a very abnormal EEG in the sedated state. There is presence of eight electrographic [MEDICAL CONDITION] at least one of which was subclinical the others being convulsive in nature. This represents [DIAGNOSES REDACTED]. This also documents, (R1) needs continuous EEG, have to transfer to (a larger hospital). On 3/25/19 at 10:55 AM, V3 Registered Nurse stated the hospital is supposed to send paper scripts with the resident but the hospital did not send them with R1 for the Onfi and [MEDICATION NAME]. V3 stated V3 did not contact the hospital for the written scripts. V3 stated that V3 faxed V4 R1's Physician for written scripts for the Onfi and [MEDICATION NAME] but did not get a reply from V4. On 3/25/19 at 11:15 AM, V2 Director of Nursing stated they have to have medication orders to the pharmacy by 10:00 PM to receive the medications at the 5:00 AM delivery time. They have some back up medications in the facility but V2 stated V2 is unaware if R1's medications were in the back up supply. V2 stated they can use the facility's pharmacy for back up for stat (immediate) orders and get them with in four hours. V2 confirmed R1 did not admit with the needed prescriptions from the hospital and it is their practice that the nurse admitting the resident should contact the hospital discharging the resident to get the needed prescriptions. V2 confirmed there is no documentation that anyone contacted the discharging hospital for the needed prescriptions for R1. V2 stated that V4 R1's Physician can take awhile to return their phone calls. V2 stated the hospitals are good about sending admissions on Fridays after 6:00 PM and it is difficult to get medications at that time. On 3/25/19 at 12:24 PM V5 Licensed Practical Nurse (LPN) stated V5 did not contact the hospital regarding the prescriptions since V6 entered the medication orders. On 3/25/19 at 1:47 PM, V6 Assistant Director of Nursing stated V6 assisted with R1's admission from V6's home. V6 stated V6 entered R1's medications into the computer. V6 stated after the medications were entered V6 notified V5 LPN through text messaging that R1's medications were in the computer and V5 needed to fax them to the pharmacy. V6 confirmed the nurse should have contacted the hospital where R1 was discharged regarding the paper prescriptions for the Onfi and [MEDICATION NAME]. V6 stated, unfortunately calling V4 on Friday at 6:00 or 7:00 PM is not the easiest time to get ahold of V4. On 3/26/19 at 2:45 PM, V17 Pharmacist confirmed by R1 not receiving the [MEDICAL CONDITION] medications, Onfi and [MEDICATION NAME], that could've caused R1 to have [MEDICAL CONDITION]. V17 stated [MEDICATION NAME]'s half life (the time it takes for half the medication to be metabolized and eliminated from the blood stream) is 10.6 to 13 hours depending on the residents weight. V17 stated the half life of Onfi is 36 hours. V17 confirmed they have trouble getting paper prescriptions from Physicians over the weekends. V17 stated [MEDICATION NAME] and Onfi are controlled substances and require a script but V17 stated the Physician could have given them a verbal order for these two medications due to their class. V17 stated if the pharmacy had received the verbal order from the Physician or written script for the Onfi and Vampit and the nurse would have called them for a stat order, the pharmacy could have sent the medications within 4 hours. The manufacturer's information provided by the pharmacy printed 3/26/19 for [MEDICATION NAME] documents the Discontinuation of therapy: As with all AEDs (Antiepileptic drugs), gradually withdraw lacosamide ([MEDICATION NAME]) over a minimum of 1 week to minimize the potential of increased [MEDICAL CONDITION] frequency in patients with [MEDICAL CONDITION] disorders. The manufacturer's information provided by the pharmacy printed 3/26/19 for Onfi documents the Discontinuation of therapy: Withdraw gradually by decreasing the total daily dosage by 5 to 10 mg/day on a weekly basis until discontinued. On 3/25/19 V2 Director of Nursing provided an addendum to R1's medication error dated 3/20/19 which documents, Please refer to med (medication) error created on 3/20/19. In addition to meds (medications) mentioned add [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (hormone for the [MEDICAL CONDITION]). This addendum was signed by V2. R1's POS dated 2/25/19 through 3/25/19 documents orders for [MEDICATION NAME] 150mcg (micrograms) one tablet orally once a day at 5:00 AM and [MEDICATION NAME] (antibiotic) reconstituted solution 4.5 grams Intravenously every six hours at 8:00 AM, 2:00 PM, 8:00 PM and 2:00 AM. The order start date for these medications is 3/16/19. R1 was admitted to the facility on [DATE]. The medications were ordered on discharge from the hospital on [DATE]. R1's Nurses Progress Notes dated 3/15/19 at 6:00 PM by V5 Licensed Practical Nurse (LPN) documents R1 was admitted to the facility from the hospital and R1 had a PICC (Peripherally Inserted Central Catheter) line to the left arm, intact and patent. R1's Medication Administration History dated 3/1/19 to 3/25/19 documents [MEDICATION NAME] 150 mcg (micrograms) give one tablet once a day was not given on 3/16/19 or 3/17/19 with the reason documented on the Medication Administration History as drug/item unavailable; [MEDICATION NAME] 4.5 gram intravenous every six hours was not given on 3/15/19 at 8:00 PM, 3/16/19 at 2:00 AM, 8:00 AM, 2:00 PM, 8:00 PM, 3/17/19 at 2:00 AM, 8:00 AM, 2:00 PM, 8:00 PM, 3/18/19 at 2:00 AM, 8:00 AM, 2:00 PM with the reasons documented on the Medication Administration History as drug/item unavailable and intravenous site unavailable R1's Nurses Progress Note dated 3/15/19 at 6:00 PM by V5 LPN documents, Has Picc line to left arm, intact and patent. Dressing to left chest, intact, dry and clean. On IV (intravenous) ABX (antibiotics) (due) to left chest wound infection. R1's Progress Note dated 3/16/19 at 12:24 PM by V3 RN (Registered Nurse) documents, RN contacted MD (Medical Doctor) due to resident not having an access site for IV antibiotics, MD gave a telephone order to send resident to the (hospital) [MEDICATION NAME] radiology department for PICC insertion, upon contacting the (hospital), RN was notified by operator that IR ([MEDICATION NAME] radiology) is only open (until) noon on the weekends and to call IR and leave message. R1's Emergency Department Course/Medical Decision Making documentation dated 3/18/19 at 1:53 PM by V12 documents R1 did not have any of R1's IV antibiotic medication for at least 48 to 72 hours and R1 requires that medication to make sure R1's infection is under control. On 3/25/19 at 10:55 AM, V3 RN stated according to R1's medical record R1 admitted with a PICC line but it was not there when V3 completed R1's assessments on 3/16/19. V3 stated no one knew what happened to the access site. On 3/25/19 at 11:15 AM, V2 Director of Nursing stated R1 had a PICC line on admission but it was gone in the morning on 3/16/19 and no one knew what happened to it. On 3/25/19 at 12:24 PM, V5 Licensed Practical Nurse (LPN) stated R1 had a PICC line when R1 admitted to the facility on [DATE]. V5 stated V5 assisted with R1's shower and saw the PICC line then. V5 stated V6 Assistant Director of Nursing assisted V5 with the admission and V6 put the medications in the system so V6 should've faxed them to the pharmacy and V6 should've known R1 needed to receive the IV meds at 2:00 AM. V5 stated R1's [MEDICATION NAME] (antibiotic) was Intravenous and V5 had no idea how the PICC line was gone on 3/17/19. On 3/25/19 at 1:47 PM, V6 Assistant Director of Nursing stated V6 knew R1 had an IV (intravenous) ordered but no one notified V6 that there was no Registered Nurses available at the facility to administer the IV. On 3/27/19 at 9:55 AM, V4 R1's Physician stated if the hospital started the IV antibiotic the facility should have continued it. V4 stated the hospital should have sent paper prescriptions with R1. If they did not then the facility should have followed up with the hospital to get those prescriptions. V4 stated that R1 not receiving the Onfi and [MEDICATION NAME] could have caused R1 to have [MEDICAL CONDITION]. V4 stated if R1 would have gotten the anticonvulsant medications R1 probably would have been fine.

Based on interview, record review, and observation the facility failed to transfer resident with two assist and failed to monitor resident while on the toilet for one resident (R7) of three residents reviewed for falls in the sample of 11. This failure resulted in R7 receiving 11 sutures to R7's left forehead. Findings include: R7's Progress Note dated 5/31/18 at 5:59 PM, documents R7 returned from the hospital with 11 sutures to the facial laceration. The facility's Serious Injury Incident Report dated 5/31/18 documents R7 was on the toilet in the West/North hallway shower room and leaned forward and fell hitting R7's forehead. In this Incident report, V9 Certified Nursing Assistant (CNA) stated V9 was with R7 but could not get to Ry before R7 fell . R7's Restorative Nursing - ADL (Activities of Daily Living) Skills Analysis dated 5/1/18 documents R7 requires extensive assistance of two person for toileting. R7's Minimum Data Set ((MDS) dated [DATE] documents R7 requires full staff performance by two plus staff for toileting. R7's Care Plan dated 2/6/18 documents R7 requires extensive assistance of one staff and has not been updated since 2/6/18. R7's Fall Risk assessment dated [DATE] documents R7 is at high risk for falls. R7's Hospital Patient Care Summary dated 5/31/18 documents R7's Discharge [DIAGNOSES REDACTED]. This Summary also documents to remove sutures in eight days. On 6/4/18 at 4:30 PM, R7 was in R7's room in wheelchair. R7 had several sutures on R7's left forehead. The sutured laceration was approximately two inches long. On 6/5/18 at 9:08 AM, R11 stated R11 was headed to the bathroom when R11 saw V9 (CNA) take R7 to the bathroom in the hall and leave R7 in there. R11's MDS dated [DATE] documents R11 is cognitively intact. On 6/5/18 at 10:50 AM, V9 stated R7 was in the dining yelling that R7 needed to go to the bathroom so V9 took R7 to the shower room closest to the dining room. V9 first stated she took washcloths in the bathroom with her but then V9 stated she got washcloths out of a cabinet in the shower room. V9 stated she was with R7 when R7 fell and V9 stated she never left the bathroom/shower room while R7 was on the toilet. On 6/5/18 at 11:27 AM, V10 Registered Nurse (RN) stated V10 was informed by staff that R7 had fallen in the bathroom and she immediately went to assess R7. V10 stated V11 told her V11 was at the sink talking to R7 when R7 leaned over and fell off the toilet. V10 stated she did not see anything, it was just reported to her. On 6/5/18 at 2:28 PM, V2 (Director or Nursing) stated V9 should have followed whatever R7 was assessed at for transfers. If R7 was assessed as a two person transfer and toileting then there should have been two staff with R7. On 6/5/18 at 3:00 PM, V1 (Administrator) stated there was no reason to doubt V9's statement that V9 did not leave R7 alone in the bathroom. On 6/5/18 at 3:45 PM, V1 stated she watch the camera surveillance of the date and time of the fall and V9 did leave R7 alone in the bathroom. V1 is unsure why V9 left R7 in the bathroom or why V9 lied about being in the bathroom. V1 stated V9 should have never left R7 alone in the bathroom. On 6/6/18 at 1:18 PM, V13, (R7's Physician) stated if R7 was supposed to have more assistance then R7 should have had more assistance to help prevent falls.

Based on observation, interview and record review, the facility failed to complete skin risk assessments upon admission and implement appropriate interventions to prevent pressure ulcers, failed to complete pressure ulcer measurements and wound assessments upon admission and development of a pressure ulcer, failed to complete wound treatments as ordered treatments and failed to assess nutritional requirements upon pressure ulcer development for two of three residents( R1, R3) reviewed for pressure ulcers in the sample of 10. These failures resulted in R3's stage II pressure ulcer deteriorating to a stage IV pressure ulcer within one week. Findings Include: The facility undated Prevention of Pressure Ulcer Policy documents assess for any special needs of the resident; a special mattress, foam/gel/aircushion to relieve pressure, position changes every two hours or as needed. This policy also documents that for residents with poor nutrition, the Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment, notify the physician and monitor laboratory values, talk to physician and dietician about supplements. Administer vitamins, mineral and protein supplements in accordance with recommendations. The facility undated Assessment to be completed upon admission and readmission documents the following will be completed upon admission and readmission: Full Body Assessment with vitals, Skin Risk Assessment and if applicable, a Wound Assessment including measurements then clean and redress the wound. The facility Decubitus Care/Pressure Area Policy documents this policy is to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcers, once identified. This policy also documents the pressure area will be assessed and all areas of a wound assessment should be completed: size, stage, site, depth, drainage, color, odor, and treatment, upon identification and that nursing personnel are to notify dietary personnel of any pressure area to seek nutritional support and monthly reviews by the Registered Dietician. 1.) R3's undated face sheet documents R3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R3's MDS (Minimum Data Set) dated 2/22/18 documents R3 is alert and oriented and requires extensive assistance with bed mobility and transfers. R3's Skin Risk assessment dated [DATE] documents R3 is at risk for skin breakdown. R3's Care Plan dated 12/6/17 documents R3 is at risk for pressure ulcers related to generalized muscle weakness and decreased mobility and is to use a pressure relieving mattress for pressure reduction when in bed. On 5/16/18 at 9:35 am, 11:40 am and 2:10 pm, R3 was lying in bed on a regular mattress, not a pressure reducing mattress as care planned, with a pillow under R3's hip and buttock. R3's Progress Notes document the following: 12/8/17 - 12/22/17 - R3 has a poor appetite and refuses meals. 1/9/18 - R3 has a pinpoint opening on coccyx. There is no wound assessment or measurements of this pinpoint opening on the coccyx. 1/12/18 - R3 was in the dining room for breakfast but stated R3 was not hungry and left without eating. There is no documentation in R3's medical record on the size or condition of the wound from 1/9/18 until 1/17/18. This Progress Note documents, V4 Physician notified of R3's stage IV to mid sacrum, treatment being initiated, V5 Wound Physician to see R3, and a new order for a liquid protein supplement with added vitamins and minerals for advanced wound healing was received. This 1/17/18 Progress Noted also documents that V16 Dietary Manager messaged RD (Registered Dietician) r/t {related to} recommendations for open area, {8 days after the wound developed}. R3's Wound History Report documents the first measurement of a Mid Sacrum stage IV Pressure Ulcer on 1/19/18 that measures 3.0 cm (centimeters) in length by 1.5 cm in width by 1.5 cm in depth. On 5/21/18 at 1:40 pm, V6 LPN (Licensed Practical Nurse) / Wound Nurse stated the mid sacrum wound, on the History Report, is the same wound that was documented on as the coccyx, in the Progress Notes. V6 stated V6 remembered seeing R3's wound initially and that it was pinpoint and that the 1/17/18 measurement, on the History Report, is the first time measurements were documented {8 days after the wound developed} and that the wound deteriorated from a stage II to a stage IV and increased in size during those eight days. R3's (MONTH) (YEAR) POR (Physician order [REDACTED]. R3's (MONTH) (YEAR) TAR (Treatment Administration Record) documents the order for the Barrier Cream but there is no documentation that the treatment was initiated as this treatment was never signed off as being completed. R3's Progress Notes document the following: 1/20/18 - R3 had a change in condition, is lethargic and hard to arouse. Order received to send R3 to the emergency room . 1/21//18 - R3 has been admitted to ICU (Intensive Care Unit) with a [DIAGNOSES REDACTED]. The Hospital Course Summary dated 2/10/18 documents: R3 was admitted to the hospital with [REDACTED]. R3 was found to have polymicrobial bacteremia with a source relating to {R3's} infected decubitus ulcer. R3 had visible speculated bone to {R3s} coccyx. Therefore, {R3} had osteo[DIAGNOSES REDACTED]. R3's Progress Notes document R3 returned to the facility on [DATE]. The Wound History Report documents the first time R3's Mid Sacrum wound was measured and assessed, post hospitalization , was on 2/16/18 {6 days after re-admission to the facility}and was a stage IV pressure ulcer measuring 8.5 cm by 7.0 cm by 3.0 cm. On 5/21/18 at 1:40 pm, V6 LPN / Wound Nurse stated R3 has never been able to reposition R3. V6 also stated that since R3's wound treatment order was not signed off as being completed back in January,during the time that the wound deteriorated from a stage II to a stage IV, it is hard to tell if it was done or not. V6 stated that when wounds start to deteriorate, the floor staff is to tell V6 so that V6 can get V5 Wound Physician to see the resident. V6 stated V6 could not recall if staff alerted V6 to R3's deteriorating wound or not. V6 stated that residents with a stage IV pressure ulcer usually get put on a low air loss mattress and confirmed that R3 had a regular mattress, not an air mattress. On 5/21/18 at 1:50 pm, R3 was lying in bed with a pillow under her hip and buttock. R3 stated, I {R3} have never had an air mattress but I wish I did. This bed has springs that poke my bottom, that's why I'm laying on this pillow. It's more comfortable this way. R3 stated R3 can not remember if staff were putting the ordered cream on open area before she was admitted to the hospital. On 5/21/18 at 2:00 pm, V7 RN (Registered Nurse) who works with R3 stated, V7 remembers doing a treatment of [REDACTED]. On 5/21/18 at 2:55 pm, V4 Physician stated, facility should have completed the ordered treatment and notified V4 about the wound getting worse, before it deteriorated to a stage IV. V4 stated that with R3 being at risk for breakdown, the facility should have taken extra precautions like having R3 on an air mattress. V4 also stated hydration and nutrition are important for skin healing and R3 should have been see by an RD for recommendations. Prevention is key. If a resident is at risk {for breakdown}, skin should be checked all the time and they need to be turned frequently. I {V4} am very aggressive when it comes to wounds, even if they are very small. If I was aware of this getting worse, I would have ordered for (V5) to see (R3), before V4 did. On 5/21/18 at 4:00 pm, V3 ADON (Assistant Director of Nursing) stated that R3 was not seen by V5, for the sacral wound, until after returning from the hospital. 2.) R1's Nursing Progress Notes document R1 was admitted to the facility on [DATE] with a surgical site to the left hip, an open area on the coccyx and several open areas to bilateral feet. There is no wound assessments or measurements documented in the progress notes or on the admission assessment. R1's Skin Risk Assessment completed on 3/7/18 documents R1 is at moderate risk for skin breakdown. The facility provided a Wound History Report for all of R1's wounds by V6 LPN (Licensed Practical Nurse) / Wound Nurse that documents the following : Right heel Deep Tissue Pressure Injury wound was first measured on 3/9/18 (3 days after admission) and measured 3.0 cm (centimeters) in length by 2.0 cm in width by 0 cm in depth. Mid Sacrum, a stage III Pressure Wound, was first measure on 3/16/18 (10 days after admission) and measured 0.5 cm by 0.6 cm by 0.1 cm. Medial Plantar Top of Right Foot, stage II Pressure Wound, was first measured on 3/6/18 (3 days after admission) and measured 3 cm by 1.5 cm by 0.1 cm. Right Achilles Wound, stage II Pressure Wound, was first measured on 3/16/18 (10 days after admission) and measured 1.7 cm by 0.6 cm by 0 cm. Left Medial Ankle, stage II Pressure Wound, was first measured on 3/9/18 (3 days after admission) and measured 1.0 cm by 2.0 cm by 0.1 cm. Left Metatarsal, stage III Pressure Wound, was first measured on 3/9/18 (3 days after admission) and measured 2.5 cm by 1.5 cm by 0.2 cm. R1's Care Plan dated 3/12/18 documents R1 was admitted to the facility with pressure ulcers related to a displaced fractured left femur and that R1 should have a pressure relieving mattress on the bed. On 5/16/18 at 10:15 am, R1 was lying in a bed that had a regular mattress. On 5/21/18 at 2:05 pm, V3 ADON (Assistant Director of Nursing) stated, when a resident has a stage III or stage IV wound, they are placed on an air mattress to help with their wounds. V3 confirmed that R1 did not have an air mattress.

Based on interview and record review the facility failed to notify the physician for a change of condition for one of three residents (R12) reviewed for change in condition in the sample of 15. This resulted in R12 being admitted to the hospital unresponsive with a temperature of 105 degrees Fahrenheit and [DIAGNOSES REDACTED]. Findings include: On 7/13/2017 at 10:20AM, Z5 (R12's Physician) stated I was not notified of the temperature until I ordered (R12) to be sent out. Yes I should have been notified of (R12's) temperature when it occurred and definitely when the Tylenol was not effective in controlling the fever. I would have sent (R12) to the hospital at that time knowing the history of urinary tract infections. (R12) would more than likely been admitted to the hospital for intravenous (IV) antibiotic therapy, but the temperature would have never got to the point of 105 degrees Fahrenheit and (R12) becoming unresponsive. The sooner the IV antibiotics are started the better. The facility policy Acute Condition Changes documents #1) During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay: for example someone with unstable vital signs. #2) In addition the nurse shall assess and document/report the following baseline information: vital signs. R12's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. R12's Progress Note dated 1/28/2017 at 9:20PM, documents Noted at this time (R12's) temperature is 102.1 degrees Fahrenheit. (R12) is in bed laying supine with some shivering. (R12) does not seem to be in distress except for being cold. Passed on to the midnight nurse. R12's progress note dated 1/29/2017 at 6:39AM, documents (R12's) temperature 103.2 degrees Fahrenheit at 11:53PM. (R12's) skin very hot and red. (R12) was not responding to verbal stimuli and not responding to sternal rub. (R12) would not open eyes when talked to or having sternal rub applied. (R12) moaning and respirations were labored at 12 breaths per minute. Oxygen Saturation 77% on room air, applied nasal cannula with Oxygen Saturation 6 liters got Oxygen Saturation up to 85%, medics (ambulance staff) arriving at this time. Pulse 109, Respirations 12 Blood Pressure 101/43. Doctor was called about resident's temperature and Doctor gave an order to send to the emergency room . Medics (ambulance staff) informed us that resident was not stable enough to be transported to preferred hospital. (R12) was transported to the nearest hospital. Director of Nursing was informed of (R12) being sent out. (R12's) Power of Attorney was called with no answer, message was left awaiting call back. 3:27AM the hospital called letting us know resident was going to be admitted to telemetry floor for [MEDICAL CONDITION]. (R12) was still unresponsive at that time and rectal temperature was 105. Oxygen Saturation per the hospital was in the 80's. The hospital nurse informed this nurse that (R12's) creatinine, Blood Urea Nitrogen (BUN), Glomerular Filtration Rate (GFR) levels are showing kidney failure. (R12) is on fluids and two antibiotics at the hospital. There were no other documented progress notes or vital signs in R12's clinical record for 1/28/2017 or 1/29/2017. On 7/12/2017 at 10:00AM, E2 (Director of Nursing) stated There should have been follow up after the first temperature was noted on 1/28/2017 at 9:31AM as well as documentation in the progress notes. The doctor should have been called when the Tylenol was ineffective with the 8:53PM dose. R12's hospital Urine Culture and Sensitivity report dated 1/29/2017, documents heavy growth (greater than 100,000) Proteus Mirabilis. R12's Basic Metabolic Panel dated 1/29/2017 document BUN (Blood Urea Nitrogen)-29 high (normal 8-25), GFR (Glomerular Fill Rate)- 25 low (normal 8-25) and Creatinine 2.15 high (normal 0.70-1.50).

Based on interview and record review the facility failed to recognize and monitor changes in condition for one of three residents (R12) reviewed for change in condition in a sample of 15. This failure resulted in R12 being admitted to the telemetry floor of the hospital unresponsive to verbal/painful stimuli with a temperature of 105 degrees Fahrenheit and [DIAGNOSES REDACTED]. Findings include: R12's face sheet documents a [DIAGNOSES REDACTED]. R12's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. R12's Progress Note dated 1/28/2017 at 9:20PM, documents Noted at this time (R12's) temperature is 102.1 degrees Fahrenheit. (R12) is in bed laying supine with some shivering. (R12) does not seem to be in distress except for being cold. Passed on to the midnight nurse. R12's progress note dated 1/29/2017 at 6:39AM, documents (R12's) temperature 103.2 degrees Fahrenheit at 11:53PM. (R12's) skin very hot and red. (R12) was not responding to verbal stimuli and not responding to sternal rub. (R12) would not open eyes when talked to or having sternal rub applied. (R12) moaning and respirations were labored at 12 breaths per minute. Oxygen Saturation 77% on room air, applied nasal cannula with Oxygen Saturation 6 liters got Oxygen Saturation up to 85%, medics (ambulance staff) arriving at this time. Pulse 109, Respirations 12 Blood Pressure 101/43. Doctor was called about resident's temperature and Doctor gave an order to send to the emergency room . Medics (ambulance staff) informed us that resident was not stable enough to be transported to preferred hospital. (R12) was transported to the nearest hospital. Director of Nursing was informed of (R12) being sent out. (R12's) Power of Attorney was called with no answer, message was left awaiting call back. 3:27AM the hospital called letting us know resident was going to be admitted to telemetry floor for [MEDICAL CONDITION]. (R12) was still unresponsive at that time and rectal temperature was 105. Oxygen Saturation per the hospital was in the 80's. The hospital nurse informed this nurse that (R12's) creatinine, Blood Urea Nitrogen (BUN), Glomerular Filtration Rate (GFR) levels are showing kidney failure. (R12) is on fluids and two antibiotics at the hospital. There are no other documented progress notes or vital signs in R12's clinical record for 1/28/2017 or 1/29/2017. On 7/12/2017 at 10:00AM, E2 (Director of Nursing) stated There should have been follow up after the first temperature was noted on 1/28/2017 at 9:31AM as well as documentation in the progress notes. The doctor should have been called when the Tylenol was ineffective with the 8:53PM dose. R12's hospital Urine Culture and Sensitivity (report) dated 1/29/2017, documents heavy growth (greater than 100,000) Proteus Mirabilis. R12's Basic Metabolic Panel dated 1/29/2017 document BUN (Blood Urea Nitrogen)-29 high (normal 8-25), GFR (Glomerular Fill Rate)- 25 low (normal 8-25) and Creatinine 2.15 high (normal 0.70-1.50). The hospital record documents R12 received [MEDICATION NAME]/Tazobactam (antibiotics) 3.375 grams intravenous piggy back. On 7/13/2017 at 10:20AM, Z5 (R12's Physician) stated I was not notified of the temperature until I ordered (R12) to be sent out. Yes I should have been notified of (R12's) temperature when it occurred and definitely when the Tylenol was not effective in controlling the fever. I would have sent (R12) to the hospital at that time knowing the history of urinary tract infections. (R12) would more than likely been admitted to the hospital for intravenous (IV) antibiotic therapy, but the temperature would have never got to the point of 105 and (R12) becoming unresponsive. The sooner the IV antibiotics are started the better. The facility policy Acute Condition Changes documents #1) During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay: for example someone with unstable vital signs. #2) In addition the nurse shall assess and document/report the following baseline information: vital signs.

Based on interview and record review the facility failed to ensure pain medications were available and administered as ordered for one of three residents (R21) reviewed for medications in the sample of 15. As a result R21 went without scheduled pain medication causing severe pain and diminished activities of daily living. Findings include: R21's Facility Face Sheet dated 9/28/2013 documents a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents R 21 is cognitively intact. R21's Physicians Order Sheet dated 8/1/2015 documents Hydrocarbon-[MEDICATION NAME] 7.5-325 milligrams every 6 hours orally for pain was ordered 7/6/2015 and [MEDICATION NAME] 25 mcg/hr one patch administered every 72 hours ordered 7/6/2015. R21's Medication Administration History dated 8/1/2015 through 8/26/2015 documents R 21 did not receive the prescribed dose of Hydrocarbon-[MEDICATION NAME] 7.5-325 milligrams on 8/23/2015 at 11:00 AM, 5:00 PM, or 11:00 PM and 8/24/2015 at 5:00 AM. The Medication History also documents R 21 did not receive a scheduled [MEDICATION NAME] Patch on 8/5/2015. The Medication History documents R 21 received a [MEDICATION NAME] on 8/2/2015 the not again until 8/9/2015 six days later. On 8/26/2015 at 9:30AM, E2 (Director of Nursing) stated (R21) did not receive a [MEDICATION NAME] on 8/5/2015. The patch was not available and was not reordered until 8/8/2015. I expect that the nurses reorder the [MEDICATION NAME] before the last one is used. On 8/26/2015 at 8:30AM, R21 stated I had severe pain in my hands and all over my body last Sunday (8/23/2015) and Monday (8/24/2015) in the morning because I did not get my pain pills. I hurt so bad I couldn't stand to be moved in bed that night or have my incontinence brief changed regularly that night. My pain level was higher than a rating of 10 on a scale of 1-10. I have constant pain especially in my hands and feet with my pain medications given it keeps my pain level down to a 7 or less rating. I also missed a pain patch once this month but I'm not sure of the date. I know any time I miss my pain medication it takes a day or two for the pain to be tolerable again. R21's care plan dated 10/16/2013 documents Administer medications as ordered, and return to assess effectiveness. On 8/25/2015 at 11:25AM, E8 (registered Nurse) stated I called (R21's) physician and the pharmacy to order the [MEDICATION NAME]- [MEDICATION NAME] 7.5-325 milligrams on 8/24/2015 at approximately 9:00AM. R21 received the scheduled 11:00AM dose. I'm not sure why the pharmacy didn't send the medication sooner. I know (R21) has chronic pain and rates pain as a 7 or 8 on a scale of 10 even when (R21) receives the scheduled pain medications. On 8/25/2015 E9 Licensed Practical Nurse (LPN) stated Medications are ordered at least three days before the prescription runs out. If a resident misses a medication more than three times for any reason the doctor must be notified. On 8/26/2015 at 8:57AM, E7 (LPN) stated I worked on 8/23/2015 when (R21) did not have any prescribed Hydocodone at the facility. (R21) is always in pain. I did call the on call physician for orders but did not receive any. I did not call the Medical director for orders. The medication is in the convenience box but we are not able to give the medication with out a code from pharmacy. (R21) needed a new order so they would not give me the code, therefore (R21) missed four doses of the scheduled [MEDICATION NAME] in a row. The facility Controlled Substance Box documents the following contents: [MEDICATION NAME] 25 mcg/hr patch two patches and [MEDICATION NAME]- [MEDICATION NAME] 7.5-325 milligrams six tablets. On 8/26/2015 at 2:30PM, E2 (Director of Nursing) stated (R21) is not currently seeing a pain physician or going to a pain clinic. R21's regular physician increased the [MEDICATION NAME]-[MEDICATION NAME] from 5-325 milligrams to 7.5-325 milligrams on 6/28/2015.

Based on interview and record review the facility failed to assess for level of pain when scheduled pain medications were omitted for two of three residents (R21 and R18) reviewed for pain medications in a sample of 15. This failure resulted in severe pain causing R21 to cry and refuse repositioning or incontinence care due to severe pain. Findings include: R21's Facility Face Sheet dated 9/28/2013 documents a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents R 21 is cognitively intact. R21's Physicians Order Sheet dated 8/1/2015 documents Hydrocarbon-[MEDICATION NAME] 7.5-325 milligrams every 6 hours orally for pain was ordered 7/6/2015 and [MEDICATION NAME] 25 mcg/hr one patch administered every 72 hours ordered 7/6/2015. R21's Medication Administration History dated 8/1/2015 through 8/26/2015 documents R 21 did not receive the prescribed dose of Hydrocarbon-[MEDICATION NAME] 7.5-325 milligrams or have pain scale assessed on 8/23/2015 at 11:00 AM, 5:00 PM, or 11:00 PM and 8/24/2015 at 5:00 AM. The Medication History also documents R 21 did not receive a scheduled [MEDICATION NAME] Patch on 8/5/2015. The Medication History documents R21 received a [MEDICATION NAME] on 8/2/2015 then not again until 8/9/2015 seven days later. On 8/26/2015 at 9:30AM, E2 (Director of Nursing) stated (R21) did not receive a [MEDICATION NAME] on 8/5/2015. The patch was not available and was not reordered until 8/8/2015. I expect that the nurses reorder the [MEDICATION NAME] before the last one is used. On 8/26/2015 at 8:30AM, R21 stated I had severe pain in my hands and all over my body last Sunday (8/23/2015) and Monday (8/24/2015) in the morning because I did not get my pain pills. I hurt so bad I couldn't stand to be moved in bed that night or have my incontinence brief changed regularly that night. Any time staff touched me the pain was excruciating and made me cry. My pain level was higher than a rating of 10 on a scale of 1-10. I have constant pain especially in my hands and feet with my pain medications given it keeps my pain level down to a 7 or less rating. I also missed a pain patch once this month but I'm not sure of the date. I know any time I miss my pain medication it takes a day or two for the pain to be tolerable again. The progress note dated 8/24/2015 at 6:09AM, documents R21 refused positioning through out the night. No pain scale document for any time on 8/23/2015 at 11:00AM through 8/24/2015 at 11:00AM. On 8/26/2015 at 8:35AM, Z2 (R21's family) stated (R21) cried all day in pain the day the pain medication was missed. What I don't understand is why if the medication is in the facility convenience box (R21) had to suffer. (R21) is in chronic pain if (R21) misses the pain medication it takes (R21) a day or two to get the medicine back in (R21's) system for it to work right. R21's care plan dated 10/16/2013 documents Administer medications as ordered, and return to assess effectiveness. On 8/25/2015 at 11:25AM, E8 (registered Nurse) stated I called (R21's) physician and the pharmacy to order the [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 milligrams on 8/24/2015 at approximately 9:00AM. R21 received the scheduled 11:00AM dose. I'm not sure why the pharmacy didn't send the medication sooner. I know (R21) has chronic pain and rates pain as a 7 or 8 on a scale of 10 even when (R21) receives the scheduled pain medications. On 8/25/2015 E9 Licensed Practical Nurse (LPN) stated Medications are ordered at least three days before the prescription runs out. If a resident misses a medication more than three times for any reason the doctor must be notified. On 8/26/2015 at 8:57AM, E7 (LPN) stated I worked on 8/23/2015 when (R21) did not have any prescribed Hydocodone at the facility. (R21) is always in pain. I did call the on call physician for orders but did not receive any. I did not call the Medical director for orders. The medication is in the convenience box but we are not able to give the medication with out a code from pharmacy. (R21) needed a new order so they would not give me the code, therefore (R21) missed four doses of the scheduled [MEDICATION NAME] in a row. The facility Controlled Substance Box documents the following contents: [MEDICATION NAME] 25 mcg/hr patch two patches and [MEDICATION NAME]- [MEDICATION NAME] 7.5-325 milligrams six tablets. On 8/26/2015 at 3:15PM, E2 (Director of Nursing) stated (R21) is not currently going to a pain management physician or clinic for pain control. 2) R18's physician's orders [REDACTED]. R18's Medication Administration History for 6/1/15-6/30/15 states R18 did not receive her prescribed dose of [MEDICATION NAME]-[MEDICATION NAME] on 6/17/15 at 11:00 PM, 6/18/15 at 5:00 AM, and 6/18/15 at 11:00 AM. R18's Medication Administration History for 6/1/15-6/30/15 indicates R18 was not assessed for pain on 6/18/15 at 11:00 AM. On 8/26/15 at 11:30 AM, R18 stated there was an occasion when she did not receive her prescribed dose of [MEDICATION NAME]-[MEDICATION NAME]. R18 could not recall when this occurred but stated she receives [MEDICATION NAME]-[MEDICATION NAME] for pain in her shoulder.

Based on record review and interview, the facility failed to ensure that R3's wheelchair was safely secured in the facility van during transportation. This failure resulted in R3's wheelchair rolling forward, causing a laceration to R3's right leg requiring 21 sutures. R3 is one of three residents reviewed for accidents in the sample of three. The facility staff also failed to safely transfer two (R1, R3) of three residents reviewed for accidents and assistive devices in the sample of three. Findings include: A. The Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents that R3 is an extensive assist of two and uses a wheelchair for mobility purposes. Facility Nursing Notes document that on 1/26/15, R3 was transported to a physician appointment via facility van. R3 sustained a laceration while on the facility van to the right leg and was taken to the emergency room . R3 required 21 sutures to close the wound. The facility report titled Final Report dated 1/27/15 documents that on 1/26/15, R3 was transported to a physician appointment by facility van. The report documents that E5, Van Driver did not properly secure R3's wheelchair in the van when returning from R3's physician appointment. R3's unsecured wheelchair rolled forward and R3 bumped R3's right leg on a bolt on the back of a seat causing a laceration. E5 turned the van around and took R3 to the emergency room for evaluation and treatment and notified the facility. The Emergency Department records dated 1/26/15 for R3 document the following assessment and treatment: There is a complex laceration located over the right shin which is 12 centimeters in length wound prepared and cleaned, wound edges are ragged, runs in an angled orientation skin closed with 21 sutures of 4-0 nylon wound closed and approximated as best as possible, small (one centimeter) area in center unable to be closed due to sutures tearing through skin. (Two) steri strips applied to this area. An untitled facility report dated 1/27/15 documents that (E5) failed to properly secure (R3) during transport from a doctors appointment. This resulted in resident skin tear .(E5) is cautioned to adhere to all facility policies and procedures with particular emphasis on safety. This report is signed by E16, Regional Clinical Consultant. The facility policy titled Vehicle Safety Policy and Procedure Manual directs van operators as follows: Seat belts, shoulder harnesses and wheelchair restraints (occupant restraint systems) shall be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their restraints. On 6/23/15 at 2:30 pm E5 Van Driver stated I spaced out. I put (R3) in the van and I just forgot to secure the wheelchair. I did not lock the wheelchair or strap it in. When we went around the corner (R3) rolled forward and hit (R3's) right leg on the metal back of the seat. There was blood everywhere. I turned into the emergency room and two aids came and took (R3) in. I almost lost my job over this. I made a big mistake. On 6/24/15 at 3:15 pm E13, Regional Administrator acknowledged facility failure and stated We expected an investigation. B.1.) The Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R3 as mildly cognitively impaired. This same MDS documents that R3 is totally dependent with two assist in transfers and uses a wheelchair for mobility purposes. The facility Fall Risk assessment tool documents that on 1/16/15, 5/4/15 and 6/5/15, R3 is at high risk for falls. A facility report titled Occurrence Report dated 1/22/15 documents that R3 was being transferred from the commode to R3's wheelchair when R3's legs gave out. R3 was lowered to the floor, receiving a skin tear to the right arm. The post fall intervention documented is that R3 is to be a mechanical lift transfer only. The report is signed by E14, former Director of Nursing. R3's Plan of Care updated on 1/23/15 documents that R3 is to be a two person assist with mechanical lift for all transfers. On 5/4/15 Nursing Notes document that R3 was again lowered to the floor by two Certified Nursing Assistants (CNA's), E11 and E12 while toileting R3 on the commode. R3's legs gave out from under R3. When R3 was lifted from the floor R3 received two skin tears, one on each upper arm. The facility report titled Fall Occurrence Investigation Report dated 5/4/15 documents R3 was lowered to the floor by CNA's while being transferred from a chair to the commode. Physical Therapy Notes dated 4/9/15 to 5/11/15 document the following: (R3) continues to have functional deficits including unsteadiness, decreased activity tolerance and deficit balance recovery On 6/24/15 at 2:15 pm Z1, Physical Therapy Coordinator stated R3 was declining during this time period of 4/15 through 5/11/15 and was assessed as a mechanical lift transfer due to her leg weakness and general decline. On 6/24/15 at 2:30 pm E8, Care Plan and MDS coordinator stated (R3) has been a (mechanical lift) transfer for a long time The staff know this. (R3) has been a (mechanical lift), I know since January. 2.) The Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R3 as mildly cognitively impaired. This same MDS documents that R3 is totally dependent with two assist in transfers and uses a wheelchair for mobility purposes. The facility Fall Risk assessment tool documents that on 1/16/15, 5/4/15 and 6/5/15, R3 is at High Risk for falls. R3's Plan of Care dated January 2015 through May 2015 documents that R3 is a two person assist with mechanical lift for all transfers. Nursing Notes for 6/9/15 document that staff used a mechanical lift to get R3 up from bed. During the transfer, the lift bumped into R3's glasses causing bruising beneath R3's eye. A facility report titled Occurrence Report dated 6/9/15 documents the following: E15, Certified Nursing Assistant was taking R3 off the mechanical lift and the lift slipped and hit R3's glasses causing bruising on R3's cheek and under eye. On 6/24/15 at 11:40 am E2, Director of Nursing stated there should have been two CNA's using the (mechanical lift) on (R3). On 6/25/15 at 9:00 am E2 was going over the facility policy titled Lifting Machine, Using a Portable and stated that the policy documents that one CNA can operate the lift if the resident is able to participate. E2 stated I guess we need to change that. E2 acknowledged that R3's Plan of Care documents that two staff members are needed for assistance when using the mechanical lift. 3.) R1's face sheet lists the following Diagnoses: [REDACTED]. R1's Careplan dated 2/3/15 documents R1 requires extensive assist of two with bed mobility and a {full weight bearing}mechanical lift for transfers, toileting . An Occurrence Report for R1 dated 2/5/15 documents, alarm sounding .(R1) was noted to be lying on her right side .asked CNA if she used a gait belt, CNA stated no, CNA stated that she lowered (R1) to the floor. Progress Notes dated 2/5/15 documents, (E9 CNA) stood (R1), just as (E9) had (R1) place buttocks on shower chair, (R1) went to sit and slid off shower chair, (E9) guided (R1) to the floor. On 6/24/15 at 10:40 am E7 Restorative CNA confirmed that R1 was an extensive assist of two at the time of the 2/5/15 Occurrence. E7 stated R1 should not have been transferred with just one staff. E7 stated, (R1) had been a two person assist, with a gait belt but due to her recent decline at that point, she had been changed to use a {partial weight bearing} mechanical lift to help her stand, after this fall is when she was made a {full weight bearing} lift. On 6/24/15 at 10:45 am when questioned about the careplan dated 2/3/15 documenting that R1 was a {full weight bearing} mechanical lift, E8 Care Plan Coordinator stated, I changed her to a full mechanical lift after that incident, but I didn't added it as a new intervention, I just added it under the problem area, that is why the date is off, but (R1) was a {partial mechanical lift} at the time of the incident.

Based on interview and record review, the facility failed to administer pain medication in accordance with Physician order [REDACTED]. This failure resulted in R1 experiencing severe, sustained pain from her Fractured Left Humerus on two separate occasions, [MEDICATION NAME] 50.5 hours and 39 hours respectively. The pain limited R1's participation in Activities of Daily Living and her rehabilitative therapy. Findings include: R1's Physician order [REDACTED]. R1's POS documents that R1 is to receive [MEDICATION NAME] 7.5 milligrams (mg)/325mg, one tablet every four hours as needed for pain. R1's Pain Observation for Cognitive Awareness dated 07/11/13 documents that R1 experienced constant, daily pain, rated on the pain scale as a nine out of ten (with ten being the worst pain possible), and times when pain is "horrible or excruciating." Progress Notes document that R1 was admitted to the facility on [DATE] at 7:15pm. R1's July 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R1's Pain Scale Assessments dated 07/11/13 through 07/12/13 document that R1 rated her pain as five, six, and seven out of ten on the pain scale, with ten being the worst possible pain. On 08/02/13 at 11:25am, R1 stated that she was in terrible pain on 07/10/13 through 07/12/13 and then again 07/17/13 and 07/18/13. R1 stated that she asked for the pain medication frequently, but the facility was unable to get the [MEDICATION NAME] (pain medication). R1 stated that the pain was "terrible, so bad I couldn't move. I cried so much my head hurt awful. I couldn't go to therapy or eat... Stayed in my recliner, cried all the time, cried myself to sleep." R1 stated that the facility had offered to send her to the hospital for pain management, but "I said no because it hurt too much to be moved or ride on that bus." On 08/02/13 at 11:30am, E3, Licensed Practical Nurse (LPN), stated that when she cared for R1 on 07/11/13, R1 was "in very much pain and rated the pain as a ten out of ten, with ten being the worst possible pain." E3 stated that she called the pharmacy on 07/11/13 to try to get the pharmacy to contact Z4, Primary Care Physician (PCP), to authorize the [MEDICATION NAME]. On 08/02/13 at 12:01pm, E4, LPN, stated that on 07/10/13 she tried several times to contact Z4 to authorize the [MEDICATION NAME], but Z4 did not return her calls. E4 stated that she notified E2, Director of Nursing (DON) on 07/10/13 that Pharmacy had not sent R1's supply of [MEDICATION NAME] and that she had been unsuccessful at contacting Z4. On 07/31/13 at 2:15pm, Z2, Registered Pharmacist (RPh), stated that R1's [MEDICATION NAME] was not dispensed until 07/12/13 because Z4, PCP, did not return the pharmacy's calls and faxes or send in a signed prescription for the [MEDICATION NAME] until 07/12/13. On 07/16/13 R1's POS documents a change in R1's [MEDICATION NAME] order: [MEDICATION NAME] 7.5mg/5mg, one or two tablets every four hours as needed. R1's MAR indicated [REDACTED]. On 08/02/13 at 10:10am, E6, LPN, stated that R1's supply of [MEDICATION NAME] ran out on 07/17/13 after the 3:22pm dose. R1's MAR indicated [REDACTED]. R1's Pain Scale Assessments dated 07/17/13 through 07/19/13 document that R1 rated her pain as a ten (three times) and as an eight (three times) on the pain scale, with ten being the worst possible pain. On 08/02/13 at 11:58am, Z1, LPN (who no longer works at the facility), stated that on 07/18/13 R1 told her "I can't take it (the pain) anymore." Z1 stated that she called the pharmacy "a couple of times, and gave them (Z4's) cell phone number" so he could be contacted for authorization of the [MEDICATION NAME]. Z1 stated that she notified E2, DON, that R1 was in pain and out of [MEDICATION NAME]. On 08/02/13 at 10:50am, Z3, Registered Pharmacist and Pharmacy Manager, stated that R1's increased order for [MEDICATION NAME] was not dispensed until 07/19/13 because Z4 did not return calls or faxes for authorization of the medication until late on 07/18/13 (order was verbally given to a nurse on 07//16/13). On 07/31/13 at 2:25pm, E2, DON, stated that the facility has difficulty getting Physicians to authorize controlled medications in a timely manner. E2 stated that Z4 is the Facility's Medical Director, and she has not discussed the difficulties obtaining authorization for controlled medications with him. E2 stated that an eight hour turn around time (the time from which the medication is ordered to having it in the facility to be administered) is acceptable.

Based on interview and record review, the facility failed to provide pain medication as ordered by the Physician to manage pain for one of three residents (R1) reviewed for pain in the sample of twelve. This failure resulted in R1 experiencing severe, sustained pain from her Fractured Left Humerus on two separate occasions, [MEDICATION NAME] 50.5 hours and 39 hours respectively. The pain limited R1's participation in Activities of Daily Living and her rehabilitative therapy. Findings include: R1's Physician order [REDACTED]. R1's POS documents that R1 is to receive [MEDICATION NAME] 7.5 milligrams (mg)/325mg, one tablet every four hours as needed for pain. R1's Pain Observation for Cognitive Awareness dated 07/11/13 documents that R1 experienced constant, daily pain, rated on the pain scale as a nine out of ten (with ten being the worst pain possible), and times when pain is "horrible or excruciating." Progress Notes dated 07/10/13 document that R1 was admitted to the facility on [DATE] at 7:15pm. R1's July 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R1's Pain Scale Assessments dated 07/11/13 through 07/12/13 document that R1 rated her pain as five, six, and seven out of ten on the pain scale, with ten being the worst possible pain. On 08/02/13 at 11:25am, R1 stated that she was in terrible pain on 07/10/13 through 07/12/13 and then again 07/17/13 and 07/18/13. R1 stated that she asked for the pain medication frequently, but the facility was unable to get the [MEDICATION NAME] (pain medication). R1 stated that the pain was "terrible, so bad I couldn't move. I cried so much my head hurt awful. I couldn't go to therapy or eat... Stayed in my recliner, cried all the time, cried myself to sleep." R1 stated that the facility had offered to send her to the hospital for pain management, but "I said no because it hurt too much to be moved or ride on that bus." On 08/02/13 at 11:30am, E3, Licensed Practical Nurse (LPN), stated that when she cared for R1 on 07/11/13, R1 was "in very much pain and rated the pain as a ten out of ten, with ten being the worst possible pain." E3 stated that she called the pharmacy on 07/11/13 to try to get the pharmacy to contact Z4, Primary Care Physician (PCP), to authorize the [MEDICATION NAME]. On 08/02/13 at 12:01pm, E4, LPN, stated that on 07/10/13 she tried several times to contact Z4 to authorize the [MEDICATION NAME], but Z4 did not return her calls. E4 stated that she notified E2, Director of Nursing (DON) on 07/10/13 that Pharmacy had not sent R1's supply of [MEDICATION NAME] and that she had been unsuccessful at contacting Z4. On 07/31/13 at 2:15pm, Z2, Registered Pharmacist (RPh), stated that R1's [MEDICATION NAME] was not dispensed until 07/12/13 because Z4, PCP, did not return the pharmacy's calls and faxes or send in a signed prescription for the [MEDICATION NAME] until 07/12/13. On 07/16/13 R1's POS documents a change in R1's [MEDICATION NAME] order: [MEDICATION NAME] 7.5mg/5mg, one or two tablets every four hours as needed. R1's MAR indicated [REDACTED]. On 08/02/13 at 10:10am, E6, LPN, stated that R1's supply of [MEDICATION NAME] ran out on 07/17/13 after the 3:22pm dose. R1's MAR indicated [REDACTED]. R1's Pain Scale Assessments dated 07/17/13 through 07/19/13 document that R1 rated her pain as a ten (three times) and as an eight (three times) on the pain scale, with ten being the worst possible pain. On 08/02/13 at 11:58am, Z1, LPN (who no longer works at the facility), stated that on 07/18/13 R1 told her "I can't take it (the pain) anymore." Z1 stated that she called the pharmacy "a couple of times, and gave them (Z4's) cell phone number" so he could be contacted for authorization of the [MEDICATION NAME]. Z1 stated that she notified E2, DON, that R1 was in pain and out of [MEDICATION NAME]. On 08/02/13 at 10:50am, Z3, Registered Pharmacist and Pharmacy Manager, stated that R1's increased order for [MEDICATION NAME] was not dispensed until 07/19/13 because Z4 did not return calls or faxes for authorization of the medication until late on 07/18/13 (order was verbally given to a nurse on 07//16/13). On 07/31/13 at 2:25pm, E2, DON, stated that the facility has difficulty getting Physicians to authorize controlled medications in a timely manner. E2 stated that Z4 is the Facility's Medical Director, and she had not discussed the difficulty with obtaining authorization for controlled medications with him. E2 stated that an eight hour turn around time (the time from which the medication is ordered to having it in the facility to be administered) is acceptable.

Based on observation, interview and record review the facility failed to implement a pressure relieving mattress for R18, resulting in the development of an avoidable Stage 3 pressure ulcer to the right lateral ankle and a Stage 2 pressure ulcer to the right buttock. The facility failed to reapply a dressing in a timely manner to R3's coccyx pressure ulcer. The facility failed to assess and document weekly pressure ulcer measurements for R21. R18, R3 and R21 are three of six residents reviewed with pressure ulcers in the sample of 15. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set((MDS) dated [DATE] stated that R18 is at risk for pressure ulcers, but does not have any pressure ulcers. The MDS dated [DATE] stated R18 has one Stage 2 and one Stage 3 pressure ulcer. The assessment states R18 requires extensive assist with bed mobility and transfers. The Care Plan dated 3/6/13 identifies an intervention dated 10/4/12 for a "pressure reducing mattress." The Progress Note dated 1/22/13 documents, "(R18) has unstageable pressure ulcer to right lateral ankle measuring 0.6cm(centimeter) by 0.7cm..." The note dated 1/29/13 states, "Stage 3 pressure ulcer right lateral malleolus now 1.4cm by 1.3cm with presence of 90% slough......" The note dated 3/19/13 states, "(R18) has open area to (right) buttocks measuring 2.5cm by 1.5cm by 0.1cm, (right) ankle measuring 0.4cm by 0.5cm......" The note dated 4/9/13 states, "right ischium 0.4cm by 0.5cm by 0.1cm, right ankle has no open area...." The Wound Evaluation Sheet dated 4/16/13 states R18 has a pressure ulcer(reopened) on the "Malleolus Lateral/Ankle Right, Stage III" measuring 1.0cm by 1.0cm by 0.2cm with granulation and slough 15%....[DIAGNOSES REDACTED]/redness-Blanchable..." The Wound Evaluation Sheet states R18 has a pressure ulcer on the buttock, "Stage II" measuring 0.5cm by 0.5cm by 0.1cm with "light exudate....non blanchable [MEDICATION NAME] wound bed..." The Progress Note dated 5/7/13 states, ""right lateral ankle is 1.0cm by 1.0cm by 0.1cm......Buttocks is 0.4cm by 0.7cm by 0.1cm....." The weekly Pressure Ulcer Log dated 5/7/13 identifies R18's right lateral ankle ulcer as Stage 3 and the right buttock ulcer as a Stage 2. On 5/15/13 at 9:50am an oversize bed frame with a regular mattress was in R18's room. At 10:55am E6, Certified Nurse Aide(CNA) transferred R18 to the bed. At 1:30pm R18 was lying in bed in her room. The mattress on the bed was not pressure relieving. E3, Housekeeping Supervisor, stated on 5/15/13 at 12:25pm that R18's bed and mattress were rented for her, but E3 did not know whether the mattress was pressure relieving or not. E3 stated she thought R18 had the mattress and bed for awhile but did not know the date when it was ordered. At 12:50pm E3 confirmed the bed and mattress which was rented for R18 was not a low air loss mattress. E3 stated she checked with the company the bed/mattress was rented from, and was told the mattress was a regular one, not pressure relieving or reducing. The undated invoice from the equipment company documents a bariatric bed with regular mattress was delivered to the facility on [DATE]. E3, Housekeeping Supervisor, confirmed on 5/16/13 at 2:30pm that the invoice provided was for R18's bed/mattress which was delivered on 6/20/12. On 5/15/13 at 10:55pm E4, LPN(Licensed Practical Nurse) did the treatment to R18's pressure ulcer on the right buttock/ischium. At 1:35pm E4 measured R18's right lateral malleolus/ankle pressure sore. The ulcer measured 1.0cm by 1.0cm, the wound bed was covered with yellow slough with [DIAGNOSES REDACTED]/redness in the peri wound. E4 then did the treatment to the ankle. E4 stated on 5/15/13 at 1:45pm that R18 always lays on her right side when in bed, which puts pressure on her right lateral/outer ankle area. E4 stated staff will turn R18 to the left, but she will turn herself back to the right, which puts pressure on the right outer ankle. E4 stated, "I know a lot of it is because she(R18) won't stay off of it(right side)." E4 stated R18 has a history of a pressure ulcer on the right lateral ankle, which will close and reopen. 2. The Weekly Pressure Ulcer assessment dated [DATE] states that R3 has a Stage 3 pressure ulcer on the coccyx measuring 1.5cm by 0.6cm by 0.2cm with a small amount of exudate and slough. The Progress Note dated 5/7/13 states, "coccyx is 2.0cm by 0.9cm, slough 100%......" The physician's orders [REDACTED]." On 5/13/13 at 11:40am, 12:30pm and 1:00pm R3 was sitting in the wheeled recliner chair. At 1:30pm E7 and E6, CNAs transferred R3 from the chair to the bed. E4 cleaned R3's perineal/rectal area following a bowel incontinence. The dressing to R3's coccyx was not in place when R3's disposable brief was removed. The wound bed of the ulcer contained slough. E5, LPN, cleaned the ulcer, applied Santyl, calcium alginate and a bordered foam dressing to the ulcer. E7 and E6, CNAs stated on 5/13/13 at 1:55pm that the dressing on R3's coccyx ulcer pulled off when they turned R3 prior to getting her up for lunch. E7 and E6 stated they got R3 up in the chair for lunch at around 11:15am. E7 and E6 stated they told E5, LPN, that R3's dressing had come off. At this same time, when asked why she did not replace R3's dressing when it was reported, E5 stated that R3 was up in the chair for lunch when she found out the dressing was off, so she waited until 1:35pm when R3 was put back to bed to reapply the dressing. 3. R21's Admission Progress Note dated 3/13/13 documented no pressure ulcer on admission. R21's initial MDS dated [DATE] identified R21 as cognitively intact, requiring extensive assistance of one staff for bed mobility and transfers. R21 was assessed on 3/22/13 at risk of developing a pressure ulcer but having no pressure ulcers. Progress Notes dated 4/22/13 document that R21 had developed an open area to the left buttock. The note documented the area measured 1.0cm x 0.5 cm. The note documents R21 refused to off load the area. The Progress Notes dated 4/23/13 documents the ulcer measured 1.0 cm x 1.0 cm x 0.1 cm. The area was cleansed with Normal Saline and [MEDICATION NAME] was applied per the 4/23/13 Physician Order. Progress Note dated 4/30/13 documents "resident developed small ulcers to buttocks. 3 small stage II ulcers measuring 1.0 cm x .5 cm x 0.1 cm. [MEDICATION NAME] applied to area. Encourage off loading with no effect." Progress note dated 5/06/13 and the facility Pressure Ulcer report documented on 5/06/13 R21 developed stage I pressure ulcers to the right and left elbows. The Pressure Ulcer report dated 5/13/13 did not include any current measurements for the left coccyx pressure ulcer last measured 4/30/13, nor the status of the stage 1 ulcers of the elbows that developed on 5/06/13. There was no evidence of weekly documentation for 5/07/13, or 5/14/13 to monitor the size and condition of the ulcers in the electronic record. The Director of Nurse's E2 stated on 5/14/13 at 12:45 pm that the facility Wound Nurse, E19 documents pressure sore measurements weekly on Tuesdays. E19 was currently on vacation. E2 was to do the weekly pressure ulcer measurement and documentation for R21 on Tuesday (5/14/13) but stated she got busy and did not do it. E2 could not find any documentation in the electronic record nor any hard copy documentation for the previous weekly pressure ulcer documentation that was due on 5/07/13. On 5/16/13 at 9:00 am E2 assessed R21's pressure ulcer to the left coccyx ulcer as a stage 2, measuring 0.6 cm x 0.3 cm x 0.1 cm. The facility "Skin Condition and Pressure Ulcer Assessment Policy dated 2008 states, #14. An individual Skin Integrity Observation will be initiated when a pressure and or other ulcer...are identified by licensed nurse. This form is a permanent clinical record. Until the wound heals, the Skin Integrity Observation may be maintained with the residents Treatment Administration Record... #15 Pressure Ulcer and other ulcers..will be measured at least weekly and recorded in centimeters on the Skin Integrity Report....the report will include type of ulcer, Size (length x width x depth), Stage (I-IV and Unstageable), Odor, Drainage amount,...description of wound bed and date and signature of individual performing assessment. #20 For each wound location , previous skin measurements will be reviewed weekly for wound progress and healing.. #24 Weekly the Treatment Nurse or designee will complete the Pressure Ulcer and Skin Report. "

Based on interview and record review, the facility failed to ensure that supervision and assistive devices were in place for three of five residents (R5, R10, R13) reviewed for falls, in the sample of 15. These failures resulted in falls. R10 sustained a laceration to the head requiring two staples and R5 sustained a scalp soft tissue contusion and possible nasal bone fractures. Findings include: 1. According to the current POS for 6/2012, R10 has multiple [DIAGNOSES REDACTED]. The MDS dated [DATE] assesses R10 with severe cognitive impairment, physical and verbal behaviors and requiring extensive to total assistance for activities of daily living. R10 has history of falls and was assessed on 3/31/12 as a high fall risk. The fall log from 1/1/2012 lists falls for R10 from the chair and bed on 2/17/12, 2/20, 3/5, 3/15, 6/21, 6/23, 6/24 and 6/25/12. The incident report for 2/17/12 under Root Cause Analysis stated that R10 attempted to sit in w/c (wheelchair) and w/c moved. Interventions included PT (Physical Therapy) for safety awareness, autolock brakes, and alarms in chair and bed. Subsequent incident reports with interventions noted state the following: 2/20 - slipped out of w/c - anti-slip pad to w/c; 3/6 - got up from recliner and found on floor - "chair and alarm placed, toileting schedule;" 3/16 - stood up from w/c, "lost balance and fell backward over the w/c" - anti-tippers for w/c; 6/22 - fell out of w/c in room - leave w/c unlocked when alone in room; 6/23 - found on floor by bed - "get up for dinner. . .make rounds early;" 6/24/12 - "appeared to be getting out of recliner to go to bed" - offer assistance every half hour. None of these reports or investigations indicated whether alarms were sounding or in use. The 6/25/12 incident report and nurses notes at 11:45am states the following: "Resident was in w/c in room, found on floor by closet door. Laceration to back of head.{Complained of} pain to head." R10 was sent to the hospital. R10 returned at 4:30pm. The Emergency Department Instruction Sheet states R10 has a 3 centimeter laceration and received two staples. The Manager's Investigation on the incident report states, "Resident got up from w/c and walked in room unassisted. Resident has been refusing medications. Resident lost balance and fell to the floor hitting his head on the edge of a dresser. . . .PT to evaluate." The report showed no further investigation or interviews with staff. The report shows no indication if alarms were in use or sounding. On 6/25/2012 R10 was seated in the recliner chair in his room from 8:30am to 11:00am. No alarms were noted to be in the recliner chair. At 11:45am, R10 was up in the wheelchair in the dining room. No alarm was noted on the chair. E8 (Certified Nurse Aide/CNA) stated at that time that R10 only has an alarm on when he is in bed. On 6/27/12 at 12:15pm, E7 (CNA) stated that on 6/25/12, he and another unnamed CNA got R10 up to the wheelchair for lunch. R10 became combative, so they left him alone in the room in the wheelchair. Then a few minutes later R10 was found on the floor. E7 stated that R10 did have an alarm on in the chair. On 6/27/12 at 12:30pm, E4, the nurse on duty at the time of the 6/25/12 fall, stated that no alarm was sounding, and that R10 does not use an alarm when up in the chair, only in bed. On 6/27/12 at 1:25pm, R10 was transferred to bed by E9 and E10 (CNAs). No alarm was noted on the chair at that time. E9 and E10 stated at that time that R10 only uses an alarm in bed, not in the chair, because "when he is in the wheelchair he doesn't try to get up." Z2 (PT aide) stated on 6/28/12 at 11:30am that when she found R10 on the floor on 6/21/12, she had heard a yell twice, and found R10 on the floor. Z2 stated there were no alarms sounding. The careplan last reviewed on 4/15/12 under the problem of potential for falls lists interventions dated 5/31/11 referring to environment, ask for assistance, observe and restorative. A handwritten intervention dated 11/16/11 instructs staff to "encourage w/c use when gait is unsteady." The handwritten addition dated 3/6/12 states "rising alarm to chair." No other interventions as per the incident reports are listed on the careplan. On 6/28/12 at 10:00am, E2 (Director of Nursing) confirmed that R10 should have an alarm on the chair. E2 stated that at some point someone removed the chair alarm. R10 had been doing better and sometimes the alarms agitated him so the alarm was removed. E2 stated that removing the alarm was not an interdisciplinary or managerial decision. A physician's orders [REDACTED]. 2. R5's Physician order [REDACTED]. R5's Minimum Data Set ((MDS) dated [DATE] documents that R5 is moderately cognitively impaired and is totally dependent on staff for bed mobility, transfers, and locomotion on and off the unit. The MDS documents that R5's balance is unsteady, requiring the physical assistance of staff to stabilize, and that her range of motion of one upper and one lower extremity is impaired. R5's Fall Risk assessment dated [DATE] documents R5's fall risk score as 18, or high risk (a score of 10 or greater indicates high risk). The Patient Care Improvement Report (PCIR) dated 10/18/11 at 7:15am documents that R5 was found lying on her left side on the dining room floor with her wheelchair to the side and tipped forward. The PCIR documents that R5 is unable to maintain a sitting/standing balance and unable to walk or transfer independently. The Wheelchair Assessment and Safety Recommendation dated 10/18/11 (conducted by Physical Therapy after the fall that morning) recommended that a foot rest extender be added to R5's wheelchair for "increased support and stability to assist with positioning." The foot rest extender allowed R5 to maintain a "midline position and push with her feet." The Recommendation directs "If (R5) thrusts forward and (is) unable to push (her) bottom back, lay her down." R5's Care Plan dated 08/15/11 addressing Potential for Falls contained no additions or revisions indicating implementation of the foot rest extender. On 06/28/12 at 10:55am, E11, Restorative Certified Nursing Assistant (CNA), stated that the leg/foot buddy was the assistive device implemented for R5 after her fall 10/18/12. The PCIR dated 10/23/11 at 7:05am documents that R5 was again found on the floor of the dining room, "with the wheelchair on top of her--she had a large amount of blood from her nose, hematoma to forehead, and nose out of alignment." The PCIR documents that R5 is unable to maintain a sitting/standing balance and unable to walk or transfer independently. Documentation dated 10/24/11 on the PCIR dated 10/23/11 by E2, DON, states "Calf buddy was not placed on wheelchair," and "staff was getting other residents to come to breakfast." The Medical Imaging Report dated 10/23/11 documents R5's injuries as "Prominent nasal septal deviation towards the right, possible nasal bone fractures involving the tip of the nasal bones, and scalp soft tissue contusion of the frontal region." On 06/27/12 at 3:30pm, E2, DON, stated that the calf buddy was not in place on 10/23/11 at 7:05am when R5 fell in the dining room, nor were any staff present in the dining room supervising the residents seated at the tables. E2, Director of Nursing (DON), E11, and Z1, Physical Therapist confirmed that a "calf buddy," "leg/foot buddy," and "foot rest extender" are the same assistive device. E11 and Z1 confirmed that the foot rest extender prevented R5's legs and feet from slipping or falling behind the wheelchair foot rests. 3. The Minimum (MDS) data set [DATE] states that R13 has cognitive impairment, requires supervision for transfers, limited assist for ambulation and is at risk for falls. The Incident Report dated 4/5/12 at 1:40am states, ""(E15) CNA(Certified Nurse Aide) was weighing (R13). (R13) states, 'I rolled too fast off of scale. She(E15) wasn't behind me and she didn't catch me.' While getting off of the scale (R13) rolled backwards in w/c(wheelchair) and flipped back hitting his head....." The Incident Report documents the incident occurred using the wheelchair scale located in the "smoke room." The report documents the CNA(E15) was "re-educated regarding obtaining weights for residents in w/c..." The Statement dated 4/10/12 written by E15, CNA states, "When I got done weighing (R13), I wheeled him back and when we got toward the bottom I took one hand off wheelchair to open the door to get out room and when I did he flipped back in his chair and I couldn't catch him so he fell back his shoulder landed on my foot and he said his head hit the floor when I asked." The "smoke room" where the wheelchair scale is located, is a large room with adequate space available so staff are able to turn a wheelchair around to exit the room. E2, DON, stated on 6/28/12 at 11:10am that when she talked to R13 about the incident, R13 stated he had the brake locked on the wheelchair while on the scale. E2 stated that R13 said, when she(E15) said "I'm done", he took the wheelchair brakes off, started wheeling down off the scale and "(E15) couldn't catch me." When asked what conclusion she came to after completing the investigation, E2 stated, "(E15) didn't take proper precautions. We know he's(R13) impulsive, expect him to take himself off the scale. Don't say I'm done, because (R13's) out of there." E2 stated the "smoke room" is large enough, after the weight is obtained, for staff to turn the wheelchair/recliner chairs around and then exit the room.

Based on observation, record review and interview, the facility failed to provide safe transfer technique or utilize a gait belt or assistive device for a non-weightbearing resident (R1) of four residents sampled for falls/abrasions to prevent injury. These failures resulted in a laceration of the inner ankle that required hospital treatment and sutures. Findings include: According to admission records and the current physician's orders [REDACTED]. The Minimum Data Set (MDS) for 2/20/12 assesses R1 with severe cognitive impairment, R1 does not ambulate, and requires total assistance for all activities of daily living (ADLs), including two-person physical assist for transfers. According to the Hospice Plan of Care and confirmed by Z1 (Hospice nurse) on 5/17/12 at 9:00am, R1 has received Hospice services since 8/10 for Dementia, and was again recertified for Hospice on 5/16/12. . The incident report dated 4/3/12 states that three skin tears were discovered on R1's left arm. The Manager's Investigation signed by E6 (Director of Nursing) states that, according to Z1 (Hospice nurse), R1 "wiggles in chair and scratches through sleeve protectors" to scratch skin. The incident report dated 4/20/12 stated that E3 (Certified Nurse Aide/CNA) and Z2 (Hospice CNA), "transferred res. (resident) and repositioned res. from bed to {highback specialized} wheelchair. {Z2} noticed blood on L' (left) heel. Laceration to L' heel. Sent to ER (emergency room ) for evaluation." The Manager's Investigation signed by E6 states "{E3 and Z2} educated on transferring {with} care. Both CNAs verbalized understanding. . ." E3's written statement dated 4/20/12 states that Z2 asked E3 to help transfer R1 from the bed to the wheelchair. "With the 2 of us we transferred her. We straightened her up. . . . {R1} was bleeding from her left heel." Z2's written statement states that "when transferring {R1} from her bed to chair with {E3}, her leg must have been bumped, patient didn't say 'ow'. I noticed blood dripping, covered wound and grabbed staff nurse." The Nurses Note for 11 - 7 on 4/20/12 states "Resident sent to {hospital} for large laceration on L' heel at 6:40am. . . ." The hospital Emergency Department Nursing Record dated 4/20/12 notes "pt (patient) has approximate 7cm (centimeter) by 3cm gapping wound to medial left ankle. . . ." R1 was treated with sutures and steri-strips. The Physician notes on this report also describes the "7 - 8cm very irregular shaped laceration with torn very macerated tissue. . . ." This report also demonstrates by diagram an area of "tissue loss." On 5/10/12 at 10:20am, Z1 had just finished changing R1's dressing to the laceration. Z1 stated that the area was now "healing well" and R1 had been on antibiotics as a precaution. Z1 stated that R1 had been a 2 person transfer "because she was less than 150 pounds" and now was a mechanical lift. Z1 stated that in investigating the incident, they determined that R1 hit her inner ankle on the exposed screw/bolt on the left outer side of the folding footrest on the specialty wheelchair. Upon examination, the screw/bolt was not sharp, but did have hard, defined edges. Z1 stated that R1's skin was "very thin and very fragile." On 5/19/12 at 9:15am, the lacerated area was observed with Z1. While the laceration was healing well, the surrounding skin on the ankle and lower leg was noted to be thin, dry, and friable in appearance. Another small skin tear was noted above the laceration on the lower leg approximated with steri-strips. E3 confirmed her written statement on 5/10/12 at 11:45am. E3 stated that, on the morning of 4/20/12, Z2 asked E3 to help with the transfer, and that R1 was already dressed and set up at the edge of the bed. E3 demonstrated how she and Z2 transferred R1, lifting her "under the arms" while transferring from the bed to the chair. E3 stated they then lifted R1 again to "straighten her out" to get her farther back into the seat of the chair, and that is when E3 thinks R1's ankle "caught" on the bolt on the outer part of the footrest. E3 reports that R1 did not react, but Z2 did see the blood, and called the nurse. E3 stated she "thought this would be a smooth transfer, but it did not turn out that way." E3 stated that R1 does not bear weight, and E3 "did not remember" if they used a gait belt for the transfer. On 5/10/12 at 12:25pm, Z2 also confirmed her written statement. Z2 stated they do not use a gait belt and that they have "transferred {R1} that way forever." Z2 stated she always gets help to transfer R1, as she did that morning with E3. Z2 stated they lifted R1 under her arms to the chair, and then lifted R1 up again to sit her back in the chair. Z2 stated that is when R1 hit her ankle on the side of the footrest that was "sticking out." Z2 stated that the footrest was folded up, but R1's ankle hit that outer connection. Z2 stated she covered the laceration immediately and got the nurse. Z2 stated that R1 does not bear weight, and that R1 "likes to keep her legs tight together." The careplan approach under the problem of Totally Dependent for all ADLs dated 7/13/11, last reviewed on 3/6/12, was "Transfer PRN (as needed) using pivot transfer." A handwritten undated addition had changed this to mechanical lift. The facility's Gait Belt Policy states "Mandatory gait belt usage for all resident handling with the exception of bed mobility and medical contraindications. This policy is to be followed at all times. Failure to adhere to this policy will result in disciplinary action. . . ." On 5/10/12, E2 (Assistant Director of Nursing) was asked if there was any transfer assessment as to the most appropriate type of transfer for R1, given R1's non-weightbearing status. E2 returned at 2:00pm with CNA ADLs Documentation sheets for 2/12 and 5/12 that indicate staff provide total assistance with 2 staff for transfers. At 2:30pm, E2 and E1 (Administrator) stated they did not have a transfer assessment by Physical or Occupational Therapy, and also discussed if a stand-pivot transfer was appropriate for R1, even if a gait belt had been used, as staff did not have control of R1's legs/lower body. On 5/17/12, Functional Assessment sheets were provided, that were not in the current medical record. Starting with 11/8/11, R1's transfers were scored as extensive assist with 1 staff person for stand-pivot transfer. However, weight bearing status was described as "NWB" (non-weightbearing). Also indicated as NWB with one assist were the Functional Assessments for 1/31/11, 7/4/11, and 9/26/11. When asked if there were any more current assessments, the facility provided two more. The first one dated 2/20/12, indicates "PWB" (partial weight bearing) and requiring 2 assist for transfers; however, no other functions on this assessments had changed or improved. The assessment dated [DATE] again indicated NWB, requiring 2 assist for transfer, did not indicate a transfer technique, and no other functions had changed. On 5/17/12 at 8:45am, E6 stated she was not aware that the CNAs were not using a gait belt, and that, "in retrospect," the mechanical lift would have been the safest choice for R1's transfers.

Based on observation, interview, and record review the facility van driver failed to reseat R17 in a bus seat and re secure her in a seat belt after mechanical problems with the buses wheelchair lift forced the driver to release the parking brake of the vehicle. This caused the bus to lurch forward and R17 fell , fracturing her femur. R17 is one of nine residents sampled for falls/fractures out of a total sample of 15 and one supplemental resident. Findings include: The April physician's orders [REDACTED]. The Fall Risk assessment dated [DATE] documents R17 has a history of falls in the last three months, requires the use of a walker, has taken three to four drugs in the last 7 days that make her unsteady, and has 1-2 diseases that make her predisposed to falling. Nurses notes dated 5/6/2011 8:30 AM state, "...Res (resident) (R17) out to Infusion Center (dialysis unit) via facility bus. The nurses note dated 5/6/11 12:30 PM states, "...When res arrived back to facility via facility bus, the driver had put the bus E-(emergency) brake on but did not put it in park. When the driver realized this he went back to put bus in park. When he did the bus jumped forward. Res was already standing up by this time. When the bus went forward, res fell forward. Scraped knee on floor. On assessment found Rt (right) knee swollen slightly with abrasion. C/O (complained of) pain (and) inability to put any weight down on Rt leg..." The hospital Medical Imaging Report dated 5/06/2011 reads as follows: "...Impression: Comminuted fracture of the distal femur extending from the junction of the middle and distal third diaphysis of the femur into the intercondylar notch region and lateral cortex of the distal femoral condyle just above the level of the femoral condyle..." E5, facility van driver confirmed on 5/19/2011 at 12:50 PM that he picked R17 up from dialysis on 5/6/2011 and drove her back to the facility . E5 stated he parked the van and thought he had put the automatic transmission in "Park." He also stated he set the parking brake and left the vehicle running. E5 stated the wheelchair lift will not work if the vehicle is not running. He then went to the back of the passenger compartment of the van to ready the wheelchair lift. E5 stated R17 was standing with the aide of her walker at that time. After readying the lift he exited the van and opened the outside double doors that prefaces the wheelchair lift. He stated he then reentered the van and attempted to operate the controls that lower the wheelchair lift. E5 stated the controls would not "power up" and the lift would not lower. E5 stated he then walked back to the drivers seat to see what was wrong. E5 stated that on his way back to the drivers compartment he told R17 to sit down, but he admitted he did not make sure she did and he stated he did not fasten her into a safety belt. E5 stated he released the parking brake but failed to apply the vehicle foot brake before he pulled the parking brake release lever. E5 stated when he released the parking brake the vehicle "lurched" forward. E5 stated he "hit" the foot brake and the vehicle abruptly stopped. E5 stated he did not hear R17 fall but heard her moan. E5 stated he saw R17 on the floor and then obtained help from inside the facility. The facility bus viewed on 5/19/2011 at 1:30 PM shows the drivers seat is somewhat lower (has a cockpit appearance) than the floor of the passenger compartment and someone sitting in the drivers seat would not have quick access to the passenger compartment. While in the drivers seat E5 would not have been able to keep R17 from falling if she were standing.