Every finding on record at Hillside Rehab & Care Center

Based on interview and record review, the facility failed to provide and maintain an appropriate size wheelchair for resident's body habitus and condition.This failure resulted in R1 sustaining a 5.5cm (centimeter) by 7cm skin tear to her right lower abdomen during transfer/repositioning that required closure with 9 sutures/stitches in Emergency Department.This applies to 1 resident (R1) reviewed for accidents in a sample of 4.The findings include:R1's Face sheet shows the following diagnoses: congestive heart failure, morbid severe obesity, type 2 diabetes mellitus, edema, pressure ulcer of right buttock and pressure ulcer of sacral region. R1's MDS (Minimum Data Set) dated 7/23/26 shows her cognition is intact.R1's progress note dated 7/23/26 at 1:53 PM by V6 (RN) states resident was being transferred from bed to her motorized chair when her right flank got caught against the chair armrest resulting in a 5.5cm x 7.0cm skin tear. R1's progress note dated 7/24/26 at 5:56 AM by V8 (Nurse) states resident returned from hospital via ambulance noted 9 stitches to her right lower abdomen. Follow up with primary care physician in 8 to 9 days for suture removal.The facility's submitted Long Term Care Facility & IID- Serious Injury Incident and Communicable Disease Report dated 7/28/26 at 5:30 PM states R1 reported feeling crooked in her wheelchair, leaning to the right side. Shortly after V3 (DOR/Director of Rehab), V4 (OT/Occupational Therapist), and V5 (CNA/Certified Nurse Assistant) repositioned R1 to her midline position, R1 was observed to be bleeding from right side of her abdomen. V6 (RN/Registered Nurse) was notified of R1's wound and applied steri-strips and dressing. R1 with known history of swelling and edema. R1 sent to ED (Emergency Department) and returned the next morning with 9 stitches. Upon final investigation, it was determined that resident's skin tore when brushed against wheelchair armrest. Wheelchair was deemed not appropriate in sizing any longer.On 8/19/26 at 11:02 AM R1 said on 7/23/26, the staff were transferring her into her rental power wheelchair so she could practice using it. R1 said after the transfer, V4 (OT) said you're bleeding and R1 responded, that's not funny. R1 said then she had to go to the hospital and get 9 stitches on her right side.On 8/19/26 at 12:02 PM, V3 (DOR) said R1 was measured for power wheelchair on 5/22/26, the chair was delivered and trialed on 6/23/26 and the skin tear occurred on 7/23/26. V3 said R1 has a lot of lymphedema (swelling from fluid) around her abdomen. V3 said on 7/23/26, after transferring and repositioning R1 in the power wheelchair, she noticed R1's shirt and mechanical lift sling were wet. V3 said she then lifted R1's shirt and saw the skin tear-an oozing half-moon shaped skin flap. V3 said 7/23/26 was the first day R1 had gotten up into the power chair since it was delivered and trialed a month earlier on 6/23/26. V3 said while up in the chair, R1 had a bulge of skin sticking out under the arm rest, where the fluid was leaking from and the skin tear must have occurred from friction with the arm rest.On 8/19/26 at 1:15PM, V5 (CNA) said on 7/23/26, after they had repositioned R1 in the power wheelchair, she saw the mechanical lift sling was soiled with blood and that was when she noticed R1's skin tear. V5 (CNA) said R1 had a roll/bulge of skin hanging out under the power wheelchair armrest.On 8/19/26 at 1:31 PM V6 (RN) said V3 (DOR) came to get him on 7/23/26 and told him R1 had a skin tear. V6 said when he got to R1's room, he had to lift the power wheelchair armrest to get a better look at R1's skin tear and dress the wound. V6 said R1's body was pressed up against the power wheelchair armrests, and he thinks that is how R1 sustained the skin tear. V6 said part of R1's abdomen was hanging below the armrests, and part of her abdomen was pressing against the sides of the armrests. V6 said R1's power wheelchair didn't fit her and was not wide enough.On 8/19/26 at 3:14PM, V2 (DON/Director of Nursing) said if a wheelchair fits appropriately, the resident's skin folds should not be hanging over the sides of the chair. V2's statement written after R1's skin tear incident occurred states, wheelchair was too small.On 8/19/26 at 3:23 PM, V1 (Administrator) said her investigation concluded that R1's abdominal fold rubbed against the power wheelchair armrest causing the skin tear. V1 said if a wheelchair fits a resident appropriately, the skin folds should not be hanging over the sides of the chair. V1 said she thinks R1's wheelchair fit her when it was delivered and trialed on 6/23/26, but did not fit her correctly on 7/23/26 when she sustained the skin tear.R1's Care Plan initiated on 7/24/26 states R1 is at risk for skin breakdown related to fragile skin. Interventions include resident went to the ER where they had to stitch her skin tear with 9 stitches and therapy to reevaluate for a proper sized motorized wheelchair.The facility's policy titled, Assistive Devices last revised May 2023 states, Policy: Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents. Procedure: 1. Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to: a. wheelchairs (manual and powered).5. The following factors will be addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment. a. Appropriateness for resident condition-.b. Personal fit-.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene during provisions of incontinence care and medication administration. The facility failed to ensure that staff wear complete PPE (Personal Protective Equipment) during care for a resident on EBP (Enhance Barrier Precaution). The facility also failed to ensure that soiled linens are in a linen bag while being transported to the soiled utility room, and a CPAP (Continuous Positive Airway Pressure) machine is stored in a hygienic way. This applies to 10 of 21 residents (R4, R13, R18, R20, R22, R23, R26, R36, R48, R62) reviewed for infection control in the sample of 21. The findings include: 1. On May 05, 2026, from 8:39 AM through 9:53 AM, V4 administered medications to different residents (R18, R23, R26, R62). These residents have different routes such as oral (R18, R23, R26), inhalers and eye drops (R18), and gastrostomy tube (R62). At 8:39 AM, V4 was observed preparing R23's medications. V4 wore a set of gloves, touched different surfaces, opened medication cart drawers, checked R23's vital signs, touched some of the medications with his gloved hands while placing them in a cup, and then he administered those medications to R23. After R23's medication administration, V4 removed his gloves, donned another set of gloves without hand hygiene and prepared the medications for R26. V4 again performed different tasks and administered medications while wearing the same soiled gloves and without performing hand hygiene in between tasks and residents. V4 continued to repeat this same cycle with R18, and R62. Facility's Undated Policy and Procedure for Medication Administration show: Preparation: Hand Washing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after ophthalmic, topical vaginal, rectal, and parenteral preparations and medication via enteral tubes. 2. On May 5, 2026, at 10:32 AM, there was an EBP (Enhance Barrier Precaution) signage posted outside R48's bedroom. According to V15 (Nurse), R48 has an arterial wound to left foot, hence the EBP. On May 5, 2026, at 11:48 AM, V11 and V12 (Both Certified Nursing Assistants/CNA) rendered incontinent care to R48 who was wet with urine and had a bowel movement. V12 wiped R48 from front to back of his perineum with a wet towel, then she applied barrier cream to the peri-area, put on a new incontinence brief, and pulled his pants back in place, while wearing the same soiled gloves all throughout the care. V11 and V12 also did not wear a gown during the provision of incontinence care. On May 6, 2026, at 11:55 AM, V2 (Director of Nursing/DON) stated staff must perform hand hygiene prior to providing care and prior to putting on gloves, they must do hand hygiene from dirty to clean tasks, in between residents, and after removal of gloves. This is a standard of care to prevent infection. If a resident is on EBP and the staff is directly providing care to this resident, the staff should wear complete PPE such as a gown and gloves. The staff should also wear masks and face shields when appropriate. R48's Enhance Barrier Precaution (Signage Posting) showed: Providers and staff must wear gloves and a gown for the following activities: Changing briefs or assisting with toileting. 3. R13's EMR (Electronic Medical Record) showed R13 was admitted to the facility on [DATE], with multiple diagnoses including dependence on dialysis, end stage renal disease, chronic kidney disease, depression, obesity, cerebellar infraction, hypertension, and peripheral vascular disease. R13's MDS (Minimum Data Sheet) dated February 16, 2026, showed R13 was severely cognitively impaired and needed setup/clean-up assistance with eating, supervision/touching assistance with oral and personal hygiene, and substantial/maximal assistance with bathing, dressing, mobility, and transfers. R13's Physician Order Report showed R13 had a current order dated March 20, 2026, for EBP (Enhanced Barrier Precautions). On May 5, 2026, at 9:30 AM, there was an EBP sign outside R13's room and a 3-drawer cart with PPE (Personal Protective Equipment). V6 (Certified Nursing Assistant, CNA) put on a mask and a gown. V6 pulled a pair of gloves from her pants pocket and wore those gloves. V6 walked into R13's room with her gloved hands and pulled the privacy curtain with the gloved hands. V6 opened R13's closet by touching the closet handle with her gloved hands and removed clothes that R13 was going to wear to her appointment later this morning. V6 pulled out a shirt, pants, and a pair of non-skid socks. V6 went into R13's bathroom and opened the bathroom door by touching the door handle with her gloved hand. In the bathroom, V6 filled a basin with soap and water and put washcloths into this basin. V6 came back to R13 and with the same gloved hands, V6 touched a washcloth that was in the basin and handed it to R13. R13 wiped her face with this washcloth. V6 with her gloved hands took the same washcloth that R13 had just used to wipe her face and V6 wiped R13's eyes with it. V6 placed this soiled washcloth on the seat of R13's wheelchair that was in the room. V6 helped R13 take off her shirt. V6 took another washcloth from the basin and wiped the front of R13's body. V6 placed this soiled washcloth on the seat of R13's wheelchair. V6 used a dry washcloth to dry the front of R13's body. V6 used the same gloved hand to touch R13's spray deodorant bottle and sprayed the deodorant into R13's underarms. V6 used the same gloved hands to put a shirt on R13. V6 touched the remote control of the bed and raised the bed. V6 undid R13's incontinence brief and tucked it under R13, and this brief had visible brown substance in it. With the same gloved hands, V6 pulled out another washcloth from the basin. V6 used this washcloth to wipe R13's perineal area and put this soiled washcloth on the seat of R13's wheelchair. V6 got another washcloth from the basin and wiped under R13's abdomen. V6 asked R13 to roll to R13's right side and V6 rolled the soiled incontinence brief and the incontinence pad under R13. V6 took another washcloth from the basin and wiped R13's back and placed the soiled washcloth on the seat of R13's wheelchair. V6 took another washcloth from the basin and wiped R13's buttocks front to back to remove the brown substance. V6 took the soiled incontinence brief and placed it on the incontinence pad and placed a new incontinence brief under R13. V6 used the same gloved hands to get a white bottle with white powder and put some of that into R13's new incontinence brief. V6 stated this was a cornstarch-based powder that she puts in R13's briefs. V6 asked R13 to reposition onto her back. V6 took off her gloves and threw that into the garbage can. V6 pulled out another pair of gloves from her pants pocket and wore these gloves. V6 did not perform any hand hygiene before putting on these new pair of gloves. With these new gloves, V6 took the soiled incontinence brief and put that in the garbage can and then took the used incontinence pad that was on the bed and put it on the seat of R13's wheelchair. V6 put on the tabs of the new incontinence brief. With the same gloved hands, V6 put on R13's pants and non-skid socks. V6 then touched the remote control of the bed and lowered R13's bed. V6 took the plastic bag with the soiled incontinence brief from the garbage can and placed it on the floor. V6 placed a new plastic bag in the garbage can. V6 took R13's shirt she had worn and opened R13's closet with her gloved hand and put the shirt where the rest of R13's laundry was. V6 took another plastic bag and put the soiled washcloths and incontinence pad from the wheelchair and placed this bag on the floor too. V6 did not wipe R13's wheelchair. R13 stated she does use her wheelchair when she goes to therapy. V6 took off her gown and gloves and put that into the bag with the soiled incontinence brief. On May 6, 2026, at 9:41 AM, V2 (Director of Nursing, DON) stated her expectation is for her nursing staff to remove gloves from the box and not from their pockets. V2 stated she expects the CNA to change her gloves after getting all her supplies ready before starting resident care. V2 stated this CNA should have changed her gloves and performed hand hygiene before touching resident items and new clothes. V2 also stated she expects the nursing staff to perform hand hygiene before putting on gloves and performing hand hygiene after removing gloves. V2 stated the soiled washcloths and incontinence briefs should not be placed on a resident's wheelchair. V2 continued to say the CNA should have brought the hamper and placed it outside the resident's room and put the washcloths and incontinence pad in there or she should have had another basin to put the soiled items in. V2 also stated this CNA should not have put any soiled washcloths on the wheelchair but in this case, the CNA should have sanitized the wheelchair. V2 stated that no plastic bags with soiled items should be placed on the floor. 4. R4 is a [AGE] year-old male with a diagnoses history of vascular dementia, obstructive sleep apnea (breathing disruptions during sleep), heart failure, partial paralysis following a stroke, endocarditis (bacterial related heart inflammation), atherosclerotic heart disease with angina (chest pain), atrial fibrillation (irregular heart rhythm), bacterial enzyme resistance to antibiotics, and a history of urinary tract and other skin infections who was admitted to the facility January 30, 2024. On May 04, 2026, at 11:15 AM, R4's CPAP (continuous positive airway pressure) machine was sitting on his nightstand with the mask uncovered and unlabeled lying against the base of the machine and there was visible dust on the machine base. R4 said he uses his CPAP machine every night. On May 05, 2026, at 9:40 AM, R4's CPAP machine was sitting on his nightstand with the mask uncovered and unlabeled lying against the base of the machine and there was visible dust present on the machine base. R4 said he used his CPAP machine last night and uses it every night because he has sleep apnea and requires it for breathing and can't live without it. R4's current physician orders show an active order effective October 25, 2024, for using a CPAP machine nightly for obstructive sleep apnea. On May 06, 2026, at 1:05 PM, V2 (Director of Nursing) said when a CPAP machine is not in use, it should be clean, dry, bagged, and labeled with the resident's name to prevent respiratory infection and for infection control. The facility's Respiratory Tubing policy received 05/06/2026 shows: Tubing is placed in the container when not in use. 5. R22 was admitted to the facility on [DATE]. R22 has multiple diagnoses including paraplegia, chronic embolism and thrombosis, depression, dysfunction of the bladder, irritable bowel syndrome, constipation, major depressive disorder with psychotic symptoms, urinary tract infection, rash, chronic pain syndrome, muscle weakness, and lack of coordination. R22's MDS dated [DATE], showed R22 was cognitively intact and requires maximal assistance from staff for hygiene, toileting, and dressing. R22 was totally dependent on staff for showers. On May 05, 2026, at 10:11 AM, R22 received incontinence and perineal care from V11 (CNA) and V12 (CNA). V11 and V12 applied gloves while entering R22's room without performing hand hygiene. V12 gathered all materials and removed the soiled incontinence product and linens from R22. V12 cleansed R22's perineal area, applied a new incontinence product, and assisted R22 with her clothing, while wearing the same soiled gloves. V11 placed soiled linens into a plastic bag and with the same soiled gloved hands, touched resident's personal items and continued to adjust V11's glasses on their face. V11 and V12 did not perform hand hygiene or change gloves after removing soiled incontinence products and bagging up soiled linens. V11 and V12 with same soiled gloves entered the soiled utility room to empty trash and place soiled linens into laundry bags. V11 and V12 removed gloves and took the laundry bags containing soiled linens outside to the shed to be picked up by an outside company. V11 and V12 did not perform hand hygiene after incontinence care with R22. 6. R36 was admitted to the facility on [DATE]. R36 has multiple diagnoses including acute embolism and thrombosis, anemia, hypertension, hypo-osmolality, hyponatremia, anxiety, insomnia, chronic pain, skin breakdown, and osteoporosis. R36's MDS dated [DATE], showed R36 has moderate cognitive impairment and requires maximal assistance from staff for toileting, personal hygiene, dressing and transfers. On March 04, 2026, at 10:30 AM, V11 provided incontinence care for R36. V11 placed linens and incontinent products that were saturated in urine into a plastic bag. With the same soiled gloves on V11 touched R36's personal items on the bedside tray and placed R36's call button along the wall next to the bed. With the same soiled gloves, V11 continued to readjust the glasses on their face several times. V11 removed the soiled linen and trash from R36's room and placed them in the soiled utility closet. V11 threw the gloves in the trash but did not perform hand hygiene after care. 7. R20 was admitted to facility on October 22, 2025, with multiple diagnoses including chronic obstructive pulmonary disease, cerebral infarction, asthma, atrial fibrillation, cardiomyopathy, cardiac defibrillator, hypertension, low back pain, lymphedema, sciatica, anxiety, rheumatoid arthritis, visual hallucinations, osteoarthritis, constipation, and morbid obesity. R20's MDS dated [DATE], showed. R20 has severe cognitive impairment. R20 utilizes a wheelchair for mobility and is dependent on staff for toileting, bathing, dressing, transfers and personal hygiene. On May 05, 2026, at 10:47 AM, V10 (CNA) exited R20's room with unbagged soiled linen in her hands following incontinence care. R20 took the linen into the soiled utility room across the hall. On May 06, 2026, at 10:36 AM, V11 said that hand hygiene should be performed before care after care and in between providing care to different patients. V11 said that hands should be washed for a minimum of twenty seconds, and hand sanitizer may be utilized as well. On May 06, 2026, at 10:45 AM, V2 (DON), said that staff are expected to wash their hands for twenty seconds before going into residents' rooms. They may also use sanitizing material before and after resident care. The staff are also expected to perform hand hygiene whenever they put their gloves on or take them off. On May 06, 2026, at 12:08 PM, V1 (Administrator), said that dirty linen should be placed into a plastic bag and taken directly to the soiled utility room. Linen should be carried away from clothing. The facility's Infection Prevention and Control Programs Policies and Procedures- Hand Hygiene General Statement showed good hand hygiene is a requirement of standard precautions. Wash or sanitize hands before and after each care contact for which hand hygiene is indicated by acceptable professional practice, utilizing designated time frames, and products. Hands should be washed with soap and water when they are visibly soiled, or if they have come in contact with blood or other body fluids, before or after eating or handling food, and times specified by other applicable regulations. The facility's policy titled, Infection Control, dated July 2017, showed under Procedure, that staff will use proper glove and hand washing technique and use proper linen handling technique. The facility's policy titled, Giving a Bed bath, dated July 2014, showed under Steps in the Procedure for Perineum, the staff are to remove gloves and discard in the designated container. The facility's Linen Handling Policy showed it is the policy that linen will be handled in a manner to prevent infection and spread of disease. Procedure: 3. Removing Soiled Linen: a. using gloved hand, place all soiled linen in a plastic bag. k. Place bagged linen in the soiled linen barrel. m. Wash hands.

Based on observation, interview and record review, the facility failed to implement physician orders for IV PICC (intravenous peripherally inserted central catheter) line dressing change as needed, failed to have a care plan in place for management of care of IV site in order to prevent infection. This applies to 1 of 2 residents (R40) reviewed for IV therapy in the sample of 21. The findings include:R40's face sheet showed that R40 was admitted on [DATE], with multiple diagnoses including non-pressure chronic ulcer of right heel and midfoot with unspecified severity, pressure ulcer of unspecified site, urinary tract infection, pain, type 2 diabetes mellitus with foot ulcer, neuropathy. R40's admission MDS (minimum data set) dated February 18, 2026, showed that R40 was cognitively intact. R40's POS (Physician Order Summary) showed that R40 was initially (start date April 18, 2026) on IV antibiotic vancomycin in 0.9 sodium chloride solution; 1.5 gram/250 ml (milliliter) every 12 hours (8:00AM, 8:00PM) related to diagnosis of non-pressure chronic ulcer of right heel and midfoot with unspecified severity. R40's P0S showed that the order was on hold from April 21, 2026-April 23,2026. Vancomycin in 0.9 sodium chloride solution piggyback 1 gram/200 ml was resumed on April 23, 2026, every 12 hours (8:00AM, 8:00PM), and was again placed on hold from April 29, 2026-April 30, 2026. R40's POS showed that on May 1, 2026, vancomycin in 0.9 sodium chloride solution; 1.5 gram/250 ml was resumed. The same POS showed that on May 4, 2026, the pharmacy filled this order with a different (non-equivalent) drug to Tyzavan intravenous piggyback 1.5 gram/300ml once a day (start time 10:00AM, end time 12:00AM). On May 4, 2026, at 11:27 AM, R40 stated I am taking antibiotic by IV every day for infection for my right foot. I have a wound. I have had it over a year. R40 had a PICC line covered by a transparent dressing on R40's left arm that was not dated but showed faded illegible initials where the frayed edges were peeling off. The IV site was covered by a circular disc and the transparent dressing that taped was over it was noted curling at the edges. R40 stated that the transparent dressing is changed every 7 days, and it was last changed on April 25, 2026. R40 remarked It had a date on the edge, but it came off. It (the dressing) needs to be changed. A red sign was posted on R40's bedside wall showed PICC LINE left arm. Arm circumference 39 cm (centimeters). Date April 18, 2026, 1540 (3:40 PM). R40 stated that the IV antibiotics were started on that date originally. On May 4, 2026, at 12:11 PM, on inquiry when the dressing was changed, V5 (Registered Nurse) stated It is the PM nurse that changes the dressing, but I cannot tell you when she last changed it. V4 stated that the circular covering is a bio patch. When V5 was shown that edges of transparent dressing that were peeling off, R40 stated It needs to be changed.Ancillary orders on POS (start date April 18, 2026) included IV PICC line: change dressing and caps per sterile technique weekly once a day on Saturday; (2:00PM-10:00PM) and prn (as needed).MAR (medication administration records) for dates from April 18, 2026-April 5, 2026, showed that IV PICC line dressing and caps were changed on April 18, 2026, April 25, 2026, and May 2, 2026. The same MAR had no notations for measurement of arm circumference. Facility did not have a care plan in place for IV antibiotics. On May 6, 2026, at 1:57 PM, V8 (MDS Coordinator) stated that he did not put a care plan for R40's antibiotics as he assumed that it was discontinued. V8 stated that R40's Vancomycin was adjusted multiple times based on lab results and he thought that it was discontinued on May 1, 2026. V8 added that the facility template care plan for antibiotics does not include details about dressing change and measurement of arm circumference. On May 5, 2026, at 2:42 PM, V7 (Registered Nurse) stated that she did the dressing change on IV site on April 25, 2026, and she used a kit that included tools, dressing and bio patch for the same. V7 showed the kit that included a measuring tape. V7 stated that she believes she did not use the measuring tape and/or measure the arm circumference to ensure that there is no swelling.V1 (Administrator) stated that based on initials on MAR, an agency nurse had changed the IV PICC line dressing on May 2, 2026, and she is not sure that she would be able to reach the nurse. On May 5, 2026, at 10:44 PM and 2:42 PM, V2 (Director of Nursing) stated that she is new to the facility and is not sure if they have a policy with regard to measurement of arm circumference. V2 stated that the nurses should be doing measurement of the arm circumference so that it (tip of IV site) is not migrating.Facility (undated) policy titled 'IV Therapy' included:Central Lines: A. PICC Line 3. Care of Line-24-hour post insertion dressing change then every 7 days if transparent dressing. Requires sterile dressing change Instructions for Peripheral Venipuncture procedure' included 23. Apply a transparent dressing directly over the insertion site. 25. Label with type of devise, gauge and length of devise, date time and nurses' initials.

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident assessed to need assistance with all activities of daily living care needs had access to their call light to call for assistance. This applies to 1 of 3 residents (R4) reviewed for accommodation of needs in the sample of 21. The findings include:R4 is a [AGE] year-old with a diagnoses history of vascular dementia, heart failure, and partial paralysis following a stroke who was admitted to the facility January 30, 2024. On May 04, 2026 at 11:15 AM, R4 said he needed to go to the bathroom. R4 said he doesn't know where his call light is. R4's call light was sitting on the floor behind his bed wrapped around the frame. On May 04, 2026 at 11:34 AM, R4's call light remained on the floor behind his bed wrapped around the frame. R4 said he really needed to go to the bathroom. On May 05, 2026 at 9:40 AM, R4 said he needed to use the bathroom, he would use his call light to ask for assistance but he can't find it. R4's call light was sitting on the floor behind his bed wrapped around the frame. R4's current care plan shows he is usually able to make his needs known and understands when spoken to and requires a mechanical lift with two-person assistance for transfers. On May 05, 2026 at 1:05 PM, V2 (Director of Nursing) said R4's call light should be accessible at all times because he can't get out of bed on his own, he is bed bound, and requires assistance from staff with all areas of care. The facility did not provide a policy regarding call light accessibility as requested on May 06, 2026 at 1:15 PM

Based on observation, interview, and record review, the facility failed to ensure that an adaptive device was in place according the physician order. This applies to 1 of 2 residents (R33) observed for range of motion in the sample of 21.The findings include:R33's electronic medical record (EMR) shows R33 has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R33's Physician Order Summary (POS) dated April 30, 2026, shows to apply a splint (carrot) to the left hand (orthosis) in affected extremities daily as tolerated. R33's Minimum Data Sheet (MDS) dated [DATE], showed R33 is alert and oriented. On May 4, 2026, at 10:45 AM, during facility's unit rounds with V13 (Certified Nursing Assistant/CNA), R33 was observed resting in bed. V13 said that R33 is alert and oriented and totally dependent on activities of daily living (ADL) care. R33's left arm and hand were noted with limited movement. R3's left hand and fingers were very stiff. There was no splint in place. At 1:30 PM, R33 remained in bed, there was no splint on his left hand. R33 stated he doesn't know where his splint is. On May 5 and May 6, 2026, R33 was observed multiple times without a splint on his left hand. There was no carrot splint noted anywhere near R33. On May 6, 2026, at 10:51 AM, V16 (Rehab Director) and V17 (Registered Occupational Therapist/OTR) both stated the carrot splint is for functional position and to decrease likelihood for further contraction, and it is an atonic inhibitor. On May 6, 2026, at 10:57 AM, V16 and V17 went to R33's bedroom to apply the carrot splint. V16 and V17 both looked everywhere inside R33's bedroom and they were unable to find it. V16 left R33's bedroom and came back with a carrot splint. Prior to applying the splint, V17 stated R33 was non-compliant with the carrot splint because he has low tolerance with the pain or discomfort it causes him whenever it was in place. V16 and V17 explained to R33 the importance of using this carrot splint. When V17 applied the splint to R33's left hand, R33 initially verbalized discomfort as it was being placed in his palm and fingers but did not further complain about it after it was fully applied on his left hand. R33 stated that he didn't feel it at all, and there was no pain after it was applied. On May 6, 2026, at 12:19 PM, V2 (Director of Nursing/DON) stated staff should ensure that splint is in place as ordered and to check the skin integrity of the hand. V2 said she does not see a care plan for the carrot splint, and there was no documentation of R33 refusing to wear the carrot splint.

Based on observation, interview, and record review, the facility failed to provide incontinence care in a timely manner for residents who were identified as incontinent and failed to ensure the indwelling urinary catheter bag was always below the resident's bladder. This applies to 2 of 6 residents (R3, R9) reviewed for incontinence and catheter care in the sample of 21. The findings include:1. R3's electronic medical record (EMR) showed R3 had multiple diagnoses including type 2 diabetes mellitus with chronic kidney disease uncontrolled and congestive heart failure (CHF). R3's Physician Order Summary (POS) showed R1 was receiving Torsemide (diuretic or water pill) 20 milligrams (mg) twice a day for CHF. On May 4, 2026, at 10:43 AM, R3 was sitting in his wheelchair in his bedroom, R3 said he has heart failure and renal failure. According to V13 (Certified Nursing Assistants/CNA), R3 is alert and oriented and requires extensive assistance with activities of daily living (ADL) care. On May 5, 2026, at 12:35 PM, V11 and V13 (Both CNA) assisted R3 to the toilet. R3's incontinence brief was heavily saturated with urine, a strong urine odor emanated when R3's incontinence brief was removed. R3 said the last time his brief was changed was early that morning. On May 5, 2026, at 12:45 PM, R3 said he doesn't know when he was voiding so he couldn't tell staff when to change his incontinence brief; however, he asked the staff to assist him to change his disposable brief because it had been a while since he was last changed. R3's care plan dated March 5, 2026, showed R3 has urinary incontinence. The goal is to keep R3 dry and clean as much as possible. This same care plan showed several approaches which include providing incontinent care as needed. The Facility's Undated Perineal Care Policy and Procedure showed: The purpose of this procedure is to provide cleanliness and comfort to the residents, to prevent infections and skin irritation, and to observe the resident's skin condition.The Facility's Undated Toileting Policy and Procedure showed: It is facility's policy to ensure all their residents' toileting needs are met. This same policy shows procedures including:2. Check each resident every two hours and change if found incontinent.3. Provide perineal care after each incontinent episode. 2. R9's EMR showed R9 had multiple medical diagnoses including chronic kidney disease, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, calculus of kidney, urinary tract infection. On May 6, 2026, at 10:34 AM, V13 and V18 (Both CNA) transferred R9 from bed to wheelchair via mechanical lift. R9 has an indwelling urinary catheter. The urinary bag was placed/hung on the sling hook bar of the mechanical lift which was above R9's bladder. There was sedimentations noted inside the urinary catheter tube. During transfer the urine in the tube was noted flowing back towards R9. On May 6, 2026, at around 10:55 AM, V13 said she also observed the urine flowing back to R9. Care Plan shows R9 requires indwelling urinary catheter related to neurogenic bladder. This same care plan shows interventions including positioning of the urinary bag below level of bladder. On May 6, 2026, at 12:06 PM, V2 (Director of Nursing/DON) stated the staff should check residents who are incontinent every 2 hours and as needed. This is to be done to prevent skin breakdown and urinary tract infection, and to promote comfort. The indwelling urinary catheter should always be positioned below the bladder so it could drain by gravity, and the urine doesn't backflow to the bladder, to prevent UTI (Urinary Tract Infection).

Based on observation, interview, and record review the facility failed to ensure safe storage of controlled medications. This applies to 2 of 2 residents (R6 and R18) reviewed for medication storage in the sample of 21. The findings include:R18's EMR (Electronic Medical Record) showed R18 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, spinal stenosis, low back pain, muscle spasms, pain unspecified, pain in right arm, and migraine. R18's Physician Order Report showed an order dated September 13, 2024, for hydrocodone-acetaminophen(Pain medication) 5-325 mg (milligrams) twice a day (7:00 AM to 11:00 AM, 4:00 PM to 7:00 PM). On May 6, 2026, at 12:12 PM, during the controlled substance count of the Wing 2 cart with V5 (Registered Nurse, RN), R18's blister punch card for hydrocodone-acetaminophen 5-325 mg had 20 tablets remaining. The back of the blister punch card on the compartment with the number 20 on it was open and the opening was big enough for the tablet to come out. V5 verified the compartment number 20 was open and the tablet should have been discarded. She was not aware of how this happened. V5 stated this tablet should have been disposed of with two nurses and documented as wasted on the controlled drug receipt/record/disposition form. R6's EMR showed R6 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis, obesity, pain in left foot, pain in right knee, and osteoarthritis. R6's Physician Order Report showed an order dated December 31, 2025, for hydrocodone-acetaminophen 10-325 mg tablet four times a day (6:00 AM, 10:00 AM, 3:00 PM, and 8:00 PM), On May 6, 2026, at 12:18 PM, as the controlled substance count for Wing 2 cart continued. R6's hydrocodone-acetaminophen 10-325 mg controlled drug receipt/record/disposition form showed there were supposed to be 21 tablets remaining, but in the blister punch card, there were only 20 tablets. There was a tablet that was placed in a clear unsealed plastic pouch with R6's name handwritten on it and V5 confirmed it was the hydrocodone-acetaminophen 10-325 mg tablet. V5 stated she was the one that put the tablet in this plastic pouch. V5 stated she popped this tablet out at around 9 AM this morning but she did not realize she had already placed a hydrocodone-acetaminophen 10-325 mg tablet in R6's medication cup so this tablet was not needed. V5 did not know she had to dispose of the controlled substance tablet right away because V5 stated she needs to dispose of the tablet when she can find another nurse to do it with. On May 6, 2026, at 12:42 PM, V2 (Director of Nursing, DON) confirmed R6's hydrocodone-acetaminophen 10-325 mg should not be placed in a plastic bag, and it should have been wasted right away with two nurses. V2 also confirmed she saw that R18's blister punch card had compartment number 20 completely opened and she stated this pill should have also be wasted with two nurses. V2 stated these controlled substance medications should have been wasted with two nurses right away because these medications could end up in the wrong hands. V2 continued to say R18's hydrocodone-acetaminophen 5-325 mg tablet could have fallen out from the blister punch card from the open compartment number 20, and it was exposed to bacteria. The facility's undated policy titled, Controlled Substances, showed under Procedures that accurate accountability of the inventory of all controlled drugs is always maintained. The facility's undated policy titled, Controlled Substance Disposal, showed under Procedures that when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses or a pharmacist and nurse, and the disposal is documented on the accountability record/book on the line representing that dose.

Based on observation, interview, and record review, the facility failed to follow physician order and failed to follow their policy and procedure with administering inhaler medication. There were 25 medication opportunities with 3 errors resulting in 12% medication error rate. This applies to 2 of 4 residents (R18, R62) reviewed for medication pass in the sample of 21. The findings include:1. On May 5, 2026, at 9:12 AM, V4 (Nurse) administered medications to R18 including Advair HFA oral inhaler and Incruse Ellipta inhaler. V4 handed the Advair inhaler to R18 without instructions R18 took 2 puffs of the Advair one after another, then V4 handed the Incruse Ellipta right after. R18 took a puff of the Incruse Ellipta within 5 seconds after the Advair. R18 Medication Administration record dated May 2026 showed an order of Advair HFA (Fluticasone Propion-Salmeterol) 230-21 mcg/actuation inhaler 1 puff once daily.Facility's Undated Policy and Procedure for Oral Inhalation Administration show:Purpose: To allow for safe, accurate, and effective administration of medication using an oral inhaler or nebulizer. Procedure for metered dose and dry-powder inhalers shows: If another puff of the same or different medication is required, wait at least 1-2 minutes between, then repeat procedures above. 2. On May 5, 2026, at 9:53 AM V4 administered several medications to R62 via gastrostomy tube (g-tube) including 5 milliliter (ml) of the Levetiracetam (anticonvulsant).R62's medication administration record (MAR) showed the order of Levetiracetam Solution 100 milligrams (mg)/ml, to administer 250 mg (2.5 ml) twice a day. However, V4 administered 5 ml (500 mg). On May 6, 2026, at 11:35 AM, V2 (Director of Nursing/DON) stated nurses are expected to follow physician orders and instructions for medication administration, and they are to follow the principle of medication administration which is the right patient, dose, medication, route, and time.Facility's Undated Policy and Procedure for Medication Administration showed:Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by person legally authorized to do so. Procedure: PreparationFive Rights: Right resident, right drug, right dose, right route, right time. A triple check of these 5 rights is recommended at three steps in the process of preparation for administration. (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication is put away.

Based on observation, interview, and record review, the facility failed to ensure residents received their showers.This applies to 4 of 5 residents (R1, R3, R4 and R5) reviewed for bathing in a sample of 6 residents.Findings include:Findings include:1.On 04/01/26 at 11:27 AM, R3 stated he has not been getting his two showers a week and he wanted them. R3 stated his shower days are on Wednesday and Saturday. R3 stated there are only two staff that will shower him when requests to be showered. During the interview R3 had a foul body odor.The POC (Point of Care) documentation for R3 shows he had a total of four showers for the month of February 2026, and R3 did not receive a shower for six days from 2/12/26-2/17/26. R3's March 2026 POC documentation showed R3 was not showered from 3/08/26 to 3/15/26. R3's physician orders direct R3 to be showered twice weekly on Wednesday and Saturday evenings.2.On 04/01/26 at 10:42 AM, R4 stated he does not get showers he gets bed baths, but he did not have a preference. R4 did not recall when he was last bathed. During the interview R4 had a stale body odor and his hair was unkempt.R4's orders state R4 is to be showered twice per week on Tuesday and Friday. R4's POC documentation for February 2026 shows R4 received a total of four bed baths for the entire month. R4's POC documentation for March 2026 shows he received a total of three bed baths provided for the entire month.3.On 04/01/26 at 10:12 AM, R1 stated he is not getting showered twice a week. R1 stated he has been washing up at the bathroom sink but prefers to have his showers.R1'a POC shower documentation for February 2026 shows he received four showers for the entire month. R1's March 2026 POC documentation shows he was not bathed or showered for eight days 3/08/26- 3/15/26. R1's order states CNA (Certified Nursing Assistant) to shower R1 twice per week on Monday and Thursday evenings.4.On 04/01/26 at 11:11 AM, R5 stated she had not had a shower in over three weeks. R5's hair was greasy.The facility was unable to provide any documentation of a shower for R5 for the month of February 2026. R5's POC documentation shows she received one bed bath on 03/31/26 for the month of March 2026. On 04/01/26 at 1:35 PM, V1 Administrator stated if a resident has refused to shower or bath, the CNAs are to document the refusal in the POC. V1 stated there was no other shower documentation for R5 for the month of February and March.On 04/01/26 at 1:51 PM, V4 CNA stated sometimes she may have 18 to 22 residents to care for. V4 stated that when she can't provide a shower for a resident, she will inform the oncoming CNA and sometimes they will complete the shower / bath.On 04/02/26 at 2:58 PM, V2 CNA / Scheduler stated when they are working shorter staffed, residents do not always receive showers. V2 stated shower / bath documentation is always done in the EMR (Electronic Medical Record) in POC. The facility's July 2014 Bathing a Resident policy states it is the policy of the facility that residents will receive a shower / bath scheduled regularly and as needed.

Based on observation, interview and record review the facility failed to ensure residents who were high risk for falls were supervised to prevent falls. These failures resulted in R1 & R3 falling being sent to the hospital and sustaining fractures. This applies to 2 of 3 residents (R1 & R3) reviewed for safety/supervision in the sample of 5. The findings include:1. R1's face sheet lists his diagnoses to include: congestive heart failure, shortness of breath, Type 2 diabetes mellitus, morbid obesity, anxiety disorder and wedge compression fracture of first lumber vertebra. On 1/7/26 at 9:57 AM, R1 was sitting in his wheelchair in his room. He stated, he had pain in his back. This surveyor asked him why what happened? He stated, he had a fall and hurt his back. He was going to the bathroom, and the CNA (V3 Certified Nursing Assistant) was on the phone. He told her he was done and ready to get up, she told him to wait because she was on the phone. He was sitting there for 25 minutes already and did not want to wait. He tried to get into his wheelchair by himself and fell. After he fell, V3 CNA had another CNA (V20 CNA) assist her with getting R1 back up and into his wheelchair. R1 stated, she never told the nurse that he fell. When he got back to his room, he complained of the pain in his back and told the nurse he fell. The nurse said V3 CNA never told him R1 fell. He was sent to the hospital where they told him he had crack in his spine. On 1/7/26 at 12:14 PM, V4 Licensed Practical Nurse (LPN) stated, he was the nurse caring for R1 the night he fell in the shower room. He stated, he was at the nursing station and saw R1 pass by him with clean clothes in his hand. Some time later, he saw the call light going off in the shower room, he ran to the room and saw V3 CNA and R1 in the shower room. He went back to the nurses station. About 10 minutes later, he saw V3 CNA wheeling R1 back to his room. R1 then reported to V4 LPN that he was in pain and had a fall. V4 LPN asked, when he fell and R1 told him just a few minutes ago in the shower room. R1 stated, he wanted to go to the hospital because his back hurt so bad. He did send him to the hospital. After V3 CNA put R1 in his room, she went outside. When she came back inside the facility, V4 LPN asked her why she did not report to him that R1 had fallen so he could assess R1. V3 CNA stated, another CNA was in the area and she helped get him up. She was going to tell him. He told her, that is not ok and she must always report when a resident falls so the nurse can assess the patient. On 1/7/26 at 12:20 PM, V3 CNA stated, R1 went to the shower room by himself after she told him not to and he ended up falling. He didn't listen to me. She stated, she was fired for the incident and she didn't understand why she was fired for it. She said she was not on her phone. She also stated, she didn't remember the statement she had written up when asked about the information that was in her statement (see statement below). R1's progress notes dated 8/10/25 shows, Around 3pm resident went to the shower room to take a shower. Post shower, resident reported that he fell in the bathroom. Writer asked resident how he got up from the floor, resident said he was helped up from the floor by the CNAs who did not report to the nurse that resident fell. Resident complained of crucial spine pain and that he wants to go to the hospital. V4 LPN's written and signed statement dated 8/12/25 shows, This writer saw the bathroom light went off around 2:55pm on pm shift on 8/10/25, writer ran towards the bathroom, knocked at the door, asking who was inside? V3 CNA replied she was in with R1. Writer then returned to the nurse's station. By 3:10pm, R1 was brought to his room on his wheel-chair by V3 CNA. The CNA never reported to writer that resident had a fall. Around 3:15pm R1 reported to writer that he fell in the shower room, that his back is hurting on his spine, that he wants to go to the hospital. Writer asked resident, when did he fall and how he got up from the floor? R1 replied that V3 CNA got him up. Writer replies that how come he the nurse was not called or informed? By 3:45pm when the CNA who went outside came back into the building, writer asked CNA why she did not report that R1 had a fall in the shower room? CNA replied that she was going to tell writer. Writer replied that, the CNA supposed to call for the nurse first with any fall. CNA replies that she told resident not to take off his rubber shoes, that resident did not listen. She added that she did not witness the fall. Which means she was not with resident prior to the fall. V3 CNA's written and signed statement dated 8/10/25 shows, I told R1 not to take his shoes off in the shower and he didn't listen to me, he stood up in the shower and slipped on the floor. V20 CNA's written and signed statement (no date) shows, On 8/10 (8/10/25) I was in [another resident] room taking care of her. I was taking the trash, clothes and linens to the soiled utility when I was in the soiled utility getting rid of the dirty clothes and trash V3 CNA approached me telling me that she told R1 to go to the shower room to take a shower. I asked her if he was in the shower room. She told me yes. I told her that she should go in there and help him because he can't take a shower by himself. I left the soiled utility and took the linens out to the shed. When I came back V3 CNA approached me to tell me that R1 had fallen in the shower and asked me to help her get him up. She had her gait belt on him and was lifting from the back, I was lifting him on his right side and he was pulling himself from the bar and we got him into his chair. I did not know if she told the nurse or not. I had just walked in from taking linens out. The facility's serious injury and communicable disease report dated 8/21/25 shows, .Final: Interviews conducted w/ (with) staff and residents regarding incident. Upon final investigation, it was determined that resident slipped and had a fall while in the shower room. Resident reported pain in his back, POA (power of attorney)/NP (Nurse Practitioner) notified and orders received for resident to be send to the ED (emergency department) for further evaluation. On 8/11/25 , nurse on duty called hospital to follow up on status of resident and at this tie nurse notified that resident was admitted to hospital w/ dx (diagnosis) closed compression fracture of L1 vertebra per CT scan. Addendum to 8/15/25 final: Interviews conducted w/ staff and residents regarding incident. Upon final investigation, it was determined that resident removed shoes and attempted to self-transfer when he slipped and had a fall while in the shower room. CNA not present in the room at the time of the fall. On 1/7/26 at 10:35 AM, V1 Administrator stated, V3 CNA no longer worked at the facility following the incident with R1. She had a prior incident with V3 CNA and this was the second time something had happened. She had left R1 in the shower room by himself and she is not supposed to leave him alone. He fell and got a fracture. On 1/7/26 at 1:20 PM, V5 NP stated, the fall was the reason for R1's compression fracture. R1 is very impulsive and they should not ever leave him alone. When he is done he will not wait for staff. R1's history and physical by the local hospital dated 8/11/25 shows, Chief complaint: slip and fall in shower. History of Present Illness: Briefly, R1 is a [AGE] year old other male with extensive pas medical history listed below is a skilled nursing resident mostly wheelchair bound for last few years suffered a slip and fall in shower hitting his head and started experiencing neck and back pain afterwards. Brought to the emergency room where CT showed the has L1 compression fracture. Patient admitted . The same report shows, Imaging: CT lumber spine without IV contrast: Result date: 8/10/25, Impression probable acute low-grade compression fracture involving the inferior endplate of L1 is present, new compared to prior CT. R1's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R1's care plan for ADLs (activities of daily living) functional status with a start date of 8/26/22 shows, he requires 1 assist with bathing.R1's care plan for falls with a start date of 11/11/24 shows, resident has a history of falling and has had multiple falls. 2. R3's face sheet lists his diagnoses to include: pain in right knee, vascular dementia; major depressive disorder and type 2 diabetes mellitus. R3's electronic medical records shows, he had a fall on 10/7/25 resulting in a right leg tibia fracture. He had two falls on 10/19/25 resulting in two separate emergency room visits. The second emergency room visit, he was admitted and the fall resulted in anterior right 5th and 6th rib fractures. The facility's serious injury incident and communicable disease report dated 11/13/25 shows, R3 had another fall on 11/12/25. Detailed incident summary: Initial: R3 is a 79 y/o (year old) Caucasian male w/ BIM score 00 (cognition score- not cognitively intact). Resident noted to be on floor laying on his L (left) side outside room. Resident reported pain to his back, L shoulder, L hip. Resident transported to local ED (emergency department) for further evaluation. Final: Upon final investigation, it was determined that resident's fall resulted in fx (fracture) to L femur, dx given at hospital. R3's hospital communication with the facility from his hospital admission of 10/19/25 shows, V1 Administrator asking if the hospital can discuss memory care with the family, as it might be more appropriate for him. The same documents also show, he had a 1:1 sitter while in the hospital. R3's progress notes for 11/12/25 shows, Resident noted to be on the floor laying on his left side outside RM [ROOM NUMBER].On 1/7/26 at 2:17 PM, V1 Administrator stated, R3 was very impulsive and had dementia. They had discussed with the family that they felt a memory care unit was more appropriate for him. When he was admitted on [DATE] to the local hospital, they asked the hospital to look for other placement however the family insisted they wanted him to come back to the facility. He needed 1:1 support. They were not able to provide 1:1 to care for him all the time but still accepted him back to the facility. On 1/7/26 at 2:34 PM, V6 Registered Nurse (RN) stated, she was his nurse for his first fall on 10/7/25. R3 was very impulsive. When she was working she always had R3 with someone as best as they could otherwise he would get up and fall. He was a 1:1 sometimes. They tried to 1:1 as much as they could. R3's care plan with a start date of 9/17/25 shows, he was at risk for falls due to his vascular dementia. The care plan lists interventions to include: alarms located on chair and bed and keep in visual range of floor staff. The facility's falls management policy dated 4/21/22 shows, Policy: It is the policy of [the facility] to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. Definition: The definition of a fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and wound have fallen, if not for staff intervention, is considered a fall. Unless there is evidence suggesting otherwise, when a resident is observed on the floor, a fall is considered to have occurred. Procedure: .2. Resident's identified as high risk will have fall prevention addressed on the plan of care. 3. If a resident falls, reports falling or is suspected of falling, the following will be implemented: a. Assess for injury, provide treatment and document in the E.H.R. (electronic health record).

Based on observation, interview, and record review, the facility failed to follow the nurse practitioner's orders to consult a wound care doctor for treatment of a new acquired wound. The facility also failed to reposition a resident who was at risk for pressure ulcers. This applies to 2 of 3 residents (R1 and R8) reviewed for pressure ulcers in the sample of 8. This failure resulted in the R1's wounds declining, enlarging and developing into full thickness injuries. The findings include: 1. R1's electronic medical record showed R1 was originally admitted to the facility on [DATE]. R1's medical record also showed he was discharged to the hospital on May 21, 2025 and readmitted to the facility on [DATE]. R1's medical record showed R1 had medical diagnoses that included encephalopathy, malignant melanoma of the skin/shoulder, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia. R1's Minimum Data Set, dated [DATE] showed that R1 required substantial/maximal assistance to reposition in the bed. R1's Braden scale for predicting pressure sore risk dated May 19, 2025 showed that R1 was confined to the bed and was a high risk for developing pressure sores. R1's nursing progress note and admission assessment written by V12 (Registered Nurse/RN) dated May 29, 2025 showed that R1 had redness to his buttocks. There was no mention in the assessments of the condition of R1's heels. On June 17, 2025 at 12:22 PM, V12 (RN) stated R1 was readmitted on [DATE] around shift change, and she did a head to toe assessment on him and charted it. V12 stated R1 had redness to buttocks on both sides, but there was no open area noted. V12 stated she looked at R1's whole body and his heels were also red. V12 stated R1's red heels were not a new issue. V12 stated she forgot to document the heel assessment. V12 stated she only told the next shift of the redness to R1's buttocks because the redness to R1's heels was not a new issue. R1's nursing progress note written by V2 (Licensed Practical Nurse) dated June 2, 2025 showed the following: Resident is having skin breakdown on both buttocks, redness and open areas of about 0.1 x 0.1 cm (centimeter). Cleaned with wound cleanser, used calcium alginate and covered with bordered gauze. On June 16, 2025 at 4:55 PM, V2 (Licensed Practical Nurse) stated that on June 2, 2025, he found that R1 had redness to his buttocks with an open area. V2 stated he notified the doctor by leaving a message via their messaging system. V2 stated he does not remember if the doctor gave him orders or not. V2 stated he did not put any orders in the computer nor did he record the wound in wound rounds. R1's Progress note dated June 5, 2025 showed that R1 was sent to the hospital via 911 related to shallow breathing, faint pulse and not responding to name or touch. R1's history and physical from the hospital dated June 5, 2025 showed that R1 was admitted to the hospital with a diagnosis of sepsis and pressure wounds to his feet and sacrum. R1's hospital medical records dated June 5, 2025 described R1's feet wounds as follows: 1). Location: left heal, full thickness, pressure injury. Present on admission Wound type: evolving deep tissue pressure injury. Wound description: red moist tissue 100% Wound size: 7 centimeters (cm) x 7 cm x 0.2 cm Wound edges: defined, unattached epidermal tissue Drainage Moderate serous on dressing 2). Location: Right heal, full thickness, pressure injury. Present on admission Wound type: evolving deep tissue pressure injury Wound description: Maroon/violet tissue 90%, Red moist tissue 10% Wound size: 5 cm x 6 cm x 0.3 cm Wound edges: defined, unattached epidermal tissue Drainage: none The picture of R1's sacrum/buttocks taken on June 5, 2025 at the hospital showed a very large area of redness that extends from the middle of R1's buttocks to the top of his sacrum where there was a large purple discoloration. There was some exudate, different degrees of redness, some open areas and loose scabs/crust. On June 17, 2025 at 12:32 PM, V7 (Nurse Practitioner) stated she was contacted by a nurse on June 2, 2025 regarding R1's wound. V7 stated she told him to consult with wound care for treatment orders. V7 stated she expected wound care to be contacted immediately and for the wound to be treated. V7 stated she knows her order was not put in the computer, and therefore, they were not providing treatment to the resident (R1). V7 stated the risk of not following provider's orders is harmful to resident. The wound could get worse, the resident can become septic, or the resident could lose a limb. On June 18, 2025 at 11:14 AM, V7 (Nurse Practitioner) stated she was aware that R1 also had redness to his heels. V7 stated R1's lack of treatment and the facility not following her order caused the worsening of the R1's skin and sacrum/buttocks wounds. V7 stated the big issue at the facility is there is a communication problem and no one is following up on orders. On June 18, 2025 at 3:10 PM, V11 (Regional Clinical Director) stated that she expects staff to put doctor's order in the computer, and carry out the orders as prescribed. V11 stated she expect nurses to follow up with doctor and resident to make sure wounds are not progressing. Residents who have skin breakdown or who are at risk for skin issues should have a skin care plan. R1's care plan was absent of any skin or wound care plan. R1 had no treatment orders nor a wound care consult for his sacral/buttocks wound or for heel redness. (May 29, 2025 through June 5, 2025) R1's name does not appear on the facility's in-house or discharged list of residents identified with facility acquired wounds from January 2025 through June 2025. The facility's wound management program policy dated January 20, 2023 showed the following: Physician orders should be obtained and followed for each resident. Resident's identified as risk on the Braden scale will have this addressed on their care plan and will have interventions put in place for preventative measure. The nurse will call physician to obtain appropriate treatment order. 2. R8's electronic medical record showed R8 was admitted to the facility on [DATE] with diagnoses that included rhabdomyolysis, acute embolism and thrombosis of unspecified deep veins of the lower extremity, chronic kidney disease, fatigue, and muscle weakness. R8's Minimum Data Set, dated [DATE] showed that R8 required substantial/maximal assistance to reposition in the bed. R8's Braden scale for predicting pressure sore risk dated May 19, 2025 showed that R8 was a moderate risk for developing pressure sores. R8' name appeared on the facility's list of residents with facility acquired pressure wounds. The list showed R8 has an ulcer to her coccyx identified on May 4, 2025. R8's first wound doctor note identifying the coccyx/sacral wound was on June 6, 2025 and the doctor described it as an unstageable deep tissue injury. R8 was observed on June 17, 2025 at 9:30 AM, 10:40 AM, and 11:59 AM, 1:44 PM and 3:26 PM lying in the same position which was partially on the right side and right back. On June 17, 2025 at 3:26 PM, observed R8 with a pressure wound to her coccyx/sacrum. V14 (LPN) stated that R8 is bed bound and bed bound residents should be repositioned every 2 hours to prevent pressure ulcers. V14 was informed that R8 has been observed in the same position multiple times throughout the day. V14 stated they keep R8 on her right side to keep her off her coccyx pressure ulcer. R8's care plan was absent of any skin or wound care plan. The facility's Repositioning of Resident policy dated May 2, 2019 showed the following. Repositioning is critical for a resident who is immobile or dependent upon staff or repositioning. Residents who are in bed should be on an every 2 hour turning schedule.

Based on interview and record review, the facility failed to ensure that a resident who requested medical records were provided the records in a timely manner. This applies to 1 of 2 resident's (R2) reviewed for medical records in the sample of 8. The findings include: R2's electronic medical record showed R2 was admitted to the facility on [DATE] with diagnoses that included myopathy, inflammatory and immune myopathies, pain in leg, anxiety, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and history of falling. On June 16, 2025 at 11:33 AM, R2 stated she asked V15 (Director of Rehab) several times to give her some therapy medical records. R2 stated, V15 said multiple times she would get the medical records for R2 but she still has not received the medical records she requested. On June 17, 2025 at 2:40 PM, V1 (Administrator) stated she received a written request for medical records from R2 on June 5, 2025. V1 stated that V10 (Business Office Manager) told V1 later that day that the R2 no longer needed the paper work. V1 stated therefore, she did not provide the paperwork to R2. On June 17, 2025 at 2:48 PM, V10 stated, she spoke to R2 on June 5, 2025 after V1 asked her to go see R2. V10 stated she talked to R2 and R2 did not want V10 to explain or go over the medical records her. V10 stated R2 wanted paper copies of the medical records to give it to her attorney. V10 stated she notified V1 about R2's request for medical records. V10 stated she was then waiting for V1 to give her the medical records for R2. V10 stated she documented it in the progress notes under the social services tab. R2's progress note dated June 5, 2025 written by V10 showed the following: Writer discussed with resident the request for occupational discharge. Informed resident I can go over the document with her, however she stated she does not want to go over such document. She just wants to have the document to send to her attorney. Writer informed resident that when document is available to give to her I will bring it down to her and go over it with her. On June 18, 2025 at 12:32 AM , V15 (Director of Rehab) stated that R2 did request medical records from her and she spoke to her supervisor and her supervisor stated those requests are handled by the facility. V15 stated she did not inform R2 that she needed to request the medical records from the facility. V15 stated the facility was in communication with R2, therefore, she assumed they were handling R2's request for medical records. R2's request for medical records form was not dated, however, on June 17, 2025 at 2:40 PM, V1 stated this form was submitted to V1 on June 5, 2025 by R2.

Based on interview and record review, the facility failed to notify a resident's family/POA (Power of Attorney) of a new wound to the resident's sacrum. This applies to 1 of 4 residents (R1) reviewed for change of condition notification in the sample of 8. The findings include: R1's electronic medical record showed R1 was originally admitted to the facility on [DATE]. R1's medical record also showed he was discharged to the hospital on May 21, 2025 and returned to the facility on May 29, 2025. R1's medical record showed R1 had medical diagnoses that included encephalopathy, malignant melanoma of the skin/shoulder, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia. R1's progress note dated June 2, 2025 written by V2 (Licensed Practical Nurse) showed the following: Resident is having skin breakdown on buttocks, redness, and open areas of about 0.1 x 0.1 centimeters. Cleaned with wound cleanser, used calcium alginate and covered it with a boarded gauze. On June 16, 2025 at 1:04 PM, V8 (R1's family, POA) stated the facility never notified him that R1 had any wounds to his heels or buttock/sacrum. R1 stated he found out R1 had wounds when he saw R1 in the hospital on June 5, 2025. On June 16, 2025 at 4:55 PM, V2 stated he did not notify R1's family of the new wound that he found on June 2, 2025. V2 stated they should notify the doctor and the family of any change in resident condition like this new wound that was found. V2 stated that notification of the doctor and the family representative should be documented in the progress notes. There was no documentation in the progress notes that showed that V2 or anyone else notified R1's family that R1 had a new wound. The facility's Change in a Resident's Condition or Status policy showed the following: the facility will immediately notify the resident's family or representative of a significant change in the resident's physical, mental, or psychosocial status or deterioration of the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to properly transfer a resident who required hands-on assistance to ascend stairs of a transport van. This applies to 1 of 3 residents (R2) reviewed for transfers in the sample of 8. The findings include: R2's electronic medical record showed R2 was admitted to the facility on [DATE] with diagnoses that included myopathy, inflammatory and immune myopathies, pain in leg, anxiety, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and history of falling. On June 16, 2025 at 11:33 AM, R2 was crying and stated V9 (Certified Nursing Assistant/CNA) came without a wheelchair to take her to a doctor's appointment. R2 stated she told V9 she could not walk that far to the van and he had to get a wheelchair. R2 stated V9 then returned with a wheelchair. R2 stated V9 wheeled her to the van, but could not put her in the back of the van where residents in wheelchairs normally sit because he said there was a bunch of equipment back there and told her to get in the front seat. R2 stated she told V9 she didn't have the strength in her arms and legs to go up the stairs and into the front seat. R2 stated V9 told her he would help her. R2 stated V9 did not have a gait belt around her. R2 stated V9 then helped her stand up. R2 stated she turned and told him again she would not be able to lift her foot up and V9 said try and he would help her. R2 stated so she lifted her 1st foot up on put it on the grate and tried to put pressure on it and her legs gave out. R2 stated her legs felt like noodles and were flopping and hitting things all around. R2 was crying while telling the story. R2 stated then V9 pushed her from her back up into the seat. R2 stated, the same thing happened when she tried to get into the van on the way back to the facility. R2 stated she told R2 she could not get up and he said again he would help her up. R2 stated again her legs gave out and he put his knee up to catch her and she was sitting on his knee. R2 stated while she was sitting on his knee he pushed her up and into the seat. R2 stated that V9 kept on saying he was sorry. R2 stated when they got back to the facility V9 went to get help and V10 (CNA) came to help V9. R2 stated V13 (Former Director of Nursing) came right away the next morning. R2 stated her bilateral knees and her lower legs were bruised. R2 stated she had x-rays done the next day but there was no fractures found. R2's progress note written by V13 dated May 16, 2025 showed the following: Administrator notified this nurse at approximately 12:30 PM that resident was complaining of some bruising secondary to her knee giving out while being transferred into the building van. Bruising noted to right medial ankle, extending down into the heel, left lateral foot into heel, left anterior knee, and small 2 cm bruise to her right middle axillary chest. The nurse practitioner was notified and orders for STAT imaging received. R2's progress note dated May 17, 2025 written by V12 (Registered Nurse) showed the following: R2 is alert and oriented x4. R2 complained of aching throughout her body and back. Received x-ray results for left and right ribs, spine, right and left foot, left ribs, right ankle, and left knew. Results showing no acute fracture or dislocation. The nurse practitioner was notified. R2 stated as needed acetaminophen was ineffective. R2 requires 1 person assist with transferring. Able to walk short distances. On June 17 20225 at 12:45 PM, V9 (CNA) stated he took R2 on Thursday May 15th in the afternoon to a doctor's appointment. V9 stated he asked the CNA and nurse on duty how she transferred and they told him R2 used a walker with one assist. R2 told him she could not walk to the van. V9 then retrieved a wheelchair for the R2 and took R2 to the facility's van. V9 stated there was stuff in the back of the van so he could not put R2 back there where the residents in wheelchairs usually ride. V9 stated R2 tried to stand up to get into the front seat. V9 stated R2 grabbed the handle of the door and V9 assisted her into the van. V9 stated he did not have a gait belt with him. V9 stated on the way back when R2 attempted to go up the stairs of the van again. V9 stated when R2 took her first step up onto the stair and her legs gave out. V9 stated he immediately put his leg underneath R2 to keep her from falling. V9 stated he picked R2 up like a groom holds his wife going over the threshold and her knee hit the dashboard when he was putting her in the van. V9 demonstrated how he carried R2 when he placed her in the van. V9 stated R2 could have gotten the bruising to her legs when he was putting her in the van. R2's physical therapy note dated May 14, 2025 showed the following: R2 to be a fall risk and R2 gets dizzy when ambulating. R2 performed stair training going up/down 2 steps with contact guard assist. R2's physical therapy note dated May 15, 2025 showed the following: R2 is a fall risk and gets dizzy when ambulating. The therapist instructed the resident on stair training going up/down 3 steps with bilateral upper extremity support and contact guard assistance. The resident required verbal cues on the proper technique and increased safety awareness. On June 17, 2025 at 1:52 PM, V16 (Physical Therapy Assistant) stated that on June 14, 2025 R2 came to therapy in a wheelchair and they used contact guard assist with the therapist holding on to her while practicing going up and down two stairs. V16 stated on June 15, 2025 they saw R2 earlier in the day. V16 stated R2 came in a wheelchair and practiced walking up and down three stairs with contact guard assist. V16 stated a gait belt was used going up stairs for R2's safety because she complained of weakness. V16 stated R2 can verbally tell staff what she needs. V16 stated R2 required bilateral upper extremity support and contact guard assist (CGA) to go upstairs. V16 stated CGA means that the therapist is holding onto the resident using a gait belt. V20 (Occupational Therapy) stated you never know when someone may have periods of dizziness so they recommend a gait belt when ambulating residents. V15 (Director of Rehab) stated R2 had a history of vertigo. V15 stated R2 gets dizziness during therapy. On June 18, 2025 at 3:10 PM, V11 (Regional Clinical Director) if a staff CNA is transferring a resident who requires assistance, then she expects the staff to use a gait belt when ambulating or transferring the resident for the resident's safety. The facility's safe handling program showed the following: Gait and transfer belts will be used where manual assistance is required for ambulation and transfer activities.

Based on observation, interview, and record review, the facility failed to properly label/date/store food items, maintain proper levels for sanitation bucket, and wear hair restraint while preparing and serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/4/25 documents the total census was 45 residents. On 3/5/25 at 1:30 PM, V2 (DON-Director of Nursing) said there is only one resident on NPO (Nothing by Mouth); all other residents eat from the facility kitchen. On 3/4/25 starting at 9:53 AM, the facility kitchen was toured in the presence of V9 (Culinary Director), and the following was found: V9 and V15 (Cook) were not wearing hair covering. V15 was preparing food items for lunch. In the dry storage room, the following food items were found opened and undated: two bags of gravy mixes, one bag of panko , and one big jar of peanut butter. There were also two cans of 106 oz (ounces) corn and one can of 106 oz mandarin orange that were dented. In the preparation counter, there was an opened and undated bag of potato chips that was half full. In the freezer, there were two bags of opened and undated tater tots and one bag of opened and undated potato wedges. In the chiller, there was half a pitcher of opened and undated orange juice and almost consumed jug of cranberry juice. On 3/4/25 during the kitchen tour, V9 tested the sanitation bucket. V9 put a test strip into the bucket. The test strip appeared very light in color and was zero ppm (parts per million). The manufacturer's guidelines posted on the wall document that the test strip should have read 12.5 ppm. V9 was unable to explain why the sanitation bucket was that way. On 3/5/25 at 10:30 AM, V9 and V16 (Cook) were observed preparing mechanical and pureed food without wearing hair covering. V16 had thick and long facial hair that was not covered. On 3/5/25 at 11:45 AM, V9 tested the sanitation bucket. The testing strip's color was orange instead of green meaning there was no sanitation chemical in it. Again, V9 was not able to say why the sanitation bucket was that way. On 3/6/25 at 10:50 AM, V9 said all staff in the kitchen should wear hair restraints covering all their hair including facial hair. He said hair restraint is needed to avoid hair falling into resident food causing contamination. He said all opened foods should be labeled and dated for food safety, so staff knows how long it was opened and when to throw them out. He said food cans should be inspected upon delivery to make sure there is no leakage or dents that may be a sign of contamination. He said sanitation buckets should be at the proper level to prevent contamination of food preparation areas. Facility's Food and Supply Storage Policy dated January 2012 stated the following: 6. All foods will be covered, labeled, and dated. Facility's Personal Hygiene & Uniform Appearance Policy dated January 2012 stated the following: Policy: Hair nets or hair coverings shall be worn while in the kitchen or storage areas. Facial hair shall be covered with a beard cover. Facility's Sanitizing and Disinfectant Solutions Policy dated 2020 stated the following: Guideline: Employee shall refer to the manufacturing guidelines for the proper use of sanitizer and disinfectant solutions. Procedures: 1. The employee will prepare sanitizer solution or disinfectant solution in accordance with manufacture guidelines.

Based on observation, interview and record review the facility failed to review and update the Infection Control Policy Annually, Implement a system of surveillance to identify infections or communicable diseases, appropriately handle and store linens, wear appropriate Personal Protective Equipment, prevent cross contamination during wound care and incontinence care, perform appropriate hand hygiene and implement Enhanced Barrier Precautions. This affects all 45 residents in the facility during the time of this survey. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/4/25 documents that the total census was 45 residents. On 3/5/25 at 12:02 PM, V2 (DON) provided the state surveyor the facility's current copy of their Infection Control policy with a date of August 2018. V2 and V18 (IP) both confirmed that it was the facility's current Infection Control policy. On 3/6/25 at 12:41 PM V2 said that the Infection Control policy should be reviewed an updated annually to keep compliant with the most recent or current CDC (Center for Disease Control) or local health departments regulations. 2. On 3/5/25 at 12:02 PM, V2 DON (Director of Nursing) and V18 IP (Infection Preventionist) were being interviewed for infection control. V18 said that it was her 1st day at being the facility's IP. V2 said that the facility has not been doing infection surveillance since October 2024 and V18 was unable to provide documents showing a surveillance plan for the facility after October 2024. V2 said that since the facility has stopped doing infection surveillance after October 2024, they do not know where the infections are, and they cannot track infections and put prevention measures in place. 3. On 3/4/25 at 12:21 PM, there was a bag of dirty linen on the floor in the shower room. V12 CNA (Certified Nurse's Assistant) said that it is left on the floor and when the bag is full it is taken out. V12 said they do not have a cart to put the dirty linen in. At 12:24 PM, V11 (CNA) was in the soiled utility room and several bags of clean linen bags were observed on the floor of the soiled utility room. V11 said that the facility does not have a cart to put the soil linen in, and when he removes the bag of soil linen, he puts it in a trash can, and he takes it out to the shed outside and empties the trash can into the shed for pick up on Fridays. V11 said that the clean linen bags are stored in the soiled linen room on the floor. On 3/5/25 at 12:02 PM V18 (IP) said the clean soiled linen bags are to be kept in the clean linen room, not on the floor in the soiled linen room because of cross contamination and infection. On 3/5/25 at 12:02 PM V2 (DON) said the soiled linen should not be on the floor, they should be in a hamper or container with a lid that closes. V2 said that the soiled linen should not be on the floor for infection prevention and contamination. 4. On 3/4/25 at 12:00 PM, V12 (CNA) went into R16's room to deliver R16 his lunch tray, there was a sign on the wall next to R16 door showing that R16 was on contact precautions and staff are to wear gowns and gloves before entering the room. V12 left out of the room and came back into the room with crackers for R16, again no gown or gloves on. Then V12 went back to the cart of lunch trays and grabbed R7's tray and delivered R7 his lunch tray. V12 did not clean her hands after leaving R16's room before grabbing R7's tray. On 3/6/25 at 12:02 PM, V2 (DON) said that if a resident is on contact precautions the staff delivering trays must put on gloves and gowns at minimum and should clean their hands before delivering trays to the next resident to prevent infections from spreading. 5. On 3/6/25 at 11:26 AM, V13 (Nurse) was providing wound care for R35's right foot. V13 carried a wash basin into the room with his supplies and placed it on R35's over the bed side table. V13 needed to cut a piece of calcium alginate but did not have scissors. R35 gave V13 a pair of scissors from his drawer. V13 cut open the sterile 6.5-inch x 6.5-inch package of calcium alginate and cut a 1-inch x 1- inch piece off it and then placed the remainder back in the opened packaged. V13 then placed the piece of calcium alginate on R35' wound. At V13 was done with wound care, V13 carried the basin with the supplies back out to the wound cart and placed it on the top of the wound cart but did not clean the basin first. Then V13 gathered supplies into the basin for R16. R16 is on contact precautions. V13 entered R16's room at 11:16 AM. V13 placed the same basin on R16's over the bed side table. V13 cut a 1.5-inch x 1.5-inch piece of calcium alginate from the same 6.5-inch x 6.5-inch calcium alginate he had left from R35. V13 then place the 1.5 x 1.5 piece of calcium alginate on R35's wound to his left foot. After V13 finished wound care on R35, V13 took the cart into the clean utility room and put an adhesive dressing back into the lower drawer of the cart. V13 did not clean the basin that he had brought into both R35 and R16's rooms. On 03/06/25 at 01:04 PM, V2 (DON) said that the nurse shouldn't have used R35's scissors for infection control measures, the scissors were not cleaned, the nurse should have cleaned the wash basin after leaving R35' room before placing it on the wound cart and then bringing back into R16's room. V2 said that her expectations are that the nurse cleans the basin after leaving 1st room before placing on cart for infection control purposes. V2 said that the nurse should not have used the opened calcium alginate that was used for R35 because he cut it with the unclean scissors, this is an infection control issue. V2 said that the adhesive dressing is contaminated and since he did not clean it, he should have disposed of it and not put it in the drawer with stock because it is contaminated and now, he has contaminated the clean stock. V2 said that this could possibly spread bacteria, viruses or any other organisms. The facility's Infection Prevention and Control Program Policies and Procedures General Statement dated August 2018 shows that the organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. The organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidence-based approaches to infection prevention. The infection prevention and control program: investigates, controls, and prevents infections in the organization, decides what procedures such as isolation should be applied to the individual resident, maintains a record of incidents and corrective actions related to infections, has written procedures as a basis of determination for isolation transmission based precautions to help prevent the spread of infection, has an employee health directive to prevent the spread of communicable diseases through work restriction and hand hygiene. Hand hygiene general statement good hand hygiene is requirement of standard precautions. Wash and sanitize hands before and after each care contact for which hand hygiene is indicated and acceptable professional practice, utilizing designated time frames and products. Hands should be washed with soap and water when they are visibly soiled, or if they have come in contact with blood or body fluids, before or after eating or handling food, and time specified by other applicable regulations. The facility's Isolation Precautions/Enhanced Barrier Precaution policy dated April 1st 2024 showed that Standard precautions are required by healthcare workers to eliminate the degree of risk associated with a given task or plan for appropriate personal protective equipment. Enhanced barrier precautions are used in combination with standard precautions to expand the use of personal protective equipment (PPE) to donning of gown and gloves during high contact resident care activities. 46003 6. On 03/04/25 at 11:09 AM, during incontinence care for R17, V11 CNA (Certified Nursing Assistant) placed a plastic bag with a urine-soaked brief on the floor. V11 then removed his soiled gloves put them in the garbage bag and pulled another pair of gloves from his pants pocket and put them on without performing hand hygiene. V11 turned on the room light switch with his gloved hand and continued to provide incontinance care to R17. V11 placed a clean brief on R17 and went to his closet to look for items without removing his gloves or performing hand hygiene. With the same gloves V11 placed a gait belt on R17 and placed him in his wheelchair. V11 then removed his gloves and loosed bed sheets from the corner of R17's bed. V11 then put a new pair of gloves from his pocket and partially bagged the soiled linen. V11 picked the bag with the soiled undergarment on R17's bed and finished bagging the soiled bed linens. V11 then removed the glove from his left hand and opened the room door with his soiled gloved right hand. V11 then took the bagged soiled linen and garbage bag to the soiled utility room. V11 placed the soiled linen in the in the cart and soiled undergarment in the large can and removed his remaining glove. V11 then reached in the garbage can with his ungloved gloved hands opened the bag with the soiled undergarment and sifted through the contents. V11 stated he was making sure he didn't throw away a washcloth. 7. On 03/05/25 at 09:36 AM, with ungloved hands V12 CNA (Certified Nursing Assistant) placed soiled linen on the foot of R8's bed. V12 dropped a washcloth with brown stains on the floor. With ungloved hands V12 picked the soiled washcloth off the floor and put it on R8's bed. Without performing hand hygiene V12 then went to the soiled utility room took out a soiled linen cart. V12 then walked to the clean linen closet and removed a clean flat sheet. V12 then took the soiled linen cart and flat sheet back to R8's bedroom. V12 placed the soiled from R8s bed in the soiled linen cart. V12 then placed the flat sheet on R8's. On 03/06/25 at 11:42 AM, V2 DON (Director of Nursing) stated staff should not place soiled items and garbage on residents' bed. If staff handle soiled linen and garbage they should do hand hygiene. They should do hand hygiene before moving to next care area. Staff should not touch door handles with soiled hands. Staff should not handle clean linen with soiled hands. V2 stated staff should perform hand hygiene before and after removing gloves and providing care. The facility policy Linen Handling dated April 2015 states linen will be handled in a manner to prevent infection and spread of disease. The facility policy Incontinence Brief Disposal dated April 2015 states incontinence briefs are disposed of properly to prevent odors and spread of infection. The facility policy Handwashing dated December 2020 states all staff thoroughly cleanses hands with friction, soap and water to control infection and reduce transmission of organisms. Hands should be thoroughly washed before and after providing resident care. Proper hand washing techniques must be followed at all times. Hand antiseptic / sanitizer is a supplement or alternative to the use of soap and water when hands are not visibly soiled. 46380 8. On 3/4/2025 at 11:20 AM, R3 was observed to have indwelling Foley catheter. R3 said she has a wound on her left lower leg. No signage for EBP (Enhanced Barrier Precaution) was observed on the door, no PPE (Personal Protective Equipment) bin noted by R3's door. On 3/5/2025 at 9:39 AM, transfer was observed. R3 is transferred using a mechanical lift. R3 was assisted by V12 (CNA-Certified Nurse Assistant) and V22 (CNA). V12 and V22 were only wearing gloves during transfer. Both CNAs were handling and repositioning R3's indwelling urinary catheter during the transfer. R3's EHR (Electronic Health Record) documents she has indwelling urinary catheter for neurogenic bladder and has a surgical wound on her left lower leg. R3's POS (Physician Order Sheet) does not show any order for EBP. R3 had no care plan for EBP. 9. On 3/4/2025 at 11:45 PM, R27 observed to have indwelling urinary catheter. R27 stated she has a wound on her right heel. No signage for EBP was observed on the door, no PPE bin noted by R27's door. On 3/4/2025 at 12:30 PM, wound care was observed. Wound care was provided by V8 (RN-Registered Nurse). While providing care, V8 was only wearing gloves and surgical mask. R27's EHR documents she has indwelling urinary catheter for urine retention and has an unstageable diabetic wound on her right heel. R27's POS does not show any order for EBP. R27 had no care plan for EBP. On 3/6/2025 at 9:30 AM, V2 (DON-Director of Nursing) said EBP should be observed for residents with colonized infection, indwelling urinary catheters, feeding tubes and wounds. She said she expects staff to wear proper PPE when providing care to residents under EBP. She said proper PPE includes gown, gloves, face mask and eye protection if there is risk for spray. She said wearing proper PPE protects staff and residents and for infection control. Facility's Isolation Precautions/Enhanced Barrier Precaution (EBP) Policy dated April 1, 2024 sated the following: Policy: It is the policy of Helia Healthcare to make every effort to prevent the spread of infection in the facility. Enhanced Barrier Precautions is used in combination with Standard Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Procedure: EBP will be used for any resident who meets the following criteria: Chronic wounds, such as, pressure ulcer, venous stasis ulcers, diabetic ulcers, unhealed surgical wounds. Indwelling medical devices, such as, central lines, urinary catheters, feeding tubes, and tracheostomies. 31327 10. On 3/4/25 at 10:55 AM, there was no EBP (Enhanced Barrier Precautions) sign outside of R23's room. On 3/5/25 at 12:30 PM, there was no EBP sign outside of R23's room. On 3/6/25 at 10:30 AM, there was still no EBP sign outside of R23's room. Throughout the survey, R23 was observed to have a g-tube and catheter. On 3/5/25 at 12:58 PM, V8 (RN-Registered Nurse) wiped port of g-tube with alcohol pad. She checked for placement by instilling about 10 cc of air and then auscultated with her stethoscope. V8 administered three medications of Keppra, Claritin, and Miralax via g-tube to R23. R23 did not wear a gown. R23's face sheet shows diagnoses of: other mechanical complication of surgically created arteriovenous shunt, sequela and neuromuscular dysfunction of bladder R23's POS (Physician Order Sheet) shows orders of Change indwelling catheter monthly and PRN (As Needed). Special instructions: Foley catheter size: 16 FR (French)/ 10 cc once a day on the 21st of the month days 6 AM to 2 PM. Enteral Feeding: Formula-Isosource, Strength 1.5, Flow Rate 40: Special Instructions-Isosource 1.5 at 40 ML (Milliliters) x 22 hour until or until 881 ML infused. Check Tube Placement by auscultating air passage. There was no order for EBP precautions on R23's POS. R23's care plan shows a problem which documents: (R23) requires an indwelling urinary catheter related to neurogenic bladder (1/23/25). R23's care plan (1/23/25) shows: Problem-(R23) requires feeding tube related to aphasia. Approach: Check placement and patency of feeding tube before each feeding or medication administration. R23 did not have a care plan for EBP precautions. On 3/6/25 at 9:42 AM, V2 (DON-Director of Nursing) stated, There should be signs on the doors of residents who are on EBP (Enhanced Barrier Precautions). The nurse should wear a gown, eye protection, gloves and masks when taking care of things like catheter and g-tube.

Based on observation interview and record review the facility failed to provide hygiene and grooming care assistance to dependent residents. This applies to 4 of 4 residents (R8, R17, R21, R22) reviewed for ADL (Activities of Daily Living) in a sample of 16. Findings include: 1. On 03/04/25 at 11:07 AM, R17 was sleeping in bed lying on his right side facing the wall. R17's undergarment was exposed and was saturated. R17's top bed sheet and bottom bed pad and bed sheets were saturated with urine. On 03/04/25 at 11:09 AM, V11 CNA (Certified Nursing Assistant) was called in by surveyor to provide incontinence care assistance to R17. V11 stated he provided incontinence care at 6 AM. V11 stated he had not changed or provide incontinence care since 6 AM. On 03/06/25 at 11:42 AM, V2 DON (Director of Nursing) stated residents need to be checked every two hours and as needed. The expectation is for hourly rounding can be done by a nurse or CNA. Even if a resident is sleeping, staff should be checking them and providing incontinence care. R17 does not have any history or documentation of refusing incontinence care. The facility policy Perineal Care dated July 2017 states the purpose of the procedure is to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the resident's skin condition. 41384 2. On 03/04/25 at 11:08 AM, R22 was observed with long jagged nails over a 1/2 inch long and facial hair on her upper lip and chin. R22 said that she wanted to be shaved that the facial hair bothers her, and she could not remember the last time she was shaved. R22 said that her long jagged nails bothered her, and she wanted staff to provide nail care for her. R22's 2/7/25 MDS (Minimum Data Set) showed that R22's cognition is intact and that she is dependent on staff for personal hygiene. On 03/06/25 at 12:53 PM, V2 DON (Director of Nursing) said that staff should provide personal hygiene including shaving facial hair and grooming of fingernails daily and as needed. The facility provided Quality of Life - Accommodation of Needs policy dated February 2012 when asked for their ADL (Activities of Daily living) The Quality of Life - Accommodation of Needs policy shows the facility's environment and staff behaviors are dedicated towards assisting the residents in maintaining and or achieving independent functioning, dignity and well-being. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or residents would be endangered. The facility provided their Shaving policy dated July 2014 and the policy showed that shaving promotes cleanliness and provides skin care. 31327 3. On 3/04/25 at 11:11 AM, R8 was in bed. Her hair was greasy and was not combed. R8 had facial hair above her upper lip. R8 stated, I've not gotten a bath or shower yet since I have been here. They have never washed my hair. I told the CNA's (Certified Nursing Assistants) to shave me, but they never have any time. On 3 /05/25 at 12:06 PM, R8 still had facial hair on her upper lip. Her hair was still greasy and not combed. R8 stated, I still have not got my shower or bed bath. At 12:10 PM, her CNA (V6) said, We shave as needed, when it's visible and if is she is ok with it. Showers are supposed to be twice a week. We don't give (R8) showers because the nurse told me her oxygen is dropping. (R8) said, But you see my oxygen tank is right there. They are supposed to take my oxygen tank with me to the shower room and give me a shower. They don't even do that or give me bed baths. R8's face sheet shows the following diagnoses: chronic obstructive pulmonary disease with acute lower respiratory infection, chronic respiratory failure with hypoxia, shortness of breath, chronic congestive heart failure, anxiety disorder, depression. R8's POS (Physician Order Sheet) shows an order: Oxygen: Continuous 5 liters/minute per nasal cannula. Maintain SPO2 (oxygen rate) greater than 90%. R8's MDS (Minimum Data Set) dated 2/20/25 shows a BIMS (Brief Interview for Mental Status) score of 9, which means she is moderately impaired in cognition. Section GG Functional Abilities. R8 was as 3 for shower/bathe self, which means she is partial/moderate assistance. Staff does less than half the effort. Staff lifts, holds, or supports trunk or limbs, but provides less than half the effort. For tub/shower transfer, R8 was 2, which means she is substantial/maximal assistance which means the staff does more than half the effort. Staff lifts or hold trunk or limbs and provides more than half the effort. Facility was unable to provide any shower sheets for R8. 4. On 3/04/25 at11:11 AM, V17 (R21's fiancee) was sitting next to R21 while she was in bed. V17 stated that the last two Thursdays, R21 received no showers. V17 stated that Monday and Thursday are her shower days. V17 said, This past Friday, I told the nurse that (R21) didn't get a shower and if she could get one. The nurse said, Oh well, at least they forgot. Our make-up day is Sunday, so I can't give her a shower until then. V17 said that R21 finally got the shower on Monday. R21 confirmed to surveyor that what V17 said was true. R21's face sheet shows diagnoses of cerebral infarction due to embolism of unspecified cerebral artery, unspecified combined systolic (congestive) and diastolic (congestive) heart failure and acute respiratory failure, unspecified whether with hypoxia or hypercapnia. R21's MDS dated [DATE] shows a BIMS score of 8, which means she has moderate impairment in cognition. R21's baseline care plan (3/1/25) shows that she needs assistance with bathing. R21's shower sheet shows she only received showers on 3/3 and 3/6/25 for this month. On 3/6/25 at 9:42 AM, V2 (DON-Director of Nursing) stated, Residents should get showers twice a week. (R8) should have had a shower in the shower room because she has a portable oxygen tank. That's standard. Sometimes, the doctor will write an order that residents can be off oxygen for a short period of time too.

Based on observation, interview, and record review, the facility failed to follow physician orders and apply restorative devices to prevent further worsening of contractures. This applies to 1 of 2 residents (R23) reviewed for restorative in a sample of 16. The findings include: On 3/4/25 at 10:55 AM, R23 was sleeping. Both of her hands were severely contacted. She had no assistive restorative devices on her hands. On 3/5/25 at 12:30 PM, surveyor went with V8 (RN-Registered Nurse) inside R23's room. R23 is nonverbal. R23 still did not have any splint, carrot or other assistive device in both of her hands. Surveyor asked V8 where they were. V8 stated, I don't know. They should be here. She used to have a carrot but, it's soiled. V8 looked around and found one of the rolled up towels under the bed. She put the rolled up towel into the left contracted hand. She stated she will make another one for R23's right hand. On 3/5/25 at 1:10 PM, V1 (Administrator) said, (V7-Former RN) was our MDS (Minimum Data Set) nurse and she oversaw our restorative program. She left us and is at another facility. We currently have no restorative nurse. We have no restorative aides. The CNA's (Certified Nursing Assistants) are supposed to do restorative therapy. Resident # 23's husband removes the carrot. I will try to find documentation on that. He does the restoratives exercises on her. On 3/6/25 at 9:50 AM, V2 (DON-Director of Nursing) stated, (R23) is supposed to have rolled towels in both her hands to prevent worsening of her contractures. She used to have carrots, but her husband took them out. On 3/6/25, at 11:49 AM, V2 stated that she was unable to find any documentation in the progress notes that R23's husband removes the carrots. She said that her husband's behavior of removing them are not care planned. R23's face sheet shows the following diagnoses: other disorders of the brain in diseases classified elsewhere, nontraumatic intracerebral hemorrhage, multiple localized. R23's POS (Physician Order Sheet) shows orders of: Restorative therapy program for PROM (Passive Range of Motion) 6-7 times a week twice a day and splint to affected extremity-carrot inside hand twice a day-7am to 11am, 3pm to 6 pm. R23's care plan (1/23/25) shows she is in a restorative program and requires total dependence. She is in a comatose state. R23's MDS dated [DATE] shows R23 was assessed as 1, which means she is dependent on staff for all functional abilities such as personal hygiene, putting on/taking off footwear, upper/lower body dressing, showering/bathing self, toileting hygiene and oral hygiene. R23's BIMS (Brief Interview for Mental Status) score was left as blank. R23 was triggered as 3, which means she is severely impaired in cognitive skills for decision making. She is also impaired on both sides of her upper and lower extremities. R23's care plan dated 7/22/22 shows: Approach: ensure carrot/washcloth is in the palm of hands. Facility's policy titled Restorative Nursing (August 2023) shows: 1. Restorative nursing services are provided by restorative nursing assistants, certified nursing assistants and other staff trained in restorative techniques. 2. Restorative nursing is under nursing supervision a. Range of Motion-active and passive. d. splint or brace assistance.

Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and implanted defibrillator and ensure that it was readily available in the resident's medical record. This applies to 3 out of 3 residents (R3, R27, R30) reviewed for pacemakers in a sample of 16. Findings include: 1. R3's face sheet documents an admitted [DATE]. R3's face sheet documents the following diagnoses: atrial fibrillation, hypertension, and presence of automatic implantable cardiac defibrillator. R3's medical record was reviewed. There was no physician order documenting the defibrillator and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the defibrillator. It was also unknown as to when the defibrillator was last assessed. On 3/6/2025 at 2:44 PM, V2 (DON-Director of Nursing) said facility does not have a Policy on Pacemakers and Defibrillators. 2. R27's face sheet documents an admitted [DATE]. R27's face sheet document the following diagnoses: atrioventricular block, paroxysmal atrial fibrillation, hypertension, and presence of cardiac pacemaker. R27's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the pacemaker. It was also unknown as to when the pacemaker was last assessed. Facility Policy titled Cardiac Pacemaker Monitoring dated July 2014 does not indicate that information regarding pacemaker/defibrillator should be obtained. The policy stated the following: Purpose: To monitor cardiac pacemaker function on a regular basis to detect malfunction prior to clinical symptoms. Procedure: A physician/ cardiologist will rite an order for the pacemaker check and frequency of subsequent pacemaker check if they choose to monitor pacemaker and battery function. 31327 3. R30's face sheet shows an admitted [DATE]. R30's face sheet shows the following diagnoses: presence of cardiac pacemaker, essential primary hypertension, and hyperlipidemia. R30's hospital notes (5/1/23) from the medical doctor indicates: Past medical history 8. status post pacemaker. Past surgical history: 1). Pacemaker implantation. R30's MDS (Minimum Data Set) dated 1/17/25 shows a BIMS (Brief Interview for Mental Status) score of 12, which means moderate impairment in cognition. R30's care plan (3/1/25) shows: Problem: History and active hypertension. R30 has pacemaker. R250's medical record was reviewed. There was no physician order documenting the pacemaker and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the pacemaker. It was also unknown as to when the pacemaker was last assessed. On 3/6/25 at 9:42 AM, V2 (DON-Director of Nursing) stated, Here is a care plan for the pacemaker. I don't see a model or serial number. There should be a model and serial number on the care plan. If something were to happen, the hospital needs to know that information for trouble shooting and they need to know what kind of pacemaker it is. It is the admitting nurse's responsibility to get all that information at the time of admission.

Based on observation, interview, and record review, the facility failed to ensure proper positioning of indwelling catheters. This applies to 1 of 3 residents (R33) who were reviewed for catheter care in a sample of 16. The findings include: On 03/04/25 at 12:40 PM, R33 was observed in his bed with an indwelling catheter leg bag on his right leg. R33 said that he wears his leg bag all day, every day, including when he is in the bed during the day. R33 said that the staff only puts the large drainage bag on at night before he goes to bed for the night. On 03/05/25 at 09:59 AM, V2 DON (Director of Nursing) said that R33 should not have the leg bag on when in bed. V2 said that the catheter bag should be lower than the level of the bladder to prevent back flow into the bladder, UTIs (Urinary tract infections,) and improper drainage. R33's diagnoses include history of UTIs, and benign prosthetic hyperplasia with lower urinary tract symptoms. R33's 9/4/24 care plan showed that R33 is at risk for UTIs due to catheterization secondary to a diagnosis of urinary retention with approaches including observe for signs and symptoms of UTI - pain, cloudy urine, odor, bladder distention, burning sensation, dysuria, and observe for urinary retention. R33's 4/8/24 care plan showed that R33 has an indwelling catheter and is at risk for UTI, obstructive and reflux uropathy. The care plan shows approaches including assess urine color/odor/clarity, provide good perineal and catheter care every shift and as needed. On 03/06/25 at 01:19 PM, V2 DON (Director of Nursing) said that the catheter leg bag should not be on R33 when he is in bed because the drainage bag should be below the level of the bladder. V2 said that if the catheter drainage bag does not hang below the level of the bladder it can cause UTIs and cause urine to back up and retain in the bladder. V2 said that wearing a leg bag all day long can cause skin break downs. The facility's Catheter Care, Urinary policy dated February 2012 showed that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to ensure a female resident was protected from another resident who has a known history of sexual abuse. This failure resulted in the resident entering the room of another female resident, then touching her breasts and face and kissing her. This applies to 1 of 4 residents (R1) reviewed for sexual abuse in a sample of 5. This has the potential to affect all 24 female residents (R1, R3-R25) residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/31/23 at 4:00 AM when R2, who has a history of sexual abuse, entered R1's room and put his hands down her gown and touched her breasts. V1 (Administrator) was notified of the Immediate Jeopardy on 11/16/23 at 1:55 PM. Although the immediacy was removed on 11/17/23, the facility remains out of compliance at Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including in-servicing of staff and compliance with 1:1 monitoring of R2. The findings include: The Resident Roster report dated 11/14/23, shows the facility census was 43 residents, and 24 of those residents are female. The facility's 10/31/23 Final Serious Injury Incident and Communicable Disease Report for R1 and R2 showed Final: Upon final investigation, it was determined that resident (R2) entered the room of resident (R1) and touched her face and breast without resident's consent .Resident (R2) remains on 15-minute checks by staff . On 11/14/2023 at 9:43 AM, R1 was in bed watching television. The back of the head of R1's bed is perpendicular to the doorway to her room, and it is immediately to the right of the doorway. R1 is unable to see anyone entering her room from the hall when she is in bed. R1 is Spanish speaking; translation was done by a Spanish speaking surveyor. R1 said two weeks ago on 10/31/23, R2 came to her room around 3:00 AM, stood behind her, and asked her to come out to the hallway. R1 said she told R2 no, and R2 then put his hands down her gown and touched her breasts. R1 said she used her call light, and V3 (Certified Nursing Assistant/CNA) came and asked R2 to leave. R1 said a second incident occurred a week later (11/7/23) where R2 came into her room. R1 stated R2 asked her to go out to smoke, and then from behind, kissed her head, forehead, and eyes, and then put his hands in her gown and touched her breasts again. R1 said she used the call light and staff came to her room and asked R2 to leave. R1 said the incident made her feel unsafe. R1 said she has had a stroke, which left the left side of her body paralyzed. R1 said she does not feel safe at the facility because residents are able to wander in and out of rooms. On 11/14/2023 at 10:51 AM, V3 (CNA) said when R1's incident occurred on 10/31/23 at approximately 4:00 am, V3 went to R1's room and found R2 in her room, standing over R1. V3 said she asked R2 to leave R1's room. V3 said R1 told her that R2 touched her face. V3 said she asked R1 three times if R2 touched her inappropriately, but R1 said R2 only touched her face. V3 said she informed V6 (Licensed Practical Nurse/LPN) and V6 told her to monitor R2 every 15-minutes. V3 said prior to that incident, she was unaware of R2 being on 15-minute monitoring for wandering. V3 said she taken care of R2 since the incident on 10/31/23. When the Surveyors asked V3 if R2 was still on 15-minute checks, V3 answered no. On 11/15/2023 at 7:50 AM, V6 (LPN) said on 10/31/2023, V3 was doing her rounds, and R2 was in R1's room. V6 said V3 redirected R2 out of R1's room. V6 said she asked R1 if R2 touched her, and R1 said no. V6 said R2 had been on 15-minute monitor checks prior to this incident, and the CNAs are to monitor and redirect R2. On 11/14/2023 at 2:09 PM, V2 (Director of Nursing/DON) said she was informed by V4 (Licensed Practical Nurse/LPN) on 10/31/2023 on the evening shift that R1 had reported to her that an incident had occurred between R1 and R2 during the night. V2 said she spoke to R1, and R1 told her that R2 came to her room on the third shift and touched her left breast. V2 said R1 told her that V3 (CNA) and V6 (LPN) came to her room after the incident occurred. V2 said she reported the incident to V1 (Administrator), and the police were called. V2 said R2 has a history of wandering into female resident rooms, touching them inappropriately, and making verbally inappropriate comments to female staff. V2 said prior to this incident with R1, R2 was placed on 15-minute checks monitoring for wandering. R2's Every 15-minute Check Sheet showed that R2 was in R1's room on 10/31/2023 at 4:00 AM. On 11/14/2023 at 3:07 PM, V1 (Administrator) said on 10/31/23, V2 (DON) informed of her the incident that occurred between R1 and R2. V1 said R2 has a history of wandering into female residents' rooms and touching their breasts. V2 said they had moved R2's room and placed him on 15-minute checks prior to this incident due to this behavior. V1 said she initiated the investigations and believed what R1 said had occurred with R2, even though it was not witnessed. R1's face sheet showed that R1 was admitted to the facility on [DATE] and had the following diagnoses of cerebral infarction, occlusion, and stenosis of the left carotid artery, depression, acute respiratory failure, and cognitive communication deficit. R1's 8/08/2023 MDS (Minimum Date Set) showed she is cognitively intact and needs extensive assistance of two or more staff for bed mobility, transfers, toileting, and personal hygiene. R2's sexual abuse history of R21 was known as noted previously in the CMS 2567 with an exit of 11/4/2023: The 10/5/23 facility final incident shows it was determined that R3 (known as R2 for purposes of this investigation) entered the room of R2 (known as R21 for purposes of this investigation) and touched her breast without her consent. On 11/4/23 at 1:00 PM, V7 (RN-Registered Nurse, and known as V19 for purposes of this investigation) said on 10/5/23, R3 (R2) approached her and said he had entered R2's (R21) room, and R2 (R21) wanted him to touch her breasts. V7 (V19) said she did not see R3 (R2) in R2's (R21's) room but knows he does wander around the facility. V7 (V19) said R3 (R2) has a history of making sexual comments to staff but unaware he had done the same to any female residents. V7 (V19) said she immediately reported the incident to the administrator. She said R3 (R2) had begun refusing to take his medications and it seemed to make him hypersexual. On 11/4/23 at 1:20 PM, V1 (Administrator) said before the reported incident, R3 (R2) had been verbally inappropriate with staff, but nothing sexual. He would ask for hugs. V1 said upon the report of the incident she notified R2's (R21's) husband, and he searched the video footage from the camera in the room. He located the video and shared it, and it shows R3 (R2) entering R2's (R21's) room and placing his hand under the blankets. V1 said she substantiated the allegation of sexual abuse against R3 (R2). On 11/6/23 at 8:30 AM, V13 (R2's husband, or V20 for purposes of this investigation) said he viewed the footage of the camera from 10/5/23. He said the video showed R3 (R2) coming into the room and touching R2's (R21's) face and breasts. He said if she were able to move, she would have fought back and called for help, but she was unable to do so. V13 (V20) said R3 (R2) looked at the door then did his thing and thinks R3 (R2) knew what he was doing. On 11/6/23 at 9:00 AM, video footage of the incident was reviewed. The video shows R3 (R2) entering R2's (R21's) room. R2 (R21) was lying in bed with a sheet covering her body up to her shoulders. R3 (R2) looks back towards the door and approaches R2's (R21's) bed. He caresses her cheek then lifts the sheet and moves his hand under her gown. He then moves his hand from one breast area to the other and then repeats the same motion again. R3 (R2) then removes his hand from under R2's (R21's) gown and touches her cheek again before leaving the room. R2's face sheet showed that he was admitted to the facility on [DATE] with diagnoses of other sequela of cerebral infarction, vascular dementia mild with agitation and with other behavioral disturbances, and depression. R2's 8/17/2023 MDS showed that his cognition is severely impaired and needs limited assistance with bed mobility, transfers, supervision with toilet use and extensive assistance with one person assist with personal hygiene. R2's care plan (created 10/17/23) showed that R2 exhibits problems as seen by wandering, verbally abusive, socially inappropriate, disruptive, resisting care, making inappropriate sexual comments to staff. The goal of this care plan showed Resident's behavior will not adversely affect self or others through next review date. On 11/14/2023 at 10:00 AM, R2 was observed in bed resting. R2 was confused and not able to be interviewed. Prior to the incident with R1 and after the 10/5/23 incident with R21, R2's 10/24/23 Psychiatric Nurse Practitioner progress note showed Seen today upon request by nursing for hallucination and sexually inappropriate behaviors. Per nursing, has been hallucinating at night that he is involved in sexual activity. Patient continues with increased inappropriate sexual behavior toward others . R2's 10/27/23 nursing progress note from 8:49 AM showed Resident having increased hallucinations, stating that a staff member is getting raped, and he needs to save her because she belongs to him. Resident will not stay in his room or in the [letter] hall, repeatedly going to the [name] hall looking for a CNA staff member . The facility's Abuse Prevention Program policy with revision date of 9/29/2023, states Sexual abuse is non-consensual sexual contact of any type with a resident The facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. The facility's Safety and Supervision of Residents policy (revised 12/31/17) showed 5. The facility shall monitor interventions to mitigate accident hazards in the facility modify, as necessary. 6. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS . 8. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers individual resident risk factors, and then adjusts interventions accordingly . 10. The type and frequency of resident supervision may vary among residents and over time for the same resident The facility presented an immediacy removal plan on 11/16/23 at 5:05 PM and it was reviewed by the survey team and returned to the facility without approval. The facility's revised removal plan was received on 11/17/23 at 11:34 AM, and it was not approved and was returned. The facility's revision was presented on 11/17/23 at 12:42 PM and was not accepted after review. The final immediacy removal plan was accepted on 11/17/23 at 1:20 PM. The Immediate Jeopardy that began on 10/31/23 was removed on 11/17/23 when the facility took the following actions to remove the Immediacy. 1. R2 was placed on 1:1 constant observation on 11/14/2023 at 6:00 PM for behavior of wandering and sexual inappropriateness towards other female residents. All direct care staff were in-serviced on R2's updated Care Plan that reflects the 1:1 constant observation implemented on 11/14/2023. The Director of Nursing and/or designee will monitor and document q shift x 7 days for 1 week, daily for 1 week, weekly for 1 month, and monthly for 3 months to ensure 1:1 constant observation is maintained daily on all 3 shifts. Charge nurse will ensure alternative staff replacement for 1:1 Staff Monitor when Staff Monitor takes a break. If 1:1 Staff Monitor is not observed monitoring R2, alternate Monitor will be placed and immediate re-in servicing will take place on all staff on all three shifts. Charge Nurse will immediately notify Administrator or Director of Nursing. 2. The Daily Schedule revised on 11/14/2023 for 2p-10p shift to reflect employee 1:1 constant observation employee assignment to R2 on all shifts, 7 days a week. DON to ensure staffing is followed. 3. All 24 female residents have had a new Trauma Assessment completed on 11/9/2023. 4. R2 Care Plan updated on 11/14/2023. 5. R1 Care Plan updated on 11/14/2023. 6. Administrator and/or Director of Nursing will ensure R2 has an employee assigned to conduct the constant 1:1 observation at all times on all shifts, 7 days a week. 48944

Based on observation, interview, and record review, the facility failed to assess nutritional needs on admission, follow recommendations for monitoring daily weights and provide nutrition supplement to a resident with high nutrition risk and weight loss. This resulted in R233 losing 7.4% (10.6 pounds) weight in 13 days. This applies to 1 of 2 residents (R233) reviewed for nutrition in the sample of 13. The findings include: R233's EHR (electronic health record) included that R233 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R233's MDS (minimum data set) dated 10/26/21 included that R233 was cognitively intact. R233's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same POS included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R233's EHR included admission weight of 143 pounds on 10/14/21. On 10/25/21 at 12:02 PM, R233 was observed eating lunch with special utensils and was edentulous (lacking teeth). R233 received a regular consistency pork cutlet, rice pilaf (that had wild rice in it) and carrots. R233's diet card showed a nutritional supplement dessert at lunch and did not receive the same. R233 also did not receive the nutritional supplement drink with R233 meal which was on the diet order. R233 was noted to be seated leaning backward in the wheelchair that was set at 45-degree angle and the food was spilling unto R233's lap. R233 only ate a few bites and stated that R233 had difficulty chewing and pointing to the meat and remarked This takes a lot for me and I have to work hard to eat this. On 10/27/21 at 1:44 PM, R233 was in R233 room and was asked if he drank the nutritional supplement drink and stated They did not give me any today at lunch. I like it and wish they gave it to me. On 10/26/21 at around 11:01 AM, R233's daily weights were requested from the facility. On 10/27/21 at 11:03 AM, V2 (Interim Director of Nursing) stated We looked for the weights yesterday and couldn't find it. They didn't get it done daily. V2 was able to produce R233's weight log that listed the following weights in pounds: 143 (10/14/21), 136 (10/22/21), 135.8 (10/23/21). Facility weight was obtained for 10/27/21 and entered in the computer as 132.4 lbs. These weight changes showed that there was a significant weight loss of 7.4% since admission (10/14/21-10/27/21). On 10/27/21 at 12:47 PM, V13 (Dietitian) stated that she comes to the facility twice monthly, and the facility also contacts her with referrals as needed. V13 stated that R233 was admitted on [DATE] and that she received an initial consult for R233 on 10/19/21. V13 stated that on that same day (10/19/21) she recommended a 3-day calorie count and added nutrition supplements and requested for daily weights for one week. V13 stated that she has not received the calorie count to and weights yet. V13 stated that she expects that R233 receives nutrition supplements as recommended and ordered by Physician. On 10/27/21 at 1:18 PM and 4:15 PM, V2 stated that she expects that the facility sends the completed calorie count back to V13 at least by 10/25/21 and that the weekly weight be done as ordered and V13 be notified of the same. V2 also stated that V13 should have been notified a lot sooner than 10/19/21 of R233's initial nutrition consult. On 10/28/21 at 12:16 PM, V17 (Physician Assistant) stated that it would be the intend that the facility follow the dietician recommendations that were approved by the Physician. V17 added that when issues of chewing or swallowing are brought to their attention, the Physician would recommend a speech therapist consult to downgrade the diet as needed. V17 stated that R233 had multiple issues, chewing problems, and not receiving supplements could be factors that contribute to weight loss. V13's referral progress note dated 10/19/2021 11:10 AM included the following: (This assessment is being completed remotely). Received communication from Admin [administration] which indicates resident is getting weak and is malnourished - and Admin is requesting for supplement for calories and protein. Recommendations: (nutritional supplement drink) BID [two times daily], (nutritional supplement dessert) with lunch and dinner, daily weight x 1 week then weekly weights, calorie count x 3 days (and fax to dietitian when complete). Facility policy and procedure titled Nutrition Assessment (revised January 2012) included the following: Policy: All residents who experience significant weight loss shall be assessed for nutritional status and required intervention by the registered licensed dietitian. A course of action increasing calories shall be implemented unless the weight loss is deemed desirable and necessary for improvement of medical status. Residents on supplementation shall be monitored for acceptance of the supplemental calories by Dietary/Nursing. Weight shall be reported to the RDLD [Registered Dietitian Licensed Nutritionist] for review and assessment. Procedure: 3. Dietary staff shall provide the increased calories according to the Physician order. 4. Residents shall be thoroughly assessed for progress monthly by the consultant dietitian and adjustments to care made according to progress. 5. Residents progress shall be reviewed with the Director of Nursing and Dietary Manager.

Based on interviews and record review, the facility failed to perform physician ordered laboratory blood tests for monitoring of residents receiving a blood thinner. This affected 4 residents of 5 (R1, R3, R4, and R5) reviewed for management of prescribed blood thinners and resulted in R1 being admitted to the hospital for an acute epidual hematoma bleeding in the head requiring emergency treatment. According to the facility EMR (electronic medical record), R1 has lupus [DIAGNOSES REDACTED]tosus, paralysis from the waist down, [MEDICAL CONDITION], enlarged heart, migraine headache, and recent history of [MEDICAL CONDITION] ([MEDICAL CONDITION]. [MEDICAL CONDITION] is also known as a blood clot. R1 is receiving [MEDICATION NAME] (blood thinner) for the [MEDICAL CONDITION]. According to the facility EMR, a blood draw was ordered for R1 for 12/26/20 to check the PT/INR ([MEDICATION NAME] time/international normative units - the effective level of [MEDICATION NAME], a blood thinner). The record revealed no lab results for 12/26/20. The laboratory technician was sent to the facility on [DATE]. The lab technician was not able to draw the blood on R1 because R1 was admitted to the hospital on [DATE] and had not returned to the facility as of 12/29/20. The record shows at the hospital R1 was found to have an INR of 7.5. The laboratory reference range for [MEDICATION NAME] INR is 0.8 to 3.5, depending on the therapeutic goal. The record from the hospital shows R1 was admitted with an acute epidual hematoma - bleeding in the head outside the brain and was given [MEDICATION NAME] complex concentrate to stop the bleeding. A radiological scan done the following day showed there was no increase in the bleeding and no displacement of the brain. The same record shows that one reason for the hematoma would be the blood thinner. The hospital record continues to document on December 28, 2020, hematoma, likely secondary to supratherapeutic INR. On 1/11/21 at 2:33pm, V5 (Registered Nurse - RN) stated the nurse receives the order for blood draw from the doctor and routinely uses 3 different methods to send that order to the lab (laboratory): through the EMR email system, telephone call, and by faxing a copy of the order. The laboratory service then sends a technician to draw the blood on the appointed day. V5 stated this didn't happen on 12/26/20. No technician arrived and no blood was drawn. V5 stated she keeps the log of INR blood draws. V5 stated the laboratory has been getting worse for 2 to 3 months and has been especially bad in the past month. V5 stated the nurses could draw the blood but the sample would still need to be picked up by the lab in a timely manner and the facility has no other options available. On 1/11/21 at 3:10pm, V4 (Medical Doctor) stated R1 had a very high INR and there was a missing blood test. V4 stated if he had had the test result information on 12/26/20, he would have known and been able to stop the [MEDICATION NAME] and administer medication to reverse the [MEDICATION NAME]. V4 stated it is critical to have these tests in a timely way because [MEDICATION NAME] needs to be monitored to protect the patient. R3 has [DIAGNOSES REDACTED]. According to the lab report R3 had blood draw for INR on 12/23/20 and V4 ordered another draw in one week (12/30/20). The facility could produce no evidence that the ordered blood draw was done. No lab result report or reference to such report could be found for 12/30/20. R4 has [DIAGNOSES REDACTED]. The facility POS (physician's orders [REDACTED]. R5 has [DIAGNOSES REDACTED]. The EMR for R5 shows a physician order [REDACTED]. The facility could provide no information. The next INR test shown in the record was for 1/6/21. On 1/12/21 at 11:00am, V1 (Administrator) stated no blood test was done for R5. On 1/7/21 at 2:00pm, V2 (Director of Nurses) stated the facility has obtained permission from the corporate office to contract with a new laboratory and we have set up a meeting with them to discuss it next week. We have not made other arrangements to get the blood tests done when the technician failed to arrive. On 1/11/21 at 1:17pm, V7 (Registered Nurse) stated the lab has missed many blood draws. I talked with the DON and Administrator. V7 stated she has spent a lot of time talking to the lab on the phone trying to ensure the labs get done or to get results. V7 stated she talked with the DON about this just last week again. On 1/11/21 at 5:22pm, V6 (Licensed Professional Nurse - LPN) stated the laboratory has been a problem. We fax, call, and email and get verification and they wouldn't show up. V6 stated when she was able to get through to their office, they would say they did the blood draw when they didn't. V6 stated this has been going on for more than a month. All the Nurses are mad! V6 related, one day the laboratory technician refused to do the blood draw because we had just cleaned up the resident (R4) and the room still smelled a little even after air freshener. And V6 stated, I have told the DON and the Administrator about this. They are trying to find a new Laboratory.

Based on observation, interview and record review the facility failed to assess and monitor two residents (R11 and R15) change in bowel elimination, notify the Physician of these changes, and failed to utilize appropriate assessment tools for pain management/comfort for one resident (R1). This deficient practice resulted in R11's hospitalization and [DIAGNOSES REDACTED]. This applies to 2(R11, R15) of 6 residents reviewed for incontinence/bowel management in the sample of 15, and one (R1) of 13 residents reviewed for hospice pain management in the sample of 15. The Findings Include: The facility's medical record documents that R11 is a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. The admission Minimum Data Set (MDS) for R11 dated March 3, 2017 documents: Toilet use- total dependence (full staff performance every time) and always incontinent for bowels. The POS (physician's orders [REDACTED]. [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10-325mg oral every 4 hours as needed for pain (February 25, 2017); [MEDICATION NAME] HC ([MEDICATION NAME]) suppository, insert rectally twice a day (March 15, 2017); Review of R11's MAR for March/2017 showed that R11 had been taking the [MEDICATION NAME] up to 4 times a day. The facility's nurse's notes dated February 1, 2017 documented R11 had 2 bowel movements (BMs). The next documented BM was February 6, 2017. Nurse's notes dated February 8 & 9 documented, R11 complained of sharp abdominal pain, R11 stated she has to use the toilet, had a small pasty bowel movement with firm abdomen and bowel sounds hypoactive. R11 was given Senna Laxative and fleet enema and had BM. The nurse's notes contained no documented BMs from March 1-9, 2017. However, one note dated March 3, 2017 documented, resident stated she feels like she has to go. March 10, 2017 the nurse's notes documented that R11 had a BM which contained blood. R11 had emesis (vomit) on March 11, 2017 and was refusing lunch due to upset stomach. She was given [MEDICATION NAME] at 8:30 am and 12:35pm. On March 12, 2017 the nurse's notes documents that R11 complained of feeling the need to have a BM but can't get it out. CNA (Certified Nursing Assistant) staff states resident has stool seen in the rectum that is hard and cannot be passed. At 10:30pm, she did not void (urinate) all day, and there was blood in her stools. Z1 (Medical Doctor) ordered laxative and straight catheterization. On March 14, 2017, R11 was again complaining of constipation. On March 15, 2017, the nurse's notes documents that R11 complained of abdominal pain at 7:20am and received an order for [REDACTED].>At 10:38am, R11 was in bed and appeared drowsy. E3 (Registered Nurse/RN) entered R11's room to administer [MEDICATION NAME] suppository and [MEDICATION NAME] for pain. Upon entry into the room, R11 was under her covers and lying on a bed pan. E3 stated she would come back once R11 was done. At 11:14am, E3 went back to R11's room and emptied the bed pan. There was a hard dark colored stool noted in the bed pan, along with some soft stools. E3 stated R11 was constipated. E3 wiped R11 with tissue, and then there were liquid and pasty stools coming from her rectum. Z1 entered as E3 wiping the stools from R11. There were pasty stools on her buttocks at the time. Z1 then assessed R11's stomps, and stated we have to get you eating. E3 got E5 and E6 (both Certified Nursing Assistants/CNAs) to finish cleaning/bathe R11. As staff cleansed R11, she groaned and complained of severe abdominal pain. R11 was sent to the hospital at 2:45pm after continued complaints of abdominal pain. On March 15, 2017, E2 (Director of Nursing) provided R11's bowel and bladder tracking. On March 16, 2017 at approximately 9:00 am, E2 stated the facility does not have a bowel and bladder program. R11 remained in the hospital. E2 stated that tracking forms are kept in the binders by the CNAs on the unit. As of 1:50pm on March 16, 2017, there was no bowel and bladder tracking provided. There were no tracking sheets in the CNA binder for R11. Upon entry into E2's office, E7 (RN) was sitting at a desk documenting on papers. There were a pile of bowel and bladder tracking forms on the desk. E2 stated she has the tracking sheets for R11. E2 then provided sheets for March 1- 15, 2017, which documented R11 was having 1-4 bowel movements daily. This was inconsistent with her nursing notes, and no description of all the stools documented. E2 provided the tracking forms for January-February 2017. E2 then searched through the pile by E7 and located the forms. E2 stated that E7 came in to assist with forms. There were several days of the incontinence section not being completed. The tracking sheets were not consistent with R11's nursing notes. On March 16, 2017 at 3:00pm, Z1 stated R11 had been having hard stools, with some solid dark color stools. Z1 stated there would be blood noted after R11 had hard stools. Z1 stated R11 received suppositories and enemas but her stomach pain was not related to constipation. Z1 added when R11 had a soft stool, it meant at that time she was momentarily relieved. Z1 stated R11's stools are not consistent with constipation. Z1 also stated that it is the facility's responsibility, and not his to monitor R11's stools every day. A hand written Interim Care Plan dated January 30, 2017 for R11 documented: Constipation- will have a bowel movement every 2-3 days. Monitor for bowel movements and record. Computer generated care plans with a reviewed/revision dated of February 9, 2017 did not contain a care plan for constipation or elimination. R11's CT (Computed Tomography) report from the local hospital dated March 15, 2017 documents: Impression: Severe fecal loading and rectal impaction with findings suggestive of stercoral [MEDICAL CONDITION]. The facility's policy titled Effective Bowel Elimination documents: When a potential problem, constipation/diarrhea, is identified, a care plan will be developed by the interdisciplinary team, to include nursing and dietary. -Each day, the bowel record will be reviewed and the laxative list for residents who have not had a bowel movement in three days will be initiated. Face Sheet documents R1 was admitted on [DATE] with admitting [DIAGNOSES REDACTED]. On March 14, 2017 at 10:02 AM, R1 was laying in bed with a large bruise on the temporal forehead and attached steri-strips. R1 also had bruises to the face and hands. R1 was unable to answer any questions about the bruising. Z2 ( power of care for R1) was in the room visiting, Z2 said she visits twice a week and hopes everything is well. On March 15, 2017 at 9:49AM, E2(Director of Nursing) said the wound care physician had just changed R1's stage 3 pressure sore wound. On March 15, 2017 at 10:00AM, R1 was laying in bed, there was no one else in the room. R1 was moving her head from left to right and groaning, my butt hurts. There was no accessible call light. E4(Nurse) was immediately made aware at the nursing station and responded R1 had a sacral wound treatment with the wound care physician earlier and received no pain medicine. E4 went into the room and quickly exited and said, R1 did not complain of any pain. E4(Nurse) went back into R1's room, shortly after communicating there was no pain. At 10:07AM, E4 asked R1 if she was in pain, R1 looked from the left to the right and in a low voice said my butt, my butt hurts. As E4 began to verbally question R1 about the pain R1 became confused, and said, I don't know , I don't know with tears in her eyes. E4 said she assesses R1 using a verbal pain scale, then E4 said she would get the aides to change R1's position in bed. E4 said she would administer Tylenol to R1. On March 15, 2017 at 10:12AM, E15(Certified Nursing Assistant, CNA) entered the room to change R1's position. R1 eyes enlarged and she began to cry during the turning. On March 15, 2017 at 10:15AM, E17(Social Worker) said R1 always grimaces and moans, that is her usual state. On March 15, 2017 at 1:09 PM, R1 was sitting in an adult recliner slumped down, crying facing the window in the room with the door opened. There was no one else in the room. R1 repeated several times in a low pitched voice help me , help me. There was no call light accessible. Immediately E4(Nurse) was informed at the nursing station. E4 responded, I will send the aids down to her room to reposition R1. E4 made no observation assessment. On March 15, 2017 at 1:12 PM, E13(CNA) and E14(CNA) both entered the room and began to move R1 from the adult recliner to the bed. R1 was groaning and grimacing during the procedure. During the transfer, E13(CNA) said she is very familiar with R1 and said R1 is always in pain and is on hospice and R1's pain and comfort is not being managed. E13 said she worked on March 13, 2017 and came into the dining room and saw R1 on the floor with a pool of blood all over. That is why R1 has all of the bruises. R1 fell out of the chair because of the pain on her butt. With all of the blood on the floor due to the facial laceration, R1 just kept complaining about butt pain. They want us to move R1 in bed every 2 hours, get her up in the adult recliner, R1 can't take all of this she is on hospice. R1 has been in significant pain for the last 2 weeks, I told the nurse, no one listens. I care about this resident, R1 is just not getting what she needs. As R1 was placed in bed, the dressing on R1's sacrum was soiled and dated 3/14/2017. On March 15, 2017 at 1:26 PM E7(Nurse) entered the room and said moving forward she will call and get hospice to make new pain management/comfort orders for R1 because R1 should be kept pain free and comfortable, that is the goal of hospice. On March 15, 2017 at 1:36 PM E4(Nurse) entered the room and said she used the verbal pain scale for R1 earlier and she was rated a 4 on a scale of 1-10, and administered Tylenol. E4 said R1 has an order for [REDACTED]. Physician Orders, Hospice Visit and Social Service Notes dated November 22, 2016 shows R1 was admitted to hospice. Physician order [REDACTED]. Hospice Intake Sheet dated February 23, 2017 states, R1 was switched to another Hospice provider on 2/23/2017 with orders for [MEDICATION NAME] 5-10 Milligrams every 4 hours for moderate to severe pain/dyspnea and [MEDICATION NAME] Suppository 650 Milligrams rectal every 6 hours for mild pain/fever. The last Pain Questionnaire implemented for R1 was dated December 8, 2016. Wound Care Specialist Initial Evaluation Notes dated January 25, 2017 document R1 developed a stage 3 pressure ulcer of at least 1 days duration and Fall Incident Report dated March 11, 2017 states, R1 fell out of the adult recliner sustaining facial and hand lacerations. There was no Comprehensive Pain Assessment for R1 following the development of the sacral sore or the fall. Social Service Note dated March 2,2017 states, R1 is on Hospice due to cognition and health decline and recently changed hospice providers. R1 is confused and short and longterm memory is not good. The Medication Administration Record [REDACTED]. No further pain medications were administered. The Hospice Care Plan dated November 22, 2016 and revised on March 2, 2017 goals is as follow, For facility and Hospice to work together as a team in creating an environment and level of care that will focus on building R1's needs. There is no pain management or comfort interventions in the plan of care. The pressure ulcer care plan initiated on January 2017 does not address pain but does list to turn and reposition and lay down after meals. Restorative Program for March 2017 documents R1 is still on Passive Range of Motion and turning and repositioning programs. Minimum Data Set Brief Status for Mental Health dated March 2, 2017 documents R1 with moderately impaired cognition. The Facilities' Policy titled Pain Management last revised July 2014 states, Residents should be evaluated and treated for [REDACTED]. On March 16, 2017 at 10:00AM, E2(Director of Nursing, DON) said we are moving forward and initiated a PANAID scale for R1 to utilize for pain assessment, this is for confused residents. We should work together with hospice to ensure residents are assessed and managed effectively for pain and comfort. E2 said there was no comprehensive pain assessment and it will be implemented along with additional pain/comfort measures/orders for R1. On March 16, 2017 at 3:11 PM, Z1(Medical Doctor) said he was the physician for R1 and pain/comfort are the goals for hospice. Z1 said the nurses should contact the hospice doctors for pain/comfort order and changes. R15 admitted to facility December 22, 2016 with complaint of abdominal pain. No further assessment of abdominal pain. R15 was being consulted for hospice services on admission. December 24, 2016 nurses notes documentation includes the only December 2016 bowel movement monitoring, stating had a loose BM (bowel movement), resident stated It's been a while. R15's January 03, 2017, 5:15 PM progress note documents resident complaint of rectal pain at 5 PM. [MEDICATION NAME] given per request. Looked at bottom, no open sores, no discoloration noted, barrier cream applied, will monitor. No further monitoring was documented related to rectal pain. The next nurse's progress note is dated January 11, 2017 documenting physician ordered a stool softener (Senna tab 8.6 milligram daily). R15's next descriptive bowel movement documentation was January 14, 2017 R15 had one time (X1), small mushy BM. The next nursing progress note dated January 20, 2017, 5:50 PM including complaint of pain on urination. No further documentation of assessing R15 for pain or difficulty with urination. The next nursing progress note dated January 21, 2017 9:00PM including R15 had blood on anus when nurse aide changed R15. No wounds noted, area opening red and somewhat excoriated. R15 vomited brownish liquid. Nurse called to bedside by nurse aide. There is no documentation R15's physician was notified of these condition changes. No monitoring of residents rectal bleeding or vomiting documented after initial observation January 21, 2017 at 9:00PM. The next nursing progress note January 22, 2017 at 9:15AM, including resident is slow responding to verbal stimuli, blood pressure 100/78, significantly lower than previous readings / baselines documented. No documentation of physician notified of sluggish response and decreased blood pressure. The next nursing progress note January 22, 2017 4:00PM including blood pressure lower 92/56, no documentation of physician notification. The next nursing progress note January 22, 2017 4:20 PM stating no respirations, no blood pressure or pulse, confirmed with another nurse. R15's physician was called at 4:40 PM. Other than the December 24, 2016 and January 14, 2017 nursing progress notes, there is no other descriptive documentation of R15's bowel movements / even with symptoms of gastrointestinal changes. During interview March 17, 2017, 9:55 AM E2 (director of nurses), stated after reviewing R15's medical records E2 was unable to locate any other documentation than that listed above regarding change in condition, descriptive bowel movement monitoring or physician notification of change in condition.