Every finding on record at Ignite Medical Mchenry

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 3 residents (R1) reviewed for safety in the sample of 3The findings include:R1's Physician Order Sheet dated 7/26 show R1 has diagnoses that include history of urinary tract infections (UTI), stroke affecting left dominant side and muscle weakness.R1 fall risk assessment dated [DATE] shows R1 is high risk for falls.R1's fall incident report dated 7/8/26 timed at 17:50 (5:50PM) documents, this nurse heard someone yelling out down the hall, upon entering [R1's} room, she was observed on the floor next to her bed wrapped up in a blanket and her oxygen tubing.environmental assessment show that this incident was most likely related to residents generalized weakness, impaired mobility history of CVA (stroke) with left hemiplegia. R1's care plan dated 6/29/26 show, The resident is at risk for falls. (R1) had an unwitnessed fall with no injury - observed on the floor next to her bed wrapped up in a blanket and her oxygen tubing. With intervention to include: 07/08/2026: Place a bedside floor mat adjacent to the bed to provide a cushioned surface during bed mobility and reduce the risk of injury associated with a change of plane. Bed in low position when in [NAME] 7/16/26 at 9:15 AM, R1 was in bed with oxygen via nasal cannula intact. R1's bed was not in low position; it was elevated to hip level. There was no fall mats noted on R1's floor. R1 said she had fallen out of bed from getting out of bed by herself. At 9:30 AM, V3 (Registered Nurse) and V4 (Certified Nursing Assistant-CNA) were in R1's room to reposition R1 in bed. R1's overbed table was also moved near R1. R1's bed was not in the lowest position. There were no floormats noted in R1's room. At 10AM, 11AM, and 12:30 PM, this surveyor noted R1 remained in bed, R1's bed was not in the lowest position. There were no floor mats on the residents' floor.On 7/16/26 at 1:15 PM, V5 (Certified Nursing Assistant-CNA) said she was R1's CNA today. V5 said she saw R1 around 7 this morning for initial rounds then later to check R1's vital signs. R1's bed was not in lowest position. V5 said there was no floor mats noted. V5 said this was the first time she was taking care of R1 and was not familiar with her care or fall interventions. On 7/16/26 at 1PM, V4 (CNA) said she was in R1's room earlier assisting V3 (RN) to reposition R1 in bed. V4 also said she did not notice any floormats and R1's bed was not in low position. On 7/16/26 at 12:30 PM, V3 (RN) said R1 was a fall risk due to history of falls. R1 was highly anxious. R1 does not wait for assistance. R1 has behaviors of getting out of bed unassisted not waiting for assistance. V3 said there were no floormats in R1's room and R1's bed was not kept in the lowest position. V3 said for R1 who has history of falling out of bed due to attempts of getting out of bed unassisted, keeping the bed in the lowest position reduces the distance of the fall. Floormats can reduce the risk of injury if a resident falls out of bed. On 7/16/26 at 12:40 PM, V2 (Asst Director of Nursing) said fall interventions should be in place for residents identified as high risk of falls or with history of falls. Bed should be maintained in lowest position for residents' safety. Floormats should be in place. If the floormats are soiled, and need cleaning, a replacement should be provided for the intervention to remain in place.The facility policy on Fall Prevention dated 5/2026 shows, to ensure all residents have the necessary interventions in place to help prevent falls and promote safety in accordance with all state and federal regulations. Each resident residing at this facility will be provided with services and care that ensures that the residence environment remains as free from accident hazards as possible and its resident receives adequate supervision and assistive devices to prevent accidents.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: The facility incident report sent to the Illinois Department of Public Health showed on 6/8/26 that V2 (CNA-Certified Nurse Aide) reported V3 (CNA) hit a resident (R1) in the head. R1's face sheet printed on 6/16/26 showed diagnoses including but not limited to left femur fracture (at admission), age-related osteoporosis, heart disease, protein-calorie malnutrition, and dementia. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance needed for hygiene care, dressing, rolling, and transfers. The same assessment showed that R1 is always incontinent of urine and bowel. R1's care plan showed a focus area related to potential for alterations in psychosocial well-being, can get agitated due to dementia, mostly in the evenings. Interventions included allow resident time to answer questions and to verbalize feelings, perceptions, and fears (start dated 5/22/26). R1's care plan showed a focus area related to impaired cognition function and/or impaired thought processes. Interventions included ask yes/no questions in order to determine needs, communicate with resident, cue, reorient and supervise as needed (start dated 5/22/26). On 6/16/26 at 11:45 AM, V2 (CNA) said on a Monday (6/8/26) around 9:30 PM, he was being trained by another CNA (V3). V2 said they entered R1's room and began evening care including changing the incontinence brief. V2 said he had been told R1 can be aggressive and combative during cares. V2 said they were rolling R1 from side to side to change the brief. V3 was not using any comforting language and was being rough while turning R1. V3 was turning R1 quickly and not responding to R1. R1 repeatedly said stop, ouch, get away. V3 did not change her speed or care methods. V2 said V3's actions were clearly causing R1 to get upset. R1 began cussing and swinging her arms at V3. V2 said the resident ended up hitting V3 in the face. V3 paused a few seconds and then hit R1 on top of the head. V2 stated, I know the difference between a reflective action and using a decision to act. It was not an oh my gosh moment, I need to protect myself. It was clearly retaliatory. V2 said V3 never said anything during the exchange with R1. V2 said Oh wow, you just hit a patient. That is crazy. V3 just looked at me without response. R1 stopped swinging her arms and moved her hands toward her head. V3 covered R1 up with a blanket and they both exited the room. V2 said he was dumbfounded and walked a quick lap around unit. V2 stated then he reported the incident to the floor nurse (V4). V2 said he sent a text to the general manager (V1) after that. V2 said V3 got pulled from the floor shortly after that. V2 said V3 should have left the room and returned later as soon as R1 became aggressive. V3 should have stopped the care and reported it to the nurse. V2 said the fact that V3 continued care caused R1 to be even more combative. On 6/16/26 at 12:05 PM, V3 (CNA) stated she was terminated on 6/8/26 due to the accident involving R1. V3 said she was providing incontinence care to R1 and was training a new aide (V2). R1 became combative while being rolled side to side in bed. R1 was hitting out with her hands, swinging her arms and trying to scratch at V3. R1 was confused and yelling out for her mother to come help her. V3 said she was holding R1's hands and continued doing the care when all of the sudden R1 hit V3's cheek. V3 said she was moving herself backwards to get out of the way and accidentally touched R1 on the head. V3 said R1 does scream a lot during cares. V3 said normally she tries to calm R1, give her choices, and ask what she wants to do. V3 said I know I need to be gentle and talk with R1 to keep her calm. R1 was calm at first then it just went away in the middle of things. V3 said she told the floor nurse (V4) about the exchange as soon as she left the room. V3 said she was sent home shortly after that until an investigation was done. V3 said she was never allowed to return to work after that evening. On 6/16/26 at 10:56 AM, V4 (Licensed Practical Nurse) stated he was working the evening of 6/8/26. V3 was training a new aide (V2). V4 said at some point that evening V3 asked him to look at her eye for any swelling because R1 had just hit her. V4 said he looked at V3's eye and then said he needed to report the incident. V4 said right after that V2 came to him and said he witnessed a disturbing incident. V2 told him that V3 hit a resident. V2 reported that R1 had swung at V3 and V3 swung back at her. They were doing resident care together and R1 became aggressive. V4 stated R1 normally is combative and gets aggressive if she does not want to be touched. R1 is confused with dementia. Staff need to explain what they are doing and keep a safe distance if she is in a fighting mood. She swings her arms a lot during care. Her mood varies between sweet one day then aggressive the next. V4 said he reported the incident to the chain of command. V4 said he called V7 (Assistant Director of Nurses) and she reported it to the abuse coordinator (V1). V4 said he was told to send V3 home, pending the investigation which he did. V4 said he spoke to V3 before she left the building. V3 said she was trying to defend herself while changing R1 and V3 hit her back. V4 said he definitely remembered V3 said those exact words. V3 was trying to make it sound like an accident though. V4 stated he assessed R1 immediately after the incident and did not see any injury or signs of pain. V4 continued monitoring R1 throughout the night and did not see any changes. On 6/16/26 at 12:45 PM, V5 (CNA) stated we are trained to calm down combative residents by using a calm voice and give them space. We should use a reassuring voice, don't hold them down or continue to force care. If someone is clearly distressed and yelling out that is an indication something is wrong. Aides should go tell the nurse and re-approach later. On 6/16/26 at 1:00 PM, V6 (Licensed Practical Nurse) stated R1 has known behaviors, especially during personal care with the aides. R1 slaps out, grabs arms, and yells out with confusion. Staff should stop what they are doing and let the floor nurse know. It is important for resident safety and staff safety. On 6/16/26 at 1:10 PM, V7 (ADON) said she did receive a call on 6/826 from V4. It was reported that V2 witnessed V3 hit a resident during care. V7 told V4 to remove V3 from resident care and V1 was notified. V7 said she spoke with V2 and V3 the same evening. V2 told her R1 hit V3 first and V3 smacked R1 back on the head. V7 said V3 denied hitting her, but that she just touched her face to tell her not to hit. V7 said that statement does not make sense. V3 was terminated after the incident. V7 said the definition of abuse is any willful infliction of harm of any type. Holding a resident's arms, striking, or hitting a resident are all forms of abuse. On 6/16/26 at 1:43 PM, V1 (General Manager, Abuse Coordinator) stated V7 called him the evening of 6/8/26 and reported V3 had been suspended. V1 spoke with V2 and it was reported V3 hit R1 after she became combative during care. V1 said staff should use a person centered approach during care. If a resident becomes combative staff should separate and let the resident deescalate. R1 definitely reacts better to slow motions. Staff should not hold arms down or restrain residents. That is against our abuse policy. Staff should follow personal interventions to ensure a quick way to deescalate. It is the correct and safe thing to do. V1 confirmed V3 was terminated after the investigation. V1 said it was determined V3 could have done things differently and did not follow the policies for deescalating a resident. The facilities Abuse and Neglect policy last revision dated April 2026 states: It is the policy of this facility to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property by implementation of specific procedures listed in the required components of the policy. The policy defines abuse as: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. The facility provided documentation of V3's termination form dated 6/11/26. The form showed V3 was terminated due to the incident of 6/8/26 after it was determined the staff member failed to follow the facility abuse policy and competency training regarding de-escalation of agitated residents.

Based on interview and record review the facility failed to ensure pain medications were administered in a timely manner which applies to 1 of 3 residents (R1) reviewed for Pain Management in a sample of 3.The findings include:R1's admission Record printed 2/23/26 showed R1 is an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery and presence of left artificial hip joint.R1's Brief Interview for Mental Status assessment dated [DATE] showed R1 was cognitively intact.R1's Physician Order Summary Report printed 2/23/26 showed R1's pain medication ordered upon admission was Oxycodone-Acetaminophen oral tablet 10-325 milligrams (Percocet) to be given every 4 hours as needed for pain.On 2/23/26 at 12:25 PM, R1 stated they were taking their pain pills every 4-5 hours. R1 stated if they went longer than that the pain would get bad. R1 stated on 2/14/26 they told V15 Certified Nursing Assistant (which fits the description given by R1) around 7 PM they needed some pain medication. R1 stated they were told it was shift change, and it may be a little bit before the nurse was in. R1 stated the next person she saw was V11 Licensed Practical Nurse at 8:30 PM. R1 stated their pain had gotten pretty bad (7/10) by the time V11 came to the room. R1 stated V17 (R1's family) was on speaker phone at that time. R1 stated V11 stated they were not told R1 had asked for pain medication.On 2/23/26 at 2:15 PM, V17 stated they were on the phone with R1 at 8:30 PM on 2/14/26. V17 stated R1 sounded upset, told them R1 request medication at 7:00 PM, and had not seen anyone since. V17 stated V11 came into the room to see R1. V17 stated V11 said she was not informed R1 had asked for pain medication. V17 stated they heard R1 tell V11 their pain was 7/10.On 2/23/26 at 6:10 PM, V11 stated they rounded on R1 for evening medication rounds. R1 was grimacing, agitated, and said she was in pain (7/10). V11 stated they were not told in report or by a CNA R1 had requested pain medication prior to V11 entering the room. V11's shift started at 7 PM. V11 stated they entered R1's room around 8:30 PM on 2/14/26. V11 stated if they were told R1 needed pain medication they would have administered it sooner.R1's Vital Summary (pain) printed on 2/23/26 showed R1's pain level was a 7/10 at 8:30 PM on 2/14/26.R1's Medication Administration Record printed 2/23/26 showed R1 received a doses of Oxycodone on 2/14/26 just before 2:00 PM and the next dose at 8:30 PM (6.5 hours between doses).On 2/23/26 at 12:40 PM, V3 Director of Nursing stated a resident's pain level is what they say it is. If a CNA is told by a resident they need pain medication the CNA needs to let the nurse know so the nurse can do something about it.R1's Initial Care Plan dated 2/12/26 showed R1 is having pain in the left hip and lower back. An intervention for pain is to respond immediately to any complaint of pain.The facility's Pain Management Policy dated 1/1/26 showed the facility must ensure that pain management is provided to residents who Require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on interview and record review, the facility failed to ensure medications were administered to a resident (R1) per physician's orders. This applies to 1 of 4 residents reviewed for pharmacy services in the sample of 4.The findings include:R1's electronic face sheet printed on 12/11/25 showed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to interstitial pulmonary disease, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, congestive heart failure, and pulmonary hypertension.R1's physicians orders dated 11/27/25 showed,Incruse Ellipta Inhalation 62.5mcg/act 1 puff inhale 1 time a day for COPD.R1's medication administration record for November and December 2025 showed R1 did not receive his Incruse Ellipta inhaler from 11/28-12/1. (4 missed doses)On 12/11/25 at 10:18AM, V3 (R1's significant other) stated, The day after (R1) was admitted , I called the nurse & asked if he got his medications and the nurse said they were trying to find them, so he didn't have them yet. She said she couldn't get the inhaler and the Incruse because they needed some type of authorization because of the cost. She said she would go try to find them. The next morning (12/29) they didn't have the inhaler and the Incruse and the Combivent. Tuesday (12/2) I said I don't ever remember him getting his Incruse and the nurse said it wasn't on her schedule to give to him. She opened the medication drawer and his Incruse was there, and it had a date of 11/28 with his name and the directions. The medication was brand new and had never been opened. The day (R1) went to the hospital; I asked to see his medications and his Incruse had only 2 doses used for the 6 days (R1) was at the facility.On 12/11/25 at 12:12PM, V8 (Registered Nurse) stated, Pharmacy deliveries are twice a day but I'm not sure about the weekends. For new admissions we put all of their orders in the computer and the pharmacy usually gets the medications to us by the next day at the latest. We aren't usually informed by the pharmacy if a medication needs a prior authorization unless the pharmacy just doesn't deliver it. That's about the only way we know until they send a prior authorization slip to us. On 12/11/25 at 12:52PM, V11 (Licensed Practical Nurse) stated, I remember (R1's) wife asking for all of his medications when he went to the hospital and one of his inhalers, I think Incruse or something like that only had 2 doses used for the 6 days he was in the facility. She was pretty upset about that.On 12/11/25 at 2:10PM, V2 (Director of Nursing) stated, Medications arrive three times a day in the facility and we have STAT orders we can do too. We find out if medications need prior authorization before the residents are admitted so we can get that taken care of prior to admission. I wasn't aware (R1) needed any prior authorization for any medications. I'm not aware that he missed any doses of his Incruse. Nurses should be communicating with me when a medication is not available.The facility's policy titled, Physician's Orders dated 11/2024 showed, All medications will be administered as ordered by a healthcare professional .

Based on interview and record review, the facility failed to ensure a resident (R4) did not experience a significant medication error. This applies to 1 of 4 residents reviewed for medications in the sample of 4.The findings includeR4's electronic face sheet printed on 12/11/25 showed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to type 2 diabetes, cerebral infarction, dementia without behaviors, and atrial fibrillation.R4's physician's orders dated 12/3/25 showed, Insulin Glulisine 100units/ml Inject per sliding scale three times a day for diabetes mellitus .R4's medication administration record for December 2025 showed R4 did not receive any of his Insulin Glulisine doses on 12/4/25 (3 missed doses) and had blood sugar readings between 240-365 which would have required sliding scale insulin administration per R4's physician's orders.On 12/11/25 at 12:17PM, V9 (Licensed Practical Nurse) stated, Medications for new admissions come the next morning, we have a morning, afternoon, and nighttime run. If they have nighttime medications, they probably just wouldn't get the medications. I would notify the residents provider and pharmacy if insulin wasn't available upon admission. I was told (R4) couldn't be on 2 rapid acting insulins per his insurance, so he was changed to just 1. We should be calling the provider immediately if something significant like insulin isn't available, you can't just not give it. On 12/11/25 at 2:10PM, V2 (Director of Nursing) stated, Medications arrive three times a day in the facility and we have STAT orders we can do too. We find out if medications need prior authorization before the residents are admitted so we can get that taken care of prior to admission. I wasn't aware (R4) needed any prior authorization for any medications .(R4) missing his insulin doses is considered a significant medication error and should have been communicated to the physician immediately to obtain new insulin orders. Nurses should be communicating with me when a medication is not available.The facility's policy titled, Physician's Orders dated 11/2024 showed, All medications will be administered as ordered by a healthcare professional .The facility's policy titled, Administration of Medications dated 07/2025 showed, .22. If a medication is ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication.

Based on observation, interview and record review the facility failed to store controlled drugs in a secure manner. This applies to all the residents in the facility.The findings include:The Centers for Medicare and Medicaid Services form 671 dated 11/18/2025 shows there were 84 residents in the facility. On 11/19/2025 at 2:00 PM the Medication room on the [NAME] unit was observed. In the unlocked refrigerator in the medication room, three convenience containers were observed to contain Lorazepam (a schedule class 4 controlled substance and an anti-anxiety medication). Six vials of Lorazepam 2 milligram (Mg) per milliliter (ML) and 3 vials of Lorazepam 2mg per ML in 30ml vials.On 11/29/2025 at 9:50 AM, V2 Chief Nursing Officer said Lorazepam is a controlled drug and should be double locked. V2 later said the refrigerator was not able to be locked.The facility policy with a revision date of 11/2024 for controlled medications shows medications listed in schedules 2-5 are to be stored under double lock in a locked cabinet or safe designated for that purpose.

Based on observation, interview and record review the facility failed to maintain a sanitary kitchen environment. This applies to all the residents in the facility.The findings include:The Center for Medicare and Medicaid services form 671 dated 11/18/2025 shows there were 84 residents in the facility.On 11/18/2025 at 10:00AM, work surfaces in the kitchen, the floors of the kitchen, the floors of the dry storage, refrigerator and freezer were observed with food debris. The carts used to transport the resident food trays to the units were observed with dried food debris. A large pile of empty boxes and other garbage bags were observed within the kitchen on the floor. The monthly cleaning list posted in the kitchen was dated October 1, 2025, with the direction that assigned staff must initial after completion of the task. The form had only four spaces completed. No sheet for November 2025 was observed.On 11/19/2025 at 11:00 AM, V5 Executive Chef said the dietary department is short of staff and could use another employee to run the dishwasher and assist with the cleaning duties. V5 said it's important to have a clean kitchen to prevent a food borne illness. V5 said he always checks with the staff to make sure the cleaning has taken place before the employees leave for the day, but he was not checking the cleaning list for completion of the tasks.The Dietary cleaning policy with a revision date of 11/2024 shows the facility will store, prepare, distribute and serve food under sanitary conditions to ensure that proper sanitation and food handling practices to prevent the outbreak of food borne illnesses is attained continuously. The procedures show wipe any spills on the floor immediately, keep the floor free of debris. The staff will use a clean as you go technique to the kitchen areas clean. Clean and sanitize the work area, tables, chairs using sanitizer spray. Sweep floors in kitchen and then wet mop the floors. Staff members are responsible for checking the cleaning schedules daily to ensure that tasks scheduled are completed.

Based on observation, interview, and record review the facility failed to provide complete grooming/personal hygiene for a female resident with long facial hair to her chin for 1 of 1 residents (R9) reviewed for activities of daily living in the sample of 34.The findings include:On 11/19/2025 at 9:16 AM, R9 was sitting in a padded wheelchair in the common area. R9 was dressed and had a blanket over her lap. R9 had long white whiskers to her chin area. R9 was observed scratching the hair on her chin. R9 was confused and could not be interviewed. On 11/19/2025 at 2:11 PM, V10 Certified Nursing Assistant - CNA stated residents are given showers twice per week and shaving is done for men and women at that time. V10 stated they don't have any female residents that refuse to have facial hair shaved. V10 went to R9's room to see the facial hair that was present and stated hospice was doing her showers and stated she would talk to hospice about it. On 11/19/2025 at 2:21 PM, V11 Licensed Practical Nurse - LPN went to R9's room and stated R9 needed to be shaved. V11 stated that he thought she had it done in the beauty shop and the last time she went to the beauty shop was two weeks ago. The Minimum Data Set, dated [DATE] for R9 showed moderate cognitive impairment; dependent for shower/bathing, and personal hygiene. The Care Plan dated 11/7/25 for R9 showed she has an activity of daily living self-care performance deficit and limited physical mobility related to fatigue, impaired balance due to weakness and advanced disease, and chronic back pain. Shower/bathe self: extensive assist. Personal Hygiene: assist. The Face Sheet dated 11/19/25 for R9 showed diagnoses including heart failure, epilepsy, syncope and collapse, atrial fibrillation, hypertension, dorsalgia, dementia, chronic respiratory failure, peripheral vascular disease, delusional disorder, cardiac pacemaker, osteoarthritis, major depressive disorder, acute embolism and deep venous thrombosis. The facilities Activities of Daily Living policy (10/2024) showed, Procedure: A. Hygiene - Resident self-image is maintained.

Based on observation, interview, and record review the facility failed to provide care for a residents long thick toenails for 1 of 1 resident (R9) reviewed for activities of daily living in the sample of 34.The findings include:On 11/19/2025 at 9:16 AM, R9 was sitting in a padded wheelchair in the common area. R9 was dressed and had a blanket over her lap. R9 had slip on shoes with vented holes in them and her long thick toenails were visible through the holes. On 11/19/2025 at 2:11 PM, V10 Certified Nursing Assistant went to R9's room with the surveyor. R9 was lying in bed with her bare feet exposed. R9 had long thick nails and a thick yellow buildup on her great toes. R9 had flaky cracked skin to her feet. V10 stated the CNAs don't provide nail care to the resident's feet; it is done by podiatry. V10 stated when they notice a resident needs their toenails cut, they notify the nurse. On 11/19/2025 at 2:21 PM, V11 Licensed Practical Nurse - LPN went to R9's room and stated R9 needed to be seen by the podiatrist. The Minimum Data Set, dated [DATE] for R9 showed moderate cognitive impairment; dependent for shower/bathing, and personal hygiene. The Care Plan dated 11/7/25 for R9 showed she has an activity of daily living self-care performance deficit and limited physical mobility related to fatigue, impaired balance due to weakness and advanced disease, and chronic back pain. Shower/bathe self: extensive assist. Personal Hygiene: assist. The Face Sheet dated 11/19/25 for R9 showed diagnoses including heart failure, epilepsy, syncope and collapse, atrial fibrillation, hypertension, dorsalgia, dementia, chronic respiratory failure, peripheral vascular disease, delusional disorder, cardiac pacemaker, osteoarthritis, major depressive disorder, acute embolism and deep venous thrombosis. The facilities Activities of Daily Living policy (10/2024) showed, Procedure: Nail care will be provided as needed. CNAs or Nursing can reduce fingernails; however, toenails will be reduced by podiatry.

Based on observation, interview, and record review the facility failed to ensure an indwelling catheter was kept below the level of the bladder and off the floor during a transfer for 1 of 2 residents (R128) reviewed for catheters in the sample of 34.The findings include:On 11/18/25 at 12:16 PM, R128 was lying in bed with his lower body dressed, a hospital gown on his upper body, and sling to his left arm. R128 had the total lift sling under his body. R128 had an indwelling catheter draining clear yellow urine into the drainage bag attached to the side of the bed. R128 said they're getting me ready for my appointment. R128 said he was going to the urologist to get his catheter changed and for a check-up. V6 and V7 (Certified Nursing Assistants - CNAs) entered R128's room with the total lift. V6 and V7 attached the loops of the sling to the total lift. V6 (CNA) removed the catheter bag from the side of the bed and hooked it above the level or R128's bladder, on the lift sling. R128's urine flowed back into the tubing towards his body. R128 was lowered into the wheelchair and his catheter bag sat on the floor while they removed the lift from the room. V6 picked R128's catheter drainage bag off the floor and placed it in a privacy bag, under the wheelchair. R128's Face sheet dated 11/20/25 showed diagnoses to include but not limited surgical after care following a cardiac defibrillator placement, heart failure, ulcerative colitis, anxiety disorder, benign prostatic hyperplasia (enlarged prostate), anemia, generalized muscle weakness, difficulty walking and need for assistance with personal care. R128's Brief Interview for Mental Status Evaluation dated 11/20/25 showed he was cognitively intact. R128's Physician Order Sheet dated 11/20/25 showed he had an indwelling catheter. On 11/20/25 V3 (Assistant Chief Nursing Officer) said during a total lift transfer R128's catheter should not have been placed above the level of the bladder. V3 said the drainage bag placed above the level of the bladder can cause the urine to flow back into the bladder and increase the risk of an infection developing. V3 said the catheter should be placed in the resident's lap, lower than the bladder and not on the sling to prevent accidental dislodgement during the transfer. V3 said R128's catheter should not have been on the floor due to risk of contamination. The facility's revised policy 11/2024 showed, .14. Hang collection bag appropriately to the side of the bed, keeping it below the bladder and off the floor.

Based on observation, interview, and record review the facility failed to ensure gowns were worn when care was provided for residents on enhanced barrier precautions. The facility failed to ensure gloves were removed and hand washing was done after incontinence care and prior to touching resident contact surfaces. This applies to 3 of 8 residents (R42, R128 & R111) in the sample of 34.The findings include: 1. On 11/18/2025 at 11:02 AM, R42 was in bed on her back with a clean incontinence brief on and her pants down around her thighs. The soiled incontinence brief was in the garbage next to R42's bed. V8 Certified Nursing Assistant was next to R42's bed providing care; he had gloves on and did not have a gown on. V8 stated he just finished providing care for R42 and was getting her dressed. V8 turned R42 side to side to finish pulling up her pants. V8 removed R42's hospital type gown and put a shirt on her. V8 removed his gloves, left the room to get help for a mechanical lift transfer. R42 stated V8 helped her eat breakfast, changed her and got her dressed so she could get up. V8 came back into the room with V6 CNA, and V9 Therapy Tech to transfer R42 from her bed to wheelchair using the mechanical lift. They all had gloves on; no one was wearing gowns. They put offloading boots on her feet and positioned her feet on the footrests. V6 CNA was showed the magnet on R42's door frame that stated she is on enhanced barrier precautions. V6 stated R42 was on EBP for her wound and the magnet is up as a precaution, so they wear gloves when touching R42 or her boot. The magnet on the door frame stated enhanced barrier precautions. Everyone must clean their hands including before entering and when leaving room. Provider and staff must also wear gloves and gown for the following high contact guest activities: dressing, .providing hygiene, changing briefs or assisting with toileting On 11/19/2025 at 9:50 AM, V2 Director of Nursing - DON stated the EBP magnets are up for residents on EBP so people know they are on it, and it shows staff what they should wear such as gowns and gloves for the care listed on magnet sign. V2 stated they are up for infection control. V2 stated it is important to prevent staff from getting anything or the resident from getting anything. The Face Sheet dated 11/19/25 for R42 showed diagnoses including chronic kidney disease, type 2 diabetes mellitus with foot ulcer, peripheral vascular disease, diabetic neuropathy, obstructive sleep apnea, hypothyroidism, neuromuscular dysfunction of the bladder, retention of urine, major depressive disorder, glaucoma, hyperlipidemia, hypertension, urinary tract infection, charcot's arthropathy, pressure ulcer of left heel, anemia, and heart failure. The Physician Orders for R42 for November 2025 showed guest is on enhanced barrier precautions related to wounds. The Wound Round documentation dated 11/19/25 for R42 showed a left pedal foot partial thickness diabetic/vascular wound that was 9 cm x 5.5.cm x 0.10 cm. The Care Plan dated 11/17/25 for R42 showed R42 is on enhanced barrier precautions due to chronic wounds. The resident will have appropriate isolation precautions and procedures followed during the period that isolation is necessary per facility policy. The facility's Enhanced Barrier Precautions policy (March 2024) showed, this facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality. EBP is used in conjunction 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. Gowns and gloves are used during high -contact activities with increased risk for MDRO transmission to staff clothing and hands including but not limited to: dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care.wound care: any skin opening requiring a dressing. 2. On 11/18/25 at 12:16 PM, R128 was lying in bed with his lower body dressed, a hospital gown on his upper body, and sling to his left arm. R128 had the total lift sling under his body. R128 had an indwelling catheter draining clear yellow urine into the drainage bag attached to the side of the bed. V6 and V7 (Certified Nursing Assistants – CNAs) entered R128's room with the total lift. V6 and V7 were not wearing gown or gloves. They touched R128's bedding and attached the total lift sling. V6 removed R128's catheter bag from the side of the bed and placed it on the lift sling. They transferred R128 to the wheelchair using the total lift. V6 picked R128's catheter off the floor and placed it in the privacy bag, then assisted R128 with removing his sling and gown. V6 assisted R128 with putting on his T-shirt and zip up jacket, then placed the sling back on R128's left arm. R128's Physician Order sheet dated 11/20/25 showed he had an order for Enhanced Barrier Precautions due to an indwelling catheter and incision. This order was initiated 11/16/25. R128's Facesheet dated 11/20/25 showed diagnoses to include but not limited surgical after care following a cardiac defibrillator placement, heart failure, ulcerative colitis, anxiety disorder, benign prostatic hyperplasia (enlarged prostate), anemia, generalized muscle weakness, difficulty walking and need for assistance with personal care. On 11/20/25 at 9:08 AM R128's door had a sign that showed he was on Enhanced Barrier Precautions. This sign showed provider and staff must also wear gloves and gown for high contact activities. These activities included, but were not limited to dressing, transferring, and device care. The surveyor asked V3 (Assistant Chief Nursing Officer) if she knew why R128 was on Enhanced Barrier Precautions. V3 removed the sign and looked at the back and stated he had a catheter and wound. V3 said staff should be wearing a gown and gloves whenever providing hands on care to R128. V3 said a gown and gloves should have been worn for a total lift transfer, dressing, and handling R128's catheter. V3 said the purpose of wearing proper Personal Protective Equipment (PPE) during high contact activities was to protect the residents and staff. 3. R111's admission Record, provided by the facility on 11/20/2025, showed he had diagnoses including, but not limited to urinary tract infection (UTI), acute kidney failure, fracture of the third lumbar vertebra, age-related osteoporosis with current pathological fracture, COPD, anemia, vitamin D deficiency, muscle weakness, and need for assistance with personal care. R111's Order Summary Report, printed by the facility on 11/20/2025, showed an order started on 11/18/2025 for Enhanced Barrier Precautions due to R111 having an intravenous line (IV). The report also showed an order for Amoxicillin-Pot Clavulanate (a combination prescription antibiotic used to treat a wide range of bacterial infections) 875-125 mg (milligrams). Take one tablet by mouth two times a day for UTI for 10 days. R111's care plans, provided by the facility on 11/20/2025, showed R111 was on enhanced barrier precautions related to having an IV, had impaired cognitive function, and was dependent on staff for toileting, dressing, personal hygiene and transfers. On 11/18/2025 at 12:50 PM, V17 (Registered Nurse-RN) and V18 (Certified Nursing Assistant-CNA) were providing incontinent care for R111. R111 had been incontinent of stool. V18, cleaned the stool from R111. V18 left the gloves on used for incontinent care and touched R111's bedside table to move it out of way. V18 touched the door handle to R111's closet, reached in and grabbed a pair of shorts, pulled up R111's socks and put the shorts on him. V18 touched the arm of the wheelchair to move it over, grabbed some wipes and cleaned a moderate amount of stool from the seat of R111's wheelchair. V18 removed the gloves and put on another pair of gloves. No hand hygiene (alcohol-based hand rub or soap and water) was performed between glove changes. V18 tied off the trash bag in R111's room, pulled her gown back, reached into her scrub pocket, grabbed a roll of bags out of her pocket and put a new bag in the trash can. V18 put the roll of bags back in her pocket, picked up a gait belt and placed the gait belt in her other pocket. On 11/20/2025 at 11:37 AM, V2 (Director of Nursing) and V16 (VP of Clinical Operations) said for infection control measures, the CNA should have removed the gloves used for incontinence care and performed hand hygiene, before touching anything in the environment, or the resident. V2 and V16 said V18 should have performed hand hygiene before putting the new gloves on. The facility's policy and procedure titled Handwashing, with a review date of 11/2024, showed proper hand washing is necessary for the prevention and the transmission of infectious disease. The policy showed 1. Handwashing is done before and after resident contact, before and after any procedure, after using a (tissue) or the restroom, before eating and handling food, when hands are obviously soiled and regardless of glove use. The facility's policy and procedure titled Gloves, with a review date of 11/2024, showed 1. Gloves are worn when there is a chance of coming into contact with excretions, secretions, blood, body fluids, mucous membranes, non-intact skin or other potentially infective material. 2. Gloves are discarded in the waste receptacle in the resident's room. 3. Staff should not walk in the hall or from room to room with the same gloves on their hands. 4. Hands should always be washed after removing the gloves. 5. Gloves are a one-time use only item.

Based on observation, interview, and record review, the facility failed to ensure residents were changed in a timely manner for 1 of 5 residents (R5) reviewed for ADLs (activities of daily living) in the sample of 7.The findings include:On 8/11/25 at 10:22 AM, R5 was lying in bed in her room. A strong, foul odor was immediately noted upon entering R5's room. V6 and V7, Certified Nursing Assistants (CNAs) were in R5's room to change her. R5's brief, pad, and sheet were all saturated through to the mattress with dark, foul-smelling urine.On 8/11/25 at 10:39 AM, R5 said no one changed her earlier.On 8/11/25 at 1044 AM, V7 said she did not change or help change R5 earlier today and she doesn't know when R5 was last changed as V4 was R5's CNA.On 8/11/25 at 12:33 PM, V4 said R5 is her resident today and she and V6 changed R5 at about 7:30 AM today. V4 said residents should be changed every two hours.On 8/11/25 at 1:01 PM, V2, Director of Nursing/Chief Nursing Officer, said incontinent residents are supposed to be changed every two hours and as frequently as needed. V2 said staff are to prioritize the residents who cannot tell if they are wet or not, and they should be changed first. V2 said if a resident is changed and they are wet again in an hour, then they must change them again.R5's current care plan initiated on 10/18/21 shows R5 is incontinent of urine. R5's current care plan initiated on 12/28/23 shows R5 has an ADL (activities of daily living) self-care performance deficit. R5 is dependent on staff for toileting and toileting hygiene.The facility's Incontinence Care Policy (last reviewed 11/2024) shows incontinence care is provided to keep residents as dry, comfortable and odor free as possible. Incontinent residents are changed every two hours and more frequently if needed.

Based on observation, interview, and record review the facility failed to provide notification when R1's psychiatric medication was discontinued for 1 of 9 residents reviewed for notification in the sample of 9.On 08/06/2025 R1 was not in the facility.R1's MDS-Minimum Data Set, dated [DATE] shows, R1's Brief Interview for Mental Status shows, moderately impaired.R1 has multiple diagnoses including, ADHD-Attention Deficit Hyperactivity Disorder, traumatic brain injury, dementia.On 08/06/2025 at 9:30AM, V6 R1's Husband said, a few years ago R1 had a cardiac event and lost consciousness. As she fell, she hit the front part of her head; we lost a large part of who she was. R1 has a diagnosis of ADHD. I do not know why the facility did not notify me of this change in treatment. R1 currently lives in Assisted Living with me. It allows me to care for her and prepare our house for sell. I contacted R1's psychiatrist. The psychiatrist said the treatment should not have been stopped. I would think the facility's physician would contact the treating specialist prior to stopping psychiatric treatment.On 08/07/2025 at 08/07/2025 12:59PM, V1 Administrator said, the physician's progress note was taken as the order to stop R1's medication. I do not have documentation that shows the resident, or family was notified of the medication change.R1's Physician's Progress Note dated 07/14/2025 by V8 Medical Doctor shows, ADD-Attention Deficit Disorder- Stable, STOP lisdexamfetamine, patient prescribed medication by psychiatrist as outpatient.

Based on observation, interview, and record review the facility failed to ensure R1 and R2 had a Physicians Order for the use of a CPAP-Continuous Positive Airway Pressure machine for 2 of 3 resident (R1,R2) reviewed for Respiratory Services in the sample of 9. 1.On 08/06/2025 at 10:18AM, R2 was lying in bed. R2's CPAP-Continuous Positive Airway Pressure device was on the bedside.On 08/06/2025 at 10:18AM, R2 said, my family set up the CPAP machine for me. The facility keeps the machine filled with distilled water. I put it on myself.R2's Physician's order dated 07/11/25 shows, Respiratory Therapy evaluate and treat if indicated.On 08/07/2025 at 3:00PM, V5 RT-Respiratory Therapy said, R1, R2, and R3 all use their home CPAP machines. As respiratory therapy we do not do anything with the resident's home machine. The Nursing staff contacts the physician for an order for the CPAP; the physician's order also contains the prescribed settings needed for the machine to operate correctly.R2's Physician's Orders on 08/06/2025 shows, R2 did not have an order for a CPAP machine.2.On 08/06/2025 R1 was not in the facility.On 08/06/2025 at 9:30AM, V6 R1's Husband said, I brought R1's CPAP machine to the facility. I showed the CNA-Certified Nursing Assistant how to use it. The CNA brought distilled water to the room. When I returned the next day the CPAP tank was dry; the gallon of distilled water was not open. No one helped R1 to apply her CPAP at night.On 08/06/25 at 1:56PM, V4 RN-Registered Nurse said, we get report from the hospital a resident is arriving with a CPAP. It is often written in the hospital discharge instructions. RT is not here all the time. If I see the resident has a CPAP at the bedside I will ask if they are using it. I will call the doctor and get an order. The Physician's Order populates in the Medication Administration Record and prompts the nurse to apply the CPAP or check that it is on and functioning.R1 Physician's Orders dated 07/03/2025 to 07/25/2025 shows, R1 did not have a Physician's Order for a CPAP.R1's Physician's Progress Notes dated 07/14/2025 shows, R1 has a multiple diagnosis including obstructive sleep apnea.R1's Hospital discharge Record dated 07/29/2024 shows, R1 is CPAP dependent.R1's Follow-Up by Nurse Practitioner Visit dated 07/22/2025 shows, patient reports she uses a CPAP every night.The facility's Respiratory Supplies policy reviewed 11/2024 shows, the policy does not address the need for a physician order for respiratory treatment.

Based on observation, interview, and record review the facility failed to ensure consents for administration were obtained prior to administering anti-psychotic and anti-anxiety medications. This applies to 1 of 4 residents (R2) reviewed for psychotropic medications in the sample of 6. The findings include: R2's Census Report shows R1 originally admitted to the facility on [DATE] and left the faciity on 5/4/25 for a hospital stay. R2 returned to the facility on 5/11/25. R2's Hospital Discharge Paperwork dated 5/1/25 shows R2 was ordered to take escitalopram oxalate 20 milligrams (mg) one tablet daily and trazodone 50 mg one tablet nightly as needed. R2 was not ordered to take quetiapine while at the hospital or upon discharge from the hospital. On 6/2/25 at 12:15 PM, V8 (R2's Family Member) could not recall the facility providing V8 with a consent form to sign to provide V8 with quetiapine. V8 said V11 (R2's Son) and R2 were also both unaware of receiving a consent form to be administered quetiapine. V8 said while R2 has been taking quetiapine at the facility, R2 has not experienced any negative reactions and R2's behavior, mood, and speech have improved. 1. R2's May 2025 Medication Administration Record (MAR) shows R2 received quetiapine fumarate 50 mg at bedtime on 5/3/25. Facility provided consent for psychotropic medication use form for quetiapine fumarate, dated 5/1/25, does not have a signature from R2, V8, or V11 and does not show that V8 or V11 provided verbal consent over the phone for R2 to receive quetiapine fumarate. Facility provided consent for psychotropic medication use form for quetiapine fumarate, dated 5/13/25, shows R2 consented to receiving 50 mg quetiapine twice daily; once in the morning and once at bedtime, for a total of 100 mg. 2. R2's May 2025 Medication Administration Record (MAR) shows R2 received escitalopram 20 mg once daily for depression on 5/2/25 and 5/3/25. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/1/25, does not have a signature from R2, V8, or V11 and does not show that V8 or V11 provided verbal consent over the phone for R2 to receive escitalopram. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/12/25, shows R2 consented to receive escitalopram 20 mg daily. 3. R2's May 2025 Medication Administration Record (MAR) shows R2 received trazodone 50 mg once daily at bedtime for anxiety on 5/1/25, 5/2/25, and 5/3/25. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/1/25, does not have a signature from R2, V8, or V11. On the bottom of the form, with a date of 5/11/25, a signature from V8 was provided for R2 to receive trazodone 50 mg once daily. Facility provided consent for psychotropic medication use form for escitalopram, dated 5/16/25, shows R2 consented to receive trazodone 50 mg nightly for insomnia. On 6/2/25 at 3:39 PM, V13 (RN/Assistant Director of Nursing- ADON) said consents should be obtained prior to administering medications such as an anti-psychotic, an anti-anxiety, and an anti-depressant. Even if a resident admits to the hospital and was taking these medications at the hospital, the facility should still receive consent to administer these medications before administration. Facility Psychotropic Medications policy dated 12/2019 states, . Any and all psychotropic medication orders will be initiated by the facility only after the physician has completed and returned an Informed Consent related to the drug with the elder and/or responsible party/family. The drug order will include a start date on completion of the Informed Consent form .

Based on interview and record review the facility failed to implement fall interventions into the care plan after a fall for a resident at risk for falls, for 1 of 3 residents (R1) reviewed for safety in the sample of 7. The findings include: R1's Face Sheet shows she was admitted to the facility 3/25/24 and discharged [DATE]. R1's admitting diagnoses included muscle weakness, unsteadiness on her feet, reduced mobility, cellulitis of the left upper limb, end stage renal disease, and need for assistance with personal cares. R1's admitting Fall Risk Evaluation shows she scored a score of 12 which indicated she is a high fall risk. An Un-witnessed fall incident report dated 4/10/24 shows R1 had a fall that day in her room. She was found lying on the floor between her bed and her wheelchair. A second Witnessed fall incident report dated 4/22/24 shows R1 had another fall on 4/22/24 while transferring into bed, she slid off the bed and onto the floor. R1's Fall Risk Care Plan shows it was initiated on 3/25/24 (on admission) and included 4 standard admitting interventions: Anticipate and meet the resident's needs, ensure bed brakes are locked, follow facility fall protocol, and review information on past falls to determine the root cause. No interventions were changed or added to R1's Care Plan after the fall on 4/10/24 or 4/22/24. On 4/30/25 at 12:27 PM, V2 (Director of Nursing) said she can only speak for the current practice, however when a resident has a fall the Care Plan should be updated to document the fall with the interventions that will be added. The facility provided Fall Prevention policy dated November 2020 shows that the facility should add safety interventions to a residents Care Plan for residents at risk for falls. The policy also shows the facility team members get to know the resident interventions should be individualized toward that resident to help avoid factors that may cause a fall.

Based on observation, interview and record review the facility failed to ensure staff followed physician orders for pressure injuries. This applies to 2 of 4 residents reviewed for pressure injures in the sample of 4. The findings include: 1. R2's electronic medical records (EMR) lists his diagnoses to include: displaced intertrochanteric fracture of right femur, muscle weakness and need for assistance with personal care. On February 20, 2025 at 12:05 PM, V3 wound care nurse (WCN) was changing R2's sacral dressing. R2's sacral dressing was dated February 16, 2025 and there was stool on the bottom portion of the dressing. Once the dressing was removed there was an open wound on both buttocks. The right side was approximately a quarter size open area. The left side was an elongated quarter size open area. Both wound areas were red and pink. The right side had some purplish tissue inside the wound. R2 stated, he fell and broke his hip which resulted in him laying in the bed too much. He stated, the dressings have only been changed 3 or 4 times. Some one changed them a few days ago otherwise no one has looked at his wound. V3 WCN verified the dressing was dated February 16, 2025. R2's wound assessment details report dated for February 20, 2025 shows, Wound: left ischial tuberosity, type: pressure, clinical stage: unstageable, size: 2.00 cm (centimeters) X 5.00 cm X 0.20 cm (length x width x depth). Another assessment dated [DATE] shows, Wound: right ischial tuberosity, type: pressure, clinical stage: unstageable, size: 4.00 cm X 3.00 cm X 0.20 cm. R2's treatment administration record (TAR) for the month of February 2025 shows, Left ischium: cleanse with NS (normal saline), pat dry then apply oil emulsion to wound bed, cover with foam until resolved. Change every Monday, Wednesday and Friday The last time the wound was signed off as being completed was February 19, 2025 (Wednesday) (the dressing was dated February 16, 2024(Sunday)). There is no sign offs for February 7th, 10th, 14th or 17th, 2025. The same TAR for the right ischium shows, the same phyisican order as well as no sign offs on the same dates. The TAR also shows, the last time the right ischium was changed was on February 19, 2025 (Wednesday) (the dressing was dated February 16, 2025(Sunday)). On February 20, 2025 at 12:05 PM, V3 WCN stated, he is responsible for the dressing changes during the week (Monday-Friday). There is another nurse that helps on the weekends or if he is not there. If he is unable to get to dressing changes he does let the nurses know. The floor nurses are responsible if he is not able too. He was on vacation for the past two weeks and today (February 20, 2025) was his first day back. On February 20, 2025 at 1:10 PM, V6 Assistant Director of Nursing stated, V3 WCN does the treatments. He was on vacation for the past two weeks. Ultimately the nurses are responsible for the dressing changes. R2's Minimum Data Set, dated dated dated [DATE] , 2025 shows, he is cognitively intact. R2's care plan dated January 18, 2025 shows, Focus: R2 has an actual alteration in skin integrity r/t (related to) Pressure Injuries to Right Heel, Left Heel, as well as to Bilateral Ischium, a Skin Tear to Left Elbow, a Partial Thickness wound to Right Shin and a Surgical Incision to Right Hip all noted upon admission to facility. Interventions: Provide skin/wound treatments as ordered . 2. R1's EMR lists his diagnoses to include: chronic kidney disease, heart failure, diabetes mellitus type II, chronic obstructive pulmonary disease, morbid obesity, difficulty in walking and need for assistance with personal care. On February 20, 2025 at 9:45 AM, V7 hospital Registered Nurse (RN) stated, R1 was her patient at the hospital. He self reported that the dressing on his sacrum had not been changed in over a week. R1 was a good historian and alert and oriented x 3. R2's physician order details form dated February 10, 2025 shows, Wound #1 Right buttock is an acute unstageable pressure injury obscured full thickness skin and tissue loss pressure ulcer and has received a status of not healed . Plan: Wound Orders: Wound #1 right buttock: cleanse with normal saline and dakins 1/4 strength, protect periwound with barrier treatment, apply barrier cream/ointment, apply foam dressing and change daily . R1's TAR for February 2025 does not show the order the physician ordered on February 10, 2025. The TAR shows, Right ischium: cleanse with NS (normal saline), pat dry then apply zinc oxide until resolved. There is the same order for left ischium and sacrum as well. All three orders are for every shift (days and evenings). Every evening is signed off as completed however only four of the day shifts are signed out as completed. There is nothing on R1's TAR that shows he has a dressing to cover the wound or to be changed daily. R1's Minimum Data Set, dated dated dated [DATE] shows, he is cognitively intact. R1's care plan dated January 30, 2025 shows, Focus: R1 has an actual alteration in skin integrity r/t Pressure Injuries to sacrum, left and right ischia as well as Partial Thickness wounds to BLE (bilateral extremities). Interventions: Provide skin/wound treatments as ordered. On February 20, 2025 at 12:45 PM, V3 WCN confirmed that R1's orders were not entered as the wound care doctor had ordered them. He stated, the wound care doctor is new to the facility and he was on vacation for the past two weeks. The facility's skin policy and procedure dated March 2020 shows, .If the resident has, on admission, or develops pressure sore(s), he/she will receive necessary and appropriate treatment and services to promote healing, prevent infection and prevent further development of additional impaired skin integrity. The interdisciplinary team, including the physician will create a written plan for the treatment of impaired skin integrity which will be included in the resident's individualized plan of care.

Based on observation, interview, and record review the facility failed to ensure a resident's midline catheter dressing was changed according to standard of practice for 1 of 3 residents (R2) reviewed for venous catheters in the sample of 3. The findings include: On 1/13/25 at 9:34 AM, R2 was sitting at the bedside and had a midline line catheter (a type intravenous (IV) line for administering IV medications) in his right arm. R2's midline line had a gauze like dressing at the insertion site of the line underneath a transparent bandage. The gauze was visibly and completely saturated with dried blood. R2's midline line dressing was dated 1/9/25. R2 said the hospital put the line in the day he was discharged to the facility so he could get antibiotics. On 1/13/25 at 11:50 AM, V4 Registered Nurse (RN) said PICC (Peripherally Inserted Central Catheter - a type of IV line for administering IV medications) or midline dressings are changed every 7 days or as needed and there is an order that comes up in the Medication Administration Record when it is due to be changed. On 1/13/25 at 11:52 AM, V5 RN said PICC or midline dressings are changed every 7 days or as needed if the dressing is loose or soiled in order to prevent infection. V5 said she had not looked at R2's line yet and was not aware of when R2's catheter was inserted or when the dressing was changed. V5, with this surveyor, observed R2's right arm midline. V5 confirmed the dressing was dated 1/9/25. R2's gauze dressing at the insertion site was still visibly saturated with blood and appeared to have some oozing at the site. V5 said R2's dressing needs to be changed. On 1/13/25 at 12:05 PM, V2 Director of Nursing said the facility policy for PICC or midline care consists of checking the site for signs and symptoms of infection and changing the dressing every 7 days and as needed in order to prevent infection. R2's Physician Orders (POS) shows R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes with foot ulcer and cellulitis of both lower extremities. This same POS does not contain orders for dressing changes/care of R2's midline catheter. The facility's Central Line Care Policy dated 04/2023 shows PICC line care dressing change, maintenance and removal will be completed according to standard of practice by Licensed Nurses only. If the PICC line insertion occurred within 24 hours an RN must change the dressing. Following the initial 24 hours dressing change and RN or LPN will change the injection cap and dressing at a minimum weekly or any time the dressing becomes moist, loosened or soiled.

Based on observation, interview, and record review, the facility failed to perform ADL (Activities of Daily Living) assistance for a resident that requires assistance and failed to replace a soiled blanket for one of three residents (R4) reviewed for ADL assistance in the sample of four. The findings include: R4's Admission Record dated October 15, 2024 shows she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, peripheral vascular disease, diabetes mellitus, asthma, major depressive disorder, obesity, osteomyelitis, and heart failure. R4's Care Plan initiated May 12, 2021 shows she has an ADL self care performance deficit and limited physical mobility related to limited mobility and pain. R4 requires one staff member for personal hygiene and dressing. R4 requires the assistance of two staff members for bed mobility and toileting. On May 15, 2024 at 10:50 AM, V3 CNA (Certified Nursing Assistant) provided incontinence care for R4. V3 checked R4's incontinence brief and said, Oh, your definitely wet. R4's incontinence brief was saturated with dark urine from the front of the brief to the back of the brief. There was urine noted to the blanket underneath R4's buttocks. R4 said, I've been in bed too long, my body hurts. At 11:05 AM, V3 said she last performed incontinence care to R4 at about 8:00 AM. V3 said that R4 is a heavy wetter. V3 laid R4 back onto the soiled blanket and left R4's room. The facility's ADL policy reviewed April 2023 shows, The facility will provide all residents with care, treatment and services according to the resident's individualized care plan. The facility's Linen Management Infection Control policy revised May 2023 shows, Dirty/soiled linens are contained in a closed container or bag.

Based on observation, interview, and record review, the facility failed to have pressure injury prevention interventions in place and failed to change a soiled pressure injury dressing for two of three residents (R2, R4) reviewed for pressure injuries in the sample of four. The findings include: 1. R2's Admission Record dated October 15, 2024 shows R2 was admitted tot he facility on August 23, 2024 with diagnoses including wedge compression fracture of first lumbar vertebra, paraplegia, diabetes, spinal stenosis, osteoarthritis, depression, and dysphagia. R2's Care Plan shows she was admitted to the facility with a stage four pressure injury to her sacrum and provide skin/wound treatments as ordered. R2's Order Summary Report dated October 15, 2024 shows sacrum cleanse with normal saline, apply moistened gauze to wound bed. Secure with foam until resolved. Every day shift every Monday, Wednesday, and Friday. It also shows an as needed order. R2's Risk Profile dated September 20, 2024 shows she is at high risk for developing pressure injuries. Protect elbows and heels if being exposed to friction. R2's Treatment Administration Record shows her dressing to her sacrum was last changed October 14, 2024. On October 15, 2024 at 9:49 AM, R2 was observed laying on her back in bed. There was a strong malodorous smell in R2's room. There was a contact isolation sign outside of R2's door. At 10:33 AM, V3 CNA (Certified Nursing Assistant) provided incontinence care to R2. There were two pairs of heel protectors/heel boots located on R2's closet and chair. R2's heels were directly on the bed. There was a lidocaine patch to R2's back dated October 15, 2024. There was a foam dressing to R2's sacrum that was half intact. The dressing was completely saturated with dark drainage. There was a strong odor. On October 15, 2024 at 11:53 AM, V6 WCN (Wound Care Nurse) said R2's pressure injury dressing is changed every Monday, Wednesday, Friday, and as needed. V6 said the dressing should be changed if it becomes soiled or not intact. V6 said dressing changes are done by him or the floor nurses can do them if he is not in the facility. V6 said if the dressing on R2's sacrum is soiled, then it should be changed. V6 said the floor nurse let me know the dressing needed to be changed a few hours ago. On October 15, 2024 at 1:50 PM, V6 changed R2's dressing to her sacrum. R2's pressure injury to her sacrum was large, approximately a softball size. There was dead tissue in R2's pressure injury. The gauze that was in R2's wound was saturated with brown drainage. V6 placed R2's heels back onto the bed after changing the foam dressing to her heels. The protective boots were in the same spot in R2's room. 2. R4's Admission Record dated October 15, 2024 shows she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, peripheral vascular disease, diabetes mellitus, asthma, major depressive disorder, obesity, osteomyelitis, and heart failure. R4's Care Plan initiated May 17, 2021 shows R4 has actual impairment to skin integrity related to pressure injuries to bilateral buttocks. R4's Care Plan shows she has a history of an unstageable pressure injury to her left heel. Follow facility protocols for treatment of injury. R4's Order Summary Report dated October 15, 2024 shows an order for Right Ishium: Cleanse with normal saline, apply oil emulsion dressing to wound bed, then cover with foam dressing until resolved every Monday, Wednesday, Friday, and as needed. R4's Pressure Injury Risk assessment dated [DATE] shows she has a moderate risk of developing pressure injuries. R4's Wound Assessment Details Report dated October 15, 2024 shows R4 has a stage II pressure injury to her right ischial tuberosity (right buttocks). R4's Treatment Administration Record shows her dressing was last changed on October 14, 2024. On October 15, 2024 at 10:50 AM, V3 CNA provided incontinence care to R4. Both of R4's heels were directly on the bed. There were heel protector boots noted on R4's chair. R4 complained of pain when V3 wiped her buttocks. There was an open area noted to R4's right upper buttocks. R4 said she has a sore on her buttocks that is painful. R4 said she has had that sore for a few days. There was no dressing in place to R4's open area. V3 finished wiping R4's buttocks, placed cream to R4's buttocks, and then laid R4 back onto her back after placing a clean incontinence brief on. On October 15, 2024 at 11:53 AM, V6 WCN said R4 should have medihoney, oiled gauze, with a foam dressing in place to her right buttocks. V6 said he did not know that R4's dressing to her buttocks was not in place. V6 said pressure injury prevention interventions include air mattresses, wedge cushions, repositioning every two hours, and off loading. V6 said the purpose of pressure injury dressings and dressing changes are to see if the wound is getting better. Dressings keep the wounds clean. V6 said if soiled dressings are kept in place, then chances are that the skin around the wound will become macerated. V6 said the goal of dressings and dressing changes are to heal the wounds. V6 said if a pressure injury dressing is not in place or it is not changed, then the wound can get worse or bigger. The facility's Wound Care Program Policy reviewed April 2023 shows, the goal of the wound care program is to promote optimal skin integrity of all residents and guests and prevent acquired skin conditions by implementation of the following: In addition to scheduled skin assessments, skin will also be assessed with ADL (Activities of Daily Living) care is provided, as well as when treatments are being completed. Round will be conducted frequently throughout all shift by the licensed nurse and/or nursing administration to ensure wound care interventions are in place and being completed. The facility Wound Policy and Procedure policy reviewed May 2023 shows, any resident with a wound receives treatment and services consistent with the resident's goals of treatment. Risk reduction measures such as use of heel protectors, elevation of lower extremities, participation in bowel and bladder program, etc are initiated if determined appropriate.

Based on interview and record review, the facility neglected to identify that (R1) had a left ventricular assist device (LVAD), and neglected to ensure facility staff were trained on caring for (R1's) LVAD. These failures resulted in staff not assessing R1's LVAD and R1's LVAD depleting it's battery life and becoming non-operational. As a result, R1 was hospitalized for shock where he expired on [DATE]. The findings include: The Immediate Jeopardy began on [DATE] when R1 was admitted to the facility with an LVAD. V19 (General Manager) was notified of the Immediate Jeopardy on [DATE] at 12:00PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on [DATE] showed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, presence of cardiac and vascular implant device, congestive heart failure, presence of heart assist device, pulmonary hypertension, and atrial fibrillation. R1's care plan dated [DATE] showed, (R1) has an altered cardiovascular status related to congestive heart failure and use of LVAD. R1's nursing progress notes dated [DATE] showed, Guest arrived to community at about 2100 hours .Alert and oriented x ,d+[DATE] .VAD Heartmate III on left upper quadrant of the stomach. No further nursing progress notes were entered regarding R1's LVAD being assessed or monitored for battery life. R1's physician's orders dated [DATE] (after R1 was sent to the hospital) showed, check LVAD batteries every shift .Keep LVAD with current settings .VAD Heartmate III, pump flow (lpm) 4.9, Pump speed (rpm) 5800, Pump power (W) 4.5, Pulsatility index 2.2. Backup controller in room with batteries and charger. On [DATE] at 10:30AM, V8 (Certified Nursing Assistant-CNA) stated, [DATE] was my first day caring for (R1) so I didn't know what his baseline was .The report I got from the previous CNA was that he had tube feedings and a wound vac. I have critical care experience so when I saw his device I knew he had an LVAD machine and I went and told the nurse. I saw four batteries on the table by his bed and 2 of them were showing yellow lights and 2 were showing green lights but I'm not sure what that means. On [DATE] at 11:04AM, V10 (Licensed Practical Nurse) stated, I was the last person that worked with (R1) before he got sent out and I am very upset. We are getting training tomorrow on LVAD's but we should have received training prior to this resident even coming here. I had never worked with (R1) before and didn't even know what his baseline was. I asked overnights for report and all she told me was that he was not oriented so when I saw him not responding much I thought that was normal. I have never worked with an LVAD device nor have I received any training on it. I was so upset when I found out (R1) had this device because I had no idea how to take care of him or monitor it. I went and got (V3-Assistant Director of Nursing) right away because I had no idea what I was doing. (V20-Cardiac Nurse Practitioner) came to see (R1) and she was asking me for his settings and information on the LVAD clinic and I couldn't find it anywhere in the chart. There was nothing plugged in when I went in his room except for his tube feeding pump. Once (V20) got there I didn't go back in the room so I don't know what she did while she was in there. On [DATE] at 11:35AM, V2 (Director of Nursing) stated, I did do training with staff on LVAD's on [DATE] (after R1 went to the hospital) but it was just on our LVAD policy. We are getting training tomorrow by a Cardiologist on LVAD's. We don't have anywhere specifically that we document LVAD coordinator information but that's something we will be developing. On [DATE] at 12:04PM, V2 stated, I think when we first opened our facility a few years ago we had LVAD training and I know there are a few nurses that are still here from that time. (V22-Licensed Practical Nurse) admitted (R1) to the facility and he has LVAD training. It was kind of a hectic admission because it was a Friday night and Admissions asked if we could take (R1) and I knew the nurse's working over the weekend were familiar with LVAD's so I accepted him with the intent to train the rest of the staff the following week. It's not best practice to admit residents with devices that the nurse's aren't trained on but (V3) and (V20) were here so I felt confident. (V3 did not work from [DATE]-[DATE] and V20 is a contracted Nurse Practitioner that did her first visit with R1 on [DATE]). On [DATE] at 12:28PM, V3 stated, I have not received any LVAD training while working in this facility. I know enough about LVAD's to know when there is a problem with them. I was here on [DATE] when (V8-CNA) came and got me and told me (R1) had an LVAD. He asked me to come see him and so I went and saw him around 9:00AM and he would open his eyes, look at me, and then close them again. I didn't check anything on his LVAD at that time because there was nothing on the display to look at. I left the room and gave (V10) some brief training on the LVAD from what I had read about them. About an hour later I went into (R1's) room and he was a little less responsive I didn't look at the LVAD at that time because I didn't see the need to. A little while later I went back in the room with (V20-Nurse Practitioner) and (R1) was completely unresponsive. (V20) told me the LVAD was working at that time. On [DATE] at 1:13PM, V12 (Registered Nurse) stated, I took care of (R1) the night before he got sent out to the hospital. I never even knew he had an LVAD until he was sent to the hospital. I've never gotten training on an LVAD from the facility and have never cared for a patient who has one. I didn't assess anything or change the batteries because I didn't know he had the device. The only thing I got in nursing report was that he was a tube feed and he was an ok resident to care for. Nothing else was reported to me. On [DATE] at 2:10PM, V20 stated, I walked into (R1's) room and he was on CPAP or BiPAP and seemed drowsy and couldn't respond to me. I didn't get any information from the facility on his LVAD because they didn't know any information. There was literally nothing in the chart. The screen was not on but I'm not familiar with this device so I don't know if it was functioning or not. I did hear a hum upon auscultation of his heart but there is no way to tell how well the heart was pumping just by auscultation. I did not see anything plugged into the wall at the time of my assessment. On [DATE] at 9:03AM, V21 (Cardiologist) stated, I just did training for all the nurses on LVAD's as I know there was recently at patient here with one. If a patient can be on the battery life then that's ok because it gives them the ability to get up and function as normal without being plugged into the wall; however, if a patient is limited in mobility then the device can be plugged into the wall and you don't have to worry about depleting your batteries. I have been told by (V20) that she heard a hum when she assessed this patient so that would mean the device was functioning. I can only go by what was reported to me because I never actually saw the patient. It sounds like an unfortunate situation especially because LVAD's are very easy to take care of as long as you keep them charged. The hardest part about having one is remembering to change the batteries when they are low. If batteries are red then they are no good and if they are yellow then they are charged. (R1's batteries had 2 yellow and 2 red). On [DATE] at 10:44AM, V22 (Licensed Practical Nurse) stated, On the first night (R1) came to the facility, the batteries were beeping so I changed them. I have never had LVAD training before and had only read about them but I knew enough to change the batteries. I have never had hands on experience with an LVAD so that would have definitely been beneficial to have prior to caring for a resident with one. To be honest, I never saw any settings on the screen but you could see the battery life on the screen and the LVAD would beep when the batteries were low so we knew when to change them. I don't recall any information coming from the hospital on his LVAD. On [DATE] at 11:02AM, V7 (Registered Nurse) stated, (V22) showed me how to change the batteries on [DATE] at the start of my shift because the LVAD started beeping that it had low batteries. Other than that, I didn't do anything with the LVAD because I had never been trained on using one and have never cared for anyone with one. On [DATE] at 11:12AM, V9 (Paramedic) stated, We were called to the facility for an unresponsive resident. Upon arrival to (R1's) room, we immediately noticed he had an LVAD. I pushed the battery indicator button and the screen was completely blank. I took the old batteries out and put new ones in and it started up right away. The resident was in his room alone when we arrived so we went and asked the nurse for the LVAD settings and clinic information and she couldn't find anything. She told us that she had never been trained on the LVAD. She also told us that the Cardiac Nurse Practitioner had been in earlier and didn't feel the pump was functioning. She finally found some general paperwork for the LVAD but nothing with settings or contact information so we loaded (R1) up and took him to the hospital. On [DATE] at 10:10AM, V23 (VAD clinic nurse practitioner) stated, (R1) had a long stay at the hospital prior to going to the facility. He had a brain bleed and was to be rehabbing at the facility. The purpose of R1 having an LVAD was to help pump blood from his left ventricle out into his body. We were assured by the social worker and liaison that the facility had LVAD training and was equipped to take the patient. It was reported to us that the patient had been sleeping on his batteries. He had been on the same batteries for an extended period of time (they last about 16 hours). The batteries would have been beeping around 12am-1am. There is an internal battery that alarms and we educate our patients that they have about 15 minutes on the internal battery. Depending on how fast the pump is going, it can run ,d+[DATE] hours on that internal battery but it is designed to be a backup in the event of a power outage and a patient cannot plug their device in. We educate that you should never have to use the internal battery. It alarms when external batteries are low and it is loud but if you're under blankets it might be a little softer. The resident had a brain bleed and wouldn't have known to change his batteries. He was intermittently alert prior to d/c from hospital to facility. The engineers from our department downloaded his device activity and you can see the timeline specifically when there was low power. Around 10am the nurse practitioner saw him and saw the agonal breathing and thought it was CPAP related. She didn't do anything with the pump. He was in significant shock when we got him. He passed away early Saturday morning. In R1's case, his LVAD was not functioning and his heart was not able to keep up his blood flow; therefore, he went into shock and when we got him he was critically ill and he passed away on Saturday morning. (5 days after hospital admission). R1's emergency medical services (EMS) report dated [DATE] showed, Dispatched to the scene of an unconscious person. Upon arrival, patient was found alert and oriented x 0. Nursing staff called EMS because he was not at his normal mental status as reported by the previous shift at shift change. Upon assessment of patient it was found patient had an LVAD. Upon inspection of the LVAD it was found non-operational. Both batteries in the LVAD were dead. Nursing staff stated they had not been trained on patient's LVAD and did not know how to work it or check its operation. Nursing staff stated that the on call Staff Cardiologist has been in to check the patient recently and stated, They thought the LVAD was dead. EMS was able to locate the LVAD battery charging bank in the room, and then changed the batteries with two full charged batteries. After EMS changed the batteries the LVAD appeared to go into its start-up mode. It made several beeps and then lit up and began displaying numbers. Nursing staff were unable to locate any information for the LVAD coordinator when asked by EMS, nor any information on the device .Nursing staff was able to locate some basic paperwork for the LVAD; however, none that indicated any settings or baseline operation or how to contact the LVAD coordinator . R1's local hospital emergency room notes dated [DATE] showed, Chief complaint-LVAD was turned off for an unknown amount of time at (facility) new batteries put in from EMS. Nonresponsive for EMS .Randomly moaning to painful stimuli .LVAD hum . R1's LVAD reports provided by the LVAD clinic showed, The event log confirmed the pump off event at [DATE] at 3:11AM due to loss of all power .In addition, the event log indicates that the patient doesn't utilize the power module. Patient at the time was sleeping on battery power (not recommended) .The Heartmate 3 instructions for use warns that the patient must always connect to the power module or mobile power unit for sleeping when there is a chance for sleep as they may not hear the system alarm .The log also captured low power advisories, low power hazard alarms prior to the pump stopping due to battery depletion .When we first saw the patient at approximately 4:15PM today ([DATE]) the pump had been on and the clock ready approximately 4:45PM so we assume the pump had been running since 11:30AM today. Therefore, the pump was off from 3:11AM-approximately 11:30AM .The first low power advisory alarms was captured on [DATE] at 10:32PM and became a low power hazard at 12:39AM on [DATE]. The facility's policy titled, Left Ventricular Assist Device (LVAD) dated [DATE] showed, Definition-A VAD is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood .Additional training may be provided to facility nursing staff to ensure competency with the LVAD device .Care of the resident utilizing an LVAD device may include but is not limited to: monitoring of blood pressure, assessment of the LVAD to ensure proper functioning, ensuring additional batteries are available for the LVAD device (check battery function each shift), following physician's orders for care and treatment of the LVAD device. Instructions on care, treatment, and troubleshooting the LVAD will be made available to nursing staff as needed . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: F600 Neglect Abatement Action Plan Review for screening- all guests with LVAD devices are at risk. No current guests at facility with LVAD device. All possible admissions have the potential to be at risk related to admission with a specialized device. Goals- Nurses will receive education on the definition of LVAD, Indication for LVAD use, Components of LVAD, Care of LVAD and Issues encountered with an LVAD. All nursing staff will be able to communicate updates regarding resident care and treatment each shift. Nursing staff will receive training and/or have an understanding of specialized devices prior to any guest's admission. Actions to be taken- (facility) LVAD Policy and Procedure will be updated to include LVAD coordinator contact information. All Nurses will receive an in-service on updated LVAD policy and procedure prior to the start of their next scheduled shift. All Nurses will attend live and/or be provided one on one education by use of power point LVAD presentation completed by (V21-Cardiologist) prior to their next scheduled shift. All Nurses and CNA's will receive training on Shift-to-Shift report, including review of Shift-to-Shift report policy prior to being placed on the schedule for their next shift. All referrals will be reviewed by CNO and VP of Clinical for high acuity guests and will be reviewed prior to admission. All guest's identified with specialized devices will be reviewed at morning clinical meeting as well as weekly QAPI meeting. Responsible staff- (V19-General Manager) and V2 (Director of Nursing) Date [DATE] Staff training to be 100% completed by [DATE]. Specialized Device and shift-to-shift audits will be completed 5x/week for 4 weeks and reviewed at QAPI with IDT and Medical Director. On [DATE], a review of the facility's in-service documentation showed 75% of the facility's nursing staff were educated on care of residents with an LVAD, how to maintain functioning of LVAD's, and how to perform accurate shift to shift reporting. 33% of staff received training on the new LVAD policy and 40% of staff received training on shift-to-shift report. The remainder of staff and any new agency staff will be educated prior to the start of their next shift. Interviews with staff working on [DATE] showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan.

Based on interview and record review, the facility failed to monitor a resident's (R1) left ventricular assist device (LVAD) resulting in R1's LVAD device depleting it's batteries and R1 experiencing shock and being sent to the local hospital where he expired on [DATE]. The findings include: The Immediate Jeopardy began on [DATE] when R1 was admitted to the facility with an LVAD. V19 (General Manager) was notified of the Immediate Jeopardy on [DATE] at 12:00PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on [DATE] showed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, presence of cardiac and vascular implant device, congestive heart failure, presence of heart assist device, pulmonary hypertension, and atrial fibrillation. R1's care plan dated [DATE] showed, (R1) has an altered cardiovascular status related to congestive heart failure and use of LVAD. Assess fingers and toes for warmth and color, assess for chest pain every shift, assess for shortness of breath and cyanosis every shift, and elevate head of bed to alleviate shortness of breath. R1's nursing progress notes dated [DATE] showed, Guest arrived to community at about 2100 hours .Alert and oriented x ,d+[DATE] .VAD Heartmate III on left upper quadrant of the stomach. R1's physician's orders dated [DATE] (after R1 was sent to the hospital) showed, check LVAD batteries every shift .Keep LVAD with current settings .VAD Heartmate III, pump flow (lpm) 4.9, Pump speed (rpm) 5800, Pump power (W) 4.5, Pulsatility index 2.2. Backup controller in room with batteries and charger. R1's hospital discharge instructions dated [DATE] showed, Daily VAD Care: Record daily weight, temperature, VAD parameters each morning at the same time and if you feel symptomatic or poorly, notify the VAD coordinator right away. Inspect equipment for damage daily. Clean your VAD equipment once a week. Be sure to always have your backup controller and two batteries with you at all times. Page the 24-hour VAD pager at (phone number) to report the following: chest pain, shortness of breath, fever greater than 101.5 degrees, weight gain over 3lbs in one day or 5lbs in one week, any changes in your driveline or incisions including redness, swelling, drainage, or excessive pain, any LVAD alarms, any acute changes in your normal VAD parameters, pump power greater than 6 [NAME], RED alarms or any yellow alarms, if you need to change your system controller, and if you have a headache or bloody nose that will not stop after 15 minutes of holding pressure .please call 911, then notify the VAD team via 24 hour VAD pager if you develop a sudden or severe headache, vision changes, one sided weakness, numbness and tingling, facial droop, altered mental status, confusion, altered speech or difficulty swallowing . R1's electronic medical record dated [DATE]-[DATE] showed no assessments of R1's LVAD or his clinical condition related to his LVAD. On [DATE] at 10:30AM, V8 (Certified Nursing Assistant-CNA) stated, [DATE] was my first day caring for (R1) so I didn't know what his baseline was. I went in around 7:30AM, said good morning to him and he said what? and then fell asleep. I went back in around 9:30AM and checked him and he just grunted when I spoke to him. I went back around 11:00AM and as I was changing him he was completely unresponsive. I remember he got sent out shortly after that. The report I got from the previous CNA was that he had tube feedings and a wound vac. I have critical care experience so when I saw his device I knew he had an LVAD machine and I went and told the nurse. I saw four batteries on the table by his bed and 2 of them were showing yellow lights and 2 were showing green lights but I'm not sure what that means. (CNA working on the previous shift did not return surveyor or facility's calls and is no longer employed at facility). On [DATE] at 11:04AM, V10 (Licensed Practical Nurse) stated, I was the last person that worked with (R1) before he got sent out and I am very upset. We are getting training tomorrow on LVAD's but we should have received training prior to this resident even coming here. I had never worked with (R1) before and didn't even know what his baseline was. I asked overnights for report and all she told me was that he was not oriented so when I saw him not responding much I thought that was normal. I have never worked with an LVAD device nor have I received any training on it. I was so upset when I found out (R1) had this device because I had no idea how to take care of him or monitor it. I went and got (V3-Assistant Director of Nursing) right away because I had no idea what I was doing. On [DATE] at 11:21AM, V4 (Assistant Director of Nursing) stated, When nurses are performing shift-to-shift report it is very important for them to relay any information related to the resident that is new or unusual. It would definitely be something to pass on that a resident has an LVAD device because the nurse's need to be monitoring that. On [DATE] at 12:04PM, V2 (Director of Nursing) stated, Nurse's should be monitoring all residents for a change in condition. I'm not sure how fast (R1's) decline was but if he came to the facility alert and oriented x ,d+[DATE] then I would think decreasing responsiveness would trigger the nurse to do an assessment. On [DATE] at 12:28PM, V3 stated, I have not received any LVAD training while working in this facility. I know enough about LVAD's to know when there is a problem with them. I was here on [DATE] when (V8-CNA) came and got me and told me (R1) had an LVAD. He asked me to come see him and so I went and saw him around 9:00AM and he would open his eyes, look at me, and then close them again. He didn't have a great seal on his CPAP (Continuous Positive Airway Pressure) mask at that time. I didn't check anything on his LVAD at that time because there was nothing on the display to look at. I left the room and gave (V10) some brief training on the LVAD from what I had read about them. About an hour later I went into (R1's) room and he was a little less responsive and the CPAP mask still didn't seem right so I tried to get a better seal on it but I couldn't really get one. I didn't look at the LVAD at that time because I didn't see the need to. A little while later I went back in the room with (V20-Nurse Practitioner) and (R1) was completely unresponsive. (V20) told me the LVAD was working at that time. On [DATE] at 1:13PM, V12 (Registered Nurse) stated, I took care of (R1) the night before he got sent out to the hospital. I never even knew he had an LVAD until he was sent to the hospital. I've never gotten training on an LVAD from the facility and have never cared for a patient who has one. I didn't assess anything or change the batteries because I didn't know he had the device. The only thing I got in nursing report was that he was a tube feed and he was an ok resident to care for. Nothing else was reported to me. I took care of his tube feeding and checked his blood sugar that night but never noticed an LVAD. On [DATE] at 2:10PM, V20 stated, I walked into (R1's) room and he was on CPAP or BiPAP and seemed drowsy and couldn't respond to me. I didn't get any information from the facility on his LVAD because they didn't know any information. There was literally nothing in the chart. The screen was not on but I'm not familiar with this device so I don't know if it was functioning or not. I did hear a hum upon auscultation of his heart but there is no way to tell how well the heart was pumping just by auscultation. I did not see anything plugged into the wall at the time of my assessment. R1's emergency medical services (EMS) report dated [DATE] showed, Chief complaint: unconscious for 5 hours .Dispatched to the scene of an unconscious person. Upon arrival, patient was found alert and oriented x 0. Nursing staff called EMS because he was not at his normal mental status as reported by the previous shift at shift change. Upon assessment of patient it was found patient had an LVAD. Upon inspection of the LVAD it was found non-operational. Both batteries in the LVAD were dead. Nursing staff stated they had not been trained on patient's LVAD and did not know how to work it or check its operation. Nursing staff stated that the on call Staff Cardiologist has been in to check the patient recently and stated, They thought the LVAD was dead. EMS was able to locate the LVAD battery charging bank in the room, and then changed the batteries with two full charged batteries. After EMS changed the batteries the LVAD appeared to go into its start-up mode. It made several beeps and then lit up and began displaying numbers. Nursing staff were unable to locate any information for the LVAD coordinator when asked by EMS, nor any information on the device. Patient was very warm to the touch and he had been previously diagnosed with a urinary tract infection. Patient was currently on a CPAP machine that appeared to be a sleep style machine. When asked if the patient was continuously on it during the day also, nursing stated they had no idea as it was not in the chart .patient was put on 6 liters oxygen via nasal cannula .Nursing staff was able to locate some basic paperwork for the LVAD; however, none that indicated any settings or baseline operation or how to contact the LVAD coordinator R1's local hospital emergency room notes dated [DATE] showed, Chief complaint-LVAD was turned off for an unknown amount of time at (facility) new batteries put in from EMS. Nonresponsive for EMS .Randomly moaning to painful stimuli .LVAD hum . R1's LVAD reports provided by the LVAD clinic showed, The event log confirmed the pump off event at [DATE] at 3:11AM due to loss of all power .In addition, the event log indicates that the patient doesn't utilize the power module. Patient at the time was sleeping on battery power (not recommended) .The Heartmate 3 instructions for use warns that the patient must always connect to the power module or mobile power unit for sleeping when there is a chance for sleep as they may not hear the system alarm .The log also captured low power advisories, low power hazard alarms prior to the pump stopping due to battery depletion .When we first saw the patient at approximately 4:15PM today ([DATE]) the pump had been on and the clock ready approximately 4:45PM so we assume the pump had been running since 11:30AM today. Therefore, the pump was off from 3:11AM-approximately 11:30AM .The first low power advisory alarms was captured on [DATE] at 10:32PM and became a low power hazard at 12:39AM on [DATE]. The facility's policy titled, Left Ventricular Assist Device (LVAD) dated [DATE] showed, Definition-A VAD is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood .Additional training may be provided to facility nursing staff to ensure competency with the LVAD device .Care of the resident utilizing an LVAD device may include but is not limited to: monitoring of blood pressure, assessment of the LVAD to ensure proper functioning, ensuring additional batteries are available for the LVAD device (check battery function each shift), following physician's orders for care and treatment of the LVAD device. Instructions on care, treatment, and troubleshooting the LVAD will be made available to nursing staff as needed . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: F684 Quality of Care Abatement Action Plan Review for screening- all guests with LVAD devices are at risk. No current guests at facility with LVAD device. All possible admissions have the potential to be at risk related to admission with a specialized device. Goals- Nurses will receive education on the definition of LVAD, Indication for LVAD use, Components of LVAD, Care of LVAD and Issues encountered with an LVAD. All nursing staff will be able to communicate updates regarding resident care and treatment each shift. Nursing staff will receive training and/or have an understanding of specialized devices prior to any guest's admission. Actions to be taken- (facility) LVAD Policy and Procedure will be updated to include LVAD coordinator contact information. All Nurses will receive an in-service on updated LVAD policy and procedure prior to the start of their next scheduled shift. All Nurses will attend live and/or be provided one on one education by use of power point LVAD presentation completed by (V21-Cardiologist) prior to their next scheduled shift. All Nurses and CNA's will receive training on Shift-to-Shift report, including review of Shift-to-Shift report policy prior to being placed on the schedule for their next shift. All referrals will be reviewed by CNO and VP of Clinical for high acuity guests and will be reviewed prior to admission. All guest's identified with specialized devices will be reviewed at morning clinical meeting as well as weekly QAPI meeting. Responsible staff- (V19-General Manager) and V2 (Director of Nursing) Date [DATE] Staff training to be 100% completed by [DATE]. Specialized Device and shift-to-shift audits will be completed 5x/week for 4 weeks and reviewed at QAPI with IDT and Medical Director. On [DATE], a review of the facility's in-service documentation showed 75% of the facility's nursing staff were educated on care of residents with an LVAD, how to maintain functioning of LVAD's, and how to perform accurate shift to shift reporting. 33% of staff received training on the new LVAD policy and 40% of staff received training on shift-to-shift report. The remainder of staff and any new agency staff will be educated prior to the start of their next shift. Interviews with staff working on [DATE] showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan.

Based on observation, interview, and record review the facility failed to ensure R1 was showered in a safe manner for 1 of 5 residents (R1) reviewed for falls in the sample of 10. This failure resulted in R1 falling in the shower and sustaining fractures to the left arm. The findings include: On 8/14/23 at 8:58 AM, R1 was laying in bed with her left arm in a splint and a sling and her left foot with a dressing and foam cushioned boot on. R1 stated I fell in the shower. I was standing in the shower and the staff was drying me off. I was holding on to the rail, but I slipped on a towel or something trying to turn so the staff could dry me. I had no balance or support when turning. I fell on my right side with my left arm hanging onto the rail. When I took my arm down it really hurt. The ambulance came and took me to the hospital. I fractured it in three places. I was really hanging on. On 8/14/23 at 9:02 AM, V4 Licensed Practical Nurse said V5 Certified Nursing Assistant (CNA) was giving R1 a shower and yelled out into the hall for help. V4 said R1 had fallen on her right side in the shower. V4 said upon assessment R1's vitals were within normal limits and R1 was alert and oriented but complaining of pain to her left arm/wrist. V4 said R1 fell on her right side, and she could tell R1 had hit her head because R1's head was leaning on the wall with her neck bent up. V4 said R1 fractured her arm in three places. V4 said R1 told her she slipped and went down. V4 said she thought the staff used a shower chair for R1, but they didn't at that time. V4 said since the fall, they now use the shower chair. On 8/14/23 at 10:06 AM, V5 CNA said she gave R1 a shower using the bench that was in the shower. V5 said she put a bath blanket down and had R1 stand up and hold the rails. V5 said when she let go of R1, R1 slid down. V5 said she tried to grab R1 but R1 was naked and there was nothing to grab onto. V5 said R1 had wounds on her left foot but was not aware of any weight bearing restrictions with the left foot. On 8/14/23 at 10:32 AM, V7 CNA said she transferred R1 to the shower bench using a gait belt. V7 said while R1 was sitting on the bench in the shower, she removed R1's clothes and wrapped R1's left foot in a plastic bag to protect the dressings from getting wet during the shower. V7 said V5 did R1's shower. V7 said when she came into the room, R1 was laying on the shower floor on her right side with her head on the right side of the shower facing the wall and her feet under the shower bench on the left side of the shower. V7 said R1's feet were on a towel, and it looked like the towel had slid with her. V7 said this should have never happened and they should have been more diligent making sure everything was dry. V7 said she was not aware of any change in R1's weight bearing status to the left foot. On 8/14/23 at 10:24 AM, V6 Nurse Practitioner said R1 fell during a shower and complained of left wrist pain. V6 said R1 was sent to the hospital. V6 said R1 sustained fractures in her forearm and had a splint placed. On 8/14/23 at 10:45 AM, V8 Physical Therapy Director said prior to R1's fall, R1 was not ambulating but was able to stand and pivot to transfer but needed to limit weight bearing on her left foot due to her wound. V8 said during standing, R1 couldn't bear full weight on the left foot, only partial pressure. V8 said staff should have been using a shower chair not having R1 stand during a shower. V8 said R1 is able to stand and pivot to transfer from a wheelchair to a shower chair and back. R1's Progress Note dated 8/5/23 shows At 9:40 AM writer was called to guest room by CNA. Guest was standing in the shower stall being dried off, and having pants pulled up following a shower when she stated I slipped, and I just went down. Writer entered to find guest laying on her right side on the floor of the shower. Guest states she did hit her head on the way down, but no pain. Guest could move all extremities per usual, and could wiggle fingers on both hands, but was complaining of left arm/wrist pain. R1's After Visit Summary from the hospital dated 8/5/23 shows R1 was seen for a fall and has diagnosis of forearm fracture (both bones) without reduction and fracture of the distal radius. R1's Progress Note dated 8/5/23 at 5:17 PM, shows Guest returned to facility with diagnosis of non-displaced fractures to radius and ulna. Left arm splinted and placed in a sling. Guest to follow up with Orthopedic. R1's Physical Therapy Notes dated 8/4/23 shows Precautions: Weight Bearing on the left lower extremity only for transfers. R1's Physician Orders dated 8/1/23 shows Limit bearing weight to left feet when transferring. R1's Physician Note dated 8/3/23 shows R1 was admitted to the facility after transfer from the hospital. On 7/28/23 patient went to the cardiologist appointment and was sent directly to the emergency room for concerns of her chronic left foot wound. Noted to have Staphylococcus Aureus infection of left foot wound infection with associated cellulitis of the leg. She was started on intravenous antibiotics. Cardiology deemed patient not candidate for revascularization and might require a below-knee amputation if things do not heal. Podiatry recommended aggressive offloading of her feet and likely without improvement in her blood flow things will worsen. Pertinent Medical history: type 2 diabetes, food ulcer left, peripheral vascular disease, osteomyelitis left ankle and foot, history of right and left toe amputation. R1's Fall Risk Evaluation dated 8/2/23 shows R1 is at High Risk for falls due to generalized weakness and limited/poor mobility. R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact and requires one-person physical assistance for bathing and transferring, and is not steady during transitions and walking, only able to stabilize with staff assistance. R1's Care Plan shows R1 has an activities of daily living self-care performance deficit and limited physical mobility requiring a wheelchair for ambulation and one staff for stand/pivot transfers. The same Care Plan shows R1 is at risk for falls related to deconditioning, gait/balance problems, poor safety awareness and history of repeated falls. The facility's Fall Prevention Policy dated 11/2018 shows The facility is committed to reducing the number of falls as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible.