Every finding on record at Highland Health Care Center

Based on observation, interview and record review the facility failed to prevent physical abuse for 2 (R49, R32) of 3 residents in a sample of 44. The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on 1/5/2026 and was corrected on 1/19/2026, prior to the start of this survey, and was therefore Past Noncompliance.Jnoknptnporemg]Findings include: R49's Undated Face Sheet documents she was initially admitted to the facility on [DATE] and diagnosis of Alzheimer's disease. R49's Care Plan, dated 4/15/2025 addressed she has the potential for abuse. R49's Quarterly Minimum Data Set (MDS) dated [DATE] documents she is not alert, has disorganized thinking, verbal behaviors exhibited 1 - 3 days and no physical behaviors exhibited. R49's Nursing Note, dated 1/5/2026 at 1:30 PM documents allegation of abuse was reported. Comprehensive investigation initiated. Notifications completed per facility protocol.R49's Nursing Note, dated 1/5/2026 at 6:58 PM documents skin inspection showed no injuries after abuse allegation today. On 2/19/2026 at 11:30 AM R49 was observed sitting in the dining room on the memory unit and stated she didn't recall hitting R32. R32's Undated Face Sheet documents she was initially admitted to the facility on [DATE] and diagnosis of Late Onset Alzheimer's disease and dementia. R32's Care Plan, dated 5/20/2024 addressed she has the potential for abuse. R32's Quarterly MDS, dated [DATE] documents she was not alert, verbal behaviors exhibited 1 - 3 days and exhibited other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 - 3 days. R32's Nursing Note, dated 1/5/2026 at 1:30 PM documents allegation of abuse was reported. Comprehensive investigation initiated. Notifications completed per facility protocol.On 2/19/2026 at 11:15 AM R32 observed laying in bed with her eyes open, R32 stated she recalled another resident smacked her across the face but it has been a while and she didn't remember the residents name but stated it hurt and she put ice on her face after it occurred. On 2/19/2026 at 2:10 PM, V7 CNA stated she recalled the resident-to-resident altercation between R49 and R32. V7 stated the residents were watching a movie and R32 said something to R49 and then she observed R49 smack R32 across the face. V7 stated she told the nurse (name unknown) as soon as it occurred and she separated the residents immediately. V7 stated she told the nurse what she saw but she didn't write a statement regarding the incident and no one asked her to write a statement regarding the altercation. On 2/19/2026 at 3:36 PM V1, Administrator stated it was determined the resident to resident altercation between R49 and R32 was unsubstantiated because both residents reside on the dementia/memory unit and it wasn't willful intent so it wasn't considered physical abuse.The facility acknowledges the deficiency cited; however, the alleged deficient practice occurred prior to 01/19/2026 and was corrected on 01/19/2026. The facility returned to compliance on 01/19/2026 and remains in compliance.1. How the facility corrected the deficient practiceUpon identification of the deficient practice related to abuse identification and reporting, the facility took immediate corrective action.The resident involved in the incident had their behavior history reviewed by the Interdisciplinary Team (IDT) and the care plan was reviewed and updated on 01/17/2026 to include interventions addressing behaviors and supervision needs.Affected residents received psychosocial follow-up completed by the Social Services Director on 01/19/2026 to ensure their emotional well-being.Additionally, all staff were re-educated on 01/19/2026 regarding the facility's abuse prevention policy, including identifying, preventing, and reporting abuse.2. How the facility identified other residents who had the potential to be affectedThe facility determined that all residents had the potential to be affected by the deficient practice.Behavior monitoring logs and incident reports were reviewed to identify residents exhibiting aggressive behaviors. Residents identified with behaviors were reviewed by the Interdisciplinary Team and care plans were updated as appropriate to ensure proper supervision and interventions were implemented.3. Measures implemented to ensure the deficient practice will not recurThe facility implemented the following systemic changes: Staff education regarding abuse prevention, identification, and reporting requirements was completed on 01/19/2026. Staff were educated on their responsibility to immediately report suspected abuse according to facility policy and regulatory requirements. Behavior tracking processes were reinforced to ensure early identification and monitoring of aggressive behaviors. Daily QA meetings include review of behavior tracking reports to identify new or escalating behaviors requiring intervention.4. Monitoring process to ensure ongoing complianceThe Administrator or designee will conduct staff interviews by randomly selecting three staff members weekly for three weeks to validate staff knowledge of abuse identification and reporting requirements.Results of the monitoring will be reviewed by the Quality Assurance (QA) Committee monthly to ensure continued compliance. The QA Committee will implement additional corrective actions if concerns are identified.Date Compliance Achieved: 01/19/2026Facility's abuse policy dated 1/2026 states Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers, and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches regularly and update as necessary.

Based on observation, interview and record review the facility failed to perform a thorough abuse investigation for 2 (R49, R32) of 3 residents reviewed for abuse in the sample of 44.The surveyor confirmed by observation, interview and record review that the deficiency practice occurred on 1/5/2026 and was corrected on 1/19/2026, prior to the start of this survey, and was therefore Past Noncompliance.Findings include: R49's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis of Alzheimer's disease. R49's Care Plan, dated 4/15/2025 addressed she has the potential for abuse. R49's Quarterly Minimum Data Set (MDS) dated [DATE] documents she is not alert, has disorganized thinking, verbal behaviors exhibited 1 - 3 days and no physical behaviors exhibited. R49's Nursing Note, dated 1/5/2026 at 1:30 PM documents allegation of abuse was reported. Comprehensive investigation initiated. Notifications completed per facility protocol.R49's Nursing Note, dated 1/5/2026 at 6:58 PM documents skin inspection showed no injuries after abuse allegation today. On 2/19/2026 at 11:30 AM R49 was observed sitting in the dining room on the memory unit and stated she didn't recall hitting R32. R32's Undated Face Sheet documents she was initially admitted to the facility on [DATE] and diagnoses included Late Onset Alzheimer's disease and dementia. R32's Care Plan, dated xxx addressed she has the potential for abuse. R32's Quarterly MDS, dated [DATE] documents she was not alert, verbal behaviors exhibited 1 - 3 days and exhibited other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 - 3 days. R32's Nursing Note, dated 1/5/2026 at 1:30 PM documents allegation of abuse was reported. Comprehensive investigation initiated. Notifications completed per facility protocol.On 2/19/2026 at 11:15 AM R32 observed laying in bed with her eyes open, R32 stated she recalled another resident smacked her across the face but it has been a while and she didn't remember the residents name but stated it hurt and she put ice on her face after it occurred. V7's Typed Statement dated 1/5/2026 at 1:25 PM documents we were sitting in the activity room watching a moving (movie.) Residents were sitting within close proximity next to each and R32 said something and that's when I looked over and seen R49 make contact with R32. I immediately separated residents and was able to redirect. Staff documented R49 and R32 unable to recall incident. This typed statement did not include what actually occurred between R49 and R32. On 2/19/2026 at 2:10 PM, V7 CNA stated she recalled the resident-to-resident altercation between R49 and R32. V7 stated the residents were watching a movie and R32 said something to R49 and then she observed R49 smack R32 across the face. V7 stated she told the nurse (name unknown) as soon as it occurred and she separated the residents immediately. V7 stated she told the nurse what she saw but she didn't write a statement regarding the incident and no one asked her to write a statement regarding the altercation. A Physical Abuse Report Form - IDPH Notification, dated 1/5/2026 documents brief description of the incident/event: allegation of physical abuse. Verification of Incident Investigation/Administrative Summary: a comprehensive investigation was completed regarding an allegation of abuse reported on 1/5/2026. The allegations was reported by V7, CNA. Staff immediately separated residents and notified Administrator of allegation. An investigation was initiated immediately. Interviews were conducted with the resident and staff. It was determined that while both residents were participating in an activity, they became agitated and were in close proximity resulting in contact being made. Both residents were unable to recall the details of incident. Based on the investigation, findings including resident statements, staff interviews and clinical assessment. The allegation of abuse was determined unsubstantiated. On 2/19/2026 at 3:46 PM V1, Administrator stated it was determined the resident to resident altercation between R49 and R32 was unsubstantiated because both residents reside on the dementia/memory unit and it wasn't willful intent so it wasn't considered physical abuse. V1 stated she interviewed V7 regarding the resident to resident altercation between R49 and R32 but she couldn't recall what V7 stated and that she documented the interview and included it in the abuse investigation.The facility acknowledges the deficiency cited; however, the alleged deficient practice occurred prior to 01/19/2026 and was corrected on 01/19/2026. The facility returned to compliance on 01/19/2026 and remains in compliance.1. How the facility corrected the deficient practiceUpon identification of the deficient practice related to abuse identification and reporting, the facility took immediate corrective action.The resident involved in the incident had their behavior history reviewed by the Interdisciplinary Team (IDT) and the care plan was reviewed and updated on 01/17/2026 to include interventions addressing behaviors and supervision needs.Affected residents received psychosocial follow-up completed by the Social Services Director on 01/19/2026 to ensure their emotional well-being.Additionally, all staff were re-educated on 01/19/2026 regarding the facility's abuse prevention policy, including identifying, preventing, and reporting abuse.2. How the facility identified other residents who had the potential to be affectedThe facility determined that all residents had the potential to be affected by the deficient practice.Behavior monitoring logs and incident reports were reviewed to identify residents exhibiting aggressive behaviors. Residents identified with behaviors were reviewed by the Interdisciplinary Team and care plans were updated as appropriate to ensure proper supervision and interventions were implemented.3. Measures implemented to ensure the deficient practice will not recurThe facility implemented the following systemic changes: Staff education regarding abuse prevention, identification, and reporting requirements was completed on 01/19/2026. Staff were educated on their responsibility to immediately report suspected abuse according to facility policy and regulatory requirements. Behavior tracking processes were reinforced to ensure early identification and monitoring of aggressive behaviors. Daily QA meetings include review of behavior tracking reports to identify new or escalating behaviors requiring intervention.4. Monitoring process to ensure ongoing complianceThe Administrator or designee will conduct staff interviews by randomly selecting three staff members weekly for three weeks to validate staff knowledge of abuse identification and reporting requirements.Results of the monitoring will be reviewed by the Quality Assurance (QA) Committee monthly to ensure continued compliance. The QA Committee will implement additional corrective actions if concerns are identified.Date Compliance Achieved: 01/19/2026The Facility's Abuse Policy Prevention Program, dated 1/2020 documents internal investigation: all incidents will be documented whether or not abuse occurred, was alleged or suspected. Any incident or allegation involving abuse will result in an investigation. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Final investigation report: the investigator will report the conclusions of the investigation in writing to the Administrator or designee within 5 working days of the reported incident. The final investigation report shall contain the following: name, age, diagnosis and mental status of the resident allegedly abused, the original allegation (note day, time, location, the specific allegation, the alleged perpetrator, witnesses to the occurrence, circumstances surrounding the occurrence, ad any noted injuries), facts determined during the process of the investigation, review of the medical record, and interview of witnesses, conclusion of the investigation based on known facts, police report if applicable.

Based on observation, interview and record review the Facility failed to ensure R30's dialysis site was being monitored for potential complications for 1 of 3 residents (R30) reviewed for dialysis in the sample of 44.Finding include:R30's Physician Order Sheet (POS) for February 2026 documents a diagnosis of end stage renal disease, dialysis, atrial fibrillation, depression, chronic pulmonary edema, hyperlipidemia, hypertension, heart failure, diabetes, dysphagia, glaucoma, anemia, and Acquired absence of left leg below knee (left BKA). R30's POS does not have an order for dialysis and/or checking the dialysis site for possible infection before this survey on 2/19/2026. R30's Care Plan dated 10/1/2025 documents, Resident has an impaired genitourinary status r/t (related to) end-stage renal disease (ESRD), receives dialysis.R30's Minimum Data Set (MDS) dated [DATE] document R30 is cognitively intact for decision making of activities of daily living. R30's Follow up Notes dated 1/9/2026 at 8:20 AM, END STAGE RENAL DISEASE Dialysis: Ongoing, 3x/week, Monday, Wednesday, and Friday. No current issues reportedR30's Annual Wellness Note dated 2/1/2026 at 2:48 PM, END STAGE RENAL DISEASEDialysis: Ongoing, 3x/week, Monday, Wednesday, and Friday. No current issues reported.On 2/18/2026 (Wednesday) at 12:39 PM, R30 was not in the Facility. On 2/18/2026 at 12:55 PM, V2, Director of Nursing stated (R30) goes to dialysis every Monday, Wednesday and Friday. V2 stated she was not aware there was no order to assess and monitor (R30's) dialysis R30's Medication Administrator Records (MAR) and her Treatment Administrator Records (TAR) do not document anything related to her dialysis site before 2/19/2026.On 2/19/2026 at 10:33 AM, R30 stated she goes out to dialysis every Monday, Wednesday and Friday. No staff in the facility ever look at her catheter or port in her chest area. They just have the dialysis center do everything.On 2/19/2026 at 4:00 PM, R30's dialysis site (catheter) was on her upper right chest. The area has a gauze bandage covering it. The bandage is loosely covered.On 2/19/2026 at 4:11 PM, V12, Licensed Practical Nurse (LPN) stated she was familiar with (R30) and she does receive dialysis. She personally, has never been instructed to remove the bandage on her dialysis catheter and/or to visually inspect the wound/port. I have not touched any other dressing related to her catheter. On 2/20/2026 at 9:20 AM, V14, LPN stated if the resident's TAR had orders to check the site then we follow the orders. We always follow the order. If it is not on the TAR then it is not done.On 2/20/2026 at 9:24 AM, V13, Registered Nurse (RN) stated, We always follow the doctor's orders. If treatment is on the TAR then it is done. On 2/20/2026 at 10:17 AM, V16, Nurse Practitioner stated, staff should be assessing and inspecting all dialysis access sites daily. She was not aware there was no order on the POS or TAR for inspections. If the site was not being assessed and it became infected and with (R30's) diagnosis of diabetes and past history of amputation it does have the potential to have harm if the are had become infected and was not assessed and treated timely it would not be good. The Care of Resident With End-Stage Renal/Dialysis Policy with a revision date of 10/27/2023 documents, Purpose: To provide guidance to staff on the appropriate care of a resident with end-stage renal disease/receiving dialysis treatment. Policy: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff include, specifically: The nature and clinical management of ESRD (including infection prevention and nutritional needs) The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD. How to recognize and intervene in medical emergencies such as hemorrhages and septic infections.

Based on observation, interview and record review, the Facility failed to provide at least 80 square feet per resident bed in multiple resident bedrooms for 14 of 86 residents (R2, R21, R22, R27, R26, R30, R32, R36, R39, R41, R43, R51, R76, and R84) reviewed for room size in the sample of 44. Findings include:1-Seven resident bedrooms provide 77.1 square feet per resident bed. Each of these seven rooms measure 15 feet 2 inches by 10 feet 2 inches. These rooms are two-bed rooms, and all are certified for Medicaid/Medicare. These rooms are as follows: 105, 106, 107, 117, 118, and 119.This was verified during room measurements and affect the following residents R21, R22, R32, R36, R41, R51, R76, R84, and R852-Three resident bedrooms provide 74 square feet per resident bed. These rooms measure 15 feet 3 inches by 21 feet, with wardrobes measuring 23 inches by 63 and 24 inches by 94 inches. These rooms are all certified for Medicaid/Medicare. These rooms are as follows: 225, 227, and 228 and affect the following residents R26, R27, R30, R39, and R43On 2/18/2026 at 9:10 AM V1, Administrator stated she had recently become the Administrator and was aware they had room waivers for multiple beds in the facility. They try to ensure that any resident placed in the rooms that their needs are being met and there are no issues with the smaller room sizes.Throughout the survey, there were no complaints from the residents who reside in the undersized rooms regarding room size. There was no infection control concerns related to room size and/or issues with clutter, and/or resident satisfaction.On 2/19/2026 at 11:39 AM, V1 stated she was not aware of any issues from residents occupying the smaller rooms and/or complaints from residents related to the size.The Facility Room Waiver Policy documents, The residents that occupy these rooms have been evaluated and consideration for special needs, and adverse effect on health and safety, space for adequate nursing care, space for furniture and equipment, and appliances. Space for private activities, no infection control problems, resident satisfaction, and quality assurance plans.

Based on observation, interview and record review the facility failed to provide incontinence care for 2 of 3 Residents (R8, R9) reviewed for neglect in the sample of 3. This resulted in R8 and R9 both left saturated in urine for hours and using a reasonable person approach resulted in psychosocial harm that a person would feel ashamed, humiliated, hopeless, and neglected being left in their own incontinence of bowel/bladder. Findings include: 1. R9 R9's undated face sheet documents that he was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety. R9's admission Bowel and Bladder Assessment, dated 11/17/2025, documents that he has occasional incontinence episodes and requires one-person assistance with toileting. R9's Nurse's Note, dated 10/29/2025 at 7:55 PM, documents that the resident arrived from a local hospital via facility transport. He was able to answer questions appropriately, acclimated to the room, and was given a call light. No signs or symptoms of distress or injury were noted. Staff turned on the television per his request. The resident was sitting in a wheelchair in his room and requested a dinner tray, stating he was hungry. There was no documentation indicating whether R9 was incontinent of urine. A review of R9's Electronic Medical Record revealed no documentation of an Interim Care Plan upon admission dated 10/29/2025. R9's admission Evaluation dated 10/29/2025 at 4:00 PM contains no documentation regarding bladder continence status. Toileting assistance was documented as requiring one-person assistance. A review of R9's Progress Notes dated 10/29/2025 through 11/21/2025 revealed no documentation indicating that R9 refused care related to incontinence. R9's admission MDS, dated [DATE], documents that he was alert, exhibited no rejection-of-care behaviors, and was continent of bladder. R9's Comprehensive Care Plan dated 11/21/2025 documents that he has episodes of bladder incontinence and is resistant to care. Interventions were noted on the care plan to address these issues. On 11/21/2025 at 12:50 PM, V3 (ADON) stated she worked the floor as a CNA on 11/16/2025 and was assigned to R9. V3 recalled that R9 refused care from her during that shift. She stated she did not recall whether she documented R9's refusal of care on 11/16/2025, nor whether she informed administration. On 11/21/2025 at 10:50 AM, R9 was observed alert, sitting in his wheelchair in the hallway. He stated he could no longer control his bladder and p***** on himself all day long. He stated that V16, CNA, did not change him one time during the 11/20/2025 day shift, and he remained saturated with urine until night-shift CNA V11 cleaned him up and showered him. R9 stated it was humiliating to sit in p*** all day without staff assistance. He was visibly upset and stated he felt V16 had neglected him. R9 stated that V16 never offered incontinence care, and he did not refuse care from her at any time. On 11/21/2025 at 4:38 PM, V11, CNA, stated she worked the night shift on 11/20/2025 and was assigned to R9. During rounds, she noted a strong odor of urine upon entering R9's room and observed that R9 was upset. R9 told her that day-shift CNA V16 did not take care of him, and he had been soaked in urine all day. V11 stated she removed the blanket, which was saturated with urine to the point it was dripping onto the floor, and the bed was also soaked. V11 stated R9 was crying and said he was ashamed of being left in urine. V11 reported this to V15, Night Shift CNA Supervisor, who came to observe R9's condition. V11 stated she immediately provided R9 with a shower, and R9 did not refuse any care from her. On 11/21/2025 at 11:35 AM, V16, CNA, stated she worked the 11/20/2025 day shift and was assigned to R9 from 7:00 AM to 7:30 PM. She stated she entered R9's room multiple times throughout the shift and asked if he needed anything, and claimed he refused care and told her to get out of his room. V16 stated she did not report R9's alleged refusals of care and believed he was having a bad day and could care for himself regarding incontinence. At shift change, when she observed R9 saturated with urine alongside V11, she told V11 not to tell on her. After leaving the facility, V16 called V3, ADON, and reported R9 refused all care that day because she didn't want to get in trouble. V16 stated this was her first shift caring for R9, and she did not receive a report from the previous staff. She did not know he was incontinent and assumed he used a urinal. She also stated that when she told V3 about R9's alleged refusals, V3 informed her that R9 had refused care on 11/16/2025 as well. On 11/21/2025 at 12:50 PM, V3, ADON, stated V16 called her the evening of 11/20/2025 and reported that R9 refused care all day and that the night shift found him saturated with urine. V16 stated she did not know what to do and did not want to get in trouble for not taking care of R9. 2. R8 R8's undated face sheet documents she was initially admitted on [DATE] with diagnoses including dementia and anxiety. R8's care plan, created on 6/5/2023, documents the focus: the resident has bladder incontinence. Interventions include: check every two hours and assist with toileting; provide bedpan/commode; provide pericare after each incontinence episode. R8's revised care plan, dated 5/6/2025, documents that she is resistant to care, removes soiled blankets, and throws them on the floor. Interventions include using a different caregiver, reassuring the resident if she resists ADLs, and leaving and returning later to reattempt care. R8's Quarterly MDS dated [DATE] documents cognitive impairment, daily rejection-of-care behaviors, and urinary incontinence. R8's Progress Notes dated 11/20/2025 contain no documentation of care refusals or any interventions attempted to address incontinence care overnight. On 11/21/2025 at 9:38 AM, R8 was observed lying in bed with eyes open. She stated, I am full of p***. A strong odor of urine was noted. R8 pulled down her blanket and showed the surveyor she had no clothes on, stating, I took my diaper and gown off because it was p*** filled! She stated lying in wet, cold p**** for hours made her feel disgusting and extremely humiliated. Her breakfast tray was untouched. R8 asked, Would you eat if you were cold and covered in p***? On 11/25/2025 at 9:15 AM, V7, CNA, stated she worked the night shift and was assigned to R8 on 11/20–11/21/2025. She stated R8 is mean, combative, curses at staff, is racist, and rarely allows any hands-on care, including incontinence care. V7 recalled R8 throwing her urine-soaked gown and brief at her around 3:00 AM and refusing all care despite offers to assist her with cleaning and dressing. V7 stated she removed the soiled items from the room and placed them in the soiled utility room. On 11/21/2025 at 9:41 AM, V17, CNA, stated she was assigned to R8 for the day shift. At 9:45 AM, V17 entered the room and observed V18 CNA and V19 CNA providing care to R8. R8 yelled, Well, it's about damn time someone came to get me out of these p*** filled sheets! V19 assisted R8 to roll, revealing a saturated yellow-stained pad with multiple urine rings. V19 stated the pad and sheet were saturated. She provided incontinence care, changed the sheets, applied a clean brief and gown, and R8 was cooperative. V19 stated she was not assigned to R8 but assisted because R8 was saturated. She stated she did not know why R8 was without a gown or brief. On 11/21/2025 at 9:57 AM, V17 stated she arrived at 7:30 AM and conducted rounds at 7:40 AM. No report was given to her. She stated she did not wake R8 because she did not want to disturb her, and she was unaware of R8's incontinence status or that she had no clothing or brief on. She stated she delivered breakfast at 9:30 AM, and R8 was still resting. V17 stated R8 is combative and yells at her frequently, so she lets her sleep when she is resting. She stated she had not provided any ADL or incontinence care that morning. On 11/21/2025 at 12:50 PM, V3, ADON, stated R8 is known to refuse care and will remove her gown and brief. V3 stated she does not know why the resident does this. On 12/5/2025 at 9:15 AM, V2, DON, stated she expects staff to check and change incontinent residents every two hours and PRN to ensure they remain clean and dry. She stated that residents have the right to refuse care; however, refusals must be reported to the charge nurse within two hours. The charge nurse must assess the resident, document refusals, document interventions attempted, and provide education on consequences (e.g., skin breakdown). Continued refusals must be reported to the provider. V2 stated she expects staff to follow all facility policies. The State Operations Manual (SOM) defines Neglect at 483.5 as: the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview and record review the facility failed to ensure 2 (R8, R9) of 3 residents received adequate and timely incontinence care for ADL dependent residents reviewed for incontinence in the sample of 3.Findings include:1. R9's Undated Face Sheet documents R9 was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety. R9's admission Bowel and Bladder assessment dated [DATE], documents R9 has occasional incontinence episodes and needs one assist with his toileting needs.R9's Nurse's Note, dated 10/29/2025 at 7:55 PM, documents resident arrived from local hospital via facility transport. Resident able to answer questions appropriately. Resident acclimated to room and given call light. No s/s (side or symptoms) of distress or injury. TV turned on per resident's request. Resident sitting in wheelchair in room, requested dinner tray as resident states he is hungry. No documentation if resident is incontinent of urine. R9's Electronic Medical Record no documentation of an Interim Care Plan upon admission dated 10/29/2025. R9's admission MDS dated [DATE] documents he was alert, no rejection of care behaviors, continent of bladder. R9's Comprehensive Care Plan dated 11/21/2025 documents R9 has episodes of bladder incontinence and is resistive to care. Staff documented interventions on the care plan to address these issues. On 11/21/2025 at 10:50 AM R9 alert, up in wheelchair in hallway stated he can't control his bladder anymore so he p***** on himself all day long and V16, CNA (Certified Nurse Aide) didn't change him one time yesterday (11/20/2025) during the day shift and he was saturated with urine until night shift V11, CNA came in and helped clean him up and showered him. R9 stated V16 never offered to change his brief due to peeing at all that shift and he never refused care from her. On 11/21/2025 at 4:38 PM V11, CNA stated she worked night shift on 11/20/2025 and was assigned to R9. V11 stated she did rounds, and she entered R9's room there was a strong smell of urine. R9 told V11 that the day shift CNA V16 didn't take care of him all day and that he was soaked in urine. V11 stated she removed the blanket from R9 and it was so saturated with urine it was dripping urine on the floor and R9's bed was soaked with urine. V11 stated she immediately gave R9 a shower and got him cleaned up and R9 didn't refuse care from her at all. On 11/21/2025 at 11:35 AM V16, CNA stated she worked day shift on 11/20/2025 and was assigned to R9 from 7:00 AM to 7:30 PM. V16 stated she entered R9's room multiple times throughout the shift and asked if R9 needed anything and that he refused care and stated to get out of his room. V16 stated she didn't report R9 refusing care and thought he was just having a bad day and that he could take care of himself regarding incontinence. When night shift staff came in she did rounds with V11, CAN she noted R9 was saturated with urine and V11 stated she was going to tell on her that she didn't take proper care of him so she called V3, ADON after she had left the facility that R9 had refused care all day and that he was found saturated with urine when night shift arrived because she didn't want to get in trouble for not taking care of R9. V16 stated that was the first time she was assigned to take care of R9 and no staff gave her report on him and she didn't know R9 was incontinent of urine, she thought he used a urinal. V16 stated when she reported that R9 refused care to V3 that V3 told her he refused care for her on 11/16/2025 as well so she was aware he refuses care at times. On 11/21/2025 at 12:50 PM V3, ADON stated V16 called her in the evening on 11/20/2025 and stated R9 refused care from her all-day shift and that the night shift reported to her that R9 was soaked with urine because V16 didn't change his incontinence brief throughout her shift. V16 reported to V3 that she didn't know what to do and she didn't want to get in trouble for not taking care of R9 but that he refused all care from her, and she didn't know what to do.2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including dementia and anxiety. R8's care plan creation date, 6/5/2023 documents focus: resident has bladder incontinence. Interventions: check resident every 2 hours and assist with toileting as needed, provide bedpan/bedside commode, provide peri care after each incontinence episode. R8's Revised Care Plan, dated 5/6/2025 documents focus: resident is resistant to care, takes blankets off the bed when soiled and throws them on the floor. Interventions: try changing caregiver if resident is not cooperative with care, if resident resists with ADLs (Activities of Daily Living) reassure resident then leave and return later and try again. R8's Quarterly Minimum Data Set (MDS) dated [DATE] documents she is cognitively impaired, rejection of care occurred daily and incontinent of urine. R8's Progress Notes, dated 11/20/2025 no documentation of resident refusing care or what interventions were attempted to provide incontinence care overnight to R8. On 11/21/2025 at 9:38 AM R8 lay in bed with her eyes open. R8 was alert and stated, I am full of p***. There was a strong odor of urine in the room. R8 pulled her blanket down and showed the IDPH surveyor she didn't have clothes on. R8 stated, I took my diaper and gown off because it was p*** filled! Would you want to wear a p*** filled gown and diaper? I doubt it! On 11/25/2025 at 9:15 AM V7, CNA (Certified Nurse Aide) stated she works night shift and was assigned to R8 on 11/20/2025 into 11/21/2025. V7 stated R8 is mean, combative and curses at staff, she is racist and V8 rarely allows her to provide any hands-on care to her, including incontinence care. V7 stated she recalled the night shift of 11/20/2025 into 11/21/2025 and R8 refused all care and R8 threw her urine-soaked gown and depend at her that night around 3:00 AM. V7 stated she offered to assist R8 in getting cleaned up and dressed and R8 just cursed at her and so took the gown and brief out of R8's room and put them in the soiled utility room. On 11/21/2025 at 9:41 AM V17, CNA stated she was assigned to R8 for day shift. On 11/21/2025 at 9:45 AM V17 entered R8's room and observed V18, CNA and V19 CNA providing care to R8. R8 yelled, Well it's about damn time someone came to get me out of these p*** filled sheets! V19 assisted R8 to roll to her right side and showed a saturated yellow stained pad that had several stained urine rings on it. V19 stated the pad and sheet were saturated with urine. V19 provided incontinence care for V8 and changed her sheets, applied a clean incontinence brief and a clean gown to R8, R8 was cooperative with care at that time. V19 stated she wasn't assigned to R8 that shift and she was helping out to get R8 cleaned up because she was saturated with urine, V19 didn't know why R8 didn't have an incontinence brief on or clothes on at that time. On 11/21/2025 at 9:57 AM V17, CNA stated she was assigned to R8 day shift. V17 stated she got to work at 7:30 AM and she did rounds at approximately 7:40 AM, V17 stated no staff gave her report that morning and she didn't know when the last time staff provided care to R8. During rounds V17 stated R8 was resting in bed and didn't want to wake her up. V17 stated she didn't know if R8 was incontinent of urine or not at that time because she didn't want to wake her up and she didn't know if R8 had clothes on. V17 stated she delivered R8's breakfast tray to her room around 9:30 AM and R8 was still resting. V17 stated R8 is very combative and yells a lot at her so when she rests, she lets her rest. V17 stated she hadn't provided any ADL care including incontinence care to R8 that morning because R8 was resting. V17 stated she usually checks and changes incontinent residents every two hours and PRN (when needed) but she didn't want to wake R8 up that morning and wasn't aware she was incontinent or that she didn't have clothes or an incontinent brief on that morning. V17 stated R8 is capable of removing her clothes and brief and she throws them at staff often when they are wet with urine. On 11/21/2025 at 12:50 PM V3, ADON stated R8 is known to refuse care and R8 removes her gown and her incontinence brief and V3 stated she doesn't know why R8 does that. On 12/5/2025 at 9:15 AM V2, Director of Nurses (DON) stated she expects staff to check and change incontinent residents every two hours and PRN (when needed) to ensure they are getting their needs met and stay as dry and clean as possible. V2 stated residents have the right to refuse care but if they refuse care like incontinence care and they are soiled she expects the CNA to report the refusal of care to the charge nurse within two hours and the charge nurse should go assess the resident, if the resident continues to refuse incontinence care V2 expects the charge nurse to document the resident is refusing incontinence care and what interventions staff have attempted and what education the resident was given for consequences of refusing incontinence care i.e. skin breakdown. The refusal of incontinence care and education is expected to document in the resident's nurses notes and if the resident continues to refuse incontinence care V2 expects the charge nurse to notify the resident's provider. V2 stated she expects staff to follow all facility policies. The Facility's Incontinence Care Policy, revised 5/16/2022, document's purpose: to provide guidelines to all nursing staff for providing proper incontinence care in order to clean skin clean, dry, free or irritation and odor. Policy: All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Responsibility: It is the responsibility of the CNA to provide incontinence care. It is the responsibility of the charge nurse to ensure that all residents receive appropriate incontinence care. It is the responsibility of the Director of Nurses to ensure that all nursing staff have received adequate training on the provision of proper incontinence care. The Facility Refusal of Care Policy revised 7/18/2022 document's purpose: to provide guidance to facility staff on resident's right to refuse care. If resident refuses care the unit manager, charge nurse or Director of Nurses will meet with the resident to determine why the resident is refusing care, try to address concerns and discuss alternative options and discuss the potential outcomes or consequences (positive and negative) of the resident's decision. Detailed information relating to the refusal of care will be documented in the resident's medical record. Documentation pertaining to a resident's refusal shall include at least the following: the date and time care was attempted, type of care, the resident's response and stated reason(s) for refusal, the name of the person attempt to administer care, that the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the treatment, the resident's condition and any adverse effects due to the request and the date and time the practitioner was notified as well as the practitioner's response. The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequence of the request.

Based on interview and record review, the facility failed to implement a systematic approach to assess and evaluate a resident's unsafe wandering, record resident specific information, and monitor a resident with known exit seeking behaviors for 1 of 3 residents reviewed for elopement. This failure resulted in R2 eloping out of the facility on an unknown date and getting down a public street before staff were able to catch up with him and again on 8/25/2025 when R2 was seen exiting the facility unsupervised when police officers patrolling the area heard the alarm and found R2 exiting the fire door attempting to leave unsupervised and with no staff anywhere around. R3's room remains adjacent to the fire door exit. This failure has the potential to affect all 11 residents who are at risk for elopement and wandering.The Immediate Jeopardy began on 7/19/2025, when R2 eloped from the facility through the front doors unattended. On 9/3/2025 at 10:00 AM V1, Administrator; V2, Director of Nursing (DON), and V28 Chief Operating Officer, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 9/3/2025, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Finding include:R2's Undated Face Sheet documents R2 was originally admitted to the facility on [DATE] and has a diagnosis of Dementia, Anxiety Disorder, and Depression.R2's MDS dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing, chair/bed to chair transfers, and a wander/elopement alarm is not used.R2's Care Plan Date Initiated 8/19/2025 documents R2 is at risk for elopement due to cognitive issues and impaired safety awareness. Interventions/tasks Date Initiated 8/19/2025 documents calmly redirect and divert resident's attention, distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, and books, promptly check when alarm system goes off to ensure resident is safe and remains in facility. Interventions/Tasks Date Initiated 8/25/2025 documents 15-minute visual checks.R2's Potential Risk of Elopement dated 8/19/2024 documents R2's Risk for Elopement is resolved.R2's Elopement Risk assessment dated [DATE] at 7:35 AM documents R2 was not considered at risk for elopement.R2's Elopement Risk assessment dated [DATE] at 9:00 AM documents R2 was not considered at risk for elopement.R2's Elopement Risk assessment dated [DATE] at 5:56 AM documents R2 was not considered at risk for elopement.R2's Quarterly Nursing Evaluation Summary Note dated 8/6/2025 at 2:47 PM documents R2 is at high risk for elopement, R2 wanders within the facility or has a history of wandering, R2 verbalizes, or exhibits exit seeking behavior, and R2 has a previous history of attempted or actual elopement.R2's Elopement Evaluation dated 8/25/2025 at 8:45 PM documents R2 is a high risk for elopement, has a previous history of attempted or actual elopement, and verbalizes or exhibits exit seeking behaviors. R2's Medical Record reviewed with no clinical documentation regarding R2's elopement attempts.R2's Nursing Note dated 8/16/2024 documents R2 arrived at facility in private car accompanied by his son. R2' Son states that resident was living in a hotel locally for several months after unsuccessful integration attempts in other Long Term Care (LTC) Facilities; resident was caring for himself and became progressively weaker.Local Police Report dated 8/25/2025 at 8:31 PM documents while patrolling East on 27th Street, I heard an audible alarm coming from [NAME] Health Care Facility. I could see an elderly male in a wheelchair exiting a rear fire exit door and determined that this was the source of the alarm. I met with R2, a resident at the facility. R2 was upset and complained that he wanted to leave the facility with police. I asked staff if R2 was a patient with Alzheimer's or Dementia or agitation. Staff indicated they did not know. I became concerned about R2 continuing to try to leave the facility unsupervised by staff and concerned about staff apparent lack of knowledge regarding the patient, his diagnoses, or needs.On 8/28/2025 at 8:05 AM R2's room location is adjacent to a fire exit door.On 8/28/2025 at 8:15 AM no binder for residents at risk for elopement noted at nurse's station. On 8/28/2025 at 8:45 AM V4, Registered Nurse (RN), stated the facility has many residents that wander. V4, RN, stated if a resident is at risk for wandering, they will have an ankle bracelet on and an alarm pad in their wheelchair. V4 stated the facility does not have a list of residents that are at risk for leaving the facility unattended.On 8/28/2025 at 8:52 AM, V5, Licensed Practical Nurse (LPN), stated if a resident is at risk for wandering, the resident will have a Wander Guard on and the facility will watch them closely. V5 stated the facility does not have a list of residents that are at risk for elopement or wandering.On 8/28/2025 at 9:20 AM V8, Certified Nursing Assistant (CNA), denied knowing of a list or book of residents that are at risk for wandering/elopement.On 8/28/2025 at 9:26 AM V9, CNA, stated residents will have a Wander Guard in place if they are at risk for exiting. V9 stated the facility does not have a list or book of residents that are at risk for wandering or eloping that she knows of.On 9/2/2025 at 12:38 PM V11, CNA, stated if a resident is at risk for wandering, the resident will have a Wander Guard in place on their wrist or ankle. V11 denied knowing if the facility keeps a list of residents who are at risk for elopement.On 9/2/2025 at 12:42 PM V13, LPN, stated the facility does not have a book or list of residents that are at risk for wandering/elopement, and residents that are at risk will have a Wander Guard in place.On 9/2/2025 at 12:48 PM V23, CNA, stated the facility does not have a list or book of residents at risk for elopement that she knows of. V23 stated resident that are at risk for eloping will have a Wander Guard on and she will get told in shift report which residents at are risk.On 9/2/2025 at 12:53 PM V24, LPN, stated the facility's computer system use to have a communication page where you could tell if a resident was at risk for eloping the facility. V24 denied the facility having a list or book of resident who are at risk for eloping.On 8/29/2025 at 1:30 PM V2, Director of Nursing (DON), stated a resident's Elopement Assessment score will determine if a resident is at risk for elopement and if the need for a Wander Guard is applicable as stated in the facility's Wandering/Elopement Policy.On 9/2/2025 at 3:51PM V26, RN, stated the facility does not have a book or list of residents that are at risk for wandering or elopement. V26, RN, stated the facility just knows who is at risk and staff with watch those residents closely, and most of those residents will have a Wander Guard on.On 8/28/2025 at 11:35 AM V11, CNA, stated R2 has always walked up and down the hallways and has made the comment that he wants to go into the alleyway outside and leave the facility. V11 stated there is an exit door by R2's room that R2 will look at and say he wants to go out the door to that alley.On 8/28/2025 at 11:45 AM V12, Activity Aide, stated R2 does have exiting seeking behaviors and likes to wander. V12, stated R2 has gotten out of the facility a couple months ago and just a couple days ago. V12, stated 2 local police officers were doing their rounds in the area a couple days ago, when they heard the door alarm and found R2 and brought R2 back into the facility.On 8/28/2025 at 12:00 PM V13, LPN, stated R2 will wander in the hallways and tries to go out of the facility by the front door.On 8/28/2025 at 1:25 PM V14, LPN/MDS/Care Plan Coordinator, stated R2 does exit seek and has had a couple episodes where R2 has tried to exit the facility. V14 stated she is unsure of the exact dates R2 has tried to elope from the facility. V14 stated the facility had a recent episode where R2 tried to exit the facility and the local police department were patrolling the area, heard the door alarms, and saw R2 trying to exit the facility, but is unsure of the exact date.On 8/28/2025 at 2:12 PM V15 LPN stated she was working on 8/25/2025 when she heard R2 had gone out of one of the doors of the facility and police brought R2 back inside the facility.On 8/28/2025 2:31 PM V17, CNA, stated she was working the evening on 8/25/2025 when R2 got out of the facility. V17 stated she was in another residents room providing care when she heard a nurse state over the intercom that the G Hall door was open. V17 stated she was unable to response to the door alarm due to providing resident care. V17 stated R2 does like to exit seek and by the time she was done providing care to her resident, there were local police officers in the facility that had assisted R2 to his room. V17 stated after the incident R2 was placed on 15-minute checks.On 8/28/2025 at 2:54 PM V18, CNA, stated she was in another resident's room putting a resident to bed when she heard the nurse say the G Hall door alarm was going off. V18 stated she was unable to leave the resident she was helping to check the door alarm. V18 stated R2 does wander the facility and tries to exit the facility.On 8/28/2025 at 3:03 PM V2, DON, stated if R2 gets upset, R2 will want to go outside. V2, DON, stated R2 has never exited the building without being accompanied by staff. V2, DON, stated on 8/25/2025 V3, Local Police Officer, was driving by the facility doing surveillance when V3 heard the door alarm going off and could see R2's wheelchair in the doorway. V2 stated R2 did not get out of the doorway threshold and never made it outside of the facility. V2 stated R2 did not get out of the facility, so an incident report did not need to be done. V2 stated R2 was placed on 15-minute checks on the evening of 8/25/2025 after the incident and R2 remains on 15-minute checks.On 8/28/2025 at 3:57 PM V16, RN stated she was passing medication on the front side of the building when she heard the G Hall door alarm go off. V16 stated she paged for staff to go look at the door. V16 stated when she got down the hall to the G Hall door, R2 was by the door and the local police department officers were with R2. V16 stated local police officers talked to R2, brought R2 back inside the facility and helped R2 back into his room. V16 denied knowledge of R2 previously trying to get out of the facility.On 8/29/2025 at 10:00 AM R4 stated her room is right by the G Hall exit door and R2 tries to exit the door and get out of the facility. R4 stated R2 has gotten out of the facility a couple months ago and made it all the way down the road and staff have had to chase him. R4 stated R2 will tell her he wants to leave the facility. R4 stated on 8/25/2025 R2 told her that he did not want to stay in the facility and wanted to leave. R4's MDS dated [DATE] documents R4 is cognitively intact.On 8/29/2025 at 10:16 AM V21, LPN, stated R2 tries to exit the facility and has exit seeking behaviors.On 8/29/2025 at 10:22 AM V3, Local Police Officer, stated he was on patrol the evening of 8/25/2025 and was in the area outside of the facility when he heard an alarm sounding. V3 stated he could see a fire exit door open and a resident trying to go outside of the door unattended. V3 stated R2 was in the process of exiting the facility and the front wheels of R2's wheelchair was already out of the doorway when he walked up to the door. V3 stated no staff was near R2 when he approached R2. V3 stated he happened to be in the right place at the right time and if he didn't hear the alarm or see R2, R2 could have gotten farther outside of the facility then he did. V3 stated he was able to speak with R2 and R2 kept saying he wanted to leave the facility. V3 stated he is unsure how R2 was able to get the door open and start leaving with no staff around him. V3 stated when he got R2 back in the facility the nurse V16 just stood there and did not assess R2 or take him back to his room. V3 stated V16 did not know any health information on R2 when V3 asked regarding R2's cognition. V3 stated when he spoke to staff regarding how R2 was able to get the facility door open, no one had any idea what was going on or could tell him any information about R2 and R2's medical diagnosis. V3 stated it seemed odd that no staff knew the cognitive status of R2 or how he was able to get the door open.On 8/29/2025 at 11:10 AM V7, Social Services Director (SSD), stated R2's cognition fluctuates and with his lack of safety awareness at time, staff needs to be present with R2 when outside.On 8/29/2025 at 11:25 AM V2 stated R2 has gone for walk down the street with staff. V2 stated she would not encourage R2 to be outside by himself. V2 stated she would expect her staff to follow the documentation policy and to document when any event or behaviors occurs. V2 stated there is no documentation regarding the event from 8/25/2025 and there was no incident report done regarding R2 trying to get out of the facility on 8/25/2025 because R2 did not make it out of the facility. V2 stated she was told by V3 that an incident report would not be made, and they would consider this a wellness check. V1, Administrator, stated R2 has never gotten out of the facility and no elopement events have occurred with R2 or any resident. V1, stated she is not aware of R2 exiting the facility without staff present. V1 stated if something is not documented, then it didn't happen.On 8/29/2025 at 11:41 AM V22, RN, stated R2 is confused and thinks he needs to leave the facility. V22 stated R2 wanted to go outside previously, and she walked with him outside of the facility down the road to see the church nearby. V22, LPN, stated she is unsure the date that she walked R2 down the road by the church, but knows it was hot outside.On 9/1/2025 at 8:48 AM V19, R2's Son, stated R2 is forgetful at times and needs staff assistance with getting out of bed into his wheelchair. V19 stated he has never been informed by the facility that R2 has tried to exit the facility or has been successful with exiting the facility.On 9/2/2025 at 12:42 PM V13, LPN, stated R2 has a history of wandering the facility and trying to exit. V13 stated R2 has always been that way and will tell staff that he wants to go home.On 8/29/2025 at 1:10 PM V20, Facility Medical Director, stated R2 has a diagnosis of mental illness and dementia and does not comprehend or understand what is going on at times. V20 stated he was informed about a month ago that R2 had exited the facility out of the front lobby door and made it down the road before staff could get to him. V20 stated it is not safe for R2 to be outside unattended due to his cognition and safety awareness. V20 stated he was not informed of R2 setting off the door alarm or the police seeing R2 in the doorway trying to exit the facility on 8/25/2025.On 9/2/2025 at 1:01 PM V20, Facility Medical Director, stated he has been R2's medical doctor since R2 was admitted to the facility. V20 stated R2 has always exhibited exit seeking behaviors since admission and V20 has given the facility his opinion that R2 be on the locked unit. V20 stated it is not appropriate for R2's room to be close to any door in the facility due to his exit seeking behaviors. V20 stated if R2 was to get outside of the facility unattended, R2 could get hit by a car, get lost, fall, hit his head, and/or die.On 9/3/2025 at 10:00 AM IJ template presented and read to V1, Administrator, V2, DON, and V28, Chief Operating Officer (COO). At presentation of the IJ template, V1, stated V2 had a soft file on the incident that happened in July while she was on vacation, which the facility called her on. V1 wanted the survey team to look at this file. Survey team stated the file would be looked at after the presentation of the IJ template. V1 and V2 were reminded they were asked for any documentation or incident reports on R2's elopement attempts or exit seeking behaviors. V1 and V2 were reminded that they stated in previous interviews that the facility did not have any documents on any elopement attempts or incidents regarding R2.On 9/3/2025 at 11:23 AM V28, COO, present this surveyor with R2's soft file dated 7/19/2025. The file contained 5 Staff Witness statements dated 7/19/2025 from V12, Activity Aide; V16, RN; V22, RN; V29, CNA; and V30, LPN. 4 of the 5 witness statements dated 7/19/2025 documented signature via phone and were not signed by the staff member. Witness statement dated 7/19/2025 by V16, RN, documents I was in another residents room, and heard door alarm. I seen R2 at the door, so I ran to him. R2 was upset because the door on the hallway was closed and was wanting to go outside. I couldn't keep R2 inside so I went outside with him and called V22, RN. V22 then came outside and stayed with him until he was ready to come back in. We then put him on 15 minute checks. During this investigation in a previous interview on 8/28/2025 at 3:57 PM with V16, V16 denied R2 trying to exit the facility prior to the incident on 8/25/2025.The Facility's Charting and Documentation Policy Date Revised 11/21/2020 documents Policy Interpretation and Implementation: The following information is to be documented in the resident medical record: objective observations, treatment or services performed, changes in the resident's condition, events, incidents, or accidents involving the resident.The Facility's Wandering/Elopement Policy Date Revised 3/13/2024 documents All residents are assessed for risk of unsafe wandering and/or elopement and those who are identified as at risk will be assessed for utilizing the safety interventions of a Wander Guard bracelet (where applicable) to prevent unsafe exit from the center. If not applicable, the Interdisciplinary Team will meet to discuss other safety measures that will be put in place. Policy Interpretations and Implementations section documents If a resident exhibits exit seeking behaviors or expresses the desire/determination to leave and if that resident is not cognitively able to support independent decision making, a new Elopement Risk Assessment and review by the interdisciplinary team will be conducted. Other safety interventions may be utilized pending the assessment. On 9/3/2025 at 11:43 AM Abatement #1 not accepted.On 9/3/225 at 12:39 PM Abatement #2 accepted.The facility took the following actions to remove the Immediacy:1.Immediate Actions Taken for Identified ResidentsR2 continues to reside in the facility.The following immediate actions were initiated on September 2, 2025, by V31, Regional Resident Services Director:Care plan reviewed to ensure appropriate interventions addressing exit-seeking behaviors. Elopement risk assessment reviewed for accuracy and completeness.2. Identification of Other Residents Who Could Potentially Be AffectedAll residents were considered to have the potential to be affected.3. Measures Implemented / System Changes Elopement assessments for all residents were reviewed and updated for accuracy as needed (initiated September 2, 2025, by V31)Care plans for residents identified as at risk for elopement were reviewed and revised with appropriate interventions (initiated September 2, 2025, by V31).Behavior tracking was initiated for all residents identified as at risk for elopement or exit-seeking behaviors (initiated September 2, 2025, by V31).Staff Education (initiated September 2, 2025, led by V2, DON):Elopement policy and procedures.Recognition of exit-seeking behaviors. Accurate and timely documentation requirements.Location and use of the facility's Elopement Binder.Licensed nursing staff received additional targeted training on documenting elopement attempts and exit-seeking behaviors.If staff are unable to be reached, the facility will ensure those staff members are educated prior to working their next shift to ensure compliance.Policy Review: The Elopement Policy and Documentation Policy regarding exit-seeking behaviors were reviewed and approved by the below on September 3rd, 2025.V32, Chief Nursing OfficerV28, Chief Operating Officer4. Monitoring of Corrective ActionsDON or designee will:Review the 24-hour report and behavior tracking logs daily (Monday-Friday) for 12 weeks to identify and address exit-seeking behaviors (initiated September 3, 2025).Review all new admissions and readmissions daily (Monday-Friday) for 12 weeks to ensure elopement assessments are accurate and care plans reflect appropriate interventions (initiated September 3, 2025).The Administrator or designee will:Provide monthly in-services on elopement policy, identification of exit-seeking behaviors, and implementation of appropriate interventions (initiated September 3, 2025). Conduct weekly monitoring of three residents identified as at risk for elopement (initiated September 3, 2025) to ensure:Elopement assessments are completed.Wandering/exit-seeking behaviors are documented and addressed with interventions.Care plans are updated as needed. Results of all monitoring activities will be reviewed during weekly Quality Assurance and Performance Improvement (QAPI) meetings led by the Administrator for 12 weeks (initiated September 3, 2025). Additional education and corrective measures will be implemented as necessary until sustained compliance is achieved.Removal/Completion Date: 9/3/2025Surveyors validated the removal of abatement by reviewing medical records and the facility's elopement book. R2's medical record was furthered reviewed. Surveyors reviewed additional sampled resident's medical records to ensure the facility's following the Wandering/Elopement policy. Employees including V1, Administrator; V2, DON; V6, CNA Supervisor; V7, SSD; V11, CNA; V27, LPN; V30, LPN/Infection Control; V33, Kitchen/Activity Aide; V34, Laundry; V35, CNA; V36, CNA; V37, CNA; V38, COTA; V39, Human Resources Coordinator; V40, Speech Language Pathologist; V41, Activity Director; V42, Assistant Director of Nursing; V43, Housekeeping Supervisor; V44, Nurse Aide Non-Certified; V45, LPN/Nurse Supervisor/Wound Care Coordinator; V46, Food Service Director; and V47, Activity Aide interviewed regarding the facility's in-services. Date of Completion 9/3/2025. V1 stated all staff have been in-serviced on the facility's Wandering/Elopement policy and where the facility's Elopement book is located, and if they haven't been they will be in-serviced on the policy prior to the start of their shift.

Based on observation, interview and record review, the facility failed to prevent resident to resident sexual abuse for 1 of 1 (R2) residents reviewed for abuse in the sample of 4. This failure resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, fearfulness and humiliation. This past compliance occurred from 4/14/2025 to 4/15/2025. Findings include: 1.R2's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including dementia, psychotic disorder with hallucinations and post traumatic stress disorder (PTSD.) R2's MDS, dated [DATE] documents he is cognitively impaired. R2's Care Plan, dated 3/6/2025 staff documented potential for abuse and was also care planned for history that indicates he may have experienced significant trauma during his lifetime. Resident identified trauma related to triggers include people grabbing and observations of other being grabbed. R2's ER (emergency room ) documentation, dated 4/14/2025 patient presenting for evaluation of possible sexual assault. Patient was coming from VA (Veterans Association) hospital with transfers apparently, they cannot evaluate any type of sexual assault. Patient reports over the weekend believe was Saturday he was groped by a facility member there. Patient reports he was squeezed on his buttocks reports no handing of his genitalia including testicles or penis. Patient denies anything entering his rectum or any pain around his anus. Patient denies any rash or discharge. Police have been contacted. ED progress note documents patient reports he was groped apparently was squeeze down his buttocks. Did perform visual exam which was unremarkable. Did discuss with patient and family on obtaining forensic evidence such as a rape kit which at this time did not see any need for as there was no insertion injury. Clinical impressions documented: sexual assault by bodily force by caregiver. On 4/16/2025 at 8:15 AM V2, Director of Nursing (DON) stated V1 is the Administrator, and they were notified of residents having an incident on 4/15/2025, that involved (R1) and (R2) and that both resided on the dementia unit and (R2) is not interviewable. She stated (R1) was moved from the dementia unit after the allegation and is now on a 1:1 with staff. V2 stated neither resident have a history of sexual touching between themselves or others. V2 stated (R1) was walking down the hall and came up to (R1) and touched his butt both residents had clothes on at the time and staff separated them immediately. V14, Registered Nurse (RN) was the nurse and V12 was the CNA, this incident occurred on 4/13/2025 at approx. 8:00 PM. V2 stated (R2) is out of the facility for a physician's appointment today and isn't expected back until late this evening. On 4/16/2025 at 9:14 AM V1 stated V11, Case Manager at the veteran's association primary care office called the facility on 4/14/2025 at approximately 10:00 AM and stated (R2) stated he was grabbed on the back side by (R1), he started an investigation at that time. V1 stated neither resident has a history of sexual touching. A Witness Statement, dated 4/14/2025 V11, VA (Veteran's Association) Nursing Home Consultant documents (R1) presented to ED for medical evaluation. Another resident attempted to sexually assault him in the facility and stated a hand was fully into his rectum, being sent to another hospital for sexual assault evaluation. On 4/16/2025 at 2:14 PM V11, VA Nursing Home Consultant stated she called the facility to notify them of the allegation of sexual abuse on 4/14/2025 and she reported what was (R2's) VA medical record, that is where she got the information from. The VA social worker referred (R2) to a local ER because they do not do sexual assault kits at the VA. V11 stated she read (R2's) hospital paperwork and noted it documents a different version of what occurred to (R2) and she wasn't sure what actually occurred in the incident but that she reported what (R2's) VA medical record documented. A Witness Statement, dated 4/14/2025 V12, Certified Nurse Aide (CNA) documented, Yes, I provided care for him (R2) his family was with him and completed routine checks. Family arrived around 12:00 PM and left and came back. Family was still here when I left at 8:45 PM. V13, R2's family member reported that another resident touched his butt. I reported it to V14, RN around 8:20 PM (R2) stated R1 touched his (R2) butt around 8:15 PM. (R2) stated that resident (R1) came up from behind and first grabbed his arm then grabbed his butt with both hands. On 4/16/2025 at 12:50 PM V12, CNA stated he worked 4/14/2025 day shift and stayed a few hours extra to help out and was assigned to (R2.) Around 8:20 PM (R2's) family member (V13) reported to him that (R1) grabbed (R2's) buttocks and he reported it to V14, RN immediately. He spoke to (R2) and he told him that (R1) walked up being him and grabbed his buttocks with both hands. V12 stated (R2) is alert with bouts of confusion but that he was very alert when he spoke to him regarding the incident. V12 stated he didn't witness (R1) grope or touch (R2.) An Undated Witness Statement, documented V14, RN, Yes I provided care for (R2). He voiced that (R1) touched him on the butt in the TV room, he doesn't like it because (R2) will trigger him and he doesn't want to hurt her. On 4/16/2025 at 10:40 AM R1 was observed sitting with V15, Activity Aide. R1 stated she doesn't do anything with any man other than her husband and stated she didn't touch anyone inappropriately and she would never do that. On 4/16/2025 at 4:30 PM, V14, RN stated she worked 4/14/2025 and was the assigned nurse to (R1) and R2. Sometime during the evening of 4/14/2025 (R2) was upset and reported to her that (R1) grabbed his buttocks in the activity room, and he stated it wasn't appropriate and that he doesn't want (R1) touching him ever again. V14 stated she didn't witness the incident between the residents, but she reported the incident to V1 immediately. On 4/16/2025 at 4:20 PM, V13 R2's family member stated he came to visit (R2) on the evening of 4/14/2025 and (R2) told him that a lady groped his buttocks with both hands, and it triggered him and he felt embarrassed to tell him about it but he didn't want to be groped by the lady again. V13 reported it to the nurse on duty at that time, V14 and she reported she would let Administration know of the incident. V13 stated he was upset that the VA office he initially took (R2) to be assessed documented that (R2) reported the female put her hands down his pants and touched (R2's) rectum because he was with (R2) the entire time he was at the VA office and (R2) never reported that occurred. V13 stated when they got to the hospital that staff wanted to do a rectal exam on (R2) declined it stating no one touched his rectum. On 4/16/2025 at 4:50 PM R2 was observed walking around his room. He was alert and stated a few days ago (exact date unknown) a female resident ran up from behind him, pulled down his pants and grabbed his buttocks, R2 showed how the female resident (R1) grabbed his buttocks by grabbing a pillow and he showed how she grabbed his buttocks with both fists and squeezed really hard. R2 stated he felt terrible about it and was very embarrassed because it occurred in front of other residents. When (R1) grabbed his buttocks like that he screamed because it hurt. (R1) grabs at him and other residents often and he's told her time and time again don't touch me, I don't like being touched. If it was a man that grabbed me like that he would have been on the floor with a knock out punch to the face but since it was a female I just walked away from the situation but she better not grab me ever again like that. On 4/16/2025 at 11:00 AM V4, Social Services Director stated V2, DON reported to her on 4/14/2025 that (R2) went to an outside physician's appt and the office called and stated (R2) told them that a female resident grabbed his bottom the day before. She spoke to (R2) the same day and he told her he didn't want to be grabbed on his buttocks by other residents he didn't report the name of the resident that grabbed his buttocks he said some old lady grabbed his buttocks. V4 stated (R2) wasn't crying when she spoke to him about the incident he just stated he doesn't want his buttocks to be grabbed because it could trigger him. V4 stated she will follow up with him with the psychosocial assessment every 3 days for 30 days to see how he's doing regarding the incident. V4 attempted to interview (R1)but she didn't respond to any questions regarding her touching (R2's) buttocks. V4 stated neither resident has a history of sexual touching in the past but (R1) does has a history of grabbing residents but this is the first time she grabbed a resident inappropriately and she's been on 1:1 for this behavior since the incident was reported on Monday 4/14/2025. V4 stated the incident occurred on the dementia unit and since the incident occurred (R1) was moved from the dementia unit. The Facility's Abuse Policy, revised 1/9/2024 documents purpose: to provide guidance and procedures to the facility to assure the residents remain to be free from abuse. This facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse and mistreatment of residents.

Based on interview and record review the facility failed to provide pain management for one of three residents (R3) reviewed for pain in the sample of 5. This failure resulted in R3 not receiving pain management for a fall with serious injury for 24 hours. This past non-compliance occurred from 11/16 until 11/18/24. Finding Include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired, and R3 requires substantial to maximum assistance. R3's MDS dated [DATE] documents R3 is moderately cognitively impaired. R3 needs partial assistance from another person for any activities. R3's Electronic Health Record documents R3 has diagnoses of FX (Fracture) of Unspecified Part of Neck of Left Femur and Traumatic FX. R3's Pain Care Plan 11/13/24 documents R3 has potential for pain related to unstable angina and COPD (Chronic Obstructive Pulmonary Disease) Interventions: anticipate the residents need for pain relief and respond immediately to any complaint of pain. Observe report to nurse any S/SX (signs and symptoms) of nonverbal pain. R3's Fall Investigation dated 11/17/24 documents resident (R3) noted to have witnessed fall (CNA) (certified nursing assistant) V9 resident noted to fall on her left side of body, head, shoulder hip, and leg. No obvious signs of trauma to left hip, left shoulder, and left leg PERRLA (pupils are equal round and reactive to light and accommodation) within normal limits for this resident. Pupils equal and brisk. No c/o (complaint of) headache or discomfort, able to move all extremities as prior. Adduction and abduction without issues and WNL (within normal issues) for this resident. Bruising to left upper lip and posterior facial cheek. No gait alterations noted, no difficulties ambulating, no indication of further emergent medical need at this time. MD (Medical Doctor) updated, POA (Power of Attorney) updated and nurse. Intervention: place pressure pad alarm in bed. R3's Left Femur Left Hip X-ray dated 11/18/24 at 5:32 PM documents slightly impacted subcapital FX of femoral neck. Impression impacted subcapital FX. R3's Medication Administration Record (MAR) for the month of November documents Pain assessment not completed for November 16-21. R3's November 2024 MAR documents Pain record highest level of pain Q (every) shift, 11/16 on days R3's pain was a 10 on day shift. R3 was not given pain medications on 11/16/24. On 11/17 pain was not evaluated, and pain medications were not given on 11/17/24. On 11/18/24, R3's pain was rated a 6 on days and evenings; however, R3 was not given pain medications on this day. On 11/19 R3's pain was a 6 on days and evenings, on 11/20/24 R3's pain was a 6 on days and evening; however, R3 was at the hospital and not residing at the facility. R3's MAR also documents R3 was given Tylenol 325 milligrams (mg) two tablets Q (every) 6 hours PRN (as needed) and was given on 11/22 for a pain level of 2 and it was effective. R3 was not given any pain medication on 11/18 although her pain was rated at a 6. R3's MAR documents Tramadol 50mg Q 8 hours PRN for chronic pain was last given on the 10th of November. R3's Physician Order Sheet (POS) dated 5/14/24 documents Norco 5/325mg (milligrams) give one tablet by mouth every 6 hours as needed for pain. Do not exceed 4 GM (grams) daily. R3's POS dated 11/20/23 documents Tramadol 50mg 1 tablet every 6 hours as needed for pain. R3s POS dated 11/22/24 documents Acetaminophen 325mg give 2 tablets by mouth every 4 hours as needed for pain fever. R3's After Visit Summary from a local hospital documents R3 was discharged on [DATE]. On 12/3/24 at 3:50 PM, V2 Director of Nursing stated, I recognized there was a problem, and I did a plan of correction right away. Everyone was in serviced on Pain Management. On 12/5/24 at 9:36 AM, V12 Physician stated, absolutely I expect her (R3) pain to be treated, if she (R3) complained. The facility policy Management of Pain dated 5/16/22 documents promptly and accurately assessing and diagnosing pain. Encourage the resident to self-report pain. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 11/18/24. Immediate Actions: 1.The facility in serviced all nurses regarding pain management and the administration of pain medications on 11/18/24. This was completed by V2. 2. The facility added pain management as an action plan to quality assurance as well as monitoring compliance beginning on 11/18/24.

Based on observation, interview, and record review, the Facility failed to properly store and label medications and dispose of expired medications for 4 of 4 residents (R25, R59, R63, R283) reviewed for medication storage and labeling in the sample of 46. Findings include: On 9/26/24 at 9:15 AM, the medication cart on the B Hall was inspected with V12, Registered Nurse (RN). The medication cart contained the following: 1-R63's Humalog Quickpen labeled 8/24 in black marker. V12, RN, stated insulin pens are dated upon opening and are usually thrown out after 30 days. 2-R63's unopened vial of Epogen with packing instructions documenting, Refrigerate. 3-One half of a white circular tab in a medicine cup that was not labeled or dated. V12, RN, stated, That is magnesium for R59. She gets half a tab in the morning and the other half in the afternoon. 4- One opened carton of thickened lemon water labeled 5/20 in black marker. V12, RN, stated that will be thrown away. On 9/26/24 at 9:22 AM, the medication cart on the F hall was inspected with V10, RN. The medication cart contained the following: 5-R25's sealed, unopened Latanoprost Opthalmic Solution 0.005% eye drops with the packing instructions, Refrigerate Unopened. 6-R25's Tresiba FlexTouch Solution Pen-Injector 100 unit/milliliter dated 8/24/24 in black marker. 7-One opened Humalog pen dated 8/1/24 in black marker that was not labeled with any resident's name. 8-One opened Novolog Kwikpen dated 3/14/24 in black marker that was not labeled with any resident's name. V10, RN, stated she does not know who the insulin pens belong to, because night shift gives the morning insulin. 9-One bottle of Pro-Heal that was opened, but was not dated upon opening. The bottle documented manufacturer's instructions to discard the product 60 days after opening. 10-One bottle of Multivitamin Senior Tabs with the manufacturer label, Best by 1/2024. 11-One bottle of 500 milligram (mg) calcium citrate tablets with the manufacturer label, Best by 6/2024. 12-One bottle of 650 mg sodium bicarbonate tablets with the manufacturer label, Best by 6/2024. On 9/26/24 at 3:43 PM, V2, Director of Nursing (DON), stated insulin pens should be labeled with resident names, dated upon opening, and discarded within 30 days of opening. She stated expired items should be thrown away, and manufacturer's instructions for medication storage should be followed. The Facility's Medication Storage Policy revised 8/23/22 documents, This facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. Medications shall be administered prior to the manufacturer's expiration date. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on interview and record review the facility failed to maintain a system of unnecessary or inappropriate antibiotic use for 4 out of 4 residents (R16, R28, R45, R48) investigated for antibiotic use in a sample of 36. Finding include: 1. R16's EMR (Electronic Medical Records) dated 11/14/23 documents that resident was admitted to the facility. R16's EMR dated 11/14/23 documents diagnose of Chronic Kidney Disease, Stage 4 (Severe), Neuromuscular Dysfunction of Bladder, Unspecified, and END STAGE RENAL DISEASE. R16's Care Plan dated 02/29/24 documents (R16) has end stage renal failure r/t (related to) End stage disease. R16's MDS (Minimum Data Set) dated 08/07/24 documents a BIMS (Brief Interview for Mental Status) score is 14. The MDS documents that the resident requires substantial/maximal assistance with toilet hygiene. The MDS documents that the resident is always incontinent of bladder and bowel. R16's Nursing Note dated 07/20/24 at 5:23 PM documents Wife and resident aware of positive uti and beginning Cipro. Resident continuously pulls off oxygen and it needs to be replaced. Wife states resident did this frequently at hospital previously when wearing 02. Frequent monitoring of resident this shift to ensure 02 is attached to machine and in resident nose. R16's Physician Order dated 07/20/24 documents Cipro Tablet 500 MG (Ciprofloxacin HCl); Give 1 tablet by mouth every 12 hours for UTI. R16's Urine Bacteria Culture dated 07/17/24 documents Streptococci, Beta Hemolytic Group B. There is not a susceptibility report associated with this report to show which antibiotics are resistant or susceptible to the bacteria. R16's MAR (Medication Administration Record) dated July 2024 documents that resident received 7 doses of Ciprofloxacin HCl. 2. R25's EMR dated 11/01/21 documents that the resident was admitted to the facility. R25's EMR dated 12/04/20 documents a diagnose of Benign Prostatic Hyperplasia with lower urinary tract symptoms and Overactive Bladder. R25's EMR dated 01/14/23 documents a diagnose of Chronic Kidney Disease, Stage 4 (Severe). R25's Care Plan dated 12/09/20 documents Impaired urinary elimination R/T obstruction of urethra R/T BPH. R25's MDS dated [DATE] documents a BIMS score of 4. The MDS documents that the resident requires substantial/maximal assistance with toilet hygiene. The MDS documents that the resident is always incontinent of bladder and bowel. R25's Nursing Note dated 06/14/24 documents UA with C and S results faxed to MD. Per MD resident has UTI and to start ABX Cipro 500 mg PO BID x 10 days. POA notified of UTI and ABX and aware. Order placed and sent to pharmacy. Will continue to monitor. R25's Physician Order dated 06/14/24 documents Ciprofloxacin HCl 500 MG Tablet; GIVE 500 MG BY MOUTH TWO TIMES A DAY FOR UTI FOR 10 DAYS. R25's MAR dated June 2024 documents that the resident received 19 doses of Ciprofloxacin. R25's Urine Bacteria Culture dated 06/10/24 documents Streptococci, beta hemolytic group B. There is not a susceptibility report associated with this report to show which antibiotics are resistant or susceptible to the bacteria. 3. R45's EMR dated 08/24/21 documents that the resident was admitted to the facility. R45's EMR dated 08/24/21 documents Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R45's Care Plan dated 06/19/24 documents (R45) has a Urinary Tract Infection. R45's MDS dated [DATE] documents a BIMS score of 3. The MDS documents that the resident requires substantial/maximal assistance for toilet hygiene. The MDS documents that the resident is always incontinent of bladder and frequently incontinent of bowel. R45's Nursing Note dated 06/18/24 at 8:59 PM documents New orders received for cephalexin 500mg x 7 days. Awaiting culture. R45's Physician Order dated 06/18/24 documents Cephalexin 500 MG Capsule; Give 1 tablet by mouth every 8 hours for ABT for UTI for 7 Days. R45's MAR dated June 2024 documents that the resident received 20 doses of Cephalexin. R45's Urine Bacteria Culture dated 06/14/24 does not documents a bacteria specimen and susceptibility report. 4. R48's EMR dated 02/21/22 documents that resident was admitted to the facility. R48's EMR dated 11/11/21 documents a diagnosis of Chronic Kidney Disease, Unspecified. R48's Care plan dated 12/06/23 documents (R48) has renal insufficiency r/t CKD (chronic kidney disease), acquired absence of kidney. R48's MDS dated [DATE] documents a BIMS score of 4. The MDS documents that the resident is independent. The MDS documents that the resident is occasionally incontinent of bladder and always incontinent of bowel. R48's Nursing Note dated 09/18/24 at 7:23 PM documents resident returning to facility per family member. Dx: bladder infection. N.O fluconazole 150mg 1 dose. Bactrim DS. take 1 tab BID x 5 days. family aware. R48's Physician Order dated 09/19/24 documents Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim); Give 1 tablet by mouth two times a day for UTI for 5 Days. R48's MAR dated September 2024 documents that resident received 10 doses of Bactrim. R48's Urine Bacteria Culture dated 09/18/24 document Escherichia Coli. The susceptibility report documents that Bactrim is resistant to E. Coli. On 09/26/24 at 2:50 PM, V2, DON (Director of Nursing) stated that she has hard time getting the doctor to stop prescribing antibiotics before the cultures come back. Facility policy Antibiotic Stewardship Policy/Procedure dated 12/13/23 documents It is the policy of this facility to maintain an Antibiotic Stewardship Program (ASP) with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Components of this policy were developed by using evidence-based practice guidelines and are aligned with the Core Elements of Antibiotic Stewardship for Nursing homes, published by Centers for Disease Control and Prevention (CDC) (1), and the State Operations Manual (Appendix PP): Guidance to Surveyors of Long Term Care Facilities, published by CMS (2).

Based on observation, interview and record review, the Facility failed to provide at least 80 square feet per resident bed in multiple resident bedrooms for 13 of 80 residents (R9, R35, R41, R50, R51, R54, R63, R70, R77, R133, R134, and R183) . Findings include: 1. Seven resident bedrooms provide 77.1 square feet per resident bed. Each of these seven rooms measure 15 feet 2 inches by 10 feet 2 inches. These rooms are two-bed rooms, and all are certified for Medicaid/Medicare. These rooms are as follows: 105, 106, 107, 117, 118, and 119. This was verified during room measurements. 2. Three resident bedrooms provide 74 square feet per resident bed. These rooms measure 15 feet 3 inches by 21 feet, with wardrobes measuring 23 inches by 63 and 24 inches by 94 inches. These rooms are all certified for Medicaid/Medicare. These rooms are as follows: 225, 227, and 228. On 9/26/24 at 9:10 AM V2, Director of Nursing (DON) stated the facility pays attention to the room size and the residents' bed size when determining what room to place a resident in on admission. She stated they make sure it is a safe environment for the residents and is able to be kept free of clutter. Throughout the survey, there were no complaints from the residents who reside in the undersized rooms regarding room size. There were no infection control concerns related to room size.

Based on interview and record review, the facility failed to assist residents with activities of daily living for dependent residents including oral and hygiene care for 1 of 4 residents (R2) reviewed for Activities of Daily Living (ADLs) for dependent residents in the sample of 24. This failure resulted in psychosocial harm as a normal person would have been embarrassed if they could not maintain good hygiene and be clean and odor free when going out in public. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, dated dated [DATE], documents R2 has severe cognitive impairment, is incontinent of bowel /bladder and is dependent with Activities of Daily Living (ADLs). R2's Care Plan, dated 11/16/22, documents R2 has an ADL self-care performance deficit and requires physical assistance with daily care needs. R2's SBAR (Situation, Background, Assessment, Response), dated 6/9/24 at 4:14 PM, documents the following: blood pressure of 116/74; pulse of 78, respirations of 18, temperature of 97.8; reason for transfer: gastrostomy tube (G-Tub) blockage or dislodgement, G-tube clogged. Unable to get any nutrition or fluids to resident, refused to eat or drink by mouth. No change in mental status or functional ability. This morning upon assessment, the G-tube feeding was not connected to the resident and leaking all over the floor. Went to flush the resident with no success. Attempted to milk the tubing, pulsating fluids through, and hot coffee to de-clog it however, was not successful. Another nurse attempted to get the clog out with no success. Resident would not eat or drink anything that was offered. Sent resident to ED (Emergency Department) to get a new tube placed. MD notified at 11:20 AM; SBAR timed at 3:02 PM. R2's Progress Note, dated 6/9/24 7:57 PM, called local hospital for update on resident. Resident will be transferred to outside hospital to ICU (Intensive Care Unit) with a diagnosis of Sepsis. R2's ED Provider Notes, dated 6/9/24, documents the following: [AGE] year old female with a history of intracranial hemorrhage with craniotomy, seizure disorder, Parkinson's disease, dysphagia, failure to thrive and G-tube dependence presents with a reported G- tube malfunction. Upon arrival, patient is appearing severely tachycardic and hypotensive with SBP (Systolic Blood Pressure) 80's/50's. Physical exam: chronically ill with severe debility, acutely toxic appearing, neck in contracture to right, dry mucous membranes, cracked lips, tachycardic. Foley catheter inserted in LUQ (left upper quadrant) gastrostomy site. Perineal erythema and skin sloughing. Eyes closed, minimal response to noxious stimuli, spontaneous movement in all extremities, contractures to right upper and lower extremities, no verbal response. Lactic Acid - 3.3 (High) normal 0.4-2 MMOL/L; Sodium 163 (High) normal 136-145. Problems addressed: acute kidney injury, hypochloremia, severe, associated with hypovolemia, hypernatremia, severe associated with hypovolemia, septic shock, and supraventricular tachycardia resulting in worsening hypotension. Cardioversion attempted twice with adenosine and was unsuccessful. Returned to sinus tachycardia following 5mg (milligrams) of Cardizem. Disposition: transfer to another facility for ICU (Intensive Care Unit). R2's History & Physical, dated 6/9/24, documents the following: [AGE] year old female with a past medical history of traumatic subdural hematoma (March 2022) requiring a craniotomy, Parkinson's disease, bed bound, non-verbal, G-tube fed, seizures, dyslipidemia and hypothyroidism presents as a transfer from the local hospital. Patient is non-verbal at baseline and unable to supply history. History is obtained from ED and previous records. Patient resides at a nursing facility. She is G-tube fed. She had issues with the G-tube being clogged several months ago when a urinary catheter was put in place of the G-tube. She apparently never had a follow up with Gastroenterology for proper tube replacement. Today staff noted that her G-tube would not flush, so she was sent to the ED. On arrival to the ED, patient was tachypneic, tachycardic and hypotensive in the 80's. Per RN (Registered Nurse) notes, she appeared dry and disheveled on exam. She was noted to have poor dental hygiene, dry mouth, cracked lips, caked dried vaginal secretions on perineum and thighs, with a foul smell and excoriated skin that was difficult to clean. Physical exam of the skin: excoriation/erythema of the inner thigh/perineum with foul smelling drainage. Concern for elder abuse/neglect. On 6/14/2024 at 10:39 PM, V1, Administrator, stated R2 had a G-tube, it was clogged, would not flush and they sent her to the local ER. When the facility marketer spoke with the case manager at the hospital, they told us the family was concerned about R2's state and the care the facility provided. R2 was transferred from the local hospital to an outside hospital and was septic. V2, DON, spoke with the one of R2's sons on Wednesday or Thursday evening. They were mad about the catheter, which she did not have while she was here, concerns about her wound, she had an ongoing pressure ulcer on her sacrum, and they were upset and said the facility neglected her. On 6/20/24 at 3:15 PM, V10, Registered Nurse, RN, was contacted by telephone and stated R2's G-tube was clogged, and she was unable to unclog it. V10 stated R2 looked normal that morning, normally doesn't talk, is rigid. V10 stated that afternoon, she was pale and didn't look the same as she had that morning because she hadn't eaten all day. V10 stated they tried to get her to eat and drink, but she wouldn't open her mouth. V10 stated R2 did have orders for tube feeding but were unable to administer it because the tube was clogged. V10 stated she isn't sure if R2 had vaginal secretions or her pubic area/ pubic hair was matted or dry or if oral care had been completed. On 6/21/24 at 9:30 AM, V11, ED Nurse, stated R2 entered theirER on [DATE] from EMS (Emergency Medical Services) at 3:13 PM. V11 stated R2 was normally non-verbal. V11 stated R2's head was turned to the right side, her lips were dry and cracked, there was a film coating her teeth, her tongue had a scab on it and was cracked. V11 stated R2's vital signs upon arrival were 85/64 (blood pressure); 100.6 (temperature); 32 (respirations), 119 (heart rate), 62.2 kilograms (136.8 pounds). V11 stated she went to insert an indwelling urinary catheter and R2's pubic hair was adhered to her labia from vaginal secretions, and she had sloughing on the inner groin area from her diaper. V11 stated she had to clean her perineal area before she could even try and insert the catheter. V11 stated once the catheter was inserted, she only had 20cc (cubic centimeters) of return urine after having a fluid bolus IV (intravenously). V11 stated R2 had a very strong odor in her mouth and perineal area. V11 stated she was told by the nursing facility that R2's G-tube was clogged, and she hadn't had any nutrition since the night before and nothing was done about it until the day shift came in. V11 stated she was very concerned with R2's lack of hydration and that R2 hadn't received basic care at the facility when she was sent to the ED on 6/9/24. On 6/27/24 at 9:10 AM, V38, R2's Son, stated R2 would have been embarrassed and would not have gone out to the hospital or in public without being clean, dry, teeth brushed and without odors. V38 stated R2 was a nurse and spent her life caring for others and would have wanted to be cared for in the same way she cared for them. V38 stated R2 has Parkinson's Disease, is unable to speak, her hands are curled up, she must be fed and needs complete care. The Perineal Care Procedure, undated, documents the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations and to observe the resident's skin condition. The Oral Care Policy, with a review date of 4/6/23, documents the purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth and to prevent oral infection.

Based on interview and record review, the facility failed to provide timely care/treatment for 1 of 4 residents (R2) reviewed for quality of care in the sample of 24. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 has severe cognitive impairment is dependent upon staff for ADLs (Activities of Daily Living), has coughing with thin liquids, loss of liquids/solids from mouth when eating/drinking, choking/coughing when eating, swallowing medications, and receives 51/% or more of total calories through tube feeding; receives 501cc/day or more of fluids by tube feeding. R2's Care Plan, dated 11/16/22, documents R2 has an ADL self-care performance deficit, requires physical assistance with daily care needs, has the potential for fluid deficit and requires a tube feeding due to dysphagia. R2's SBAR (Situation, Background, Assessment, Response), dated 6/9/24 at 4:14 PM, documents the following: blood pressure of 116/74; pulse of 78, respirations of 18, temperature of 97.8 (degrees Fahrenheit); reason for transfer: gastrostomy tube (G-Tub) blockage or dislodgement, G-tube clogged. Unable to get any nutrition or fluids to resident, refused to eat or drink by mouth. No change in mental status or functional ability. This morning upon assessment, the G-tube feeding was not connected to the resident and leaking all over the floor. Went to flush the resident with no success. Attempted to milk the tubing, pulsating fluids through, and hot coffee to de-clog it, however, was not successful. Another nurse attempted to get the clog out with no success. Resident would not eat or drink anything that was offered. Sent resident to ED (Emergency Department) to get a new tube placed. MD notified at 11:20 AM with a recommendation from the primary clinician to send to the ED. The SBAR had no documentation on the time that R2 was sent to the ED as recommended by the physician. R2's ED Provider Notes, dated 6/9/24, documents the following: [AGE] year old female with a history of intracranial hemorrhage with craniotomy, seizure disorder, Parkinson's disease, dysphagia, failure to thrive and G-tube dependence presents with a reported G- tube malfunction. Per report, the patient is completely G- tube dependent. She was seen in this ED previously after G-tube dislodgment in 1/2024. At that time, a replacement G-tube was unable to be placed but a urinary catheter was inserted in place of the G-tube for continuation of feeds. Instructions were provided to follow-up with the patient's Gastroenterologist, V13, who placed the initial G-tube, however, this follow-up was never completed. She was sent to the ED today after staff was unable to flush the tube. Upon arrival, patient is appearing severely tachycardic and hypotensive with SBP (Systolic Blood Pressure) 80's/50's. Physical exam: chronically ill with severe debility, acutely toxic appearing, neck in contracture to right, dry mucous membranes, cracked lips, tachycardic. Foley catheter inserted in LUQ (left upper quadrant) gastrostomy site. Perineal erythema and skin sloughing. Eyes closed, minimal response to noxious stimuli, spontaneous movement in all extremities, contractures to right upper and lower extremities, no verbal response. Lactic Acid - 3.3 (High) normal 0.4-2 MMOL/L; Sodium 163 (High) normal 136-145. Problems addressed: acute kidney injury, hypochloremia, severe, associated with hypovolemia, hypernatremia, severe associated with hypovolemia, septic shock, and supraventricular tachycardia resulting in worsening hypotension. Cardioversion attempted twice with adenosine and was unsuccessful. Returned to sinus tachycardia following 5mg (milligrams) of Cardizem. Disposition: transfer to another facility for ICU (Intensive Care Unit). The care timeline documents R2 arrived at the ED at 3:13 PM. The care timeline documents R2 did not arrive at the ED until 3 hours and 53 minutes following the recommendation by the primary clinician that was documented on R2's SBAR dated 6/9/24. On 6/20/24 at 3:15 PM, V10, Registered Nurse, RN, was contacted by telephone and stated R2's G-tube was clogged, and she was unable to unclog it. V10 stated R2 looked normal that morning, normally doesn't talk, is rigid. V10 stated that afternoon, she was pale and didn't look the same as she had that morning because she hadn't eaten all day. V10 stated they tried to get her to eat and drink, but she wouldn't open her mouth. V10 stated R2 did have orders for tube feeding but were unable to administer it because the tube was clogged. On 6/21/24 at 9:30 AM, V11, ED Nurse, stated R2 entered theirER on [DATE] from EMS at 3:13 PM. V11 stated she was told by the nursing facility that R2's G-tube was clogged, and she hadn't had any nutrition since the night before and nothing was done about it until the day shift came in. V11 stated she was very concerned with R2's lack of hydration and that R2 hadn't received basic care at the facility when she was sent to the ED on 6/9/24. V11 stated in her medical opinion, there was a delay in treatment which affected R2's plan of care. On 6/21/24 at 12:05 PM, V22, RN, stated R2 had a urinary catheter that was being used in place of her G-tube and was put in by the hospital months ago. V22 stated it clogged often with the tube feeding and water flushes. V22 stated they were also giving R2's medications through the G-tube. V22 stated she isn't sure if there was a plan to replace the urinary catheter with an actual G-tube. V22 stated R2 was able to eat food and drink fluids. V22 stated R2's appetite varied, she would eat 25-50% of meals. V22 stated she wasn't here when R2 was sent to the hospital but was told it was due to her tube being clogged and they were unable to unclog it. The Acute Change of Condition Policy, with a revision date of 1/23/23, documents this facility shall identify and treat residents with acute changes of conditions. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications. The physician will help identify and authorize appropriate treatments. If it is decided, after sufficient review, that care or observation cannot reasonably be provided at the facility, the physician will authorize a transfer to an acute hospital, emergency room or another appropriate setting.

Based on interview and record review, the facility failed to provide gastrostomy tube care per standards of practice for 1 of 4 residents (R2) reviewed for tube feeding management in the sample of 24. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, MDS, 6/9/24, documents R2 has severe cognitive impairment is dependent upon staff for ADLs (Activities of Daily Living), has coughing with thin liquids, loss of liquids/solids from mouth when eating/drinking, choking/coughing when eating, swallowing medications, and receives 51/% or more of total calories through tube feeding; receives 501cc/day or more of fluids by tube feeding. R2's Care Plan, dated 11/16/22, documents R2 has an ADL self-care performance deficit, requires physical assistance with daily care needs, has the potential for fluid deficit and requires a tube feeding due to dysphagia. R2's Physician Order Sheet, POS, documents an order dated 1/10/24, to refer to V13, R2's Gastroenterologist, related to G-tube (gastrostomy tube) replacement. R2's Progress Note, dated 1/10/2024 at 12:51 PM, document the following: orders placed for a Gastroenterology referral with V13, R2's Gastroenterologist, related to replacing the G-tube. (V39, Certified Nursing Assistant, CNA), notified of orders for referral, waiting for MD (medical doctor) signature to set up appointment. There was no further documentation in R2's progress notes that the referral/appointment was made with V13. R2's Progress Note, dated 1/14/2024 at 9:30 AM documents the following: R2 was transferred to the local hospital for G-tube displacement. R2's SBAR (Situation, Background, Assessment, Response), dated 6/9/24 at 4:14 PM, documents the following: blood pressure of 116/74; pulse of 78, respirations of 18, temperature of 97.8; reason for transfer: gastrostomy tube (G-Tube) blockage or dislodgement, G-tube clogged. Unable to get any nutrition or fluids to resident, refused to eat or drink by mouth. No change in mental status or functional ability. This morning upon assessment, the G-tube feeding was not connected to the resident and leaking all over the floor. Went to flush the resident with no success. Attempted to milk the tubing, pulsating fluids through, and hot coffee to de-clog it, however, was not successful. Another nurse attempted to get the clog out with no success. Resident would not eat or drink anything that was offered. Sent resident to ED (Emergency Department) to get a new tube placed. MD notified at 11:20 AM with a recommendation from the primary clinician to send to the ED. R2's ED Provider Notes, dated 6/9/24, documents the following: [AGE] year old female with a history of intracranial hemorrhage with craniotomy, seizure disorder, Parkinson's disease, dysphagia, failure to thrive and G-tube dependence presents with a reported G- tube malfunction. Per report, the patient is completely G- tube dependent. She was seen in this ED previously after G-tube dislodgment in 1/2024. At that time, a replacement G-tube was unable to be placed but a urinary catheter was inserted in place of the G-tube for continuation of feeds. Instructions were provided to follow-up with the patient's Gastroenterologist, V13, who placed the initial G-tube, however, this follow-up was never completed. She was sent to the ED today after staff was unable to flush the tube. Upon arrival, patient is appearing severely tachycardic and hypotensive with SBP (Systolic Blood Pressure) 80's/50's. Physical exam: chronically ill with severe debility, acutely toxic appearing, neck in contracture to right, dry mucous membranes, cracked lips, tachycardic. Foley catheter inserted in LUQ (left upper quadrant) gastrostomy site. Perineal erythema and skin sloughing. Eyes closed, minimal response to noxious stimuli, spontaneous movement in all extremities, contractures to right upper and lower extremities, no verbal response. Lactic Acid - 3.3 (High) normal 0.4-2 MMOL/L; Sodium 163 (High) normal 136-145. Problems addressed: acute kidney injury, hypochloremia, severe, associated with hypovolemia, hypernatremia, severe associated with hypovolemia, septic shock, and supraventricular tachycardia resulting in worsening hypotension. Cardioversion attempted twice with adenosine and was unsuccessful. Returned to sinus tachycardia following 5mg (milligrams) of Cardizem. Disposition: transfer to another facility for ICU (Intensive Care Unit). The care timeline documents R2 arrived at the ED at 3:13 PM. The care timeline documents R2 did not arrive at the ED until 3 hours and 53 minutes following the recommendation by the primary clinician that was documented on R2's SBAR dated 6/9/24. R2's History & Physical, dated 6/9/24, documents the following: [AGE] year old female with a past medical history of traumatic subdural hematoma (March 2022) requiring a craniotomy, Parkinson's disease, bed bound, non-verbal, G-tube fed, seizures, dyslipidemia and hypothyroidism presents as a transfer from the local hospital. Patient is non-verbal at baseline and unable to supply history. History is obtained from ED and previous records. Patient resides at a nursing facility. She is G-tube fed. She had issues with the G-tube being clogged several months ago when a urinary catheter was put in place of the G-tube. She apparently never had a follow up with Gastroenterology for proper tube replacement. Today staff noted that her G-tube would not flush, so she was sent to the ED. On 6/14/2024 at 10:39 PM, V1, Administrator, stated R2 had a G-tube, it was clogged, would not flush and they sent her to the local ER. When the facility marketer spoke with the case manager at the hospital, they told us the family was concerned about R2's state and the care the facility provided. R2 was transferred from the local hospital to an outside hospital and was septic. On 6/20/24 at 3:15 PM, V10, Registered Nurse, RN, was contacted by telephone and stated R2's G-tube was clogged, and she was unable to unclog it. V10 stated R2 looked normal that morning, normally doesn't talk, is rigid. V10 stated that afternoon, she was pale and didn't look the same as she had that morning because she hadn't eaten all day. V10 stated they tried to get her to eat and drink, but she wouldn't open her mouth. V10 stated R2 did have orders for tube feeding but were unable to administer it because the tube was clogged. V10 stated she isn't sure if R2 had vaginal secretions or her pubic area/ pubic hair was matted or dry or if oral care had been completed. On 6/21/24 at 9:30 AM, V11, ED Nurse, stated R2 entered theirER on [DATE] from EMS at 3:13 PM. V11 stated R2 was normally non-verbal. V11 stated she was told by the nursing facility that R2's G-tube was clogged, and she hadn't had any nutrition since the night before and nothing was done about it until the day shift came in. V11 stated she was very concerned with R2's lack of hydration and that R2 hadn't received basic care at the facility when she was sent to the ED on 6/9/24. V11 stated she was told by the facility that R2's G-tube was clogged, and she hadn't had any nutrition since the night before and nothing was done about it until the day shift came in. V11 stated R2 had been seen in their ER in January 2024 for a dislodged G-tube, they weren't able to replace it, so she was transferred to an outside hospital for replacement. V11 stated at the outside hospital, either because they couldn't replace it or didn't have the correct supplies to replace it, a urinary catheter was inserted in place of the G-tube so R2 could continue to receive her feedings. V11 stated R2 was supposed to follow up with V13, R2's Gastroenterologist and never did. V11 stated she was very concerned with R2's lack of hydration and that R2 hadn't received basic care at the facility when she was sent to theirER on [DATE]. V11 stated R2 had an acute kidney injury and was in kidney failure due to having no hydration for over 24 hours. V11 stated in her medical opinion, there was a delay in treatment which affected R2's plan of care. On 6/21/24 at 10:57 AM, V18, V13's Nurse Manager, stated V13 was not able to speak with the surveyor at this time but she discussed R2 with him and he stated he doesn't remember being consulted on R2 in January, he would have seen her and taken her to the operating room to replace the G-tube. V18 stated she saw in January 2024 on R2's after visit summary, where the hospital ordered R2 to follow up with V13 ASAP (as soon as possible) for G-tube replacement. V18 stated they have gone through their records and there have not been any telephone encounters for an appointment request for R2 in 2024. V18 stated V13 would not have recommended a urinary catheter be used as a G-tube any longer than a few days maybe a couple of weeks until a G-tube could be replaced, not 5 months as in R2's case. On 6/21/24 at 11:15 AM, V2, Director of Nursing, stated she does not see where the follow-up appointment with V13 was scheduled for R2. On 6/21/24 at 12:05 PM, V22, Registered Nurse, RN, stated R2 had a urinary catheter that was being used in place of her G-tube and was put in by the hospital months ago. V22 stated it clogged often with the tube feeding and water flushes. V22 stated they were also giving R2's medications through the G-tube. V22 stated she isn't sure if there was a plan to replace the urinary catheter with an actual G-tube. V22 stated R2 was able to eat food and drink fluids. V22 stated R2's appetite varied, she would eat 25-50% of meals. V22 stated she wasn't here when R2 was sent to the hospital but was told it was due to her tube being clogged and they were unable to unclog it. On 6/21/24 at 12:10 PM, V23, CNA Coordinator, stated R2 needed complete care, was non-verbal and unable to tell them what she needed. V23 stated R2 was able to eat and drink by mouth, was fed usually between 25-50% and drank fluids through a straw. On 6/21/24 at 12:15 PM, V4, RN, stated the night of 6/8/24, she worked the midnight shift into 6/9/24. Stated R2 had a Foley catheter that was being used as a G-tube and it had gotten clogged at the beginning of her shift, and she was able to unclog it and it was working. Stated R2 received her tube feeding all night and didn't have any further problems with it. Stated R2 had water flushes that were programmed into the feeding pump that gave her flushes, the nurses would also give her 60cc water flushes twice during the night. V4 stated R2 was sent back from the hospital months ago with a urinary catheter being used in place of a G-tube and she isn't sure why. V4 stated recently, unable to give exact time frame, R2's tube began to clog frequently, and it needed replaced. V4 stated they would have to milk it and flush it often to keep it from clogging up. On 6/21/24 at 12:25 PM, V24, Licensed Practical Nurse, LPN, stated she worked the weekend before R2 was sent to the hospital and she didn't see any changes in R2's condition. V24 stated R2 was receiving tube feeding continuously and water flushes were administered via the feeding pump plus they were giving a 60cc water flush twice a shift to keep it from clogging up. On 6/21/24 at 2:10 PM, V8, MDS/LPN, stated R2 was receiving tube feeding and was dependent on staff for all care. On 6/27/24 at 9:10 AM, V38, R2's Son, stated R2 has Parkinson's Disease, is unable to speak, her hands are curled up, she must be fed and needs complete care. V38 stated when R2 went to the hospital in January 2024, V13, R2's Gastroenterologist was on vacation so he couldn't be consulted while R2 was in the ER. V38 stated the facility called him to get the contact information for V13, which he provided. V38 stated he was not aware that a urinary catheter was placed as a temporary gastrostomy tube until V13 could replace R2's gastrostomy/feeding tube. V38 stated R2 was sent to the hospital recently due to problems with her feeding tube. V38 stated R2 was able to take food and fluids by mouth but he doesn't know if the facility was doing that because she was dehydrated and had a blood infection when she went to the hospital.

Based on observation, interview, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 7 residents (R4, R5, R6) reviewed for physical environment in the sample of 7. Findings include: 1. On 6/6/24 at 9:40 AM, R4 was lying in bed in her room. She stated that she usually has to ask staff to change her sheets once a week. She stated that her main complaint about the Facility is clutter in the hallway and said, It's like an obstacle course out there. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was cognitively intact. On 6/6/24 at 10:35 AM, V3, Certified Nursing Assistant (CNA), stated some of the units could use more attention from Housekeeping. On 6/6/24 at 12:17 PM, the shower in the B Hall bathroom smelled strongly of urine. 2. On 6/6/24 at 12:30 PM, R5 was sitting in his wheelchair in his room. He stated, (Odors) are horrible about 90% of the time. It smells like a bathroom. They have put out deodorizers, but they are not very good. He stated CNA's change his bed sheets about once a month. R5's MDS, dated [DATE], documented that R5 was cognitively intact. On 6/6/24 at 1:05 PM, the E Hall bathroom smelled of bowel movement, and there was a smear of stool on the floor next to the shower drain. There was a yellow bin that was full of soiled linens and was not covered, leaving the contents open to air. On 6/6/24 at 3:35 PM, V19, R7's Family, stated that she visits every day, and the Facility does have odors. She also stated that her daughter would say it smells all the time, but she thinks it smells of urine or bowel movement about 60-70% of the time. On 6/7/24 at 8:50 AM, the F Hall Unit was lined with two mechanical lift machines, a specialty chair, a sit to stand device, a linen cart and a cart with a cooler. On 6/7/24 at 8:59 AM, the G Hall North Unit was lined with two sit to stand devices, a specialty chair, a linen cart, a blood pressure machine, a bedside table, and a Wet Floor sign. On 6/7/24 at 9:01 AM, the G Hall South Unit was lined with a meal cart, a medication cart, a linen cart, a specialty chair, a bedside table and chair, a wheeled walker, and a Wet Floor sign. 3. R6's Facility Grievance, dated 3/20/24, documented concerns with the cleanliness of his bathroom. The Summary of Findings documented R6's bathroom did have an odor. The Facility's Resident Council Meeting Minutes, dated 3/19/24, documented that residents were concerned about how often linens are being changed. On 6/6/24 at 1:21 PM, V1, Administrator, stated there is no policy on changing bed sheets, but the Standard of Practice is to change them on shower days and as needed. She stated it is important that the Facility does not have odors. On 6/7/24 at 9:42 AM, V1, Administrator, stated she expects staff to follow the Facility's policies and keep the Facility clean and odor free. The Facility's undated, Daily Cleaning Procedures Policy, documented, The restroom should be cleaned which includes disinfecting the toilet area, hand rails, call lights, and tub/shower, and the floor should be mopped.

Based on observation, interview, and record review, the Facility failed to ensure progressive fall interventions were in place for 1 of 3 residents (R1) reviewed for accidents and hazards in the sample of 6. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart failure, type 2 diabetes mellitus, unspecified dementia, restlessness and agitation, and history of falling. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, ambulated via wheelchair, was dependent with transfer, and required substantial/maximal assistance with toileting, bathing, dressing, oral hygiene and rolling from side to side. R1's Undated Care Plan documents R1 is at risk for falls and injuries related to medications and medical factors, including heart failure, type 2 diabetes mellitus, and history of falling. R1's Fall Risk assessment dated [DATE] documented R1 was at high risk of falls. R1's 5/4/22 Fall Report documents R1 was found sitting in the middle of the floor in his room. R1 reported he was trying to get a newspaper off the floor and accidentally knocked over his water pitcher and slipped. There were no injuries. The Root Cause was determined to be R1 reaching for an item that fell on to the floor and knocking over a beverage, causing him to slip. The intervention was providing R1 with a reacher to prevent the need to bend for items out of reach. R1 was also educated on using the reacher. R1's Care Plan Intervention dated 5/4/22 documents, Reacher provided to assist and prevent the need for bending to obtain out of reach items. R1's 11/11/23 Fall Report documents R1 was found on the floor in his room next to his bed with the alarm sounding. R1 was crawling on the floor toward his wheelchair, stating he was hungry and was going to breakfast. There were no injuries. The Root Cause was determined to be R1 trying to get up and get snacks. The intervention was staff to provide snacks at bedside. R1's Care Plan Intervention dated 11/11/23 documents, Provide Snacks at bedside. On 3/13/24 at 11:21 AM, R1 was not in his room. There were no visible snacks in his room or on top of his nightstand. There was no bedside table on R1's side of the room. On 3/13/24 at 3:30 PM, R1 was sleeping in bed in his room. There were no visible snacks on R1's nightstand or within reach of R1. On 3/14/24 at 5:35 AM, R1 was lying in bed in bed in his room. There was no reacher or snacks within R1's reach. V12, Night CNA (Certified Nursing Assistant) Supervisor, was in R1's room and stated, He has a reacher. V12 looked under R1's bedding and asked R1, Where's your reachie bar? R1 replied, The stick? Someone stole it. V12 began to look around R1's room and inside his closet. On 3/14/24 at 5:55 AM, V12, Night CNA Supervisor, stated, We found the reachie bar. Someone put it in his roommate's chair. I call it the reachie bar because that's what (R1) calls it. On 3/14/24 at 8:35 AM, V17, CNA, stated R1 is supposed to have a reacher, and they gave it to him earlier this morning. She stated she was not aware that R1 needed snacks in his room, and they usually just keep them at the nursing station. On 3/14/24 at 8:50 AM, V18, CNA, stated R1 is supposed to have a reacher with him, but she did not know he was supposed to have snacks in his room. On 3/13/24 at 2:42 PM, V5, Physician, stated fall interventions should always be in place to help prevent falls. On 3/14/24 at 6:35 AM, V2, Director of Nursing (DON), stated she expects fall interventions to be implemented and followed. The Facility's Accidents and Incidents Policy revised 9/7/23 documents, All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected party. The Interdisciplinary Team (IDT) will conduct a thorough investigation of the accident/incident. Findings of the investigation, including root cause of the accident/incident and appropriate interventions will be indicated in the incident report and implemented. The MDS nurse shall update the care plan with implemented interventions and communicate interventions with line staff.

Based on interview and record review, the facility failed to report an allegation of abuse in 2 of 8 residents (R4, R6) reviewed for abuse in the sample of 9. Findings include: On 10/20/23 at 2:00 PM, V1, Administrator, stated she has a soft file on an allegation of sexual abuse involving R4 and R6, but it wasn't reported, because it was investigated and wasn't sexual abuse. On 10/24/23 at 9:05 AM, V1, Administrator, stated she reported the incident involving R4 on Friday October 20th after talking to surveyor about it. V1 stated, she has not completed the investigation or the final report. The facility's abuse investigation, dated 10/20/23, involving R4 and R6 documents, the following information: date of incident: 10/20/23 at 4:00 PM, Alleged sexual abuse involving R4 and R6. Reported to IDPH, (Illinois Department of Public Health), POA, (Power of Attorney), MD, Family and Police on 10/20/23. Interview with R4 dated 10/17/23, R4 stated, he had his hand (R6) and was telling him that he (R6) needed his fingernails cut and cleaned. R4 tried to clean them, but someone else is going to have to help him (R6). 10/20/23 - R4 stated, R6 was going by and he (R4) noticed his (R6's) fingernails were dirty so he was trying to help him clean them out. R6 unable to answer questions. On 10/24/23 at 8:25 AM, attempted to interview R6 and he would not answer any questions when asked by surveyor. On 10/24/23 at 8:35 AM, R4 stated, he had a problem with an accusation that he was trying to touch another male resident, unable to recall name. R4 stated, no way in h***, I wasn't trying to touch him like that. R4 stated, there was a lady, staff member, unsure of name, that is always in somebody's business, she was asking me about it and then the police came and asked me about it. R4 stated, he isn't sure when this was supposed to have happened, maybe a month ago, he isn't sure. The Abuse Policy, dated 10/24/22, documents, the facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH, Ombudsman, Local Police Department, POA and MD in a timely manner.

Based on observation, interview and record review, the facility failed to ensure fall prevention interventions were in place in 1 of 3 residents (R6), reviewed for falls in the sample of 9. Findings include: R6's Minimum Data Set, (MDS), dated [DATE], documents, R6 has moderate cognitive impairment. R6's Care Plan, dated 2/27/19, documents, R6 is at risk for falls with an intervention, dated 8/12/23 for a pull tab alarm when in bed or up in wheelchair. R6's Fall Risk Assessment, dated 5/20/23, documents, R6 is at high risk for falls. R6's Progress Note, dated 8/12/23 at 3:14 AM, documents, the following: Staff entering room to do bed check at 2:40 AM, found resident curled up on floor on right side of bed, blood coming from skin tear to right elbow, unwitnessed fall, neuro checks started, ROM, (Range of Motion), WNL, (Within Normal Limits), no other apparent injuries noted, administration notified, POA, (Power of Attorney), notified, MD notified, risk management report being completed, will continue to monitor at this time, floor matt and bed alarm in place at this time. R6's Progress Notes go on to document, falls on 8/23/23 and 10/2/23 with no injuries. On 10/24/23 at 8:25 AM and 10/24/23 at 1:55 PM, R6 was observed up in his wheelchair in his room. The pull tab alarm was attached to R6's wheelchair but was not attached to him. On 10/24/23 at 3:05 PM, V1, Administrator, stated she would expect fall interventions to be in place. The Fall Policy, dated 9/15/19, documents, the following: Investigate and follow up Action: The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties.

Based on observation, interview, and record review, the Facility failed to properly store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 83 residents living in the Facility. Findings include: On 10/10/23 at 9:04 AM, the ice scoop was resting on the ice inside the ice machine. The handle was in direct contact with the ice. V4, District Manager, stated, Why did they do that? and placed the scoop on a hook out of the ice. On 10/10/23 at 9:05 AM, in the standing refrigerator there were nine pitchers with various colored liquids that were not labeled or dated. There was a red liquid spilled over onto the bottom door of the refrigerator. Inside the bottom refrigerator, red liquid was spattered on cartons of milk. On 10/10/23 at 9:09 AM, in the standing freezer there were two boxes of raw beef patties on a shelf above French toast, frozen pancakes, and biscuits. There was a plastic bag containing frozen pancakes that was previously opened and resealed but was not labeled or dated. There was a bag containing small, diced, orange-colored food that had been previously opened and resealed, but was not labeled or dated. V4, District Manager, stated, Those are carrots. We got new stickers for the labels, but they haven't stayed sticky. On 10/10/23 at 9:12 AM, there was water on the floor of the walk-in refrigerator. There was a package deli meat that was dated 10/9 but was not labeled. There was a red liquid spattered on cartons of nutritional shakes inside a crate. There was a container that appeared to contain diced onions but was not labeled. On 10/10/23 at 9:15 AM, in the dry storage room there were several bottles of chemicals stored directly on the floor below shelves of food. V4 stated, Those should go in the storage room, but they ran out of room in there. There was a plastic bag full of cloths directly on the floor. The bag was not sealed up. V4 stated, I think those are clean. They usually go on the shelf, but my guess is housekeeping just threw them on the floor. On 10/10/23 at 9:17 AM, V4 stated This one (sanitizing solution in bucket) needs to be dumped. It's from this morning. V4 poured the solution down the sink and refilled the container with the liquid labeled dish detergent. V4 then placed a test strip in the solution. The test strip did not change color. V4 stated, My mistake, I put the wrong liquid in there. V4 stated she was searching for another test strip but was unable to locate any. V4 stated she was going to check in the office, and if they were not there, she would have someone bring her more test strips. On 10/10/23 at 9:17 AM there was water on the floor next to the three-compartment sink. There was a significant amount of dust on vent above the food preparation table and on the fire extinguisher next to the oven hood. On 10/11/23 at 7:40 AM, V10, Floating Dietary Manager, took the temperature of the oatmeal from the steam table, then wiped the thermometer with a rag. V10 then inserted the thermometer into the scrambled eggs and wiped it off with the same rag. V10 then inserted the thermometer into the pureed eggs, mechanically ground sausage, and pureed sausage, using the same rag to wipe the thermometer between each temperature. On 10/11/23 at 7:58 AM, V10 used tongs to serve a sausage patty, then placed a piece of toast on the same plate using the same tongs. On 10/11/23 at 8:30 AM, V4 stated she expects staff to follow food service policies. On 10/12/23 at 10:35 AM, V1, Administrator stated she expects staff to follow food service policies. The Facility's Safe Storage of Food Policy dated 9/1/21 documents, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Toxic materials will not be stored with food. All chemicals will be in a separate/secured area. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 10/10/23 documents there are 83 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to provide complete and thorough catheter care to prevent infections for 3 of 7 residents (R1, R2, and R4) reviewed for Urinary Tract Infections, (UTIs), in the sample of 10. This failure resulted in R2 being hospitalized for sepsis with the source of Catheter Associated Urinary Tract Infection, (CAUTI). Findings include: 1-R2's Face Sheet documents R2 has diagnoses including obstructive uropathy, urinary tract infection, Alzheimer's disease, coronary artery disease, congestive heart failure, hypertension, arthritis, and depression. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was moderately cognitively impaired, required extensive assistance with bed mobility and toileting, and was dependent for transfers. The MDS documents R2 has an indwelling urinary catheter and is frequently incontinent of bowel. R2's Care Plan dated 1/31/23 documents, High Risk for Urinary Tract Infection due to: Indwelling Catheter, Obstruction, With Need Presenting: During Stay. Resident will not experience s/s (signs/symptoms) of urinary tract infection each week through review date. Change catheter and drainage bag per MD (Medical Doctor) orders. Empty catheter drainage collection bag QS (every shift). Ensure catheter tubing and drainage bag are properly positioned to prevent urinary back-flow or contamination. Foley: Fr (French):16 Bulb Size: 5-10 cc (Cubic Centimeters). Follow up with Nephrology as ordered. R2's Order Summary Report printed 2/28/23 documents 3/31/22 orders for Foley Catheter: 16 French 5-10 mL (milliliter) balloon to gravity drainage and Foley catheter care every shift related to obstructive reflux uropathy, unspecified. On 2/28/23 at 11:48 AM, V2, Director of Nursing (DON), stated, We do peri care once a shift and we work 12-hour shifts. R2's Provide catheter/Peri care QS (every shift) 30 Day Look Back dated 3/1/23 documents R2 only received catheter care once per day on 2/3/23, 2/8/23, 2/11/23, 2/15/23, and 2/20/23. The Facility's Monthly Infection Control Log documents R2 had UTI's on 12/19/22, 1/24/23, and 2/8/23. The UTIs on 12/19/22 and 2/8/23, and 2/22/23 were caused by the organism Escherichia coli. R2's Progress Notes dated 12/22/22 at 12:48 PM document, When told to suck on straw for water, resident blew bubbles into cup, needing repetitive instruction to take morning medications. Sent to (Local) hospital via ambulance due to change in condition. Tachycardia (HR [heart rate] 125), O2 (Oxygen Saturation) 87%, dark urine. (V10, Nurse Practitioner) aware and husband contacted. R2's Hospitalist History and Physical dated 2/22/23 documents, [AGE] year-old with multiple medical problems presented with altered mental status, she is a nursing home resident and staff noticed increased confusion with hypoxia. In the ED (Emergency Department) she was hypotensive and found to have a UTI, she was given a fluid bolus and blood pressure improved. admitted for further care. Plan: Admit to inpatient for sepsis with the source of CAUTI. R2's Hospital Records document urine culture collected 2/22/23 was positive for Providencia Stuartii and Escherichia Coli, (E. Coli), with probable Extended Spectrum Beta Lactamase, (ESBL). On 2/28/23 at 11:48 AM, V2, Director of Nursing, (DON), stated, We were just notified that (R2) will not be returning from the hospital today. They are wanting to keep her for a couple more days so she can finish up her course of IV, (intravenous), antibiotics. On 3/1/23 at 1:56 PM, V10, Nurse Practitioner, stated, (R2) has a chronic (indwelling urinary catheter) and is a larger person, so that is setting her up for issues. The infective organism, E. coli, more than likely was caused from bowel incontinence. Bowel incontinence can absolutely contribute to UTIs. (R2) didn't used to have many UTI's and she has had the catheter the whole time, so something has changed. V10 stated UTIs caused by E coli are most likely caused due to poor or incomplete incontinent or catheter care. 2-R1's Face Sheet documents R1 has diagnoses including obstructive and reflux uropathy, chronic kidney disease, unspecified, personal history of malignant neoplasm of bladder, multiple sclerosis, and benign prostatic hypertrophy without lower urinary tract symptoms. R1's MDS dated [DATE] documented R1 was moderately cognitively impaired, required extensive 2+ person assistance for bed mobility, required total dependence of 2+ persons for transfer, had an indwelling catheter, was occasionally incontinent of bowel, and had one stage 2 pressure ulcer. R1's Care Plan dated 1/27/23 documents, High Risk for Urinary Tract Infection due to: Indwelling Catheter r/t (related to) Obstructive and Reflex Uropathy/Neuromuscular Dysfunction of Bladder. Resident will not experience s/s of urinary tract infection each week through review date. Change catheter and drainage bag per MD (Medical Doctor) orders. Empty catheter drainage collection bag QS (every shift). Ensure catheter tubing and drainage bag are properly positioned to prevent urinary back-flow or contamination. Labs as ordered. Provide catheter/Peri care QS. R1's Order Summary Report printed 3/1/23 documents, Foley Catheter: 16 French 10 mL (milliliter) balloon to gravity dated 1/31/23 and Foley catheter output every shift dated 1/27/23. The Facility's Provide catheter/Peri care QS Look Back for the last 30 days documents R1 only received peri care once a day on 2/3/23, 2/7/23, 2/9/23, 2/21/23, 2/24/23, and 2/27/23. R1 is not listed on the Facility's Infection Control Log for January or February 2023. R1's Progress Notes from 2/7/23, 2/8/23, 2/9/23, 2/10/23 and 2/12/23 all documented R1 continued on antibiotic for UTI. R1's Progress Notes dated 2/27/23 at 6:42 PM document, Changed resident's foley bag and collected a UA (urinalysis) due to gross amount of sediment in urine. Resident tolerated procedure with no pain or complaints. R1's Progress Note by V10, Nurse Practitioner, on 2/28/23 at 11:28 AM documents, Urinary tract infection, site not specified. Start Cipro 500mg BID (twice daily) x 10 days. Encourage increase in oral fluids. Await final urine C&S (Culture and Sensitivity) results. R1's Physician Order dated 2/28/23 documents, Cipro Oral Tablet 500 mg - Give 1 tablet by mouth every 12 hours for UTI until 3/9/23. On 2/28/23 at 4:04 PM V7, Certified Nursing Assistant (CNA) performed catheter care for R1. V7 washed her hands and donned gloves, then used disposable wipes to cleanse R1's penis, scrotum and catheter tubing. V7 dabbed around the head of R1's penis, not fully cleansing the entire area, then wiped his right and left groin with disposable wipes. V7 only wiped small areas of R1's penile shaft and scrotum and did not thoroughly cleanse either area. When V7 had put a new adult diaper under R1 and was preparing to fasten the sticky tabs to hold it closed, R1 still had white crumbly debris sticking to his scrotum and penis where it had not been thoroughly cleansed. V7 stated this was probably old barrier cream from yesterday. V7 did not try to cleanse the debris off R1's penis or scrotum but, fastened the diaper and repositioned him in bed. On 3/1/23 at 1:50 PM, V2, Director of Nursing (DON), stated she would expect staff to perform complete catheter care, including cleansing around the insertion site of the catheter, cleansing the entire penis and scrotum, and cleansing the catheter tubing. On 3/1/23 at 1:56 PM, V10, Nurse Practitioner, stated, There should not be any remaining residue or debris after peri care is done. If the area is not completely cleaned it can cause UTIs or skin breakdown. All of a sudden we have been treating lots of UTIs, and maybe some of them could have been prevented. 34964 3. On 3/1/23 at 2:40 PM V12, CNA performed catheter care for R4. R4's penis is split, and his catheter is inserted just above his scrotum, not in the tip of his penis. V12 hand sanitized and donned gloves and cleansed R4's right and left groin, using a back-and-forth wiping motion, recontamination of areas he just cleansed. V12 wiped the head of R4's penis with two swipes with disposable wipes, not thoroughly cleansing all around the head of the penis or down the shaft of the penis, and he did not cleanse around the catheter where it is inserted into the penile shaft, just above the scrotum. R4's Face Sheet documents his diagnoses to include Obstructive and Reflux Uropathy and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. MDS dated [DATE] documents R4 is moderately cognitively impaired and requires extensive assist with bed mobility, dressing and toileting. It further documents he is dependent on staff for transfers and independent with eating. Per the MDS R4 was admitted with one stage 3 pressure ulcer and 1 deep tissue injury. R4 has an indwelling urinary catheter and is always incontinent of bowel. R4's Care Plan dated 1/17/23 documents: High Risk for Urinary Tract Infection due to: Indwelling Catheter, With Need Presenting: greater than 6 months prior to Admission related to (r/t) Obstructive and Reflux Uropathy. The goal for this care plan is documented as: Resident will not experience s/s of urinary tract infection each week through review date. Interventions for this care plan include: Provide catheter / Peri care QS, (every shift), and Provide thorough perineal hygiene daily. Review of R4's Electronic Medical Record documents, on his Provide Catheter/Peri Care QS look back, dated 2/1/23 to 2/28/23, that R4 only received catheter care one time instead of every shift as ordered on February 2, 3, 4, 6, 8, 11, 18, 22, and 28. The Facility's Catheter Care Daily (Male) Policy issued 9/15/19 documents, Purpose: To provide direct care staff with guidelines for the administering proper catheter care to male residents. Retract foreskin at site of catheter insertion. Cleanse around meatus in circular motion. Cleanse area at insertion site, moving away from the opening, taking care not to pull on catheters, or advance further. Wash from front to back, using a new area of the washcloth with each cleansing. The facility's policy, Catheter Care Daily (Female) dated 9/15/19 documents, Policy: Catheter care will be provided daily and as needed to all residents who have an indwelling catheter to reduce the incidence of infection.

Based on interview and record review the facility failed to assess and monitor for injury related to pain after a fall for 1 of 3 residents (R2) reviewed for quality of care in the sample of 9. This delay in treatment resulted in R2 having a decline in activities of daily living, not being assessed for pain and unable to follow orthopedic orders and complete physical therapy. Findings include: R2's Social Service Notes dated 12/17/2021 document, The resident was admitted to (Facility) from (local Hospital) following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident is understood when speaking, however does have dementia. R2's Admission Assessment with an effective date of 12/19/2022 at 6:01 PM, documents R2 was at the facility for therapy, with the goal of returning to prior level of care, he has no contractures, was full weight bearing, with no impairments on the upper or lower extremities. R2's Fall Risk assessment dated [DATE] at 6:00 PM, document R2 was High Risk for falls and had no falls in the past three months. R2's Minimum Data Set (MDS) dated [DATE] document R2 was moderately impaired for cognition, requires extensive assist with one staff for bed mobility and toileting, extensive assist with 2 staff members for transfer, uses a walker, and has no impairment for range of motion. R2's Progress Notes dated 12/31/2021 at 6:22 PM, This writer heard resident call out, 'can someone help me.' Entered Room and noted him lying on the floor, on his back, partially under his bed with head at the end of the bed. Wheelchair sitting beside bed with brakes locked. Socks with no shoes on, bed was not locked. Resident stated he was trying to get into bed and the bed moved. Neuros and range of motion within normal limits. Assisted to standing and into bed by 2 staff with gait belt. R2's Order Date of 1/13/2022 by V10 (Physician) documents, Obtain CT (computerized tomography) scan of bilateral hips/pelvis due to pain and decline in mobility since fall. R2's medical records document he had 3 falls while at the facility, 12/18/2022, 12/31/2021 and 1/3/2022. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Tylenol was the only pain reliever documented for the use of pain. R2's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/2022 at 12:45 PM, V8 (Family of R2) stated, I would go into the home every day and visit my husband. At the end of December when I went to visit him, I could tell he was in a lot of pain. I asked him are you hurting and in pain and he said yes, he had fallen. When R2 came in the nursing home, he was walking with a walker. After his fall, I took him to (Outside Orthopedic Center) and they took an x-ray and told me R2 had a [CONDITION(S)]. No wonder he was in so much pain. R2 did not have any surgery because they said the fracture was 6 weeks old, I believe, so they wanted him to have physical therapy. R2 told me he fell because he was trying to get into bed and the bed moved and he fell . It just does not make sense to me. R2's Progress notes dated 1/17/22 at 12:27 PM documents, Note Text: MD (physician) ordered CT of leg and pelvis, unable to schedule until written order received. Request for written order sent to MD, waiting response. Order: 1/13/2022 at 10:07 AM Obtain CT Scan of bilateral hips/pelvis due to pain and decline in mobility since fall. (4-day delay in order). R2's CT image report, dated 1/27/2022 (14 days later), documents R2 was positive for hip pain, stress fracture and mildly distracted fracture of the right greater trochanter (hip). On 3/18/2022 at 12:15 PM, V2 (Director of Nursing) stated, It looked like V10 (Physician) came and saw R2 on 1/13/2022 and ordered the CT and when they went to schedule it the hospital needed a written order that was put in on 1/17/2022. I have no idea why there was a gap between those dates. I wonder if therapy may have contacted V10 regarding pain, but I really don't know for sure. R2's Physical Therapy (PT) Note, dated 1/4/202, documents, Patient has fallen, unwitnessed, since onset of therapy. Patient overall has responded to therapy program with positive outcomes. Skilled training and reinforcement continues to be indicated to maximize patient's independence and safety. Balance and strength continue to be less than optimal. Prognosis for Further Progress: Good due to patient, demonstrates physical potential to be mod I, unfortunately safety and independence are contingent on cognitive status which fluctuates widely. R2's PT daily treatment note dated 1/10/22 (no time listed): PT complained of right hip pain with increased weight bearing through RLE (Right Lower Extremity). Patient requires mod (moderate) assist when weight bearing through RLE to advance LLE (Lower Left Extremity). Patient has increased difficulty staying on task. Nursing made aware of hip pain. R2's PT daily treatment note from 1/13/2022: Patient ambulated 6 feet with w/w (wheeled walker) and mod assist with weight shifting to RLE and bearing weight to advance LLE. Patient complained of increased right hip pain with increased weight bearing through RLE. R2's PT daily treatment note from 1/18/2022: Patient ambulated 6 feet with w/w and modified assist with weight shifting to RLE and bearing weight to advance LLE. Patient complained increased right hip pain with increased weight bearing through RLE. R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's PT Note, dated 1/17/2022, documents Patient demonstrated a decline in functional abilities last reporting period with pain with use of right lower extremity in any position. At this time patient has pain in Right hip during straining activities and stance phase on R (right). MD has put in orders for a CT scan. Patient is a high risk for falls on his feet requiring need for skilled training, overall functional abilities have declined since onset of Right hip pain. Prognosis for Further Progress: Fair due to patient's progress has been limited by R hip pain. X-rays are (-). Pending CT scan of hips. R2's Progress Notes and Physical Therapy Notes do not document the Physician was notified for any pain medication and there was no order for any pain Management for R2. R2's PT Note dated 2/3/2022 documents, Picture of Right hip came back positive for fracture of right greater trochanter, no fracture of femoral neck or head of femur demonstrated. Pain has limited patient's participation and progress in therapy. Fracture is not in a location of concern for negative response to weight bearing. Continued standing, attempts to ambulate are not contraindicated. R2's Orthopedic Report dated 2/14/2022 documents, Patient is here today in regards to a right [CONDITION(S)]. X-ray today shows [AGE] year old male with a history of fall in a nursing home about '6-7 weeks ago' according to the patient's wife. The patient was found on the floor by the nursing staff. According to the wife, the staff ordered an x-ray 'weeks later', followed by a CT weeks after that. Non-displaced fracture of the right greater trochanter. This will be managed conservatively. This will consist of protective weight bearing, NSAIDS, Nonsteroidal anti-[CONDITION(S)] drug and pain control. The patient verbalizes understanding. Weight bearing as tolerated (WBAT) with 2 hands on walker at all times. Physical Therapy evaluation and treatment three times per week for 6 weeks. Strength Training and Gait Training. (R2 was never started on any NSAIDS). On 3/18/2022 at 1:10 PM, V10 (Physician) stated he was aware of the R2's fall and recalled ordering CT scan, but is unable to remember the exact details. Reports general hesitation to give older adults NSAIDs due to renal function and narcotics due to potential for instability or fall. States he was out of work for 10 days around that time frame and is unable to remember further details. On 3/18/22 at 1:30 PM, V14 (Physical Therapist) stated, The first day I saw R2 he talked with me. Stood up walked with me hand-held and walked to the shower. R2 was cognitively loosely and sharp. R2 had severe dementia and his performance fluctuates with his mental status. R2's first assessment was on 12/20/2021, he walked about 150 feet that day. His wife said he was walking in the house before that. His course of therapy was all over the place. Not a steady course. He dealt with pain and we put him on therapy. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . I was aware that they found him on the floor. He had no safety awareness. He voiced pain on occasion, so somedays he was not able to sit up and would say his hip hurt and he would say he could not move it. We talk to the nurses I do not know in the case. There was a fall, there was a report nothing in urgency stood out. He would move and then he would have pain, it was hard to say. He voiced pain and it was hindering his abilities. He tried to work through the pain. The best day he had was the first day he was here. He had some behavior issues too. We let the R2's nurse know that he has pain. He was already being seen by PT. He was already seeing therapy. We were not making any progress with him the goal was to go home with the wife. R2 was declining and was not improving with therapy. With his dementia and decline we stopped therapy because we felt he was not able to improve. It had nothing to do with money, or days he was just declining. The facility's Management of Pain policy with revision date of 9/16/2020 documents, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. We will achieve these goals through promptly and accurately assessing and diagnosing pain, aggressively assessing pain in non-verbal and cognitively impaired residents, monitoring treatment efficacy and side effects, and preventing and minimizing anticipated pain when possible. Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by physician. Thorough communication with the physician will ensure an appropriate pain management plan. When new pain or an exacerbation of pain is suspected, the comprehensive Pain Assessment will be completed. Drug therapy will be reviewed on a regular basis by the physician and pharmacist following the guidelines of the World Health Organizations Three Step Analgesic Ladder and the American Geriatric Society. Initiate an interdisciplinary plan of care based on the initial assessment, the choice of a pain rating scale, and the development of pain-relieving strategies. Document interventions and responses in the medical record as appropriate (i.e. Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, observation and record review, the facility failed to prevent the formation of pressure ulcers, failed to provide treatments as ordered, and failed to provide pressure relief for 3 of 6 residents (R17, R18 and R278) reviewed for pressure ulcers in the sample of 49. This failure resulted in R18 developing a facility acquired unstageable coccyx pressure ulcer. Findings include: 1.R18's Admission Record, not dated, documents R18's admitted as 5/17/2021. The Record documents R18 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/2021 from 11:20 AM to 2:20 PM, R18 was observed sitting in the wheelchair, at 15-minute intervals, without the benefit of repositioning. On 10/26/2021 at 2:50 PM a wound treatment was observed with V6, Registered Nurse. V6 removed the urine soiled dressing to R18's coccyx revealing a circular pressure ulcer. R18 pressure ulcer wound bed was necrotic with a white open area in the center of the necrotic tissue. The peri-wound was intact and deep red in color. The red peri wound was non blanching. V6 measured the wound with 1.2 centimeters (cm) x 0.8 cm wound. R18's Admission Nursing Assessment, dated 5/17/2021, documents R18's skin Clear, intact- no skin issues. R18's Braden Assessment, dated 5/17/2021, documents R18 is high risk for pressure ulcer. R18's Care Plan, revision date 5/24/2021, documents Potential for impaired skin integrity related to: Dementia, Depression, impaired mobility. It also documents Interventions 5/24/2021 Encourage to reposition as able. 5/24/2021 Observe skin integrity during am/pm care. 5/24/2021 Notify MD (doctor) promptly of skin breakdown. R18's Minimum Data Set, dated dated [DATE], documents R18 has short- and long-term memory problems and is moderately impaired cognitively. It also documents that R18 requires extensive assistance of 1 staff for bed mobility, transfers, toileting and locomotion on and off the unit. R18's Braden Assessment, dated 8/5/2021, documents R18 is moderate risk for pressure ulcers R18's Wound Assessment, dated 10/24/2021, documents R18 has a stage one necrotic pressure ulcer to her coccyx area measuring 0.8 cm (centimeters) x 0.6 cm. It also documents that R18's necrotic pressure ulcer was facility acquired on 10/24/21. R18's General Notes, dated 10/24/2021 at 1:58 AM, documents Note Text: This nurse called to resident's room. Resident has reddened area to coccyx measuring 0.8 x 0.6 cm with darkened area in middle. Area cleaned. SS ([MEDICATION(S)]) with collagen sprinkles applied, calcium alginate applied, and covered with dressing. MD (doctor) and POA (power of attorney) to be notified in AM. Will continue to monitor. R18's Order Summary Report, Active Orders as of 10/26/2021, documents: Order and Start Date 10/24/2021 Area to Coccyx- Clean area with wound cleanser- Apply SS/Collagen sprinkles/Calcium Alginate-Cover with dressing. Discontinue when healed every night shift for wound care. On 10/26/2021 at 12:30 PM V16, Certified Nurse's Assistant (CNA) stated that she works on the unit primarily. V16 stated that R18 is dependent on staff to reposition her. V16 stated that the area was identified 2 weeks ago. V16 stated that at that time the area was red. V16 stated that the red area did not go away. V16 stated that she was off and when she returned the area was black. V16 stated that she notified the Director of Nursing and the Assistant Director of Nursing when the area was red. V16 stated that there were not any interventions put in place at the time the area was red. On 10/26/2021 at 3:00 PM V6 stated that the area has increased in size. V6 stated that R18 is not able to reposition herself in her chair or bed and requires staff to reposition her. V6 stated that with R18 having the wound to her coccyx she would expect staff to be repositioning R18 hourly. On 11/2/2021 at 2:30 PM V32, R18's Primary Physician, stated that if the staff were aware R18's bottom being red he would expect the staff to put things in place to prevent the progression into a pressure ulcer. V32 stated that he would have expected the staff to contact him and the dietician for monitoring and interventions such as supplements and medication interventions to prevent this pressure ulcer. V32 stated that he would expect the staff to document it as soon as they found it. 2. R17's Admission Record, print date of 10/27/21, documents R17 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R17's MDS, dated [DATE], documents R17 is severely cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and is totally dependent on 3 staff members for transfer. R17's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply to right buttock ev (every) topically every shift for open area. Apply to right buttock every shift and PRN (as needed). Cleanse area with NS (normal saline). Apply SSD ([MEDICATION(S)] Cream 1%) cream with collagen sprinkles. Cover with Calcium Alginate and dry dressing. R17's Wound Assessment, dated 10/14/21, documents, Observations / Data. 1. Location: Right Buttock 2. Indicate whether this site was acquired during residents stay or whether it was present on admission: Acquired. 2b. Date acquired: 9/17/21. 3a. Type: Pressure. 4. Pressure Ulcer Stage. 4a. I. Stage at the highest level do not downgrade wound. 4b. I. 5. Describe Wound Tissue. 5b. Epithelial tissue present (pink). It continues, 6. Drainage. 6a. Type: none. It continues, 7. Odor. 7a. Odor present? No. It continues, 8. Wound Measurements. 8a. Length (cm) (centimeters). 0.8 8b. Width (cm) 0.9 8c. Depth (cm). 0.1 9. Peri-wound Tissue. 9a. Description of peri-wound tissue: Intact. It continues, D. Evaluation. Wound Progress: healing. R17's Wound Assessment, dated 10/21/21, documents, Observations / Data. 1. Location: Right Buttock 2. Indicate whether this site was acquired during residents stay or whether it was present on admission: Acquired. 2b. Date acquired: 9/17/21. 3a. Type: Pressure. 4. Pressure Ulcer Stage. 4a. I. Stage at the highest level do not downgrade wound. 4b. I. 5. Describe Wound Tissue. 5b. Epithelial tissue present (pink). It continues, 6. Drainage. 6a. Type: none. It continues, 7. Odor. 7a. Odor present? No. It continues, 8. Wound Measurements. 8a. Length (cm) (centimeters). 0.7 8b. Width (cm) 0.9 8c. Depth (cm). 0.1 9. Peri-wound Tissue. 9a. Description of peri-wound tissue: Intact. It continues, Treatment: area healing well. wound bed pink with no drainage. D. Evaluation. Wound Progress: healing. R17's Care Plan, dated 9/22/21, documents, Stage I to right buttock (downgraded to Stage II). Treatment Ordered: See Current EHR (Electronic Health Record) orders. Check dressing placement q (every) shift. On 10/26/21 at 3:20 PM, R17 was lying in bed on her right side with no heel protectors on. R17 had a Stage II pressure ulcer to her right buttock. R17's wound bed was red with slough around the edges. The pressure ulcer was approximately the size of a quarter with no dressing present. R17's left buttocks has an abrasion approximate the size of a dime. The wound bed is bright red with no dressing present. At that time, V7 CNA stated, She (R17) does have a dressing that go on there they do a cream and a big dressing with two patches. We just took them off not too long ago because they were soiled. On 10/26/21 at 3:36 PM, V31 LPN entered R17's room to do R17's pressure wound treatments. V31 stated, The wound is treated with [MEDICATION(S)] cream with collagen sprinkles, we put that on the wound and then cover it with calcium alginate and a larger dressing. The wound on her left buttocks looks like an abrasion from the previous dressing. V31 donned gloves , cleansed the pressure ulcer with normal saline, changed gloves, cleansed the abrasion to the left buttocks with normal saline, with the same gloves, V31 dried both wounds with the same piece of 2 x 2 gauze, V31 obtained the [MEDICATION(S)] and collagen sprinkles mixture and spread it on the wounds with her gloved finger. V 31 then applied the foam dressing. V31 failed to put the calcium alginate dressing on. On 11/2/21 at 9:30 AM, V2, Director of Nurses (DON), stated, (R17) should have had a dressing on her buttocks and I expect the staff to do treatments as the Physician has ordered. The facility policy and procedure Pressure Ulcer / Injury Risk Assessment, dated 7/2017, fails to identify the need to follow Physician prescribed treatment orders. No other policies and procedures for pressure ulcers were provided by the facility for review. 3. R278's Minimum Data Set (MDS), dated [DATE], documents that R278 is severely cognitively impaired. R278's MDS documents she is totally dependent on two staff persons for bed mobility. R278's Care plan, dated 09/13/21, documents R278 has a Stage 4 Sacrum (Upper Coccyx) pressure ulcer which was present on admission. The Care Plan documents Requires two assist with turning and repositioning. Reposition every 2 hours in bed. On 10/25/21 from 10:31 AM until 1:32 PM, based on 15-minute observations, R278 was not turned or repositioned while lying in bed on her back and slightly to her right. On 10/25/21 at 1:45 PM, V8, Certified Nursing Assistant (CNA), stated that residents should be turned and repositioned every 2 hours. V8 didn't know why R278 hadn't been turned. V8 stated I was down on the other end. On 10/25/21 at 1:50 PM, V7 CNA, stated that they turn and reposition the residents at least every 2 hours. On 10/27/21 at 1:45 PM, V9 Licensed Practical Nurse (LPN), provided wound care for R278. R278 had two opened areas on her sacrum. One area was approximately the size of a quarter (2cm) it was noted to be red granular tissue and the second area was approximately the size of a half dollar (3cm) and noted to have necrotic tissue present. On 11/01/21 at 9:15 AM, V18, CNA stated that she would turn and reposition the resident every 2 hours unless they called for something else like every hour. On 11/01/21 at 11:51 AM, V2 stated that it is her expectation that the residents are to be turned every two hours.

Based on record review, observation and interview, the facility failed to monitor, assess, and provide interventions to prevent significant weight loss for 1 of 11 residents (R18) reviewed for weight loss and nutrition in the sample of 49 This failure resulted in R18 having a 26.5 pound weight loss in 24 days. Findings include: R18's Care Plan, revision date 5/31/021, documents, Altered nutrition and hydration risk r/t (related to) dx (diagnosis) Dementia, Depression, Hypertension, Infection/[CONDITION(S)] (urinary tract infection). It also documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R18's Admission Record, not dated, documents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's weight record indicated on 10/4/2021 a weight of 120.1 pounds (lbs) pounds and on 10/28/2021, a weight of 93.6 lbs, a 22% weight loss in 24 days. R18's Documentation Survey Report Eating & Amount, dated October 2021, indicated the average intakes between were between 0-50 % overall. It also documents R18 refused 16 meals. 12 meals had no documentation of R18's intake. It also documented R18 consumed 0%-25% for 14 meals, 26%-50% for 17 meals, 51%-75% for 9 meals, and 76%-100% for 13 meals. No substitutes or alternates were documented. On 10/25/2021 at 11:20 AM, R18 was sitting in the dining room at the table with food in front of R18. R18 had thin, frail appearance. R18 made no attempts to eat her food. At 11:25 AM, V16, Certified Nurses assistant (CNA), asked R18 if she wanted anything. R18 did not respond. At 11:27 AM, R18 was holding a dinner roll in her right hand. R18 made no attempts to eat her meal. At 11:39 AM, R18 was holding her dinner roll in her left hand and her fork in her right hand. R18 was twirling her fork on the table. From 11:39 AM to 11:52 AM, R18 made no attempts to eat her meal. At 11:53 AM, V5, CNA, standing over R18, gave R18 a bite of meat and left the table. V5 returned to the table and picked up R18's spoon and attempted to give her another bite without success. V5 then left the table. At 12:08 PM, V5 returned to R18's table, standing over her, gave her a bite of corn and left the table. From 12:08 PM to 12:17 PM, R18 was sitting at the table, no attempts made to eat the meal. At 12:20 PM, V16 removed R18's tray from the table. V16 verified that R18 ate 0% of her meal. V16 offered R18 a bowl of soup and said she would return with it. At 1:21PM, R18 spilled her drink on the table and floor. At 2:20 PM, V5 removed R18 from the table. No soup was ever brought to the table. V5 and V16 did not sit, encourage, and assist R18 with eating her meal. V5 and V16 did not provide an alternate for the meal that she did not eat. On 10/25/2021 at 1:30 PM, V16 stated that R18 needed assistance and encouragement with her meals. V16 stated that R18 needs someone to help her eat at times. V16 stated that sometimes R18 will feed herself and some days she will refuse. V16 stated that R18 has not been eating and that she has lost some weight. V16 stated that she is not sure if R18's weight loss is being addressed. V16 stated that R18 does not get any supplements. On 11/1/2021 at 9:46 AM, V27, Registered Dietician, stated that she had seen R18 in August 2021 for a 5lb weight loss from May 17, 2021 to August 6, 2021. V27 stated that R18 was consuming 50% of her meals. V27 stated that at that time she did not make any recommendations because R18 was already receiving supplements. V27 stated that R18 has had a significant weight loss. V27 stated that with R18 having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V27 stated that she was not aware of R18's change in intake or her pressure ulcer. R18 stated that even with supplements the lack of consumption and encouragement caused the significant weight loss. V27 stated that R18's weight loss is concerning. On 11/1/2021 at 10:59 AM, V2, Director of Nursing (DON), stated with R18 having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/2021 at 2:30 PM, V32, R18's Primary Physician, stated that R18 has dementia. V32 stated that R18 had a significant weight loss. V32 stated that with R18's disease process it is inevitable that dementia patients will transition into other stages of dementia and not eat. V32 stated that with R18's disease progression, he would have expected the staff to sit down, encourage, and assist R18 to eat her meal. V32 stated that he would expect the staff to be monitoring R18's intake and notify the dietician and himself of R18 not eating to get intervention put in place to prevent this significant weight loss. V32 stated that he was not notified of R18 change in meal intake prior to 10/26/2021. The Facility's Condition Changes-Clinical Protocol, revised date March 2018, documents 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. 4. Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse.

Based on observation, interview and record review the facility failed to perform safe transfers, and conduct root cause analysis of accidents and implement progressive itnerventions to prevent falls and injuries for 4 of 6 (R6, R17, R18 and R41) residents reviewed for accidents and incidents. This failure resulted in R18 sustaining multiple skin tears, the largest measuring 9.5 centimeters by (x) 7 cm x 0 cm on her left arm. Findings include: 1. R18's Face Sheet, printed on 10/26/21, documents R18 has diagnoses of Dementia without Behavioral Disturbances and Anxiety Disorder. R18's Incident Report, dated 6/4/2021 2:45 PM, documents 2 s/t's (skin tears) observed to LLE (left lower extremity) on 6/4/20 @ (at) this time. This nurse assisted with getting resident up this AM and s/t were not on LLE @ that time. No active bleeding noted to s/t's on LLE. One s/t noted to be 3 cm (centimeters) x (by) 3cm v-shaped. Second s/t noted to be 1 x 1cm V-shaped s/t. Res (resident) does propel herself independently in w/c (wheelchair) when up. Res frequently resistive to care and can be combative with staff @ times. It also documents R18 is oriented to person. The Report documents R18 is confused, impaired memory, and other as predisposing factors. The incident investigation does not identify how R18 sustained the skin tears and interventions put into place to prevent future injuries. R18's Care Plan, initiated on 6/16/21, documents that R18 had a skin tear. The Care Plan documented the following interventions with initiation date of 6/16/21: Encourage good nutrition and hydration in order to promote healthier skin; Identify potential causative factors and eliminate/resolve when possible; If skin tears occurs, treat per facility protocol and notify MD, family; Inform/instruct staff of causative factors and measure to prevent skin tears; Keep skin clean and dry. Use lotion on dry scaly skin; Monitor/document location, size and treatment of skin tear. Report abnormalities failure to heal, signs and symptoms of infection, maceration etc. to MD; and treatment as ordered. R18's Incident Report, dated 8/19/2021, documents Nursing Description: CNA (certified nurse's assistant) informed the nurse that the resident accidentally hit her RLE (right lower extremity) to the bed rail when she was trying to lay down. Resident did not c/o (complain of) pain during assessment. Skin tear to RLE 2 cm (centimeters) x 0 cm x 0 cm. was able to approximate the skin tear, cleansed it c (with) wound cleanser, applied TAO (triple antibiotic ointment) et (and) steri strips. The Report documents Resident Description: no idea what happened. The Report did not document potential causative factors and or interventions to prevent R18 from future injuries/skin tears. R18's Care Plan Focus, dated 8/20/21, documented R18 sustained a skin tear to her right lower leg. There were no progressive interventions added to the Care Plan at that time to prevent R18 from future injuries/skin tears. R18's General Note, dated 9/8/2021 at 2:51 PM, documents Note Text: Skin tear noted to left shin. New treatment orders received. V32, Physician and V36, Power of Attorney, aware. R18's Care Plan Focus, dated 9/9/21, documented R18 sustained a skin tear to her lift shin. There were no progressive interventions added to the Care plan at that time to prevent R18 from future injuries/skin tears. On 10/27 and 10/28/21, the surveyor requested documentation of how R18 sustained the skin tear on 9/8/21. The facility did not provide any documentation regarding R18's skin tear. R18's Incident Report, dated 9/17/2021 at 10:10 AM, documents CNA's gave resident a shower. After shower resident crossed her legs resulting in a skin tear to anterior RLE. R18's Care Plan Focus, dated 9/17/21 documented R18 sustained a skin tear to her right shin. R18's Care Plan Interventions, dated 9/17/21, documents Shin guards to BLE (bilateral lower extremities) at all times. R18's Nursing Note, dated 9/20/2021 at 7:26 AM, documents Note Text: Root Cause: Resident's skin is very thin and fragile. Intervention: Immediate first aide performed. Treatment initiated. Shin guards to be worn at all times. R18's Care Plan Interventions, dated 9/20/21 document the following: Staff education on transfers, good skin care; and Towel around legs during showers. R18's Incident Report, dated 9/24/2021 at 7:34 AM, documents Nurse was called in the resident's room during early morning bed check. resident was laying on her lt (left) side facing the wall. she was holding her lt (left) arm covered with her night gown. blood noted et (and) skin tear was located to the lower anterior arm. able to approximate the skin tear 9.5 cm x 7 cm x 0 cm. cleanse with wound cleanser, applied steri strips et xeroform, covered with kerlix. informed MD et left VM (voice mail) to daughter call the facility back. The Report did not document how R18 sustained the skin tear or what interventions were implemented to prevent R18 from future injuries. R18's Care Plan Focus, dated 9/24/21, documented R18 sustained a skin tear to her right upper arm. There were no progressive interventions added to the Care plan at that time to prevent R18 from future injuries/skin tears. R18's Incident Report, dated 10/14/2021 at 11:25 AM, documents Nursing Description: resident was laying on her bed when nurse was getting ready to get her tx done for the day et found a couple skin tear to her left upper arm. it looks like she obtained it over 24 hrs. ago. #1: 1.5 cm x1 cm x 0 cm #2: 3 cm x 3 cm x 0 cm. soak the skin with the wound cleanser et was able to approximate the skin tear. applied steri strips et xeroform et cover it with dry gauge It also documents Resident Description: States she rubbed her arm on her cup on accident and tore her skin slightly. The Report did not document progressive interventions to prevent her from future skin tears. R18's Care Plan, revision date 10/15/2021, documents The resident has a Skin Tear L (left) forearm, 8/20/21 Right lower leg. 9/9/2021 Skin tear to left shin. 9/17/2021 Skin tear to right shin. 9/24/2021 Skin tear to right upper arm. 10/14/2021 skin tear to left upper. Interventions 9/17/2021 shin guards to BLE (bilateral lower extremities) at all times. 10/15/2021 Geri sleeves at all times. On 10/25/2021 at 11:30 AM R18 was sitting in the wheelchair in the dining room with a short sleeve shirt on and pants. R18's her upper chest, arms were exposed. There was a dressing to R18's left lower arm, left upper arm and right arm. On 10/25/21, at 2:20 PM R18 was assisted to the toilet and observed a dressing to both legs. R18 was not wearing geri sleeves or shin guards. On 10/25/2021 at 2:23 PM, V5, Certified Nurse's Assistant (CNA), stated that he is not sure how the skin tears happened and is not aware of her interventions. V5 stated that he has not put on geri sleeves on shin guards on R18. V5 stated that R18 has thin and fragile skin. V5 stated that he is not aware of a shin guard that R18 is supposed to wear. On 10/26/2021 at 11:30 AM V2, Director of Nurse's stated that she was aware of the skin tears. V2 stated that she removed the bedrail from R18's bed. V2 stated that the geri sleeves and shin guard was the intervention put in place to prevent further skin tears but had not been put in place. V2 stated that they had been ordered but had not came in yet. V2 stated that she would prefer for R18 to wear long sleeves. V2 stated that there were no other interventions put in place while waiting for these items to come in. On 10/26/2021 at 2:50 PM V16, CNA, stated that R18 has multiple skin tears. V16 stated that R18 has fragile skin and the slight bump will cause her skin to tear. V16 stated that R18 does not have any interventions put in place to prevent more skin tears. V16 stated that she has requested the padding of R18's wheelchair and bed. V16 stated that R18 moves her own wheelchair at times. V16 stated that R18 doesn't have foot pedals and the metal prongs stick out next to R18's legs. V16 stated that she has not seen any shin guards and have not put them on her. V16 stated that they have put geri sleeves on R18 and she would remove them. V16 stated that no other interventions were put in place. V16 stated that R18 usually wears short sleeves. V16 stated that R18 should have something in place but at this time she doesn't. V16 stated that R18 needs something or the skin tears will continue to happen. On 11/2/2021 at 2:30 PM, V32, Physician, state that he was notified of R18's skin tears. V32 stated that R18 is an older lady that is thin and frail. V32 stated that due to this her skin is fragile and easily injured. V32 stated that expects the staff to investigate and document incidents and accidents. V32 stated that he would expect the facility to put interventions in place and apply them to prevent reoccurring injuries to this resident. 2. R6's Admission Record, print date of 10/28/21, documents R6 was admitted on [DATE] with diagnoses of Chronic Pulmonary Obstructive Disease and [CONDITION(S)]. R6's MDS, dated [DATE], documents R6 is cognitively intact and requires extensive assist of 2 staff members for transfers. On 10/25/21 at 9:55 AM, V25 CNA and V26 CNA entered R6's room to do a mechanical lift transfer for R6 from the wheelchair to the bed. V25 operated the lift and pushed the mechanical lift to the bed while V26 CNA stood on the other side of the bed. V26 at no time held onto the mechanical sling while transferring R6 to bed. On 11/1/21 at 11:00 AM, V2 stated that she expects 2 staff to be present for a mechanical lift transfer and that the second person should hold onto the sling during the transfer. 3. R17's Admission Record, print date of 10/27/21, documents that R17 was admitted on [DATE] with diagnoses of History of Falling, Anxiety, [CONDITION(S)] and Difficulty in Walking. R17's MDS, dated [DATE], documents that R17 is severely cognitively impaired, requires extensive assistance of 2 staff members for bed mobility, is totally dependent on 2 staff members for transfers, the activity of walking did not occur and during a surface to surface transfer R17 is not steady and is only able to stabilize with staff. On 10/26/21 at 3:20 PM, R17 was lying in bed on her right side. R17's wheelchair was parked on the floor mat right beside R17's bed. R17's Nurses Notes, dated 3/18/21, documents, This nurse called to room due to resident being found in the floor next to her bed. Resident noted to be left side lying with head between nightstand and bed. Resident assessed and rolled to her back for transfer back to bed via (mechanical) lift. Transferred to bed without incident x 3 staff. Increased pain noted with PROM to left leg. Laceration 1 cm (centimeter) x 0.03 cm to right scalp above ear. 1 cm X 1 cm circular abrasion to area on scalp above left ear. Red area to forehead 11 cm x 4 cm top of left 4th toe 1.5 cm X 0.5 cm abrasion top of left 5th toe 4 mm (millimeter) X 3 mm abrasion. R17's Incident Description, dated 3/18/21, documents, Notes: Resident observed on the floor between her bed and night stand next to her window. Resident unable to state what had happened. root cause: poor safety awareness. intervention: floor mat by bed. R17's Nursing Note, dated 8/29/21, documents, Roommate reported fall to staff. (R17) tried to climb out of bed. Sitting on knees next to bed, holding grab bar on bed-so she was sitting upright. Did not hit appear to hit head. No injuries noted anywhere. Has a skin/fungal rash on abdomen, back, groin, buttocks-applied [MEDICATION(S)] cream & antifungal as ordered. Has areas on toes- treatment with [MEDICATION(S)]. All extremities with normal range of motion. Denies pain. She had been up for breakfast & lunch & down in bed between meals. She was wide awake. She said she tried to get up and was sitting on knees upright next to bed, holding grab bar on bed. Her normal orientation is confused. She is unaware of her physical limitations. Poor safety awareness. Total dependent 2 assist with transfers, toileting, dressing, bed mobility. R17's Fall Report, dated 8/29/21, documents, Notes, dated 8/31/21, Resident observed on the floor next to her bed on her knees. stated she tried to get up. No injury noted. root cause: poor safety awareness, attempting to stand without assistance. intervention pad alarm in bed. R17's Incident Description, dated 9/11/21, documents, This nurse called to room by (R17's) roommate. Advised that (R17) had fallen out of bed. She was sitting on side of bed facing toward her roommates' side of room. She was holding on to side rail of bed. She denied having pain or discomfort. Resident Description: Resident stated she did not know how she fell out of bed or what she was doing when she fell . Predisposing Physiological Factors: Incontinent, Impaired Memory. Predisposing Situation Factors: Side Rails. R17's Incident Follow up Note, dated 9/12/21, documents, Root Cause Analysis: pain response. Interventions: give HS (hour of Sleep) meds (medication) as soon as resident gets laid down, and position resident closer to wall side of bed to reduce the risk of a roll out. R17's Nursing Note, dated 9/24/21, documents, This nurse called to room by CNAs (Certified Nurse's Aides). Upon entering room this nurse noted res (resident) on floor next to bed on lt (left)side. Res noted to be incont (incontinent) of urine. non-skid socks in place. Bed noted to be in low position. No injuries noted. ROM (range of motion) wnls (within normal limits) for this res. no s/s (sign or symptom) of pain or distress noted. Res assisted back into bed with staff assti (assistance) of 2 with (mechanical) lift. R17's Incident Report, dated 9/24/21, documents, Predisposing Physiological Factors: Confused, Incontinent, Impaired Memory. Predisposing Situation Factors: Side Rails IP. Notes, dated 9/27/21, Root Cause: Resident was incontinent of urine. Intervention: 1 hour check and change while in bed. R17's Care Plan, dated 6/10/19, documents, At risk for falls and injuries r/t Medications: [CONDITION(S)] Meds/ Cardiovascular Meds. Medical Factor: [CONDITION(S)] (stroke), Dementia and DM (Diabetes Mellitus. Date initiated 3/1/21: 1 hour checks for safety and assistance. Date initiated 9/27/21: 1 hour check and change while in bed. On 11/3/21 at 12:05 PM, V2 stated that she agrees that R17 has fallen multiple times and no true root cause analysis has been done on some of the falls and that some of the fall investigations fail to document the time of the fall and when the resident was seen or assisted last. V2 stated that that type of information would be in the CNA charting. The facility policy and procedure Transfers, dated 9/15/2019, documents, Transfers. Policy: To promote safe transfer for the residents, as well as the staff, gait belts, (mechanical) lifts, and or sit to stand will be used, unless otherwise specified. It continues, 3. A minimum of two staff members is recommended when transferring with a (mechanical) lift. 4. When using a (mechanical) lift, pay close attention to be sure the (mechanical lift) sling is properly positioned. 5. When using a gait belt, apply the belt around the resident' s waist over clothing. Never apply gait belt over bare skin. It continues, Follow Plan of Care to ensure the use of proper transfer technique. The facility's policy and procedure Assessing Falls and Their Causes, dated 3/2018, documents, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. It continues, Defining Details of Falls: 1. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. It continues, Identifying Causes of a Fall or Fall Risk: 1. Immediately after meeting safety and care needs, the nurse will determine the most likely case and implement a strategy to prevent further falls or reduce the possibility of injury and update care plan. 2. Within 24 hours of a fall=, begin to try an identify possible or likely causes of the incident. Refer to resident specific evidence including medical history, known functional impairments, etc. (et cetera). 3. Evaluate chain of events or circumstances preceding a recent fall, including: a. time of day of the fall; b. Time of last meal; c. What was the resident doing; d. Whether the resident was standing, walking, reaching, or transferring form one position to another; e. Whether the resident was among other persons or alone It continues, h. Whether there is a pattern of falls for this resident. It continues, 3. All interventions will be fully implemented, added to the care plan and monitored for efficacy. 4. R41's Admission Record Sheet, undated, documents R41was admitted on [DATE] and had diagnoses of fracture of neck of femur (9/22/21), dementia, restlessness and agitation. R41's MDS dated [DATE] documents; R41 is moderately cognitively impaired, needs extensive assistance of two staff persons for h bed mobility, transfers, and toilet use. R41's MDS documents her balance was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface-to- surface transfers. R41's Incident Report Dated 9/16/2021 at 3:30PM documents Nurse was called in the resident's room and was informed that she was found in someone else's room. Resident was found by a corporate nurse sitting on the floor next to a chair. Resident stated that she was just walking around to see what's going on. She tried to sit on the chair inside the room and lost her balance and ended up on the floor next to the chair. Room was dark at that time. Resident was A&O1-2 (alert and oriented times one-two). Recently admitted to the facility with the dx of [CONDITION(S)] et (and) taking antibiotics for it. Also Documents R41 was confused, impaired memory and gait imbalance. R41's Care Plan Intervention, dated 9/16/21 documents R41 is at risk for falls and injuries related to history of falls, poor balance, unsteady gait, weakness and diagnosis of Alzheimer's. The Care Plan Intervention, dated 9/16/21 at 3:40 PM, documents Resident educated on asking for assistance with transfers. R41's Incident Report Dated 9/16/2021 at 6:30 PM document R41 was found sitting with legs straight out in middle of room. Resident states that she was feeling nauseous and pointed towards the trash can. Also documents R41 was confused, impaired memory and gait imbalance. R41's Care Plan Intervention, dated 9/16/21 at 6:30 PM documented Rollator moved from side of bed and replaced with w/c (wheelchair). Resident encouraged to use w/c and staff will assist with any use with rollator. The Care Plan did not address if R41 needed increased supervision due to two falls in one day. R41's Incident Report Dated 9/16/2021 at 7:45 PM documents; Nurse was called in the resident room by the night shift CNA. Resident was sitting on the floor in the middle of her room, facing her closet. her legs were laying straight out while sitting on rt side. She was very confused. Facial grimacing flushed and is touching her left hip like its bothering her bad. When this nurse and two CNAs got her up, she was not able to bear weight on the left leg/hip. She could not find the right word of how she's feeling. She was asked again if it hurt and she did not answer, she was asked if it's just spasms and she said no. She was placed on her wheelchair and all she did was moan and touching/ pushing on her left hip like it relieving something. R41's Care Plan, dated 9/16/21, at 7:45 PM documented, low bed, scoop mattress. R41's Hospital Emergency to Admission Record; dated 9/16/2021, documents; CT (Computed tomography) Results on 9/17/2021 findings, Acute fracture across the femoral neck near the subcapital region. Cephalad displacement of the distal component by half a shaft. Anterior apex angulation. On 11/1/2021 at 9:45 AM, V2 stated that she would expect for the appropriate intervention to be put in place.

Based on interview, and record review, the facility failed to allow residents to have end-of-life [MEDICATION NAME] care visits from family for one of three residents (R2) reviewed for visitation in the sample of 7. This failure resulted in psychosocial harm in that R2 died alone in the facility while family observed through the window. A reasonable person would have been afraid and anxious while dying alone without family present. Finding includes: R2's Nurse's Note dated [DATE] at 8:51 AM documents Nurse called and informed resident's family members that resident's status was not well. Nurse encouraged family to come to window to see resident sooner rather than later. On [DATE] at 09:35 AM V12, R2's Daughter/Power of Attorney, stated, My mom got sick on a Thursday. V12 stated A staff member called and advised me I needed to come to facility 'now' on Saturday morning. V12 stated when she arrived at the facility she began banging on the front door. V12 stated a staff member pointed to an exterior window. V12 stated she walked up to R2's room window and saw her mother (R2) gasping for air alone in the room. V12 stated she began banging on R2's window and a male Certified Nurse's Assistant (CNA) appeared and looked around and left to get the nurse. V12 stated A nurse came into the room and listened to my mother using a stethoscope, looked at us and began shaking her head side to side. V12 began crying and stated, I watched my mom gasping all alone and they wouldn't allow me to be with her. On [DATE] at 9:40 AM V3, Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON) stated, We do allow family in room if resident is actively dying. V3 stated The nurse that worked that weekend doesn't work at the facility full time, she just works every other weekend, so she probably didn't know. On [DATE] at 12:10 PM V10 LPN stated regarding [MEDICATION NAME] care visits, It is okay for family to visit residents. On [DATE] at 12:20 PM V11 LPN stated regarding [MEDICATION NAME] care visits, Family has to be screened, and have on personal protective equipment (PPE) to visit an actively dying resident. On [DATE] at 3:04 PM V5 Register Nurse (RN) stated, I got report from (V7 LPN) night nurse. V5 stated, I asked (V7) what to do if family requested to visit with (R2). V5 stated that V7 responded Staff are not allowing family visitations now due to if someone would contract COVID they may sue facility. V5 stated, I went to give (R2) her morning medications and observed (R2) not doing well, so I called (R2's) daughter and advised her she needs to come to facility before 1pm as scheduled. V5 state I was the first nurse in (R2) room. V5 stated, It broke my heart. I put my cell phone on speaker so (R2's) daughter could speak to her mother. V5 stated the facility's policy and procedure is constantly changing so she's not sure about visitation and the communication is not good at the facility. V5 stated, (V7) is part of the management team so I thought she would know. On [DATE] at 3:29 PM V7 LPN stated, I worked midnights and gave report to (V5). V7 stated that R2's breathing was declining, and she was still alive on night shift. V7 stated (R2) was alert for me, made no complaints, and able to answer questions. V7 stated there was active dying residents that were allowed to have visitors. V7 stated, I called (V2, Director of Nurse/DON) who stated, 'We are not allowing family visits inside facility.' V7 stated, I am not familiar with the facility's policy and procedure on family visitations. On [DATE] at 4:34 PM V6, CNA, stated he was working another hall and he heard a page to come to R2's room to move her bed closer to window. V6 stated I was the only one in (R2's) room so I quickly moved her bed as fast as I could and left. V6 stated, I don't know why (R2's) daughter didn't come inside facility. V6 CNA stated, The facility's policy and procedure is 1 person at a time with gown and mask on regarding [MEDICATION NAME] care visits. On [DATE] at 9:31 AM V15, R2's Physician, stated regarding [MEDICATION NAME] care visitation, Absolutely, I would expect the facility to follow their policies and procedures on family visits. On [DATE] at 11:31 AM V16 LPN stated, (R2) had already passed, when I entered the room. I was the second nurse to confirm. V16 stated, Family was outside (R2's) window visibly upset. V16 stated, We were told by (V2) that visitors are not allowed. On [DATE] at 3:15 PM V2 stated, We have had many in services on that. V2 stated, I think it was probably a staff member who doesn't work a lot and didn't know the situation. The Facility's Policy and Procedure, End of Life/Hospice Visitor Policy, dated [DATE], which considers COVID-19 precautions documents 2. When a resident is showing signs and symptoms of end of life, family will be permitted to visit their loved one. 3. When entering the facility, the family will be screened at the door for temperature and signs and symptoms of COVID. 4. The family will wear a mask and gown when visiting their loved one. 5. The facility will escort the family directly to the resident's room. The family will not be allowed to wander freely through the facility. 6. 2 members of the family will be permitted to visit the resident. This includes immediate family only. The facility Administration will make the decision on which family/friend is permitted to visit and the length of the time of the stay.

Based on observation, interview, and record review, the facility failed to accurately evaluate and provide a pain management regimen to promote comfort and compliance for effective wound care for 1 (R4) of 3 residents reviewed for pain the sample of 17. This failure resulted in R4 experiencing pain, compromising the effectiveness and compliance level of wound care, and resulted in R4 acquiring a maggot infestation with otitis externa to his right ear requiring emergency room evaluation and treatment on 9/11/20 and 9/12/20. Findings Include: In a policy titled Management of Pain with a revision date of 9/16/20, the document states, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain .Aggressively assessing pain in non-verbal and cognitively impaired residents . The policy goes on to state, For the purposes of this policy, pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. Nursing observation is an important part of the pain assessment, especially in the non-verbal resident. Using the chart provided with the pain assessment, nursing will observe behaviors that may indicate pain in the non-verbal or cognitively impaired resident. Pain may also be indicated when there are changes in the following: facial expressions, vocal behaviors, body movements, routines, mental status. A Minimum Data Set, dated dated dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score as 10, indicating moderate cognitive impairment. Review of R4's Plan of care documents a problem area with a revision date of 9/10/19 stating (chronic) pain r/t (related to) Arthritis, Cancer (skin), gout with interventions including but not limited to, Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. Review of R4's current and active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The same physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Clinical Record documents a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] = (equals) 650mg related to [CONDITION(S)] of Skin, Unspecified, assess for pain if pain is > (greater than) 4 notify MD (Medical Doctor) AND Give 2 tablet by mouth every 8 hours as needed for pain 1-4. Notify MD if pain is greater than 5/10 related to [CONDITION(S)] of Skin, Unspecified PRN (as needed) is not to be given within 8 hours of scheduled dose. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse [CONDITION(S)] to right ear, left nares/upper lip with n/s (normal saline), pat dry. Monitor for weeping/drainage/bleeding. Start date 10/18/19 and discontinue date of 10/15/20, White [MEDICATION(S)] Apply to left nose/upper lip topically every day shift for wound care unsupervised self-administration cleanse with normal saline. Additional Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Instill 3 drop in right ear four times a day for ear infestation for 10 Days. Emergency Department (ED) Provider Notes from the local hospital document on 9/11/20, R4 was seen for evaluation and treatment related to R4's right ear being impacted with maggots. Upon arrival to the ED, R4 denied pain but stated his right ear did not feel as good as the left. The same document states R4's ear was irrigated with multiple maggots being flushed out. Review of Systems documents R4 was positive for ear discharge. History of Present Illnesses documents R4 as having a history of facial melanoma brought in by Emergency Medical Services (EMS) .Pt. (patient) is apparently not getting treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Department Provider Notes from the local hospital document on 9/12/20, R4 was seen for evaluation and treatment related to Infestation (maggots in right ear). The report states R4 was present in the ED yesterday for the same complaint in which numerous maggots were irrigated, and no further evidence of maggots was noted. Upon recheck by facility staff today, maggots were noted to then again be present. Review of Symptoms documents R4 as positive for ear pain. A Physical exam was conducted in which it was noted R4 had Several chronic [CONDITION(S)] within the helix. On initial inspection greater than 10 maggots were seen in the auditory canal. Movement of the [NAME] resulted in significant pain. ED Course documents shortly after R4's arrival [MEDICATION(S)] [MEDICATION(S)] was placed in R4's external auditory canal to reduce discomfort. Treatment included flushing R4's right ear in which 15 maggots were produced. After allowing R4 to rest, the ear was irrigated again producing an additional 6 maggots. The report documents irritation within the external auditory canal consistent with otitis externa and suspect this as cause of patient's maggot food source. R4's visit diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is documented as being discharged back to the facility on [MEDICATION(S)] drops, with hope of reducing inflammation and aiding in clearance of any further debris or infestation. Review of an article found at https://journals.lww.com/em-news/fulltext/2019/ /infocus__acute_otitis_externa_pain_can_be_severe,.10.aspx, dated February 2019 and titled, Acute Otitis Externa Pain Can Be Severe, but Relief Can Be Had in the ED states: The pain from acute otitis externa will bring patients to your ED rather quickly. The onset can be fast and the pain excruciating. It is not usually life-threatening, but emergency physicians should still be aware of the issues surrounding acute otitis externa and how to approach it in the ED. This syndrome has multiple causes but is usually caused by a common bacterial infection. On 10/14/20 at 1:25 PM, R4 was observed as being alert to person and place. R4 describes his care at the facility as, I'm passed by. R4 states he is unsure why staff don't tend to him but states, Anything is better than what I've got. R4 denies ever being offered pain medication prior to having wound care. R4 describes his face and right ear wound area as itchy mainly and hurts a little. When asked if he would like to receive pain medication prior to wound care to see if that would make care more comfortable for him, R4 states yes. When asked to rate his pain on a scale of 0-10 with 10 being the worst and 0 being no pain at all, R4 describes pain to his wounds as a 0-1 now when they aren't being bothered, and close to a 10 when they are messing with it. On 10/14/20 at 12:44 PM, V20 (Registered Nurse, RN) states that she works as a wound nurse at the facility. V20 states R4's wounds to his face and right ear are cancer [CONDITION(S)] which he has refused to have surgery on. V20 states R4 is care planned to provide his own wound care and staff just assist as needed or he requests. V20 states many times R4 refuses assistance with wound treatment and care. V20 was observed as placing normal saline into a medicine cup, gauze, and cotton tipped applicators on a barrier on R4's bed side table. V20 removed the already partially removed, visibly soiled with a red substance dressing from R4's right ear. V20 asked if that was enough supplies she had laid out for R4 to do his wound care, in which he didn't respond, but just stared at the supplies. After a short moment of time passing with no response or action taken by R4, V20 stated she would help R4 in which she moistened gauze with normal saline and began wiping the outer edges of R4's right ear, which he allowed without resistance. V20 asked if she could clean inside of R4's right ear in which he stated, No, it would hurt. V20 ensured R4 she would be gentle and stop if it hurt too bad, with R4 then agreeing to the care. V20 moistened a cotton tipped applicator with normal saline and began wiping inside R4's right ear when he stated, That hurts! That's too much! V20 ceased wound cleansing at that time and placed a dry dressing over R4's right ear. V20 states R4 did not receive pain medication or pain alleviating treatments prior to receiving wound care. V20 acknowledges R4 was experiencing pain during care, which may have factored into his resistance with wound care. V20 was not observed as asking R4 to rate or describe any pain he was experiencing. On 10/14/20 at 1:39 PM, V1 (Director of Nursing) states R4 continuously picks at his facial and ear wounds. V1 states the wounds are cancer [CONDITION(S)] and acknowledges he has had a maggot infestation in the right ear wound while residing at the facility. V1 states R4 doesn't allow the staff to clean the wounds good. V1 states they have not attempted administering pain medication prior to providing wound care and states R4 likes to do his own care. V1 acknowledges that R4 expressed he was in pain while staff attempted to provide wound care and that his resistance to care could be possibly due to pain associated with the wounds. V1 states she will talk to the doctor regarding R4's pain management and plan of care. On 10/20/20 at 2:00 PM, V45 (Licensed Practical Nurse, LPN) stated she was the nurse on duty when the maggots were observed in R4's ear. V45 states R4 complained that his ear was hurting, and she asked if she could look at it. V45 states R4 allowed her to, and that's when she observed the maggots. V45 states R4 doesn't complain of pain until you touch the ear to do the treatment, and then he will yell to stop. V45 states R4 did not get any type of pain medication prior to cleaning the ear. On 10/19/20 at 8:41 PM, V39 (RN) states R4 is non-compliant with wound care. V39 states R4 does experience some pain with his face and ear cancer wounds and states the ear seems more painful for him, rather than his face. V39 states she is unsure if R4 receives any medication or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/19/20 at 8:57 PM, V40 (LPN) describes R4 as being alert to person and place only. V40 states R4 has never made direct complaints of pain to her, but will express phrases which indicate pain, such as him stating not so hard despite the wound area being touched gently. V40 states R4 is resistive to wound care and refuses much of the time. V40 states R4 has an as needed Acetaminophen order, but states he will not ask for it, you have to ask him. On 10/20/20 at 12:21 PM, V42 (Physician) states he cared for R4 in the past regarding his skin cancer [CONDITION(S)] to his face and ear. V42 states if R4 was expressing or demonstrating that he is experiencing pain or resistive to care possibly due to pain, he would expect a pain treatment regimen to be implemented and re-evaluated as needed. V42 states he has not been notified of any pain R4 is experiencing. V42 states with an effective pain treatment regimen it is possible R4 would be more receptive and tolerable to cleaning the wounds which could help prevent a maggot infestation. On 10/16/20 at 11:30 AM, V43 (Family Member) states the facility has not contacted her regarding options for pain management with wound care/conditions or been involved in a care plan meeting at all for R4. Despite staff interviews acknowledging R4 experiences wound pain and refusal/resistance to wound treatment, observation of R4 experiencing pain/resistance with wound treatment, and R4's own expression of pain, review of R4's Medication Administration Records for 07/2020 - 10/13/20 documents 0 as R4's pain ratings with no administration of as needed pain medication documented.

Based on observation, interview and record review the facility failed to asses, develop, and implement an effective plan of care for cancerous [CONDITION(S)], in order to prevent otitis externa and a maggot infestation within a wound for 1 (R4) of 5 residents reviewed for wound care in the total sample of 17. This failure resulted in R4 acquiring a maggot infestation with otitis externa to his right ear, requiring emergency room evaluation and treatment on both 9/11/20 and 9/12/20. The Findings Include: R4's admission record documents an admitted [DATE] and includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly MDS (Minimum Data Set) dated 10/13/20, documents a BIMS (Brief Interview of Mental Status) of 10 indicating a moderate cognitive impairment. On this same MDS for ADL (Activities of Daily Living) care, R4 is coded as needing a one-person physical assist for: bed mobility, transfers between surfaces, walking in room, walking in corridor, dressing, toilet use, and personal hygiene. R4 is coded as needing a one-person physical assist for bathing. These were all coded the same on all MDS's dated on a quarterly on 9/29/20, and annual MDS on 8/27/20 and an annual MDS on 6/15/20. R4's care plan, dated 9/14/20, has a focus area of: resident has noncompliance by refusing to allow staff to do treatment to cancer [CONDITION(S)] for face/ear, and refuses to keep dressings on. The goal is for the resident to verbalize understanding of consequences of non-compliance through review date. The interventions/tasks listed for this problem area include: 1) accept residents right to refuse, 2) discuss with resident his/her objections, reasons, fears, ideas, 3) give positive feedback and reinforcement for resident's compliance, 4) inform resident about risks of noncompliance, 5) offer as many alternatives as possible for resident to choose from. The care plan also has a focus area stating that the resident has impaired cognitive function/dementia or impaired thought processes with a revision date of 9/16/19. The goal for this focus area is that the resident will maintain current level of cognitive function through review date and that resident will be able to communicate basic needs, on a daily basis through review date. Interventions for this focus area include: administer medications as ordered and monitor/document for side effects and effectiveness, communicate with resident/family/caregivers regarding resident's capabilities and needs, and to cue/reorient/supervise as needed. A focus area on the same care plan documents that R4 has the potential for impaired skin integrity due to cognitive deficits and resident picks at skin. The goal is for no new pressure areas to develop in the next 90 days. Interventions for this focus area include: bath/shower per schedule and observe skin integrity during am/pm care. On 10/14/20 at 11:30 AM , R4 was observed to be seen sitting on the side of his bed with a bandage hanging loose off his right ear. The bandage was saturated with a brownish-red substance. R4's undershirt and flannel shirt were observed to have the same brownish-red dried substance down the front, as well as dried white liquid down the front of his shirt. R4's bed linens and pillow case had the same dried brownish-red substance on them as well. On 10/14/20 at 1:25 PM, R4 was observed as being alert to person and place and describes his care at the facility as, I'm passed by. R4 states he is unsure why staff don't tend to him but states, Anything is better than what I've got. R4's progress notes documented by V20 (Registered Nurse/RN) and dated 9/7/20, state that R4's right ear had serous drainage from area noted to be cancerous. The ear was assessed and tolerated by resident. Serous drainage was cleansed from neck and outer ear with normal saline and gauze. R4 would only allow light cleansing to [NAME] close to ear canal. Gauze was lightly packed to [NAME] and ear covered with medical tape to secure. On 9/9/20 a progress note was entered stating that R4 was seen by doctor on 9/8/20, and no changes to plan of care. A 9/9/20 Progress Note by V20 documents the following: that resident was having serous drainage from his R (right) ear. V20 went to assess resident's ear. Upon entering room R4 was noted to be picking at the [NAME] of his Right ear. V20 asked resident why he was picking at the cancerous spot to his ear. R4 stated I'm not. Serous drainage was observed to R4's nails. Per tolerated by resident, area cleansed with NS (normal saline), gauze. No additional drainage noted from opening of right ear canal. R4 would not allow additional assessment of ear. Right ear [NAME] was lightly packed with gauze and secured with medical tape. R4's nails were trimmed, and hands cleansed. On 9/10/20, V31 (LPN) documented the following in a Progress Note: V31 was alerted to resident's room by CNA. R4 was noted with moderate amount of dried and bright red blood to right ear, lateral neck and anterior neck/throat regions. Active bleeding from right ear noted. R4 also noted with dried blood to nail plates and right hand. Resident known for picking at cancerous lesion areas. V31 asked R4 if he had been picking at his right ear. Blood noted to tissues on the over the bed table as well as in the trash can. Care and assistance offered to R4. R4 was resistant and refused initially. Encouragement and education provided to resident for proper wound care and hygiene. R4 then allowed this nurse to assist. R4 was carefully cleansed of blood from right ear then from neck and throat region. R4 would not allow nurse to assess ear or other cancerous [CONDITION(S)] further once cleansed. Ear packed with gauze per resident's tolerance of pressure and secured in place with a gauze wrap around his head. Gauze was secured with tape. A Progress Note dated 9/11/20 at 5:45AM shows that V45 (LPN) documented that R4 complained of pain to right ear. Upon assessment, right ear canal found to be impacted with maggots. Nurse on call notified. MD (Medical Doctor) notified and stated to send to Emergency Department for evaluation and treatment. Resident's Power of Attorney notified. At 6:18AM, R4 was transferred out via ambulance. At 1:00 PM on 9/11/20, R4 returned from emergency room , documenting that the right ear was flushed during emergency room visit. No new orders at this time. On 10/20/20 at 2:00 PM, V45 stated that she was the nurse on duty when the maggots were found in R4's ear. She had just passed medications and R4 stated that his ear was hurting, and she asked if she could look at it, which he allowed. V45 stated the order at that time was that nursing is to supply the items for him to clean his own ear. V45 stated that when she looked into the ear, she found the maggots. V45 stated that there were a large amount of flies in his room that evening, more than usual. V45 stated that R4 scratches his ear often, likely because it itches. He doesn't complain of pain until you touch the ear to do the treatment, and then he will yell to stop. V45 stated R4 did not get any type of pain medication prior to cleaning the ear, and that poor hygiene and the large number of flies likely caused the maggot infestation. V45 stated that R4 went to the hospital twice before all the maggots were removed from his ear. Documentation from the local hospital emergency department notes report at 6:11 AM on 9/11/20, R4 came into the emergency department due to a wound nurse discovering R4's right ear to be impacted with maggots at the long-term care facility after she had been on vacation for a week. R4 at this time stated that his right ear did not feel as good as his left ear. The discharge note made by the physician states that the ear was irrigated, and multiple maggots were flushed out of the ear. R4 tolerated procedure fairly. Another Progress Note on 9/12/20 at 2:37AM, documents that R4 was again transferred on a gurney via ambulance to acute care hospital. Right ear impacted with maggots. Medical Doctor notified of transfer. R4 was back in building on 9/12/20 at 5:49AM. emergency room stated they flushed his ear twice and removed 21 maggots. At this time, a new order was received for antibiotic ear drops 4 times a day for 10 days. Emergency department notes dated 9/12/20 at 3:13 AM, document that R4 was seen in the emergency department yesterday with complaints of a maggot infestation in right ear. R4 is reporting an 8/10 pain in the right ear. R4 has cancer lesion to the right ear. Long Term Care facility reports R4 digs in right ear with finger. Visible redness and inflammation on outer part of ear. Physician medical discharge note was that [MEDICATION(S)] [MEDICATION(S)] was placed in right external auditory canal to decrease discomfort. Normal saline was used to irrigate ear aggressively. 15 maggots were removed, and after 30 minutes of rest, 6 more were removed with further irrigation. There does appear to be some irritation within external auditory canal consistent with otitis external. Suspect this as cause of R4 maggot food source. [MEDICATION(S)] drops were prescribed with hope of decreasing inflammation and aiding in clearance of any other debris or infestation. A Progress note from 9/14/20 documents that R4 refuses personal hygiene. On 9/15/20, a new order was received to keep ear clean and dry by V26 (Physician). On 9/21/20, a note is made by V20: right ear inspected. R4 would only allow external examination. Drainage to [NAME]/ear canal opening noted. Nothing new to report. On 9/23/20, a progress note made by V20 documents; right ear inspected. R4 would only allow external examination. Drainage to [NAME]/ear canal opening noted. Nothing new to report. No further progress notes were documented after 9/23/20 through 10/16/20 regarding the condition of R4's right ear. On 10/14/20 at 12:10 PM, V8 (Licensed Practical Nurse/LPN) was passing medications, and R4 was observed to be scratching and digging in his right ear, then stated he needed assistance with his ear. V8 stated she would send someone in to help him. Beginning at 12:10 PM, after a continuous observation and speaking with R4, the call light was pushed at 12:39 PM, and V20 arrived at 12:44 PM. At this time, V20 (Registered Nurse, RN) states that she works as a wound nurse at the facility. V20 states R4's wounds to his face and right ear are cancer [CONDITION(S)] which he has refused to have surgery on. V20 states R4 is care planned to provide his own wound care and staff just assist as needed or as he requests. V20 was observed as placing normal saline into a medicine cup, gauze, and cotton tipped applicator-tips on a barrier on R4's bed side table. V20 removed the already partially removed, visibly soiled with a red substance from R4's right ear. V20 asked if that was enough supplies she had laid out for R4 to do his wound care, in which he didn't respond, but just stared at the supplies. Despite R4 observed as having a large amount of red/brown dried substance appearing to be blood to his shirt, pants, pillowcase, floor, wheelchair, hands, face, neck, arms, and blankets on his bed, no assistance with hygiene was noted to be offered or encouraged prior to providing him supplies to self-administer his own wound care. After a short moment of time passing with no response or action taken by R4, V20 stated she would help R4 in which she moistened gauze with normal saline and began wiping the outer edges of R4's right ear. V20 asked if she could clean inside of R4's right ear in which he stated, No, it would hurt. V20 ensured she would be gentle and stop if it hurt too bad, which R4 then agreed to the care. V20 moistened a cotton tipped applicator-tip with normal saline and began wiping inside R4's right ear. During wound care multiple flies were observed landing on the wound care supplies, R4, V20, and multiple surfaces in the room. When asked if R4 has a problem with flies in his room, V20 pointed to a purple glowing light mounted directly above R4's bed, nodding yes. V20 states the light is supposed to help with the flies, but acknowledges they are still present. When asked why she thought there was such a problem with flies in R4's room, V20 states, the blood maybe? A progress note made on 10/14/20 by V20 documents the following: physician notified of serous drainage to resident's right ear. Resident's call light on for assistance and answered by this nurse. R4 asked for additional assistance to ear. Drainage to ear cleansed with normal saline, gauze, cotton tipped applicator per R4's tolerance. R4 would only let this nurse cleanse outer ear and [NAME] to ear. Minimal discomfort expressed by resident. No complaints of continued discomfort after ear bandaged. Additional supplies offered to R4 for cleansing purposes, and refused. Assistance offered for cleansing of nose/upper lip. R4 declined assistance. Outer ear canal assessed at time of cleansing. No noted additional changes to ear. New order given per physician for as needed assistance per resident request and tolerance. R4's September and October medication administration reports (MAR) show an order that was initiated on 11/22/19 as: Resident self-administers. Cleanse lesion to right ear with normal saline and pat dry. Monitor for weeping/draining/bleeding every shift. This was marked with a checkmark twice a day indicating it was completed until 10/15/20 when order was discontinued. The order as of 10/16/20 on the October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply a thin layer of petroleum jelly and cover lightly with gauze and tape. Monitor for weeping/drainage/bleeding. On 10/14/20 at 1:39 PM, V1 (Director of Nursing) states R4 continuously picks at his facial wounds. V1 states the wounds are cancer [CONDITION(S)] and acknowledges he has had maggots in the wound in the past while residing at the facility. V1 states R4 doesn't let the staff clean the wounds good. V1 states they have not tried administering pain medication prior to providing wound care and states R4 likes to do his own wound care. V1 acknowledges R4's poor hygiene as his hands are visibly very soiled with a dark red/brown substance appearing to be dry blood, long fingernails, dark red/brown substance caked under his fingernails. V1 acknowledges the concerns of if effective wound care could be completed by the resident himself, not only due to his visibly poor hygiene status, but the fact that the wounds are on his face and inside his right ear, making it not visible to himself. V1 acknowledges the presence of flies in R4's room. V1 was notified of observations of staff including but not limited to, V20 (Registered Nurse) and V8 (Licensed Practical Nurse) entering R4's room and despite R4 observed as having a large amount of red/brown dried substance appearing to be blood to his shirt, pants, pillow case, floor, wheel chair, hands, face, neck, arms, and blankets on his bed, no assistance with hygiene was noted to be offered or encouraged. V1 states she will talk to the doctor regarding R4's care. On 10/16/20 at 11:40 AM, V1 (Director of Nursing) states that R4's physician is medical director and he comes every Tuesday to the facility. He assessed that R4 was able to provide self-care. V1 says however, this assessment was not a formal assessment, so there is no documentation to provide. V1 went on to state that since admission, R4 has declined somewhat in his cognition level. V1 states that no one monitors R4's self- care to his ear, they just ensure that he has all the necessary items in his room to take care of himself. V1 says that since it was not a physician order, the wound self care is not documented on the treatment record as being completed/refused. V1 goes on to state that nurses would just pop in and check on R4 to see if he needed any assistance at various times of the day. V1 decided yesterday (10/15/20) that the nursing staff will begin to attempt to assist R4 daily, and document refusals because they need to attempt to 'at least give it a try to help clean it.' V1 believes that the smell, poor hygiene and improper cleansing of the right ear, along with all that drainage in the right ear attracted the flies and resulted in the maggot infestation. V1 states that in hindsight, she believes R4 only cleaned it superficially and that is why the maggot infestation happened. V1 is now having the staff check on him every 2 hours and change his clothes, wipe his hands and change sheets if soiled. On 10/16/20 at 11:50 AM, V31 (LPN) states that she feels R4's cognition fluctuates, but he is normally with it. V31 states R4 is resistant to most treatments, and poor hygiene has likely caused the maggot issue in his ear, adding that sometimes a nurse can start the treatment, but it is not typically completed. V31 further states that it is up to R4 to do his own care, but the wound/treatment nurse would sometimes peek in at him. V31 says that when R4 would be checked in on, if the right ear looked like it wouldn't have been cleaned, she would ask why, and he would say he didn't have the supplies. V31 would get the supplies for him, which consisted of petroleum jelly and cotton tipped applicator for a moist barrier. V31 states if R4 would decline treatment, nursing staff try to re-approach him, otherwise they let the doctor know on Tuesday when he comes in. V31 says no change in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/20/20 at 3:20 PM, V26 (Physician) stated that R4 was placed on the antibiotics at the emergency roiagnom on [DATE]. R4 has had cancer for years and has refused surgical treatment to remove it. V26 feels that R4 is oriented most of the time but has intermittent confusion. V26 stated R4 refuses most treatment from nurses and doctors, so it was determined self-care would be the best for R4 to maybe get it cleaned up as best as it could be. When the dressing was applied to R4's ear to try to stop the drainage it occluded the ear, and caused the perfect environment for the maggots to hatch. Poor hygiene likely was part of the cause of the maggot infestation. The flies are attracted to both the blood and decaying skin. V26 feels that the staff update him adequately on R4's condition.

Based on observation, record review, and interview, the facility failed to reassess the clinical condition for more frequent turning and repositioning, and failed to provide appropriate pressure relieving interventions to prevent the development of pressure ulcers for two of three residents (R1, R2) reviewed for pressure ulcers in the sample of 16. This failure resulted in R2 developing a Stage III pressure ulcer to the left buttock, and Unstageable pressure ulcer to the coccyx, and Deep Tissue Injury (DTI) to the right and the left heels. Findings include: 1. R2's physician's orders [REDACTED]." The Minimum Data Set (MDS), dated 2/05/2015, documents R2 is severely impaired with cognition, requires extensive assistance for bed mobility, transfers, personal hygiene, has an indwelling urinary catheter and is incontinent of bowel. R2's Care Area Assessment (CAA), dated 2/05/2015, documents R2 is at risk for developing pressure ulcers, but has no documented pressure related areas. On 3/04/2014 at 10:25 AM, R2 was in bed positioned to the left side. R2 had an alternating air loss mattress. R2's heels were directly on the mattress. On 3/04/2015 at 11:13 AM, 11:36 AM and at 12:15 PM, R2 was in bed lying on her back, with her heels resting directly on the mattress. An isolation sign was posted on the door of R2's room with personal protective equipment (PPE) in the hall near the door. On 3/04/2015 at 12:16 PM, E7, Certified Nurses Aide (CNA) stated, "Normally (R2) stays in bed. She's not due for anything until 1:00 (PM)." On 3/04/2015 at 12:55 PM, R2 remained positioned on her back with her heels directly on the mattress. R2's incontinent brief was soiled with feces. A foam heel protector was in place to R2's right foot, but not on the left foot. A pillow was on the floor at the foot of R2's bed. When asked if she was in pain, R2 stated, "My feet hurt." On 3/04/2015 at 1:25 PM, E3, Assistant Director of Nursing (ADON) applied PPE and entered R2's room. R2's left heel was still lying on the mattress. E3 reported R2 was on respiratory isolation [MEDICAL CONDITION] in the nares. On 3/04/2015 at 1:50 PM, E11, Registered Nurse (RN) applied PPE and removed R2's dressing from her coccyx area. A quarter sized open area was on R2's coccyx covered with yellow slough. A healing open wound was on R2's left buttock. R2's rectal area was dark red. R2's right heel had a large unstageable black area (eschar). R2's left heel had a smaller dark brown area with surrounding dark purple tissue. The Weekly Pressure Ulcer Management Report for 2/2015 documents on 2/15/2015 R2 had a facility acquired, unstageable pressure ulcer to the left buttock, measuring 2.0 cm (centimeter) X 1.0 cm with slough, a facility acquired and an unstageable pressure ulcer to the coccyx, measuring 4.0 cm X 2.0 cm, with slough. The Weekly Pressure Ulcer Report for 2/2015 documents on 2/18/2015 R2 developed a facility acquired SDTI, (suspected deep tissue injury) pressure ulcer to the right heel, measuring 5.0 cm X 5.5 cm, dark purple and a SDTI to the left heel, measuring 2.0 cm X 3.0 cm, dark purple. R2's Care Plan, dated 2/02/2015 and updated 2/16, 2/17, 2/19 and 2/24/2015, documents R2 is to be turned and repositioned every 2 hours while in bed. There is no turning and repositioning schedule for R2 documented when she is in the wheelchair at all. An intervention was added to R2's Care Plan on 2/19/2015 as "free float heels when in bed" to address the SDTI to both heels. On 3/06/2015 at 8:10 AM, E4, RN/Wound Nurse reported R2 was identified as a high risk for pressure ulcers on admission (1/29/2015), but was not placed on an alternating air loss mattress until 2/18/2015 after the development of the pressure ulcers. E4 reported the repositioning schedule completed by the staff is documented electronically in the computerized system entitled, "Administration Documentation History Detail." E4 reported when the facility uses agency staff there may be a lack of documentation in the electronic recording system for R2. The Administration Documentation History Report for R2 in 2/2015 and 3/2015 fails to document R2 was repositioned on 2/02, 2/08, 2/09, 2/13, 2/17, 2/19, 2/20, 2/21, 3/02, and 3/03/2015. On 3/05/2015 at 11:00 AM, Z2, Special Wound Consultant/Nurse Practitioner (NP) reported facility staff should make sure R2's heels are floated. Z2 stated, "It wouldn't hurt to reposition (R2) more often than every 2 hours. (R2) has chronic issues with diabetes, chronic incontinence and poor dietary intake." On 3/05/2015 at 3:18 PM, Z4, Physician reported he would recommend repositioning R2 every 2 hours, but may need to reposition R2 more often to heal the wounds. When asked if he felt R2's ulcers were unavoidable, Z4 refused to answer and stated, "Let me talk to the nurses." Z4 left the room and did not return with a response. The Basic Metabolic Profile, dated 2/03/2015, were unremarkable with no indications of dehydration. The physician's orders [REDACTED]. R2's clinical record has no PO or laboratory reports for a protein or [MEDICATION NAME] level for R2 to see if she is malnourished. R2's Nutrition Screening and Assessment, dated 2/08/2015 from E13, Registered Dietitian (RD), documents, in part, "admitted at 190.4 pounds, height 63 inches, IBW (ideal body weight) 104-127 pounds, BMI (basic metabolic index) 34. No indication of pressure ulcers. Abnormal labs (1/28/2015) include decreased Hgb (hemoglobin), does not appear to be nutritionally related." 2. R1's POS for 3/2015 documents diagnoses, in part, as "Diabetes Mellitus, [MEDICAL CONDITIONS] and History of Sacral Decubitus." The MDS, dated [DATE], documents R1 is moderately impaired with cognition, requires extensive assistance for bed mobility, transfers and personal hygiene, has limited range of motion to the lower extremities, and is incontinent of bowel. The CAA, dated 9/19/2014, documents R1 is at risk for pressure ulcers due to needing assistance of 2 staff with turning and positioning. On 3/04/2015 at 8:28 AM, 10:15 AM, 11:00 AM, 11:25 AM, and 12:15 PM, R1 was seated in the dining room in a wheelchair. R1 had bilateral foam heel protectors to both feet. R1 was obese. On 3/05/2015 at 9:07 PM, R1 was transferred to bed by E5, CNA and E12, RN with a mechanical lift. At this time, E12 reported R1 is totally dependant on staff for turning and repositioning in the bed and the wheelchair. E12 stated, "What caused his foot ulcer is the foot rest of the wheelchair. We reposition him in bed every 2 hours. When he's in the wheelchair, we try to reposition him with a (mechanical lift) and shift his weight. He doesn't like to go back to bed." R1 had a dressing to his left foot. The Change of Condition SBAR (Situation Background Assessment Response) PU (pressure ulcer), dated 1/20/2015, documents R1 has a new facility acquired, fluid filled blister to the left heel, measuring 3.0 cm X 3.0 cm, with treatment as "Cleanse left heel with NS (normal saline), Skin prep daily." The Pressure Ulcer Evaluation Record, dated 1/20/2015, documents R1's left heel intact blister as a DTI (deep tissue injury). The Pressure Ulcer Evaluation Record, dated 1/26/2015, documents R1's left heel as a Stage II, open blister. R1's Care Plan for an actual pressure ulcer, updated 2/12/2015, documents R1 is to be repositioned every 1 hour while in the wheelchair and every 2 hours while in bed. The Nutritional Progress Notes for R1 from E13, dated 1/26/2015, document, in part, "Current weight 230 # (pounds). No significant weight changes recently. Has a Stage II decubitus on left heel 2.0 X 3.0 cm. Appetite is fair to good. Current regimen meets/exceeds estimated needs. On 3/6/2015 at 8:30 AM, E4, reported R1's left heel ulcer was caused by ill fitting shoes, and that R1 no longer is wearing shoes at this time. The facility's policy and procedure, entitled, "Pressure Ulcer," dated 2006, documents, in part, "PURPOSE-To prevent skin breakdown and development of pressure sores. EQUIPMENT-Skin lotion as necessary, and per the resident's preference, elbow protector, heel protector, appropriate support surface for bed, appropriate support surface for chair, foot cradle, pillows."

Based on observation, record review, and interview the facility failed to thoroughly evaluate siderails and bolsters for entrapment hazards and implement progressive interventions to prevent falls for 4 of 4 residents (R4, R6,R7, R12) reviewed with a history of falls in the sample of 15, and two residents (R20, R21) in the supplemental sample. This failure resulted in R7 becoming entangled in the siderail and falling from bed. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/30/14, the facility remains out of compliance at severity level two, while the facility continues to educate staff on siderail assessment and recognition of potential hazards related to the use of siderails as positioning devices. Findings Include: 1. The US FDA publication "Hospital Bed System Dimensional Assessment Guidance to Reduce Entrapment-Guidance for Industry and FDA Staff" issued March 10, 2006 documents, in part, "To reduce the risk of head entrapment, opening in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. " The publication documents, "FDA is therefore using a head breadth dimension of 120 mm (millimeters) (4 3/4 inches) as the basis for its dimensional limit recommendations." The publication documents "FDA is recommending 60 mm (2 3/8 inches) as an appropriate dimension for neck diameter." The publication documents regarding chest entrapment, "The openings in a bed system should be wide enough not to trap a large chest through the opening between split rails. The FDA's dimensional limit for chest is 12 1/2 inches." The publication documents a potential area for entrapment as "Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board. Zone 6 is the space between the end of the rail and the side edge of the headboard or foot board. This space may present a risk of either neck entrapment or chest entrapment. In addition, any V-shaped opening between the end of the rail and the head or footboard may present a risk of entrapment due to wedging. This space may change when raising or lowering the head or foot sections of the bed. This space may increase ,decrease, become less accessible or disappear entirely. Thus, in some positions, the potential for entrapment and encourages facilities and manufactures to report entrapment events at this zone." 2. Significant Change Minimum Data Set ((MDS) dated [DATE] documents R7 as having long and short term memory deficits. It documents R7 as requiring extensive assistance from two staff members with bed mobility and transfers. The Facility Fall Risk assessment dated [DATE] documents R7 as high risk for falls. The Side Rail Rationale Screen dated 8/19/2014 for R7 documents, in part: "Resident is not ambulatory. Resident has had a decline in safety awareness. Resident has demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed. The resident is not at a risk for entrapment, but not limited to agitation, small body mass and/or gaps between the side rail and the bed." Progress Notes dated 8/19/2014 at 6:02 PM document R7 was observed with "..body halfway out of bed with R (right) side on siderail." 8/19/2014 at 7:01 PM, Z4, Registered Nurse - Hospice, documented,in part, "Call received from (E6) staff nurse. He (E6) stated pt (patient) rolled out of bed (R7)....He (E6) states pt has a canoe mattress and she has to get over the rail and bolster in order to fall out of bed and feels this poses a danger to the pt (R7)." On 8/19/2014, The Facility Interview /Investigative Record written by E6, Licensed Practical Nurse (LPN) documents, " Called to room 245....Res (resident) off left side of bed, head resting on the floor mats, right leg and buttocks held up by siderail..." On 10/30/2014 at 9:00 AM, E6 Registered Nurse (RN) and E8 LPN stated, E8 saw the position R7 was in at this time of fall from bed on 8/19/2014. E6 got a sheet and laid in R7's bed to demonstrated the position of R7 at the time of the fall on 8/19/2014 as follows: E6 rolled from her back to her left side. E7's right leg was up over the raised siderail with her left hip and leg were against the siderail. E6 bent at the waist, moved off the mattress demonstrating her head, left shoulder, left arm and torso off the bed in the space between the headboard and the side rail. E8 agreed this was the position R7 had been in at the time of the fall. On 8/31/2014, an Injury of Unknown Origin Report documents R7 as having a bruise under her right arm. The report documents, "Probable or likely etiology: Resident leaning against bedrail, increased anxiety, arms of Broda chair not padded, also note soft fall 8/19/2014." On 10/28/2014 at 9:50 AM, R7 was lying in bed with the bilateral P-shaped helper rails in the down position creating a 1/2 siderail in the middle of the bed. R7 was restless and moving about the bed. On 10/29/2014 at 9:50 AM, R7 was lying in bed with bilateral siderails in the middle of the bed. R7 was restless, grabbing and pulling on the rails. On 10/30/2014, at 8:55 AM, Zone 6, the space between the headboard and the siderail was 30.5 inches distance on the left side of the bed and 16.5 inches in the same space on the right side of the bed. On 10/30/2014 at 9:00 AM, during the interview with E6 and E8, they stated R7's bed had been brought in by the Hospice provider, but was changed after the fall on 8/19/2014. E6 and E8 agreed R7 is currently in the same type of bed with siderails, when in the down position are in the middle of the bed frame, the same position as when R7 fell on [DATE]. 3. R6's Admission MDS dated [DATE] documents his cognition is moderately impaired and he requires extensive assist of 2 staff for transfer, bed mobility ambulation and bathing. On 6/19/2014 at 1:15 AM the Facility's Situation, Background, Assessment, Response (SBAR) form documents R6 was , "...Found on the floor next to bed". No new intervention was added to the Plan of Care. On 6/19/2014 at 8:30 PM the SBAR form documents R6 was, " found res (resident) face down on floor between bed and nightstand." No new intervention was added to the Plan of Care On 6/20/2014 at 12:18 AM the SBAR form documents, Resident (R6) found on floor next to bed." The form documents side rails and an alarm were added to his Plan of Care. The Fall Assessments for R6 dated 6/21, 7/2, 8/1 and 9/2/2014 all document him at "High Risk" for falls. On 10/28/2014 at 1:15 PM, R6 was lying in bed with a siderail in the middle of the bed frame. The gap from the head board to the siderail was 13 inches. October 2014 physician's orders [REDACTED]. On 10/30/2014, E2, Director of Nursing (DON) stated we do not consider R6's grabber bar side rail as a restraint. The Facility provided documentation for the "No Guard Assist Rail" documents, " The Product Description: 1/2 rail that attaches to midsection of the bed. Offers three positions that provide safety while the resident is in the bed. Promotes healthy transfers in the up position, swivels out of the way for easy access and caregiver assisted transfers......View the Bed Rail Entrapment Risk Notification Guide." 4. The physician's orders [REDACTED]. The POS has no orders for the use of side rails or bolsters to R4's bed. The MDS, dated [DATE], documents R4 is moderately impaired with cognition, is non ambulatory, has limited range of motion to all extremities, has unsteady balance and requires extensive assistance with transfers. The Fall Risk Assessment, dated 8/14/2014, documents R4 is a high risk for falls. On 10/28/2014 at 9:35 AM, R4 was asleep on her back. There were two wide bolsters to the middle edges of R4's bed. R4 had 1, P-shaped helper side rails in the raised position. There was a large gap from the head of the bed to the side rail measuring 13 1/2 inches. A fall mat was next to the bed and R4 had a pressure pad alarm on the bed. R4's bed was positioned next to the wall. The Behavior Tracking for 10/2014 documents R4 has physically aggressive behaviors with staff, at times kicking and hitting during care. There was no side rail assessment or restraint assessment for the use of the bolsters or the P-shaped helper rails in R4's clinical record. There is no documentation of the risk, including entrapment, versus benefits of the use of these devices for R4. The Care Plan, dated 8/14/2014, documents R4 has had falls from the bed on 8/14/2014 and 11/19/2013. 5. The POS for 10/2014 for R12 documents diagnoses, in part, as "Parkinson's Disease, Personal History of Fall, Closed Femur Fracture, Dementia with Behavioral Disturbance and Abnormal Posture." The MDS dated [DATE] documents R4 has unsteady balance with normal range of motion (ROM) to the upper extremities, and limited ROM to the lower extremities and requires extensive assistance for bed mobility and transfers. The POS for 10/2014 documents an order for [REDACTED]. The Fall Risk Assessment, dated 5/12/2014 and 6/27/2014 documents R12 is a high risk for falls. On 10/30/14 at 9:08 AM, R12's bed had 2, P-shaped helper rails in the up position with 2 roll bolsters in the center edges of the bed. A 15 inch space was between the helper rails and the head board of R12's bed. On 10/30/2014, at 1:45 PM, E9 and E10, Certified Nurses Aides, (CNA) transferred R12 from the wheelchair to bed with a gait belt. R12 grabbed the P-shaped helper rail with her right hand. At that time, E9 stated, "(R12) uses the side rails, grabs onto them and tries to swing her feet over too. She doesn't like to lay down." E19 stated, "(R12) climbs out of bed at night. That's the reason for the bolsters. (R12) grabs the side rails to sit up sometimes." R12's Care Plan, dated 9/17/2014, documents R12 has a history of falling from the bed and wheelchair. There is no assessment documented to include the risks, including entrapment, and benefits for the use of the helper rails or roll bolsters in use on R12's bed. 6. The POS for R20 for 10/2014 documents diagnoses, in part, as "Closed Fracture of Acetabulum, Compression Fracture and Osteoporosis and Legal Blindness. The MDS, dated [DATE], documents R20 has normal range of motion to all extremities, unsteady balance and is moderately impaired with cognition. On 10/28/2014 at 9:35 AM through 10/30/2014 at 9:05 AM, the 2 P-shaped helper rails were attached to R20's bed. The space between the head of the bead and the rails was 15 inches. The POS for 10/2014 documents an order for [REDACTED]." The Fall Risk Care Plan, updated 10/12/2014, documents R20 has had falls from the bed on 9/17/2104 and 10/12/2014, increasing the risk of entrapment from the use of the side rails. The Report of Incident SBAR-Actual or Suspected Fall, dated 9/17/2014 at 12:40 PM, documents R20 "slid out of bed in her sock feet with 2 siderails up, pad alarm failed to sound and pad alarm replaced. (R20) left facility via ambulance for complaint of right hip and pelvic pain, negative for fracture. At last bed check when 1/2 side rail placed down, severed the cord on alarm." There was no assessment in R20's clinical record for the use of the P-shaped helper side rails, including the risks versus benefits for the use of these devices on R20's bed. On 10/30/2014, at 11:30 AM, E5, MDS/Care Plan Coordinator reported no resident in the facility had been assessed for the use of the P-shaped helper rails because they were only being used in the up position to help residents turn and reposition. E5 reported she was unaware if any resident's P-shaped side rails were being used in the down position in the middle of the beds. The Facility's policy and procedure, entitled, 'Fall Management', document, in part, "PURPOSE-To evaluate risk factors and provide interventions to minimize risk, injury and occurrences. ASSESSMENT GUIDELINES-May include, but are not limited to: Fall risk factors/Fall history, MDS/Falls Care Area Assessment, Post fall evaluation and observation. EQUIPMENT- Fall prevention equipment may include, but is not limited to: Alarms, sensor mats, transfer poles, floor pads, non-skid mats, handrails, grab bars, trapeze, adaptive equipment, transfer lifts, etc. (and other things). 7. On 10/30/14, at 1:15 PM, R21 was observed laying in bed with both helper rails / side rails lowered, positioned at the middle of the mattress. R1 was observed to intermittently pull against the rail then stop then try again. When approached, R21 stated, "please don't leave, I'm waiting for my father to come." R21' chart contained S-BAR Forms that documented several falls from bed on 3/20/14, 5/04/14, and 5/6/14. R21's Fall assessment dated [DATE] documented she had a score of 14 / high risk for falls. The Minimum Data Set ((MDS) dated [DATE] documented a cognitive score of 6 / severely impaired. R21's Care Plan dated 5/5/14, documented R21 had intermittent confusion, was chair bound, and had poor gait and balance. On 10/31/14 at 11:10 AM, E5, MDS Nurse stated that no residents in the facility had no restraint assessments for R21 or any resident in the facility for the the use of helper rails. E5 stated that the rails should not be placed in the down position, as they are helper rails, and should have only been in the up position on R21's bed. The space between the head board and the side rails was 13 inches. 8. The Immediate Jeopardy situation was identified and determined to have begun on 8/19/14 at 6:02 PM, when R7 was found hanging over her side rail by facility staff. E1, Administrator, E2, Director of Nurses, and E3, Assistant Director of Nurses were notified of the Immediate Jeopardy on 10/30/14 at 4:05 PM. The surveyors confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 10/30/14 R7's siderails in question were removed and/or replaced with an appropriate rail to prevent entrapment. 2. On 10/30/14 the facility re-assessed all resident who use side rails to verify they were necessary for mobility and are a reflection of the needs of the residents. 3. On 10/30/14 at 6:30 PM, R7's siderails were reviewed to verify her siderails in question were removed, and replaced with a rail that did not present a safety hazard. 4. On 10/30/14 the facility began in-servicing all direct care staff that perform functions in resident rooms on recognition and reporting of potential bed related hazards. All staff had been inserviced by 11/3/14.

Based on observation, record review and interview, the facility failed to identify the medical justrification, properly assess the risks versus benefits, evaluate and monitor the use of side rails for four of six residents (R4, R6, R7, R12) reviewed for side rails in the sample of 15 and 41 residents (R20, R21, R22, R28 through R65) in the supplemental sample. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 10/30/2014, the Facility remains out of compliance at severity level two, while the Facility continues to educate staff on side rail assessment and recognition of potential hazards related to the use of side rails as positioning devices. Findings include: 1. Significant Change Minimum Data Set ((MDS) dated [DATE] documents R7 as having long and short term memory deficits. It documents R7 as requiring extensive assistance from two staff members with bed mobility and transfers. The Facility Fall Risk assessment dated [DATE] documents R7 as high risk for falls. The Side Rail Rationale Screen dated 8/19/2014 for R7 documents, in part: "Resident is not ambulatory. Resident has had a decline in safety awareness. Resident has demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed. The resident is not at a risk for entrapment, but not limited to agitation, small body mass and/or gaps between the side rail and the bed." Progress Notes dated 8/19/2014 at 6:02 PM document R7 was observed with "..body halfway out of bed with R (right) side on siderail." 8/19/2014 at 7:01 PM, Z4, Registered Nurse - Hospice, documented,in part, "Call received from (E6) staff nurse. He (E6) stated pt (patient) rolled out of bed (R7)....He (E6) states pt has a canoe mattress and she has to get over the rail and bolster in order to fall out of bed and feels this poses a danger to the pt (R7)." On 8/19/2014, The Facility Interview /Investigative Record written by E6, Licensed Practical Nurse (LPN) documents, " Called to room [ROOM NUMBER]....Res (resident) off left side of bed, head resting on the floor mats, right leg and buttocks held up by siderail..." On 10/30/2014 at 9:00 AM, E6 Registered Nurse (RN) and E8 LPN stated, E8 saw the position R7 was in at this time of fall from bed on 8/19/2014. E6 got a sheet and laid in R7's bed to demonstrated the position of R7 at the time of the fall on 8/19/2014 as follows: E6 rolled from her back to her left side. E7's right leg was up over the raised siderail with her left hip and leg were against the siderail. E6 bent at the waist, moved off the mattress demonstrating her head, left shoulder, left arm and torso off the bed in the space between the headboard and the side rail. E8 agreed this was the position R7 had been in at the time of the fall. On 8/31/2014, an Injury of Unknown Origin Report documents R7 as having a bruise under her right arm. The report documents, "Probable or likely etiology: Resident leaning against bedrail, increased anxiety, arms of Broda chair not padded, also note soft fall 8/19/2014." On 10/28/2014 at 9:50 AM, R7 was lying in bed with the bilateral P-shaped helper rails in the down position creating a 1/2 siderail in the middle of the bed. R7 was restless and moving about the bed. On 10/29/2014 at 9:50 AM, R7 was lying in bed with bilateral siderails in the middle of the bed. R7 was restless, grabbing and pulling on the rails. On 10/30/2014 at 9:00 AM, during the interview with E6 and E8, they stated R7's bed had been brought in by the Hospice provider, but was changed after the fall on 8/19/2014. E6 and E8 agreed R7 is currently in the same type of bed with siderails, when in the down position are in the middle of the bed frame, the same position as when R7 fell on [DATE]. 2. The physician's orders [REDACTED]. The POS has no orders for the use of side rails or bolsters to R4's bed. On 10/28/2014 at 9:35 AM, R4 was asleep on her back. There were two wide bolsters in the middle edges of R4's bed. R4 had 1, P-shaped helper side rails in the raised position. There was a large gap from the head of the bed to the side rail measuring 13 1/2 inches. A fall mat was next to the bed and R4 had a pressure pad alarm on the bed. R4's bed was positioned next to the wall. The Behavior Tracking for 10/2014 documents R4 has physically aggressive behaviors with staff, at times kicking and hitting during care. There was no side rail assessment or restraint assessment documenting the risks versus benefits for the use of the bolsters or the P-shaped helper rails in R4's clinical record. The Care Plan, dated 8/14/2014, documents R4 has had falls from the bed on 8/14/2014 and 11//19/2013. 3. On 10/30/14 at 9:08 AM, R12's bed had 2, P-shaped helper rails in the up position with 2 roll bolsters at the center edges of the bed. A fall mat was next to the bed. The POS for 10/2014 for R12 documents diagnoses, in part, as "[MEDICAL CONDITION], Personal History of Fall, Closed Femur Fracture, Dementia with Behavioral Disturbance and Abnormal Posture. The MDS dated [DATE] documents R4 has unsteady balance with normal range of motion (ROM) to the upper extremities, and limited ROM to the lower extremities and requires extensive assistance for bed mobility. The POS for 10/2014 documents an order for [REDACTED]. There is no medical justification for the use of the siderails and bolsters . On 10/30/2014, at 1:45 PM, E9 and E10, Certified Nurses Aides, (CNA) transferred R12 from the wheelchair to bed with a gait belt. R12 grabbed the P-shaped helper rail with her right hand. At that time, E9 stated, "(R12) uses the side rails, grabs onto them and tries to swing her feet over too. She doesn't like to lay down." E19 stated, "(R12) climbs out of bed at night. That's the reason for the bolsters. (R12) grabs the side rails to sit up sometimes." R12's Care Plan, dated 9/17/2014, documents R12 has a history of falling from the bed and wheelchair. 4. The POS for R20 for 10/2014 documents diagnoses, in part, as "Closed Fracture of Acetabulum, Compression Fracture and [MEDICAL CONDITION] and [MEDICAL CONDITION]. The MDS, dated [DATE], documents R20 has normal range of motion to all extremities, unsteady balance and is moderately impaired with cognition. On 10/28/2014 at 9:35 AM through 10/30/2014 at 9:05 AM, the 2 P-shaped helper rails were attached to R20's bed. The POS for 10/2014 documents an order for [REDACTED]. The Fall Risk Care Plan, updated 10/12/2014, documents R20 has had falls from the bed on 9/17/2014 and 10/12/2014, increasing the risk of entrapment from the use of the side rails. There was no assessment regarding the risks versus benefits of using the P-shaped helper rail in R20's clinical record for the use of the P-shaped helper side rails. On 10/30/2014, at 11:30 AM, E5, MDS/Care Plan Coordinator reported no resident in the facility had been assessed for the use of the P-shaped helper rails because they were only being used in the up position to help residents turn and reposition. E5 reported she was unaware if any resident's P-shaped side rails were being used in the down position in the middle of the beds. The Facility policy and procedure entitled, 'Restraint Devices, Physical', dated 2006, documents, in part, "PURPOSE: To restrict movement to protect the resident during treatment and diagnostic procedures. To prevent the resident from injuring himself or others. Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff. To improve the resident's mobility and independent function. To treat medical symptoms. ASSESSMENT GUIDELINES--May include but are not limited to: Ability to understand instructions and ability to make self understood. Behavior and mood state. Functional ability. Safety. Potential to injure self or others. Cooperation. Ability to move in bed. Ability to transfer safely. PHYSICAL RESTRAINTS are define as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body." PROCEDURE- Assess resident's need for restraint device use. Obtain informed consent for restraint device use. Obtain physician's orders [REDACTED]. The Facility's policy and procedure, dated 2008, entitled 'Side-rails, Use and Safety of' documents, in part, "It is the policy of this facility to utilize bed side rails in a safe manner, which prevents injury, when any type of rail is required to assist with bed mobility or used per resident's request for an increased sense of security; or when full bilateral rails are deemed necessary by the Interdisciplinary Team (IDT) as a physical restraint per restraint policy and procedure. PURPOSE-To meet residents' safety needs. To use side rails safely. ASSESSMENT GUIDELINES- Resident desire for the use of bed rails and/or reasons to use bed rails. Risks versus benefits associated with use (if restrictive). Type of rails (if any) most appropriate for use. PROCEDURE-1. Side rail safety assessment will be done by a licensed nurse and/or the IDT on admission and when changes to existing bed rail use is deemed indicated." 5. R6's Admission MDS dated [DATE] documents his cognition is moderately impaired and he requires extensive assist of 2 staff for transfer, bed mobility ambulation and bathing. On 6/19/2014 at 1:15 AM the Facility's Situation, Background, Assessment, Response (SBAR) form documents R6 was , "...Found on the floor next to bed". No new intervention was added to the Plan of Care. On 6/19/2014 at 8:30 PM the SBAR form documents R6 was, " found res (resident) face down on floor between bed and nightstand." No new intervention was added to the Plan of Care On 6/20/2014 at 12:18 AM the SBAR form documents, Resident (R6) found on floor next to bed." The form documents side rails and an alarm were added to his Plan of Care. The Fall Assessments for R6 dated 6/21, 7/2, 8/1 and 9/2/2014 all document him at "High Risk" for falls. On 10/28/2014 at 1:15 PM, R6 was lying in bed with a siderail in the middle of the bed frame. October 2014 physician's orders [REDACTED]. On 10/30/2014, E2, Director of Nursing (DON) stated we do not consider R6's grabber bar side rail as a restraint. The Facility provided documentation for the "No Guard Assist Rail" documents, " The Product Description: 1/2 rail that attaches to midsection of the bed. Offers three positions that provide safety while the resident is in the bed. Promotes healthy transfers in the up position, swivels out of the way for easy access and caregiver assisted transfers......View the Bed Rail Entrapment Risk Notification Guide". 6. On 10/30/14, at 1:15 PM, R21 was observed laying in bed with both helper rails / side rails lowered, positioned at the middle of the mattress. R21 was observed to intermittently pull against the rail then stop then try again. When approached, R21 stated, "please don't leave, I'm waiting for my father to come." R21's chart contained S-BAR Forms that documented several falls from bed on 3/20/14, 5/04/14, and 5/6/14. R21's Fall assessment dated [DATE] documented she had a score of 14 / high risk for falls. The Minimum Data Set ((MDS) dated [DATE] documented a cognitive score of 6 / severely impaired. R21's Care Plan dated 5/5/14, documented R21 had intermittent confusion, was chair bound, and had poor gait and balance. R21's Side Rail Rationale Screen failed to document the medical justification and risk versus benefit for the use of the siderails. On 10/31/14 at 11:10 AM, E5, MDS Nurse stated that no residents in the facility had no restraint assessments for R21 or any resident in the facility for the the use of helper rails. E5 stated that the rails should not be placed in the down position, as they are helper rails, and should have only been in the up position on R21's bed. 7. On 10/28, 10/29 and 10/30/2014, R22, and R28 through R65 had the same type of P-shaped helper rails, that when folded down became 1/2 side rails located in the middle of the beds. The Zone 6 of these side rails were measured on 10/30/2014 at 8:45 AM until 9:15 AM. The Zone 6 areas varied in measurement from bed to bed. The side rail to the head of the bed measurement was from 10 inches to 17 inches when in the raised "helper" position and from 20 to 27 inches when lowered in the middle of the bed. These side rails did not meet the FDA dimension limit recommendations. On 10/30/2014, a review of the clinical records for R22 and R28 through R65 failed to have any documentation or assessments for the use of these type of side rails when in the raised or down position. 8. The Immediate Jeopardy situation was identified and determined to have begun on 8/19/14 at 6:02 PM, when R7 was found hanging over her side rail by facility staff. E1, Administrator, E2, Director of Nurses, and E3, Assistant Director of Nurses were notified of the Immediate Jeopardy on 10/30/14 at 4:05 PM. The surveyors confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 10/30/14 R7's siderails in question were removed and/or replaced with an appropriate rail to prevent entrapment. 2. On 10/30/14 the facility re-assessed all resident who use side rails to verify they were necessary for mobility and are a reflection of the needs of the residents. 3. On 10/30/14 at 6:30 PM, R7's siderails were reviewed to verify her siderails in question were removed, and replaced with a rail that did not present a safety hazard. 4. On 10/30/14 the facility began in-servicing all direct care staff that perform functions in resident rooms on recognition and reporting of potential bed related hazards. All staff had been inserviced by 11/3/14.

Based on interview and record review the facility failed to ensure staff was aware of their scope of care and treatment for one of three residents (R1) reviewed for incidents/ occurrences in the sample of 3. This failure resulted in R1 incurring a burn with blisters and recurring pain to the right hip. Findings include: WRITTEN REPORT/RESIDENT OCCURRENCE dated 5/5/14 documents at approximately 1:40pm on 4/30/14, the Licensed Nurse entered R1's room to do her daily treatment and noted an area of redness with a fluid filled blister to R1's right hip. E2, Certified Nurse Aid, CNA, was in the room and informed the nurse that she had applied a hot pack to the resident earlier that day, about 10:30am, due to R1 complaining of right hip pain. E2 went to therapy department and got hot pack with E3's, Therapist, instructions on properly wrapping it with protective covers and she then placed it to R1 right hip for approximately 30 minutes. R1 presented with a 19 centimeter (cm) by 13 cm area of redness to her right hip, with a 2 cm by 2cm fluid filled blister towards the middle aspect of the reddened area. Basic first aid was provided. On 5/8/14 at 1:03pm E9 was interviewed regarding R1 having hot packs applied to the right hip. E9 stated she saw E2 in the hall with a hot pack but didn't know who it was for. E2 then left for lunch. E1 Licensed Practical Nurse (LPN) later called E9 into R1's room after the hot packs had been removed and noted burn/blister on right hip. R1 was complaining of pain. Interview on 5/8/14 at 10:10am with E3, Therapist, stated E2 did come into the therapy room and asked for hot packs. E3 gave instructions for padding the hot packs for protection. E2 replied she knew. E3 further states CNA's do come in for hot packs to use on themselves and did not know E1 was going to put them on R1. Interview on 5/8/14 at 1:40pm with E11 Rehabilitation Director stated staff does come into the therapy room and ask for hot packs for their own use. E11 stated E2 spoke with E3 and said nothing about any resident she was going to use the hot pack on. Interview on 5/8/14 at 10:10am with E6 CNA, 1:03pm with E8 CNA, 1:03pm with E9 CNA, at 2:20pm with E12 CNA and at 2:24pm with E13 CNA all stated hot packs are not to be applied to any resident by CNA's. Interview at 1:05pm with E10 CNA stated hot packs are only put on and taken off residents by nurse or therapist. Interview with Z1 Specialized Wound Nurse stated area is doing what it should, dark area will slough off, area without infection and treatment appropriate. Interview with Z2, on 5/9/14 at 9:50AM by telephone, Nurse Practitioner (NP) stated surround discolored tissue is a concern, uncertain what will become of it. On 5/8/14 at 2:30pm with E5 Director of Nursing (DON) removed the dressing on R1's right hip and a foul odor was noted. The area on the right hip was the size of a golf ball and the brown/black area with yellowish slough. Above that was 2 superficial open areas about dime size. The surrounding area of the right hip had about 4.5 inches of light purple tinge E5 stated R1's right hip was clear prior hot pack incident. NURSES PROGRESS NOTE & CARE PLAN documented on 4/30/14 at 1:40pm R1 complained of right hip pain. CNA placed hot pack on R1's right hip. and removed it at 11:00am. No redness or blister noted. E1 went to R1's room to do treatments E1 pulled cover back and noted burn 19 cm(centimeter) by 13cm and 2cm by 2cm blister to right hip. R1 complained of pain in right hip. Doctor was informed and ordered ointment. Review of Specialized Wound Nurse form dated 5/1/14 documents Wound Type/Grade Burn/ 2nd degree to right hip. Length 16cm by 13cm. Area 208cm. Specialized Wound Management dated 5/8/14 documents length 15cm by 13cm and unable to determine depth. Area 195cm. Center of wound measures 4cm by 5cm necrosis. Review of Z2's visit dated May 7, 2014 documents patient is under weight and frail. Right trochanter area caused by burn on the trochanter 4cm by 3cm blister denuded. Surrounding tissue has discoloration variegated purplish colored area below the surface of the skin. R1 is uncomfortable and has history or joint pain from arthritis and contractures of joints. Policy: Compresses,Clean-Warm (General Guidelines) policy dated 2006 documents BASIC RESPONSIBILITY; Licensed Nurse. PROCEDURE. Check physician's orders [REDACTED].

Based on interview, observation and record review the facility failed to follow the Plan of Care and provide necessary supervision to prevent an accident with injury for 1 of 4 residents (R2) reviewed for falls in the sample of 10. This failure resulted in R2 falling and fracturing her left hip in January 2013. This fracture required surgery. R2 fell again in March 2013 and re- fractured her left hip. Findings include: R2 was admitted to the facility on [DATE]. Review of the Facility Occurrence Log documents that R2 fell 17 times between 11/24/12 and 3/23/13. The fall investigation dated 1/5/13 documents that R2 fell from her wheelchair after attempting to stand, and was hospitalized , requiring surgery to repair a fracture to her left hip. R2 has [DIAGNOSES REDACTED]. Fall assessments dated 11/16/12 through 2/14/13 document that R2 is at high risk for falls. The Minimum (MDS) data set [DATE] and 1/18/13 document that R2 is moderately cognitively impaired, requires extensive assistance with most activities of daily living including bed mobility , is unable to balance with out help and is frequently incontinent. Review of R2's Plan of Care which was last updated 2/29/13 documents that R2 has decreased ambulation listed as a problem. Under the approach area is documented, "do not leave resident unattended, high risk of falls." Review of the facility Incident Investigation dated 3/23/13, documents under the summary area, " Resident noted to be laying on bathroom floor in front of toilet. Certified Nurses Aid (CNA) transferred resident to the toilet and left the bathroom for a few minutes." Another CNA discovered R2 when she attempted to take a second resident in to use the bathroom. Review of the emergency room records for R2 document that R2 complained of pain at a level of 8-9/10, in both hips, left hand and foot. when seen in the emergency room . The left hip showed a, "Fracture Fragment at the lesser trochanter noted." " No superimposed acute fracture or dislocation is present in the left hip." R2 remained in the hospital for two days, then was transferred to another facility. During an interview on 4/3/13 at 2:25 PM E11 Licensed Practical Nurse (LPN) stated, " You could not leave (R2) alone at any time. She could not walk by herself she was always falling and her balance was poor, we had to keep her out at the nurses station a lot to keep and eye on her. You could not trust her to be left alone." E8, LPN stated during an interview on 4/3/13 at 2:25 PM, "(R2) could not be left alone at any time, she was not safe. At one point she had a 1:1 sitter when she was really agitated, no one was officially assigned for that." During an interview on 4/3/13 at 3 PM, E9 the CNA who was caring for the resident when the fall occurred stated, "I took (R2) to the bathroom per wheelchair then transferred her to the toilet. I got her on the toilet then told the other CNA on the unit that I was going on break. When I came back I heard they found her on the floor. I had not been working that unit in a while." .

Based on interview and record review the facility failed to notify the Physician that tests for [MEDICATION NAME] Time and International Normalized Ratio had been missed for 2 of 9 residents (R3, R6) reviewed for Anticoagulant Monitoring in a sample of 10. This failure resulted in the hospitalization and ultimate death of R3. Findings Include; On [DATE] at 8:30 AM, an audit by E2 Registered Nurse, Director of Nurses (RN/DON) discovered that laboratory (lab) tests for [MEDICATION NAME] Time (PT), and and International Normalized Ratio (INR), which are done to monitor bleeding times, had not been completed on R3 (originally ordered for [DATE]). The same audit documents that R6 had a PT/INR ordered for [DATE]. The ,[DATE] PT/INR for R6 had also been missed. The initial report written by E1 Administrator, was sent to the Department on [DATE] and documented as a medication error involving only R3. The follow up report which was written by E2 DON, and is undated documents, that on [DATE] a PT/INR was drawn in the evening and results were received on [DATE], at 1:02 AM. The Physician was notified and ordered that the blood thinner, [MEDICATION NAME] be held for two days and the PT/INR should be rechecked in two days ([DATE]). The nurse placed the order into the electronic medical record but not into the laboratory system on the computer. This resulted in the PT/INR not being drawn on [DATE] and the [MEDICATION NAME] being administered from [DATE] through [DATE]. After the audit on [DATE], E2 RN/DON, put the lab tests that were missed, into the computer to be done on [DATE]. She did not notify the physician. After Lunch on [DATE], R3 experienced a change in her condition, and started to vomit. The physician was notified of the vomiting and an order to "send to the emergency room if weak or unable to keep down liquids by morning." He was not informed about the missed laboratory tests. At 7:30 PM on [DATE], staff noted (R3) to be unresponsive with a blood pressure of ,[DATE] and pinpoint pupils. R3 was then transported to the local Hospital. The facility was notified on [DATE] at noon that R3 had expired. In an interview with E2 on [DATE] at 3:30PM, she stated she did not notify the doctor when she discovered that the labs had not been drawn, she just put the orders on the lab schedule for the next day. She did not look at the previous lab results. Review of the State of Illinois Death Certificate documents the cause of death to be "Hemorrhagic Stroke, [MEDICATION NAME] Overdose." Review of Nurses Notes for the Month of March document no Physician notification of the missed laboratory tests for either R3, or R6. 2. Review of the Physician orders [REDACTED]. The Facility Anti-Coagulant Audit Log for the Month of March documents that R6 did not have her lab test drawn on [DATE] as ordered. The missed lab was not noticed until an audit was completed on [DATE]. After the [DATE] audit, E2 RN/DON added R6 to the Laboratory test list to have a PT/INR drawn on [DATE]. On [DATE] at 1:15PM, E 2 stated she did not notify the physician about the missed labs. The lab results from the test completed on [DATE] document that both the PT and INR were Extremely elevated PT-54.9 (Normal 9XXX,[DATE].0 Seconds), INR 4.9 (Normal 2XXX,[DATE].5) for aggressive anticoagulation. 3. Review of the facility policy titled Anticoagulant Therapy and Dated ,[DATE], documents under procedure; notify the Physician of laboratory results and 1. Obtain Orders for therapeutic lab monitoring from the Physician. 4. E2 DON stated in interview on [DATE] at 1:15 PM, that Anticoagulant Audits were previously done on a weekly basis, but since the incident we now do daily audits. There was an audit done [DATE] but the results would not have been back yet on (R3) for me to catch that the lab had not been done. I caught the missed labs for both (R3 and R6) during the audit on [DATE]. During an interview on [DATE] at 3:30 PM E2 stated. I did not notify the doctor when I discovered that the labs had not been drawn, when I found the errors, I didn't get orders from the doctor on when he wanted the next labs to be drawn, I just put the residents on the lab schedule for the next day. I did not look back to check the previous lab results for myself or to let the Physician know.

Based on record review, interview and observation the facility failed to provide safe transfers, and interventions to prevent falls, for three (R1, R2, R5) of seven sampled residents with a history of falls. This resulted in one resident R2 falling from a mechanical lift and sustaining a fracture to her left femur (leg) and a partial rotator cuff tear (shoulder). Findings include: 1. A review of R2's physician's order sheet dated 11/1/10 indicated a [DIAGNOSES REDACTED]. R2 also uses oxygen per nasal canula. R2's most recent Minimal (MDS) data set [DATE] indicated she is an assist of two staff for Dressing, Hygiene and Bathing. R2 uses a mechanical lift for all transfers with the assist of 2 staff. Review of the facility fall report indicated 10/07/10, witnessed fall from mechanical lift. Witnessed by 2 cna staff. Equipment failure, removed from service. Bruising and discoloration to R2 as noted: Left elbow 7cm x 3cm bruise, Right elbow 1cm x 0. 5cm bruise, right wrist 1cm x 1cm bruise, left shoulder redness 3cm x 2cm, face / forehead bruise 7cm x 5cm, nose 2cm x 1cm bruise, right knee 3cm x 2cm redness, left knee 5cm x 2cm redness. R2 was sent to the emergency room for evaluation. Review of the facility Incident Investigation Summary dated 10/18/10 indicated; While being transferred to bed from wheelchair by 2 cna's and mechanical lift, the T-bar swiveled and one of the loops came off causing resident to fall to the floor. Resident landed on knees and hit face on CNA's shoe. CNA's were pushing lift towards bed, lift legs spread, when T-bar swiveled and one loop came off. Resident was leaning forward at same time resulting in resident falling to floor. CNA's state resident moving a lot while in lift sling. On 11/16/10 at 1:50 PM, E22 and E25, transferred R2 to bed from her wheel chair. After attaching the sling straps to the swivel bar hooks, E22 began lifting R2 off of her wheel chair. At no time did E22 stop and check that the position of the straps was secure, before E25 removed the wheel chair and R2 was moved to her bed. On 11/16/10 at 1:50 PM, a review of the lift shows that the strap hooks are circular, winding over on themselves. The strap is wound inside the hook. E22 stated, the straps should not unscrew / unloosen themselves without staff help. On 11/18/10 at 11:00 AM, E22, Certified Nurses Aide stated that R2 routinely yelled out during mechanical lift transfers. E22 indicated R2 would say Help me, Your gonna kill me, Your gonna drop me, and would sometimes wiggle her arms and legs during the transfer. E22 stated at times when R2 was yelling, E22 did not ask for additional help with the transfer. E22 stated she did not see R2 as unsafe during these times. E22 stated she did not ask the charge nurse for advice on R22's behavior when being lifted, and would usually continue the lift even though R2 was restless. E22 stated that R2 was displaying these behaviors on 10/7/2010 when R2 fell from the lift. E22 stated that on 10/7/10, E25, Certified Nurses Aide, was helping with the transfer of R2. E22 stated she lifted R2 from her chair with the lift, and E25 removed the wheel chair from beneath R2. At this point R2 began to lean forward and before E22 could react to stop R2, she fell forward out of the lift sling. E22 stated at that time she noticed the right lower strap of the sling (by R2's right leg) "had come loose" from the lift. E22 stated she did not know how the sling became detached. E22 stated that R2 fell and landed "belly flop style" across the legs of the lift and R2's face landed on R22's shoe, which left an imprint of the shoe on R2's face for more than a week. On 11/18/10 at 11:00 AM E1, administrator stated that the mechanical lift had been immediately removed from service and all parts checked including the sling. E1 indicated there were no malfunctions found with the lift and staff were retrained on it's use. Additionally, on 11/18, E1 indicated he was aware of R2's yelling and fidgeting when in the lift, but, had not thought R2's movements when in the lift were significant enough to be a safety concern. On 11/18/10 at 12:00 PM, E2, Director of Nursing stated that she felt R2's fall was "truly an accident", and she (E2) thought the lift straps came off due to R2's moving about in the sling. E2 indicated that R2 had displayed this behavior on more that one occasion. E2 did not indicate why this behavior of R2's was not addressed as a safety concern prior to her fall. A review of R2's care plan dated 9/16/10 indicated R2 was a mechanical lift of 2 staff. The care plan failed to indicate R2's restless behavior during transfers and failed to provide interventions to prevent possible falls. Behavior tracking prior to R2's falls did not address R2's restlessness during transfers. The Nursing Maintenance quarterly note dated 9/3/10 indicated R2 was a mechanical lift for safety, and that she tolerated the transfers "well - fair". On 11/18/10 an update to R2's care plan was added that addressed R2's moving in the lift when being transferred. A review of the facility policy for mechanical lift indicated the facility does not have an operationalized policy for staff to follow. The policy states that staff are to follow the "general guidelines" manual that came with the lift. On 1/19/10 a review of the manual "Manual/Electric Portable Patient Lift", General Guidelines; Page 13, "Use common sense in all lifts. Special care MUST BE taken with people with disabilities and who cannot cooperate while being lifted." Page 14, Section 1, General Guidelines indicates: "When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem - otherwise, injury or damage may occur. Adjustments for safety and comfort should be made before moving the patient. Patient arms should be inside of the straps." On 1/19/10, at 1:15 PM, in an additional interview with E22, she stated " I did not check the position of the straps on 1/16/10, when transferring R2, I just forgot to do it." E22 stated she had been trained to do this as instructed in the guidelines manual. Additionally, E22 stated on the afternoon of R2's fall 10/7/10, she had forgotten and had not checked the position of the lift straps, as directed in the manual, prior to E25 removing the wheel chair from under R22. 2. A review of R5's physician's order sheet dated 11/1/10 indicated a [DIAGNOSES REDACTED]. R5's most recent Minimal Data Set indicated R5 is Severely Cognatively Impaired, and an assist of 2 staff for transfers, and activities of daily living. A review of R5's incident report dated 10/19/10 at 7:45 PM, indicated R5 was in his wheel chair, had propelled himself outside into the facility courtyard, and had attempted to get up and fell . The report indicated R5 suffered no injuries. R5 told staff at that time that he was trying to get to his truck. The report indicated that an alarm was sounding but failed to specify what alarm was sounding. A review of the facility Incident verification report indicated; Res propelled self out to courtyard in wheel chair, found on ground with no injuries. Resident stated, I was trying to get my truck. Follow up action: Safety teaching with resident, encouraged to use call light. Wanderguard ordered and placed on resident, continues to work with therapy. On 11/18/10 at 10:00 AM, E20 stated on 10/19/10, E20 was working on the Silver Creek Hall, and at about 7:45 PM he was told by staff that R5 was outside and had fallen. E20 stated that he went out the door by the administrator's office to the courtyard, and noted that R5 was sitting on the ground, and R5's personal alarm was sounding but no other door alarms were sounding. E20 stated that he saw the door across the courtyard, leading into the dining, area was propped open and no alarm was on. E20 stated it was dark outside. E20 indicated that family members who were visiting a resident on the "F" hall, had looked thru the room's bedside window and saw R5 outside on the ground and alerted staff. E20 indicated he did not know how R5 got outside, or why the door to the back hall was propped open with no alarm sounding. On 11/18/10 at 2:15 PM, E26 stated on 10/19/10 at about 7:45PM, some family members told us (staff) that R5 was outside on the ground. E26 stated that she went out the door by the 200 hall dining room / "Broadway" dining room, and noted that no alarm was sounding on the inside door leading to the courtyard. Additionally, the outer door had been propped / tied open. E26 was not sure if R5 and tied the door open or if someone else had done it. E26 stated it was dark outside, and R5 was sitting on the ground but was not hurt. E26 stated she was in charge of R5's care on 10/19, and had last seen him around 7:30 PM, watching some resident's in the dining room play cards. E26 stated that R5 is usually monitored at the nursing station when up in his wheel chair, due to wandering. E26 stated that on 10/19, R5 was calm and seemed to be enjoying the activity so she left him in the dining room while she attended to other residents. E26 stated that R5 must have slipped out so quick, because no one noticed him leave the area or they would have called for staff. On 11/18/10 at 12:00 PM E1, Administrator, E2 Director of Nursing, and E4 Corporate Nurse all stated that they were aware R5 had gotten outside. E1, E2, and E4 indicated R5 had a history of [REDACTED]. A wandergaurd leg alarm was put on R5 to prevent him from leaving the facility without staff knowledge in the future. E1, E2, and E4 denied knowledge of information given by staff, that the alarm on the Broadway hall exit had not been sounding as it should, or that R5 was seen first by family members after he had gotten outside. Observation of R5 throughout the survey indicated a highly confused resident. He routinely asked for help from staff and visitors passing by. On 11/17/10 at 3:45 PM, R5 stated he was in the facility to help fix equipment, pointing to a radiator. Then said he didn't know where to go or how he would get food. R5 was pleasant but confused in his conversations. On 11/18/10 R5's wife visited and helped to feed him lunch. She stated that R5 was very confused and she was not surprised he tried to go outside. A review of R5's care plan dated 10/4/10 failed to indicate R5's history of wandering or need of supervision for such. R5's behavior tracking for the month of October 2010, indicated he was monitored for Anxious complaints, Crying, Anger with others at times, and Restlessness due to fears. After R5's fall on 10/19, the safety care plan indicated; Safety teaching as needed, Encourage use of call light, Encourage to let staff assist with transfers, Do not leave alone in room in wheel chair by self, Personal alarm, bed alarm, chair alarm, mat on floor, and redirect as needed. The safety plan failed to address R5's wandering, use of wanderguard, and supervision needs related to wandering. Throughout the survey it was noted that the doors leading to the facility courtyard were disarmed from 8:00 AM until 4:00 PM. There was no evidence that the doors were being actively monitored for residents going in or out through these doors during the day. On 11/18/10, E1 indicated the doors to the courtyard are left unarmed during the day. The alarms are turned on in the evening at 4:00 for "winter hours" to alert staff to residents going in the courtyard after sunset and after the maintenance man leaves. On 11/19/10, E2, Director of Nursing indicated; after R5's fall on 10/19, the facility failed to initiate a program to monitor the non-alarmed courtyard doors during the day. E2 stated a program was going to start immediately on 11/19/10. 3a. A review of R1's physician's order sheet dated 11/1/10 indicated a [DIAGNOSES REDACTED]. R1's Minimal (MDS) data set [DATE] indicated she was alert and independent with transfers and activities of daily living. Further record review indicated on 6/29/10, R1 slipped in the bathroom while getting off of the toilet, and fractured her left hip. At the time of R1's fall she was in room 357, next to the nursing station on the B / G hall. The facility Incident Investigation dated 6/29/10, indicated "upon return to the facility, resident room will be moved to a more supervised area with more foot traffic." On 11/16/10, E22, Licensed Practical Nurse, stated that R1, needs assistance of 2 staff for transfers. However, R1 is not always compliant with asking for staff assistance. Review of an incident investigation dated 9/7/10, indicated R1 took herself from her room, to the community bathroom and attempted to toilet herself. R1 fell in the bathroom. The follow up actions indicated Staff teaching, don't get up without calling for help first, call bell within resident reach at all times, personal alarms on and working at all times, don't leave resident in bathroom unattended, and continues to work with skilled rehab therapy. The goal of R1's room being in a more supervised area was not addressed on the care plan. On 11/17/10, R1 was found to be residing at the far end of the A-hall, in room 103, one door away from the emergency exit door, and 6 rooms down from the A-hall nursing station. E2, Director of Nursing, stated, R1 was moved to this room due to needing to be in a Medicare certified bed. b. A review of a facility Fall assessment dated [DATE] indicated R1 scored 14, high risk, for falls. The most recent MDS dated [DATE] indicated R1 was dependent on 2 staff for all transfers. The most recent fall assessment dated [DATE] indicated R1 was scored 16, a high risk for falls. Review of an incident / accident investigation dated 10/22/10 indicated , CNA assisting resident off toilet with gait belt and resident slipped and slid to floor. Fall transferring off toilet by staff with complaint of knee pain. Safety teaching with staff and resident. 2 person assist with transfers, mechanical lift PRN. On 11/17/10, R1, when asked about the fall on 10/12, stated, "I told that girl I needed 2 people to transfer, but, she didn't listen to me." R1 stated that since the fall her leg continued hurt off and on. On 11/17/10, E27, Certified Nurses Aide, stated on 10/12 she was assigned to care for R1, however she had not been informed that R1 was a two person assist for transfers. E27 stated that she had put R1 on the toilet, and when she attempted to take R1 off the toilet, R1's left leg gave out and R1 fell into the toilet stall wall and then slid down to the floor. A review of R1's care plan showed it was updated 9/7/10 and again on 10/21/10, but failed to clearly identify what type of transfer R1 was to utilize. The care plan indicated R1 was at times able to transfer by herself, transfer with two staff, and transfer with a mechanical lift.

Based on interview and record review, the facility failed to provide timely treatment for one (R17) resident in respiratory distress. This resulted in R17 being transferred via ambulance to the hospital and expiring from cardio-respiratory arrest. The facility failed have an adequate interim care plan in place to address the needs of 1 (R14) sampled resident with peritoneal [MEDICAL TREATMENT], and failed to follow procedures ensure safe [MEDICAL TREATMENT] care for R14. Findings include: 1. On [DATE], at 9:00 AM, E14, Registered Nurse (RN), faxed Z2, R17's physician, a note indicating R17 had a congested cough with yellow sputum and lung crackles upon inspiration. On [DATE], Z2 responded, via fax, and [MEDICATION NAME](an antibiotic), 500 milligrams, twice daily for 10 days. In addition, Z2 ordered [MEDICATION NAME] DM (cough medicine), one tablet twice daily. R17's nurse's notes, dated [DATE], indicated R17 was given the Cipro, and had no coughing or discomfort noted. R17's nurse's notes, dated [DATE], did not indicate she had any respiratory distress or coughing. Her Medicare Skilled Documentation Flow sheet indicated her lungs were clear and her vitals were normal. R17's nurse's notes, dated [DATE], did not indicate R17 was experiencing any respiratory distress or coughing. Her Medicare Skilled Documentation Flow sheet for this date indicated her lungs were clear and her vitals were normal. R17's nurse's note, dated [DATE], at 2:30 AM, noted "cont. (continue) on ABT (Antibiotic) for URI (Upper Respiratory Infection) as ordered. (No) adverse reactions noted. PO (By mouth) fluids encouraged." The note indicated R17 was not experiencing any shortness of breath and her oxygen blood level was at 97 % on room air. The noted indicated "(NO) S/S (signs or symptoms) of distress noted." R17's "CHANGE OF CONDITION REPORT-CHIEF COMPLAINT" form, dated [DATE], at 8:35 AM, noted "(Blood Glucose Monitoring) 128. O2 (Oxygen) started @ 2 Liter per minute, via NC (Nasal Cannula)...MD (medical doctor) called-sent to ER, (emergency room ). To ER at 8:50 AM. ([MEDICATION NAME] mg po BID (twice daily) x 10 days and [MEDICATION NAME] DM (one) tab BID." This report indicated R17's oxygen saturation level was 68 % (per cent), with oxygen. Her blood pressure was ,[DATE]. Her temperature was 96.9 F (Fahrenheit) and Respirations were 16 per minute. The ambulance report for R17 noted the ambulance arrived at the facility on [DATE] at 8:42 AM. Upon the ambulance arrival, R17's blood pressure was ,[DATE], with a weak pulse of 58. Her blood saturation level was 85 %. She was placed on 6 Liter/minute of oxygen. At 8:52 AM, the Emergency Technicians Suctioned R17's air-way. The ambulance arrived at the local hospital at 9:04 AM. The NARRATIVE section of the ambulance report noted "Find patient supine in bed unresponsive and pale with cyanosis to lips. Audible respiratory efforts with sputum accumulation noted at lips. No palpable radial pulse, weak carotid. Promptly rolled patient to side to facilitate sputum drainage and used washcloth to remove bulk material." The hospital Emergency Report, dated [DATE], at 9:10 AM, noted R17 arrived unresponsive with labored breathing. She was transferred from the nursing home with difficulty breathing and oxygen saturation levels of 60%. She was wheezing bilaterally, drooling and listless. The hospital's Emergency Report Nurse's note, at 9:00 AM, noted "Suctioned frequently, nasally and orally x 3 - frothing sputum noted." R17 expired at 11:00 AM from Cardio Respiratory Arrest according to the emergency room report. On [DATE], at 1:38 PM, an interview was conducted with E10, Certified Nurse's Assistant (CNA). E10 was the CNA who cared for R17 prior to the ambulance being called on [DATE]. E10 noted when she began work on the day shift, [DATE], R17 was in her wheelchair, was drooling and "didn't look right". E10 works 6:00 AM to 2:00 PM. E10 indicated she and E15, CNA, transferred R17 into bed. E10 indicated R17 would not assist with the transfer, and had to be lifted into bed. E10 noted she took R17's temperature and it was really low. E10 could not recall R17's actual temperature. E10 indicated she reported R17's low temperature to E16, Licensed Practical Nurse. E10 noted E16 told her the temperature must be wrong. E10 then took R17's temperature again. According to E10, R17's temperature remained low. E10 again told E16 of R17's low temperature. E10 indicated "She (E16) blew it off". E10 indicated she had expressed to E17, Activity Assistant, that R17 was not doing well, and E16 would not do anything. E10 reported she requested E17 look at R17. E10 noted R17 was not doing very well. E10 indicated she got a pulse oximeter. R17's blood oxygen saturation level was 60% with a pulse in the 40's per minute. E10 indicated she again told E16 of R17's condition. E10 reported, "She was passing medications and didn't seem concerned." E10 noted finally E16 came in to check on R17 and then called the ambulance. E10 indicated R17 went to the hospital and died . E10 indicated "The day before, she (R17) was normal. When I saw her (R17), stuff was running out of her mouth." E10 indicated it took at least ,[DATE] hour or more for E16 to response to her concerns regarding R17. E10 indicated she wrote out a statement regarding E16's lack of concern and failure to address R17's decline in condition. However, she noted "Nothing was done about it." On [DATE], at 3:00 PM, E17 was interviewed. E17 noted around 7:30 AM, E16 was passing medications in the G-hall dining room. E17 indicated E10 came to her and asked her to look at R17. E17 indicated she went into R17's room. E17 reported R17 was lying in bed, and was foaming at the mouth. E17 indicated E10 took R17's temperature twice and it was low. E17 indicated she went into the room multiple times during this time because she was concerned that E16 would not come in to check on R17. E16 indicated R17 started to turn gray, was wheezing and was foaming at the mouth. E17 noted E10 rolled R17 on her side several times so she wouldn't choke. E17 indicated E10 went and told E16 several times, but E16 would not respond. E17 indicated "I was by (R17's) bedside. She (R17) grabbed my arm when she was leaving. By her face, she knew something was wrong. She was so sweet." E17 began to cry during the interview, and indicated R17 had no problems prior to this and was "so sweet". E17 indicated it took about ,[DATE] hour for E16 to respond to E10's request to come and check on R17. On [DATE], at 3:35 PM, an interview was conducted with E16. E16 reported on [DATE], at around 6:30 AM, R17 was sitting in her wheelchair at the nurse's station. E16 confirmed R17 was drooling and didn't look right. E16 indicated she took R17's vitals and her vitals signs were normal. E16 confirmed she did not document this anywhere in R17's medical record. E16 indicated she told E10 to put R17 into bed. E16 noted she was not aware anything was wrong with R17 until E10 came to her. E16 indicated she went into R17's room. E16 reported R17 was gasping for air and was having difficult breathing. E16 indicated she notified Z2, R17's physician at 8:35 AM, and he indicated R17 should be sent to the hospital. E16 indicated she notified the ambulance, and they took R17 to the hospital. E16 indicated she was given nothing in report the morning of [DATE] to suggest R17 was having respiratory distress. E16 indicated she did not document anywhere R17's decline in condition or her vital signs. On [DATE], at 12:20 PM, Z2, R17's physician, was interviewed regarding if the facility should have contacted him regarding R17's drooling, which was not normal for this resident. Z2 responded "It probably would have been a good idea. I'm not sure if I was on call or if someone was covering. I would have probably sent her to the ER." On [DATE], at 3:40 PM, E1, Administrator, indicated an investigation had been conducted regarding R17. E1 indicated E17 had notified the previous DON after her shift ended on [DATE]. E1 noted E17 expressed her concern over what transpired with R17 and her concern R17 didn't receive timely treatment. E1 indicated that investigation was documented but could not be located. 2. A review of R14's record indicated she was recently admitted on [DATE], with a [DIAGNOSES REDACTED]. R14 receives peritoneal [MEDICAL TREATMENT] (PD)daily. A review of R14's initial treatment plan indicated but was not limited to; Altered Health / Resident has a Dx of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) and does Peritoneal [MEDICAL TREATMENT]: [MEDICAL TREATMENT] per MD order, Monitor for signs and symptoms of infection to PD site, Tx to PD site per MD order, Nursing to work with Davita [MEDICAL TREATMENT] related to changes, labs, and any cares or concerns. Monitor for restlessness, pale clammy skin, [MEDICAL CONDITION], excessive thirst, [MEDICAL CONDITION], SOB, if sign / symptoms observed report to MD and RAI as indicated. On [DATE] at 12:20 PM, R14 was not in her room. However, it was observed there were several open boxes containing bags of [MEDICAL TREATMENT] fluid and tubing. These opened boxes were sitting scattered on the floor of R14's room. Laying half out of the sink of R14's room were three empty [MEDICAL TREATMENT] fluid bags that had been drained into the sink. On [DATE] at 9:00 AM, a review of R14's room indicated R14, sitting on the side of her bed eating breakfast. R14 stated that the night nurse had finished her [MEDICAL TREATMENT] exchange, and had disconnected R14 from the [MEDICAL TREATMENT] "Cycler" machine. It was noted that additional boxes of supplies had been delivered (since observed the day before) and these were also lying about on the floor of R14's room. The Cycler ([MEDICAL TREATMENT] machine) still had the bags of [MEDICAL TREATMENT] fluid attached to it and one laying on top of the machine. The bag of drained peritoneal was in a box on the floor below the machine, and was still connected to the Cycler. The CCPD / Daily Record flow sheet, lay on top of the bedside table. It was noted this form had not been completed on ,[DATE], with no information regarding R14's weight, blood pressure, Temp, and post [MEDICAL TREATMENT] drainage results. The form on ,[DATE] also lacked R14's vital signs, weight, and the strength of fluid used (strength = 1.5, 2.5, 4.5). On ,[DATE], the vital signs and fluid strengths were listed, however not post [MEDICAL TREATMENT] drainage or exchange amounts were noted. At 9:05 AM, E14 Licensed Practical Nurse stated that she had not disconnected R14 from the Cycler, that it had been done by the night nurse. E14 indicated she had not filled out the form as she had not done the [MEDICAL TREATMENT]. At 9:15 AM, E2, Acting Director of Nursing came to the room and stated that post [MEDICAL TREATMENT] exchange information could be obtained from the computerized memory of the cycler, and she then began pushing buttons on the machine and read off the drain / exchange information. E2 indicated that this should have been done by the person staff who completed R14's [MEDICAL TREATMENT], but, it also could be obtained by E14. At this time E2 did not disconnect any of the tubing from the machine. When asked about the CCPD flow sheet, E2 stated that staff should be filling it out, and that all staff had been trained how to do the [MEDICAL TREATMENT] for R14. E2 indicated that there was a booklet at R14's bedside, and that there was a handout left by the [MEDICAL TREATMENT] provider that explained how the procedure was to be done. E2 indicated that the facility used the booklets left by the [MEDICAL TREATMENT] provider and they were to be considered facility policy for PD. E2 indicated that the facility had no operationalized procedure for PD residents outside of these booklets. A review of the xerox copied booklet "what to know when taking care of a peritoneal [MEDICAL TREATMENT] patient" was reviewed and indicated the following: Page 2: The environment that the [MEDICAL TREATMENT] should be performed in should be clean and organized. Supplies should be kept in an area away from extreme cold or heat. Page 2: Peritonitis symptoms that occur are: cloudy drainage, abdominal pain, nausea and vomiting, Diarrhea, Fever. If the patient exhibits any of these signs please get hold of the [MEDICAL TREATMENT] clinic ASAP. Page 3: Daily vital signs are crucial to take care of the PD patient. Correct weights, blood pressure and pulse help the care giver make decisions on which strength of [MEDICATION NAME] to use. Page 3: The caregiver may also be asked to give the patient weekly sub-cutaneous injections of [MEDICATION NAME]. This is to prevent [MEDICAL CONDITION]. Page 11: Disconnect / 1) End of Therapy. Hit arrow down and write in flow sheet the following info: Drain, Total UF and Average Dwell. 2) Press arrow back up to the end of therapy and press go. 3) Close transfer set and clamp all lines and press go. 4) Disconnect yourself appears on screen. Put on mask and wash hands. 5) Disconnect transfer set from patient line and place new minicap on transfer set. 6) Press go. Turn me off appears on the screen. Remember to take the cassette out of the door before turning machine off. Remove and throw away used supplies. On [DATE] at 1:30 PM, Z3, [MEDICAL TREATMENT] nurse consultant, stated that she had trained several facility nurses on the care of R14 prior to her admission on [DATE]. Z3 indicated that this is not the first PD patient she has monitored care for in this facility. Z3 indicated that R14's room should not have opened supply boxes laying around. Z3 stated that staff should not be using R14's sink to empty any of the solutions in, as it is where staff have to wash their hand prior to starting [MEDICAL TREATMENT] and to prevent contamination to R14. Z3 also stated that staff are to be filling out the CCPD flow sheet each day, and it should be kept is R14's record as a reference and resource for evaluating of the effectiveness of [MEDICAL TREATMENT]. Further review of R14's interim care plan indicated it failed to address peritonitis signs and symptoms as noted in the [MEDICAL TREATMENT] handout, and failed to address the drug Epoetin including necessary monitoring of hematocrit and hemoglobin levels when taking this medication, and / or interactions with other medications. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record failed to show any nurses signature as having administered the [MEDICAL TREATMENT] on ,[DATE], ,[DATE], and ,[DATE]. On [DATE] at 3:00 PM, E1, Administrator, stated R14's room needed to be organized to accommodate her [MEDICAL TREATMENT] supplies. Three training / documentation forms for Peritoneal [MEDICAL TREATMENT] were reviewed for staff signatures. They were dated [DATE], [DATE] and one was undated. It was noted that from [DATE] thru [DATE], E19, E20, and E21, Licensed Practical Nurses, cared for R14 and her [MEDICAL TREATMENT] needs. However, their names did not appear on the sheets indicating they had been trained to care for R14's when receiving [MEDICAL TREATMENT]. On [DATE] E2, DON, gave no further information as to why untrained staff were providing [MEDICAL TREATMENT] care for R14.