Every finding on record at Loft Rehab of Decatur

Based on observation, interview, and record review the facility failed to answer call lights in a timely manner for five (R1, R4, R5, R7, R8) of five residents reviewed for call lights in a sample list of eight residents.Findings Include:On 6/26/26 at 8:11 AM, R8's call light was on, at 8:15 AM. V11 Certified Nursing Assistant (CNA) went into the room and shut off call light. This writer heard V11 tell R8 that R8's CNA is feeding other residents in the dining room and R8 would have to wait.On 6/26/2026 at 9:05 AM, R5 was in R5's room sitting in recliner watching TV. R5's call light was on floor on the right side of recliner out of R5s reach.On 06/25/26 at 08:17 AM, V3 (R1) family member, stated R1 called V3 at 03:44 AM on 6/11/26 stating that R1's call light had been on since midnight, and no one had answered it.On 6/26/26 at 8:30 AM, R8 stated R8 had to use the bathroom, but the Certified Nursing Assistant (CNA) didn't ask R8 what R8 needed or anything. R8 stated, R8 gets put off like that routinely. R8 stated if the staff come and put R8 in the bathroom, they leave, and R8 has to wait for them to come back a lot of times too. R8 doesn't know how long it is but seems like a lifetime to R8. R8 stated waiting on staff has never caused R8 to have an accident.On 6/26/2026 at 9:00 AM, R4 stated call lights are not answered in a timely manner and causes R4 to have accidents (urinary incontinence) due to this.On 6/26/2026 at 9:21 AM, R7 stated, call lights do not get answered in a timely response. R7 stated some staff take longer than others.On 6/26/2026 at 11:23 AM, V12 License Practical Nurse (LPN) stated V12 received a call from R1's family who stated that the call light was activated and R1 needed assistance. V12 confirmed the call light was activated for an unknown amount of time.On 6/26/26 at 11:54 AM, V2 Director of Nursing (DON) stated V2 would expect the CNA to help the resident. On 6/26/26 at 11:49 AM, V15 LPN stated V15 would expect CNAs to help the resident. V15 stated everybody is to help everybody here. Depending on the CNA and workload they have.On 6/27/2026 at 12:34 PM, R7 stated that R7's call light is usually answered in 15-20 minutes. R7 stated, I (R7) can put my light on after supper at 7:00 PM and staff will not answer until 8:00 PM. R7 stated this happens all the time.On 6/27/2026 at 12:38 PM, V2 stated that call lights should be answered as soon as possible. V2 stated within 15 minutes.R1 was admitted to the facility on [DATE] and was discharged on 6/11/2026. R1's Care plan dated 6/27/26 documented diagnosis of Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Pancytopenia, Acute and Chronic Respiratory Failure with Hypoxia, Unilateral Primary Osteoarthritis Right Knee, Chronic Kidney Disease, Essential (Primary) Hypertension, Acute Right Heart Failure, Anemia in Other Chronic Diseases Classified Elsewhere, and Non-St Elevation (Nstemi) Myocardial Infarction. R1's Minimum Data Set completed on Jun 10, 2026, documents a Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicates R1 is cognitively intact.R4 was admitted on [DATE] with Diagnosis of Exudative Age-Related Macular Degeneration, Bilateral, Stage, Contracture Right Hand, Osteoarthritis, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Lack of Coordination, Contracture Right Shoulder, Contracture Right Elbow, Contracture Right Wrist, and Difficulty in Walking. R4's Minimum Data Set in section GG dated 05/26/2026 states R4 is dependent on assistance for toileting hygiene, substantial/maximal assistance with lower body dressing and toilet transfers. R4's Minimum Data Set completed on 5/20/2026 documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates R4 is cognitively intact.R5 was admitted on [DATE] with a diagnosis of History of Falling, Muscle Weakness, Age-Related Osteoporosis Without Current Pathological Fracture, Primary Generalized (Osteo)Arthritis, Polyosteoarthritis, Thyrotoxicosis, Hypotension. R5 Minimum Data Set in section GG dated 05/15/2026 states R5 is partial/moderate assistance for toileting hygiene. substantial/maximal assistance with lower body dressing and Partial/moderate assistance for toilet transfers. R5's Minimum Data Set completed on 05/15/2026 documents a Brief Interview for Mental Status (BIMS) score of 08. A score of 08 indicates R5 is Moderately Impaired.R7 was admitted on [DATE] with diagnosis of Muscle Weakness, Glaucoma, Unilateral Primary Osteoarthritis Left Hip, Radiculopathy Lumbar Region, Spondylosis Without Myelopathy or Radiculopathy Lumbar Region, Pain in Right Knee, Unilateral Primary Osteoarthritis Left Knee, Pain in Left Knee, Unilateral Primary Osteoarthritis Right Knee, Localized Edema Cervical Region, Osteoarthritis, Carpal Tunnel Syndrome, Mass Index [BMI] 40.0 44.9, Adult (Z68.41). R7's Minimum Data Set in section GG dated 03/25/2026 states R7 is substantial/maximal assistance for toileting hygiene, substantial/maximal assistance with lower body dressing and partial/moderate assistance for toilet transfers. R7's Minimum Data Set completed on 3/24/2026 documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R7 is cognitively intact.R8 was admitted on [DATE] with diagnosis of Age-Related Osteoporosis, Nontraumatic Intracerebral Hemorrhage in Hemisphere, Acute Embolism and Thrombosis of Iliac Vein Bilateral, Epilepsy, Iron Deficiency Anemia, Muscle Wasting and Atrophy. R8's Minimum Data Set in section GG dated 05/11/2026 states R8 has an impairment on one side of body to upper extremity and lower extremity. R8 is dependent for toileting hygiene, lower body dressing and toilet transfers. R8's Minimum Data Set completed on 5/11/2026 documents a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicates R10 is cognitively intact.On April 23, 2026, the Resident Council minutes show concerns from residents with CNAs entering rooms to turn off call lights without providing necessary assistance.Facility's Call Lights: Accessibility and Timely Response Policy last revised on 02/06/2025 states, 8. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 9-A response times should be a Priority. 9-D Listen to the resident's request and respond accordingly.

Based on interview and record review the facility failed to ensure incontinence care was provided per current standards of practice for three (R1, R5, and R6) of five residents reviewed for incontinence care in the sample list of eight residents.Findings Include:On 06/25/26 at 08:17 AM, V3 (R1's) family member, stated when family visited R1 on 6/7/26 in the morning hours, R1 told family R1 had not been checked for incontinence in 15 or more hours. R1 further stated to family that R1 was wearing two (2) incontinence briefs. V3 stated R1 was observed wearing two (2) incontinence briefs that were saturated with urine and staff was asked to change R1.On 6/26/2026 at 9:05 AM, R5 stated R5 has been recently had double depends (incontinence briefs) at night every so often. R5 does not recall who does it. R5 does not like wearing double depends (incontinence briefs) at night.On 6/26/2026 at 9:16 AM, R6 stated R6 has been recently had double depends (incontinence briefs) at night not per request.On 6/26/2026 at 9:35 AM, V9 Certified Nursing Assistant (CNA) stated residents are not to have two (2) incontinence briefs in place. V9 further stated if we see this, we are supposed to report to the Director of Nursing.On 6/26/2026 at 10:08 AM, V2 Director of Nursing (DON) stated residents are not to be wearing two (2) incontinence briefs at the same time, and staff are to report it to the lead CNA if they observe it.R1 was admitted to the facility on [DATE] and discharged on 6/11/2026. R1's Care plan dated 6/27/26 documents diagnosis of Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Pancytopenia, Acute and Chronic Respiratory Failure With Hypoxia, Unilateral Primary Osteoarthritis Right Knee, Chronic Kidney Disease, Essential (Primary) Hypertension, Acute Right Heart Failure, Anemia in Other Chronic Diseases Classified Elsewhere, and Non-St Elevation (Nstemi) Myocardial Infarction. The same care plan documents R1 is at risk for skin breakdown related to immobility. Interventions documented state to keep R1 clean and dry as possible, minimize R1's skin exposure to moisture. R1's Minimum Data Set completed on Jun 10, 2026, documents a Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicates R1 is cognitively intact.R5 was admitted on [DATE] with diagnosis of History of Falling, Muscle Weakness, Age-Related Osteoporosis Without Current Pathological Fracture, Primary Generalized (Osteo)Arthritis, Polyosteoarthritis, Thyrotoxicosis, Hypotension. R5 Minimum Data Set in section GG dated 05/15/2026 states R5 is partial/moderate assistance for toileting hygiene. substantial/maximal assistance with lower body dressing and Partial/moderate assistance for toilet transfers. R5's Minimum Data Set completed on 05/15/2026 documents a Brief Interview for Mental Status (BIMS) score of 08. A score of 08 indicates R5 is Moderately Impaired. R5's Care Plan last revised on 5/19/2026 has interventions in place that states, Keep (R5) clean and dry as possible. Minimize (R5's) skin exposure to moisture.R6 was admitted on [DATE] with diagnosis of Muscle Weakness, Contracture of Muscle, Left Upper Arm, Other Disorders of Sclera, Shortness of Breath, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Cerebral Edema. R6's Minimum Data Set in section GG dated 04/14/2026 states R6 has impairment on one side of lower extremity. R6 is dependent for toileting hygiene, and lower body dressing. R6's Minimum Data Set completed on 04/14/2026 documents a Brief Interview for Mental Status (BIMS) score of 08. A score of 08 indicates R6 is Moderately Impaired. R6's Care Plan last revised 4/10/2026 states R6 is a full mechanical lift with assistance of two staff for all transfers. Care plan states I (R6) am at risk for skin breakdown related to limited mobility. Interventions states that Keep (R6) clean and dry as possible. Minimize (R6's) skin exposure to moisture.Facility's Incontinence Policy last revised 2/2/2026 states in 1. The facility must ensure that residents who are continent of bladder and bowel upon admission received appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

Based on interview and record review the facility failed to protect residents' (R84, R10) right to be free from physical abuse by another resident (R70) for three of three residents (R84, R10, R70) reviewed for abuse in the sample list of 57 residents. This failure resulted in psychosocial harm of R84 as evidenced by R84 crying and avoidance of R70. Findings include: The facility's Abuse, Neglect, Exploitation Policy dated 1/23/26 documents abuse is the willful infliction of injury, intimidation or punishment that results in physical harm, pain or mental anguish. This policy documents staff will be trained on understanding behavioral symptoms of residents that may increase the risk of abuse/neglect including aggressive or catastrophic reactions, wandering/elopement behaviors, resisting care, outburst/yelling, or difficulty in adjusting to new routine or staff. 1.) The facility's State Report documents on 3/22/26 at 7:50 PM, a Certified Nursing Assistant (V25 CNA) witnessed R70 knock R84's glasses off R84's face while in the hallway as they passed each other. This report documents that R84 was interviewed and stated R70 told R84 that R84 didn't belong there and knocked R84's glasses off R84's face. R70's Minimum Data Set (MDS) dated [DATE] documents R70 has severe cognitive impairment. R70's active care plan documents R70's diagnoses include Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety. R84's MDS dated [DATE] documents R84 has severe cognitive impairment. R70's Nursing Note dated 4/17/26 at 9:37 PM documents R70 became aggressive with staff after transferring R70 into the wheelchair. R70 grabbed the CNAs' wrists and hit their arms, and R70 threatened to punch staff in the face. On 5/3/26 at 1:43 PM, V25 Certified Nursing Assistant (CNA) stated the following: V25 CNA was coming down the southeast hallway at approximately 9:00 PM-9:30 PM and witnessed R70 swinging at R84's face and R70 hit R84's glasses off R84's face. V25 CNA stated R70's actions were intentional and not accidental. R84 said R70 hit R84 a few times, but V25 CNA did not witness this. There was a red mark on R84's nose and R84 cried after the incident. R70 and R84 both do a lot of yelling, but V25 CNA did not see what caused the incident and there were no other witnesses. R70 gets aggressive with staff during cares. Staff had to keep R70 and R84 separated the rest of the night, R84 didn't want to go near R70, R84 still seems to recognize R70 and avoids R70. 2.) R70's Nursing Note dated 4/24/26 at 5:31 AM documents the nurse (V26 Licensed Practical Nurse) heard screaming for help and found R70 in R10's bed and witnessed R70 open handed smack R10 in the face on the right side of R10's cheek. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has severe cognitive impairment. R10's active diagnoses list includes Dementia, Anxiety, and Depression. The facility's State Report documents on 4/24/26, V26 LPN witnessed R70 sitting on R10's bed and open handed smacked R10 on the right cheek.Attempts were made to contact V26 LPN. On 5/04/2026 at 12:39 PM, V1 Administrator confirmed R70 and R10's altercation was witnessed by V26 LPN as described in the facility's State Report and R70's nursing note. V1 stated V26 LPN witnessed R70 make contact with the right side of R10's face.

Based on observation, interview, and record review the facility failed to implement pressure relieving interventions, evaluate nutritional status, and prevent cross contamination during pressure ulcer treatments for one (R11) of four residents reviewed for pressure ulcers in the sample list of 57 residents. These failures resulted in R11 developing bilateral heel deep tissue injuries that deteriorated to stage three and stage four pressure ulcers. Findings include:The facility's Skin Integrity- Foot Care policy dated 2/20/26 documents the following: Interventions will be based on the identified risk assessment, skin assessment and assessment of foot ulcers. Interventions include offloading or use of pressure-relieving devices, and interventions will be modified in the resident's care plan. Consider modifications if there are new onset foot ulcers, lack of progression of healing, or resident non-compliance. The facility's Pressure Injury Prevention and Management policy dated 2/10/26 documents an avoidable means the resident developed a pressure ulcer/injury and the facility did not implement at least one of the following: evaluate clinical condition and risk factors, define and implement interventions, monitor/evaluate the impact of the interventions, or revise the interventions as appropriate.The facility's Hand Hygiene policy dated 2/10/25 documents staff will perform hand hygiene when indicated, consistent with standards of practice and the use of gloves does not replace hand hygiene. This policy documents to perform hand hygiene immediately after removing gloves. The facility's Referrals to the Dietitian policy dated 1/23/26 documents between consulting visits the facility is responsible for notifying the dietitian of new clients whose medical condition may place them at nutritional risk, which include pressure injuries. R11's admission Minimum Data Set (MDS) dated [DATE] documents R11 has moderate cognitive impairment, requires dependence on staff for rolling/turning in bed, and has no pressure ulcers. R11's MDS dated [DATE] documents R11 has severe cognitive impairment, has one facility acquired stage three pressure ulcer and one facility acquired stage four pressure ulcer. R11's Braden assessment dated [DATE] documents R11 is at risk for developing pressure ulcers. R11's Skin Assessments dated 12/19/25 - 12/24/25 document R11's skin as intact and does not identify any pressure relieving interventions were implemented as prompted by the assessment. R11's Care Plan dated 12/20/26 documents R11 is at risk for developing pressure ulcers related to immobility secondary to spinal stenosis. This care plan includes interventions for a dietitian consultation, heel protectors as resident will allow (1/2/26), use pillows or foam wedge to avoid direct contact with bony prominences, and use pressure relieving devices on appropriate surfaces. This care plan documents R11's diagnoses include Muscle Weakness/Atrophy and Dementia. R11's December 2025 Treatment Administration Record (TAR) does not document any treatments for R11's heels prior to 12/25/25. R11's January 2026 TAR documents pressure reducing boots on at all times every shift starting on 1/5/26 and remains as an active order as of 5/5/26. R11's Certified Nursing Assistant tasks document pressure relieving boots at night was added on 1/14/26. There is no documentation the facility developed and implemented pressure relieving interventions to address heel pressure or repositioning needs prior to R11 developing heel wounds on 12/25/25, and no documentation that R11 refused to wear pressure relieving boots. R11's Nursing Note dated 12/19/2025 at 12:50 PM documents R11 admitted from home due to stenosis of vertebrae, R11 has back pain that increases with movement and R11 requires assistance with activities of daily living and transfers. R11's Nursing Note dated 12/25/25 at 3:17 AM documents R11 turned call light on and complained of heel pain and burning. There was drainage on R11's sheet underneath R11's right heel. R11's socks were removed and there was a darkened area approximately 4 centimeters (cm) by 4 cm on right heel and a fluid filled blister with darkened red area on the left heel that measured 6 cm by 6 cm. Treatment orders were obtained. R11's Nursing Note dated 12/28/2025 at 7:35 PM documents area assessed and is consistent with positioning and immobility, wound nurse to assess during rounding, physician aware, treatment entered, and care plan updated. R11's Wound Weekly Observation Tools dated 12/25/25 documents R11's heel wounds as deep tissue injuries acquired on 12/25/25. R11's left heel measured 3 cm by 3 cm by 0.1 cm depth, and right heel measured 4 cm by 4 cm by 0.1 cm. R11's Initial Wound Evaluation & Management dated 1/5/26, recorded by V17 Wound Physician, documents stage two pressure ulcer right heel measured 2 cm by 3 cm by 0.1 cm and stage three pressure ulcer left heel measured 4 cm by 5.5 cm by 0.2 cm, with 40% slough (dead tissue/fibrin). The estimated time to heal both wounds is noted as two to four months. This evaluation includes recommendations for offloading wounds, repositioning per facility protocol, turn side to side, floating heels in bed, and pressure off-loading boots.R11's Wound Evaluation & Management Summary dated 1/12/26 documents right heel wound deteriorated to stage three pressure ulcer and measured 3.3 cm by 3.8 cm by 0.1 cm, with 30 % slough, and exacerbated due to infection. R11's left heel stage three pressure ulcer measured 4 cm by 5.5 cm, depth was immeasurable due to being covered with nonviable tissue, 40 % slough, and 60% necrotic (dead) tissue. R11 was not wearing pressure-relieving boots and was educated on the importance. R11's prealbumin level was 15 grams/liter on 1/12/26. Recommendations included the same as 1/5/26 with the addition of dietitian consultation. R11's Wound Evaluation & Management Summary dated 1/26/26 documents R11's right heel wound deteriorated to stage four pressure ulcer, measured 2.5 cm by 3.4 cm with depth immeasurable due to being covered with nonviable tissue. R11's left heel stage three pressure ulcer measured 3.7 cm by 4.3 cm by 0.4 cm. V17's recommendations included a dietitian consultation and the same interventions as 1/5/26.R11's Wound Evaluation & Management Summary dated 5/4/26 documents right heel stage four pressure ulcer measured 1.8 cm by 1.3 cm by 0.2 cm. R11's left heel stage three pressure ulcer measured 2 cm by 1.5 cm by 0.2 cm. V17's recommendations are the same as previously noted. R11's Physician's Order dated 1/6/26 documents Tetracycline Hydrochloride (antibiotic) 500 milligrams (mg) by mouth twice daily for fourteen days for wound. R11's Physician's Order dated 1/13/26 documents Levaquin (antibiotic) 750 mg by mouth daily for ten days for wound.There is no documentation in R11's medical record that R11's nutritional status was evaluated by a dietitian after 12/22/25.On 5/3/26 at 11:16 AM, V20 (R11's) Family Member stated R11's heel wounds started developing at home prior to admission. V20 stated R11 was treated for wound infection after being admitted to the facility. R11 was sitting in a wheelchair in R11's room, R11 was not wearing pressure relieving boots. V20 stated R11 only wears the boots when in bed. R11's bed contained a standard foam mattress.On 5/04/2026 at 10:32 AM, V17 Wound Physician, V2 Director of Nursing, and V30 Certified Nursing Assistant (CNA) entered R11's room to provide wound care. V17 applied multiple pairs of gloves. V17 cleansed R11's heel wound with the same gauze and same pair of gloves. V17 administered R11's wound treatment as ordered, removing the outer layer glovers after dressing each wound. V17 did not perform hand hygiene after cleaning the wounds or between each wound treatment administration. R11's bed contained a standard mattress.On 5/05/2026 at 9:46 AM, R11 still had a standard foam mattress on R11's bed. On 5/4/26 at 10:45 AM, V17 Wound Physician confirmed the same gauze and gloves were used to cleanse both wounds. V17 confirmed V17 wore multiple pairs of gloves removing with the outer pairs removed after cleansing the wounds and after each dressing change, with no hand hygiene during the wound treatment. V17 stated V17 performed hand hygiene prior to applying the gloves.On 5/05/2026 at 9:37 AM, V31 Licensed Practical Nurse (LPN) stated heel protector boots or floating heels are only implemented if there are wounds or redness and R11 didn't have any wounds or redness when V31 LPN assessed R11's skin on 12/20/25 and 12/21/25. V31 LPN stated the heel boots are entered for the nurse to sign off on the TAR and to prompt the CNAs to apply. V31 stated an alternating pressure mattress is implemented once they develop a wound and to prevent the wound from getting worse, but usually for coccyx wounds. V31 stated R11 is cooperative with wearing pressure relieving boots. On 5/05/2026 at 10:00 AM, V2 Director of Nursing (DON) stated R11's heel wounds were closed when R11 admitted , they were deep tissue injuries and had skin protectant wipes in place. V2 DON confirmed this would be documented on the TAR and there was no documented treatment for this. V2 DON assessed R11's wounds on 12/25/26, heel boots and offloading heels were implemented as interventions. V2 confirmed heel boots were not added to R11's TAR until 1/5/26 or R11's tasks until 1/14/26. V2 DON stated R11 was not referred to V17 until after R11's heel wounds opened. V2 DON stated V2 updates the dietitian weekly regarding wounds and implement Vitamin C, Zinc and Prostat. V2 stated V2 does not look at V17's Wound Physician notes, V27 LPN, who works at (sister facility), rounds with V17 and enters V17's orders. V2 stated V2 thought R11 had an alternating pressure mattress, usually this type of mattress is put in place for all wounds. V2 DON stated each wound should be done from start to finish, cleaning each wound separately. V2 stated V17 Wound Physician had on multiple pairs of gloves. V2 stated staff should change gloves and perform hand hygiene during each wound treatment, after cleansing and applying the clean dressing. On 5/5/26 at 11:47 AM, V2 confirmed R11's care plan was not updated with pressure relieving interventions for R11's heels until heel protectors were added on 1/2/26. On 5/6/26 at 10:50 AM, V2 confirmed there was no documentation that R11 refuses heel boots. On 5/5/26 at 12:53 PM, V13 CNA stated R11 wears pressure relieving boots in bed, and occasionally in the wheelchair if R11 is complaining of R11's feet hurting. V13 CNA stated R11 is cooperative in wearing the boots. On 5/05/2026 at 2:07 PM, V25 CNA stated R11 admitted with back pain and had no complaints of heel pain or wounds until about a week after R11 admitted to the facility. V25 CNA stated R11 wasn't using the pressure relieving boots when R11 first admitted , the boots weren't implemented until after R11's wounds developed. V25 CNA stated R11 wears the boots when R11 is in bed and occasionally when R11 is in the wheelchair. V25 CNA stated R11 is cooperative in wearing the boots. On 5/5/26 at 10:40 AM, V27 LPN stated V27 rounds with V17 Wound Physician and enters the treatment orders, but that is all. V27 LPN stated I know there was noncompliance with (R11) not wearing (R11's) boots at one point but was unsure if it was related to staff not putting them on or R11 refusing. V27 LPN stated V27 reviews V17's notes but V27 does not notify the dietitian, V2 should have been sending a weekly wound report on Thursdays to V21 Dietitian. V27 stated V27 does not enter orders for offloading or pressure relieving boots. On 5/5/26 at 11:11 AM, V21 Dietitian stated usually the facility sends a weekly wound report, but that hasn't happened for several months. V21 stated V21 just runs V21's own reports and looks at assessments to determine who has wounds. V21 stated R11 is on V21's list to be seen today, but V21 has not evaluated R11 since R11's admission in December. V21 stated V21 was not aware that R11 had wounds. V21 Dietician stated usually the facility sends a weekly wound report to V21, but that hasn't happened for several months. V21 is just running her own reports and looking at assessments to determine who has wounds. V21 has R11 on V21's list to see today, but V21 hasn't evaluated R11 since admission in December. V21 was not aware that R11 had wounds. V21 stated V21 would have ordered Vitamin C, Zinc and multivitamin to aid in wound healing. On 5/5/26 at 11:34 AM, V22 Physician stated R11 had been in the hospital and was declining which continued once R11 returned home, leading to long term care placement. V22 stated R11 was wheelchair bound and R11's ability to be independent had declined, and Dementia contributed to this. V22 Physician stated preventative measures include offloading heels or cushioning heels, and R11 would benefit from having an alternating pressure mattress. V22 confirmed the dietitian should have been consulted. V22 stated V22 would agree that R11's pressure ulcers were avoidable and wound deterioration prevented if these interventions were implemented. On 5/5/26 V1 Administrator provided R11's mattress information. The specification for this mattress documents the mattress is recommended for high risk level up to stage two pressure ulcers.

Based on interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance committee meetings. The facility failed to provide documentation of its ongoing Quality Assurance & Performance Improvement Program meeting minutes for two quarters of 2025. This failure has the potential to affect all 91 residents.FindingsOn 5/4/26 at 09:25 AM, V1 Administrator provided Quality Assessment and Assurance (QAA) meeting attendance sheets for the first quarter 2026 and fourth quarter 2025 QAA meetings. V1 stated the QAA team meets quarterly to discuss issues/concerns.The January 2026 QAA meeting attendance signature sheet does not document the facility Administrator (administrator, owner, board member or other individual in a leadership role) was present for the meeting.On 5/4/26 at 9:30 AM, V1 Administrator confirmed that V1 Administrator was not in attendance for the January 2026 QAA meeting.There were no documented attendance sheets or QAA meeting minutes available in the second or third quarter of 2025.On 5/6/25 at 02:00 PM, V1 Administrator confirmed there were no minutes or attendance sheets for quarters two and three 2025. The Quality Assurance & Performance Improvement Policy dated 1/22/26 documents the following: The meeting is to systematically monitor performance indicators as part of the QAPI program. Performance indicators are established based on data analysis and monitored/evaluated in the QAA Committee meetings, which take place on a monthly basis and as needed.The Long-Term Care Facility Application for Medicare and Medicaid dated 5/3/2026 documents the facility has a census of 91 residents.

Based on observation, interview, and record review, the facility failed to implement their water management plan including an annual risk assessment, control measures, and testing protocols to reduce the risk of Legionella and other opportunistic pathogens in the facility's water systems. This failure has the potential to affect all 91 residents in the facility.Findings Include:The facility's Water Management Program, dated as revised 1/21/26, documents a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. Based on the risk assessment, control points will be identified. The list of identified points shall be kept in the water management program binder. Control measures will be applied to address potential hazards at each control point. The measures shall be specified in the water management program action plan. Testing protocols and control limits will be established for each control measure. The water management team shall regularly verify that the water management program is being implemented as designed.On 5/5/26 at 9:25 AM, V15 Maintenance Director was turning pages in the facility's Water Management Program Binder. This binder did not include documentation of the facility's annual risk assessment, identification of control points, the control measures to address potential hazards at each control point, or the testing protocols and control limits for each control source. At this time, V15 confirmed that the binder lacked the documentation.On 5/5/26 at 3:30 PM, V6 Infection Preventionist/Assistant Director of Nursing, and V15 Maintenance Director stated an annual risk assessment was done last year, but they are unsure of the completion date and are unable to locate the assessment. V6 and V15 confirmed that they started an assessment on 5/5/26 but they were not able to complete the assessment or identify any risks at this time. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/3/26 documents a census of 91 residents.

Based on observation, interview, and record review the facility failed to document that narcotic medications were counted at the beginning and end of each shift and failed to destroy or send discontinued antibiotics back to the pharmacy. This failure affected 23 of 26 residents reviewed for medication storage on the sample list of 57 residents.Findings include:1. The facility's Controlled Drug Policy and Procedure, revised in August of 2024, documents that controlled drugs, as determined by the facility, are counted every shift by the nurse reporting on duty with the nurse reporting off-duty.On 05/04/2026 at 9:19 AM, the Northeast Medication cart was reviewed with V6 Assistant Director of Nursing (ADON). The Substance Controlled Check form dated May of 2026 did not contain documentation that narcotics were counted on 5/1/26 by the nurse coming off the 6 AM to 6 PM shift, 5/1/26 the nurse coming on and off the 6PM to 6AM shift, on 5/2/26 by the nurse coming on and off the 6AM to 6PM shift, on 5/2/26 by the nurse coming off the 6PM to 6AM shift, on 5/3/26 by the nurse coming on the 6AM to 6PM shift, on 5/3/26 by the nurse coming on and off the 6PM to 6AM shift, and on 5/4/26 by the nurse coming on the 6AM to 6PM shift. At this time, V6 ADON confirmed the missing entries on the form. In this medication cart was a medication card for R5 containing three patches of Buprenorphine 5 micrograms per hour, a card for R5 containing 19 tablets of Lorazepam 0.5 milligrams, a card for R7 containing 30 tablets of Tramadol 50 milligrams, a card for R7 containing 10 tablets of Tramadol 50 milligrams, a card for R22 containing 6 tablets of Norco 5-325 milligrams, a card for R22 containing 30 tablets of Norco 5-325 milligrams, a card for R28 containing 30 tablets of Lorazepam 0.5 milligrams, a card for R28 containing 14 tablets of Tramadol 50mg tablets, a card for R57 containing 15 Tramadol 50 milligrams, a card for R63 containing 30 tablets of Norco 5-325 milligrams, a card for R63 containing 30 tablets of Norco 5-325 milligrams, a card for R67 containing 11 tablets of Norco 5-325 milligrams, a card for R67 containing 30 tablets of Norco 5-325 milligrams, a card for R79 containing 8 Tramadol 50 milligrams, a card for R79 containing 15 tablets of Tramadol 50 milligram tablets, a card for R81 containing 16 Norco 5-325 milligrams, a card for R89 containing 24 tablets of Norco 5-325 milligrams, a card for R90 containing 30 tablets of Tramadol 50 milligrams, and a card for R91 containing 10 tablets of Lorazepam 0.5 milligram tablets.On 05/04/2026 at 9:19 AM, V6 ADON confirmed the Substance Controlled Check Form should be filled out at the beginning and end of each shift when narcotic medications are counted.On 05/04/2026 at 9:36 AM, the Southeast medication cart was reviewed with V9 Licensed Practical Nurse (LPN). The Substance Controlled Check Form dated May of 2026 did not contain documentation that narcotics were counted on 5/1/26 by the nurse coming off the 6am to 6PM shift. At this time, V9 LPN confirmed the missing entry on the form. In this medication cart was a medication card for R59 containing four patches of Fentanyl 25 microgram per hour, a card for R59 containing seven tablets of Norco 7.5-325 milligram tablets, a card for R15 containing 15 tablets of Tramadol 50 milligrams, a card for R16 containing seven tablets of Tramadol 50 milligrams, a card for R16 containing 30 tablets of Tramadol 50 milligrams, a card for R46 containing 27 tablets of Tramadol 50 milligrams, a card for R54 containing eight tablets of Tramadol 50 milligrams, a card for R54 containing 18 tablets of Tramadol 50 milligrams, a card for R70 containing 28 tablets of Lorazepam 0.5 milligrams, a card for R84 containing eight tablets of Lorazepam 0.5 milligrams, and a card for R84 containing 14 tablets of Lorazepam 1 milligram.On 05/04/2026 at 9:36 AM, V9 Licensed Practical Nurse confirmed that this should be completed at the beginning and end of every shift when narcotics are counted.On 05/05/2026 at 2:30 PM, an additional review of the Northeast Substance Controlled Check Form dated May of 2026 did not contain documentation that narcotics were counted on 5/4/26 by the nurse coming off of the 6AM to 6PM shift and on 5/4/26 of the nurse coming off of the 6PM to 6AM shift.On 05/04/2026 at 1:15 PM, V2 Director of Nursing, stated that the Substance Controlled Check Form nurse sign on and off sheets should be completed by the nurses each shift. There should not be any entries missing, but if there are the expectation is that the nurse should count with the previous shift and correct the missing entries. The nurses do get confused when filling out the sign-in and out sheets because we have a lot of split shifts here and staff should be re-educated. The Narcotic sign on and off sheet is audited daily by a nurse manager.2. The facility's Medication Destruction Policy, with an effective date of 10/25/2014 and no revision date, documents that discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed.On 05/04/2026 at 09:36 AM, while observing the South Medication storage room with V9 Licensed Practical Nurse, medications cards were observed in a cabinet for current and discharged residents. These medications were as follows:R50's Cephalexin 500 milligrams had 19 capsules remaining with a documented order completion date of 02/22/2026 and currently resides in the facility.R40's Tetracycline 500 milligrams had 16 tablets remaining with a documented order completion date of 03/02/2026, Amoxicillin- Potassium Clavulanate 875-125 milligrams had 12 tablets remaining with a documented order completion date of 02/23/2026, and Cephalexin 500mg had eight capsules remaining with a documented order completion date of 02/15/2026. R40 was discharged from the facility on 04/27/2026.R106's Cefuroxime 500 milligrams had 11 capsules remaining with a documented order completion date of 03/12/2026. This resident was discharged from the facility on 04/20/2026.R105's Cephalexin 500 milligrams had two capsules remaining with an order completion date of 03/18/2026. This resident was discharged from the facility on 04/17/2026.On 05/04/2026 at 09:36 AM, V9 Licensed Practical Nurse confirmed these medications should have been returned or destroyed after the antibiotic course was completed.On 05/04/2026 at 1:15PM, V2 Director of Nursing stated that when a resident is discharged their medications should be sent back to the pharmacy or with the resident. The discharging nurse is responsible for ensuring this is done. Medications that are no longer in use or for a discharged resident should be sent back to pharmacy the same day. Pharmacy comes daily to pick up medications. The nurse manager should verify that this is completed.

Based on observation, interview, and record review the facility failed to ensure medications were properly labeled and stored for five (R97, R28, R81, R73, R22) of 26 residents reviewed for medication storage on a sample list of 57 residents.Findings include:1. The facility's Vials and Ampules of Injectable Medications policy, with an effective date of 10/25/2015 and no revision date, documents that the date opened and the initials of the first person to use the vial are recorded on multidose vials.The product insert for Incruse Ellipta documents to discard six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first.The product label for Systane Complete Preservative Free (PF) Ophthalmic Solution documents that it must be discarded 90 days after opening.On 05/04/2026 at 9:19 AM, the Northeast medication cart was reviewed with V6 Assistant Director of Nursing. Three unlabeled medication cups were observed in top of cart with medication in them. V6 stated these medications were for R97 and R28 for the 7 AM to 10 AM medication pass and that there were no narcotics in the cups. V6 stated that these residents were not yet ready to take their medication, so V6 put them in to top of the cart. V6 confirmed that the medications should not be kept unlabeled in cups in the top of the cart. At this time, the following medications were observed in the Northeast medication cart without dates: R81's Insulin Lispro Subcutaneous Solution Pen-injector 200 UNIT/ML (milliliter), R81's Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, R73's Systane Complete PF Ophthalmic Solution 0.6 % Propylene Glycol, and R22's Incruse Ellipta 62.5 MCG (microgram)/ACT Aerosol Powder. V6 confirmed these medications were not dated and should be. V6 then was observed placing all undated medications back into cart.On 05/04/2026 at 1:15 PM, V2 Director of Nursing confirmed that if medications are in cups and the resident is not ready to take them or does not want to take them until later, that the nurse is expected to destroy the medications at that time and get new ones ready when the resident is ready for their medication. V2 confirmed medications should not be left in the top drawer of the medication cart. On 05/05/2026 at 11:24 AM, V2 Director of Nursing stated that all medications besides medication cards, should be dated. Nurse managers audit carts to ensure this happens.2. The facility's Medication Storage policy, revised on 2/2/26, documents that during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 05/03/2026 at 11:31 AM, Tums in a medication cup were observed on R97's bedside table. R97 stated that the nurse left them there for R97 to take.On 05/03/2026 at 11:32 AM, V32 Licensed Practical Nurse stated R97 was supposed to take the Tums right as V32 was walking out. V32 stated V32 thinks R97 has a self-administration order.On 05/03/2026 at 1:45 PM, V2 Director of Nursing stated V2 was unsure if R97 had a self-administration assessment, order, or care plan and would look for one in the chart, but V2 was unable to locate one at this time.On 05/04/2026 at 9:02 AM, V2 confirmed R97 did not have a self-administration of medications order, assessment, or care plan and R97 should not have medication left at R97's bedside.

Based on observation, interview, and record review, the facility failed to prevent cross contamination during urinary catheter care for one (R9) of two residents reviewed for urinary catheters in the sample list of 57 residents. Findings include: The facility's Catheter Care policy dated 1/26/26 documents the following steps for female urinary catheter care: 9. Gently separate the labia to expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). 11. Use a new part of the cloth or a different cloth for each side. 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. 13. Dry area with towel.On 5/3/26 at 8:52 AM, R9 received antibiotics for blood-tinged urine, symptoms have come and gone with additional antibiotic treatment. R9 stated staff don't clean R9's catheter daily, only intermittently. R9 stated R9 has occasional diarrhea with incontinence at times and requires staff assistance with toileting. On 5/05/2026 at 1:36 PM, V29 and V28 Certified Nursing Assistants entered R9's room and provided urinary catheter care. V29 used disposable wipes and cleansed R9's urinary catheter tubing in a downward motion. V29 then used separate wipes to wipe each inner labia and each inner thigh while coming into contact with R9's catheter during each wipe. V29 did not clean R9's urinary catheter last. On 5/5/26 at 2:03 PM, both V29 and V28 stated they used to clean the tubing last as part of catheter care until corporate staff recently instructed them to clean the tubing first. Both stated cleaning the labia and thighs causes cross contamination of the catheter tubing if the tubing is cleaned first. R9's Minimum Data Set, dated [DATE] documents R9 as cognitively intact and R9 requires substantial/maximal staff assistance with toileting hygiene. R9's Physician Order dated 2/2/26 documents to ensure catheter care is completed every shift. R9's urine culture dated 2/27/26 documents greater than 100,000 colony forming units per milliliter (CFU/mL) of Klebsiella Pneumoniae Extended Spectrum Beta-Lactamase (multidrug resistant organism) and 70-99,000 CFU/mL of Pseudomonas Aeruginosa, indicating an infection. R9's Physician's Orders dated 1/24/26, 2/26/26, 2/28/26, and 3/5/26 document orders for Meropenem-Sodium Chloride 1 gram/50 mL intravenously for Urinary Tract Infection. On 5/5/26 at 2:51 PM, V2 Director of Nursing confirmed the facility's policy documents to clean the catheter tubing as the last step during female catheter care.

Based on observation, interview, and record review the facility failed to accurately document the refusal of protective arm sleeves on the treatment administration record for one (R73) of one resident reviewed for accidents on the sample list of 57 residents. On 5/3/2026 at 9:00 AM, R73 was sitting in a wheelchair in R73's room. R73's right arm was bent with R73's hand lying on R73's chest. R73 was wearing a sweater; R73's left arm was in the arm of the sweater but R73's right arm was bare. R73's physician order dated 7/2/2025 documents an order to apply protective arm sleeves when up in wheelchair as resident allows. On 5/3/2026 at 1:44 PM, R73 was sitting in R73's wheelchair in R73's room. R73 was not wearing protective arm sleeves. When asked if staff offered to apply the protective skin sleeves, R73 stated, no. On 5/4/2026 at 9:30 AM and 2:35 PM and on 5/5/2026 at 09:31 AM, R73 was sitting up in the wheelchair and was not wearing protective skin sleeves. R73's Treatment Administration Record dated April of 2026 and May of 2026 documents that R73's protective skin sleeves were applied every day. R73's care plan dated 2/8/26 does not include interventions for the use of the skin sleeves. On 5/5/2026 at 09:57 AM, V3 Licensed Practical Nurse, stated R73 is already up, dressed and sitting at the cart when V3 arrived at work. On 5/5/2026 at 11:10 AM, V2 Director of Nursing stated the protective skin sleeves are to prevent skin tears and abrasions. The intervention for skin sleeves should be on the care plan. When asked about the refusal of R73 to wear the skin sleeves V2 stated that staff should let V2 know if R73 is refusing so V2 can contact the physician for a discontinue order. V2 also stated if R73 does not wear the skin sleeves the nurses should not sign it off.

Based on interview and record review the facility failed to provide bathing as scheduled for one (R9) of four residents reviewed for activities of daily living in the sample list of 57 residents. Findings include:The facility's Activities of Daily Living (ADLs) policy dated 1/20/26 documents bathing as part of the care and services provided by the facility, and residents who are unable to carry out ADLs will receive the necessary services to maintain grooming and personal hygiene. On 5/03/2026 at 9:43 AM, R9 stated R9 receives bed baths because R9 does not like to take showers. R9 stated R9 needs to be bathed more often because R9 does not receive baths weekly. R9 stated R9 did not think R9 had scheduled bath days. R9's Minimum Data Set, dated [DATE] documents R9 as cognitively intact and requires substantial/maximal staff assistance for bathing. R9's April and May 2026 Shower Documentation Survey Report documents R9's baths are scheduled on Wednesday and Saturday evenings but prompts for shower documentation on Tuesdays/Fridays. This report documents R9 was unavailable on 4/7/26, and not applicable on 4/10/26, 4/14/26, and 4/28/26. There is no documentation in R9's medical record as to why R9 was unavailable for shower on 4/7/26. On 5/5/26 at 2:03 PM, V29 Certified Nursing Assistant (CNA) stated R9's baths are scheduled for Wednesday and Saturday evening. On 5/6/26 at 9:33 AM, V29 CNA reviewed R9's shower documentation and confirmed the report does not document baths being given on the dates listed above. V29 CNA stated R9's bath days are Wednesday and Saturday, it shouldn't prompt for documentation on Tuesday and Friday. V29 CNA confirmed this is the only place bathing/showers are documented.

Based on observation, interview, and record review the facility failed to provide podiatry services for one (R8) of four residents reviewed for activities of daily living in the sample list of 57 residents. Findings include:The facility's Skin Integrity-Foot Care policy dated 2/20/26 documents the facility will provide foot care and treatment according to professional standards of practice, including preventions of complications from the resident's medical conditions; and the facility will assist the residents in making appointments with a qualified person. This policy documents diabetes as a risk factor for impaired skin integrity of the foot, adequately trained nurses may perform nail care to diabetic resident determined by the podiatrist to be low risk, and podiatry referrals will be made when appropriate. On 5/03/2026 at 8:58 AM, R8 stated R8 needs to see a podiatrist as R8's toenails are long. On 5/5/26 at 11:35 AM, V23 Licensed Practical Nurse removed R8's right sock, R8's toenails were long past the edge of R8's toes. There was an adhesive dressing on R8's right great toe.R8's active care plan documents R8 was admitted to the facility on [DATE] and R8 has Type 2 Diabetes Mellitus. R8's Skin Check dated 3/27/26 documents R8's right great toenail fell off and there was swelling and redness around the nailbed. R8's Physician Order dated 3/28/26 documents to cleanse right great toe, apply Bacitracin ointment and cover with adhesive bandage daily. There is no documentation in R8's medical record that R8 has been seen by a podiatrist after being admitted to the facility. On 5/5/26 at 12:33 PM, V2 Director of Nursing stated the facility recently switched podiatry companies and toenails are an issue. V2 stated R8 is diabetic.On 5/5/26 at 12:40 PM, V10 Social Services Director stated the facility changed podiatry companies in March and the prior podiatrist was coming monthly and in between visits if V10 reached out to them as needed. V10 stated the new company has rounded once so far in April but did not see R8 as the podiatrist started with residents on the opposite side of the building. V10 stated R8 is on the podiatry list for May 27th. V10 confirmed V10 schedules the podiatry visits and maintains the podiatry list. V10 stated V10 was not aware that R8's toenail fell off. V10 was unsure if R8 had seen a podiatrist since admission. On 5/5/26 at 1:36 PM, V10 stated V10 reached out to request podiatry consent and notes for R8. On 5/5/26 at 3:10 PM, V1 Administrator stated R8 was initially supposed to be a short stay, so R8 was never seen by a podiatrist.

Based on observation, interview, and record review the facility failed to apply range of motion devices used for contractures for two (R57, R73) of 24 residents reviewed for range of motion on the sample list of 57 residents.On 5/3/26 at 9:27 AM, R57 was resting in a high back reclining chair in the room. R57's right hand was closed in a fist and bent towards R57's chest. R57 was not wearing a splint to the right hand. On 5/3/26 at 1:30 PM, V3 Licensed Practical Nurse stated she is not aware that R57 needs a brace and has never seen a brace for R57. At this time, V3 looked up R57's physician orders and stated that R57 does have an order for a brace. R57's physician order dated 9/30/25 documents an order to apply splint to right hand when resting, may take off for meals per therapy. On 05/04/26 at 10:50 AM, V5 Certified Nurse's Aide stated V5 has never seen a brace for R57. On 5/4/26 10:54 AM, R57 was resting in R57's room in the reclining geriatric chair. A blue splint was lying on the side table next to R57. R57's therapy notes dated 9/30/25 documents R57 requires placement of resting hand splint on right upper extremity during time of rest to prevent contractures. R57's therapy notes dated 1/15/26 documents R57 will safely wear a resting hand splint on right hand for up to four hours with minimal signs and symptoms of redness, swelling, discomfort, or pain. On 5/3/2026 at 9:00 AM, R73 was sitting in a wheelchair in R73's room. R73's right arm was bent with R73's hand laying on R73's chest. R73's right hand was closed with nothing in it. When asked if the staff put something in R73's hand R73 stated sometimes they do put lotion in it. R73's physician orders dated 12/7/2021 document an order to monitor right elbow splint upon application and removal for any skin changes daily and as needed every shift. R73's physician orders dated 5/19/2022 documents to apply palm protector at nighttime or as tolerated, release, and check skin routinely and to apply right hand splint in the PM (afternoon) for up to four hours or as tolerated, release and check skin routinely every evening shift. On 5/3/2026 at 1:44 PM, R73 was sitting in R73's wheelchair in R73's room. There was no splint applied to R3's right elbow or right hand. When asked about the palm protector R73 replied they don't put it in, and they haven't for a long time. R73 stated, when asked about R73's right elbow and hand splint, R73 reported some ask to put them on, but some don't. I (R73) haven't worn those in a while. On 5/5/2026 at 09:31 AM, R73 stated when asked if staff applied R73's palm protector, right elbow sling or right-hand splint yesterday evening or night R73 stated no, they never do. On 5/5/2026 at 9:55 AM, V5 Certified Nurse's Assistant, stated V5 has never seen R73 with a palm protector when V5 arrives in the mornings. When asked if V5 had seen R73's palm protector, right elbow splint or right-hand splint V5 stated no, but V5 stated V5 will look in R73's room soon and see if V5 can find anything. On 5/5/25 at 10:02 AM, V5 was checking drawers in R73's room. V5 then came into the hallway and stated that V5 did not see anything that looked like a brace or a palm protector.

Based on interview and record review the facility failed to re-assess elopement risk, identify wandering/exit seeking as targeted behaviors, and develop a care plan for wandering/exit seeking behaviors and risk for elopement for one (R70) resident reviewed for elopement/wandering in the sample list of 57 residents. Findings include: The facility's Elopement and Wandering Residents policy dated 2/2/26 documents the facility will use a systematic approach to monitor and manage residents at risk for elopement and unsafe wandering, including identification and assessment of risk, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions as necessary. This policy documents residents will be assessed for risk of elopement and unsafe wandering on admission and throughout their stay and the interdisciplinary team will evaluate factors contributing to risk in order to develop a person-centered care plan. R70's Minimum Data Set (MDS) dated [DATE] documents R70 has severe cognitive impairment. R70's active care plan does not include a problem, goals, and interventions to address R70's wandering behaviors or risk for elopement. R70's last documented Elopement Evaluation dated 3/2/26, documents R70 is at risk for elopement but does not include any goals or interventions as prompted by the assessment. This assessment documents no to R70 verbally expresses the desire to go home, packs belongings to go home or stays near exit doors; and wandering behaviors likely affects the safety, well-being, or privacy of others. The facility's State Report documents on 4/24/26 V26 Licensed Practical Nurse witnessed R70 sitting on R10's bed and open handed smacked R10 on the right cheek. V1 Administrator interviewed R70 who reported R70 was confused, R70 thought R70 was in R70's room and that someone was in R70's bed. R70's Nursing Notes document the following: On 4/16/26 at 9:00 PM, R70 pulled the fire alarm twice after 6:00 PM stating R70 wanted to leave the facility. On 5/3/26 at 2:02 AM, R70 had been up in R70's wheelchair since 12:15 AM, R70 was confused and was exit seeking. R70 was redirected multiple times but continued to roam around in R70's wheelchair. R70's February-May 2026 Behavior Tracking does not identify wandering/exit seeking behaviors as a targeted behavior. R70's active Certified Nursing Assistant (CNA) tasks only lists monitoring and interventions for physical/verbal aggression towards staff/residents and does not identify wandering/exit seeking behavior as a targeted behavior. On 5/3/26 at 1:43 PM, V25 Certified Nursing Assistant (CNA) stated R70 does wander/exit seek, and staff usually bring R70 to the nurse's station or offer R70 a snack. V25 stated R70 usually gets really confused, roams the halls and talks about leaving and wanting to go to see R70's family. V25 stated R70 wanders into other resident rooms.On 5/04/2026 at 1:14 PM, V10 Social Services Director stated there is an elopement risk binder at the front desk that the receptionist checks. V10 stated V10 notifies staff when V10 adds a resident to the binder. V10 stated V10 is responsible for updating the care plan with elopement risk and interventions and V10 reviews the CNAs tasks and nurses charting for behaviors. V10 confirmed R70's Elopement Evaluation documents R70 is at risk, and R70's care plan does not address R70's wandering behaviors or elopement risk. V10 confirmed R70 should have targeted behavior monitoring for wandering/exit seeking behaviors. On 5/4/26 at 1:30 PM V10 confirmed 3/2/26 was R70's last documented elopement risk assessment and confirmed no was answered to the question regarding voicing desire to go home, which would affect the risk score. V10 stated V10 completes the elopement risk assessments quarterly and with any changes in between.On 5/4/26 at 1:25 PM the elopement risk binder at the front desk was reviewed and did not contain R70's information, this was confirmed with V11 Receptionist. V11 stated R70 is an elopement risk as R70 tried to go out the front door today just a little while ago, and V11 noticed today that R70's information was not in the binder.

Based on interview and record review the facility failed to implement fall interventions to prevent injury for one of three residents (R10) reviewed for falls in the sample list of 15. These failures resulted in R10 sustaining a fall with a head laceration that required staple closure. Findings Include: The facility's Fall Prevention Program dated 2/2/26 documents the facility will assess each resident's fall risk and implement interventions to decrease residents' risk of falls and subsequent injuries.R10's Medical Diagnoses list dated January 2026 documents R10 is diagnosed with abnormalities of gait and mobility, lack of coordination, muscle weakness, and altered mental status.R10's Minimum Data Set (MDS) dated [DATE] documents R10 is moderately cognitively impaired and requires moderate staff assistance for transfers.R10's care plan dated 1/7/26 documents R10 is at risk for falls related to muscle weakness. Interventions included floor mats placed on the side of the bed, which were implemented on 1/6/26.R10's nurses' notes dated 1/25/26 document R10 was found on the floor in her room. V29, Registered Nurse (RN), documented R10 was lying on the floor on the right side of her bed in the fetal position. R10 stated she fell from the bed and that her head and neck hurt. R10 had blood on the right side of her head. Emergency Medical Services (EMS) was called, and R10 was sent to the emergency room for evaluation.R10's computed tomography (CT) results dated 1/25/26 document, R10 fell and sustained mild subcutaneous soft tissue swelling and a hematoma in the right posterior parietal region, as well as subcutaneous emphysema, which suggests sequelae from a laceration.R10's emergency room notes dated 1/25/26 document, R10 sustained a fall resulting in a head laceration requiring five staples.On 2/5/26 at 1:40 p.m., V29, Registered Nurse (RN), stated she was R10's nurse overnight on 1/24/26-1/25/26. V29 confirmed that at approximately 3:00 a.m. on 1/25/26, R10 fell from her bed to the floor. V29 stated R10 did not have fall floor mats in place on the side of the bed at the time of the fall. V29 confirmed R10 struck her head and sustained a right-sided laceration. V29 stated she sent R10 to the Emergency Department for evaluation.R10's progress notes dated 1/25/26 document, R10 returned to the facility with five staples to her head.On 2/5/26 at 2:45 p.m., V27, [NAME] President of Clinical Services, confirmed R10 had fall mats placed as a fall prevention intervention on 1/6/26 and that the mats should have been in place on the floor when R10 was in bed and at the time of the fall on 1/25/26. V27 confirmed fall mats help decrease the risk of injuries from falls and were a previously implemented intervention that should have been in place.

Based on interview and record review the facility failed to administer multiple medications per physician order. This failure affected three of three residents (R13, R14, R15) reviewed for medication administration on the sample list of fifteen. Findings Include: The facility's Medication Error Policy dated 2/2/26 documents the facility shall ensure medications are administered according to physician orders. If medication errors occur, staff are to notify the physician, document the incident in the medical record, and report the incident to the appropriate supervisor.The Resident/Family Complaint Form dated 1/26/26 documents R13 filed a complaint stating she did not receive her evening medications on 1/23/26.On 2/5/26 at 11:48 a.m., V2, Director of Nursing (DON), stated residents on the Northeast Hall did not receive their evening medications on 1/23/26. V2 stated R13 filed a grievance regarding the incident. V2 stated she reviewed which residents missed their medications, identified the medications that were omitted, and reviewed the incident and any potential outcomes with V13, Medical Director.R13's Medication Administration Record (MAR) dated January 2026 documents the following medications were not administered on the evening of 1/23/26: Famotidine 20 milligrams (mg), Fluticasone Propionate nasal spray, Potassium Chloride 20 milliequivalents (mEq), Baclofen 10 mg, Diclofenac Sodium Gel 1%, and Gabapentin 1200 mg.R14's Medication Administration Record (MAR) dated January 2026 documents the following medications were not administered on the evening of 1/23/26: Atorvastatin 40 mg, Carvedilol 25 mg, Clonidine 0.1 mg, Doxazosin 4 mg, and Eliquis 2.5 mg.R15's Medication Administration Record (MAR) dated January 2026 documents the following medications were not administered on the evening of 1/23/26: Fluticasone Furoate inhalation 200-25 micrograms and Rosuvastatin 5 mg.On 2/5/26 at 11:48 a.m., V2, Director of Nursing (DON), confirmed nurses are required to administer medications per physician orders and to notify the physician and nurse supervisor when medications are not administered.

Based on observation, interview and record review the facility failed to recognize and report allegations of abuse to the administrator for two (R1, R3) of three residents reviewed for abuse on the sample list of 15.Findings include: 1.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities. The MDS further documents R1 is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated during the look-back period, and uses a manual wheelchair requiring partial to moderate assistance once seated. R1 has had no behaviors toward self or others and no rejection of care.On 01/16/26 at 2:40 p.m., R1 was lying on her back in bed. R1 stated, The girl with the ponytail (later identified as V8, Certified Nursing Assistant) is the one who did this to me. At least that is the first time I saw these bruises. She is (specified race) and works in the morning. R1 raised both of her sleeves, revealing bruises to the posterior mid-forearms. R1's left forearm had a quarter-sized purple bruise surrounded by a yellow halo-like faded area, indicative of older bruising. On the right forearm, R1 had a nickel-sized bruise that was purple in the center and surrounded by yellow halo-like fading, also indicative of older bruising.R1 then grabbed her right neck area and stated, She also hurt my neck when she was transferring me. It's when she is giving me care-she hurts me. It kind of choked me up. She grabbed behind my neck to set me up to transfer, and it made me cough. I'm scared she might do it again. I didn't say anything to her. I should have. She has helped me many times before, and that did not happen. She was here today, this morning. That girl (V8, CNA) with the ponytail is rough, and I should tell her to slow down or be more careful when she gives me care. Other than that, I feel she is a good CNA. She needs to provide my care slower and gentler. I think she's always in a hurry. I am really scared since the other day when that happened. When she comes in here, I know she could hurt me. She hasn't any other time, but it could happen again.R1 also stated, I told the lady up in the front offices (later identified as V4, Social Service Director). She's the one who noticed my arm bruises. I told her all about that girl being rough with me. She's a very nice (specified race) lady. She's young and has an office up in the front hall. I don't know her name. Nobody ever came in and talked to me about it, but she told me she was going to report it to her boss. I thought someone would be asking me questions. Nobody has. I trusted that lady would do something about that girl.On 01/16/26 at 2:50 p.m., this surveyor reported the allegation details of rough care, physical abuse, and arm bruising reported by R1 to V2, Director of Nursing, and V3, Regional Nurse Consultant. V3 contacted V1, Interim Administrator/Abuse Prevention Coordinator/Vice President of Operations, for a conference call. V1, V2, and V3 all stated they were not aware of any allegations of abuse that had been reported, including the allegation regarding R1.The facility's January Concern Log - Year 2026 documents a grievance dated 01/14/26 as follows: Night Shift, Unit 1. Concern reported by Patient (R1). Name: Social Service Director (V4) / Business Office Manager (V18). Concern Type: Care-Staff Approach. Patient Name and Brief Description: (R1) wants to discharge home; stated she is tired of the mean CNA that works nights. She stated the CNA is rough with care. Concern Assigned to: Administrator (V1, Interim Administrator/Abuse Prevention Coordinator). Resolution Communication Method: Employee - Written Notice. Date Resolved: 01/14/26 (same day the grievance was reported).On 01/20/26 at 1:30 p.m., V4, Social Service Director (SSD), reviewed the grievance log and confirmed she received and recorded a grievance on 01/14/26 regarding R1's allegation that V8, Certified Nursing Assistant, was rough with care, caused bruising to R1's bilateral forearms, and caused neck pain. V4 stated she reported the allegation of abuse to V1, Interim Administrator/Abuse Prevention Coordinator. As noted above, V1, V2, and V3 all stated this allegation was not reported to them.On 01/22/26 at 3:42 p.m., V8, Certified Nursing Assistant, stated she was suspended on 01/16/26, two days after the grievance dated 01/14/26 regarding the physical abuse allegation involving R1.On 01/27/26 at 10:30 a.m., V7, Local County Community Support Services Manager, confirmed she was present on 01/14/26 with R1 and V4. V7 stated R1 described a CNA with a ponytail who was rough when getting her up that morning. V7 stated R1 had small bruises on both forearms that appeared faded and that R1 was unsure how they occurred but associated them with being transferred out of bed to a standing position. V7 further stated R1 reported feeling a pull to her neck during the transfer. V7 stated R1 had been hospitalized approximately one week earlier for chest and neck pain and that this information was included in her complaint to ensure investigation. V7 stated R1 was afraid the CNA would be rough with her care again. Although R1 was not tearful, she was upset about therapy and expressed fear regarding the CNA's care. V4 acknowledged R1's incident of rough care and stated it would be reported to the Administrator and investigated as possible abuse.2. R3's current Diagnoses sheet documents: Other Specified Postprocedural Status; Aftercare Following Joint Replacement Surgery.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment.The facility's January Concern Log - Year 2026 documents a grievance dated 01/07/26 as follows: Night Shift, Unit 1. Concern reported by Patient (R3). Name: Social Service Director (V4). Concern Type: Care-Staff Approach. Patient Name and Brief Description: (R3), CNA on phone during care. Concern Assigned to: Social Service. Resolution Communication Method: Employee - Written Notice. Date Resolved: 01/07/26 (same day reported).On 01/20/26 at 1:55 p.m., V4 reviewed the grievance log and R3's grievance. V4 stated R3 reported the CNA was on her phone while providing care, was rude, and was rough with care. V4 identified the CNA as V11. V4 stated she contacted V11 on her personal cell phone and addressed the phone use. V4 stated she did not consider the situation abuse because she knew the CNA personally and believed she was a good person. V4 stated she informed the Director of Nursing only about phone use and did not report the allegation of rough care. V4 acknowledged abuse allegations are required to be reported immediately but stated uncertainty regarding who the Administrator was at the time.On 01/20/26 at 2:45 p.m., R3 was seated in his wheelchair at the bedside with his left arm in a sling. R3 stated he reported the incident on 01/07/26 to V4 because the CNA was on her phone the entire time she was providing care, appeared rushed, and was rough. R3 stated he reported the incident to prevent other residents from receiving rushed or rough care. R3 stated he did not believe the CNA intentionally abused him but felt her distraction resulted in rough care. R3 stated he was afraid other residents would receive rough care.On 01/20/26 at 3:25 p.m., R3 stated the CNA belittled him while on the phone, stating he was lazy and did not need the help she was providing. R3 stated he reported this to V16, Licensed Practical Nurse, and to therapy staff.On 01/20/26 at 3:40 p.m., V16, Licensed Practical Nurse (LPN), confirmed she was aware of R3's allegations of verbal and physical abuse but did not report them to the Administrator because she was unsure who the Interim Administrator was at the time.On 01/20/26 at 4:35 p.m., V1, Interim Administrator/Abuse Prevention Coordinator, and V2, Director of Nursing, stated they were not aware of R3's grievance reported to V4.On 01/21/26 at 9:45 a.m., V2 stated she was not informed of allegations involving rough or belittling care and stated such allegations should have been reported immediately as possible abuse and investigated.On 01/21/26 at 11:20 a.m., V14, Physical Therapy Assistant (PTA), confirmed she was aware of R3's allegations of verbal and physical abuse and had escorted R3 to V4's office to report them but did not report the allegations to the Administrator.

Based on interview and record review multiple facility staff had knowledge of allegations of rough care and derogatory comments, failed to report to the Administrator/Abuse Prevention Coordinator which resulted in a delay in initiating an investigation and failure to remove the alleged staff perpetrators. This failure had the potential to affect two of three residents (R1 and R3) reviewed for abuse on the sample list of 15.Findings include:1. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities and is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated during the look-back period, and uses a manual wheelchair requiring partial to moderate assistance once seated. The MDS further documents R1 has had no behaviors toward self or others and no rejection of care.On 1/16/26 at 2:40 p.m., R1 was lying on her back in bed. R1 stated, The girl with the ponytail (later identified as V8, Certified Nursing Assistant) is the one who did this to me. At least that is the first time I saw these (bruises). She is (specified race) and works in the morning. R1 raised both arm sleeves. Both posterior mid-forearms had bruising. R1's left forearm had a quarter-sized purple bruise surrounded by a yellow halo-like faded bruise, indicative of older bruising. On the right forearm, R1 had a nickel-sized bruise with a purple center surrounded by yellow halo-like fading, also indicative of older bruising.R1 then grabbed her right neck area and stated, She also hurt my neck when she was transferring me. It's when she is giving me care that she hurts me. It kind of choked me up. She grabbed behind my neck to set me up to transfer. It made me cough. I'm scared she might do it again. I did not say anything to her. I should have. She has helped me many times before and that did not happen. She was here today, this morning. That girl (V8, CNA) with a ponytail is rough, and I should tell her to slow down or be careful when she gives me care. Other than that, I feel she is a good CNA. She needs to provide my care slower and gentler. I think she's always in a hurry. I am really scared since the other day when that happened. When she comes in here, I know she could hurt me. She hasn't any other time, but it could happen again.R1 also stated, I told the lady up in the front offices (later identified as V4, Social Service Director). She's the one that noticed my arm bruises. I told her all about that girl and being rough with me. She's a very nice (specified race) lady. She's young and has an office up in the front hall. I don't know her name. Nobody ever came in and talked to me about it, but she told me she was going to report it to her boss. I thought someone would be asking me questions. Nobody has. I trusted that lady would do something about that girl.On 1/16/26 at 2:50 p.m., this surveyor reported the allegation details of rough care/physical abuse and arm bruises R1 reported to this surveyor. The allegation was reported to V2, Director of Nursing, and V3, Regional Nurse Consultant, who contacted V1, Interim Administrator/Abuse Prevention Coordinator/Vice President of Operations, for a conference call. V1, V2, and V3 all stated they had no reported allegations of abuse, including the allegation regarding R1.The facility's January Concern Log Year 2026 documents a grievance dated 01/14/26 as follows: Night Shift, Unit 1. Concern reported by patient (R1). Name: Social Service Director (V4)/Business Office Manager (V18). Concern Type: Care-Staff Approach. Patient Name and Brief Description: (R1) wants to discharge home; stated she is tired of the mean CNA that works nights. She stated the CNA is rough with care. Concern Assigned To: Administrator (V1, Interim Administrator/Abuse Prevention Coordinator). Resolution Communication Method: Employee-Written Notice. Date Resolved: 01/14/26.On 1/20/26 at 1:30 p.m., V4, Social Service Director (SSD), reviewed the grievance log and confirmed she received and recorded a grievance on 1/14/26 regarding R1's allegation that V8, Certified Nursing Assistant, was rough with care, caused bruising to bilateral forearms, and caused neck pain. V4 stated she reported the allegation to V1, Interim Administrator/Abuse Prevention Coordinator. As noted above, V1, V2, and V3 all stated this allegation was not reported to them.On 1/22/26 at 3:42 p.m., V8, Certified Nursing Assistant, stated she was suspended on 1/16/26, two days after the grievance dated 1/14/26 was reported to V4.V8's timecard documents that on 1/15/26, V8 worked eight and one-half hours after the grievance of abuse was reported.On 1/27/26 at 10:30 a.m., V7, Local County Community Support Service Manager, confirmed she was present on 1/14/26 with R1 and V4, Social Service Director. V7 stated R1 described a CNA with a ponytail who was rough when getting her up that morning. V7 stated, R1 had a small bruise on both forearms that appeared faded. R1 was not sure how they occurred but associated them with being transferred out of bed to a standing position. V7 also stated, R1 felt a pull to her neck as she stood during that transfer. I know she had gone to the hospital a week or so before for chest and neck pain. I included this in my complaint to make sure it was investigated. I don't know if it had anything to do with rough care.V7 further stated, R1 said she was afraid that CNA would be rough with her care again. Although R1 was not tearful, she was upset about therapy and said she was afraid of the CNA's care. The Social Service Director acknowledged R1's incident of rough care and said it would be reported to the Administrator and investigated as possible abuse.2. R3's current Diagnoses sheet documents the following: Other Specified Postprocedural Status, Aftercare Following Joint Replacement Surgery.R3's Minimum data Set (MDS) dated [DATE] documents the following: R3's Brief Interview of Mental Status score as 15, out of a possible 15, indicating no cognitive impairment.The facility January Concern Log Year 2026 documents a grievance dated 01/07/25 as follows: Night Shift, Unit 1. Concern Reported by Patient (R3). Name: Social Service Director (V4, SSD). Concern Type; Care-Staff Approach. Patient Name and Brief Description: (R3's), CNA (V11, Certified Nursing Assistant) on Phone during care. Concern Assigned to: Social Service. Resolution Communication Method: Employee - Written Notice. Date Resolved: 01/07/26 (same day, as noted above that the concern was reported ).On 1/20/26 at 1:55 pm V4, Social Service Director (SSD) reviewed the grievance log where V4, SSD had documented R3's grievance, noted above. The grievance was dated 01/07/26. V4, SSD stated (R3) came to me after he had breakfast. I was in here (office). He (R3) rolled in, and was like, 'I want to talk to you about something'. He said last night he had this CNA (V11, Certified Nursing Assistant), while she was supposed to be giving him care, she was rough with him and was talking to someone on the phone. He described her as (described race, height and color of dyed hair V11, CNA). I said to him (R3), you know what, they (staff) are not supposed to be on phones. He (R3) said she (V11) was rude to him and rough with his care because she (V11, CNA) was not paying attention to what she was supposed to be doing. He said she was talking to somebody else, and not him. The CNA still wasn't asking him (R3) questions and stuff like that. I told him all their attention should be on the residents, and not on their phone calls. So, I called (V19, Lead CNA and Scheduler). I asked her (V19) who was the CNA that worked last night. She let me know it was (V11, Certified Nursing Assistant/CNA). I know (V11, CNA) personally, she is a relative of mine. So, I went outside to the back parking lot, on my personal cell phone. I called her and I was yelling at her. I told her (V11, CNA) she should not be talking on her phone when she is giving resident care. That's not proper. That is totally disrespectful, and she knew it. This surveyor then asked V4, SSD though, she felt comfortable talking to V11, CNA, did she recognize the situation of rough care as possible abuse, and did she report to anyone when she came back into the building. V4, SSD stated I guess I did not think it was abuse because I know (V11, CNA). She is a good person. I did tell the DON (V2, Director of Nursing) there was an issue with a CNA being on the phone when giving care, but I took care of it. (the allegation of rough care). This surveyor reviewed another section of the same grievance log and asked if I could get a copy of the written notice the grievance log documents. V4, SSD stated The Employee -written notice documented on the grievance log, just means I filled out a grievance form, and it involved an employee. The same thing I did with (R1). It was not a warning to the employee. V4 also stated (V11, CNA) knows she should take care of these residents, like she would take care of our (V4 and V11) Grandma. I did not think of it as abuse. I felt it was just awful and disrespectful. (R3) did not think of it as abuse either. If it was someone I did not know, I guess, I probably would have reported (the allegation of abuse). I do know we are supposed to report abuse immediately to the Administrator, so it can be investigated. I am not sure if (V20, Previous, Interim Administrator/Abuse Prevention Coordinator) was still the Administrator (01/07/26, day of grievance). I don't think (V1, Current, Interim Administrator/Abuse prevention Coordinator) was here (working in the facility) yet.On 1/20/26 at 2:45 pm R3 was seated in his wheelchair bedside. R3 had a sling on his left arm. R3 stated I reported on 01/07/26, to (V4, Social Service Director). I reported that the CNA (V11) was on her phone the whole time she was taking care of me. She was rushed and was rough with care. I told (V4, Social Service Director) so that, other residents, that CNA (V11) takes care of, wouldn't get rushed, rough care. There are other residents in worse shape than me. I feel like I am looking out for other residents, not just myself.On 1/20/26 at 3:25 pm R3 stated I remembered something else I forgot to tell you. I was thinking about everything I told (V4, SSD). When that CNA was on the phone, she was belittling me, to whoever she was talking to. She said she was helping me get ready for bed, and I did not need all the help she had to give me. She told (said to) that person (on the phone), I (R3) was just lazy. I told (V16, Licensed Practical Nurse/LPN). She knows all about it. I also told her and a therapy girl (later identified as V14, Physical Therapy Assistant) too.On 1/20/26 at 3:40 pm V16, Licensed Practical Nurse (LPN) stated Regarding (R3), actually, I had gone into his (R3's) room. He was working with a new therapist. I think her name is (later identified as V14, Physical Therapy Assistant/PTA). I'm not very familiar with her. He (R3) reported to the therapy staff (V14, PTA) and me that a CNA (Certified Nursing Assistant) named (V11, Certified Nursing Assistant), the night before, was on the phone belittling him. He said he had just told the therapy girl (V14, PTA) that when (V11, CNA) provided his care she was rough. He said she was calling him lazy and said he couldn't do anything for himself. She (V11, CNA) had to do everything for him. He is one of my favorites. When he told me that I wanted to cry right then. He is such a kind person. V16, LPN also stated I told the DON (V2, Director of Nursing) about it right after he (R3) told me. I left his room and went straight to (V2) DON. I think (R3) had already reported all this to (V4, Social Service Director). I know I am supposed to report to the Administrator, too. I did not know who the administrator was. I am still not sure if we have an Administrator (V1, Interim Administrator/Abuse Prevention Coordinator/ [NAME] President of Operations).On 1/20/26 at 4:35 pm V1, Interim Administrator/Abuse prevention Coordinator and V2, Director of Nursing said they were not aware of (R3's) grievance reported to V4, Social Service Director.On 1/21/26 at 9:45 am V2, Director of Nursing stated she was not aware of an allegation on 01/07/26 of R3 receiving rough care. V2 DON stated That should have been reported immediately, as an allegation of abuse, to the Administrator. I should have been given all the information. That could be abuse, or very poor nursing care. We would have to investigate this to be sure. It was not reported to me at all. We don't have that investigation.V11's Timecard documents V11 worked the following hours, after the incident occurred on 01/6/26 and was reported on 1/7/26 after breakfast:On 1/07/26, V11 worked for 11 hours and 15 minutes.On 1/08/26, V11 worked for seven hours.On 1/09/26, V11 worked for 16 hours.On 1/12/26, V11 worked for seven and a half hours.On 1/13/26, V11 worked for eight hours.On 1/14/26, V11 worked for seven hours and forty-five minutes.On 1/15/26, V11 worked for eight hours.On 1/16/26, V11 worked for seven hours and forty-five minutes.On 1/17/26, V11 worked for eight hours.On 1/18/26 V11 worked for eight hours.On 1/19/26 V11 worked for eight hours.On 2/3/26 at 9:15 am V11, Certified Nursing Assistant, stated That was a long time ago (1/07/26) when (R3) said something to my sister (V4, Social Service Director) about me being on the phone. I don't remember anything about him (R3) saying anything about giving him rough care. My sister called me and told me he complained about me being on the phone during his care. I was on the phone with (V23, CNA). She works down that hall more often. That was the first time I took care of him. He said he did not want a (disposable incontinence brief) on. I called her to find out if he was supposed to wear one. I have never left a (disposable incontinence brief) off a resident, when I put them to bed, if they usually wear one. I did not say anything about him doing anything for himself. I had given him a shower earlier that evening, before dinner. It was about 4:00 pm. It was about 7:30 pm when I was helping him get ready for bed. I had put the sling on him after the shower and took it off after I transferred him to bed. He did not say anything like I was rough with him. He is easy to take care of. He is not a (require a mechanical full or stand lift), so I could do (transfer) him (R3) by myself. He never even said ouch during my care. V11, Certified Nursing Assistant confirmed that her timecard documents V11, CNA has worked ten shifts since 01/07/26, the evening of the allegation. V11 then stated she works all halls and has had full access to all residents each time she worked. V11 stated she was not suspended after V4,SSD talked to V11. V11 stated she was suspended on 01/21/26, after the allegation was reported by this surveyor, as an allegation of physical and mental abuse to the V1, Interim Administrator/Abuse Prevention Coordinator.On 2/03/26 at 12:30 pm, This surveyor and V1, Interim Administrator/Abuse Prevention Coordinator/ [NAME] President of Operations reviewed V11, CNA's timecard, the facility grievance log. V1 confirmed R3's allegations of rough care/physical abuse was reported on 1/07/26 to V4 Social Service Director, V14, Physical Therapy Assistant and V16, Licensed Practical Nurse but was not reported to V1. V1 acknowledged that V11, CNA continued to work throughout the facility for repeated shifts and should have been suspended at the time of the allegation was reported on 1/07/26.The facility policy Abuse, Neglect, Exploitation Policy dated as reviewed 01/23/26 and documents the following:Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions:Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative. visitor or others but has not yet been investigated and, if verified. could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Covered individual is anyone who is an owner, operator, employee, manager, agent or contractor of the facility. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s), and Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment, and Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.The same Abuse, Neglect, Exploitation Policy dated as reviewed 01/23/26 documents: VI. Protection of ResidentThe facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation.B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.C. Increased supervision of the alleged victim and residents.D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.E. Protection from retaliation.F. Providing emotional support and counseling to the residents during and after the investigation, as needed.The same policy documents: VII. Reporting/ResponseA. The facility will have written procedures that include:I. Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.2. Assuring that reporters are free from retaliation or reprisal.3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint.4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence(s} to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences.b. Defining how care provision will be changed and/or improved to protect residents receiving services:c. Training of staff on changes made and demonstration of staff competency after training is implemented.d. Identification of staff responsible for implementation of corrective actions.e. The expected date for implementation; andf. Identification of staff responsible for monitoring the implementation of the plan. The same policy Abuse, Neglect, Exploitation Policy dated as reviewed 01/23/26 documents: B. The Administrator will follow up with government agencies, during business hours. to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident. as required by state agencies.

Based on observation, interview and record review the facility failed to ensure residents right to dignified care for two of three residents (R1 and R3) reviewed for quality of care/abuse on the sample list of 15.Findings include:1. R1's current diagnoses list documents the following: Essential Hypertension; Chronic Obstructive Pulmonary Disease, unspecified; Bipolar Disorder with current episode depressed, mild or moderate severity, unspecified; Muscle wasting and atrophy, not elsewhere classified, multiple sites; Unsteadiness on feet; Lack of coordination; and History of falling.R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview of Mental Status score as nine out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1 has limited range of motion of the bilateral upper extremities. The MDS further documents R1 is totally dependent for all activities of daily living except eating. R1 requires substantial to maximum assistance with toileting, has not ambulated during the look-back period, and uses a manual wheelchair requiring partial to moderate assistance once seated. R1 has had no behaviors toward self or others and no rejection of care.R1's current Physician Order Sheet documents Physical Therapy to continue three to five times per week for 41 days for therapeutic activities, therapeutic exercise, neuromuscular reeducation, gait training, and group therapy, with a start date of 12/18/25 and an end date of 01/28/26.The facility's January Concern Log - Year 2026 documents a grievance dated 01/14/26 as follows: Night Shift, Unit 1. Concern reported by Patient (R1). Name: Social Service Director (V4) / Business Office Manager (V18). Concern Type: Care - Staff Approach. Patient Name and Brief Description: (R1) wants to discharge home; stated she is tired of the mean CNA that works nights. She stated the CNA is rough with care. Concern Assigned to: Administrator (V1, Interim Administrator/Abuse Prevention Coordinator). Resolution Communication Method: Employee - Written Notice. Date Resolved: 01/14/26 (same day the grievance was reported).On 01/20/26 at 1:30 p.m., V4, Social Service Director (SSD), reviewed the grievance log with this surveyor. V4 stated R1 was upset and wanted to be discharged related to therapy. V4 stated, I reached out to her case manager (V7, Community Support Services Manager for the local county), and we all met. They came down to my office, and we were all sitting here talking to (R1). Therapy staff were going to pick her back up for therapy. She said, 'I just want to go home. I don't want to do it there.' This was the next day, on the 14th. She said it shouldn't have to take all this to go home and that it wasn't fair. I told her there were other programs I could look into and mentioned Starting Point. I told (V7) I knew she would assist (R1) with access in the community and help with resources. She said she didn't want to lose (V7's) assistance. I told her I would look into some options. She got mad. I'm going to be honest-I noticed bruises on her arms. I asked her what happened. It looked like she bumped the backs of both arms on something. She had been in the hospital on [DATE], and I asked if the bruises were from IV access. She said a night CNA-a (specific race) girl with pulled-back hair-was rough with her care.On 01/22/26 at 3:42 p.m., V8, Certified Nursing Assistant (CNA), stated, I was suspended. All I know is I got a call last Friday and was told I was on administrative leave because (R1) made some kind of abuse allegation about me. I have taken care of her for almost a year. Her hall is the only hall I have ever worked on. She is one of the easiest residents to take care of. She is so sweet. I would never hurt any of my residents on purpose. I have racked my brain trying to figure out what upset her about my care. All I can think of is she has a bad rash between her legs, and when she urinates, it burns her rash. I had to be extra careful when providing perineal care. She said the last morning I got her up that the washcloth was too rough. Our washcloths are rough. She was urinating, and I tried to catch it with the washcloth before it got on her labia and upper inner thighs. That is when she said it was rough-she meant the washcloth. When I washed her, I was careful. She never said anything else about it. I always put a lot of barrier cream on the rash. The nurses apply nystatin powder all over her rash and in her brief. I got her dressed, and she never said anything. If she thought I was hurting her in any way, I would have left the room and gotten another CNA. I would have reported it myself if she accused me of being rough. I think it is important that all residents are treated right.On 01/27/26 at 10:30 a.m., V7, Local County Community Support Services Manager, confirmed she was present on 01/14/26 with R1 and V4. V7 stated R1 described a CNA with a ponytail who was rough when getting her up that morning. V7 stated R1 had small bruises on both forearms that appeared faded. R1 was unsure how they occurred but associated them with being transferred from bed to a standing position. V7 also stated R1 reported feeling a pull in her neck during the transfer. V7 stated R1 had been hospitalized a week prior for chest and neck pain and that this information was included in the complaint to ensure investigation. V7 stated R1 was afraid the CNA would be rough with her care again. Although R1 was not tearful, she was upset about therapy and expressed fear regarding the CNA's care. V4 acknowledged the allegation of rough care and stated it would be reported to the Administrator and investigated as possible abuse.2. R3's current Diagnoses sheet documents: Other Specified Postprocedural Status; Aftercare Following Joint Replacement Surgery.R3's current Physician Order Sheet (POS) documents a splint (sling) to the left arm, to be worn daily. The POS further documents, effective 01/21/26, continuation of Occupational Therapy three to five times per week for four weeks for activities of daily living retraining, therapeutic exercises, therapeutic activities, neurological reeducation, wheelchair management, manual therapy, and group therapy.R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status score of 15 out of 15, indicating no cognitive impairment. The same MDS documents range of motion impairment of one upper extremity. The MDS further documents R3 requires substantial/maximal assistance with upper and lower body dressing, defined as the helper performing more than half the effort, including lifting or holding the trunk or limb.The facility's January Concern Log - Year 2026 documents a grievance dated 01/07/26 as follows: Night Shift, Unit 1. Concern reported by Patient (R3). Name: Social Service Director (V4). Concern Type: Care - Staff Approach. Patient Name and Brief Description: (R3), CNA on phone during care. Concern Assigned to: Social Service. Resolution Communication Method: Employee - Written Notice. Date Resolved: 01/07/26 (same day reported).On 01/20/26 at 1:55 p.m., V4 reviewed R3's grievance. V4 stated R3 reported the CNA was on her phone while providing care, was rude, and was rough with care. V4 identified the CNA as V11. V4 stated she contacted V11 on her personal cell phone and addressed the phone use. V4 stated she did not consider the situation abuse because she knew the CNA personally and believed she was a good person. V4 stated she informed the Director of Nursing only about phone use and did not report the allegation of rough care. V4 acknowledged that abuse allegations are to be reported immediately but stated uncertainty regarding who the Administrator was at the time.On 01/20/26 at 2:45 p.m., R3 stated he reported the incident so other residents would not receive rushed or rough care. R3 stated he did not believe the CNA intentionally abused him but felt her distraction caused rough care.On 01/20/26 at 3:25 p.m., R3 further stated the CNA belittled him on the phone, calling him lazy and stating he did not need help. R3 reported he informed nursing and therapy staff.On 01/20/26 at 3:40 p.m., V16, Licensed Practical Nurse (LPN), confirmed R3 reported the CNA was on the phone, belittling him, and rough with care. V16 stated she immediately informed the Director of Nursing.On 01/20/26 at 4:35 p.m., V1, Interim Administrator/Abuse Prevention Coordinator, and V2, Director of Nursing, stated they were not aware of R3's grievance.On 01/21/26, facility leadership confirmed the allegation was not reported or investigated as potential abuse.

Based on interview and record review the facility failed to protect a resident's right for dignity and respect. This failure affected one of three residents (R3) reviewed for Abuse on the sample of five. Findings Include: The Resident's Rights for People in Long Term Care Facilities pamphlet dated November 2018 documents the facility must treat residents with dignity and respect and must care for residents in a manner that promotes their quality of life. The State Report dated 12/8/25 documents R3 alleged a staff member (later identified as V11 Certified Nurse Assistant CNA) was rude to her and threw the container of sanitary wipes at her and told her she needed to clean someone else's feces off of the toilet seat before she used the bathroom. R1's Minimum Data Set, dated [DATE] documents R3 is cognitively intact and requires partial/moderate assistance for toileting hygiene and toilet transfers. On 1/14/26 at 3:00 PM R3 stated she was being helped to the bathroom by V11 CNA when V11 noticed another resident's feces was on the toilet seat. V11 told R3 to use the wipes and clean off the toilet seat before sitting down to use the toilet. R3 stated it was not her own feces on the toilet seat and V11 told R3 she couldn't help her to the bathroom until R3 cleaned it up. V11 threw the container of wipes towards R3 and waited until R3 did as she asked. R3 stated it made her feel upset, embarrassed and disrespected and no one had ever treated her that way before. On 1/14/26 at 3:20 PM V1 Administrator confirmed V11 CNA did not treat R3 with dignity and was terminated due to her behavior in regards to the incident.

Based on observation, interview, and record review the facility failed to ensure two residents were properly secured in wheelchairs before transporting them in a van for two of three residents (R2, R5) reviewed for accidents in the sample list of five. This failure resulted in R2 falling from the wheelchair when the van suddenly stopped and suffering fractures to the humerus, fibula, and tibia with resulting pain and immobility.Findings include:R2's Current diagnoses list includes the following diagnoses: Chronic Kidney Disease Stage 5, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, Atrial Fibrillation with Anticoagulant, Type II Diabetes with Neuropathy, Heart Disease, Anxiety, and Depression.R2's Care Plan updated 8/17/25 documents (R2) uses a wheelchair for locomotion and requires a full body lift for transfer. This care plan also documents R2 is at risk for falls.R2's final report of incident documents On 9/16/25 (R2) was being transported to an appointment. During the transport the driver abruptly applied the brakes. (R2) fell forward on to the wheelchair foot rests. (R2) suffered fractures of the left humerus, left tibia and left fibula. Investigation determined the seatbelt did not properly lock in place.On 10/9/25 at 10:00AM V7, Human Resources Director stated (V9) Transportation Aide was terminated because (V9) was driving the facility van and hit the car in front of her. When (V9) hit the car (R2 and R5) were in the van going to a doctor's appointment. (R5) was shook up but not hurt. I think (R2) broke her leg and her shoulder. (V9) got a ticket. A copy of the citation (V9) was given for Failure to use due care was provided by V7.On 10/9/25 at 10:06AM V9 stated I was driving the facility van to (the hospital) for doctor's appointments with (R2, and R5). (R2) was seated behind me and (R5) was behind (R2). A car in front of me slammed on the brakes and I slammed on my brakes and slid into the other car. (R2) was not secured in the seat because the shoulder belt was broken and would not tighten. I told the last two Administrators, but nothing was done. I couldn't even use the other front wheelchair seat because the lap belt was missing. (R2) slid out of her wheelchair and on to the floor and hit the foot pedals. She was crying in pain. (R5) slid forward but not out of the wheelchair and she was anxious but ok. I immediately called 911 and the police and ambulance were there after a few minutes. They helped me get (R5) back in her chair and they ambulance crew took (R2) to the hospital.R2's Xray report of Left Tibia and Fibula dated 9/16/25 at 2:21PM states Oblique fractures involve the proximal meta diaphysis of the tibia with slight posterior and lateral angulation of the distal fragment. Oblique fracture involves the proximal diaphysis of the fibula. Fractures also involve the distal tibial metaphysis with the margins ill-defined. Fracture undermines the medial malleolus. R2's Xray report of Left shoulder dated 9/16/25 at 2:21 PM states Mildly displaced angulated fracture of the proximal humerus, centered at the surgical neck.On 10/9/25 at 9:30AM V12, Maintenance Director accompanied the surveyor to the transport van. V12 stated the van is currently not in service because several pieces have been ordered from the mobility company that services the harnesses because they were broken. The wheelchair securement system in the van was observed to be disassembled in several areas. V12 stated he does not know why the mobility company was called as he has just been in his position the past few days.On 10/9/25 at 9:45AM V13, former Maintenance Director stated After the van driver got fired, I went to pick up a resident from dialysis. I noticed the right front seatbelt was completely gone and the left front belts were broke and couldn't be tightened. I called (the mobility company) and they sent someone out. I think now we are waiting on parts. I did walk throughs in the van with the transporter, but I really didn't know how those harnesses worked.On 10/9/25 at 9:50AM V11, a technician from the company that builds and services wheelchair securement systems, stated On 10/7/25 according to my notes I went to (the facility) to inspect and repair a wheelchair securement system. What I found in the front row of seating was that both shoulder belts were malfunctioning. One would not pull out and the other would not retract. One of the two seat belts was completely missing. Employees securing residents should have known it wasn't in safe working order. The occupant securement system was not fully functioning and that van should not have been in service. We recommend the securement system be inspected every six months. The last inspection we did was dated May of 2024.R5's Minimum Data Set MDS dated [DATE] documents R5 is cognitively in tact. On 10/9/25 at 2:00PM R5 was seated in her room in a wheelchair. R5 was agreeable to be interviewed. R5 stated Boy do I ever remember that wreck. The first I knew (V9) screamed out and I went flying forward. I didn't get tossed out of my chair because I got trapped between my wheelchair and the back of (R2's) wheelchair. (R2) went flying right out of her wheelchair and she hollered 'OUCH Help me Help me.' Then the cops (police) and ambulance guys came. I wasn't hurt, but I was lucky and I was sure shook up. (R2) was hurt and I haven't seen her back. That kind of worries me. (R2's) seat belts were real loose and I didn't have the lap belt or the shoulder belt on. I guess it could have been worse, but I was scared. On 10/9/25 at 2:30 V14, Nurse Practitioner verified the 9/16/25 accident caused the fractures of (R2's) humerus, fibula, and tibia.

Failures at this level required more than one Deficient Practice Statement. A. Based on interview and record review the facility failed to immediately notify the physician, complete a pain assessment, complete a physical assessment, and provide pain management when severe pain with redness and swelling to the left knee began suddenly and continued for five days for one (R401) of three residents reviewed for significant change in condition in the sample list of 27. These failures resulted in R401 experiencing severe pain from 3/9/25 to 3/14/25 when R401 was hospitalized with a left femur fracture which required surgical repair. The Immediate Jeopardy began on 3/9/25 when the facility failed to immediately notify the physician, complete a pain assessment, complete a physical assessment, and provide pain management when severe pain with redness and swelling to the left knee began suddenly and continued for five days for R401. V1 Administrator, was notified of the Immediate Jeopardy on 4/24/25 at 2:40 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/28/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Notification of Changes policy revised 2/10/25 documents the facility will promptly inform the resident, physician and residents' representative when there is a change in condition requiring notification. The facility's Pain Management policy revised 2/10/25 documents the facility will ensure that pain management is provided to residents who require such services. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of resident's pain. In collaboration with the physician, resident and resident's representative the facility will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. R401's Minimum Data Set (MDS) dated [DATE] documents R401 is severely cognitively impaired. This same MDS documents R401 is dependent on staff for activities of daily living and transfers. R401's Medical Diagnosis List documents R401 has a diagnosis of Dementia without behaviors. R401's current care plan documents R401 requires a full mechanical lift with two staff members for transfers . R401's Nurse Progress Note dated 3/9/25 at 2:41 PM, documents R401 was having pain and discomfort to the left knee. The Note documents R401 yelled out when her left knee was touched, non-pitting edema was noted to the left knee and that R401 was given Tylenol and V3 Medical Director was notified. On 4/21/25 at 2:00 PM, V4 Licensed Practical Nurse stated on 3/9/25 R401 was sitting in a high back wheelchair at the nurse's station, upright and lunging forward in the wheelchair. V4 stated she and V8 Licensed Practical Nurse repositioned R401 with the mechanical lift sling in R401's chair and R401 yelled my knee. V4 stated she assessed R401's left knee and noticed it was swollen and red. V4 stated she had the certified nursing assistants V10, V11, and V12 lay down R401 in her bed, and V4 faxed V3 Medical Director to make V3 aware of R401's left knee change. On 4/21/25 at 2:15 PM, V5 Certified Nursing Assistant stated on 3/9/25, V5 was assisting R401 with getting dressed in the morning and R401 was screaming out in pain when V5 was putting on R401's socks. V5 stated she removed R401's pants and her left knee was red and swollen. V5 stated she made the nurse aware of R401's pain and swelling in the left knee. V5 further stated that R401 had not had any falls or tried to get up on her own in a long time. V5 stated that R401 complained of pain daily the week of 3/9/25-3/14/25. R401's Physician Orders dated 3/10/25 document an order for doxycycline 100 milligrams twice a day for seven days for redness and swelling to left knee. On 4/24/25 at 12:35 PM, V20 Licensed Practical Nurse stated V20 worked on 3/10/25 dayshift from 6:00AM-6:00 PM and cared for R401. V20 stated she remembers R401 complained about pain in her left leg the week of 3/9/25-3/14/25 and would yell out when staff repositioned R401. On 4/24/25 at 12:00 PM, V19 Certified Nursing Assistant stated on 3/11/25 around 2:00 PM, V19 went into R401's room to perform perineal care. V19 stated that R401 was crying and telling V19 that her left leg was hurting. V19 stated that R401 did not want to move in bed and refused to get up for dinner and go to the dining room which R401 normally does. V19 stated that R401's left knee was swollen and red. V19 stated that she reported R401's pain to V20 Licensed Practical Nurse. On 4/24/25 at 1:00 PM, V15 Certified Nursing Assistant stated she cared for R401 the morning of 3/14/25. V15 stated that she went into R401's room to get R401 dressed for the day and R401 told V15 to be careful when rolling her because her side was hurting. V15 stated she went to roll R401 and R401 screamed it hurts really bad. V15 stated she did not get R401 out of bed that day because she was in so much pain. V15 further stated R401 had no urinary out put on V15's shift and did not eat meals. V15 stated she made V20 Licensed Practical Nurse aware of R401's condition and V20 told V15 that R401 would be having an X-ray done later in the day. V15 stated she just knew something wasn't right. R401's electronic medical record does not contain a nursing assessment or a pain assessment from 3/9/25 -3/14/25. R401's electronic medication administration record (MAR) documents on 3/12/25 at 8:54 AM R401 received Tylenol 325 Milligrams for pain. R401's MAR does not document Tylenol given on any other date for the month of March. R401's medical record does not contain a response to the Tylenol administered to R401 on 3/12/25. R401's Nurse Progress Notes dated 3/14/25 at 4:00 PM, document on site radiology came to the facility to perform an X-Ray of R401's left lower extremity and a displaced fracture was diagnosed . The Note documents R401 was in severe pain with movement of joint/extremity and was hollering out with facial grimacing. The Note documents R401's left leg was immobilized to prevent further injury and R401 was transferred by ambulance to the local emergency room . R401's medical chart does not contain documentation of the rationale for obtaining the X-ray for R401. R401's hospital records dated 3/14/25 document R401 arrived at emergency room by ambulance after an onsite X-ray at the facility noted a left distal femur fracture with moderate angulation and displacement. This note further documents R401 will be having an Open Reduction and Internal Fixation to left leg on 3/15/25. The facility's Incident Witness statements dated 3/17/25-3/21/25 document interviews with V4 Licensed Practical Nurse (LPN), V14 LPN, V5 Certified Nursing Assistant CNA, V9 CNA, V10-V13 CNA, V15 CNA, V16 CNA which all confirmed R401 had pain with transfers, dressing and personal cares to the left leg with redness and swelling during the week ok 3/9/25-3/14/25. On 4/22/25 at 2:00 PM, V9 Nurse Practitioner stated when the resident had ongoing continuous pain, the facility should have notified V9 as V9 is in the facility Monday-Friday. V9 stated the facility reported redness on 3/10/25, but never reported ongoing complaints of severe pain. V9 further stated V9 ordered doxycycline on 3/10/25 because at the time the facility had an issue with wounds and based on the information V9 was given he felt R401 may have cellulitis. On 4/22/25 at 1:45 PM, V3 Medical Director stated he expects the facility staff to call or text V3 if a resident is screaming out in pain, so that V3 can arrange to have the resident sent to emergency room for evaluation and treatment. The Immediate Jeopardy that began on 3/9/25 was removed on 4/28/25 when the facility took the following actions to remove the immediacy. 1. The facility Nursing Staff was in serviced on 4/23/25 by V2 Director of Nursing and V17 Regional Nurse Consultant regarding pain management, evaluation and treatment, physician notifications, documentation and follow- up. In-servicing initiated on 4/23/25 all nursing staff who have not attended the in-service will be in-serviced prior to their start of next scheduled shift. Nursing staff not in-serviced will not be able to return to work until in-service has been completed. 2. All residents were assessed for pain by V6 Assistant Director of Nursing on 4/23/25. All residents have a pain scale documented on their Medication Administration Record to be completed every shift. A nonverbal pain scale was added for resident's who are not cognitively intact. 3. On 4/24/25 V2 Director of Nursing implemented daily clinical rounds with the nursing staff to ensure all acute/chronic pain is addressed, appropriate assessments are completed, and notification of the physician has been completed appropriately. Reports will be reviewed/addressed during morning clinical meeting each day. Daily morning Clinical sheets were reviewed and V2 Director of Nursing has been completing daily. 4. On 4/23/25 V2 and V6 in-serviced Nursing Staff regarding physician notification of changes by phone with follow up by fax and text message. Random review of progress notes confirm physicians have been notified by phone with condition changes. 5. On 4/28/25 at 10:00 AM, each nurses station contained a list of hot rack charting for nurses to review daily. V2 is updating hot rack sheets daily with changes. Facility Nurses will use hot rack charting with their report sheet for shift to shift nursing report to assist with communication and follow up. The report sheets will be reviewed by V2 and discussed in morning QA (Quality Assurance) meetings. 6. On 4/28/25, V2 Director of Nursing provided a print out of the daily dashboard electronic clinical record. V2 Director of Nursing is reviewing the Point Click Care Dashboard, 24- hour report, pain management, and physician notification of change, daily for four weeks, to ensure effective measures are implemented for quality resident care. 7. V2 Director of Nursing provided a pain management weekly audit sheet dated 4/23/25 and 4/27/25. This audit documents five residents are being reviewed weekly for pain management. 8. The facility Pain, Change in condition, and notification of changes in-service dated 4/23/25 documents V2 Director of Nursing reviewed policies and procedures with all nursing staff. V2 Director of Nursing will discuss pain management policy and procedure and notification of changes at monthly nursing meeting. 9. On 4/23/25 and 4/25/25 V2 Director of Nursing and V1 Administrator held an interdisciplinary meeting to discuss changes in conditions of residents. V1 provided quality assurance meeting notes dated 4/23/25 and 4/25/25. The facility presented an abatement plan to remove the immediacy on 4/24/25. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 4/24/25 and the survey team accepted the abatement plan on 4/25/25. 37813 Based on interview and record review the facility failed to assess a resident following a fall and failed to recognize a change in condition following a fall for one resident (R408) of five residents reviewed for falls in a sample list of 27 residents. This failure resulted in R408 being hospitalized with a subdural hematoma resulting in left midline shift of the brain tissue, increasing pressure on the brain, hemiparesis and pain from left hip displacement requiring neurosurgery and orthopedic repair. Findings Include: R408's current diagnoses list includes the following diagnoses: Fractured Left femur with Left Hip Replacement, Type II Diabetes, Heart failure with Cardiomyopathy, and Alzheimer's Disease. R408's Minimum Data Set (MDS) dated [DATE] documents R408 is cognitively intact, and able to rise from sitting to standing with partial/moderate assistance upon admission 4/16/25. R408's Fall risk assessment dated [DATE] documents R408 is at high risk for falls. R408's Medication Administration Record for April 2025 does not document R408 was administered Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (milligrams) 1 tablet by mouth every 6 hours as needed for Pain between 4/16/25 (admission) until 4/19/25 following an unwitnessed fall. On 4/19/25 at 02:06AM R408's Progress Note documents (R408) was yelling out for help, (V24 agency LPN) and staff arrived (to) room and observed (R408) laying on the floor on her back under the bed wrapped in her blanket, resident examined for injuries including head and body no complaint of pain or discomfort. Full Range of Motion for all extremities. No neurological checks or post fall assessments are documented from 4/19/25 at 5:20AM until 4/19/25 at 9:57 PM. No neurological checks or post fall assessments are documented at any time on 4/21/25 or 4/22/25. R408's Medication Administration Record for April 2025 documents R408 was administered Hydrocodone-Acetaminophen Oral Tablet 10-325 MG 1 tablet by mouth 4/19/25 at 3:57AM, 4/20/25 at 12:25AM and 7:09AM, 4/22/25 at 9:10AM and 6:12PM, and 4/23/25 at 8:27AM. On 4/29/25 at 10:30 AM, V20 Licensed Practical Nurse stated she cared for R408 on 4/22/25 from 6:00 AM-6:00PM. V20 stated R408 asked for a pain pill in the morning for leg pain. V20 stated R408 asked for another Norco two hours later. V20 stated it was too soon for R408's Norco so V20 offered R408 a Tramadol. V20 stated R408 told her that Tramadol doesn't work for her, and she has told the staff that. V20 stated she also offered R408 a Tylenol to have instead of Tramadol and R408 stated if Tramadol doesn't help then neither will Tylenol. V20 stated she gave R408 another Norco by the end of her shift and left a note on the report sheet requesting R408's Norco frequency be increased because she does not feel the Tramadol was helping. V20 stated she did not complete neurological assessments for R408 on her shift or an assessment on R408 because V20 was not informed R408 had a fall on 4/19/25. On 4/29/25 at 10:45 AM, V23 Certified Nursing Assistant stated V23 cared for R408 on 4/22/25 from 6:00 AM-2:00PM. V23 stated R408 was complaining of pain her entire shift. V23 stated R408 was complaining of pain on her left side and her left arm was drawn up with bruises. V23 further stated R408 had redness on her left side. V23 stated she got R408 up with a sit to stand mechanical lift. V23 stated R408 went to therapy after V23 got R408 ready for the day. V23 stated when R408 came back from therapy R408 wanted to use the toilet. V23 stated when R408 was finished using the toilet V23 was unable to get R408 off the toilet. V23 stated it took three staff members to get R408 off the toilet with a sit to stand mechanical lift and a gait belt. V23 stated R408 was not bearing any weight during the transfer. V23 stated she made V20 Licensed Practical Nurse aware of R408's pain and change in condition several times during her shift. V23 further stated she also cared for R408 the morning of 4/23/25. V23 stated she went to V1 Administrator to make her aware of V23's concerns about R408 and V1 went with V23 to get R408 ready for the day. V23 stated R408 was unable to move when they were changing R408 in bed. V23 stated V1 stated she was going to change R408's transfer status to full mechanical lift transfers. V23 stated later that day R408 was sent to the hospital. A witness statement signed by V1, Administrator dated 4/23/25 documents (V27), Admission Coordinator reported to (V1) (R408) had discoloration to top of left hand 4/23/25 at approximately 8:15AM. (V1) went to investigate discoloration to left hand. This statement also documents (V1) assisted (V23) CNA (Certified Nurse's Aide) with morning cares and during cares (V1) noted flaccid left upper and lower extremities. (R408) voiced no complaint of pain. (V1) immediately spoke with husband and facility Director of Nursing regarding her clinical observations and concerns while cares. After discussing, it was determined further medical evaluation was necessary. (R408) was then transported via facility van to the emergency room . On 4/28/25 at 10:00AM V1, Administrator verified the above statement was correct. R408's head CT (Computerized Tomography) dated 4/23/25 at 11:24AM documents Acute Extra axial hemorrhage overlying the right cerebral hemisphere extending along the tentorium most likely subdural. This document also states Proximally 7MM (millimeter) of midline shift is present. R408's physician's progress note dated 4/24/25 at 6:25AM from higher level trauma hospital documents Patient is a 70 yrs. (years) old female with a subdural hematoma and a dislocated left Hemiarthroplasty. This document also states Neurosurgery team plans to take patient to Operating Room today for subdural evacuation. Orthopedic team will be there to attempt closed reduction under sedation prior to initiation of subdural evacuation. On 4/29/25 at 1:40PM V9 Advanced Practice Nurse for the facility stated according to current standards of practice if a resident is taking increasing pain medication particularly following a fall the physician should be notified to determine the cause of the increased pain. If a resident has had a fall the resident should be assessed at least every shift for the possible effects of the fall including neurological signs. I saw (R408) for the first time 4/22/25. I saw she had the diagnosis Alzheimer's Disease. I did not know her baseline cognition. (R408) was confused when I saw her, and I assumed it was her baseline. On 4/30/25 at 1:56 PM V29, the physician who completed R408's history and physical in ICU (Intensive Care Unit) verified The ICU team agree the fall was the cause of the left hip dislocation and the subdural hematoma. A subdural hematoma is a traumatic brain bleed. If R408 had been seen sooner the 7MM midline shift in the brain might have been avoided. The midline shift is critical because it causes compression of the brain. A stroke or brain bleed is a brain attack, and delays cause loss of function. The Vicodin might have masked part of the pain from the hip dislocation. The other factor in the pain is once the bleed started R408 might have had decreased sensation to the left side of her body. The delay in care was detrimental to R408's outcome. The left sided neglect I saw in R408 was one of the worst I have seen in my residency. In fact, I raised R408's hand and asked her if it was her hand and she said it was one of my colleague's hand because her brain was unable to recognize it as hers. The facility's Notification of Changes policy revised 2/10/25 documents the facility will promptly inform the resident, physician and residents' representative when there is a change in condition requiring notification.

Based on observation, interview and record review the facility failed to provide adequate supervision/assistance when ambulating a resident to prevent a fall for one of four residents (R2) reviewed for accidents in the sample list of four residents. This failure resulted in R2 falling and suffering a fractured humerus when staff stepped away from R2 to untangle oxygen tubing. Findings include: The Care Plan dated 4/1/25 documents R2 was admitted to the facility on [DATE]. The Care Plan dated 4/1/25 documents R2 was admitted with the following diagnosis: systolic (congestive) heart failure, type 2 diabetes mellitus with unspecified complications, chronic gout, morbid (severe) obesity due to excess calories, polyneuropathy, dependence on renal dialysis, end stage renal disease, cellulitis of left lower limb, cellulitis of right lower limb, type 2 diabetes mellitus with diabetic nephropathy, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, dyspnea, muscle wasting and atrophy, multiple sites, unsteadiness on feet, and other lack of coordination. The Nurses Progress Notes dated 2/28/2025 at 2:40 PM document R2 was walking with therapy with the walker as the therapist trailed behind with the wheelchair. The therapist was attempting to adjust the oxygen tubing when the resident had some weakness and lost balance. The Note documents R2 complained of right shoulder pain and was unable to perform range of motion. R2 was subsequently sent to the local emergency room . On 4/1/25 at 2:07 PM V3, Physical Therapy Aide, stated that V3 was ambulating R2 in the hallway. V3 stated R2 was using a walker for ambulation, when R2's oxygen tubing became tangled around the wheelchair that was being pulled behind R2 during ambulation. V3 stated V3 bent over to untangle the tubing and R2 fell forward landing on the floor. On 4/1/25 at 2:07 PM V3, Physical therapy aide, demonstrated being behind the wheelchair bent over to untangle the oxygen tubing and unable to reach R2 due to the gap between V3 and R2. The Physical Therapy Progress Note dated 2/28/2025 at 4:20 PM documents R2 as requiring CGA (Contact Guard Assist) for ambulation with recovery breaks in between each set. The Note documents R2 notes increase in fatigue and SOB (Shortness ff Breath). R2 fell this session, while standing, R2's oxygen tube was caught on the wheelchair. While dislodging the tube R2 fell forward and has an abrasion on her right knee, elbow and cheek bone notified nursing of the accident. On 4/2/25 the NIH (National Institute of Health) Web Site defines Contact Guard Assist as the caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task. https://www.ncbi.nlm.nih.gov. Hospital Records dated 2/28/25 at 4:18 PM document R2 arrived at the hospital with a Chief Complaint of fall while doing physical therapy and that R2 reports right shoulder pain and states she hit her face as well. Hospital Records dated 2/28/25 at 6:17 PM document R2 was diagnosed with a closed comminuted fracture of the right humerus, facial contusion, multiple abrasions and right elbow pain. On 3/31/25 at 11:24 AM V5, R2's Family, confirmed that R2 was admitted to the hospital for a fractured right humerus and needed surgical repair. On 4/1/25 at 10:00 AM V1 confirmed that V3 was ambulating R2 in the hallway by himself with a walker while trailing R2 with a wheelchair that was carrying R2's oxygen on the back of the wheelchair. On 4/1/25 at 10:40 AM V9, Director of Rehabilitation, confirmed V3 was ambulating R2 in the hallway by himself with a walker while trailing R2 with a wheelchair that was carrying R2's oxygen tank on the back of the wheelchair. V9 confirmed V3 was behind the wheelchair and not in reach of R2 or the gait belt around R2. V9 confirmed two staff members will be used to ambulate residents with multiple pieces of equipment.

Based on observation, interview, and record review the facility failed to implement repositioning and incontinence cares every two hours, implement pressure relieving interventions, implement pressure ulcer treatments, identify pressure ulcers, monitor and assess pressure ulcers upon identification and weekly, and notify a physician and dietitian of newly identified and current pressure ulcers and deterioration for two (R52, R345) of six residents reviewed for pressure ulcers in the sample list of 48. These failures resulted in R52 developing left heel stage two and right heel stage three pressure ulcers and being hospitalized for an infection of the stage three pressure ulcer. R52 subsequently developed a coccyx pressure ulcer that deteriorated into a stage four pressure wound. This failure resulted in an Immediate Jeopardy: The Immediate Jeopardy began on 02/22/2025, when the facility failed to continue ongoing monitoring and assessments of R52's wound and skin, maintain R52's wound dressing, ensure R52's pressure reliving interventions were implemented, ensure R52's pressure ulcers were identified timely, and ensure R52's pressure ulcer was evaluated by a physician and ensure R52's nutritional status was evaluated by a dietitian, per their submitted abatement plan to the State Agency for F686J cited on 02/25/2025. V1 Administrator was notified of the Immediate Jeopardy on 3/6/25 at 10:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/7/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Wound Treatment Management policy dated 2/1/25 documents wound treatments will be administered as ordered, if there are no orders then notify the physician, check and monitor dressings daily to ensure they are intact. This policy documents the effectiveness of treatments will be monitored by the nursing staff, Director of Nursing, and wound nurse through regular assessments of the wound and to consider modifications if there is a lack of progression of healing. The facility's Pressure Injury Prevention and Management policy dated 2/10/25 documents the following: The facility shall establish a systematic approach for pressure ulcer prevention and management, including prompt assessment and treatment, reducing underlying risk factors, interventions to stabilize, monitoring the effectiveness of interventions, and modifying interventions. The facility will use a pressure injury risk assessment and consider other risk factors such as impaired mobility, co-morbid conditions, cognitive impairment, bowel and bladder incontinence, nutritional status, and previous healed pressure ulcers. The nurses will complete weekly full body skin checks and with any newly identified pressure ulcer and document these assessments in the resident's medical record. Nurses will assess pressure ulcers and document the assessment, including staging of the pressure ulcer. A care plan will be developed to include appropriate interventions for pressure ulcer prevention and management, interventions will be communicated to relevant staff, and compliance will be documented in weekly charting. Pressure ulcer preventative interventions will be implemented for all residents identified to be at risk or who have pressure ulcers. These interventions include redistributing pressure through support surfaces and offloading/repositioning, minimizing exposure to moisture, and maintaining or improving nutritional status. The Unit Manager or designee is responsible for reviewing pressure ulcer and skin documentation weekly and documenting findings in the medical record. The physician will be notified when new pressure ulcers are identified, wound progression, and complications. 1. On 3/03/25 at 9:32 AM R52 was sitting in a wheelchair in R52's room. R52 stated R52 thinks R52 has a sore on R52's bottom, but was unable to give any additional information about R52's wound and wound care. On 3/3/25 intermittent observations were conducted from 9:32 AM until 3:12 PM of R52 sitting in a wheelchair in R52's room. There was a foam cushion on R52's wheelchair seat. On 3/03/25 at 2:19 PM V11 Certified Nursing Assistant (CNA) stated V11 last offered to lay R52 down and provide toileting assistance at 10:00 AM and R52 refused at that time. V11 stated R52 is suppose to be laid down/repositioned and toileted at least every two hours and refusals of care are suppose to be reported to the nurses, but V11 had not reported R52's refusal of care today. V11 stated there are usually four or five CNAs working on R52's unit and North Wing, but today there were only three CNAs. V11 entered R52's room. There was a strong urine odor in the room, confirmed with V11. V11 stated V11 was just getting ready to lay R52 down, and the staffing today has affected V11's ability to provide R52's cares. At 2:41 PM R52 was in R52's room scooted down in the wheelchair. V10 and V11 CNAs entered R52's room and attempted to transfer R52 from the wheelchair. R52 was tearful, moaning and shaking. R52's fists were clenched and R52 complained of buttock pain when V11 and V10 CNAs attempted to transfer R52. V10 and V11 stated R52 acts like this when R52 is in pain from sitting in the wheelchair too long, they will need to allow R52 time to calm down and reapproach later. At 3:12 PM V11 and V19 CNA transferred R52 into bed and provided incontinence care. R52 was tearful, anxious, shaking, moaning, and complaining of R52's bottom hurting. R52's brief was saturated with urine and R52 had a golf ball sized pressure ulcer to the coccyx. Slough covered approximately 10% of the wound bed. The wound was not covered with a dressing at the time of the transfer. V11 stated R52 had a dressing on early this morning, V11 didn't pay attention to when it became dislodged, and did not report this to the nurse. R52's Minimum Data Set (MDS) dated [DATE] documents R52 required dependence on staff for toileting and supervision/touching assistance for bed mobility and transfers; and R52 had one facility acquired stage two pressure ulcer. R52's MDS dated [DATE] documents R52 has cognitive impairment, R52 is dependent on staff for toileting and transfers, and needs partial/moderate assistance with bed mobility. R52's Braden assessment dated [DATE] documents R52 is at risk for developing pressure ulcers and R52's Braden assessment dated [DATE] documents R52 is at high risk of developing pressure ulcers. These forms do not document implementation of pressure relieving interventions as indicated on the forms. R52's (active) Care Plan documents R52 has Parkinson's Disease and Alzheimer's Disease, R52 is incontinent of bowel and bladder and has Moisture Associated Skin Damage of the sacrum. This care plan includes interventions to report signs of skin breakdown, provide prompt incontinence care, administer treatments as ordered, follow dietitian recommendations, refer to the wound provider, and complete weekly wound assessments. This care plan does not include pressure relieving interventions for heels, besides repositioning and an air mattress. There are no documented weekly skin assessments in R52's medical record after 12/5/24 until 12/26/24. R52's Skin Check dated 12/26/24 documents R52 had a new facility acquired intact blister on the right heel. There is no documentation that this wound was reported to a physician or that treatment orders and preventative measures were implemented for R52's heel wound. R52's Nursing Note dated 12/28/24 at 12:16 AM documents R52 was drowsy, difficult to arouse, and had refused medications. R52 had a large open, draining, blister on the right heel/ankle and another small open, draining wound on the left ankle. R52 was transferred to the emergency room . R52's Hospital Notes dated 12/28/24 document R52 was admitted to the hospital with a stage two pressure ulcer of the left heel and cellulitis of a stage three pressure ulcer of the right heel. R52 was given intravenous antibiotics and hospitalized until 1/1/25. R52's Skin Check dated 1/10/25 documents R52 had right and left heel blisters and a new facility acquired sacral wound that measured 1.8 centimeters (cm) long by 0.5 cm wide. This wound is described as Moisture Associated Skin Damage (MASD). R52's Hospital Note dated 1/14/25 documents R52's sacral wound as a stage two pressure ulcer. R52's Wound assessment dated [DATE] is the last recorded assessment of this wound in R52's medical record. This assessment documents R52's sacral wound as MASD that measured 1.5 cm by 0.8 cm by 0.1 cm deep. R52's Skin Monitoring Forms (shower sheets) dated 2/17/25, 2/20/25 and 2/24/25 indicate impaired skin on R52's sacrum but there are no descriptions of this area. R52's skin assessments dated 2/20/25 and 2/27/25 do not include R52's sacral wound. R52's March 2025 Treatment Administration Record (TAR) documents to cleanse sacral wound and apply honey hydrocolloid dressing every three days on night shift as of 2/9/25. R52's Initial Wound Evaluation & Management Summary dated 1/8/25 and recorded by V21 Wound Nurse Practitioner, documents R52's right heel stage two pressure ulcer measured 2.5 cm by 4.5 cm and to use skin protectant daily, float heels in bed, offload wound, and use a pressure relieving boot. There is no documentation in R52's medical record that R52 was evaluated by V21 after 1/8/25 until 3/5/25. There is no documentation in R52's medical record of when R52's sacral pressure ulcer deteriorated and that a physician was notified to obtain new treatment orders, or that R52's nutritional status was evaluated by a dietitian between 12/1/24 and 3/3/25. R52's Wound Evaluation and Management Summary dated 3/5/25, recorded by V21, documents R52's right heel ulcer is resolved and R52's coccyx wound as a stage four pressure ulcer that measured 2.3 cm by 1.3 cm by 2.1 cm deep. This wound contained 30% necrotic (dead) tissue and 40% slough (dead tissue). The wound is described as being odorous with gray colored drainage, periwound is erythematous and painful to palpation. This wound required debridement to remove the dead tissue. V21 ordered Doxycycline (antibiotic) 100 milligrams twice daily by mouth for 14 days and a new treatment for 0.125% Dakins (bleach) solution soaked gauze packed into the wound and covered with a dressing twice daily. V21 recommended offloading the wound, repositioning per facility protocol, using an air inflated wheelchair cushion, and limiting time in the wheelchair to two hours at a time. There is no documentation that R52's order for Doxycycline was implemented as of 3/6/25 at 10:15 AM. The facility's Wound Log dated 2/25/25 does not include R52's sacral pressure ulcer. On 3/3/25 at 2:36 PM V10 CNA stated there were three CNAs for the evening shift last night on the North Wing and R52's unit, which was not enough staff, causing toileting and incontinence cares to fall behind. V10 stated R52's wound was present three weeks ago when V10 started working for the facility, the wound has gotten worse and R52 complains of pain. V10 stated the nurses were aware of this. On 3/03/25 at 3:37 PM V22 Wound Nurse stated V22 has not done any treatments for R52 and was unsure if R52 had any wounds. V22 assessed R52's wound and stated the wound was unstageable due to slough. V22 stated V22 would notify the physician and get a treatment order. On 3/04/25 at 10:31 V24 Licensed Practical Nurse (LPN) stated R52 had an intact blister on the right heel and V24 was unsure if the physician was notified or any treatments/interventions were implemented for this wound. V24 stated since it (blister) is intact, we don't really apply a treatment. On 3/04/25 at 10:39 AM V3 Assistant Director of Nursing (ADON) stated V3 assessed R52's buttocks on 2/20/25 and described R52's sacral area as the skin being whitish/pink in color and superficially open between the epidermis and dermis layers of skin. V3 reported this to the former DON and did not notify the physician or get new treatment orders. V3 stated the CNAs are suppose to notify the nurse when dressings are dislodged so that a new dressing can be applied. On 3/4/25 at 11:41 AM V23 LPN stated V23 transferred R52 to the hospital in December 2024 due to a right heel blister that was open and draining. V23 stated within the last two weeks V23 has changed R52's sacral dressing at least once or twice and it looked as though the wound was getting worse. V23 thought V23 notified V34 (R52's Physician) and documented this in a note, but sometimes V34 is difficult to get a hold of so V23 may have passed it onto the day shift to follow up on. V23 was unsure if the facility's Medical Director (V35) should be contacted in the event that a resident's physician is unable to be reached. At 3:25 PM V23 stated V23 could not recall if any heel pressure relieving interventions were implemented for R52. V23 stated R52 had a dressing on the left heel that V23 did not remove and R52 did not have any active treatment orders for R52's heel wounds the day V23 sent R52 to the hospital in December. V23 stated to refer to R52's TAR to determine when V23 last administered R52's sacral wound treatment. V23 stated at that time the wound was deeper, had slough, and was draining. R52's February 2025 TAR documents V23 administered R52's sacral wound treatment on 2/24/25 and 2/27/25. On 3/4/25 at 10:07 AM V2 Director of Nursing (DON) stated V2 saw R52's wound today and R52 had sacral MASD that opened within the last two weeks. V2 stated if there is a wound then it should have a wound assessment completed weekly in the assessments section of the electronic medical record, and the physician should be notified of wounds which would be documented in the nursing notes. V2 stated skin checks should also be completed weekly in the assessments section and should include wound identification. V2 stated the standard of care is for residents to be repositioned and provided incontinence care every two hours. V2 stated R52 should have physician orders for pressure relieving boots or floating heels and this should also be documented in R52's care plan. At 2:25 PM V2 stated R52's nursing note dated 1/13/25 was the only documentation V2 could find that R52's wounds were reported to a physician. V2 confirmed there were no orders or care plan for heel pressure relieving interventions. On 3/06/25 at 11:08 AM V2 stated if the nurses are unable to reach V34 (R52's Physician) then they should contact either V35 Medical Director or V18 Nurse Practitioner, who both are available to take calls 24 hours per day. On 3/4/25 at 10:57 AM V18 Nurse Practitioner stated residents at risk for developing pressure ulcers and those with pressure ulcers should be provided incontinence care and repositioning/offloading at least every two hours. V18 confirmed if wounds are not monitored/assessed, wound dressings aren't maintained, pressure relieving interventions, incontinence care and repositioning aren't implemented, and newly identified wounds and deterioration aren't being reported to a physician, these things can contribute to the development of pressure ulcers and wounds deteriorating. V18 stated pressure ulcers should be reported to the facility's wound provider and evaluated. V18 stated V18 was notified yesterday of R52's sacral wound. V18 stated the facility should have reported R52's heel wounds, implemented pressure relief for R52's heels such as floating heels or heel protectors, and implemented a protective dressing treatment for R52's intact blister. V18 confirmed wounds should be covered with dressings maintained as ordered. V18 stated if these things aren't implemented then the resident is at risk for the wound becoming infected, developing sepsis, and the wound deteriorating. On 3/4/25 at 3:16 PM V20 Registered Dietitian (RD) stated V20 has been the facility's dietitian since September/October 2024 and V20 rounds in the facility weekly. V20 stated V20 was not made aware that R52 had wounds, so V20 did not evaluate R52 until today. V20 confirmed R52's nutrition had not been evaluated between 12/1/24 and 3/3/25. V20 stated V20 recommended adding fortified foods with R52's meals and will probably recommend adding Vitamin C and Zinc. V20 stated V20 would have recommended these things sooner if V20 was notified of R52's wounds. On 3/5/25 at 3:48 PM V21 Wound Nurse Practitioner stated V21 just evaluated R52's wound which presented as an unstageable pressure ulcer with slough and necrosis that required debridement. After debridement it is a stage four pressure ulcer that measured 2.3 cm by 1.3 cm by 2.1 cm deep. V21 stated V21 had to stop the debridement due to the amount of pain R52 experienced. V21 confirmed R52 should have been evaluated by V20 RD and V21, should have been repositioned and provided incontinence care every two hours, have dressing maintained, and wound assessments and monitoring completed. V21 stated these are certainly big factors in wound healing and can contribute to R52's wound deterioration. V21 stated V21 had last evaluated R52 for a heel ulcer, which is now healed, but that was prior to R52 going to the hospital. V21 stated no one notified V21 that R52 had returned from the hospital and that R52 had wounds. V21 stated V21 is ordering Doxycycline and additional blood work due to R52's pain and concern for infection. V21 stated the facility has had a lot of wound nurse turnover. On 3/6/25 at 10:15 AM V22 Wound Nurse confirmed V22 rounded with V21 on 3/5/25 and V21 mentioned ordering Doxycycline. V22 stated either V22 or V2 are responsible for entering V21's orders and R52's Doxycycline order had not yet been transcribed/implemented. The facility presented an abatement plan to remove the immediacy on 3/6/25 at 12:08 PM and presented revision of the abatement plan on 3/6/25 at 12:28 PM, 12:42 PM and 2:42 PM, and on 3/7/25 at 9:37 AM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 3/6/25 at 12:20 PM, 12:32 PM, and 2:12 PM, and on 3/7/25 at 9:24 AM. The facility presented a revised abatement plan on 3/7/25 at 9:46 AM and the survey team accepted the abatement plan on 3/7/25 at 9:47 AM. The Immediate Jeopardy that began on 2/14/25 was removed on 3/7/25 when the facility took the following actions to remove the immediacy: 1.) R52 was assessed and treated by the Wound Care Physician on 3/5/25. 2.) V22 Wound Nurse was hired on 2/26/25 as the facility's full time wound nurse, confirmed with V22 on 3/7/25. 3.) V2 Director of Nursing and V22 Wound Nurse conducted facility wide skin checks on 3/6/25 and 3/7/25 of all residents. 4.) V22 Wound Nurse initiated audits on 3/7/25 that included a review of the resident skin checks, provisions of incontinence care, turning and repositioning, notifications to the physician and Registered Dietician, and monitoring of wound treatments. 5.) On 3/6/25 and 3/7/25 V2 Director of Nursing conducted an inservice training for nurses and Certified Nursing Assistants on the topics of skin assessments, wound assessments, identifying and reporting new and deteriorating wounds, implementing and maintaining wound treatments, notification of physician and dietitian, incontinence care, and turning and repositioning. This was confirmed through documented in-service sign in sheets and staff interviews confirmed on 3/7/25. Any remaining staff will receive this training prior to their next scheduled shift, confirmed with V2 and V22 on 3/7/25. 6.) On 3/6/25 V22 was in-serviced by V2 on the facility's skin and wound management programs and notification of registered dietitian and physician. This was confirmed on 3/7/25 through documented in-service and interviews with V2 and V22. V2 and V22 confirmed V22 will be responsible for monitoring/tracking/processing of physician orders and dietitian recommendations. 7.) On 3/7/25 at 2:37 PM V2 stated V22 will bring the audits to the Quality Assurance meetings to be reviewed by the interdisciplinary team weekly, monthly, and quarterly. This was also confirmed with V1 and V22. 52228 2. R345's care plan dated 2/11/25 documents R345 has history of Pressure Ulcers and that R345 is cognitively intact and has no signs and symptoms of delirium. On 3/5/25 at 1:45 PM, V6 (Licensed Practical Nurse) and V19 (Certified Nursing Aide) laid R345 down in R345's bed. There was a pencil eraser sized partial thickness wound to R345's right buttock. R345's wound did not have a treatment on it. V6 stated V6 was unaware of the open area and stated that she will have the wound doctor look at it. V6 stated there is no treatment for this area. R345 stated this area has been present and was seen by the nurse a couple nights ago. R345's nurse's note dated 2/19/25 at 6:39 PM documents R345 has a new skin issue to the buttocks. R345's physician order sheet does not contain a treatment order for the right buttock. R345's Initial Wound Evaluation note dated 3/5/25 documents R345 has a 0.1 centimeter (cm) by 0.2 cm stage two pressure ulcer to the right buttock. This note documents the duration of this wound as greater than two days. This evaluation contains an order for medical honey to be applied once daily and covered with a gauze dressing.

Based on observation, interview and record review the facility failed to effectively manage pain by failing to accurately assess for pain, notify the physician of pain and implement orders for pain medications for two (R52, R84) of two residents reviewed for pain in the sample list of 48. This failure resulted in R52 experiencing uncontrolled pain as evidenced by moaning, grimacing, tearfulness, clenched fists and complaints of pain. Findings Include: The facility's Pain Management policy dated 2/10/25 documents the facility will recognize when a resident is experiencing pain, observe for nonverbal signs of pain, identify circumstances when pain can be anticipated, conduct ongoing pain assessments using a tool that is appropriate for the resident's cognitive status, and collaborate with the resident's physician to manage or prevent pain in accordance with the resident's care plan, assessment, and current standard of practice. 1.) On 3/03/25 at 9:32 AM R52 was sitting in a wheelchair in R52's room. R52 stated R52 thinks R52 has a sore on R52's bottom, but was unable to give any additional information about R52's wound and wound care. On 3/3/25 intermittent observations were conducted from 9:32 AM until 3:12 PM of R52 sitting in a wheelchair in R52's room. There was a foam cushion on R52's wheelchair seat. On 3/03/25 at 2:19 PM V11 Certified Nursing Assistant (CNA) stated V11 last offered to lay R52 down and provide toileting assistance at 10:00 AM and R52 refused at that time. At 2:41 PM R52 was in R52's room scooted down in the wheelchair. V10 and V11 CNAs entered R52's room and attempted to transfer R52 from the wheelchair. R52 was tearful, moaning and shaking. R52's fists were clenched and R52 complained of buttock pain when V11 and V10 CNAs attempted to transfer R52. V10 and V11 stated R52 acts like this when R52 is in pain from sitting in the wheelchair too long, they will need to allow R52 time to calm down and reapproach later. At 3:12 PM V11 and V19 CNA transferred R52 into bed and provided incontinence care. R52 was tearful, anxious, shaking, moaning, and complaining of R52's bottom hurting. R52's brief was saturated with urine and R52 had a golf ball sized sacral pressure ulcer. R52's Minimum Data Set (MDS) dated [DATE] documents R52 has cognitive impairment, R52 does not receive scheduled or as needed (PRN) pain medications, R52 is dependent on staff for toileting and transfers, and R52 needs partial/moderate assistance with bed mobility. R52's (active) Care Plan documents R52 has Parkinson's Disease and Alzheimer's Disease, R52 is at risk for pain and has sacral moisture associated skin damage (MASD). This care plan includes interventions to administer pain medications as ordered, assist to reposition frequently for comfort, notify the physician of changes in pain, report nonverbal expressions of pain, and treat pain prior to treatments and turning to ensure resident comfort. R52's Wound assessment dated [DATE] documents R52's sacral wound measured 1.5 cm by 0.8 cm by 0.1 cm deep. R52's March 2025 Treatment Administration Record (TAR) documents to cleanse sacral wound and apply honey hydrocolloid dressing every three days on night shift as of 2/9/25. R52's February and March TARs document R52's pain is assessed every shift and rates R52's pain as 0 on a 1-10 scale. There are no active physician orders for pain medication in R52's medical record as of 3/3/25 or that R52's pain was reported to a physician prior to 3/4/25 when Tylenol 650 milligrams every eight hours was ordered. R52's Wound Evaluation and Management Summary dated 3/5/25, recorded by V21 Wound Nurse Practitioner, documents R52's sacral wound as a stage four pressure ulcer that measured 2.3 cm by 1.3 cm by 2.1 cm deep. This wound contained 30% necrotic (dead) tissue and 40% slough (dead tissue). The wound is described as being odorous with gray colored drainage, periwound is erythematous and painful to palpation. This wound required debridement to remove the dead tissue. V21 ordered Doxycycline (antibiotic) 100 milligrams twice daily by mouth for 14 days and a new treatment for 0.125% Dakins (bleach) solution soaked gauze packed into the wound and covered with a dressing twice daily. V21 recommended offloading the wound, repositioning per facility protocol, using an air inflated wheelchair cushion, and limiting time in the wheelchair to two hours at a time. On 3/3/25 at 2:36 PM V10 CNA stated R52's wound was present three weeks ago when V10 started working for the facility, the wound has gotten worse and R52 complains of pain. V10 stated the nurses were aware of this. On 3/4/25 at 3:25 PM V23 Licensed Practical Nurse (LPN) stated the last time V23 administered R52's sacral wound treatment the wound was deeper, had slough, and was draining. R52's February 2025 TAR documents V23 administered R52's sacral wound treatment on 2/24/25 and 2/27/25, the last times that V23 administered R52's wound treatment. On 3/4/25 at 10:07 AM V2 Director of Nursing (DON) confirmed R52 would have potential for pain related to R52's wound, R52 has no pain medication ordered, and R52's pain assessments document no pain. V2 stated physician notification would be documented in a nursing note. On 3/4/25 at 10:57 AM V18 Nurse Practitioner stated the nurses should have reported R52's pain so that we could implement pain medication orders for R52. V18 stated (R52) should not be in pain. On 3/5/25 at 3:48 PM V21 Wound Nurse Practitioner stated V21 just evaluated R52's wound which presented as an unstageable pressure ulcer with slough and necrosis that required debridement. After debridement (mechanical removal of dead tissue) it is a stage four pressure ulcer that measured 2.3 cm by 1.3 cm by 2.1 cm deep. V21 stated V21 had to stop the debridement due to the amount of pain R52 experienced. V21 stated V21 is ordering Doxycycline and additional blood work due to R52's pain and concern for infection. 2.) On 3/02/25 at 9:46 AM R84 stated R84 has frequent pain to lower back and knees, which the nurses are aware of, and R84 had recent back surgery. R84 stated R84's pain medications help take the edge off. On 03/02/25 at 9:57 AM R84 was lying in bed with legs elevated on a pillow. R84 yelled out and moaned when V7 CNA lifted R84's legs off of the pillow and with turning when V7 provided R84's incontinence cares. R84 yelled out, R84's breathing was heavy, R84 whimpered, and R84 had tears in R84's eyes during R84's cares. There was a dressing on R84's lower back. V7 told R84 I'm sorry. R84 stated R84's knees hurt and the pain travels up R84's back. R84 told V7 that R84 needed a pain pill from the nurse and R84 rated R84's pain as a 10. On 3/02/25 at 1:55 PM and on 3/3/25 at 9:23 AM R84 was lying in bed asleep. R84's MDS dated [DATE] documents R84 as cognitively intact, R84 does not receive scheduled pain medication, and R84 has moderate pain frequently. R84's active Care Plan documents R84 has pain related to radiculopathy, spinal stenosis and osteoarthritis. This care plan includes interventions to administer pain medication as ordered, assess pain, discuss precipitating factors, and notify the physician of any changes in pain. R84's February and March 2025 Medication Administration Records document R84's pain is assessed every shift and R84's pain rating was between 4 and 8 on nine occasions between 2/1/25 and 3/2/25. Norco 5-325 milligrams (mg) was given 16 times and Tramadol 50 mg was given nine times between 2/1/25 and 3/2/25. R84's March MAR does not doucment pain medication was administered until 2:03 PM on 3/2/25. On 3/02/25 at 1:28 PM V6 LPN stated R84 mostly complains of pain during R84's cares and during therapy. V6 stated V6 offered R84 a pain pill at 7:30 AM and again at 12:47 PM, but R84 declined the pain medication. V6 stated R84 has orders for Tramadol and Norco PRN and no scheduled pain medications ordered. V6 stated R84 will deny being in pain and then 15-20 minutes later will complain of pain during therapy. V6 stated that no one had reported that R84 requested a pain pill today and R84 had not received any pain medication during V6's shift today. On 3/03/25 at 1:14 PM V37 Certified Occupational Therapy Assistant stated R84 has back pain and pretty severe pain in R84's legs causing R84 to be sensitive to touch. V37 stated R84's pain affects R84's ability to participate in therapy and it is difficult for R84 to stand in the lift device. V38 Physical Therapy Assistant stated R84 has constant pain to both knees and back pain that comes and goes. V38 stated R84's knees are bone on bone and R84 was suppose to have knee replacement surgery prior to R84's back surgery. V37 and V38 stated they both have discussed R84's pain with the nurses, but R84 only has PRN pain medication which R84 often doesn't request until R84 is in therapy already and in pain.

Based on observation, interview, and record review the facility failed to assess a wound, prevent cross contamination during wound care, administer wound treatments as ordered, timely notify the physician of a dehisced surgical wound, monitor bowel movements and hydration, and implement bowel interventions for three (R52, R30, R41) of 24 residents reviewed for quality nursing care in the sample list of 48. These failures resulted in R52 and R41 developing bowel obstruction and fecal impaction requiring hospitalization and treatment. Findings Include: 1.) R52's Minimum Data Set (MDS) dated [DATE] documents R52 is dependent on staff for toileting. R52's MDS dated [DATE] documents R52 has cognitive impairment and R52 is dependent on staff for toileting. R52's Care Plan dated 11/7/22 documents R52 is at risk for constipation and includes interventions to encourage R52 to sit on the toilet and monitor/report symptoms of constipation. R52's Care Plan dated 5/23/22 documents R52 is incontinent of bowel and bladder and includes an interventions to monitor bowel habits, notify the nurse of bowel concerns, administer bowel management medications as ordered, and notify physician of concerns. R52's care plan has not been updated to include R52's history of bowel obstruction or any new bowel interventions after 10/22/22. R52's Nursing Note dated 1/13/25 at 1:04 PM documents R52 was transferred to the hospital for seizure like activity. R52's hospital note dated 1/13/25 documents R52 arrived with abdominal distention, abdominal pain, and no bowel movements for the past day. R52's Hospital Note dated 1/14/25 documents R52's abdominal computed tomography indicated high-grade small bowel obstruction and low-grade partial colonic obstruction. A nasogastric tube was inserted and R52 was hospitalized until 1/17/25. R52's January 2025 and March 2025 Medication Administration Records do not document any orders for bowel medications. R52's January 2025 bowel tracking documents between 1/1/25 and 1/13/25 R52 had three small bowel movements. Bowel incontinence is recorded once on 1/2/25 and 1/6/25, but not applicable is recorded for size and consistency of bowel movements. There are no documented bowel movements between 1/1/25 and 1/7/25, 1/11/25, and 1/12/25, besides these entries. R52's February and March 2025 bowel tracking documents R52's last recorded bowel movement was a small bowel movement on 2/22/25, besides bowel incontinence on night shift on 3/11/25. This entry documents not applicable for size and consistency. R52's medical record does not document any assessments of R52's abdomen or that R52's constipation was reported to a physician after 2/22/25. On 3/04/25 at 9:54 AM V28 Certified Nursing Assistant (CNA) stated V28 is R52's assigned CNA today and R52 had not had a bowel movement. V28 stated bowel movements are documented by the CNAs in the bowel tracking. V28 was unsure when R52's last bowel movement was and V28 would have to look at R52's bowel tracking. On 3/05/25 at 9:31 AM V39 CNA stated V39 is assigned to R52's care today and R52 had not had a bowel movement today. On 3/04/25 at 9:58 AM V13 Licensed Practical Nurse stated nothing had been passed on in shift report about R52's bowels. V13 stated the CNAs are suppose to chart bowel movements and if the resident hasn't had a bowel movement in so many days then the nurses are suppose to contact the doctor for orders. R52's bowel tracking was reviewed with V28 who confirmed R52 going three or more days without bowel movements and confirmed R52 has no active orders for bowel medications. V28 stated V28 will follow up and get orders. On 3/4/25 at 10:13 PM V40 CNA confirmed V40 documented incontinent bowel movement for R52 on night shift on 3/3/25. V40 stated the bowel movement was not enough to even consider a bowel movement, it was pate like and a minimal amount. V40 was unsure when R52 last had a bowel movement. On 3/04/25 at 10:07 AM V2 Director of Nursing stated the CNAs should be documenting bowel movements in the resident's bowel tracking. V2 stated R52 should have bowel and hydration monitoring and stool softeners ordered since R52 has a history of bowel obstruction. V2 stated fluid intake is documented as part of meal intakes recorded by the CNAs, but is not recorded unless the resident is on strict intake and output monitoring. R52's bowel tracking was reviewed with V2 and confirmed 2/22/25 was the last recorded bowel movement. V2 confirmed no bowel medications or interventions have been implemented. V2 stated physician notification is documented in a progress note. On 3/04/25 at 1:02 PM V2 confirmed R52's December 2024 and January 2025 bowel tracking documents lack of bowel movements and R52 had no bowel medications ordered prior to R52's bowel obstruction. V2 confirmed bowel movement size and consistency should be recorded for each bowel movement. On 3/05/25 at 10:56 AM V2 stated the facility does not have a bowel protocol/policy. On 3/06/25 at 9:36 AM V3 Assistant Director of Nursing was requested to assess R52's abdomen and bowel sounds. R52 denied stomach pain and nausea. V3 asked R52 if R52 had a bowel movement and R52 replied no. V3 asked R52 when R52 last had a bowel movement and R52 was unsure. V3 palpated R52's abdomen and used a stethoscope to assess R52's bowel sounds. V3 stated R52's abdomen is soft and not distended, and V3 heard bowel sounds in all four quadrants of R52's abdomen. V3 stated V3 will follow up with V18 Nurse Practitioner or V35 Medical Director. V3 told R52 that V3 would get an order and give something for R52 to have a bowel movement. V3 confirmed physical assessments should be noted in a progress note or in the assessment section of R52's electronic medical record. On 3/03/25 at 1:44 PM R52's January 2025 hospitalization for bowel obstruction was discussed with V18 Nurse Practitioner. V18 stated the facility should have been tracking and monitoring R52's bowel movements and notified the physician so that a stool softener or laxative could be ordered prior to R52's hospitalization . On 3/4/25 at 10:57 AM V18 stated the facility should have informed V18 or V34 (R52's Physician) that R52 was not having routine bowel movements so that R52 could be started on a bowel medication such as Senna. V18 confirmed the staff should be monitoring R52's bowel movements closely and reporting concerns. V18 stated with R52's history of bowel obstruction V18 is prone to developing another obstruction. V18 stated signs would be complaints of abdominal pain, but R52 has Alzheimer's Disease which makes it complicated due to impaired cognition and communication. V18 stated if a bowel obstruction is left undetected and untreated for a prolonged period it could lead to death, but usually there are signs of symptoms such as abdominal distention/bloating and vomiting. V18 stated the facility should also be monitoring and ensuring adequate hydration for R52, which would also help with R52's constipation. 2.) On 03/02/25 at 9:14 AM R30 had a wound vacuum attached to a dressing on R30's left below knee amputation surgical wound. R30 stated the nurses did not initiate a wound treatment when R30 admitted to the facility and R30 had to have additional surgery for an infection of the surgical incision. R30's MDS dated [DATE] documents R30 as cognitively intact. R30's nursing notes document R30 admitted to the facility on [DATE]. R30's Skin Check dated 12/31/2024 at 10:50 PM documents R30 had a new wound to the left knee amputation site that measured 3 centimeters (cm) long by 1.5 cm wide by 0.25 cm deep. This wound had 90% granulation, 100% slough, and purulent pus drainage. R30's Nursing Note dated 1/3/2025 at 10:04 AM documents an open area below R30's left knee measured 3 cm by 1.5 cm by 0.25 cm and physician (V35) was notified. R30's Nursing Noted dated 1/7/2025 at 12:51 PM documents R30's amputation site was warm to touch, and had pus, foul odor, and was larger from prior observation. Antibiotics and would culture was ordered. There is no documentation in R52's medical record that this wound was reported to V35 prior to 1/3/25 and reported to V41 (R52's Surgeon) prior to 1/9/25. R30's Hospital Notes and Operative Report dated 1/10/25 documents dehiscence of amputation surgical site with breakdown exposing muscle and tendon that required debridement and wound vacuum placement. R30's December 2024 and January 2025 Treatment Administration Records (TARs) do not document any wound treatments were implemented for R30's surgical wound after 12/31/24 until 1/3/25. R30's Physician Order dated 2/16/24 documents negative pressure wound therapy for left below knee amputation and change every Monday, Wednesday, Friday and as needed. There are no orders for a petroleum gauze dressing as part of R30's surgical wound care. R30's Skin Checks dated 2/18/25, 2/19/25 and 2/26/25 do not document an assessment and/or measurements of R30's surgical wound. There are no documented wound assessments for R30's surgical wound in R30's electronic medical record after 1/31/25. On 3/03/25 at 10:35 AM V22 Wound Nurse performed hand hygiene and applied gown and gloves prior to entering R30's room to administer R30's surgical wound treatment. V22 removed the surgical wound dressing and did not remove V22's gloves. V22 handled R30's personal cellular phone to obtain a picture of R30's wound, per R30's request and then cleaned R30's wound while wearing the same gloves. V22 changed gloves, performed hand hygiene, applied a petroleum gauze directly to R30's wound, applied foam and attached the wound vacuum. On 3/3/25 at 10:58 AM V22 stated the floor nurses should be assessing the wound each time the dressing is changed and recording weekly as a skin assessment under the assessments section of R30's electronic medical record (EMR). V22 reviewed R30's EMR and skin assessments 2/19/25 and 2/26/25. V22 confirmed R52's EMR does not contain weekly assessments and/or measurements of R52's wound between 2/1/25 and 3/3/25. V22 stated V22 applied the petroleum dressing because R30 had requested it for comfort. V22 confirmed R30's wound care orders do not include the use of petroleum gauze. On 3/6/25 at 9:26 AM V22 stated gloves should be changed during wound treatments after removing the old dressing, after cleaning the wound, and when the treatment is finished. V22 confirmed V22 did not change gloves and perform hand hygiene after removing R30's wound dressing and handling R30's phone, prior to cleaning R30's wound. On 3/03/25 at 1:44 PM V18 Nurse Practitioner stated surgical wounds should be assessed regularly and treatments should be initiated when wounds are identified, if this is not implemented it could lead to sepsis. V18 stated R30 should have been evaluated by a wound provider or surgeon (V41) when R30's wound reopened. On 3/04/25 at 1:25 PM V41 confirmed V41's office was not notified of R30's surgical wound reopening until 1/7/25. V41 stated the facility should have absolutely notified V41's office when the draining wound was first identified so that R30 could have been evaluated in V41's office sooner. V41 stated R30 could have had an internal infection brewing over the prior two weeks that finally blew open and may have required incision and drainage regardless. The facility's Wound Treatment Management Policy dated 2/1/25 documents notify the physician to obtain treatment orders when wounds are identified, treatments are documented on the TAR, follow physician's orders when administering wound care, and monitor the progression of the wound through regular assessments. The facility's Dressing Change Clean policy dated 8/23/24 documents remove gloves after removing the dressing, perform hand hygiene and apply clean gloves prior to cleansing the wound. 50322 3.) On 3/5/25 at 10:50 AM, R41 was lying in bed and appeared alert. R41 stated she has suffered from constipation for months since coming to the facility. R41 stated they now have her on a stool softener, and she feels she is having more regular bowel movements, but prior to her hospitalization in January of this year she couldn't even recall how long it would be between bowel movements. R41 stated it was long enough that using the bed pan was very painful but that is what is offered. R41 stated prior to hospitalization in January, she had days of horrible chest and stomach pain that wouldn't subside and finally her niece had to tell facility staff to send her to the hospital. R41 stated she had an infection at that time as well and remembers having to have multiple tests done. R41's minimum data sheet (MDS) dated [DATE] documents R41 is cognitively intact. R41's care plan with print date of 3/5/25 documents a plan of care for constipation related to decreased mobility and use/side effects of medication (tramadol) with an initiation date of 1/16/25. R41's Physician Visit Notes dated 12/17/24 document constipation as an active diagnosis. R41's bowel and bladder elimination document dated December 2024 documents R41 had no bowel movements for the following dates: 12/1, 12/2, 12/3-12/7, 12/9, 12/11, 12/13-12/17, 12/20, 12/22, 12/25-12/26, and 12/28-12/29/24 and documents no response for 12/8, 12/18 and 12/23/24. R41's bowel and bladder elimination document dated January 2025 documents R41 had no bowel movements for the following dates: 1/1-1/3, 1/5-1/8, 1/11-1/13, 1/21-1/24, 1/26-1/27 and 1/29/25 and documents no response for the dates of 1/4, 1/10 and 1/18/25. The document documents from 1/13-1/16/25 R41 was out of the facility. R41's bowel and bladder elimination document dated 2/3/25 through 3/5/25 documents no bowel movement for the following dates: 2/8, 2/9, 2/10, 2/12, 2/13, 2/16-2/19, 2/24-2/26, 3/1, 3/2, and 3/5 and documents no response for the dates of 2/14, 2/27, 2/28, and 3/4/25. R41's December 2024 Medication Administration Record (MAR) documents no orders or medications administered for constipation management and that R41 received Tramadol twice daily and as needed. R41's January 2025 MAR documents R41 received Tramadol 50mg by mouth twice daily and as needed and documents no orders or medications administered for constipation management until 1/17/24 when Colace 100mg by mouth twice daily was started. R41's progress notes dated 1/12/25 at 10:09 PM document R41 complained of chest heaviness and the medical provider ordered to send R41 to the emergency room if R41 continued to complain of chest pain. At 11:22 PM on 1/12/25 progress notes document R41 complained of chest heaviness at a rate of 5/10 but documents R41 declined to go to the hospital. On 1/13/25 at 5:37 PM progress notes document R41 complained of pain radiating down the right thigh, lower back, and chest. The Progress Notes document R41's power of attorney (POA) requested R41 be sent to the hospital. At 6:01 PM on 1/13/25, notes document R41 was sent to the local emergency department. On 1/14/25 at 5:44 am, nursing notes document R41 was admitted to the hospital for pyelonephritis and fecal impaction. R41 hospital records dated 1/14/25 document admission diagnoses of pyelonephritis and fecal impaction. Hospital Records document an admitted [DATE] with complaints of left flank pain radiating into R41's abdomen and chest, as well as left leg pain that shoots up her side and into her arm for the last couple days, but that pain was increased and constant on this date. Computed Tomography of the abdomen documents large amounts of stool noted in the colon with distension and probable fecal impaction. On 3/5/25 at 11:30 AM, V17, Pharmacist, stated there are no recommendations or orders for bowel protocol medications prior to 1/13/25 (hospital admission) for R41. On 3/5/25 at 1:50 PM, V18, Nurse Practitioner stated the facility has bowel standing orders for Colace and MiraLAX for constipation to give and increase as needed. V18 stated R41 should be assisted to the toilet and not using bed pan for elimination.

Based on interview and record review the facility failed to identify significant weight loss, notify a physician or registered dietician regarding significant weight loss or implement interventions to prevent further weight loss for one of five residents (R45) reviewed for Nutrition on the sample list of 48. This failure resulted in continued weight loss even after a severe weight loss was identified. Findings Include: The facility's Weight Monitoring policy dated 2/10/25 documents Based on the resident's comprehensive assessment; the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. Newly recorded resident weights should be compared to the previous recorded weight. A significant change in weight is defined as 5% change in weight in one month, 7.5% change in weight in three months, 10% change in weight in six months. The physician should be informed of a significant change in weight and may order nutritional interventions. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions and any actions should be recorded in the nutrition progress notes. Specific interventions should be noted on the care plan and any new orders should be administered as directed. R45's Medical Diagnoses List dated March 2025 documents R45 is diagnosed with Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Anemia, Protein Calorie Malnutrition, Vitamin D Deficiency, History of other Endocrine, Nutritional and Metabolic Disease, and Hypokalemia. R45's Physician Order Sheet (POS) dated March 2025 documents an order for a regular diet and monthly weights. R45's Care Plan dated 10/14/24 documents R45 has had a significant weight loss and staff should monitor R45's weight for any further loss and notify the medical doctor and registered dietician. The registered dietician needs to evaluate and make recommendations as needed. The same care plan dated 5/22/24 documents R45 requires assistance with eating including supervision by staff, finger foods when having difficulty with utensils, and milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food; or provide nutritious foods that can be taken from a cup or a mug where appropriate. R45's Weight Log documents R45 weighed 158.4 pounds on 7/5/24 and six months later, on 1/7/25 R45 weighed 137.4 pounds. This is a -13.26% weight loss in six months' time. R45 continued to lose weight and in February 2025 her weight was 135.8 pounds. R45's Nutrition/Dietary Note dated 1/14/25 documents R45's current weight as 137 pounds. This is noted to be a significant weight loss. The note documents R45's physician (V35) would be notified and staff would request extra calories with meals. (This notification was not documented/completed and no new interventions were implemented). R45's Mini Nutrition assessment dated [DATE] documents R45's weight loss is greater 6.6 pounds in the last 3 months. R45's Mini Nutrition Score is 8 which puts her in the at risk of malnutrition category. On 3/6/25 at 1:00 PM V36 Certified Nurses Assistant reported R45's March weight was 134.2 pounds. On 3/05/25 at 1:00 PM V20 Registered Dietician confirmed R45 had significant weight loss from July to January 2025 and V20 was not notified and did not have the opportunity to implement any interventions to prevent further weight loss. V20 confirmed she could have added more calories or implemented other interventions had she been notified but she was not and has not assessed R45 since October of 2024. V20 confirmed R45 could be at risk nutritionally due to her diagnoses and staff should be monitoring monthly weights closely and making proper notifications. On 3/5/25 at 1:45 PM V18 Nurse Practitioner stated he was never notified of R45's weight loss and did not have the opportunity to put any interventions in place to prevent further weight loss. V18 stated staff should be monitoring resident's weights on a regular basis. V18 confirmed if new interventions would have been implemented it could have prevented further weight loss. On 3/5/25 at 3:00 PM V2 Interim Regional Director of Nurses confirmed staff need to be monitoring resident's weights and if there is a consistent unplanned weight loss or significant weight loss the physician should be notified and the registered dietician should be consulted. V2 confirmed there is no documentation in R45's record that V35 physician or V20 dietician were notified of R45's consistent unplanned or significant weight loss and no new interventions were put into place. R45 continued to lose weight over the next two months.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal and mental/emotional abuse by staff members for two (R345, R195) of 32 residents reviewed for abuse on the sample list of 48 residents. This failure resulted in fear, emotional harm and mental anguish for both R345 and R195. Findings Include: 1. R345's care plan dated 2/11/25 documents R345 has medical diagnoses of COPD (Chronic Obstructive Pulmonary Disease), Asthma, History of Chronic Respiratory Failure, History of Fracture to the the Right Femur, Arthritis to right hand, Depression, Diabetes Mellitus, Anemia, Pneumonia, and Hypertension. R345's minimum data assessment dated [DATE] documents that R345 is cognitively intact and has no signs and symptoms of delirium. On 3/2/25 at 10:23 AM, R345 was sitting in his wheelchair in his room. When asked how R345 is treated in the facility R345 put his hands together and quietly stated, I am afraid of retaliation if I tell you. R345 then stated a couple weekends ago (2/22/24 and 2/23/24) he asked for a pain pill and nobody came so he called his daughter (V25) to tell her so that she could get someone to bring him a pain pill. R345 stated a few minutes later V26 (Licensed Practical Nurse) came into his room and was mad and yelled at him that she has 30 other residents to take care of and V26 can't jump every time R345 calls. R345 stated then V26 stated she didn't appreciate being reported two days in a row. R345 began to cry and stated V26 scared R345 and he was afraid of what V26 might do. On 3/3/25 at 10:44 AM, V25 stated R345 had called her upset that the nurse had not brought his pain pill. V25 stated she called the facility and talked to V26. V25 stated a little bit later R345 called and was crying and stated that V26 came into his room yelling at him and stated V26 doesn't like to be reported and has too many people to take care of. On 3/06/25 at 9:23 AM, V1 (Administrator) stated that R345 is alert and orientated, makes his own decisions, and, If he said it happened, it happened. V1 stated V1 would consider V26 yelling at R345 as verbal abuse. 35380 2. R195's undated Diagnoses List, documents R195's diagnoses as: Cerebral Infarction due to unspecified occlusion or stenosis of Left Posterior Cerebral Artery, Metabolic Encephalopathy, Rhabdomyolysis, and Hemiplegia, unspecified affecting left nondominant side. R195's Care Plan dated 2/6/25, documents R195 requires substantial/maximum assist by one staff member to eat. R195's Minimum Data Set (MDS) dated [DATE], documents R195 has an impairment on one side of both the upper and lower extremities. On 3/2/25 at 8:57 AM, R195 stated during night shift, unknown CNA told R195 he uses his call light too much and took it away from him so he couldn't get any help. R195 stated the staff laugh at him at night and are rough with him when they transfer and roll him. R195 was visibly upset when speaking about this and stated the interaction made him very distraught as he was not able to get the help he needed without his call light. R195 stated it was hurtful when staff laughed at him and were rough. On 3/5/25 at 10:30 AM, V2 Interim Director of Nursing (DON) confirmed R195 is at risk for abuse due to him needing assistance with Activities of Daily Living (ADL's) and because of his diagnoses. V2 confirmed staff should never take away a resident's call light or make them feel badly for using it to call for assistance. V2 confirmed staff should treat residents with respect and never be rough or laugh at them. The facility's Abuse, Neglect and Exploitation Policy dated Revised 2/11/25, documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse. Mental Abuse includes humiliation, harassment, and deprivation and it is the policy of the facility to provide protection for the health, welfare and rights of each resident.

Based on observation, interview, and record review the facility failed to implement resident centered interventions to prevent skin breakdown and worsening of pressure sores and failed to notify the wound physician and dietician of new open areas for one resident (R2) of three residents reviewed for pressure ulcers in a sample list of five residents. These failures resulted in R2 developing a stage four pressure area to R2's right ischium and unstageable pressure areas to R2's bilateral heels. The Immediate Jeopardy began on 1/20/25 when the original open area was observed to R2's Right Gluteal Fold and the wound nurse practitioner was not notified. V1 Administrator was notified of the Immediate Jeopardy on 2/20/25 at 4:00PM. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 2/21/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and wound care audits. Findings Include: The facility's policy Pressure Injury Prevention and Management reviewed 2/6/24 states The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document findings in the medical record. The attending physician will be notified of the presence of a new pressure injury upon identification, the progression towards healing or lack of healing, of any pressure injuries weekly. Any complications (such as infection, development of a sinus tract etc.) as needed. The facility's policy Incontinence reviewed 12/19/24 states: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services to ensure resident is maintained at highest functioning level related to continence of bowel and bladder and to assist in maintaining that level. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Appropriate skin care will be maintained for those residents that are incontinent. On 2/19/25 at 3:35PM R2's Ischium/Coccyx wound measured approximately four inches in diameter and three inches deep with malodorous yellow drainage. Muscle and bone were visible. Both heels had leathery black eschar approximately 2.5 inches in diameter. R2's Admission Progress Note dated 12/18/24 at 3:00PM documents Skin is intact; old bruising from fall that caused hospital admission. R2's Physician's Order Summary printed 2/6/25 includes the following diagnoses: Obesity, History of Cerebral Infarction, Muscle Weakness, Generalized Anxiety Disorder, Major Depression, Paralytic Gait, and Reduced Mobility. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact, wheelchair dependent, dependent for transfer and toileting, and requires substantial/maximal assistance of staff for rolling in bed. This MDS also documents R2 is frequently incontinent of urine and bowel. R2's standardized skin evaluation (Braden Scale) dated 12/30/24 at 1:15PM documents Braden Evaluation: Moisture: Occasionally moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Adequate. Friction and shear: Potential problem. R2's progress note dated 1/20/2025 at 2:58AM documents CNA stated that she had found an open area on right buttock while changing resident and performing care to get ready for bedtime. Writer cleansed area with wound cleanser and applied (Medical Grade) honey and covered with border gauze. There is no documentation a physician or family was notified. There is no wound assessment documented until 1/23/25. The facility's Wound Weekly Observation Tool dated 1/23/25 identifies this wound as number four. This wound assessment documents the wound measures 1.3 x 0.6 x 0.1 cm (centimeters). The section of the assessment concerning peri wound appearance is left blank on this assessment. The January Treatment Administration Record (TAR) for January 2025 documents a treatment order change dated 1/24/25. The treatment orders: Cleanse right gluteal fold with wound cleanser. Pat dry. Apply (Medical Grade) honey then hydrocolloid every three days. The next documented Wound weekly observation tool is dated 2/5/25. In this document the wound is renamed Right Ischium and measures 3.8 x 4.5 x 0 cm. This evaluation does not identify the wound as pressure wound and no stage is identified. R2's Wound Evaluation and Management Summary dated 2/5/25 by V8 Wound Nurse Practitioner documents a Stage IV pressure wound of greater than 10 days duration to R2's right ischium measuring 3.0 cm length by 3.6 cm width by 0.6 cm depth. This evaluation recommends a low air loss mattress. R2's Wound Evaluation and Management Summary dated 2/19/25 by V8 Nurse Practitioner documents the Stage IV Pressure Ulcer to R2's right ischium now measures 8.0 x 5.0 x 4.5 cm. R2's progress note dated 1/9/25 at 9:27PM documents (R2) has blood blisters to both heels. Left heel wound measurement 1.2 cm X 1.5 cm. Right heel wound measurements 1.2 cm x 1.0. On 1/9/25 a physician's order was initiated per R2's January Treatment Administration Record (TAR) to Cleanse wounds with Normal Saline pat dry. Applied betadine to wound. Abdominal pad and wrapped with (rolled gauze) to both feet. Wound nurse notified of heels. No treatment is documented on R2's Medication Administration Record (MAR) until 1/11/25. Treatment is ordered daily. R2's MAR does not document treatment as completed as ordered 1/13/25, 1/24/25, or 1/28/25. R2's Initial Wound Evaluation and Management Summary dated 1/22/25 by V8 Nurse Practitioner documents an unstageable deep tissue pressure injury of greater than 14 days duration measuring 0.9 cm length by 2.2 cm width on R2's right heel and an unstageable deep tissue pressure injury of greater than 13 days duration measuring 3.8 cm length by 4.4 cm width on R2's left heel. There is no documentation to address R2's open area on the right gluteal fold. This evaluation recommends pressure relieving boots. R2's Wound Evaluation and Management Summary dated 1/29/25 by V8 Nurse Practitioner documents an unstageable deep tissue pressure injury of greater than 21 days duration on R2's right heel and an unstageable deep tissue pressure injury of greater than 20 days duration measuring 3.8 cm length by 4.5 cm width on R2's left heel. This evaluation recommends pressure relieving boots. R2's Wound Evaluation and Management Summary dated 2/5/25 by V8 Nurse Practitioner documents an unstageable deep tissue pressure injury of greater than 28 days duration measuring 2.8 cm length by 2.5 cm width on R2's right heel and an unstageable deep tissue pressure injury of greater than 27 days duration measuring 3.8 cm length by 4.5 cm width on R2's left heel. R2's Wound Evaluation and Management Summary dated 2/19/25 by V8 Nurse Practitioner documents the Stage IV Pressure Ulcer to R2's right ischium now measures 8.0 x 5.0 x 4.5 cm. On 2/6/25 at 10:50AM R2 was seated in the therapy room in a bariatric wheelchair. At 11:30AM R2 was at the lunch table eating in the wheelchair. At 1:30PM R2 was sitting in R2's room in the wheelchair. R2 stated I put on my call light and very often the aides come in and turn off the call light and then don't return to help me. I have bed sores and they don't change my (adult diaper). I (urinated) this morning in therapy and I have sat up in this chair since about 9:00AM without being changed. I'm afraid to complain because it might get worse. The wound doctor was pretty upset yesterday. I have these bed sores on my feet and the doctor has been seeing me for those, but I have one on my butt too and they didn't tell the doctor about that until yesterday. There were no pressure relieving boots in place during the above observations. R2 does not have a pressure relieving mattress in place to her bed. R2 stated the doctor said I should have a special mattress, but I haven't got one. On 2/6/25 at 2:00PM V2, Director of Nursing stated V2 is the person responsible for wound care. V2 verified the wound Nurse Practitioner has recommended a low air loss mattress for (R2), and that the mattress was ordered. V2 did not offer an explanation as to why the pressure relieving boots were not in place. V2 verified that R2 should be checked and changed at least every two hours and as needed or when requested and that staff should never turn off a call light and fail to return. The facility Resident Council Meeting Minutes dated 1/27/25 document complaints of call lights taking 30 minutes or longer to be answered. Residents voiced that the staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident's need. On 2/6/25 at 3:39PM V8 wound care Nurse Practitioner verified it would have been V8's expectation that incontinence care should be completed every two hours and as needed and moisture is a contributing factor in (R2's) facility acquired pressure injuries and interferes with heeling. V8 stated (R2) is right I was very concerned the facility did not report the area on (R2's) ischium until it was a Stage IV (pressure sore). Pressure caused the skin breakdowns and moisture contributed to the worsening. V8 further stated I think the facility should provide training for the nurses and the DON in wound care. Also offloading (weight) off the wound is critical. V8 verified the pressure ulcers R2 is experiencing were avoidable. V8 also stated maybe that area on (R2's) ischium did start out as a moisture associated skin deterioration, but by the time I saw it was definitely a Stage IV pressure ulcer. R2's Wound Evaluation and Management Summary dated 2/12/25 documents Unstageable Pressure wound to right heel 2.8 x 2.6 cm, Unstageable Pressure wound to left heel 3.9 x 4.0 cm, Stage IV Pressure Ulcer to right Ischium 7.0 x 5.0 x 3.0 cm. On 2/19/25 at 9:30AM R2 was not wearing boots as recommended by Wound Nurse Practitioner. R2 stated the boots were in her drawer. R2, who is cognitively intact per most recent MDS, stated she had become incontinent of bowel while standing in therapy at around 4:00PM yesterday. R2 stated Therapy Staff brought R2 back to her room and put on the call light. R2 states a CNA came to R2's room and turned off the call light but did not clean R2. R2 stated R2 put the call light back on at 4:30 PM and the same CNA came in and turned off the call light and stated they were busy and would clean R2 up as soon as they could. R2 stated it was 7:00PM by the time R2 was cleaned up. On 2/19/25 at 9:10AM V12 CNA stated she was familiar with the care needed for R2 as V12 takes care of (R2) most days. V12 stated V12 was not aware R2 needs to wear the boots. V12 also stated I believe what (R2) says is accurate. On 2/19/25 at 9:10AM V13, LPN verified R2 told V13 this morning (R2) was left without being cleaned yesterday from 3PM to 7PM, V13 stated I don't know why (R2) would say that if it didn't happen. On 2/19/25 at 12:30PM V18 Dietary Manager verified R2 had not been seen by the dietitian for (R2's) Pressure ulcers. On 2/19/25 at 12:40PM V14, Corporate RN verified that it is the facility's expectation that all residents with new skin concerns be evaluated immediately by the dietitian. On 2/19/25 at 3:35 PM V8, Wound Care NP stated if I had been aware of the wound on R2's Ischium sooner I could have made recommendations and evaluated and treated before the wound became so extensive. R2's ischium/Coccyx wound measured approximately four inches in diameter and three inches deep with malodorous yellow drainage muscle and bone were visible. Both heels had leathery black eschar approximately 2.5 inches in diameter. The Immediate Jeopardy that began on 1/20/25 was removed on 2/21/25 when the facility took the following actions to remove the immediacy. 1. On 2/19/25 R2's wounds were assessed and treated by wound care consultant staff. 2. On 2/20/25 R2 was educated on benefits of preventative measures and current treatment regimen. 3. On 2/19/25 a facility-wide skin audit was conducted by V2 DON/Designees with completion on 2/21/25. 4. On 2/20/25 facility-wide risk for skin breakdown assessments were initiated by V2DON/Designees with completion on 2/21/25. 5. On 2/21/25 an audit was conducted by V2 DON/RNC to ensure completion of risk for skin breakdown assessments and weekly/daily skin checks. 6. On 2/19/25 In-servicing was initiated by V2 DON/Designee for all Licensed Nurses on Pressure Injury Prevention and weekly skin checks. Completed on 2/19/25. V2 DON/Designee will be responsible for ensuring compliance of the program. 7. On 2/19/25 In-servicing was initiated by V2 DON/Designee of all Licensed Nurses and CNAs on incontinence care and call light response. Completed on 2/19/25. 8. V2 verified V2DON/designee will review four residents skin checks weekly for four weeks and then four residents skin checks bi-weekly for four weeks to ensure that all skin issues have been identified and properly treated. 9. V1 verified V1 Administrator/Designee will monitor call light response time four times a week for four weeks and then randomly thereafter. 10. V2 verified V2 DON/Designee will in-service Licensed nursing staff and CNAs on call light response time, incontinence care, skin checks, and pressure injury prevention policy once a month for 3 months. 11. V2 verified V2 DON/Designee will be responsible for monitoring/tracking/processing of MD orders. 12. CNAs were in-serviced by DON/RNC/ADMINISTRATOR on reporting skin concerns to nurses with skin report sheet. Completed on 2/19/25. 13. The Facility is not utilizing agency staff at this time, but if the facility in the future utilizes agency staff DON/Designee will ensure in-serving on all processes prior to start date. 14. V2 verified V2 DON/Designee will be responsible for notification of Registered Dietitian and processing the recommendations. The facility presented an abatement plan to remove the immediacy on 2/21/25. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 2/24/25, and the survey team accepted the abatement plan on 2/24/25.

Based on observation, interview and record review the facility failed to recognize/remove an accident hazard to prevent a residents injury and investigate a potential root cause for a residents acute fracture. These failures affect two (R1, R3) of 3 residents reviewed for accidents in a sample list of four. R1 sustained a laceration to R1's leg requiring 21 sutures to close. Findings include: 1. R1's Care Plan reviewed 11/2/23 includes the following diagnoses:Heart Disease, Dysphasia, Depression, Lung Cancer, Polyneuropathy, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is Severely Cognitively Impaired and requires maximum assistance by staff for transfer. R1's Progress Note dated 1/12/24 at 8:19 PM by V4, Registered Nurse (RN) documents Description of condition change: (V5, Certified Nurse's Aide) (CNA) called (V4) to (R1's) room at 7:55 PM, as V5 saw blood coming from (R1's) right leg while transferring from (R1's) wheelchair to bed. Upon assessment noted (R1) has a large skin tear on (R1's) right lower lateral leg and it was bleeding heavily. Noted blood on the frame, as per (V5). (R1) did not make any complaints of pain or discomfort when (R1) was being assisted to bed. (V5) noticed the blood on the floor and called the writer to the room (R1) was laying in bed, with legs on the floor, assisted R1's legs to bed. (V4) applied abdominal pad to stop the bleeding and applied large towel for pressure, elevated the leg. (R1) was just laying in bed alert, answering appropriately, not moaning or making any complaints of pain. Called Power of Attorney (POA) at 8:05 PM and updated about the condition and (POA) requested resident to be sent out to (hospital). Called 911 and (R1) was transferred out at 8:15 PM. R1's Progress Note dated 1/13/24 at 1:17AM documents (R1) returned from (hospital) at 12:55 AM via ambulance on stretcher in alert and awake condition without any paper work. As per hospital's nurse verbal report resident had 21 stitches on (R1's) right lower leg laceration and dressing secured with (stretch gauze wrap). On 1/29/24 at 10:31 AM, V4, RN stated On the evening of 1/12/24 V5, CNA came running up to me telling me (R1) was bleeding from (R1's) leg. I went in and (R1) had a large deep laceration on (R1's) right leg. I cleaned it off and put an abdominal Pad in place with pressure to stop the bleeding. We called 911 right away and sent (R1) to the hospital. (R1) came back with 21 sutures. On 1/29/24 at 10:33 AM, V5 stated On 1/12/24 when (R1) got cut, I transferred (R1) first from the recliner to the wheelchair and wheeled (R1) to the bed. I put the wheelchair brakes on and pivoted (R1) to the bed. When I was removing (R1's) pants I noticed (R1's) leg was bleeding a lot. I put (R1) in the bed and went to get the nurse right away. The nurse (V4) cleaned (R1) up and we put pressure on the cut until the paramedics came. On 1/29/24 at 2:00 PM (R1) was resting in her recliner with her feet up. (R1) stated I remember cutting my leg on the bed and going to the hospital. It was a mess. Of course, it hurt very bad and it's still sore. There was a sharp thing on the bed, and it was not a little accident. It was awful. (R1) raised her blanket and her pant leg and pointed to a stretch gauze wrap on her right lower leg. On 1/29/24 at 9:55 AM, V3 Maintenance Director stated When I inspected the bed (R1) was in after (R1) cut herself on 1/12/24, at some point in the past the bed rail was removed leaving a sharp bracket on the bed. It was sharp and it stuck out. That should have been removed too but it wasn't. There were dark stains on the bracket which looked to me like blood, so we decided that caused the cut to (R1). I removed the bracket and inspected all the other beds to make sure there was nothing like that. While the facility provided a policy to address Incidents and accidents, the policy did not include any procedure or intervention in place to identify and reduce environmental accident hazards. 2. R3's Care Plan reviewed 12/6/23 documents the following diagnoses: History of Falls, Anxiety, Type II Diabetes, Morbid Obesity, Neuropathy, Chronic Kidney Disease Stage III, Chronic Ulcers of the Buttocks. R3's Minimum Data Set, dated dated dated [DATE] documents R3 is cognitively intact Requires staff assistance for transfer and uses a wheelchair for mobility. R3's Incident report dated 11/17/23 at 3:57 PM, documents (R3) was seen by the Wound Medical Doctor on 11/16/23 due to wound to rule out osteomylitis. X-ray was done on 11/17/23. Type of injury: Acute fracture to lateral malleolus. Medical Doctor and Power of Attorney Notified New order for (R3) to be nonweight bearing on left leg, Orthopedic referral and Tramadol 50 milligrams every six hours as needed. On 1/29/24 at 1:55 PM, R3 stated They found out I had a broken ankle in November when they did an Xray for my sore to see if I had Osteomyelitis. I had some pain, but I thought it was the sore hurting. I honestly couldn't tell you how it happened. I'm a big man and when they move me it sometimes they get a little rough but I never though I had a broken bone. I can't really say I have ever been mistreated. I suppose I could have caught it between the mattress and the footboard. I slip down in bed, but I don't know. 1/29/24 at 2:15 PM, V1 Administrator stated V2, Director of Nurse's (DON) is responsible for incident investigations. On 1/29/24 at 2:30 PM V2, Director of Nurse's (DON) stated I never thought of R3's fracture being possible abuse. I can see there is no documentation to support we identified a root cause for the fracture. I did not interview staff or other residents. I also did not interview (R3) and directly ask if he had ever been treated roughly. We never did figure out what caused the fracture.

Based on observation, interview and record review the facility failed to utilize safe handling device (gait belt) during an unsteady pivot transfer for one (R1) of five residents on the total sample list of nine. This failure resulted in R1 being lowered to the floor by staff while R1 continued to hold onto a wheeled walker injuring R1's shoulder, R1 sustained a clavicular fracture. Findings include: R1's medical record documents on 3/12/2023 at 11:30 AM, Fall Progress Note: called to resident room because physical therapy had to lower resident to the floor. Physical therapy stated while walking resident resident hit her leg on the bottom piece of wheelchair, and resident got weak and had to be lowered to the floor. While lowering resident to the floor resident would not let go of walker. Upon assessment resident complained of pain on right shoulder. Change in condition: Signs & Symptoms: Resident was lowered to the floor and has laceration on lower right leg and pain in left shoulder. R1's Physical Therapy Treatment Encounter notes document on 3/12/23 by V3 Physical Therapist, Patient tolerated most therapy exercises/balance/gait activities with contact guard assist and stand by assist. At around 11:45 AM as patient was performing a stand pivot transfer with contact guard assist, patients right leg was slightly caught in leg rest/wheel joint area and patient was controlled lowered onto PT thigh, R1 was then controlled lowered into long sitting position in a controlled fashion, R1 had a hold of the front wheeled walker during this process and complained of left shoulder pain after she was resting in long sitting. R1's medical record documents on 3/12/2023 at 4:00 PM, returned from hospital and has stitches in lower right leg that need removed in 7 days and sling on left arm. Resident has fracture to left collar bone. R1's emergency room records dated 3/12/23 documents, Chief complaint: complaints of left shoulder and right ankle pain after falling while working the physical therapy, states she lost her footing with her walker, wound on right leg. Radiology findings: Left Shoulder: mildly displaced midclavicular fracture is present. A 6 centimeter laceration on right lower leg, Skin closure: 13 sutures. On 3/22/23 at 2:30 PM R1 was laying in bed with sling to R1's left arm. R1 stated, I was in this room doing leg routines (exercises) with the therapist, he had me stand up, he did not have one of those belts on me, I took a few steps, I could tell my feet were not very sturdy, he said something about going back to bed, I turned slowly to sit back down and my legs gave out, I kept telling him I falling, im falling he said no you are not, I could tell he didn't have a hold of me very well and I knew he didn't have one of those belts on me and I am a bigger lady, he got me down on the floor, my shoulder was killing me and I saw the blood all over the floor then, I didn't know what I had done to my leg, it must have got caught on something. It all happened so quickly. R1 had steri strips and a bordered dressing to the right shin area. On 3/23/23 at 10:45 AM V3 Physical Therapist stated, I had worked with (R1) about 4 weeks prior, (R1) was looking to discharge to an assisted living, I went to (R1's) room, (R1) was a stand by assist, contact guard assist, (R1) was dressed and up in her wheelchair, we started with seated exercises, (R1) completed all of those, then we did standing exercises, (R1) was a stand by assist for a pivot transfer, she did fine, I did not put a gait belt on (R1). We started to ambulate with wheelchair close to follow, we were all done I asked (R1) if (R1) wanted to lay down or sit in the wheelchair and (R1) said sit in the wheelchair, during the pivot transfer (R1's) leg grazed the front right wheel on the wheelchair, (R1) said ouch my leg is caught and lunged forward towards cross bar on walker, I grabbed on to (R1) and kept telling (R1) I was going to lower (R1) to the floor, (R1) was panicking and kept yelling, I had (R1) in a half squat position seated on my thigh and (R1) looked at her leg gash and kept saying let me down, let me down. I told (R1) I would let (R1) slide down my leg onto the floor, so we did a slow slide into a seated position, (R1) kept ahold of the walker and didn't let go, when (R1) got sat down on the floor (R1) complained of shoulder pain, I removed (R1's) hands off the walker. The Facility's investigation report documents, On 3/12/23 (R1) hit her right lower leg on the wheelchair pedal while walking with therapy and was lowered to the floor after she got weak. (R1) noted to have laceration on right lower leg and complaints of left shoulder pain. Obtained order and sent to emergency room . Summary of investigation: (R1) was working with therapy in her room, During a pivot transfer (R1) caught her distal right lower leg on the foot pedal connected on the wheelchair. Resident loudly stated, my leg, my leg, (R1) then leaned forward and looked down and saw blood panicked and started to go to a sitting position while still holding on to the walker. (R1) was positioned lateral to the wheelchair, therapist was positioned behind her with his hands at her hips and he used his leg for support as resident continued to repeat I want down, therapist assured resident that he was able to support her while she was lowered to his thigh. (R1) continued to stated let me down therapist then lowered resident to a long sitting position, during this time (R1) was still holding on to the walker and her arms were still in a hyper flexed position. Therapist removed residents hand from walker and called for help. (R1) transferred to emergency room . Disposition: Interventions- therapy staff to be in-serviced on gait belt use. Returned form emergency room with appointment with orthopedic physician, a sling to her left arm and 13 sutures on right lower leg. Type of injuries: Fracture of the left collar bone, Right lower leg laceration. On 3/23/23 at 2:20 PM V2 Director of Nursing stated, (R1) was in her room with the therapist (V3). They were doing a pivot transfer, (R1) caught her leg on something on the wheelchair, (R1) started screaming my leg, my leg, saw blood and panicked, and (V3) lowered onto his thigh and (R1) continued to yell out and hold onto the walker, and (V3) lowered (R1) down his shin onto the floor, during the entire lowering (R1) kept ahold of the walker and did not let go, (V3) had to remove (R1's) hands from the walker, (V3) had kept ahold of (R1) on her side/hip area. During my investigation I determined there is an area on the wheelchair where the foot pedals sit on top of that R1 may have hit her leg, so the intervention is to keep the foot pedals on the wheelchair at all times, during transfers they can be swung out. (V3) was not using a gait belt, I think (V3) would have had better control of (R1) if a gait belt would have been used, (R1) is a larger lady. V2 confirmed, (R1) panicked and would not let go of the walker, and a gait belt would have made (R1) feel more secure. The facility's policy, with a revision date of 12/15/22, titled Safe Resident Handling/Transfers documents, It it the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize the risks for injury and provide and promote safe, secure and comfortable experiences for the resident while keeping the employees safe in accordance with current standards and guidelines. 5- handling aides may include gait belts, transfer boards, inflatable [NAME] lift assists, transfer bars or any additional mounted equipment like grab bars. 13- staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action.

These Failures require more than one deficient practice statement. A. Based on interview and record review the facility failed to provide properly functioning anchorage equipment in a facility transportation vehicle and failed to properly secure a residents wheelchair in a transportation vehicle, resulting in R2's wheelchair tipping over backwards during transportation, causing R2 to strike head, resulting in an emergency room visit due to a posterior head laceration requiring 5 staples. (R2) was one of three residents reviewed for accidents on the total sample list of eight. B. Based on observation, interview and record review the facility failed to implement fall prevention measures and failed to thoroughly investigate whether fall prevention measures were in place for two separate fall occurrences for one of three residents (R1) reviewed for accidents on the total sample list of eight. Findings include: The facility's policy, with a revision date of 12/6/22, titled Incidents and Accidents documents, Policy: It is the policy of this facility for staff to utilize PCC/Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident- refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Policy explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. a 1.) R2's progress notes document on 1/9/2023 at 8:40 AM, staff reported that patient had tipped backwards during transport patient bleeding from laceration in back of head, transported to Emergency Department. R2's post fall observation note dated 1/9/23 documents, Location of fall: outside of facility grounds, Detailed description of fall: fell backwards on facility van, Potential factors that could have contributed to fall: wheelchair security in van. R2's Fall IDT (interdisciplinary team) note documents, Time of fall: 9:25 AM, Date of fall: 1/9/2023. Location of fall & position found: Resident was laying on her back in her wheelchair on the floor of the van. Unwitnessed. Activity at time of fall: Resident was being transferred to (Physician) appointment. Description of injuries/pain: Resident had a laceration on the back of her head, was transferred to emergency room . Root Cause: when the driver turned, the wheelchair tipped causing resident and the wheel chair to tip over. Description of actions/interventions taken: Resident was assessed immediately after the event, was then taken to the emergency room for treatment. Intervention: driver to have safety awareness training while driving and to be re-educated on driving both facility vans. The facility's fall investigation report file documents, R2 was being transported back to facility from an appointment, wheelchair tipped backwards causing resident to fall backwards and hit her head on the floor of the van. Statement of witness form completed by V6 Transport Driver documents, Date 1-9-23, I unlocked the ramp and loaded resident as usual, locked both wheels and used all 4 straps to strap down wheelchair. We proceeded to head to towards (stop light), once the light turned green I proceeded to go that's when I heard (R2) holler, I turned into the closest parking lot to check (R2) out, (R2) told me she was okay but hit her head, she demanded me to take her to the emergency room . Statement of witness form signed by R2 documents, on 1-9-23 (V6) pushed me onto the van and buckled my wheelchair, took a couple turns and I felt my wheelchair falling in slow motion, I tried to grab onto something but their was nothing to hold on to. My chair fell backward I hit my head on the ramp thing I reached up to touch my head to block it and I felt my head was bleeding (V6) pulled over to check on me. I asked (V6) for something to put on my head, (V6) gave me some towels then (V6) called the hospital and (V6) took me there. R2's emergency room after visit summary documents Reason for visit: Fall, Diagnosis: Laceration to scalp. Emergency Department triage note, date of service: 1/9/23 at 8:58 AM, Patient here from (nursing home) by van when the wheelchair tipped over backwards, had to assist the chair back up. Patient has laceration to the back of head and is complaining of neck and mid upper back pain. C-Collar applied. Bleeding controlled to her head. R2's progress notes document on 1/9/2023 at 12:20 PM, return to facility 5 staples to laceration, order to keep area clean and dry. R2's Skin Observation Tool form dated 1/9/23 documents, Site: back of head, Type: Laceration, approximately 5 staples. On 1/11/23 at 11:20 AM, V6 (Transport Driver) stated, on 1/9/23 (R2) had an appointment at 8:45 AM, our facility van was in the shop so I was using the van from next door. It was the first time ever using that van, instead of loading chairs in from the rear of the van, you load them from the side. I got the ramp down, pushed (R2) onto the ramp, locked the wheels and secured the straps (tie-downs) to (R2's) wheelchair using four straps. I had (R2's) wheelchair facing the left side of the van and (R2's) back was to the right side of the van (sideways in the van). Two of the floor straps did have some give in them (the front left and back right), I tried to tighten them the best I could, I thought they felt secure. I had secured (R2's) chair by placing the two front floor anchor straps (tie-downs) through the back of the wheel spokes, one on each side and the rear anchor straps (tie downs) were secured to (R2's) cross bars on the rear of the wheelchair. The lap belt in that particular van was not working properly, so I did not have a lap belt on (R2). I left the facility parking lot and pulled up to the stop light, went to turn left and (R2's) wheelchair tipped backwards, (R2) had hit head on the loading ramp. I heard (R2) holler, I immediately pulled over, assessed (R2), (R2) requested to go the emergency room , I called the facility, left (R2) in that position, and took (R2) to emergency room , staff there helped get (R2) up. I took the van straight to V8 (transport driver) and asked what I did wrong because I could not figure it out, we looked at it and determined the straps were not tightening down (locking in place). On 1/11/23 at 1:30 PM, V8 (Transport Driver) stated the lap belt works in the van, the issue was (V6) had (R2) facing the wrong direction. V3 (maintenance) replaced the anchors in this van yesterday, they were old and sometimes the latching mechanism would not work properly, preventing the belt from locking, instead was sliding out. On 1/11/23 at 11:20 AM, V3 Maintenance stated, I was notified to the (floor anchors/tie down straps) were needing replaced in the transport van, I replaced the straps on 1/10/23. The straps I took off had no rips or tears, there were just dated. On 1/11/23 at 11:00 AM, V1 Administrator stated, On 1/9/23 (V6) Transport Driver was using the transport van from next door, (V6) wheeled (R2) into the van and buckled (R2's) wheelchair straps to the floor placing 4 straps across the rims of the wheelchair. (V6) pulled out of the facility parking lot to the stop light and went to turn, I believe left and when turned heard a noise and heard (R2) holler out, (V6) turned into the nearest parking lot and went back to assist (R2). (R2) was laying backwards wheelchair had tipped backwards, (R2) had hit head and wanted to stay in that position and requested to go to the emergency room . (R2) went to the emergency room , had laceration to head and received staples. Straps in that van needed replaced and education was given to (V6) to ensure equipment is functioning properly. (V6) had stated she had noticed the straps had some give to them when she fastened them and tried to tighten them up. The corporations undated Facility transport van safety checklist and rules, documents: 16. Secure wheelchair (front and back) with straps on floor of van: secure straps to back and front frame of wheelchair. 17. To tighten straps push red button at base of strap then hand tighten with know. 18. Attach lap belt to back ratchet strap, crossing strap across resident' slap, attach shoulder belt across residents shoulder/chest. 19. Check to ensure all straps are locked down on wheelchair tightly, seat lets are properly in place. Also double check the wheelchair brakes are locked and secured from movement. Q'Straint User instructions manual documents, A- Secure Wheelchair. 1- Place wheelchair facing forward in securement area, apply wheel locks or turn power off. 2. Attach tie downs into floor anchorages and ensure they are locked in. 3- Attach the four tie-down hooks to (wheelchair) solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown on figure 2 (between a 40 to 60 degree angle on the front wheelchair frame). Do not attach hooks to the wheels, plastic or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack. Inservice education report completed by V7 Transport driver instructor, dated 1/9/23 and documents Content: Safety Awareness while driving training, re-education on driving transportation vans was completed with V6 Transport Driver. b 1.) R1's medical record documents an admitted [DATE]. R1's admission diagnosis include: History of falls. R1's care plan, with a start date of 10/18/22, documents, Focus: I am at risk for falling related to generalized weakness, poor standing balance, history stroke with left side weakness, asthma, history of falls, anemia, peripheral vascular disease, start date: 10/18/22. Interventions: (1/2/23-fall) Scoop mattress, (12/19/22 - fall) Body Pillow, (12/30/22-fall) mattresses on floor, (12/7/2022 fall)- Staff to increase room checks and to ensure toileting needs are met. Assure I am wearing my eyeglasses daily. Assure they are clean and in good repair (10/18/22). Keep call light within reach at all times (10/18/22). Keep personal items and frequently used items within reach (10/18/22). R1's progress notes document on 12/19/2022 at 6:10 AM, resident observed lying on floor next to bed on right side. R1's Fall IDT (interdisciplinary team) note documents, unwitnessed fall, Root cause: resident has a twin bed and while (R1) sleeps, (R1) rolls to the side and this time when (R1) rolled, (R1) fell on to the mats next to (R1's) bed. Interventions: include a body pillow while (R1) is in bed sleeping. R1's progress notes document on 12/30/2022 at 2:10 AM, Witness: no, Location: resident was observed on floor, lying on right side, beside (R1's) bed, in (R1's) room. R1's Fall IDT note documents, Unwitnessed fall, Root cause: resident has been really restless at night lately, rolling around in bed. When (R1) does this (R1) rolls off the side of the bed onto the floor. Intervention: (R1) is to have two mattresses on both sides of (R1's) bed. R1's Post Fall observation form dated 12/30/22 documents, Location of fall: residents room, Detailed description of fall: resident was lying on floor, on the right side, beside bed, in room. Footware: bear feet. Were any measures in use at the time of the fall, none is documented. R1's progress notes document on 1/2/2023 resident fell by bedside from bed, acquired skin tears bilateral upper extremities. R1's Fall IDT note documents, Time of fall: 11:15 AM, Unwitnessed, Root Cause: when resident sleeps (R1) tends to roll from side to side in the bed, when rolls tends to roll out of the bed. Intervention: (R1) to have a scoop mattress for (R1) to be able to define the parameters on (R1's) mattress. R1's Post Fall observation form dated 1/2/23 documents, Witness: no, Location: resident room, resident found by aid laying on the mat beside (R1's) bed, bed was in low position, fall mats were beside the bed, Were any measures in use at the time of the fall: low bed, fall mats. R1's medical record and facility investigation notes did not document whether R1 had a body pillow (fall prevention measure) in use at the time of the fall occurrences on 12/30/22 at 2:10 AM and 1/2/23 at 11:15 AM. On 1/17/23 at 11:50 AM, R1 was lying in bed with scoop mattress on bed, bilateral fall prevention mats on each side of the bed, body pillow to the right of R1, bed was in low position. There was a push pad call light on the floor at the head of the bed, under the bed frame. V16 Certified Nursing Assistant came in R1's room and confirmed R1's call light was on the floor under the head of the bed, V16 stated, (R1) gets to moving around in the bed and may have knocked it off or it may not have been clipped on the bed very well. V16 picked up the call light and placed it in reach for R1, V16 stated, (R1) is alert and able to use the call light and tell you everything (R1) wants. On 1/17/23 at 9:00 AM, V2 Director of Nursing stated, I am new to doing the fall investigations, I don't document everything through interviews on paper, it is just scratch paper. I believe R1 had a body pillow when R1 fell out of bed on 12/30/22. On 1/17/23 at 2:45 PM, V1 Administrator confirmed R1's fall interventions include: body pillow and call light to be in reach.

Based on observation, interview and record review the facility failed to supervise and assist a resident in a safe manner (R3), failed to investigate a fall, develop and implement post fall interventions, and update a residents fall prevention plan of care (R4, R2 and R1) for four of four resident reviewed for accidents on the total sample list of eight. This failure resulted in R3 rolling off the edge of an elevated bed, falling onto a hard floor surface resulting in a subdural hematoma (closed head injury) requiring hospitalization . Findings include: 1. R3's medical record documents, Date of fall: 11/8/22, time of fall: 5:50 AM, observed resident lying on right side with legs curled up close to body on the floor. Activity at time of fall:: Certified Nursing Assistant (V4) was providing incontinent care at time of event. Resident/Staff (if witnessed) description of fall:: CNA stated, I was doing incontinent care on resident. (R4) was turned on (R4's) side and when I went to put a clean brief on (R4), the top of (R4's) body started to slide off the side of the bed. I was unable to stop (R4) from sliding off the bed, (R4) hit her head during the fall. Resident was complaints of pain everywhere. Resident was sent to (local hospital) via ambulance. Root Cause: Resident has poor trunk strength and needs assist with positioning. Resident was turned on left side while CNA was changing her brief. Resident's upper torso began to slide off the bed. CNA was unable to prevent resident from sliding off the side of the bed. Resident may have slide to side of bed during cares. R3's Post Fall Evaluation: 11-8-22 Detailed Description of Fall 4: was stated by CNA that res rolled off side of bed Summarize potential factors that could have contributed to the fall: resident might have been too close to side of bed. R3's hospital records, dated 11/8/22, signed by V15 emergency room Physician, documents: Chief Complaint: Fall. The accident occurred less than 1 hour ago. The fall occurred from a bed. (R3) fell from a height of 1 to 2 feet. (R3) landed on a hard floor. There was no blood loss. The point of impact was the head. The pain is present in the head. Associated symptoms include headaches. Clinical Impression: 1. Fall, initial encounter. 2. Closed head injury, initial encounter. Examination: CT head or brain without contrast, Indications: head trauma, Findings: A small area of extra-axial hemorrhage is demonstrated in the right temporoparietal region. Impression: Small acute extra-axial hematoma over the right temporoparietal region is demonstrated. This most likely represents a subdural hematoma. Called and discussed with (V16 Radiologist), states patient definitely has a subdural hematoma. Called (specialty hospital) for trauma transfer. On 11/15/22 at 12:54 PM V4 Certified Nursing Assistant stated, it was approximately 5:30 AM (11/8/22) I was in (R3's) room changing (R3's) incontinence brief to get (R3) ready for the day. We were visiting and having a conversation, (R3) was alert and oriented. (R3) was lying on (R3's) right side facing towards the window, the bed was elevated because I am a shorter gal, I was on the back side of the bed, between the bed and the door to the room, my stomach was pressed up against the bed frame, (R3's) back was towards me, as I was tucking the incontinence brief under (R3's) hip, (R3) rolled forward and rolled right out of the bed towards the window onto the floor. (R3) had an air mattress on the bed. There was no way for me to grab ahold of (R3) once (R3) started to roll off. I could not see how close I had (R3) positioned on the side of the bed. On 11/15/22 at 6:40 PM V3 Registered Nurse stated, around 5:50 AM (11/8/22) the CNA (V4) was in (R3's) room doing rounds and changing (R3), I was in the hallway and (V4) alerted me to come to (R3's) room, (R3) was lying on the floor on (R3's) right side close to (R3's) bed, (R3's) bed was elevated, (R3) was complaining of a headache and was found that (R3) had hit (R3's) head, sent (R3) to the emergency room . (V4) had stated (V4) had rolled (R3) over and (R3) was on the side of the bed and (R3) rolled off the bed onto the floor. On 11/16/22 at 11:10 am V11 Corporate Nurse Consultant stated, (R3) was rolled over in bed by the CNA (V4), the CNA pushed down on the mattress to place a pad under (R3) and (R3) was too close to the edge of the bed and rolled of the bed. CNA was educated to not roll residents away but towards herself when changing them. The Facility's Investigation Final report form documents: Nurse observed resident on the floor next to bed. It appeared (R3) rolled out of bed, and did strike (R3's) head. Due to change in cognition and current orders of [MEDICATION(S)] resident was transferred via ambulance to the local emergency room . Resident was diagnosed with subdural hematoma. Investigation initiated and in progress. CNA was providing incontinent care at the time of the event. Resident was assisted to turn on side and began placing brief under (R3) and the resident started to roll off the bed. Employee was unable to stop the resident from rolling off the bed. (R3) has poor trunk stability and was laying too close to the edge of the mattress. 2. R4's medical record documents, 9/2/2022 at 5:20 PM, Resident slid out of chair on to the floor in sports bar. Fall was witnessed by activity staff. R4's medical record did not contain a post fall assessment or updates to R4's fall prevention plan of care, after R4's fall on 9/2/2022. R4's care plan, with an initiation date of 11/23/2021, documents at risk for falls related to diagnosis: [CONDITION(S)], Incontinence, [CONDITION(S)] Joint Disease, Memory Loss, [CONDITION(S)]. History of falls. R4's Minimum Data Set assessment, dated 10/27/22 R4 requires extensive assistance of two staff members for toilet use. R4's medical record documents on 11/3/2022 at 3:42 PM, Resident was taken to the bathroom, aide went to check on another resident and when she came back resident was lying on the floor in her room next to the bathroom door. Root Cause: Resident has poor safety awareness, and while CNA was assisting another resident, resident attempted to stand up per self and pull up her pants. Resident lost her balance while doing so and slid to the floor. Staff were educated to not leave the resident unattended in restroom. On 11/16/22 at 1:15 PM, V14 CNA stated, on 11/3/22 I took (R4) to the bathroom, I told (R4) I was going to go down and change someone else, I got out from changing another resident, (R4) was already out of the bathroom and was sitting on floor. V11 told me not to leave (R4) unattended in the bathroom. On 11/16/22 at 1:00 PM V11 Corporate Nurse Consultant stated, (R4's) post fall investigation was not fully completed by nurse after (R4's) fall on 9/2/22, new interventions were not developed. (R4's) fall on 11/3/22 the (V14) left (R4) unattended in bathroom (R4) stood up and fell , the CNA was educated not to leave resident unattended in bathroom, (R4's) [CONDITION(S)] disease is advancing. 3. R2's medical record documents, on 11/3/2022 at 3:00 AM, Walked by residents room heard a noise, looked in residents room saw (R2) on the floor beside bed lying on left side with left leg partially underneath her, complained of left hip pain. Further exam a lump on her left forehead. Area discolored and slightly bleeding. Transported resident to (local hospital). Root Cause: Resident fell because attempted to get out of bed. Intervention will be body pillow. R2's medical record documents R2 readmitted to the facility from the hospital on 11/14/22. R2's fall prevention care plan did not document new interventions of body pillow On 11/15/22 at 2:00 PM and 11/16/22 at 10:35 AM R2 was lying in bed with eyes closed, bed in low position, over the bed table by the bed with call light on top and within reach. R2 had no body pillow in bed or located in R2's room. On 11/16/22 at 10:40 AM V11 Corporate Nurse Consultant stated, the intervention for R2's fall on 11/3/22 is a body pillow. V11 confirmed the body pillow should be on R2's fall prevention care plan and used while in bed. 4. R1's Side Rail Use Assessment form completed by V13 dated 9-26-22 documents, side rails do not appear to be indicated for R1 at this time. Interventions: lower the bed to the floor and mat on floor. On 11/16/22 at 9:40 AM V13 Certified Occupational Therapy Assistant stated, (R1's) family had requested (R1) to have siderails, I completed a side rail evaluation on (R1). (R1) was not a candidate, and other recommendation for bed in low position and mat beside the bed were implemented. R1's care plans document: Focus: At risk for falls related to decreased mobility, weakness, initiated: 9/24/22. Interventions/Task: Minimize risk for falls for resident. 11/11/2022 fall, MD to evaluate resident at hospital and provide orders upon return. Staff to encourage resident's son to not bring in foods that are fried or spicy due to cholelithiasis. Educate resident to ask for assist with transfers. Encourage to change position slowly. Encourage to wait for assist when call light is on. Place call light in reach and remind to use for assist. Focus: I am at risk for falling related to history of falls, poor standing balance, Diagnosis: CerbroVascular Accident with left weakness, [CONDITION(S)], pain in knee, [CONDITION(S)], initiated: 10/11/22. Interventions/task: (10/12/22-fall) body pillow, Educate me in safety awareness and to call when I need assistance. Keep call light in reach at all times, Keep personal items and frequently used items within reach, Monitor me for any signs/symptoms or complaints of pain/discomfort, notify my nurse to administer pain medication if ordered and update physician on any unresolved discomfort noted. R1's fall risk/prevention care plans did not document prevention measures to Keep R1's bed in low position or mat beside the bed. On 11/16/22 at 9:25 AM V11 Corporate Nurse Consultant stated, keeping (R1's) bed in low position and a mat by the bed should be on (R1's) care plan and on the Kardex. V11stated, for some reason R1 has two fall care plans. V11 confirmed fall prevention measures of keeping R1's bed in a low position and a mat beside R1's bed was not on R1's care plan or on R1's Kardex. The facility policy, with a revision date of 12/1/2020, titled Fall Prevention Program documents, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 6- Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a- Interventions will be monitored for effectiveness. b- The plan of care will be revised as needed. 7. When any resident experiences a fall, the facility will: a- assess the resident, b- complete a post fall assessment, c- notify the physician and family, d- review the residents care plan and update as indicated, e- document all assessments and actions.

Based on interview and record review the facility failed to provide interventions and monitoring for a resident identified as high risk for skin breakdown for one of three (R1) residents reviewed for pressure ulcers on the sample of three residents. These failures resulted in R1 developing an Unstageable Pressure Ulcer to the right heel three weeks after admission. Findings include: The facility's policy, with a revision date of 9/5/22, titled Pressure Injury Prevention and Management, documents, Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Definition: Avoidable- mean that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with residents needs, resident goals and professional standards of practice, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate. Policy explanation and compliance guidance: 2- the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, interventions to stabilize, reduce or remove underlying risk factors, monitoring the risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate. 3- Assessment of Pressure Injury Risk, a- licensed nurses will conduct a pressure injury risk assessment on admission and weekly for four weeks. b- This tool will be used in conjunction with other risk factors not captured by the risk assessment. c- licensed nurses will conduct a full body skin assessment on all residents upon admission, weekly and after any newly identified pressure injury. d- assessments of pressure injuries will be performed by a licensed nurse and documented, the staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. e- nursing assistants will inspect skin during bath and will report any concerns to the nurse immediately after the task. 4- Interventions for prevention and promote healing. 1- after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries. c- evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury (ie: Redistribute pressure (such as repositioning protecting and/or offloading heels, etc.). f- interventions will be documented in the care plan and communicated to all relevant staff. R1's medical record documents an admitted [DATE] to the facility. R1's admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Braden Assessments (skin risk assessment) dated 8/19/22 and 9/3/22 document a score of 12 indicating R1 was at high risk for skin breakdown. No Braden assessment was completed for R1 the week of 8/26/22. R1's skin integrity assessment dated [DATE] (admission) does not document R1 had any pressure ulcers present on admission. R1's progress notes dated 8/19/2022 document, Resident received in bed alert, oriented, able to make her needs known, admitted to the facility for Physical Therapy/Occupational Therapy strengthening post fall at home, had (surgery) on Right hip on 08/10/22. Weight Bearing As Tolerated to right leg. Upon body assessment, has no open areas on body, has two surgical sites with sutures. Scattered bruising on both arms from venipuncture/IV needle sticks. Old incision scar from left knee replacement. Also has some old healed scars/marks on right lower shin from old injuries. Heels are clear, pedal pulses palpable, no [CONDITION(S)] noted. Toe nails are hard, has scab on 3rd left toe. (Physician) visited and assessed the resident. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physical Therapy Evaluation and Plan of Treatment documents, start of care: 8/20/22. Reason for referral: recently admitted to the hospital due to fall at home resulting in right hip intertrochanteric fracture with displacement and angulation status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Functional Mobility Assessment: roll left to right- Substantial/maximal assistance, sit to lying- substantial/maximal assistance, lying to sitting on side of bed- substantial/maximal assistance. R1's baseline careplan dated 8/19/22 documents, Skin risk: Current skin integrity issues is not checked and History of skin integrity issues is not checked. There are no interventions documented on R1's baseline care plan for skin breakdown prevention. R1's Comprehensive Care plan with initiation dates of 8/19/22, 8/26/22 and 9/1/22 do not document R1 being at risk for skin breakdown, prevention measures in place or a plan for pressure ulcer treatment after the development of wounds on 9/6/22. R1's Minimum Data Set assessment dated [DATE] documents, section M: R1 is at risk for pressure ulcers, pressure relieving device to bed and chair yes is checked, and turning and repositioning program: no is checked. Section G: Bed Mobility, requires extensive assistance of two staff members, dressing total dependence on staff members, and bathing total dependence on staff members. R1's Occupational Therapy Encounter notes document on 9/5/22 by V8 Certified Occupational Therapist Assistant: bed mobility training with task breakdown for sequencing, patient benefits from increased time to perform rolling side to side at contact guard assist. Patient reports sore heels, and notes redness on bilateral heels, reported to nurse and nurse to perform skin assessment. R1's electronic medical record does not document skin monitoring for R1 after 8/19/22 through 9/6/22. R1 had 2 paper skin monitoring forms completed, one dated 9/5/22 and one dated 9/8/22. A Skin monitoring form dated 9/5/22 signed by V11 Certified Nursing Assistant with R1's first name and incorrect last name, documents on the body assessment: posterior right heel circled and black is documented beside it, posterior left heel is circled and redness is documented, this form is also signed and dated 9/5/22 by V6 Licensed Practical Nurse. V11 CNA confirmed the skin monitoring form completed on 9/5/22 was for R1, V11 confirmed documenting the wrong last name on the form. R1's skin monitoring form dated 9/8/22 documents, went home no skin assessment completed. On 10/6/22 at 12:50 PM V11 Certified Nursing Assistant stated, when I gave (R1) a shower on 9/5/22 (R1) had one heel that was black and the other one was red. I told the nurse about it, I don't remember who the nurse was, the nurse told me to get (R1) some heel protectors, when I came in the next day (R1) still had the heel protectors on. When (R1) first got to the facility (R1) didn't want to get out of bed much because of the pain from the hip fracture but then (R1) started working with therapy and was getting stronger. R1's medical record does not document an assessment was completed for R1's skin conditions to bilateral heels on 9/5/22 after V11 reported them to the nurse nor after V8 COTA reported them on 9/5/22 to nursing staff. R1's progress notes dated 9/6/2022 at 11:27 AM, document, Resident noted having a blister to right heel, and resident left heel is red and mushy. (V14 Physician) notified, new orders received, encouraged to keep heels floated. R1's skin observation tool dated 9-6-22 documents right heel type: blister 4 centimeter length by 5 cm width, no depth is documented, stage is blank. Location: Left heel, type: red and mushy, measurement columns are blank, stage is blank. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/6/22 at 10:40 AM V9 Licensed Practical Nurse stated, I believe V8 came to me and said that (R1) was complaining of heels hurting. I did an assessment on (R1's) heels. (R1) had a fluid filled blister on one of the heels and the other heel was red and mushy (boggy skin), I encouraged (R1) to keep her heels up. (R1) had no heel protectors in place prior to to this. On 10/6/22 at 10:15 AM V2 Acting Director of Nursing (DON) stated, a full body assessment is done on admission, braden (skin risk assessment) is completed on admission. If a resident admits with or develops any type of skin condition I have the wound physician see them, the nursing staff do not stage wounds, I let the wound doctor do that. Skin observations should be done weekly, using the skin observation tool in the electronic medical record. Skin observations are also done with showers, they are documented on paper forms. I never saw (R1's) heels, the wound doctor was supposed to see (R1) the day of (R1's) discharge but since (R1) was going home that day I had the nurse practitioner see (R1) for orders. On 10/6/22 at 9:30 AM V4 Nurse Practitioner stated, I saw (R1) the day (R1) was discharging to home. (R1's) insurance ran out and (R1) could not afford to stay in a long term care facility so (R1) was discharging home with family. (R1) stated (R1) was having increased pain in the right lower extremity. (R1) had a recent fracture to the right hip and a blood clot in the right extremity while in the hospital and (R1) said (R1) thought it was related to all of that. I looked at (R1's) heels, (R1) had a blister to one heel and the other heel was unblanchable and boggy. I was specifically concerned about the pain to the right leg due to (R1's) history. (R1) did have one plus generalized [CONDITION(S)] to both lower extremities, I spoke with (R1's) daughter and encourage her to have (R1) seen soon due to the complaints of pain and (R1's) history. (R1's) daughter was going to take (R1) to the emergency room when they left the facility. Because of the location of the blister area to (R1's) heel and the mushy area to the other heel, the areas were caused by friction or rubbing of the heels, could have been on the mattress or on something when up in the wheelchair, (R1) wore diabetic shoes. All residents should have frequent monitoring of the skin, especially if they are high risk. Heels are at risk for pressure ulcers, especially if a patient has history of hip fractures or blood clots and decreased sensation. If (R1) would have had heels floated in bed (R1) would have benefited. R1's Hospital History and Physical dated 9/8/22 documents, Assessment-plan: Right heel ulcer unstageable. R1's hospital records document, date: 9/8/22, Emergency Provider notes, patient presents to the emergency room from extended care facility for right foot ulcer, patient recently had a right hip fracture and has been at extended care facility for rehab for the past three weeks. States past 3 or 4 days has noted pain in right heel, is diabetic and states blood sugars have been from 200 to 400, was due to be discharged from extended care facility today. Skin- Right heel with large pressure ulcer noted. R1's MRI (Magnetic Resonance Imaging) of the right foot without contrast documents, exam: 9/9/22, Findings: There is soft tissue ulceration/blister over the posterior aspect of the calcaneus. On 10/11/22 at 10:15 AM V2 Acting DON stated, I was not able to find any other skin monitoring for (R1) besides the paper ones dated 9/5/22 and 9/8/22. R1 had a baseline care plan, (R1's) comprehensive care plan was being developed when R1 discharged . I am not certain what skin prevention measures (R1) had in place off the top of my head.

Based on record review, observation and interview the facility failed to ensure fall careplan interventions were implemented and failed to ensure an audible safety alarm was functioning for one (R1) resident out of three residents reviewed for falls in a sample list of three residents. This failure resulted in a fall with harm due to R1 sustaining a extra-axial hemorrhage, bruising and laceration requiring four sutures to upper Right Forehead. Findings include: The facility policy titled 'Incidents, Accidents and Supervision' implemented 1/1/2020 documents the following: Policy: the resident environment remains as free of accidental hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: Monitoring for effectiveness and modifying interventions as necessary. Supervision is a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. R1's Undated Face Sheet documents medical diagnoses of Left Extra-Axial Hemorrhage, Left Temporal Laceration requiring Sutures, and History of Falling, [CONDITION(S)] and Collapse, Hearing Loss, Bilateral [CONDITION(S)] and Difficulty in Walking, R1's Minimum Data Set (MDS) dated [DATE] documents moderate cognitive disability level. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, transfers, walking in room, walking in corridor, dressing, toileting, personal hygiene and supervision for eating. R1's Care Plan fall intervention dated 4/28/22 documents R1 is to have bed alarm. This same Care Plan documents a fall intervention dated 7/16/22 which documents R1 is to be laid down in bed after breakfast. R1's Physician Order Sheet (POS) dated September 1-30, 2022 documents a physician order starting 9/20/22 to monitor Right side of head laceration for any signs and symptoms of infection example redness, swelling, warmth, drainage and notify Physician of any changes. This same POS documents physician orders for Aspirin chewable 81 milligram (mg) daily ordered 10/5/21 and discontinued 9/22/22, [MEDICATION(S)] ([MEDICATION(S)]) 75 milligrams (mg) daily started 8/22/22 for Acute [CONDITION(S)] and discontinued 9/22/22 and Sutures to be removed seven to ten days from day of fall 9/19/22. Remove sutures Tuesday 9/27/22. R1's Physician Progress Note dated 7/14/22 documents (R1)'s hearing loss does contribute to falls as (R1) does not hear bed alarm. R1's Fall Risk assessment dated [DATE] documents a score of 60 which indicates R1 is at high risk for falling. R1's Nurse Progress Notes dated 9/19/22 at 3:52 PM documents (R1) was sent to emergency room this morning for fall , hit head , right side Hematoma. Hospital did Computerized Tomography (CT) scan , results of bleeding in Subdural Hematoma , four sutures to laceration. Remove in 7-10 days. Remove Tuesday 9-27. R1's Fall Investigation Report dated 9/19/22 documents 'Predisposing Environmental Factors' includes fall alarm. This same report documents (V7) Certified Nurse Aide (CNA) notified (V3) LPN that (R1) was on the floor. Upon entering (R1) room, (R1) was extended, back leaned on the bed. (R1) hit head on the Right side, bleeding and swollen Right side Hematoma. Resident description: I was trying to get in bed. R1's Post Incident Interview Questions dated 9/19/22 documents immediate intervention taken to prevent another fall was 'need new bed and chair alarm'. R1's Resident Post Fall Review dated 9/19/22 documents 'how can we prevent from falling in the future as bed alarm, chair alarm. This same report documents the last time a staff member assisted (R1) was 'before breakfast'. This same report documents (R1) stated I was going to bed when asked why (R1) thinks (R1) fell . R1's Post Fall Observation dated 9/19/22 documents R1 as confused, transferring from wheelchair to bed after breakfast which resulted in Right Hematoma due to hitting head. This same Report documents R1's fall alarm was present but did not go off (did not sound). This same Report documents R1 is confused and does not ask for assistance with transferring. R1's Final Incident Report to Illinois Department of Public Health (IDPH) dated 9/23/22 documents (R1) was discovered on the floor in room with legs extended and back resting on the bedframe. (R1) told staff (R1) was trying to get in the bed. (R1) noted to have a head injury, as visible swelling was noted to the Right Temporal area with external bleeding from a small laceration. (R1) was sent to the emergency room and a Computerized Tomography (CT) scan was done. (R1) was diagnosed with a small intracranial bleed. (R1) was returned to the facility with orders to hold Aspirin 81 milligrams (MG) and [MEDICATION(S)] ([MEDICATION(S)]) 75 mg for two weeks and monitor. (R1) does not remember to ask for assistance. (R1) has a Brief Interview for Mental Status (BIMS) score of 7 out of 15 possible points indicating moderate cognitive impairment and is extremely hard of hearing. R1's emergency room progress note dated 9/19/22 documents Head- (R1) has a 2.5 centimeter (cm) laceration of the Right Forehead. Four sutures placed to Right Forehead. This same progress note documents Chief complaint as fall. R1's Computerized Tomography (CT) of Head or Brain Without Contrast dated 9/19/22 documents Findings: a scalp Hematoma is present. There is small extracranial high density seen within the left frontal parietal region compatible with extra-axial hemorrhage. No mass effect or midline shift is seen. Chronic Subdural hygromas are present bilaterally right greater than left. Impression: Acute extra-axial hemorrhage demonstrated on the left. This is felt to be superimposed on a small chronic Subdural hygroma. On 9/29/22 at 1:25 PM R1 was laying in bed with call light in reach. Large softball sized area around R1's Right Eye and Right Forehead area were yellowed and gray. R1' s suture line on upper Right Forehead was dry, scabbed with no sutures in place. On 9/29/22 at 1:40 PM V5 Certified Nurse Aide (CNA) stated residents' fall interventions are kept in a binder at the nurses station. V5 CNA asked other floor staff where fall intervention binder was. Other floor staff stated there is no fall intervention binder and all the fall interventions could be located through the electronic charting program used by the CNA's. V5 CNA walked to the wall kiosk where electronic charting could be completed. V5 used electronic search engine to learn how to sign in to electronic charting software. V5 CNA then signed in to electronic software charting and clicked in several different areas before finding R1's fall safety interventions. V5 CNA stated I sure didn't know they were there. V5 CNA stated V5 regularly cares for R1. On 9/29/22 at 3:50 PM V3 Licensed Practical Nurse (LPN) stated the day (R1) fell and hit (R1)'s head, I did not hear (R1)'s alarm sounding. The staff came and told me (R1) fell so I went straight to (R1)'s room. When I entered (R1)'s room (R1) was in a sitting position with legs extended in front of bed. (R1)'s back was leaning against bed and (R1) was facing door to room. (R1)'s head was bleeding so we (staff) took (R1)'s vitals and sent (R1) to the emergency room for evaluation of (R1)'s head injury. Sometimes when (R1) lays on the alarm or sits on the alarm for long periods the alarm does not sound immediately when (R1) repositions or transfers. Sometimes the alarm takes 15-30 seconds before it sounds. I saw the chair alarm in the wheelchair but it was not sounding. (R1) was fully dressed since (R1) had been down to the dining room for breakfast prior to (R1)'s fall. (R1)'s bed was not made. On 9/30/22 at 8:35 AM V8 Certified Nurse Aide (CNA) stated I was passing hall trays with (V7) CNA the morning (R1) fell and hit (R1)'s head. (R1) was eating breakfast in the dining room and brought himself back to the room. We (V7, V8) did not know (R1) was in (R1)'s room because we (V7, V8) was assigned to pass hall trays. (V13) CNA was assigned to stay on the hall but (V13) was giving someone a shower. So there was no one watching (R1). That is how (R1) got back to (R1)'s room without us knowing. When I walked past (R1)'s room I heard (R1) hollering 'help' so I went in to check on (R1). (R1) was sitting up with legs extended out. (R1)'s back was against the bed and (R1) was facing towards the room door. (R1)'s wheelchair was sitting next to bed with cushion and wheelchair alarm in place. (R1)'s wheelchair did not seem disturbed. (R1)'s incontinence pad on bed was hanging off of bed. I think (R1) had brought himself back from breakfast, transferred himself from wheelchair to bed and then tried to get out of bed to use the bathroom and fell . It looked like (R1) had scooted himself off of the bed and hit (R1)'s head on the dresser. That is what it looked like to me. (R1)'s alarm was not sounding. (R1)'s wheelchair alarm was sitting in wheelchair and turned off. I do not know if (R1) turned off the alarm himself or someone forgot to turn it on. (R1) does turn off (R1)'s alarm sometimes that is why we (staff) have to watch (R1) closely. I guess it doesn't matter, either way it wasn't sounding. (R1) must have been there for some time because (R1) had time to get back from the dining room and transfer self. On 9/30/22 at 9:30 AM V10 Physician stated (R1) is advanced age and cognitively impaired. It is difficult for (R1) to understand the implications of him falling. (R1) has a tendency to get up by himself. The facility needs to make sure (R1)'s fall risk precautions are being implemented. Not ensuring fall interventions are being implemented could cause residents in general and especially (R1) significant problems or trauma. (R1) did obtain an acute small extra-axial Hematoma over a chronic Subdural hygroma. (R1) does have some atrophy which allows extra space for this small bleed and Hematoma to occur. So, basically because of the atrophy, the acute bleed and Hematoma has extra room to occupy. It is hard to tell how (R1)'s Hematoma will behave due to the atrophy. It could progress to intracranial mass effect causing herniation and significant increase in mortality. At this point, (R1) has not had any further significant neurological problems but also because of the space created by the atrophied brain the symptoms will most likely not show for weeks to months. At that point, those neurological symptoms could lead to increased mortality for (R1). (R1) was on Aspirin and [MEDICATION(S)] at the time of (R1)'s fall which could lead to increased bleeding which is what happened with (R1)'s fall on 9/19/22. On 9/30/22 at 11:30 AM V2 Director of Nurses (DON) stated (R1) is a high fall risk resident who will shut off the fall alarms sometimes. We (facility) knew this prior to (R1)'s 9/19/22 fall. We (facility) are responsible for (R1)'s safety since (R1) is cognitively impaired and we (facility) know (R1) is such a high fall risk. I have educated the staff multiple times regarding falls prior to (R1)'s fall on 9/19/22. They (staff) just do not listen apparently. It is the responsibility of the staff to ensure the bed and chair alarms are functioning properly and turned on at all times even when (R1) shuts the alarm off, the staff should make sure it is turned back on. The staff know that (R1) needs closely supervised. If some of the CNA's are passing hall trays then the CNA assigned to (R1) should have been monitoring (R1) until the ones passing the trays were available to monitor also.

Based on observation, interview and record review, the facility failed to obtain and implement orders for a Gastrostomy Tube treatment for one of one resident (R125) reviewed for Gastrostomy Tubes on the sample list of 37. This failure resulted in skin breakdown, extremely red and excoriated, around R125's abdominal Gastrostomy Tube site. Findings Include: R125's Admit/Readmit Screener sheet dated 9/8/22 documents R125 was admitted to the facility from the hospital and is totally dependent on staff for all ADL's (Activities of Daily Living). This Screener also documents R125 has bruising to the abdomen but does not mention any skin breakdown to the abdomen. On 9/13/22 at 11:25 AM, V6 LPN (Licensed Practical Nurse) and V17 CNA (Certified Nursing Assistant) entered R125's room to provide cares. R125 G-Tube (Gastrostomy Tube) insertion site had an undated dressing taped over it. V6 LPN stated G-tube dressings are generally to be changed nightly. V6 removed R125's dressing {two 4x4 gauze pads}; the gauze pad closest to R125's skin was saturated with a thick, black, slimy substance, and R125's peri-stoma was extremely red and excoriated. V6 LPN stated R125's G-tube site is always moist and stated the black substance must be old feeding that had leaked out. V6 LPN stated it doesn't look like the dressing was changed during the night. R125's September 2022 Order Summary Report documents R125 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . This Report also does not document an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R125's September 2022 TAR (Treatment Administration Record) does not document that R125 has had R125's G-tube dressing changed since admission on 9/8/22 {5 days}. On 9/14/22 at 11:03 AM, V8 ADON (Assistant Director of Nursing)/Wound Nurse stated residents with G-Tubes should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 measured the red excoriated area around G-tube insertion site at 4 cm (centimeters) x (by) 2.5 cm. V8 stated, upon (R125's) re-admit from the hospital, (R125's) stoma site was slightly red but nothing like this. V8 confirmed if R125 was admitted from the hospital without an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/14/22 at 12:32 PM, V31 NP (Nurse Practitioner) stated V31 use to be a wound nurse. V31 stated residents absolutely need to have a layer of protection around the G-tube to absorb the leakage that is bound to happen. Without a dressing, the skin can start to breakdown. Really the dressing should be changed every shift because if the dressing is wet and kept on the skin, it will cause breakdown. In R125's case, that is what happened. That soiled dressing had been sitting on R125 and that is why the area around the insertion site so red and excoriated, the skin is angry and breaking down. The facility Gastrostomy Site Care Policy dated 1/1/20 documents the facility should verify there is a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure a resident's code status, advanced directive, reflected their wishes when they failed to document a discussion with R5 regarding R5's wishes to have a Do Not Resuscitate (DNR) order placed in R5's medical record. The facility also failed to contact R5's physician to obtain a signed DNR order. This failure affects one (R5) of seven residents reviewed for advanced directives in a sample of ten residents. This failure resulted in R5 unnecessarily sustaining Cardiopulmonary Resuscitation on [DATE] at the facility and during transport to a local hospital. R5 expired at the local hospital when CPR (Cardiopulmonary Resuscitation) ceased in accord with R5's wishes. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at the Severity Level 2. The facility is in the process of educating staff on Resident Rights Regarding Treatment and Advanced Directive Policy and Communication of Code Status Policy, as well as continuing to reach out to resident families to verify resident Code Status. Findings Include: R5's Progress Notes dated [DATE] at 5:03 am by V31 RN (Registered Nurse) documents, at 4:00 am, the CNA (Certified Nursing Assistant) was in R5's room performing morning cares/bed check. R5 was alert and speaking to the CNA. The CNA reports R5 suddenly began breathing really fast and turned red. The CNA summoned for the RN (Registered Nurse), who responded and found R5 without a pulse and not breathing. CPR was initiated immediately. 911 was called at 4:08 am and EMS (Emergency Medical Services) arrived at 4:15 am. CPR continued. At 4:21 am, V19 (R5's Daughter) was called and notified of R5's current status. V19 stated V19 is aware that (R5) wishes to be a DNR, however, (V19) is not in possession of POLST(Practitioner Orders for Life-Sustaining Treatment)/Living Will paperwork. This writer reported to V19 that R5 would be transported to the Hospital ED (Emergency Department) via EMS squad at this time. At 4:34 am, R5 was transported out of facility via stretcher with CPR continuing via the rescue squad. On [DATE] at 1:09 pm, V19 stated V19 met with facility staff; V23 Marketing and V24 Admissions prior to R5 being admitted to the facility. V19 stated R5 had voiced wishes to be a DNR so V19 alerted V23 and V24 to R5's wishes and they replied R5's hospital discharge orders would have R5's code status for the facility to implement. V19 explained that on [DATE], V19 received a call from the facility telling V19 that they were in the process of doing CPR on R5, V19 told them R5 was suppose to be a DNR, that was his (R5's) wishes. V19 stated the facility reported they had already been working on him (R5) for 20 minutes and (R5) was being sent to the hospital. V19 explained that when R5 arrived at the hospital, CPR was ceased due to the hospital having a DNR for R5 and R5 was then pronounced dead. V19 stated, it was a horrible experience that we should not have had to go through. R5's [DATE] Physician Order's do not document a code status. R5's Admission assessment dated [DATE] by V31 RN (Registered Nurse) documents R5's code status as DNR (Do Not Resuscitate). R5's MDS (Minimum Data Set) dated [DATE] documents R5's BIMS (Brief Interview for Mental Status) was not performed however per staff, R5's long and short term memory were OK. On [DATE] at 2:17 pm, V23 Admissions stated R5 was admitted on a Friday {[DATE]} and that V23 did not discuss R5's advanced directive wishes with R5 at that time because R5 came to the facility with a POLST from dated [DATE] which documents R5 wishes to have CPR attempted. V23 also stated that R5's hospital discharge orders dated [DATE] document R5 as a DNR, as of [DATE], which is a discrepancy that the nurse should have clarified. On [DATE] at 2:38 pm, V2 Interim DON (Director of Nursing) confirmed if there are discrepancies in a resident's orders, the nurse should be getting the orders clarified. V2 explained that R5 was admitted with a POLST from the hospital that documents to attempt CPR however R5's discharge orders documented R5 as a DNR. V2 further explained that if R5 has a DNR at the hospital but this facility doesn't have a signed DNR form, then R5's status would be a full code at the facility until the facility received the signed DNR order, especially with also having a POLST saying to attempt CPR. On [DATE] at 1:38 pm, V31 RN confirmed V31 completed R5's admission assessment and that R5, who was alert and oriented, made it known that R5 wished to be a DNR. It was passed on in report to me that V17 Physician had all of the DNR paperwork at V17's office and that V19 (R5's daughter) was suppose to be bringing it into the facility. V31 stated R5 ended up coding a few days later and due to the facility not having the signed DNR paperwork, CPR was initiated. On [DATE] at 4:00 pm, V17 Physician stated in [DATE], R5 was brought into the hospital and was very frail and declining in health. The last known code status for R5 was a full code from back in 2018. V17 explained that due to R5's condition V17 and R5 had a conversation if R5 wanted to remain a full code and it was at that time, in [DATE], that R5 chose to become a DNR. V17 stated R5 was cognitively intact and able to make that decision independently. V17 stated that after R5 passed away, V19 contacted V17 and was upset that R5 had to be put through CPR when R5's wishes were to be a DNR. V17 explained that the DNR was the most recent order and that's what the facility should have followed but the if the facility had questions, they should have called V17 to clarify R5's code status. The facility definitely made a mistake with this case and these quality of care issues need to be taken care of. The facility Cardiopulmonary Resuscitation Policy dated [DATE] documents, It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR. If a resident experiences a [CONDITION(S)], facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services and in accordance with the resident's advance directives. The facility Residents' Rights Regarding Treatment and Advanced Directives Policy dated [DATE] documents, it is the policy of this facility to support and facilitate a residents' right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The facility will include in the standing orders: Advance directive as indicated by the resident and/or resident representative. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communication to the staff. Upon admission, should the resident/resident representative execute a new advance directive; or, if a resident or resident representative changes the advanced directive: Social Service Designee or designee will notify the resident's nurse and the IDT (Interdisciplinary Team) of the advance directive/change to advance directive, the resident's nurse will notify the attending physician of advance directive/change to advance directive. The nurse will document in the progress notes that the physician is notified of the advance directive and that the original POLST form is awaiting physician signature. The advance directive will be added to the Physician Orders, The copy of the POLST will be scanned into resident record pending physician signature, the original of the POLST will be scanned into resident record after signed by the physician. The Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to ensure a resident's code status, advanced directive, reflected their wishes by failing to document a discussion with R5 regarding R5's wishes to have a Do Not Resuscitate (DNR) order placed in R5's medical record, and failed to contact R5's physician to obtain a signed DNR order. On [DATE] at 11:58 am, V1 Administrator and V2 Interim DON were notified of the Immediate Jeopardy situation. On [DATE] between 9:30 am - 10:50 am, The surveyor confirmed through interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.) Chart Audits were completed on [DATE] - [DATE] by V25 SSD (Social Service Director) to verify that resident Physician Orders, Care Plans and POLST forms all contained the same information. 2.) An Educational Inservice was conducted by V2 Interim DON for all nursing staff regarding Resident Rights Regarding Treatment and Advanced Directive Policy and Communication of Code Status Policy on [DATE]-[DATE]. V2 supplied the sign in sheets for education and stated V2 discussed the the admission process, verifying a resident code status, and to clarify the code status with the physician if there are discrepancies with the orders and/or resident wishes. On [DATE], V30 LPN (Licensed Practical Nurse) and V39 Agency RN both stated they received inservice training last week regarding Advance Directives and what to do if there were discrepancies. On [DATE], V38 LPN stated V38 was aware V2 was conducting educational training on Advance Directives last week but that V38 did not receive that education until [DATE]. 3.) Audits were initiated on [DATE] by V25 SSD to ensure the Advance Directive orders on resident charts are accurate according to resident and/or family wishes. On [DATE], V25 stated V25 discussed code status with alert and oriented residents and/or resident families, if the resident was not able to make that decision on [DATE]. V25 provided audit sheets that document V25 was able to clarify a resident Code Status with 56 out of the 60 residents who reside at the facility and is still waiting to hear back from four of the families. V25 also stated resident code status will be reviewed with each quarterly care plan meeting and with any significant change of condition.

These Failures require more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to monitor, observe, assess, notify and implement targeted interventions to prevent the development and or worsening of unstageable pressure ulcers for one of four resident (R6) reviewed for pressure ulcers. These failures include lack of: skin assessment/checks, pressure wound monitoring, repositioning assistance, incontinence care assistance, transfer assistance, for a resident who required extensive assistance. This failure affects one of four residents (R6) reviewed for pressure ulcers. R6 developed two additional unstageable pressure ulcers between 12/31/2021 (readmission) and 1/25/2022. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/1/2022, the facility remained out of compliance at a severity level two. Onsite record review and interview verified that the facility is in the process of staff re-education on the facility Pressure Ulcer, Change of Condition, Abuse Neglect and Exploitation policies and protocols. Findings include: The facility's policy, with a revision date of 12-1-2020, titled Pressure Injury Prevention and Management documents, Policy: this facility is committed to the prevention of avoidable pressure injuries and the promotion of healing existing pressure injuries. Definitions: Pressure Ulcer/Injury: refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with the residents needs, resident goals, and professional standards of practice; monitor and evaluate the impact of interventions; or revise the interventions as appropriate. Policy Explanation and Compliance Guidance: 2- The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3- Assessment of Pressure Injury Risk: c- Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, after any newly identified pressure injury. Findings will be documented in the medical record. d- Assessments of pressure injuries will be performed by a licensed nurse, and documented on the (fill in the blank for designated form- not filled in). The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. 4: Interventions for Prevention and to Promote Healing: a- after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b- Interventions will be based on specific factors identified in the risk assessment, skin assessments and any pressure injury assessment (e.g: moisture management, impaired mobility, nutritional deficit, staging, wound characteristics.) c- Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i- Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc), ii- Minimize exposure to moisture and keep skin clean, especially of fecal contamination, iii- Provide appropriate pressure redistributing support surfaces. iv- Maintain or improve nutrition and hydration status. 5: Monitoring, a- The Nurse Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. b- The attending physician will be notified of: i- The presence of a new pressure injury upon identification, ii- The progression towards healing, or lack of healing, of any pressure injuries weekly. R6's Admission assessment form dated 12/21/2021, documents, Skin: Site- Coccyx: scar, (there are no measurements documented). R6's Admission assessment does not document any other skin concerns/or pressure ulcers present. R6's medical record documents on 12/22/2021 at 2:24 AM, Skin: has old scar on coccyx, no open areas noted. R6's medical record documents a physicians order to Cleanse left heel with normal saline, pat dry. Paint with [MEDICATION(S)] twice a day, every shift for wound care, dated 12/22/2021. R6's medical record documents on 12/29/2021, Resident was working with therapy and eyes rolled back to head and unresponsive. Was sent to (local hospital) for evaluation and treatment. R6's (Readmission assessment) form dated 12/31/2021, Skin: Site: Left heel, Type: Pressure. the Length, Width, Depth and Stage columns are blank. R6's medical record does not document wound monitoring/assessments to include the measurements and/or characteristics of R6's Left heel (Deep Tissue Injury) pressure ulcer from 12/21/2021 (original admission) through 12/29/21 (discharge to hospital) and 12/31/2021 (readmission) through 1/25/2022. R6's Treatment Administration Records dated January 2022 do not document the completion of physician ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Paint with [MEDICATION(S)] twice a day, every shift for wound care on days (6 AM to 6 PM) on 1/8/2022, 1/10/2022, 1/11/2022, 1/17/2022, 1/20/2022, 1/21/2022 and 1/22/2022. R6's medical record documents on 1/10/2022, complaints of pain when wiping due to pressure wound on right buttocks. There is no documentation of the type, size or characteristics of the pressure wound located on R6's right buttocks from 1/10/2022, until 1/16/2022. There is also no physician notification documented until 1/16/2022. R6's medical record documents Skin Observation Tool: date 1/16/2022, Site: Right Buttock, Type: Other- Unstageable Deep Tissue Injury, Length: 7 centimeters, Width: 5 centimeters, Depth: 0.1 centimeters, Stage: Unstageable. This same form documents the definition of Unstageable as: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R6's medical record documents on 1/20/22 at 6:45PM by V19 Registered Dietician, Wound status reviewed. Noted resident with an unstageable DTI to his right buttock. Recommendation for Liquid Protein three times a day and Multivitamin sent on 1/18/22 for approval by (physician). The facility's Dietary Recommendation/Follow up form documents, Date: 1/18/22, R6, Recommedations: Liquid Protein three times a day and Multivitamin for Unstageable Deep Tissue Injury, signed by V19. Responses section and Attending Physicians signature line were blank. On 1/26/2022 at 1:30 PM, V5 Wound nurse stated, I found a new area to (R6's) right heel yesterday. It is an unstageable deep tissue injury. It is on the right lateral outer ankle, it measured 3 centimeters by 4.5 centimeters. R6's left heel wound measured 9 cm by 7 cm. V5 stated, I have not found documentation regarding the dietician's recommendation (from 1/18/2022) was followed through with, (R6) is not currently receiving the recommended dietary supplements for wound healing. On 1/26/2022 at 11:25 AM, R6's left buttock/sacral wound was approximately golf ball in size, asymmetrical with beefy red tissue noted inside the wound from approximately 9:00 to 12:00, there was obvious depth to the wound, there was also dry yellow/brown slough observed from approximately 12:00 to 6:00. Directly below was an additional open area with a beefy red center, half-moon shaped approximately 2 cm by 2 cm in size. R6 moaned loudly during the cleansing of the wounds to the left buttock. R6 had dry black hard eschar covering the entire bottom of the left foot proceeding upwards on the back of the heel. R6 had dry black hard eschar covering the right lateral outer ankle/heel area. On 1/27/2022 at 1:35 PM, V5 Wound Nurse stated, R6 admitted on [DATE] with an Unstageable Deep Tissue Injury to the Left heel, I saw the wound and it was hard black eschar tissue, it covered the entire heel, it was an Unstageable Deep Tissue Injury, I do not see any measurements or assessment with wound description in R6's medical record. On 1-16-22 R6 was found to have an Unstageable DTI to the left buttock, we have been documenting the area was on the right buttock but it has always been on the left buttock. The wound doctor was notified of the area to the left buttock on 1-16-22. R6 is incontinent of bowel and bladder, R6 needs assistance with transferring, bed mobility, and incontinence care. Since R6 was at risk for skin breakdown and admitted with a pressure ulcer to the left heel R6 should have had at least weekly body audits being completed. R6's care plan, created on 12/22/2021 documents, Focus: I am at risk for alteration in skin integrity related to left metacarpal fractures, gout, hypertension, history of falls, [CONDITION(S)] nodule and [CONDITION(S)], has Deep Tissue Injury to left heel Interventions: Encourage resident to reposition as needed, provide preventative skin care routinely and as needed, skin audits as ordered, treatment to left heel as ordered. R6's additional care plan, created on 1/15/2022 documents, Focus: Has actual Deep Tissue Necrosis to left heel, has an unstageable Deep Tissue Injury to right buttock. Interventions: Follow physician treatment orders, (Pressure reducing boots) on as resident allows/tolerates, resident needs (pressure relieving/reducing mattress, pillows, sheepskin padding etc) to protect skin while up in chair, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R6's medical record does not document the completion of complete skin/body audits by licensed nursing staff between 12/31/2021 (readmission) through 1/25/2022. On 1/25/2022 at 1:30 PM, R6 was lying in bed with non skid slipper socks on bilateral feet. R6 had a cast covering R6's entire hand/wrist/arm area. There was a blue (pressure reducing) boot and pink foam heel pressure reducing device noted in R6's room on top of cart. R6 stated, yes I have a sore on my butt and my heel. I'm supposed to wear a boot. On 1/26/2022 at 8:15 AM, R6 was lying in bed, breakfast tray on over the bed table, eating breakfast. R6 was wearing non skid slipper socks to bilateral feet, R6 stated, I am not wearing my boot, R6 pointed to the cart in the room and stated see it is over there, they didn't put it on. There was a blue pressure reducing boot and pink foam heel pressure reducing device on a stand in R6's room. On 1/25/2022 at 1:50 PM, V5 Wound Nurse stated, Body audits are to be completed by Licensed Nursing staff weekly, they initial off on the Treatment Administration Record and will document on the skin observation tool if a new area is identified. (R6) is compliant with wearing the boot, (R6) should be wearing (pressure reducing boot). R6's Minimum Data Set assessment dated [DATE] documents R6 requires extensive assistance of 2 or more staff members for bed mobility, transfers, toilet use and total dependence of two or more staff members for bathing, and always incontinent of bowel and bladder. This same MDS documents R6 has a current pressure injury and is at risk for pressure injuries/ulcers. This assessment also documents R6 has 1 Unstageable pressure injury presenting as a deep tissue injury. Turning and Repositioning program and Nutritional or Hydration intervention to manage skin problem documents NO. R6's task forms do not document assistance was provided or conducted 1/7/2022 through 1/17/2022 with bathing, transfers, bed mobility, bowel and bladder elimination and skin observations. R6's Physical Therapy Plan of Care notes dated 1-2-2022 document, Reason for referral: receiving skilled Physical Therapy for rehab to home after a fall resulting in left finger fractures. Patient continues to demonstrate decreased functional activity intolerance due to early onset fatigue, required extensive assistance to transition to different positions due to generalized weakness and limited use of left upper extremity and total dependence in functional transfers and gait due to impaired balance and weight bearing tolerance. Functional deficits current level: Bed mobility, rolling side to side: dependent 100 percent assist. Bed mobility, bridging/scooting: dependent 100 percent assist. Bed mobility, supine to sit: dependent 100 percent assist. Bed mobility, sit to supine: dependent 100 percent assist. On 1/31/22 at 9:30 AM V2 DON stated dietary recommendations are given to myself, V5 Wound Nurse and I think V1 Administrator, I then forward them to the physicians, if a response is not received from the physician within 5 days I follow back up with a phone call, etc. We did not follow back up on R6's dietary recommendation until 1/28/22. V2 stated it should have been followed up with sooner. R6's medical record documents on 1/28/2022 12:11 PM, Resident was seen by the wound (physican) V8 on wound rounds today. Resident received new orders for a wound vac (negative pressure wound therapy). R6's Initial Wound Evaluation and Management Summary form dated 1/28/2022, completed by V8 Wound Physician documents, Chief Complaint: This patient has multiple wounds. Exam: Peripheral Vascular: Examination of left and right lower extremities: foot cool, wound present, mild [CONDITION(S)]. Pedal pulses left and right: Dorsalis Pedis detected by portable doppler, Posterior Tibial detected by portable doppler. Back, buttock, left lower extremity and right lower extremity: wound present. Focused Wound Exam (site 1): Arterial Wound of the Right Heel Full Thickness: Wound size: 2.5 centimeters (length) by 5 cm (width). 100 percent thick adherent black necrotic tissue (eshar). Focused Wound Exam (site 2): 9 cm (length) by 8.5 cm (width), 100 percent thick adherent black necrotic tissue (eschar). Focused Wound Exam (site 3): Stage Four Pressure Wound Sacrum Full Thickness, Etiology: Pressure, Wound size: 3.5 cm (length) by 4.5 cm (width) by 2.5 cm (depth). Surface area: 15.75 cm. Undermining: 4.5 cm at 3:00. Exudate: Moderate Serous. Thick adherent devitalized necrotic tissue: 20 percent, Slough: 20 percent, Other viable tissue: 60 percent (muscle, bone). Recommendations: Float heels off bed, Off-load wound, Reposition per facility protocol, Turn side to side and front to back in bed every one to two hours if able, group two mattress. On 2/1/22 at 1:30 PM V8 Wound Physician stated, I diagnosed R6's heel wounds as arterial, R6's feet were cool to touch, non palpable pulses (detected with doppler) and the appearance of the wounds, given the fact of being told it had not gotten worse since it was first identified. All areas are pressure, someone with diabetes or circulation problems are more susceptible to breakdown, less pressure is required for this to occur. Nutritional interventions should be started when wounds are identified. Routine weekly wound monitoring should be occurring. From what I was told by V5 was R6's pressure to the buttocks started out as superficial, if repositioning is not occurring that will contribute, could have been a combination of all. Facility's should be proactive with situations, if you recognize someone with limited mobility at risk for pressure ulcers, then prevention measures should be implemented. Lack of communication with systems in the facility is where it all starts, basic communication from the certified nurses aids, to the nurses, to the wound nurse is necessary. An Immediate Jeopardy situation was identified on 1-28-22. The Immediate Jeopardy was identified to have begun on 12/31/21 when the facility failed to assess R6 for pressure wounds/skin integrity. On 1/28/22 at 4:00 PM, V1 Administrator and V2 Director of Nursing, was notified of the Immediate Jeopardy situation. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1. On 1/28/22, a facility-wide skin audit was conducted by DON and ADON. 2. On 1/29/22, Braden assessments were completed for every resident by MDS Coordinator and Unit Managers. 3. On 1/29/22, audit conducted by DON to ensure completion of Braden assessments and weekly/daily skin checks. 4. On 1/29/22, Care Plans updated for all skin concerns/pressure ulcers by MDS Coordinator. 5. On 1/29/22, Resident Representatives notified of wound rounds and all treatment orders by DON and Treatment Nurse. 6. On 1/29/22-1/30/22, progress notes regarding assessments, new orders and physician/resident representative notifications were entered into medical records by DON and Nurse Managers. B. Based on observation, interview, and record review, the facility failed to assess and implement interventions to prevent the development and worsening of pressure ulcers in two of three (R7, R8) residents reviewed for pressure ulcers. Findings include: 1.b. R7's medical record documents an admitted [DATE]. R7's medical record documents on 12/29/2021 at 2:29 PM, Resident arrived at facility, full code, alert and orientated times 3 not situation, hard of hearing, bed bound, poor sitting balance, puree diet thin liquids, needs to be fed, was bed bound at hospital, has poor sitting balance, is incontinent of bowel and bladder, she has wound to her buttock. R7's Braden risk assessment form dated 1/4/2022 documents a score of 12, indicating R7 is at high risk for skin breakdown. On 1/25/22 at 2:00 PM V5 Wound Nurse stated, R7 admitted with diaper [CONDITION(S)] to her buttocks, she was at risk for skin breakdown. She was being seen by the wound physician. On 1/5/2022 she developed a Unstageable Deep Tissue Injury, I don't know what caused the area, she didn't have a special mattress before she got the area. R7's care plan, with a creation and initiation date of 12/29/2021 documents, Focus: (R7) is at risk for skin breakdown related to asthma, congestive heart failure, hypertension, gastroesophageal reflux, [CONDITION(S)] disorder, diabetes mellitus, spinal stenosis and history of stroke. Interventions: Encourage, ensure and assist me with repositioning every routinely (initiation date: 12/29/21), Keep me clean and dry as possible (initiation date: 12/29/21), Maintain adequate nutrition and hydration (initiation date: 12/29/21), Provide incontinence care after each incontinent episode (initiation date: 12/29/21), Provide me with any and all treatment/ dressings if ordered by my physician (initiation date: 12/29/21). R7's Wound Evaluation and Management Summary form dated 12/30/21, signed by V8 Wound Physician documents, Chief Complaint: patient has a rash. Exam: buttocks/groin: irritated [CONDITION(S)]. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Wound Evaluation and Management Summary form dated 1/5/2022, signed by V8 (Primary Wound Physician) documents, Patient presents with a wound on her sacrum. She has an unstageable DTI sacrum for at least 1 days duration. Exam skin: buttock/groin: Irritated [CONDITION(S)]. Focused Wound Exam (site 1): Unstageable Deep Tissue Injury Sacrum Full Thickness. Etiology: pressure. Wound size: 3.1 cm (length) by 0.9 cm (width) by 0.2 cm (depth), Surface area: 2.79 square centimeter, Exudate: Moderate Serous, 20 percent: Thick adherent devitalized necrotic tissue, 20 percent: slough, 60 percent: granulation tissue. Recommendations: off load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able, group two mattress. R7's Wound Evaluation and Management Summary form dated 1/10/22, signed by V9 Wound Physician documents, Focused Wound Exam (site 1): Unstageable Deep Tissue Injury Sacrum Full Thickness, Etiology: Pressure, Duration: greater than 6 days, Wound Size: 3 cm by 1 cm by 0.2 cm, surface area: 3.00 cm2, 70 percent thick adherent devitalized necrotic tissue, wound progress: deteriorated. Focused Wound Exam (site 2): Stage 2 Pressure Wound of the Right Buttock partial thickness, etiology: pressure, duration: greater than one day, Wound size: 2.3 cm by 6 cm by 0.1 cm, surface area: 13.80 cm2. R7's Wound Evaluation and Management Summary form dated 1/17/22, signed by V10 Wound Physician documents, Focused Wound Exam (site 1): Stage 4 Pressure Wound Sacrum Full Thickness, Etiology: Pressure, Stage: 3, Duration: greater than 14 days, Wound size: 2.5 cm by 1.5 cm. Surface area: 3.75 cm2. 100 percent thick adherent devitalized necrotic tissue, Wound Progress: deteriorated. Focused Wound Exam (site 2); Etiology: pressure, Duration: greater than 8 days, Wound size: 0.5 cm by 0.4 cm by 0.2 cm. Other Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Physical Therapy plan of care notes dated 12/30/21 document R7 requires moderate to maximum assist with bed mobility and on 1-9-22 maximum assist with bed mobility. R7's Minimum Data Set assessment dated [DATE] documents R7 requires assistance of 2 or more staff members for bed mobility, transfers, toilet use and bathing, and occasionally incontinent of bladder and always incontinent of bowel. This same MDS documents R7 has a current pressure injury and is at risk for pressure injuries/ulcers. This assessment also documents R7 has 1 Unstageable pressure injury presenting as a deep tissue injury. Turning and Repositioning program and Nutritional or Hydration intervention to manage skin problem documents NO. R7's medical record documents on 1/17/2022, Resident was seen by wound (physician) on wound rounds. Resident wound to sacrum deteriorated, wound to right buttock improved. Resident son called with update on wound, son concerned that resident is not getting up out of bed, not walking and not being concerned about her own health. R7's task forms do not document assistance was provided or conducted 1/5/2022 through 1/15/22 with bed mobility and transfers. R7's Wound Evaluation and Management Summary form dated 1/28/22, signed by V8 (Primary Wound Physician) documents, Focused Wound Exam (site 1): Stage 4 Pressure Wound Sacrum Full Thickness, Etiology: Pressure, Duration: greater than 23 days, Wound size: 2 cm by 1 cm by 0.4 cm. Focused Wound Exam (site 2): Stage 3 Pressure Wound of the Right buttock, resolved on 1/28/2022. R7's care plan, with a creation and initiation date of 1/24/2022, documents, Focus: The resident has actual impairment to skin integrity of the right buttocks/sacrum. On 1/27/22 at 10:00 AM V5 Wound Nurse confirmed R7's care plan was not developed for R7's open pressure areas to the sacrum and buttocks until 1/24/22. On 1/26/22 at 3:00 PM, R7 had an open area (slit like appearance) to the sacrum area approximately 2 cm by 1 cm, the area had yellow slough covering the center of the wound bed. R7 did not have any visible open areas on the right buttock, there was scar tissue noted to the right buttock. R7's Dietary Recommendation/Follow Up form documents, date: 1-6-22, R7, Recommendations: Add pro-stat (liquid protein) twice a day and Multivitamin for wound healing, signed by V19 Registered Dietician, Responses: blank. Attending Physicians signature of V29 (Physician) is documented. R7's Dietary Recommendation/Follow Up form documents, date: 1-18-22, R7, Recommendations: pro-stat twice a day and Multivitamin for wound healing, signed by V19 Registered Dietician, Responses: blank, Attending Physician signature: blank. On 1-31-22 at 10:40 AM V2 DON stated, V19 Registered Dietitian had a recommendation for pro-stat and multivitamin for wound healing. The physician returned the recommendation dated 1-6-22 and had approved, the order was never carried through. V19 evaluated (R7) again on 1-18-22, since the recommendation wasn't back and sent another rec back to the physician. (R7) has no current order and is not receiving the pro-stat. 2.b. R8's progress note printed 1/25/21 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital record dated 11/21/21 through 11/26/21 document R8 was admitted to the hospital during that time for acute pneumonia. R8's Admission/Readmission assessment dated [DATE] at 5:18PM documents R8 has Strong Pulses, No [CONDITION(S)], and No Unhealed Pressure Ulcers. R8's Progress Note dated 11/28/21 documents R8 has a new Deep Tissue Injury to her Left heel. No measurements documented. R8's progress note dated 12/1/21 at 2:39AM documents Deep tissue injury remains intact to Left heel. No measurements or assessment documented. R8's Wound-Weekly Observation dated 12/2/21 documents a Facility Acquired Assessment 37 centimeter by 4 centimeter fluid filled blister. [MEDICATION(S)] twice daily. On 1/27/22 at 10:00AM V5, Wound Nurse stated the note should have read 3.7 centimeters by 4 centimeters. The first wound physician documentation is dated 12/8/21. V8, wound Physician classified the left heel wound as a unstageable pressure ulcer of the left heel and documents it has a 4.4 centimeter surface area. V8 plan of care includes Elevate legs. Float heels in bed. offload wound. Reposition per facility Protocol. Turn side to side and front to back every one to two hours if able, and prevention boots. 1/26/22 at 12:30PM R8 was in bed lying on her back. R8 did not have prevetnion boots, and heel protectors in place. R8's blanket was wrapped tightly over feet and ankles and tucked under the mattress. 1/26/22 at 2:00PM R8 was lying on her back. She had soft heel protectors to both feet, but her heels were not on a pillow. V5 wound nurse removed the heel protector from R8's left foot. R8 had a round unstageable pressure ulcer to her left heel with a dime size black center. There was no dressing present to the area. R8's January Treatment Administration Record (TAR) includes an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply collagen sheet with silver. Cover with border gauze dressing daily and PRN (as needed). The dressing is not initialed as completed 1/20/22,1/21/22,1/22/22,or 1/25/22. On 1/26/22 at 2:30PM V5 wound nurse stated The floor nurse should be doing the wound dressings. I do wound assessments and round with the wound doctor. The floor nurse also does the weekly skin audits. They initial they are done on the TAR, but I am not sure where they document what they see. R8's January TAR includes an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These skin checks are not initialed as completed 1/20/22,1/21/22, or 1/22/22. There is no documentation R8 has been assessed by the dietitian for wound healing. R8's January MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's progress note dated 1/30/2022 at 5:23PM documents Skin assessment completed on 1/28/22. Bilateral breast underneath slightly red, abdominal folds also red, with small areas open, treatment in place for yeast. New area noted on left calf area, that lines up exactly with pressure reduction boot. Area is not open. 1.8 (centimeters) x 1.8 (centimeters). Discolored. Treatment initiated. Will update wound MD (Physician) to review. Family notified. All questions answered. On 1/31/22 at 10:00AM V2, Director of Nursing stated We did skin sweeps over the weekend and (R8) has area on her left lower leg. We have a treatment in place. On 2/1/22 at 1:40PM V8, Wound physician stated A resident who is wound healing should be assessed by the dietitian and my recommendation would be Zinc, Multiple Vitamin, and (liquid protein supplement). My understanding is the facility starts that immediately when a wound is identified. I think definitely if a resident has a wound they would do at minimum weekly skin assessments. There needs to be a process in place where the CNA's and floor nurse's notify the wound nurse and the wound nurse notifies me. If there is not skin breakdowns could be missed. It all comes down to communication. It should be supervised by the Director of Nursing.

Based on interview and record review the facility failed to ensure one resident (R17) was not subjected to mental or physical abuse by a staff member. R17 is one of seven residents reviewed for abuse in a sample list of 60 residents. This failure caused (R17) to suffer psychosocial harm manifested by tearfulness, fear, embarrassment, and voluntarily discharging from the facility to home and forfeiting remaining eligibility for therapy services, to avoid possible further occurrences of mistreatment. Findings include: R17's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's progress note dated 1/18/22 at 5:10PM documents Able to self propel in wheelchair. Able to verbalize needs. Alert and Oriented X (times) 4 (Person,Place,Time,and situation). This note also documents (R17) baseline generalized weakness. However, is able to sit on side of bed per self. Transfers with 1 and gait belt. Steady gait with walker. (R17) uses a Bedside Commode and is continent x 2 (Bowel and bladder). On 2/1/22 at 2:40PM R17 stated On 1/22/22 night shift, I put on my call light. First an aide came in and said she needed to go get help. The aide got (V22), LPN (Licensed Practical Nurse) to help. I told them I needed to move my bowels. I had my feet off the side of the bed, but I am weak in my upper body and need help to sit up. (V22) grabbed my leg hard, spun me around back in the bed and told me in a very rude way to 'just poop in my pants and they'd clean it up.' (V22) refused to give me the name of the aide. I started crying and I was afraid. They left me and finally I just had to go in my pants. I was embarrassed. I stayed dirty until my husband and the nurse who came in on day shift cleaned me up. I wanted to stay long enough to get some more therapy and get stronger, but I had my husband take me home that day. I just couldn't take it any longer. During the interview R17 was crying. R17 stated I don't even like to remember it. I get nervous. (V24), R17's family member stated (R17) had dried bowel movement on her. They just let her sit in filth all night. On 1/31/22 at 12:30PM V21, Licensed Practical Nurse (LPN) stated When I came in the morning of 1/22/22 (R17) and (V24) were very upset and wanted to take (R17) home. When I got in the room to check on (R17) (R17) was shaking and crying. I asked if I could help and (R17) said (V22) and a CNA who refused to give her name came in during the night when she rang her call light. (R17) can scoot herself to the edge of the bed but she is weak in the upper body so she needs help sitting up. (R17) said (V22) told her to get back in bed. She told (V22) she needed to go to the bathroom to have a bowel movement. (V22) yelled at her and said just go in your pants and we will clean it up later. (R17) is mostly continent and just wears an adult diaper for dribbling like when she coughs. Then (V22) grabbed (R17) hard by the leg and put (R17) in the bed. (R17) said it scared her. I wrote this all up and gave it to (V3), LPN (Licensed Practical Nurse) on 1/22/22. I have been a nurse since 1996. I would say this was abuse. I honestly couldn't find out who the CNA was. (R17) was alert and oriented and able to let us know what she needed or wanted. On 2/1/22 at 11:00AM V25,CNA Certified Nurse's Aide stated I was the CNA with (V22) who took care of (R17) the night before she left. I saw (V22) put (R17) back in the bed. This was the first time I ever had (R17) and I didn't know she could be up. I don't know if (V22) knew her either. It was the third time (R17) had put on her call light and I wasn't sure if I could get her up by myself or not. I didn't hear or see anything else. On 2/1/22 at 11:15AM V22 was interviewed by telephone . V22 stated in a loud voice I know you want to talk about a resident that left the facility. I already had to come in and write a statement. We went in and (R17) was hanging her legs off the bed. Her knees were against the wheelchair. I though she might fall. There was nothing unusual that night. I heard through the grapevine you already think I'm guilty. The facility's Abuse, Neglect and Exploitation policy dated 6/8/20 states 5. Prevention of abuse neglect, and exploitation-The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: j. Supervise staff to identify inappropriate behaviors such as using derogatory language, rough handling, or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds.

Based on interview, and record review, the facility failed to assess or treat new skin issues for two residents (R5 and R9) of three residents reviewed for skin alteration in a sample list of 60 residents. This failure caused (R9) to develop full thickness wounds to the toe and heel and (R5) to experience worsening bruised swollen lower leg wounds. Findings Include: 1. R9's progress notes printed 1/25/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's progress note dated 11/15/21 at 1:36PM stated Family notified of all skin issues, calloused area has fallen off tip of left great toe already, also noted a black 2nd toe on this foot, staff state this is not new, it has been there for a long time, but x-ray will be done to rule out injury. There is no other documentation to address the wound on the second toe until R9's progress note of 11/23/21 which documents : Wound found on left foot 2nd toe (between 2nd and 3rd digit, but on lateral part of 2nd toe) noted 4x4 gauze laying over wound, with dried bloody drainage. Cleansed, Unable to measure due to pain and resident not allowing. Pat dry. Applied calcium alginate and dry dressing-band-aid, until seen by wound doctor. Notified family of all orders, and treatment also notified wound facility nurse, family states this was noted on Sunday by Family concerned due to resident being a diabetic. R9's physician's wound documentation dated 11/26/21 documents a full thickness wound to R9,s Left Distal second toe with a surface area of 2.8 centimeters. The etiology is documented as infection. The wound physician's notes on 12/8/21 document minimal change to R9's left second toe. However, there is an additional newly acquired full thickness arterial wound to left heel with surface area documented as nine centimeters. On 1/17/22 R9 was seen by V10, wound doctor. V10 recommended referral to a vascular surgeon. R9's progress note by V5, wound nurse dated 1/18/22 at 1:12PM documents (R9) seen by wound doctor (V10) on wound rounds 1/16/22. Resident (family) at bedside and talked with (V10) regarding resident skin issues to left foot. (family) voiced understanding and will talk (other family) regarding resident seeing the vascular surgeon and get back with (facility). R9's progress notes document R9 was not assessed by the facility dietitian until 1/18/22. Dietitian recommended a liquid protein supplement at that time. As of 1/25/22 there is no follow up documented to support the facility has followed up with family related to vascular consult. On 2/1/22 at 1:40PM V8, wound doctor stated It is my understanding (R9's) family does not want a vascular consult for (R9). (R9) has dry gangrene in that left foot. I would expect at minimum skin checks every week for high risk residents as well as dietitian consultation. (R9) is diabetic so that puts her at risk in itself. Good foot care is very important in a diabetic resident. 2. R5's Progress notes printed 1/25/22 include the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Progress note dated 1/7/22 at 5:29AM documents Writer was called into the room as (R5) was having bleeding from skin tears on her right leg. Noted R5 has two skin tear about the size of 2x5(centimeters) and other one about the size of 1x1(centimeters) below the knee. Cleansed with Normal Saline, applied steri-strips. Resident unable to tell how it happened. Denies any pain. Will continue to monitor. There is no documentation of skin assessments until a progress note dated 1/19/22 at 5:19PM which documents This writer was called into R5's room due to her leg weeping, cleansed and put treatment in place, (Physician) and Power of Attorney notified. No skin assessment was documented. On 1/24/22 at 10:10AM V31, R5's family member stated we removed (R5) last week (from the facility) Her legs looked awful. They were edematous, leaking fluid. We had (telehealth) appointment with (V16, Physician) who had (family member) remove the bandages and (R5's) legs were bruised with open wounds, (V16) said it looked like it was from trauma, not being careful moving her. It was the calf area on the right leg. On 1/25/22 at 2:13PM V16 stated I have been (R5's) primary care physician for quite some time. I did a telehealth visit with (R5) with (family members) present in (R5's new facility). I instructed family to remove bandages from (R5's) right lower leg. I found what I saw disturbing. (R5) had two triangular shaped lacerations on her right lower leg surrounded by ecchymosis. I also noted the right leg had more [CONDITION(S)] than the left leg. I would not attribute this to (R5's) Congestive Heart Failure. These areas appeared to be traumatic as one would see in rough treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/25/22 V2 Director of Nursing stated (R5) was transferred to (new facility) by our van on 1/21/22. I am not aware (R5) had any wounds. The facility's policy Wound Treatment Management dated 12/1/20 states To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound treatments will be provided in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. In absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. This policy also states The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards wound healing b. Changes in characteristics of the wound and c. Changes in the resident's goals and preferences, such as end of life or in accordance with his/her rights.

Based on observation, record review, and interview, the facility failed to monitor intake and output of a resident with [MEDICAL CONDITION], assess a mental/physical condition change of a resident and notify the physician timely regarding a change in condition for one of three residents (R1) reviewed for quality of care on the sample list of five. This failure resulted in R1 being admitted to the hospital with [REDACTED]. Findings Include: R1's POR (Physician order [REDACTED]. R1's Progress Notes document the following: 1/26/20 - R1 is alert and oriented, able to make R1's needs known. Has poor appetite. Indwelling catheter patent, draining amber urine. Fluids encouraged, R1 has [MEDICAL CONDITION]. 1/27/20 - R1's indwelling catheter is patent and draining amber urine. 1/31/20 at 2:20 pm - R1's son is concerned that R1 is dehydrated, concerned regarding IV (Intravenous Fluids). Nurse explained that facility would monitor resident and notify V13 Physician if R1's fluid intake does not improve today. 1/31/20 at 3:32 pm - R1 noted to be lethargic and groining. Skin cool and pale, skin turgor very poor. R1 noted to have poor fluid and food intake times three days. PRN (as needed) [MEDICATION NAME] {Narcotic} given as ordered. V13 Physician and new orders for laboratory testing ordered STAT (right now). These notes document R1 was sent to the ER (emergency room ) at 6:45 pm, and subsequently admitted to the hospital due to abnormal and critical laboratory values. There was no prior documentation of V13 or V15 FNP (Family Nurse Practitioner) being notified of R1's poor fluid and food intake for three days, or amber colored urine. Laboratory Values dated 1/31/20 document the following: Potassium = 6.3 mmol/L (millimoles per liter) {Critical Level} - Normal Range is 3.5-5.1 mmol/L BUN (Blood Urea Nitrogen) = 189 mg/dL (milligram per deciliter) {high} - Normal Range is 6 - 19 mg/dL [MEDICATION NAME], blood = 7.10 mg/dL {high} - Normal Range is 0.5 - 1.3 mg/dL GFR (Glomerular Filtration Rate) = 7 {low} - Normal Range is greater than or equal to 60. R1's Hospital Consultation Notes dated 2/1/20 by V18 Nephrologist documents [DIAGNOSES REDACTED]. These notes document R1's baseline serum [MEDICATION NAME] are likely between 2.1 -3.0 and are currently at 6.6, down from 7.1 last night {1/31/20}, and with R1 being at stage IV, this insult my force him (R1) into chronic [MEDICAL TREATMENT]. The facility Intake and Output Policy dated May 2017 documents; the policy objective is to maintain an accurate record of the resident's fluid balance which may include output on a resident with an indwelling catheter. R1's Vitals Report documents R1's last meal intake on 1/24/20 and last urinary output as 750 ml (milliliters) at 9:50 pm on 1/29/20. The entire Vitals Report dated 1/1/20 - 2/4/20 does not document how much fluid intake R1 consumes and only documents urinary output five times, for the month of January 2020. On 2/4/20 at 11:07 am, V2 DON (Director of Nursing) stated staff are to document intakes in the computer for all residents and outputs for residents with catheters. V2 confirmed no intake has been documented for R1 since 1/24/20 and no output has been documented since 1/29/20 and was inconsistent prior to that. V2 stated that if staff noticed a change in R1's output, even if not documented, V13 or V15 FNP (Family Nurse Practitioner), who is in the facility three times a week, should have been notified. On 2/4/20 at 12:00 pm, V6 CNA (Certified Nursing Assistant) stated, V6 was assigned to R1 on 1/31/20. V6 stated in the recent past, R1 was able to feed R1's self but had not been able to the last couple of days. V6 stated V6 had to feed R1 and give R1 drinks, as R1 couldn't do it independently anymore. {R1} wasn't the same, he wasn't all the way there. I {V6} thought it was dementia kicking in. {R1} was like that for about 2 days but had not been R1's normal self for about 1 week prior to that. V6 stated on 1/30/20, V6 reported to an unidentified nurse that R1 was no longer able to feed himself and that R1 was out of it. V6 stated the nurse told V6 that it was the medication they were trying him on. V6 explained that on 1/31/20, R1 was still out of it and maybe only ate three bites of breakfast and was sleeping at lunch. V6 stated R1's lips were dry and had been like that all day. V6 also stated the day R1 was hospitalized , R1 had only about 50 ml's (milliliters) urine output all day and that it was dark yellow and cloudy. V6 stated that they were to be keeping track of R1's intake and output but couldn't remember if it had decreased prior to 1/31/20 or not. On 2/4/20 at 1:34 pm, V7 RN (Registered Nurse) stated, V6 CNA had informed V7 that R1's son was at the bedside and requesting R1 to receive IV fluids because he thought R1 was dehydrated. V7 stated R1's lips were dry, but staff put moisturizer on them, and that staff were offering R1 fluids. V7 stated V6 told V7 that R1 had not eaten or drank during the shift and only had 50 ml's (milliliter's) urine output. V7 stated V7 told R1's son that if R1's intake did not improve, V7 would notify V13 but did not due to it being the end of V7's shift. On 2/4/20 at 1:42 pm, V8 LPN (Licensed Practical Nurse) stated R1 was a good eater and drinker. A couple days prior to R1 being hospitalized , R1's appetite started to decrease. R1 always had good output from R1's catheter. If R1 is not eating or drinking for a day, I would consider that a significant change. On 2/5/20 at 9:55 am, R1 stated, R1 was sent to the hospital due to being dehydrated and admitted with kidney failure. The doctors have been talking to me about [MEDICAL TREATMENT] but I (R1) don't know what is going to happen. R1 stated R1's appetite was decreased due to nausea and R1 knew R1 needed IV fluids and the facility wouldn't give R1 any. R1 stated R1 had been sick for about two weeks, not really eating or drinking. R1 stated R1 only has one kidney due to having R1's right kidney removed about 3 years ago [MEDICAL CONDITION], so I'm aware of what I was needed. R1 stated R1 was so weak, I (R1) wasn't able to eat or drink by myself. On 2/5/20 at 11:25 pm, V15 FNP confirmed V15 is at the facility three times a week and sees residents for acute illnesses. V15 stated nobody notified V15 of R1 being nauseated, lethargic, not being able to feed himself or nothing, so V15 is unsure if R1 had been sick two weeks as R1 stated or two days as staff stated, since nothing is documented regarding R1's change of condition until the day R1 was sent to the hospital {1/31/20}. V15 stated V15 should have been notified at the first sign of those changes. V15 would have ordered labs, a urinalysis, and IV fluids. If fluids would have been ordered and given at that point, it could have prevented him from being admitted to the hospital with [REDACTED]. A resident with any type of drainage tube, including an indwelling catheter, should always be on I&O (intake and output). The facility should be monitoring that every shift and V15 should have been notified of any changes in output also, as soon as it happened. R1 is on skilled nursing so assessments, vitals and I&O should be being completed every shift. On 2/5/20 at 12:45 pm, V20 RN stated, V20 took care of R1 on 1/29/20. V20 stated R1 has been complaining of nausea for a while now so V20 would always offer R1, R1's PRN (as needed) [MEDICATION NAME] {Antiemetic}. V20 stated R2 had vomited on the night of 1/28/20, so R1 stayed in bed all day on 1/29/20, which was a change for R1. R1 would normally get up for at least one meal a day. V20 stated R1 was receiving skilled care while at the facility but wasn't {under} Medicare so we {facility} wouldn't be doing head to toe assessments. V20 stated V20 never reported R1's nausea to V13 Physician or V15 FNP because that has been going on for a while and (R1) said the [MEDICATION NAME] was effective. R1's Progress notes for the month of January 2020 do not document R1's intake and output each shift, R1's history of nausea, R1's episode of emesis on 1/28/20, or R1's change in condition from being independent with eating and drinking to requiring staff assistance. The facility Change in Resident's Condition or Status Policy dated May 2017 documents, Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. The nurse will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter the resident's treatment significantly. The nurse will record in the resident's medical record any changes in the resident medical condition or status.