Every finding on record at Jerseyville Manor

Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R157) reviewed for abuse in the sample of 42. This failure resulted in R157 fracturing her left hip which required surgical intervention and subsequently led to R157's death.Findings Include:The Facility Investigation, undated, documents the following: R136 pushed R157 causing her to fall to the floor. R157, an alert and confused female. Her BIMS (Brief Interview for Mental Status) score is 3 indicating severe cognitive impairment and her primary diagnosis is Unspecified Dementia. R157 walks independently on the unit with staff supervision. After the fall R157 complained of pain during assessment. Family and physician were notified. Resident was sent to the local hospital and was admitted with a proximal left femur fracture. R157 underwent surgical repair on 10/15/25 which was deemed successful. R157 was continuously monitored for pulmonary edema and advanced COPD. R157's family rescinded R157's DNR (Do Not Resuscitate) status for a 24-hour period to manage initial postop care expectantly. R157 coded and full ACLS (Advanced Cardiac Life Support) protocol was conducted. R157 was pronounced deceased on [DATE] at 10:43 PM. R136, is an alert and confused female. R136's BIMS score is 3 indicating severe cognitive impairment and her primary diagnosis is Alzheimer's Disease. R136 walks independently on the unit with staff supervision. After the incident resident was immediately placed on 1:1 (one on one) supervision. R136 had no explanation for pushing R157 and had very little recall of the incident at all. Family and physician were notified. R136 was immediately sent to the local hospital for evaluation and was returned the same day with a new order to treat UTI Urinary Tract Infection). The Psychiatrist was contacted with new prescription orders given for severe agitation and transfer to outside hospital for inpatient admission. R136 was transferred and admitted for psychiatric hospitalization on 10/15/25 and she remains hospitalized at this time and her return is uncertain at this time. In conclusion, the fall incident has been thoroughly investigated. The root cause of the fall was directly linked to the actions of resident (R136). Due to her (R136) cognitive status, she is unable to account for or explain her actions. R136 has had no prior physical incidents since being admitted to the facility. There is no sufficient evidence to suggest that the reactions were intentional. Will continue to monitor. The Facility Investigation Note, undated, documents the following: Upon investigation, see fall event details, provided by V20, RN (Registered Nurse). Prior to fall, R157 was walking independently on the unit per normal routine. V19, CNA (Certified Nursing Assistant) was down the hall and witnessed R157 and R136 approach. V19 was unable to reach duo in time to prevent R136 from pushing R157 to the floor. While approaching the fall, V19 observed R136 standing over R157 talking nonsensible per her normal routine. V19 did not report witnessing any behaviors that would indicate the event would occur. Neither resident was able to provide credible details of the fall and what lead up to R136 pushing R157 to the floor. V8, CNA, V23, CNA, nor V18, RN, witnessed the fall. V18 assessed R157 and she complained of pain everywhere. Family and physician were notified. LHNA (Licensed Nursing Home Administrator) notified. R157 was sent to the local ER (Emergency Room) and was admitted with a fractured left hip. Family is pleased with her care and wishes her to return to the facility for rehabilitation after surgical repair. The care plan will be reviewed and updated upon her return. Will continue to monitor.R136's Face Sheet, undated, documents R136 has the following diagnoses, in part, Alzheimer's Disease, Paranoid Schizophrenia, Dementia with Agitation, Delusional Disorders, Depressive Episodes, and Severe Dementia Severe with Psychotic Disturbance. R136's MDS (Minimum Data Set), dated 7/30/25, documents the following: R136 has a BIMS score of 3, indicating severe cognitive impairment, displays verbal behavioral symptoms directed towards others. R136's MDS, dated , 11/26/25, documents the following: R136 has a BIMS score of 2, indicating severe cognitive impairment, displays physical/verbal behaviors directed towards others, other behaviors not directed towards others, wanders, and rejects care. R136's Care Plan, dated, 3/7/25, documents the following: R136 receives psychotropic medications due to having a diagnosis of Schizophrenia and Cachexia. Per family interview, they stated that she was put on medication due to being aggressive. She exhibits verbal, physical behaviors towards others and rejection of care. She shows rejection of care with medications, meals and daily routine and waiting for staff assist. She may become territorial when other residents who enter her room or go through her personal belongings or are in her space. She may wander and has a history of exit seeking. Interventions include: validate where she is trying to go, redirect to room or common area, remind her that her family knows where she is, engage in talk about Spanky, [NAME] or [NAME] to distract, provide strolls in Courtyard or facility if unable to redirect, inform of possible harm to self if ambulating on her own, offer activities food and fluids, likes saxophone music to distract and redirect. R136's Progress Note, dated 8/9/25 at 3:56 PM, documents the following: July Behavior Note- R136 is tracked on the behavior program for showing verbal behaviors and may curse or scream at staff providing care. She shows physical behaviors and may kick or shove staff providing care. She shows rejection of care with meals, and daily routine or ADLs (Activities of Daily Living). She was noted to show no behaviors this month. She has been moved from Memory Lane to Liberty Lane. Staff will continue to monitor resident and use interventions as needed to help decrease the behaviors. R136's Progress Note, dated 8/14/25 at 4:22 PM, documents the following: Behavior note- R136 has been placed on the behavior tracking form for increased wandering/exit seeking potential program. R136's Progress Note, dated 8/16/25 at 9:35 AM, documents the following: Resident was kissing brother-in-law in dining room this morning at breakfast. She had gotten verbally upset that we separated them. Writer took resident to sit on couch while breakfast was being finished. Resident walked back over to brother-in-law; CNAs separated them again and placed wife next to husband. Resident was then walked to her room. R136's Progress Note, dated 9/4/25 at 7:04 AM, documents the following: August Behavior Note: Resident is a recent admit and has been displaying some verbal/physical behaviors related to rejection of care. She may scream or curse, shove, kicking, hitting and or scratching staff providing care. Proactive interventions are in place and if used consistently often prevent the behaviors. Formal programming in place. R136's Progress Note, dated 10/3/25 at 8:46 AM, documents the following: September Monthly Behavior Note: For the month of September, she has met her goal of having a reduction in verbal/physical behaviors related to rejection of care and upon redirection. She may scream or curse, shove, kick, hit and or scratching staff providing care, or toward others. Proactive interventions are in place and if used consistently often prevent the behaviors. Formal programming in place. R136's Progress Note, dated 10/13/25 at 8:00 AM, documents the following: See event note per V20, RN, for resident 4175-01 (R136) on 10/12/25 at 8:00 PM. Resident was immediately placed on 1:1, Administrator, notified per V20 immediately, MD (Medical Doctor) and POA (Power of Attorney) were notified. R136's Progress Note, dated 10/13/25 at 8:40 AM, documents the following: Resident resting in bed at his time. She remains 1:1 due to prior incident. R136's Progress Note, dated 10/13/25 at 8:53 AM, documents the following: Behavioral outburst including screaming and slapping at staff member who was attempting to redirect her from another residents room. R136's Progress Note, dated 10/13/25 at 10:15 AM, V23, Psychiatrist, called and was notified of increased behaviors and orders to send resident to ER for psychiatric evaluation. POA called and notified, in agreeance with plan of care. 911 implemented at this time. R136's Progress Note, dated 10/13/25 at 10:50 AM, V23 called facility regarding resident and recent increased behaviors. Stated she would like her to have an inpatient stay and has notified an outside behavioral health center. At this time there is no bed available for her at this time, however she is on the waitlist for a bed when it does become available. Face sheet, recent labs, nurse's notes, and med list faxed to the behavioral health center per their request. R136's Progress Note, dated 10/13/25, at 1:39 PM, documents the following: Resident returned to the community by ambulance at 1:35 PM, accompanied by 3 attendants. Placed on visual 1:1 with staff due to earlier violent outburst. Diagnosed at the local hospital with UTI. IM (Intramuscular) Rocephin administered at the ER. New orders for Augmentin 500mg (milligrams)-125mg oral tablets, 1 tablet every 12 hours for 5 days. Resting in bed at this time. R136's Progress Note, dated 10/13/25 7:06 PM, documents the following: New orders from V23 for Ativan 1mg IM daily PRN (As Needed) for severe agitation, Ativan 1mg po (by mouth) BID (Twice Daily) PRN for severe agitation and Zyprexa 4mg po daily at 4:00 PM. Son informed by phone. R136's Progress Note, dated 10/14/25 at 10:50 AM, documents the following: Staff from behavioral health called facility and informed writer that they would most likely have a bed for resident tomorrow morning. Stated they would call facility to let us know in the morning. POA called and notified, thanked writer for call. R136's Progress Note, dated 10/15/25 at 1:10 PM, documents the following: Spoke with RN at the behavioral health center to give report on resident and to inform them of when she left the facility as requested. Resident left in family vehicle with her son at 12:40 PM.R157's Face Sheet, undated, documents R157 has the following diagnosis, in part, Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Anxiety Disorder, Unspecified Psychosis, Repeated Falls, Weakness, Unsteadiness on Feet, Reduced Mobility, Schizoaffective Disorder, COPD (Chronic Obstructive Pulmonary Disease), Depression, Age Related Osteoporosis, Heart Failure, Hyperlipidemia, Vitamin Deficiency, Iron Deficiency Anemia, and Cough.R157 MDS, dated [DATE], documents the following: R157 has a BIMS score of 3, displays verbal behaviors towards other and other behaviors not directed towards others, requires assistance with ADLs, and has a history of falls.R157's Care Plan, dated 6/6/22, documents the following: R157 is at risk for falls related to diagnoses, cognitive deficits which may alter safety awareness, needing assistance with ADL care, B&B (Bowel & Bladder) incontinence, and use of psychotropic medications & opioid medications.R157's Care Plan, dated 6/6/22, documents the following: R157 receives psychotropic medications due to having a diagnosis of Anxiety, Schizoaffective Disorder, and Psychosis. Family stated resident was anxious and pacing at previous facility. She is delusional in her thought process at times evidenced by thinking she does not live here. Resident displays anxiety with pacing from nurses' station to room with repetitive questioning. She has shown an increase in verbal/physical expressions related to rejection of care and upon redirection from her delusions. She may reject care with taking meds, toileting, changing clothes, showers and ADL care. She displays other behaviors evidenced by pacing, picking at skin causing bruising and bleeding. [NAME] does not retain info and is unaware of her safety needs.R157's Progress Note, dated 8/6/25 at 7:00 AM, documents the following: July Behavior Note: For the month of July, resident has shown a decrease in verbal/physical behaviors related to rejection of care and upon redirection from her delusions. She may reject care with taking meds, toileting, changing clothes, showers and ADL care. She displays other behaviors evidenced by pacing, picking at skin causing bruising and bleeding. [NAME] does not retain info and is unaware of her safety needs. Proactive interventions are in place and if used consistently, may often prevent the expressions. Formal programming in place for verbal/physical behaviors and rejection of care, will continue with.R157's Progress Note, dated 8/12/25 at 1:24 PM, documents the following: Resident restless/anxious most of the day, continuing to pace, delusional in her thoughts, asking about how she goes about getting the lighting ordered and taken care, she is easily redirected for a moments time.R157's Progress Note, dated 9/4/25 at 6:56 AM, documents the following: August Behavior Note: For the month of August, resident has shown a decrease in verbal/physical behaviors related to rejection of care and upon redirection from her delusions. She may reject care with taking meds, toileting, changing clothes, showers and ADL care. She displays other behaviors evidenced by pacing, picking at skin causing bruising and bleeding. Resident does not retain info and is unaware of her safety needs. Proactive interventions are in place and if used consistently, may often prevent the expressions. Formal programming in place for verbal/physical behaviors and rejection of care, will continue with.R157's Progress Note, dated 10/3/25 at 9:33 AM, documents the following: September Monthly Behavior Note: For the month of September, resident has shown a decrease in verbal/physical behaviors related to rejection of care and upon redirection from her delusions. She may reject care with taking meds, toileting, changing clothes, showers and ADL care. She does not retain info and is unaware of her safety needs. Proactive interventions are in place and if used consistently, may often prevent the expressions. Formal programming in place and will continue with. [NAME] displays other behaviors evidenced by pacing, picking at skin causing bruising and bleeding. Goal and approaches in place.R157's Progress Note, dated 10/12/25 at 8:00 PM, documents the following: Loud noise heard in hallway by nurse's desk. Resident observed on the floor lying on left side. ROM (Range of Motion) x (times) 4 with pain and limitation to LLE (Left Lower Extremity). Shallow skin tears present to left eyebrow and left forearm. Resident c/o (complains of) severe pain everywhere. Vitals pulse 66, respirations 22, temperature 98.0, SpO2 94% RA (Room Air), unable to obtain blood pressure due to resident moving arms. CNA witnessed another resident come out of their room and push resident to the floor unprovoked. CNA stated resident's head hit the floor very hard. Ambulance paged per nursing judgement.R157's Progress Note, dated 10/13/25 at 12:08 AM, documents the following: Received call from the local ER nurse. Resident is being admitted with Dx (Diagnosis) of fractured left hip.R157's Progress Note, dated 10/13/25 at 11:55 AM, documents the following: Spoke with POA, he stated resident was going to have surgery on Wednesday. Gave him my condolences and will keep them in my prayers. He thanked this writer for calling.R157's Progress Note, dated 10/15/25 at 11:41 PM, documents the following: Call received from the local hospital that resident has expired.R157's Fall Safety Event, dated 10/12/25 at 8:00 PM, documents the following: location: hallway; resident was pushed by another resident; CNA witnessed another resident come out of their room and push resident to the floor unprovoked; c/o severe pain everywhere; Shallow skin tear to left eyebrow and left forearm. ROM painful/limited to LLE; immediate intervention: Ambulance was paged due to painful/limited ROM to LLE and possible head/neck injury from hitting head on the floor.R157's Hospital Records, document the following: ER Note, dated 10/12/25, Patient was at a memory care unit when another resident pushed her and the resident fell in an unsupervised context. Assessment/plan - Lt femur fracture. Operative Note, dated 10/15/25, ORIF (Open Reduction Internal Fixation) of the left hip. Patient was sent to PACU (Post Acute Care Unit) in stable condition. MD Progress Note dated 10/15/25 at 11:05 PM, I was called to evaluate the patient during code. BP (Blood Pressure) unresponsive to escalating doses of Levophed given through the IO (Intraosseous) line. Three liters of fluid were also given prior to the code in resuscitation efforts postop via the IO line placed in the right tibia. A sat was never identified due to the profound unresponsive hypotension consistent with overwhelming cardiac failure as a primary feature of her neurologic condition preop. Patient never responded to any bedside interventions. Epinephrine and shocks delivered during the AED (Automated External Defibrillator) application prior to the arrest. Ventricular Fibrillation degenerated very quickly to PEA (Pulseless Electrical Activity) which sustained on two checks. Code was called due to anticipated demise in an agonal rhythm that would predictably degenerate to asystole in a short time frame. Expired on 10/15/25 at 10:53 PM, full ACLS protocol followed. R157's Death Certificate, dated 10/20/25, documents the following: date of death : 10/15/25; immediate cause of death: acute displaced left femur intertrochanteric fracture, conditions leading to the cause of death: status post insertion intramedullary nail of the left femur, underlying cause: dementia moderate, significant conditions contributing to death: pulmonary edema, schizoaffective disorder.On 1/22/26 at 8:10 AM, V4, LPN (Licensed Practical Nurse), stated R157 would walk around the unit, she was up, down, up down and would ask repetitive questions. V4 stated R157 could have verbal and physical behaviors towards staff but not any of the residents. V4 stated she is not familiar with R136.On 1/22/26 at 8:25 AM V15, Memory Care Specialist, stated she was not working when the incident between R136 and R157 occurred. V15 stated R157 would occasionally have behaviors but not directed towards others. V15 stated R136 wound have verbal behaviors towards the staff but not towards the other residents. V15 stated she does not recall any other incidents involving R136 or R157.On 1/22/26 at 9:13 AM V19, CNA, stated she was working and witnessed the incident between R136 and R157 on 10/12/25. V19 stated R157 was walking laps towards the doors and walked past room [ROOM NUMBER], R136's room. V19 stated R157 stopped approximately 5-6 feet outside of R136's doorway and was saying something and pointing her finger. V19 was unable to hear what R136 was saying. V19 stated R136 came out of her room running with both of her arms out in front of R157 and pushed her to the ground. V19 stated after this occurred R136 ran back into her room and when V19 approached, R136 was laughing and shut the door to her room. V19 stated R157 hit her head hard on the floor, was bleeding and crying in pain. V19 stated prior to this incident, R136 had a few issues at the supper table, where she would put her hands on the residents that would annoy her. V19 stated R136 was easily annoyed by the other residents. V19 stated they have a couple of residents that have behaviors that could potentially be physical towards other residents but they intervene prior to an incident occurring. On 1/22/26 at 9:25 AM, V8, CNA, stated she was working but did not witness the incident between R136 and R157. V8 stated R136 stayed in her room most of the time, she would verbally cuss or tell other residents to stay away, and they would try to intervene. V8 stated they would redirect R136 to her room, give her a snack, have her watch TV and divert her away from the situation. On 1/22/26 at 11:20 AM, V22, Medical Director, stated the incident between R136 and R157 was unexpected. R136 nor R157 had displayed any physical behaviors towards others. V22 stated in her opinion R157 due to poor postoperative monitoring after hip surgery. V22 stated R157 was cleared by the Cardiologist for the surgery, came through the surgery just fine, her blood pressure was to be checked every 30 minutes, it was fine and then it wasn't checked for 2 hours and during that time her blood pressure crept down, R157 coded and died. The Abuse Prohibition and Reporting Policy, with a revision date of 11/18/19, documents, in part, the following: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms. The purpose of the policy is to protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse. These behaviors would include residents with a history of aggressive behaviors such as entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on the facility failed to implement current fall interventions for 1 (R118) of 9 resident reviewed for accidents in a sample of 42. This failure resulted in R118 sustaining a Left Patellar Fracture.Findings Include:R118's Undated Face Sheet documents R118 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia, Weakness, and Alzheimer's Disease.R118's Minimum Data Set, dated [DATE] documents R118 is severely cognitively impaired, uses a walker, and needs substantial/maximal assistance with lying to sitting on side of bed, sitting to standing, chair/bed to chair transfers, and walking 10 feet.R118's Care Plan Last Reviewed/Revised 1/15/2026 documents Problem: R118 is at risk for falls related to diagnoses, cognitive deficits which may alter safety awareness, needing assistance with Activities of Daily Living (ADL) care, Bowel and Bladder (B&B) incontinence, and use of psychotropic medications & potential use of opioid medication related to end of life care. R118 is unaware of her safety needs and often ambulates without assist and device. Interventions Dated 12/6/2025 documents Approach: Concave mattressR118's Care Plan Last Reviewed/Revised 1/14/2026 documents Problem: Resident Care Information. Interventions Dated 12/6/2025 documents Approach: Fall Approaches: Concave Mattress, Neon tape to walker, walker to kept beside R118 at all times and encourage R118 to ask for assist when ambulating. Alternate call and offer res to toilet with each alternate call round. Staff to put lighter weight pj's on resident during bed time.R118's Progress Note dated 12/6/2025 at 11:30 PM documents Noise heard from room [ROOM NUMBER]. Resident observed on the floor lying on left side with her head against the closet door. Range of Motion (ROM) x4 without pain or limitation. No shortening, rotation, or deformity present. No redness or swelling noted. Resident was incontinent of bladder and urine was on the floor next to the bed. Resident was wearing a hospital gown and grip socks. Resident was previously resting in bed.R118's Event Report Dated 12/7/2025 documents R118 had a fall on 12/6/2025 in room [ROOM NUMBER]. Interventions immediate measure taken documents rest, increased toileting, low bed, alternate call.R118's Fall Investigation Dated 12/8/2025 documents upon entering, resident was noted of floor lying on left side with her head against the closet door. Resident incontinent of bladder. Previously seen resting in bed in lowest locked position. Blankets appear disheveled, as though resident slid out of bed. Call light was within reach but not activated. Resident is confused and does not always remember to ask for assistance. Root Cause Analysis: resident slid out of bed. Resident placed on concave mattress.R118's Nursing Note dated 12/15/2025 at 10:01 AM documents Resident found on floor of bedroom on her Left (LT) side. Roommate came to this nurse and informed that someone was on her bedroom floor. Upon assessment small hematoma noted to back of head, and small abrasion noted to LT knee. ROM x4 without pain or limitations while laying down however when stood to ambulate to bed resident seemed to limp from RT hip/leg. No shortening/rotations/ deformities. Resident states only pain on her head.R118's Fall Investigation Dated 12/15/2025 documents at approximately 10 AM staff was called to room by roommate stating someone was on the floor in her room. Staff responded noting resident on the floor lying on her left side near the closet. [NAME] was at bedside and did not appear to be in use at the time of the fall. Resident was assessed with small abrasion to left knee and hematoma to the back of her head. No rotation and/or shortening to left lower extremity. Resident was able to bear weight. Staff noted unsteady gait with a slight limp which is common for her.R118's Event Report Dated 12/15/2025 documents R118 had a fall in room [ROOM NUMBER]. Body assessment: small hematoma to back of head, abrasion to left knee.R118's Nursing Note dated 12/16/2025 at 9:53 AM documents Resident up to breakfast this am, staff reporting resident reluctant to ambulate so resident was pushed to table in wheelchair. ROM in lower extremities stiff, resident is inconsistent with location of pain related to fall yesterday. No bruising or swelling noted to lower extremities.R118's Nursing Note dated 12/17/2025 at 12:31 PM documents x-ray results mentions a patellar fracture but not specifying if old or new or acknowledging in findings.R118's Nursing Note dated 12/17/2025 at 3:51 PM documents This nurse called to inquire clarification on x-ray results. They stated radiologist had reread the x-ray and it shows an acute patellar fracture.R118's Left Radiologic Examination, femur, minimum 2 views Report Dated 12/17/2025 documents Impression: acute patellar fracture.R118's Nursing Note dated 12/17/2025 at 6:46 PM documents X-ray clarification results show Fracture of Left Patella.R118's X-ray Knee 1 or 2 Views Left dated 12/18/2025 documents Impression: Transverse fracture of the patella with apex anterior angulation and articular surface step-off.R118's Nursing Note dated 12/18/2025 at 7:33 PM documents Resident returned from Local Hospital emergency room with a diagnosis of Left Patellar Fracture. Immobilizer brace in place on left leg.On 1/22/2026 at 8:24 AM no concave mattress observed on R118's bed.On 1/22/2026 at 9:29 AM R118 resting in bed with a regular mattress noted on the bed.On 1/21/2026 at 3:02 PM V2, Director of Nursing (DON) stated when a resident falls the facility will start an event note regarding the fall and an immediate intervention will be put into place. V2 stated an intervention is placed after every fall and the resident's Care Plan is updated with the interventions.On 1/22/2026 at 9:24 AM V15, Certified Nursing Assistant (CNA), stated R118 needs assistance with getting up out of bed and walking. V15 stated R118 always gets up on her own and has had recent falls. V15 stated R118 is always incontinent and never uses her call light when she needs assistance. V15 stated R118 has not had a special mattress the whole time she has worked on the hall and R118 has a regular mattress. V15 denied R118 having a concave mattress in place.On 1/22/2026 at 9:29 AM R118 R6 was not interviewable due to his cognitive status and medical condition.On 1/22/2026 at 9:32 AM V24, CNA, stated R118 needs assistance to get out of bed and with walking. V24 stated R118 tries to get out of bed by herself a lot.On 1/22/2026 at 9:36 AM V4, Licensed Practical Nurse, LPN, stated R118 currently has a knee immobilizer in place due to a fractured knee from a fall. V4 stated 118 gets up all the time on her own and R118 does require assistance to get up.On 1/22/2026 at 11:28 AM V21, Medical Doctor, (MD), stated the facility should have interventions ordered and in place after every resident fall. V21 stated if R118 had an order for a concave mattress after a fall, she would expect the facility to have the mattress in place to help prevent falls. V21 stated R118's Dementia is so bad that R118 does not know what she is doing at times or what is going on.On 1/22/2026 at 1:30 PM V30, CNA, stated R118 likes to get up at the spur of the moment and R118 does require assistance to get out of bed and ambulate.On 1/22/2026 at 10:11 AM V2 stated the Facility does not have a policy on Fall Prevention. On 1/22/2026 at 10:27 AM V2 provided an Accident/incident Prevention document and stated the document is part of the facility's nursing manual. The Accident/Incident Prevention document is undated and had no facility name listed. The Accident/Incident Prevention states When a resident has been identified as a high risk for accident/incident, interventions will be put into place per the induvial resident assessment and care plan.

Based on interview and record review, the facility failed to ensure staff were knowledgeable and competent to utilize a deep brain stimulator (DBS) and know signs and symptoms of internal generator not charged for 1 of 1 resident (R79) in the sample of 42.Findings include: R79's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnosis including Parkinson's disease and deep brain stimulator. R79's Care Plan dated 8/7/2024 documents problem: resident care information: no documentation. Goal: long term goal target date: 3/16/2026 no information documented. Approach start date: 8/29/2024: brain stimulator - charge every Wednesday and Sunday. Place round disk on right side of chest and charge for approximately 2 hours or until fully charged. R79's Physician Order Sheet (POS), dated 1/2026 physician's order to charge brain stimulator every Monday/Wednesday/Sunday. Place round disk to right side of chest and charge for approximately 2 hours or until fully charged. Disk must be charged before placing on chest. R79's Treatment Administrator Record (TAR) dated 1/2026 staff document R79's DBS is charged three times a week per physician's orders on night shift. On 1/19/2026 at 11:00 AM R79 observed sitting up in wheelchair and stated he has Parkinson's and staff are supposed to charge his DBS but staff don't what they are doing with it and sometimes his DBS isn't charged. On 1/21/2026 at 11:37 AM V9, Licensed Practical Nurse (LPN) stated she used to work night shift, and she used to charge R79's deep brain stimulator at night. V9 stated she wasn't inserviced on how to charge it but followed the directions from R79's family on how to use the device. V9 stated the family and R79 told her if his DBS wasn't charged he would be lethargic and possibly unresponsive. On 1/22/2026 at 8:00 AM V13, LPN stated she hasn't been inserviced on how to use, read or charge R79's DBS device. V13 stated she knows when R79's DBS needs charged when his left arm starts shaking more and he has difficulty swallowing. On 1/22/2026 at 9:55 AM, V18, RN (Registered Nurse) stated she just graduated a few months ago and she hasn't been inserviced on anything to do with a DBS and would read the manufacture's booklet if needed but she would feel more comfortable if she got a formal inservice from management on how to use the device. V18 stated she didn't know what symptoms R79 would exhibit if his DBS wasn't charged. On 1/22/2026 at 10:00 AM V32, LPN stated she hasn't been inserviced on R79's DBS or how to use the device at all and wouldn't know if it was charging the device or what symptoms R79 would exhibit if his DBS wasn't charged. On 1/22/2026 at 10:03 AM V31, LPN stated she hasn't been inserviced on R79's DBS. V31 didn't know how to use the device at all and wouldn't know if it was charger was charging the device or what symptoms R79 would exhibit if his internal battery was not charged. On 1/22/2026 at 10:16 AM V29, LPN stated she hasn't been inserviced on DBS and she doesn't know anything about the DBS including how to charge it, how to tell if the device is charging R79's DBS or what symptoms R79 would exhibit if the DBS wasn't charged. On 1/22/2026 at 10:20 AM V28, LPN stated she hasn't been inserviced on the deep brain stimulator by facility staff and stated R79's family takes care of it and they charge the device and R79 charges his DBS. V28 stated when R79's DBS isn't charged R79 starts to cough more while eating and has increased delayed speech and increased tremors. V28 stated she keeps a close eye on R79 because she knows if his DBS needs charged when he exhibits slurred/slow speech, increased coughing and increased tremors. On 1/22/2026 at 10:19AM V26, MDS Coordinator/RN stated she works the floor occasionally. V27 stated doesn't recall being inserviced on a DBS and stated there is a light on the charging device to show it is charging the DBS and if it's not working R79 can become lethargic. On 1/22/2026 at 10:23 AM V27, MDS Coordinator/RN stated she works the floor occasionally and she hasn't been inserviced on DBS anything regarding a DBS including how to charge it or how to ensure it is charging the resident's DBS. V26 stated there is a light on the device to show it is charging. V26 stated if the resident's DBS isn't working, he can become lethargic. On 1/21/2026 at 1:33 PM V2, Director of Nurse (DON) stated if R79's DBS isn't charged he exhibits symptoms of slow speech and difficulty swallowing but she doesn't know the extent of his symptoms that could occur if his DBS isn't charged. V2 stated she has been the DON at the facility for over 10 years, and she hasn't inserviced staff on how to use R79's DBS. On 1/21/2026 at 1:36 PM V3, Assistant Director of Nurses (ADON) stated when R79's DBS isn't charged his Parkinson's symptoms i.e. difficulty swallowing and slow movements return like they were before the stimulator was placed. V3 stated she recalled when R79 was initially admitted to the facility in 8/2024 and his family showed her how to charge and read his DBS device and she wasn't inserviced on how to use the DBS device. On 1/22/2026 at 3:32 PM V36, R79's Neurologist's Medical Assistant stated she has worked with R79's neurologist for over 10 years and she had permission to speak to me on behalf of R79's neurologist. V36 stated R79 has a DBS because he has severe Parkinson's and it decreases his Parkinson's symptoms including tremors, slurred speech and shuffling gait. V36 stated if R79's DBS isn't charged then his Parkinson's symptoms increase. V36 stated she has never seen a resident's DBS not being charged that the resident becomes lethargic, there was no correlation to a resident's DBS not being charged to them being lethargic. V36 stated they don't have a lot of patients that reside in a nursing home that have a DBS but she assumes management would show staff how to charge his DBS and to educate staff on symptoms he would exhibit if the DBS isn't charged. On 1/22/2026 at 11:35 AM V21, Medical Director stated when R79's DBS isn't charged he would exhibit symptoms of Parkinson's i.e. out of control tremors and increased Parkinson's symptoms. V21 stated R79's DBS not being charged doesn't result in R79 being lethargic. 21 stated she expected staff to be inserviced on how to use R79's DBS charger and stated she expected the facility has a policy on how to use the DBS device as well. A DBS Policy revised 1/2013 documents objective: to provide necessary care to the resident with a DBS. Equipment: DBS. Procedure: keep equipment dry and hand it gently to avoid damage and follow manufacturer's instructions as indicated by specific device manual. Nursing consideration: charge as often as your doctor recommends and notify physician of any change of condition related to device as indicated. This policy didn't have the facility name documented on it.

Based on interview and record review, the Facility failed to evaluate swallowing function of a resident who choked a timely manner for 1 of 9 residents (R3) reviewed for accidents and hazards in the sample of 42.Findings include: 1-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, cerebral infarction, and dysphagia (difficulty swallowing). R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired, required setup or clean-up assistance with eating, was on a mechanically altered therapeutic diet, had holding of food in mouth/cheeks or residual food in mouth after meals, and had coughing or choking during meals or when swallowing medications. R3's Care Plan initiated 3/8/23 documents R3 has a diagnosis of dysphagia which increases risk of aspiration, choking, and swallowing difficulties. R3's Diet Order dated 7/31/25 documents mechanical soft. R3's Progress Note dated 1/10/26 at 12:58 PM documents during noon meal, R3 had an episode where a piece of bread became lodged in throat. On 1/23/26 at 8:10 AM, V6, Licensed Practical Nurse (LPN), stated on 1/10/26 she was notified by staff she needed to go check on R3 in the dining room. V6 went to the dining room and R3 had already expelled the bread. On 1/20/26 at 12:33 PM, R3 was sitting at a table in the dining room with a plate of food in front of her. There was a slice of bread in a wax paper bag next to the plate. V33, Cook, stated residents on mechanical soft diets are allowed to get bread. R3's Physician Order dated 1/15/26 documents ST (Speech Therapy) to evaluate and treat as indicated. On 1/20/26 at 2:50 PM, V34, Speech Language Pathologist (SLP), stated V6 made a referral for R3's swallow to be evaluated after R3 had her recent episode. V6 has not evaluated her yet but plans to do that sometime this week. On 1/21/25 at 2:50 PM, V2, Director of Nursing (DON), stated if a resident chokes the team discusses it at a morning meeting and V34 will evaluate them, but was unsure how soon residents should be evaluated in this situation. On 1/22/25 at 11:25 AM, V21, Medical Director, stated she was aware of R3 choking and was unsure why it took V34 so long to evaluate her because it is normally the next day. R3's SLP Evaluation and Plan of Treatment dated 1/21/26 documents R3's swallowing function was evaluated on 1/21/26. The Facility's Therapy Evaluation/Reassessment Policy revised 2/2005 does not address a time frame in which residents should be evaluated following a speech therapy referral for choking.

Based on observation, interview, and record review, the facility failed to protect 1 of 5 residents (R2) from abuse from (R1) when reviewed for abuse in the sample of 5. Findings Include: On 9/2/25 at 8:05 AM, R2 was observed in the dining room, calm, asked surveyor to get him some silverware, surveyor gave R2 his silverware and attempted to talk/interview R2 and R2 would not answer.R1 has been discharged from the facility.R1's Face Sheet, undated, documents R1 has the following diagnoses: Cerebral Infarction, Hemiplegia/Hemiparesis of the Right Side, Aphasia, Dysphagia, Unsteadiness on Feet, Weakness, (UTI) Urinary Tract Infection, Insomnia, HTN (Hypertension), and Hyperlipidemia.R1's MDS (Minimum Data Set), dated 8/20/25, documents R1 has a BIMS (Brief Interview of Mental Status Score) of 5, indicating R5 has severe cognitive impairment. R1 has no mood indicators and doesn't exhibit any behaviors.R1's Progress Note, dated 07/15/2025 at 12:36 PM, documents the following: Resident noted to be tearful, refusing meals, agitated and attempting to exit seek. Staff members were able to redirect resident to room, resident requested to be put to bed. Resident denies any pain or discomfort.R1's Progress Note, dated 07/15/2025 at 11:14 PM, documents the following: Resident refused HS (Bedtime) medications, which is atypical for resident. Resident became tearful and would not speak or look at writer. When resident did speak, he would say no and begin sobbing. Resident's usual demeanor is very happy and carefree. Resident's urine noted to be cloudy and odorous with large amounts of sediment present. Resident cried out while receiving catheter care as well. Foley catheter changed and clean urine sample obtained and dipped in house. Multiple abnormalities present including (+) positive Leukocytes and (+) blood. Resident meets McGeer's Criteria. PCP/DON (Primary Care Physician/Director of Nurses) notified. R1's Progress Note, dated 08/20/2025 at 11:40 AM, documents the following: Mood and Behavior note- Assessment reviewed for 08/20/2025. During the past quarter R1 has exhibited physical, other and rejection of care behaviors. During the PHQ/patient health questionnaire R1 voiced no mood concerns.R1's Progress Note, dated 08/21/2025 at 8:41 AM, documents the following: Quarterly social assessment note: Assessment reviewed 8/21/2025. Resident has shown some behaviors this quarter. Resident continues to socialize with others. Will continue to encourage out of room time and assist as needed.R1's Progress Note, dated 08/22/2025 at 9:00 AM, documents the following: Resident and family aware of room move. Moved to new room and introduced to roommate. Move went great. When I left room, everyone in room was in high spirits.R1's Progress Note, dated 08/25/2025 at 4:31 AM, documents the following: During evening med pass writer heard yelling coming from R1's room and writer entered the room. Resident appeared to be frustrated. Resident attempted to stand up and grabbed curtain divider and pulled it back. As this occurred, CNA (Certified Nurse's Assistant) entered the room. Resident continued to yell loudly and attempting to go onto roommates' side of the room. Writer and CNA attempted to deescalate the situation by asking resident to sit down and give reassurance. After sitting down resident stated to hit and kick the CNA and writer. We offered resident coffee, snacks, Jello due to resident may be wanting what roommate was eating. We offered to take him to the restroom, sit in his wheelchair, and go into the hallway to sit with staff. Noted 2 small bruises to left forearm and a small scratch next to bend of elbow. To resolve the situation roommate was moved to another room for the night.R1's Progress Note, dated 08/25/2025 at 5:53 AM, documents the following: Resident slept through the night. Noted slight agitation while being changed by staff.R1's Progress Note, dated 08/25/2025 at 6:10 AM, documents the following: Resident up in wheelchair propelling self. Noted resident approach another resident and pushed him to the floor. Staff intervened immediately. Resident placed 1:1 (one on one) with staff.R1's Progress Note, dated 08/25/2025 at 7:00 AM, documents the following: Continues to be 1:1 with staff. EMS (Emergency Medical Services) in the facility to transport resident to the ER (Emergency Room) for evaluation. Resident was cooperative with transfer to gurney. 7:15 AM-Left facility per stretcher via ambulance accompanied by 2 EMS.R1's Progress Note, dated 08/25/2025 at 1:52 PM, documents the following: Writer spoke with son regarding this morning's incident. Son informed of investigative details thus far. Son reports the local hospital suggested, and he agrees that R1 be transferred to a smaller home that can accommodate a private room. Son is very understanding of the need to keep others safe. He asked that his things be packed up and he will be in later this week to retrieve them. Will continue to monitor.R2's Face Sheet, undated, documents R2 has the following diagnoses: Fracture of the Right Femur, Heart Failure, HTN, COPD, Unsteadiness on Feet, Weakness, Cognitive Communication Deficit, OA, Atrial Fibrillation, Severe Dementia with Anxiety, Insomnia, and Muscle Weakness.R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact. R2 has no mood indicators and has verbal behaviors directed towards others.R2's Care Plan, dated 6/24/25, documents R2 is adjusting to changes in his status, routine and surroundings. R2 has exhibited verbal and rejection of care behaviors. He will become focused on a topic and remain there and will make repetitive comments which leads to other behaviors. He often talks about going home and will ask others to assist him there. Herb exhibits exit seeking behaviors. R2 is voicing delusional statements. R2 has been crawling on the floor per his preference and states he prefers to sleep there and needs to fix items. R2 has exhibited physical behaviors towards staff.R2's Care Plan, dated 8/22/25, documents R2 has Anxiety and Insomnia.R2's Progress Note, dated 07/16/2025 at 5:44 AM, documents the following: Resident yelling out off and on throughout the night. Staff assists residents with his needs, reorientated resident when he is confused about time, place and situation. However, resident will continue to yell out moments later. O2(Oxygen) in place per NC (Nasal Cannula) @ 2L/min. No SOB (Shortness of Breath) or respiratory distress present. Continent of B/B (Bowel/Bladder). Melatonin administered @ HS (Bedtime) as order states with very little effectiveness this shift. Bed placed in lowest locked position. Call light placed within reach.R2's Progress Note, dated 08/15/2025 at 7:18 PM, documents the following: Previous shift reported that resident yelled out most of the night. Numerous attempts to get up without assist. O2 at 2L/NC. LCTA (Lungs Clear to Auscultation). Occasional nonproductive cough noted. Fluids encouraged. Afebrile. Incontinent care provided as needed.R2's Progress Note, dated 08/21/2025 at 3:45 PM, documents the following: Resident has been displaying extreme anxiety/agitation. He has made attempts to exit, stating his car is in the parking lot, and he needs to leave. He has been yelling at staff (not due to being HOH (Hard of Hearing), and is unable to comprehend anything said to him, which is only exacerbating the agitation. Staff has attempted offering food/fluids, has attempted to lay resident down, and then gotten right back up due to climbing OOB (Out of Bed), attempted to involve in activities, therapy, and even 1:1. Any/All redirection attempts have been unsuccessful. Family came and sat with resident for an hour and was finally able to calm only some of his anxiety. Daughter and son are upset, stating resident would have never displayed these kinds of behaviors, and they are requesting he get something for anxiety. MD (Medical Doctor) aware.R2's Progress Note, dated 08/24/2025 at 12:30 PM, documents the following: Resident exit seeking. Accusing others of hiding his tractor keys. Looking for a trailer to back up. Cursing at staff, insisting that he had to go home. Staff attempting to redirect. Resident put himself on the floor in dining room, crawling under table. Saying that he needed to fix, flip a lever. Nurse unable to straight catheter to obtain urine specimen due to anatomical abnormality. Attempting to obtain due to no void and acute mental status changes. POA (Power of Attorney), MD, NP (Nurse Practitioner) and nursing management aware. Resident sent to ER (Emergency Room) per family request. R2's Progress Note, dated 08/25/2025 at1:03 AM, documents the following: Returned from ER at approximately 7:30 PM. His behaviors have continued since, literally crawling on the floor. Stated I want to sleep down here Redirected many times to no avail, medication including pain med were given by the nurse. The local hospital completed scan of the bladder and found small amount of urine in bladder (350 ml (milliliters). Resident did not void for more than 12 hours and had only 350 ml of urine in his bladder and has increased behaviors and restlessness. Can we try some fluids please, Message was sent to MD, NP, DON and ADON (Assistant Director of Nurses).R2's Progress Note, dated 08/25/2025 at 4:43 AM, documents the following: Resident has been putting himself on the floor throughout the entire night, continuously yelling and screaming out for help. resident is very confused and grabbing and reaching for things that are not there. resident is very hard of hearing and complaining of pain to the right hip. pain medication was given for the pain and didn't seem to help. resident is confused and asking staff if they have a vehicle and stating that he needs a ride home and needs to get out of there, asking where our dads are, if our dads are home, and stating that his parents are needing him at the house.R2's Progress Note, dated 08/25/2025 at 6:10 AM, documents the following: Resident sitting at nurse's station. Noted another resident approach this resident and pushed this resident to the floor from wheelchair. Staff intervened immediately. No injury noted. Assisted back to wheelchair with two staff members.R1 and R2's Abuse Investigation, dated 8/24/25 and 8/25/25, documents the following: In conclusion, on Sunday, 8/24/25, during the evening medication pass, staff were alerted to room R2's room after hearing R2 yelling for help. When staff entered the room, they noted that R2 had spilled his Jello and R1 became angry. After multiple attempts, staff were unable to determine why R1 was upset. At no time did R1 make contact with R2. The staff immediately removed R2 from the room and had him sleep in room [ROOM NUMBER] for the night. The next morning, after morning ADL (Activities of Daily Living) care, R1 propelled his wheelchair from the 200 hall into the common area, located R2, who was sitting in his wheelchair in front of the oxygen room. R1 lunged at R2 and pulled him from the wheelchair, onto the floor, while attempting to hit and kick him. Staff immediately intervened and the residents were separated. No injuries were noted to either individual. Family and physician aware, local police department notified and R1 was placed on 1:1 monitoring until he was sent to the local hospital for evaluation. The local hospital recommended that R1 be transferred to a smaller home that can better meet his needs.On 9/2/25 at 7:55 AM, V4, Housekeeping, stated R1 and R2 both resided on the Bounce Back/400 hallway, not as roommates, and R1 had moods, not good, would hit at others. R2 did have some behaviors but not too much. V4 stated she is not aware of any altercations between R1 and R2.On 9/2/25 at 8:00 AM, V5, RN (Registered Nurse), stated R2 will crawl on the floor, he thinks he's working on trucks or tractors, hollers, curses, and is exit seeking. V5 stated R2's family comes and sits with him every day. V5 stated R2 is confused. V5 stated she is unaware if R1 had behaviors prior to moving to the 200 hallway, she hadn't worked with him prior. V5 stated R1 and R2 had gotten into a yelling match, unsure of date, but there was no physical contact made.On 9/2/25 at 8:05 AM, V6, CNA, stated R2 yells but she thinks it's because he can't hear. V6 stated R1 had just moved to room [ROOM NUMBER] with R2 a couple of days prior and R1 wasn't happy that he had moved from his prior room on the Bounce Back (Rehab) hall to the nursing home side. V6 stated she is not aware of any behaviors with R2 and was unaware of any altercations between R1 and R2. On 9/2/25 at 8:10 AM, V2, DON, stated she was not here when the altercation between R1 and R2 took place. V2 stated R1 was a brand-new stroke patient when he was admitted to the facility. He didn't have any behaviors but due to the stroke he would become tearful and cry. On 9/2/25 at V3, R2's Family, stated on Friday morning, 8/22/25, R1 was moved into the room with R2, things were fine 8/23/25 and during the day on 8/24/25. On 8/24/25, she had gone with R2 to the hospital and by the time they returned to the facility, it was 7:15 PM, R2 was hungry, so she alerted staff, and they got him a plate of food. When staff brought the tray in, R1 became agitated, the nurse and CNA were trying to calm R1 down, they offered food, drinks, etc. V3 stated R2 was in bed at that time so she left the facility around 7:45 PM. V3 stated around 8:00 PM, she was notified that there was a commotion in the room and R1 was trying to get to R2. R1 kicked the nurse and twisted the CNAs arm. V3 stated she was told by staff that they had separated R1 and R2. V3 stated on 8/25/25 at 6:45 AM, she received a call that R2 was up, dressed, and at the nurse's station, waiting to go to breakfast. R1 was going to the dining room for breakfast and grabbed R2 by the shirt and was trying to hit and kick him. V3 stated the facility sent R1 out but R2 didn't have any injuries so he was not evaluated at the hospital. V3 stated R1 had a stroke and was paralyzed on the left side and couldn't speak. V3 stated R1 was not confused. V3 stated there has been conflicting information provided by V1, Administrator, and other staff. V3 stated the police were called but there were no arrests or investigations completed, and no police report was filed. V3 stated R2 was traumatized for about a week afterwards but is fine now. V3 stated R2 would doze off, wake up upset and clenching his fists. V3 stated the physician's assistant ordered R2 an anti-anxiety medication the day the incident happened. V3 stated R1 was mad because he went from the Bounce Back unit to the regular nursing home side. V3 stated she is not aware of R1 having any behaviors prior to being moved on the 200 hallway, into the room with R2.On 9/2/25 at 8:50 AM, V1, Administrator, stated R1 was on the Bounce Back unit and was moved to the 200 hallway. V1 stated R1 was admitted to the facility with a new stroke, was aphasic, and was only in room [ROOM NUMBER] for 3 days. V1 stated there hadn't been any problems that Friday and Saturday night, then on Sunday 8/24/25, R1 became frustrated was trying to talk, but was unable to. V1 stated V3, R2's Family, was at the facility, and told her that staff tried to get R1 to calm down, they were offering him food, drinks, etc., but R1 was angry and kicked the nurse and twisted the CNAs wrist. V1 stated they moved R2 to a room on the 300 hallway for the night. V1 stated the next morning R2 was at the nurse's station waiting to go to breakfast as R1 was going to breakfast, and R1 pulled R2 out of his wheelchair, was hitting and kicking R2. Staff separated them. V1 stated R1 hadn't had any behaviors prior to this incident, and she would have never thought this would have happened. V1 stated neither resident was hurt during the incident and R1 was sent to the local hospital and then to a Geriatric Psychiatric unit at another hospital for further intervention. V1 stated R1 didn't have any behaviors or mental illness diagnosis that would have alerted the facility staff that R1 would be capable of this.On 9/2/25 at 9:25 AM, V8, Speech Language Pathologist, stated she had worked with R1 since he was admitted to the facility on communication, expressive and receptive. V8 stated R1 would mostly answer yes/no questions. V8 stated they tried to utilize a communication board with numbers, but he wasn't always accurate in his responses. V8 stated R1 was comfortable on the Bounce Back unit, he knew the staff and other residents, then he was moved to the 200 hallway, where he didn't know the staff or other residents. V8 stated R1 wasn't confused, he wasn't always able to fully understand different scenarios or situations. V8 stated R1 also had a history of UTIs. V8 stated she had never observed R1 being aggressive, his emotions would fluctuate, he would be happy/sad/tearful at times. V8 stated she worked with R1 for a long time and didn't see any anger or aggression with him. V8 stated she has not seen R1 since he was moved to the 200 hallway, they were waiting on more visits to be approved prior to R1 being sent to the hospital.On 9/2/25 at 10:13 AM, V10, LPN (Licensed Practical Nurse) stated she was passing medications on 8/24/25, when she heard R2 yelling, upon entering the room, R1 was agitated, she was unsure why and R2 was unable to explain what had happened or what was wrong. V10 stated R1 stood up from his bed and attempted to go towards R2, they attempted to redirect R1 but were unable to, so they moved R2 to a room on the 300 hallway and once R2 was moved from the room, R1 calmed down and R2 was calm and okay in the other room. V8 stated prior to this incident, she had seen R1, he wasn't agitated, aggressive, or irritable, he seemed fine but was growling and rolling his eyes. She talked with him briefly, then left the room, and about an hour later was when the incident with R1 and R2 in their room happened. V8 stated the next morning, R1 found R2, pushed him to the ground, R1 was also kicking/hitting at staff when they were trying to intervene. V8 stated they were able to deescalate the situation and R1 was placed on 1:1 observation.On 9/2/25 at 10:25 AM, V11, CNA, stated she was charting and heard R2 yelling, she thought he had crawled onto the floor, which he frequently did. V11 stated she entered the room and found that R2 had spilled his Jello and was upset. V11 stated she helped R2 clean it up, while doing this R1 ripped the curtain back and looked like he was going to hit R2, she tried to get R1 to calm down, but he wasn't listening. V11 stated R1 was trying to rip through them to get to R2. V11 stated they finally got R1 to sit down on the bed, but that didn't help, he began kicking V10, LPN, and twisted her (V11's) arm. V11 stated they were keeping R1 away from R2 and moved R2 to another hallway. V11 stated once R2 left the room, R1 calmed down. V11 stated she was not aware of any prior incidents with R1 or R2. The Abuse Prohibition and Reporting Policy, dated 11/1999, documents the following: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraint not required to treat resident symptoms. Special attention will be given to identifying behavior that increases the residents potential for abusing self or others or being the victim of abuse, These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as: entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff.

Based on observation, and interview the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen and that food was stored, prepared, and served under sanitary conditions. This has the potential to affect the 138 residents living in this facility. Findings include: On 2/13/2024 at 9:12 AM, in the refrigerator there were 12 cases of milk stacked in crates containing 4 gallons in each milk in each container stacked 3 crates high. The milk was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the refrigerator, next to the milk was a pull-out cart that had a large clear container of cabbage and a clear plastic bag of green onions. Both items were cut into small pieces, and there was no date and/or label. On 2/13/2024 at 9:18 AM, in the refrigerator there was a large industrial metal pan that had turkey inside of it, but the plastic was missing partially on the one side and the turkey meat was being exposed to the air in the refrigerator. On 2/13/2024 at 9:15 AM, in the freezer area there was a large industrial 13-pound box labeled breadsticks that was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the freezer on the opposite side of the breadsticks was a large industrial box labeled white meat sitting directly in the floor. On 2/13/2024 at 9:18 AM, V12, Dietary Manager stated I would expect all items to be dated and labeled and no items to be sitting directly on the floor. I would expect all items to be completely covered. I just pushed the cabbage on the cart back into the refrigerator when I heard that you all were in the building. The cabbage and onions are fresh, I am cooking them today, but it does not have a date and or label. Everything should be dated and labeled. On 2/13/2024 at 9:22 AM, in the dry storage area there was large industrial bin of white substance that had the scoop inside touching the powdery substance. On 2/13/2024 at 9:24 AM, V12 stated, I would not expect the scoop to be inside the container, and it should be hanging and not inside the thickener. On 2/13/2024 at 9:26 AM, the ice machine in the dry storage area had no air gap present. The metal drainage hose from the ice machine went directly into a screen under the machine and there was no air gap present. This allows for potential backflow into the ice machine from the sewage drain. On 2/13/2024 at 9:33 AM, V12 stated I do not know anything about air gaps. We use the ice for everyone in the facility. You will need to talk to the maintenance man. On 2/15/2024 at 8:32 AM, V1, Administrator stated, We pulled the ice machine and there was no air gap, and we are fixing it now. The Water and Sewage Code Section 890 documents, Air Gap: The unobstructed vertical distance through the free atmosphere between the lowest opening from any pipe or faucet supplying water to a tank or plumbing fixture and the flood-level rim of the receptacle. An air gap in a drainage system is a piping arrangement in which a drain from a fixture, appliance or device discharges indirectly into another fixture, receptacle or interceptor at a point above the flood level rim. The air gap between an indirect waste and the drainage system shall be at least two (2) times the diameter of the fixture drain or drainage pipe. The Food Storage and Labeling Procedure with a revision date of 9/22 documents, To provide staff with guidelines for food storage and labeling of foods. Store food at least 6 inches off the floor. Labeling of refrigerated foods: The label should include Product name, date, and discard date. The Long-Term Care Facility Application for Medicare and Medicaid form, CMS 671, dated 2/13/2024 documented the facility had a census of 138 residents.

Based on observation, interview and record review, the facility failed to ensure appropriate fall interventions were in place, monitor and provide safe transfers for 6 of 7 residents (R14, R28, R72, R63, R280, R297) reviewed for falls and transfers in the sample of 57. This failure resulted in R63's fall sustaining a right hip fracture. Findings include: 1. R63's Resident Face Sheet, undated, documented diagnoses of Cerebral Infarction due to thrombosis of unspecified precerebral artery-CVA with right sided hemi, Unsteadiness on feet and other lack of coordination. R63's Minimum Data Assessment (MDS) dated [DATE], documented that his cognition was severely impaired and that he was totally dependent upon staff for bathing. It continues to document that he has functional limitation in range of motion to his lower extremity on 1 side and that his balance was not steady and only able to stabilize with staff assistance during transitions. R63's MDS, dated [DATE], documents that he was totally dependent of 2 staff members. R63's Care Plan, dated 12/27/2017, documented, (R63) is at risk for falls (related to history of falls), balance deficits, unsteady gait, impairments, incontinence episodes, vision impairment, decreased safety awareness, need for assist (with Activities of Daily Living), & use of psychotropic/cardiac/opioid meds. It continues, Approach Start Date: 09/01/2020 Non-skid to (wheelchair) seat when available. It continues, Approach Start Date: 12/27/2017, Administer medications as ordered and monitor for ill effects. Approach Start Date: 12/27/2017 Keep brakes locked on bed. Approach Start Date: 12/27/2017 Keep personal items and frequently used items within reach. Bath Days: Mon/Thurs on day shift. R63's Fall Risk assessment dated [DATE] documented that he was a high risk for falls. R63's Occupational Therapy (OT) Therapy Progress Report, dated 08/08/2022, documented R63 can sit unsupported (times) 30 seconds with feet flat on floor and no back support, R63 cannot stand without (upper extremity) support (with assistive device) as needed (times) 10 seconds, and Test/sit Balance Sitting Balance Scale was Not tested . R63's OT Discharge Summary, dated 08/25/2022, documented, The patient was trained on (Neuromuscular Re-education) for functional transfer training, core strength training, sitting and standing balance training with safety (education) to decrease fall risk. R63's Physical Therapy (PT) Discharge Summary, dated 08/25/2022, documented, Skilled Interventions-Skilled PT interventions includes (lower extremity Active Range of Motion), strengthening, to further improve transfer techniques. static/dynamic standing balance training with standing aid to improve functional activity, balance during transfers. safety awareness/(technique)/education application to improve impulsiveness needed during mobility, transfers. R63's Event Report, dated 10/25/2022, documented, V26 (Certified Nurse Assistant/CNA) bathing resident in shower room. Resident leaned forward tipping shower chair, CNA could not stop resident from falling forward, resulting resident landing on (Right) hip. It continues, Describe surrounding environment. Shower Room, shower running, ground free of clutter or potential hazards, adequate lighting. It continues, Following fall, X-Ray performed in house, resulting negative. Resident consistent with pain, resident sent to (emergency room ) for evaluation. It continues, Resident in shower room with V26 (CNA) performing bathing ADLs (activities of daily living). Resident leaned forward tipping shower chair. CNA could not stop resident from falling forward, resident landed on (Right) hip. No deformities or shortening noted upon assessment. X-Ray performed in house per V28 (Family Nurse Practitioner-Certified/FNP-C)) resulting negative. Resident consistent with pain complaint, sent to (emergency room ) for further evaluation per (Power of Attorney)/Nursing Judgement. On 12/15/2022 at 8:45 AM, V26 (CNA) stated that she took R63 into the shower room in the shower chair that day. V26 stated that once there, she was standing in front of R63 facing him, untying his gown. V26 stated he was leaning forward, started to fall forward, she could not stop him, and he fell out of the chair. V26 stated that she was unable to recall if the floor was wet or not or if his feet were touching the floor or on the footrest of the shower chair. V26 stated that maybe if there were 2 of them (staff) or if the shower had floor mats, this may not have happened. On 12/15/2022 at 9:20 AM, the shower chair that R63 was sitting on at the time of his fall was observed. It was approximately 4 to 4.5 foot tall from top to bottom, had front and back wheel locks and had a footrest. On 12/14/2022 at 09:30 AM, V27 (Licensed Practical Nurse/LPN), stated that R63 was having behavior issues earlier in the day, but not when he was called into assess R63 after his fall in the shower room. V27 stated that he does not recall if the floor was wet or not when he came into the shower room. On 12/14/2022 at 10:00 AM, V28 (FNP-C) stated that this fall was probably situational and that everyone would like 2 staff in there during care. On 12/15/2022 at 8:55 AM, V1 (Administrator) stated that R63 was picked up for Physical Therapy and Occupational Therapy in June, July and August of 2022 and at that time he was able to sit for 10 seconds unsupported sitting on the mat with feet flat on the floor, no backrest or arm rest and they did not recommend a 2 person assist for showers. When asked why R63 was picked up by therapy in June, she stated that she did not know why. R63's Hospital Record, dated 10/26/2022, documented, 64 (year old) male with medical history that includes (Traumatic Brain Injury, Cerebral Vascular Accident, Chronic Obstructive Pulmonary Disease) and dysphagia admitted for oblique, comminuted intertrochanteric fracture of the right femur (status post) fall. Patient resides in (Nursing Home) and staff reports patient fell while in shower . It continues, Exam: CT (computed tomography) Pelvis w/o (without) contrast order date: 10/25/2022 (Reason for Procedure: Trauma/Injury Impression: 1 Highly comminuted right intra-trochanteric hip fracture. 2. There appear to be old healed bilateral superior and inferior rami fractures. No acute pelvic fracture see. 3. Moderate to severe fecal impaction of the colon and rectum. An Electronic mail to V1 (Administrator) dated 10/29/2022, V32 (Medical Director) documented, One thing you did not mention is that (R63) is completely flaccid on the right side. In addition, this causes a right sided neglect. It continues, His paralysis would have prevented him stopping the fall and hemi-neglect would have prevented him from even trying. On 12/12/2022 at 03:16 PM, R63 was lying in bed, asleep. The bed was in the lowest position and the call light within reach. There was no non-skid pad in his wheelchair seat. 42108 2. R14's Care Plan, dated 12/12/2022, document Problem: Resident Care Information it also documents APPROACH: Safe Resident Handling Procedures-Transfer Method: Stand aid. Level of assistance: Assist x 1. R14's MDS, dated [DATE], documents that R14 is cognitively intact, always incontinent of bowel and bladder, and requires extensive physical assist of 1 staff member for toileting and transfers. On 12/12/22 at 9:40 AM, V4 (Certified Nurse Assistant/CNA) assisted R14 with toileting. Upon completion of voiding, V4 assisted R14 into the standing position using the stand aide. V4 performed care and dressed R14. V4 then closed the seat on the stand aide. V4 then transported R14 from the bathroom to the opposite side of the room and removed the seat, grabbed R14 by the waist and assisted R14 into the wheelchair. V4 did not apply a gait belt. R4's gait belt was observed around her waist during the transfer. 3. R28's Care Plan, dated 12/12/22, documents APPROACH: Safe Resident Handling Procedure: Transfer Method: Stand Pivot. Level of Assistance: Assist x 1. R28's MDS, dated [DATE], documents that R28 requires extensive physical assist of 1 staff member for toileting and transfers. On 12/14/2022 at 9:20 AM, V7(Certified Nurse Assistant/CNA) and V20 (Certified Nurse Assistant/CNA) assisted R28 with toileting. V7 assisted R28 onto the standing aide. V4 (CNA) then transported R28 across the room into the bathroom and on to the toilet. V7 then removed the seat and assisted R28 into a seated position onto toilet using R28's hips to assist. After R28 voided, V7 and V20 grabbed R28 under her shoulder and assisted R28 into a standing position. R28 grabbed a hold of the front bar of the stand aide. R28 knees buckled and R28 started lowering. V7 and V20 grabbed R28's shirt and hip and assisted R28 into a sitting position on the toilet. V7 grabbed a hold of R28's arm and assisted R28 into standing position. V7 performed peri care and assisted R28 with dressing. V7 closed the seat to the stand aide and V20 transported R28 from the bathroom across the room and on to the bed. V7 and V20 did not apply a gait belt to R28. 4. R72's Care Plan, dated 11/14/2022, documents PROBLEM: RCIS (Resident Care Information Sheet.), APPROACH: Safe Resident Handling Procedures -Transfer Method: Stand and pivot with gait belt. Level of assistance: Assist x 1 R72's MDS, dated [DATE], documents that R72 requires extensive assist with toileting and limited assist of 1 staff for transfers. On 12/13/2022 at 10:10 AM, V4 (CNA) assisted R72 with toileting. Upon completion of toileting, V4 assisted R72 into a standing position by grabbing a hold of R72 right arm. R72 grabbed a hold and leaned forward on to the wheelchair's armrest. R72 balance was unsteady with R72 observed wavering back and forth. V4 pulled up R72 pants. V4 grabbed a hold of R72 waist and transferred R72 into the wheelchair. V4 did not apply or use a gait belt during the transfer. On 12/15/2022 at 12:50 PM, V33 (LPN) stated that she would expect the staff performing a manual transfer to utilize a gait belt. 44967 5. R280's Care Plan, dated 12/1/22, documents (R280) is at risk for falling related to recent illness/hospitalization and new environment. Interventions: Instruct (R280) to call for assist before getting out of bed or transferring. Encourage (R280) to stand slowly, orient (R280) to room, surrounding areas, and use of call light system. Encourage (R280) to use side rails/enablers as needed, Therapy to evaluate and treat as ordered, Provide (R280) with specialized equipment (such as walker, wheelchair. It continues, Resident Care Information: Safe Resident Handling Procedures-Transfer Method: Stand pivot. Level of assistance: Assist x 2. R280's MDS, dated [DATE], documents that R280 has a moderate cognitive impairment and requires extensive assistance from two staff members for transfers, bathing, and toileting. R280 requires extensive assistance from one staff member for all other ADL's. On 12/13/22 at 11:40 AM, R280, was lying in bed as V15 (Certified Nurse Assistant/CNA) and V16 (Certified Nurse Assistant/CNA) entered the room to perform incontinence care on R280. After incontinent care was completed, both CNAs assisted R280 to the side of his bed, put a gait belt around him, assisted R280 to stand and pivot. Just as R280 had turned and pivoted, the unlocked wheelchair started to move backwards and V16 grabbed the wheelchair and pulled it toward R280 then they lowered him to his wheelchair. 6. R297's Care Plan, dated 12/5/22, documents (Safe Resident Handling Procedures-Transfer Method: Full Body mechanical lift. Level of assistance: Assist x 2. Sling Style: long seat Sling Size: XL. R297's MDS, dated [DATE], documents that R297 is total dependent on two staff members for transfers. On 12/13/22 at 10:05 AM, R297 was lying in bed with the mechanical lift device sling under him. V15 (CNA), V16 (CNA) and V17 (CNA) all in the room to transfer R297 from his bed to his recliner chair. V15 operated the lift device. The sling straps were attached to the lifting device, V15 lifted R297 off the bed and pulled R297 away from his bed to in front of his recliner and was freely swinging with no one having constant contact with R297 during this move. V16 and V17 did grab onto R297 once he was pushed over to his recliner and then assisted him down to the chair. R297 was unhooked from device, covered up with blanket, feet elevated, and call light on his lap. On 12/15/22 at 9:30 AM, V24 ( Licensed Practical Nurse/LPN) stated I use a gait belt for all resident transfers, including the stand-aides. The Facility's Safe Resident Handling Policy, dated 11/2012, documents Purpose: This program is designed to limit and remove as much manual lifting as possible. Staff commitment is vital both to the success of the program and to experience its benefits. Facility has made a significant investment in modern, safe and easy to use equipment for staff to use. Every staff member is expected to support this program 100% and with that commitment, the program will be successful. It continues, 5. All staff members required to use the lifting devices will be oriented and trained on the proper use. Each staff member will have first-hand experience on what the lift feels like from a resident's perspective. Staff is to report any concerns about transfers that may pose an unacceptable risk for injury to a resident or staff to DON. Resident will then be reassessed for safe procedures. When using Full Mechanical lift, two staff members are used with additional help as needed. When using the non-mechanical standing device, one staff member is used with additional assist as needed. If care planned with two assist it must be used with two staff members. It continues, 9. When physically transferring residents, gait belts will be used to maintain appropriate transfer techniques.

Based on interview, observation, and record review, the facility failed to properly store and label medications. This has the potential to affect all 139 residents in the Facility. Findings include: On [DATE] at 3:20 PM, the medication storage room for the 400 and 500 halls was inspected. The medication room contained the following medication: 1-Bottle of Tubersol with no opened date. V10 (Licensed Practical Nurse/LPN) stated, I think that has been opened since the cap is off. On [DATE] at 1:48 PM, V21 (Licensed Practical Nurse/LPN) stated, We give the Tubersol on admission, then yearly, as needed. All the residents have standing orders to get it once a year. On [DATE] at 2:24 PM, V2 (Director of Nursing/DON), Tubersol has an expiration date on it, but it also has to have an opened date on it. The opened date is how we know when the product is expired. I would expect my nurses to put a date on it after opening. It is a multi-dose vial. Everyone receives it unless they have an allergy to it. On [DATE] at 3:10 PM, V1 (Administrator) and V2 (DON) stated that they were unsure whether the facility should follow manufacturer's instructions for Tubersol and would like to refer to their policy. The Facility's Pharmaceutical Procedures Policy revised [DATE] does not address multi-dose vials. Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated [DATE], documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Resident Census and Conditions of Residents, CMS 672, dated [DATE] documents the facility has 139 residents living in the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards. This has the potential to affect all 139 residents living in the facility. Findings include: On 12/13/22 at 11:45 AM, in the dry storage room, there was a large tub containing a white powdery substance labeled food thickener. There was no date on this container. On the shelf in the dry storage room, there was a plastic bag with macaroni that was wrapped up, but not labeled or dated. On 12/13/22 at 11:47 AM, in the walk-in freezer, there was a plastic bag full of biscuits that had been opened and tied up but was not labeled or dated. There was a bag containing pieces of oblong shaped meat that had been tied up but was not labeled or dated. V3 (Dietary Manager) stated, Those are pork riblets. On 12/13/22 at 11:48 AM, in the walk-in refrigerator, there was a container covered in aluminum foil with M/S chicken and 12/6-12/12 written in black marker. There was a container labeled coleslaw and 12/6/-12/12 on top. V3 (Dietary Manager) stated, These should have been thrown out on the twelfth. I'm going to get these out of here. On 12/13/22 at 11:55 AM, in the 100-hall satellite kitchen, temperatures were obtained from the steam table using metal calibrated thermometer. The mechanically altered beef measured 127 degrees Fahrenheit (F), and the pureed beef measured 127 degrees F. On 12/15/22 at 10:50 AM, V1 (Administrator) stated, I would expect my staff to follow our food service policies. The Facility's Purchasing, Receiving and Food Storage Policy revised 9/10 documents, It is the policy of the facility to provide quality and wholesome food by following assigned budget, and to receive and store food by following sanitation standards, which are in compliance with state and federal rules and regulations. Unless its identity is unmistakable, bulk food not stored in the original labeled container or package in which it was obtained shall be stored in a container labeled to identify the common name. The Facility's Food Temperatures-Measuring Procedure Policy adopted 8/19 documents, Hot foods should be held at least 135 degrees F or higher. 135 degrees F for hot holding-held in warming cabinet or on steam table. The Facility's Meal Service Procedure Policy, adopted 11/14/22, documents, Food items should be returned to the kitchen if hot food is below 135 degrees F. The Resident Census and Condition of Residents Form (CMS 672) dated 12/12/22 documents there are 139 residents living in the Facility.

Based on observation, interview and record review, the facility failed to perform complete catheter and incontinent care for 5 of 7 residents (R4, R14, R74, R119, R288) reviewed for toileting in the sample of 57. Findings include: 1. R14's Care Plan, dated 12/12/2022, documents Problem: Resident Care Information it also documents Approach: Bowel and Bladder: Incontinent of both. Incontinence Products: Large brief. R14's Minimum Data Set (MDS), dated [DATE], documents that R14 is cognitively intact, always incontinent of bowel and bladder, and requires extensive physical assist of 1 staff member for toileting. On 12/12/22 at 9:40 AM, V4 (Certified Nursing Assistant/CNA), performed incontinent care. R14 was incontinent of urine. R14 voided on toilet as well. V4 assisted R14 into the standing position. Using cleaning wipes, V4 cleansed R14's buttocks and peri area. V4 did not cleanse R14's inner labia and inner thighs. On 12/12/2022 at 9:43 AM, V4 stated that R14 was incontinent of urine. 2. R4's Care Plan, dated 12/13/2022, R4 has a (indwelling urinary) catheter related to obstructive uropathy. It continues Resident Care Information documents APPROACH: Provide catheter care as needed. R4's MDS, dated [DATE], documents that R4 has a catheter and requires limited physical assist of 1 staff for toileting. On 12/13/2022 at 8:50 AM, V5(Certified Nursing Assistant/CNA) and V6 (Certified Nursing Assistant/CNA) assisted R4 with toileting. R4 was incontinent of a small amount of bowel. R4 then had a bowel movement on the toilet. V6 then, using a personal cleansing cloth, performed peri care. V6 cleansed both sides of R4's groin. V6 then cleansed R4's outer and inner labia wiping from dirty to clean. V6 cleansed R4's inner labia and noted to have a large amount of stool on personal cleansing cloth. V6 did not provide any further peri care. V4 then cleansed R4's buttocks. V4 cleansed R4's anal area and stool noted on personal cleansing cloth. V4 placed cloth in trash can and assisted R4 with pulling up R4's brief and pants. V4 and V6 did not perform catheter care. 3. R74's Care Plan, dated 11/17/2022, documents PROBLEM: Resident Care Information. It continues APPROACH: Bowel and bladder: Continent of both. Incontinency product: Underwear. R74's MDS, dated [DATE] documents that R74 is continent of bowel and bladder and requires extensive physical assist of 1 for toileting. On 12/13/2022 at 9:10 AM, V5 (CNA) and V6 (CNA) assisted R74 with incontinent care. R74 was incontinent of a large amount of soft bowel. V6, using personal cleansing cloths, cleansed R74's penis, scrotum and groin area. V5 and V6 turned R74 onto his left side and cleansed R74's right buttock and partial left buttock. V5 and V6 then placed clean incontinent brief under R74. V5 and V6 then turned R74 onto his back and fastened R74's incontinent brief. V5 and V6 did not cleanse R74's entire left buttock. On 12/15/2022 at 11:30 AM, V2 (Director of Nursing/DON) stated that she would expect the CNAs to perform catheter care when performing incontinent and peri care. 44967 4. R288's Care Plan, dated 11/10/22, documents (R288) Resident is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization , malnutrition/low H&H (Hemoglobin and Hematocrit), and B&B (Bowel and Bladder) incontinence. Interventions: Provide incontinent care after each incontinent episode. It continues R288 has a UTI (Urinary Tract Infection). Interventions: Assist (R288) with perineal care/incontinence care as needed, Encourage fluids, administer antibiotic as ordered. R288's MDS, dated [DATE], documents that R288 has a moderate cognitive impairment and requires extensive assistance from two staff members for most of his ADLs (activities of daily living). R288 requires extensive assistance from two staff members for toileting. On 12/13/22 at 10:35 AM, V18 (Certified Nursing Assistant/CNA) and V16 (Certified Nursing Assistant/CNA) went into R288's room to perform perineal care for R288. R288 was inquiring about why they are doing this and V18 stated that they had to show how they do perineal care. Both CNAs donned gloves without performing hand hygiene prior. R288 rolled over, and her brief/underwear pulled down and incontinence pad rolled under her. V18 doffed her gloves, donned clean gloves with no hand hygiene done. V18 wiped once across top of pubic area, once down each groin, once down R288's vagina, and then wiped the right and left outer buttocks. V18 did not wipe between R288's buttocks and anal area and there was no drying of R288 after any cleansing. V18 did not change her gloves after performing perineal care and began putting a clean incontinence pad onto the bed. R288 was rolled to her side and the soiled linen was removed. R288's underwear and pants were pulled up using the same soiled gloves. V16 and V18 then doffed their gloves and hand hygiene performed. R288 was still asking why they were doing this and V18 repeated to her that they had to show how they do perineal care. V18 stated that R288 was not incontinent and wore her own underwear and that she was not even wet, but they just wanted to show how to do perineal care. 40650 5. On 12/13/2022 at 9:35 AM, V30 (Certified Nursing Assistant/CNA) took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold. V30 threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth, and cleansed R119's left groin area. V30 asked V31 (CNA) to help hold open R119's labia and V30 took a cleansing wipe and cleansed down the center of R119's perineum. None of these areas were dried after staff used a Personal Cleansing Cloth. V30 then took a Personal Cleansing Cloth, cleansed R119's right hip, obtained a new cloth and cleansed R119's perirectal area several times, with different wipes, due to R119 was smearing stool. These areas were not patted dry and were left wet. V30 and V31 rolled R119 over onto her right side. V30 cleansed R119's left hip with a Personal Cleansing Cloth, obtained a new personal cleansing cloth, and cleansed R119's peri rectal area again. No areas were dried after care. R119's Braden Scale, dated 11/1/2022 documented that she was at moderate risk for skin breakdown and that her skin was very moist. R119's Care Plan, dated 7/30/2022, documented, Provide incontinent care after each incontinent episode. On 12/13/2022 at 11:30 AM, V29 (Customer Service Representative) from the makers of Personal Cleansing Cloths, stated that the company does not give recommendations for use and that it is left up to the facility to put something in their policy. On 12/14/2022 at 11:15 AM, a test of the time for drying after use of personal cleansing cloth was performed. Antecubital area was cleansed with personal cleansing cloth. The antecubital was closed for 1 minute to provide skin to skin contact. After 1 minute of skin to skin contact the antecubital area remained moist. The facility's Perineal Care policy, dated 11/18, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure: 4. Wash perineal area with soap and water, perineal cleanser or wipes. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. The facility's Catheter Care Policy, dated 6/05, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure 4. Wash perineal area with soap and water or perineal cleanser. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean portion of the washcloth is used for each wiping motion. On a female resident, clean the labia; then spread the labia to wash the inner folds. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel.

Based on interview, observation, and record review, the facility failed to adhere to infection control practices to prevent the spread of COVID 19 and other infectious organisms by failure to utilize appropriate PPE (Personal Protective Equipment), perform hand hygiene, and maintain clean oxygen equipment, for 5 of 7 residents (R12, R114, R119, R123, R281) reviewed for infection control in a sample of 57. Findings include: 1. On 12/14/22 at 7:55 AM, the door to R93's and R122's room, which is a Positive COVID (Coronavirus Disease) Isolation room, was left open and V19 (Housekeeper) was going in and out of the room, cleaning the floor in the room, placing the mop in the bucket outside the room and was only wearing a yellow surgical mask and no other PPE. V19 then left the unit with the housekeeping cart remaining in the unit. V19 was seen afterwards emptying trash in numerous rooms with the same yellow surgical mask on. On 12/15/22 at 9:28 AM, V24 (Licensed Practical Nurse/LPN) stated For any COVID/Isolation room, everyone who enters must wear full PPE, including N-95 mask, gown, and goggles, regardless, if you are doing resident care or not. On 12/15/22 at 9:35 AM, V25 (Housekeeper) stated Anytime I walk into a COVID or Isolation room, I wear a N-95 mask, gown, and goggles. I take the gown off before I leave the room and do hand hygiene. I don't want to take that home. The trash we tie up and put with the regular trash unless it is wet. The linen we put into a red bag, double bag, and take it to laundry. R122's Care Plan, dated 12/7/22, documents R122 has respiratory symptoms consistent with COVID 19 with the Approach Droplet isolation precautions with eye protection. 2. R12's Care Plan, dated 12/12/22, documents (R12) is at increased risk for skin breakdown related to decreased mobility, weakness, occasional bladder incontinence, low albumin, potential for friction and shearing with transfers and repositioning. Interventions: Open area to top of right second toe will heal/improve by the next review: Monitor for signs and symptoms of infection. Treat as ordered. See TAR (Treatment Administration Record). Notify MD (Medical Doctor)/NP (Nurse Practitioner) for changes. R12 will have minimized risk for skin breakdown during this quarter: Provide perineal care following each episode of incontinence, assist resident with turning and repositioning. It continues (R12) Resident Care Information. Interventions: Incontinent of urine and bowel at times. Assist Incontinence Products: Large pullups. R12's Minimum Data Set (MDS), dated [DATE], documents that R12 has a severe cognitive impairment. R12 requires limited assistance from one staff member for most of her ADL's (Activities of Daily Living). R12 requires extensive assistance from one staff member for toileting and personal hygiene. R12 is always incontinent of both bowel and bladder. On 12/13/22 at 9:55 AM, V14 (Registered Nurse/RN) went into R12's room to perform wound care to R12's right second toe. V14 carried in supplies on a clean folded towel, dumped the wound care supplies onto R12's bed, with comforter on top, and used the clean folded towel to put under R12's right foot. V14 donned a pair of gloves, without performing hand hygiene prior to donning gloves and removed the old dressing, dated 12/13/22, from R12's right second toe open wound, pink in color, and had no drainage. V14 used the same soiled gloves to spray wound cleanser onto R12's toe and used a 4X4 gauze to cleanse the wound. V14 used the same soiled gloves and cut a piece of Alginate dressing and applied it to the open wound, V14 then applied a 2X2 gauze dressing on top of the Alginate and taped it to her toe. V14 used the same soiled gloves to get a pen located in his shirt pocket and dated the dressing, then put his pen back in his pocket. V14 then gathered the remaining supplies and some trash using the same soiled gloves and exited the room. V14 put the wound cleaner spray, the pair of scissors, and other dressing supplies back in the wound supply cart, then removed his soiled gloves and did not perform hand hygiene as he took the cart away from the room. 3. R281's Care Plan, dated 12/7/22, documents (R281) is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . Interventions: (12/6/22) (specific type/brand of mattress) mattress to bed, monitor for signs and symptoms of infection. treatments as ordered. See TAR. Notify MD/NP for changes, provide incontinent care after each incontinent episode, pressure reducing device in wheelchair and bed, assist resident with turning and repositioning, side rails/enablers to assist with turning and repositioning. It continues (R281) Resident Care Information. Interventions: Turning and Repositioning: As needed. two quarter rails, Skin Care: Barrier cream as needed. Skin Checks each shift, Bowel and Bladder: Incontinent of both. Incontinence Products: Medium brief. R281's MDS, dated [DATE], is not completed. On 12/13/22 at 9:05 AM, V12 (Certified Nursing Assistant/CNA) and V11 (LPN) in R281's room for wound care. Supplies setting on clean towel on bedside table. Both V11 and V12 performed hand hygiene and donned clean gloves. The old dressing was removed from R281's coccyx which was dated 12/13/22. V11 doffed her gloves and performed hand hygiene. V11 donned clean gloves and used normal saline and gauze pads to cleanse R281's wound. Using the same soiled gloves, V11 applied Xeroform to the wound, then a padded dressing applied and dated. V11 then doffed her gloves and performed hand hygiene. R281's Nurses Note, dated 12/6/22 at 11:04 AM, documents Called and informed POA (Power of Attorney) of shearing area to the right buttock area that measures 1 cm (centimeters) x 0.7 cm and new treatment orders explained and understanding met. R281's Physician Note, dated 12/6/22, documents Cleanse open area to right buttock and apply Xeroform gauze and padded dressing daily and PRN (As Needed). On 12/15/22 at 10:53 AM, V1 (Administrator) stated, I would expect the staff to follow the infection control guidelines, including the wearing of appropriate PPE when necessary, especially going into COVID or isolation rooms, the changing of gloves when soiled, and proper hand hygiene when indicated. The Facility's Standard Precautions Policy, dated 8/2009, documents Standard precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard precautions are based on principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. It continues Procedure: 1. Hand hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR). b. Wash hands when they are visibly soiled, before and after eating or handling food, before or after assisting a resident with meals, before and after assisting a resident with the toilet and after contact with a resident with infectious, whether or not gloves are worn. c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer or microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedure on the same resident to prevent cross-contamination of different body sites. d. Unless hand washing is specifically required, antimicrobial agents are appropriate for cleaning hands and can be used for direct resident care. 2. Gloves: a. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and non-intact skin. c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments. The facility's COVID-19 Policy, dated 11/14/22, documents: The infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage and isolation of potentially infectious residents. It continues Residents with confirmed COVID-19: 5. Resident with confirmed COVID-19 infection will be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. It also documents, 8. Staff will wear N-95 respirators, eye protection, gowns and gloves when caring for residents with COVID-19. 40650 4. 12/13/22 9:35 AM, V30 (Certified Nursing Assistant/CNA) and V31 (Certified Nursing Assistant/CNA) performed hand hygiene and donned gloves. V30 unfastened R119's soiled incontinent brief and rolled it down between R119's legs. Then V30 took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold with her left hand, threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth and cleansed R119's left groin area. V30 continued to provide incontinent care without benefit of hand hygiene or glove changes. 5. On 12/12/2022 at 10:54 AM, R114's nasal cannula tubing was lying on the floor. R114's Resident Face Sheet, undated, documents, diagnoses of Congestive Heart Failure and Pneumonia. R114's Physician Order Report, dated 10/21/2022, documents an order for O2 at 2 (liters/min) nasal cannula (as needed) for (shortness of breath). R114's Care Plan, dated 07/08/2022, documented, Oxygen: 2 liters as needed. 6. On 12/12/2022 at 11:12 AM, R123's Oxygen nasal cannula tubing was lying on the floor under his bed. R123 stated that he wears oxygen when they put it on him. R123's Resident Face Sheet, undated, documents, diagnoses of Anemia, unspecified and Chronic diastolic (congestive) heart failure. R123's Physician Order Report, dated 12/14/2022, documented, that he was on Palliative Care. It does not document an order for Oxygen usage. R123's Care Plan, dated 10/09/2022, documented an approach of O2 at 2 (liters/nasal cannula) as needed. R123's MDS, dated [DATE], documented that his cognition was moderately impaired.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 5 of 5 residents (R26, R106, R303, R330, R331) reviewed for antibiotic stewardship in the sample of 57. Findings include: 1.The Facility's Monthly Infection Log for the month of December 2022 does not document an organism causing R26's infection. The log documents R26 was treated with the antibiotic Azithromycin. R26's Physician Order Report for 12/1/22-12/14/22 documents order for 250mg (milligram) Azithromycin tablet - 2 tabs day 1, then 1 tab, oral for chronic obstructive pulmonary disease, unspecified, with start date of 12/6/22 and end date of 12/10/22. R26's Medication Administration Record (MAR) for the month of December 2022 documents R26 received 4 of 6 prescribed doses of Azithromycin. On 12/14/22 at 1:00 PM, documentation to justify the use of Azithromycin was requested. On 12/15/22 at 2:44 PM, no documentation was received. 2. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R106's infection. The log documents prophylactic for laceration and the use of antibiotic Cephalexin. R106's Physician Order Report from 7/1/22 to 12/14/22 documents order for 500mg Cephalexin capsule - 1 capsule oral every 8 hours for encounter for prophylactic measures, unspecified, with start date of 7/13/22 and end date of 7/20/22. R106's MAR for the month of July 2022 documents R106 received 27 of 27 prescribed doses of Cephalexin. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Cephalexin was requested. On 12/15/22 at 11:45 AM, V2 (Director of Nursing/DON) stated, There was no culture. They were treating him prophylactically. That is very common. 3. R303 was not listed on the Facility's Monthly Infection Log for any month in 2022. R303's Physician Order Report from 7/14/22 to 12/14/22 documents order for 250mg Keflex (cephalexin) capsule oral, once a day, for trigeminal neuralgia with start date of 10/23/21 and end date open ended. R303's MARs for July 1, 2022 through December 14, 2022 document R303 received 167 doses of Keflex. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Keflex was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. 4. The Facility's Monthly Infection Log for the month of August 2022 does not document an organism causing R331's infection. The log documents prophylactic and use of the antibiotic Amoxicillin. R330's Physician Order Report from 8/1-22 to 9/30/22 documents order for 250mg Amoxicillin capsule - 1 capsule oral with special instructions to take for 90 days per (V6, physician). The diagnosis was documented as encounter for prophylactic measures, unspecified with start date of 8/29/22 and discharge date of [DATE]. R330's MARs for the months of August and September 2022 document R330 received 17 doses of Amoxicillin. On 12/14/22 at 1:00 PM, documentation to justify the appropriate use of the antibiotic Amoxicillin was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. 5. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R331's infection. The log documents prophylactic and the use of antibiotic Bactrim. R331's Physician Order Report from 7/14/22 to 12/14/22 does not document order for Bactrim but does document order for 250mg Zithromax Z-Pak (Azithromycin) tablets - 2 oral for other specified diseases of upper respiratory tract with start date of 7/19/22 and end date of 7/19/22. There is also an order for 250mg Zithromax Z-Pak (azithromycin) tablet - 1 oral for other specified diseases of upper respiratory tract with start date of 7/20/22 and end date of 7/23/22. R331's MAR from 7/1/22 to 7/31/22 documents R331 received 5 doses of Zithromax Z-Pak. On 12/14/22 at 1:00 PM, documentation to justify appropriate use of Zithromax Z-Pack was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. On 12/14/22 at 9:40 AM, V23 (Infection Control Preventionist/ICP) stated, I read progress notes, run reports, look up antibiotic reports for new antibiotics, and fill out the monthly infection control log first thing in the morning before the morning meeting. Every time I get an antibiotic order I check to see if it is warranted. I look at the results first, and if it says 'no culture to follow' I put 'no' on the log. If not, I check with the doctor. Usually, they will say not to continue or to discontinue it. The Facility's Antibiotic Stewardship Policy revised 12/18/19 documents, It is the policy of the facility to follow an Antibiotic Stewardship program, including the core elements as outlined by the CDC (Centers for Disease Control). The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. The facility will track antibiotic use daily. The facility will communicate with the physician(s) prescribing antibiotics with a Utilization report on a monthly basis and as needed. The Facility's Infection Control Policy revised 12/17/19 documents, Nursing staff will develop weekly reports on antibiotics, including review to ensure appropriate use of antibiotics.

Based on observation, interview and record review, the facility failed to supervise residents to prevent falls for 1 of 3 residents (R6) reviewed for falls in the sample of 12. This failure resulted in R6 sustaining a broken finger and facial bruising around the eye, cheek and chin. Findings include: On 9/22/22 at 11:08 AM, R6 was sleeping in her wheelchair. R6 had purple and fading yellow bruising around her right eye, cheek and chin. R6 has an ace bandage on her right hand. R6's Physician Order Report, dated 9/1/22 - 9/22/22 documents R6 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes, Dementia and depression. R6's Minimum Data Set, dated dated [DATE], documents that R6 is independent of daily decision making, requires extensive assistance of 2 staff members for bed mobility and transfer, extensive assistance of one staff member for toileting, personal hygiene and dressing and limited assistance of one staff member for locomotion on the unit. This MDS also documents R6 is not steady and only able to stabilize with staff assistance and that she uses a wheelchair. This MDS also documents R6 is occasionally incontinent of bowel and bladder. R6's Nurse's Note, dated 9/14/22, documents, Resident found on floor in bathroom, laying on R (right) side in front of toilet. Floor is clean, dry, and free of clutter. Resident states she did hit her head. Resident assisted to bed via 3 staff members. Skin tear to R wrist noted measuring 2cm (centimeters) x 1cm. Edges approximated and (brand) thin adhesive bandages applied. Hematoma noted to R side of forehead measuring 4cm x 3cm. Small open area to bridge of nose. Resident states that she was putting pants on in bathroom unassisted prior to falling. Stated I think I lost consciousness for a few minutes. VS (vital signs) as follows- 134/88, P (pulse) 71, R (respirations) 22, T (temperature) 97.8, O2 (oxygen) 93% on 3L (liters) per NC (nasal canula). Resident requesting transfer to (local) ER emergency room ) for evaluation. Ambulance paged at this time. V25 (R6's Power of Attorney) called and notified, verbalized appreciation of call. R6's Fall investigation, dated 9/14/22, documents that R6 was on the toilet trying to put her pants on herself when she fell off the toilet. Sent to the Emergency Department. R6 came back with bruising and swelling to right 5th finger, bruising to her right forehead and a skin tear to her chest. X-ray was obtained and findings showed suspicious for acute fracture of the distal aspect of the proximal phalanx of the 5th digit. R6's local hospital discharge instructions, dated 9/14/22, documents, You have been evaluated today for the following conditions: Multiple contusions with soft tissue hematoma to the forehead, chin and right hand. R6's CT (Computed Tomography) Head and Neck, dated 9/14/22, documents, Scalp hematoma of the right supraorbital region noted. R6's X-ray of right fingers, dated 9/14/22 at 8:46 PM, documents, Findings suspicious of acute fracture of the distal aspect of the proximal phalanx of the 5th digit with some ventral angulation best seen on lateral projection view. On 9/22/22 at 3:10 PM, V6 (Certified Nurse Assistant/CNA) stated, R6 really doesn't do anything for herself. She is a two-person assist. We dress her. We will take her to the bathroom; she can't go with you in there, so we give her the call light and tell her to call us. She will fall asleep in there, so you gotta go and wake her up. She will also get tired of waiting for us to answer the light, and she will try to stand, which she can't, and she falls. She thinks she can stand and transfer herself. On 10/3/22 at 9:50 AM, R6 stated, They take me to the toilet and sometimes I take myself. Usually, the staff get me dressed, but that morning an aide came in and took me to the bathroom and told me to get myself dressed. I said okay because I like to do things for myself or at least try to help myself. I was trying to put my pants on, and I fell off the toilet. On 10/4/22 at 9:00 AM, V24 (Licensed Practical Nurse/LPN) stated, (R6) cannot dress herself. We encourage her to help with the top, but the pants, no, she couldn't do that because, of course, she can't stand by herself. On 10/4/22 at 10:00 AM, V23 (Certified Nursing Assistant/CNA) stated, I was the aide the morning R6 fell and got the black eye. I went in in the morning, and I used the stand-aide to take her to the bathroom. I put her on the toilet. I left her with her clothes to put on. The next thing I know, she is on the floor. She would get dressed in the bathroom on the toilet by herself, but somedays she needed help. On those days, I would help her. On 10/4/22 at 10:10 AM, V27 (Certified Nursing Assistant/CNA) stated, I was on the hall that day (9/14/22) but I don't remember getting her up. When I get her up, I take her to the bathroom using the sit-to-stand and get her on the toilet. I would stand outside with my arm in the door. I like to give her privacy, but I am not leaving her alone on the toilet. She will not use the call light. She will take herself to the bathroom. I have caught her. I tell her she shouldn't do that and that she is going to fall, and she says, I know. I put her pants on her while she is in bed; it is just easier that way. She might be able to put on her shirt, but I always help her. On 10/4/22 at 10:59 AM, V28 (Licensed Practical Nurse/LPN) stated, I was the nurse the morning R6 fell and needed to go to the hospital. I was sitting at the desk and heard an awful scream from R1 (R6's roommate). I went running; actually, we all did. I went in the room, R1 said 'It's R6. She is hurt.' I opened the bathroom door and R6 was on the floor. I didn't see any blood, but she did start to have a goose egg on her head. I asked her if she wanted to go to the hospital; she said 'No.' Myself and other staff got her up and back in bed. I assessed her. She said she had fallen off the toilet. She then told me that she wanted to go to the hospital and be checked out. I called 911 and called V25 (R6's POA) and left a message about the fall and that I was sending her out and I would keep her updated. When R6 came back, I called V25 and left a message that R6 was back. The paramedics had R6 all wrapped up in a blanket; when I unwrapped R6, I noticed how swollen R6's hand was. I knew something was wrong. I called the Nurse Practitioner, and she gave me an order to get an X-ray. Which I did. I had left several messages for V25, and she never called me back. A few days had gone by and V25 called and told me she was concerned because R6's sister had been in to visit and her sister told her how bad R6 looked. I explained to V25 that bruising always gets worse before it gets better and that she (R6) is on aspirin and [MEDICATION(S)], which is going to make her bruise more easily. R6 will not use the call light. She always says she does not want to bother us. R6 is not able to dress herself. On 10/4/22 at 2:30 PM, V2 (Director of Nurses/DON), stated that R6 should not be left alone to dress herself because R6 does need assistance. The facility policy Emergencies, dated 4/3/2018, documents, A. Falls. 1. Check the resident immediately for ability to move extremities; check for bruised areas and / or cuts. 2. Check resident's ability to explain what happened; evaluate resident's condition before fall. 3. Check if, or with anyone who witnesses the accident. Determine, if possible, where, how, and when the accident occurred.

Based on observation, interview and record review, the facility failed to provide complete incontinent care for 1 of 5 residents (R6) reviewed for incontinent care in the sample of 12. Findings include: R6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Minimum Data Set, dated dated [DATE], documents that R6 is independent of daily decision-making, requires extensive assistance of 2 staff members for bed mobility and transfer, extensive assistance of one staff member for toileting, personal hygiene and dressing, and limited assistance of one staff member for locomotion on the unit. This MDS also documents R6 is not steady and is only able to stabilize with staff assistance and that she uses a wheelchair. This MDS documents R6 is occasionally incontinent of bowel and bladder. On 10/3/22 at 9:35 AM, V16 (Certified Nurse's Aide/CNA) and V6 (Certified Nurse's Aide/CNA) entered R6's room to take her to the restroom. R6 was transferred from her wheelchair to the toilet using a stand-aide lift. V16 pulled R6's pants and incontinent brief down. R6 sat on the toilet. R6 removed her incontinent brief. V6 asked if the brief was wet, R6 stated, 'Yes, it is.' V6 took the wet incontinent brief from R6 and threw it away. The brief was visibly wet with urine. R6 urinated and told V6 and V16 she was finished. R6 was assisted to the standing position using the stand-aide. V16, using toilet paper, wiped R6 with one wipe and then pulled up R6's new incontinent brief and pants. R6 was then transferred to her wheelchair using the stand-aide. On 10/4/22 at 2:30 PM, V2 (Director of Nurses/DON) stated, Staff should provide incontinent care with soap and water and all areas that have been in contact with urine or feces should be washed. The policy Incontinence Care, dated 2/04, documents, 7. Wash all soiled skin areas and dry very well, especially between skin folds.

Based on observation, interview and record review, the facility failed to maintain proper infection control practices as evidenced by failing to place a resident on isolation, failing to perform hand hygiene and failing to use appropriate PPE (Personal Protective Equipment) to prevent the spread of infection. This has the potential to affect all 146 residents in the facility. Findings include: R2's Care Plan dated 3/10/22, documents R2 is at risk for skin breakdown related to decreased mobility, potential for poor appetite, potential for friction and shearing with transfers and re-positioning, generalized muscle weakness and abnormal labs. R2 is frequently incontinent of bowel and bladder. R2 may show rejection of care with his ADL's (Activities of Daily Living) such as transfers, showers, incontinence care, changing linens, getting up and going to bed. R2's Minimum Data Set (MDS) dated [DATE], documents that R2 has a severe cognitive impairment and requires extensive assistance from two staff members for all of his ADL's. R2 is dependent on two staff members for toileting and bathing. R2 is always incontinent of both bowel and bladder. R2's Lab result resulted on 4/17/22 from a culture of right shoulder blister, documents [CONDITION(S)] ([CONDITION(S)]-Resistant Staphylococcus Aureus) positive in the wound. R2's Lab result resulted on 5/21/22 from a right posterior thigh blister, documents [CONDITION(S)] positive in the wound. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note dated 4/17/22 at 12:40 PM, documents R2 continues on [MEDICATION(S)] per order with no adverse reactions noted. R2 does continue to scratch and pick at skin. Culture to wound areas noted to be positive for [CONDITION(S)]. Contact isolation precautions initiated. New order to start [MEDICATION(S)] 600 mg every twelve hours for seven days per NP (Nurse Practitioner). Voicemail left for POA (Power of Attorney) to return call to inform. R2's Progress Note dated 5/21/22 at 2:12 PM, documents Lab informed R2 has [CONDITION(S)] from wound culture. POA was notified. DON (Director of Nursing) notified, dressing placed over open wounds. Isolation set up. R2's Progress Note dated 5/21/22 at 2:39 PM, documents Dressing placed on resident, resident noted to pull dressings off and place them on floor. Redirected multiple times with little success. R2's Progress Note dated 5/21/22 at 3:03 PM, documents New order per Physician for [MEDICATION(S)] twice a day for seven days along with [MEDICATION(S)] 500 mg daily for seven days for blister like rash to body. POA called and notified of new orders, verbalized appreciation. On 5/23/22 at 1:15 PM, V6 (Licensed Practical Nurse/LPN), stated R2 was on isolation as of two days ago according to his chart. After I was asked about R2's blisters, I looked up in R2's chart and it says that R2 was started on antibiotics and isolation. I saw that R2 was not on isolation so I had the housekeeper set up isolation in the room. R2 does have an appointment with a dermatologist this coming Thursday (5/26/22). On 5/23/22 at 1:25 PM, V6 (LPN) stated The isolation cart is supposed to be on the outside of the door because now we have contaminated everything in that cart. The clean cart should be outside and the trash can inside. On 5/23/22 at 1:27 PM, V4 (Housekeeper Supervisor) stated I have been here fifteen years and we have always put the isolation carts inside the room. On 5/23/22 at 2:10 PM, V1 (Administrator) stated They called me on Saturday (5/21/22) to tell me that R2 had [CONDITION(S)] and that R2 was put on isolation. I do not have an open room to move R2's roommate (R5) to or I would have done that too. We currently have 146 residents here and only one true isolation room and I had to put a C-Diff ([CONDITION(S)]) resident in that room. After reading the progress notes, I assumed that R2 was on isolation but I guess he wasn't. On 5/23/22 at 2:15 PM, V1 stated Yes, I would have expected staff to put R2 on isolation like they charted. On 5/24/22 at 8:00 AM, V2 (Director of Nursing/DON) stated I would expect the staff to put PPE for isolation in place for R2 or for any resident who needs it. On 5/24/22 at 8:05 AM, V2 (DON) stated I would expect the staff to perform hand hygiene prior to care, after glove changes, and after care is given to a resident. On 5/24/22 at 8:15 AM, V2 stated I am going to talk to the nurse who documented that R2 was on isolation and have him fix his charting. I was told that the nurse told a CNA (Certified Nursing Assistant) and not housekeeping to put R2 on isolation. Our housekeeping is the one who brings and sets up all the PPE for an isolation room. On 5/24/22 at 9:35 AM, V4 stated I think I will put a sign on the door so people will know this is an isolation room. On 5/23/22 at 9:00 AM, V5 (Certified Nursing Assistant/CNA) and V10 (Certified Nursing Assistant/CNA) were seen going into R2's room with just a mask and goggles on, then exiting and proceeded into each room on the XXX to provide care to residents in those rooms, including R1's, R4's, R6's, R7's, and R8's rooms. On 5/23/22 at 9:50 AM, V5 and V10 brought in full body mechanical lift to assist R2 back to bed and perform incontinence care. V5 stated she will be the clean one and will turn and hold R2, while V10 will be the dirty one and perform the perineal care. R2's pants and incontinence brief was removed with small amount of stool noted and minimal amount of urine. Multiple open sores from popped blisters were noted on R2's right posterior thigh with a blister on top of his penis. During R2's perineal care, V10 ran out of wash cloths and used her soiled gloves to reach over to R2's roommate's (R5) call light, which was lying on R5's clean bed, and pushed the call light button to get help. Using the same soiled gloves, V10 dried R2 off. R2's bed linen was soiled with R2's oozing sores, blisters and urine. There was no gown worn, no hand hygiene done and no glove changes done by either CNA during R2's care. On 5/23/22 at 8:45 AM, R2 was seen grabbing R5's bed rails to assist himself around the bed. On 5/23/22 at 8:43 AM, R5 (R2's roommate) was seen leaving the room in his wheelchair and rolling himself down the XXX hall, to the nurse's desk and to the open living area. On 5/24/22 at 10:15 AM, During R2's oral care, R2's sink and counter was used which is shared by R5 who is not on isolation. On 5/24/22, at 8:25 AM, R5 was seen sitting in the dining room for breakfast. On 5/24/22 at 8:30 AM, V12 (Certified Nursing Assistant/CNA) put a gown on and entered R2's room to give him his breakfast tray. V12 did not put gloves on. V12 took off her gown and using her bare hands pushed it into a full soiled linen bag, which included R2's soiled bed linen. No hand hygiene was done before leaving R2's room. V12 was seen going to the dining room to assist R7 with breakfast. On 5/24/22 at 9:35 AM, V13 (Housekeeper) was seen walking into R2's room to fill paper towels with no PPE on. V13 then exited with no hand hygiene done. V13 continued to go into every room on the XXX hall to replace paper towels. The Facility's Categories of Transmission-Based Precautions Policy dated 9/2018, documents It is the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. It continues Procedure: 1. Transmission-Based Precautions (Isolation Precautions) will be implemented, in addition to the Standard Precautions, that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. It continues Contact Precautions must be implemented, in addition to standard precautions, for resident known to be infected or colonized with organisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. It continues b. Resident Placement: 1. Place the resident in a private room, or 2. Place with a resident with the same infection with the same microorganism. c. Gloves and Hand Hygiene: 1. Wear gloves upon entering the room if contact with resident or potentially contaminated surfaces is possible. 2. During the course of caring for resident, change gloves and perform hand hygiene (wash hands if dealing with C. Difficile) after having contact with infective material. 3. Remove gloves before leaving the room and perform hand hygiene (wash hands if dealing with C. Difficile). 4. After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environment surfaces or items in the resident's rooms. It continues d. Gown: 1. Wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room; if the resident is incontinent; or if the resident has diarrhea, an [CONDITION(S)], a [CONDITION(S)], or wound drainage not contained by a dressing. The Facility's Standard Precautions Policy dated 8/2009, documents Standard precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. It continues 1. Hand Hygiene: b. Wash hands when they are visibly soiled, before and after assisting a resident with the toilet and after contact with a resident with infectious, whether or not gloves are worn. c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedures on the same resident to prevent cross-contamination of different body sites. It continues 2. Gloves: c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments.

Based on observation, interview and record review, the facility failed to prepare food according to safe food handling practices. This has the potential to affect all 136 residents living in the facility. Findings include: On 11/08/2021 at 10:45 am, V8 (Dietary Manager) was pureeing baked chicken and her face mask was below her nose during this task. On 11/08/2021 at 11:55 am, V7 (Dietary Cook) picked hard pieces of chicken out of pureed chicken with gloved hands, lifted up on the trash can lid and discarded it into the trash can. V7 then removed her gloves and put another pair on without performing hand hygiene. At 12:05 pm, V7 lifted up the trash can lid and threw something away and changed gloves without benefit of hand hygiene. At 12:20 pm, V7 changed her gloves without benefit of hand hygiene. On 11/16/2021 at 01:38 pm, V8 (Dietary Manager) stated that she would expect the staff to wash their hands after removing gloves and putting a new pair of gloves on and also she would expect the staff to keep their facemask above their noses. The facility policy, Standard Precautions, dated 08/2009 documents, C. Hand Hygiene should be performed immediately after gloves are removed . It continues, 3. Masks, Eye Protection, Face Shields. a. Wear a mask and eye protection or a face shield to protect mucous membranes of the eye, nose and mouth during procedures and resident-care activities . The Resident's Census and Conditions of Resident, CMS 672, dated 11/9/2021, documents that the facility has 136 residents living in the facility.

Based on interview and record review, the facility failed to provide a written notice to the resident upon transfer to the hospital for 4 of 4 residents (R82, R118, R290, R294) reviewed for transfer in the sample of 71. Findings include: 1. Current Facility Admission Records document R118 was admitted to the facility on [DATE] and transferred to the hospital for failing renal status on 10/19/2021 and readmitted back to the facility on [DATE]. R118's Nurses Notes, dated 10/19/2021 at 4:29 PM, document Ambulance arrived at this time. All appropriate information and paperwork given to EMS (Emergency Medical Services); including Renal Function Panel that was drawn this AM. Resident en route to (Regional) hospital. Report given to (Regional) hospital and notified of FNP-C (Family Nurse Practitioner) and POA's (power of attorney's) requests. On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. 2. Current facility Admission records documents R290 was admitted to the facility on [DATE] and transferred to the hospital for a fall on 11/04/2021 and readmitted back to the facility on [DATE]. R290's Nurses Note, dated 11/4/2021 at 3:52 AM, documents CNA (Certified Nurse Assistant) heard a loud slam and responded immediately to room (R290's room). Resident noted to have fallen out of his bed. Resident laying on L (left) side of body on the floor. Bed in an elevated position. Resident states he was trying to go to the bathroom and forgot to ask for help. He stated he thought he could raise his bed up and do it on his own. Resident wearing a depend and no other clothing. Floor dry, clear of clutter. Denies hitting head. During assessment resident's L leg noted to be externally rotated with some shortening present, the rest of the leg noted to be swollen. Resident c/o (complained of) pain to L wrist, L knee and L hip. Due to the L leg being rotated outward with shortening and the amount of pain resident states he is in, 911 paged to transport resident to ED (Emergency Department) for evaluation. Emergency contact notified, expressed understanding and thanked writer for call and update. Mediprocity (secure messaging for long term care providers) sent to NP (Nurse Practitioner) to update on condition and transportation to hospital. On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. 3. Current facility Admission records documents R294 was admitted to the facility on [DATE] and transferred to the hospital for numbness and weakness to left arm on 11/09/2021 and readmitted back to the facility on [DATE]. R294's Nurses Note, dated 11/09/2021 at 9:00 AM, documents Resident voiced complaints of numbness and weakness to L arm. Res (resident) pupils equal and reactive and foot strength was equal. L grip strength noticeably weaker than the Right. BP (blood pressure) noted to be 178/98. Writer notified NP of assessment and vitals and received order to send resident to (Local) ER (emergency room ) for evaluation and tx (treatment). On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. On 11/15/2021 at 4:04 PM, V25 (Licensed Practical Nurse/LPN) stated that no paperwork is given to the resident. V25 stated that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V25 stated that report and all documentation is given to the EMTs. V25 stated that she does not give any written documentation of why they are going to the hospital to the resident. V25 stated that the business office does the bed holds. On 11/15/2021 at 4:16 PM, V23 (Registered Nurse/RN) stated that he sends the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V23 stated when sending a resident to the hospital all of the paperwork is given to the EMTs. V23 stated there is not any documentation stating why they are going to the hospital given to the resident by nursing. V23 stated that business office handles the bed hold. On 11/16/2021 at 11:43 AM, V2 (Director of Nursing/DON) stated that some nurses print off the sheet and some don't. V2 stated that it is not normal practice at this facility to give the resident written documentation of why they are being sent out or about the bed hold. The bed hold information is mailed out the next day. 4. R82's Nurses note, dated 09/13/2021 at 01:43 PM, V18 (LPN) documented, Resident lethargic with poor nutrition and hydration for an extended period. Called (Power of Attorney) to send out to be evaluated. (Power of Attorney) okay with decision, resident physician notified. Resident was transported to hospital via ambulance at 12pm. On 11/16/2021, the facility was unable to provide documentation to notify residents or representative of the reason for transfer. On 11/16/2021 at 3:13 PM, V2 (DON) stated that the facility does not have a policy for notification of requirements before transfer or discharge.

Based on record review and interview, the facility failed to provide written information to the Responsible Party regarding the transfer, bed hold policy, and permitting the resident to return to the facility for 4 of 4 residents (R82, R118, R290, R294) reviewed for hospital transfer in the sample of 71. Findings include: 1. Current facility Admission records document R118 was admitted to the facility on [DATE] and transferred to the hospital for failing renal status on 10/19/2021 and readmitted back to the facility on [DATE]. R118's Nurses Notes, dated 10/19/2021 at 4:29 PM, document Ambulance arrived at this time. All appropriate information and paperwork given to EMS; including Renal Function Panel that was drawn this AM. Resident en route to (regional) hospital. Report given to (regional) hospital and notified of FNP-C (Family Nurse Practitioner) and POA's (power of attorney's) requests. A review of R294's Health Record shows no documentation of bedhold given or sent with resident and given to power of attorney. On 11/16/2021, the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization . 2. Current facility Admission records documents R290 was admitted to the facility on [DATE] and transferred to the hospital for a fall on 11/04/2021 and readmitted back to the facility on [DATE]. R290's Nurses Note, dated 11/4/2021 at 3:52 AM, documents, CNA (Certified Nursing Assistant) heard a loud slam and responded immediately to room (R290's room). Resident noted to have fallen out of his bed. Resident laying on L (left) side of body on the floor. Bed in an elevated position. Resident states he was trying to go to the bathroom and forgot to ask for help. He stated he thought he could raise his bed up and do it on his own. Resident wearing a depend and no other clothing. Floor dry, clear of clutter. Denies hitting head. During assessment resident's L leg noted to be externally rotated with some shortening present, the rest of the leg noted to be swollen. Resident c/o (complained of) pain to L wrist, L knee and L hip. Due to the L leg being rotated outward with shortening and the amount of pain resident states he is in, 911 paged to transport resident to ED (Emergency Department) for evaluation. Emergency contact notified, expressed understanding and thanked writer for call and update. Mediprocity (secure messaging for long term care providers) sent to NP (Nurse Practitioner) to update on condition and transportation to hospital. A review of R290's Health Record shows no documentation of bedhold given or sent with resident and given to the Power of Attorney. On 11/16/2021 the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization . 3. Current facility Admission records document R294 was admitted to the facility on [DATE] and transferred to the hospital for numbness and weakness to his left arm on 11/09/2021 and readmitted back to the facility on [DATE]. R294's Nurses Note, dated 11/09/2021 at 9:00 AM, documents Resident voiced complaints of numbness and weakness to L arm. Res pupils equal and reactive and foot strength was equal. L grip strength noticeably weaker than the Right. BP noted to be 178/98. Writer notified NP of assessment and vitals and received order to send resident to (local) ER (emergency room ) for evaluation and tx (treatment). A review of R294's Health Record shows no documentation of bedhold given or sent with resident and given to Power of Attorney. On 11/16/2021 the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization . On 11/15/2021 at 4:04 PM, V25 (Licensed Practical Nurse/LPN) stated that no paperwork is given to the resident. V25 stated that report and all documentation is given to the EMTs (Emergency Medical Technicians). V25 stated that she does not give any written documentation of why they are going to the hospital to the resident. V25 stated that the business office does the bed holds. On 11/15/2021 at 4:16 PM, V23 (Registered Nurse/RN) stated that when sending a resident to the hospital all of the paperwork is given to the EMTs. V23 stated there is not any documentation stating why they are going to the hospital given to the resident by nursing. V23 stated that business office handles the bed hold. On 11/16/2021 at 11:43 AM, V2 (Director of Nursing/DON) stated that some nurses print off the sheet and some don't. V2 stated that it not normal practice at this facility to give the resident written documentation of why they are being sent out or about the bed hold. The bed hold information is mailed out the next day. 4. R82's Nurses note, dated 09/13/2021 at 01:43 PM, V18 (LPN) documented, Resident lethargic with poor nutrition and hydration for an extended period. Called (Power of Attorney) to send out to be evaluated. (Power of Attorney) okay with decision, resident physician notified. Resident was transported to hospital via ambulance at 12pm. On 11/16/2021, the facility was unable to provide documentation that they notified the resident or representative of the facility bed hold. The Facility's Bedhold and Readmission Policy and Procedure, revised date 12/2011, documents Policy: The facility shall provide written information to the resident, family, or legal representative on the responsibility of the facility to hold a bed on admission and when a resident goes to the hospital or on therapeutic leave. It also documents Procedure: Hospital stay: Before a resident is transferred to a hospital, or within 24 hours in case of an emergency. It also documents, The bedhold policy shall accompany the resident to the hospital and, if needed, sent to the Power of Attorney or guardian. Social Services shall ensure that documentation has been made in the progress notes.

Based on observation, interview and record review, the facility failed to provide complete and timely incontinence care, urinary catheter care, timely and appropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R9's Progress Note dated 10/27/21 at 12:36 PM documents Resident observed walking in hallway with all of her clothing in both hands heading up the hall. Stating someone was stealing her clothes. Resident stated that she was taking them back to room (number) that she had been moved. Resident's room is (number). This writer and staff member validating her concerns when resident stated that she had to use bathroom, she also stated that it burned when she urinated. Staff member and writer assisted resident to bathroom and cleaned her and got a sample of urine for nurse. Resident remains confused and came into my office and was looking for a car over at the rest home and talking about her husband. Then she wanted to call her sister. This writer took her to dining room to speak with her sister. Nursing aware. R9's Progress Note dated 10/27/21 at 1:11 PM documents Urine specimen taken to lab. Sent medi-procity (secure messaging for long term care providers) of Urinalysis (UA) results to Family Nurse Practitioner (FNP). Waiting orders. R9's Progress Note dated 10/27/21 at 3:00 PM documents FNP reviewed UA results and orders received. [MEDICATION(S)] 100 milligram (mg) 1 oral (PO) twice a day (BID) for seven days. R9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's UA culture dated 10/27/21, results on 10/30/21, documents (R9) had a [CONDITION(S)] showing Extended Spectrum Beta-Lactamase (ESBL) with the organism of Escherichia Coli (E-Coli). It continues with ESBL is resistant to [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)] ([MEDICATION(S)]) antibiotics. R9 was already receiving [MEDICATION(S)], which was not stopped and R9 did not have a medication change once results were obtained. R9 continued for another four days on [MEDICATION(S)]. On 11/8/21, at 9:00 AM, R9 was lying in bed, confused and not speaking or following commands from staff. R9's Progress Note dated 11/8/21 at 10:20 AM documents Went in to speak with resident this AM, resident laying in bed with eyes closed and did not acknowledge that I was in the room. Will continue to monitor. R9's Progress Note dated 11/8/21 at 11:27 AM documents Resident continues to be monitored post antibiotic for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident continues to display signs of altered mental status. Resident is refusing medications by pursing lips tightly shut. Staff continues to encourage caloric and fluid intake; however, resident is not receptive of the encouragement and is observed again, pursing lips tightly, refusing medications. Resident is also observed refusing activities of daily living (ADLs) and becoming easily agitated and combative. Resident is not easily comforted or redirected during ADLs. Orders have been received to send resident to the local hospital emergency room (ER) for further evaluation and treatment. Power of Attorney (POA) has been contacted via telephone and made aware. POA verbalized understanding. On 11/8/21 at 11:30 R9 continued to display signs of altered mental status: confusion, refusing her ADLs and became easily agitated and combative with staff. R9's Progress Note dated 11/8/21 at 11:38 AM documents 911 has been telephoned for transport. R9's Progress Note dated 11/8/21 at 4:07 PM documents Resident returned from local hospital per ambulance and two Emergency Medical Technician (EMT) assists with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Attending Family Nurse Practitioner (FNP) is aware and provided orders to discontinue ER Physicians order for [MEDICATION(S)] 750mg; 1 tablet daily for seven days due to resident's unwillingness to take oral medications at this time due to altered mental state. FNP has opted to order [MEDICATION(S)] 1gram (g) Intramuscular (IM) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The culture from 10/27/21 showed that the organism was resistant to [MEDICATION(S)]. R9's Progress Note dated 11/8/21 at 4:11 PM documents A new prescription order was transcribed per the order of FNP. [MEDICATION(S)] ([MEDICATION(S)]) recon solution; 1g (gram); injection Once - One Time. 07:00 AM - 10:00 PM. R9's Progress Note dated 11/8/21 at 8:44 PM documents Antibiotic administered for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ([MEDICATION(S)]) 1gm IM (intramuscular) injection, reconstituted with 2.5 milliliters (ml) of [MEDICATION(S)] 10mg/ml, was administered to the right dorsogluteal muscle. Resident tolerated well. Resident is resting per bed and continues to be monitored. R9's Progress Note dated 11/10/21 documents Lab called and stated resident has ESBL in urine. Orders received to insert urinary catheter until infection resolved. Urine catheter inserted per sterile procedure with a good return of yellow urine. (R9) tolerated procedure well. Fluids encouraged. On 11/15/21, at 10:50 AM, V25 (Licensed Practical Nurse/LPN) stated, (R9's) UA came back on 10/30/21 with ESBL (E-Coli) in urine. She (R9) was put on [MEDICATION(S)] 100mg for seven days at that time. I believe she (R9) finished that round of antibiotics. She (R9) began having behaviors and was sent to theER on [DATE]. She (R9) was returned to the facility that day with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Then the lab called me on 11/10/21, with her recent culture results from 11/8/21, which showed ESBL (E-Coli) in her urine. Because (R9) won't take pills, the physician changed it to the [MEDICATION(S)] 1gm IM. I see now that ESBL is resistant to both [MEDICATION(S)] and [MEDICATION(S)] and it wasn't addressed. We must have missed that. I will notify the physician and let her know. When asked about the urinary catheter inserted, V25 stated We really can't have an isolation room in this unit because other residents can go into the rooms. We can't have a portable toilet next to their bed because other residents will go in and use it too. That is why a urinary catheter was put in her. When asked about moving the resident to another room to be isolated, V25 stated, That is up to our Administrator. On 11/15/21, at 12:50 PM, V29 (FNP) stated, (R9's) UA from 10/27/21 documents that she (R9) had a colony count of greater than 100,000 and was considered to be colonized. Anything over 100,000 I would consider the person to be colonized. (R9) was treated with [MEDICATION(S)] first because we didn't know the culture results yet. The [MEDICATION(S)] was supposed to be discontinued and changed to something else. V3 (Assistant Director of Nursing/ADON) looked and the order was not discontinued and was anything else started. V29 then stated, (R9) continued with worsening symptoms and was sent to theER on [DATE]. She was given [MEDICATION(S)] IM because if the ER physician thought she needed an antibiotic, who was I to think differently, so I gave her the [MEDICATION(S)] one time dose. When asked about giving meds that are resistant to ESBL, V29 stated, Sometimes it's like a 'Hail Mary' and we are hoping that it may treat something underlying. When asked about the urinary catheter insertion, V29 stated, That might be a facility policy to use a catheter instead of moving a resident to another room. On 11/15/21, at 1:15 PM, V30 (Medical Doctor/MD) stated, I would consider a UA result with anything over 50,000 colonization as significant and treat with something that would work. I would not consider (R9) to be colonized. (R9) was probably given [MEDICATION(S)] first because that's what my FNP and I always use first. I see a note where my FNP was supposed to stop the [MEDICATION(S)] and change it to [MEDICATION(S)], but [MEDICATION(S)] would not have been the correct drug either. (R9's) urinary catheter should not have been put in. The right thing would have been to move the resident to a room where they could have isolation, but that is the facility Administrator's decision. We really have not treated (R9) yet for her [CONDITION(S)], but I assure you it will be taken care of immediately. On 11/16/21, at 11:50 PM, V2 (Director of Nursing/DON) stated, We asked (V29/FNP) about (R9's) UA results and if we could put a urinary catheter in her (R9), and (V29) stated to go ahead and do that. R9's progress note dated 11/15/21 at 1:46 PM documents (V30/MD) called and gave orders for [MEDICATION(S)]-DS twice a day for seven days. The UA is to be repeated on the eighth day. If (R9's) urine is negative for ESBL, remove the urinary catheter. This was a delay of 16 days from the results of the culture to the treatment with the appropriate antibiotic for the [CONDITION(S)]. On 11/17/21, at 11:50 AM, V2 (DON) stated, We don't have a policy on urinary catheter insertion or the criteria to insert a urinary catheter, we just follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Care Plan dated 11/4/21 documents that R9 is at risk for a decline in activity participation due to having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It continues that (R9) requires assistance with washing face and hands related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer antibiotic as ordered, assist (R9) with perineal care/incontinence care as needed. It continues that (R9) has a urinary catheter related to ESBL in urine, monitor for signs and symptoms of [CONDITION(S)]. R9's Minimum Data Set (MDS) dated [DATE] documents (R9) has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers, and bathing. It continues that (R9) requires extensive assistance from one staff member for dressing, toileting, and personal hygiene, needs supervision with set up for eating, and (R9) is frequently incontinent of bladder and always continent of bowel. 2. On 11/09/2021 at 01:25 PM V34 (Certified Nursing Assistant/CNA) used non rinse foam soap to cleanse R90 after an incontinence episode. V34 cleansed front to back of R90's perineal area but did not clean the inner labia nor did she dry area. V27 (CNA) rolled R90 on to her left side. V34 cleansed R90's right thigh and up to buttock but did not dry it afterwards. V27 rolled R90 over onto her right side and V34 cleansed R90's left thigh up to R90's buttock and did not dry area. R90 was repositioned on her left side. V34 did not cleanse R90's peri rectal area. R90's Care Plan dated 12/09/2018 documents Incontinent of urine and bowel. It continues use moisture barrier product to perineal area as needed. R90's MDS dated [DATE] documents that R90 is always incontinent of urine and feces and requires extensive assistance of 2 staff for toilet use. 3. On 11/10/2021 at 9:30 AM V32 (CNA) assisted V33 (CNA) in performing catheter care for R101. V33 cleansed R101 with no rinse cleanser, cleansed pubic area, cleansed bilateral groin area and cleansed the outer labia but did not dry these areas. V33 cleansed the urinary catheter from the outer labia outward. V33 did not spread the outer labia and cleanse the inner labia nor cleanse the catheter from the urethral opening to the outer labia. R101 was turned onto her right side; R101 had a bowel movement, V32 removed feces with dirty incontinent brief, cleansed left buttock and peri rectal area but did not dry the area. Neither V32 or V33 cleaned R101's left thigh, right thigh or right buttock. R101's Care Plan dated 06/29/2020 documented, Provide catheter care (every) shift and as needed. R101's MDS dated [DATE] documents that R101 has an indwelling urinary catheter and was always incontinent of feces. 4. On 11/10/2021 at 9:50 AM V39 (CNA) used no rinse foam, cleansed R116's front, bilateral groins and outer labia but did not spread outer labia to cleanse inner labia. V39 cleansed the indwelling catheter from the outer labia, outwards approximate 4 inches but did not cleanse from the urethral opening to the outer labia. V38 rolled R116 onto her left side, cleansed the right hip and buttock, cleansed and patted dry, then rolled onto right side and the left hip and buttock was cleansed and patted dry. V39 did not clean R116's peri rectal area. R116's MDS dated [DATE] documented that R116 has an indwelling urinary catheter and was always incontinent of feces. R116's Care Plan dated 01/30/2021 documented, Provide catheter care as needed. On 11/10/2021 at 10:38 AM V2 (DON) stated she would expect the CNAs to dry the no rinse cleanser, spread the outer labia apart to cleanse the inner labia and cleanse the catheter from the inner labia outward. 5. R68's Face Sheet, print date of 11/10/21, documents that R68 was admitted on [DATE] and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R68's MDS dated [DATE] documents that R68 is severely cognitively impaired, requires extensive assistance of 2 staff members for toileting and personal hygiene and is always incontinent of bowel and bladder. R68's Care Plan dated 10/17/2019 documents (R68) is at increased risk for skin breakdown R/T (related to) age, incontinence, decreased mobility, potential for friction and shearing with repositioning and transfers, potential for poor appetite. Intervention: Provide incontinent care following each episode. On 11/10/21 at 1:00 PM, V27 (CNA) and V28 (CNA) transferred R68 to bed using the mechanical left. R68's wheelchair seat was noted to be wet. Once laid down, V27 removed R68's urine saturated pants and incontinence brief. V27 rolled R68 to her left side. R68 buttocks, inner thighs and back of her upper thighs were bright red and appeared wrinkled. V27 took two premoistened periwash cloths and wiped R68 right buttock and discarded them. V27 got one premoistened periwash cloth and cleansed the left buttock. V27 then placed a new incontinence brief under R68 and rolled R68 onto her back. V27 then pulled the incontinent brief up between R68's legs and fastened it. V27 failed to cleanse R68's rectal area, inner thighs, back of upper thighs, groin area and peri vaginal area. On 11/10/21 at 1:45 PM, V2 (DON) stated, I expect the staff to provide timely incontinent care. If someone is soiled, the staff should be performing complete incontinent care, which includes cleansing every part that was soiled and of course spread the labia of a female. 6. R289's Care Plan, revision date 11/5/2021, documents Resident Care Information. It also documents Bowel and Bladder: Incontinent of both. Incontinence Products: Large brief. R289's MDS dated [DATE] documents that R289 is cognitively severely impaired, frequently incontinent of bowel and bladder and requires extensive assist of 2 people for toileting. R289's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/8/2021 at 11:30 AM, V4 (CNA) and V14 (CNA) assisted R289 with incontinence care. V4 and V14 rolled R289 onto his right side and pulled pants down revealing a heavily urine soaked undergarment. V4 and V14 loosened the undergarment and V4 rolled undergarment beneath R289. V4 then using disposable wipes cleansed R289's groin area, shaft of penis and top of scrotum. V4 did not lift R289's scrotum and cleanse beneath. V4 did not cleanse R289's inner thighs. V14 and V4 assisted R289 over onto his side. V14 then, using the disposable wipes, cleansed R289's inner buttocks, applied and fastened R289's undergarment. V14 did not cleanse R289's right and left buttock. On 11/10/2021 at 2:06 PM, V4 stated that she usually pulls up the scrotum and doesn't know why she didn't do that when performing incontinence care on R289. V4 also stated that she is not sure why V14 didn't cleanse R289's buttocks during incontinence care. V4 stated that cleansing beneath the scrotum, outer buttocks and inner thighs is part of incontinence care. The Facility's Incontinent Care Policy, dated 2/04, documents Objective: 1. To keep skin clean, dry, free of irritation and odor. It also documents Procedure: 7. Wash all soiled skin areas and dry very well, especially between skin folds. The Facility's Catheter Care Policy, Revised date 6/05, documents Procedure: 4. On a female resident, clean the labia; then spread the labia to wash the inner folds. It also documents Gently clean catheter tubing nearest the body, wiping away from where it enters the meatus.

Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and [MEDICATION(S)] vial, and discard expired medications. This has the potential to affect newly admitted residents and residents residing on the 400 Hall and the 200 Hall. Findings include: On 11/8/2021 at 10:00 AM the 400 Hall medication room was inspected. The refrigerator, located in the medication storage room on 400 Hall, contained the following: 1. One unlabeled with open date vial of [MEDICATION(S)] (TB). V3 (Assistant Director of Nursing/ADON) verified that the medication did not have an open date and that the medication was being used. 2. One unlabeled plastic resealable medication bag with 8 pills of [MEDICATION(S)] 125 milligran (mg) capsules in it was observed folded in a drawer in the medication room that contained tape, plastic trash bags and scissors. The pharmacy label had been partially removed. V3 verified that the Pharmacy label was removed. On 11/2/2021 at 10:10 AM, V3 (ADON) stated that the [MEDICATION(S)] medication should be stored in the medication cart. V3 stated that it should not be in a drawer in the medication room with tape, bags, scissors and random non medical items. V3 also stated that the TB should be labeled with an open date and be kept in its original box. On 11/16/2021 at 9:40 AM, V37 (Licensed Practical Nurse/LPN) stated that the drawer label storage drawer is not for medication, it is a normal storage drawer with batteries and other things but no medication should be stored in this drawer. V37 also stated that the TB in the refrigerator is the medication that is used for all residents that are admitted . V37 stated that it is part of the admission process that residents receive a two step process and the medication is obtained from the refrigerator. On 11/16/2021 at 3:13 PM, V2 (Director of Nursing/DON) stated that it is not normal practice for the pharmacy label to be removed from the packaging and placed in a storage drawer. V2 stated that all medications are to be stored in the medication cart. V2 stated that the TB vial is to be labeled when use and not used past its expiration date. On 11/8/21 at 11:57 AM, the 200 Medication cart was inspected with V15 (Registered Nurse/RN). 3. R7's [MEDICATION(S)] injection pen was open and did not have a date of when it was opened. R7's [MEDICATION(S)] injection pen had an opened date of 10/7/21. R7's Medication Administration History, dated 11/1/21 - 11/10/21, documents, [MEDICATION(S)] KwikPen Insulin (insulin [MEDICATION(S)]) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R7 received [MEDICATION(S)] sliding scale injection 11/1/21 - 11/10/21. R7's Medication Administration History, dated 11/1/21 - 11/10/21, documents, [MEDICATION(S)] FlexTouch U-100 Insulin, insulin pen; 100 unit/ml (3 ml); Amount to administer: 10 units; subcutaneous. This Medication Administration History documents that R7 received [MEDICATION(S)] insulin injection 11/1/21- 11/10/21. 4. R77's [MEDICATION(S)] injection pen and [MEDICATION(S)] injection pen were both open and did not have a date of when they were opened. R77's Medication Administration History, dated 11/1/21 - 11/10/21, documents, [MEDICATION(S)] [MEDICATION(S)] U-100 Insulin. insulin pen;100 units/ml (3ml); Amount to administer: 12 units subcutaneous. This Medication Administration History documents that R77 received the [MEDICATION(S)] injection 11/1/21 - 11/9/21. R77's Medication Administration History, dated 11/1/21 - 11/10/21, documents, [MEDICATION(S)] KwikPen Insulin (insulin [MEDICATION(S)]) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R77 received [MEDICATION(S)] sliding scale injection 11/1/21 - 11/3/21, 11/5/21 - 11/8/21. On 11/8/21 at 11: 35 AM, V15 (RN) prepared R77's medications. At this time, V15 was questioned about the date of opening of the [MEDICATION(S)] injection pen. V15 stated, It doesn't have a date on it. Somebody didn't date it. V15 then entered R77's room and gave R77 2 units of the [MEDICATION(S)] subcutaneous injection to R77's left lower abdomen. 5. R33's [MEDICATION(S)] injection pen was open and did not have a date of when it was opened. R33's Medication Administration History, dated 11/1/21 - 11/10/21, documents, [MEDICATION(S)] KwikPen Insulin (insulin [MEDICATION(S)]) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R33 received [MEDICATION(S)] sliding scale injection 11/1/21 - 11/9/21. 6. There was also a [MEDICATION(S)] injection pen with no resident name or date of opening that had been used found in the cart. On 11/8/21 at 12:05 PM, V15 (RN) stated that he usually doesn't work this hall and that the insulin pens should be dated when they are opened. On 11//8/21 at 3:55 PM, V2 (DON) stated, The insulin pens all should have a label of the residents name and the date it was opened. The [MEDICATION(S)] Full Prescribing Information, revision date of 5/2019, documents that [MEDICATION(S)] 3 ml (milliliter) single use - patient - use [MEDICATION(S)] prefilled pen if in use is good for 28 days after opening. The [MEDICATION(S)] Full Prescribing Information, revision date of 6/2017, documents that [MEDICATION(S)] 3 ml KwikPen if in use is good for 28 days after opening. The [MEDICATION(S)] Full Prescribing Information, revision date of 3/2012, documents that the 3 ml [MEDICATION(S)] KwikPen if in use is good for 42 days after opening. The [MEDICATION(S)] Full Prescribing Information, revision date of 12/2015, documents, 5.1. Never Share [MEDICATION(S)] KwikPen Between Patients. [MEDICATION(S)] KwikPens must never be shared between patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. It continues, In use Pen. The pen you are using should be thrown away after 28 days, even if it has insulin left in it. [MEDICATION(S)] Purified Protein Derivative (Mantoux) [MEDICATION(S)] package insert, dated April 2016, documents A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. The Facility's Policy No: 3.17 Pharmaceutical Procedures, revised date, 10/18/19, documents IV. Procurement and Labeling of Drugs: Drug Labeling The label of each individual container filled by the pharmacist shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, date of expiration of all time-dated drugs, the initials of the pharmacist filling the prescription, and amounts of medication contained in each prescription. In addition, the pharmacy's name, address, and telephone number shall be on all prescriptions. A. Only the pharmacist, or authorized personnel under the direct supervision of the pharmacist, prepares labels or makes changes in labels. It also documents, C. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist for relabeling or disposal. Medications in containers having no labels shall be destroyed in accordance with state and federal regulations. It continues, V. Care and Storage of Medications H. All discontinued, unlabeled, and expired medications shall be returned to the pharmacy for proper disposition and crediting considerations.

Based on observation, record review and interview, the facility failed to provide safe transfers for 2 of 5 residents (R1, R3) reviewed for transfers in the sample of 5. This failure resulted in R3's fall and right femur fracture. Findings include: 1. R3's Resident Face Sheet, dated 6/13/19, documents [DIAGNOSES REDACTED]. R3's Minimum Data Set, dated dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 0, severely impaired cognition and totally dependent on 2 person physical assist for bed mobility and transfers. R3's Care Plan, dated 11/19/13, documents, Bed in lowest position. It continues, Approach start date: 9/27/17 Full mechanical lift for all transfers. R3's Fall Risk Assessment Tool, dated 10/20/18, documents, Total fall Risk Score: Score: 19 Level: High Fall Risk. On 6/11/19 at 8:35 am,V17, R3's wife, stated, I was told they were putting (R3) in (R3's) chair using the lift and they dropped (R3). R3's Progress Note, dated 6/2/19 at 11:47 am, V13, License Practical Nurse (LPN), documented Writer called to room, resident observed lying somewhat on back side, weight on left shoulder and left hip. Eyes open. ROM (Range of Motion) x (times) 4 without pain/limitations per norm. It continues, Small red area noted to L (left) eyebrow at this time measuring 1 cm (centimeter) in length. CNA (Certified Nurses Assistant) reports, I got (R3) ready and on (R3's) (mechanical lift) pad, I turned around to grab (high back reclining geriatric) chair and resident fell to floor. R3's Progress Note, dated 6/8/19 at 8:55 PM, V14, Registered Nurse (RN), documented, Received report on resident regarding yellow bruising on right side. Writer observed yellow bruising from top of right hip to mid calf with noted dark purple behind right knee. Hospice nurse, (V11), here visiting another patient and agreed to look at resident. She notified the MD (Medical Doctor) and received orders to have right hip, femur and knee x-rays done. (X-ray company) called and made aware of stat order. R3's Patient Report of the Right Radiologic Examination, Femur; Minimum of 2 Views, dated 6/8/19, documents, Impression: 1. Acute distal femoral metaphyseal fracture. 2. Fixated intertrochanteric [MEDICAL CONDITION] with intact hardware. R3's Evaluation Notes, V2, Director of Nurses (DON), dated 6/10/19, documents, It is felt that the resident sustained [REDACTED]. R3's Progress Note, dated 6/10/19 at 6:39 am, Resident moaning, prn (as needed) [MEDICATION NAME] given. Hospice nurse/ NP (V12, Nurse Practitioner) notified of resident condition and received orders to ace wrap or immobilize right femur. Immobilizer put in place. On 6/12/19 at 1:25 PM, V21, CNA, stated, (R3) was close to the edge of the bed, I was by myself, I went out to the hallway to get (R3's) (high back reclining geriatric chair) and when I came back in and (R3) was on the floor. (R3) was shaking a lot. On 6/13/19 at 10:21 am, V13, LPN, stated, I was called into the residents (R3's) room by CNA, and (R3) was lying on the floor, on (R3's) back with most of (R3's) weight shifted to the right side toward the door to the hallway. We got (R3) back in bed, I pulled up (R3's) shirt to look at (R3's) back and then pulled down (R3's) pants, but not all the way down, to check (R3's) bottom and legs. I didn't see any injuries to those areas V13, stated, the (high back reclining geriatric chair) was in the hallway because the rooms are too small. V13, further stated, When I worked last weekend, I reported to the next nurse, (V14), about, (R3's), yellow bruising to (R3's) right leg. On 6/12/19 at 12:44 PM, V11, Hospice RN, stated, I was in the building that day (6/8/19), admitting another resident, and was told about (R3's) leg pain. I saw the yellow bruising, notified the doctor (V15) and he ordered an x-ray of the right hip, femur and knee to be done. V11 also stated yellow bruising would be an old bruise. On 6/13/19 at 2:20 PM,V12, Nurse Practitioner, stated, I'm not sure if the fall caused this fracture because (R3) has severe [MEDICAL CONDITION] but it could have possibly caused a hairline fracture. V12 continued, Given the information, for example (R3) was left to close to the edge of the bed and no supervision when the CNA left the room to retrieve (R3's) wheelchair, then yes, the fall could have been avoided. On 6/13/19 at 2:05 PM, R3 had a faint yellowish bruise noted from R3's lateral right hip down to just above R3's lateral right knee and on the back of R3's right knee was a faint brownish bruise. R3's right side of bed faces the door to the hallway. On 6/12/19 at 10:15 am, V21 and V4, CNA's, used the full mechanical lift to transfer R3 from the bed to the high back, reclining geriatric chair. Neither CNA checked that all the lift pad straps were secure before further lifting R3 off of the bed. V21 did not maintain contact with R3's bilateral legs during transfer, allowing R3's legs to dangle. Neither V3 or V4 locked the high back, reclining geriatric chair wheels during lowering to the chair. On 6/12/19 at 1:49 PM, V2, DON, stated, I would expect the staff to check a residents skin after a fall, even if staff has to remove the pants and shirt. It continues, I also expect them to do range of motion. 2. On 6/12/19 at 11:30 am, V18, V19 and V20, CNA's, used the full mechanical lift to transfer R1 from the bed to the wheelchair. None of the CNA's checked the lift pad straps were secure before further lifting R1 off of the bed. V20, CNA, did not maintain contact with R1's legs during transport, allowing R1 to dangle and spin in a circle while up in the air. Neither V18, V19 or V20 locked the brakes on R1's wheelchair prior to lowering him into it. R1's MDS, dated [DATE], documents BIMS score of 08, moderately impaired cognition and totally dependent for transfers with 2 person physical assist. R1's Care Plan, dated 10/31/19, documents, Approach Start Date: 10/31/18. Safe resident handling procedures: Transfer method: Full body mechanical lift, x-large long seat sling. Level of assistance: Assist x (times) 2. R1's Fall Risk Assessment Tool, dated 3/7/19, documents, Total Fall Risk Score: Score: 21 Level: High Fall Risk. On 6/13/19 at 3:00 PM, V2, DON, stated, We don't have a policy or procedure for the (full mechanical lifts) but we have the staff watch a video about it. V2 further stated, We don't have a transcript of the video. V2 further stated, I don't expect the staff to lock the brakes of the wheelchair because they were taught not to lock the brakes of the wheelchair or bed. Facility policy, Safe Resident Handling, dated 11/12, documents, All staff members required to use the lifting devices will be oriented and trained on the proper use. User Manual for the full mechanical lift, not dated, documents, If the resident is being lifted from a wheelchair or transfer chair or bed, ensure brakes on the chair or bed are locked. It continues, Lift resident 1-2 inches over bed or chair, stop and then check that all straps are secure, the sling is holding resident before further lifting.

Based on observation, interview and record review the facility failed to identify/assess, monitor skin conditions and implement pressure relief to prevent pressure uclers for 5 of 7 residents (R2, R3, R5, R9, and R21) reviewed for pressure ulcers in the sample of 24. This failure resulted in R9 devloping a Stage III pressure ulcer to his left heel. Findings include: 1. R9's Braden Scale for Predicting Pressure Ulcer Development , dated 8/30/16, ocumented R9 was at risk for developing pressure ulcers. R9's MDS, dated [DATE], documented R9 was severely cognitively impaired and required extensive assistance of at least two staff for bed mobility, transfers, dressing, hygiene and toilet use. On 09/29/16, R9's physician's orders [REDACTED]. The Skin Report-Pressure Areas Sheet documented on 10/09/16, R9's in-house acquired stage III pressure ulcer on the left heel measured 1.0 centimeter (cm) by (x) 2.0 cm. On 10/18/16, the POS documented R9 was to wear heel protectors to bilateral feet daily, remove to clean feet. R9's POS, dated 11/01/16, documented R9 had the following diagnoses, in part as, [MEDICAL CONDITION], Pressure Ulcer Left Heel, Non-Pressure Right Ankle, Parkinsonism, [DIAGNOSES REDACTED] and generalized [MEDICAL CONDITION]. On 11/3/16, the Skin Report-Pressure Areas sheet documetned the right outer ankle area measured 1.5 cm x 1.5 cm x 0.2 cm. On 11/10/16, the Skin Report measurements were the same. There were no changes in the orders for the right outer ankle. On 11/10/16, the Skin Report-Pressure Areas sheet documented the left heel ulcer measured 1.0 cm x 1.5 cm x 0.2 cm. On 11/17/16, the left heel measurements were 1.0 cm x 1.0 cm x 0.2 cm. The Care Plan, dated 11/14/16, documented R9 was to have heels up when in bed, was at risk for skin breakdown, had a poor appetite and was a potential for friction and shearing with turning and repositioning. On 11/15/16 at 12:00 PM, R9 was in a wheelchair with no foot pedals or heel protectors in place. R9's lower extremities were observed to be swollen and deeply reddened with the heels on the floor. R9 had non-skid socks on his feet. On 11/15/16, at 1:40 PM, E27 and E28, Certified Nurse's Aides, CNAs, transferred and provided incontinent care for R9. When E27 removed R9's socks, there was three to four plus [MEDICAL CONDITION] noted to bilateral lower extremities with the deep indentations from the elastic on the socks. There was a dressing on the right outer ankle, dated 11/13/16, as well as a dressing on the left heel, also dated 11/13/16. On 11/16/16 at 8:30 AM, R9 was sitting up in a wheelchair without foot pedals or heel protectors on in his room. R9's heels were resting on the floor with three to four plus [MEDICAL CONDITION] to bilateral lower extremities. At 10:30 AM, R9 was in bed on his back with bilateral heels resting on the mattress. On 11/17/16 at 2:00 PM, E21, Wound Nurse, E24, Assistant Director of Nursing (ADON) and E30, Licensed Practical Nurse (LPN) were observed during dressing change and measuring of open areas for R9. R9's right heel was observed to be resting directly on the mattress when E21 removed the old dressing from the right outer ankle. The old dressing had brown serosanguineous drainage on it. R9's right outer ankle pressure ulcer had yellow/pink mixed color on the wound bed and the surrounding boarder was swollen and reddened. E21 measured the wound at 1.4 centimeters (cm) by (x) 1.5 cm x 0.3 cm. E21 described this area to be a healing stasis ulcer and had reopened from last year. E24 stated that R9 constantly rubs his ankle on the mattress and tends to turn the right foot in an outward direction causing the open area. E21 used a gauze soaked with wound cleanser and wiped the wound in a circular motion. E24 then applied a small piece of silver alginate ([MEDICATION NAME] AG) and a dry 4 x 4 gauze and covered with a foam dressing. No heel protector was applied to the right foot. E21 then removed the left heel protector and old dressing. The dressing was soiled with bloody, brown drainage. The ulcer was observed to be bleeding in the 12 - 1 o'clock position surrounded by reddened wound bed. There was black necrotic tissue at the 5 o'clock position. E21 measured the pressure ulcer at 1.0 cm x 1.0 cm x 0.2 cm. E21 cleansed the wound bed with a gauze soaked with wound cleanser in a circular motion. E24 applied a small piece of silver alginate ([MEDICATION NAME] AG) with a 4 x 4 gauze and covered with a foam dressing. E24 and E30 applied roll gauze and a heel protector. On 11/17/16 at 2:20 PM, E24, ADON stated R9 developed the open areas due to his constant rubbing and shuffling his feet on the mattress. 2. R3's MDS, dated [DATE], documented R3 was severely cognitively impaired and required total assistance of at least two staff for bed mobility, transfers, dressing, hygiene, bathing and toileting. It also documented R3 was no longer ambulatory and required total assistance with locomotion. On 09/20/16, R3's Braden Scale for Predicting Pressure Ulcer Development documented score was 14, moderate risk. R3's POS, dated 11/01/16, documented R3 had the following diagnoses, in part as, [MEDICAL CONDITIONS] Humerus and Contractures of all four extremities. The Care Plan, dated 11/08/16, documented R3 had a fractured right humerus (09/17/16) and required a brace with an immobilizing strap that would only be removed for cleansing and showers. It also documented, monitor for swelling and circulation. R3's Nurse's Note, dated 11/08/16, documented Removed brace for cleansing and noted areas red, irritated, foul odor with moderate amount of drainage. Open area noted to the right posterior arm with indentation from the brace. Area measured 1.2 cm x 0.8 cm. On 11/08/16, the POS documented Cleanse right axillary and shoulder with soap and water. Dry and apply antifungal cream and [MEDICATION NAME] dry sheet in axillary area. On 11/15/16 at 9:20 AM, R3 was lying on his left side with a hard shelled brace on the right upper arm. At 1:17 PM, E27 and E28, CNAs, transferred and provided incontinent care for R3. R3's right arm was in a hard shelled brace that came up under the right axillary. An immobilizing strap was under the left axillary and across R3's chest and up on the right shoulder. It was not securing the right brace at this time. A pillow was propped underneath the right arm after care was completed. On 11/16/16 at 3:30 PM, E8, Occupational Therapist, demonstrated how the brace and immobilizer should fit. She pointed out that a pressure ulcer was developed from the outside edges of the hard shell rubbed underneath the right arm near the axillary. E8 pointed out the extra padding that was applied to the edges to lessen the damage to R3's skin. On 11/17/16 at 2:25 PM, E24, ADON and E30, LPN were observed during dressing change for R3. R3 was observed with his right arm behind his back, out of the immobilizer. E24 and E30 removed the brace and the old dressings. There was two open areas underneath the right arm and were surrounded by swollen, red skin that E24 described as a heat rash. E30 washed open areas with a 4 x 4 moistened with wound wash. R3 winced with pain when the open areas were cleansed. Then E30 applied fungal powder to the red swollen skin. E30 then placed a piece of silver alginate ([MEDICATION NAME]) on each wound bed and covered with foam dressings. No measurements were recorded at this time. On 11/17/16, a Nurse's note documented R3 had a new open pressure injury to right upper axillary, Stage II, pain noted to area. The area was measured at 0.5 cm x 0.9 cm with scant drainage. On 11/17/16, the POS documented Cleanse area with wound cleanser or normal saline, apply [MEDICATION NAME] AG and [MEDICATION NAME] dressing. On 11/17/16, E8, OT and E24, ADON, stated the open areas to R3's right upper arm was caused by the rubbing of the brace. 3. R5's Admission Nursing Notes dated 10/3/16 at 2:40 PM documents R5 has a brace to right foot to be worn when up, history of amputation of 4th and 5th toe right foot. Admission Nursing Notes documents heels are firm. The Minimum Data Set ((MDS) dated [DATE] identifies R5 as being cognitively intact, and requires extensive assistance of two staff for transfers. R5 requires extensive assistance of one staff for bathing and dressing. R5 ' s Braden Scale for Predicting Pressure Sore Risk, dated 10/3/16 documents R5 at moderate risk for developing pressure ulcers. R5 ' s Braden Scale for Predicting Pressure Score Risk dated 10/10/16 documents that R5 is at moderate risk for developing pressure ulcers. R5's Care Plan, dated 10/3/16, documents that R5 is at increased risk for skin breakdown related to decreased mobility, potential for poor appetite, potential for friction and shearing with transfers and repositioning, decreased sensory perception. The Care Plan documents R5 wears a brace to Right Lower extremity. The Care Plan documents the goal is for the Stage II pressure ulcer to R5 ' s right heel will show improvement by next review with interventions to monitor right heel for any increase in discomfort or signs and symptoms of discomfort. The Care Plan documents R5 not to wear Right brace or shoe to assist with wound healing per therapy recommendation, heel protector to right heel to be removed during bathing. The intervention documents to cleanse stage II to right heel with wound cleanser. Apply small amount of debridement cream to area of eschar only. The Care Plan documents to apply collagen dressing to area of tissue granulation. Change daily and as needed. Physical Therapy (PT) Plan of Care dated 10/03/16 documents R5 referred to therapy due to recent hospital admission and decline with weakness, with precautions of status [REDACTED]. Wound Management Sheet dated 10/05/16 documents ulcer to right heel appears as open blister that was not present on admission. Measurements 6X5 X 0.1 depth with serosanguinous exudate and 95% of wound covered by eschar tissue. Physical Therapy Treatment Note dated 10/6/16 at 4:03 PM documents skin inspection of feet revealed open area to right heel and nursing notified and dressing applied by nursing staff. The Note documented R5 was educated in need to have material between supportive boot and skin for moisture absorption. PT Treatment Notes dated 10/7/16 at 3:13 PM documents supportive boot removed, moisture and 3 small open areas as well as drainage at the heel. R5 was informed of need to have boot off and need to wear a long stocking. PT Therapy Treatment Notes dated 10/10/16 at 2:21 PM documents that therapy discussed R5's current wound status with nursing staff who denied any concerns related to dependent position of right foot on wheelchair rest (non-elevating style foot rest is currently being used) and nursing requested to pad side of foot rests to decrease risk of skin breakdown due to rubbing/pressing on side of footrest attachment. PT padded the length of the footrest post attachment and used rolled towel next to right thigh to position right lower extremity. On 10/12/16 Therapy notes document therapy discussed R5's right heel wound status with nursing staff who agreed to have therapy change wheelchair footrest to elevating type and use large pressure-relieving soft boot to decrease pressure to area. PT Therapy Notes dated 10/17/16 documents R5 ambulated without any shoe or supportive boot on right lower extremity due to open wound to heel, but right ankle demonstrated severe inversion times 2 episodes causing instability to right lower extremity, R5 and spouse agreed to limit weight bearing to standing and pivot transfers for general safety. On 11/16/16 at 2:46 PM therapy documents R5 educated in need for elevation and pressure relief to right heel area. Skin Pressure Report dated 11/10/16 documents stage 2 to right heel measuring 5.0 X 5.5 and unable to determine depth. Skin Pressure Report dated 11/17/16 documents stage 2 to right heel measuring 4.0 X 5.0 and unable to determine depth and wound management sheet documents necrotic tissue. On 11/16/16 at 9:00 AM E23, LPN stated that ulcer to R5's right heel is unstageable. On 11/17/16 at 2:00 PM E32, RN stated therapy notified him of pressure area to R5's Right heel on 10/6/16. E32 stated that therapy found the area. E32 stated that the area looked like a fluid filled blister that had popped. E32 stated that he was aware R5 was a high risk for pressure ulcers on admission. On 11/18/16 at 9:09 AM E2, Director of Nursing (DON) stated that she would expect nursing staff to have identified R5 had a pressure area, prior to being notified by therapy. On 11/16/16 at 7:55 AM R5 sitting in room in wheelchair feet elevated on foot rest, supportive boot on R foot., and remained there until 9:00 AM. The facility's Pressure Injury Prevention and Treatment Protocol dated 10/15 and revised 07/16 documents the purpose is to ensure that measures are taken to prevent skin breakdown. The procedure documents staff will be trained on pressure injury prevention and safety measures to be taken. 4. R21's POS for November 2016, documents [DIAGNOSES REDACTED]. R21's Minimum Data Set (MDS), dated [DATE], documents R21 required extensive assist of 2+ persons physical for bed mobility, transfers and hygiene. R21's Braden Score, dated 9/14/16, documents R21 is at High Risk for developing pressure ulcers. R21's Care Plan, dated 9/1/16, documents, in part, is at increased risk for skin breakdown r/t (related to) decreased mobility, incontinent episodes, potential for poor appetite, potential for friction and shearing with transfers and repositioning decreased sensory perception. The same Care Plan documents Approaches to include Pressure relieving device in bed. R21's Progress Notes, dated 11/13/16 at 2:13 PM, documents E25, Registered Nurse (RN) was notified that R21 had a blister to his left heel, R21 assessed the area and began treatment. R21's Care Plan does not document any new approaches put into place for Pressure Ulcer prevention. On 11/17/16 at 2:30 PM, E21, Nurse Practitioner/Wound Nurse, stated R21 has a Stage II Pressure Ulcer to his left heel, measuring 1.5 centimeters (cm) x 2 cm. E21 stated (Heel Protectors) and repositioning would have helped prevent the pressure area. E21 states she will write an order for [REDACTED].>On 11/17/16 at 12:50 PM, E4 stated He constantly is moving his feet in bed and when he sits in his recliner he always keeps his legs crossed at the ankle. He needs assistance with repositioning. He always has problems with that heel. The facility's Pressure Injury Prevention and Treatment Protocol, dated 7/16, documents in part, K. Special devices will be used to relive pressure. 5. R2's face sheet dated 4/7/16, documents in part, R2 has [DIAGNOSES REDACTED]. R2's MDS, dated [DATE], documents R2 as having severely impaired cognition, and requires extensive assistance of two or more staff for dressing, toileting and bed mobility. The MDS further documents, R2 is frequently incontient of bowel and bladder. R2's mode of transport is a wheelchair. Braden Score dated 8/23/16 identifies R2 as high risk for pressure ulcers. Care Plan, dated 9/1/16, documents R2 at risk for skin breakdown related to decreased mobility and sensory preception. Phyisican Orders Sheet dated 2/4/16 documents, Oxygen(O2) at 3 liters per nasal cannula as needed for shortness of breath. Based on 15 minutes or less observation intervals on 11/15/16 from 11:20 AM to 12:54PM, R2 was sitting in the main dining room in the wheelchair. At 11:20AM, E3(Licensed Practical Nurse/LPN) removed the nasal cannula from R2's face and reapplied oxygen(O2) tubing after placing O2 tubing in glass of water to ensure oxygen was being delivered. R2's right and left facial cheek area had deep crease indentations that remained throughout the meal until 12:54 PM.

Based on record review and interview, the facility failed to perform a safe transfer techniques for 2 of 5 residents (R1, R2) reviewed for transfers in the sample of 7. This failure resulted in R2 sustaining a fracture to his right arm and R1 sustaining a right hip fracture due to unsafe transfer techniques. Findings include: 1. R2's Physician order [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2 requires extensive assistance of 2+ persons for bed mobility, transfers, dressing, hygiene and toileting. R2's Care Plan, initiated 4/5/16 and updated 9/20/16, documents Total dependent x 2 full body lift. R2's Progress Notes, dated 9/17/16, at 1:47 PM, document E15, Licensed Practical Nurse (LPN) was called to R2's room and noted bruising, redness and swelling to the right arm. The same Progress Note documents Z5, Primary Care Physician, Administration and family were notified. The Progress Notes from the same day, timed 2:28 PM, document an order to send R2 to the local hospital for evaluation and treatment. Progress Notes, timed 5:34 PM, document report was received from the local hospital, reporting R2 has a fracture to his right arm. An X-ray report from the local hospital, dated 9/17/16 and untimed, documents Displaced and overriding fracture of the mid humerus. Local Hospital emergency room notes, written by Z6, emergency room Doctor, document R2 has a R (right) humerus fracture, is to wear a brace to the right arm and follow up with Z1, Orthopedic Doctor, on Monday. On 9/22/15 at 9:30 AM, E1, Administrator, stated she was notified on 9/17/16 by E15 about the bruising and swelling to R2's arm and that R2 was being sent to the local hospital. E1 stated she reported the incident to the State Public Health Department and began an investigation. E1 stated she interviewed staff that worked the day before and the day of the incident. E1 stated she discovered during the investigation that E12, Certified Nursing Assistant (CNA), was the last person to transfer R2 back to bed after supper. E1 stated E12 was unable to remember if anyone assisted him with this transfer. All other staff that took care of R2 were able to give names of coworkers that assisted in any transfers or care of R2. E1 stated that after the investigation, including all interviews, she concluded E12 transferred R2 by himself, causing injury to R2's arm. E1 states E12 was suspended, pending full investigation and as of 9/22/16 was terminated from the facility. E1 stated all mechanical lift transfers are to have at least two people. E1 stated no resident should ever be transferred with one person. The facility's Policy and Procedure Safe Resident Handling dated 11/12, documents, in part, When using Full Mechanical Lift or Sit to Stand Mechanical Lift, two staff members are used with additional help as needed. The same Policy documents, It is not acceptable to substitute a staff transfer for a full mechanical lift or for a standing lift without the authorization of the nurse and the modification of the care plan. On 9/23/16 at 1:50 PM., Z1 stated during a telephone interview that he compared X-ray films of R2 from 10/17/15 and the current X-ray report to 9/17/16 and the injury is new. 2. R1's Admission Face sheet documented R1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Facility's Final Investigation Report, dated 9/16/16 documented On 9/12/16 at approximately 10:19 am resident (R1), an alert and confused female, complained of pain to her R (Right) lower extremity. Family and Physician notified. Order received to send resident to (Local Hospital) for evaluation. Resident admitted to (Local Hospital) with fx (fractured) R hip. The Report documented Origin of fx noted as a CNA (Certified Nurse's Assistant) assisted transfer from bed to wheelchair on 9/11/16 at approximately 5:31 PM during which (R1) tangled her legs with the assisting CNA. During completion of the transfer (R1) struck her right lower extremity on the right arm of her wheelchair. R1's Hospital Report, dated 9/12/16 documents Closed Fracture of Neck of Femur - Intertrochanteric .Right inhtertrochanteric fracture with almost 90 degrees angulation. R1's MDS, dated [DATE], showed R1 as moderately impaired for cognition and extensive assistance with two-person physical assist for transfers. R1's Care Plan, revised on 9/16/2016, documented that prior to the fall, R1 required assist of two for transfers. On 9/23/16 at 10:41 AM, E1, Administrator, stated prior to R1's right hip fracture, R1 was a two-person pivot transfer. R3's Current Care Plan (after right hip fracture) revised on 9/14/2016, documents R1 requires extensive assist of two for bed mobility and requires staff to transfer R1 a mechanical lift. On 9/23/16, at 12:30 PM, Z3, R1's POA/daughter, confirmed being notified of the incident, and is aware of the facility reporting the incident. Z3 stated She (R1) was able to bear weight prior to this (right hip fracture). She (R1) will never be the same. On 9/23/16, at 2:00 PM, E4, CNA, stated she transferred R1 by herself on 9/11/16. E4 stated she wasn't familiar with working on the hall R1 resided. E4 stated she should have looked at the Point of Care (POC), which is a resident profile and tells how to transfer R1. The facility's policy on Safe Resident Handling, revised on November, 2012, documented the following, 2. Transfer without using a mechanical lifting device are limited : Assisting residents who are ambulatory or stable with weight bearing transfer in and out of bed, wheelchairs, chairs, .3. Lift assignment and strategy: Residents are evaluated for the type of lift necessary for their needs and this evaluation is incorporated into the care plan. The Policy documents 5. If care planned with two assist it must be used with two staff members.

Based on interviews, observations and record review, the facility failed to identify, assess and monitor for weight loss, and failed to develop and implement interventions to address refusals of meals and decreased food consumption to maintain residents' nutritional status for 3 of 4 residents (R3, R7 and R8) reviewed for weight loss in a sample of 8. This resulted in R3 having a significant weight loss, 8.4 % in one month, Findings include: 1. The September 2015 physician's orders [REDACTED]. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as having cognitive deficit and requiring limited assistance of one staff for eating. R3's Care Plan, dated 3/31/15, documents R3's problem as having a [DIAGNOSES REDACTED]. R3's Care Plan Goal is to tolerate present diet without complications, and weight will stabilize during this review period but does not identify her at an elevated risk of weight loss. Interventions include diet as ordered, monitor weight and record weekly and as needed (PRN) , monitor labs, staff to assist as necessary and medication review. On 6/25/2015, the Care Plan Intervention was revised to monitor and record intakes per Registered Dietician (RD) request. E13's RD note, dated 12/30/14, documents no weight loss recently, but 16 pounds weight loss in past year with her weight recorded as 143 pounds. R3's RD note, dated 6/15/15, documented R3's weight as 133 pounds, on a mechanical soft diet, eats 25-50% of meals, and requires assistance in eating. The note also documents R3 holds food in her mouth and cheeks, coughing/choking during meals, and has missing teeth. R3's physician's orders [REDACTED]. On 7/17/15, the RD note documents R3's weight at 131 pounds, a 12 pounds loss in the past 6 months. A Weight Event Report for R3, dated 8/12/15, documents her as having a significant weight loss of 8.4% in one month and a 22 pound weight loss in 6 months. The Event Report documented her current weight as 120 pounds, an 11 pound weight loss in one month. The Event Report documents R3 has a very poor appetite, often refuses meals, diet recently downgraded to a liquid puree per SLP (speech therapist), with a recommendation for HCHP (high calorie, high protein) supplements. The Event Report also recommended Impact Advance Recovery, 1 can BID (twice daily), may consider appetite stimulant. On 8/17/15, the RD note documents R3's weight as 120 pounds, down 11 pounds in one month, 22 pounds in 6 months. The RD note also documents, Often refusing meals, diet downed to liquid puree and she suggested Impact 1 can twice (BID) daily. R3's Care Plan was not revised at this time to address R3's refusal of meals, holding food in her mouth and cheeks, coughing and choking, or when her intake is consistently poor. R3's PO, dated 8/19/2015, documents R3 should receive [MEDICATION NAME] 15 milligrams (mls) every bedtime (HS). The physician's orders [REDACTED]. On 9/9/15 at 9:40 AM, Z1, R3's daughter, stated she has the feeling that staff really didn't assist her mother to eat as much as they could when she was eating in the Main Dining room and that she had previously been eating in the 200 hall dining room. Z1 stated she went into the facility on the eve of 9/4/15 and fed R3 supper which she ate 100% of her meal. Z1 stated she discussed the lack of assistance with the facility and R3 was moved back to the 200 hall dining room in the past several days. Z1 stated on the eve of 9/4/15, R3 still ate in the main dining room and she noted staff not providing consistent help in eating for other residents in that dining room. On 9/9/15, R3 was totally fed her noon meal in the 200 hall dining room and received immediate assistance from E6, Certified Nurses Aide (CNA), when her plate was delivered. R3 did not participate in feeding herself at all and often shut her eyes, refused to open her mouth, and turned her head. R3 required frequent cues/encouragement to eat and ate less than 25%. R3 did not eat her power pudding and consumed less than 50% of her HCHP supplement. On 9/12/15 at the supper meal, R3 was again totally fed by E17, CNA, as soon as her tray was delivered. She ate 100% of her power pudding, less than 25% of her meat and potatoes/gravy, 50% of her vegetable, no bread, and 100% of a carton of Impact. She did not have fortified Milk or HCHP. Intake records document R3 as taking 26-50% of her evening meal. There is no documentation or revision of Plan of Care regarding R3's increase in assistance needed to eat from the MDS, dated [DATE], when she was identified as needing only assistance at times. R3's intake records, from 8/20/15 through the noon meal on 9/9/15, documented R3's intake for only 62 of 83 meals given. Of R3's documented food intake totals, 11 documented none or no intake at all and 29 of the 62 documented intake as only eating 1-25%. On 8/30/15, the noon meal was documented twice, once for none and once for 1-25%. For the evening meal on 9/4/15 when R3's daughter was present and fed her 100% of her supper meal, staff did not record anything. On 9/15/15 at 3:15 PM, E11, Licensed Practical Nurse (LPN), stated meal intakes did not start for R3 until 8/13/15 when a weight loss event was opened even though she was at risk for weight loss in February 2015. On 9/15/15 at 3:03 PM, E11 stated nurses provide the Impact cartons, but do not record what percentage is consumed. E11 stated it could work out that R3 gets the Impact at mealtime if it's given AM and PM. R3 receives her Power Pudding, High Cal/High Protein supplement along with her full meals three times daily, but nothing in between. Documentation of the HCHP supplement for the month of August show she consumed 180 (cubic centimeters) cc three times daily except 15 times when she consumed only 90 cc. There is no documentation if R3 consumed the Power Pudding or of the Impact which she receives twice daily. On 9/9/15 at 1:55 PM, E7, Speech Therapist, stated R3 had a hospitalization in the summer and although not diagnosed , they think she had a deep infarct that was undetected that possibly affected her oral phase of eating since it has worsened in the past several months since that time. E7 stated R3 is not on a liquefied puree, but a regular puree now. On 9/15/15 at 9:20 AM, E13 stated R3 has been declining for a while. E13 stated she didn't realize there were days when R3 ate nothing, but added that the facility does pass snacks for everyone in between meals. E13 stated she didn't think to add a snack between meals, but that she could do that in an effort to increase calories. E13 stated staff may need an inservice in what foods to focus on when feeding residents in a effort to increase calories at mealtime. E13 stated she does not typically watch residents eat or staff provide assistance. 2. The Admission Record documents R7's [DIAGNOSES REDACTED]. The MDS, dated [DATE], documents R7 has cognitive deficits and requires extensive assist of one staff to eat. The September 2015 POS documents R7 is on a puree diet, receives Active Critical Care (a protein nutritional supplement) 30 milliliter (ml) every day, Power pudding 3 times a day with meals x 2 days PRN and HCHP with meals. The Care Plan, dated 2/10/15, documents R7's problem as poor appetite with a history of weight loss and a [DIAGNOSES REDACTED]. Interventions include monitor and record intakes per RD request, monitor and record monthly weight and PRN, Monitor labs when available, offer subs (substitutes) for food dislikes, [MEDICATION NAME] as ordered, and staff to assist as necessary all implemented on 2/10/14. The Care Plan was revised on 10/7/14 with an intervention for HCHP. The Care Plan intervention was revised on 5/12/2015 for a pureed diet. The Care Plan intervention was revised on 8/17/2015 for fortified pudding at every meal. A statement at the bottom of the Care Plan (undated) documents resident receives HCHP puree diet, 2 fortified milks at every meal and 1 fortified pudding at every meal to aide with calorie and protein intake. Resident continues to have a poor appetite. R7's RD note, dated 2/27/2015, documents R7's weight as 165 pounds and his [MEDICATION NAME] as 3.5. A Progress Notes, dated 8/17/15, written by the RD E13, documented R7's weight is 154 pounds with a 9 pound weight loss in the past month, 14 pounds down in last 3 months, 21 pounds down in 6 months. The note continues to document R7 currently has a stage II pressure ulcer on his coccyx, outer heel and left heel sole. E13 documented R7's [MEDICATION NAME] was low, 2.1, which may indicate moderate depletion of protein stores. R7's weights show a gradual weight loss monthly from admission 5/4/15 when he weighed 168 pounds, to June 165 pounds, July - 163 pounds, 8/7/15 - 154 pounds, 8/17/15 - 152 pounds, 8/24/15 - 149 pounds, and an increase recorded on 8/31/15 to 154 pounds, then back down again to 149 pounds on 9/8/15. On 9/10/15 at 11:15 AM, R7 was sitting in his wheelchair at the dining room table awaiting his noon meal. R7 dosed off and then awoke when staff delivered a bowl of applesauce and a red drink at 12:04 PM. At 12:05 PM, E14, CNA, sat down briefly and gave R7 a couple bites of applesauce before getting up to deliver other residents meal trays. R7 sat there until 12:21 PM when his plate was delivered by E15, CNA. R7 was given a plate which had puree spaghetti, mixed vegetables, potatoes/gravy on it along with pureed bread, a cup of peach cobbler, a Styrofoam container of chocolate ice cream, a bowl of power pudding, and 2 glasses of fortified milk. E15 fed R7 slowly offering him sips of the fortified milk between bites. At 12:45 PM, E15 stood up and removed R7's bib. He had consumed 100% of his spaghetti and vegetables, less than 25% of his potatoes and applesauce. R7 consumed 1 1/2 glasses of the HCHP supplement but ate none of the ice cream, power pudding or peach cobbler. E15 did not even attempt to give him any of the power pudding and/or the ice cream before pushing him away from the table at 1:00 PM. Meal intake records document from 8/27/15 thru 9/14/15, of the 57 opportunities to document R7's meal intake, recorded only 40. Of those 40 documented, R7 was documented as taking none for 5 meals. On 9/15/15 at 1:05 PM, E11 Licensed Practical Nurse (LPN) stated the facility does not document intake for any supplements but the HCHP and that R7's meal intake was not recorded until 8/27/15 even though the care plan documents it was initiated 2/10/15. E11 stated since R7 had not been identified with significant weight loss, intakes weren't required until they filled out a weight loss event for him. There is no documentation the facility developed a plan of care to address R7's refusal to eat or less than 25% of intake at meals. On 9/15/15 at 9:20 AM, E13 stated R7 has not had a significant weight loss, but agreed that he has had a consistent gradual weight loss since admission. Again, E13 was not aware that R7 had no intake at all for some meals and stated she had not made any recommendations to provide nutritional supplements other that what he got at meals. E13 also stated the facility has a weight committee that meets weekly, but does not attend herself. 3. The Admission Record documents R8 has [DIAGNOSES REDACTED]. The MDS, dated [DATE], identifies R8 to require extensive assist of one staff for eating. The September 2015 POS documents R8 is to receive a puree diet with HCHP 180cc/meal. The Care Plan, dated 9/24/15, documents the goal to be to tolerate prescribed diet with no overt signs of aspirations most of the time while supporting nutrition. The interventions include encourage small bites of food with frequent sips of water, keep head in midline, look to see if resident's mouth is clear of food, monitor for watery eyes, runny nose, coughing/choking and drooling, be sure she sits up for 30 minutes after she eats. A second goal documents to stabilize weight this period but none identify R8's risk of weight loss. Interventions include HCHP and puree diet, a speech therapy evaluation to follow. A Progress Note written by E13 RD, dated 8/17/15, documents R8's weight as 148 pounds, 12 pounds down in one month. The note documents R8 has been spitting food out. Recommendations include to change diet to liquefied puree, weekly weights, and continue with HCHP. The note adds that R8's current Body Mass Index (BMI) is 27.1, indicating overweight. R8's monthly weights are recorded as such: 3/27/15 - 170 pounds, 4/7/15 - 164 pounds, 5/4/15 - 163 pounds, 6/8/15 - 160 pounds, 7/6/15 - 160 pounds, 8/7/15 - 148 pounds, 8/17/15 - 148 pounds, 8/24/15 - 145 pounds, 8/31/15 - 150 pounds, and 9/8/15 - 150 pounds. On 9/10/15 at 11:15 AM, R8 was sitting at the table in the dining room awaiting her noon meal. At 12:04 PM, E6 CNA delivered a bowl of applesauce and a red drink to R8. R8 picked up her fork with her right hand and attempted to eat a few bites without any intervention from staff. E6 left a few minutes later after giving a table mate a couple bites of his applesauce. At 12:24 PM, R8's puree food was delivered to her in separate bowls. She had a bowl of spaghetti with white gravy on it, a bowl of bread, vegetables, peach dessert, potatoes and a Styrofoam container of chocolate ice cream. E15 CNA was sitting at R8's right side feeding a tablemate. E8 occasionally asked need help? as R8 took an occasional bite of food but did not cue and/or encourage to eat her food or to use the proper utensil. At one point, R8 was attempting to eat her ice cream with her right hand only due to being unable to use to her left due to paralysis. R8 slid the ice cream container about the table in an effort to load her spoon until she finally managed to push it against another dish and take a bite. This continued with no assistance. R8 ate none of her spaghetti, vegetable, or bread and only 50% of the peach dessert and 100% of her potatoes. She drank none of the fortified milk and 100% of her red drink. Meal intake records document she ate 26-50% of her lunch meal which is inaccurate. On 9/12/15 at the supper meal, R8 was sitting at the table at 5:10 PM. She did not receive any salad as others in the dining room did but sat at the table with a glass of water and lemonade in front of her. At 6:05 PM, E16 delivered R8's meal to the table. She had puree bread, green beans, potatoes/gravy, ground meat, power pudding, ice creams and fortified milk. Shortly after her meal was delivered, E18, CNA sat down to her left and fed her. R8 allowed E18 to feed her and consumed no bread, bites of green beans, less than 50% of her meat, less than 25% of her potatoes, none of the power pudding, about 25% of her fortified milk, and 100% of her ice cream. Her meal intake was recorded as 26-50% of her entire meal. Meal Intake Records reviewed from 8/2/15 thru 9/13/15 record only 80 meal out of 111 opportunities. Of those 80 meals documented, 19 meals are recorded as none for intake. Of the 80, 47 meals are recorded as R8 have 1-25% intake. There is no documentation in the RD 's notes and/or the Progress notes during this time frame that suggests the facility identified R8 having no intake at some meals and no evidence they developed a plan to meet R8's nutritional needs when no intake is recorded in an effort to increase her caloric needs. On 9/10/15 at 9:10 AM, E1 Administrator stated R8 has not really had a significant weight loss until August but agreed that her weight had been gradually decreasing. E1 stated she understood that facility should identify when a resident does not eat and offer something later in an effort to ensure food intake occurs. E1 stated the weight committee had identified her at risk and provided documentation. The Weight loss committee note dated 8/13/15 documented R8 to have had a 12 pound weight loss in the past month, followed by speech therapy, who recommended a liquefied puree diet and is receiving HCHP supplements. The note indicates the physician and family were notified of the weight loss with no new orders received and that R8 had experienced an upper respiratory infection requiring antibiotics. There is no evidence that the committee developed and/or considered any new interventions in an effort to increase R8's intake and nutritional status or included her speech therapy recommendations for safe eating. Speech Therapy notes, dated 8/12/15, document R8 has oral phase dysphagia and her diet had been downgraded to liquefied puree. The note continues that R8 requires assistance of staff at all intakes to ensure use of safe swallow strategies. The note documents R8's prognosis as good due to excellent support staff and the ability to follow simple directions. On 9/15/15 at 12:45 PM, a policy and procedure on weight loss was requested. A policy entitled Weight Monitoring Committee was provided. This policy documents It is the policy of this facility to appropriately monitor the weights of the residents as needed and monitor intake to improve health status whenever possible. The purpose is documented as to assure each resident is monitored by measurement of weight and intake on a periodic basis to assess and improve health status whenever reasonably possible. Under procedure, it documents The Dietician should review the monitoring documents and the intake lists on each visit and make recommendations as needed and residents on weight monitoring report should be reviewed for intake needs and have such addressed with the necessary dietary adjustments, medication or supplement orders, staff training, adjustment to care plan as needed or other issues as appropriate. The policy entitled Feeding Assistance documents its objective as to serve attractive, well-balanced meals and to provide nutrients for the well being of the resident. Under procedure, it directs the staff that if residents resists, arrange to keep food warm, and try again, if the resident cannot see the food, tell him what is on the tray, and record intake as required. It also documents staff are to report eating difficulties or lack of appetite to the physician.

Based on observation, interview and record review, the facility failed to provide accurate assessment and timely intervention for a fractured upper arm and failed to properly assess, monitor and ensure medication as ordered is administered to address the pain related to the fracture for 1 of 3 residents (R2) reviewed for injuries of unknown origin in the sample of 6. Findings include: R2's Minimum Data Set (MDS), dated [DATE], documents R2 has active [DIAGNOSES REDACTED]. R2's Physical Therapy Discharge Summary, dated 2/17/15, documents R2 performs sit to stand transfers and pivot transfers with minimum/moderate assist x 1 or minimal assist x 2. R2's Care Plan, At Risk for Pain, with target date 4/2/15, documents approaches to include: Assess pain characteristics: date, time, intensity, pain behavior observed or stated by resident. Medication as ordered. R2's Physician order [REDACTED]. R2's Pain Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There is no documentation on R2's pain severity, frequency and periodic monitoring of pain status on 2/18/15. R2's Nurses Notes dated 2/18/15 at 6:45 AM, documents, "Staff reported (R2) is complaining of severe pain to right arm with movement and touch. (R2) is unaware of injuries. No bruising or swelling noted to area at this time. Pain medication offered and refused multiple times and knocked medication out of nurses hand. " R2's Nurses Note dated 2/18/15 at 12:29 PM documents, "Spoke with (Z2, Hospice Nurse) in regards to (R2) yelling out in pain of right arm. Nurse stated she would get back with orders for pain medication. No bruising or swelling noted at this time, Refused pain medication when offered. Has refused all medications today. " R2's Nurses Notes dated 2/18/15 at 5:00 PM, documents, "Received new orders for [MEDICATION NAME] liquid to be given every 2 hours as needed for pain...(R2) resting comfortably but cries out in pain when right arm is moved...Refused oral meds with evening meal..." R2's Nurses Notes dated 2/18/15 at 11:30 PM documents, "(R2) has swelling, redness and bruising to RUE (right upper extremity). Screams out when RUE is moved or touched. [MEDICATION NAME] has not been delivered yet. Call placed to hospice...new order to have X-ray done to right humerus, right shoulder and right elbow. " R2's Nurses Notes dated 2/19/15 at 1:00 AM documents, "...X-ray of RUE. results are complete oblique fracture shaft of humerus...notified hospice nurse. New order to send to local ER (emergency room ). MD (physician) and POA (Power of Attorney) notified. " R2's Nurses Notes dated 2/19/15 at 4:20 AM documents, "..returned to facility.. right arm immobilized with splint and sling. Received pain medication [MEDICATION NAME] while in hospital. " R2's X-ray result dated 2/19/15 documents an acute angulated and displaced [MEDICAL CONDITION] right humeral shaft. On 2/19/15 at 3:30 PM, R2 sat in a geriatric chair with a sling and splint on her right arm. On 2/23/15 at 9:44 AM, E8, Certified Nursing Aide (CNA), stated that on 2/18/15 day shift she was working in the 200 Hall with E10, CNA. E8 stated at the start of the shift she entered R2's room and helped E10, CNA, transfer R2 to the wheelchair. E8 stated R2 sat in the wheelchair and started to slide off the wheelchair with both hands positioned behind her holding on to the armrest of the wheelchair. E8 stated she and E10 scooted R2 back in the wheelchair. E8 stated R2 did not fall or hit her right arm. E8 stated R2 was not complaining of pain at the time. On 2/23/15 at 10:17 AM, E5, Licensed Practical Nurse (LPN), stated on 2/18/15, E10 reported R2 complained of severe pain on the right arm when E10 was getting her dressed. E5 stated she assessed R2's right arm and barely touched it because R2 hollered when touched but there was no swelling or bruising or deformity noted. E5 stated she offered R2 [MEDICATION NAME] which was the prn (as needed) medication for pain but R2 spit it out. E5 stated she called Z3, Hospice Nurse, and told her about R2's pain and spitting the pain medication and obtained an order for [REDACTED]. E5 stated there was no swelling and redness noted and she thought it was just pain. E5 stated she would have given R2 the [MEDICATION NAME] liquid if she had gotten it because she did not want R2 laying in bed and suffering. E10 stated R2 is not able to ask for pain relief because of her cognitive status. On 2/24/15 at 9:08 AM, E10 stated she took care of R2 on 2/18/15 day shift. E10 stated she went to provide R2 morning care at 6 AM. E10 stated E8 assisted her to transfer R2 from the bed to her wheelchair. E10 stated R2 sat in the chair but started sliding off and both scooted R2 back in the chair. E10 stated she noted R2 started screaming in pain when E10 tried to put her right arm into a front zippered hooded sweatshirt. E10 stated she called E5 immediately to check on R2. E10 stated E5 tried to touch R2's right upper arm and R2 screamed in pain. E10 stated she could hear R2 moaning when R2 tried to move in bed or in the wheelchair. E10 stated R2 did not fall and did not hit her right arm that morning. On 2/24/15 at 10:31 AM, Z3, On-call Hospice Nurse, stated that on 2/18/15 at 2:00 PM she gave an order for [REDACTED]. On 2/24/15 at 8:44 AM, Z2, R2's Hospice Nurse, stated if she received the first call regarding R2's right arm pain she would tell E10 to have an X-ray done on R2's arm considering the severity of the pain. Z2 stated that would be her judgment call. The facility Policy on Pain Management revised 9/2010 documents, "Policy: The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms. Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in resident's condition. A standardized 0-10 scale or Verbal Descriptor Scale (VDS) will be utilized to determine pain intensity. Residents will be monitored until pain is resolved or is under control and periodically thereafter. "

Based on record review and interview, the facility failed to provide timely treatment for [REDACTED]. This failure resulted in R2 having a decline in condition, she was hospitalized for [REDACTED]. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set, MDS, dated [DATE], documents R2 is dependent on staff for all activities of daily living and has an indwelling urinary catheter. The Physicians Order for 12/11 and 1/12 documents, "Change (indwelling urinary catheter) monthly, once a day on the 5 th of the month; shift 2. Change drainage bag monthly and PRN (as needed)." The Nurses Note, dated 12/06/11, at 4:20 AM documents R2's urinary catheter was changed at that time. The Treatment Administration Record (TAR) for January 8 through February 7, documents the next catheter change is scheduled for 2/05/12. No documentation could be found in the Nurses Noted from 1/06/12 through 1/19/12 that R2 had the urinary catheter and drainage bag changed since 12/06/11. The physician's orders [REDACTED]." The Nurses Note, dated 1/04/12, at 4:00 PM, documents R2 was discharged home to receive home health services. The Nurses Note, dated 1/06/12, at 4:10 PM documents R2 was readmitted to the facility. The Nurses Note, dated 1/16/12, at 4:32 AM, documents R2's urine was amber in color. The Nurses Noted dated, 1/16/12, at 10:49 PM, documents R2's family notified the facility of "gaulded under her abdominal fold and peri-area. Family was also concerned about color and clarity of urine. Request was sent to MD (medical doctor) for [MEDICATION NAME] (antifungal) powder and any labs MD may want." A faxed request from E9, Licensed Practical Nurse (LPN) to Z2, Physician dated 1/17/12, 12:38 AM, documents "(R2) has been getting pale over the last couple of days. Her (indwelling urinary catheter) is also tea colored urine. She also has some trace [MEDICAL CONDITION] about her face. She is also having some gaulding in her peri-abdominal fold and under her breast. Do you want any labs? And may we have an order for [REDACTED]. Wash gaulded areas with soap and water, pat dry and apply [MEDICATION NAME] powder every shift until areas have resolved." No orders were received addressing R2's tea colored urine and [MEDICAL CONDITION] about her face. On 1/30/12, at 3:55 PM, E5, Registered Nurse (RN) was interviewed. E5 reported R2 had redness under both breasts and had been "lethargic for a couple of days." E5 reported R2 did not want to go to therapy. E5 reported R2's urine was amber in color and had to be encouraged to eat and to drink fluids. E5 reported Z1, PA came to the facility on [DATE], in the afternoon and read the fax from E9. E5 reported Z1 did not examine R2. E5 stated, "She (Z1) looked across the room, and said she didn't see any [MEDICAL CONDITION]. She did not examine (R2's) urine." E5 reported on 1/19/12, she told Z1 that R2 was really lethargic. E5 stated, "She (Z1) didn't say anything. There were no new orders except to discharge R2 the next day. She (Z!) thought maybe it was the [MEDICATION NAME], (a medication prescribed for R2) but couldn't do anything about it, and asked if R2's vital signs were within normal limits." E5 reported she did not examine R2's Intake & Output (I & O) records for 1/12, and was not aware of the decline in R2's oral intake. E5 stated, "CNA's (Certified Nurses Aides) put the I & O on the computer and tell us if it is not good for us to monitor." E5 reported she received no reports from the CNA's related to R2's decreased oral intake for the past several days. The facility's daily Resident Intake and Output for R2, dated 1/12, documents the following in cubic centimeters (CC): 1/15/12-Intake 1420 cc Output 1,000 cc 1/16/12-Intake 1120 cc Output 750 cc 1/17/12-Intake 1080 cc Output 750 cc 1/18/12-Intake 1070 cc Output 950 cc 1/19/12-Intake 1120 cc Output 870 cc On 1/30/12, at 2:30 PM, E4, LPN was interviewed. E4 reported on 1/19/12, R2 was quiet and had to be encouraged to eat breakfast. E4 reported she was unaware of R2's fluid intake for 1/19/12. E4 reported on 1/19/12, R2's urine was dark amber and was given medication for complaints of nausea. E4 reported R2's family arrived at the facility to transport her to another facility at 2:30 PM. R2 reported she did not take R2's vital signs, but was informed by Z3, an off duty RN from the facility and a friend of the family that R2 needed something for nausea, and that is when she administered [MEDICATION NAME] to R2. E4 reported R2's skin was pale, R2 had a "bland affect" and was diaphoretic. The Nurses Note, dated 1/18/12, at 3:01 PM, documents R2 was very lethargic and was difficult to arouse for 2:00 PM medication [MEDICATION NAME] and [MEDICATION NAME], which was held. The Nurses Note, dated 1/18/12, at 3:15 PM, documents R2 was very lethargic, had to be awakened for meals, had a poor appetite, fluids were encouraged, and the catheter was draining amber urine. The Nurses Note, dated 1/19/12, at 8:00 AM, documents R2 was drowsy and refused to eat breakfast. The Nurses Note, dated 1/19/2, at 12:30 PM, documents R2 refused to eat lunch. On 1/30/12, at 11:05 AM, E2, Director of Nursing (DON) was interviewed. E2 reported she went to R2's room after her family had arrived to pick her up and witnessed emesis on a towel. E2 stated "She (R2) had been puking." E2 reported R2's family called an ambulance and R2 was transferred to the local hospital on [DATE]. On 1/30/12, the facility's laboratory reports for R2 were reviewed. There was no urinalysis reports or urine C & S reports for January 2012 in the clinical record. R2's Care Plan, updated 01/06/12, documents R2 "is at risk for infection related to indwelling catheter" and approaches documented, in part, are, "Monitor for signs and symptoms of UTI such as; acute confusion, urgency, frequency, bladder spasms, malaise, nausea/vomiting chills, fever, foul odor, concentrated urine, blood in urine, obtain labs as ordered." Monitoring a residents daily I & O is not listed as an approach in R2's current Care Plan. On 1/31/11, at 11:55 PM, E2, DON confirmed Z1 should have ordered a urinalysis for R2 when she began to have decreased oral intake and output, with abnormalities to her urine. On 1/30/12, at 2:13 PM Z1, PA was interviewed. Z1 reported she was unaware of R2's decreased oral intake and output. Z1 reported she did not know if she had been informed by the facility of R2's lethargy or poor oral intake. Z1 stated, "Telling me someone's urine is amber doesn't mean they have a UTI. Did she (R2) have a fever? No. If I had ordered a urine C & S on 1/16/12, it would have taken 2 days for the return results." Z1 confirmed the fungal infection of Candidiasis would have showed up in the results of a urine C & S. Z1 reported the abnormal laboratory results, BUN (blood, urea, nitrogen) of 54 (normal =7-17 mg (milligrams) per dL ([MEDICATION NAME]) done at the local hospital on [DATE] were incorrect. The Emergency Medical Services (ambulance) record ,dated 1/19/12, at 3:46 PM, documents an intravenous line was attempted twice in an attempt to rehydrate R2, without success. On 1/30/11, R2's local hospital records, dated 1/19/11, at 4:06 PM, were reviewed. The chief complaint is documented as "Nausea, vomiting, UTI". The Nursing Admission Assessment, dated 1/19/12, documents, in part, "Patient complaint of hurting all over. Obese skin hot, dry, pale with tremors. Has [MEDICAL CONDITION] in legs with (indwelling urinary) catheter in place. Received [MEDICATION NAME] 8 [MEDICATION NAME](oral dissolving tablet) enroute for nausea." R2's temperature was 98.4 degrees Fahrenheit. The Assessment documents R2 had amber colored urine in the catheter drainage bag. The Emergency Department Physician's Record for R2, dated 1/19/12, documents, in part, R2 was anxious, with diminished lung sounds, bilateral lower leg tenderness, and 2 + [MEDICAL CONDITION] to lower extremities. The Nurses Note, dated 1/19/12, at 5:30 PM, documents, in part, " (indwelling urinary catheter) inserted with some difficulty. Unable to get catheter to drain, irrigated with 30 ml of NS (normal saline). Noted yeast infection in pelvic area, and patient is tender in the area. The Nurses Note, dated 1/19/12, at 7:00 PM, documents R2 had a urine output as "scant amount". The Physician's Record documents a [DIAGNOSES REDACTED]." The laboratory reports from the local hospital, dated 1/19/12, documents BUN-54-high (normal =7 -17 mg/dL), Creatinine-8.6=high (normal=0.7-1.2 mg/dL, Sodium-122-low (normal=137-45), WBC (white blood cell)-12.3-high, (normal=4.5-11.0). On 1/31/11, R2's critical care hospital record dated, 1/20/12 at 12:00 AM, documents in part, R2 had a dry mouth, had been vomiting for 3 days, with decreased urinary output, and increased thirst, and had [MEDICAL CONDITION] to mid calves. The [DIAGNOSES REDACTED]. The physician's History Progress Notes, dated 1/25/12, documents, in part, R2's urine contained the fungus, Candida, and she was placed on a daily dose of intravenous, Fluconazole (antifungal medication). 2. R4's POS for January 2012 documents R4 has a diagnosis, in part, as Chronic [MEDICAL CONDITION]. The Infection Control Log for January 2012 documents on 1/12/12 R4 began displaying symptoms of an UTI, such as, mental status change and sediment in the indwelling urinary catheter tubing. The Nurses Notes, dated 1/10/12, at 6:01 PM, document R4's catheter contained slight amount of sediment. A urine specimen was obtained. The urinalysis report, dated 1/10/12, documents R4's cloudy urine contained WBC of over 100 (normal=0-5), and RBC (red blood cells) of 6-10 (normal=0-3), with 1 + bacteria. The Nurses Note, dated 1/11/12, at 1:39 PM, documents Z1, PA was informed of the urinalysis results form 1/10/12. The final urine C & S, dated 1/12/12, at 8:06 AM, documents R4's urine contained the bacteria, Escherichia coli of over 100,000 colony count per ml. The Nurses Note, dated 1/12/12, at 3:30 PM, documents a new order was received and processed for the oral antibiotic, [MEDICATION NAME] twice daily for 10 days for a UTI. The physician's orders [REDACTED]." The Nurses Note,dated 1/13/12, at 2:19 AM, documents R4 was "very tired and lethargic. She will begin taking the antibiotic for UTI in AM. Suprapubic catheter draining yellow urine with some sediment." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 1/31/12, at 11:20 AM, E3, Assistant Director of Nursing (ADON) was interviewed. E3 reported that [MEDICATION NAME], ([MEDICATION NAME]) is located in the facility's convenience box, and the nursing staff should have began the treatment for [REDACTED]. E3 provided a list of the antibiotics kept in the facility and [MEDICATION NAME] was listed. On 1/31/12, at 12:00 PM, E2, DON confirmed the nurses should have obtained the [MEDICATION NAME] from the facility's convenience storage supply, but no policy or procedure was available for it's usage.

Based on interviews, observations and record review, the facility failed to ensure that 2 (R17 and R18) of 21 in-house sampled residents received assessmen and treatment for [REDACTED]. Findings include: 1. R18's Minimum Data Set ((MDS) dated [DATE] identifies her to be a [AGE] year old female who has short/long term memory deficits and moderate cognitive impairment. The MDS identifies her to have no pain and requires total assist of 1-2 staff for all activities of daily living. The physician's orders [REDACTED]. The PAIN MANAGEMENT - PAIN ASSESSMENT FOR COGNITIVELY AWARE dated 10/23/10 indicates R18 has pain "almost constantly" over the past 5 days which has made it hard for her to sleep at night and has limited her day to day activities. No scale was used but R18 described her pain as "severe." The description of pain identifies joint pain and other, aching/sharp, throbbing in the early morning, afternoon, and evening" that is constant and persistent. Other expressions of pain include anxiety and crying/whining" with emotional outbursts. Contributing factors identify "[MEDICAL CONDITION]" The assessment also indicates R18 has a limited range of motion related directly to pain. The careplan dated 9/15/10 identifies R18 to have signs/symptoms of pain or discomfort due to [MEDICAL CONDITION]. Interventions include administer pain meds as needed, monitor resident for pian and effectiveness of pain medications, assess resident for any restlessness, agitation, or facial grimacing indicative of pain. On 11/16/10 at 2pm, R18 was in her room in her wheelchair. E7 and E8, Certified Nurses Aides (CNA's) entered the room and asked R18 if she was ready to go to bed and asked her if her legs hurt. R18 replied "If I could get in bed and straighten them out they'll quit hurting so bad." R18's legs were noted to be dangling 6-8 inches off her wheelchair with no support and both feet were noted to be extremely [MEDICAL CONDITION]. As the CNA's transferred R18 using a mechanical lift, R18's face turned very red and tears dropped down both her cheeks. R18 again voiced pain with her legs. E8 stated they would tell the nurse that R18 was complaining of leg pain. Both CNA's stated she cries easily and often complains of her legs hurting. The nurses notes do not include any documentation about the bilateral leg [MEDICAL CONDITION] and the associated pain on a consistent basis. Nor does the care plan include positioning and/or the [MEDICAL CONDITION]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Crying BLE (bilateral lower extremity) pain" with medication documented as "effective." The MAR indicated [REDACTED]. The nurses notes fail to contain any reference to the [MEDICATION NAME] given on 11/5/10 and 11/10/10 and it's discontinuation but does include a note written on 11/7/10 which reads "resident yelling out and crying in pain liquid [MEDICATION NAME] given en with good results." On 11/19/10 at 12:20pm, E17, R18's nurse for the day shift was asked when and why R18's [MEDICATION NAME] was discontinued. E17 stated it was discontinued because R18's pain was managed well with the extra strength Tylenol and the physician decided to discontinue it. More information was requested from the Administrator but as of 11/19/10 at 1pm, no further information was provided. On 11/18/10 at 12:49pm R19 was again observed in her wheelchair at bedside. R19 was again crying with tears falling down her cheeks. E8, CNA, stated it was "pretty normal for her to complain of her legs." E18 stated R18 had no pedals for her wheelchair to support her lower legs because "she didn't like them" when they had tried them a couple times. E18 Licensed Practical Nurse (LPN) was asked if R18 had received any pain medication and stated she hadn't yet but she would get some for her. E18 stated R18 "gets muscle spasms, charlie horses, poor thing." On 11/19/10 at 9:45am, E2, Director of Nurses stated that R18 now has pain tracking in place when discussing the facility's lack of monitoring for pain even though the assessment indicated constant pain. E2 stated that crying is a behavior and that she does it often thinking it was not always related to pain. E2 stated R18 also received [MEDICATION NAME] for [MEDICAL CONDITION]/hallucinations and increased agitation. According to the policy on PAIN MANAGEMENT, the facility is to identify residents experiencing pain to establish control of pain to the residents satisfaction and to relieve related symptoms. The procedure includes using a Geriatric Pain Assessment and a standardized 0-10 scale or verbal descriptor Scale to determine pain intensity. The policy indicates an individualized care plan will be developed and implemented and a pain tracking log will be used to track pain and the resident's response to pain medication and treatments. The policy also indicates other interventions will be used to provide comfort such as positioning, etc. R18 was observed to have her feet dangling off her wheelchair without any support. According to R18's Physical Therapy note dated 4/10/10, lower extremities were discontinued due to discomfort when wearing. At that time, the assessment indicates she was unable to ambulate but was a sit to stand pivot transfer. The care plan for the leg extension exercises include no intervention toward pain management. During the survey, R18 was observed transferred only via a total mechanical lift. 2. The MDS dated [DATE] identifies R17 as being cognitively impaired and requiring 1-2 staff for all activities of daily living. According to the Treatment Administration Record for November, the weekly skin report dated 11/5/10 states "excoriated area c (with) foul odor (under) left breast." R17 is a right side [PROCEDURE]. The physician's orders [REDACTED]." Interventions include applying treatments as ordered, monitoring resident's skin for any redness, irritation, or breakdown, notifying the physician with request for treatment, and others. The nurses notes show no followup to this area and the next weekly skin check is dated 2 weeks later with no followup documented as to the left breast. On 11/18 at 11:20am, R17 was observed to have excoriation under her left breast with was beefy red with cheesy clumpy ointment present. E10 and E20 were both aware of the excoriation when the skin check was done. The nurses notes for 11/18/10 at 9:44am indicate R17 is "excoriated under L (left) breast, area look/smells yeasty. M.D. notified." However, there was no evidence that R17's left breast had been cleansed at the time if was documented/assessed since the ointment was thick and clumpy. R17 had been observed on her left side asleep throughout the morning. At 3:52pm, a new order was received for [MEDICATION NAME] powder. At 9:45am on 11/19/10, the Assistant Director of Nursing confirmed that the area was being treated but had no information as to why it took from 11/5/10 when the foul smelling excoriation was noted until 11/18/10 to notify the physician and request treatment.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent development of pressure sores and promote healing of existing pressure sores for 6 (R4, R11, R12, R13, R15), of 10 sampled residents reviewed for pressure sores. This failure resulted in R12's stage 4 pressure sores on her coccyx and right buttock increasing in size. R12's unstageable pressure sore on the right outer foot was open and draining and increased in size. Findings include: 1. R12's Minimum Data Set (MDS) of 8-23-10 shows no cognitive impairment. The MDS of 10-1-10 shows R12 is totally dependent on staff for transfer and requires extensive assistance of 2 for bed mobility and has a urinary catheter. R12's Care Plan of 3-3-10 identifies R12 as being at high risk for skin breakdown related to decreased mobility, poor circulation, poor appetite and non compliance with diabetic diet, bowel incontinence, possible shearing/friction with transfers and history of skin breakdown. She was admitted to the facility with multiple pressure and diabetic ulcers. She has a stage III pressure ulcer to the RT (right heel and Stage IV areas to the lt (left) heel, Rt (right) buttock and coccyx. Note of 7-7-10 states on readmission to facility R12 was noted to have a stage II to right heel and stage III to left heel, right buttock and coccyx. Note of 8-20-10 states stage III to left is now healed. 9-02-10, "Area to the left heel has reopened. 10-28-10 Lt. heel now healed." Note of 11-17-10 states, "Suspected DTI "Deep Tissue Injury." Care Plan approach, in part, "Assist with turning and repositioning every 2 hours and prn (as needed); Assist with toileting q (every) 2 hours and prn; Flat sheet to be used as cover over oscillating mattress and a disposable incontinence pad to be used to protect mattress from soiling; Contact isolation precautions; Position resident's heels off bed using "Heelzup" elevating device." R12's dietary note of 11-16-10 states she is on a regular diet and has gained 16 lbs over the past month and intake is 75%. The Dietary Manager stated on 11-18-10, that the facility does not have any diabetic diets due to company policy. R12's Physician order [REDACTED]. An order of 11-17-10 to apply skin prep to suspected DTI (Deep Tissue Injury) to bottom of left foot daily and prn. An order of 10-1-10 to cleanse wound to right buttock, loosely pack with iodaform and cover change daily and prn and an order to cleanse coccyx wound with wound cleanser, loosely pack with iodaform and cover and change daily and prn till healed. POS showed an order 10-28-10 to cleanse left heel with wound cleanser, apply [MEDICATION NAME] and wrap with Kling. Change every 3 days and prn. An order of 7-5-10 to clean right heel with wound cleaner, cover entire wound with collagen, cover collagen with non bordered foam, and wrap with stretch gauze change daily and prn. On 11-16-10, R12 was taken to her room after lunch, at 1PM. At 1:25PM, a Certified Nurses Aide (CNA) was observed to go by R12's room and state from the hallway, "She says it's OK to stay up." At 1:27PM, R12 was asked why she was staying up and R12 stated she asked to stay up to go to the country music program. R12 stated she is suppose to lay down due to sores on her skin. R12 stated she would probably be up until 3PM. R12 was observed in the music activity at 1:51PM and remained there until last observation at 3PM. On 11-17-10 at 10:13AM, R12 was lying in bed on a sheet and bed pad. R12 had a urinary catheter. E13, Licensed Practical Nurse (LPN) and E2, Director of Nursing (DON) went into R12's room to do dressing changes. R12 had scabbed areas to the top of both great toes. R12 had a bandage to her right outer foot that was dated 11-15-10. E13 removed the bandage and measured 2 black area next to each other at 2.7 cm x 1.4 cm. E13 cleansed the areas with wound cleanser and put skin prep on the areas and placed [MEDICATION NAME] over the black areas. R12's right heel was bandaged with Kerlix. E13 removed the Kerlix and bandage. The bandage had drainage on it. R12's right heel had a large open area and black surrounding tissue. E13 measured the pressure sore at 3.7 cm x 5 cm. She did not measure depth. E13 washed the pressure sore with wound cleanser and used skin prep on the outer black area. E13 put collagen cover [MEDICATION NAME] on the pressure sore and non adhesive wrap with Kerlix. R12's left heel was bandaged. E13 removed the bandage. R12 had a light scabbed area on her left heel that was oblong in shape and approximately 1 cm x 2 cm. E13 did not measure this scabbed area. E13 cleaned the area with wound cleanser and put [MEDICATION NAME] over the area. R12 had a deep red line on her lateral foot. E13 stated she was unaware of the pressure sore until that time. The pressure sore appeared to be a Stage 1 pressure sore that was caused from the foot pressing against the foot board of the bed. E13 measured the pressure sore at 2.4 cm x 1.6 cm. R12 was turned on her side. R12 had a pressure sore on her right buttock and coccyx with no dressing/treatment. E13 stated it must have come off when R12 was using the bed pan. When asked, E13 stated staff had not informed her that R12's pressure sore bandages had come off on the coccyx and buttock. There was no packing in the pressure sores and no dressing in R12's bed. E13 measured the right buttock as 1.4 cm x .8 cm x. 8 cm depth. E13 stated that she was going to pack both wounds with gauze rope. E13 cleansed the pressure sore and packed the pressure sore using a Q tip and put gauze and border gauze over the pressure sore. The pressure sore on her coccyx measured 3.6 cm x 2.4 cm x .4 cm and had macerated rolled edges. E13 pointed out the macerated edges to E2 who confirmed and stated they would get a new treatment order. E13 packed the pressure sore with gauze rope and place gauze pads and gauze bandage. The facility Weekly Infection Control Report shows the following measurements for the stage 3 pressure sore on R12's right heel: 11-3-10 - 3.5 cm x 3 cm with no depth 11-10-10 - 5 cm x 3 cm x .1 cm 11-17-10 - 5 cm x 3.7cm. The report of 11-17-10 did not identify depth, yet the pressure sore did have depth and drainage when observed on 11-17-10 and the facility failed to get a new treatment since 7-5-10. The Weekly Infection Control Report shows the following measurements for the stage 4 pressure sore on R12's right buttock; 10-27-10 - .8cm round with .1 cm depth 11-3-10 - 1 cm x 1 cm x 1cm depth. 11-10-10 - .6 cm x .4 cm x .3 cm depth with .5 cm undermining. 11-17-10 - 1.4 cm x .8 cm x .8 cm depth. The Weekly Infection Control Report for R12's Stage 4 pressure sore on the coccyx shows the following measurements: 10-27-10 - 3.2 cm x 1 cm x .5 cm 11-3-10 - 3 cm x 1.5 cm x .8 cm. 11-10-10- 2.8 cm x 1.6 cm x .3cm with .3cm tunneling. 11-17-10 - 3.6 cm x 1.6 cm x .4 cm. The Weekly Infection Control Reports do not identify the pressure sore on the left heel or the black areas on the right outer foot or the left lateral foot. The facility Skin Pressure Ulcer Documentation of 11-3-10 shows the pressure sore on R12's coccyx had slight maceration at wound edge and was larger in size, yet the facility failed to get a change in treatment. Note of 11-17-10 states, "Area slightly larger in size however tunnel has resolved. No s/s (sign and symptom of infection. Will continue to monit/treat as ordered." On 11-19-10, E9, Assistant Director of Nursing, stated R12 is non compliant with lying down and provided a typed statement written by the facility and signed by R12 that R12 was offered to lay down for an hour after lunch before activity, but she preferred to stay up. (R12 stated at 11-10-10 at 1PM, that she would lay down before activities if staff didn't have to undress her and then dress her before she gets up. R12 stated they insist on removing her disposable incontinent brief when she's in bed. She stated it's to much trouble for staff to undress her and then redress her before getting back up but if she could keep the brief on it would be no problem to lay down for 1/2 hour. Also there is nothing on R12's Care Plan identifying she is non compliant with lying down or interventions.) E9 stated R12's left heel was healed and therefore not on the Weekly Infection Control Report. E9 was asked about R12's left lateral foot as being identified as a DTI. E9 stated she would look at it with Surveyor. E13, LPN, was in the room doing a dressing change. E9 agreed the Pressure sore was not DTI and was a stage 1 pressure sore that she expected to resolve without opening. E13 agreed. The facility had padded the foot board of R12's bed. At 1:30PM, E9 stated she wanted to look at R12's left heel. E9 removed the bandage on the left heel and stated, "Oh, I think I just pulled off the scab." The scab was stuck on the bandage E9 had just removed. R12 was lying on a sheet and bed pad. E9 confirmed R12 should not be lying on a bed pad due to the air pressure mattress. 2. R11's Care Plan of 10-14-10 states R11 is at high risk for skin breakdown related to sensory impairment, incontinent episodes, decreased mobility, poor appetite at times and potential for friction and shearing. Care Plan approach includes, in part, turn and reposition every 2 hours and prn and to toilet using bed pan every 2 hours. Care Plan also shows R11 is totally dependent on staff for transfers using a mechanical sling lift. R11 was observed at 11-16-10 from 11:55AM to be sitting in her wheel chair at the dining room table. R11 was fed by staff and ate over 90%. At 12:50PM, R11 was taken directly from the dining room to the beauty shop. R11 remained in her wheel chair while in the beauty shop. R11 remained in the beauty shop until 1:50PM and was taken to activities. At 3PM, R11 was still in the activity when observation ended. 3. R4's Care Plan of 9-30-10 identifies R4 as being at high risk for skin breakdown related to decreased mobility, bowel and bladder incontinence, potential for friction/shearing with transfers, decreased sensory perception and poor appetite at times. Care Plan approaches include, in part, assist with turning and repositioning and scheduled toileting program every 2 hours from 6AM to 10PM. Facility Weekly Infection Control Report for 11-17-10 shows R4 has a stage 2 pressure sore developed in house on 5-18-10 on his left lateral ankle measuring .6 cm round x .1 cm deep. R4 was observed on 11-16-10 from 11:55AM to to 12:55PM to be up in his wheel chair with his wife visiting. R4's wife stated he had been up in his wheel chair when she arrived at the facility at 10:30AM and had not been toileted or repositioned. At 12:55PM, R4's call light was on and his wife stated he needed to use the bathroom. A CNA went into his room and stated she needed to get help. At 1:15PM, E15 and E20, CNA's, went into R4's room and using a mechanical standing lift, put R4 onto the toilet. R4 incontinent brief was wet with urine. On 11-17-10, R4 was observed to be up in his wheel chair from 11:55AM to 2:08PM. R4's wife was visiting and stated he was when she arrived at the facility at 10:45AM and was not toileted or taken out of his wheel chair until after therapy when E21, Physical Therapy Assistant took him. She stated R4 had been incontinent of urine. 4. R15's Minimum Data Set (MDS), dated [DATE], documented that R15 was a severely cognitively impaired resident who was assessed as needing extensive assistance of one to two plus persons physical assistance with mobility and transfer and a Stage II pressure sore. The facility's Weekly Infection Control Report, dated 10-20-10 to 10-27-10, documented that R15 had a left heel unstageable pressure sore measuring 1cm x 1.5cm. The facility's Weekly Infection Control Report, dated 10-6-10 to 10-13-10, documented that R15's left heel measured 3cm x 6cm at that time. The facility did not have an effective plan of pressure sore prevention for the development of R15's left heel pressure sore. Interview on 11/19/10 during the daily meeting with E1, Administrator, indicates the facility has no further information/documentation toward R15's pressure ulcer to provide.