Every finding on record at Helia Southbelt Healthcare

Based on observation, interview and record review, the facility failed to ensure a resident's call lights, preferences and needs were reasonably accommodated for 4 of 13 residents (R1, R2, R5 and R8) reviewed for accommodation of needs in a sample of 13. 1- On 7/2/2026 at 2:02 PM, R1 has a tracheotomy in his neck. R1 was laying on his back in his bed. On 7/2/2026 at 2:05 PM, R1 stated, I am bed bound, and call lights vary depending on who is working. Sometimes it is better than other times. I think the night shift is the worst. It is not uncommon for us to have to wait. Staff are bad about coming into the room, turning off the light, and not coming back. R1's Minimum Data Set provided by the facility dated 3/13/2026 does not document R1's cognitive status. The MDS does document R1 is able to make decisions regarding tasks of daily life and his decision are consistent/reasonable. R1's Progress Notes dated 7/7/2026 at 12:20 AM, document R1 was alert and orientated x 4 and able to make needs known. 2-R2's MDS dated [DATE] document R2 was cognitively intact for decision making for activities of daily living. On 7/2/2026 at 3:33 PM, R2 stated call lights have been better since she moved, but before it was not uncommon for her to wait over 30 minutes waiting for help. It just depends on who is working. 3-R5's Minimum Data Set, dated [DATE] documents R5 was cognitively intact for decision making for activities of daily living. He has an acquired absence of his right leg below the knee. R5's Care Plan date initiated 7/18/2025. Problem: Resident is incontinent of bowel and bladder. Goal with a date of 7/13/2026 documents, Resident will be kept dry and clean as possible by next review date. Problem: Resident exhibits inappropriate behavioral symptoms, AEB (as evidence by) urinating on self and asking for bedpan, when resident is continent and able to transfer self to toilet. He states, the CNAs (Certified Nursing Assistants) do for everyone else, they can do for me too On 7/2/26 at 4:02 PM, R5 was observed in his room in the wheelchair. R5 is missing his right leg. On 7/2/2026 at 4:05 PM, R5 stated he attends Resident Council Meeting, and they have discussed the issue of call lights not being answered in a timely manner for the past three months. The call lights are not getting better, and residents continue to complain. They are complaining of staff walking in the room, shutting off the light, and never coming back or not even answering the call light. He has personally waited over 30 minutes at least four times this week. He can do most things by himself, but he does need assistance with toileting and cleaning up and it's frustrating when nobody wants to help you or answer your call light. They say I can do it myself, but sometimes I need help, that is why I am here. 4-R8's MDS dated [DATE] document R8 was cognitively intact for decision making for activities of daily living. On 7/2/2026 at 4:15 PM, R8 stated they attend Resident Council Meeting Minutes, and they have been complaining about call lights not being answered in a timely manner, and it is not getting better. Resident Council Meeting Minutes dated 6/23/2026 Continues issues with call lights and phone use, discussed concerns with DON (Director of Nursing). On 7/5/2026 at 5:04 AM, V8, CNA stated she was working the 300 and 400 hall. She is the only CNA on the 300 hall. She does have two residents on that hall that require mechanical lift. They do the best they can do for the call lights. She also goes back and forth to both halls. On 7/7/2027 at 10:04 AM, V14, Ombudsman stated, I was just in the building last week. Call lights seems to be the major issue and it is not getting better. I got a lot of complaints. I had several residents complaining about them. On 7/7/2026 at 3:30 PM, V2, Director of Nursing stated she had complaints from (V14) regarding the call lights not being answered timely and from residents and she was looking into it. The Answering the Call Light Policy with a revision date of 7/2014 documents, The purpose of this procedure is to respond to the resident's requests and needs. Answer the resident's call as soon as possible. Be courteous in answering the resident's call.

Based on interview and record review, the facility failed to ensure appropriate written notification was provided for a room change for 4 of 4 residents (R2, R6, R9 and R12) reviewed for resident rights. Findings include: On 7/7/2026 at 12:55 PM, V1, Administrator stated at times they do have to move residents and do room changes throughout the facility. If a resident has to go on contact isolation, or if census goes low, then we have to move them to a different hallway. We always let them know ahead of time and give them notice. Our Social Service Director would supply the written notices to the residents and she left in March, so we have a few residents that did not get any written notices. Our new Social Service Director started yesterday. On 7/7/2026 at 1:00 PM, written notices for room changes were requested for R2, R6, R8 and R9. On 7/7/2026 at 1:55 PM, V2, Director of Nursing (DON) stated nursing does not provide any notices in writing for room changes. If there are written notices, I think it would be done by Social Service and we have not had anyone in that position since March, so I doubt there are any written notices that were provided for R2, R6, R9 or R12. 1-R2's Minimum Data Set (MDS) dated R2's dated 5/15/2026 document she is cognitively intact for decision making of activities of daily living. R2 on the Census Activity Report was documented as having a room change on 4/16/2026 and 5/7/2026. R2's Progress Notes for April and May, 2026 do not document any room change notes. On 7/2/2026 at 2:18 PM, R2 stated she has had to move rooms several times in the past three months, and it is a pain in the a*s. The facility never provided her with any written notice about her room change. On 7/7/2026 at 4:03 PM, V17, Family of R2 stated they have moved my mom at least two times the past three months. Nobody told me or notified me about the room change. This stressed my mom out and I feel like she should be given a notice if they have to move her because it is so stressful. 2-R6's MDS dated [DATE] document R6 was cognitively intact for decision making for activities of daily living. R6's Progress Notes for May 2026 do not document anything related to a room change. R6 on the Census Activity Report was documented as having a room change on 5/15/2026. R6's Progress Notes do not document anything related to a room change. On 7/7/2027 at 2:44 PM, R6 is on a tracheostomy. R6 is able to shake his head yes or no. R6 shook his head yes that he did have a room change in May. R6 shook his head no, that he does not remember them giving him any paperwork about the room change. 3-R8's MDS dated [DATE] document R8 was cognitively intact for decision making of activities of daily living. R8's Progress Notes for June 2026 do not document anything related to a room change. R8 on the Census Activity Report was documented as having a room change on 6/8/2026. On 6/5/2026 at 2:33 PM, R8 stated she did have a room change a few weeks and was not provided anything in writing related to the room change. Moving all of your stuff is always stressful! 4-R9's MDS dated [DATE] document R9 was moderately impaired for cognition for activities of daily living. R9 on the Census Activity Report was documented as having a room change on 5/4/2026. On 7/5/2026 at 5:30 AM, R9 stated she had to move rooms back in May, and she was not provided anything in writing for her room change. R9's Progress Notes were reviewed for May, 2026 and do not document anything related to a room change. On 7/7/2026 at 2:02 PM, Social Service Director stated she started working here yesterday and was told there had not been any SSD since March, 2026. She was aware that the facility is required to give residents a written notice for any room changes. On 7/7/2026 at 5:15 PM, V1 stated they did not have any written notices for bed holds for (R2), (R6), (R8) or (R9). The Facility Room to Room Transfer with a revision date of November, 2016 documents, The facility must also promptly notify the resident and the resident representative, if any, when there is a change in room or roommate assignment. The resident should be consulted about the room transfer. The resident's request will be given consideration in making the transfer. The facility will give residents written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

Based on interviews and record review, the facility failed to properly secure a resident's wheelchair in the transport van during transport for 1 (R2) of 3 residents reviewed for accidents in the sample of 16. This failure resulted in R2 falling from her wheelchair while the van was in motion, sustaining multiple serious injuries: a periprosthetic proximal femur fracture, intertrochanteric fracture of the left femur, distal fracture of the right femur, nasal fracture, and a scalp laceration. R2 required surgical fixation of the right femur (open reduction internal fixation) and suturing of the forehead laceration.An Immediate Jeopardy began on 4/24/26 when R2 was being transported to doctor's appointment in the facility van. R2 was not properly secured in her wheelchair in the facility van when the van driver had to brake to avoid an accident, R2 fell forward out of her wheelchair onto the van's floor. V1, Administrator; V21, Regional Director of Clinical Services; and V22, Regional Director of Operations were notified of the Immediate Jeopardy on 6/2/26 at 11:20 AM. The surveyor confirmed by record review and interview that Immediate Jeopardy was removed on 4/24/26.Findings include:R2's EMR (Electronic Medical Record) documents that the resident was admitted to the facility on [DATE].R2's EMR dated 4/30/26 documents a diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing.R2's EMR dated 4/30/26 documents a diagnosis of periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter.R2's EMR dated 4/30/26 documents a diagnosis of fracture of nasal bones, subsequent encounter for fracture with routine healing.R2's EMR dated 4/30/26 documents a diagnosis of laceration without foreign body of scalp, subsequent encounter.R2's EMR dated 5/17/26 documents a diagnosis of local infection of the skin and subcutaneous tissue, unspecified.R2's Care plan dated 5/5/26 documents Problem: IMPAIRED WHEELCHAIR Mobility R/T (related to) limited mobility, limited ROM (range of motion), fatigue, and pain. Contributing DX (Diagnosis): Osteoarthritis, Obesity, HTN (hypertension).R2's Care plan dated 5/28/26 documents Resident has impaired skin integrity due to: 4/30/26 Surgical incision to the right medial distal knee. 4/30/26 Stage IV pressure to right lower neck. 5/5/26 Non pressure to left lower buttock. 5/11/26 Skin tear to sacrum.R2's Care plan dated 5/18/26 documents Resident requires antibiotic for wound infection.R2's MDS (Minimum Data Set) dated 5/4/26 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident is dependent for roll left and right and chair/bed to chair transfer. The MDS documents that the resident was experiencing frequent pain that affected her sleep and interfered with her day-to-day activities. The MDS documents that the resident has 1 stage 4 pressure ulcer and surgical wounds.R2's RN (Registered Nurse) Note dated 4/24/26 at 7:40 AM documents Resident fell from wheelchair in transportation van.Facility's Injury Investigation dated 4/24/26 documents Received call from (V10) Transportation Aid at 7:00 AM on 4/24/26. (V10) reported to me that resident (R2) and Transportation Aid (V10) were traveling to (Metropolitan Hospital) in St. Louis for an outpatient surgery where an incident occurred. (V10) explained that after exiting the facility van, she and (R2) ended up at the wrong part of the hospital. (V10) stated they asked a staff member for directions to arrive at the right place. (V10) stated they got back in the van to travel to the correct location. (V10) stated that a car cut in front of them. She stated that she applied the brakes quickly causing (R2) to fall forward and hit her head. (V10) stated that she was close to the ER (Emergency Room) and was able to get help immediately. ER staff assisted getting (R2) out of van to be evaluated in the ER. (R2) was admitted to (Metropolitan Hospital) on 4/24/26 with a diagnosis of a fractured hip and nose. When Administrator interviewed (R2) she stated that (V10) had not secured the wheelchair when they got back into the van to go to the correct location. She stated that (V10) said she applied shoulder strap to secure but when hitting the brakes (R2) fell forward. (R2) has a BIMS score of 15 and was consistent with her story during 2 sperate interviews. When (R2) was interviewed, she stated (V10) did not secure me in the van. (V10) was suspended following the accident pending investigation completion. A drug test was performed and showed positive. A Worker's compensation report was completed as (V10) sustained no visible injuries. An Ad Hoc performance plan was put into place. The van was inspected by (V9) on April 24, 2026. All safety mechanisms were noted to be functioning properly. Education on safety including proper procedures for installing and securing wheelchairs and passengers in the transport van was initiated and completed on April 24, 2026, for all transport personnel. After completing the investigation, it was concluded that the wheelchair was likely not secured by (V10) prior to transporting (R2) from the incorrect location at (Metropolitan Hospital) to correct location. (V10's) employment was terminated for not properly following safety procedures and following the safety of residents when transporting making sure resident is secure and safe during transport.R2's LPN (Licensed Practical Nurse) Note dated 4/30/26 at 5:10 PM documents Resident returned from to facility at 5pm from (Metropolitan Hospital) on stretcher accompanied by emts (Emergency Medical Technicians). Resident AxOx4 (Alert and Oriented to person, place, time, and situation) can make needs known, refuses skin assessment right now r/t pain, will try again. Resident has L (left) IT (intertrochanteric) femur fx (fracture), R (right) distal femur fx, left nasal bone fx, and complex frontal scalp lac (laceration). Resident VS (vital signs) 101/63 73 r (respirations) 95%. On contact ISO (isolation) r/t C-aures (Candida auris) and VRE (Vancomycin-resistant Enterococci). C/o (complaint of) sore throat r/t intubation in hospital. Hasn't had a bowl movement since being in the hospital per report. Meds put into (Electronic Computer App). Resident in bed resting, being fed. Call-light within reach. Resident afraid to be turned r/t to pain and discomfort. MD (Medical Director) Notified.R2's Progress Notes dated 5/1/26, 5/4/26, 5/5/26, 5/6/26, 5/7/26, 5/8/26, 5/9/26, 5/11/26, 5/12/26, 5/15/26, 5/16/26, 5/17/26, and 5/18/26 documents that the resident refused activities of daily living including turning and repositioning, wound care, and incontinent care due to pain.R2's RN note dated 5/12/26 at 1:11 PM documents Resident requested hospice information, r/t pain from injuries.R2's Wound Culture dated 5/15/26 documents (1) Klebsiella Aerogenes (organism known to possess inducible Beta-lactamase suggest clinical observation for the development of resistance after using Cephalosporins or extended spectrum penicillin.) (2) Escherichia Coli ESBL (Extended-spectrum Beta-Lactamases (ESBLs) are enzymes that mediate resistance to extended-spectrum (third generation) Cephalosporins and Monobactams but do not affect Cephamycin's. Recommend caution and monitoring of patients during/after therapy. (3) Diphtheroid Bacillus, no sensitivity will be done.R2's LPN Note dated 5/17/26 at 2:48 PM documents N.O (New Order) for IV (intravenous) ABT (antibiotic) Zosyn t.i.d (three times a day) 3.375mg (milligrams) x 6weeks. IV med will come mixed with Normal Saline. per Pharmacist recommendation. Hospice (V19) gives ok for recommendation. Also noted in special instructions.On 5/28/26 at 9:37 AM, V1, Administrator stated that (R2) told him that she was not strapped in. He stated that (V10) was fired for not following safety protocols and being positive for marijuana.On 5/2826 at 12:39 PM, V10, Former Transportation Driver stated that (R2) was buckled, and wheelchair was locked towards the front of the van. She stated that the wheel locks are made for manual wheelchairs and not electric wheelchairs. She stated that R2 had an electric wheelchair. She stated that after going to the first office and finding out they were at the wrong place, R2 was at the back of the van with just a shoulder strap seatbelt holding her in. She stated that she did not attach the wheel locks. She stated that after she slammed on the brakes to avoid the accident, she saw R2 on the floor of the van. She stated that she pulled into a parling lot to check on R2. She stated that R2 had fallen forward out of her wheelchair. She stated that the seatbelt buckle had popped and R2 fell out.On 5/28/26 at 1:13 PM, V11, RN Case Manager for R2's Hospice Company stated that she is the one that admitted (R2) into hospice. She stated that she believes that (R2) was admitted into hospice because of the [NAME] effect from her injuries. She stated that (R2) was in a lot of pain and was refusing all care. She stated that she was refusing to be turned and repositioned and her wounds got infected. She stated that pain is not an admitting diagnosis for hospice that her diagnosis is heart disease.On 5/29/26 at 11:48 AM, V18, Wound Nurse stated that (R2's) pressure ulcers on her left lower buttock and her right neck were from (R2) not wanting to move because of the pain from her injuries. She stated that the pressure ulcer on her left lower buttock got infected. She stated that the wound had an odor. She stated that she swabbed and cultured it. She stated that is why she was sent to the hospital for IV antibiotics.5/29/26 at 12:24 PM, V10, Former Driver stated that the last time she smoked marijuana was on April 18th. She denies smoking marijuana prior to her shift on the day of the incident. On 5/29/26 at 2:34 PM, V19, R2's Hospice Physician stated that he feels that along with the injuries that (R2) sustained from the facility's van incident, her other comorbidities, the infected wounds from not moving due to intractable pain is what caused (R2) to need to be on hospice. He also stated that it is fair to say that transporting a resident in a wheelchair in a facility van not secured per protocol has the potential to cause severe harm or potential death.Facility's Van Usage Policy and Procedure dated 2025 documents Purpose: The purpose of this policy is to establish procedures by which employees formally acknowledge and accept responsibilities of operating a facility owned van on behalf of Four Fountains/[NAME] South belt. Further, it establishes requirements for enforcement of operating procedures and safe driving practices. Procedure: To ensure proper van usage: 3.b. Wear seat belts anytime the vehicle is in motion and require all passengers to wear seatbelts. 3.c. Ensure all residents and wheelchairs are safely secured.The Immediate Jeopardy that began on 4/24/26 was removed on 4/24/26 when the facility took the following actions to remove the immediacy:Removed involved licensed staff from resident care pending investigation.The resident received immediate medical evaluation and treatment following the incident. The resident's physician, responsible party, and appropriate regulatory agencies were notified.An immediate audit was completed of facility transportation vehicle to ensure wheelchair tie-down systems, occupant restraints, seat belts, and safety equipment were present and functioning properly with all safety features.The facility transportation policy and procedure were reviewed and all staff responsible for resident transportation received re-education on: this was completed on 4/24/2026. Safety mechanisms in place, proper procedures for installing and securing wheelchairs and passengers in transportation van with return demonstration, van safety for transports, and call EMS for transportation for incidents.

Based on interview and record review the facility failed to revise and update a comprehensive care plan for 2 of 3 (R2, R3) residents investigated for pressure ulcers in a sample of 16.Findings include:1.R2's EMR (Electronic Medical Record) documents that the resident was admitted to the facility on [DATE].R2's EMR dated 4/30/26 documents a diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing.R2's EMR dated 4/30/26 documents a diagnosis of periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter.R2's EMR dated 4/30/26 documents a diagnosis of fracture of nasal bones, subsequent encounter for fracture with routine healing.R2's EMR dated 4/30/26 documents a diagnosis of laceration without foreign body of scalp, subsequent encounter.R2's MDS (Minimum Data Set) dated 5/4/26 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident is dependent for roll left and right and chair/bed to chair transfer. The MDS documents that the resident was experiencing frequent pain that affected her sleep and interfered with her day-to-day activities. The MDS documents that the resident has 1 stage 4 pressure ulcer and surgical wounds.R2's Progress Notes dated 5/1/26, 5/4/26, 5/5/26, 5/6/26, 5/7/26, 5/8/26, 5/9/26, 5/11/26, 5/12/26, 5/15/26, 5/16/26, 5/17/26, and 5/18/26 documents that the resident refused activities of daily living including turning and repositioning, wound care, and incontinent care due to pain.R2's RN note dated 5/12/26 at 1:11 PM documents Resident requested hospice information, r/t pain from injuries.No care plans noted for R2 regarding hospice or pain from injuries.2.R3's EMR (Electronic Medical Record) documents that the resident was admitted to the facility on [DATE].R3's EMR dated 10/10/24 documents a diagnosis of malignant neoplasm of prostate.R3's EMR dated 4/4/24 documents a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance.R3's EMR dated 4/4/24 documents a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side.R3's MDS (Minimum Data Set) dated 4/15/26 documents a BIMS (Brief Interview for Mental Status) score of 3 out of 15. The MDS documents that the resident required partial/moderate assistance for roll left and right. The MDS documents that the resident was dependent for sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and toilet transfer. The MDS documents that the resident had diabetic foot ulcers and open lesions other than ulcers, rashes, cuts.No care plan noted for skin integrity, pressure ulcers, or diabetic wounds.R3's Hospital Discharge Paperwork dated 3/2/26 documents Wound 2/24/26 Pressure Injury Buttocks Left; Medial. Wound 2/24/26 Pressure Injury Hip/trochanter Posterior; Right Device Related. Wound 2/24/26 Pressure Injury Hip/trochanter left; posterior. Wound 2/24/26 Pressure Injury Heel Right; Plantar. Wound 2/24/26 Pressure Injury Foot Right; Medial.R3's LPN (Licensed Practical Nurse) Note dated 3/5/26 at 10:20 AM documents This nurse was notified that resident has two pressure ulcers on Right lateral foot, heel and ankle. All responsible parties notified. Treatment order in place.R3's LPN Note dated 3/12/26 at 7:59 PM documents Pressure ulcer to the L (left) hip was reported to this nurse. All appropriate parties were made aware. This nurse cleaned the wound, soaked it in (wound solution), and applied a dry dressing.R3's LPN Note dated 3/18/26 at 3:02 PM documents This nurse notified that resident has new area on right hip, this nurse assessed notified wound care nurse, treatment order in place. MD (Medical Director) Notified.R3's Wound Evaluation & Management Summary dated 4/13/26 documents Patient has wounds on his right lateral ankle; right heel; left hip; right hip; left lateral foot, right lateral foot. Focused Wound Exam (Site 2) Diabetic Wound of the right, lateral ankle full thickness. Healing/Maintaining healing. Wound size: 2.8 cm. (centimeter) x 2.7 cm. x 0.4 cm. Moderate serous exudate. 75% thick adherent devitalized necrotic tissue. 25% granulation tissue. Improved evidenced by decreased necrotic tissue. Focused Wound Exam (site 3) Diabetic Wound of the right heel full thickness. Healing/Maintaining healing. Wound size: 4 cm. x 4 cm. x not measurable cm. No exudate. Skin intact with purple/maroon discoloration. Improved evidenced by decreased surface area. Wound Exam (Site 4) End Stage skin failure of the left hip with evidence of multisystem organ failure, with life expectancy of < 2 weeks, with minimal recent caloric intake, with multiple sites of simultaneous skin breakdown. Poor healing potential. Wound size: 13.3 cm. x 16 cm. x 0.3 cm. Moderate serous exudate. 100% thick adherent black necrotic tissue. Improved evidenced by decreased surface area. Focused Wound Exam (site 5) End-stage skin failure of the right hip with evidence of multisystem organ failure, with life expectancy of < 2 weeks, with minimal recent caloric intake, with multiple sites of simultaneous skin breakdown. Poor healing potential. Wound size: 13.4 cm. x 9.8 cm. x not measurable cm. no exudate. skin intact with purple/maroon discoloration. Improved evidenced by decreased surface area. Focused Wound exam (site 6) Diabetic Wound of the left, lateral foot. Healing/maintaining healing. Wound size: 3.4 cm. x 11 cm. x not measurable cm. skin intact with purple/maroon discoloration. Improved evidenced by decreased surface area. Focused Wound Exam (site 7) End-stage skin failure of the right, lateral foot with evidence of multisystem organ failure, with life expectancy of < 2 weeks, with minimal recent caloric intake, with multiple sites of simultaneous skin breakdown. Noted to be present on admission per staff. Poor healing potential. Wound size: 2.4 cm. x 12.4 cm. x not measurable cm. Skin intact with purple/maroon discoloration. Improved evidenced by decreased surface area.On 6/4/26 at 9:13 AM, V3, ADON (Assistant Director of Nursing)/MDS Coordinator stated that (R2) should have care plans for hospice and severe pain. She stated that (R3) should have had a care plan for wounds.Facility's Baseline Plan of Care policy dated August 2017 documents Policy: The facility will develop and implement a Baseline Plan of Care for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality of care. The baseline care plan will include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and will identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Procedures: 5. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which are not identified in the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative.

Based on observation, interview, and record review, the Facility failed to store and prepare food in a manner that prevents potential contamination. This has the potential to affect all 94 residents living in the Facility.Findings include: On 3/24/26 at 7:46 AM, V6, Dietary Aid, was plating breakfast from the steam table and was not wearing a hairnet. V6 stated she was wearing a hairnet, but it is clear because the Facility buys clear hairnets. On 3/24/26 at 7:54 AM, in the dry storage room there were several stacks of boxes all over the floor that included three boxes of bread, two boxes of brown sugar, a box of dry cereal, a box of apple juice, a box of potato chips, a box of jelly, a box of syrup and a box of non-dairy creamer. V4, Dietary Manager, stated the boxes were delivered yesterday and they were short staffed and did not get them put away yet. On 3/24/26 at 11:00 AM, V4 stated the Facility does not buy clear hairnets. The hairnets used in the kitchen have thin black webbing and can be harder to see on dark hair, but are not invisible. On 3/24/26 at 3:30 PM, V1, Administrator, stated he expects all dietary staff to wear hairnets in the kitchen and store food per policy guidelines. The Facility's Cleaning and Sanitation - General Policy revised January 2012 documents the kitchen will be maintained in a clean and sanitary condition, and hairnets or hair coverings will be worn at all times. The Facility's Food and Supply Storage Policy revised January 2012 documents food and supplies will be stored six inches above the floor on clean racks or shelves. The Facility's Daily Census Report dated 3/24/26 documents there are 94 residents living in the Facility.

Based on interview and record review, the facility failed to notify a resident's representative and physician of a change in condition in 1 of 3 residents (R7), reviewed for notifications of changes in the sample of 3.Findings Include:On 3/24/26 at 9:20 AM, V7, R7's Family, stated after R7 passed away they received a bill from a wound care company that had seen R7 for a wound and something was removed, the family was not notified of any wounds and didn't know about it until they received a bill. V7 stated they did not notify the family that R7 had been removing her tracheostomy tube, and the communication was horrible. R7's Face Sheet, undated, documents R7 had the following diagnoses: Intracerebral Hemorrhage, Anxiety Disorder, Unspecified Dementia, Tracheostomy Status, Acute Respiratory Failure, and Depression. V7 is listed as R7's emergency contact and power of attorney.R7's MDS (Minimum Data Set), dated 9/28/25, R7 had a BIMS (Brief Interview of Mental Status) score of 00, indicating R7 had severe cognitive impairment. R7 utilizes a tracheostomy with ventilatory support.R7's Care Plan, dated 9/24/25, documents R7 is at risk for respiratory difficulties related to respiratory failure with an intervention to notify her physician of any changes.R7's Progress Note, dated 9/27/25 at 9:17 AM, documents the following: Resident decannulated herself. RT (Respiratory Therapy) attempted three times to replace trach. Resident's stoma closed quickly. Stoma care provided and resident placed on 3 lpm nasal cannula. Resident's cough is strong, and saturation levels are wnl. Will continue to monitor.On 3/24/26 at 9:00 AM, V2, DON (Director of Nurses) stated R7 was a resident at the facility for about two weeks. V2 stated R7 did have a history of removing her tracheostomy tube. V2 was not sure if R7's family or physician was notified of any changes. On 3/26/26 at 12:10 PM, V3, ADON (Assistant Director of Nurses) and V30, MDS/Care Plan Coordinator, stated they were unsure if R7's family was notified of any changes in condition. On 3/26/26 at 12:15 PM, V15, LPN (Licensed Practical Nurse), stated she is not familiar with R7, however does notify the residents families with any changes in condition.On 3/26/26 at 12:25 PM, V26, LPN, stated R7 did have a history of pulling at her tracheostomy tube, the feeding tube, and anything within her reach. V26 stated after R7 extubated herself and was placed on oxygen she was moved to the 200 hallway and that is where she (V26) took care of her. V26 stated she always notified R7's family and physician of any changes. The Change in a Resident's Condition or Status Policy, dated 11/2016, documents the facility must immediately inform the resident, consult with the resident's physician, and notify, consisitent with his or her authority, the resident representative when there is any changes in the level of care, resident rights, etc. Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will immediately notify the resident's family or representative anytime there is a significant change in the resident's physical, mental or psychosocial status.

Based on interview and record review, the facility failed to implement preventative measures for a resident with a known history of attempting self extubation of the tracheostomy tube in 1 of 3 residents (R7), reviewed for respiratory/tracheostomy care in the sample of 13.Findings Include: On 3/24/26 at 9:20 AM, V7, R7's Family, stated R7 was admitted to the facility from another state, it was a disaster from when she was admitted until she passed away. R7 pulled out her tracheostomy tube on several occasions. V7 stated they did not notify the family that R7 had been removing her tracheostomy tube, and the communication was horrible. R7's Face Sheet, undated, documents R7 had the following diagnoses: Intracerebral Hemorrhage, Anxiety Disorder, Unspecified Dementia, Tracheostomy Status, Acute Respiratory Failure, and Depression. R7 was admitted to the facility on [DATE].R7's MDS (Minimum Data Set), dated 9/28/25, documents R7 had a BIMS (Brief Interview of Mental Status) score of 00, indicating R7 had severe cognitive impairment. R7 had little interest or pleasure in doing things, exhibited verbal behaviors directed towards others, had a tracheostomy with ventilatory support provided. R7's Care Plan, dated 9/23/25, documents R7 is experiencing episodes of anxiety and is at risk for respiratory complications related to respiratory failure. There were no documented interventions in R7's records to indicate the facility implemented preventative measures/interventions for R7 pulling out her tracheostomy tube. R7's POS (Physician Order Sheet) documents an order dated 9/23/25, documents R7 is to utilize a size 7 tracheostomy tube. R7's Progress Note, dated 9/23/25 at 6:14 PM, documents the following: 84 y/o (year old) female resident arrived at the facility via EMTs (Emergency Medical Technicians) at 6:00 PM from an outside hospital. Resident previously had a stroke r/t (related to) a flaccid left sided weakness with minimum ROM (Range of Motion). Mild edema to LUE (Left Upper Extremity). Small bruising on right anterior forearm, Skin dry. 2 second capillary refill. Resident has small skin tear on ride side of chest per skin assessment. Lung sounds clear upon auscultation. Dry dressing placed. Alert and orient x4 and can make needs known per nurses' report. Incontinent of BB (Bowel and Bladder). ABD (Abdomen) soft, non-tender. Last bowel movement 9/22/25. VS (Vital Signs) 111/75, 70, 18, 98% ON 4L O2 (Liters of Oxygen). Gastrostomy tube in place. Tube-feeding patent and running per order. Resident uses her right hand to grab at things, like to pull at trash and gastrostomy tube per report. Hx (History) of hypertension, atrial fibrillation, and type 2 diabetes. All orders put in and MD (Medical Doctor) notified.R7's Progress Note, dated 9/23/25 at 9:50 PM, documents the following: (R7) has pulled off her trach collar times 3, saturations are 96%. RT (Respiratory Therapy) will continue to monitor.R7's Progress Note, dated 9/24/25 at 7:26 AM, documents the following: Resident remains on new admit day 1. resident is A&O (Alert and Oriented) x3. resident has a left sided weakness r/t right sided stroke. resident is trached not vented. lung sounds clear. Incontinent of B&B. active bowel sounds in all 4 quads. abdomen soft and non- tender. G-tube (Gastrostomy Tube) intact and patent. resident extremely restless. resident having to be repositioned multiple times. resident tried multiple times to remove vent mask. resident gave herself 2 skin tears on her upper right chest. both areas are 3x1. Both areas have been cleaned, and dry dressing have been applied. MD and POA (Power of Attorney) have been made aware. Wound nurse has been made aware, and she will be seen by wound doctor upon next visit. resident is currently resting quietly with call light in reach.R7's Progress Note, dated 9/24/25 at 9:20 AM, documents the following: Resident has pulled herself off of trach collar four times this morning. She has also emptied humidity water bottle x2. O2 tank and water bottle moved to foot of bed to avoid spilling. Will continue to monitor resident. O2 saturation has stayed in the mid 90's.R7's Progress Note, dated 9/27/25 at 9:17 AM, documents the following: Resident decannulated herself. RT attempted three times to replace trach. Resident's stoma closed quickly. Stoma care provided and resident placed on 3 lpm nasal cannula. Resident's cough is strong, and saturation levels are wnl (within normal limits). Will continue to monitor.R7's Progress Note, dated 9/29/25 at 7:37 AM, documents the following: Resident is A&Ox3. resident has a left sided weakness r/t right sided stroke. resident is decannulated and on 3 L of O2 NC (Nasal Cannula). resident continues to take NC off and leaving it off. resident continues to maintain an O2 SAT (Saturation) of 93-96% while NC is off. incontinent of B&B. active bowel sounds in all 4 quads. abdomen soft and non- tender. G-tube intact and patent. resident extremely restless. resident having to be repositioned multiple times. resident treatment to chest completed resident tolerated well. resident is currently resting quietly with call light in reach.R7's Progress Note, dated 10/01/25 at 12:44 AM, documents the following: (R7) removed her nasal cannula X2, her saturations were 90%. RT put 1 liter NC on her and her saturation went up to 99%. RT will continue to monitor.On 3/24/26 at 9:00 AM, V2, DON (Director of Nurses) V2 stated R7 was a resident at the facility for about two weeks and passed away. V2 stated R7 did have a history of removing her tracheostomy tube. On 3/26/26 at 12:10 PM, V30, MDS/Care Plan Coordinator, stated R7 extubated herself, he isn't sure if she had a history of doing this or if there were any preventative measures in place. On 3/26/26 at 12:25 PM, V26, LPN (Licensed Practical Nurse), stated R7 did have a history of pulling at her tracheostomy tube, the feeding tube, and anything within her reach. V26 stated R7 was very anxious and they got her on some medications and after a while, they did help to calm her down. V26 stated as preventative measures, they placed an abdominal binder over R7's g-tube site and kept other items out of her reach. V26 stated with R7's tracheostomy tube, there wasn't anything they could do to keep her from pulling at it and it was inevitable that she was going to pull it out. The Problematic Behavior Management Clinical Protocol Policy, dated 2/2012, documents the staff will use protocols to identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The Physician will help identify and authorize appropriate, targeted, and symptomatic treatments. As part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition, problematic behavior, or mental illness. In addition, the nurse shall assess and document/report whether a resident is a danger to themselves or others.

Based on interview and record review, the Facility failed to ensure residents only smoke in designated, safe areas and tobacco and smoking supplies are kept in secure locations for 1 of 3 residents (R2) reviewed for accidents and hazards in the sample of 7. Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, cerebral infarction, and nicotine dependence.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact and ambulated independently.R2's Care Plan initiated 9/22/25 documents, Resident is exhibiting non-compliance behavior by smoking in his room.R2's Care Plan initiated 10/15/25 documents, Resident wishes to smoke cigarettes and has been assessed as potentially being unsafe to smoke independently after smoking observation weas completed. He has broken smoking protocols by smoking in his room.R2's Grievance dated 9/30/25 documents, Resident unhappy about cigarettes put in safe spot for smoking. On 11/13/25 at 11:57 AM, V1, Administrator, stated R2 has been caught smoking in his room. He has been told he cannot smoke in his room, but he still tries to sneak in there, and staff have found ashes.On 11/13/25 at 1:05 PM, V6, Certified Nursing Assistant (CNA), stated R2 smokes in his room all the time. R2 is in the hospital now, but if he was here, you would probably smell it. On 11/13/25 at 1:09 PM, V8, Nurse Manager, stated R2 has been caught smoking in his room numerous times. We educate him and show him where cigarettes are supposed to be kept, but he will not follow the rules. On 11/13/25 at 2:40 PM, V2, Director of Nursing (DON), stated multiple staff have smelled smoke and seen ashes in R2's room. She stated, It's a problem.On 11/14/25 at 7:55 AM, V11, Licensed Practical Nurse (LPN), stated, (R2) has been caught smoking in his room so many times. We smell it on him and in the air in the hallway. When we come in, he tries to flush it down the toilet and says he doesn't have anything on him.On 11/14/25 at 8:00 AM, V12, Registered Nurse (RN), stated R2 does his own thing and smokes in his room, not in the designated smoking areas. Staff tell him the rules, but he is not cooperative. V12 stated people can smell it out in the hallway, and she has also seen him with a lit cigarette in the hallway. Cigarettes are supposed to be locked up, but R2 gets them when he leaves the facility, or visitors bring them in for him.On 11/14/25 at 9:29 AM, V5, RN, stated R2 has been educated multiple times regarding the importance of not smoking in his room, but he does not follow the rules. She has smelled smoke in his room and has found tobacco rolling tubes in his room. Administration is aware, but it keeps happening.R2's 8/28/25 Progress Note documents R2's room and bathroom smelled like smoke. There were ashes in the bathroom sink and pieces of tobacco on the toilet seat.R2's 8/31/25 Progress Note documents R2 went into the 300 Hall shower room which smelled of strong cigarette smoke odor after he left.R2's 9/10/25 Progress Note documents R2 was smoking a cigarette in the 300 Hall bathroom and flushed the cigarette as staff were entering the room. R2 stated he was not smoking as clouds of cigarette smoke and tobacco smell filled the room with him.R2's 9/30/25 Progress Note documents R2 had cigarettes and a lighter. V13, LPN, told R2 he needed to return the items, but he used profanity and instead kept the items.R2's 10/10/25 Progress Note documents R2's bathroom smelled like cigarette smoke, and there were ashes on the toilet seat. R2's room was searched, and a box of rolling tubes were found.R2's 10/14/25 Progress Note documents R2 was found with tobacco and rolling tubes on the floor between the bed and the wall.R2's 10/15/25 Progress Note documents R2's bathroom smelled like smoke, and there were ashes on his toilet seat.R2's 10/20/25 Progress Note documents resident was smoking in the bathroom.R2's Smoking Risk assessment dated [DATE] documented R2 was a Potentially Unsafe Smoker and should Follow Facility Policy.On 11/14/25 at 9:08 AM, V1 stated residents are not allowed to smoke in their rooms and cigarettes should be locked up when not in use for resident safety.The Facility's Smoking Policy and Procedure revised October 2015 documents the purpose of the policy is to assure all residents are safe while smoking. Smoking materials must be secured at the nurses' station when not in use and will not be kept in resident rooms. Smoking will only be allowed in the designated smoking areas of the facility.The Facility's Undated Smoke Times documents smoking will take place outside in the courtyard, weather permitting.

Based on observation, interview, and record review the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for hand contracture management and treatment for 1 of 1 resident (R34) reviewed for quality of care in the sample of 57. This failure resulted in R34 experiencing severe pain, infection, and a wound on her left hand. Findings Include: R34's face sheet, print date of 9/23/25, documented R34 has diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness. R34's MDS (Minimum Data Set), dated 7/4/25, documented R34 is moderately cognitively impaired. R34's care plan, undated, documented resident has contractures of the right hand with interventions of ensure proper positioning as tolerated in bed and chair, meds as ordered and observe effectiveness of meds, observe for pain or increased stiffness, and notify MD of changes, provide gentle ROM (range of motion) during daily care as tolerated, and turn and reposition as needed while in bed/chair. R34's progress note, dated 9/15/25 at 2:10 AM, documented resident requested to go to hospital r/t pain in her left hand, this nurse informed her the wound care doctor would be in, resident stated I fired him, he's insane send me to the hospital please this pain is unbearable. This nurse informed MD. EMS (emergency medical services) currently here to transport resident to (local hospital). R34's local hospital after visit summary, dated 9/15/25, documented reason for visit: finger pain, diagnoses deformity of left hand, injury, finger, left, initial encounter. Instructions: keep fingers apart as much as possible so not injuring each other. R34's care plan was not updated to reflect any interventions to keep R34's fingers apart as much as possible to prevent further injuries. R34's wound evaluation and management summary, dated 9/15/25, documented chief complaint: patient has a wound on her left plantar hand. Etiology: infection. Dressing Treatment Plan: antifungal OTC (over the counter) apply once daily and as needed. Etiology: infection. Duration: more than 3 days. Estimated time to heal: 9-12 months. Wound size (L x W x D): 3.2 x 2.1 x 0.3 cm. Surface area: 6.72 cm. Exudate: Light serous. Dressing treatment plan: antifungal OTC (over the counter) once daily and as needed, silver sulfadiazine once daily and as needed, gauze sponge once daily and as needed. R34's wound evaluation and management summary, dated 9/23/25, documented wound of the left, plantar hand, full thickness. Etiology: infection. Wound size (L x W x D): 3.5 x 2.1 x 0.3 cm. Surface area: 7.35 cm. Exudate: moderate serous. On 9/22/25 at 12:30 PM R34 was observed lying in bed with her left hand tightly contracted. R34's left hand had a foul odor coming from it. R34 did not have any devices in her left hand to reduce pressure between her fingers and the palm of her hand. R34's right hand was not observed to be contracted as documented in R34's care plan. On 09/24/2025 at 3:31 PM R34 stated her left hand hurts all the time and the pain in her hand has gotten worse since she went to the hospital on 9/15/25. A foul odor was noted coming from R34's left hand. On 9/24/25 at 10:45 AM V20 Care Plan Coordinator stated she thought R34's right hand is her contracted hand. V2 DON (Director of Nursing) was present and stated she would go and observe R34's hands to check for contractures. On 9/24/25 at 10:57 AM V2 DON stated she checked R34's hands and it is her left hand that is contracted. V2 stated R34's care plan documented R34's right hand is contracted, and it is R34's left hand that is contracted. On 9/24/25 at 11:00 AM V27 Regional Nurse stated she expects the facility care plan staff to identify the correct extremities with contractures and implement appropriate interventions for contracture care. Surveyor asked V27 if she expects the facility staff to implement contracture care plan interventions such as hand rolls/hand splints to reduce the risk of residents developing wounds and/or infection and V27 replied yes.The facility's ROM (range of motion)/Contracture Care Policy and Procedure, dated 2011, documented all residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy and/or restorative nursing, as applicable. The program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. Formalized therapy will work closely with nursing staff, as appropriate, communicating and planning for goals and approaches so the team can be consistent in providing the care and services for maintaining joint mobility and for contracture care. It continues, procedure: 1. The nurse will start the functional assessment of new residents by completing the physical function sections of the MDS. 2. When further assessment is triggered for contracture risk or contracture care, further assessment will be done utilizing the designated functional assessment/rehabilitation module to perform further evaluation. 3. A physician's order will be obtained for physical or occupational therapy to evaluate and treat if there is any indication that the resident could benefit by these services. It continues, 8. When a resident has a contracture or contractures already present, formalized therapy will evaluate and work with the nursing department in setting up goals and approaches for the plan of care that specifically addresses this individuals' unique needs. 9. When splints and other contracture devices are part of the plan, formalized therapy will instruct nursing staff as to their use and recommend a schedule for applying and removing the device. 10. Individual plans for preventative ROM (range of motion) and contracture care will be followed as planned seven days a week.

Based on observation, interview, and record review, the facility failed to properly store medication and label insulin vials. This has the potential to affect all 89 residents residing in the facility.Findings include:On [DATE] at 8:45 AM the facility's 400 Hall medication cart was inspected. The cart contained the following:1. Open and partially used 250-unit multi dose Lispro Pen. The pen documented no name and no open or expiration date. The Lispro pen documents discard after 28 days.2. R60's open and partially used 250-unit multi dose Glargine Pen. The pen documented no open or expiration date.3. R60's open and partially used multi dose Glargine Vial. The vial documented no open or expiration date. The multi dose vial had a label open date, expiration date, initials all blank.4. R11's open and partially used multi dose Lantus vial. The vial documented no open or expiration date. 5. Multiple identifiable loose pills of varying shapes, sizes and color in multiple drawers of the 400-hall medication cart. V28, Licensed Practical Nurse (LPN), opened drawer with 4 rows of medication card. V28 removed a row of cards and counted 200 pills of various shapes and colors loose in the cart in that row. The pills varied in shapes from triangle, circle, oblong, half and whole tablets and capsules. The pills ranged from white, beige, yellow, green, purple, and blue in color. On [DATE] at approximately 9:04 AM V28 stated that she could not identify all the pills loose in the cart or who they belong to. V28 stated that the insulins once open should have an open and expiration date. V28 stated that once open the expiration date is shortened to 28 days. V28 stated that the open and expiration date lets them know when the 28th day is.On [DATE] at approximately 9:10 AM 100 hall back medication cart was inspected. The medication cart contained the following:6. Multiple loose and scattered pills of varying shapes and color in the medication cart.On [DATE] at 9:33 AM Medication Cart for Front 100-Hall inspected. The medication cart contained the following:7. A total of 9 small white pills, a large white pill, a small blue pill, and 3 pink pills loose and scattered at the bottom of the medication drawers.On [DATE] at 9:34 AM V13 stated she could not identify any of the pills or who the pills belong to.On [DATE] at 9:48 AM 500 hall medication cart was inspected. The medication cart contained the following:8. Multiple pills of various shapes, sizes and color loose and scattered throughout the drawers located in the medication cart. On [DATE] at 9:50 AM 300 Hall medication cart was inspected. The medication cart included the following:9. 1 bottle of Oyster Shell Calcium 500mg with use by date [DATE]. No other expiration date was identified on the bottle.On [DATE] at 9:51 AM V9, LPN, stated that the calcium bottle was open, in use and expired. V9 stated that the medication should not be in the cart and should be discarded.On [DATE] at approximately 10:00 AM the 200 Hall medication cart was inspected. The medication cart contained the following:10. Multiple pills of various shapes, sizes and color loose and scattered throughout the drawers located in the medication cart. On [DATE] at approximately 10:12 AM V10, LPN, stated that if she dropped a pill she would get a new one.On [DATE] at 2:02 PM V27, Regional Nurse, stated that the multidose vials and pens are to have an open and expiration date. V27 stated that she expects the nurses to destroy spilled, loose or scattered medications. The facility's Medication Storage policy, dated [DATE], documents that Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. It also documents that Procedures: c. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication and reordered from the pharmacy if a current order exists. It also documents Expiration Dating: C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. D2. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial. E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating (See FORMS: MEDICATIONS WITH SHORTENED EXPIRATION DATES).The CMS dated [DATE] documents 89 people residing in the facility.

Based on interviews, observation and record reviews the facility failed to serve food that conserved nutritive value, flavor and safe appetizing temperature for 5 out of 5 residents, (R17, R11, R43, R71 and R73); reviewed for Food and Nutrition Services in a sample size of 57.Findings include: R17's Face sheet documented they were admitted to the facility on [DATE]. R17's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. R11's Face sheet documented they were admitted to the facility on [DATE]. R11's MDS dated [DATE] documented he was cognitively intact. R43's Face sheet documented they were admitted to the facility on [DATE]. R43's MDS dated [DATE] documented he was cognitively intact. R71's Face sheet documented they were admitted to the facility on [DATE]. R71's MDS dated [DATE] documented he was cognitively intact. R73's Face sheet documented they were admitted to the facility on [DATE]. R73's MDS dated [DATE] documented he was moderately cognitively impaired. The facility's Resident Council Meeting Minutes dated 7/21/25 documented the residents had concerns with dietary portion sizes, real fish, soggy fries and menu changes. On 9/22/25 at 9:15 AM, R17 stated the food is sometimes cold when it gets to her and the food could taste better. On 9/23/25 at 2:45 PM, during the Resident Council Meeting, R21, R43, R71, and R73 all stated the food tastes bad, it is cold. R21, R43, R71, and R73 all stated there was reduction in portion sizes and poor quality of food. R21, R43, R71, and R73 stated the food is cold both in dining room and when delivered. On 9/24/2025 at 12:29 PM, Cauliflower was 122 degrees Fahrenheit. The cauliflower was cold and had no flavor, was bland. On 9/25/25 at 12:03 PM V1 Administrator stated he expects the food to taste good and be appropriate temperatures. V1 stated the facility does not have a policy for food palatability.

Based on observation, interview, and record review, the facility failed to ensure clean sanitary conditions in the kitchen, food was labeled, dated correctly, removed from the walk-in refrigerator as indicated, and perform proper hand hygiene during food service. This failure has the potential to affect all the residents who receive food from the kitchen. Findings Include:On 09/22/2025 at 8:50 AM, Initial tour of the kitchen was done. This surveyor washed her hands prior to inspection started and there were no paper towels in the dispenser. The sink where employees wash their hands was dirty. There was dirt and a slimy film and rust around the faucet on the sink. There was a bait trap that had been stepped on lying on the floor by the trash can, the trashcan had dirty marks on the lid, and there was an empty buck that had a hole in the top and there was a pink liquid with dirt on the lid of the bucket. On 09/22/2025 at 8:58 AM, The food storage room was inspected at this time and the following was seen:1. There was a large trash can on wheels that was full (overflowing) of dirty towels and blankets. and there was a white blanket in it. V24, [NAME] threw a dirty rag in the trashcan. On 09/22/2025 9:05 AM The walk-in refrigerator was inspected at this time and the following was seen:2. There was water on the floor immediately to the left of the refrigerator door. There was a towel lying up against the wall in between the wall and the rack holding food. The towel was saturated with water and had brown stains on it. V24, [NAME] said it was from condensation from the freezer next to the refrigerator. 3. Parmesan garlic sauce with the date of 07/05/25 on the lid. 4. Two and a half rolls of uncooked hamburger meat on a tray with blood drainage noted on the tray and the date of 09/16/25. V24 said the date on the tray is the day he took it out of the freezer. 5. Raspberry whipped dessert in a bowl covered with cling wrap with the date of 09/14. V24 took it and threw it away.6. There were two sealed containers of unlabeled fruit (V24 stated it was cantaloup and honeydew melon) both dated 09/08. The honeydew melon appeared to have a slimy film coating the cut-up melon.7. A tray with three grilled cheese sandwiches covered with cling wrap dated 09/18. 8. There was a vegetable tray with a lid, it was dated 09/08 and was unlabeled. In the tray there was pickles, onions, and tomatoes. On 09/22/2025 at 09:15 AM, When going into the walk-in freezer there was water running out of the front and to the left towards the walk-in refrigerator. During noon time meal service, the following was seen: 1. On 09/22/2025 at 11:47 AM, V24, [NAME] had gloves on he took a piece of pork loin to the table next to the stem table, he cut the meat on a cutting board, wiped the knife off then came back to the steam table started to serve the meal with the same gloves on. 2. On 09/22/2025 at 11:49 AM, The timer on the oven behind the steam table went off, V24 went over and turned it off with the same gloves on and then went back to serving food with no hand hygiene or change of gloves done. 3. On 09/22/2025 at 11:56 AM, V24 laid the tongs he had been using to handle the pork loin on the counter of the stem table, then dished up other food with their utensils, when he was done plating the resident's tray, he picked the tongs up off of the counter and placed them back in the pan holding the meat without cleaning/wiping them off. 4. On 09/22/2025 at 11:59 AM, V24 went into the walk-in refrigerator with gloves on and came out with a container that had pickles, onions, and tomatoes in it, he then went back to serving food with the same gloves on with no hand hygiene or change of gloves done. 5. During the meal service V25, Dietary Aide touched dirty counters, dirty carts, and then touched multiple resident food trays without doing any hand hygiene and no gloves were worn during the meal service. On 09/25/25 at 11:43 AM, V26, Dietary Manager stated the food in the walk-in refrigerator if unopened it should have the received date on it, if it is open the food item should have the date received, the open date, and the date to use by. V26 said the container that had the pickles, onions, and tomatoes was their relish plate. She said it is used more often, and when it is empty they are to wash, sanitize, and put a new date on it. V26 said they usually like to always keep at least one roll of hamburger in the refrigerator in case of an emergency. She said they will usually allow three days for thawing of the meat and the meat should be used within three to four days of taking it out of the freezer. V26 said when it comes to handwashing the kitchen staff should be doing it frequently. She said when it comes to the kitchen aide who is putting the food onto the carts as long as they aren't touching the top of the plate then they don't have to wear gloves and if they leave the line for any reason V26 would expect them to wash their hands. V26 said she would expect the cook to wash their hands and change their gloves if they left the food service line and went to the refrigerator to get something. On 09/25/25 at 12:50 PM, V27, Regional Nurse stated she would expect the kitchen staff to keep the kitchen clean and sanitary, she would expect the food to be labeled and dated, and she would expect staff to do hand hygiene. On 09/25/25 at 12:55 PM, V1 Administrator said he would expect the staff in the kitchen to label and date the food, perform hand hygiene, and to make sure the kitchen is clean and sanitary. The facility's food and supply storage policy, revision date of 01/2012, documented Policy: Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Procedure: 1. Food services will maintain clean food storage areas. It further documented 4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. It also documented 6. All foods will be covered, labeled, and dated. The facility's Handwashing policy, revision date of January 2012, documented Policy: Handwashing facilities will be readily accessible and equipped with paper towels and soap. Staff will wash hands frequently as needed throughout the day following proper handwashing procedure. Procedure: After touching ears, nose, mouth, hair, ect. Any contact with infected or otherwise unsanitary areas of the body. It also documented Hand contact with unclean equipment or work surfaces, hand contact with soiled clothing or other materials that are soiled. Handling raw food or partially cooked meat or poultry.

Based on interviews, observations and record reviews the facility failed to perform hand hygiene for 5 out of 5 residents, (R39, R28, R53, R81, R82); reviewed for Infection Control in a sample size of.Findings include:R39's Face sheet documented they were admitted to the facility on [DATE]. R28's Face sheet documented they were admitted to the facility on [DATE].R53's Face sheet documented they were admitted to the facility on [DATE].R81's Face sheet documented they were admitted to the facility on [DATE].R82's Face sheet documented they were admitted to the facility on [DATE].On 9/22/25 at 12:06 PM, V6 (dietary aide), pushed out the resident's meal cart for the main dining room and delivered lunch plates to R39, R28, R53, R81, and R82 without performing hand hygiene prior to serving or in between and after each resident. On 9/24/25 at 1:16 PM, V13 (LPN) stated hand hygiene is supposed to be completed every time a food tray is passed. On 9/24/25 at 1:23 PM, V33 (CNA) stated hand hygiene is supposed to be completed before, in-between and after serving each resident.On 9/24/25 at 2:40 PM, V22 (Nurse Manager) stated hand hygiene is expected to be completed in between each tray by staff. The facility's Safe Food Preparation and Handling policy dated 1/2012 documented hands will be washed properly, frequently, and at appropriate time. Proper handwashing techniques will be used. The facility's Handwashing policy dated 4/2015 documented hands should be thoroughly washed before and after providing resident care. Proper handwashing techniques must be followed at all times. Hand antiseptic/hand sanitizer is a supplement or alternative to the use of soap and water when hands are not visibly solid.

Based on interviews, observation and record reviews the facility failed to promote respect and dignity for 1 out of 1 residents, (R64); reviewed for in Resident Rights in a sample size of 57.Findings include:R64's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, dependence on respirator, encounter for attention to tracheostomy and major depressive disorder.R64's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact and required oxygen therapy, suctioning scheduled and as needed, tracheostomy care, and an invasive mechanical ventilator.R64's Care Plan dated 7/25/25 documented she is risk for respiratory complications with interventions for staff to do the following (all created on 2/6/24): observe for signs and symptoms of pain (grimacing, moaning), provide meds as ordered, provide suctioning as ordered and as needed, respiratory / trach care as ordered.On 9/22/25 at 9:50 AM, R64's room, R64 was coughing in her bed and did not stop coughing, looked up with concern while grimacing, and stated she needed help from staff. This surveyor notified V3, Respiratory Therapist (RT), V4 (RT) and V5 Registered Nurse (RN) at the end of the hall a couple rooms down that she was asking for help while standing in front of R64's doorway. V3 remained sitting and stated oh, she does that all the time. V5 asked R64 if she wanted RT and then told V3 that she needed her while standing in front of R64's doorway. V3 continued to sit and talk with V4 at the end of the hall. On 9/22/25 at 9:53 AM, R64 stated she felt ignored and disrespected by staff as she looked around and waved her hands asking where they were. R64 stated her vent was causing her itchiness and discomfort in her throat and the respiratory treatments help relieve that. On 9/22/25 at 10:00 AM, V3 and V4 continued to sit at end of hall talking after R64 requested help at 9:50 AM.On 9/22/25 at 10:04 AM, V3 and V4 continue to talk at end of hall.On 9/22/25 at 10:09 AM, R64's call light went on and V3 then, went to her door to respond. On 9/24/25 at 1:16 PM, V13 (LPN) stated it should take about 3-5 minutes to respond to a resident asking for assistance or as soon as possible. V13 stated it would absolutely not be acceptable to continue talking to a coworker after being requested by a resident, V13 stated she would absolutely feel ignored and disrespected if she was in that situation as a resident. V13 stated hand hygiene is supposed to be completed every time a food tray is passed. On 9/24/25 at 1:20 PM, V19, Respiratory Therapy (RT) stated it would be acceptable to respond to a resident requesting assistance as soon as she can, sometimes they are in the middle of resident care so as soon as that is completed. V19 stated it is not acceptable for staff not to respond to a resident and continue talking to a coworker instead of checking on them, V19 stated yes of course she would feel ignored or disrespected if she was a resident and that happened to her.On 9/24/25 at 1:23 PM, V33 (CNA) stated responding to a resident's request for assistance should be immediate. V33 stated it would not be acceptable to talk to continue talking to a coworker instead of responding to a resident's request for assistance and she would feel ignored or disrespected if she was a resident and that happened to her. On 9/24/25 at 2:06 PM, V1 (Administrator) stated it is not acceptable for staff not to respond after being requested for assistance at least to assess the situation. The facility's Resident Rights policy dated 8/31/23 documented the resident has the right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility, including: the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for 3 of 7 residents (R34, R44, R76) reviewed for care plans in a sample of 57. Findings include: 1.R34's face sheet, print date of 9/23/25, documented R34 has diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness. R34's MDS (Minimum Data Set), dated 7/4/25, documented R34 is moderately cognitively impaired and requires assistance with all ADLS (activities of daily living). R34's care plan, undated, documented resident has contractures of the right hand with interventions of ensure proper positioning as tolerated in bed and chair, meds as ordered and observe effectiveness of meds, observe for pain or increased stiffness, and notify MD of changes, provide gentle ROM (range of motion) during daily care as tolerated, and turn and reposition as needed while in bed/chair. R34's progress note, dated 9/15/25 at 2:10 AM, documented resident requested to go to hospital r/t pain in her left hand, this nurse informed her the wound care doctor would be in, resident stated I fired him, he's insane send me to the hospital please this pain is unbearable. This nurse informed MD. EMS (emergency medical services) currently here to transport resident to (local hospital). R34's local hospital after visit summary, dated 9/15/25, documented reason for visit: finger pain, diagnoses deformity of left hand, injury, finger, left, initial encounter. Instructions: keep fingers apart as much as possible so not injuring each other. R34's care plan was not updated to include any interventions to prevent R34's left hand contracture from causing further injuries. R34's care plan does not address R34's left hand contracture at all. R34's wound evaluation and management summary, dated 9/15/25, documented chief complaint: patient has a wound on her left plantar hand. Etiology: infection. Dressing Treatment Plan: antifungal OTC (over the counter) apply once daily and as needed. Etiology: infection. Duration: more than 3 days. Estimated time to heal: 9-12 months. Wound size (L x W x D): 3.2 x 2.1 x 0.3 cm. Surface area: 6.72 cm. Exudate: Light serous. Dressing treatment plan: antifungal OTC (over the counter) once daily and as needed, silver sulfadiazine once daily and as needed, gauze sponge once daily and as needed. R34's wound evaluation and management summary, dated 9/23/25, documented wound of the left, plantar hand, full thickness. Etiology: infection. Wound size (L x W x D): 3.5 x 2.1 x 0.3 cm. Surface area: 7.35 cm. Exudate: moderate serous. On 9/22/25 at 12:30 PM R34 was observed lying in bed with her left hand tightly contracted. R34's left hand had a foul odor coming from it. R34 did not have any devices in her left hand to reduce pressure between her fingers and the palm of her hand. R34's right hand was not observed to be contracted as documented in R34's care plan. On 09/24/2025 at 3:31 PM R34 stated her left hand hurts all the time and the pain in her hand has gotten worse since she went to the hospital on 9/15/25. A foul odor was noted coming from R34's left hand. R34 was noted to be unkempt with greasy hair. R34's point of care completion summary report, dated 8/26/25 - 9/23/25, documented R34's last shower/bed bath was completed on 9/16/25. On 9/22/25 at 12:15 PM V8 CNA (Certified Nurse Assistant) stated R34 refuses to get out of bed for showers. R34's care plan does not address R34's hand wound nor the wound treatment ordered by R34's physician nor does it document an intervention to keep R34's fingers apart as documented on R34's local hospital after visit summary. R34's care plan does not address R34's refusal of hygiene care nor any interventions for R34's refusal of care. 2.R44's face sheet, print date of 9/25/25, documented R44 has diagnoses including COPD (chronic obstructive pulmonary disease), hypertensive heart disease, chronic kidney disease, diabetes mellites, schizoaffective disorder, pre-glaucoma, history of falling, and idiopathic epilepsy with seizures. R44's MDS, dated [DATE], documented R44 is severely cognitively impaired and requires assistance with all ADLS. R44's fall risk assessment, dated 9/10/25, documented R44 was assessed as a high fall risk. R44's progress note, dated 9/15/25 at 2:11 AM, documented resident rolled from bed to floor mat and crawled back in bed, no injury noted. Intervention for fall - large colored tag placed on side rail to remind resident to lower side rail once in bed. R44's care plan, undated, does not document the fall R44 sustained on 9/15/25 nor does it document an intervention was added to reduce R44's risk of incurring further falls. 3.R76's face sheet, print date of 9/24/25, documented R76 has diagnoses including hemiplegia and hemiparesis following cerebral infarction, anemia, hypertension, unspecified convulsions, dementia, and diaphragmatic hernia. R76's MDS, dated [DATE], documented R76 is severely cognitively impaired and requires assistance with ADLS including eating. R76's weight records, print date of 9/25/25, documented R76 weight on 3/3/25 was 138.4 lbs. and R76's weight on 9/16/25 was 115.2 lbs. R76's progress note, dated 9/22/25 at 6:24 PM, documented the patient's diet has been downgraded to pureed texture with regular liquids due to persistent difficulty at meals masticating advanced textures. Please see SLP (Speech-Language Pathologist) for questions or concerns. R76's care plan, undated, documented R76's weight will remain stable with no loss or gain of 3% or more per month per quarter, diet: 2 gm NA (sodium), low cholesterol, low fat diet with thin liquids. This care plan does not address R76's diet order change to pureed nor does it address R76's 16.67% weight loss since 3/3/25 although R76 has been receiving speech therapy and is being monitored by a Registered Dietitian. On 9/24/25 at 11:05 AM surveyor asked V27 Regional Nurse if she expects facility staff to update care plan interventions with each fall, with weight loss interventions including diet order changes, and with interventions related to residents' non-compliance with care and V27 stated yes. On 09/24/2025 at 10:38 AM V27 Regional Nurse stated the facility does not have a care plan policy and they follow the RAI (Resident Assessment Instrument) manual.

Based on observation, interview, and record review the facility failed properly and safely transfer 2 of 5 residents (R45 and R30) reviewed for safety in a sample of 57. This failure resulted in R30's leg being hit on the mechanical lift and experienced pain.Findings include: 1. R45's Care Plan, not dated, does not address R45's transfers. R45's Minimal Data Set (MDS), dated [DATE], documents that R45 has short- and long-term memory problems and is severely cognitively impaired. It also documents that R45 is dependent on staff for bed to chair transfers.R45's Clinical Observation - Transfer Assessment, dated 9/19/25, documents that R45 is to use the full body/Hoyer lift for all transfers.On 9/22/2025 at 10:08 AM observed V29, Certified Nurses Assistant (CNA), and V30, CNA, transfer R45 from the bed to the reclining wheelchair using a full body lift. V29 and V30 applied the sling straps to the lift bar. V30, operating the controls, with V29, standing at the foot of the bed, then raised R45 into the air above bed allowing R45 to swing back and forth without staff contact hitting R45's left leg on the machine bar causing R45 to have facial grimacing, squint eyes, and scowl on face. V29 then grabbed R45's feet. V30 operating the controls started to pull R45 from over the bed. V29 let go of R45's feet. V30, operating the controls with V29, standing on the other side of the wheelchair, then transported R45 across the room to the reclining wheelchair allowing R45 to swing back and forth without staff contact. V29 then leaned over the wheelchair, grabbed the sling, and pulled R45 over the wheelchair. V30 and V29 then lowered R45 into the wheelchair.On 9/25/2025 at 11:08 AM V30 stated that R45 is a full body lift with 2 staff members.On 9/25/2025 at 11:57 AM V37, CNA, stated that R45 transfers with a full body lift and 2 staff. V37 stated that 1 staff operates the machine and the other guides the resident keeping in contact with the resident during the transfer to protect the resident form being hurt.On 9/25/20025 at 12:13 PM V28, Licensed Practical Nurse, stated that R45 is nonverbal and makes uncomfortable faces, grimacing, squinting of eyes and scowling of face that indicate pain. V28 stated that if this occurs R45 is having pain.On 9/25/2025 at 12:15 PM V10, LPN, stated that when a resident is being transferred in the full body lift 2 staff are present and actively participating in the transfer. V10 stated that 1 staff operates the machine and 1 staff guides the resident. V10 stated that a staff member is to be in contact with the resident during the entire transfer.The facility's Safe Patient Handling Program, dated January 2017, documents that Purpose: To identify, assess, and develop strategies to control the risk of injury to residents, nurses and other health care workers associated with lifting, transferring, repositioning, or movement of a resident. This program applies to all staff-assisted resident lifts, transfers and ambulation performed by employees under normal conditions, during the performance of non-routine tasks and in the event of emergencies. Policy Residents identified as Totally Dependent or Extensive Assistance, for example, will be transferred by means of lift equipment and/or other resident assist devices instead of by manual lift. Gait/Transfer belts, including two-handled gait/transfer belts were deemed appropriate, will be used where manual assistance is required for ambulation and transfer activities. Friction reducing devices, such as lift sheets, will be used when repositioning in bed.2. R30's Care Plan, dated 9/15/2025, documents that Resident is a long-term nursing care resident R/T (related to) advanced age, and debility. The resident's inability to independently perform activities of daily living has decreased since admission. Resident needs assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Contributing DX: Heart failure, unspecified; Morbid (severe) obesity due to excess calories; Chronic obstructive pulmonary disease, unspecified.R30's MDS, dated documents that R30 requires Substantial/maximal assistance with transfers.R30's Transfer Assessment, dated 9/19/2025, documents that R45 use gait belt with 2 assists with all transfers.On 9/24/2025 at 9:20 AM V30, CNA, assisted R30 to the bathroom. V30 assisted R30 into the standing position with a count of 3 and grabbed ahold of R30's right arm and assisted R30 into the standing position. V30 then using a wheeled walker walked into the bathroom. No staff contact. Upon completion of toileting R30 using a cane and towel bar pulled self into a standing position. V30 then assisted R30 with clothes management. V30 then walked out of bathroom to reclining chair without staff contact.On 9/24/2025 at 9:20 AM V30 stated that R30 was supervision assist with transfers.On 9/25/2025 at 2:02 PM V27, Regional Nurse, stated that she would expect the residents to be transferred properly and safely. On 9/25/2025 at 2:03 PM V2, Director of Nursing, stated that she would expect the residents to be transferred properly and safely. The facility's Gait Belt Use policy, dated July 2014, documents that Policy: It is the policy of [NAME] Healthcare that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee.

Based on observation, interview and record review the facility failed to perform complete incontinence care for 1 of 3 (R30) residents reviewed for toileting in a sample of 57.Findings include: R30's Care Plan, dated 3/21/23, documents that Problem: Resident is at risk for impaired skin integrity r/t (related to) incontinent of B&B and decreased mobility. Approach: Provide incontinence care for episodes of incontinence. Resident is incontinent of bowel and bladder and is not appropriate for B&B (bowel and bladder) program due to physical limitations. Approach: Provide incontinent care as neededR30's Minimum Data Set, dated [DATE], documents that R30 is frequently incontinent and dependent on staff for toileting.On 9/24/2025 at 9:20 AM observed V30, Certified Nursing assistant (CNA), provide incontinent care to R30. Observed R30 ambulating to the bathroom with heavily soiled incontinent brief hanging between R30's legs. V30 assisted R30 with removing the heavily soiled incontinent brief and R30 sat on toilet. V30 then wet a towel applied soap and handed the towel to R30. R30 then wiped under her abdominal fold twice. R30 then stood and V30 wiped R30's buttocks. V30 then applied R30's incontinent brief and R30 walked out of the bathroom to the reclining chair. V30 did not cleanse R30's labia, perineum, and thighs.On 9/24/2025 at 9:24 AM V30 stated that R30 cleans her front and the staff clean the back.On 9/25/2025 at 2:02 PM V27, Regional Nurse, stated that she expects all areas of incontinence to be cleaned. The facility's Perineal Care policy, dated July 2017, documents Steps in the Procedure: For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perinea! area, wiping from front to back. (I) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. c. Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. f. Rinse thoroughly using the same technique as described in e above. g. Dry area thoroughly.

Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 3 residents (R9) reviewed for abuse in a sample of 3.Findings Include:R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has a medical diagnosis of Psychoactive Substance Abuse, Blindness Right Eye Category 3, Blindness Left Eye Category 3, and Hallucinations.R9's Minimum Data Set (MDS) dated [DATE] documents R9 is moderately cognitively impaired and has displayed verbal behaviors directed towards others. R9's Care Plan R9's Care Plan Last Reviewed/ Revised 8/18/2025 documents resident is considered at risk for abuse/neglect. R9's Progress Note dated 9/8/2025 at 6:05 PM documents This resident had an altercation with another resident related to resident hitting him in the groin. Then resident started slapping other resident in the face. No injury noted Admin and Director of Nursing (DON) made aware and police was call. Stated to keep everyone separated.The Facility's Initial Serious Injury Incident and Communicable Disease Report dated 9/8/2025 documents the following: Resident to Resident Immediately separated. Administrator notified. Final to follow.On 9/11/2025 at 1:50 PM V1, Administrator, stated he got a call Monday 9/8/2025 evening that there was an incident with R9 and R10. V1 stated R9 was outside of the facility with another resident when an argument occurred and R9 made contact with R10. V1 stated nursing staff separated the residents and both were assessed. On 9/11/2025 at 1:55 PM V7, Licensed Practical Nurse (LPN) stated V22, Certified Nursing Assistant (CNA) came to her and stated that she saw R9 hit R10 and herself and V22 went outside of the facility to separate the residents and assess each resident. On 9/11/2025 at 2:05 PM V25, LPN, stated she was informed by nursing staff that R9 had hit R10. V25 stated she went outside of the facility with V7 to access R9 and R10.On 9/11/2025 at 2:24 PM R9 stated he was outside with R8 when R10 started arguing with them. R9 stated R10 hit him in his private area and R9 smacked R10 back.On 9/11/2025 at 3:16 PM V22, CNA, stated she was in a resident room passing a food tray when she saw R9 smack R10 through the room window. V22 stated she told V7 what she has seen, and they went outside along with V25 to separate the residents. The Facility's Abuse Prevention Policy, Revision Date 9/29/2022, documents This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.

Based on observation, interview and record review the Facility failed to ensure residents requiring assistance for transfers were getting assistance and transferred with the mechanical lift for 1 of 3 residents reviewed for transfers in the sample of 11. Findings include: R3's Physician order Sheets (POS) for August 2025 documents a diagnosis of Unspecified osteoarthritis, unspecified site; Chronic venous hypertension (idiopathic) with other complications of unspecified lower extremity; Essential (primary) hypertension; Type 2 diabetes mellitus with hyperglycemia; Morbid (severe) obesity due to excess calories; Body mass index [BMI] 45.0-49.9, adult; Hyperlipidemia, unspecified; Hypothyroidism, unspecified; Other chronic pain; Insomnia; and Overactive bladder. R3's MDS dated [DATE] document R3 was cognately intact for decision making of activities of daily living. R3 uses a motorized wheelchair and is dependent on staff for transfers.R3's Care Plan with a revision date of 6/23/2025 documents. Problem: Resident is limited in (mobility/functional status) and requires the use of (mechanical lift).On 8/20/2025 at 9:33 AM, R3 stated, Several months ago during resident council I complained about the (mechanical lifts) not always working and the machines being dead when they need to use them. I talked with (V1) about them and (V5, Ombudsman). (V1) told me he will get some new batteries. (V5) has been sick but she usually always follows up with stuff. I am not sure what is happening. I usually, like to lay down at 4 PM. Some of the staff know that I like to lay down around and (V6, CNA) she is really good about asking me I want to lay down because she knows me. Over the weekend (V6) told me she could not put me down because the (mechanical lift) was not working. I was really tired, and I wanted to lay down and I had to wait an hour and a half for the battery to charge so she could put me to bed. I was so upset and in tears. This is supposed to be my home and when I am tired, and I need help they should help me back in bed when I need it. It's August now and they are still having problems with the (mechanical lift) and putting me down.On 8/20/2025 at 12:55 PM, V5, Ombudsman stated, Working (mechanical lifts) have been on ongoing issue for the past several months. When staff need the (mechanical lifts) they are not available to lay residents down and or get residents up. (V1) is a new administrator and I believe he started at the end of May as he was at the May Resident Council Meeting. (V1) said in May that he would order new batteries for the lifts. Residents are saying the lifts are not available mostly during the weekends. I personally, observed the (mechanical lift) being dead on 8/5/2025 and no staff used the manual lift and residents were not transferred. Residents and staff are still saying it is an issue that they are not getting transferred because the lifts are not available and/or the staff do not want to use the other lifts.On 8/20/2025 at 11:03 AM, V7, Certified Nursing Assistant (CNA) stated, We are constantly having issues with the (mechanical lifts) working. First, they told us it was a battery issue, and they were getting new batteries, but it is still a problem.On 8/20/2025 at 11:05 AM, V8, CNA stated, We are constantly running around trying to find a working (mechanical lift) because half the time they are not working. This has been going on for months.On 8/20/2025 at 11:07 AM, V9, CNA stated, That (mechanical lift) is dead. I think the battery needs charged. We were supposed to be getting new batteries. We have been having issues with these lifts for a few weeks now.Resident Council Meeting Notes dated 5/27/2025 document, Chargers for (mechanical lifts).On 8/22/2025 at 3:32 PM, V1, Administrator stated, We do not have a policy on batteries for the equipment, like the (mechanical lift).The Mechanical Lift Policy with a revision date of 9/8/2025 documents, The mechanical lift may be used to lift and move a resident with a limited ability during transfer while providing safety and security for the resident and nursing personnel. The mechanical lift must be able to accommodate the weight of the residents.The Resident Right Policy dated November 2018 documents, Your rights to dignity and respect. You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.

Based on observation, record review, and interview, the facility failed to prevent resident to resident abuse for 1 of 6 residents (R3) reviewed for abuse in the sample of 8. This failure resulted in R3 having lacerations and bruising. Findings Include:On 8/13/25 at 1:00 PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 was alert to self only.R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment.R3's Care Plan, with a review date of 7/22/25, documents R2 is exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. He invades other's spaces without intention, gets confused where his room is. Interventions include: approach resident in a calm manner and to calmly que and redirect. R3's Progress Note, dated 4/4/2025 at 2:17 AM, documents the following: Resident very confused. Wants to go back home, goes in others' rooms, got into verbal fight with (previous resident) in room [ROOM NUMBER] because (R3) kept going into the (previous resident's) room. Got into room [ROOM NUMBER], refused to get out of the female resident's room. Hit CNA (Certified Nursing Assistant), kicked me, the nurse. Together 3 CNAs got him into his room. Will keep monitoring.R3's Progress Note, dated 4/4/2025 at 5:13 AM, documents the following: Slept for 90 minutes, still going into other rooms, up and down, monitored behavior.R3's Progress Note, dated 4/7/2025 at 2:39 AM, documents the following: CNA informed this nurse (R3) wandered in another resident room and was attacked by resident. This nurse went in to check on (R3) and he was lying in bed, c/o (complaining of) back and neck pain. This nurse observed bruising and lacerations on his upper back and showers (shoulders). Resident AOx1 (Alert and Oriented to Self) and not able to describe what happened. Resident sent to (local hospital) for evaluation. Bed hold policy and all appropriate documents sent with resident.POA (Power of Attorney) called and informed of incident. MD (Medical Doctor) made aware.R3's Hospital AVS (After Visit Summary), dated 4/7/25, documents R3 was seen in the emergency room due to being an assault victim. R3's Abuse Investigation Final Report, dated 4/7/25, documents the following: A resident-to-resident altercation was reported to the Administrator that took place to between residents R3 and R8 (Former Resident). It was reported that R8 stormed R3 due to him trying to get into his (R8's) room. R8 was seen hitting, kicking, and scratching, R3 with scissors. The residents were immediately separated. R3 was assessed and was found to have scratches and was sent to the local emergency room for further assessment and treatment. He returned the same day with NNO's (no new orders). The scissors were taken from R8, and he was sent to the local hospital for a psychiatric evaluation. Upon his admission to the hospital, he was given an emergency discharge from the facility. R8's state guardian was notified of the decision. The facility MD (medical doctor), POA's, and local police were notified.R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male with Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia. The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.On 8/13/25 at 9:25 AM, V1, Administrator, stated he was not employed by the facility when the altercation between R3 and R8 took place. On 8/13/25 at 9:52 AM, V10, R3's Physician, stated he does not recall the incident between R3 and R8. The Abuse Prevention Policy, dated 9/29/22, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse for these residents.

Based on interview and record review the facility failed to make sure medications were provided and given for 1 of 3 residents, (R2) reviewed for significant medications in the sample of 18. This failure resulted in R2 missing, 9 doses of his Glaucoma medication, which is a significant medication error. Findings Include: R2's Minimum Data Set, (MDS), dated [DATE] documents, R2 is severely cognitively impaired. R2's Care Plan dated, 05/03/23, did not document anything about his Glaucoma, for bedside usage of Glaucoma medications. R2's Physician Order Sheet, (POS), dated 11/08/23, documents, Brimonidine/Timolol 0.2%-0.5% BID, (Twice Daily), may have drops at bedside, for resident to insert. R2's POS dated, 02/19/24, documents, Brimonidine/Timolol 0.2%-0.5%), May have drops at bedside, Pharmacy last filled on 02/03/24. R2's Progress Note, dated 02/19/24, documents, order for eye drops, clarified with Pharmacy. Insurance will pay for eye drops every 18 days. Resident is allowed to keep eye drops at bedside, resident also has Timolol drops and Brimonidine drops, separate for use when the Timolol-Brimonidine mix is not available. Drops, administered to resident, by me personally, resident aware of the procedure for administration, ordering and storage. R2's Medication Error/Discrepancy Report, dated 02/19/24, documents, from 02/17/24 through 02/19/23 Brimonidine/Timolol, eyedrops were empty. Individual drops used, related to combo order not available. Med, (medication), is out, an unable to obtain, (more combination drops), individual was used. Education to nurses and family, 2 eye drops were used VS, (versus), the combo eye, family states, eye drops were out of date, by manufacturer, this was verified as out of date. On 04/02/24 at 10:45AM, V13 [NAME] Specialist stated, We sent the facility Brimonidine/Timolol on February 4th and February 23. On 04/02/24 at 10:50AM, V14 Pharmacist stated, We sent the combo medication of Brimonidine/Timolol on 11/08, 12/05, 01/13, 02/02, 02/21, and 03/31, and we always sent the combo dosages. We did not put that in the convenience box. We only have Atropine in that box. On 04/02/24 at 12:08AM, V2 Director of Nursing, (DON), stated, Well the family insist that he keep it at his bedside. The bottle is good for 18 days. It hit on the weekend. It was a refill too soon. We found two separate bottles not the combination medication. The bottles were sent back with him from the hospital. So that is what we used. We verified that the manufacturer's date, was not outdated even though the bottle had been opened. So, we gave the medication, until after the weekend, where we could order it. We have now made sure, an extra bottle in the Convenience Box. The family insist that he keeps the medication at bedside, but he is not always alert and we feel he should not have it at the bedside. We don't know the bottle was emptied. R2's Medication Administration Records, (MAR), were reviewed for the months of January and February the Brimonidine/Timolol was given in January. R2 missed dosages of this medication on February 15th, AM dose, February 17th, both the AM and PM dosage. February 18th, the AM dose. February 21st, the PM dose and February 26th, the AM dose. R2's MAR for January and February, also documents, may have drops at bedside for resident to insert himself. R2's MAR for the month of March, and R2 missed one dose of Brimonidine/Timolol on 03/04/24. On 04/3/24 at 1:38PM, V16 covering Primary Care Physician stated, in the community people can miss dosages, but it is unacceptable for doses to be missed in a Skilled Nursing facility. On 04/03/24 at 1:00PM, V15 Pharmacist stated, it is a significant medication error.

Based on interview and record review the Facility failed to ensure Physician Orders were being followed and residents were free from any significant medication errors for 1 of 6 residents (R2) reviewed for medication errors in the sample of 24. This failure resulted in R2 not receiving her medications and being hospitalized for six days with a diagnosis of urinary tract infection and urosepsis. Findings include: R2's Physician Order Sheet for February 2024 documents, a diagnosis of thyrotoxicosis; adrenocortical insufficiency; heart failure. R2's POS does not document, any loss of an adrenal gland. R2's POS with a start date of 2/26/2024 documents, hydrocortisone 10 milligrams (mg), once a day. The POS with start date of 7/20/2023 documents, triple dose of hydrocortisone for illness, nausea, abdominal pain or cramping. R2's Minimum Data Set, dated dated dated , 12/22/2023 documents, R2 is cognitively intact for cognition for activities of daily living. The MDS documents, she uses a walker and is independent. R2's Medication Administration Record, (MAR), for January 2024 does not document any order for triple dose of hydrocortisone PRN for illness, nausea, abdominal pain or cramping. R2's MAR for February 2024, does not document, any Physician Orders of triple dose of hydrocortisone was administered to R2. R2's Progress Notes, document, she was in the hospital from 2/1/2024 to 2/5/2024 and 2/17/2024 to 2/22/2024. R2's Progress Notes dated, 2/16/2024 at 9:57 AM, SSD, (Social Service Director), was asked to speak to the resident's daughter, (V6) via phone, to set up a Care Plan Meeting. Writer offered to set up the meeting and (V6) indicated she wanted to talk about her mother's current presentation and the need to send her to the hospital now. Using strength-based validations, SSD attempted to focus on the specific areas that were of concern at this time. (V6) indicated the fall from this morning, and overall decline in functioning without a change in her medications as recommended by the Endocrinologist, have resulted in the request to send the resident to the hospital. SSD continued, the conversation with the resident present and she was in agreement to go to the hospital. SSD will f/u, (follow up), with the floor Nurse to confirm the request to send the resident to the hospital. R2's Endocrinology, Progress Notes dated, 12/20/2023: documents DX; Left 1-adrenalectomy for cortisol producing adrenal nodule 13, January 2023. 2- Secondary Adrenal insufficiency resolved with return of pituitary ACTH production, 3-Primary adrenal insufficiency, 4-Multinodular goiter/hyperthyroidism. (None of these dx are in the POS for the facility). Hospital records, also documents, Triple the dose of hydrocortisone for illness, nausea abdominal pain or cramping. Illness and increase in hydrocortisone will likely require increase in insulin. On 2/29/2024 at 3:09 PM, R2 stated, I got out of the hospital on Monday. I went because two weeks prior I had gone to (Hospital) I remember the Nurse coming in and saying that I had to go to the hospital, and he was telling me my whole face, arms and legs were swollen at that time. I was there for about a week. I came back a couple days and then was sent out again, because the second time I felt really bad and not normal. Aching, hot and cold, body pains, I just felt like I had the flu. All I know is that they almost coded me, then I was in the ICU, (intensive care unit), for a few days. They removed my adrenal glands, because I do not produce cortisol. I am supposed to take hydro cortisol every day. My Endocrinologist called them and sent them a fax that they should increase my dosage and the facility did not increase my cortisol and they are thinking that is why I ended up at the hospital. I just got out of the hospital, and they said I had a bad UTI. I wanted to go to the hospital before a few days night before and called my daughter and said something about the ambulance because they did not think I was bad enough but if she wanted to take me then she could take me to (hospital). Then two days later it was snowing, and I went over to (Hospital) and they said I had a UTI, (urinary tract infection). I have been here since 6/19/2023. I am starting to feel better. On 3/1/2024 at 12:32 PM, V27, Pharmacist stated, I would expect all Physician orders to be followed, all medications to be administrated per Physician orders. All medications should be given per Physician orders. Any medication not given I would say should be given. On 3/1/2024 at 1:13 PM, V23, Physician Internal Medicine Endocrinologist stated, The facility should have been following my orders and (R2) should have been receiving the hydrocortisone due to her medical condition and her issues with her adrenal gland. I would consider this a significant medication error and it could have easily contributed to her having to go out to the hospital and having a urinary tract infection. R2's Hospital Records dated 2/16/2024 documents, Patient has a history of recurrent UTI, (urinary tract infection). Recent admission on 1/30/2024 to 2/5/2024, patient developed UTI and urosepsis. The Facility Physician Order Policy with a revision date July 2014 documents, It is the policy of the (Facility) that physician a orders will be obtained by a licensed personnel and followed. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified.

Based on interview, and record review, the facility failed to supervise a resident that is a high risk fall falls while toileting for 1 of 3 (R7) residents reviewed for falls in the sample of 9. This failure resulted in R7 falling and sustaining a fracture to T12. Findings Include: R7's Face Sheet documents an admitted [DATE]. Diagnosis to include Acute Coronary Thrombosis not resulting in Myocardial Infarction, Vitamin B12 Deficiency Anemia due to intrinsic factor deficiency, Transient ischemic Attack (TIA), and Cerebral Infarction without residual deficits, Weakness, Pain in Left Leg and Hypertension. R7's care plan dated 11/12/2023 documents R7 is new to facility and needs time to acclimate to facility life, favorite act. is playing bingo. Interventions include: Inform R7 of upcoming activities by: provide activity calendar, verbal reminders, encouragement. R7's Minimum Data Set, MDS not yet finalized. R7's fall risk assessment dated [DATE] documents R7 is high risk for falls. R7's Progress Notes dated 11/12/23 documents in part, Resident is A & O (Alert and oriented) x 2/3, verbal & able to make needs known. Resident has L (left) sided weakness due to an old CVA; drop foot noted as well with brace in place. Resident noted to have slurred speech upon admission R7's progress notes dated 11/14/2023 at 4:32 PM by V3 (Licensed Practical Nurse) documents this nurse was called to R7's room. Upon entering room, R7 noted to be on floor in bathroom, next to toilet. R7 stated she fell trying to get to toilet from wheelchair, stating her wheelchair was unlocked. R7 reported hitting right side of head but denied pain. no visible injuries noted by writer upon assessing area. R7 alert/orientated at baseline. Able to move all extremities at baseline. Writer attempted to obtain post fall vitals, R7 refused. Writer educated R7 on importance of using call light system for assistance when needed, and importance of locking wheelchair when ambulating from wheelchair. Understanding verbalized by resident. R7 then requested to go to hospital related to fall. Sent to hospital. R7's progress notes dated 11/17/2023 at 10:23PM document R7 returned from hospital at this time. R7 able to make needs known, speech garbled from previous Cerebral Vascular Accident, CVA. R7 transferred to bed with assist x 2. Denies pain. skin warm dry and intact. Left sided weakness noted. R7's History and Physical dated 11/14/2023 documents, R7 presented to local hospital after sustaining an unwitnessed fall at nursing home. R17 stated that she fell while transferring out of her wheelchair in the restroom. Soon after wards R7 started complaining of left hip and [NAME] pain. Impression of CT scan: Acute appearing fracture of T12 with 25% loss and no retropulsion. Operative findings document T12 kyphoplasty with spine jack 8cc of freshly made bond cement was instilled in T12 vertebral body. On 11/21/2023 at 12:00PM, V2 (Director of Nursing) stated, I think what happened with R7 was inadequate footwear and not locking wheelchair. On 11/21/2023 at 11:10AM, V13 stated, I was the CNA working when R7 fell recently. I had her in the restroom and I was assisting her roommate with something. R7 must've gotten up and she fell to the floor. She had her shoes on. She just got up. On 11/21/2023 at 3:00PM, V3 ( Licensed Practical Nurse) stated, From what I remember that day, (V13) came and got me and R7 was on the floor in the bathroom. (V13) said R7 was in the bathroom and (V13) was helping the roommate. R7 tried to get up and fell . I think she just got impatient and tried to get up herself and fell . On 11/22/2023 at 10:00AM, V15 (Nurse Practitioner) stated, Since R7 was assisted to the restroom, the staff member should've stayed in the restroom and provided supervision. Facility's fall policy dated 7/2017 states It is the policy of (Facility Name) to assess and manage resident falls through preventions, investigation, and implementation and evaluation of interventions.

Based on interview and record review, the facility failed to perform safe transfers for 1 of 10 residents (R86) reviewed for falls in the sample of 45. This failure resulted in R86 sustaining a head laceration that required five staples in the emergency room (ER). Findings include: R86's Face Sheet documents diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypo-osmolality and hyponatremia, nonspecific low blood-pressure reading, dysarthria following cerebral infarction, long term (current) use of anticoagulants, anxiety disorder, and pain. R86's Minimum Data Set (MDS) dated [DATE] documented R86 was moderately cognitively impaired and required limited one-person physical assistance with bed mobility, transfer, and toileting. R86's Care Plan starting 7/22/2022 documents, Resident at risk for falls r/t, (related to), recent RCVA, (right sided stroke). Care Plan revision dated 2/26/23 documents, Requires assistance with Toileting and Potential for bleeding or decrease in blood coagulation R/T use of anticoagulant for blood clot prophylaxis (prophylaxis). R86's Orders printed 7/13/2023 document open ended order dated 12/29/22 for the anticoagulant Eliquis (Apixaban) tablet; 2.5 mg (milligram); 1 tab; oral; twice a day. R86's Fall Risk Assessment Tool dated 5/8/2023 documented resident was at moderate fall risk. R86's Progress Note dated 7/8/2023 at 5:43 AM by V12 (Licensed Practical Nurse/LPN) documents, Resident was heard calling out for help, this writer went into resident's room and observed resident on floor in front of toilet. Resident had blood all over face, this writer assisted resident into wc (wheelchair), after cleaning with NS (Normal Saline), there was a 3-5 (inch), laceration to top of head, resident A&Ox3-4 WNL, (alert and oriented x 3-4 within normal limits), vitals T(Temperature)-97, P(Pulse)-84, BP(Blood Pressure)127/74, R(Respiration)-18, O2(Oxygen)-99% , RA (Room Air), stated, I fell asleep while sitting on the toilet and hit my head on the board on the wall this writer held pressure, site was still actively bleeding when resident left building, resident is on Eliquis, EMS, (Emergency Medical Services), collected resident via ambulance and transferred resident to (Local Hospital). R86's Fall and Investigation dated 7/8/2023 documents, R86 was observed on the bathroom floor in front of the toilet. The fall was not witnessed, and R86 had a laceration to the top of her head. First Aid and pressure to wound were applied before sending R86 to the emergency room , (ER). The intervention was to educate R86 to use call light and request assistance with toileting (R86 is moderately cognitively impaired). R86's After Visit Summary dated 7/8/2023 documents, What You Need to Know: Staples are often used to close a wound. R86's Progress Note dated 7/8/2023 at 12:28 PM by V23 (Licensed Practical Nurse/LPN) documents, Resident returned to facility via car with daughter. Resident arrived with 5 staples located on the top of her head. On 7/13/2023 at 8:15 AM and 1:02 PM, V12 (LPN)) caring for R86 during the shift R86 fell , was unavailable by telephone. V13 (Certified Nursing Aid/CNA), caring for R86 during the shift R86 fell , was employed by a staffing agency, and contact information was not available. On 7/13/2023 at 2:55 PM, V2 (Director of Nursing/DON) stated, (R86) tries to transfer herself at times, but I expect staff to be assisting her with toileting. On 7/13/2023 at 10:37 AM, V17 (Nurse Practitioner/NP) stated that she was informed of R86's fall on 7/8/23. She stated, she would have expected someone to be with her in the bathroom, and if they had been with her the fall probably could have been prevented. The Facility's Falls Management Policy revised July 2017 documents, It is the policy of (Facility) to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. The Facility's Safe Patient Handling Program Policy revised January 2017 documents, Purpose: To identify, assess, and develop strategies to control the risk of injury to residents, nurses and other health care workers associated with lifting, transferring, repositioning, or movement of a resident. All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's Care Plan. All residents will be assessed by the Care Plan team about the need for assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements. All employees shall also receive training at the time of hire, at least annually and retraining whenever necessary. The training provided will emphasize: Resident Transfer criteria including the facility's communication system for transfer status (care plan, transfer assessment, E.H.R. (Electronic Health Record), change in status); Types of approved resident transfers (1 person, 2 person). Restorative/CNAs are responsible to: Using at least as much assistance to transfer residents as the transfer assessment indicates. CNAs may always choose to use more assistance, but never less than the assessment indicates.

Based on observation, interview and record review, the facility failed to implement safety measures for falls for one of three residents (R4) reviewed for falls in the sample of nine. Findings Include: R4's Care Plan, dated 10/23/22 documents, R4 is limited in physical mobility. R4 is unable to independently change position, while in bed as evidenced by not being able to turn, sit up, or move to the head of the bed. R4 is at risk for falls related to mobility. R4's Fall Risk Assessment, dated 10/20/22, documents she is at high risk for falls. R4's Nurses Note from Event Report, dated 10/19/22 at 4:49 PM, documents that resident (R4) had witnessed fall out of bed, V6 (Certified Nursing Assistant/CNA) was changing her, and resident, R4, rolled out of bed and fell to the floor hitting her head. Resident, R4, was sent to a (local hospital), POA (Power of Attorney), and MD (Medical Doctor) was notified. VS (vital signs), prior to leaving 97.8, 93, 18, 132/77, 94%. R4's Nurses Note, from Event Report, dated 10/19/22 11:09 PM, documents Resident, R4, returned from a (local hospital), ER (emergency room ), with 11 sutures in-tact to forehead with bruising noted to both eyes. Resident, R4, transferred to bed with assist x (times) 4. Bed rails up and call light within reach, resident, R4, denies pain at this time. R4's Nurse Practitioner Note, dated 10/20/22, documents patient, R4, was seen today for readmission. Patient, R4, had a fall out of bed on 10/19/2022, that resulted in an ED, (Emergency Department) visit, and 11 sutures into the middle of the forehead. Bruising noted around both eyes. Patient, R4, is alert and awake. Patient states she is having a little bit of pain all over, Tylenol as needed, made nursing aware. Records requested from ED visit. Not available for review at this time. On 11/2/22 at 1:13 PM, R4 refused to be transferred or gotten out of bed. R4 did have bed rails on her bed. On 11/3/22 at 8:32 AM, V6 (CNA) stated, her (R4) bed didn't have bed rails, and she needed cleaning up. I went to turn her, R4, and she kept rolling and rolled off the bed onto the floor. It was a regular bed with a remote. She, R4, was a two-assist, but I tried to do her myself. On 11/3/22 8:40 AM, V7 (Licensed Practical Nurse/LPN) stated, this was a week or two ago. Well, she rolled out of the bed and fell . I had to send her out to the hospital, she hit her head. Her room was recently changed when she came back from the hospital. The rails were on order for her bed. On 11/3/22 1:42 PM, V18 (Nurse Practitioner/NP), stated R4, fell from the bed. It could have been easily prevented with side rails on the bed. She was placed in a new bed without side rails. The policy, entitled Falls Management, dated 7/2017, documents It is the policy of facility to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. The definition of a fall refers to unintentionally coming to rest on the ground, floor, or other lower level.

Based on interview and record review the Facility failed to follow physician's orders for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 15. This failure resulted in R2 having increased urinary incontinent episodes and feelings of embarrassment. Findings include: R2's Physician Order Sheet (POS) dated August 2022 documents a diagnosis of overactive bladder. R2's POS documents on order for [MEDICATION(S)] tablet extended release 24 hours 10 milligrams (mg), once a day for an overactive bladder AM Daily 8:00 AM - 10:00 AM. (7/13/2022 start date, stop date open ended). R2's POS also documents an order for [MEDICATION(S)]-acetaminophen - Schedule II tablet 5-325 mg: a tablet by mouth, Special instructions: Double check dose strength before administration. Three times a day 4:00 AM, 10:00 AM, 10:00 PM. (start date 11/3/2021, end date open ended.) [MEDICATION(S)]-acetaminophen - Schedule II tablet 7.5-325 mg: a tablet by mouth, Special instructions: Double check dose strength. Once a day PM daily 4:00 PM. (start dated 11/3/2021, end dated open ended) and an order for [MEDICATION(S)] tablet 50 mg. amount 50 mg; amount 25 mg by mouth at bedtime 9:00 PM. (start dated 1/21/2022, end date open ended). R2's Minimum Data Set (MDS), dated [DATE], documents R2 was cognitively intact. R2's Care Plan with a problem start date pf 12/30/2019 documents, Category: Urinary Incontinence: (R2) has urinary Incontinence. Approach: Administer medication per Medical Doctor Order. Monitor for improvement in continence. On 8/18/2022 at 11:03 AM, R2 stated, I have not had all my [MEDICATION(S)] medication and pain medication. I was supposed to get 10 milligrams (mg) of the [MEDICATION(S)] this morning and I did not get it. Now, I know the state was in the building and you would think that maybe that would motivate them to get my medication. I do not understand this at all. I have an overactive bladder and the medication helps me. I notice that when I do not get my medicine, I have more accidents. I have been running out of medications for the last three months off and on. I tell staff but nothing changes. I talked with V2 (Director of Nursing/DON)) and she said she would look into it, but I am still having issues with my medication. I am thankful it is a pill that if I miss, I will not die. Because, then I would really be in trouble. I do not think it is right that they are not making sure I get the medicine I need. They do not have enough staff here and because of my medication I have more accidents and I have been left sitting in urine for hours at a time. It happened again two nights ago. I put my call light on and waited for over an hour finally one of those student nursing assistants came into my room and I asked her if she could put me on the bed pan and she said she was helping down the hall because (R14) had fallen. Now, I am a reasonable woman so if (R14) fell I understand that is priority. But then she left and never came back or told anybody that I needed to go to the bathroom. I waited so long that the next shift finally helped me and cleaned me up. It was not a good day for me. I was cold and sitting in urine for hours. I do not understand this at all. I have an overactive bladder and the medication helps me. I notice that when I do not get my medicine, I have more accidents and I get embarrassed. Nobody wants to wet their pants. I have been running out of medications for the last three months off and on. I tell staff but nothing changes. I talked with V2 (DON) and V9 (Ombudsman) she said she would look into it, but I am still having issues with my medication. I am thankful it is a pill that if I miss, I will not die. Because, then I would really be in trouble. I do not think it is right that they are not making sure I get the medicine I need. I have talked with V9 about it as well. It is like they don't care if I pee myself when this medicine helps me not to have accidents. Plus, I really don't want to get a urinary tract infection either. R2's Medication Administration Record (MAR) dated 8/1/2022 to 8/17/2022 document R2 did not receive her [MEDICATION(S)] tablet extended release 24 hours 10 milligrams (mg) tablet on 8/13/2022, 8/15/2022, 8/16/2022 and 8/17/2022 at 10:00 AM. R2's MAR dated 7/1/2022 to 7/31/2022 document R2 did not receive her [MEDICATION(S)] capsule, extended release 24 hours, 4 mg tablet for her overactive bladder on 7/5/2022, 7/8/2022, 7/10/2022, 7/11/2022, 7/12/2022 and 7/13/2022 at 10:00 AM. R2's MAR dated 7/1/2022 to 7/31/2022 document R2 did not receive her trazadone 50 mg tablet on 7/8/2022, 7/9/2022, 7/10/2022 and 7/31/2022 at 9:00 PM. R2's Progress Notes dated 5/11/2022 at 2:23 PM, Resident voiced complaining of her narcotics running out and not being filled. I notified (MD) Medical Doctor on 5/10 of new order needed. MD stated she will write it and bring on 5/11. Resident ran out of oxy 5.325 last night, resident stated pain at a 7. Got RX (prescription) from MD faxed to pharmacy, I called the pharmacy to have them Erun the medication. Received at 12:05 PM, gave to resident. Resident pain is decreasing. MD added new order for cranberry tab daily, resident aware. Will continue to monitor. R2's Progress Notes does not address any of her missed medication in July and or August of 2022. On 8/18/2022 at 10:49 AM, V6 (Licensed Practical Nurse/LPN) stated, I am an agency nurse. When I went to pass out medications today R2 did not have all of our medications in the cart. I was not able to give her all of her medications because the medications were not in the medication cart. I am not sure if it was ordered, when it was ordered. I do know and could not say. I did not give the medication because it was not in the cart. On 8/18/2022 at 11:29 AM, V7 (Pharmacist) stated, We sent the [MEDICATION(S)] tablet extended release 24 hours 10 milligrams (mg) on 8/16/2022. I am reviewing my records and I see that we received the order, filled the order and sent the medication to the facility. Once the medication leaves the facility it should be at the facility, and I never received any phone calls telling me they were missing any medication for R2. I am not sure why R2 did not get her medications. My records show that the medication was sent. This medication is for an overactive bladder and if she does not get this medication, it could keep her from having urinary accidents, give her headaches, and fatigue if it was abruptly stopped. The [MEDICATION(S)] medication was a once-a-month supply and it was sent to the facility on [DATE]. Again, it is similar to the other medication as far as if she would not get it, she could have urinary incontinent episodes, headaches and fatigue. I am showing the [MEDICATION(S)] was sent to the facility as well. Whatever is happening with R2's medication, it is not from the pharmacy side. On 8/18/2022 at 1:09 PM, V2 (DON) stated, I am not sure why R2 has not been getting her medication. I had them get her medicine today from the Emergency kit. The pharmacy said they sent the medication on 8/16/2022 but we have not been able to locate it. I was not aware there were any issues with R2's medication before today. I know there were some issues with her insurance. On 8/18/2022 at 1:44 PM, V9 (Ombudsman) stated, I have talked with V1 (Administrator), V2 (DON) and on several occasions regarding (R2's) medications not being available for her. This has been going on for several months. They tell me they will look into and/or there are insurance issues, but it still keeps happening every month. They say they will look into it but then it continues to happen. R2 is concerned because without the medicine she has accidents, and the medicine helps her to avoid accidents. It upsets her when she has accidents and this medicine helps her but the facility is always running out of her medicine and not making sure it is available for her. This has been going on for at least three months. On 8/18/2022 at 2:35 PM, V3 (Nurse Manager) stated, I know R2 had some issues with her trazadone because of insurance issues but we took care of that quite quickly. I called pharmacy today and they told me they sent out R2's medication on 8/16/2022. I looked at the packet and somebody signed for the medication, but I can't find the medication. I know it is important to R2 and the medicine helps her with her incontinence. We just can't find the medication and the [MEDICATION(S)] is missing. I don't know what happened to it. I know I have been taking it out of the E Kit, but we no longer have the [MEDICATION(S)] in our E kit now. We are looking into it. On 8/18/2022 at 3:07 PM, V2 stated, I do not have any other policy regarding medication administration and or what staff should do if the medication is not available. The General Dose Preparation and Medication Administration Policy dated 12/7/2007 documents, This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medication. The Administration Medication Policy with a revision date of December 2012 documents, Medications shall be administrated in a safe and timely manner, and as prescribed. Medications must be administrated in accordance with the orders, including any required time frame. Medication must be administered within one hour of the prescribed times, unless otherwise specified.

Based on observation, interview and record review, the facility failed to assess and monitor residents that are high risk for skin breakdown. The facility failed to monitor turning, repositioning and provide effective pressure relieving interventions, to prevent the formation of pressure ulcers for 3 of 8 residents (R61, R199, R298) reviewed for pressure ulcers in the sample of 52. This failure resulted in R199, developing a large, necrotic unstageable pressure ulcer to the left buttock and a large unstageable deep tissue injury to the right heel. Findings include: 1. R199's, physician's orders [REDACTED]. The comprehensive Minimum Data Set (MDS), dated [DATE], documents, R199, is; moderately impaired with cognition and decision making, requires extensive assistance with bed mobility and personal hygiene, and is incontinent of bowel and bladder. The MDS documents, R199, is at risk for skin breakdown. The Progress Notes, documents, R199, was admitted to the facility on [DATE], at 2:43 PM. The Progress Note dated 7/12/2019, at 1:36 PM, documents, R199, had a skin check at that time. The Progress Note documents, in part, no necrotic or open areas, left heel boggy but blanchable redness, will place order for (protective skin wipe) and podiatry consult per MD, (medical doctor), no open areas to the coccyx, barrier cream provided for protection. A physician's orders [REDACTED]. The facility's Wound Log, dated 3/01 to 9/01/19 documents R199 developed a facility acquired, unstageable, DTPI (deep tissue pressure injury) to the coccyx measuring 1.5 cm (centimeter) X 2.0 cm and an unstageable callous to the left heel on 8/06/2019, measuring 0.4 cm X 0.2 cm. The Wound Log has no date documented when R199 developed the DTPI to the coccyx. On 9/05/19 at 9:12 AM, R199 was in bed on his back, asleep with his legs drawn up and heels directly on the mattress. There were no pressure relieving boots or protectors on his feet. R199 was wearing gripper socks. There was a pressure relieving cushion in his wheel chair. The head of his bed was raised slightly, placing pressure to the coccyx area. On 9/06/19 at 10:42 AM, R199 was in bed on his back with the head of his bed raised 30 degrees. At that time, R199 reported he has a wound on his tailbone that has a dressing and one on his right heel. R199's heels were directly on the mattress. He had a dressing to the right heel and was wearing gripper socks on both feet. R199 complained of pain to his buttocks. On 9/06/19 at 11:02 AM R199 had both heels directly on the mattress. V6, Registered Nurse, (RN)entered the room. V6, RN removed the right sock and old dressing to the right heel that was dated 9/5/19. R199 had an open area to the outer right heel, with a small amount of serosanguinous drainage on the dressing. V6 cleansed the heel with normal saline (NS), applied hydrogel ointment and a new dressing. V6 removed the sock to the left foot. There was an unstageable, purple deep tissue injury (DTI) to left heel. There was no odor to either heel. V6 removed the dressing to the left buttock/coccyx area. There was a large unstageable pressure ulcer, with slough and necrosis. V6 reported a wound culture had been recently obtained of the area. V6 reported the open area looked better than it had the previous day. R199's wheelchair had a pressure relieving cushion, but had a nonskid pad on top of it, with a folded incontinent pad on the top of the nonskid pad reducing the pressure relief of cushion. On 9/06/19 at 1:16 PM, V13, Certified Nurse's Aide (CNA) stated to R199, We have to turn you to get you off your bottom. R199 was repositioned on the left side with a pillow placed behind his back. On 9/06/19 at 1:35 PM a pillow was placed between R199's knees, and a pillow was placed under the left outer ankle. V13 floated R199's heels on a pillow as well. R199 was wearing the same gripper socks. On 9/10/19 at 11:36 AM, R199 was in bed on his back with both heels directly on the mattress. He was wearing only gripper socks. He was confused. There was no low air loss (LAL) mattress. R199's heels not floated. On 9/10/19 at 12:47 PM Resident # 199 Per SWM report from V8, FNP' dated 9/9/19 Left buttock pressure ulcer, 4X4 depth undetermined, 100% necrotic, depth obscured, with a moderate amount of exudate. LAL mattress ordered today. On 9/10/19 at 1:24 PM, R199 was on his right side with LAL mattress in place. His heels were directly on mattress with gripper socks on. The Progress Note, dated 8/4/2019 at 1:59 PM documents, noted open area to right heel. No measurements are documented. There is no documentation V16, Physician was notified. There is no PO for this date in R199's POS. There is a PO dated 8/05/2019 that documents, cleanse right lateral heel with NS and apply hydrogel, 4X4 and wrap with (elastic gauze wrap). The Wound History Report for R199 dated as first evaluated on 8/6/2019, documents R119 has the right heel is open, measuring 1.8 X 1.5 X 0.2 cm, facility acquired, pressure ulcer. There is no documentation of staging the area on the Report. The Wound History Report for R199 dated 9/6/2019 documents the pressure ulcer to the right heel measures 0.5 X 1.0 X 0.1 cm, which is some improvement. The Progress Note for R199, dated 8/15/2019 at 3:31 AM documents, noted small red area to right inner buttocks, not open at present, barrier cream applied. There are no measurements of the area documented. There is no documentation a physician was notified. There is no PO for that date related to the right inner buttocks. The Wound History Report for R199, dated 8/29/2019, documents an open area to the coccyx, measuring 1.5 X 2.0 cm, unstageable, DTPI with induration, with necrotic eschar (dead infectious tissue) with no odor. The next Wound History Report for R199, dated 9/06/2019 documented R199 has an open, DTPI, with moderate exudate measuring 4.5 X 4.5 cm, with undetermined depth. The Progress Note, dated 8/27/2019, documents, (R199) found to have DTI to coccyx with induration. DTI is 1.5 (cm) X 2.0 (cm) and blue in color. Induration is 4X4 and surrounds the DTI. MD notified. Barrier cream ordered to cover the area. A PO for R199 dated 8/27/2019 documents, Barrier cream to buttock, coccyx and peri (perineal) area daily per shift and PRN (as needed). The Wound History Report, dated 8/06/2019, for R199 documents a facility acquired, left heel open area, measuring 0.5 X 2.0 X UTD (undetermined) depth with necrotic eschar. Type of wound: other-callous. There is no Progress Note dated 8/06/19 to address the open left heel. The Progress Note dated 8/31/19 at 11:47 AM, documents, Has dark area to bottom of left heel. This nurse applied (protective barrier wipe) to the area. A Progress Note, dated 9/4/19 at 3:17 PM, documents V21, Physician ordered a special wound consult. The Progress Note documents, in part, Has new small 0.5 X 0.5 X 0.1 cm open area to right coccyx. Treatment ordered for barrier cream. Right coccyx is now bright red and continues to have blue spot with induration around the blue spot. Will continue to treat areas with barrier cream and incontinence care. Awaiting orders from (V21, Physician). The Progress Note dated 9/06/19 at 6:22 AM documents new dressing to area to left buttock as ordered. Continues with purulent drainage moderate amount. Initiated ATB (antibiotic), resident has been T/P (Turned and repositioned) every 2 hours as resident will allow. Expresses pain when area touched. The special wound consultant Report for R199, completed by V8, Nurse Practitioner on 9/09/2019 documents, in part, Left buttock pressure ulcer, noted on 8/27. Unstageable, depth obscured, 100% (percent) necrotic 4 X 4 X UTD, exudate moderate amount, color-serosanguinous. LAL (low air loss) ordered today, nursing is repositioning every 2 hours and providing incontinence care. On 9/11/2019 at 1:51 PM, V21, stated, The area to the sacrum (left buttock/sacral area) started out as a Stage I, small pressure wound, that is now infected. When it opened it became infected. I didn't know he was incontinent. He (R199) did not progress with therapy, and now is on custodial status as of 8/31/2019. V21 reported he was aware of the purple area to the left heel. V21 reported the facility should have been offloading R199's buttocks and feet to prevent pressure ulcers. The Report had no documentation related to R199's heels at all. V21's Progress Note, dated 8/27/2019 documents R199 has a Stage 2 pressure ulcer to the right buttock, and a Stage 2 pressure ulcer to the right heel. V21's Progress Note, dated 9/06/2019 documents, in part that R199 has decubitus ulcer of the coccygeal region, unspecified ulcer stage. (R199) has been having worsening wound to buttock, late last week there was some induration and was started on topical mupirocin (topical antibiotic ointment). Yesterday it broke open with large amount of purulent drainage. This was cultured and started on [MEDICATION NAME] (oral antibiotic). R199's laboratory/wound culture of the coccyx, dated as collected 9/5/19 and result reported 9/09/2019 documents the open area contained a heavy growth of the bacteria, Escherichia coli. The culture report does not identify and document if bacteria is sensitive to [MEDICATION NAME]. R199's Care Plan, revised 8/6/2019 documents he is at risk for skin breakdown due to weakness and decreased mobility. 8/6/2019 0.5 X1.0 X 0.1 right heel callous opened, treatment in place. The pressure ulcer of the coccygeal area and the left heel is not documented in R199's Care Plan. R199's laboratory report dated 8/27/19 documents a level of Protein-6.7 g/dL (grams per deciliter) (normal=6/4-8.9), Serum [MEDICATION NAME]-3.3 g/dL (normal=3.5-5.7). The Report dated 9/5/19 documents Protein 5.4(normal-6.4-8/9), Serum [MEDICATION NAME] 2.6 (3.5-5.7). R199's Treatment Administration Records (TAR) for 7/19, 8/19 and 9/19 documents weekly skin checks are completed but does not address the results. 2. R298's MDS, dated [DATE] documents he was admitted to the facility on [DATE] and has moderate impairment with cognition, requires extensive assistance with bed mobility, transfers, personal hygiene, with a limited range of motion to one lower extremity. The MDS documents R298 is at risk for pressure ulcers and had none on admission. R298's POS for 8/10 through 9/10/2019 documents diagnose, in part, as Aftercare following joint replacement surgery, displaced fracture of base of neck of left femur (leg), and muscle weakness. On 9/05/19 at 10:29 AM, R298 had both feet on pillow, but his heels were not floated. R298 was moving the right leg in bed. R298 was on his back. On 9/06/19 at 11:19 AM, R298 remained in bed on his back. V6, RN entered the room for a skin check. R298's heels were directly on the mattress. There was a very large, dark purple DTI to R298's left heel. V6 reported it was new. R298 reported pain to his left leg. V6 stated, I will call the doctor and get a treatment for [REDACTED]. V6 did not measure the dark purple area to the left heel. On 09/10/19 at 11:40 AM, R298 was in his room in a wheelchair, asleep. There was no LAL mattress on the bed. A foam heel protector on his bed. On 9/10/19 at 1:27 PM, R298 was in bed with HOB (head of bed) raised 30 degrees. His left foot has foam protective boot, but the right heel was directly on the mattress. R298's Progress Note, dated 9/6/19 at 11:44 AM, documents Purple area to left heel. A PO for 298 dated 9/6/2019 documents, Cleanse left heel with NS and apply skin prep daily and PRN, Float heels when in bed. Multi-podus boots to left foot when OOB (out of bed). R298's Care Plan, dated as revised 9/06/2019 documents, in part, Is at risk for skin breakdown related impaired mobility and muscle weakness. 9/6/9-left heel purple area 3.0 X 3.0 cm. There is no intervention in the care plan that addresses a turning or repositioning schedule or interventions related to R298's heels. On 9/11/2019, V2, Director of Nursing (DON) reported the facility does not complete the Wound Healing Tracking form as outlined in their policy and procedure for pressure ulcer prevention and treatment. V2 stated, We do all these things that are listed for the Wound Healing Tracking form, but I can't find any filled out for the residents with a pressure ulcer. On 9/11/2019 at 1:31 PM, V16, Physician reported she would expect the facility to provide pressure relieving interventions for her residents who are a risk for skin breakdown. V16 stated, Turning and repositioning every 2 hours, LAL mattress, nutritional assessment with interventions. For the feet, the same thing; relieving pressure points to the skin, feet, heels. V16 reported she was aware of the issue with R298's heel but could not remember which one. 2. R61's Admitting [DIAGNOSES REDACTED]. Unstageable Pressure Ulcer left heel. Currently has a stage 3 pressure ulcer to right outer ankle, acquired in the facility. R61 admission MDS (Comprehensive Assessment) dated 2/6/2019, documents R61 has moderately impaired cognitive status, requires extensive assistance of two-persons for bed mobility. The MDS documents R61 has functional limitation to range of motion affecting his upper and lower extremities and had two unstageable pressure ulcers, and only one of these pressure ulcers present on admission/entry or reentry. The MDS documents R61 is at risk for pressure ulcer development. R61's Braden Scale for Predicting Pressure Score Risk Assessments dated 1/25/2019 documents he is a moderate risk for skin breakdown, R61's Braden Scale dated 4/01/2019 documents he is now a high risk for pressure ulcer development. R61's Care Plan revised 9/01/2019 documents on 1/28/2019., R61 was admitted with unstageable pressure injury to the left heel and a DTPI to the right heel. Wound treatments in place. SWM to follow weekly 3/11/2019 right heel resolved. 3/18/2019 left shin abrasion 6.0 x 0.5 x 0.1 shin resolved. 3/29/2019 DTI right lateral lower leg, right ankle. 8/24/2019 left lower extremity abrasion, 12.5 x 2.0x 0.2, treatment in place. 9/1/2019 left heel r/t DTI 2.5 x 2.5 x 0.3, continues to see SWM. Approach documents low air loss mattress. 2/18/2019, low air loss mattress dc (discontinue), resident complains that he does not like the mattress, resident will have pressure relieving mattress. Turn and reposition at least every two hours dated 1/31/2019. R61's Blood chemistry dated 1/28/2019 documents, Total Protein level 6.9 (normal range is 6.4-8.9) Serum [MEDICATION NAME] 3.1 (normal range is 3.5 to 5.7, and Glucose 225 (normal range 70-105). R 61's Registered Dietician consultation dated 3/18/2019 documents appetite is good eating 75% to 100% of meals, weight is up 7 lbs. Continue supplement with liquid protein 1 ounce three times a day. R61's Progress Note dated 3/29/2019 11:33 AM, noted purple area to R lateral ankle measuring 1.5 x 1.5 x utd (unable to determine), 100% purple area to R lateral lower leg measuring 1.0 x 0.5 x utd 100% purple. The Facility Wound report documented 4/1/2019 reports wound location right ankle, stage is (DPTI) Deep Tissue Pressure Injury measures length of 1.5 x 1.5 x Unable to determine depth. Necrotic/Eschar and Facility Acquired. Specialized Wound Management consulting treatment. The facility wound report documented 9/09/2019 reports right ankle pressure wound, stage 3, length 0.5 x width 0.5 x depth unable to determine. Tissue type is Necrotic/Eschar. Facility's policy and procedure titled, Wound Management Program, revision dated of (MONTH) (YEAR), documents in part, Policy: It is the policy of Helia Healthcare to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions. Procedure: 1. The facility is provided with Wound Care Protocols. These are to be utilized to assist in the care and treatment of [REDACTED]. The facility will use the Braden Scale or the Norton Plus Pressure Ulcer Scale (NUR1210a) on each resident at admission, weekly for four weeks post admission and readmission, and quarterly thereafter to assess skin breakdown risk: 3. Residents identified at risk on the Braden or Norton scale will have this addressed on their care plan and will have interventions put in place for preventative measures. Interventions: pressure reducing mattress and/or cushion, be review by a dietician and lab values as needed. Resident's identified with wounds will have a care plan initiated regarding impaired skin integrity. 4. b The skin assessment will be documented on the Weekly Skin Assessment (NUR1220a) which is completed as follows: 4. c If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it, Skin Tear Protocol (NUR1225) or New Skin Condition Protocol (NUR1230). 5. The Weekly Skin Assessment (NUR1220a) should also be completed whenever a new skin condition is noted. 9. It is the responsibility of the Administrator to review the Pressure Wound Report and Non-Pressure Injury Report Weekly. The Facility Protocol, titled, New Skin Condition Protocol, Revised (MONTH) 2014, for Helia Healthcare, documents in part the following, When you discover a new skin condition; reddened area, etc., complete a Weekly Skin Assessment (NUR1220a) and document the new area on the 24-Hour Report (NUR140aO and in the nursing notes. You also need to update the Braden Scale in the chart and document every new wound in the wound book for the Wound Nurse to assess. The nurse responsible for treatments will assess the area, measure it and obtain the appropriate treatment order. This protocol is designed to protect the area until such assessment is completed.

Based on observation, interview and record review the facility failed to safely transfer 1 of 8 (R51) residents reviewed for accidents/hazards/falls in the sample of 52. This failure resulted in R51 requiring hospitalization at a local hospital for a [MEDICAL CONDITION] upper leg. Findings include: R51's Minimum Data Set ((MDS) dated [DATE] documented R51 is an extensive assistance of two plus staff person for transfers. And R51 is only able to stabilize with staff assistance when moving from seat to standing, moving on and off the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair) Per Illinois Department of Public Health, Serious Injury Incident Report, dated 12/11/18 at 06:00 AM, documents under Incident Category: Other; and next to other it is blank. In that same document, under Detail Incident Summary: R1 was transferring with Certified Nurse Assistance (CNA) assist from bed to wheelchair. While transferring the CNA heard a pop. No pain upon assessment by the nurse. Observation of slight external rotation. In house x-ray ordered. It goes on to state in the final report of that document, Resident has a history of a previous right [MEDICAL CONDITION] which occurred on 3/2013 and that this x-ray confirmed a [MEDICAL CONDITION] distal shaft of the right femur. There is no documenting of another CNA assisting with this transfer. R51's Progress Note, dated 12/11/18 at 6:22 AM documents, CNA (certified nurse's assistant) reports that while transferring resident from bed to wheelchair CNA heard a pop. Resident appears to have an indentation of femur above the knee and some external rotation of foot. Medical doctor made aware. Order received for X-ray. Doctor contacted and made aware. Director of Nurse (DON) sent message via text and cp voicemail. There is no documenting of another CNA assisting with this transfer. Per 12/11/18 Written Hand Statement at 6:15 AM, V7 (CNA), documented, On (MONTH) 11, (YEAR) at about 6:15 am, I was preparing (R51) for breakfast. I changed her brief and I put on her bottoms. I went to try and transfer (R51) from the bed to the chair. In the process of me transferring (R51), her leg twisted and I hear a pop. I immediately put her in the chair to check and see if maybe the brief had unsnapped or ripped. Its further documents, I tried to scoot her leg, it is looking weird to me. It was just dangling. I than hurried and told the nurse for that hall. There is no documenting of another CNA assisting with this transfer. On 09/10/19 at 11:30 AM, V7 (CNA), stated that R51 can be combative with care. However, this time she wasn't and when she was transferring R51 from the bed to the wheelchair, she heard a pop so, she sat R51 back onto the bed and called for the nurse. V7 stated that V20, CNA assisted her with the transfer. On 9/10/19 at 2:10 PM, call placed to V20. No answer. Left message on voicemail. On 9/10/19 at 3:40 PM, V15, Licensed Practical Nurse (LPN) stated that she was not sure how many CNA's where in R51's room. On 9/11/19 at 11:00 AM, V2 Director of Nurses (DON) stated that she would expect the staff, if ordered, to use 2 or more staff persons for assist with transfer. V2 also stated that they talked to V7 regarding V20 assisting her with R51, but somehow it didn't add up. R51's Progress Notes, dated 12/15/2018 at 05:57 PM documents (A call) from local hospital sending resident back had surgical repair to right distal femur. Resident is toe touch weight bearing. Sutures intact, has follow-up date removal. in part. On 9/11/19 at 1:35 PM V16, Attending Physician, stated that she could not say if fracture was from, without looking at her supporting documents. She would have to look at her clinical records, in which she does not have access to at this time. The facility Gait Belt Use policy and procedure dated July/2014 documents, Policy: It is the policy of Helia Heathcare that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee. Procedure: #7 Request the assistance from a coworker if necessary

Based on observation, interview and record review the facility failed to implement safe eating interventions for one of three residents (R2) reviewed for safety with eating in the sample of 3. This failure resulted in R2 sustaining second [MEDICAL CONDITION] her left and right inner thighs. Findings include: R2's Progress Note, dated 12/27/18 at 6:34 PM, documents R2 spilled coffee on herself at dinner time, and redness was noted to her left and right inner thighs. The Progress Note also documents, medical doctor made aware, and a new order was given to monitor every shift until resolved. The progress note also documents if the skin breaks down notify the medical doctor and consult wound management. R2's Event Report, dated 01/03/19, for event on 12/28/18 at 7:13 AM documents R2 spilled coffee on herself at dinner last night Physician and family notified at that time, treatment in place. The event report documents interventions implemented as staff will offer resident a cup with a lid. R2's Progress Note, dated 12/27/18 at 6:56 PM, documents a nail size blister to right inner thigh, and V7, Physician, ordered skin prep twice daily and a non adhesive dressing until resolved. R2's Wound Report, dated 12/27/18, documents R2's left inner thigh burn measures 6 centimeters (cm) x 1.5 cm, and her right inner thigh burn measures 5 cm x 6.5 cm x 0.1 cm. R2's Physician order [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a Brief Interview for Mental Status (BIMS) score of 12, which represents moderate cognitive impairment. R2's MDS also documents R2 needs supervision, oversight, encouragement or cueing, and set up for eating. R2's Care Plan, dated 12/28/18, documents the problem as R2 has episodes of shakiness and she can not hold full cups causing her to spill them on herself at times. The Goal documents R2 will not burn herself with hot liquids due to inability to hold her cup. The approach documents R2 will use a cup with two handles or a lid or both for all hot liquids at minimum, as she does not like the idea of a special cup. On 01/03/19 at 11:02 AM, V3, Licensed Practical Nurse (LPN), entered the R2's room and asked R2 to look at her dressings. R2 had one dime size area that was dark red surrounded by a larger area half dollar size that was red on her right inner thigh. R2's left inner thigh had three dime size areas to her left inner thigh that are surrounded by a half dollar size reddened area. A full cup of coffee in a regular coffee mug and an empty regular coffee mug were on R2's bedside table. The mugs were not adaptive equipment with lids or 2 handles. On 01/03/19 at 11:05 AM, R2 stated, I spilled coffee on myself. Sometimes, I shake a lot. At that same time, V3 also said R2 does shake sometimes when she tries to hold drinks. On 01/03/18 at 12:00 PM V9, R2's Power of Attorney (POA), stated, (R2) was shaky before Christmas, and (V10, Certified Nurses Aide, CNA) told me they would put a sippy cup on (R2's) Christmas list. (R2) did get a sippy cup for Christmas, but they didn't use it for my mom. In an interview on 01/04/19 at 10:20 AM, V11, LPN, stated, During dinner, (V4, CNA) came and got me and told me she (R2) spilled coffee on herself (in her room). I looked at her legs and they were both red. I called (V8, Physician), and she said monitor her legs until resolved, if skin breaks down occurs call her back. When the kitchen delivers the meals (for the hall trays), they also deliver a drink cart. The coffee came off the drink cart. On 01/03/19 at 1:15 PM, V4, CNA, stated, She (R2) shakes a little. In a second interview on 01/04/19 at 10:35 AM, V4 stated, (R2) loves coffee, and she asked me for a cup of coffee. (R2) always eats in her room. I went and got her a cup of coffee. I went to the dining room, and was told she spilled coffee on herself by another aide. I cleaned her up. The nurse was notified. She seemed ok, when I gave her the coffee. We go back and forth to check on the residents eating. https://www.webmd.com documents, Second-[MEDICAL CONDITION](partial thickness burns) affect the epidermis and the dermis (lower layer of skin). They cause pain, redness, swelling, and blistering.

Based on observation, interview, and record review, the facility failed to assess and monitor the formation of pressure ulcers for 1 of 7 residents (R104) reviewed for pressure ulcers in the sample of 55. This failure resulted in R104 developing four unstageable pressure ulcers. Finding includes: On 8/24/18 at 8:15 AM, V9, Licensed Practical Nurse (LPN) completed R104's pressure ulcer treatment. V9 removed the undated dressing to R104's center back revealing a pressure ulcer with a yellow colored center with red edges, and no drainage. V9 cleaned the pressure ulcer with normal saline, applied Santyl and border gauze, dated and initialed the dressing. V9 then removed a dated dressing to R104's coccyx, cleaned the area with normal saline, and applied Santyl, and covered it with a clean, dated, and initialed dressing. V9 was preparing to apply skin prep to R104's left heel, when it was brought to V9's attention that there was an open area to R104's left heel. V9 assessed the left heel, but failed to see the open area. V9 did not apply the skin prep. V9 then removed the right heel dressing, revealing a red, raw, open pressure ulcer. V9 applied hydrogel gauze and border gauze. V9 stated that she would hold the skin prep to the left heel and notify the physician for new orders, since the area was open. The facility wound report, Wound Type: Pressure, dated 07/28/2018 - 08/04/2018 and 08/04/2018 - 08/11/2018 does not document R104 on the report. The facility wound report, Wound Type: Pressure, dated 08/12/2018 - 08/18/2018 documents R104 's pressure ulcer to the right heel, first observed on 8/16/18, measured 4.5 centimeters (cm) in length, 4.0 cm in width, and unable to determine depth of the wound. R104 also has a documented pressure ulcer to her coccyx, first observed on 8/16/18, measures 5.5 cm in length, 1.0 cm in width, no documented measurement for depth, and staged unstageable. No other wounds were documented on this report. The facility's undated Wound Information report documents an open wound to the coccyx and the right heel, evaluated on 08/16/2018 and first observed on 08/16/2018. Both are documented as facility acquired. The coccyx pressure ulcer measured 5.5 centimeters (cm) by 1.0 and was unstageable. The Report documented the right heel pressure ulcer measured 4.5 cm by 4.0 cm unable to determine depth in cm (UTD cm), and is unstageable. The facility's undated Wound Information report documented an opened pressure ulcer to the coccyx, the right heel, and midback. The coccyx wound measured 5.5cm by 1.1cm and was unstageable. The Report documented R104's right heel pressure ulcer measures 3.1cm by 5.5cm and was unstageable. The Report documented R104's midback pressure ulcer was observed on 08/21/2018, and measured 3.5 cm by 1.7 cm and was unstageable. The Report documented this pressure ulcer was facility acquired. The facility's undated Wound Information report documented R104 had a pressure ulcer to the left heel, evaluated on 08/24/2018 and first observed on 08/24/2018, measures 0.3 cm by 0.3 cm with depth undetermined and unstageable, and is facility acquired. R104's Electronic Physician order [REDACTED]. R104's Face Sheet documents R104 was admitted to the facility on [DATE] at 02:04 PM. R104's Minimum Data Set ((MDS) dated [DATE] document R104's Brief Interview Mental Status (BIMS) of a score of 12 out of 15 (cognitively intact). R104's Care Plan with a start date of 08/15/2018 documents in part, Resident has the potential for skin failure areas related to immobility and incontinence. Noted pressure area to Right heel with eschar present, Left heel soft, coccyx reddened, on admission, also buttocks reddened. 8/16/18 noted open area to coccyx. 8/21/18 noted Deep tissues injury to Right heel eschar off, open pressure area to mid [MEDICATION NAME] region, and red area to Right medial foot. Treatment per Medical Doctor (MD) order. On 08/23/18 at 10:15 AM, R104 states My feet are really bothering me today. My heels are really hurting me. On 08/21/2018 from 9:42 AM - 11:42 AM, R104 was sitting in her wheelchair with 2 pressure relieving boots on each foot. Both of R104's feet were on the pedals of the wheelchair directly with the boots. R104 is turned and positioned exactly at 11:42 AM (2 hours). On 08/23/2018 at 1:16 PM, R104 stated, Both of my heels are really bothering me. On 08/24/2018 at 2:24 PM, V23, Physician stated, Yes, due to (R104's) [DIAGNOSES REDACTED]. The number one thing the facility can be doing for (R104's) pressure ulcers is turning and repositioning less and 2 hours is too much time for her. The Pressure Ulcer Policy dated (MONTH) (YEAR) document in part, It is the policy of the (Facility) to manage resident skin integrity through prevention, assessment, and implementation and evaluation of intervention. 3. Resident identified as risk on the Braden or Norton scale will have this addressed on their care plan and will have interventions put in place for preventive measure. 9. It is the responsibility of the Administrator to review the Pressure Wound Report and Non Pressure Injury Report weekly.

Based on observation, interview and record review the facility failed to assess/monitor and treat pain during treatments for 2 of 4 residents (R104 and R328) reviewed for pain in the sample of 55. This failure resulted in R104 and R328 calling out in extreme physical and emotional pain during treatments without staff intervention. Findings include: 1. R104's Electronic Physician order [REDACTED]. R104's Face Sheet documents R107 was admitted to the facility on [DATE] at 02:04 PM. R104's Minimum Data Set ((MDS) dated [DATE] document R104's Brief Interview Mental Status (BIMS) of a score of 12 out of 15 (cognitively intact). R104's Care Plan with a Start Date of 08/15/2018 documents in part, Resident has potential for pain related to decreased mobility, and history of [MEDICAL CONDITION]. Resident has medications per Medical Doctor Order for pain relief if needed. On 08/23/18 at 10:15 AM, R104 stated My feet are really bothering me today. My heels are really hurting me. On 08/23/2018 at 1:16 PM, R104 stated, Both of my heels are really bothering me. R104's Electronic Physician order [REDACTED]. On 08/23/2018 at 9:50 AM, V10, Licensed Practical Nurse (LPN) stated, (R104) does not take any kind of pain medicine. On 08/23/18 at 1:20 PM V10 begins to remove the old dressing from R104's foot and R104 begins to scream. V10 stated, Take a deep breath and continues the treatment. R104 states again, Oh my God that hurts so bad! R107 lips are contracted during the entire treatment and R104's teeth are clenched down tight. V10 continues the treatment and then moves to the other foot. At no point is R104 asked if she would like any pain medication; R104 again screams out, I know it is not your fault but that hurts so much. V10 continues without stopping and finished the treatment without asking R104 if she needed any pain medication and completed both feet without stopping or assessing for pain or seeking pain medication for R104. On 08/23/2018 at 1:32 PM, R104 stated, Yes, I would like some type of pain medication during wound treatments. It is so painful if they could give me something to help with the pain I would appreciate it. On 08/23/2018 at 1:35 PM, V10 stated, I will call the doctor and request some pain medication for R107. On 08/24/2018 at 8:15 AM, R104 moaned and stated how bad this hurts when the right heel dressing was removed. V9, Licensed Practical Nurse (LPN) stated, take deep breaths and continues with the treatment on both feet. On 08/24/2018 at 8:15 AM, R104 stated, No, they did not give me any medication before the treatment today. Yes, I would like some pain medication during those treatments I told them that yesterday. On 08/23/2018 at 1:35 PM, V10 is asked if she had called the Physician regarding pain medication for (R104) and V10 stated, I will call the doctor tomorrow and see if I can get her something. R104's Electronic POS dated for (MONTH) (YEAR) document an order for [REDACTED]. On 08/28/2018 at 1:40 PM, R104 was asked to rate her pain with treatment on a scale of 1-10 with 10 being the highest and R104 rated her pain during treatment at a 10. 2. R328' POS dated (MONTH) (YEAR) documents in part, Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin and [MEDICAL CONDITION]-resident staphylococcus aureus (MRSA) in the wound. On 08/21/2018 R328's door has a sign posted stating Contact Isolation Precautions. On 08/28/2018 V2, Director of Nursing (DON) stated, (R328) was on contact isolation [MEDICAL CONDITION] in her wounds. R328's Treatment Administration Record (TARS) for the month of (MONTH) documents cleanse bilateral lower extremity with saline solution and apply [MEDICATION NAME] powder then santyl and wrap with elastic toes to knees daily and as needed. R328's TARS documents no [MEDICATION NAME] or oral [MEDICATION NAME] was given to R328 for pain during the month of August. On 08/23/2018 at 1:40 PM. R328 had 2 elastic bandages on both legs. R328 was lying in bed. V10, Licensed Practical Nurse (LPN), began to remove the bandages and R328 began to moan, Oh, Lord Jesus please help me, that hurts, that hurts! R328 continued to cry out. Once the elastic bandages were removed there were bandages wrapped around R328's wounds. Some of the areas on the gauze were soaked with blood and the gauze was sticking to the area. As V10 began to remove the bandages they are sticking to the gauze and R328 again is crying out in pain stating, Oh Lord Jesus. Please help me. Oh dear God, please help me! V10 did not stop at any time or ask R328 if she wanted any medicine and continued to do treatments on R328's other leg. V10 did both legs without stopping or asking R328 if she would like any pain medication and R328 was crying out in pain during the entire treatment. V10 did not stop during treatment or assess pain at any time during this treatment. On 08/28/2018 at 1:16 PM, V2, Director of Nursing stated, If a resident is experiencing pain, either verbal of nonverbal (crying, yelling out facial expressions, etc) I expect staff to stop treatment and assess for pain. The Pain Prevention and Treatment Policy dated (MONTH) (YEAR) documents To assess for, reduce the incidence of and the severity of pain and to help residents attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible. The facility will develop and implement a plan, using pharmacological and /nonpharmacological interventions to manage pain and/or try to prevent the pain consistent with the resident's goals. Pain Management- the assessment of pain and if appropriate, treatment in order to assure the needs of residents who experience the problems with pain are met. 2. Residents found to have pain as indicated by a score of greater than 5 on the Pain Observation Screen will be further assessed using the Comprehensive Pain Assessment. After completion of the assessment, the resident will receive interventions to reduce or alleviate the pain. These interventions may be non-pharmacological or pharmacological (with physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to provide dignity during Activities of Daily Living (ADL's) for 2 of 22 residents (R2 and R13) reviewed for dignity in the sample of 22. This failure resulted in R13 feeling isolated, and upset, with loss of appetite. Findings Include: 1. The Minimum Data Set, (MDS), dated [DATE] documents R13 is cognitively intact and requires two staff to assist for transfers. R13's physician's orders [REDACTED]. On 8/24/2016 at 11:14 AM, R13 told E9, Certified Nurse Aide, (CNA) and E10, CNA that she wanted to go to the dining room to eat lunch. On 8/24/2016 at 12:15 PM, R13 was in bed. E9 and E10 were in R13's room assisting R13 with the lunch tray. When asked if she still wanted to go to the dining room to eat, R13 said, Yes, I do. E9 stated, in front of R13, We don't have time to take her down to the dining room. It takes two people to get her up, and we don't have time to do that. It is unfair to the people in the dining room that need help if we take time away to get her up. R13 became teary eyed and said, I'm not very hungry. On 8/24/2016 at 3:30 PM, E1, Administrator, reported that (R13) has spoken to him about feeling lonely and isolated in her room. On 8/25/2016 at 8:20 AM, R13 said, I wanted to eat in the dining room with all of the other ladies. I feel so isolated in my room. I'm so upset that I don't get to eat with the other ladies. I see them being taken to the dining room, and I am just laying here in my bed. I am so hungry, and I have to lay here and wait so long for my tray. I see them going back to their rooms before I get my tray. Then, I am so upset that I am not hungry. I hear them (staff) whispering about me like I don't matter. It really makes me feel like a child that isn't allowed to go out and play with the other children. 2. R2's Care Plan, dated 8/08/15 documents R2 requires extensive to total assist with most ADL's. R2's Care Plan, dated 8/18/15 documents R2 has a history of depression. R2's Physician order [REDACTED]. On 08/23/16 at 11:30 AM, R2 wheeled himself with difficulty from the dining room to his bedroom, and urinated all over himself and the floor. R2 left a large puddle underneath his wheel chair. At 11:58 AM, R2 was eating his lunch on his over the bed table, while sitting in his wheelchair with a puddle of urine underneath the wheelchair. At 12:05 PM, R2 continued to eat with the puddle of urine underneath his chair. On 08/23/16 at 12:17 PM, R2's lunch tray was removed from the bedroom by E12, CNA. Incontinent care was not done by E12, and housekeeping was not asked to clean the puddle of urine. On 08/23/16 at 12:35 PM, R2 continued to sit in a puddle of urine, while E27, Housekeeper, cleaned the other rooms in his location, but did not enter his room. When asked did she clean the entire 100 hall, E27 stated, Yes. On 08/25/16 at 12:00 PM, R2 was in the 100 hall day room eating his meal. When asked where he usually eats, R2 stated, I usual eat my meals in here everyday. When asked why he didn't eat in the day room yesterday, R2 didn't answer. R2's affect was sad. The facility's Policy entitled Quality of Life/ Dignity, dated 2/2012, documents, in part, Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self esteem and self worth.

Based on observation, record review and interview, the facility failed to initiate progressive effective interventions and provide adequate supervision for 2 of 4 residents (R1 and R10) reviewed for falls in the sample of 22. This failure resulted in R10 having repeated falls resulting in a femur fracture. Findings include: 1. On 08/23/16 at 2:30 PM, R10 was sitting up in her wheelchair in the lobby area near the central nurses station. On 08/25/16 at 12:10 PM, R10 was lying in her bed. The bed was observed in the high position, curtain pulled so that R13 could not be seen from the hall, call light was underneath her body and her wheelchair approximately 3 feet away from the bed. The physician's orders [REDACTED]. The Care Plan, dated 05/25/16, documented R10 was identified as requiring extensive assist with most Activities of Daily Living (ADL's), frequently incontinent of both bowel and bladder, potential for pain, weakness and episodes of tearfulness and agitation. The approaches were listed as equip resident with device that monitor rising. Check for proper functioning; keep call light in reach at all times; monitor for pain; proper footwear; do not leave on the toilet unattended; low bed with mat; encourage safe seating and to ask for help to transfer; staff to increase rounds; keep bed at lowest level; remind to wait for assistance for transfers and not to attempt alone and requires one assist with daily transfers. The Minimum Data Set (MDS), dated [DATE], documented R10 had moderate cognitive impairment and required extensive assistance of at least one staff with transfers and bathing; and required total assistance of at least one staff for hygiene. It also documented R13 was frequently incontinent of both bowel and bladder. The Incident/Accident Report, dated 09/14/15, documented R10 was found on the floor at the foot of her bed. It documented R10 stated she fell trying to transfer from the wheelchair to the bed. It documented R10 was incontinent at the time and the wheelchair alarm did not sound. The interventions put into place were to check the alarms, proper footwear and check on resident more frequently. The Incident/Accident Report, dated 09/27/15, documented R10 fell out of bed trying to transfer to the wheelchair. It documented no alarm sounded because R10 had disconnected the alarm. The interventions were listed as increase rounds on resident and provide safe environment. The Incident/Accident Report, dated 10/03/15, documented R10 was found on the floor on her right side with a pillow under her head. Alarm did not sound. No documentation as to why the alarm did not sound. The interventions were to increase rounds on resident and assess pain. The pain assessment at the time was zero. The Incident/Accident Report, dated 10/05/15, documented R10 fell out of her wheelchair. It documented no alarm sounded because R10 had unplugged the alarm. The interventions were listed as frequent checks/monitoring, inform resident to use call light, consult with neurosurgery and therapy evaluations. The Incident/Accident Report, dated 11/08/15, documented R10 fell in the hallway ambulating with wheeled walker without assistance. The interventions were listed as wear shoes, use wheelchair to ambulate and move resident room. The nurses notes, dated 11/09/15, documented R10 was moved to a different room with the same roommate. The Incident/Accident Report, dated 11/12/15, documented R10 fell out of the wheelchair because she had tipped the wheelchair backwards. It documented R10 had her feet propped on the bed while sitting in the wheelchair. No alarm sounded. The interventions were listed as safe footwear, frequent monitoring, education to R10 about safe seating and to ask for help to transfer to bed. The Incident/Accident Report, dated 11/21/15, documented R10 fell out of her wheelchair in the dining room hitting her head on the floor. It documented that R10 had thrown herself on the floor. No alarm sounded. The interventions were listed as frequent monitoring for further behavior's and possibly tracking if needed. The Incident/Accident Report, dated 11/24/15, documented R10 was lowered to the floor from the wheelchair, because R10 was leaning forward too far. No alarm sounded. It documented that a self releasing seat belt was suggested, but family was undecided. an order for [REDACTED]. The Incident/Accident Report, dated 11/25/15, documented R10 was unattended and fell off the toilet. It documented R10 was taken to the bathroom by staff and left on the toilet to wait for assist to get up. It documented R10 hit her head on the bathroom door landing on her right side. Originally, the report documented no injury. The report documented four days later, the fall committee met and noted R10 was complaining of severe right hip pain. X-rays were ordered and revealed R10 had an acute fracture of the right femur and was subsequently sent to the emergency department for evaluation. The interventions were listed as a low bed with mat on the floor and not to leave resident on the toilet unattended. The Incident/Accident Report, dated 11/29/15, documented R10 was found on the floor after the X-ray had been completed and the staff had left the room leaving R10 unattended. The interventions were the same as 11/25/15. The Incident/Accident Report, dated 12/26/15, documented R10 was found on the floor on top of the mat on the floor. It documented bed alarm did not sound, because R10 had pulled it apart. The interventions were to increase monitoring, low bed, mat on floor and safe footwear. The Incident/Accident Report, dated 02/23/16, documented R10 was found on the floor from bed. It documented R10's bed was wet, as well as the sheet that was wrapped around her. No alarm sounded. It documented R10 was trying to transfer from the bed to the wheelchair. It documented R10 complained of bilateral hip pain. X-rays were obtained of bilateral hips and was negative for fractures. The interventions were to educate staff, increase rounds on resident and toileting/hygiene program. The Incident/Accident Report, dated 07/24/16, documented R10 was found on the floor attempting to transfer self from bed to the wheelchair. It documented R10's call light was on when she fell . The interventions were to encourage resident to ask for help and increase monitoring. The Incident/Accident Report, dated 08/18/16, documented R10 fell out of the wheelchair in the lobby area. The interventions were to put resident to bed for proper rest and obtain a Depakote level due to increased behaviors of leaning forward in wheelchair. The laboratory report, dated 08/20/16, documented Depakote level was low and an order was given to give a larger dose that evening. The POS, dated 08/23/16, documented to discontinue the Depakote. The original order was given on 08/11/16. The Incident/Accident Report, dated 08/21/16, documented R10 was found on the floor in her room. It documented that R10 had been incontinent in bed, the CNA had assisted R10 to the wheelchair and turned her back to change the bed and R10 fell forward out of the wheelchair. On 08/25/16 at 12:10 PM, E11, CNA stated that staff were informed that R10 was to remain in bed, even for all meals, because R10 had falls out of her wheelchair over the weekend. 2. R1's physician's orders [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE] documents R1 is severely impaired with cognition and decision making, is nonambulatory, has unsteady seated to standing balance, and requires extensive assistance of one staff for transfers and toileting. R1's Fall Risk Assessment, dated 6/14/2016, documents R1 is a high risk for falls. On 8/23/2016 at 12:45 PM, E25, Certified Nurses Aide (CNA) came out into the hall by R1's room, and reported she had just put R1 on the toilet. E25 stated, He said he really had to go. At this time, R1 was trying to get up from the toilet by holding onto the wheelchair beside him. E25 was in the hall by R1's room. This surveyor quickly informed E25 that R1 was standing. E25 quickly intervened and instructed R1 to sit back down. R1 had a pressure pad alarm in the wheelchair, that had been turned off. R1 was confused. R1's Incident/Accident Report, dated 11/18/2015 at 7:30 PM, documents R1 was found on the floor after sliding from the wheelchair. R1 had no injury. The interventions documented to prevent further falls are documented to increase monitoring and a sensor alarm device to R1's wheelchair. R1's Incident/Accident Report, dated 12/31/2015 at 6:55 AM, documents R1 tried to get up from the wheelchair and slid to the floor with no injury. The Report documents R1's alarm was not sounding because R1 had no alarm. The interventions after this fall are documented to place an alarm on R1's wheelchair and a nonskid pad. R1's Incident/Accident Report, dated 1/03/2016 at 7:45 AM, documents R1 was found on the floor in front of the wheelchair with no injury. The Report documents R1's tab safety alarm was not working, and that R1 often removes it. The intervention documented to prevent further falls for R1 is to move the tab alarm to where R1 cannot reach it, and apply a pressure pad safety alarm to the wheelchair. R1's Incident/Accident Report, dated 1/15/2016 at 10:00 AM, documents R1 was found on the floor after sliding form the wheelchair. No alarm was sounding. The intervention documented in this Report is to check R1 for a UTI (urinary tract infection). The Incident/Accident Report, dated 1/22/2016 at 7:25 AM, documents R1 attempted to transfer himself from the wheelchair to a regular chair and fell . R1's safety alarm was sounding. The intervention documented for this fall is to speak with R1 regarding safety and the need to wait for assistance. The Incident/Accident Report, dated 3/01/2016 at 12:10 PM, documents R1 was left unattended on the toilet and fell . R1 sustained a bump to the left forehead. The intervention for R1 is documented to educate the staff about toileting and an OT (Occupational Therapy) evaluation. The Incident/Accident Report, dated 7/20/2016 at 6:15 PM, documents R1 fell from the wheelchair with no injury. The intervention is to replace R1's wheelchair alarm with a pressure pad alarm. The Incident/Accident Report, dated 7/31/2016 at 7:06 PM, documents R1 stood up from the wheelchair and hit his head on a bookcase, sustaining a large hematoma to the left side of the head, requiring emergency treatment at the local hospital. The intervention for R1 documented for this fall is to apply a pressure pad alarm after removing the tab alarm. R1's Care Plan, updated as revised 8/03/2016, documents, in part, R1 is at risk for falls due to Altered Mental Status, Cerebral Vascular Accident, Dementia and Weakness. R1's Care Plan documents the pressure pad alarm was recommended on 7/20/2016 after that fall. The facility's policy and procedure, dated 7/2014 and entitled, 'Falls Management' documents, in part, It is the policy of (facility name) to assess and manage resident falls through prevention, investigation and implementation and evaluation of interventions. The Post Fall Investigation, which is attached to the incident report, is given to the Director of Nursing.

Based on interview, observation, and record review, the facility failed to consistently assess, monitor, and treat a surgical incision line for signs and symptoms of infection for 1of 5 residents (R2) reviewed for wound care/management. This failure resulted in R2 developing an infection, being directly admitted to the hospital from the physician's office, and undergoing surgery on for revision and debridement of her surgical wound. Findings include: 1. According to the Admission Sheet, R2 is a [AGE] year old female admitted to the facility on [DATE] following hospitalization for a recurrent umbilical hernia c (with) repair (herniorrhaphy with panniculectomy) on 3/6/12. The hospital Discharge Summary dated 3/9/12 describes R2's mid abdominal incision line as "25cm well approximated - steri strips intact" and the lower abdominal lateral incision line as "20cm well approximated - steri strips intact." Treatment Orders for the facility included "ABD (abdominal) pads covering incisional sites held in place w (with)/abdominal binder. Change dressing daily." The Hospital Discharge summary also indicates R2 needs assistance to ambulate with walker. The facility's Admission Nursing assessment dated [DATE] identifies R2 as being oriented, cooperative with her surgical site presenting as an "upside down T" measuring 25cm midline, 27cm vertical. Interim care plan identifies the dressing change to be done daily. The nurses notes written on admitted d 3/9/12 do not include documentation of the incisional line. The first entry into the nurses notes that reflect R2's incision is on 3/10/12 and documents "(changed) drsg (dressing) today - left some tape on steri strips where s/s (signs and symptoms) bleeding thru steri strips" but no identification as to where the bleeding was noted or how much. The next entry/documentation of R2's surgical incision line is on 3/12/12 at 10am "Abdominal dressing has steri strips to T incision. Small amt (amount) of Dried bloody drainage at lower incision." No further documentation of the wound site is reflected in the nurses notes nor is there any information given toward R2's compliance with wearing the abdominal binder. On 3/14/12 at 10:45am, the nurse notes documents "Abd drsg (dressing) done per wnd (wound) nrs (nurse) this am + intact." The wound/treatment nurse, E4 Licensed Practical Nurse (LPN), documented on the back of the treatment administration record (TAR) dated 3/14/12 and describes R2's incisional line as "not approximated well" with no drainage noted. This is a change from the "well approximated" incision line on admisison. On 3/29/12, E4 provided her "own notes" that she keeps in her office which describes R2's incisional line as being 27 cm (centimeter) side to side c 10 cm incisional forming an upside down T shape - has an area that's pulled apart at (cross section) - area approx (approximately) 2cm x .7cm c tissue pinkish/red - (no) odor - (no) slough of tissue - (no) open hole in tissue observed - wound bed c pinkish/red tissue - does have some sero sang (sanguneous) drainage to mid abd. site - cleansed c drsg applied as directed." E4 also stated that R2 was non-compliant with wearing her abdominal binder from the start but does not have that documented in her notes. There is no indication the physician and/or the surgeon were notified of any changes to R2's incision line or her non-compliance with the binder. On the evening of 3/14/12, the nurses notes at 9pm document that R2 was complaining to E11, LPN, of "very intense pain" at the lower abdominal incision line. Z2 (primary physician) was called and he told E11 to call the surgeon. At 9pm, E11 documented the physician on call for R2's surgeon was called and gave orders to send R2 to the emergency room . In addition, E1 documented that R2's incision line had "some drainage" but the line was not warm to touch. At 10:50pm on 3/14/11, the surgeon gave an order to send R2 to the emergency room which E11 did. She documented that R2 returned to the facility following the emergency room visit at 2:30am. No other information was provided in the nurses notes. emergency room documentation dated 3/15/11 at 12:10am documented "Noted large incision across lower abd with saturated abd dressings with serosanginous drainage. A & O X 3 (alert and oriented times three)." Additional notes describe the line as having "redness noted" with some bruising adjacent to the line but have no signs of infection and that R2 stated she had stopped taking her pain medications at the nursing home. R2 returned with an order for [REDACTED]. There is no further documentation in the nurses notes regarding R2's incisional line until 3/17/12 at 3pm when E12 LPN documents "drsg ch'd (changed) to abd (lower) sero sanguiness drgn (drainage)" The notes include no specifics as to how much drainage was present, color, odor, or location of the drainage. A check list nurses note dated 3/18/12 was completed that identifies R2 as being cooperative, continent, with a surgical treatment site with a statement "abd. wnd (wound) sersangous drng mod (moderate) amount" added. There is no indication either R2's physician or surgeon was notified and no documentation of the incision line itself. The next entry into the nurses notes is 2 days later on 3/20/12 at 315p when is documents Z2 (R2's primary physician) "here to see" R2." There is no documentation that indicates the nurses followed up on the line that was documented earlier in the week as being unapproximated and/or the presence of drainage. Z2's progress notes/orders dated 3/20/12 restate R2's primary [DIAGNOSES REDACTED]. On 3/30/12 at 8:45am, Z2 stated he saw R2 on 3/20/12 as she sat outside the facility and she asked to go home. Z2 stated she told him she was seeing the plastic surgeon (Z1) the next day and he told her if everything went well, she could be discharged from the nursing home after that. Z2 stated he did not look at R2's surgical incision line on 3/20/12 as she was outside and she was seeing the surgeon the next day. Z2 stated he was not informed of any drainage or redness of the incision line at any time during her stay at the facility. When asked if that was something he or the plastic surgeon should have been informed on, stated "Absolutely." The next entry into the nurses notes is written on 3/20/12 (no time) by E4 Treatment nurse and documents "reported by housekeeping supervisor that resident observed taking drsg apart et stuffing wash cloths to abd incision site -redirected et drsg replaced - floor nurse to monitor for changes." On 3/29/12 at 2:15pm, E4 stated she did not do the dressing change but told the floor nurse E9 (LPN) to do it. E4 stated she was unaware as to whether or not the facility had a wound management policy or not but by instructing her to "monitor" the site would expect the nurse to "reevaluate and look for drainage, any change to the site, odor, appearance, any increase in redness, any complaints of tenderness" or any change from before. There is no documentation either in the nurses notes or on the treatment sheet that the nurse followed these instructions. On 3/30/12, E9 stated she was never informed that R2 was "stuffing" wash clothes in her abdominal fold until after R2's discharge to the hospital but did recall doing her dressing that evening around 7:45pm to 8pm. E9 stated the incisional line looked "great" that night with no redness, no discoloration or odor. She stated it had some serosanguinous drainage present. The next entry into the nurses notes is written by E5 LPN on 3/21/12 (no time) and documents "ABD pads were present vertically c no drainage present to the outside of the pad Res then lifted abdominal apron + pulled a drainage soaked wash clothe from under the center ABD pad. Res then c/o (complained of) foul odor from incision Nurse advised that she should express her concerns to her surgeon that she was seeing today Nurse further advised against this nurse from performing drsg (change) as it would be in the res best interest to see the amount of drainage + the odor so that way the dr can best address her concerns. res agreeable to allow dr to (change) drsg." On 3/28/12 at 3pm, E5 LPN stated when he approached R2 to ask about her dressing, she voiced concerned then lifting her abdominal fold up, reached under it and pulled out a drainage saturated washcloth from her fold. E5 stated R2 did not have a binder on as it was hanging in the closet but did have ABD dressings intact that were not soiled as she reached under them. E5 stated R2 hardly ever wore her binder. E5 described the wash cloth as having brownish drainage that had a "funky foul infection smell" to it. He said he told her to leave it alone so the doctor could smell it. E5 stated he had not taken care of R2 before that day and that he was shocked when she pulled the cloth out. He stated the "whole room had that odor." E5 stated he did not look at R2's incision line nor did he touch her after that. E4's personal notes dated 3/21/12 provided after asking E4 if she had any other documentation, document that R2 refused to have E5 change her dressing and that the nurses reported to her that R2 "stuck her hand up under the abd pads et pulled out wash cloths from abd area incision area - goes to dr's appt (appointment) today." E4 stated she did not approach R2 regarding the wound drainage in an attempt to assess it. Nurses notes dated 3/21/12 (no time) documents that R2's mother was in the facility and reported that resident was sent from Z1's office to the hospita on 3/21/12 for another surgery adding that the incision line had a foul odor to it and needed to be "cleaned out." The surgery was performed 3/22/12. According to the hospital Surgical Note dated 3/22/12, R2's abdominal incision line measured 23.5cm mid abdomen with the horizontal incision line measuring 65cm across. It was described as reddened around the edges, incision has opened up minimal amount to this area and draining a purulent drainage, foul smelling with some steri strips still intact. Interview with Z4 Registered Nurse (RN) on 3/29/12 at 10:45am stated she did the dressing change on 3/22/12 at the hospital prior to surgery provided pictures taken of R2's surgical site dated 3/21/12 and pointing to an area on the upper right of the picture stated R2 had a large black necrotic area present on the right and a boggy soupy area with foul smelling copious amounts of drainage on the lower left. Z4 stated that "if drainage and odor are present, its a clear indication of something going on and someone should be notified." Z4 also stated that as they were cleansing the incisional line, R2 stated "they never did that at the nursing home." but did put a new dressing on. R2 told Z4 she was putting wash cloths over the incision line to catch the drainage. Z4 stated R2 is alert/oriented and reliable and interview with her is possible. At 11:15am on 3/29/12, R2 was in bed in the hospital. She had a [DEVICE] on and stated she was comfortable at the time. R2 was asked about the wound drainage at the nursing home and stated she put wash cloths under her abdomen because that's what the nurses were doing to catch the drainage. R2 said that the nurses at the nursing home did not change the dressings daily and did not clean the wound like they do in the hospital. R2 stated the incisional line started to smell with drainage and that she had a lot of pain with it. On 3/29/12 at 2:20pm, Z5, Z1's office nurse said Z1 stated that R2 is of sound mind and could tell you anything you wanted to know." Z5 stated that drainage is something Z1 would have wanted to know about. R2's Hospital Discharge Summary from her surgery on 3/22/12, documents discharge condition as "DX (diagnoses) Infection of Abdominal surgical site." On 3/30/12 at 8:45am, Z2 stated he was not informed R2 developed a "bad infection that was overlooked by the facility." On 3/30/12 at 1pm, E1 Administrator provided a "late entry" note dated 3/14/12 that she identified as being written that morning by E11 LPN that documents "res c/o drainage c order from (lower) abd drsg. Abd pad removed, incision intact c steri strips abd pad had some serosanguineous drainage c no odor noted. Res made aware of integrity of incision. Skin not warm to touch around incision site (no) inflammation noted at the time. Drsg (changed( + abd binder reapplied." An additional note documents "Dr (Z1) notified of drainage + assessment to abd incision + res c/o pain. Z1 stated that from the details of the assessment, an infection does not seem likely, however, d/t (due to) uncontrollable pain, its okay to send res to ER (emergency room ) for tx (treatment) + eval (evaluation.). This documentation conflicts with the emergency room notes that identifies some seperation of the line and redness. A policy/procedure on Wound Management was requested from E1 and E2, Director of Nurses on 3/29/12 and a policy entitled PRESSURE ULCER MEASUREMENT AND ASSESSMENT was provided. E1 stated the facility does not have a specific policy on wound management but they use the pressure ulcer one. The policy under assessment documents that each ulcer will be measured in centimeters; include location, measurement, size, depth, drainage, and approximate amount, undermining or tunneling, odor, color and type e.g. slough or eschar, description of wound edges and surrounding tissue. Document pain is present, nature and frequency." An additional statement includes "ulcers that appear purulent require physician notification." .

Based on record review and interview, the facility failed to provide timely treatment for [REDACTED]. This failure resulted in a two day delay in treatment for [REDACTED]. Findings include: 1. R22's Nursing Notes dated 5/15/11 (no time on note), documented, "Resident lying in bed, calling out, this nurse went into room, ask resident what was wrong. He stated his leg hurt.....he stated, it's in my groin area....small old yellow bruise on left knee, multiple scabs areas on lower extremity, left foot has 2+ [MEDICAL CONDITION].stated he was anxious, nervous, also stated he couldn't breathe and his back hurt, pulse ox taken, 99% in room air. Morning meds, Tylenol and [MEDICATION NAME] also given." There is no documentation that the physician was notified of R22's complaints of pain, anxiety, difficulty breathing, or [MEDICAL CONDITION] in his lower left extremity on 5/15/11. On 5/17/11 at 2:00 PM, Nursing Note documented, "Res. c/o (complaining of) pain in left leg. Staff reports res. c/o pain with transfer. When checked noted 3+ [MEDICAL CONDITION] to left leg, from knees to toes, pedal pulse (not) palpable d/t (due to) [MEDICAL CONDITION].PROM to left leg (not) done d/t guarding. (Physician) was called....N.O. Send to ER for eval of left leg...." The Hospital History and Physical, H&P, dated 5/17/11 documented (in part), "He (R22) presented through the emergency roiagnom on the 17th late afternoon with left leg pain and swelling since Sunday per the patient's family.....This patient had a film done that revealed a femur fracture.....Doppler's done this morning confirmed a large, left lower extremity [MEDICAL CONDITION].requires an IVC (Inferior Vena Cava) filter to be placed prior to surgery." The H&P dated 5/17/11 documented the Assessment and Plan (in part): "Left femur fracture with a recent fall. Orthopedics has been consulted and will go to the operating room after an IVC filter placed. Acute left leg [MEDICAL CONDITIONS]. He will be consulted to Vascular for IVC filter and then to operating room for left hip arthroplasty. Anticoagulation postoperatively....." 2. R16 with diagnoses, in part of Congestive Obstructive [MEDICAL CONDITION] Disease and [MEDICAL CONDITION] Reflux, was originally admitted to the Facility from the hospital on [DATE]. R16's Nutritional assessment dated [DATE] documents that R16 weighed 204.8 pounds. The Patient Weight Tracking documents that R16 weighed 214.1 pounds in July 2011 and 173.8 pounds in August 2011. This an 18.8% weight loss in 1 month. R16's Nutritional assessment dated [DATE] does not list an ideal or usual body weight. E6, Dietary Manager, stated on 8/11/11 at 10:15 AM, that R16 was weighed on 8/6/11 and needed to be reweighed. E6 stated that R16 had not been reweighed yet due to his refusal. E2, Director of Nurses, was present and stated that "R16 retains a lot of fluid at times and often refuses care". Fluid retention and refusing care is not documented in his clinical record. R16's physician's orders [REDACTED]. There is no documentation in R16's clinical record regarding why the [MEDICATION NAME] was ordered. R16's diet was changed on 6/28/11 from Regular to Regular, No Added Salt. There is no documentation why his diet was changed. R16 was reweighed on 8/11/11 at 12:05 PM. It was noted that R16 weighed 174.8 pounds. This is a 39.3 pound weight loss between July 2011 and August 2011. R16's 6/6/11 admission assessment documents that his scrotum was swollen to "nearly cantaloupe size". R16's clinical record does not address any [MEDICAL CONDITION] or weight loss. E2 confirmed on 8/11/11 at 10:35 AM that the Facility has failed to assess R16 for weight loss and/or [MEDICAL CONDITION], and failed to consult with R16's physician regarding his weight loss. On 8/11/11 at 9:30 AM, R16 said that he did not know why he is loosing weight - "I just don't have an appetite". R16's July and August 2011 Monthly Appetite Log documents that R16 consumes between 50-100% at every meal. On 8/11/11 at 11:20, E10, Certified Nurses Aide, CNA, said that R16 was weighed the first week of August and she does not know how the weight of 173.8 was derived. E10 had been performing all of the weights and maintaining the weight logs up until July 2011. After that time, different CNA's were weighing residents. E10 said that sometimes the wheel comes loose from the shower chair and therefore the weights are not accurate. R16's Minimum Data Set ((MDS) dated [DATE] documents he is not cognitively impaired, ad is dependent for all activities of daily living except for eating. The MDS documents that R16 requires no setup or physical help for eating. The Facility's Weight Policy documents that "All weights will be completed in the first week of every month. If there is a discrepancy of 5% or 5 pounds from the previous weight (gain or loss) a re-weigh will be done immediately. The hall nurse or Quality Assurance nurse will notify the resident's attending physician and responsible party of any weight gain or loss of 5% or 5 pounds in 1 month".

Based on observation, interview and record review, the facility failed to prevent the formation of pressure ulcers and provide pressure relief for 2 of 3 residents (R9 & R11) reviewed for pressure ulcers in the sample of 24. This failure resulted in R9 developing a facility acquired stage II and stage III pressure ulcer. Findings include: 1. R9's Norton Plus Pressure Ulcer Score dated 01/12/11 documents R9 is a high risk for skin breakdown. The Minimum Data Set, MDS, dated [DATE] documents R9 is severely impaired with cognition, requires total assist with bed mobility, transfers, personal hygiene and is incontinent of bowel with an indwelling urinary catheter. The Care Plan dated 01/24/11 identifies R9 to be at high risk for skin breakdown and pressure ulcer formation r/t (related to) incontinent of bowel and bladder, decreased mobility and [DIAGNOSES REDACTED]. Interventions documented were to turn/reposition every two hours and have pressure reducing devices for bed and wheelchair. The MDS dated [DATE] documented R9 to have no pressure ulcers. A nursing visit note obtained from hospice nurse dated 01/11/11, documented "skin intact." A Telephone Contact Report dated 01/14/11 documented "...hospice Certified Nursing Assistant (CNA) reports an open area on residents back. Writer assessed resident, area noted to mid upper back. Area measured 0.1 X 0.1, received new orders...pressure relieving mattress ordered for resident's bed." A Nurses Note dated 02/08/11 documented "Stage II pressure ulcer noted to gluteal fold, scant serosanguineous exudate, red wound bed with clear periwound. Measure 1.5 X 1.3 X 0.2. Physician notified..." A Telephone Contact Report dated 02/16/11 documented "...Treatment nurse request hospice supply a cushion for resident's back. Stage II to mid upper back..." On 02/21/11, a verbal consent was obtained for Specialized Wound Management consultation. A Skin Integrity Report - Pressure Sores dated 02/18/11 documented R9's [MEDICATION NAME] spine wound as a Stage III and the wound on the coccyx as a Stage II. As of 08/08/11, documentation indicated that R9's [MEDICATION NAME] spine wound measured 1.5 X 1 X 0.3 and the coccyx wound measured 3 X 3 with necrosis. On 08/09/11 at 11:15 AM, Z2, Wound Consultant, stated that R9's wounds were facility acquired. There is no documentation to indicate that these pressure ulcers were considered to be unavoidable by the facility. 2. On 8/10/11 at 8:51 AM, R11 was sitting the dining room in her wheelchair. R11 was wearing shoes. At 9:13 AM, E12, CNA, took R11 to her room and assisted her to the toilet. At 9:31 AM, E12 assisted R11 back into her wheelchair, and took her to an activity. During this time, R11 was wearing shoes. The Skin Integrity Report -Pressure Sores dated 7/15/11 documented R11 acquired an area to her left foot measuring 0.9 centimeters (cm) by 0.5 cm. The report indicated the area was a tissue injury. There was no documentation in R11's nurse's notes indicating R11 had received an injury to this area. R11's Physician order [REDACTED]. The physician order [REDACTED]. Heel protector to L (Left) heel til area resolved." R11's Care Plan which was updated on 7/15/11 documented "At risk for skin breakdown and pressure formation d/t (due to) frequently incontinent of bowel and bladder, decreased mobility, and dx (diagnosis) of A-fib, left humerus fx (fracture), and [MEDICAL CONDITION]. Norton Plus Pressure Ulcer score =12, moderate risk. The Care Plan documented R11 had an area on her left heel measuring 0.8 cm by 0.5 cm dark skin area , Sure Prep daily applied - heel protector til resolved." The Skin Integrity Report-Pressure Sores dated 8/5/11 documented the area to R11's left heel had healed. On 8/11/11 at 3:10 PM, E13, CNA, took R11 to her room and removed the sock from R11's left foot. R11 had a small purplish black area to the outer aspect of her left heel. When asked how R11 acquired this area, E13 stated she did not know. E14, Licensed Practical Nurse, was in the room, and stated she did not know how R11 acquired the area to her left heel.

Based on observation, record review, and interview, the facility failed to failed to prevent the formation of pressure ulcers and provide pressure relief interventions for two, (R4, R9) of three residents reviewed for pressure ulcers in the sample of fourteen. Findings include: 1. The physician's orders [REDACTED]. On 10/03/11 at 1:20 PM, R4 was in bed laying on his left side with the head of the bed elevated 30 degrees. R4's feet were laying directly on the mattress. On 10/3/11 at 2:11 PM, 3:10 PM, and 3:45 PM R4 remained sleeping on his left side without a change in position. His feet remained laying directly on the mattress. R4's feet had no heel protectors on, and his feet were not floated off the mattress. No pressure relieving device was in R4's wheelchair. On 10/04/11 at 8:45 AM, R4 was in bed laying on his left side, with his knees together and his feet directly in the mattress. No heel protectors were in place to R4's feet. No pressure relieving device was in R4's wheelchair. In an interview on 10/04/11, at 9:05 AM, E4, Licensed Practical Nurse, (LPN) and Treatment Nurse reported R4 has no skin breakdown. On 10/04/11 at 9:45 AM, R4 was laying on his back with his feet against the foot board of the bed and his heels directly on the mattress. At 10:05 AM and 10:40 AM, R4 remained in bed without heel protectors or his feet floated. On 10/4/11 at 10:40AM, R4's incontinent brief was removed to do a skin check with E4, LPN. R4 had been incontinent of bowel. E4 identified a new Stage I pressure ulcer to R4's left inner buttock measuring 1.8 cm (centimeters) X 0.5 cm. E4 identified the red area as a Stage I ulcer, "that I'll monitor." When asked if R4 should have pressure relieving devices for his feet or his wheelchair, E4 stated, "I don't think so. I'll check and see. I'll get a pressure relieving cushion." R4's Care Plan dated 9/07/11 documents R4 is "at risk for skin breakdown and pressure ulcer formation due to decreased mobility, requires extensive assist with bed mobility, has history of pressure ulcer to the coccyx which was healed 5/21/09, and frequently incontinent of bowel and bladder. Antifungal cream every shift and heel protectors when in bed as preventative. Norton Pressure Ulcer Score =10, high risk." Approaches listed in R4's Care Plan, in part, are "(pressure relieving) cushion in wheelchair and (pressure relieving) mattress, assist with turning/positioning every 2 hours and PRN (as needed) when in bed for pressure relief and comfort, and apply heel protectors when in bed as ordered." 2. The physician's orders [REDACTED]. The facility Skin Integrity Report-Pressure Sores, dated 9/23/11, documents R9 has a Stage III pressure ulcer to the coccyx and a Stage III pressure ulcer to the [MEDICATION NAME] spine that is being treated by a special wound consultant. On 10/03/11 at 1:16 PM, R9 was in bed laying on her left side on an electric low air loss mattress, with a support pillow behind her back. R9's feet lay directly on the mattress. On 10/3/11 at 2:10 PM, R9 remain on her left side without a change in position. R9 remained on her left side on 10/3/11 at 3:05 PM, without any pressure relieving devices for her feet. On 10/3/11 at 3:06 PM, E5, Certified Nurses Aide, (CNA) came into R9's room to reposition her. R9's left hip was red, but blanchable. Her right heel was red and slightly mushy. E5 reported R9 is turned and repositioned every 2 hours. On 10/04/11 at 8:45 AM, R9 was in a geriatric chair in the dining room being fed. R9's feet had socks on them, and her heels were resting directly on the foot rest of the chair. On 10/4/11at 9:00 AM, E4, LPN, reported R9's pressure ulcers were not resolving due to R9's poor nutrition and refusing to eat at times. E4 confirmed R9 is receiving hospice services. E4 reported R9 is turned every 2 hours. A sign was posted on a clipboard in R9's room documenting she is to turned every one hour to prevent skin breakdown. On 10/04/11 at 9:45 AM and 10:05 AM, R9 remained up in the geriatric chair in her room, with her heels directly on the footrest of the chair. No pressure relieving devices were in place for R9's feet. The Care Plan for R9 dated 9/19/11 documents, "At risk for skin breakdown and pressure ulcer development due to incontinent of bowel. (Indwelling urinary catheter) inserted 5/17/11 to aid in wound healing. Has decreased mobility and [DIAGNOSES REDACTED]. Currently has Stage III pressure ulcers to coccyx and [MEDICATION NAME] spine. Treatment in progress. (Special wound consultant) to follow. Low air loss mattress to bed. Cushion to (geriatric chair). Norton Plus Pressure Ulcer Score=9, high risk." Approaches documented in R9's Care Plan include, in part, "Assist with turning/positioning every one hour and PRN when in bed for pressure relief and comfort." The Care Plan does not address any interventions to prevent pressure relief for R9's heels or feet. On 10/04/11 at 3:22 PM, E3, Assistant Director of Nursing, (ADON) reported on 9/29/11 the facility had a PAR (People at Risk ) meeting to discuss R9's decline in health status. E3 reported it was decided to change R9's turning and repositioning schedule to every two hours because she moans and cries out when she is moved to reposition. E3 confirmed R9's Care Plan had not been updated to reflect this. E3 reported the current low air loss mattress provide pressure relief for the feet, contraindicating the use of heel protectors or floating heels. On 10/04/11, the manufacturer's guidelines for R9's pressure relief mattress were reviewed and read, in part, "Heel zone with sloping air tubes reduces pressure in critical heel area." The manufacturer's guidelines do not state the mattress prevents pressure to the heel.

Based on observation, interview, and record review, the facility failed to develop and implement effective interventions for repeated falls for 5 of 11 residents (R3, R5, R10, R7 and R20) reviewed for falls in a sample of 24. This failure resulted in R5 falling from bed and/or wheelchair multiple times, sustaining subdural hematoma on three separate occasions, and R10 falling from wheelchair and sustaining a fractured femur. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented R5 as having short/long term memory deficits with severe cognitive impairment, requires extensive assist of two staff for bed mobility, and is totally dependent for transfers. The MDS also indicates R5 has balance deficits. The Care Plan dated 06/22/11 identifies R5 at high risk for falls due to fall history. R5's Incident/Accident Report dated 01/10/11 at 3:10 AM documented "Resident found sitting and scooting on floor on her bottom. No injury." Documentation indicates that a bed alarm was in use, but R5 "took it off." Fall committee recommendations: "low bed with bed/chair alarms." R5's Incident/Accident Report dated 01/25/11 at 6:50 AM documented "Resident found lying face down on floor in hallway of 200 Hall. No response to name, bruise to head, resident was snoring." Documentation indicates R5 was "walking unassisted in hallway." Documentation indicates that R5 was admitted to the hospital with [REDACTED]. There was no documentation to indicate that any interventions had been updated, or put into place on the care plan. R5's Incident/Accident Report dated 02/03/11 at 3:30 PM, documented "called by Certified Nurses Aide (CNA) states resident had fallen. Nurse noted resident on floor face down. Sluggish and slow to respond. No visible injuries noted. Neuro checks started. No visible new areas on scalp. Reported by staff, resident stood up out of wheelchair in dayroom and fell ." Report documents that there was no chair alarm used and R5 was in a high back reclining wheelchair. Fall committee recommendations: "therapy evaluation, change to a 'Geri chair' reclining chair and change sensor pad to tabs." There was no documentation that indicates that there were any updated interventions on the care plan. R5's Incident/Accident Report dated 02/17/11 at 9:10 AM, documented "Resident found on floor in front of chair. No apparent injuries, no complaint of pain or discomfort. Moving all extremities without difficulty. Alarm sounding." Documentation indicates that R5 was in a reclining chair at time of fall. Fall committee recommendation: "Keep in supervised area when up in Geri chair (reclining chair)." R5's Incident/Accident Report dated 02/23/11 at 4:00 AM, documented "CNA found resident on floor, face down in resident's room and alerted this nurse. 5cm laceration noted to left eyebrow. First aid given, resident assisted to bed." Documentation indicates that R5 was taken to the hospital with a subdural hematoma, steri strips were applied to left eyebrow and bruise noted to left shoulder. Fall committee recommendations: "Reposition bed in room, Mattress on floor." Documentation indicates under, "What devices were in use prior to accident? Bed alarm and Mats of floor." R5's Incident/Accident Report dated 03/31/11 at 11:25 AM, documented "Hospice Aide walked in resident's room found resident on floor on mat next to bed. ROM within normal limits. No signs and symptoms of pain or discomfort expressed." Fall committee recommendations: "Discuss with wound nurse risk and benefits of (pressure relieving) mattress. ROHO removed." There was no documentation that a (pressure relieving)mattress was ever applied to R5's bed. R5's Incident/Accident Report dated 04/18/11 at 10:05 AM, documented "Resident in dining room to listen to music activity. Nurse found resident on floor lying on right side, ROM checked and within normal limits. No signs and symptoms of pain or discomfort at this time. Tab alarm sounding at time seen on floor." Documentation indicates R5 was in a "Geri chair" reclining chair at time of fall. Fall committee recommendations: "Attempt to keep in supervised area, instructed hospice aide also." R5's Incident/Accident Report dated 05/09/11 at 6:05 PM, documented "Resident was in feeder dining room and tipped her chair over landing on and sitting on the bottom of her chair. Did not land on floor. Buttocks sitting on bottom of the chair. Resident tilted wheelchair forward." Documentation indicated that R5 was sitting in a "Geri chair" reclining chair at time of fall. Fall committee recommendations: "Remind staff to reposition frequently." R5's Incident/Accident Report dated 06/15/11 at 1:20 PM, documented "Resident fell forward out of 'Broda' high back reclining chair onto head on floor. Unable to state what happened. 3/4 laceration to forehead sustained." Documentation indicates that R5 was in a high back reclining chair with alarm. Documentation indicates that alarm did not sound. R5 was admitted to the hospital for observation with a subdural hematoma. Fall committee recommendations: "change to 'Geri chair'." This was documented as a previous intervention for her fall on 02/03/11. R5's Incident/Accident Report dated 07/31/11 at 4:15 AM, documented "Resident found on floor in room, alarm not sounding. Laceration to left elbow." Fall committee recommendations: "New bed alarm, continue with current interventions." On 08/09/11 at 12:35 PM, R5 was observed in her room leaning forward with head dangling just above knees in a wheelchair with a pummel cushion and lap buddy device unsupervised. 2. The MDS for R10 dated 06/14/11 documented "Resident is at high risk for falls r/t altered mobility requiring extensive assist of two staff, functional limitations in range of motion, balance problem and gait disturbance related to CVA (Cerebral Vascular Accident)." The Care Plan for R10 dated 06/21/11 also documented, "Resident is at high risk for falls r/t an impaired memory/recall requiring cues and supervision with decisions, decreased ability to transfer self and decrease in mobility with very limited ROM to right upper and lower extremities requiring assist with daily ADL's (Activities of Daily Living) related to CVA and fall on 05/09/11 resulting in right hip fracture." R10's Incident/Accident Report dated 04/23/11 at 4:55 PM, documented "Resident found sitting on floor beside her bed, wheelchair approximately two feet to her right side, no injury noted, resident had removed socks/shoes." Fall committee recommendations: "Non skid placed in wheelchair, PT (Physical Therapy) orders received." R10's Incident/Accident Report dated 05/09/11 at 11:45 AM, documented "Resident leaned over to pick up a bib off the floor, wheelchair slipped back, resident fell on floor on right side. Range of Motion (ROM), complains of pain to right hip during flexion." Fall committee recommendations: "Anti-roll backs for wheelchair and follow up with right leg x-ray." On 05/09/11, 05/11/11 and 05/13/11, documentation indicated that R10 continued to complain of right hip pain and x-rays were obtained and negative. On 05/13/11, R10 was sent to hospital for evaluation and subsequently was admitted with a right hip fracture and DVT (Deep Vein Thrombosis). On 08/09/11 at 9:35 AM, E5, Quality Assurance/Infection Control Nurse, stated the facility attributed the fracture to the fall on 05/09/11. 3. R20's Incident/Accident Report dated 10/26/10,at 6:20 PM documented "Res (Resident) noted lying on floor in hallway." The Accident Investigation Report documented R20's chair alarm was not working at the time of the incident. The Report documented as a recommendation "Change w/c (wheelchair) sensor pad." R20's Care Plan was revised and documented "Fall committed recommends QA (Quality Assurance) nurse change alarm battery. R20's Incident/Accident Report dated 11/5/10 at 2:50 PM documented "This nurse summoned to day room @ (at) end of hall - Res found sitting on floor knees bent - Res states ' I just slid out of chair. ' "The Physical therapy Fall Screen documented as a recommendation "Non-skid in w/c. Room change." R20's Incident/Accident Report dated 11/9/10 at 2:30 AM documented "Alarm sounding staff responded to find res sitting on mat next to bed. Res had 1 cm (centimeter) skin tear to R (Right) great toe." The Physical Therapy Fall Screen documented as a recommendation "Low bed c (with) mat." R20's Incident/Accident Report dated 11/18/10 at 12:10 AM documented "Resident was found on floor next to w/c in 200 hall dayroom. States he was trying to go to bed. The Accident Investigation Report documented the wheelchair alarm was not sounding and the battery was changed after the incident. The Physical Therapy Fall Screen documented the following recommendation: "Evaluate for self-releasing seat belt initiated on 11/23/10." R20's Incident/Accident Report dated 12/8/10 at 2:35 AM documented "CNA (Certified Nurse's Assistant) was just in room putting extra blanket on resident when heard bed alarm going off. Found resident on mat." The Physical Therapy Fall Screen dated 12/17/10 documented "Res places self on mattress as his choice. CP (Care Plan) updated to reflect." R20's Care Plan was not revised to address R20 placing himself on the floor. The Care Plan documeneted "@ (at) 2:35 am found on mattress next to bed." R20's Incident/Accident Report dated 12/30/10 at 9:00 PM documented "Res put to bed @ 8:40 p (PM) D/T (Due To) drowsiness in w/c. About 15 min (minutes) later heard yelling out et (and) alarm sounding. Res lying on floor half way on floor et half way on mattress on floor. The physical therapy fall screen, dated 1/4/11 documented "(Change) goal. Res to cont (continue) to accept staff interventions (and) modifications to the environment in order to prevent falls from occurring or reduce res risk for significant injury." R20's Care Plan was not revised with new interventions to prevent future falls. R20's Incident/Accident Report dated 2/20/11 at 4:00 AM documented "CNA found resident in day room lying on Rt (Right) side. Resident unable to state what happened. C/O (Complained Of) soreness Rt shoulder." The Physical Therapy Fall Screen dated 2/24/11 documented "Change care plan goal." R20's Care Plan documented "@ 4 AM found on floor in day room lyingon Rt (Right) side. Fall committed discussed and will (change) goal." The Care Plan was not revised with new interventions to prevent future falls. R20's Incident/Accident Report dated 3/19/11 at 10:25 AM documented "Alarm sounding when going to check on resident found on floor in front of toilet. The Physical Therapy Fall Screen dated 3/22/11 documented "PT (Physical Therapy) to screen." R20's Incident/Accident Report dated 4/11/11 at 1:45 PM documented "One of the Special Needs Aids told this nurse that PT (Patient) was locked in the restroom. Found pt. on the floor in the restroom @ the end of hallway. The Physical Therapy Fall Screen, not dated, documented "PT orders." This was the same intervention implemented for the previous fall. R20's Incident/Accident Report dated 4/29/11 at 1:50 PM documented "Heard alarm resident in shower room sliding out of chair, unable to hold resident up, resident lower to floor. The Physical Therapy Fall Screen dated 5/2/11 documented "Continue c (with) skilled therapy." This was the same interventions implemented for the last two previous falls. R20's Incident/Accident Report dated 5/12/11 at 7:55 PM documented "Found in other pt room 208 on R (Right) knee. Stated he was trying to go to bathroom." The Physical Therapy Fall Screen dated 5/16/11 completed four days after the fall documented "Initiated QA (Quality Assurance) to toilet resident p (after) meals (and) as requested." R20's Incident/Accident Report dated 5/28/11 at 5:40 PM documented "Nurse in hallway heard sound, found resident on floor by bathroom door, he stated he hit his head. Red area found to left side also stated lt (left) hip hurt. The Physical Therapy Fall Screen dated 6/2/11 documented "Skilled therapy d/c'd (discontinued) 5/31. Continue to provide safe environment." The Care Plan dated 5/28/11 documented "cont (continue) current interv (interventions)." R20's Incident/Accident Report dated 6/4/11 at 3:50 PM documented "Staff reports res asleep in w/c et started flailing arms et fell out of w/c." The Physical Therapy Fall Screen dated 6/7/11 documented "Continue to provide a safe environment. Attempt to keep in a supervised area." R20's Incident/Accident Report dated 7/9/11 at 2:35 AM documented "CNA was making rounds and found res lying on the floor besides the bed. Res stated that he had to use the restroom and fell trying to get there." The Accident Investigation Report, no date, documented he sustained a 1 and 1/2 inch hematoma to the right side of his head. The Physical therapy Fall Screen dated 7/12/11 documented "QA to offer toileting q (every) two (hours) at NOC (night)." R20's Incident/Accident Report dated 7/16/11 at 11:00 PM documented "Res was found sitting on floor mat. Bed alarm was sounding." The Physical Therapy Fall Screen dated 7/19/11 documented "PT eval to decrease risk of falls." R20's Incident/Accident Report dated 7/26/11 at 1:10 AM documented "CNA notified nurse that resident was on floor mat by bed." The Physical Therapy Fall Screen dated 8/2/11 documented "Cont PT tx (treatment)." On 8/11/11 at 8:00 AM, during an interview with E5, Quality Assurance/Infection Control Nurse, she stated " I don't know what else we can do with him." 4. The Incident/ Accident Report dated 3/13/11 documented R7 was assisted to the toilet by E8 and E9, CNA's. R7 fell forward on the toilet, and hit her head on the floor resulting in a large hematoma to the left side of forehead. R7 was sent to the emergency room for evaluation. The Physical Therapy Fall Screen dated 3/15/11 for R7's fall on 3/13/11documented recommendation: staff reminded - do not leave resident on toilet unattended, and care plan updated. The Notice of Employee Separation for E8 and E9, CNA's, confirms their failure to monitor R7 while on the toilet. On 8/11/11 at 11:25 AM, E4, MDS/Care Plan Coordinator, acknowledged that R7 was not steady, and only able to stabilize with physical assist while toileting according to the MDS dated [DATE], and the MDS prior to the fall dated 2/17/11. 5. A review of R3's physician's orders [REDACTED]. The MDS dated [DATE] documented R3 as a one person assist for transfers and hygiene. The Care Plan dated 8/8/11 documented R3 was an alert resident, and R3 had a history of [REDACTED]. Interventions documented in the Care Plan included in part; 1 - assist with transfers, remind to ask for assistance, non-skid pads on top and bottom of wheel chair, Falling Leaf Program - place leaf on doorway and on walker. A review of an incident report dated 4/4/11 documented "bed and personal alarm placed for safety", but this was not documented on the Care Plan dated 8/8/11. On 8/9/11, 8/10/11, and 8/11/11 no falling leaf was seen on R3's door or on her wheel chair. During the day of 8/10/11 and the morning of 8/11/11, R3's wheel chair failed to have a non-skid pad on the seat when R3 was observed in her chair. No personal alarm was attached to R3's wheel chair when R3 was observed sitting in her chair. On 8/11/11 at 9:30 AM, R3 was observed lying in her bed, but the bed alarm was not plugged in. On 8/11/11 in an interview with E5, QA Nurse, she stated "R3 is on the falling leaf program, and a leaf is put on her door and walker / wheel chair of the resident to alert staff that R3 has a history of falls. The leaf is to remind staff to keep an eye on R3, and offer to assist her with transfers." On 8/11/11 at 10:30 AM, E5 observed R3's room and equipment with the surveyor. E5 verified that there was no non-skid pad in R3's chair, no falling leaves on either the door frame or on R3's equipment, the alarm attached to R3's chair was laying next to the TV on the chest, and the bed alarm was unplugged. At this time R3 stated, "I had my daughter remove the alarm from the wheel chair yesterday. I had her undo the bed alarm too." R3 stated she did not like to ask for help, and had not told the staff she had undone the alarms. E5 stated staff had not reported the alarms not being on, or having been refused by R3. E5 stated she did not know why the falling leaf's were not on R3's door, or on her equipment as noted in the Care Plan.

Based on observation, interview, and record review, the facility failed to follow physician's orders, and timely assess and implement interventions to prevent weight loss for 2 of 8 residents (R1 and R18) reviewed for weight loss in the sample of 24. Findings include: 1. R18's Physician's Orders dated August 2011 documented R18 was to receive a house supplement (a nutritional supplement) three times daily with meals. R18's [MEDICAL CONDITION] Risk assessment dated [DATE] documented she had a score of 14, indicating she was at high risk for [MEDICAL CONDITION]. The Weight Tracking Log dated 8/9/11 documented R18 had the following weights: 2/11: 106.2 pounds 3/11: 97.2 pounds 4/11: 96.2 pounds 5/11: 96.0 pounds 6/11: 96.2 pounds 7/11: 109.0 pounds There was no documentation in R18's medical record documenting R18 had been re-weighed to determine the accuracy of R18's July 2011 weight. On 8/4/11, Z1, R18's physician, discontinued R18's house supplement due to her weight increase. The facility's re-weigh sheet dated 8/10/11 documented R18 weighed 85.4 pounds. This was a 23 pound weight loss in one month. On 8/10/11 at 10:00 AM, E10, Certified Nurse's Aide (CNA) stated she had been responsible for getting the residents weights; however, she had stopped doing the weights because she was working as a hall CNA. E10 stated she thought the other CNAs who were taking the weights were not sure how to subtract the weight of the shower chair. E10 stated "(R18's) July weight is wrong. She doesn't eat. She didn't gain that much weight." The Meal Intake Log dated August 2011 documented R18 had eaten 25 % or less of her meals from 8/1 through 8/11/11. The Facility's Weight Policy which was not dated documented "All weights will be completed by the Rehab Aides who will be assisted by the QA (Quality Assurance) Nurse (as needed) in the first week of every month. If there is a discrepancy of 5% or 5 pounds from the previous weight (gain or loss) a re-weigh will be done immediately. 2. A review of R1's weight record documented the following weights: 2/2011 - 151.6 lbs, 3/2011 - 152.4 lbs, 4/2011 - 152.4 lbs, 5/2011 - 153.6 lbs, 6/2011 - 154.0 lbs, and 7/2011 - 145.10. The Physician Visit Notes dated 7/18/11 documenteded the following; wt loss secondary to depression, [MEDICATION NAME] 7.5 at Hs, supercereal at breakfast, ice cream with meals, call psych MD for evaluation. On 7/23/11, R1's fasting lipid panel documented: Protein 7, (normal) [MEDICATION NAME] 2.5 -(3.2 - 5.5) below normal. A note on the laboratory report documented "MD / NNO" (doctor informed / no new orders). R1's weight log documented a weight on 8/2011 of 140.40 lbs., which results in a 8.83 % total weight loss during the last two months. On 8/9/11 at 12:36 PM, R1 was served her lunch meal. R1 was served chicken, baked potato, sliced carrots, roll/butter, and pudding with vanilla wafers. R1 was also given a cup of hot chocolate, glass of juice, and glass of water. No ice cream was given to R1 with the noon meal on 8/9/11. During the meal R1 picked at her food and ate only 2 bites of chicken and potato, and a bite of pudding. R1 drank less than 1/3 of her hot chocolate, and only 1-2 sips of water. During this time no staff came to encourage R1 to eat her meal, offer her a substitute, offer her ice cream, or some other food she may prefer. R1 left the dining room at 12:55 PM. After she left the table, her table mates R34, and R35 stated "She (R1) used to eat better, she hardly eats anything anymore." On 8/11/11 at 4:00 PM, in an interview with E2, Director of Nursing, she stated R1's husband had passed away in April 2011, and R1 had become depressed with a decrease in appetite, and referred to the R1's, 7/18 physician's note. E2 stated she "felt the facility was addressing R1's weight loss." On 8/12/11, R1's meal again had no ice cream served with it. At 12:45 PM, R1 remarked "I don't know why I just keep thinking about my husband today", as she picked at her meal. R1 again only ate bites of food, a few sips of juice, and left the dining room with no encouragement of staff to eat more. On 8/12/11 at 2:00 PM, E6, Dietary Manager, stated she had reviewed R1's dietary menu card, and had found that "R1 had not been getting ice cream as ordered by R1's physician, as it not been added to the menu card." E6 also stated R1's most recent weekly weight done 8/11/11 was 139.6 lbs." Since June 2011's weight of 154 lbs, R1 has lost a total of 14.4 lbs or 9.3% of her weight.