Every finding on record at La Bella of Morrison

Based on observation and interview, the facility failed to ensure the shower room was maintained in a safe, functional and operating condition. This applies to all residents residing in the facility reviewed for physical environment in the sample of 9. The findings include: The census report dated 8/24/26 shows 49 residents residing in the facility. On 8/25/26 at 9:35 AM, a tour of the facility was conducted with V8 (Maintenance Director). The shower room on the north hall had several wet bath blankets placed outside the doorway leading into the hallway. Black debris and buildup were present throughout the shower room floor. The shower room was dirty, unmaintained and contained fecal matter on the floor. Missing tiles near the base of floor were patched over with black tape, rust and erosion were observed at the bottom of the metal door trim. On 8/25/26 at 9:40 AM, V8 stated that the shower room needs a new floor and that any black debris in a wet room is most likely mold. V8 stated the shower room needs a complete remodel as everything has been patched over repeatedly, and it has been working. The water does not flow in the direction of the drain, instead it flows out onto the hallway which is why staff place the blankets outside of the shower room. This is major, it's bad and not in good condition. V8 stated he has been employed at the facility for a couple of months, and the building has been neglected for years. On 8/25/26 at 1:12 PM, V1 (Administrator) said she has been at the facility for about two months. There have been a lot of repairs done due to the facility not being maintained and the shower room has been on her list to be repaired.

Based on interviews and record review, the facility failed to ensure a physician follow-up visit was completed for a resident after readmission from the hospital. This applies to 1 of 3 residents (R2) reviewed for physician services in the sample of 9. The findings include: R2's face sheet shows she was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, type 2 diabetes, hypertension, atrial fibrillation, osteoarthritis, and benign hyperplasia. On 8/24/26 at 10:07 AM, R2 was in her room sitting in her wheelchair with her eyes closed. V13 (R2's spouse) was in the room visibly upset about the lack of care R2 was receiving. V13 stated This place sucks! They are short-handed and I'm not happy at all. I would not recommend this place to anyone. V13 stated R2 will be transferred to another facility this week and added R2 has not been seen by a physician since her admission. On 8/25/26 at 10:22 AM, V2 (DON) said the physician and nurse practitioner rounds monthly on residents. New admission residents are usually seen by the provider within the first two weeks. V2 said she is not sure if R2 has been seen by a physician. At 2:00 PM, V2 confirmed R2 had a change of condition, was sent out to the hospital, and returned on 8/17/26 but had no physician visits completed since her return. V2 confirmed she was unaware R2 had not been seen by the physician. R2's progress notes dated 8/14/26 show R2 had a change of condition involving slurred speech and weakness and was sent out to the local hospital. R2's progress note dated 8/17/26 shows she returned to the facility. R2's hospital discharge orders dated 8/17/26 include following up with the primary care provider within 7 days. R2's EHR (electronic health records) showed no documented physician visits following readmission. The facility did not provide a policy regarding frequency of physician visits.

Based on observation, interview and record review, the facility failed to ensure a complete comprehensive nutritional assessment was performed and failed to ensure a nutritional supplement was provided for a resident at risk of weight loss. This applies to 1 of 3 residents (R2) reviewed for nutrition in the sample of 9. The findings include: R2's face sheet shows she was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, pneumonia, type 2 diabetes, hypertension, atrial fibrillation and benign prostatic hyperplasia. R2's Physician Order Sheets dated August 2026 show orders including house nutritional supplement with meals. On 8/24/26 at 12:01 PM, during the noon meal service. R2 was not observed in the dining room. At 12:18 PM, R2 was in her room lying in bed with her eyes closed and her meal tray was not in her room. On 8/24/26 at 12:21 PM, V10 (CNA) said she brought in R2's meal tray but she did not eat much. R2 took a few bits of her spaghetti and needs encouragement to eat. R2's meal tray was in serving cart and V10 showed this surveyor R2's tray. R2's meal tray did not have her nutritional supplement. V10 said she is supposed to have a shake with her meal. V10 said R2 did not receive her supplement with her meal. On 8/25/26 at 10:22 AM, V2 (DON) said she is not sure when the dietitian rounds but confirmed R2's nutritional assessment was not done. V2 said R2 has poor appetite and should receive a nutritional supplement with her meals. V2 said weights are usually done weekly for one month and confirmed R2's weights were not completed. On 8/31/26 at 9:14 AM, V14 (Dietitian) said she performs her nutritional assessments remotely based on the facility assessments date. V14 said she goes to the facility once a quarter to perform a physical observation. Typically, the nutritional assessment is completed within 14 days of admission. The assessment should include the resident's weight, height, BMI (body mass index). The assessment then calculates the resident's nutritional needs and implement nutritional recommendations. V14 confirmed she did not complete R2's nutritional assessment. I'm not sure why R2 was missed. Weekly weights are also the standard of practice for new admissions for the first month. R2's progress notes reviewed from July 31, 2026 to August 25, 2026 show documentation of R2's poor intake and refusal of meals on 8/7/26, 8/19/26, 8/20/26, 8/22/26 and 8/24/26. R2's EHR (electronic health record) shows there was no nutritional assessment completed and no nutritional progress notes documented. R2's weight report provided on 8/25/26 shows her weight recorded on 7/31/26 at 133.2 lb. (pounds) and does not show weekly weights recorded. No other weights were recorded until this surveyor requested a weight. The facility's undated Weight Monitoring Policy states, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight, or desirable body weight.a comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information a. general appearance, b. height, c. weight, d. food and fluid intake, e. fluid loss or retention.newly admitted residents-monitor weekly for 4 weeks.

Based on observation, interview and record review, the facility failed to ensure residents who are dependent on staff received showers. This applies to 2 of 3 (R2, R3) residents reviewed for activities of daily living in the sample of 9. The findings include: 1. On 8/24/26 at 10:07 AM, R2 was in her room sitting in her wheelchair with her eyes closed. R2's shirt was noticeably soiled that appeared to be dried food. V13 (R2's spouse) was in the room visibly upset about the lack of care R2 was receiving. V13 stated This place sucks! They are short-handed and I'm not happy at all. I would not recommend this place to anyone. V13 said R2 will be transferring to another facility. On 8/24/26 at 11:07 AM, V11 (Certified Nursing Assistant-CNA) said residents should receive showers twice a week. If they refuse, the shower sheet should be signed by the resident in the shower book. V11 stated R2 is dependent on staff for cares. R2's current care plan dated 7/31/26 does not show she requires staff assistance for her personal hygiene needs. R2's Shower Sheets for August 2026 show she received one shower out of 25 days. 2. On 8/24/26 at 10:17 AM, R3 was observed in her room. R3 stated I'm not getting my showers. R3 stated she is supposed to receive her showers twice a week on Wednesday and Saturdays. She said the staff are reporting she's refusing her showers and stated, That's a bunch of bullsh*t. R3 stated they've had a lot of staff walk of the job and there are a lot of agency staff. They don't come in and offer me a shower and then say I refuse. R3 stated she had a care plan meeting on July 15th with her showers being a concern. I'm supposed to sign the shower sheet if I refuse and I have not signed any shower sheets. R3 stated she had one shower in August. R3 stated she would be open to agency staff providing her with her showers, because the facility can't keep their own staff. On 8/24/26 at 11:00 AM, V9 (CNA) said R3 refuses showers at times and does not prefer agency staff to assist her. Staff should have her sign the shower sheet when she refuses. Showers should be offered twice a week and documented in the shower book. V9 showed this surveyor the shower book located at the nurse's station. R3's August 2026 Shower Sheets showed two showers offered in August on 8/13/26 and 8/15/26 as refused however, there was no signature by R3, there were no other showers recorded on this sheet. On 8/25/26 at 10:22 AM, V2 (DON) stated R3 refuses her showers sometimes. There are certain staff she prefers for her showers. Staff should be documenting refusals, and she has requested R3 sign the shower sheet when she refuses. V2 stated I know they are not doing it R3's refusals are not being signed. R3's revised care plan dated 7/17/26 shows her shower days are on Wednesdays and Saturdays when her preferred CNA works and agreed to shower when the staff is available. When R3 refuses her shower, she is to sign that she refused the shower. The facility provided R3's shower sheet on 8/25/26 that differed from the original shower sheet observed in the shower book on 8/24/26. R3's shower sheet provided on 8/25/26 show 6 showers offered with 2 refusals. The documented refusals did not contain R3's signature. The facility's undated Resident Shower Policy states, It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues.residents will be provided showers as per request or as per facility schedule.

Based on observation, interview and record review the facility failed to ensure a resident was free from significant medication error. This applies to 1 of 3 residents (R5) reviewed for medications in the sample of 9. The findings include: R5's face sheet shows diagnoses including diabetes mellitus, generalized anxiety, migraine without aura, and major depressive disorder. On 8/24/26 at 12:29 PM, R5 was in his room with the light off. R5 stated, he is supposed to get an injection once a month for his migraine and has not been receiving it monthly. On 8/25/26 at 10:22 AM, V2 (DON) said she approved R5's injectable migraine medication today, it was not covered by his insurance. V2 said R5 has migraines and confirmed R5's medication was not administered in June or July. Medications should be administered as ordered and nursing should follow up if the medication is not available. R5's Physician Order Sheets dated August 2026 shows orders dated 4/25/26 including Fremanezumab subcutaneous solution 225 mg (milligrams)/1.5 ml (milliliters) inject one syringe subcutaneously on 25th of every month related to migraine. R5's Medication Administration Records for June 2026 and July 2026 show orders including Fremanezumab subcutaneous solution 225 mg (milligrams)/1.5 ml (milliliters) inject one syringe subcutaneously on the 25th of every month related to migraine. R5's MAR shows the medication was not administered on June 25th and July 25th. The facility's undated Medication Administration Policy states Medications are administered by licensed nurses, or other staff who legally authorized to do in the state as ordered by the physician and in accordance with professional standards of practice.

Based on observation, interview and record review the facility failed to ensure a working call light system for 10 of 10 (R2, R3, R8, R9, R10, R11, R12, R13, R14, R15) residents reviewed for call lights in the sample of 15.The findings include:On [DATE] at 10:00 AM, R2 said she had a fall last week at about 9:00 PM. She was in a different room down the south hallway. After the fall, she moved to the North Hall because it has a call light, and the room on the south hall did not have a working call light. R2 said when she fell, she was all by herself and tried to get up 4 times. She believed she had a seizure while washing her face and fell hitting her chin on the sink. R2 said she had to go to the nurse who was down the hallway, because there was no call light in the bathroom. R2s hospital record of [DATE] documents R2 sustained a fractured jaw.On [DATE] at 1:30 pm, R14, R2's former roommate said she recalled R2 falling and saw her crawling on the floor to go get help. R14 said the rooms and bathrooms have not had any call lights since she had been admitted .On [DATE] at 1:35 PM the call light system on the south hallway was found to be not working in the residents' rooms, or bathrooms. No signals were sent to the nurses' station, and rooms did not have lights outside their rooms that would indicate a call light was lit. On [DATE] at 1:35 PM, R3 said there are no call lights on the unit. He said the residents were given some type of noise maker to use when trying to get help. R3 had a small tambourine with a stick to hit the tambourine drum and make noise. On [DATE] at 1:40 PM, R15 said the room and the bathroom are without any call lights. She sometimes must go get the nurse to help (R8), her roommate. R8 was lying in bed with her buttocks hanging off the edge of the bed. She was wearing oxygen nasal cannula. A call light was attached to the rail of R8s bed and did not work. R8 appears elderly and frail.On [DATE] at 1:43 PM, R12 said she had no call light since her admission. When asked what about in the event of an emergency, and R12 said Well, I guess I would die.On [DATE] at 1:46 PM, R13 had her call light on the bedside table, and it did not work. She stated in an emergency I guess I'm out of luck On [DATE] at 1:50 PM, R10's room was observed to have no call light cords in the room or the bathroom.On [DATE] at 1:50 PM, R11 said the call light does not work, if help is needed the residents have to go out to find help. On [DATE] at 1:55 PM, R9 said the staff on the unit are supposed to do 15-minute checks on the hallway. Other than that, I guess we have to yell out for help. Literally yell out for staff to get us help.On [DATE] at 2:00 PM, call lights in the rooms on the south hallway were not working, lights outside of the rooms were not working, and the lights to not show up at the nurse's station. The unit had one nurse on the unit.On [DATE] at 1:15 PM, V11 (Registered Nurse/RN) said there have not been any functioning call lights since she has been working. The residents have to come out to the nurse's station if they need anything or call out for help. On [DATE] at 8:10 PM, V10 (RN) said she had complained to management numerous times about not having call lights on the units. All of the residents are alert and oriented but also are on oxygen or diabetic and could have a low blood sugar and have other medical issues. And when accidents occur, like the fall with R2, they have to come and get staff to get help because they have no call lights. On [DATE] at 2:02 PM, V1 (Administrator) said when she came to the building in June, the south hallway was already open and had residents. The first one was admitted on [DATE]th. V1 said the staff are supposed to be doing 15-minute checks on the hallway since the residents have no call lights. V1 said some of the residents have noise makers, and she is working with corporate to get the issue resolved. Her last inquiry was made on [DATE]. V1 said having no call lights does limit who can be admitted to the unit. The residents would have to be alert and ambulatory.The facility's undated policy for call lights: Accessibility and timely response document the purpose of the policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 8. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (examples include replace call light, provide a bell or whistle, increase frequency of rounding, etc.)

Based on observation, interview, and record review the facility failed to follow their policy for a safe community pass for 1 of 3 residents (R1) reviewed for safety in the sample of 4. The findings include:On 5/27/26 at 11:05 AM, R1 was sitting outside in his wheelchair. R1 said he recently went out on pass with his girlfriend to his girlfriend's house. R1 said he fell asleep watching a movie and it got late so he stayed the night there and came back to the facility in the morning the next day. R1 said he signed himself out of the facility. On 5/27/26 at 11:20 AM, V7 (Licensed Practical Nurse) said she worked on the day R1 went out on pass. V7 said R1 had asked to go out on pass and V7 asked V1 (Administrator) if R1 was allowed to go out. V7 said V1 said R1 had a high enough cognition score that he could go, but normally you are supposed to call the doctor and get an order. V7 said R1 is alert and oriented times three, is able to transfer himself and has no safety concerns that she was aware of. On 5/27/26 at 11:22 AM, V8 (Registered Nurse) stated, Oh yeah, you are supposed to call the doctor! On 5/27/26 at 11:40 AM, V1 (Administrator) said for a resident to go out on community pass they need to have a high cognition score. V1 said she was not aware of needing a doctor's order or not, nursing would know that. V1 said she would need to look at their policy. R1's Physician Orders for May 2026 do not contain an order to go out on a therapeutic leave. The facility's Resident Sign Out/In Records shows R1 signed out on 5/17/26 at 6:30 PM. R1's Social Service Quarterly assessment dated [DATE] shows under Community Survival Skills Evaluation that R1 is marked yes for the resident is sufficiently alert, and oriented, coherent and knowledgeable allowing him/her to be considered for independent outside pass privileges and resident is able to move/navigate/negotiate safely on community streets, maintain a safe distance around cars, uses sidewalks, if in a wheelchair propels safely/carefully. R1's Care Plan shows R1 has diagnoses of chronic congestive heart failure, anemia, cardiac pacemaker, acquired absence of right and left foot, and acquired absence of right leg below knee. This same Care Plan shows R1 is able to transfer himself independently. This Care Plan does not address R1's Community Pass ability. The facility's Therapeutic Leave Policy dated 5/2026 shows It is the policy of this facility to allow resident to leave the facility for a non-medical visit, thereby known as therapeutic leave, in accordance with Federal and State guidelines and applicable Medicaid, and private insurance guidelines. The nurse will obtain an order from the practitioner specifying approval of a therapeutic leave. The facility will document in the medical record the resident's leave of absence, any medications, sent with the resident and any education given to the resident and/or representative prior to the leave.

Based on observation, interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 3 of 13 residents (R4, R6 & R12) reviewed for dignity in the sample of 15. The findings include: On 5/4/26 at 9:03 AM, R6 stated, V10 former agency Certified Nursing Assistant (CNA) just showed up going into rooms asking if we wanted to go to the bar and get drunk. I told him no. I don't care for that goofball. I don't give a shit about him. On 5/4/26 at 9:12 AM, R4 stated, V10 former agency CNA was her CNA. He would give her cares but never say much to her. All of the sudden she found out that he was terminated from the facility and he came in acting like her best friend. He came in her room and tried to hug her. A nurse (V11 Licensed Practical Nurse (LPN)) was in the hallway telling him, he shouldn't be there and to leave. She stated, she was in shock and didn't know what was going on. On 5/4/26 at 11:36 AM, R12 stated, V10 former agency CNA came in his room asking if I wanted to go the bar with him. I told him no, get out of my room. On 5/5/26 at 12:43 PM, V11 LPN stated, she found V10 former agency CNA in R4's room laying on her. R4 was screaming and very upset. He stood up and left the room. I stayed and consoled R4. She was upset and scared because of the things he was saying to her about being terminated. She thought she was going to get blamed for it or involved in it. On 5/6/26 at 12:06 PM, V1 Administrator stated, V10 former agency CNA was DNR'd (do not return) for creating a non-homelike environment. He came back two times after being DNR'd causing a scene and bothering residents. He was asking residents to go to the bar and trying to get them to say bad things about the facility. R4's minimum data set (MDS) dated [DATE] shows, she is cognitively intact. R6's MDS dated [DATE] shows, he is cognitively intact. R12's MDS dated [DATE] shows, he is cognitively intact. The facility's resident rights policy dated 10/1/25 shows, Resident Rights: The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 4. Respect and dignity. The resident has a right to be treated with respect and dignity. 8. Safe environment. The resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 4 residents (R4) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).R4's resident assessment dated [DATE] showed R4 was cognitively intact.R1's current care plan showed R1 was severely cognitively impaired due to her diagnosis of dementia. The plan showed R1 was ambulatory and wandered throughout the facility. The plan showed, Resident wandering and rearranging another resident's room. Resident likes to touch, hug, or kiss others. Resident has a history of being physically aggressive. On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated, (R1) was mad. She punched my right arm. It wasn't a slap; it was a punch. On 5/4/26 at 12:10 PM, V8 Licensed Practical Nurse (LPN) stated, On 2/22/26, (R1) wandered into (R4's) room but there was no physical contact. On 2/26/26, (R1) wandered into (R4's) room again. That's when (R1) hit (R4). V8 stated she immediately reported the physical altercation to V1 Administrator as V1 was the facility's abuse coordinator.On 5/4/26 at 11:55 AM, V1 Administrator stated that a resident hitting another resident is a form of physical abuse and is investigated as abuse. V1 stated she did not report or investigate the incident on 2/26/26 between R1 and R4 because she knew nothing about the incident. I was not aware of this incident until today.The facility's Abuse, Neglect, and Exploitation policy dated 10/13/25 showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking.

Based on interview and record review the facility failed to report an allegation of physical abuse to the facility administrator and other officials, including the State IDPH for 1 of 4 residents (R4) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated, (R1) was mad. She punched my right arm. It wasn't a slap; it was a punch. On 5/4/26 at 12:10 PM, V8 Licensed Practical Nurse (LPN) stated she immediately reported the physical altercation on 2/26/26, between R1 and R4 to V1 Administrator as V1 was the facility's abuse coordinator.On 5/4/26 at 11:55 AM, V1 Administrator stated that a resident hitting another resident is a form of physical abuse and is investigated as abuse. V1 stated staff are to report any facility abuse allegations to her immediately. V1 stated she did not report or investigate the incident on 2/26/26 between R1 and R4 because she knew nothing about the incident. I was not aware of this incident until today. V1 stated V8 LPN never reported the 2/26/27 incident, involving R1 and R4, to V1.The facility's Abuse, Neglect, and Exploitation policy dated 10/13/25 showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review the facility failed to investigate an allegation of physical abuse for 1 of 4 residents (R3) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated, (R1) was mad. She punched my right arm. It wasn't a slap; it was a punch. On 5/4/26 at 12:10 PM, V8 Licensed Practical Nurse (LPN) stated she immediately reported the physical altercation on 2/26/26, between R1 and R4 to V1 Administrator as V1 was the facility's abuse coordinator.On 5/4/26 at 11:55 AM, V1 Administrator stated she did not report or investigate the incident on 2/26/26 between R1 and R4 because she knew nothing about the incident. I was not aware of this incident until today. V1 stated V8 LPN never reported the 2/26/27 incident, involving R1 and R4, to V1.The facility's Abuse, Neglect, and Exploitation policy dated 10/13/25 showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. An immediate investigation is warranted when suspicion of abuse neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation; 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause; 6. Providing complete and thorough documentation of the investigation.

Based on observation, interview and record review the facility failed to ensure prescribed treatments were done for a resident with a surgical wound. This applies to 1 of 3 residents (R6) reviewed for wound care in the sample of 15. The findings include:R6's face sheet lists his diagnoses to include: absence of left foot, absence of right leg below the knee, severe protein-calorie malnutrition and chronic systolic congestive heart failure. On 5/5/26 at 10:15 AM, V4 Registered Nurse (RN) was changing R6's dressing to his right stump surgical dehiscence. R6 had a small pinpoint open area on the incision where he had a below the knee amputation. She cleaned the wound and was going to apply xeroform (petroleum based gauze) to his wound and cover with a dressing. R6 told her, No that is not the right dressing. She asked, what do you mean? Your orders say xeroform and a dressing. R6 stated, no they changed that order and have been using the white stuff (collagen) and then a dressing. He continued to explain the xeroform was keeping the wound wet and the wound care doctor didn't want that. V4 RN said, ok and she would check the orders. V4 RN and this surveyor went out of the room to the computer to verify the order. The order in the computer for R6 at that time was for xeroform and to cover with a dressing. V4 RN went back to R6 and explained what the order stated. He stated no, that is incorrect. V4 RN told him ok and she would follow up with the wound care doctor. V4 RN stated, the wound care doctor was just there on Friday and she would find out what the orders were. R6's skin and wound note dated 5/1/26 shows, R6 has a wound to his right stump surgical dehiscence. Treatment recommendations: 1. Cleanse with wound cleanser. 2. Apply collagen to base of the wound. 3. Secure with bordered dressing. 4. Change 3 times per week, and PRN (when needed). Assessment/Plan: Changed recommended treatment on 5/1/26. R6's skin and wound note dated 4/24/26 shows, R6's treatment recommendations at that time were xeroform with bordered dressing. R6's skin and wound note dated 4/10/26 & 4/17/26 shows, R6's treatment recommendations at that time were collagen with bordered dressing. Based off R6's skin and wound notes/treatment recommendations were as follows: collagen with bordered dressing ordered 4/10-4/24/26 & 5/1/26 and xeroform with bordered dressing 4/24/26-5/1/26. R6's April 2026 treatment administration record (TAR) shows, RLE (right lower extremity) stump: cleanse with normal saline. Apply collagen to the base of wound. Secure with bordered dressing. Start date 4/15/26, D/C (discontinued) date 4/27/26. The collagen order was not changed until 4/15/26 (5 days late) and R6 missed 1 dressing change with new treatment orders. The same record also shows, the collagen was discontinued on 4/27/26 and R6 received no treatment change that day. (The new order for xeroform was not put in until 4/29/26 (see next statement) and neither treatment was signed out for 4/27/26. R6's April 2026 and May 2026 TAR shows, Right stump: cleanse with normal saline, apply xeroform and cover with a border dressing. Start date 4/29/26, D/C date 5/2/26. The same record shows, R6 received the xeroform treatment on 5/1/26 and not the new treatment for collagen. On 5/6/26 at 11:08 AM, V2 Assistant Director of Nursing (ADON) and V3 ADON from another facility both verified the orders were entered late and R6 did not receive the correct treatment on those days. They also stated, the wound care doctor comes on Fridays and sees residents. They don't get new orders until the next business day, Monday in this case. V2 ADON stated, she is new here and tries to get the orders in as soon as she gets them. R6's Minimum Data Set, dated [DATE] shows, he is cognitively intact. R6's current care plan shows, Focus: Resident has actual impairment to skin integrity (surgical) to blle (bilateral) r/t (related to) amputation of toes and BKA (below knee amputation). Interventions: Treatment as ordered. Cleansing, application of medication, packing and/or dressings change w/wound (with wound) status and progress- See Orders in chart/eTAR (electronic TAR) for current treatments. The facility's wound treatment management (no date) shows, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy explanation and compliance guidelines: 1. Wound treatments will be provided in accordance with physician orders, including cleansed method, type of dressing, and frequency of dressing change.

Based on observation, interview and record review the facility failed to ensure a resident with a pressure injury received the prescribed treatment. This applies to 1 of 3 residents (R12) reviewed for wound care/pressure ulcer in the sample of 15. The findings include:R12's face sheet lists his diagnoses to include: diabetes mellitus, type 2, heart failure, chronic kidney disease, pressure ulcer of right buttock, stage 3, major depressive disorder, peripheral vascular disease, atrial fibrillation, coronary artery disease and hypertension. On 5/5/26 at 1:46 PM, V4 Registered Nurse (RN) was changing R12's dressings. He had an open pressure ulcer about the size of a dime on his right buttock. She pulled the dressing off and there was a white piece of collagen and a dressing over it. She stated, that wasn't his dressing and wasn't sure why that was on there. The current order was for hydrocolloid paste and to leave open to air. She stated, because the wound looked like it could benefit from being covered she would call and get different orders. R12's treatment administration record for May shows, Left buttock (wrong buttock), cleanse wound with wound cleanser, apply hydrocolloid dressing to cover wound q3days (every 3 days) and PRN (when needed). Start date 4/29/26. There were no orders for the right buttock. R12's skin and wound note dated 5/1/26 shows, R12 had a pressure ulcer to his right buttock. The treatment recommendations were for hydrocolloid (does not specify a dressing or cream) and leave open to air. On 5/6/26 at 11:08 AM, V2 Assistant Director of Nursing (ADON) stated, she called and clarified the order and it was for a hydrocolloid dressing which is why the TAR showed a dressing. She was not sure why the nurse put a collagen piece then the dressing. She also confirmed it was his right buttock and not left buttock. R12's current care plan shows, Focus: documented pressure ulcer. Interventions: .Provide wound care per treatment order. The same care plan also shows, Focus: Resident HAS area(s) of skin impairment. R (right) buttock stage 3 pressure ulcer, R BKA (below the knee amputation) surgical dehiscence, and abrasion of L (left) dorsal foot. R12 sees the wound Dr. see wound notes for current treatments. Interventions: Administer/apply medications, ointments, creams as orders- see MAR/physician orders. The facility's wound treatment management (no date) shows, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy explanation and compliance guidelines: 1. Wound treatments will be provided in accordance with physician orders, including cleansed method, type of dressing, and frequency of dressing change. The facility's pressure injury prevention and management policy (no date) shows, Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.

Based on observation, interview and record review the facility failed to ensure staff did not provide a THC vape pen to a resident for use. This applies to 1 of 15 residents (R6) reviewed for safety in the sample of 15. The findings include:On 5/5/26 at 1:20 PM, V13 laundry/housekeeping stated, he saw V10 former agency Certified Nursing Assistant (CNA) outside with the residents while they were smoking. He saw V10 give R6 a THC (marijuana) vape pen to use. R6 took the pen and used it. He asked other staff members if they knew about it and other staff members stated, he has done it before. He did not report that information to V1 Administrator. He confirmed he knew it was THC by the style of vape pen and they look different than nicotine vape pens. On 5/5/26 at 1:35 PM, V12 Registered Nurse (RN) stated, she had heard that staff were giving THC pens to residents. V13 laundry/housekeeping told her that he saw him give the THC pen to R6. She told him, he needed to report that to V1 Administrator. She has had a few days where residents appear high however, nothing has ever been found. On 5/5/26 at 12:45 PM, V11 Licensed Practical Nurse (LPN) stated, she was aware that staff were giving residents THC pens. She stated, V13 laundry/housekeeping told her, he saw V10 give his THC pen to R6 outside on the patio. On 5/6/26 at 1:05 PM, R6 denied, V10 former agency CNA gave him a THC pen. He stated, he has given him his nicotine vape to smoke but never a THC pen. He has used the nicotine vape pen when he gave it to him. On 5/6/26 at 8:16 AM, V10 former agency CNA denied, giving any THC pens to residents. He said he smokes marijuana at home but not at work.On 5/6/26 at 12:06 PM, V1 Administrator stated, V10 former agency CNA was DNR'd (do not return) from the facility for allegations of sleeping while working and an incident where he let residents smoke outside of their scheduled smoke time. She was not aware V10 was giving THC pens to R6. R6's Minimum Data Set, dated [DATE] shows, he is cognitively intact. The facility's safety for residents with substance use disorder (no date) shows, Policy: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder.The facility's employee handbook & code of conduct dated 12/1/23 shows, Drug and alcohol workplace testing and substance abuse: Our company has a responsibility to provide a safe, healthy, and productive environment for our residents and employees. The use of illegal drugs and alcohol has an adverse effect on employee performance, jeopardizes the safety of employees, residents, and visitors, and constitutes a risk to the overall interests of the company.

Based on observation, interview and record review the facility failed to manage a resident's pain by not administering analgesic pain medications as prescribed for 1 of 3 residents (R8) reviewed for pain management in the sample of 15.The findings include:A physician order for R8 dated 4/20/26 showed, Hydrocodone-Acetaminophen (Norco/narcotic pain medication) 5/325 milligrams, give 1 tablet every 6 hours as needed for pain.R8's provider note dated 4/21/26 showed resident has continued complaints of right foot/heal pain, which she states has already had imaging of and is awaiting insurance approval for CT scan. She currently has orders for Hydrocodone-acetaminophen for pain as needed.On 5/4/26 at 10:32 AM, R8 was in bed. R8 stated she didn't feel well because she had not received any Norco since last Thursday (4/30/26). R8 stated, I have rheumatoid arthritis, fibromyalgia, and pain in my foot. I usually take 2 Norco a day for my pain. I haven't gotten it (Norco) since last week because they say they ordered my medication, but it hasn't been delivered yet. R8 rated her current pain level as a 9/10 however, R8 appeared calm, was not restless, and appeared drowsy at times. R8's April 2026 and May 2026 Medication Administration Records (MAR) showed R8 last received a dose of Norco on 4/30/26. R8's May MAR showed no doses of Norco were administered to R8 from 5/1/26-5/4/26. On 5/4/26 at 10:39 AM, V6 Registered Nurse stated, (R1) is out of her Norco. Her last dose was last week. It looks like the Norco was ordered on 4/20/26 but it hasn't been delivered from the pharmacy yet. I am not sure what the delay is. (R1) did complain of pain this morning, so I gave her a Flexeril (muscle relaxant medication). I know its not the same as Norco. When V6 was asked if the facility had a Pyxis machine (electronic medication dispensing machine) that she could get a dose of Norco from for R8, V6 stated, I am agency. I asked if the facility had a Pyxis and I didn't really get an answer, so I am not sure. On 5/4/26 at 11:01 AM, V2 Assistant Director of Nursing stated staff are to reorder medications when a resident has seven doses left so the facility does not run out of the medication and pharmacy has time to deliver the medications. V2 stated the facility's pharmacy makes deliveries to the facility daily. V2 stated she was unaware the facility had not received R8's Norco. V2 stated, Staff are to notify me or (V1 Administrator) if we run out of medications for a resident. V2 stated the facility does have a Pyxis system that nursing could have pulled doses of Norco from for R8. V2 stated, I am not sure why nursing didn't pull Norco from the Pyxis for (R8) over the weekend.The facility's Pain Management policy (undated) showed, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.The facility's Medication Reordering policy (undated) showed, It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. Acquisitions of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication.

Based on interview and record review the facility failed to monitor and prevent a resident, with a diagnosis of dementia, from wandering into other resident rooms for 1 of 1 residents (R1) reviewed for dementia care in the sample of 15. The findings include:R1's current care plan showed R1 was severely cognitively impaired due to her diagnosis of dementia. The plan showed R1 was ambulatory and wandered throughout the facility. The plan showed, Resident wandering and rearranging another resident's room. Resident likes to touch, hug, or kiss others. Resident has a history of being physically aggressive. The plan showed staff were to closely monitor and intervene when needed to prevent R1 from wandering into other resident rooms by offering R1 structured activities and pleasant diversions. R1's health status notes dated 2/22/26 and 2/26/26 showed R1 was found in a resident's room (R4), attempting to take belongings from R4. On 2/22/26, R1 and R4 got into a verbal argument due to R1 being in R4's room. R1 attempted to hit R4 but was unsuccessful as staff intervened in time. On 2/26/26, R1 again entered R4's room and attempted to take belongings from R4's room. R1 and R4 began to argue. The notes showed R1 hit R4 before staff intervened. On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated staff did not enter her room until after R1 had punched R4.On 5/4/26 at 8:42 AM, R3 stated R1 wanders into my room a lot. I just talk to her and eventually she leaves.On 5/4/26 at 8:51 AM, R7 stated, (R1) wanders around every day and goes into rooms and takes things. We have to watch out for her, so she doesn't take our stuff.On 5/4/26 at 9:27 AM, R9 stated, (R1) wanders into my room all the time. She comes right up to your face, like there is no personal space. Last week, she came in and tried to take my roll of my tray. I swatted at her and shooed her away. R9 stated no staff were present during the incident. On 5/4/26 at 9:50 AM, V4 Registered Nurse stated staff are aware of R1's wandering behaviors. V4 stated, (R1) does wander into resident rooms and tries to take things. We try to watch her and keep her in activities.On 5/4/26 at 10:00 AM, V9 Certified Nursing Assistant stated R1 was a grabber. V9 stated R1 will go into rooms and grab resident's things. We try to keep her busy and watch her.On 5/4/26 at 10:05 AM, V5 Social Services stated R1 has a known behavior of wandering into other resident's rooms and taking belongings from those rooms. V5 stated staff should be monitoring R1 and intervening when R1 attempts to enter other residents' rooms. The facility's Dementia Care policy (undated) showed, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.The facility's Elopements and Wandering Residents policy (undated) showed, This facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk.

Based on observation and interview the facility failed to have a working heating/air conditioning unit in a resident room. This applies to 2 of 4 residents (R4 and R7) reviewed for clean, comfortable and homelike conditions in the sample of 7. The findings include: On 5/1/26 at 9:30AM, R4 stated, I have had no AC (Air conditioning) or heat in my room for the last 2 weeks. The unit does not work. On 5/1/26 at 10:30AM Surveyor observed the AC/ Heat unit in R4 and R7's room. The unit was a wall unit, plugged into the wall. Surveyor pushed the power button, but the unit would not turn on. On 5/1/26 the internet showed it was about 55 degrees outside, however on April 21, 22, and 23 the temperature outside was in the low to mid 80's. R4 had 2 fans on an overbed table both on and pointed at her bed. On 5/1/26 at 12:00PM V3 (Maintenance Director from a sister facility) stated, I didn't know it was not working. V3 then walked with Surveyor to R4 and R7's room to look at the unit. V3 was unable to turn the unit on. V3 pushed two buttons on the unit's electrical cord plug several times and stated, This is not good, there is no click. I have a new one of these units, I will change it out right now. As V3 and Surveyor were leaving the room V3 explained to R7 what he was going to do. R7 stated, (V1- Administrator) lied to my face and said it was going to be fixed by Friday. V3 stated, Well today is Friday. R7 stated, No, last Friday. We told her it wasn't working and she told us it was going to be fixed, and it is still not working. V3 stated, I am going to replace it now.On 5/1/26 at 12:35PM V3 stated, The fuse is blown- (V1) knew about it last week but the old maintenance guy (left last Thursday) said it was fixed. The unit was going bad, so the compressor was getting too hot and blowing the circuit breaker. I am going to replace the unit now. On 5/1/26 at 3:00PM V1 stated, They (R4 and R7) brought it to my attention at the end of last week that their AC was not working. The old maintenance guy told me he fixed it and it was working. Then (V3) said it tripped the breaker and the unit needed to be replaced and the one I said was the wrong size happens to be the one that they need for that room, so he went ahead and replaced it. (R7) has very manipulative behaviors. I don't know about (R4).

Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received incontinence care and showers. This applies to 1 of 3 residents (R1) reviewed for activities of daily living (ADL) in the sample of 7. The findings include: R1's face sheet shows she has diagnoses including COPD, lymphedema, type 2 diabetes, peripheral vascular disease, chronic kidney disease, major depressive disorder, morbid obesity, and generalized anxiety. On 5/1/26 at 9:14 AM, V7 and V8 (Certified Nursing Assistant's) were in R1's room providing incontinence care. A strong smell of urine was permeating from her room. On 5/1/26 at 9:17 AM, R1 was laying in bariatric bed. R1 said she was soaked with urine and the last time she was changed was at 10:30 PM last night. R1 said she prefers not be woken up when she is sleeping during the night, but would like staff to change her in the early morning. R1 said she's been up since 5:00 AM, and staff did not change me until now. R1 said her shower days are on Wednesday and Saturdays. She did not receive a shower for 10 days in April. R1 said when the regular aides are working, she receives her showers. R1 said she does not receive her showers when agency staff are here. R1 said she spoke to V1 (Administrator) regarding her showers. On 5/1/26 at 9:15 AM, V8 (Certified Nursing Assistant-CNA) said R1 is alert and oriented, she is larger resident and is dependent on staff for incontinence care. Yeah, R1 was soaked this morning. R1 was last changed on night shift, she gets changed after breakfast usually at 8:30 AM. R1's shower days are Wednesday and Saturdays. If she refuses we should notify nursing. On 5/1/26 at 9:43 AM, V8 (CNA) said R1 was soaked with urine this morning, she was changed last during night shift. She should get changed in the morning before first shift. R1 should get showers twice a week. V8 said R1 reported she had not received her shower for almost two weeks. She gave R1 a shower after R1 reported to her she did not receive her showers. V8 said she reported the concern to V1 (Administrator). V8 said R1 is fine with me, she is compliant with receiving cares. R1 is dependent on staff for incontinence care and showering. On 5/1/26 at 12:22 PM, V1 (Administrator) said there was a concern about R1 not getting her showers. According to some of the CNA's she refuses her showers and R1 reported she is not refusing her shower. V1 said she followed up with staff and confirmed she did not receive a weekly shower. On 4/18/26, R1 was supposed to receive a shower, the agency aide did not give R1 a shower. If a resident refuses a shower, the aide should report to the nurse and document the medical record. R1's current care plan shows she is dependent on staff ADL assistance with showers and incontinence care. Staff have been advised to do cares in pairs, she has a history of refusing showers. R1 will be offered AM shower first, before PM showers. If offered PM shower with refusal, AM shower is to offered AM next day. Interventions include implementing a special care strategy of 2 caregivers to address and observe the entire situation. R1's care plan shows she is incontinent; she has requested staff to check on her every two hours during the day shift. She wants her last check (incontinence care) between 11:00 PM and 12:00 AM. R1 would like her next check of the day between 4:00 AM to 5:00 AM. R1's shower reports reviewed from April 15, 2026 to April 25, 2026 shows she did not receive her weekly shower. R1's shower report dated 4/18/26 documents she refused her shower. R1's nurses notes reviewed from April 2026 shows there was no documentation for refusals of showers. The facility's undated Resident Showers Policy states, It is the best practice of this facility to assist residents with bathing to maintain proper hygiene, stimulated circulation and help prevent skin issues as per current standards of practice.

Based on observation, interview, and record review the facility failed to have a call system in place allowing residents to call for assistance for 3 of 3 residents (R1, R2, and R3) reviewed for call system in the sample of 3.The findings include:1. R1's admission Record printed on 4/27/26 showed R1 admitted to the facility on [DATE]. The same document showed R1 was [AGE] years old.On 4/27/26 at 11:43 AM, R1 was in her room. R1's call light by her bed and in the bathroom were not working. R1 confirmed her call lights were not working. R1 said staff provided her with a drum to use when she needed help. R1 said she was not able to use the drum. R1 attempted to use the drum. No audible drum noise could be heard at R1's door. R1 said when she needed help, she had to yell or wait for staff to check on her.On 4/27/26 at 11:43 AM, V3 (R1's Daughter in-law) said R1 was not physically capable of making a loud sound with the drum and the call light system had not worked since R1 was admitted to the facility on [DATE].R1's Fall Care Plan with an initiated date of 4/17/26 showed to make sure R1's call light was within reach and encourage R1 to use it for assistance as needed.2. R2's admission Record printed on 4/27/26 showed R2 was diagnosed with a traumatic brain injury and convulsions.On 4/27/26 at 11:01 AM, R2 was in bed. There was no call light in R2's room. R2 was asked if her call light was working. R2 said she would not know if it was working because she did not have one. R2 said when she needed help she had to walk to the nurses desk and find staff. R2 said it would be helpful to have a call light. R2 said staff did not provide an alternative call system like a noise maker. No drum/noise maker were noted in R2's room. The call light in R2's bathroom was also not working. 3. R3's admission Record Printed on 4/27/26 showed R3 was diagnosed with diabetes and anxiety. On 4/27/26 at 11:22 AM, R3 said his call light was not working and staff did not provide an alternative call system such as a noise maker. R3 said he had to look for staff if he needs help. No noise maker/drum were noted in R3's room. On 4/27/26 at 10:51 AM, V1 (Administrator) said the call light system on the south hallway had not been working for about 2 weeks.On 4/27/26 at 11:21 AM, V5 (Certified Nursing Assistant) said the call lights on the south hallway had not been working and the facility had provided noise makers, such as drums, to residents. On 4/27/26 at 11:34 AM, V4 (Acting Maintenance Director) said the former maintenance director quit last week. V4 said he became aware of the call light system not working last week. V4 said it was important to have a working call light system so the residents can get ahold of staff.

Based on observation, interview, and record review the facility failed to ensure an initial assessment was completed of wounds upon admission and failed to ensure weekly wound assessments were completed for 2 of 3 residents (R3, R1) reviewed for wounds in the sample of 7.The findings include:1. R3's face sheet showed he was admitted to the facility 3/12/26 with diagnoses to include chronic obstructive pulmonary disease, severe calorie malnutrition, gangrene, chronic respiratory failure, and retention of urine. R3's record showed he was admitted on hospice services. R3's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires extensive assistance for all cares.On 4/14/26 the facility provided wound assessments for R3's skin conditions including a 3/12/26 Skin check which showed, . Foot evaluation completed. Skin Issues: . Location Right heel. This assessment showed no measurements and did not include R3's wound to his left foot. The only other assessment found in R3's record was dated 4/10/26 and showed, . Wound 1. Left foot. Size: 27 cm x 11 cm x 1 cm, Wound Base: 100% eschar. Wound 2. Right foot. Size: 27 cm x 12 cm x 0.1 cm, Wound Base: 100% eschar. Assessment/Plan: Continue recommended treatment 4/10/26. Patient has frostbite to bilateral feet. The patient is currently under hospice services. Goals of care remain to minimize pain and risk of infection. Continue palliative wound management. Patient is very high risk for ongoing wound decline and development of new wounds. The patient's current wounds are considered unavoidable. It is anticipated that as the patient continues to progress toward end of life that they will continue to experience wound decline. No wound assessments were documented for R3's right and left lower extremity wounds upon admission 3/12/26 and no weekly assessments were documented the week of 3/19, 3/26, or 4/2. On 4/14/26 at 1:28 PM, V2 DON (Director of Nursing) said, Since I started here March 17th we have a contract with [a wound care company] . the floor nurses were doing the weekly assessments but now since [the wound care company] started, they are doing the weekly measurements of the wounds.On 4/14/26 at 2:05 PM, V1 (Administrator) said, The former DON was the one who was responsible for doing the wound measurements and the oversight of the assessments in the [Electronic Health Record]. We identified some concerns with her, and she has since been terminated from her position. We hired [V2] as our new Director of Nursing and brought on a wound care company. The wound company has rounded twice now since their contract started. They saw [R1] and [R2]. The problem we identified with the previous DON doing the weekly assessments looked like the first of March through the third week of March.2. R1's face sheet showed he was admitted to the facility 1/15/26 with diagnoses to include chronic congestive heart failure, insomnia, acquired absence of right leg below knee, acquired absence of right foot, acquired absence of left foot, cardiac pacemaker, and severe protein-calorie malnutrition. R1's 3/9/26 facility assessment showed he has no cognitive impairment. R1's care plan initiated 2/5/26 showed, Resident has actual impairment to skin integrity (surgical) to bilateral lower extremities related to amputation of toes and BKA (below knee amputation) . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.R1's weekly wound assessments showed they were completed to his right and left amputation surgical sites on 2/27/26. The next wound assessments completed for R1's surgical amputation sites to his right and left lower extremities was completed 3/27/26. No weekly assessments were completed for the right stump wound or the left stump wound on 3/6/26, 3/13/26, 3/20/26, and 4/3/26.R1's complete medical record showed no evidence of R1 refusing wound assessments. On 4/14/26 at12:43 PM, R1 said, They come and measure it now. The wound doctor does it. there was a guy who would come in here every once in a while, to measure them but he only came in a couple times.The facility's policy and procedure implemented 10/1/25 showed, Wound Treatment Management. Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: .Lack of progression towards healing.Changes in the characteristics of the wound . Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.The facility's policy and procedure implemented 10/1/25 showed, Documentation of Wound Treatments. Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Policy Explanation and Compliance Guidelines: .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: .Type of wound (pressure injury, surgical, etc.) and anatomical location. Measurements: height, width, depth, undermining, tunneling. Description of wound characteristics: Color of the wound bed.Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium).Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated). Presence, amount, and characteristics of wound drainage/exudate.Presence or absence of odor.Presence or absence of pain.

Based on interview and record review the facility failed to safely transfer residents and in a manner to prevent resident falls and injuries for 2 of 5 residents (R1, R3) reviewed for resident safety and supervision in the sample of 7. This failure resulted in R1 sustaining a large leg skin laceration, during a transfer, that required emergent transport to a local hospital for suture repair. The findings include:1.R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. R1 was discharged back to the facility on antibiotics for the laceration and with orders to follow up with the hospital's wound care team.R1's admission physical therapy evaluation dated 1/8/26 showed, Per consultation, patient demonstrated fear of falling as evidenced from patient getting anxious and unable to stand with 1 person assist despite max assistance given. Patient demonstrated severe posterior lean when attempted to stand. Patient was able to stand with CGA (contact guard assistance) of 2 people. The evaluation showed R1 required the assistance of 2 staff for transfers and standing. On 2/23/26 at 11:16 AM, V7 Certified Nursing Assistant (CNA) stated she was transferring R1, from her wheelchair to the bed, on 1/23/26 when R1's leg laceration occurred. V7 stated, It was my first time taking care of her, so I didn't know how she transferred. I went to stand her up and she started freaking out. She became frantic and panicked which made me anxious, so I just hurried up and got her on the bed. She immediately said her leg was hurting. I pulled up her pant leg and saw a big skin tear. My guess is that her leg got caught on the leg of the wheelchair when I was transferring her. I should have stopped and gotten someone else to help me move her. I should have given her time to calm down. On 2/23/26 at 2:19 PM, V12 Restorative Nurse stated to ensure R1's safety, R1 should be transferred by two staff due to her extreme anxiety and fear of falling. On 2/23/26 at 12:11 PM, V10 Medical Director stated staff are to transfer residents in accordance with the recommendations made by skilled therapy or restorative services. V10 stated his expectation is that residents are not injured while being cared for by staff. 2.R3's care plan dated 11/5/25 showed R3 had history of falls in the facility. R3 was at risk for falls due to her impaired cognition and the paralysis of her right arm and right leg due to a previous stroke. R3 was nonverbal. The plan showed R3 required the use of a gait belt and the assistance of one staff for transfers, standing, and ambulation. R3's fall incident report dated 1/27/26 showed R3 sustained a fall in her bathroom while being cared for by V4 CNA. R3 struck her head on the sink as she fell. R3 complained of right leg pain post-fall. R3 was emergently transported by ambulance to a local hospital for an evaluation. R3's hospital radiology studies were negative for any fractures or injuries. R3 was discharged back to the facility on 1/27/26. On 2/23/26 at 2:04 PM, V4 CNA stated on 1/27/26, she assisted R3 to a standing position, off the toilet, without using a gait belt. V4 stated, When I turned away from (R3) to take off my gloves and wash my hands, she fell to the ground. I wasn't holding onto her at all when she fell.On 2/23/26 at 2:19 PM, V12 Restorative Nurse stated staff are to use a gait belt when transferring R3. The facility's Use of Gait Belt policy dated 10/13/25 showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.

Based on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication administration in the sample of 7. This failure resulted in R1 requiring 1:1 supervision related to increased restlessness and agitation and resulted in R1 not receiving prescribed antibiotics and being readmitted to the hospital with pneumonia. The findings include: R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. R1's October 2025 Physician Order Sheet showed he was admitted with orders for buspirone, alprazolam, Cefdinir, Doxycycline, and furosemide. R1's Care Plan initiated 10/17/25 showed, [R1] has an eye infection, Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment. Instill 1 application in both eyes three times a day for reduce redness, swelling, or itching. Infection will be resolved without complications. Give therapeutic ointments, drops as ordered by physician.R1's October 2025 eMAR (electronic Medication Administration Record) showed R1 missed doses of his antibiotic ointment for his eye infection, Neomycin-Polymyxin-Dexamethasone Ophthalmic Ointment on 10/16/25, 10/17/25, 10/18/25, 10/19/25, and 10/20/25. R1's Care Plan initiated 10/17/25 showed, [R1] has bacterial pneumonia he takes doxycycline and Cefdinir for 4 days. [R1] pneumonia will be resolved without complications. Give medications as ordered.R1's October 2025 eMAR showed R1 missed doses of his antibiotic, Cefdinir on 10/16/25, 10/17/25, 10/18/25 and 10/19/25 (7 doses). R1's Care Plan initiated 10/17/25 showed, [R1] is on diuretic therapy Lasix (furosemide) and Spironolactone related to edema and hypertension. Administer diuretic medications as ordered by physician. R1's October 2025 eMAR showed R1 missed doses of his diuretic furosemide and spironolactone on 10/16/25 and 10/17/25.R1's Care Plan initiated 10/17/25 showed, [R1] uses anti-anxiety medications Xanax (Alprazolam) and Buspirone. the resident will be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Administer antianxiety medications as ordered by physician.R1's October 2025 eMAR showed R1 missed doses of his antianxiety medication, buspirone on 10/16/25, 10/17/25, and 10/18/25 (5 missed doses). The same eMAR showed R1 missed doses of his antianxiety medication, alprazolam on 10/16/25, 10/17/25, 10/18/25, and 10/19/25 (7 missed doses). On 11/25/25 at 10:01 AM, V11 (Facility's Pharmacist) said the first delivery of R1's medications to the facility occurred on 10/19/25 at 3:45 AM. The pharmacy's Packing Slip Proof of Delivery showed the 10/19/25 delivery included R1's following medications: buspirone, doxycycline, and furosemide. V11 said R1's Cefdinir (antibiotic) and Alprazolam (antianxiety medication) was delivered to the facility 10/20/25 at 2:43 AM and R1's antibiotic eye drops were delivered to the facility 10/21/25 at 3:21 AM. On 11/22/25 at 11:15 AM, V4 LPN (Licensed Practical Nurse) said, [R1] was in a really bad state of being. [R1] was mostly nonverbal. He was 1:1 at times due to being very combative. I was told in report that he was in a bed that was low to the floor, he was constantly hitting and kicking, and trying to get ahold of staff but because of his condition he was not very successful with that.On 11/25/25 at 9:21 AM, V7 RN (Registered Nurse) said, [R1] was very anxious, he was combative, and it was very hard to communicate with him and calm him down. They had him on 1:1 due to his agitation, anxiety, and combativeness. He would kick and hit if you got too close. Once the alprazolam and buspirone were onboard, it helped. That is why he was a 1:1, we were contacting the pharmacy constantly telling them we needed these. On 11/25/25 at 12:05 PM, V10 (Previous CNA Supervisor) said, [R1] was 1:1 due to increased behaviors. He was a very high fall risk. He became agitated from time to time. He would yell out and become combative at times. On 11/25/25 at 1:18 PM, V1 (Administrator) said, I started [R1] on the one-on-one supervision because when he first arrived, he was trying to climb out of the chair and out of the bed, I didn't want him to fall and get hurt. He had trouble communicating. I started it for safety. It started the day he came because of him climbing out of everything. R1's Nursing Progress Note dated 10/26/25 at 6:13 PM showed, Resident was sitting up in broda chair next to nurse's station, napping off and on comfortably. No issues. CNA (Certified Nursing Assistant) came to this Nurse stating resident's wife came and took him in his broda chair into his room and was giving him drinks of water while he was lying back in the broda. Upon entering the room this Nurse saw the wife sitting beside resident with a cup of water on the bed stand next to them. The wife/POA began saying how the resident has been coughing all day and that she only gave him water because he was thirsty. This Nurse observed no coughing issues during the 2 hours I was around the resident. POA/wife wanted to call 911 because she knows he has Pneumonia I told her that was her choice if she wanted him to be evaluated. VS taken (blood pressure) 90/60 (Pulse) 64 (Respirations)18 Temperature 97.8 SPO2 88% on room air. Call to 911 was placed. R1's Nurse Progress Note dated 10/27/25 at 1:00 AM showed, Writer called [local acute care hospital] and spoke to ER (Emergency Room) nurse. the resident is admitted for pneumonia.The facility's policy and procedure revised 10/1/25 showed, Medication Errors. Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safety in an environment free of significant medication errors. Medication Error means the observed or identified preparation or administration of mediations of biologicals which is not in accordance with the prescriber's order. Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. c. In accordance with accepted standards and principles which apply to professionals providing services. 4. The facility will consider factor indicating error in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: . Medication omission.

Based on observation, interview, and record review the facility failed to ensure interventions were placed when a pressure injury was identified and failed to ensure treatments and pressure reducing interventions were in place for 2 of 3 residents (R33, R21) reviewed for pressure in the sample of 12. This failure resulted in R33 sustaining a stage 3 pressure injury to her coccyx. The findings include: 1. On 3/3/25 at 10:15 AM, R33 was in bed sleeping. R33's air mattress was deflated, and R33 was laying on the bed frame. The air mattress controller said standby. Heel protection boots were observed in R33's wheelchair in the room. At 10:19 AM, V3 Certified Nursing Assistant came into the room and said the air mattress controller was not supposed to say standby. V3 tried to un-plug and re-plug the unit and the mattress did not inflate. V3 looked at the control unit again and discovered the unit was turned off. V3 turned on the unit, and the mattress inflated. V3 said the mattress needs to be turned on in order to relieve pressure and R33 is supposed to have the heel protection boots on when in bed. On 3/4/25 at 9:46 AM, V2 Director of Nursing said the floor nurses do weekly skin assessments and complete a progress note if there is a skin issue. V2 said the nurses are supposed to do an assessment with measurements, get treatment orders, and alert her if there is a wound. V2 said she checks the documented measurements and makes sure the doctor is contacted for treatment orders. V2 said, if necessary, the wound doctor can see them. R33's Skin/Wound Note dated 2/17/25 at 10:45 PM shows, Resident had shower this evening. Bilateral lower and upper (BL/UL) discolorations. Open sore on coccyx. R33's Skin/Wound Note dated 2/27/25 at 1:49 PM shows Pressure wound to sacrum measuring 2.1 x 1.5 x 0.3 cm [centimeters] found during cares. [V6 Wound Physician] in building and saw resident today. Will admit to wound care services. Area cleaned with wound cleanser. New treatment order from [V6] to cleanse wound with wound cleanser. Apply hydrocolloid sheet BID [twice per day] and PRN [as needed] for 30 days. On 3/4/25 at 1:52 PM, V2 said R33 has a facility acquired pressure injury. V2 said last Thursday (2/27/25) the Certified Nursing Assistants reported it to her after the wound was found while R33 was being changed. V2 said she looked at the wound and V6 was in the building, so she had him see R33. V2 said she was not aware that it was found on 2/17/25 according to the nurse progress note. V2 said the nurses should have notified her and got treatment orders. V2 said R33 has pressure reducing interventions including an air mattress and cushioned heel boots. V2 said the air mattress should be plugged in and the resident should not be laying on a deflated mattress. V2 said R33 should have her heel boots on when in bed. On 3/5/25 at 10:44 AM, V7 Licensed Practical Nurse said she was in training on 2/17/25 and recalled R33's open area but could not recall details of the wound. V7 said she did not take measurements, get treatment orders, or notify V2. On 3/5/25 at 2:25 PM, V6 Wound Physician said he saw R33 for the first time on 2/27/25 and was told they had found the wound that day. V6 said he classified the wound as a stage 3 pressure injury. V6 said his report shows duration of > (greater than) 3 days, which was based on his clinical judgement of how the wound looked to him. V6 said he saw granulation tissue in the wound and it takes more than 48 hours for granulation tissue to evolve, it doesn't show up right away. V6 said he would expect without treatment, a wound would decline further. V6 said a wound would not improve on its own. V6 said lack of treatment and pressure reducing interventions would contribute to the wound worsening. R33's Most recent Braden Scale for Predicting Pressure Ulcer Risk (provided by the facility) dated 7/27/24 shows R33 is at high risk for pressure injury. R33's Initial Wound Evaluation and Management Summary by V6 is dated 2/27/25 and shows, Stage 3 Pressure Wound Sacrum Full Thickness, duration: >3 days, measuring 2.1 x 1.5 x 0.3 cm. Recommendations off-load wound, reposition per facility protocol, group 2 mattress. R33's Physician Orders for February 2025 do not contain wound treatment orders or pressure relieving interventions for R33's coccyx wound until 2/27/25. R33's treatment order were started on 2/27/25 and show, air mattress to bed for proper weight distribution, check every shift and PRN for proper inflation. 40798 2. R21's Wound Evaluation & Management Summary dated 1/23/25 shows R21 has a stage 2 pressure wound of her left, medial buttock (Site 10) with a duration greater than three days measuring 3.6 centimeters (cm) by 1.9 cm by 0.1 cm and is to receive wound treatment three times a week for 30 days. R21's Wound Evaluation & Management Summary dated 1/30/25 shows R21's Stage 2 pressure wound (Site 10) had increased in severity to a stage 3 pressure wound measuring 11.2 cm by 6.7 cm by 0.2 cm. R21's Treatment Administration Record (TAR) for 1/1/25 through 1/31/25 does not show any treatment scheduled for R21's pressure ulcer of her left, medial buttock. R21's current Order Summary Report for 1/20/25 through 3/31/25 and Order Summary Report for 1/20/25 through 3/31/25 for discontinued orders both show there are no orders for wound treatment of R21's pressure ulcer of her left, medial buttock from 1/23/25 through 2/5/25. On 3/4/25 at 1:52 PM, V2, Director of Nursing and Wound Care Nurse, said R21's pressure ulcer of her left medial buttock was identified when she was doing wound rounds with the Wound Care Physician, V6. On 3/5/25 at 10:19 AM, V2 said V6 does his progress notes of each resident wound right away after his wound rounds on Thursdays. V2 said she accesses V6's progress notes (Wound Evaluation & Manage Summary) and enters his treatment orders into their computer system and treatment orders are started the next day. On 3/5/25 at 2:22 PM, V6 said he would expect a wound to worsen/decline if wound treatment is not being provided. The facility's Assessment of Skin Alteration Policy dated 11/2017 shows residents with skin alteration will be assessed and treatment will be provided as ordered by the physician.

Based on observation, interview, and record review the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a left leg laceration requiring 29 sutures. The findings include: The facility's Reported Incident Final dated 12/29/23 shows on 12/27/23, R1 sustained a skin tear to left lower extremity. Per staff interviews on file, it was noted resident was being assisted by 2 Certified Nursing Assistants (CNA) from wheelchair to bed using a mechanical lift. During the transfer resident was noted to bump leg on wheelchair. On 1/3/24 at 9:15 AM, R1 was sitting up in a reclining wheelchair in her room. R1 had padded protection sleeves on both arms and lower legs. V4 CNA rolled the padded sleeve down on R1's left lower leg. R1 had a gauze bandage covering her left lower leg. R1 stated I had 29 stitches. It hurts still. I can tell there is something there. V4 said she and V5 CNA were transferring R1 from her bed to the wheelchair and they bumped R1's leg on the wheelchair. V4 said R1 had the sleeves on her legs at the time. V4 said they were in the process of lowering R1 into the wheelchair when R1 said ouch! V5 entered the room, joined the conversation, and said when R1 said ouch, they finished lowering her to the wheelchair and then rolled down the protective sleeve. V5 said there was a large piece of skin hanging with fresh bright red blood dripping. V5 said the skin tear was very large and was more long than wide. V4 and V5 said they got the nurse right away. R1 said she remember saying ouch when being transferred but didn't remember what her leg bumped. On 1/3/24 at 9:34 AM, V3 Registered Nurse lowered R1's protective sleeve on her left leg. V3 removed the gauze dressing. R1's left lower shin contained a large uneven laceration with visible sutures. R1's wound had sutures visible along the edges where R1's skin flap was secured back in place. R1's wound was red with some open areas that appeared moist. R1 complained of soreness during the dressing removal and change. V3 said R1 had picked out some of the sutures herself and was scheduled to have the sutures removed after 10 days. V3 said R1's laceration happened during a transfer with the mechanical lift. R1's Hospital Emergency Department Physician Note dated 12/27/23 shows Patient has a laceration to her left distal shin. Patient is bed bound, injured while on mechanical lift at facility. Laceration is 6 centimeters in length. Shape: irregular, flap. Skin closure: 29 sutures, simple technique, interrupted technique. The same paperwork shows R1 was prescribed tramadol 50 mg twice daily for pain. The facility's witness statement from V4 dated 12/27/23 shows shortly after 3 PM, this CNA and another CNA (V5) used the mechanical lift to transfer R1 into her reclining wheelchair. During the transfer residents left leg hit side of chair. R1 said ouch my leg. After we lowered her into chair, V5 pulled down leg sleeve then noticed skin. Nurse was then notified. The facility's witness statement from V5 dated 12/27/23 shows shortly after 3 PM went to check and change resident, when done transferred her into the reclining wheelchair and her leg hit the side of the wheelchair. The resident said ouch. We proceeded to lower her into the chair. When resident was safely in her chair, I pulled down the leg sleeve and noticed a skin tear and notified the nurse. On 1/3/24 at 10:24 AM, V1 Administrator said the investigation revealed that R1's injury happened during the transfer when her leg hit the side of the wheelchair. The facility's Limited Lift Resident Handling Policy and Procedures shows purpose: to ensure that employees use safe resident handling and movement techniques for tasks that are designated as high-risk for safe resident handling and movement injuries.

Based on observation, interview and record review the facility failed to assess and monitor a resident (R7) with a history of pneumonia showing a change in condition. This failure resulted in R7 being admitted to the hospital in poor condition. The facility also failed to correctly apply elastic bandages to a resident (R29) with lower extremity edema. This applies to two of two residents (R7 and R29) in the sample of 12 reviewed for quality of care. The findings include: 1. The Physician Order Sheet (POS) for R7 shows diagnosis to include anemia, coronary artery disease and chronic obstructive pulmonary disease. The POS shows orders for oxygen at 2-4 liters via a nasal cannula as needed to keep the oxygen saturations above 90%. The facility assessment dated [DATE] shows R7 to be cognitively intact. On 5/23/23 at 9:21 AM, R7 was observed being taken from the bathroom by staff and placed in her wheelchair. R7 immediately fell asleep, and her breathing sounded congested. R7 would wake up when her name was said but would immediately fall back to sleep. R7 had an oxygen concentrator in her room but it was not being used. At 9:30AM, V3 Licensed Practical Nurse (LPN) was asked about R7's current condition and V3 said R7 has been like this lately due to her medications being changed. On 5/23/23 at 10:16 AM, R7 continued to sit in her wheelchair in her room asleep, leaning over to the right, with her right hand hanging down. R7's breathing sounds congested, and she was coughing. On 5/23/23 at 10:44 AM, R7 was still in her room asleep in her wheelchair, both hands are hanging down by her side. On 5/23/23 at 11:48 AM, R7 was moved to the dining room leaning over to the right, still sleeping, hands hanging down. The staff and other residents were saying her name and she would wake up for a very short period and immediately fall back to sleep. R7 was spilling her lunch on the floor. R7 could be heard coughing at times. At 12:48PM, R7 had been pushed into the activity room and was still asleep in her wheelchair with her hands hanging down by her side and leaning to the right side. At 1:16 PM, R7 was still in the activity room, asleep in her wheelchair. On 5/23/23 at 1:20PM, R7 was pushed down the hall by 2 Certified Nursing Assistants (CNA). One CNA was pushing the wheelchair and the other was holding her legs up. V3 came into R7's room and checked her blood pressure and oxygen saturations. V3 applied the oxygen nasal cannula to R7 and was observed adjusting the oxygen and rechecking her oxygen saturations. V3 left the room and returned with a oxygen mask which she then applied to R7 and continued to check R7's oxygen saturation. V3 left the room again and returned with a nebulizer treatment for R7. V3 said she had notified the Nurse Practitioner for a chest x-ray order. R7 continued to have a difficult time staying awake and following commands. On 5/23/23 at 1:55 PM, R7 was in bed asleep, and her oxygen is set at 8 liters using the mask. R7 was observed using her abdominal muscles to breath. On 5/23/23at 2:59 PM, R7 was asleep in bed with her oxygen at 8 liters per mask, using accessory muscles to breath. On 5/24/23 at 8:00AM, R7 was not in her room. R7's medical record shows a note dated 5/23/23 at 3PM by V3 that R7 was having a hard time staying awake, was lethargic and slept through lunch. V3 documented that R7's oxygen saturation was 81% and she had started oxygen at 6 liters via a mask. V3 wrote she had contacted the NP and an order was received for a chest Xray and cough syrup. The note also shows a nebulizer treatment was completed and R7's saturations went up to 91% on 6 liters of oxygen. No further nursing notes were made by V3 that day for R7 regarding her change in condition. On 5/24/23 at 9:15 AM, V5 NP said she would have expected the nurse on duty to intervene and assess her earlier in the day since you informed her of the lethargy, cough and congestion. V5 said earlier intervention does have better outcomes. On 5/24/23 at 1:53 PM, V7 CNA said R7 does act more tired in the morning and will fall asleep quickly but yesterday was different, she spilled food on her for breakfast and for lunch. She usually [NAME] up after breakfast but yesterday she did not. That was different I told the nurse she was acting differently that day. On 5/25/23 at 8:17 AM, V6 LPN said she was the nurse who sent R7 out to the hospital. V6 said she was told in report at 6 PM that R7 was very sleepy, her oxygen saturations were in the 70's and was having a hard time breathing, hard to arouse. When I went in around 8PM to give meds, her skin was gray, she was having a hard time breathing and was hard to arouse, she would not take her meds, she was short of breath and had crackles in her lungs and was spitting up green sputum. V6 said she called the NP and was told to send her to the emergency room . V6 said she later called the hospital to check on R7 and was told she had to be transferred to another hospital for high flow oxygen. On 5/25/23 at 9:54 AM, V3 said when this surveyor approached her about R7, she felt it was just the usual behavior for R7. She did not feel the need to go check her. V3 said when she saw the CNA's bring her down the hall holding up her feet, she decided to go check her. Her oxygen saturations were 71 % at that time. V3 said she started the oxygen and gave R7 a breathing treatment and notified the NP that R7 was unresponsive, had low oxygen saturations and was coughing. I received an order for a chest x-ray and cough syrup. V3 said R7 had just had pneumonia last month and getting a chest X-ray was standard protocol for shortness of breath. The nursing progress notes for R7 shows V6 documented at 8PM that R7's color was gray, she was very lethargic, short of breath and R7 could not tell V6 where she was. R7 was coughing up green phlegm. The chest X-ray report came back showing R7 had pneumonia. The NP was notified and R7 was to be sent to the emergency room . There were no nursing notes showing R7 was monitored or assessed between 3 PM and 8PM on 5/23/23. The emergency room note from the local hospital R7 was first sent to shows R7 was brought to the hospital by ambulance for shortness of breath and pneumonia. The note shows the report they received from the nursing home was R7 had been short of breath that day and her oxygen saturations were in the 70's and that no call had been made earlier for a patient evaluation. R7's temperature was recorded as 100.7 and oxygen saturations were 86%. The note also shows R7 was transferred to another hospital in poor condition. The records for R7 shows a COBRA transfer record to send R7 to another hospital for a higher level of care due to her unstable condition. The hospital notes from the second hospital R7 was sent to shows a plan to treat her bilateral pneumonia, respiratory failure and sepsis. The X-ray obtained at the facility dated 5/23/23 showed a right basilar pneumonia. R7's facility care plan shows for chronic obstructive pulmonary disease (COPD) with interventions to include: instruct and monitor for early signs of COPD exacerbation such as confusion or excessive sleepiness, shortness of breath and coughing. The facility policy with a revision date of 12/7/17 for notification for change in resident condition or status shows the facility shall promptly notify appropriate individuals such as NP or the residents attending physician when there has been a marked change in relation to usual signs or symptoms. 2. On 5/23/23 at 9:35 AM, V3 was observed doing wound care on R29. R29's both lower leg were edematous and discolored. V3 wrapped R29's legs with ace wrap for his edema. V3 started at the knee and wrapped the ace wrap down to the toes. On 5/25/23 9:00AM, V2 LPN said when wrapping a residents lower legs, always start at the bottom and work your way up. On 5/25/23 at 9:11 AM, V4 Registered Nurse (RN) said when wrapping ace wraps to a residents legs for edema, always start at the bottom and work your way to the top to promote venous return. On 5/25/23 at 2:00PM, V11 Wound Physician said to promote venous return to lower legs for edema, always wrap from the toes to about 2 inches below the knees. The Physician Order Sheet (POS) for R29 shows diagnosis to include hypertension and type 2 diabetes. The POS shows an order for ace elastic bandages to affected areas daily. The care plan for R29 shows alteration in circulation to both lower legs and causing stasis ulcer/wounds. The facility stated they had no policy for application of elastic bandages.

Based on observation, interview, and record review, the facility failed to ensure a resident's (R8) safety by having only one staff member in the room while a resident with dementia and a history of falls was sitting on the edge of the bed for 1 of 2 reviewed for falls in the sample of 12. The staff member turned to get clothing for the resident and the resident fell off of the bed. This failure resulted in R9 hitting her face during the fall and being sent to a local hospital with multiple facial fractures. The findings include: R9's 12/7/21 facility assessment showed she had moderate cognitive impairment with long-term and short-term memory problems. The assessment showed R9 required extensive assist from two staff members for bed mobility and transfers. R9's Profile Face Sheet, provided by the facility on 7/28/22 showed she had diagnoses including repeated falls, abnormality of gait and movement and weakness. R9's July 2022 Physician's Orders sheets also showed a diagnosis of dementia. R9's activities of daily living (ADL) care plan provided by the facility on 2/28/22, showed R9 had an alteration in bed mobility: Unable to move independently in bed related to diagnosis of obesity, and dementia, as evidenced by confusion. The care plan showed R9 had severe dementia and is unable to make needs known to staff. The ADL care plan also showed R9 required two staff assist for transfers. R9's fall care plan interventions started on 8/24/20 showed Resident has been known to attempt to get out of bed unattended. On 7/27/22 at 1:05 PM, R9 was transferred from her geriatric chair to her bed with the assistance of two staff members (V20 and V21/Certified Nursing Assistants-CNAs) using a gait belt and two wheeled walker. V20 and V21 rolled R9 onto her right side to provide incontinence care. R9 seemed anxious and let out a yell when she was rolled near the edge of the bed. R9's Nurse's Notes dated 1/1/22 at 5:30 AM, showed CNA with resident assisting resident to get up for the day. CNA turned to get her socks. Resident sitting on the side of the bed, stood up and fell hitting the left side of her face causing laceration contusion. Pressure held to resident's face with wash cloth. CNA and nurse got resident off of the floor with (mechanical sling lift). Put resident in bed .Nurse and CNA trying to look at resident's face. Resident resisting. Pulling away and swatting at Nurse and CNA's hands. Day Nurses and CNA's to be on the floor in 5-7 minutes. Nurse attempted to continue to look at resident's face. R9's Nurse's Note dated 1/1/22 at 6:00 AM showed This Nurse arrived for shift at this time received report from night shift Nurse that resident had fallen out of bed obtaining a laceration to cheek and was unable to properly assess area due to bleeding and resisting. Gauze currently in place to slow bleeding. Resident lying supine in bed at this time .Removed gauze dressing to assess area on left cheek. Observed large deep laceration with surrounding swelling and bruising beginning. Area still bleeding but has slowed. Immediately called 911 for ambulance transport to ER (emergency room ) for evaluation and treatment of laceration/contusion to left cheek. R9's documentation from a local hospital dated 1/2/22, showed CT (computerized tomography) scan of the facial bones is reviewed, which demonstrates a displaced left zygomatic arch (the side of the cheek bone) fracture, and a minimal mandibular coronoid process (jawbone) fracture, and a non-displaced left orbital floor fracture. R9's Nurse's Note dated 1/3/22 showed Patient arrived at facility at (7:00 PM) via ambulance .Swelling noted to left side of face along with 5 stitches closing laceration. Patient states she was in pain. On 7/28/22 at 9:15 AM, V3 (MDS/Care Plan Nurse) said R9 was sitting on the edge of the bed. The CNA turned to grab clothes and R9 fell . V3 said the CNA could not catch her. V3 said the cause of the fall was the CNA turned to grab clothes. On 7/28/22 at 11:32 AM, V2 (Director of Nursing) said the cause of R9's fall on 1/1/22 was the CNA was not following R9's needs. She left her sitting on the edge of the bed and then turned away. V2 said R9 was a two assist and there was only one staff member in the room. There should have been another staff member in the room. Someone should have been by R9 at all times when she was sitting on the edge of the bed. V2 said the CNA could have gathered supplies beforehand or put R9's socks on in bed before getting her up. The facility's policy and procedure titled Fall Prevention, with a revision date of 9/3/15 showed Fall Prevention Interventions: 11. Transfer with proper number of assist and gait belt.

Based on observation, interview, and record review, the facility failed to have fall prevention interventions in place and failed to safely transfer residents with a gait belt for three of five residents (R23, R8, R21) reviewed for falls in the sample of 12. This failure resulted in R23 falling onto the floor and sustaining an impacted left femoral neck fracture requiring surgery. The findings include: On 09/14/21 at 09:58 AM, R23 was resting in bed with his eyes closed. The right side of his head adjacent to the eye and upward was bruised. There was a small band aid to the top of his head on the right side. R23 did not respond when spoken to. On 09/14/21 at 11:07 AM, V6 Certified Nursing Assistant (CNA) and V7 CNA were preparing to transfer R23 from the chair to bed. There were steri-strips to R23's right hand and a 4 inch X 4 inch padded dressing to the top of the head posteriorly. V7 placed a gait belt around R23's waist. V6 and V7 lifted R23 under his arms and lifted R23's full body weight during the transfer. R23's feet slid across the floor during the transfer as R23 did not bear any weight to his legs. At 11:34 AM, V6 and V7 entered R23's room with a total mechanical lift to transfer R23 from the bed to the chair. This surveyor asked V7 why a lift was being used this time and V7 said because you were concerned about him not bearing weight. There was a dressing in place to R23's left hip. R23 cried out in pain when being turned from side to side in bed and yelled Jesus Christ. On 9/14/21, V3 Licensed Practical Nurse (LPN) said when R23 fell on [DATE] she heard the fall from the nurse's station. When she got to R23's room he was laying on the floor. On 9/15/21 at 12:26 PM, V2 Director of Nursing (DON) said a resident's care plan tells you how much assistance a resident requires for transfers. V2 said If a resident can't bear weight, they should be a mechanical lift (total mechanical lift). R23 was to be weight bearing as tolerated (on the left leg). R23 used a total mechanical lift as needed. On 09/16/21 at 08:35 AM, V11 CNA said, the morning of 8/20/21, me and V3 Licensed Practical Nurse heard R23 fall. We were at the nurses' station. We heard him hit the floor so me and V3 ran in there. R23 was laying on his right side next to the bed. Prior to that he was in bed. He was bleeding from the back of his head and complained of pain to the right leg. There were no alarms on and the floor mat was not in place. The floor mat was on the other side of the room. On 9/16/21 at 9:38 AM, V13 Nurse Practitioner said she expects fall prevention interventions to be in place if they are indicated. R23's alarm wouldn't have prevented his fall but if R23's fall mat had been in place it could have lessened the injury. R23's fractured hip was caused from the fall to the floor. R23's face sheet showed admission to the facility on [DATE]. R23's 5/10/21 nurses note showed he was found on the floor in his room lying on his back. R23's 5/12/21 care plan intervention showed to use a chair/bed pressure alarm. R23's 8/3/21 fall care plan showed the resident has been known to attempt to get out of bed unattended, mat on floor. Resident has dementia and poor safety awareness. He is confused and unaware of safety limitations at times. The facility's 8/26/21 incident summary showed on 8/20/21 at 6:20 AM, V3 Licensed Practical Nurse and V11 CNA heard a noise come from R23's room and R23 was found on the floor next to his bed. R23's 8/20/21 CT scan of the left lower extremity showed an impacted left femoral neck fracture. R23's 8/21/21 post op left hip x-ray showed recent left hip arthroplasty hardware intact. During the survey, there was a poster on the wall in the staff bathroom that showed- Always ask yourself, is this the safest transfer for our resident? Can't bear weight for 5 seconds or more? Get a lift! Safer transfers for residents are safer transfers for caregivers. R23's local hospital history and physical showed the patient was found on the ground and is a known total mechanical lift patient. The patient has not ambulated for some time. He has no history of recent hip fractures. The patient did not receive any pain medications or anything else when he fell , he was just transferred here to the hospital. A CT of the left lower extremity showed an impacted femoral neck fracture and a large joint effusion (fluid accumulation). He has some scalp abrasion and a skin tear on his scalp. R23's 8/24/21 local hospital discharge summary showed the patient had an unwitnessed fall at the facility and injured his left hip. The patient underwent a left hip hemiarthroplasty (partial hip replacement) R23's 8/28/21 facility assessment showed R23 was not cognitively intact and was dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. This assessment showed no unhealed pressure injuries. This assessment showed R23 was not steady and only able to stabilize with staff assistance for surface to surface transfers. An 8/24/21 intervention showed extensive assistance of two with gait belt or total mechanical lift for transfers. R23's 9/13/21 continence care plan showed antibiotic therapy for infection to left hip surgical site. R23's physician order sheet showed a 9/13/21 order for antibiotics every six hours for 10 days. The facility's 11/10/18 Fall Prevention Policy showed the purpose of the policy was to provide for resident safety and to minimize injuries related to falls. Appropriate interventions will be implemented for residents determined to be at high risk. The facility's 10/30/08 Mechanical Lift Policy showed the mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel. 2. The September 2021 POS shows R21 was admitted on [DATE]. The 5/18/20 care plan documented R21 to have impaired physical mobility and was to be transferred using 2 staff and a gait belt for all transfers. On 9/15/21 at 9:00 AM, V8 and V9 CNA's (Certified Nursing Assistants) assisted R21 to her room to place her in bed. V8 placed a gait belt around R21's waist, with staff on both sides, V8 placed her arm under R21's left under arm and with her right hand grabbed the waist band of R21's pants and pulled R21 out of her wheelchair. R21 was not able to bear weight during the transfer and she was moved from her wheelchair to the bed with only her toes sliding across the floor. After the transfer, V9 said R21 really does not stand, but she has always been a gait belt transfer. A facility safety poster about safe transfers reads Can't bear weight for five seconds or more? Get a Lift! Safer transfers for residents are safer transfers for caregivers. 3. On 9/15/21 at 9:18 AM, V5 and V8 placed a gait belt around R8's waist. V8 pulled up under R8's arm and with her right hand, she grabbed the back of R8's pants and pulled her up out of the wheelchair. On 9/15/21 at 12:41 PM, V2 DON (Director of Nursing) said the gait belt is used to assist them to transfer a resident, not to completely lift them. Staff should never be using the waist band of the pants or under the arm to lift a resident. R21 should be a mechanical lift if she does not bear weight during a transfer. The facility's 12/17/12 policy for transfer belt/ gait belts documents 7. Monitor the resident during transfers for C. Inability to participate in transfer. D. Anything that is not normal for the way the resident usually transfers. 8. Report any changes in resident's performance during transfers to the charge nurse.

Based on interview, and record review the facility failed to prevent non-consensual sexual contact between two residents. This failure resulted in R2 experiencing non-consensual contact by R1. This applies to two of two residents (R1 & R2) reviewed for sexual abuse in the sample of ten. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on May 10, 2021 when R1 went through a connecting bathroom and avoided using the hallway to get into R2's room. R1 went into R2's room and fondled R2's penis. The Immediate Jeopardy was identified on May 20, 2021. V1 Administrator was informed of the Immediate Jeopardy on May 21, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on May 22, 2021; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The 5-Day Final Report dated 5/10/21 for R1 and R2 showed, Summary: It was reported to the Administrator that R1 had alleged inappropriate contact with R2. Witness: V9 CNA (Certified Nursing Assistant) states that she walked in and witnessed R1 touching R2 inappropriately. R2 giggled when he saw her. She immediately left the room and got the nurse. Witness: V7 LPN (Licensed Practical Nurse) states that she was alerted that R1 was in R2's room. When she went into the room and asked, What are you doing? she observed R1's hand touching R2's private area in the front of his pants. R1 was immediately removed from the room and put on a one on one. On 5/20/21 at 9:24 AM, R2 was sitting in his room in a high-backed wheelchair. When the interview with R2 started, he was asked a question and would only respond with a laugh/giggle. Eye contact and louder tone of voice was used to ask R2 questions; he then responded to the questions and did not just giggle as a response. R2 was asked what happened and he said, Nothing. R2 was asked if R1 came into his room he stated yes. R2 was asked if R1 touched him and he said yes. R2 stated he was okay with R1 touching him but not in the private area. R2 stated it made him upset that R1 touched him in the private area. R2 did not remember telling R1 that it was okay for him to touch him. R2 dropped his head, avoided eye contact, appeared tearful and stated it was embarrassing to talk about what happened with R1. On 5/20/21 at 11:21 AM, V3 CNA (Certified Nursing Assistant) stated, If I am showering R1 he is focused on excessive peri-care. I will do his peri-care and he will keep asking for it. R1 wants me to clean his peri area over and over, specifically his penis. The other day I had the hiccups and he said it makes your boobs grow. V3 stated that she has never seen R2 with any sexual behaviors or even hint at it. R2 is confused and has [CONDITION(S)]. On 5/20/21 at 11:28 AM, V4 CNA stated, R1 will make inappropriate sexual comments. Sometimes he will try to touch you inappropriately especially in the shower. When I gave him a shower before he tried touching my boob. One time when I was washing his feet he asked me if I saw his penis and if I looked at it. At breakfast on 5/20/21, I had him follow me to the dining room, he seemed confused. I started to take him to a farther away table in the dining room and they said it was not where he was supposed to sit. I talked to my nurse and she said I was right to sit him there. R1 then said to me, They are afraid I am going to touch him (R2) again. R1 can propel his wheelchair and he can walk with a walker pretty good. V4 stated she has never known R2 to have any sexual behaviors or inappropriate comments. On 5/20/21 at 12:22 PM, V2 DON (Director of Nursing) stated, R1 makes inappropriate comments. Staff have said when they give him a shower that he has said they can wash down there a little bit more. R1 masturbates in his room. Aside from the incident (5/10/21) that took place it has never been beyond those things. We notified R1's son of what happened and I think this is something they knew about. R1's son made some comments about finding pornography at his dad's house. They didn't share that with us before admitting R1. I don't know if he has ever touched another resident before. I moved R1 because he had a roommate that couldn't speak up for himself and R1 would masturbate. I felt the other resident would be safer out of the room. I did that 2-3 months ago. I moved him again after the incident so R1 and R2 wouldn't share a bathroom. R1 was moved to the far corner room by himself with no shared bathroom. He already had delusions care planned but I am not sure if the care plan was updated for sexually inappropriate behaviors. I was here when it happened V7 LPN told V9 CNA to come and get me. V7 met me in the hallway and told me what happened. She said the CNA's came and got her and said R1 had his hands on R2's penis. As soon as she opened the door R2 put his penis away. R1 was moved the same day of the incident and put on 1:1 monitoring as well as every 15-minute checks. V2 stated R2 is [CONDITION(S)] and talks to himself. R2 has delusions but he is not sexually inappropriate. R2 is confused but he has periods where he is more alert than others. On 5/20/21 at 1:18 PM, R1 stated, I was a naughty boy. I went into another resident's room and I was fondling our privates. The nurse came in and saw that. I have been a naughty boy since. We had adjoining rooms. I could go into his (R2) room without going into the hall. This one incident took place. We are not in a relationship; we were friends but not no more. He doesn't want to be around me because of what happened. I was punished but he wasn't. I touched him and he never told me to stop. He didn't seem upset. The administrator thinks I have Alzheimer's and that I fantasize about things that are happening. I went into the bathroom and then into his bedroom in the next room. I was fondling his organs and he touched me but not as bad as I touched him. I initiated the contact. I thought we were friends but he doesn't want to talk to me anymore since this happened. On 5/20/21 at 2:49 PM, V7 LPN (Licensed Practical Nurse) stated, I was getting the medication pass ready and R1 had returned from an appointment 10-15 minutes prior. V9 CNA was in a panic and said to come here, I need you to see this. I followed her to R1's room and when I got there the door was open. R1 was in a wheelchair and I thought he was giving R2 oral sex because R1 was bent over. I stepped in and could see what was going on. I startled them both. R2 put his privates in his pants and I removed R1 from the room. R2 was just sitting there. They were talking like nothing was happening and R1 was doing this to R2. R2 had his hands on the wheelchair arm rests. From what I saw it was all R1; he had his hand in R2's brief. R2 seemed embarrassed. R2 said R1 entered his room through the bathroom. R2 is confused, has delusions and hallucinations. They were talking and R2 did this little laugh but he does that when he can't hear you. R1 was talking real low so I know R2 couldn't hear him so he did his nervous little laugh that he always does. R1 has confusion off and on but for the most part he is with it. He can tell you his medications and doctors. He has episodes that they think are seizures. R1 is alert and oriented. He actively masturbates. On 5/20/21 at 3:02 PM, V13 (Social Service Director) stated, There are no behavior sheets for R1. He doesn't have any [CONDITION(S)] medications to warrant any behavior sheets. The nurses chart behaviors in their notes. Our regional director wanted our behavior logs to match our medication lists. R1 has been masturbating since he got here. R1 would masturbate and then call the CNA's in to clean him up and the aftermath. I went and talked to him and told him it was his right but he could clean up afterwards and supplies would be given to him. I haven't heard anything after that. After the incident with R2, I heard R1 was going into other rooms. They told me there was a room change and that I needed to change the room sign. R1 had another room change previous to this; R10 was his previous roommate. R1 is very smart. He is intelligent and definitely knows the system. He was a nursing home administrator in the past. R1 masturbates a lot. When he first came in he made inappropriate comments. He made one to the occupational therapist. She was trying to get socks out of his drawer and he said he would let her get into his drawers. I have never seen R2 be inappropriate or otherwise say anything sexually inappropriate. R2 stays to himself and is pretty quiet. On 5/20/21 at 3:46 Pm, V9 CNA stated, We do get up at 4:00 PM for supper. I walked into R2's room because the door was shut. R1 had his back to the door and R2 had his pants down. I saw R1 touching R2's penis. I went and got the charge nurse and she went into the room. R1 has behaviors and has made some comments towards us girls. He has never tried to touch me. R1 is alert and oriented most days. R2 is not alert and oriented. On 5/20/21 at 3:55 PM, V2 DON stated, V14 NP (Nurse Practitioner) started him on the Depo [MEDICATION(S)] injection. I originally called her about his behaviors of masturbating and comments to staff and she said she wanted to start him on [MEDICATION(S)]. Then the incident with R2 happened and I requested the Depo [MEDICATION(S)] injections. On 5/20/21 at 3:58 PM, V1 (Administrator) stated, We don't have a policy on behavior tracking sheets and we only track behaviors for residents on [CONDITION(S)] medications. I will ask for a policy on behaviors. On 5/20/21 at 4:01 PM, V2 DON stated, The every 15 minute check sheets were initiated on 5/18/21. Prior to that they were documenting in the nurse's notes. Our regional director said to initiate the every 15-minute check sheets on 5/18/21. Prior to that R1's chart was placed in the hot rack to be documented on every shift. R1's Nurses Notes showed he arrived at the facility on 12/30/20 and was alert and oriented x 4 (to person, time, place and situation). There were no documented behaviors of masturbating or inappropriate comments to staff in his nurse's notes from admission to 5/2/21. R1's Nurses Note's showed, 5/2/21 - R1 was witnessed today going into other resident's rooms without their permission. At this time, witnessed R1 tickling another resident's feet. Again educated the resident that he cannot touch another resident or invade their personal space. R1 became agitated, yelling and using foul language towards this nurse; 5/10/21 - Entered a resident's room and observed R1 and another resident partaking in inappropriate behaviors; 5/11/21 - R1 came out into the hallway in his wheelchair and began to enter another male resident across the hallways room. I spoke with the resident and explained we are not going to do visits tonight so please let me help you back to your room. R1 began yelling and stated I can go in any room to visit anytime I want; 5/13/21 - CNA was ensuring R1's alarm was on. R1 asked what the CNA was doing, and the CNA told R1 who replied, Are you going to turn me on next?; 5/15/21 - R1 in wheelchair at nurse's station requesting to go into another resident's room to look for his rings. Explained to resident hat he is not allowed into other resident's rooms. R1 stated the resident took his rings. The other resident is immobile and made R1 aware that he (other resident) would not be able to steal rings. R1 became agitated stating he will just call the cops. Unaware of what rings R1 is referring to and made him aware that we would keep a look out for them possibly in his room; 5/18/21 at 1:00 PM - R1 made an inappropriate comment to the CNA this AM. The CNA had the hiccups and R1 stated to the CNA, You have hiccups because your boobs are getting bigger; 5/18/21 at 7:20 PM - This nurse outside of R1's room in the hallway and noted R1 saying to the CNA as she was getting him ready for bed, She wants me to strip now. I am ready for a date now; 5/19/21 - This nurse was passing pills to R1 and he states, R10 is looking for a man. This nurse asked R1 why R10 would be looking for a man. R1 stated you know why. R1's Social Service Progress Notes dated 1/19/21 showed she met with R1 and discussed him masturbating and then asking staff to clean up after. There were no additional Social Service Progress notes showing behaviors for R1. R1's Care Plan dated 1/13/21 that was reviewed by the facility again on 4/8/21 showed, Resident is known/history of displaying inappropriate behavior and/or resisting care/services. Specific behavior exhibited - inappropriate sexual comments. R1 on occasion will make inappropriate comments to staff. Initiate behavior monitoring program to attempt to identify patterns, precursors, and causes of behavior and to attempt to understand the behavior. Help resident to understand why behavior is inappropriate/disruptive and the impact it has on personal well-being and the well-being of others. The facility did not have a behavior monitoring program in place for R1. The Care Plan for R1 was not updated after the incident on 5/10/21 with R2. There weren't any new interventions put in place for sexually inappropriate behavior on R1's current care plan. The Every 15-minute check sheets for R1 showed they were started on 5/18/21; eight days after the incident on 5/10/21. The Cognitive assessment dated [DATE] for R1 showed a score of 13; 13-15 is cognitively intact. The Cognitive assessment dated [DATE] for R1 showed a score of 11; 8-12 is moderately impaired cognition. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Nurses Note's from 1/23/21 to 5/9/21 showed no documentation of sexually inappropriate behaviors or comments. R2's Care Plan dated 3/7/21 showed, Impaired cognition as related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's sentences are not always fluid, and do not always make sense to the current situation of R1 will laugh when asked questions; Self-care deficit needs supervision and/or assist to complete quality care and/or poorly motivated to complete ADL (activities of daily living). Related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is known to have/has history of hallucinations and/or delusions. Specific delusions described emotional delusions of persecution that others are out to get him. The Facility's Abuse Prevention Program policy (11/28/16) showed, The facility is committed to protecting our residents from abuse by anyone including: but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Sexual abuse is non-consensual contact of any type with a resident. The Immediate Jeopardy that began on May 10, 2021 was removed on May 22, 2021 when the facility took the following actions to remove the immediacy: 1. Education: The Regional Clinical Director, reeducated the Director of Nursing and Administrator on the Abuse and Neglect policy with a specific focus on sexual abuse and what constitutes sexual abuse, how to manage escalating behaviors, abuse reporting and procedures to be taken when suspected abuse is reported, which includes immediate investigation to be initiated on May 21, 2021 at 11:30 AM. The Director of Nursing /Administrator to in-service all staff before their next scheduled shift on the Abuse and Neglect policy with a specific focus on sexual abuse and what constitutes sexual abuse, how to manage escalating behaviors, abuse reporting and procedures to be taken when suspected abuse has occurred which includes immediate investigation to be initiated May 21, 2021 at 12:00 PM and will be completed by May 22, 2021 at 5:30 PM. 2. Incident follow up: The facility licensed staff completed an assessment for any evidence of injury/ distress on May 10, 2021 at 4:30 PM and none was noted by licensed staff for either resident R1 or R2. R1, the alleged perpetrator, was placed on 1 on 1 monitoring since notification of alleged incident on May 10, 2021. On May 10, 2021 at 545 PM, R1, the alleged perpetrator, was moved to a private room with the adjoining bath/ bedroom that was unoccupied and is to remain empty. On May 21, 2021 at 2:19 PM, the MDS (minimum data set) coordinator updated R1's care plan to reflect the measures the facility took to prevent a reoccurrence of non-consensual sexual behavior by R1. The Social Service Director completed an audit of BIMS (brief interview of mental status) scores of all residents to assist in determining vulnerable residents to ensure that no vulnerable residents reside in a room nearby R1. The Physician / NP (nurse practitioner) completed medication review on May 10, 2021 at 5:10 PM for possible changes needed to medications. 3. System: The IDT team will meet and discuss during morning meeting items related to: Abuse and neglect policy, and new admissions vulnerability will be discussed prior to accepting to new admissions to facility, including an ongoing plan to ensure all resident safety from non-consensual sexual advances. This will be accomplished by proper safe room placement, and continued monitoring of R1. Continuing education will be provided annually and PRN (as needed) post any alleged incident 4. QA: The DON/designee will conduct rounds daily to monitor for compliance of proper education of abuse and neglect policy of all new hires, current staff knowledge related to abuse and neglect policy, as well as review of proper staffing, and monitoring for R1. The DON and IDT team will review weekly behavior tracking documentation for all residents with behaviors to ensure that proper Behavior tracking is in compliance which will allow the team to immediately note a pattern or trend as well as any escalation in behaviors. If a pattern or trend is noted the IDT team will immediately educate staff of any potential escalation as well as newly observed behaviors and interventions will be immediately put in place to ensure safety of all residents. These rounds will continue daily for four weeks and then will be followed by random review to maintain compliance. Ad hoc education will be given immediately to staff during such round.

Based on observation, interview, and record review, the facility failed to provide care in a safe manner to prevent a resident from sliding out of a shower chair. This failure resulted in the resident having bilateral femur fractures requiring surgical intervention. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's February 21, 2017 discharge summary from a local hospital shows she was admitted on [DATE]. The hospital order form shows the reason for R1's visit to the hospital was a left femur fracture and a right femoral neck fracture, a urinary tract infection and hyperkalemia. On February 23, 2017 at 2:50 PM, E4 (Certified Nursing Assistant-CNA) said on February 16, 2017 she gave R1 a shower and was standing in front of R1 trying to button her shirt in the back. E4 said when the shower chair with the black seat is wet it is very slippery and R1 started sliding. E4 said because she was standing in front of R1, she could not put her back into the shower chair so she had to lower her to the ground. E4 added Her legs were together and off to the side. She was sitting upright so I laid her down to her left side. On February 23, 2017 at 12:07 PM, E5 (CNA) said she and E4 were the only CNAs working when R1 fell in the shower, adding that she was on another hall when R1 fell . E5 said she went to help E4 transfer R1 back to her geriatric chair after the fall. On February 23, 2017 at 1:12 PM, E6 (Licensed Practical Nurse-LPN) said she was the nurse working on February 16, 2017 until 6:00 AM. E6 said she was on the other hall when R1 fell at 4:45 AM. E6 said E4 was the only one in the room with R1 during the fall. R1's December 6, 2016 Fall Risk Assessment shows she is a high risk for falls. R1's December 5, 2016 Minimum Data Set (MDS) shows she has severe cognitive impairment with inattention and disorganized thinking. The MDS shows R1 has impaired range of motion bilaterally to her upper and lower extremities and is totally dependent on 2 staff members for bed mobility, transfers, and bathing. On February 23, 2017 at 9:05 AM, R1 was reclined in a geriatric chair on the north hall by the nurse's station. R1's eyes were closed and she appeared to be sleeping. Bruising was noted on R1's left hand and forearm. R1's right arm was under a blanket. At 12:30 PM, E10 and E11 (Certified Nursing Assistants-CNAs) transferred R1 from the geriatric chair to her bed using a mechanical sling lift. Bruising was noted on R1's right hand and forearm. On February 24, 2017 at 12:10 PM, Z1 (emergency room Doctor) said R1's x-rays showed an oblique displaced left femur fracture and a right impacted subcapital neck femur fracture, the left fracture had bone fragments. Z1 said he spoke with the orthopedic surgeon at another local hospital to inform him of his findings and sent R1 to the other hospital for surgery. On February 23, 2017 between 10:45 AM-11:08 AM E15 (CNA) and E16 (Restorative CNA) said staff can find out what the residents needs are by looking in the resident's care plan or the Kardex in the resident's room. E16 said the bottom portion of the ADL (Activities of Daily Living) flow record shows the assistance needed by each resident. E14 stated, The ADL flow records used to be filled out for everyone. Now some are and some are not filled out. (R1's) is not filled out. E15 said she is familiar with R1 and she is total care for showers with 2 staff. R1's March 14, 2016 ADL care plan shows Provide bathing, hygiene, dressing and grooming per resident's preference as able. The care plan does not address how many staff are needed for bathing. R1's January and February ADL Flow Records and the Kardex located in R1's room do not address how many staff are needed for bathing. R1's August 7, 2014 Admission History and Physical shows she was admitted to the facility with [DIAGNOSES REDACTED]. The document shows R1 has generalized weakness in her muscles, joints, spine and flank areas and has been unable to walk since 2007. E3 (Regional Nurse Consultant) said she would assume from R1's most recent MDS that R1 should be a 2 assist with bathing and showering. E3 Stated, I would assume there would be 2 staff members in the room during the shower. The February 16, 2017 5:45 AM Nurse's Notes show At 4:45 AM resident was in the shower room with CNA. Resident slid out of shower chair when CNA was putting resident's shirt on. CNA lowered resident to floor. The February 21, 2017 hospital progress notes show R1 underwent open reduction internal fixation of the left femoral shaft fracture and cannulated screw fixation for a right femoral neck fracture.

Based on observation, interview, and record review the facility failed to ensure daily skin monitoring was done for a resident at high risk for pressure ulcers. The facility failed to thoroughly assess a pressure ulcer upon identification, and failed to monitor R1's pressure ulcers with weekly pressure ulcer assessments. The facility failed to include interventions to treat R1's pressure ulcers in the pressure ulcer care plan. This failure contributed to R1 acquiring a stage four pressure ulcer to her coccyx on 11/3/14, and a stage four pressure ulcer to R1's left shin on 11/3/14. This applies to 1 of 5 residents (R1) reviewed for pressure ulcers in the sample of 14. The findings include: R1's Minimum Data Set (MDS) of 12/11/14 shows R1 requires extensive assistance from staff with dressing, repositioning in bed, transfers, hygiene, and bathing. R1's Physician order [REDACTED]. R1's Pressure Ulcer Risk Assessments dated 9/25/14 and 12/11/14 show R1 is at high risk for pressure ulcers. R1's facility admission assessment dated [DATE] shows R1 was admitted to the facility without pressure ulcers to her coccyx, and bilateral shins. On 2/26/15 at 9:45 AM, E3 (Registered Nurse- RN), and E14 (Licensed Practical Nurse- LPN) rolled R1 onto her left side. E3 removed the dressing to R1's coccyx. R1 had an irregular circular open area to her coccyx with a deep, pink wound bed. E3 said "this is much better than what it was" and "there is a little tunneling going up the coccyx". E3 cleaned R1's wound with saline, and then packed the wound with a medicated, wet gauze. E3 and E14 rolled R1 onto her back and R1 had a pink scar to her left shin. E3 said the pressure ulcer to her shin "healed". R1's Nurse notes dated 10/21/14 shows "Noticed two bruises with open area in buttocks. ...Telephone order. Clean buttocks with normal saline. Apply Barrier cream to right buttocks with open area, cover with border dressing 3x daily". The next wound entry did not occur until 10/23/14 and states "treatment completed to coccyx as ordered... 10/30/14 Nurse notes show "treatment to coccyx performed. Area a stage 4 with moderate amounts of yellow/brown drainage with 0.5cm depth. Area has dark brown/black necrotic tissue present in wound bed ". The 11/5/14 at 10:30 AM, Nurse notes show "Treatment to coccyx changed...DON (Director of Nursing) consulted concerning severity of wound...Resident yelling in pain...wound bed displaying increased - medium amount of yellow slough". The November, 2014 Treatment Administration Record (TAR) shows "11/2/14 Coccyx: cleanse with wound cleanser apply santyl ointment to slough areas, cover with bordered gauze. The first documented assessment of R1's coccyx wound on the TAR did not get completed until 11/17/14, almost 4 weeks (27 days) after the wound was identified. The initial assessment in the nurse notes did not include a description of stage, size, shape, depth, color, drainage, or description of the wound bed. There were no other weekly wound assessments completed on the November, 2014 TAR. The facility Weekly Wound Tracking sheet shows the onset of R1's coccyx wound was 10/21/14 and the first assessment was not documented until 11/3/14, (13 days after the wound was identified). The 11/3/14 assessment shows "Coccyx, Stage IV, 4cm, 3.4cmx .5cm, deteriorating status, and minimal drainage". R1's nurse notes dated 10/24/14 at 2:30 AM shows "2.5 cm x 2.2cm bruise noted to anterior left shin and 1.5cm x 1.7cm blister noted to lateral left shin. 1.5cm x 1.7 cm red area to top of foot..." This assessment did not include the stage, size, shape, or description of the wound bed and surrounding tissue. The November TAR shows a treatment ordered 11/2/14 "areas on left shin cleanse with wound cleanser apply and cover two times per day...D/C (discontinue) when necrotic tissue/slough is minimal..." The facility did not provide any documented TAR assessments of the wound to R1's shin for October or November. The facility Wound Tracking documents show the onset of R1's "left lateral shin wound" was 10/21/14 (nurse notes identify as 10/24/14). The first assessment was not completed until 11/3/14 (10 days after it was identified in the nurse notes) and showed "Stage IV Pressure Ulcer, 2.3cm x 1.4cm x 0.2cm, deteriorating status and minimal drainage". R1's 11/13/14 physician orders [REDACTED]. R1's 12/1/14 Wound Care Clinic notes shows a full thickness, Pressure injury to the left lower leg-lateral, measuring 1.3cm x 0.8cm x 0.1cm. This report shows a small amount of purulent, yellow, brown, green drainage, and "large (67-100%) necrotic tissue and adherent slough. R1's 12/1/14 Wound Care Clinic notes show a Stage III pressure injury to coccyx, measuring 3.5cm x 3cm x 2.3cm. This assessment shows the wound had a medium amount of red/brown drainage. On 2/25/15 at 3:00 PM, E12 (RN) said when a new pressure ulcer is identified the nurse completes an initial assessment to include a description of the wound, size, stage, depth, odor, drainage and wound bed. E12 said this information is documented on the forms in the wound packet and also in the nurse notes. E12 said a complete assessment should be documented in the nurse notes when the wound is identified. On 2/26/15 at 9:45 AM, E3 and E14 said R1 was high risk for skin breakdown before her pressure ulcers developed. E3 and E14 said a daily skin assessment should be completed by the nurse on all residents who are high risk for skin breakdown. E3 and E14 said these assessments are documented on the TAR daily and if any change is noted or a new area is discovered an assessment is completed on the back of the TAR and in the nurse notes. E3 and E14 said if a wound is identified, a full assessment is completed weekly to include stage, size, color, odor, and wound bed, and is documented on the back of the TAR, on the weekly Pressure Ulcer Monitoring sheet, and in the nurse notes. R1's September, 2014 TAR shows an order written [REDACTED]. R1's high risk for pressure ulcer care plan has an intervention dated 4/8/14 "High Risk-Daily skin check with documentation and as needed with any new open area". R1's High Risk for Pressure Ulcer care plan did not include the pressure ulcer to R1's coccyx, or R1's shin. This care plan does not have any interventions or treatments ordered for R1's left shin pressure ulcer. R1's Pressure Ulcer Care Plan did not have an intervention to reposition from side to side only, and up for meals only, as ordered by the wound care clinic on 12/9/14. On 2/26/15 at 9:25 AM, E2 (Director of Nursing-DON) said the Pressure Ulcer Risk Assessment determines whether skin monitoring is completed by the nurses daily or weekly. E2 said if a resident is high risk for breakdown the resident will get a skin assessment completed daily by the nurse. E2 said this assessment is documented on the TAR, and each resident has either a weekly or daily skin assessment. E2 said R1 was a high risk and should have had daily skin assessments completed by the nurse and documented on the TAR. E2 said she would "absolutely" expect a wound to be identified as a stage I if daily skin assessments are being done. E2 said daily skin assessments are done on high risk residents so problem areas can be identified right away. E2 said when a wound is identified a complete assessment should be documented to include "wound bed, drainage, stage, and size". E2 said this assessment should be documented in the nurse notes, and on the back of the TAR on identification, and then weekly. E2 said she could not find an assessment of R1's wounds in October, and only one assessment of R1's coccyx on the Novemeber TAR. E2 said she did not have any assessments on the TAR in October or November for the wound to R1's shin. E2 said a complete desription of the wounds, including stage, and wound bed should have been documented in the nurse notes and the assessment completed on the back of the TAR when the pressure ulcer was identified to R1's coccyx, and shin. E2 said any pressure ulcer treatment, order from the wound care clinic, and pressure relieving interventions should be part of the pressure ulcer care plan. On 2/26/15 at 12:10 PM, Z1 (Medical Physician) said he would consider R1 high risk for pressure breakdown prior to development of the pressure sores in October, 2014. Z1 said he would expect a complete assessment of a pressure ulcer to be completed on identification and no later than three days after identification if a wound care team was completing the assessment. Z1 said complete weekly skin assessments should be done after identification until the wound heals. Z1 said if daily skin assessments were completed a resident would "not likely" go from nothing to a stage III or stage IV, and it would be "unusual" to go from no wound to a "stage III" in one day. The 1/02 facility policy "Skin Condition Monitoring" states 1. Upon notification of a [MEDICAL CONDITION], wound, stasis ulcer, or other skin abnormality, the Charge Nurse will assess and document the findings. 4. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic 1. Size 2. Shape 3. Depth 4. Color 5. Presence of granulation tissue or necrotic tissue b. Treatment and response to treatment. c. Prevention techniques. The 4/06 facility policy "Pressure Sore Prevention Guidelines" states: "To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the (pressure ulcer risk assessment tool). The following guidelines will be implemented for any resident assessed at a Moderate of High skin risk. Daily skin checks Care Plan Entry - Skin risk and appropriate interventions are to be placed on the Care Plan. If despite interventions, a Pressure ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further preventions of pressure ulcers. Any resident scoring a High or Moderate risk for skin breakdown will be noted on the Treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet." The 5/07 facility policy "Decubitus Care/Pressure Areas" states 1) Upon notification of skin breakdown a Newly Acquired Skin Condition report will be completed... 2) The pressure area will be assessed and documented on the Treatment Administration Record (TAR). 3) Complete all areas of the TAR i) Document size, stage, site, depth, drainage, color, odor, and treatment... 5) Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include: i) Characteristic (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc)."

A. Based on observation, interview, and record review the facility failed to ensure staff disinfected a glucometer after resident use to prevent the spread of a blood borne pathogen. Harm is likely to occur to the 4 residents if immediate action is not taken. This applies to 4 residents (R41, 50, 51, & R54) reviewed for infection control in the supplemental sample. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ began on [DATE]. Although the immediacy was removed on [DATE] at 7:45 PM, the facility remains out of compliance at a level 2 due to the need to evaluate the implementation of the training provided to staff. The finding includes: On [DATE] at 4:30 PM, E19 (Licensed Practical Nurse - LPN) was observed conducting a blood glucose test on R51. E19 said the glucometer was used for all of the residents on the south wing. After conducting the test, E19 cleaned the machine using an alcohol pad, and placed the machine in the top drawer of the medication cart. E19 said it was the facility policy to clean the glucometer after each resident use with an alcohol pad and at the end of the shift clean the machine with a 1:10 bleach solution, disinfectant cloth. E19 said that is the way she has always cleaned the blood glucose meters. On [DATE] at 4:15 PM, E22 (LPN) said it is the facility policy to clean the glucometer after each resident use with a 1:10 bleach sani-cloth, and allow to air dry. E22 said all of the nursing staff were in-serviced a few months ago on the proper way to clean the multi-resident use blood glucose meter. Resident [DIAGNOSES REDACTED]. R49 is diabetic and the blood glucose machine used for R49 is also used for R41, 50, 51, & R54. Facility In-services show that on [DATE], nursing staff were educated on the facility's policy and procedure regarding how to clean and disinfect a multi-resident glucometer. E19's signature was affixed to the in-service sign in sheet, signifying her presence at the meeting. R49 has been a resident in the facility since [DATE]. The facility's Cleaning and Disinfecting of Glucometer policy and procedure ([DATE]) states, "The blood glucose meters will be cleaned between each resident test to avoid cross contamination issues. The procedure is as follows: Cleaning and disinfecting with a Germicidal Disposable Wipe will be completed each time the blood glucose meter is used with a pre-moistened towelette...Note: If Germicidal Disposable Wipe is not available the facility may dilute 1 ML of household bleach (5%-6% sodium hypochlorite solution) in 9 ML of water to achieve a 1:10 dilution. The solution can then be used to dampen a paper towel. Then use the dampened paper towel to thoroughly wipe down the meter. On [DATE] at 7:15 PM, E1 (Administrator) and E2 (Director of Nursing) said the risk of cleaning the glucometer incorrectly could potentially spread blood borne illnesses's to other residents using the same glucometer. E1 said they had not followed up to make sure staff were performing the cleaning and disinfecting of the glucometers, after the in-service of [DATE]. E1 said the facility had an extra glucometer and it has been assigned solely for R49's use. E1 (Administrator was informed of the Immediate Jeopardy on [DATE] at 7:15 PM. Through interview and record review the surveyor confirmed that the facility took the following steps to remove the immediacy of the situation: 1. The facility in-serviced all nursing staff in the building on [DATE]. The in-service consisted of Standard Precaution, glucometer cleaning and disinfection. 2. Nursing staff was in-serviced regarding R49 being assigned her own glucometer. All future diabetic residents with a current blood borne pathogen will be issued their own glucometer. Any nursing staff not working on [DATE] will be in-serviced prior to starting their next shift. 3. On [DATE], the Director of Nursing (E2) and/or Administrator (E1) ensured Sani-cloth Plus Wipes were available to all nurses for proper cleaning and disinfecting of medical equipment including but not limited to glucometers. 4. As of [DATE], E1 and E2 ensured availability of glucometers to assign diabetic residents with a [DIAGNOSES REDACTED]. 5. To ensure compliance with the glucometer cleaning and disinfecting policy and procedure the facility will do the following: a. Beginning [DATE], Random audits of the nursing staff cleaning and disinfecting glucometer will be conducted by E2 and/or designee daily, Monday through Friday, for 2 weeks and then 3 times weekly for 2 weeks and then weekly for 2 weeks and monthly for 2 months. If failure occurs, the QA process will start over with the weekly checks. After completion of the QA process, to assure continued compliance, we will add glucometer cleaning to the annual mandatory in-service list. Annually we will have all nurses demonstrate proper cleaning technique of the glucometer. b. Beginning [DATE], In-Services on Glucometer Cleaning and Disinfecting, and the Infection Control Policy and Procedure will be conducted monthly for the next 3 months. c. As of [DATE], all newly hired nurses and all agency nurses will be trained on proper cleaning and disinfecting of glucometers in addition to the need for an assigned glucometer for all diabetic residents with blood borne pathogens. d. The regional Clinical Director will conduct a Directed in-service on Infection Control and Glucometer cleaning and disinfection for all nurses. B. Based on observation, interview, and record review the facility failed to ensure staff monitor resident and employee illnesses's for the past year; failed to cleanse hands after resident contact; and failed to ensure staff cleanse hands after removing soiled gloves. This applies to all 56 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on [DATE] the facility housed 56 residents. 1. The facility presented their infection control logs. The facility could only show there were tracking and trending Resident illnesses/organisms and employee illnesses since [DATE]. On [DATE] at 9:00 AM, E1 said, "If they (the facility) was tracking resident and employee illnesses before July, I can't answer. This is the only tracking we have." 2. On [DATE] during the noon medication pass, E16 (Licensed Practical Nurse) used a personal blanket of the resident's and cushioned behind R39's knees, to protect them from pressure. E16 did not cleanse her hands prior to leaving the resident's room and before continuing her medication pass. During the same medication pass, E16 assisted R55 with his [MEDICATION NAME] inhaler. After administering the inhaler, E16 placed the inhaler in her uniform pocket, potentially contaminating both the inhaler and her uniform. 3. On [DATE] at 1:15 PM, E4 (Activity Director) donned a pair of gloves and applied lotion to R46's hands. After completing the activity, E4 removed her gloves, left the room and went to obtain a clean wash cloth from the linen closet. E4 did not cleanse her hands prior to leaving the resident's room. E4 said she was going to wash R46's face. E4 went to the south wing linen closet, potentially contaminated the closet door, and any other linen she handled. 4. On [DATE] at 10:50 AM, E8 and E12 CNA's (Certified Nursing Assistants) were providing incontinence care to R12. Each CNA donned gloves. E8 removed a urine saturated incontinence brief. E8 then provided incontinence care, using clean linens but wearing the same soiled gloves. E8 placed a new incontinence brief on R12 which was placed on top of a soiled (wet) mechanical lift lift sling, and then pulled up R12's pants, as R12 lay on the wet lift sling. E8 touched bedding, linens, the peri wash bottle, the bedside table and drawers while wearing the original soiled gloves first donned prior to initiation of care. Once E8 removed the wet lift sling from beneath R12, she removed the gloves and used a hand gel. At no time did E8 wash her hands. 5. On [DATE] at 3:00 PM, E10 and E15 CNA's, (Certified Nursing Assistants), entered the room of R33 to provide incontinence care. Both CNA's donned gloves. E10 took multiple wash cloths to R33's bathroom sink. She prepared some with soap and others with clear water and set them on R33's bedside table. E10 and E15 then lifted R33 from the recliner using a gait belt. R33 steadied himself with assist of a walker while E10 and E15 removed his belt, allowing his urine soaked pants to fall to the floor. E10 and E15 removed R33's urine saturated incontinent brief which was also overtly soiled with stool. E10 began washing R33's peri area while wearing the soiled gloves used to remove the soiled brief. E15 reached down to the garbage can to retrieve a bag for E10 to discard the soiled linens, also still wearing the soiled gloves used to remove the soiled incontinent brief. E10 then began cleaning the area between R33's right and left buttock cheek, (never changing gloves). E10 used all of the wet wash cloths she had prepared at the sink in the bathroom prior to beginning care. Each cloth continued to be visibly soiled with stool. E15 retrieved a clean incontinent brief from R33's closet while wearing the contaminated gloves. E10 and E15 then assisted R33 to sit again in his recliner on a clean incontinent brief and E10 took the towel and went to the bathroom to wet a portion of the towel. R33 was again assisted to a stand position and the clean incontinent brief in the chair was visibly soiled with stool. E10 continued to wipe R33's buttocks each time with stool on the linens. E10 and E15 were asked to separate R33's buttock cheeks to visualize the anal area for a possible wound. Upon spreading R33's cheeks, the anal area could not be visualized as the buttock crack remained soiled with stool. E10 stated "Oh I guess he has more." E10 took a dry towel and dabbed at the stool. E10 put barrier cream on the excoriated area still contaminated with stool and still wearing the same pair of gloves initially donned when entering the room. After completion of cares, E10 assisted R33 to dress...still wearing the soiled gloves. Numerous episodes of cross-contamination occurred during the provision of cares with E10 not changing her gloves., or using handwashing or gel cleanser until she was ready to leave R33's room. 6. On [DATE] at 12:55 PM E9 and E10 (Certified Nurse Assistants- CNA ' s) provided incontinence care to R36. E9 removed R36 ' s soiled pants and incontinent brief. E9 then removed R36 ' s external catheter and washed R36 ' s peri area. E9 did not change her soiled gloves and used her hand to search the bedside drawer. E9 applied lotion to R36 ' s legs and reached in the supply box in the closet for a new external catheter. E9 positioned the new external catheter and placed a pillow under R36 ' s legs, put right and left heel protectors on R36 and covered R36 with bedding.

Based on interview and record review the facility failed to monitor R4's heels by completing weekly skin checks and failed to identify a pressure ulcer to R4's right heel until it was unstageable. The facility also failed to assess and monitor a low risk resident's (R1) skin, after applying a restraint, to prevent R1 from acquiring multiple pressure sores. These failures resulted in R4 developing a necrotic area to her right heel requiring debridement and specialty wound care beginning on 5/2/11 and R1developing 3 Stage II pressure ulcers to his coccyx and Stage I pressure ulcers to his bilateral elbows. This applies to 2 of 3 residents (R1, R4) reviewed for pressure ulcers in a sample of 5. The findings include: 1. The physician's orders [REDACTED]. R4's Braden Scale for Predicting Pressure Ulcer Risk shows that R4 scored a 17. (17-20= Moderate Risk) R4's Nursing Admission assessment dated [DATE] shows that R4 had "no open areas or bruises". The facility document entitled, Newly Acquired Skin Conditions, dated 5/2/2011 shows that R4 has an Unstageable pressure ulcer to her right heel measuring 2.4 X 3.0 (unit of measurement not indicated). This form shows that R4 stated, "It hurts." The Weekly Wound Tracking Report dated 5/5/2011 shows that R4's right heel measured 2.4 x 2.4 cm and had a black center with minimal drainage. An untitled document dated 6/9/11 states, " (R4) here for wound treatment to right heel. Reports some pain. Not walking much. No other problems or complaints. Sharp debridement of heel wound done then Santyl ([MEDICATION NAME] ointment) applied, skin prep and foam dressing. Right heel wound- apply Santyl BID (twice a day) to heel wound, use skin prep around heel wound, cover with foam dressing. Juvan ( protein supplement) BID. Return in 1 week. Float heels at all times." On 10/20/11 at 1:15 PM R4 was asked how she got the wound on her right heel. R4 stated, "I have no idea. One day it started hurting and they looked at it and there was a hole. I was walking but I can't now. I can't wear my shoes either." 2. The Minimum Data Set of 8/23/11 shows that R1 has [DIAGNOSES REDACTED]. R1's Braden Scale for Predicting Pressure Ulcer Risk dated 8/12/11 shows that R1 scored a 22 (Greater than 20=low risk). The Nurse's Notes dated 8/19/11 states, "Resident placed in (reclining wheelchair) at this time. (7:30 PM). Resident sitting quietly in (reclining wheelchair) at 10:00 PM. " The NN dated 8/21/11 states, "Attempting to climb out of (reclining wheelchair). Using bilateral arms to lift buttocks off of seat in attempt to get out from under the tray." R1's Treatment Flow Sheet for August 2011 shows that R1 was to receive weekly skin checks by a licensed nurse. The skin checks scheduled to be done on 8/13 & 8/20 were not completed. On 8/28/11 the NN state,"Open area noted to coccyx. Treatment implemented. [MEDICATION NAME] to wound bed." The Monthly Wound Tracking Report for August 2011 describes R1's coccyx wound as 0.5 x 0.5 x <0.1 cm. The facility document entitled Newly Acquired Skin Conditions dated 9/5/11 shows that R1 developed a Stage I pressure sore to his left elbow (3.7 x 2.5 cm), a Stage I pressure sore to his right elbow (7.8 x 5.2 cm) with a scabbed area (0.5 x 0.6 cm) and 3 pressure sores to his coccyx -1) 0.5 x 0.7 x <0.1, 2) 0.4 x 0.6 x <0.2, 3) 0.7 x 0.4 x <0.1.