Every finding on record at Manor Court of Princeton

Based on interview and record review the facility failed to investigate an alleged allegation of physical abuse. This applies to 1 of 3 residents (R1) reviewed for physical abuse in the sample of 4. The findings include:On 6/13/26 at 11:10 AM, V8 Certified Nursing Assistant (CNA) stated, she came into work and was receiving report from V6 CNA. V6 CNA told V8 that R1 was acting crazy on her shift and that it was so bad, she had to pin him down. V8 asked V6 what she exactly meant by that. V6 demonstrated to V8 that she grabbed R1 by his hands and was holding him down. V8 reported that to V7 Registered Nurse (RN). On 6/13/26 at 10:49 AM, V7 RN stated, V8 CNA reported to her during CNA to CNA report, V7 reported R1 was wound up that shift and she had to hold him down to keep him in bed. V8 reported that she questioned what that meant and asked V6 CNA to demonstrate what she did. V8 reported to V7 that V6 showed her, she held him down in bed. V7 RN stated, V6 CNA was already gone for the night from her shift. She tried to call V1 Administrator and V2 Director of Nursing with no answer, so she messaged them both on the facility's secure messaging system. No one responded to her message until 5:00 AM. She stated, V2 Director of Nursing responded at 5:00 AM saying she received the message and would investigate the incident. V7 RN stated, V6 CNA was not suspended and continued to work with R1 after she reported that to V1 and V2. She was confused because normally they suspend the employee until they investigate the incident but V6 CNA was never suspended and they did not investigate the incident. R1's electronic medical record shows, he was admitted on [DATE] and passed away 5/30/26 on hospice. On 6/13/26 at 12:00 PM, V2 Director of Nursing (DON) stated, she had never heard of any incidents with R1. She would have to check the messaging system but she didn't recall anything ever being said about V6 CNA holding R1 down in bed.On 6/13/26 at 9:45 AM, V1 Administrator stated, she didn't have any abuse allegations for the past three months. At 12:06 PM, it's the first time I'm hearing anything about R1. She was not aware of any incidents with V6 CNA and R1. At 12:39 PM, she stated, V2 DON looked through all of her messages on their secure messaging system and couldn't find anything. On 6/13/26 at 1:01 PM, V1 Administrator stated, she was opening a physical abuse allegation for R1. V6 CNA would be suspended until they investigated the incident. The facility's abuse prohibition and reporting dated 11/28/19 shows, Policy: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms. Purpose: To protect 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. Staff responsible: 1. Administrator, 2. Director of Nursing, 3. HR (human resources) manager, 4. Department Heads/Employees, 5. Shift Coordinators, 6. Shift Nurses. Procedure: .B. Initial steps and reports of alleged abuse or neglect- 1. Facility employees or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator, then the facility employee or agent should immediately report the matter to the facility DON. 6. If the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident. C. Investigation- 1. Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff of residents who may have witnessed the incident, and any other person who may have information related to the incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation. 4. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health. 5. The Administrator shall be responsible for resident's protection from retaliation during and after the investigation. 6. Investigation checklist will be utilized when necessary.

Based on interview and record review the facility failed to notify local police and a resident's physician of an allegation of sexual abuse for one of eight residents (R1) reviewed for abuse.Findings include:The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents the following under Procedure: Prevention of Abuse; 4. The administration shall immediately contact local law enforcement authorities in the following situations: Sexual abuse by a staff member, another resident, or a visitor. This policy also documents under Abuse or neglect examination and protection: 1. The shift nurse on duty who is first made aware of any alleged abuse or neglect concerning any resident shall immediately examine the resident. and 7. The shift nurse shall call the resident's attending physician.On 1/8/25 at approximately 10:00am, V1 Administrator provided a document titled Regulatory Timeline - Allegation of Abuse. The Timeline documents the following: The facility received a concern involving (R1) on 12/27/25 at 1:15pm. The nurse (V6 RN/Registered Nurse) was approached by (R1's) HCPOA/Health Care Power of Attorney) and informed of a man that had touched (R1's) breast. The Timeline documents the investigation of the allegation was completed on 12/29/25.On 1/7/26 at approximately 12:30pm V1 Administrator stated she was notified on 12/27/25 of an allegation of sexual abuse by a resident by V6 RN/Registered Nurse on duty. V1 stated V6 reported R1's HCPOA had approached her and reported R1 just told her someone had touched her breast during the night.On 1/7/26 at 3:05pn V6 RN stated, while on duty on 12/27/25, R1's HCPOA reported R1 told her a man touched her breast in the middle of the night on 12/27/25. V6 denied notifying R1's physician nor the local police department of the allegation. V6 stated she just reported it to administration and that was the extent of her responsibility for the event.On 1/8/26 at approximately 1:30pm V1 verified the facility did not notify R1's physician or the local police department of the allegation of sexual abuse reported by R1's HCPOA.

Based on Observation, Interview and Record Review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of an antipsychotic medication and provide appropriate justification for a failed gradual dose reduction of Risperdal (antipsychotic) for one of one resident (R2) reviewed for antipsychotic medications in the sample of 34. Findings include: The facility's Psychopharmacologic Drug Usage Procedure policy, dated 10/18/17, documents A Psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety medications, and sedatives/hypnotics. This policy also documents, Use of psychopharmacological medications requires assessment by the attending physician, and specific orders must be written by the attending physician with supporting diagnosis. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. Response to medication reduction must be clearly documented on a routine basis. Unsuccessful reduction of medication must be substantiated by documentation, including rationale from the physician as to why the medication cannot be reduced further. The ultimate goal of successful gradual dose reduction is to discontinue the medication necessary for the benefit of the resident and to minimize adverse consequences. On 4/29/25 at 12:45 PM, R2 was sitting in the dining room eating lunch. R2 denied concerns and was pleasantly confused with conversation. R2 was not displaying any behaviors. R2's discontinued Physician Order sheet, dated 4/29/25, documents R2's order for Risperidone (Risperdal, antipsychotic medication) 0.25 milligrams (mg) at bedtime was discontinued on 3/7/25. R2's current Physician Order Sheet, dated 3/10/25, documents R2 has an order for Risperidone 0.25 mg by mouth at bedtime for a diagnosis of Vascular Dementia, unspecified severity, with other behavioral disturbance. R2's current Care Plan, dated 4/27/25, documents R2 was admitted to the facility on [DATE] and has a diagnosis of Vascular Dementia. This same care plan documents a plan of care dated 4/2/24, for Psychotropic drug use (R2) has depression and vascular dementia with other behavioral disturbance. Interventions: Administer medication as ordered, Risperidone 0.25 mg, one tablet by mouth at bedtime. Monitor for side effects, including boxed warnings. Review medication during behavior committee meeting for gradual dose reduction. R2's Nursing Progress notes, dated 3/10/2025 at 3:03 AM, documents (V16, Nurse Practitioner) updated on trouble sleeping and unexplainable sadness at this time. R2's Nursing Progress notes, dated 3/10/2025 at 10:30 AM, documents New order received from (V16) (regarding) recent difficulty sleeping and continued symptoms of depression: Restart Risperidone 0.25 mg every bedtime. On 4/29/25 at 12:50 PM, V14 (Licensed Practical Nurse) stated (R2) does not have any behaviors at all. She is at no risk of harm for herself or other residents. On 4/29/25 at 1:00 PM, V15 (Certified Nursing Assistant) confirmed she has taken care of R2 several times and knew R2 before she was admitted to the facility. V15 stated, (R2) is not combative towards me. She is no harm to herself or other residents. (R2) can be grouchy at times or not want to participate in exercise but that just depends on the day. Mostly (R2) just wants to be home and gets grouchy about no longer living with her spouse, selling her house, and needing to live here and not at home. On 4/29/25 at 2:30 PM, V13 (Activity Director) confirmed R2 has not displayed any behaviors of psychosis since admission. V13 stated, I check the behavior programs and interventions every day. (R2) doesn't have behaviors care planned because once she got a private room her behaviors which were mostly verbal, became better. (R2's) behaviors were directed at her roommate (former facility resident). They were mostly about the television being too loud and just more argumentative behaviors. She has a private room now so she really hasn't had them anymore. In the last six months it looks like (R2) has had two documented verbal behaviors, both before January 2025. (R2) is not a harm to anyone. The behavior tracking is charted by the staff in and will fall in categories of verbal, physical, rejection, wandering and others. So staff can document any behaviors exhibited in those categories, they are not specifically targeted to (R2). On 4/30/25 at 9:48 AM, V2 (Director of Nursing) confirmed R2 did not get along well with her previous roommate and stated she has been in a private room since January 2025. V2 stated, (R2's) last gradual does reduction (GDR) of Risperdal was done on 3/7/25, where we discontinued the medication. This GDR failed because she had symptoms of insomnia and tearfulness. So, (V16, Nurse Practitioner), decided on 3/10/25 to restart the Risperdal.

Based on interview and record review, the facility failed to revise a care plan to accurately reflect a resident's wound condition for one of 21 residents (R13) reviewed for care plan accuracy in the sample of 34. Findings include: R13's current medical record documents the following diagnoses: Acute Hematogenous Osteomyelitis of right ankle and foot; Stage IV Pressure Ulcer of right heel; Type 2 Diabetes Mellitus with Diabetic Nephropathy; Type 1 Diabetes Mellitus with other specified complication; and Peripheral Vascular Disease. On 04/28/25 at 01:25 PM, V11 (Registered Nurse) stated R13 was admitted to the facility with a venous stasis wound on her right heel. V11 stated, (R13) recently had a skin graft in place on her right heel. The current physician's orders are to leave her foot dressing in place until she goes back to see the wound doctor. R13's current Care Plan documents the following focuses: (R13) requires Enhanced Barrier Precautions related to presence of diabetic ulcer to right heel; (R13) is at increased risk for pressure ulcers and impaired skin integrity related to poor intakes, osteomyelitis of right foot, peripheral vascular disease, diabetes mellitus, diabetic neuropathy, incontinence of bowel and bladder, decreased mobility, and generalized muscle weakness following recent illness and hospitalization . At increased risk for bruising related to anticoagulation medication. On 02/14/25: admitted with diabetic ulcer to right heel. On 04/30/25 at 09:20 AM, V2 (Director of Nursing) stated R13's current Care Plan is inaccurate. V2 stated, (R13's) right heel wound is a pressure ulcer. Her care plan is not correct and needs to be revised. The wound on her heel is not a diabetic ulcer. It is a pressure ulcer.

Based on observation, interview, and record review, the facility failed to address and implement care plan interventions for a resident's ongoing, significant weight loss for one of three residents (R42) reviewed for weight loss in the sample of 34. Findings Include: The Facility's Weight Monitoring Policy dated/revised 09/06/24, documents, To consistently assess for significant weight loss or gain. Licensed staff will notify physician of the following, 7.5% or more gain or loss in a 90-day period, 10% or more gain or loss in a 180-day period, events will be opened for a significant weight loss. Notification to the physician must be documented, and whether or not new orders were received for either significant weight losses or gains. Families/POA (power of attorney) must be notified of significant weight loss or gain. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the RD (registered dietician) as needed. The 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. On 04/28/25 02:30 PM, R42 was sitting in his wheelchair and appeared to have a flat affect. R42 stated he has been feeling depressed lately and that he feels sad a lot. R42 also stated has not been eating much. R42's electronic record documents on 11/23/2024, R42's weight was 196 lbs (pounds). R42's electronic record documents on 1/7/2025, R42's weight was 184 lbs. R42's electronic record documents on 4/27/2025, R42's weight was 171 lbs, a significant weight loss of 12.76% in a six-month period. R42's current care plan does not address R42's weight loss. V12's (Registered Dietician) Progress Note (dated 01/28/25) documents the following regarding R42: Weight on 1/28/25 was 176 lbs, BMI (basic mass index) 25, acceptable. Weight down 3% in 1 month and 10% in 2 months. Diet, regular, meal intakes are variable, often fair/good per recorded percentages. No open areas, no recent labs. Weight loss likely related to fluid shifts. R42 takes Lasix (diuretic) and has a diagnosis of CHF (congestive heart failure). Recommend continue diet as ordered, monitor weight. V12's Progress Note (dated 02/05/25) documents, (R42's) weight on 2/4/2025 176 lbs, BMI 25, acceptable. Weight loss of 4% in 1 month and 10% in 2 months noted. R42 continues to take Lasix. Diet: regular, no problem with tolerance to diet identified, appetite is fair. No open areas per wound management. No recent labs available. Diet prescription meets estimated needs and remains appropriate. As weight has begun to stabilize, will recommend continue present management for now and monitor weight. V12's Progress Note (dated 03/07/25) documents, (R42's) weight on 3/1/2025 175 lbs, BMI 24, acceptable. Weight triggers a loss of 8% in 3 months but has been stable x (times) 1 month. Diet regular, no problem with appetite identified. No open areas per wound management. No labs uploaded. R42 continues to take Lasix. As weight has stabilized, will advise continue present management. Some weight loss may be related to fluid shifts with diuretic versus CHF. Monitor weight. On 4/30/2025 at 11:30 AM, V2 (DON/Director of Nursing) confirmed R42 has lost weight over the past six months. V2 stated, (R42) did not trigger in our system under significant weight loss. V2 confirmed she was unaware of R42's decrease in appetite and mood until this week, and no new interventions have been implemented for R42's weight loss.

Based on observation, interview and record review, the facility failed to maintain cleanliness of tube feeding equipment for one of one resident (R102) reviewed for tube feeding in a sample of 34. FINDINGS INCLUDE: The facility policy, Tube Feeding dated (revised) 03/03/2022 directs staff, To provide a source of nourishment when oral feedings are neither possible nor desired due to a resident condition. When feeding is completed, assure comfort of resident. Non-disposable equipment is to be wiped down with a damp cloth on a daily basis and PRN (as needed) to maintain cleanliness with the facility approved disinfectant. Personnel Responsible: Licensed Staff. R102's current Physician Order Sheet, dated April 2025 includes the following diagnoses: Cerebral Infarction, Hemiplegia and Hemiparesis and Dysphagia. Also included are the following physician orders: Give Osmolyte (nutritional supplement) 1.2 at 75 ML (Milliliters)/HR (Hour) x 23 hours. Assess for placement of tube prior to administration of feeding via aspirating gastric contents. Once A Day at 8:00 P.M. On 4/28/25 at 10:06 A.M. R102 was lying in bed. Osmolyte 1.2 was infusing at 75 CC (Cubic Centimeters)/HR (Hour) via pump into a gastronomy tube. Tan, dried material was present on the feeding pump, pole, floor underneath the feeding pole and (R102's) bed rails. At 2:04 P.M. the same tan, dried material remained on R102's feeding pump, feeding pump pole, floor, bed rails and nearby nightstand, despite facility staff being in and out of R102's room throughout the day. On 4/29/25 at 8:06 A.M. R102 was lying in bed. Osmolyte 1.2 was infusing at 75 CC (Cubic Centimeters)/HR (Hour) via pump into a gastronomy tube. Tan, dried material was present on the feeding pump, pole, floor underneath the feeding pole and (R102's) bed rails. At 11:04 A.M. the same tan, dried material remained on R102's feeding pump, feeding pump pole, floor, bed rails and nearby nightstand. At that time, V5/Registered Nurse verified the presence of the debris. V5/Registered Nurses stated, That shouldn't be there. I will get someone to clean it up right away.

Based on observation, interview and record review, the facility failed to ensure aseptic technique was followed during intravenous medication administration and failed to perform a physician-ordered flush prior to the administration of an intravenous medication for one of one residents (R80) receiving intravenous medications, in a sample of 34. FINDINGS INCLUDE: The facility policy, Pharmaceutical Procedures, dated (revised) 01/05/23 directs staff, All medications shall be given upon the written order of a physician. All such orders shall be given as prescribed by the physician. The facility policy, Infection Control, dated (revised) 12/17/2019 directs staff, All residents with known or suspected infectious conditions shall be cared for using the most appropriate nursing care determined for the benefit and safety of the resident concerned, the other residents in the facility and the safety of the employees. Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions, non-contact skin and mucous membranes may contain transmissible infectious agents. Standard Precautions include but are not limited to: Safe injection practices; Handling of equipment. R80's current Physician Order Report, dated April 2025 includes the following diagnoses: Leukemia; Malignant Neoplasm of Thyroid Gland; Secondary Malignant Neoplasm of Bone; Chronic Myeloproliferative Disease; Pressure Ulcer of Sacral Area, Stage 4; Methicillin Resistant Staphylococcus Aureus Infection; Extended Spectrum Beta Lactamase Resistance, Urinary Tract Infection. This same document also includes the following physician orders: PICC (Peripherally Inserted Central Catheter) line for duration of IV (Intravenous) antibiotic therapy. Normal Saline Flush (Sodium Chloride 0.9%) 10 ML (Milliliters). Flush with 10 ML before and after infusion. Meropenem 1 gram in 100 ML Normal Saline every 8 hours. On 4/28/25 at 1049 A.M., V5/Registered Nurse (RN) prepared to administer intravenous Meropenem (Antibiotic) for R80. A sign posted outside of R80's room read, Contact Precautions. V5/RN donned a gown, a mask and gloves, and prior to entering R80's room, dropped the intravenous bag of antibiotic medication and tubing on the floor. At that time, V5/RN picked up the intravenous bag of antibiotic medication and tubing, and entered (R5's) room. (R5) exposed her right arm, a (Peripherally Inserted Central Catheter) PICC line was present in (R80's) right upper, inner arm. V5/RN swabbed the port of the PICC catheter with an alcohol swab, connected the intravenous tubing, set the dial on the tubing to 100 CC (Cubic Centimeters)/HR (Hour) and watched as the medication began infusing. At that time, V5/RN disconnected the tubing, flushed the port with 10 ML (Milliliters) of Normal Saline, reconnected tubing and left the room. At that time, V5/RN confirmed she had dropped the intravenous bag of medication and tubing on the floor, prior to administering it and did not flush R80's PICC line prior to the administration of the medication.

Based on Interview and Record Review, the facility failed to ensure a resident with a diagnosis of Dementia had a Care Plan to include goals and interventions to manage Dementia, for one of one resident (R2) reviewed for Dementia Care in the sample of 34. Findings include: The facility's Care Plan policy, dated 6/1/22, documents It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. This same policy documents The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. R2's current electronic Face Sheet documents R2 was admitted to the facility on [DATE] and has a diagnosis of Vascular Dementia. R2's current Care Plan does not have a plan of care for R2's Dementia with measurable goal and outcomes to manage R2's Dementia Care. On 4/30/25 at 10:45 AM, V2 (Director of Nursing) confirmed R2 has a diagnosis of Vascular Dementia does not have a Dementia Specific Care Plan.

Based on interview and record review, the facility failed to document a rationale for the continued use of antibiotic therapy for one of three residents (R69) reviewed for unnecessary medications in a sample of 34. Findings include: The facility's Antibiotic Stewardship policy, revised 12/18/19, documents that the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. R69's current Physician Order Sheet, documents an order for Cephalexin (antibiotic) 250 milligrams daily for prophylactic antibiotic for frequent UTI's (urinary tract infection). This form also documents a diagnosis of long term (current) use of antibiotics. R69's medical record does not contain documentation or a rationale for the continued use of antibiotic therapy. On 4/30/25 at 8:45 AM, V2, Director of Nursing, verified that R69 does not have the documentation or rationale for the continued use of an antibiotic.

Based on observation, interview, and record review the facility failed to provide a clean and sanitized floor in the facility kitchen. This failure has the potential to affect all 99 residents who receive food from the kitchen. Findings include: On 5/30/24 at 10:00am, V3 Dietary Manager stated that all (99) residents in the facility receive food from the kitchen. On 5/28/24 at 9:33am, a tour of the facility kitchen found built-up brown/black discolored grease, grime, and debris on the floor in front of both sides of the food preparation table, stove, and throughout other areas in the kitchen. At that time, V3 Dietary Manager stated that the floor guy had already done the floors that morning and that's the way it still looks. V3 stated the kitchen staff are also supposed to mop the floor every evening. An undated posted kitchen sign in the kitchen documents: Nightly Checklist before leaving: Floors swept and mopped. On 5/29/24 at 9:10am, the kitchen floor was free of the built-up grime and debris, however stains of where the grime and built-up grease had been remained. At that time, V3 stated Yes (stains), since they got it off now and I guess it should've been done that way before. On 5/30/24 at 2:05pm, V18 Custodian/Floors stated When we go in the morning to clean the floor with the machine we try to get in/out as quickly as possible to get out of the way. It took more time this morning, we had to go over and over the built-up grease and grime to get it off. We also had to use a different pad which was more abrasive. The other pad just went over those areas without removing the build-up.

Based on interview and record review, the facility failed to ensure Advanced Directives were documented correctly in the resident's clinical record for one (R17) of two residents reviewed for Advanced Directives in a sample of 40. Findings include: The facility's Practitioner Orders for Life-Sustaining Treatment (POLST), revised ,d+[DATE], documents Policy: The facility will establish and follow a set cardiopulmonary resuscitation procedure. Purpose: To establish the decision-making process that will institute or stop cardiopulmonary resuscitation. Procedure: 7. Notations regarding this decision will be made in the resident's medical chart by Nursing. R17's Face sheet documents Advanced Directive: Full Code. R17's current Physician Order Sheet/POS documents Full Code status. The facility's Shift Notes (report sheet for nurses) for R17's hall documents all residents' code statuses; R17's is listed as Full Code. R17's POLST documents DNR (Do Not Resuscitate) and was signed on [DATE] by R17. On [DATE], at 2:15pm V4 Registered Nurse/RN confirmed R17's Face sheet, POS, and Shift Report sheet document Full Code status. V4 stated the following: When there is a code, I look at the report sheet first since it lists their code status. I would also look at their Face sheet and check their POLST (Practitioner Order for Life-Sustaining Treatment). R17 confirmed at this time that R17's POLST documents R17 is a Do Not Resuscitate. V4 explained that if R17 had coded V4 would have had the staff start CPR (Cardiopulmonary Resuscitation) on (R17) then V4 would have looked up (R17's) code status on (R17's) Face sheet and POLST. I would have had to yell for them to stop CPR after seeing the DNR on (R17's) POLST.

Based on observation, interview and record review, the facility failed to include indwelling urinary catheter with cares on a Baseline Care Plan for one (R257) of 21 residents reviewed for Care Plans in a sample of 40. Findings include: The facility's Care Plan Policy, revised 11/28/19, documents Policy: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Explanation and Compliance Guidelines: Base Line Care Plan: Base Line Care Plan: 1. The baseline care plan will: a. Within 48 hours of a resident's admission, the admitting nurse, or supervising nurse on duty, shall develop the Baseline Care Plan by gather information from the admission body assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative. b. Include the minimum healthcare information necessary to properly care for a resident representative. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders. b) Physician orders. c) Dietary orders. d) Therapy services. e) Social Services. f) PASARR recommendation, if applicable. 2. A written summary of the baseline care plan shall be provided to the resident and resident representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. On 5/28/24, at 10:30am, R257 was lying in bed with an indwelling catheter draining clear amber urine. R257's clinical record documents R257 admitted to the facility on [DATE], transferred out to the hospital on 5/22/24 then returned on 5/23/24 with an indwelling urinary catheter. R257's current Physician Order Sheet/POS includes an order for a 16F (French) 30cc (cubic centimeters) (named indwelling) Catheter continuous with diagnosis of Retention of Urine, unspecified. R257's Baseline Care Plan does not include indwelling catheter/cares. On 5/30/24, at 10:49am, V14 Care Plan Coordinator/RN, stated the following: Catheters are not on the template that the nurses can pull up, but it should be on the Baseline Care plan. I would pull up the Care Plan Summary to see what's on it to know what then goes on the care plan. V14 printed R257's Care Plan Summary at this time and this summary documents (R257) has the following Physician and Nursing Orders in place: 16F (French) 30cc (cubic centimeters) (brand name) Catheter continuous.

Based on observation, record review and interview, the facility failed to revise a Comprehensive Care Plan for one resident (R7) of 21 residents reviewed for Care Plan revision in a sample of 40. Findings includes: The facility's Care Plan Policy dated 6/1/22 documents: It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those change shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. 10. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. R7's Progress Note dated 4/26/24 documents: (V16 Wound Physician) here to see resident for wound care. Area to coccyx has reopened due to incontinence,New order for collagen and dry dressing daily. Wound is 0.6x0.4x0.3 with moderate Serosanguinous drainage. 100% granulation tissue. Area is pink with irregular edges. R7's Physician Order dated 4/26/24 documents: Cleanse coccyx with normal saline/N.S. Pat dry apply collagen and island dressing daily. R7's Wound Evaluation and Management Summary dated 5/24/24 documents: Stage four pressure wound coccyx full thickness. Wound size .4 x .4 x .3 centimeters/cm. On 5/29/24 at 1:15pm, observation of R7's coccyx area showed a small opening at mid coccyx area; no redness. At this time, V17 Licensed Practical Nurse/LPN provided R7's coccyx wound care treatment. V17 LPN stated: R7's wound is chronic, heals and then comes back; (R7) is seen by (V16 Wound Physician) once weekly for wound care. R7's current Care Plan does not document R7 has a wound on her coccyx. On 5/29/24 at 2:35pm, V14 Registered Nurse/RN/Minimum Data Set/MDS/Care Plan Coordinator stated that R7's Stage 4 coccyx wound issue should have been included in (R7's) care plan. At this same time, V14 RN stated, (R7's) wound had been in her care plan; it healed and then it came back; got the order for it on 4/26/24 and I was not aware of this; just found out today the wound had come back. I added this to the care plan just now.

Based on observation, interview, and record review the facility failed to change gloves and sanitize between glove changes during Indwelling Urinary Catheter cares for one (R257) of three residents reviewed for Catheters in a sample of 40. Findings include: The facility's Infection Control policy, revised 11/28/19, documents Standard Precautions: Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), 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 (Personal Protective Equipment) (gloves, gowns, mask, etc.) .Gloves, disposable in nature, will be worn unless sterile gloves are necessary. Gloves will be changed after direct contact with resident's secretions or excretions, even if care of resident has not been completed. R257's current Physician Order Sheet/POS includes an order for a 16F (French) 30cc (cubic centimeters) (named indwelling) Catheter continuous with diagnosis of Retention of Urine, unspecified. On 5/28/24, at 1:20pm, R257 was lying in bed with an indwelling urinary catheter draining clear amber urine. With gowns and gloves on V7 and V8 Certified Nursing Assistants/CNAs lowered R257's shorts and soiled incontinence brief to perform catheter care for R257. Neither V7 nor V8 performed hand hygiene or changed gloves at this time. V8 cleansed R257's meatus and catheter tubing. Without performing hand hygiene V8 changed V8's gloves then dried R257's meatus and catheter tubing. Without performing hand hygiene and donning new gloves, both V7 and V8 touched R257's bare skin to assist him to turn. V8 removed R257's soiled incontinence brief then both CNAs placed a new one on and assisted R257 to roll back onto his back. On 5/28/24, at 1:46pm, V8 confirmed she did not change her gloves after drying R257 off and stated, I probably should have so stuff doesn't get contaminated. O5/28/24, at 1:47pm V7 confirmed he did not perform hand hygiene in between glove changes and should have. On 5/30/24, between 1:47pm and 3:00pm, V2 Director of Nursing DON stated she expects the staff to use hand sanitizer or wash hands in between glove changes during cares and to change gloves when going from dirty to clean. V2 stated they do not have a glove policy that supports her expectations.

Based on interview and record review, the facility failed to obtain weekly weights as ordered by the physician for one of two residents (R92) reviewed for nutrition in the sample of 40. Findings include: The facility's Weight Monitoring Policy revised 6/21 states, Objective: To consistently assess residents for significant weight loss or gain. This same policy documents weekly and monthly weights are recorded by dietary in the resident's electronic medical record. R92's Face Sheet documents R92 admitted to the facility with diagnoses to include but not limited to: Cerebral Infarction; Dysphagia; and Gastrostomy Status. R92's current Physician Orders documents orders for the following: Osmolite 1.5 Cal (Calorie) Nutritional Supplement via Gastric Tube; Free Water Flushes via Gastric Tube; Daily Supplement Shakes; and Weekly Weights. R92's Vitals Weight Summary documents a weight of 215.8 pounds on 5/8/24. As of 5/30/24, no further weights are documented in R92's medical record. On 5/30/24 at 10:43 AM, V3 (Dietary Manager) stated V3 was not aware of R92 having weekly weights ordered. At this time, V3 verified R92's weekly weight physician order and stated that V3 would be responsible for entering R92's weights into R92's medical record. V3 verified V3 could not provide any documentation showing V3 had been weighed again since 5/8/24. On 5/30/24 at 11:05 AM, V5 (Registered Nurse) stated R92 has been on weekly weights since R92 admitted to the facility due to R92 being on tube feedings. At this time, V5 verified R92 has not been weighed since 5/8/24 and should have been weighed weekly.

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen humidifier bottle was not empty while in use for one (R254) of one resident reviewed for Oxygen in a sample of 40. Findings include: The facility's Oxygen Therapy policy, revised 05/12, documents Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same .Procedure: 2. Assemble equipment at bedside: a. Humidifier bottle attached to tank flow meter and filled to appropriate level with sterile distilled water. This policy also states, Safety Factors: 1. Must have Oxygen in Use sign posted in space that is visible prior to actually entering room. On 5/28/24, at 9:26am, R254 sat in a wheelchair in her room wearing oxygen per nasal cannula via a portable oxygen tank. The oxygen concentrator next to R254's bed contained an empty, undated, humidifier bottle. R254 stated I use that one (concentrator) mostly at night. R254's room does not have an Oxygen in Use sign at the door. R254's current Physician Order Sheet/POS includes an order dated 5/22/24 for oxygen at 4L (liters) nasal cannula continuous for SOB (Shortness of Breath). R254's current POS includes but is not limited to diagnoses of Shortness of Breath, Other Pulmonary Embolism without Acute Cor Pulmonale, Panlobular Emphysema, Shortness of Breath, Other Pulmonary Embolism with and without Acute Cor Pulmonale, and Acute Respiratory Failure with Hypoxia. On 5/29/24, at 9:35am, R254 sat in her room with oxygen on per nasal cannula via oxygen concentrator. The humidity bottle was full and dated 5/28. R254 stated that after lunch she was hooked up to oxygen with the concentrator and it was hard to breathe, like it was dry air. I told V7 Certified Nursing Assistant/CNA and V7 said it was dry and told the nurse (V4 Registered Nurse/RN). (V4) came in a put a new one on. There is no Oxygen in Use sign on R254's entrance to room. On 5/29/24, at 9:43am, V4 RN confirmed that R254's oxygen humidifier container was empty yesterday while in use by R254. I changed it yesterday after being alerted to it by (V7 CNA). On 5/30/24, at 8:40am, R254 is in bed with oxygen in use. No Oxygen in Use sign on the door. On 5/30/24, at 8:44am V5 RN confirmed there is no Oxygen in Use sign on R254's door and stated, There should be a sign.

Based on observation, interview, and record review the facility failed to provide an appropriate indication for use for an antipsychotic medication, failed to identify target behaviors, and failed to identify non-pharmacological interventions for one (R2) of five residents reviewed for unnecessary medications in the sample of 40. Findings include: Facility Policy/Psychopharmacologic Drug Usage procedure, dated 10/18/17, documents: Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. Psychopharmacological medication usage must also be addressed in the Care Plan, including appropriate goals, likely medication effects, and potential for adverse consequences. R2's Current Physician's Orders, with an order date of 4/3/24, documents R2 receives Risperidone (antipsychotic) 0.5mg (milligrams) at bedtime for Vascular Dementia with Other Behavioral Disturbance. R2's Behavior monitoring/tracking documentation record dated 4/3/24 - 5/30/24 does not identify specific behaviors to be monitored. R2's care plan did not include administration of an antipsychotic medication, goals, side effects, or interventions. On 5/28/24 and 5/29/24 R2 was seen in her room and in the dining room. R2 did not display any inappropriate, disruptive, or psychotic behaviors. On 5/31/24 at 1:45pm, V2 DON (Director of Nursing) stated there should have been a care plan initiated for R2's Risperidone. V2 stated they did not know why R2 was on Risperidone when she was admitted (on 4/2/24) or what behaviors she was displaying. V2 also stated R2 has had no behaviors since admission.

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precaution/EBP signage was posted and PPE (Personal Protective Equipment) was available for two (R257 and R25) of nine residents reviewed for Infection Control in a sample of 40. Findings include: The facility's Enhanced Barrier Precautions/EBP policy, undated, documents Policy: It is the policy of the facility to use proper PPE (Personal Protective Equipment) during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-drug resistant organisms) to staff hands and clothing. Purpose: The purpose of the program is to prevent the indirect transfer of MDROs from resident-to resident during high-contact care activities using EBP (Enhanced Barrier Precautions). Key Points: 1. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 3. EBP are indicated for residents with any of the following .b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies .Procedure: 1. Post clear signage on the door or wall outside of the resident room indicating Enhanced Barrier Precautions are required. This will include type of PPE and potential high-contact resident care activities. 1. R257's current Physician Order Sheet/POS includes an order for a 16F (French) 30cc (cubic centimeters) continuous (named indwelling) Catheter with a diagnosis of Retention of the Urine, unspecified. On 5/28/24 at 10:30am, R257 was in bed with an indwelling urinary catheter draining clear amber urine. There is no signage posted for EBP, or an infectious linen trash bin located in R257's room. On 5/30/24 at 10:35am, V6 Infection Control Nurse confirmed that R257's room did not have EBP signage up the morning of 5/28/24. V6 stated that (R257) should have been in Enhanced Barrier Precautions with the sign up once he came back from the hospital on 5/23/24 for his midline (intravenous catheter), and his urinary catheter. 30899 2. R25's Hospital Note, dated 4/3/24, indicates Exam: Ileostomy right, midline in abdominal crease; appearance of fistulas approximately 1cm (centimeter) lateral and 10cm lateral with evidence of leakage of stool. Assessment/Plan: Course has been complicated by multiple fistulas near ileostomy site and difficulty with pouching/leakage of ostomy. R25's Current Physician's Orders document Change ostomy bag to ileostomy and fistula every three days, and as needed. R25's current care plan indicates R25 was admit to the facility was related to the fistula of the intestine. On 5/29/24 at 1:30pm, R25 had ileostomy/fistula sites with an ostomy drainage collection bag in place over entire lower abdomen. R25 stated the drainage from the fistula is pus-like mixed with stool. R25 stated her physicians told her the fistula will only get worse over time and will likely need to go on antibiotics at some time. On 5/28/24 and 5/29/24, R25 did not have an EBP sign posted anywhere outside of her room, and did not have quick access to gowns before entering her room. On 5/30/24 at 12:45pm, V5 RN (Registered Nurse) stated that she recently changed R25's ostomy bag, and R25 has an ileostomy stoma and a small fistula opening that looks like hyper granulation tissue that does intermittently leak. V5 stated that there is also a small drain site from a previous drain device. V5 stated that she is unsure whether the drain site is actively draining, however the instructions are to keep all three sites covered with the ostomy appliance/bag to collect potential drainage. V5 confirmed the fistula is chronic and was told will only get worse with time as R25 is not a surgical candidate. On 5/30/24 at 2pm, V6 Infection Preventionist stated R25 was not placed on EBP as she did not consider the fistula and drain sites when R25 was evaluated, and acknowledged as draining wounds, R25 will be placed in Enhanced Precautions.

Based on interview and record review, the facility failed to follow their policy to ensure that an effective discharge plan was developed and implemented. The facility also failed to ensure that referrals were made to the appropriate community resources at the time of discharge for one of four residents (R1) reviewed for discharge planning in the sample of four. Findings include: The facility's Discharge Planning, Process, and Procedure revised 9/23 documents the objective is to assist the resident in attaining a safe transition back to the community. This same procedure states, 6. The resident's individualized discharge plan shall be discussed from a multidisciplinary perspective during the Medicare meeting. 7. The Admissions/Social Service Director shall then communicate post discharge needs to the nurse. 8. Medical considerations are to be made and teaching and training related to medical equipment, post discharge care, etc. shall be provided to the resident by qualified nursing staff prior to discharge from the facility. Such education and training shall be documented in the medical record. 9. The Admissions/Social Service Director shall discuss any post discharge supply needs or continued services with the resident and/or responsible parties, and then provide assistance in making referrals to appropriate agencies to attain needed services and equipment. Documentation of discussion and contact with outside agencies shall be placed in the medical record. 10. The Admissions/Social Service Director shall consult with nursing staff regarding specific discharge date and needs. Nursing staff shall then contact the physician to obtain orders for discharge and any post discharge service or supply needs. At the time of discharge, discharge instructions and medications shall be reviewed with the resident and/or responsible parties by a qualified nurse. This discussion shall be documented in the medical record. 13. A discharge summary shall be completed by the discharging nurse following the resident's discharge from the facility. The facility's Care Plan Policy dated 6/1/22 states, 5. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent. 7. The comprehensive care plan will describe at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. c. The resident's goals for admission, desired outcomes, and preferences for future discharge. d. Discharge plans, as applicable. 8. The comprehensive care plan will be prepared by an interdisciplinary team. The facility's Social Service/Admissions Director Job Description revised 9/19, states, Job Function: Completion of Admission and Discharge Planning Process, Delivery of all other Social Service Functions. Primary responsibilities: 4. Serve as a liaison between facility, residents, responsible parties, and outside agencies. 5. Facilitate the discharge planning process; development and implementation of discharge care plans. 6. Refer resident to outside agencies as appropriate. Specific Duties: 1. Complete admission paperwork and processes. 2. Complete on-going discharge planning documentation and discharge care plan for all short-term residents. Follow up with residents post-discharge. This same Job Description documents the Social Service/Admissions Director assists in the development of the resident's care plan and is responsible for discharge planning documentation. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to: Pressure Ulcer of Unspecified Site; History of Falling; Reduced Mobility; Lack of Coordination; Weakness; Non-pressure Ulcer of Left Ankle; Polyosteoarthritis. R1's Census Report documents R1 admitted to the facility on [DATE] and discharged home on 10/9/23. R1's Progress Note dated 9/24/23 at 4:08 PM signed by V5 (Licensed Practical Nurse/LPN) documents R1 admitted to the facility after a hospital stay. (R1) fell at home and laid on the floor for four days. This led to anemia, duodenal ulcer, and pressure areas to coccyx/buttocks. R1's Discharge Minimum Data Set/MDS assessment dated [DATE] documents the following: R1 admitted to the facility from the hospital. R1 to be discharged home and a return to the facility was not anticipated. R1 is cognitively intact. R1 required setup or clean-up assistance for toilet hygiene. Supervision or touching assistance-Helper provides verbal cues an/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R1 required supervision or touching assistance for showering/bathing, lower body dressing, putting on/taking off footwear, the ability to stand up from a sitting position, the ability to transfer to/from a bed to a chair, the ability to get on/off a toilet, and the ability to get in/out of tub/shower. R1 is 80 inches tall. R1 has one unhealed stage 3 pressure ulcer. R1 takes high-risk drug class medications: Diuretics, Opioids, and Hypoglycemics. R1's Admission Observation Report dated 9/24/23 documents the following: R1 lives alone. R1 does not have assistance with personal care. R1 has fallen in the last month. R1 experiences unsteady gait and weakness with activity. R1 uses a walker and wheelchair. R1's Discharge Planning Observation Report signed by V4 (Social Service/Admissions Director) and dated 9/26/23 documents Post Discharge Service/Referrals as outpatient therapy. Other possible measures to be taken at discharge, including home health care are blank and not marked. Post Discharge Supply Needs including dressings, bandages, gauze are blank and marked as none of the above. R1's Wound Evaluation and Management Summary dated 10/6/23 and signed by V3 (R1's Wound Physician) documents R1 has wounds to R1's coccyx, left lower medial leg, left posterior ankle, right lower buttock, and left lower buttock. This same note states, Stage 3 Pressure Wound Coccyx Full Thickness. Etiology: Pressure. Wound Size: 1 Centimeter (cm) x 0.5 cm x 0.2 cm. Exudate: Light sero-sanguineous. A primary dressing treatment plan is documented as Hydrocolloid Sheet (thin) apply three times per week for 30 days. R1's non-pressure wound of the left, posterior ankle documents an etiology of trauma/injury and measures 1.5 cm x 2 cm. The primary dressing treatment plan is documented as apply skin barrier protectant wipes once daily for 30 days. R1's non-pressure wound of the left lower medial leg documents an etiology of trauma/injury and measures 3.5 cm x 1 cm x 0.1 cm. The primary dressing treatment plan is documented as Xeroform gauze apply three times per week for 30 days. R1's left lower medial leg documents a secondary dressing of apply Abdominal Gauze Pad and cover with a gauze roll three times a week for 30 days. R1's non-pressure wound of the left lower buttock documents an etiology of trauma/injury and measures 0.4 cm x 0.4 cm x 0.1 cm with light sero-sanguineous exudate. The primary dressing treatment plan is documented as Hydrocolloid Sheet (thin) apply three times per week for 30 days. R1's non-pressure wound of the right lower buttock documents an etiology of trauma/injury and measures 0.6 cm x 0.3 cm x 0.1 cm with light sero-sanguineous exudate. The primary dressing treatment plan is documented as Hydrocolloid Sheet (thin) apply three times per week for 30 days. This same Wound Care Summary states, Follow-up: Evaluation by a wound care specialist within seven days with further intervention as indicated. R1's Physician Order Report dated 9/24/23-10/26/23 documents an order dated 10/2/23 that R1 may discharge home with PT/OT (Physician Therapy/Occupational Therapy). This same Physician Order Report documents an order dated 10/5/23 that R1 may discharge home with all current medication, treatments, and outpatient PT/OT. R1's Notice of Medicare Non-Coverage signed by R1 on 10/5/23 documents payment for R1's skilled nursing services will end on 10/8/23. R1's Social Service Note on 10/5/23 at 10:56 AM signed by V4 documents R1 was issued a NOMNC/Notice of Medicare Non-Coverage and documents R1 will discharge home on 10/9/23 with outpatient therapy. This same Social Service Note does not document R1 discharging with home health care or nursing services. R1's Social Service Note on 10/6/23 at 11:10 AM signed by V4 documents R1 was requesting to appeal R1's NOMNC due to (R1) does not feel that he is strong enough to return home at this time. R1's Progress Note on 10/8/23 at 9:30 AM signed by V6 (Special Care Unit Coordinator) states, Spoke to (R1) about his appeal being denied. (R1) stated that he still needs help in getting stronger. (R1) is going to call the QIO (Quality Improvement Organizations) right away and speak to them about reconsideration. (V6) spoke to (R1) that it would take 14 days to process and if denied (R1) would be responsible for his stay at (name of skilled nursing facility). R1's Social Service Note on 10/9/23 at 8:15 AM signed by V4 states, (R1's) appeal was denied. (R1) would like to discharge home today with therapy at (name of outpatient physical therapy center). R1's Nursing Progress Note on 10/9/23 at 12:20 PM signed by V7 (LPN) documents R1 left the facility via personal vehicle. This same note states, (V7) went over discharge instructions with (R1) and gave him a copy upon discharge. Medications sent with as well. This same progress note does not contain documentation that wound care teaching was completed with R1 or any caregivers for R1. On 10/26/23 at 10:49 AM, V4 (Social Service/Admissions Director) V4 stated that V4 is responsible for all discharge planning for residents and ensuring all discharge orders/instructions are set up prior to discharge. V4 stated that R1 lived alone and did not have much family support. V4 denied that R1 denied nursing care services at home at the time of R1's discharge from the facility. V4 stated V4 was not aware that R1 had wounds that required treatments while R1 was a resident at the facility. V4 stated V4 would absolutely have arranged nursing care for R1 at home to help with R1's wound treatments. V4 stated V4 was arranged for outpatient physical therapy and no other services at the time of R1's discharge. On 10/26/23 at 1:43 PM, V9 (Wound Nurse/Infection Preventionist/Registered Nurse) stated that if a resident has wounds and they are going home without much support at home, home health is generally ordered. V9 stated that R1's wound dressings were to be changed three times a week which would have sufficed for home health. V9 stated, R1's wounds were ok to be managed at home but under the direction of a nurse. You worry about infection concerns especially with wounds around the coccyx. Wounds in the coccyx area need well covered and cleaned. You risk contamination from urine or feces, increasing your risk of infection. V8 stated that due to the anatomical location of R1's wounds, R1 would not have been capable of cleaning R1's wounds or changing the dressings himself. V8 stated R1 was very tall and even reaching the wounds on R1's legs would have been difficult for R1. V8 stated, (R1's) wounds needed to be cared for under the direction of a skilled provider. V8 stated if it had been a situation where home health nursing care was being refused, V8 or another nurse would have had to ensure that education with return demonstration was completed with the caregiver who would have been responsible for caring for R1's wounds. V8 stated V3 (R1's Wound Physician) saw R1 in the facility on 10/6/23. V8 stated, That would have been a great opportunity for the nurse to speak out and explain each step of the wound care being completed with R1's caregiver. I wasn't aware on Friday (10/6/23) that (R1) would be discharging home so soon. At this time, V8 denied that V8 provided wound education of any kind to R1 or any of R1's family/friends for caring for R1's wounds at home. V8 stated that two to three days of wound care supplies are also sent home with residents to make sure they are well-equipped with supplies to treat the wound site or area before home health comes or more supplies are ordered. V8 stated a detailed progress note would be completed after wound teaching was completed. On 10/27/23 at 9:57 AM, V8 (R1's Family Member) stated that R1 lives alone and does not have family other than R1's ex-wife and V8. V8 stated that V8 picked R1 up from the facility on 10/9/23 to drive R1 home. V8 stated, I was there to take (R1) home, and no one talked to me or told me anything. We sat in (R1's) room for a while waiting for the nurse to go over his instructions, his medications, his wounds, anything. No one came in. Staff kept popping their head in and out to see if we were still in the room, but no one ever came and talked with us. (R1) has wounds. How are we supposed to care for them? What did they need? I don't know. I work out of town, and for at least 10 hours a day, (R1) is by himself. Those wounds are on (R1's) butt and his lower legs. There's no way he can reach them on his own. He's 6 foot 8 (inches) and 240 pounds. He's a big guy. He can't even reach the ones on his legs. The dressings weren't changed for about 10 days until his ex-wife came to visit. He had to call places to get help himself. It's not right. At this time, V8 verified that no wound supplies of any kind were sent home with R1 and that no staff from the facility educated R1 or V8 about caring for R1's wounds and did not have V8 demonstrate how to perform R1's wound treatments. On 10/27/23 at 10:15 AM, R1 stated that prior to leaving the skilled nursing facility, R1 was not set up with home health care or nursing services. R1 denied ever telling anyone that R1 didn't want help at home after discharging from the facility. R1 stated R1 was asked about Physical Therapy and that's it. R1 stated, I wasn't anywhere ready to be on my own. I need the help. I took it on my own to call around to get a nurse or an aide in here to help me. I have wounds on my backside that I can't get to. I tried taking care of them on my own; it's too hard by myself. R1 stated that when R1 left the skilled nursing facility, R1 nor any caregivers for R1 were provided wound care instructions, no wound teaching was completed, and R1 was not given any wound care supplies. As of 10/27/23 R1's medical record did not contain documentation that R1 was offered home health or nursing services after discharge. That R1 had ever declined home health or nursing services and that R1 was arranged for home health or nursing services after discharge. There was not documentation that R1 or any caregivers for R1 were provided wound care teaching with return demonstration; or that wound care supplies/treatments were provided to R1 at the time of R1's discharge from the facility.

Based on interview, record review and observation, the facility failed to ensure that equipment in the kitchen was clean and free of debris. This has the potential to affect all 84 residents residing in the facility. Findings include: The facility's Bag-In-Box Juice Dispenser Procedure, dated 08/2019, documents Daily cleaning, dispensing gun: Detach the black nozzle from the dispensing gun by twisting it gently pulling down, then soak both the nozzle and dispensing gun in lukewarm water for 10-15 minutes. This form also documents that if the diffuser area (exposed when the nozzle is removed) appears to have residue, clean with a small gentle brush like a soft toothbrush. The Dining Services Department Daily Cleaning Schedule, undated, documents to clean the following equipment after each use: Oven (wipe down) inside and out. On 4/24/23 at 9:45am, a tour of the facility's kitchen was conducted with V13 (Dietary Manager). The left convection oven contained a black, burnt, crusty substance present throughout the floor of the oven, and a brownish-sticky substance was observed running down the glass of the oven door. The right convection oven contained a brown, burnt substance on the glass of the oven door. V13 verified that the convection ovens had spillage/boil over and was unsure of the last time they had been cleaned. V13 then indicated the substances on the ovens had been there for a while. V13 stated that the brown substance on the oven doors appeared to be grease. V13 then stated that maintenance is supposed to clean the ovens monthly but does not keep a log of the cleaning. The kitchen's large warmer had five cookie sheets on the shelves, which had dried food and oily substances present on them. The kitchen's warmers contained a large area of a dark brown coating on the floor. V13 stated that the warmers are used to transport meals from the main kitchen to the kitchenettes on each unit. V13 verified that the dried brown substance in the warmers was left from supper that was served on 4/23/23. V13 stated that both the convection ovens and warmers should be cleaned after each use. The juice dispensing nozzle contained a large amount of an orange, reddish, sticky build-up. V13 stated that kitchen staff does not clean the juice dispensing nozzle. On 4/24/23 at 2:00pm, V1 (Administrator), stated that the kitchen staff are supposed to clean the ovens, not maintenance. V1 also stated that the ovens and the warmers should be cleaned after each use. V1 stated that the juice nozzle dispenser should be cleaned according to the manufacturer's instructions.

Based on interview and record review, the facility failed to develop and implement interventions to prevent falls for two (R19 and R20) of seven residents reviewed for falls in a sample of 19. This failure contributed to a fall with fracture of R19's right hip which required surgical repair. Findings include: 1. R19's Physician order [REDACTED]. The Investigation/Event reports, dated 4/3/14 and 4/8/14, document R19 fell out of bed in R19's room. R19's Fall Care Plan, for these dates, documents "no changes at this time" with no new intervention put into place. The Investigation/Event report, dated 4/11/14, documents R19 fell on the side of R19's bed sustaining "painful/limited (ROM) range of motion in lower extremity." R19's Progress Notes, dated 4/15/14, document R19 as having "right leg pain and swollen...needs to be seen at (doctor) office or ER (emergency room ) before X-ray will be ordered. Appointment made for 4/16/14." R19's Progress Notes, dated 4/16/14, document R19 "will be admitted ...for non-displaced (fracture)." R19's Radiology Report, dated 4/16/14, for X-ray of R19's right hip, documents "There is a nondisplaced intertrochanteric fracture." R19's Progress Notes dated 4/18/14 documents that a phone call was received from the hospital which reported that "(R19) had surgery today on the RT (right) femur..." On 4/2/15, at 1:40pm, E2, Director of Nursing (DON), stated "Sometimes we can't find any new reason so we keep trying the interventions we have in place." 2. R20's Physician order [REDACTED]. The Investigation/Event reports, dated 3/29/14, 6/4/14, 6/7/14, and 11/2/14, document R20 fell out of bed in R20's room. R20's Fall Care plan, for these dates, document "No changes at this time." The Investigation/Event report, dated 8/2/14, documents R20 fell out of chair with intervention of "Instructed resident not to walk without assistance." The Investigation/Event report, dated 12/28/14, documents R20 fell out of bed. R20's Fall Care Plan, for this date, documents, "All current interventions remain appropriate." On 4/2/15, at 3:10pm, E6, Minimum Data Set (MDS)/Care Plan Coordinator, stated "If no root cause found, current intervention remains appropriate with no changes at this time."

Based on observation, record review and interview the facility failed to implement interventions as planned and provide supervision in the bathroom for two of seven residents (R10, R2) at risk for falls in the sample of 18. These failures resulted in R10 sustaining a fractured elbow and R2 sustaining a laceration to the forehead which required sutures. Findings include: 1. R10 was in a wheel chair with a tab alarm clipped to the back of her shirt at the following dates and times: 4-17-12 at 10:50 AM, 4-18-12 at 8:45 AM, and 4-19-12 at 10:05 AM. PT (Physical Therapy) recommendations for R10, dated 9-12-11, state that R10 requires supervision, verbal cueing, and demonstration, but no physical assistance to ambulate. R10's care plan includes an intervention, dated 9-16-11, of "(R10) is to ambulate with the walker and CGA (care giver assistance) in the problem titled "at increased risk for falls" and an intervention,dated 3-28-12, that states, "Stand by assist for all transfers." "Safety Event" documentation, dated 9-13-11, states that R10 slid from a WC (wheel chair) after removing a personal alarm. The documentation also included "chair alarm" was the immediate measure to be taken at the time of the fall. Progress Note by E2/DON (Director of Nursing) on 9-13-11 at 3:11 PM states that (fabric to prevent sliding) would be placed in R10's wheel chair as an additional intervention. Witness statement written by E10/RN (Registered Nurse), regarding an incident involving R10 on 10-9-11, indicates that E10 saw R10 slide out of a regular chair on to the floor. Incident investigation report regarding the incident, signed by E1/Administrator states,"CNAs (Certified Nursing Assistants) will apply (fabric to prevent sliding) to the chair when they transfer her from the wheelchair." On 4-19-12 at 2:45 PM, E1 confirmed that during the investigation of the incident it was determined that the (fabric to prevent sliding) was not transferred along with R10 from the wheelchair to the regular chair. "Safety Event" documentation dated 10-16-11 states that R10 was sitting in rocking chair, stood up to transfer self into wheelchair, and fell . E1 stated on 4-19-12 at 2:45 PM that when R10 fell on [DATE] there was no personal alarm attached to R10 or the rocking chair to alert staff that R10 was attempting to transfer self. "Safety Event" documentation dated 2-24-12 states that R10 had a fall at 2:48 AM, while going to the bathroom, and that the "Interventions-Immediate measure taken" was a bed alarm. Progress Note dated 2-24-12 at 1:40 PM, signed by E11/RN (Registered Nurse) states that R10 had a 5.5 cm (centimeter) X 3.3 cm bruise to the posterolateral L(eft) upper forearm." Progress Note dated 2-24-12 at 2:14 PM and signed by E2 states, "(R10) ambulated self to bathroom. She was observed on the bathroom floor." Care Plan problem for R10, titled "is at risk for falls..." includes an intervention, dated 9-12-11 that states, "Pressure alarm in place to bed," and an intervention dated 2-24-12 that states, "Do not leave in BR (bathroom) unattended." Progress Note, dated 4-12-11 at 6:40 PM and written by E10/RN states, "this nurse saw (R10) walking from her bedroom towards the door without a walker and suddenly lost her balance and off to the floor." "Safety Event" documentation dated 4-13-12 documents that R10 fell in the bathroom at 9:48 AM and that the immediate measures taken were a bed alarm and chair/wheelchair alarm. It also documents that R10 sustained bruising and a skin tear to the right elbow at that time. Progress Note dated 4-13-12 at 1:25 PM and written by E5/LPN (Licensed Practical Nurse) states, "hematoma to right elbow continues to fill with fluid and enlarge in size, resident c/o (complains of) pain to site, call place to Dr. (doctor) and order received to send to ER (emergency room )." Progress Note dated 4-13-12 at 4:14 PM and written by E12/LPN states, "resident returned from ER with [DIAGNOSES REDACTED]." Incident Investigation Report, dated 4-13-12 and written by E7/Garden Court Coordinator states that the nurse responded to calls for help from R10 and discovered her on the bathroom floor. On 4-19-12 at 2:45 PM, E1 confirmed that on the 2-24-12, 4-12-12, and 4-13-12 there were no alarms sounding at the times that R10 had falls. E1 was not sure if there were no alarms in place or if they were not functioning. 2. R2's Care Plan dated 3/1/12 notes R2 to have [DIAGNOSES REDACTED]. R2's problem list on the care plan notes "Fall Risk" to be a potential problem, which was initiated on 1/24/06. A specific intervention initiated on 6/10/08 reads, "Take wheelchair out of bathroom when (R2) is in, staff is not to leave her in there alone". R2's Nurse's Notes dated 9/24/11 at 8:07 A.M. states, "Res was on toilet, wheelchair was outside of the bathroom. CNA (Certified Nurse's Aide) came to me (Nurse) and stated that res (R2) was on the floor in her bathroom. Res had blood coming out of the left side of her forehead and a hematoma a little smaller than a tennis ball. " R2's Nurse's Notes dated 9/24/11 at 10:20 A.M. reads, "Res just returned to facility with two sutures to the left eyebrow/forehead." Employee Disciplinary Action form dated 9/24/11 reads, "(E9) assisted a resident (R2) into the bathroom. (R2) is a fall risk and has alarms and seatbelt. E9 left (R2) alone in the bathroom which resulted in a fall. It is our facility policy any resident that is a potential fall risk, that has alarms on is never to be left alone in the bathroom." On 4/19/12 at 2:15 P.M. E2 stated that on 9/24/11, staff should not have left R2 alone in the bathroom. E1 also stated that the employee was disciplined and inserviced.