Every finding on record at Lakewood NRSG & Rehab Center

Based on observation, interview, and record review, the facility failed to identify a resident's change in condition with subsequent Physician notification, resulting in a delay of care and hospitalization.This applies to 1 resident (R69) reviewed for quality of care.Findings include:On 06/03/2026 at 11:03 AM, V35 (R69's family member) said R69 was admitted to the hospital ICU (Intensive Care Unit) on 05/24/2026 with septic shock. V35 said R69 was originally admitted to the facility from the hospital for therapy on 05/18/2026, and R69 has stage 4 cancer and takes water pills for maintenance therapy. V35 said she visited R69 on 05/22/2026 after 6 PM, and R69 was lethargic and warm. V35 said R69 was breathing heavily, and she asked for a pulse oximeter. V35 said R69's saturation was 77%, even with using oxygen at 2 liters via nasal cannula. V35 stated R69 was not sent to the hospital until 5/24/2026. V35 continued and said she asked the nurse to check R69's temperature, which showed normal, and then V35 asked the nurse to check it with a thermometer that was working. V35 said R69's temperature was 101.9 F, and she told the nurse that something was not right and that they should run some tests because she thought R69 was developing sepsis again. V35 said the nurse told her she would call the physician and order some lab tests. V35 said she does not think the facility called the doctor and did any labs or urine collection on R69. V35 said she and her sibling had to escalate the situation to have R69 sent to the hospital. V35 said her sister spoke to a nurse (unknown) on 5/23/26 who said EMS is closed and they can't send R69 to the hospital. V35 stated on 05/24/2026, her sibling called V1 (Administrator), and the facility arranged to send R1 to the hospital. V35 stated R69 was intubated and admitted to the ICU with septic shock.The hospital physicians' history and physical data dated 05/24/2026 and 05/25/2026 showed that R69's chief complaint was fever and shortness of breath. During the evaluation, R69 was in respiratory distress and speaking in short sentences due to conversational dyspnea, hypotensive, and was put on pressor support, requiring ICU admission. R69's pulse was 127, and respiration was 41. Further hospital physician's assessment and plan showed R69 presents with sepsis, acute chronic hypoxic respiratory failure, pneumonia of both lungs, and elevated troponin, and possible urinary tract infection upon admission. 05/25/2026 hospital attending physician's report showed that upon admission to the ICU, the patient had difficulty achieving adequate saturation, had abnormal lab results, and was intubated.On 06/04/2026 at 9:29 AM, V31 (Registered Nurse) stated that on 05/22/2026, V35 asked her to take the temperature, and when she did, it was normal. V31 said she realized her thermometer was broken and took the temperature with a different thermometer, which read 101.9 degrees Fahrenheit. V31 said V35 requested V31 to call the doctor and send R69 to the hospital. V31 said she told V35 that she would give R69 Tylenol and would check on her. V31 said she didn't call the doctor. V31 said she does not recall R69's saturation level and did not document anything in the electronic medical record.On 06/04/2026 at 11:08AM, V30 (Registered Nurse-Supervisor) said that if the family requests to call the doctor with concerns, the nurse should call the doctor. V30 said he was not made aware of the situation with R69.R69's face sheet showed that she was admitted to the facility from the hospital for physical therapy with diagnoses including pneumonia, chronic obstructive pulmonary disease, sepsis, lung cancer, pancreatitis, blood disorder, and supplemental oxygen use. On 06/04/2026 at 11: 10 AM, V1 (Administrator) said R69's family had called and said they would like to send R69 to the hospital because she had a fever, and he spoke with V2 (Director of Nursing) and she said she would set it up. V2 said that when the family requests that the resident be transferred to the hospital, the facility needs to notify the doctor and facilitate the transfer. V2 further stated that family and residents have rights.The facility's Notification of Change in Condition Policy stated, in part, that changes in condition were reported immediately to the attending physician, and that the resident's family/representative was educated about treatment options and supported in making an informed decision.

Based on observation, interview, and record review, the facility failed to ensure residents with LVADs (Left Ventricular Assist Devices) received care and services to ensure their LVADs were functioning.This failure resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on [DATE] when R1 experienced a change in condition and staff did not know to assess the function of his LVAD. R1 experienced cardiac arrest, was emergently transferred to the hospital, and later expired. This applies to 1 resident (R1) reviewed for LVADs and has the potential to affect 1 other resident (R4) in the facility that uses an LVAD. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the IJ on [DATE] at 10:36 AM and the IJ template was provided.The facility presented an Immediacy Removal Plan on [DATE] at 2:16 PM, which was returned for revision at 3:22 PM. The second Removal Plan was accepted on [DATE] at 3:38 PM. The surveyor confirmed the immediacy was removed on [DATE] at 12:26 PM; however, the facility remains out of compliance at a severity level II due to the need to evaluate the initiation of an LVAD policy and procedure, the training on the policy and procedure, and Quality Assurance Monitoring. The findings include:1.On [DATE] at 2:09 PM, R2 (R1's roommate) stated that on [DATE] around 4:00 AM, he heard R1 coughing and hacking like I do to clear my throat and he asked R1 if he needed the nurse. R2 stated he could not understand what R1's answer was, so R2 put on the call light.On [DATE] at 1:29 PM, V16 (Agency CNA/Certified Nurse Assistant) said she was the assigned CNA providing care for R1 on [DATE] and responded to R2's call light. V16 stated she works for a staffing agency and has worked at the facility less than 10 times. V16 stated R2 said R1 was in distress and was having difficulty breathing and she immediately notified V12 (Agency LPN/Licensed Practical Nurse). R1's [DATE] ambulance Patient Care Report showed paramedics were dispatched at 4:11 AM and arrived at R1 at 4:18 AM, and that CPR (cardio-pulmonary resuscitation) was initiated at 4:20 AM. The Report narrative showed .Upon arrival crew found two staff members standing next to the patient stating that he had stopped breathing. Staff stated prior to our arrival that the patient was not waking up, but still breathing. Crew immediately started assessing the patient and checking vitals. Patient was in cardiac arrest. Patient had black satchel next to his side crew asked the staff what the satchel was, but staff stated that she was unsure and did not know his medical history.One of the crew members was assessing the black satchel next to the patient- device was an LVAD that did not appear working. Crew removed both batteries and replaced them with two that were on the charger next to the patient's bed. LVAD device appeared to turn green and the screen turned on and appeared to be working. Crew did a quick rhythm check and the patient had a rhythm, but did not have a carotid pulse. On [DATE] at 10:59 AM, V7 (Hospital Outpatient Nurse Practitioner with VAD Team) described an LVAD device in very basic terms as a piece of metal that is surgically implanted to the heart that provides assistance for the heart to pump. V7 stated a driveline comes out of the patient's body, and the line is connected to a controller. V7 stated the controller is powered by two rechargeable batteries, or it can be plugged into a wall outlet. V7 stated the data collected from R1's LVAD device on [DATE] showed low battery at 1:39 AM and no external power at 2:22 AM. V7 stated the data showed the device as off at 4:21 AM. On [DATE] at 11:33 AM, V12 (Agency LPN) stated she was assigned to R1 on [DATE]. V12 stated she enlisted the help of V17 (Registered Nurse/RN) and she called 911 when R1 became verbally unresponsive. On [DATE] at 3:52 PM, V17 (RN) said he has never received any LVAD training and has been assigned as R1's nurse once previously. V17 said he had never changed the batteries in an LVAD before, but if he had to, he would call google and find out. V17 said on [DATE], V12 (Agency LPN) told him R1 was not looking good so he went with her to check R1, he noticed labored breathing and went to get oxygen.On [DATE] at 10:33 AM, V12 said the only nurse working on the same side of the building with her on [DATE] was V17 (RN). V12 stated this is her first skilled facility and she usually works in Assisted Living or Memory Care. V12 said she had not had any LVAD training. V12 said the nurse she received report from told her that R1 had a heart monitor but did not call it an LVAD or mention any LVAD assessments that V12 that needed to do. V12 stated that on [DATE], she did not assess R1's LVAD and she was just looking at R1's breathing and took his vital signs. V12 stated when V16 (CNA) told her R1 stopped breathing, V17 went to get the backboard, and then the paramedics showed.On [DATE] at 2:39 PM, V11 (Paramedic) said on [DATE] during R1's CPR, he noticed the satchel next to R1 with a line going into his abdomen. V11 stated he asked V12 (Agency LPN) what the satchel was and V12 told him she did not know. V11 said he continued ALS (Advanced Life Support) for R1.On [DATE] at 2:09 PM, V23 (Firefighter/Paramedic) said R1 was already in cardiac arrest when he arrived at the bedside. V23 stated he asked about the satchel and the guys on the ambulance said the staff told them they didn't know what it was. V23 said he then opened it and saw the two batteries. V23 said he removed the batteries one by one, checked their power/charge level, saw that each battery was dead/black. V23 stated he replaced them both with two batteries from R1's battery charging station and a green light immediately came on. V23 said the LVAD was not plugged in to any other power source besides the two dead batteries. V23 said after he replaced R1's LVAD batteries, he pressed a button on the LVAD main screen, the screen illuminated for the first time and showed some numbers, and he heard the paramedics say R1 had a cardiac rhythm on their monitor. V23 said R1 was then transferred to the hospital.On [DATE] at 4:09 PM, V6 (R1's Son-In-Law/Emergency Contact) said R1 was in the facility because he could not be left by himself since having a stroke. V6 said he thought the facility staff were monitoring R1's LVAD because the facility had to be LVAD certified to take care of R1. On [DATE] at 9:41 AM, V7 (LVAD Nurse Practitioner/NP) said the facility should be assessing and monitoring their LVAD patients according to the facility's policy and procedures. On [DATE] at 4:14 PM, V2 (Director of Nursing-DON) said the facility does not have a policy on LVADs, they follow the LVAD manufacturer Clinical Theory and Operation and System Controller: Alarms & Troubleshooting handout. On [DATE] at 4:05 PM, V2 said V12 (Agency LPN) should have followed the LVAD Emergency Protocol from the LVAD binder kept at the nurse's station. V2 said even if an LVAD resident is managing their own LVAD, if the resident becomes incapacitated, the staff should know how to troubleshoot and manage the LVAD. After Contact the Patient's LVAD Team Immediately, the first intervention showed ASSESS IF PUMP IS RUNNING: Auscultate the left chest over the apex of the heart. A continuous mechanical revving sound indicates the pump is running. Assess the System Controller. If the green pump running symbol [drawn symbol] is illuminated, the pump is running.On [DATE] at 12:03 PM, V21 (R1 and R4's Physician) stated a nurse providing care for an LVAD resident should be trained in LVADs. V21 said the bedside nurse should know basic things about their patients, including what devices/machines their patients have and why they have them. V21 said it is a standard expectation that the bedside nurse should be checking the battery of the LVAD at a minimum every shift during their nursing assessment. R1's Face sheet shows he was first admitted to the facility on [DATE] with diagnoses of chronic combined systolic and diastolic congestive heart failure, atrial fibrillation, presence of heart assist device, ischemic cardiomyopathy, cerebral infarction due to embolism of bilateral carotid arteries, and need for assistance with personal care. R1's Care Plan (initiated [DATE]) showed R1 is at potential risk for cardiac complications related to diagnosis including hypertension, atrial fibrillation, stroke, congestive heart failure, cardiomyopathy, peripheral vascular disease, heart assist device and sedentary lifestyle causing deconditioning. R1's POS (Physician Order Sheet) as of his discharge to hospital on [DATE] does not show any orders for LVAD assessment, such as auscultating heart sounds or checking LVAD battery function/charge status.On [DATE] at 1:11 PM, V7 (VAD Team NP) stated R1 expired on [DATE].2. R4's Face sheet shows an initial admission date of [DATE] with diagnoses unstable angina, chronic systolic and diastolic congestive heart failure, ventricular tachycardia, end stage heart failure, atrial fibrillation, hypertension, and presence of heart assist device. On [DATE] at 12:05 PM, R4 said he has been missing the power cord for his mobile power unit to connect his LVAD to wall electricity while he sleeps at night. R4 said he is afraid his batteries will die while he is asleep because they only last seven hours. R4 said he has been missing the cord since he was admitted and the staff are aware, and he asked them to contact the LVAD team to send his missing cord. On [DATE] at 2:05 PM, R4 said the staff have come to him and he has taught them about his LVAD, and he ain't getting paid for this sh*t! R4 then demonstrated how to check the battery charge level and noticed that one of his two batteries was low. He then removed that battery and the LVAD started beeping continuously until he replaced it with a charged battery. R4 then said, See? It's not that hard!On [DATE] at 4:05 PM, V2 (DON) said she was not aware that R4 did not have the necessary LVAD cord to connect to wall electricity at night. On [DATE] at 12:03 PM, V21 (R4's Physician) said it is concerning that R4 does not have the required cord for his LVAD to connect to wall electricity while he sleeps. V21 said he thinks the facility staff should be reaching out to the LVAD team to obtain the missing equipment so R4 does not have to rely on batteries. The facility provided an undated handout from LVAD manufacturer) entitled Clinical Theory and Operation. On page 31 of the handout, it showed Equipment Required for discharge: .One mobile power unit with power cord.---------------------The IJ that began on [DATE] was removed on [DATE] at 12:26 PM when the facility took the following actions to remove the immediacy:LVAD Nursing Care Guideline Policy was adopted and reviewed and approved by Medical Director and LVAD team.u 1.All licensed regular staff nurses received mandatory training on [DATE] by LVAD manufacturer, for emergency LVAD procedures, identifying alarms, and battery replacement. u 3.Plan for new hire and/or agency LVAD training will be completed prior to any shift worked.u 1.Obtained orders for R4, who is residing in the facility, with frequency to monitor LVAD battery function. R4's Care Plan was updated to include LVAD management. Verified R4 has a minimum of 2 fully charged LVAD batteries, and 4 batteries are on charging unit. Mobile power unit with power cord obtained for R4.u 2.LVAD resident POS will include the following LVAD orders: check battery function and level every shift, follow procedure for dressing changes, monitor for signs and symptoms of infection daily and PRN, report to LVAD team if any signs or symptoms of infection are noted, Auscultate heart sounds twice a day, if heart sounds are absent notify the LVAD team at (phone number).u 4.Any potential LVAD admission will be reviewed and discussed by the interdisciplinary team prior to admission and refresher education will be provided as needed. u 5.LVAD Manufacturer's Emergency Care for the Heartmate 3 LVAD patient will be placed in binders at nursing stations and at the bedside of LVAD residents.u 6. Audits will be completed 5 times a week for 4 weeks, then monthly until substantial compliance is achieved on the following: -Ensuring orders and monitoring are in place for LVAD battery function and monitoring -LVAD company contact information posted -Ensure a minimum of 2 fully charged LVAD battery units are in place at all times -Care Plan includes LVAD management and battery monitoring - Emergency Care of LVAD Patient guide at nurse's station and bedside -Staff able to articulate and/or teach back steps to ensure device is functioning as intended, including but not limited to battery function and emergency care guide -QAPI will be completed upon acceptable Removal Plan

Based on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs.This has the potential to affect all 113 residents in the facility.Based on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs. This has the potential to affect all 113 residents in the facility. Findings include: The Facility Data Sheet dated 10/14/25 showed the facility's total census was 113 residents. The Facility Assessment Tool (last updated 10/10/25) showed the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. It also showed that when the facility decides to accept residents with care needs it has not previously admitted , the Facility Assessment helps determine which areas require attention, such as training, education, and competencies necessary to provide the level and types of care needed for the resident population. The section of the Facility Assessment titled Resident Count - Special Treatment and Conditions showed the facility identified itself as capable of accepting and caring for residents with Left Ventricular Assist Devices (LVADs), noting two active residents in that category as of 10/10/25. R1's face sheet showed R1 was initially admitted to the facility on [DATE] and discharged on 5/30/25. R1's face sheet shows his most recent admission date as 8/11/25 with a diagnosis list that includes presence of heart assist device. R4's face sheet shows an admission date of 7/17/25 with a diagnosis list that includes presence of heart assist device. On 10/17/25 at 10:33 AM, V12 (Agency Licensed Practical Nurse/LPN) said she had cared for R1 on 10/12/25. Per V12, she had never received any LVAD training or education from the facility. V12 stated there was another nurse, V17 (Registered Nurse/RN), who was working in the same area of the building when R1 experienced a change in condition. On 10/15/25 at 3:51 PM, V17 (RN) said he had not received any training about LVADs. On 10/15/25 at 4:14 PM, V2 (Director of Nursing/DON) said the only LVAD In-Service/Education completed was on 5/29/25-11 days after R1's original admission date of 5/18/25. Per V2, R1 should not have been accepted for admission before staff received training. On 10/17/25 at 12:03 PM, V21 (R1 and R4's Physician) said that in general, the facility should only accept residents with devices if the staff are trained and competent to care for those devices. V21 stated at minimum, nurses should know what these machines are, what they do, and why residents have them-that's Nursing 101. On 10/17/25 at 9:41 AM, V7 (Hospital Outpatient Nurse Practitioner with VAD Team) said that nurses caring for residents with LVADs should be trained according to facility protocol. Per V7, after the LVAD In-Service/Education done on 5/29/25, the facility should have reached out to her team or to the LVAD manufacturer to obtain additional training. The facility's LVAD Education sign-in sheet dated 5/29/25 lists 11 nurses who attended the training. Review of the facility's nurse roster shows a total of 23 nurses on staff (excluding agency staff), indicating that at least 12 nurses had not been trained prior to this survey. On 10/24/25 at 11:22 AM, V2 (DON) said the Special Treatments and Conditions section of the Facility Assessment refers to the acuity level the facility is able to care for. Per V2, the facility does not have a system in place to train agency staff. On 10/24/25 at 12:15 PM, V1 (Administrator) confirmed that the purpose of the Facility Assessment is, as stated on the first page, to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies, including training.

Based on interview and record review, the facility failed to assess the urinary status of a resident with an indwelling urinary catheter. This failure resulted in the resident experiencing urinary retention and being hospitalized with a diagnosis of UTI (Urinary Tract Infection). This applies to 1 of 3 residents (R1) reviewed for catheters in a sample of 3. The findings include: R1's face sheet shows an admission date to the facility on 2/24/25. R1's face sheet showed his diagnoses chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of bladder. R1's 4/30/2025 MDS (Minimum Data Set) showed he was severely cognitively impaired and had an indwelling urinary catheter. R1's progress note from 5/17/25 at 12:21 PM showed [R1] being discharged to another nursing home .Ambulance here to transfer [R1] during transport with paramedic staff informed writer that due to vital signs and resident's mentality status, they were diverting [R1] to [local hospital] . R1's 5/17/2025 History of Present Illness ER note from 2:07 PM showed he had his [indwelling urinary catheter] changed out with doing this there was frank pus in the [catheter] and he had about 1.9 liters of brisk urine output with replacement of the [catheter]. On 5/28/25 at 9:52 AM, V3 LPN (Licensed Practical Nurse) stated she was R1's nurse on 5/17/2025 and she couldn't remember anything about his catheter. V3 stated the CNA (Certified Nursing Assistant) most probably emptied it out and the CNAs performed catheter care on R1. V3 stated if something was wrong with his catheter, I would attempt to irrigate it. If that doesn't work, I will change it. R1's 5/17/2025 emergency room (ER) notes showed Diagnosis: Urinary Tract Infection associated with indwelling urethral catheter. On 5/17/25 at 12:26 PM, Bladder exceptionally full unable to fully measure on bedside ultrasound. He does have chronic indwelling Foley catheter . however it is dry, there is no urine in the bag. Suspect, [it] has been displaced. At this point, high suspicion for urosepsis due to urinary retention, likely [acute kidney injury] and electrolyte disturbance present .will reassess .once his bladder is decompressed . Imaging studies: CT (Computerized Tomography) abdomen pelvis with IV Contrast-Final Result . Bilateral urothelial thickening suspicious for ascending urinary tract infection . R1's Electronic Medical Record (EMAR) showed the order Catheter: Record output from urinary catheter every shift. R1's last recorded output was 300 cc at 10:30 PM on 5/16/2025, with nothing documented at the end of night shift (approximately 6:30 AM on 5/17), or prior to R1 discharging the facility around noon on 5/17/2025 (approximately 13 hours after the last documented output). On 5/28/25 at 9:29 AM, V2 (DON-Director of Nursing) stated the following: Catheter care is done daily and as needed by the CNA's (Certified Nursing Assistants) or nurses. On 5/30/25 at 12:16 PM, V2 stated nurses are to assess the resident's catheter to see if it's patent and draining. V2 stated they should look at the bag and at the urine color and see if it's normal. V2 stated nurses should check the abdomen for distention and should feel the abdomen and assess for discomfort. V2 stated nurses should change the tubing when the urine is cloudy or when it's not draining, adding nurses have to do a basic nursing assessment. V2 stated as long as the CNAs see the catheter draining and they empty it, they don't consider there is a blockage anywhere. V2 stated there are not specific times when the staff empty the catheters, but it should be per shift. V2 stated normally, CNAs empty catheters at the end of the shift. V2 verified there was no documentation of R1's urinary output on 5/17/2025. On 5/30/25 at 12:30 PM, V6 (Nurse Practitioner) stated she did not see R1's catheter on the day he was discharged . V6 stated that as long as there is urine output and the catheter is draining, then the catheter is functioning. V6 stated there should be urine that's not bloody or cloudy in the tubing. V6 stated nurses should look to see if the catheter is draining appropriately. R1's POS (Physician Order Sheet) shows orders for Indwelling Catheter: Catheter Care daily and as needed. Catheter: Record output from urinary catheter every shift. The facility's Catheter Care, Urinary (revised September 2005) policy showed The purpose of this procedure is to prevent infection of the resident's urinary tract 7. Maintain an accurate record of the resident's daily output, per facility policy and procedure . 12. Empty the collection bag at least every eight (8) hours . 14. Observe the resident for signs and symptoms of urinary tract infection and urinary retention . Report findings to the supervisor immediately .

Based on interview and record review the facility failed to ensure residents felt safe voicing grievances without fear of retaliation. This applies to 10 of 10 residents (R31, R36, R45, R48, R49, R50, R63, R79, R82, R167) reviewed for grievances in the sample 23. The findings include: On March 31, 2025 at 10:10 AM, R48 stated she has had other residents tell her not to say anything about the care for fear of retaliation. R48 is a [AGE] year old admitted to the facility on [DATE]. R48 Minimum Data Set (MDS) dated [DATE] showed her to be cognitively intact. On March 31, 2025, at 11: 00 AM, R167 stated it takes 2 hours for them to answer call lights. R167 stated, If you complain you get hurt. R167 stated she has reported to the staff regarding how long it takes to get help. R167 stated after she complained the help got worse. R167 stated the staff were rough-handling her and she had even longer times to wait for assistance. On March 31, 2025 at 11:16 AM, R63 stated she had a Certified Nursing Assistant (CNA) tell her they can't change R63 every time she urinates. R63 stated they are not nice when you tell them you need something. R63 stated, I'm not here because I want to be here. I'm tired of their attitudes. R79 is [AGE] years old and was admitted to the facility on [DATE]. R79 care plan dated August 12, 2024 showed she had a self-care performance deficit. On March 31, 2025 at 11:42 AM, R79 stated when she calls for help, if they don't want to come they don't come. R79, she doesn't complain because there is no use. 2. On April 1, 2025, at 12:54 PM, a resident council meeting was held during the facility's annual survey. In attendance were R31, R36, R45, R49, R50, R82, and R167. R31's EMR (Electronic Medical Record) showed R31 was admitted to the facility on [DATE], with diagnoses that included Guillain-Barre syndrome, weakness, disorder of muscle unspecified, and muscle atrophy. R31's MDS dated [DATE], showed R31 was cognitively intact. R31 required moderate staff assistance for toileting, showering, and dressing. R36's EMR showed R36 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, muscle wasting, and phantom limb syndrome with pain. R36's MDS dated [DATE], showed R36 was cognitively intact. R36 required set-up or clean up assistance for eating and showering. R45's EMR showed R45 was admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, morbid obesity, muscle wasting and atrophy. R45's MDS dated [DATE], showed R45 had moderate cognitive impairment. R45 required moderate staff assistance with toileting, showering, and lower body dressing. R49's EMR showed was admitted to the facility on [DATE], with diagnoses that included chronic atrial fibrillation, chronic obstructive pulmonary disease, muscle wasting and atrophy of multiple sites. R49's MDS dated [DATE], showed R49 was cognitively intact and required staff moderate assistance for toileting, showering, and dressing. R50's EMR showed R50 was admitted to the facility on [DATE], with diagnoses that included disorder of the muscles, history of falls, dizziness and giddiness, weakness, and chronic obstructive pulmonary disease. R50's MDS dated [DATE], showed R50 was cognitively intact. R50 was dependent on staff for toileting, maximal assistance for showering, dressing, and personal hygiene. R82's EMR showed R82 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis without rheumatoid factor, unspecified acquired deformity of right and left hands, and muscle weakness. R82's MDS dated [DATE], showed R82 was cognitively intact. R82 was dependent on staff for toileting, and lower body dressing. R82 required maximal assistance for showering and personal hygiene. During the resident council meeting, all residents in attendance stated they were afraid to report a grievance to anyone in the facility because of fear of retaliation by the staff members. R82 said her roommate (R79) wanted to come to the resident council meeting but refused to come because she was afraid of retaliation. R167 said her roommate also refused to come to the meeting for fear of retaliation. R167 said there is retaliation by the staff members which included the staff not answering the call lights timely, not assisting them with care, and being rough with them when they do assist with care. R49 said retaliation from staff is always in the back of her mind when she has concerns and R31, R36, R45, R50, and R82 all agreed with R49. The facility's Resident Rights given at admission, show the following: The facility must ensure that you are free from retaliation and discrimination in exercising your rights. The facility's resident rights guideline revised October/2023 showed that residents have, the right to voice grievances to the staff of the facility, or any other person, without fear of discrimination or reprisal. 43389 Based on interview and record review the facility failed to ensure residents felt safe voicing grievances without fear of retaliation. This applies to 10 of 10 residents (R31, R36, R45, R48, R49, R50, R63, R79, R82, R167) reviewed for grievances in the sample 23. The findings include: On March 31, 2025 at 10:10 AM, R48 was able to be interviewed and stated she has had other residents tell her not to say anything about the care for fear of retaliation. R48 is a [AGE] year old admitted to the facility on [DATE]. R48 Minimum Data set (MDS) dated [DATE] showed her to be cognitively intact. On March 31, 2025, at 11: 00 AM, R167 stated it takes 2 hours for them to answer call lights. R167 stated, If you complain you get hurt. R167 stated she has reported to the staff regarding how long it takes to get help. R167 stated after she complained the help got worse. R167 stated the staff were rough-handling her and she had even longer times to wait for assistance. R167 stated, It puts some fear in you. On March 31, 2025 at 11:16 AM, R63 was able to be interviewed and stated she had a Certified Nursing Assistant (CNA) tell her they can't change R63 every time she urinates. R63 stated they are not nice when you tell them you need something. R63 stated, I'm not here because I want to be here. I'm tired of their attitudes. R79 is [AGE] years old and was admitted to the facility on [DATE]. R79 care plan dated August 12, 2024 showed she had a self-care performance deficit. On March 31, 2025 at 11:42 AM, R79 was able to be interviewed and stated when she calls for help, if they don't want to come they don't come. R79, said she doesn't complain because there is no use. It is not good for us. They will take actions on us. They will gang up on you. I don't want to say anything because I will get problems. They will gang up on you and we suffer. The facility's Resident rights given at admission show the following: The facility must ensure that you are free from retaliation and discrimination in exercising your rights. The facility's resident rights guideline revised 10/2023 showed that residents have, the right to voice grievances to the staff of the facility, or any other person, without fear of discrimination or reprisal.

Based on observation, interview and record review, the facility failed to assist residents, who were identified as needing assistance, with hygiene and grooming. This applies to 5 of 5 residents (R54, R81, R86, R366, R368) reviewed for ADL (activities of daily living) in the sample of 23. The findings include: 1.R81 has multiple diagnoses including disorder of the muscle and need for assistance with personal care based on the face sheet. R81's admission MDS (minimum data set) dated February 25, 2025, showed the resident is cognitively intact. The same MDS showed the resident has functional limitation in range of motion on both sides of his upper extremities and he needs assistance with personal hygiene. On March 31, 2025, at 9:52 AM, R81 was observed sitting in his wheelchair. He is alert, oriented, and verbally responsive. He was observed to have long and unkempt facial hair. When asked, R81 stated he wanted the staff to shave him. On April 1, 2025, at 9:30 AM, R81 was sitting in his wheelchair and still had long and unkempt facial hair. R81 stated he wants the staff to trim his facial hair. V2 (Director of Nursing) was present during this observation. He said to V2 food gets stuck in the hair. V2 acknowledged the resident needs facial hair grooming. R81's current care plan initiated on February 21, 2025, showed he has ADL self-care performance deficit due to decreased mobility, weakness, and other disease processes. The same care plan states R81 requires staff assistance for all ADLs. The facility's policy for ADL effective February 2023 showed under guidance, In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: bathing, dressing, grooming and oral care. 16746 2. R54 had multiple diagnoses including displaced intertrochanteric fracture of the left femur and muscle wasting and atrophy, based on the face sheet. R54's admission MDS dated [DATE] showed that the resident was moderately impaired with cognition. The same MDS showed that R54 had functional limitation in range of motion to both upper extremities and required total assistance from the staff with personal hygiene. On March 31, 2025 at 10:22 AM, R54 was sitting in her wheelchair inside her room. R54 was alert and oriented. R54's fingernails were long and jagged. According to R54 she had asked the staff several times for her fingernails to be trimmed and no one had assisted her with the trimming. On April 1, 2025 at 9:38 AM, R54 was sitting in her wheelchair inside her room. R54 was alert and oriented. R54's fingernails were long and jagged. R54 stated that she wanted the staff to trim her fingernails. V2 (Director of Nursing) was present during the observation and acknowledged that R54's fingernails were long and needed to be trimmed. R54's active care plan initiated on March 12, 2025 showed that the resident has ADL self-care performance deficit related to decreased mobility, weakness, and other disease processes. The same care plan showed that R54 required staff assistance for all ADLs. 3. R366 had multiple diagnoses including acute respiratory failure with hypoxia, and muscle wasting and atrophy, based on the face sheet. R366's admission MDS dated [DATE] showed that the resident was cognitively intact. The same MDS showed that R366 had functional limitation in range of motion to both upper extremities and required assistance from the staff with personal hygiene. On March 31, 2025 at 11:34 AM, R366 was sitting in her wheelchair inside her room. R366 was alert and oriented. R366's fingernails were long, jagged with black substances under some of her fingernails. R366 wanted the staff to trim and clean her fingernails. On April 1, 2025 at 9:16 AM, R366 was in bed, alert and oriented. R366's fingernails were long, jagged with black substances under some of her fingernails. In the presence of V2, R366 stated that she wants the staff to trim and clean her fingernails. V2 acknowledged that R366's fingernails needed trimming and cleaning. R366's active care plan initiated on March 26, 2025 showed that the resident has ADL self-care performance deficit related to decreased mobility, weakness, and other disease processes. The same care plan showed that R366 required staff assistance for all ADLs. 4. R368 had multiple diagnoses including multiple sclerosis, muscle wasting and atrophy, stiffness of the left and right hand, and functional quadriplegia, based on the face sheet. R368's admission MDS dated [DATE] showed that the resident was cognitively intact. The same MDS showed that R368 had functional limitation in range of motion to both upper extremities and required assistance from the staff with personal hygiene. On March 31, 2025 at 10:53 AM, R368 was sitting in his motorized wheelchair inside his room. R368 was alert and oriented. R368's fingernails were long and jagged. The resident wanted the staff to trim his fingernails. On April 1, 2025 at 9:46 AM, R368 was in bed, alert and oriented. R368's fingernails were long and jagged. R368 stated that he wants the staff to trim his fingernails. V2 was present during the observation and acknowledged that the resident needs assistance with fingernails trimming. R368's active care plan initiated on February 10, 2025 showed that the resident has ADL self-care performance deficit related to multiple sclerosis, decreased mobility, weakness, and other disease processes. The same care plan showed that R368 requires staff assistance for all ADLs. On April 2, 2025 at 9:35 AM, V2 stated that it is part of the nursing care and service, and the staff are expected to assist residents needing assistance with ADL including trimming of facial hair and nail care to ensure and maintain resident's good hygiene and grooming. 41855 5. R86's EMR (Electronic Medical Record) showed R86 was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes, morbid obesity, weakness, dependence on supplemental oxygen, and dependence on other enabling machines and devices. R86's MDS (Minimum Data Set) dated March 12, 2025, showed R86 was cognitively intact and was dependent on staff for toileting, showering/bathing, and personal hygiene. R86 was incontinent of bowel. R86's care plan showed R86 had an ADL (Activity of Daily Living) self-care performance deficit related to decreased mobility and weakness, related to respiratory failure, morbid obesity, pain, weakness and disease process. The interventions included staff are to provide assistance as needed for transfers, walk in room, walk in corridor, bathing dressing, eating, toileting hygiene, and oral hygiene ADLs. On March 31, 2025, at 9:52 AM, R86 was in bed and there was a foul odor noted when standing next to the bed. R86 had long facial whiskers and said he needs help to shave because he cannot see to do it himself. R86 said he prefers bed baths and his scheduled days are Monday and Thursday. R86 said his last bed bath was last Monday (March 24, 2025). R86 said if it is not his shower day, they do not offer to provide any care at all. R86's urinal with 800 ml (Milliliters) was sitting on his over the bed tray table. R86 said was sitting there when the staff brought his breakfast tray. He said the staff just set his breakfast next to the urinal. At 12:07 PM, urinal with 400 ml sitting on his over the bed tray table. At 12:55 PM, Resident was eating lunch in his room, tray was on the over the tray table next to his urinal which had 400 ml of urine. Resident said this bottle has been sitting for a while, since before they brought my lunch tray. R86 said he is not able to get out of bed to use the bathroom and that is why he has the urinal and not able to empty it himself. On April 2, 2025, at 10:03 AM, V2 (DON/Director of Nursing) stated that on non-shower days the expectation is that the CNAs (Certified Nurse Assistants) still provide hygienic care to the resident and that includes washing face, hands, perineal care, underarms, oral hygiene, combing hair, and dressing. V2 added that normally residents get shaved on shower days, but it can be done whenever needed. V2 stated that nail care should be done when needed and that staff from activities will also go around and help with nail care for the residents. V2 stated that emptying the urinal is part of R86's toileting care.

Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications, and failed to ensure that narcotic medication is stored in a sealed packaging. This applies to 4 of 5 residents (R5, R32, R91, R315) reviewed for controlled medications in the sample of 23. The findings include: 1. On April 1, 2025, at 4:12 PM, controlled medication was counted with V9 (Nurse) of the 700 hallway's medication cart. R315's blister pack of Tramadol HCl 50 mg (milligrams) with 16 tablets remaining that were intact and sealed. R315's controlled drug receipt/record/disposition form for the Tramadol showed that there should be 17 remaining in the blister pack. V9 stated that he gave a tablet of Tramadol to R315 earlier and he forgot to sign it out. 2. On April 1, 2025, at 4:41 PM, controlled medication was counted with V25 (Nurse) of the 600 hallway's medication cart. R5's blister pack of Tramadol HCl 50 mg has 1 tablet remaining (tablet number 1). The seal of the packaging of tablet number 1 was broken and taped over. On April 1, 2025, at 5:10 PM, controlled medication was counted with V8 (Nurse) of the 100 hallway's medication cart and the following were observed: 3. R91's blister pack of Lorazepam 0.5 mg number 15 tablet was torn. 4. R32's blister pack of Methylphenidate 10 mg with 10 tablets remaining that were intact and sealed. R32's controlled drug receipt/record/disposition form for the Methylphenidate showed that there should be 11 remaining in the blister pack. V8 stated that she gave a tablet of Methylphenidate earlier to R32. On April 2, 2025, at 1:46 PM, V2 (Director of Nursing/DON) stated that as soon as the nurse pulls out a narcotic medication from the container, the nurse must sign it out at the controlled drug receipt/record/disposition form for accurate tracking or inventory of the medication. If a narcotic packaging is torn, the nurse should not tape it over, but instead they should discard it with another nurse as witness to prevent potential diversion of drugs. The facility's Policy and Procedure for Controlled Substances dated October 25, 2014, shows: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedures: D. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the administration record (MAR): 1. Date and time of administration. 2. Amount administered. 3. Remaining quantity. 4. Initial of the nurse administering the dose, completed after the medication is actually administered. E. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose.

Based on observation, interview, and record review, the facility failed to label medication for the date it was opened to determine expiration date. The facility also failed to remove medication upon its used by date. This applies to 4 of 6 residents (R4, R32, R33, R315) reviewed for labeling and storage of medication in the sample of 23. The findings include: On April 1, 2025, from 3:56 PM to 5:10 PM, medication carts and medication room inspection was conducted with V8, V9, and V25 (All Nurses) and the following were observed: 1. R315's Trelegy Ellipta (Fluticasone furoate, umeclidinium, and vilanterol inhalation powder) 100 mcg/62.5 mcg/ 25mcg was opened and not dated. The Pharmacy Audit Assistance Service ([NAME]) form shows to discard 6 weeks after this medication was opened. 2. R32's Trelegy 200 mcg/62.5 mcg/25 mcg was opened and not dated. [NAME] form shows to discard 6 weeks after this medication was opened. 3. R4's Fluticasone propionate/Salmeterol Inhaler 250 mcg-50 mcg showed that it was opened on 1/20/25 and used by 2/20/25. [NAME] shows to discard 1 month after it was opened. In addition, R4's Incruse Ellipta 62.5 mcg opened and not dated. [NAME] shows to discard this medication 6 weeks after it was opened. 4. R33's Arnuity Ellipta 100 mcg (Fluticasone Furoate) was opened and not dated. [NAME] shows to discard 6 weeks after this medication was opened. On April 2, 2025, at 1:36 PM, V2 (Director of Nursing/DON) stated the staff must date all insulin, inhalers, eye drops, upon opening to determine expiration date based on manufacturer's guidelines.

Based on observation, interview and record review, the facility failed to follow the menu extension sheet to provide portions as shown for mechanical soft and pureed consistency diets. This applies to 6 of 6 residents (R2, R14, R17, R19, R33, and R34) reviewed for dining. The findings include: Week at a glance menu for week 2 (Monday) lunch meal included Lemon Baked Tilapia and Sliced Zucchini, Dinner roll. Facility menu extension sheet for mechanical soft diets showed to serve 1 each [piece] of Lemon Baked Tilapia. The extension sheet for pureed diets showed to provide 1/2 cup pureed Lemon Baked Tilapia and 1/3 cup pureed zucchini. Facility Portion Control Chart for scoops showed as follows in cups or oz (ounce) capacity. #16=1/4 cup or 2 oz, #12 =1/3 cup , #10 =3 oz, #8 =1/2 cup or 4 oz On March 31, 2025 at 12:07 PM, V6 (Cook) was platting the food for the lunch meal service in the facility kitchen. V6 used a #16 scoop to serve ground Lemon Baked Tilapia and R2, R14, R17, R33, and R34 who were on mechanical soft diets received the same. V6 used two #16 scoops to serve pureed Lemon Baked Tilapia and one #16 scoop pureed zucchini to R19 who was on a pureed diet with double protein. R19 did not receive pureed soup nor pureed bread. On March 31, 2025 at 12:50 PM, V5 (Dietary Manager) was asked how many ounces one piece of Lemon Baked Tilapia was and why the scoop size for mechanical soft Lemon Baked Tilapia was not listed on the menu. V5 responded I have no idea. I am not a big fan of this menu program. The lady who helps with the program is on vacation. V5 was shown the scoop sizes used on the tray line for above diets observed, V5 stated that V6 should have provided the portion sizes as shown on the menu for pureed diets. V5 stated that she will consult with the menu services to report back on serving portions for mechanical soft diets. V5, on checking with V6, stated that the pureed soup and pureed bread was not prepared. V5 added that soup is an always available item served on the menu for all consistency diets. On April 2. 2025 at 9:50 AM and 2:10 PM, V18 (Dietitian) stated that Lemon Baked Tilapia is 3 oz portion and that the facility should have used a #10 scoop instead of the #16 scoop for the mechanical soft diets in order to receive 3 oz portions. V18 stated that the facility should have used #8 scoop to provide 1/2 cup portion of pureed Lemon Baked Tilapia instead of using #16 scoop and that for double portions protein the resident should receive two #8 scoops. V18 stated that the facility should have used a #12 scoop to serve 1/3 cup of pureed zucchini instead of using the #16 scoop. V18 added that the Pureed diets should receive whatever is offered to other residents. Facility Diet Type Report listing diet orders of residents printed on March 31, 2025, showed that R2, R14, R17, R33, and R34 were on mechanical soft consistency diets, and R19 was on pureed diet with double protein.

Based on observation, interview, and record review, the facility failed to follow infection control practices during provisions of ADL (Activities of Daily Living) care, medication pass, or while providing therapy services. This applies to 6 of 6 residents (R15, R86, R111, R265, R365, R366) reviewed for infection control in the sample of 23. The findings include: 1. R86's EMR (Electronic Medical Record) showed R86 was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes, morbid obesity, weakness, dependence on supplemental oxygen, and dependence on other enabling machines and devices. R86's MDS (Minimum Data Set) dated March 12, 2025, showed R86 was cognitively intact and was dependent on staff for toileting, showering/bathing, and personal hygiene. R86 was incontinent of bowel. R86's care plan showed R86 had an ADL (Activity of Daily Living) self-care performance deficit related to decreased mobility and weakness, related to respiratory failure, morbid obesity, pain, weakness and disease process. The interventions included staff are to provide assistance as needed for transfers, walk in room, walk in corridor, bathing dressing, eating, toileting hygiene, and oral hygiene ADLs. On March 31, 2025, at 9:52 AM, R86 was in bed with his over the bed tray table in front of him. He had a urinal with 800 ml (milliliters) of urine sitting on his over the bed tray table. R86 said it was sitting there since before breakfast. R86 said the staff delivered his tray and just left the urinal with urine sitting next to his breakfast tray. At 12:07 PM, R86 had a urinal with 400 ml of urine in it sitting on his over the bed tray table. At 12:55 PM, R86 was eating his lunch in bed and his urinal with 400 ml urine in it was sitting next to his lunch tray. R86 said this was the same urine from earlier. On April 2, 2025, at 8:04 AM, R86 had 450 ml of urine in his urinal sitting on his over the bed tray table next to his breakfast tray. On April 2, 2025, at 8:15 AM, V2 (DON/Director of Nursing) went into R86's room with surveyor and saw the urinal on the over the bed tray table next to his breakfast tray. V2 said the staff should be emptying the urinal and not leaving a urinal with urine on the over the bed tray table especially when eating meals. 36567 2. R265's face sheet included diagnoses including extended spectrum beta lactamase (ESBL) resistance, neuromuscular dysfunction of bladder, unspecified, urinary tract infection, site not specified, encounter for fitting and adjustment of urinary device, other abnormalities of gait and mobility. R265's POS (Physician Order Summary) showed EBP (Enhanced Barrier Precautions) due to indwelling urinary catheter. On April 1, 2025 at 10:41 AM, R265's doorway had a signage of Enhanced Barrier Precautions. Signage included directives that providers and staff should wear gloves and gown for following high contact resident care activities including transferring. Outside the room door there was a bin that contained PPE (personal protective equipment) that included gloves and gown. Two staff members (V19 Occupational Therapist and V20 Physical Therapist) were noted going into R265's room and after applying gloves was seen holding R265 by the gait belt and arm while walking R265 back and forth in the room, guiding R265 as he used his walker. R265 had an indwelling catheter and was wearing a hospital gown. R265's nurse V17 (Registered Nurse), who was in the hallway, stated that V19 and V20 are from therapy. V17 stated that R265 is on EBP related to his indwelling catheter and his roommate R2 is also on EBP for having a colostomy bag. V2 (DON) who also was in the vicinity stated that V19 and V20 should be wearing gloves and gown when providing physical therapy as R2 is on EBP. Facility policy titled Enhanced Barrier Precautions (revised March 21, 2024) included as follows: It is the practice of this facility to implement enhanced barrier precautions for prevention of transmission of multi drug-resistant organisms. Definitions: Enhanced barrier precautions refer to use of gown and gloves for use during high-contact resident care activities for residents to be colonized or infected with MDRO [multi drug-resistant organisms] as well as those at increased risk of MDRO acquisition (Example: residents with wounds or indwelling medical devices). Enhanced barrier precautions should be followed outside the residents room . when working with residents in the therapy gym, specially when anticipating close physical contact while assisting with transfers and mobility, or high contact activity. 29562 3. On March 31, 20225, at 5:11 PM, V8 (Nurse/RN) administered insulin to R15. V8 removed the cap of R15's insulin needle and dropped the syringe causing the needle to make direct contact to R15's blanket. V8 picked up the syringe and proceeded to administer the medication to R15 without discarding the old syringe and drawing a new insulin syringe. 4. On April 1, 2025, at 9:00 AM, V9 (Nurse/LPN) prepared 9 different medications and vitamins in a tablet form. V9 placed the medications in a medicine cup and handed it to R111. R111's hands were unsteady, and she dropped the medicine cup. The medicines spilled all over her lap and wheelchair. V9 picked the medications with bare hands and handed it back to R111. Again, R111 took the medicine cup from V9 and accidentally dropped it and V9 picked it up again bare handed and gave it to R111 to take. R111 was able to eventually take all the same medications all over her lap and wheelchair and touched by V9's bare hands. On April 1, 2025, at 12:28 PM, V2 (DON) stated that when a nurse accidentally dropped an open insulin syringe and the needle contacted an object or surface, the nurse must discard the contaminated syringe and must prepare a clean a new one. If the oral medications were dropped on the resident's lap, wheelchair or floor, the nurse must clean it up and prepare new set of medications. This must be done because the medications were potentially contaminated. 16746 5. R365 had multiple diagnoses including sacral region pressure injury, and acute local infection of the skin and subcutaneous tissue, based on the face sheet. On March 31, 2025 at 11:02 AM, R365 was in bed, alert, oriented and verbally responsive. While donning a gown and a pair of gloves, V15 (Licensed Practical Nurse) handled the urinary catheter bag of R365 to check for sediments and then reposition the said catheter bag. While using the same pair of gloves, V15 was about to touch R365's right upper arm PICC (Peripherally Inserted Central Catheter) line. V15 had to be prompted to remove his used gloves, perform hand hygiene and put on a new pair of gloves before touching/handling R365's PICC line. On April 1, 2025 at 2:33 PM, V2 (DON) stated that V15 should remove his gloves after handling R365's urinary catheter bag, perform hand hygiene then put on a new pair of gloves, before touching/handling the resident's PICC line. V2 added that this is performed to prevent cross contamination and prevent infection. 6. On April 1, 2025 at 8:59 AM, V7 (Registered Nurse) prepared R366's medications, including Aspirin. V7 poured three Aspirin tablets inside the said medication container cap/lid, then she (V7) used her ungloved finger to get one of the Aspirin tablet out of the container cap, transferred it inside the medication cup and then administered the Aspirin tablet and the rest of the medications to R366. After administering the medications (consisting of tablets and capsule) to R366, V7 put on a pair of gloves and touched R366's left arm to check for edema. V7 then removed R366's socks and palpated both of the resident's lower extremities to check for edema. After the procedure, using the same gloved hands, V7 picked up the medication cup containing R366's Nystatin suspension medication and handed the said medication cup to the resident to take. On April 2, 2025 at 9:38 AM, V2 stated that nurses should not touch a resident's medications using bare hands or fingers. V7 should use a spoon or put on gloves to take the medication out from the container cap/lid to ensure not touching the medication with bare finger. V2 also stated that V7 should remove her gloves after touching R366 to check for edema on the arm and lower extremities. After removing the gloves, V7 should perform hand hygiene, either use of alcohol rub or washing hands, then re-gloved, before handling R366's Nystatin suspension medication cup. According to V2, this is to prevent cross contamination and to maintain infection control. The facility's glove use guideline last revised on August 2024 showed in-part, Sterile gloves and examination gloves are removed and placed into appropriate waste containers: .d. Before moving from a contaminated surface/area to an uncontaminated surface/area.

Based on observation, interview and record review, the facility failed to ensure that the electronic monitoring alarm control panel was functioning. This applies to 4 of 4 resident (R48, R58, R70, R95) reviewed for use of electronic monitoring devise in the sample of 23. The findings include: 1. R58 had multiple diagnoses including dementia without behavioral disturbance and Alzheimer's disease, based on the face sheet. R58's admission MDS (minimum data set) dated February 26, 2025 showed that the resident was cognitively impaired. On March 31, 2025 at 11:17 AM, R58 was in bed and had an electronic monitoring device on his left ankle. According to V15 (Licensed Practical Nurse), the resident had the monitoring device because R58 would attempt to leave the facility, especially at night. R58's progress notes dated March 13, 2025 at 5:18 PM, created by Social Service showed in-part, Social Service informed by [Director of Nursing] that [R58] was exit-seeking. Social Service completed elopement risk assessment. Upon completion of assessment, it is noted that the resident is high risk for elopement. An [electronic monitoring device] was placed for monitoring on [R58's] left ankle. Advised representative [family] of resident exit seeking behaviors and monitoring device being placed on the resident. Family verbalized understanding and reason for elopement monitoring. R58's elopement risk assessment dated [DATE] showed that the resident is high risk for elopement. R58 had an active physician order dated March 13, 2025 for an electronic monitoring device. On April 1, 2025 at 9:53 AM, R58 was observed with an electronic monitoring device on his left ankle. At 3:23 PM, the facility was requested to test the electronic monitoring device to ensure that it was functioning. V2 (Director of Nursing) stated that the facility checks the electronic monitoring device for functioning by bringing the resident to the exit doors. R58 was walking independently with V1 (Administrator) to the front lobby/main door to test the electronic monitoring device. When R58 reached the main door, the electronic monitoring alarm control panel did not activate, and no alarm sounded. The electronic monitoring alarm control panel that was mounted on the wall close to the main door was not lit to indicate that there was power on it. V23 (Maintenance Director) checked the alarm control panel and confirmed that there was no power on it, which was why it was not alarming when R58 was close to the front lobby/main exit door. At 3:45 PM, V23 stated that he spoke to the electronic monitoring device company and was informed that the transformer of the alarm control panel was not working, and it needs to be replaced. On April 2, 2025 at 9:45 AM, V2 (Director of Nursing) stated that the facility has four residents (R48, R58, R70 and R95) identified as high risk for elopement. V2 stated that the facility expects for the electronic monitoring device and alarm control panels on all exit doors to be always functioning, to ensure the safety of the residents who are elopement risk. 2. R48 had multiple diagnoses including dementia with other behavioral disturbance, restlessness and agitation and cognitive communication deficit, based on the face sheet. R48's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition. The same MDS showed that R48 uses wheelchair for mobility and can also ambulate with moderate assistance from the staff. On April 2, 2025 at 12:09 PM, R48 was observed sitting in her wheelchair inside the main dining room. R48 had an electronic monitoring device on her left ankle. V2 stated that R48 uses her wheelchair for locomotion. According to V2, R48 is high risk for elopement. R48's elopement risk assessment dated [DATE] showed that the resident is high risk for elopement. R48 had an active physician order dated June 27, 2024 for an electronic monitoring device. 3. R70 had multiple diagnoses including vascular dementia without behavioral disturbance, based on the face sheet. R70's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition. The same MDS showed that R70 uses wheelchair for mobility. On April 2, 2025 at 12:08 PM, R70 was observed sitting in her wheelchair inside the main dining room. R70 had an electronic monitoring device on her right ankle. V2 stated that R70 uses her wheelchair for locomotion. According to V2, R70 is high risk for elopement. R70's elopement risk assessment dated [DATE] showed that the resident is high risk for elopement. R70 had an active physician order dated February 28, 2025 for an electronic monitoring device. 4. R95 had multiple diagnoses including dementia without behavioral disturbance, based on the face sheet. R95's quarterly MDS dated [DATE] showed that the resident was moderately impaired with cognition. The same MDS showed that R95 uses wheelchair for mobility and can also ambulate with supervision or touching assistance from the staff. On April 2, 2025 at 12:10 PM, R95 was observed sitting in a regular chair inside the main dining room. R95's rolling walker was beside her. R95 had an electronic monitoring device on her right ankle. V2 stated that R95 ambulates using a rolling walker. According to V2, R95 is high risk for elopement. R95's elopement risk assessment dated [DATE] showed that the resident is high risk for elopement. R95 had an active physician order dated February 28, 2025 for an electronic monitoring device. The facility's elopement and search guideline revised on September 4, 2024 showed in-part, 5. Residents who have been identified as cognitively impaired and who have been assessed as an elopement risk will be provided with an elopement prevention device (arm or ankle bracelet). 6. Bracelets will be observed for placement and checked for function daily. Facility exit door alarms are checked daily for function. All personnel are responsible for promptly reporting/replacing malfunctioning elopement prevention devices. Maintenance is responsible for fixing/replacing any exit doors that do not alarm.

Based on observation, interview and record review the facility failed to assess and provide appropriate adaptive eating equipment to maintain ability to eat independently for a resident identified with limited range of motion on the upper extremities. This applies to 1 of 1 resident (R51) reviewed for adaptive eating equipment in the sample of 23. The findings include: R51 had multiple diagnoses including dementia without behavioral disturbance, cerebral infarction, cerebral ischemia and cognitive communication deficit, based on the face sheet. R51's quarterly MDS (minimum data set) dated January 8, 2025 showed that the resident was severely impaired with cognition. The same MDS showed that R51 had functional limitation to both upper extremities and required setup or clean-up assistance from the staff with eating. On March 31, 2025 at 12:58 PM, R51 was sitting in her recliner wheelchair inside the first floor main dining room. R51 was eating her lunch meal independently. R51 was not able to move her left arm and hand and uses only her right hand to eat using a fork. While attempting to get/scoop her food consisting of baked fish and rice, most of the food fell out of her plate to the table and while eating, some of her food fell on the resident's protective clothing because, R51 was having a hard time bringing the fork with food to her mouth. No staff assisted R51 during this meal observation. During the same meal observation V21 (Restorative Nurse) removed a chunk of fish from R51's protective clothing, but no assistance was provided to the resident to ensure that the resident consumes the rest of her meal. On April 1, 2025 at 12:48 PM, R51 was sitting in her recliner wheelchair inside the first floor main dining room. R51 was eating her lunch meal independently. R51 was not able to move her left arm and hand and uses only her right hand to eat using a fork. While attempting to get/scoop her food consisting of stuffed cabbage roll, two chunks of meat fell on the floor and while eating the cabbage, some of it fell on the resident's protective clothing. R51 was observed getting the cabbage that fell on her protective clothing using her right hand fingers and eating it. During this meal observation, no staff assistance was provided. At 1:02 PM, V22 (Restorative Certified Nursing Assistant) removed the cabbage from R51's protective clothing and started to assist R51 with eating. During this time, V2 (Director of Nursing) was called to the main dining room. It was pointed to V2 that two chunks of meat from the stuffed cabbage roll fell on the floor while R51 was attempting to get/scoop her food. V2 was also informed of R51's lunch meal observation on March 31, 2025. V2 was asked if R51 was assessed for the need to use any adaptive equipment for eating. V2 stated that she will ask the restorative department or the therapy department to assess R51. R51's restorative nursing program documentation dated April 1, 2025 at 3:26 PM created by V21 (Restorative Nurse) showed, that eating restorative program was assessed. The restorative nursing program documentation showed that R51 had limited ability to feed self independently. The goal was for R51 to feed self, using a scoop plate as adaptive equipment and the staff to assist R51 as needed daily. The same program documentation showed, She participates with occasional cueing and staff assist as needed. Resident continues to spill food occasionally during self-feed but does benefit from a scoop plate. On April 2, 2025 at 9:28 AM, V21 stated that she assessed R51 on April 1, 2025 after lunch, for the need for adaptive eating equipment to aide in resident self-feeding. V21 stated that based on her assessment, R51 needed a scoop plate as an adaptive eating equipment to prevent her food from spilling out of her plate and to improve her ability to eat independently. V21 added that R51 can grip the regular utensils like fork or spoon and the resident does not need a special utensil. During the same interview, V21 stated that the staff should provide cueing and/or assistance to R51 as needed to ensure nutritional intake. On April 2, 2025 at 9:43 AM, V2 (Director of Nursing) stated that as part of the nursing care and services, the nursing staff are expected to report to the nurse or to the therapy or restorative department any resident needing adaptive eating equipment or utensils, to ensure that the resident is assessed appropriately and promptly, so that needed adaptive eating equipment or utensils could be provided to ensure nutritional intake.

Based on observation, interview and record review, the facility failed to provide lunch meal options of similar nutritive value to the main entree. This applies to 2 of 2 residents (R32, R266) reviewed for dining in the sample of 23. The findings include: Week at a glance menu for week 2 (Monday) lunch meal included Lemon Baked Tilapia, Wild [NAME] Blend and Sliced Zucchini. Facility Alternate Menu listing included grilled cheese sandwich. On March 31, 2025 on 12:12 PM and 12:24 PM during lunch meal service, R32 and R266 received a grilled cheese sandwich with a side of zucchini. R32 and R266 meal tickets showed that they had ordered the grilled cheese sandwich in substitute for the main meal. V6 (Cook) who prepared the sandwiches stated that he used 2 slices of American cheese with 2 slices of bread to make the grilled cheese sandwich. Nutrition facts for American cheese slices included that 1 slice has 3 grams protein. On April 2, 2025 at 2:10 PM, V18 (Dietitian) stated that Lemon Baked Tilapia is a 3 oz/ounce portion. V18 stated that 1 oz =7 grams of protein and that 3 oz portion=21 grams of protein. V18 agreed that since only 2 slices of cheese was used to make the grilled cheese sandwich, the item only had 6 grams of protein. V18 also agreed that the facility should have offered an additional item to provide 21 gram of protein for the substitute meal to meet the nutrition needs for the meal. Facility policy titled Selective Menus (effective June 2023) included as follows: Policy: It is the Policy of [facility] if selective meals are offered, selections will be provided within allowed dietary modifications Purpose: The purpose of this policy is to create nutritious menus and portion control in which will be freshly prepared and served by culinary chefs at the communities and to identify the basic factors involved in menu planning.

Based on observation, interview, and record review, the facility failed to follow physician's order during medication administration. There were 26 medication opportunities with 2 errors resulting to 7.69% medication error rate. This applies to 1 of 4 residents (R15) reviewed for medication administration in the sample of 23. The findings include: On March 31, 2025, at 5:05 PM, V8 (Nurse/RN) prepared and administered multiple medications to R15 including, 10 milliliters (ml) of Lactulose Solution (10 mg/15/ml) orally and 6 units of Novolog (Aspart) to R15 subcutaneously. Prior to medication administration R15's blood sugar level was checked, and the result showed 213 mg/dl (milligrams per deciliter). R15's Medication Administration Record (MAR) dated March 2025, showed that R15 is supposed to receive Lactulose 30 ml (20 grams) and the Novolog sliding scale shows that R15 is supposed to receive 4 units based on his blood sugar reading of 213. On April 1, 2025, at 12:21 PM, V2 (Director of Nursing/DON) stated the nurse must administer medication per physician order. They should follow the 5 rights of administering medications which include right dose. Facility's medication administration policy and procedure with effective date of October 25, 2014, shows: Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review, the facility failed to follow physician's order for oxygen administration. The facility also failed to change the oxygen tubing and maintain water level in humidifier bottle per facility's policy and procedure. This applies to 1 of 1 resident (R81) reviewed for oxygen therapy in the sample of 23. The findings include: R81 has multiple diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen based on the face sheet. On March 31, 2025, at 9:52 AM, R81 was observed sitting in his wheelchair. R81 had oxygen via nasal canula at one liter per minute using an oxygen concentrator. The oxygen tubing was dated March 23, 2025. The water in the humidifier bottle was almost empty and there were no bubbles noted. There was no date on the humidifier bottle. On April 1, 2025, at 9:30 AM, R81 was sitting in his wheelchair. V2 (Director of Nursing) was present during this observation. V2 was asked to look at the oxygen concentrator. She acknowledged that the tubing was dated March 23, 2025, and the patient was receiving one liter per minute of oxygen. V2 stated the oxygen tubing is changed weekly every Wednesday and as needed. R81's current physician's order dated February 26, 2025, showed an order for continuous oxygen at two liters per minute via nasal canula. R81's current care plan initiated on February 19, 2025, showed R81 has chronic obstructive pulmonary disease, obstructive sleep apnea, and hypoxia. Under interventions, it showed oxygen to be administered as directed. On April 2, 2025, at 9:41 AM V2 (Director of Nursing) acknowledged physician orders need to be followed for oxygen administration since oxygen is a medication. The oxygen tubing is to be changed weekly and as needed for infection control purposes. V2 also acknowledged humidifier bottles on oxygen concentrators need to have appropriate water level and it should be bubbling when in use to provide moisture to the residents. The facility's policy for oxygen administration last revised in March 2004 showed under preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Under steps in the procedure showed in-part, 11. Periodically re-check water level in humidifying jar.

Based on observation, interview, and record review, the facility failed to ensure that foot care is provided for a resident who needs total assistance for personal care. This applies to 1 of 1 resident (R56) reviewed for foot care in the sample of 23. The findings include: Face sheet shows R56 is [AGE] years-old who has multiple medical diagnoses including needs for assistance with personal care, Alzheimer's disease with late onset. Minimum Data Set (MDS) dated [DATE], shows that R56 has severe cognitive impairment and requires total care for all her activities of daily living. On April 1, 2025, at 1:45 PM, R56 was lying in her bed, she was non-verbal and displayed flat affect. V13 (Nurse/LPN), removed R56's socks and revealed skin flakes and very dry skin on the feet. R56's toenails were noted to be overgrown on both feet. V13 measured. R56's toes were all in its proper upright position, however, all her left and right toenails grew sideways each measuring 0.5 centimeter (cm) in length on the small toes. The left big toenail which was also overgrown was slightly misaligned from the toe. The bottom left side of the left big toenail separated from the nail matrix and cuticle creating a gap with unknown black substance in between. While the right big toenail was sticking sideway as well measuring 1.8 cm in length. On April 1, 2025, at 2:04 PM, V13 (Nurse/LPN) stated that the facility certified nursing assistants (CNA) or the hospice CNA staff should notify the nurses for R56's needs of podiatry consult for toenail clipping. It should have been clipped because it can snag into the socks which can cause discomfort or misalignment of the nails, or it can cause the nail to get pulled off the nail bed. V13 was unable to tell when R56 was last seen by the podiatrist. On April 1, 2025, at 3:04 PM, V2 (Director of Nursing (DON) stated that toenails should be assessed by the staff. If the toenails needed clipping, the staff should refer it and obtain consent from either the resident or family member for podiatry consult as needed. Care of Fingernails/Toenails Policy and Procedure dated April 2007: Purpose: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin

Based on observation, interview and record review, the facility failed to do a smoking assessment and revise the plan of care when a resident resumed smoking. This applies to 1 of 1 residents (R71) reviewed for smoking in the sample of 23. The findings include: R71's EMR (electronic medical records) showed diagnoses of type 2 diabetes mellitus with hyperglycemia, cerebral infarction, difficulty in walking, not elsewhere classified, need for assistance with personal care, history of falling. R71's POS (Physician Order Sheet) admitted to Hospice on February 6, 2025 with diagnoses of liver cancer. R71's Significant Change MDS (minimum data set) dated February 7, 2025 showed that R71 was cognitively intact. On March 31, 2025 at 10:10 AM, R71 stated I am a smoker. I smoke outside depending on the weather. My CNA (Certified Nursing Assistant) or somebody takes me. Review of R71's EMR on March 31, 2025 did not show any current Smoking Assessment or current plan of care for smoking. The same EMR showed that R71 had signed a smoking contract on April 19, 2024. Facility also provided an initial Smoking Assessment and care plan done for R71 on April 16, 2024. On April 1, 2025 at 9:57 AM, V11 (Social Service Assistant) stated that the facility fills out a smoking contract and also does an assessment and plan of care for resident's who smoke. V11 stated that he is not aware that R71 currently smokes. V11 stated that he will look into the matter and provide information. On April 1, 2025 at 10:12 AM, V11 returned with V10 (Social Service Director) who stated that V11 had done an evaluation in February 2025 and at that time R71 stated that she is not smoking. V10 stated that R71 has had a previous smoking contact in place on April 19, 2024 and an assessment and plan of care was done then. V10 stated We are hearing from nursing that she is wanting to smoke again and we are going to update her contract and review the smoking policy with R71 and do an assessment and plan of care. V10 stated that the contract is renewed and assessment and care plan done during an Annual, quarterly, significant change and as needed if the resident decides to smoke. On April 1, 2025 at 11:12 AM, R71 was seen smoking outside the facility in enclosed courtyard seated beside V16 (Hospice Volunteer). R71 had a lighter and cigarette and was able to light the cigarette by herself. R71 stated that her son provides the cigarettes and lighter. V16 stated that she visits every Friday and for the past 4 Fridays has taken R71 out to smoke. V16 stated that counting April 1, 2025, she has accompanied R71 five times. V16 stated that she gets a pouch containing cigarettes and a lighter from nursing staff as they keep the pouch in a cart. On April 2, 2025 at 11:53 AM, V24 (Registered Nurse) stated that he recalls that R71 has been smoking after she was moved to the current unit and has been more than one month. V24 stated that R71's pouch with cigarettes and lighter is kept in the cart near the nurses station. Facility policy titled Resident Smoking (effective date November 1, 2023) included as follows: Standards: It is the policy that smoking is allowed in designated smoking areas. Responsible Party: All facility personnel, residents and visitors. 2. All residents who desire to smoke will have a smoking assessment performed by a member of the Social Services Department an/or nursing department to determine if they are safe to smoke independently. The assessments will be reviewed by the interdisciplinary team for determination of appropriate interventions, if needed as well as care plan development. 3. Smoking risk assessment's are performed upon admission and quarterly or with any changes which could affect the safety of the resident. These assessments are reviewed by the interdisciplinary team for agreement and planning of interventions including adaptive devices, safety precautions and or further evaluation by therapy.

Based on interviews and record reviews, the facility failed to provide timely tracheotomy (trach) care to a resident with a tracheotomy that required suctioning as needed to maintain the airway and Oxygen levels. This failure has caused severe respiratory distress, oxygen desecration, and the need for hospitalization . This applies to 1 of 3 residents (R1) reviewed for respiratory care and treatment in a sample of 3. The findings include: R1 is a [AGE] year-old male admitted on [DATE] with an admitting diagnosis including cerebral infraction, hemiplegia, chronic respiratory failure, tracheotomy (trach), and gastrostomy. On 2/4/25 at 12:10 PM, V12 (Licensed Practical Nurse/LPN) stated that she cared for the trach resident R1 last week, who is admitted to the hospital now. V12 said R1 requires a lot of care, including oral and trach suctioning, and that she had to suction R1 thrice during her shift. V12 added that R1 was nonverbal but could nod or thump up with the caregiver's questions. The health status progress note dated 1/27/25 at 2:33 AM documents that R1 was noticed with breathing difficulty using the accessory muscle at 01:50 AM, having oxygen saturation of 86% (low levels) with oxygen delivery at 10 liters per minute. 911 was called, and R1 was transported to the nearest hospital. On 2/4/25 at 1:50 PM, V10 (Registered Nurse/RN) stated, I took care of R1 during the afternoon shift on 1/26/25. I can't tell how many times I suctioned his trach during my shift on 1/26/25. R1 is a difficult resident to care for, and we had to provide oral and trach suction as needed. I really take care of him during my shift. We have so many agency nurses working here. The nurse I endorsed R1's care on the 1/26/25 night shift was also from the agency (V11). On 2/5/25 at 11:10 AM, V8 (R1's Certified Nursing Assistant/CNA on the 1/26/25 night shift) stated, The nurse (V11) is the one who found R1 with respiratory distress. I made my rounds at 1:00 AM, and he was sleeping with little breathing noise from the trach. But he was fine as that was his normal. I don't know if V11 suctioned him after she found him in respiratory distress. She called 911 to send him out to the local hospital. On 2/4/25 at 11:35 AM, V3 (Fire Department EMS coordinator) stated, I got a report from my crews. According to my crews, R1 was in severe respiratory distress and was struggling for breath with low oxygen saturations. R1 was a trach patient who was taken to hospital via 911 two times in two weeks. We need to provide extensive suctioning at both times. He had so much mucus and secretion, and the suction wasn't done properly. On 1/27/25, R1's roommate said that R1 was struggling for almost an hour and thirty minutes, and nobody made rounds or cared for him. On 2/5/25 at 1:35 PM, V4 (Fire Department Lieutenant) stated, When we got there, no staff was present in R1's room. It was just R1 and his roommate. R1 was in poor condition with respiratory distress. The nurse told us that R1 had difficulty breathing for five minutes, but the roommate said R1 had been struggling to breathe for an hour to an hour and thirty minutes. We suctioned R1 and a significant amount of secretions came out. His oxygen saturation improved from the low 70s to the mid-90s. I did not see a mucus plug, but I heard from colleagues verbalizing it. On 2/5/25 at 12:00 PM, V5 (Fire Department Crew) stated that R1 was in respiratory distress when he arrived. R1 had been struggling so long that he looked tired of breathing. V5 continued that he didn't think the nurse had suctioned his trach and mouth, and she wasn't even there in R1's room when his team arrived. V5 also stated that the facility seemed disorganized, and V5 and his team suctioned R1's trach; a good amount of secretion came out. As soon as they suctioned him, he was much improved, and a mucus plug came out when they suctioned R1 in the ambulance. V5 added that R1's oxygen saturation improved from below 80 to over 95%, and R1's skin color returned to normal. On 2/5/25 at 1:10 PM, V6 (Fire Department Crew) stated, The nurse (V11) was not even in his room. R1 had a very difficult time breathing, and his right leg was hanging on the right side of his bed. His oxygen saturation was only mid-70s. He was breathing through the mouth; his trach was occluded. There were blood-tangled secretions on his pillow, and his trach mask was not connected to the oxygen tubing; it was disconnected. The nurse didn't mention anything about whether she had suctioned R1 or not. She said R1 had breathing difficulty for 5 minutes, and she left after handing over the paperwork. R1 roommate told my colleagues that R1 had been struggling to breathe for 60-90 minutes. On 2/5/25 at 2:45 PM, V9 (Nurse Practitioner/NP) stated, R1 has been on trach, ventilated, and had respiratory issues. He requires mouth and trach suction. Staff should suction as needed. If a trach resident is having breathing difficulties and oxygen is below 90, I would expect staff to suction his trach and mouth and call 911, as he is in respiratory distress. On 2/4/25 at 1:05 PM, V2 (Director of Nursing/DON) stated that R1 was producing a lot of secretions, and they had suction set up at the bedside to suction him. V2 continued that on 1/26/25, at midnight, an agency nurse (V11) took over R1's care, and a couple of hours later, V11 called my ADON (Assistant Director of Nursing) and called 911 due to R1 being tachycardic and using accessory muscles to breathe. V2 added that she didn't have any documentation proving that V11 suctioned R1 while he struggled to breathe. The order was to suction as needed. On 2/5/25 at 11:50 AM, V2 also stated that if she sees a resident with a trach is having breathing difficulties and if oxygen is below 90%, she will suction him to improve his oxygen level. R2 (R1's roommate on 1/26/25) is a [AGE] year-old male admitted on [DATE] with cognition intact as per the MDS dated [DATE]. On 2/4/25 at 12:30 PM, R2 stated, R1 was his roommate on 1/26/24 when he transferred to the hospital. R1 was gaging and choking that night. Sometimes they suction him, and sometimes they don't. The afternoon shift nurse (V10) tried to suction him. He was coughing with bloody sputum. The night nurse was from an agency, and she was not qualified to suction R1. She called 911. R1 might have had that breathing difficulty for 30-90 minutes. On 2/5/25 at 10:00 AM, R2 added, When R1 was having breathing difficulty on 1/27/25 in the early morning, the CNA (V8) called the nurse (V11), and she came in, and I don't remember if V11 suctioned R1. R1 was making some specific unusual sounds with a mouthful of phlegm. The night nurse (V11) was from the agency. R1 was suctioned during the previous shift by V10. V11 told the EMS (Emergency Medical Service) that R1 had breathing difficulty for 10 minutes. But he had that difficulty for 30-60 minutes. A review of R1's care plan documents that R1 was care planned for shortness of breath related to respiratory failure, with interventions including maintaining a clear airway by encouraging the resident to clear their own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear them. The facility provided Tracheotomy Care policy (revised June 2005) document: Provide tracheotomy care as often as needed, at least once per shift, and PRN. On 2/5/25 at 10:40 AM, V13 (Ombudsman) stated that she receives many complaints from residents. The fire department called her and reported that the facility was not suctioning R1, causing severe respiratory distress and hospitalization .

Based on interview and record review, the facility failed to monitor a resident who was having a decline in health condition. This applies to 1 of 3 residents (R1) reviewed for change in health condition. The findings include: R1 face sheet documents that R1 is a [AGE] year old admitted to the facility July 13, 2024 with multiple diagnoses including: unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, heart failure, sepsis, end stage renal disease, dependence on renal dialysis, colostomy status, cutaneous abscess of abdominal wall, psoas muscle abscess, methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, elevated prostate specific antigens, cognitive communication deficit, chronic kidney disease, unspecified, pressure ulcer of sacral region and muscle wasting. R1's history of present illness shows that R1 was sent from the nursing home on September 25, 2024 with progressive lethargy and loss of consciousness and found to have seizures, in status, and was intubated. R1's EEG report dated September 27th shows that R1 has multiple episodes of generalized electrographic abnormality consistent with electrographic seizures. The findings were consistent with electrographic status epilepticus. Marked diffused slowing into delta range was noted. This constellation of findings can be seen in encephalopathy due to metabolic/toxic etiology, medication effects or diffuse cerebral injury. The physical therapy treatment notes dated October 10, 2024, shows R1 was diagnosed with UTI, acute respiratory failure, encephalopathy, and seizures. R1 was intubated on September 26, 2024, for airway protection and was extubated on October 3rd. Progress Note dated 9/25/24 shows that R1 was sent to the hospital for change in condition status. R1's hospital medical records shows: R1 was seen in the emergency department from the nursing home, and was admitted in the hospital on September 25, 2024, due to altered mental status, less oral intake, and sleeping all day. On October 29, 2024, at 11:26 AM, V4 (Nurse) stated R1's normal baseline condition was that he was alert and oriented, he was able to talk to the staff, was able to eat on his own, and he usually likes to sit on his wheelchair. V4 added that on the morning of September 23, R1 was sleeping, had no energy and could not feed himself. According to V4, the staff fed him for breakfast and lunch but R1 had a poor appetite. R1 went out for dialysis in the afternoon and continued to be lethargic. V4 stated that R1 remained lethargic the next day and reported the change to V2 (RN-Director of Nursing). V2 instructed V4 to contact the physician, V3. V4 could not confirm if the physician was called September 24 about R1's status. V4 stated that R1 continued to be sleepy and needed assistance with meals. V4 stated she endorsed R1's status to V5 (Nurse) who was working the evening shift to monitor R1 closely due to change in condition On October 29, 2024, at 3:07 PM, V11 (Certified Nursing Assistant/CNA) stated that R1 was alert and oriented, he was able to verbalize his needs. He was able to eat by himself and usually had small appetite. According to V11, R1 did not eat his lunch on September 23, 2024, and she notified V4 about it. On September 24, 2024 R1 refused dinner and refused to drink water. He slept majority of the time, he was very lethargic, and V11 notified V5 about his change On October 29, 2024, at 3:25 PM, V5 (Nurse) stated that R1's baseline condition was alert and oriented, he could feed himself, and a lot of the times he doesn't like the food, so he ate 75% or less. On the 23rd of September, when V5 came in on the evening shift, R1 was already in the dialysis center He was alert when they picked him up. On October 30, 2024, at 8:12 AM, V10 (CNA) stated that R1 was a lively person, she had a good rapport with R1, and she was familiar with R1's condition. V10 usually assisted R1 to his wheelchair every morning after breakfast. R1 could stand and pivot for transfer. Usually, R1 would come back weak from dialysis but he would always bounce back. On September 23, 2024, V10 recalled that R1 came back a little bit later than usual from the dialysis center and he was very weak. The next day (September 24th), V10 remembers that she did not get R1 up to the wheelchair because he was very lethargic. He didn't eat breakfast, and he barely touched his lunch, he notified V4 about this change in R1. V10 stated that on September 25, 2024, R1 remained weak and needed additional support. V10 stated that R1 was confused and unable to remember V10's name. R1 did not eat breakfast and did not eat his lunch. V10 stated she notified the nurse and then R1 was sent to the hospital. On October 30, 2024, at 09:54, V3 (Primary Physician) stated that R1 has chronic dialysis, he was immuno-compromised, he has pressure ulcer, and has a colostomy. V3 was notified of R1's change in condition on September 24, 2024. V3 instructed the staff to monitor R1's condition closely. When V3 ordered to monitor the patient closely, that means the staff should monitor their vital signs, do neurocheck, when there is a change in mentation, do assessments and document everything. On October 29, 2024, at 10:04 AM, V14 (R1's Sister) stated that she visits R1 every other day. V14 said that she visited R1 on September 22, 2024 (Sunday) and he was semi awake. When she came to visit the next day Monday (September 23, 2024) to check his condition, R1 was still in the dialysis center. As they were driving back to the facility R1 was very lethargic, he could barely open his eyes and could barely talk. According to V14, the staff nurse (V5) said that he would document R1's condition. V14 stated that the next day (Tuesday), R1 was still in the same lethargic state, they could barely wake him up. By Wednesday (September 25, 2024), the staff couldn't arouse him, they finally decided to send him to the hospital. R1 was admitted to the hospital ICU (Intensive Care Unit). R1 was in the hospital from September 25 to October 12, 2024. A review of nursing notes and progress noted show no evidence of documentation that nursing staff monitored and documented R1's condition and mentation as ordered by V3 (Medical Doctor). Vital signs log shows R1's vital signs were checked on September 23, 2024 at 8:28 AM and 9:36 PM, and on September 24, 2024 at 11:03 AM, and 7:46 PM. There was no record of vital signs on September 25, 2024.

Based on observation, interview, and record review, the facility failed to provide personal hygiene for 6 residents (R25, R97, R73, R3, R37 & R64), who are dependent on ADL care (Activities of daily living) in a sample of 27. Findings include: 1. On 05/21/24 at 10:36 AM, R25 was observed with long jagged curling fingernails. R25's electronic health record showed that R25 is an [AGE] year old male admitted to the facility on [DATE] with diagnoses including Parkinson's disease, difficulty walking, lack of coordination, legally blind, dementia, and need for assistance with personal care. R25's 5/2/24 MDS (Minimum Data Set) section C showed that R25's cognition is severely impaired, and section GG for personal hygiene showed that R25 is dependent for care (helper does all the effort, & resident does none of the effort to complete the activity). R25's 4/28/2023 care plan for ADLs showed, self-care performance deficit related to decreased mobility, weakness, lack of coordination, dementia, and legally blind. R25 requires assistance for all ADL's. The approach showed, provide supervision, setup, and assistance as needed for hygienic cares. 2. On 5/21/24 at 10:47 AM, R97 was observed with long oily hair and severely dry flaking skin on his feet. R97 said that he receives a sponge bath once or twice a week and has not received any lotion to his body in a couple of months. R97 said that he has been asking for someone to come to his room to cut his hair because he cannot get out of bed. R97 said that he has asked staff, but he has not received an answer. R97's health records showed that R97 is a [AGE] year old male admitted on [DATE] with diagnoses including morbid obesity, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and need for assistance with personal care. R97's 3/11/24 MDS section C showed that R97's cognition is intact, and section GG showed under personal hygiene that R97 is dependent for care, (resident does none of the effort to complete the activity). R97's 1/9/24 ADL care plan showed, self-care performance deficit related to decreased mobility, weakness related to respiratory failure, morbid obesity, pain, weakness, and other disease process. The care plan approaches included, provide staff assistance as needed for maintaining personal hygiene. 3. On 5/21/24 at 11:34 AM, R73 was observed with oily hair. R73 said that the last time she received a shower was last Wednesday 5/15/24, 6 days past. R73 said that she is to get showers on Wednesdays and Saturdays, but she did not get a shower on last Saturday 5/17/24, because there was no help. R73's electronic health record showed that R73 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including chronic kidney disease, major depressive disorder, lack of coordination, mononeuropathy of left lower limb, weakness, and need for assistance with personal care. R73's 03/22/2024 MDS section C showed that R73's cognition is intact and section GG, Personal Hygiene showed that R72 needs supervision or touching assistance help, provides verbal cues and or touching steady and or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or it intermittently. R73's 12/22/2023 ADL care plan showed, activities of daily living self-care performance deficit related to decreased mobility, weakness, mononeuropathy of left lower limb, difficulty walking, and other disease processes. Require staff assistance for all ADL's. The approaches included provide staff assistance as needed for maintaining personal hygiene ADLs. 4. On 5/21/24 at 12:10 PM, R3 was observed with long jagged nails. R3's electronic health record showed that R3 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including polyarthritis, osteoporosis with current pathological fractures, weakness, hemiplegia and hemiparesis affecting right dominant side, and muscle wasting and atrophy. R3's 2/29/2024 MDS section C showed that R3's cognition is intact, and section GG personal hygiene showed that R3 need substantial maximal assistance, (helper does more than half the effort). R3's 3/10/2023 ADL care plan showed, ADL self-care performance deficit related to decreased mobility, weakness, osteoarthritis, and hemiparesis hemiplegia affecting her right dominant side. 5. On 5/21/24 at 12:13pm R37 was observed with long jagged nails. R37 said that she did not know the last time her nails were cut but she would like for someone to cut them. R37's electronic health record showed that R37 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting right dominant side, muscle wasting and atrophy, and need for assistance with personal care. R37's 03/05/2024 MDS section C showed that R37's cognition is intact, section GG personal hygiene showed that R37 needs substantial maximal assistance for personal hygiene, (helper does more than half the effort.) R37's 03/09/2023 ADL care plan showed a self-care deficit related to history of CVA (cerebral vascular accident) with hemiparesis hemiplegia to right dominant side, dementia, weakness, and requires extensive assist. R37's 02/07/2024 care plan showed, resident has a splint/brace to right hand related to hemiplegia and hemiparesis affecting right dominant side and requires a restorative splint/brace program. The approaches include provide hygiene to appropriate extremity before applying splint. On 5/23/24 at 12:15pm, V2 DON (Director of Nursing) said that all ADLs should be done when it is needed. V2 said that nails should be trimmed and cleaned for infection control and so the resident doesn't injure himself or others. V2 said that lotion should be applied to skin and hair should be washed for infection control. The facility's Activity of Daily Living policy dated 2/2023 showed under Purpose: Based on comprehensive assessment of the resident and consistent with the residence needs and choices, our facility provides necessary care and services to ensure that our residents mobility and activities of daily living do not diminish . The policy showed under Guidelines: In accordance with the comprehensive assessment, together with respect for individual residents needs and choices, our facility provides care and services for the following activities: hygiene, bathing, dressing, grooming, oral care, and elimination - toileting. 48526 6. On 05/21/24 at 11:28 AM R64 was in her room, resting in the bed. R64's fingernails on her right hand were long with a dark colored substance underneath. R64's fingernails to her left hand were long with a dark colored substance underneath. R64 said she wanted her nails cleaned and clipped. On 05/23/24 at 09:12 AM R64 was resting in the bed. R64's fingernails to her right hand continued to be long with a dark colored substance underneath. R64's fingernails to her left hand continued to be long. R64 said I do not refuse to get my nails cut, any qualified person can cut and clean my nails. On 05/23/24 at 09:29 AM V7 (Registered Nurse) said the nursing department is responsible for cleaning and cutting residents fingernails. V7 said residents nails should be short and clean. V7 said fingernails should be filed so they are not sharp and cut the skin. If nails are long, residents can get skin tears and possible infections. On 05/23/24 at 09:50 AM V3 (Assistant Director of Nursing) said all residents nails should be trimmed and clean. The staff should check the residents nails every day while doing morning care. V3 said if the residents nails are long and dirty, they can scratch themselves, tear their skin or get an infection. The staff are expected to clean and trim nails if they are long, dirty, and or jagged. R64's Face Sheet showed R64 had diagnoses of peripheral vascular disease, mood disorder, neuromuscular dysfunction of bladder, weakness, unspecified fracture of T11-T12 vertebra, T12 compound fracture, polyarthritis, unilateral post traumatic osteoarthritis, right hip post-surgical, diabetes, and hypertension. R64's MDS dated [DATE] showed R64 was cognitively intact. The same MDS showed R64 required partial to moderate assistance with personal hygiene. R64's ADL care plan dated 02/06/24 showed provide staff assistance as needed for transfers, walk in room, walk in corridor, dressing, eating, toileting, and maintaining personal hygiene ADL's as an intervention.

Based on observation, interview and record review the facility failed to transcribe a dressing treatment plan and failed to administer a pressure injury treatment as ordered for a resident with stage 4 pressure injury to promote healing. This applies to 1 of 5 residents (R47) reviewed for pressure injury in the sample of 21. This failure resulted in R47 not receiving the ordered treatment for 43 days that resulted in the delayed healing of the resident's right ischium pressure injury. The findings include: R47 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's annual MDS (minimum data set) dated 1/14/22 shows that the resident is severely impaired with cognition and would require extensive to total assistance from the staff with most of his ADLs (activities of daily living). R47's active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Once a day. On 3/8/22 at 9:04 AM, R47 was in bed, sleeping with oxygen via nasal cannula at 2 liters/minute. With the assistance of V15 (CNA/Certified Nursing Assistant), V6 (Treatment Nurse) removed the dressing from R47's right ischium. R47 had a stage 4 pressure injury on his right ischium with drainage. V6 stated that the wound doctor had seen R47 on 3/7/22 and had debrided the wound. According to V6, the wound doctor comes to the facility and sees R47 every Monday. V6 cleansed R47's right ischium pressure injury with gauze and normal saline, dried the wound area with a dry gauze, packed the wound with a non-sterile gauze wet with normal saline. V6 then applied Santyl ointment directly on the foam dressing then covered the wound with the said foam dressing. Based on this observation the Santyl ointment was not directly applied to R47's pressure injury and the gauze used to pack the wound was not sterile as ordered. V6 was asked why the Santyl ointment was not directly applied to R47's right ischium wound bed. V6 had no answer but stated that she will clarify the order with the wound doctor. R47's wound evaluation and management summary dated 1/24/22 created by V5 (Wound Doctor) shows that the resident has a stage 4 pressure injury to the right ischium, measuring 9.5 cm x 6.2 cm x 5.0 cm (length x width x depth), no undermining documented, with heavy serosanguineous exudate, with 40% thick adherent devitalized necrotic tissue, 20% slough, 20% granulation tissue and 20% other viable tissue (fascia, bone). The wound doctor performed surgical excisional debridement of the necrotic tissue on the right ischium. Further review of the same wound management summary shows the dressing treatment plan of Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days: Gauze sponge sterile apply once daily for 30 days and Secondary dressings, foam with border apply once daily for 30 days. R47's succeeding wound evaluation & management summaries created by V5 dated: 1/31/22, 2/7/22, 2/14/22, 2/21/22 and 2/28/22, shows that the wound doctor performed surgical excisional debridement of the necrotic tissue on the right ischium. All these wound evaluation & management summaries shows that V5's dressing treatment plan for R47's right ischium was to apply alginate calcium, Santyl, sterile gauze sponge and cover with foam dressing. R47's wound evaluation & management summary dated 2/28/22 shows, Wound progress: Deteriorated. R47's wound evaluation and management summary dated 3/7/22 created by V5 shows that the resident has a stage 4 pressure injury to the right ischium, measuring 8.5 cm x 6.2 cm x 4.3 cm (length x width x depth) with undermining of 4.0 cm at 12 o'clock and with heavy serosanguineous exudate. The undermining was first documented on this evaluation summary. There was 15% thick adherent devitalized necrotic tissue, 20% slough, 55% granulation tissue and 10% other viable tissue (fascia, bone). The wound doctor performed surgical excisional debridement of the right ischium pressure injury. Further review of the same wound management summary shows the dressing treatment plan for R47's right ischium is to apply Alginate calcium, Santyl, gauze sponge sterile and foam border dressing daily. R47's treatment flowsheets from 1/24/22 through 3/8/22 (43 days) shows documentation that the facility was cleansing the resident's right ischium with normal saline, pat dry, applying Santyl and sterile gauze sponge then covering with foam dressing. These treatment flowsheets did not document that Alginate calcium was also being applied on R47's right ischium per V5's treatment plan. Review of R47's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated, Cleanse right ischium with NS (normal saline), pat dry. Apply Santyl. Apply Alginate calcium. Apply gauze sponge sterile. Apply foam dressing daily and PRN (as needed) until healed. R47's active care plan initiated on 10/12/21 shows that the resident has pressure injury to the right ischium. This care plan has multiple approaches which included, Treatment (application of ointment/medication and/or dressings) to site per physician order. On 3/8/22 at 3:27 PM, V5 (Wound Doctor) stated that for R47's wound treatment on the right ischium, the Santyl ointment should be in contact with the wound bed because it is the medication to remove the dead tissue from the wound so it can start to heal, then the alginate calcium to fill the wound cavity and help absorb the wound exudate since the resident's pressure injury has heavy serosanguineous drainage, then the sterile gauze to pack the wound and then cover with a foam dressing for protection. V5 stated that the sterile gauze is to be used to pack the wound to ensure that it is clean, instead of the non-sterile gauze. V5 was informed that since 1/24/22, the facility has been applying Santyl ointment to the right ischium without the alginate calcium and that it was observed that morning (3/8/22) during treatment with the nurse, that the wound was packed with a regular gauze wet with normal saline and the Santyl ointment was applied directly on the foam dressing and not on the wound bed, and that the foam dressing (with Santyl ointment) was placed on top of the wet gauze. According to V5, the treatment procedure that was observed by the State agency was wrong because the Santyl ointment should be in contact with the wound bed, then the gauze should be sterile and not wet. V5 added that he was not aware that the facility has not been following his treatment/dressing plan since he documented it sometime January 2022. V5 stated that because the treatment order on R47's right ischium was not followed since sometime January 2022, there was a slow healing process on the resident's pressure injury. V5 added, What is the purpose of giving the treatment order, if it will not be followed. Not good. On 3/9/22 at 10:02 AM, V2 (Director of Nursing) stated that based on her review of R47's wound doctor notes, the resident's treatment order for the right ischium should have been changed on 1/24/22 to include the Alginate calcium, Santyl ointment and sterile gauze and not just the Santyl ointment and sterile gauze. According to V2, the Alginate calcium, Santyl ointment and sterile gauze order should have been the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 added, the wound doctor treatment plan should have been followed, until the wound doctor changed the order/treatment plan.

Based on observation, interview and record review the facility failed to follow the physician's treatment order for a resident who had a stage IV pressure sore and the facility also failed to provide treatment to prevent a pressure sore from declining. This failure resulted in decline of R91's pressure sore. This applies to 1 of 7 residents (R91) reviewed for pressure injury in the sample of 25. The findings include: According to the Electronic Health Record (EHR) R91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident progress note dated 01/09/19 shows R91 has bilateral ischial pressure sore, right pressure sore measured the following: Length 3 cm, width 2.4 cm, depth 2.5 cm. The left pressure sore measured the following: Length 3.2 cm, width 1.8 cm and depth 3.5 cm on R91's admission. The Minimum data set ((MDS) dated [DATE] showed R91 had 2 stage IV pressure sores. The Minimum Data Set ((MDS) dated [DATE] showed R91 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points. R91 needed supervision of one person for bed mobility, dressing, and toilet use. R91 also needed supervision and set up help only for transfer, locomotion on unit, eating and bathing. The Physician order [REDACTED]. and cover with foam dressing daily and PRN (as necessary) if loose/soiled. On 05/09/19 at 12 :00 PM, V4 (wound nurse) stated that he informed R91's physician on 04/24/19 regarding progressive decline of R91's wound. V4 said that R91 went to the wound doctor on 04/26/19 (Friday) and had a new treatment order. V4 said that he received the new treatment order in his mail box on 04/29/19 (Monday) when he returned to work. V4 further stated that he works from Monday to Friday and the nurses on the floor are the ones who do the wound treatment when he is not working. V4 said that he entered the new treatment order on 04/29/19. V4 further stated that R91 wound is larger than before when seen 2 days ago (Tuesday), undermining is developing. V4 said that when he did the measurement last week (05/02/19) there was no tunneling. V4 confirmed that the new treatment order for twice a day was not done as ordered as the order was not on the TAR (Treatment Administration Record). The new wound treatment order dated 04/26/19 for R91 showed: - right ischium - clean with saline, apply [MEDICATION NAME] plus gauze and [MEDICATION NAME] 2 x a day, Skin prep to surrounding tissue. - Left ischium calcium alginate daily cover with foam. On 05/09/19 at 11:20 AM, wound observation was done with V4. V4 measured and described the right ischium wound as follows: Length- 7.7 cm, Width- 5.5 cm, Depth- 2.6 cm, undermining 4.6 cm at 12 o'clock direction, with heavy serosanguineous exudate, Stage IV, 60 % of wound covered by granulation tissue, 20 % of wound covered by slough tissue, 20 % of wound covered by clean non granulation tissue, wound edges not attached to base, irregular wound edges, macerated, soft well defined wound edges. V4 said that R91's wound status is declining. R91's wound assessment on the following dates showed: - On 05/07/19 the Right ischium: - Length - 6.5 cm, Width -5.5 cm, Depth - 2.5 cm, with heavy serosanguineous exudate, stage IV, undermining 4.2 cm at 12 o'clock direction, 80 % granulation tissue, 20 % of wound covered by clean non-granulation tissue, wound status is declining. - On 05/02/19 the Right ischium: - Length - 5.8 cm, Width - 5.2 cm, Depth - 2 cm, with heavy serosanguineous exudate, stage IV, undermining present - No, 70 % of wound covered by granulation tissue, 25 % of wound covered by clean non-granulation tissue, wound healing status is improving. - On 04/23/19 the Right ischium: - Length - 6 cm, Width - 6 cm, Depth - 2.1 cm, with heavy serosanguineous exudate, stage IV, undermining present - No, 70 % of wound covered by granulation tissue, 30 % of wound covered by clean non-granulation tissue, wound healing status is declining. - On 04/18/19 the Right ischium - Length - 5.6 cm, Width - 4.2 cm, Depth - 1.9 cm, with moderate serosanguineous exudate, stage IV, undermining present - No, 85 % of wound covered by granulation tissue, 15 % of wound covered by clean non-granulation tissue, wound healing status is improving. Review of R91's (MONTH) 2019 TAR showed that the treatment to R91's right ischium wound was done only once a day instead of twice a day as ordered by the physician. Also on (MONTH) 27 (Saturday) and (MONTH) 28 (Sunday) TAR showed that the treatment was not done as ordered by the physician, since the new order was not transcribed until 04/29/19 by V4. On 05/09/19 at 1:55 PM, R91 stated that he asked the afternoon nurse to do the treatment, but some nurses will not do it. R91 said that he was not refusing treatment for [REDACTED]. R91 was also asked about the new wound treatment order dated 04/26/19 that he received after the visit to the wound doctor. R91 said that he gave the order to the nurse on the same day when he returned from his appointment. On 05/09/19 at 1:15 PM, V2 (Director of Nursing, DON) said that V16 and V22 (nurse) told her that R91 does the wound treatment himself. V2 was asked for any documentation to show resident changed his own. V2 said that there was no documentation by nurses that R91 was doing the wound treatment by himself. V2 said that she told the nurses that they have to document and circle if the resident refused. V2 added that if it is not documented it is not done. V2 also confirmed that there were no progress notes documented by nurses regarding R91's wound treatment for [REDACTED]. On 05/15/19 at 1:30 PM, V24 (R91's physician) was asked his expectation from the facility staff regarding R91's wounds. V24 said that V4 told him about R91's wound was deteriorating couple weeks ago. V24 said that R91 went for second follow up last week to an outside wound doctor and had the same wound treatment order. V24 was asked regarding the treatment order from outside wound doctor last 04/29/19 which was change from daily to twice a day and that the facility staff were just doing the treatment daily. V24 said that they have to follow the wound treatment order. The care plan showed that R91 had alteration in skin integrity as evidence by pressure ulcers on his both ischium related to decreased mobility. Wound healing may be hindered by [MEDICAL CONDITION], diabetes and [MEDICAL CONDITION], declining to have staff change the dressing. Goal- Ulcer will show improvement as evidence a decrease in size next review date unless co- morbidities/resident choices cause unavoidable decline Approach - Treatment application of ointment/medication and or dressing to site per physician order.

Based on interview, and record review the facility failed to provide treatment to prevent a pressure sore for a diabetic resident and failed to provide podiatry or wound physician consultation for a worsening pressure sore. This failure resulted in the resident sustaining osteo[DIAGNOSES REDACTED] requiring hospitalization , intravenous antibiotics, and a [MEDICAL CONDITION]. This applies to 1 of 3 residents (R3) reviewed for pressure sores. The findings include: According to the Electronic Health Record (EHR) R3 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] showed R3 was cognitively intact with a Brief Interview for Mental Status (BIMS) 15 out of 15 possible points. R3 needed extensive assistance of one person for bed mobility, transfers, locomotion, dressing, hygiene. Needs limited assistance of one person for eating and supervision of one person for toilet use. The MDS did not show any unhealed pressure sores, diabetic ulcers, or venous or arterial ulcers. The MDS showed R3's height was 6 feet 3 inches (75 inches) tall and weighed 180 pounds. The Physician order [REDACTED]. lateral left foot/posterior heel with normal saline or wound cleanser, pat dry, apply nickel thick application of Medi-honey to wound bed, cover with ABD and secure with gauze wrap daily. The POS showed only one change in treatment dated 03/11/19 to the distal lateral left foot to cleanse with normal saline or wound cleanser, pat dry, paint wound with [MEDICATION NAME], cover with ABD and secure with gauze wrap daily. The treatment to the posterior left heel remained the same. A Care Plan dated 02/22/19 showed R3 had altered peripheral perfusion due to [MEDICAL CONDITION], arterial ulcers of the left foot and was readmitted with a reopened pressure ulcer with interventions including to offload heels at all times and elevate the lower extremities when possible if [MEDICAL CONDITION]. The Care Plan does not show R3 was non-compliant with care or treatment. No Care Plan interventions or Physician orders [REDACTED]. A Nursing Progress Wound Nurse Note dated 02/22/19 showed R3 was assessed with [REDACTED]. R3 reported no sensation on his bilateral feet (below the medial/lateral malleolus) when writer tapped them with a cotton tipped applicator, weak pedal pulses, and left foot [MEDICAL CONDITION]. The note showed the following wounds: Wound 1: Distal lateral left foot wound measuring 4.0 centimeters (cm) by 3.6 cm by undetermined depth, wound bed noted with thick adherent eschar and a 0.5 cm depression, wound edges regular, no exudate observed, surrounding tissue dry/flaky; Wound 2: Medial lateral left foot wound measuring 3.8 cm by 2.2 cm by undetermined depth, wound bed noted with thick adherent eschar and a 0.4 cm depression, wound edges regular with what appears to the writer as a flap of peeled skin on the proximal margin from a de-roofed blister, no exudate observed, surrounding tissue dry/flaky; and Wound 3: Proximal lateral left foot/posterior left heel blister measuring 12.0 cm by 10.5 cm by undetermined depth, blister cap intact (ruptured/opened on the superior aspect), wound bed observed through intact tissue with dark purple discoloration on the superior aspect of the effected area, wound edges irregular and macerated, moderate amount of sero-sanguineous exudate observed, surrounding tissue dry/flaky. Wound care nursing notes document the declining of the left heel wound (Wound 3): on 03/11/19 the wound measured 3.5 cm by 6.2 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue-granulation 10 percent, slough 30 percent, eschar 60 percent; on 03/21/19 the wound measured 11 cm by 6 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue-granulation 20 percent, eschar 40 percent, non-granulation tissue 40 percent, declining; and on 03/26/19 the wound measured 11 cm by 7.6 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue-granulation 20 percent, eschar 40 percent, non-granulation tissue 40 percent, declining. Wound care Nurse notes also document the declining of the left top of foot wound (Wound 1 and Wound 2, merged as one): on 03/11/19 the wound measured 5.2 cm by 2.8 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue, 100 percent eschar, declining; on 03/21/19 the wound measured 10.2 cm by 4.3 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue, 100 percent eschar, declining; and on 03/26/19 the wound measured 10.6 cm by 5 cm, depth could not be measured, full thickness through dermis and down to subcutaneous tissue and muscle, necrotic tissue, 100 percent eschar, declining. On 04/02/19 at 3:17 PM V6, Registered Nurse (RN) Wound Nurse, said R3 had [MEDICAL CONDITION] of the lower extremities, very poor pedal pulses and was non-compliant with his care needing reeducation for offloading and elevating his feet. V6 said R3 was a little bit taller and would often lie in bed with his feet against or on the footboard. V6 said when R3's heel wound was discovered it was necrotic and V6 was unsure how it was not noticed until it became necrotic. V6 said there were no notable concerns prior to that. V6 said the foot wounds had progressively worsened after they were discovered. V6 said the nurse practitioner examined R3 but a physician did not see him. V6 said when R3 returned from the hospital the two lateral foot ulcers had become one ulcer. V6 said the facility does not automatically refer a resident to the wound doctor for all wounds. According to V6, the facility would refer a resident to the wound doctor if there wasn't any improvement after treatment. V6 said he would have spoken with the wound doctor during the week of 04/01/19 due to the wound worsening, however, R3 had been discharged to the hospital over the weekend before the wound doctor came to the facility. V6 said there should be a wound progress note once a week. V6 did not know why there was 10 days between wound care notes of 03/11/19 and 03/21/19. R3's wounds were initially discovered on 02/22/19. Between 03/09/19 and 03/29/19 (20 days), R3's multiple left foot pressure ulcers had progressively worsened without being referred to a wound doctor or podiatrist for consultation. A Podiatry Consultation from V9, Podiatrist, dated 03/31/19 showed R3 was admitted to the hospital intensive care unit [MEDICAL CONDITION], leukocytosis secondary to pneumonia and a left foot infection. The note includes R3 stated the ulceration began approximately four weeks prior to hospitalization which started as a blood blister. The note shows R3 also stated at the facility he was sleeping in a bed which was too short as his feet continued to rub and pressured against the foot board which (V9 wrote) may have developed other ulcerations. The consultation notes showed R3 had a severe equino-varus deformity to his left foot, mild to moderate [MEDICAL CONDITION] of the left leg, with minimal [DIAGNOSES REDACTED] localized to the left foot. The note showed R3 had necrotic tissue to the lateral aspect of the fifth metatarsal and posterior heel which was unstageable and a plantar midfoot ulceration with 100 percent fibrotic tissue and dry blister formation consistent with the history of a blister with mild sero-sangounous drainage, malodor and [DIAGNOSES REDACTED]. On 04/03/19 at 4:31 PM when asked about a note from the (MONTH) 9th hospitalization regarding an open blister on the foot, V9 (Podiatrist) said he believed that note was in reference to a separate blood blister which was on the bottom (arch area) of R3's foot. V9 said the blood blister was a diabetic ulcer. V9 said the unstageable necrotic tissue behind the heel and outside of the lateral forefoot, were from resting against a surface, which was definitely caused by a pressure ulcer. V9 said R3 definitely had comorbidities and had a deformity where his ankle turns in almost like a club foot, but V9 felt R3's wound may have been prevented if the right treatments and the right preventative measures were put in place. V9 said R3 was a very tall man and probably needed a bed mattress extender. V9 also wondered if (R3) had an offloading boot as the unstageable necrotic tissue and bone infection doesn't happen overnight. V9 guessed it probably happened within the last month and said the facility should have sent R3 for consult with this type of wound. V9 said R3 was sent to the hospital for pneumonia with an elevated White Blood Count (WBC) and they were not notified of the foot wound. V9 was consulted when R3 was admitted to the hospital 03/29/2019 for fever and pneumonia unrelated to the foot ulcers and the hospital discovered R3's foot ulcers. V9 said a Wound Doctor should have been consulted when a wound like this was discovered, especially when it was worsening. V9 said once the wound was necrotic it was already too late When it's necrotic, we don't know how deep it is or what is under there. An Orthopedic Surgeon Consultation Note (V10, Orthopedic Surgeon) dated 04/01/19 showed (R3) had a left foot ulcer appropriate for amputation. (R3) also had pneumonia, [MEDICAL CONDITION], and multiple medical comorbidities. Non-amputation options could be tried however given the severity of his general condition, wound healing potential, diabetes, limited sensation and current appearance of the foot I believe this would be a long and difficult process which would likely ultimately result in amputation regardless. On 04/03/19 at 4:50 PM V10, Orthopedic Surgeon, said R3 should have been followed by a podiatrist for the wound and his diagnoses, as they would have a better idea of his potential for wound healing. V10 said R3 had osteo[DIAGNOSES REDACTED]. On 04/04/19 at 9:33 AM V11, Nurse Practitioner (NP) said he had not physically seen R3's foot wound. V11 said he relied on the nurse's report if there are any changes or declines to a resident's wounds that they would tell me. V11 said he did not write any orders for the treatment of [REDACTED]. According to V11, if he was aware R3's wound was getting worse he would try to make changes to the treatment or refer R3 to a podiatrist. After showing V11 the Wound Care Notes of 03/11/19, V11 said he would have ordered a wound physician consult because wounds were not his area of expertise. On 04/04/19 at 10:34 AM V12, Registered Nurse (RN) and V5 (RN) said R3 had an extended bed prior to going to the hospital 03/05/2019 but when R3 returned from the hospital on [DATE] he only had a regular bed. V12 said she had asked maintenance last week about getting him the bed extender but then he was sent out to the hospital over the weekend. Both V5 and V12 said R3 probably had pressure relieving boots but he refused to wear them. R5 looked in room wardrobe and drawers where R3's belongings were still present and could not locate the heel protector boots. At 2:31 PM V5, said R3 did not have a low air loss or alternating pressure mattress in place because R3 didn't have any pressure sores on his back or buttocks. On 04/04/19 at 3:55 PM V2, Director of Nursing (DON), said R3's wounds were diabetic ulcers, not pressure ulcers and weren't really worsening. They may have been getting larger in size, but the appearance of the wound wasn't really worsening. When asked how it could be determined the wound wasn't worsening underneath the eschar and necrotic tissue, V2 said Well you can't determine what is under the eschar, but the outer appearance had remained the same. V2 said she thought R3 had a physician wound consultation during the early (MONTH) hospitalization was unable to provide a report of the consultation or any treatment orders upon R3's return from the hospital on [DATE]. The facility's Pressure/Skin Breakdown Clinical Protocol dated (MONTH) (YEAR) included The physician will help the staff define the type of an ulceration. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. The physician will help characterize the likelihood of wound healing, based on a review of pertinent factors.

Based on interview and record review the facility failed to supervise a developmentally disabled resident from wandering and sexually assaulting a female resident, R1. This applies to 1 of 4 residents (R4) reviewed for monitoring and supervision. As a result, R2 was able to enter R1's room repeatedly and physically touch and kiss R1 against her will and caused R1 terror, fear, and psycho-social harm. Findings include: R1 is a [AGE] year old resident admitted to the facility (MONTH) 6, (YEAR). R1 is coded per her MDS (Minimum Data Set) Assessment of (MONTH) 13, 2019 to be cognitively intact and able to express her needs and is able express herself. R1 also has impaired mobility and spends the majority of her time in bed. On (MONTH) 26, 2019 at 11:20 AM, R1 was lying down in bed. R1 stated that she's bed bound, she has a lot of pain so she chooses to stay in bed. R1 said, On (MONTH) 15, 2019 at 10:00 PM, I was sleeping. My curtain was drawn around my bed (from head to the foot part of the bed), then a patient (R2) opened my curtain, shoved my bedside table away from the bed and tried to kiss me on my lips. R1 explained that she was able to cover her lips and face with her hands but R2 still was able to kiss her repeatedly on her forehead. R1 claimed she was so terrified and was screaming for help. She turned her call light on but by the time the staff came 10 minutes after, R2 left my room. I told those (staff) what happened. They said they will monitor him (R2). R1 claimed that she reported this incident to V1 (Administrator) on 2/18/19. R1 also stated, On (MONTH) 23, 2019 (Saturday) at 5:00 PM, a Certified Nursing Assistant was in my room getting ready to change me (incontinence care) and R1 came in my room. I screamed and told the Certified Nursing Assistant to get him out! The Aide told him to get out and he did. Then at 6:30 PM that same day, he was back again. R1 was by my door already. I was very scared. I keep telling them (staff) to please monitor him but nothing happens. Then on (MONTH) 24, 2019 at 12:45 AM, he (R2) got in my room again. Good that the nurse was in my room giving me my medications at the time. The nurse told him to get out and he did. They said they will monitor him but he was able to manage to come back 3 more times after the initial incident. No, I do not feel safe and I am so terrified. The facility incident report and social service notes dated (MONTH) 18, 2019 showed that on (MONTH) 15, 2019 at 10:00 PM, R1 claimed that R2 went to R1's room and kissed her repeatedly. The incident that occurred on (MONTH) 15, 2019 (Friday) was not reported by the staff to V1 (Abuse Coordinator/Administrator). On (MONTH) 18, 2019 (Monday) R1 requested to speak to V1 to report this incident. On (MONTH) 26, 2019 at 11:01 PM, V1 stated that the staff did not report this incident to her and this is the first time she's hearing it (and from the patient/R1) On (MONTH) 26, 2019 at 1:20 PM, V5 (7-3 and 3-11 shift Nurse in Charge on (MONTH) 15, 2019) confirmed that V5 did not report this to V1 or endorsed it to the next shift. On (MONTH) 28, 2019 at 1:00 PM via phone, V8 (11-7 shift Nurse on (MONTH) 15, 2019) said I was not told about the incident. On (MONTH) 26, 2019 at 10:50 AM, V3 (Social Service Director) presented R2's electronic records and explained that the administration was not made aware of this incident until 3 days after the initial incident (February 15, 2019). V3 stated that R1 explained to V3 that R2 went to R1's room and repeatedly tried to kiss her. R1 tried to cover her mouth and face while calling for the nurse. R2 was able to kiss R1 repeatedly on R1's forehead and there were 3 other incidents that occurred (February 23 at 5:00PM and at 6:30 PM and on (MONTH) 24, 2019 at 12:45 PM) where R2 went to R1's room without supervision. On (MONTH) 27, 2019 at 11:00 AM, R2 was observed sitting in the wheelchair in the front lobby with activity aide. R2 was nonverbal but would look up when his name was called. R1's MDS assessment dated [DATE] codes R1 as having cognitive impairment and needing staff assistance with ADL (Activities of Daily Living). R2's electronic progress notes dated (MONTH) 18, 2019, V4 (Social Service Director) documented R2 is nonverbal and developmentally delayed (with [DIAGNOSES REDACTED]. On (MONTH) 26, 2019 at 1:20 PM, V5 (Nurse) described, R2 is nonverbal and with mental [MEDICAL CONDITION]. R2 uses wheelchair and is also able to ambulate with assistance.R2 does not stay in one place, he wanders around. I was the nurse that day (February 15, 2019 -Friday 2nd shift) but I did not witness what happened. The Certified Nursing Assistant (V5 cannot remember who) reported to me that R2 kissed R1 on her head several times and R1 was upset about it. I went and talked to R1 and she was still upset about it. On (MONTH) 1:30 PM, V6 (Certified Nursing Assistant) stated, R2 always goes to other resident's room. He usually goes to the 500 unit and some residents there are alert so, they just tell him to get out. R2's is in a wheelchair but sometimes he will ambulate by himself. On (MONTH) 27, 2019 at 10:40 AM, V7 (Social Service Staff) said, R2 has cognitive deficit, is not able to communicate/ with no verbal response. He is a wanderer, goes up and down on the hallways but is easily re-directed. Yes he should be supervised and should be placed in a supervised area. R2's plan of care showed the following: 1. Problem: Risk for elopement, R1 was very active and likes to walk around - the intervention documented was to encourage R1 to sit in a supervised area. 2. Problem: Behavior: (1) has profound cognitive deficits and is a wanderer. There was no intervention to address this identified problem area (wanderer). 3. Problem: Has been known to gently reach for people as they pass by him in the halls (hallways). The intervention was to keep R2 at a relatively safe distance from others. These interventions were not followed and implemented that resulted in R2 to be able to get in R1's room unsupervised and was able to kiss R1 repeatedly. There was no nursing documentation noted in R2's electronic records regarding this incident on (MONTH) 15, 2019. There was no revision in R2's plan of care to protect other residents with this identified behavior of R2.

Based on Interview and Record Review the facility failed to follow plan of care for a resident who was identified as high risk for fall. This applies to 1 of 3 residents (R3) reviewed for fall. This failure resulted in a fall with severe head injury for R3. The findings include: R3 is a [AGE] year old resident who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/26/14 and 2/17/14, general observations show many residents with alarms on and in place. All resident's needing assistance are receiving aid from staff. On 2/27/14 at 11:15 am R1 was sitting in a wheelchair in her room with her husband. A clip alarm is in place and is on. On 2/27/14 at 11:30am R2 is sitting in a wheelchair in the dining room with a clip alarm on and in place. At 11:45 on 2/27/14, E7 Registered Nurse for the south unit stated, "All staff look at the care cards kept in the closets to find out what kind of alarm is needed and if the bed should be a low position with or without mats". R3's fall risk assessment performed on admission on 10/24/13 scores at 10 which is indicates high risk for falls. R3 had falls documented for 10/27, 11/9, 11/29, 12/21/13 and then on 2/22/14. A care Plan for R3"S fall risk was initiated 10/24/13. Interventions put in place include to keep the bed in low position, bilateral floor mats, and a clip alarm to bed and chair. The Care Card shows the staff how the resident's bed should be positioned, if floor mats are needed, and what kind of alarms are needed for the bed and chair. This card also identifies if the resident is at risk for falls and or needs assistance. This yellow card is kept in the resident's closet. R3's care card does not identify him at risk for falls. It directs the staff to use a pad alarm in the chair and bed. It does not identify bed position or if floor mats are needed. An Event Report Sheet dated 2/22/14 show at 5:54 am R3 was found on the floor next to the bed and was bleeding. The blood was noted to be by R3's face. R3 was then sent to the community hospital via ambulance. On 2/27/14 at 10:00am Z1 registered Nurse (hospice) stated, "He could walk with assistance but he should have been on fall precautions. Mostly from his weakened stated from his disease and being on a Fentanyl patch (Narcotic) Z2 Certified Nursing assistant (Hospice) stated, "I have seen staff walk with R3 with a walker several times. I saw him three times a week. When I gave him a bed bath I would always put his bed back down in the low position and mats to each side of R3's bed. R3 had a clip alarm and a pad alarm on his bed. Only a clip alarm was on R3's chair." On 2/27/14 at 10:45am E5 Restorative Nurse stated, "I just started overseeing falls. I was not aware of any changes in interventions for R3 to prevent falls." "I never did a detailed assessment for R3." On 2/27/14 at 11:30am via telephone E3 Registered Nurse stated, "I was called to the room by E4 Certified Nursing Assistant. E4 CNA told me R3 was on the floor. R3 was face down and there was blood on the floor. I couldn't tell where it was coming from. I called 911 right away and then did vital signs. The bed was not in the lowest position. It was 2 to 3 feet off the ground and there were no floor mats on the floor. I am not sure where the alarm was but I never heard it. I thought E4 had already gotten R3 out of bed as he is on the get up early list." On 2/27/14 at 11:45am via telephone E4 Certified Nursing Assistant stated, "R3 started screaming get me up at 4:00am. I went to change my resident's first. I started at the beginning of my assignment. Around five minutes to five I heard him scream "Help me." I did not hear the alarm. He was on the floor. the bed was not in the low position and the floor mats were not on the floor." According to the assignment sheet provided by the facility for E4, On 2/22/13 E4 was caring for eleven resident's including R3. On 2/27/14 at 1:40pm via telephone Z3 Medical Doctor for R3 stated, R3 was admitted with Parkinson's disease, Dementia, poor judgement and balance. Iam not sure what his injuries were. I know he went from the hospital to hospice care." On 2/27/14 at 1:55pm via telephone Z4 Medical Doctor for The Hospice home R3 is now staying stated, "He came from the hospital with a Subdural Hematoma. R3 also was on Coumadin (a blood thinner). He has not regained consciousness but is calmer now. This injury is a direct result of the fall he had." On 2/27/14 at 2:45pm E2 Director of Nursing stated, "I talked to the daughter on Monday after I was able to perform an Investigation. I told her I could not explain why the floor mats were not on the floor or why the bed had not been lowered."

Based on interview and record review the facility failed to appropriately supervise 1 resident with a history of falls, and failed to implement targeted, appropriate interventions, to reduce the risk of future falls. These failures resulted in 1 resident (R1) sustaining a hip fracture after falling in his room at the nursing home. R1 expired on [DATE] due to complications of right hip fracture. This is for 1 resident out of 2 reviewed for falls in the sample of 18. The findings include: R1 was readmitted to the nursing home on [DATE] with multiple [DIAGNOSES REDACTED]. R1 was admitted to Hospice care on [DATE], according to hospice documentation in the electronic medical record. R1 requires extensive assistance for bed mobility, transfers and toilet use, according to the Minimum Data Sets ((MDS) dated [DATE]. R1 has intermittent confusion, impaired balance during transition, decreased safety awareness, and is prescribed medication with possible side effects that could increase fall risk, according to the Care Area Assessment (CAA) for Falls dated [DATE]. R1 was assessed at high risk for falls according to a fall assessment dated [DATE]. Social Service progress notes dated [DATE] document that R1 is alert and oriented with forgetfulness, confusion with impaired decision making ability. The note also states that R1 is considered a fall risk and has a history of removing his chair alarm and bed alarm so that he can care for himself. R1 sustained falls in his room on [DATE] (12:59 AM), [DATE] (3:00 AM), [DATE] (12:55 AM), [DATE] (1:02 AM) and [DATE] (1:30 AM), according to progress notes and Fall Event reports. The care plan did not reflect specific interventions to supervise or monitor R1 to minimize the risk of further falls between 12:55 AM and 3:00 AM. There is no documentation to support that R1 was monitored appropriately during the night. On [DATE] R1 sustained a hip fracture when he fell in his room after attempting to take himself to the bathroom. On [DATE] at 3:35 PM E7 (Restorative Nurse) stated that there were no targeted care plan interventions in place to minimize the risk of R1 ' s early morning falls. E7 stated that trends in falls are identified and documented on the Comprehensive Fall Review Reports. The Comprehensive Fall Review Reports identified that most of R1 ' s falls are related to him trying to get out of bed without assistance to use the toilet. On [DATE] an intervention was added to the care plan to " review toilet schedule. " On [DATE] an intervention was added to " provide bolsters and concave mattress. " On [DATE] an intervention was added to the care plan to " educate staff to follow toilet schedule. " On [DATE] an intervention was added for " Hospice to evaluate. " There were no care plan interventions related to monitoring R1 more frequently between 12:55 AM and 3:00 AM and no documentation to support that R1 was monitored during the night. On [DATE] at 9:15 AM E3 (Assistant Director of Nursing) stated that interval rounding checks, i.e., every 15 minutes, are not done on residents with a known history of falls.

Based on observation, record review and interview, it was determined the facility failed to implement their skin care policy for facility acquired pressure sores, including early identification, and intervention monitoring of skin alterations, for 6 of 6 sample residents (R4, R15, R16, R5, R17, R18) reviewed for pressure sores in the sample of 18. Findings include: Facility policy titled, "Prevention of Pressure Ulcers", dated 8/08, requires, "6) The facility should have a system / procedure to assure assessments are timely and appropriate, and changes in condition are recognized, evaluated, reported to the practitioner..." "9) Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs or symptoms of irritation or breakdown. Immediately report any signs of developing pressure ulcer." "General Preventative Measures: For a person in bed; a) Change position at least every two hours or more frequently if needed. For a person in a chair; a) Change position at least every hour." 1) According to the face sheet, R15 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS), dated [DATE], identified R15's Functional Status / Bed Mobility as "Extensive assistance with one person physical assist." R15's careplan, dated 11/11/11 and in place on 1/9/12, included the following instructions; "Conduct a systematic skin inspection daily." "Skin check with ADL care, report any abnormality." "Report any alterations immediately to nurse". The facility's Pressure Ulcer Report sheet, dated 1/14 - 1/20/12, documented that on 1/9/12, R15 acquired a Stage 3 pressure sore on his right heel. According to the Wound Care Nurse's (E5) progress note, dated 1/9/12, at 12:24 PM, she was called to the shower room, where the Certified Nursing Assistant (CNA) said skin came off R15's heel when she took his sock off. The affected area measured 3 x 2 x 0.1 cm. A nurse's progress note, dated 1/10/12, documented, "Event day #1. Hospice CNA was removing pt's socks when a piece of dead skin came off with sock leaving an open wound." E5 was interviewed on 1/24/12, at 1:15 PM. She confirmed the record findings and said R15's pressure ulcer was not discovered until it was a Stage 3. She stated she did not look into why his heel wound was not identified until already a Stage 3. 2) According to the face sheet, R4 is a [AGE] year old with [DIAGNOSES REDACTED]. The MDS, dated [DATE], identifies R4's Functional Status / Bed Mobility as "Extensive assistance with two+ persons physical assist." The current careplan, updated 11/11, includes interventions for prevention of skin breakdown. These interventions were, "Encourage / assist (R4) to turn and reposition every 2 hours and as needed." R4 was observed in her room, lying on her back in bed, at 10:15 AM, on 1/23/12. There were no positioning devices in her bed, except for one pillow under both heels. During this observation, R4 said she likes to have breakfast in bed, and can't walk. She stated she had been on her back since 7 AM, and complained that her "bottom was very sore", that she had "bedsores". R4 stated that staff doesn't turn her enough and she can't do it by herself. She said staff does not always answer her call light promptly when she needs to be turned or changed. E8 (CNA) was interviewed on 1/23/12, at 10:25 AM. She said another CNA (E9) was assigned to R4, but they work together providing care. According to E8, she positioned R4 towards the right, with pillows, at approximately 8:30 AM, however she confirmed at 10:25 AM, that R4 was on her back without postioning devices in the bed. E9 was interviewed at 10:35 AM, on 1/23/12, and said she was assigned to R4. E9 said she positioned R4 on her back at 8 AM, for breakfast, and had not turned her since that time,approximately 2.5 hrs ago. E10, Agency RN, was interviewed on 1/23/12, at 2 PM. She said that she was assigned to care for R4, and that she was told that R4 had redness on her bottom, no breakdown. The next morning, on 1/24/12, at 9 AM, R4's skin was assessed with [REDACTED]. R4 was lying in bed on her back, and said that her "bottom was sore". Upon turning R4, her buttocks was noted to be red, the area around her sacrum was moist and reddish-white in color, and there was an area of breakdown on the right side of her coccyx, approximately 1/2 inch in diameter. E5 said she was informed R4 had redness, but was not aware of breakdown, and that staff should immediately report any skin breakdown to her. According to E5, R4's breakdown is a stage 2, however the next days Bath and Skin report, dated 1/25/12, still identified only sacral redness, no breakdown. R4's Treatment Flow sheets (TAR) include spaces for staff to initial each shift for "Turn and reposition every 2 hours, every shift". R4's TAR lacked shift documentation that this order was carried out for the following: 12/11 - 8 shifts missing, 1/12 = 19 shifts missing. E5 confirmed the TAR findings and stated on 1/24/12 at 1:15 PM, that nurses are to initial on the TAR that the residents are turned as ordered. According to E5, on 1/24/12 at 9:30 AM, R4 gets up in a wheelchair for approximately 4 hours each day. She said that residents stay in wheelchairs/ adult reclining chairs for up to 4 hours at one time. They are encouraged to shift their weight in the chair, and if they cannot, the CNA's lift and shift the residents weight for them. Residents are not routinely taken out of recliners or wheelchairs unless they request it, or have above Stage 2 breakdown on pressure areas. This was confirmed by E2, the Director of Nursing on 1/24/12, at 2:15 PM. 3) According to the face sheet, R16 is a [AGE] year old with [DIAGNOSES REDACTED]. The Pressure Ulcer Report, dated 1/14/12 to 1/20/12, documents that R16 developed a facility acquired pressure ulcer on her coccyx on 8/15/11. R16's MDS, dated [DATE] and 11/17/11, identifies her Functional Status / Bed Mobility as "Extensive Assistance with two persons physical assist." Her careplans, dated 7/1/11 and 8/25/11, included "Turn and reposition every 2 hours". E5's progress notes document the following: "8/15/11 = Writer called to room noted right buttocks Stage 2..." "9/12/11 = Noted to coccyx red in color stage 2..." "9/15/11 = ...(urine catheter) to be inserted due to Stage 3 on right buttocks and coccyx..." "9/28/11 = right buttocks remains stable, coccyx has deteriorated." 12/13/11 - coccyx wound documented as Stage 4. 1/24/12 - Coccyx wound is still documented as "Stage 4". According to the Wound Care Specialist's (physician) Evaluation form, dated 8/30/11, the "Right upper buttocks wound is "Unstageable necrosis." On 9/13/11, the Specialist documented both the right buttock and coccyx ulcers as "Unstageable Necrosis". Nurses' progress notes, document that R16 was hosptalized on [DATE],and readmitted to the facility on [DATE]. R16's Treatment Flow sheets (TAR) lacked documentation that the resident was turned every 2 hours as ordered, for the following months; 8/11 - 7 shifts missing, 10/11 - no documentation for 19 days, 12/11 - 14 shifts missing, 1/12 - 22 shifts missing . R16's record findings were confirmed by E5 on 1/24/12, at 1:15 PM. E5 was interviewed on 1/24/12, at 1:15 PM, and said she reports on pressure ulcers at the daily management meetings, and at the Quality Assurance meetings. E5 stated she thought the Director of Nursing (E2) investigates pressure ulcer incidents. E2 (Director of Nursing) was interviewed on 1/24/12, at 2:15 PM, and stated she thought the Wound Care Nurse looked into contributing factors of pressure ulcers, such as the lack of turning documentation on the TARs. E2 said she does not, and has no documentation of, investigations regarding pressure ulcer developments. According to E2, there is no policy and procedure for investigating the cause of acquired pressure ulcers. E1 (Administrator) was interviewed on 1/24/12, at 3:15 PM, and said that she is a member of the Quality Assurance (QA) Team, however E5 is QA Coordinator. She stated E5 only investigates the cause of acquired pressure sores that are Stage 3 and above. According to the Pressure Ulcer Report, dated 1/14/12 to 1/20/12, the following are additional residents with facility acquired pressure ulcers: R5 - bilateral heel wounds acquired on 11/8/11 at Stage 2. E5 (Wound Care Nurse) confirmed on 1/24/11, at 11:20 AM, that R5 is in isolation for [MEDICAL CONDITION] in her heel wounds. R17 - bilateral heel wounds acquired on 1/9/12 at a Stage 2. R18 - bilateral heel wounds acquired on 1/16/12 at Stage 2.