Every finding on record at Hillcrest Retirement Village

Based on interview and record review, the facility failed to ensure their abuse policy was implemented for one of seven residents (R1) reviewed for abuse in the sample of seven.The findings include:R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including suicidal ideation, dementia, Parkinson's disease, insomnia, generalized anxiety disorder, spinal fusion, chronic pain, alcohol abuse, and history of falling. R1's Minimum Data Set (MDS) dated [DATE], shows that R1 is cognitively intact. R1's MDS also shows that that R1 does not have any behavioral symptoms. The facility's Final Investigation shows, On May 2, 2026, at 8:35 PM, the administrator received a phone call from the nurse stating that the alleged certified nursing assistant (CNA) [V7] yelled and pushed resident [R1]. After reviewing the interviews, it was determined that verbal and physical abuse had occurred. Police were called and report was made on May 2, 2026.On May 13, 2026, at 9:19 AM, V1 (Administrator/Abuse Coordinator) said she received a call from V8 (Licensed Practical Nurse-LPN) that stated V7 (Certified Nursing Assistant-CNA) had gotten into R1's face, yelled at her, and pushed her. V1 said that V7 took her three fingers and placed them onto R1's forehead and pushed. V1 said she was an hour away from the facility, so she called V3 (Assistant Director of Nursing-ADON) since V3 was closer to the facility. V1 said that V3 went to the facility and interviewed R1, V5 and V6 (CNAs). V1 said that V6 was in R1's room but was working with R1's roommate. V1 said that V5 witnessed some of the altercation between R1 and V7 (CNA). V1 said she got to the facility and brought V7 into her office to interview her. V1 said that V7 was with V8 the entire time after the incident. V1 said that V7 told V1 that R1 was calling V7 fat, that V7 did not know what she was doing. V7 and R1 were in each other's face. V1 said nothing like this has ever happened before with V7. On May 13, 2026, at 9:56 AM, V6 (CNA) said staff should never swear at a resident because it is disrespectful and unprofessional. V6 said that staff shouldn't say anything to the residents, if the residents are cursing at staff.On May 13, 2026, at 11:08 AM, V5 (CNA) said she was putting another resident to bed when she heard yelling, from across the hall, so she went into the room. V5 said she saw V7 take her three fingers to R1's head and pushed it. V5 said R1's head went back. V5 said that V7's reaction was not ok. V5 thought V7's reaction was impulsive and not right. V5 said that V7 physically abused R1. V5 said the situation made her feel scared and uncomfortable. R1 refused to be interviewed by this surveyor and would not allow this surveyor to come into her room.The Police Report dated May 2, 2026, shows V7 (Certified Nursing Assistant) was being charged with aggravated battery/victim 60+. At 11:57 PM, the police office attempted to reach V7 via phone multiple times but there was no answer. A warrant will be sought if V7 does not call back.On May 13, 2026, at 11:02 AM, V7 (CNA) said she no longer works at the facility and said she was wrongfully terminated. V7 said that V1 (Administrator) tried to accuse her of abuse. On May 13, 2026, at 12:30 PM, V1 said V7 should have just walked away and not yelled or gotten into R1's face.The facility's Abuse Prevention Program Policy dated November 22, 2017, shows, The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse.

Based on interview and record review the facility failed to ensure a resident was not abused for one of seven residents (R1) reviewed for abuse in the sample of seven.The findings include:R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including suicidal ideation, dementia, Parkinson's disease, insomnia, generalized anxiety disorder, spinal fusion, chronic pain, alcohol abuse, and history of falling. R1's Minimum Data Set (MDS) dated [DATE], shows that R1 is cognitively intact. R1's MDS also shows that that R1 does not have any behavioral symptoms. R1's Care plan-initiated October 1, 2025, shows, Caregivers to provide opportunity for positive interaction, attention. Resident has interactional problems with both staff and peers. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings.The facility's Final Investigation shows, On May 2, 2026, at 8:35 PM, the administrator received a phone call from the nurse stating that the alleged certified nursing assistant CNA [V7] yelled and pushed resident [R1]. After reviewing the interviews, it was determined that verbal and physical abuse had occurred. Police were called and report was made on May 2, 2026.On May 13, 2026, at 9:19 AM, V1 (Administrator/Abuse Coordinator) said she received a call from V8 (Licensed Practical Nurse-LPN) that stated V7 (Certified Nursing Assistant-CNA) had gotten into R1's face, yelled at her, and pushed her. V1 said that V7 took her three fingers and placed them onto R1's forehead and pushed. V1 said she was an hour away from the facility, so she called V3 (Assistant Director of Nursing-ADON) since V3 was closer to the facility. V1 said that V3 went to the facility and interviewed R1, V5 and V6 CNAs. V1 said that V6 was in R1's room but was working with R1's roommate. V1 said that V5 witnessed some of the altercation between R1 and V7 CNA. V1 said she got to the facility and brought V7 into her office to interview her. V1 said that V7 was with V8 the entire time after the incident. V1 said that V7 told V1 that R1 was calling V7 fat, that V7 did not know what she was doing. V7 and R1 were in each others face. V1 said nothing like this has ever happened before with V7. On May 13, 2026, at 9:56 AM, V6 (CNA) said he had asked V7 to help him with R2 (R1's Roommate). V6 said V7 was helping him transfer R2 and R1 started getting irritate. V6 said V7 and R1 were swearing back and forth to each other, but he was focused on R2 and getting her safely because her forehead was bleeding from a previous fall. V6 said while he was helping R2, V7 went over by R1 and then R1 all of a sudden said she touched me, she touched me. V6 said the whole situation was unnecessary. V6 said staff should never swear at a resident because it is disrespectful and unprofessional. V6 said that V5 (CNA) came into the room because V5 could hear the yelling from across the hall. V6 said that V8 (LPN) also came into the room and took V7 out of the room. V6 said he felt very uncomfortable during the altercation. V6 said he did not see V7 touch R1. V6 said that staff shouldn't say anything to the residents, if the residents are cursing at staff.On May 13, 2026, at 11:08 AM, V5 (CNA) said she was putting another resident to bed when she heard yelling, from across the hall, so she went into the room. V5 said she saw that V6 and V7 were trying to put R1's roommate into bed. V5 said she doesn't remember what R1 was yelling about. V5 said she saw V7 take her three fingers to R1's head and pushed it. V5 said R1's head went back. V5 said R1 started yelling more and was yelling out for the nurse. V5 said the nurse came into the room and R1 got into her wheelchair and left the room. V5 said that V7 said to V5 and V6 I didn't touch her, right? You saw that I didn't touch her! V5 said she saw V7 touch R1 but was afraid to say anything right at that moment. V5 said that V7 reaction was not ok. V5 thought V7's reaction was impulsive and not right. V5 said that V7 physically abused R1. V5 said the situation made her feel scared and uncomfortable.On May 13, 2026, at 10:48 AM, V3 (ADON) said V1 (Administrator) called her and asked her to go to the facility to start the investigation since V3 lived closer to the facility. V3 said when she got to the facility, V7 was with V8 (LPN) at the nurses' station. V3 said R1 was sitting in R1's room and V3 talked with R1. V3 asked R1 what happened. V3 said that R1 told V3 that CNAs were caring for R2 when R1 was verbally fighting with V7 about who cares for R2 better. V3 said that R1 told her that R1 was calling V7 names. R1 said that V7 said say it again to R1 and so R1 did. V3 said that V7 took her three fingers and pushed them against R1's forehead. V3 said that V5 walked into the room because V5 heard yelling from the hallway. V3 said that V5 witnessed V7 pushing R1's forehead. V3 said that V1 came into the facility and took V7 with her. The police were called right away and interviewed R1. V7 (CNA) was yelling in the lobby and getting into staffs faces, so they made V7 leave the facility. V3 said V7 did not call the police back, and there was now a warrant out for V7's arrest. R1 refused to be interviewed by this surveyor and would not allow this surveyor to come into her room.The Police Report dated May 2, 2026, shows, V7 (Certified Nursing Assistant) was being charged with aggravated battery/victim 60+. At 11:57 PM, the police office attempted to reach V7 via phone multiple times but there was no answer. A warrant will be sought if V7 does not call back.On May 13, 2026, at 11:02 AM, V7 (CNA) said she no longer works at the facility and said she was wrongfully terminated. V7 said that V1 (Administrator) tried to accuse her of abuse. V7 said she was helping another CNA with R1's roommate when R1 started to call V7 names. V7 said R1 called V7 a black bi**h. V7 said she told R1 No, we aren't going to do this today. V7 said she told R1 to stand back. I kind of blacked out, I was getting angry. I may have said a curse word, she got into my face. Next thing I knew, (R1) flung herself back and said I pushed her in her head. V7 said she was standing in the lobby with her friend/coworker after the incident waiting since V1 (Administrator) told her she couldn't be around residents. V7 said that R1 came to the lobby and smirked at V7 and said you are not going home, you're going to jail. V7 said she did not say anything to R1. V7 said she cannot remember if she touched R1 or not, but could remember telling R1 to get the hell out of her face. V7 said that R1 was yelling that R1 did not feel safe in the facility and wanted V7 out of the building. V7 said she has not spoken to the police, nor have they tried to contact her. V7 said she is now working somewhere else through an agency.An attempt was made to contact V4 (Police Officer) but was unsuccessful. On May 13, 2026, at 12:30 PM, V1 said V7 should have just walked away and not yelled or gotten into R1's face.The facility's Abuse Prevention Program Policy dated November 22, 2017, shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident.

Based on observation, interview, and record review the facility failed to ensure R1 was provided care that enhanced the quality of life for 1 of 4 residents reviewed for Resident Rights in the sample of 4.The findings include: On 02/17/2026 at 9:50AM, R1 was sitting in her room in an overstuffed reclining chair. On 02/17/2026 at 9:31AM, V1 Administrator said, R1 did not like the tone of voice V3 CNA-Certified Nursing Assistant used when providing care. R1 felt like it was condescending and reported it to me. V3 CNA received disciplinary action. V3 CNA's Disciplinary Warning Notice dated 01/14/2026 shows, Discourteous behaviors to resident.

Based on interview and record review the facility failed to document a residents fall and update a care plan post fall for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of seven.The findings include: R2's Progress Notes showed, 12/24/25 at 10:09 AM, catheter dislodged. New 16 French catheter inserted per physician order using aseptic technique. At 6:30 PM, R2 has catheter removed during her recent fall. At 9:43 PM, catheter removed during fall. R1's Progress Notes did not show the date, time, location or any additional information related to her fall.R2's Care Plan dated 12/15/25 showed R2 is at risk for falls related to hallucinations, antidepressant use, behaviors (resident intentionally slides herself out of wheelchair to the floor when she is up longer than she wants). The care plan was not reviewed and/or revised after her fall on 12/24/25.On 1/13/25 at 1:35 PM V4 Licensed Practical Nurse - LPN stated if a resident falls, they are assessed immediately. Neurological checks are done if it is an unwitnessed fall or a fall that they hit their head. V4 stated If the resident complained of pain or shoulder they would get an X-ray. V4 stated an incident report is done for the fall. V4 stated she did not know when a resident's care plan is updated or who updates them after a fall.On 1/13/26 at 2:08 PM, V2 Director of Nursing - DON stated after a resident falls they are assessed by the nurse right away and if there is no injury the mechanical lift is used to get the resident up. V2 stated the incident is to be documented in risk management. A note is populated into the resident's notes but only if the box is checked for it to go there. V2 stated other nurse's will just write a separate note in the progress notes for the fall. V2 stated post fall monitoring is done and charted for 3 days. V2 stated the resident's care plan is updated after a fall. V2 stated she is the one that updates the care plans, and she did not update R2's care plan after her fall. V2 stated she was not even aware R2 had a fall. V2 stated R2 did not have any injuries when she went to the hospital recently. R2 was admitted for a change in condition and diagnosed with metabolic encephalopathy and chronic kidney disease. V2 stated R2 is in the hospital every couple of weeks.On 1/13/26 at 2:38 PM, V2 stated the nurse never put a note in risk management or any note about R2's fall in the electronic medical record. V2 stated the nurse should have documented what happened. V2 stated she was not aware of R2's fall and should have been.The Face Sheet dated 1/13/26 for R2 showed diagnoses including dementia, major depressive disorder, restlessness and agitation, wedge compression fracture, hypothyroidism, dehydration, acute metabolic acidosis, anxiety disorder, ulcerative colitis, chronic kidney disease, adult failure to thrive, paroxysmal atrial fibrillation, peripheral vascular disease, hematuria, hallucinations, urinary tract infection, hydronephrosis, insomnia, anemia, type 2 diabetes mellitus, hyperkalemia, adjustment disorder, hypertension, atherosclerotic heart disease, acute embolism, ileostomy, and retention of urine.The facility's policy and procedure for falls (no date) showed, the nurse is to complete risk management in point click care for un-witnessed and/or witnessed falls. Nurse to complete incident note under progress notes in electronic medical record at the time of the incident. Interventions will be initiated immediately by licensed nurse based on residents' specific needs.

Based on observation, interview and record review the facility failed to ensure the sanitizing solution level was within range to sanitize food contact surfaces and failed to ensure expired bread was discarded. This applies to all residents residing at the facility.The findings include:On 8/25/25 at 9:30 AM, the sanitation solution in the bucket was checked for sanitation level. V3 (Dietary Manager) took a strip and checked the solution, after 10 seconds it registered as light orange. V3 then compared the strip quat color coded level- the light orange was 0 level. V3 placed the strip again in the sanitizing solution and this time V3 waited for approximate 20-30 seconds. The strip still registered as light orange which was still in the 0' level. V3 said the sanitizing solution should be in the 200's-400's which the strip should turn dark blue to be able to sanitize food prep areas to prevent foodborne illness. V3 also said the sanitizing solution was only good for 2 hours, it needed to be replaced now. At 12 PM, V5 Dietary Aide said she mixed the sanitizing solution at 6AM, it was supposed to be replaced at 8AM to be effective.The Facility Policy on Manual Sanitizing documents: Equipment. Utensils and table wares will be washed and sanitized. Quat 200-400 ppm concentration changed every 2 hours.2. On 8/25/25 during the kitchen tour, the bread cart was checked (loaves of bread, burger buns and hotdog buns.) A bag of hotdog bun was noted to have a date of 8/8/25. V3 said all bread packs were dated on the day of delivery and discarded within six days. V3 said the bun should have been discarded last 8/15/25. (6 days after delivery)The 671 CMS form dated 8/25/25 show there were 126 residents residing at the facility.The Facility Policy on Labeling and Dating of foods documents, to decrease the risk of foodborne illness and to provide the highest quality food is labeled with the date received the date open and the date by which the item should be discarded

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 6 of 26 residents (R8, R46, R65, R11, R3 and R64) reviewed for infection control in the sample of 26.The findings include: 1. On 8/25/25 at 9:38 AM R8's room had no EBP signs on or near the entrance to his room and no Personal Protective Equipment (PPE) was located outside of his room. R8's admission Record dated 8/25/25 shows R8 has a diagnosis of gastrostomy status. R8's Order Summary Report dated 8/25/25 shows he receives enteral nutrition via a gastrostomy tube and a current order from 3/11/25 for EBP. 2. On 8/25/25 at 9:45 AM, R46's room had no EBP signs on or near the entrance to his room and no Personal Protective Equipment (PPE) was located outside of his room. R46 said he has had a (urinary) catheter for at least three months. R46's Order Summary Report dated 8/25/25 shows a current order for EBP from 1/3/25 and a current order from 3/18/25 to change his indwelling urinary catheter every month. 3. On 8/25/25 at 10:06 AM, R65's room had no EBP signs on or near the entrance to his room and no Personal Protective Equipment (PPE) was located outside of his room. R65 had a bandage to his left lateral knee. R65 said he got an infection from a leg brace he was wearing at another facility. R65's Order Summary Report dated 8/25/25 shows a current order for wound treatment to his left lateral knee wound and a current order for EBP. R65's Wound Evaluation & Management Summary dated 8/20/25 shows he has a stage 4 pressure wound on his left, lateral knee. 4. On 8/25/25 at 10:13 AM, R11's room had no EBP signs on or near the entrance to her room and no Personal Protective Equipment (PPE) was located outside of her room. V17, R11's husband, said R11's (urinary) catheter drainage bag is changed to a leg bag during the day. R11's Order Summary Report dated 8/25/25 shows a current order from 10/16/24 for EBP and a current order from 6/12/25 to change her indwelling urinary catheter every month. On 8/26/25 at 12:45 PM, V4, Infection Prevention Nurse, said any resident with a chronic wound, a g-tube, or an indwelling urinary catheter should be on EBP. 5/6. On 8/25/25 at 10:20 AM, there was no Enhanced Barrier Precaution (EBP) sign posted on/around R3 and R64's room. The Facility's Matrix (802) printed on 8/25/25 showed R3 and R64 reside in the same room. R3's Physician orders printed on 8/27/25 showed R3 has orders for G-tube (feeding tube) maintenance and tube feeding bolus feeding. R64's Physician orders printed on 8/27/25 showed R64 has orders for sacral wound treatments and dressings. The facility's EBP Policy dated 2025 (copyright) showed residents with medical devices including catheters and feeding tubes and residents with chronic wounds need to be on EBP precautions. Residents on EBP isolation need to be identifiable they are on the isolation status.

Based on observation and interview the facility failed accommodate a residents needs and preferences. This applies 1 of 26 residents (R30) reviewed for resident rights in the sample of 26.The findings include:On 8/25/25 at 9:13 AM, during initial tour, R30 was observed in her wheelchair leaving the dining room. R30 said she's having problems with R121 (her roommate). R30 said R121 gets jealous when she has visitors and says inappropriate things to her. I don't have to put up with this and I don't want to go back to my room.On 8/25/25 at 11:25 AM, R30 was in the dining room for the noon meals. R30 said the facility talked about moving rooms, but I shouldn't have to move, she should. I like my room. R30 said she feels uncomfortable when R121 has behaviors toward her.On 8/25/25 at 1:35 PM, R121 was lying in her bed, crying. R30 (her roommate) was sitting next to her in her wheelchair, holding her hand trying to console her. V10 and V11 (Both Certified Nursing Assistant's) came into the room to transfer and provide care to R30. R121 was calling out for R30 Are you here, don't leave me, repeatedly to R30. R30 said I'm not leaving, I'm going to lay down. R121 continues to call out, crying, and R30 in her bed trying to nap. V9 and V10 did not intervene or re-direct when R121 to call out for R30. On 8/26/25 at 12:21 PM, V15 (R30's spouse) said he reported his concerns to management regarding R121's behaviors affecting his wife. V22 said the other night R30 called him 15 times upset about her roommate issues.On 8/26/25 at 1:19 PM, V2 Director of Nursing (DON) said V15 (R30's spouse) reported R121's behaviors are affecting his wife. R121 is driving R30 insane and it's not fair to R30. A room change was discussed but there were some concerns about R121 could follow R30 in the facility and the behaviors would continue.On 8/26/25 at 1:44 PM, V6 (Social Services) said R121 hovers over her R30, causing R30 to get upset. V15 reported concerns about R121's behaviors affecting his wife (R30) and wants more boundaries and limits to be put in place to protect his wife.

Based on observation, interview, and record review, the facility failed to ensure a female resident was shaved and free of facial hair for 1 of 26 residents (R1) reviewed for Activities of Daily Living (ADLs) in the sample of 26.The findings include:On 8/25/25 at 10:26 AM, R1 was in the dining room drinking coffee. R1 had prominent whiskers covering her chin.On 8/26/25 at 10:40 AM, V16, Certified Nursing Assistant (CNA), said all residents gets a shower twice a week and they include shaving for men and women.On 8/26/25 at 1:40 PM, V19, CNA, said resident have a shower at least twice a week and shaving is included.On 8/27/25 at 10:32 AM, V1, Administrator said shaving takes place on shower days.R1's current care plan provided by the facility shows R1 has an ADL self-care performance deficit and has limited physical mobility. R1's Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment and requires substantial/maximal assistance with personal hygiene, including shaving.The facility's Grooming a Resident's Facial Hair Policy (undated) shows it is the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene.

Based on observation, interview, and record review the facility failed to have pressure relieving interventions in place for residents at risk for pressure injuries for 2 of 6 residents (R5 and R30) reviewed for pressure injuries in the sample of 26.The findings include:1. R5's Medication Review Report printed on 8/26/25 showed an order for an air mattress and it was to be on at all times. On 8/25/2025 at 2:06 PM, R5 was in bed. There was an air mattress pump hanging on the foot of R5's bed. The lights on the air mattress pump were off and the pump was unplugged. On 08/26/2025 at 1:42 PM, R5 was in bed. The air mattress pump on the foot of the bed remained with the lights off and unplugged. On 08/27/2025 at 9:01 AM, V13 Licensed Practical Nurse said an air mattress pump is a pressure relieving intervention. R5's Braden Scale for Predicting Pressure Sore Risk with an effective date of 8/18/25 showed R5 was at risk for pressure injuries. R5's care plan with a revised date of 8/19/25 showed R5 had the potential for skin impairment. Listed under interventions was an air mattress. 2. On 8/25/25 at 1:35 PM, V10 and V11 (both Certified Nursing Assistants/CNAs) transferred R30 into her bed with the mechanical lift and provided incontinence care, The CNAs positioned R30's feet on the mattress and did not apply the protective boots. A bright colored sign was posted on the wall above her bed with a turning schedule and cradle boots on at all times when in bed. On 8/26/25 at 12:33 PM, V8 Registered Nurse (RN) said R30 is at risk for pressure, dependent on staff for cares and should have her protective boots applied when in bed. R30's current care plan shows has potential impairment to skin integrity related to fragile skin. Interventions include air mattress, wheelchair cushion and protective boots while in bed. The facility's undated Pressure Injury Prevention and Management Policy states, the facility shall establish and utilize a systemic approach for pressure injury prevention and management, starting with prompt assessment and treatment including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate .interventions will be implemented for all residents who are assessed and considered at risk .

Based on observation, interview, and record review the facility failed to ensure a catheter drainage bag was maintained below the level of the bladder for 1 of 4 residents (R11) reviewed for catheters in the sample of 26. The findings include:On 8/25/25 at 12:53 PM, R11 was in the dining room sitting in her wheelchair. R11's indwelling urinary catheter drainage bag (leg bag) was attached to the top of her thigh in a position which did not allow for gravity to aid with drainage. The tubing was short and there was no slack in the tubing. On 8/26/25 at 1:40 PM, V19, Certified Nursing Assistant (CNA), said the urinary catheter drainage bag should be below the waist to prevent Urinary Tract Infections (UTIs)/infections. R11's current care plan provided by the facility shows R11 has a history of frequent UTIs. R11 has an indwelling urinary catheter, and the drainage bag and tubing should be below the level of the bladder. R11 is at risk for developing an infection due to the presence of the indwelling catheter.The facility's Catheter Care Policy (undated) shows drainage bags should be located below the level of the bladder to discourage backflow of urine.

Based on observation, interview and record review the facility failed to implement interventions and provide services for a resident who is displaying increased behaviors of anxiety who has a diagnosis of dementia. This applies to 1 of 5 residents (R121) reviewed for dementia in the sample of 21.The findings include:R121's face sheet shows she has diagnoses including unspecified dementia, moderate with anxiety, anxiety, hypertension, and muscle weakness.On 8/25/25 at 11:27 AM, R121 was observed sleeping in her room.At 12:09 PM, R121 remained sleeping in her room. At 12:10 PM, V10 (Certified Nursing Assistant-CNA) delivered R121's room tray. Loud yelling was heard from R121's room from the hallway. R121 was yelling out loud Stay out of my life, Get out of it. I can do what I want. GET OUT. V10 left the room and said she was going to tell V7 (Registered Nurse-RN). R121 continued to yell loudly Get them out of here. V7 came to R121's room and attempted to re-direct her but she continued to yell and was agitated. V7 said R121 is normally not like this, I think she has urinary tract infection. V7 said this morning staff reported R121 said the staff were trying to kill her. R121 is normally very sweet and pleasant. When residents have increased behaviors, we try to rule out a urine infection and notify the physician.On 8/25/25 at 12:26 PM, V10 (CNA) said R121 has behaviors when she gets upset, she screams, cries and can be difficult to redirect at times.On 8/25/25 at 1:35 PM, R121 was lying in her bed, crying. R30 (her roommate) was sitting next to her in her wheelchair, holding her hand trying to console her. V10 and V11 (Both Certified Nursing Assistant's) came into the room to transfer and provide care to R30. R121 was calling out for R30 Are you here, don't leave me, repeatedly to R30. R30 said I'm not leaving, I'm going to lay down. R121 continues to call out, crying and upset. R30 trying to console and reassure R121 with the privacy curtain closed. V9 and V10 did not intervene or approach R121 while she was displaying behaviors and continued to provide care to R30. R121 was tearful and crying when this surveyor left the room, asking for a kiss. 08/26/25 at 8:58 AM, R121 was wandering in her room, pacing in her room and restless.On 8/26/25 at 9:00 AM, V12 (CNA) said R121 has behaviors, she cries, hallucinates, she misses her family and needs a lot of reassurance. R121 had an episode of delusions this morning, she's not aggressive and enjoys exercise groups.On 8/26/25 at 10:12 AM V8 (Licensed Practical Nurse-LPN) said R121 is very emotional, confused, worries a lot, hallucinates, and usually she is easily redirected. R121 is very protected over R30 her roommates, she likes to take care of R30. Staff should attempt to get R121 out of her room, try to distract and intervene when she is having behaviors. R121's family stopped coming frequently because her behaviors would increase when they leave.On 8/26/25 at 1:19 PM, V2 (DON) said R121's has behaviors, she's always sad, crying and anxious. We have struggled with her behaviors. Staff should redirect, distract, and involve her in activities. R121's family requested her antidepressant medications to be decreased and when that happened, she had increased behaviors. Family as of recent were agreeable to increase her antidepressant. V15 (R30's spouse) reported R121's behaviors are affecting his wife.On 8/26/25 at 1:44 PM, V6 (Social Services) said R121 gets very anxious and nervous, she hovers over her roommate. R121's family requested her anti-depressant to be decreased and her behaviors increased. R121's family recently agreed to increase her anti-depressant and we were waiting to see if her behaviors decreased. R121 tends to hover over her roommate (R30) and triggers behaviors for both. V15 (R30's spouse) has reported R121's behaviors towards R30 and requested for boundaries and limits be put in place. Staff should intervene when R121 is becoming obsessive with R30 and try to redirect her and provide assurance. Staff should engage, encourage activities and refer her to psych with increased behaviors.R121's Social Services note dated 8/18/25 documents V22 (R121's daughter) was called to discuss concerns of her anxiety. R121 is very pre-occupied with R30 and tends to hover over her.R121 also becomes agitated is she observes R30's husband interact with others. V18 agrees, her mom (R121) is very anxious and get pre-occupied with multiple things. will continue to monitor for changes, aid resident with concerns and provide re-assurance and reminders.R121's nurses note dated 8/18/25, documents at heard yelling from her room get away. (R121) standing over R30's bed, crying. V8 (LPN) explained R30 does not want to be bothered and wants to sleep. (R121) she's mad at me.The progress notes shows there was no documentation on 8/25/25 of R121's increased behaviors or interventions implemented for her behaviors. R121's current care plan shows her cognition is moderately impaired, she is dependent on staff for emotional intellectual, physical and social stimulation. She requires invites and reminders. Staff should encourage her to attend group activities and engage in conversation.R121 appears to worry a lot, she obsesses over her roommate and hover over her in her room upsetting the roommate to the point roommate will yell at her to leave her alone. This will then lead to anxiety on her part. Interventions include consult with pastoral care, social services, and psych services, encourage participation, increase communications between, family, care givers, monitor response.The facilities undated Dementia Care Policy states, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs or is diagnosed with dementia, to meet his or her highest practical physical, mental and psychosocial wellbeing. the facility will assess, develop, and implement care plans.the care plan interventions will be related to each resident's individual symptomology and rate of dementia.,. Care and services will be person-centered and reflect each residents' individual goals.individuated, non-pharmacological approaches to care will be utilized to include meaningful activities. appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood or behavioral status.

Based on interview and record review the facility failed to ensure a resident received their routine medication for 1 of 5 residents (R88) reviewed for pharmacy services in the sample of 26.The findings include:R88's Face Sheet printed on 8/26/25 showed R88 was diagnosed with chronic obstructive pulmonary disease (COPD). It was listed as R88's principal diagnosis. R88's Medication Review Report printed on 8/26/25 showed an order for ipratropium-albuterol inhaler to be given four times a day for COPD. On 8/26/25 at 9:30 AM, R88 said about a week ago he missed two doses of his inhaler medication. R88 said he was not sure why he missed two doses of his inhaler medication.R88's Medication Administration Record for August 2025 showed on 8/18/25 the 3:00 PM and 8:00 PM doses of ipratropium-albuterol inhaler did not indicate R88 received the medication. For the 3:00 PM and 8:00 PM doses, there was a code that referred to progress notes. The corresponding progress notes dated 8/18/25 showed the medication was not available for the 3:00 PM and 8:00 PM doses.On 8/26/25 at 10:00 AM, V14 (Licensed Practical Nurse) said on 8/18/25 she went to give R88 his scheduled ipratropium-albuterol inhaler and it was not in the medication cart resulting in R88 not receiving doses. V14 said she re-ordered the medication. V14 said it was her understanding the inhaler was found the next day at the end of R88's bed. V14 added the inhaler should have been in the medication cart.On 08/26/2025 11:21 AM, V2 (Director of Nursing) said R88's inhaler was misplaced and it should have been stored/kept in the medication cart.R88's Care Plan with a revision date of 11/6/24 showed R88 had COPD. Listed under interventions was to give medication as ordered. The facility's Medication Administration Policy (undated) showed medications are administered as ordered.

Based on observation, interview, and record review the facility failed to ensure controlled medications were secured with a dual lock system and failed to discard an outdated insulin pen which applies to 2 of 2 residents (R61, R93) reviewed for medication storage in a sample of 26. The findings include: 1 On 8/26/25 at 11:10 AM, V8 Licensed Practical Nurse (LPN) opened the 100-200 hall medication room. The resident medication refrigerator had an open lock hanging on the latch of the refrigerator. The refrigerator door had a new box or R93's Methadone Oral Concentrate (Schedule II controlled substance) 10 milligrams per milliliter (mg/ml). V8 stated the refrigerator should be locked. R93's Physician Orders printed on 8/26/25 showed R93 has an order for Methadone Oral Concentrate 10 mg/ml to be given 4 ml by mouth one time a day for pain. On 8/26/25 at 11:30 AM, V2 Director of Nursing stated the medication room refrigerator should be locked. The facility's Medication Storage Policy dated 2025 (copyright) showed the facility will provide safe and effective storage of all drugs/narcotics and biologicals in a locked storage area under proper temperature controls with limited access by authorized personnel consistent with state or federal requirements and professional standards of practice. 2. On 8/26/25 at 9:13 AM, R61's Humalog KwikPen (insulin) was labeled with a written expiration date of 8/23/25. V18, Registered Nurse (RN), said the insulin pen should have been thrown away. V18 said the nurse labels insulin with a use by date which is 30 days from when it is opened. R61's admission Record dated 8/26/25 shows he has a diagnosis of diabetes. R61's Medication Review Report shows he has an active order for Humalog KwikPen to be administered before meals and at bed time as per a sliding scale. The facility's Insulin Pen Policy (dated 7/2022) shows insulin pens should be disposed of after 28 days.

Based on interview and record review, the facility failed to ensure 1 of 1 residents (R11) received routine dental care in the sample of 26 reviewed for dental services.The findings include:On 8/25/25 at 10:13 AM, V17, R11's husband said R11 has been residing in the facility for over two years and has not received any preventative dental care. On 8/27/25 at 10:12 AM, V17 said he was notified in writing in early July 2025 that a dentist would come to the facility and see R11 if he enrolled her in the program. V17 said R11 has not seen a dentist since she was admitted .R11's admission Record dated 8/25/25 shows she was admitted to the facility on [DATE]. R11's current care plan provided by the facility shows R11 has oral/dental health problems.On 8/27/25 at 9:56 AM, V1, Administrator, said R11 has not seen a dentist since she was admitted to the facility. V1 said R11 was eligible for the dental program, but she was not enrolled in the program, so she did not receive dental care.On 8/27/25 at 11:21 AM, V2, Director of Nursing (DON), said the facility has no dental policy, it does not exist. On 8/27/25 at 1:32 PM, V2 said R11 was not offered enrollment in the dental plan upon her admission, she was Medicaid pending and should have been told about it after she was on Medicaid.

Based on interview and record review the facility failed to ensure the safety of a resident. This failure resulted in R1 being found in bed with R1's left hip being internally rotated and later being diagnosed as a displaced left hip fracture. This applies to 1 of 3 residents (R1) reviewed for falls with injury in the sample of 3. The findings include: R1's Facesheet dated 2/26/25 shows R1 has diagnoses including, but not limited to, osteoarthritis, dementia, cataract, major depressive disorder, gastro-esophageal reflux disease, hyperlipidemia, and unspecified abnormalities of gait and mobility. R1's Minimum Data Set (MDS) dated [DATE] shows R1 required substantial/maximal assistance to sit upright from a lying position while in bed. R1's MDS also shows that R1 required partial/moderate assistance to stand from a seated position. On 2/27/25 at 8:00 AM, V5 (LPN) said for the last few months, V5 and other nursing staff transferred R1 using a mechanical lift for transfers including, but not limited to, getting R1 in and out of bed. On 2/26/25 at 11:06 AM, V5 said she worked a double shift working both the morning shift from 6:00 AM until 2:00 PM and the evening shift from 2:00 PM until 10:00 PM on Friday, 2/21/25. V5 said R1 did not express any complaints of pain in her left hip during either shift nor did R1 experience any falls. On 2/26/25 at 11:25 AM, V3 (RN) said when she came in for the overnight shift and took report from V5, V5 said V12 (Certified Nursing Assistant- CNA) had put R1 down for bed earlier in the evening shift because R1 was not feeling well. On 2/26/25 at 2:25 PM, V12 said she worked the evening shift from 2:00 PM until 10:00 PM on 2/21/25. V12 said at the beginning of her shift, V5 instructed V12 to put R1 to bed because R1 was not feeling well and was tired. When V12 put R1 to bed, V12 stated R1 had no complaints of hip pain and no bruising to R1's face. V12 said she rounded on R1 throughout the shift and last recalls changing R1 due to incontinence between 7:00 PM and 8:00 PM on 2/21/25. V12 said R1 was resting peacefully and there were no falls with R1 during V12's shift. On 2/26/25 at 5:32 PM, V11 (CNA) said R1 was already in bed sleeping when V11's shift started at 10:00 PM on 2/21/25. During V11's initial round on R1, V11 said R1 was not incontinent and did not need to be changed so V11 let R1 sleep and continued to round on R1 every few hours. V11 stated that there were no indications that R1 had fallen during V11's shift. On 2/26/25 at 11:25 AM, V3 said during the morning medication pass around approximately 5:30 AM on 2/22/25, V3 entered R1's room and noted R1 to look flushed (including R1's face), was sweating, and was not responding per baseline. V3 and V11 both denied seeing bruising to R1's face. When V3 removed the covers from R1, V3 noticed that R1's left hip was rotated inward and looked dislocated. When V3 and V11 tried to provide care to R1, both V3 and V11 noted R1 to be crying out in immense pain and reaching towards R1's left leg. V3 then notified V1 (Administrator), V2, and V13 (Physician) who instructed to send R1 to the local hospital for emergency treatment. On 2/27/25 at 2:03 PM, V15 (Lead Paramedic) said when V15 arrived to the facility, a nurse (presumably V3) met V15 and the crew in the hallway outside of R1's room. V3 told V15 that V3 was going to change R1 when V3 noticed that R1 was wet. When V3 went to change R1, V3 noted R1's hip deformity. V15 then conducted a physical assessment of the resident, noting R1 had a deformity to R1's left hip and redness to the left cheek. V15 stated the redness to R1's cheek was not equal to both sides, just on the left cheek. Based on the hip deformity and the redness to R1's cheek, V15 asked V3 if R1 had fallen and V3 denied any falls. Local Fire Department prehospital care report, written by V15, dated 2/22/25 states, . The patient was assessed and noted to be feverish and uncomfortable. A rapid trauma assessment was preformed [sic] noting an obvious deformity to the patients left hip as well as redness to the patients left cheekbone that had the appearance of bruising. The staff denied the patient having any fall, however the crew suspects a fall did occur due to the noted injuries. R1's hospital records from 2/22/25 hospital stay shows R1's x-ray imaging findings included a comminuted fracture left hip interotrochanteric region and base of the hip with displaced lesser trochanteric fragment, indicating R1's hip had been fractured in multiple places just below the neck of the femur where the femoral head enters the pelvis. On 2/26/25 at 2:40 PM, V13 said the facility notified V13 of the incident after it occurred and the local hospital notified V13 of the x-ray findings, noting R1 was not a candidate to receive a surgery for the hip fracture. V13 believes this type of fracture could be the result of a fall but V13 did not know all of the specifics at that time. On 2/26/25 at 2:15 PM, V2 said V1 and V2 conducted an investigation and at this time, R1's injuries are considered an injury of unknown origin and that any type of abuse had been ruled out.

Based on observation, interview, and record review the facility failed to supervise a resident with a history of falls, failed to ensure a safe transfer was performed, and failed to review/revise fall interventions post fall for 3 of 24 residents (R114, R23, R93) reviewed for safety in the sample of 24. This failure resulting in R114 sustaining a right hip fracture and R23 sustaining a head wound. The findings include: 1. On 09/23/24 at 10:54 AM, R114 was sitting in his wheelchair, in the activity room by nurses station. R114 was unable to answer any questions. The facility's Reporting to IDPH worksheet dated 6/25/24 shows fall with injury-R114 was sent to hospital for evaluation and treatment of bruising to right groin. Notified that R114 had a femur fracture and would be admitted for treatment. On 09/25/24 at 10:02 AM, V1 Administrator said V17 CNA came and told V2 Director of Nursing that something was wrong with R114, he was not walking right. V1 said upon assessment, R114 had some discoloration in his right groin area. V1 said they spoke with the doctor and got an order for an x-ray. V2 said the x-ray company wasn't coming soon enough, so they sent R114 to the hospital. V2 said she interviewed staff and R114 had no out of the normal behavior, no documented incident, no falls and no signs of pain, but something happened to his hip. R114's Progress Note dated 6/24/24 at 10:25 PM, shows writer called and followed up with hospital, per emergency room Nurse, R114 is being admitted due to closed fracture of right hip. R114's hospital x-ray report dated 6/24/24 shows comminuted intertrochanteric right hip fracture (bone broken in at least two places, caused by severe trauma- fall, car accident). On 09/25/24 at 11:07 AM, V17 Certified Nursing Assistant (CNA) said she got R114 up in the morning (6/24/24) and took him to breakfast. V17 said R114 sat up fine and had no complaints of pain. V17 said later when she was putting him back to bed (after therapy), R114 had a hard time standing up, and appeared to be in pain so she told the nurse. On 09/25/24 at 10:17 AM, V18 Physical Therapist said she got R114 from the dining room that morning and took him to therapy. V18 said R114 was hardly able to stand up, which was not his norm so she brought him back to his room. V18 said she thought maybe R114 was just tired. V18 said R114 normally wants to stand up and has to be close to the nurses station for supervision. On 09/25/24 at 11:12 AM, V16 Licensed Practical Nurse said she was the evening nurse from 6:00 PM to 6:00 AM over the weekend (6/21/24-6/23/24) and she had no issues with R114. V16 said R114 has behaviors of trying to get up out of the chair, and can be antsy. V16 said she would keep him in eyesight for supervision due to history of trying to get up. On 09/25/24 at 11:39 AM, V14 CNA said she worked the evening shift (6/23/24) and she didn't see R114 out of bed after she put him to bed, but R114 can swing his legs over and try to get up. On 09/25/24 at 12:01 PM, V15 Registered Nurse said she worked with R114 all weekend (during the day) and nothing out of the ordinary occurred. V15 said R114 was antsy and was up and down all weekend and not sleeping. On 09/25/24 at 12:20 PM, V13 (R114's Power of Attorney) said he got a call from the facility that R114 had a fall in evening trying to get up. V13 said they sent R114 to hospital. V13 said he was upset that this happened, R114 needed hip surgery and needed screws. V13 said R114 had a fall before this with bruising to his face. V13 said since R114 had a stroke, he has trouble with balance and walking. V13 said R114 needs to be monitored more. On 09/25/24 at 11:34 AM, V20 Orthopedic Doctor (performed hip surgery at hospital for R114) was phoned and a message was left with the nurse for the doctor to call back. V20 did not return this surveyor's call. R114's Morse Fall Scale dated 6/2/24 shows R114 is at moderate risk for falling due to medical diagnoses, impaired gait, and overestimates or forgets his limits. R114's Care Plan shows R114 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, aphasia, history of transient ischemic attack, dementia and restlessness and agitation. The same Care Plan shows R114 has moderately impaired cognitive function requiring cues and supervision in daily decision making. R114 will attempt to get up on own and has been observed crawling on bedroom floor. Resident is not verbal for the most part and has difficulty communicating. Resident is at risk for falling. The intervention for risk for falling of mattress to be placed on floor next to bed at all times. Resident crawls from bed at times, was added on 9/25/24. This same Care Plan does not include interventions of close supervision. 35178 2. On 09/24/24 at 11:38AM, R23 was sitting in the dining room. R23 with a 3.5-centimeter by 1.5-centimeter irregular shaped scabbed wound on the center of the forehead. On 09/25/2024 at 9:30AM, V1 Administrator said, V11 CNA-Certified Nursing Assistant was with R23 when she fell on [DATE]. R23's fall on 09/13/2024 caused the wound to R23's forehead. On 09/25/2024 at 9:56AM, V11 CNA said, I was with R23 when she fell . I transferred her, as I was situating her in the chair, it was like she threw herself forward. I transferred R23 with a full body mechanical sling lift; I transferred her by myself. Normally a mechanical sling lift is supposed to be performed by two staff members. On 09/25/2024 at 11:29AM, V2 DON-Director of Nursing said, there should be two staff members present when transferring a resident with a mechanical sling lift. R23's Progress Notes dated 9/15/2024 at 5:53PM, shows, Incident Note, Note Text: Notified by CNA that upon transferring resident out of bed onto wheelchair, resident leaned forward and fell to the ground onto her side. R23's Fall Risk assessment dated [DATE] shows, High Risk for Falls. The facility's undated Mechanical Lift policy shows, two staff members must be present when using any mechanical lift. One staff member directs mechanical lift towards the receiving surface while the other staff member gently guides resident. 47552 3. R93's Face sheet dated 9/24/24, shows R93 has diagnoses including (but not limited to) Parkinson's disease, dementia, and epilepsy. R93's Morse Fall Scale dated 3/7/24 shows R93 has a score of 55 which denotes R93 is at high risk of falling. This document also shows R93 has a history of falling, has an impaired gait, and overestimates or forgets her own limits. R93's un-witnessed fall report dated 3/7/24 shows R93 had an unwitnessed fall in the dining room with no injuries. R93's un-witnessed fall report dated 6/6/24 shows R93 had an unwitnessed fall in her room with no injuries. R93's Care Plan dated 9/24/24 shows R93 has a care plan focus created on 1/22/2023 that states, The resident is a risk for falls r/t (related to) Parkinson's Disease, confusion, psychotropic medication use, vision. This care plan and all interventions were last revised on 1/8/2024. No revisions were made after the un-witnessed fall on 3/7/24 or 6/6/24. Facility Accidents and Supervision policy reviewed on 6/2024 states, . 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions (EBP) were in place for 6 of 6 residents (R98, R41, R111, R114, R93, R117) reviewed for infection control in the sample of 24. The findings include: 1. On 09/23/24 at 09:55 AM, during initial tour, R98 was in bed sleeping, with a urinary collection bag hanging from the bed frame. There was no enhanced barrier precaution sign on his door. V25 Licensed Practical Nurse said R41 and R98 have urinary catheters and R114 has a urostomy. 2. On 9/23/24 at 10:09 AM, R111 said he had wounds on his toes that the nurse was putting a bandage on. R41's, R111's, and R114's rooms did not have EBP signs on their doors. On 09/25/24 at 09:33 AM, V4 Infection Control Nurse said she thought EBP was still voluntary. V4 said she will get that going and has a lot of reading to do regarding EBP. V4 said the facility did not yet have a policy on EBP. The facility's provided list of wounds, catheters, urostomy, ileostomy, and feeding tubes shows R41 and R98 have urinary catheters, R114 has a urostomy, and R111 has arterial wounds. 47552 3. R93's Care Plan created on 3/7/24, shows R93 has an indwelling catheter. On 9/24/24 at 9:16 AM, R93 was sitting in a wheelchair in her room. R93 was wearing shorts that rested just above her knee and her catheter bag was visible, sticking out from underneath the bottom of her shorts. The door to R93's room did not have any signage denoting R93 was on enhanced barrier precautions and there was not a personal protective equipment (PPE) station located outside of R93's room. 4. R117's Care Plan created on 6/4/24, shows R117 receives nutrition through a percutaneous endoscopic gastrostomy (PEG) tube. On 9/24/24 at 10:19 AM, R117 was lying in bed in her room. The door to R117's room did not have any signage denoting R117 was on enhanced barrier precautions and there was not a PPE station located outside of R117's room.

Based on observation, interview, and record review the facility failed to ensure a blender pitcher used to puree lunch was sanitized before use. This applies to 4 of 4 residents (R22, R26, R34, R72) reviewed for pureed diets in the sample of 24. The findings include: On 9/23/24 at 9:35 AM, V23 (Dietary Aide) filled all three compartments of the three-compartment sink. On 9/23/24 at 9:39 AM, V22 (Cook) was beginning to puree the pureed couscous for lunch. At 9:52 AM, V22 finished the pureed couscous and brought the blender pitcher and blender lid to the three-compartment sink to be washed. At 9:53 AM, V22 proceeded to run the blender pitcher and blender lid through the three-compartment sink. At 9:55 AM, the blender pitcher and blender lid were removed from the third sink and allowed to air dry. On 9/23/24 at 9:57 AM, V22 grabbed the blender pitcher from the drying area to begin pureeing the mixed vegetables. V22 grabbed a new, clean pitcher lid from a nearby rack before starting the puree mixed vegetables. On 9/23/24 at 10:11 AM, V23 (Dietary Director) used a test strip to check the concentration of the third sink for the three-compartment sink. V23 said the test strip didn't register there was any sanitizer solution in the sink and that the sink did not appear to have any sanitizer in it. V23 proceeded to empty the sink and re-filled the sink with a pre-diluted sanitizer and water mixture. When finished filling the sink, V23 re-tested the concentration and the test strip read at 400 parts per million, within the manufacturer's range for effective sanitizing. Facility provided list of residents on a puree diet show R22, R26, R34, and R72 receive pureed diets. Facility Manual Sanitizing in the Three-Compartment Sink policy dated 2017 states, . After washing and rinsing the utensils and equipment are sanitized in the third sink by immersion in either: . Chemical sanitizing solution used according to manufacturer's instructions.

Based on observation, interview, and record review the facility failed to ensure a resident was provided care and services who required a rheumatology consult. This applies to 1 of 24 (R22) residents reviewed for quality of care in the sample of 24. The findings include: R22's face sheet shows she is a [AGE] year old female with diagnoses including age related osteoporosis, arthropathic psoriasis, dysphagia, heart disease, atrial fibrillation, and protein calorie malnutrition. On 9/23/24 at 10:07 AM, R22 was lying in bed, her arms were thin and bony. She complained of pain to her back, toes, shoulders form her psoriatic arthritis. She said she used to take a medication for her arthritis that helped. She had an appointment scheduled to see the Rhemotologist months ago and it was canceled. She said she would still like to see the Rhemotologist, but does not know what is going on with her appointment. On 9/24/24 at 1:39 PM, V2 (DON) said R22 is alert and oriented, she has terrible arthritis. She had an appointment scheduled on July 24, 2024 and they called the day before and canceled because they did not take her insurance. She sets up the appointments for residents and confirmed she did not schedule another appointment for R22. She needs it, she is definitely uncomfortable. R22's Nurse Practitioner Note dated 7/10/24 documents (R22) is requesting for Rheumatologist .she reports chronic arthritic pain to multiple sites including shoulders, back, hips, knees and toes. R22's Nurses note dated 7/12/24 documents appointment scheduled with Rheumatologist for July 24, 2024.

Based on interview and record review the facility staff failed to safely transport a resident in a wheelchair for 1 of 3 (R1) residents in the sample of 10 reviewed for accidents/incidents. This failure resulted in R1 experiencing a femur fracture. The findings include: On 2/20/2024 at 11:12AM, V7 Certified Nursing Assistant (CNA) said on 1/27/2024 she was in a resident's room when she heard the door alarm going off. V7 said she left the residents room and saw [R1] trying to leave the facility out the back door. V7 said she approached [R1] to prevent her from going outside because it was cold and icy that day. V7 said [R1] became agitated and began hitting her. V7 said she was able to turn around [R1's] wheelchair and started pushing her down the hallway. V7 said there were no foot pedals on [R1's] chair because she self-propels down the hallway on her own using her feet. V7 said [R1] began trying to put her feet on the floor to stop the wheelchair from going and putting her feet behind the front wheel of the wheelchair. V7 said she tried to redirect [R1] from putting her feet down but she kept putting her feet down. V7 said [R1] tried to throw herself out of the wheelchair. V7 said she put her arm around [R1] to prevent her from falling. V7 said she couldn't see the angle of [R1's] foot because she was behind the resident. On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she saw [R1] trying to get out of the back door. V5 said she came up to [V7] pushing [R1] down the hallway in the wheelchair. V5 said [V7] caught [R1] from falling forward in the wheelchair by putting her arm around her. V5 said she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. On 2/20/2024 at 12:36PM, V4 Doctor said the resident was admitted to [a local area hospital] on 1/27/2024 and found to have a fractured femur. V4 stated the x-ray report read a commuted displaced fracture of the distal femur shaft. V4 said it was a nasty break. V4 said the type of fracture [R1] sustained was not pathological and there would need to be some type of mechanical force to create it. V4 said [R1] needed surgery to repair her broken femur. On 2/20/2024 at 11:43AM, V2 Director of Nursing (DON) said if a resident was becoming combative and putting their feet down on the ground while pushing their wheelchair staff should stop and get help. V2 said the resident is at risk of catapulting out of the chair and staff should get additional help. V2 said stopping and getting additional help would be done to keep the resident safe. R1's progress notes dated 1/27/2024 stated Resident admitted for closed fracture to distal end of right femur. R1's Care Plan dated 1/29/2024 states [R1] has thrown herself out of her wheelchair when agitated. [R1] is able to slowly self propel in wheelchair throughout the facility. [R1] is a CNA safe lift transfer x2 assist for all transfers. The facility's Policy for preventing accidents and incidents, not dated, states the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents.

Based on interview, and record review the facility failed to ensure a nurse reported a potential injury promptly to another nurse or physician. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 10. This failure resulted in R1 experiencing a delay in care/assessment and experiencing increased pain. The findings include: On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. V5 said [R1] did complain of pain upon palpation of the leg. V5 said she did not see any swelling at that time. V5 said she moved [R1] down to the nurse's station she was working at to watch the patient. V5 said she was not the primary nurse for [R1] that day. V5 said she did not report the information to [R1's] primary nurse. V5 said she told V8 Certified Nursing Assistant (CNA) about the incident when (V8) came to get (R1) approximately 30 minutes after the incident occurred. V5 said she should have told [R1's] primary nurse about the incident and the resident's complaint of pain. On 2/20/2024 at 11:12AM, V7 CNA said [R1] was sitting at the nurse's station for approximately 20-30 minutes before V8 came to get [R1] and take her back to her unit. On 2/20/2024 at 1:09PM, V6 Licensed Practical Nurse (LPN) said around 3:00-3:30PM she could see [R1] sitting down by the other nursing station. V6 said she asked V8 to bring [R1] back down the hallway to keep an eye on her. V6 said V8 reported the resident was complaining of pain. V8 said [R1] had right knee swelling that was clearly visible and appeared twisted. V8 said she went to find V5 and ask her what happened. V8 said V5 told her [R1's] foot had got stuck behind the front wheel of the wheelchair. V8 said she notified V2 Director of Nursing right away and an order for an x-ray was obtained. V8 said the stat x-ray was taking a long time, up to 45 minutes. V8 said [R1] was placed back in bed via (mechanical) lift from the wheelchair and further assessed [R1's] leg. V8 said the swelling appeared to be worse after removing [R's] pants. V8 said she contacted V2 again and [R1] was sent out after calling 911 via EMS (emergency medical) transport. V6 said [R1] didn't complain of much pain while sitting in her wheelchair. On 2/20/2024 at 11:43AM, V2 said if anything changes with the resident or seems wrong there should be an assessment completed. V2 said oww would indicate a resident is hurt or something is wrong. V2 said following the assessment if any swelling or pain is noted the physician should be notified for further orders, tests, or to send the resident out of the facility. R1's progress notes dated 1/27/2024 states around 3:15PM the resident was brought back to the unit by CNA. CNA informed nurse of the resident's complaint of pain. X-ray order was obtained, and PRN Tylenol was administered per order. Resident continued to scream out in pain whenever resident is moved. Resident was placed back in bed with (mechanical) lift x3 staff. Upon removing pants, residents' right knee was visibly swollen and blue/purple. Resident was in tears and crying out for help. DON was informed again. Resident was sent out to [a local area hospital]. On 2/20/2024 at 12:36PM, V4 Doctor said the resident was admitted to [a local area hospital] on 1/27/2024 and found to have a fractured femur. V4 stated the x-ray report read a commuted displaced fracture of the distal femur shaft. V4 said it was a nasty break. V4 said the type of fracture [R1] sustained was not pathological and there would need to be some type of mechanical force to create it. V4 said [R1] needed surgery to repair her broken femur.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being punched in the face by staff and sustaining a right eye contusion and right eye laceration requiring stitches. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's undated Final Incident Investigation Report documents on 11/29/22 at approximately 7:50 PM, [V4 (Terminated CNA)] notified the nurse [V3 (LPN)] that he and [R1] had an altercation and [V4] struck [R1] in the face and he was bleeding. [V4] was attempting to assist [R1] to bed for the night. When [V4] attempted to remove his pants [R1] became verbally and physically aggressive towards [V4]. [R1] kicked [V4] in the groin and attempted to grab his arms. [V4] then struck [R1] in the face to stop him from grabbing him. [V4] was escorted out of the building and awaited the police arrival [V4] was arrested and [R1] was sent out to the local hospital. [V4] was terminated from the facility and [R1] returned to the facility and received two stitches to the right inner eye lid. On 12/5/22 at 9:09 AM, R1 was sitting in his wheelchair in the common area. Diffuse bruising was observed under his right eye and a laceration observed to his right inner eye. R1 was unable to answer any questions with no behaviors observed at this time. On 12/5/22 at 10:21 AM, V3 (LPN) said he was the nurse the day of the incident with R1. V4 (Terminated CNA) came up to him and said that R1 was bleeding from his face but did not say what happened. V3 went to R1's room and he was bleeding from the right side of his face/cheek. I touched his cheek and [R1] pulled away and put his hands in the air and said, 'don't hit me'. V3 said R1, was traumatized, he cowed away and could not tell me what happened. V3 said he left R1's room and saw V4 at the nurses' station. He asked V4 what happened. V4 mumbled something, then he asked him again what happened. [V4] said he punched [R1] in the face. Never should staff hit another resident. [R1] has a history of being physically aggressive towards staff, you get out of his way and re-approach him when he has behaviors. I've been hit by [R1], he's not that strong. On 12/5/22 at 10:32 AM, V6 (CNA) said she was working on 11/29/22 when the incident happened with R1. V6 said, [V3] said that [V4] punched a resident and I needed to take over his assignment. [R1] can be aggressive, but if you take care of him properly, he is calm. You should explain what you're doing and reapproach him if he gets combative and notify the nurse. You should never hit a resident. [V4] usually keeps to himself and doesn't interact with people too much. On 12/5/22 at 11:46 AM, V1 (Administrator) said she got a call on 11/29/22 and staff reported that V4 hit R1 in the face. She notified the police and called 911. The police were there, and they interviewed V4. V4 said he went to R1's room to put him to bed and R1 kept on saying things that were not true and that V4 was in the army. R1 kicked V4 in the groin and attempted to grab him then V4 struck R1 in the face. V1 said that V4 was arrested and is still in jail. R1 was sent out to the local hospital and had a right eye laceration and required two stitches. V4 never said he was sorry or showed remorse for his actions. V4 was very quiet and did his job. V1 said that R1 has verbal and physical behaviors and is not easy to care for. V1 said, If there is no reasoning with him staff should leave him alone and re-approach him when he has behaviors. R1's face sheet showed he was an [AGE] year-old male with diagnoses that included hearing loss, dementia, urine retention, hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, and heart disease. R1's Minimum Data Set assessment, dated 10/11/22, showed he had severely impaired cognition and incidents of verbal and physical behaviors, and rejections of care. The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Policy states, The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. b. Abuse: The willful infliction of injury. with resulting in physical harm, pain or mental anguish, which can include staff to resident abuse. Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.

Based on observation, interview, and record review the facility failed to safely transfer a resident to bed who has a history of falls. This failure resulted in R98 being left unattended at the foot of the bed losing his balance, falling backwards, hitting his head, and sustaining a open laceration requiring nine staples. The facility failed to supervise a resident during a transfer and use a gait belt. This applies to 2 of 22 residents (R98, R3) reviewed for safety in the sample of 22. The findings include: 1. R98's Physician Order Sheets dated through July 2022 shows he is a [AGE] year old male admitted on [DATE] with diagnoses including [CONDITION(S)], abnormalities of gait/mobility, muscle weakness, history of falls and laceration of the scalp. R98's Fall Risk assessment dated [DATE] shows he is a HIGH risk for falls. R98's Minimum Data Set assessment dated [DATE] shows he is cognitively intact, requires extensive two person assist with transfers, bed mobility toileting, and requires extensive assist with walking. On 7/11/22 at 10:27 AM, R98 was sitting in his wheelchair. Purple bruises were observed to both hands and R98 had a laceration to the back of his head. R98 said he had a fall in his room. On 7/13/22 at 9:41 AM, V4 (CNA) said on 6/16/22 she toileted R98 and was assisted him back to bed. V4 said she left R98 unattended at the foot of the bed and she went to the head of the bed telling R98 to come closer to her, but R98 is very hard of hearing and he could not hear me. V4 said R98 took one step and he fell backwards hitting his head on the metal door hinge. V4 said she was too far away to grab R98 and she was not holding on to his gait belt. V4 states, it was horrible. On 7/11/22 at 12:21 PM, V3 (RN) said R98 was admitted to the facility last month with a history of falls from home and very hard of hearing. V3 said she was R98's nurse when he fell on [DATE]. V3 said V4 (CNA) assisted R98 after toileting and she left him unattended and he lost his balance and fell hitting his head on the wall. V3 said R98 was bleeding from his head, he sent out to the local hospital and required staples to his head. V3 said R98 had a previous fall the same day and V4 should have held onto his gait belt and not left him unattended. On 7/12/22 at 12:48 PM, V5 (CNA) said R98 is a two person assist and he is not steady when walking. The nurse's note dated 6/16/22 documents (R98) was in the room with V4 (CNA) assisting him after using the bathroom. R98 was walking towards his bed, but lost his balance and fell backwards and hitting his head and acquiring a laceration. R98 was sent out to the local hospital R98 returned to the facility with nine staples to his head. The facility's Accident and Supervision Policy reviewed 6/2021 states, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards and risks 2. Evaluating . 3. Implementing interventions . 4. Monitoring for effectiveness and modifying interventions when necessary . 2.) R3's face sheet shows she has diagnoses including: unspecified dementia with behavioral disturbances, [CONDITION(S)] disorder and a history of falling. R3's 6/27/2022 facility assessment shows she has an unsteady gait and requires extensive 2 person staff assistance with transfers and toileting. R3's active care plan shows she has a self-care deficit and requires extensive assistance for all transfers. R3's 6/27/2022 fall risk assessment shows she is at high risk for falls. On 7/11/2022 at 1:11 PM, V8 (CNA) entered R3's room to assist her to use the toilet. R3 had been incontinent of stool that had leaked out of her pants and onto the floor in her room. R3 was sitting in her wheelchair and V8 pushed R3 into the bathroom. V8 did not apply a gait belt on R3 and R3 began to stand up from her wheelchair. V8 left R3 in the bathroom and went to clean stool off the floor in the room. V8 then said she was going to get housekeeping to assist with the stool on the floor and left R3 alone in the bathroom. When V8 returned R3 was standing up between her wheelchair and the toilet. V8 assisted R3 to pull down her pants and sit on the toilet. At 1:19 PM, R3 was finished using the toilet. Without applying a gait belt V8 told R3 to push up using the arms of her wheelchair to stand up. V8 pulled up R3's pants and helped her turn and sit in the wheelchair. On 7/12/2022 at 12:28 PM, V6 (Licensed Practical Nurse/LPN) said gait belts should be used for all residents during transfers and a resident should never be left alone standing up in the bathroom for safety reasons. On 7/12/2022 at 12:30 PM, V7 (CNA) said gait belts are always supposed to be used during transfers and residents should not be left alone in the bathroom for safety reasons. The facility's Safe Resident Handling/Transfers policy dated 2021 states, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with the current standards and guidelines . 5. Handling aids may include gait belts, transfer boards and other devices. 13. Staff members are expected to maintain compliance with safe/handling transfer practices .

Based on observation, interview, and record review the facility failed to safely transfer one of three residents (R1), reviewed for falls. This facility failure resulted in R1 sustaining a broken clavicle, broken scapula, and broken ribs, having severe pain, and an increase in R1's immobility. The findings include: The facility face sheet for R1 shows [DIAGNOSES REDACTED]. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires extensive assist of two staff to complete personal care and transfers. The assessment also shows R1 has impaired mobility to both sides for her upper and lower extremities. The facility reported incident dated 9/30/19 shows R1 was being transferred using a mechanical lift on 9/29/19 when the mechanical lift sling hook malfunctioned and R1 fell on her right side. On 10/9/19 at 9:15 AM, R1 was lying in bed leaning to her right side. R1 was wearing oxygen and her breathing was fast and labored. R1 was coughing with a pained expression on her face. R1 said, Did you hear what happened, the (mechanical) lift broke and I fell to the floor. I landed on the legs of the lift. It hurts so bad, it hurts to cough, it hurts to breathe. When I get out of bed now it hurts so much and I'm afraid it will happen again. R1 said she is just miserable now and wishes she could just go to sleep and wake up better. R1 said she is back on a pureed diet because she was having so much coughing at dinner one night; the staff were afraid she would choke, so they put her on pureed food. On 10/9/19 at 12:00 PM, R1 was being assisted out of bed by five staff and the mechanical lift. The staff turned R1 from side to side to provide incontinence care and placed the lift sling under R1. R1 was moaning and saying, It hurts, it hurts. The staff had to stop giving care at one point to allow R1 time to rest. R1 was coughing and grimacing during the transfer. On 10/9/19 at 11:13 AM, V10 CNA (Certified Nursing Assistant) said she was one of the staff that was transferring R1 on 9/29/19. V10 said as they were moving R1 from her bed to the wheelchair, the metal hook on the lift broke off and R1 fell to the floor landing on the legs of the lift. V10 said R1's face turned red and looked like she had the wind knocked out of her. On 10/9/19 at 11:39 AM, V9 CNA said she was helping R1 get out of bed the night she fell from the mechanical lift. V9 said as they were moving R1 from her bed to the wheelchair, the metal hook on the lift just snapped. V9 said R1 fell to the floor landing on the legs of the lift. V9 said R1 looked like she had the wind knocked out of her. On 10/9/19 at 1:37 PM, V6 RN (Registered Nurse) said when she was called to the room after R1 fell from the lift, she found R1 lying on the legs of the lift crying and saying her back hurt. On 10/9/19 at 9:50 AM, V1 Administrator said the metal piece that was holding the 4 hook attachment broke on the mechanical lift. V1 said it was metal on metal friction that caused the break. On 10/9/19 at 9:45 AM, V2 DON (Director of Nurses) said the mechanical lifts had not been checked for safety for over a year. V2 said the lifts should be checked monthly and it was not being done by the staff. On 10/9/19 at 11:30 AM, V3 nursing supervisor said the facility did not have any logs for checking the mechanical lifts. V3 said, It was not being done. On 10/9/19 at 12:50 PM, V7 Maintenance Director said there were no routine inspections or maintenance being done on the lifts. On 10/9/19 at 11:15 AM, V4 service representative for the mechanical lifts said the facility should be checking the lifts monthly. V4 said having the metal break on the mechanical lift is unheard of and he has never seen this happen. On 10/9/19 at 1:05 PM, V2 DON said the x-ray taken at the facility showed R1 had a broken right clavicle after the fall from the lift. V2 said R1's pain medications were increased to help with the pain. V2 said R1 was sent to the hospital the next morning for continued complaints of pain and more x-rays were taken and it was discovered R1 had some broken ribs as well. V2 said R1 was seen by a pain specialist while at the hospital and additional pain medications were ordered for R1 to help with the pain. V2 said R1's diet order was changed to a pureed diet after the nurse felt she was coughing too much and was afraid she would choke due to all the coughing at the table. V2 said R1 will be seen by the speech therapist to evaluate her swallowing. V2 said R1 will be getting up for all meals to avoid respiratory problems and four staff will be assisting her with the transfer. On 10/9/19 at 2:00 PM, V5 (R1's doctor) said R1 has a broken clavicle, a broken scapula and broken ribs. V5 said basically her right shoulder is broken. V5 said R1 will have a very long and painful recovery and his biggest concern is R1 developing pneumonia. V5 said R1 is being given as much pain medication as is possible. V5 said R1 will have limited range of motion to her right shoulder because of the injury she sustained from falling out of the mechanical lift. On 10/9/19 between the hours of 10:25 AM and 11:27 AM, V11-V15 all CNA's said they never check the metal parts of the mechanical lift before transferring a resident. The nursing progress note dated 9/29/19 shows R1 fell from the mechanical lift after the metal part broke on the lift. The note dated 9/30/19 at 3:39 AM shows the results of the x-ray shows a right fractured clavicle. The nursing progress notes dated 10/7/19 (day of readmission to facility from the hospital) to 10/9/19 shows R1 complaining of pain, receiving a strong narcotic for pain relief, needing assist of four staff to get out of bed, and a congested frequent cough. The x-ray dated 9/30/19 shows R1 has a [MEDICAL CONDITION] clavicle. The hospital discharge papers dated 10/7/19 for R1 shows the addition of a narcotic pain patch, a new dosage for her scheduled narcotic pain pills, and as needed pain medications, and a breathing treatment. The physician's orders [REDACTED]. The POS also shows the changes in R1's pain narcotic regimen. The Physician note dated 10/8/19 for R1 shows right shoulder trauma and multiple right sided rib fractures. The care plan for R1 printed on 10/9/19 shows a mechanical lift is being used for safe transfers, reassure the resident during transfer and anti-anxiety medications are available related to her anxiety was initiated on 7/2/19 (Prior to the fall). The care plan also shows a history of pain for R1 prior to the fall and staff are to provide pain relief as needed. The same care plan for history of shortness of breath dated 7/2/19 shows due to neuromuscular impairment, and decreased lung expansion R1 is at risk for complications with her breathing. The facility provided mechanical lift inspection results for the mechanical lifts dated 6/6/18 (over a year ago). The next time the lifts were inspected was on 9/30/19 at which time one mechanical lift had a broken hanger bar and another lift had a worn hanger bar that was in need of replacement. The owner's manual for the mechanical lifts shows a general visual inspection of the external parts and all functions should be carried out to ensure no adverse damage has occurred. The manual also shows apply [MEDICATION NAME] grease to all smooth surfaces where metal on metal contact occurs.

Based on interview and record review the facility failed to provide the necessary care and services for a resident at risk for choking (R12) following an acute choking episode on (MONTH) 7, 2019. This failure resulted in R12 having a second choking episode on (MONTH) 10, 2019 that resulted in R12 requiring CPR (cardiopulmonary resuscitation), emergent transport to the hospital, and hospitalization . R12 expired on (MONTH) 12, 2019 from choking, and cardio-pulmonary arrest. This applies to 1 of 31 residents (R12) reviewed for quality of care in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 7, 2019 when R12 choked during the evening meal. On (MONTH) 23, 2019 at 8:40 AM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 23, 2019. While the immediacy was removed, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. The findings include: R12's Care Plan dated (MONTH) 19, 2019 showed R12 was cognitively impaired with [DIAGNOSES REDACTED]. R12's Care Plan also showed to monitor, document, and report any signs and symptoms of dysphagia which included choking, coughing, and pocketing of food. R12's Admission Summary Note dated (MONTH) 19, 2019 showed R12 was readmitted to the facility after being hospitalized for [REDACTED]. R12 was readmitted on a pureed diet with honey thickened liquids. R12's Speech Therapy Plan of Care showed R12 received speech therapy services from (MONTH) 22, 2019 through (MONTH) 11, 2019, due to (R12's) [DIAGNOSES REDACTED]. A Physician order [REDACTED]. R12's Health Status Note dated (MONTH) 7, 2019 at 5:31 PM showed R12 choked during the evening meal (first choking episode in the facility). R12's face began turning blue and (R12) required back blows by facility staff to facilitate coughing and removal of food from (R12's) mouth. The Note showed R12 opened (R12's) mouth, food was scooped out of (R12's) mouth, and (R12) coughed and spit out chunks of unchewed bread and fish . R12's Discharge Summary Note dated (MONTH) 10, 2019 at 5:15 PM, showed R12 choked a second time, during the evening meal. The Note showed R12 began choking on food, became unresponsive with no palpable pulse, and required CPR. R12 was transferred to a local hospital emergently via ambulance. R12's hospital Emergency Department Documentation dated (MONTH) 10, 2019 showed R12 arrived to the emergency room in an unresponsive state after a choking episode in a nursing home, with no pulse .CPR performed briefly and paramedics attempted intubation without success secondary to food obstruction . R12's hospital Physician Documentation showed R12 was declared brain dead and expired on (MONTH) 12, 2019. On (MONTH) 17, 2019 at 1:48 PM, V4 Speech Therapist (ST) stated he began treating R12 in (MONTH) 2019, for dysphagia. V4 stated, (R12) needed supervision with eating and repeated cues to take small bites and slow down when eating. He did not have great safety awareness when eating due to (R12's) cognition. I upgraded (R12's) diet to regular consistency on (MONTH) 5, 2019, because (R12) had been doing ok with regular consistency foods during therapy. When V4 ST was asked why R12's diet was not downgraded immediately after (R12's) first choking episode on (MONTH) 7, 2019, V4 stated, I was aware (R12) choked on (MONTH) 10. I was not notified (R12) choked on (MONTH) 7. I would have downgraded (R12's) diet immediately on (MONTH) 7 if I had known (R12) choked. On (MONTH) 17, 2019 at 2:00 PM, V5 Licensed Practical Nurse (LPN) stated she was the nurse caring for R12 on (MONTH) 7 and 10, 2019, during both of R12's choking incidents. V5 stated that on (MONTH) 7, 2019, during R12's first choking incident, R12 began choking in the dining room while eating dinner. (R12's) lips got blue and (R12's) mouth was full of food .The CNA (certified nursing assistant) hit (R12) on the back a few times and (R12) started coughing and spitting out food. We did get the food out and took (R12) to the bathroom to get (R12) cleaned up. No, I never notified (R12's) doctor about this. I didn't tell anyone about (R12) choking but I did write about it in (R12's) chart. I figured they would read the note on Monday. I didn't downgrade (R12's) diet. I didn't really even think about doing that. V5 LPN also stated she did not consider R12's first choking episode on (MONTH) 7, 2019, a major concern at the time. On (MONTH) 17, 2019 at 2:25 PM, V6 Physician stated, I had absolutely no idea (R12) had a choking episode on (MONTH) 7. Had I known this, I would have immediately downgraded (R12's) diet on (MONTH) 7. I was not notified of any of this. I just knew (R12) choked on (MONTH) 10 and expired in the hospital. On (MONTH) 17, 2019 at 1:55 PM, V3 Nursing Supervisor stated V5 LPN never notified her of R12's first choking incident on (MONTH) 7, 2019. V3 stated, Nurses can immediately downgrade a resident's diet after a choking episode. We don't need to wait for a physician's orders [REDACTED]. On (MONTH) 18, 2019 at 9:05 AM, V9 Registered Nurse (RN) stated, If a resident had a choking episode, I would immediately downgrade that resident's diet and call the doctor. Every nurse should know what to do when a resident chokes. It's basic nursing. The facility's Diet Orders Policy (undated) showed, 6. Speech/MD/Nursing is able to downgrade (diet) if there is a change in condition or resident request, or staff concern. Through observation, interview and record review on (MONTH) 23, 2019, the surveyor confirmed the facility took the following steps to remove the immediacy. 1. The facility's administrator, medical director and DON (Director of Nursing) have reviewed the Diet Orders Policy and approved it as written. All licensed personnel were reeducated on the Diet Orders Policy on (MONTH) 23, 2019. The policy states that licensed personnel are able to downgrade a resident's diet if there is change in condition. 2. As of [DATE], all residents who are at risk for aspiration, eat in a supervised dining area. All residents will continue to be evaluated for aspiration risk upon admission, and if there is a significant change in condition by speech therapy.

Based on observation, interview and record review the facility failed to supervise a resident who was exhibiting attempts to get out of R1's chair and was at risk for falls. This failure resulted in R1 sustaining fractures of the 1st and 2nd cervical vertebrae of the neck. The facility failed to safely turn a resident in bed to prevent resident from rolling out of bed. This applies to 2 of 3 residents (R1, R2) reviewed for safety and supervision in the sample of 5. The findings include: 1. R1's Physician order [REDACTED]. R1's Minimum Data Set assessment dated (MONTH) 19, (YEAR) shows R1 is moderately cognitively impaired. The same MDS shows R1 has limited range of motion on upper and lower extremities. R1's Fall Risk assessment dated (MONTH) (YEAR) shows R1 is at high risk for falls. R1's Progress Notes dated (MONTH) 19, (YEAR) at 5:07 PM shows, R1 on the floor from reclined wheelchair, lying on right/center forehead. R1 sent to local hospital via 911. R1's Emergency Report dated (MONTH) 19, (YEAR) shows that R1 came from a nursing facility who fell out of R1's chair. R1 was nonverbal. R1 was sent directly for CT scan. (Computerized x-ray) of R1's head and neck. R1's CT scan results shows R1 has neck fractures of the spine, Cervical 1 and Cervical 2 (1st and 2nd cervical vertebrae of R1's neck.) R1's Neuro Surgery Note dated (MONTH) 20, (YEAR) shows (R1 has) mildly displaced fractures of left arch of C1 and left lateral body of C2. (Neck fractures) and due to overall health condition and nature of R1's fractures, treatment will be conservative, no surgical intervention. On (MONTH) 27, (YEAR) at 2:00 PM, R1 was at a local hospital, lying quietly in bed. R1 would open R1's eyes but R1 was nonverbal. R1 had cervical collar on R1's neck. On (MONTH) 27, (YEAR) at 7:10 AM, V3 (family member) said that V3 was at the facility on (MONTH) 19, (YEAR). R1 was in R1's room sitting in R1's reclined wheelchair. R1 kept on moving in R1's chair. R1 would repeatedly attempt to lean forward or swing R1's good leg (left leg) to try to get out from R1's reclined wheelchair. V3 said there were no staff that would come and check on R1. V3 said V3 left R1 at around 3:45 PM and was worried that R1 will fall out of R1's wheelchair. V3 stated, That is exactly what happened, I received a phone call from the facility, I was informed that (R1) threw herself on the floor. I don't believe that, how can R1 threw R1's self, R1 was paralyzed. (R1) leaned forward and fell .out of R1's wheelchair. V3 said V3 was informed that R1 sustained 2 fractures in R1's neck. V3 said V3 was told by hospital staff that R1 was not a good candidate to undergo surgery. On (MONTH) 27, (YEAR) at 10:11 AM, V4 (R1's friend) said V4 went to visit R1 on (MONTH) 19, (YEAR) the day R1 fell . V4 said R1 was repeatedly attempting to lean forward. V4 said R1 also smelled like R1 had a bowel movement. V4 said V4 went and told the nurse that R1 was leaning forward, R1 seems uncomfortable and R1 might need to be changed. V4 said no staff went to check on R1. V4 said R1 continued to lean and pull R1's self up from the chair. V4 said V4 would remind R1 to sit back in R1's chair. V4 stated at around 4:30 PM, I went to the nurse again and told her that I am leaving now, R1 was by R1's self in R1's room and that R1 might fall as R1 was leaning forward and kept moving in R1's chair. I learned later that night from R1's son that R1 fell and was sent to the hospital. On (MONTH) 27, (YEAR) at 12:35 PM, V5 (Registered Nurse-RN) said V5 was the nurse working the day R1 fell . (August 19, (YEAR)). V5 (RN) said R1's friend (V4) came to the nurses station and informed V5 that R1 was leaning forward and that R1 might fall from R1's chair. V5 said V4 also told V5 that R1 might need to be changed. V5 said V5 knew R1 was gotten up at around 3:00 PM and that R1 was dry. V5 said V18 (R1's Certified Nursing Assistant- CNA) was on break and the other CNA's were busy with other residents. V5 said when V4 informed V5 that V4 was leaving and that R1 was leaning forward V5 said V5 went to check on R1. R1 was leaning forward so she repositioned R1 and reclined R1's chair so R1 would not fall. V5 said V5 also turned R1's chair so R1 can watch the TV. V5 said V5 left R1's room and went to check the other residents. V5 said later that afternoon, while V5 was passing the evening medication, a family member of another resident informed V5 that R1 fell out of R1's chair. V5 said V5 immediately went to R1. R1 was on the floor, on the side of R1's chair. V5 said R1 was sent to the hospital via 911. V5 said V5 tried to monitor R1 at the same time V5 was passing V5's medication but V5 was also busy with other residents at that time. V5 said R1's CNA was assigned to both the 300 and 500 wing. On (MONTH) 28, (YEAR) at 12:45 PM, V18 (CNA) said V18 was assigned to R1 on (MONTH) 19, (YEAR) the day R1 fell . R1 was sliding down from R1's chair, V18 said R1 seems uncomfortable in R1's chair. V18 said V18 didn't know why. V18 said V18 then went to take care of the other residents assigned to V18 in 300 wing then went on break. V18 said V18 was informed that R1 fell and was sent to the hospital. On (MONTH) 28, (YEAR) at 11:41 AM, V2 (Director Of Nursing) said R1 had been attempting to get out of bed or R1's wheelchair since day 1. R1 should have been placed in a highly populated area where R1 was visible. R1 should have been closely supervised. R1's care plan dated (MONTH) (YEAR) shows R1 is at risk for falls related [MEDICAL CONDITION] right sided [MEDICAL CONDITION] with interventions that include: prompt response to all requests for assistance. On (MONTH) 28, (YEAR) at 12:06 PM, V9 (Orthopedic Doctor) said neck fractures (C1 and C2) are very dangerous and can be fatal. 2. R2's POS dated (MONTH) (YEAR) shows R2 has [DIAGNOSES REDACTED]. R2's MDS dated (MONTH) 28, (YEAR) shows R2 needs extensive assist of 2 staff for bed mobility. R2's medical record also shows R2 was just readmitted to the facility on (MONTH) 21, (YEAR) after undergoing a right hip surgery. R2's Progress Notes dated (MONTH) 22, (YEAR) at 3:30 AM shows writer called to the room, (R2) was on the floor between the wall and the bed. CNA was in the middle of changing R2. CNA turned around to get to the other side of the bed and R1 rolled out bed. R2 stated R2 fell off the bed and landed on R2's right side. (Surgical site.) On (MONTH) 27, (YEAR) at 9:30 AM, R2 was in the dining room eating her breakfast. R2 said R2 fell from R2's bed and had surgery but cannot remember when. On (MONTH) 28, (YEAR) at 12:02 PM, V14 (CNA) said that on (MONTH) 22, (YEAR) at around 3:00 AM, V14 went to change R2 who was wet. V14 said V14 pulled R2's bed away from the wall to get to the other side of the bed to change R2. V14 said V14 turned R2 facing the wall and told R2 not to move. V14 said R2 rolled out of bed between the wall and the bed. V14 said V14 thought V14 could change R2 by V14's self. On (MONTH) 28, (YEAR) at 9:12 AM, V13 said that on (MONTH) 22, (YEAR) at 3:00 AM, V13 was informed by V14 that R2 fell between the bed and the wall. V13 said V14 was turning R2 by V14's self. V13 said V13 told V14 that R2 is a two person assist for bed mobility. R2's Physical Therapy assessment dated (MONTH) 22, (YEAR) shows R2 need maximum assist of 2 staff when rolling R2 side to side when R2 was in bed. An undated facility policy entitled Accident and supervision shows the resident environment remains free of accident hazards as possible and each resident receives adequate supervision to prevent accidents.

Based on observation, interview and record review the facility failed to ensure equipment device for toileting was in safe condition and failed to ensure a resident was supervised while toileting who is at risk for falls. These failures resulted in R1 falling from the toilet and sustaining a laceration above the left eye and a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 7. The findings include: The Physician order [REDACTED]. The Minimum Data Set assessment dated (MONTH) 19, (YEAR) shows R1's cognition is intact and requires two person extensive assist with transfers. The fall risk assessment dated (MONTH) 19, (YEAR) shows R1 is at risk for falls. The Care Plan dated through (MONTH) (YEAR) shows R1 is at risk for falls related to gait/balance problems, has limited physical mobility related to a stroke affecting (R1's) left side. R1's interventions include (R1) should be supervised during toileting. The facility's Incident Report dated (MONTH) 25, (YEAR) shows R1 had a fall with injury. R1 is alert and oriented and was found on the bathroom floor and was bleeding. R1 was able to recall what happened and said (R1) was trying to scoot (R1's) self on the toilet chair and slid down on (R1's) left side and hit (R1's) head. R1 was sent to the local hospital and was treated for [REDACTED]. On (MONTH) 27, (YEAR) at 9:20 this surveyor was in R1's room talking with R7 (R1's roommate). R1 was not in R1's bed. At 9:22 AM, V10 (Certified Nursing Assistant-CNA) entered the room and knocked on the bathroom. R1 was in the bathroom unsupervised. R1 had a laceration with sutures above R1's left eye/brow and bruising below R1's left eye. V10 transferred R1 from the toilet to the wheelchair. R1 was not steady on R1's feet during the transfer, R1 stated, I'm having a hard time moving my left foot. At 10:00 R1's toilet had a white plastic toilet riser placed over the toilet. The riser was unsteady and moved when gripped. On (MONTH) 27, (YEAR) at 9:30 AM, R1 said R1 fell a couple of days ago. R1 said a CNA (Certified Nursing Assistant) assisted R1 to the bathroom. R1 told the CNA R1 needed a toilet riser. R1 said the CNA got the toilet riser from the shower and placed it over the toilet. R1 said the CNA transferred (R1) from the wheelchair to the toilet. R1 said (R1) placed R1's hands on the toilet riser's arm rest to reposition R1's self on the toilet seat. R1 said the toilet riser was unstable and (R1) tipped over and fell on the floor. R1 said (R1) hit (R1's) head on the floor and (R1) was bleeding. R1 stated, It scared the[***]out of me. R1 said (R1) fell because the toilet riser wasn't right. On (MONTH) 27, (YEAR) at 10:50 AM, V10 (CNA) said (V10) assisted R1 to the bathroom the day (R1) fell on (MONTH) 24, (YEAR). V10 said R1 told (V10), (R1) needed to use the bathroom. V10 said (V10) was not too familiar with R1. V10 said (V10) got a plastic chair from R1's shower and placed it over the toilet. V10 said (V10) transferred R1 from (R1's) wheelchair to the toilet and left the bathroom. V10 said (V10) waited in the hallway when (V10) heard R1 yell help me. V10 said R1 was on the floor in the bathroom and (R1) was bleeding from (R1's) face. V10 said (V10) asked R1 what happened. R1 told V10, (R1) was trying to reposition (R1's) self on the toilet and fell . On (MONTH) 27, (YEAR) at 10:40 AM, V8 (Licensed Practical Nurse-LPN) said (V8) was R1's nurse on (MONTH) 24, (YEAR). V8 said V10 alerted (V8) R1 fell in the bathroom and was bleeding. V8 said R1 is alert and oriented and said (R1)was trying to move (R1's) self on the toilet. On (MONTH) 27, (YEAR) at 11:25 AM, V11 (Maintenance) said (V11) removed R1's toilet riser today because it slides, does not lock and does not have grippers. On (MONTH) 27, (YEAR) at 12:08 PM, V2 (Director of Nursing-DON) said R1 is a high risk for falls and should be supervised during toileting. V2 said if equipment is not in working order staff should report it. The undated Policy for Accidents and Supervision states, The resident environment remains as free of accidents and hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents.

Based on observation, interview, and record review the facility failed to ensure resident safety and supervision for cognitively impaired residents when drinking hot tea. This applies to 2 of 3 residents (R1 and R2) reviewed for safety and supervision in the sample of 3. These failures resulted in R1 sustaining second to third degrees burns to her thighs and R2 sustaining a first degree burn to her thigh. The findings include: R1's computerized [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) dated [DATE] shows moderate cognitive impairment and requires extensive staff assistance with bed mobility, locomotion, dressing, and hygiene. The same MDS shows R1 requires extensive staff assistance of one person with eating and drinking. R2's computerized [DIAGNOSES REDACTED]. R2's MDS dated [DATE] shows R2 was unable to complete the cognitive assessment and requires extensive staff assistance with bed mobility, locomotion, dressing, and hygiene. The same MDS shows R2 requires limited staff assistance of one person with eating and drinking. On June 13, 2017 at 10:15 AM, E9 (Dietary Aide) was in the main dining room next to a waist high coffee bar counter. E9 was observed pouring water into the top of a rectangular, insulated container marked coffee that was sitting on the coffee bar counter. A second rectangular insulated container was in the area labeled vanilla coffee and a third cylinder thermal container was labeled hot water. E9 stated she was pouring cold water into the containers because it is too hot when it comes out of the kitchen. E9 said about two weeks ago she was directed to begin the cooling down process because some resident was burned on the legs from the hot water used for tea. E9 stated coffee and hot water was being served to residents directly out of the kitchen dispensers before the cooling down process was initiated in the dining room. This surveyor requested E9 to test the temperature of the coffee and hot water in the kitchen dispensers which showed 155 degrees and 174 degrees Fahrenheit respectively. Steam was observed coming out of both mugs while temperatures were recording. On June 13, 2017 at 10:30 AM, R1 was lying in bed while E4 (Wound Care Nurse) was performing a dressing change to her inner thighs. R1's right and left inner thighs had egg sized reddened areas with yellow slough in the centers. Clear liquid was oozing out of each wound. R1 was questioned by this surveyor how the thigh wounds occurred and she replied she did not know. E4 stated she (R1) got a thermal burn from hot tea. It happened about two weeks ago. E4 said the burns started as redness, progressed to open blisters, and now have necrotic (dead) tissue. E4 stated the burns show full thickness skin loss. E4 was questioned by this surveyor if any other residents have experienced burns from hot water temperatures. E4 stated, Yes, (R2) was burned before (R1) but her burns weren't as bad. She spilled hot tea on herself too. On June 13, 2017 at 11:00 AM, R2 was observed self propelling her wheelchair in the main dining room and down the 500 wing hallway. R2 had a brown mug in her hand with a tea bag hanging out of the side. R2 stated she sustained a burn to her thigh a few days ago I think. R2 said she got the burn due to a mug of hot tea she dropped into her lap. R2 said, It was too hot. On June 13, 2017 at 11:05 AM, R4 stated the coffee temperatures were lowered about two weeks ago because she heard someone got burned. On June 13, 2017 at 11:30 AM, R3 stated liquids served in the dining room are served at a lower temperature now because a couple people got burned. R3 stated she witnessed R2 spill hot tea into her lap while self propelling in her wheelchair. R3 said it was two or three weeks ago. On June 13, 2017 at 11:45 AM, E3 (Nurse Supervisor) stated two residents (R1 and R2) sustained thigh burns after spilling hot tea on themselves. E3 said R1 was seated in the ADL section (staff assist area) of the dining room when the spill occurred. E3 stated that R1 is seated at an assistance table for cueing and supervision. E3 said R1 spilled hot tea on herself during the dinner meal. E3 stated the ADL section is supervised by Certified Nurse Aides (CNAs) during meals. At 12:40 PM, E7 (CNA) stated she was in the ADL dining room but did not see R1 spill the hot tea. At 12:45 PM, E5 (LPN) stated she was passing medication in the ADL dining room but she did not see R1 spill her hot tea. At 2:04 PM, E6 (CNA) stated he was in the ADL dining room but he did not see R1 spill her hot tea. R1's incident report dated May 29, 2017 states: This writer was informed by dining room ADL CNA that resident had spilled hot tea on her lap. Incident was not witnessed however CNA heard her yell . On June 13, 2017 at 11:55 AM, E3 stated R2 spilled hot tea on herself while self propelling in her wheelchair. E3 said R2 is able to fill her own tea mugs with hot water directly from the coffee bar counter in the dining room. At 3:30 PM, E3 stated the dining room is open 24/7 and fully accessible to all residents. E3 stated the dining room should be staffed at all times between 6 AM to 9 PM to ensure resident safety. R2's incident report dated May 23, 2017 states: Res (resident) yelling out in DR (dining room) Help! Staff ran in to check on resident. Resident screaming saying that she spilled coffee and its burning . The facility's Accident/Incident Tracking Log was reviewed with E3. E3 clarified to this surveyor that R2's burn occurred on May 23, 2017 and R1's burn occurred on May 29, 2017 (6 days later). E3 stated she did not know the temperature of the liquids being served to residents during that time period. E3 said both residents sustained the thigh burns due to the hot water used for tea. On June 13, 2017 at 12:05 PM, E8 (Dietary Director) stated she was first notified that R2 had been burned with hot tea. E8 stated that the time of R2's burn, coffee and hot water were being served to residents at a temperature of at least 160 degrees (Fahrenheit). E8 stated she was not performing any temperature checks on the liquids but knew it was at least that high because it was brewing just fine. E8 said after R2 was burned she attempted to turn the temperature down on the coffee and hot water machines but it still wasn't going down for the next five days. E8 stated the liquids continued to be available to residents in the 160 degree range. E8 stated, at that time, she did not have any upper temperature she would consider too hot to serve to residents. E8 said it wasn't until R1 was burned (six days after R2) that the facility began the practice of adding cold water to coffee and tea in order to reach a serving temperature of 130 degrees Fahrenheit. On June 13, 2107 at 1:00 PM, E1 (Administrator) stated he contacted the coffee/hot water machine manufacturer representative after R2 was burned. E1 stated the water temperature of liquids available to residents remained above 160 degrees because the representative told him brewing will not take place if the temperature is less. E1 said it was not until R1 was burned (6 days after R2) that cold water began to be added to hot tea water and hot coffee after the brew process. E1 stated he did feel that the high water temperatures caused both residents to sustain burns. On June 14, 2017 at 1:20 PM, Z1 (Wound Physician) stated R1's thigh wounds are a deep partial loss of skin in some areas and a full thickness loss of skin in the worse areas. Z1 stated they are bad burns. Z1 stated R1 is in need of weekly wound visits until the burns are fully resolved. Z1 stated he does not routinely see residents with first degree burns. Current burn wound classification standards rate partial thickness skin loss as a second degree burn and full thickness skin loss as a third degree burn. Burns resulting in [DIAGNOSES REDACTED] (redness) only are classified as first degree burns. R1's Progress Note dated May 29, 2017 shows: resident had spilled hot tea on her lap escorted resident out of dining room to be assessed .there was redness and blisters forming to bilateral inner thighs near groin. R1's wound observation reports dated May 30, 2017 show: right medial thigh wound measurement of 3.5 cm (centimeter) length, 3.5 cm width and blister is from a burn d/t (due to) spilled hot tea. R1's left medial thigh wound measurement section states: 4.0 cm length and 4.0 cm width. R2's Progress Note dated May 23, 2017 shows: res (resident) screaming saying that she spilled coffee and it's burning .taken back to her room .res assessed .blister to L (left) groin. R2's wound observation report dated May 23, 2017 shows: thermal burn noted on left groin, size: 2 cm length, 2 cm width. The facility's Coffee/Water Temperature Logs were reviewed and showed an initiation date of May 30, 2017 (one day after the second resident burn). The facility was unable to provide any policy relating to coffee or tea temperatures prior to the May 2017 burn incidents. The facility did provide a Food Preparation Policy dated May 30, 2017 that states: water temps. Not to exceed 130 degrees in dining room coffee and tea served.

Based on observation, interview, and record review the facility failed to assess and effectively manage pain prior to dressing changes. This failure resulted in R1 experiencing unrelieved pain during two burn wound dressing changes. This applies to 1 of 3 residents (R1) reviewed for pain in the sample of 3. The findings include: R1's computerized [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) dated [DATE] shows moderate cognitive impairment and requires extensive staff assistance with bed mobility, locomotion, dressing, and hygiene. The same MDS shows R1 requires extensive staff assistance of one person with eating and drinking. R1's computerized physician orders [REDACTED]. R1's care plan shows a focus area: 5/29/17 burn on the left and right medial thigh. The intervention section states: Cleanse left and right medial thighs using wound cleanser, apply santyl and cover with dry gauze dressing once daily until resolved. Monitor dressing once every shift, and change if saturation is more than 50%. Date Initiated: 05/31/2017. On June 13, 2017 at 10:30 AM, R1 was lying in bed while E4 (Wound Care Nurse) was performing dressing changes to her right and left inner thighs. R1's hands were clenched and her face was set in a grimace. R1's right and left inner thighs had egg sized reddened areas with yellow slough in the centers. Clear liquid was oozing out of each wound. R1 was questioned by this surveyor how the thigh wounds occurred and replied she did not know. R1 also stated I don't know what's going on right now. My leg hurts. Ouch!! E4 stated she (R1) got a thermal burn from hot tea. It happened about two weeks ago. E4 said [MEDICAL CONDITION] as redness, progressed to open blisters, and now have necrotic (dead) tissue. E4 was observed cleansing both thigh wounds while R1 continued to moan, OOOOO and Ohhh boy! throughout the dressing change. R1 repeatedly said, Don't hurt me anymore, and Both my legs hurt. E4 stated R1 has a prescription for (pain medication) to be given every six hours. E4 stated he did not know when R1 last received pain medication and he did not administer any type of pain medication prior to beginning the dressing changes. E4 stated R1's right and left thigh dressings are changed on a daily basis and more often if needed. E4 completed the dressing changes and exited R1's room without performing any pain level assessment or providing any pain relief treatment. On June 13, 2017 at 1:45 PM, E2 (Director of Nurses) stated signs of pain include, but are not limited to: skin redness, blistering, facial grimacing, restlessness, change in behavior, yelling out, and verbalizing pain itself. E2 said nurses should be assessing resident pain levels and giving medication if pain is present. E2 stated pain medications should be given 30 minutes prior to dressing changes to ensure pain relief can kick in. E2 said any signs of pain should be addressed as soon as a resident expresses them. R1's June 2017 Medication Administration Record [REDACTED]. R1's MAR indicated [REDACTED]. The pain assessment for June 13, 2017 day shift shows a pain level of zero was obtained while R1 was sleeping. The facility's Policy for Pain Management dated 2012 states : 1. Resident's complaints of pain (be it Acute, Chronic, Nociceptive, Neuropathic or Incident) will be addressed promptly. Attempts will be made to address the possible cause, and treat when possible thru appropriate measures. 7. The medication and/or treatment will be administered by the nurse for the control of pain and will be monitor by both the nurse and other staff, regarding it's effectiveness.

Based on observation, interview and record review, the facility failed to analyze and identify the causal factors placing R4 at risk for the development of a pressure ulcer, failed to develop a plan of care addressing pressure sore prevention; implement relevant and individualized interventions in order to promote healing and failed to identify R4 ' s pressure ulcer Stage correctly. This applies to two of four residents (R4 and R7) in the sample of 24 residents reviewed for pressure sores. These failures contributed to the development of R4's avoidable, unstageable pressure ulcer on the right lateral ankle (malleolus). The findings include: 1. On 11-06-13 at 11:50 AM, R4 was in the dining room sitting in a wheelchair with off-loading device (bunny boot) on the left foot. None was noted on the right foot. On 11-06-13 at 11:50 AM, E15 (Certified Nursing Assistant) said R4 needs extensive assistance from staff in all of her activities of daily living. She needs (R4) a sit to stand transfer. She does not walk anymore. She usually gets up at 7:15AM and goes back to bed after lunch around 1:30 PM. She cannot reposition herself. On 11-07-13 at 11:25 AM, the Treatment Nurse/E3 stated R4 used to walk, then she had a fall on 09-07-13. Her legs become swollen and unable to walk after that. It was on 10-07-13 when they initially found the pressure ulcer on her right lateral ankle. It was a 95% blackened area when found. It was already necrotic. It was due to pressure and immobility. R4 is confused and needs total assistance with her activities of daily living and in turning and repositioning. " R4's wound care specialist initial evaluation dated 10-11-13, under additional information (page 2 of 2) reads: per nursing staff, patient(R4) fell and had ankle pain but no fracture on x-ray since then patient has been in bed more ... R4 ' s (initial) wound-weekly observation tool dated 10-08-13 showed: Instructions: Use the following definitions for staging of pressure ulcers: Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable - A full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. (B) Observation/Data: (1) Location Right lateral ankle (2 b) Date acquired- 10-08-13 (3 a) Type- Pressure (4) Pressure ulcer stage: (4 a) Original -Suspected Deep Tissue Injury (SDTI) (4 b) Current- Suspected Deep Tissue Injury. (5) Visible Tissue: (5 e) Necrotic tissue present (brown, black, leathery, scab-like) (5 i) 100% necrotic tissue. (8) Wound Measurements 0.6 cm X 0.8 cm. The facility identified R4's pressure ulcer as "SDTI" (wound weekly observation tool page 2 of;section 4 (4a) (4b). Based on this assessment tool R4 pressure ulcer should be staged as unstageable not Suspected Deep Tissue Injury. The wound assessment flow sheet showed on 10-18-13, R4's pressure ulcer was measured at 1.0 cm X 1.0 cm and described with 75%- black necrotic and with 25% slough - identified as Stage IV. This documentation also showed a treatment order for [MEDICATION NAME] with foam dressing since 10-14-15 up to the present. On 11-07-13 at 2:25 PM, during treatment observation E3 identified and described R4's wound as located on the right lateral ankle (malleolus), acquired in the facility, covered with yellow slough of around 90%, Stage IV and the measurements are 0.6 cm X 0.8 cm. " According to National Pressure Ulcer Advisory Panel (NPUAP) and the Wound, Ostomy and Continence Nursing Society R4's pressure ulcer is "unstageable." The NPUAP Pressure Ulcer Stages/categories define unstageable pressure ulcers as full thickness tissue loss in which actual depth of the ulcer is completely obscure by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The Wound, Ostomy and Continence Nursing Society define Unstageable as Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 11-07-13 at 12:00 PM, E3 presented R4's most current Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE]. This assessment showed a score of 18 (mild risk per Braden score scale). E3 stated there was no preventative skin plan of care. E3 claimed, R4 is s not high risk for pressure ulcers and that ' s why there's no care plan developed. R4's care plan interventions dated 10-08-13 was not individualized based on the identified problem and needs of R4 and there was no revision done. The following are the interventions listed: The resident requires the bed as flat as possible to reduce shear ...Assess/record/monitor wound healing ...Avoid positioning the resident on right ankle, right side. Cleanse ...wound with NSS and apply foam dressing ...educate resident ...as to cause of skin breakdown ... and Follow facility policies/protocols for the prevention/treatment ... On 11-07-13 at 1:00 PM, E3 was unable to provide documentation the facility analyzed R4 ' s risk factors for the development of pressure ulcers. E3 said they use the Braden Scale for Predicting Pressure Sore Risk Assessment. The weekly wound assessment flow sheet- where measurements are written, the weekly observation tool, the treatment administration record and the care plan and the doctor's notes are the only documentation. 2. On 11/05/2013 at 12:12 pm E14 (Certified Nurse Aide) provided incontinence care for R7. There was a dressing on R7's sacral area. E14 stated it was applied that morning. E14 also stated R7 had diarrhea last week and that is why she needed a dressing on her sacrum. On 11/07/2013 at 10:00 am E3(Treatment Nurse) stated R7 has redness on her bottom with a dressing covering it. On 11/07/2013 at 1:48 pm E3 did dressing change on R7's sacrum. E3 stated R7 developed excoriation on 11/05/2013, and also had flu last week. There was no dressing on R7's sacrum when the adult incontinence briefs were removed. E3 measured R7's sore on her sacrum and described area as 2.2 cm x 1.1 cm, stage 3 as granulation tissue is yellow and 40% non-viable tissue and it is a pressure sore. On 11/07/2013 at 2:10 pm E3 stated wound doctor was phoned and received an order for [REDACTED]. R7's Braden Scale for predicting Pressure Sore Risk dated 08/30/2013 shows score of '11.' R7's Progress Note dated 11/05/2013 16:00 hours showed "Resident noted with redness to sacrum with excoriation to area present, resident is up for meals only and to be repositioned every 2 hours by staff. Will continue daily skin assessment to area and treat every shift. To apply Moisture Barrier Cream after each incontinent episode at this time." The facility did not conduct an evaluation of R7's tissue tolerance to determine an individualized repositioning schedule. The facility also did not conduct a comprehensive evaluation of R7's pressure sore risk factors to show if R7's pressure sore was unavoidable. There was no nursing plan of care for R7's pressure ulcer.

Based on observation, record review and interview the facility failed to: - Have an effective system to conduct a comprehensive assessment that included analysis of pressure sore risk factors, comorbidity and to determine why residents are at risk for acquiring pressure sores; - Develop and implement individualized and specific interventions for the prevention of the pressure sores; - Provide treatment and services including providing pressure sore treatment as ordered by the physician, turning and repositioning and providing incontinence care. As a result of these failures: (1) R1 acquired on 3/21/11 an unstageable pressure sore to her Coccyx. On 5/10/11 underwent surgical debridement of Eschar and Slough and the pressure sore to be a Stage IV (Length 3.8 cm x Width 2.2 cm x 2.8 cm depth) (2) R2 on 4/30/11 acquired a Stage II pressure sore on her Sacrum. On 7/1/11 the sore measured 1.0 cm length x 1.0 cm width x 0.2 cm depth. This is for two of two residents (R1 and R2) in the sample who have developed pressure sores in the facility. R1 was admitted to the facility on [DATE]; and R2 was admitted to the facility on [DATE]. These residents did not have a pressure sore upon their admission to the facility. Findings include: 1. On 6/30/11 at 11:00 am R1 was in her bed lying on her left side, she was alert, pleasant but confused. R1 had low air loss mattress on her bed. There was sheet on the mattress and there were layers of absorbent pads under R1's bottom and she had a diaper on. There was wound vacuum (WV) on her bed that was connected to her pressure sore on her Coccyx. The WV was set at a negative pressure of 80. R1 was slow in response, confused and disoriented, unable to express her needs and dependent on staff for her activities of daily living including turning and repositioning On 6/30/11, E2 the Director of Nurses presented a list of residents that have pressure sores according to Wound Assessment Flow Sheet. The list indicated R1 acquired an unable to stage pressure sore (1 cm x 1.1 cm x 1 cm). As of 4/23/11 this sore measured 4.0 cm x 4.0 cm x 2.0 cm with a 12 O' clock 1.1 cm undermining, remained at unable to stage and serosanguineous drainage noticed from the center of the sore. On 4/30/11 large amount of foul smelling serosanguineous drainage noticed. On 5/10/11 R1 underwent surgical debridement to remove slough and eschar tissue at the hospital. On 5/10/11 hospital pressure sore surgical intervention report noted a moderate amount of drainage and eschar and slough tissue was removed. The sore was a Stage IV and measured Length 3.8 cm x Width 2.2 cm x 2.8 cm depth. R1 has a Braden Scale for Predicting Pressure Sore Risk that was done on 3/12/11 and 6/2/11. On both dates scored '13' which determined R1 to be at moderate risk for acquiring pressure sore. The Braden Scale risk factors included sensory perception, moisture, activity, mobility, nutrition, friction and shear. The facility did not analyze these risk factors to determine if the these risk factors could be modified or not. There was no base line assessment guiding the development and implementation of individualized interventions for the prevention of the development of pressure sores. The facility Policy and Procedure for pressure sore assessment and management also did not include to conduct a comprehensive assessment based on the risk factors identified in the Braden Scale. After R1 acquired an unstageable pressure sore on 3/21/11 in the facility, the facility did not conduct any comprehensive assessment to determine why she developed an unstageable pressure sore, or if the pressure could be prevented. Again there was no assessment that guided the development and implementation of the interventions. R1's 9/29/10 admission Minimum Data Set (MDS) triggered problems included pressure sores. The Resident Assessment Protocol (RAP) summary or the assessment is not comprehensive to show why she is at risk for the development of pressure sore. The summary simply noted the risk factors. R1's 6/7/11 MDS also triggered for pressure problem and indicated she has a Stage IV pressure sore. No Care Assessment Areas (CAA) for pressure sore was developed. R1's 3/21/11 plan of care interventions for pressure ulcer prevention treatment are not individualized. For example: One of the intervention noted in the care plan 'turn and position her per physician order.' There is no physician order for [REDACTED]. On 6/30/11 evening shift lead CNA (E5) stated R1 needs to be repositioned every two hours. On 7/1/11 day shift CNA (E6) did not reposition R1 for over two hours (from 10:30 am to 12:40 pm). At noon the surveyor entered to see if R1 was turned at this time E6 was in the room and was about to leave. When questioned if she turned R1, E6 said 'yes'. The surveyor reminded R1 was on her left side at 10:30 am and she is still on her left side. E6 said she was going to get help to turn her. R1 was not turned until 12:40 pm when she was up for noon meal. On 6/15/11 CNA guide had a plan of care for R1's pressure sore prevention. This guide indicated to turn and reposition at least every two hours. Another intervention noted in 3/21/11 care plan was 'instruct the resident to notify the nurse whenever there is pain at the wound site.' R1 is confused and disoriented and unable to express her needs. One of the risk factors identified in R1's Braden Scale is 'shearing.' R1's 6/15/11 CNA guide care plan intervention noted R1 has a low air loss mattress and do not put draw sheet under R1, except when turning, other wise it will defeat the purpose of having low air loss mattress. This intervention was not implemented on both days of the survey (6/30/11 and 7/1/11). There was a sheet on the mattress and three layers of Chux under R1 which could cause shearing. On 7/1/11, E7 lead CNA day shift and E2 stated the CNAs are not supposed to place any layers under R1 when she is in low air loss mattress. On 7/1/11 E8, the pressure ulcer treatment nurse stated she does not develop the care plans for the pressure ulcer, she does the treatments. The MDS and Care Plan coordinator develops the care plans. When asked how the pressure sore care plans are coordinated if pressure ulcer treatment nurse is not developing the care plan. E2, stated the previous pressure ulcer treatment nurse left the job in 3rd week of April 2011 and new treatment started in 2nd week of May 2011. E2 also stated their Assistant Director of Nurses, who does MDS and care plans, filled in to do treatments and she is also skilled in providing pressure ulcers treatments. The facility failed to conduct a comprehensive pressure ulcer assessment; develop and implement individualized pressure ulcer prevention interventions. R1's Stage IV pressure sore on her Coccyx could have been prevented, 2. On 6/30/11 from 11:40 am to 11:55 am E3 (CNA) provided incontinence of bowel and bladder care for R2. R2 had absorbent dressing on her Sacrum pressure sore. The dressing had no date on it. E3 wiped R2's once with incontinent wipe, then with another wipe wiped stool. In the process E3's gloves got soiled with stool. With soiled glove hand she put a clean diaper, touched the clean linen and R2's clothing. Through out the procedure E3 did not change gloves or washed her hands. On 7/1/11 at 10:45 am E8 provided pressure sore treatment for [REDACTED]. E8 cleaned stool and urine. E8 the opened pressure sore dressing on Sacrum. The dressing had no date on it to indicate when the dressing was changed. E8 cleaned the site with Normal Saline Solution, applied a wound gel and covered with an absorbent dressing. R2's 6/1/11 physician order for [REDACTED]. E8 stated, [MEDICATION NAME] dressing was not available. R2 is receiving Hospice care and Hospice is supposed to supply the treatment supplies. Therefore she is using an absorbent dressing that was available in the facility. On 7/1/11 Hospice Nurse (Z1) stated the treatment supplies are on back order. R2 has been receiving services since December 2010, and hoping to receive the supplies soon. E2, on 7/1/11 stated the physician empowers the treatment nurse which supplies to use for the treatment is the prescribed treatment is not available, but there is no physician to authorize the change in treatment. R2's weekly wound assessment flow sheet indicated she acquired a Stage II (1 cm x 1 cm x 0.1 cm) pressure sore on her Sacrum 4/30/11. As of 7/1/11 the sore remained at Stage II and measured 1 cm x 1 cm x 0.2 cm even after two months. R2 has Braden Scale done on 11/1/10 (score 14), 11/27/10 (score 13), 2/8/11 (score 12) and 3/11/11 (score 9). A score of 13-14 is moderate risk; score of 10-12 high risk. The risk factors included: sensory perception, moisture, activity, mobility, nutrition and friction. The facility did not analyze these risk factors to determine if the these risk factors could be modified or not. There was no base line assessment guiding the development and implementation of individualized interventions for the prevention of the development of pressure sores. No care plan for the treatment of [REDACTED]. R2's pressure sore care plan interventions are not individualized. For Example: One of the interventions noted 'turn and position the resident per physician orders.' Where as there is no physician order for [REDACTED]. The facility failed to conduct a comprehensive pressure ulcer assessment; develop and implement individualized pressure ulcer prevention interventions. R2's Stage II pressure sore on her Sacrum could have been prevented.