Every finding on record at Manor Court of Freeport

Based on observation, interview, and record review, the facility failed to provide incontinent care to a resident dependent on staff for 1 of 5 residents (R1) reviewed for Improper Nursing in the sample 5. The findings include: R1's Quarterly Minimum Data Set, dated [DATE], shows Moderate Cognitive Impairment, Incontinent of Bowel and bladder and the need for assistance from staff.R1's Psychotropic Medication Consent, signed 06/26/2026, shows multiple diagnosis including, irritant contact dermatitis due to fecal, urinary or dual incontinence, diarrhea, hemorrhoids, Pain. On 07/13/2026 at 9:13AM, R1 was lying in bed. R1 had a reclining wheelchair, a standard wheelchair, and a full body mechanical lift sling in the room.On 07/13/2026 at 9:13AM, R1 said, It takes two staff members to get me ready. Having the staff clean up my excrement is not fun, it's embarrassing to me. I do not like being around people; I like to keep to myself.On 07/13/2026 at 10:50AM, V3 (CNA-Certified Nursing Assistant) said, I was the shift lead on July 4, 2026. (V4, CNA) asked if I could help with (R1). When I entered (R1's) room, urine was dripping from the bed forming a puddle on the floor. The sheets had brown rings that extended to (R1's) shoulders almost down to the feet. It was clearly more than two hours since (R1) had been cared for. I do not think (R1) has the mental acuity to report this incident. Immediately after (V4) and I were done assisting (R1), I texted (V1, Administrator) and (V2, DON-Director of Nursing).On 07/13/2026 at 3:41PM, V1 (Administrator) said, (V3, CNA) sent me a text and a video of the incident.V1 held the phone showing the text conversation, no video, dated July 4, 2026 around 9:30AM, showing V3 (CNA) alerted V1 and V2 about R1's condition. V1 (Administrator) responded to V3, This is unacceptable and requested more details about R1. V3 (CNA) responded V4 (CNA) was R1's CNA on the previous shift also.V1 (Administrator) said, I obtained statements from the staff and completed an investigation. (V4, CNA) was terminated after the investigation was completed.R1's Investigation, dated 07/08/2026, shows R1 was noted to be wet on the morning of 7/4/26. Investigation revealed that R1 was on furosemide, a diuretic that increases urination. We have spoken with nursing staff about proper bed checks.

Based on interview and record review, the facility failed to ensure accuracy of medical records for 1 of 3 residents (R1) reviewed for medical records in the sample of 3.The findings include:On 6/30/26 at 9:22 AM, R1 was on the locked memory care unit. R1 could not recall the events of her fall on 6/20/26 or even that she had fallen. R1's facility Fall Investigation for 6/20/26 indicated R1 was unable to be interviewed. R1's progress note, dated 6/20/26 at 2:28 PM, showed R1 was in her room walking to the bathroom with V8 (Certified Nursing Assistant- CNA), tripped backwards, and landed on her buttock. The progress note indicated staff were present and the fall was witnessed. On 6/30/26 at 10:11 AM, V8 said he was providing care to R1's roommate in the bathroom with the bathroom door closed when he heard R1 yell. V8 said he opened the bathroom door and saw R1 had fallen next to her bed. V8 said he was not walking with R1 when she fell and did not witness R1 fall. V8 said when he opened the bathroom door there were no other staff present to witness the fall. V8's interview indicated there were no staff present when R1's fell and the fall was unwitnessed. On 6/30/26 at 9:43 AM, V2 (Director of Nursing) confirmed V8 was the CNA in R1's progress note dated 6/20/26 at 2:28 PM that was allegedly walking R1 at the time of the fall. V2 said she reviewed R1's progress note dated 6/20/26 at 2:28 PM and interviewed V8. V2 was asked why there was a discrepancy between the progress note of 6/20/26 at 2:28 PM and the interview that V8 gave. V2 said V3 (Registered Nurse), who entered the progress note for 6/20/26 at 2:28 PM, said she saw R1 follow V8 into R1's room and that is why she documented what she did. On 6/30/26 at 12:05 PM, V1 (Administrator) said he based his initial report to IDPH on the progress note dated 6/20/26 at 2:28 PM. V1 added that during the investigation they interviewed V8 and found out that the progress note dated 6/20/26 at 2:28 PM was not accurate. V1 said when V8 was interviewed V8 stated he was providing care to R1's roommate and was not with R1 when she fell as the progress noted indicated. The facility's Resident Documentation policy, with a revised date of 12/03, showed the facility shall maintain accurate documentation on all nurses' notes.

Based on observation, interview, and record review, the facility failed to ensure there were staff available to administer resident medications according to schedule administration times for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for staffing in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4, Licensed Practical Nurse (LPN), said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday, 4/18/26, one of the 3 scheduled nurses for day shift called off, so they were short. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 (who live down that hallway) were very upset. V4 said when there are 3 scheduled nurses, 2 of the nurses split the memory care unit so there isn't a nurse in that unit all the time. 1.On 4/23/26 at 11:05 AM, R1 was in his wheelchair sitting at the dining room table. R1 said on Saturday, they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including insulin) before breakfast at 7:30 AM. R1's Medication Administration Record (MAR) shows on 4/18/26, R1 received Depakote at 10:27 AM (scheduled time 7:00 AM), furosemide 10:27 AM (scheduled time 6:00 AM-10:00 AM), gabapentin at 10:27 AM (scheduled time 7:00 AM) and lispro insulin at 10:27 AM (scheduled at 7:00 AM).2. On 4/23/26 at 9:38 AM, R2 was in his room, sitting in his wheelchair. R2 said his medications were so late on Saturday (4/18/26), he had to run down the hall to find the nurse to get them. R2 said he takes his medications before breakfast, but on Saturday it was way past breakfast before he finally got them, and his lunch medications were late as well.R2's MAR shows on 4/18/26 R1 received carbidopa-levodopa at 1:07 PM (scheduled time 11:00 AM) and his gabapentin at 9:52 AM (scheduled time 7:00 AM) and at 1:07 PM (scheduled time 11:00 AM).3. On 4/23/26 at 11:40 AM, R3 was sitting in a recliner in her room with her family at the bedside. R3 said she felt there weren't enough nurses scheduled. R3 said she often gets her medications late and has to wait a long time to get her pain medications. R3's MAR shows on 4/18/26, R1 received hydralazine at 8:54 AM (scheduled time 7:00 AM) for her blood pressure of 172/68.4.On 4/23/26 at 11:00 AM, R5 was in his room watching TV. R5 said he was not sure what was going on this past weekend; it seemed like there were only two nurses working. R5 said they didn't give him his insulin until after breakfast and they didn't check his blood sugar before lunch. R5's MAR shows on 4/18/26, R1's blood sugar was checked at 12:36 PM (scheduled time 10:00 AM) and his insulin was given at 9:20 AM (breakfast is served at 7:30 AM).5. On 4/23/26 at 11:50 AM, R4 was sitting up in his wheelchair in the dining room. R4 said the nurses were really busy this weekend; the staff was telling us there were only 2 nurses on most of the shifts. On 4/23/26 at 9:15 AM, V6, LPN, said on Saturday 4/18/26, one of the scheduled day shift nurses called off and so there were just two nurses. V6 said the night nurses stayed for awhile to help but no one passed one whole hallway. V6 said the morning medications pass is very heavy and it is stressful, even when there are 3 nurses working. V6 said it is a huge responsibility when you have that many residents to care for, there is so much to do, so much to remember and that's when you can start making mistakes. V6 said sometimes she administers medications for 38 residents. V6 said on her weekend they are lucky to have 3 nurses. On 4/23/26 at 12:15 PM, V2, Director of Nursing, said staffing is based on census and usually there are 4 nurses scheduled for day shift. V2 said they did have a call off on Saturday 4/18/26, but she was able to get a nurse to come in at 10:00 AM to work. V2 said she did not come in to help.The facility's Nurse 1st shift schedule 6A-2:30 P shows there was only 3.5 nurses on 4/18/26.The facility's Resident Council Minutes from March 2026 shows, Nurses on second shift are not getting the pills passed out to certain residents on time at night some residents don't get their pills until 9:00 PM and they feel it is not fair.

Based on observation, interview, and record review, the facility failed to administer resident medications according to Physician Orders for 4 of 5 residents (R1, R2, R3, R5) reviewed for medications in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4, Licensed Practical Nurse, said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday, 4/18/26, one of the 3 scheduled nurses for day shift called off, so they were short. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 were very upset.1.On 4/23/26 at 11:05 AM, R1 was sitting in his wheelchair in the dining room. R1 said on Saturday they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including insulin) before breakfast at 7:30 AM. R1's Medication Administration Record (MAR) shows on 4/18/26, R1 received Depakote at 10:27 AM (scheduled time 7:00 AM), furosemide 10:27 AM (scheduled time 6:00 AM-10:00 AM), gabapentin at 10:27 AM (scheduled time 7:00 AM) and lispro insulin at 10:27 AM (scheduled at 7:00 AM). 2.On 4/23/26 at 9:38 AM, R2 was sitting in his wheelchair in his room. R2 said his medications were so late on Saturday (4/18/26) he had to run down the hall to find the nurse to get them. R2 said he takes his medications before breakfast, but on Saturday it was way past breakfast before he finally got them, and his lunch medications were late as well. R2's MAR shows on 4/18/26 R1 received carbidopa-levodopa at 1:07 PM (scheduled time 11:00 AM) and his gabapentin at 9:52 AM (scheduled time 7:00 AM) and at 1:07 PM (scheduled time 11:00 AM). 3.On 4/23/26 at 11:40 AM, R3 was sitting in a recliner in her room with her family at the bedside. R3 said she felt there just weren't enough nurses scheduled. R3 said she often gets her medications late.R3's MAR shows on 4/18/26, R1 received hydralazine at 8:54 AM (scheduled time 7:00 AM) for her blood pressure of 172/68.4.On 4/23/26 at 11:00 AM, R5 was sitting in his room watching TV. R5 said he was not sure what was going on this past weekend, it seemed like there were only two nurses working. R5 said they didn't give him his insulin until after breakfast and they didn't check his blood sugar before lunch. R5's MAR shows on 4/18/26, R1's blood sugar was checked at 12:36 PM (scheduled time 10:00 AM) and his insulin was given at 9:20 AM (breakfast is served at 7:30 AM).On 4/23/26 at 12:20 PM, V2, Director of Nursing, said medications are to be given following the scheduled time or time frame on the MAR. V2 said resident blood sugars should be checked prior to meals and insulin given as ordered prior to meals. The facility's Medication Administration Policy, dated 2/04, shows, All medications must be administered to the resident in the manner and method prescribed by the physician.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant errors for 4 of 5 residents (R1, R2, R3, R5) reviewed for medications in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4 Licensed Practical Nurse said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday 4/18/26 one of the 3 scheduled nurses for day shift called off, so they were short. V4 said the night nurses had to stay to help pass medications. V4 said she said she got busy doing her assigned hallways and was not sure what the night nurses were doing. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 were very upset.1.On 4/23/26 at 11:05 AM, R1 was sitting in his wheelchair in the dining room. R1 said on Saturday they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including insulin) before breakfast at 7:30 AM. R1's Medication Administration Record (MAR) for April 2026 shows R1 has diagnoses of conversion disorder with seizures, type 2 diabetes, intervertebral disc degeneration, low back pain edema, and hereditary and idiopathic neuropathy. R1's MAR shows an order for blood sugar checks four times a day. On 4/18/26 this MAR shows R1's blood sugar checks scheduled for 6:00 AM-10:00 AM was completed at 10:45 AM. This same MAR shows orders for Depakote 500 mg three times a day, furosemide 40 mg twice daily, gabapentin 600 mg three times a day, and lispro insulin sliding scale three times a day before meals. The MAR shows on 4/18/26, R1 received Depakote at 10:27 AM (scheduled time 7:00 AM), furosemide 10:27 AM (scheduled time 6:00 AM-10:00 AM), gabapentin at 10:27 AM (scheduled time 7:00 AM) and lispro insulin at 10:27 AM (scheduled at 7:00 AM).2. On 4/23/26 at 9:38 AM, R2 was sitting in his wheelchair in his room. R2 said his medications were so late on Saturday (4/18/26) he had to run down the hall to find the nurse to get them. R2 said he takes his medications before breakfast, but on Saturday it was way past breakfast before he finally got them, and his lunch medications were late as well. R2's MAR for April 2026 shows orders for carbidopa-levodopa 25-250 mg, twice a day, for Parkinson's disease with dyskinesia scheduled at 11:00 AM and gabapentin 300 mg twice a day for left hip pain scheduled at 7:00 AM and 11:00 AM. The MAR shows on 4/18/26 R2 received carbidopa-levodopa at 1:07 PM and his gabapentin at 9:52 AM (instead of 7:00 AM) and at 1:07 PM (instead of 11:00 AM).3. On 4/23/26 at 11:40 AM, R3 was sitting in a recliner in her room with her family at the bedside. R3 said she felt there weren't enough nurses scheduled. R3 said she often gets her medications late.R3's MAR for April 2026 shows an order for hydralazine 25 mg, three times a day for hypertensive heart disease with heart failure. This MAR shows on 4/18/26, R3 received hydralazine at 8:54 AM (instead of 7:00 AM) for her blood pressure of 172/68.4.On 4/23/26 at 11:00 AM, R5 was sitting in his room watching TV. R5 said he was not sure what was going on this past weekend; it seemed like there were only two nurses working. R5 said they didn't give him his insulin until after breakfast and they didn't check his blood sugar before lunch. R5's MAR for April 2026 shows R5 has a diagnosis of diabetes mellitus. This same MAR shows orders for blood sugar monitoring before meals and at bedtime scheduled for 7:00 AM, 10:00 AM, 5:00 PM, and 8:00 PM, and glargine insulin 30 units twice a day scheduled at 6:00 AM- 8:00 AM, and 7:00 PM-9:00 PM. This MAR shows on 4/18/26 R5's blood sugar was checked at 12:36 PM (instead of 10:00 AM) and his insulin was given at 9:20 AM (breakfast served at 7:30 AM).On 4/23/26 at 12:20 PM, V2 Director of Nursing said medications are to be given following the scheduled time or time frame on the MAR. V2 said resident blood sugars should be checked prior to meals and insulin given as ordered prior to meals. The facility's Meal time document shows Breakfast is at 7:30 AM and lunch is at 12:00 PM.The facility's Medication Administration Policy dated 2/04 shows To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident.

Based on interviews and record review, the facility failed to protect a resident from abuse. This applies to one of three residents (R2) reviewed for abuse in the sample of three.The findings include:A facility reported incident, dated 3/19/26, shows R2 was found at around 5:30AM on 3/11/26, in her bed, with R1 standing over her placing a pillow over R2's head area. R1 was removed from the room by the two Certified Nursing Assistants (CNA). R2 did not seem in any distress.The facility face sheet for R2 shows she was admitted to the facility with a diagnosis of dementia. The facility assessment for R2, dated 2/17/26, shows her to have severe cognitive impairment and required supervision with her mobility. A progress note, dated 3/11/26, shows communication with R2's Power of Attorney (POA) that R2 had been awakened by her roommate who had held a pillow to her face.The facility face sheet for R1 shows she was admitted to the facility with a diagnosis of Alzheimer's Disease. The facility assessment, dated 3/12/26, shows her to have severe cognitive impairment and requires supervision for her mobility. A progress note, dated 3/11/26 at 3:56PM, shows the writer of the note (V3, Memory Care Unit Director) was notified by staff that R1 was found to be holding a pillow over R2's face. The staff removed R1 from the room. R1's POA was notified and R1 was given a room change. The note shows the Director of Nursing (DON) was notified at that time.On 3/25/26 at 8:43 AM, V5, Certified Nursing Assistant/CNA, said she was working the night of the incident with R1 and R2. V5 said R1 had been up during the night wandering around the unit like she sometimes does. V5 said she redirected her back to her room and told her to lie down. V5 said about 10 minutes later she went to do a bed check on R2, at around 5:30 AM, and when she and another CNA (V4) entered R1 and R2's room, they saw a couch pillow over R2's face. V5 said she removed the pillow and V4 took R1 out of the room. V5 said R2 was sleeping and when she woke her up, she was agitated and asked V5 what she was doing and grabbed V5's arm. V5 said she told R2 who she was, and she calmed down. On 3/26/26 at 8:55 AM, V4, CNA, said she was working the night R1 and R2 had their incident. V4 said R1 had been up wandering on the unit like she sometimes does and R1 was redirected to go lie down. V4 said she and V5 went into R1 and R2's room to do a bed check on R2 at around 5:30 AM, and she saw R1 standing over R2 holding a gray pillow over R2's face. V4 said she immediately removed the pillow and took R1 from the room. V4 said R2 was not reacting in any way at the time. On 3/25/26 at 10:45 AM, V3, Memory Care Director, said she was notified at around 3 PM by V4 about what had happened that morning. V3 said she was told during a bed check they saw R1 holding a pillow over R2's face. V3 said she made a room change to separate R1 and R2 and called the POA for R1 to tell her a room change had been made. V3 said she then told the DON what she had discovered. V3 said the information about the incident was supposedly passed through in report, but she was not made aware.On 3/25/26 at 11:46 AM, V2, Director of Nursing/DON, said she was notified around 4:20 PM by V3 about the incident between R1 and R2. V2 said she was told V4 and V5, CNA's, saw R1 holding a pillow over R2's face at around 5:30 AM. V2 said she immediately notified the Administrator and began her investigation into the matter. V2 said this should have been reported when it occurred.On 3/25/26 at 12:08 PM, V1, Administrator, said he was notified by the nurse consultant at around 4 PM on 3/11/26. V1 said this should have been reported immediately for the safety of the residents.The facility abuse investigation into this incident on 3/11/26 at 5:30AM shows V4 stating they entered the room of R1 and R2 and saw R1 holding a pillow over R2's face. V5 stated when they entered the room of R1 and R2 she saw a large pillow over the face of R2. In the investigation, R3 stated she spoke with both V4 and V5 and was told R1 was standing over R2 holding a pillow over her face. She also stated the CNAs could not find the nurse to report the incident and they both thought the third CNA had gone to report it. (The third CNA could not be reached by phone and was not present in the facility at the time of investigation.) A telephone statement made by V13 during the investigation shows she was on the unit between 5 and 5:30 AM, the rest of her shift she was on another hall she was also assigned to. V13 stated she was not told of the incident, but the staff are good at reporting things to her. The facility abuse policy, with a revision date of 11/28/19, shows the purpose is to protect residents from any kind of abuse such as verbal, sexual, mental, physical. A facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility administrator.

Based on interview and record review, the facility failed to report an allegation of physical abuse of a resident in a timely manner. This applies to one of three residents (R2) reviewed for abuse in the sample of three.The findings include:A facility reported incident, dated 3/19/26, shows R2 was found at around 5:30AM on 3/11/26, in her bed, with R1 standing over her placing a pillow over R2's head area. R1 was removed from the room by the two Certified Nursing Assistants (CNAs). R2 did not seem in any distress.The facility face sheet for R2 shows she was admitted to the facility with a diagnosis of dementia. The facility assessment for R2, dated 2/17/26, shows her to have severe cognitive impairment and required supervision with her mobility. A progress note, dated 3/11/26, shows communication with R2's Power of Attorney (POA) that R2 had been awakened by her roommate who had held a pillow to her face.The facility face sheet for R1 shows she was admitted to the facility with a diagnosis of Alzheimer's Disease. The facility assessment, dated 3/12/26, shows her to have severe cognitive impairment and requires supervision for her mobility. A progress note, dated 3/11/26 at 3:56PM, shows the writer of the note (V3, Memory Care Unit Director) was notified by staff that R1 was found to be holding a pillow over R2's face. The staff removed R1 from the room. R1's POA was notified and R1 was given a room change. The note shows the Director of Nursing (DON) was notified at that time.On 3/25/26 at 8:43 AM, V5, CNA, said she was working the night of the incident with R1 and R2. V5 said R1 had been up during the night wandering around the unit like she sometimes does. V5 said she redirected her back to her room and told her to lie down. V5 said about 10 minutes later, she went to do a bed check on R2 at around 5:30 AM, and when she and another CNA (V4) entered R1 and R2's room, they saw a couch pillow over R2's face. V5 said she removed the pillow and V4 took R1 out of the room. V5 said R2 was sleeping and when she woke her up, she was agitated and asked V5 what she was doing and grabbed V5's arm. V5 said she told R2 who she was, and she calmed down. V5 said she never told the nurse about what she had witnessed.On 3/26/26 at 8:55 AM, V4, CNA, said she was working the night R1 and R2 had their incident. V4 said R1 had been up wandering on the unit like she sometimes does and R1 was redirected to go lie down. V4 said she and V5 went into R1 and R2's room to do a bed check on R2 at around 5:30 AM and she saw R1 standing over R2 holding a gray pillow over R2's face. V4 said she immediately removed the pillow and took R1 from the room. V4 said R2 was not reacting in any way at the time. V4 said she did not report the incident at the time but did call the Memory Care Director that afternoon when she woke up. V4 could not remember what time that was. On 3/25/26 at 10:45 AM, V3, Memory Care Director, said she was notified at around 3 PM by V4 about what had happened that morning. V3 said she was told during a bed check they saw R1 holding a pillow over R2's face. V3 said she told V4 that this type of behavior needs to be reported right away and was told by V4 she fell asleep after her shift and called when she woke up. V3 said she made a room change to separate R1 and R2 and called the POA for R1 to tell her a room change had been made. V3 said she then told the DON what she had discovered. V3 said the information about the incident was supposedly passed through in report, but she was not made aware.On 3/25/26 at 10:50 AM, V6, CNA, said she worked the morning shift on 3/11/26 and was not told anything about the incident in report regarding R1 and R2.On 3/25/26 at 11:34 AM, V7, Registered Nurse (RN), said she worked the morning of 3/11/26 and she was not given any information regarding the incident between R1 and R2.On 3/25/26 at 11:46 AM, V2, Director of Nursing/DON said she was notified around 4:20 PM by V3 about the incident between R1 and R2. V2 said she was told V4 and V5, CNA's, saw R1 holding a pillow over R2's face at around 5:30 AM. V2 said she immediately notified the Administrator and began her investigation into the matter. V2 said this should have been reported when it occurred.On 3/25/26 at 12:08 PM, V1, Administrator, said he was notified by the nurse consultant at around 4 PM on 3/11/26. V1 said this should have been reported immediately for the safety of the residents.The facility abuse investigation into this incident on 3/11/26 at 5:30AM shows V4 stating they entered the room of R1 and R2 and saw R1 holding a pillow over R2's face. V5 stated when they entered the room of R1 and R2 she saw a large pillow over the face of R2. In the investigation, R3 stated she spoke with both V4 and V5 and was told R1 was standing over R2 holding a pillow over her face. She also stated the CNAs could not find the nurse to report the incident and they both thought the third CNA had gone to report it. (The third CNA could not be reached by phone and was not present in the facility at the time of my investigation.) A telephone statement made by V13 during the investigation shows she was on the unit between 5 and 5:30 AM, the rest of her shift she was on another hall she was also assigned to. V13 stated she was not told of the incident, but the staff are good at reporting things to her. The facility abuse policy, with a revision date of 11/28/19, shows the purpose is to protect residents from any kind of abuse such as verbal, sexual, mental, physical. A facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility administrator.

Based on interview and record review, the facility failed to perform weekly skin assessments, failed to identity a pressure ulcer prior to late stages for 1 resident, failed to obtain physician's orders for treatment of a pressure ulcer for 1 resident. This failure resulted in R3 obtaining a Stage 3 pressure ulcer that required surgical debridement and advanced to a Stage 4 pressure ulcer. These failures apply to 1 of 3 residents reviewed for pressure ulcers in the sample of 3.The findings include:R3's electronic face sheet, printed on 3/19/26, showed R3 has diagnoses including but not limited to dementia without behaviors, pain in right hip, stage 3 pressure ulcer to right hip, and depression.R3's facility assessment, dated 12/13/25, showed R3 has moderate cognitive impairment, requires partial/moderate assistance to roll left and right, and is at risk of developing pressure ulcers.R3's care plan, dated 6/10/25, showed, Resident is at increased risk for pressure ulcer related to decreased mobility, generalized muscle weakness, and need for staff assist with transfers .assist resident with turning and repositioning.R2's care plan, dated 6/10/25, showed, Skin checks each shift.R3's physician's orders showed no orders for weekly skin assessments from December 2025-January 2025.R3's pressure injury event, dated 1/2/26, showed, 1/2/26 Resident has what appears to be an unstageable pressure injury, measuring 2 x 2 cm (centimeters), to the right ischial protuberance. The wound bed is completely dry. The edges are indurated. Bordered foam placed for protection. Will contact primary for treatment orders. Endorsed to next shift.R3's physician's orders, dated 1/6/26, showed, Right hip: clean and pat try. Skin prep to peri wound then apply hydrogel with silver and a bordered gauze. No treatment orders or documentation of any treatments were present in R3's medical record from 1/3-1/5 for her pressure wound.R3's wound physician notes, dated 1/5/26, showed, Stage 3 pressure wound of the right hip, full thickness >1 day. Wound size 1.9cmx2.0cmx0.2cm. Light serous (clear) exudate.R3's wound physician notes, dated 1/12/26, showed, Necrotic tissue: 20%, Slough: 20%, Granulation tissue: 20% .Surgical excisional debridement procedure: remove necrotic tissue and establish margins of viable tissue. Post-Stage: Stage 4 pressure wound of the right hip, full thickness.As of 3/19/26, R3 continues to have a Stage 4 pressure ulcer to her right hip as evidenced by continued wound physician visits on a weekly basis and continued treatment to R3's pressure ulcer.On 3/17/26 at 10:21AM, V4 (Registered Nurse) stated, Whatever I charted is what the wound looked like. I can't remember that long ago to tell you anything about it. You'll just have to look at the documentation.On 3/19/26 at 9:08AM, V8 (Registered Nurse) stated, Skin assessments are done weekly on every resident. In our computer system, you go into the treatment record, and it will show you whether or not they have skin assessments or treatments or anything. We don't really have a check system, we put in a progress note that the resident had a skin assessment and whether or not their were findings. On 3/19/26 at 9:36AM, V2 (Director of Nursing) and V9 (Wound Care Nurse) stated, Every resident gets a skin assessment on their shower days. The aides report anything out of the ordinary to the nurse. If there are no skin alterations, then the nurse doesn't do a skin assessment. No shower sheets are done for residents. Some residents do have skin assessments that are done by the nurse. (R3's) wound was identified on 1/2/26 and was unstageable to her right hip. (V10, Wound Care Physician) saw her on the 5th and staged it at a stage 3 and initiated treatment. It's an issue that is was found at a stage 3 because that means the wound has been going on for a while and should have been identified earlier.On 3/19/26 at 11:39AM, V10 stated, In general, if a wound is necrotic then that is a problem to be identified as a stage 3. I wouldn't have debrided a wound that wasn't necrotic. It would have remained as an unstageable wound and we would have treated it as such. If I stated in my note that it was full thickness, then that means there was loss of skin and the wound was open. That would not have occurred within a few days. I was able to stage it better after debridement and it was moved to a stage 4 wound. It is the responsibility of the facility staff to ensure and encourage offloading measures. If a resident is not compliant, that should be documented. There are many residents who are noncompliant and facility's are able to identify a wound at early stages. At the end of the day, skin assessments should be completed on all residents to ensure even the smallest wound alterations are identified and treated immediately to prevent wound progression.On 3/19/26 at 12:32PM, V1 (Administrator) and V2 (Director of Nursing) provided documentation to surveyor of unavoidable pressure injury for R3 following surveyors interview with V10. V2 stated, (R3) does refuse interventions but we don't have it documented like we should. Perhaps if we would've had that in place, we could have thought of alternative interventions. I do not see documented weekly skin assessments for her and she is one that should have them as she is noncompliant with interventions. I understand where you are explaining the late stage finding, and again, this is a learning experience for me and my nurse's.The facility's policy titled, Bath (Shower), revised 01/04, showed, Objectives .2. To observe the skin .15. Report any reddened areas, skin discolorations, or skin breaks to the nurse .The facility's policy titled, Pressure Injury/Pressure Ulcer Prevention and Treatment, revised 10/24/22, showed, Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue .Principles: 2. An individualized plan of care will be developed for the resident following the guidelines of the assessment .

Based on interview and record review, the facility failed to honor a residents (R1) Advanced Directive, resulting in (R1) being resuscitated against her wishes. This failure applies to 1 of 3 residents reviewed for Advanced Directives in the sample of 3.The findings include:R1's electronic face sheet, printed on [DATE], showed R1 had diagnoses of COVID-19, rib contusion, chronic kidney disease, depression, and venous insufficiency.R1's physician's orders, dated [DATE], showed, Do Not Resuscitate (DNR).R1's banner on her electronic medical record, created [DATE], showed, Full Code.R1's Physician's Orders for Life Sustaining Treatment (POLST) form, dated [DATE], showed, No CPR (Cardiopulmonary Resuscitation): Do not attempt Resuscitation. R1's POLST form was not scanned into her electronic medical record until [DATE].R1's nursing progress notes, dated [DATE], showed, This nurse called to residents' room regarding a fall. Went to resident's room and she was on the floor facing down, her arms tucked in and she was bleeding. Printed paperwork and shortly 911 responders came. Resident on her way to local emergency room for evaluation. Received a call from local hospital that resident did not make it. Stated while Emergency Medical Services (EMS) was helping her she became unresponsive.R1's local EMS report, dated [DATE], showed, (Ambulance Crew) dispatched to extended care facility for a (resident) who fell and is COVID positive. Upon arrival, crew found patient lying prone on the floor next to her bed with a small amount of blood coming from her nose. Patient breathing normally. Patient was moaning in pain, and crew attempted to communicate with the patient, but she did not have her hearing aids in. Staff member was standing next to the patient and told the crew that the patient was a full code. Manual C-Spine precautions were taken. Patient was log rolled onto a full body splint. C-collar was applied on the patient. Patient was secured to the full body vacuum splint. Patient was carried to the cot and secured. Crew noted the patient started to have agonal breathing. Crew checked patients' carotid pulse and no pulse was felt. Manual chest compressions were started while moving. Manual chest compressions were continued. Patient was placed on cardiac monitor via pads. Patient was showing PEA (Pulseless Electrical Activity) on the cardiac monitor. CPR was continued at a rate of 30:2 with ventilations done BVM (Bag valve mask). BVM was attached to oxygen at 15 liters. Intraosseous (IO) line was placed in left proximal tibia. Patient was given 1:10 Epinephrine via IO and followed with rapid 10mL saline flush. [NAME] device (mechanical CPR system) applied on patient. Compressions were changed to a continuous rate, and ventilations were done at a rate of every 5-6 seconds. Second 1:10 epinephrine was given via IO. Crew noted patient was still in PEA on the monitor. Patient was given a third 1:10 Epinephrine via IO. Upon arrival to the emergency department, patient was showing asystole on the monitor. Patient was taken to room, and verbal report was given to nursing staff. CPR was continued by EMS and hospital staff. CPR was discontinued due to hospital staff having a valid DNR on file that was signed 5 days ago.On [DATE] at 8:25AM, V7 (Registered Nurse) stated, I remember telling the EMS provider that (R1) was a full code because that's what her chart said. I was made aware of the issue with (R1's) code status. There just isn't the management support that I feel we need as nursing staff. There should be someone doing a double check of code status and I don't think the floor nurses have time to be doing that. I went by what was on her banner at the top of her chart and I feel terrible that she was resuscitated and shouldn't have been. It's how we have always done it. Whatever their banner says is what their code status is and we've never questioned it.On [DATE] at 9:36AM, V2 (Director of Nursing) and V9 (Wound Care Nurse) stated, Advanced Directives are usually shared in report with a new admission. Everyone is a full code until we have the paperwork showing otherwise. Once we have the paperwork we change the code status. We do not enter the order or change any code status until we have the POLST form. Sometimes the POLST is faxed ahead of time. The hospital that (R1) came from is kind of a mess right now with the new ownership. Sometimes they will fax the paperwork and sometimes they will send the paperwork with the resident. It is definitely a concern that (R1) was resuscitated and shouldn't have been. The admitting nurse would not have put the order in for DNR unless she saw the paperwork so that means we had the POLST here somewhere so the banner should have been changed to DNR as well to avoid any confusion.The facility's policy titled, Advance Directives, dated 02/2018, showed, To ensure that the resident and/or representative has been informed and educated about the right to formulate an Advanced Directive, and the facility's policy regarding these rights; the resident has been assisted in exercising these rights; and the residents choices regarding these rights have been incorporated into the treatment, care, and services. Documentation of the resident's Advance Directives shall be present within the medical record and specified on the individual's face sheet. All Advanced Directives shall be uploaded into (medical record system) and stored in the resident's clinical record .

Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from significant medication errors. This applies to 1 of 3 residents reviewed for medications in the sample of 3.The findings include:R2's electronic face sheet, printed on 3/19/26, showed R1 has diagnoses including but not limited to Parkinson's Disease, pressure ulcer of sacral region stage 4, Alzheimer's disease, and dementia without behaviors.R2's care plan, dated 3/10/26, showed, (R2) has a wound infection. Antibiotic therapy to be completed 4/22/26.R2's CT (Computed Tomography) scan, dated 3/4/26, showed, Correlate for cellulitis and sinus track at the natal cleft with induration extending centrally to the coccygeal segments with significant posterior bone loss and erosions in the mid and lower coccygeal segments. Osteomyelitis has similar appearance. Correlate for surgical debridement .R2's wound physician note, dated 3/9/26, showed, Investigations recommended and/or reviewed: CT scan of Stage 4 pressure wound sacrum demonstrates osteomyelitis. Similar finding on 3/4/26 Prescription recommendations: Ciprofloxacin 500mg (milligrams) twice daily for 42 days, Linezolid 600mg twice daily for 42 days.R2's physician's orders, dated 3/9/26, showed, Linezolid 600mg twice daily.R2's medication administration record for March 9th-17th showed R2 received 4 of the 16 scheduled doses of his Linezolid.On 3/17/26 at 8:53AM, V11 (R2's daughter) stated, The only thing the facility has allowed us to do regarding my dad's linezolid is to call the VA (Veterans Administration) and now it's being covered. They just told me rules and regulations do not allow us to bring his medications in that would be cheaper. I called (V10-Wound Physician) and he said he would sign the prescription for me so that it could be covered with a different pharmacy. I contacted the Ombudsman, but they told me to call you. My dad has a wound on his foot, neuropathy, edema, and a pressure sore that is causing the osteomyelitis. He was prescribed the medication and then 2 days later is when it was started. It would have been longer if I wouldn't have said something about the VA.On 3/17/26 at 10:21AM, V4 (Registered Nurse) stated, (R2's) linezolid was discontinued this morning. I didn't discontinue it; I don't know who did. It looks like we didn't have it so I'm not sure what is going on with it.On 3/19/26 at 9:36AM, V2 (Director of Nursing) and V9 (Wound Care Nurse) stated, (V10-wound physician) ordered linezolid for (R2) for osteomyelitis and also ordered cipro. The pharmacy sent the pricing to say that it was a high-cost medication. I didn't know it was a high-cost medication until family reacted because he's private pay and would have to pay for it. I tried to figure out how to get it paid for; tried to get a prior authorization through our pharmacy and then I found out he has the VA too. I was trying to make sure I could get it at a lower price for them. They are not able to bring it in from an outside pharmacy; they already signed paperwork that they would go through (facility pharmacy). He already has the benefits through the VA so that wouldn't be considered an outside pharmacy. His medication normally goes through (facility pharmacy). When (facility pharmacy) found out it was high cost they sent me a few days' worth of the medication. On Tuesday (3/17) I let (V10) know that we were working on getting the medication and asked if we could put it on hold. We looked into an alternative medication to see if there was something that would give the same coverage but there isn't. (V10) didn't know if there was anything else that would give the same coverage either. He just said to keep giving cipro until linezolid came in. The VA has not contacted me yet to let me know if it's covered or not.On 3/19/26 at 10:20AM, V1 (Administrator) stated, (R2's) daughter informed me that he had VA benefits because this actually came up in conversation with his daughter about otic medications. (V9) is working on getting the antibiotic he needs as well. Private pay medications that are high cost are handled by me. I contact the family and let them know what the cost is. I informed the daughter that insurance wasn't going to cover it. Whenever pharmacy sends me the sheet then that's how I know it's over our threshold. We have to maintain our contract with Medicare and go through a specific pharmacy. The VA is different because they are a federally funded medication. Even though he is here under private pay we still have to go through Medicare guidelines on medications. He can't bring them in from anywhere other than our pharmacy or the VA.On 3/19/26 at 11:39AM, V10 stated, It is important for (R2) to receive the linezolid to treat his suspected osteomyelitis. We are not seeing bone exposure or clear infection at this point. I would like to see him on the linezolid soon. He has subacute to chronic osteomyelitis. That's the only oral antibiotics recommended for treating osteomyelitis. We have a number of alternatives that can be given IV (Intravenously) but some of those come with different things like having an RN available to be in house, so that's why we are trying to get the linezolid because there was uncertainty about having an RN available to care for intravenous medications. I told the facility if it's impossible to get the linezolid then let's just convert it to IV. It's hard to know if the 4 doses were even beneficial or not, we would have to do another CT scan. Based on recommendations and current guidelines it wouldn't make much of difference just getting a few doses.On 3/19/26 at 12:32PM, V2 (Director of Nursing) stated, (R2's) son/Power of Attorney told us not to treat him after he heard the cost of the medication. We discussed it with (V10) and he said we could hold the medication. I didn't document any conversation with (V10) about the medication, but we did discuss doing an intravenous medication and (V10) didn't want to do that. It was never us as a facility denying the IV medication. I don't know where that came from. I know that if I didn't document it, I can't prove it so that's a learning experience for me. We have many conversations with him that don't get documented and they probably should. Either way, I agree that (R2) needs treatment, we can't keep holding it off. He has an infection that needs to be treated. No documentation was present in R2's progress notes regarding a conversation with V10 regarding R2 not receiving treatment until 3/17/26. The facility's policy titled, Medication Administration, revised on 02/04, showed, Objective: To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident .6. All medications must be administered to the resident in the manner and method prescribed by the physician .

Based on observation, interview, and record review, the facility failed to ensure proper cooling techniques were utilized, failed to maintain cleanliness of unit food storage areas, and failed to maintain facility freezer in proper working condition. These failures have the potential to affect all residents in the building. The facility roster, dated 11/23/25, showed 110 residents residing in the facility.On 11/23/25 at 11:00AM, the initial tour of the kitchen was conducted. The thermometer reading on the facility's walk-in cooler registered at 0 degrees Fahrenheit. V25 (Cook) stated the temperature should be higher than that. A container of Salisbury steak inside the cooler appeared frozen. A previously cooked pork roast was loosely covered in a pan with aluminum foil and showed a use by date of 11/27/25. V25 stated the roast was cooked on Thursday (11/20/25). The facility's walk-in freezer had a thick layer of ice from water that dripped on food items on the top shelf and on top of ice cream cups and popsicles. Additionally, a layer of thick frost/ice was on the top left shelf on top of bagged items. V25 stated ice builds up and they have to defrost it.On 11/24/25 at 10:30AM, the Resident Council meeting was held with 17 residents in attendance. All residents agreed with R102 when she stated tthe kitchenette areas on the hallways were filthy and needed a good cleaning.On 11/24/25 at 1:00PM, all resident dining areas and cupboards were observed. All drawers with coffee, utensils, and condiments had crumbs and spilled coffee grounds inside of them. One of the unit cupboards that were unlocked had a 3/4 full bottle of glass cleaner located inside of it.On 11/25/25 at 9:10AM, the facility's freezer was observed and continued to have ice buildup on the ceiling of the freezer and on top of foods on the left and right top shelves. V3 stated, We try to keep an eye on that but it's hard to have to defrost it all the time. It's better than it used to be, but it still shouldn't be like that. The cooler should be kept at 40 degrees or less and if it's reading 0 I would get a different thermometer and check the temperature. If it's still reading low, then I would have maintenance come check it and do an adjustment.On 11/25/25 at 9:36AM, V3 stated, We haven't done any cooling logs recently and we don't have one for the pork roast that was cooked last week that's in the cooler. Honestly, we have had a lot of new cooks and changeover in the kitchen. Housekeeping and Dietary staff clean the kitchenette areas, but we don't have anyone specifically going through the cupboards and cleaning them; I guess that's something I should implement because I've never thought about it. The facility's policy titled, Food Storage and Labeling Procedure dated 9/22 showed, Store food at the proper temperatures.Refrigerator 41 degrees or below, Freezer 0 degrees or below.The facility's recipe for Ginger & Honey Pork Roast showed, Cool- Product must reach 70*F or less within 2 hours and 41*F or below within 4 hours. Total cooling time should not exceed 6 hours. Separate into shallow pans as needed for proper cooling.

Based on observation, interview, and record review, the facility failed to ensure a resident with dysphagia received thickened liquids and was supervised when eating to prevent her from eating another resident's food and large amount of food at once for 1 of 1 resident (R33), and the facility failed to ensure the hot water and coffee in 3 of 4 dining rooms were at safe temperatures, for residents reviewed for safety and supervision in the sample of 50. This failure has the potential to affect residents in 3 of 4 dining areas.The findings include: 1. On 11/23/25 at 12:32 PM, R33 was sitting in her wheelchair at a dining room table, with three other residents and a resident's wife for the noon meal. R33 was sitting next to R22, who had a grilled cheese that was quartered. R33 had taken a quarter of R22's grilled cheese sandwich, used it like a spoon, put meat on top of it, and then shoved it in her mouth. There were no staff at the table at this time. V19 (R115's wife) was at the table and alerted staff R33 somehow got R22's sandwich. V11, Certified Nursing Assistant, walked over to the table, looked at the residents, then walked away. On 11/24/25 at 11:58 AM, V6, Licensed Practical Nurse – LPN, stated R22 is on a SB 6 diet and stated it is a mechanical soft diet that she had questioned, and was told it meant small bites, but she did not know what the 6 meant. V6 stated R33 has thickened liquids and is on the SB 6 diet. V6 stated R33 wanders around a lot, takes things including other people's food. V6 stated the grilled cheese should be bite sized and it should have been taken away and replaced. On 11/24/25 at 12:10 PM, R33 was given a regular glass of water with ice cubes in it; the water was not thickened. On 11/24/25 at 12:22 PM, V17, Dietary, stated she did not give R33 the regular water; she had her thickened water sitting here for her. V10, CNA, stated she gave the water to R33 and that a different resident was sitting in that spot earlier. On 11/24/25 at 3:22 PM, V2, Director of Nursing, was updated on the dining observations and stated what happened was not okay. V2 stated her first concern was about the diet. V2 also stated she was concerned with cross contamination by eating someone else's food and for the risk of aspiration. V2 stated staff know what a resident eats because the resident has a diet slip at mealtime, and it shows what their diet is with diet and type of liquids. V2 stated staff should follow the diet order. V2 stated R33 is a resident that wanders, and she was not aware R33 was taking other resident's food. On 11/25/25 at 9:26 AM, V12, Registered Dietician, stated, SB6 is part of the International Dysphagia Diet Standards Initiative (IDDSI) diet program. SB means small bite sized food at a level 6. There are different levels. It is like the old mechanical soft, chopped diet. Typically bread and bread products are not typical on this, but the Speech Yherapist at the facility has okayed the use of bread and bread products. The bite size for the SB6 would be 1/2 inch or smaller. The grilled cheese may or may not be okay; it depends on the size of the pieces. Thin liquids given to (R33) is not in line with the physician prescribed diet. (R33) receiving water with ice is a safety concern; she has dysphagia and is a choking risk. The Registered Dietician Note, dated 11/16/25 at 11:55 AM for R33, showed she has diagnoses including Alzheimer's dementia; her diet is soft, and bite sized with slightly thickened liquids. R33 was evaluated by Speech Therapy in September due to coughing/choking during oral intake and her diet was downgraded to slightly thickened liquids. The Minimum Data Set, dated [DATE] for R33, showed supervision or touching assistance needed when eating, severe cognitive impairment. The Speech Therapy Discharge summary, dated [DATE] for R33, showed she was seen for Alzheimer's disease and dysphagia. A soft, bite sized diet and slightly thick liquids were recommended. Supervision at mealtime due to swallow safety was needed 26-49 % of the time. On 11/24/25 at 4:30 PM, V2, DON, stated the facility uses the medication Administration policy for all orders including following diet orders because the policy stated they should follow physician orders. The Medication Administration policy (11/2011) showed all medications must be administered to the resident in a manner and method prescribed by the physician. The policy did not state anything related to diet orders. The facility's Resident Diet: IDDSI policy (2/2021) showed the purpose of the policy.to provide residents with a safe diet as prescribed by the physician. Nursing will enter each new diet or diet change into computer as ordered by the physician. IDDSI diets are as follows: dysphagia level 6: soft and bite sized. Liquid level 1: slightly thick. 2. On 11/24/25 at 1:00PM, 3 of the 4 resident dining areas had a pot of hot coffee and pot of hot water located on the counter, on top of the hot plate of the machine and the machine turned on. On 11/25/25 at 10:42AM, R33 was in the resident dining area, unattended. The hot coffee and hot water pots were full, and the machine was turned on. R33's facility assessment, dated 10/21/25, showed R33 has severe cognitive impairment. On 11/25/25 at 11:16AM, V3 (Food Service Supervisor) obtained the temperatures of the hot liquids. The hot coffee was 175.8 degrees Fahrenheit and the hot water was 168.8 degrees Fahrenheit. V3 stated that is how hot he would expect the liquids to be and that would probably cause a burn if a confused resident spilled it on them. On 11/25/25 at 11:26AM, R2 was in the resident dining area, unattended. The hot coffee and hot water pots were full, and the machine was turned on. R2's facility assessment, dated 11/18/25, showed R2 has severe cognitive impairment. The facility was unable to provide a policy regarding hot liquids.

Based on observation, interview, and record review, the facility failed to provide privacy to a resident during a blood sugar check and insulin administration. This applies to three of three residents (R28, R42, R90) reviewed for privacy in the sample of 50.The findings include:The face sheet for R28 shows a diagnosis of Type 2 Diabetes Mellitus. The POS (Physician Order Sheet), dated 11/2025, for R28 shows an order for blood glucose monitoring before meals and at bedtime. The face sheet for R90 shows a diagnosis of Type 2 Diabetes Mellitus. The POS, dated 11/2025, for R90 shows an order for blood glucose monitoring four times a day and an order for insulin injections to be given at breakfast, lunch and dinner.The face sheet for R42 shows a diagnosis of Type 2 Diabetes Mellitus and the POS shows an order for blood glucose testing for before meals and at bedtime. The POS also shows orders for insulin injections four times a day as needed. On 11/23/2025 at 11:32 AM, V28, RN (Registered Nurse), performed a blood glucose test on R28 while she was sitting at the dining room table with other residents around her. At 11:46 AM, V28 again checked a blood glucose test on R90 while she was sitting at the dining room table with other residents around her. V8 then administered an injection of insulin into R90's arm while at the table. At 11:50 AM, V28 performed a blood glucose test on R42 while he was at the dining room table surrounded by other residents. V28 then gave R42 an insulin injection at the table with other residents in the dining room watching. On 11/23/2025 at 12:00 PM, V28 said she was not able to get the residents blood sugar testing and insulin administration done before the residents were moved to the dining room.On 11/25/2025 at 11:19 AM, V7, RN (Registered Nurse), said blood glucose test and insulin administration should not be done in the dining room. V7 said to provide privacy for the resident, they should be taken out of the dining room. On 11/24/2025 at 3:30 PM, V2, DON (Director of Nursing), said the residents should always be removed from a public area to have a blood glucose test and insulin administration. V2 said it's a HIPAA (Health Insurance Portability and Accountability Act) violation. V2 said the facility does not have a policy regarding privacy.

Based on observation, interview, and record review the facility failed to ensure a resident received assistance to eat (R79) and failed to ensure showers were provided (R22) for 2 of 3 residents reviewed for activities of daily living in the sample of 50. The findings include: 1. R79's face sheet, printed on 11/24/25, showed diagnoses including but not limited to cerebral infarction, dementia, and depression. R79's facility assessment, dated 7/28/25, showed severed cognitive impairment. The assessment showed R79 is completely dependent on staff for oral hygiene, toileting, dressing and hygiene. The same assessment showed substantial to maximal staff assistance required for eating. On 11/23/25 at 12:35 PM, R79 was in bed with her lunch over her, on the bedside table. R79 was alone in the room and was picking at the blueberry pie. R79 was confused and repeatedly tried to bring the pie to her mouth, without realizing nothing was in her fingers. At 12:40 PM, V22 (CNA-Certified Nurse Aide) entered the room, dropped a fork and spoon onto the bedside table, then exited the room. On 11/23/25 at 12:39 PM, R79 was using both her hands to bring a cup to her mouth. All the cups on the table had been drunk and were empty. R79 continued to repeatedly raise the cup to her mouth and was confused. This surveyor remained in the room continuously while interviewing R79's roommate family member. At no time did staff enter the room to offer cueing, encouragement, or feeding assistance. This surveyor exited the room at 1:05 PM. On 11/23/25 at 1:10 PM, V21 (CNA) was pushing a garbage can past R79's room. V21 glanced into the room and said, She (R79) is still in there picking at that plate. V21 did not enter the room and continued on. At 1:16 PM, V22 (CNA) removed R79's lunch tray. Less than one-fourth of the meal had been eaten. On 11/24/25 at 12:44 PM, R79 was in bed and alone in the room. Her lunch tray was over her and none of the food had been eaten. All three cups on her tray had been completely drunk. R79 was staring into space and holding a stuffed animal. At 12:51 PM, V20 (CNA) verified the lunch trays had been delivered to the unit approximately 40 minutes ago. On 11/24/25 at 12:45 PM, V23 (Registered Nurse) stated, (R79) can only say simple yes or no words. She is not able to use the call light and does not get out of bed. A CNA or a family member has to feed her. All meals need to be fed to her. (R79) can reach for a cup and use a spoon or fork on some days but needs encouragement with dining. On 11/25/25 at 12:41 PM, V2 (Director of Nurses) stated the aides should be assisting R79 with meals. It is important to ensure she get the adequate nutrition and good food intake. The facility's Feeding Assistance policy, revision dated 02/04, states: 1. To provide nutrients for the wellbeing of the resident. Encourage resident to assist as much as he is able. 2. The Face Sheet, dated 11/24/25, for R22 showed diagnoses including severe dementia, Alzheimer's disease, cognitive communication deficit, diarrhea, and chronic kidney disease. The Minimum Data Set, dated [DATE], for R22 showed she needs substantial/maximal assistance for showers. The Progress Notes for R22 from 11/19/25 – 11/24/25 showed no behaviors, refusal of care. The Care Plan, dated 11/24/25, for R22 showed her shower days are in the PM on Tuesday and Friday. On 11/23/25 at 12:32 PM, R22 was wearing a black and white striped shirt and black pants while sitting in her wheelchair in the dining room. R22 was at the dining room table for the noon meal. R22's hair was greasy. On 11/24/25 at 11:58 AM, R22 was dressed, sitting in her wheelchair at the dining room table for the noon meal. V18 (R22's son) was visiting and assisting her with her meal. On 11/24/25 at 12:53 PM, V18 stated he was at the facility on 11/21/25 or 11/22/25 and her hair was greasy then. V18 stated it looked worse now. V18 stated R22 doesn't know any different, but if she did, she would not like it. V18 stated R2 was very particular about her hair. V18 stated he would like to see it washed. On 11/24/25 at 1:37 PM, V10, Certified Nursing Assistant - CNA, stated she was R22's CNA for the day. V10 stated R22's shower days are in the shower book. V10 pulled the shower book out and stated R22 is supposed to have a shower on Tuesdays and Fridays on the PM shift. V10 stated they document in the computer in the point of care charting when a shower is completed. V10 stated she doesn't havethe ability to see when the last shower was done; they are not able to see the history. V10 stated she would have to rely on report for the information of a shower not being completed. On 11/24/25 at 1:42 PM, V4, Lead Shift Coordinator, stated if R22's hair is greasy then they should attempt a bed bath or dry shampoo. V4 stated they don't have any scanned shower forms anymore. V4 stated they have Duty Sheets that they use. V4 stated R22 should have had a shower on 11/21/25. V4 pulled the Duty Sheet, dated 11/21/25, and stated R22's name was not listed on the form for the day to receive a shower; no shower was given. On 11/24/25 at 3:22 PM, V2, Director of Nursing – DON, stated showers are to be done twice a week and hair is washed at that time. V2 stated a resident's hair can be washed sooner if it is needed. V2 stated, The resident showers for the day are put on the Duty Sheet for the aides. If staff could tell by looking at (R22) that she missed a shower, then they should have followed up on it. There are shift coordinators on every shift for a reason. The facility's Bath (Shower) policy (1/2004) showed the procedure for giving a shower. Documentation: date and shower given. Resident Care Plan: amount of assistance required should be listed on the resident's plan of care.

Based on observation, interview, and record review, the facility failed to ensure pressure relieving interventions were in place for 1 of 3 residents (R47) reviewed for non-pressure wounds in the sample of 50. The findings include: R47's face sheet, printed on 11/25/25, showed diagnoses including but not limited to peripheral vascular disease, cellulitis of left lower limb, type two diabetes mellitus with foot ulcer, right leg atherosclerosis with ulceration of part of foot, and non-pressure chronic ulcer of right foot with exposed fat layer on toes. R47's facility assessment, dated 10/7/25, showed severe cognitive impairment. The assessment showed the presence of five venous/arterial ulcers and the risk of development of pressure ulcers. R47's wound evaluation and management summary report, dated 11/17/25, showed wound physician recommendations including but not limited to float heels in bed and off-load wounds. On 11/23/2025 at 11:09 AM, R47 was in bed and covered with a light blanket. A pair of blue heel protectors were in a box, next to his bed. V20 (CNA-Certified Nurse Aide) removed the blanket and R47's feet were directly on the bed. R47 had a white gauze wrap on his left foot and an anti-skid sock on his right foot. V20 asked R47 why he was not wearing his heel protectors. R47 was confused and did not respond. At 12:26 PM, R47 was in the group dining room, seated in a wheelchair. R47's left foot was directly on the floor. The right foot was directly on the footrest.On 11/24/25 at 9:11 AM, R47 was in a wheelchair in his room Both heels were directly on the wheelchair foot pedals. At 11:47 PM, R47 was seated in the group dining room. Both feet were directly on the floor. On 11/24/25 at 11:55 AM, V2 (Director of Nurses) stated, (R47) was admitted with chronic wounds on both feet. He has poor circulation and diabetic issues. He is seen weekly by the wound physician, but the wounds will likely never heal. He has several toe amputations, poor skin integrity, and history of heel wounds. The goal now is infection and pain control. V2 said off-loading is needed for prevention. On 11/25/25 at 12:34 PM, R47 was seated in the group dining room with both feet directly on the ground. At 12:41 PM, V2 stated, (R47) should have heel boots on both feet, especially with all his open areas. I can't say why the staff are not using them. Offloading reduces the pressure and helps with healing the injuries he already has.On 11/25/25 at 12:19 PM, V1 (Administrator) stated there are no facility policies related to non-pressure wounds.

Based on observation, interview, and record review, the facility failed to identify pressure ulcers prior to becoming advanced stages for 2 of 3 residents (R83, R6) reviewed for pressure ulcers in the sample of 50. The findings include: 1. R83's face sheet, printed on 11/25/25, showed diagnoses including but not limited to heart failure, non-pressure chronic ulcer of left heel and midfoot, spinal stenosis, and pain in right leg. R83's facility assessment, dated 9/30/25, showed R83 is cognitively intact. The same assessment showed partial/moderate staff assistance needed for transfers, lower body dressing, and putting on/taking off footwear. R83's pressure score risk assessment, dated 9/30/25, showed R83 was at risk. R83's physician orders showed an order start, dated 11/3/25, for the left foot wound treatments to be done every Monday, Wednesday, and Friday. On 11/23/25 at 11:21 AM, R83 was seated in her room in a wheelchair. R83 stated she cannot dress herself below the waist and needs help with all transfers. R83 stated she has been having right heel pain during the transfers while using the sit to stand mechanical lift. R83 had a blue heel protector lying next to her bed. R83 said she had a sore on her right foot in the past and wears the heel protector at night to prevent another problem. R83 said she has a small sore on her left foot that they treat and change the bandage on every three days. On 11/25/25 at 9:13 AM, R83 stated she had received a shower that morning and the dressing on her left foot needs to be replaced. R83 said the wound doctor and a facility nurse saw her yesterday for the weekly assessment on her left foot wound but did not mention anything about her right heel. On 11/25/25 at 9:19 AM, V23 (Registered Nurse) stated R83 is very alert and knows what is going on. V23 reviewed R83's medical record and stated there were no new orders regarding her right heel. V23 said she had not received any report from the morning aides about any new skin concerns after R83's shower. On 11/25/25 at 9:32 AM, V24 (Registered Nurse) stated she did wound rounds on R83 yesterday and never saw anything on her right heel. V24 said R83 did not voice anything to her and this is the first time she had heard of it. On 11/25/25 at 9:43 AM, V23 replaced the dressing on R83's left foot. V23 and this surveyor observed the area on R83's right heel. A quarter size dark-purple area was noted. V23 said this looks like a bruise that is not open. V23 said the Nurse Practitioner was in the building and will be notified that an assessment needs to be done on it. On 11/25/25 at 10:04 AM, V27 (Nurse Practitioner) and this surveyor observed the area on R83's right heel. V27 pushed on the area and R83 reported pain. V27 measured the dark area at 3.5 x 3.5 centimeters and said it is non-blanchable. V27 said, It can't be staged because it is closed. It is mushy underneath. V27 was asked what a deep tissue injury (DTI) would look like. V27 said, It would start as a stage two then progress from there. A DTI is all the way down to the bone or muscle. I have not seen any of those here. On 11/25/25 at 12:01 PM, V4 (Lead Shift Coordinator/ CNA Supervisor) stated aides look at resident skin every shift, during all cares. Any bruising, redness, openings, or scratches should be reported. Resident skin is checked at every shower day from head to toe. Any skin changes need to be reported right away. Not reporting can cause a delay in care or treatment. On 11/25/25 at 12:41 PM, V2 (Director of Nurses) stated a DTI would appear as a dark area that is closed and painful to the touch. V2 said R83's heel sounds like a DTI. V2 said, Nothing has been reported regarding (R83's) heel. Nurses do weekly skin checks. Aides do them on shower days and at all care. It is important that skin issues are reported as soon as possible so a plan of care is started, and it doesn't get worse. R83's wound physician was attempted to be reached for interview but did not return the call during the survey. R83's shower sheets showed she received a shower on 11/21/25 and 11/25/25. There was no documentation in R83's progress notes of a wound to her right heel until 11/25/25 by V27 (after the Nurse Practitioner's assessment). R83's care plan showed a focus area related to increased risk for pressure ulcers related to decreased mobility and generalized muscle weakness. A new intervention to: Apply treatment as ordered to the right heel until resolved was start dated 11/25/25 (day of survey). The facility's Pressure Ulcer Prevention and Treatment Protocol policy, last revision date 10/16/24, states: 4. Staff will be trained on pressure injury prevention and safety measures to be taken, including identifying redness that remains when pressure is relieved and proper positioning procedures. The policy states under the Stages of Pressure Injury Definitions: Deep Tissue Injury (DTI): Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure or shear. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared to adjacent tissue. 2. The face sheet for R6 shows diagnoses to include Parkinson's Disease, stage 4 pressure ulcer to the sacral region, stage 2 pressure ulcer to right heel and malnutrition. The facility assessment, dated 9/16/2025, for R6 shows him to be cognitively intact and requires maximum assistance with transfers. The same assessment shows R6 to be at risk for pressure ulcers. The wound management detail, report dated 11/3/2025, shows a new pressure ulcer was found to his right heel measuring 1 by 0.9 by 0.1 cm (centimeters) with a moderate amount of exudate (a fluid that leaks from blood vessels often due to inflammation or injury). The Wound Physicians wound evaluation and management summary, dated 11/3/2025, shows a stage 2 pressure ulcer to R6's right heel measured 1 by 0.9 by 0.1 cm, with a moderate amount of exudate. The report also shows open areas with exposed dermis (thick layer of tissue below the skin). On 11/23/2025 to 11/25/2025, R6 was observed sitting up in his wheelchair attending meals and activities. On 11/24/2025 at 10:38 AM, V8, CNA (Certified Nursing Assistant), said R6 likes to stay up in his wheelchair each day and will only get into bed in the late afternoon. V8 said skin checks are done on the resident's shower day. On 11/24/2025 at 3:30 PM, V2, DON (Director of Nursing), said skin checks should be done every time a resident is given care. V2 said R6 is at high risk for pressure ulcers and the ulcer to his heel should have been found before it became a stage 2. On 11/24/2025 at 1:51 PM, V15, Wound Physician, said R6 is at high risk for pressure ulcers and a good skin check should be completed to find a new area of concern before it advances to a stage 2 or above. The Pressure Ulcer policy, with a revision date of 10/16/2024 shows, To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. 4.Staff will be trained on pressure injury prevention and safety measures to be taken, including identifying redness that remains when pressure is relieved and proper positioning procedures.

Based on observation, interview, and record review, the facility failed to keep the catheter drainage bag of the bed and below the level of the bladder for 1 of 3 residents (R13) reviewed for catheters in the sample of 50.The findings include:On 11/23/25 at 12:01 PM, R13 was in bed on her back and V5, Certified Nursing Assistant - CNA, and V8, CNA, were getting ready to transfer her from the bed to her wheelchair using a mechanical lift. V5 picked the catheter bag up and attached it to the sling laying on the resident's bed. V5 and V8 raised the lift arm up and the bag was attached to the upper loops of the sling. The drainage bag was at the level of R13's head during the transfer. After the transfer, V8 stated the drainage bag should be below the resident's bladder to prevent backflow of urine causing a urinary tract infection. On 11/24/25 at 3:22 PM, V2, Director of Nursing, stated the catheter bag should be kept below the waist to prevent backflow in the tubing and prevent infection. The drainage bag should not be on the bed for infection control and cross contamination.The Face Sheet, dated 11/24/25 for R13, showed diagnoses including obstructive and reflux uropathy, retention of urine, and VRE (Vancomycin-resistant Enterococcus- an antibiotic-resistant infection) carrier. The Physician Orders, dated 11/24/25 for R13, showed she is on an antibiotic, cephalexin 500 mg by mouth three times per day for retention of urine. R13 takes a cranberry supplement daily for urinary tract infection. The Care Plan, dated 11/24/25 for R13, showed R13 has a urinary tract infection with her antibiotic therapy to be completed on 12/1/25. The Minimum Data Set, dated [DATE] for R13, showed moderate cognitive impairment; partial/moderate assistance needed for transfers and toileting hygiene.The facility's Catheter care policy (6/2005) did not show any thing regarding keeping the drainage bag below the level of the bladder or infection control to include not placing it on the bed.

Based on observation, interview, and record review, the facility failed to provide the physician with the dietician recommendations for a resident with a significant weight loss, and the facility failed to ensure a resident received fluids with her meal and ordered supplements. This applies to 2 of 5 residents (R33 & R8) reviewed for nutrition in the sample of 50. The findings include: 1. R33's Face Sheet, dated 11/24/25, showed diagnoses including Alzheimer's disease, vitamin B12 deficiency, iron deficiency, type 2 diabetes, aortic valve stenosis, atrial fibrillation, atherosclerotic heart disease, hypertensive heart disease with heart failure, hyperlipidemia, congestive heart failure, pain, bursitis, carpal tunnel syndrome, anxiety, depression, and insomnia. The Registered Dietician - RD Note, dated 11/16/25 at 11:55 AM for R33, showed, RD Review. Weight: 11/6 = 116 # (pounds). Weight history: 10/7 = 117.4#, 8/5 = 121#, 5/6 = 129#, significant weight loss -10% x 6 months. Weight on 9/3 = 219.9# clearly an error. Diet: Soft & Bite Sized, slightly thickened liquids. Supplement: protein shake 8oz x 1 daily as provided by family. She was evaluated by speech therapy in September due to coughing/choking during oral intake and her diet was eventually downgraded to slightly thickened liquids. Appetite and intakes are variable. She is at nutrition risk for altered appetite and weight changes related to advanced age and progressive effects of dementia, dysphagia and modified texture diet may impact appetite and meal enjoyment. Recommend add High Calorie/High Protein fortified items to diet for additional kcal/pro. Assist with meals as needed, encourage intakes, honoring preferences as able. Monitor nutritional status and consult RD as needed. The Nutrition Care Report, dated 11/16/25 for R33, showed the same note documented in her chart on 11/16/25 at 11:55 AM. The action portion of the report showed fortified foods: add high calorie/high protein diet. Primary care physician fax attached. The Physician Orders for R33, dated 11/24/25, did not show any orders for High Calorie/High Protein fortified items to be added to her diet. On 11/23/25 at 12:32 PM, R33 was sitting in her wheelchair at the dining room table for the noon meal. R33 took 1/4 of another resident's grilled cheese, used it like a spoon to put meat on it, and shoved it in her mouth. R33 was using her hands to eat meat, diced carrots, and mashed potatoes. Staff were not consistently at the table to assist and/or cue her to eat or use silverware. When R33 was given a fork with meat and potatoes on it, she ate the food. On 11/25/2025 at 9:09 AM, V7, Registered Nurse – RN, stated, There are orders when there is a recommended diet change. A card is filled out and put in (V3, Dietary Manager's) mailbox. V7 stated she has not seen any orders for the fortified foods, high calorie, high protein diet for R33. V7 stated the only thing R33 has is a supplement that is supposed to be brought in by the family, but they have not been bringing them in. V7 stated the RD places the orders for the recommendations. V7 stated she doesn't know what happened to the order for R33. On 11/25/25 at 9:13 AM, V3, Dietary Manager, stated the RD will make a recommendation and emails V,2 Director of Nursing – DON, and then it's given to nurses to follow up on. V3 stated the RD copies him in the email; he reviews it and waits for the nurses to send him an order. V3 stated he saw that the Dietician made the recommendations for R33, and he has been waiting. R33 is not on what is recommended right now. On 11/25/2025 at 9:26 AM, V12, Registered Dietician, stated she attaches a recommendation to the electronic report that gets sent to the Dietary Manager and the DON. V12 stated she doesn't enter any orders; she makes recommendations and sends them to the facility. V12 stated her recommendation for R33 was based on her weight change and nutritional risk. V12 stated she can verify there is a consultant request report that was done on 11/16/25. The recommendation was High Calorie/High Protein fortified items to her diet and nutritional supplement that the family would bring in. V12 stated the report was sent to corporate, the DON, and the Dietary Manager. V12 stated she did not know what happened to the recommendations after that. On 11/25/25 at 12:52 PM, V2, Director of Nursing - DON, stated when they receive recommendations from the Dietician it is given to the physician to sign off on and agree. The order is put in by the nurses and the physician signs the order. V2 stated the Dietician will send the recommendations, V2 prints off the report, and it is given to the floor nurse to obtain the order. V2 stated the Dietary Manager also receives a copy of the report from the Dietician. V2 stated it is important to follow up on the recommendations and obtain the orders because the resident could be missing out on the nutrition that is needed. The facility did not have a policy regarding the process for dietary recommendations from the RD. No policy for significant weight loss was received. 2. The facility face sheet for R8 shows diagnoses to include Alzheimer's Disease and chronic kidney disease. The facility assessment, dated 9/23/2025, shows severe cognitive impairment and requires set up and clean up assistance with dining. The care plan for R8 shows problems with weight loss and requires house supplements and a high calorie, high protein diet. On 11/23/2025 at the noon meal, R8 was observed being assisted to the dining room table for lunch. There were no drinks in front of R8. R8 was served her plate of food, but no drinks. R8 was observed eating her meal unassisted and ate most of her plate of food. R8 sat at the table until 1:00 PM and was never offered anything to drink. On 11/25/2025 at 9:11 AM, V13, LPN (Licensed Practical Nurse), said all residents should get drinks with their meals. V13 said R8 is to get fortified chocolate milk at lunch. V13 said the nurse and the CNAs hand out the supplements. On 11/25/2025 at 9:17AM, V14, CNA (Certified Nursing Assistant), said all resident get drinks with their meals. V14 said it must have been overlooked that R8 did not get any drinks on Sunday 11/23/2025. V14 said the CNAs don't give out the supplements, the nurses do. On 11/24/2025 at 3:30 PM, V2, DON (Director of Nursing), said there is no reason R8 was not given fluids at lunch. V2 said R8 is at risk for urinary tract infections and should be given extra fluids. On 11/25/2025 at 9:30 AM, V12, Registered Dietician, said the residents should get fluids with all their meals, it provides additional nutrition. V12 said R8 continues to have fluctuations in her weight and it may be due to disease progression and the supplements she has recommended for R8 should be given to keep her from losing to much weight. The Physician orders for R8 dated November 2025 shows orders for a regular diet, 8 ounces of nutritional supplement twice a day, and fortified chocolate milk at lunch and supper. The facility policy for meal service, dated 11/14/2022, shows three beverages should be served at each meal. Serve ice water and 2 additional beverages.

Based on observation, interview, and record review, the facility failed to sanitize the blood glucose testing monitor between residents. This applies to three of eight residents (R28, R42, R90) reviewed for infection control in the sample of 50.The findings include:On 11/23/2025 at 11:32, V28, RN (Registered Nurse), was observed checking blood sugars on three residents R28, R42 and R90. After each blood sugar test, V28 wiped down the blood glucose monitor with an alcohol wipe.On 11/23/2025 at 12:00 PM, V28 said it was fine to use alcohol wipes or the micro kill wipes in the medication cart.On 11/24/2025 at 10:00 AM, V13, LPN (Licensed Practical Nurse), said the blood glucose monitor should be cleaned between each resident with the micro kill wipes.On 11/24/2025 at 3:30 PM, V2, Director of Nursing, said the blood glucose testing monitor must be cleaned with the micro kill wipes to prevent cross contamination between residents sharing the monitor.The blood glucose monitors package instructions for cleaning the meter shows the meter must be cleaned between residents using a EPA registered disinfecting wipe. The disinfection process reduces the risk of transmitting infectious diseases if properly performed.

Based on interview and record review, the facility failed to notify a resident's Power of Attorney after the resident fell from her bed. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 3. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE]. The Face Sheet showed V5 was R1's Healthcare Power of Attorney and R1's Daughter (HPOA/POA). R1's 9/22/25 Progress Note from 2:00 AM showed R1 fell out of bed. R1 was assessed by the nurse and there were no injuries. Will call POA (Power of Attorney)/Emergency contact around 6:00 AM. (Note was authored by V6, Registered Nurse.) On 10/9/25 at 10:26 AM, V5 stated she was furious because she had not been notified of R1's fall on 9/22/25. V5 stated it is her expectation to be notified of any changes immediately after a regardless of the time. V5 stated, I need to know what's going on with my mom. V5 stated she was notified of the fall by R1's Sister, V5's Aunt, on 9/22/25 sometime after 1:00 PM. V5 said her aunt had visited R1 on 9/22/25 and during the visit R1 had mentioned the fall to her sister. V5 stated her aunt then called her after the visit and notified her of the fall. On 10/10/25 at 8:15 AM, V6 stated she did document she would call V5 at 6:00 AM and she forgot to call V5. V6 stated she believed V5 was notified later that day by the nurse on duty. On 10/10/25 at 8:48 AM, V2, Director of Nursing, stated, Family should be notified immediately for any changes in condition including falls. Notification is important so family members can make informed decision regarding the care of the resident. V2 stated V6 should have called V5 immediately after the fall. The facility's Fall Information Acknowledgement (Adopted 3/2012) showed, Those residents, who fall, shall have the following steps taken: Notify the Physician, Notify the POA.

Based on observation, interview, and record review, the facility failed to provide safe mobility for residents by not ensuring footrests were on wheelchairs when pushing residents for 4 of 6 residents (R1, R4, R5, & R6) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of the wheelchair and sustaining a laceration that required 3 sutures to close.The findings include:1.R1's Face Sheet, dated 8/19/25, showed diagnoses including vascular dementia, moderate, with psychotic disturbance, encephalopathy, type 2 diabetes mellitus, nutritional anemia, atherosclerotic heart disease, hyperlipidemia, hypokalemia, hypothyroidism, vitamin D deficiency, anxiety disorder, depression, idiopathic gout, pain, overactive bladder, diarrhea, constipation, dysuria, and muscle weakness. The Minimum Data Set (MDS) dated [DATE] for R1 showed moderate cognitive impairment; substantial/maximal assistance needed for toileting, shower/bath, and lower body dressing; partial/moderate assistance needed for upper body dressing, personal hygiene, and wheeling 50 feet in manual wheelchair.R1's Current Care Plan, dated 6/11/25, showed Resident at risk for falling related to poor safety awareness and generalized muscle weakness (start date 9/13/25); last reviewed 8/5/25. The care plan was updated on 8/4/25 and showed staff assist of two with mechanical lift for transfers. Keep foot pedals in place if staff is providing transport assist. If R1 is self-propelling through the unit, allow her to self-propel (updated 7/28/25). The Nurses note, dated 7/26/25 at 9:32 PM for R1, showed, resident exhibiting behaviors this shift. Screaming, crying, running into things/people with her wheelchair, setting off the door alarm and going into others resident's rooms. At approximately 8:30 PM, (V3, Certified Nursing Assistant/CNA) began to push (R1) to her room when (R1) planted her feet firmly on the floor and fell face first onto the floor. Blood was noted on the floor and a small laceration to her forehead was observed. Pressure was applied to the wound and the resident was made comfortable while the nurse called 911. (R1) was transported to the emergency department (ED). Husband/power of attorney (POA) notified. Medical Doctor (MD) notified. Director of Nursing (DON) notified.The Long-Term Care Facility & IID - Serious Injury Incident and Communicable Disease Report for R1, dated 7/30/25, showed it was the final report for an incident that occurred on 7/26/25. The report showed R1 has multiple diagnoses including a history of vascular dementia and encephalopathy. R1 takes medications including Lexapro and risperidone. On 7/26/25 at approximately 8:30 PM, R1 was observed having a loss of plane. Upon notification the nurse immediately completed an assessment and noted a small laceration to R1's forehead with a small amount of blood loss noted. Mild discomfort to her head. Range of motion x 4 with no shortening, rotation, or deformity noted. Neuros within normal limits at baseline. Maintained position. At approximately 8:35 PM, the on-call physician was notified with orders to send to the emergency department (ED) to evaluate and treat. Power of attorney (POA) was phoned. 911 was phoned and arrived to transport R1 at 8:50 PM and left the building to the hospital ED. At approximately 12:36 AM on 7/27/25, resident returned to the facility with orders to cleanse forehead with soap and water. Three sutures noted and a hematoma formed. Upon investigation, it was determined that when R1 was being transported in her wheelchair, she had firmly placed her feet on the floor, which resulted in her falling forward out of her wheelchair. On 8/19/25 at 8:47 AM, V1 (Administrator) stated, (V2, Director of Nursing/DON), did the incident investigation. (R1) was going to pull the fire alarm and (V3, Certified Nursing Assistant/CNA) went to stop her. (V3) moved (R1), and when she did this, the resident planted her feet on the floor. This caused a forward motion. (R1) fell out of her wheelchair and hit her head. (R1) had a laceration to her head. V1 stated when he came to the facility in September 2024, he did training/in servicing with the staff about using foot pedals when pushing a resident in their wheelchair. V1 stated it is his rule for resident safety. (V3) did not follow the rule for resident safety. (V3) didn't follow the procedure. When someone plants their feet, then staff should stop immediately right there and call for help, and put the foot pedals on. It is done for the resident's safety.On 8/19/25 at 9:17 AM, V3, CNA, stated, (R1) was having behaviors all day, and she was exit-seeking. (R1) did not have foot pedals on her wheelchair because she moves around in her chair on her own. (R1's) wheelchair is reclined in back a little, but she doesn't sit all the way back in it; she never does. I went to move (R1) away from the door and when I turned (R1) around, she planted her feet. (R1) fell out of her wheelchair. (R1) did not have any foot pedals assigned to her.2.R4's Face Sheet, dated 8/19/25, showed vascular dementia, parkinsonism, atherosclerotic heart disease, long term use of antithrombic/antiplatelets, hyperlipidemia, overactive bladder, retention of urine, pain, vitamin deficiency, abdominal pain, depression, anticoagulant use, elevation of levels of lactic acid dehydrogenase, constipation, shortness of breath, vomiting, and hypoxemia.R4's MDS, dated [DATE], showed severe cognitive impairment; partial/moderate assistance needed for toileting, upper body dressing, personal hygiene, and wheeling in a manual wheelchair 50 feet. R4's Care Plan, dated 6/27/25, showed resident is at risk for falling related to need for staff assist with daily activities and well as safety reminders. Staff assist of one with walker or grab bar for pivot transfers. Instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Orientate resident to room, surrounding areas, and use of call light system. Encourage resident to use side rails/enablers as needed. Provide resident with specialized equipment i.e. walker and wheelchair. Assist resident with activities of interest. On 8/19/25 at 11:31 AM, V4, CNA, brought R4 into the dining room. V4 was pushing R4 in his wheelchair without any foot pedals in place. On 8/19/25 at 11:39 AM, V4 stated when pushing residents in the wheelchair, they should have the footrests on their chairs. V4 stated there is a blue bag on the back of the chair that holds the footrests. V4 she is supposed to use them, just got in the moment, and forgot. All residents should have a bag on the back of their wheelchair with the footrests in them. V4 stated they are supposed to use them for the resident's safety.3.R5's Face Sheet, dated 8/19/25, showed diagnoses including Peripheral vascular disease, unspecified hypertensive urgency, dysphagia, left sided weakness, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with necrosis of muscle, laceration without foreign body, left foot, subsequent encounter, atrial septal defect, unspecified, hypomagnesemia, left wrist contracture, hypertension, abnormal posture, dysarthria and anarthria, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder due to known physiological condition, constipation, long term (current) use of antithrombotic/antiplatelets, and cognitive communication deficit.R5's MDS, dated [DATE], showed severe cognitive impairment; dependent for toileting, shower/bath, upper body dressing, lower body dressing, persona hygiene, and wheeling in a manual wheelchair 150 feet; partial/moderate assistance wheeling in a wheelchair 50 feet. On 8/19/25 at 11:33 AM, V5, Licensed Practical Nurse (LPN), pushed R5 into the dining room in his low padded wheelchair. R5's foot was sliding across the floor when she was pushing him. There wasn't a footrest in place. V5 stated she did not know why there wasn't a footrest on his chair; his chair would not have footrests like a regular wheelchair. V5 stated when residents are pushed in their wheelchairs, the foot pedals are supposed to be on the chair. V5 stated there is a blue bag on the back of the wheelchairs that holds the foot pedals. V5 stated the foot pedals should be used for residents' safety.4.R6's Face Sheet, dated 8/19/25, showed diagnoses including cerebral infarction, spinal stenosis, dysarthria following cerebral infarction, muscle weakness, unspecified fall, subsequent encounter, aphasia following cerebral infarction, dysphagia following cerebral infarction, hypertension, other abnormalities of gait and mobility, hyperlipidemia, benign prostatic hyperplasia without lower urinary tract symptoms, (osteo)arthritis, pain, insomnia, constipation, and long term (current) use of antithrombotic/antiplatelets.R6's Care Plan, updated on 8/4/25, showed: Resident at risk for falling related to generalized muscle weakness and need for staff assist with daily cares. Staff assist of two with stand aid for transfers with arm sling on right arm, high-profile toilet to aid in rest room use. Provide resident with specialized equipment, wheelchair, walker. Instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Orientate resident to room, surrounding areas, and use of call light system. Encourage resident to use side rails/enablers as needed. Assist resident with activities of interest.R6's MDS, dated [DATE], showed moderate cognitive impairment; substantial/maximal assistance needed for toileting and lower body dressing; Partial/moderate assistance needed for shower/bath, upper body dressing, personal hygiene, and wheeling in a manual wheelchair 150 feet. On 8/19/25 at 11:37 AM, R6 did not have footrests on his wheelchair when V4, CNA, was pushing him into the dining room for lunch.On 8/19/25 at 11:39 AM, V4 stated when pushing residents in the wheelchair, they should have the footrests on their chairs. V4 stated there is a blue bag on the back of the chair that holds the footrests. V4 she is supposed to use them, just got in the moment, and forgot. All residents should have a bag on the back of their wheelchair with the footrests in them. V4 stated they are supposed to use them for the resident's safety.On 8/19/25 at 12:23, V1 (Administrator) stated he did not have a policy for footrests being on wheelchairs when he did the in-service and training. V1 stated corporate told him there was a policy; so he did the in servicing. V1 stated he ordered the blue bags for the back of the wheelchairs to hold the footrests. At 12:26 PM, V1 stated V2, Director of Nursing (DON), contacted the corporate nurse who told her there wasn't a policy related to footrests, but all wheelchairs should have them. The In-Service Education/Meeting Report, dated 7/28/25, showed, this is our policy and for their safety. All residents that are using a wheelchair must have wheelchair peddles. If for any reason you need to push a resident in a wheelchair, they must have pedals on at all times. If you don't have pedals, you don't push them.The facility's Safe Resident Handling policy (11/2012) showed the facility is dedicated to providing quality care to residents who have entrusted their lives to us and provide a work environment that is safe and enjoyable to staff. Our Safe Resident Handling Program is designed to meet the following goals: Protect staff and residents from injury. All residents will be assessed for safe resident handling and moving. The assessment will consider: Staff and resident safety. The facility's Geriatric Chairs policy (2/2004) showed, adjust foot pieces. On 8/19/25, the facility did not have a policy regarding the use of foot pedals on wheelchairs.

Based on interview and record review, the facility failed to administer a resident's (R1) sodium tablets for 12 days following his admission to the facility. This failure resulted in R1 experiencing a critically low sodium level, confusion, hallucinations, and a 15 day hospital stay to correct his sodium levels. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's electronic face sheet printed on 7/8/25 showed R1 has diagnoses including but not limited to permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of bladder. R1's census report showed R1 was admitted to the facility on [DATE], and discharged to a local hospital on 6/16/25. R1 did not return to the facility. R1's local hospital discharge orders, dated 6/5/25, showed, NEW: Sodium Chloride 1gm PO (oral) QID (4 times per day) .Discontinued: sodium chloride 1,000mg PO TID (3 times per day) . R1's physician's orders for June 2025 showed no orders for R1 to receive Sodium Chloride 1gm PO QID. R1's medication administration record for June 2025 showed no evidence R1 ever received Sodium Chloride during his stay at the facility from 6/5/25-6/16/25. R1's nurse practitioner visit note, dated 6/9/25, showed: 4. SIADH- chronic- managed with sodium chloride 1gm po qid . On 7/8/25 at 10:23AM, V4 (R1's son) stated, (R1) went to an appointment which required them to draw blood and his sodium level was 115. The facility called my sister to let her know because she was at a different appointment with (R1), and she took him to the emergency room. He went back to (local hospital) where they had to slowly increase his sodium levels back up to normal. When she got him to (local hospital), he was hallucinating and saying he was seeing people outside of his eyes and was completely disoriented. I have no idea how she even handled him at the appointment. He knew he wasn't right, and he told us he felt disoriented, and he knew he was hallucinating. It took 2 weeks in the hospital before they got his levels regulated again. The orders were clearly on his discharge paperwork so I'm unsure why (facility) never gave him his medications. On 7/8/25 at 9:48AM, V5 (R1's Nurse Practitioner) stated, SIADH is usually the reason we see someone on a sodium replacement and that's what (R1) was getting it for. 10 days without the sodium tabs could have detrimental effects and create a critically low sodium level which would put him at risk for nausea, vomiting, increased confusion, and potentially seizures depending how low his sodium was. I never saw what his labs were because he was out at an appointment at the time, and they drew the labs and got the critical lab value. I saw him on 6/9/25 and nobody ever reported to me that he wasn't getting his sodium tabs, so I assumed what I saw on the discharge report was being given because I certainly did not discontinue his sodium tabs. I never received any notification that there were any issues with getting the medication or entering it into the system. On 7/8/25 at 9:57AM, V3 (Licensed Practical Nurse) stated, If my name was next to the orders for admission then I must have been the nurse who admitted (R1), but I don't remember much about him. When I do an admission, I look at discharge paperwork and reconcile the orders. Sometimes the hospital will send the orders before the resident comes but it usually comes with the resident. I don't recall having any issues entering any medications or not being able to find medications. If I was the nurse that put the orders in, then there is another nurse from night shift that checks orders so someone besides me should have caught this. If a resident is not receiving sodium as ordered, they could potentially have cardiac effects. I can't really say much because I'm not a doctor or anything. On 7/8/25 at 10:07AM, V2 (Director of Nursing) stated, When a resident is admitted , the floor nurse enters the medications. Usually, it is the nurse from that hall but if another nurse is available, they will do it. Third shift nurses are then responsible for double checking the discharge orders from the hospital and reconciling it with our list. I remember (R1) a little bit, but he wasn't here long. He went to the hospital because of low sodium and change in mental status. He was out at an appointment at the time we got the call about his low sodium, so his daughter drove him to the hospital. I'm not even sure when the labs were done or what the level was. On 7/8/25 at 11:42AM, V2 stated, We were able to get the labs from the hospital and it showed (R1's) sodium levels were 115 when he got to the hospital, which is a critically low level. He was confused and hallucinating which are signs of low sodium. I have no idea how this order was missed when he was admitted to the facility because 2 nurses checked the orders so it should have been caught. This is a perfect example of a significant medication error. R1's local hospital records showed, 6/16/25 Sodium 115 (Critical Lab Value) 6/17/25 119 (Critical Lab Value) . The facility's policy titled, admission of A Resident revised 01/04 showed, Objective: 1. To facilitate the transition from prior living arrangement to long-term in a caring, professionally comprehensive manner .Procedure .13. Obtain physician's orders . The facility's policy titled, Medication Administration revised 02/04 showed, Objective: 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident .Procedure .5. All physician's orders must be accurately transcribed to the MAR (medication administration record). 6. All medications must be administered to the resident in the manner and method prescribed by the physician. 7. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the MAR (Medication Administration Record) .

Based on observation, interview, and record review, the facility failed to ensure a safe transfer by not using a gait belt for one resident, (R3), and failed to ensure one resident (R1) was safely transferred. This failure resulted in R1 falling during a staff assisted transfer and sustaining multiple lacerations to her head requiring sutures. This applies to 2 of 3 residents (R1 and R3) reviewed for safety in the sample of 3. The findings include: 1. R1's Care Plan shows, Transfer Program: 1. Set up devices for transfer. 2. Encourage [R1] to stand using chair arms or edge of bed to push off from and come to a standing position. 3. Encourage [R1] to turn using walker until back of body is in front of source to transfer to. 4. Encourage [R1] to reach back and place hands on chair arms or edge of bed prior to sitting. 5. Encourage [R1] to sit down slowly. R1's Emergency Department Note, dated 1/3/25, shows, Pt (Patient) states she fell while getting out of bed. Pt has laceration to forehead Patient hit her face on the ground. She presents with a laceration type injury to her left forehead as well as underneath her left orbit. She complains of pain at the laceration site Laceration 1 .Forehead .left .7 cm (centimeters) .7 sutures Laceration 2 .under left orbit .4 cm 4 sutures On 1/9/25 at 8:55 AM, R1 was sitting in a wheelchair in her room. R1 had a laceration to the left side of her forehead, with sutures in place, and a laceration to under her left eye, with sutures in place. There was yellow/purple bruising around both lacerations. R1 stated, I fell out of bed. On 1/9/25 at 9:43 AM, V4, Certified Nursing Assistant (CNA) said she went into R1's room the morning of 1/3/25 to get R1 up to the shower. V4 said she assisted R1 to sit on the side of the bed and put on R1's slippers. V4 said she applied a gait belt on R1, and positioned her wheelchair near her bed. V4 said she positioned herself between the side of the bed and the wheelchair, placed her right hand onto the gait belt, and had R1 stand up. V4 said R1 took one or two steps to turn to sit in her wheelchair when she fell forward. V4 said her hand slipped off of the gait belt due to the force, so she was unable to assist her to the floor. V4 said she fell forward and hit her head on the floor. V4 said R1 was not using a walker during the transfer. On 1/9/25 at 11:00 AM, V7 (Physical Therapy Assistant) said staff should always use a gait belt when assisting a resident with a transfer for the resident's safety. V7 said if a resident starts to fall, the staff member can either prevent the fall or assist them to the ground in a controlled manner to try and prevent any injuries. V7 said staff should be holding the gait belt during the entire transfer, and should be as close to the resident as they can during the transfer. V7 said if a resident is transferring from the bed to the wheelchair, the wheelchair should be parallel to the side of the bed, and the staff member should be standing in front of them and holding onto the gait belt with both hands during the transfer if they are not using a walker. V7 said R1 should be using her walker and a gait belt during transfers. V7 said it would be safer for her. V7 said if a resident is using a walker for a transfer, the walker should be placed in front of the resident and the the staff should be holding the gait belt standing by the residents side opposite of the wheelchair. V7 said walkers help resident's with balance during transfers. On 1/9/25 at 1:50 PM, V2 (Director of Nursing) said she interviewed V4 about what happened, and she said the resident had slippers on, and she thinks the slippers did not have enough grip on the bottom and caused R1 to slip. V2 said R1 fell forward and away from V4, and she was unable to catch her. V2 said R1 does use a walker. V2 said gait belts should be used at all times when transferring a resident, and the resident should be transferred in the manner shown in their care plan. V2 said staff should be able to use the gait belt to assist the resident to the ground in a controlled manner if they start to fall to prevent injuries. V2 said if a resident uses a walker, that would give them better stability as well. 2. R3's current Care Plan shows that she is at risk for falls related to weakness. R3's Resident Care Information shows, Safe Resident Handling Procedures-Transfer Method: 1 assist with pivot transfers. Level of assistance: staff assist of one . On 1/9/25 at 8:43 AM, V3 (CNA) transferred R3 to the toilet. V3 did not apply a gait belt to R3 before the transfer. On 1/9/25 at 8:50 AM, V3 said she totally spaced out putting a gait belt on R3 for her transfer to the toilet, but should have applied one. The facility's Gait Belts Policy, revised on 12/02, shows, No resident will be transferred or ambulated without the use of a gait belt, unless to do so is contraindicated and this would be identified on resident's plan of care. The facility's Sit to Stand Procedure, revised on 8/14, shows, Apply the gait belt keep a wide balanced stance and the resident close to your body .Have the resident's assistive device (if any) in front of them. Stand on the resident's weak side .Assist the resident by holding onto the gait belt with one hand and the assistive device with the other hand

Based on interview and record review, the facility failed to ensure a resident was wearing non-skid footwear and was being held by the gait belt when being transferred/ambulated for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3 residents. This failure resulted in R1 falling and sustaining a rib fracture, two transverse process fractures of the lumbar vertebrae, and a skin tear. The findings include: R1's Face Sheet, dated 11/25/24, shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, fracture of neck of right femur (hip), presence of right artificial hip joint, Parkinson's disease, muscle weakness, unsteadiness on feet, pain, and an unspecified fall. R1's Fall Risk, dated 10/2/24, shows R1 was a high fall risk. R1's Care Plan (problem start date 10/3/24) shows R1 is at risk for falling. The facility's Event Report, completed 11/20/24 at 3:26 PM, shows R1 had a fall on 11/19/24 at 9:42 PM in his room. The report shows R1 feels he fell because he slipped as the CNA was transferring him to bed. R1 complained of pain to his left ribs and a skin tear was noted. Evaluation Notes from the report state, Encourage use of non-skid footwear for transfers and ambulation. R1's Progress Notes, dated 11/19/24 at 9:24 PM, shows the nurse observed R1 lying on his backside on the floor in his room. R1 reported he slipped when transferring to his bed without wearing shoes. R1 said he hit his back and head and felt like he cracked a rib. R1's Progress Notes, dated 11/19/24 at 11:04 PM, shows facility staff spoke to a nurse at the hospital and were informed R1 fractured his left posterior twelfth rib and left lumbar vertebrae (L3 and L4) transverse process and sustained a skin tear on his left arm. R1's CT abdomen and pelvis without contrast study, dated 11/19/24 at 10:33 PM, shows the following: Impression: Left posterior 12th rib fracture. Left L3 and L4 transverse process fractures. On 11/25/24 at 9:20 AM, V3, Licensed Practical Nurse, said she was doing her med pass and the shift coordinator, V6, reported a resident was on the floor. V3 said V4, Certified Nursing Assistant (CNA), was in the room with R1 when she arrived. V3 said R1 was lying on his back on the floor and had a skin tear on his left forearm. V3 said R1 was wearing regular socks, they are slippery socks and no shoes. V3 said R1 said it felt like his rib cracked. V3 said R1 told her he slipped. V3 said she was, not sure why they would put a gait belt on him and not shoes. On 11/25/24 at 11:22 AM, V4 said she was assisting R1 from his recliner to his bed. V4 said R1 stood up and took a couple steps with his walker and fell back and sideways into the window. V4 said it happened so fast she was unable to catch him. V4 said she was not holding onto R1's gait belt when he fell , she just had her hands on his waist and was guiding him. R1 was wearing socks and no shoes. When asked if she would have done anything differently, V4 replied she would have made sure R1 had shoes on, and would have held on to him tighter. On 11/25/24 at 11:42 AM, V2, Director of Nursing (DON), said V4 told her she was transferring R1 to his bed, and R1's feet started slipping and she could not catch him from falling. V2 said after investigating R1's fall, she educated staff to make sure they are holding on to the gait belt, and to be cognizant about what the residents are wearing. On 11/25/24 at 12:19 PM, V5, Assistant DON, said V5 said R1 was a fall risk. V5 said they treat everyone as if they are a fall risk and they use a fall risk scale (John Hopkins Fall Risk Assessment Tool) to identify residents who are at a higher risk for falls. V5 said all residents should have non-skid socks or shoes on when they get up.

Based on observation, interview, and record review, the facility failed to immediately notify a physician of a fall with new onset of pain, failed to monitor and assess a resident post fall for pain and change of condition, and failed to provide pain medication for a resident experiencing pain after a fall for 1 of 3 residents (R1) reviewed for quality of care. This failure resulted in R1 not being transferred to the acute care hospital for evaluation for 19 hours after a fall with a fractures. The findings include: R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, dysphagia, Chronic Obstructive Pulmonary disease, Malignant neoplasm of prostate, Alzheimer's Disease with late onset, muscle weakness, venous insufficiency, chronic kidney disease, atherosclerotic heart disease of native coronary artery, unsteadiness on feet, anxiety disorder, repeated falls, and abnormality of gait and mobility. R1's facility assessment, dated 7/2/24, showed he has severe cognitive impairment and requires substantial/maximal staff assistance for transfers. (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) R1's Incident Report showed, At approximately 5:45 AM on 8/30/24, it was reported to the nurse that resident had been lowered to the floor when transferring due to bilateral weakness of his legs. Resident complains of some pain to the left shoulder area but range of motion was assessed to be WNL (within normal limits), and Tylenol was given for pain. At approximately 1:29 PM on 8/31/24, resident was complaining of increased pain to left arm. He was assessed and bruising noted and unable to complete ROM (range of motion). Order received to send to ER (emergency room ) for evaluation. Resident transferred to [local acute care hospital] at 1300 (1:00 PM) on 8/31/24 for evaluation. Resident returned from [local acute care hospital] at 19:19 (7:19 PM) on 8/31/24 with orders for sling to the left arm at all times. Pain management provided with ice and oral medication. Orthopedic appointment scheduled for 9/6/24. X-ray of left shoulder conclusion: Humeral head neck impacted angulated comminuted fractures seen. X-ray of left elbow conclusion: Subtle nondisplaced fractures injury at the posterior lip of olecranon. Advanced demineralization is noted. [Nurse Practitioner] confirmed diagnosis of osteopenia. Therapy to evaluate for safest level of transfer need and strengthening. R1's Acute Care Hospital emergency room documents, dated 8/31/24, showed, . Patient Visit Information . Humerus fracture . Prescriptions: 1. Hydrocodone/acetaminophen 5-325 mg every 4 hours as needed . Procedure: Radiographic image of the shoulder, left 2-4 views . Indications: Fall yesterday. Hematoma on left arm, with decreased use of arm . Conclusion: Comminuted angulated impacted fractures seen with surrounding soft tissue swelling . Procedure: Radiographic image of the elbow, left . Indications: Fall yesterday; hematoma on left arm with decreased usage Conclusion: . Correlate for subtle nondisplaced fractures injury at the posterior lip of olecranon. Soft tissue swelling . R1's 8/30/24 Nursing Note entered at 5:45 AM showed, This nurse was called into residents room by CNA (Certified Nursing Assistant). CNA reported resident was slowly lowered to the ground due to resident bilateral lower extremity weakness. Resident typically transfers with 1 assist to wheelchair. Resident reports pain to left shoulder area that is new. PRN (as needed) Tylenol administered for pain relief. No injuries observed. ROM (range of motion) within normal limits for resident POA (power of attorney) and NP (Nurse Practitioner) notified. R1's Physician Notification form, dated 8/30/24 at 5:25 AM, showed it was reviewed by the V16 (NP/Nurse Practitioner) on 9/3/24. On 9/11/24 at 1:45 PM, V16 (Nurse Practitioner) said staff completed a physician notification form and placed it in her binder in the facility for review on her next visit. V16 said she would have expected staff to call and notify her of R1's fall with new onset of pain so she could give orders. V16 said if she had been notified immediately of R1's fall with new onset of pain, she would have ordered an x-ray to be done in house, or would have given orders to transfer R1 to the acute care hospital for evaluation. V16 said if a resident is experiencing a new onset of pain, especially after a fall, it needs to be addressed. R1's next nursing note was dated 8/30/24 at 8:23 PM and showed, Post fall observation. Vital signs within normal limits for this resident. Continues to have complaints of discomfort to the left shoulder. Scheduled Tylenol administered as ordered. continues on antibiotic treatment for suspected osteomyelitis . This was the only pain relief medication administered to R1 between 5:38 AM and 8:23 PM. There was no evidence of R1 being assessed by a nurse from 5:45 AM on 8/30/24 through 8:23 PM on 8/30/24. On 9/10/24 at 2:19 PM, V6 (CNA/Certified Nursing Assistant) said she came in to work on 8/30/24 right after R1's fall at approximately 5:30 AM. V6 said R1 had never complained of shoulder pain to her before and she works his hall very frequently. V6 said, I could tell he was in a lot of pain. I would have said his pain would have been at a 10. He would scream out in pain if we touched it. It was obvious to me that something was wrong. On 9/10/24 at 2:38 PM, V4 (CNA) said she worked day shift on 8/30/24 after R1's fall. V4 said, [R1] was hurting a lot. I touched his arm and flinched and winced. When we would roll him he said 'ow ow ow' which was something he never did . His pain stayed the same throughout my shift, he wouldn't eat, he just stayed in bed. I tried to feed him and he spit it out. On 9/10/24 at 3:28 PM, V9 (CNA) said she worked day shift on 8/30/24 after R1's fall. V9 said, We were taking care of him and he was screaming and hollering in pain. I told the nurse something was wrong with him. She said he was lowered to the floor and had no injuries. I told her he is not acting like someone who was 'lowered to the floor' . I was really upset because the nurse wasn't listening to me. I told her 'I'm sorry but he is hurt.' They didn't send him out. She kept dismissing me and saying she got in report he was fine . On 9/10/24 at 3:41 PM, V7 (RN/Registered Nurse) said R1's fall happened just before she came on shift. V7 said she received in report that R1 had a witnessed fall with no injury, and was told they gave R1 some Tylenol. V7 said she went in and saw R1, and he looked tired, and said his arm was sore. V7 said, I checked on him and there appeared to be nothing abnormal or of concern. There was no evidence of V7 assessing R1 found in his medical record. R1's August 2024 eMAR (electronic Medication Administration Record) showed no pain control medication was administered during V7's shift on 8/30/24 from 6:00 AM to 2:30 PM. On 9/10/24 at 1:17 PM, V5 (R1's Spouse) said the nurse called and told her R1 had a fall. V5 said when she got to the facility on [DATE] she could tell he had pain, but nothing 'too bad' if he was laying still. V5 said when they would try and move R1 he was hurting and he did not want to move his arm. R1's 8/31/24 Nursing Note entered by V17 (RN) at 5:22 AM showed, Resident is being monitored post fall and for treatment of possible osteomyelitis . Resident did not voice any issues or concerns throughout the night. On 9/11/24 at 1:35 PM, V17 (RN) said she works night shift. V17 said she does not go into resident's rooms unless she is passing medications or if the aides report their vitals are off. When asked about assessing a resident who had recently had a fall, V17 said she would not go in and assess a resident just because they had a recent fall. R1's 8/31/24 Nursing Note entered at 1:29 PM showed, Resident reporting moderate pain to left arm from fall, he was unable to tolerate any ROM, significant purple bruising noted from elbow to wrist. [Physician] was notified and gave order to send to the ER (emergency room ) transferred resident to [acute care hospital] for eval at 1:00 PM. R1's 8/31/24 Nursing Note entered at 9:32 PM showed, Received report from [acute care hospital] prior to resident's return. He is to wear sling to LUE (left upper extremity). Resident had no meds at hospital and slept the whole time. He has new orders for Norco 5/325 q4h (every 4 hours) PRN (as needed) for pain to LUE fx (fractures) . PRN Tylenol was given R1's 9/1/24 Nursing Note entered at 5:41 AM showed, Resident has been moaning et (and) expressing feelings of pain et discomfort, does state having pain in left shoulder, have attempted different positions . On 9/11/24 at 12:42 PM, V15 (ADON/Assistant Director of Nursing) said, When a fall happens, the nurse on duty notifies the provider and family. If it is urgent, they will get an order to send the resident to the hospital. After a fall, the CNAs get vitals on the resident for 3 days, as fall follow ups and the nurses should be doing an assessment. They would document their assessment under the progress notes. They know to do and document assessments after falls because that is what they are trained to do here. They should be monitoring for changes. V15 said she would have expected the day shift nurse on R1's hall to do an assessment and document in the medical record, especially since the fall had just happened prior to her starting her shift. V15 said R1 should be monitored for pain, and pain should be treated appropriately. V15 said resident's should be assessed for range of motion after falls and if there is pain, they should notify the provider and either send to the hospital or get x-rays in house. On 9/11/24 at 1:00 PM, V2 (DON/Director of Nursing) said she expects post fall assessments and vital signs to be documented for at least 72 hours after the fall. V2 said, The CNAs do the vitals and turn into the nurses, but the nurses should be monitoring them, so if there is any changes in range of motion or increased pain they can let the doctor know. The nurse should have contacted the doctor, and let the doctor know (R1) had a fall rather than place a note in the nurse practitioners binder to be reviewed on the nurse practitioner's next office day. V2 said if R1 was complaining of pain she would have expected there to be pain medications given and the physician or nurse practitioner notified. The facility's policy, revised 12/02, showed, . Subject: Change in a Resident's Condition; Purpose: Our facility shall promptly notify the resident, and/or resident's representative, and his or her attending physician of changes in the resident's condition and/or status . Procedure: 1. The nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury . The facility's policy and procedure, revised 4/3/18, showed, . Subject: Emergencies; Policy: It is the policy of the facility to provide emergency care to a resident in need of it Falls: 1. Check the resident immediately for ability to move extremities; 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall.; 3. Check if, or with anyone who witnessed the accident. Determine if possible, where, how, and when the accident occurred.4. check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives . 6. Call the resident's physician . The facility's policy and procedure revised 3/3/22 showed, . Subject: Pain Management; Policy: The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms 3. Residents will be observed and asked about pain at a minimum of each shift by the nurse using a standardized 0-10 scale or Verbal Descriptor Scale to determine pain intensity. 4. The physician will then be contacted, if needed, regarding the pain or pain indicators .

Based on observation, interview, and record review, the facility failed to perform a safe transfer for 1 of 3 residents (R1) reviewed for safety in the sample of 5. This failure resulted in R1 experiencing a fall and fracturing his left arm and shoulder. The findings include: R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, dysphagia, Chronic Obstructive Pulmonary disease, Malignant neoplasm of prostate, Alzheimer's Disease with late onset, muscle weakness, venous insufficiency, chronic kidney disease, atherosclerotic heart disease of native coronary artery, unsteadiness on feet, anxiety disorder, repeated falls, and abnormality of gait and mobility. R1's facility assessment, dated 7/2/24, showed he has severe cognitive impairment and requires substantial/maximal staff assistance for transfers. (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) On 9/10/24 at 1:17 PM, R1 was lying in bed with his eyes closed. R1 had a sling on his left arm. R1's wife was at bedside. R1's care plan, initiated 12/28/22, showed, Resident Care Information. This care plan showed an approach started 6/29/24 Approach: Safe Resident Handling; Procedures- Transfer Method: stand aid transfer . This care plan showed a new approach, started 9/10/24, Approach: Safe Resident Handling; Procedures- Transfer Method: full mechanical lift with staff assist of two . R1's Incident Report showed, At approximately 5:45 AM on 8/30/24, it was reported to the nurse that resident had been lowered to the floor when transferring due to bilateral weakness of his legs. Resident complains of some pain to the left shoulder area, but range of motion was assessed to be WNL (within normal limits), and Tylenol was given for pain. At approximately 1:29 PM on 8/31/24, resident was complaining of increased pain to left arm. He was assessed and bruising noted and unable to complete ROM (range of motion). Order received to send to ER (emergency room ) for evaluation. Resident transferred to [local acute care hospital] at 1300 (1:00 PM) on 8/31/24 for evaluation. Resident returned from [local acute care hospital] at 19:19 (7:19 PM) on 8/31/24 with orders for sling to the left arm at all times. Pain management provided with ice and oral medication. Orthopedic appointment scheduled for 9/6/24. X-ray of left shoulder conclusion: Humeral head neck impacted angulated comminuted fractures seen. X-ray of left elbow conclusion: Subtle nondisplaced fractures injury at the posterior lip of olecranon. Advanced demineralization is noted. [Nurse Practitioner] confirmed diagnosis of osteopenia. Therapy to evaluate for safest level of transfer need and strengthening. On 9/10/24 at 9:30 AM, V2 (DON/Director of Nursing) provided a typed out statement that showed, I talked to [V11, Certified Nursing Assistant/CNA] this morning about how she was transferring [R1] on Friday morning. She showed me using the stand aid, that she pushed it up to him where he was sitting on the bed. His feet were placed on the stand aid and she assisted him to place his hands on the bar that you pull up with. She then said that he was a hard lift to get him to stand and before she could lower the seat pads, his legs gave out and he was still holding on to the bar . R1's Acute Care Hospital emergency room documents, dated 8/31/24, showed, . Patient Visit Information . Humerus fracture . Prescriptions: 1. Hydrocodone/acetaminophen 5-325 mg every 4 hours as needed . Procedure: Radiographic image of the shoulder, left 2-4 views . Indications: Fall yesterday. Hematoma on left arm, with decreased use of arm . Conclusion: Comminuted angulated impacted fractures seen with surrounding soft tissue swelling . Procedure: Radiographic image of the elbow, left . Indications: Fall yesterday; hematoma on left arm with decreased usage Conclusion: . Correlate for subtle nondisplaced fractures injury at the posterior lip of olecranon. Soft tissue swelling . On 9/10/24 at 10:49 AM, R3 said staff transfer her usng the stand aid. R3 said the staff don't use a gait belt when transferring her, but they will help me stand by reaching under my arms and lifting or they will pull me up by my hands. On 9/10/24 at 1:17 PM, V5 (R1's Spouse) said she comes to the facility every day and stays from approximately 1:00 PM until 7:00 PM. V5 said R1 would be transferred different ways depending on who was working. V5 said some of the staff would use a gait belt, and some wouldn't when using the stand aid. V5 said some staff would just grab R1 by the back of his pants to assist him up. On 9/10/24 at 2:03 PM, V3 (RN/Registered Nurse) said she was working at the time of R1's fall on 8/30/24. V3 said she was doing her morning medication pass when she heard V11 (CNA/Certified Nursing Assistant) yelling because R1 was in the middle of falling while she was transferring him from the bed to his wheelchair. V3 said when she entered R1's room to assist, he was already laying on the floor. V3 said there was a stand lift in the room, but it was in the corner of room and not near where R1 was laying on the floor. V3 said it did not appear V11 was using the stand lift at the time of the fall. V3 said she did not witness how R1 ended up on the floor. V3 said as she was heading down the hall to respond to R1's room, V11 opened the door and R1 was already on the floor. V3 said V11 told her R1 was a stand pivot transfer. On 9/10/24 at 2:19 PM, V6 (CNA) said she worked 8/30/24 starting at 6:00 AM. V6 said when she came on shift, V11 and V3 were using the mechanical lift to get R1 off of the floor. V6 said she uses the electric stand lift when transferring R1 because he is not strong enough to bear the weight in his legs and arms to use the stand aid. V6 said R1 was not a stand pivot transfer. V6 said she was told V11 was trying to transfer R1 as a one person assist. V6 said R1 has not been a one person assist for months, and would not be capable to being transferred with one assist. V6 said it was obvious R1 was in a lot of pain because he would scream out in pain if staff touched his arm or tried to move him. V6 said it was obvious to her R1 had an injury. On 9/10/24 at 2:25 PM, V12 (CNA) said staff use the stand aid when transferring R1, but they have to use 2 people. On 9/10/24 at 2:38 PM, V4 (CNA) said she worked 8/30/24 starting at 6:00 AM. V4 said she was working with V6. V4 said she thought R1 was a two assist for transfers. On 9/10/24 at 3:28 PM, V9 (CNA) said she worked 8/30/24 on day shift. V9 said when she came in that morning and was getting report, she was told that whoever was working night shift came out of R1's room and said he was lowered to the floor. We were taking care of him and he was screaming and hollering. V9 said she knows they had started using the electric lift for R1 because he was not strong enough for the manual stand aid. On 9/10/24 at 3:41 PM, V7 (RN/Registered Nurse) said R1 had fallen the shift before she arrived on 8/30/24. V7 said she received in report that R1 fell during a transfer, so it was witnessed, and he had received Tylenol. On 9/11/24 at 9:48 AM, V13 (CNA) said R1's transfer status was to use the manual stand aid. On 9/11/24 at 11:44 AM, V11 (CNA) said she was the aide that was transferring R1 when he fell . V11 said she went into R1's room and had him sitting up at the edge of the bed. V11 said she went to get the stand aid and went back to R1's room to transfer him. V11 said the stand aid has two grab bars for the resident to grab. V11 said she positioned the stand aid in front of R1, and placed his hands on the first bar, and had him start to stand. V11 said she then moved R1's hands to the second bar so he would stand up higher. V11 said as R1 was starting to stand up further and she trying to put the seat flap down behind him, R1's legs gave out and he started to fall. V11 said R1 let go of the stand aid with one hand, but kept one hand on the bar as he was falling. V11 said as R1 was going down to the floor she was able to get behind him. V11 said she was trying to get R1 to let go with his other hand to be lowered. V11 said R1 has good and bad days, and can usually follow directions such as letting go of the bar. V11 said she was yelling for help, and when the nurse arrived to R1's room, she had already lowered him to the floor and he was leaning against her legs. V11 said she moved the stand aid away from R1. V11 then said V3 (RN/Registered Nurse) responded to the room moved the stand aid. V11 said she did not use a gait belt during R1's transfer with the stand aid, and had never been told before that she needed to use one. V11 said since the fall happened V2, DON (Director of Nursing), has told them they have to use a gait belt when performing a stand aid transfer, so they are able to assist a resident if they become weak during the transfer. On 9/11/24 at 12:42 PM, V15 (ADON/Assistant Director of Nursing) said they have meetings every other Friday and discuss transfer status changes along with other topics. The staff know they can always downgrade a transfer status, but they can't go to a lesser assistance without the resident having a physical therapy evaluation. V15 said to be appropriate for the stand aid, the resident would have to be able to reach and pull themselves up, but they don't need to be able to bear their own weight, but if the staff is having to physically assist the resident into the standing position they would need to use a gait belt. V15 said if a resident is having more difficulty transferring, she would expect the staff to downgrade their transfer status and let the administrative staff know so they can get a therapy evaluation ordered. On 9/11/24 at 1:00 PM, V2 (DON/Director of Nursing) said, If you are performing a transfer and the resident can't understand what they are supposed to be doing, their transfer status needs to be looked at. The resident needs to be able to grab onto the bar and bear his own weight to use the stand aid. It was never brought to my attention they were struggling or were needing assistance with his transfers. Staff should all know the resident's transfer status and it should be a consistent. We can make him a (mechanical lift) without waiting for therapy, so they would have been able to do that, and let us know he will need to see therapy. If a resident is having difficulty, they should be having someone else help them. V2 said she expects staff to use a gait belt with the stand aid for the safety of the resident in the event that the resident's knees buckle they would have something to grab onto besides their pants. On 9/11/24 at 1:45 PM, V16 (Nurse Practitioner) said R1 had been experiencing a steady decline in health and his transfer status should have been reassessed, because incidents like this happen more frequently when residents are declining. The facility's policy and procedure, revised 4/3/18, showed, . Subject: Emergencies; Policy: It is the policy of the facility to provide emergency care to a resident in need of it Falls: 1. Check the resident immediately for ability to move extremities; 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall.; 3. Check if, or with anyone who witnessed the accident. Determine if possible, where, how, and when the accident occurred.4. check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives . 6. Call the resident's physician . The Standing Transfer Aid user's manual showed, . Transfer functions of all types are quick and require minimal caregiver assistance. Each unit is equipped with a crossbar where users can grasp and pull their self up into a standing position using their own strength. A patient or resident who qualifies to use the [stand aid] must have enough leg and lower body strength to stand up and remain in the standing/sitting position. Adequate arm strength is required if the patient must use the cross-bar . For patients who lack these requirements, a sit-to-stand lift such as the electric powered patient lift is preferred and recommended.

Based on observation, interview, and record review, the facility failed to identify a pressure wound prior to becoming advanced stages, failed to identify deterioration of an existing pressure ulcer, failed to perform weekly wound assessments, failed to perform accurate wound assessments for 2 residents (R75, R63), failed to provide wound treatments, failed to maintain documentation of wound assessments for 1 resident (R16), and failed to ensure pressure ulcer prevention measures were in place for 1 resident (R63). These failures resulted in R75 experiencing sepsis requiring hospitalization , surgical debridement of his necrotic wound, and placement of a colostomy due to an infected wound. These failures also resulted in R63's bilateral heel wounds not being identified until they were unstageable wounds and becoming necrotic. These failures apply to 3 of 6 (R75, R63, R16) residents reviewed for pressure ulcers in the sample of 23. The findings include: 1. R75's electronic face sheet, printed on 8/29/24, showed R75 has diagnoses including but not limited to pressure ulcer stage 4, infection following sacral debridement, Parkinson's disease, Alzheimer's disease, dementia without behaviors, and colostomy. R75's care plan, dated 6/23/24, showed, Resident is at increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . R75's admission nursing assessment, dated 7/17/24, showed R75 had no skin alterations upon admission. R75's care plan, dated 7/18/24, showed, (R75) has a colostomy related to sacral wound infection and need to keep the area clean. R75's facility assessment, dated 8/22/24, showed R75 has no cognitive impairment, has one stage 4 pressure ulcer, and utilizes and ostomy. R75's wound assessment report, dated 6/26/24, showed, dermatitis-7x6cm (centimeters). Red, open blisters to inner natal cleft. Scar tissue to coccyx and buttocks. Wound bed 50% slough and 50% granulated. Not recorded as pressure injury due to between skin folds. R75's wound assessment report, dated 7/3/24, showed, dermatitis-10x5cm-declining-macerated and excoriated scar tissue, grey in color. R75's nursing progress notes showed, 7/4/24 Writer was taking resident to supper and noted his face appeared red and flushed. Writer took temperature and temperature was 101.2. Resident had some confusion to what time it was and seemed a bit slower than usual to respond. (Physician on call) notified gave order to restart cefdinir 300mg (milligrams) bid (twice per day) x 5 more days and if resident worsens tonight may send to emergency room . 7/5/24 Power of Attorney here and concerned that (R75) has confusion and was not acting like himself. Vitals taken temperature was 101.4. He is on antibiotic for UTI (urinary tract infection) .911 called and took resident to local emergency room . R75's local hospital records, dated 7/5/24, showed, .brought in for evaluation from nursing home after developing fever and altered mental status again yesterday. Daughter states he appeared to have some labored breathing from time to time as well .evidence of sepsis with urinary catheter has a large unstageable sacral decubitus foul-smelling necrotic wound that requires debridement sepsis criteria likely secondary to wound to coccyx. R75's operative note, dated 7/6/24, showed, Reason for operation: sepsis with necrotic decubitus ulcer .findings: necrotic decubitus involving skin and subcutaneous tissue with purulence (drainage) .scalpel was used to excise necrotic infected tissue . R75's surgery progress note, dated 7/8/24, showed, May need to consider diverting ostomy as patient seems to be intermittently incontinent of stool .wound is approximately 8-9cm in diameter and 5-6cm in depth . R75's surgery progress note, dated 7/9/24, showed, Discussed with patient and daughter that we suggest additional debridement of wound as well as construction of diverting ostomy for stool incontinence. They are in agreement .surgery within 24-48 hours. (R75's ostomy surgery was completed on 7/10/24) R75's hospital physician note, dated 7/10/24, showed, Sacral ulcer: wound cultures reporting prevotella and morgnella (bacteria). On 8/27/24 at 11:40AM, R75 stated, I have a horrible sore on my bottom. I got it while I was here and needed surgery on it, and then they gave me this (pointing to colostomy) because the sore was so bad. On 8/28/24 12:30PM, V17 (Wound Care Nurse) stated, (R75) had dermatitis, but I'm not exactly sure when it started. We were watching it and he had some areas that were red. I guess it broke open. I was doing the wound assessments for (R75) at the time. I don't really recall much about him, but looking at the physician communication notes, he must have had some chapped skin that we were trying to soften up or something. It's strange that there are no wound assessments other than the physician communication forms. I'm not sure where they would be or even how to find them. I would think if the nurse saw a change in the wound, she would notify the physician for new orders and document that. I'm only here one day a week, so if there is something new with the wound, then that is up to the floor staff to notify the physician. On 8/28/24 at 12:38PM, V2 (Director of Nursing) stated, There are nursing skin assessments in (R75's) chart, dated 6/18/24 and 6/26/24, but they do not show any open areas. I don't see any full wound assessments documented in (R75's) chart. It is the expectation that (V17) does a full wound assessment including measurements and characteristics of every resident with a wound when she is in the facility. If a new wound is identified when she is not here, then the floor staff do the assessment and initiate orders. It is also the expectation that if a change is seen with a wound, the staff notify the physician for new orders. We now have a Wound Physician that comes once a week, but he started after all of this with (R75), so he did not start seeing him until 7/22/24. On 8/29/24 at 11:07AM, V26 (Wound Care Physician) stated, It's not normal to change from dermatitis to an unstageable wound. It might have started as a stage one and then progressed to a higher stage, but this was never dermatitis. When you have granulation and slough, you don't have dermatitis. There is no broken skin with dermatitis. From the wound assessments that were performed initially, this wound should have been classified as a pressure ulcer and treated as such. It should have been reclassified as soon as his skin broke open. With the slough and granulation present, I would have probably classified this as a Stage 3 pressure ulcer initially. A wound can become necrotic within a few days if not receiving the proper wound care. The nurses should have noticed the wound was necrotic and odorous, and he should have been seen by a Wound Care Physician as soon as possible. When a wound becomes necrotic, it becomes very dark and liquified and very noticeable. He was not receiving the proper treatments for this wound, which led to the complications he had. The facility's policy titled, Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol, dated 10/24/22, showed, 6. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size (measure length x width x depth), wound bed, drainage (amount, color, type), odor, tunneling, undermining or sinus tract, wound edges, surrounding tissue and pain at site. B. determine the injury's current stage of development: Stage 3 Pressure ulcer: full thickness skin loss: Full thickness loss of skin, in which subcutaneous fat is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slouch and/or eschar may be visible but does not obscure the depth of tissue loss .if slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/injury . 2. R63's face sheet, printed on 8/29/24, showed R63 has diagnoses including but not limited to peripheral vascular disease, pneumonia, pressure-induced deep tissue damage of left hip, atherosclerosis, and anxiety disorder. R63's facility assessment, dated 6/25/24, showed R63 has mild cognitive impairment and has 1 unstageable pressure ulcer. R63's care plan, dated 11/22/23, showed, (R63) is at increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . Pressure areas present to heel, foot and hip. Apply pressure reducing waffle boots to lower extremities when at rest .pressure reducing device in wheelchair and bed. R63's wound management detail report, dated 12/13/23, showed, Right heel pressure ulcer-unstageable 2.5 x 5cm, 100% eschar, dark purple or rusty discoloration. R63 did not have a wound assessment performed 12/20/23 and 12/27/23. R63's wound management detail report, dated 1/3/24, showed, Right heel pressure ulcer-unstageable deep tissue 2x5.8cm 100% necrotic eschar. On 8/27/24 at 11:02AM, R63 was laying in his bed with no heel protectors in place, and both of his heels were resting on the mattress. R63's heel protectors were observed on the spare bed in R63's room. On 8/27/24 at 11:26AM, V30 (hospice aide) provided incontinence care to R63, and stated R63 should always have his heel boots on because he has many wounds on his feet. V30 then transferred R63 to his wheelchair with no cushion in the chair. V30 stated R63 used to have a cushion, but she is unsure of where it is at. On 8/28/24 at 2:15PM, V2 (Director of Nursing) stated, All residents that are at risk for pressure ulcers and cannot reposition themselves should have heel protectors on at all times when they are in bed. If (R63) has that many wounds, then it is critical that all of the interventions are in place. I don't really know a lot about his wounds, but any wound should be identified as early as possible to allow for early intervention to try to heal the wounds. On 8/29/24 at 11:07AM, V26 (Wound Care Physician) stated, A deep tissue injury is intact skin with discoloration underneath. You cannot have a deep tissue injury with necrotic eschar. That is when the wound is open and becomes unstageable, so this assessment is incorrect. I wouldn't be surprised if that developed over a day or 2 without wearing heel protectors. If his skin was being assessed every day, this would have been caught when it was a red area; I would see a stage 1 red area. Wounds with eschar should be caught earlier and are signs that the wound is declining and is now open. 39543 3. R16's 8/27/24 Wound Clinic assessment showed she had a Stage 3 pressure injury to her left heel and two unstageable pressure wounds to her right foot. On 8/27/24 at 3:45 PM, R16 stated she has wounds on both of her feet. R16 stated her pressure wounds developed after she fell and sustained a fracture to her right ankle. R16 stated some of the pressure injuries developed while she had the cast on, and were not discovered until the cast was removed. R16 stated the pressure ulcer dressings were changed at the wound clinic on 8/27/24; however, prior to this, they had not been changed since Friday, 8/23/24. On 8/27/24 at 4:02 PM, V28, R16's daughter, stated she attended R16's wound clinic appointment that day. R16 stated the dressing was dated 8/23/24. On 8/28/24 at 12:19 PM, V16 (Wound Clinic Registered Nurse) stated she was the nurse who removed R16's dressing. V16 stated the dressings to both of R16's feet were dated 8/23/24. V16 stated the date on the dressing means the date that it was last changed. On 8/28/24 at 1:28 PM, V2 (Director of Nursing) stated the facility does not have the assessments for R16's wounds because the assessments are done at the wound clinic. V2 stated she did not believe the facility needed to keep records of R16's wounds if the weekly assessments were done outside the facility. R16's August 2024 Treatment Administration History (provided on 8/28/24, Commonly referred to as a TAR, Treatment Administration Record) showed an order to provide treatment and dressings to the left heel every 3 days. The TAR showed the treatment due on Monday 8/26/24 was left blank. R16's August 2024 TAR showed an order to treat and dress the wounds to the right foot every other day. The TAR showed the treatment due on Monday 8/26/24 was left blank. R16's Progress Notes from 8/26/24 (Monday, when the dressing changes were scheduled to be completed.) showed she left for an appointment at an unknown time; however, she returned at 4:30 PM. The progress notes do not show a refusal for dressing change. On 8/28/24 at 1:20 PM, V17 (Wound Nurse) (facility's wound nurse) stated, The date on the dressing is the date that it was changed. The purpose of the dressing is to removed exudate, promote healing and prevent infection. After a dressing change is done, they should document in the treatment list that the dressing change is done. The floor nurses do dressing changes when I am not here. I am here Wednesday. The dressings to both heels should have been changed Monday. If she (R16) refused, it should have been documented. I didn't assess them (foot wounds) she went to the wound clinic (the wound clinic assesses the wounds). One of them was pressure the other was due to a cast, I think. V17 stated she does not assess R16's wounds. The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol (revised 10/24/22) showed, .Weekly measurement will be conducted and entered in the chart under Wound Management .All treatments and charting of pressure ulcers/injuries will be done by licensed staff .

Based on observation, interview, and record review, the facility failed to implement interventions for residents with significant weight loss for 3 of 4 residents (R82, R70, R83) reviewed for weight loss in the sample of 24. These failures caused R82 to experience a 9.91% weight loss in 1 month, R70 to experience a 10.40% weight loss in 1 month, and R83 to experience a 12.18% weight loss in 1 month and a 18.55% weight loss in 3 months. The findings include: 1. R82's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation, congestive heart failure, pressure ulcer of sacral region, anxiety disorder, anemia in chronic kidney disease, and obstructive and reflux uropathy. On 8/28/24 at 9:12 AM, R82 said he has lost weight since he has been at the facility. R82 said he thinks maybe they may want him to lose weight. R82 said he is not on any nutritional supplements. R82's record showed on 7/11/2024, he weighed 212 lbs. (pounds) and on 8/08/2024, the resident weighed 191 pounds which is a 9.91 % weight loss in 30 days. R82's record showed the Nurse Practitioner was notified of the significant weight loss on 8/14/24 (6 days after the significant weight loss was identified). R82's Registered Dietitian Note dated 8/20/24 (12 days after the significant weight loss was identified) showed recommendations to complete weekly weights, nutritional shake twice daily, and continue to monitor intakes. R82's care plan for nutrition was started 8/28/24 (20 days after significant weight loss was identified). R82's care plan showed, Resident has experienced weight loss . Diet: Regular, high protein; encourage oral intake of food and fluids; monitor and record intake of food . There was not nutritional care plan in place prior to 8/28/24. On 8/28/24 at 3:46 PM, V3, ADON (Assistant Director of Nursing), said there are no meal intakes documented for R82. On 8/29/24 at 10:39 AM, V6 (Dietary Manager) said they have a few people who get fortified milk as a supplement, but they have no residents on fortified foods. V6 said if V27 (Registered Dietitian) recommends fortified foods, the resident would receive either mashed potatoes, soup, a cookie, or pudding. V6 said the CNAs get the weights and turn them in to him. He enters the weights and generates a report from the electronic health record which he gives to V2 (Director of Nursing), V3 (Assistant Director of Nursing), and V27 (Registered Dietitian, RD). V6 said the report is sent to V27 by email, since the facility does not have a permanent RD at this time. V6 said it has been about 4-6 months since they have had a permanent RD. V6 said the RD responds to let him know she received it and works on it at her convenience, whenever she has time. V6 said if V27 has recommendations, she emails them back to the DON to generate the changes. V6 said the nursing department puts the changes in to place and they change the diet card. V6 said R82 is on a high protein/high calorie diet and has no other nutritional supplements. V6 said the facility usually does an IDT (interdisciplinary team) meeting to discuss weights, but they have not had that meeting for the last few months since the kitchen has been short staffed. On 8/28/24 at 4:00 PM, V2, DON (Director of Nursing), said the facility does not start any nutritional supplements without a physician order. V2 said they notify the physician of weight changes, and they give the orders. The facility has no standing orders for nutritional supplements. On 8/29/24 at 12:09 PM, V2 said the RD does all her work remotely and does not come into the facility. V2 said she thinks the Registered Dietitian reviews residents with weight loss, new admissions, and those with their facility assessments coming up. V2 said she is not included in weight monitoring; all weights are given to V6, Dietary Manager. V2 said if the RD has recommendations, she writes it up and sends an email to her and to V6. V2 said recommendations are forwarded to the Nurse Practitioner, the resident's physician, or the Medical Director. V2 said those recommendations should be in place no later than 3 days after receiving them and they try and get them in place the same day or the next day. V2 said after the weight loss is identified, the RD should be reviewing as soon as possible. V2 said they don't monitor and document meal intakes on everyone, but they would do them for residents with weight loss. V2 said monitoring meal intakes would be put into place when the Dietary Manager enters the weight and identifies the weight loss. On 8/29/24 at 1:22 PM, V27 (Registered Dietitian) said she has been hired by the facility to cover until they find a permanent RD. V27 said she does all her work for the facility remotely, and was hired to work 8 hours per month. V27 said she lives out of state, and she goes in and enters notes on the residents she was referred to review every 2 weeks. V27 said V6 (Dietary Manager) sends her a list of residents to review, and she does a progress note for those. V27 said if she has recommendations, she writes those down and sends them to V6, Dietary Manger, and V2, DON. V27 said she would hope they would have those recommendations in place within the week of receiving them, but she would want interventions started right away. V27 said the gap between identifying the significant weight loss and starting interventions (18 days for R82) is too long because the residents could be losing more weight during that time. V27 said residents with a high protein/high calorie diet are supposed to receive fortified oatmeal at breakfast and fortified milk at all meals. 41639 2. R70's electronic face sheet, printed on 8/29/24, showed R70 has diagnosed including but not limited to dementia without behaviors, type 2 diabetes, peripheral vascular disease, and cognitive communication deficit. R70's care plan, dated 8/28/24, showed, Resident has experienced weight loss. Monitor and record intake of food. On 7/11/24, R70 weighed 125 lbs. On 8/10/24, R70 weighed 112 pounds which is a 10.40 % weight loss within 1 month. R70's progress notes, dated 8/15/24, showed, (Nurse Practitioner) noted weight loss. No new orders. R70's Registered Dietician note, dated 8/20/24, showed, Per nursing note 8/15 (Nurse Practitioner) notified of weight loss with no new orders. Recommend Hi calorie diet. Will continue current nutrition interventions. Will continue to monitor intakes, weight, skin, and plan of care. R70's meal intake record for July and August 2024 had no documentation of meal intakes. R70's progress notes, dated 8/27/24, showed, (Nurse Practitioner) agreed with Dietician's request to change diet to Hi calorie diet due to recent weight loss. (17 days after weight loss identified). 3. R83's electronic face sheet, printed on 8/29/24, showed R83 has diagnoses including but not limited to dementia with behaviors, hypertension, and anxiety disorder. R83's facility assessment, dated 6/11/24, showed R83 has experienced a weight loss of 5% or more within 1 month or 10% or more within 6 months. R83's care plan, dated 8/28/24, showed, Resident has experienced weight loss. Monitor and record intake of food. On 5/8/24, R83 weighed 124lbs. On 8/8/24, R83 weighed 101lbs, which is a 18.55% loss in three months. On 7/11/24, R83 weighed 115 lbs. On 8/8/24, R83 weighed 101lbs, which is a 12.17% loss in one month. R83's progress notes, dated 8/15/24, showed, (Nurse Practitioner) noted weight loss no new orders. R83's Registered Dietician note, dated 8/20/24, showed, Resident continues to drop significant weight. Recommend increasing protein supplement to 8 oz three times a day and weekly weights. Will continue current nutrition interventions. Will continue to monitor intakes, weight, skin, and plan of care. R83's meal intake record for July and August 2024 had no documentation of meal intakes. R83's progress notes, dated 8/27/24, showed, (Nurse Practitioner) agreed with Dietician's request to increase residents' protein supplements and to add weekly weights due to recent weight loss. On 8/28/24 at 3:46PM, V23 (Assistant Director of Nursing) stated, We do not have meal intakes for these residents. We only chart by exception typically, so the only thing we have documented on them is whether they consume their supplements. I guess it would be helpful to know how much our residents are eating over time, but that's not our policy to document meal intakes on all residents. The facility's policy titled, Weight Monitoring, dated 06/21, showed, Objective: To consistently assess residents for significant weight loss or gain .4. Licensed Staff will notify the physician of the following: A. 5% or more gain or loss in a 30-day period B. 7 1/2% or more gain or loss in a 90-day period C. 10% or more gain or loss in a 180-day period. 5. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the Registered Dietician as needed. 6. The Registered Dietician will review significant weight losses and any other residents referred by the weight committee on a monthly basis, and make recommendations to physicians as necessary.

Based on observation, interview, and record review, the facility failed to ensure a resident (R1) who is a high risk for falls was provided with the appropriate shower device during a shower. The failure resulted in R1 sustaining a fracture to his right hip. This applies to one of three residents, (R1) reviewed for showers in a sample of three. The findings include: R1's face sheet, printed on 1/5/24, showed diagnoses to include but not limited to systolic/diastolic congestive heart failure, anemia, respiratory failure, atrial fibrillation, chronic kidney disease stage 5, difficulty walking, and generalized muscle weakness. R1's MDS (Minimum Data Set), dated 1/2/24, showed R1 has no cognitive impairment. R1 requires partial to moderate assist with shower transfers and showers. R1 has had one major fall with an injury. R1's care plan dated, 12/5/23-1/5/24, showed R1 is at risk for falls related to recent illness, hospitalization and new environment. R1's quarterly fall risk assessment, dated 12/6/23, showed R1 as high risk for falls. R1's fall event, printed on 1/5/24, showed R1 had a fall on 9/29/23 at 9:21 PM. R1 was lowered to the floor by certified nursing assistant. No injuries. R1's radiology report, dated 1/2/24, showed impression: There is a questionable right femoral neck fracture. Follow up CT would be helpful. R1's radiology report, dated 1/3/24, showed conclusion: Comminuted impacted displaced fractures of the right femoral head neck is seen with minor fragmentation extending to the greater trochanter . R1's progress note, dated 1/2/24 at 8:38 PM, showed, (V10, Certified Nursing Assistant/CNA) notified this writer (V8, Registered Nurse/RN) that (R1) fell in the bathroom during a shower . (R1) was found lying on right side partially under the sink with a shower chair under him. (R1) had an abrasion noted to the right forehead and he stated he hit his head. He was unsure if it was on the sink or the floor. (V10, CNA) stated she turned around to the sink to grab a towel and when she turned back around he was on the ground; she stated he fell into her backside and then hit the floor. She stated he hit his head on the floor. Initial assessment, (R1) was alert and oriented stating he was fine and he wanted to get up. PERRLA (pupils, equal, round, react to light, accommodation) and strong equal hand grasp noted. Full range of motion (ROM) noted. (R1) was able to stand up with assistance. Vital signs were stable and (R1) was following commands appropriately. Call placed to on call (V15, MD on call) and (V14, Power of Attorney/POA) to notify of fall. Neuro checks were initiated at 7:45 PM, approximately ten minutes later (V10) came and notified this nurse (V8) that there was a change in condition. This nurse assessed (R1) in bed unresponsive and having labored breathing. (R1) was not following commands or with drawing to painful stimuli. Sternal rubs (using the ball of your knuckles of the hand to rub the upper mid chest area to cause pain and get a reaction from the person) were performed with no response from (R1). (R1's) oxygen saturation was found to be sixty-eight percent on room air. Oxygen was applied and EMS (Emergency Medical Support) was called (R1) did open his eyes after the oxygen was applied but was not talking or following commands. (R1) began to dry heave when the EMS transported him to the cart. Call placed to on call (V15) MD again for orders to be sent to the local hospital and the (V14) POA was updated on condition. On 1/5/24 at 9:26 AM, V8, RN, said, (V10,CNA) came and got me and said (R1) had fallen that she was giving him a shower. I did an assessment his vital signs were stable and he was answering questions. He said he was ok. We got him up. I called (V15, Medical Doctor) on call and the family. (V10) came and got me he was in bed non responsive. His breathing was not normal. I did a sternal rub and he did not respond. I put him on oxygen and the emergency medical team was called. V8 said, I think he was a fall risk, I'm not sure. I'm sure he is; he is in a wheelchair. I assume he needed assist with transfer. On 1/5/24 at 11:34 AM, V13 (Social Service Director) said his last fall was on 9/29/23. On 1/5/24 at 11:55 AM, V9, RN said, I am his regular nurse. I was here during the day shift. It was in his room in the shower where he fell . He was on the shower bench and there are no seat belts. (V2 - Director of Nursing/DON) said it was a gray or white bench that he was sitting on. (V10) said he fell into her back and it was a good thing he did or he would have hit his head on the sink. The progress note said he had an abrasion to the right side of his forehead. V9 said, She (V10) was not supposed to be using that bench it did not fit him. (R1) was a fall risk and his risk factors are his vision, limited mobility and being in the wheel chair bound. We are an alarm free facility. On 1/5/24 at 12:08 PM, V2, DON, said, The bench was thrown away. It was a white bench and it was not a facility bench. I don't know who brought the bench in. (V10) was not to use that bench. Anything that is brought in has to be approved. If she would have used one of ours they have arm rest and a back support they look like a regular chair (shower). V2 said, It was just a bench with no arms or back. It would be a risk for falls and injuries. On 1/5/24 at 1:45 PM, V11 (Occupational Therapist/OT) said most of the showers have the bench seat that is attached to the wall and folds down. V11 said, If a bench is used incorrectly it could be a safety fall risk. The bench should be inspected before it is used. There should also be a towel placed on the bench because it could get slippery. On 1/5/24 at 2:07 PM, V10 said, I used a shower bench. I asked him to sit; usually I put a towel down. I did not put a towel down on the bench. I turned to get the washcloth; he was sitting down with both hands on the grab bar. I turned for just a minute, and he hit up against my back. He is a 1 assist. There was no seat belt or strap, there was no arm rest or a back support. The bench toppled over and that is when I felt him hit my back. V10 said he was injured, but he did say he was ok. We used a gait belt to get him up it took three of us. I gave him a shower after the fall. It was a quick shower. I did have someone help me get him into bed. The nurse said it was ok to give the shower. I would not use that bench again. I don't know how long it had been here. On 1/5/24 at 3:11 PM, V7 (Nurse Practitioner/NP) said when you are sedentary, bed bound, or non- weight bearing, you get a lot of falls. V7 said, The fall was most likely the cause of the hip fracture. There is no diagnoses of bone disease that I am aware of. On 1/5/24 at 3:38 PM, V2, DON, said, The (Unit Coordinator/UC) on the night shift sent me this picture. I said to get that out of there and throw it away. The CNA should not have used that bench. She should have used the facility shower chair. V2 said (V16 - Unit Coordinator/ R1's daughter) said (R1) told her the bench was/seemed like it was slippery and he slid off the bench. The family said they did not bring the bench type chair into the facility. On 1/9/24 at 1:45 PM, V17 (2nd shift Unit Coordinator/UC) said, It was reported to me that (V10) was going to give him a shower and he slipped off of the bench and toppled over. I have a picture of the bench I sent to (V2) they were trying to figure out where the bench came from. I asked (V10) where it came from and who told her to use it to give him a shower on that bench and she said it was a long time ago and could not remember. The facility's policy, revised on 4/3/18, showed, It is the policy of the facility to provide emergency care to a resident in need of it. 4. Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives.

Based on interview and record review the facility failed to ensure residents were free from physical abuse for 2 of three residents (R1, R3) reviewed in the sample of three. This failure resulted in R2 physically abusing R1 and R3 on 4/20/23 when R2 twisted R1's arm and caused a skin tear to her left hand. R2 sat on R3 while she was in bed and hit her. On 4/28/23 R2 hit R3 repeatedly with a call light. The findings include: 1. The Event Documentation dated 4/20/23 at 1:28 AM for R1 showed she was called into a resident's room by a CNA (Certified Nursing Assistant). R1 was lying in bed with a bloody gown covering her left hand. R1 had a skin tear on the top of her left hand that measured 4.5 cm. The edges were approximated, cleansed, (Brand) thin adhesive wound closure strips placed, and covered. When I asked what happened R1 stated, She squeezed my hand with her hands and told me to leave her house; she pushed on my chest really hard. The CNA stated around 1:00 AM he redirected R2 back to her room after he found her standing in the doorway of R1's room. R1 complained of pain; Ibuprofen given. On 5/2/23 at 9:00 AM, V1 (Administrator) stated on Thursday (4/27/23) V16 (R1's daughter/Power of Attorney) came in to visit R1 and reported to us that R1 had bruises and a skin tear from another resident. V16 asked what we were going to do about her mother's situation, and I had no idea what she was talking about until she told me. V1 stated V2 took over this incident. V1 stated that the incident was resident to resident abuse. On 5/2/23 at 11:01 AM, V4 (Registered Nurse/RN) stated she was called to the dementia unit. The CNA told her that R2 was standing in the doorway of R1's room. The CNA did not think to check R1 at that time or to tell her about it. V7 (Certified Nurse Assistant/CNA) went to do a bed check and came back saying R1 was bleeding. V4 stated R1 had a skin tear to her hand that she cleaned, applied (Brand) thin adhesive wound closure strips and a dressing to. V4 stated R1 told her someone pushed her on her chest. On 5/2/23 at 11:22 AM, V7 (CNA) stated, R2 was by R1's room and I told her to go back to her room. I called the nurse. I went to change R1 at bed check, and there was blood on the sheets. I screamed for my co-worker and the nurse. R1 had a skin tear to her left arm. The nurse talked to R1, and R1 told her that the lady (R2) was trying to fight her. R2 wanders in rooms and is difficult. R2 is very difficult to watch. R2 goes in other rooms thinking she is in her house. R2 constantly moves around. R2 gets irritated when you talk to her. R2 is hard to re-direct. On 5/2/23 at 11:38 AM, V6 (Certified Nurse Assistant/CNA) stated that she was in a resident's room when V7 (CNA) found R2 in the doorway of R1's room. At bed check, V7 screamed for her and V4 (RN) and said that R1 was bleeding. R1 said a lady came in and grabbed her. V6 stated that was all she knew. On 5/2/23 at 1:03 PM, V9 (Certified Nurse Assistant/CNA) stated R2 is a resident who wanders and can be combative. V9 stated R2 goes into other residents' rooms. V9 stated staff can redirect R2 unless she is really worked up. If R2 is worked up, they have to back off her and make sure no residents are around her. When R2 gets into her moods, she can be out of control. On 5/2/23 at 1:41 PM, V10 (Certified Nurse Assistant/CNA) stated she found out about R2 and R1 in report after the incident happened. R2 went into R1's room and caused a skin tear to her arm. V10 stated that all R1 said was that some lady did it. V10 stated after the incident with V2 and other residents on 4/20/23, the facility did not tell them to do anything different with R2. V10 stated no education was given and nothing was done. On 5/2/23 at 3:32 PM, V12 (Certified Nurse Assistant/CNA) stated she was not aware of anything happening between R2 and any other residents. V12 was not aware of R2 being a wanderer or needing any closer supervision. On 5/2/23 at 3:40 PM, R1 was sitting in a chair in the common area of the dementia unit. R1 had a long, curved, scabbed red line across her left hand. R1 had several bruises to her left arm and a bruise to her right hand. R1 stated, She cut me with her nail across here and pointed to her left hand. R1 stated, She was squeezing me and grabbed her left arm with her right hand to show how she was being squeezed. R1 stated it hurt when the lady did that. R1 stated that the lady hit her in her shoulder. R1 pointed to her right shoulder. R1 stated it was scary when the lady grabbed her arm and hit her. On 5/3/23 at 7:47 AM, V2 (Director of Nursing/DON) stated someone told her the next day that R2 had given R1 a skin tear. V2 stated the nurse on the night shift did not tell her that it happened. V2 stated she was not told about it until 4/21/23. V2 stated it was resident-to-resident abuse. V2 stated abuse training is done when staff are hired and annually. On 5/3/23 at 9:05 AM, V15 (Nurse Practitioner/NP) stated she has received paperwork about R2's behaviors, and for a while she was increasing R2's medications. V15 stated she was leery of increasing the medications too much because there needs to be some time in there to see how the medications are working. V15 stated sometimes residents with dementia will have behaviors because they are not being attended to. Residents will wander and get upset. V15 stated that for R2, she would expect staff to redirect R2 and spend more time with her. If R2 becomes aggressive then back off, remove other residents from the area if they can't move R2. V15 stated she would expect staff to keep other residents safe. They should be monitoring R2 closer and the types of behaviors she has. V15 stated she reviews the progress notes when she comes in. If there isn't any documentation of what was happening for the resident, then she would not know about it. On 5/3/23 at 9:16 AM, V16 (R1's daughter/Power of Attorney) stated, last Thursday, on 4/27/23, I came into the facility for my weekly visit. R1 was lying down, and I saw her arms and hand. R1's left forearm was swollen and bruised to her fingertips. R1 had a large cut that was nasty looking to her left hand. R1 had a bruise to her right hand. I asked R1 what happened, and she said someone came in her room in the middle of the night, squeezed her arms and it hurt really bad. I went out of the room and asked V10 (CNA) about R1's arms. She said I should talk to V5 LPN (Licensed Practical Nurse). I asked V5 what happened. She looked in the computer and said R1 was attacked by a resident. V5 said it happened on 4/20/21 between 1-1:30 AM. V5 said I should talk to V1 (Administrator) or V2 (DON). We just want our mom to be safe, feel safe, and be content. R1 is [AGE] years old and doesn't have much time left. If R1 didn't have dementia she would be horrified and have trauma. R1 maybe wouldn't be able to sleep because she would be worried it would happen again. R1 would probably want to leave. R2's Face Sheet dated 5/3/23 showed medical diagnoses including dementia, anxiety, type 2 diabetes mellitus, chronic kidney disease, post-traumatic stress disorder, unsteadiness on her feet, pain, fall, and disorientation. The Physician Order's for R2 dated 4/3/23 - 5/3/23 showed, walk with assistance and walker. The Progress Notes for R2 showed she was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] for R2 showed severe cognitive impairment; physical, verbal, and other behaviors; and no assessment of her functional status. The Care Plan for R2 dated 4/28/23 showed she has diagnoses of anxiety, dementia, and post-traumatic stress disorder. Due to these she is displaying physical behaviors, verbal behaviors and wandering. At times she wanders the unit or into other resident's rooms disturbing them. At times, it is difficult to redirect R2. The Care Plan was updated on 5/2/23 and did not show frequent monitoring. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. 2. The Nurse's Note dated 4/20/23 at 1:21 AM for R3 showed the nurse was called into R3's room by the CNA. The CNA stated she entered R3's room and her roommate (R2) was sitting on top of R3. R3 stated R2 was yelling at her; telling her to get out of her bed. R3 stated R2 punched her. R3 was pointing to the area just below her right clavicle. R3 stated she told R2 that it hurt and reached for her call light. R2 was removed from the room. On 5/2/23 at 11:01 AM, V4 (RN) stated she was called to the dementia unit on 4/20/23 around 1:00 AM or 1:30 AM by the CNAs. V4 stated she went to R3's room and R2 was sitting on top of R3. V4 stated she wasn't sure if she notified V1 (Administrator) or V2 (DON). V4 stated Sure and I don't know when she was asked if V1 (Administrator) and V2 (DON) are supposed to be notified of resident-to-resident abuse. On 5/2/23 at 11:22 AM, V7 (CNA) stated R2 was sitting on top of R3 and was trying to fight her. R2 was screaming to get R3 out of there. The nurse went in and talked to R2. On 5/2/23 at 11:38 AM, V6 (CNA) stated at some point in the night R2 was sitting on R3. V6 stated her and V7 saw it and told the nurse. V6 couldn't remember if R2 stated R3 had hit her or not. V6 stated R2 said that R3 talks and talks and wants to fight. On 5/2/23 at 1:51 PM, V1 (Administrator) stated he did not know anything about R2 sitting on R3 or hitting her on 4/20/23. V1 stated it was never reported to him and it should have been. V1 stated it was resident to resident abuse. On 5/3/23 at 7:47 AM, V2 (DON) stated no one told her about what happened between R3 and R2 on 4/20/23. V2 stated she was reading a note and R2 had hit and sat on R3. V2 stated she read about it the next day when she was looking at R2's information. V2 stated it was resident to resident abuse. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. 3. On 5/3/23 at 1:03 PM, V9 (CNA) stated she saw R2 hit another resident. On Friday, 4/28/23, she stated she came into work in the morning and got report. At around 6:30 AM, there was a call light going off and she went to answer it. When she went into the room R2 had the call light and was hitting R3 with it. R3 was trying to get out of bed on her own to get away. V9 stated she yelled for help and V10 (CNA) came down. On 5/3/23 at 1:18 PM, V10 (CNA) stated on Friday 4/28/23 R3's call light went off and V9 (CNA) caught R2 whipping the call light at R3's back. R2 was in the first bed and R3 was in the second bed. V10 stated they cleaned R3 up and removed her from the room. On 5/3/23 at 2:35 PM, V1 (Administrator) stated V2 (DON) sent him a text message on Friday, 4/28/23 at 6:31 AM, that we needed to do something with R2 because she had been hitting people with a call light. It didn't get reported to IDPH. V1 stated it was abuse. V1 stated he thought it didn't get reported because they were busy with R1's daughter and what happened to R1. A review of R3's medical record did not show any documentation of her being hit by another resident on 4/28/23. The last Progress Note for R3 was dated 4/26/23. On 5/2/23 at 3:50 PM, V1 stated the last Progress Note in R3's chart was dated 4/26/23. V1 stated he asked V2 (DON) why the incident on 4/28/23 between R3 and R2 was not documented in the progress notes. V2 said V5 (Licensed Practical Nurse/LPN) should have documented it in the progress notes. On 5/3/23 at 7:47 AM, V2 (DON) stated the morning (4/28/23) that they said R2 hit R3 with a call light she sent a message to V1 (Administrator) and V14 (Social Services). V2 stated she told them R2 needed to be put in a different room, so they were aware of what happened. V2 stated V5 (LPN) should have put a note in the resident's medical record. V2 stated the incident was reported to her and she reported it to V1. V2 stated it was resident-to-resident abuse. On 5/3/23 at 8:45 AM, V5 (LPN) stated she was the nurse on duty on 4/28/23 on the dementia unit. V5 stated a CNA went to answer R3's call light. V5 stated she was told that R2 was over R3's bed, hitting R3 with the call light. V5 stated they got R3 dressed and out of the room. V5 stated she asked V14 (Social Services) to ask V1 (Administrator) how to chart the incident. V5 stated no one got back to her on charting. V5 stated another nurse had told her they wanted things charted a certain way. V5 stated she could have documented, but the day got away from her and she didn't do it. V5 stated she reported what happened to V2 (DON) because it was resident-to-resident abuse. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. The following will be documented in the resident's medical record: a. The nature and extent of any injuries sustained or the condition resulting from the alleged incident. b. Whether the resident was sent to the hospital. c. Whether the resident's physician was called.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident during a shower for 1 of 3 residents (R1) reviewed for falls in the sample of 8. This failure resulted in R1 falling and sustaining a left femur fracture requiring surgical repair. The findings include: R1's Physician Order Report dated 7/15/22-7/18/22 shows diagnoses to include fracture of the shaft of left femur, urinary tract infection, weakness, [CONDITION(S)], [CONDITION(S)], unilateral primary [CONDITION(S)] of left hip, difficulty walking, and [CONDITION(S)]. The Minimum Data Set of May 3, 2022 shows R1 is cognitively intact and requires supervision of one staff with transfers, ambulation, toileting, and personal hygiene. This assessment shows R1 requires extensive assistance from 1 staff with dressing and help from staff with bathing. The assessment shows R1 has had no falls since admission. R1's care plan Resident Care Information dated 5/2/21 shows Bathing Type: PM Shower, Bath Days: Monday and Thursday with an approach date of 5/21/21. This care plan does not identify the assistance needed for showering. R1's progress note dated 7/11/22 at 9:30PM shows resident was showering with staff assist. Resident stated she was attempting to finish showering when her feet spread apart and she went down to the floor. Staff notified this nurse, resident stated she could not move. 911 called and with staff assist got her onto the stretcher, in route to [local hospital] R1's Event Report dated 7/11/22 shows the resident was showering prior to the fall and resident states she slipped and went down and resident had severe pain- horrible intense to the left hip knee. V4's (Certified Nursing Assistant/CNA) incident statement dated 7/11/22 shows she was helping R1 in the shower and had all the proper towels down to help prevent falls. R1 went to stand up and she grabbed both bars and her left leg gave out and she landed right on top of her left leg . R1's Orthopedic Consultation dated 7/12/22 shows a left femur periprosthetic fracture at the level of the distal tip of the prosthesis. R1's progress note dated 7/12/22 shows she was admitted to the hospital with diagnosis of Left Femur Fracture. R1's 7/15/22 progress shows resident returned by ambulance, gauze dressing in place to outer aspect from hip to knee covering surgical incision. On 7/19/22 at 9:45AM, R1 was in bed on her back with the head of her bed slightly elevated. R1 said she was having a lot of pain. The pain is better if they leave me alone. R1 said she was taken into her shower and sat on the thing [shower seat/bench]. R1 said the girl asked me to stand up so she could wash my back and I grabbed the bar. There is nothing to catch you on the bar and my hands slid on the bar and my right foot went out like I was doing the splits. My left foot turned in. They usually have towels on the floor and tell me to wait until they get wet and I then I stand on them. The girl was standing by the sink when I stood up, there is no way she could have got to me in time. My left leg was under me and the girl brought it out after I fell . It was slippery inside the shower. There was nothing down to keep my footing. They should make the floor gritty and the bar so it's not slick. I had both hands on the bar and one leg went under and the other out in front. R1 had a bathroom in her room that had a shower located in the corner. The shower had a bench seat in the back that could be folded up. The shower seat was open and was at the height of a standard chair. R1 had towels on the seat. The shower floor had a slightly ridged texture. On 7/18/22 at 1:54PM, V3 (Certified Nurse Aide/CNA) said she was the CNA coordinator the night R1 fell . V3 said V4 (R1's CNA) came to get her to help after R1 fell . V3 said R1 was screaming and she grabbed a pillow to put behind her. V3 said R1 was on the floor of the shower with her back against the seat and both legs out in front of her. She said there were two towels right there where she was sitting, rolled up by her hand. The towels were wet, and we use them so water doesn't go out. V3 said R1 is independent but they stay with her when she showers. V3 said she lays towels down or a bath blanket on the shower floor for the resident to stand on when she helps a resident with a shower. On 7/18/22 at 2:19PM, V4 (CNA) said she was helping R1 take a shower the night she fell . V4 said she had never helped R1 shower before. She put green pads, towels, and a bath blanket long ways to catch water in the shower. She said she used 3 green pads, and 2 regular towels under the green pad on the floor and 3 towels to cover the seat. She placed the pads and 2 towels right where the seat is under her feet. V4 said she does this with every shower she gives so it's not slippery when the resident stands. V4 said after she washed and rinsed R1's back she washed her legs and feet. V4 said R1 wanted to stand to get her hair washed. R1 grabbed the bars and stood and her left leg gave out and she did the splits. V4 said she tried to catch her and couldn't and R1 landed on her left leg. I tried to lower her to the floor but I couldn't . V4 said she moved R1's leg from under her to relieve pressure and went to get help. At 2:46PM, V4 went to the linen closet and grabbed 3 large green cloth incontinence pads. V4 placed two towels on the floor and then placed 3 cloth incontinence pads over the towels and said she already had the linen placed on the floor of the shower before R1 went in so it's not slippery. The incontinence pads were cloth, approximately twice the width of the towel. On 7/19/22 at 10:45AM, V5 (Licensed Practical Nurse/LPN) said she was in the hall when R1 fell . V5 said R1 was holding her hip saying oh my god it hurts. R1 said when I fell I heard something snap. V5 said she told R1 they needed to call for the paramedics to get her up and she stayed with R1. V5 said R1 said her legs split apart, they spread apart and she lost her balance and fell . V5 (LPN) said because they know R1's knees and hips are bad they put towels down on the shower floor as a preventative measure because it gets slippery so they don't fall. V5 said there were towels down on R1's shower floor and on the bathroom floor. Sometimes the floor gets soapy and this helps with the slippery floor. V5 said R1 told her she was standing up to rinse the soap off. R1 has her own way of doing things. V5 said R1 does get up on her own but does require some assistance because her knees and hips are bad. She tells the staff what she wants and how she wants it. On 7/18/22 at 10:00AM, V2 (Assistant Director of Nursing/ADON) said residents should not stand or transfer where water is on the floor. They do not have them stand on top of linen during the shower. On 7/19/22 at 10:17 AM, V2 said the CNA's can put towels done outside the shower in case the water leaks out but it is not for the resident to stand on. They do not recommend putting towels down for the residents to stand on.

Based on observation, interview, and record review, the facility failed to prevent the diversion of residents' narcotic pain medication and the substitution with an unknown substance. This failure lead to a resident (R2) experiencing pain, with no narcotic relief available. This failure applies to 3 of 3 residents (R1, R2, R3) reviewed for misappropriation of resident property in the sample of 8. The Immediate Jeopardy began on 5/16/21 at 2:57 PM when V8, Registered Nurse notified V1, Administrator of inconsistencies regarding a [MEDICATION(S)] order for R1. The Immediate Jeopardy was identified on 5/27/21. V1 was notified of the Immediate Jeopardy on 6/22/21 at 4:10 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/7/21, however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R2's Face Sheet from 5/28/21 showed she is on hospice and she has an original admitted [DATE]. R2's Face Sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's 3/10/21 Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15 and she had no acute onset of mental status change. The MDS showed R2 required extensive assistance of two staff for bed mobility, dressing, toileting, and personal hygiene. On 5/19/21 at approximately 5:30 PM, V1 was sent photographs that had been taken by the facility's pharmacy. The photographs showed a known, untampered, bottle of [MEDICATION(S)] with the [MEDICATION(S)] being a medium blue color. The photograph also showed a bottle of [MEDICATION(S)] that had been returned from the facility. The pharmacy identified the returned bottle as having been tampered with; it contained a green liquid, a foam seal, and the volume of liquid was not what was indicated on the bottle. On 5/28/21 at 1:49 PM, V2, Director of Nursing (DON), stated R2 had three bottles of [MEDICATION(S)] and 2 of the 3 bottles were pulled from the nurses' cart because the color of the liquid was not consistent with what is known to be the color of [MEDICATION(S)]. On 5/27/21 at 1:40 PM, V2 Director of Nursing, produced R2's bottles of [MEDICATION(S)] that had been in the nurses' cart. One bottle was labeled as [MEDICATION(S)] with approximately 22 milliliters (ml) of a light green colored liquid. The other bottle contained a darker green liquid. Neither bottle contained a liquid that was consistent with the photos of [MEDICATION(S)] on 5/19/21. On 6/1/21 at 10:00 AM, R2's third bottle of [MEDICATION(S)], that had been left in the nurses' cart for R2's use, was determined to not be [MEDICATION(S)] or possibly a diluted concentration of [MEDICATION(S)]. The color of the [MEDICATION(S)] was not consistent with the photographs on 5/19/21 and the bottle showed it was only a 15 ml bottle, indicating her original 30 ml bottle had been replaced with a 15 ml bottle of unknown contents. On 5/28/21 at 9:30 AM, V4, Pharmacist/Pharmacy Director, stated she has contacted the [MEDICATION(S)] manufacturer in previous cases of drug diversion. V4 stated she was assured the color of the blue [MEDICATION(S)] remains consistent over different lots and does not change over time. On 6/2/21 at 2:15 PM, V4 stated she had contacted the facility and they do not use foam seals, but a paper faced seal with a waterproof barrier between the [MEDICATION(S)] and the paper. On 5/28/21 at 8:00 AM, R2 stated there have been times when her [MEDICATION(S)] doesn't seem to work and today is one of them. R2 stated she had received [MEDICATION(S)] about an hour ago and her pain was 12 out of 10. R2 said she is having pain in her legs. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (R2 was receiving [MEDICATION(S)] from the bottle determined to contain a liquid that was either not [MEDICATION(S)] or not the correct concentration of [MEDICATION(S)]. On 5/28/21, the facility was aware of [MEDICATION(S)] tampering.) R2's controlled substance count sheet for the current bottle of [MEDICATION(S)] showed the facility received 30 ml bottle of [MEDICATION(S)] and as of 6/1/21, 17 ml had been given to R2. (The bottle when dispensed by the manufacturer contained 15 ml per the label on the bottle.) On 6/2/21 at 10:48 AM, V7, Licensed Practical Nurse (LPN) stated R2 has quite a bit of pain. V7 stated R2 has required increases in narcotic pain medications to manage her pain. V7 stated she has noticed issues with [MEDICATION(S)] going from blue to clear with R2's [MEDICATION(S)] in the past. On 5/28/21 at 1:49 PM, V2 said, Whatever she (R2) received was not [MEDICATION(S)] or the correct concentrations of [MEDICATION(S)]. She is not getting the correct pain control. If it's not [MEDICATION(S)], then what is in there? The medications in the cart are owned by the residents and they are the resident's property. On 6/1/21 at 11:50 AM, V13, Nurse Practitioner, stated [MEDICATION(S)] is a narcotic pain medication generally reserved for hospice patients in the long-term care setting. V13 stated hospice nurses started noticing issues with [MEDICATION(S)]; that it was becoming lighter in color. V13 was unable to recall a date or resident. V13 stated, To me that says it's being diluted or it something totally different. If it's not [MEDICATION(S)] or diluted [MEDICATION(S)] then they're not getting the pain relief from the [MEDICATION(S)]. V13 stated R2 does have real, chronic pain due to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/23/21 at 9:05 AM, R2 stated she can definitley notice a difference in the effectiveness in her [MEDICATION(S)]. R2 said it made her upset that she would ask for [MEDICATION(S)] and not get pain relief. As of 6/1/21 at 10:00 AM, R2 had the contents of 3 [MEDICATION(S)] bottles which were diverted. The facility's Abuse Prohibition and Reporting Policy revised on 11/28/2019 showed, The facility actively prohibits resident abuse including .misappropriation of property .No person shall misappropriate or steal any resident property. 2. R3's Face Sheet from 5/28/21 showed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's 4/6/21 Minimum Data Set (MDS) showed he was not cognitively intact with a Brief Interview for Mental Status score of 0 out of 15. The MDS showed he required extensive or total assistance for his care. The MDS showed R3 had pain during the review period. On 5/28/21 at 9:05 AM, R3 had two bottles of [MEDICATION(S)] in his cart. One was open and in use and had a light blue liquid, the other bottle had a foam seal and had a green liquid. Based on color of the liquid, both bottles showed signs of tampering. R3's [MEDICATION(S)] count sheet showed on 5/27/2021 at 11:00 AM, he required pain medication when .25 milliliters of his as needed pain medication were given. (R3's [MEDICATION(S)] at this time was either the incorrect concentration due to dilution, or it was not [MEDICATION(S)].) On 6/1/21 at 11:50 PM, V13 Nurse Practitioner stated R3 is .probably always in pain but he just doesn't ask for it (referring to pain medication.) On 6/2/21 at 2:15 PM, V4 said the she had contacted the manufacturer and was told they do not use foam seals. V4 said in the several years she has ordered this [MEDICATION(S)] from this particular manufacturer, they have never used foam seals. As of 6/1/21 at 10:00 AM, R3 had the contents of 2 [MEDICATION(S)] bottles in which the original [MEDICATION(S)] in the bottle appears to have been tampered with and/or diverted. 3. R1's Face Sheet showed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 3/16/21 Minimum Data Set showed a Brief Interview for Mental Status score of 10 out of 15 and he had no acute mental status changes. The facility's investigation regarding tampering of R1's [MEDICATION(S)] showed on 5/14/21 at 4:00 PM a nurse by the name of either V3, V9, or V10, Registered Nurses, contacted R1's physician which was sent to the on-call physician. The request showed, one of the three nurses were requesting comfort meds (a comfort pack includes liquid [MEDICATION(S)] as well as other medications) because R1 is on [MEDICATION(S)] (pain medication) but is becoming increasingly agitated. Can on-call address this request? A phone number was left to call back, which is not a number at the facility. On 5/27/21 at 9:22 AM, V1 stated that during his investigation, he had called the phone number earlier and it was for the local county health department. V1 stated V3 worked part-time for the same county health department. The facility's investigation showed a second phone call was placed to the on call physicion on 5/15/21 at 10:20 AM. The communication to the on call physician's answering service documented V8 Registered Nurse as the person who made the second request for the comfort medications. The on-call physician responded via electronic communication at 10:40 AM, All meds have been sent. On 5/28/21 at 8:15 AM, V8, RN, denied ordering comfort medications and stated she was not working on 5/15/21 at 10:20 AM. V8 stated, in fact, when she had seen the fax implying she had called and requested the comfort medications, she called V1 Administrator and informed him of the situation. V8 stated she was instructed to remove the [MEDICATION(S)] from the nurses' cart and lock it where nurses would not have access to it. V8 said V3 had done medication pass with the nurses' cart earlier that day. The facility's timeline of events showed V8 notified V1 regarding the comfort medication discrepency on 5/16/21 at 2:57 PM. The investigation showed the facility returned the bottle of [MEDICATION(S)] to the pharmacy the evening of 5/18/21. The investigation showed on 5/19/21 at 3:50 PM the facility was notified that R1's returned [MEDICATION(S)] bottle had been tampered with: it was not the correct color, the seal was not correct, and the bottle was 30 ml bottle but only contained 15 ml of fluid. On 5/27/21 at 9:22 AM, V1stated V3 was suspended and has not been allowed to return to the facility. V1 stated, R1's copay for the [MEDICATION(S)] was $12.49. On 5/28/21 at 1:30 PM, V3, Registered Nurse (RN), denied requesting comfort medications. V3 stated, (R1) wanted a pain medication and he said the pills he was getting were making him crazy. On 5/28/21 at 10:00 AM, R1 stated he had no pain at that time. R1 said, The [MEDICATION(S)] works good for me, it does okay. R1 stated he had never asked for a stronger pain medication except, maybe when I first got here I did ask for [MEDICATION(S)], but not in a long time. I like the [MEDICATION(S)] it doesn't make me feel bad. On 5/28/21 at 3:59 PM, V5 ,RN stated she confronted V3 on Sunday morning (5/16/21) because it was either her (V3) or V9, Registered Nurse, ,that requested the [MEDICATION(S)]. V5 stated V3 said she called for the doctor for another resident, not R1, because that resident was having behaviors. V5 said there were no faxes from the doctors office regarding another resident. V5 said, Then she (V3) lied to me and said she never called. V5 said, There is [MEDICATION(S)] that starts blue and over time it becomes clear. Hospice staff have taken back [MEDICATION(S)] from us because it looks like it has been tampered with .I have never known (R1) to ask for anything other than [MEDICATION(S)]. he does get confused at night .I have never gotten report that he is agitated; he does well with the [MEDICATION(S)]. On 5/27/21 at 2:21 PM, V10, RN, stated she had worked at the facility for [AGE] years. V10 said she never called for comfort medications. V10 said, I didn't work that day .I did receive the medication from the delivery driver on 5/15/21. So I saw the [MEDICATION(S)] when it came in and I was surprised. I had (R1) that day and he was fine. He has [MEDICATION(S)] as an order and that works fine for him. V10 said, That is bologna, he tolerates the [MEDICATION(S)] just fine; it doesn't make him agitated or crazy. He has been on it for months. [MEDICATION(S)] works well for his pain. He has never asked me for [MEDICATION(S)] or anything stronger than [MEDICATION(S)]. V10 said, There has been issues with her (V3) and [MEDICATION(S)] going clear and second bottles of [MEDICATION(S)] being opened that didn't need to be opened and those bottles going clear. 4. On 6/1/21 at 10:00 AM, V14, Pharmacy Nurse Consultant, pulled the emergency supply of 3 [MEDICATION(S)] bottles from the dispensing machine (Statsafe) and took them to the conference room with V1 and V2. All three bottles showed signs of tampering. Two bottles had greens stains on either the seal, the cap, or the bottle label. All bottles contained a liquid that was not consistent with the color of the liquid provided to V1 on 5/19/21. One bottle with the lot number 8003D showed it was a 15 ml bottle of [MEDICATION(S)]; the bottle contained greater than 30 ml of a green liquid. All three bottles had a foam seal with creases. The facility's Statsafe access log for the drawer containing the [MEDICATION(S)] showed 3 people accessed the Statsafe after 2 of 3 [MEDICATION(S)] bottles had been accepted into the dispensing machine on 4/7/21. On 6/2/21 at 10:05 AM, V1 stated V5 RN had a valid reason to access the [MEDICATION(S)] drawer, which was to remove medications for a newly admitted resident. On 6/2/21 at 2:15 PM, V4, Pharmacy Director stated that V18, Pharmacy Representative, accessed the [MEDICATION(S)] drawer to clear errors in the Statsafe system. The Statsafe access log shows that the only other person who accessed the [MEDICATION(S)] drawer after 4/7/21 was V3. V14 accessed the drawer on 6/1/21 at 9:47 AM, in the presence of V2 and was in the presence of 2 nurses. On 6/2/21 at 10:40 AM, V2 stated there was no reason for V3 to access the Statsafe [MEDICATION(S)] drawer and remove a [MEDICATION(S)] (Narcotic pain pill.) V2 said the resident that V3 pulled the [MEDICATION(S)] for had plenty of [MEDICATION(S)] left in the nurses' cart. As of 6/1/21 at 10:00 AM, the contents of three [MEDICATION(S)] bottles had been diverted from the emergency supply safe. The Immediate Jeopardy that began on 5/16/21 was removed on 6/7/21 when the facility took the following actions to remove immediacy: 1. On 6/1/21 the facility removed all [MEDICATION(S)] from resident use until a known supply could be obtained. A new supply of [MEDICATION(S)] arrived on 6/1/21. 2. On 6/7/21 the facility trained it's staff on drug diversion and misappropriation or resident property. 3. On 6/1/21 the facility implemented and trained on a new [MEDICATION(S)] control policy. Education of staff was verified to be completed on 6/1/21. The facility implement a two key safe for all resident [MEDICATION(S)]. The keys are kept by two separate staff members and the [MEDICATION(S)] bottle does not leave the medication room. On 6/4/21, R2's [MEDICATION(S)] was observed to be the correct color of [MEDICATION(S)]. There were no other in-use bottles of [MEDICATION(S)]. Staff stated R3 had passed away on 6/4/21 and his [MEDICATION(S)] was disposed of. 4. On 6/3/21 the facility trained staff on it's controlled substance policy; to include the color of [MEDICATION(S)], the seal on [MEDICATION(S)] bottles, and the reporting of discrepancies.

Based on observation, interview, and record review the facility failed to have procedures to identify [MEDICATION(S)] that had been tampered with and failed to ensure residents did not receive [MEDICATION(S)] that had been tampered with. This failure also resulted in the facility not having access to liquid [MEDICATION(S)] for residents in pain. This failure applies to 3 of 3 residents (R1, R2, R3) reviewed for controlled substances in the sample of 8. The Immediate Jeopardy began on 5/16/21 at 2:57 PM when V8 Registered Nurse notified V1 Administrator of inconsistencies regarding a [MEDICATION(S)] order for R1. The Immediate Jeopardy was identified on 5/27/21. V1 was notified of the Immediate Jeopardy on 6/3/21 at 1:00 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/3/21, however, noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. On 5/27/21 at 1:40 PM, V2 Director of Nursing pulled two bottles of [MEDICATION(S)] out of a locked cabinet in her office. V2 stated they had been R2's [MEDICATION(S)] and were pulled out of the nurses' cart on 5/19/21 because the color was not consistent with the blue color that was expected. One of the bottles indicated R2 had received approximately 8 ml of the unknown mint green liquid. V2 said only two bottles of R2's [MEDICATION(S)] was pulled from the nurses' cart and one bottle of [MEDICATION(S)] was left in the cart for R2's use. On 6/1/21 at 10:43 AM, V2 pulled R2's remaining bottle of [MEDICATION(S)] from the nurses' cart. The bottle of [MEDICATION(S)] contained approximately 10 milliliters (ml) of a light green liquid. The [MEDICATION(S)] bottle indicated it had originally contained 15 ml (milliliters) of [MEDICATION(S)] however; R2's narcotic count sheet and the pharmacy label on the bag showed a 30 ml bottle was dispensed. (Indicating the 30 ml bottle was taken and switched with a 15 ml bottle of unknown substance). On 6/1/21 at 10:43 AM, V14, Pharmacy Nurse Consultant stated R2's in-use [MEDICATION(S)] was a light green color (not the correct color) and it should be a 30 ml bottle not a 15 ml bottle. R2's Narcotic Count sheet showed her in-use bottle was first used on 5/19/21 at 7:30 PM and she had received 17 ml of the unknown liquid, including a dose on 6/1/21 at 11:53 AM, after the bottle was identified to have been tampered with. On 6/1/21 at 3:18 PM, V2 stated the dose of [MEDICATION(S)] given to R2 at 11:53 AM on 6/1/21 had to have been given from the bottle of [MEDICATION(S)] that was known to have been tampered with. V2 stated the liquid in the bottle was most likely either diluted [MEDICATION(S)], or an unknown substance. On 6/2/21 at 10:48 AM, V7, Licensed Practical Nurse, stated she has witnessed R2's [MEDICATION(S)] go clear. V7 stated there was an instance where R2's [MEDICATION(S)] was so clear she was unable to see the liquid in the bottle. V7 said she reported this to V2, Director of Nursing, and was told to destroy the [MEDICATION(S)] and open a new bottle. V7 said R2 has had two open bottles of [MEDICATION(S)] at the same time which was a red flag. V7 said R2 has lots of pain and hospice has had to increase her [MEDICATION(S)] to being scheduled to assist in controlling her pain. On 5/28/21 at 3:59 PM, V5, Registered Nurse (RN), stated, We have had issues with [MEDICATION(S)] for awhile. There is [MEDICATION(S)] that starts blue and over time it becomes clear. Hospice staff have taken back [MEDICATION(S)] from us because it looks like it has been tampered with. (R2) had [MEDICATION(S)] that had a pin hole leak in it, and the [MEDICATION(S)] in the bottle looked diluted . On 6/1/21 at 11:50 AM, V1, Nurse Practitioner,stated if a medication is not known what it is, it should not be given. It could be something harmful to the resident like [MEDICATION(S)] (blood thinner.) 2. On 6/2/21 at 10:05 AM, R3's bottle of [MEDICATION(S)] was compared to his previously, in use, bottle of [MEDICATION(S)]. The new bottle that was received on 6/1/21 at 9:45 PM contained [MEDICATION(S)] that was a medium blue color with an intact paper faced seal. A side-by-side comparison of the new bottle of [MEDICATION(S)] and the previous bottle showed the previous bottle to have a liquid of a noticeably different color. The liquid was noticeably [NAME]. The color of R3's previously in-use [MEDICATION(S)] was not the same shade of blue provided to the facility in the photographs of 5/19/21 and the bottle was not pulled from use until 6/1/21. R3's Narcotic Count sheet showed he received a dose of the unknown green liquid that was in the [MEDICATION(S)] bottle. The Narcotic count sheet showed the [MEDICATION(S)] was pulled from use on 6/1/21. R3 was without [MEDICATION(S)] until that evening at 9:45 PM. On 5/28/21 at 9:05 AM, in addition to the open bottle of [MEDICATION(S)] described above, R3 had a bottle of [MEDICATION(S)] with a green liquid that was sealed with a foam seal. In a side-by-side comparison, the sealed bottle was noticeably [NAME] than the opened bottle and also not the same color as the photographs of 5/19/21. The facility's Pharmaceutical Procedures policy revised on 10/18/2019 showed, The medications of each resident shall be kept and stored in their originally received container. Medications shall not be transferred between containers. The policy showed that the facility should maintain an emergency supply of medications for immediate use. 3. The facility's investigation regarding tampering of R1's [MEDICATION(S)] showed on 5/14/21 at 4:00 PM a nurse by the name of either V3, V9, or V10, Registered Nurses, contacted R1's physician which was sent to the on-call physician. The request showed, one of the three nurses were requesting comfort meds (a comfort pack includes liquid [MEDICATION(S)] as well as other medications). The facility's investigation showed a second phone call was placed to the on call physicion on 5/15/21 at 10:20 AM. The communication to the on call physician's answering service documented V8 Registered Nurse as the person who made the second request for the comfort medications. The on-call physician responded via electronic communication at 10:40 AM, All meds have been sent. On 5/28/21 at 8:15 AM, V8, RN, denied ordering comfort medications and stated she was not working on 5/15/21 at 10:20 AM. V8 stated, in fact, when she had seen the fax implying she had called and requested the comfort medications, she called V1 Administrator and informed him of the situation. V8 stated she was instructed to remove the [MEDICATION(S)] from the nurses' cart and lock it where nurses would not have access to it. V8 said V3 had done medication pass with the nurses' cart earlier that day. The facility's timeline of events showed V8 notified V1 regarding the comfort medication discrepency on 5/16/21 at 2:57 PM. The facility's drug diversion investigation showed on 5/19/21 at 3:50 PM the facility was notified by their pharmacy that a bottle of liquid [MEDICATION(S)], originally prescribed to R1, had been returned to the pharmacy and it had been tampered with. The facility was notified by their pharmacy that the seal was not the correct type, the color of the liquid was different, the NDC (National Drug Code, code to identify the medication) did not match what was originally sent to the facility, and the patient label on the bottle had been wiped clean. On 5/19/21 at approximately 5:30 PM, V1 was sent photographs that had been taken by the facility's pharmacy. The photographs showed a known good bottle of [MEDICATION(S)] next to R1's bottle of [MEDICATION(S)]. The known bottle of [MEDICATION(S)] was a medium blue color with R1's [MEDICATION(S)] being a medium green color. On 5/28/21 at 11:07 AM, V6, RN, stated there has been issues with [MEDICATION(S)] at the facility. V6 said, residents would have [MEDICATION(S)] bottles taken out of the stat safe (emergency supply) when they already had [MEDICATION(S)] and she has observed drops of water on the seals of [MEDICATION(S)] bottles that appeared lighter in color. On 5/28/21 at 8:15 AM, V8, RN, stated she has noticed issues with [MEDICATION(S)] becoming lighter in color from one shift to her next shift. 4. On 6/1/21 at 10:00 AM, V2 Director of Nursing and V14 Pharmacy Nurse Consultant, removed the three available bottles of [MEDICATION(S)] form the Statsafe (Dispensing system with multiples drawers containing emergency supply of medications for the residents.) The bottles were taken to the conference room for observations. All three bottles where in a resealable bag. The bag had a label and the label showed a lot number. The lot numbers on the all three bags did not match the lot number for the bottle of [MEDICATION(S)] they contained. The bottle with lot # 8003D had a National Drug Code indicating it was a 15 milliliter (ml) bottle; however, it was filled to at least 30 ml of liquid. This bottle also had green stains on the manufacturer label and the label appeared well worn and used. All three bottles had foam seals that were creased. The bottle with lot # 8003D had green stains around it's seal and inside the cap. All three bottles contained liquid in different shades of green except the bottle with lot number 8003D which had a slight blue color. On 5/27/21 at 12:59 PM, V4, Pharmacist/Pharmacy Director, stated the [MEDICATION(S)] her pharmacy purchases has been a particular shade of medium blue since she started with the pharmacy in 2018. V4 said less expensive [MEDICATION(S)] can be purchased that is clear, however, the pharmacy pays extra to purchase the [MEDICATION(S)] from their supplier due to their blue coloring of [MEDICATION(S)]. V4 said there may be slight variations in color from one lot to the next; however, that variation would not be perceptible. V4 said she has never seen the manufacturer use a foam seal, it's always a paper faced seal. On 5/28/21 at 9:30 AM, V4 said she has had conversations with the manufacturer when drug diversion issues have come up. V4 said she was assured by the manufacturer the color of the [MEDICATION(S)] they produce does not change over time and the shade of blue is consistent across lots. V4 said it would not make sense to have a drug diversion deterrent that changes from one lot to the next. On 6/2/21 at 2:15 PM, V4 stated she contacted the [MEDICATION(S)] manufacturer and she was told the seals have not changed and they are the same as they have always been. V4 said she has used this manufacturer for many years and it has always been a paper faced seal with some sort of foil/plastic under the paper to waterproof the paper. (The seals found on the three Statsafe [MEDICATION(S)] bottles were foam.) On 6/1/21 at 9:45 PM, V1 stated the pharmacy driver arrived at the facility with new [MEDICATION(S)]. At 9:55 PM, three bottles of [MEDICATION(S)] were observed. The bottles of [MEDICATION(S)] were delivered in tamperproof bags. One bag contained the bottles for the Statsafe and the other bag contained [MEDICATION(S)] for R2 and R3 as well as other controlled substances. The bottles contained a blue liquid with medium darkness. The color of the liquid was a blue color that had not been observed in any [MEDICATION(S)] bottle in the facility as of the start of the survey on 5/27/21. The seals were smooth paper faced; however, under the paper face the seal felt substantial as if there was a thick plastic or foil layer below. The seals on the new bottles were unlike the previous 3 Statsafe bottles in both it's material and sturdiness. The Statsafe [MEDICATION(S)] that was observed on 6/1/21 at 10:00 AM showed two [MEDICATION(S)] bags labeled 1L-777. (1L indicates the drawer in the Statsafe where it is stored. Drawer 1L contained [MEDICATION(S)] as well as well as other controlled substances.) Both 1L-777 [MEDICATION(S)] bottles showed signs of tampering and liquid that was not consistent with [MEDICATION(S)]. The facility's Statsafe Access Logs for drawer 1L showed the two [MEDICATION(S)] bottles, 1L-777, were accepted into the Statsafe on 4/7/21 at 8:58 PM by V5 Registered Nurse. (Actual time was 10:58 PM per V4 Pharmacy Director. Statsafe clock was not corrected until 6/2/21 and was off by two hours prior to this date; all times referenced will be the actual/corrected time.) The logs showed V5 accessed the drawer again on 4/10/21 to pull Oxycodone for R4, a new admission on 4/10/21. The next access was by V3 ,RN on 4/18/21 at 9:32 AM for R5. V3 pulled one tablet of [MEDICATION(S)] (narcotic) with acetaminophen 5/325 milligrams (ml). The third and final person who accessed drawer 1L, prior to 6/1/21, was a pharmacy representative who was clearing errors. R5's [MEDICATION(S)]/Acetaminophen ([MEDICATION(S)]) controlled substance count record showed on 4/18/21 as of 9:32 AM, when V3 accessed the Statsafe, R5 had 20 tablets of [MEDICATION(S)] available in the nurses' medication cart. On 6/2/21 at 11:51 PM, V4 Pharmacist/Pharmacy Director stated there was no reason for V3 to access the Statsafe on 4/18/21. V4 said it is a multistep process to access the Statsafe and nurses do not like accessing it unless they have to, because it is a hassle. On 6/2/21 at 10:40 AM, V2 said there was no reason for V3 to pull [MEDICATION(S)] from the Statsafe for R5. V3's Time Card showed she worked on 4/18/21 from 6:00 AM to 10:24 AM. (V3 has been scheduled on certain shifts to assist with morning medication pass.) R2's [MEDICATION(S)] count sheet showed she had already been given the green liquid 3 times on 6/1/21 and would not have an opportunity to receive [MEDICATION(S)] until nearly 10:00 PM; 12 hours after the Statsafe [MEDICATION(S)] was identified to be in question. On 5/27/21 at 10:00 AM, the facility provided a list of residents on [MEDICATION(S)]. R2 and R3 were the only residents listed. As of 6/1/21 at 10:00 AM, R2, R3, and the facility's Statsafe [MEDICATION(S)] were all in question and no [MEDICATION(S)] was available for any resident in the facility. On 6/2/21 at 10:48 AM, V7 Licensed Practical Nurse stated she was frustrated that [MEDICATION(S)] issues had been reported over several months and nothing is done. It's like we're not heard. We can't even trust each other with all the problems we've had. As of 6/1/21 at 10:00 AM, the facility was known to have 8 bottles of [MEDICATION(S)] in their possession that had been tampered with and a 9th bottle that had been returned to the pharmacy. On 6/4/21 at 8:50 AM, V1 Administrator stated there was an allegation of drug diversion involving [MEDICATION(S)] in November 2020. V1 stated [MEDICATION(S)] in the facility was replaced. V3's Personnel File showed she was available for employment in 2/3/2020. The Immediate Jeopardy that began on 5/16/21 was removed on 6/3/21 when the facility took the following actions to remove immediacy: 1. On 6/1/21 the facility removed all [MEDICATION(S)] from resident use until a known supply could be obtained. A new supply of [MEDICATION(S)] arrived on 6/1/21. 2. On 6/1/21 the facility implemented and trained on a new [MEDICATION(S)] control policy. Education of staff was verified to be completed on 6/1/21. The facility implement a two key safe for all resident [MEDICATION(S)]. The keys are kept by two separate staff members and the [MEDICATION(S)] bottle does not leave the medication room. On 6/4/21, R2's [MEDICATION(S)] was observed to be the correct color of [MEDICATION(S)]. There were no other in-use bottles of [MEDICATION(S)]. Staff stated R3 had passed away on 6/4/21 and his [MEDICATION(S)] was disposed of. 3. On 6/3/21 the facility trained staff on it's controlled substance policy; to include the color of [MEDICATION(S)], the seal on [MEDICATION(S)] bottles, and the reporting of discrepancies. 4. On 6/3/21 the facility implemented and trained staff on new policies for the control of empty [MEDICATION(S)] bottles. Empty bottles of [MEDICATION(S)] are to be kept in the double lock safe in the medication room until V2 can render the bottle useless. On 6/4/21, R3's empty bottle was observed in the double lock safe. 5. On 6/3/21 staff were educated on documenting narcotic and controlled substances in the resident's record. 6. On 6/3/21 the facility implemented an auditing process and controlled substances was added to the Quality Assurances agenda.

Based on observation, interview, and record review, the facility failed to identify pressure injuries prior to becoming a Stage two or greater, failed to offload pressure to prevent pressure injuries and worsening of pressure injuries, and failed to use infection control measures to prevent wound contamination for three of five residents (R5, R23, R64) reviewed for pressure in the sample of 18. This failure resulted in R64 acquiring six unstageable pressure injuries. The findings include: 1. On 4/6/21, R64 was observed, supine with feet in waffle boots, with heels resting on mattress at 10:45 AM and 1:45 PM. On 4/7/21, R64 was supine in bed at 8:13 AM, 8:44 AM, 8:48 AM, 9:54 AM, 11:07 AM, 12:02 PM, 1:00 PM and 2:12 PM. R64 had waffle boots on both feet, which were in contact with the mattress. On 4/7/21 at 8:13 AM, V4, wound nurse, said she just finished R64's dressings and is going to change the treatment because the wounds are getting ugly. V4 said the blister on R64's right wrist opened up and has slough. I would say the wounds are due to pressure on the bed, especially the feet. At 12:30 PM, V4 said ways to prevent pressure injuries include: repositioning, waffle boots, air mattresses, waffle cushions for chairs, and verbally tell/educate residents to reposition. Some ways to offload pressure include: waffle boots, elevate feet on pillows, repositioning every two hours to adequately remove pressure from an area. V4 stated I do the weekly wound assessments. I am not wound care certified. We do not have a wound doctor that comes to the facility. Pressure injuries should definitely be found before becoming a stage 2-4. If a wound is not identified prior to becoming a stage 2-4 there could be an infection, the resident could become septic, the wound could get to the bone, cause pain and then they don't eat. If ordered treatments are not being done the wound is not going to heal, the wound could get worse and have delayed wound healing. A superficial wound can become very serious. I don't do a head to toe assessment. The staff nurses would do the skin checks and the Certified Nursing Assistants (CNAs) during care and showers. On 4/8/21 at 9:11 AM, V13, Director of Rehab ,said all of R64's functional transfers required moderate to maximum assistance on admission. R64 could only minimally move his right leg on his own. On 4/8/21 at 10:40 AM, V12 Nurse Practitioner (NP) said Waffle boots do not offload pressure if the feet are still laying on something. They're still sitting on something softer but pressure is not offloaded. Anyone recovering from a [CONDITION(S)] would be at increased risk for pressure injuries due to immobility. R64's pressure injuries could have been prevented or reduced had preventative measures been put in place. Just because orders are written doesn't mean it's getting done, necessarily. The residents obviously aren't getting the preventative care they need. I would expect preventative interventions to be put into place for pressure injury prevention. V4 gives me wound care recommendations. R64's face sheet showed admission to the facility on [DATE] from a local hospital after a right [CONDITION(S)]. R64's hospital history and physical dated 12/5/20 showed R64 slipped (at assisted living facility) while trying to get into his pants, lost his balance and fell backwards landing on his hip. This note showed R64 was scheduled for right hip surgery on 12/6/20 and was otherwise quite functional and independent. R64's physical therapy assessment dated [DATE] showed R64's discharge plan was to return to the assistive living facility. This assessment showed he required moderate assistance with bed mobility, maximum assistance with transfers and R64 was highly motivated to regain abilities and had the potential to do so. R64's facility assessment dated [DATE] showed R64 required extensive assistance of two plus persons to physically assist him to move in bed and for hygiene. This assessment showed no pressure injuries and functional impairment of one lower extremity. R64's 12/15/20 care plan showed R64 was able to turn and reposition himself. R64's pressure injury risk assessment dated [DATE] showed R64 was not at risk for developing pressure injuries. R64's Admission Observation form dated 12/9/20 showed no skin integrity impairments besides the surgical incisions to the right hip, bruises, a rash and abrasion to the left knee. This assessment showed R64 was unable to walk, and had right lower extremity weakness and impaired functional range of motion. R64's skin integrity event report dated 12/16/20 showed a right heel deep tissue injury fluid filled blood blister. R64's 12/16/20 pressure ulcer care plan showed to apply treatment as ordered to right and left heel blisters. R64's wound assessments have no mention of a left heel blister. R64's 12/29/20 pressure injury risk assessment dated [DATE] showed R64 was not at risk for developing pressure injuries. R64's 3/8/21 skin integrity events showed a stage two pressure injury to the medial ball of the left foot and a stage two pressure injury to the dorsal aspect of the right heel. R64's 3/10/21 Wound assessment showed the right heel wound was unstageable and the left foot wound had increased in depth. This assessment showed additional wounds; an unstageable wound to the right outer ball of the right foot, an unstageable wound to the inner right foot and a stage two wound to the right inner ankle. R64's 3/24/21 wound assessment showed worsening of the right heel wound, right inner foot wound, right outer foot wound, right ankle wound (unstageable), left outer ball of foot (unstageable). This assessment showed a new pressure injury to the left heel for a total of six pressure injuries. R64's 3/31/21 wound assessment showed a new unstageable pressure injury to the outer ball of the left foot. R64's 4/7/21wound assessment showed a new unstageable blister to the right hand. R64's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R64's treatment administration record for April 2021 showed no treatment done for the right hand, right outer foot and left heel. 2 On 4/6/21 at 8:22 AM, V4 wound nurse performed wound care for R5. V4 washed R5's feet and wounds using a single wash cloth with soap and water. V4 then applied iodine to the foot wounds, applied waffle boots to both feet. V4 said Oh shoot. I forgot to measure them. V4 removed the waffle boots and measured all wounds except for the scabbed area to the right great toe area. V4 recorded all measurements on a paper measuring tape with a pen. All of the washing of wounds, handling of the waffle boots, and touching the sheets, measuring tape, and pen were done with the same gloves on. V4 pulled the room door open with the same gloved hands to retrieve dressing supplies from the treatment cart in the hall. V4 removed and replaced the gloves in the hallway. V4 cleaned R5's involuntary stool then proceeded with the same gloves on to do the wound treatment to R5's coccyx and buttock. There were two open areas to the coccyx and V4 said I just measure and treat it as one wound. A new open area to the right buttock was observed. V4 measured all three wounds with the paper measuring tape and recorded her measurements on the tape with a pen. Then, V4 put hydrogel on her gloved finger and applied it directly on the coccyx wound bed with her contaminated gloves. V4 then applied a collagen alginate dressing over the hydrogel and then applied additional hydrogel on the dressing. V4 used scissors to cut a foam dressing and tape, then touched the foam dressing with her gloved hands and placed it over the coccyx wound. V4 laid the scissors on R5's bed. V4 again applied hydrogel to her gloved hand and applied it directly on the new wound on the buttock. V4 applied a collagen alginate dressing over the buttock wound. V4 again used the scissors to cut the foam dressing and tape and laid the scissors back on the bed before touching the foam dressing and placing it over the wound. The two coccyx wounds and new buttock wound were not cleaned after removing the old dressing and applying the new ones. V4 never changed her gloves from the time she entered the room or after cleaning off feces. The same gloved hands were used. On 4/6/21 at 8:15 AM, V4 said R5's wounds were from friction and shear. On 4/7/21 at 1:30 PM, V4 said Infection control during wound care is important because a superficial wound can become very serious. Gloves should be changed from wound to wound and when visibly soiled. If good infection control is not done you can make wounds worse and spread organisms to other wounds and other residents. V4 said she was embarrassed when observations of not changing gloves were shared. On 4/8/21 at 10:40 AM, V12, Nurse Practionaer, said if infection control measures are not used during wound care, then infections and wound decline could absolutely occur. R5's wound assessment dated [DATE] do not mention the new open buttock wound or treatment done. There is no assessment of the new wound. There is no staging of any of the wounds. There are no assessments of the peri wound, absence or presence of drainage or odor, and no identification of wound types. There is no assessment of the wound beds except for the coccyx wound. R5's April 2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It showed to apply the collagen alginate dressing directly to the wound bed. R5's face sheet showed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Infection Control dated 12/17/19 showed gloves will be changed after direct contact with resident's secretions or excretions, even if care of resident has not been completed. Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions should be applied to the care of all residents regardless of the suspected or confirmed presence of an infectious agent. Standard Precautions include but are not limited to: 1. Hand Hygiene, 3. Proper Use of PPE, 6. Handling of Equipment. Hand washing is the foundation of controlling infectious disease. Personnel must wash their hands when coming on duty; when they are visibly soiled; after they handle dressings; 3. On 4/6/21 at 10:00 AM and 2:16 PM, R23 was lying in bed on her back. There were bilateral support hose both legs and feet were on the mattress. There were no offloading measures in place. On 4/6/21 at 10:00 AM, R23 said her right heel hurt and rated the pain a 10 on a scale of 0-10. It's been hurting about half an hour. I let staff know. I don't know why anyone isn't doing anything. I'm tired and sore and frustrated said R23. At 11:55 AM, V5 ,Certified Nursing Assistant (CNA) and V7 CNA transferred R23 with a total mechanical lift from the bed to the wheelchair. R23 asked V5 and V7 if anything was going to be done about her foot and complained about pain to her right heel. R23 grimaced and moaned when a non-slip booty was placed on her right foot. V7 asked R23 if she had a good nap and R23 responded no, because my foot hurts. V7 told R23 she would tell the nurse about her leg again. On 4/7/21 at 8:11 AM, 9:53 AM, 11:05 AM, 12:02 PM, and 1:36 PM, R23 was lying in bed on her back with both bare feet /heels on the mattress. At 1:36 PM, this surveyor requested assistance from V8 CNA to inspect R23's heels. R23's posterior right heel had a non-blanchable dark brown, light black colored closed wound present. V8 said there is something there. R23's face sheet showed admission to the facility on [DATE] after hospitalization for a right [CONDITION(S)]. R23 was hospitalized and readmitted on [DATE] after having a stroke. R23's care plan dated 1/29/21 showed R23 was in the facility for short term rehab following a right femur fracture. Prior to hospitalization , R23 was ambulating independently with a wheeled walker and was able to complete her own cooking and cleaning. R23 wished to return home once her therapy stay was complete. R23's care plan dated 2/1/21 showed to assist resident with turning and repositioning and to reposition every two hours. R23's Admission assessment dated [DATE] showed weakness to the right lower extremity and no skin issues besides bruises to the left forearm. R23's facility assessment dated [DATE] showed R23 required extensive assistance of two plus persons to physically assist with bed mobility, transfers, dressing and hygiene. R23 was totally dependent on two plus persons for bathing. This assessment showed functional limitation of one lower extremity and no pressure injuries present.

Based on interview and record review the facility failed to assure a resident was given the correct medications for one of three residents (R1) reviewed for medications in the sample of 3. This failure resulted in R1 being transferred to the local hospital intensive care unit for two days. The findings include: R1's facility face sheet shows R1 to be [AGE] years old and has [DIAGNOSES REDACTED]. R1's facility assessment shows R1 to have moderate cognitive impairment and requires extensive assist with care. The facility incident report dated [DATE] shows R1 received the medications of another resident (R2) in addition to R1's own medications that morning. V3 RN (Registered Nurse) was preparing the medications for R2 when R1 began to get up from the table. V3 went to help R1 sit back down and then proceeded to give R1 the pills meant for R2. The report shows R1 received R1's own medications which consisted of Tylenol 500mg, calcium, stool softner, [MEDICATION NAME], multi vitamin, cranberry, [MEDICATION NAME] 60mg (water pill), an eye vitamin and [MEDICATION NAME]. In addition, R1 also received an additional does of tylenol 650 mg , multi vitamin and calcium, two blood pressure medications, two anti-diabetic medications, and an additional 60 mg of [MEDICATION NAME]. On [DATE] at 9:35AM, V4 (R1's POA) said her (parent) was admitted to the intensive care unit at the hospital after receiving the wrong medications. V4 said her (Parent's) heart rate kept dropping very low and they were monitoring R1's blood pressure and blood sugars as well. V4 said this is not the first time her (parent) has received the wrong medications while at the facility. On [DATE] at 9:42 AM, V3 RN said she was the nurse that gave R1 the medications of R2. V3 said she became distracted while passing medications to the residents on the dementia unit. V3 said R1 was getting up alone and she went over to assist R1 and gave R1 the medications she had crushed up for R2. On [DATE] at 10:45AM and 2:30PM, V1 Director of Nursing said V3 has had medication errors before and has been moved off the dementia unit due to her getting distracted. V1 said she moved V3 to a unit with more independent residents because they are able to say who they are and can identify their medications better. V1 said if V3 had not realized the error she had made and reported it, R1 could have easily died . V1 said she expects all nurses to follow the 5 Right's of administering medications which are: right medication, right patient, right dosage, right route and right time. On [DATE] at 2:00 PM, V2 Nurse Practioner said R1 had to be hospitalized after the medication error. On [DATE] at 10:40 AM, V8 pharmacist said the medications R1 received by mistake on top of R1's medications could have caused a drop in blood pressure, a drop in heart rate, an increase in urination,nausea, dizziness and if left untreated could lead to [MEDICAL CONDITION] and loss of conciousness. The hospital records for R1 show the [DIAGNOSES REDACTED]. The records show low blood sugars as low as 64 (normal is ,[DATE]) and unstable heart rate as low as 30. (Normal heart rate is 80) The records show R1 was treated with intravenous fluids. The records also show the daughter reporting to hospital staff that this was the second time her (parent) has been given the wrong medications while at the facility. The facility employee disciplinary action record dated [DATE] shows V3 was given a written warning for failure to administer medications following the 5 rights of medication administration resulting in a medication error. The facility policy with a revision date of ,[DATE] shows the objective is to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize a specified [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to safely intervene to a resident's catastrophic reaction to care, this failure resulted in a resident receiving a large skin tear and bruising to the resident's arms. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3. The findings include: R1 is a resident on a dementia care unit. R1's face sheet shows a [DIAGNOSES REDACTED]. R1's behavior analysis report for 1/1/2019 to 3/12/2019 shows she is being monitored for physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others, and rejection of care. On 3/12/2019 at 8:35 AM, R1 was resting in bed, with her right forearm wrapped in gauze. R1 said she wasn't sure what had happened but that it still hurt. R1 was calm and pleasant. On 3/13/2019 at 8:48 AM, R1 was asleep in her bed with her clothes on. R1 was awakened by the wound care nurse to change the dressing to her right arm. R1 seemed irritated and confused about why she was being woken up. R1 had a skin tear to her right forearm measuring eight centimeters in length. The skin was held together with steri-strips. The top of R1's left forearm had two old looking bruises about the size of a thumb. There was no bruising to the underside of R1's arm. R1 said she did not know how she got the bruises. On 3/12/2019 at 10:50 AM, V4 dementia care coordinator said she was called to the facility early in the morning on 3/6/2019 because R1 had a large skin tear and the staff working were not able to get in touch with the administrator. V4 said when she got to the unit the nurse in charge told her R1 had a large skin tear. V4 said she assessed R1 and spoke with the staff working that night and was told V11 (CNA) was asked to get R1's blood pressure by the nurse around 3:30 AM and after that was done, R1 walked to the nurse's station and showed the staff her skin tear. V4 said if a resident is becoming agitated with any care the staff are to back away and try again later. On 3/12/2019 at 10:35 AM, V5 Licensed Practical Nurse (LPN) said she had asked V11 to get R1's blood pressure so she could get it documented. V5 said V11 entered the room and then she heard a scream from R1's room. V5 said she just figured V11 had scared her, waking her up and that was why she screamed. V5 said she was two doors down on the hallway from R1's room. V5 said she needed the blood pressure for follow up to a fall R1 had earlier in the week. V5 said the blood pressure was not that important and she could have just charted refused. V5 said if a dementia resident is refusing care the staff should stop and try later. On 3/13/2019 at 2:47 PM, V11 said he was asked to get R1's blood pressure at around 3:30 AM. V11 said he went into R1's room and did not turn on the light, but used the flash light on his cell phone and woke her up. V11 said he did this so he wouldn't frighten R1. V11 said R1 screamed when she saw him. V11 said he then proceeded to get the blood pressure and tried to do incontinence care on R1 but she starting swinging at him and would not calm down. V11 said R1 was too slow at swinging at him and he did not get hit but he did get her blood pressure. V11 said he was not aware that R1 had gotten a skin tear, but V11 felt that maybe she hit her arm on the side rail when she was swinging at him. On 3/13/2019 at 11:15 AM, V2 Director of Nurses (DON) said the staff are expected to back away from the resident if they become resistive with any care including obtaining a blood pressure or incontinence care. On 3/13/2019 at 8:32 AM, V1 administrator said he expects the staff to walk away from a resident if they are refusing care or become agitated. V1 said a blood pressure is okay to walk away from if the resident refuses. R1's nursing progress notes shows her becoming combative with care on 1/30/2019 where she received a skin tear to her left hand, on 3/4/2019 during a shower, she became combative and she slid down a wall to the floor. The nursing note dated 3/6/2019 shows R1's obtained a large skin tear to her right arm measuring 7 by 2.5 centimeters. The same day a note at 8:20 AM shows, R1 was sent by ambulance to local hospital for evaluation of the skin tear. The investigation into this incident dated 3/7/2019 shows R1 was combative with V11 and tried to strike him while care was trying to be performed. R1's care plan shows interventions dated 10/25/2016 to allow R1 to sleep in the morning, until she wakes up naturally. The intervention dated 3/5/2019 shows if R1 is combative or resistive with care, allow time to cool off and let another staff member approach the task. The hospital records dated 3/6/2019 for R1's shows she was seen in the emergency room for a forearm laceration. R1 was prescribed an antibiotic for five days and an order was received for daily dressing changes. On 3/14/2019 at 3:55 PM, V2 stated the facility had no specific dementia care policy.

Based on observation, interviews, and record review, the facility failed to assess, monitor, and provide interventions to prevent pressure ulcers. The facility's failure resulted in R100 developing a stage III pressure ulcer. The facility failed to implement interventions to promote healing and prevent multiple recurrent pressure ulcers on a resident (R92) with minimal risk for the development of a pressure ulcer. This applies to 2 of 7 residents ( R100, R92) reviewed for pressure ulcers in the sample of 22. The findings include: 1. The facility's electronic continuity of care document shows R100 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Facility's Admission Body assessment dated [DATE] showed that R100 was admitted on [DATE] with no pressure sores. The Braden skin assessment dated [DATE] showed R100 has a high risk for the development of pressure ulcers. On October 14, 2015 at 10:20 AM, E10, Licensed Practical Nurse (LPN) and E12, Certified Nursing Assistant (CNA) were doing a dressing change to the pressure area located on R100's coccyx. R100 had an open area the size of a half dollar with slough present on the top edge and the wound bed. There was tunneling present under the wound. edges. The peri-wound area was reddened. E10 cleansed the wound bed with wound cleanser and applied [MEDICATION NAME] to the wound bed. After a few minutes, E10 packed R100's wound with calcium alginate. E10 said She's (R100) a real trooper, she only flinched a couple times. Before she would be jumping quite a bit during the dressing change. E10 said, It used to be where you could pretty much see the bone. E10 said there was some slight drainage to the wound. E10 said there was one day that she removed the dressing to change it and there was a very foul odor and purulent drainage was present. E10 said she was unsure of the date this occurred, but it was not that long ago. On October 15, 2015 at 9:00 AM, E2, Director of Nursing (DON) stated, I did not find a Braden Assessment (Pressure ulcer risk assessment tool) for R100 on admit. E2 said the Braden assessment dated [DATE] was the only one she could find. E2 said the approaches listed on the care plan dated May 12, 2015 were to encourage resident to attend activities to promote change of position. On October 16, 2015 at 8:35 AM, E2 said Considering her (R100) medical condition, I would expect there to be interventions put in place to reduce pressure. The interventions should have been updated as she (R100) declined. E2 said if the CNAs, Shift coordinators, or Nurses see something that needs to be changed, they let the MDS (Minimum Data Set) Coordinator know and they would add it to the resident's care plan. On October 15, 2015 at 12:00 noon, E2 said the CNAs should let the nurses know when there is a red area or they have any concerns, so they can get a treatment in place. E2 stated, I would expect the CNAs to notice an area of pressure prior to stage III or unstageable. E2 said she would expect them to notice it when it is red. (stage I) On October 15, 2015 at 10:55 AM, Z1 (Wound Care Consultant from American Medical Technology) stated the pressure ulcer located on R100's left inner buttocks was a stage III the first day that she looked at it on July 21, 2015. Z1 said the pressure ulcer on R100's coccyx was unstageable when she first observed it. Z1 stated she would expect the facility to notify her prior to a stage III or unstageable pressure ulcer. On October 16, 2015 at 8:35 AM, E2 (DON) stated R100's pressure ulcer was facility acquired. On October 16, 2015 at 2:02 PM, Z2 (Nurse Practitioner) said you would see reddened skin that was unblanchable prior to the development of a pressure ulcer. If a pressure ulcer is not identified and treated, it would get worse and it is easier to treat at the earlier stages. Z2 stated, Stage III is not an acceptable stage to identify a pressure ulcer. Resident Progress Nursing Notes reviewed from May 12, 2015 through October 15, 2015. No mention of R100 having a pressure ulcer was in nursing notes until July 14, 2015 at 12:47 PM. The Nursing Notes showed a stage III pressure ulcer noted to R100's coccyx measuring 1.2 x 1.2 x 2 cm. The nursing notes dated July 16, 2014 show a stage II pressure ulcer on R100's medial aspect of left buttocks measuring 1.0 x 1.0 x 0.1 cm. The Nursing Notes dated August 18, 2015 showed the wound nurse assessed R100 and recommended [MEDICATION NAME] put in wound and on peri-wound 30 seconds before dressing change. The Facility's Observation Reports for R100 show that the pressure ulcer on R100's coccyx deteriorated from a stage III measuring 2 x 1.5 x 0.1 cm on July 16, 2015 to a stage IV pressure ulcer with heavy, cloudy serosanguinous drainage and undermining on October 1, 2015. R100's Facility's Observation Report related to pressure ulcer documentation of her left buttocks wound, dated July 16, 2015 showed she had a stage II pressure ulcer on her left medial buttocks that measured 1 x 1 x 0.1 cm with no drainage. Z1's (Certified Wound Care Consultant) evaluation of R100 dated July 21, 2015 showed R100 had a stage III pressure ulcer on her left inner buttock measuring 3.4 x 3.5 cm with serous drainage that was facility acquired. Z1's evaluation showed that the pressure ulcer on R100's coccyx deteriorated from unstageable measuring 2.5 x 2.3 cm with slough (non-viable, dead tissue) in the wound bed on July 21, 2015, to a stage III pressure ulcer with undermining on September 5, 2015, to unstageable measuring 3.5 x 2 cm with the depth of the wound unable to be determined due to ivory slough covering half of the wound bed on October 13, 2015 (3 months later). R100's Care Plan for pressure ulcer risk start date May 12, 2015 showed (R100) is at risk for pressure ulcer formation related to weakness and immobility as evidenced by [DIAGNOSES REDACTED]. The Care Plan showed interventions implemented at that time were encourage resident to attend activities of choice to promote position change, and encourage (R100) to attend activities outside of her room to promote position change. The Care Plan showed that no further interventions were initiated until after July 14, 2015 (after R100 developed pressure ulcer on coccyx). The Facility's Pressure Ulcer Prevention and Treatment Protocol Revised May 2007 showed a skin risk assessment is completed upon admission , weekly for the first four weeks after admission and quarterly thereafter. The protocol shows an individual plan of care will be developed for the resident following the guidelines of the assessment. All high and moderate risk residents may have the following, and if so, they will be addressed on the Care Plan. A)special mattress and wheelchair cushions, B) Passive Range of Motion, C) Protein and/or Nutritional Supplements, E) Skin checks, F) Elbow/heel protectors. The Protocol shows Staff will be trained on pressure ulcer prevention and safety measures to be taken, including redness that remains when pressure is relieved and proper positioning procedures. The protocol lists chronic or end stage renal, liver or [MEDICAL CONDITION], and [MEDICAL CONDITION] as some of the predisposing factors. R100's MDS dated [DATE] showed R100 has the [DIAGNOSES REDACTED]. The facility's Care Plan policy and procedures revised November 2013 shows The care plan meeting provides a framework for providing good resident care and sets direction for meeting the needs of the individual resident. It provides a valuable communication tool for staff to ensure that individual plan of care is carried out. The document shows if the need arises that indicates that the plan of care needs to be reviewed prior to the three month review, a special care plan meeting shall be held. R100's Treatment Administration History showed R100 had a weekly skin check starting May 20, 2015. The Treatment history showed no documentation regarding a pressure ulcer until July 15, 2015. The document showed orders to clean stage III decubitus, apply skin prep to peri-wound bed and cover with bordered foam every day. The Documentation from July 16, 2015 shows orders to apply collagen to stage II pressure ulcer on left buttock and cover wit bordered foam until resolved. The Treatment Administration History showed that on July 21, 2015 there was an order to cleanse stage III decubitus cluster to coccyx. Apply skin prep and hydrogel disc to wound and cover with white bordered foam dressing every day. The Facility's Observation Report related to pressure ulcer documentation of R100's coccyx wound showed between July 23, 2015 and August 13, 2015 R100's pain level increased from a 4 out of 10 moderate (distressing/miserable) pain at the ulcer site on July 23, 2015 to a 9 out of 10 (10 being excruciating, worst possible pain-interferes with ability to carry on with daily routines, socialization, or sleep) before orders were obtained for pain control prior to packing R100's wound. The Facility's electronic Current Orders for R100 show [MEDICATION NAME] Ointment squirt some in wound bed and gently spread with swab, wait 30 seconds to pack wound. was ordered on August 19, 2015. On August 21, 2015 [MEDICATION NAME] 100 mg/5 ml (20 mg/ml) Give 0.75 ml 30 minutes prior to dressing change. was ordered. R100 went from July 14, 2015 to August 19, 2015 before the facility addressed her pain. 2. The September 29, 2015 MDS (Minimum Data Set) shows R92's [DIAGNOSES REDACTED]. The nursing notes document that R2 had developed a pressure wound (at the facility). On December 16, 2014 nursing notes show R92's wound measured 0.5 cm (centimeter) x 1 cm on the coccyx and the notes show R92's wound continued to worsen, increasing in both area and depth: Stage 2 (0.7 cm x 0.6 cm) on January 1, 2015, Stage 2 (2.5 cm x 2. 4cm x 0. 4cm) on January 15, 2015 and Stage 3 (5.0 cm x 2.5 cm x 0.1 cm) on February 3, 2015. The nursing notes shows a Stage 2 pressure ulcer Mw on R92's sacrum (lower back) was identified on April 24, 2015. The wound measured 2.0 cm x 1.3 cm x 0.1 cm. On May 26, 2015 the contracted wound care nurse measured the same wound as 0.5 cm x 2.5 cm x 0.1 cm and rated the pressure wound at a facility acquired Stage 3 (Full Thickness Pressure Wound). On September 8, 2015 at 2:59 PM the nursing notes by E14 RN (registered nurse) shows 2 new Stage 2 pressure ulcer on R92's coccyx area, measured at 1.0 cm x 0.2 cm x <0.1 cm and 0.8 cm x 0.2 cm x <0.1 cm. One week later, on September 14, 2015 R92's wound measured 0.8 cm x 0.2 cm x<0.1 cm. The following Braden Risk Assessments were completed for R92: 1. February 2015 - Score of 16 (At (low) risk for developing pressure ulcers; 2. April 2015 - Score of 19 (Not at risk); and 3. September - Score of 23 (Not at risk). The Braden Scale shows, 19 or higher-NOT AT RISK, 15-18 AT RISK, 13-14 MODERATE RISK, 10-12 HIGH RISK, and 9 or less VERY HIGH RISK. R92's care plan shows Skin Integrity was first added to the plan of care on February 11, 2015, nearly two months (56 days) after R92 had developed a pressure wound. There were no documented interventions identified to prevent R92 from developing a new pressure wound. On October 15, 2015 at 10:15 AM, E3, ADON (Assistant Director of Nursing) said, it was her expectation that no residents received a facility acquired pressure ulcer, and if a resident did receive a pressure ulcer that it did not progress to a higher stage. E3 would also expect the care plans to be initiated for a new pressure ulcer, or modified if the pressure ulcer does not heal or worsens. On October 15, 2015 at 2:47 PM, E2 DON (Director of Nurses) said, it would be her expectation that no residents receive a facility acquired pressure ulcer, and if a resident did receive a pressure ulcer that it did not progress to a higher stage. E2 would also expect a care plan to be initiated if the pressure ulcer is new, or modified if the pressure ulcer is not healing or getting worse. The May, 2007 Pressure Ulcer Prevention and Treatment Protocol shows, under the heading, Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of [REDACTED]. The same protocol list one of the treatment measures as providing pressure relieving devices. The November, 2013 Care Plan Policy and procedure shows, care plans provide a valuable communication tool for staff to ensure that individual plan of care is carried out. Under the heading, Frequency of Care Plan Meetings .#4 Special Review: If the need arises that indicates that the plan of care needs to be reviewed .a special care plan meeting will be held.

Based on Observation, Interview and Record Review, the facility failed to monitor, document and prevent a stage II pressure ulcer from progressing to a Stage 3 which resulted in the wound requiring debridement, ultrasound and electronic stimulation treatment (R18). The facility failed to prevent and identify a Stage 3 pressure ulcer. (R26) This applies to 2 of 7 residents ( R18, R26, ) reviewed for pressure ulcers in the sample of 14. The findings include: 1. R18 is a [AGE] year old female resident admitted post Right [MEDICAL CONDITION]/Repair according to the Computer Generated [DIAGNOSES REDACTED]. The MDS also shows R18 was admitted for rehabilitation and plans to return to the community. On 9/13/11 at 11:50 AM, R18 was observed in the Physical Therapy Department lying on her left side receiving Electronic Stimulation treatment to her right heel wound. The wound was noted to be healing from the inside out. The deeper center tissue was beefy red with granulation tissue forming on the wound margins. The documentation of R18's heels began on 7/2/11. On 7/2/11, the Skin Integrity Event documents a Stage 2 Pressure Ulcer with Granulation Tissue and Light drainage. The Nursing Note of 7/2/11 documents: "Resident has a blister that fluid has drained from on R (right) heel. Area measured 5.1 X 2.9 (no depth documented). Applied [MEDICATION NAME] dressing to absorb drainage and additional pillows as well as heel protectors." On 7/6/11, the Nursing Note showed the right heel wound measured 4 cm X 3 cm (no depth documented). The Nursing Note documents a transparent dressing was applied. The 7/7/11 event documentation identified the wound as a Stage 2 with moderate serous drainage. No further measurements or documentation on the wound status was available until 7/20/11 (14 days later). The documentation found was as follows: ? 7/20/11 Event Documentation identified the right heel wound as a Stage 3 with light purulent drainage and Necrotic Slough. ? 7/27/11 Event Documentation identified the right heel wound as a Stage 3 with light purulent drainage and [DIAGNOSES REDACTED] to surrounding tissue. ? 7/27/11 , 7/28/11 and 7/29/11 PT (Physical Therapy) Treatment Note showed "wound cleansed with 4 X 4's and wound care cleanser, removing non-viable tissue as able." ? 8/10/11 Event Documentation (13 days later) - Stage 3 with light sero-sanguineous drainage and surrounding wound tissue Maceration. ? 8/15/11 PT Progress Note - Removed devitalized tissue. ? 8/23/11 PT Progress Note - Removed devitalized tissue, debridement as needed to remove non-viable tissues. During the interview on 9/14/11 at 9:40 AM, E5 shared the following time line of events, notifications, documentation and order changes related to R18's Pressure Ulcer: ? E5 noted draining blister on 7/2/11 to R18's right heel. E5 notified the Nurse Practitioner and an order was obtained for an occlusive dressing to be applied and changed every 5 days. ? 7/22/11 - dressing changed to Calcium Alginate and [MEDICATION NAME] dressing "because the wound wasn't healing. A protein supplement was also started two times a day to promote healing and because R18 was losing weight." ? 7/26/11 - started ultrasound with Physical Therapy with resident received through 8/26/11. ? 8/16/11 - dressing changed to Santyl and Border Gauze. ? 8/29/11 - Electronic Stimulation started and continues to present. E5 stated Braden Scales (Risk Tool for development of Pressure Ulcers) are only done by the nurse on admission to the facility. R18's Braden Scale score was 13 which is "moderate risk" for development of pressure ulcers. The facility's Protocol for Pressure Ulcer Prevention and Treatment, revised 03/04, states the objective as "To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of [REDACTED]." The Principles show: "a skin risk assessment is completed on all residents upon admission, and quarterly thereafter." Under number 7, the policy states, "Assess the pressure ulcers(s) for location, size (measure length, width, and depth), tunneling, drainage, color, odor, and necrotic tissue. Weekly individual treatment report will be done and put on clinical chart." 2. R26 is an [AGE] year old male resident with [DIAGNOSES REDACTED]. A physician notification fax dated 7/12/11 identified "area previously fluid filled and swollen now is open. Open area 1.5 cm X 3 cm X <0.1 cm. Center with slough. Below wound area red and irritated." On 7/13/11, the Event Pressure Ulcer Documentation shows a Stage 3 pressure ulcer to right inner buttock with Necrotic Slough and light cloudy sero-sanguineous drainage. [DIAGNOSES REDACTED] to surrounding tissue. Factors present included immobility and history of pressure ulcers. R26's Braden Scale dated 7/10 identified him as low risk for development of pressure ulcers. The Pressure Ulcer Event Documentation showed the following changes in wound characteristics: ? 7/20/11 - 2.4 cm X 0.4 cm (no depth) with Necrotic Slough and Purulent drainage; ? 7/27/11 - 1.5 cm X 2.8 cm (no depth) with purulent drainage and Erythremia to surrounding tissue; ? 8/9/11 - wound edges pink and tender ? 8/17/11 - mild pain 8/24/11 - mild pain