Every finding on record at Goldwater Care Peoria Heights

Based on nterview and record review, the facility failed to prevent staff to resident theft of resident funds for one of three residents (R1) reviewed for misappropriation of property in the sample of four. Findings include:The facility's Illinois Abuse Prevention and Reporting Policy, dated 12/17/21, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent.R1's MDS (Minimum Data Set) Assessment, dated 3/31/26, documents R1 is cognitively intact.R1's Online Banking Account Statement Screenshot, dated 6/2/26, documents four cash withdrawals were made on 6/2/26 of 202.50 dollars, 202.50 dollars, 203.50 dollars, and 203.50 dollars.V7's (CNA/Certified Nursing Assistant) Termination Notice, dated 6/11/26 and signed by V1 (Administrator), documents, Last day worked: 5/31/26. Reason for separation or termination: Theft/Dishonesty. (R1) gave you (V7) his bank card to go withdraw 800.00 dollars . When (V7) returned with the money, (V7) only gave (R1) 700.00 dollars. (V7) said that (V7) did not withdraw the full 800.00 dollars because (V7) was on break. Upon looking at (R1's) bank statement 800.00 dollars was withdrawn from (R1's) account.On 7/12/26 at 9:40 AM, R1 stated, On 6/2/26 (V7) stole 100.00 dollars from me. I asked (V7) to use my debit card and withdraw 800.00 dollars out for me. When (V7) returned she gave me 700.00 dollars and said she was only able to withdraw 700.00 dollars. When I looked at my bank account, (V7) had withdrawn 800.00 dollars. I did not tell anyone for a few days as I hated to get (V7) in trouble.On 7/12/26 at 10:00 AM, V1 (Administrator) stated, I was informed on 6/5/26 that (R1) was reporting that (V7) stole 100.00 dollars from (R1). (R1) has no reason to lie and is truthful. I went to talk to (R1) immediately and (R1) told me that he had given his debit card to (V7) to withdraw 800.00 cash. (R1) said when (V7) returned, (V7) only gave (R1) 700.00 dollars cash. (R1) said (V7) told him she was only able to withdraw 700.00 dollars. When (R1) looked up his bank account, (R1) noticed (V7) had taken out 800.00 dollars on 6/2/26. I called (V7) and (V7) told me she was only able to withdraw 700.00 dollars out of (R1's) account because she had to make four different withdrawals and was in a hurry. I confirmed by looking at (R1's) bank account that (V7) had in fact withdrew four separate withdrawals of 200.00 dollars each which in total was 800.00 dollars. I knew then that (V7) was lying and did not give (R1) all of his money that she withdrew. I tried calling (V7) back and she did not answer the phone and never returned to work. (V7) was terminated for stealing 100.00 dollars from (R1). (V7) should have never took (R1's) debit card in the first place.On 7/13/26 at 9:35 AM, this surveyor tried to call V7 by telephone for an interview and no answer was received.On 7/13/26 at 9:40 AM, V8 (Receptionist) stated, After (R1) reported that (V7) had stolen 100.00 dollars from (R1), I had to help (R1) set up an online banking account so he could monitor his account. When (R1) set up the account (R1) and me was able to see (R1's) account and confirmed that on 6/2/26, (V7) withdrew 200.00 dollars out of his account four separate times for a total of 800.00 dollars plus fees for using the ATM (Automated Teller Machine).

Based on interview and record review the facility failed to formulate a desired advanced directive for one resident (R2) of three residents reviewed for Advanced Directives. This failure resulted in R2 receiving CPR (Cardiopulmonary Resuscitation) when he did not wish to. This past non-compliance occurred [DATE] through [DATE].The Facility's Advanced Directives policy dated [DATE] documents At the time of admission each resident will be asked if they have made advanced directives and provided educational information regarding state and federal law. The resident, the legal representative, or the individual who has been authorized as the resident's health care representative will be asked if an Advanced Directive, as recognized under the state law, has been executed. Documentation concerning this inquiry and the individual response shall include the date the entry was made and the individual making this inquiry. This information shall be included in the resident's medical record. The Facility's Advanced Directives policy dated [DATE] documents Copies of the resident's Advanced Directive shall be made and maintained in the resident's clinical record and financial folder. If a resident or health care representative indicates as Advanced Directive regarding CPR or Scope of Treatment (POLST or POST form), the appropriate forms will be completed. R1's Medical Record documents he was admitted on [DATE] with diagnosis to include but not limited to Acute Respiratory Failure with Hypoxia, Ventilator Dependent, Tracheostomy status and Gastronomy tube status. R1's Medical Record documents that he was alert and oriented and able to make his needs known via text message, mouthing words or gestures. On [DATE] V16 (Licensed Practical Nurse-LPN) stated on [DATE] around 8:00 AM that R2 was pulseless and not breathing. V16 (LPN) stated that V6 (R2's Spouse) was at bedside and told her that R2 was a DNR (Do Not Resuscitate) but V6 could not provide a signed Physician Order to not resuscitate R2 so she began CPR. V16 (LPN) stated that R2 was worked by facility staff and paramedics when they arrived giving full life saving cares with chest compressions and ventilation and medications. R2 was then transported to the hospital. V16 stated she looked everywhere to include Electronic Medical Record and all loose paperwork from hospital and could not locate any paperwork or documentation of R2's Advanced Directive. On [DATE] V6 (R2's Spouse) stated that when she entered R2's room on [DATE] around 7:50 AM or 8:00 AM he was pulseless and had no respirations. V6 stated she began yelling for help and staff responded. V6 stated she told anyone who would listen that R2 was a DNR but she did not have the paperwork. V6 stated (R2) would have never wanted to have CPR or any of that other stuff done. Since he has gotten sick, he has been very clear that he did not want CPR done. No one asked me for any paperwork when he was admitted . They should have asked him, he would have told them, he probably did, he was very sure on this, I hate that this happened to him. He ended up being declared brain dead and we turned everything off in the hospital and he died. R2's admission Note dated [DATE] at 2:20 PM documents Resident is a No CPR. R2's Hospital Referral packet documents that R2's status at the hospital prior to admission to the facility was No CPR Full Arrest: Do Not Attempt Resuscitation. On [DATE] V17 (Regional Nurse Coordinator) confirmed that R2 should have had a POLST form indicating his desire to not receive any life saving measures if found pulseless and without respirations. We should have obtained a copy of his DNR immediately when he said he wanted to be a DNR. Prior to the survey date of [DATE] the facility took the following actions to correct the non-compliance: Social Service Director and admission team was educated on the facility's Advanced Directives guidelines, including but not limited to ensure that all residents and/or resident representatives are informed concerning the right to accept or refuse medical or surgical treatment and at the resident's option, formulate an advance directive by Director of Nursing/Designee or Administrator on [DATE]. Licensed staff who are on FMLA (Family Medical Leave of Absence) or vacation will be in-serviced prior to returning to the facility by the Director of Nursing/Designee or Administrator.Social Service Director and admission team was educated on providing copes of state statutes, regulations, and information regarding Advanced Directive (s), to resident, legal representatives upon admission, and also to families who wish to receive such information and assistance regarding Advanced Directive(s) and decisions regarding life sustaining measures and in no event shall give legal advice on the need for medical care directives by Director of Nursing/Designee or Administrator on [DATE]. Licensed staff who are on FMLA or vacation will be in-serviced prior to returning to the facility by the Director of Nursing/Designee or Administrator.All licensed staff were educated on the facility's Advanced Directive guidelines, including but not limited to ensure that all residents and/or representatives are informed concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive by Director of Nursing/designee or Administrator on [DATE]. Licensed staff who are on FMLA (Family Leave Act) or vacation will be in-serviced prior to returning to the facility by the Director of Nursing/Designee or AdministratorFacility wide audit was conducted by the Social Services Director to ensure copies of advanced directives are uploaded into each resident's chart, physician order is accurate, and care plan have been reviewed and updated accordingly.The Director of Admissions and Marketing was in-serviced on ensuring POLST form will be uploaded prior to admission by the [NAME] President of Operations on [DATE].The Director of Marketing and Admissions or admission Group will obtain current POLST form from referring hospital or facility prior to admission to (the facility.) a. The Director of Marketing and Admissions/Admissions Group will obtain the POLST from referring hospital (Electronic Medical Record) system and upload into (Electronic Medical Record). If POLST cannot be obtained prior to admission to (the facility), the Director of Marketing and Admission/admission Group will notify the Facility admission email group that there is no POLST on file. a. The Social Service Director will meet with resident, POA (Power of Attorney)/Guardian, to obtain a new POLST form. For weekend and after-hours admissions, the Manager on Duty will be obtain POLST form from Resident or POA/Guardian.The Social Service Director of Manager on Duty will scan and upload POLST into resident's chart. Social Service Director or Manager on Duty will ensure the Nurse Management team is aware of POLST or Code Status. The Nurse Managers will ensure the correct code status order is entered into the resident's chart in (Electronic Medical Record).Nursing Management will be responsible for the updating the clinical staff on the resident's current code status. An Impromptu QAPI (Quality Assurance Performance Improvement) was held with medical director and staff IDT team to discuss deficiency and facility action plan. The facility will conduct audit (5 days per week for 6 weeks) to ensure all admission and readmissions have copies of advance directives are uploaded into each resident's chart, physician orders are accurate, and care plan have been reviewed and updated accordingly. A QA tool will be completed to verify this practice has occurred by the Director of Nursing/Designee, 5 days per week for 6 weeks. There will be oversight of the QA tool by the Administrator. Completed date: [DATE]

Based on observation, interview, and record review, the facility failed to monitor, provide adaptive smoking materials, and a smoking apron for one resident (R3) of three residents reviewed for smoking in a sample of five. These failures resulted in R3 burning his second and third fingers resulting in third degree burns, which required the wound doctor to order treatment to the burned areas. Findings include:Facility Smoking safety, dated 11/28/12, documents To provide a safe and healthy living environment. Appropriate safety devices including smoking aprons shall be readily available. A smoking safety assessment will be completed to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. R3's final report to state, dated 5/21/26, documents on 5/15/26 at 3PM the following: Diagnosis: Diabetes Mellitus. Occurrence/Injuries: Resident has a burn to the right second and third fingers. Actions: Wound Doctor treated and new orders received. Resident is a smoker, independent with smoking, smokes the cigarette all the way down to the filter. R3's Wound Evaluation and Management Summary report, dated, 5/15/26, documents Patient has wounds to his right second and third finger. Right third finger wound size 3x1.3cm/centimeters. Light Serous Exudate. 100% necrotic tissue. Third degree burn. 4-6 months estimated time to heal. Xerofoam gauze daily and as needed. The wound was surgically excised of devitalized tissue and necrotic periosteum. Right second finger wound size 4x1cm. 100% necrotic tissue. Third degree burn. 4-6 months estimated time to heal. Skin prep daily and as needed. R3's medical record documents the following diagnoses: Diabetes Mellitus, and Peripheral Vascular Disease. R3's medical record has a smoking safety assessment screen last done on 4/1/25, no further assessments completed until R3's incident on 5/15/26. The 4/1/25 smoking screen indicates R3 is a daily cigarette smoker, severe difficulty handling cigarettes, requires assistance and supervision with smoking, requires a smoking apron, and has burns on his fingers and clothing from not using finger grips. R3's smoking care plan initiated on 1/19/24 and current care plan documents (R3) expresses the desire to smoke and will be monitored/supervised smoking program to fully assess compliance and ability to smoke independently. (R3) exhibits the physical ability to smoke with the use of adaptive equipment when smoking. Adaptive device: finger guards, Clothes pin; extendable cigarette holder as resident will allow initiated on 5/18/26. Monitor resident to ensure he is using the cigarette clip correctly and safely initiated on 7/19/24. Utilize smoking apron initiated on 1/19/24.On 6/17/26 at 12pm, R3 was alert and oriented, stated he smokes independently, and showed surveyor his right hand second and third fingers that were burned black at the middle knuckles. R3 stated the black burns were from smoking, he does not use a smoking apron, can handle smoking materials but has limited feeling in his fingers, smokes out front where the secretary lets him out to smoke; and he is diabetic. On 6/17/26 at 2:31PM, V1 Administrator stated via phone (R3) is an independent smoker and nobody monitors independent smokers, and smoking assessments are to be done quarterly (verified R3's last smoking assessment was on 4/1/25 and should have been done since then prior to the smoking incident on 5/15/26 where R3 was smoking independently and burned his fingers). (R3) was seen by our wound doctor for treatment to his fingers, and R3 was to use adaptive devices for his cigarettes due to his limited feeling in his fingers. On 6/17/2026 at 2:56 PM V21 Receptionist stated There is no official list of who can go out and smoke. I have a mental list of cognitively intact residents. Only person who does anything different is (R3) where sometimes he uses a clothes pin so that when the cigarette gets low he doesn't burn himself. I know that because I have seen him with it and asked him but no one has told me he needs to do that. Other than that residents are considered independent to smoke.

Based on interview and record review, the facility failed to thoroughly screen a resident prior to admission for one (R1) of three residents reviewed for admission/discharge/transfers in a sample of five. This failure resulted in R1's behaviors not being properly controlled to where R1 was involuntarily discharged to the hospital, and currently waiting placement for a long term care facility. Findings include:Facility admission of Resident, undated, documents To facilitate smooth transition into a health care environment. To gather comprehensive information as a basis for planning individualized therapeutic care. Conduct head to toe nursing assessment of body systems, parts, and surfaces identifying functional status abilities, needs, or problems. Findings from the assessment required to meet the resident's needs, which can in turn be conveyed to the physician.R1's medical record documents he was admitted on [DATE] from another hospital, and discharged on 6/4/26 to a local hospital. R1's pre-admission notes, sent to the receiving facility on 4/14/26, documents a note dated 4/12/26 by V22 MD/Medical Doctor of transferring hospital Neurologically reserve Lorazepam for clearly documented seizures or severe agitation. These pre-admission notes document PRN/as needed medications of Lorazepam 0.5mg/milligrams every four hours and Lorazepam 2mg every 15 minutes as needed. This pre-admission paperwork further documents to the receiving facility that R1 was in bilateral mittens, full side rails, and a bed alarm.R1's admission progress note at the receiving facility, dated 4/28/2026 at 7:39PM by V13 LPN/Licensed Practical Nurse documents Resident arrived with mittens on both hands. When assessing resident, resident became combative trying to hit both nurses.R1's Involuntary Discharge delivered to R1 and signed by V1 Administrator on 6/3/26 documents This facility seeks to transfer or discharge you. The reason for this proposed transfer or discharge is the safety of individuals in this facility is endangered.On 6/17/26 at 8:43AM, V5/R1's wife stated via phone The (facility) was aware of (R1's) behaviors before admission, and they served me with involuntary discharge paperwork when (R1) was sent to the hospital. (R1) is feisty, irritable, and combative with staff. (R1) is still at the hospital until we can find a placement for him that has a trach/vent unit.On 6/17/26 at 2:03PM, V2 Acting DON (Director of Nursing)/CNO (Chief Nursing Officer) stated they have a team of three for admissions, do not always lay eyes on a person before admission, but reviews paperwork before admission, and RT/Respiratory Therapy evaluates the resident if a new admit for the trach/vent unit.On 6/17/26 at 2:15PM, V19 admission Director stated, I asked if (R1) was clinically ok and (V1) and (V20) both said yes. (V1) and (V20) reviewed (R1's) file for the clinical side; and I reviewed for the financial side. I leave the clinical side up to the nursing facility because they are the ones that know if they have the capability of taking care of the resident.On 6/17/26 at 2:31PM, V1 Administrator stated via phone she was part of the admission screening for R1 along with V20 prior DON, and RT since he was to be admitted to the respiratory unit due to his trach/vent status. V1 stated she is a nurse and looked at R1's medications before admission; knew R1 was a TBI/Traumatic Brain Injury; left the clinical nursing decisions to her V20 DON; RT looks at the resident needs to make sure they can meet their needs; stated I did not review R1's current medications prior to admit because that was left up to V20 DON; doesn't recall reading where R1 had mittens on at the hospital in the hospital notes; and stated I was aware the wife brought mitts to the nursing home for (R1). Any time a resident is admitted to their facility they are reviewed by her and V20, and if to therespiratory department their RT reviews. Then after their decision to admit or not it then goes to the head of their admission team located in [NAME], IL. We reviewed his paperwork, no one laid eyes on R1 prior to admit.

Based on interview and record review, the facility failed to ensure timely assessment, physician notification, documentation, and implementation of treatment interventions for pressure ulcers for one resident (R2) of five residents reviewed for pressure ulcers in the sample list of five. These failures resulted in delayed treatment implementation for pressure ulcers identified on admission and resulted in R2 developing two stage two pressure ulcers and one stage three pressure ulcer to the coccyx while residing in the facility.Findings include: The facility's policy titled Skin Condition Assessment & Monitoring - Pressure and Non-Pressure, revised 6/8/18, documents a skin assessment and pressure ulcer risk assessment would be completed upon admission/readmission. The policy further documents when pressure injuries or skin conditions were identified, a wound assessment would be initiated and documented, changes would be promptly reported to the charge nurse, and at the earliest sign of pressure injury the resident, legal representative, and attending physician would be notified. The policy further documents interventions would be implemented to address skin breakdown and prevent worsening.R2's census line documents R2 was admitted to the facility on [DATE] and discharged from the facility on 3/18/26.R2's Medical Diagnosis List documents Acute Respiratory Failure with Hypoxia, Nontraumatic Intracerebral Hemorrhage, Encephalopathy, Gastrostomy Status, Tracheostomy Status, and Diabetes Type 1.R2's Minimum Data Set (MDS) assessment dated [DATE] documents R2 is severely cognitively impaired and dependent on staff for activities of daily living. This MDS further documents R2 had one stage two pressure ulcer upon discharge from the facility.R10's Skin Condition Report dated 3/10/26 documents R10 has an open pressure ulcer to the right rear thigh, redness to the right buttocks, redness to the left buttocks, and a recurring rash to the right front thigh. This assessment did not contain wound measurements, detailed descriptions of the identified skin concerns, and did not contain notification to R2's Physician that any skin issues were present. R2's admission Braden assessment dated [DATE] documents R2 is at Moderate risk for Pressure Ulcers. R2's Wound Note dated 3/13/26 documents R2 has a stage two pressure ulcer to the right buttocks measuring 4 centimeters (cm) x 2 cm x 0.1 cm, a stage two pressure ulcer to the left buttocks measuring 3 cm x 1.5 cm x 0.1 cm with serosanguinous drainage, and a stage three pressure ulcer to the coccyx measuring 1.5 cm x 0.8 cm x 0.3 cm with serosanguinous drainage. This note further documents a new treatment was initiated on 3/13/26 for all three pressure ulcers to have hydrocolloid (moisture retentive) dressing to be applied three times a week and as needed if saturated or dislodged. R2's Care Plan did not contain Pressure Ulcer prevention or Pressure Ulcer relieving interventions until 3/13/26.R2's Treatment Administration Record (TAR) dated March 2026 documents a treatment order initiated 3/16/26 for a stage two pressure ulcer to the left buttocks to cleanse with wound cleanser, pat dry, and apply hydrocolloid dressing every Monday, Wednesday, Friday, and as needed if soiled or dislodged. The TAR documented the treatment order was discontinued on 3/17/26. R2's TAR dated 3/16/26 documented a new order for wound care for a stage three pressure ulcer to the coccyx to cleanse with wound cleanser, pat dry, and apply hydrocolloid dressing every Monday, Wednesday, Friday, and as needed if soiled or dislodged with a start date of 3/20/26. R2's TAR dated 3/16/26 documented a new order for wound care for a stage two pressure ulcer to the right buttocks to cleanse with wound cleanser, pat dry, and apply hydrocolloid dressing every Monday, Wednesday, Friday, and as needed if soiled or dislodged beginning 3/16/26.R2's Physician Orders did not contain a treatment for R2's pressure Ulcer's until 3/13/26.R2's Nurse Progress Note dated 3/17/26 documents the hydrocolloid dressings became dislodged and were not staying in place appropriately. The note documents treatment was updated to silicone foam dressing three times weekly and as needed if soiled or dislodged. The physician and responsible party were notified.R2's Nurse Progress Note dated 3/18/26 at 8:48 PM, documents R2 experienced an abrupt drop in oxygen saturation levels ranging between 60% (percent) and 74% despite interventions including repositioning, elevation of the head of the bed, suctioning, nebulizer treatments, oxygen administration up to 40%, Venturi mask application, and respiratory therapy interventions. The note documents R2's oxygen saturation levels remained unstable and continued fluctuating between 78% and 90%. V9 Assistant Director of Nursing was notified and agreed R2 should be transferred to the hospital for further evaluation and treatment. The record further documented emergency medical transport transferred R2 to the hospital, and the party responsible and V10 (Medical Director) were notified.R2's hospital records dated 3/18/26 documents R2 had an unstageable pressure injury present on admission located at the coccyx extending into the sacrum. The wound assessment documents measurements of 8 cm x 6 cm with no undermining or tunneling present. The wound base consisted of 50% pink tissue, 40% purple tissue, and 10% brown tissue. The assessment further documents intact peri wound skin, scant serosanguinous drainage, no visible structures, and no odor present.On 5/26/26 at 9:50 AM, V8 (R2's Family Member) stated R2 was admitted to the facility from the hospital on 3/10/26. V8 stated after approximately one week at the facility, R2 became dehydrated and was transferred to the emergency room by ambulance. V8 further stated R2 developed a coccyx wound that became significantly deep during R2's stay at the facility and that R2's wound was deep enough to place two eggs inside. V8 stated the staff at the facility did not notify V8 that R2 had pressure ulcers until a couple of days after he was admitted to the facility and that staff were not very good about turning or repositioning R2.On 5/27/26 at 9:00 AM, V9 (Assistant Director of Nursing/Wound Nurse) stated she was not made aware of R2's pressure ulcers until 3/13/26 because she had been on vacation prior to that date. V9 stated she completed a skin assessment with wound measurements on 3/13/26 and confirmed R2's electronic medical record did not contain a prior skin assessment with wound measurements or detailed descriptions of the pressure ulcer sites. V9 further confirmed R2 did not have treatment orders in place for the pressure ulcers until 3/13/26. V9 stated when she assessed R2 on 3/13/26, R2 had a stage two pressure ulcer to the right buttocks, a stage two pressure ulcer to the left buttocks, and a stage three pressure ulcer to the coccyx.On 5/26/26 at 2:00 PM, V2 (Director of Nursing) stated residents should receive a skin assessment upon admission to the facility and if skin concerns were identified, measurements and descriptions of the wounds should be documented. V2 further stated treatment interventions should be initiated upon admission. V2 confirmed there was no treatment order in place for R2's wounds until 3/13/26 and there is no documentation in R2's medical record that a physician was contacted for treatment orders.On 5/27/26 at 9:30 AM, V10 (Medical Director) stated the facility should contact the physician any time abnormal findings or new concerns are identified with a resident. V10 stated he did not receive notification regarding R2's wounds on admission and further stated if V10 had been notified upon admission, treatment orders would have been implemented to prevent worsening of the wounds.

Based on observation, interview, and record review, the facility failed to allow autonomy/freedom of choice, and failed to treat residents equally as compared to others for one (R28) resident; and failed to treat residents with dignity/respect when providing cares for one (R2) resident, and when assisting with feeding for ten (R6, R11, R17, R19, R30, R38, R48, R52, R53, and R57) of 40 residents reviewed for resident rights in a sample of 48. These failures resulted in R28 feeling embarrassed and becoming withdrawn from social interaction with staff and residents.Findings include: Facility Resident Rights, reviewed 1/4/19, documents Purpose is to promote the exercise of rights for each resident. A resident should be able to assert these rights based on his or her degree of capability. Resident rights include: exercise his or her rights; be informed about his or her rights; and privacy and confidentiality. Exercising rights means that residents have autonomy and choice about how they wish to live their everyday lives and receive care. The facility will not hamper, compel, treat differently, or retaliate against a resident for exercising his/her rights. Facility Employee Handbook, dated 1/2023, documents Use of personal cell phones, including photographing and texting during business hours, should only be in designated break rooms. The facility provided a form titled Assisted Room, undated, that had 10 (R6, R11, R17, R19, R30, R38, R48, R52, R53, and R57) residents listed that need assistance eating. 1.R28's Medical Record documents that he was admitted to the facility on [DATE] with diagnosis to include major Depression, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. R28's Medical Record documents that R28 is cognitively intact and makes all of his own decisions. Throughout the survey R28 answered all questions appropriately and had proper recall of previous conversations. The Facility's Final Abuse Investigation, dated 2/27/2026, documents that a staff member witnessed R28 and R35 making contact with each other. Staff saw R28 with his hand in R35's beard and pulling and R35's hand on R28's shirt pulling. The investigation documents that R28 and R35 were arguing about the vending machine. The determination listed is unable to determine who initiated contact. The Facility's Final Abuse Investigation, dated 2/27/2026, documents Police want to charge (R28) with battery because they (police) know him from the neighborhood. On 4/28/2026 V18 (Vice President of Operations/VPO) stated she did not know why R28 was on a 1:1/one on one and R35 was not. V18 could not present any safety assessment or Interdisciplinary Team Meeting documentation that would explain why R28 was considered the aggressor in the incident with R35. V18 VPO confirmed that R35 has had other verbal and physical altercations with other residents in the past also. The Facility's Final Abuse Investigation, dated 3/12/2026, documents that staff members witnessed R40 walking past R28 in the hallway. R28 asked what R40 was looking at and R40 stated I'm looking at you. R28 was observed then kicking R40's leg and R40 called R28 derogatory names. The Facility's Final Abuse Investigation, dated 3/12/2026, documents that the police came to the facility and issued only R28 a notice to appear in court for battery. (R28) continues to be 1:1 with staff. On 4/28/2026 V18 VPO confirmed that R28 continued to be a 1:1 after incident with R40. V18 could not provide any safety risk assessment or reasoning for R28's continued 1:1. V18 confirmed that R40 has had some run ins with other residents in the past where It has been a while. R28's Counseling notes written by V27 Contracted Social Service documents on 3/9/2026 R28 stated he had no external social support by any friends or family. R28 voiced that he wants a romantic relationship and wants someone to care about him. R28's Counseling notes, dated 3/25/26, documents that R28 identified prayer being a place of ease and nonjudgement. R28's Counseling notes, dated 3/25/26, documents R28 feels bored and unstimulated, and not getting along with other residents and staff. R28's Counseling Notes written by V27 Contracted Social Service documents on 4/15/2026 R28 told V27 Social Service that he was anxious, bored and indecisive. R28's Counseling notes, dated 4/16/2026, documents that R28 was upset that he cannot go to church and has been bored and not finding anything to do, resulting in isolation in his room watching TV. R28's Counseling notes, dated 4/22/2026, documents that R28 stated he was bored. R28's Counseling notes, dated 4/24/2026, documents that R28 felt like he is being ignored, not getting enough attention, and bored and indecisive. On 4/28/2026 V29 Certified Nurse Aide/CNA reported that she was the staff member responsible for R28's 1:1 over the past weekend. V29 CNA stated she took R28 to the main dining room for lunch and was sitting with him when V12 Dietary [NAME] told R28 he had to leave the dining room by saying You can't be in here. V29 CNA stated that R28 asked why not and V12 Dietary [NAME] stated You know why. V29 CNA stated she and R28 left the dining room. V29 CNA stated I don't understand why he cannot be in the dining room especially if he already has a 1:1 and he wasn't doing anything. (R28) already feels like everyone hates him, and I don't think that stuff helps. On 4/28/2026 V12 Dietary [NAME] confirmed that he had asked R28 to leave the dining room over the weekend. V12 stated I was told by management he was not to be in the dining room, that is all I know. V12 confirmed at the time he asked R28 to leave the dining room that he was calmly sitting at a dining room table with V29 CNA sitting with him. On 4/27/2026 V40 (Activity Director) stated that R28 used to come to a lot of activities. V40 (AD) stated that since R28 has been put on a 1:1 for behavior issues that he doesn't really come out as much anymore. On 4/28/2026, at 12:15PM, V42 Ombudsman confirmed that she was aware that R28 was a 1:1 and that he stayed in his room most of the time because he did not like having the 1:1. V42 stated she wasn't sure how long the 1:1 had been in effect. On 4/26/2026 at 10:00 AM, R28 stated I can't go anywhere in this place because I have to have a 1:1. It is embarrassing to have to have a babysitter. I don't understand why I have to have one (1:1) and the other guys (R35 and R40-residents that R28 had been in altercations with) don't have to be 1:1 also. They (Management Staff) even said they didn't know who started either fight, which I say they (R35 and R40) did. Shouldn't they watch some camera footage or something so they can set me free (from 1:1)? R28 stated that with both altercations he was issued a notice to appear in court, and in both instances the charges were dismissed due to lack of evidence. The Facility could not provide any documentation of any safety risk assessments, or documentation of reasoning for continued 1:1 for R28. The facility could not provide any documentation or policy of what a 1:1 should entail, how long it should last, or what the criteria is for continuing or stopping a 1:1. 2. On 4/26/26 at 8:35AM, V29 CNA was pushing R28 in a wheelchair into the dining room, and had an ear bud in her left ear when she turned her head to speak to the state. 3. On 4/28/26 at 12:35PM, V30 CNA was the only staff member in the assisted dining room feeding residents with one hand and had her phone in her lap typing in the phone with her other hand. At that time, V30 stated We feed residents in the assisted dining room, and we have about ten residents who need assistance with feeding or need to be fed. 4. On 4/29/2026 around 11:30AM, V33 CNA was providing cares to R2, V33's phone rang on two different occasions, and on two different occasions V33 silenced her phone when with R2. On 4/28/2026 at 1:27PM, V1 Administrator stated Staff is not to have their ear buds, or phones out in resident care areas.

Based on interview and record review, the facility failed to ensure a resident received treatment as ordered for multiple pressure ulcers for one of two residents (R39) reviewed for pressure ulcers in a sample of 48. This failure resulted in R39's pressure ulcers worsening over time.Findings include:The facility's Pressure Injury and Skin Condition Assessment policy, revised 1/17/2018, documents dressings used for healing purposes will be removed at least weekly or more often in accordance to physician's orders and that physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record/TAR.R39's admission Record documents R39 was admitted to the facility 11/22/2023 with diagnoses including, but not limited to, acute infarction of spinal cord, paraplegia, neuromuscular dysfunction of bladder, cauda equina syndrome, monoplegia of lower limb affecting unspecified side, pressure ulcer of other site (stage 3), pressure ulcer of right buttock (stage 4), pressure ulcer of left buttock (stage 4), pressure ulcer of right heel (stage 4), and pressure ulcer of left heel (stage 3).R39's TAR for the month of February 2026 documents orders dated 2/5/2026 to cleanse dorsum of right foot and left heel with soap and water, pat dry. Apply mesalt to wound bed, cover with gauze and secure with a foam dressing every day shift for wound management. Treatments were not documented as administered on 2/5/2026, 2/6/2026, 2/7/2026, 2/9/2026, 2/11/2026 and 2/13/2026. No further documentation was in R39's record as to why the treatments were not administered as ordered.R39's Wound Clinic progress note, dated 3/30/2026, documents heel sites worse than last visit. Pt (patient) did not have correct dressings on arrival to wound center today. Pt (patient) only had telfa (sterile, non-adherent pad) dressings on all sites. This progress note also includes a wound clinic visit note on 3/2/2026 which documents heel sites measurements worse than last visit. Pt (patient) did not have correct dressing on arrival to wound center today.R39's Wound Clinic visit note, dated 3/30/2026, documents R39 has a left ischial stage four pressure ulcer, a right ischial stage four pressure ulcer, left lower leg stage three pressure ulcer, left heel unstageable pressure ulcer, and a right heel stage four pressure ulcer.R39's Treatment Administration Record (TAR) for the month of March 2006 documents an order dated 2/16/2026 to cleanse dorsum of right foot and left heel with soap and water, pat dry. Apply mesalt to wound bed, cover with gauze and secure with a foam dressing every day shift for wound management. Treatments were not documented as administered on 3/16/2026 and 3/29/2026. No further documentation was in R39's record as to why the treatments were not administered as ordered.R39's medical record has no documentation on R39's current care plan that R39 refuses treatments.On 4/26/2026 at 10:42 AM, R39 stated R39 had concerns that staff have used the wrong dressings on R39's multiple pressure ulcers.On 4/28/2026 at 9:30 AM, R39 refused wound care observation stating dressings were changed the night before and R39 did not want to get back in bed and have dressings changed again for the purpose of observation.On 4/29/2026 at 10:15am, V37 Wound Clinic Registered Nurse stated that on 3/2/2026, (R39) was seen at the wound clinic with all wounds observed covered in the wrong dressings and missing the ordered mesalt (sterile, sodium chloride impregnated gauze) dressing. All R39's wounds have the same dressing order to avoid confusion. On 3/30/2026, (R39) was seen at the wound clinic with all wounds observed covered in telfa (name brand non-adherent dressing) dressings instead of the physician ordered mesalt dressing. (R39's) wounds have worsened, and the facility not using the physician ordered dressings probably contributes to the worsening of the wounds.

Based on interview and record review, the facility failed to ensure staff members are offered the COVID-19 vaccine, track staff member COVID-19 vaccinations, and provide staff education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. These failures have the potential to affect all 53 residents who reside in the facility.Findings include:Facility COVID-19 Vaccination Guidelines- Residents and Employees, revised 6/6/23, documents To minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19. When COVID-19 vaccine is available to the facility each staff member is offered the COVID-19 vaccine unless contraindicated, or has already been immunized. Before offering the COVID-19 vaccine all staff members are provided with education about the risks and benefits of the vaccine to employees. The facility maintains documentation that staff were provided COVID-19 education, offered the COVID-19 vaccine, and COVID-19 vaccination status of staff. V3's IP/Infection Preventionist certification for the Nursing Home Infection Preventionist Training Course, dated 1/26/25, documents V3 completed the required hours for the course. On 4/28/2026 at 1:09PM, V3 LPN/Licensed Practical Nurse IP stated I am not sure what vaccinations we offer to staff. I would have to look that up. We do monitor COVID-19 vaccinations of staff (unable to provide at that time.) On 4/29/2026 at 10:05AM V3 LPN IP stated she was not tracking COVID-19 vaccinations for staff, did not offer education, and did not offer the vaccination to staff.Facility Long-term Care Application for Medicare and Medicaid CMS 671, dated 4/26/26, documents 53 residents currently reside in the facility.

Based on interview, observation, and record review, the facility failed to provide the services of a Registered Nurse for at least eight consecutive hours a day, seven days a week. This failure has the potential to affect all 53 residents residing in the facility.Findings include:The facility's Resident Roster provided by V1 Administrator documents 53 residents currently reside in the facility. The facility was unable to provide any document or policy addressing RN/Registered Nursing scheduling requirements or guidance throughout the course of the survey 4/26-4/29/26. On 4/28/26, V18 VPO/Vice President of Operations for the facility's corporation stated there was no policy addressing necessary RN/Registered Nurse coverage for the facility. V18 stated, until recently, when the facility hired two RNs for weekend coverage, there were only LPNs/Licensed Practical Nurses scheduled to deliver direct care to residents and staff the facility, and the DON/Director of Nursing was only in the facility Monday through Friday, with no RN coverage on the weekends.On Sunday, 4/26/26 at 8:15am, there was no RN on duty in the facility and the Daily Assignment posting verified no RN was scheduled to work on the Day or Night 12-hour Nursing shifts.On 4/26/26 at approximately 8:35am, V10 LPN on duty stated there were no RNs currently assigned to work on 4/26/26.On 4/26/26 at approximately 1:00pm, V2 DON stated, We don't have very many RNs. V2 stated she is an RN and is in the facility eight hours a day Monday through Friday only, and weekend RN coverage has not been consistent. The facility was unable to provide the January 2026 Nursing schedule, or the Daily Assignment postings for the month of January. On 4/29/26 at 10:00am, V18 VPO stated there were RNs scheduled in January 2026, because there were residents with IV/Intravenous infusions residing in the facility at that time. The facility's Nursing schedules for February, March and April of 2026 were provided by the facility and document no RN coverage for the following dates: February 2, 7, 8, 14, 15, 21, 22, and 28; March 7, 8, 14, 15, 21, 22, 28, and 29; and April 11,18, 19, and 25. Facility Long-term Care Application for Medicare and Medicaid CMS 671, dated 4/26/26, documents 53 residents currently reside in the facility.

Based on observation, interview and record review the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. These failures have the potential affect all 53 residents who live in the facility.Findings include:The facility's Dietary Policies and Procedures Manual, dated 2025, documents the following under Dress Code. [NAME] nets should be used for employees with facial hair.On 4/26/26 at 8:15am, during meal service V12 Dietary Cook/Server had no beard net covering his beard while filling residents' breakfast plates.On 4/26/26 at 9:00am, V11 Dietary Manager stated V12 should be wearing a beard net in the kitchen. On 4/26/26 at 12:15pm during lunch service, V12's beard net was askew on his chin, and only partially covered his full-facial beard while standing over the steam table, and filling plates for lunch.On 4/27/26 at 8:15am and 12:00pm, during meal service, V12 was filling plates at the steam table, and V12's beard net was under his chin leaving the facial beard exposed and uncovered.On 4/28/26 at 8:05am, V12 was serving breakfast at the steam table with a beard net under his chin leaving most of his beard uncovered.The facility's Food Storage policy, dated 2025, documents: Containers are to be dated and labeled with the contents. All food not in original containers should be labeled, dated, and stored in approved containers.On 4/26/26 at 8:12am, a large undated, unidentified plastic container of thick red liquid was noted on a shelf in the walk-in refrigerator as well as a large personal beverage container with no label/no date was noted in the walk-in refrigerator in the kitchen.On 4/26/26 at 8:20am, six undated, and unidentified individual servings of a pasta dish in the kitchen cooler/refrigerator were on a metal tray dated 4/14/26. V12 Dietary Cook/Aide stated these were servings of pasta salad left over from last week. An undated, unidentified restaurant carry-out container of chicken wings and two plastic containers of sauce were noted in the kitchen cooler/refrigerator. V15/Dietary Aide stated, That's mine. I put it in there just this morning. On 4/26/26 at 9:08am, V11 Dietary Manager stated, regarding the walk-in refrigerator foods, the large undated plastic container of leftover tomato soup should have been dated and cannot be used. V11 stated the large reusable personal beverage container was his and, it shouldn't be there. Regarding the food in the kitchen cooler/refrigerator, V11 stated, the undated pasta salad servings were on a tray and dated 4/14/26 but should have been discarded. V11 stated the restaurant carry-out container in the kitchen refrigerator was an employee's lunch and should not be in the kitchen refrigerator but stored in the Employee Break Room located just outside the Dining Room door.On 4/28/26 at approximately 3:35pm, V33 Regional Director of Operations verified employee food should be stored in the Employee Break Room and not in the facility's kitchen.Facility Long-term Care Application for Medicare and Medicaid CMS 671, dated 4/26/26, documents 53 residents currently reside in the facility.

Based on interview and record review, the facility failed to keep linens in the hallway covered, and failed to include in their water management program the frequency for testing, testing protocols, acceptable ranges, and a system to document the testing and corrective actions for Legionella; failed to have any baseline testing performed to establish for their ranges or testing frequency; failed to do routine flushing of water lines; and failed to implement their policy following a water main break. These failures have the potential to affect all 53 residents who reside in the facility.Findings include:CDC- https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-All-Modules.pdf-February 17, 2026, Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), documents the following: People at increased risk for Legionnaires' disease: Includes people 50 years or older, current or former smokers, people with a chronic lung disease (like emphysema), people with weak immune systems or who take drugs that weaken the immune system, people with cancer, and people with underlying illnesses such as diabetes, kidney failure, or liver failure. Routine Legionella testing: Testing for Legionella to establish a baseline measurement for performance indicators or for validating a water management program or corrective action. Validation: Activities to confirm the water management program is working as intended and is effective for Legionella control. Routine Testing for Legionella Purpose Use this document to help analyze hazards and establish Legionella control measures and complement existing resources for testing, sampling, and water management programs (WMPs). Elements of a healthcare water management program includes control measures, their locations and how to monitor them, and interventions when control limits are not met. It also ensures the program is running as designed and is effective, and includes documentation and communication on all activities. Facility Water Management Program Reduce Legionella Growth, dated 6/30/17, documents To identify and reduce the risk of Legionella growth and spread. Additional monitoring or actions may need to be implemented for the following risk factors: Water main breaks: Changes in water pressure can dislodge biofilm and free Legionella into the water, while dirt and other materials can be introduced into the water and use up disinfectant. The water management program should be reviewed at least once per year, and when data review shows control measures are persistently outside of control limits. Facility Water Management Program Reduce Legionella Growth, revised 5/17/24, has no documentation for the frequency of testing, testing protocols, acceptable ranges, and a system to document the testing and corrective actions for Legionella. Facility Long-term Care Application for Medicare and Medicaid CMS 671, dated 4/26/26, documents 53 residents currently reside in the facility. The facility was unable to provide any baseline testing of their water, or any water sample analysis from the health department/town on their water. On 4/27/26 at 8:10AM V17 Maintenance stated he does not have any water testing results or testing protocols, does not use heat or chemical water treatment, has not been adjusting water temperatures, or increasing water monitoring for Legionella since the water main break on Thursday 4/23/26. V17 stated he has no health or water department testing of their water for comparison to determine acceptable testing ranges, no way to document if testing is performed, and has no corrective actions in place for Legionella prevention. V17 was unable to answer how they would know if the facility had Legionella in their water, and what the facility water quality baseline range is. On 4/28/2026 at 1:09PM, V3 LPN/Licensed Practical Nurse IP/Infection Preventionist stated she does do not do anything with Legionella surveillance or prevention. On 4/28/2026 at 2:34PM, V18 VPO/Vice President Operations stated We don't have any legionella testing. On 4/29/26 at 10:16AM, V17 Maintenance stated the facility had a water main break on Thursday (4/23/26) and it was repaired on Saturday (4/25/26), the nursing home has and is on a boil order, and has not followed their policy for implementing additional monitoring following the water main break. On 4/28/2026 at 3:07 PM V11 DM/Dietary Manager stated the boil order was lifted. On 4/29/2026 at 9:06 AM, V17 Maintenance stated he has not been flushing the facilities water pipes and does not do any routine water pipe flushing; does not have a diagram of the facilities piping; is unsure what parts of the building has stagnant pipes; is not water testing and does not have a testing kit in the facility, and; does not have baseline water reports for Legionella. On 4/29/2026 from 9:40AM-10:05AM continuous observations, the linen cart on the [NAME] wings cover was lifted up on top of the cart and was exposing towels, bath blankets, sheets, gowns, bedspreads, pillow cases, briefs, and gloves. At that same time, V29 CNA/Certified Nurse Aide was grabbing linen off the linen cart to go in and out of a resident room, did not pull the linen cart cover down over the linens, and left them exposed. On 4/29/2026 at 10:05 AM V3 LPN IP walked past the linen cart on the [NAME] wing and pulled the linen cover down, and verified the linen should be covered any time no staff is standing in front of the linen cart.

Based on interview and record review, the facility failed to track antibiotic start and stop dates, labs/cultures drawn and what organism, and failed to use their infection assessment tool prior to administration of an antibiotic. These failures have the potential to affect all 53 residents who reside in the facility.Findings include: Facility Infection Surveillance, Tracking, and QA Reporting, revised 2/14/18, documents To identify, monitor, track and report infections and monitor adherence to infection control practices. Review of laboratory/microbiology reports and results; Review documentation of clinical signs and symptoms to determine if Mc Greers criteria for infection were met and antibiotic use is appropriate; Track physician antibiotic prescribing practices as appropriate; Complete Infection Tracking Log for all residents with infection and/or treated with antibiotics. Facility Antibiotic Stewardship Program, dated 11/28/17, documents This facility is dedicated to implementing an Antibiotic Stewardship Program to reduce the unnecessary use of antibiotics. This program helps ensure our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, and reduce healthcare costs. This facility uses Mc [NAME]'s Criteria for determining if an infection meets criteria for treatment with an antibiotic. Review the clinical record for new antibiotics starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. Pub Med Central National Library of Medicine online information on 5/1/26 documents The Mc [NAME] criteria are standardized, evidence-based definitions used for infection surveillance in long-term care facilities (LTCFs). They help identify infections (UTI, respiratory, skin/soft tissue, gastroenteritis) to guide antibiotic stewardship, track outbreaks, and improve clinical outcomes, often distinguishing between surveillance definitions and the minimum criteria needed for initiating antibiotics. Key Aspects of Revised Mc [NAME] Criteria: Purpose: To standardize infection tracking in nursing homes and LTCFs. Common Applications: UTI: Requires specific localizing symptoms (e.g., dysuria, fever, new confusion) and microbiologic data. Respiratory: Criteria for pneumonia vs. lower respiratory infections (e.g., cough, sputum, fever, pulse > 100/min). Skin/Soft Tissue: Presence of pus or at least 4 symptoms (redness, warmth, tenderness). Gastroenteritis: Specific definitions for diarrhea and vomiting. Implementation: Used by infection preventionists for prospective or retrospective surveillance. Mc [NAME] Criteria: Used for surveillance (tracking infection rates, outbreaks). These criteria are essential for combating antibiotic resistance by reducing unnecessary treatments. V3's IP/Infection Preventionist certification for the Nursing Home Infection Preventionist Training Course, dated 1/26/25, documents V3 completed the required hours for the course. Facilities January to April 2026 Infection control tracking was reviewed and was not complete with antibiotic start/stop dates, what diagnosis the antibiotic was prescribed to treat, labs/cultures drawn and what organism, and if they used their infection assessment tool prior to administration of an antibiotic. On 4/28/2026 at 1:09PM, V3 LPN/Licensed Practical Nurse IP/Infection Preventionist stated There was no infection control tracking log being done until I took over this job in December 2025. At that time, V3 verified the January to April 2026 tracking form was not complete with the above information and she should be tracking start, stop, diagnosis, labs/cultures, organism, and using their infection assessment tool (Mc [NAME]) prior to administration of an antibiotic to a resident. V3 stated the Mc [NAME] is completed by her, not the nurse obtaining the orders for the antibiotic for the resident at the time, and she may do the assessment after the antibiotic is already ordered and not indicated for use. V3 verified the Mc [NAME] should be completed before an antibiotic is started on a resident; and V8 MD/Medical Doctor has started a resident on an antibiotic before getting the urinalysis/culture/Mc [NAME] which indicated no antibiotics were indicated.Facility Long-term Care Application for Medicare and Medicaid CMS 671, dated 4/26/26, documents 53 residents currently reside in the facility.

Based on interview and record review, the facility failed to ensure the Advance Beneficiary Notice (ABN) CMS-10055 form was issued to Medicare Part A beneficiaries notifying the resident and/or resident's Power of Attorney, if applicable, the date Medicare Part A covered services will end for four of six residents (R4, R14, R30, R65) reviewed for ABN in a sample of 48.Findings include:The facility was unable to provide a NOMNC/Notice of Medicare Non-Coverage or Resident Beneficiary Notice policy.On 4/27/26 at approximately 8:05am, V1 Administrator provided a list of the following five facility residents discharged from Medicare A covered services in the past six months, due to expiring Medicare A coverage: R4, R13, R30, R59 and R65. On 4/27/26 at 11:35am, this survey requested NOMNC notices from the facility for R14, R30, and R59. On 4/27/26 at approximately 2:30pm, V1 provided NOMNC/Beneficiary Notification documentation for R13 only, stating, There were no NOMNC/Beneficiary Notices for the other two residents (R4 and R59). On 4/27/26 at approximately 3:00pm, NOMNC notices were requested for R14, R30 and R59, residents discharged from Medicare A covered services in the past six months. On 4/28/26 at approximately 1:55pm, V1 provided NOMNC notices for R59 only, stating there were no NOMNC notices for R14 or R30. On 4/28/26 at approximately 2:00pm, V1 verified NOMNC notices should have been provided for the residents discharged from Medicare A covered services (R4, R14, R30, R65) and this had not been done.

Based on record review, observation, and interview the facility failed to provide a clean environment for five (R14, R20, R24, R32, R42) of five residents reviewed for the environment in a total sample of 48.R14's Electronic Health Record documents R14 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Acute Kidney Failure, Diabetes, and Heart Failure. On 4/27/26 at 11:16 AM, V22 (R14's family member) reported R14 was transferred to a different facility on 4/20/26. V22 reported during R14's stay R14 had gotten another resident's feces on R14's pants while using the shared bathroom. V22 reported the bathroom had feces on the floor and toilet and R14 could not wait to go to the bathroom so he got the feces on his pants. On 4/29/26 at 9:06 AM, R45 reported he was R14's roommate prior to R14's discharge from the facility. R45 reported R14's previous roommate was R24, R24 has a colostomy bag, and R24 cleans the colostomy bag in the bathroom. On 4/29/26 at 9:30 AM, R24's bathroom had feces splattered on the toilet and in the sink. There was also undigested food particles on the drain guard of the sink. On 4/29/26 at 9:30 AM, V17 Maintenance Director reported R24 has a colostomy bag, cleans the colostomy bag in the sink, and stated, I wish (R24) wouldn't do that. On 4/29/26 at 9:40 AM, V25 Housekeeping Director reported she is aware R24 cleans his colostomy in the bathroom sink and has instructed housekeeping staff to check R24's bathroom several times a day to be sure it is clean. V25 reported this information was only relayed verbally and there is not any type of tracking to indicate how often the bathroom is checked and cleaned. On 4/29/26 at 9:48 AM, R24 reported he empties and cleans his colostomy bag and staff help sometimes. R24's care plan intervention with a revision date of 3/19/26 documents, Provide ostomy care daily and [as needed]. On 4/29/26 at 10:17 AM, V25 Housekeeping Director reported it has been discussed in multiple meetings with administration and department heads about R24 emptying and cleaning his colostomy bag himself in the bathroom and leaving feces on the floor, toilet, and sink. On 4/29/26 at 1:43 PM V2 DON/Director of Nursing confirmed R24, R20, R32, and R42 all share a bathroom.

Based on interview and record review, the facility failed to ensure that all allegations of abuse were reported immediately to the Administrator or designated official, and state agency for one (R46) of two residents reviewed for abuse in the sample list of 48. Findings include:The facility's Abuse Prevention and Reporting Policy revised 10/24/22, documents mental and verbal abuse or conduct that may cause humiliation, intimidation, or distress, including insulting or threatening language. The policy required all staff to immediately report any allegation, suspicion, or observation of abuse to the Administrator or designated authority.R46's census line documents R46 was admitted to the facility on [DATE].R46's Minimum Data Set (MDS), dated [DATE], documents R46 is cognitively intact. A subsequent MDS, dated [DATE], documents R46's cognition was not assessed, and documented R46 is dependent on staff for toileting and transfers.On 4/27/26 at 10:37 AM, R46 stated that over the weekend, an agency Certified Nursing Assistant/CNA (identified as V19) refused to provide care when requested. R46 stated she asked V19 to assist her with toileting prior to leaving the facility with family, and V19 refused twice. R46 further stated that V19 told R46, they should have left your ass in the bed, and someone could have got you up and ready right before you left. R46 reported the interaction was upsetting and inappropriate. R46 stated she reported the incident to V2 (Director of Nursing) on 4/26/26, and V2 apologized and stated she would address it.On 4/27/26 at 11:00 AM, V1 Administrator stated she had not been made aware of any abuse allegation involving R46. Upon notification by the surveyor, V1 and the surveyor interviewed R46, who reiterated the above concerns and confirmed she reported the incident to V2.On 4/27/26 at 11:05 AM, V2 stated that R46 had informed her that a staff member was not nice on the previous day and she had requested V19 not return to the facility because of attitude related problems and rudeness. V2 acknowledged she did not report the allegation to the Administrator, or initiate the facility's abuse reporting process.On 4/27/26 at 11:30 AM, V1 stated that V2 should have made V1 aware of the abuse allegations as soon as she was made aware.

Based on interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated and that appropriate actions were taken to prevent further potential abuse for one (R46) of two residents reviewed for abuse in the sample list of 48. Findings include:The facility's Abuse Prevention and Reporting Policy revised 10/24/22, documents that all allegations of abuse be thoroughly investigated, including the collection of statements, documentation of findings, and implementation of corrective actions to prevent recurrence.R46's census line documents R46 was admitted to the facility on [DATE].R46's Minimum Data Set (MDS) dated [DATE] documents R46 is cognitively intact. A subsequent MDS, dated [DATE], documents R46's cognition was not assessed, and documented R46 is dependent on staff for toileting and transfers.On 4/27/26 at 10:37 AM, R46 stated that over the weekend, an agency Certified Nursing Assistant/CNA (identified as V19) refused to provide care when requested. R46 stated she asked V19 to assist her with toileting prior to leaving the facility with family, and V19 refused twice. R46 further stated that V19 told R46, they should have left your ass in the bed, and someone could have got you up and ready right before you left. R46 reported the interaction was upsetting and inappropriate. R46 stated she reported the incident to V2 Director of Nursing on 4/26/26, and V2 apologized and stated she would address it.On 4/27/26 at 11:05 AM, V2 Director of Nursing stated R46 had informed her that V19 CNA was not nice on the previous day. V2 acknowledged she did not initiate an investigation into the allegation.On 4/27/26 at 12:04 PM, V1 Administrator stated that V2 blocked V19 from working in the facility on 4/26/26 without conducting a formal investigation into the allegation. V1 further stated R46's abuse allegations should have been investigated and reported to the state agency.

Based on interview and record review the facility failed to notify the local Ombudsman of transfers and discharges, and the facility failed to notify one resident's family (R23) of three residents reviewed for transfers and discharges. These failures have the potential to affect all 53 residents that currently reside in the facility. The facility's Physician-Family Notification-Change of Condition policy, dated 11/13/2018, documents the purpose of the policy is to ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely. efficient, and effective manner. A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g. an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g. the use of any medical procedure, or therapy that has not been used on that resident before). R23's Nurse's Notes, dated 1/3/2026 at 11:52 PM, document that R23 had continuous vomitus episodes that he said tasted like blood. R23 requested to be sent to the emergency room to be evaluated. R23's SNF (Skilled Nursing Facility)/NF (Nursing Facility) to Hospital Transfer Form, dated 1/3/2026, documents that R23 was sent to the Emergency Room. The SNF/NF to Hospital Transfer Form documents Resident Representative (V41) notified of transfer? No. Aware of clinical situation? No. On 4/29/2026 at 9:36 AM, V41/R23's Family member stated I am his only contact person. I am the person the nurses usually call when something happens. I did not get called about the January 3rd hospitalization. (R23) told me about it. On 4/28/2026 at 11:00 AM, V42 Ombudsman stated she was not getting notified in any way of transfers or discharges from the facility. On 4/29/2026 at 1:00PM, V1 Administrator confirmed that the facility could not provide any documentation of the Ombudsman being notified of transfers and discharges from the facility. That should have been getting done and it wasn't. The facility's Resident Census and Report, dated 4/26/2026, documents 53 residents currently reside in the facility.

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I/II re-screen and/or referral was completed following a significant change in mental health status when a new mental illness diagnosis was added for a resident, implement and follow recommendations outlined in a Short-Term expired PASRR for three (R11, R28, and R35) of five residents reviewed for PASRR in the sample list of 48.Findings include:The facility's PASRR (Preadmission Screening and Resident Review) policy (revised [DATE]) documents the facility will coordinate with the state PASRR authority, complete Level I screenings annually and with significant changes in status, and report changes to the appropriate state authority to ensure residents receive necessary services. 1.R11 was admitted to the facility on [DATE] as documented on the census line. R11's Notice of PASRR Level II outcome, dated [DATE], documents diagnoses of Bipolar Disorder and Dementia with Alzheimer's disease. This PASRR Level II did not include a diagnosis of Post-Traumatic Stress Disorder/PTSD. R11's Medical Diagnosis List documents PTSD was added to R11's medical diagnosis list on [DATE]. R11's current care plan documents chronic PTSD related to past abuse, with noted difficulty accepting medications due to beliefs that medications may be incorrect. R11's Minimum Data Set/MDS assessments dated [DATE] and [DATE] both documented a diagnosis of PTSD. The [DATE] MDS also documented that R11 is cognitively impaired. On [DATE] at 10:26 AM, V1 Administrator stated the facility did not have a PASRR Level II completed for R11. V1 stated a new PASRR was not initiated when the diagnosis of PTSD was added to R11's medical diagnosis list on [DATE] and this should have been done. 2. R35's admission Record documents R35 admitted to the facility [DATE]. R35's Electronic Health Record documents a level one PASRR completed upon admission with no level two indicated. R35's admission Record documents a diagnosis of bipolar disorder with an onset date of [DATE]. R35's MDS, dated [DATE], documents an active diagnosis of bipolar disorder. R35's prior MDS, dated [DATE] does not document an active diagnosis of bipolar disorder. On [DATE] at 12:15 PM, V18 [NAME] President of Operations/VPO stated that typically if a new mental health diagnosis is confirmed, the MDS coordinator would update the MDS and then let the Social Service Director know of the new diagnosis. The Social Service Director would then initiate the PASRR, but there is no record of this being done. 3.R28's PASRR Level II documents PASRR Determination: Short Term Approval without Specialized Services. Date Short Term Approval Ends: [DATE]. The Facility could not provide any updated PASSR for R28. On [DATE] V18 VPO confirmed R28's PASSR was expired as of [DATE] and that R28 should have been reassessed.

Based on interview and record review, the facility failed to implement a safety plan as identified on a Level II Preadmission Screening and Resident Review (PASSR) for one (R28) of five residents reviewed for PASSR in a total sample of 48.Findings include: The Facility's Preadmission Screening and Annual Resident Review (PASSR) policy, dated 11/17/2017, documents The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. Coordination of Care. Upon admission, the facility will include the PASARR level II determination and evaluation report into the residents 'assessment, comprehensive care plan ii. The facility will care plan and provide the specialized services as indicated in the level II determination. The services will be provided under the direction of the qualified personnel indicated.R28's Illinois PASRR Summary of Findings, dated 7/24/2025, documents You have called EMS (Emergency Medical Services) needing someone to talk to. You expressed thoughts of self-harm, You deny intent or a plan. R28's Illinois PASRR Summary of Findings, dated 7/24/2025, documents A crisis intervention services or plan. A safety plan needs to be in place should you have thoughts of self harm and need support. Individual, group and family psychotherapy; and talking to a counselor might help. R28's Medical Record does not contain any information related to a safety plan in place for R28. R28's Counseling Notes, dated 3/9/2026, document the beginning of therapy for R28. R28's counseling notes from 3/9/2026 through present document denial of any suicidal thoughts by R28. On 4/27/2026 V27 Contract Social Service/Counselor stated he was not aware of PASRR level II results for R28, and he was not aware of any history of suicidal ideation by R28.On 4/27/2026 Both V1 Administrator and V18 [NAME] President of Operations denied knowledge of the results of R28's PASRR level II that indicated a history of suicidal ideations. On 4/27/2026 R28 denied making suicidal statements. I do not believe in suicide, it is a sin. I said I wish the good Lord would go ahead and take me. But I would never pretend to know better than the Lord.

Based on interview and record review, the facility failed to ensure the resident and representative were invited to participate in care plan meetings and failed to review and revise the comprehensive care plan on an ongoing basis for two (R11, R28) of five residents reviewed for care planning in the sample list of 48. Findings include:The facility's Comprehensive Care Plan policy, revised 11/17/2011, documents the Interdisciplinary Team (IDT) is responsible for reviewing and revising the care plan after each assessment, including quarterly reviews, and that the residents and/or representatives are to be invited to participate at least quarterly, either in person, by phone, or via video conference.R11's Census Line Documents R11 admitted to the facility on [DATE].R11's Minimum Data Set/MDS dated [DATE] documents R11 is cognitively impaired and is dependent on staff for activities of daily living. R11's electronic medical record does not contain documentation of a care plan meeting or care plan notes.On 4/27/2026 at 12:27 PM, V20 (R11's Family Member) stated communication with the facility was very difficult. V20 stated calls to the facility often go unanswered with no return calls. V20 further stated he had not been contacted for a care plan meeting in over one year. V20 expressed concerns regarding R11's roommate turning the television volume up loudly, which bothered R11, including during family visits. V20 stated these concerns had been voiced to staff but not resolved. V20 also reported R11 experienced a recent fall, and he was not notified by the facility, learning of the incident days later from the resident. V20 stated, The only way we know what's happening is hospice.On 4/27/2026 at 1:15 PM, V21 MDS Coordinator stated she was unable to locate documentation of a care plan meeting for R11 within the past year. V21 stated she had been in the role approximately four weeks and was in the process of organizing records. V21 stated that care plan meetings should be held quarterly and as needed with changes and the resident and residents representative should be invited to the meetings.

Based on observation, interview, and record review, the facility failed to provide adequate administrative oversight to ensure the facility implemented policies for wound care, medication administration, treatment administration, quality assurance measures, and basic activities of daily resident care. These failures resulted in a facility-wide lack of supervision and care leading to residents experiencing worsening pressure ulcers, severe pain, a lack of resident care for gastrostomy tubes and pressure ulcer treatments with subsequent infections requiring hospitalization, untimely assistance with incontinent care and showers resulting in residents being left in soiled conditions for extended periods, missed medication administrations with significant medication errors, and not providing a functional, licensed and engaged leadership team. This negligence posed a high potential for, and resulted in, actual harm to residents, and has the potential to affect all 53 residents residing in the facility.These failures resulted in Immediate Jeopardy. The Immediate Jeopardy started on 11/7/25 when R4 was identified at high risk of developing a pressure ulcer. V1/Administrator-in-Training, V2/Corporate/Interim Director of Nursing, and V19/Administrator from sister facility were notified of the Immediate Jeopardy on 2/4/26 at 2:04 PM. While the immediacy was removed on 2/10/26 the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Daily Census Report, dated 1/26/26, documents 53 residents reside in the facility.The Facility Assessment, dated 11/1/25, documents in section three Facility Resources needed to provide competent support and care for our resident population on a daily basis and during emergencies include an Administrator, Assistant Administrator, Activity Director and other activity staff.The Administrator Job Description, dated 5/2/17, documents Summary: The Administrator directs the day-to-day functions of the facility in accordance with current federal and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice, ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures, Assist in recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etcetera, Assist department directors in the topic section, planning, conducting, and scheduling of in-service training classes and on-the-job training and orientation program to assure that current material and programs are continuously provided, ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times, and performs other duties as assigned. Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of knowledge, skill, and/or ability required. Must possess a current, unencumbered, active license to practice as a Nursing Home Administrator.The Director of Nursing Job Description, dated 5/2/17, documents Summary: The primary purpose of the Director of Nursing position is to plan, organize, develop, and direct the overall operation of our Nursing Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical director, to ensure that the highest degree of quality care is maintained at all times. Essential duties and responsibilities: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations and guidelines that govern the nursing care facilities Develop, maintain, and periodically update written policies and procedures that govern the day-today functions of the nursing service department. Make written and oral reports/recommendations to the Administrator as necessary/required, concerning the operation of the nursing service department. Develops methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care. Maintain ongoing quality of assurance program for the nursing department. Participate in the facility surveys made by authorized government agencies as necessary or as may be directed. Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies. Assist with discharge planning and perform administrative duties such as completing medical forms, reports, evaluations, studies charting, etcetera. Monitor the facility's Quality Indicators and Quality Measures and survey reports. Assist in the developing plans of action to correct potential or identified problem areas. Assist in calculating the number of direct nursing care personnel on duty each shift. Assign a sufficient number of licensed practical and/or registered nurses for each tour of duty to ensure that quality care is maintained. Assign a sufficient number of certified nursing assistants for each tour of duty to ensure that routing nursing care is provided to meet the daily nursing care needs of each resident. Develop work assignments and schedule duty hours, and/or assist nursing supervisory staff in completing and performing such tasks. Delegate to nursing personnel the administrative authority, responsibility and accountability necessary to perform their assigned duties. Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments. Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled. Provide direct nursing care as necessary.R1, R2, R4, R5, R6, R7, and R9's medical records document multiple missed significant medications, wound treatments, gastrostomy (g-tube) cares, and scheduled showers from 11/1/25-2/9/26.R4 was admitted to the facility on [DATE] with no pressure ulcers. On 12/12/25 a stage three pressure ulcer was found on R4's coccyx. Treatment was not started for 24 hours. Sixteen treatments were not done between 12/12/25 and 1/21/26. On 1/21/26 R4 was sent to the emergency room with complaints of fever and lethargy. R4 was admitted to the hospital with diagnoses of Severe Sepsis and Stage IV Sacral Ulcer with concern for osteomyelitis. Radiology Report documents Stage IV (four) sacral ulcer with ill-defined lower sacral and coccygeal posterior cortices which suggests osteomyelitis.R9 was admitted to the facility on [DATE] with treatment orders for a stage four pressure ulcer on his sacrum. On 12/09/25, R9 had a change in condition and was sent to a local hospital and admitted for Sepsis from stage IV sacral wound with osteomyelitis. R9 returned to the facility on [DATE]. From 12/23/25 - 1/17/26, multiple wound treatments were not completed. On 1/1/26 R9's rectal tube was accidentally removed, and the facility did not replace it due to lack of supplies. R9's sacral wound was subsequently exposed to fecal matter for extended periods of time from 1/1/26 - 1/17/26. R9's Treatment Administration records dated from 11/20/25- 1/17/26 documents multiple g-tube site care treatments and residual checks were not completed for a total of 15 uncompleted g-tube site cleansing and 26 missed residual assessments. On 1/17/26 R9 had a change in condition and was sent to a local hospital and admitted for fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance, and a diagnosis of sepsis from multiple suspected sources including g-tube site infection with pus leaking drainage and a stage IV sacral wound with osteomyelitis.On 1/28/26 at 11:08 AM, V4 (Assistant Director of Nursing) confirmed that residents who have or are at risk for pressure ulcers should have skin assessments performed daily by nursing and those are not being documented for R4 or R9 who both have stage four pressure ulcers and multiple comorbidities. V4 stated Wound care and skin checks and assessments should be completed by the floor nurses.On 1/29/26 at 12:50 PM, V33 (emergency room Physician) stated I saw (R9) in the hospital. He is a very sick person and it's unfortunate. When we admitted him for the second time for Sepsis (1/17) we had him in the ER for a longer period. Any tube coming out of the body has the potential to get infected. At the time of his admission, we also were concerned with his g-tube site with purulent pus like drainage which can relate to the sepsis. If you don't take care of the g-tube properly with cleansing and flushes, then you can get infection at the site. Additionally, if the feeding is going into the abdominal cavity due to becoming dislodged it also is a risk factor for that becoming infected. I believe the g-tube was removed by gastrointestinal surgeons while in the hospital.R1's (MAR) Medication Administration Record, dated 12/1/25-12/31/25, documents R1 did not receive 18 scheduled doses of physician ordered medications in December, including Eliquis (anticoagulant), Juven (nutritional wound supplement), Zonisamide (anticonvulsant), Keppra (anticonvulsant), Metoprolol (antihypertensive), Vimpat (antiepileptic) and Modafinil (stimulant). These medications were left blank or document to see nurses notes. Follow up nursing notes for the unadministered medications document on order, not available.R2's MAR, dated November 1st - 4th 2025 documents 100% (percent) of scheduled Norco (pain medication) (5-325mg) (milligrams) doses (12 out of 12) were not administered.R4's MAR dated December 2025 documents R4 missed four doses of scheduled Vimpat Oral Tablet 100 MG, seven doses of physician ordered Keppra Oral Tablet 750 MG, and six doses of physician ordered Hydrochlorothiazide 25 MG.R6's MAR dated January 11th - January 20th, 2026, documents R6 missed seven doses of Enoxaparin Sodium Injection Solution Prefilled Syringe 30 MG/0.3 ML (milliliter).On 1/29/26 at 1:04 PM, V30/Facility Nurse Practitioner stated she has heard there are problems with the facility not having the medications available for the residents. R1, R4, R5, R6, R7, and R9's medical records do not document evidence of R1, R4, R5, R6, R7, or R9 receiving a shower in the months of December 2025 and January 2026.On 1/29/26 at 1:10 PM, V2/DON (Director of Nursing) stated she could not provide evidence or documentation showing R1, R4, R5, R6, R7, or R9 received a shower in the months of December 2025 and January 2025. V2 confirmed that no one is overseeing that showers are being documented and completed as scheduled.On 1/26/26 and 1/27/26 between 9:00 AM and 3:30 PM, facility residents were not observed in activities, no announcements were made about activities, and no current activity calendar was observed around the facility or in resident rooms.On 1/28/26 R10, R11, R12, and R13 all stated the facility does not have activities every day. At this same time, R14 also confirmed there are no daily activities and stated, They do not have a fulltime Activity Director.On 1/28/26 at 11:38 AM V25/Housekeeping Supervisor stated she fills in at times to perform activities with the residents since the facility does not have an Activity Director, but it's not often. V25 verified no activities were performed with the residents on 1/26/26 and 1/27/26. V25 stated, The last two days I had to help on the floor, so I was unable to ensure activities were being done with the residents. There are no planned activities after 4:00 PM or on the weekends for the residents.On 1/28/26 at 11:45 AM, V1/Administrator in Training verified the facility does not have a current activity director, and activities are not getting one daily.On 1/26/26, the facility did have an Administrator or Director of Nursing present in the facility until after 10:30 AM (after the state agency surveyors arrived and administration was notified.)Throughout the survey from 1/26/26 through 2/3/26 multiple observations were made of V1/AIT (Administrator in Training) and V2/Interim Director of Nursing's office doors closed. V2's window on the office door remained covered throughout the survey with a dark panel, giving the appearance that the office is dark when the door is closed.On 1/27/26 at 11:20 AM V1/AIT stated I do not have a temporary license yet. I am in the classes but not eligible to apply for the AIT licenses yet. I have worked here since July of 2025 in this role. (V14) is the corporate vice president of operations (VPO), and she is the administrator over this building. (V14) is not here every day.On 1/27/26 at 12:02 PM V17/Ombudsman stated the biggest complaint she has heard in resident council meetings is that the residents are not getting showers on second and third shifts. V17 also stated there have been resident complaints about management not coming out of their office or management keeping their doors closed so the residents never know who to talk with about issues or concerns. V17 stated During resident council today, the residents stated they were very bored. The facility has not been having activities going on, no calendar has been posted or passed out to the residents' rooms, and they have not been offering daily activities. Residents have told me they have to figure out their own activities to do.On 1/30/26 at 1:22 PM, V4/Assistant Director of Nursing confirmed that V1/AIT is not in the facility on this date. On 2/2/26 at 10:00 AM, Both V1/AIT and V2/Interim Director of Nursing confirmed they were not in the building on Friday (1/30/26). At this time V1 and V2 were notified of an immediate jeopardy finding for R4 and R9's pressure ulcers.On 2/2/26 at 11:00 AM V14/ Regional VPO, confirmed she is the administrator over the facility and is training V1. V14 stated I am VP of operations over eleven homes, so I travel amongst them for regional support. From entrance of this survey (1/26/26), 2/2/26 is the first time V14 was seen in the building.On 2/3/26 at 1:33 PM V2/Interim DON stated V4/LPN (Licensed Practical Nurse)/Wound Nurse/Infection Preventionist is responsible for looking at the resident's MARS and TARS (Treatment Administration Records) daily to ensure medications were being given and treatments were being provided as physician ordered. V2 stated V4 is also responsible for ensuring the wound program is implemented and followed. V2 stated, I was not aware (V4) was not monitoring the resident's MARS and TARS daily to ensure physician orders were being followed to ensure resident's received appropriate care. I should have been aware.On 2/3/26 at 2:20PM V4/LPN/Wound Nurse/Infection Preventionist stated, I was not educated on the process of the wounds at the facility. I tried to audit to see where things were at with wounds in this facility because no wound logs were left to show who even had wounds. In December 2025 when I started, (V5/Former Director of Nursing) didn't really know what to tell me to do. V2/Interim Director of Nursing just showed me on 2/2/26 how to monitor MARS and TARs. I was not delegated to monitor TARS and MARS prior to 2/2/26.On 1/27/26 at 12:47 PM V35/LPN stated In December (V1/AIT) and (V2/Interim Director of Nursing) were calling people in and stating they couldn't tell state (agency surveyors) things and couldn't chart certain things. They didn't want us to bring up any issues or let anyone know the issues. They just wanted to hide what was going on.On 2/3/26 at 12:04 AM V41/CNA stated the facility's management is not stable. They don't take care of problems or don't seem to care about the residents. Their doors are always shut. They can do better as people and better professionally. There are no scheduled activities in the evenings for the residents. V1/Administrator-in-Training and V2/Interim Director of Nursing both keep their door shut.On 2/3/26 at 12:35 PM, V43/CNA stated that she has worked on and off at the facility for 15 years but will never step a foot back in the building since they have gotten new management. The staffing is absolutely horrible. Evenings will have two to three CNAs working. There have been times when there were only one CNA and one nurse on night shift. There are no activities in the evening. Call lights are not answered timely. It can take an hour or longer. There were several residents that did not get their pain medication as needed and would complain. Wound treatments were not being done daily. When we say we are short on staff management says, we need to make it work. V1/AIT and V2/Interim Director of Nursing's doors are always closed. V2/Interim Director of Nursing only comes in once a week to give write-ups. I got a write up because I was not taking my lunch. I didn't have time to take lunch because we were short staffed. Just because there may be enough CNAs in the building if they are agency they are not as efficient, and we are not able to give the residents the care they deserve. On 2/3/26 at 1:00 PM, V42/CNA stated she has worked at the facility for about six months. The facility does not have enough staff to take care of the residents. Agency is used a lot. Nurses do the best they can, but treatments do not get done as often as they should.On 1/29/26 at 12:15 PM, V22 (Facility's Medical Director) stated The continuity of care with changes in staff and management is an issue. My communication with (V1, AIT) has been sporadic. When I come in the Administrator (V1, AIT) and DON (V2, Director of Nursing) should make me aware of concerns and issues that are happening in the building and then we can address those things in QA (Quality Assurance) and talk about solutions. I have not been notified that there is such an issue with missing treatments, missing medications and (resident) care concerns.The facility's records did not include Annual QAPI (Quality Assurance and Performance Improvement) training for all staff, 12 hours of mandatory in-service training for (CNAs) Certified Nursing Assistants, or quarterly Quality Assurance meetings.On 1/29/26 at 2:03 PM V2/Corporate/Interim Director of Nursing stated, I cannot provide documentation to show that we provided 12 hours of training to any CNAs in the past year.On 2/4/26 at 10:14 AM V1/AIT (Administrator-in-Training) verified that facility staff have not received the annual QAPI training.On 2/10/26 at 11:15 AM V14 stated that the facility has not had a QAA meeting since 7/2025 and prior to that she has no records to show the meetings were held. V14 stated when V1 started in July QA was addressed and meetings were to be held monthly per the facility and quarterly per the regulation requirement. V4 confirmed that she wasn't aware of the multiple failures and thought things were being managed when she was not in the building. On 2/10/26 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Licensed Nurses on Physician Orders- Entering and Processing, and Documentation in the Health Record. The Physician Orders- Entering and Processing policy was included. On 2/9/26 all licensed nurses were educated on the facility's Physician Orders - Entering and Processing policy including but limited to when receiving, entering, and confirming physician or prescriber's orders the order is entered into the resident's chart under EMR (electronic medical record) by V2 (Director of Nursing) and V4 (Assistant Director of Nursing/ Wound Nurse).2. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Licensed Nurses on Pressure Injury and Skin Condition Assessment. The Electronic Health Record policy was included. On 2/9/26 all licensed nurses were educated on the facility's Documentation - Electronic Health Record policy including but not limited to entries made in the electronic health record shall be timely, accurate, relevant, and complete by V2 (Director of Nursing/Designee) or V1 (Administrator).3. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff on Change of Condition and Physician-Family Notification. The Physician- Family Notification- Change in Condition policy was included. On 2/9/26 all licensed and certified nursing assistants were educated on the facility's Physician-Family Notification - Change in Condition policy by V2 (Director of Nursing/Designee) or V1 (Administrator).4. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff on Comprehensive Care Plan/Baseline Care Plan. The Baseline Care Plan was included.5. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff on admission of residents. The admission of Resident Care Plan was included.6. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on the admission of Resident/Admission- readmission Checklist. The admission Checklist was included.7. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced IDT starting on 2/2/26 on Comprehensive Care Plan. The Comprehensive Care Plan was included.8. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff on Infection Prevention and Control Program. The Infection Prevention and Control Program policy was included.9. A Facility Audit was started on 2/9/26 to identify all residents with Pressure Ulcers. This included the wound assessment being completed, the physician contacted, the wound nurse contacted, a reassessment of the wound in 24 hours, and consents to see the Wound Physician. There were 56 residents assessed. 10. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In Serviced staff on Pressure Injury and Skin Condition Assessment. The Pressure Injury and Skin Condition Assessment policy was included. The facility developed a process in which the direct care nurse is required to review the Treatment Administration Record prior to providing wound care.11. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In Serviced staff on Pressure Ulcer Prevention and Med Error, Adverse Drug Reaction, Physician Orders- Entering and Processing, Documentation- Heath Record, and Comprehensive Care Plan, Baseline Care Plan. The Pressure Ulcer Prevention policy, Medication Administration General Guidelines, Physician Orders- Entering and Processing, and Comprehensive Care Plan were included. The facility implemented a process to ensure staff are trained to develop and provide interventions to prevent pressure areas and prevent pressure ulcers from worsening. These interventions include 1. Educate staff to review the Care Plan before care. 2. Nurses were educated on the facility Skin Policy. 3. Nurses were educated on Weekly Skin Assessments. 4. Nurses were educated on following physician orders. 5. Staff were educated on residents that have pressure ulcers and are dependent on staff for repositioning. 6. Clinical Staff and Dietary Staff were educated to follow the Physician Order and Meal Ticket to ensure the resident receives the correct diet and supplements. 7. Nurses were educated on following Physician Orders and reviewing the Medication Administration Record and Treatment Administration Record prior to conducting a medication pass and performing wound care. 8. Nurses were educated on conducting skin assessments when a resident returns from the hospital. 9. Nurses were educated to open risk management for skin breakdown and to notify the Wound Nurse and Director of Nursing. 12. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff on Pressure Injury and Skin Condition Assessment, and Skin Condition Assessment and Monitoring Pressure and Non-Pressure. The Pressure Injury and Skin Condition Assessment policy was included.13. On 2/9/26 V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Nurses and Certified Nursing Assistants on Pressure Ulcer Prevention. The Pressure Ulcer Prevention policy was included. 14. A facility wide audit was started on 2/2/26 for all residents wound care plans. Updated Wound Care Plans were included.15. A facility wide audit of residents with wounds were reviewed for any changes needed and the physician was updated. A Wound Report was included.16. On 2/9/26 all licensed nurses were educated on the facility's complete Gastrostomy Tube - Feeding and Care policy by V2 (Director of Nursing), V3 (Minnimum Data Set coordinator), and V4 (Assistant Director of Nursing/ Wound Nurse).17. On 2/4/26 a facility wide audit of all residents' who have gastrostomy tubes to ensure stoma site have a treatment order in place, tube feeding orders are in place in the EHR, residual check in on the resident's MAR for prior to water flushes, medication administration and bolus feeding or a start of new bottle through feeding pump, and signs/symptoms of nausea, vomiting, distended abdomen, cramping, sluggish or absent bowel sounds, dry heaves/retching and cold sweats the physician has been notified and is documented in the EHR. Any skin abnormalities at stoma site, the characteristics are documented and physician notified and documented; care plans for those individuals have been reviewed and all interventions are in place and updated on the resident's treatment administration record (TAR) by the nurse by the V2 (Director of Nursing/Designee).18. On 2/9/26 V3/RN (Registered Nurse) V4/Wound Nurse in-serviced all Licensed Staff and Certified Nursing Staff on the facility's entire Pain Management Policy.19. On 2/9/26 V3/RN, V4/Wound Nurse, and V46/Clinical Review Nurse in-serviced all Licensed Staff and Certified Nursing Staff on the facility's entire Pain Assessment Policy.20. On 2/9/26 V3/RN and V4/Wound Nurse in-serviced all Licensed Nurses on the facility's Medication Administration General Guidelines.21. On 2/9/26 V3/RN and V46/Clinical Review Nurse in-serviced all Licensed Nurses and Certified Nursing Staff on the entire Resident Rounds Policy and procedure.22. On 2/9/26 V3/RN and V46/Clinical Review Nurse in-serviced all Clinical Staff on the facility's entire Bathing-Shower and Tub Policy.23. On 2/9/26 V3/RN and V4/Wound Nurse in-serviced all Licensed Nurses and Certified staff on the facility's entire Incontinence Care Policy and Procedures.24. On 2/9/26 V1/Administrator-in-Training in-serviced V25/Housekeeping Supervisor on the facility's Activities Program Policy.25. On 2/9/26 V1/Administrator-in-Training in-serviced all staff on the facility's Residents Rights and Dignity Policy.26. On 2/5/26 V14/Corporate [NAME] President of Operations in-serviced Facility Leadership regarding the entire facility Quality Assurance Performance Improvement Program Procedure.27. On 2/5/26 V14/Corporate [NAME] President of Operations in-serviced Facility Leadership on Program of Angel Round to ensure they are available for residents, resident's family members, and staff.28. On 2/5/26 V14/Corporate [NAME] President of Operations in-serviced facility leadership regarding ensuring oversight of the facility and implementing policies for wound care, medication administration, treatment administration, quality assurance measures, and basic activities of daily resident care, including but not limited to review of job description.29. On 2/5/26 V14/Corporate [NAME] President of Operations re-oriented V1/Administrator-in-Training on Administrator duties for the facility. 30. On 2/9/26 an Impromptu was held with medical director and interdisciplinary team to discuss deficiency and facility action plan.31. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure residents who have pressure injuries have wound prevention orders on EMR (Electronic Medical Record), assessment of wound completed upon admission/re-admission or weekly wound assessment completed in accordance with facility's policy.32. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure resident's treatment was performed, initialed, and dated per facility's policy.33. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure resident's care plan is revised timely and care plan interventions are linked to Kardex for clinical staff to reference treatments are charted and signed off on by the nurse on the EMR in PCC (Point Click Care).34. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure resident's wound physician progress notes re reviewed and POS (Physician Order Sheet) is updated with physician treatment, labs, supplements, and pressure relieving devices are processed prior to next scheduled wound care procedure.35. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure resident's weekly skin assessment is completed by responsible nurse.36. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident five days per week to ensure nurses are revieing TAR (Treatment Administration Record) prior to performing wound care procedures.37. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per week to ensure Dietary Department is providing resident with correct diet/supplements.38. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day to ensure facility Infection Prevention Guidelines are followed when performing wound care.39. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one new admission per day to ensure all equipment and supplies required are obtained and in the facility.40. From 2/6/26 to 2/9/26 the missed administration report and medication administration report were completed daily to ensure the resident's MAR is accurate and complete per facility policy and procedure guidelines.41. From 2/6/26 to 2/9/26 (and ongoing) a daily audit was completed to ensure resident who have ensure stoma site have a treatment order in place and TAR is signed off for completion, tube feeding orders are in place in the EHR (Electronic Health Record), residual check in on the resident's MAQR for prior to water flushes, medication administration and bolus feeding or a start of new bottle through feeding pump, and signs/symptoms of nausea, vomiting, distended abdomen, cramping, sluggish or absent bowel sounds, dry heaves/retching and cold sweats they physician has been notified and is documented in the HER. Any skin abnormalities at stoma site, the characteristics are documented and physician notified and documented by the nurse.42. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed incorrectly on missed administration report and Medication Administration Reports. V14 reports they were not seeing when a medication was documented as on hold, only if a nurse didn't sign out the medication. V14 stated they are going to monitor all residents' MARS (Medication Administration Records) daily to ensure residents are not going without medication.43. From 2/6/26 to 2/9/26 (and ongoing) an audit was performed on one resident per day five days a week to ensure residents ar

Based on interview and record review, the facility failed to provide physician ordered gastrostomy care including cleansing, laboratory monitoring, flushes, residual checks and tube insertion site assessments for a resident with an internal percutaneous endoscopic gastrostomy (PEG) tube for nutritional support for one of three residents (R9) reviewed for gastrostomy tubes (G-tube) in the sample of 16. This failure resulted in R9 transferring to the emergency room and being admitted to the hospital with fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance and a diagnosis of sepsis from multiple suspected sources including a g-tube site infection with pus filled drainage.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 11/22/25 when R9's scheduled gastrostomy tube cares were not completed. V1 (Administrator in Training) and V2 (acting Director of Nursing) were notified of the Immediate Jeopardy on 2/4/26 at 9:30 AM. While the immediacy was removed on 2/10/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Gastrostomy Tube- Feeding and Care policy, dated 8/3/20, documents Purpose to provide nutrients, fluids and medications, as per physician orders, to residents requiring feeding through an artificial opening into the stomach. Measurement of gastric residual is usually ordered for new g-tube placement/ feeding and before advancing the hourly feeding rate to determine resident's tolerance to feeding of to detect complications related to gastric emptying and absorption. Observe the resident for signs and symptoms of nausea, vomiting, diarrhea, abdominal distention/ cramping. Notify physician. This same policy documents Stoma site care. Inspect the surrounding skin for redness, tenderness, swelling, irritation, purulent drainage, or gastric leakage; immediately report skin irritation or infection and provide treatment. Clean skin with soap and water or antiseptic of choice. Begin next to stoma site, using spiral pattern and moving outward, clean under skin disk with cotton swab. Dry thoroughly; leave area open to air to minimize dampness, skin irritation, and maceration; use a dressing only if ordered.R9's Care Plan, dated 12/16/25, documents R9 has diagnoses including but not limited to Tracheostomy status, Gastrostomy status, Critical illness Myopathy, Pressure ulcer of Sacral region, stage IV (four), Osteomyelitis of vertebra, Sacral and Sacrococcygeal region. This care plan documents I require tube feeding Osmolyte 1.5 to infuse at 70 milliliters an hour for 22 hours, starting daily at 5:00 AM. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. I am dependent with tube feeding and water flushes. See Physician orders for current feeding orders. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated.R9's Physician Order Summary (POS), documents R9 was admitted to the facility on [DATE] with treatment orders for R9's G-tube site care to cleanse and apply split gauze every shift for infection control and a treatment to check residual before medications and feedings, if greater than 100 (milliliters) hold feeding and medications and notify physician every shift and an order. This order was not initiated until 11/25/25 (five days after admission). This summary also documents R9 has an order starting on 12/24/25 to cleanse g-tube insertion site everyday with soap and water during ADL (Activities of Daily Living) care, every shift for g-tube.R9's Treatment Administration Record (TAR), dated 11/20/25-11/30/25, documents R9 did not receive g-tube site cleaning and new gauze on 11/22/25 evening shift. This TAR also documents R9 did not have any g-tube residual monitoring from 11/20-11/25/25 prior to feeding and medication administrations.R9's Treatment Administration Record (TAR), dated 12/1/25-12/31/25, documents R9 did not receive scheduled g-tube site cleaning and new gauze on seven occasions and was not provided scheduled g-tube residual monitoring on nine occasions. This same record also documents three scheduled soap and water cleansings of R9's g-tube site were not completed from 12/24-12/31/25.R9's Medication Administration Record (MAR), dated 12/1/25-12/31/25, documents an order for enteral feed flush to flush with 30 milliliters (ml) of water before giving medications, flush with at least five ml between medications, and flush with a minimum of 30 ml after all medications given. This MAR documents R9's g-tube was not flushed on day shift on 12/5/25 and on evening shift in 12/29/25.R9's Treatment Administration Record (TAR), dated 1/1/26-1/31/26, documents from 1/1-1/17/26, R9 was not provided g-tube site cleaning and new gauze on seven occasions, was not provided scheduled g-tube residual monitoring on seven occasions and scheduled soap and water cleansings of R9's g-tube site were not completed on six occasions.R9's nursing progress note, dated 1/1/26 at 10:23 PM, documents Resident rectal tube fell out. Called MD (V22, Facility Medical Director) and he said to monitor and call the surgeon (unknown gastric surgeon). This nurse could not find surgeon's number. DON (V2, Director of Nursing) notified, care ongoing.R9's progress notes, dated 1/1/26- 1/17/26, does not document a gastric surgeon was notified of R9's rectal tube removal and does not document that the rectal tube was ever replaced.R9's nursing progress note, dated 1/6/26 at 9:45 AM, documents Residents POA (Power of Attorney, V32) requested that a new rectal tube be placed. Reported to APN (Advance Practice Nurse, V30) in facility. States (V30) will check and see if we can order one and speak with (V32) about this. No concerns at this time.R9's nursing progress note, dated 1/12/26 at 9:55 AM, documents Got in report that (R9) has had emesis last night into this AM. Feeding shut off for two hours.R9's progress note, dated 1/13/26 at 11:44 PM and completed by V30, documents Patient has had vomiting two nights ago, last evening at 6 PM and this morning at 6 AM. Vomiting on three occasions over the past two days. Monitor for improvement in symptoms or for any worsening.R9's nursing progress note, dated 1/14/26 at 9:53 AM, documents (R9) had emesis this (morning) at 7:35 AM. Feeding paused at this time Zofran (nausea medication) given for nausea. Will continue to monitor.R9's progress note, dated 1/16/26 at 5:41 PM and completed by V30, documents (R9) had another episode of vomiting this AM, nursing states (R9) has had vomiting for the past three to four days. He has metoclopramide (antiemetic medication) ordered on a schedule and ondansetron (nausea medication) as needed. This progress notes also documents diarrhea is also being reported to V30.R9's nursing progress note, dated 1/17/26 at 9:54 AM, documents G-tube leakage noted. (V22, Facility's Medical Director) notified. Orders for CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and KUB (Kidney Ureter Bladder imaging). Will continue to monitor.R9's electronic medical record does not document that R9 had a CBC or BMP drawn or laboratory (lab) results were received.On 1/30/26 at 1:22 PM, V4 (Assistant Director of Nursing) confirmed R9 does not have results for a CBC or BMP. V4 stated (R9) does not have any lab results because none were completed at the facility, only at the hospital.R9's Nursing Progress note, dated 1/17/2026 at 8:00 PM, documents (V22) ordered a KUB due to leaking g-tube. KUB results came back with no clear results due to faulty imaging. (V32, R9's family) came for a visit. Resident's feed has been turned off by day-shift nurse due to leaking. (V32) came to this nurse and wanted a re-assessment. Upon assessment, tube drain and gown were soaked with feed, took tube drain off and had a slight yellow-pink color to it mixed with feed. G-tube site kept continuously leaking feed. Resident complained of no abdominal pain, or pain anywhere else. (V23) wanted (R9) sent to be evaluated due to no clear results from KUB imaging. Resident sent to (local hospital ER) per request of (V32). (V22) aware.R9's Hospital admission record, dated 1/17/26, documents R9 was admitted to the hospital with fever, abdominal pain, diarrhea, nausea and vomiting, toxic appearance and a diagnosis of sepsis from multiple suspected sources including g-tube site infection with pus leaking drainage. On 1/28/26 at 12:40 PM V32 (R9's family member) stated Saturday (1/17/26) when he was taken to the hospital I went in there and his belly was covered with crust. Feeding was coming out of his stomach. Then when I lifted the gauze there was yellow puss coming out of his belly. I told the nurse that he needed to go to the hospital. It was awful. (R9's) g-tube was not cared for correctly. The feeding tube was removed in the hospital due to an abscess and sepsis.On 1/29/26 at 12:15 PM, V22 (Facility's Medical Director) confirmed he wanted R9's surgeon notified when his rectal tube came out (1/1/26), due to potential concerns with the bowel. V22 stated I wanted (R9) to follow up with the GI (gastrointestinal) surgeon (unknown) due to the G-tube and worried about the bowel and possible placement issues with that. So, I did want the surgeon notified when it came out. I have not been notified that there is such an issue (in the facility) with missing treatments, missing medications and care concerns.On 1/29/26 at 12:50 PM, V33 (emergency room (ER) Physician) stated I saw (R9) in the hospital. He is a very sick person and it's unfortunate. When we admitted him for the second time for Sepsis (1/17/26) we had him in the ER for a longer period. Any tube coming out of the body has the potential to get infected. At the time of his admission, we also were concerned with his g-tube site with purulent pus like drainage which can relate to the sepsis. If you don't take care of the g-tube properly with cleansing and flushes, then you can get infection at the site. Additionally, if the feeding is going into the abdominal cavity due to becoming dislodged it also is a risk factor for that becoming infected. I believe the g-tube was removed by gastrointestinal surgeons while in the hospital.On 2/4/26 at 9:30 AM, V2 (acting Director of Nursing) confirmed she reviewed R9's hospital admission and electronic records and stated she was unaware that R9 was not receiving adequate g-tube care. V2 stated she cannot provide documentation to show a gastric surgeon was notified after R9's rectal tube came out.On 2/10/26 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1. On 2/9/26 all licensed nurses were educated on the facility's complete Gastrostomy Tube - Feeding and Care policy by V2 (Director of Nursing), V3 (Minimum Data Set coordinator), and V4 (Assistant Director of Nursing/ Wound Nurse).2. On 2/9/26 all licensed nurses were educated on the facility's Physician Orders - Entering and Processing policy including but limited to when receiving, entering, and confirming physician or prescriber's orders the order is entered into the resident's chart under EMR (electronic medical record) by V2 (Director of Nursing) and V4 (Assistant Director of Nursing/ Wound Nurse).3. On 2/9/26 all licensed nurses were educated on the facility's Documentation - Electronic Health Record policy including but not limited to entries made in the electronic health record shall be timely, accurate, relevant, and complete by V2 (Director of Nursing/Designee) or V1 (Administrator).4. On 2/9/26 all licensed nurses were educated on the facility's Skin Condition Assessment & Monitoring - Pressure and Non- Pressure policy by V2 (Director of Nursing/Designee) or V1 (Administrator).5. On 2/9/26 all licensed and certified nursing assistants were educated on the facility's Physician-Family Notification - Change in Condition policy by V2 (Director of Nursing/Designee) or V1 (Administrator).6. On 2/9/26 an impromptu QAPI meeting was held with medical director and staff IDT team to discuss deficiency and facility action plan.7. On 2/4/26 a facility wide audit of all residents' who have gastrostomy tubes to ensure stoma site have a treatment order in place, tube feeding orders are in place in the EHR, residual check in on the resident's MAR for prior to water flushes, medication administration and bolus feeding or a start of new bottle through feeding pump, and signs/symptoms of nausea, vomiting, distended abdomen, cramping, sluggish or absent bowel sounds, dry heaves/retching and cold sweats the physician has been notified and is documented in the EHR. Any skin abnormalities at stoma site, the characteristics are documented and physician notified and documented; care plans for those individuals have been reviewed and all interventions are in place and updated on the resident's treatment administration record (TAR) by the nurse by the V2 (Director of Nursing/Designee).8. The facility will conduct audits (7 days per week for 6 weeks) to ensure resident who have ensure stoma site have a treatment order in place and TAR is signed off for completion, tube feeding orders are in place in the EHR, residual check in on the resident's MAR for prior to water flushes, medication administration and bolus feeding or a start of new bottle through feeding pump, and signs/symptoms of nausea, vomiting, distended abdomen, cramping, sluggish or absent bowel sounds, dry heaves/retching and cold sweats the physician has been notified and is documented in the EHR. Any skin abnormalities at stoma site, the characteristics are documented and physician notified and documented by the nurse. A QA tool -will be completed to verify this practice has occurred. The QA tool will be completed by V2 (DON) or designee, daily for 6 weeks. This started on 2/4/26 and is ongoing.

Based on interview and record review, the facility failed to identify, assess, and treat a facility-acquired pressure ulcer, prevent a pressure ulcer from worsening, administer wound treatments as ordered, develop and implement pressure relieving interventions and a pressure ulcer care plan for two of three residents (R4, R9) reviewed for pressure ulcers in the sample of 16. This failure resulted in R4 developing a facility acquired pressure ulcer and R4 and R9's wounds worsening without adequate treatment and being transferred to the hospital with lethargy, high fever and requiring extensive hospitalization for diagnoses of sepsis and a stage four decubitus pressure ulcer with osteomyelitis.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/7/25 when R4 was identified at high risk of developing a pressure ulcer. V1 (Administrator in Training) and V2 (acting Director of Nursing) were notified of the Immediate Jeopardy on 2/2/26 at 10:00 AM. While the immediacy was removed on 2/10/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:Findings include: The Pressure Ulcer Prevention policy dated 1/15/18 documents Purpose: To prevent and treat pressure sores/pressure injury. Guidelines: 1. Maintain clean/dry skin during daily hygiene measures. 2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. 5. Turn dependent resident approximately every two hours or as needed and position resident with pillow or pads protecting bony prominences as indicated. 6. Employ active and passive range of motion exercises to improve circulation as indicated (in accordance with physician order and plan of care). 12. Encourage resident to maintain proper nutrition and hydration, providing supplements as ordered and necessary assistance at mealtime as needed. 14. Moisture barrier may be applied by CNA (Certified Nursing Assistant) as needed to intact skin and may be kept at bedside. The Skin Condition Assessment and Monitoring -Pressure and Non-Pressure policy dated 6/8/18 documents Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Guidelines: Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident's chart when pressure and/or other non-pressure skin conditions are identified by licensed nurse. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. Caregivers are responsible for promptly notifying the charge nurse of skin breakdown. At the earliest sign of the injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. Wound Assessment/Measurement: 6. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. 7. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses note. 1. R4's computerized Medical Record documents that R4 is a [AGE] year-old that admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Tracheostomy Status, Gastrostomy Status, and Encephalopathy. R4's Skin Condition Report dated 10/28/25 documents that R4 had no wounds. R4's MDS (Minimum Data Set) assessment dated [DATE] Section C (Cognitive Patterns) documents that R4 is severely cognitively impaired. Section GG (Functional Ability) documents R4 is dependent on staff for all activities of daily living/ADLs, toileting, bed mobility, and transfers. R4's Risk assessment dated [DATE] documents a Braden Risk Level of 9 (nine) Very High Risk. R4's current Care Plan does not have a care plan that R4 is at risk for pressure ulcers and does not have any interventions to prevent pressure ulcers. R4's Skin/Wound Note written by V4/Wound Nurse dated 12/12/25 at 2:08 PM, documents Notified by CNA (unidentified) (R4) had a wound on her coccyx. Evaluated. Open area to coccyx noted with moderate serous drainage. Appears to have large amount of scarring to the area. Fax sent to MD (Medical Doctor). Placed tx (treatment) order. R4's Progress Note written by V30/Nurse Practitioner/NP dated 12/24/25 documents (R4) is bedbound, in a vegetative state, nonverbal, and fully dependent for all ADLs. Interventions: Positioning and Skin Care: Dependent for all repositioning; staff to provide frequent turning and repositioning. Regular skin assessments; care of coccyx open wound. R4's Progress Note written by V30/NP dated 12/30/25 documents that R4's has a stage 3 (three) pressure ulcer to the sacral region. The wound measures 7 cm (centimeters) by 6.5 cm by 0.20 cm. Care Plan is for frequent turning/repositioning to off-load pressure from sacral area and dressing changes. R4's Treatment Administration Record for 12/1 - 12/31/25 documents to apply (medicated dressing) and gauze to R4's coccyx two times a day at 8:00 AM and 8:00 PM starting 12/12/25 at 8:00 PM. The treatment was not started until 12/13/25 at 8:00 PM. The treatments were not documented as being done on 12/17 at 8:00 AM, 12/18 at 8:00 PM, and 12/20 at 8:00 AM. On 12/20/25 the order was changed to apply (medicated dressing) and gauze to R4's coccyx every shift day and night starting 12/20/25 at 6:00 PM. The treatments were not documented as being done on 12/23, 12/26, 12/28 on days and 12/29/25 on nights. R4's Skin/Wound Note written by V4/Wound Nurse dated 1/9/26 at 3:15 PM, documents Left message for (POA/Power of Attorney) to obtain consent for wound MD (Medical Doctor) evaluation of wound to coccyx as it continues to decline and should be followed by Wound MD. R4's Follow UP Note written by V30/NP dated 1/15/26 at 6:55 PM, documents New tunneling of wound. R4's Nursing Note dated 1/18/26 at 10:21 PM, documents ''Wound bed is draining copious amounts of dark yellow drainage almost constantly. R4's Progress Note written by V30/NP dated 1/19/26 documents that R4's pressure ulcer is a stage 4 (four) measuring 8 cm by 10 cm with deep tunneling, purulent, odorous drainage, with concerns for infection. R4's Nursing Note dated 1/21/26 at 7:53 PM, documents that R4 was slightly clammy with an increase in respirations and shortness of breath. R4's coccyx wound seems to have worsened. V22/Primary Care Physician was notified about concerns. V22 gave an order to send R4 to the hospital to be evaluated to rule out Sepsis. R4's Hospital Report dated 1/21/26 documents that Infectious Disease consulted and requested (V34/Hospital Doctor) for evaluation and antibiotic recommendation. R4 was admitted to the hospital by V34 on 1/21/26 with admitting diagnosis of Sepsis. Call placed to (the facility) and no one answered the phone today, 1/22/26 after multiple attempts. So unclear how long (R4) was ill at facility. ER (Emergency Room) notes indicate (R4) arrived with reports of fevers there 104-106 (degrees) unknown measurement or how long; accompanied by lethargy. R4's Nursing Note dated 1/22/26 at 1:23 AM, documents that the hospital reported there were signs pointing to Sepsis. R4 was started on Zosyn and Vancomycin. R4's Hospital Records dated 1/22/26 at 2:49 PM, documents that R4 presented to the ER/emergency room from the facility with complaints of fever and lethargy. Radiology Report documents Stage IV (four) sacral ulcer with ill-defined lower sacral and coccygeal posterior cortices which suggests osteomyelitis (this may also have a large component of volume averaging artifact). R4's Hospital Report dated 1/23/26 at 12:21 AM, documents (R4) has sepsis which could be from the pneumonia and/or wound infection of her chronic pressure ulcer, or both. R4's Hospital Clinical Notes dated 1/25/26 at 1:25 PM, documents that bedside surgical debridement was done. Necrotic skin bridges were sharply excised, and the wound bed was mechanically debrided. There was an area of darkened tissue over R4's sacrum that was unable to be debrided at the bedside. R4's Treatment Administration Record for 1/1 - 1/31/26 documents to apply (medicated dressing) and gauze to R4's coccyx every shift day and night. The treatments were not documented as being done on 1/2 and 1/5/26 on days, 1/8/26 on days or nights, and 1/12, 1/17, and 1/21/26 on days. On 1/21/26 at 4:00 PM, the order was changed to apply (medicated dressing) and gauze to R4's coccyx four times a day and as needed at 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM. The dressing was done on 1/21/26 at 4:00 PM then R4 went to the hospital. On 1/27/26 at 12:47 PM V35/Licensed Practical Nurse stated that wound care could not be completed most of the time on night shift. The medication pass alone was too aggressive and then the charting had to be completed. Wound care would be the last thing we (staff) would do if we could even get to it. V35 also stated If I was working and the treatment was left blank it would mean I didn't do it due to not having enough time. On 1/28/26 at 11:00 AM, V4/Wound Nurse stated that she started doing the wounds around 12/1/25 taking over for V23/Prior Wound Nurse. V23 did not have any wound logs or wound measurements documented. V4 stated the first time she was told about R4's wound was on 12/12/25 and V4 would classify it as a Stage 3. The dressings were to be done twice a day then was changed to four times a day due to the amount of drainage. V4 stated The wound was getting worse. I thought it needed debrided. I brought it up to (V30/NP) and had to order the supplies. (R4) was sent out before we got the wound debrided. V4 also stated I check the Care Plan weekly and there was not a Care Plan for (R4's) wound as of last week. I have not put anything in yet. It is my job to do it and when it is identified it should be put in a care plan. V4 stated If the treatment is not signed out in the treatment log it did not get done. On 1/29/26 at 1:04 PM, V30/Facility Nurse Practitioner stated that the first time she saw R4's pressure ulcer was on 12/24/25. R4 was completely dependent on staff for her care. R4's wound continued to get worse and when R4 was sent to the hospital (1/21/26) the wound was a Stage 4 and was infected. V30 also stated that the dressings need to be changed as ordered or it absolutely would cause a problem causing the wound to worsen. 2. R9's admission Observation assessment, dated 12/22/25, documents R9 originally admitted to the facility on [DATE] with a stage four pressure ulcer wound to his coccyx and is dependent on staff for all activities of daily living, mobility and care. R9's Care Plan, dated 12/16/25, documents R9 has diagnoses including but not limited to Tracheostomy status, Gastrostomy status, Critical illness Myopathy, Pressure ulcer of Sacral region, stage IV (four), Osteomyelitis of vertebra, Sacral and Sacrococcygeal region. This care plan documents I have a pressure ulcer coccyx related to immobility, history of CVA (cerebrovascular accident), bowel incontinence and as evidenced by Braden (skin assessment) score. Administer treatments as ordered and monitor for effectiveness. Follow facility protocols for the prevention/treatment of skin breakdown. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. The resident requires a pressure reliving/reducing mattress on bed. R9's Physician Order sheet dated, 11/20/25-2/10/26 documents R9 has an order started on 11/20/25 to monitor placement and empty contents of rectal tube every shift for wound care and a wound treatment order to cleanse coccyx wound with (wound cleaner) and gauze. Apply skin prep to peri wound skin, foam to the wound bed and drape with wound vacuum every Monday, Wednesday and Friday. This order sheet also documents an order started on 12/23/25 to cleanse stage IV (four) coccyx wound with wound spray, pat dry and apply (wound cleanser) wet to dry dressing and cover with padded covering two times daily and as needed (PRN) for wound care. R9's Treatment Administration Record (TAR) dated 11/20/25-11/30/25 documents two of R9's scheduled wound treatments were not administered, and zero PRN treatments were completed. R9's TAR dated 12/1/25-12/9/25 documents two of R9's scheduled wound treatments were not administered, and zero PRN treatments were completed. R9's Hospital Summary, dated 12/22/25, documents R9 was evaluated in the emergency room with altered mental status and concern for infection and admitted to the hospital on [DATE] for Sepsis with suspected sources including a chronic stage IV sacral ulcer with imaging evidence of underlying abscess and sacrococcygeal osteomyelitis. This summary documents R9's deep wound cultures grew multiple bacteria including Enterococcus and Citrobacter freundii which R9 was treated for at the hospital before discharging back to the facility on [DATE]. On 1/28/26 at 12:40 PM, V32 (R9's Family) stated that three weeks into (R9's) stay at the facility, he was re-admitted to the hospital with a wound infection. V32 stated (R9's) wound is to the bone and the size of a [NAME] and when staff clean R9's bowel contents up, the pad over his wound also becomes soiled. I have seen that stool-soaked wound pad sit for over four hours before a nurse changed the wound dressing. R9's TAR dated 12/23/25-12/31/25, documents R9's physician ordered coccyx wound treatment was to be completed two times daily and as needed. This record documents five scheduled treatments were not completed and zero as needed treatments were administered. R9's TAR dated 1/1/26-1/17/26, documents R9's physician ordered coccyx wound treatment was to be completed two times daily and as needed. This record documents seven scheduled treatments were not completed and zero as needed treatments were administered. This same administration record documents R9 was ordered to have Sodium Hypochlorite external solution 0.125% applied to the coccyx wound topically every 12 hours related to pressure ulcer treatment. This same record documents, ten scheduled sodium hypochlorite applications were not completed. R9's TAR's dated 11/20/25-1/17/26, do not document any site monitoring or assessments were ever completed for R9's rectal tube. R9's electronic medical record does not document R9 was provided daily nursing skin checks throughout R9's stay in the facility. R9's nursing progress note, dated 1/1/26 at 10:23 PM, documents Resident rectal tube fell out. Called MD (V22, Facility Medical Director) and he said to monitor and call the surgeon. This nurse could not find surgeon's number. DON (V2, Director of Nursing) notified, care ongoing. R9's progress note, dated 1/10/26 at 10:03 AM and completed by V30 (Facility Nurse Practitioner), documents Wound MD (Medical Doctor, V54 wound physician) stated that if (R9) does not want the fecal tube in place that is okay to leave out. The wound will heal better with it in place. Asked (R9) what his wishes were and he shook his head no. Rectal tube was placed to prevent contamination of wound, this has come out on two occasions this admission. No replacement rectal tube at bedside. Previously attempted to re-order and product was out of stock. (V32, R9's family) would like one re-ordered. Will verify with (R9) and re-order as needed. R9's progress note, dated 1/12/26 at 4:14 PM and completed by V30, documents Rectal tube was placed to prevent contamination of wound, this has come out on two occasions this admission. No replacement rectal tube at bedside. Previously attempted to re-order and product was out of stock. (V32) would like one re-ordered. Discussed with (R9) today that the rectal tube can help with wound healing so that it does not get contaminated. He did consent that this would be OK to re-insert. Will follow up with DON (V2) about ordering. R9's progress notes, dated 1/1/26- 1/17/26, do not document R9's gastric surgeon (unknown) was notified of the rectal tube removal and does not document that the rectal tube was ever replaced. R9's nursing progress note, dated 1/17/26 at 9:54 AM, documents V22 (Facility Medical Director) was notified of R9's gastrostomy tube (g-tube) leaking and a new order was received for CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and KUB (Kidney Ureter Bladder imaging). R9's electronic medical record does not document any laboratory results throughout R9's entire admission [DATE]-[DATE]. R9's nursing progress note, dated 1/17/26 at 8:00 PM, documents (V22) ordered a KUB due to leaking g-tube. KUB results came back with no clear results due to faulty imaging. This same note documents V32 (R9's family) wanted R9 to be sent to the hospital due to no clear results from KUB imaging. (R9) sent to (local Emergency Room) per request of (V32). (V22) aware. R9's Hospital Emergency Department-admission record, dated 1/17/26, documents R9 presented to the emergency room with fever, abdominal pain, diarrhea, nausea and vomiting and R9's appearance was ill-appearing and toxic-appearing. This record also documents R9 was admitted with a diagnosis of Sepsis with several contributing sources including a stage four decubitus ulcer. On 1/28/26 at 11:08 PM, V4 (Assistant Director of Nursing (ADON)/ Wound Nurse) confirmed R4 and R9 do not have any documentation of daily skin monitoring. V4 stated nurses should be completing skin assessments on all residents especially when they have a high risk of skin breakdown, to identify concerns. On 1/30/26 at 1:22 PM, V4 stated R9 does not have any laboratory results in his medical record because none were completed at the facility. On 1/29/26 at 12:15 PM, V22 (Facility Medical Director) confirmed that wound treatments should be completed according to the physician orders, and the physician should be notified if there are issues completing wound treatments. V22 stated I had no idea wound treatments weren't being completed. Stool getting into a wound would definitely cause contamination. When (R9's) rectal tube came out, I wanted him to follow up with the gastric surgeon due to the g-tube (gastrostomy tube) and worried about his bowel and possible placement issues with that. So, I did want the surgeon notified when it came out and I wasn't aware they didn't notify the surgeon. On 1/29/26 at 12:50 PM, V33 (emergency room Physician) confirmed seeing R9 in the emergency room on admission to the hospital (1/17/26) and confirmed that R9 has been admitted to the hospital twice with Sepsis and a Stage IV pressure ulcer with osteomyelitis. V33 stated (R9) is a very sick person and it's unfortunate. The Sepsis could come from multiple sites. In (R9's) case he had a stage IV, very deep, decubitus ulcer. Certainly, if stool were to enter into that wound bed it can lead to infection. Even just improper care of a wound or not completing treatments, without stool involvement, can cause it to become infected. On 1/27/26 at 12:47 PM V35 (Licensed Practical Nurse) stated wound care could not be completed most of the time on third shift. V35 stated The medication pass alone was too aggressive and then the charting had to be completed. Wound care would be the last thing we would do if we could even get to it. If I was working and the treatment was left blank it would mean I didn't do it due to not having enough time. On 1/29/26 at 1:20 PM, V30 (Nurse Practitioner) confirmed R9's sacral pressure ulcer was to the bone and R9 had a rectal tube to keep his wound clean which was removed on 1/1/26. V30 stated The rectal tube was never re-inserted for R9 due to it not being available. V30 also stated nurses should be assessing residents' skin daily to monitor for signs of pressure or impaired skin integrity. On 2/2/26 at 10:00 AM, V2 (Director of Nursing) stated she was not aware that R9 was not receiving wound treatments, nursing skin assessments, physician ordered labs and rectal tube monitoring. V2 confirmed when the rectal tube was unavailable from their supplier, the facility did not reach out to the hospital to purchase a replacement tube. On 2/10/26 at 1:00 PM, V4 (ADON/ Wound Nurse) confirmed that R9's rectal tube was in place to help keep his sacral pressure ulcer clean. V4 also confirmed this tube was not on his care plan and R9's electronic medical record does not contain documentation to show that it was monitored every day. V4 stated The order for (R9's) rectal tube was not put in correctly and so there is no record that the site was monitored, including the amount of stool or nursing assessment to ensure placement was secure. He did not have a care plan in place for the rectal tube and should have. On 2/10/26 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Licensed Nurses on 2/2/26 on Physician Orders- Entering and Processing, and Documentation in the Health Record. The Physician Orders- Entering and Processing policy was included. 2. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Licensed Nurses starting on 2/2/26 on Pressure Injury and Skin Condition Assessment. The Electronic Health Record policy was included. 3. A Facility Audit was started on 2/9/26 to identify all residents with Pressure Ulcers. This included the wound assessment being completed, the physician contacted, the wound nurse contacted, a reassessment of the wound in 24 hours, and consents to see the Wound Physician. There were 56 residents assessed. 4. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In Serviced staff starting on 2/2/26 on Pressure Injury and Skin Condition Assessment. The Pressure Injury and Skin Condition Assessment policy was included. The facility developed a process in which the direct care nurse is required to review the Treatment Administration Record prior to providing wound care. 5. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In Serviced staff starting on 2/2/26 on Pressure Ulcer Prevention and Med Error, Adverse Drug Reaction, Physician Orders- Entering and Processing, Documentation- Heath Record, and Comprehensive Care Plan, Baseline Care Plan. The Pressure Ulcer Prevention policy, Medication Administration General Guidelines, Physician Orders- Entering and Processing, and Comprehensive Care Plan were included. The facility implemented a process to ensure staff are trained to develop and provide interventions to prevent pressure areas and prevent pressure ulcers from worsening. These interventions include 1. Educate staff to review the Care Plan before care. 2. Nurses were educated on the facility Skin Policy. 3. Nurses were educated on Weekly Skin Assessments. 4. Nurses were educated on following physician orders. 5. Staff were educated on residents that have pressure ulcers and are dependent on staff for repositioning. 6. Clinical Staff and Dietary Staff were educated to follow the Physician Order and Meal Ticket to ensure the resident receives the correct diet and supplements. 7. Nurses were educated on following Physician Orders and reviewing the Medication Administration Record and Treatment Administration Record prior to conducting a medication pass and performing wound care. 8. Nurses were educated on conducting skin assessments when a resident returns from the hospital. 9. Nurses were educated to open risk management for skin breakdown and to notify the Wound Nurse and Director of Nursing. 6. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on Pressure Injury and Skin Condition Assessment, and Skin Condition Assessment and Monitoring Pressure and Non-Pressure. The Pressure Injury and Skin Condition Assessment policy was included. 7. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all Nurses and Certified Nursing Assistants starting on 2/2/26 on Pressure Ulcer Prevention. The Pressure Ulcer Prevention policy was included. 8. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on Change of Condition and Physician-Family Notification. The Physician- Family Notification- Change in Condition policy was included. 9. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on Comprehensive Care Plan/Baseline Care Plan. The Baseline Care Plan was included. 10. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on admission of residents. The admission of Resident Care Plan was included. 11. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on the admission of Resident/Admission- readmission Checklist. The admission Checklist was included. 12. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced IDT starting on 2/2/26 on Comprehensive Care Plan. The Comprehensive Care Plan was included. 13. V2/Interim Director of Nursing and V4/Assistant Director of Nursing/Wound Nurse In-Serviced all staff starting on 2/2/26 on Infection Prevention and Control Program. The Infection Prevention and Control Program policy was included. 14. V14/Vice President of Operations In-Serviced Administration on Ensuring all New Admissions (referrals)- equipment and supplies are obtained prior to admission. 15. A QAPI Meeting was held with the medical director and IDT o discuss deficiencies and facility action plans. QAPI meeting notes were included. 16. A facility wide audit was started on 2/2/26 for all residents wound care plans. Updated Wound Care Plans were included. 17. A facility wide audit of residents with wounds were reviewed for any changes needed and the physician was updated. A Wound Report was included. 18. The facility will conduct audits (seven days per week for six weeks) for all residents with pressure injuries. The audits were included. On 2/9/26 at 12:50 PM V47/Agency Licensed Practical Nurse stated on 2/2/26 she was supposed to do all the skin sweeps for the abatement plan but stated she did not get to everyone. V47 stated she was the only nurse on the tracheostomy/ventilator unit and could not get to all the residents to check their skin. V47 also stated she was given a paper to sign to sign for in-services, but stated she was not educated on them. On 2/9/26 at 2:15 PM V14/Corporate [NAME] President of Operations verified the skin checks for all residents were not completed on 2/2/26 and they were starting to work on all skin sheets now. On 2/9/26 at 3:06 PM V51/Agency stated she was not in-serviced by anyone at the facility regarding the above topics in the abatement plan. Based on observation, interview, and record reviews conducted on 2/10/26 the facility completed all measures on the abatement plan, including providing in-servicing all of the staff on abuse and dementia policies. Therefore, the abatement plan could be approved on 2/10/26.

Based on observation, interview, and record review the facility failed to ensure residents' call lights were answered promptly and residents received timely incontinence care for two of four residents (R2 and R15) reviewed for dignity in the sample of 16. These failures resulted in R2 and R15 lying in urine and feces for an extended period of time, causing R2 to feel pain, embarrassed, ashamed, disgusted, and R15 experiencing pain and burning to R15's buttocks causing R15 to feel like H*ll and disgusted. Findings include:Findings include:The facility's Daily Census Report, dated 1/26/26, documents 53 residents reside in the facility.The facility's Dignity Policy, dated 4/23/18, documents Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the residents' lifestyle and personal choices identified through the assessment process to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth.The Ombudsman Resident's Rights Booklet, dated 11/18, documents Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your rights to safety: Your facility must provide services to keep your physical and mental health at their highest practical levels.The facility's Incontinence Care Policy, dated 4/20/21, documents Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode.The facility's Call Light Policy, dated 2/2/18, documents Purpose: To respond to resident's requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in a timely manner. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident room to respond to call system and promptly cancel the call light when the room is entered. Procedure: 1. Answer light (signal) promptly.The facility's Certified Nursing Assistant Job Description, dated 5/2/17, documents Certified Nursing Assistant: Summary- The CNA (Certified Nursing Assistant) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare, and safety of all residents. Essential Duties and Responsibilities: Provide for resident comfort by utilizing resources and materials; answering call lights and requests; reporting observation of the residents to the nursing supervisor.On 1/27/26 at 12:02 PM V17/Ombudsman stated every month during resident council the residents complain of call light waiting times. On 2/10/26 at 12:58 PM R16 stated that the last four resident council meetings residents have complained about their call lights not getting answered timely and having to sit in urine and feces for long periods of time. R16 also stated The resident's state that it's more on second and third shift that staffing is short. The staff will tell them they (staff) don't have enough staff to get to everyone timely. 1.R2's admission Record documents R2 is a [AGE] year-old female who was admitted to the facility on [DATE] with the following but not limited to diagnoses: Periprosthetic Fracture around Internal Prosthetic Left Knee Joint, Type Two Diabetes Mellitus, Unspecified Fracture of Lower End of Left Femur, Muscle Wasting and Atrophy, Restless Leg Syndrome, Fibromyalgia, Age-Related Osteoporosis without current Pathological Fracture, and Other Abnormalities.R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively intact, is dependent on staff for ADLs (Activities of Daily Living) including toileting hygiene and is frequently incontinent of bowel and bladder.R2's current Care Plan documents, R2 requires dependent assistance for toileting hygiene and requires a mechanical lift with two staff to transfer R2 from the chair to the bed.On 1/27/26 at 1:29 PM R2 stated, I laid in poop and pee for hours before any staff would answer my call lights at the facility. I was able to use the bed pan. If staff didn't answer my call light timely, I would have an accident and lay in my own poop and pee. Sometimes I would wait more than two and a half hours before someone could clean me up. I was so embarrassed and ashamed to lay in my own poop and pee that long. If the staff did get me on the bed pan in time, the staff wouldn't come back and take me off the bed pan, leaving me sitting on the bed pan for sometimes two hours. It was very painful. I came to the facility after I had surgery and was completely helpless and relied on staff to provide me with care. They would not get me up out of bed because it took two of them and they would say they didn't have enough staff to get me up and then put me back to bed later. It caused me complete embarrassment and humiliation along with disgust. In my opinion that facility should be shut down. R2 reported staff would always say they did not have enough staff to change everyone timely on their shift.On 1/27/26 at 12:47 PM V35/LPN (Licensed Practical Nurse) stated she was working at the facility when R2 was a resident. R2 was able to make her needs very known. R2 required dependent assistance with changing her and was incontinent at times. V35 stated, The Administration felt like the amount of CNA's we had were adequate on second and third shift, but a lot of the residents are two assist or cares in pairs, so the CNAs never had enough time to round on every resident in eight hours. There were times (R2) had to wait a while before a staff could get to her to clean (R2) up.On 1/29/26 at 11:43 AM V52/LPN stated, I can say it's true that they have to wait longer periods of time on nights due to the staffing. It's a constant complaint about waiting long periods of time to be changed or just not getting their call light answered timely in general. (R2) was one of them who had to wait.On 2/3/26 at 10:43 AM V6/Occupational Therapist stated, I only worked with (R2) once, but she was very cooperative. (R2) did complain to me about having to sit on the bed pain for an extended amount of time, I believe over two and half hours.2.R15's admission Record documents R15 is a [AGE] year-old-male who was admitted to the facility on [DATE] with the following but not limited to diagnoses: Nontraumatic Intracerebral Hemorrhage, Acute Kidney Failure, Muscle Wasting and Atrophy, Hyperkalemia, Acute Cystitis without Hematuria, Hypertension, Pain (unspecified), Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, and other Intervertebral Disc Degeneration (Lumbar Region).R15's MDS dated [DATE] documents R15 is dependent on staff for ADLs including toileting hygiene, toileting transfers, is occasionally incontinent of bladder, and frequently incontinent of bowel.R15's current Care Plan documents, R15 has an ADL self-care performance deficit related to having a stroke, requiring substantial to maximum assistance with toileting hygiene and transfers.On 2/10/26 from 1:02 PM to 1:36 PM, R15's call light remained on during this time.On 2/10/26 at 1:37 PM R15 was lying in his room with the covers pulled down and had on a disposable brief. R15 stated, A CNA (Unknown) came in around 25 minutes ago and asked what I needed. I told them I was wet and had pooped and I needed to be changed. The CNA told me she was going to go get washcloths and be right back. She never returned. This happens all the time and makes me feel disgusted and like h*ll. My call light has been on for at least thirty to forty minutes, and I have had to sit in my own poop. Last Sunday I pooped and peed in my bed, turned on my call light around 3:30 PM and sat there until 6:30 PM until a staff member came to my room. My butt was burning and sore. Staff always say, We don't have enough staff, so you will have to wait until we get to you.On 2/10/26 at 1:38 PM V49/CNA was observed sitting in a chair in the hallway documenting on the computer. V49 stated, I just got back to this hall a little bit ago. I didn't realize (R15's) call light had been going off that long. V49 stated she was not the staff member who told R15 she would be right back with wash cloths to clean him up but stated, Staff be dipping out like that on resident's all the time. Answer the call light, tell the resident they will be right back, then not go back in.On 2/10/26 at 1:42 PM V50/CNA stated, I was the assigned CNA on (R15's) hallway. I know that (R15's) call light has been on for a while, but I was the only CNA on this side at the time. Another CNA and I were the only two passing hall trays and having to answer all the call lights. Then by time we are done with that, the residents come back from the dining room, so then they want to be laid down. It's hard to get to everyone timely.On 2/13/26 at 12:36 PM V2/Corporate Interim Director of Nursing stated the staff should answer residents' call lights as soon as they can and that thirty to forty-five minutes is too long for a call light to not be answered.

Based on interview and record review the facility failed to administer prescribed opioid medications to keep a residents' pain controlled, failed to perform pain assessments and implement pain relieving interventions while the resident was not receiving their prescribed pain relieving opioid medication, and failed to notify the physician of the need for a opioid medication refill order and complaints of increased pain for one of three residents (R2) reviewed for pain in the sample of 16. These failures resulted in R2 experiencing restlessness and unrelieved excruciating pain after five days of going without her prescribed pain medication.Findings include:The facility's Pain Management Policy, dated 7/6/18, documents Purpose: To establish a program which can effectively manage pain in order to remove adverse physiological and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. Guidelines: It is the goal of the facility to facilitate resident independence, promote resident comfort, preserve and enhance resident dignity and facility life involvement. The purpose of this policy is to accomplish that goal through an effective pain management program. Definition: The resident's descriptive words regarding the quality, duration, and location not pain will be used to evaluate the pain and to identify changes in pain. When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital signs change, and changes in behavior and mood will be used to determine the presence of pain. The pain management program includes the following components: Documentation of pain assessment and monitoring. Standards: 1. Pain assessment protocol will be initiated under any of the following situations: a. Any indication of pain based on the pain assessment performed for each resident at the time of admission and with any condition change and/or incident associated with the potential of pain. c. Resident receives routine pain medication and/or pain is controlled.The facility's Pain Assessment Policy, dated 7/6/2018, documents Purpose: To establish guidelines for appropriate assessment and intervention to manage pain. To respect and support the residents' right to optimal pain management. To measure and document the effectiveness of the plan using objective and subjective assessment criteria. Responsibility: Licensed Nurse. Guidelines: 1. A pain assessment tool will be used as indicated as a guide in determining a resident's pain level in addition to their descriptive words, and/or physician signs and behaviors. 2. A pain assessment will be performed as part of the admission assessment. A pain assessment may be completed as indicated by diagnosis and other events during the residents' stay may initiate additional pain assessments (Example: Post falls or new diagnosis of compression fractures, etcetera.) 3. Prior to administration of PRN (as needed) pain medications, non-pharmacological interventions will be attempted if patient is responsive and willing. Medications will be administered at the specific request of the patient and when the patient refuses other such interventions.The facility's Medication Administration General Guidelines Policy, undated, documents Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). Administration: 2. Medications are administered in accordance with written orders of the prescriber.R2's Physician Order Report documents R2 was admitted on [DATE] with the diagnoses of Age-related Osteoporosis, Restless Leg Syndrome, Anxiety Disorder, Periprosthetic Fracture around Prosthetic Left Knee Joint, Type Two Diabetes Mellitus, Fibromyalgia, Depression, Unspecified Fracture of Lower End of Left Femur, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Other Lack of Coordination, Complex Regional Pain Syndrome of Upper Limb, and Major Depressive Disorder. This same Physician Order Report documents, Start Date: 10/28/25- Hydrocodone-Acetaminophen 5-325mg (Milligrams) one tablet every six hours for pain management.R2's Care Plan dated 10/26/25 documents Potential for pain related to recent fracture, recent surgery, and fibromyalgia. Approach: Administer medications as ordered. Assess for signs of pain. Notify Doctor if pain medications are ineffective. This same care plan documents R2 has a history of Periprostatic fracture and to administer pain medications as ordered.R2's MAR (Medication Administration Record), dated October 24th, 2025, through October 31st, 2025, documents R2's scheduled Norco-Acetaminophen 5-325mg was not administered on 10/31/25 at 8:00 PM.R2's Order's Administration Note written by V37/LPN (Licensed Practical Nurse) dated 11/1/25 at 1:05 AM, documents Hydrocodone-Acetaminophen Oral Tablet 5-325mg. Give one tablet by mouth every six hours for Pain Max Acetaminophen 3 gm (grams)/24 hours. Medication unavailable in cart.R2's MAR, dated November 1st, 2025, through November 4th, 2025, documents R2's scheduled Norco-Acetaminophen 5-325mg were not administered for 12 out of the 12 doses ordered.R2's Order's Administration Notes, dated 11/1/25 through 11/4/25, documents Hydrocodone-Acetaminophen Oral Tablet 5-325mg. Give one tablet by mouth every six hours for Pain Max Acetaminophen 3 gm (grams)/24 hours. Medication on order.R2's Health Status Note, written by V23/LPN on 11/2/25 at 10:36 AM, documents (R2) is out of Hydrocodone, prescription faxed to (V22/R2's Physician), awaiting refill.R2's Electronic Medical Record does not include any pain-relieving interventions, physician's notification of R2 not receiving the prescribed pain medication, or comprehensive pain assessments after the 13 occasions between 10/31/25 and 11/4/25 when R2 did not receive her Norco as prescribed.On 1/27/26 at 9:29 AM R2 stated she had a fall at home around a month prior to her admission to the facility and ended up having a left leg fracture resulting in R2 being hospitalized . R2 stated, I was in severe pain and needed therapy and pain management at the facility. When I was admitted to the facility, I was not receiving enough pain medication to control my pain. My doctor had ordered an increase in my pain medication. I received my pain medication for a few days, but at the end of October to early November 2025, the facility kept telling me I was out of my pain medication, and the doctor needed to sign some kind of script in order for my pain medication to be refilled. I was in severe pain and crying out and the staff would tell me there was nothing they could do, so they just assigned me to an ombudsman to speak with. I could not move on my own, I was in severe pain, I could not get comfortable, and the staff did nothing during the time I had no pain medication. It messed with me psychologically and was more than what I could handle, so when I was sent out to the hospital eventually, I requested to not return to the facility.On 1/27/26 at 12:47 PM V35/LPN (Licensed Practical Nurse) stated I was working at the facility when (R2) was a resident. (R2) was able to make her needs very known I do know (R2) was not receiving her pain medications like (R2) should have been and was always complaining of pain in her left leg especially. I know there was a change in prescription with (R2's) pain medication in the beginning, and after that change, pharmacy kept saying (R2's) Norco was on hold. I am not aware if (R2) received any other pain-relieving interventions during the time her Norco (Hydrocodone-Acetaminophen) was out.On 1/27/26 at 1:02 PM V1/Administrator-in-Training stated, I know at one time (R2) had filed a grievance stating the facility was out of her pain medication and that she was in pain. I know at that time we were waiting for (R2's) prescription to be filled. (R2) was not happy with the response, but we (the facility) had to wait for the pharmacy to fill it. (R2) should not have gone without her pain medication.On 1/28/26 at 2:02 PM V22/Facility Medical Director stated he expects the facility to notify him if a resident's pain medication is not being refilled by the pharmacy. V22 can then prescribe an alternative pain relief. V22 stated, (R2) should not have gone without her scheduled pain medication given (R2's) condition. The facility should have gotten ahold of me when they realized (R2's) Norco was out and the pharmacy was stating it was on hold. I am always available by phone call.On 1/29/26 at 11:43 AM V52/LPN stated, (R2) complained of all over pain quite frequently when I worked with her.On 1/29/26 at 1:23 PM V30/Facility Nurse Practitioner stated she does recall R2 complaining of pain quite frequently and stated if the facility had an issue with getting R2's pain medication from the pharmacy she would have expected them to notify her or V22/Facility's Medical Director to get an order for something else to give R2 for the pain while awaiting the refill. On 1/29/26 at 2:03 PM V2/Corporate/Interim Director of Nursing verified that R2 missed all scheduled doses of Hydrocodone from the evening of October 31, 2026, through November 4, 2026, and did not receive any PRN (as needed) pain medication or pain interventions during that same time. V2 stated that if a resident's pain medication is unavailable, nursing staff are expected to contact the pharmacy immediately to determine the delivery schedule of the medication that is unavailable, utilize backup supplies if the delivery for the unavailable medication does not arrive the same day, and/or coordinate with the physician for a local pharmacy script if the unavailable medication is not in the facility's backup stock, ensuring there is no gap in administration. V2 verified R2's progress notes dated 10/31/25 through 11/4/25 documented R2's Norco was on hold but did not have any documentation of the nurses notifying any physician to get R2's Norco delivered the same day or get something alternative ordered.On 2/3/26 at 10:43 AM V6/Occupational Therapist stated, I only worked with (R2) once, but she was very cooperative. (R2) complained of pain during that session. (R2) had diagnoses that supported why (R2) would be in severe pain. It seemed like (R2) was in the most pain when being moved.On 2/10/26 at 12:05 PM V3/MDS Coordinator stated, The floor nurses are assigned to perform an electronic pain assessment on a resident when they are admitted to the facility or during any acute change in condition. I do not see where anyone performed a pain assessment at any time during (R2's) admission to the facility. That would have helped the staff respond appropriately to (R2's) pain and try alternatives to relieve (R2's) pain when (R2) was out of her pain medication.

Based on Interview and Record Review, the facility failed to ensure a residents fecal collection system (rectal tube) was assessed and monitored, replaced after removal and care planned to ensure optimal outcome for one of one resident (R9) reviewed for rectal tubes in the sample of 16. This failure resulted in R9 going 17 days without proper fecal management collection and contributing to R9 developing infection in a stage four sacral pressure ulcer, requiring hospitalization with a diagnosis of sepsis and stage four sacral ulcer with osteomyelitis.Findings include:The facility's Guidelines for Management of Fecal Incontinence with (flexible seal) policy, dated 2/2011, documents Objective: To effectively divert and contain liquid and semi-liquid stool away from the body. Outcomes: Keep skin clean and dry; free from contaminants that contribute to skin breakdown. Contain infectious body waste contained within a closed drainage system to minimize risk of spread of bacteria. Protect surgical wounds and pressure ulcers from contamination by stool. Keep environmental odor to a minimum. Increase patient comfort. Notify physician if any of the following occur: persistent rectal pain, rectal bleeding, abdominal distention. As with the use of any rectal device the following adverse events could occur, excessive leakage of stool around the device, loss of anal sphincter muscle tone could lead to temporary anal sphincter dysfunction, pressure necrosis of rectal or anal mucosa, infection, bowel obstruction, perforation of the bowel. Maintenance: observe the device frequently for obstructions from kinks, solid fecal particles or external pressure.R9's admission Observation assessment, dated 12/22/25, documents R9 originally admitted to the facility on [DATE] with a stage four pressure ulcer wound to his coccyx and is dependent on staff for all activities of daily living, mobility and care.R9's Care Plan, dated 12/16/25, documents R9 has diagnoses including but not limited to Tracheostomy status, Gastrostomy status, Critical illness Myopathy, Pressure ulcer of Sacral region, stage IV (four), Osteomyelitis of vertebra, Sacral and Sacrococcygeal region. This care plan documents I have a pressure ulcer coccyx related to immobility, history of CVA (cerebrovascular accident), bowel incontinence and as evidenced by braden (skin assessment) score. Administer treatments as ordered and monitor for effectiveness. Follow facility protocols for the prevention/treatment of skin breakdown. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. The resident requires a pressure relieving/reducing mattress on bed. This same care plan does not document a plan of care for R9's rectal tube.R9's Physician Order sheet dated 11/20/25-2/10/26 documents R9 has an order started on 11/20/25 to monitor placement and empty contents of rectal tube every shift for wound care.R9's Treatment Administration Record (TAR), dated 11/20/25-1/17/26, does not document any monitoring of R9's rectal tube placement, assessment or bowel contents.R9's nursing progress note, dated 1/1/26 at 10:23 PM, documents Resident rectal tube fell out. Called MD (V22, Facility Medical Director) and he said to monitor and call the surgeon. This nurse could not find surgeon's number. DON (V2, Director of Nursing) notified, care ongoing.R9's progress note, dated 1/10/26 at 10:03 AM and completed by V30 (Facility Nurse Practitioner), documents Wound MD (Medical Doctor, V54 wound physician) stated that if (R9) does not want the fecal tube in place that is okay to leave out. The wound will heal better with it in place. Asked (R9) what his wishes were and he shook his head no. Rectal tube was placed to prevent contamination of wound, this has come out on two occasions this admission. No replacement rectal tube at bedside. Previously attempted to re-order and product was out of stock. (V32, R9's family) would like one re-ordered. Will verify with (R9) and re-order as needed.R9's progress note, dated 1/12/26 at 4:14 PM and completed by V30, documents Rectal tube was placed to prevent contamination of wound, this has come out on two occasions this admission. No replacement rectal tube at bedside. Previously attempted to re-order and product was out of stock. (V32) would like one re-ordered. Discussed with (R9) today that the rectal tube can help with wound healing so that it does not get contaminated. He did consent that this would be OK to re-insert. Will follow up with DON (V2) about ordering.R9's progress notes, dated 1/1/26- 1/17/26, do not document R9's gastric surgeon (unknown) was notified of the rectal tube removal or that the rectal tube was not ever replaced.On 1/28/26 at 12:40 PM, V32 (R9's Family) stated that three weeks into (R9's) stay at the facility, he was re-admitted to the hospital with a wound infection. V32 stated the facility never replaced R9's rectal tube after it came out for the second time. V32 stated (R9's) wound is to the bone and the size of a [NAME] and when staff clean R9's bowel contents up, the pad over his wound also becomes soiled. I have seen that stool-soaked wound pad sit for over four hours before a nurse changed the wound dressing.R9's Hospital Emergency Department-admission record, dated 1/17/26, documents R9 presented to the emergency room with fever, abdominal pain, diarrhea, nausea and vomiting and R9's appearance was ill-appearing and toxic-appearing. This record also documents R9 was admitted with a diagnosis of Sepsis with several contributing sources including a stage four decubitus ulcer with concerns for osteomyelitis.On 1/29/26 at 12:15 PM, V22 (Facility Medical Director) stated Stool getting into a wound would definitely cause contamination. When (R9's) rectal tube came out, I wanted him to follow up with the gastric surgeon due to the g-tube (gastrostomy tube) and worried about his bowel and possible placement issues with that. So, I did want the surgeon notified when it came out and I wasn't aware they didn't notify the surgeon.On 1/29/26 at 12:50 PM, V33 (emergency room Physician) confirmed seeing R9 in the emergency room on admission to the hospital (1/17/26) and confirmed that R9 has been admitted to the hospital twice with Sepsis and a Stage IV pressure ulcer with osteomyelitis. V33 stated (R9) is a very sick person and it's unfortunate. The Sepsis could come from multiple sites. In (R9's) case he had a stage IV, very deep, decubitus ulcer. Certainly, if stool were to enter into that wound bed it can lead to infection.On 1/29/26 at 1:20 PM, V30 (Nurse Practitioner) confirmed R9's sacral pressure ulcer was to the bone and R9 had a rectal tube to keep his wound clean which was removed on 1/1/26. V30 stated The rectal tube was never re-inserted for R9 due to it not being available. V30 also stated nurses should be assessing residents' skin daily to monitor for signs of pressure or impaired skin integrity.On 2/2/26 at 10:00 AM, V2 (Director of Nursing) stated she was not aware that R9 was not receiving rectal tube monitoring. V2 confirmed when the rectal tube was unavailable from their supplier, the facility did not reach out to the hospital to purchase a replacement tube.On 2/10/26 at 1:00 PM, V4 (ADON/ Wound Nurse) confirmed that R9's rectal tube was in place to help keep his sacral pressure ulcer clean. V4 also confirmed this tube was not on his care plan and R9's electronic medical record does not contain documentation to show that it was monitored every day. V4 stated The order for (R9's) rectal tube was not put in correctly and so there is no record that the site was monitored, including the amount of stool or nursing assessment to ensure placement was secure and without concern. (R9) did not have a care plan in place for the rectal tube and should have.

Based on interview and record review the facility failed to ensure physician ordered wound treatments and dressing changes were performed as ordered for 1 resident (R1) of 3 residents reviewed for wounds in a sample of 4. This failure resulted in R1 being admitted to the hospital for wound treatments. Findings include: The Nursing Services policy dated 9/27/17 documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related services to attain or maintain each resident highest practical physical, mental and psychosocial well-being based on the comprehensive assessment of the resident and consistent with the resident's preference, needs and choices. 2. Treatments and procedures ordered by the physician shall be properly administered including enemas, irrigations, catheterizations, applications, application of dressings and/or bandages, diet supervision. The Decubitus Care/Pressure Areas policy dated 1/2018 documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. 6) Reevaluate the treatment for response at least every two (2) to four (4) weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order. R1's Medical Records documents R1 was admitted to the facility on [DATE] with diagnosis Acute Infarction of Spinal Cord (Embolic) (Non embolic), Paraplegia, Monoplegia of Lower Limb Affecting Unspecified Side, Pressure Ulcer of Right Heel (Stage 4), Pressure Ulcer of Left Heel (Unstageable), Pressure Ulcer of Left Ankle (Unstageable), Pressure Ulcer of Other Site (Unstageable, Pressure Ulcer of Left Buttock (Stage 4), Pressure Ulcer of Right Buttock (Stage 4), Neuromuscular Dysfunction of Bladder, and Sepsis. R1's Minimum Data Set/MDS assessment dated [DATE], documents R1 is a paraplegia with medically complex conditions. R1 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R1 is dependent for toileting, bed mobility, and most activities of daily living. R1 does not reject care. R1 has one stage 3 pressure ulcer, three stage 4 pressure ulcers, and three unstageable pressure ulcers. R1 did not have any of the wounds when R1 admitted to the facility. R1 has impairment on both sides of his lower extremity. R1 has an indwelling catheter and is always incontinent of bowel. On 3/18/24 at 10:47 AM, V3 (Ombudsman) stated she had talked to the wound clinic and was told R1's wounds were dirty and smelled horrible. On 3/18/24 at 11:03 AM, V4 (Ombudsman) stated on 3/15/24 V4 was told by R1 that R1 needed his dressing changed. V4 told a nurse (unknown) R1 wanted his dressing changed. It took over an hour to for the nurse to change R1's dressing. V4 said V4 heard the nurse say how bad it smelled. On 3/20/24 at 10:53 AM, V5 (Wound Clinic Nurse) stated R1 was not having his wounds dressed as ordered. On 2/22/24 V5 talked to the facility about the dressing the clinic wanted the facility to use for R1's wounds. V5 was told, That dressing is too expensive, and we will not be getting it. V5 told the facility the clinic would order a less expensive dressing to see if it would work but if it did not work the facility needed to get the (antimicrobial foam) dressing. V5 said when R1 came back to the clinic on 2/29/24 R1's wounds were not getting any better so V15 (Wound Doctor) ordered the (antimicrobial foam) dressing again. A sample of the (antimicrobial foam) dressing was sent with R1 to the facility so the facility could use until the facility could get the dressing ordered. V5 said no one from the facility called to say they were not going to order the new dressing. V5 said when R1 returned to the wound clinic on 3/13/24 R1's wounds were much worse. R1's wounds were larger and deteriorating. R1 told V5 the facility ran out the sample dressing and R1 is not sure the facility will get anymore. R1 told V5, V1 (AIT) is trying to get the correct dressing ordered. On 3/20/24 at 11:00 AM, V15 (Wound Clinic Doctor) stated R1 is alert/oriented and a good historian of his treatments. V15 said, several times R1 has come to the wound clinic from facility with incorrect dressings in place. R1 told V15 the facility has a new administrator (V1) who is working on ordering the correct dressings. R1 told V15 the facility was having staffing issues so sometimes the dressings were not being changed. V15 stated the lack of appropriate dressings being in place has caused R1's wounds to worsen. V15 said on the 3/13/24 visit R1 continued to have the incorrect dressing on, and the wounds were noted to have a foul odor and large amounts of purulent drainage indicating infection. V15 advised R1 he needed to go to the hospital and be seen because V15 felt the wounds were worsening and appeared infected. V15 stated, I feel (R1's) wounds have worsened as a result of incorrect dressings being in place from the facility. I don't understand why the facility would send (R1) to a wound clinic for an expert opinion and then not follow the treatment orders. On 3/18/24 at 11:24 AM, V1 (Administrator in Training) stated R1 is in the hospital, and it has something to do with his wounds. On 3/20/24 at 11:28 AM, V16 (Regional Director of Operations) was asked why R1 was not getting the dressing to his wounds as V15 (Wound Doctor) ordered. V16 stated, The ball got dropped. On 3/19/24 at 12:30 PM, R1 stated the facility is not doing his dressing changes like they are supposed to do them. R1 must ask to have the dressings changed and if the nurses are busy the dressings are not changed. They are not using the right kind of dressing and it has caused R1's wounds to get worse. On 3/20/24 at 11:18 AM, V1 (Administrator in Training) stated whoever the nurse was working when R1 came back from the wound clinic should have put the new orders in. V19 (Previous Director of Nursing) was monitoring wounds and orders but V19 is no longer at the facility. On 3/20/24 at 11:30 am V17 (Licensed Practical Nurse) stated she has worked in facility for four days. V17 has observed V6 (RN) do R1s dressing change while she was in training. V17 stated V6 read the treatment came up on TAR and V6 packed the wound on R1's ischium with gauze which was soaked in solution she could not remember name of. V17 was asked if she had ever seen the (antimicrobial foam) dressing used on R1's ischium and V17 stated, I have not seen kind of dressing here. R1's Physician Order for bilateral ischial wounds dated 2/8/24 at 4:49 PM, documents to cleanse with normal saline solution, pat dry. Apply (antimicrobial foam dressing), apply (non-adherent dressing) and cover with an abdominal pad. Cover with (clear adhesive to hold dressing in place). Change daily and as needed. R1's Nursing Note written by V19 (Previous Director of Nursing) dated 2/9/24 at 11:47 AM, documents, (R1) came back with orders are not able to attend. May continue with (topical antiseptic) solution until next visit. R1's Nursing Note written by V19 dated 2/16/24 at 3:17 PM, documents, New orders processed and reviewed. Call placed to wound clinic. (Antimicrobial foam dressing) is unavailable at this time as well as (biodegradable gel dressing). Orders received to continue with (topical antiseptic) at 0.5 % (percent) as well instead of 0.25%. Will continue with daily treatments. R1 agrees with current treatment plan. R1's Wound Note dated 2/22/24 documents, (R1) did not have correct dressing on both ischial sites or on lower legs upon arrival today. Facility did not have any (antimicrobial foam dressing) on those sites today. Leg dressings were dated 2/18/24 when they should be changed daily. Poor prognosis for healing especially with additional factors of non-adherence to wound center orders. R1's Wound Clinic note dated 2/29/24 documents R1 is alert and oriented to person, place, and time. (R1) did not have correct dressing on both ischial sites or on lower legs upon arrival today. Facility did not have any (antimicrobial foam) dressing on those sites today. (R1) advised correct dressings were not on his wounds today. (R1) states the facility has a new administrator will order the correct dressings. R1 advised regarding healing. Poor prognosis for healing especially with additional factor of nonadherence to wound center orders. R1's Wound Orders dated 2/29/24 to bilateral ischial areas documents to pack wounds with (absorbent topical dressing), cover with (antimicrobial foam dressing), cover with (nonadherent dressing) and abdominal pad, and secure with (surgical tape). R1's Treatment Administration Record/TAR dated 3/1 - 3/31/24 documents, bilateral ischium-(povidone iodine) to base. Apply (topical antiseptic) solution 0.5% (percent) cover with ABD (Abdominal) pad and secure with (surgical tape). The last treatment documented was on 3/17/24. The TAR was not signed the ischium treatments were done on 3/4, 3/7, 3/8, 3/12, 3/15, and 3/16/24. (There was not an order to pack wounds with absorbent topical dressing), cover with (antimicrobial foam dressing), cover with (nonadherent dressing) and abdominal pad, and secure with (surgical tape) on the TAR) R1's Wound Clinic Note dated 3/13/24 documents, Left Ischial- Pressure ulcer stage 4 -base with pale granulation tissue. Moderate amount of yellow gray sloth at the base. Large foul-smelling drainage. Right Ischial -Pressure ulcer stage 4 - base with red granulation tissue at the base. Small amount of yellow sloth at the base. Small amount of exposed tendon and bone at the base. Moderate foul-smelling drainage. Large amounts of foul-smelling drainage from both hip sites noted today. (R1) states the facility ran out of the (antimicrobial foam) dressing a few days ago. Per RN, (R1) only had gauze packed into hip wounds. No (povidone iodine) dressing on lower extremities noted on arrival per RN. Unfortunately, wound center orders do not seem to be followed at the facility limiting options for healing. (R1) also has refused to consider negative pressure therapy in the past. (R1) has worsening infections of both hips. (R1) advised to immediately present to the nearest emergency room . R1's Wound Clinic Measurements dated 3/13/24, documents the left ischial wound edges are open. The wound bed granulating, moist, slough, purple. Large amount of drainage. Drainage characteristics/odor serous, creamy, purulent, yellow, malodorous. Wound length 4.6 cm/centimeters, wound width 5 cm, wound surface 23 square cm, tunneling depth 6.5 cm, undermining 6.2 cm. (Compared to) R1's Wound Clinic Measurements dated 12/21/23, documents the left ischial wound bed red, slough. Moderate amount of drainage. Drainage characteristics/odor serosanguineous. Wound length 4.5 cm/centimeters, wound width 4.5 cm, wound surface 20.25 square cm, no tunneling depth or undermining. R1's Wound Clinic Measurements dated 3/13/24, documents the right ischial wound edges are open. The wound bed moist, slough. Large amount of drainage. Drainage characteristics/odor malodorous, purulent, yellow, serous. Wound length 4.1 cm/centimeters, wound width 6.5 cm, wound depth 6.5 cm, wound surface 20.5 square cm, undermining 7 cm. (Compared to) R1's Wound Clinic Measurements dated 12/21/23, documents the right ischial wound edges are open. The wound bed red, slough. Moderate amount of drainage. Drainage characteristics/odor serosanguineous. Wound length 5 cm/centimeters, wound width 5 cm, wound depth 5.5 cm, wound surface 20.5 square cm, undermining 7 cm, no tunneling depth, or undermining. R1's Nursing Note dated 3/13/24 at 12:46 PM, documents R1 returned from the wound clinic visit at 12:30 PM. R1 stated, They want to add me to go to the hospital again for follow up. R1's Nursing Note dated 3/16/24 at 2:36 AM, documents R1 requested wound care be done on his buttock. More yellow exudates on the right wound, the left wound has reddened pinkish walls. There was not a strong smell from the wound as compared from before. (R1) Expresses plans of going to the Hospital today. R1's Hospital Record dated 3/18/24 documents R1 presents to the hospital for a wound check. Worsening buttock wound with purulent discharge. History (R1) is an unfortunate [AGE] year-old male with past medical history significant for history of paraplegia with a history of chronic and multiple wounds including history of osteomyelitis with frequent admissions to the hospital. (R1) has been in a nursing home but apparently the correct wound dressing has not been applied and when the patient was last seen in the wound clinic on the 13th of this month (R1) had the wrong dressing on and was recommended to be hospitalized but at point of time (R1) would refuse. R1 was seen in the emergency room and his sacral and buttocks Decubitus appear to be worse with some purulent drainage and tunneling as well. Assessment and Plan Probable Sepsis. Secondary to infected unstageable sacral/buttocks decub (Decubitus ulcer). R1's Nursing Note (Late entry) dated 3/20/24 at 8:02 PM written by V29 (Registered Nurse), documents, In report from AM (morning) nurse (V6/Registered Nurse) said the doctor had wanted (R1) to return to the hospital due to increased size of (R1's) ischium wounds. (V6) said administration was aware of this situation. (V25/Agency Coordinator) and (V28/Regional Nurse) we're in the Director of Nursing office and we're aware of the situation as well. I (V29) had asked if administration needed called-but since the doctor had wanted (R1) to go to the hospital per (V6) it was assumed administration knew (R1) was going. (R1) had finally agreed to go to the hospital. (R1's) packing gauze length was increased 8 (eight) inches to each ischium wound to a total length used of approximate 21 inches length of each packing gauze. The ischium wounds also had increased tunneling and increased dark yellow exudate per (V6) in report. (R1) was aware his wounds may be getting bigger and (R1) wanted them treated before they had gotten worse. (R1 was sent to the hospital on 3/17/24).

These failures resulted in three deficient practice statements. A. Based on interview and record review the facility failed to monitor laboratory tests results for a high-risk medication, Warfarin (anticoagulant) for one of two residents (R11) reviewed for anticoagulants in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter). B. Based on interview and record review the facility failed to provide medications and discontinue a medication as ordered for 4 of 4 residents (R4, R8, R12 and R13) reviewed for medication administration. This failure resulted in R4 experiencing ongoing, unrelieved pain from 01/13/24 through 01/23/24. C. Based on observation, interview and record review, the facility failed to recognize a potential ongoing life-threatening double dosage of medication from 6/24/23 when a second, similar medication was added to a resident's daily medication regime, for one of seven residents (R5), reviewed for medications, in a sample of 42. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/25/24, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite. Findings include: The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 11/6/18, documents, It is the policy of the facility adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes and documented in the Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consult Pharmacist. This policy also documents A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered. Wrong dose administered. Medication administered by wrong route. Medication administered to wrong resident. Medication administered at wrong time. Medication not administered. A medication discrepancy report shall be completed for any of the above occurrences. A. R11 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation and with an order for Warfarin 5mg (milligrams) every evening, with no physician ordered PT/INR labs to be drawn. R11's MMR (medication monthly review) dated 7/31/23, 8/29/23 and 9/27/23, documents (R11) receives warfarin and the most recent INR documented in the medical record is 2.4mg/dl from 7/8/23, the date he was admitted to this facility. (R11) does not have orders stating when to draw the next PT/INR. This form documents the Rationale for Recommendation: Warfarin has a BOXED WARNING describing the potential for major, sometimes fatal, bleeding. To avoid adverse consequences (e.g., bleeding, thrombosis), individuals should be closely and continually assessed both clinically and through appropriate INR monitoring. R11's first PT/INR, dated 10/4/23, documents an elevated PT of 25.6 seconds (normal range: 9.8-12.2 seconds) and elevated INR of 2.5 (normal range: 0.9-1.2mg/dl). R11's PT/INR dated 1/8/24, documents a high PT of 21.9 seconds and INR of 2.1mg/dl. R11's medical record has no documentation indicating R11's high PT/INR results were called to V17, (R11's Primary Care Physician). R11's Progress Notes, dated 1/18/24 at 6:45pm, documents R11 has had three episodes of a bleeding nose. R11's Progress Notes at 9:30pm, document, R11's epistaxis episodes around 8:40pm, R11 was observed with chest covered with blood and a bloody towel in his hand. Blood was running out from R11's left nostril like a faucet. R11 reported he felt lightheaded. R11's blood pressure was 88/44 (diastolic/systolic), pulse was 72, respirations 18 and pulse oximetry was 99 percent. (V17) was notified and orders were received to send R11 to the emergency room for labs and start intravenous fluids. R11's emergency room diagnosis, dated 1/18/24, include Hypotension Epistaxis, Acute Renal Failure, Supratherapeutic INR. R11's Hospital Problems list includes Hypovolemic Shock. On 1/18/24 R11's PT was 42.3 seconds (11.6-14.8 seconds) and INR was 4.5 mg/dl (Milligrams per deciliter). R11's hemoglobin was low at 8.8g/dl (grams per deciliter) R11's hospital notes document R11 received two units of red packed blood cells due to a diagnosis of hypovolemic shock. R11's Readmission Physician Orders, dated 1/25/24, documents Warfarin dose reduced to 5mg every evening due to elevated INR on date of admission as well as new drug interactions with antibiotics. Repeat INR in 3 days. On 2/20/24 at 11:00am, R11 stated his labs are not drawn on a regular basis. R11 stated on 12/18/23 he had a bloody nose for most of the day. He was told to hold pressure on it. R11 stated by evening, he was seeing double and lightheaded. R11 stated his blood pressure was very low. R11 stated he was sent to the emergency room and admitted to the intensive care unit. R11 also stated he received two units of blood while in the hospital. R11 verified he has not had any labs drawn since being readmitted to the facility. On 2/23/24 at 11:30am, R11 stated he still has not had any labs drawn. On 2/26/24 at 11:30am, R11 stated he had to go the emergency roiagnom on [DATE]. R11 verified labs were drawn at that time. On 2/20/24 at 12:00pm, V17, R11's Primary Care Physician, verified anyone on Warfarin is to have a PT/INR drawn monthly and every 3 days if on an antibiotic. V17 stated he was not notified of R11's PT/INR results on 1/8/24, when an elevated PT/INR results were obtained. V17 also stated he was not notified of R11's bloody nose until the evening he gave the orders for R11 to be sent to the emergency room . At 2/20/24 at 3:00pm V2, Director of Nursing, was unable to provide R11's INR results were to be drawn within the three days after readmission. V2 verified R11's INR was not drawn. On 2/21/24 at 11:00am, V2 stated the facility does not have any policy's concerning high risk medications. 32061 B. 2. R4's Physician Order Sheet, dated February 2024, documents R4 has diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction, Pain and Neuropathy. This same order sheet documents R4 has an order to receive Pregabalin (Analgesic) 300 MG (Milligrams)two times daily for nerve pain. R4's Medication Administration Record (MAR), dated February 2024, documents R4 did not receive the ordered medication on 2/13/24 through 2/23/24. R4's Progress notes for February 2024 document that R4 was not given the twice daily doses of his scheduled medication due to not available. 3. R8's Physician Order Sheet, dated December 2023 and January 2024, documents R8 has diagnoses of Traumatic Hemorrhage of Right Cerebellum, Traumatic Brain Injury and Pain. These same order sheets document R8 has an order to receive Pregabalin (Analgesic) 300 MG (Milligrams)two times daily for nerve pain. R8's Medication Administration Records (MAR), dated December 2023 and January 2024, document R8 did not receive the ordered medication from 12/14/2023 through 01/03/2024. R8's Progress notes for December 2023 and January 2024 document R8 was not given the twice daily doses of his scheduled medication due to not available. 4. R12's Physician Order Sheet, dated February 2024, documents R12 has diagnoses of Peripheral Vascular Disease, Diabetes Mellitus, Cerebral Infarction, Polyneuropathy. These same order sheets document R12 has an order to receive Pilocarpine (Cholinergic Agonist) 5 MG three times daily. R12's Medication Administration Records (MAR), dated February 2024, documents R12 did not receive the ordered medication on 2/13/2024, 2/14/2024 and 2/15/2024. R12's Progress notes for February 2024 document that R12 was not given the thrice daily doses of scheduled medication due to not available. On 2/17/24 at 11:30 A.M., V2/Director of Nurses confirmed that facility staff should notify Pharmacy immediately if a medication was unavailable. 5. R13's Monthly Medication Review, dated 1/23/24, documents R13's medical record documents the following irregularities were noted on the medication administration record (MAR)/prescriber order sheets (POS): 1/16/24 (R13) had Eliquis 2.5mg BID (twice daily) ordered but the pre-existing 5mg BID dose was not stopped. R13's MAR (Medication Administration Record), dated 1/16/24, documents to take Eliquis 5mg tablet twice daily and Eliquis 2.5mg twice daily. R13's MAR has each medication signed out as being given on 1/19/24 through 1/23/24. R13's MAR documents that R13's Eliquis 5mg was discontinued at 1:08pm. On 2/20/24 at 3:00pm, V2, Director of Nursing, stated that R13's Eliquis order was decreased due to a pharmacy recommendation, but the previous 5mg dose was not discontinued. V2 verified that R13 did receive the wrong dose of Eliquis for three and half days. --- C. R5's Physician Order Sheet, dated June 2023 includes the following medications: Calcium 600 MG (Milligrams) with Vitamin D 800 MG. Give 2 tablets orally one time a day for Supplement - Start Date 06/01/2023 and Oyster Shell Calcium 500 MG. Give 3 tablets orally one time a day for supplement -Start Date 06/24/2023. On 2/15/2024 at 9:18 A.M., V11/Licensed Practical Nurse prepared to administer medications for R5. After adding Calcium 600 MG with Vitamin D 800 MG two tablets and Oyster Shell Calcium 500 MG three tablets to the plastic medication cup, V11/LPN stated, I don't know why (R5) gets so much calcium. That's like a double or triple dose. V11/LPN then administrated R5's pills, with the Calcium and Oyster Shell Calcium, to R5. On 2/20/24 at 12:30 P.M., V17/R5's Physician stated, (The dosage of calcium) that (R5) receives can be toxic. (R5) should have never been given that much calcium. The Immediate Jeopardy was identified on 2/23/24. V1 (Administrator) and V3 (Administrator in Training) were notified of the Immediate Jeopardy on 2/23/24 at 09:30 am. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 2/27/24, V1, Administrator, provided copies of Staff In-Services Attendance Sheets, dated 2/24/24 with indication that education in the following areas was provided to nursing staff on the facility's policy and protocol for lab monitoring of high risk medications, notifying the Physician of a change on condition on any resident and notification to physician and conformance with physician order by V18, Cooperate Director of Clinical Services. R11's medical record was audited for completeness on 2/26/24 by V24, Regional Clinical Nurse. The facility's Quality Assurance Audit Form have been implemented to monitor and ensure that the IDT team including a nurse will review all admissions for high risk medications during Quality Assurance meetings. The IDT team including a nurse will review all admissions for lab orders. V24 or designee will follow the quality assurance monitoring program of high risk medications and labs twice weekly for three months.

Based on interview and record review the facility failed to notify physician of abnormal laboratory results, a change in condition and a medication error for two of 13 residents (R11 and R13) reviewed for physician notification in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter). Findings include: The facility's Notification for Change in Resident Condition or Status policy, revised 12/7/17, documents the facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, (Director of Nursing), Physician, Guardian, HPOA (healthcare power of attorney) of changes in the resident's medical/mental condition and/or status. 1. R11's was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation. R11 also had an order to take Warfarin (anticoagulant) 5mg (milligrams) every evening. R11's medical record did not have an order to complete laboratory work for a PT/INR (Prothrombin International Normalized Ratio) level. R11's PT/INR dated 1/8/24, documents a high PT of 21.9 seconds and INR of 2.1mg/dl (milligrams per deciliter). R11's medical record has no documentation indicating R11's high PT/INR results were called to V17, (R11's Primary Care Physician). R11's Progress Notes, dated 1/18/24 at 6:45pm, documents R11 has had three episodes of epistaxis (a bleeding nose). R11's Progress Notes at 9:30pm, document R11's epistaxis episodes around 8:40pm, R11 was observed with chest covered with blood and a bloody towel in his hand. Blood was running out from R11's left nostril like a faucet. R11 reported he felt lightheaded. R11's blood pressure was 88/44 (diastolic/systolic), pulse was 72, respirations 18 and pulse oximetry was 99 percent. V17 was notified and orders were received to send R11 to the emergency room for labs and start intravenous fluids. 2. R13's Monthly Medication Review, dated 1/23/24, documents (R13's) medical record documents the following irregularities were noted on the medication administration record (MAR)/prescriber order sheets (POS): 1/16/24 (R13) had Eliquis 2.5mg BID (twice daily) ordered but the pre-existing 5mg BID dose was not stopped. R13's Medication Administration Record, dated 1/16/24, documents to take Eliquis 5mg tablet twice daily and Eliquis 2.5mg twice daily. R13's MAR has each medication signed out as being given on 1/19/24 through 1/23/24. R13's MAR documents R13's Eliquis 5mg was discontinued at 1:08pm. On 2/20/24 at 12:00pm, V17 (R11's Primary Care Physician) stated he was not notified of R11's PT/INR results on 1/8/24, when an elevated PT/INR results were obtained. V17 also stated he was not notified of R11's bloody nose until the evening he gave the orders for R11 to be sent to the emergency room . V17 also stated he was not notified R13 received the wrong dose of Eliquis in January. On 2/20/24 at 3:00pm, V2, Director of Nursing, stated R11's medical record does not have any documentation V17 was notified of R11's abnormal labs or bloody nose. V2 also verified V17 was not notified of R13's medication error.

Based on interview, observation and record review, the facility failed to identify, assess, report and treat a facility-acquired pressure ulcer for one resident (R6); failed to administer wound treatment as ordered using proper infection control technique; failed to develop and implement pressure relieving interventions or care plan; failed to conduct a pressure ulcer development risk assessment for a resident identified as high risk for pressure ulcer development; and failed to develop a pressure ulcer care plan after a pressure ulcer developed for three of three residents (R1, R4, R6) reviewed for pressure ulcers in the sample of nine. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/19/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite. Findings include: The facility's Skin Care-Wound Care- Teaching Protocols dated 4/07 document, CNAs (Certified Nursing Assistants): Skin check with ADLs (Activities of Daily Living) and 100% (percent) Skin check with bath/shower. Report any changes in skin to the charge nurse. Report problems noted with wound or treatment coverings to charge nurse. Float heels while in bed. Document interventions on CNA Flow Sheet. Read care plan-Report interventions not on care plan to Care Plan Coordinator. Charge Nurse: Complete Interventions as listed for Prevention Protocols: Report wound area to physician during same shift discovered whenever possible. Obtain order for treatment of wound. Order to include: Method of Cleansing, type of treatment, specific location of area to be treated, type of dressing or leave open to air, frequency of how treatment is performed, treatment ending date. Assess for pain, notify physician as necessary and intervene as necessary to minimize pain, Initiate daily skin check on TAR (Treatment Administration Record) per score risk, Complete weekly assessment of wound to include wound locations, size in cc (centimeters), shape, color, depth, and presence of drainage, necrotic tissue granulation present, Initiate nursing intervention and place on TAR as necessary (Door Flag, specialty mattress, specialty chair, float heels, elevate legs, apply lotion, barrier cream ), Communicate new interventions and orders obtained to nursing office via the New Acquired Skin Condition Report, Document on Nurses' Note notification, interventions and current condition/wound description, Notify the physician of any changes in skin integrity or lack of progress. MDS (Minimum Data Set) Coordinator: Ensure Braden completed on newly acquired wound and PRN (as needed), Ensure care plan completed for presence of wound and new interventions including treatment, Ensure CNAs and nurse understand C/P (Care plan) interventions and documentation supports MDS and C/P. Director/Assistant Director of Nursing: Ensure inclusion of necessary interventions for prevention and treatment based on standards of practice and P&P (Policy and Procedure), Ensure completion and documentation of daily skin checks on TAR, Insure completion of weekly progress note includes wound location, size in cc, shape, color, depth and presence of drainage, necrotic tissue, granulation present, Ensure treatment completed as ordered, Ensure proper infection control technique is observed, Ensure physician notification of changes in skin integrity, presence of signs and symptoms of infection and/or lack of healing progress, Ensure completion of care plan and coordination of care by interventions listed. Administrator: Ensure above parties listed complete tasks as delegated, Review TARs to determine compliance with above tasks, Review MDS, Care Plans and charting to determine compliance with regulation. The facility's Skin Care Prevention-Teaching Protocols, dated 04/07, documents to complete Braden Risk Assessment on admission. Inspect skin head to toe first three shifts after admission-document results in nurse's notes. Complete Nursing Admission Assessment. Obtain order for prescriptions as needed for prevention (Vitamin/Mineral Supplements, antibiotic creams/ointments, prescription creams .) The facility's Treatment Protocol Guidelines Policy undated documents, Always maintain a clean field- Sterile if ordered, Wash hands after removing old dressings, cleansing and before applying new dressings, Sanitizer should be rubbed in for at least 30 seconds, Document the treatment on the TAR immediately upon completion, Document treatment progress at least weekly, Notify the Physician if a treatment is not producing progress within 2 weeks of starting. This protocol also documents to follow the Treatment Administration Record for all cleansing, medication application and dressings. 1. R1's TAR, dated 9/17/23, documents a new order to cleanse R1's left gluteal wound, then apply Santyl External Ointment (debridement ointment) topically, cover with calcium alginate (medicated dressing) and secure with a border gauze every day and night shift. This treatment is not signed out as being completed on 9/23/23. This treatment was not signed out as being done 9/28/23 through 10/8/23. R1's TAR, dated 10/8/23, documents to cleanse R1's right and left buttock wounds with normal saline, dry the wound, then apply Santyl ointment, cover with calcium alginate and a dry dressing. This treatment is not signed out as being done on 10/11/23, or from 10/16/23 through 10/27/23. R1's Weekly Wound Tracking, dated 9/17/23, documents both R1's left and right buttocks wounds are stage III facility acquired wounds. R1's right buttock wound measuring 5.2cm (centimeters) x 3.7cm x 0.1cm (no treatment ordered for the right buttocks wound) and left buttock wound 5.5cm x 5.0cm. On 9/26/23, R1's right buttock wound measured 6.0cm x 6.0cm x 0.0 cm and left buttock wound 5.5cm x 5.0cm x 0.0cm. On 10/5/23, R1's right buttock wound measured 6.0 cm x 5.5. cm x 1.0 cm and R1's left buttocks measured 5.5 cm x 4.5 cm x 0.5 cm. Both wounds documented as increasing in size. R1's Weekly Wound Tracking, dated 10/10/23, documents R1's right buttock wound measured 6.0cm x 6.0cm x 1cm and left buttocks wound 6.0cm x 6.0cm x 2cm. R1's right buttocks wound measured 6.0 cm by 6.0 cm by 3.0 cm on 10/17/23, and his left buttocks wound measured 6.0 cm by 6.0 cm by 3.0 cm. On 10/24/23, R1's right buttocks measured 6.0 cm by 6.0 cm by 5 cm and the left buttocks wound measured 6.0 cm by 6.0 cm by 4 cm. Both wounds increasing in size. R1's Progress Notes, dated 10/27/23 at 6:06 PM, document R1 has a temperature of 102.2 degrees Fahrenheit, 117 heart rate, and was sent to hospital for suspected sepsis. R1's Re-admission order sheet, dated 11/22/23, documents R1 was being treated for lower extremity paralysis, history of opioid abuse, infected ulcer of the skin, undifferentiated connective tissue disease, normocytic anemia, acute osteomyelitis of calcaneus, osteomyelitis of left side of pelvis, positive blood culture, hyponatremia, hypoalbuminemia. R1's admission orders document to cleanse R1's right and left gluteal/ischial wounds with normal saline and gauze, protect the perineal wound with a no sting barrier spray, then apply Sodium Hypochlorite moist gauze to the wound bed, cover with an ABD (abdominal gauze) and bordered dressing. Change twice a day and PRN (as needed). On 12/11/23 at 1:00 PM, R1 stated the facility does not have the Sodium Hypochlorite (Dakin's) solution for his wound care. R1 stated his wounds on his bottom are not being done twice a day as ordered. R1 stated he just returned from a hospital stay because of his wounds being infected. R1 stated he is now on a long term intravenous antibiotic treatment because of the wound infections. R1 stated his wounds on his buttocks had to be surgically debrided. On 12/12/23 at 1:15 PM, V17, Registered Nurse, washed her hands, then applied gloves. V17 un-taped R1's incontinent brief, soiled with a small amount of soft mushy BM (bowel movement). V17 removed the dressing from R1's right ischial wound. V17 sprayed the wound bed with wound cleanser, then used a gauze pad to wipe the inside of the wound. V17 soaked a roll of gauze in a glass of sterile water. V17 took the end of the sterile water-soaked gauze and packed it into R1's wound. V17 covered R1's wound packing with a calcium alginate and a foam dressing. V17 did not change her gloves or perform hand hygiene during this part of R1's wound care. V17 left, removed her gloves, then went to the bathroom to perform hand hygiene. V9, Licensed Practical Nurse/Wound Nurse, was assisting R1 to roll over on his side. V9 left R1 lying on the side of the bed and R1 rolled out of bed to the floor. V17 and V9 assisted R1 back to bed with the mechanical lift. V17 applied gloves and pulled back on R1's soiled brief. V17 attempted to place the calcium alginate dressing back in place, after it was out sitting on the soiled brief. V17 discarded the soiled calcium alginate dressing, applied a new calcium alginate to R1's wound, then covered the wound with a foam dressing. V17 performed hand hygiene then applied clean gloves. V17 removed the dressing on R1's left ischial wound. V17 cleansed R1's wound with wound cleanser, then wiped the wound out with gauze. V17 then soaked a roll of gauze in a cup of sterile water. V17 packed R1's wound with the sterile water-soaked gauze and covered it with calcium alginate, then a foam dressing. V17 and V9 then cleaned R1's BM covered buttocks. On 12/12/23 at 2:10 PM, V17 verified she did not perform hand hygiene when moving from a soiled area to clean. V17 stated incontinence care should have been done prior to the wound care. V17 stated she did not do R1's wound care as they were ordered. V17 verified the facility has been out of Sodium Hypochlorite for some time. V17 stated V9, Assistant Director of Nursing/Wound Nurse, told her to apply the calcium alginate over the gauze packing. On 12/13/23 at 3:00 PM, V2, Director of Nursing, verified the only wound R1 had on admission was the burn to his left lateral lower leg. V2 also verified the facility is unable to get Sodium Hypochlorite (Dakin's) solution. V2 stated sterile water is not a substitute for the Dakin's solution. V2 stated all the Sodium Hypochlorite orders were to be changed to normal saline but were not. V2 verified R1's wound is to be cleansed with wound cleanser then the Sodium Hypochlorite-soaked gauze is to be packed in the left and right buttocks wounds, then covered with an ABD (Abdominal Pad). V2 stated she does not know where the calcium alginate or sterile water came from. V2 stated R1's incontinent care should have been done, prior to wound care being started. V2 stated hand hygiene is to be done when going from a dirty area to a clean area. 2. R4's Admission Skin Assessment, dated 11/30/23, documents upon admission to the facility (11/30/23) an unstageable pressure injury to her coccyx, measuring 4.8 cm (centimeter) by 7.2 cm and a depth of 0.3 cm. The wound bed has slough with purulent drainage, with an odor. R4's admission orders, dated 11/30/23, documents to cleanse R4's right gluteal wound with Sodium Hypochlorite (Dakin's) 0.125% solution, apply moist to dry gauze dressing using 0.125% Sodium Hypochlorite (Dakin's) solution. R4's TAR (Treatment Administration Record), dated 11/30/23, does not have any pressure ulcer treatments documented as ordered. R4's TAR, dated 12/1/23 through 12/6/23, does not have wound care or pressure ulcer orders transcribed or documented as being done as ordered. R4's Skin Check weekly, based on Braden, one time daily every Tuesday and Friday was not completed on 12/5/23. R4's TAR, dated 12/7/23, documents to cleanse R4's left buttock wound with Dakin's (1/2 strength) then cover with a wet normal saline gauze and a dry dressing. R4's Progress Notes, dated 12/8/23, at 12:05 PM, R4 was lethargic and vomiting, blood pressure is 69 (systolic)/59 (diastolic) and a pulse of 120 beats per minute. R4's Progress Notes, dated 12/10/23, documents R4 is being admitted for wound debridement, intravenous fluids and unable to eat. R4's hospital admission diagnosis, dated 12/8/23, documents sepsis secondary to infected sacral ulcer/urinary tract infection, urothelial metastatic cancer, physical deconditioning and encephalopathy. On 12/13/23 at 3:00 PM, V2, Director of Nursing, stated R4's skin assessment was completed on admission, but the pressure ulcer and fall risk assessments were not completed as required. V2 stated R4 did not have an interim pressure ulcer care plan implemented. V2 also stated R4's admission wound care orders were not transcribed onto the TAR's. V2 verified R4's wound care was not done from 11/30/23 through 12/7/23. V2 stated if the TARs are not initialed, then the wound care is considered to not be done as ordered. V2 verified the wound measurements are not being done weekly as required. V2 stated she was not aware the skin issues were so bad until the state agency came in to investigate. On 12/14/23 at 9:20 AM, V9, Assistant Director of Nursing/Wound Care, stated she is having a hard time keeping up with the wound care duties because she is getting pulled to the floor to work all the time. V9 verified the floor nurses are responsible for doing treatments expect for when V19, Wound Physician, is in the building. 49187 3. On 10-17-23 R6's Initial Wound Evaluation and Management Summary signed by V19 (Wound Physician) documents R6 presented with a wound on R6's left heel and a rash. A stage III (three) pressure wound of the left, medial heel full thickness. Wound size 2cm x 3.5cm x 0.2cm. Exudate: Light Serous-Sanguineous. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater depth today. Relevant conditions including infection considered and address through treatment changes or investigations. Dressing treatment plan: Primary dressing(s)- Xeroform gauze apply once daily for 30 days. Secondary dressing(s) ABD (Abdominal Pad) apply once daily for 30 days; Gauze roll (kerlix) 2.25 inches apply once daily for 30 days. Recommendations: Float Heels in Bed; Off-Load Wound; Reposition per facility protocol; (heel protector). Other Diagnosis: Cellulitis of the left foot. Duration: At least 1 day(s). Additional treatment information: Recommend Tetracycline 500 mg (milligrams) PO (by mouth) BID (twice a day) for 14 days. Probiotics daily for 30 days. Clinical data and material reviewed: Deep swab technique performed on stage three pressure wound of the left, medial heel on 10-17-23. R6's current POS (Physician Order Sheet) documents R6 has diagnoses of, but not limited to, Type Two Diabetes Mellitus without Complications, Hypertension, Major Depressive Disorder, Cerebral Infarction, Paralytic Ileus, Muscle Weakness, Heart Failure, Chronic Congestive Heart Failure, and other lack of coordination. R6's most recent completed MDS (Minimum Data Set) assessment dated [DATE] documents R6 had no pressure ulcers and is at risk for pressure ulcers. This same assessment documents R6 requires extensive assistance with one staff member for bed mobility, and dependent assistance with two staff members for transfers and toileting. R6's Braden Scale for Predicting Pressure Ulcer Risk (completed prior to pressure sore development) dated 5-15-23 documents, Activity: 2. Chairfast- Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Mobility: Very limited- Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Skin Treatment Review: Indicate all used in last 7 days: Float Heels- No. This same assessment documents R6 has a score of 14 (high risk for developing pressure sores). R6's Current Care Plan last revised 11-21-23 does not include a skin management or wound care management plan of care prior to wound development (to prevent pressure wound) with interventions. This same plan of care does not include the wound development with interventions (to prevent wound from worsening). R6's MAR (Medication Administration Record) dated 10-01-23 to 10-24-23 documents an order for Tetracycline 500 mg capsule by mouth two times a day for wound infection until 11-2-23, with a start date of 10-19-23, two days after V19 Wound Physician recommended the order for an infection to the left heel on 10-17-23. R6's TAR (Treatment Administration Record) dated 10-01-23 to 10-24-23 does not document a treatment to apply xeroform gauze daily for 30 days, ABD pad daily for 30 days, or kerlix daily for 30 days to R6's left heel as ordered per V19 Wound Physician on 10-17-23. On 10-24-23 R6's Wound Evaluation and Management summary signed by V19, Wound Physician, documents R6 had a stage III pressure wound of the left, medial heel full thickness. Wound size 2cm x 3cm x not measurable cm. Peri-wound radius: Odor. Exudate: Moderate Serosanguinous. This same summary documents a diagnosis of Cellulitis to the left foot. Progress: Not improved. Recommend d/c (discontinue) Tetracycline and start Bactrim DS (Double strength) BID (twice daily) for 14 days. Levaquin 500 mg PO (by mouth) daily for 14 days. Probiotics daily for 30 days (based on culture report). Deep swab technique of stage III pressure wound of the left, medial heel demonstrates Pseudomonas Aeruginosa and MRSA (Methicillin-resistant Staphylococcus aureus) on 10-24-23. Dressing treatment plan: Add Gentamicin ointment daily for 30 days, Alginate Calcium daily for 30 days, ABD pad daily for 23 days, and Kerlix daily for 23 days. Discontinue Xeroform Gauze. On 11-7-23 R6's Wound Evaluation and Management summary signed by V19 Wound Physician documents (R6's) pressure sore of the left medial heel has now worsened from a stage III to a stage IV. R6's TAR dated 10-24-23 to 11-7-23 documents an order to apply Gentamicin Ointment BID to left heel, calcium alginate- silver BID to left heel and cover with an island dressing. These same orders were not started and signed off in the TAR until 10-25-23. From 10-25-23 to 11-07-23, five treatments were not signed as completed on R6's pressure ulcer, causing it to worsened from a Stage III to a Stage IV. R6's TAR dated 11-16-23 to 12-12-23 documents an order to apply Gentamicin Ointment every night to left heel, calcium alginate-silver every night to left heel and cover with an island dressing. From 11-16-23 to 12-12-23, ten treatments were not signed out as completed. R6's TARs dated 10-1-23 to 12-13-23 does not document an order for a daily skin check per policy despite having a facility acquired left heel pressure ulcer and a high-risk Braden Assessment score. R6's progress notes dated 10-1-23 to 12-13-23 does not include any documentation of R6's facility acquired left medial heel pressure sore including size, appearance, signs and symptoms of infection, etc. R6's MARs and TARs dated 10-1-23 to 12-13-23 does not include an order to monitor left heel pressure sore for signs and symptoms of infection. R6's Weekly Wound Tracking documents left heel wound measurements on the following dates: 10-17-23, 10-24-23, 10-31-23, 11-7-23, 11-14-23, 11-21-23, and 11-28-23. No further measurements to R6's left heel wound were documented after 11-28-23. On 12-13-23 at approximately 9:55 AM, V5 Agency LPN (Licensed Practical Nurse) prepared treatment for R6's facility acquired left heel wound. R6 was lying in bed with both heels elevated on a pillow. V5 LPN removed R6's dressing to the left heel with gloves. R6's left heel had a quarter-size pink area with a scant amount of light pink drainage and slight redness around the wound. V5 took off his soiled gloves and without sanitizing his hands put on new gloves before applying R6's treatment. V5 verified he did not use hand sanitizer or wash his hands between glove changes. V5 stated, I should have applied hand sanitizer in between glove changes. V5 stated he does not document any assessment anywhere on the wounds he only initials in the TAR that the treatment was completed. Immediately after R6's treatment R6 stated, My left heel has caused me severe pain. I have told the staff that I am in pain, but they won't come back to give me anything. Occasionally, they will bring me back a Tylenol, but it's not often. On 12/13/2023 at 1:30 PM, V2 DON (Director of Nursing) confirmed there was no skin assessment completed for the month of October 2023 upon identification of wound of the left heel. On 12-14-2023 at 9:20 AM, V14 (R6's Primary Physician) verified R6's facility acquired left heel pressure sore could have been avoidable if prior wound interventions were put into place and could have been avoidable from worsening if facility would have followed V19's Wound Physician orders, provided the treatment as ordered, and implemented/followed wound interventions. V14 stated if the facility is not following their wound care protocol and a resident's wound treatment is not completed as ordered the wound can worsen. On 12-14-23 at 10:54 AM, V9 Assistant Director of Nursing/ Wound Nurse stated, I am unsure of the exact date R6's left heel pressure sore had developed. I know it was approximately one week prior to the (V19) Wound Physician seeing (R6). (V20, CNA) found the area to the left heel when the CNA was getting (R6) dressed and reported it to an Agency Nurse (V21) that no longer works at the facility, around 10-11-23. I can't remember who the CNA was that found it. I did not see (R6's) left heel pressure wound until that Saturday 10-14-2023. I looked at the wound but did not document on the wound or fill out any papers regarding (R6's) left heel pressure sore. (V21) who was initially made aware of (R6's) newly identified skin issue should have filled out an initial skin report, measured the wound, assessed/documented on the wound, initiated a daily skin check treatment, and notified (V14/R6's Primary Physician). V9 verified that an initial skin report had not been filled out, the wound was not initially measured, assessed/documented on, a daily skin check was not put in place, and the physician was not notified. V9 also stated that R6's left heel pressure sore was facility acquired and no treatment orders or interventions were put in place when R6's pressure wound was identified until the V19 (Wound Physician) evaluated R6 on 10-17-23. V9 stated, (V19) Wound Physician wrote treatment orders on 10-17-23 but the order did not get processed, and no treatments were performed on (R6's) left heel pressure sore during that time until (V19) Wound Physician came back on 10-24-23 and wrote new orders. We (the facility) sometimes have a delay with processing (V19's, Wound Physician) orders because we are too busy. I did wound measurements on (R6's) left heel pressure sore from 10-17-23 to 11-28-23 but have not measured (R6's) left heel wound since that date. I have been too busy over the past two weeks to keep up, sometimes I can't even get the wound physician notes and new orders processed until a week or two later. On 12-14-23 at 3:30 PM, V2 DON verified R6's had missing treatments on the TARs dated 10-1-23 to 12-13-23. V2 verified no care plan was in place with interventions for skin breakdown and after R6's pressure sore was identified. V2 stated, The staff should always wash/sanitize their hands between glove changes. The Immediate Jeopardy was identified on 12/14/23. V1 (Administrator in Training) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 12/18/23 at 01:35 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: On 12/20/23, V2 (Director of Nursing) provided copies of Staff Inservice Attendance Sheets (dated 12/18/23) with indication that education in the following areas was provided to V1 (Administrator in Training) and V2 (Director of Nursing) by V24 (Regional Nurse): Care Plan Updating Audit, Skin Assessment Audit, Assessment of Wounds/Wound Measurements, Identification of Wounds, Physician Notification of a Change in Wound Status, and Implementation of Interventions of Pressure Ulcers. On 12/20/23, V2 (Director of Nursing) provided copies of Shower/Abnormal Skin Report Sheets which included documentation of skin assessments completed on all facility residents on 12/18/23. On 12/20/23, V2 (Director of Nursing) provided copies of Braden Scale Assessments, which indicate risk for pressure ulcer development, completed on all facility residents on 12/19/23. On 12/20/23, V2 (Director of Nursing) provided a copy of the facility's Weekly Wound Tracking Log (dated 12/19/23). V2 stated this log was made current once every resident in the facility had a skin assessment and a Braden Scale Assessment completed on 12/19/23. On 12/20/23, V2 (Director of Nursing) provided copies of Staff Inservice Attendance Sheets (dated 12/18/23) with indication that education in the following areas was provided to all licensed nurses and Certified Nursing Assistants: Assessment of Wounds, Identification of Wounds, Physician Notification of a Change in Wound Status, and Implementation of Interventions of Pressure Ulcers. On 12/20/23, the following staff members were interviewed and were knowledgeable regarding the recent education that was administered: V17 and V22 (Registered Nurses); V5 (local agency Licensed Practical Nurse); and V8, V13 and V18 (Certified Nursing Assistants). On 12/20/23, V2 (Director of Nursing) provided a copy of the facility's resident roster with indication of their Braden Scale Assessment scores. V2 stated residents with a score of 17 or higher receive weekly skin checks, and residents who scored 16 or below receive daily skin checks. V2 also provided a copy of the current skin check order for all facility residents dated 12/19/23. On 12/20/23 at 09:45 AM, V1 (Administrator in Training) stated ongoing compliance will be monitored and discussed daily amongst V1 and the members of the interdisciplinary team. V1 stated the facility's Quality Assurance meeting to discuss wounds is scheduled to be conducted on 12/21/23. On 12/20/23, V2 (Director of Nursing) provided copies of R6's current Treatment Administration Record with indication that all wound treatments have been completed as ordered as of 12/19/23. On 12/20/23 at 1:55 PM, V2 provided a copy of the following: R6's current Care Plan, which has been revised with pressure relieving interventions; R6's Treatment Administration Record; and R6's Pain Assessment (dated 12/18/23). No pain was reported by R6 at that time. V2 stated R6's wound measurements are current on the facility's wound log and no new orders were written by V19 (Wound Physician) when R6 was seen on 11/21/23. V2 stated R6 has completed the duration of her antibiotic therapy that was prescribed for R6's wound infection. On 12/20/23, V2 provided R6's Full Body Skin Assessment (dated 12/18/2023). On 12/20/23, V2 provided a copy of R1's Care Plan with new revisions including pressure relieving interventions. On 12/20/23 at 2:00 PM, V2 stated R4 is still hospitalized and indicated that upon R4's return to the facility, R4's Pressure Ulcer Care Plan will be updated, and the physician orders accompanying R4 from the hospital will be entered into R4's medical record immediately. On 12/21/23, V2 provided a copy of the facility's Quality Assurance Audit Form. This form documents the following: A weekly audit is in place to ensure the Wound Log is current, and it was completed 12/19/23; A weekly Quality Assurance meeting is in place, and the first meeting was conducted the morning of 12/21/23; A daily audit of all resident TAR's (Treatment Administration Record) is in place and has been conducted daily since 12/19/23.

Based on interview and record review, the facility failed to conduct a fall risk assessment and implement fall interventions for two of three residents (R1 and R4) and failed to ensure a resident (R2) was properly transferred with a mechanical lift. This failure resulted in the mechanical lift tipped over while R2 was in the sling resulting in fracture of the right distal tibia and required a surgical repair. Findings include: The facility's (mechanical lift) Owner's Manual (dated 2017) documents the following: Please note that the (mechanical lift) is designed to perform all types of lifts. It can be used as a bath lift in many situations. When used as a bath lift, we recommend using a (mechanical lift mesh bath sling). This same manual also documents, Lift Legs Position. Legs should be opened at the following times: To allow access around chairs, toilets or other impediments; To increase stability particularly with heavier patients; So, it is recommended to have legs open when lifting or lowering if possible though not required except as set forth below; Legs must be opened at the following times: For use with a walking harness; For patients who are active or swing around in the lift. The facility's Fall Prevention policy (revised 11/10/18) documents to conduct a fall risk assessment on the day of admission, quarterly and with a change in condition. Identify, on admission, the risk for falls. All staff must observe residents for safety. If a resident with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. Assessment of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be high risk at the time of admission for up to 72 hours. The admitting nurse will determine the temporary risk category. 1. R2's current medical record documents R2's current diagnoses to include: Hemiplegia and Hemiparesis following cerebral infarction affecting right non-dominant side; and Muscle Weakness. R2's current care plan documents the following focus: Alteration in transfer ability. Unable to transfer independently related to diagnosis of CVA (stroke) with right-sided Hemiparesis as evidenced by dependent on staff for all transfers. Resident Specific Information: (R2) requires the use of (mechanical lift) and staff assist of two to complete all transfers. On 12/11/23 at 02:40 PM, V3 (Certified Nursing Assistant) stated she was present during the 12/06/23 transfer when R2 was injured. V3 stated, We had just given (R2) a shower, and we were transferring (R2) from the shower bed back into her bed. She transfers with a (mechanical lift), and we just left the sling underneath her during her shower, so it was really, really wet. (R2) was moving when she was lifted, and the entire lift tipped over in the middle of the transfer. She did hit her head and the entire right side of her body struck the wall pretty hard. The position of the sling was not centered, and it was very, very wet since she just had the shower. V3 stated the mechanical lift's legs were not opened to increase stability at the time of R2's fall. V3 added R2 has a deficit on her right side, and R2's right arm lost positioning during the transfer. V3 stated, She (R2) cannot hold her right arm across her chest for the entire transfer, so her arm did slide down, but she remained still enough for me to guide the sling. On 12/11/23 at 04:05 PM, V4 (Certified Nursing Assistant) stated she was one of the staff members present when R2 sustained an injury during a mechanical lift transfer on 12/06/23. V4 stated, (V3, Certified Nursing Assistant) and I had just given (R2) a shower. We had transferred her to a shower bed for the shower, and we were transferring her back into her bed once her shower was completed. We did leave the mechanical lift sling underneath (R2) while we gave her the shower. It was not a shower sling, so it absorbed a lot of water, and there was water everywhere. I operated the controls, and (V3) was guiding (R2) while she was lifted in the sling. I had to leave the (stabilizing) legs closed because there just wasn't enough room to open them. When I pushed the mechanical lift toward (R2's) bed, the sling began swinging and then the entire lift tipped over. The top of the lift struck the wall. (R2) hit her head and her body struck the wall pretty hard. At that point, (V2, Director of Nursing) came in and took over. We put her back in bed once lifting help arrived. (R2) has a strong right sided deficit. She was adjusting her arms during the transfer because she cannot maintain her right arm positioned across her chest for very long. She was not flailing around. She was still enough for us to transfer. What made the lift fall was the momentum created from us moving the lift. I think they called 911 for additional lifting assistance. She was still in the facility when I left at the end of my shift. R2's Incident Investigation (dated 12/06/23) documents the following: (R2) in (mechanical lift) following shower. (R2) was active in (mechanical lift) sling causing the (mechanical lift) to sway. Water dripping from sling during the transfer. The momentum and legs were not fully extended, caused the (mechanical lift) to tip over. 911 activated to assist with returning resident to bed. Again, assessed for injury by staff nurse. Neurological checks intact. Pain 3/10 in lower back. Later in shift resident noted to have increased swelling of extremity. V14 (R2's Physician) made aware and orders received for X-ray. (Local mobile X-ray provider) at facility to perform X-ray (fracture observed). Resident transferred to (local hospital) for evaluation. X-rays there confirmed closed fracture of the proximal fibula. This same investigation documents, Resident scheduled for surgery at this time. During surgery an open reduction internal fixation using intramedullary nail in distal tibia, and five screws to secure the fibula. Root Cause: Resident moving around in the (mechanical lift). Interventions: Resident will be educated about behavior in the (mechanical lift) upon return from the hospital. Nursing staff will be in-serviced on proper use of the (mechanical lift), which (mechanical lift) slings are appropriate for the transferring situation, weight limits for (mechanical lifts), and resident behavior in a (mechanical lift). R2's (local hospital) medical record (dated 12/07/23) documents the following: R2 had an X-ray of her right tibia and fibula with the following impression: Distal Right Tibial Fracture. These same records document R2 had surgery on 12/08/23, and an intramedullary nail with five locking screws were inserted into R2's right tibia to stabilize R2's fracture. On 12/12/23 at 03:50 PM, V2 (Director of Nursing) stated, The only correct thing that occurred with (R2's) transfer (on 12/06/23) was the correct (mechanical lift) was utilized, it was appropriate for her weight. The legs of the (mechanical lift) should have been fully expanded and locked for stability, and they were not. Never take the center of gravity away, or someone is going to get hurt. (V3 and V4, Certified Nursing Assistants) did not use the correct sling for the situation. Using a regular sling in the shower is going to absorb excess water weight, and water was dripping everywhere creating a fall hazard. They (V3 and V4) knew to use a shower sling but did not because they could not locate one. V2 then confirmed R2 has right-sided weakness and may not be able to maintain her arm across her chest for the duration of a mechanical lift transfer. V2 verified the newly implemented intervention of, Resident Education was not an appropriate intervention to implement for R2's mechanical lift transfers and indicated the failure came from the two staff members transferring R2. V2 stated, (R2) initially reported her pain at 3/10 around 04:00 PM on 12/06/23. At 06:00 PM, increased swelling was noted R2's right leg, and she was reporting increased pain. We ordered a mobile X-ray, and they were at the facility around 06:30 PM. As soon as the X-ray was taken, you were able to see an obvious break, so (R2) was sent to (local hospital) at 06:40 PM and is still hospitalized . She has not yet returned to the facility. The hospital identified a fracture in her right tibia. She had to have surgery to repair the fracture, and she had some hardware to stabilize the fracture. 34048 2. On 12/12/23 at 01:15 pm, V17 (Registered Nurse) and V9 (Assistant Director of Nursing/Wound Nurse) were performing wound care to R1's right and left buttocks wounds. V17 left R1 lying on the side of the bed, while V17 performed hand hygiene. V9 was assisting R1 with maintaining his position on his left side, and R1 was lying along the edge of the bed. V9 asked R1 if he was ok in that position, and then proceeded to walk away from him. R1 then fell off the side of the bed, onto the floor, landing on his knees. V17 and V9 assisted R1 back to bed with the mechanical lift. Neither V17 nor V9 performed a full body assessment on R1 after he had fallen. R1's current care plan documents that R1 is as risk for falls, due to gait/balance problems, history of falls, monoplegia of lower limb, musculoskeletal impairment. R1's current electronic medical record does not contain a fall risk assessment. On 12/13/23 at 3:00 pm, V2, Director of Nursing, stated R1 should not have been left lying on the side of the bed alone. On 12/14/23 at 9:20 am, V9 stated she should not have left R1 on the side of the bed unattended. V9 verified R1 does have a history of falls. 3. R4's Progress Notes document R4 was admitted to the facility on [DATE], and documents that on 12/01/23, R4 verbalized reports of feeling, so weak. R4's medical record does not have a fall risk assessment or an interim fall risk care plan in place. On 12/7/23, R4's Progress Notes document R4 was visualized on the floor next to her bed near the window with range of motion within normal limits and no visible pain. R4 was assisted back to bed. On 12/13/23 at 3:00 pm, V2 (Director of Nursing) verified R4 did not have a fall risk assessment completed upon admission. V2 stated R4 did not have an interim fall prevention care plan.

Based on interview and record review, the facility failed to investigate, report a fall with major injury to state agency, and provide one to one supervision to prevent a fall for one of three residents (R1) reviewed for falls in a sample of three. These failures resulted in R1 sustaining a C6 cervical fracture, abrasion to her right eyebrow, right abrasion to head, abrasion to the left lower extremities, and abrasion to her right hand. Findings include: Facility Fall Prevention Policy, revised 11/10/18, documents, To provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. All staff must observe residents for safety. Facility Abuse Policy, undated The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: Dementia management and resident abuse prevention. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Serious bodily injury: an injury causing extreme physical pain; involving substantial risk of death; involving impairment of the function of a bodily member, or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Once the administrator or designee receives an allegation, the person in charge of the investigation will obtain a copy of any documentation relative to the incident. After a conclusion based on the facts of the investigation are determined, internal reports, interviews and witness statements shall be released. The person in charge of the investigation will update the administrator or designee on the progress of the investigation. The administrator or designee will report the conclusions of the investigation within five working days including the allegation, facts, conclusion, and a summary of all interviews conducted with the names, addresses, and phone numbers. The administrator or designee will review the report, forward a written report to (State agency) within five working days of the reported incident. The report shall be made not later than 24 hours after (incident) and a written report shall be sent to (State agency) including date, time, location and circumstances of the incident and any injuries. Facility staffing sheets dated 2/1/22 and 2/2/22 verify V8 Registered Nurse/RN worked 2/1/22 and 2/2/22 from 6:00 am until 6:00pm, V9 Licensed Practical Nurse/LPN worked 2/1/22 from 6:00 pm until 2/22/22 at 6:00 am, V10, V11, and V12 (Certified Nurse Aides/CNAs) worked 2/1/22 night shift (10:00 pm) until 2/2/22 day shift came in at 6:00 am. On 2/10/22, V1 provided a document titled, Quality Care Reporting Form, dated 2/2/22 by V9 LPN/Licensed Practical Nurse, regarding R1's fall which documented the following, On 2/2/22 at 5:15am (R1) fell with an abrasion to her right eyebrow, right abrasion to head, abrasion to the left lower extremities, and abrasion to her right hand. Physician and responsible party notified, and (R1) sent to the (local) hospital. V1's summary of event and actions taken, dated 2/2/22 by V1, documents the following, (R1) remains a one to one with caregiver due to poor safety awareness and impulsiveness. On 2/10/22, V1 was unable to provide any investigation notes or interviews regarding R1's fall. On 2/15/22 at 8:12am, V1 (Administrator) confirmed that V1 did not report R1's fall with injury to the (State agency) and did not investigate R1's 2/2/22 fall with injury until 2/15/22. R1's facility medical record documents R1 is [AGE] years old, admitted to the facility on [DATE] with the following diagnoses: [CONDITION(S)] like activity, closed non-displaced fracture of pelvis, late onset Alzheimer's/Dementia. R1's Facility Inquiry/Referral Form, dated 1/27/22, documents under Nursing homes R1 lived at an assisted living Memory Care unit; Current Diagnosis or reason for hospitalization : Ground level fall and possible [CONDITION(S)]. Late onset Alzheimer's/Dementia. R1's Facility New Referral Form, dated 1/27/22, documents, (R1) is a patient from (Assisted Living memory care unit); admitted to hospital on 1/8/22 with a closed non displaced fracture of pubis; and late onset Alzheimer dementia. R1's hospitalization dated 1/8/22 through 2/1/22, documents R1's Cervical spine without contrast Computed Tomograghy (CT) scan performed on 1/8/22 and 1/9/22 had, No acute fracture or subluxation of the cervical spine. R1's facility Nurses' notes, dated 2/1/22 at 3:00pm by V8 RN documents, (R1) was brought into the facility by (Local Ambulance Service), is alert but not oriented, had fall with hip fracture and the pelvis (other facility), able to stand and walk but gait unsteady, restless, and agitated with incoherent speech. Requires one to one care, as it's difficult to get her in bed. R1's Facility Fall Risk Assessment, dated 2/1/22, documents R1 is at high risk for falls. R1's Facility AIM for Wellness, no date, documents Alert, Disoriented. Needs redirection frequently. R1's Facility Nursing Admission Assessment, dated 2/1/22 by V8 RN, documents Admitting Diagnosis: [CONDITION(S)] like activity, skin tear to left elbow, no excoriation, and redness to coccyx. R1's facility admitted Care Plan, admitted [DATE], documents, High risk fall assessment, poor safety awareness, fall history, wanders, and psych med use. R1's facility Elopement Evaluation, dated 2/1/22, documents, Poor decision making skills, inability to identify safety needs, and severe medical illness/Dementia. IDT (Interdisciplinary Team) has reviewed the resident's capabilities, needs and preferences and has determined the resident is at risk of leaving home unattended. R1's Facility Investigation Report for Falls, dated 2/2/22 documents, (R1) demented, what fall prevention techniques were in use prior to the fall? One on one; patient is impulsive with poor safety awareness due to a diagnosis of Dementia. R1's hospitalization dated 2/2/22 documents R1's cervical spine without contrast CT scan, C6-7 vertebral fracture activity, particularly evident anterosuperior related, at which point there is an element of major fragment distraction. Recommend neurosurgical consultation. The T3 vertebral level incompletely delineated on this cervical spine exam, suggesting acute on chronic fracture activity. R1's After Visit Summary, dated 2/2/22 documents Reason for visit: Fall, and head injury. Diagnoses: C6 cervical fracture, fall, and forehead laceration with instructions for the Aspen Collar from Neurologist. You need to wear the Aspen collar at all times except for collar care. R1's facility Nurses; notes, dated 2/2/22 at 2:30pm by V8 RN, documents, (R1) came back from the hospital at 2:30 pm and she had a cervical fracture which was sustained from the fall, she has aspen collar. On 2/9/22 at 4:36pm, V4 (R1's family) stated, (R1) is (at another facility now) She was discharged from (local hospital) on [DATE], and was at (nursing home) 15 hours only and she fell and broke a bone in her neck, laceration on her right hand, head, left leg, scalp, and right arm. (R1) can't walk but she is a fall risk, she was at an assisted living and memory care home prior to the nursing home, she fell there and went to the hospital. On 2/10/22 at 9:05am V1 Administrator I have not had a reportable fall for the past three months. On 2/10/22 at 11:30am V2 Director of Nursing/DON, (R1) was here 3-4 days. She fell when she stood up from her wheelchair, lost her balance, hit her head at nurses station, sent to ER (emergency room ), she was a one to one, the nurse that was watching her went around the station to help someone and (R1) fell . (R1) got a laceration with maybe 6 sutures and discoloration to orbital area. She was one to one for impulsive and poor safety awareness, she was a new admit, she was a referral from the hospital. On 2/15/22 at 12:49pm, V8 Registered Nurse/RN stated, I worked 2/1/22 and 2/2/22 during the day from 6:00 am until 6:00 pm, I wrote the Nurses' note on 2/1/22 for (R1) and performed the admission assessment. (R1) did not have a cervical collar or cervical fracture that day but she was admitted from (local hospital) with a hip fracture. (R1) was very confused, required one to one staff, and was very busy moving around and couldn't get settled. On 2/2/22 when I worked from 6:00 am until 6:00 pm, I got report that (R1) was sent to the hospital for a fall, and when (R1) came back on my shift she had a cervical fracture and had a neck collar on. On 2/15/22 at 12:54pm, V9 LPN/Licensed Practical Nurse stated I worked 2/1/22 from 6:00 pm until 2/2/22 until 6:00 am. I was (R1's) nurse. Around 10pm on 2/1/22 (R1) was confused, had Alzheimer's, was restless, trying to get out of bed, and was in a psychotic state so she was brought out to the Nurses station for closer observation. (R1) did have a one to one sitter but she was pulled to work the floor as a Certified Nurse Aid/CNA so (R1) was brought out to the Nurses' station for me to watch her. I was the only nurse in the building, a resident needed pain medication, I left (R1) to pass the pain medication, and (R1) fell while I was gone. (R1) had an abrasion to her right eyebrow, right ankle, and right temporal area. (R1) went to (local) hospital about 5:30-5:40am. On 2/15/22 at 1:56pm, V10 CNA stated, (V11 CNA) was (R1's) sitter on 2/1/22 midnight shift. (V11) was pulled to work the floor as a CNA so the resident was up behind the Nurses' desk with the nurse watching her. While we were on rounds (R1) fell while the nurse was watching her. On 2/15/22 at 3:30pm, V11 CNA/sitter stated, (R1) was a one to one resident, the nurse was supposed to be watching her when she fell , but the nurse left her alone and (R1) fell .

Based on observation, interview, and record review, the facility failed to provide supervision and intervene when a cognitively impaired, high risk elopement resident, with previous exit attempts was in a non-resident care area displaying non purposeful wandering behavior, and failed to ensure that one exit door's alarm was enabled and this same exit door's other alarm was in working condition for one (R1) of four residents reviewed for elopement in a sample of five. These failures resulted in R1 leaving the building unsupervised for approximately three hours putting the resident at risk for serious injury or death. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on December 18, 2020, the facility remains out of compliance at a severity level two, as the facility continues to monitor the effectiveness of training regarding facility staff knowledge on elopement and residents who are high risk for elopement and the continued effort of staff to investigate why an exit door alarm was not enabled and functioning. Findings include: The facility's Elopement Prevention Policy, revised 10/06, documents It is the policy of (facility) to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement. Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. This policy continues with Procedure: 3. A facility staff member will take a photograph of the resident upon or within 8 hours of admission. The photograph will be placed in the Medication Administration Record. Any resident assessed to be at high risk for elopement will have their photograph and basic identifying information placed in a special folder or binder to be maintained at the nurse's station. 4. Department supervisors will be provided with a listing of residents at high risk for elopement. Each department supervisor will confidentially disclose this information to their employees as necessary. 5. The Interdisciplinary Team will initiate a plan of care for any resident determined high risk for elopement. Facility specific measures as well as resident specific measures with be included in each high risk resident's plan of care to minimize risk factors. Communication of these interventions will be made to direct care staff through exposure to the resident's plan of care and periodic review and disclosure of the contents of Elopement File/Binder. 6. Interventions of personal door alarm devices and monitoring will be initiated as deemed necessary by the IDT (Interdisciplinary Team) and documented in the individual resident's plan of care. 7. Any high risk resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or resident room when noted to be near an exit door. R1's facesheet documents R1 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The facility's reported incident on R1 notes the following: Missing Resident Timeline: 12-3-2020 at 12:15pm (V4) Business Office Manager/BOM noted (R1) pacing back and forth outside (V4's) office. At 12:30pm (V4) noticed (R1) was missing and advised Administrator (V2 former Administrator). All staff were alerted and missing resident protocol was initiated. This same report documents the following interview by V4: At 12:15pm I noticed (R1) pacing back and forth outside my office. I had to walk up to the front printer and was up there for about 15 minutes. At 12:30pm I walked back to my office and did not see (R1) so I checked all the rooms that I could down by my office. Once I noticed that he was not in any of the rooms, I notified (V2). R1's A.I.M. (Assess, Intercommunicate, Manage) for Wellness, dated 12-3-2020 and signed by V3 former Director of Nursing/DON, documents the following regarding an Exit Attempt which started on 12-3-2020; (R1) has been known to wander in vicinity of doors, states he needs to take care of the farm; 12:30pm this nurse (V3) and nursing home administrator (V2) made aware at approximately 12:30pm resident noted to exit facility. R1's ED (Emergency Department) to Hospital Admission report, dated 12-4-2020, documents Hospital Course: Patient has moderate dementia and lives at (named facility). Skip from the facility on 12/03. Was found wandering outside and brought to the ED. On 12-17-2020, at 9:15am, V5 Social Service Director/SSD walked surveyors to the area where R1 was found on 12-3-2020 by local emergency crews. This area where R1 was found was a walking distance of approximately 1100 feet from the front of the facility. The facility and area where R1 was found is surrounded by large wooded areas with a known ravine to the west, has a four lane highway with a 45mph (mile per hour) speed limit to the east approximately 700 feet away, and a large river about 800 feet further east of the highway. R1's Minimum Data Set/MDS assessment, dated 11-23-2020, documents R1 has a BIMS (Brief Interview Mental Status) of 11 (moderately impaired cognition) with disorganized thinking; R1 has [DIAGNOSES REDACTED]. R1's Elopement Evaluation, dated 11-16-2020 and signed by V3 former Director of Nursing/DON, documents that R1 is physically able to exit the building independently; has poor decision making skills; has inability to identify safety needs; has altered perception of awareness leading to seeking exit/escape;has a level of agitation requiring supervision; has dementia: history of wandering in vicinity of exit doors in the last 90 days; and wandering in vicinity of exit doors. Score = 7; 5-10 is high risk. Interventions: Ambulate indoors, redirect to common areas. This evaluation includes a hand written note by V3 stating R1 frequently talks about having to take care of his cattle/horses. R1's Elopement Evaluation, dated 11-23-2020 and signed by V8 Minimum Data Set/MDS Coordinator, documents R1's elopement risk score = 5; 5-10 is high risk. This evaluation includes Interventions: Ambulate indoors, redirect to common areas. V8's hand written note documents (R1) talks about taking care of the farm. R1's current Care plan includes impaired cognition with need for supervision with ADLs (Activities of Daily Living); R1 known to wander, may seek to leave the home; related [DIAGNOSES REDACTED]. R1's Care Plan also includes that R1 wandered in vicinity of doors; start date of 11-16-2020. On 12-10-2020 at 12:55pm, V4 BOM stated the following: (On 12-3-2020) R1 was pacing outside my office. I could hear and see (R1) going back and forth. It was between 12 and 12:30pm when I last saw (R1) looking through the windows of the East side door (leading to a resident hallway). I headed up front to the copy machine for 5-10 minutes then walked back. I didn't see or hear (R1) anymore. It was not normal for (R1) to be back here. The alarm wasn't going off when I got back to my office. I never heard an alarm (sounding on 12-3-2020); it is very loud. V4 stated V4 quickly checked the rooms and offices in the hallway where R1 was last seen. When V4 did not see R1 anywhere V4 immediately ran to V5 SSD's office which is where V2 (former Administrator) also was and informed V2 and V5 that V4 believed R1 left the building. V4 stated V2 took off running. I did another sweep here (near the East exit door). V4 stated After the facility sweep I checked the (East) door alarm box and noticed that it was unlocked. V4 stated a key is needed to turn the red box door alarm on and off and V4 has a key to this alarm. V4 stated I then locked the alarm box and told (V2). The door alarm is supposed to be locked at all times. Not sure why it wasn't. At this time, V4 verified that for the alarm to sound from the red alarm box on the door, the alarm needs to be in a locked position and that each exit door has a second alarm which sounds at the nurse's station. On 12-16-2020 at 1:10pm, V4 BOM stated I was not aware (R1) was an elopement risk. I would have had (R1) come to the printer with me (instead of leaving R1 alone, unsupervised). On 12-16-2020, at 10:50am, an Elopement binder was on a shelf at the nurse's station. This binder included R1 as a high risk for elopement and contained R1's photo and demographic information. On 12-10-2020 at 1:11pm, V5 Social Service Director/SSD stated (On 12-3-2020) I was in my office with (V2) when (V4 BOM) came in and said (V4) thought (R1) got out (of the facility). (V2) and I swept the facility; we divided up. I last saw (R1) walk back towards (V4's) office. V5 continued to state (R1) was not redirected. I would assume someone should have been alerted to redirect (R1) before (V4) left (R1). (R1) is confused at times. V5 also stated The elopement book is for residents who wander and are high risk for elopement. Anyone in this elopement book found wandering out of their area should be redirected immediately. At this time, V5 confirmed that R1 is in the elopement binder as a high risk for elopement and should never be left unsupervised near an exit door. On 12-16-2020 at 1:25pm, V5 stated that there were no alarms going off (on 12-3-2020 when R1 walked out of the facility). If (an alarm) at the door was going off I would hear it in my office which is where I was when it happened (R1 walked out of the facility). R1's Psychosocial History, dated 11-26-19 and signed by V5 SSD, documents a Social Service Interim Treatment Plan which includes Safety/Mood/Behaviors of wanders and elopement watch. On 12-18-2020 at 10:01am, V5 SSD stated that V5 completed and signed the Psychosocial History form, dated 11-26-2019. V5 stated that V5 marked that (R1) wanders on the form because V5 could tell (R1) was confused, (R1) kept asking why (R1) was here while wandering all around the building. R1's Community Survival Skills Assessment, dated 11-26-2020 and signed by V5 SSD, documents R1 is not sufficiently oriented and coherent affording (R1) the potential for independent pass privileges, and R1 is not capable of unsupervised outside pass privileges at this time. R1's Nursing Summaries, dated 12-3-19 and 3-3-2020, each document under Mood/Behavior that R1 wanders. On 12-10-2020 at 1:31pm, V23 Certified Nursing Assistant/CNA stated (R1) was in (R1's) room (on 12-3-2020) until I went to bring juice to (R1). (R1) was walking out of (R1's) room so I said 'hi' and left the juice in (R1's room). (R1) walked straight down Northwest hall - (R1's) hall. V23 verified that no alarms were sounding on 12-3-2020 when R1 eloped from the facility. V23 continued to state I am not sure if (R1) was in the elopement binder. (R1) did get out before. (R1) kind of wandered; walks around the building all the time. (R1) went outside once saying he went to check the cows. V23 verified that no call was received from (V4 BOM) reporting that (R1) had wandered near V4's office. On 12-10-2020 at 1:40pm, V6 Maintenance Director stated I was not at the facility the day (R1) left the building. I did hear that the red alarm box was disarmed. I don't know why that would have been. I did not do an investigation into why the box was unlocked. On 12-16-2020 at 9:54am, V6 stated There is a button that pops out in the door jam that makes it alarm. I don't believe anyone told me the button jammed. I would expect to be told if so. I would have replaced it (the button) even if the door alarm continued to work afterwards. At this time, V6 verified V6 was informed the alarms didn't sound that day. V6 denied being aware of which residents in the facility are high risk for elopement. On 12-11-2020 at 1:45pm, V10 Maintenance Assistant stated (On 12-3-2020) I started hearing people running around while I was in my office which is on the West side by the nurse's station. I heard commotion so I asked (what was happening) and they said a resident was missing. V10 stated I didn't hear any alarm going off or see it lit up on the panel. On 12-16-2020 at 10:50am, when V10 was asked what elopement means, V10 responded with a long pause and then said, I don't know, does it mean to cause problems? I haven't been told much about the residents. I see residents walking around but I just assume people are allowed to. I went through a lot of paperwork with orientation and I signed a lot, but I don't remember anything about elopement or an elopement binder. On 12-10-2020 at 2:15pm, V7 Licensed Practical Nurse/LPN stated I worked 6am-6pm on [DATE]rd. I am agency. I know (R1). I was passing meds (medications), but not on (R1's) side of the hall yet. Staff were passing lunch trays. (V2 former Administrator) came and said we think (R1) got out. I gathered staff up, did a head count and searched rooms. (On 12-3-2020) I saw (R1) in the hall right before lunch. (R1) was trying to get into the Covid unit so (V11 Certified Nursing Assistant/CNA) redirected him. (R1) redirects easily. I heard (R1) talks about (R1's) cattle. (R1) was an elopement risk. (R1) needs to be watched closely. On 12-11-2020 at 3:55pm, V11 CNA stated (On 12-3-2020) I saw (R1) by the Covid hall and I deterred (R1) away. I told (R1) it was lunch time and to go to (R1's) room. (R1) was trying to get into the Covid hall on northeast but turned around. There was no alarm sounding (on 12-3-2020) or I would have went to the panel to see what door it was then gone to that door. I don't remember any alarm going off. On 12-11-2020 at 2:21pm, V16 CNA stated That day (12-3-2020) I was on East hall in the Covid unit. There was no alarm sounding. V16 stated that R1 would wander and that V16 is not familiar with an elopement binder. V16 also stated The door that (R1) escaped from we would have heard the alarm at the East exit door. That door is right there where we are so it's so loud I can hear it. On 12-11-2020 at 2:57pm, V24 LPN stated I was called in that day (12-3-2020) for four hours to help look for (R1). (R1) wandered throughout the building. I would imagine (R1) was in the Elopement book. I'm agency and not there consistently. Communication there is not very good. On 12-17-2020 at 1:50pm, V15 CNA denied knowing which residents are at high risk for elopement and denied receiving training on elopement prior to 12-3-2020. V15 stated they did not go over which residents were elopement risk or have training on elopement. V15 continued to state No, I did not know (R1) was a risk for elopement before 12-3-20. On 12-11-2020 at 1:31pm, V17 CNA stated (On 12-3-2020) I last saw (R1) picking up trash and I told (R1) to go back to (R1's) room for lunch. (R1) was (near to and) kind of across from V5's office where there is a chair. (R1) said ok and then I went out the front door. When I came back in (V7 LPN) asked me if I saw (R1). I told (V7) where (I last saw R1) and (V7) said (R1) wasn't there. I went to check in the front area and (R1) was no longer there. No alarm was going off. V17 continued to state I know about the Elopement binder now, but didn't then. I never saw the elopement binder before (R1) got out. But I know my residents and have been there almost [AGE] years. I know (R1) was high risk for elopement. (R1) wanders around the facility all the time. On 12-15-2020 at 8:59am, V2 former Administrator stated (On 12-3-2020) (V4 BOM) let me know that (V4) believed that (R1) had left the building. I called a code for a missing resident. (R1) was found on the other side of the apartment buildings by the water pumps. V2 continued to state (R1) was a wanderer, mobile. Redirects easily. It was unusual behavior and out of character for (R1) to be over there (hallway by V4's office). Alarms did not sound (from the East exit door R1 eloped from on 12-3-2020) and that was unusual. We had the alarms checked and found there was a button that was stuck in the door frame (of the East exit door). (V10 Maintenance Assistant) fixed that and checked all the other doors. A more experienced maintenance man, (V22 Maintenance) came to look at alarms and said he had never seen anything like that happen before. Normally, when the door is open, the button pops out and that triggers the alarm (to sound). (On 12-3-2020) the button did not pop out for some reason. The red box alarm (on the East exit door) did not go off either. V2 verified at this time that the red box alarm should not have been turned off for any reason. On 12-15-2020 at 11:00am, V3 former Director or Nursing/DON stated I was working the floor that day (on 12-3-2020) and a nurse ran down and told me that they (facility staff) couldn't find (R1). We went room to room and did a head count. I went to (V2) and asked where (R1) was last seen. (V2) had said (R1 was last seen) around (V4's) office around 12:15pm. The search was initiated at 12:25pm because they (facility staff) thought he (R1) had gotten out. V3 stated (R1) would stand at the front door and set the alarms off. (On 12-3-2020), it was found that the button on the door frame did not pop out which would trigger the alarm at the nurse's desk. The button got stuck and no alarms were sounding. The red box alarm didn't sound because it wasn't (turned) on. It should have been. V3 also stated that (R1) had attempted to exit seek before, and that staff should be knowledgeable as to who the elopement risk residents are. On 12-17-2020 at 12:52pm, V19 LPN stated (R1) was sometimes confused. I was not working when (R1) left (on 12-3-20). I had taken care of (R1) before when (R1) had tried to get out. At this time, V19 verified that R1 had attempted to exit seek two other times when V19 was working at the facility; once on 8-30-2020 and again on 11-13-2020; both times R1 redirected easily. I knew (R1) was a wanderer. (R1) was quiet. (R1) just goes around through the building. I would expect (R1) to be redirected if (R1) was found in a non-patient care area or away from (R1's) hall if not supervised. (R1) shouldn't be left unsupervised. I know a couple other elopement risks, but that's it. I don't know all of them. You see, I'm agency. R1's Nursing Note, dated 8-30-2020 at 10:15am and signed by V19 LPN, documents R1 exited the facility stating that R1 was going to get the cattle. (R1) was accompanied back into the facility and placed on 15 minute checks. R1's Nursing Note, dated 11-13-2020 and signed by V19 LPN, documents R1 attempted to go out of the door on West Hall; alarm went off, this resident stated I don't know what happened it just went off. (R1) accompanied back to (R1's) room and placed on 15 min checks. Administrator notified. On 12-17-2020 at 3:06pm, V25 R1's family member/Power of Attorney/POA stated (R1) has early onset dementia pretty bad. He lived on his own prior. He would go out at night walking. He would end up in other towns. It got so bad that one time in the winter, he walked a half mile up the road from his home and he was found outside laying on the ground of his neighbor's yard. The neighbor called 911 and he was taken to the hospital. The doctor at the hospital said there was no way he could return to living alone at home, so he went to (named facility). V25 continues to state It was well known when he admitted to the facility that he had a history of [REDACTED]. He is a lot of times confused and he doesn't know where he's at. He was a farmer and I know he was having fears about his cattle being stolen. He keeps talking about his cattle and his farm. V25 also stated (V5 SSD) called me that day (12-3-2020) to notify me that (R1) had gotten out of the facility and they (facility staff) were trying to locate (R1). I asked (V5) if the alarms had gone off and (V5) said the alarms didn't go off and that (R1) slipped out. On 12-10-2020 at 2:26pm, V1 Regional Director of Clinical verified R1 eloped from the facility on 12-3-2020. V1 stated All staff should know who is an elopement risk. It is part of their orientation. Everyone's responsible to know who's in the elopement binder. A resident in the elopement binder should be redirected or call staff to alert them or speak to the resident to see how/what they are doing. V1 verified that a high risk elopement resident shouldn't be left pacing. The Immediate Jeopardy was identified on 12-17-2020 at 9:50am. The Immediate Jeopardy began on 12-3-2020 at 12:30pm when staff failed to supervise and redirect R1 while R1 was wandering aimlessly in a non-resident care hallway. On 12-17-2020 at 9:50am, V1 Regional Director of Clinical and V26 Administrator in Training were notified of the Immediate Jeopardy. On 12/19/2020 at 11:00am, the surveyor confirmed through observation, interview and record review that the facility took the following Corrective Action: Actions completed by V1/Regional Director of Clinical and V6/Maintenance Director include: On 12/3/2020 through 12/18/2020 all employees were in-serviced on Door Alarms, Preventing Elopement and Missing Residents Policy and Resident Monitoring Policy including 15 minute checks. On 12/3/2020 V6 changed door alarm checks from monthly to daily for 30 days. On 12/4/2020 R1 returned to the facility and was placed on every 15 minute checks.

Based on observation, interview and record review, the facility failed to safely utilize a mechanical lift during transfer for one of three residents (R1) reviewed for resident injury in the sample of three. This failure resulted in R1 sustaining left and right leg distal femoral fractures (thigh bones). Findings include: On 2/25/20 at 11:40 a.m., R1 was lying in her bed with her sister (V5) at bedside. R1 had a large golf ball size hematoma on the left eyebrow area and the left eye area was heavily bruised. A small amount of bruising was noted on R1's right inner eyelid area. R1's left and right legs were both in splints. V5 stated R1 is experiencing excruciating pain during any type of movements. V5 stated R1 screams when she is moved. R1's Nurses Notes dated [DATE] at 9:55 p.m., V4 (Registered Nurse) documented While I was in (R1's) room preparing (R1's) medications and (R1's) feeding, (V3/Certified Nurse Aide) was getting the (full mechanical lift) ready for (R1) to be transferred from her (wheelchair) to her bed. As (V3) started using the lift, one (sling loop) became unsecured and (R1) fell hitting both knees on the floor and her head hit the floor as well. Left forehead bruising beginning with swelling noted. Bilateral knees are reddened and swollen, no open areas noted. A Statement written by V3 (Certified Nurse Aide) dated [DATE]20, states I (V3) was attempting to put (R1) in bed. Me and (V4/Registered Nurse) were in (R1's) room as I was attempting to raise up the (full mechanical lift). I thought I had clipped all four ends (loops on sling) but I didn't and (V4) was mixing up (R1's) feeding and medications with her back turned to us and I tried to catch her but was unsuccessful in doing so. It happened so quick. (R1) hit her head on the dresser after she went down on her knees. On 2/25/20 at 3:20 p.m., V3 stated I was transferring (R1) from her wheelchair to her bed for the night. (V4) was in the room but did not assist with the transfer because she was getting (R1's) tube feeding and medications ready. (V4) did not observe (R1) fall from the (mechanical lift) as her back was to (R1) and I. Technically (V4) should have been actively assisting me with (R1's) transfer but she was busy doing her thing. I was taught by the facility to always have two staff assist with a (full mechanical lift) transfer. On 2/26/20 at 11:23 a.m., V4 (Registered Nurse) stated she was getting R1's medications and tube feeding prepared when V3 was transferring R1 with the mechanical lift and R1 fell and sustained major injuries. V4 stated she was not assisting V3 with R1's transfer. R1's Left knee X-Ray report dated [DATE], documents Impression: Distal Femoral fracture. R1's Right knee X-Ray report dated [DATE], documents Impression: Distal Femoral medial cortical fracture. On 2/26/20 at 1:05 p.m., V2 (Director of Nursing) stated there should always be two staff when transferring a resident with a mechanical lift. V2 stated, Just having two people in the room is not good enough. They are both to be participating in the transfer and ensuring the residents safety.

Based on observation, interview, and record review, the facility failed to monitor and implement interventions to promote the healing of pressure ulcers and prevent development of new pressure ulcers for two of five residents (R8 and R17) reviewed for pressure ulcers in the sample of fifteen. This failure resulted in R17 developing two Stage II pressure ulcers, one of which worsened from a Stage II to a Stage IV, and R8 developing an avoidable Stage II pressure ulcer. Findings include: 1. R17's medical record documents R17's current [DIAGNOSES REDACTED]. R17's MDS (Minimum Data Set) Assessment, dated 6/11/14, documents R17 requires extensive assist of two for bed mobility and extensive assist of one for transfers and ADL's (Activities of Daily Living). R17's Braden Skin Assessment, dated 5/14/14, documents a Braden score of 16 (high risk). On 7-14-14 at 2:15 pm, during wound care R17 was observed with a large area to the left and right coccyx approximately 10 cm x 10 cm, grayish in color with a thick flap of skin and obvious tunneling. The area to the coccyx had a strong odor and there was a small open area to both R17's right and left heels. A facility Pressure Ulcer Report, dated 6/3/14, documents a facility-acquired Stage II pressure ulcer to R17's left and right coccyx. According to the report, the wound was first observed on 5/28/14 measuring 4.0 cm x 5.0 cm. A facility Pressure Ulcer Report, dated 6/29/14, documents R17's wound to the coccyx measured 8.0 m x 9.0 cm, Stage II. The report also documents a newly acquired Stage II pressure ulcer to R17's left heel, along with a stage II pressure ulcer to the right heel, which was present upon admission. The facility's Pressure Sore Prevention guidelines Policy dated 11/12, documents, "To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale. Intervention: Turning and positioning may be more often than every two hours for high risk if indicated. Special Mattress with specification of type of mattress on the care plan, and Care Plan Entry: Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions a Pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of pressure ulcers." The facility's Decubitus Care/Pressure Areas Policy dated 05/07 documents under Procedure: " 1) Upon notification of skin breakdown, a Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 3) Completed all areas of the TAR (Treatment Administration Record) i) document size, stage, site, depth, drainage, color, odor, and treatment. 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include: i) Characteristic, treatment and response to treatment. 6) Reevaluate the treatment for [REDACTED]. Most pressure areas will respond to treatment in this amount time. If no improvement is seen in this time frame, contact the physician for a new treatment order. 8) Initiate problem on care plan. R17's Plan of Care dated 6/3/14, failed to document the development of pressure ulcers and implement interventions to prevent R17's coccyx wound from worsening. R17's medical record does not document any changes in the characteristics or the treatment to R17's coccyx from the date it was acquired at a Stage II and now at a Stage IV. On 7-15-14 at 12:11 pm, E4 (CPC/Care Plan Coordinator) stated, "(E3) normally puts wounds on the care plan along with new interventions. (E3) did not realize they were not on for R17 until now." On 7-15-14 at 12:20 pm, E2(DON/Director of Nursing) during interview verified no documentation has been done regarding pressure ulcers in the nursing notes or R17's medical record. E2 also verified the physician should be notified in two weeks if there is no improvement in any wounds, and the care plans for R17 should have addressed the pressure wounds and new interventions. E2 stated, "R17's coccyx pressure wound worsened since there were no interventions in place and the facility can not produce a turning and positioning log. On 7/15/14 at 8:45 am, R17 was sitting in the wheelchair in R17's room, leaning to the left side. No one entered R17's room until 9:30 am at which time R17 was pushed to therapy. R17 was still observed leaning to the left side in the wheelchair while in therapy, only swinging his legs in therapy. R17 was then pushed to the dining room, still leaning to the left side. At 1:00 pm that day, R17 was pushed to R17's room and left in the wheelchair still leaning to the left side. On 7/15/14 at 1:50 pm, R9 and R10 both R17's (CNA's/Certified Nursing Assistants) verified they did not put R17 to bed, toilet or reposition R17 and verified R17 had been in the wheelchair the entire shift. On 7-15-14 at 2:15 pm, E5 (Medical Director) verified R17's wound to the coccyx has worsened from a Stage II to a Stage IV, and R17 also has Stage II pressure ulcers to both heels. E5 also verified if interventions were put in place the wounds could have been avoided and not progressed to a worse stage. 2. R8's Treatment Administration Record, dated 07/01/14-07/31/14, indicates a four centimeter by one centimeter by 0.8 centimeter wound to coccyx. On 07/15/14 at 10:50 am, E8, Licensed Practical Nurse (LPN), performed wound care to R8's coccyx wound and observed a new pressure ulcer one by one centimeter in diameter on labia. Area is open and red with a small amount of bloody drainage. On 07/15/14 at 10:50 am, E8 verified that R8 did not have the wound on the labia yesterday. E8 also verified that this wound is a Stage II.

Based on interview, observation and record review, the facility failed to implement preventative interventions prior to the development of a pressure ulcer for one of three residents (R16), and failed to turn and reposition two of three residents (R12 and R16) reviewed for pressure ulcers in a sample of 17. This failure resulted in R16 developing a Stage III pressure ulcer. Findings Include: R16's Physician order [REDACTED]. R16's Braden Scale for Predicting Pressure Ulcer Risk dated 07/18/13 documents R16 is at, "Moderate Risk," for pressure ulcer development. Facility's Turning and Positioning Program policy dated March 2003 documents, "Turning schedule will occur as indicated by the resident's plan of care." R16's current Pressure Ulcer Care Plan dated 07/22/13 documents, "Reposition per positioning schedule." R16's current Self Care Deficit Care Plan dated 07/22/13 documents, "unable to position self without assist of one staff." R16's Physician order [REDACTED]." R16 was continuously observed on 09/03/13 from 10:05 a.m. to 11:32 a.m. R16 remained seated in R16's wheelchair throughout this timeframe. On 09/03/13 at 12:55 p.m., R16 was sitting in R16's wheelchair. R16 stated that R16 had been sitting in R16's wheelchair, "all day since they (facility staff) got me out of bed this morning." On 09/03/13 at 12:45 p.m., E3, Licensed Practical Nurse, stated that R16 should be turned and repositioned every two hours. On 09/03/13 at 1:15 p.m., E2, Director of Nursing, stated that R16 is supposed to be turned and repositioned, "at least every two hours." Upon review of R16's Physician order [REDACTED]. On 09/04/13 at 12:45 p.m., E2, Director of Nursing, stated R16's pressure ulcer was discovered on 08/10/13, "and it was open, which is a Stage II." E2 stated that a pressure-relieving wheelchair seat was instituted to R16's plan of care on 08/15/13, "but no other interventions were instituted until after 08/21/13, when it (R16's pressure ulcer) had progressed to a Stage III." E2 then verified that R16's pressure ulcer was avoidable. Facility's Decubitus Care/Pressure Areas policy dated May 2007 documents, "Upon notification of skin breakdown, a Newly Acquired Skin Condition Report will be completed and forwarded to the Director of Nurses." On 09/05/13 at 9:00 a.m., E2, Director of Nursing, stated E2 was unable to provide a Newly Acquired Skin Condition Report for R16, "I've already looked for it and cannot find it." 2. R12's Braden scale dated 8/7/13 notes R12 to be a moderate risk for pressure sores and having a history of pressure sores on her coccyx. Braden scale notes that R12 is on a 2 hour turning and repositioning schedule. On 9/4/13 R12 was observed lying in bed from 8:40AM until 11:35 AM without a change in position. This was a total of two hours and 55 minutes. On 9/4/13 at 11:35AM R12 stated that her bottom was very sore.