Every finding on record at Landmark of Richton Park Rehab & NSG CTR

Based on interview and record review, the facility failed to follow their change in resident condition policy by failing to notify one resident's (R1) representative of R1's need to transfer to the hospital. In addition, the facility failed to notify the physician and dietician of not having the prescribed enteral feeding for one resident (R19) available and substituting the feeding with another formula. This failure affected two of three residents reviewed for change in condition. Findings Include: R1 was admitted to facility on 05/29/2026 with a diagnosis of severe protein malnutrition, gastrostomy status, chronic obstructive pulmonary disease, heart failure, anemia, peripheral vascular disease. R1's face sheet documents V3 as emergency contact.R1 brief interview for mental status score dated 6/8/26 documents a score of 5/15 which indicates severe cognitive impairment. R1's progress note dated 6/2/26 at 11:00AM by V5(nurse) documents: CNA informed writer of resident vomiting and stated he does not feel well assessed resident's vitals unstable oxygen placed on resident DON made aware MD notified with message sent. R1's progress note dated 6/2/26 at 11:05AM by V5(nurse) documents: writer called 911 for resident to be sent out.Review of R1's medical record did not document any attempt or notification to R1's family on 6/2/26. R1's admission paperwork documents uploaded on 5/7/26 to R1's medical record under contacts V3 (R1's family ) as emergency contact with Phone number matching the phone numbers on current face sheet. Facility policy change in residents condition undated documents: Unless otherwise instructed by the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: it is necessary to transfer the resident to the hospital. R19R19 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, aphasia, dysphagia and gastrostomy placement.R19's physician orders dated 3/28/25 documents: Glucerna 1.2 every eight hours. R19's progress notes dated 6/23/26 documents: This writer assessed resident. Resident resting in bed with head of bed elevated. Resident took medication whole no issues. Resident did not complain of pain or any discomfort . Resident clean and dry. Resident ate breakfast and lunch. No adverse reaction to any medication. This writer assessed resident's skin no new bruises or skin tears. Resident g-tube. Facility has no Glucerna 1.2. This writer was given Glucerna 1.5 for substitution. Family aware and at bedside.There was no other documentation in R19's medical record of any notification related to feeding substitution. On 8/20/26 at 11:22AM, V42 (Dietician) said for any changes in feedings or feedings not being available the facility should notify her so she can recommend a replacement. V42 said she does not recall any of those concerns for R19 and would have documented any changes. V42 was unable to find any documentation related to a change in R19's feeding. On 8/21/26 at 11:15AM, V52(MD) said the dietician should be notified of any changes in feeding or feeding not being available. V52 said he expects the orders to be followed as written and unable to recall any concerns related to R19's feeding not being available.On 8/21/26 at 11:30AM, V2(DON) said staff should notify the dietician of any new changes in feeding orders. The dietician recommendations would be reviewed by the physician and then be put in place. If the feeding is not available, staff should call dietician and physician to make aware and follow their orders.

Based on interview and record reviews, the facility failed to follow their abuse policy by not preventing inappropriate sexual incidents between residents. This affected two of five residents (R17, R18) reviewed for abuse. This failure resulted in R18 exposing his penis at R17's bedside and R18 sniffing R17's buttocks on another day.Findings Include: R17 was admitted to the facility on [DATE] with a diagnosis with Mild Neurocognitive Disorder due to known physiological condition without behavioral disturbance, Bipolar Disorder, current episode Depresses, severe with psychotic features Schizoaffective disorder and Anxiety disorders. R17 's Minimum Data Set, dated [DATE] documents a brief interview score for mental status score of thirteen which indicates cognitively intact. On 8/19/26 at 11:50am, R17 who was assessed to be alert to person, place and time said, she was sleeping in bed, felt someone standing over her but was still in and out of sleep. R17 said she was awoken when R18 lifted her arm. R17 said, she saw R18 standing on the side of her bed with his penis exposed. R17 said, R18 lifted her arm and attempted to guide it towards R18's penis. R17 said, she snatched her hand back. While explaining the incident, R17 started grabbing at the hem of her dress attempting to pull her dress down further than it could go. R17 pulled at the hem of her dress at least four times attempting to cover her leg that was exposed from the upper calves to her ankles. R17 said she felt uncomfortable and not good. R17 said, she told the nurse at the nursing station. R17 said she did not talk to the police. R17 said there was another incident with R18 after this incident where R18 was pulling up her skirt when she was in the hallway near the nursing station. R17 was unable to give any further details and said she was tired. R18 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder, autistic disorder, mood disorder, intellectual disabilities and psychosis. R18's brief interview for mental status score dated 6/29/26 documents 10/15 which indicate moderately impaired cognition. On 8/19/26 at 11:18am, R18 who was assessed to be alert and oriented at time of interview, R18 said, he didn't want to inform the surveyor of what happen because he didn't want to go to jail. R18 said he licked R17's buttock and that was it. R17's Social service note dated 7/13/26 documents: Resident (R17) in peer-to-peer incident. R17 said peer tried to get her to touch inappropriately. Staff asked if she felt safe and secure in facility. R17 said, Yes, I'm fine. He (R18) didn't touch me he wanted me to touch him and it didn't happen, but it was weird. Staff asked if she needed anything. Resident(R17) said no, I'm fine, I just wanted him to know I'm dating someone else, not him.R18's social service note dated 7/13/26: Behavior: Resident aggressor in peer to peer incident. Female resident reports that resident tried to pull her hand towards him inappropriately. Resident separated immediately. Resident placed on one to one with Social Service staff. Md notified, and ordered psychiatric work up. Staff awaiting transportation to hospital.Facility Initial reportable event dated 7/13/26 documents: Residents involved R17 and R18. R17 reported male peer attempted to try to have her touch him inappropriately, but that did not happen and she did not touch him. R18's ambulance run report dated 7/13/26 documents: R18 needs ambulance transport due to intellectual disability and needing one to one supervision. Report from nursing staff an hour prior to Ambulance arrival R18 had sexually assaulted a female resident at the facility.R18's involuntary petition dated 7/13/26 documents: R18 was found having inappropriate contact with peer. R18 admitted to social services of incident.R18's Point of Care charting dated 7/29/26 documents: Behavior Symptoms. Sexually Inappropriate was checked by V44(restorative aide).On 8/20/26 at 11:35am, V44 (restorative aide) said, R17 reported to me that R18 sniffed R17's butt while standing at the nursing station. V44 reported concern to the nurse. R18's Nursing note dated 7/30/26 documents: Resident (R18) noted with inappropriate sexual behavior towards peer, redirecting unsuccessful. Placed on staff 1:1. NP Psychiatry notified received order to petition to Hospital. R18's involuntary petition dated 7/30/26 document R18 observed with inappropriate sexual behavior towards other residents and staff, redirected unsuccessful.Facility abuse prevention program revised 3/1/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and crime against a resident in the facility. Sexual abuse including but not limited to sexual harassment, sexual coercion or sexual assault.

Based on interview and record review, the facility failed to follow their abuse policy by not reporting an allegation of resident-to-resident sexual harassment/abuse. This affected two of five residents (R17, R18) reviewed for reporting abuse.Findings include: On 8/20/26 at 10:03am, V1 (administrator) said, sexual abuse is unwanted sexual contact or any contact that is sexual and unwanted. V1 said, those incidents will be reported to the Illinois Department of public health immediately and the police would be called. V1 was asked if residents sniffing other resident's buttocks would be reported and V1 confirmed that incident would be reported to the state. R18's Point of Care charting dated 7/29/26 documents: Behavior Symptoms. Sexually Inappropriate was checked by V44(restorative aide).On 8/20/26 at 11:35am, V44 (restorative aide) said, R17 reported to me that R18 sniffed R17's butt while standing at the nursing station. V44 reported concern to the nurse. R18's Nursing note dated 7/30/26 documents by V35(Nurse): Resident (R18) noted with inappropriate sexual behavior towards peer, redirecting unsuccessful. Placed on staff 1:1. NP Psychiatry notified received order to petition to Hospital. On 8/19/26 at 10:10AM, V35 (nurse) said she recalled R18 sniffing other residents butts but unsure which female residents. Resident was always being inappropriate with staff and asking for sexual acts to be performed. R18's involuntary petition dated 7/30/26 documents, R18 observed with inappropriate sexual behavior towards other residents and staff, redirected unsuccessful.Facility abuse prevention program revised 3/1/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and crime against a resident in the facility. Sexual abuse including but not limited to sexual harassment, sexual coercion or sexual assault. If you suspect abuse fax report immediately to Illinois department of public health. The final investigation report will be completed within 5 working days of the reported incident. The administrator or in the absence of the administrator, the director of nursing is then responsible for forwarding a final written report of the results of the investigation and of any corrective action taken to the department to public health within five working days.

Based on interview and record review, the facility failed to follow their abuse policy by not conducting a through investigation of an allegation of resident-to-resident sexual harassment/abuse. This affected two of five residents (R17, R18) reviewed for investigating allegation of abuse.Findings include: R17's Social service note dated 7/13/26 documents: Resident (R17) in peer-to-peer incident. R17 said peer tried to get her to touch inappropriately. Staff asked if she felt safe and secure in facility. R17 said, Yes, I'm fine. He (R18) didn't touch me he wanted me to touch him and it didn't happen, but it was weird. Staff asked if she needed anything. Resident(R17) said no, I'm fine, I just wanted him me I'm dating someone else, not him.R18's social service note dated 7/13/26: Behavior: Resident aggressor in peer to peer incident. Female resident reports that resident tried to pull her hand towards him inappropriately. Resident separated immediately. Resident placed 1on1 with Social Service staff. Md notified, and order psychiatric work up. Staff awaiting transportation to hospital.Interview attempts with V40(social service) were unsuccessful during the survey.Facility Initial reportable event dated 7/13/26 documents: Resident involved R17 and R18. R17 reported male peer attempted to try to have her touch him inappropriately, but that did not happen and she did not touch him. Under conclusion: After a thorough investigation, including interviews with involved residents, staff and review of available information, the allegation could not be substantiated. R1 stated no physical contact occurred. Both residents counseled regarding appropriate interpersonal boundaries and care plans updated as necessary.Facility investigation included the following: Witness statement dated 7/13/26 document: V35(Nurse) was notified by assigned nurse that resident (R18) was observed with inappropriate sexual behavior towards resident. There were three other statements dated 7/13/26 that were not signed by person giving the statement. R17 statement said he was thinking about smelling my butt, I know what people are thinking, I can read minds. I asked him to smell my butt because I know that Is what he is thinking, but he walked away from me. R18 statement documents: I did not touch her, she came to me asking if I wanted to smell her butt, that she would bend over so I can. I walked away from her. Why would she ask me that. I have no interest in her. Agency nurse statement: R17 told me that R18 wanted to sniff her butt. I went to see where R18 was and he was napping in his room. R17 could not tell me the day or time it happened. R17 said she can read minds. There were no other documents related to the investigation. On 8/20/26 at 10:03am, V19administrator) said an investigation consists of interviewing resident involved and other residents on the unit it occurred, interviewing staff that were present or on unit depending on the allegation. V1 was asked if residents sniffing other resident buttocks would be reported and V1 confirmed that incident would be reported to the state agency and an investigation would occur. On 8/20/26 at 11:02pm, V1(administrator) was asked about the second allegation of R18 sniffing R17 buttocks and V1 said both allegations by R17 occurred at the same time (7/13/26). V1 confirmed there was no investigation for allegation on 7/29/26.R18's Point of Care charting dated 7/29/26 documents: Behavior Symptoms. Sexually Inappropriate was checked by V44(restorative aide).On 8/20/26 at 11:35am, V44 (restorative aide) said, R17 reported to me that R18 sniffed R17's butt while standing at the nursing station. V44 reported concern to the nurse. R18's Nursing note dated 7/30/26 documents by V35(Nurse): Resident (R18) noted with inappropriate sexual behavior towards peer, redirecting unsuccessful. Placed on staff 1:1. NP Psychiatry notified received order to petition to Hospital. On 81926 at 10:10AM, V35 (nurse) said she recall R18 sniffing other residents butts but unsure which female residents. Resident was always being inappropriate with staff and asking for sexual acts to be performed. R18's involuntary petition dated 7/30/26 document R18 observed with inappropriate sexual behavior towards other residents and staff, redirected unsuccessful.Facility abuse prevention program revised 3/1/21 documents: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and crime against a resident in the facility. Sexual abuse including but not limited to sexual harassment, sexual coercion or sexual assault. Investigation: All incidents, allegations or suspicions of abuse, neglect, exploitation or a crime against a resident will be documented. Any incidents, allegations or suspicion of abuse, neglect, exploitation or a crime against a resident will result in an abuse investigation. The charge nurse must complete an incident report and written statement from witnesses if any within 24 hours of the occurrence of such incident. All residents that are near the alleged incident and in the facility will be interviewed for concern related to abuse.

Based on interview and record review, the facility failed to follow physician orders for a resident's prescribed enteral nutrition feeding and failed to ensure recommended feedings were available for administration for one resident. This affected one of three (R19) residents reviewed for physician orders being followed. This failure resulted in (R19) receiving a different formula of feeding.Findings include:R19 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, aphasia, dysphagia and gastrostomy placement.R19's physician orders dated 3/28/25 documents: Glucerna 1.2 every eight hours. R19's progress notes dated 6/23/26 documents: This writer assessed resident. Resident resting in bed with head of bed elevated. Resident took medication whole no issues. Resident did not complain of pain or any discomfort . Resident clean and dry. Resident ate breakfast and lunch. No adverse reaction to any medication. This writer assessed resident's skin no new bruises or skin tears. Resident g-tube. Facility has no Glucerna 1.2. This writer was given Glucerna 1.5 for substitution. Family aware and at bedside.On 8/21/26 at 11:15AM, V52(MD) said he expects his orders to be followed as written and feedings should be given as recommended by the dietician. Facility's guidelines for physician orders (following physician orders) dated 6/18/23 documents it is the policy of the facility to follow the orders of the physician.R19's nutritional assessment dated [DATE] documents current enteral feeding at 1.2 formula @200miliiters three times a day. Continue current diet and supplements.R19's nutritional assessment dated [DATE] documents current enteral feeding at 1.2 formula @200miliiters three times a day.R19's nutritional assessment dated [DATE] documents current enteral feeding at 1.2 formula @200miliiters four times a day. (changed 7/10/26)R19's physician orders dated 7/4/26 documents: Glucerna 1.5 every eight hours and was discontinued on 7/10/26.On 8/21/26 at 11:15AM, V52(MD) said he usually follows the dietician recommendations for any changes in feeding. V52 said he was unable to recall why the feeding was changed for R19 and does not recall the feeding not being available as a reason. V52 said the dietician should be notified of any changes in feeding or feeding not being available. On 8/20/26 at 11:22Am, V42 (Dietician) said R19 was receiving Enteral nutrition 1.2 formula and does not recall changing the feeding to 1.5. V42 said for any changes in feedings or feedings not being available the facility should notify her so she can recommend a replacement. V42 said she does not recall any of those concerns for R19 and would have documented any changes. V42 was unable to find any documentation related to a change in feeding. V42 said the difference in formulas is 1.5 has more calories but is more dense which can be harder to digest.On 8/21/26 at 11:30AM, V2(DON) said R19's feedings were ordered and possibly misplaced. V2 said they got the feeding order changed until the supply was available. V2 is unsure how long the supply was not available for staff.

Based on interview and record review, the facility failed to ensure one resident who was admitted with a sacral wound had wound care treatment orders on admission, failed to provide treatment to the wound and failed to ensure antibiotic was given as ordered for a wound infection for one (R1) of three residents reviewed for pressure ulcer treatment.Findings include:R1 was admitted to facility on 05/29/2026 with a diagnosis of severe protein malnutrition, gastrostomy status, chronic obstructive pulmonary disease, heart failure, anemia, peripheral vascular disease.R1's admission paperwork documents under physician orders dated 5/11/26: sacrum cleanse with normal sterile saline, apply dakins moistened fluffed gauze and zinc oxide to periwound and apply bordered dressingR1's admission notes dated 5/29/26 documents: Multiple scabbed over lesions noted in various places on both arms. A dressing was noted on Sacrum. Upon assessment a wound is present with minimal pink drainage noted.R1's admission skin assessment dated [DATE] documents: coccyx with no other information documented.R1's medical record does not document any further skin assessments until 6/15/26.R1's medication administration record does not document any treatments provided to R1's wound site.R1 did not have any treatment administration records for May 2026 through June 2 2026.R1's electronic medication administration note dated 5/31/26 documents: Antibiotic (Linezolid )Give 1 tablet via G-Tube one time a day for wound infection until 06/09/2026 Awaiting pharmacy delivery.R1's electronic medication administration note dated 6/1/26 documents: Antibiotic (Linezolid )Give 1 tablet via G-Tube one time a day for wound infection until 06/09/2026 Awaiting pharmacy delivery.R1's medication administration record for May 2026 documents for antibiotic (Linezolid) Give 1 tablet via G-Tube one time a day for wound infection until 06/09/2026 was not given on 5/31/26 and 6/1/26.On 8/14/26 at 12:43PM, V30 (pharmacy) said R1's antibiotic was delivered to the facility on 6/1/26 at 4:07PM.On 8/21/26 at 11:15PM, V52 (MD) said he expects his orders to be followed and would expect to be notified if medications are not available.On 8/21/26 at 2:31PM, V2(DON) said all new admissions should be seen by wound care within 24 hours. Admitting nurse should verify orders and ensure orders are in place for any open areas. Facility management DON and ADON should review admission orders to ensure all orders are carried out upon admission.On 8/14/26 at 2:35PM, V32(wound care nurse) said all new admissions are usually assessed within 24 hours by wound care if available. If not, the next day they are scheduled. V32 said the admitting nurse will conduct an admission assessment and obtain orders for any wound care treatments. Initial wound measurements are usually done by wound care nurse under assessments if a resident is admitted to the facility with wounds. Wound treatments are documented on the treatment record. V32 said he was unable to find any initial wound care note for R1 to include wound measurements. V32 was unable to find any wound treatment orders or documentation of any treatments being performed on R1.On 8/21/26 at 4:00PM, V54 (wound consultant) said all wounds should have treatment orders and treatment provided as ordered to prevent any infection or the wounds from worsening.R1's hospital record dated 6/2/26 documents: Septic shock under clinical imagine it documents wound sacrum and wound to back left medial dated 6/2/26. Ct of pelvis with contrast dated 6/2/26 documents: sacral decubitus ulcers with erosive changes of the right posterior iliac crest and posterior sacrum, which can be seen in the setting of osteomyelitis.Facility's wound assessment policy dated 05/19/17 documents that it is the policy of this facility to complete a systematic, ongoing assessment of all wounds that will provide a consistent means of wound evaluation to determine the response to treatment modalities and to facilitate continuity of care and communication among staff and health care providers on an ongoing basis. The presence of any wounds, injuries, and/or other skin abnormalities will be identified upon admission/readmission or identification of a new wound, pressure injury, or other skin abnormality. The staff nurse will complete a skin and wound assessment upon admission/readmission, identify any wounds, pressure injuries, or other skin abnormality, and document it in the medical record. The wound team will complete a skin and wound assessment and document the presence of any wounds, injuries, or other skin abnormalities including measurements and the wound assessment in the medical record within 24 hours of admission Monday to Friday and within 72 hours over the weekend. Any wound, pressure injury, or other skin abnormality identified during the resident's stay will be documented in the same manner as when identified upon admission/readmission.Facility's guidelines for physician orders (following physician orders) dated 6/18/23 documents it is the policy of the facility to follow the orders of the physician. At the time of admission the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. Two nurses will review admission and readmission orders to serve as a double check for the accuracy of the orders. If a discharge summary accompanies the resident on admission or readmission it will be compared to the list of orders on the orders sheet and any discrepancies will be addressed and clarified at that time to ensure accuracy of the orders that will be in place.

Based on observations, interviews, and record reviews, the facility failed to provide tracheostomy care in accordance with physician orders, including the administration of oxygen, and failed to date and label oxygen tubing in accordance with facility policy and procedure. This affected three of three residents (R65, R11, and R85) reviewed for oxygen therapy in a sample of 54 residents.Findings include:On 5/19/26 at 10:10 AM, two oxygen concentrators were observed by the nurses' station. The smaller oxygen concentrator was blue in color and could provide up to 5 liters of oxygen. The larger concentrator was grey in color and could provide up to 10 liters of oxygen.On 5/20/26 at 1:05 PM, V20 CNA (certified nurse aide) stated that R65 had an oxygen concentrator in her room, it was the smaller one. V20 stated that the concentrator did not go up to 10 L of oxygen. V20 stated that R65 was exhibiting shortness of breath at times.On 5/21/26 at 3:35 PM, V22 LPN (licensed practical nurse) stated that R65 was admitted to this facility with oxygen via a trach collar. V22 stated that she did not recall how much oxygen was ordered for R65, but the oxygen concentrator was blue.On 5/22/26 at 8:20 AM, V34 (central supply) stated that the oxygen concentrators that could provide up to 10 liters of oxygen were light grey in color. The blue oxygen concentrators were smaller and could provide up to 5 liters of oxygen.R65's POS (physician order sheet) notes an order, dated 4/27, give oxygen at 8 liters via trach collar continuous and pulse oximetry every shift. On 4/29 at 8:17 PM, re-admission orders included, but not limited to, change inner cannula every day shift, tracheostomy care every shift, pulse oximetry every shift, titrate oxygen to maintain oxygen saturation level 96%, and 10 liters of oxygen via trach continuous for shortness of breath.R65's MAR (medication administration record), dated April 2026, does not note R65 received tracheostomy care, suctioning, or had inner cannula changed on 4/29 or 4/30.V43's (nurse) pulse oximetry documentation notes R65's oxygen level was 88% on room air on 4/30 at 7:18 AM.There is no documentation found in R65's medical record noting V43 notified the physician, reassessed R65's oxygen level, assessed R65's lung sounds, or placed R65 on oxygen via trach.On 4/28/26 at 4:50 AM, V44 (nurse) noted she was summoned to R65's room. Upon arrival, R65 stated I Can't breathe. Oxygen at 8 liters. Vital signs: pulse 100 beats/minute, respirations 22/minute, oxygen saturation level 89% on 8 liters via trach. R65 was transported to the hospital via EMS (emergency medical services) 911.4/30/26 at 7:15 PM, V22 (nurse) noted Paramedics arrived on unit, stated R65 called EMS 911 with complaint of difficulty breathing/shortness of breath. R65's hospital record, dated 4/28/26, notes R65 presented to the emergency room with shortness of breath. The physician noted R65 with acute on chronic hypoxic (body does not receive enough oxygen at the tissue level to function properly) respiratory failure secondary to COPD (chronic obstructive pulmonary disease). R65 was discharged back to facility on 4/29/26 with discharge order for 10 liters of oxygen via trach collar.R65's hospital record, dated 4/30/26, notes R65 presented to the emergency room with shortness of breath. Per EMS crew, facility did not have adequate oxygen support at their facility for R65. Physical exam was positive for shortness of breath.R11 and R85:On 5/19/26 at 11:25 AM, R11 was observed in her room. R11 was receiving 3 liters of oxygen via nasal cannula. R11's oxygen tubing did not have a date on it. R11 was observed to have a blue oxygen concentrator that could provide up to 5 liters of oxygen.On 5/19/26 at 12:35 PM, R85 was observed in her room. R85 was receiving 3 liters oxygen via nasal cannula. R85's oxygen tubing did not have a date on it. R85 was observed to have a blue oxygen concentrator that could provide up to 5 liters of oxygen.On 5/21/26 at 11:00 AM, V2 DON (director of nursing) stated that oxygen tubing should be labeled with date and nurse's initials.The facility's oxygen administration policy, undated, notes in part residents with oxygen orders, routine and as needed, will have oxygen saturation levels measured by oximetry per physician order indicating clinical oxygen saturation to be maintained. Oxygen saturation will be checked and documented every shift to meet order specifications. Oxygen concentrators are provided to residents with oxygen orders. Check orders for accurate oxygen liter flow. Tubing and humidifier bottles will be changed and maintained weekly. Each will be labeled with date, time, and initialed by staff completing this service to equipment. Physician will be notified whenever titration is required to maintain a saturation, which may indicate a condition change. Lung sounds and assessment will be reported to the physician at that time.

Based on observation, interview and record review the facility failed to ensure residents who smoke follow facility smoking policy. This deficiency has the potential to affect all 44 residents on the 3rd floor reviewed for Resident Rights. Findings include:On 5/13/26 at 12:15PM, during observation surveyors smelled illicit substances on the 3rd floor hallways. On 5/13/26 at 12:15PM, V10 (Registered Nurse) confirmed with surveyor and identified illicit substance smell on the 3rd floor. V10 said that when they smell that on the floor, they call administration, but nothing gets done.On 5/13/26 at 12:20pm, V5 (Maintenance) said that there has been smell of illicit substances in the building, because the facility brings in new younger residents. V5 said administration is aware. On 5/13/26 at 12:30PM, V1(Director of Nursing) made aware of illicit substance smell on the 3rd floor, V1 verified that it did smell of illicit substances, said there has been concerns and have identified residents not following smoking policy, V1 said the facility has provided a twenty-one day letter of intent to discharge with notice date of discharge 5-11-26.Facility Policy Guidelines for SmokingPolicy:There will be no smoking permitted inside the facility. Smoking will be allowed for residents, staff and visitor centers in designated areas only. Smoking must be at least 15 feet. Or as dictated by any (State/ Local laws/mandates) from any door, way, window or vent system of the facility. All residents smoking materials will be kept in by the facility in a secure location.Purpose:To provide a healthy and safe smoke environment as possible for all residents, staff and visitors to include those who smoke and those who do not smoke. Also, to determine if a resident is an independent smoker. Or At Risk smoker before the resident exercises the privileges to smoke while residents sitting in the facility. Further, to establish smoking islands for all residents that desire to smoke at the facility.(1) Allowing the use of medical marijuana in a long-term care facility would violate federal law. Marijuana for recreational use by any person to include residents, staff visitors others- is strictly prohibited in this nursing facility- as well as on grounds/premises of the facility.

Based on observation, interview and record review the facility failed to ensure residents who were dependent on staff for showering and bed baths received those services for one of three residents (R2) reviewed for ADL assistance (Activity of Daily Living).Findings Include:On 5/13/2026 at 10:40am R2 was observed sitting on the side of his bed with a urine odor, soiled clothes and linen.On 5/13/2026 at 10:42am R2 said I have been asking the (Certified Nursing Assistant -CNA) could they please assist me with a bed bath and a change of clothes they say, yes and never return.On 5/13/2026 at 10:48am V4(Assistant Director of Nursing-ADON) said she will have R2 CNA come right away and assist him.On 5/14/2026 at 10:00am V17(Certified Nursing Assistant-CNA) said I was R2's CNA, I did return as soon as I finished with the resident I was with and assisted him with a bed bath, he did have a urine odor, and his clothes were soiled I work on all units; I was his CNA only once before I don't know how long it had been since he had a bed bath or shower. On 5/14/2026 at 11:00am V1(Director of Nursing-DON) said I expect all nursing staff to attend to dependent residents as soon as possible, he was cleaned up right away.A resident information document indicates that R2 has a diagnosis of morbid obesity, GERD, COPD, and depression, a care plan dated 4/9/2026 that indicates R2 has a self-care deficit and needs assistance and encouragement from staff.Facility Policy: Guidelines for Activities of Daily Living (Routine Care)Policy: Residents are given routine daily care and HS care by a C.N.A. or a nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as a care planned and or as needed. ADL care is coordinated between the residents and the care givers with emphasis on resident preference as much as possible.Some tasks include:Assisting the residents in personal care such as bathing, showering, dressing, eating, haircare, oral care, nail care.

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents(R3) reviewed for medication administration.Findings include:On 5/14/2026 this writer reviewed an (Electronic Medication Administration Record-EMAR) for R3 that indicates on 4/23/2026 at 1700 Clonidine HCL 0.3mg by mouth for hypertension was not given the code (5) which indicates the drug was held and to see the nurses note, A medication Hydralazine HCL 50mg by mouth had a code of (5) and a medication Carvedilol 25mg by mouth with a with a code of (6) which indicates hospital and resident was in the facility.On 5/14/2026 at 1:30pm V18(Nurse) was asked did she administer R3's medication and V18 said those are my initial for 4/23/2026 at 1700, I did not administer R3's medications because he was sleeping I called his name three times, he was not in any distress, I did not return to try and administer again.On 5/14/2026 at 2:00pm V1 (Director of Nursing-DON) said the nurses should wake every resident up for medication administration. An order summary report indicates that R3 has a physician order for Carvedilol 25mg by mouth two times a day for hypertension, Clonidine HCL 0.3mg three times a day for hypertension, and Hydralazine HCL 50mg by mouth. A progress note dated 4/23/2026 at 22:36:00 indicated that V18 wrote a progress note stating V18 was in the resident room to administer medication, noted bed pushed to the side, resident sleeping chest rising and falling unable to administer medication.Facility Policy: Drug Administration-General GuidelinesPolicy:Medications are administered as prescribed , in accordance with food nursing principles and practices and only by persons legally authorized to do so.Procedure:2. Medications are administered in accordance with written orders of the attending physician.17. All medications will be given PO (by oral route) unless otherwise stated.

Based on observation, interview and record review, the facility failed to ensure that food substitutes offered to residents who declined the planned meal were of similar nutritive value to the original menu. This failure affected all 98 residents that consume food from the facility's kitchen. Findings include: Facility census, dated 4/13/26, documents 101 occupied residents at the facility. Record review of facility document titled, Diet Type Report, dated 4/14/26, list 3 residents that are NPO (nothing by mouth). On 4/13/26, facility presented document titled, (Facility) Substitution Menu Always Available, undated, that documents, in part, 1. Cheeseburger or Hamburger; 2. Hot Dog; 3. Deli Meat Sandwich; and 4. Peanut Butter and Jelly Sandwich which are the facility's substitutes if a resident does not prefer the meal being served. The substitution menu documents all sandwich type substitutions, with no vegetable or other balanced side. On 4/13/26 at 11:37am, R2 said, I have been here since March 6th (3/06/26). OH, and the food. The food is cold period there's no substitutes; all the substitutes are sandwiches and hot dogs. I can't even have a salad. They (facility staff) are not concerned about anything, you think they (facility staff) are concerned about my privacy bag? I had to call the ambulance myself when the balloon broke to my catheter. They (staff) don't take care of my catheter (urinary). You see this thing (R2 pointed to R2's adhesive catheter anchoring device on R2's right leg)? They (facility) don't even have these (adhesive catheter anchoring device), when this one (adhesive catheter anchoring device) is gone, I'm screwed. My catheter is going to come out. This place (facility) is not what you think it is. It's (facility) going downhill. Get them (facility staff) to get me my medications on time and more than just sandwiches and then get them (facility) to get me a privacy cover for my bag (urinary bag). According to the Electronic Health Record (EHR) R2 has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and absence of left leg below knee. R2's BIMS (brief interview for mental status) score, dated 3/15/26, is 13 which indicates R2 is cognitively intact. R3's face sheet documents in part the following diagnoses: heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, obesity. R3's minimum data set (3/5/2026) documents a brief interview of mental status (BIMS) summary score of 14, indicating that R3 is cognitively intact. R3's physician's orders (11/20/2025) document in part an active order for Regular texture, Thin consistency, for diabetic no pork and tomato productOn 4/13/2026 at 11:38 AM, R3 explained, The food here is terrible, let me show you what I mean. I had to take pictures because you wouldn't believe what they serve me. R3 showed surveyors pictures of food served to R3 including an unappetizing plate of plain white rice and mixed vegetables (50% of the plate was rice, the other 50% mixed vegetables, no protein), a roll of bread and small bowl of plain oatmeal (no protein), and an unidentifiable mass of a brown meat substance that appeared burnt over 50% of the meat. R3 stated, Do these look appetizing to you? Absolutely not. That burnt meat, they couldn't even tell me what it was. The roll, they told me it was a muffin but it tasted more like cornbread. The day with the rice and vegetables and the oatmeal, I got no protein. They frequently don't give me protein. I don't eat beef or pork but they should be able to accommodate that. Please, I know you're probably really busy, but could you look at the food they send me today for lunch? You need to see how terrible it is. Yes, they do offer substitutes, but they aren't comparable to what's actually being served. How is giving me a PB and J (Peanut Butter and Jelly Sandwich) nutritionally equivalent to a pork chop? It's not. They could be giving me a piece of chicken or like some turkey. One time, they gave me a peanut butter and jelly at breakfast instead of sausage. They could be getting me turkey sausage. I am not asking for anything unreasonable, you don't need to go and order out food for me. I just want to be able to have something similar to what is being served, and something that fills you up the same so I don't get hungry. On 4/13/26 at 1:46pm, V4 (Regional Director of Operations for Dietary Department) said, Yes, we (facility) also have an always-available menu. Residents make their selections before the meal, but they (residents) can also get something off the always-available menu even during mealtimes. The menus are posted by the dining room doors. According to the menu, we (facility) also accommodate special diets for some residents. We (facility) currently have about six to eight residents on renal diets. They (residents on renal diets) cannot have starches but can have rice. We (facility) use a spreadsheet that lists each resident's special preferences. Residents can choose items from the always available menu, which are nutritionally equivalent to the entrée portions of the meal. Everything is protein oriented. If a resident says they do not like green beans, we (facility) provide an alternative vegetable. There are also alternative vegetables and starches not listed on the always available menu, but they vary. For example, one resident has eaten a cheeseburger without bread for six years. While this is not on the spreadsheet, we know his preference. Vegetables are not posted in advance, but they are listed on the meal ticket. If a resident does not like a vegetable, it may not automatically be replaced unless requested. In some cases, alternatives are not printed on the ticket, so we prepare an alternative as needed. We (facility) gather information about residents' likes and dislikes and base our service on those preferences. Meal tickets are updated according to each resident's preferences, and we are careful to monitor allergies as well. We do our best to meet their needs by interviewing every resident upon admission. Preferences can change over time, so we remain flexible. At any given time, we are trying to satisfy many different tastes, and there can be countless reasons why a resident may not want a certain food on a given day. For example, it may simply feel too hot for something like beef stew. While we (facility) cannot please everyone all the time, we do our best to offer alternatives, sometimes even preparing multiple options when necessary. Our goal is to accommodate all residents as much as possible. Some days are more successful than others, but our job is to provide the best customer service we (facility) can. We (facility) pay close attention to what residents are requesting. However, when adding items to the always-available menu, we (facility) must also consider factors such as perishability, like for example, lettuce spoils quickly. Overall, we (facility) rely on resident interviews and ongoing communication to understand their likes and dislikes and to provide meals that best meet their preferences. R2's Concern Referral Form, dated 4/13/26, documents, in part, Resident (R2) interviewed for meal references and dislikes. Resident (R2) likes salads and vegetables. Mealt ticket updated to reflect salads and double vegetables for lunch and dinner. On 4/14/26 at 11:19am, V17 (Registered Dietician) said, Yes and no, let's put it that way, in regard to nutritional value meeting the same nutrient requirements as the Always Available menu (1. Cheeseburger or Hamburger; 2. Hot Dog; 3. Deli Meat Sandwich; and 4. Peanut Butter and Jelly Sandwich). When looking for protein content, a hamburger would be good, I don't know about a hot dog. What's missing is the vegetable. Even a glass of tomato juice can be added to the alternative menu to meet the equivalent nutritional value of the meal. On 4/14/26, V1 (Administrator) said that the facility has a new Always Available substitution menu, but the food was ordered and will not be in until next week. Record review of Facility's new Always Available substitution menu documents, in part, 1. Cheeseburger or Hamburger; 2. Chef Salad / With Meat; 3. Deli Meat Sandwich; 4. Peanut Butter And Jelly Sandwich; 5. Egg Salad With Crackers; and 6. Pasta Meat Salad / Dressing. The new alternative menu increased food group variety, and the updated options include multiple food groups beyond bread-based items: Vegetables (salad), Protein (meat, eggs, peanut butter), and Grains/starches (crackers, pasta). Record review of facility policy titled, Menu Alternates (per your request menu), dated 5/31/21, documents, in part, Policy: Nutritionally comparable menu items shall be available to accommodate resident food preferences. Alternate menu items are planned during the menu planning process for protein source, grains, fruits and vegetables. Record review of facility policy titled, Dietary Preferences, Nutritional Requirements, and Portion Management, dated 10/30/25, documents, in part, To ensure that all residents receive nourishing, palatable, and well-balanced meals that meet their assessed nutritional needs while honoring individual cultural, religious, and personal food preferences. The facility will make every reasonable effort to accommodate each resident's cultural, religious, and personal dietary preferences while ensuring that all meals meet the resident's nutritional requirements as determined through comprehensive assessment and care planning. The facility recognizes each resident's right to self-determination in dietary choices and will honor those choices to the extent that they are consistent with safe, appropriate, and regulatory-compliant food service practices. All resident preferences, substitutions, and approved special portion exceptions will be documented in the resident's record.

Based on observation, interview, and record review, the facility failed to cover the urinary catheter drainage bag for 1 (R2) resident. This failure affected one (R2) of three residents reviewed for urinary catheters.Findings include:On 4/13/26 at 11:37am, R2's urinary drainage bag was observed hanging uncovered from R2's wheelchair, with approximately 225 mL of clear yellow urine observed present in the bag. R2 said, They (facility staff) are not concerned about anything, you think they (facility staff) are concerned about my privacy bag? I had to call the ambulance myself when the balloon broke to my catheter. This place (facility) is not what you think it is. It's (facility) going downhill. Get them (facility staff) to get me my medications on time and more than just sandwiches and then get them (facility) to get me a privacy cover for my bag (urinary bag). Yeah, I would like a privacy cover.According to the Electronic Health Record (EHR) R2 has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and absence of left leg below knee.R2's BIMS (brief interview for mental status) score, dated 3/15/26, is 13 which indicates R2 is cognitively intact.R2's care plan, dated 4/13/26, documents in part, I (R2) have an Indwelling/Suprapubic Catheter/Urostomy.On 4/13/26 at 12:19pm, V9 (Registered Nurse/RN) said, Oh, yeah. I'll go put one (urinary privacy cover) on now.On 4/15/26 at 10:18am, V2 (Director/DON) said, The facility's expectation for residents with urinary catheters is that everyone with a urinary catheter bag should have a privacy cover because it's a dignity issue as well.Record review of facility policy titled, Guidelines For Observing and Implementing-Resident Rights (f-550, f-942), dated 7/12/23, documents, in part, Policy: It is the policy of the facility to observe and implement RESIDENT RIGHTS as dictated by CMS. These rights and protections are mandated by Federal and State laws. These rights and protections are a requirement in Medicare and/or Medicaid certified nursing homes. Each resident has the right to be treated with dignity and respect. It is important that staff be aware of the RESIDENT RIGHTS to include but not limited to: A dignified existence-resident being treated with dignity in all situations. To Achieve This staff will treat each resident with respect and dignity.

Based on interview and record review, the facility failed to follow policy and procedure and failed to implement a valid PRN (as-needed) order for one resident (R2) receiving psychotropic medications, in accordance with federal regulations and facility policy. This failure affected one resident (R2) in a sample of three residents reviewed for medication administration. Findings include:According to the Electronic Health Record (EHR) R2 has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and absence of left leg below knee.R2's BIMS (brief interview for mental status) score, dated 3/15/26, is 13 which indicates R2 is cognitively intact.On 4/13/26 at 11:37am, R2 said, I have been here since March 6th (3/06/26). I kept telling her (V14/Registered Nurse/RN) that they (facility nurses) had my medication doses wrong and giving them to me at the wrong time and they (facility nurses) wouldn't listen. They're (R2's medication orders) fixed now. Do you think I would have signed a consent (psychotropic medication) for the wrong dose of medications (psychotropic medications). Yes, I sign my own consents. And I pay my own bills. They (facility nurses) are always passing my medications late and I really need those medications to help me. Sometimes, I don't get them (medications) at all. They (facility staff) are not concerned about anything, you think they (facility staff) are concerned about my privacy bag. I had to call the ambulance myself when the balloon broke to my catheter. Get them (facility staff) to get me my medications on time and more than just sandwiches and then get them (facility) to get me a privacy cover for my bag (urinary bag). Yeah, I would like a privacy cover.R2's physician order, ordered date: 3/04/26; end date: indefinite, documents, in part, Haloperidol Lactate Injection Solution 5 MG/ML (Haloperidol Lactate): Inject 0.4 ml intramuscularly every 6 hours as needed for antipsychotics/antimanic agents, chemicals. This order does not have a stop date as required by federal regulation. Discontinued 4/14/26, 41 days after original ordered date.R2's physician order, ordered date: 3/04/26; end date: indefinite, documents, in part, Haloperidol Oral Tablet 2 MG (Haloperidol): Give 2 mg by mouth every 6 hours as needed for antipsychotics/antimanic agents, chemicals. This order does not have a stop date as required by federal regulation. Discontinued 4/14/26, 41 days after original order date.On 4/14/26 at 2:15pm, V21 (Assistant Director of Nursing/ADON) said, Yes, I'm in charge of psychotropic meds (medications). Facility policy (psychotropics) is to get consent before taking medications, within 24 hours, and they (residents) have to sign and agree when taking that medication. PRN psychotropic medications are only to be ordered for 2 weeks and after 2 weeks they (residents) need to be reassessed by the psychiatrist. R2's PRN Haldol was ordered more than 14 days. She (V22/Family Nurse Practitioner/NP) seen it and had me DC (discontinue) it. 14 days for PRN medications because they have to be monitored. I'm not sure. She (V22) just said 14 days for PRN have to be DC' d. Not sure why.On 4/14/26 at 2:23pm, V22 (Family Nurse Practitioner) said, Yeah, I saw R2 for the first time on the 10th (3/10/26). He (R2) had PRN Haldol and was having no behaviors. I didn't see him (R2) back in March (2026). There's was no behaviors since admission. Haldol should be ordered for 14 days to check for adverse side effects like catatonia or anything else and make sure dose (current dose) is working properly.On 4/14/26 at 4:26pm, V14 (Registered Nurse/RN) said, He (R2) never told me that he (R2) was going the wrong meds. He (R2) would just scream down the hall Where are my meds? I want my meds. On 4/15/26 at 10:18am, V2 (Director/DON) said, The Assistant Director of Nursing (V21) and Infection Preventionist split up reconciling admission medications around the facility. Psychotropic medications that are PRN, the orders should be written for every 14 days. The purpose of psychotropic PRN medication order to be written for only 14 days is to avoid a chemical restraint. Also, the PRN orders are to be accompanied by documentation on effects on the resident, so it (psychotropic PRN order) can possibly transfer from PRN to a schedule dose, or the resident may need to go down or up on the dose.Record review of facility policy titled, Guidelines for Psychotropic Medication, dated 6/05/23, documents, in part, The facility will monitor any ordered and administered psychotropic medication for the following: Duration. PRN Orders for Psychotropic Medications: PRN orders for psychotropic drugs will be limited to 14 days, unless the physician identifies and documents rationale to extend the medication beyond 14 days. PRN antipsychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. If a resident is admitted to the facility and is currently on a psychotropic medication, the attending physician in collaboration with the consulting pharmacist will re-evaluate the continued use of the psychotropic medication and consider whether or not the medication can possibly be reduced or discontinued upon admission or soon after. PRN orders for antipsychotic drugs are limited to 14 days. The resident will be monitored for behavior, non-pharmacological interventions and outcomes with the results being reported to the physician. If the physician believes that the PRN order should be extended beyond the 14 days, the physician must document rationale in the medical record to support this extension. If the PRN is an antipsychotic medication, the medication will be limited to 14 days and not renewed unless the physician evaluates the resident for appropriateness of the medication and documents this information in the medical record.Record review of facility policy titled, Guidelines for Use of Unnecessary Drugs to Include Chemical Restraints, dated 3/05/25, documents, in part, What is a Psychotropic Drug? Psychotropic drugs include antipsychotics, anticonvulsants, anxiolytics, depressants, and other drugs that fit into the broader category of psychotropic drugs, which CMS defines as any drug that affects brain activities associated with mental processes and behaviors; Right to be fully informed.The resident and/or their responsible Party/POA have the right to be fully informed of, and to participate in, or refuse treatment. This includes the use of psychotropic medication. Before initiating or increasing a psychotropic medication, the resident and/or their Responsible Party/POA must be notified of-and have the right to participate in--the right to accept or decline the medication. The intent of this requirement is to ensure residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. The information shared should include the benefits, risks and alternatives for the specific medication(s) to include any Black Box Warnings for any antipsychotic /psychotropic medications in advance of any initiation or increase of the medication. Proof that this was done must be documented in the medical record-usually by use of a comprehensive consent form. It must be clear that after being informed-the option of the specific medication(s) use was the option chosen by the resident and/or their Responsible Party/POA; Supporting documentation for use. The use of psychotropic medication must be identified by a practitioner and documented in the clinical record. This documentation must also include the rationale for its use. This must be based on the assessment of the residents' condition as well as their therapeutic goals, and also after other treatments have been deemed clinically contraindicated. If the practitioner has not documented that it has been determined that other treatments have been deemed clinically contraindicated, the indication for use will be considered inadequate; Resident will not receive psychotropic drugs pursuant to a PRN order, unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; PRN orders for psychoactive drugs are limited to 14 days-unless the attending physician or prescribing practitioner believes that is appropriate for the PRN order to be extended beyond 14 days. The rationale for extended use must be documented in the medical record by the attending physician or prescribing practitioner as well as the duration for the order; PRN orders for antipsychotic medications are limited to 14 days and the attending physician or prescribing practitioner must evaluate the resident for the appropriateness of use of that specific medication; What else does CMS state as being an adequate indicator for use of these drugs? Note: One or more of the following must be met: 1. Following manufacturer's recommendations, 2. Clinical Practice Guidelines, 3. Clinical Professional Standards of Practice, 4. Medication References, 5. Clinical studies or evidence-based review articles that are published in medical and/or pharmaceutical journals; CMS Guidance--- Residents who use psychotropic drugs must receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, and in an effort to discontinue these drugs. CMS's definition of GDR- Stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discussed.Record review of the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, You have the right to make your own choices. You have the right to be free from physical or chemical restraints. You have the right to be in charge of taking your own medicine if your care plan team and your doctor say that you are able to do so. Your facility must provide services to keep your physical and mental health at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items [N] (dated October 2025) documents in part the following: Health-related Quality of Life: The use of unnecessary medications in long term care settings can have a profound effect on the resident's quality of life. Antipsychotic medications are associated with increased risks for adverse outcomes that can affect health, safety, and quality of life. In addition to assuring that antipsychotic medications are being utilized to treat the resident's condition, it is also important to assess the need to reduce these medications whenever possible.

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors and failed to follow their medication administration policies. These failures affected two residents (R2, R3) in a sample of three residents reviewed for medication administration. Findings include: R3's face sheet documents in part the following diagnoses: heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, obesity. R3's minimum data set (3/5/2026) documents a brief interview of mental status (BIMS) summary score of 14, indicating that R3 is cognitively intact. R3's physician orders document in part active orders for the following medications: Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for vitamin (1/10/2025), Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 40 mg by mouth one time a day for antihyperlipidemic (11/10/2025), Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 35 unit subcutaneously at bedtime for diabetes Notify MD/NP if BS < 70 or >400 (4/2/2026), NIFEdipine ER Tablet Extended Release 24 Hour 60 MG Give 1 tablet by mouth one time a day for hypertension (12/04/2025), Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth two times a day for tachycardia/hypertension hold if blood pressure less than 100/60 and heart rate less than 60 (12/22/2025), Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day for pain (11/10/2025), Renvela Oral Tablet 800 MG (Sevelamer Carbonate) Give 3 tablet by mouth with meals for renal (12/18/2025). On 4/13/2026 at 11:39 AM, R3 expressed that R3 frequently gets medications late. R3 stated, I never get my medications on time. It's like hours late. I got back from dialysis at 10:30 AM and I still haven't gotten my medications. It's not all the time, it's only some of the nurses, like the nurse I have now. I haven't gotten any medication today-- I haven't seen my day nurse yet today. On 4/13/2026 at 12:17 PM, V18 (Registered Nurse) entered the room and obtained R3's blood pressure. Observed R3's blood pressure 147/89 and heart rate of 100 on the machine. Observation was confirmed with V18 and R3. V18 told R3, Yeah you're blood pressure was high because you're getting your medicine so late. You on a beta blocker and if you don't take the hypertension medications it drives your blood pressure up. On 4/13/2026 at 12:24 PM, V18 prepared R3's morning medications. Observed V8 open pill packs and place the pills in a medication cup. V18 stated, Okay so we have nifedipine 60 mg extended release 24 hour, the half tablet of metoprolol tartrate 25 mg, gabapentin 100 mg capsule, selevemir 800 mg, calcitriol, 0.5 mcg. These medications should have been given around 9 o'clock, they are late. (R3) got back from dialysis around 10:30. On 4/13/2026 at 12:30 PM, V18 administered the medications to R3. V18 told R3, Yes, the meds are late. You're not supposed to go outside of the medication times; it's supposed to be one hour before or one hour after. It's a legal thing from the state. But your blood pressure is high so you should take them now. V18 swallowed the medications. On 4/13/2026 at 12:33 PM, V18 explained, our procedure with medication administration is to check vital signs and then that drives the medication use. (R3) got back from dialysis around 10:30, (R3)'s medications should have been given as soon as possible when (R3) came back. I did not give the medications timely because I am taking care of 27-30 residents at a time. I don't think that's an appropriate staffing set up given all the residents with behaviors, but I don't think there's anything they can do about that. Yeah, I have given her medications late before too. With the way it is set up, it is hard to get all of the meds passed timely with these residents. (R3) frequently runs high for blood pressure, that's why (R3) needs those medications. With (R3) getting back from dialysis earlier, I would expect the blood pressure to be lower. Yes, if metoprolol and nifedipine aren't given, it could cause rebound hypertension. On 4/13/2026 at 12:43 PM, V18 stated V18 is one of the nurses that frequently gives R3 medications late. On 4/14/2026 at 10:30 AM, V16 (Pharmacist) affirmed that V16 is the consultant pharmacist for the facility. V16 explained that R3's nifedipine and metoprolol are being used to treat blood pressure. V16 stated, If a resident doesn't receive them (high blood pressure medications), their blood pressure is going to go up. For the nifedipine, (R3) should be getting that at the same time every day. That medication works as extended release over a 24-hour period, so it's important that it is given each time at the same time. As for the metoprolol . it's twice per day so it really just depends on the last time it was given as to if it would increase the blood pressure. Let me check. V16 assessed R3's medical record and stated, There's no documentation on when it was given the night before (4/12/2026). I don't know if the nurse just didn't document it or if it was not given. There is no documentation that says if it was given. Yes, the nurse should be documenting when medications are administered or if medications are refused. Yes, if (R3) isn't receiving the nifedipine at the same time daily or if the metoprolol wasn't given or is late, yeah of course (R3's) blood pressure I'd expect to be high. If they are on dialysis during the time the medications are scheduled, the nurses should be reaching out to the provider to be changing the scheduled time so it is able to be administered at the same time every day and so it is not due during dialysis. I would be expecting them to be following their procedures for medication administration. On 4/14/2025 at 4:27 PM, V2 (Director of Nursing) explained, Yes, we have a process for medication administration. We have a time frame that allows the medications to be scheduled 1 hour before and 1 hour after. If a resident is on dialysis, the medications should be scheduled in a way that they can be administered at the same time every day. If they are in dialysis when medications are due, the nurses should be notifying the provider and asking for a different medication schedule, so it won't be during dialysis. V2 accessed R3's electronic health records and affirmed R3 is on dialysis. V2 reviewed the orders for R3's Nifedipine and Metoprolol Tartrate and affirmed that they are scheduled for 9 AM, which is during R3's chair time in dialysis. V2 reviewed R3's medication administration records and affirmed that R3 has not been consistently getting the metoprolol at 9:00 AM/6:00 PM and nifedipine at 9:00 AM. V2 stated if a resident has medications scheduled during dialysis, they should be giving the medications to them as soon as they can when they get back to try and remain on schedule. V2 affirmed that V18 could have administered the medications closer to the schedule instead of 12:30. V2 affirmed there is no documentation that the metoprolol was administered on 4/12/2026 at 6:00 PM. V2 stated, According to the MAR, the metoprolol wasn't given (on 4/12/2026). V2 stated nurses are required to document every time they give a medication, if there is no proof, then we cannot tell if the medication was administered. V2 reviewed records and confirmed V18 documented 9 - See Progress Notes for the medications given with the surveyor. V2 reviewed the progress notes and affirmed V18 did not document any progress notes related to the medication administration. V2 confirmed that there is no documentation in the progress notes from the other nursing staff that indicate why medications were given late or not documented. Record review of R3's Medication Administration Audit Report (4/14/2026) documents V18 administered R1's metoprolol tartrate late on the following dates: 4/1/2026 (due at 4:00 PM, administered at 11:42 PM), 4/13/2026 (due at 6:00 PM, administered on 4/14/2026 at 8:26 AM). V18 administered R1's nifedipine late on 4/1/2026 (due at 9:00 AM, given at 2:09 PM). Additionally, R3's nifedipine (due at 9:00 AM) was administered late on the following dates: 4/8/2026 (administered 2:57 PM), 4/10/2026 (administered 11:49 AM), 4/11/2026 (administered 11:33 AM), 4/12/2026 (administered 10:44 AM). R4's metoprolol tartrate (due at 9:00 AM and 6:00 PM) was administered late on the following dates: 4/4/2026 (administered 10:04 PM), 4/5/2026 (administered 9:24 PM), 4/8/2026 (administered at 3:00 PM), 4/8/2026 (administered 10:01 PM), 4/10/2026 (administered at 11:49 AM), 4/11/2026 (administered at 11:32 AM), 4/11/2026 (administered 4/12/2026 at 4:30 AM). There is no documentation of the time when R3 was administered Metoprolol Tartrate for the 6:00 PM dose on 4/6/2026 and 4/12/2026. Record review of R3's medication administration record (4/2026) does not document that the 6:00 PM dose of Metoprolol Tartrate was given on 4/6/2026 and 4/12/2026. Record review of R3's progress notes (4/1/2026-4/14/2026) document that R3 requested R3's morning medications to be administered after dialysis that morning. There is no other documentation of why the medications were administered timely according to the facility policies. No further documentation was received on why the medications were administered late or if R3 received the medications prior to the exit of the survey. There is no documentation to R3's provider that indicates the provider was made aware of the late medication administration. Facility policy titled, Ten 'Rights' for Medication Administration (undated) documents in part, .4. The right time: administer drugs as instructed on the MAR and within the time frame established by your facility . Facility policy titled, Tips for Safe Medication Administration (undated) documents in part, .3. Accurately dispense medications to residents.a. Allow one (1) hour before to one (1) after schedule time of medication to administer medication (i.e.: Noon medication be giving prior to 11:00 a.m. or after 1:00 p.m.) .4. Follow good clinical practices for administration of medications: a. Obtain and record any vital signs as necessary prior to medication administration. b. Sign out medications as soon as they are given. ALWAYS use your medication book. c. Document if the medication is refused and the reason. d. For medication thatFacility policy titled, 5.2: MEDICATION ADMINISTRATION (undated) documents in part, Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis . According to the Electronic Health Record (EHR) R2 was admitted to the facility on [DATE] and has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and absence of left leg below knee. R2's BIMS (brief interview for mental status) score, dated 3/15/26, is 13 which indicates R2 is cognitively intact. On 4/13/26 at 11:37am, R2 said, I have been here since March 6th (3/06/26). I kept telling her (V14/Registered Nurse/RN) that they (facility nurses) had my medication doses wrong and giving them to me at the wrong time and they (facility nurses) wouldn't listen. They're (R2's medication orders) fixed now. Do you think I would have signed a consent (psychotropic medication) for the wrong dose of medications (psychotropic medications). Yes, I sign my own consents. And I pay my own bills. They (facility nurses) are always passing my medications late and I really need those medications to help me. Sometimes, I don't get them (medications) at all. They (facility staff) are not concerned about anything, you think they (facility staff) are concerned about my privacy bag? I had to call the ambulance myself when the balloon broke to my catheter. Get them (facility staff) to get me my medications on time and more than just sandwiches and then get them (facility) to get me a privacy cover for my bag (urinary bag). Yeah, I would like a privacy cover. Record review of R2's hospital Discharge Medication List, dated 3/04/26, documents, in part, Eliquis 5 Mg Tablet: 5 mg oral twice a day. Last Taken: 03/04/26. R2's MAR (Medication Administration Record), dated March 2026, documents, in part, Eliquis Oral Tablet 5 MG (Apixaban): Give 1 tablet by mouth one time a day for anticoagulants; Start Date: 03/05/2026 0900; D/C Date: 03/13/2026 1711 (5:11pm). Review of R2's MAR (Medication Administration Record), dated March 2026, shows R2 received Eliquis 5mg only one time a day instead of the required twice a day from 3/05/26 through 3/12/26 (8 days). R2's MAR (Medication Administration Record), dated March 2026, documents, in part, Eliquis Oral Tablet 5 MG (Apixaban): Give 1 tablet by mouth two times a day for anticoagulants / afib (atrial fibrillation) management; Start Date: 03/13/2026 1800 (6:00pm). Eliquis order corrected. R2's progress note, dated 3/10/26 at 3:42pm, documents, in part, Pharmacy called in regards to resident (R2) medication order Eliquis 5mg, stated the medication is always given twice daily, needs the MD (medical doctor) to correct the order. The order now is to be given once daily. Reached out to the provider but no response. will call again to confirm the change. On 4/14/26 at 10:52am, V16 (Pharmacist) said, No, it's (Eliquis) never given once a day. Manufacture recommends twice daily. In adults' it (Eliquis) peaks within 3-4 hours. Based on studies before it (Eliquis) goes on market, twice a day showed being most effective. If only receiving once a day for Afib (atrial fibrillation) management, it could cause a potential for irregular heart rate to occur; and if only receiving once a day for an anticoagulant you can cause be at an increased risk for clots. On 4/14/26 at 4:26pm, V14 (Registered Nurse/RN) said, He (R2) never told me that he (R2) was going the wrong meds. He (R2) would just scream down the hall Where are my meds? I want my meds. On 4/15/26 at 10:18am, V2 (Director/DON) said, The Assistant Director of Nursing (V21) and Infection Preventionist split up reconciling admission medications around the facility. Eliquis is supposed to be given BID (twice a day). The NP (nurse practitioner) reviewed and changed R2's Eliquis to BID. R2 was getting the wrong Eliquis dose for a few days. The admitting nurse put R2's Eliquis order in wrong. I have educated that nurse. If R2 doesn't get Eliquis BID, he (R2) can experience some sort of cardiac event or a blood clot. Record review of facility policy titled, Guidelines For Physician Orders (Following Physician Orders), dated 6/18/23, documents, in part, Policy: It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the residents' immediate care. The facility will have orders to provide essential care to the resident, consistent with the residents' mental and physical status upon admission. Two nurses will review admission and readmission orders to serve as a double check for the accuracy of the orders. All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received. Record review of facility policy titled, Section 5.0 Medication Administration, undated, Policy: Medications are administrated as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters and routes, contraindications, allergies, precautions, and side effects. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations. 2. Medications are administered in accordance with written orders of the attending physician. If an unusual dose is ordered, considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition; the physician is contacted for clarification prior to the administration of the medication. The pharmacist is also available for consultation for drug therapy concerns or questions. This interaction with the physician is documented in the nursing notes and elsewhere in the medical records as appropriate. 8. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administrated precisely as ordered. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. 9. The residents' MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided on the MAR or on a master signature sheet. 11. If a dose of regularly scheduled medication is withheld, refused, or given at other time than the scheduled time (e.g., resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a medication are withheld or refused, the physician is notified. 13. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR is 'flagged' per facility protocol. After completing the medication pass, the nurse returns to the missed resident to administer the medication. The right dose and dosage form. Record review of CMS's RAI (Resident Assessment Instrument) 3.0 Manual Chapter 3 MDS Items (N) (dated October 2025) documents in part the following: N0415: High-Risk Drug Classes: Use and Indication: Anticoagulant; Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring.

Based on observation, interview and record review, the facility failed to prepare/serve food in in manner that was palatable and attractive. This failure affected one resident (R3) reviewed for dietary services. Findings include: R3's face sheet documents in part the following diagnoses: heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, obesity. R3's minimum data set (3/5/2026) documents a brief interview of mental status (BIMS) summary score of 14, indicating that R3 is cognitively intact.R3's physician's orders (11/20/2025) document in part an active order for Regular texture, Thin consistency, for diabetic no pork and tomato productOn 4/13/2026 at 11:38 AM, R3 explained, The food here is terrible, let me show you what I mean. I had to take pictures because you wouldn't believe what they serve me. R3 showed surveyors pictures of food served to R3 including an unappetizing plate of plain white rice and mixed vegetables (50% of the plate was rice, the other 50% mixed vegetables, no protein), a roll of bread and small bowl of plain oatmeal (no protein), and an unidentifiable mass of a brown meat substance that appeared burnt over 50% of the meat. R3 stated, Do these look appetizing to you? Absolutely not. That burnt meat, they couldn't even tell me what it was. The roll, they told me it was a muffin but it tasted more like cornbread. The day with the rice and vegetables and the oatmeal, I got no protein. They frequently don't give me protein. I don't eat beef or pork but they should be able to accommodate that. Please, I know you're probably really busy, but could you look at the food they send me today for lunch? You need to see how terrible it is.The facility menu cycle indicates on 4/13/2026, the facility is serving beef stew, cornbread, a side salad, dressing of choice, ice cream novelty, and coffee/hot tea. On 4/13/2026 at 12:15 PM, V19 (Certified Nursing Assistant) delivered R3's lunch tray. R3 was served a small bowl of that looked to be chicken and corn soup. A thick layer of orange grease covered approximately 50% of the broth. Next to the bowl was a piece of cornbread that was approximately 3 inches by 2 inches. No other food was on the plate. Also on the dray was a bowl of dry iceberg lettuce, a condiment cup with approximately 1/5 of the cup containing a white dressing, and a bowl of melted strawberry ice cream. Approximately 75% of the ice cream was liquid and melted. V19 confirmed the observations and stated, Yeah that doesn't look good at all. The salad looks very dry and I think that is a chicken soup. The ice cream is pretty much all melted, it shouldn't be. The cornbread looks like a bite or two at most. Yeah, the resident's complain about the food a lot, a lot of them say it taste bad or they don't get enough food. These people is hungry in here, The dietary people know better, (R3) shouldn't be served this (food). R3 added, I don't even like iceberg lettuce. I guess I have to eat it . I told you it was bad. On 4/13/2026 at 12:18 PM, V18 (Registered Nurse) observed R3's tray and confirmed that the lettuce appeared dry, the ice cream was melted and the chicken soup did not appear appetizing. V18 stated, I don't know what that is. Maybe a soup? I can't tell. Maybe it's like a soup casserole? R3 ate the soup entree and described it as bland without any flavor at all. Chicken and water. V18 stated that residents often complain about the food. V18 explained, I just don't think it's good quality food. It's not something I would want to eat or feed to my family. The residents end up ordering out a lot because they don't like the food, which puts them at risk of other health issues. They don't even have the money to be ordering out as often as they do. The best time residents get food if it's made for an activity or when they get some type of outing. I don't know of any resident that likes the food. On 4/13/2026 at 2:03 PM, V4 (Regional Director of Operations of Dietary Department) affirmed that V4 is the interim dietary manager for the facility. V4 stated that V4 is very familiar with R3 and R3's dietary requests. V4 explained, (R3) voices a lot of concerns about the food. There is a ton of things (R3) doesn't want listed on (R3's) dietary ticket. We have been making (R3) grilled turkey sandwiches when (R3) doesn't like the entree and V4 seems to be liking that. We can accommodate (R3's) needs. V4 denied any knowledge of R3's lunch tray or denied observing R3's lunch try prior. Surveyor showed V4 pictures of R3's lunch tray that was served to R3 on 4/13/2026. V4 stated, Unfortunately, that does not look appetizing. The ice cream is melted, it shouldn't be like that when it is served. That in the bowl is a chicken stew we made just for (R3) trying to accommodate her requests. It's got chicken and corn in it. I will review this with the dietary team and figure out what happened. V4 explained that presentation is important because the eyes are keys to the stomach. On 4/14/2026 at 11:25 PM, V17 (Registered Dietician) affirmed V17 is the consultant dietician and is familiar with R3. V17 stated R3 has a lot of dietary concerns in the past and is very particular about food preferences. V17 affirmed that the facility could meet the requests or have a conversation to meet in the middle about food entrees. When asked why food appearance was important, V17 replied, Well appearance is a matter of opinion. You eat with your eyes. The ice cream i doubt came out of the kitchen melted, but what happened in-between the transport between the kitchen and the resident's room? It should have been served at an appropriate temperature and food should generally appear attractive so people will want to eat it. Facility policy titled FOOD PRESENTATION (developed 10/02/2023) documents in part, Meals will be prepared and served in an attractive manner that enhances palatability.

Based on interview and record review, the facility failed to follow physician order for STAT (Immediately) laboratory testing. This deficiency affected one (R8) of three residents reviewed for physician orders. Findings include:On 3/17/26 at 2:05PM, V13 (Registered Nurse) said that she received orders for STAT lab work to be drawn for R8, called lab and got a confirmation number. V13 said she does not know if they came or not because it was not on her shift anymore, she endorsed to upcoming shift for follow up pending lab work.On 3/17/26 at 2:31PM, V1 (Director of Nursing) said that her expectations for nurses are to carry out orders given from physicians or nurse practitioners and follow up, for STAT labs, should be called in and obtain a confirmation number and if endorsed to upcoming nurse for follow up, then nurses should call labs and check the estimated time of arrival or if the lab was not able to be drawn then notify the physician or nurse practitioner. V1 made aware that no labs were drawn for R8 on 12/31/25 and no documentation for R8 on 1/1/26 for any follow up charted or any vital signs obtained for R8. R8 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Myopathy, spinal stenosis, hypertensive heart disease, heart failure, chronic kidney disease stage 3, unspecified atrial fibrillation, type 2 diabetes, morbid obesity, peripheral vascular disease, anemia, and a history of falling. Physician order dated 12/31/25 for: Midodrine 5mg by mouth three times daily, ensure supplement three times daily, resident vital signs to be done three times daily, blood sugar monitoring three times daily, STAT lab order for Complete blood count, and Comprehensive metabolic panel. Facility Policy on Following - revised 6/18/23Policy: It is the policy of the facility to follow the orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission. Two nurses will review admission. and readmission orders to serve as a double check for the accuracy of the orders. If a Discharge Summary accompanies the resident on admission or readmission-it will becompared to the list of orders on the orders sheet and any discrepancies will be addressed and clarified at that time-to ensure accuracy of the orders that will be in place.4} All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received.

Based on observation, interview and record review, the facility failed to provide routine Dental services. This deficiency affected one (R7) of three residents reviewed for dental services. Findings include:On 3/10/26 at 1:45PM, R7 said that she chews on the left side of her mouth because on the right side of her mouth upper and lower teeth have holes and it is painful when food gets stuck.On 3/11/26 at 11:17AM, V1(Director of Nursing) stated that residents are to be screened upon admission and quarterly for any dental concerns and as needed. V1 said R7 has not been seen by dental services throughout her stay at the facility. R7 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Quadriplegia, unspecified severe protein calorie malnutrition, neuromuscular dysfunction of bladder, asthma, myasis, myopathy, essential hypertension.Facility Policy on Dental ServicesPolicy: It is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services.Procedure:1) A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status.NOTE: Dental condition status refers to the condition of the teeth, gums and other structures of the oral cavity that may affect the resident's nutritional status, commutation abilities or quality of life. The assessment should include the need for and use of dentures or other dental appliance(s).2) These assessments will be conducted initially upon admission, quarterly, annually and when there is a significant change in the resident's condition that affects the oral cavity.3) The assessing nurse will ask the resident (if the resident is interviewable) if they are experiencing any difficulties with chewing or if they have any pain in their oral cavity.4) The assessing nurse may need to observe the resident during meals.5) The assessing nurse will review the medical record for documented staff observations.6) The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities.7) The assessing nurse will monitor for: Broken or loose fitting full or partial dentures Chipped, cracked, unable to be cleaned, or loose-fitting dentures/partial(s) No natural teeth-or only tooth fragments Abnormal mouth tissue (ulcers, mass, oral lesion(s) including under dentures/partial(s) Darkness on a tooth (likely decay) or broken natural teeth Bleeding or loose teeth Mouth or facial pain-Discomfort or pain when chewing Unable to examineNOTE: Negative findings will be immediately addressed. The attending physician will be notified as well as the facility's dental provider. The DON, MDS Coordinator and SSD will also be notified as well as the resident or their responsible party.

Based on interviews and records review, the facility failed to follow its guideline on Discharge/Transfers for one of one resident (R5) reviewed for transfers in a sample of 11 residents.On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location with no face sheet, physician order, or medication administration sheet. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that staff are aware of resident's appointments the day prior to the appointment and should have the paperwork ready on the day of the appointment. V2 stated that the facility's protocol is for a face sheet and a physician order sheet to be given to the transporter when a resident is picked up. During an interview on 2/17/26 at 4:30pm, V20 (RN, R5's night nurse) stated that she was not aware that R5 had an appointment. V20 stated that she did not send R5 with paperwork to his appointment because she could not get access to the computer room to retrieve the face sheet and physician order sheet that she had printed.Facility policy titled Guidelines for discharge and transfer.Purpose: A resident will be discharged or transferred by order of the attending physician in accordance with the specific state of federal standards and practice guidelines. All discharge plans will be care planned. Procedure. 4. Types of discharge for reference.A. Higher level of care (Emergency or planned Hospital Transfer). 1) Complete transfer form in (Electronic Health Record) EHR-EHR Discharge/Transfer Forma) Send face sheetb) Send advance directivesc) Send MAR/TARd) Other pertinent information or required information as per State regulation.Guidelines for activities of daily living. (ADL) (Routine Care) Policy: Residents are given routine daily care and HS by a Certified Nursing Assistant (CNA) or Registered Nurse (RN) to promote hygiene, provide comfort and provide a home-like environment. ADL care is provided throughout the day, evening and night as care planned and or as needed. ADL K is coordinated between the residents and the caregivers with emphasis on resident preference as much as possible.

Based on interview and record review, the facility failed to follow its guideline policy for activities of daily living for one of one resident (R5) reviewed for activities of daily living in a sample of 11 residents.On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location unclean, unkempt and has not been changed for some time. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that she was informed by R5's family that R5 was sent for his appointment on 2/10/26 unclean. V2 stated that R5's night nurse informed her that she did not have time to get R5 ready for his appointment. V2 stated that staff are aware of appointments the day prior to the appointment and should have the resident ready on the day of the appointment. V2 stated that R5 has a stage three pressure ulcer on his right heal which is being treated by the wound doctor. V2 stated that the facility's protocol is for a face sheet and a physician order sheet to be given to the transporter when a resident is picked up.During an interview on 2/17/26 at 4:30pm, V20 (RN, R5's night nurse) stated that she was not aware that R5 had an appointment. V20 stated that she instructed a nursing assistant to clean R5 while she prepares R5's paperwork. V20 stated that she is not sure if R5 was cleaned.Facility policy titled: Guidelines for activities of daily living. (ADL) (Routine Care)Policy:Residents are given routine daily care by a Certified Nursing Assistant (CNA) or Registered Nurse (RN) to promote hygiene, provide comfort and provide a home-like environment. ADL care is provided throughout the day, evening and night as care planned and or as needed. ADL K is coordinated between the residents and the caregivers with emphasis on resident preference as much as possible.

Based on observation, interview, and record review, the facility failed to follow its colostomy care policy, resulting in a colostomy leak that led to potential skin irritation and infection. This applies to 2 of 2 residents (R3 and R8) reviewed for colostomy care in a sample of 11.The findings include:R3 is a [AGE] year-old male admitted on [DATE] with cognition intact as per 11/25/25 and admitted with an admitting diagnosis including colostomy and urinary tract infection (UTI).On 2/17/26 at 2:00 PM, R3 was observed in his bed with his colostomy bag leaking.On 2/17/26 at 2:10 PM, V5 (Certified Nursing Assistant / CNA) stated that she didn't get a chance to check on R3 upon his arrival back from the hospital. The colostomy shouldn't leak, and the nurses are supposed to take care of the colostomy.On 2/18/25 at 10:25 AM, R3 was observed in his bed with a new colostomy bag and was leaking through the base dressing. On 2/18/26 at 10:25 AM, V25 (CNA) stated that she will notify the nurse and that the colostomy shouldn't leak.R8 is a [AGE] year-old male admitted on [DATE] with severe cognitive impairment as per the MDS dated [DATE].On 2/17/26 at 2:30 PM, R8 was observed on his bed with a colostomy leaking with a moderate amount of stool on his stomach.On 2/17/26 at 2:30 PM, V7 (Licensed Practical Nurse / LPN) stated, The colostomy was changed today. I don't know who changed it, and it shouldn't leak.On 2/18/26 at 12:05 PM, V3 (Nurse Consultant) stated, Nurses are supposed to change colostomy, and it shouldn't leak as it can cause skin irritation and infection.The facility presented an undated colostomy care policy document (version #2). The purpose of colostomy care is to prevent infection and skin irritation.

Based on observation, interview and record review, the facility failed to provide a resident with services to avoid emotional distress and anguish by failing to assist a post-op patient with follow-up appointment, failed to ensure that resident was receiving therapy as ordered and failed to ensure that staff assist the resident with activities of daily living (ADL). These failures affected one (R3) of four residents reviewed for quality of care. As a result, R3 developed increased swelling, increased pain and blood clot to his right hip and stated that he feels hopeless since being admitted because he thinks nobody cares about his pain and healing process.Findings include:R3 is a [AGE] year-old male admitted to the facility on [DATE] post open reduction and internal fixation (ORIF 1/16/2026), past medical history includes fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, person injured in unspecified motor vehicle accident, anemia, anxiety disorder, other psychoactive substance abuse, uncomplicated, etc.On 2/13/2026 11:00AM, R3 was observed in bed, awake and alert, and said he came to the facility 2 weeks ago post-surgery to his right and left hip. R3 said he missed his follow up appointment two weeks ago (2/3/2026) and last Wednesday (2/11/2026), facility did not give him any explanation, they said they did not know where he was supposed to go for the appointment scheduled 2/3/2026. R3 said he feels very upset and hopeless because no one at the facility cares, he came here for therapy but has not been receiving any therapy since admission. R3 said that he has not received any shower or bed bath, he tried to get himself up from bed to wheelchair because staff does not answer the call light. R3 said he has pooped on himself twice and sat on his urine and poop for hours because no one came to assist him.Physician order summary dated 1/27/2026 documented the following: Follow up appointment February 3, 2026 post op patient visit 10:15 am hospital outpatient center 2160 s first avenue Maywood Illinois 60153-3328 708 216 3834. Hospital discharge summary also has the same appointment boldly written on the first page. R3 also has the following orders: Clarification order, PT eval Tx 3x/wk. 4wks for therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, etc., for 30 days, start date 1/29/2026. Clarification order PT OT ST eval Tx one time only for 30 days, start date 1/29/2026.On 2/13/2026 at 11:45AM, observed dressing change for R3 with V5 (LPN/Wound Care) and noted resident's surgical site on his right hip to be swollen with staples intact, R3 said that the site is tender to touch and more painful than before. V5 said that he changed the dressing on R3's surgical site yesterday, the right hip was a little swollen but not as much as it is today, V5 is not sure if R3 is receiving therapy yet. R3 rated his pain as 10 on a scale of 1 to 10. V5 said he will notify the doctor and later said that the doctor ordered an X-ray and doppler for R3.On 2/13/2026 at 2:09PM, V2, Director of Nursing (DON) said that she did not know about R3's follow -up appointment scheduled for 2/3/2026, the admitting nurse is supposed to look at the order and pass the information to the scheduler. Surveyor informed V2 that the follow up appointment was in resident's physician order and was clearly written on the first page of the hospital discharge summary and she said that she is not sure why the appointment was not scheduled, she will investigate it. V2 later stated that she could not find out anything, resident's appointment was missed due to miscommunication. For the appointment that R3 missed on 2/11/2026, V2 said that the ambulance the facility arranged for R3 did not have a stretcher and could not transport R3. V2 said that she called and rescheduled the appointment for Monday February 16, 2026On 2/17/2026 at 10:36AM, V2 said that R3 missed his appointment again yesterday (2/16/2026) because the ambulance did not show up. V2 did not document anything about resident's missed appointments or notify the physician, stated that she told the floor nurse to write a progress note. V2 is not sure what date resident's staples are supposed to come out; the wound care nurse was supposed to call the doctor and get an order for that. Nurses are supposed to assess residents' surgical sites and document every shift. There are no documented assessments of resident's surgical sites in medical records by the nurses.On 2/13/2026 at 2:45PM, V6, Therapy Director said that he is familiar with R3, therapy saw resident for two weeks only and could not continue because resident had a non-weight bearing order from orthopedics. V6 said that they could only do upper body training for R3 and were waiting for his follow up appointment and an update on his weight bearing status.On 2/17/2026 at 10:32AM, V6 said that R3 is still not in therapy yet, he will start as soon as the ortho doctor gives an order for weight bearing status. V6 said that therapy for post operative patients should start as soon as they are admitted but R3 has a non-weight bearing order from the hospital, V6 thought that R3 will go for his follow up appointment and get an updated weight bearing order.On 2/18/2026 at 8:03AM, V13, Wound Doctor said that he just saw R3, the swelling to resident's surgical site could be due to edema or subcutaneous hematoma, they did an arterial and venous doppler that showed possible blood clot, he is ordering a venous ultrasound that may show what is causing the swelling. If the swelling is edema, it may resolve on its own but if it is a hematoma, it may need to be evacuated at the hospital. Regarding the staples to resident's surgical site, V12 said that they can be taken out anytime, but they are still there because R3 have not been to his post op appointment with orthopedics, but the site looks stable with no signs of infection. V13 is not sure why R3 has not been to his post-op appointment, that could be discussed with facility management.Radiology report dated 2/16/2026 for right lower venous doppler extremity- (hip and femur), indication localized swelling, mass and lump, pain and localized edema. Impression: Right popliteal vein is not compressible with possible echogenic material, likely due to deep vein thrombosis. Recommend clinical and lab correlationsMinimum Data Set (MDS) assessment dated [DATE], section C documented that R3 is cognitively intact, section GG (functional status) indicated that R3 requires substantial /maximal assistance for most Activities of Daily Living (ADL) needs, and dependent for toileting hygiene and transfers.ADL care plan initiated 2/6/2026 stated that in part: R3 has self-care deficit and require assistance with ADLs to maintain highest possible level of functioning. Interventions include substantial/maximal assist for bed mobility, partial/ moderate assist with bathing, dependent for transfers, etc.On 2/13/2026 at 11:30AM, surveyor observed a full urinal on R3's bedside table with his snacks and other personal items. Surveyor presented this observation to V4, Certified Nursing Assistant (CNA) who said that she is not assigned to the resident, the urinal is not supposed to be sitting on resident's bedside table because it is a hazard. V4 said that the urine should have been emptied by staff to avoid it spilling all over resident. V4 emptied resident's urinal.On 2/17/2026 at 11:38AM, during dressing change for R3 with V5, surveyor observed a urinal that was almost full of urine on resident's half rail, presented this observation to V5 who shook his head and dumped the urine in the bathroom.On 2/17/2026 at 9:50AM, V12, CNA said that she is not assigned to R3 today but have taken care of him in the past. She cannot recall giving resident a bed bath or assisting him with showers.Physician visits for medical specialties outside facility policy (undated) stated in part: Purpose - To coordinate visits with physicians that do not work within the facility for residents that require specialized services that are not provided within the facility.Procedure 1. Licensed nurse receives orders from the attending physician for the specialized medical services required. 2 The licensed nurse fills out an appointment communication form which is forwarded to medical records. 3. Medical records personnel makes the first available appointment for the resident with medical specialist. 5. The medical records personnel make transportation and escort arrangements as necessary.Guidelines for activities of daily living policy (undated) state in part: Residents are given routine daily care and HS care by a certified nurse assistant (C.N.A) or a nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed.

Based on observation interview and record review, the facility failed to manage post-op pain for one resident (R3) by failing to administer pain medications (Oxycodone and Tylenol) as ordered, failed to monitor and document effectiveness of pain relief, and failed to use non-pharmacological interventions as part of the pain control regimen as care planned. This failure affected one (R3) of four residents reviewed for pain management. These failures contributed to R3 suffering psychological harm and feeling a sense of hopeless because no one cared about his pain or healing and pain rated 10 on a scale of 1-10.Findings include: On 2/1/2026 11:00AM, R3 was observed in his room, awake and alert, said that facility is not controlling his pain and not getting his pain medication orders straight, they told him he does not have an order for oxycodone, but was clearly listed in his discharge summary that was provided to the facility. Resident rated his pain as 10 on a scale of 1 to 10.Face sheet documented the following past medical history: Fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, person injured in unspecified motor vehicle accident, anemia, anxiety disorder, other psychoactive substance abuse, uncomplicated, etc.Physician order summary dated 1/27/2026 documented the following active orders:Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Pain.Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 3 tablet by mouth every 6 hours as needed for Pain.On 2/3/2026 at 11:15AM, V3, Licensed Practical Nurse (LPN) was passing medication on the third floor, stated that she was assigned to R3, he wanted pain medication and V3 told him that his pain medication was not scheduled. Surveyor asked V3 what time R3 was medicated for pain last, and she said, I don't know, he is asking for oxycodone, and it is ordered for every 4 hours, he does not even have the medication in the narcotic box right now.On 2/13/2026 at 2:09PM, V2, Director of Nursing (DON) said that R3 has an order for oxycodone, his medication is in stock, the nurse could not find it earlier but was able to find it now and it is in stock.On 2/13/2026 at 11:45AM, observed dressing change for R3 with V5 (LPN/Wound Care) and noted swelling to resident's right hip surgical site which he said was tender to touch and more painful than before, R3 again rated his pain as 10 on a scale of 1-10.On 2/17/2026 at 9:30AM, R3 said that the facility ran out of pain medication again, he did not receive any pain medication for the past 2 days.On 2/17/2026 at 9:45AM, surveyor asked V11 (RN) if R3 had any OxyContin in the narcotic box. V11 said, I was asked if R3 has any oxycontin in the narcotic box and I said, I already told him that that he has the medication, what is he complaining about now? Resident gets oxycontin every 4 hours and he asks for it on the clock, because it is a narcotic it must be reordered, resident runs out sometimes, he only gets 28 tablets at one time. V11 was asked if she has ever given R3 Tylenol for breakthrough pain and she said, he will not take Tylenol, he only wants oxycodone.Care plan initiated 2/10/2026 states that R3 is at increased risk for alteration in pain/discomfort. Goal: R3 will express relief/decreased discomfort 20-30 minutes after analgesic use. Interventions: Administer analgesic medication as ordered by the plan of care, Offer PRN analgesic medication prior to ADL activities/Rehabilitation, wound care etc. as indicated for pain management, observe resident for effectiveness of pain relief, Notify MD for any new resident complaints of pain and/or S/S of pain to obtain new order for medication regimen or break-through pain management.On 2/17/2026 at 12:51PM, reviewed Medication Administration Record (MAR) for R3 and noted the following: MAR for January showed that Oxycontin or Tylenol was not signed out as given from time of admission [DATE]) to the end of the month. Per pharmacy manifest, oxycodone 10mg 30 tablets were delivered to the facility on 1/31/2026. Surveyor requested the narcotic receipt and disposition form for January and V2 said that she could not find it. For the month of February, Oxycontin was signed as given about 5 times, Tylenol has not been signed out at all. Pharmacy manifest for the month of February showed that oxycodone 10mg 24 tablets were delivered on 2/11/2026 and 28 tablets were delivered on 2/17/2026.Surveyor presented this observation to V2 who said that R3 was getting oxycodone, the nurses are just not signing out the MAR, but they are signing out the narcotic sheet, she is going to provide education. R3 is supposed to be offered his Tylenol and if he refuses, it should be documented. V2 added that according to facility medication administration policy, the MAR was supposed to be signed by the person giving the medication.Medication administration general guidelines (undated) stated in part- medications are administered as prescribed in accordance with good nursing principles and practices and only persons legally authorized to do so. Procedure #9. The MAR is initialized by the person administering medication in the space provided under the date, and on the line for that specific medication does administration. MAR are verified with a full signature in the space provided in the MAR or on a master signature sheet.10. When as needed (PRN) medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection or applicable site.b. Complaints or symptoms for which medication was given.c. Results achieved from giving the dose and the time results were noted.d. Signature or initial of person recording administration and signature or initials or person recording effects if different from person administering.Guidelines for pain management (undated) state in part: It is the intent of the facility to promote resident independence, comfort and to preserve resident dignity in an ongoing effort to promote the highest level of quality for their lives. One aspect of this commitment is to maintain an effective pain management plan to and therefore enhance their overall comfort and wellbeing.Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.

Based upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain physician orders for blood glucose monitoring/sliding scale insulin, failed to receive blood glucose parameters for physician notification, failed to follow physician orders, failed to ensure that medication was administered/documented within regulatory requirements, and/or failed to ensure that (critical) blood glucose levels were addressed by a physician/nurse practitioner for two of four residents reviewed for change in condition. These failures resulted in R1 sustaining critical blood glucose levels ranging from 413-500 (without intervention) for a total of 8 days within 1 month. These failures also resulted in R2 sustaining a critical blood glucose level of 400 (without prescribed sliding scale insulin) for 11 hours.Findings include:On 8/21/25, IDPH (Illinois Department of Public Health) received neglect allegations due to facility staff refusing to contact a doctor when resident blood sugars were elevated.R1 was admitted to the facility on [DATE] with diagnoses which include but not limited to morbid obesity due to excess calories and type II diabetes mellitus. R1 was discharged on 7/2/24 (prior to this survey).R1's (6/5/24) care plan includes potential for complications of metabolic functioning as evidenced by hyper/hypoglycemia, interventions: monitor blood sugars as ordered and cover as ordered per sliding scale. Report abnormal blood sugars to Medical Doctor. R1's (6/1/24) POS (Physician Order Sheets) include check blood glucose before each meal and at bedtime [parameters for physician notification are excluded]. Glargine (insulin) inject 85 units every morning and at bedtime. Humalog (Insulin) inject 50 units before meals. [Sliding scale insulin is excluded].On 9/3/25 at 1:19pm, surveyor inquired if any residents were recently sent out to the hospital due to blood sugar concerns V2 (DON/Director of Nursing) stated We haven't had anybody go out for hyperglycemia or hypoglycemia recently, not that I'm aware of. Surveyor inquired if any residents or family members recently reported concerns regarding blood sugars V2 responded No. Surveyor inquired when R1 was discharged from the facility V2 replied He (R1) has been gone a while, he discharged I wanna say back in 2024. He (R1) was short term stay; I (V2) don't believe he was sent out for blood sugar. I (V2) do remember him (R1) having issues with his blood sugar because the wife (V3) was bringing in all the wrong foods. She (V3/Wife) brought him (R1) whatever he wanted, and we (staff) had to have a meeting with her (V3) about it. She was educated on his diet. We (staff) also found out that she (V3) was giving insulin to him when she was here, and we have that care planned. R1's progress notes state (6/2/24) 9:22am, upon entering resident room, writer noted resident wife with a filled syringe in her hand about to administer it to resident but stopped when I entered the room. Writer made appropriate parties aware [R1's 6/2/24 blood glucose was 330 at 7:30am and 339 at 11am per MAR/Medication Administration Record]. (6/5/24) 3:47pm, Staff reports resident's wife was observed with a vial of insulin to administer to the resident [R1's 6/5/24 blood glucose was 202 at 4pm per MAR]. R1's (June 2024) MAR also affirms that blood glucose levels were (critical) high on the following dates: 6/1: 413. 6/7: 432. 6/15: 500. 6/18: 419. 6/20: 469. 6/23: 450. 6/24: 430. 6/27: 419 however R1's (June 2024) Nurses Notes exclude critical high blood glucose levels and physician notification of resident change in condition. On 9/4/25 at 1:01pm, surveyor inquired about resident blood glucose monitoring V6 (Medical Director) stated, If someone's uncontrolled we (staff) would probably be checking that with meals. Surveyor inquired what parameters should be inclusive for hyperglycemia V6 responded We have about 3 different options; it would be 350 or 400. Surveyor inquired about staff requirements if a resident's blood glucose is 400 or above V6 replied It should be whatever the order is [R1's Physician orders exclude sliding scale insulin] and affirmed the physician should be contacted. Surveyor inquired about potential harm to a resident with a blood glucose level that's 400 or above V6 stated Medical comorbid conditions associated with hyperglycemia which could be infection, DKA (Diabetic Ketoacidosis), or hyperosmolarity.On 9/4/25 at 2:20pm, surveyor inquired if there was any documentation in R1's EMR (Electronic Medical Records) regarding notification for R1's (6/15/24) critical blood glucose level of 500 - per MAR V2 (DON/Director of Nursing) reviewed R1's EMR and stated No, there's no documentation that she (Nurse) called the Physician or Nurse Practitioner for the 15th. Surveyor inquired if there was any documentation that R1's Physician was notified for any of R1's (June 2024) critical blood glucose levels V2 reviewed the EMR to no avail and responded They (staff) were giving the insulin that was ordered but nobody thought about a sliding scale. He (R1) had no sliding scale the entire time he was here, everybody missed it [R1 resided at the facility for over 1 month]. __R2's diagnoses include diabetes mellitus with hyperglycemia however the (9/3/25) facility glucose monitoring log - excludes R2's name. R2's POS includes (8/27/25) Lispro (Insulin) 25 units before meals. Glargine (Insulin) 50 units two times daily. (8/29/25) Lispro inject per sliding scale 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units 300-349 =8 units, 350-399 = 10 units at bedtime. [Blood Glucose Monitoring is excluded].R2's (11/7/18) care plan states resident has hyperglycemia related to disease process, interventions: monitor for signs/symptoms of hyperglycemia, report to Nurse and Physician as needed. R2's (7/31/25) BIMS (Brief Interview Mental Status) determined a score of 10 (moderate impairment).On 9/3/25 at 4:09pm, surveyor inquired if R2 has any facility concerns that she would like to discuss R2 responded No, I've always been with the Santa Clause therefore not appropriate for interview. R2's (9/2/25) MAR affirms the following: blood glucose level was 486 (at 5:00pm) and 9 (see nurse note) was documented. R2's blood glucose level was 400 (at 9:00pm) and 9 was documented. [R2's blood sugar was not rechecked until 8am the following day - 11 hours later]. On 9/4/25 at 9:19am, surveyor inquired what 9 indicates on the MAR V2 (DON) stated If they (staff) didn't give it for whatever reason they'll put in a 9 and put in a nurses note. Surveyor presented R2's (September 2025) MAR and inquired if R2 received insulin on 9/2 when the blood glucose was 400 and above V2 responded Let me (V2) see, I'll have to see if the Nurses made any note and did anything with that. The sliding scale only goes up to 399 so she (V5/Registered Nurse) should have called the doctor. They (staff) should know you follow the sliding scale, if the blood sugar is higher than what it is, you reach out to the physician and find out if they (Physician) want to give insulin. R2's (9/2/25) Medication Administration Note states (10:33pm) medicated with 25 units Lispro insulin for blood sugar of 486 per Nurse Practitioner (V7). (10:40pm) Medicated with 10 units Lispro insulin per (V7) however R2 was prescribed sliding scale insulin at 5pm and 9pm - therefore not administered within regulatory requirements (1 hour before or after the scheduled time). On 9/4/25 at 2:16pm, surveyor inquired why V5 (Registered Nurse) documented on 9/2/25 that R2 received Lispro (25 units) at 10:33pm and Lispro (10 units) at 10:40pm (7 minutes later) per electronic Medication Administration Note V2 (DON) responded She (V5) should have put it was given at 5pm or whenever it was given. On 9/4/25 at 3:23pm, surveyor inquired if the Physician was notified of R2's critical blood glucose levels on 9/2/25 V5 (Registered Nurse) stated The Nurse Practitioner (V7) gave the orders to the ADON (Assistant Director of Nursing/V8) she (V7) said to give the 25 units when she (R2) was 486 and then I (V5) gave the 25 units. She (V7) said recheck in 30 minutes, call her (V7) back and it was 400. She (V7) said follow the sliding scale and affirmed that R2 received Lispro 10 units at that time [R2's sliding scale only covers a blood glucose level up to 399 - therefore the sliding scale was not followed]. Surveyor inquired what time R2 received the 25 units and 10 units of Lispro on 9/2/25 V5 responded It was about 5pm but I didn't sit down to chart it then. Surveyor inquired if insulin was administered to R2 on 9/2/25 (at 9pm) as prescribed V5 replied She (R2) gets Lantus at night, so I gave her the Lantus [Sliding scale Lispro - scheduled for 9pm administration was excluded]. Surveyor inquired if V7 was notified of R2's (9/2/25) critical blood glucose level (at 9pm) V5 replied I called her (V7) twice (at 5pm and a half hour later) and during the 9pm, I didn't call her because she (R2) was within the limits to give her a sliding scale. At 9pm, I covered her with the sliding scale because she was under 400. For the 9pm, I just give her the insulin I didn't make a note [R2's blood sugar at 9pm was 400 - therefore not within sliding scale parameters and 9 was documented on the MAR which affirms Lispro was NOT administered as ordered]. Surveyor inquired (again) which insulin was administered to R2 on 9/2/25 at 9pm (due to inconsistent statements) V5 responded I gave her Lantus. The (undated) blood glucose monitoring policy states blood sugars found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. Notify physician if blood glucose is outside resident's parameters for blood glucose as ordered by their physician. Nursing interventions for treatment of hyperglycemia: follow the sliding scale parameters for fast acting insulin and any additional orders received from the physician. Immediately notify the physician and the resident's representative any time the resident's blood sugar is outside the ordered parameter range as well as any interventions taken to address a hypoglycemic or hyperglycemic event. Complete all appropriate documentation.

Based on observation, interview, and record review the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to a resident who is at high risk for skin impairment. The facility failed to formulate wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. These failures resulted R54 to develop DTI (Deep tissue injury) on right heel. This deficiency affects all five residents (R28, R36, R45, R54 and R59) in the sample of 17 reviewed for Wound/Pressure ulcer prevention and treatment management. Findings include: On 3/4/25 at 8:07AM, Observed R28 sleeping in a LAL (low air loss) mattress bed with V10 Family member at bedside. V10 said that R28 is totally dependent with ADLs (Activity of Daily Living). V10 said that last week Friday (2/28/25), R28 re-opened her sacral pressure ulcer. V10 said she noticed it when she assisted the CNA (Certified Nurse Assistant) in performing incontinence care and they applied wound dressing. V10 said she notified the ADON (Assistant Director of Nursing), and V5 Wound Care Coordinator (WCC) came to see R28, both were aware of R28's re-opened sacral pressure ulcer. Observed R28 has fitted sheet covered the LAL mattress and a cloth pad over the mattress. R28 wears disposable brief. On 3/4/25 at 8:11AM, Observed R59 lying in LAL mattress bed with flat sheet folded in half and cloth pad over the mattress. R59 wears disposable adult brief. V11 CNA said that R59 should only have flat sheet over the LAL mattress. The night shift CNA is the one who did apply the multi layers of linen over the mattress. On 3/4/25 at 8:20AM, Observed R36 lying in LAL mattress bed with V11 CNA. Observed R36 has flat sheet and cloth pad over the mattress. R36 wears disposable brief. On 3/4/25 at 8:25AM, Observed R54 lying in LAL mattress bed with V5 WCC. Observed flat sheet and cloth pad over the mattress. R54 wears disposable brief. V5 said that R54 should only have flat sheet over the mattress. No multi-layer of linens as manufacturer's recommendation. On 3/4/25 at 8:30AM, Observed R45 lying in LAL mattress bed with V5 WCC. Observed flat sheet and cloth pad over the mattress. R45 wears disposable brief. V5 said that R45 should only have flat sheet over the mattress. No multi-layer of linens. Informed V5 of above observation made to R28, R36 and R59 with multi layers of linen over the LAL mattress. V5 said that residents on LAL mattress should only be on flat sheet so it will not affect the purpose of LAL mattress. On 3/4/25 at 10:04AM, V5 WCC said that she is responsible for wound assessment and treatment for resident with pressure ulcers and other skin conditions. She said, resident who is admitted with skin impairment or open wound should have skin assessment with measurement done by the floor nurse or herself. The physician will be notified to obtain appropriate treatment and care plan will be updated. V5 presented list of residents with skin impairment/pressure ulcers in the facility. The list did not indicate R28 and R54. On 3/4/25 at 10:21AM, Informed V5 WCC of V10 Family member reported that R28 has re-opened her sacral pressure ulcer last Friday (2/28/25). V5 said that she is not aware, and this is her first time hearing this report. V10 Family member denied statement of V5 and reminded her that she came to see R28 on 2/28/25 after she reported to ADON about R28's re-opened sacral wound. V10 added that V5 did not see the wound because the floor nurse applied wound dressing, but she reported to her. V5 said, she probably forgot about it. V5 then started preparing to perform wound assessment and treatment. She wears only gloves, she opened R28's disposable brief then she repositioned R28 to her left side and removed her brief. The brief is clean, but the wound dressing is contaminated with black fecal matters. Observed R28 has fitted sheet and cloth pad over the LAL mattress. R28 has sign posted at her door indicated Enhanced Barrier Precaution. V5 cleansed open sacral wound with normal saline solution (NSS). V5 said, R28 has stage 2 pressure ulcer. Observed clean pinkish tissue and whitish color (maceration) at peri wound. V5 measured sacral wound and obtained 0.5cm x 0.4cm x0.1cm. V5 said that she will call R28's physician to obtain treatment order. On 3/4/25 at 10:41AM, Observed R54 lying in LAL mattress bed. He has tracheostomy tube connected to ventilator. He has gastrostomy tube connected to feeding bag. He is awake and non-verbal. V5 assisted with V8 Restorative Nurse to remove R54's bilateral heel protectors. Observed R54 dressing on the following: Left dorsal foot, left lateral ankle, right inner/medial lower leg, and right heel. Wound dressing dated 3/2/25. V5 said that she was not aware of this wound dressing because there is no order in his chart. V5 removed all wound dressing and cleansed with NSS then did measurement. Left dorsal foot has 1.5cm x1.5cm dry necrotic scab. Left lateral ankle pressure ulcer measures 2.5cm x 1.3cm with 50% pinkish tissue and 50% necrotic dry scab. Right inner/medial lower leg measures 1.5cm x 0.5cm. Observed bleeding granulating, reddish tissue, full thickness. Right heel DTI measures 4.5cm x 6cm, 35% necrotic tissue, 10% red tissue exposure, 65% maroon discoloration. V5 painted betadine to all wounds and covered with bordered dressing. V5 said that she calls the physician to obtain treatment orders to all new identified skin impairments for R54. On 3/4/25 at 11:19AM, Observed R45 lying in LAL mattress bed. He is alert, responsive but with episodes of confusion. V5 WCC assisted with V18 CNA preparing R45 for wound care. V18 open his disposable brief. He as morbid obese abdomen. Surveyor requested to check for underneath his abdominal folds. R45 screams for pain as V18 lifted his abdomen. Observed MASD (Moisture associated skin disorder) underneath the abdominal folds with fluids. Both V5 and V18 said that the fluid from his urine (due to anatomical position of his genital/penis). R45 continues to scream for pain as V18 and V5 cleansed the abdominal folds. Surveyor asked V5 if R45 has scheduled pain medication. Both said that R45 always complains of pain even just touching him. V5 said that she is not aware of this MASD, and this is new for her. V5 applied barrier cream. Then V18 positioned R45 to his left side. V5 said that R45 has Stage 4 sacral pressure ulcer. She applied collagen sheet and covered with foam dressing. V5 said that she will call R45's physician about MASD on abdominal folds. On 3/6/25 at 10:03AM, Reviewed R28, R54, R45, R36 and R59 medical records with V5 WCC. R28 is readmitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Dementia, Contractures on right and left ankle, left and right hand, Gastrostomy, Chronic Kidney disease. Active physician order sheet indicates: Weekly skin checks for wound prevention. Moisture barrier ointment apply to buttocks and peri area topically every shift for skin protection secondary to incontinence. No wound treatment addressing to re-opened sacral wound on 2/28/25. Comprehensive care plan indicated she has as alteration in skin integrity and is at risk for additional and or worsening of skin integrity issues related to impaired cognition related to dementia, impaired mobility, and other medically related diagnosis. Intervention: Skin will be checked during routine care daily and during weekly bath/shower schedules. Any skin integrity issues /concerns will be conveyed to the charge nurse for further evaluation and or treatment changes/new interventions and the physician will be called as needed. Pressure reducing/relieving mattress. Informed V5 that Physician was not notified of re-opened sacral wound, did not obtain appropriate treatment intervention, care plan was not implemented and updated not until the surveyor addressed the concerns during survey. Informed V5 that wound assessment done with surveyor on 3/4/25 was dated 3/3/25, it was signed on 3/5/25. R54 is admitted on [DATE] with diagnosis listed in part but not limited to Encephalopathy, Respiratory failure, Emphysema, Chronic obstructive pulmonary disease, paralytic syndrome following cerebral infarction bilateral, Tracheostomy status, Gastrostomy status, Muscle wasting and atrophy. Braden scale/skin assessment upon admission (2/11/25) and most recent (3/2/25) indicated that He is at very high risk for developing pressure sore. No admission wound assessment and measurement was done. Admission notes dated 2/11/25 indicated open areas multiple, scrotum under red, right outer leg open, back open area, multiple scabs back, back upper open area, back middle open area, toenails thick, top right great toe bruise, left hand callus, right ball foot scab, heel right red area, right inner lower leg red open area, left leg multiple scars, right lower leg scars. Active physician order indicated No treatment orders addressing the identified skin impairment upon admission. V5 did not complete skin assessment after admission. Wound care physician initial wound assessment dated [DATE] indicated: 1) Diaper dermatitis on perineal and buttocks. Treatment recommended- moisture barrier or zinc oxide, 2) Venous stasis on left big toe. Treatment - betadine paint. 3) Open blister on left mid back. Treatment- zinc oxide or Vit A& D. Treatment ordered were written in physician order sheet and not carried out not until the surveyor addressed the concerns. V5 write the treatment recommended by wound care physician on 2/17/25 not until 3/4/25 during survey. R54 physician order sheet and Treatment administration record indicated that treatment orders recommended by wound care physician was only documented on 3/4/25. Informed V5 WCC that they failed to implement its policy and procedure on prevention and treatment management of pressure and non-pressure wounds. They failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to resident who is at high risk for skin impairment. R54 developed DTI on right heel, open wound on lateral ankle and open wound on right medial lower leg. It was not identified, documented, and did not obtain appropriate treatment from the physician not until the surveyor identified it during survey. No comprehensive care plan was developed upon admission to address the skin impairment and prevention of developing pressure ulcer. V5 said that the previous MDS/Care plan coordinator was the one responsible for developing wound/pressure ulcer care plan. V5 submitted all new identified wounds with assessment and measurement done with surveyor on 3/4/25, signed and dated on 3/6/25. R45 is readmitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Senile degeneration of brain, Chronic obstructive pulmonary disease, Hemiplegia, and hemiparesis following cerebral infarction affecting left non dominant side, Vascular dementia, Muscle wasting and atrophy. Most recent Braden scale/skin assessment (1/24/25) indicated that he is at high risk for skin impairment. Active physician order indicated Sacrum: cleanse with NSS, apply collagen sheet or puracol, zinc oxide around then cover with foam silicone dressing daily and as needed. Weekly skin assessment. Moisture barrier ointment apply to buttocks and peri area topically every shift for skin protectant secondary to incontinence. No treatment order for MASD abdominal folds that was identified on 3/4/25 with surveyor. Comprehensive care plan indicated that he has an alteration in skin integrity and is at risk for additional and or worsening of skin integrity issues. Interventions: Skin will be checked during routine care on daily basis and during weekly bath /shower. Any skin integrity issues/concerns will be conveyed to the charge nurse for further evaluation and or treatment changes new interventions and the physician will be called as needed. Pressure reducing/relieving mattress (low air loss mattress). Informed V5 WCC that they failed to implement its policy and procedure on prevention and treatment management of pressure and non-pressure wounds and implement care plan interventions. They failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to resident who is at high risk for skin impairment. R36 is readmitted on [DATE] with diagnosis listed in part but not limited to Parkinson, Dementia, Muscle wasting and atrophy, Stage 3 sacral region pressure ulcer. Active physician order sheet indicates: Low air loss mattress. Treatment sacrum: Apply protective dressing as needed for skin protective dressing. Comprehensive care plan indicated she is at risk for alteration in skin integrity. Most recent Braden scale assessment dated [DATE] indicated at risk for developing pressure ulcer sore. Informed V5 WCC of multilayers of linens over the mattress on 3/4/25. R59 is readmitted on [DATE] with diagnosis listed in part but not limited to Sequelae of cerebral infarction, Senile degeneration of brain, Metabolic encephalopathy, Subarachnoid hemorrhage, Vascular dementia. Comprehensive care plan indicated she is at risk for alteration in skin integrity related to impaired cognition, incontinence of bladder and bowel and impaired mobility. Intervention: Pressure relieving/reducing mattress. Informed V5 WCC of multilayers of linens over the mattress on 3/4/25. On 3/6/25 at 12:51PM, Informed V24 Medical Director of above concerns identified that the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to residents who are at high risk for skin impairment. The facility failed to develop wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. V24 said that they should follow and implement the facility's policy and procedures in prevention, treatment and management of wound/pressure ulcers. Facility's policy on Wound Assessment indicates: It is the policy of this facility to complete a systematic, ongoing assessment of all wounds that will provide a consistent means of wound evaluation to determine the response to treatment modalities and to facilitate continuity of care and communication among staff and healthcare providers on an ongoing basis. Procedure: I. The presence of wounds, injuries and or other skin abnormalities will be identified upon admission/readmission or identification of a new wound, pressure injury, or other skin abnormality. A. The staff will complete a complete skin and wound assessment upon admission/readmission, identify any wounds, pressure injuries or other skin abnormality and document it in the medical records. B. The wound team will complete a skin and wound assessment and document the presence of any wound assessment in the medical record. C. Any wound, pressure injury or other skin abnormality identified during the resident's stay will be documented in the same manner as when identified upon admission/re/admission. II. Wounds are measured weekly by the wound team or designee A. The status of the wound is documented in the medical record B. Wound status is also monitored with each dressing change C. Any changes in the wound are documented at the time identified and the physician and family are notified. Facility's policy and procedures on Treatment/services to prevent /heal pressure and non-pressure wounds revised 11/2/23 indicated: Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: 1a. A resident receives care, consistent with professional standards of practice to prevent pressure and non-wounds and does not develop pressure or non-pressure wounds unless the individual's clinical condition demonstrates that they were unavoidable as documented by the wound care specialist. 1b. A resident with pressure ulcers or non-pressure wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing. 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 3. Interventions will be implemented by the nurse in the resident's plan of care to prevent pressure sore development when the resident has no areas of concern. 4. When the resident is admitted with a pressure or non-pressure wounds the admitting nurse or wound care nurse will document the size, location, odor, drainage, and current treatment ordered. 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure and non-pressure wound. 6. The admitting nurse will notify the attending physician as well as the resident and or resident's representative of the condition of the wounds that were observed on admission. 7. The pressure and non-pressure wounds will be evaluated weekly by the wound care nurse and or the wound care specialist. 8. If the wound care specialist changes any treatment or indicates other interventions the wound care nurse will put these orders in the resident's electronic medical record. 9. The nurse will notify the resident and or the resident's representative of any changes related to the improvement, deterioration and or treatment changes on an ongoing basis. Facility's policy Guidelines for Low Air Loss Mattress use dated 7/18/23 indicated: Purpose: To provide the features of a support system for the resident that provides a flow of air in managing the heat and humidity (microclimate) of the skin. Procedure: 8). A single non fitted sheet may need to be utilized on the mattress for assistance in positioning and repositioning the resident. Fitted sheets are not recommended. Quilted reusable pads and incontinent briefs tend to block the airflow and trap moisture against the skin. Disposable, air permeable incontinence pads designed for low air loss mattresses should be used instead.

Based on interviews and records reviewed the facility failed to treat one resident with respect and dignity by placing him in the hallway tied to a wheelchair and having pictures taken.This failure affected one of one resident (R5) reviewed for dignity. Using the reasonable person concept it is reasonable to conclude that R5 felt cold, uncomfortable, and dehumanized when he was sitting in a wheelchair, in the hallway, with a sheet, no shoes, no socks. The findings include: On 8/29/23 an image of identified resident R5 obtained. Image is of a male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, in the hallway, leaning forward, back exposed, no hospital gown is seen in the picture. R5 appears to be covering his face or head with a white sheet. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility decor. No face for the resident is visible and his feet are exposed, no shoes or socks. Additionally, the picture shows R5 tied with a white sheet to the wheelchair and two knots in the back. A gait belt is visible around the back of the wheelchair. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 9/10/24 at 9:46AM V24, CNA, said V19 told her was going to take pictures of the situation with R5. V24 said I didn't report it because I wasn't in the facility. On 9/10/24 at 10:40AM V18, Scheduler said she heard V19 talking about R5 on the phone and say I'm going to take pictures and send them. V19 said staff taking pictures of resident is a HIPPA violation. On 8/30/24 at 12:29PM V5, DON, said she had seen V19 on his phone while on duty and told him to get off the phone. V5 said another staff heard V19 talking on the phone about R5. V19 said talking about the patient to someone else is a HIPPA violation. On 9/3/24 at 3:20PM V5, DON, said V18 called me and told me V19 was on the phone talking to someone about R5 and about how bad he is and something about pictures. V5 said, V18 and V24 should have reported V19. On 9/10/24 at 12:07PM V25, Administrator, said V19 probably should not have completed the shift on 7/26/24. V25 said if I had been there, V19 would not have been allowed to return to the floor after walking out. V25 said I did not know anything occurred with R5 until V5 spoke with me after she spoke with the surveyor. On 9/12/24 at 11:50AM V26, Infection Preventionist, said when a resident comes out of the room, to a common area they should have clothing on, no gown, be clean, face washed, and have their walker or wheelchair. V26 said for footwear we use non skid socks if they don't have shoes or slippers. V26 said we can use donated clothing from laundry that they can wear, or we can double gown to cover their front and back. V26 said we would double gown to give them some privacy. V26 said if they are out in a common area not dressed or with a their back exposed they could most definitely feel uncomfortable and maybe a little cold. The facility abuse prevention dated 1/2019 states during orientation of new employees the facility will cover the following topics sensitivity of resident rights and resident needs, staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any kind of crime against the resident, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions. Dementia management and resident abuse prevention. What constitutes abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This prohibitions against taking, using, keeping, distributing photographs, recording of residents. The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident sensitive and resident secure environment. Staff taking or using a photograph or recording of a resident in a manner that demeans or humiliate a resident, regardless of the residents cognitive status, is strictly prohibited and will be handled as an allegation of abuse.

Based on interviews and records reviewed the facility failed to follow their abuse policy to prevent unauthorized photos of a resident restrained to a wheel chair in the hallway. This affected one of three residents R5 reviewed for mental abuse. This failure resulted in R5 having unauthorized photos taken of him restrained to a wheelchair which is demeaning, and humiliating. Findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 I saw R5 had a gait belt around him. V19 said I was assigned to be R5's one to one, monitoring him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5 before she left like at 4:30PM. V19 said they said if you don't want to watch the patient, then go home. V19 said I left the floor and then I came back up to the floor around 6:00PM or 7:00PM and R5 had the sheet around him. V19 said I got fired because of this. V19 said I saw R5 with the sheet tied with two knots around his stomach and he was sitting on a regular wheelchair, he also had the gait belt on. V19 said I documented it, V19 provided pictures to IDPH from his personal phone. On 8/29/23 an image of identified resident R5 obtained. Image is of a male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, leaning forward, back exposed, no hospital gown is seen in the picture. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility decor. No face for the resident is visible and his feet are exposed, no shoes or socks. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 9/10/24 at 9:46AM V24, CNA, said on 7/26/24 around 5:00PM - 5:30PM I was at home when V19 called me, he said they stuck him with a one to one monitor. V24 said V19 said they were restraining the resident. V24 said V19 was going to document by taking pictures. V24 said I don't think V19 took pictures of R5's face, just the restraint. V24 said I didn't report to anyone because I felt V19 had it under control and I didn't see it because I wasn't in the facility. On 9/10/24 at 10:40AM V18, Scheduler, said I heard V19 on the phone when I was walking in the hallway, after dinner between 5:15-5:30. V18 said I heard V19 telling someone, this resident he doesn't sit down, he is getting on my nerves. V18 said I don't know who V19 was talking to. V18 said I asked V19 if he was taking pictures and he said no he was not. V18 said I told V5 I heard V19 say I'm going to take pictures and send them. V19 said V24 mentioned V19 told her he was going to send the pictures. V18 said I told V19 you can't take pictures. V18 said I didn't see V19 take pictures. The surveyor asked V18 do you have to see abuse happen to report it? V18 said no. V18 said I felt I needed to call V5 to see if V19 needed to be sent home, because he was on the phone. V18 said V19 stayed with R5 until the end of his shift. V18 said staff are not allowed to take pictures of the residents because it is a HIPPA (Health Insurance Portability and Accountability Act) violation. V18 said staff are not supposed to be on the phone while on duty with a resident. V18 said staff are not to be on the phone while assigned one to one monitoring with residents. On 8/30/24 at 12:29PM V5, Director of Nursing, said V19 was terminated for being on his cell phone, twice. V5 said on 7/26/24 I told him to get off the phone when I saw him. V5 said another staff observed V19 on the cell phone and heard V19 talking about R5 and how bad R5 was and R5 did not need to be here. V5 said that same night V19 was mad and said he was leaving, he was upset about having to do the one to one. V5 said when I spoke to V18 by phone, it may have been 9:00PM or 10:00PM. V5 said V19 did not finish his shift, we got someone else to monitor R5. V5 said taking resident pictures is a HIPPA violation. V5 said I told V18 to take V19 off the schedule until I speak with him on Monday. On 9/3/24 at 3:20PM V5, said V18, Scheduler, called me while I was at home and said when she walked in R5's room and saw V19 on the phone. V5 said V18 reported V19 was on the phone talking to someone about how bad R5 is and something about pictures. V5 said V18 said she asked V19 if he was taking pictures. V5 said V19 was the only CNA assigned to R5. V5 said after the surveyor spoke with me (on 8/30/24) I spoke with my staff and V24 said V19 called me and said he was going to take pictures of the resident. V5 said V24 said she didn't report it because it didn't involve me and she didn't want to get involved. V5 said V18 and V24 should have both reported V19 on 7/26/24. On 9/10/24 at 12:07PM V25, Administrator, said V19 probably should not have completed the shift on 7/26/24. V25 said V19 talking about R5 on the phone violates policy. V25 said if I had been there, V19 would not have been allowed to return to the floor after walking out. V25 said I did not know anything occurred with R5 until V5 spoke with me after she spoke with the surveyor. V19 employee file notes his hire date is 7/10/24. Review of V19's employee file conducted. V19's HIPPA Quiz dated 7/10/24 has no responses for the questions. On 7/10/24 V19 signed I acknowledge that I have received and read the facilities abuse prevention program policy and procedure. I have received and read the social media policy. I understand the requirements of the social media policy represents the standards and policies of the facility. The facility provided two Personnel Change Forms for V19, both dated 7/29/24. One notes termination is voluntary Employee left on his own accord. Last day worked 7/29/24. The second form notes termination is Involuntary violation of facility policy. No last day worked is noted. IDPH received three pictures of R5 on 8/29/24 at 11:49AM. The last time V19 worked with R5 was on 7/26/24. R5 retained the pictures in his phone for 34 days. The facility abuse prevention program policy and procedure dated 1/2019 states during orientation of new employees the facility will cover at least the following topics prohibitions against taking, using, keeping, or distributing photographs, recordings of residents or a resident's personal space, as described in section below. The facility defined mental abuse includes taking or using photographs or recordings in any manner that would demean or humiliate the resident. This includes taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (cameras, smart phones, and other electronic ) devices and/or keeping or distributing them through multimedia messages or on social media networks.

Based on interviews and records reviewed the facility failed to ensure one resident was not physically restrained by being tied into a wheelchair with a gait belt and a bed sheet. This failure affects one of three residents (R5) reviewed for restraint use. This failure resulted in R5 having his freedom of movement inhibited and ongoing agitation, aggression, and anxiety. It is reasonable to conclude that R5 felt embarrassed and dehumanized. The findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 R5 was on one to one monitoring, he was a lunatic. V19 said R5 was trying to throw himself on the floor. V19 said I saw R5 had a gait belt around him and I told them, I don't feel comfortable with the belt on him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5, before she left like at 4:30PM. V19 said I didn't say anything about the sheet. V19 said they said if you don't want to watch the patient, then go home. V19 said I left the floor and then I came back up to the floor around 6:00PM or 7:00PM and R5 had the sheet around him. V19 said I got fired because of this. V19 said I saw R5 with the sheet tied with two knots around his stomach and he was sitting on a regular wheelchair, he also had the gait belt on. V19 said I documented it, V19 provided documentation to IDPH. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disroder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 8/29/24 at 1:18PM V10, Registered Nurse (RN), said I did the admission for R5. V10 said R5 was a little aggressive and he was not verbal. V10 said when I spoke with R5 he understands a little and was alert times 1-2. V10 said R5 was not mobile, he was not steady, he liked to grab at people. V10 said R5 was a complete assist, he needs staff assistance for everything. V10 said R5 was a fall risk. V10 said I had to call for someone to sit with him. V10 said R5 was constantly trying to get up and he was aggressive. V10 said R5 sat in a regular wheelchair. V10 said we got a sitter for him in the evening. V10 gave a description of R5, she said he was an African American male, about 110 pounds, 5'3 - 5'2, thin, and he had a gastric tube when he first came to us. V10 described R5's hair as not well kept and he had a thin beard. V10 was shown a picture of a male, sitting in a chair, in a room and V10 said that is him identifying R5. On 8/29/24 1:33PM V11, Licensed Practical Nurse (LPN), said we needed a one to one for R5. V11 said R5 had behaviors. V11 said R5 would throw things at staff, use verbal profanity, and he would not stay seated for 2 seconds. V11 said the assigned monitors reported R5 was hitting them and he would urinate wherever he was. V11 said R5 sat in a wheelchair. On 8/29/24 at 2:25PM V14, CNA, said I used to take R5 outside to try and calm him down, in a wheelchair. V14 said I know V19, CNA, was assigned as one to one monitor for R5 on 7/26/24. V14 said I saw V19 standing outside of R5's room, and not in the room like he should have been. V14 said at one point, R5 was brought out to the nurses station, he was in a gown, in a wheelchair. V14 said R5 was always trying to stand up. V14 said I had seen R5 leave urine on the floor. On 8/30/24 at 10:09AM V16, CNA, said on 7/26/24 V19 got pulled to monitor R5. V16 said R5 was really anxious, he tried to get up, and his legs go weak. V16 said we kept coming back to check on V19 because R5 was anxious, he was in the wheelchair rolling everywhere. V16 said at first V19 was nervous with R5, I had to pull him out the room and talk to V19 about how to address R5's behavior. V16 said R5 and V19 were in the hallway and in the room. V16 said I think V19 had blue scrubs on that day. V16 said V19 said R5 was throwing feces. V16 said R5 was in a wheelchair. V16 said V19 was having a panic attack after R5 was throwing feces and urinating. V16 said V19 came to the nurses' station, and he said this is too much, I can't deal with this and R5 was in the room. V16 said I told V19 you need relief for a one to one. V16 said V19 was belligerent, he was not listening and having a panic attack, and V19 went down the stairwell. V16 said V19 ended up coming back to the floor, he was gone like 10 minutes. V16 said V19 was doing this around 5:30PM, mealtime. V16 said R5 had tried to throw himself out of the chair or lean forward. V16 said V18, Scheduler, tried to do education with V19 about how to care for R5. V16 said the shift ends at 11:00PM, and V19 sat with R5 until 11:00PM. On 8/30/24 11:10AM V5, Director of Nursing (DON), said we issue gait belts to the CNAs and we expect them to use them for transfers. V5 said they have the gait belts on them, they are expected to carry them while at work. V5 said R5 was all over the place he kept getting up from his wheelchair. V5 said we assigned a one to one monitor because we were afraid R5 was going to fall. V5 said R5 was standing, difficult to redirect, pulling at his gastric-tube, reaching and grabbing for the CNAs. V5 said we got a wheelchair for R5 and sat him at the nurses' station because he kept trying to stand. V5 said V19 was pulled to monitor R5. V5 said R5 was at risk for falls, not redirectable, not listening, and not interested in anything. At 12:29 V5 said V19 was terminated for being on his cell phone twice on 7/26/24 while he was assigned the one to one with R5. V5 said a CNA observed V19 on the cell phone, and heard him talking about R5 and how bad he was and he did not need to be here. V19 said that same shift V19 said he was mad and he was leaving. V5 said V19 was upset about having to do the one to one. V5 said a physical restraint would be to tie a resident down in bed or a chair using a gait belt or a sheet. V5 said a restraint would be anything used to keep a resident from getting up. The surveyor asked V5 does a restraint inhibit freedom of movement, can it cause anxiety, agitation, and aggression? V5 responded yes to all. V5 said the use of physical restraint is considered abuse. 9/10/24 9:46AM V24, CNA, said I was at home when V19 called me on 7/26/24. V24 said V19 said they stuck him with a one to one. V24 said V19 said they were restraining R5. V24 said V19 said that R5 was restrained to a chair. V24 said it was around 5:00-5:30PM when V19 called me. 9/10/24 10:40AM V18, Scheduler, said as I walking in the hallway, I heard V19 telling someone on the phone this resident he doesn't sit down, he is getting on my nerves. V18 said I don't know who V19 was talking to. V19 said when I went in R5's room V19 was standing behind R5 holding him down. V18 said I told V19 it could be intimating to be behind him. On 9/3/24 at 3:20PM V5 said V19 was assigned to R5 and from the start he was mad and upset because he did not have the option to refuse. V5 said one of the CNAs I spoke to said V19 called me and said he felt uncomfortable taking care of this patient because the resident was restrained. V5 said V18 called me on 7/26/24, after I had gone home, and said when she walked in R5's room V19 had R5 in a choke hold in the wheelchair, trying to hold him down, and talking on the phone. V5 said, V18 said V19 was on the phone talking to someone about how bad R5 is. On 9/10/24 at 11:51am V15, Assistant Director of Nursing, said there are no restraint use assesmsents because we are a restraint free facility. On 9/10/24 at 12:07PM V25, Administrator, said during orientation I say no restraints, unless notified otherwise, and then we would assess the resident on an as needed bases. V25 said I spoke with V19 yesterday (9/9/24) and all he could tell me is that when he got to the floor R5 had a gait belt on the chair. V25 said I asked if the ambulance had left him like that, V19 said he didn't know. The surveyor asked V25 if the ambulance transfers residents to them in wheelchairs, V25 said typically they don't come in with a wheelchair. V25 said the camera only shows the hallway. V25 said the camera looks down towards the dining room. V25 said there is only one camera, it can see the nurses' station, elevator, towards the dining room, and the entrace to the dining room. V25 said it is very blurry I can't make out a whole lot. On 8/29/24 an image of identified resident R5 obtained. Image is of African American, dark-skinned male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, leaning forward, back exposed. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility decor. A white with beige, red, and blue striped gait belt is visible with a long tail portion off the lower back of the wheelchair. A white linen, possibly bed sheet, is visible tied around the resident, left and right side of wheelchair have the same linen and 2 knots with a visible loop is present on the back of the wheelchair. No face for the resident is visible, but he is in a hospital gown and feet exposed, no shoes or socks. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. On 8/30/24 at 12:15PM V20, Human Resources, said V19 worked 7/26/24 3:00PM-11:00PM with a 30 minute lunch from 9:01PM- 9:30PM. V20 provided V19's time card. On 8/30/24 at 12:57PM V5 provided two samples of gait belts given to CNAs for use in the facility. One sample is beige with three stripes, blue, red, blue and metal clip. This belt is similar to the one seen in the picture used on R5. Review of R5's careplan and assessments. No risk of abuse assessment is in R5's chart. No restraint use assessment is in R5's chart. Facility provided Restraint Policy and Procedure dated 1/15/21 states physical restraint is any manual method, or physical, or mechanical device, material, or equipment attached or adjacent to the individual's body that the individual cannot remove easily, which restricts freedom of movement or access to his or her body. Any resident that has restraint will have it removed during activities, meals, one to one and activities of daily living (ADLs) when and if staff can safely monitor the resident. Any resident requiring a physical restraint will be assessed prior to application to determine the least restrictive restraint used. A verbal consent at minimum will be obtained prior to the physical restraint application. A plan of care will be developed for all residents with chemical and physical restraints.

Based on interview and record review, the facility failed to prevent an incident of physical abuse during a resident to resident verbal altercation for one resident (R4) of five reviewed for abuse in a total sample of 11. This failure resulted in R4 being physically attacked by R5 suffering from a bruised face and bleeding from the mouth after being hit in the face by R5. Findings Include: R4 is a [AGE] year old with the following diagnosis: schizoaffective disorder, psychosis, post traumatic stress disorder, and subdural hematoma. R5 is a [AGE] year old with the following diagnosis: Alzheimer's disease. A Nursing note dated 1/13/23 documents around 2 AM the nursing staff responded to a call from R4. Upon arrival to the room, R5 was observed assaulting R4. A general assessment on R4 was remarkable for left lower eye bruising/swelling and minimal buccal bleeding. On 3/1/24 at 12:26PM, R4 denied remembering getting into a fight with any other residents in the facility. R4 denied any having any problems with any other residents in the facility. This surveyor assessed cognition and R4 was only able to state name and a location of Chicago. R4 was not able to state the date, president, or what kind of place R4 was living in. On 3/1/24 at 12:39PM, R5 denied getting into a fight with anyone at the facility. R5 was unable to recall if R5 was called a racial slur by anyone at the facility. R5 was unable to respond to questions with answers that made sense due to cognition. This surveyor assessed cognition and R5 was only able to state R5's name. When asked other questions, R5 would respond with an answer that was unrelated to the question asked. On 3/1/24 at 6:31PM, V6 (CNA) stated staff heard R4 screaming and when they entered the room, R5 was punching and slapping R4 in the face. V6 reported R4 was lying in bed and R5 was standing over R4 and hitting R4. V6 stated R5 was using open and closed fists when hitting R4. V6 denied hearing R4 using any racial slurs before hearing R4 call for help. V6 reported R4 had bruising on the face and R4's lip was bleeding. V6 stated this would be considered physical abuse. On 3/5/24 at 11:09AM, V9 (Nurse) stated staff notified V9 of the altercation between R4 and R5 and both residents were separated by the time V9 came into the room. V9 reported R4 had bruising and possibly some bleeding but V9 able to recall where. V9 stated this would be physical abuse. V9 reported R4 is not able to walk and could only lie in bed and defend R4's self. On 3/5/24 at 11:34AM, V1 (Administrator) stated while investigating this altercation, it was believed that R4 called R5 a racial slur and R5 proceeded to hit R4 after being called the N-word. V1 stated both residents are confused and did not remember the altercation but R5 did report being called the N-word by R4. The Hospital Transfer Form dated 1/13/24 documents R4 was being sent to the hospital for left lower eye swelling and bruising. The Hospital Transfer Form dated 1/13/24 documents R5 was sent to the hospital for an evaluation after a physical altercation. The Police Report dated 1/13/24 documents the police were dispatched to the facility for an assault occurring between residents. When the police arrived, V9 told police two mentally deficient residents were involved in a physical altercation. V9 told the police that R5 physically assaulted R4 by hitting R4 in the face. The Hospital Records dated 1/13/24 documents R4 was brought to the emergency department after an altercation with another resident. R4 was punched in the face by another resident, and was struck around the eye. Upon assessment, R4 has minimal bruising noted around the left orbit and scattered abrasions over the left lower leg. R4 had a discharge diagnosis of facial trauma. The Hospital Records dated 1/13/24 documents R5 was brought to the emergency room for aggressive behavior toward another resident. R5 was confused with disorganized thoughts. The Facility Incident Report Form dated 1/13/24 documents the nurse heard R4 yelling and entered the room. R5 was observed hitting R4 in the face. R4 was noted to have swelling to the left lower eye and scant amount of bleeding to R4's mouth. R4 is noted to call R5 racist names. R5 does not remember the incident. When asked about the incident, R4 just said, Oh, that n*gger. The Care Plan dated 4/17/20 documents R4 demonstrates behavioral distress as manifested by verbally abusive behavior, use of profanity, verbal threats, and yelling, racial slurs. R4 also exhibits physically, abusive behavior when agitated by attempting to push, shove, scratch, or harm another person. R4 was involved in altercations on 4/16/20, 8/10/20, 9/5/21, 1/29/22, and 1/13/23. The Care Plan dated 12/14/20 documents R4 has a history that reveals a previous suspected abuse and/or neglect or factors that may increase susceptibility to abuse/neglect. R4 demonstrates behavioral symptoms and difficulty in adjustment with mood. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as eight (moderate cognitive impairment). Section E of the MDS documents R4 has not had any physical or verbal behavioral symptoms directed towards others since the last assessment. The Care Plan dated 1/13/24 documents R5 displays conflictual, difficult behavior as manifested by complaints about roommate and unprovoked expressions of anger towards staff and peers. R5 was the aggressor in an altercation with a roommate. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as six (severe cognitive impairment). The policy titled, Abuse Prevention Program, dated 01/2019 documents, It is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility . This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals . For the purpose of this policy and to assist staff members in recognizing abuse, the following definition shall pertain: 1. Abuse: The willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to perform dressing changes as ordered by the wound physician for one resident (R6) of three reviewed for wound care in a total sample of 11. This failure resulted in R6's wound(s) declining by increasing in size on two separate occasions. Findings Include: R6 is a [AGE] year old with the following diagnosis: paraplegia, osteomyelitis, pressure ulcer of the sacral region stage four, pressure ulcer of the right buttocks stage four, and pressure ulcer of the right hip stage 4. On 3/5/24 at 3:13PM, R6 stated, there is one full time wound nurse (V13) and one part time wound nurse (V12). R6 stated V13 left the country for over a month and the only time R6's dressings would be changed was when V12 was in the facility. R6 reported telling V2 (DON) the dressing changes weren't being changed and V2 reported having a conversation with the nurses about doing the dressing changes. R6 admitted the nurses continued to not change the dressing for about two weeks until R6 went to the hospital. R6 stated when R6 got back from the hospital V13 had returned to work and the dressing changes now take place as ordered. R6 reported nurses told R6 they refused to do the dressing changes because they were not certified for that care. R6 was unaware how many dressing changes were missed and was not aware if the wounds declined or not. On 3/7/24 at 10:21AM, V12 (Wound Care Nurse) stated staff nurses are responsible for completing the ordered wound treatment when V12 or V13 (Wound Care Coordinator) are not in the building. V12 reported if a wound has a decline then the wound could get larger in size, have more necrotic tissue, or develop foul odor. V12 stated all wound treatments should be completed as ordered and there is no reason the treatments should not be completed. V12 stated R6 has mentioned to V12 that the staff nurses have not been completing the wound treatments but V12 was unsure of how many. V12 denied checking the Treatment Administrator Record to see if the wound treatments were being completed on R6 and denied notifying the physician or management about the missed wound treatments. V12 reported residents who have wound treatments are round on by the wound doctor weekly. V12 stated a staff nurse should round with the wound physician if V12 or V13 are not in the building so residents can still receive the weekly wound assessment. On 3/7/24 at 11:04AM, V13 stated, V13 was out of the country from 01/01/24 through the second week of 02/2024. V13 reported V12 and V13 normally take care of the dressing cares but in their absence staff nurse need to complete the wound treatments. V13 stated the orders for what treatments to provide are in the TAR and that can be accessed by the nurses. V13 stated residents are rounded on by the wound physician weekly. V13 was unaware that the wound physician was not able to assess resident wounds in the facility on one or two occasions and reported a staff nurse should have rounded with the physician so the wounds could have been assessed. V13 stated the importance of the wound physician seeing residents each week is to observe and document any changes to the wound and changes treatment as necessary. V13 reported if dressing changes are not completed then a wound could have a decline. V13 defined a decline in a wound as the wound growing in size or developing a smell. V13 stated all wound treatments in the TAR should be documented as completed and if they are not documented then it is considered not done. On 3/7/24 at 11:35AM, V2 (DON) denied R6 reporting wound treatments were not being completed when V13 was out of town. V2 stated R6 has a habit of refusing wound treatments but the refusal should be documented in a progress note if R6 refuses. V2 reported staff nurses are responsible for completing the wound treatments when V12 and V13 are not in the building. V2 denied there being a reason an ordered treatment should not be completed. V2 reported the nurses might have completed the treatments on the days that the TAR are empty but understands if the treatment is not charted then it is considered not completed. V2 stated the wound physician sees residents with wounds on a weekly basis to assess the wounds to see if there are any changes in the wounds. V2 recalled maybe two occasions when the wound physician had to cancel weekly visits because no one was able to round with the physician. On 3/7/24 at 1:08PM, V14 (Wound Physician) stated V14 visits the facility weekly to round on the residents. V14 reported on two occasions staff was not available to round with V14 so those weeks the rounds were not completed. V14 stated the residents were not seen until the following week due to V14 going to other facilities. V14 reported having no staff to round with to V2. V14 stated per the wound company's regulations V14 has to have a staff member round with V14. V14 reported V14 assesses the wounds weekly because it is part of the residents wound care plan. V14 denied being made aware by staff that R6's wound treatments were not being completed as ordered. V14 stated that unless clinically contradicted then the wound treatments should be completed as ordered. V14 did not recall R6 refusing any wound treatments. V14 reported wounds can possibly get worse if the dressing changes aren't done. V14 defined getting worse as increasing in size or developing an infection/more necrosis. On 3/7/24 at 4:12PM, V16 (Nurse) stated if a resident refuses a wound treatment then it is documented on the TAR as refused. V16 reported if the TAR is empty a nurse could have forgotten to chart the treatment was completed, but stated if it is not charted then there is no way to prove the treatment was completed. V16 reported R6 did report to V16 that nurses were not doing the wound treatment but V16 did not follow up with R6's statement by notifying V2 or V14. V16 stated if the wound treatments are not completed then the wound can get worse by getting bigger or becoming infected. The Treatment Administration Record (TAR) dated 01/2024 has orders for a treatment to the sacrum, right hip, and right ischium that are ordered to be completed every day shift. R6 missed a total of six treatments for each wound from 01/19/24 through 1/31/24. The TAR dated 02/2024 has an order for a treatment to the sacrum, right hip, and right ischium that are ordered to be completed every dayshift. R6 missed a total of one treatment for each of these wounds on 2/9/24. There is no documentation that R6 refused wound care treatments on any of the days the treatments were not completed. The Wound Physician note dated 1/9/24 documents R6 has a stage four sacrum measures 3.3 cm 3.5 cm x 1 cm. The stage 4 wound to the right ischium that measure 6 cm x 6 cm x 1.5 cm. The stage four to the right hip measures 5.5 cm x 6 cm x 1.5 cm. The Wound Physician note dated 1/16/23 documents the stage four to the sacrum measures 3.1 cm 3.2 cm x 1 cm. Wound is documented as improved as evidence by decreased service area. The stage four wound to the right ischium measures 6.4 cm x 7.5 cm x 1.5 cm. This wound is documented as not at goal. The stage four to the right hip measures 5 cm x 5.5 cm x 1 cm and is documented as improved as evidence by decreased surface area. The Physician Wound note dated 1/23/24 documents R6's visit has been rescheduled due to facility staffing for rounds. There is no documentation of any assessments of the wounds for this day. The Wound Physician note dated 1/30/24 documents the stage four wound to the sacrum measures 3.1 cm x 3.3 cm x 1 cm. The wound is documented as not goal. The stage four to the right ischium measures 6.5 cm x 6.5 cm x 1.5 cm. This is documented as improved as evidenced by decreased surface area. The stage four to the right hip measures 6 cm x 5.7 cm x 1 cm. This wound is documented as not at goal. This wound increased in size from 1/16/24 to 1/30/24. Weekly wound evaluations are completed in 01/2024 on 1/09/24, 1/16/24, and 1/30/24 (the measurements of the wounds and other documentation coincide with the wound physician notes). There is no weekly wound evaluation for the week of 1/21/24 through 1/27/24. R6 left the faciity on [DATE] and returned from the hospital on 2/8/24. The physician did not see R6 on the day R6 was readmitted , but a weekly wound evaluation completed for R6. The Weekly Wound Evaluation dated 2/8/24 documents R6 has a right hip wound that is a stage four that measures 5 cm x 5 cm x 0.5 cm. The right ischium stage four measure 5.8 cm x 6.8 cm x 1.5 cm. The stage four to the sacrum measures 3.2 cm 3.2 cm 1.0 cm. No weekly wound evaluation was completed the week of 2/11/24 through 2/17/24. The next weekly wound evaluation was completed on 2/20/24 when the wound physician rounded at the facility. There are no wound physician notes in 02/2024 until 2/20/24. The following measurements are for 2/20/24. The stage four to the sacrum measures 3 cm x 3.5 cm x 1 cm and is documented not at goal. The stage four to the right ischium measures 6.9 cm x 7.3 cm x 1 cm and is documented as not at goal. The stage four to the right hip measures 6 cm x 6.2 cm x 1.3 cm and is documented not at goal. All three of these wounds suffered a decline by increasing in size from the last time they were measured and assessed on 2/8/24. There are no documented measurements of the wounds from 2/8/24 through 2/20/24. The Care Plan dated 8/19/22 documents R6 has an alteration and skin integrity and is it risk for additional and/or worsening of skin integrity issues related to comorbidities. Interventions include: Administer wound care treatments per physician orders. See the TAR for current orders. The Braden Scale for Predicting Pressure Sores dated 3/1/24 documents score of 12 indicating R6 is a high risk for developing pressure ulcers. The policy titled, Skin Integrity - Care and Prevention Policy, dated 8/27/18 documents, Purpose: To ensure that based on the comprehensive assessment of a resident, a resident that enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary services to promote healing, prevent infection, and prevent new sores from developing. Procedure: .Monitor and evaluate the impact of the interventions and revise as appropriate .c. Wound care nurses will assess and measure wounds weekly and document. d. Wound care nurses will track pressure ulcer/wound progression on weekly wound log.

Based on observation, interview and record review the facility failed to follow their practice to confirm and follow physician orders to monitor blood glucose and administer insulin per sliding scale as prescribed for a resident diagnosed with type 2 diabetes with hyperglycemia. This affected one of three (R8) residents reviewed for physician orders. This failure resulted in 13 missed opportunities for blood sugar checks and 13 opportunities for insulin administration, R8 was sent to hospital, evaluated and treated for diabetic ketoacidosis, R8's blood glucose 658mg/dl. Findings include: R8's face sheet shows diagnosis of type 2 diabetes mellitus with hyperglycemia. On 12/8/23 at 10:23 pm, V19 (R8 family) said when she visited R8 on 11/16/23 around 11:30am-11:45am, R8 was observed in the dining room slumped over in his wheelchair, V19 said she called out to R8 and R8 replied help me V19 said she informed the nurse of R8's condition. V19 said the Nurse checked R8's blood sugar and she informed her that it was reading high. V19 said the facility gave R8, 8 units of insulin a couple of times but the reading remained high. V19 said while in the hospital R8's blood sugar was over 600 mg/dl. V19 said when R8 recovered days later R8 told her he was not getting his insulin like he should have been. On 12/8/23 at 12:20 pm V20 (LPN) said she was informed that R8 was in the dining room and R8 was experiencing a change in condition. V20 said she checked R8's blood glucose at that time and it was reading high. V20 said she had not check R8's blood sugar prior to the change in condition, she did not administrator insulin prior to the change in condition. V20 said she did not check R8's blood sugar that morning before breakfast, she did not administrator insulin to R8 before breakfast. V20 said she does not know if R8 is a type 2 diabetic or type 1 diabetic. V20 said she just follows the orders on the M.A.R- (medication administration record). V20 said if there was not an order for blood glucose monitoring then she did not check R8's blood sugar. Follow up interview with V20, V20 said she administered R8 insulin on 11/16/23 from an insulin pen that R8 had from a previous insulin order. On 12/8/23 at 11:27 am, V9 (Director of Nursing) said R8's Humalog insulin had not arrived at the facility by 11/16/23. V9 said the order was pending in the electronic system. V9 explained that the pharmacy has authority to change a medication as appropriate, V9 said that's a therapeutic interchange. V9 said the original medication will be discontinued and the new medication would be started, pharmacy will enter the order. V9 said the nurses are supposed to check for pending orders and confirm orders so that the pharmacy can send the medication. V9 said she was made aware on 11/16/23 that R8 was having a change in condition and so she checked R8's orders. V9 said she noticed that R8 had a pending order for Humalog insulin. V9 said she confirmed the order on 11/16/23 as R8 was being transferred to the hospital for the change in condition. V9 said R8's Humalog had not arrived before he was sent to the hospital. V9 said she checked the electronic records and there are no blood glucose results for R8 outside of 11/10/23 date. V9 said the nurse should check the blood glucose level before administering insulin. V9 said the blood glucose results are attached to the insulin orders. V9 said the nurse should follow the physician orders for monitoring the blood glucose levels. V9 was asked how the facility ensures that the resident with diabetes mellitus continue to receive blood glucose monitoring when the insulin order is in a pending status. V9 said the policy for blood glucose must be reviewed, V9 said she can't answer that. V9 said assessing the blood glucose is basic nursing practice, the nurse should know to check the blood glucose before administering insulin. V9 was asked if R8 received blood glucose monitoring before being given insulin at nighttime. V9 restated that she cannot find any blood glucose results outside of the 11/10/23 date. V9 presents glucometer used by facility, V9 said the glucometers will give blood glucose up to 600 mg/dl (milligrams/decaliters). V9 said any blood glucose results after 600mg/dl will read hi on the glucometer. V9 said the nurses have been in-serviced on checking the electronic records for pending orders. V9 omitted if staff was in-serviced /trained on monitoring the blood glucose for diabetic residents when the blood glucose order are in pending status with the insulin orders. V9 continued to say assessing blood glucose is basic nursing practice. V9 explained that the letters BS noted on the MAR refers to blood glucose results, V9 said to administer insulin sliding scale the nurse must check the blood glucose. V9 explained that the blood glucose results should be documented to the MAR and signed off by the nurse that checked the blood glucose and administered the insulin. V9 said the pending order is an active order. On 12/12/23 at 2:12 pm, V22 (Medical Doctor) said he was not aware that R8 missed 13 opportunities for accu-checks and 13 opportunities for insulin administration. V22 said he was not aware that R8's blood glucose was reading was over 600mg/dl. V22 said the facility informed him today (12/12/23) of the situation. V22 said he does have a Nurse Practitioner that sees his residents and that the NP sent R8 out to hospital on 11/16/23, but she should have informed him. V22 said R8 is diabetic and should have his blood glucose monitored before meals, and R8 should be administered insulin per sliding scale. V22 said the blood glucose monitoring order and insulin order should not be attached together, V22 said there should be 2 orders. V22 said there should be 2 orders to ensure that the blood glucose is continued to be monitored. V22 said the facility needs to correct this. V22 said R8 did not need blood glucose monitoring for the 9:00 pm insulin but R8 did need to have his blood sugar monitored before meals. V22 said the nurse should have notice that R8 was not receiving accu-checks before 11/11/23- 11/16/23. On 12/12/23 at 2:46 PM, V24 (Pharmacy Rep) said R8's insulin was delivered to the facility on [DATE] at 12:30 according to his report. On 12/12/23 at 3:04 PM during observation tour of medication room on second floor with V23 (LPN), there was 2 insulin pens to be returned to pharmacy labeled with R8's name, dated 11/10/23, one pen was labeled Humalog, and the other pen was labeled Novolin. V23 said those medications were removed from the medication cart and will be returned to pharmacy. V9 (DON- Director of Nursing) arrived at the unit to observe insulin pens for R8 that remained in facility on 12/12/23. V9 said she can see that R8 has insulin pens, and they are to be returned to pharmacy. V9 reviewed the label on the pens and verified date of 11/10/23, V9 verified there was medication inside both insulin pens, V9 said she does not know how much medication is inside the Humalog insulin pen. V9 said the Novolin insulin pen had 250 units of insulin inside. R8's progress notes dated 11-16-23 completed by nurse practitioner, denotes lethargic, change in mental status, HPI: R8 is a [AGE] year-old male seen today at the request of nursing due to change in condition, including lethargy, hyperglycemia. Resident seen lying in bed. Nursing reports that he slumped over in the dining room. He was found to have blood glucose reporting high on the glucometer and taken to his room. His wife had come to have lunch with him and was at his bedside. Nurse had administered 8 units of lispro before lunch. Resident did not eat lunch, ordered 8 more units of lispro. BP 99/59, HR 56, T 96.6F, SpO2 95% RA. BGM (blood glucose monitoring) 15 minutes later was still high on glucometer. Ordered administration of an additional 8 units lispro. Resident was alert and oriented x2. Reporting abdominal pain, discomfort, asking for help, stating his sugar was high. Resident not answering questions, anxious facial expression. Resident had facial symmetry, however, left side flaccid. About 10 minutes, resident raised hand to his wife, previous flaccidity may have been attributed to not following instructions, still ambulance was made aware of possible stroke alert. Per wife, resident had a TIA during his last episode of severe hyperglycemia. Writer and nursing management with resident until EMTs arrived. Resident was transported to the ED. R8's physician order sheet dated 11/11/23 denotes orders for Humalog Kwik pen 100 units/ML (milliliters) solution pen injector, inject as per sliding scale: if 120-150=3 units, 151-200=6 units, 201-250= 9 units, 251-350=12units, subcutaneously before meals related to type 2 diabetes mellitus with hyperglycemia. Novolin N subcutaneous suspension 100 unit/ ML (insulin NPH (human) (isopheal) inject 12 units subcutaneously at bedtime for diabetes. Review of R8's (MAR- medication administration record) dated 11/11/23 at 4:00 pm, there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/12/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/13/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/14/23 at 730am, 11:00am, and 400pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/15/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/16/23 at 7:30am, and 11:00am there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. The facility missed 13 opportunities out of 13 opportunities to monitor R8 blood sugar and administrator insulin as prescribed between the dates 11/11/23 through 11/16/23. R8's emergency room records dated 11/16/23 denotes in-part R8, [AGE] year-old male past medical history on dialysis, CVA, DM, L tibia fracture, presents to ED via EMS from nursing home for altered mental status. Wife found patient at noon with altered mental status, ambulance was not called by, and mark for over an hour, reason unknown. Per EMS he was very hyperglycemic with readings high s/p (status post) 10 units prior to arrival and remains hypotensive s/p 500 bolus in transit. He was not given insulin today prior to incident. Comprehensive metabolic panel denotes in-part glucose results 658mg/dl, reference range is 70-99 mg/dl. Active problem list denotes in-part diabetic ketoacidosis. Facility physician order policy, no date noted denotes in-part it is the policy of the facility to follow orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the residents mental and physical admission. Facility policy titled Blood Glucose Monitoring no dated noted, denotes in part it is the facility policy to ensure that residents who require blood sugar monitoring due to hyperglycemia or hypoglycemia secondary to diabetes or for any reason deemed necessary by the physician receives this monitoring. All glucose monitoring will be ordered at the direction of the resident's physician except in emergency situations. High and low parameters will be determined by the physician to maintain residents blood sugar within normal limits. Blood sugar found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. Explain procedures to resident, clean finger, perform finger stick, place blood on accu-check strip and obtain a reading, record accu-check reading on the facility blood glucose monitoring tool, administer insulin to include sliding scale insulin per physician order.

Based on observation, interview and record review the facility failed to have an effective policy for contraband material to ensure that contraband is not brought into the facility. This affected two of two residents (R5 and R15), this failure resulted in R5 found unresponsive sent to hospital, tested positive for opioids on 9/6/23 and 10/31/23, R15 sent to hospital for chest pain and diagnosis with marijuana use. Findings include: 1. On 12/6/23 at 11:35 am, R5 observed alert to person, place, time and situation. R5 said on 9/6/23 he got heroin from someone in the facility, then R5 said he received heroin from someone that delivered the drugs to him. R5 said he was outside the front of the facility and someone in a car pulled up and dropped it off to him. R5 said he took too much heroin that day he overdosed. R5 would not say if he received deliveries of street drugs on any other day. V9 (Administrator) made aware of R5 alleged he got heroin from someone in the facility, then stating he got heroin from someone outside the facility. On 12/14/23 at 12:12 pm, V25 (Assistant Director of Nursing) said on 9/6/23 R5 was found on the first floor unresponsive, R5 was given Narcan and responded to the Narcan, 911 was called, escorted R5 to hospital and R5 returned with diagnosis of drug overdose. V25 said she does not know where R5 retrieved the drugs from. V25 said R5 was readmitted back to the facility the same night. On 12/14/23 at 12:19 pm, V11 (social services) said on 9/6/23 he saw R5 prior to R5 being found unresponsive outside visiting with someone in a black vehicle. V11 said about an hour later there was a code blue announcement for R5. V11 said he did not see anything in R5 hand when R5 return to the facility. V11 omitted to searching R5 upon return to the facility. V11 said R5 will not tell him or staff in the facility where he retrieved the drugs from. V11 said the resident's food and packages are opened in front of the staff. R5's hospital records dated 9/6/23 denotes in-part R5 is a [AGE] year-old male who presents today for concerns for a drug overdose. Urine drug screen positive for amphetamine, and opiates. R5 progress notes dated 10/31/23 denotes in-part contacted hospital to inquire on residents' status, resident admitted to room xx with opioid overdose accidental or intentional. 2. On 12/13/23 at 11:58 am, R15 observed alert to person, place, time and situation. R15 said he had a seizure on 10/18/23, he doesn't know about using marijuana. R15's progress notes dated 10/18/23 denotes resident went out via ambulance x4 assist to hospital. Resident stable and alert. Resident complains of chest pain and n/v (nausea/ vomiting). Vitals b/p=110/76 O2=98 pulse=69 temp=98.1. Resident reports pain level of 4. Writer spoke with MD (medical doctor). MD ordered to send resident out to hospital. Orders carried out. Writer spoke with sister. Sister satisfied transfer. DON (director of nursing) made aware. ADON (Assistant Director of nursing) made aware. No s/s of distress noted. Bed hold policy in place. Resident returned from hospital via stretcher per ambulance service. Accompanied x 2 attendants. Alert and oriented x 2-3. DX (diagnosis) marijuana use, Vomiting. No C/O chest pain. T 98.6 p76 R 18 b/p 130/78 pulse ox 98% to room air. Family made aware DON (Director of Nursing) made aware. On 12/13/23 at 11:07am V9 (Director of Nursing) said R15 did not have an independent pass privilege on 10/18/23, V9 said she does not know where R15 retrieved the marijuana from. On 12/14/23 at 12:19 pm, V11 (social services) said he does not know where R15 retrieved marijuana from, V11 said R15 won't tell him when asked. Review of R15 physician order sheet, there is no orders noted for use of marijuana. Facility policy titled contraband material, no date noted, denotes the facility reserves the right to check individuals and conduct room inspections if there is reason to believe resident or visitors are harboring contraband materials. Contraband material includes, but not limited to alcohol, illicit or street drugs, weapons including any sharp objects, smoking material (if a resident is a safety risk). Rooms may also be searched for lost or stolen property. These processes will only occur when the administrator, director of nursing or mental health practitioner suspects a resident or residents are harboring contraband materials. The search of an individual or rooms will be conducted with privacy and dignity.

Based on observation, interview and record review, the facility failed to conduct daily skin assessment, follow physician's treatment orders and implement interventions in preventing the development and reopening of a pressure ulcer for two (R14 and R74) of four residents reviewed for pressure ulcers. This failure resulted in R14's healed pressure ulcer on the sacral area reopening and being classified as a facility acquired unstageable deep tissue injury and R74's intact skin developed a facility acquired Stage 3 pressure ulcer on the sacrum. Findings include: 1. R14 is an 89-year- old, female, originally admitted in the facility on 06/24/22 with diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. According to Wound Evaluation and Management Summary dated 03/14/23, R14 has a Stage 4 pressure ulcer on the sacrum. R14's current POS (Physician Order Sheet) dated 03/07/23 documented: Calcium Alginate - Apply to sacrum topically as needed for soiled dressing change. Cleanse wound with saline solution, apply calcium alginate and cover with gauze island dressing. And apply to sacrum topically everyday shift for wound care. On 03/14/23 10:09 AM, wound care was observed on R14. It was observed that there was no covered dressing noted on her sacral area. V6 (Wound Care Director) was asked regarding R14's wound dressing. V6 stated, During incontinence care, if the wound dressing is soiled, the nurse has to replace it with a new dressing if wound care team is not here. Never leave the wound uncovered. V6 was also asked regarding her (R14) sacral pressure ulcer. V6 verbalized, When she came here she had a healed open area on the sacrum, then it reopened and healed, then it opened again. R14's Wound Evaluation and Management Summary documented the following: 07/26/22: Stage 3 pressure ulcer, sacrum - resolved 12/20/22: Unstageable DTI (deep tissue injury) sacrum, measurement: 3.0 cm (centimeters) x 2.0 cm x not measurable cm 12/27/22: Stage 3 pressure ulcer sacrum R14's progress notes recorded the following: 12/06/22 - R14 was admitted in the hospital due to COVID (Coronavirus Disease) positive. 12/16/22 - received resident (R14) via stretcher via ambulance, accompanied by two attendants. Resident (R14) is alert and verbally responsive. Resident (R14) requires assistance with all ADLs (activities of daily living), old scars that are heal from previous wound on buttocks, also noted old scar of left eyebrow. 12/20/22 - Skin/Wound note: sacral wound noted to have re-open during regular routine rounds with the wound doctor. This site was noted healed in the recent time; resident has history of wound on same site as observed during the assessment at the time of original admission to the facility. It was recorded as closed scar upon admission, now re-opened. On 03/15/23 at 11:24 AM, V6 was interviewed regarding R14's sacral pressure ulcer. V6 stated, Prior to 12/20/22, I don't see any documentation pertaining to any skin alterations. On 12/20/22, it was seen as Unstageable DTI sacrum. Basically, the site was still fragile, so there is a possibility that it may open up again. It had become a facility acquired pressure ulcer. The only reason for reopening was the site was still fragile. Immobility, poor nutrition and incontinence could also be some of the predisposing factors. We maintain the use of low air loss mattress, foam pad on the sacrum, staff does the weekly skin checks and should report it to me if there is a skin issue. According to R14's Bath and Skin Report from November to December 2022, there were no skin concerns documented. On 12/18/22 report, there was a check mark indicating normal/redness but no wound assessment was completed. There was also no documentation that nurse or wound care team was notified of any skin concerns even prior to 12/20/22 when the sacral wound reopened. V13 (Wound Doctor) was asked during wound care regarding R14. V13 replied, Any pressure ulcer resolved makes it risky for resident to have pressure ulcers again. She (R14) has Dementia, has chronic disease, likely bowel and bladder incontinent, immobility. In preventing the occurrence of pressure ulcers, interventions should be implemented based on the facility's policy and regulations. On 03/15/23 at 1:21 PM, V2 (Director of Nursing) was asked regarding pressure ulcer management and prevention. V2 stated, Repositioning every two hours, use of low air loss mattress; notifying the doctor for any skin changes; making sure residents are provided with meals; document any change in condition; staff needs to do skin checks during shower days and notify doctor and wound care team for any skin changes and document. R14's Care plan dated 07/05/2022 regarding Alteration in skin integrity and is at risk for additional and/or worsening of skin issues documented: Interventions: Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule Precautions for prevention of pressure ulcers will be completed: Good pericare and drying of the skin, Apply protective barrier cream, Reposition resident (R14) frequently when in bed/chair/reclining chair and/or wheelchair, offload heels PRN (when needed), CNA (Certified Nurse Assistant) showers/skin observations to be reported to nurse for any unusual findings/changes in residents skin integrity Administer Wound Care (Treatments) per MD (medical doctor) orders. Facility's policy titled Wound Management Program dated 05-19-17 stated in part but not limited to the following: Risk and Skin Assessment Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure injuries. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure II. All residents will have a visual inspection of their skin B. Skin checks are completed weekly by the nurse. C. Skin check is completed on each shower day by nursing assistant staff 1. Shower sheet may be used to document the skin check. 2. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 3. Appropriate measures will be instituted. D. The nursing assistant visually inspects the skin daily and with care. 1. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 2. Appropriate measures will be instituted. Pressure Injury Prevention Skin Care and Early Treatment Skin Assessment Complete Skin Assessment - The complete skin assessment is an integral part of the Pressure Injury Prevention Program. It is through these inspections that early skin problems can be identified and interventions implemented. Observations should continue daily for residents at risk for skin breakdown. Monitor skin condition for color, moisture, temperature, integrity, and turgor with close attention to the bony prominences. Also observe skin areas around medical devices such as oxygen cannulas, catheters, collars and braces. A weekly assessment should be completed on all residents. This can be completed by the nurse or the nursing assistant and should be documented in the medical record. Special attention should be given to bony prominences and skin folds. Wound Cleansing and Dressings Policy: It is the policy of this facility to perform wound dressing changes as ordered by the physician using clean technique on all chronic or contaminated wounds. A moist wound environment is most favorable for optimal wound healing. 40920 2. R74 is a [AGE] year-old male who is a long-term resident of the facility, with past medical history including, but not limited to schizophrenia, bipolar disorder, cognitive communication deficit, hyperlipidemia, major depressive disorder, weakness, etc. 03/14/23 9:15AM, observed wound care for resident with V3 (wound care nurse) and noted a large area of excoriation at the resident's sacrum with a big hole in the middle packed with dressing that is saturated and brownish in color. Per wound care doctor, area is measuring 3.4 x 3.8 x 0.9, and still a stage 4. Per V3, (wound care nurse) resident was admitted with no skin issues, not sure if he was on air loss mattress, resident usually do not get an air loss mattress unless they have stage 3 or 4. Per record review, admission assessment dated [DATE] documented no skin abnormalities under skin and foot observation. Braden score assessment dated [DATE] coded resident with a score of 9, placing him at a high risk for skin alteration. A focused wound exam dated 6/14/2022 documented a stage 3 pressure wound to the sacrum measuring 3.0 x 9.0 x 0.1cm, duration >than 1 day. Weekly wound evaluation dated 6/28/2022 documented a stage 4 pressure ulcer, in house acquired, to the sacrum measuring 3.0 x 3.3 x 0.2 identified on 6/14/2022 with moderate serous exudate described as thin watery. Wound evaluation dated 3/14/2023 documented a stage 4 pressure ulcer to the sacrum measuring 3.4 x 3.9 x 0.9 cm with moderate serous exudate. No previous skin assessments provided to confirm that resident skin was being monitored to prevent skin breakdown prior to new wound being identified. Care plan initiated 3/24/2021 stated that resident has a self-care deficit and requires assistance with ADLs to maintain the highest possible level of functioning, resident is total dependence x2 person assist for toileting, total assist x1 for eating, total assist x2 person for bed mobility, total assist x1 staff for locomotion on and off unit, total assist x 2 with mechanical lift for transfers. Incontinent care plan initiated 1/31/2022 stated that resident is incontinent of bowel and bladder due to diagnosis of hemiplegia and hemiparesis. Interventions include to toilet resident at regular intervals throughout the day, check and change at minimum of every 2-3 hours. Report any new skin integrity issue to nursing. Facility Minimum Data Set (MDS) assessment dated [DATE] coded resident in section H (Bowel and Bladder) as always incontinent. Review of physician order summary showed an order for air loss mattress dated 10/18/2022. On 3/15/2023 at 11:37AM, V6 (wound care nurse) said that resident's pressure ulcer was first identified as a stage 3 and then it progressed to a stage 4, the wound deteriorated at one point but is improving now, resident is incontinent of bladder and bowel and is dependent on staff for all ADL care. V6 added that the certified nurse assistants (CNAs) are trained to report any skin alterations or discoloration to the nurse, who in turn will notify the doctor to get an order and notify the family. Residents that are at risk for alteration in skin integrity are supposed to be turned and repositioned frequently, other risks for pressure ulcer development will include proper nutrition and making sure resident are not sitting on soiled incontinent briefs for a long time.

Based on interview and record review, the facility failed to adequately assess residents for a fall risk, failed to have appropriate fall interventions in place, failed to ensure that staff are familiar with residents fall risk status and fall interventions and failed to provide appropriate and sufficient supervision for residents assessed as requiring staff assistance and supervision for Activities of Daily Living (ADLs). This failure affected two ( R15 and R62) of 14 residents reviewed for falls. This failure resulted in R62 falling in her room, being sent to the hospital where she was found to have a left hip fracture and required a surgical procedure; this failure also resulted in R15 falling, while walking outside, in the facility's smoking patio, without the use of assistive device, which resulted in a left foot fracture. Findings include: 1. R62 is a [AGE] year-old female who is a longtime resident with past medical history including, but not limited to acute respiratory failure with hypoxia, weakness, peripheral vascular disease, generalized muscle weakness, unspecified dementia unspecified severity without behavioral disturbance, essential primary hypertensin, etc. On 03/13/23 11:47 AM, during observation on the second floor, R62 was observed in her room, awake and alert with some confusion, resident was sitting in a wheelchair, no floor mats noted in the room. 03/15/23 10:30 AM, R62 was observed again in her room sleeping, bed not very low, no floor mats were noted on either side of the bed. Review of resident's progress note dated 1/24/23 showed the following: Around 2120 resident observed on floor in Lt side lying position near foot of bed. Resident stated, I was trying to go to the bathroom and my legs went down. Resident complained of pain 5/10 to LLE. LLE immobilized and immediately assessed head to toe for injury, then assisted back to bed for further assessment. No bruising or swelling noted. Neuro checks initiated, LOC within baseline limitations. Orders given for PRN pain medication. Medication tolerated well. Voicemail left for POA to call facility. DON, and MD notified of incident. Orders given to send resident hospital for further evaluation. Resident departed facility via 911 with RPFD with 2 attendees in route to hospital. On 1/25/2023, a nurse documented, Resident admitted at Hospital with dx- hip fracture. Nursing care plan dated 1/31/2023 stated that 27 staples to the left hip removed per PCP order. Site noted closed, no drainage or sign of dehiscence observed. Resident in stable condition, remains alert and oriented x3. Doctor's progress note dated 2/13/2023 documented the following: HISTORY OF PRESENT ILLNESS: Patient is a [AGE] year-old female, long-term resident of the facility, who was sent to the hospital because of fall when she fell to her left side sustained left hip pain. The patient was evaluated in the ER. She was found to have left hip fracture. She was evaluated by ortho service. She was found to have displaced intertrochanteric fracture of the left hip. The patient was evaluated by cardiology service, and she was cleared for surgery. She was taken to the OR and underwent open reduction internal fixation. Postoperatively, the patient was admitted to the ortho floor. She was started on physical therapy and occupational therapy and transferred back to the facility. She is currently in rehabilitation. Hospital record dated 1/28/2023 stated in part, Resident is a [AGE] year-old female with past medical history .transferred from an outside hospital for surgical management of a left sided intertrochanter femur fracture after a mechanical fall. Patient had a left sided head trauma as well and lost consciousness for an undetermined amount of time. Fall risk assessment dated [DATE] scored resident as 14, indicating a high risk for falls, another fall risk assessment dated [DATE] was incomplete and documented as to be determined, resident did not have any other fall assessment from 1/1/2022 till the fall on 1/24/2023. ADL care plan initiated 2/11/2018 stated in part that resident has an ADL self-care deficit, requires assistance with ADLs to maintain .following limitations and potential contributing diagnosis of respiratory failure, CHF, muscle weakness and lack of coordination, bed mobility - extensive x1, toileting extensive x1, transferring extensive x1, dressing and personal hygiene extensive x1. Fall risk care plan initiated 3/15/2021stated that resident is at risk for falls characterized by history of falls/injury, multiple risk factors due to impaired balance, unstable health condition, unsteady gait, etc. Interventions includes staff to make frequent rounds when resident is in a room alone, assist her up from bed when she is not feeling tired and keep her in common areas in easy view of staff when up. Minimum data set assessment (MDS) section G coded a resident as requiring extensive assistance with one-person physical assist for all ADL care, section H (bowel and bladder) coded resident as frequently incontinent. 3/14/2023 at 4:10 PM, V2 (DON) said that she completed resident's fall incident, resident self-propels, needs assistance with transfer, is considered a fall risk but she is not sure of any interventions at the top of her head. V2 added that fall assessment is done on residents upon admission and quarterly and when there is any incident. 3/15/2023 at 3:03 PM, V20 (C.N.A) said that she works on the second floor and is familiar with resident, prior to the fall, resident is independent, uses wheelchair, goes to the bathroom by herself but sometimes require staff assistance. V20 said that she is not sure if resident is a fall risk, she does not have any fall interventions that she can recall, she is not sure of the exact time of the fall, she was covering for the assigned C.N.A who was on break. V20 said that she saw resident on the floor, she went and got the nurse, she was not sure how long resident was on the floor, she continued with her assignment after she notified the nurse. 3/16/2023 at 11:52 AM, V37 (MDS) said that fall risk assessment is done upon admission, change in condition, quarterly and after a fall. V37 added that she did not find any fall risk assessment for resident from 1/1/2022 until the fall on 1/24/2023. At 1:05 PM, V38 (LPN) said that she is familiar with the resident and was assigned to her the day she had a fall. The C.N.A found resident on the floor around 9PM on her left side on her buttocks. Resident stated that she was trying to go to the bathroom, resident was assessed, she was complained of pain to her left leg, neuro check was initiated, doctor was called, and order received to sent resident to the hospital for further evaluation. V38 said that prior to the fall resident mostly required supervision and requires limited assistance with ADLs, resident goes in and out, is not a fall risk and V38 said that she does not recall if resident had any fall interventions. She added that residents who are fall risk sometimes have sign on the door and they are also listed on the fall binder located at the nursing station. The fall binder contains the fall interventions for those residents, she does not recall R62 being on that binder or having any listed fall interventions. CT lower extremity w/o contrast stated that there is a nondisplaced fracture extending obliquely from the greater trochanter superiorly the medial of the base femoral neck/intertrochanteric region no lytic or destructive lesion. Facility falls prevention policy undated presented by V2 (DON), stated that the facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The document further states in part that the purpose of the fall prevention and management program is to provide residents with an interdisciplinary approach to assess risks for falls, provide appropriate interventions, etc. 40718 2. R15 is a [AGE] year old male with a diagnoses history including Stroke, Partial Paralysis, Unspecified Convulsions, Lack of Coordination, Generalized Muscle Weakness, Unspecified Abnormalities of Gait and Mobility effective 2/13/2015, Epilepsy effective 4/7/2015, Foot Drop Left Foot effective 8/1/2018, Other Abnormalities of Gait and Mobility effective 9/21/2018, Weakness effective 12/20/2020 who was admitted to the facility 02/13/2015. The facility's Fall log from 10/01/22 - 03/13/23 documents R15 had falls on 11/30/22, 12/18/22, 12/28/22, Per the facility's Matrix Reviewed 03/13/23 R15 had a fall with a major injury. On 03/14/23 at 11:46 AM Observed R15's with a brace on his left lower leg. R15 stated he fractured his foot during his most recent fall at the facility. R15 stated he fell outside during smoke break while walking to the garbage can to dispose of his cigarette butt. R15's Incident report dated 11/30/22 documents prior to the incident he was returning from smoking. Staff was called to the room per staff, and he was noted on his back. Resident was assisted to feet by three staff. Resident stated he was returning from smoking and was going to sit on his bed and missed the bed because it was dark in his room. R15's Incident report dated 12/18/22 documents prior to the incident R15 was outside smoking. Staff informed the writer that R15 fell outside. R15 stated he was coming back from smoking and tripped over a bottle cap. R15's Incident report dated 12/28/22 documents writer was notified by staff that R15 was observed losing his balance and falling to ground while outside on patio during smoke break. Residents stated that he lost his balance and fell . Final Incident Investigation Report dated 01/03/2023 documents on 12/28/22 R15 was observed with a sudden loss of balance where staff attempted to intervene and was unable to reach him which resulted in him falling to the ground on his buttocks. R15 stated he was walking back to return from smoking when he lost his balance and fell to the ground. R15 is non-compliant with the use of his cane. It was determined that he was ambulated at a faster pace than usual when he lost his balance suddenly and fell to the ground. R15 complained of mild pain to left ankle. X-ray revealed closed fracture of left ankle. 03/14/23 04:13 PM V2 (Director of Nursing) stated fall risk assessments are completed on admission, after a fall and quarterly. V2 stated the admitting nurse completes an initial fall risk assessment then restorative completes a follow up assessment. V2 stated R15 is a fall risk. V2 she will have to follow up with information on R15's initial fall risk and any current fall risks. R15's Current Care plan documents he is high risk for falls related to stroke with left side partial paralysis, Seizure diagnoses and a history of falls; non-compliance with use of cane (4/30/20) - [Date Initiated: 01/08/2019, and Created on: 02/26/2015] with interventions including: Physical therapy to screen and treat, Re-educate the importance of utilizing cane while Ambulating, [Date Initiated: 12/19/2022]; was encouraged to use his cane while ambulating.(2/26/19) [Date Initiated: 02/26/2019]; Encourage to comply with using cane. Therapy to screen resident for ambulation and safety. (4/30/2020); Staff to assist with sitting, and cue R15 to sit in high back chair in dining room (2/3/2020); Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. [Date Initiated: 01/08/2019]; Be sure R15's call light is within reach and encourage him to use it for assistance as needed. [Date Initiated: 01/08/2019]. R15's progress note dated 11/9/2022 documents Resident received sitting on side of the bed, alert and oriented to person, place, and situation; Resident is ambulatory, gait is unstable due to left-sided weakness. Resident continues to refuse to use his cane. Continue to educate on the purpose of the cane. Resident continues to refuse. Will continue to monitor. R15's Progress note dated 11/24/2022 documents resident returned back to the facility from family visit, sister called and said resident fell at her house, on his buttock, nursing assessment was performed, denies any pain or discomfort, no apparent injury or bruises noted. R15's Progress note dated 11/30/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls Nursing observations, evaluation, and recommendations are: Resident had a fall in the room no apparent injuries were noted, and the room was dark. Bedside light was turned on so resident will be able to see in the room; Prior to the incident, the resident was coming back from smoking. Staff was called to the room per staff, and the resident was noted on back. Resident stated he was coming back from smoking he was going to sit on his bed and missed the bed because it was dark in the room. R15's Progress note dated 12/18/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls Nursing observations, evaluation, and recommendations are: Prior to the incident, the resident was outside smoking. Staff informed the writer that the resident fell outside; Prior to the incident, the resident was outside smoking. Staff informed the writer that the resident fell outside. R15's Progress note dated 12/19/2022 documents well being check. Staff reported that he fell . Writer met with resident to check on his wellbeing. Writer discussed why he doesn't use the cane despite counsel. Resident reported that he doesn't like. Writer encouraged him to use it. R15's Progress note dated 12/28/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls; While resident was outside on patio during smoke break staff observed resident losing his balance and falling to the ground landing on his buttocks. Staff was unable to catch resident before the fall. Writer and certified nursing assistant assisted resident into wheelchair and resident bought back to unit due to safety reasons via wheelchair. Upon further assessment writer observed minimal swelling to left ankle. Resident complained of pain to area when applying pressure. Resident reminded that he should use his cane while ambulating. Resident is being seen by Physical Therapy. R15's Quarterly Fall risk review dated 7/2/2021 documents a High Risk for Fall score of 10 with risk factors including medications, needing assistance with ambulation, Gait Imbalances including requiring use of assistive device, and status of 3 or more health conditions. No Fall Risk review was located in R15's medical records from 07/02/2021 - 11/30/22. R15's Fall risk review dated 11/30/22 documents a High Risk for Fall score of 10 with risk factors including falls within the last 3 months; medications, and status of 3 or more health conditions; ambulation noted as independent, noted as having normal gait/balance. R15's Fall risk review dated 12/18/22 documents a High Risk for Fall score of 11 with risk factors including falls within the last 3 months; medications, balance problem with standing and walking, and status of 3 or more health conditions; ambulation noted as independent. R15's Fall risk review dated 12/28/22 documents a High Risk for Fall score of 13 with risk factors including falls within the last 3 months; medications, balance problem with standing and walking, and status of 1-2 health conditions; ambulation noted as independent. On 03/15/23 at 01:35 PM V2 (Director of Nursing) stated a fall risk review is completed depending on the reason and circumstances of a fall. V2 stated a fall risk review should have been conducted when his family member reported he had a fall while out of the facility on 11/24/22. V2 stated that incident could have indicated an increase in his fall risk. V2 stated R15 uses a cane that he is not compliant with. V2 stated R15 can walk independently with a cane, but without cane can his balance is not stable when walking. V2 stated the way that the fall risk assessment is completed affects the fall risk score. V2 stated the higher the fall risk score the higher risk for falls. V2 stated if fall risk reviews are not completed accurately it can potentially contribute to their risk of falls. V2 stated she cannot explain why R15's fall risk assessments did not indicate he had more than 3 conditions that contribute to fall risk and why the information regarding his gait and balance did not reflect his gait imbalance. V2 stated a root cause analysis of falls is conducted and interventions are updated based on the interdisciplinary teams findings. V2 stated based on R15's non-compliance with the use of his cane he would benefit from increased monitoring.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for providing dental care for residents by not identifying dental care needs and not ensuring dental services were provided for residents. This failure applies to four (R19, R27, R36, R55) of four residents reviewed for dental care and resulted in (R55) being hospitalized due to a dental infection and facial cellulitis. Findings include: 1. R55 is a [AGE] year old male who originally admitted to the facility on [DATE] and still resides in the facility. R55 has multiple diagnoses including but not limited to the following: COPD, Type II DM, ESRD, moderate protein calorie malnutrition, HTN, anemia, dependence on renal dialysis, aphasia, abnormalities of gait and mobility. Facility progress note dated 3/7/23 states in part but not limited to the following: Upon rounds this morning, observed resident face swollen on both sides. Received orders to send to emergency room . Hospital records dated 3/8/23 state in part but not limited to the following: Patient presented to emergency department from nursing facility secondary to external facial swelling, likely secondary to poor dental hygiene. Patient admits to mouth pain but information limited due to patient's baseline mentation. Multiple significant dental carries with missing maxillary incisors. Multiple periapical lucencies are seen at the maxillary and mandibular teeth. Thrush noted. Preorbital soft tissue edema extending to the nasal bridge. Dental consultation is recommended. Facility progress note date 3/10/23 states in part but not limited to the following: Resident readmitted to the facility from hospital with facial swelling, tooth pain, and infection. On 3/14/23 at 10:53AM, V14 (Social Service Director) was interviewed regarding the dentist and dental hygienist visits. V14 says the dentist or dental hygienist comes once a month. They rotate their schedule. They provide cleanings, exams, and mouth care. We provide them with a list of residents to see while in the facility. The list includes new admissions and any resident that wants or requests to have dental services at that time. R55 has not been seen by the dentist or dental hygienist since he admitted on [DATE]. This surveyor asked if the CNA's (certified nursing assistants) are required to be providing daily maintenance such as brushing their teeth and identifying any concerns in which V14 said yes. On 3/15/23 at 12:20PM, V2 (Director of Nursing) was interviewed regarding dental services. V2 said all residents should be seen on a monthly basis by the dentist or the dental hygienist and CNA's should be providing residents with daily dental hygiene as needed. On 3/16/23 at 11:10AM, V2 was interviewed again. V2 says it is my expectation that the CNA's assist the residents with dental hygiene and report any concerns to their nurse. The nurses should be assessing the resident's oral hygiene every time they do an assessment. If the nurse's recognize a concern, they should be notifying the doctor. R55's admitting diagnosis was swelling of the face and he came back on an antibiotic due to an infection. Per facility care plan dated 11/3/22 states in part but not limited to the following: Focus: I have a self-care deficit and I require assistance with ADL's to maintain the highest possible level of functioning. Desired Outcome: I will maintain my current level of ADL functioning without significant decline unless the disease process causes unavoidable deterioration. Interventions: Personal hygiene and oral care: I require total assistance and one staff for personal hygiene and oral care. (Total dependent on staff). Physician order sheet shows the following orders: dental consult as needed with order date of 3/11/2023; clindamycin HCl capsule 300 mg- Give 1 capsule by mouth one time a day every Tuesday, Thursday, Saturday for tooth infection until 3/21/2023; Metronidazole tablet 500 mg- Give 1 tablet by mouth three times a day for oral infection until 3/20/2023. It is to be noted that a dental consultation has not been scheduled or conducted at this time. Per facility policy titled Oral Hygiene and Denture Care states in part but not limited to the following: It is the policy of the facility to assist the residents as much as necessary to see that they have good oral hygiene. 40718 2. On 03/14/23 at 1:16 PM, V28 stated she believes R19 may have an infection in his mouth. V28 stated the facility is not providing any oral hygiene for him or and he is taking care of himself and no one at the facility is managing that. V28 stated R19 had a mouth full of rotten teeth since he's been at the facility and now they're gone. On 03/14/23 at 4:31 PM, Observed R19 with no visible teeth in his mouth. R19's Current care plan does not include dental care. R19's Current Physician Orders document an active order effective 12/20/22 for Dental Consult As Needed. 3. On 03/14/23 at 12:26 PM, R27 stated she needs to see a dentist and hasn't seen one in quite a while. R27 stated she believes you have to be put on a list to be seen. R27 stated she forgets after she informs staff she would like to be seen because she doesn't receive any follow up. Observed R27 missing teeth in front of her mouth. R27's Current care plan does not include dental care. 4. On 03/14/23 at 12:07 PM, Observed R36 with crooked teeth, missing teeth, and dark build up on bottom row of teeth. R36 stated he needs dentures. R36 stated it's been a long time since he has seen the dentist. R36's Current care plan does not include dental care. The facility's Dental Reports indicating residents that were seen for dental services from September 2022 - February 2023 does not document that R36 was seen for dental services. The facility's Dental Reports indicating residents that were seen for dental services from September 2022 - February 2023 does not document that R19, R27, or R36 were seen for dental services. On 03/16/23 at 11:00 AM, V2 (Director of Nursing) stated nursing staff would identify the need for dental services and social services would assist with being seen by the dentist. V2 stated the nurse should assess residents for dental service needs each time they see the resident. On 03/16/23 1:05 PM, V37 (MDS/Care Plan/Restorative LPN) stated dietary is responsible for developing dental care plans and did not identify any dental care planning needs for R27 or R36. The facility's Dental Services Policy reviewed 03/16/23 states: It is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services. A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status. These assessments will be conducted initially upon admission, quarterly, annually and when there is a significant change in the resident's condition that affects the oral cavity. The assessing nurse will ask the resident if they are experiencing any difficulties with chewing. The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities. The assessing nurse will monitor for: broken or loose fitting full or partial dentures; chipped, cracked, unable to be cleaned, or loose fitting dentures/partial(s); no natural teeth-or only tooth fragments; darkness on a tooth (likely decay) or broken natural teeth.

Based on interview and record review, the facility failed to develop an effective plan that includes supervision, and intervention to reduce or prevent the risk of falling for 1 of 3 residents (R3) reviewed for fall prevention, This failure resulted in R3 having four falls within 8 days which resulted in a Right Acute Subarachnoid Hemorrhage and Right Subdural Hematoma, bruising to the face and a Left Subdural Hematoma. Findings include: R3 had the diagnosis of Hemiplegia and Hemiparesis following Cerebral Infraction affecting the left dominant side, Convulsion, reduce mobility, history of falling, lack of coordination, weakness and Syphilis. Brief interview for mental status dated 12/3/22 documents a score of twelve which indicates moderate impairment. Section G (functional status) documents: R3 needs extensive assistance with one person physical assist with bed mobility, transfers walking in room/corridor, locomotion on/off unit and toilet use. Balance during transitions and walking: R3 was not steady, only able to stabilize with staff assistance (moving from seated to standing position, walking, turning around and surface to surface transfers) Functional limitation in range of motion: R3 had upper/lower extremity impairment on one side. Fall review dated 1/25/23 documents a score of 14 which indicated as a high risk for falls. Care plan initiated 11/5/21 documents: R3 was a risk for fall related to history of falls, left hemiparesis and alcohol abuse. (2/1/23 fall) On 2/15/23 at 1:00pm, R3 was observed not positioned upright in his broader chair. R3's buttock was observed in the middle of the chair seat, slid down from the back of the chair. On 2/15/23 at 1:05pm, R3 who was assessed to be alert and oriented to person, place and time said, my first fall, I stood up to get a snack, I dropped that fell under my bed. I fell when I bent over and hit the right side of my eye brow on the floor. R3 pointed to his right eye brow. I was discharged to the hospital. On 2/15/23 at 1:38pm, V3 (asst. social service director) said, R3 is alert and oriented to person, place and time now. R3 is coming back to himself today. R3 was so confused when R3 was falling. On 2/15/23 at 2:13pm, V7 (restorative nurse/mds) said, R3 was found on the floor in his room in a sitting positon beside his bed. R3 reported trying to get some hot sauce from under the bed. R3 had an opening to the right eye brow. R3 was discharged to the hospital. We provided R3 a Reacher. On 2/16/23 at 12:38pm, V7 said, giving a R3 a Reacher when nothing was found on the floor was not an ineffective intervention. On 2/16/23 at 2:32pm, V9 (CNA) said, I was called in to reposition R3 in the chair. I had to pull R3 up in the chair. Nursing note dated 2/1/2023 documents: 5am-during routine rounding, observed R3 sitting on the floor on his buttocks near his bed. R3 was observed small open area noted to right brow. R3 stated, I was trying to pick my hot sauce from off the floor. R3 had on non-slip sock and lock wheelchair was beside the bed. 911 called. Incident dated 2/1/23 documents: R3 (A0X3) was found on the floor, beside the bed in a seated position with a small open area to the right brow. Predisposing physiological factors- gait imbalance. R3 stated, he was trying to pick up my hot sauce from the floor. There wasn't any food or hot sauce on the floor in R3's room. Upon further assessment wheelchair observed unlocked. Hospital paperwork dated 2/1/23 documents: R3 came in from a fall at the nursing home found to have a right acute subarachnoid hemorrhage and a right subdural hematoma. R3 overestimates/forget limitation. Final reportable dated 2/6/23 documents: R3 was transferred to the hospital, CT scan revealed subarachnoid hemorrhage. R3 stated that he was trying to pick up some hot sauce when he got out of bed without calling for assistance. It was determined that R3 was attempting to ambulate without assistance while bending down. Reacher provided to R3 with teaching on use with a safe and accurate return demonstration. (2/5/23 fall) On 2/15/23 at 1:05pm, R3 said, my second fall was due to me attempting to walk to my dresser to get a snack. On 2/16/23 at 12:43pm, V7 said, education and reminders to lock the wheelchair and sit down slowly are not effective interventions for R3 who was only orientated and alert to self. Nursing note dated 2/5/2023 documents: R3 was in the hallway like 50 feet from writer (V16 nurse). Writer (V16) observed R3 attempting to stand up out of his chair, writer (V16) tried running to catch R3 before fall with no success. R3 chair was unlocked. R3 fell on his buttock. R3 has an unstable gait. On 2/15/23 at 2:13pm - V7 (restorative nurse/mds) said, R3 had a fall on 2/5/23. R3 stood up from his wheel chair, to put his coat that R3 was sitting on, on the back of his wheelchair. When R3 attempted to sit back down, the wheelchair moved. R3 was educated and reminded to lock wheelchair and sit down slowly, physical therapy to evaluate for transfer and gait, to ensure wheelchair is clutter free. On 2/15/23 at 3:30pm, V12 (CNA) said, R3 has two falls on 2/5/23. R3 had a fall before, I started my shift. I was informed by V16 (nurse). Ten minutes into my shift, I heard a boom-flesh/skin hitting the floor. I entered R3's room. R3 keep stating, I have to use the bathroom. R3 had a urinal on the side of R3's wheelchair. R3 was confused. I guess R3 felt the need to stand up to void. I helped R3 to the bathroom. On 2/16/23 at 12:43 pm, V7 said, it is possible to educate a resident (R3) who was only alert to self. R3 was very confused. As team, we should of came up with something else for R3 and needed to review the full picture of R3 to determine interventions. Incident dated 2/5/23 documents: Mental status: R3 was alert to person. Predisposing physiological factor: gait imbalance. Predisposing situation factors: admitted with in the last 72 hours, ambulating without assist and recent room change. (2/6/23 fall) On 2/15/23 at 1:05pm. R3 said, I don't recall this fall. Nursing note dated 2/6/2023 documents: R3 was observed on floor mat near bedside in left side lying position. R3 was unable to give description of what happened. Floor mats in place. All safety precautions in place. Resident to be sent to hospital for CT scan. Incident dated 2/6/23 document: R3 was oriented to person. Injuries observed at the time is the incident: bruise to face. Care plan created on 2/6/23 documents: low bed, medication review, labs, and urinalysis. Hospital paperwork dated 2/6/23 documents: CT scan (2/7/23) documents: Right subdural hematoma has not changed significantly is approximately 8mm thick, mildly enlarged when compared to 2/1/23. Left subdural hematoma is also new since 2/1/23. (2/8/23 fall) On 2/15/23 at 1:05pm. R3 said, I don't recall this fall On 2/15/23 at 2:13pm, V7 (restorative nurse/mds) said, R3 had a fall in the dining room. R3 slid from wheelchair onto his buttock. Care planed intervention for R3 to take a nap after lunch was not an effective intervention. R3 should have cushion, if R3 was in the wheelchair. On 2/15/23 at 3:48pm, V14 (physical therapy) said, R3 was not at baseline, could not sit up or stand. R3 was a high fall risk who could maintain his balance. R3 was not considered for a lap buddy, seat belt or wedge cushion. R3 was given a broad-chair. On 2/16/23 at 1:00pm, V18 (activity aide) said, it was around 4:00pm in dining room. I was the only staff in the dining room. Activities had started at 1:00pm ended at 300pm. R3 was sleeping during the activity time and after the activity. R3 was in bigger chair like a geri-chair. R3 was sitting up in chair. One Resident yelled, he (R3) is moving. R3 was observed half way up out of the chair on the right side. I went to go get R3 but R3 was on the floor. I was about three tables away. R3 had raised his body up over the side and R3 hit the floor. I was collecting items from the residents at the tables prior to R3's fall. V18 said, she yelled for someone. R3 was just looking at me. R3 was alert but did not respond, not at his baseline. R3 unable to say what happened. R3 will sometimes sleep while in the dining room. Usually the fall risk residents need to be monitored in the dining room. When asked how long residents can sleep in the dining room, V18 said, fall risk resident have to be monitored and usually will not go back to the room. Nursing note dated 2/8/2023 documents: At approximately 4:30pm, writer (V17 nurse) was called to the dining room by staff. R3 was observed trying to get up from his chair. Staff attempted to intervene but was unable to catch R3. R3 was observed on the floor on his butt. R3 stated 'I slid from my chair. Incident dated 2/8/23 documents: R3 was oriented to person. Wheelchair bound. Witnessed statement documents: V18 (CNA) said, I was in the dining room during activities, R3 suddenly woke up from his sleep and began trying to get up. I immediately attempted to intervene but was unable to reach R3. R3 fell to the floor. It was determined R3 was observed on the floor lying on left side. R3 was unable to state what happen. Care plan intervention dated 2/8/23 documents: offer R3 to take a nap after lunch. Incident/Accident/Fall policy not dated did not apply.

Based on observation, interview and record review, the facility failed to have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to activate 911 emergency services and monitor one vent dependent resident (R17) who was in respiratory distress. Additionally, the facility failed to ensure a ventilator was set up and ready for use at the time of (R17) admission. This failure affected 2 of 4 residents (R6, R17) reviewed for respiratory services. These failures resulted R6 experiencing respiratory distress, the facility staff removing R6's inner/outer cannulas and were unable to correctly replace the cannula back in place for R6. R6 became cyanotic (blue), 911 activated and R6 expired upon arrival to the local hospital, and the failure resulted in R17 experiencing respiratory distress, using accessory muscles to breathe and expiring at the facility without assistance. This was identified as an Immediate Jeopardy situation that began on [DATE] and was removed on [DATE]. V2(Director of Nursing) was informed of the Immediate Jeopardy on [DATE] at 1:20 PM. However, the deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the in-services given to the facility staff members. Finding include: 1. R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 preadmission paperwork dated [DATE] under operative report: Creation of [CONDITION(S)]. R6's respiratory therapy assessment dated [DATE] at 6:05 AM documents: inner cannula changed; under suctioning: medium clear thick secretions; under lung sounds: diminished in bilateral upper and lower lungs. R6's respiratory therapy assessment dated [DATE] at 8:47 AM documents: Under secretions: medium thick yellow secretions, under lung sounds: rhonchi in bilateral upper and lower lungs. On [DATE] at 2:53 PM, V24 (RT) who was assigned respiratory therapist to R6 on [DATE], said she performed suctioning on R6 around 9:00 AM with no concerns. V24 said around 9:30 AM, V28 (wound care) reported R6 [CONDITION(S)] dressing had not been cleaned for a while. V24 said [CONDITION(S)] site, looked nasty. It was crusty and had dried blood around it. V24 said R6 had maybe 4 -5 stitches around [CONDITION(S)] site. V24 said she cut all the stitches and cleaned the area. On [DATE] at 11:26 AM, V28 (wound care nurse) said that a female respiratory therapist identified as V24 requested scissors from him to cut a resident's sutures. He stated that he asked if this was okay to do and RT replied yes. R6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:53 PM, V24 (RT) who was assigned respiratory therapist to R6 on [DATE], said she heard ventilator alarms in R6's room and R6 was having a hard time breathing. V24 said she attempted to suction R6 but was unable to pass the suctioning catheter through. V24 said called for help and respiratory staff attempted to utilize ambu bag over R6's [CONDITION(S)] site but unable to compress the ambu bag. (Ambu bag- is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately.) V24 said staff took both inner and outer cannulas out of R6 and replaced with a new one. R6 oxygen level was decreasing, vent pressure was high and R6 was using accessory muscles to breathe. Staff attempted to bag R6 via mouth but unsuccessful. V24 said there was no rise and fall of R6's chest. 911 arrived and took over. V24 said she did not see a mucous plug. On [DATE] at 2:05 PM, V17 (nurse) was assigned to R6 on [DATE] said she saw R6 about an hour before rapid response with no concerns. V17 said she responded to rapid response. Respiratory therapist thought she had a [MEDICATION(S)] plug and attempting to suction her. One staff pulled out the outer cannula and replaced it but it was not in place because R6's face turned blue and swollen. R6 ambulance report dated [DATE] documents: dispatched at 12:54 pm and at patient at 1:00 pm. Narrative documents: patient was observed in bed in supine position accompanied by nursing home staff. Staff informed crew that patient had a mucous plug in her [CONDITION(S)] that they were having a hard time clearing. Staff also informed crew that the RT pulled [CONDITION(S)] out, suctioned and replaced it with a new one in an effort to clear the mucous plug. Patient was unresponsive but had pulse. Pulse oxygen saturation was at 15 liters per minute at 47 %. Patient was being provided ventilations via BVM (bag valve mask) by nursing home staff but there was resistance and crew did not note any chest rise or fall. Patient was also being suctioned and her face was blue and extremely swollen. Per staff patient face was not swollen prior to the insertion of new [CONDITION(S)], patient continued not being able to be ventilated via new [CONDITION(S)] at 1:17 PM the resident went into [CONDITION(S)]. On [DATE] at 1:52 PM, V8 (pulmonologist) said staff should not have removed R6's sutures from new [CONDITION(S)] site. [CONDITION(S)] sutures are typically removed seven to ten days post operation because the area needs time to heal. If the sutures are removed too early it can cause an air leak, which can lead to subcutaneous [CONDITION(S)] (occurs when air gets into tissue under the skin caused from rib fracture, lung wound or [CONDITION(S)] trauma). On [DATE] at 11:45 AM, V8 said he never gave any orders to remove R6's sutures. On [DATE] at 1:52 PM, V8 said it is not recommended to remove new [CONDITION(S)] outer cannula and he would not even remove new [CONDITION(S)] outer cannula because there could be post-surgical complications and resident should be sent to hospital right away. It is recommended to wait a month before changing a new [CONDITION(S)] out, even if mucous plug suspected because the [CONDITION(S)] site can close in seconds and patient will not have an airway. Staff should have maintained airway and called 911. Ventilator patient in distress may display rapid respiratory rate or decreased oxygen saturation. If patient turns cyanotic (blue), it indicates they are not getting any oxygen. R6's hospital record dated [DATE] document: Per report patient had mucous plug in her [CONDITION(S)]. Staff at long term care facility changed [CONDITION(S)] out, patient coded. Subcutaneous [CONDITION(S)] tracking across neck and chest. Patient arrives without [CONDITION(S)] in place. R6's death certificate dated [DATE] documents under cause chronic respiratory failure and congestive heart failure. Facility policy titled [CONDITION(S)] Care version [DATE] documents: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway that aseptic technique is used during dressing changes until the [CONDITION(S)] is healed and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy titled: [CONDITION(S)] Emergent Management version [DATE] documents: It is the policy of this facility to prevent airway obstruction and if an obstruction occurs, to correct the airway obstruction quickly as possible in a safe and effective way in accordance with applicable rules and regulations and the standard of care. According to Respiratory Care [DATE], Volume 55 number 8 titled: When to Change a [CONDITION(S)] documents: Conventional practice recommends changing the tube ,d+[DATE] days following the placement. A surgically placed [CONDITION(S)] can include creation of cartilaginous flap, and the tube is secured to the neck by placing sutures through the flanges to the skin in addition to the [CONDITION(S)] ties. Stay sutures are usually placed to facilitate opening the stoma in the event of accidental decannulations and can be lifesaving in the event of a decannulation occurring in an obese patient with increased neck circumference. All sutures are usually removed at time of first tube change. It is important to remember first tube change can be associated with risk. Patient with increased neck circumference or elevated body mass index are at increased risk of having the tube placed into false passage in the anterior mediastinum. If this happens the patient can develop massive subcutaneous [CONDITION(S)] and [CONDITION(S)]. 2. R17 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 ambulance run report dated [DATE] documents at destination at 5:30 PM. Under Vital Signs at 5:28 PM documents : Blood pressure ,d+[DATE], Pulse 120, Respirations 14 mechanically assisted, 0xygen saturation at 100 percent. R17's Respiratory therapy assessment dated [DATE] at 6:39 PM documents under vital signs: Pulse 126, respirations 26 and oxygen saturation at 100%. Under description of breathing; rapid breathing with use of accessory muscles. Patient is resting comfortably. R17's nursing progress notes dated [DATE] at 7:30 PM documents: Patient was transferred from local hospital. Vitals signs; Blood pressure ,d+[DATE], Respirations 24, Pulse 120, oxygenation saturation 99% via vent/[CONDITION(S)]. Family made aware and verbalize She is now do not resituate and I want her to have enteral feeding while I process her hospice paperwork. R17's respiratory flow sheet dated [DATE] 8:30 PM with lock date [DATE] 7:20 AM documents by V18 (RT): Under vital signs pulse 120 beats per minute; respirations 36; oxygenation saturation 98% via ventilator. Under notes documents: Patient in respiratory distress, labored breathing, accessory muscle use. Nursing is aware of patient condition. On [DATE] at 2:53 PM, V24 (RT) who was the assigned respiratory therapist for R17 upon admission, said R17 arrived in distress and V24 administered a breathing treatment and repositioned resident which calmed R17. V24 said at the end of her shift (7pm), R17 was calm. R17's medical record did not document any respiratory treatments administered to R17 on [DATE]. On [DATE] at 11:49 AM, V18 (RT) who was assigned respiratory therapist to R17 from 7pm-7am said, R17 was in respiratory distress. She had an elevated respiratory rate and labored breathing. V18 said he informed the nurse, performed suctioning, and administered a breathing treatment. V18 said, R17 respiratory rate started to decrease and she appeared calm. R17's medical record did not document any respiratory notes after [DATE] at 8:30 PM. R17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's progress notes dated [DATE] at 09:09 PM by V25 (nurse) documents: Resident received in the room lethargic and breathing with accessory muscle, head of bed elevated, reposition and comfort care provided. Family made aware. Will continue to monitor. On [DATE] at 3:59 PM, V25 (Nurse) who was assigned to R17 on [DATE] said R17 arrived to the facility not in good condition, with no report or notice from the transferring hospital. R17's whole body appeared swollen, respiratory rate was rapid and abnormal around 28 breaths per minute. V25 said, R17 was fighting the ventilator. V25 said he notified V33 (MD) that R17's condition had deteriorated from previous stay at this facility and R17 had Do Not Resituate (DNR) orders. V25 said R17 was transitioning. When V25 was asked to clarify what transitioning meant, V25 said an increase in respirations, use of accessory muscles to breath and elevated blood pressure. V25 said R17's vent alarms kept going off and R17's blood pressure was high. V25 said he administered a blood pressure medication and R17 appeared to calm down. On [DATE] at 4:08 PM, V25 was asked to clarify what comfort care was provided to R17 per his progress note on [DATE] at 9:09 PM. V25 said it was not hospice comfort care. Staff changed her linen and incontinence product. V25 said the Respiratory therapist never informed him that R17 was in respiratory distress. V25 said it is not abnormal for a vent patient to have an elevated respiratory rate. V25 said they did not call 911 because R17 is a do not resuscitate. V25 said that a do not resuscitate status is hospice. R17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's February 2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 last documented blood pressure was at 7:30 PM ,d+[DATE]. There were no documented nursing assessments to reassess R17's status. R17's Hospital discharge date d [DATE] documents: [MEDICATION(S)] next dose due [DATE]. On [DATE] at 4:08 PM, V25 (nurse) said he administered [MEDICATION(S)] (blood pressure) medication to R17 on [DATE]. V25 said any medication administrated should be documented on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:03 PM, V33 (MD) said he does not recall being notified of any respiratory distress for R17. V33(MD) said he would expect staff to send resident to the hospital if any sign of distress and inform him of any change in condition. R17's progress notes dated [DATE] at 11:15 PM documents: Resident observed unresponsive. No pulse noted. No Blood pressure. No respiration, Temperature, 95.7, oxygen saturation 97% on [CONDITION(S)]/vent. Code status: DNR. Writer and staff Nurse called expired @ 11:10 pm. V33 (MD) made aware and Daughter made aware. On [DATE] at 3:59 PM, V25(Nurse) said he saw R17 about an hour before she expired with no concerns. V25 said around 11:00 pm, R17 was observed with no pulse, body was warm. On [DATE] at 11:49 AM, V18 (RT) said he checked on R17 again but unable to recall when. V18 said, later that shift the nurse got him to check on R17. R17 did not have a pulse and was cold. R17's death certificate dated [DATE] documents: chronic respiratory failure. On [DATE] at 2:53 PM, V24 (RT) who was the assigned respiratory therapist for R17 upon admission, said she did not setup the respiratory equipment in R17's room. V24 said the equipment was already set up in the room. V24 said they used ventilator circuit from transporting ambulance to connect R17 to facility ventilator. R17 ambulance run report dated [DATE] documents at destination at 17:30. Crew delayed due to facility not having vent ready. R17's Respiratory therapy assessment dated [DATE] 6:39 PM documents under ventilator serial number 6. During the survey on [DATE] at 11:00 AM, observation of ventilator number 6 (R17's ventilator on [DATE]) with document attached titled: Defective Equipment dated [DATE]. Under description of problem documents: Preventative maintanece is due ,d+[DATE]. Preventative maintanece sticker on unit documents due ,d+[DATE] or at 29,602 hours. On [DATE] at 2:33 PM, R17s ventilator ( 6) hours were at 32,800.8. Invoice dated [DATE] documents: Ventilator 6 documents blower replacement due at 30,000 hours. Preventative maintanece due ,d+[DATE] or 29,602 hours. On [DATE] at 11:57 AM, V35 (Ventilator Rep) said recommended ventilator maintenance is every 2 years or about 10,000 hours. Ventilator Machine can be used after maintenance date but it is not recommended due to parts can degrade over time and may cause issues with use. If ventilator was not working properly it would alarm that patient needs were not being met. Staff should conduct a leak test to see any concern with ventilator circuit (airway tubing that connects the ventilator and the patient) or ventilator settings prior to use. On [DATE] at 940 AM, V11 (Respiratory Therapy Director) said staff should check ventilator prior to use and perform leak test with the ventilator circuit that will be used on the patient. A leak test could not have been performed on R17's ventilator because we did not have any ventilator circuits at the facility. V11 said that R17's ventilator should not have been used because it was due for preventative maintenance and unsure why is was used on R17. Facility was unable to provide any documentation that any checks were done to R17's ventilator prior to use on R17. Ventilator manual revised [DATE] documents under maintence every 2 years or hour whichever comes first: replace internal battery, calibrate traducers, replace power board, and replace sounder assembly. A leak test Facility policy titled change in condition dated [DATE] documents: During medical emergencies such as unstable vital signs, respiratory distress, uncontrolled bleeding and unresponsiveness 911 will be notified for transport to the hospital. Facility policy titled ventilator set up dated [DATE] documents: residents who are ventilator dependent must have ventilation and oxygenation maintained; therefore the equipment must be ready and set up prior to arrival of the resident. Prior to arrival equipment function verified by therapist prior to resident arrival. The surveyor confirmed through observation, interview and record review that the following actions to remove the immediacy: The following actions have been initiated by Nurse Consultant, Respiratory Therapy Manager, DON, ADON, and Administrator: Education: All Licensed Practical Nurses, Registered Nurses, and Respiratory Therapists will be in serviced on the following topics which were initiated on [DATE] and completed [DATE].: 1) Following physicians' orders 2) Must have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 3) Changes in condition 4) Immediate Notification to MD NP or 911 Any symptom, sign or apparent discomfort that is: o Acute or Sudden in onset, and: o A Marked Change (i.e., more severe) in relation to usual symptoms and signs, or o Unrelieved by measures already prescribed Non-Immediate Notification o New or worsening symptoms that do not meet above criteria 5) Recognizing respiratory distress and assisting respiratory therapists. 6) Notification to 911 services when there is a sudden change in the resident's condition resulting in respiratory distress. 7) DNR code status to be followed, DNR is not hospice and change of condition policy must be followed for changes in resident condition- initiated ,d+[DATE] and will be ongoing to ensure that all new hires, all shifts, and all staff are in serviced. Agency staff will be in serviced by the DON, ADON, Supervisor on duty or Administrator upon arrival to the facility prior to reporting to the unit for work. Those who were unable to be in-serviced due to FMLA, vacations, etc. will not be permitted to work until the training has been completed. The following actions have been completed: 1) R17's ventilator has been removed from service since [DATE] and was checked by Midwest Biomedical Resources on [DATE] and is tagged out/locked out to ensure it is not utilized. 2) All Ventilator equipment has been checked and verified in working order and safety checks have been completed- Facility owned ventilators were checked by Midwest Biomedical Resources, Inc. on [DATE], and rented equipment was checked by [NAME] on [DATE] and [DATE]. 3) An audit tool was created on [DATE] to ensure that Ventilator equipment in use and for new admissions is within hours and PM has been completed. This will be completed by the Respiratory Director or respiratory therapist weekly with oversight from facility administrator. 4) Respiratory therapists received training and competency relating to ventilator equipment, exchanging of [CONDITION(S)], and [CONDITION(S)] care including need for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Competencies will be completed during new hire orientation for new respiratory staff and annually for all respiratory staff. 5) A lock out tag out was completed on [DATE] per existing facility policy for all ventilators that are not appropriate for resident use and will remain ongoing to ensure ventilators requiring service is not available for use with residents. 6) Ventilator circuits were purchased on [DATE] that are appropriate for the ventilators in use and facility will maintain a par level to ensure that circuits remain available. Agency staff will be in serviced by the DON, ADON, Supervisor on duty or Administrator upon arrival to the facility prior to reporting to the unit for work. Those who were unable to be in-serviced due to FMLA, vacations, etc. will not be permitted to work until the training has been completed. Education will be provided by regional nurse consultants, Respiratory company, Pulmonologist, DON, ADON, Supervisor on duty and Administrator, this education was initiated on [DATE] and completed on [DATE]: 1) Change of Condition 2) Utilization of 911 services 3) Checking ventilators for use. 4) Review of admissions and verification all equipment in place. 5) Physicians' orders 6) Carrying out physicians' orders. 7) Ventilator equipment checks 8) Replacement of [CONDITION(S)] Agency staff will be in serviced by the DON, ADON, Supervisor on duty or Administrator upon arrival to the facility prior to reporting to the unit for work. Those who were unable to be in-serviced due to FMLA, vacations, etc. will not be permitted to work until the training has been completed. Education will be ongoing to ensure that all new hires, shifts and all staff are in serviced. Moving forward this will be our standard of practice, therefore we have no end date. No changes to policies or procedures have been completed. However, the facility's expectation is that we monitor this practice 1x per week for 3 months with a QA tool that will be monitored by facility Administrator or designee. All findings will be reported to Quality Assurance for review. Last QAPI meeting to address F695 was held on [DATE].

Based on interview, and record review, the facility failed to follow their abuse policy by purchasing items on a resident's behalf without obtaining consent for one (R48) of four residents reviewed for misappropriation of funds. This failure resulted in R48 having her money spent on unwanted items purchased by the facility totaling $899.00 and the resident not being able to use the money to assist her family. Findings include: R48 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident's brief interview for mental status score dated 11/5/21 is 13. A score of 23 indicates cognitively intact. On 01/19/22 02:20pm, R48 alert, and oriented at time of interview said V7(Business Office Manager)BOM, asked her if she needed any clothing or items. R48 said she requested one pair of shoes and 2 jogging suits. R48 said she received socks, bras, dresses, 2 pairs of shoes and 2 blankets. R48 said she never asked for those items or approved the facility to purchase those items on her behalf. R48 said she only wanted the requested items and thought it may cost around 200 dollars for the items. R48 said she never would have approved a purchase for 899 dollars. R48 said she accepted the items because she felt she had to use the money so she could continue to receive her social security benefits. R48 said she did not want to spend that money on clothing and would have liked to give the money to her son. R48 said she did not need all that clothing because she had clothing and people donate clothing. R48 said she only wanted one pair of shoes and did not need any blankets because the facility provided blankets. R48 said her son is currently incarcerated and has been sending him money. R48 said she could of used the money to bond her son out and makes her anger and sad that she cannot help him. On 01/19/22 at 02:50 PM, V7 (Business Office Manager) said she asked R48 if she needed any items. V7 said she will order items from catalog and purchased items for R48. V7 said R48 approved purchase for 899.00 dollars but was unable to provide documentation that the order was approved by R48. V7 said R48 was not in any kind of spend down. Facility concern form dated 5/7/21 documents: Writer (V7) spoke to resident. Resident said that writer can purchase clothing. Facility document titled resident essential receipt documents: two cotton anklets for 30.00; seven bras for 150.00; best walking shoes for 79.00; stability walker shoes 85.00, two comforters for 150.00; 5 pullover muumuus for 210.00; 5 dresses for 240.00. Total of 899.00 dollars. R48's statement landscape documents on 5/11/21 personal needs items for 899.00 was removed from residents account. Facility abuse prevention program policy revised 6/21/20 documents: It is the policy of this facility to prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary or permanent, use of resident's belongings or money without residents consent.

Based on interview and record review, the facility failed to ensure residents who are dependent on staff for incontinence care were checked and changes at least every 2 hours and provide with assistance for proper personal hygiene. This failure affected 4 of 4 (R12, R33, R43, R160) reviewed for incontinence care. This Failure resulted in R12 not being changed in until the next day. R12 was left in feces and urine. R12 expressed feelings that demonstrated psychosocial harm to the resident. Findings Include: 1. On [DATE] 1:03 PM R12 light is on R12 states she needs to be changed she has not been changed since yesterday morning and she has had urine and bowel movement. R12 states she put on the light the last time around lunch. Someone came and said they would be back and never came back. At 1:07 pm V20, (CNA) states he is not working on the 3rd floor and states he just came up to check on R12 enters R12's room. V20 states he came to change R12. While R12's received care from V20, the surveyor observed R12's incontinence brief was stained from front to back with stool and urine. Stool and urine appear deeply saturated into the incontinence brief. The blue pad underneath resident was stained brownish. V20 looks at R12's incontinence brief and states it looks likes it has been sitting on R12 for 2 shifts. R12 had a sacral wound was healing. On [DATE] 10:07 AM R12 states when they left her all evening and all day without changing her, I felt s****y and wet. I felt bad and neglected because I was laying up in filth. They put me back there (in the COVID + unit) and forgot about me. On [DATE] at 11:00 AM V2 (DON) states residents should be cleaned up upon request or every two hours. V2 states nurses and CNA's are expected to do rounds. On [DATE] at 11:47 AM V22 (LPN) states she just got on the floor they called her up because they were short staffed. At 12:50 V22 states they were short staffed. V22 states It is a crisis. On [DATE] at 1:54 PM. V5 states for the ,d+[DATE] shift we don't have as many CNA's as were supposed to have. The 4th floor should have one CNA for ,d+[DATE]. There was no CNA on the 4th floor on the night of the 15th. On [DATE] at 11:35 V29 (CNA) states, we are normally short all the time. It is very rare that we get 2 CNA's on the 4th floor. On [DATE] at 2:40 PM V30 (nurse) states she did not have a nurse or a CNA the night of [DATE] to help her on the 4th floor. V30 states she wasn't able to get all her work done. V30 states, The lights were going off and there was no one there but me. Review of staffing for [DATE] for the 11 PM -7 AM documents no CNA scheduled on the 4th floor. Review of facility's Activities of Daily living policy documents the following: ADL Care is provided throughout the day, evening and night as care planned and/or as needed. Review of R12's MDS BIMS score is ,d+[DATE]. Review of R12's MDS section G documents R12 requires extensive one person physical assist for personal hygiene and toileting. 2. R33 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data set dated [DATE] section C (brief interview for mental status) documents a score of 9 which indicates moderate impairment, section G (functional status) documents: R33 requires extensive assistance with one person physical assist for toileting. Section H (bladder and bowel) documents: R33 is frequently incontinent with 7 or more episodes of urinary incontinence. Care plan initiated [DATE] documents: R33 had bowel and bladder incontinence. R33 will maintain a clean/dry and odor free appearance. On [DATE] at 11:47am, R33 had a strong smell of urine. R33 was observed lying in bed, soak and wet with an adult brief on, multiple large dried/wet, brown/yellow irregular shaped rings which covered the entire middle portion of R33's bed sheet. R33 was unable to report, the last time she was toileted/changed. V37 (nurse) said, I smell urine. R33 is soaked and wet with urine. R33 is confused. R33 is totally dependent on staff for toileting. The multiple large rings means R33 has not been provided incontinence care. R33 had multiple bladder incontinent episodes. R33 should have been toileted every two hours at a minimal. Activities of daily living policy not dated documents: Residents are given routine care to promote hygiene. Care is provide throughout the day, evening and night as care planned or as needed. Assist the resident. 3. R43 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data set dated [DATE] section G (functional status) documents: R43 requires total dependence with two plus person physical assist for toileting. Section H (bladder and bowel) documents: R43 is frequently incontinent with 7 or more episodes of urinary incontinence. Care plan initiated [DATE] documents: R43 has a mixed and functional bowel and bladder incontinent related to confusion impaired mobility and physical limitations. Check and change R43 every ,d+[DATE] hours. On [DATE] at 12:07pm, R43 had a strong smell of urine. R43 was observed lying in bed soak and wet with yellow and browns irregular rings underneath R43's body. R43's gown was wet on the right side leading up his back. R43 was unable to report the last time care was provided. V38 (cna) said, I smell urine. R43 is soak and wet with urine. Those stains are dried/ wet stains of urine. R43 is totally dependent on staff for toileting. R43 has not been provide any incontinence care. Activities of daily living policy not dated documents: Residents are given routine care to promote hygiene. Care is provide throughout the day, evening and night as care planned or as needed. Assist the resident. 4. R160 has the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimal data set dated [DATE] section G (functional status) documents: R160 requires supervision with toileting. Section H (bladder and bowel) documents: R160 is occasionally incontinent with less than 7 episode of incontinence. Care plan requested and not provided by the facility. On [DATE] at 9:22am, R160 had a strong smell of urine. R160 was observed with wet jeans on the right lateral hip and sitting in two wet/died yellow/brown irregular shaped rings. R160 was unable to report the last time he was toileted last. V5 (staffing coordinator) said, I smell urine. I see a brown/yellow wet rings. Staff did not provide any incontinence care. If care was provide, R160 would not have yellow/brown, wet/dried stains of urine. V27 (cna) said, I did not provide incontinence care for R160. Activities of daily living policy not dated documents: Residents are given routine care to promote hygiene. Care is provide throughout the day, evening and night as care planned or as needed. Assist the resident.

Based on observation, record review, and interview, the facility failed to follow their wound management program policy and procedures, failed to implement wound care as ordered by the physician and failed to assess and document evaluation of wounds for three (R73, R106, R164) of four residents reviewed for pressure ulcers. As a result, R106 was left being without wound treatment for 7 days to a stage 3 pressure ulcer to left inner thigh. Findings include: 1. R106 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/18/22 at 2:25PM, R106 observed in bed. R106 was on a pressure reduction mattress with pillow in-between lower legs. Pillow was observed with dried brownish/red circles. R106 had wound dressing to left hip and right lower leg. V28 (therapy director) was present and assisted R106 with moving lower extremities which where contracted into a fetal position. Upon assessment surveyor observed open area to left inner thigh. Wound bed was red and yellow in color and had depth to the area. At 2:31 PM, V13(nurse) said, R106 was on pressure reduction mattress not an air loss mattress. V13 confirmed that there was an open area to R106 inner thigh with no dressing noted in the bed or on the resident. On 1/18/22 at 2:34PM, V27 Certified Nurse Aide (CNA) said, was assigned to R106 on 1/18/22. V27 said, did observe any new open area to R106 and was unaware of open area to left inner thigh. On 1/18/22 at 2:44PM, V18 (wound nurse) said she was not aware of open areas to left inner thigh. V18 said R106 was seen and examined in the morning by wound doctor and herself and they did not observe area on left inner thigh. V18 said, open areas should be reported to the nurse, and wound care so treatments can be ordered. R106 should be placed on an air loss mattress due to wounds. V18 measured wound on left inner thigh to be 4cmx1.5cmx0.2 depth. On 1/19/22 at 5:46PM, V26(QA Nurse) said, the nurse who found the open areas on 1/11/22 should have placed orders on physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R106 treatment administration record for January 2022 documents treatment orders for left hip and right shin with start date of 1/15/22. R106's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R106's Braden risk review dated 1/14/22 documents a score of 16 which indicates a low risk for development of pressure ulcers. R106 Braden risk review dated 1/18/22 documents score of 13 which indicates moderate risk for development of pressure ulcers. R106's progress notes dated 1/11/22 documents: Writer noted skin laceration to left hip, left leg; left inner thigh, right lower leg, right inner lower leg, and small blister to middle of back. Cleansed with normal saline and applied dry dressing. MD made aware with new orders for wound care to assess and treat. R106's wound evaluation and management summary dated 1/18/22 documents: unstageable deep tissue injury to left lateral hip; unstageable deep tissue injury to right upper medial calf; wound to right shin. R106's medical record did not document any wound assessments prior to 1/18/22. Wound assessment dated [DATE] for left medial thigh documents a stage three wound measuring 4cmx1.5cmx0.1depth identified on 1/18/22 with moderate exudate. Facility wound management program undated documents: residents will have a visual inspection of their skin, the nursing assistant visually inspects the skin daily and with care. If an area is identified, the nurse will be notified. Under wound management: Identification of a new wound or pressure injury staff nurse will complete a skin and wound evaluation and document in the medical record. Wound nurse will complete a skin and wound assessment document wounds, measurements and wound assessment in the medical record. Under wound cleaning and dressing: It is the policy if this facility to perform wound dressing changes as ordered by physician using clean technique. Documentation of the dressing change is completed on the treatment administration record. 2. R73 is [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R73 is alert and oriented during interviews, cognitive scores intact. On 01/16/22 at 3:00 PM R73 said they have not been doing my dressings daily. R73 said the guy who does them is on vacation. R73 said my but dressing has not been changed in about a week. 01/16/22 03:15 PM V26, Quality Assurance Nurse, said floor nurses do their own treatment on the weekends. On 01/16/22 at 3:52 PM Surveyor observed wound care for R 73. V26 removed R73's abdominal dressing, no date on the dressing. V26 had difficulty removing the packing. V26 had to irrigate with saline to pry the packing off. Following the abdominal dressing V26 was assisted to turn R73's to perform his sacral dressing. The dressing was observed by surveyor as a square pad with adhesive and additional strips of tape had been applied to the dressing. Surveyor observed the dressing removed to have heavy, brown colored drainage, that saturated the dressing. On 01/17/22 at 12:06 PM V18, Wound Care Nurse, observed removing R73's abdominal dressing. V18 was able to remove the packing easily. Surveyor observed V18 provide sacral wound care. V18 removed the dressing. V18 said the dressing has moderate drainage on it. Surveyor observed dressing light tan in color. On 01/18/22 at 10:08 AM V31, Wound Doctor, said I expect the facility nurses to follow the wound care orders I have written for them. On 01/18/22 at 10:36 AM surveyor observed wound care on R73 with V18 and V31. Surveyor observed V18 easily remove the packing on R73's abdomen. Sacral dressing was removed and V18 said it has moderate drainage. On 1/19/2022 at 9:47AM V26, Quality Assurance Nurse, said if electronic medical record and treatment administration records are not documented on then it was not done. Nursing 101. Review of R73's Treatment Administration Record for January 2022 has no signatures on 1/9 and 1/15 for sacral and abdominal wounds. The facility undated policy for Wound Management Program notes Wound Cleansing and Dressings. It is the policy of this facility to perform wound dressing changes as ordered by the physician. 3. R164 is [AGE] years old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R164 was last seen by the wound doctor on 1/4/22 when left and right buttock stage 3 wounds were resolved. R164 is alert and oriented during interviews, cognitive assessment indicates he is intact. On 01/16/22 at 11:37 AM R164 said I have skin sores on my bottom. R164 said my wound care has not been done. On 01/16/22 at 3:16 PM R164 said no one has been back to me and did my wound dressing. R164 said no one is here to do them, the wound nurse is on vacation. On 01/16/22 at 4:01PM V9, Licensed Practical Nurse, said R164 doesn't have treatments to be done. V9 checked R164's orders while surveyor was speaking to her. Surveyor accompanied V9 to check R164's bottom side. When R164 turned onto his side 2 areas observed bleeding bright red blood and blood running down R164's right and left buttocks. On 01/17/22 at 1:23 PM V18, Wound Care Nurse, said today is her first day in the building. V18 said she had not been provided wound treatment to R164 today. V18 said she was not made aware that V18 has a new wound. Surveyor, accompanied by V18, observed one foam dressing on R164's left buttock and one on his right buttock. V18 removed the dressing and noted an open area on the left buttock. V18 said if someone has dressings on, then there should be a physician order. V18 said R164 has a superficial opening on top of his scar tissue. On 1/19/22 at 9:47AM V26, Quality Assurance Nurse, said when a new wound is observed the nurse is expected to look at the new skin alteration, assesses the wound, completed an incident report, call the doctor, initiate any order, and follow up with wound care, on the same day. V26 said regarding the Treatment Administration Record if it's not documented then it was not done, nursing 101. Review of R164's Braden skin risk assessment dated [DATE] states R164 is at high risk for skin breakdown. R164 is noted to be constantly moist and have limited mobility. Review of R164's Order Summary Report dated 1/18/22 note left buttock cleanse with normal saline, pat dry, apply [MEDICATION(S)] every shift. Order date 1/17/22 and start date 1/17/22 Review of Treatment Administration Record dated January 2022 has no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R164's Progress Notes have no note related to wound care on 1/17/22. Review of R164's Weekly Wound Evaluations dated 1/17/22 note Left Buttock Pressure Ulcer, stage 3, length: 2.5 width 2.0 depth 0.1. When was the wound identified 1/17/22. Right Buttock Pressure Ulcer stage 3, length1.3 width 1.0 depth 0.1. When was the wound identified 1/17/22. The facility undated policy for Wound Management Program notes upon identification of a new wound A.The staff nurse will complete a skin and wound assessment upon admission/readmission, identify any wounds, pressure injuries, or other skin abnormality, and document it in the medical record.

Based on observations, interviews, and records review, the facility failed to administer [CONDITION(S)] medications 2 of 4 days to one resident who has a known history of violence, aggressive and unstable behaviors. This applies to 1 of 32 resident (R158) reviewed for aggressive behaviors. This failure resulted in R158 hitting himself in the face with a closed fist multiple times, throwing items, and sustaining a wound to the lip. Findings include: On 01/16/22 3:35 PM, Surveyor observed R158 beating himself in the face and head, throwing things. Staff screaming no R158 and running behind the nurse's station. R158's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Give [MEDICATION(S)] 0.5MG two times a day related to anxiety disorder. [MEDICATION(S)] tablet 4 MG give 1 tablet by mouth two times a day related to [CONDITION(S)], Unspecified. Review of resident's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/19/2022 at 11:35 AM, V29 (CNA) states, I heard someone throwing something. I did my rounds and found it was R158. R158 was throwing stuff in his room. He went out of the room and started pacing. I asked what was wrong and he said he was agitated and then started punching himself in the face. He was punching himself with a closed fist. R158 busted his lip and had a little blood, a bruise, and a cut. We are normally short all the time. It is very rare that we get 2 CNA's. On 1/17/2022 at 10:00 AM, record review showed no mention of R158's incident. V1 (Administrator) did not learn of the incident until surveyor mentioned it and V1 said, she would investigate it. V1 returns to 1st floor conference room and states, nurse did not document anything and that nurse was asked to come in to document. Review of R158's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/16/2022 surveyor on the 4th floor between 11:00 AM and 3:40 PM and did not witness medications being passed by nurses. On 1/16/ 1:47 AM, V22 states, she just got up on the floor. She was pulled from the 2nd floor. On 1/16/2022 at 12:42 PM V22 states, someone called off and We are short staffed. It is a crisis. I have not given any medications yet. Surveyor looks with V22 at the residents on the floor and each one electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V22 states, she is going to call the medical director and ask if she can give the medications to the entire floor late. On 1/17/2022 at 12:11 PM, V23 states, sent R158 out for behavioral issues multiple times in the past. V23 states, he was not told that R158 had a violent outburst on 1/16/22. V23 states, with less medication R158 gets agitated quickly. V23 states, If R158 doesn't get his medication he will be a lot more problematic and very aggressive physically. V23 states, R158's outburst on 1/16/2022 can be related to not getting his medications. V23 states, he expects and prefers the facility call him if a resident has a violent outburst. V30 (LPN) was the evening nurse for R158 and did not return phone calls. On 1/17/2022 at 11:00 AM, V2 Director of Nurses(DON) states, nurses should be giving medications based on doctor's orders. V2 states, medications should be given an hour before or an hour after scheduled time. V2 states, 10 people gave medications yesterday. V2 states, V22 told her she gave medications on the fourth floor in the afternoon. Review of the facilities Medication Administration Policy and Procedure documents the following: Policy: unless otherwise specified by the physician, medications will be administered within 60 minutes before or after the facility's dosing schedule, except before or after meal orders and non -routine time ordered medications.

Based on interviews and records reviewed the facility failed to follow their abuse policy and prevent a resident-to-resident physical attack. Against 1 of 3 (R2) residents reviewed for physical abuse and failed to follow its abuse policy and prevent an incident of staff to resident verbal abuse for 1 of 3 R9 residents reviewed for verbal abuse. This failure resulted in R2 being physically assaulted by R1, R1 hit R2 over the head and in the face resulting bleeding from the face, a swollen bruised left eye. Based on interviews and records review, the facility neglected to provide incontinence care for more than 8 hours to one resident (R3) who is dependent on care for ADL's. This failure effected one resident (R3) of three residents reviewed for abuse/neglect. This neglectful act resulted in R3 verbalizing she felt abused and abandoned by the facility staff. Findings include: A.R1 is a [AGE] year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical history includes Nursing Facility Placement Assessment Summary dated 10/5/20 notes R1 had physical aggression, violence, and agitation. R1 physically attacked a nurse unprovoked. R2 is a [AGE] year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/21 at 12:20PM R1 said she has gotten into more than one fight with residents. R1 said I cracked R2 over the head and left her bleeding on the floor. On 12/14/21 at 12:30PM V6, Certified Nursing Assistant (CNA), said R1 has mental issues. V6 said she has seen R1 throw meal trays. On 12/14/21 at 12:38PM V4, Licensed Practical Nurse, said R1 is known to fight with other residents for nothing. V4 said R1 is sometimes angry, and we don't know why she is angry. V4 said he saw R2 after her altercation on 11/15/21 with R1. V4 said he saw R1 had black, dark color, discoloration under half her eye from the corner outward. V4 said R1 said R2 hit her. On 12/14/21 at 1:46PM V7, Social Service Director, said R1 and R2 had an altercation on 11/15/21 resulting in R1 sustaining a black eye. V7 said R1 has had altercations with other residents. On 12/14/21 at 2:21PM V8, Social Services, said R1 has had physical altercations with other residents. V8 said when one resident hits another resident it is abuse. On 12/15/21 at 10:34AM V18, CNA, said she was working on the unit with R1 and R2. V18 said she saw R1 hit R2. V18 said after R1 hit R2 she had a scratch over her left eye, and she was bleeding. V18 CNA said she was not given instructions when starting the shift with R1 related to interventions for behavior. V18 said she did not know R1 could be aggressive towards other residents. During a second interview at 12:15PM V18 said neither R1 nor R2 had been on one to one supervision prior to the incident on 11/15/21. On 12/15/21 at 11:18AM R2 said she was punched in the head and face by R1. R2 said she tried to talk to R1 and R1 kept walking away from R2. R2 said when she turned to walk away she tripped on her feet and fell . R2 said R1 then started hitting her. V18 said after being attacked the right side of her head was bleeding, she had contusions and bruises over her left eye and face. On 12/15/21 at 11:59AM V7 said R1 and R2 have had a previous physical altercation with each other. On 12/15/21 at 12:07PM V3, Quality Assurance Nurse, said on 8/3/21 R1 threw coffee at R2. V3 said following this incident R1 and R2 were separated to live on different floors. V3 said when R2 got hit on 11/15/21 both R1 and R2 were residing on the same floor. On 12/15/21 at 12:39PM V2, Director of Nursing, said she would separate residents involved in physical alterations by moving them onto separate floors. V2 said after an altercation resident should be on one-to-one supervision to ensure the safety of the other residents. On 12/15/21 at 1:20PM V17, CNA, said residents should not be hit by other residents. On 12/15/21 at 1:48PM V15, CNA, said she was assigned to work the floor where R1 and R2 had a physical altercation on 11/15/21, but she was not on the floor when the altercation happened. V15 said she did not know that R1 and R2 had had an altercation in the past. V15 said before R1 has a behavior outburst she can see her become tense. V15 said no residents were on one to one on the floor on 11/15/21 prior to the altercation. On 12/16/21 at 9:14AM V1, Administrator, said she investigated R1's and R2's altercation from 8/3/21 as a potential abuse investigation. V1 said the investigation did not substantiate abuse had occurred but the residents were separated by moving R2 to another floor. V1 said regarding R1's and R2's physical altercation investigation on 11/15/21 abuse was substantiated. V1 said the residents were residing on the same floor again, because one of the residents had requested to return to the floor. V1 said R1 and R2 are living on separate floors now. On 12/17/21 via phone interview V26, Doctor, said if there is bad blood between residents, such as a history of fighting or aggression towards each other, it would not be prudent to put residents in the same place. V26 said it was not a wise decision to place R1 and R2 on the same floor. R1 incident reported dated 5/12/21 notes R1 initiated physical aggression. Incident report dated 8/3/21 notes R1 threw liquid at R2. Incident report dated 11/15/21 notes R1 made physical contact with R2. The facility incident date report 11/15/21 notes R1 made contact with R2. The Abuse Prevention Program revised 01/2019 states It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitations, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Facility reported incident documents the following: It was reported that housekeeping staff V23 allegedly acted inappropriate towards Resident R9. Conclusion: The CNA staff overheard poor customer service being communicated towards resident R9. Based on findings the allegations were substantiated disciplinary actions taken. R9's social service progress note dated 12/8/2021 documents: Resident reported he was ok and the housekeeper was rude and verbally inappropriate. On 12/15/201 at 12:06 PM V5 (Housekeeping supervisor) states V22 (housekeeper) went to clean R9's room and she didn't knock on the door. He told her that and she had an attitude. V5 states a CNA witnessed V22 call R9 a name. On 12/15/2021 at 2:17 PM V23 (CNA) states it was after breakfast and he heard V23 (housekeeper) curse at R9 and say to R9 I don't care about this f****** job. You can report me if you want. On 12/16/2021 at 11:40 PM R9 states, the situation with the housekeeper (V22) was she was rude. She came in my room and turned on the light and didn't even knock on the door. I was just waking up and I asked her to come back in 10 minutes. She said, I'm going you fat M* F* and as she was walking out, she said I can't stand that fat M* F*. R9 states one of the staff heard her. R9 states V23 always had an attitude. R9 states regarding V23, she hurt my feelings. I felt disrespected and angry. R3's ADL Care plan documents: R3 has a Self-Care Deficit: Requires extensive to total assist with ADL's to maintain highest possible level of functioning as evidenced by the following limitations and potential contributing diagnoses; cerebral infarction, lack of coordination, and weakness. May resist ADL care at times. Last revision on 10/28/2020. MDS section GG dated 9/30/2021 documents on admission resident required: Partial to moderate assistance with Toileting. Staffing schedule for 12/14/2021 document 3 CNA's on the 3rd floor V11, V13, and V14. V26 (RN) states she was assigned to R3 on 12/14/2021. On 12/15/2021 at 1:22 PM R3 states I'm tired of begging staff to help me. I don't have a CNA every day or they didn't know they were assigned to me. R1 states, yesterday (12/14/2021) she didn't get her depends changed all day until 4:30 PM. R3 said, first they told me it was V14. V14 stated it was V11 (CNA). V11 never came to the room. R3 states, I'm persistent on my light and no one came to help me change until 4:30 PM. There was no supervisor. I requested a supervisor and they said she was in a meeting and was busy. On12/17/2021 at 1:58PM, R3 states I felt abandoned and abused because I can't help myself. I know it's not supposed to be like that. Staffing schedule for 12/14/2021 document 3 CNA's on the 3rd floor V11, V13, and V14. V26 Registered Nurse (RN) states she was assigned to R3 on 12/14/2021. On 12/15/2021 at 2:03 PM outside 1st floor conference room. V26 (RN) states she did not clean or help clean R3 on 12/14/2021. V26 states the CNA's clean the resident's up but the nurses will assist if needed. V26 states, she was R3's assigned nurse on 12/14/2021 for the day shift. On 12/15/2021 at 2:04 PM V13 (CNA) states she did not have R3 yesterday and did not change her. On 12/15/2021 at 2:05 PM V14 (CNA) states V14 states she worked on the 3rd floor during the 1st shift, but R3 was not assigned to her. V14 states R3 requires assistance with incontinence care. V14 states she cleaned R3 up during the evening shift. V14 states was told to clean R3 up. V14 states, she didn't see R3 before that. I did not change her during the day shift. When I changed R3, she told me she had not been changed all day. On 12/15/2021 at 2:51 PM V11 (CNA) states R3 didn't want me to care for her. R3 called me a devil. V11 states she did not change her during the shift. V11 states, she did not ask R3 if she needed anything. Surveyor askes V11, Did you ask someone to check on R3 during your shift? V11 states, Yes, I did, a supervisor from another floor checked on her. I don't know the name of the supervisor because I'm new. I don't know everyone yet. On 12/22/2021 at 11:50 AM V1 (Administrator) states it is her expectation that if R3 refuses care from one person then the facility would find someone else to help her. V1 states a couple months ago this started, and she went a couple days without anyone caring for her. The facility's Abuse Prevention Program Policy dated 1/2019 documents the following: it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and crime against a resident in the facility.

Based on interviews and records review, the facility neglected to provide incontinence care to one resident (R3) for more than 8 hours. This failure effected one resident (R3) of three residents reviewed for ADL Care. This failure resulted in R3 saying she felt abuse, and abandoned by facility staff. Findings include: On 12/15/2021 at 1:22 PM R3 states I'm tired of begging staff to help me. I don't have a CNA every day or they didn't know they were assigned to me. R1 states, yesterday (12/14/2021) she didn't get her depends changed all day until 4:30 PM. First they told me it was V14 CNA. V14 stated it was V11 (CNA). V11 never came to the room. R3 states, I'm persistent on my light and no one came to help me change until 4:30 PM There was no supervisor. I requested a supervisor and they said she was in a meeting and was busy. On12/17/2021 at 1:58PM, R3 states I felt abandoned and abused because I can't help myself. I know it's not supposed to be like that. On 12/15/2021 at 2:03 PM outside 1st floor conference room. V26 (RN) states she did not clean or help clean R3 on 12/14/2021. V26 states the CNA's clean the resident's up but the nurses will assist if needed. V26 states, she was R3's assigned nurse on 12/14/2021 for the day shift. On 12/15/2021 at 2:04 PM V13 (CNA) states she did not have R3 yesterday and did not change her. On 12/15/2021 at 2:05 PM V14 (CNA) states V14 states she worked on the 3rd floor during the 1st shift, but R3 was not assigned to her. V14 states R3 requires assistance with incontinence care. V14 states she cleaned R3 up during the evening shift. V14 states was told to clean R3 up. V14 states, she didn't see R3 before that. I did not change her during the day shift. When I changed R3, she told me she had not been changed all day. On 12/15/2021 at 2:51 PM V11 (CNA) states R3 didn't want me to care for her. R3 called me a devil. V11 states she did not change her during the shift. V11 states, she did not ask R3 if she needed anything. Surveyor askes V11, Did you ask someone to check on R3 during your shift? V11 states, Yes, I did, a supervisor from another floor checked on her. I don't know the name of the supervisor because I'm new. I don't know everyone yet. On 12/22/2021 at 11:50 AM V1 (Administrator) states it is her expectation that if R3 refuses care from one person then the facility would find someone else to help her. V1 states a couple months ago this started and she went a couple days without anyone caring for her. Facility's Activities of Daily Living Routine Care Policy and Procedure documents the following: Residents are given routine daily care and HS care by a C.N.A or Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day at intervals that are coordinated between the care giver and the resident.

Based on observation, interview and record review the facility failed to follow there practice for pressure injury prevention, and turn and reposition a resident every two 2 two hours, and failed to develop an individualized plan of care for off-loading a wound. This affects 1 of 3 residents (R8) reviewed for pressure injury. This failure resulted in R8 wound continued to worsen and developing necrosis that required surgical intervention of debridement. Findings include: R8 face sheet shows R8 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 MDS (Minimum Data Set) dated 09/29/21 shows R8 requires extensive assist and two plus person physical assist with bed mobility. Section C shows R8 rarely/ understood. Section M for skin condition shows R8 has a one stage 3 pressure ulcer/ injury and one stage 4 pressure ulcer/injury. On 12/14/21 at 11:39am V33 (R8 Family) said R8 is not turned every two hours and R8 has a pressure ulcer. V33 said the wound doctor informed her that R8 wound is getting better but she does not have details about R8's wound. V33 said R8 did not have the wound to the right thigh prior to admission to the facility. On 12/15/21 at 11:39 R8 was observed resting in bed, R8 observed resting on air mattress in static position, R8 has gastric tube feeding running at rate of 75militers hour, R8 observed to have [CONDITION(S)] connected to a ventilator. R8 was not alert. R8 is laying on her back, with lower body (hips, thighs, knees) resting to the right side. R8 was observed with a rolled cloth resting between R8 knees, and also a rolled cloth resting under R8 right knee. R8 has heel protector boots bilaterally. At 12:32p.m V29 (Nurse) provided wound care to R8's right thigh (back), R8 was observed to have a large wound to the back of R8's right thigh, the wound had 2 openings, the wound bed was observed with pink, tannish and faint black tissue, surrounding skin appeared to be R8's skin tone. After the wound care treatment, V29 placed R8 back in the same position at 12:42p.m. When V29 and V6 (Restorative Aide) turned R8, R8 was observed to be contracted in a fixed position, (there were no obvious range of motion observed). At 1:59p.m V11 (CNA-Certified Nursing Aide) said she was going to provide care to R8 with assist of V14 (CNA). At 2:02p.m when surveyor entered R8 room, V6 (Restorative Aide) said she was finished providing care and stated she repositioned R8. R8 was observed in the same position. V6 lift the sheet to allow for observation of R8's position, R8 was observed resting on her back, with hips and knees resting to the right side, R8 had a rolled cloth between the knees and a rolled cloth under her right knee. R8 was observed resting in the same position that that she'd been in since 11:39a.m. During this wound care observation, and review of R8's TAR and POS, R8 received wound care according to physician orders. On 12/16/21 at 1:15pm V11 (CNA) said she was the aide assigned to R8 on 12/15/21 on the 7:00am-3:00pm shift. V11 said residents are supposed to be turned and repositioned every two hours, V11 said turning and repositioning takes the pressure off the residents, and if the residents are not turned and repositioned the residents can get pressure ulcers. V11 said the resident position should change otherwise that's not repositioning. On 12/15/21 at 9:30am V9 (Wound Care Director) said if a resident cannot turn themselves, they should be turned and repositioned every two hours, V9 said 2 to 10 minutes is not enough time to allow for pressure relief to a wound, V9 said pressure relief should be for two hours. V9 (Wound Care Director) said the facility does not have a turn and reposition program, and that he checked that box because there were no other options for him to choose from for turning and repositioning. V9 said R8 is completely immobile and unresponsive and R8 requires assistance with turning and repositioning. V9 said the Braden review is completed to determine the residents risk for pressure ulcers and the care plan is completed based on the risk identified. R8 progress note dated 03/19/2020 shows in-part new admit, [AGE] year old from SNF, and eyes open, nonverbal, [CONDITION(S)] to ventilator. G-tube intact. BLE (bilateral lower extremities) contracted, with right great toenail discolored, no exudate, no swelling, surrounding skin intact, has open wound to right lateral ankle, no s/s of infection. MD (medical doctor) notified, new tx (treatment) order received, documented and provided to site. See wound assessment for further details. Spoke to resident mother and informed her of resident skin alterations, treatments and interventions in place and that d/t (due to) R8 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 mother verbalized appreciation and understanding of the information received. Resident on low air-loss mattress. Has BLE (bilateral lower extermity) heel protectors. Kept clean, dry, and repositioned every 2 hrs. Moisture barrier applied per incontinent episode. R8 wound evaluation and management dated 12/14/21 completed by V48 (wound care Physician), shows in part Site 1, stage 4 pressure wound of right thigh full thickness, etiology; pressure, stage;4, duration; 223 days, objective; healing, wound size is 11.2 centimeters in length by 4.9 centimeters in width by 3.1 centimeters in depth, surface area of 54.88 centimeters squared, undermining; 3 centimeters at 12o'clock position, moderate exudate, 10% thick adherent devitalized necrotic tissue, 90% granulation tissue, wound progress is improved, 10% thick adherent devitalized necrotic tissue, 90% granulation tissue, primary dressing treatment; [MEDICATION(S)] ointment apply once daily for 7 days: alginate calcium apply once daily for 16 days, secondary dressing -gauze island with boarder apply once daily for 16 days, and peri wound- skin prep apply once daily for 16 days. Site 2, wound right medial first toe full thickness, 1 day duration, objective; healing, surface area 1.15centimeters, moderate exudate, 100% granulation tissue. Plan of care reviewed and addressed; recommendations are to off load wound; reposition per facility protocol; sponge boot. Surgically excise 5.49 centimeters squared of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 3.2 centimeters and healthy bleeding tissue was observed. R8 weekly wound evaluation dated 12/7/21 shows in-part site- right thigh rear (35), pressure ulcer( pre-admission), stage 4, 11centimeters in length by 2 centimeters in width by 3.5 centimeters in depth, wound identified on 7/18/21, wound not healed, pain management in place, no tunneling, yes for undermining at 3 o' clock position, no [MEDICATION(S)] tract, exudate-serous, moderate, thin watery and foul, wound bed-non verbal, does not hurt, and is warm to touch, tissue type-90% granulation, 0% slough, and 10% necrotic, wound color is pink, yellow and red, peri wound is defined, with surrounding tissue is warm, comments- cleanse with NSS (normal saline), apply [MEDICATION(S)] ointment, loosely pack with alginate and skin prep with peri wound then cover with boarder gauze island dressing daily, treatment date 11/16/21, other interventions are pressure redistribution mattress, specific turning/repositioning program, nutritional supplements, vitamins, positioning devices, protein supplements, heel boots, low air loss mattress, wound debrided today, current wound status-seen today by wound doctor during weekly routine rounds at the facility. This site noted with improvement, no odor, resident on IV ABT (intravenous Antibiotics) family and physician notified, care plan reviewed and updated. R8 wound management summary (procedure summary) dated 12/21/21 shows in-part, surgically excise 3.92 centimeters squared of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed at a depth of 3.2 centimeters and healthy bleeding tissue was observed. R8 wound management summary (procedure summary) dated 07/27/21 shows in-part, surgically excise 13.00 centimeters squared of devitalized tissue and necrotic muscle and surrounding fascial fibers along with slough and biofilm were removed at a depth of 0.4 centimeters and healthy bleeding tissue was observed. R8's plan of care with initiated date of 04/13/2020 shows R8 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to impaired cognition/communication, incontinence of bladder/bowel, impaired mobility status, impaired nutritional status, vent and tract due to respiratory failure, and obesity. Location(s): 5/3/21 Right thigh (pressure ulcer), 7/20/21 right lateral ankle (pressure ulcer) (Healed 10/8/21), and 7/20/21 right distal 1st toe (paronychia) (Resolved 8/10/21). See the weekly skin notes for site, stage, measurements, progress, etc. Date Initiated: 05/03/2021 Created on: 04/10/2020. Revision on: 10/14/2021. The goal is R8's wound will show improvement as evidence by S/S (sign and symptoms) of healing thru next review unless the disease process causes further unavoidable deterioration. R8 will be free of any additional skin integrity issues, unless the disease process causes further unavoidable deterioration thru next review. Interventions- every day shift for wound care cleanse right great toenail with NSS ( normal saline), pat dry and apply triple ABT ( antibiotic) ointment then cover with dry dressing daily and PRN ( as needed) if dressing becomes loose/soiled, skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. Any skin integrity issues/concerns will be conveyed to the Charge Nurse for further evaluation and/or treatment changes/new interventions and the MD (medical doctor) will be called PRN. Pressure reducing/relieving mattress and W/C (wheel chair cushions) cushion as needed. Weekly measurements and documentation and monitor for S/S of infection and report to MD (medical doctor) as indicated. On 12/23/21 at 10:45am V2 (Director of Nursing) said care plan's are individualized to the resident needs, and the care plan are update as needed. Care Plan for R8 skin alteration plan of care does not address turn, reposition and off-loading R8's wound to the right thigh. R8 Braden review dated 10/28/21 shows Braden score of 8 (very high risk) for pressure ulcer development). Assessment type (other) Sensory perception unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. Or limited ability to feel pain over most of body surface. Constantly moist skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Bedfast: Confined to bed. Mobility -Does not make even slight changes in body or extremity position without assistance. Nutrition (adequate) - Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered or is on a tube feeding or TPN regimen which probably meets most of nutritional needs. Friction /sheer (problem) - Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contractures or agitation leads to almost constant friction. Facility policy Titled Care Planning and Procedure with last update of 04/2017 shows in-part each resident will have a comprehensive assessment completed that will assist in the development of an individualized plan of care that will include goals and interventions aimed to improve or maintain the resident highest level of function, prevent decline, decrease risk of complications of medical conditions, medication and diagnosis, decrease risk of injury or to promote comfort at end of life. The resident has the right to unless adjudged to be incompetent or otherwise found to be incapacitated under the law of the state, participate in planning care and treatment changes in care and treatment. The facility must have evidence that the resident and/or responsible party was afforded the opportunity to participate in care planning. It is the policy of the facility to assist residents to participate. Each resident will have a comprehensive assessment complete by the Interdisciplinary team upon admission, quarterly and with significate changes and an individualize care plan will be developed and updated as needed with quarterly assessments, readmissions and changes in condition. Facility policy Titled Wound Management Program date 05/19/2017 shows in part the purpose of the wound management program to ensure our residents have access to the appropriate assessment and management in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Risk and assessment- the purpose of this policy is to establish consist and objective method of assessing the residents risk for pressure injury development and to implement a standardized plan of pressure injury prevention based upon reliable and valid assessment of pressure injury risk. Pressure Injury Prevention- it is the policy of this facility to implement measurements to protect the resident's skin integrity and prevent skin breakdown whenever possible. The purpose of this policy is to establish and provide consistent measures for the prevention of pressure injuries based upon the assessment of pressure injury risk. The procedure shows this facility will implement interventions based upon the results of the skin risk assessment. Resident who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. Etiology of the wound- a pressure injury is a lesion caused by unrelieved pressure that results in damage to the underlying tissue. Wound Cleansing and Dressing-It is the policy of the facility to perform wound dressing changes as ordered by the physician using clean technique on all chronic or contaminated wounds. A moist wound environment is most favorable for optimal healing. On 12/21/21 at 5:27pm V48 (Physician) said a resident should be turned and repositioned every two hours, and every two hours are standard practice from CMS and the national pressure injury advisory panel recommendation. V48 (Physician) said 2 to 10 minutes is not enough time for off laoding, and the standard is 2 hours for off loading. V48 said it is her expectation that the residents are turned and repositioned very two hours to allow for off-loading of the wound. V48 said when a pressure wound is not offloaded (relieved of pressure) it causes lack of oxygen to the tissue, which in turns cause the tissue to become necrotic. V48 said necrotic tissue has to be debrided. V48 said [MEDICATION(S)] is not a bad thing because it expose viable tissue to promote wound healing. V48 said if a resident is not turned and repositioned to wound off-loaded every two hours, it contributes to impeding wound healing. V48 said there are 3 factors that contribute to impeding wound healing, which are pressure, lack of oxygen, and biofilm. V48 said a lack of oxygen causes the tissue to die and become necrotic, biofilm cause bacteria (which contribute to infection) and pressure is micro injuries. V48 (Physician) said on July 27, 2021, R8 stage 2 wound was debrided to reveal a stage 4 pressure injury. V48 acknowledge that alginate calcium with silver was ordered on 07/20/21 to promote wound healing, V48 said it is her expectation that the treatment orders are implemented. V48 said alginate calcium with silver is an absorbent (of exudate), antimicrobial, and [MEDICATION(S)] wound treatment.

Based on interview and record review the facility failed monitor the g-tube site to prevent an avoidable accident while providing direct care to 1 of 3 resident (R12) reviewed for avoidable accidents. This failure resulted in the g-tube becoming dislodged during incontinence care requiring R12 to be sent to the local hospital to have the g-tube replaced. Based on interviews and records reviewed the facility failed to effectively monitor and supervise a resident with a history of aggressive behaviors for 1 of 3 residents (R1) reviewed for supervsion. This failure resulted in R1 striking a co-resident (R2) over the head and in the face resulting in brusing and swelling to R2's left eye. Findings include: 1. R12 diagnosis include [CONDITION(S)] affecting the right side, encounter for gastrostomy. R12 progress notes dated 9/29/21 shows resident g-tube (gastric tube) observed dislodged from abdomen. Resident is currently on a pureed diet with honey thicken liquids with a good appetite usually consumes 100% of meals and fluids. V46 (Physician) made aware. Order for a 3 day calorie count put in place. Nursing staff will continue to monitor. V46 gave order to send resident to emergency room for g-tube replacement. On 12/22/21 at 1:45pm V14 (CNA) said on 9/29/21 during incontinent care, R12 gastric tube was accidently pulled out when she turned R12 and to remove the soiled linen from under R12. V14 said she did not look and make sure R12 gastric tube was in a position so that it would not get pulled out. V14 said she should have checked and made sure the gastric tube was out of the way, during care, so that the tube is not pulled out. V14 said she immediately reported this to the director of nursing at that time. V14 said she remember that R12 had to go to the hospital after his g-tube was pulled out. V14 restated that it was an accident. On 12/23/21 at 10:45am V2 (Director of Nursing- DON) said the aide/nurse should make sure make they observe the position of the g-tube before initiating care, turning and repositioning, so that they can know where it is and before doing care, they should ensure the g-tube is secure and out of the way so that the g-tube is not pulled out and or dislodged. V2 said the gastric tube is delicate and it can be pulled out causing discomfort. V2 said if the tube is pulled out the resident would have to have it replaced. On 12/22/21 at 2:00pm V3 (Quality Assurance Nurse) said she remember something about R12 gastric being pulled, and the DON at that time doing an inserve with the aides. V3 presents an in-service dated 9/29/21 showing the aides were in-service on ensuring all g-tube are properly labeled per MD orders, G-tube site monitored for any s/s ( signs / symptoms of infections, and ensuring all residents with g-tubes are safely repositioned and g-tube visible during care. V14 and V47 (CNA) name is not noted on the in-service training staff education document. 2. R1 is a [AGE] year old with diagnosis including, but not limited to [CONDITION(S)], Depressive Disorder, Anxiety, [CONDITION(S)], [CONDITION(S)], and Delusional Disorders. R1's medical history includes Nursing Facility Placement Assessment Summary dated 10/5/20 notes R1 had physical aggression, violence, and agitation. R1 physically attacked a nurse unprovoked. R2 is [AGE] year old with diagnosis including, but not limited to Schizoaffect Disorder, Depressive Disorder, and Anxiety Disorder. On 12/14/21 at 12:20PM R1 said she has gotten into more than one fight with residents. R1 said I cracked her (R2) over the head and left her bleeding on the floor. R1 said she hit R2 because R2 threw a chair at her. On 12/14/21 at 12:38PM V4, Licensed Practical Nurse, said R1 is known to fight with other residents for nothing. V4 said R1 is sometimes just angry and we don't know why she is angry. V4 said he saw R2 after her altercation on 11/15/21 with R1. V4 said he saw R1 had black, dark color, discoloration under half her eye from the corner outward. V4 said R1 said R2 hit her. On 12/14/21 at 1:46PM V7, Social Service Director, said R1 has had altercations with other residents. V7 said she did not witness the altercation. On 12/14/21 at 2:21PM V8, Social Services, said R1 has had physical altercations with other residents. V8 said he did not witness the altercation. On 12/15/21 at 10:34AM V18, CNA, said she was working on the unit with R1 and R2 on 11/15/21. V18 said the altercation happened across from the nurses' station. V18 said she saw R1 on R2, R1 was hitting R2. V18 said she did not see what provoked R1. V18 said after R1 hit R2 she had a scratch over her left eye and she was bleeding. V18 said she did not know R1 could be aggressive towards other residents. During a second interview at 12:15PM V18 said she did not see or hear a chair having been thrown. V18 said neither R1 or R2 had been on one to one supervision prior to the incident on 11/15/21. On 12/15/21 at 11:18AM R2 said she was punched in the head and face by R1. R1 said she had thrown a chair at R2 because R1 kept walking away when R2 tried to talk to her. R1 said when she turned to walk away she tripped on her feet and fell . R1 said R2 then started hitting her. V18 said after being punched the right side of her head was bleeding, she had contusions and bruises over her left eye and face. On 12/15/21 at 11:59AM V7 said R1 and R2 have a history of physical aggression prior to 11/15/21. On 12/15/21 at 12:07PM V3, Quality Assurance Nurse, said on 8/3/21 R1 threw coffee at R2. V3 said following this incident R1 and R1 were separated to different floors. V3 said when R2 got hit on 11/15/21 R1 and R2 were residing on the same floor. On 12/15/21 at 12:39PM V2, Director of Nursing, said after an altercation residents should be on one to one supervision to ensure the safety of the other residents. V2 said the sound of a chair being thrown should cause staff to react because a chair being thrown is a warning that something is about to happen. On 12/15/21 at 1:48PM V15, CNA, said she was assigned to work the floor where R1 and R2 had a physical altercation on 11/15/21, but she was not on the floor when the altercation happened. V15 said she did not know that R1 and R2 had had an altercation in the past. V15 said no residents were on one to one on the floor on 11/15/21 prior to the altercation. On 12/16/21 at 9:14AM V1, Administrator, said she investigated R1's and R2's altercation from 8/3/21 as a potential abuse investigation. V1 said the residents were separated by moving R2 to another floor. V1 said regarding R1's and R2's physical altercation investigation on 11/15/21 abuse was substantiated. V1 said the residents were residing on the same floor again, because one of the residents had requested to return to the floor. On 12/17/21 via phone interview V26, Doctor, said if there is bad blood between residents, such as a history of fighting or agression towards each other, it would not be prudent to put residents in the same place. V26 said it was not a wise decision to place R1 and R2 on the same floor. R1's incident report dated 5/12/21 notes R1 initiated physical aggression. Incident report dated 8/3/21 notes R1 threw liquid at R2. Incident report dated 11/15/21 notes R1 made physical contact with R2. R1 facility census dated 10/4/21 notes R1 was moved to the same floor as R2. The facility incident date report 11/15/21 notes R1 made contact with R2. R1's care plan date initiated 11/26/20 notes 10/05/20 per PASSR screen R1 has several arrests for property damage, aggravated battery, assault with deadly weapon, and verbally threatening to shoot a policy officer. R1's care plan date initiated 5/20/21 notes difficulty controlling anger and depression, feelings of paranoia, loss of control, misinterpretation/misperception secondary to mental illness. Interventions include staff will redirect behavior. R1's care plan initiated 11/26/20 notes R1 displays conflictual, difficult behavior as manifested by covert/open conflict with or repeated criticism of staff. Conflict/anger toward family/friends, unprovoked expressions of anger towards staff and peers. These behaviors are related to poor and ineffective coping skills and psychiatric illness. The Abuse Prevention Program revised 01/2019 states It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitations, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interview, and record review, the facility failed to follow their mechanical lift transfer policy by using a defective transfer sling to safely transfer 1 of 1 (R2) reviewed for safe transfers. This failure resulted in a sling strap breaking and R2 falling from the mechanical lift to the floor, where R2 sustained a fracture to right femur. Findings Include: R2 was admitted with the diagnosis of aftercare for joint replacement surgery, [CONDITION(S)], Heart Failure, Hypertension, Muscle wasting and atrophy, lack of coordination, generalized weakness, unsteadiness on feet, peripheral vascular disease, atherosclerosis of native arteries of extremities with rest pain, bilateral legs. Brief interview for mental status dated 9/29/21 documents a score of twelve which indicates moderate cognitive impairment. Section G (functional status) dated 9/29/21 documents: R2 requires total dependence with two plus person physical assist with transfers. R2's functional limitation in range of motion documents impairment on both sides of both upper and lower extremities. Care plan initiated on 11/01/19 documents: R2 required total assistance with two staff for transfer using a lift. Ensure equipment is safe and in good repair. Staff will follow the facility lift policy to ensure safety and correct procedure with use of equipment. Check for signs of fraying, loose threads and or stains, the sling must not be utilized until repaired or replaced. Progress note dated 10/2/21 document: R2 was discharged to the hospital for bilateral fractures to the lower extremities. On 10/7/21 at 11:42am, R2 who was assessed to be alert to person, place, and time said, I fell from the lift. The top part of the sling popped. The strap broke. I was not moving around. On 10/7/21 at 12:29pm, V6 (CNA) said, we used a blue mesh shower sling with the hole in the middle for the buttock. We hooked R2 to the lift, turned R2 to the side. R2 started fidgeting. R2 was scared, R2 tightened her body up while in the sling. The lift tilted over, one leg tilted in the air off the ground and the neck of the lift landed on R2's bed. I tried holding R2 from underneath but couldn't. R2 fell on the floor. R2 fell because she was moving and putting more weight and pressure on one side of the sling. We have lifts that can hold up to 450 pounds and or 600 pounds. On 10/7/21 at 1:20pm, during the tour of the laundry room, numerous of clean slings were noted hanging on the wall ready to use, one blue sling was noted hanging with broken loops, and straps. Another blue sling was noted in the completed washed cycle with white clothes and place in the dryer by V11 (laundry). On 10/8/21 at 11:19am, V8 (CNA) said, we used the mesh sling with the hole in the middle. R2 was pushing and pulling against us. R2 kept moving and wiggled out of the lift pad. The lift tilted over. R2 kept saying she was hurting. R2 was trying to reposition self, the sling was probably hurting the back of R2's leg. R2 fell in a sitting position. We put another pad under R2 to get her up off the floor. I threw the pad, the initial sling R2 used in the trash, I didn't want anyone else to get hurt, it was a discolored older sling, and the hole may have expanded with R2's weight causing resulting in a fall. I got a stronger pad to get R2 off the floor. Restorative, and laundry are supposed to check the pad for wear, and tear and the straps for sturdiness. I don't know why we didn't put R2 back over in bed. On 10/8/21 at 12:07pm, V2 (DON) said, I conducted the investigation, and interviews. V16 (nurse) said, R2 was on the floor and one of the straps on the sling broke. R2 wiggled, the lift leaned to one side and one of the straps broke. R2 was not under the sling when R2 was on the floor. Staff got another sling to get R2 off the floor. Certified nursing assistant (CNA) and laundry personnel are supposed to check the slings after washing and the CNA must check it prior to use. I have not received any report about R2 being restless or wiggling in the lift before this fall. They should have put R2 back in bed if she was wiggling and moving while on the lift in the sling. R2 weighed 159 pounds. On 10/8/21 at 12:35pm, V12 (restorative nurse) said, I interviewed R2 after the fall. R2 reported being told the sling broke which is why R2 fell . The sling was not functional and it broke. V16 (nurse) documented, the sling broke. I would have used the mesh sling for the shower but not the mesh sling with the hole positioned at the buttock. The mesh sling with the hole is for toileting residents. If a resident is using the lift, they will have poor truck control and the inability to sit on the toilet which is why the blue mesh sling with the hole should have not been used for transferring R2. On 10/08/21 at 3:55pm, V1 (administrator) said, I fired V10 (laundry) for not inspecting the slings. On 10/12/21 at 11:28am, V23 (director of housekeeping) said, we are meticulous about going through the sling daily looking for holes for fraying, loose threads, and broken straps. Once we find any affected sling it would be removed. Slings cannot be put in the dryer. We don't dry the slings to prevent any heat damage to the material. We wash the slings separately to decrease contamination. The slings should not be washed with white clothing. The temperature to wash the sling is 100-degree Fahrenheit (F) for ten minutes. White clothes are washed at 120-140F for twenty minutes. Nursing note dated 9/30/21 document V16 (nurse) was call by CNA to observe and assess R2 on the floor. V16 was informed R2 fell in the process of transferring with the lift. Incident report dated 9/30/21 documents: During lift transfer, R2 fell from the lift and landed on buttock. Witness statement dated 10/1/21 documents: V2 (DON) interviewed with V16 (nurse). V16 (nurse) said, R2 was placed back in bed with another pad, and sling. The other sling, and pad may be damaged. R2's CT scan dated 10/1/21 documents: Minimally displaced comminuted (fracture in which the bone is splintered or crushed into numerous pieces) fracture of the right femur (thigh bone). Mildly comminuted oblique (slanting) fracture of the left femoral. Final reportable dated 10/6/21 documents: R2 sustained an injury as a result of a fall during a transfer. R2 began making abrupt jerky like movements, while in the lift, causing R2 to fall onto the floor. R2's electronic record did not document any behaviors related to R2 wiggling and moving in the sling prior to this incident. Employee Disciplinary action Form dated 10/7/21 documents: V10 (Laundry) was terminated for policy violation and performance/quality of work. Hospital paperwork dated 10/1/21 documents: R2 fell on to her bottom from the electronic lift. R2 had some mild buttock and hip pain afterwards. CT scan documents: R2 has a fracture of left femoral diaphysis (the main or midsection (shaft) of a long bone and comminuted (bone broken into three or more piece) fracture of RIGHT femur (thighbone, upper bone of the leg). Mechanical Lift Transfer Policy revised 10/10/11 documents: To assure that all residents that are assessed to require extensive assistance and or total assistance in transfer are transferred safely with no injury to resident. Inspection of the sling: The lift sling should be inspected after each laundering session.

Based on interview, and record review, the facility failed to follow their Abuse Prevention Policy, and failed to monitor and implement appropriate interventions to keep a resident safe from physical abuse for 1 of 3 residents (R1) reviewed for abuse. This failure resulted in R1 being hit by R2 during aa verbal altercation causing the resident to fall and sustain a laceration to the left eyebrow. Findings Include: The Facesheet documents that R1 is a 59 - year old resident admitted to the facility with a [DIAGNOSES REDACTED]. Incident Report dated 3/16/21 documents that R1 was in a verbal altercation with R2 and was hit by the resident causing R1 to fall. R1 was observed on the floor with a laceration to the eyebrow. R1 was sent out to the hospital for evaluation and required four sutures. R2 was placed on 1:1 monitoring and was hospitalized for [REDACTED]. Nurse's Notes dated 3/16/21 documents that staff was alerted to the resident's room by a loud sound. R1 was observed on the floor bleeding from the forehead. R1 tried to get up and walk against staff's orders and was observed to be weak, and unsteady. R1 was assisted to the floor, pressure applied to the resident's forehead until the paramedics arrived. Social Service Notes dated 3/17/21 documents that R1 admitted to staff that there was an incident of aggression between R1 and R2. The residents' were separated and R1 was relocated to a different room. R1's care plan documents that the resident is at an increased risk for abuse related to a history of behaviors. The Brief Interview for Mental Status (BIMS) Score dated 1/20/21 documents that R1 scored 13 out of 15 and is cognitively intact. R1's Minimum Data Set ((MDS) dated [DATE] documents that the resident has an unsteady gait and ambulates with a cane or wheelchair. Nurse's Notes dated 3/2/21 documents that R2 had an argument with a peer while standing in line and hit the resident without warning. Staff intervened and separated the residents. R2's care plan documents that the resident has conflict with staff and other residents' related to open criticism and unprovoked expressions of anger. On 3/23/21 at 2:55pm R1 was observed lying in bed with a laceration to the left eyebrow. R1 stated I got this scar on my head because R2 hit me and I fell and hit my head on the floor. R2 has never hit me before. I feel safe in the facility now since the resident is gone and they moved my room. On 3/23/21 at 12:05pm V2 (Social Service) stated After the incident I interviewed R1 and the resident was reluctant to say what happened. R1 did admit to being hit by R2 after having a disagreement while being in the resident's room. R1 fell and there was a laceration over the eye and the resident was sent to the hospital. The residents' were separated and R2 was counseled and placed on 1:1 monitoring until the resident was transferred to the hospital for a psychiatric evaluation. The Abuse Prevention Policy documents that the facility will prohibit and prevent resident abuse, neglect, exploitation, mistreatment, misappropriation of resident property and a crime against a resident in the facility.

Based on interviews, and record reviews, the facility neglected to assess a resident found on the floor, next to the bed after an avoidable fall incident. The facility also neglected the resident by walking around the resident leaving the morning medication at the bedside, and documented in the nursing notes that the resident was sleeping on the floor. This affected one of four (R2) residents reviewed for neglect. These neglectful actions resulted in R2 being left on the floor for over 2 hours until morning staff found R2 on the floor. R2 told staff that R2 had fallen the night before attempting transfer to the bed from the wheelchair. R2 was assessed at the hospital and diagnosed with [REDACTED]. This situation was identified as an immediate jeopardy. The immediate jeopardy began on 10/06/2020. The immediate jeopardy was identified on 01/14/2021. The Administrator was notified on 01/27/2021. The surveyor confirmed by observation, interview, and record review, the immediate jeopardy was removed on 02/04/2021 but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff in-services). Based on interviews, and record reviews, this facility failed to ensure the safety and well-being of a resident, and prevent the physical assault of a resident to resident attack for one of four (R4) residents reviewed for physical abuse. This failure resulted in R4 being hit in the left eye by another resident's closed fist without provocation. R4 sustained bruising and swelling to left eye. Findings include: R2: Review of the medical record notes R2 with [DIAGNOSES REDACTED]. On 1/8/2021 at 2:45pm, R2 stated that on 10/7/2020 at 11:00pm, R2 fell while attempting to self-transfer from R2's wheelchair to bed. R2 stated that the CNA (Certified Nurse Aide) unlocked R2's bed brakes while changing bed linen and forgot to activate the bed brakes when done causing R2 to fall later that day. R2 stated that staff did not round on R2 during the night. R2 stated that R2 laid on the floor until the day shift staff found R2 between 8:30am and 9:00am the following morning. On 1/12/2021 at 4:30pm, V5 RN (Registered Nurse) stated that V5 received report on 10/7/2020 from the off-going nurse, but was not informed of R2's fall during the night. V5 stated that while V5 was rounding on V5's assigned residents, V5 found on R2 on floor. V5 stated that R2 is alert, and oriented times three. V5 stated that when R2 fell , R2 was unable to reach the call light cord. V5 stated that R2's call light cord was at the head of the bed and R2 was on the floor at the foot of the bed. V5 stated that R2 informed V5 that R2 fell during the night. V5 stated that R2 is paraplegic and has decreased sensation to lower body; did not complain of right leg pain. Review of R2's medical record, dated 10/7/2020 at 8:54am, V5 RN (Registered Nurse) noted R2 is alert, and times four. R2 was observed on the floor in R2's room, R2 was alert, and responsive. R2 was assessed for signs of fractures, altered level of consciousness and neurological alterations, no changes/impairments observed. Head to toe assessment completed. R2 within R2's baseline function. No signs/symptoms of distress. R2 denies any pain at this time. No grimace noted. R2 was transferred to bed with staff assistance. R2 reports that R2 fell trying to get in bed, upon skin assessment bruising noted to upper back, upper arm, and upper body (front). Vital signs: blood pressure 90/60, pulse 114 beats/minute, respirations 16 breaths/minute, temperature 97.2 degrees Fahrenheit, oxygen saturation level 98% on room air. R2's physician notified, orders received for X-ray of left arm and lumbar-sacral spine, orders noted, family member contacted but unsuccessful. Staff will continue to monitor. R2's incident report, dated 10/7/2020, was reviewed. V31's LPN (Licensed Practical Nurse) statement notes V31 went into R2's room at 6:00am to give R2 medications and R2 was laying on the floor with pillow behind head. V31 noted R2 gets in and out of wheelchair by himself. V31 thought R2 got down on floor by himself. V31 left R2's medication and left R2's room. V31 noted V31 did not do a fall assessment. V32's TNA (Temporary Nurse Aide) statement notes V32 did not know V32 had to round on residents every two hours. V32 did not check on R2 until 5:00am when V32 observed R2 on the floor. V32 did not assist R2 back to bed. V33's TNA statement notes V33 rounded on residents at 5:00am when V33 was assisting residents. V33 did not round on R2. V34's CNA (Certified Nurse Aide) statement notes when V33 came in at 6:30am, V31 LPN informed V34 that R2 was on the ground sleeping. R2's statement notes R2 slipped out of wheelchair to the floor. R2 did not see any staff until 6:00am. V31 LPN left medications. V31 asked if R2 was okay and left R2's room. R2 notes R2 slipped onto buttocks and sustained scratches due to hitting wheelchair. R2 leaned up and grabbed pillow and sheets off bed and stayed on the floor. V31, V32, and V33 were unavailable for interview during this survey. Review of R2's MDS (minimum data set), dated 12/26/2020, notes R2's BIMS (brief interview of mental status) score is 14 out of 15. R2's falls risk review, dated 10/19/2020, notes R2 is at high risk for falls. Review of R2's incident report, dated 10/16/2020, notes R2 was transported to the hospital due to change in condition. Facility received a call from hospital stating R2 has a fractured right femur. This facility determined fracture due to fall on 10/6/2020. R2 returned to this facility after surgical intervention to repair right femur fracture. Review of R2's falls care plan, initiated 2/8/2020, notes R2 is at risk for falls related to [MEDICAL CONDITION], decreased strength and endurance. Interventions identified include: R2 educated on the importance of using call light for assistance, be sure call light is within reach, staff to respond promptly to all requests for assistance, and anticipate and meet the needs of R2. The immediate jeopardy that began on 01/27/2021 was removed on 02/04/2021 when the facility took the following actions to remove the immediacy: Landmark of Richton Park Removal Plan The nursing staff will be re-inserviced on the fall protocol by the Nurse Consultant/designee which will include: what constitutes a fall, proper supervision, assessments, notifications, interventions, providing immediate assistance as needed, high fall risk symbols, completing the fall assessment, post fall meetings and proper documentation that is to be completed post fall. The education was conducted on 1/27/21 at 1pm, 3pm and completed 2/4/21. Any employee who is on vacation will be inserviced prior to returning to duty by the Consultant/designee 1/27 and on-going. Any employee who has not been inserviced will be educated via the phone and a signature will be provided upon return to the facility prior to reporting to their assigned area. 2/4 and on-going All residents were reassessed by the MDS coordinator to determine if they were at risk for fall risk. 1/26/21 and on-going. Any new and re-admission will have a fall risk assessment completed the licensed staff to identify if they are at risk. The fall assessments will be completed quarterly and as needed. This process is on-going. The DON will provide a list of residents who has been identified as risk for falls. The list will be updated daily by the DON as needed to indicate residents who are at risk for falls. The list will be updated according to the results of the assessment that are done upon admission/readmission or if the a fall occurs. The list will be kept at each nursing station in a binder. Completion date of 2/4/21. The maintenance department will be inservice on ensuring that the beds are locked and properly working. 2/4 ongoing The Maintenance Director will check all beds in the facility to ensure that the wheels are secure, and they are properly working., 2/4 on-going The restorative nurse consultant will identify residents who are at risk for falls via a smiling symbol located above resident's beds, 1/26 and on-going An immediate assessment will be initiated by the licensed staff nurse if a resident experience a fall. 1/26 on going. A fall and pain assessment will be completed post each fall by the licensed staff. 1/27 ongoing. The DON will complete an audit tool post falls to verify that the residents were assessed, and a proper intervention was put in place,1/26 and on-going. Angel rounds will be conducted by the interdisciplinary team twice daily, using an audit tool to indicate that residents are properly supervised, 2/4 ongoing. b. R4: On 1/12/2021 at 3:15pm, V3 (social services) stated that V3 knows R5 from R5's prior facility. V3 stated that R5's behaviors can be stable one minute and then change quickly; R5 reacts to internal and external stimuli. V3 stated that on 12/18/20, R5 informed V3 that R5 does not remember the event of running through the halls on the nursing unit and hitting another resident; only remembers what staff told him. On 1/12/2021 at 4:45pm, V6 LPN (licensed practical nurse) stated that R4 is an older Spanish speaking only resident with dementia. V6 stated that R4 was very confused at times, needed constant re-direction. On 1/14/2021 at 3:05pm, V12 CNA (certified nurse aide) stated that V12 gave R4 a sponge bath with another CNA; did not observe any alterations in skin integrity, bruising. V12 stated that V12 was off couple of days and when V12 returned to work, the nurse pointed it out to her that R4 had a black eye. V12 stated that V12 is unsure of the date, but incident occurred before Christmas. Per staffing sheets, V12 CNA worked 12/18 and then 12/21. V12 was not scheduled to work on 12/19 and 12/20. Review of the medical record notes R4 was admitted to this facility on 12/11/2020 with [DIAGNOSES REDACTED]. Review of R4's medical record, dated 12/26/2020, V15 LPN, noted upon rounds V15 noticed a bruise around the R4´s left eye. R4 was assessed and no other open areas were noted on the R4's body. R4 denies any pain or discomfort. Vital signs are stable and R4 is functioning at his baseline. Review of R4's care plan, dated 12/26/2020, notes R4's history reveals a previous suspected abuse and/or neglect or factors that may increase susceptibility to abuse/neglect. R4 demonstrates: observable signs of distress. Nursing noted discoloration of R4's eye. Goal: R4 will be treated with respect and dignity and will reside in the facility free from mistreatment. Interventions identified include: R4's physician notified with orders for hospital evaluation, R4 encouraged to notify staff, observe R4 for signs of fear and insecurity during delivery of care, and take steps to calm R4 and help R4 feel safe. Review of R4's police report, dated 12/26/2020 at 1:33pm, notes R4's family contacted the local police department alleging R4 was assaulted at this facility. The police officer noted R4 was observed with bruising to left eye with swelling. The police officer attempted to speak with several nurses regarding this incident and ended with negative results. The nurses and other staff involved in this incident were not at this facility at this time. EMS (emergency medical services) were called to this facility to evaluate R4. A second police officer, bilingual in English/Spanish spoke with R4 in R4's primary language, Spanish. R4 reported that R4 was struck in the eye by another resident. R4 reported that R4 was hit with a fist. R4 reported that the back of head, left eye, and left ear hurt. EMS determined R4 should be transported to the hospital for further evaluation. While R4 was walking with paramedic and police officer to the elevator, R4 pointed to R5 and reported that R5 is the person that hit R4. A third responding police officer noted V15 LPN reported that 4-5 days ago, R4 was battered by R5 in the hallway on the fourth floor nursing unit just outside R4's room. V15 reported that V15 believes R5 was having a panic attack due to R5 seeming distressed and pacing back and forth in the hall. V15 advised the police officer that R5 was walking past R4's room when R4 stepped into the hall at which point R5 struck R4 in R4's left eye with a closed fist causing bruising around the struck area. V15 stated that R4 and R5 were separated.

Based on interviews, and record reviews, this facility failed to provide effective basic life support/cardiopulmonary resuscitation for one resident (R1) who required resuscitative care. R1 was found to be non-responsive without a pulse and was only receiving ventilations via [MEDICAL CONDITION] when EMS (emergency medical services) arrived. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified on [DATE]. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on [DATE] but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff in-services). Findings include: On [DATE], V14 RT (respiratory therapist) stated that V14 received R1 from the hospital on [DATE]. V14 stated that V14 connected R1's [MEDICAL CONDITION] to the ventilator and left R1's room to gather [MEDICAL CONDITION] care supplies. V14 stated that when V14 returned to R1's room, R1 appeared paler than usual, unable to obtain a pulse, called a code blue, and instructed staff to call 911 EMS (emergency medical services). V14 stated that paramedics arrived and took over CPR (cardiopulmonary resuscitation). On [DATE], this surveyor reviewed the EMS report for [DATE] with V14. V14 acknowledged that staff were not performing chest compressions when the paramedics came in R1's room. V14 stated that initially chest compressions were performed but then staff stopped. V14 was providing ventilator support via R1's [MEDICAL CONDITION] and is unsure how much time elapsed from when staff stopped chest compressions and when paramedics arrived. On [DATE] at 4:20pm, V20 CNA (certified nurse aide) stated that V20 worked on the third floor nursing unit evening shift on [DATE]. V20 stated that all of the staff responded to R1's room when the code blue was called. V20 was not able to state if a staff member was performing chest compressions. V20 stated that V20 did not assist with CPR. On [DATE] at 3:10pm, V24 LPN (licensed practical nurse) stated that V24 was the nurse supervisor working the evening shift on [DATE]. V24 stated that V24 was also working as a floor nurse on the dementia nursing unit. V24 stated that V24 worked with V29 LPN on ,[DATE] and V29 responded to the code blue and V24 stayed on the dementia unit to monitor residents. V24 stated that there is no reason not to respond to a code blue if the resident is a full code. V24 stated that there is a code blue book noting who is DNR and who is not; this book is kept at each nurses' station. V24 stated that a resident's code status is also documented in the resident's electronic medical record. V24 stated that when a code blue is called, the crash cart is brought to the resident's room, the resident is assessed for vital signs, CPR is initiated, and V1 (administrator), EMS, and V2 DON (director of nursing) are notified. V24 stated that code blue sheets are kept on top of the crash cart. V24 stated that staff should be doing CPR until EMS arrives and takes over the care of the resident. On [DATE] at 3:30pm, V29 LPN stated that on the evening of [DATE] a code blue was paged overhead on a different nursing unit and V29 responded to it. V29 stated that R1 had just arrived at this facility when the code blue was called. V29 stated that when V29 arrived at R1's room, V29 asked if staff confirmed R1's code status and V21 LPN stated yes. V29 stated that V29 instructed staff to stop CPR until V29 confirmed R1's code status. V29 stated that V29 went to the nurses' station, confirmed R1's code status, printed up R1's face sheet for EMS, and then returned to R1's room. V29 stated that V29 took over chest compressions, but does not recall who V29 took over for or if anyone took over for V29. V29 stated that one nurse was checking R1's vital signs, one nurse was documenting on the code blue sheet, and one nurse was checking R1's blood sugar level; V29 is unable to identify who was doing what and what the results were. V29 stated that CPR should continue until EMS arrives. On [DATE] at 5:47pm, V30 (EMS paramedic) stated that V30 responded to [MEDICAL CONDITION] on the evening of [DATE] at this facility. V30 stated that upon entering R1's room, V14 RT was performing ventilation via R1's [MEDICAL CONDITION]. V30 stated that R1's trachea was clear and without any secretions. V30 stated that there were ,[DATE] staff members surrounding R1's bed not performing chest compressions or assessing R1 for vital signs. V30 stated that a staff member informed V30 that R1 was new admission to this facility one hour ago and they did not have any information on R1 to provide to EMS. V30 stated that R1 was immediately placed on heart monitor; monitor showed asystole (no contraction of the heart muscle and no blood flow to the rest of the body). The paramedics performed CPR for 20 minutes before obtaining a pulse. V30 does not recall the names of the staff present. Review of the medical record notes R1 was admitted to this facility on [DATE] with [DIAGNOSES REDACTED]. R1 was hospitalized [DATE] to [DATE] with [DIAGNOSES REDACTED]. R1 arrived at this facility at 7:30pm. Review of R1's EMS record, dated [DATE], notes EMS was called at 8:34pm and at R1's bedside at 8:40pm. Upon arrival, crew found R1 supine in bed with staff surrounded around R1 only performing ventilation via R1's [MEDICAL CONDITION] and not performing CPR. Per the staff, R1 just arrived at this facility approximately one hour ago therefore they did not know current information on R1. Per V14 RT, the staff was doing CPR for 25 minutes prior to EMS arrival. Crew performed a pulse check and did not obtain any palpable pulse. R1 was placed on multi pads showing asystole. Crew initiated CPR. Crew performed CPR for 20 minutes before obtaining a pulse. Review of this facility's emergency procedure - cardiopulmonary resuscitation policy, revised ,[DATE], notes the goal of early delivery of CPR is to try to maintain life until emergency medical response team arrives to deliver advanced life support. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. All rescuers should provide chest compressions to victims of [MEDICAL CONDITION]. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Landmark of Richton Park Removal Plan The nursing staff will be re-inserviced on the CPR process by the Nurse Consultant/Designee. The education was initiated on,[DATE] at 1:00pm, 3pm & completed on ,[DATE]. The education will be on-going for staff that were absent, and it will be given prior to them starting there shift. Please note, those who were unable to be in-serviced due to FMLA, vacations or anything will not be able to work until the education has been completed** The BOM (Business Office Manager) will be taking the lead with regards to monitoring CPR cards. In the absence of the BOM the administrator will be completing the spreadsheet. LICENSE STAFF WILL NOT BE PLACED ON THE SCHEDULE IF WE DO NOT HAVE THE PROPER DOCUMENTATION THAT THE STAFF MEMBER IS CERTIFIED. Moving forward this will be our standard of practice, therefore we have no end date. All nursing and respiratory CPR certification are current and up to date. The BOM will monitor this practice 1x per week & on-going. Completion date is ,[DATE] and on going. 1. Mock codes will be conducted randomly throughout the quarter to include all 3 shifts. These mock codes will be performed by the facility DON, or designee 6 times per quarter with mock codes being conducted on each shift. A mock code will be conducted twice on each shifts per each quarter. The mock codes will be done every ten days per month each shift. A mock code can be done prior to the 10th day but it will not exceed ten days from the last code called. The code will be called on an opposite shift within or by the 10th day of the month. A mock code was initiated on ,[DATE] at 7pm. The mock code targeted the licensed nursing and respiratory. A total of 15 staff members responded. The mock codes will be on-going to capture the licensed nursing staff and others who will respond. 2. The DON or designee will keep an organized binder separated by month to indicate the outcome of the mock code that will be documented on a code blue drill form. 3. The BOM will monitor that the licensed nursing staff will have current and valid CPR cards. ,[DATE] ongoing. The CPR cards will be monitored by the BOM or Administrator via a spread sheet. ,[DATE] Every Monday BOM, Administrator, and scheduler will meet and discuss whose CPR card is expiring. This will be communicated to staff in writing. This letter will explain that their CPR card will be expiring and that the staff member will not be able to be on the schedule until the CPR certification is completed. This will be on-going. Administrator is expected to take notes during the Monday meeting. All new hires will be added to excel spreadsheet by BOM and will be reviewed during Monday's meetings. The list will be updated weekly as needed to by the BOM. 4.If a resident has a changed in condition and the pulse is absent a code blue will be call and CPR will be initiated if he/she is a full code by the licensed nursing staff. 5. A code blue will be called by a staff member and the emergency response will be initiated pending a resident is a full code. 6. The licensed nursing staff will initiate CPR if the resident is unresponsive with no breaths, breathing at an irregular fashion (i.e. gasping) and no pulse. 7. Rescue breaths will be initiated if the resident has respiratory arrest. 8. Additional staff will respond to the room to assist with the management of the code. 9.The licensed staff member will remain with the resident until resident is transferred for further treatment or the resident is expired. 10. A code blue worksheet will be completed by the assigned nurse. 11.The DON/designee will review and audit the code blue worksheet and the changed of condition documentation. ,[DATE] on going 12. All info with regards to new hires, CPR cards/classes, completion and mock code results will be reviewed during monthly QA meeting. At QA meeting effectiveness of plan and errors must be discussed and revisions made monthly if needed. 13.The policy was revised and updated on [DATE]. Inservicing was initiated on ,[DATE] at 1pm & 3pm. The in-servicing. Completion date ,[DATE] and on-going for staff who are on vacation or who are not able to be in-serviced will not be able to report to work until the in-servicing have been completed. COMPLIANCE WILL BE TRACKED BY LOG SHEET THAT IS BEING MONITORED EVERY MONDAY BY ADMINISTRATOR OR DESIGNEE.

Based on interviews, and record reviews, this facility failed to ensure that wheel locks on a residents bed were engaged in the locked position, and working properly to prevent an avoidable fall for one of three residents (R2) reviewed for safety and falls. The failure resulted in R2 attempting to transfer from a wheelchair to the bed, the bed began to roll R2 fell to the floor and sustained a right femur fracture that required surgical intervention. Findings include: Review of the medical record notes R2 with [DIAGNOSES REDACTED]. On 1/8/2021 at 2:45pm, R2 stated that on 10/7/2020 at 11:00pm, R2 fell while attempting to self-transfer from wheelchair to bed. R2 stated that R2 laid on the floor until the day shift staff found R2 between 8:30am and 9:00am. R2 stated that the CNA unlocked R2's bed brakes while changing bed linen and forgot to lock brakes when done causing R2 to fall later that day. R2 stated that staff did not round on R2 during the night. On 1/12/2021 at 4:30pm, V5 RN (registered nurse) stated that V5 received report on 10/7/2020 from the off-going nurse, but was not informed of R2's fall during the night. V5 stated that while V5 was rounding on assigned residents, V5 found on R2 on floor. V5 stated that R2 is alert, and oriented times three. V5 stated that when R2 fell , R2 was unable to reach the call light cord. V5 stated that R2's call light cord was at the head of the bed and R2 was on the floor at the foot of the bed. V5 stated that R2 informed V5 that R2 fell during the night. V5 stated that R2 is paraplegic and has decreased sensation to lower body; did not complain of right leg pain. On 10/7/2020 at 8:54am, V5 RN (registered nurse) noted R2 is alert, and oriented times four. R2 was observed on the floor in R2's room, R2 was alert and responsive. R2 was assessed for signs of fractures, altered level of consciousness and neurological alterations, no changes/impairments observed. Head to toe assessment completed. R2 within R2's baseline function. No signs/symptoms of distress. R2 denies any pain at this time. No grimace noted. R2 was transferred to bed with staff assistance. R2 reports that R2 fell trying to get in bed, upon skin assessment bruising noted to upper back, upper arm, and upper body (front). Vital signs: blood pressure 90/60, pulse 114 beats/minute, respirations 16, temperature 97.2 degrees Fahrenheit, oxygen saturation level 98% on room air. R2's physician notified, orders received for X-ray of left arm and lumbar-sacral spine, orders noted, family member contacted but unsuccessful. Staff will continue to monitor. R2's incident report, dated 10/7/2020, was reviewed. V31's LPN (licensed practical nurse) statement notes V31 went into R2's room at 6:00am to give R2 medications and R2 was laying on the floor with pillow behind head. V31 noted R2 gets in and out of wheelchair by himself. V31 thought R2 got down on floor by himself. V31 left R2's medication and left R2's room. V31 noted V31 did not do a fall assessment. V32's TNA (temporary nurse aide) statement notes V32 did not know V32 had to round on residents every two hours. V32 did not check on R2 until 5:00am when V32 observed R2 on the floor. V32 did not assist R2 back to bed. V33's TNA statement notes V33 rounded on residents at 5:00am when V33 was assisting residents. V33 did not round on R2. V34's CNA (certified nurse aide) statement notes when V33 came in at 6:30am, V31 LPN informed V34 that R2 was on the ground sleeping. R2's statement notes R2 slipped out of wheelchair to the floor. R2 did not see any staff until 6:00am. V31 LPN left medications. V31 asked if R2 was okay and left R2's room. R2 notes R2 slipped onto buttocks and sustained a scratch due to hitting the wheelchair. R2 leaned up and grabbed the pillow and sheets off the bed and stayed on the floor. V31, V32, and V33 were unavailable for interview during this survey. Review of R2's MDS (minimum data set), dated 11/11/2020, notes R2's BIMS (brief interview of mental status) score is 14 out of 15. R2's falls risk review, dated 10/19/2020, notes R2 is at high risk for falls. Review of R2's incident report, dated 10/16/2020, notes R2 was transported to the hospital due to change in condition. Facility received a call from hospital stating R2 has a fractured right femur. This facility determined fracture due to fall on 10/6/2020. R2 returned to this facility after surgical intervention to repair right femur fracture. Review of R2's falls care plan, initiated 2/8/2020, notes R2 is at risk for falls related to [MEDICAL CONDITION], decreased strength and endurance. Interventions identified include: R2 educated on the importance of using call light for assistance, be sure call light is within reach, staff to respond promptly to all requests for assistance, and anticipate and meet the needs of R2. Review of this facility's accident incident reporting policy, dated 08/2017, notes if a resident is involved in an accident/incident an immediate assessment of the resident is completed. The nurse is to notify the attending physician/nurse practitioner and resident's family.

Based on interview, and record review, the facility neglected to have a system in place or implement actions to initiate ordered hemodialysis of a newly admitted resident with a history of end stage [CONDITION(S)] (R18) and by failing to in itiate hospital discharge orders to continue total [MEDICATION(S)] nutrition (TPN) for one resident with a history of malabsorption (R3) for two residents (R3 and R18) residents out of six residents reviewed for improper nursing care in total sample of 20. As a result, (R18) missed a total of 6 [CONDITION(S)] session and became unresponsive and needed emergency services (cardiopulmonary resuscitation/CPR) and was hospitalized and received acute [CONDITION(S)]. R18 was diagnosed with diabetic ketoacidosis, acute [CONDITION(S)] and septic shock. R18 expired three days after his admission to the hospital. The situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified on [DATE] at 12:41PM. The surveyor confirmed by observation, interview, and record review the immediate jeopardy was removed on [DATE] but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff In-services). Findings Include: Scenario #1: 1. R18 an [AGE] year-old resident was admitted to the facility on [DATE]. R18 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's transferred hospital records dated [DATE] documents R18 last known [CONDITION(S)] was [DATE]. R18 tolerated [CONDITION(S)] well and had a total of 2 liters removed. R18's nursing note dated [DATE] documents R18 has a left arm fistula. Bruit and thrill present. R18's care plan dated [DATE] documents R18 receives [CONDITION(S)] Mondays, Wednesdays, and Fridays at the facility. No [CONDITION(S)] communication notes were available for R18. 2. The facility's policy titled, Policy and Procedure Community Hemodialysis, dated [DATE] documents, All residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis unit prior to admission. The following interviews were conducted regarding facility's system for providing [CONDITION(S)] for a resident and R18's lack of [CONDITION(S)] services at the facility: On [DATE] at 1:19PM, V16 ([CONDITION(S)] Director) stated, Our corporate office sends a referral letting us know there will be a possible admission to one of our facilities and they will need [CONDITION(S)]. They are put on our pending list until they are admitted . Our staff calls the floors each day to keep checking to see if the resident is here yet, or not. Once we confirm they are here they are automatically added to our schedule. The floors are sent schedules each week that are updated with new residents. If they are on the pending list, we are anticipating they will be coming to the facility. If someone is admitted that has an order, they should be receiving [CONDITION(S)]. No, R18 never received [CONDITION(S)]. He always remained in the pending section on the schedule. V17 ([CONDITION(S)] Nurse) will be able to give you more information about what happened. She was the [CONDITION(S)] nurse that was calling up to the floors. If a resident miss's [CONDITION(S)] after they have been admitted they are at risk for fluid overload, electrolyte imbalance, and even death. It is inexcusable to miss [CONDITION(S)] if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:07PM, V17 ([CONDITION(S)] Nurse) stated, I get the list from the admission director on who could be admitted to the facility. When I call up to the floor to have them send down the regularly scheduled patients, I also go over the list with the pending names on it to see if any of them were admitted . It's always a waiting process. No one will ever call down to tell us when a new [CONDITION(S)] admission is in the building. I'm always calling around the whole place to see if these people are coming in. I always call all the floors and check the whole list of the pending because I never know what room they are going to. I remember asking every floor about him (R18) every [CONDITION(S)] day which is every Monday, Wednesday, and Friday. I would always get from the nurses on the floor 'we don't have a resident by that name.' That is what they would always say to me. I never physically went to the floors myself to check because I can't leave the [CONDITION(S)] unit. I was here every Monday, Wednesday, and Friday so I called all those days and got the same answer every time. He stayed on the pending list the entire time. If a resident missed that amount of [CONDITION(S)], they could get [CONDITION(S)] which a high level of potassium can be very dangerous for you. You will also have fluid volume overload to remove the fluid because most of these people can't pee. You would just need to at least be hospitalized to the waste from your system. If I'm not the one calling to the floors the communication is nonexistent. On [DATE] at 12:52PM, V8 (Nurse) stated, Admissions will let the nurse know when a resident comes in who needs [CONDITION(S)]. We call the [CONDITION(S)] unit to let them know a new admit is here. It is the nurse's responsibility to call the [CONDITION(S)] unit to let them know when a resident comes in. I don't know why [CONDITION(S)] was never called from him (R18). On [DATE] at 12:09PM, V22 (Medical Director) stated, When a new resident arrives the nurses need to review the records and call the doctor to go through the medications and orders. I tell them all the time that if there is any confusion in the orders from the hospital you need to call them back to clear up any discrepancies. That is the only way we know what is going on. Hemodialysis is used to remove toxins from the bod. That is the only way to remove the toxins because these residents don't produce urine. It means they are in end stage [CONDITION(S)] and this is the only way to remove the waste. A normal hemodialysis schedule is 3 times a week. I don't think a person will be able to live if they miss 2 weeks' worth of [CONDITION(S)]. You will also experience fluid overload to where you will have difficulties breathing. I normally check the blood work for a resident if they miss one session to make sure none of their electrolytes are at a critical level. 3. R18's nursing note dated [DATE] documents R18 was found unresponsive. A code blue was called, cardiopulmonary resuscitation (CPR) was started, and 911 was called. Paramedics transferred R18 to the hospital. On [DATE] at 2:18PM, V20 (Nurse) stated, When I walked in his room, he wasn't responding to anything and we could not find a pulse. We started CPR and got a pulse back right around when the paramedics got there. They took him to the emergency room after that. When I saw him, he was having a hard time breathing and gasping for air. The Hospital Records from hospital #1 dated [DATE] document R18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR was in progress when R18 arrived at the emergency room for 7 minutes per the paramedics. R18's breath sounds were coarse, and wet on both sides. R18 had uncompensated metabolic acidosis to facilitate respiratory compensation for the metabolic process and to help with the work of breathing. Am insulin drip was started to help control R18's blood sugar. R18's kidney function labs (BUN and Creatinine) were severely elevated. R18's blood urea [MEDICATION(S)] (BUN) was 374mg (normal is 7mg to 20mg) and the creatinine was 21.5mg/dL (normal is .84mg/dL to 1.2 mg/dL). R18 was transferred to another hospital late that day. The Hospital Records from hospital #2 dated [DATE] document R18 arrived from an outside hospital for higher level care. R18 was directly admitted to the intensive care unit where continuous renal replacement therapy (CRRT) was started. The social worker at the hospital called the facility to confirm when the last [CONDITION(S)] session was, and the facility reported the last [CONDITION(S)] session was [DATE]. The Death Certificate dated [DATE] documents the cause of death as complications of [MEDICATION(S)] force injuries of the head and fall. Significant conditions contributing to death are hypertension and end stage [CONDITION(S)]. The immediate jeopardy that began on [DATE] was removed when the facility took the following actions to remove the immediacy: Abatement Plan Director of Nurse (DON) and nursing staff were reeducated by the Regional nurse consultant on the facility's policy and procedure related to [CONDITION(S)] to include but not limited to: Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . or readmission, timely communication to the [CONDITION(S)] center of resident arrival and need for such treatment, documenting via the medical record as [CONDITION(S)] treatment as being carried out, ongoing monitoring of patient as indicated. (initiated) [DATE]-completed [DATE]. The communication in-service and training included but was not limited to: when the communication form is to be completed, pre and post vitals that are to be obtained, the indication of any changes the resident may experience prior to or during [CONDITION(S)] service, specific medications if given, resident's name, date and last date of service. (initiated)[DATE]- completed [DATE] The admissions director will be in-serviced by the Nurse Consultant on prompt communication to the DON, Administrator, and to [CONDITION(S)] center nurse, regarding residents that have been approved and are scheduled for [CONDITION(S)]. [DATE] and on-going Admissions director will provide prompt notification of any delays in expected [CONDITION(S)] admissions to the [CONDITION(S)] center, Administrator, and DON with updated and accurate information of the resident new admitted and expected time of arrival. [DATE] and on-going Referral for all admissions will be sent to the admission coordinator, who will then communicate need for referral reviewal to the DON and administrator. Revised [DATE] and on-going. The DON will review each referral packet and identify if the resident is ordered and receiving [CONDITION(S)] treatment. If the patient is appropriate for acceptance to the facility the admissions director will then forward this information on to the [CONDITION(S)] center for approval. If this criterion is met, and the resident is scheduled to be admitted , the admission director will have direct and timely communication with the [CONDITION(S)] center, Administrator, and DON regarding the patient specifying the date and approximate time of arrival.[DATE] and on-going The DON reviewed and verified all [CONDITION(S)] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON will continue to review and verify order for all newly diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The DON will give the unit nurse report via the pre-admission form after reviewing and accepting a resident prior to admission. Once admitted to the facility, the admission director (will then notify the [CONDITION(S)] center, Administrator and DON again that the patient has been admitted to the facility with orders for [CONDITION(S)] scheduled treatments and times with confirmation to the administrator and DON. [DATE] and on-going The Admission Director will inform the Interdisciplinary Team of the new admissions and those who are to receive specialize services via a list daily and as needed. The Admission Director will meet with each IDT member and provide them with the list. The IDT member will sign to indicate they have received the information via an audit tool. [DATE] and on-going The Admission Director will communicate all newly admitted residents during the morning meeting and include if they are receiving [CONDITION(S)] services.[DATE] and on-going The DON will then communicate directly with the admitting nurse to ensure that all orders related to [CONDITION(S)] have been transcribed and carried out onto the MAR. DON will validate the date, and time that [CONDITION(S)] is to be given via the [CONDITION(S)] nurse. The DON will identify all residents who are receiving [CONDITION(S)] services. [DATE] The [CONDITION(S)] nurse will confirm the [CONDITION(S)] scheduled and times of the services with the DON three days a week and ongoing upon new admissions. [DATE] and on-going A communication sheet will be completed daily for residents who receives [CONDITION(S)] via the assigned nurse and the [CONDITION(S)] nurse (Amber White) prior to and after each treatment. [DATE] and on-going The assigned unit/floor nurse will be responsible for initiating the [CONDITION(S)] communication form three time a week and as needed. The floor nurse will have the resident who is scheduled for [CONDITION(S)] transported via the assigned aide. The floor nurse will call the [CONDITION(S)] services to verify that the resident is in [CONDITION(S)] to receive services. The [CONDITION(S)] nurse will indicate the resident's status during and post treatment via the communication form and send it will be sent to the unit via the transporting aide after the completion of [CONDITION(S)] services. Medical Record will collect the forms three days a week and as needed. The communication sheet will be given to the administrator and review with the DON to ensure proper follow-through. [DATE]. Employee who are on vacation will be notified that they are not return to work until all in-services have been completed. The plan was revised on [DATE]. Completion Date [DATE] Scenario #2 R3 is a [AGE] year-old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 admitted to the facility on [DATE]. R3 discharged from the facility on [DATE]. A note dated [DATE] documents R3 was sent to the hospital for a low hemoglobin level. The Hospital records dated [DATE] document an abdominal mass was noted on R3's abdominal CT scan. R3 was given 1 unit of packed red blood cells and transferred to another hospital for further care. A note dated [DATE] documents R3 returned from the hospital and the port-a-Cath was removed and the TPN was stopped. The Hospital After Visit Summary dated [DATE] documents R3 is ordered to start TPN and fat [MEDICATION(S)] (lipids) every evening. No documentation in the hospital records documenting port-a-Cath removal or discontinuation of TPN. A Dietary note dated [DATE] documents R3 returned to the facility and TPN has been stopped. R3 is on a general, regular diet. Monitor weight and oral intake. A nursing note dated [DATE] documents R3 has a poor appetite and complained of nausea. R3 ate 25% of lunch. A Nurse Practitioner note dated [DATE] documents R3 returned from the hospital and during hospital course the TPN and port-a-Cath were discontinued. Staff to follow hospital discharge plan and scheduled appointments. A note [DATE] documents R3 left the facility for a scheduled doctor appointment in stable condition. No further notes are documented after this note. The Incident Report dated [DATE] documents the facility received a call from the hospital regarding the POS for R3. The investigation determined R3's POS and the discharge summary had irregularities. The facility educated nurses regarding this and the doctor was notified. On [DATE] at 1:04PM, V8 (Nurse) stated, I got report from another nurse that admitted her, and I never checked the hospital papers. I never knew she had a TPN order. It was my first time working on the floor. Usually we have a QA nurse check the hospital records to make sure everything is ok. I don't know if the QA nurse checked her orders. She would eat like maybe 25% of breakfast and sometimes a couple bites of lunch. I never saw dinner. I sent her to the doctor that day and they called asking about the TPN. I just said it was discontinued from what I was told. I know she went to the hospital after that, but I don't know why. On [DATE] at 2:28PM, V21 (Dietician) stated, I never saw this resident. For someone on TPN I would expect to be notified. A person can be on TPN for a lot of reasons but if they don't take in enough nutrition orally then the TPN is their main source of nutrition. I can't say why she had TPN because I never saw her. It looks like her weights stayed around her baseline the entire time she was here. I don't know if she should have been getting the TPN or not because I never followed her. If it was ordered, then yes she should have been getting it. I can't speculate and say what would happen if a resident wouldn't get their TPN. A lot of different things can occur when TPN isn't given. Weight loss and abnormal electrolytes would mostly likely happen if the resident mainly relied on TPN. On [DATE] at 11:12AM, V5 stated, She was on weekly weights because she was on TPN. She ate a general diet too. She ate ok from what I can remember. I would say she ate better before she went out to the hospital than when she came back. When she came back her PO intake was varied. When a resident comes back, I look at the medical records as well as talk with the nurses. I remember being told her TPN was discontinued. I don't remember why but that is what I was told. I don't remember seeing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I'm not sure what would happen besides that. She was a thin lady to begin with, so I don't know if she lost more weight. For any enteral feeds or weight loss the dietician gets involved. I don't know why the dietician never saw her. On [DATE] at 12:09PM, V22 (Medical Director) stated, When a new resident arrives the nurses need to review the records and call the doctor to go through the medications and orders. We also had an NP in the building at that time that was also probably reviewing orders from admissions. I tell them all the time that if there is any confusion in the orders from the hospital you need to call them back to clear up any discrepancies. That is the only way we know what is going on. TPN is used when a resident is not able to eat, or their GI tract is not working all the way to get nutrition to the patient. If a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If they miss, I would say more than a couple days then they are going to lose weight. They body is also going to start breaking down muscle mass to provide energy for the body so the patient will have muscle mass loss too. IDPH attempted to request hospital records approximately three times for the admission on [DATE]. The hospital kept sending the documentation from the [DATE] admission. V8 (nurse) and R3's family member confirmed R3 was admitted to the hospital on [DATE]. IDPH attempted to contact the oncology doctor at the hospital but the doctor nor anyone from the team would answer questions regarding R3.

Based on interview, and record review, the facility failed to initiate ordered hemodialysis of a newly admitted resident with a history of end stage [CONDITION(S)] (R18) and failed to initiate hospital discharge orders to continue total [MEDICATION(S)] nutrition (TPN) for one resident with a history of malabsorption (R3) for two residents (R3 and R18) residents out of six residents reviewed for improper nursing care in total sample of 20. As a result, (R18) missed a total of 6 [CONDITION(S)] session and became unresponsive and needed emergency services (cardiopulmonary resuscitation/CPR) and was hospitalized and received acute [CONDITION(S)]. R18 was diagnosed with diabetic ketoacidosis, acute [CONDITION(S)] and septic shock. R18 expired three days after his admission to the hospital. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified on [DATE] at 12:41PM. The surveyor confirmed by observation, interview and record review the immediate jeopardy was removed on [DATE] but noncompliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of the facility's inventions (including staff in-services). Findings Include: Scenario #1: 1. R18 an [AGE] year-old resident was admitted to the facility on [DATE]. R18 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's transferred hospital records dated [DATE] documents R18 last known [CONDITION(S)] was [DATE]. R18 tolerated [CONDITION(S)] well and had a total of 2 liters removed. R18's nursing note dated [DATE] documents R18 has a left arm fistula. Bruit and thrill present. R18's care plan dated [DATE] documents R18 receives [CONDITION(S)] Mondays, Wednesdays, and Fridays at the facility. No [CONDITION(S)] communication notes were available for R18. 2. The facility's policy titled, Policy and Procedure Community Hemodialysis, dated [DATE] documents, All residents that are admitted to the facility with needs for hemodialysis will have coordination of services between the facility and the hemodialysis unit prior to admission. The following interviews were conducted regarding facility's system for providing [CONDITION(S)] for a resident and R18's lack of [CONDITION(S)] services at the facility: -On [DATE] at 1:19PM, V16 ([CONDITION(S)] Director) stated, Our corporate office sends a referral letting us know there will be a possible admission to one of our facilities and they will need [CONDITION(S)]. They are put on our pending list until they are admitted . Our staff calls the floors each day to keep checking to see if the resident is here yet or not. Once we confirm they are here they are automatically added to our schedule. The floors are sent schedules each week that are updated with new residents. If they are on the pending list, we are anticipating they will be coming to the facility. If someone is admitted that has an order, they should be receiving [CONDITION(S)]. No, R18 never received [CONDITION(S)]. He always remained in the pending section on the schedule. V17 ([CONDITION(S)] Nurse) will be able to give you more information about what happened. She was the [CONDITION(S)] nurse that was calling up to the floors. If a resident miss's [CONDITION(S)] after they have been admitted they are at risk for fluid overload, electrolyte imbalance and even death. It is inexcusable to miss [CONDITION(S)] if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -On [DATE] at 2:07PM, V17 ([CONDITION(S)] Nurse) stated, I get the list from the admission director on who could be admitted to the facility. When I call up to the floor to have them send down the regularly scheduled patients, I also go over the list with the pending names on it to see if any of them were admitted . It's always a waiting process. No one will ever call down to tell us when a new [CONDITION(S)] admission is in the building. I'm always calling around the whole place to see if these people are coming in. I always call all the floors and check the whole list of the pending because I never know what room they are going to. I remember asking every floor about him (R18) every [CONDITION(S)] day which is every Monday, Wednesday, and Friday. I would always get from the nurses on the floor 'we don't have a resident by that name.' That is what they would always say to me. I never physically went to the floors myself to check because I can't leave the [CONDITION(S)] unit. I was here every Monday, Wednesday, and Friday so I called all those days and got the same answer every time. He stayed on the pending list the entire time. If a resident missed that amount of [CONDITION(S)], they could get [CONDITION(S)] which a high level of potassium can be very dangerous for you. You will also have fluid volume overload to remove the fluid because most of these people can't pee. You would just need to at least be hospitalized to the waste from your system. If I'm not the one calling to the floors the communication is nonexistent. -On [DATE] at 12:52PM, V8 (Nurse) stated, Admissions will let the nurse know when a resident comes in who needs [CONDITION(S)]. We call the [CONDITION(S)] unit to let them know a new admit is here. It is the nurse's responsibility to call the [CONDITION(S)] unit to let them know when a resident comes in. I don't know why [CONDITION(S)] was never called from him (R18). - On [DATE] at 12:09PM, V22 (Medical Director) stated, When a new resident arrives the nurses need to review the records and call the doctor to go through the medications and orders. I tell them all the time that if there is any confusion in the orders from the hospital you need to call them back to clear up any discrepancies. That is the only way we know what is going on. Hemodialysis is used to remove toxins from the bod. That is the only way to remove the toxins because these residents don't produce urine. It means they are in end stage [CONDITION(S)] and this is the only way to remove the waste. A normal hemodialysis schedule is 3 times a week. I don't think a person will be able to live if they miss 2 weeks' worth of [CONDITION(S)]. You will also experience fluid overload to where you will have difficulties breathing. I normally check the blood work for a resident if they miss one session to make sure none of their electrolytes are at a critical level. 3. R18's nursing note dated [DATE] documents R18 was found unresponsive. A code blue was called, cardiopulmonary resuscitation (CPR) was started, and 911 was called. Paramedics transferred R18 to the hospital. On [DATE] at 2:18PM, V20 (Nurse) stated, When I walked in his room, he wasn't responding to anything and we could not find a pulse. We started CPR and got a pulse back right around when the paramedics got there. They took him to the emergency room after that. When I saw him, he was like having a hard time breathing and gasping for air. The Hospital Records from hospital #1 dated [DATE] document R18's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CPR was in progress when R18 arrived to the emergency room for 7 minutes per the paramedics. R18's breath sounds were coarse and wet on both sides. R18 had uncompensated metabolic acidosis to facilitate respiratory compensation for the metabolic process and to help with the work of breathing. Am insulin drip was started to help control R18's blood sugar. R18's kidney function labs (BUN and Creatinine) were severely elevated. R18's blood urea [MEDICATION(S)] (BUN) was 374mg (normal is 7mg to 20mg) and the creatinine was 21.5mg/dL (normal is .84mg/dL to 1.2 mg/dL). R18 was transferred to another hospital late that day. The Hospital Records from hospital #2 dated [DATE] document R18 arrived from an outside hospital for higher level care. R18 was directly admitted to the intensive care unit where continuous renal replacement therapy (CRRT) was started. The social worker at the hospital called the facility to confirm when the last [CONDITION(S)] session was, and the facility reported the last [CONDITION(S)] session was [DATE]. The Death Certificate dated [DATE] documents the cause of death as complications of [MEDICATION(S)] force injuries of the head and fall. Significant conditions contributing to death are hypertension and end stage [CONDITION(S)]. The immediate jeopardy that began on [DATE] was removed when the facility took the following actions to remove the immediacy: Abatement Plan DON and nursing staff were reeducated by the Regional nurse consultant on the facility's policy and procedure related to [CONDITION(S)] to include but not limited to: Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (initiated) [DATE]-completed [DATE]. The communication in-service and training included but was not limited to: when the communication form is to be completed, pre and post vitals that are to be obtained, the indication of any changes the resident may experience prior to or during [CONDITION(S)] service, specific medications if given, resident's name, date and last date of service. (initiated)[DATE]- completed [DATE] The admissions director will be in-serviced by the Nurse Consultant on prompt communication to the DON, Administrator, and to [CONDITION(S)] center nurse, regarding residents that have been approved and are scheduled for [CONDITION(S)]. [DATE] and on-going Admissions director will provide prompt notification of any delays in expected [CONDITION(S)] admissions to the [CONDITION(S)] center, Administrator, and DON with updated and accurate information of the resident new admitted and expected time of arrival. [DATE] and on-going Referral for all admissions will be sent to the admission coordinator, who will then communicate need for referral reviewal to the DON and administrator. Revised [DATE] and on-going. The DON will review each referral packet and identify if the resident is ordered and receiving [CONDITION(S)] treatment. If the patient is appropriate for acceptance to the facility the admissions director will then forward this information on to the [CONDITION(S)] center for approval. If this criterion is met, and the resident is scheduled to be admitted , the admission director will have direct and timely communication with the [CONDITION(S)] center, Administrator, and DON regarding the patient specifying the date and approximate time of arrival.[DATE] and on-going The DON reviewed and verified all [CONDITION(S)] physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON will continue to review and verify order for all newly diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The DON will give the unit nurse report via the pre-admission form after reviewing and accepting a resident prior to admission. Once admitted to the facility, the admission director (will then notify the [CONDITION(S)] center, Administrator and DON again that the patient has been admitted to the facility with orders for [CONDITION(S)] scheduled treatments and times with confirmation to the administrator and DON. [DATE] and on-going The Admission Director will inform the Interdisciplinary Team of the new admissions and those who are to receive specialize services via a list daily and as needed. The Admission Director will meet with each IDT member and provide them with the list. The IDT member will sign to indicate they have received the information via an audit tool. [DATE] and on-going The Admission Director will communicate all newly admitted residents during the morning meeting and include if they are receiving [CONDITION(S)] services.[DATE] and on-going The DON will then communicate directly with the admitting nurse to ensure that all orders related to [CONDITION(S)] have been transcribed and carried out onto the MAR. DON will validate the date and time that [CONDITION(S)] is to be given via the [CONDITION(S)] nurse. The DON will identify all residents who are receiving [CONDITION(S)] services. [DATE] The [CONDITION(S)] nurse will confirm the [CONDITION(S)] scheduled and times of the services with the DON three days a week and ongoing upon new admissions. [DATE] and on-going A communication sheet will be completed daily for residents who receives [CONDITION(S)] via the assigned nurse and the [CONDITION(S)] nurse (Amber White) prior to and after each treatment. [DATE] and on-going The assigned unit/floor nurse will be responsible for initiating the [CONDITION(S)] communication form three time a week and as needed. The floor nurse will have the resident who is scheduled for [CONDITION(S)] transported via the assigned aide. The floor nurse will call the [CONDITION(S)] services to verify that the resident is in [CONDITION(S)] to receive services. The [CONDITION(S)] nurse will indicate the resident's status during and post treatment via the communication form and send it will be sent to the unit via the transporting aide after the completion of [CONDITION(S)] services. Medical Record will collect the forms three days a week and as needed. The communication sheet will be given to the administrator and review with the DON to ensure proper follow-through. [DATE]. Employee who are on vacation will be notified that they are not return to work until all in-services have been completed. The plan was revised on [DATE]. Completion Date [DATE] Scenario #2 R3 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 admitted to the facility on [DATE]. R3 discharged from the facility on [DATE]. A note dated [DATE] documents R3 was sent to the hospital for a low hemoglobin level. The Hospital records dated [DATE] document an abdominal mass was noted on R3's abdominal CT scan. R3 was given 1 unit of packed red blood cells and transferred to another hospital for further care. A note dated [DATE] documents R3 returned from the hospital and the port-a-cath was removed and the TPN was stopped. The Hospital After Visit Summary dated [DATE] documents R3 is ordered to start TPN and fat [MEDICATION(S)] (lipids) every evening. No documentation in the hospital records documenting port-a-cath removal or discontinuation of TPN. A Dietary note dated [DATE] documents R3 returned to the facility and TPN has been stopped. R3 is on a general, regular diet. Monitor weight and oral intake. A nursing note dated [DATE] documents R3 has a poor appetite and complained of nausea. R3 ate 25% of lunch. A Nurse Practitioner note dated [DATE] documents R3 returned from the hospital and during hospital course the TPN and port-a-cath were discontinued. Staff to follow hospital discharge plan and scheduled appointments. A note [DATE] documents R3 left the facility for a scheduled doctor appointment in stable condition. No further notes are documented after this note. The Incident Report dated [DATE] documents the facility received a call from the hospital regarding the POS for R3. The investigation determined R3's POS and the discharge summary had irregularities. The facility educated nurses regarding this and the doctor was notified. On [DATE] at 1:04PM, V8 (Nurse) stated, I got report from another nurse that admitted her and I never checked the hospital papers. I never knew she had a TPN order. It was my first time working on the floor. Usually we have a QA nurse check the hospital records to make sure everything is ok. I don't know if the QA nurse checked her orders. She would eat like maybe 25% of breakfast and sometimes a couple bites of lunch. I never saw dinner. I sent her to the doctor that day and they called asking about the TPN. I just said it was discontinued from what I was told. I know she went to the hospital after that but I don't know why. On [DATE] at 2:28PM, V21 (Dietician) stated, I never saw this resident. For someone on TPN I would expect to be notified. A person can be on TPN for a lot of reasons but if they don't take in enough nutrition orally then the TPN is their main source of nutrition. I can't say why she had TPN because I never saw her. It looks like her weights stayed around her baseline the entire time she was here. I don't know if she should have been getting the TPN or not because I never followed her. If it was ordered then yes she should have been getting it. I can't speculate and say what would happen if a resident wouldn't get their TPN. A lot of different things can occur when TPN isn't given. Weight loss and abnormal electrolytes would mostly likely happen if the resident mainly relied on TPN. On [DATE] at 11:12AM, V5 stated, She was on weekly weights because she was on TPN. She ate a general diet too. She ate ok from what I can remember. I would say she ate better before she went out to the hospital than when she came back. When she came back her PO intake was varied. When a resident comes back I look at the medical records as well as talk with the nurses. I remember being told her TPN was discontinued. I don't remember why but that is what I was told. I don't remember seeing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I'm not sure what would happen besides that. She was a thin lady to begin with so I don't know if she lost more weight. For any enteral feeds or weight loss the dietician gets involved. I don't know why the dietician never saw her. On [DATE] at 12:09PM, V22 (Medical Director) stated, When a new resident arrives the nurses need to review the records and call the doctor to go through the medications and orders. We also had an NP in the building at that time that was also probably reviewing orders from admissions. I tell them all the time that if there is any confusion in the orders from the hospital you need to call them back to clear up any discrepancies. That is the only way we know what is going on. TPN is used when a resident is not able to eat, or their GI tract is not working all the way to get nutrition to the patient. If a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If they miss, I would say more than a couple days then they are going to lose weight. They body is also going to start breaking down muscle mass to provide energy for the body so the patient will have muscle mass loss too. IDPH attempted to request hospital records approximately three times for the admission on [DATE]. The hospital kept sending the documentation from the [DATE] admission. V8 (nurse) and R3's family member confirmed R3 was admitted to the hospital on [DATE]. IDPH attempted to contact the oncology doctor at the hospital but the doctor nor anyone from the team would answer questions regarding R3.

Based on observation, interviews, and record review the facility failed to conduct an initial assessment and evaluation of a swollen arm for 1 (R2) of 4 residents reviewed for quality of care. This failure resulted in R2 being observed with a swollen arm on 8/6/2018 and no assessment, evaluation or X-ray until 8/9/2018 and another delay in reporting the results of the abnormal x-ray until 8/11/2018 with findings that R2 had a dislocated right shoulder. Findings: On 9/25/18 at 11 AM a review of the resident records was conducted. On 8/6/18 at 7:10 AM V12 (Hospice Registered Nurse / RN) notes Patient noted with [MEDICAL CONDITION] to the upper right arm ., Informed facility nurse (R2's assigned nurse V9 (Licensed Practical Nurse) of the [MEDICAL CONDITION] to R2 right arm. R2's resident record noted 8/7/18 at 1:28 PM by V9 (Licensed Practical Nurse / LPN) Nurse alerted to observe resident. (Alerted by Hospice Certified Nursing Assistant (V13)). Right upper arm appears swollen. Resident was able to move arm with help from nursing staff. (Assistance with movement up and down and circular. R2 had no physical impairments to her upper extremities prior to the incurring [MEDICAL CONDITION] to her upper arm. Taken from Minimum Data Sheet Report dated 8/12/18 Section G Functional Limitation in Range of Motion Upper Extremities coded 0 No Impairment) No distress or pain noted while assessing patient. Nurse Practitioner notified. (Nurse Practitioner informed nurse to have Hospice Nurse assess arm the following day 8/8/18).Will Follow Up with hospice. On 8/8/18 at 2:27 PM V14 (Registered Nurse / RN) noted Read in progress note that this resident had swelling to her right upper arm. Nurse Practitioner made aware of this condition last night. Resident is able to lift arm with assist. No contractures, no bruising, no [MEDICAL CONDITION]. Appears to be in no pain. Hospice nurse is to arrive on PM shift and decide if she wants to order an x-ray. Nurse Practitioner, Hospice Nurse, and Director of Nursing notified of situation. Right arm elevated high on pillow. Arm feels normal body temperature. Will continue to monitor. On 8/8/18 No Hospice Nurse arrived at facility to examine resident on 8/8/18 but the scheduled Hospice Certified Nursing Assistant attended to R2. No Order for x-ray obtained or reached out for by facility. On 8/9/18 at 10 AM V15 ( Hospice Licensed Practical Nurse) notes Arm elevated on pillow, x-ray ordered ., [MEDICAL CONDITION] Right Arm. On 8/9/18 at 10:08 PM V8 (Licensed Practical Nurse) notes Resident continues on hospice , right arm noted with [MEDICAL CONDITION]. Range of Motion to right upper extremities tolerated well without pain or limits. Medical Doctor (Not MD (V17) but Nurse Practitioner (V7)) noted orders obtained for x-ray of entire right upper extremity. Mobile x-ray company contacted will be out tonight. On 8/11/18 at 5:10 AM V11 (Licensed Practical Nurse) noted call placed to mobile x-ray to follow up on x-ray results of right arm. Impression: right shoulder, scapula, clavicle, and humerus: antererior dislocation of the humeral head with no fracture noted at this time. (Head of bone out of socket of arm.) Right arm is swollen and warm, painful to the touch ., Hospice nurse contacted and made aware of results. Hospice Nurse (V16) stated we will not give any orders and the facility should contact primary care physician. Primary Care Physician should follow up with this matter. Medical doctor (V17) paged two times still awaiting a response. Nurse Practitioner, Director of Nursing, House Supervisor, Nurse Consultant, Administrator, and Family all made aware. Received order from nurse consultant to send resident out to the hospital emergency room for evaluation due to injury of unknown origin ., On 9/26/18 at 2 PM V2 (Director Of Nursing / DON) stated Staff did not get ahold of me on 8/7/18. I later noted that R2 had [MEDICAL CONDITION] to her right arm (8/9/18) but no pain and no abnormalities in range of motion. They were informed by the Nurse Practitioner to contact hospice to see what hospice wanted to do. (Hospice informed facility that R2's admission to Hospice was for Organic Brain Issues and Dementia and they had no oversight regarding the [MEDICAL CONDITION] to the arm). On 8/9/18 the nurse called the Nurse Practitioner and obtained an order for [REDACTED]. After speaking with mobile x-ray we learned of the dislocation on 8/11/18. The x-ray was ordered on [DATE] at 10:55 PM and taken an hour or so after that. Did not know results till we contacted the mobile x-ray company and they faxed results over on 8/11/18. Resident was then sent to the hospital for evaluation of the arm. That is when V1 (Administrator) began investigation for injury of unknown origin. On 9/27/18 at 2 PM V18 (Mobile X-ray Director) stated We obtained the x-ray order on 8/9/18 at 10:54 PM. The x-ray was obtained after 11 PM that night. The results were read early the next morning on 8/10/18. We waited till 5:52 AM on 8/10/18 to fax the order. On 8/10/18 at 6:10 AM we attempted to call the facility three times. No one answered the phone. We tried one additional time to call the facility at 6:15 AM. There was still no answer. However we had already faxed the results that morning at 5:52 AM. Surveyor asked about the mobile x-ray's policy of calling. V18 stated We fax the results and call. Surveyor asked Do you call till you get someone? V18 answered We call till we get someone but did not accomplish that on this incident. Surveyor asked for a copy of the facility policy and the x-ray results with the callers initials on the results with times of fax and calls as V18 claimed he had the copy indicating attempts and fax time. After two requests, never received requested material. On 9/27/18 at 10 AM V7 (Nurse Practitioner) stated I was out of town during this weekend of R2's [MEDICAL CONDITION] to her arm. I was taking call via phone text messages and return phone calls. On 8/7/18 V9 (Licensed Practical Nurse) messaged me about R2's arm. I called back and was informed that the arm had [MEDICAL CONDITION] but no pain, deformity, or limitations to her movement. As R2 was under the care of hospice, I informed the nurse to have the hospice nurse assess the resident when she comes to the facility. V7 was asked about her expectations regarding monitoring R2 during this time of [MEDICAL CONDITION] from an unknown origin. V7 stated I would expect the nurses to assess for any pain, deformity, comfort, and document these observations on every shift ., I felt they did monitor her. V7 further added Yes R2 could have tolerated range of motion to her arm with the dislocation. The range of motion may even have been easier. I am a nurse practitioner, I do not need to call to inform the medical doctor as I can operate independently. On 10/3/18 at 9 AM V2 (Director of Nursing) stated I never spoke with the nurses on 8/6/18 through 8/8/18. I did note that V14 (Registered Nurse) had documented on the chart that she contacted me on 8/8/18 but I did not receive any communication from her on that day. In addition, R2 was a under the care of hospice here at the facility. Due to R2's age and clinical condition it was not uncommon for a hospice patient to have swelling. Swelling was nothing to be alarmed about. I was first made aware of R2's arm on 8/9/18. When we received the x-ray results of the dislocation on 8/11/18, I then came into the facility. V1 (Administrator) had begun an investigation of injury of unknown origin on 8/11/18. On 10/3/18 at 11 AM V1 (Administrator) provided the policy for Accident Incident Reporting Policy (dated 8/3/17). The policy notes Any accident/incident may be reported immediately to the nurse or appropriate person designated to be in charge. A report may be completed for any individual involved in an accident or an incident while residing in the facility ., The physician/nurse practitioner may be informed of any changes in the resident's condition that have been identified. Orders for treatment/intervention may be obtained as deemed necessary. If the attending physician or physician on call can not be reached, the Medical Director should be notified and orders obtained as necessary. Any actions or communications are to be documented in the resident's medical record. On 10/3/18 at 11 AM V1 provided the policy entitled Change in Resident's Condition or Status (dated 6/26/11). The policy notes The Nurse will notify the resident's attending physician when the resident is involved in any accident or incident that results in an injury including injuries of unknown origin ., There is a significant change in the resident's physical, mental, and psychosocial status ., A significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan ., the nurse will record in the resident's medical record any changes in the resident's medical condition or status. On 10/8/18 at 1 PM a review of R2's Medical Record was conducted. It was noted that R2's documentation of her medical condition was noted on 8/7/18, 8/8/18, 8/9/18, 8/11/18. On 8/7/18 documentation occurred at 1:28 PM and 10:25 PM. There was no documentation on night shift. On 8/8/18 documentation at 2:27 PM. There was no documentation on afternoon shift or night shift. On 8/9/18 there was documentation at 10:08 PM. There was no documentation on day shift or night shift. On 8/10/18 there was no documentation on days, afternoons or night shifts. On 8/11/18 documentation at 1:02 AM and 5:10 AM. After having received orders to transfer resident to hospital for evaluation at 5:10 AM, there are no further documentation of resident assessment, ambulance transfer, nor notifications documented in resident chart. On 9/27/18 at 10 AM V7 (Nurse Practitioner) stated I was out of town during this weekend of R2's [MEDICAL CONDITION] to her arm. I was taking call via phone text messages and return phone calls. On 8/7/18 V9 (Licensed Practical Nurse) messaged me about R2's arm. I called back and was informed that the arm had [MEDICAL CONDITION] but no pain, deformity, or limitations to her movement. As R2 was under the care of hospice, I informed the nurse to have the hospice nurse assess the resident when she comes to the facility. V7 was asked about her expectations regarding monitoring R2 during this time of [MEDICAL CONDITION] from an unknown origin. V7 stated I would expect the nurses to assess for any pain, deformity, comfort, and document these observations on every shift ., I felt they did monitor her. V7 further added Yes R2 could have tolerated range of motion to her arm with the dislocation. The range of motion may even have been easier. I am a nurse practitioner, I do not need to call to inform the medical doctor as I can operate independently. On 9/26/18 at 10 AM V7 (Nurse Practitioner) stated I was texted on 8/7/18 of the [MEDICAL CONDITION] to R2's arm. (See narrative above). No one ever interviewed me regarding the arm for any incident or injury or unknown origin. On 9/27/18 at 1:10 PM V11 (Licensed Practical Nurse) I worked with R2 on 8/11/18 and called for the x-ray results. However, I was not questioned about the injury or incident regarding R2. On 10/3/18 at 10 AM V12 (Hospice Registered Nurse) stated I saw the [MEDICAL CONDITION] to R2's arm. I reported it to the facility nurse (V9) on 8/6/18. No one ever asked me about the injury or incident. On 10/3/18 at 9 AM V2 (Director of Nursing) stated I never spoke with the nurses on 8/6/18 through 8/8/18. I did note that V14 (Registered Nurse) had documented on the chart that she contacted me on 8/8/18 but I did not receive any communication from her on that day. In addition, R2 was a under the care of hospice here at the facility. Due to R2's age and clinical condition it was not uncommon for a hospice patient to have swelling. Swelling was nothing to be alarmed about. I was first made aware of R2's arm on 8/9/18. When we received the x-ray results of the dislocation on 8/11/18, I then came into the facility. V1 (Administrator) had begun an investigation of injury of unknown origin on 8/11/18. On 10/3/18 at 11 AM V1 (Administrator) provided the policy for Accident Incident Reporting Policy (dated 8/3/17). The policy notes Any accident/incident may be reported immediately to the nurse or appropriate person designated to be in charge. A report may be completed for any individual involved in an accident or an incident while residing in the facility ., The physician/nurse practitioner may be informed of any changes in the resident's condition that have been identified. Orders for treatment/intervention may be obtained as deemed necessary. If the attending physician or physician on call can not be reached, the Medical Director should be notified and orders obtained as necessary. Any actions or communications are to be documented in the resident's medical record. On 10/3/18 at 11 AM V1 provided the policy entitled Change in Resident's Condition or Status (dated 6/26/11). The policy notes The Nurse will notify the resident's attending physician when the resident is involved in any accident or incident that results in an injury including injuries of unknown origin ., There is a significant change in the resident's physical, mental, and psychosocial status ., A significant change in condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan ., the nurse will record in the resident's medical record any changes in the resident's medical condition or status. On 10/8/18 at 1 PM a review of R2's Medical Record was conducted. It was noted that documentation of R2's medical condition was noted on 8/7/18, 8/8/18, 8/9/18, and 8/11/18. On 8/7/18 documentation occurred at 1:28 PM and 10:25 PM. There was no documentation on night shift. On 8/8/18 documentation at 2:27 PM. There was no documentation on afternoon shift or night shift. On 8/9/18 there was documentation at 10:08 PM. There was no documentation on day shift or night shift. On 8/10/18 there was no documentation on days, afternoons or night shifts. On 8/11/18 at documentation at 1:02 AM and 5:10 AM. After having received orders to transfer resident to hospital for evaluation at 5:10 AM, there are no further documentation of resident assessment, ambulance transfer, nor notifications documented in resident chart. On 9/27/18 at 1 PM V5 (Shift Supervisor / Registered Nurse) stated On 8/11/18 at around 6 AM, I was informed by V1 (Administrator) to interview staff regarding any information regarding R2 having a fall or incident that may have caused the injury or unknown origin. I interviewed the staff on my shift and passed the message on to the oncoming shift. I turned in the statements to V2 (Director of Nursing). On 10/5/18 at 10:10 AM V9 (LPN) stated Earliest date I was made aware of the [MEDICAL CONDITION] was 8/7/18 by the Hospice CNA. I informed V7 (Nurse Practitioner) of the [MEDICAL CONDITION]. (See narrative above). No one interviewed me in regard to any investigation of an injury of unknown origin. We have had inservices regarding injuries, incidents, and change of condition. I do not remember what date these were last done but not too long ago. When surveyor asked V9 about R2 having a change in condition, R2 responded Yes, R2 could have been an incident of unknown origin and/or change of condition. Surveyor asked about communication regarding nurse care. V9 stated We began a 24 hour log on 8/9/18 by our new Director of Nursing. However I did not read the 24 hour report. The night shift nurse did not give me report as we should have done on 'stand up and no I did not read the hospice communication log ., To me when I observed the shoulder, it looked to me as some sort of fluid filled sack on the ball joint of the shoulder. On 10/2/18 at 10 AM V1 (Administrator) stated I did not know about the arm swelling on 8/6/18. Although when I was aware of the [MEDICAL CONDITION], I did not read the Hospice Communication Log. (The communication log was taken back by Hospice on the day she was sent to the hospital for evaluation. When Hospice was called to get the log, they stated it was an internal communication material and destroyed when it was returned to the hospice office.) V1 stated I did not know of the incident/unknown injury until 8/11/18. Staff have been trained on what to do when there is an injury of unknown origin. I believe they followed our policy on change in condition when they got the x-ray results. I am not sure where any other documentation may have been communicated besides the progress notes, 24 hour log and the hospice communication log. I am aware that there was no documentation regarding R2's arm on 8/18/18 and am not sure why none was recorded. We did not start the investigation until 8/11/18 as we did not believe there was an injury or incident until 8/11/18 when we learned of the x-ray results. I agree there was a period of time delay from the injury till the x-ray was taken. This occurred as this patient is a hospice patient and hospice becomes the primary whenever they have a patient. We did not suspect abuse when we learned the first reports on 8/7/18. We did not initiate a reported from 8/6/18 through 8/10/18. We started the reportable of injury of unknown origin on 8/11/18. I had the shift nurse supervisor do the interviews. I sent in the initial report and the final was completed by the Director of Nursing. On 10/2/18 at 2 PM V17 (R2's Primary Care Physician) stated This patient is a hospice patient and has been for over a year and a half. The nurses and nurse practitioner reported to me that there was no pain or deformity to the patient's arm. The patient was able to have range of motion to her arm with assistance. As hospice is comfort care, we provided comfort for R2 by placing her arm on a pillow to decrease the swelling. We do not normally send hospice patients out or do any intervention that are aggressive. Surveyor asked if V17 thought a hospice nurse should have been sent out or called hospice or facility medical directors. V17 stated This was just swelling to the arm. Hospice patients have swelling commonly. If hospice drops the ball, the facility nurses should then call me. In this situation as they were not able to contact me, they did not need to call the facility medical director as this was just swelling or the arm in the beginning and the nurse did not report any deformity or pain. Patient care come first. On 9/26/18 at 10:50 AM V8 (Licensed Practical Nurse) stated I noted the swelling and the resident did not appear to have any pain. I called the nurse practitioner (V7) and she gave an order for [REDACTED]. I left a message with the Power of Attorney (POA). I took vital signs and they were within normal limits. I left a message with the hospice 24 hour phone line around 7 to 8 PM. I believe the hospice nurse was there that day on 8/9/18. On 10/3/18 V8 stated I did do range of motion with R2 when I assessed her. I would lift the arm up in front of her and to the side. I also did small circular motions. I did not see any facial grimacing nor did she moan. During this time, I did try calling V17 (Medical Doctor) but only paged and did not receive a return call. I called the mobile x-ray around 10:55 PM on 8/9/18. They have up to 4 hours to come and do the x-ray as this was not a Stat (emergency) x-ray. We generally get the results the next day. I did not have anyone ask to interview me regarding R2's injury, incident or change of condition. On 9/26/18 at 3:45 PM V6 (Hospice Director of Nursing) stated As a hospice nurse or certified nursing assistant our duty is to report any issues to the facility nursing staff in charge of the patient. We intervene only when it is regarding any issue that the patient has been admitted for by hospice. R2 was admitted to hospice for organic brain issues or dementia. The [MEDICAL CONDITION] to her arm was not under our reason for providing care. On 10/8/18 at 10 AM V19, V20, V21 and V22 (Certified Nursing Assistants) stated We were never interviewed regarding an investigation of a fall of unknown origin. On 10/11/18 at 9 AM V20 (Certified Nursing Assistant) stated I don't know how R2 incurred the injury to her arm. I worked with her all the way back from 8/7/18. In addition, I was never interviewed regarding any investigation of an injury of unknown origin.

Based on interview and record review the facility failed to monitor vulnerable residents vitals and changes in physical condition for immediate medical service, after staff noticed an uncomfortable environmental condition. This failure applies to two residents of eight residents (R1 and R2) reviewed for change of condition. As a result R1 and R2 change in physical condition was left unnoticed by nursing staff until each resident coded and needed emergency services. Each resident was found with elevated body temperatures (107.7 and 108 degrees Fahrenheit) and subsequently died . Findings Include: On [DATE] at 10:02 am Z3 (Police Officer) stated that he was at the facility three times on [DATE] regarding a resident's call. Z3 stated that he did not enter any resident rooms but noticed that the temperature in the hall was hot. On [DATE] at 11:43 am E5 (Maintenance Worker) stated that on Saturday [DATE] the facility heat was off during the day and he turned the heat back on before leaving on Saturday [DATE] around 3:30 pm. E5 stated that on [DATE] during the morning shift when he arrived to the facility he was informed by a Nurse and a Certified Nursing Assistant/CNA (not sure of the name) that the facility was too warm. E5 stated that he turned the facility boiler off, opened windows, put fans in the hallways and opened the stairwell doors along with the roof top door to allow cool air to circulate through the facility. E5 stated that he called E6 (Maintenance Director) between 7:00 am - 7:30 am on [DATE] to inform him about the facility temperatures being too warm. On [DATE] at 10:24 am during a 2nd interview, E5 (Maintenance Worker) stated that a Nurse (not sure of name) called him on Saturday [DATE] around 4:00 pm to report that the facility was too hot. E5 stated that he told the Nurse to open some windows, turn on the fans and call E6 (Maintenance Director). E5 stated that he did not call E6 because he told the nurse to call E6. On [DATE] at 2:56 pm E7 Licensed Practical Nurse (LPN) stated that on Saturday [DATE] during 3:00 pm - 11:00 pm the 3rd floor of the facility was extremely hot. E7 stated that she called E5 (Maintenance Worker) on [DATE] at 4:00 pm to inform him that the facility was too hot. E7 stated that E5 stated that it was nothing that he can do about the heat. E7 stated that she worked [DATE] - [DATE] during the night shift and the facility remained extremely hot. E7 stated that most of the residents on the 3rd floor are ventilator dependent and non-verbal. E7 stated that she was not assigned to care for R1 and R2 on [DATE] - [DATE]. E7 stated she provided ice for residents who could have ice, flushed gastrostomy tubes, provided cold compresses to residents and opened the room windows. The facility could not provide documented evidence of above interventions upon surveyor's request. On [DATE] at 10:52 am E2 Director of Nursing (DON) stated that she was notified of the issues in the building on [DATE] when she called the facility to check on the staffing for the day. E2 stated that she did not receive any calls from staff on [DATE]. E2 stated that in emergencies the staff should notify the DON and the Administrator. E2 stated that when the temperature in the facility is assessed to be too warm the nurses should keep residents well hydrated, provide fans, open windows, monitor vital signs and document the findings. On [DATE] at 10:30 am, E11, LPN stated that he worked Saturday [DATE] on the night shift. E11 stated that there were only two nurses for about forty ventilator and [MEDICAL CONDITION] residents. E11 stated that the 3rd floor was extremely hot on Saturday night. E11 stated that E7, LPN reported that she called Maintenance and he (E11) called E2 (DON) at 1:00 am but did not get an answer and did not leave a message. E11 stated that he opened all of the windows, flushed the gastrostomy tubes, and applied cool towels and sheets to residents head and under arms. E11 stated that the facility remained hot despite opening windows. E11 stated that he was not assigned to R1 and R2 but assisted with the code blue for both. E11 stated that he documented on R1's code but did not document on R2's code because he was off duty. E11 stated that R1 and R2 did not have a nurse assigned to them because of short staffing. E11 stated respiratory therapy suctioned the residents and the CNA's turned and repositioned. The facility could not provide documentation to support the above interventions. On [DATE] at 12:30 pm E12 CNA stated that she worked on Saturday [DATE] and Sunday [DATE]. E12 stated that the 3rd floor was so hot that she was perspiring. E12 stated that she opened windows and made sure her residents heating vents were in the off position but the facility remained hot. According to R1's face sheet, R1 was a [AGE] year old who was admitted to the facility on [DATE]. R1 had [DIAGNOSES REDACTED]. R1's orders note dated [DATE] documents that R1 was on contact isolation for ,[MEDICAL CONDITION]. difficle. R1's nurse's note dated [DATE] at 4:06 pm documents R1 appeared to have anasarca (swelling throughout entire body), +1 [MEDICAL CONDITION] in bilateral arms, lung sounds bilaterally clear, urine amber color with sediment in urinary catheter noted, remains on total parental nutrition 150 ml/hr x 16 hours, talked to in-house Nurse Practitioner about R1, new orders given. R1's progress/nursing notes do not includes what Physician orders [REDACTED]. R1's nurses note dated [DATE] at 5:10 am documents R1 noted unresponsive to verbal and tactile stimuli, Cardiopulmonary Resuscitation (CPR) immediately administered, code blue called, 911 phoned, Emergency medical services arrived, transferred to hospital, family made aware, message left with on call Nurse Practitioner, awaiting call back. R1's Physician order [REDACTED]. No new orders for [DATE] were noted. On [DATE] at 12:45 E22 Registered Nurse (RN) stated that she took care of R1 on [DATE] and the Nurse Practitioner ordered labs after being informed of R1's change in condition. E22 stated that R1's condition as documented in the notes was a change in condition for R1. During the survey the facility could not provide laboratory orders for R1 on [DATE]. R1's electronic Medication Administration Record [REDACTED]. R1's eMAR documents [DATE] on the evening shift the following; blood pressure - ,[DATE] mmHg, temperature 98.4 degrees Fahrenheit, pulse - 84 beats per minute, respirations 20 breaths per minute. R1's eMAR does not include vital signs for [DATE] night shift. R1's Fire Department Paramedic report documents in the narrative that R1 was unresponsive and not breathing, CPR was being performed by staff. The Fire Department continued CPR and transported R1 to the hospital. R1's Fire Department report provided by the hospital documents under skin: hot and mottled. R1's hospital record dated [DATE] documents R1 was pronounced dead at 5:55 am. R1's hospital records documents R1 remained pulseless and unresponsive upon arrival to the hospital. R1's hospital records dated [DATE] at 5:30 am documents a rectal temperature of 107.7 degrees Fahrenheit, and 0 for the pulse, blood pressure, respirations and oxygen saturations. R1's hospital documents under integument that R1 was very warm (febrile). R1's hospital records documents R1 blood glucose level at 460 milligrams/deciliter. According to R2's face sheet, R2 was a [AGE] year old admitted to the facility on [DATE]. R2's face sheet [DIAGNOSES REDACTED]. Fire Department Paramedic report dated [DATE] at 8:12 am documents that R2 was not breathing and CPR was in progress. R2's Fire Department Paramedic report dated [DATE] at 8:13 am documents R2 had no blood pressure, pulse, or respirations. R2's paramedic report documents R2's skin was diaphoretic (moisture), hot and cyanotic (blue). R2's hospital records dated [DATE] documents R2 arrived with blood glucose of 27 mg/dl, temperature of 108 degrees Fahrenheit and no blood pressure, pulse, respirations or oxygen saturations. R2's hospital records documents R2 appears cachectic with a sickly appearance. R2's hospital records documents that EMS came to desk, notified nurse that it was extremely hot in R2's room (at the facility). R2's POS includes an order dated [DATE] for vital signs every shift and an order dated [DATE] Do Not Attempt Resuscitation (DNR). The facility could not provide R2's DNR paperwork that confirms this is the correct order. R2's eMAR vital signs for [DATE] day, evening and night shift documents blood pressure - ,[DATE] mmHg, temperature - 98.4, pulse - 88 beats per minute, respirations - 18 breaths per minute and oxygen saturation 94% on day and evening and 96% on night shift. R2's progress/nursing notes had no nursing documentation regarding R2's condition for [DATE] or [DATE]. R2's progress/nursing notes did not include documentation of R2's condition on [DATE] prior to or during time of unresponsiveness. R2's progress/notes did not include documentation of any interventions during uncomfortable facility environmental temperatures. On [DATE] at 1:40 pm Z5, Medical Examiner stated that the final report denoting whether heat was a factor in R1's death is not complete. However, Z5 stated that R1 started to decompose quickly which is common with high body temperatures. On [DATE] at 1:25 pm Z6 (Nurse Practitioner) stated that R1's [DIAGNOSES REDACTED]. Z6 stated that it was natural for R1 to have an elevated temperature because of the infection and total parental nutrition. Z6 stated that ambient room temperature does not play a role in elevated body temperatures. Z6 stated that staff is expected to monitor vital signs, medicate as needed for elevated temperatures and notify Physician or NP for change of condition. R1's (MONTH) (YEAR) eMAR temperatures and vital summary do not include documentation of elevated temperatures. On [DATE] at 1:50 pm Z7 (R2's Pulmonologist) stated that he cannot comment on R2's temperature. Z7 stated that R2 had the [DIAGNOSES REDACTED]. Z7 stated that it is possible to be susceptible to high temperatures related to R2's condition. Z7 stated that if the room temperature is elevated staff must make ensure the resident temperature is not elevated, evaluate and treat if needed. On [DATE] at 10:04 am E16 LPN stated that she worked on [DATE] during the day shift. E16 stated that she was not assigned to the 3rd floor where there was a concern. E16 stated that the facility was warm on [DATE]. E16 stated that she received a call from the emergency room to inform of resident elevated temperatures. E16 stated that she spoke with maintenance, who stated the heat was turned off. E16 stated that she told staff to keep residents cool, check to make sure all residents were well hydrated, and take vital signs of all the residents. E16 stated that once she received the call from the emergency room she reported to the manager on duty who called the Director of Nursing. On [DATE] at 10:47 am E17 LPN stated that he worked at the facility on [DATE] and [DATE] from 7:00 am - 11:00 pm. E17 stated that the facility temperatures were very hot and uncomfortable. E17 stated that he noticed that the facility temperatures were too warm on [DATE] during the day shift. E17 stated that maintenance was aware of the high facility temperatures but there was no solution. E17 stated that the DON is new and no one had contact information for her so there were no means to contact, report and communicate with the DON. E17 stated that he provided ice packs and Tylenol to his residents. E17 stated that he is not aware of the weather emergency policy. On [DATE] at 12:45 pm E22 RN stated that the facility on 10/',[DATE] during the day shift was warm. E22 stated that a family member (cannot recall who) and staff complained about the warm temperature. E22 stated that most of the residents on the 3rd floor are non-verbal and could not express if the warm temperatures were uncomfortable. The facility could not provide documentation of the interventions or assessments for residents physical conditions, when the nursing staff acknowledged uncomfortable facility temperatures on [DATE].

Based on interview and record review the facility failed to assess, monitor and document vital signs and any changes in physical condition of ventilator and [MEDICAL CONDITION] dependent residents during uncomfortable facility environmental temperatures. This failure applies to 2 of 8 residents (R1, R2) reviewed for change in condition. As a result, R1 and R2 being found unresponsive, and arrived to the emergency room with temperatures of 107.7 and 108 degrees Fahrenheit and ultimately dying. Findings Include: R1's face sheet [DIAGNOSES REDACTED]. R1's face sheet documents that R1 was a [AGE] year old who was admitted to the facility on [DATE]. R1's orders note dated [DATE] documents that R1 was on contact isolation for ,[MEDICAL CONDITION]. difficle. R1's nurse's note dated [DATE] at 4:06 pm documents R1 appeared to have anasarca (swelling throughout entire body), +1 [MEDICAL CONDITION] in bilateral arms, lung sounds bilaterally clear, urine amber color with sediment in urinary catheter noted, remains on total parental nutrition150 ml/hr x 16 hours, talked to in-house Nurse Practitioner about R1, new orders given. R1's progress/nursing notes do not includes what Physician orders [REDACTED]. On [DATE] at 12:45 E22 Registered Nurse (RN) stated that she took care of R1 on [DATE] and the Nurse Practitioner ordered labs after being informed of R1's change in condition. R1 stated that R1's condition as documented above was a change in condition for R1. The facility could not provide laboratory orders for R1 on [DATE]. R1's Physician order [REDACTED]. R1's nurses note dated [DATE] at 5:10 am documents R1 noted unresponsive to verbal and tactile stimuli, Cardiopulmonary Resuscitation (CPR) immediately administered, code blue called, 911 phoned, Emergency medical services arrived, transferred to hospital, family made aware, message left with on call Nurse Practitioner, awaiting call back. R1's POS includes an order dated [DATE] for vital signs every shift. R1's electronic Medication Administration Record [REDACTED]. R1's eMAR documents [DATE] on the evening shift the following; blood pressure - ,[DATE] mmHg, temperature 98.4 degrees Fahrenheit, pulse - 84 beats per minute, respirations 20 breaths per minute. R1's eMAR does not include vital signs for [DATE] night shift. R1's Fire Department Paramedic report documents in the narrative that R1 was unresponsive and not breathing, CPR was being performed by staff. The Fire Department continued CPR and transported R1 to the hospital. R1's Fire Department report provided by the hospital documents under skin: hot and mottled. R1's hospital record dated [DATE] documents R1 was pronounced dead at 5:55 am. R1's hospital records documents R1 remained pulseless and unresponsive upon arrival to the hospital. R1's hospital records dated [DATE] at 5:30 am documents a rectal temperature of 107.7 degrees Fahrenheit, and 0 for the pulse, blood pressure, respirations and oxygen saturations. R1's hospital documents under integument that R1 was very warm (febrile). R1's hospital records documents R1 blood glucose level at 460 milligrams/deciliter. R2's face sheet documents that R2 was a [AGE] year old admitted to the facility on [DATE]. R2's face sheet [DIAGNOSES REDACTED]. R2's POS includes an order dated [DATE] for vital signs every shift and an order dated [DATE] Do Not Attempt Resuscitation (DNR). The facility could not provide R2's DNR paperwork. R2's eMAR vital signs for [DATE] day, evening and night shift documents blood pressure - ,[DATE] mmHg, temperature - 98.4, pulse - 88 beats per minute, respirations - 18 breaths per minute and oxygen saturation 94% on day and evening and 96% on night shift. R2's progress/nursing notes do not include documentation for [DATE] or [DATE]. R2's progress/nursing notes do not include documentation of R2's condition on [DATE] prior to or during time of unresponsiveness. R2's progress/notes do not include documentation of any interventions during uncomfortable facility environmental temperatures. R2's Fire Department Paramedic report dated [DATE] at 8:12 am documents that R2 was not breathing and CPR was in progress. R2's Fire Department Paramedic report dated [DATE] at 8:13 am documents R2 had no blood pressure, pulse, or respirations. R2's paramedic report documents R2's skin was diaphoretic (moisture), hot and cyanotic (blue). R2's hospital records dated [DATE] documents R2 arrived with blood glucose of 27 mg/dl, temperature of 108 degrees Fahrenheit and no blood pressure, pulse, respirations or oxygen saturations. R2's hospital records documents R2 appears cachectic with a sickly appearance. R2's hospital records documents that EMS came to desk, notified nurse that it was extremely hot in R2's room. On [DATE] at 1:20 pm R3 stated that her room was too hot on Saturday [DATE] and Sunday [DATE]. R3 stated that she complained to the staff and was told that the heat was not on. R3 stated that hot air continued to blow out of the heating vent so she placed a blanket over the vent to block the heat. R3's blanket was observed covering the heating vent. R3 stated that the Certified Nursing Assistant (CNA) opened her window and turned on the portable fan but the room remained too hot. R3 stated that her hair was soaked with perspiration on [DATE] because it was so hot in her room. On [DATE] at 1:25 pm R4 stated that the room was extremely hot on [DATE] and [DATE]. R4 stated that the CNA turned her fan on but the room was still too hot. On [DATE] at 2:32 pm E9 CNA stated that he worked Saturday [DATE] and Sunday [DATE]. E9 stated that the facility was too hot. E9 stated that anyone who could speak complained about the heat. E9 stated that on Saturday [DATE] the staff opened windows and on Sunday [DATE] Maintenance brought fans to the 3rd floor. On [DATE] at 7:55 am E10 CNA stated that the facility was hot on [DATE]. E10 stated that on [DATE] she was pulled from her assignment to take temperatures throughout the building. E10 stated that Maintenance opened windows and put fans out. On [DATE] at 8:10 am R6 stated that his room temperature was too hot over the past weekend. On [DATE] at 10:02 am Z3 (Police Officer) stated that he was at the facility three times on [DATE]. Z3 stated that he did not enter any resident rooms but noticed that the temperature in the hall was hot. . On [DATE] at 2:56 pm E7 Licensed Practical Nurse (LPN) stated that on Saturday [DATE] during 3:00 pm - 11:00 pm the 3rd floor of the facility was extremely hot. E7 stated that she called E5 (Maintenance Worker) on [DATE] at 4:00 pm to inform him that the facility was too hot. E7 stated that E5 stated that it was nothing that he can do about the heat. E7 stated that she worked [DATE] - [DATE] during the night shift and the facility remained extremely hot. E7 stated that most of the residents on the 3rd floor are ventilator dependent and non-verbal. E7 stated that she was not assigned to care for R1 and R2 on [DATE] - [DATE]. E7 stated that she provided ice for residents who could have ice, flushed gastrostomy tubes, provided cold compresses to residents and opened the room windows. The facility could not provide documentation of above interventions. On [DATE] at 10:52 am E2 Director of Nursing (DON) stated that she was notified of the issues in the building on [DATE] when she called the facility to check on the staffing for the day. E2 stated that she did not receive any calls from staff on [DATE]. E2 stated that in emergencies the staff should notify the DON and the Administrator. E2 stated that when the temperature in the facility is assessed to be too warm the nurses should keep residents well hydrated, provide fans, open windows, monitor vital signs and document the findings. On [DATE] at 10:24 am during a 2nd interview, E5 (Maintenance Worker) stated that a Nurse (not sure of name) called him on Saturday [DATE] around 4:00 pm to report that the facility was too hot. E5 stated that he told the Nurse to open some windows, turn on the fans and call E6 (Maintenance Director). E5 stated that on Sunday [DATE] the windows on the 3rd floor were closed and he removed the chains from the windows to allow them to open fully. E5 stated that sometimes the wind will close the windows after they have been opened. On [DATE] at 10:30 am E11 LPN stated that he worked Saturday [DATE] on the night shift. E11 stated that there were only two nurses for about forty ventilator and [MEDICAL CONDITION] residents. E11 stated that the 3rd floor was extremely hot on Saturday night. E11 stated that E7 reported that she called Maintenance and he (E11) called E2 (DON) at 1:00 am but did not get an answer and did not leave a message. E11 stated that he opened all of the windows, flushed the gastrostomy tubes, and applied cool towels and sheets to residents head and under arms. E11 stated that he was not assigned to R1 and R2 but assisted with the code blue for both. E11 stated that he documented on R1's code but did not document on R2's code because he was off duty. E11 stated that R1 and R2 did not have a nurse assigned to them because of short staffing. E11 stated respiratory therapy suctioned the residents and the CNA's turned and repositioned. The facility could not provide documentation to support the above interventions. On [DATE] at 12:30 pm E12 CNA stated that she worked on Saturday [DATE] and Sunday [DATE]. E12 stated that the 3rd floor was so hot that she was perspiring. E12 stated that she opened windows and made sure her residents heating vents were in the off position but the facility remained hot. On [DATE] at 1:15 pm E14 LPN stated that she worked on the 3rd floor of the facility on [DATE] during the evening shift. E14 stated that the facility was so hot that she became ill from the heat. E14 stated that E7 LPN called maintenance to report the hot temperatures in the facility. E14 stated that she opened windows, turned on fans and took vitals. E14 stated that some residents appeared to be in distress but she was not familiar with the residents. E14 stated that R1 had a slight temperature of 99 degrees Fahrenheit. E14 stated that R1 did not look good when E7 and E14 went into the room to hang his total parental nutrition and intravenous fluids, so she took the blanket off of R1. E14 stated that R2 temperature was not high but he was warm to touch. E14 stated that the building was too hot. On [DATE] at 3:05 pm Z4 (R5's family) stated that she visited the facility on [DATE] at 6:00 am and the facility was extremely hot. Z4 stated that R5, the staff and she were sweating because the facility was so hot. On [DATE] at 1:40 pm Z5 Medical Examiner stated that the final report denoting whether heat was a factor in R1's death is not complete. Z5 stated that R1 started to decompose quickly which is common with high body temperatures. On [DATE] at 12:05 pm E1 Administrator stated that she was notified about the concerns of the temperatures in the facility on Sunday [DATE] between 9:30 am - 10:00 am. On [DATE] at 1:25 pm Z6 (Nurse Practitioner) stated that R1's [DIAGNOSES REDACTED]. Z6 stated that it was natural for R1 to have an elevated temperature because of the infection and total parental nutrition. Z6 stated that ambient room temperature does not play a role in elevated body temperatures. Z6 stated that staff is expected to monitor vital signs, medicate as needed for elevated temperatures and notify Physician or NP for change of condition. R1's (MONTH) (YEAR) eMAR temperatures and vital summary do not include documentation of elevated temperatures. On [DATE] at 1:50 pm Z7 (R2's Pulmonologist) stated that he cannot comment on R2's temperature. Z7 stated that R2 had the [DIAGNOSES REDACTED]. Z7 stated that it is possible to be susceptible to high temperatures related to R2's condition. Z7 stated that if the room temperature is elevated staff must make ensure the resident temperature is not elevated, evaluate and treat if needed. On [DATE] at 1:38 pm E15 (Activity Director/Manager on Duty) stated that on Saturday [DATE] no one informed her of temperatures being too hot. E15 stated that she was in the building on Saturday [DATE] during the morning shift and the temperatures were comfortable to her. E15 stated that on Sunday [DATE] during the morning shift the facility did appear to be hot. E15 stated that she asked E5 about the heat and he stated that he turned the heat off. On [DATE] at 10:04 am E16 LPN stated that she worked on [DATE] during the day shift. E16 stated that she was not assigned to the 3rd floor where there was a concern. E16 stated that the facility was warm on [DATE]. E16 stated that she received a call from the emergency room to inform of resident elevated temperatures. E16 stated that she spoke with maintenance, who stated the heat was turned off. E16 stated that she told staff to keep residents cool, check to make sure all residents were well hydrated, and take vital signs of all the residents. E16 stated that once she received the call from the emergency room she reported to the manager on duty who called the Director of Nursing. On [DATE] at 10:47 am E17 LPN stated that he worked at the facility on [DATE] and [DATE] from 7:00 am - 11:00 pm. E17 stated that the facility temperatures were very hot and uncomfortable. E17 stated that he noticed that the facility temperatures were too warm on [DATE] during the day shift. E17 stated that maintenance was aware of the high facility temperatures but there was no solution. E17 stated that the DON is new and no one had contact information for her so there were no means to contact, report and communicate with the DON. E17 stated that he provided ice packs and Tylenol to his residents. E17 stated that he is not aware of the weather emergency policy. On [DATE] at 12:45 pm E22 RN stated that the facility on 10/',[DATE] during the day shift was warm. E22 stated that a family member (cannot recall who) and staff complained about the warm temperature. E22 stated that most of the residents on the 3rd floor are non-verbal and could not express if the warm temperatures were uncomfortable. The facility could not provide documentation of the interventions or assessments for residents when the uncomfortable facility temperatures were identified on [DATE]. The facility's weather emergency dated ,[DATE] documents that the facility will maintain a safe and comfortable temperature level; if temperature is above the comfort zone, extra fluids will be administered; if an area is above or below comfort zone due to equipment failure, residents will be removed from the area while repairs are made and staff follow emergency procedures as needed.

Based on observation, interview and record review the facility failed to provide wound treatment as prescribed, failed to prevent wound infection and failed to turn and reposition at least every two hours for three residents (R1, R7 and R17) out of seven reviewed for pressure ulcers. As a result R1 was admitted to the hospital [MEDICAL CONDITION] and necrotic wound resulting in surgical wound debridement. Findings Include: R1's face sheet [DIAGNOSES REDACTED]. R1's nursing admission clinical observation dated 2/3/17 indicates that R1 was admitted with a right hip scar, a sacral wound and right heel wound. R1's wound assessment details dated 2/4/17 indicates that R1 was admitted with an unstageable pressure ulcer to the sacral and a deep tissue injury (DTI) to the right heel. R1's Braden scale for predicting pressure sore risk dated 2/4/17 indicates that R1 had a high risk for developing pressure sores. R1's wound assessment details dated 2/8/17 indicates that while rendering care R1 was noted with a new open open area to the right hip. R1's wound assessment indicates that R1 was observed with a facility acquired deep tissue pressure injury to the right trochanter (hip) measuring 4 X 3.5 centimeters. R1's wound assessment indicates that R1 was observed with a facility acquired deep tissue injury to the right lateral foot on 2/16/17. R1's wound assessment details indicates that R1 was observed with facility acquired (DTI) to the left heel, left lateral foot, the left mid foot and the left lateral ankle on 3/9/17. R1's wound care note dated 3/14/17 includes the following, R1 noted with DTI wounds on left foot, R1 noted with no heel boots during rounds. R1's wound treatment note details dated 2/23, 3/2, 3/9, 3/16, 3/23, 3/30, 4/6/17 indicates that the following dressing were applied to R1's right trochanter (hip): calcium alginate, santyl and xeroform. R1's order summary includes an order dated 2/20/17 and discontinued 4/14/17 for santyl ointment, apply to right hip topically every day shift for wound care cleanse with normal saline, apply Santyl, then cover with calcium alginate then cover with dry dressing. R1's right hip dressing does not include an order for [REDACTED]. R1's wound care specialist evaluation dated 4/13/17 indicates that R1's unstageable (due to necrosis) of the right hip was deteriorated with 4 centimeters undermining, moderate serous exudate and 100% necrotic tissue. R1's wound care treatment recommendation was Dakin's wet to moist twice daily. R1's wound care specialist evaluation dated 4/27/17 indicates that R1's wound care treatment was recommended for Dakin's wet to moist twice daily and to be evaluated by general surgery for [REDACTED]. R1's wound assessment details dated 4/27/17 indicates that R1's right trochanter pressure ulcer was a stage 4 with 4 centimeter undermining. R1's wound treatment notes dated 4/13 and 4/27/17 indicates that R1 had the following dressing applied: Dakin's 1/4 strength solution, santyl and xeroform guaze. R1's order summary report includes an order dated 4/14/17 for Dakin's solution 0.25% apply to right hip every day and evening shift for wound care, cleanse with normal saline, apply Dakin's wet to moist. R1's order summary does not include an order to apply santyl and xeroform with Dakin's solution to the right hip. R1's April 2017 Treatment Administration Record (TAR) indicates as evidenced by no initials or documentation that R1's right hip dressing was not changed on the evening shift on 4/15/17, 4/16/17, 4/21/17, 4/231/7, 4/25/17 and 4/29/17. R1's TAR indicates as evidenced by the abbreviation NA (not available) that R1 did not receive a dressing change on the evening shift to the right hip on 4/17/17 and 4/18/17. R1's nursing notes and TAR do not include documentation to indicate why R1 right hip dressing was marked as not available. R1's pressure injury care plan imitated 2/7/17 includes interventions to turn and re-position every 2 hours, and the pressure relieving devices while in bed and chair. R1's wound care note dated 4/30/17 includes the following, right hip wound assessed for surgical consult by Physician, R1 needs to be sent out to the hospital related to infected necrotic hip wound. R1's hospital records dated 4/30/17 indicates that R1 was admitted with the chief complaint of necrotic wound [MEDICAL CONDITION]. R1's hospital records under assessment and plan indicates that had a decubitus ulcer to the right hip that may need surgical debridement. R1's hospital records dated 5/2/17 indicates that R1 had an excisional debridement of right hip wound 16 X 13 centimeters involving skin, subcutaneous tissue, fat, muscle and fascia. R1's description of procedure indicates that an area of necrotic tissue was identified to the right hip with frank pus draining out to the area of necrotic tissue. R1's description of procedure also indicates that the bone was eaten away around the edges and the cortex appeared to be gone, indicative of osteo[DIAGNOSES REDACTED]. R1's hospital discharge note dated 5/19/17 indicates that R1 [MEDICAL CONDITION] secondary to the infected decubutis ulcers. R1's blood culture drawn 4/30/17 indicates gram positive bacilli. R1's surgical wound culture collected 5/2/17 indicates moderate [MEDICATION NAME] species, [MEDICATION NAME] faecalis and moderate growth arcanobacterium haemolyticum. On 7/6/17 at 1:35 pm E6 Wound Nurse stated that wound care orders should be followed. E6 stated that if wound is not performed the reason should be documented. On 7/31/17 at 11:45 am Z11 (R1's Wound Physician) stated that Dakin's solution is a bleach solution used to obliterate bacteria burden in wounds. Z11 stated that R1's dressing was changed to Dakin's solution when a decline in the wound to the right hip was noted. Z11 stated that he suspected that R1's right hip wound was infected and he referred R1's to the wound surgeon. On 7/31/17 at 2:20 pm E6 (Wound Nurse) stated that Dakin's is a watered down bleach solution used for pseudomonas (infection) like wounds. E6 stated that Dakins's is used to decrease odor and bacteria in wounds. E6 stated that Dakin's solution is most effective if used as prescribed. E6 stated that on 4/27/17 with Z11 during R1's wound care, R1's dressing was removed and there was a very strong, foul smelling odor. E6 stated that Z11 referred R1 to the wound surgeon. E6 stated that when the wound surgeon came in to see R1 he sent R1 out to the hospital immediately. R1's death certificate dated 5/19/17 indicates that R1's cause of death [MEDICAL CONDITION], pressure ulcers, and [MEDICAL CONDITION]. R7's face sheet [DIAGNOSES REDACTED]. On 7/12/17 from 10:13 am - 12:35 pm R7 was observed resting on his back in bed with no repositioning. The facility wound report dated 6/24/17 - 7/6/17 indicates that R7 was admitted with a stage 2 sacrum wound and developed a facility acquired unstageable pressure ulcer to the left ear. R7's Minimum Data Set ((MDS) dated [DATE] indicates that R7 requires total dependence with one person assistance for bed mobility. R7's care plan for actual pressure ulcer dated 5/10/17 includes an intervention that R7 needs monitoring/reminding/assistance to turn and reposition every two hours or as needed. R17's face sheet [DIAGNOSES REDACTED]. On 7/12/17 from 10:13 am - 12:35 pm R17 was observed resting on his back in bed with no repositioning. The facility's wound report dated 6/24/17 - 7/6/17 indicates that R17 was admitted with stage 4 pressure ulcers to the sacral, head (occiput), right ischial, an unstageable pressure ulcer to the left ischial and a stage 3 pressure ulcer to the left medial foot. The facility's wound report indicates that R17 developed a facility acquired stage 4 pressure ulcer to the left ankle. R17 MDS dated [DATE] indicates that R17 requires total dependence with one person assistance for bed mobility. R17's skin breakdown care plan dated 7/7/17 includes an intervention to turn and reposition every two hours and as needed. R17's actual pressure injury care plan dated 5/5/17 includes an intervention that R17 needs monitoring/reminding/assistance to turn and reposition every two hours or as needed. The facility's Pressure Ulcer Prevention policy dated 07/2011 indicates that residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. The facility's wound cleansing and dressings policy dated 07/2011 indicates under dressing changes to apply new dressing after cleansing the wound per Physician order. The facility's wound cleansing policy also indicates that documentation of the dressing change is completed on the Treatment Administration Record (TAR).

Based on interview and record review, the facility failed to assess and observe a change in skin condition until a stage 4 pressure developed for 1 of 3 residents for pressure ulcers. This failure resulted in the delay in assessment and treatment of [REDACTED]. Findings include: R2 is [AGE] years old with [DIAGNOSES REDACTED]. On 7/22/15, 2:00 PM R2 was observed non responsive in bed [MEDICAL CONDITION] ventilator. According to E7, CNA (Certified Nursing Aide) Supervisor, R2 had very recently returned from hospitalization . The electronic medical record verified that R2 was hosptalized on [DATE] due to [MEDICAL CONDITION], and returned to the facility on [DATE]. The latest quarterly MDS (Minimum Data Set) dated 5/18/15 noted a BIMs score (Brief Interview for Mental Status) of 6 out of a possible 15. R2 is dependent on staff for all ADLs (Activities of Daily Living) and was often incontinent of bowel and bladder. The current Braden scale for predicting pressure sore risk, dated 7/14/15, scored 12.0 (high risk). Documented medical history of [REDACTED]. On 5/14/15 8:00 AM, E6's (Wound Care Nurse) progress note said, Nurse reported to writer of new open area. Upon assessment, writer noted Stage 4 to sacrum 9.5cm x 3.0 cm, 1-26% eschar, 51-75% slough. Prescribed treatment was: Apply an enzymatic [MEDICATION NAME] ointment to sacrum topically every day. Cleanse with normal saline solution, cover with dry dressing. On 7/23/15, 12:35 PM, E5, Wound Care Co-coordinator was questioned about the apparent advanced status of the newly observed wound on 5/14/15. E5 stated, I don't know how it is a new wound at stage 4. I think it is unstagable. E5 stated that she would further investigate. E5 returned at 2:15 PM and stated that it was a new wound. When asked about how it could have been newly discovered at such an apparent advanced state, E5 said, I don't know. On 7/23/15, 11:30 AM E7 CNA Co-coordinator stated that residents receive a shower twice a week. E7 stated that a chair / bed bound, incontinent resident, as R 2 was, should be repositioned and receive a skin check every 2 hours or more frequently if necessary. The daily nursing progress notes from 4/14/15 - 5/14/15 noted R2 as totally incontinent of bowel and bladder, totally dependent for toileting. The facility policy, RISK AND SKIN ASSESSMENT, dated 07/20/2011 notes, in part: It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in the facility. All residents have a visual inspection of their skin D. The nursing assistant visually inspects the skin daily and with care 1. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate. On 7/24/15, 10:45 AM in the conference room, Z2, Wound Care Doctor was asked for possible reasons concerning the reported advanced state of R2's sacral wound when it was first discovered. Z2 stated that it is possible for the skin to break down within 2-3 days. In such case, Z2 stated it is likely a Kennedy ulcer. Z2 said that a Kennedy ulcer is not likely to improve except in very rare cases if the underlying condition is reversed. Z2 also stated that death usually occurs quickly when a Kennedy ulcer appears. Z2 stated that he had not yet diagnosed R2's sacrum ulcer as a Kennedy ulcer. The skin care assessment sheet, dated 5/30/15 showed some improvement in the sacral wound size (7.2 x 6.8 cm); 6/8/15, 7.0 x 6.5 cm, when compared to the date of discovery, 5/14/15 (9.5 x 3.0 cm). The skin care assessment sheet dated 7/15/15, notes the sacral wound condition as 13.5 x 12.0 with 10% granulation and 90% slough. On 7/24/15, 11:50 AM, wound care was provided by E5, Wound Care Co-coordinator. E5 stated that the measurements should have been done that day, if Z2, Wound Care Doctor would have seen R2, but Z2 was waiting for family consent to deride the wound. The wound size appeared greater than the stated measurement for 7/15/15 with no signs of granulation. The wound bed was mostly slough with some bloody areas.

Based on interview and record review, the facility failed to ensure that safety interventions were implemented for 1 of 3 residents reviewed for falls, that was agitated (R1). These failures resulted in R1 being left sitting on the bed unsupervised, falling and sustaining facial trauma that required sutures. Findings include: Admission Record with a print date of 3/1/14 read R1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Physician order [REDACTED]. Facility Screening for Assessment for Indicators of Aggressive and/or Harmful Behavior dated 1/14/14 reads: History or recent episode of aggressive/agitated behavior (aggression toward others, including destruction of property, fire setting, or other violent acts) and/or non-compliance with medications, treatment regimen, resisting care. Score of 2 was given which indicates substantial or significant problem. On 3/7/14 at 10:53 am, E5 (licensed practical nurse) stated "She was sitting on the side of the bed. I know she's a fall risk, so I got a certified nurses assistant (CNA) (E6) to assist to transfer to the chair." R1 "refused, became combative, didn't want to be bothered. She became real agitated, so we backed away. We all left the room. After 5 minutes I came back and she was on the floor. I assessed her, she had a cut below her lip. Sometimes she can get combative, she's not always combative. Redirection wasn't working, she was becoming more angry. We would frequently monitor her because she was a fall risk. When I left her she was sitting on the side of the bed." A witness statement documented on 2/26/14 from E5 reads: Upon making rounds R1 was noted sitting up on the side of the bed in an unsafe manner. E6 and E5 attempted to intervene and assist her to get up in the chair. R1 became very agitated with us and quickly became combative lashing out and attempting to fight with us. We left her alone for a while to calm down. I went back to the room later and she again became combative and refusing for us to touch her. We left again to try to give her time to calm down. Shortly after leaving the room she tried to get up from the bed and fell to the floor. On 3/7/14 at 11:25 am E4 (certified nurses assistant) stated "I was doing round and heard a commotion. She (R1) was cursing out the nurse. She always combative. She screams and cusses out. I been working with her (R1) and she usually calms down. I left and the nurse was in there. I heard her stop cursing then 10 minutes after that I heard a lot of bumping then about 1-2 minutes later, I went in her room (R1) and I saw her on the floor and blood around her. I called the nurse (E5) and she was in another room with another resident. She (R1) was sitting on the bed when I left. It's not a safe position and that's why we try to get her in the chair. I usually sit and watch her when she sits on the bed." A witness statement documented on 2/26/14 from E4 reads: We couldn't get her to calm down so I left the room and (E5) left behind me. Shortly after we all left the room I was in the room next door. I heard some bumping and went back to her room and she was on the floor with blood coming from her face. And no one was in the room but her. On 3/20/14 at 2:06 pm E6 (certified nurse assistant) stated R3 "was sitting on the side of the bed attempting to stand up. We were scared she was gonna fall. She became combative when we attempted to transfer her." A witness statement documented on 2/26/14 from E6 reads: We went to the room and R3 start cursing us out saying she don't know either one of us so she is not going anywhere and that we can forget about trying to touch her. I went back to my assignment. About 20 minutes later I heard that she had fell and she was on her way out with 911. R1 was sent to the local hospital for evaluation and treatment. Hospital record review: physician progress notes [REDACTED]. Nurses Notes dated 2/26/14 at 6:00 am reads: Resident returned to the facility with four sutures to the inside of the mouth that will dissolve. Seven sutures under the lower lip to be taken out in 3-5 days. Facility care plan, date initiated 12/4/13 reads: The resident exhibits the symptoms of resisting care as manifested by refusing care and refusing dialysis. Resident is also being physical and aggressive with staff by scratching them during care. Resisting care is related to: misunderstanding caregiver requests. Interventions: emphasize soothing, kind slow, and compassionate speech. Do not rush or hurry the resident. Use body language that communicates patience. Refer the resident to the consulting psychiatrist for a psychiatric evaluation, as warranted. Facility care plan, date initiated 12/11/13 reads: Is at high risk for falls characterized by multiple risk factors related to: impaired balance, poor judgement, and poor safety awareness. Interventions: 1/29/14 Resident educated to use call light for assistance when needed. Staff to make frequent rounds when resident is in room alone to ensure safety. Staff to get resident up from bed when not feeling tired. 2/14/14 physical therapy to screen to resident due to new onset attempted mobility. Psychiatric Evaluation dated 1/30/14 reads: Previous symptoms: excessive anxiety Insight judgement: Impaired judgement, Impaired insight Overt Behavior(s): memory loss and confusion Behavior Management Policy reads: In the event of a behavior emergency, appropriate staff will attempt to diffuse the situation, notify the attending physician and the psychiatrist and maintain the safety of the resident with escalating behavior as well as the other residents in the immediate area. Maintaining safety was not implemented .Staff left the resident alone sitting on the side of the bed. There is no documented evidence that the physician was notified of behaviors prior to the fall incident. On 3/20/14 at 10:35 am E2 (director of nurses) stated "They should have stayed with the resident, not touched her, but stayed with her until she calmed down. They should not have left her alone."

Based on interview and record review the facility failed to follow their notification of physician policy, and failed to follow their change in residents condition policy and notify the physician and family with an accurate detailed assessment after a fall incident for 1 of 3 residents (R1), all reviewed for falls. This failure resulted in R1 not receiving physician orders [REDACTED]. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for [MEDICAL TREATMENT] when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for [MEDICAL TREATMENT]. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2, Director of Nursing (DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to [MEDICAL TREATMENT], but my leg is really hurting." On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by Certified Nurse Assistant (CNA) that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to lift R1. E9 said that there was no mechanical lift in the room, and no that staff didn't bump R1 head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able to bend within normal limits. E9 said that after her assessment she left the room because she had other residents to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to [MEDICAL TREATMENT] that she gave R1 pain medication ([MEDICATION NAME] 2mg). E9 said this about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called physicians, Z1 and Z2, and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. A 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft. On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep an eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his [MEDICAL TREATMENT] treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the change in resident condition or status policy: the facility will promptly notify the resident's attending physician and legal representative/family of changes in the residents condition and/or status. The policy indicates the nurse will notify the physician if the resident has an accident/incident that results in injury. According to the notification of physician policy the facility staff will notify the resident's attending physician when there is a significant change in the residents condition. The policy notes a significant change as requires the physician immediate input and treatment for [REDACTED]. The policy also outlines a significant change as fall with injury. According to E9's employee report dated 4/23/2013 indicates that E9 failed to document a thorough and detailed nurisng assessment for R1 after an incident. The report also indicates that E9 documented inaccurately that she notified the family and physician, when E9 only left a message for the family and paged the physican. The report indicates that due to past history E9 was being discharged from employment.

Based on interview and record review, the facility failed to accurately assess for bruising and injuries, failed to document accurately in the clinical record, and incident reporting form. The facility also failed to ensure the physician was given complete and accurate information to ensure prompt treatment for 1 of 3 residents (R1), all reviewed for post fall assessments. This failure resulted in R1's being delayed in receiving treatment for [REDACTED]. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for [MEDICAL TREATMENT] when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for [MEDICAL TREATMENT]. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2 Director of Nursing(DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to [MEDICAL TREATMENT], but my leg is really hurting." According to the [MEDICAL TREATMENT] progress note dated 4/10/2013 8:00am notes that R1 said she was dropped upstairs while being transferred prior to coming down to [MEDICAL TREATMENT]. R1 is also noted with a bump/bruise on front of head. The note indicates that the facility staff verbalized they were aware of R1's status. Nursing notes dated 4/10/2013 5:00am denotes that R1 slid to the floor while being transferred from chair to bed in preparation for [MEDICAL TREATMENT]. Head to toe assessment completed with zero injuries. R1 noted as being assisted back to the chair to prepare for [MEDICAL TREATMENT]. R1 noted with complaints of pain, pain medication given as prescribed. The note also indicates that family and physician was notified with no new orders. Nursing note 6:00am R1 down in [MEDICAL TREATMENT]. Nursing note 7:00am notes endorsed to next shift. Nurse note written by E9, Nurse. On 4/12/13 at 4:00pm E7, Restorative Nurse, said that she did an assessment of R1's mobility, and transfer status. Reviewed restorative nursing assessment needs dated 3/21/2013 with E7. E7 said that she completed this assessment. The area of the assessment (mobility) denotes for weight bearing R1 is assessed a (4) which indicates dependent, transfer from bed to chair /chair to bed R1 is assessed extensive assistance. E7 said that R1 is unable to bear weight or stand without at least (2) staff on either side using a gait belt. E7 said that during her assessment R1 was observed, and at times R1's knee would buckle and would be unable to transfer because of weakness. E7 said that if R1 knees were weak staff would be unable to transfer her at that time without the use of mechanical lift. E7 also said that when she coded R1 as extensive assistance she said it would require (2) staff to assist R1 with transfers. E7 said that she was not part of the MDS coding for R1 last update. E7 said that her restorative aide were aware that R1's knee could buckle during transfer, however E7 said she didn't make certified nursing staff aware of R1's weak lower extremity. E7 said that they should be aware because of past experience of getting R1 up. Reviewed R1's most current Minimum (MDS) data set [DATE], section G indicates that R1 requires extensive assistance and 1 person physical assist. E7 said that the assessment was incorrect and that R1 requires 2 person assistance, and mechanical lift if R1's knee were weak. E8, Certified Nurse Aide (CNA), was not available for interview during this survey, in fact the facility provided the survey team with a employee report dated 4/17/2013 indicating that E8 was discharged from employment for not responding to facility phone calls, and not reporting to an agreed upon meeting with E2, DON. However the facility provided the surveyor with a statement taken over the phone from E8. The statement indicates that E8 gave R1 care and was getting R1 dressed with the help of another certified nurse aide. The statement notes that R1 said that she could stand up for a while, so it was decided to pivot R1 into a chair. The statement indicates that once R1 stood up, that her knees gave out because R1 slid to the floor. The note indicates that R1 was being directed on what to do when her knees collapsed and R1 went down onto her knees then laid to her left side with both legs to her right side. E8 indicates that the other CNA stayed with R1, while she went and got the nurse. E8 also indicates they paged for help from other CNAs. E8 indicates that there were now 4 CNAs, and that they rolled R1 onto a sheet underneath her, and as they all lifted R1 from the floor with the sheet that R1 bumped the bed rail and ended up lying on her face. E8 said that R1 was repositioned in bed, and they went and got a mechanical lift. E8 indicates that she got R1 up by using the mechanical lift and transferred her to the chair. E8 indicates that the nurse came and gave R1 pain medication, and E8 took R1 to [MEDICAL TREATMENT]. There was no entry indicating the condition of R1's face or leg. On 4/12/13 at 4:15pm via phone E11, CNA, said that E8, CNA, asked her to assist getting R1 out bed for morning [MEDICAL TREATMENT]. E11 said that she didn't put a gait belt on R1, but thinks that E8 had placed one around R1 for the transfer. E11 said that they were able to get R1 in a standing position, and R1 started complaining about her knee hurting and leg pain. E11 said that R1 legs started to buckle, and she felt that R1's legs were going out. E11 said that R1 landed in an awkward position sitting on her buttocks with her legs underneath her. However E11 said that R1's head didn't hit anything. E11 said there was no swelling or bruising on R1's face. E11 said that after R1 was on the floor they asked (2) other CNAs to assist with putting R1 back to bed because she was to heavy to lift with just 2 people. E11 said that they rolled R1 onto a bed sheet and (1) CNA on each end of the sheet lifted R1 back to the bed. E11 said that R1 wasn't bumped during the transfer with the sheet. E11 said that the side rails on the bed was down during this transfer and that R1 head didn't bump the rail during this transfer. E11 said after R1 was back in the bed, R1's leg looked okay, however she said she didn't really look because R1 was wrapped in the sheet. E11 said that after R1 was back in bed she kept complaining of leg pain. E11 said that she left the room after this transfer to get back to her residents, and said she don't know how R1 was transferred from the bed to the [MEDICAL TREATMENT] chair. E11 said that she was not aware that R1 had lower extremity weakness, and was never informed that R1's knees might give out during transfer. On 4/12/2013 at 4:30pm E10,CNA, said that she was working on another unit when she was asked to assist getting R1 off the floor. E10 said that there were 4 aides assisting with getting R1 off the floor. E10 said that they rolled R1 side to side onto a sheet to lift her back into the bed safely. E10 said that R1 didn't hit/bump anything while being transferred from the floor to the bed. E10 said that the side rails on the bed were down during the transfer and R1's face/head didn't hit the side rails. E10 said that R1 didn't have any facial swelling and/or bruising. E10 said she was told by E8 that R1 had slid to the floor. E10 said that when she arrived to R1's room that R1 was sitting on her buttocks with her legs underneath her. E10 said that when arrived to the room R1 was not wearing a gait belt around her. E10 said once she assisted R1 back to bed that she left and didn't assist R1 anymore that day. E10 said she don't know how R1 was transferred from the bed to the chair to go to [MEDICAL TREATMENT]. E10 said that she doesn't recall seeing R1's leg, however did say that R1 complained of leg pain. On 4/12/13 at 4:35pm via telephone E12,CNA, said that E8 asked her if she could assist in getting R1 off the floor. E12 said that she entered R1's room and that R1 was on the floor sitting on her legs with her feet under her buttocks. E12 said that R1 was asking for a pain pill. E12 said that R1 wasn't wearing a gait belt when she entered the room. E12 said that they rolled R1 onto a sheet to transfer her from the floor to the bed. E12 said it was 2 aides on each side of the sheet for a total of 4 aides. E12 said that when R1 was lifted from the floor the bed was in lowest position and the side rails were down. E12 said that R1 wasn't bumped into anythng during this transfer. E12 said that R1's leg didn't look swollen, but she was put in the bed flat. E12 said that R1 was complaining of pain to the leg. E12 said that R1 didn't have any facial bruising or swelling at that time. E12 said that she left the room after the transfer, and don't know how R1 was trnsferred from the bed to the chair for [MEDICAL TREATMENT]. Nursing note dated 4/10/2013 11:30am indicates that R1 back from [MEDICAL TREATMENT] on geri chair, R1 complaining of pain, nurse indicates inflammation over the right knee, no bruising or discoloration noted. R1 also noted with a 2"x2" bump noted to the right forehead. R1 complains of pain with slight pressure. The note indicates the right knee is immobilized and ice pack applied, pain medication given. Nursing note 11:35am indicates that the physician was notified with orders to send to the hospital for evaluation. Nursing note 11:37 family notified. Nursing note 12:10pm R1 pick up by ambulance service in route to local hospital for evaluation. Note written by E13, Nurse. On 4/19/2013 at 1:45pm E13, Nurse said that when he started his shift at 7:00am on 4/10/2013 that R1 was in [MEDICAL TREATMENT], and had been involved in a fall incident. E13 said that it was reported to him that R1 didn't sustain any injuries. E13 said around 11:30am R1 was being pushed in her recliner chair through the elevator doors, E13 said that he immediately observed an moderate size bump on R1's forehead. E13 said he that immediately notified E14, Supervsior of his observation. E13 said that he notified the supervisor immediatley because he was told in report that R1 didn't sustain any injuries. E13 said that he immediatly notified R1's family member of R1's status. E13 said that he told R1's family member that he and E2 would do further assessments and would notify R1's family member of any new changes. E13 said that R1 was taken to her room and placed in bed. E13 said the sheet was removed from R1's legs and E13 said that he immediately noticed that R1 right leg was swollen, and the right knee was externally rotated. E13 said that he notified Z3, Nurse Practitioner of R1's status. E13 said that he had orders to send R1 out to the hospital for evaluation. On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by certified nurse assistant that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to lift R1. E9 said that there was no mechanical lift in the room, and no that staff didn't bump R1 head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able to bend within normal limits. E9 said that after her assessment she left the room because she had other resident to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to [MEDICAL TREATMENT] that she gave R1 pain medication ([MEDICATION NAME] 2mg). E9 said this was about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called (2) physicians Z1/Z2 and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep and eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his [MEDICAL TREATMENT] treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. According to the hospital record 4-10-13 at 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft.

Based on interview and record review, the facility failed to ensure a plan of care was implemented to reduce the risk of falling during transfer due to the potential of buckling knees, this potential fall risk was not relayed to direct care staff for 1 of 3 residents (R1) reviewed for transfers. The facility staff made an attempt to transfer R1 from the bed to the chair, this resulted in R1 lower extremity buckling and R1 falling to the floor resulting in a right femur fracture. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for dialysis when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for dialysis. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2, Director of Nursing(DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to dialysis, but my leg is really hurting." According to the dialysis progress note dated 4/10/2013 8:00am notes that R1 said she was dropped upstairs while being transferred prior to coming down to dialysis. R1 is also noted with a bump/bruise on front of head. The note indicates that the facility staff verbalized they were aware of R1's status. Nursing notes dated 4/10/2013 5:00am denotes that R1 slid to the floor while being transferred from chair to bed in preparation for dialysis. Head to toe assessment completed with zero injuries. R1 noted as being assisted back to the chair to prepare for dialysis. R1 noted with complaints of pain, pain medication given as prescribed. The note also indicates that family and physician was notified with no new orders. Nursing note 6:00am R1 down in dialysis. Nursing note 7:00am notes endorsed to next shift. Nurse note written by E9, Nurse. On 4/12/13 at 4:00pm E7, Restorative Nurse, said that she did an assessment of R1 mobility, and transfer status. Reviewed restorative nursing assessment needs dated 3/21/2013 with E7. E7 said that she completed this assessment. The area of the assessment (mobility) denotes for weight bearing R1 is assessed a (4) which indicates dependent, transfer from bed to chair /chair to bed R1 is assessed extensive assistance. E7 said that R1 is unable to bear weight or stand without at least (2) staff on either side using a gait belt. E7 said that during her assessment R1 was observed, and at times R1's knee would buckle and would be unable to transfer because of weakness. E7 said that if R1 knees were weak staff would be unable to transfer her at that time without the use of mechanical lift. E7 also said that when she coded R1 as extensive assistance she said it would require (2) staff to assist R1 with transfers. E7 said that she was not part of the MDS coding for R1 last update. E7 said that her Restorative Aids were aware that R1's knee could buckle during transfer, however E7 said she didn't make certified nursing staff aware of R1's weak lower extremity. E7 said that they should be aware because of past experience of getting R1 up. Reviewed R1's most current Minimum (MDS) data set [DATE], section G indicates that R1 requires extensive assistance and 1 person physical assist. E7 said that the assessment was incorrect and that R1 requires 2 person assistance, and mechanical lift if R1's knee were weak. E8, Certified Nurse Aid (CNA), was not available for interview during this survey, in fact the facility provided the survey team with an employee report dated 4/17/2013 indicating that E8 was discharged from employment for not responding to facility phone calls, and not reporting to an agreed upon meeting with E2, DON. However the facility provided the survey with a statement taken over the phone from E8. The statement indicates that E8 gave R1 care and was getting R1 dressed with the help of another CNA. The statement notes that R1 said that she could stand up for a while, so it was decided to pivot R1 into a chair. The statement indicates that once R1 stood up, that her knees gave out because R1 slid to the floor. The note indicates that R1 was being directed on what to do when her knees collapsed and R1 went down onto her knees then laid to her left side with both legs to her right side. E8 indicates that the other CNA stayed with R1, while she went and got the nurse. E8 also indicates they paged for help from other CNAs. E8 indicates that there were now 4 CNAs, and that they rolled R1 onto a sheet underneath her, and as they all lifted R1 from the floor with the sheet that R1 bumped the bed rail and ended up lying on her face. E8 said that R1 was repositioned in bed, and they went and got a mechanical lift. E8 indicates that she got R1 up by using the mechanical lift and transferred her to the chair. E8 indicates that the nurse came and gave R1 pain medication, and E8 took R1 to dialysis. There was no entry indicating the condition of R1's face or leg. On 4/12/13 at 4:15pm via phone E11, CNA, said that E8, CNA, asked her to assist getting R1 out bed for morning dialysis. E11 said that she didn't put a gait belt on R1, but thinks that E8 had placed one around R1 for the transfer. E11 said that they were able to get R1 in a standing position, and R1 started complaining about her knee hurting and leg pain. E11 said that R1 legs started to buckle, and she felt that R1's legs were going out. E11 said that R1 landed in an awkward position sitting on her buttocks with her legs underneath her. However, E11 said that R1's head didn't hit anything. E11 said there was no swelling or bruising on R1's face. E11 said that after R1 was on the floor they asked (2) other CNAs to assist with putting R1 back to bed because she was too heavy to lift with just 2 people. E11 said that they rolled R1 onto a bed sheet and (1) CNA on each end of the sheet lifted R1 back to the bed. E11 said that R1 wasn't bumped during the transfer with the sheet. E11 said that the side rails on the bed was down during this transfer and that R1's head didn't bump the rail during this transfer. E11 said after R1 was back in the R1's leg looked okay, however she said she didn't really look because R1 was wrapped in the sheet. E11 said that after R1 was back in bed she kept complaining of leg pain. E11 said that she left the room after this transfer to get back to her residents, and said she don't know how R1 was transferred from the bed to the dialysis chair. E11 said that she was not aware that R1 had lower extremity weakness, and was never informed that R1's knees might give out during transfer. On 4/12/2013 at 4:30pm E10, CNA, said that she was working on another unit when she was asked to assist getting R1 off the floor. E10 said that there were 4 aides assisting with getting R1 off the floor. E10 said that they rolled R1 side to side onto a sheet to lift her back into the bed safely. E10 said that R1 didn't hit/bump anything while being transferred from the floor to the bed. E10 said that the side rails on the bed were down during the transfer and R1's face/head didn't hit the side rails. E10 said that R1 didn't have any facial swelling and/or bruising. E10 said she was told by E8 that R1 had slid to the floor. E10 said that when she arrived to R1's room that R1 was sitting on her buttocks with her legs underneath her. E10 said that when arrived to the room R1 was not wearing a gait belt around her. E10 said once she assisted R1 back to bed that she left and didn't assist R1 anymore that day. E10 said she don't know how R1 was transferred from the bed to the chair to go to dialysis. E10 said that she don't recall seeing R1's leg, however did say that R1 complained of leg pain. On 4/12/13 at 4:35pm via telephone E12, CNA, said that E8 asked her if she could assist in getting R1 off the floor. E12 said that she entered R1's room and that R1 was on the floor sitting on her legs with her feet under her buttocks. E12 said that R1 was asking for a pain pill. E12 said that R1 wasn't wearing a gait belt when she entered the room. E12 said that they rolled R1 onto a sheet to transfer her from the floor to the bed. E12 said it was 2 aides on each side of the sheet a total of 4 aides. E12 said that when R1 was lifted from the floor the bed was in lowest position and the side rails were down. E12 said that R1 wasn't bumped into anythng during this transfer. E12 said that R1's leg didn't look swollen, but she was put in the bed flat. E12 said that R1 was complaining of pain to the leg. E12 said that R1 didn't have any facial bruising or swelling at that time. E12 said that she left the room after the transfer, and don't know how R1 was trnsferred from the bed to the chair for dialysis. Nursing note dated 4/10/2013 11:30am indicates that R1 back from dialysis on geri chair, R1 complaining of pain, nurse indicates inflammation over the right knee, no bruising or discoloration noted. R1 also noted with a 2"x2" bump noted to the right forehead. R1 complains of pain with slight pressure. The note indicates the right knee is immobilized and ice pack applied, pain medication given. Nursing note 11:35am indicates that the physician was notified with orders to send to the hospital for evaluation. Nursing note 11:37 family notified. Nursing note 12:10pm R1 pick up by ambulance service in route to local hospital for evaluation. Note written by E13, Nurse. On 4/19/2013 at 1:45pm E13, Nurse said that when he started his shift at 7:00am on 4/10/2013 that R1 was in dialysis, and had been involved in a fall incident. E13 said that it was reported to him that R1 didn't sustain any injuries. E13 said around 11:30am R1 was being pushed in her recliner chair through the elevator doors, E13 said that he immediately observed an moderate size bump on R1's forehead. E13 said he that immediately notified E14, Supervsior of his observation. E13 said that he notified the supervisor immediately because he was told in report that R1 didn't sustain any injuries. E13 said that he immediately notified R1's family member of R1's status. E13 said that he told R1's family member that he and E2 would do further assessments and would notify R1's family member of any new changes. E13 said that R1 was taken to her room and placed in bed. E13 said the sheet was removed from R1's legs and E13 said that he immediately noticed that R1 right leg was swollen, and the right knee was externally rotated. E13 said that he notified Z3, Nurse Practitioner of R1's status. E13 said that he had orders to send R1 out to the hospital for evaluation. On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by CNA that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to left R1. E9 said that there was no mechanical lift in the room, and no, that staff didn't bump R1's head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able bend within normal limits. E9 said that after her assessment she left the room because she had other resident to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to dialysis that she gave R1 pain medication (Hydromorphone 2mg). E9 said this about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called (2) physicians Z1/Z2 and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. The facility also prestented the survey with a copy of the mandatory inservice for all certifiied nurse aide staff dated 4-11,4-12, and 4-15. the inservice was entitled "Transfer Training" On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep and eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his dialysis treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. According to the hospital record 4-10-13 at 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft.

Based on observation, interview and record review the facility failed to follow their infection control policy and initiate isolation precautions, and provide staff with personal protective equipment for a resident admitted with MRSA (Methicillin resistant staphylococcus aureus), and failed to contact the attending physician to obtain a wound culture to rule out MRSA. The facility also failed to follow their wound management policy and obtain a physician order [REDACTED]. This failure resulted in R11 having a non-healing wound, with possible infectious organism and potential risk of developing septicemia. R11 was ambulatory through all floors of the facility so this has the potential to affect all 217 residents in the facility. These collective failures resulted in an Immediate Jeopardy. E1 (Administrator), was notified of the Immediate Jeopardy on March 15, 2013 at 4:35pm in person. The Immediate Jeopardy was determined to have begun on September 27, 2012 when R11 was admitted to the facility with a [DIAGNOSES REDACTED]. The immediate Jeopardy was removed on March 15, 2013, at 7:00pm. However the facility still remains out of compliance at a scope and severity level 2 because of the need to allow for the facility to complete staff in-service, and to evaluate the effectiveness of the new policy and procedure. Findings Include: On 3/12/13 at 6:30 AM E33 (Nurse) stated, "There is no one on this floor on isolation or infection/ precaution." There was no set-up for contact or isolation precautions on the floor. On 3/12/13 at 6:55 AM during the initial tour R11 was standing up in the room with a large dressing on the left leg. R11 stated "I have been in this room since last year because of MRSA (Methicillin resistant staphylococcus aureus) in my leg ulcer, I am on isolation precautions that is why there is no one else in the room." There was no signs anywhere in or near R11's room alerting staff/visitors or residents to any isolation or contact precautions. There was no set-up for contact or infection precautions. There was a mild foul odor was in the room. On 3/12/2013 at 11:20 AM R11 was walking around on the first floor with a left leg bandage on and moderate amount of pinkish/ red drainage on the dressing. On 3/12/13 at 11:45 AM R11 was in the room stating " I will have my dressing changed on my leg on tomorrow(3/13/2013) not today because of the pain in my leg ulcer. This wound hurts." I used to eat in the dining room but my leg is smelling due to the MRSA in it. The other residents will not let me eat in the dining room because of the smell, so I eat in my room." Again a mild foul odor was in the room. On 3/13/13 at 9:00 AM during the Group Meeting with 9 residents present(R40-R48) all residents stated " R11 's leg wound stinks all the time it has been stinking for about a year and the smell bothers us." Physician order [REDACTED]." Nursing Notes dated 9-21-2012 document "resident complained of pain, not relieved by pain medication. Doctor informed of foul smell and pain from left lower extremity wound, orders to send to hospital for evaluation." Admission record documents that R11 returned on 9-27-2012. Nursing Admission Assessment dated 9/27/2012 documents "On contact isolation for MRSA to left and explained to patient the need to move to a new room. Notified doctor upon admission." Internal Medicine Notes dated 9/30/2012, 10/7/2012 and 11/12/2012 all document "Left leg wound with cellulitis, MRSA positive culture.." Infection Control Tracking was reviewed from 9/2012 until 3/2013, there is no tracking of R11's MRSA in the leg. Physician order [REDACTED]. On 3/14/2013 at 11:54 AM E41(Nurse/ Infectious Disease) stated, "R11's leg has had a purulent odor for a while more than a year I was aware of the odor, we referred R11 to the infectious disease doctor, I can not read all of the note that the infectious disease doctor wrote on 11-28-2012. R11 should have had a culture and the infectious disease doctor should have been contacted after 11/28/2012, sooner than yesterday(3/13/13). R11 was not tracked for infection. R11 should have been tracked for infection from 9/27/2012." Infection Prevention Program dated 07/05/11 documents Purpose: to conduct surveillance of resident and employee infections to guide prevention activities. The Infection Preventionist does surveillance of infections among residents and employees. Surveillance of healthcare associated infections is accomplished through. A. Review of culture reports and other pertinent lab data. B). Review of the 24 hour report and /or morning meeting/ rounds C. Chart review, Nurse consultation and Physician consultation. Surveillance data is collected and analyzed on an ongoing basis and reported monthly." On 3/15/2013 at 10:36 AM, E37(Director of Nursing hired 3/11/13) stated, " we obtained a culture yesterday. R11 was placed on contact precautions until the culture results are in R11 should have been tracked for infection." On 3/12/2013 at 11:20 AM R11 was walking around on the first floor with a left leg bandage on and moderate amount of pinkish/ red drainage on the dressing. Physician order [REDACTED]." Infectious Disease Physician Notes dated 11/28/2012 documents, "refusing wound care from outside clinic, refusing me to examine. will evaluate next week with wound care ... left leg check MRSA reevaluate in 1 week." On 3/14/2013 at 11:54 AM E41(Nurse/ Infectious Disease) stated, "We use culture results for isolation status, I got an order from the doctor to discontinue R11 from isolation on 11/21/2012. On 3/14/2013 at 2:30 PM via telephone Z4 stated " I have not taken care of R11 for the last six months. R11 had MRSA in the leg wound. Before we discontinue contact isolation we need at least 1 negative culture or a totally healed wound. I stopped being R11's physician on 9/9/2012 I do not know who wrote a telephone order from me for R11 on 11/21/2012, It was not my order, I was no longer R11's physician." On 3/15/2013 at 10:36 AM E37(Director of Nursing) stated "we acknowledge that the telephone order to discontinue R11 from isolation received from the doctor was not an authentic order." On 3/15/2013 at 10:36 AM E2(Director of Nursing) stated that Z13 took over for R11 after Z4. On 3/15/2013 at 2:54 PM Z13 stated, " I did not become R11's Physician until December 4, 2012. R11 would have a smell that would come and go from her leg wound, R11 would refuse treatment. I was not made aware that R11 had MRSA in the leg. We need a culture to clear R11 from isolation...." On 3/21/2013 Hospital Record dated 9/21/2012 through 9/27/2012 was obtained and reviewed. The hospital record documents, "R11 was admitted to the hospital with [REDACTED]. R11 was hospitalized several times with infected left leg ulcer. There is a large amount of copious drainage soaked through the dressing with greenish phlegm highly suspicious of pseudomonas, has history of pseudomonas and MRSA in the leg wound. R11 was placed on contact isolation and treated with three different antibiotics intravenously(tigecycline, [MEDICATION NAME] and [MEDICATION NAME].) R11 was placed on oral [MEDICATION NAME]. Discharge Summary states, currently with streptococcus pseudomonas in left leg discharge to nursing home on antibiotics for 10 days." Infection Prevention Policy dated 07/05/11 states, " residents who are colonized with MDRO's that are not considered epidemiologically significant and whose secretions or drainage are contained may be discontinued from isolation. Isolation Precautions are used for residents with known or suspected MDRO infection. New resistant and significant pathogens continue to emerge. Other organisms not as well known are capable of causing severe infection and death in infected individuals, especially immunocompromised host. These include gram negative rods, extended beta-lactamase or carbapenemase producing organisms pseudomonas ande Acinetobacter." On 3/13/2013 at 1:30 PM E27(Treatment Nurse) , E28(Treatment Nurses), E31(Certified Nursing Assistant) prepared to do the dressing change for R11. E27, E28 and E31 put on gloves only. E27 took the dressing off of R11's left leg, R11 stated, " I have MRSA in my leg that is why I am in the room by myself." E27 continued treatment and stated " I believe that is a history of MRSA in the leg." E27 then removed the heavily soiled dressing from R11's left leg , there was an extremely purulent, pervasive and foul smelling odor coming from R11's leg. R11 had a large left leg full thickness skin loss ulcer with copious amounts yellow and serosanguineous drainage coming from the leg wound and saturating the dressing. E27 began to squeeze normal saline from small bottles onto the leg splashing normal saline with serosanguineous drainage onto the floor and R11 and E27's clothes. The extremely foul smelling odor lingered down the entire hallway. Surveyor exited the room and went to the Nursing Station and at 1:45 PM E29(Nurse) stated, " I have worked with R11 for at least a year and I do not know if R11 has been cleared of MRSA, I will have to go and ask the treatment nurses." On 3/13/13 at 1:49 PM all 3 staff, E27(Treatment Nurse), E28(Treatment Nurse) and E31(Certified Nursing Assistant) exited the room treatment was complete for R11 . E27and E28 got on the elevator with the treatment cart and other residents. E29(Nurse) stated at 1:49 PM, "The treatment nurse said to ask the infection control nurse if R11 still has MRSA in the wound." According to the Facility's policy on Standard Precautions dated 07/05/11, "Personal Protective equipment is provided to all employees. The type od protective barrier(s) should be appropriate for the procedure being performed and he type of exposure anticipated. Masks/ eyewear should be worn during procedures that are likely to generate droplets/splashing of blood/body fluids. Gowns/aprons should be worn when there is potential for soiling clothing with blood/body fluids." Infectious Disease physician progress notes [REDACTED]." Progress Notes dated 1/2/2013 from the advanced practice nurse documents, "Left lower extremity dressing in place moderate strike through drainage foul smelling." Nursing Progress Notes dated 1/3/13 states, " full thickness wound, skin around necrotic with odor. On 3/12/13 at 11:45 AM R11 was still in the room stating " I will have my dressing changed on my leg on tomorrow(3/13/2013) not today because of the pain in my leg ulcer. This wound hurts." On 3/13/2013 at 1:30 PM E27(Treatment Nurse) , E28(Treatment Nurses), E31(Certified Nursing Assistant) prepared to do the dressing change for R11. R11 was noted with large amounts of yellow and serosanguineous drainage and an extremely foul smell from the left leg wound. On 3/14/2013 at 1:26 PM E31(Certified Nursing Assistant) stated, " I have been taking care of R11 since 2011 as the treatment nurses' assistant. R11's leg has been smelling since September of 2011, it still smells." On 3/14/2013 at 1:26 PM E27 (Treatment Nurse) stated, " R11 's leg smells bad especially when R11 refuses to have the treatment done, the leg will smell bad, I notify the doctor when the wound smells and when R11 refuses and I documented it." On 3/15/2013 at 10:36 AM, E37(Director of Nursing hired 3/11/13) stated, " we obtained a culture yesterday. R11 was placed on contact precautions until the culture results are in R11 should have been tracked for infection." On 3/15/2013 at 2:54 PM Z13 stated, " We should have cultured R11's leg wound on 1/2/2013 when my Nurse Practitioner documented that the wound was smelling foul. R11 should have remained on isolation precautions until a wound culture was negative to clear R11. R11was at risk and put other residents at risk for developing infection." Wound Management Program dated 07/2011 documents, " It is the policy of this facility to obtain wound cultures per physician's orders [REDACTED]. Assess the wound for signs and symptoms of infection including: A). [DIAGNOSES REDACTED], B). Edema, C). Induration, D). Increased purulent, foul smelling drainage, E). fever, F). Increases Pain at the wound site. Obtain an order from the physician for the wound culture and sensitivity when infection is suspected." Change in Resident's Condition or Status Policy dated 6/07 states, The nurse will notify the residents attending physician and appropriate consulting physician as soon as possible when there is a significant change in the resident's physical, mental, or psychosocial status. According to the CMS 672 resident census and condition form dated 3/14/2013 there were 217 residents in the facility. The Facility took the following actions to remove the immediate jeopardy: On 3/15/2013, R11 was reassessed by her physician; new orders obtained and carried out including an order for [REDACTED]. The Infection Prevention Committee met to address a plan specific to R11 and review the policies and procedures related to surveillance and isolation/precautions on 3/15/2013. The immediacy was removed on 3/15/2013 at 7:00 pm.

Based on observation, interview and record review the facility failed to follow their change of condition policy and notify the physician of a burning sensation for 1 resident (R32) from the supplemental sample reviewed for change in condition. Findings include: On 3/6/2013 at 1:38 PM R32 was laying in bed. On 3/6/2013 at 1:46 PM E8, Certified Nursing Assistant (CNA) entered the room to assist R32 with getting up. E8 provided incontinent care for R32. R32 pointed to an area of redness on the left inner thigh and said, " burn, burn [MEDICAL CONDITION] area between my legs [MEDICAL CONDITION] a very long time, I have told everybody and anybody. It won't stop burning." E8(CNA) stated at this time, " we know about the burning, I put A & D ointment on it. It it probably burning from the A& D ointment. R32 has been complaining about burning for a while months, the nurse knows, but I will tell the nurse again." Nursing Progress Notes were reviewed through the last note on 1/21/2013, there was no assessment for the burning that E8(CNA) stated would be communicated to the nurse. On 3/7/2013 at 10:24 AM E6(Nurse) stated, " nobody communicated that R32 was complaining of burning, R32 could have a urinary tract infection, I will assess R32 and then call the doctor." On 3/7/2013 at 1:20 PM E6(Nurse) stated, "I assessed R32 and called the doctor and a urinalysis and urine culture and blood work was ordered." On 3/7/2013 at 1:31PM E5(Nursing Supervisor) and E6(Nurse) began to obtain a urine culture from R32. On the left inner thigh was a small opened area. E6(Nurse) stated," yes I can see the opened area, I will call the treatment nurse to come and assess it." On 3/8/2013 at 8:20AM via telephone Z5 stated, I visit R32 twice a week every week and R32 has been complaining of burning since December of 2012. On 3/13/2013( 6 days from 3/7/2013 the assessment of the opened area) at 12:19PM E3(Treatment Nurse) and E27(Treatment Nurse) assessed R32's perineal area. E3(Treatment Nurse) stated R32 has [MEDICATION NAME] cream for a rash there is no opened area." R32 continued to point to the opened area and stated again, "it burns, it burns." On 3/14/2013 at 8:00AM Z3 stated, " I came in to examine the wound today. R32 has a [MEDICAL CONDITION], there is an opening there. I am here every Saturday. My nurse practitioneer is here every Tuesday. This is the first time I was made aware of an opening and burning. They could have told me on Saturday, March 9, 2013. I ordered an antifungal and a steriod cream, I am not sure what the lesion is but if it does not improve by Saturday, R32 will have a dermatologic consult. I made a special trip in to see residents today because the State is here." Change in Resident's Condition or Status Policy dated 6/07 states, The nurse will notify the resident's attending physician and appropriate consulting physician as soon as possible when there is a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review the facility failed to follow their notification of physician policy, and failed to follow their change in residents condition policy and notify the physician and family with an accurate detailed assessment after a fall incident for 1 of 3 residents R1, all reviewed for falls. This failure resulted in R1 not receiving physician orders [REDACTED]. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for [MEDICAL TREATMENT] when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for [MEDICAL TREATMENT]. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2, Director of Nursing (DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to [MEDICAL TREATMENT], but my leg is really hurting." On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by Certified Nurse Assistant (CNA) that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to lift R1. E9 said that there was no mechanical lift in the room, and no that staff didn't bump R1 head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able to bend within normal limits. E9 said that after her assessment she left the room because she had other residents to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to [MEDICAL TREATMENT] that she gave R1 pain medication ([MEDICATION NAME] 2mg). E9 said this about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called physicians, Z1 and Z2, and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. A 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft. On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep an eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his [MEDICAL TREATMENT] treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the change in resident condition or status policy: the facility will promptly notify the resident's attending physician and legal representative/family of changes in the residents condition and/or status. The policy indicates the nurse will notify the physician if the resident has an accident/incident that results in injury. According to the notification of physician policy the facility staff will notify the resident's attending physician when there is a significant change in the residents condition. The policy notes a significant change as requires the physician immediate input and treatment for [REDACTED]. The policy also outlines a significant change as fall with injury. According to E9's employee report dated 4/23/2013 indicates that E9 failed to document a thorough and detailed nurisng assessment for R1 after an incident. The report also indicates that E9 documented inaccurately that she notified the family and physician, when E9 only left a message for the family and paged the physican. The report indicates that due to past history E9 was being discharged from employment.

A.) Based on observation, interview and record review the facility failed to initiate isolation precautions, and failed to contact the attending physician to obtain a wound culture to rule [MEDICAL CONDITION] ([MEDICAL CONDITION] ), the facility failed to notify the physician of changes in wound conditions, and persistent complaints of pain for 1 of 3 residents R11 all reviewed for quality of care, in the sample of 30. Findings Include: 1). On [DATE] at 6:30 AM E33 (Nurse) stated, "There is no one on this floor on isolation or infection/ precaution." There was no set-up for contact or isolation precautions on the floor. On [DATE] at 6:55 AM during the initial tour R11 was standing up in the room with a large dressing on the left leg. R11 stated "I have been in this room since last year because of [MEDICAL CONDITIONS] in my leg ulcer, I am on isolation precautions that is why there is no one else in the room." There was no signs anywhere in or near R11's room alerting staff/visitors or residents to any isolation or contact precautions. There was no set-up for contact or infection precautions. There was a mild foul odor was in the room. On [DATE] at 11:20 AM R11 was walking around on the first floor with a left leg bandage on and moderate amount of pinkish/ red drainage on the dressing. On [DATE] at 11:45 AM R11 was in the room stating " I will have my dressing changed on my leg on tomorrow([DATE]) not today because of the pain in my leg ulcer. This wound hurts." I used to eat in the dining room but my leg is smelling due to [MEDICAL CONDITION] in it. The other residents will not let me eat in the dining room because of the smell, so I eat in my room." Again a mild foul odor was in the room. On [DATE] at 9:00 AM during the Group Meeting with 9 residents present(R40-R48) all residents stated " R11 's leg wound stinks all the time it has been stinking for about a year and the smell bothers us." Physician order [REDACTED]." Nursing Notes dated [DATE] document "resident complained of pain, not relieved by pain medication. Doctor informed of foul smell and pain from left lower extremity wound, orders to send to hospital for evaluation." Admission record documents that R11 returned on [DATE]. Nursing Admission Assessment dated [DATE] documents "On contact isolation [MEDICAL CONDITION] to left and explained to patient the need to move to a new room. Notified doctor upon admission." Internal Medicine Notes dated [DATE], [DATE] and [DATE] all document "Left leg wound with [MEDICAL CONDITIONS] positive culture.." Infection Control Tracking was reviewed from ,[DATE] until ,[DATE], there is no tracking of R11'[MEDICAL CONDITION] in the leg. Physician order [REDACTED]. On [DATE] at 11:54 AM E41(Nurse/ Infectious Disease) stated, "R11's leg has had a purulent odor for a while more than a year I was aware of the odor, we referred R11 to the infectious disease doctor, I can not read all of the note that the infectious disease doctor wrote on [DATE]. R11 should have had a culture and the infectious disease doctor should have been contacted after [DATE], sooner than yesterday([DATE]). R11 was not tracked for infection. R11 should have been tracked for infection from [DATE]." Infection Prevention Program dated [DATE] documents Purpose: to conduct surveillance of resident and employee infections to guide prevention activities. The Infection Preventionist does surveillance of infections among residents and employees. Surveillance of healthcare associated infections is accomplished through. A. Review of culture reports and other pertinent lab data. B). Review of the 24 hour report and /or morning meeting/ rounds C. Chart review, Nurse consultation and Physician consultation. Surveillance data is collected and analyzed on an ongoing basis and reported monthly." On [DATE] at 10:36 AM, E37(Director of Nursing hired [DATE]) stated, " we obtained a culture yesterday. R11 was placed on contact precautions until the culture results are in R11 should have been tracked for infection." On [DATE] at 11:45AM, R11 was in the room. R11 stated, "I will have my dressing changed tommorrow, not today because increased pain, I dont have my [MEDICATION NAME]. When the pain escalates I wont have them touch it. This wound hurts, pain management is not effective, no [MEDICATION NAME] for two weeks." On [DATE] at 12:11PM, E29(Nurse) stated "R11 does not have any [MEDICATION NAME], some kind of insurance problem." Nurses Noted dated [DATE] states, " Resident refused dressing change she said she needed a break from the pain in changing it." Physician order [REDACTED]." Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 10:36AM, E37(Director of Nursing, [DATE]) stated, "Insurance would not cover [MEDICATION NAME] for R11. We have orderd and the facility will pay for it." The Facility's Policy on Pain Management dated [DATE], states, "The purpose of our Pain Managment Program is to ensure our residents have access to pain managment in accordance with clinicaly accepted guidlines for the treatment of [REDACTED]." Physician order [REDACTED]." Nursing Notes dated [DATE] document "resident complained of pain, not relieved by pain medication. Doctor informed of foul smell and pain from left lower extremity wound, orders to send to hospital for evaluation." Admission record documents that R11 returned on [DATE]. Nursing Admission Assessment dated [DATE] documents "On contact isolation [MEDICAL CONDITION] to left and explained to patient the need to move to a new room. Notified doctor upon admission." Internal Medicine Notes dated [DATE], [DATE] and [DATE] all document "Left leg wound with [MEDICAL CONDITIONS] positive culture.." Infectious Disease physician progress notes [REDACTED]." On [DATE] at 11:54 AM E41(Nurse/ Infectious Disease) stated, "R11's leg has had a purulent odor for a while more than a year I was aware of the odor, we referred R11 to the infectious disease doctor, I can not read all of the note that the infectious disease doctor wrote on [DATE]. R11 should have had a culture and the infectious disease doctor should have been contacted after [DATE], sooner than yesterday([DATE]). R11 was not tracked for infection. R11 should have been tracked for infection from [DATE]." On [DATE] at 1:20PM E39(Assistant Director of Nursing) stated, " Currently we have no Infectious Disease Doctors, the contract expired in [DATE]. If a resident needed to see Infectious Disease they would have to go out for it." On [DATE] at 2:54 PM Z13 stated, " I did not become R11's Physician until [DATE]. R11 would have a smell that would come and go from her leg wound, R11 would refuse treatment. We need a culture to clear R11 from isolation. I was Not aware that R11 [MEDICAL CONDITION] in the leg. To my knowledge Z4 was the physician that was caring for R11 until December of 2012. I am not aware of any other physician other than Z4 and myself caring for R11. R11 should have been seen by Infectious Disease doctor since [DATE]. On [DATE] Hospital Record dated [DATE] through [DATE] was obtained and reviewed. The hospital record documents, "R11 was admitted to the hospital with [REDACTED]. R11 was hospitalized several times with infected left leg ulcer. There is a large amount of copious drainage soaked through the dressing with greenish phlegm highly suspicious of pseudomonas, has history of pseudomonas [MEDICAL CONDITION] in the leg wound. R11 was placed on contact isolation and treated with three different antibiotics intravenously(tigecycline, [MEDICATION NAME] and [MEDICATION NAME].) R11 was placed on oral [MEDICATION NAME]. Discharge Summary states, currently with streptococcus pseudomonas in left leg discharge to nursing home on antibiotics for 10 days." According to the Facility's Infection Prevention Policy dated [DATE], " Infectious Disease experts shall be considered apporpriate for residents with MDRO or infection when resistance problems or facility transmission is identified." Infectious Disease physician progress notes [REDACTED]." Progress Notes dated [DATE] from the advanced practice nurse documents, "Left lower extremity dressing in place moderate strike through drainage foul smelling." Nursing Progress Notes dated [DATE] states, " full thickness wound, skin around necrotic with odor. On [DATE] at 1:30 PM E27(Treatment Nurse) , E28(Treatment Nurses), E31(Certified Nursing Assistant) prepared to do the dressing change for R11. R11 was noted with large amounts of yellow and serosanguineous drainage and an extremely foul smell from the left leg wound. On [DATE] at 2:54PM, Z13 stated...."We should have cultured R11's leg wound on [DATE] when my Nurse Practitioner documented that the wound was smelling foul. I was not aware." Change in Resident's Condition or Status Policy dated ,[DATE] states, The nurse will notify the residents attending physician and appropriate consulting physician as soon as possible when there is a significant change in the resident's physical, mental, or psychosocial status. Infectious Disease physician progress notes [REDACTED]." Progress Notes dated [DATE] from the advanced practice nurse documents, "Left lower extremity dressing in place moderate strike through drainage foul smelling." Nursing Progress Notes dated [DATE] states, " full thickness wound, skin around necrotic with odor. On [DATE] at 11:45 AM R11 was still in the room stating " I will have my dressing changed on my leg on tomorrow([DATE]) not today because of the pain in my leg ulcer. This wound hurts." On [DATE] at 1:30 PM E27(Treatment Nurse) , E28(Treatment Nurses), E31(Certified Nursing Assistant) prepared to do the dressing change for R11. R11 was noted with large amounts of yellow and serosanguineous drainage and an extremely foul smell from the left leg wound. On [DATE] at 1:26 PM E31(Certified Nursing Assistant) stated, " I have been taking care of R11 since 2011 as the treatment nurses' assistant. R11's leg has been smelling since September of 2011, it still smells." On [DATE] at 1:26 PM E27 (Treatment Nurse) stated, " R11 's leg smells bad especially when R11 refuses to have the treatment done, the leg will smell bad, I notify the doctor when the wound smells and when R11 refuses and I documented it." On [DATE] at 10:36 AM, E37(Director of Nursing hired [DATE]) stated, " we obtained a culture yesterday. R11 was placed on contact precautions until the culture results are in R11 should have been tracked for infection." On [DATE] at 2:54 PM Z13 stated, " We should have cultured R11's leg wound on [DATE] when my Nurse Practitioner documented that the wound was smelling foul. R11 should have remained on isolation precautions until a wound culture was negative to clear R11. R11was at risk and put other residents at risk for developing infection." Wound Management Program dated ,[DATE] documents, " It is the policy of this facility to obtain wound cultures per physician's orders [REDACTED]. Assess the wound for signs and symptoms of infection including: A). [DIAGNOSES REDACTED], B). [MEDICAL CONDITION], C). Induration, D). Increased purulent, foul smelling drainage, E). fever, F). Increases Pain at the wound site. Obtain an order from the physician for the wound culture and sensitivity when infection is suspected." Change in Resident's Condition or Status Policy dated ,[DATE] states, The nurse will notify the residents attending physician and appropriate consulting physician as soon as possible when there is a significant change in the resident's physical, mental, or psychosocial status. B) Based on interview and record review, the facility failed to monitor and address a critically elevated blood sugar for one of three residents (R34) in a sample of 13 reviewed for blood sugar monitoring. This resulted in R34 being hospitalized . R34 is a [AGE] year old resident with [DIAGNOSES REDACTED]. The [DATE] Physician order [REDACTED]. On [DATE] at 11:40am, Nurse's Notes documented by E18 (Nurse), "MD called back and informed about (R34's) temperature. Ordered labs and infectious disease consult. Order carried out. Will continue to monitor." On [DATE] at 11:15am, E18 stated R34 had a temperature of 101.1 on [DATE]. E18 gave [MEDICATION NAME] at approximately 7:15am. At approximately 8:30am, R34's temperature was 101.3 and a sponge bath and ice packs were used to reduce the temperature. At approximately 11am, R34's temperature was 100.8 and the physician was contacted. The physician ordered labs and an infectious disease consult. E18 stated the family was informed of the new orders. E18 stated on [DATE] report was received at the start of the shift and it was reported R34 was started on an antibiotic. E18 stated the physician was not contacted on [DATE] during the day shift for any changes or labs. E18 stated R34 did not have routine orders to monitor the blood sugars and none were completed on [DATE]. E18 stated R34 was not diabetic and there are no blood glucose monitoring sheet to document blood glucoses for R34. On [DATE] at 9:15pm, E22 (Nurse) documents in Nurse's Notes, "Lab results relayed to (Z1). White Blood Count 11.9 (high), Red Blood Count 4.29 (low), Hemoglobin 12.1 (low), Hematocrit 37.7 (low), [DIAGNOSES REDACTED]s 8.5 (high), Lymphocytes 19.8 (low), [DIAGNOSES REDACTED]s 71.6 (high), urea nitrogen 45 (high), glucose 591 (high). Z1 ordered [MEDICATION NAME], refer to infectious disease and repeat complete blood count and comprehensive metabolic profile on [DATE]." The Laboratory Report, [DATE], reported at 8:23pm, documents a glucose of 591 (Critically High). The reference range for the glucose is ,[DATE]. On [DATE] at 1:05pm, E22 stated, on [DATE] the physician was contacted with all of the lab results. E22 reported the high blood sugar and the doctor ordered the lab repeated the following week. E22 stated, "I repeated the blood sugar a second time on [DATE] during my shift. The doctor didn't order it but I repeated it as a nursing issue, I rechecked it because it was critically high. I didn't document it and I cannot remember what the value was or if it was abnormal. I talked to the nursing supervisor to report the lab results and the orders I received from the doctor." On [DATE] at 3:05pm, E23 (Nursing Supervisor) stated, "(E22) reported to me that R34's blood sugar was elevated and he spoke with Z1. E22 reported Z1 provided no new orders but to monitor the resident and the blood sugar. If the blood sugar remained elevated Z1 was to be contacted." E23 stated, "I do not recall what the repeated blood glucose levels were. The original one was 500 plus. I cannot remember if I followed up with E22 any further during my shift." On [DATE], Physician order [REDACTED]. On [DATE] or [DATE] R34's Nurse's Notes documents no assessment information. There are no entries on the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There are no Blood Glucose Monitoring Sheets for [DATE] for R34. On [DATE] at 12:28pm, E20 (Nurse) stated he was the nurse for R34 on [DATE]. E20 stated, "The patient had a fever. I reported it to the doctor. The antibiotic was changed. There were no other changes. I did not talk with the doctor about blood sugars. (R34) was not diabetic and I did not do any blood sugar monitoring on that shift. I'm not sure if I documented on (R34) on my shift." On [DATE] at 8:30am, E18 documents in Nurse's Notes R34 had a temperature of 102.2. The physician was notified and an order was received to send R34 to the hospital. At 8:40am the family was notified. At 9:45 it is documented R34 left the facility without any distress. On [DATE] at 11:15am, E18 stated R34 was sent to the hospital on [DATE] for a fever of 102 and appeared more weak at the time of transfer. On [DATE] at 12:40pm, E19 (Assistant Director of Nursing), stated the family (daughter) called about R34's blood sugar being elevated after R34 was admitted to the hospital. The family wanted to know what was being done at the facility to monitor R34's blood sugar. E19 stated an investigation was done after speaking with the family, but the investigation was not documented and E19 was not able to produce any documentation of the investigation. E19 stated she spoke with E22 to investigate the family concerns. E19 stated E22 reported that the elevated glucose level was relayed to the doctor and orders were to repeat the lab and an antibiotic was ordered. E19 also spoke with Z1 and Z1 did not clarify the orders that were provided to E19. E19 stated she relayed the concerns the family had and Z1 told her he would speak to the family. On [DATE] at 11:45am, Z1 stated R34 has [MEDICAL CONDITION] and is not responsive. Z1 stated, "I cannot recall if I was notified of the blood sugar. It is highly unlikely. Standard protocol would be to do a stat sliding scale with insulin and if not effective the resident should be transferred to the hospital. The nurse should have questioned me if I didn't provide orders for a blood sugar of 591. (R34) was sent to the hospital I practice at so I could continue to follow him. His [DIAGNOSES REDACTED]. I explained this to the family, what treatment should have been done. If I gave that order, why would the nurse not ask about insulin. That is why they have nurses." The facility policy, Change in Resident's Condition or Status, ,[DATE], documents the nurse will notify the resident's attending physician when there is need to alter the resident's treatment significantly, based on abnormal laboratory or radiology results. The facility policy, Blood Glucose Monitoring, ,[DATE], documents blood glucose testing is performed according to the physician order [REDACTED]. If a test result is unusual, assess resident and retest as appropriate to verify result. Notify the physician of unusual results and out of range for resident.

Based on interview and record review the facility failed to accurately assess for bruising and injuries, failed to document accurately in the clinical record, and incident reporting form. The facility also failed to ensure the physician was given complete and accurate information to ensure prompt treatment for 1 of 3 residents R1, all reviewed for post fall assessments. This failure resulted in R1's being delayed in receiving treatment for [REDACTED]. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for [MEDICAL TREATMENT] when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for [MEDICAL TREATMENT]. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2 Director of Nursing(DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to [MEDICAL TREATMENT], but my leg is really hurting." According to the [MEDICAL TREATMENT] progress note dated 4/10/2013 8:00am notes that R1 said she was dropped upstairs while being transferred prior to coming down to [MEDICAL TREATMENT]. R1 is also noted with a bump/bruise on front of head. The note indicates that the facility staff verbalized they were aware of R1's status. Nursing notes dated 4/10/2013 5:00am denotes that R1 slid to the floor while being transferred from chair to bed in preparation for [MEDICAL TREATMENT]. Head to toe assessment completed with zero injuries. R1 noted as being assisted back to the chair to prepare for [MEDICAL TREATMENT]. R1 noted with complaints of pain, pain medication given as prescribed. The note also indicates that family and physician was notified with no new orders. Nursing note 6:00am R1 down in [MEDICAL TREATMENT]. Nursing note 7:00am notes endorsed to next shift. Nurse note written by E9, Nurse. On 4/12/13 at 4:00pm E7, Restorative Nurse, said that she did an assessment of R1's mobility, and transfer status. Reviewed restorative nursing assessment needs dated 3/21/2013 with E7. E7 said that she completed this assessment. The area of the assessment (mobility) denotes for weight bearing R1 is assessed a (4) which indicates dependent, transfer from bed to chair /chair to bed R1 is assessed extensive assistance. E7 said that R1 is unable to bear weight or stand without at least (2) staff on either side using a gait belt. E7 said that during her assessment R1 was observed, and at times R1's knee would buckle and would be unable to transfer because of weakness. E7 said that if R1 knees were weak staff would be unable to transfer her at that time without the use of mechanical lift. E7 also said that when she coded R1 as extensive assistance she said it would require (2) staff to assist R1 with transfers. E7 said that she was not part of the MDS coding for R1 last update. E7 said that her restorative aide were aware that R1's knee could buckle during transfer, however E7 said she didn't make certified nursing staff aware of R1's weak lower extremity. E7 said that they should be aware because of past experience of getting R1 up. Reviewed R1's most current Minimum (MDS) data set [DATE], section G indicates that R1 requires extensive assistance and 1 person physical assist. E7 said that the assessment was incorrect and that R1 requires 2 person assistance, and mechanical lift if R1's knee were weak. E8, Certified Nurse Aide (CNA), was not available for interview during this survey, in fact the facility provided the survey team with a employee report dated 4/17/2013 indicating that E8 was discharged from employment for not responding to facility phone calls, and not reporting to an agreed upon meeting with E2, DON. However the facility provided the surveyor with a statement taken over the phone from E8. The statement indicates that E8 gave R1 care and was getting R1 dressed with the help of another certified nurse aide. The statement notes that R1 said that she could stand up for a while, so it was decided to pivot R1 into a chair. The statement indicates that once R1 stood up, that her knees gave out because R1 slid to the floor. The note indicates that R1 was being directed on what to do when her knees collapsed and R1 went down onto her knees then laid to her left side with both legs to her right side. E8 indicates that the other CNA stayed with R1, while she went and got the nurse. E8 also indicates they paged for help from other CNAs. E8 indicates that there were now 4 CNAs, and that they rolled R1 onto a sheet underneath her, and as they all lifted R1 from the floor with the sheet that R1 bumped the bed rail and ended up lying on her face. E8 said that R1 was repositioned in bed, and they went and got a mechanical lift. E8 indicates that she got R1 up by using the mechanical lift and transferred her to the chair. E8 indicates that the nurse came and gave R1 pain medication, and E8 took R1 to [MEDICAL TREATMENT]. There was no entry indicating the condition of R1's face or leg. On 4/12/13 at 4:15pm via phone E11, CNA, said that E8, CNA, asked her to assist getting R1 out bed for morning [MEDICAL TREATMENT]. E11 said that she didn't put a gait belt on R1, but thinks that E8 had placed one around R1 for the transfer. E11 said that they were able to get R1 in a standing position, and R1 started complaining about her knee hurting and leg pain. E11 said that R1 legs started to buckle, and she felt that R1's legs were going out. E11 said that R1 landed in an awkward position sitting on her buttocks with her legs underneath her. However E11 said that R1's head didn't hit anything. E11 said there was no swelling or bruising on R1's face. E11 said that after R1 was on the floor they asked (2) other CNAs to assist with putting R1 back to bed because she was to heavy to lift with just 2 people. E11 said that they rolled R1 onto a bed sheet and (1) CNA on each end of the sheet lifted R1 back to the bed. E11 said that R1 wasn't bumped during the transfer with the sheet. E11 said that the side rails on the bed was down during this transfer and that R1 head didn't bump the rail during this transfer. E11 said after R1 was back in the bed, R1's leg looked okay, however she said she didn't really look because R1 was wrapped in the sheet. E11 said that after R1 was back in bed she kept complaining of leg pain. E11 said that she left the room after this transfer to get back to her residents, and said she don't know how R1 was transferred from the bed to the [MEDICAL TREATMENT] chair. E11 said that she was not aware that R1 had lower extremity weakness, and was never informed that R1's knees might give out during transfer. On 4/12/2013 at 4:30pm E10,CNA, said that she was working on another unit when she was asked to assist getting R1 off the floor. E10 said that there were 4 aides assisting with getting R1 off the floor. E10 said that they rolled R1 side to side onto a sheet to lift her back into the bed safely. E10 said that R1 didn't hit/bump anything while being transferred from the floor to the bed. E10 said that the side rails on the bed were down during the transfer and R1's face/head didn't hit the side rails. E10 said that R1 didn't have any facial swelling and/or bruising. E10 said she was told by E8 that R1 had slid to the floor. E10 said that when she arrived to R1's room that R1 was sitting on her buttocks with her legs underneath her. E10 said that when arrived to the room R1 was not wearing a gait belt around her. E10 said once she assisted R1 back to bed that she left and didn't assist R1 anymore that day. E10 said she don't know how R1 was transferred from the bed to the chair to go to [MEDICAL TREATMENT]. E10 said that she doesn't recall seeing R1's leg, however did say that R1 complained of leg pain. On 4/12/13 at 4:35pm via telephone E12,CNA, said that E8 asked her if she could assist in getting R1 off the floor. E12 said that she entered R1's room and that R1 was on the floor sitting on her legs with her feet under her buttocks. E12 said that R1 was asking for a pain pill. E12 said that R1 wasn't wearing a gait belt when she entered the room. E12 said that they rolled R1 onto a sheet to transfer her from the floor to the bed. E12 said it was 2 aides on each side of the sheet for a total of 4 aides. E12 said that when R1 was lifted from the floor the bed was in lowest position and the side rails were down. E12 said that R1 wasn't bumped into anythng during this transfer. E12 said that R1's leg didn't look swollen, but she was put in the bed flat. E12 said that R1 was complaining of pain to the leg. E12 said that R1 didn't have any facial bruising or swelling at that time. E12 said that she left the room after the transfer, and don't know how R1 was trnsferred from the bed to the chair for [MEDICAL TREATMENT]. Nursing note dated 4/10/2013 11:30am indicates that R1 back from [MEDICAL TREATMENT] on geri chair, R1 complaining of pain, nurse indicates inflammation over the right knee, no bruising or discoloration noted. R1 also noted with a 2"x2" bump noted to the right forehead. R1 complains of pain with slight pressure. The note indicates the right knee is immobilized and ice pack applied, pain medication given. Nursing note 11:35am indicates that the physician was notified with orders to send to the hospital for evaluation. Nursing note 11:37 family notified. Nursing note 12:10pm R1 pick up by ambulance service in route to local hospital for evaluation. Note written by E13, Nurse. On 4/19/2013 at 1:45pm E13, Nurse said that when he started his shift at 7:00am on 4/10/2013 that R1 was in [MEDICAL TREATMENT], and had been involved in a fall incident. E13 said that it was reported to him that R1 didn't sustain any injuries. E13 said around 11:30am R1 was being pushed in her recliner chair through the elevator doors, E13 said that he immediately observed an moderate size bump on R1's forehead. E13 said he that immediately notified E14, Supervsior of his observation. E13 said that he notified the supervisor immediatley because he was told in report that R1 didn't sustain any injuries. E13 said that he immediatly notified R1's family member of R1's status. E13 said that he told R1's family member that he and E2 would do further assessments and would notify R1's family member of any new changes. E13 said that R1 was taken to her room and placed in bed. E13 said the sheet was removed from R1's legs and E13 said that he immediately noticed that R1 right leg was swollen, and the right knee was externally rotated. E13 said that he notified Z3, Nurse Practitioner of R1's status. E13 said that he had orders to send R1 out to the hospital for evaluation. On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by certified nurse assistant that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to lift R1. E9 said that there was no mechanical lift in the room, and no that staff didn't bump R1 head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able to bend within normal limits. E9 said that after her assessment she left the room because she had other resident to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to [MEDICAL TREATMENT] that she gave R1 pain medication ([MEDICATION NAME] 2mg). E9 said this was about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called (2) physicians Z1/Z2 and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep and eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his [MEDICAL TREATMENT] treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. According to the hospital record 4-10-13 at 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft.

Based on observation, interview and record review, the facility failed to follow their plan of care and implement preventative fall interventions for one of five residents (R17) reviewed for fall precautions in a sample of 30. Findings include: R17 is a resident with documented falls on 12/1/12, 12/3/12, 12/26/12, 1/1/13, 1/11/13 and 3/4/13. The Fall Risk Evaluation, 3/4/13, documents R17 is at high risk for falls. The Physician order [REDACTED]. The Care Plan, 1/15/13 documents a safety belt is to be utilized effective 1/16/13 to prevent falls. On 3/13/13 at 1:50pm, E39 (Assistant Director of Nurses), stated R17 requires a safety belt at all times while up in the wheelchair per family request. On 3/12/13 at 11:40am and 12:35am R17 was observed in a wheelchair without a safety belt in place in the presence of facility staff. On 3/12/13 at 1:50pm, R17 was observed visiting with a family member. R17 was in a wheelchair and had a safety belt in place. On 3/13/13 at 9:05am, 9:40am, 10:10am, and 12:00pm in a wheelchair without a safety belt in place in the presence of staff. Between 1:10pm and 1:20pm R17 was in the wheelchair in her bedroom without a safety belt. No staff were present in the room. On 3/13/13 at 12:00pm, E13 (Nurses Aid) stated R17 uses a safety belt while in the wheelchair except during activities and when staff are around to supervise R17. On 3/13/13 at 1:20pm, E14 (Nurse) stated the safety belt is off during meals and activities and every 2 hours per family request. The facility Fall Prevention and Management Program, version 2 and undated, documents the facility is to implement individualized approaches/interventions based upon resident risk.

F323 Based on interview and record review the facility failed to ensure a plan of care was implemented to reduce the risk of falling during transfer due to the potential of buckling knees, this potential fall risk was not relayed to direct care staff for 1 of 3 residents R1 reviewed for transfers. The facility staff made an attempt to transfer R1 from the bed the chair, this resulted in R1 lower extremity buckling and R1 falling to the floor resulting in a right femur fracture. Findings include: According to the accident / incident report dated 4/10/2013 5:00am, staff was preparing R1 for dialysis when R1 accidentally slid to the floor while being transferred from the bed to the chair. The report indicates a skin assessment was completed with no injuries noted. The report indicates that R1 complained of pain. However there is no description of where and/or what type of pain R1 is complaining of. There is a note indicating that prescribed pain medication was given. The report also indicates that R1's family was notified at 5:10am, by phone, and the physician was notified at 5:20am with no new orders given. The incident report noted 3 times that R1 had no injuries. According to the facilities investigation R1 said that "2 girls came into my room to get me up for dialysis. While they were transferring me I don't know what happened but I ended up sliding down to the floor. I didn't fall but my legs went behind me and it really hurts." E2, Director of Nursing(DON), indicates in the statement that R1's right knee was observed to be swollen, and externally rotated. R1 again indicates that "4 girls picked me up put me back to bed. They then went to get the mechanical lift thing, to put me in the chair and bumped my head on the metal part of the lift. The statement indicates that they took me to dialysis, but my leg is really hurting." According to the dialysis progress note dated 4/10/2013 8:00am notes that R1 said she was dropped upstairs while being transferred prior to coming down to dialysis. R1 is also noted with a bump/bruise on front of head. The note indicates that the facility staff verbalized they were aware of R1's status. Nursing notes dated 4/10/2013 5:00am denotes that R1 slid to the floor while being transferred from chair to bed in preparation for dialysis. Head to toe assessment completed with zero injuries. R1 noted as being assisted back to the chair to prepare for dialysis. R1 noted with complaints of pain, pain medication given as prescribed. The note also indicates that family and physician was notified with no new orders. Nursing note 6:00am R1 down in dialysis. Nursing note 7:00am notes endorsed to next shift. Nurse note written by E9, Nurse. On 4/12/13 at 4:00pm E7, Restorative Nurse, said that she did an assessment of R1 mobility, and transfer status. Reviewed restorative nursing assessment needs dated 3/21/2013 with E7. E7 said that she completed this assessment. The area of the assessment (mobility) denotes for weight bearing R1 is assessed a (4) which indicates dependent, transfer from bed to chair /chair to bed R1 is assessed extensive assistance. E7 said that R1 is unable to bear weight or stand without at least (2) staff on either side using a gait belt. E7 said that during her assessment R1 was observed, and at times R1's knee would buckle and would be unable to transfer because of weakness. E7 said that if R1 knees were weak staff would be unable to transfer her at that time without the use of mechanical lift. E7 also said that when she coded R1 as extensive assistance she said it would require (2) staff to assist R1 with transfers. E7 said that she was not part of the MDS coding for R1 last update. E7 said that her Restorative Aids were aware that R1's knee could buckle during transfer, however E7 said she didn't make certified nursing staff aware of R1's weak lower extremity. E7 said that they should be aware because of past experience of getting R1 up. Reviewed R1's most current Minimum (MDS) data set [DATE], section G indicates that R1 requires extensive assistance and 1 person physical assist. E7 said that the assessment was incorrect and that R1 requires 2 person assistance, and mechanical lift if R1's knee were weak. E8, Certified Nurse Aid (CNA), was not available for interview during this survey, in fact the facility provided the survey team with an employee report dated 4/17/2013 indicating that E8 was discharged from employment for not responding to facility phone calls, and not reporting to an agreed upon meeting with E2, DON. However the facility provided the survey with a statement taken over the phone from E8. The statement indicates that E8 gave R1 care and was getting R1 dressed with the help of another CNA. The statement notes that R1 said that she could stand up for a while, so it was decided to pivot R1 into a chair. The statement indicates that once R1 stood up, that her knees gave out because R1 slid to the floor. The note indicates that R1 was being directed on what to do when her knees collapsed and R1 went down onto her knees then laid to her left side with both legs to her right side. E8 indicates that the other CNA stayed with R1, while she went and got the nurse. E8 also indicates they paged for help from other CNAs. E8 indicates that there were now 4 CNAs, and that they rolled R1 onto a sheet underneath her, and as they all lifted R1 from the floor with the sheet that R1 bumped the bed rail and ended up lying on her face. E8 said that R1 was repositioned in bed, and they went and got a mechanical lift. E8 indicates that she got R1 up by using the mechanical lift and transferred her to the chair. E8 indicates that the nurse came and gave R1 pain medication, and E8 took R1 to dialysis. There was no entry indicating the condition of R1's face or leg. On 4/12/13 at 4:15pm via phone E11, CNA, said that E8, CNA, asked her to assist getting R1 out bed for morning dialysis. E11 said that she didn't put a gait belt on R1, but thinks that E8 had placed one around R1 for the transfer. E11 said that they were able to get R1 in a standing position, and R1 started complaining about her knee hurting and leg pain. E11 said that R1 legs started to buckle, and she felt that R1's legs were going out. E11 said that R1 landed in an awkward position sitting on her buttocks with her legs underneath her. However, E11 said that R1's head didn't hit anything. E11 said there was no swelling or bruising on R1's face. E11 said that after R1 was on the floor they asked (2) other CNAs to assist with putting R1 back to bed because she was too heavy to lift with just 2 people. E11 said that they rolled R1 onto a bed sheet and (1) CNA on each end of the sheet lifted R1 back to the bed. E11 said that R1 wasn't bumped during the transfer with the sheet. E11 said that the side rails on the bed was down during this transfer and that R1's head didn't bump the rail during this transfer. E11 said after R1 was back in the R1's leg looked okay, however she said she didn't really look because R1 was wrapped in the sheet. E11 said that after R1 was back in bed she kept complaining of leg pain. E11 said that she left the room after this transfer to get back to her residents, and said she don't know how R1 was transferred from the bed to the dialysis chair. E11 said that she was not aware that R1 had lower extremity weakness, and was never informed that R1's knees might give out during transfer. On 4/12/2013 at 4:30pm E10, CNA, said that she was working on another unit when she was asked to assist getting R1 off the floor. E10 said that there were 4 aides assisting with getting R1 off the floor. E10 said that they rolled R1 side to side onto a sheet to lift her back into the bed safely. E10 said that R1 didn't hit/bump anything while being transferred from the floor to the bed. E10 said that the side rails on the bed were down during the transfer and R1's face/head didn't hit the side rails. E10 said that R1 didn't have any facial swelling and/or bruising. E10 said she was told by E8 that R1 had slid to the floor. E10 said that when she arrived to R1's room that R1 was sitting on her buttocks with her legs underneath her. E10 said that when arrived to the room R1 was not wearing a gait belt around her. E10 said once she assisted R1 back to bed that she left and didn't assist R1 anymore that day. E10 said she don't know how R1 was transferred from the bed to the chair to go to dialysis. E10 said that she don't recall seeing R1's leg, however did say that R1 complained of leg pain. On 4/12/13 at 4:35pm via telephone E12, CNA, said that E8 asked her if she could assist in getting R1 off the floor. E12 said that she entered R1's room and that R1 was on the floor sitting on her legs with her feet under her buttocks. E12 said that R1 was asking for a pain pill. E12 said that R1 wasn't wearing a gait belt when she entered the room. E12 said that they rolled R1 onto a sheet to transfer her from the floor to the bed. E12 said it was 2 aides on each side of the sheet a total of 4 aides. E12 said that when R1 was lifted from the floor the bed was in lowest position and the side rails were down. E12 said that R1 wasn't bumped into anythng during this transfer. E12 said that R1's leg didn't look swollen, but she was put in the bed flat. E12 said that R1 was complaining of pain to the leg. E12 said that R1 didn't have any facial bruising or swelling at that time. E12 said that she left the room after the transfer, and don't know how R1 was trnsferred from the bed to the chair for dialysis. Nursing note dated 4/10/2013 11:30am indicates that R1 back from dialysis on geri chair, R1 complaining of pain, nurse indicates inflammation over the right knee, no bruising or discoloration noted. R1 also noted with a 2"x2" bump noted to the right forehead. R1 complains of pain with slight pressure. The note indicates the right knee is immobilized and ice pack applied, pain medication given. Nursing note 11:35am indicates that the physician was notified with orders to send to the hospital for evaluation. Nursing note 11:37 family notified. Nursing note 12:10pm R1 pick up by ambulance service in route to local hospital for evaluation. Note written by E13, Nurse. On 4/19/2013 at 1:45pm E13, Nurse said that when he started his shift at 7:00am on 4/10/2013 that R1 was in dialysis, and had been involved in a fall incident. E13 said that it was reported to him that R1 didn't sustain any injuries. E13 said around 11:30am R1 was being pushed in her recliner chair through the elevator doors, E13 said that he immediately observed an moderate size bump on R1's forehead. E13 said he that immediately notified E14, Supervsior of his observation. E13 said that he notified the supervisor immediately because he was told in report that R1 didn't sustain any injuries. E13 said that he immediately notified R1's family member of R1's status. E13 said that he told R1's family member that he and E2 would do further assessments and would notify R1's family member of any new changes. E13 said that R1 was taken to her room and placed in bed. E13 said the sheet was removed from R1's legs and E13 said that he immediately noticed that R1 right leg was swollen, and the right knee was externally rotated. E13 said that he notified Z3, Nurse Practitioner of R1's status. E13 said that he had orders to send R1 out to the hospital for evaluation. On 4/19/2013 at 3:00pm via phone E9, Nurse, said that she was notified by CNA that R1 had slid to the floor. E9 said that when she entered the room that R1 was in a seated position, on her buttocks and both legs were extended in front her. E9 said that (4) CNAs lifted R1 back into bed, E9 said that one CNA held R1's legs, one CNA supported her buttocks, one CNA supported her back, and the last CNA held her neck and head and placed R1 back into bed. E9 also said that staff also used a gait belt to left R1. E9 said that there was no mechanical lift in the room, and no, that staff didn't bump R1's head. E9 said that once R1 was placed in the bed, that she performed a head to toe assessment of R1 to include range of motion exercises to all extremities. E9 said that both of R1's knees were able bend within normal limits. E9 said that after her assessment she left the room because she had other resident to care for. E9 said that R1 did complain of pain, and was holding her right thigh. E9 said that R1 usually complains of pain either to the leg, back or somewhere. E9 said that R1 was in the chair going to dialysis that she gave R1 pain medication (Hydromorphone 2mg). E9 said this about 6:00am. E9 said that she didn't observe any bump to R1's forehead. E9 said that she called (2) physicians Z1/Z2 and informed them that R1 fell without injuries noted. E9 said that she called R1's family member and left her a message that R1 was involved in a fall incident. The facility also prestented the survey with a copy of the mandatory inservice for all certifiied nurse aide staff dated 4-11,4-12, and 4-15. the inservice was entitled "Transfer Training" On 4/26/2013 at 10:00am Z1, Physician, said that he can't recall the time but said that he was informed by a facility nurse that R1 had slipped to the floor without injury or pain. Z1 said that he gave an order to keep and eye on R1. Z1 said that he was aware now that R1 was admitted to the hospital with [REDACTED]. Z1 said that based on the assessment from the hospital report and that R1 had a broken femur that it would have been impossible for R1 have been assessed with [REDACTED]. Z1 said that if he was provided a detailed accurate assessment of R1's condition that R1 would have been sent out immediately to the hospital for treatment. Z1 said that R1 could have been evaluated and treated at the hospital then received his dialysis treatment. Z1 said that his expectation is that the facilities nursing staff obtain thorough assessments and provide accurate details when they notify the physician to assist with making prompt accurate decisions on treatment. According to the hospital record dated 4/10/2013 12:32pm R1 arrived to the emergency room , the report indicates R1 had right knee pain, discoloration, and bump on the forehead. R1 was assessed for pain to be 10 out of 10. According to the hospital record 4-10-13 at 1:58pm xray of the right knee impression, comminuted displaced fracture involving the distal femoral shaft.