Every finding on record at Mattoon Rehab & HCC

Based upon observation, interview, and record review the facility failed to ensure a resident was removed from public view by pulling a privacy curtain and closing a door to prevent exposure of body parts during care for one (R5) of one resident on a sample list of 5. R5's admission Record dated 8/20/26 documents R5 was admitted to the facility on [DATE]. R5's Care Plan, undated, documents R5 has diagnoses including Anxiety Disorder, Unspecified, Other Specified Arthritis, Hyperlipidemia, Orthostatic Hypotension, Vitamin D Deficiency, Unspecified, Personal History Of Transient Ischemic Attack, And Cerebral Infarction Without Residual Deficits, Dysphagia, Oral Phase, Other Reduced Mobility, Repeated Falls, Dysphagia, Oropharyngeal Phase, Difficulty In Walking, Not Elsewhere Classified, Dementia In Other Diseases Classified Elsewhere, Severe, With Agitation, Gastro-Esophageal Reflux Disease Without Esophagitis, Unspecified Hearing Loss, Unspecified Ear, Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms, Unspecified and Dementia, Severe, With Psychotic Disturbance. R5's Care Plan, undated, documents R5 is at risk for nutritional problems related to dysphagia, at risk for falls, has impaired skin integrity related to immobility and incontinence, has impaired cognition related to dementia and is currently taking antipsychotic medications, has a self-care deficit and requires staff assistance for all Activities of Daily Living (ADL)'s including active range of motion to extremities, and has behaviors that include agitation related to Dementia. On 8/20/26 at 11:10AM wound care was completed on R5 provided by V4, Wound Licensed Practical Nurse (LPN). Low air loss mattress noted to R5's bed and fall mat on floor next to bed. Call light in reach at right hand. R5 observed to have shirt and incontinent brief on covered by a blanket in bed. V4 Wound LPN did not close R5's door nor pull the privacy curtain prior to rolling R5 towards wall and removing R5's brief exposing R5's uncovered buttock and perineal area to hallway area. After placing R5 in this position, V4 Wound LPN removed gloves and stepped into R5's bathroom to wash hands leaving R5 exposed for a full minute. During the ten minutes that R5 had buttock exposed to open door, one staff member and one resident came into room through the open door. On 8/20/26 at 2:00PM V2 Director of Nursing (DON) stated V4 should have ensured privacy for R5 prior to starting wound care by shutting R5's door and pulling the privacy curtain. The Facility's Resident Rights Policy dated 12/2024 documents each resident has the right and will to be afforded the right to a dignified existence, and all employees are trained on this policy prior to providing any resident care.

Based on observation, interview and record review the facility failed to prevent cross contamination during wound care and failed to complete wound care as ordered for two of three residents (R5, R3) reviewed for pressure ulcers in the sample list of five.Findings include:The Facility's Resident List Report dated 8/19/26 documents 86 residents reside in the facility.The Facility's Wound Tracker, undated, documents 18 residents with current wounds.The Facility's Infection Surveillance Report dated 8/19/26 documents 11 skin and soft tissue infections identified during the last 60 days.The Facility's Wound Prevention Policy dated 08/2023 documents an objective to educate staff members about wound prevention techniques and best practices, promote a clean and safe environment to minimize risk of infection and injury, and to encourage open communication and collaboration among staff, residents, and healthcare providers to address any concerns or issues related to wound care. This policy also documents staff are to document all wound prevention measures, assessments, and interventions in the electronic health record.The Facility's Infection Prevention and Control Program Policy dated 2019 documents the mission of the policy is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections that require staff to follow hand hygiene and personal protective equipment practices consistent with acceptable standards of practice.1.) R5's admission Record dated 8/20/26 documents R5 was admitted to the facility on [DATE] with diagnoses that include Anxiety Disorder, Arthritis, Hyperlipidemia, Orthostatic Hypotension, Vitamin D Deficiency, Personal History Of Transient Ischemic Attack, Cerebral Infarction Without Residual Deficits, Dysphagia, Oral Phase, Other Reduced Mobility, Repeated Falls, Dysphagia, Oropharyngeal Phase, Difficulty In Walking, and Dementia with Psychotic Disturbance.R5's Care Plan, undated, documents R5 is at risk for nutritional problems related to dysphagia, at risk for falls, has impaired skin integrity related to immobility and incontinence, has impaired cognition related to dementia and is currently taking antipsychotic medications, has a self-care deficit and requires staff assistance for all Activities of Daily Living (ADL)'s including active range of motion to extremities.R5's Wound Physician Progress Notes document a right ischium wound stage 3 acquired in house on 7/8/26, with the following measurements documented on 7/13/26 Length of 3.00 centimeters (cm) Width of 2.50cm and Depth of 0.20cm, on 8/03/26 Length of 1.09 centimeters (cm) Width of 1.99cm and Depth of 1.79cm, on 8/11/26 Length of 0.88 centimeters (cm) Width of 1.14cm and Depth of 0.78cm, and on 8/17/26 Length of 1.12 centimeters (cm) Width of 0.85cm and Depth of 0.75cm.R5's Physician Order Sheet dated 8/20/26 documents an order starting 8/17/26 to cleanse pressure ulcer to right gluteal fold with wound cleanser and pat dry, then apply skin protectant to the peri wound, apply collagen to wound bed only (cut to fit) and cover with silicone border foam once daily and as needed.On 8/20/26 at 11:10AM wound care provided to R5 by V4, Wound Licensed Practical Nurse (LPN). Low air loss mattress noted to R5's bed and fall mat on floor next to bed. Call light in reach at right hand. R5 observed to have shirt and incontinent brief on covered by a blanket in bed. R5's bedside table was covered with towel and items for wound dressing change placed on top of the towel. V4 stated V4 had a copy of the current order on the table. V4 Wound LPN donned gown and gloves in doorway of R5's room prior to entry. Upon removal of R5's incontinent brief, an uncovered, open wound was observed on R5's right buttock at the top of the right thigh. Wound was the size of a quarter with wound edges not approximated and white in color. No drainage or odor noted from the wound. V4 stated V4 was unclear why R5 had no dressing in place. After V4 completed washing hands in bathroom, gloves were donned and V4 proceeded to touch R5's garbage can several times attempting to obtain a trash bag for wound care. V4 did not change gloves prior to cleansing R5's wound with wound cleanser. V4 Wound LPN sprayed R5's wound with wound cleanser one time and wiped off with clean gauze. With same gloves, V4 opened package of collagen and proceeded to cut collagen to fit inside R5's wound. After collagen was cut to size, V4 changed gloves. No hand hygiene completed. V4 then removed a marker from her pocket and wrote date on top of bordered gauze dressing. At this time V4 placed collagen inside open area of wound and placed bordered gauze over wound. V4 indicated the dressing change was completed at this time.On 8/20/26 at 2:00PM V2 Director of Nursing (DON) stated that hand hygiene and glove change should be completed after cleansing dirty wound prior to touching clean wound dressing. V2 DON confirmed that R5's wound order states to apply skin prep to peri area of wound after cleansing wound.2.) R3's admission Record dated 8/19/26 documents R3 readmitted to the facility on [DATE] with diagnoses that include Gout, Peripheral Vascular Disease, Celiac Disease, Unspecified Systolic (Congestive) Heart Failure, Hypertensive Heart And Chronic Kidney Disease With Heart Failure And Stage 1 Through Stage 4 Chronic Kidney Disease, Or Unspecified Chronic Kidney Disease, Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris, Sepsis, Unspecified Organism, Type 2 Diabetes Mellitus With Foot Ulcer, Hyperlipidemia, Type 2 Diabetes Mellitus With Diabetic Polyneuropathy, St Elevation Myocardial Infarction Of Unspecified Site, Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus, Adult Failure To Thrive, Neuromuscular Dysfunction Of Bladder, Unspecified, Immunodeficiency Due To Conditions Classified Elsewhere, Muscle Weakness (Generalized), Need For Assistance With Personal Care, Unsteadiness On Feet, Weakness, Methicillin Resistant Staphylococcus Aureus Infection As The Cause Of Diseases Classified Elsewhere, Pressure Ulcer Of Sacral Region, Stage 3, Other Specified Personal Risk Factors, Not Elsewhere Classified, Gangrene, Not Elsewhere Classified, Acute Bronchitis Due To Parainfluenza Virus, Encounter For Orthopedic Aftercare Following Surgical Amputation, Acquired Absence Of Left Great Toe, and Unspecified Protein-Calorie Malnutrition.R3's Care Plan, undated, documents R3 has malnutrition, has active wounds including surgical amputation of left great toe, has a self-care deficit with ADL's requiring staff assistance, has a seizure disorder, has dehydration issues and heart failure, and has Methicillin-resistant Staphylococcus aureus(MRSA), Parainfluenza, Chronic Kidney Disease requiring contact isolation precautions.Facility Resident Matrix dated 8/19/26 documents R3 has a chronic indwelling catheter, is on Transmission Based Precautions, currently taking insulin and opioids and has an active infection.R3's Physician Order Sheet (POS) dated 8/19/26 documents a new order on 8/3/26 for wound care as follows: Wound to Left foot: If wound VAC (vacuum) is not available, Saline moistened gauze BID (twice a day) with ABD (abdominal) pad, secure with rolled gauze and tape until wound VAC is available. On 8/14/26 current order was discontinued with new order for daily wound care to left foot, use saline moistened gauze and cover with abdominal pad, secure with rolled gauze and tape.R3's Treatment Administration Record for the month of August dated 8/19/26 documents wound vac dressing change was refused on 8/3 and 8/12, completed on 8/5/26, and no documentation on 8/7, 8/10, and 8/14/26. Also documents new order received on 8/14/26 was not completed on 8/15/26 day shift.R3's Progress Notes do not document R3's refusals of wound care treatment on 8/3 and 8/12 and do not document a reason for missed treatments on 8/7, and 8/10/26.On 8/19/26 at 2:30pm R3 was lying at end of the bed, R3 was covered with a blanket. R3 stated that the facility had to stop the wound vac on R3's foot because they said it wasn't working so they have been doing some kind of dressing. R3 was unable to recall how often dressing is getting done, but not every day. R3 appears well groomed but unwell. Skin is ashen gray tone, R3 denies any pain currently.On 8/20/26 at 2:00PM V2 Director of Nursing (DON) stated that there is no reason there should be treatment orders that were left undocumented. V2 DON confirmed missing documentation. V2 stated the facility seems to be having trouble with all of the wound vacs lately.

Based on observation, interview and record review the facility failed to maintain residents' dignity by failing to provide care before ambulation with therapy, for a resident with urine saturated clothes. This failure affected one (R6) of four residents reviewed for incontinence care/dignity on the sample list of six residents. Findings include:R6's Current Physician Order Sheet document the following medication that can cause an increase in bladder incontinence: Memantine HCl Oral Tablet 10 MG (milligrams), Give one (1) tablet by mouth two times a day for memory, and Donepezil HCl Oral Tablet 23 MG, Give one (1) tablet by mouth one time a day for memory.R6's Current Diagnoses Sheet documents the following: Unspecified Dementia, Unspecified Severity, and Need for Assistance with Personal Care.R6's Minimum Data Set (MDS) dated [DATE] documents the following: R6's Brief Interview of Mental Status score as 10 out of a possible 15, which indicates moderate cognitive impairment. R6's same MDS documents, R6 is totally dependent on staff assistance with toileting: Resident does none of the effort to complete the activity. Or the assistance of 2 (two) or more helpers is required for the resident to complete the activity. The same MDS documents, R6 has not had any behavior or rejection of care, and R6 is frequently incontinent of bowel and bladder.R6's Current Care Plan updated on readmission on [DATE] documents the following: R6 has Activities of Daily Living Self-Care Performance Deficit. TOILET USE: The resident requires one staff participation to use toilet.On 7/20/26 at 1:50 pm, V17 Physical Therapist (PT) applied a gait belt around R6's waist, while R6 was seated in a wheelchair at the end of the shared resident hallway. V17 PT placed a front wheeled walker in front of R6's wheelchair. V17 PT gave directions to R6 to stand upright as V17 PT guided R6's hands to a safe position to ambulate. As R6 stood with V17's assistance, R6's wheelchair cushion was visible. A strong foul urine odor permeated the end of the hall. R6's sweatpants were visibly saturated in urine, as R6 ambulated in front of the wheelchair. The full seat of R6's pants, and approximately four inches of R6's pant legs were wet. The bottom three inches of R6's shirt was also visibly wet. V17 PT stood off to the side and behind R6. V17 PT pulled R6's wheelchair down the hall behind R6 while V17 PT also held R6's gait belt from the back, and just above R6's wet pants and shirt. V17 PT continued down approximately 150 feet of the hall to R6's room. R6 was in clear view of other residents, visitors and staff. R6 entered R6's room with verbal directions from V17 PT. V17 PT then directed R6 to be seated in the same wet wheelchair that V17 PT had placed in front of R6's Television.On 7/20/26 at 1:58 pm, V17 PT confirmed the distance V17 PT had ambulated R6 was approximately 150 feet. V17 then stated I noticed (R6's) pants were really wet when (R6) stood up. I (V17) was going to get a CNA (Certified Nursing Assistant) to change (R6) after therapy. V17 also stated R6 has some Dementia, and it did not seem to bother R6 to walk past other residents, visitors or staff. When asked if V17 would feel it was a dignity issue if a cognitive person was ambulated with the same wet clothes and odor. V17 PT stated I wouldn't want to walk down the hall in front of a bunch of people like that. I can see now this was a dignity issue. I need to tell my other therapy staff not to do this either.On 7/20/26 at 2:10 pm, V18 CNA assisted R6 to the bathroom via wheelchair. As V18 CNA assisted R6 to a standing position to transfer R6 to the toilet, V18 said to R6 Your wheelchair is really wet. I will clean that cushion while you're on the toilet. V18 lowered R6's pants and incontinence brief. V18 stated I see why your wheelchair cushion is wet. R6's skin on R6's upper legs and buttocks were wet in appearance. The foul urine odor was intense. R6 then called V18 CNA by name. R6 stated to V18 CNA (V18) is that me that is stinking. I (R6) haven't been changed since before lunch. V18 CNA reminded R6 that V19 CNA changed R6 about 11:45 am, then pushed R6 out to the dining room for lunch. R6 then stated I (R6) was wet when I (R6) ate lunch, I (R6) believe. I (R6) have learned to live with it, but I (R6) don't have to like it. V18 CNA completed cares and cleaned R6's wheelchair cushion. R6 stated That is what I (R6) like, clean clothes and something clean to sit on.The facility Resident Rights Policy dated 12/2024 documents the following: Policy:Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. No staff member or contracted provider of care will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights. It is the responsibility of all who work in this community, including employees of the community and any others who provide services to the residents of the community, to advocate and protect the rights of each resident. All staff members are trained on this Resident Right Policy at the time of employment, prior to providing care to residents, and at least annually to ensure full understanding related to ensuring each resident's Resident Rights. Each resident will have the opportunity to exercise his/her rights as a citizen, or a resident of the United States and staff members will assist with exercise of those rights as needed by any/all residents.

Based on observation, interview, and record review, the facility failed to ensure three (R9, R12, R18) of six residents reviewed for abuse remained free from verbal, mental, and physical abuse. This failure resulted in the loss of dignity and the potential for humiliation and emotional distress for R9, fear and ongoing psychosocial distress for R18, and abusive behavior by R12 toward another resident. Findings include: 1. On 05/21/2026 at approximately 5:50 PM, V15 Dietary Aide observed V16 Certified Nursing Assistant (CNA) standing in the hallway on the [NAME] Hall within hearing distance of R9 during evening meal service. V15 stated the hallway was occupied by residents, staff, and dietary personnel. V15 Dietary Aide stated V15 heard V16 CNA state, I have no sympathy for this (R9), followed by, Do you know why (R9) is here? V15 stated V16 then disclosed protected resident information, stating words to the effect that R9 had gone out and used heroin, leaving R9's child at home, as an explanation for why R9 resided at the facility. V15 stated R9 was within hearing distance of the conversation. V15 believed the comments were inappropriate and immediately reported the incident to V17 Dietary Manager. On 06/30/2026 at 3:16 PM, V17 Dietary Manager stated V15 Dietary Aide reported the allegation on 05/21/2026 at approximately 5:50 p.m. V17 stated V17 immediately notified V1 Administrator who instructed V17 to escort V16 Certified Nursing Assistant (CNA), from the facility pending investigation. V17 stated V16 had already left the facility for the day and did not return to work following the incident. Record review of the Facility Reported Incident and the Facility Abuse Investigation documented the allegation was investigated and substantiated. The investigation included interviews with staff, the resident's family members, and V16 CNA. The investigation documented V16 acknowledged making comments regarding R9, stated V16 was frustrated and venting, acknowledged the comments were inappropriate, and admitted V16 should not have made them, especially with R9 nearby and able to potentially hear the conversation. The investigation concluded V16's conduct was inconsistent with resident dignity expectations and the facility's Abuse, Prevention, and Prohibition Policy. Record review of V16's Personnel Records, Employee Corrective Action Form, and Personnel Action Form documented V16 was suspended on 05/21/2026 pending the abuse investigation and was involuntarily terminated effective 05/28/2026 under Category I – Gross Misconduct (Immediate Discharge), Rule 19 – Gross Discourteous Behavior Against a Resident. The documentation stated V16 was terminated for talking negatively about a resident while in the room, upsetting the resident. The records further documented V16 was not eligible for rehire. On 07/08/2026 at 1:05 PM, V1 Administrator stated the comments made by V16 Certified Nursing Assistant (CNA) within hearing distance of R9 were unacceptable, constituted resident abuse, and were the reason V16's employment was terminated. Record review of the facility's Abuse, Prevention, and Prohibition Policy, approved 12/2024, documented verbal and mental abuse includes humiliating, harassing, intimidating, disparaging, or derogatory language or actions directed toward or within hearing distance of a resident. The policy required employees to maintain resident dignity and confidentiality, prohibited discussing a resident's protected health information with individuals who did not have a legitimate need to know, and required employees to immediately report all allegations or suspicions of abuse. The facility failed to ensure R9 was free from verbal and mental abuse when V16 Certified Nursing Assistant (CNA) made derogatory comments and disclosed protected resident information within hearing distance of R9. This conduct was inconsistent with resident dignity, violated the facility's Abuse, Prevention, and Prohibition Policy, and had the potential to cause humiliation and emotional distress. 2. On 7/7/26 at 9:29 AM, R18 was observed sitting in R18's wheelchair in R18's room. R18's head was hanging down. R18's facial hair appeared unkempt and scruffy, and R18 was wearing a dirty baseball cap. R18 stated that R18 remembers the incident involving R12, although R18 could not recall the exact date. R18 stated R18 was waiting by the door to go outside to smoke and was visiting with other residents when R12 approached R18 from R18's left side and shouted, I told you to never disgrace me like that again! R18 stated that R12 then backhanded R18 on the right cheek with R18's right hand. R18 stated R18 thought R12 was going to punch R18. R18 stated that the incident startled R18 and that R18 felt scared both during and immediately after the event. R18 stated R18 felt angry about what had occurred. R18 further stated R18 thinks about the incident frequently and that it continues to upset R18. R18's Minimum Data Set (MDS) dated [DATE] documents that R18's cognition is intact. R18's Care Plan, initiated on 6/14/26, identified R18's involvement in a resident-to-resident altercation. The care plan goal was for R18 to feel safe in the facility. Interventions included room change and increased visits by the Social Services Director (SSD) to monitor for potential psychological or social harm. An initial state report dated 6/14/2026 documents that R18 reported that another resident (R12) approached R18 in an aggressive manner and made a physical threat towards R18. Allegation was immediately reported to administration for investigation. R12 and R18 were separated and monitored to maintain resident safety. On 7/7/26 at 10:36 AM, V7 Licensed Practical Nurse (LPN) stated V7 was caring for R12 and R18 when R12 allegedly struck R18. V7 LPN stated V7 did not witness the incident but was notified by an unidentified housekeeper that V40 Registered Nurse (RN) needed V7's assistance for an altercation between R12 and R18. V7 LPN stated V40 RN reported R12 and R18 were arguing while waiting to smoke and R12 slapped R18. V7 LPN stated V7 interviewed both residents after the incident. V7 stated R18 didn't know what R18 did to provoke R12. V7 stated R12 thought that R18 was talking about R12, became upset, and struck R18. V7 stated R12 has a history of paranoid behavior. On 7/7/26 at 10:47 AM, V40 RN stated V40 witnessed an altercation between R12 and R18. V40 stated V40 was at the nurses' cart near the area where residents line up to go outside to smoke. V40 RN stated V40 was not directly observing the residents at the time, V40 heard R12 repeatedly telling R18 that R18 will not disrespect R12. V40 stated V40 then observed R12 approach R18 in R18's wheelchair. V40 RN stated when V40 reached the residents, R12 had already struck R18 on the right side of R18's face, and V40 heard a loud popping sound upon contact. V40 RN stated R18 appeared upset and the two were separated. V40 stated R12 continued making statements like nobody is going to talk to R12 like that and nobody is going to disrespect R12. V40 stated R18 didn't know what R18 did to provoke R12. On 7/7/26 at 10:43 AM, R19 stated R19 was sitting with R12 and R18 while waiting to go outside to smoke. R19 stated R12 approached R18 and told R18 to stay out of R12's business, and then R12 struck R18. R19 stated R18 and R19 were shocked by the incident. On 7/7/26 at 12:59 PM, R12 was sitting in R12's wheelchair in R12's room. R12 is wearing a ball cap and sunglasses, and R12's left arm is in a sling. R12 stated R12 is familiar with the incident involving R18. R12 stated R12 remembered the incident and reported that R12 and R18 were waiting to go outside to smoke when R18 made comments that R12 perceived as disrespectful. R12 stated R18 acts like a child and is disrespectful toward R12 and other residents. R12 referenced a scene from the movie Tombstone involving a character slapping another person to demand respect. R12's Minimum Data Set (MDS) dated [DATE] documents that R12's cognition is intact. R18's Electronic Health Record (EHR) contains a Health Status Note dated 6/14/2026 that documents V31 LPN was notified by an unidentified housekeeper that V40 RN needed V31. This note documents that V31 approached the common area outside main dining room, and V40 RN informed V31 LPN that R18 was hit by R12 in the face at 8:54 a.m. On 7/8/2026 at 1:08 PM, V1 Administrator stated R12's behavior was very inappropriate. V1 stated R12 is currently residing in a private room located near the nurses' station and that R18 was moved to another room on a different hallway following the incident. V1 also stated V1 was unaware that R18 was experiencing any ongoing negative feelings or emotional distress related to the incident.

Based on observation, interview and record review the facility to prevent cross contamination during wound care for one (R1) resident out of three residents reviewed for wound care in a sample list of four residents.Findings includeR1's Electronic Medical Record (EMR) documents medical diagnoses of Lymphedema, Edema, Difficulty Walking, Unsteadiness on Feet, Muscle Weakness, Reduced Mobility, Venous Insufficiency, Vitamin B12 Deficiency Anemia, Morbid Obesity, Type II Diabetes Mellitus, Acquired Absence of the Right Great Toe, and Non-Pressure Chronic Ulcer of the Right Lower Leg.R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact. This same MDS documents that R1 requires maximum assistance with bathing, dressing, and bed mobility.R1's Physician Order Sheet (POS), dated June 2026, documents a physician order for the Right Second Toe to cleanse the abrasion with wound cleanser, pat dry, apply skin protectant, apply medical-grade honey, weave dry gauze between the toes for moisture wicking, and cover with bordered gauze daily and as needed.This same POS documents a physician order to cleanse R1's Right Heel, pat dry, apply skin protectant, apply medical-grade honey to the wound bed, and cover with bordered foam daily and as needed.On 6/6/26 at 10:20 AM, V4 Licensed Practical Nurse (LPN) performed wound care for R1's Right Second Toe and Right Heel. V4 LPN did not change gloves or perform hand hygiene throughout the procedure. V4 LPN did not provide a clean field for placement of wound care supplies used during the dressing change.R1's roll gauze and tube of medical-grade honey used during the dressing change were placed directly on the contaminated surface of the dresser. V4 LPN used the same open tube of honey to apply the product directly to R1's Right Second Toe and then used the same tube to apply honey directly to R1's Right Heel. The tip of the honey tube came into direct contact with both wounds.V4 LPN did not dress each wound independently. V4 LPN used the same contaminated gauze to cleanse both R1's Right Second Toe and Right Heel.R1's Right Second Toe was observed to be open and draining clear/yellow fluid with a white, macerated periwound area. R1's Right Heel was observed to have an oblong-shaped open wound draining clear/yellow fluid with a white, macerated periwound area.On 6/6/26 at 10:30 AM, V4 Licensed Practical Nurse (LPN) stated he should have changed gloves and performed hand hygiene during the dressing change. V4 LPN stated it would have been better practice to use a cotton-tipped applicator to apply the medical-grade honey to the wounds rather than applying the honey directly from the tube.V4 LPN stated he had placed a clean field under R1's foot during the dressing change but forgot about placing a clean field beneath the wound care supplies. V4 LPN stated each wound should have been dressed separately.V4 LPN confirmed he cross-contaminated R1's Right Second Toe and Right Heel wounds and acknowledged that such cross-contamination could result in infection.On 6/6/26 at 11:30 AM, V2 Director of Nursing (DON) stated R1's wounds should have been dressed separately. V2 DON stated a clean field should have been placed beneath the wound care supplies, nursing staff should change gloves between removing soiled dressings and applying clean dressings, and staff should use a cotton-tipped applicator or tongue depressor to apply ointments to wounds.V2 DON stated R1's wounds were cross-contaminated several ways and indicated staff education would be provided. V2 DON stated that cross-contamination of open wounds could result in infection.

Based on interview and record review the facility failed to provide timely responses to resident grievances for three residents (R2, R3, R4) out of four residents reviewed for Activities of Daily Living (ADL) in a sample list of four residents.Findings include:R2's Minimum Data Set (MDS), dated [DATE], documents R2 as cognitively intact. This same MDS documents that R2 requires maximum assistance with bathing.R3's Minimum Data Set (MDS), dated [DATE], documents R3 as cognitively intact. This same MDS documents that R3 requires maximum assistance with bathing.R4's Minimum Data Set (MDS), dated [DATE], documents R4 as cognitively intact. This same MDS documents that R4 requires maximum assistance with bathing.The facility Resident Council Minutes, dated 4/21/26, document resident concerns regarding staff not cleaning residents well and showers not getting done.The facility Resident Council Minutes, dated 5/19/26, document resident concerns regarding residents missing showers because there was no staff.The facility Grievance Form, dated 3/17/26, with no resident name listed, documents concerns that residents were not receiving showers twice weekly. This same form lists Resident Council as the resident name. The grievance was documented as resolved on 3/23/26.The facility Grievance Form, dated 4/22/26, with no resident name listed, documents concerns that Certified Nurse Aides (CNAs) were not cleaning residents adequately and that some residents were still not receiving showers twice weekly. This same form lists Resident Council as the resident name. The grievance further documents that staff were asking residents at 10:00 PM whether they wanted a shower and that residents felt this was too late. The grievance was documented as resolved on 4/30/26.The facility Grievance Form, dated 5/19/26, with no resident names listed, documents concerns that residents were not receiving showers because of inadequate staffing. This same form lists Resident Council as the resident name. The grievance was documented as resolved on 6/1/26.On 6/6/26 at 12:45 PM, V1 Grievance Coordinator/Administrator stated that all concerns brought forward during Resident Council meetings are documented on a grievance form. V1 stated the grievance form is then provided to V1 for review and distribution to the appropriate department head. V1 stated the department head investigates the concern and develops a solution, which is then returned to the Resident Council President to determine whether the concern has been resolved.V1 stated the original resident who raised the concern is not involved in the grievance process or resolution. V1 further stated that the resident with the specific concern should be involved in the resolution process. V1 stated the facility would review the process and make adjustments to ensure resident involvement.On 6/6/26 at 12:50 PM, V11 Activity Director stated that when a concern is raised during Resident Council, the concern is listed under Resident Council on the grievance form. V11 stated there is no way to identify which resident originally raised the concern.V11 stated the grievance form is forwarded to the appropriate department head, the concern is investigated, and the completed form is returned to the Resident Council President (RCP). V11 stated the RCP determines whether the concern has been resolved and then reports back during the following month's Resident Council meeting.V11 Activity Director stated the resident who raised the concern is not involved in the process and may have to wait an entire month before learning whether the concern was resolved.On 6/6/26 at 1:55 PM, R2 stated staff were not providing his showers as scheduled but were doing better now. R2 stated he complained about not receiving showers during Resident Council meetings but never received any follow-up regarding whether the issue had been investigated. R2 stated it would be nice to know if they are working on it.On 6/6/26 at 2:05 PM, R3 stated she had complained about shower times a couple of times during Resident Council meetings. R3 stated staff ask her to shower at 9:00 PM after she has already gone to bed. R3 stated no one has ever followed up with her to discuss her concerns, ask how the issue could be resolved, or provide any potential solutions.R3 stated, It's like I speak up and that is it. Nothing happens after that.On 6/6/26 at 4:30 PM, R4 stated the facility conducts Resident Council meetings monthly. R4 stated that when a concern is raised during a meeting, it is forwarded to the department head responsible for that area.R4 stated that at every Resident Council meeting, several residents complain that they are not receiving their showers. R4 stated she is provided a document to review after the department head has addressed the issue and is asked whether she agrees with the resolution.R4 stated, It really is a messed up system. Any resident who complains should have the right to say whether the resolution is resolved to their liking. This facility has the Resident Council President decide.R4 stated the Resident Council President makes the determination and then reports back to the council at the following month's meeting.The facility's undated policy titled Resident Grievance Process documents that each grievance will be investigated and addressed with a response. The policy further documents that the response, along with any corrective actions taken, will be provided to the person initiating the grievance within five working days of the findings.

Based on interview and record review, the facility failed to follow physician orders for insulin administration for one (R3) of three residents reviewed for quality of care in a sample of 69. This failure resulted in R3 receiving a dose of insulin via a syringe while simultaneously receiving insulin from an insulin pump, causing hypoglycemia, decline in condition, and hospitalization. This past noncompliance occurred from 4/2/2026 to 4/6/2026.Findings include: R3's Census, within the facility's Electronic Health Record, documents an initial admission date to the facility as 3/18/2026.R3's undated Care Plan documents a readmission date to the facility as 4/6/2026 with the following diagnoses: Acute Kidney Failure, Hyperkalemia, Chronic Kidney Disease, Stage 3, Muscle Weakness, Need For Assistance With Personal Care, Hypo-Osmolality And Hyponatremia, Hypertensive Heart Disease Without Heart Failure, Type 2 Diabetes Mellitus With Hyperglycemia, Long Term Use of Insulin, Unspecified Cirrhosis Of Liver, Thrombocytopenia, Hypothyroidism, Morbid (Severe) Obesity Due To Excess Calories, Obstructive Sleep Apnea, Hyperlipidemia, Old Myocardial Infarction, Gastro-Esophageal Reflux Disease Without Esophagitis, Squamous Cell Carcinoma Of Skin, Personal History of other Venous Thrombosis and Embolism, and Hepatic Encephalopathy.R3's Physician Order dated 3/19/26 documents Insulin Aspart Solution 100 milligram per milliliter, Inject 140 units subcutaneously one time a day for Diabetes Mellitus II unsupervised self-administration via insulin pump; change every three days.R3's Medicine Administration Record for 4/2/2026 indicates R3's order for Insulin Aspart was marked as administered at 8:00 AM. No documentation was available for review indicating the dose given.R3's Blood Sugar Summary for 4/2/2026 contains blood sugar results as follows:4/2/2026 at 7:31 AM - 169.0 milligrams per deciliter4/2/2026 at 11:35 AM - 50.0 milligrams per deciliter4/2/2026 at 11:36 AM - 78.0 milligrams per deciliter4/2/2026 at 4:06 PM - 81.0 milligrams per deciliterThe Center for Disease Control lists a normal blood sugar range to be within 80-130 milligrams per deciliter and blood sugar readings below 70 milligrams per deciliter are considered hypoglycemic.R3' Medication Administration Record for 4/2/2026 documents Glucose gel was administered to R3 by V8 Licensed Practical Nurse at 11:35 AM.The Emergency Department Report dated 4/6/2026 documents R3 was admitted to the hospital medical floor on 4/3/2026 at 3:35 PM for observation with admitting diagnoses of Acute Altered Mental Status and Suspected Hepatic Encephalopathy. The Report documents R3 presented from a rehabilitation facility via EMS (Emergency Medical Services) for altered mental status and decreased responsiveness. Per report, she had been less responsive since the prior morning, with concern raised for possible excess insulin administration in the setting of an insulin pump.On 5/13/2026 at 12:53 PM, V7 (R3's family member) stated he arrived at the facility on 4/2/2026 at approximately 11:30 AM and observed R3 to be lethargic and confused. V7 stated R3 informed him the nurse on duty had administered insulin prior to his arrival via a syringe while R3 was wearing an active insulin pump. V7 stated V8 (Licensed Practical Nurse) initially denied administering insulin and later admitted to administering insulin to R3 via syringe. V7 stated staff provided R3 orange juice throughout the evening due to declining condition. V7 stated when he returned to the facility the following day, R3 was nearly unresponsive, and he demanded staff contact emergency medical services. V7 stated R3 was subsequently hospitalized .On 5/13/2026 at 4:43 PM, V8 (Licensed Practical Nurse) stated she administered insulin to R3 via syringe on 4/2/2026 while R3 was wearing an active insulin pump during the facility's morning medication administration. V8 LPN stated she could not recall the dose or the exact time the insulin was given. V8 stated the medication error occurred due to V8 LPN misinterpreting the physicians order for insulin.On 5/14/2026 at 12:10 PM, V11 Physical Therapist Assistant stated R3's insulin pump alarmed for low blood glucose around noon on 4/2/2026. V11 stated she informed nursing staff and overheard V8 Licensed Practical Nurse acknowledge administering insulin to R3 because R3 reportedly stated the insulin pump did not administer insulin. V11 stated R3 appeared very lethargic at that time and required orange juice with sugar for intervention.On 5/13/2026 at 11:16 AM, V5 Registered Nurse stated R3 utilized an insulin pump with a wearable blood glucose monitoring device and did not receive insulin via syringe administration.On 5/13/2026 at 8:10 AM, V2 Director of Nursing stated she became aware of the medication error on 4/3/2026 after R3 was observed lethargic and difficult to arouse. V2 stated the Medical Director was notified and R3 was transferred to the emergency room for evaluation. On 5/14/2026 at 3:25 PM, V3 (Assistant Director of Nursing) stated the insulin administered to R3 on 4/2/2026 via syringe occurred due to V8 Licensed Practical Nurse misinterpreting the physicians order for insulin and considered V8's mistake as a significant medication error.On 5/18/2026 at 11:45 AM, V14 (Medical Director) stated the incorrect dose of insulin administered to R3 by V8 on 4/2/2026 contributed to R3's hospitalization on 4/3/2026.Prior to the survey date, the facility took the following actions to correct the noncompliance. On 4/3/2026 V1 Administrator educated V2 Director of Nursing and V3 Assistant Director of Nursing on the topic of safe medication administration, correct order processing, and assessing and notifying when medication errors occur.On 4/3/2026 registered and licensed staff were in-serviced by V2 Director of Nursing on the following topics:Medication Administration policy regarding interpreting physician orders, entering physician orders and medication administration.Residents should be assessed, and the physician should be notified in the event a medication error occurs. 3. On 4/6/2026 Audits were conducted by V2 Director of Nursing to ensure compliance with physician order interpretation, transcription and medication administration for residents receiving insulin. 4. On 4/3/2026 V2 Director of Nursing conducted an audit of the last 30 days of new admission and readmission resident's prescribed insulin to ensure physician orders were entered accurately and their medication was administered per physician order. 5. On 4/6/2026 residents receiving insulin were reviewed and audited by V2 Director of Nursing to ensure physician orders were entered accurately and their medication was administered per physician order.

Based on observation, interview, and record review, the facility failed to ensure resident shower rooms were maintained in a safe, clean manner and in good repair for two of three shower rooms located on [NAME] Hall and [NAME] Hall. This failure has the potential to affect 64 of 64 residents (R4 and R7 through R69) reviewed for homelike environment in the sample list of 69.Findings include:Observations were conducted on May 15, 2026 between 3:00PM and 3:15 PM on [NAME] Hall and [NAME] Hall.Beacon Hall Shower Room: Sections of floor tile were missing, leaving uneven and damaged areas. Portions of wallboard were missing, exposing underlying material. Debris was present on the floor, and the room appeared visibly dirty. A black substance was noted along the shower walls and in the floor corners.West Hall Shower Room: Multiple tiles were missing from the shower floor. Shower chairs, a shower bed, and a mechanical lift were blocking the toilet so the toilet was not accessible. Dirt and debris were present on the floor. A black substance was present along the wall to floor junctions and shower corners.During interviews on May 15, 2026 at 3:30 PM V1, Administrator, stated the shower rooms were in need of repair and confirmed that these conditions had been present for some time. On 5/15/26 at 3:45 PM R4 and R5 stated, Yes that shower room needs lots of work, especially under the sink there is no wall. On 5/19/26 at 2:10 PM V1 Administrator stated there were no work orders in place to have the rooms repaired. The Midnight Census Report dated 5/19/26 at 3:03 pm documents R4 and R7-R69 use the [NAME] Hall and/or [NAME] Hall shower rooms.

Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal abuse by employees. This failure affected three of five (R2, R4, and R6) residents reviewed for abuse in a sample of six residents. Findings:The facility's Abuse, Prevention and Prohibition Policy dated November 2025 documented that each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members or legal guardians, friends, or other individuals.The policy prohibits mistreatment, neglect, and abuse, including the deprivation of goods or services necessary to attain or maintain a resident's physical, mental, and psychosocial well-being. It identifies prevention as a key component and affirms the resident's right to be free from verbal, mental, sexual, exploitative, or physical abuse, as well as corporal punishment and involuntary seclusion. The policy documented that the facility will regularly reassess care plan interventions and implement strategies based on resident screenings to prevent occurrences of abuse.On 04/24/2026 at 8:53 a.m., R2 was observed lying in bed covered with a blanket and reported that an evening/night shift CNA (R2 can't recall name) consistently tells her to pull up your own incontinence brief. R2 stated this CNA speaks to her in a mean and disrespectful manner, and it causes her emotional distress. R2 stated, I don't like it, and stated this CNA always speaks to her that way.R2's Minimum Data Set (MDS) dated [DATE] documented that R2 has moderate cognitive impairment. This MDS documented that R2 requires substantial/maximal assistance from staff for toileting hygiene tasks.R2's Electronic Health Record (EHR) contains a progress note dated 4/10/26 that documented V1, Administrator was notified of R2's report that a Certified Nursing Assistant (CNA) spoke to her in a verbally abusive manner and did not provide care to meet her needs. The allegation was reported to administration, and an investigation was initiated. A head-to-toe skin assessment was completed, and R2's physician and Power of Attorney/emergency contact were notified. The (local) Police Department and the Ombudsman were also informed of the allegations of verbal abuse.On 4/24/26 at 10:06 a.m., V11, CNA, reported that R2 stated a night shift CNA was consistently rude and disrespectful. V11 stated R2 also reported this concern to V14, an agency CNA. According to V11, R2 was unable to recall the alleged perpetrator's name but provided a description. V11 further stated R2 reported that the CNA instructed her to perform toileting tasks independently, telling her she could do it herself in a mean and condescending tone.On 04/24/2026 at 10:53 a.m., V14, CNA, stated R2 told V14 that a night shift CNA identified as V8 consistently tells R2 to perform tasks independently, including transfers, toileting, and toileting hygiene. V14 stated R2 has appeared down and sad recently and reported to V14 that her interactions with V8 have been upsetting to her because of how rudely V8 speaks to R2 . V14 further stated R2 expressed hesitation to call for assistance when V8 is working due to fear of upsetting V8.A state report dated 4/10/26 documented that R2 reported that a CNA spoke to her in a verbally abusive manner and did not provide care to meet her needs. The allegation was reported to administration, and an investigation was initiated. MD and POA/emergency contact were made aware.On 4/24/26 at 12:12 p.m., R4 stated that a few staff members have spoken to him in a condescending or disrespectful manner. R4 further reported that, during a recent night shift, staff left him in a soiled incontinence brief after informing him they would return to provide care but did not come back to assist him. R4 did not describe physical harm or direct abuse; however, he expressed concern regarding the tone and manner in which staff spoke to him during that incident.R4's MDS dated [DATE] documented that R4 is cognitively intact.On 4/24/26 at 12:28 p.m., R6 stated that some nurses and CNAs at the facility have spoke to him in a rude and disrespectful manner (names not recalled). R6 stated he previously brought this concern to management and stated that V4, Social Services Director (SSD), followed up with him regarding his concerns and told R6 she would look into the situation.R6's MDS dated [DATE] documented that R6 is cognitively intact.On 04/24/2026 at 2:52 p.m., V4, SSD, stated that R6 recently brought concerns to her attention regarding staff attitudes, specifically reports of rudeness and disrespect. V4 stated she could not recall the specific details at the time but indicated she would provide documentation showing the matter had been investigated.On 04/24/2026 at 1:53 p.m., V3, Assistant Director of Nursing (ADON) stated that the expectations of facility staff is that verbal abuse, disrespect, and rudeness are not acceptable. She reported she was aware of the concerns involving R2 and stated the Administrator (V1), who serves as the abuse coordinator, handled the situation. V3 reported that the alleged staff member was removed from the schedule, and an investigation was conducted. V3 emphasized that the expectation is for residents to feel comfortable requesting assistance without fear of upsetting staff and that such concerns are taken seriously.

Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to complete wound assessments, follow physician's orders, implement infection control during wound care for one of 15 residents (R5) reviewed for wounds in the sample list of 15. These failures resulted in deterioration of R5's wounds and infection that required hospitalization and intravenous antibiotics. B. Based on interview and record review the facility failed to develop and implement interventions for preventing skin tears for one of five residents (R6) reviewed for wounds in the sample list of 15. Findings include:A.) The facility's Skin Identification, Evaluation, and Monitoring Policy dated February 2026 documents a licensed nurse will complete weekly skin checks, wounds will be re-evaluated weekly and wound characteristics will be documented in the resident's medical record. Treatments will be administered per the health care provider's order.The Centers for Disease Control and Prevention Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 7/12/22 documents: Enhanced Barrier Precautions (EBP) expands the use of PPE and refers to gown and glove use during high-contact resident care activities that provide opportunities to transfer Multidrug Resistant Organisms (MDROs) to staff's hands and clothing and indirectly transferred from resident to resident during these care activities. residents with wounds and indwelling medical devices are high risk for acquiring and colonization of MDROs. Wound care is an example of a high-contact resident care activity when gown and gloves should be worn. The facility's Hand Hygiene policy dated 2019 documents hand hygiene is the primary means of preventing the transmission of infection and staff must perform hand hygiene even when gloves are used. This policy documents the use of an alcohol based hand sanitizer is acceptable hand hygiene except when hands are visibly soiled.R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician order dated 11/19/25-1/6/26 documents EBP related to wounds.R5's Wound Clinic Progress Note dated 11/26/25 documents V15 Wound Clinic Nurse Practitioner ordered daily wound care to cleanse wounds with normal saline, apply (antimicrobial fiber dressing with silver), covered with (nonadherent absorbent gel dressing), wrap with gauze roll, and apply (elastic bandage) for left lower posterior leg, right medial ankle, right posterior lower leg, left medial anterior lower leg, right anterior superior lower leg, left lateral lower leg, left medial lower leg lymphedema wounds. R5 to return in two weeks. R5's physician order dated 11/26/25-1/6/26 documents R5's wound care orders as three times weekly on Mondays, Wednesdays and Fridays during lymphedema treatments. There is no documentation in R5's chart that these changes were clarified with V15. R5's leg wound treatment orders were not transcribed to R5's November and December 2025 Treatment Administration Records (TARs). R5's Wound/Skin assessment dated [DATE] documents: Left medial calf wound measured 4.34 centimeters (cm) by 5.01 cm by 0.3 cm (length x width x depth). Right medial calf wound measured 3.4 cm by 2.73 cm by 0.2 cm. Left shin wound measured 8.01 cm by 6.87 cm by 0 cm. Right medial malleolus measured 10.01 cm by 3.52 cm by 0.3 cm. There are no documented assessments of these wounds in R5's medical record after 12/12/26 until R5 was evaluated in the wound clinic on 1/2/26. R5's Skilled Physical Therapy Treatment Encounter Notes dated 11/21/25-12/22/25 document V12 Physical Therapy Assistant (PTA) completed wound and skin assessments and care, with no wound characteristics or specific treatments documented. On 12/20/25 V12 spoke with nursing staff regarding the deterioration of R5's wound beds with increased drainage and odor. On 12/22/25 a wound culture was obtained. R5's Nursing Note dated 12/20/2025 12:53 PM documents R5 had significant decline in leg wounds with purulent green drainage and foul odor. Physician ordered wound culture and Keflex (antibiotic) 500 milligrams three times daily for 10 days. R5's Nursing Note dated 1212/20/2025 at 4:59 PM documents unable to obtain wound culture as no culture kits were available and the local hospital laboratory was contacted to deliver more kits. Physician was notified. R5's Wound Clinic Progress Notes dated 1/2/26 document right, medial, posterior lower leg wound measured 22 cm by 19 cm by 0.2 cm and had a large amount of serosanguineous drainage. The left medial, anterior, circumferential leg wound measured 15 cm by 29 cm by 0.4 cm and had large amount of serosanguineous drainage. R5's Infectious Disease Consultation dated 1/3/26 documents R5 presented to the emergency room on 1/2/26 for worsening chronic leg wounds and concern for infection. It was reported through clinical imaging and from the wound clinic that R5 had been receiving wound care at the wound clinic and dressing changes at the nursing home, however R5's wound dressings had not been changed since 12/15/25 and had significant wound drainage. R5 had purulent drainage weeping through the dressings and foul odor. R5 was last seen in the wound clinic on 11/26/25. R5's Wound Culture dated 12/22/25 showed drug resistant organisms and R5 received intravenous antibiotics while at the hospital. R5's Hospital Discharge Instructions dated 1/8/26 document R5's discharge diagnoses included cellulitis (skin infection) to both legs, complicated wound infection, polymicrobial bacterial infection, and MDR Acinetobacter baumannii infection. R5's January 2026 TAR documents R5's leg wound treatments were not signed out as administered on four days between four days between 1/22/26 and 1/31/26. R5's Wound Clinic Progress Note dated 2/4/26 documents to follow up in two weeks. On 2/18/26 at 12:45 PM R5 stated R5 has leg wounds that should be wrapped daily, but once in a while the nurses forget to change the dressings. R5 had infection in her legs and went to the hospital. On 2/19/26 at 2:33 PM V28 Registered Nurse (RN) and V6 Wound Nurse/Licensed Practical Nurse (LPN) entered R5's room and administered R5's lower leg wound treatments. R5 was on contact precautions isolation. R5's lower legs had lymphedema (swelling) and several pink/moist wounds.On 2/19/26 at 11:43 AM V16 Certified Nursing Assistant stated about a month ago R5's legs were draining which soaked through the dressings. V28 notified an unidentified nurse who changed R5's bandages. V28 stated an agency nurse had worked the day before and had not changed R5's dressings. On 2/19/26 at 11:56 AM V15 Wound Clinic Nurse Practitioner stated V15 evaluated R5's leg wounds on 1/2/26 and the dressing were dated for three weeks prior. R5's wound care orders were for daily dressing changes. The wounds had deteriorated, had an odor and had an abundant amount of green drainage. R5 was crying due to the pain and infection, and R5 required hospitalization to treat the infection. V15 spoke with V2 Director of Nursing (DON) who confirmed R5's treatment orders were received and entered but the treatments were not completed. R5 had an appointment at the wound clinic yesterday, but the facility cancelled the appointment due to transportation issues. On 2/19/25 at 1:28 PM V11 Transportation stated V11 transports residents to appointments and was not aware that R5 had a wound clinic appointment yesterday until V11 saw a note when V11 came to work today. V11 stated V11 would have taken R5 if V11 knew about R5's appointment and the staff are to notify V11 of resident appointments. At 1:42 PM V11 stated R5's only wound clinic appointment in December was on 12/12/25 but R5 refused to go, so the appointment was rescheduled for 1/2/26. On 2/19/26 at 1:57 PM V10 LPN confirmed V10 entered R5's wound orders on 11/26/25 for three times weekly. V10 stated the orders were entered to be done with R5's lymphedema treatments on Mondays, Wednesdays and Fridays by V12 and the nurses were not doing R5's wound treatments. On 2/19/26 at 2:12 PM V12 PTA stated V12 was completing R5's lymphedema treatment and wound dressing changes three times weekly. V12 stated V12 did not complete wound assessments as V6 was checking R5's wounds weekly on Fridays. At 3:20 PM V12 stated R5's lymphedema therapy treatments ended 12/22/25 once R5's wounds deteriorated and started draining copious green drainage. On 2/23/26 at 2:16 PM V12 stated the facility has not done any formal wound care competencies for V12. V12 stated R5 was not on Transmission Based Precautions or EBP and V12 did not wear a gown during R5's wound treatments. V12 described the steps of R5's wound care as perform hand washing, remove outer leg wraps, apply gloves and remove wound dressings, change gloves, cleanse wounds with wound cleanser, change gloves apply clean dressings and wrap with gauze. V12 stated hand hygiene is done during the treatment only if hands are visibly soiled, otherwise just done before/after the treatment. V12 stated R5's orders were entered for three times weekly, V12 is not in the facility daily, and nursing staff should have clarified the order. On 2/19/26 at 3:09 PM V6 stated V12 was doing R5's wound treatments but then we changed that because the treatments should be done by a nurse and the nurses are responsible for assessing wounds during each treatment. V6 confirmed R5 did not have documented wound assessments after 12/12/25 until 1/2/26, besides 12/30/25 when R5 refused and no follow up attempts were documented. On 2/23/26 at 2:51 PM V2 DON stated V2 received a call from V15 Wound Clinic Nurse Practitioner reporting R5's wound dressings had not been changed. V2 confirmed there was no documentation that the treatments were administered. V2 stated ideally the treatment orders should have been on the TAR and the nurses should have taken over R5's wound care once V12 stopped. V2 stated the wound team is responsible for assessing wounds weekly. On 2/24/26 at 4:10 PM V2 stated during wound care gloves should be changed when moving from dirty to clean and hand hygiene performed with each glove change, including after removing dressings and after cleaning wounds. V2 stated an alcohol-based hand sanitizer can be used when hands are not visibly soiled. On 2/25/26 at 10:20 AM V2 stated EBP is implemented for open wounds. V2 confirmed a gown should be worn during wound care as part of EBP. B ) R6's MDS dated [DATE] documents R6 has severe cognitive impairment.R6's incident report dated 1/22/26 at 1:23 PM documents R6 had skin tears found to left lower leg and shin. R6 stated she hit her leg on the bed. R6 was sitting in her wheelchair and is able to self-propel. R6's incident report dated 1/27/26 at 7:42 PM documents R6 had skin tear to left knee. R6 stated R6 bumped her knee. R6 was sitting in a wheelchair and is able to self-propel around her room. There is no documentation in R6's medical record that interventions were developed/implemented to protect skin from additional skin tears following these incidents.On 2/25/26 at 10:20 AM V2 DON confirmed there were no documented skin interventions developed and implemented after R6's skin tears.

Based on observation, interview and record review the facility failed to accurately account for and destroy controlled medications for three of four residents (R7, R9, R15) reviewed for controlled medications in the sample list of 15. Findings include: The facility's Controlled Substance Destruction Policy dated December 2024 documents: Controlled substances should be destroyed with a licensed nurse and licensed professional. The destruction, quantity destroyed, and date should be documented on the controlled medication count sheet and signed by the nurse and the witnessing licensed professional.The facility's Controlled Substance Policy dated December 2024 documents the nurse will sign the controlled medication out on the Controlled Substance Proof of Use Form immediately and document the medication on the Medication Administration Record (MAR) immediately after administration.1.) R9's Controlled Substance Record for Diazepam 2 milligrams (mg) documents single doses were dispensed on 1/25/26, 1/30/26, 2/2/26 and 2/8/26 between 10:30 PM and 12:30 AM, signed by V31 Licensed Practical Nurse (LPN). These entries are not recorded on R9's January and February 2026 MARs as there is no active order entered after 1/22/26. R9's Census documents R9 discharged from the facility on 2/14/26.On 2/18/26 at 10:16 AM the controlled medications in the medication cart on the Lotus Hall were checked with V10 LPN. R9's Diazepam cards contained six remaining tablets and a full card of 14 tablets. V10 stated R9 discharged to assisted living and these medications should be destroyed with the Director of Nursing (DON) or Assistant DON (ADON), but they haven't gotten to it yet. On 2/23/26 at 2:51 PM V2 DON stated when controlled medications are discontinued or the resident expires the nurse should bring the card to the ADON or DON as soon as possible to be destroyed. On 2/25/26 at 10:20 AM V2 stated R9 had an active order for Diazepam that the pharmacy sent a script for on 1/30/26, the order just wasn't placed into R9's electronic medical record and MAR. V2 confirmed the controlled medication entries on the count sheet should match the MAR. On 2/25/26 at 10:39 AM V31 stated R9 always called for Diazepam after 9:00 PM and V31 must have given the medication out of habit without checking to verify it was on the MAR. V31 stated that is my mistake, I should have checked the MAR. 2.) R7's Controlled Substance Record for Lorazepam 0.5 mg documents on 2/9/26 the remaining 13 tablets were destroyed by V10 LPN. R7's Controlled Substance Record for Norco 5/325 mg documents on 2/9/26 the remaining 9 tablets were destroyed by V10. The Narcotics Destruction Form dated 2/9/26 documents V10 destroyed R7's Lorazepam and Norco tablets and R15's Norco 5/325 mg 60 tablets, 15.5 milliliters (ml) of Morphine Sulfate 100 mg/5 milliliters (ml), 20 ml of Lorazepam concentrate 2 mg/ml, and 10 Fentanyl 25 microgram/hour patches. These forms are not signed by a second person who witnessed the destruction of these medications.On 2/23/26 at 2:51 PM V2 DON stated controlled medications are destroyed with a floor nurse and either the DON or ADON, with two signatures documented on the destruction form. On 2/25/26 at 9:20 AM V10 reviewed the controlled medication forms dated 2/9/26 and confirmed V10 is the only signature listed for the destruction of R7's and R15's listed medications. V10 stated V10 destroyed the medications with V3 ADON but V3 must have forgot to sign the form. On 2/25/26 at 9:48 AM V3 stated V3 destroyed the controlled medications on 2/9/26 with V10, but V3 forgot to sign the destruction forms.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failure affects 4 of 6 residents (R1, R11, R12, R13) reviewed for infection control practices. 1.) The Centers for Disease Control and Prevention (CDC) Transmission Based Precautions dated 4/3/24 documents for contact precautions wear gown and gloves for all interactions that may involve contact with the patient or patient's environment, apply Personal Protective Equipment (PPE) upon room entry, and discard PPE before exiting the room.The facility's undated Respiratory Syncytial Virus (RSV) policy documents: RSV is transmitted through droplets when the infected person coughs or sneezes and droplets can enter the eyes, nose or mouth. RSV can be transmitted with direct contact with the virus or through contact with an infected surface as RSV can survive for hours on hard surfaces. R12's Physician's Order dated 2/13/26 documents Maintain Droplet Isolation for Coronavirus & RSV. These orders do not include Contact Precautions.R13's Physician's Order dated 2/17/26 documents Droplet Precautions for active RSV.On 2/18/26 at 10:27 AM R12's and R13's room doors had droplet isolation signs posted indicating to apply a mask and cover eyes, and the room doors contained PPE containers. R13's PPE container did not contain gowns. There were no contact isolation signage posted for R12's or R13's rooms. On 2/18/26 at 12:15 PM R12 stated R12 admitted from the hospital with a respiratory infection and has a cough. R12 stated staff only wear masks when in R12's room. On 2/18/26 at 12:20 PM V21 Certified Nursing Assistant (CNA) was in R13's room, not wearing a gown while assisting R13 into the bathroom. At 12:25 PM V22 CNA applied PPE to enter R13's room and V21 told V22 that V22 did not need to wear a gown since R13 was not on contact precautions, only droplet precautions. V22 stated both R12 and R13 are on droplet precautions for RSV. At 12:40 PM V21 stated R12 and R13 are on droplet precautions, and only mask and gloves are required in their rooms. On 2/19/2026 at 9:00am R12's door contained Droplet Precaution signage and there were two masks hanging on the sign obstructing the full view of the isolation sign. The PPE container on the door contained gloves, gowns, and masks. On 2/19/2026 at 9:01am R13 was in his recliner with mask on and coughing. Two masks were hanging on R13's door obstructing the view of the Droplet Precautions sign. Gloves, masks and gowns were in the PPE container on the door. On 2/19/2026 at 10:25 AM V4 Occupational Therapist (OT) assisted R13 with walking in R13's room and a mask was the only PPE V4 was wearing. On 2/24/26 at 12:40 PM The sign on R13's door indicated contact and droplet precautions and to wear gown, gloves, mask, and eye protection. V43 CNA delivered R13's meal tray into R13's room while wearing only a mask. V43 touched R13's overbed table and was within close proximity to R13. V43 collected a used disposable cup from R13's overbed table and V43 was not wearing gloves. V43 left R13's room carrying the cup into the hallway and V43 had not discarded her mask upon leaving R13's room. V43 confirmed V43 did not wear gown, gloves, and eye protection in R13's room while coming into contact with R13's overbed table and touching the used disposable cup. V43 confirmed V43 did not discard her mask upon leaving R13's room. V43 stated R13 has RSV but V43 did not think gown, gloves and eye protection were required to deliver R13's meal tray. On 2/19/2026 at 10:32 AM V4 OT stated R13 was on droplet precautions, and it is required in this facility to wear a gown, gloves, and a mask when providing care to a resident that is on droplet precautions. V4 stated V4 did not wear a gown and V4 had removed V4's gloves without applying new gloves while continuing to provide R13's care. On 2/19/2026 at 2:55 PM V1 stated the facility would follow CDC guidelines regarding droplet precautions. On 2/19/2026 at 3:30 PM V5 Licensed Practical Nurse (LPN) stated it is required in this facility to wear eye protection when entering a resident's room to provide care to a resident who is on Droplet Precautions. R5 confirmed there was no eye protection available for staff to use for R12's and R13's rooms. On 2/24/26 at 4:10 PM V2 Director of Nursing (DON) stated Droplet Precautions and Contact Precautions should be followed for RSV, including wearing gowns, gloves, masks and eye protection when entering the room and all PPE discarded when leaving the room.2.) The CDC's Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 7/12/22 documents: Enhanced Barrier Precautions (EBP) expands the use of PPE and refers to gown and glove use during high-contact resident care activities that provide opportunities to transfer Multidrug Resistant Organisms (MDROs) to staff's hands and clothing and indirectly transferred from resident to resident during these care activities. residents with wounds and indwelling medical devices are high risk for acquiring and colonization of MDROs. Wound care is an example of a high-contact resident care activity when gown and gloves should be worn. R1's Skin/Wound Note dated 12/24/2025 at 5:09 PM documents new wound to left ankle, facility acquired unstageable pressure ulcer presenting as deep tissue injury. This wound measured 0.64 centimeters (cm) by 0.5 cm by 0 cm (length x width x depth) that was 100 % covered with eschar (dead tissue). R1's Skin/Wound Note dated 1/12/26 at 11:05 AM documents R1's left ankle unstageable pressure ulcer measured 1.02 cm by 1.22 cm by 0 cm, 100 % covered with slough (dead cells/fibrin). New wound to left heel, unstageable pressure ulcer measured 1.33 cm by 1.71 cm by 0 cm, 50% covered with eschar. R1's Skin/Wound Note dated 1/19/26 at 1:18 PM documents left heel wound measured 3.42 cm by 2.28 cm by 0 cm, with 50% covered with eschar. R1's left ankle stage four pressure ulcer measured 2.08 cm by 1.56 cm by 0.2 cm, and 90 % slough covered. R1's Progress Note dated 1/19/26, recorded by V27 Wound Nurse Practitioner, documents R1's left ankle wound was reclassified as a stage four pressure ulcer and was debrided (dead tissue removed).There is no documentation in R1's medical record that R1 was placed on EBP following the development of these wounds. On 2/23/26 at 11:17 AM V6 LPN/Wound Nurse confirmed R1's left ankle and heel wounds and dates acquired. V6 stated EBP is documented in physician's orders. On 2/24/26 at 12:55 PM V44 CNA stated V44 worked the day R1 was last sent to the hospital (1/20/26), R1 had wounds to his heel and ankle, and R1 was not on any precautions and gowns weren't worn for R1's cares. On 2/25/26 at 10:20 AM V2 DON stated EBP is implemented for open wounds. V2 confirmed R1 did not have an order for EBP. 3.) The facility's Hand Hygiene policy dated 2019 documents hand hygiene is the primary means of preventing the transmission of infection and staff must perform hand hygiene even when gloves are used. This policy documents the use of an alcohol-based hand sanitizer is acceptable hand hygiene except when hands are visibly soiled. R11's Minimum Data Set, dated [DATE] documents R11 is cognitively intact. R11's Physician Order dated 1/16/26 documents EBP for wounds and Peripherally Inserted Central Catheter (PICC) line. R11's Skin/Wound Note dated 2/16/2026 at 3:52 PM documents R11 admitted on [DATE] with a stage four pressure ulcer of right gluteal fold that measured 1 cm by 0.54 cm by 3.6 cm. On 2/18/26 at 1:10 PM there was an EBP sign on R11's door indicating to wear gown and gloves for high contact care activities, including wound care. R11 had an indwelling urinary catheter that was hanging on the side of R11's bed. R11's antibiotic was infusing intravenously through a PICC line to right arm. R11 stated he has been at facility for five and half weeks, R11 admitted with an open wound on his bottom, and R11 receives intravenous antibiotics. R11 stated staff do not wear gowns when providing R11's cares. On 2/18/26 at 2:35 PM V17 and V18 LPNs entered R11's room and applied gloves but no gown. V17 cleansed R11's right gluteal fold wound, applied a sodium chloride wound dressing, applied absorbent antibacterial dressing, applied a zinc oxide paste to surrounding edges of wound, and covered with a bordered foam dressing. V17 did not wear a gown for R11's wound care and did not perform hand hygiene after cleansing R11's wound prior to applying the clean dressing. On 2/19/26 at 3:31 PM V17 confirmed V17 and V18 LPN did not wear gowns during R11's wound care. V17 stated V17 changed gloves during R11's wound care but did not perform hand hygiene because V17 thought that was only needed when hands are visibly soiled, and not necessary with each glove change. On 2/24/26 at 4:10 PM V2 DON stated during wound care gloves should be changed when moving from dirty to clean and hand hygiene with each glove change, including after removing the dressing and after cleaning the wound because hands would be considered dirty, prior to applying clean dressing. V2 stated alcohol-based hand sanitizer can be used when hands are not visibly soiled otherwise handwashing is needed.

Based on interview and record review the facility failed to develop and implement pressure relieving interventions for one of five residents (R1) reviewed for wounds in the sample list of 15. Findings include:The facility's Skin Identification, Evaluation, and Monitoring Policy dated February 2026 documents: Initiate preventative and/or treatment interventions as indicated and update the care plan with each intervention. Select surface based on the resident's assessment and all residents at risk for pressure ulcers are placed on a pressure-reducing surface/mattress and refers to a mattress selection algorithm. This algorithm instructs to use flip foam pressure relieving mattress for stage one and two, alternating pressure air mattress for stage three or four pressure ulcers. Schedule frequent repositioning for bed/chair bound residents. Implement interventions that increase the potential for healing and preventative measures to reduce the risk of further tissue loss. R1's Minimum Data Set, dated [DATE] documents: R1 has severe cognitive impairment, impaired range of motion of one arm and leg, requires substantial/maximal staff assistance for transfers and partial assistance for rolling in bed. R1 has two facility acquired unstageable pressure ulcers. R1's Care Plan dated as revised 1/22/26 documents R1 has impaired skin integrity related to recent surgery, impaired mobility, incontinence and Diabetes Mellitus. R1 has a stage four pressure ulcer of the left ankle and unstageable pressure ulcer of left heel. Interventions include pressure reduction boots when in bed (12/24/25) and pressure reducing mattress (10/10/25). This care plan does not include turning/repositioning needs and/or frequency. This care plan documents R1's diagnoses include Dementia, Adult T Cell Lymphoma/Leukemia not in remission, Antineoplastic Chemotherapy Induced Pancytopenia, and Type 2 Diabetes Mellitus. R1's Braden assessment dated [DATE] documents R1 as high risk for developing pressure ulcers. R1's Skin/Wound Note dated 12/24/2025 at 5:09 PM documents: New wound to left ankle, facility acquired unstageable pressure ulcer presenting as deep tissue injury. Wound measured 0.64 centimeters (cm) by 0.5 cm by 0 cm (length x width x depth) that was 100 % covered with eschar (dead tissue). R1's Skin/Wound Note dated 1/12/26 at 11:05 AM documents R1's left ankle unstageable pressure ulcer measured 1.02 cm by 1.22 cm by 0 cm, 100 % covered with slough (dead cells/fibrin). New wound to left heel, unstageable pressure ulcer measured 1.33 cm by 1.71 cm by 0 cm, 50% covered with eschar. R1's Skin/Wound Note dated 1/19/26 at 1:18 PM documents left heel wound measured 3.42 cm by 2.28 cm by 0 cm, with 50% covered with eschar. R1's left ankle stage four pressure ulcer measured 2.08 cm by 1.56 cm by 0.2 cm, 90 % slough covered. R1's Skin/Wound Note dated 1/20/2026 at 9:00 AM documents new sacral unstageable/deep tissue injury, new rear left trochanter (hip) unstageable/deep tissue injury, and new right shin unstageable/deep tissue injury all facility acquired wounds. R1's Progress Note dated 1/5/26 recorded by V27 Wound Nurse Practitioner documents: Left ankle wound differential diagnosis includes pressure injury versus diabetic foot ulcer versus arterial ulcer given the wound's dry, punched-out appearance and diabetes. V6 Wound Nurse reports footwear friction may have contributed to wound development. Per V23 (R1's Family) R1 had prior left ankle surgery with retained hardware/screws. Continue pressure relieving interventions per facility protocol including pressure reducing mattress and routine repositioning. Use offloading boots as tolerated. R1's Progress Note dated 1/19/26, recorded by V27, documents R1's left ankle wound was reclassified as a stage four pressure ulcer and was debrided (dead tissue removed) and notes R1's left heel pressure ulcer as unstageable. R1's January 2026 Treatment Administration Record (TAR) documents the order for pressure relieving boots was discontinued when R1 transferred to the emergency room and was not resumed upon return. R1's Registered Dietitian Note dated 1/14/2026 at 9:26 PM documents R1's weight was 140 pounds on 1/9/26 and has lost 32 pounds over the past month and has been refusing nutritional supplements. Suspect weight loss is secondary to Leukemia and overall decline. On 2/18/26 at 12:30 PM V10 Licensed Practical Nurse (LPN) stated V10 transferred R1 to the hospital (on 1/20/26) and R1 passed away while at the hospital. V10 stated R1 had deep tissue injuries to sacrum, shin and greater trochanter that weren't there the day prior and R1 wasn't eating or drinking. V10 stated R1 did not have an air mattress and was using a standard pressure relieving mattress. V10 stated R1 had dementia and used pressure relieving boots but would kick them off and remove them and was noncompliant with floating heels. V10 stated R1 required two staff assist for transfers and repositioning. On 2/19/26 at 11:43 AM V16 Certified Nursing Assistant (CNA) stated V16 looks at the CNA charting and care plan for pressure relieving interventions. On 2/23/26 at 11:17 AM V6 LPN/Wound Nurse stated pressure relieving interventions are documented on the care plan and use of pressure relieving boots are documented on the TAR. V6 confirmed R1's care plan does not include the need for repositioning/turning or the frequency or pressure relieving interventions for feet prior to 12/24/25. V6 stated the standard of care is to float heels and reposition at least every two hours. V6 stated R1's left ankle pressure ulcer was facility acquired and identified on 12/24/25 and pressure relieving boots were initiated that day. V6 stated V6 rounded with V27 on 1/19/26 and R1 did not have any new wounds at that time. V6 stated the next day V6 was notified to come and assess R1 who had three more deep tissue injuries related to pressure. V6 stated R1 was overall declining and was less active. On 2/25/26 at 11:32 AM V6 stated R1's facility acquired left ankle pressure ulcer was identified during wound rounds on 1/12/26, was unstageable and covered with eschar. The type of pressure relieving mattress depends on the location of the wound and air mattresses are used for stage three or four but leaves that up to the provider to decide. V6 stated we try to float heels or use pressure relieving boots prior to changing to an air mattress/alternating pressure mattress. V6 stated V6 did not discuss the use of this type of mattress with a provider since pressure relieving boots were in place. V6 stated V6 did not realize that the facility's standard pressure relieving mattresses are only recommended for up to stage two pressure ulcers. On 2/25/26 at 9:10 AM V2 Director of Nursing confirmed R1's pressure relieving boots were not resumed on R1's TAR after 1/8/26 and should have been. The undated manufacturer's information for the facility's flip foam pressure relieving mattress, provided by V1 Administrator, documents this mattress may be appropriate for up to stage two pressure wounds but should be based on a resident specific assessment.

Based on interview and record review the facility failed to prevent falls by failing to identify trip hazards and implement fall interventions and failed to thoroughly investigate falls for two of three residents (R4, R14) reviewed for falls in the sample list of 15.Findings include:The facility's Skilled Fall Policy dated May 2025 documents: Residents will be provided care and services to ensure their environment is as free from accident hazards as possible. An occurrence report will be completed after each fall to determine root cause and interventions will be implemented.1.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment and requires partial/moderate staff assistance for transfers and toileting.R4's active care plan documents R4 is at risk for falls related to muscle weakness, dementia, impaired hearing and vision, impaired balance, and history of falls. Interventions include call don't fall sign (12/14/23), assist to bathroom as needed (2/10/25), call don't fall sign in bathroom (1/25/24), nonskid grip strips in front of bathroom door (8/21/25), nonskid grip strips in front of recliner (12/10/24), nonskid grip strips on bathroom floor (12/14/23), and nonskid grip strips replaced in front of toilet due to being worn out (1/10/26).R4's Fall Report dated 1/10/26 at 10:55 AM documents R4 was yelling for help and staff found R4 lying on right side in front of the toilet. R4's pants were down to midthigh and R4 was incontinent of bowel movement. R4 reported R4 was trying to go to the bathroom. R4 had a hematoma (swelling) to her forehead. V40 MDS Coordinator noted the grip strips in front of R4's toilet were worn down and V40 replaced the strips. This investigation does not identify when R4 was last toileted prior to this fall.R4's Fall Report dated 1/19/26 at 12:15 AM documents R4 was found on the floor of R4's room and reported pain to right wrist and right forearm from prior fall and left hip pain. V46 Certified Nursing Assistant (CNA) statement documents V46 heard R4 yelling for help and found R4 on the floor in front of her bathroom. The interdisciplinary team note documents R4 attempted to get up unassisted and fell, R4 was more confused due to recent room change. There is no documentation that R4's new room had call don't fall signs and grip strips in place at the time of R4's fall.On 2/24/26 at 11:43 AM V47 (R4's Family) stated V47 visited on 1/14/26 and R4's arm was swollen and face was bruised due to a fall. V47 stated R4 had another fall after a room change, R4's call don't fall signs and nonskid strips were not moved with R4 that day. V47 stated R4 self-transfers to get to the bathroom if staff don't offer to take R4.On 2/24/26 at 10:39 AM in regard to R4's 1/10/26 fall, V40 stated: V40 had walked by R4's room and found R4 lying on the floor, R4 had attempted to self-transfer to the bathroom. R4 had a goose egg hematoma to her forehead. V40 noticed the grip strips on the floor were worn down and V40 questions if that was the cause of R40's fall.On 2/24/26 at 11:02 AM in regard to R4's fall on 1/19/26, V42 Registered Nurse stated R4 normally is good about using her call light but that night R4 was in a new room and did not call. V42 stated R4 wasn't herself and was more confused that night. V42 stated R4 was in the recliner prior to the fall and attempted to self-transfer, there were no grip strips on the floor or call don't fall signs on R4's wall.On 2/24/26 at 4:10 PM V2 Director of Nursing (DON) stated V2 took over fall investigations in January. V2 confirmed all fall investigation documentation was provided for R4's falls. V2 stated the grip strips were found to be worn as the root cause of R4's 1/10/26 fall. V2 stated ideally the nursing staff should be checking the grip strips each time they are providing cares. V2 confirmed the 1/10/26 fall investigation does not document the last time R4 was toileted. V2 stated grip strips and call don't fall signs were current interventions and should have been moved with R4 to her new room. V2 stated the nursing staff are responsible for moving the grip strips and call don't fall signs during room changes. V2 confirmed the fall investigation does not document if these interventions were in place when R4 fell on 1/19/26. 2.) R14's MDS dated [DATE] documents R14 has severe cognitive impairment and requires partial/moderate staff assistance for chair/bed/toilet transfers.R14's Fall Report dated 12/19/25 at 8:58 AM documents R14 was found sitting on his buttocks on the floor beside R14's bed. This fall investigation contains staff interview statements but does not identify the last time R14 was toileted prior to this fall. The interdisciplinary note dated 12/24/25 documents R14 attempted to self-transfer from wheelchair to bed and fell onto the floor, and R14 was incontinent at the time of the fall. R14 was unable to say what happened. New intervention was nonskid grip strips next to bed. R14's Fall Report dated 2/3/26 at 4:57 AM documents V36 Licensed Practical Nurse (LPN) responded to R14 yelling for help. R14 was lying on the floor on his left side with wheelchair foot pedal underneath R14, and wheelchair was tipped up behind R14. R14 had a skin tear to left chest. This fall investigation contains staff interviews but does not identify if R14 had a nonskid mat in R14's wheelchair. The interdisciplinary note documents R14 was in the hallway and attempted to move his wheelchair forward, R14 fell out of the wheelchair and landed on the floor. R14's care plan was updated to replace the nonskid mat in the wheelchair. R14's Nursing Note dated 2/19/2026 at 2:25 PM documents nurse called to R14's room and R14 was sitting on the floor mat on the floor next to R14's bed. CNA (V38) was transferring R14 from wheelchair to bed, V38's foot got caught on floor mat, V38 was unable to regain balance and sat R14 on the floor. R14 bumped right elbow on wheelchair and received a crescent shaped skin tear. On 2/24/26 at 10:18 AM V41 CNA stated V41 had just gotten R14 up a few minutes prior to the fall on 12/19/25 and V41 could not recall if a nonskid mat was in R14's wheelchair when R14 fell. On 2/24/26 at 1:07 PM V38 CNA stated last week V38 transferred R14 with gait belt to bed. V38 stated V38 did not pick up the floor mat, V38's foot caught on the mat causing V38 to lose her balance and V38 lowered R14 to the floor. V38 stated R14 bumped his arm on the wheelchair causing a skin tear to right elbow. V38 stated V38 should have picked up the floor mat to prevent the fall. On 2/24/26 at 4:10 PM V2 DON confirmed all documentation was provided for R14's fall investigations. V2 stated R14 fell on 2/3/26 and the nonskid mat was replaced, V2 could not recall if it was because the nonskid mat wasn't in place or if it was because it was worn. V2 confirmed this information is not documented in R14's fall investigation. V2 stated this past Thursday R14 fell during staff assisted transfer and post fall intervention was to pick up the fall mat when R14 is out of bed.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from verbal abuse by a visitor. This failure affects one (R3) of four residents reviewed for abuse in the sample list of four. Findings include: The facility's Abuse, Prevention and Prohibition Policy dated November 2025 documents that each resident has the right to be free form abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. This policy documents that when individuals other than employees are the alleged perpetrators, those individuals, such as visitors or family members, will be immediately removed from contact with the resident. The facility will ensure that no further contact with the resident in question or any other residents is possible until the investigation is completed. If necessary, law enforcement will be contacted to assist in the removal of the perpetrator/s and protection of the residents. The notification of law enforcement should be done timely and can be implemented by the charge nurse or other employee as needed. R3's (Minimum Data Set (MDS)) dated 12/9/25 documents R3 has severe cognitive impairment.R3's Care Plan dated 6/27/25 documents R3 requires assistance from staff for (Activities of Daily Living (ADLs)) specifically R3 has a self-care performance deficit due to dementia, cognitive deficits, and impaired mobility. R3's Care Plan dated 7/16/24 documents R3 has a communication problem related to social and emotional deficit. An investigation report dated 11/11/25 documents that on this day at approximately 5:06 PM, V7 (Licensed Practical Nurse (LPN)) reported to the former administrator an allegation of a verbal altercation from a visitor towards R3. This report documents that V19 (Certified Nurse Assistant (CNA)) was also a witness to this alleged incident.A progress note in R3's (Electronic Medical Record (EMR)) dated 12/12/25 at 12:13 AM documents the following: A family member of another resident observed coming down hall out to rotunda, bending down in front of resident and stating, Are you that much of a child that you have to act like this to get attention? I think you are an idiot.On 12/23/25 at 2:22 PM, V7(LPN) confirmed V7 was a witness to the incident that occurred at the facility on 11/11/25. V7 (LPN) stated she was coming down west hall headed to the dining room when she heard screaming in the rotunda and as V7 (LPN) approached that area she observed R3 sitting in his wheelchair and a visitor was in R3's face loudly screaming, why are you acting like a child, you are an idiot. On 12/23/25 at 3:35 PM, V19 (Certified Nurse Assistant (CNA)) stated R3 was sitting in the Rotunda on the afternoon of 11/11/25 when V19 overheard a visitor yelling at R3. V19 (CNA) stated the visitor was in R3's face yelling shut the F*** up, you are a Dumb A**. V19 (CNA) stated R3 looked at the visitor weird and acted like he was not sure of what was going on. On 12/23/25 at 2:50 PM, V2 (Director of Nursing) confirmed the verbal altercation involving a visitor and R3 did occur. V2 (DON) stated that an investigation was conducted, and the incident was reported to the state agency. V2 further confirmed that R3 sustained verbal abuse from the visitor.On 12/23/25 at 3:26 PM, V20 (Regional Nurse Consultant (RNC)) confirmed that the alleged event did occur on 11/11/25 and that R3 was the victim of verbal abuse. V20 (RNC) stated the Intradisciplinary Team met and put a plan into motion to prevent further verbal abuse towards R3 and other residents.

Failures at this level required more than one deficient practice statementA. Based upon record review and interview, the facility failed to follow infection control policy and procedure during communicable disease outbreak. This failure had the potential to affect all 94 residents residing at facility.B. Based upon observation, interview and record review the facility failed to place a resident in contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) for one (R66) resident and operationalize its policy to wear proper PPE (personal protective equipment) during medication administration for one (R34) resident reviewed on contact isolation with Methicillin-Resistant Staphylococcus Aureus (MRSA) on a sample list of 41.Findings include:a. Facility Census titled Resident Census and dated 9/14/25 documents 94 residents currently in house. Infection Surveillance Monthly Report dated June 2025 documents 10 residents with respiratory infections, 5 residents with Pneumonia, 5 residents with Covid 19, and 1 resident with bronchitis. All 21 residents had similar symptoms and were placed on droplet isolation precautions. On 9/16/25 at 11:15 AM V12, Assistant Director Of Nursing(ADON)/Infection Preventionist(IP) stated she did not notify local health department regarding upper respiratory infection outbreak within the facility and no emergency quality meeting was held to identify source, trend, or plan of action. On 9/16/25 at 11:35 AM V1 Administrator stated during outbreak, the expectation would be to follow written policy guidelines. At 1:45 PM on 9/16/25, V3 Regional Nurse, stated no formal Prevention Identification Plan had been conducted regarding the respiratory outbreak. Facility's Infection Prevention and Control Program dated 2019 documents the IP is to conduct surveillance and monitoring of all organisms causing infections, antibiotic-resistant organisms, and transmission of organisms between residents and report these finding to local public health department. b. 1. R66's Minimum Data Set (MDS) dated [DATE] documents R66 as cognitively intact. This same MDS documents R66 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R66's Care plan intervention dated 7/18/2025 documents R66 is on antibiotic therapy due to wound infection. R66's CarePlan did not include a focus area, goal nor intervention for R66 requiring isolation precautions. On 9/14/25 at 10:45 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies easily accessible. On 9/15/25 at 2:15 PM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies easily accessible. On 9/15/25 at 9:30 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. There was no Personal Protective Equipment (PPE) supplies easily accessible. On 9/17/25 at 9:00 AM R66 was sitting in his wheelchair in his room. R66's door did not designate R66 was on any isolation precautions. R66 had PPE available from a container attached to his room door. On 9/15/25 at 1:20 PM V12 Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated R66 does not require any type of isolation precautions for his open, infected Left Lateral Foot Diabetic Foot Ulcer due to the size of his wound was smaller than a band-aid. On 9/16/25 at 1:00 PM V14 Licensed Practical Nurse (LPN) stated R66 has a Diabetic wound ulcer on his Left Foot. V14 stated the facility obtained a culture of R66's wound last week and R66 was started on an antibiotic. On 9/16/25 at 2:30 PM V10 Licensed Practical Nurse (LPN) stated she completed R66's Left Lateral Foot Diabetic Foot Ulcer treatment without wearing the proper Personal Protective Equipment (PPE). V10 LPN stated R66 did not have any isolation precaution signs on his room door so she was unaware R66 was on isolation precautions. On 9/17/25 at 11:05 AM V25 (R66) Power of Attorney (POA) stated V25 visits with R66 daily from before breakfast to after lunch. V25 stated the staff 'just started' wearing PPE today (9/17/25). V25 stated she was informed last week of R66's wound infection in his Left Lateral Foot. V25 stated the staff have been changing R66's dressings to his Left Foot without 'all that' (PPE). The undated facility policy titled Infection Prevention and Control Manual-Enhanced Barrier Precautions documents Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a Multi Drug Resistant Organism (MDRO) as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and may residents colonized with a MDRO are asymptomatic or not presently known to be colonized. 2. R34's Physician Order Sheet (POS) dated September 2025 documents a physician order starting 9/9/25 for R34 to be placed on Contact Isolation due to Methicillin Resistant Staphylococcus Aureus (MRSA) in her wound and Extended-spectrum Beta Lactamase (ESBL) in her urine. On 9/15/25 at 12:28 PM R34's room door posted a sign that read 'Contact Precautions'. R34's room door had a Personal Protective Equipment (PPE) storage container hanging over R34's door so that staff could access PPE from the outside of R34's room. V8 Licensed Practical Nurse (LPN) administered medication to R34 without wearing gown and/or gloves. On 9/16/25 at 1:50 PM V12 Assistant Director of Nurses (ADON)/Infection Preventionist (IP) stated staff should wear the appropriate Personal Protective Equipment (PPE) when caring for a resident on Contact Isolation. The facility policy titled Infection Prevention and Control Manual Transmission-Based Precautions Contact Precautions dated 2019 documents in addition to Standard Precautions, use Contact Precautions to prevent nosocomial spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or be indirect contact (touching) with environmental surfaces or contaminated resident care equipment. In addition to wearing gloves as outlined under Standard Precautions, clean, nonsterile gloves are worn when providing direct care to residents. [NAME] gown prior to entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the resident care environment.

Based on observation, interview and record review the facility failed to maintain essential equipment to ensure a safe operating environment in a medication room. This failure has the potential to affect all 94 residents residing in the facility. Findings include:The facility daily census dated 9/14/25 documents 94 residents reside in the facility. 1.On 9/15/25 at 12:30 PM V8 Licensed Practical Nurse (LPN) disposed of R33's medication in the [NAME] hall nurses medication room. V8 LPN applied soap to her hands then turned the handles on the facility sink to turn on the water. No water flowed from either the hot or cold water sides. V8 LPN stated the nurses medication room should have a working sink for her to wash her hands when needed. V8 stated she works on another hall also and doesn't have time to 'run from hall to hall to find a working sink'. On 9/15/25 at 12:45 PM V6 Maintenance Director attempted to turn on the hot and cold sides of the water in the [NAME] hall nurses medication room. There was no water that flowed from either side. V6 Maintenance Director opened up the cabinets underneath the sink and attempted to fix the issue. On 9/15/25 at 12:55 PM V6 Maintenance Director stated the pipes leak underneath the sink as he was attempting to fix the sink. V6 Maintenance Director stated he was not aware of the sink not working on this hall and does not know who shut the water off. On 9/15/25 at 1:40 PM V1 Administrator stated each nurses station should have a functional sink with both hot and cold running water. V1 Administrator stated the [NAME] hall sink will be fixed as soon as possible. 2. On 9/15/25 at 12:35 PM The [NAME] hall nurses medication room showed electrical cords that stretched from the facility's (medication management machine) sitting in the corner, over the countertops, behind and touching the faucet and were plugged into a wall outlet on the opposite side of the sink. On 9/15/25 at 12:47 PM V6 Maintenance Director stated electrical cords should not be that close to a running water source. V6 Maintenance Director stated the sink does not currently work but if it did, this could be a very dangerous situation. V6 stated any staff member could turn the water back on from underneath the sink. On 9/15/25 at 1:42 PM V1 Administrator stated the facility should not have electrical cords near a water source. V1 Administrator stated 'electricity and water do not mix'. V1 Administrator stated this situation would be 'handled quickly'. V1 Administrator stated she is not aware of a facility policy for these issues but the expectation would be to have a functional sink in each nurses medication room and not have electrical cords laying against the faucet of a sink that are also plugged into the wall outlet.

Based on observation, interview and record review the facility failed to prevent cross contamination of one (R66) resident's infected Diabetic Foot Ulcers out of two residents reviewed for skin conditions in a sample list of 41 residents.Findings include:R66's Minimum Data Set (MDS) dated [DATE] documents R66 as cognitively intact. This same MDS documents R66 requires moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R66's Physician Order Sheet (POS) dated September 2025 documents a physician order to cleanse R66's Left Lateral Diabetic Foot Ulcer (DFU) with wound cleanser, apply Santyl (chemical debrider) 250 units/Gram to wound bed, cover with Calcium Alginate and dry dressing daily. This same POS documents a physician order to cleanse R66's Right Second Toe DFU with wound cleanser, apply calcium alginate and dry dressing daily. On 9/17/25 at 10:30 AM V20 Licensed Practical Nurse (LPN) completed wound care for R66's Left Lateral Foot Diabetic Foot Ulcer (DFU) Right Second Toe DFU. R66's Left Lateral Foot Diabetic ulcer showed a dime sized open reddened area with raised white periwound. R66's Left Lateral Foot and Right Second Toe open wounds appeared wet with drainage. R66's dressings were not in place prior to the dressing changes on R66's Left Lateral Foot and Right Second Toe. V20 LPN placed paper towels from R66's room onto R66's bedside table that had not been cleaned off. R66's chemical debriding ointment, Calcium Alginate and scissors were placed directly on the contaminated bedside table. V20 LPN used the same contaminated scissors to cut R66's Calcium Alginate to match the wound size. V20 LPN applied R66's chemical debriding ointment and Calcium Alginate directly on R66's open wounds. On 9/16/25 at 1:00 PM V14 Licensed Practical Nurse (LPN) stated the facility obtained a culture of R66's Left Lateral Foot DFU wound last week and R66 was started on an antibiotic for a wound infection. On 9/17/25 at 10:55 AM V20 Licensed Practical Nurse (LPN) confirmed the wound supplies were not placed on the clean field for R66's dressing changes. V20 LPN stated she did not disinfect R66's bedside table prior to placing R66's wound supplies on the bedside table. On 9/17/25 at 11:50 AM V23 Clinical Reimbursement Specialist stated she and V3 Regional Clinical Nurse (RCN) have looked for a policy on clean dressing changes and are unable to find one.

Based on observation and interview the facility failed to properly maintain and store respiratory equipment. This failure has the potential to affect one of one residents (R3) reviewed for respiratory care on the sample list of 41. Findings Include: The facility's Tracheostomy Care policy dated [DATE] documents a replacement tracheostomy tube must always be available at the bedside. The same policy documents a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must always be available at the bedside. The same policy documents an emergency tracheostomy set up should be kept at the resident's bedside. R3's Medical Diagnoses dated [DATE] documents R3 is diagnosed with Anoxic Brain Damage, Anxiety Disorder, Paraplegia, Dependence on Supplemental Oxygen, and Tracheostomy Status. R3's Physician Order Sheet dated [DATE] documents facility staff are to maintain suction set up, an emergency bag valve mask, and a replacement tracheostomy tube of equal size and one size down at R3's bedside at all times. R3's Care Plan dated [DATE] documents R3 has a Tracheostomy related to Impaired Breathing Mechanics due to an Anoxic Brain Energy. Interventions include an emergency bag valve mask, humidification, oxygen tubing, and suction machine at R3's bedside. Interventions should also include a replacement tracheostomy tube of equal size, and one size down, maintained at the bedside. On [DATE] at 1:15 PM there were no tracheostomy tubes at R3's bedside. The emergency bag valve mask was stored in a ripped belongs bag with a date of [DATE] and the lubricant and other supplies in the bad expired [DATE]. There was an irrigation tray with an expiration date of [DATE] and the container of sterile water, which was more than hallway gone, was not marked with the date it was opened. On [DATE] at 1:31 PM V1 Administrator and V3 Director of Clinical both confirmed extra tracheostomy tubes need to be kept at R3's bedside readily available, opened containers of multiuse liquids need to be marked with the date they were opened, and all supplies for emergencies and tracheostomy maintenance need to be checked for expiration and integrity on a regular basis.

Based on observation, interview and record review the facility failed to prevent cross contamination during urinary catheter care for one (R29) resident out of two residents reviewed for catheter care in a sample list of 41 residents. Findings include:R29's Minimum Data Set (MDS) dated [DATE] documents R29 as cognitively intact. This same MDS documents R29 as requiring maximum assistance from staff for personal hygiene and is dependent on staff for toileting and dressing. On 9/16/25 at 2:10 PM V18 and V19 Certified Nurse Aides (CNA) completed urinary catheter care for R29. V18 CNA prepared a basin of soapy water for use in providing catheter care. V18 CNA did not rinse R29's front or rear perineal areas after washing with soapy water. R29 was incontinent of bowel. V18 CNA did not change gloves or perform hand hygiene after cleansing R29's front and rear perineal areas and before applying a new incontinence brief. R29 was wearing a urinary catheter leg drainage bag which was pulled taunt during positioning of R29. V18 did not ensure R29's urinary catheter was held secure while providing perineal care. V18 did not wipe R29's urinary catheter off during catheter care. V18 CNA did not apply barrier cream after providing perineal/catheter care for R29. On 9/16/25 at 2:30 PM V18 Certified Nurse Aide (CNA) stated she should have changed her gloves after cleansing R29's perianal area and prior to applying a new incontinence brief. V18 CNA stated not rinsing the soap off could cause irritation to R29's skin. V18 CNA stated R29's urinary catheter became 'tight' when V18 asked R29 to move her leg. V18 stated she should have adjusted the tubing or secured it differently to ensure it wasn't pulled. On 9/16/25 at 3:00 PM V1 Administrator stated staff should follow the policy when providing all cares including Perineal care and urinary catheter care. V1 Administrator stated staff who cross contaminate could put the residents at a higher risk of infection.On 9/17/25 at 11:15 AM V23 Clinical Reimbursement Specialist stated the facility does not have a specific policy for Perineal care. V23 stated the expectation is for staff to follow standard precautions and standard of care. The facility policy titled Catheter Care, Urinary revised December 2024 documents staff should use Standard Precautions when handling or manipulating the drainage system. Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Staff should fill a wash basin with warm water and place the wash basin within easy reach. Use a washcloth with warm water and soap to cleanse the labia. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site outward.

Based on interview and record review the facility failed to ensure that residents were administered medications as prescribed per phyisican orders for (R1, R2, R3 & R4) of four residents reviewed for medication administration. This failure resulted in R1 being administered medications prescribed for another resident, to include a large dose of Morphine (Opiod Narcotic medication), resulting in R1 experiencing side effects for multiple days after and also requiring the administration of Narcan (Opiod Reversal Agent). Findings include: 1.) R1's Medication Error Report dated 2/25/25 documents that R1 was administered R2's 4:00PM medications, erroneously. R2's February 25, 2025 medication administration record documents the following scheduled medication tablets for 4:00PM administration: Amoxicillin/Clavulanate 875mg/125mg (antibiotic), Colace 100mg (stool softener), Naproxen 500mg (nonsteroidal anti-inflammatory), Primodone 50mg (anti-seizure), Senna 8.6 (laxative), Vitamin C 500mg (vitamin), and Morphine Extended Release 90mg (opioid). R1's progress notes document on 2/25/25 at 4:57PM R1 was administered R2's 4:00PM medications. R1's Medication Administration Record dated 2/25/25 at 5:00PM documents 2mg of Nalaxone given intramuscularly for opioid reversal. R1's progress notes dated 2/26/25 at 9:45AM document that R1 was having several episodes of vomiting. Resident was given 8mg of Zofran (antiemetic) and continued to have episodes of emesis. V13 Medical Doctor was notified and recommended sending R1 to the hospital for evaluation and treatment. Resident refused to go out to hospital. Resident states he wants left alone. R1's progress notes dated 2/26/2025 at 9:27PM document that R1 is being monitored for being given morphine and began dry heaving after receiving his medication. Zofran (antiemetic) was given and effective. R1 did not eat dinner and states that he feels hungover. R1's progress notes dated 2/27/2025 at 10:52 document that R1 has not presented with any vomiting episodes thus far this shift. R1 stated that he was still feeling as drowsy, did not each breakfast and is still slightly lethargic. R1's progress note dated 2/27/2025 at 21:05 documents that R1 arouses more easily, was able to speak more clearly but is still feeling tired. R1 did not eat dinner. Zofran given for nausea and vomiting and it was effective with urinary output better than yesterday, but not a lot better. R1's February Medication Administration Record dated 2/26/25 documents Zofran (antiemetic) given at 9:14AM and 6:01PM. R1's progress notes dated 2/28/2025 at 1:30AM document that Zofran was given for nausea (3/1/25). R1's progress notes dated 2/28/2025 at 12:53PM document that R1 states that he still doesn't feel well. Resident refused meals today. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact. On 4/3/25 at 10:15AM R1 stated that he took the pills that were given to him except for the Lactulose. When I told (V6) that (the lactulose) wasn't my medication, (V6 Agency Licensed Practical Nurse) asked me if I was (R2) and I told him that (R2) was my roommate. I wouldn't have told him that my name is (R2). I just remember that they gave me something after that and I felt awful for a few days afterward. I was nauseous and vomited and they wanted me to go to the hospital, but I just wanted to be left alone. On 4/3/25 at 9:17AM, V2 Director of Nursing (DON) stated that on 2/25/25 R1 received R2's 4:00PM medications including 90 milligrams of extended release morphine by an agency nurse who was working his first shift in the facility. V2 stated that the error was identified when R1 would not take the lactulose and said that it wasn't his medication; however he had already swallowed the pills. Upon identification of the error, V2 DON called V13 Medical Doctor and received instructions to reverse the Morphine with Narcan, which was done. R1 then began vomiting the next day, continuing for days. On 4/3/25 at 10:33AM, V6 Agency Licensed Practical Nurse stated that he entered R1's room and asked if R1 was R2's first name and R1 responded in the affirmative. After R1 refused the lactulose, V6 stated that he asked R1 again if he was R2 and R1 said, No, that's my roommate. V6 stated that he immediately went out and found the charge nurse, told her of the error and then contacted the doctor for a Narcan order (opioid reversal agent). When asked how V6 identified R1 he stated, I looked at their pictures, but they look a lot alike. So I asked R1 if he was R2 and he said yes. V6 then stated, In that building, the beds are opposite in their numbering compared to all of the other facility's that I work. Bed one is usually by the door and bed two is usually by the window. On 4/7/25 at 9:01AM, V13 Medical Doctor stated that he was notified immediately of the error and that it was treated with Narcan (an opioid reversal agent). V13 also stated that this error could have resulted in respiratory depression and severe harm to R1. The package insert for Morphine Sulfate, dated Revised, January 2012 documents: .---INDICATIONS AND USAGE-- Morphine sulfate is an opioid agonist indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. (1) --DOSAGE AND ADMINISTRATION-- Morphine Sulfate Tablets: 15 to 30 mg every 4 hours as needed. 5.1 Respiratory Depression Respiratory depression is the primary risk of morphine sulfate. Respiratory depression occurs more frequently in elderly or debilitated patients and in those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction, in whom even moderate therapeutic doses may significantly decrease pulmonary ventilation. Use morphine sulfate with extreme caution in patients with chronic obstructive pulmonary disease or cor pulmonale and in patients having a substantially decreased respiratory reserve (e.g., severe kyphoscoliosis), hypoxia, hypercapnia, or pre-existing respiratory depression. In such patients, even usual therapeutic doses of morphine sulfate may increase airway resistance and decrease respiratory drive to the point of apnea. Consider alternative non-opioid analgesics, and use morphine sulfate only under careful medical supervision at the lowest effective dose in such patients. 6 ADVERSE REACTIONS Serious adverse reactions associated with morphine sulfate use include: respiratory depression, apnea, and to a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest. The common adverse reactions seen on initiation of therapy with morphine sulfate are dose-dependent and are typical opioid-related side effects. The most frequent of these include constipation, nausea, and somnolence. Other commonly observed adverse reactions include: lightheadedness, dizziness, sedation, vomiting, and sweating. The frequency of these events depends upon several factors including clinical setting, the patient ' s level of opioid tolerance, and host factors specific to the individual. Anticipate and manage these events as part of opioid analgesia therapy. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022207s004lbl.pdf 2.) R3's Medication Error Report dated 3/26/25 documents that at approximately 12:00PM, R3 was given 250 milligrams (mg) of Trazodone (antidepressant), instead of the 150 mg that was ordered. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as cognitively intact. R3's progress notes dated 3/26/24 document that R3's Trazodone order was increased to 150mg, however the old order of 100mg was not discontinued resulting in R3 erroneously receiving 250mg instead of the ordered 150mg. On 4/3/25 at 3:00PM, R3 stated that she was told when the medication error occurred and other than sleeping really well, she felt no ill effects from the error. 3.) R4's Medication Error Report dated 3/26/25 at 5:00PM, documents that R4 was given 5 units of Novolog Insulin and 5 units of Aspart Insulin. The order was documented to give 5 units of Novolog Insulin with meals, only, but the order was documented incorrectly, resulting in the error. R4's Minimum Data Set, dated dated dated [DATE] documents that R4 is cognitively intact. On 4/3/25 at 3:05PM, R4 stated that she was told that she received the wrong amount of insulin the other day, but that her sugars had been running high, so she did not have any issues when it was given. On 4/7/25 at 2:55PM V15 Clinical Director stated that two resident identifiers should be used any time medication is being administered including date of birth and asking the full name. V15 stated, Further inservicing and education needs to be completed to insure the issue of the right patient and right order are followed for all residents by all staff.

Based on interview and record review the facility failed to provide a safe transfer of a resident (R1) when assisting the resident to transfer into bed. This failure resulted in R1 sustaining a right shoulder dislocation which required overnight hospitalization and a surgical intervention. R1 is one of four residents reviewed for accidents on the sample list of four. Findings Include: The facility Incident Report Investigation dated 10/9/24 documents on the morning of 10/9/24 R2 complained of pain in her right shoulder and was sent to the emergency room for evaluation. R2 stated she believed the injury occurred when a staff member (V4 Certified Nurses Assistant) CNA from the evening prior transferred her into bed. R2 was found to have a right shoulder dislocation that required surgical intervention. R2's Hospital Report dated 10/9/24 documents R2 presented to the emergency room with right shoulder pain and was found to have a right shoulder dislocation. R2 stated the pain began the night prior when staff moved her into the bed. R2's Medical Diagnoses list dated October 2024 documents R2 is diagnosed with Muscle Weakness, Unsteadiness on Feet, Repeated Falls, Reduced Mobility, and Dislocation of Right Shoulder Joint. R2's Minimum Data Set, dated dated dated [DATE] documents R2 has a mild cognitive impairment and requires substantial maximal assistance from staff for transfers. R2's Transfer Status dated 10/1/24 documents R2 requires two staff persons for transfers and toileting. On 10/24/24 at 3:28 PM R2 stated her right shoulder became dislocated a second time after V4 CNA transferred her into bed for the night. R1 stated V4 transferred her alone with no gait belt. R2 stated V4 must've pulled on her arm or moved it wrong. R2 stated her pain intensified over the next fifteen minutes and she was soon in extreme pain. R2 stated the pain continued into the morning. She was then transferred to the hospital and was diagnosed with a right shoulder dislocation which required surgical intervention. On 10/25/24 at 10:19 AM V4 CNA stated she took care of R2 on the evening of 10/8/24. V4 stated she helped transfer R2 to and from the toilet and then also from the wheelchair to her bed for the night. V4 stated at the time of both transfers R2 did not have a sling on her right arm. V4 stated she was unsure if R2 was supposed to be wearing the sling but V4 denied clarifying to be sure. V4 stated she assisted R2 with no other help from staff and she did not use a gait belt during either transfer. On 10/25/24 at 11:35 AM V6 Registered Nurse stated she took care of R2 during the day on 10/8/24 and on 10/9/24. V6 stated when she came on shift at 6:00 AM on 10/9/24, R2 was in extreme pain. At about 6:30 AM, V6 assessed R2's right shoulder and it appeared out of place. R2 was sent to the emergency room for evaluation. V6 stated when she was assessing R2's pain/shoulder, R2 stated her shoulder started hurting after she was transferred into bed the night before. V6 stated the day prior (10/8/24) R2's shoulder was not in any pain. On 10/25/24 at 11:40 AM V13 Registered Nurse stated shortly after she came on shift at 10:00 PM on 10/8/24 R2 stated the staff who put her to bed had pulled on her right arm and it started hurting after that. R2 rated her pain as a 8/10 and requested Tramadol for pain, which was administered. V13 stated when she followed up with R2 a bit later, she was asleep. V13 stated at about 5:00 AM on 10/9/24 R2 woke up and was in extreme pain, again rating it as a 8/10. V13 again administered Tramadol. On 10/25/24 at 10:25 AM V8 Physical Therapist stated initially R2 was admitted for therapy after a fall at home which resulted in some foot fractures and a dislocation of her right shoulder. R2 had a sling on when she was admitted which she was to wear at all times. R2 was not allowed to use her shoulder or lift her arm at all. She should not have been transferring without her sling on or using her arm to stabilize herself at all. V4 CNA should have checked with nursing if she was not sure if R2's sling needed to be on or not. V4 should have used a gait belt when transferring R2. According to V8's assessment a week prior on 10/1/24 R2 required two staff for transfers in order to prevent falls/injury. V8 stated if R2 was not wearing the sling, used her arm in any way or V4 CNA pulled on her arm, even if by accident- it would have caused the re-dislocation to occur. On 10/25/24 at 2:00 PM V1 Administrator confirmed facility staff should ensure resident safety by following the plan of care for safe transfers in order to avoid injury.

Based on observation, interview, and record review the facility failed to obtain a physician's ordered diagnostic test in a timely manner for one of two residents (R5) reviewed for Urinary Tract Infections on the sample list of 49. This failure extended R5's suffering for a total of six days with the following symptoms: painful and burning urination, abdominal pressure, and overall discomfort. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated dated dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 6/30/24 documents R5 complained of abdominal pain and burning and pain with urination. V17 Medical Director was notified and ordered a urinalysis and culture and sensitivity to be collected and sent to the lab. R5's Urinalysis Lab dated 7/3/24 documents R5's urine was not sent to the lab until 7/3/24. R5's Urine Culture and Sensitivity Lab finally resulted on 7/6/24. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 7/6/24 documents R5 stated she has had Urinary Tract Infection (UTI) symptoms and she has not gotten any treatment. R5 stated she has abdominal tenderness and burning with urination and symptoms have gotten worse. R5 requested to go to the emergency room . R5 was sent to the emergency room . R5's Health Status Note dated 7/8/24 documents R5 returned from the hospital after being admitted with a Urinary Tract Infection. R5 returned to the facility with a Peripherally Inserted Central Catheter (PICC) line and orders for intravenous antibiotics. On 7/09/24 at 1:16 PM R5 stated she first had symptoms of an UTI on Saturday (6/30/24). R5 told the nurse and an urine culture was ordered however it took many days for it to be completed and then it took six days to get results back. On the sixth day there was still no treatment started so R5 requested to go to the emergency room . R5 stated she was admitted to the hospital with a UTI, had a PICC line inserted and antibiotics were started. R5 stated she had abdominal discomfort, burning, bloating and pain for six days without any relief or treatment. R5 stated she knows her body and she knew she needed to be treated and was tired of waiting. On 7/12/24 at 12:06 PM V17 Medical Director confirmed his expectation is for nursing to implement new orders as they are given and R5's urinalysis should have been sent to the lab on 6/30/24- the day it was ordered, not three days later. V17 confirmed he was waiting for the culture and sensitivity results before treating R5's urinary tract infection and if the urine would have been sent in sooner, treatment could have been provided sooner. V17 confirmed R5 decided to go to the emergency room for treatment on 7/6/24 and was diagnosed with a urinary tract infection and is being treated with intravenous antibiotics.

Based on interview and record review the facility failed to remove an electric space heater from a resident's room for one of three residents (R1) reviewed for accidents in the sample list of three residents. This failure resulted in R1 burning R1's leg (fluid filled blister) when R1's leg came in contact with the space heater while R1 was getting out of bed. This past non compliance occurred on 5/29/24. The Current Physician Order Sheet (POS) documents the following diagnoses for R1: Central Cord Syndrome at Unspecified Level for Cervical Spinal Cord, Subsequent Encounter, Myasthenia Gravis without (Acute) Exacerbation and Chronic Obstructive Pulmonary Disease, Unspecified. The Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. The same MDS documents R1 requires a wheelchair to move about the facility and R1 requires staff assistance with transfers, bathing, toileting and all activities of daily living. The facility submitted an incident report on 5/30/24 to Illinois Department of Public Health (IDPH) stating R1 received a fluid filled blister on the left lower extremity due to touching a space heater R1 had in his room. The Progress note dated 5/29/24 documents This writer (V7, Licensed Practical Nurse (LPN)) was notified by nurse tending to (facility) hall that R1 had burned his left lower extremity on a heater that he had in his room that he had bought and had delivered from (department store). This writer went to assess situation. MD (Medical Doctor) was notified by attending nurse on the hall. New order was received for silvadene cream to burn area. R1 denies any pain to area and states it doesn't hurt. Will continue to monitor. The Weekly Wound Evaluation dated 6/3/24 documents R1 has a burn to R1's left lower leg acquired on 5/29/24. The Evaluation documents Burn to left lower extremity remains. Fluid filled blister remains measuring 1.0 cm (centimeters) x (by) 5.5 cm. Burn area above blister is scabbed measuring 2.0 cm x 2.5 cm. R1 stated in interview on 6/11/24 at 10:05 AM I had bought the heater one week after my admission to the facility. R1 stated he thought the staff knew he had the heater because he would ring his light for them to turn the heater up or down. R1 stated on 5/29/24 when he burned his leg the heater was left on the floor. R1 stated he does not remember who left it on the floor. R1 stated R1 was getting up from bed and he touched the heater with his left leg and burned his left lower extremity. R1 stated he did not know he was doing anything wrong. R1 stated I have asked them to turn the air condition off. They told me it was central air and they could not control the air conditioner. V1, Administrator stated on 6/6/24 at 10:30 am When I was told about this incident I immediately removed the space heater and had staff do an audit on all rooms in this building to see if there were any more space heaters. V1 stated I also implemented an inservice for all staff members letting them know no electric heaters are allowed in the building. V1 stated Apparently the staff did not know electric heaters were not allowed. Prior to the survey date, the facility took the following actions to correct the noncompliance. 1. The electric space heater was removed for R1's room. Completed on 5/29/24. 2. An audit of all resident rooms was completed to ensure no one had an electric space heater in their room. Completed on 5/29/24. 3. Immediate inservice was held with all staff available and was repeated for the staff not available that day. Completed on 5/29/24. 4. The Facility Admission Contract was changed to say No electric space heaters are allowed in residents rooms. Completed on 5/29/24. 5. All [NAME] of Attorney and families were contacted with the update about electric space heaters not allowed in resident rooms. Completed on 5/29/24. 6. Audits are being performed three times a week for 60 days to ensure there are no electrical space heaters in residents rooms.

Based on observation, interview, and record review, the facility failed to safely transfer R1 to prevent a traumatic fall. This failure resulted in R1 falling face first into the ground causing a forehead laceration requiring 15 sutures at the hospital emergency department. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list (2/23/2024) documents R1's diagnoses include: Difficulty in Walking, Reduced Mobility, Muscle Weakness, Apraxia (difficulty with skilled movements even when a person has the ability and desire to do them), Unspecified Abnormalities of Gait and Mobility, History of Transient Ischemic Attack (a temporary disruption in blood flow to the brain) and Cerebral Infarction (partial brain tissue death due to disruption in blood flow), Mild Cognitive Impairment, and Expressive Language Disorder. R1's comprehensive assessment (11/17/2023) documents R1 has severe cognitive impairment and requires staff assistance to complete activities of daily living. The same record documents R1 requires staff assistance to transfer from a bed to a chair and uses a wheelchair for mobility. R1's Fall Risk assessment 1/5/2024 documents R1 is at a high risk for experiencing falls. The facility fall investigation (1/29/2024) documents V8 (Certified Nurse Aide) was transferring R1 from R1's bed to R1's wheelchair on 1/29/2024 when R1 fell face-first onto the floor resulting in lacerations to R1's right forehead requiring emergency transfer to the hospital for evaluation and treatment The same record documents V8 did not use a gait belt during the transfer of R1 from R1's bed to R1's wheelchair. The facility incident report (2/5/2024) documents R1 sustained a fall the ground on 1/29/2024 resulting in an a forehead laceration requiring emergency medical treatment at the hospital. The report further documents R1 returned the same day from the hospital, was assessed for safety, and R1's care plan was updated. R1's care plan (1/15/2024) in effect at the time of R1's 1/29/2024 fall documents R1 is at high risk for experiencing falls. The same record documents facility staff added the fall prevention interventions Use of gait belt with all transfers and Re-educate Staff on Use of gait belt with all transfers to R1's care plan on 1/30/2024. The care plan does not document the facility revised R1's care plan with any other additional fall prevention interventions in the one-week period immediately following R1's 1/29/2024 fall. R1's pain assessment (1/29/2024) documents R1 experienced aching and throbbing pain to R1's to face, neck, and left hand after R1's fall on 1/29/2024. R1's emergency room hospital report (1/29/2024) documents R1 had a witnessed fall from the wheelchair in the nursing home on 1/29/2024 resulting in a stellate (a radiating pattern like a star) forehead laceration requiring 15 sutures. The same record documents R1 received intravenous pain medication when the emergency department sutured R1's forehead laceration. On 2/27/2024 at 9:20AM, V8 reported assisting R1 transfer from R1's bed to R1's wheelchair on 1/29/2024 and when R1 was almost seated in the wheelchair, R1 lunged forward and fell to the ground. V8 alleged V8 was using a gait belt on R1 at the time of the transfer, but the gait belt slipped from V8's hands when R1 fell . V8 reporting removing R1's gait belt after the fall and then rolling R1 face up before providing additional care to R1 while waiting for emergency medical services to arrive to transport R1 to the hospital. On 2/23/2024 at 1:41PM, V2 (Director of Nursing) reported previously investigating R1's 1/29/2024 fall, and during the investigation, V8 had performed a demonstration of how R1 allegedly fell to the ground during a transfer from R1's bed to R1's wheelchair. V2 reported V8 had described and demonstrated how R1 was sitting on the edge of R1's bed and then assisted R1 to transfer to R1's wheelchair positioned adjacent to the bed, with V8 located on the opposite side of R1's wheel chair. V2 reported V8 said when R1 was transferred and seated in R1's wheelchair, R1 then leaned forward and fell to the ground. V2 reported V8 did not say whether or not V8 was using a gait belt during the transfer. V2 reported being present in R1's room after the fall and staying with R1 until the ambulance arrived and R1 remained face down on the floor and R1 was not rolled over until emergency medical services staff rolled R1 over before transport to the hospital. V2 reported R1 did not have a gait belt on during V2's observations. V2 denied R1 has a history of leaning forward while R1 is seated in R1's wheelchair. V4's (Certified Nurse Aide) witness statement (1/29/2024) documents V4 observed R1 on the floor in R1's room in a pool of blood after R1's fall on 1/29/2024. On 2/27/2024 at 1:35PM, V4 reported going into R1's room on 1/29/2024 and discovering R1 had sustained a fall and was on the floor with a head laceration and was bleeding and moaning. V4 reported observing R1 face down without a gait belt on, and V8 was present with R1. V4 reported a prior history of providing nursing care to R1 and never seeing R1 lean forward and also never having a gait belt slip from V4's hands during V4's [AGE] year history of providing cares for residents in nursing facilities. On 2/27/2024 at 2:37PM, R1 was laying in bed and had a jagged forehead laceration, appearing several inches in length and purple in color, located above R1's right eyebrow. The laceration resembled the shape of a branched lightning bolt.

Based on interview and record review the facility failed to prevent falls by failing to assist with ambulation and ensure a bed's wheel locks were in working order for two (R1, R2) of three residents reviewed for falls on the sample list of nine. These failures resulted in R1 sustaining a laceration to the forehead requiring emergency services and a subdural hemorrhage requiring hospitalization . These failures also resulted in R2 sustaining a left hip fracture which required surgical repair. Findings include: 1. R1's hospital records dated 2/1/24 documents on 1/17/24, R1 became dizzy while walking at the facility and fell . R1 sustained a right frontal scalp laceration with contusion and a small acute subdural hemorrhage along the right side of the anterior falx as a result of the fall. R1's medical record documents R1 was admitted to the facility on [DATE]. R1's Physical Therapy notes dated 1/13/24 documents R1 was evaluated and has poor balance. These notes document R1 has a history of falls. These notes document that R1 requires one assist with a walker with transfers and ambulation. R1's Physical Therapy Communication form dated 1/13/24 documents R1 requires one assist with a walker for transfers and ambulation. R1's Nurse's note dated 1/17/2024 at 6:27 PM documents, (R1) was found face down in (R1's) room from a fall in a pool of blood. (R1) had a laceration on (R1's) head and the bridge of (R1's) nose. Glasses were broken due to the fall. (R1) was sent to the hospital for injuries and evaluation. R1's Nurse's note dated 1/17/2024 at 8:56 PM documents, Called (hospital) for report on (R1) nurse was unable to give report but did inform writer that (R1) was transferred to (another hospital) with a brain bleed. V17's Licensed Practical Nurse's Witness statement dated 1/17/24 at 5:45 PM documents, (R1) left the dining room independently with (R1's) walker after supper at 5:15 PM. This statement documents the staff heard loud noise and upon entering room R1 had fallen and had bleeding from R1's head. This statement documents, R1 stated R1 got dizzy and fell to the floor hitting R1's head. This statement documents R1 was sent to the hospital. On 2/6/24 at 3:24 PM, V17 stated she saw R1 leave the dining room with his walker and next thing she knows a Certified Nurse's Assistant came running down the hall and stated R1 fell in his room. V17 stated R1 told her he fell because he felt dizzy. V17 stated it appeared he hit his head on the bed frame. V17 stated he had a laceration on his forehead area. V17 stated she did not know R1 and it was the first day she had taken care of him. V17 stated she did not know his transfer status. V17 stated she did not help him walk to his room. V17 stated he walked independently with his walker to his room. On 2/7/24 at 11:29 AM, V16 Physical Therapy Assistant stated R1 was assessed by Physical Therapy on 1/13/24. V16 stated due to R1's balance it was determined that he should be a one assist with a walker for ambulation. V16 stated the staff should have used a gait belt, walker, and assisted R1 with walking in case he lost his balance. V16 stated these interventions would have helped prevent R1's fall on 1/17/24. V16 stated the nursing staff was provided with the Physical Therapy Communication form on 1/13/24. 2. R2's nurse's notes dated 12/11/2023 at 6:29 AM documents, (R2) had an unwitnessed fall. (R2) found lying on her back, stated she fell while trying to move her bed, complains of pain to (left lower extremity). On 2/5/24 at 9:19 AM, V3 Assistant Director of Nursing stated she was the nurse on duty when R2 fell on [DATE]. V3 stated R2 is alert and oriented. V3 stated when she entered R2's room she was lying on the floor and complained of hip pain. V3 stated she was trying to move her bed to make it even with the nightstand. V3 stated when she tried to move the bed, the bed gave way and she fell out of the wheelchair. V3 stated they discovered that the bed was not locked and the bed lock was not working. On 2/5/24 at 9:30 AM, V2 Director of Nursing stated when they investigated the R2's incident they found out that R2 was pushing her bedframe and the wheel was locked but it was stripped so the bed moved when she was pushing it causing her to fall out of her wheelchair. On 2/5/24 at 9:35 AM, V4 Maintenance Director stated he inspected R2's bed after her fall and found out that the locking mechanism on the bed was worn down and past repair. V4 stated that is why the bed moved when R2 was pushing it. R2's hospital records dated 12/11/23 documents R2 sustained a left hip fracture after a fall in the facility. This documents R2's received a left hip fixation to repair R2's left hip.

Based on interview and record review the facility failed to identify, assess, report and treat a facility-acquired sacral pressure ulcer for R1. The facility failed to provide daily cares related to preserving intact skin, including cleansing, incontinence care, repositioning, and individualized pressure relieving devices to promote healing for a resident. Significant change notifications were not made to obtain treatment and implement targeted interventions to prevent the development and worsening of a stage four pressure ulcer for a resident. This failure affects one (R1) of three residents reviewed for pressure ulcers. These failures resulted in R1 developing a Stage four facility acquired pressure ulcer contributing to R1's death. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on 11/22/22. On 11/22/22 at 3:40PM, V1 Administrator and V2 Director of Nursing were notified of the Immediate Jeopardy situation. While the immediacy was removed on 11/23/22, the facility remained out of compliance at a severity level two. The facility is in the process of re-educating the staff on wound identification, assessment, notification, documentation, the facility pressure injury policy and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: The facility Weekly Skin Check Policy revised date 1/2017 documents that it is the policy of the facility to complete skin checks by the licensed nurses for all residents weekly. The nurse will assess the individual resident's skin from head to toe, to determine if there are any new or additional skin issues present. The nurse will document any scars noted over bony prominence's. Any new wounds or skin conditions will be assessed by the nurse finding the wound or skin issue. The Wound Care Nurse will follow-up to ensure all interventions are in place. The nurse will pass information on in report and add information to the communication for continued monitoring and follow-up and the physician and resident representative will be notified of any newly identified issues. Treatment orders will be obtained and new treatments started as ordered. R1's progress notes document R1 admitting to the facility on [DATE]. On the admitted , a skin assessment was completed with R1 being at moderate risk for skin breakdown with no breakdown documented on the sacrum. On 10/22/22, R1's skilled daily assessment documents, a layer of skin on the coccyx/buttock that was compromised. No description, measurements, interventions, or notifications were documented. R1's activities of daily living documentation documents two baths given over the 31 days of admission, one on 10/14/22 and the other on 10/28/22. Toilet use documented on the same record documents R1 as incontinent and on 12 of the 31 days of admission, was toileted two or fewer times in a 24-hour period. R1's Minimum Data Set, dated dated dated [DATE] documents that R1 is totally dependent for toileting and bathing. Additionally, R1 requires extensive assistance with bed mobility. On 11/6/22, R1's weekly skin report was filled out and described as a new area of skin impairment on the coccyx with no other description, measurement, or treatment was documented for the wound. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility was ordered to obtain a referral to the wound physician. R1's medical records documents that this referral was not obtained. On 11/29/22 at 10:15AM, V1 Administrator stated, They didn't even get a wound consultation because she (R1) was apparently sleeping. On 11/8/22, V3 wound nurse completed R1's only skin and wound evaluation documenting a complete description and measurements of the sacral wound during admission to the facility. Documentation describes the wound as an open lesion of unknown age located on the coccyx, in house acquired, with a size of 8.2 centimeters by 5.5 centimeters by 2 centimeters with 80% of the wound covered by slough and no evidence of infection. On 11/13/22, R1's progress notes document a fever with foul smelling drainage coming from the sacral wound. The facility physician ordered [MEDICATION(S)] 500/125 milligram antibiotic every twelve hours for the wound infection. Later that day, R1 fell out of a wheelchair and complained of pain. R1 was then sent to the emergency room . In the emergency department, surgery was consulted due to the size and infection in the wound, identified in the emergency room as the sacral area rather than coccyx, R1 was subsequently hospitalized to address the sacral wound. R1's surgical notes dated 11/15/22, documents R1's sacral wound as 21 centimeters by 10 centimeters down to and including the periosteum (periosteum is a membranous tissue that covers the outer surfaces of bones) of the sacrum. R1's surgical notes dated 11/15/22 further document that the surgeon observed the wound in the operating room and due to the severity and extensiveness of this wound combined with the urinary and stool incontinence, this wound was not survivable and recommended hospice for the patient. R1's death certificate dated 11/21/22 documents the date of R1's death as 11/20/22 cause of death stage four sacral decubitus ulcer. On 11/21/22 at 3:22PM, V8 Certified Nursing Assistant stated, I had told the nurse's every time I took care of (R1) that (R1's) bottom (sacral wound) was getting worse. At least a week or so after I told other nurses, I finally told an agency nurse and she told me that she was just going to put something on it with or without an order. I think that the nurses were having trouble getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/22/22 at 9:04AM, V3 Wound Nurse stated, (R1's sacral wound) was probably preventable from getting so bad. I just learned about the wound from a third shift nurse on 11/6/22. That's when I got the order. I count on the nurses to let me know what the wounds look like. On 11/22/22 at 9:22AM, V2 Director of Nursing stated, (R1) was at risk for skin breakdown on admission. I would have expected them to reposition (R1) frequently and to keep her dry and to let someone know what it looked like. R1's care plan from 10/13/22 (admission) through 11/13/22 (discharge) does not include interventions such as repositioning nor maintaining a dry environment for R1's skin. On 11/22/22 at 3:10PM V16 Wound Nurse Practitioner stated, I spoke with the family about (R1's) condition and how this sacral wound came to be while she was in the hospital. They stated that she was often urine soaked in the facility and that (R1) would ask them to help her change her clothes. The dressing that the facility was using on the wound was not what we would expect to see on a wound like this. It certainly didn't help with healing. I saw the wound and it was tunneling in both directions from the center. This wound size was absolutely preventable. On 11/29/22 at 10:00AM, V1 Administrator stated, After looking at this failure, I identified that our systems failed. Nurses couldn't have been looking at this wound. We are taking this opportunity to revamp our wound program, holding staff accountable, educating, and changing facility leadership to ensure that this can never happen again. V11 Medical Director came in on November 23, 2022, and we discussed the quality plan. He stated that he did not believe that he had been given an accurate representation of (R1's) wound in size or description and that had it been communicated with him, his decision making would have been different. He would have either laid eyes on the wound himself, or sent (R1) to the emergency department. The Immediate Jeopardy was identified to have begun on 10/13/22 when the facility failed to initiate treatment and services to prevent the development of R1's sacral pressure ulcer. The deficient practice was corrected on 11/23/22 when the facility took the following actions to remove the immediacy and correct the noncompliance. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediacy: 1. On 11/13/22 R1 went to the Emergency Department, was admitted to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Nursing education was initiated by the Director of Nursing and the Regional Nurse Consultant on 11/23/22 and will continue every Wednesday until completed regarding identification, assessment, notification, documentation, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. R1 is no longer a resident of the facility. The facility medical director was notified of the immediate jeopardy and approved the action plan on 11/23/22. 4. All Residents in the facility received a head-to-toe skin assessment by nursing management and care plans were evaluated and updated as needed, completed on 11/23/22. 5. The new Director of Nursing provided education for the newly appointed Wound Nurse on assessment needs for those residents at risk for skin breakdown on 11/23/22. 6. The Facility Wound Policies in concert with best practices were reviewed and approved by the Medical Director and Facility Nursing Leadership on 11/23/22. 7. Nursing Management is charged with monitoring the above actions and ensuring that wound identification, assessment, documentation, notification, and treatments are obtained correctly and timely effective date 11/23/22.

Failures at this level require more than one deficient practice statement. Based on observation, interview and record review, the facility failed to provide interventions to prevent pressure ulcers. This failure affects one of four residents (R68) reviewed for pressure injuries in the sample list of 47. This failure resulted in R68 developing a full skin thickness (stage three) facility acquired pressure injury. Findings include: 1) The facility Pressure Ulcer Prevention Policy dated 3/21 documents, A facility must evaluate resident specific risk factors and changes in the resident's condition that may impact the development and or healing of a pressure injury. The facility must implement, monitor and modify interventions to attempt to stabilize, reduce or removed underlying risk factors. Interventions for those at moderate risk include protecting heels by floating and pressure redistribution support surfaces while in the chair and bed. R68's 8/3/22 skin assessment documents R68 at moderate risk for pressure injury. R68's 8/4/22 wound physician note documents a new wound to the left posterior ankle, sized 0.5 centimeter x 1centimeter x immeasurable in depth with unstageable necrosis. R68's 8/12/22 wound physician note documents the left posterior ankle wound size as 0.3centimeter x 0.8 centimeter x unstageable necrosis. R68's 8/18/22 wound physician note documents the left posterior ankle wound size as increased to 2 centimeter x 2.5 centimeter x 0.1centimeter with a deteriorated condition. On 8/22/22 at 11:00AM, R68 was sitting in her bed without any pillows or pressure reducing devices under her left ankle/leg. Later that day at 12:28PM, R68 was sitting in the dining room in a positioning chair without any pressure relieving mechanism under her left ankle/leg. R68's ankles were resting directly on the leg/foot pedals. On 8/23/22 at 12:00PM R68 was sitting in the dining room with her ankles/legs resting directly on the positioning chair without any pressure relieving mechanism under her left ankle/leg. On 8/24/22 at 8:31AM V19 Certified Nursing Assistant stated, I remember that her left leg/ankle was red for maybe 4-5 days and then it opened and we told the nurses. She always rubbed her leg against the cast. On 8/24/22 at 8:35AM V20 Licensed Practical Nurse stated, I think that she rested that leg on the cast and over time, the pressure caused the wound. On 8/24/22 at 10:00AM, R68 was lying in bed without any pressure relieving mechanism under her left posterior calf wound. V11 Licensed Practical Nurse (LPN) stated, She should have her ankles floated on a pillow. I will do that. On 8/24/22 at 10:04AM V15 LPN and V11 LPN changed the dressing on R68's left posterior ankle. The wound appeared dime sized with yellow slough and had a deep purple, crescent shape below the open wound. On the side of the wound that slough did not cover, tissue could be seen into the fascia (full thickness). The wound was cleansed and dressed per physician order. V11 LPN stated, This was preventable if the legs/ankles had been propped with pressure reducing boots or pillows. On 8/24/22 at 10:05AM R68 stated, Oh that feels better! after V11 LPN placed a pillow under her bilateral ankles and legs. On 8/24/22 at 10:20AM, V2 Director of Nursing stated, I have to say that it was preventable. There should have been something put between the pressure areas and the skin. 2. Based on observation, interview and record review the facility failed to assess a resident for the presence of a pressure ulcer, after being notified the resident had a complaint of coccyx pain due to pressure. This failure affects one (R9) of four residents reviewed for pressure ulcers on the sample list of 47. Findings include: 2 a. R9's Daily Skilled Nurse's Note dated 8/19/2022 at 9:00 pm documents: (R9) is alert and has no memory problems. (R9) can recall all. (R9) does not have delusions, does not hallucinate, and decision making is not impaired. Signs of [CONDITION(S)]: none. Other cognitive concerns: none. On 08/21/22 at 3:34 pm R9 reached behind her back and patted her buttocks while sitting in bed. R9 stated R9 has a facility acquired pressure ulcer on R9's coccyx. R9 stated My (R9's) coccyx hurts from sitting on the bedside commode 15 -20 minutes waiting for staff to answer the call light or just come back when they say they will. R9 also stated the following The bandage came off yesterday (8/21/22) while sitting on the bedside commode and a CNA (unidentified, Certified Nursing Assistant) was aware, but no one has put a new one back on. On 8/21/22 at 3:45 pm V15, Licensed Practical Nurse (LPN) was notified by the surveyor that R9 complained of pain and pressure ulcer on R9's coccyx. V15, LPN stated R9 does not have a pressure ulcer and has not complained of pain. There is no documentation in R9's electronic medical record that R9's skin was assessed or treated by V15, LPN after the above interview. On 8/23/22 at 2:05 pm V2, DON stated I was not aware that (R9) had a pressure area. It has not been reported, as far as I know. The CNA's (unidentified) should respond to (R9's) request for transfer from the bedside commode and report her complaints of pain from sitting. She will be assessed right away. R9's Nurse Note dated 8/23/2022 at 2:45 pm, documented by V3, Assistant Director of Nursing (ADON) documents the following Health Status Note Text: This nurse (was) notified by (the) business office manager (V30) that resident (R9) had reported an open area to (R9's) coccyx to her (V3, ADON) at this time, upon assessment, resident observed to have blanchable redness to coccyx area measuring 5cm (centimeters) x 6cm (centimeters), (V3, ADON) spoke with resident (R9) regarding using protective cream to area (coccyx), resident (R9) stated that she would prefer to have a foam bandage applied to area, (V22 , Medical Director) notified, order received for [MEDICATION(S)] Gentle bordered foam, apply to coccyx, change every 3 (three) days et (and) PRN (as needed), if dressing becomes soiled or comes off, resident and husband notified of new orders, dressing applied to area. On 8/23/22 at 5:15 pm V3, Assistant Director of Nursing (ADON) stated I (V3, ADON) did a skin assessment and found (R9) had redness to her coccyx region. We had only been applying ointment. (R9) wanted foam. I applied an [MEDICATION(S)] dressing and got an order from (V22, Physician). I measured the area and documented in the chart.

Based on interview and record review the facility failed to ensure that a resident was secure in a wheelchair in the facility transport van for one of three residents (R72) reviewed for falls in the sample list of 47. This fall resulted in R72 being transported to the emergency room by the ambulance, sustaining a sprained ankle and injured finger requiring support bandage with splinting. Findings include: R72's Care Plan printed on 8/24/22 documents diagnoses including Bilateral Primary [CONDITION(S)] of the Knee, Spinal Stenosis, Lumbosacral Region, Muscle Weakness, Difficulty in Walking, History of Falling, [CONDITION(S)], [CONDITION(S)] and Pain in Leg. This Care Plan documents R72 is at risk for falls related to impaired mobility with a revised date of 7/30/19. R72's Care Plan documents R72 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired mobility dated 4/30/2019 and documents R72 requires total assist of two staff participation with transfers using a full mechanical lift dated 4/30/2019. R72's Minimum Data Set (MDS) dated [DATE] documents R72 is cognitively intact and required total assist of two staff for transfers and total assist of one staff for locomotion. On 8/22/22 at 10:03 AM, R72 stated about six months ago R72 slid out of the wheelchair in the facility van. R72 stated that R72 injured R72's ankle and finger. R72's finger is crooked at the end after the last knuckle. R72's Occurrence Report dated 3/3/22 documents a fall occurred off premises. This report documents R72 slid from R72's wheelchair during transport back to the facility following an appointment. (V24) Transport Aide reports that (R72) c/o (complained of) foot being uncomfortable during transport and as (V24) slowed down to turn, (R72) fell out of (R72's) wheelchair. (R72) was taken to local ED (Emergency Department) for evaluation. This Report documents R72's statement of what happened as staff at the hospital did not put (R72's) bottom far enough back when they assisted (R72) to the wheelchair. They told (R72) was far enough back. While in the van, (R72) felt like (R72) was sliding down. Reported to transport aide (V24) that (R72's) foot was uncomfortable and as the van began to turn, (R72) slid out of (R72's) wheelchair. On 8/24/22 at 11:43 AM, V2 Director of Nursing stated R72 went out for an infusion and V2 stated R72 told the hospital that R72 was not positioned correctly in the wheelchair and the hospital repositioned R72 and told R72 that R72 was positioned fine. V2 stated R72 told V24 that R72 had the hospital reposition R72 because R72 did not feel positioned correctly in the wheelchair. V2 stated that R72 told V24 that R72 felt like R72 was sliding out of the wheelchair. V2 stated V24 pulled over but R72 was already out of the wheelchair on the van floor. V2 stated V24 is not a CNA (Certified Nursing Assistant) so V24 cannot reposition R72. V2 stated if V24 felt like something was wrong V2 would expect V24 to call the facility. V2 stated as soon as V24 called V2, V2 went to the scene. V2 stated that the ambulance took R72 to the emergency room and performed X-rays. V2 stated that there were no fractures but they applied an elastic wrap on R72's sprained ankle and a splint on R72's injured finger. V2 stated that they determined the cause of the fall was the way that R72 was positioned in the wheelchair. V2 stated they applied a foot cradle to the wheelchair to help prevent it from happening again. On 8/24/22 at 11:57 AM, V24 Transport Aide stated that they were on their way back to the facility from R72's infusion appointment. V24 stated that R72 told V24 that R72 felt like R72 was slipping and R72's foot was uncomfortable. V24 stated that R72 bent forward to try to do something with R72's foot. V24 stated R72 took R72's seatbelt off to reach R72's foot. V24 stated that R72 told V24 R72 felt like R72 was slipping. V24 stated that V24 told R72 that R72 was fine and that R72 wasn't going to slip out of the wheelchair. V24 stated that V24 told R72 that it was just that the sling was underneath R72. V24 stated R72 told V24 that R72 told the hospital that R72 did not feel far enough back in the wheelchair. V24 stated that R72 was too big for V24 to move. V24 stated that R72 appeared stable enough to make the ride back to the facility. V24 stated that V24 was making a turn when R72 started to slide out of the wheelchair. V24 stated that V24 pulled over immediately and called 911. V24 stated that V24 was fairly new and was sure that V24 fastened R72 in the van correctly. R72's emergency room Discharge Instructions dated 3/3/22 documents diagnoses of Fall, Ankle Sprain, Knee Pain, Finger Injury and Hip Pain. Instructions were to rest, take Tylenol as needed for pain, ice the affected area, wrap an elastic bandage on ankle, elevate ankle, wear splint on finger, follow up with orthopedics. R72 was given one [MEDICATION(S)] 5-325 mg (milligram) (narcotic pain reliever). R72's Physician visit dated 3/8/22 by V22 Physician documents R72 had a fall out of the wheelchair after recent injection injured right ankle, also injured long finger on right hand. Has a splint on the finger. Appears R72 may have a [NAME] finger.

Based on observation, interview, and record review the facility failed to provide properly functioning fall prevention assistive devices to prevent a fall with injury resulting in R9 suffering a left femur fracture and pain. R9 is one of four residents reviewed for resident injury. Findings Include: 1. R9's care plan revised date 4/30/21 documents that R9 is at risk for falls due to a history of falls. Interventions include pressure pad alarms for the bed and chair. R9's progress note dated 7/15/21 documents that R9 fell from the bed with no alarm sounding. The alarm was then replaced. R9's Situation, Background, Assessment and Recommendation document dated 7/15/21 documents no change in resident condition after the fall. R9's fall investigation dated 8/21/21 documents that R9 fell from the wheelchair onto the floor. V23 (Certified Nursing Assistant/CNA) stated, I was the first person in the room when (R9) fell . (R9's) alarm was in the chair, but it didn't go off. I don't know why. V8 (Licensed Practical Nurse/LPN) stated, (V23 CNA) called me from down the hall to R9's room. I saw that (R9) had attempted to transfer herself from the wheelchair to the bed. There was no alarm sounding. R9's progress note dated 8/22/21 documents that an x-ray was ordered due to R9's complaints of pain. R9's x-ray report dated 8/22/21 documents, Distal femur fracture. Handwritten note on the x-ray report dated 8/23/21 states, Discussed with Orthopedic Surgeon and R9's Power of Attorney. Will control R9's pain in the facility as R9 is non-ambulatory signed by V22 (Medical Doctor). R9's Minimum Data Set, dated dated dated [DATE] documents R9 as severely cognitively impaired and extensive assistance for care. On 9/7/21 at 9:58AM, V9 (Registered Nurse/RN) stated, (R9) has an alarm on at all times either in the chair or in the bed, and we move the pressure pad in between them. On 9/7/21 at 11:33 AM, V6 (Physical Therapy Assistant Director) stated, We picked (R9) up for pain management since her fall. She is getting deep heat treatment to her left distal thigh area.

Based on interview and record review the facility failed to assess and treat a decline in fluid intake and cognitive function, then failed to notify the physician/resident representative of a significant change in condition for a resident. This failure affects one (R1) of five residents reviewed for quality of care in a sample list of five residents. This failure resulted in (R1) being hospitalized for dehydration, acute kidney injury, and [CONDITION(S)]. Findings include: R1's Care Plan updated 8/4/21 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan also includes the following problems: (R1) is on Diuretic Therapy related to Congestive Heart Failure. (R1) is on antibiotic (Intravenous [MEDICATION(S)] and Cephapime) related to [CONDITION(S)]. R1 has IV access: PICC (Peripherally Inserted Central Catheter) to right upper extremity. (R1) has a (urinary) catheter. (R1's) Daily Skilled Note dated 7/31/21 at 12:35AM documents (R1) is alert, has no memory problems, does not have impaired decision making or other cognitive problems. (R1's) Daily Skilled Notes regarding cognitive status remain unchanged through 8/5/21. (R1's) Daily Skilled Note 8/6/21 documents (R1) has short term memory problem, inattention, disorganized thinking, difficulty with word finding, slowed response time. (R1's) Daily Skilled Note 8/6/21 also documents the new signs/symptoms Poor appetite, tired, little energy. There is no documentation 8/6/21 to indicate the physician or resident representative were notified of these changes. On 8/7/21 R1's Daily Skilled note documents (R1) is confused, has short and long term memory problems, decision making is impaired, inattention, disorganized thinking, difficulty with word finding, slow response time, poor appetite. There is no documentation 8/7/21 to indicate the physician or resident representative were notified of these changes. R1's SBAR (Situation, Background, Assessment, Recommendation) note dated 8/8/21 at 11:15AM by V6 (Licensed Practical Nurse/LPN) documents poor appetite, poor fluid intake, confusion, talking gibberish, anxious. Documentation indicated the physician and resident representative were called, an order was received to draw labs scheduled for 8/9/21. R1's SBAR note dated 8/8/21 at 10:30PM documents Altered mental status, muscle jerking and twitching. Transfer to hospital. On 8/12/21 at 9:48AM V6 (LPN) stated I had been on vacation for a week before 8/8/21 at 11:15AM when I made the SBAR note. I really didn't know her baseline since this was the first time I had taken care of her. The CNA staff said (R1) came in alert, oriented not confused, and was able to verbalize her needs. I was told (R1) was not eating and had just been taking sips of water with her medications for a few days. I called V2 (Director of Nursing/DON) and I called the doctor. I got labs and discussed with (V2) how to proceed with (R1's) care. I did not send (R1) to the hospital. V5 (LPN) sent her on night shift. On 8/12/21 at 11:00AM V2 (DON) verbalized that (R1) had experienced a significant change in condition which continued to deteriorate from 8/6/21 until (R1) was finally sent to the hospital at around 10:30PM 8/8/21. V2 verbalized that given the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 acknowledged that there was a delay in the care of R1. R1's History and Physical by V13 (Medical Doctor, Hospitalist) documents Acute Kidney Injury. Previous Blood Urea [MEDICATION(S)]/Creatinine 30/0.72. Current 85/3.69 (kidney function laboratory indicators). Unsure if this is purely prerenal secondary to volume depletion as patient has been on diuretics and may not have been taking enough fluids. Patient is also on [MEDICATION(S)]. We will try gentle IV hydration with the patient (has a history of Diastolic Heart Failure) and monitor renal function. Hold diuretics. Need to avoid nephrotoxic (dangerous to kidneys) agents. However, patient needs [MEDICATION(S)] for Discitis/Vertebral [CONDITION(S)]. On 8/12/21 at 11:59AM V13 stated I believe (R1's) Acute Kidney Injury was brought on by dehydration, most likely due to (R1's) poor intake of fluids and complicated by continuation of the Diuretic. This led to [CONDITION(S)] (brain malfunction). That is the reason (R1) has decreased cognitive function. If (R1) had been sent to the hospital sooner it is likely, in my opinion, we could have treated the issues before the situation became so advanced. She needed the [MEDICATION(S)] for the [CONDITION(S)] and that was an additional risk factor. So the decline could have been avoided. The facility's policy Significant Condition Change and Notification (Not Dated) states Purpose: To ensure that the resident's family and/or representative are notified of resident changes such as those listed below. The list includes Change in level of consciousness such as agitation, lethargy, sudden lack of responsiveness, or manic behavior. The policy goes on to state When any of the above situations exists, the licensed nurse will contact the resident's representative and their medical practitioner. Prior to calling the medical practitioner the nurse will complete the SBAR assessment.

Based on interview and record review the facility failed to assess and implement interventions to prevent pressure ulcers for one resident (R1) of three residents reviewed for pressure ulcers in a sample list of five residents. This failure caused (R1) to develop two stage III and one full thickness skin loss pressure ulcers to R1's coccyx. Finding include: R1's Nursing Admission/Readmission Data Collection dated 7/30/21 at 5:35PM documents R1 as at Risk for skin breakdown. R1 is documented to have a Right Upper Extremity PICC line, red abdominal folds, dressing on lower back, and open area on buttocks. No wound assessments are documented for any of the listed areas. Facility Pressure Ulcer Line List dated 8/1/21 thru 8/4/21 does not include a pressure ulcer assessment for R1. The facility's Non-pressure Line List for the same date documents R1 has one open lesion on her sacrum one centimeter in length by 0.7 centimeters in width. There is no documentation to indicate an assessment of the open area on buttocks. R1's Care Plan updated 8/4/21 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . This Care Plan also includes the problem: (R1) has actual impairment to skin integrity related to open area on Coccyx. The interventions included are: Administer treatments as ordered and monitor for effectiveness. Avoid mechanical trauma: Constrictive shoes, Cutting and trimming corns and calluses, Adhesive tapes, Improper shaving, Vigorous massage. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Avoid shearing while repositioning when in bed. Educate (R1)/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Inform family/caregivers of any new area of skin breakdown. There is no documentation for the implementation of a special mattress or a pressure relieving cushion while up in chair. R1's Treatment Administration Record (TAR) for August 2021 includes a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment is documented as completed 8/5/21 and then on 8/8/21 when R1 was hospitalized . On 8/11/21 at 10:50AM V4 (Licensed Practical Nurse/LPN/Wound Nurse) stated, I was on vacation when (R1) was admitted . I don't think she had any pressure areas. She had the one area on her back with steri-strips where she'd had a procedure of some kind. R1's hospital history and physical dated 7/30/21 documents R1 had a 'biopsy of vertebral bone' on 7/27/21. I (V4) don't think (R1) had two wounds. R1's hospital wound assessment dated [DATE] at 2:39PM by V14 (Advanced Practice RN/APRN/Certified Wound Care Nurse/CWCN) documents (R1) has a shallow Stage III Pressure injury to the left buttock, a shallow stage III Pressure Injury to the Right buttock, and a full thickness skin loss in the gluteal cleft. On 8/12/21 at 9:30AM V2 (Director of Nursing/DON) stated, If (R1) had a wound on her coccyx when she was admitted , there should have been a complete assessment at least daily. The facility's policy Pressure Ulcer/Pressure Injury Prevention (PUP) revised April 2018 states A pressure ulcer/Pressure injury (PU/PI) can occur whenever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter; Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present provide treatment to heal it and prevent the development of additional PU/PIs.

Based on record review and interview, the facility failed to ensure R1 and R2 were not subjected to misappropriation, exploitation, and theft of property by an employee. This failure affects two residents (R1, R2) out of six reviewed for misappropriation. This failure resulted in financial and emotional/psychosocial harm to R1. This failure also resulted in financial harm to R2. Findings include: The facility's Abuse Prevention and Prohibition Policy dated November 2018 documents each resident has the right to be free from abuse, residents must not be subjected to abuse by anyone, the facility prohibits abuse of residents, and also prohibits misappropriation of resident property. 1. The facility's Final Report dated 10/2/20 documents R1 resided at the facility 7/31/20 through 9/5/20. This same report documents R1 experienced medical [DIAGNOSES REDACTED]. This Final Report documents R1 reported to the facility that R1's state paid LINK card (public assistance) was missing and had been used by someone other than R1's self, and R1 was reporting the possibility it could have been a facility employee but could not understand how someone could obtain R1's PIN (personal identification number) for the card. This report documents that during a police investigation, a facility employee (V3/Certified Nursing Assistant) was identified on camera using R1's LINK card. On 10/13/20 at 9:24 am, V1 (Administrator) stated, I did work with (V10/Local Police Officer) in identifying a photo of the person using (R1's) LINK card, and it was one of my employees (V3). V3 was working at that time so I brought V3 outside to the officer and suspended V3 pending the outcome of the investigation. V3 confessed to the theft of the LINK card and that V3 had obtained R1's personal information from R1's wallet by taking a picture of identification. On 10/13/20 at 11:12 am, V3, (former) Certified Nursing Assistant, stated, I did take a LINK card from R1. I know I did something bad. I did get arrested. On 10/13/20 at 4:18 pm, R1 stated, The day after I got out of (discharged from) the facility, my brother and a friend came over to help me clean out my cupboards because I had been in the hospital and facility for 2 months. Then when I went to replenish my supplies, I couldn't buy anything because I couldn't find my LINK card. I called the facility, the police, and my home care agency. I had about 750 dollars on the card when I went into the facility. My normal amount I received on the card for my food was around 55 dollars per month. Then with all this Covid (human coronavirus pandemic) stuff, the state was giving extra money for people with food stamps, but I never spent any of the extra money because I half expected the state would want that money back at some point. It was about 3 weeks later I found out it was an employee at the facility who took the card and had taken a picture of my social security card in order to be able to change my PIN. All of that money was gone, and the card was reloaded at the beginning of September with about 180 more dollars and all of that was spent except for 1 dollar 50 cents. I missed out on buying groceries for nearly a month during September until I got a new card and new PIN at the beginning of October. My family and friends helped feed me during most of September. It wasn't a good feeling being a burden when I had to rely on other people to buy me food. According to R1's accounting, the balance of the card was $928.50 at the time it was taken. 2. The facility's Final Report dated 10/2/20 documents V3 (former Certified Nursing Assistant) had admitted to taking $100.00 (cash) from another resident (R2). This report documents R2 had medical [DIAGNOSES REDACTED]. R2's record reflects R2 no longer resides in the facility. On 10/13/20 at 11:12 am, V3 stated, I know I did some bad things. I did take money from R2. V3's Employee Corrective Action Form dated 9/29/20 documents V3 was terminated from employment due to a Category 1 offense for Gross Misconduct, Immediate Discharge, including resident abuse and admitted stealing money from residents.

Based on observation, record review and interview the facility failed to prevent the formation of five facility acquired pressure injuries (multiple Stage II and Stage III pressure ulcers) by not documenting physician orders [REDACTED]. The facility also failed to prevent cross-contamination during pressure injury wound dressing change for one (R1) of three residents reviewed for pressure ulcers. Findings include: 1. R1's undated face sheet documents [DIAGNOSES REDACTED]. R1's Care Plan dated 7/16/20 documents R1 to wear heel protector boots at all times. This same Care Plan documents staff are to float R1's heels while in bed. This same Care Plan instructs staff to administer treatments as ordered and monitor for effectiveness. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 as requiring total dependence of two staff for bed mobility, transfers, and toileting. This same MDS documents R1 of being at risk for pressure injuries. This same MDS documents R1's Brief Interview for Mental Status score of 9/15 (moderate cognitive impairment). R1's Pressure Ulcer Risk assessment dated [DATE] documents a score of 14 (moderate risk). R1's Hospital Discharge Summary dated 8/25/20 documents R1 as being hospitalized from [DATE] - 8/25/20 with admitting and primary discharge [DIAGNOSES REDACTED]. Wound Clinic Physician order [REDACTED]. 2 Pressure Injury to peri-anal area - antifungal cream to be applied three times per day. There is no documentation on R1's Physician order [REDACTED]. This same POS dated September 1-30, 2020 documents a physician order [REDACTED]. Weekly Pressure Ulcer Report dated 8/12/20 documents R1's facility acquired Left Heel Deep Tissue Injury as resolved (healed). This same report dated 9/2/20 did not include documentation related to R1's Stage 3 Pressure Injury to Left Back, Stage 3 Pressure Injury to Left Gluteus and Stage 2 Pressure Injury to peri-anal area. Pressure Ulcer Weekly Wound Evaluations dated 8/28/20 and 9/8/20 did not include documented assessment of R1's Stage 3 Pressure Injury to Left Back, Stage 3 Pressure Injury to Left Gluteus and Stage 2 Pressure Injury to peri-anal area. Skin Check Weekly Assessments dated 9/3/20 and 9/9/20 did not include documentation related to R1's Stage 3 Pressure Injury to Left Back, Stage 3 Pressure Injury to Left Gluteus and Stage 2 Pressure Injury to peri-anal area. On 9/9/20 at 1:45 PM A new Deep Tissue Pressure Injury to R1's Left Heel was noted during R1's dressing change of R1's Stage 3 coccyx pressure injury. R1 was not wearing heel protector boots and did not have heels floated off of bed. Both of R1's bare heels were laying directly on fitted sheet on mattress. V5 (Licensed Practical Nurse/LPN) and V6 (LPN) acknowledged R1's new Left Heel Unstageable Pressure Injury and did not measure or assess area. On 9/10/20 at 10:55 AM V5 (Licensed Practical Nurse/Wound Nurse) stated R1 went to offsite wound clinic on 8/28/20 and was to return in three weeks for next appointment. V5 stated offsite wound clinic where R1 had appointment called facility on 9/1/20 to review R1's wounds. V5 stated V5 forgot to look in R1's electronic medical record to ensure physician orders [REDACTED]. V5 stated when R1 returned from wound clinic appointment on 8/28/20 the list of physician orders [REDACTED]. On 9/11/20 at 8:50 AM V20 (Advanced Practice Nurse/Wound Clinic Specialist) stated R1 was seen at wound clinic on 8/28/20. V20 stated R1 had ten separate wounds. V20 stated that R1 smelled of body odor and urine. V20 stated R1 also had an abundance of yeast in skin folds that needed to be cleaned up before any wound assessment could be completed. V20 stated facility should have entered orders the same day as wound clinic visit on 8/28/20 and not wait until 9/10/20. V20 stated all of R1's wounds could deteriorate without assessment and treatment. V20 stated new pressure injuries could result from facility not following physician orders [REDACTED]. V20 stated waiting 13 days to enter physician orders [REDACTED]. On 9/10/20 at 12:30 PM V3 (Medical Director) stated facility staff should follow Care Plan for each resident. V3 stated a physician order [REDACTED]. V3 confirmed that not entering physician orders [REDACTED]. 2. R8's undated Face Sheet documents [DIAGNOSES REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] documents R8 as being at risk for pressure injuries. This same MDS documents R8's Brief Interview for Mental Status score of 11/15 (moderate impairment). Hospital After Visit Summary notes dated 8/21/20 documents R8's TLSO ([MEDICATION NAME]-Lumbar-Sacral-Orthosis) brace to be on at all times when sitting upright and out of bed. R8's Physician order [REDACTED].>R8's Treatment Administration Record dated August 1-31, 2020 and September 1-30, 2020 did not document a physician order [REDACTED].>On 9/10/20 at 10:00 AM V14 (Certified Nurse Aide) and V5 (Wound Nurse/Licensed Practical Nurse/LPN) assisted R8 with perineal care and transfer in to R8's bed. R8 complained of back pain due to [MEDICATION NAME]-Lumbar-Sacral-Orthosis (TLSO) brace repeatedly during cares. R8 stated TLSO brace has been hurting his back for days. V5 removed TLSO brace to reveal a previously unidentified and unassessed Stage 2 pressure injury to R8's left lower back where R8's TLSO brace had been resting directly over bony prominence. R8's TLSO brace left a red line across entire width of lower back. V5 measured area at 1.8 cm long (height) by 4.7 cm wide open and reddened with minimal amount of clear drainage. On 9/10/20 at 10:30 AM V5 stated a medical device such as R8's [MEDICATION NAME]-Lumbar-Sacral-Orthosis (TSLO) brace could cause a pressure injury if not monitored. V5 stated R8's TLSO brace had caused a pressure injury to R8's lower left back. 3. R1's undated face sheet documents [DIAGNOSES REDACTED]. R1's Care Plan dated 7/16/20 instructs staff to check R1 every hour and as needed for incontinence. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 as requiring total dependence of two staff for bed mobility, transfers, and toileting. This same MDS documents R1's Brief Interview for Mental Status score of 9/15 (moderate cognitive impairment). R1's Hospital Discharge Summary dated 8/25/20 documents R1 as being hospitalized from [DATE]-8/25/20 with admitting and primary discharge [DIAGNOSES REDACTED]. R1's Physician order [REDACTED]. On 9/9/20 at 1:45 PM V5 (Wound Nurse/Licensed Practical Nurse/LPN) and V6 (LPN) completed R1's pressure ulcer dressing change to Stage 3 coccyx area pressure ulcer. V5 and V6 positioned R1 for dressing change. At this time R1 was laying on incontinence pad heavily saturated with urine over the entire pad with brown ring around edges of incontinence pad. V5 and V6 did not cleanse R1's lower back, buttocks or thighs that had been laying directly on urine saturated incontinence pads and did not provide perineal care after R1's urine incontinence episode and before completing R1's pressure injury dressing change to coccyx/sacral region. R1's prior dressing to Stage 3 coccyx pressure injury was saturated with urine. R1's Stage 3 coccyx pressure injury was open with approximately one third of tissue pink, one third of tissue white, soft and adherent to wound and one third tissue dark brown and dry. R1's skin surrounding coccyx wound was dark red over lower half of buttocks and upper half of back of R1's thighs. R1's open Stage 3 coccyx pressure injury had been in direct contact with incontinence pad heavily saturated with urine. Throughout R1's Stage 3 pressure injury dressing change V6 did not change gloves, wash hands or use Alcohol Based Hand Rub (ABHR) for five separate times that it was indicated between cleansing and dressing R1's coccyx/sacral. V6 did not treat each wound separately. On 9/9/20 at 2:45 PM V6 stated V6 should have washed hands or used Alcohol Based Hand Rub (ABHR) between caring for each of R1's wounds. V6 stated V6 should have treated each wound separately instead of cleansing all of them at once, then dressing all of them at once. V6 stated V6 should have provided perineal care after urinary incontinence episode before dressing pressure injuries. V6 confirmed the dressing was not adhered to R1's wounds and R1's pressure injury on coccyx was laying directly on urine saturated incontinence pad. On 9/9/20 at 3:30 PM V5 stated R1 should have been checked for urinary incontinence because R1 should not be laying on urine-soaked pads. That's bad for R1's wounds and skin. V5 stated urine can create or worsen pressure injuries. V5 stated R1 should not have been laying on two incontinence pads. V5 confirmed R1 was laying on incontinent pads approximately two feet long and width of bed that was heavily saturated with urine and had brown ring at edges of incontinence pad. The facility policy titled 'Pressure Ulcer/Pressure Injury Prevention (PUP)' revised 4/2018 documents the following: A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Implement, Monitor and Modify interventions to attempt to stabilize, reduce or remove underlying risk factors. If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's. Planning: An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of: mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. Implementation: Interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident. Moderate Risk (13-14): protect heels, float if possible. Manage moisture by providing prompt incontinent care. Daily observation of skin during care given by Certified Nurse Assistants (CNA's). High Risk (10-12): Manage friction and shear by utilizing positioning and repositioning. Manage incontinence: Cleanse skin gently at each time of soiling with a pH balanced cleanser. The facility policy titled 'Clean (Aseptic) Treatment Technique' revised 4/2018 documents the following: Remove the soiled dressings: Wash or sanitize your hands per your policy. Apply gloves. Cleansing the wound: Wash or sanitize your hands per your policy. Apply gloves. After cleansing the wound, discard cleansing tools and gloves. Apply a clean dressing: Wash or sanitize your hands per your policy. Apply clean gloves. After applying new dressing, discard soiled gloves. Miscellaneous: If there are multiple wounds, treat each wound separately.

Based on record review and interview, the facility failed to transfer a resident (R4) using two assists. These failures resulted in R4 being lowered to the floor and sustaining a laceration to the left foot requiring emergency services and sutures. R4 is one of three residents reviewed for incidents and accidents in the sample of five. Findings include: R4's Physician order [REDACTED]. This same POS documents an admitted [DATE]. The Resident Assessment Instrument (RAI) dated 3/1/19, 3/8/19 and 3/22/19 all document R4 as being cognitively intact and needing the extensive assistance of two persons for transfers. R4's 3/22/19 RAI documents R4 is not steady when moving from a seated to standing position or when turning around and is only able to stabilize with staff assistance. The facility Fall Risk assessment dated [DATE] documents R4 as being High Risk for falls due to History of Falls in the last six months. R4 is unable to independently come to a standing position, exhibits loss of balance while standing, requires hands-on assistance when moving from place to place, and has a decrease in muscle coordination. There were no other Fall Assessments prior to R4's 3/25/19 fall in R4's Medical Record. A facility Incident/Occurrence Investigation report dated 3/25/19 at 7:45AM documents R4 being lowered to the floor by V5 (Certified Nursing Assistant) during a transfer from a wheelchair to the facility weight scale. The report states R4 became unsteady and weak and was lowered to floor. The same report documents a laceration to R4's left foot requiring evaluation and treatment at the local hospital emergency room (ER). R4's emergency room Notes dated 3/25/19 at 10:20AM document the following: Patient is seen in ER with complaints of fall and left pinky injury. (R4's) foot is covered at this time. The patient was seen and examined and has a laceration to the fifth and fourth digits on the plantar aspect of the left foot. The patient had an x-ray performed. The wound was cleansed with normal saline irrigation under pressure. Wound was repaired with 11 sutures to the 5th digit and 3 sutures to the 4th digit. Sterile dressing was applied. Patient was placed on Keflex 500 milligrams four times daily for secondary [MEDICATION NAME] against infection due to location of wound and patient being diabetic. Patient was placed in a surgical shoe. X-rays read by radiology demonstrates no acute fracture, mildly displaced [MEDICAL CONDITION] digit proximal phalanx age-indeterminate possibly chronic. (R4) was advised to follow up with orthopedic on call, (V8 Orthopedist), in the next 2-3 days for evaluation of the toe. A statement provided by V5 on 3/25/19 documents the following: The nurse unhooked the resident (R4) and I got (R4) into the wheelchair and took (R4) to the shower room to get R4's weight. The nurse stated that the resident (R4) needed to stand to be weighed. The resident is a 1 (one) assist with transfers. The resident was wearing slipper socks at the time of transfer. Resident has been wearing slipper socks since (R4's) feet are swollen. When we got to the shower room, I assisted resident to stand and turn onto the scale. After resident turned, (R4's) left knee buckled. I was behind R4 and was able to lower R4 to the ground. A statement provided by V11, Licensed Practical Nurse on 3/25/19 includes the following: (V5) took (R4) to the shower room to weigh (R4) after I (V11) unhooked (R4) from (R4's) [MEDICAL TREATMENT]. I heard (V5) yell for help and entered the shower room to find (R4) sitting in the floor with (R4's) feet in front of (R4), facing the wheelchair. During my assessment I noticed blood on the bottom of (R4's) left slipper sock. Upon removal of the sock, I observed a laceration to the underneath of (R4's) 4th and 5th toes. I immediately applied a pressure dressing and notified the (Medical Doctor) and received orders to send (R4) to the ER for evaluation. A statement provided by V2, Director of Nursing includes the following: During assessment of (R4's) wheelchair to establish how (R4) received the laceration, I noted a rough area on top of the metal holder on the front right wheel. There weren't any noted rough areas to the left front wheel or bilateral pedal holder. After speaking with staff and reviewing where all equipment was placed and how (R4) was facing, it appears that this rough area on the front of the wheel housing is the reason for the laceration. On 5/8/19 at 2:00PM, V5 confirmed R4 had fallen while V5 was trying to get a weight. V5 acknowledged V5 was the only staff member transferring R4 at the time of the fall. V5 also acknowledged at this time that R4 is sometimes weak and if there had been two staff assisting R4, they would have had better control during the transfer and R4 may not have fallen. On 5/9/19 at 10:20AM, R4 stated V5 did not use a gait belt when transferring R4 to the weight scale. R4 stated V5 asked R4 to step onto the scale from V5's wheelchair. R4 stated I started to step onto the scale, it all happened so fast I fell . R4 stated I had to have 14 stitches in my foot. It set me back 2 weeks. R4 stated the wheelchair R4 uses belongs to the facility. On 5/9/19 at 11:15AM, V6 (Primary Care Physician) stated R4 should have had two staff members transferring R4 and holding R4 in a standing position to get a weight. V6 stated after residents receive [MEDICAL TREATMENT], any kind of [MEDICAL TREATMENT], they are weak. V6 stated the injury could have been prevented. V6 also agreed R4's injury did indeed cause a setback in R4's rehabilitation. On 5/9/19 at 11:45AM, V2 confirmed R4's wheelchair was facility equipment. At this same time V1stated the facility did not have a policy on maintenance of facility wheelchairs.

Based on observation, interview and record review the facility failed to follow manufacturer's instructions for air mattress overlay application and failed to ensure fall interventions were in place for three of four residents (R1, R3 and R4) reviewed for falls in the sample of five. These failures resulted in R1 falling and sustaining a hematoma with active bleeding, blood transfusions, and R3 falling and sustaining facial lacerations which required seven sutures. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R1 is severely cognitively impaired and requires extensive to total assistance from staff for transfers, bed mobility and activities of daily living. R1's Care Plan updated 6/15/17 documents an intervention of (Z6 Family Member) states that (R1) currently is not able to use the call light. (R1) will be on 15 minute visuals to assess (R1's) needs with an initiated dated of 2/25/17. The 15 minute check off sheet documents R1 was visually observed on 6/15/17 at 2:03 am and then not observed again until 2:45 am when (R1) was found on the floor. E20's (Registered Nurse) Nurses Note dated 6/15/17 states At 2:45 am this nurse went to answer the call light and resident (R1) was laying on the floor beside the bed with (R1's) head on the floor and feet tangled in the sheets on the bed. Mostly laying on (R1's) left side and back position. Assisted resident off the floor using the (mechanical lift). Neuro assessment initiated. V.S. (vital signs) and skin assessment. A 1.0 cm (centimeter) x 2.0 cm check shaped abrasion noted to left upper mid back shoulder area. Area was cleansed, TAO (triple antibiotic ointment) and protective cover applied. Area noted to be swelling, ice pack applied. PRN (as needed) pain medication given. Z1 Physician notified, orders received X-ray the left shoulder and left rib areas. Phone call to on-call nurse E14 Registered Nurse, informed of fall. Intervention was to remove the (specialty) air mattress overlay to the bed. E3's (Registered Nurse) Nurses Note dated 6/15/17 at 6:28 am states (R1) is currently experiencing severe back pain s/p (status [REDACTED].o. (new order) for back x ray, rib x ray to be done in house. CNA (Certified Nurses Aide) to CNA report occurred and noc (night) and day shift CNAs summoned the RN to the resident's bedside. Resident is diaphoretic. Blood glucose of 222. Resident reports extreme pain. E3's Nurses Note dated 6/15/17 at 6:35 am states (R1) is extremely diaphoretic, blood glucose of 222. Resident reports back pain, thoracic spine appears edematous and is painful. Send to ED (Emergency Department) per Z7 (physician) on call for Z1 Physician. The Hospital Preliminary Report dated 6/15/17 documents (R1) is found to have a large soft tissue hematoma with some active contrast extravasation (leakage) that is consistent with active bleeding posterior to the T7 (thoracic vertebra) and T8 intercostal space on the left side. There is no noted fracture, however there is a significant hematoma noted. The Report documents an assessment of Anemia likely secondary to hematoma and states that R1 was admitted to the hospital for pain control, bleeding control and a surgical consult. The Hospital Progress Note dated 6/16/17 documents (R1) has had s\s (signs and symptoms) of pain this shift treated with Dialudid (strong narcotic pain medicine). The Hospital Discharge Summary dated 6/19/17 documents (R1) was admitted after a fall at the NH (nursing home). (R1) was noted to have a traumatic hematoma to (R1's) thoracic region. Surgery was consulted and a binder was placed. On 6/16/17 (R1) had 2U PRBC (units packed red blood cells) transfused for a Hgb (hemoglobin) (blood count) less than 8 (normal 11.3-15.2) and on 6/18/17 (R1) was transfused 2U PRBC. (R1's) Hgb improved from 7.7 up to 11.3 after the transfusion and then increased again up to 11.5 the morning of discharge. The hematoma improved and (R1) was discharged back to the skilled nursing facility to continue recovery after (R1's) (prior) stroke. The Facility Occurrence Review dated 6/15/17 documents E20's Nurses Note of what happened when R1 fell on [DATE] as (specialty) air mattress overlay on bed was slid over the edge of the bed and (R1) stated that (R1) was trying to turn over. The Fall Details Report dated 6/15/17 documents that R1 was last observed prior to the fall at 1:45 AM. The Follow Up Report dated 6/22/17 documents a conclusion of The (specialty) air mattress overlay had slid off the edge of the bed when (R1) tried to turn over causing (R1) to slide off the side off the bed. The (specialty) air mattress overlay has been removed. On 6/28/17 at 4:20 am E20, RN, stated that on 6/15/17 E20 answered the call light in R1's room and found R1 half in the bed and half out of the bed. E20 stated the air mattress topper slid off the bed. E20 stated There is no strap to keep the air mattress topper on the bed, there was nothing to keep the topper on. E20 stated E20 did not know R1 was on 15 minute visual checks. On 6/28/17 at 8:55 am E17, Certified Nurses Aide (CNA), stated E17 was R1's CNA when R1 fell on [DATE]. E17 stated E17 did not know R1 was on 15 minute checks. On 6/28/17 at 9:25 am Z5, (specialty) Air Mattress Overlay System Representative, stated that the system is delivered to facilities with an instruction manual and straps that should be used to attach the overlay to the top of the mattress corners. On 6/28/17 at 10:40 am E1, Administrator, and E2, Director of Nurses, stated they were unaware of straps that secure the air mattress overlay to the mattress. The undated (Specialty) Non-Powered Mattress Overlays and Accessories Operation Manual states Attachment of Overlay Straps Note Four Overlay Straps are included to aid in securing the (specialty air mattress overlay) to the bed mattress. 1. Attach one strap to each corner of the mattress overlay. 2. Stretch the straps around the corners of the bed mattress to secure the mattress overlay to the bed mattress. On 6/28/17 at 10:53 am Z4, Hospital Attending Physician, stated (R1) suffered the hematoma when (R1) rolled out of bed. Z4 stated the hematoma continued to bleed and that was the reason (R1) was admitted the the hospital. Z4 stated (R1) has some chronic anemia but the (acute) anemia was probably realted to the hematoma. Z4 stated (R1) received four units of blood while (R1) was hospitalized . 2. R3's Physician order [REDACTED]. The same POS documents and an antipsychotic medication order of Risperdal 0.5 milligram (mg) each morning and 1 mg each evening. R3's MDS dated [DATE] documents R3 received a BIMS score of 6 out of a possible 15, rating R3 as severely cognitively impaired and is totally dependent on two physical staff assistance for bed mobility and transfer. R3's current Care Plan, dated 6/15/17 includes the following, Focus (Problem): (R3) is at risk for falls, (due to) poor comprehension, psychoactive drugs and a history of falls. The same Care Plan documents a Regular mattress with air overlay placed by Hospice, resolved 4/30/17 (post fall 4/30/17). The (Local) Home Medical Equipment Checklist dated 4/19/17, signed by the Z3, Company Representative, and E3, Registered Nurse, documents the (Local) Hospice, Alternating Pressure Mattress and Pad were delivered and set up on R3's bed 4/19/17. On 6/28/17 at 12:10 pm, E3 stated, I signed that we (the facility) received this Hospice equipment. The delivery person (Z3) applied them (Alternating Pressure Mattress and Pad) to (R3's) bed that day, 4/19/17. R3's Fall Detail Report dated 4/30/17 at 00:00 am (midnight), documents E8, Certified Nursing Assistant (CNA), witness interview statement that E8 observed R3 on the floor. (R3) was between the bed (and), trash can, by the wall, with a pool of blood underneath (R3). (R3) previously had a bolstered (raised edge) mattress. The night of the occurrence (Fall 4/30/17), (R3) had a regular mattress with an air overlay that was provided by Hospice. The mattress was springy. (R3) did not have a grab bar or side rail in place. (R3) used to have one about a month ago R3's Fall Detail Report dated 4/30/17 at 00:00 am (midnight) documents a second witness interview statement given by E21, CNA, as follows: E21 walked in the room, (R3) was lying face down on the floor with her (R3) head resting on the trash can. E21 also stated When they (E8 and E21) checked out the mattress, it was springy, and anyone would have rolled out of bed. R3's Fall Detail Report dated 4/30/17 at 00:00 am, documents the following fall investigation conclusion, written by E2, Director of Nursing: Facility has determined that the root cause of the fall was a regular, springy mattress in combination with the air overlay causing (R3) to roll out of bed. (The) mattress was replaced with the original bolstered mattress while (R3) was seeking treatment at ER (emergency room ) for injuries. The same report documents Root Cause, Human Error. On 6/27/17 at 2:25 pm, E2, DON stated the following: I did not initiate the regular mattress and waffle type air mattress topper. Usually I call them (Hospice) with the need for the equipment. That was not the case for (R3's). Hospice (unidentified person) implemented the mattress and air topper on their own. It was determined that it was Hospice human error that caused (R3) to roll out of bed (4/30/17). (R3) had a bolster / concave mattress which is what (R3) needed prior to (Hospice application of the regular mattress and air topper). We re - implemented the concave / bolster mattress, which never should have been removed, while (R3) was in ER (post fall 4/30/17) which resulted in seven stitches. The (Local) hospital Emergency Documentation report dated 4/30/17 documents the following: Chief Complaint, fall out of bed, struck head, laceration to nose, left check and left ear. The same report documents, (R3) presents via ambulance from skilled nursing facility. The patient (R3) rolled out of bed and collapsed a garbage can that was adjacent to the bed. emergency room Course, The patients (R3) wounds were cleansed with saline, a total of four milliliters of two percent lidocaine without epinephrine was infiltrated. Two times 5 - 0 nylon sutures were used to close the nasal laceration. Three times 5 - 0 nylon suture were used to close the superior pinna (top of ear) laceration. Two times 5 - 0 nylon sutures were used to close the posterior (back) left ear laceration (total of seven sutures). On 6/28/17 at 10:47 am , Z1, Physician stated the following: (R3's) fall from bed, and subsequently hitting the garbage can caused the facial lacerations that resulted in the stitches to her (R3) face (4/30/7). 3. The POS dated 6/28/17 documents R4 has [DIAGNOSES REDACTED]. The MDS dated [DATE] documents R4 is severely cognitively impaired and requires extensive to total assistance with activities of daily living. On 6/28/17 at 6:25 AM E12, CNA, and E6, CNA, repositioned R4 in R4's bed. R4 was laying in bed on a specialty air mattress over lay. At that time the air mattress overlay was not secured to the mattress. On 6/28/17 at 9:30 am R4's (specialty) air mattress overlay was observed with E10, CNA. E10 lifted the air mattress overlay off of R4's mattress and stated there is nothing on R4's air mattress to keep it from sliding. The undated (Specialty) Non-Powered Mattress Overlays and Accessories Operation Manual states Attachment of Overlay Straps Note Four Overlay Straps are included to aid in securing the (specialty air mattress overlay) to the bed mattress. 1. Attach one strap to each corner of the mattress overlay. 2. Stretch the straps around the corners of the bed mattress to secure the mattress overlay to the bed mattress. The facility Fall Prevention Policy (Safety Assessment, Fall Prevention and Education / S.A.F.E.) dated February 2014 documents the following: The S.A.F.E. program promotes Safety Assessments, Fall Prevention, and Education of both staff and residents. All Occurrence Reports are reviewed at the daily QA (Quality Assurance) meeting to ensure that intervention was immediately implemented, added to the plan of care and that the current intervention is appropriate.

Based on record review and interview, the facility failed to follow identified fall interventions for one (R1) resident. This failure resulted in R1 falling two times and sustaining a laceration on the first fall and a fractured clavicle on the second fall. In addition, facility staff failed to transfer one resident (R3) safely from a chair to a standing position. R1 and R3 are two of three residents reviewed for falls in the sample of three. Findings include: 1). a.) The Physician order [REDACTED]. The Minimum Data Set (MDS) for R1 dated 7/1/16 and 9/29/16 document R1 as being severely cognitively impaired. The same MDS's document R1 needing physical assistance of one and two respectively, with toileting and transfers. R1's Fall Risk Assessments dated July 2016 through November 2016 document R1 at High Risk for Falls. R1's Plan of Care dated November 2016 documents the following interventions for related falls: On 3/20/16, an intervention was added to the Plan of Care for R1 to be placed at the Nurse's Station or in an Activity when up in wheelchair and or at meals in order to prevent falls. On 8/31/16, the Plan of Care was updated to include the fall intervention directing staff not to leave R1's wheelchair in R1's room when R1 is in bed. A facility report titled Fall Details Report dated 8/5/16 documents the following: On 8/5/16 at 4:45 am, R1 was found on the floor in R1's room. R1 was transferred to the emergency room due to a 3.5 to 4.0 centimeter (cm) laceration above the left eye. The facility investigation report documents that R1 had been left alone at the nurses station in R1's wheelchair. R1 then propelled the wheelchair per self, back to R1's room and attempted to self-transfer back to bed. The report states staff failed to follow (R1's) plan of care of not being left alone while up in his wheelchair. The report is signed by E2, Director of Nursing. An emergency room Note dated 8/5/16 at 6:15 am documents the following: (R1) is seen in the emergency room with head injury after fall from wheelchair. There is a 5.0 cm laceration to the left eyebrow, 1.0 cm superficial laceration to the inferior orbital rim (laceration of left eyebrow) - Complex wound closure requiring subcutaneous sutures, (laceration of left infraorbital rim) - Dermabond. On 12/09/16 at 10:0 am, E2 stated the fall of 8/5/16 was due to facility staff not following R1's Plan of Care and R1 should not have been left alone at nurses station, allowing R1 to return to R1's room in the wheelchair alone. On 12/09/16 at 1:40 pm Z1, Primary Care Physician for R1 stated staff should not have allowed R1 to return to R1's room in the wheelchair alone. R1 is known for trying to self transfer and has fallen before. Z1 acknowledged the fall from the wheelchair on 8/5/16 caused R1 to sustain facial lacerations requiring treatment at the emergency room . Z1 stated staff need to follow (R1's) Plan of Care, interventions are in place for a reason. b.) A facility report titled Fall Details Report dated 10/16/16 documents the following: On 10/16/16 at 7:00 am, R1 was heard yelling for help. It appears that (R1) crawled off of mat and pulled self up with wheelchair in corner of room and then fell (R1) has mild (complaints of) left shoulder and left hip pain. Z1 ordered an x-ray to the left shoulder of R1. A Radiology Report on R1, dated 10/16/16 at 2:08 pm documents the following: Reason for x-ray - pain status [REDACTED]. On 12/9/16 at 10:10am, E2 acknowledged that R1's Plan of Care included the intervention of not leaving R1's wheelchair in R1's room. The intervention was implemented from an identified root cause on a fall dated 8/29/16 when R1 had fallen while trying to self transfer and had hit R1's head. E2 acknowledged that staff had not followed the Plan of Care and had left R1's wheelchair in R1's room on 10/16/16, allowing R1 accessibility to the wheelchair to self transfer, causing R1 to fall and fracture R1's clavicle. On 12/09/16 at 1:40 pm Z1 stated that the fall on 10/16/16 while R1 was trying to self transfer to the wheelchair did result in a fall with a fractured clavicle. Z1 stated that R1's wheelchair is not to be left in R1's room due to R1's previous attempts at self transfers. Z1 stated Staff need to follow the Plan of Care on R1. 2.) The Physician order [REDACTED]. Included on the POS is an order dated 9/27/16 for R3 to be non-weight bearing on the right casted lower extremity. R3's Minimum Data Set ((MDS) dated [DATE] documents that R3 requires extensive assistance with two staff for transfers and toileting. R3's Plan of Care dated September 2016 documents that R3 needs extensive assist with transfers, toileting, walking, and bathing. R3's Fall Risk assessment dated [DATE] documents R3 as being at high risk for falls. A facility report titled fall Details Report dated 10/7/16 documents R3 being lowered to the floor on 10/7/16 at 7:25 pm by E6, Certified Nursing Assistant (CNA). The report documents that E6 attempted to transfer R3 to a wheelchair from a recliner. When E6 stood R3 up, R3's good foot (uncasted leg) started to slide and E6 had to lower R3 to the floor. R3 had no shoes on but only slipper socks at the time. The report documents that Therapy is to in-service CNA on proper transfer. On 12/9/16 at 10:10 am, E2, Director of Nursing stated that CNA, E6 transferred R3 improperly. E2 acknowledged that E6 was in front of R3's walker and E6 was the only CNA present for the transfer.

Based on interview and record review the facility failed to assess and document the condition of surgical wounds and update the physician on signs and symptoms of infection for one of three residents (R1) reviewed for wound care in a sample of four. This failure resulted in re-hospitalization for treatment of [REDACTED]. Findings include: The Wound Assessment Policy dated August 2015 documents, It is the policy of the facility to assess each wound initially either at the time of admission or at the time the wound is identified. Each wound will be assessed weekly thereafter or with any significant noted change in the wound. Assessment and documentation should include anatomic location, size, drainage, pain, periwound skin conditions, and odor. The Daily Skilled Nurse's Note dated 12/7/15 at 6:15 PM documents R1 was admitted with three surgical wounds. One incision site was on her right great toe, the second on her right groin, and the third to her right thigh. The Nurses Note dated 12/6/15 at 3:44 PM documents E6 Registered Nurse (RN) observed the right groin incision to be red, macerated to the medial portion of the incision, and draining serosanguinous fluid. There were no other documented wound assessments regarding R1's surgical wounds for the entire duration of her stay at the facility. On 12/24/15 at 11:00 AM, E6 Registered Nurse (RN) stated she did not notify R1's physician concerning the abnormal wound assessment she observed on 12/6/15. E6 stated she was in training and believed her precepting nurse (E7 Licensed Practical Nurse LPN) notified R1's physician. On 12/24/15 at 11:45 AM, E7 LPN stated she had dropped the ball and forgot to notify R1's physician of the abnormal wound assessment observed on 12/6/15. On 12/24/15 at 11:55 AM, E2 Director of Nurses stated R1's physician should have been notified by nursing staff with regards to the abnormal wound assessment observed and documented on 12/6/15. E2 stated her expectation is that nursing staff assess and document wound observations. E2 stated the assessment and documentation should be detailed and include descriptive's that give a complete picture as to what the wound looks like. Hospital admission records acquired on 12/23/15 document R1 was admitted to the hospital on [DATE] and diagnosed with [REDACTED]. On 12/29/15 at 2:08 PM Z2 Physician stated if he would have received more complete and accurate information from facility nursing staff regarding R1's wounds, R1 could have been treated earlier and possibly avoided R1's hospitalization . On 12/29/15 at 3:00 PM Z3 Vascular Surgeon stated the facility staff could be held 75% responsible for R1's right groin wound infection. Z3 stated if the facility would have been assessing the wound and would have notified him of the abnormal wound assessment on 12/6/15, the issue could have been addressed and any infection could have been treated at an earlier time, possibly avoiding the now needed surgical intervention and hospital admission.

Based on record review and interview, the facility failed to supervise a resident (R1) and operationalize their Door Alarm Policy. This failure resulted in R1 exiting the facility unattended, falling and sustaining a fracture. R1 is one of three residents reviewed for elopement (leaving the building unnoticed) in the sample of three. Findings include: The Physician order [REDACTED]. an order for [REDACTED]. The Minimum (MDS) data set [DATE] documents R1's cognition as moderately impaired. On 10/01/14, Nursing Notes document that R1 has inattention and disorganized thinking with short and long term memory problems. R1's Nursing Notes document that on 10/3/14 the facility received a phone call at 2:45 pm from Z1, Community Neighbor of R1. Nursing Notes go on to document that Z1 reported that R1 was at his house because R1's house was locked and R1 could not get in. The same Nursing Note documents that R1 left the faciity on foot with a cane and R1 reported having a fall and complained of left shoulder soreness. The Nursing Note continues with documentation of an ambulance being contacted for transport of R1 to the local emergency room . There is no documentation in R1's facility Medical Record of R1 complaining of shoulder pain prior to 10/3/14. A Web based report titled "Weather History for Mattoon, Illinois" documents weather conditions for 10/03/14, giving the following statistics: Between the hours of 1:30 pm to 3:00 pm, the temperature recorded is documented at 62 degrees Fahrenheit. The same report records and documents a wind speed of 19 miles per hour with gusts reaching to 32 miles per hour. A Radiology Report dated 10/3/14 for R1 documents a left shoulder x-ray with the following findings: "There is a slightly displaced fracture involving the distal clavicle, best seen on lateral view...." The facility policy titled "Door Alarm Policy" and dated February 2007, documents the following: "Door alarms require immediate attention by facility staff, to insure the safety of all residents. The following procedures must be followed in relation to door alarms. Upon hire, all staff must be educated on the reason for door alarms as well as why an immediate response is crucial. Immediate response refers to any employee who immediately goes to the door that caused the alarm to sound. The employee must exit the facility and thoroughly search the surrounding area. It is not sufficient to search the surrounding area from within the facility.......When a door alarm sounds, the alarm is not to be silenced until the reason for the activation is determined. Staff must follow this procedure: Go directly to the door where the alarm is sounding. Check outside the door, do not assume anything......If the source of the activation is a visitor or a vendor, instruct them on how to properly and safely disarm the alarm before leaving the building....In regular monthly staff in-services , staff should continue to be reminded of the importance of their immediate response to door alarm activation." On 10/24/14 at 9:40 am, E1, Administrator acknowledged that R1 had left the facility unattended and three employees watched R1 leave but thought R1 was a visitor. The employees were identified by E1 as E3, Transport Aide, E4, Maintenance Assistant and E5, Nurse Practitioner. E1 acknowledged at this time that the three employees, E3, E4 and E5 did not follow the facility policy on Door Alarms. E1 stated R1 left the facility somewhere between 1:30 pm and 2:00 pm on 10-3-14. E1 stated "(R1) was last seen at 1:15 pm by staff." On 10/24/14 at 11:30 am E3 stated that she did see R1 go by with a coat and cane. E3 stated she then heard the alarm go off and then it was silenced. E3 stated "I thought (R1) was a visitor and had set the alarm off, I did not go check on the alarm." E3 acknowledged that she had not followed the Door Alarm policy. E3 stated "I thought I was going to be fired for not following the policy and letting a resident get out the door." On 10/24/14 at 12:20 pm E4 stated that he had been at the front door with his back to the door when R1 went out the door, appearing to him as a visitor. E4 stated that when E5 silenced the alarm he thought E5 knew who the person was. E4 acknowledged that E5 nor himself went outside to check with the person setting off the alarm and that he did not follow the facility Door Alarm policy. E4 stated "I should have investigated it or reported it, so as to make sure the person setting off the alarm was a visitor and not a resident." On 10/24/14 at 1:00 pm, E5 stated she thought R1 was a visitor going out the door and just didn't know the door code. E5 stated "the alarm went off and I saw (R1) going down the sidewalk." E5 stated that R1 had on a jacket with a hood up over her head and R1 had a cane. E5 stated "I did not see her face, (R1) had the hood of her coat up and she looked like a visitor from behind, it was windy that day." E5 stated she silenced the alarm. E5 acknowledged that she did not follow the facility Door Alarm policy. E5 stated "I should have went out side and asked her what her name was again, or something like that...." On 10/24/14 at 1:35 pm Z2, family member stated that R1 lived one and a half mile from the facility and R1 would have to cross railroad tracks and a busy street to reach her house. Z2 stated that R1 had been crying and wanting to go home several days prior to her leaving the facility on 10/3/14. On 10/24/14 at 2:20 pm E6, Licensed Practical Nurse and R1's Primary Nurse stated that R1 was confused and had voiced to her family that she wanted to go home on multiple occasions. E6 stated R1 was started on an anti-depressant on 9/23/14 because of her depression. E6 stated that R1 had not complained of her shoulder hurting prior to leaving the facility on 10/03/14. On 10/24/14 at 4:00 pm E9, Registered Nurse states she was one of two staff members dispatched to retrieve R1 in the community and bring her back to the facility on [DATE]. E9 stated that when she arrived at Z1's house, R1 was there. E9 stated that R1 had on khaki pants and one of the knees was covered in grass stains. E9 stated she asked R1 if she had fallen and R1 replied that she had fallen because the wind had caught her. R1 then told E9 that a young lady with a small child had helped her up off the ground and had taken her home. E9 stated that when R1 was put in the car for transport back to the facility, R1 complained that her left shoulder was hurting. E9 stated she had no knowledge of R1 complaining of shoulder pain prior to 10/3/14. On 10/24/14 at 4:45 pm, E1 stated that in-services were done with the staff on the Door Alarm policy, but they had not been done monthly as stated in facility policy.

Based on record review and interview the facility failed to provide safe transfers with mechanical lift as required and failed to implement planned interventions to prevent falls for for three of ten residents (R18, R24, R26) reviewed for falls on the sample of 18. Failure to transfer with mechanical lift resulted in R24 sustaining a fall with fracture. Findings include: 1. The Care Plan dated 7/24/13 documents that R24 is at high risk for falls related to unawareness of safety needs, impaired thought processes and gait/balance problems. The Care Plan interventions document that a mechanical lift is to be used for transfers of R24. The Occurrence Report dated 11/1/13 documents that on 10/26/13 at 6:45 am, E15 (Certified Nurses Aide) transferred R24 from bed to wheelchair using a one person pivot transfer technique. During the transfer R24's right leg crossed underneath R24, resulting in R24 saying "ouch." No further discomfort was voiced by R24 at that time. The incident was not reported by E15 until 11/1/13 when she was interviewed by E1 (Administration) for the investigation. E15 commented, "On October 26th, a Saturday, we had two aides on the hall. We were very busy that morning. I had to get (R24) out of bed.. . ". E13 (Licensed Practical Nurse)stated on 7/17/14 at 2:00 pm that R24 complaint of right ankle pain 10/26/13 at 10:09 am. Upon questioning R24, E13 could not determine a specific cause for the discomfort. E13 then initiated an investigation for an injury of unknown origin. The physician was notified and an x-ray of the right lower extremity and foot was ordered. The x-ray showed "no acute findings of the right tibia, fibula, ankle, or foot." The Nursing Notes for R24 on 10/28/13 document continued complaints of right lower extremity pain with bruising of the outer aspect of the right ankle. Tylenol (analgesic) was administered as ordered for pain with effective results on 10-28-13, 10-29-13, 10-30-13 and 10-31-13. A second x-ray of the right lower extremity and right foot was ordered on 10-31-13. The Radiology Report of 10-31-13 documents a nondisplaced fracture of the distal fibula. E1 (Administrator) stated on 7-17-14 at 2:00 pm that the incident investigation of 10/26/13 determined that R24 sustained a fracture because of an incorrect transfer. E15 did not use a mechanical lift. 2. The Care Plan dated 6/13/14 documents that R18 is at high risk for falls related to safety awareness, confusion, physical restraint use, gait/balance problems and incontinence. The Care Plan's interventions document that R18 uses an electronic alarm for her chair and bed and for staff to "ensure the device (alarm) is in place, turned on, and in working order." The Care Plan also documents "ensure (R18's) bed is in the lowest position when layed (laid) down." The Occurrence Reports dated 9/23/13,10/29/14, 11/14/13, and 2/7/14/ document that R18's alarm was not in place or not sounding at the time of the fall. The Occurrence Report dated 4/28/14 documents that R18's bed was not in the lowest position when R18 fell out of bed. The Occurrence Report dated 9/23/13 at 1:15 pm documents "(R18) attempted to transfer self and fell . Staff did not follow plan." R18's alarm was "not sounding." The reports documents "educated the CNA (E7) on ensuring alarms are on and in working order." The Occurrence Report dated 10/29/13 at 7:55 pm documents "(R18) attempted to get herself out of her bed and fell ." The report documents that no alarm was in place at the time of R18's fall. The Occurrence Report dated 11/14/13 at 11:23 pm documents "(R18) rolled out of low bed and onto mat on the floor." The report documents that no alarm was in place at the time of R18's fall. The Occurrence Report dated 2/7/14 at 3:40 pm documents "First shift did not place pressure alarm from wheelchair under the resident in bed. The report documents that no alarm was in place at the time of R18's fall and that the pressure alarm "was still in the wheelchair." The Occurrence Report dated 4/28/14 at 1:28 pm documents "(R18) was in bed and attempted to get out of bed and sat on mat next to bed. . . .First shift did not place pressure alarm from wheelchair under the resident in bed. . . . bed was not put in the lowest position, disciplinary action initiated." On 7/16/14 at 1:45 pm E12, Licensed Practical Nurse and Fall Prevention Coordinator acknowledged that R18's Plan of Care for fall prevention was not followed. E12 stated that alarms were not in place or not sounding when R18 fell on [DATE], 10/29/13, 11/14/13, and 2/7/14. E12 stated that R18's "bed was not at the very lowest position and it should have been" when R18 fell out of bed on 4/28/14. On 7/17/14 at 1:15 pm E2, Director of Nursing, stated that the CNAs are responsible to check resident's alarms, placement and function. 3. The Physician order [REDACTED].The Plan of Care dated June 2014 documents that R26 is at risk for falls due to safety needs, confusion, psychoactive drug use and gait/balance problems. The same Plan of Care directs staff to use chair and bed electronic alarms. The facility "Fall Details Report" documents R26 with a fall from his bed on 6/10/14. The report documents staff finding R26 on the floor by his bed due to self-transferring. The intervention for this fall is "Pressure Alarm pad applied under resident at all times." R26 is documented as having another fall on 6/17/14. The Fall Details Report dated 6/17/14 documents that R26 was found lying supine on the floor at 9:45 pm. There were no electronic alarms in place for R26, per this report. On 7/17/14 at 10:55 am E12, Licensed Practical Nurse and Fall Prevention Coordinator stated "(R26) should have had alarms on his bed and chair on 6/17/14".

Based on record review and interview the facility failed to have staff present in the room to supervise R14 when R14 was in a geriatric reclining chair. R14 was left unattended and sustained a fall resulting in fracture right shoulder. In addition the facility failed to utilize foot rests when transporting R8 in a wheelchair. R14 and R8 are two of seven residents reviewed for falls in a sample of 15. Findings include: 1. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] states that R14 is cognitively intact and is totally dependent on staff for all activities of daily living to include bed mobility, transfers and toilet use. The MDS states R14 requires two plus person physical assist for all activities, has impairment on both sides for upper extremities and impairment on one side for lower extremities. The same MDS states that R14 had a fall with major injury prior to admission. Fall risk assessments dated 5/6/11 and 7/16/11 state R14 is a high risk for falls. Facility report titled "Incident Report"dated 5/3/11 in the section titled "Description of Events" states R14 was sitting in a reclining geriatric chair and attempted to transfer self to the bed and was found on the floor. The section of the same report titled "Recommendations/Interventions" states : "(R14) is not to be left in room while up in reclining geriatric chair. Chair alarm and bed alarm placed." An x-ray report dated 5/3/11 for R14 states under the section titled "Findings" reads " A complete fracture through the left proximal humerus is identified...." Facility report titled "Incident Report" dated 5/19/11 in the section titled "Description of Events" states R14 was sitting in the reclining geriatric chair and attempted to transfer self and was found on the floor. The section of the same report titled "Recommendations/Interventions" states: R14 to be in visual range of staff when up in reclining geriatric chair. An x-ray report dated 6/2/11 for R14 states under the section titled "Findings" reads "Irregularity of the right humeral head is noted. A complete oblique fracture is noted through the midshaft of the right humerus...." R14's care plan dated 5/3/11 under the section titled "Fall Prevention Care Plan - High Risk" under "Interventions: states "Resident not to be left in room when up in reclining geriatric chair... On 10/21/11 at 2:10 PM E14, Licensed Practical Nu (LPN) stated that R14 was left alone in her reclining geriatric chair, fell and ended up with fracture to her right shoulder. 2. The Interdisciplinary Team (IDT) Plan of Care Meeting documents that on 5-19-11 at 11:00am E8, LPN was pushing R8 down the hall in his wheelchair without foot pedals. This report stated R8 put his foot down causing the left ankle to roll. "Pain and bruising noted to the left ankle. X-ray obtained and no fracture noted." E15, Certified Nurses Aide at 3:15pm on 10-20-11 and E14, LPN at 3:25pm on 10-20-11 each stated R8 did not have foot pedals on his wheel chair until after the incident of 5/19/11. The IDT Plan of Care Meeting report shows the foot pedals on the wheelchair and were implemented on 5-19-11.