Every finding on record at Meadowbrook Manor - Lagrange

Based on observation, interview, and record review, the facility failed to follow their wound prevention and healing policy and resident shower/bathing policy by failing to identify and assess a resident's skin for an open wound for one (R24) of four residents reviewed for wound care. 2. Failed to provide a resident with services to avoid clinical complications by failing to adequately access a resident's change in condition, failed to promptly send a resident to the hospital after receiving an order and failed to report critical lab result to the attending physician. These failures affected one (R145) of two residents reviewed for quality of care and resulted in R145 being sent to the hospital after the family noticed a change in his condition, R145 had a blood sugar of 365 and exhibited signs and symptoms of septic shock as documented in ambulance run sheet. Findings include: 1) R24 is [AGE] year-old female. Current diagnoses include but are not limited to Osteoarthritis, Severe Protein Calorie Malnutrition, Congestive Heart Failure, Venous Insufficiency, Dementia, Chronic Kidney Disease, Hypertension, Myocardial Infarction and History of Falling. R24's comprehensive assessment section C Cognitive Patterns dated 7/17/2026 documents a brief interview for mental status score of 6 which indicates a severe cognitive impairment. On 08/03/2026 11:42 AM, R24 was inquired of the dressing to her right lower leg. R24 said, It's a wound, the nurse did it. They come change it every day. They take the bandage off and it bleeds. It should be getting better. They give me Tylenol. Observed dressing to right LE. No documentation on treatment. On 08/04/2026 11:52 AM, two calls were made to speak with R24's POA (Power of Attorney) with no answer or voice mail set up. On 08/04/2026 at 12:46 PM, V23 RN was inquired of R24. V23 said, I usually work the other side of the unit. The nurse that works this side is on vacation, so I didn't know anything about a dressing on her leg. I didn't get any information on that. On 08/04/2026 at 1:11 PM, V23 RN and this surveyor went to R24's room and observed a 4x4 foam dressing to R24's anterior right lower leg just above her ankle. V23 opened the dressing to find a moderate sized wound with dried blood covered with xeroform. V23 said, I didn't know she had a wound on her leg, let me get wound care. The wound had blood-tinged drainage and xeroform covering wound with a foam bordered gauze. On 08/04/2026 at 1:22 PM, V26 Wound Care Nurse was inquired of R24's anterior right leg wound. V26 said, It could have been podiatry because they treat anything from the knee down. I didn't know anything about it. On 08/04/2026 at 1:35 PM, V26 Wound Care Nurse was inquired of R24's right leg wound. V26 said, I haven't seen a dressing on her (R24) leg. I usually do 2nd and 3rd floor. It may have been the podiatrist; they treat anything below the knee. On 08/04/2026 at 1:38 PM, V22 LPN was inquired of R24's right leg wound. V22 said, I didn't know anything was there. On 08/04/2026 at 1:45 PM, V26 and V22 LPN accompanied this surveyor to R24's room to observe the right leg wound. R24 refused to allow V26 to remain in the room. R24 initially refused to have the wound observed. Family was at bedside along with V2 DON Director of Nursing and V27 Wound Nurse Practitioner provided education and reassurance. R24 consented to allow the staff to evaluate her right leg wound. On 08/04/2026 at 1:55 PM, V27 Wound Nurse Practitioner was asked to assess R24's anterior lower right leg wound. V27 said, The wound has moderate blood-tinged serosanguinous drainage, it's covered with Xeroform, there is no odor, redness. It doesn't appear to be infected. There is hyper-granulation. It was covered with Xeroform and a foam boarded gauze which is what I would have ordered. On 08/04/2026 at 2:18 PM, V2 DON Director of Nursing was inquired of nursing performing skin assessments on residents. V2 said, They check the skin after showers. V2 was asked to provide R24's documents for review- incident report June through current of all progress notes, treatment administration records, POC charting, skin assessment from this date. On 08/04/2026 at 2:20 PM, V22 was inquired of R24's right leg wound. V22 said, It could be from trauma or is she had any previous issues to that area. On 08/04/2026 at 2:22 PM, V23 RN was inquired of performing skin assessments on a resident. V23 said, We only check the skin during showers. On 08/05/2026 at 11:20 AM, V28 Podiatrist was inquired of her 7/13/2026 evaluation and treatment for R24. V28 said, When I came to see her (R24) it was for the routine appointment. I found a dry dressing already on her right lower leg. I spoke with the treatment team about it. I did my evaluation and let the team know. She (R24) had a new wound; I classified it as a skin tear. I put the measurements in the note. It was cleaned and dressed. I ordered xeroform and dry dressing daily. I saw her (R24) on 7/13 and 7/27. On 08/05/2026 at 2:02 PM, V26 Wound Care Nurse was inquired of performing treatments and skin assessments for R24. V26 said, I work full time on 1st shift (6AM - 2PM). We try to do monthly skin assessments on the second week of the month. V45 (Wound Care Coordinator) schedules them. I did her assessment the second week of July and I didn't see anything. I work with R24 on 3rd floor. On 08/05/2026 at 2:06 PM, V2 was inquired of V45 Wound Care Coordinator. V2 said, V45 has been off on leave since the last week of June. On 08/05/2026 at 2:08 PM, V26 said, I treat R24's sacral area. Her treatment is a hydrocolloid dressing three times a week for MASD (Moisture Associated Skin Damage). I did her dressing two weeks ago and didn't notice anything on her right leg. Podiatry orders go to V45. Podiatry sends an email to V45 Wound Care Coordinator. We have two different wound care providers. V27 works for the hospital, the other one works for a wound physician. If a resident has a facility acquired wound, I do an assessment, call the doctor and get an order, do the treatment, and call the family. Put it in risk management. I don't have any way of getting orders from Podiatry. V28 Podiatrist rounds with her own nurse. She comes every other Monday. We have a podiatry book at each nursing station. If a resident refuses wound care, I let the assigned floor nurse know. Sometimes I do reach out to the family or POA (Power of Attorney), the doctor, or NP (Nurse Practitioner). They need to know about the behavior and if the wound gets worse. I document in the skin or wound note or directly in the TAR (Treatment Administration Record). On 08/05/2026 at 2:53 PM, V2 DON Director of Nursing was inquired of V45 Wound Care Coordinator's responsibilities, podiatry, and R24. V2 said, V45 is the head of the wound care department. Her responsibilities are to do the wound care plans, attend care plan meetings, complete the MDS section M, update the families, meet with wound care providers, round with wound care nurses, do podiatry recommendations from the emails, assist with wound care treatments and assessments and all other duties not assigned to the wound care nurses. If a new wound is acquired, she'll review it. She took a leave of absence the last week of June. In her absence V2 supervises the wound care nurses. I'm not on the emails from podiatry. If a resident is on the podiatry list they'll be followed by them. If there's anything on lower leg or foot wound care refers them to podiatry. Podiatry will see the resident, put in an order, email to V45 and upload the note to PCC (Point Click Care electronic medical record system). Surveyor asked how wound care nurses know if podiatry sent any new orders in V45's absence? V2 said, I think the orders would also be sent to V22 Wound LPN. I'll have to find out if all three of them get the emails from podiatry. I didn't let V28 Podiatrist know V45 would be out; that's an oversight on my part. R24 had two podiatry visits 7/13 and 7/27, they round every Monday or Tuesday. V45 reviews the orders after they're emailed and uploads them. I didn't review the 7/13 note. I can't answer if V26 Wound Care Nurse or V22 LPN reviewed it. If resident refuses care they let me know. I've called her family. Her family just says that's how she is. No direction from her doctor, just to document it and call the family. It (skin injury) had to happen between 7/9 and 7/13. Someone put a dressing on it. Nurses know to do a risk management, pain management, notify the family and doctor, get an order, and update the care plan. On 08/05/2026 at 3:33 PM, V46 Licensed Practical Nurse (LPN) was inquired of R24's skin and assessments. V46 said, 'I've worked here for three years. The last day I worked with R24 was July 12th. I worked first (6AM - 2PM) and second (2PM - 10 PM) shift. If I found an open area on a resident I would clean the area, call the doctor to get orders, refer the resident to wound care, and do a new skin condition in the computer. I don't recall seeing any new open skin on her (R24). She usually complains of generalized pain to her lower extremities. It's neuropathy for her, she takes Gabapentin. We do skin checks during showers, bed baths, and peri care even if they refuse. She usually refuses baths. Everyone gets a shower twice a week. On 08/05/2026 at 3:41 PM, the unit shower book was reviewed with V46. The shower book is scheduled by room number. R24 is scheduled for Thursday on 6AM - 2PM shift and Monday on 2PM - 10PM shift. V46 said, After a shower or bed bath we check to make sure it was done and if there's any new skin condition. If a resident refuses, we still check their skin and notify the family if they refuse. R24's record review documents the following. R24's history of incidents documents skin condition incident on 03/09/2026 bilateral inner thigh chaffing due to rubbing together. A skin condition incident on 05/24/2026 scar tissue to left buttock. Frequent exposure to moisture due to incontinence. These are the only incidents documented. On 08/04/2026 at 2:16 PM, V22 LPN provided R24's wound assessment detail report. A facility acquired skin trauma identified by V22 documents type: trauma, classification: abrasion, clinical stage: superficial. Measurements: size (cm) 5.90 x 5.80 x 0.10 (L x W x D) [NAME] x Width x Depth. Area: 34.22 cm squared. Volume: 3.42 cm squared. The skin condition documentation dated 08/04/2026 at 1:35 PM states in part: 1. A. Skin condition Right Anterior lower leg superficial open area. b. Venous Insufficiency 5. a. Notifications a. Physician, b. phone, c. 08/04/2026 1:50 PM. d. Family notified 08/04/2026 1:35 PM. Additional comments: Patient seen for wound care assessment, evaluation, and treatment following nurse on duty report of a skin alteration to the right lower leg. Upon inquiry, patient is a poor historian, provided varying accounts regarding cause of skin alterations, states it was already seen by the nurse & the doctor. Patient initially refused wound assessment from wound care team & provider; however, education was provided regarding the clinical wound assessment indication and importance of assessment, after which the patient consented. Assessment revealed no overt SOI (signs of infection). Patient denied pain at the time of evaluation. Of note, patient has a history of venous insufficiency and BLE (Bilateral lower extremity) noted with areas of cicatrices. Wound care was provided as ordered with no adverse events or distress noted. Wound care team will continue to monitor, assess, and treat the wound as clinically indicated. Pain evaluation completed, R24 indicated pain, no interventions documented. The 08/04/2026 1:35 PM injury of unknown cause documents in part: incident description: superficial open area noted to right anterior lower leg/right shin. Resident description: patient is a poor historian, gave varying accounts, stated that it was already seen by the doctor and the nurse. Immediate action taken -wound care evaluation and treatment, PCP (Primary Care Physician) notified, Family at bedside aware, head to toe skin assessment was completed and no new skin issues noted. Injury location- right lower leg (front). Notes- (skin condition note from above copied in this section). On 08/05/2026 V2 DON Director of Nursing provided the state survey agency initial report for R24 observed with a superficial open area to right shin. V28 Podiatrist documented her visit note on July 13, 2026 stating in part: Chief Complaints: 1. Wound. HPI (History Present Illness): This is an [AGE] year old who is being seen for a chief complaint of wound located on the right pretibial region. Additional history: R24 is an [AGE] year old with a PMH (past medical history) significant for CKD (chronic kidney disease) state 3B, Chronic peripheral venous insufficiency that presents for initial evaluation of wound. Dry dressing noted to right shin. Superficially debrided today to diffuse superficial granular sites. No localized SOI (signs of infection). Discussed with nurse. Additional exam findings: Wound identifier: right shin. Wound location: right shin. Wound Width (in cm): 4.0. Presence of Infection: No. Wound Depth (in cm): 0.1. Presence of Gangrene: No. Wound Base: percentage of wound base: 100%. Wound Edges: adhered, hyperkeratotic, and well defined. Wound Depth Layer: subcutaneous tissue. Wound Length (in cm): 5.0. Odor: None Impression/Plan: 1. Open wound, Right. Unspecified open wound, right lower leg, initial encounter located on the right shin. Pain Intensity: 1.0 – 1/10 Pain. Plan: Wound Evaluation and Management- wound right shin. Location Right Shin. Wound Characteristics: Area: 20 cm^2. Volume: 2 cm^3. Initial Evaluation- Xeroform and DSD (dry sterile dressing) daily. R24's order summary report as of 08/04/2026 states in part: There is no order for podiatry. Right anterior lower leg: cleanse with normal saline solution, gently pat dry with gauze. Apply Xeroform dressing & cover with dry dressing & cover with dry dressing 3x/week & as needed every day shift every Tue, Thu, Sun to promote wound healing for soiling, saturation, dislodgement. To be carried out by the floor nurse if wound nurse is unavailable. Aquaphor Advanced Therapy External Ointment (Emollient). Apply to BLE (bilateral lower extremities) as directed topically two times a day for dry skin. 02/20/2026 There is no documentation of the Aquaphor being applied as ordered on the TAR (treatment administration record) or Certified Nurse Assistant documentation survey report for June 2026 or July 2026. R24's care plan states in part: Focus: R24 has potential for impairment to skin related to Braden score and Dx (diagnosis)/PMHx (past medical history) including but not limited to CHF (Congestive Heart Failure), CKD (chronic kidney disease), Chronic Anemia, HLD (Hyperlipidemia), Peripheral Venous Insufficiency, Fall, Obesity, Impaired mobility, and incontinence. Date initiated: 02/06/2026, revised on 05/20/2026 by V45 Wound Care Coordinator. Goal: R24's skin will remain intact through next review period. Revised on 05/20/2026 by V45. Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Date initiated 02/06/2026. Identify/document potential causative factors and eliminate/resolve where possible. Date initiated 02/06/2026. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (Medical Doctor). Date initiated 02/06/2026. Focus: R24 is resistive to care as evidenced by refused skin assessment and per therapy refused therapy evaluation. 2/11/26 Resident continues to refuse care as well as all therapy services. Refuses wound care at times. Date initiated 02/06/2026, revised 08/04/2026. Goal: Will cooperate with care through next review date. Date initiated 02/06/2026, revised 02/24/2026. Interventions: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Date initiated 02/06/2026. Give clear explanation of all care activities prior to and as they occur during each contact. Date initiated 02/06/2026. If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. Date initiated 02/06/2026. Inform MD (medical doctor) and responsible party with noncompliance of care. Date initiated 02/06/2026. R24's TAR (Treatment Administration Record) was reviewed for June 2026, July 2026, and August 2026. V26 Wound Care Nurse's initials were identified as KJ3. V22 LPN's initials were identified as JML. The TAR for June 2026 does not document any dates that R24 refused treatment to her sacral wound. There is no documentation of an open area to the right anterior lower leg. The TAR for July 2026 does not document any open area to the right anterior lower leg. V28 Podiatrist identified a dressing to the area during the visit, evaluated and treated the open area to R24's right anterior lower leg on Monday 07/13/2026. V28 documented in her progress note speaking with the wound care team. V26 documented administering R24's sacral treatment on Thursday 07/02/2026 refusal by R24, and Sunday 07/05/2026. There is no documentation on the treatment record identifying R24's right anterior lower leg open area. On Tuesday 07/07/2026 Nurse initials RR1 documented R24 refused. On Thursday 07/09/2026 Nurse initials cb1 documented code 9= other see nurse notes and Sunday 07/12/2026 Nurse initials cb1 documented refusal by R24. There is no documentation in R24's progress notes regarding 07/09/2026. There is no documentation on the treatment record identifying R24's right anterior lower leg open area. V26 documented administering R24's sacral wound treatment on Tuesday 07/14/2026, Thursday 07/16/2026, Sunday 07/19/2026 and Tuesday 07/21/2026 refusal by R24, and Thursday 07/23/2026. There is no documentation on the treatment record identifying R24's right anterior lower leg open area. On Sunday 07/26/2026, V22 LPN documented administering R24's sacral wound treatment. There is no documentation on the treatment record identifying R24's right anterior lower leg open area. V26 documented administering R24's sacral wound treatment on Tuesday 07/28/2026 and Thursday 07/30/2026. There is no documentation on the treatment record identifying R24's right anterior lower leg open area. On 08/06/2026 at 3:00 PM, V3 ADON Assistant Director of Nursing brought in the names of only three nurses who documented on R24's TAR documentation. V3 was asked to provide the names of all the nurses who documented on R24's TAR, but the information was not provided as requested. R24's right anterior lower leg open area was not identified by the facility staff until 08/04/2026 when this surveyor asked V23 RN Registered Nurse about the dressing to the leg. V23 informed the wound care staff V22 and V26. V22 and V26 denied knowledge of R24's dressing to her right anterior lower leg open area despite providing wound care to R24's sacral area. R24 would have been turned and repositioned exposing her lower legs at some point during the sacral wound treatment. R24's Certified Nurse Assistant (POC point of care) Documentation Survey Report for skin monitoring for June and July 2026 does not document any skin opening/alteration despite V28 Podiatrist identifying the dressing to R24's leg on 07/13/2026. R24's shower schedule documents every Thursday on 6AM – 2PM shift and every Monday on 2PM – 10 PM shift. R24's bath record for June 2026 documents she refused a bath/shower on 6/1/2026, 6/4/2026, 6/8/2026, 6/15/2026, and 6/25/2026. R24 received 2 baths for the month of June. There is no documentation on the bath record identifying R24's right anterior lower leg open area. R24's bath record for July 2026 documents she refused a bath/shower on 7/9/2026, 7/13/2026, 7/20/2026, 7/30/2026, and 8/3/2026. On 7/13/2026, V46 signed off on R24's bath record acknowledging performing a skin check on R24. On 08/05/2026 at 3:33 PM, V46 LPN was inquired of R24's skin and assessments. V46 said, We do skin checks during showers, bed baths, and peri care even if they refuse. She usually refuses baths. Everyone gets a shower twice a week. There is no documentation in the progress notes of R24's refusing the bath/shower on 7/13/2026 or the physician or family being notified by V46. R24 received a bath on 7/16/2026 after the open area to the right anterior lower leg was identified yet there is no documentation of it on the bath record. R24's bath record for 7/23/2026 and 7/27/2026 doesn't document whether she received a shower or bed bath and it was not signed by the nurse or C.N.A. R24's right anterior lower leg open area was not identified by the facility staff after having bath/shower skin checks by multiple nurses after 7/13/2026. It remains undermined when the skin incident occurred due to the lack of skin assessments and ADL (activities of daily living) care by nursing staff. R24's nursing and medical provider progress notes were reviewed from 06/03/2026 – 08/04/2026. R24's progress notes from 6/15/2026, 6/26/2026, 7/17/2026, by V9 Nurse Practitioner, NP states in part: Subjective: Pt often refusing care. Documented. Encouraged pt to allow nursing to care for her. Pt does not appear to have good decision-making skills at this time so often continues to be non-compliant. Physical exam: Extremities: + ble (bilateral lower extremity) ace bandaged; ble skin wrinkles from resolving edema; ble + trace edema. Assessment and plan: #Overgrown toenails. #Dry skin BLE. Continue Aquaphor thick lotion bid (twice a day) to ble. Consult podiatry- order entered. #Probable Dementia/Cognitive Impairment, Adjustment Disorder, Anxiety. Psychiatry evaluation notes baseline cognitive deficits affecting medical decision making. Poor insight, impaired memory, inconsistent understanding of hospitalization. Psychiatry recommends involvement of surrogate decision maker. There is no documentation on the progress notes identifying R24's right anterior lower leg open area. R24's progress notes from 7/21/2026 and 7/28/2026 by V10 MD Medical Doctor states in part: Subjective: c/o (complains of) caregiving issues. Pt does not appear to have good decision making skills at this time so often continues to be non-compliant. Physical exam: Extremities: + ble (bilateral lower extremity) ace bandaged; ble skin wrinkles from resolving edema; ble + trace edema. Assessment and plan: #Overgrown toenails. #Dry skin BLE. Continue Aquaphor thick lotion bid (twice a day) to ble. Consult podiatry- order entered. There is no documentation on the progress notes identifying R24's right anterior lower leg open area. The treatment nurse job description states in part: Purpose of your job description: The primary purpose of your job position is to provide primary skin care to residents under the medical direction and supervision of the residents' attending physicians, the Director of Nursing Services, or the Medical Director of the facility, with an emphasis on treatment and therapy of skin disorders. You will also assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident, in accordance with established medical practices and the requirements of this state and the policies and goals of this facility. Duties and Responsibilities: Confer with the Director of Nursing Services and/or other licensed nursing personnel regarding dermatologic disorders of resident in the facility. Consult with the care planning team concerning assessment evaluations and assist in planning and developing the skin care treatment to be performed for the resident. Initiate requests for consultation or referral. Respond to requests from the resident, physician, or nursing staff. Examine the resident and his/her records and charts, and discriminate between normal and abnormal findings, in order to recognize when to refer the resident to a physician for evaluation, supervision, or directions. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. Implement and maintain established policies and procedures relative to skin care treatments. Interpret these to the physician, resident family members, and public as appropriate. Administrative Functions: Make written and oral reports/recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents. Medical Care Functions: Identify, manage, and treat specific skin disorders and primary and secondary lesions, such as skin abrasions, foot problems such as corns and callouses, decubitus ulcers, bacterial, parasitic and viral skin infections, scaling papular diseases, and benign tumors. Provide assessment and diagnostic services to residents. Perform an assessment evaluation using techniques including observation, inspection, and palpation. Provide, within established protocols and under the supervision of the physician, treatment for uncomplicated dermatologic disorders as directed by the attending physician or Medical Director. Provide information to resident and family members of prevention techniques and other ways to maintain or improve the general health and psychosocial status of the resident. V26 Wound Care Nurse signed and acknowledged the treatment nurse job description on 01/29/2026. V22 LPN signed and acknowledged the treatment nurse job description on 02/16/2022. The Director of Nursing Services job description states in part: Purpose of your job description: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Make written oral reports/recommendations to the Administrator, as necessary/required, concerning the operation of the nursing service department. Administrative Functions: Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care. Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary. Personnel Functions: Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties. Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards. Nursing Care Functions: Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care and that such care is provided in accordance with the resident's wishes. Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request. Care plan and Assessment Functions: Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident. Review nurses' notes to determine if the care plan is being followed. V2 DON signed and acknowledged the Director of Nursing job description on 4/1/2025. Wound Prevention and Healing Policy (April 2026) states in part: General: To provide wound care treatments/services (using a multidisciplinary approach) based on evidence- based standards of care under the direction of a physician. Responsibility: Nursing Procedure: 2. Wound Assessment and Documentation Tool Complete the Wound Assessment Record when a wound is identified, weekly and or as needed. Each wound will be numbered and documentation associated with each numbered wound. Goal will focus on the clinical status of the wound, guide the appropriate intervention for the wound, indicate that, if there is no change in wound status within a pre-determined timeframe, re-assess and alter the plan, monitor and evaluate overall client outcomes (progression or regression), and determine the effectiveness of treatment. Each wound may be photographed for documentation of weekly progress. 9. Continued/Ongoing Treatment a. Nurse/therapists will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment. The nurse/therapist will notify the physician for any change in the patient condition or lack of progress. 10. Wound Care and Treatments a. Wound care treatments are provided within an individualized plan of care under the direction of a physician. 11. The Multidisciplinary Wound Care Team 1. The Wound Care team is responsible for identifying problems, coordinating care, and promoting development of the team and the program. 2. Certified Wound Care Nurses (CWCN) and trained nurses are responsible for oversight of wound care rendered to all wound care patients, including the patient assessments, evaluation treatment regimens, plans of care, care outcomes, and cost effective of the treatment plan of care. 3. Wound Care Nurses provide case management, assessment and skilled interventions to patients requiring the care of specially trained wound care nurse and assist with the above. 12. Staff Education and Competency Testing 2. All nursing staff will complete competency assessments for basic wound care and prevention, including wound related topics that would be beneficial to patient care. These will be comple

Based on observation, interview and record review, the facility failed to ensure that staff use appropriate personal protective equipment (PPE) when entering a room for a resident' on contact isolation for one resident (R48), failed to have a cover on food items (drinks and desert) that were being transported in the hallway to residents' rooms, failed to transport clean linen using a cart with a solid bottom, failed to contain soiled linen prior to putting down laundry chute, failed to properly sanitize multi-use items between residents, and failed to follow facility policy for hand hygiene. These failures have the potential to affect all 136 residents at the facility. On 08/05/06, at 10:00 AM, observed linen cart being transported from the laundry area to replenish linen closets and floor linens. Linen cart did not have a solid bottom to keep linens clean. V44 (Laundry/Environmental Services Staff) stated we have used this type of cart for the 12 years he has worked here. On 08/05/06, at 10:06 AM, observed unbagged and uncontained bed sheets and bed pad soaked with yellow stains in the soiled linen bin/cart below the linen chute. V43 (Laundry/Environmental Services Director) opened the chute per surveyor request and there was an unbagged and uncontained bed pad with yellow stains and ammonia scent. V43 stated soiled linens are to be bagged and contained to prevent cross-contamination and reduce the risk of infections. V43 (Laundry/Environmental Services Director) has reported issue of unbagged and uncontained linens to the DON (Director of Nursing), ADON (Assistant Director of Nursing), and Administrator during our meetings and staff continue to not follow the policy. On 08/05/2026, at 10:30 AM, observed 1st Floor Wing B and 3rd Floor Wing B clean linen rooms and linen carts had open metal grated bottom. There was potential for splashing when housekeeping mops the clean linen rooms. V43 confirmed the two linen carts did not have a solid bottom to keep linen clean. On 08/05/2026, at 11:00 AM, V43 confirmed the linen storage, and linen transport practices were not in accordance with accepted national standards such as the CDC. On 8/3/2026 at 2:47PM, Surveyor observed the clean linen cart outside of unoccupied rooms 340/341 open and facing the hallway. A gown on the bottom shelf was hanging down and touching the floor. During the observation at 8/3/2026 at 2:47PM, V63 (Activities Director) approached the cart and put the flap down in order to close off the exposed linens from the hallway. V63 (Activities Director) relayed that she noticed the open linen cart while doing her angel rounds and acknowledged the linen cart should remain closed/covered to prevent contamination and germs to the linens. ___ During medication pass observations on 8/4/2026, V23 (Registered Nurse/RN) took the blood pressure for the first resident at 9:12AM and administered medications. Resident is on Enhanced Barrier Precautions due to ostomy. Hand hygiene was completed following the interaction, however the Blood pressure cuff was not cleaned following the care. V23 (Registered Nurse) then proceeded to the TV room at 9:20AM where the next resident was sitting with her fingers in her mouth. V23 (Registered Nurse) then took the blood pressure and pulse oximetry readings for that resident. Equipment (blood pressure cuff and pulse oximeter) were both not sanitized following this interaction. On 8/4/2026 at 9:35AM, Surveyor asked V23 (RN) about the sanitizing of equipment in between residents for multi-use items such as the blood pressure cuff and the pulse oximeter. V23 (RN) stated, Yes, I completely forgot to clean them between residents. Yes, we need to clean them between residents to not spread germs. On 8/5/2026 at 12:30PM, V2 (Director of Nursing) confirmed that all equipment used for more than one resident needs to be properly sanitized in between residents. - On 08/03/2026 1:55 PM, V19 (CNA) was observed taking food trays down the hallway on a metal cart, surveyor observed the Jello, three bean salad and the juice cups on the tray were all open. There was cover on the whole metal cart either. Surveyor presented this observation to V19 who stated that she has worked at the facility for more than 2 years and they never cover the meal cart when delivering food to the rooms. Surveyor also observed V19 delivering lunch tray to R48 who is on contact isolation, with a clear contact isolation sign on the door, instruction for PPE usage and PPE set up by the entrance door. V19 did not wear any PPE or perform any hand hygiene before and after entering the room. When presented with this observation V19 said, Oh I forgot, I usually wear some but in the midst of everything, I forgot. On 8/4/2026 at 12:15PM, V59 (Certified Nursing Assistant/CNA) was observed passing trays to multiple residents in their rooms in one hallway. No hand hygiene was completed after interacting with each resident. On 8/4/2026 at 12:20PM, Surveyor asked V59 (CNA) about the expectation for hand hygiene, and V59 (CNA) stated Yes, sorry I was nervous and forgot; we are to use sanitizer in between residents. On 8/4/2026 at 12:15PM, V7 (Dietary Manager) observed the tray pass with Surveyor, and confirmed the lack of hand sanitization in-between residents. V7 (Dietary Manager) provided education to V59 (CNA) regarding the expectation of hand hygiene after interacting with residents and their environments. Facility policy Hand Washing/Hand Hygiene (April 2025) documents in part that All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors and use an alcohol-based hand rub containing at least 62% alcohol (or soap and water) in the following instances: Before and after direct contact with residents.After contact with objects in the immediate vicinity of the resident.Before and after handling food.Before and after assisting a resident with meals. Facility policy Linen Management (June 2021) documents in part It is the policy of the facility to ensure linens are handling in a way to prevent cross contamination and the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedures include: Clean linens are to be kept covered and protected from dust and other contaminants prior to use, Clean linens should not touch the floor when folded and, Dirty linens are contained in a closed container or bag. Facility Policy Cleaning and Disinfection – Resident Equipment (June 2021) documents in part Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to discard respiratory equipment as directed, and/or failed to ensure that respiratory equipment was contained when not in use for seven residents (R2, R8, R52, R64, R111, R120, R127) in a sample of 29 residents. Findings include: 1. On 6/4/26, IDPH (Illinois Department of Public Health) received allegations that R52's oxygen tubing is short. R52's diagnoses include dementia and COPD (Chronic Obstructive Pulmonary Disease). R52's (6/25/26) BIMS (Brief Interview Mental Status) determined a score of 11 (moderate impairment). R52's (9/25/24) care plan states the resident has COPD, on oxygen therapy. R52's (12/28/24) physician orders include oxygen via nasal cannula @ 5L (liters)/minute every shift. On 8/3/26 at 10:53 am, R52's oxygen concentrator was on 5L however the attached nasal canula was on the bed. R52 was observed approaching the bathroom (without oxygen). V12 (Restorative Nurse) subsequently entered the room and assisted R52 into the bathroom, however failed to place oxygen (as ordered) on the resident. When V12 and R52 exited the bathroom surveyor inquired if R52 requires 5 liters of continuous oxygen R52 stated, Yes. Surveyor inquired if R52 has oxygen on V12 responded, No. Surveyor inquired if R52's oxygen tubing can reach the bathroom V12 replied, No. Surveyor inquired if extension tubing should be used to reach the bathroom, V12 stated, Yeah, I (V12) believe so. V12 affirmed she would get R52's assigned Nurse and left the room - without placing R52's wheelchair near the bed (so the resident could reach the nasal canula) and/or placing oxygen on R52. On 8/3/26 at 11:07am, (14 minutes later) V13 (Licensed Practical Nurse) entered the room, attached extension tubing on R52's nasal canula, then placed the nasal cannula on R52. 2. On 8/3/26 at 11:17am, R120's nebulizer mask was observed (uncontained) on the dresser. R120's nebulizer mask was dated 7/13 (3 weeks ago). Surveyor inquired if R120's nebulizer mask was contained in a bag V15 (Certified Nursing Assistant) stated, No. Surveyor inquired when R120's nebulizer mask was dated V15 responded, Seven thirteen. On 8/3/26 at 11:37am, surveyor inquired how resident nebulizer masks should be contained - when not in use V14 (Licensed Practical Nurse) responded, We (staff) put em in a plastic bag and make sure it's clean. Surveyor inquired when nebulizer masks should be changed or discarded V14 replied, We change it at least weekly. 3. R64's Face Sheet documents in part that R64 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part chronic diastolic heart failure, convulsions, unspecified dementia, cerebrovascular disease, peripheral vascular disease, and major depressive disorder. R64's Minimum Data Set (MDS) on 6/24/2026 documents in part a Brief Interview for Mental Status (BIMS) of 15, indicating that R64 is cognitively intact, and that R64 is dependent for toileting, bathing, and dressing. R64's Physician Order Summary report includes in part, Oxygen as needed via nasal cannula 1 lpm (liters per minute) as needed every shift. (11/20/2023) On 8/3/2026 at 10:42AM, gallon of half-empty distilled water was noted on R64's bedside dresser. No open date was located on the container. On 8/3/2026 at 10:42AM, V13 (Licensed Practical Nurse/LPN) affirmed that R64's distilled water had been opened, and no open date was located on the bottle. V13 (LPN) confirmed, yes, we are to mark the date on the bottle when it is opened. I (V13) think they are only good for about a month after opening. 4. R8's Face Sheet documents in part that R8 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part unspecified dementia, heart failure (on hospice effective 7/9/2026), anxiety, major depressive disorder, stage IV wound to sacrum, pressure-induced deep tissue damage to the bilateral heels, and chronic obstructive pulmonary disorder. R8's Minimum Data Set (MDS) on 7/17/2026 documents in part a Brief Interview for Mental Status (BIMS) of 4, indicating that R8 is severely cognitively impaired, and that R8 is dependent for all activities of daily living. R8's Physician Order Summary report includes in part Oxygen 2 lpm (liters per minute) as needed, keep oxygen saturation 92% or greater every shift for shortness of breath or desaturations. (6/2/2026) On 8/3/2026 at 11:12AM, gallon of distilled water was noted on R8's nightstand. Bottle had been opened and was approximately half empty. No Open date was located on the container. On 8/3/2026 at 11:18AM, V13 (LPN) affirmed that R8's distilled water had been opened, and no open date was located on the bottle. V13 (LPN) then discarded the remaining liquid from the gallon. 5. R2's Face Sheet documents in part that R2 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part paraplegia, morbid obesity, stage IV sacral wound, colostomy, diabetes mellitus, spina bifida, hepatitis C, and major depressive disorder. R2's Minimum Data Set (MDS) on 7/7/2026 documents in part a Brief Interview for Mental Status (BIMS) of 12, indicating that R2 is moderately cognitively impaired, and that R2 is dependent for toileting, bathing, and dressing. R2's Physician Order Summary report includes in part, Respiratory therapy to evaluate and treat (3/11/2026) with no current oxygen orders noted. On 8/3/2026 at 3:30PM, gallon of distilled water was noted on R2's nightstand. Bottle had been opened and was approximately ¾ full. No Open date was located on the container. On 8/3/2026 at 3:35PM, V14 (LPN) affirmed that R2's distilled water had been opened, and no open date was located on the bottle. V14 (LPN) stated she would remove it from the room. 6. R127's Face Sheet documents in part that R127 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part anemia, heart failure, leukopenia, and osteoarthritis. R127's Minimum Data Set (MDS) on 6/23/2026 documents in part a Brief Interview for Mental Status (BIMS) of 13, indicating that R127 is cognitively intact, and that R127 requires substantial/maximum assistance for toileting, bathing, and dressing. On 8/3/2026 at 1:40PM, R127's oxygen tubing and cannula were coiled up and laying on top of the oxygen concentrator. R127 verbalizes that she primarily uses oxygen at nighttime. On 8/3/2026 at 1:50PM, V13 (LPN) confirmed the placement of the oxygen tubing not currently in use and affirmed that oxygen tubing should be in a bag when not in use. V13 (LPN) noted the date on the oxygen tubing was smudged but it looks like 6/9/26? V13 (LPN) then discarded the oxygen tubing. On 8/5/2026 at 12:10PM, R127's nasal cannula remained coiled up and lying on top of the oxygen concentrator, not contained in a bag. On 8/5/2026 at 12:32PM, V61 (LPN) confirmed oxygen tubing and cannula are not covered and are open to air. V61 (LPN) affirmed that cannula should be in a plastic bag when not in use. 7. R111's Face Sheet documents in part that R111 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include in part end stage renal disease (dependence on dialysis), obstructive sleep apnea, seizures, anxiety, bipolar disorder, and chronic respiratory failure with hypercapnia. R111's Minimum Data Set (MDS) on 5/26/2026 documents in part a Brief Interview for Mental Status (BIMS) of 9, indicating that R111 is moderately cognitively impaired, and that R111 is dependent for toileting, bathing, and dressing. R111's Care Plan includes in part that R111 Requires oxygen therapy related to obstructive sleep apnea and hypercarbic respiratory failure and Altered respiratory status related to chronic respiratory failure with hypercapnia with interventions including Bipap 22/17 with 3 lpm (liters per minute) during sleep at bedtime. R111's Physician Order Summary report includes in part Bipap 22/17 with 3 lpm (liters per minute) during sleep at bedtime (12/8/2025). On 8/3/2026 at 3:42PM, R111 returned from dialysis. Surveyor noted R111's respiratory mask was laying uncovered in the basket attached to the respiratory machine. Oxygen tubing was also noted sticking out of the top drawer uncovered. On 8/3/2026 at 3:44PM, V14 (LPN) confirmed findings and stated There is a plastic bag underneath the mask. It was there, just not covering the mask. V14 (LPN) affirmed that all respiratory masks and cannulas should be covered/contained when not in use. On 8/5/2026 at 12:30PM, V2 (Director of Nursing) confirms that all respiratory equipment is to be covered while not in use and that the distilled water for the humidifiers are to be dated when opened to prevent contamination. Facility Policy Oxygen Administration (June 2021) documents in part Keep delivery devices covered in plastic bag when not in use. The oxygen administration policy (reviewed February 2026) states oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Oxygen is administered under orders of a physician. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. Keep delivery devices covered in plastic bag when not in use.

Based upon interview and record review the facility failed to ensure that interdisciplinary care plan meetings were conducted quarterly to review/revise the comprehensive care plan, and/or failed to document care plan meeting minutes for four of 29 residents (R25, R52, R83, R120) in the sample reviewed for care planning these failures have the potential to affect 136 residents in the facility.Findings include:The 8/2/26 facility census includes 136 residents.On 8/4/26 at 10:30am, V18 (Family) alleged that care plan meetings are not conducted quarterly at the facility.On 8/4/26, surveyor requested documentation for R25, R52, R83, and R120's care plan meetings for the past 12 months.R25, R52, R83, and R120's care plan meeting documentation (received on 8/5/26) affirmed that quarterly meetings were not conducted and/or documented for each resident. R25 was admitted to the facility on [DATE].On 8/5/26 at 11:21am, surveyor inquired when facility care plan meetings are conducted V31 (Social Service Director) replied, Within 72 hours of admission, significant changes, quarterly, or resident family request. Surveyor inquired when R25's care plan meetings were conducted for the past 12 months V31 stated, September 24, 2025 (over 12 months ago), and the next one is June 26 in 2026. Surveyor inquired if R25's 9/24/25 and 6/26/26 care plan meetings were documented V31 reviewed R52's progress notes and responded, I (V31) do not see any notes. Surveyor inquired about facility care plan meeting requirements V31 replied, Taking notes and documenting what was discussed. Surveyor inquired if quarterly care plan meetings were conducted for R25 V31 stated No.R83 was readmitted to the facility on [DATE].On 8/5/26 at 11:23am, surveyor inquired when R83's care plan meetings were conducted for the past 12 months V31 stated, June 5, 2026, and that is the only one (R83 was admitted 16 months ago). Surveyor inquired if R83's care plan meeting was documented on 6/5/26 V31 responded No.R52 was readmitted to the facility on [DATE].On 8/5/26 at 11:25am, surveyor inquired when R52's care plan meetings were conducted for the past 12 months. V31 stated, There was one on March 4, 2026, that was documented and another one July 10, 2026, and for this one there is a note therefore not conducted quarterly.R120 was readmitted to the facility on [DATE].On 8/5/26 at 11:29am, surveyor inquired when R120's care plan meetings were conducted for the past 12 months. V31 responded, She (R120) had one scheduled for June 15, 2026, nothing was documented on that day. The care planning policy (revised April 2026) states our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the residents and family [Care plan meeting requirements are excluded].

Based on interview and record review, the facility failed to follow policy and care plans to ensure timely response to resident call lights and requests for personal care for three residents (R8, R42, R72) in a sample of 29 residents reviewed for accommodation of needs. Findings include: On 8/4/2026 at 1:21 PM, the resident council unanimously agreed staff answering call lights was a concern that had not being addressed by the facility. The resident council explained on night shift, it takes at least two and a half to five hours for staff to answer call lights. R147's Face Sheet documents in part R147 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include diabetes mellitus, dysphagia, sepsis with septic shock, and chronic kidney disease (on dialysis). R147's Minimum Data Set (MDS) on 7/23/2026 documents in part a Brief Interview for Mental Status (BIMS) of 12, indicating R147 has moderate cognitive impairment, and R147 requires supervision/touch assistance for toileting, partial/moderate assistance for bathing, and set up assistance for dressing. R147's Care Plan while at facility included in part .at risk for falls related to unsteady gait, weakness as secondary to history of falls with interventions including Be sure call light is within reach and encourage to use it for assistance as needed. Prompt response to all requests for assistance. On 8/6/2026 at 12:15PM, R147 was interviewed via phone. Per R147, It was really bad at the facility, people scream at you, most of them. I'm glad I'm home. They are always short of help. Not my fault that they are short. I'm (R147) at risk for falls. They would get mad when I got up without help. But then when I would call, they would say, can't you do that for yourself? I couldn't win. I want to hang up now. It's making me mad talking about it. R42's Face Sheet documents in part R42 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part primary progressive Multiple Sclerosis, heart failure, dementia moderate, anxiety, and chronic obstructive pulmonary disease. R42's Minimum Data Set (MDS) on 5/14/2026 documents in part a Brief Interview for Mental Status (BIMS) of 14, indicating R42 is cognitively intact, and R42 requires substantial/maximum assistance for dressing, supervision/touch assist for toileting, and is dependent for bathing. R42's Care Plan includes in part R42 has alteration in musculoskeletal status. and interventions include in part Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Care Plan also includes potential for impairment to skin integrity related to Braden score and diagnoses/past medical history with interventions including Follow facility policies/protocols for the prevention/treatment of skin breakdowns. On 8/3/2026 at 11:00AM, R42 relayed her concerns about staff not answering call lights timely. Per R42, Getting the call lights answered late at night is next to impossible. I need help with repositioning because MS (Multiple Sclerosis) affected the lower part of my body. Even during the day, the CNAs (Certified Nursing Assistants) have to monitor residents in the TV room two times a shift for half hour, so it takes the CNAs away from us during time. R8's Face Sheet documents in part R8 is a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part unspecified dementia, heart failure (on hospice effective 7/9/2026), anxiety, major depressive disorder, stage IV wound to sacrum, pressure-induced deep tissue damage to the bilateral heels, and chronic obstructive pulmonary disorder. R8's Minimum Data Set (MDS) on 7/17/2026 documents in part a Brief Interview for Mental Status (BIMS) of 4, indicating R8 is severely cognitively impaired, and R8 is dependent for all activities of daily living. R8's Care Plan includes in part R8 has alteration in skin integrity related to Braden and diagnoses/past medical history. On 8/3/2026 at 11:12AM, R8's family was at bedside. V64 (son of R8) verbalized concerns R8 was not receiving personal care timely. V64 stated he has asked previously to have R8's incontinence products changed and was told, We will do it after lunch. This happens even before they start to serve lunch. I know they (facility staff) are busy serving residents during lunch time, so's why I try to ask before. R72's Face Sheet documents in part R72 is an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses include in part periprosthetic fracture around internal prosthetic right hip joint, chronic obstructive pulmonary disease, heart failure, arthritis, and mild protein calorie malnutrition. R72's Minimum Data Set (MDS) on 5/27/2026 documents in part a Brief Interview for Mental Status (BIMS) of 13, indicating R72 is cognitively intact, and R72 substantial/maximum assistance for bathing, toileting, and dressing. R72's Care Plan includes in part R72 has alteration in skin integrity and potential for further alteration in skin integrity related to Braden score and diagnoses/past medical history. R72's Physician Order Summary report includes in part Right Hallux/Great Toe Cleanse with Normal Saline Solution, gently pat dry with gauze, apply bacitracin and cover with dry dressing daily and as needed for soiling, saturation or dislodgement; floor nurse to carry out if wound nurse unavailable. (7/25/2026) On 8/3/2026 at 11:45AM, R72 expressed, The facility is often short staffed on the weekend and overnights. Sometimes it takes 5 hours for needs to be addressed, and I just have to sit in my pee. If they can't check on me in 6 hours, then they certainly aren't able to check on me every 2 hours. And when they do answer, they turn off the light and sometimes don't come back. So then I need to put it on again. Review of 6 months of Resident Council minutes regarding concerns of extended wait time for call light response shows: On 12/19/2025 Council suggests hiring someone to sit in the TV room, feels aide sitting in the TV room is taking away from patient care. On 1/29/2026 Council suggests hiring someone to sit in the TV room, feels aide sitting in the TV room is taking away from patient care. Resolution: Management is still looking into solution. CAN: need improvement in response time. On 7/29/2026 Concerns – After 9pm no CNAs do their rounds or checks up on her to see if she needs anything. And CNAs on 3rd shift will not make rounds or answer call lights. Review of 6 months of Grievance/Concern Forms regarding concerns of extended wait time for call light response shows: On 2/16/2026 Call light times. On 2/20/2026 CNA first shift today – poor customer service and long call light times. On 3/22/2026 Complaining of long call light times for nurse and CNA – poor bedside manner from CNA On 4/7/2026 Long call light times and improper bedside manner during 3rd shift, specifically night of arrival 4/5 On 4/16/2026 Patient stated call light felt like an hour long on 4/15 around 8pm. Patient pressed call light to use bathroom. Outcome – Call light confirmed 16 minutes long. On 4/19/2026 Long call light times 3rd shift. Staff education provided on 5/26/2026: Answer call lights within a reasonable time and make sure call lights are always in reach of the resident. Staff education provided on 6/30/2026: Staff must answer call lights in a timely manner. When you tell a resident/patient you will be back, you must return to them as soon as possible. Staff education provided on 8/4/2026: All staff to respond to call light in a timely manner or as soon as it is seen. Do not turn call light off until all services are rendered/completed. No documentation of other in-services regarding call light response (for a 6-month timeframe) were provided during the survey. On 8/5/2026 at 12:30PM, V2 (Director of Nursing) affirmed all staff are responsible for answering call lights and they should be answered as quickly as possible to address resident needs. Facility policy Call Light Response (June 2021) documents in part Any staff members who see or hear an activated call light is responsible for responding and Staff will ensure the call light is within reach of resident.

Based on observation, interview, and record review, the facility failed to ensure there was sufficient unlicensed nursing staff to meet resident needs.This applies to 15 residents (R1, R4, R6, R8-R11, R14-R21) reviewed for daily staffing levels. The findings include: 1. R1's 12/22/2025 Minimum Data Set (MDS) showed she is cognitively intact. On 2/20/2026 at 10:41 AM, R1 stated her shower days are Mondays on day shift and Thursdays on evening shift. R1 stated she did not get her shower the evening before on 2/19. R1 stated staff did not get her up and staff had to supervise the residents in the TV room. R1 stated they never have enough help.last Sunday, they had no help. On 2/24/2026 at 2:41 PM, V6 CNA (Certified Nursing Assistant) stated she was assigned to R1 on 2/19/2026. V6 stated she gave R1 a bed bath and not a shower since there was too much to do. V6 stated she wiped [R1's] hot spots and gave a quick wash down instead. V6 stated it was too hard to get R1 up with the mechanical lift for a shower since CNAs have three showers to give when they work short, she did not complete any shower sheet documentation for R1. R1's 12/22/2025 MDS showed she was dependent on staff for chair/bed to chair transfers and toilet transfers (with dependent defined as helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required to complete the activity). The same MDS showed she R1 is substantial/maximum assist for tub/shower transfers. 2. On 2/20/2026 at 12:52 PM, R6 stated she washes herself. R6 stated that one CNA has 15 residents to care for, adding it is ridiculous. R6 stated they don't have time to do their work so she tries not to bother them and will lay in bed. R6 stated that the day before, she turned on her call light at 9:40 AM and wanted to use a bedpan. R6 stated no one came and she soiled herself at 10:30 AM. R6 stated, it's not fair to the residents or the CNAs. R6 stated she was late to dialysis on 2/20/2026 since the night shift CNA had three other residents that needed attention, so the CNA was running behind. R6 stated she is to be at dialysis at 5:00 AM and she got there at 5:25 AM. The facility's Grievance Log showed on 2/16/26, R6 had also complained of call light response time. 3. R4's 6/6/2025 care plan showed he requires substantial staff assist with bathing, is cognitively impaired, and he is on a restorative program. On 2/24/2026 at 1:09 PM, V12 (CNA) stated she was not able to give R4 his scheduled shower, so she gave him a bed bath instead. V12 also stated she has five residents in her assignment that require feeding assistance and staff must spend 30 minutes sitting in the TV room to monitor residents. V12 stated if they are working short, they have to sit in there for more than an hour, adding we don't have enough time. V12 stated if you are working short, not everyone is going to get their scheduled showers. V12 stated it's impossible to take care of the residents the way they need to be taken care of. 4. On 2/26/26 at 1:11PM, R8 stated that staffing is terrible. R8 stated she needs a mechanical lift for transfers and said she didn't get a shower last Thursday. R8 stated she was so disappointed. this place was wonderful . R8 stated she is supposed to get Restorative Therapy two times a week and if R8 is lucky, she gets it once in a week. R8 also stated that on Valentines Day, she stayed in bed all day long. R8 stated then on that Sunday, they couldn't get her up for church on time. R8 stated they got her up at noon, and then she went back to bed at 3:00 PM. R8 stated Today they have 5 people working on the unit. First time in a long time. 5. On 2/26/26 at 1:20 PM, R11 stated that she needs a mechanical lift for transfers. R11 stated she gets showers on Mondays and Thursdays and will take a sponge bath on Mondays since she doesn't like to go to bed with wet hair. R11 stated she has not made any complaints about her shower, but she only gets Restorative Therapy once a week. R11 stated they bend her knees and stretch her arms, but the Restorative staff are being pulled to the unit. R11 stated they are short-staffed, and they don't have enough people. R11 stated they are late getting people up, too. 6. On 2/26/26 at 12:34 PM, R9 stated that she only gets restorative therapy once a week and the Restorative Aide wants her to do three days. R9 stated the Restorative Aide gets pulled to the unit and she doesn't see him because he is doing CNA work. 7. On 2/26/26 at 12:47 PM, R10 stated that the facility is short-staffed, especially at night. R10 stated we have to go to bed at certain times, and they don't always assist R10 to the bathroom. R10 stated and they don't come and walk me; they only come once in a while. R10 added staff very seldom answer call lights on time, especially when residents are in the bathroom. On 2/24/26 at 12: 23 PM, V11 (Restorative Aid/CNA) stated that he is one of the Restorative Aids and he is working on the floor. V11 stated he has not done restorative work today (2/24/26) since he is working on the floor as a CNA. V11 stated with Restorative, he exercises and walks the residents so that they won't lose their mobility. V11 stated thirteen (R10, R14, R15, R16, R17, R18, R19, R20, R21) of his residents are supposed to do Range of Motion and nine residents (R10, R14-R21) need assistance with ambulation. V11 stated he was pulled to the floor today and it happens at least twice per week. On 2/20/26 at 2:40 PM, V16 (Scheduler) stated they have 8-hour shifts for the nurses and 7.5-hour shifts for the CNAs. V16 stated the whole building census was 151 residents. V16 stated during AM and PM shifts, first floor has 3 nurses and 4 CNAs, depending on the census; second floor has 3 nurses and 5 CNAs; and 3rd floor has 3 nurses and 5 CNAs. On 2/20/26 at 10:20 AM, V14 (LPN) stated third floor staffing is horrible. V14 stated sometimes there are four CNAs with 15 residents apiece, and sometimes there's just three CNAs. V14 stated for proper care of the residents, they have to pass trays and do the dining area, answer call lights, watch the residents in the TV room, and give showers. V14 stated when staff work short, they are not able to give showers or answer call lights timely. The third floor day shift shower schedule showed 11 showers are scheduled for the AM shift on Tuesdays, Wednesdays, and Saturdays; 12 showers are scheduled on AMs on Thursdays and Fridays, and 13 are scheduled for AM shift on Mondays. On 2/20/2026 at 9:59 AM, V17 (CNA) stated staffing was not good and staff had been working short for weeks. V17 stated they have been trying to do their best, but staff aren't giving showers because we're swamped. On 2/20/2026 at 9:55 AM, V13 LPN (Licensed Practical Nurse) stated the shift is always short and they have 3-4 CNAs, and we rarely have five. V13 stated giving the showers is difficult and the TV room is very difficult to monitor. On 2/20/26 at 1:09 PM, V15 (Restorative Aid) had been pulled to the second floor and was monitoring the residents in the TV room. On 2/26/26 at 12:10 PM, V18 (LPN/Restorative Nurse) stated that she started in January of this year and has a total of five Restorative Aids, with one Aid to help her specifically. V18 stated sometimes this Aide also gets pulled to the unit. V18 stated that when the Restorative Aids get pulled to work as CNAs, residents are not walking, and the Restorative charting is not getting done. On 2/26/26 at 10:59 AM V10 (Restorative Aid) stated that she works with the Restorative Nurse and Restorative Aids are pulled to the floor at least 2-3 days a week. V10 stated we are short on the floor with sometimes only three CNAs and it's hard. V10 stated on second and third floors, they have a lot of mechanical lift transfers and with short staff it is hard to give showers, and the care is not going to be good. V10 stated ideally it should be five CNAs, but they don't look at the care residents need. On 2/24/2026 at 11:00 AM, V2 (DON/Director of Nursing) stated it is always a two-person transfer when a mechanical lift is used. On 2/26/26, a list was provided that showed 75 residents required the use of a mechanical lift for transfers, and another list showed 70 residents were supposed to be on restorative programs. The Facility Assessment Tool (reviewed 6/24/2025) showed it is licensed for 197 residents with an average daily census of 140. Part 1.7 under Other, the Tool showed the facility takes sleeping preferences and bathing preferences into account when determining staffing and resource needs to assist the staff in tailoring each resident's care needs and preferences. Part 3.2 in the Staffing Plan section of the Tool where it should list the full-time equivalents of Licensed Nurses and Certified Nursing Assistants needed to staff the facility was left blank. Under Individual staff assignment, the Tool showed Individual staffing assignments are determined at the facility level and take into consideration the current support/care needs of the residents that include, but are not limited to, medical/physical conditions, acuity.therapeutic needs .

Based on observation, interview, and record review, the facility failed to ensure progress notes and orders from a Dermatologist were obtained and carried out in a timely manner for a resident with basal cell carcinoma.This applies to 1 resident (R2) reviewed for non-pressure wounds. Findings include: On 2/20/2026 at 10:40 AM, R2 was in the activity room with other residents. R2's left cheek had a wound on it that was open to air. R2's fingernails were long and were stained with a dried red substance. At 11:45 AM, V3 LPN/WCD (Licensed Practical Nurse/Wound Care Director) stated R2 has a state guardian and the Wound Care Nurse Practitioner sees R2 weekly. V3 stated staff try to put a wound dressing on R2's face to cover the lesion but he removes it, and he likes to pick at the area.R2's faxed Dermatologist notes from his 2/4/2026 appointment showed a 2/9/2026 post-biopsy addendum identifying his lesion as basal cell carcinoma (BCC). The Assessment and Plan section of R2's 2/4/2026 notes showed his lesion was exacerbated from scratching and R2 had bloody residue under his left fingernails. The Plan showed instructed to cut and file nails short to prevent scratching.use occlusive dressing to prevent scratching if possible.alternatively mittens could be used at night to prevent manipulation.keep ulcer clean, as it currently is, topicals that may be helpful are Silvadene applications. The faxed notes showed they were last updated on 2/9/2026 and faxed to the facility on 2/23/2026 (during the survey), over two weeks after the appointment. After the fax cover page, a letter was included from the Dermatologist (also dated 2/23/2026) that was sent to the attention of V7 (Medical Records). The letter showed Please note the assessment and plan including recommendations for follow-up. R2's EMR (electronic medical record) showed the notes were uploaded on 2/24/2026, 20 day after the appointment.R2's facility wound progress noted from 1/13, 1/29, and 2/12/2026 (written by V5, Wound Nurse Practitioner [NP]) all showed Per staff, patient has a dermatology appointment in March 2026. V5's 2/12/2026 assessment notes for R2 showed his carcinoma lesion measured (in centimeters) 6 x 3.5 x 0.1, with 60% eschar and 40% devitalized tissue.On 2/26/2026 at 10:15 AM, V5 (Wound NP) stated a Dermatologist had seen R2 earlier in the month. V5 stated staff had told her R2's appointment was in March, and she just saw the Dermatologist recommendations today. V5 stated staff should have notified her, and she didn't have the chance to review the recommendations yet.R2's February 2026 Treatment Administration Record (TAR) showed an order from 9/13/2025 for his left cheek BCC to have betadine applied daily. The application was last signed off on 2/21/2026. R2's February 2026 Medication Administration Record (MAR) showed an order from 2/12/2026 to apply povidone-iodine daily to his BCC and it was signed off as administered last on 2/25/2026.Under General in the facility's Wound Prevention and Healing policy (reviewed April 2025), it showed To provide wound care treatments/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician. The policy also showed 11. The Multidisciplinary Wound Care Team- 1. The Wound Care team is responsible for identifying problems, coordinating care, and promoting development of the team. 3. Wound care nurses provide case management.

Based on interview and record review, the facility failed to administer medications. This applies to 1 of 3 residents (R1) reviewed for medication administration in a sample of 6. The findings include:R1's face sheet showed she was admitted to the facility with diagnoses including malignant neoplasm of unspecified part of bronchus or lung, tachycardia, congestive heart failure, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure, pulmonary embolism without acute cor pulmonale, and asthma.R1's EMR (Electronic Medical Record) showed an order for Prednisone 30 MG (Milligrams) once daily for three days starting on 1/18/2026 due to be given at 5 PM through 1/20/2026. R1's EMR showed the next order for Prednisone 40 MG once daily was ordered on 1/20/2026 starting on 1/21/2026 for seven days. R1's MAR (Medication Administration Record) showed R1 received the Prednisone 30 MG on 1/18/2026 and 1/19/2026, but the dose was not given on 1/20/2026. On 1/27/2026 at 3:25 PM, V2 (DON/Director of Nursing) said V8 (Pulmonary NP/Nurse Practitioner) ordered a new dose of Prednisone 40 MG to be started on 1/21/2026 at 9 AM, which accidentally cancelled the Prednisone 30 MG dose due at 5 PM on 1/20/2026. V2 said R1 should have received the Prednisone 30 MG dose due on 1/20/2026 at 5 PM. On 1/28/2026 at 9:46 AM, V8 said R1 should have gotten the Prednisone 30 MG dose due on 1/20/2026 at 5 PM. The facility's Medication Administration policy reviewed 4/2025 showed Facility will ensure that medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to provide appropriately sized incontinence briefs to a resident to prevent skin irritation. This applies to 1 of 3 residents (R1) reviewed for quality of care in a sample of 11. The findings include:On September 23, 2025 at 11:36 AM, R1 said she had requested the white incontinence briefs but were not given them. R1 said she had the green incontinence brief on, which were not comfortable for her. At 1:59 PM, R1 said she had skin irritation from the green incontinence brief, as they were too small for her. At 2:16 PM, R1's skin was checked by V6 (CNA/Certified Nurse Assistant) and V7 (Infection Control nurse), and her perineal area and bilateral groin areas were excoriated and red. R1 said the redness was because the brief was too small. When V6 was wiping R1's perineal and groin areas, R1 was wincing and said those areas hurt. On September 23, 2025 at 1:55 PM, V5 (CNA) said she had taken care of R1 before, and the green briefs did not fit her. V5 said R1's thighs were irritated, and she had notified the nurse, who gave her a cream to apply. V5 said she had notified central supply about R1's incontinence brief size and was told R1 was not on the list for the white, 3XL (Extra Large) incontinence briefs. V5 said she was told management based the sizing on her weight. V5 said the brief sizing should not be dependent on their weight alone, but on the actual size of her stomach and legs. On September 23, 2025 at 3:01 PM, V11 (CNA) said she had been in the facility for one year and frequently cared for R1. V11 said R1 preferred the white, bariatric 3XL incontinence briefs as the green and tan briefs cut between her legs and sides of her groin. V11 said the white bariatric briefs gave her more breathing room. V11 said she could see the difference the white bariatric briefs made versus the green ones, as the green ones caused her more skin issues. V11 said she notified central supply of R1's needs and was told there was a list and R1 was not on the list for the 3XL, white incontinence briefs. V11 said she notified V7, and V11 was told there was a list for brief sizes, and they needed to wear the size according to the list. On September 23, 2025 at 2:50 PM, V8 (Central Supply Manager) said he was given a list with the residents' names and sizes of incontinence briefs a few weeks ago. V8 said the list showed R1 required an XL brief. V8 said he was told by a few CNAs about a week ago that R1 wanted the 3XL white incontinence briefs. V8 said he was told to order and give the residents the sizes that were on the list. V8 said he provided the green 2XL briefs for R1. V8 said the 3XL briefs were more expensive and they were hand delivered to the rooms on the list. V8 said all the smaller briefs were available to the CNAs in the supply rooms. On September 23, 2025 at 2:50 PM, V8 provided a census sheet dated September 3, 2025 with all the residents' names and brief sizes. The document showed R1 was sized to receive XL incontinence briefs. On September 23, 2025 at 2:25 PM, V10 (Wound Care Nurse/LPN/Licensed Practical Nurse) said she was not aware R1 had excoriation on her groin and perineal areas. V10 said it was possible if the incontinence brief was too tight, it could cut into her skin and cause skin breakdown. V10 said there were only certain residents who had the white, 3XL briefs assigned to them, and R1 was not on the list. V10 said she was not sure who determined the sizes for the residents. On September 23, 2025 at 2:41 PM, V2 (DON/Director of Nursing) said every person's body was different and if the resident was more comfortable with a larger sized incontinence brief, the staff would let management know and they would change what they ordered for the resident. V2 said R1 was pear shaped and bigger on the bottom half. V2 said she was told by the staff on September 23, 2025 (during the survey) R1 had irritation to the leg and groin area. V2 said if a resident was larger than 250 pounds, they would measure the girth, and R1 did not meet the criteria to be measured for her girth. The EMR (Electronic Medical Record) shows R1 was admitted to the facility with diagnoses including hemiplegia and hemiparesis, stage 4 chronic kidney disease, paralytic syndrome, and pain in right shoulder. R1's MDS (Minimum Data Set) dated July 24, 2025 showed R1 had moderate cognitive impairment and required substantial assistance for toileting hygiene and personal hygiene. The facility's Resident Personal Preferences policy dated April 2025 showed It is the policy of the facility to accommodate the personal preferences of the residents that are essential to creating an individualized, home-like environment. The resident's individual preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevent foodborne illness.This applies to 128 residents receiving dietary services.Findings include:On 07/22/2025 at 3:01 PM, V1 Administrator confirmed 128 residents were receiving food services from the dietary department.On 07/22/2025 at 09:02 AM, the kitchen tour began with V32 (Dietary Manager).V32 stated the dishwasher disinfects by temperature. The goal is 180 degrees F (Fahrenheit). The staff are to look at the gauge and the test strip to assure the temperature reach 180 degrees F.V35 (Dishwasher) ran a load of dishes to test the dishwasher temperature. V35 stated the wash temperature should reach 180 degrees to disinfect the dishes. V35 placed a temperature sensitive test strip that read 160-degree F / 71 degree C (Celsius) on a plate. The wash cycle gauge maximum temperature reached 148 degrees F. The rinse tank gauge maximum temperature was 156 degrees F. The temperature sensitive test strip did not change black which would indicate the 160-degree temperature had been reached. Two stacks of dishes that had yellow and brown specks and particles on them. V35 Dishwasher stated the dishes were just taken of the dishwasher and were ready for use. The dry storage contained a 102 oz (Ounce) can of diced tomatoes that was dented. A 106 oz can of apple sauce was dented.The walk-in cooler contained a one-gallon container of mustard with on opened on or use by date and a manufacture date of 10/7/24. A large bin labeled employee food was present. The bin contained a watermelon cut in half without a label, two bags of corn tortillas with no visible date, and a personal food container with unidentifiable food had no label or dates.V33 (Kitchen Supervisor) provided test strips to test the red sanitization bucket and the three compartment sink. The test strip was pulled from a zipper bag that was affixed to the wall with other various strips that were not in their original packaging. One test strip that did have packaging taped to the wall was dated 12/1/2022. V33 stated the label taped to the wall was for the test strips that were used for testing the sanitizer level. V33 was requested to provide the original product packaging. V33 brought out a small plastic container that would have held the strips and it had no informational packaging insert. V33 stated the label affixed to the wall went with the test strips they were using to test the red sanitization buckets and the three compartment sink. V34 (Dietary Aid) stated he used the test strips from the zippered bag affixed to the wall to test the three-compartment sanitization sink.A deep freezer identified by V32 as activities freezer contained two unlabeled bags of shredded yellow cheese, a box containing of 3 pastries with no dates, and a small package of [NAME] cheese with a manufacturer's date of 4/24/24 that was open to air. A 32 oz (ounce) package of pepper jack cheese without an opened on or use by date was also present. A small package of pepper jack cheese was open to air and had no opened on or use by date. A whole pie with the plastic wrap falling off without a label to identify contents or dates was also present.A silver kitchen cabinet contained a pink purse, a green purse, a bottle of water, an umbrella, a book, two black jackets, and a 24-count box of turmeric tea bags that expired on 03/2024.On 07/24/2025 at 1:27 PM, V32 (Dietary Manager) stated no separate logs were maintained for the red sanitizing buckets because the buckets are filled from the same dispenser that fills the three-compartment sink. V32 stated dented cans should be separated from stock so they are not used. The food could become contaminated and cause the residents to become sick. All foods should have an opened on and use by date so they can assure it is safe for residents to eat. If outdated food is served to residents, they could become sick. Employee's personal items should not be stored in the kitchen prep area because there could be a cross contamination of the food. Employee food items should not be stored in the kitchen because of the risk of cross contamination. The test strips for sanitization should be stored in the original container to verify the strips and the expiration date. The dishwasher disinfects by temperature and the wash temperature should reach 160 degrees and the final rinse should reach 180 degrees F to properly disinfect the dishes. Our policy says it is ok for us to use the 160 degrees F test strip. V32 stated she did not know why the test strip did not turn black to indicate the desired temperature was reached. Staff should look at the gauge and test strip to assure the desired disinfecting temperature was reached. V32 stated she was not familiar with the test strips that were used and should have known those test strips were being used.The facility policy Machine Washing and Sanitizing dated 2021 states dishwashing machines using hot water for sanitizing may be used if the temperature of the wash waster is no less than that specified by the manufacturer, which may vary from 150 degrees F to 165 degrees F, depending on the type of machine, and the final rinse temperature is no less than 180 degrees F. The final rinse temperature is tested with a paper thermometer. The paper thermometer turns color when it registers 160-degree F which sanitizes the plates, tableware, utensils etc. (160 degrees F on the dish or utensil surface reflects 180 degrees F at the manifold where the temperature of the dishwashing machine final rinse is measure.)The facility policy Sanitation Buckets / wiping Cloths Food Contact Surfaces and Equipment Too Large To Immerse In The Sink dated 2021 states using the appropriate test strips, the strength of the sanitizing solution will be tested each time the sanitization buckets are changed.The facility policy Labeling and Dating Foods dated 2021 states to decrease the risk of food borne illness and to provide the highest quality, food is labeled with the date received, the date opened and the date by which the item should be discarded.The facility policy Storage of Frozen Foods dated 2021 states if food is taken out of its original container the food is tightly wrapped and labeled with the item name and the use by date. Frozen foods can deteriorate in quality the longer they are stored. Therefore, frozen foods are best if used within three months. Frozen food is discarded after three months. Opened products that have not been properly sealed and dated are discarded.The facility policy Personal Hygiene dated 2021 states keep spare clothes and other personal item away from food preparation and food storage areas.The facility policy Storage of Dry Goods / Foods dated 2021 states dented cans are stored in a designated area and returned to vendors.

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions for a resident with an acute GI (gastrointestinal infection). The facility also failed to follow contact and enhanced-barrier precautions and hand-hygiene when providing resident care.This applies to 5 out of 5 residents (R152, R117, R41, R104, and R8) reviewed for infection control in a sample of 30. The findings include: 1. On [DATE] at 1:30 PM, V36 (Physician) was assessing R152 in her room. R152’s room did not have any posted transmission-based precautions sign. V36 was not wearing any PPE (Personal Protective Equipment). At 1:35 PM, R152 said she had ongoing diarrhea that started on [DATE]. R152 said her stool was collected to check for C. diff (Clostridium difficile is an acute contagious GI infection) and the results were pending. R152 said she was not placed on transmission-based precautions for her suspected GI infection and staff was continuing to provide her care. On [DATE] at 1:15 PM, R152 was in her room. R152’s room had a contact precautions sign instructing everyone to don PPE, including gloves and gown, prior to entering. The sign said for everyone to clean their hands before entering and when leaving the room with ABHR (alcohol-base hand rub). On [DATE] at 2:15 PM, V2 (Director of Nursing/DON) said R152 should have been immediately placed on contact precautions on [DATE] when her GI symptoms were identified for the safety of everyone. V2 said R152’s stool sample resulted positive for C. diff on [DATE]. V2 continued to say anyone entering a resident’s room with a C. diff infection were required to perform strict hand-hygiene with soap and water not ABHR to ensure the infection could not be spread to others. V2 said she would change R152’s posted transmission-base contact sign to the correct sign of “Contact Enteric Precautions.” V2 said she expected all staff and visitors to adhere to the indicated transmission-based precautions when entering residents’ rooms. R152's stool result dated [DATE] showed positive results for “C difficile GDH Ag and Toxin A.” R152’s care plan dated [DATE] said she required “strict contact isolation rt (+) C diff” initiated on [DATE]. 2. [DATE] at 1:00 PM, R117 was in his room. V39 CNA (Certified Nurse Assistant) entered the room to remove his meal tray. V39 did not don any PPE. R117’s door had a contact precautions sign instructing everyone to wear a gown and gloves prior to entering the room. V39 said she did not believe she had to adhere to the indicated contact precautions instructions when entering a resident’s room. R117’s Order Summary Report dated [DATE] showed an order for “Contact isolation for VRE of wound” initiated on [DATE]. 3. On [DATE] at 2:40 PM, V6 (CNA) and V10 LPN (Licensed Practical Nurse) provided perineal care to R41. R41 was on EBP (Enhanced Barrier Precautions) for having a gastrostomy tube and a urinary catheter. V6 and V10 wore gloves but did not wear gowns. V6 removed the soiled disposable brief while V10 held R41 onto her right side. Neither V6 nor V10 cleansed the perineal area of R41. Neither staff member performed hand hygiene or changed gloves. Together they applied a new disposable brief on R41, repositioned her, and tidied up her bed linen while wearing the same soiled gloves. V6 removed his gloves, did not perform hand hygiene, and left the room carrying soiled linen that was not contained. On [DATE] at 1:30 PM V7 (LPN) checked the placement of the GT (gastrostomy tube) for R41. V7 wore gloves but did not wear a gown. On [DATE] at 1:40 PM, V7 and V9 (CNA) turned R41 to observe the back of the resident. Both wore gloves but did not wear a gown for the procedure. Record review for R41 showed R41 was admitted on [DATE] with diagnoses to include neuromuscular dysfunction of bladder, dysphagia, right side hemiplegia and protein-calorie malnutrition. R41’s treatment orders included Enhanced Barrier Precautions related to gastrostomy tube and indwelling urinary catheter; All must clean their hands before entering and leaving the room; Staff must wear PPE (Personal Protective Equipment) during High Contact Resident Care Activities. 4. On [DATE] at 1:10 PM V8 (CNA) pulled R104 up in bed with resident’s cooperation. R104 was on EBP for having a urinary catheter and a perma-cath. V8 wore gloves, but no gown. V8 helped R104 to sit up in Fowler’s position. V8 set up the lunch tray in front of him on the over-bed table. V8 removed her gloves, did not perform hand hygiene and left the room to handle lunch trays from other rooms. Record review for R104 showed he was admitted to facility on [DATE] with diagnoses of neuromuscular bladder, cerebral palsy, renal dialysis and gastroenteropathy. R104’s treatment orders included EBP related to urinary catheter and Perma catheter. Care-plan dated [DATE] documented EBP related to urinary catheter and Perma catheter. On [DATE] at 2:55 PM V6 (CNA) stated he should have washed his hands before leaving the room and should have worn a gown as R41 was on EBP. V6 also stated he should have taken the linen out of R41's room in a plastic bag as per facility policy. On [DATE] at 1:30 PM, V5 RN (Registered Nurse) stated a gown and gloves need to be worn when caring for a resident on EBP. 5. R8 was admitted to the facility with diagnoses including hemiplegia and hemiparesis, dementia, and thyrotoxicosis. R8’s POS (Physician Order Sheet) dated [DATE] showed an order for EBP: related to history of VRE (Vancomycin-Resistant enterococci) in the urine. Everyone must clean their hands before entering and leaving the room. Providers and staff must wear PPE during High Contact Resident Care Activities with a start date of [DATE]. On [DATE] at 11:10 AM during initial tour, R8’s room did not have any isolation signage or PPE bin outside her room or near the vicinity of her room. On [DATE] at 4:08 PM, V4 (CNA) was in R8’s room providing incontinence care. V4 did not have a gown on while providing incontinence care for R8. V4 applied the new incontinence brief onto R8 and then rearranged her blankets to cover her back up. On [DATE] at 2:09 PM, V25 (LPN) said R8 was supposed to be on EBP for the wounds. The facility’s policy titled Transmission-Based Precautions dated 06/2025 said “Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.” Facility policy on Enhanced Barrier Precautions dated [DATE] showed EBP involves the use of gowns and gloves during high contact resident care activities for residents with indwelling medical devices to prevent spread of MDROs (Multi Drug Resistant Organisms) in the facility. Facility policy on Hand Washing/Hand Hygiene dated [DATE] showed hand hygiene must be performed before and after handling an invasive device, before moving from a contaminated body site to a clean body site during resident care, after removing gloves, and before and after entering isolation precaution settings.

Based on interview and record review, the facility failed to implement its antibiotic stewardship program to monitor residents receiving antibiotics.This applies to 4 out of 4 residents (R152, R75, R117, and R136) reviewed for antibiotic use in a sample of 30. The findings include:1. On 7/23/2025 at 1:00 PM, V13 (Infection Preventionist/IP Nurse) said the facility's antibiotic stewardship program was to ensure safe antibiotic use. V13 said inappropriate use could result in antibiotic overuse and resistance. V13 said she was responsible for completing antibiotic review forms in the residents' EMRs (Electronical Medical Records) when admitted with or prescribed antibiotics. V13 said the facility determined appropriate antibiotic use based on the McGeer Criteria and if determined inappropriate the prescribing provider was notified to ensure safe use.V13 reviewed R152, R75, R117, and R136's EMRs and said they received antibiotics as prescribed. V13 said their antibiotic review forms were not completed to determine if they met the McGeer Criteria for appropriate use. On 7/23/2025 at 3:45 PM, V2 (Director of Nursing/DON) said she expected antibiotic surveillance to be completed for all residents receiving antibiotics per facility policy to ensure safe antibiotic use. V2 said she also reviewed R152, R75, R117, and R136's EMRs and they did not have their antibiotic review forms initiated.R152's Order Summary Report dated 7/24/2025 showed an order for Vancomycin oral suspension for Clostridium difficile infection (gastrointestinal infection) started on 7/23/2025.2. R75's Order Summary Report dated 7/24/2025 showed an order for Cefepime intravenous solution for a urinary tract infection started on 7/16/2025.3. R117's Order Summary Report dated 7/24/2025 showed an order for Cefepime intravenous solution for osteomyelitis started on 7/09/2025.4. R136's Order Summary Report dated 7/24/2025 showed and order for Cefdinir oral capsule for a urinary tract infection started on 7/11/2025. The facility's policy titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcome dated 11/23/2021 said Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.

Based on observation, interview, and record review, the facility failed to assess residents to self-medicate. This applies to 4 of 4 residents (R96, R16, R2, R25) reviewed for self-administration in a sample of 30. The findings include: 1. On July 22, 2025 at 11:32 AM, R96 was sleeping in bed. R96’s bedside table had a medication cup with five medications within it. The medication cup had two round, chewable tablets, one orange and one red. The medication cup also had three abnormally shaped medications, two of which were red and one purple. On July 24, 2025 at 12:50 PM, R96 said the medications in his cup were all Tums. R96 said the nurses did not stop to watch him take the Tums. R96 said he had his own bottle of Tums in the drawer next to his bed, which he said the CNAs (Certified Nurse Assistant) would grab for him when he asked for it. R96 said on July 22, 2025, of the five Tums in the medication cup, he ate two of the Tums from the facility nurse and two of his own supply of Tums. R96’s drawer had a bottle of Tums antacid calcium carbonate extra strength 750 MG (Milligrams) chewy bites assorted berries. R96’s face sheet showed he was admitted to the facility with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, vascular dementia, anxiety disorder, major depressive disorder, gastro-esophageal reflux disease, lack of coordination, dysphagia, and irritable bowel syndrome with constipation. R96’s MDS (Minimum Data Set) dated June 11, 2025 showed R96 had moderate cognitive impairment. R96’s POS (Physician Order Sheet) dated July 24, 2025 showed an order for Tums Tablet Chewable 500 MG (Calcium Carbonate Antacid) Give 2 tablets by mouth every 8 hours as needed for heartburn and Tums Tablet Chewable 500 MG (Calcium Carbonate Antacid) Give 2 tablet by mouth in the evening for indigestion, both dated April 22, 2024. R96’s care plan dated December 18, 2023 showed [R96] has alteration in thought process and cognitive- communication status [related to] dementia. R96 did not have any care plans which showed he was safe to self-administer medications. R96’s EMR (Electronic Medical Record) was reviewed, which did not show R96 was assessed to safely self-administer medications. 2. On July 22, 2025 at 10:36 AM, R16 was lying in bed, sleeping. R16’s bedside table had a medication cup with 30 ML (Milliliters) of red liquid. At 11:44 AM, R16’s bedside table still had the red liquid in the cup on the bedside table. At 12:32 PM, the red liquid in the cup was still present on R16's bedside table. On July 24, 2025 at 12:46 PM, R16 said she had sores on her feet, and staff bring her the red liquid, which she does normally take. R16 said she did not remember whether she took the medication two days ago and might have forgotten to. R16’s face sheet showed she was admitted to the facility with diagnoses including osteomyelitis of the right ankle and foot, erosive osteoarthritis, and sepsis. R16’s POS dated July 24, 2025 did not show any orders for R16 to self-administer medications. R16’s MDS dated [DATE] showed R16 had modified independence with cognitive skills for daily decision making. R16’s care plan showed [R16] has actual impairment to skin integrity and potential for further impairment to skin integrity…with interventions including [Registered Dietitian] evaluate and recommend nutritional supplement to promote wound healing. Proheal (nutritional supplement) and Nepro. The care plan dated June 11, 2025 also showed she displayed compromised mental status…R16’s care plan did not show R16 was able to self-administer medications. R16’s EMR was reviewed, and no assessments were found to self-administer medications. On July 24, 2025 at 1:01 PM, V42 (LPN/Licensed Practical Nurse) said for residents to self-administer medications, they need an order to self-medicate from the doctor. V42 said the doctor would be notified and an assessment needed to be completed. On July 25, 2025 at 1:16 PM, V13 (LPN) said she did not have any residents who were allowed to self-administer medications. V13 said when passing medications, they should stand and wait for the resident to take their medications before leaving the room. V13 said if a resident wanted to self-medicate, they would need to notify the doctor and do a self-administration consent. 3. On July 22, 2025, at 10:02 AM, R2 was lying in bed, sleeping. R2’s nightstand had 1 bottle of Nystatin (Antifungal) powder and 1 medicine cup with white cream swirled with clear ointment. At 11:30 AM, R2’s nightstand still had both the powder and cream mixture on it. R2’s face sheet showed she was admitted to the facility with diagnoses including diabetes mellitus, cirrhosis of liver, bipolar disorder, major depressive disorder, hypertension, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R2’s MDS dated [DATE], showed R2 has severe cognitive impairment. POS dated July 24, 2025, showed orders for Clotrimazole Cream 1% (Antifungal cram) Apply to affected area/s topically as need for skin condition, dated July 17, 2025, and Antifungal powder to breast/abdominal folds twice daily as needed for moisture/fungal rash, dated May 14, 2024. R2’s care plan dated May 24, 2024, showed R2 has impaired thought process secondary to bipolar disorder as well as signs and symptoms of depression and mood distress. R2’s did not have any care plans which demonstrated safe self-medication administration. R2’s EMR (Electronic Medical Record) was reviewed, which did not show R96 was assessed to safely self-administer medications. 4. On July 22, 2025, at 10:37 AM, R25 was lying in bed, watching television. R25’s bedside table had 2 bottles of Nystatin powder, 2 tubes of Recti Care (hemorrhoidal ointment), and 1 tube of Lidocaine ointment 5%. Per R25, she applies the Lidocaine ointment over her left arm AV (arteriovenous) fistula before dialysis and whenever she feels pain on that site. Per R25, she applies it whenever she needs pain relief and is not sure if there is a maximum daily dose. R25’s face sheet showed she was admitted to the facility with diagnoses including chronic kidney disease, dependence on renal dialysis, diabetes mellitus, pleural effusion, gout, lymphedema, osteoarthritis, and insomnia. R25’s MDS dated [DATE], showed R25 is cognitively intact. R25’s POS also showed orders for Antifungal powder to breast/abdominal folds twice daily as needed for moisture/fungal rash (dated July 17, 2025); Lidocaine External Cream 4% Apply to AV fistula topically one time a day for pain (dated July 9, 2025); and Preparation H External Cream 1% (Hydrocortisone Rectal) Apply to rectum topically at bedtime (dated July 23, 2025) and every 6 hours as needed (dated August 6, 2024) for hemorrhoids. R27’s POS did not show any orders for R25 to self-administer medications or to keep the medications at bedside. R25’s current care plan with completion date of June 6, 2025, does not show that R25 was assessed as safe to self-administer medication. R25s EMR was reviewed, and no assessments were found to self-administer medications. On July 23, 2025, at 2:00 PM V24 (LPN/Wound Care Coordinator) said that the only type of topical medication or cream that may be kept at the bedside is a moisture barrier. All other topical agents should be stored a locked treatment cart. The facility’s Self Administration of Medication Program dated April 2025 showed the facility will allow the resident to self-administer drugs if the interdisciplinary team (IDT) has determined that this practice is safe. Nurse will complete a Self-administration of Medication Assessment. Once the resident has been deemed safe by the IDT an order will be obtained from the resident’s physician or physician extender listing the medication(s) that may be self-administered, where the medication will be stored, who will be responsible for documentation, and the location of administration. Appropriate documentation of the above determinations will be documented in the resident’s care plan.

Based on observation, interview, and record review, the facility failed to safely store medications.This applies to 10 out of 10 residents (R136, R153, R154, R155, R156, R126, R127, R138, R66, and R52) reviewed for medication storage in a sample of 30.Findings include:1. On 7/23/2025 at 10:20 AM, the facility's first floor medication room fridge and a medication cart that housed R136's and R152's medications was checked for medication storage with V3 (Assistant Director of Nursing/ADON). R136 and R153's opened Ozempic pens were stored in the fridge. The pens were not labeled with opened-on dates, and the weekly pre-scheduled dates for dosage administrations had been left blank. R154's opened Lispro pen was also stored in the fridge without an opened-on date. R136 and R154's opened Albuterol inhalers were stored in the medication cart and did not include their opened-on dates. R136's Order Summary Report dated 7/23/2025 showed orders for Ozempic subcutaneous solution pen-Injector and Albuterol inhaler.2. R153's Order Summary Report dated 7/23/2025 showed an order for Ozempic subcutaneous solution pen-Injector.3. R154's Order Summary Report dated 7/23/2025 showed orders for Lispro Insulin solution pen-injector and Albuterol inhaler.4. On 7/23/2025 at 10:50 AM, the facility's second floor medication room was checked for medication storage with V13 (Licensed Practical Nurse/LPN). R155 and R156's Naloxone Nasal Liquid sprays were stored directly underneath the sink. V13 said R155 and R156 were discharged and was unsure why the medications were not disposed of appropriately. R155's admission Record sheet dated 7/24/2025 showed a discharge date of 5/29/2025.5. R156's admission Record sheet dated 7/24/2025 showed a discharge date of 5/22/2025.6. On 7/23/2025 at 11:00 AM, the medication cart that housed R52's and R126's medications was checked with V14 (RN). R52's Fluticasone nasal spray and R126's Albuterol inhaler medications were opened and undated. V14 said multi-use medications including nasal sprays, inhalers, and eyedrops should be labeled when open for medication administration safety. R52's Order Summary Report dated 7/23/2025 showed an order for Fluticasone nasal spray.7. R126's Order Summary Report dated 7/23/2025 showed an order for Albuterol inhaler.8. On 7/23/2025 at 11:10 AM, the medication cart that housed R66's medications was checked with V15 (LPN). R66's opened Fluticasone nasal spray was undated. R66's Order Summary Report dated 7/23/2025 showed an order for Fluticasone nasal spray. 9. On 7/23/2025 at 11:20 AM, the medication cart that housed R138's and R127's medications was checked with V16 (LPN). R138's Systane eyedrop bottle and Fluticasone nasal spray were opened and undated. R127's opened Latanoprost eyedrop bottle was also undated. R138's Order Summary Report dated 7/23/2025 showed orders for Systane eyedrops and Fluticasone nasal spray.10. R127's Order Summary Report dated 7/23/2025 showed an order for Latanoprost eye drops.On 7/24/2025 at 1:30 PM, V2 (Director of Nursing/DON) said multi-use medications had to be labeled when opened and stored appropriately to ensure safe medication administration. The facility's policy titled Storage of Medications dated 04/2025 said The facility stores all drugs and biologicals in safe, secure, and orderly manner.

Based on observation, interview, and record review, the facility failed to safely maintain and reconcile controlled medication counting logs for residents receiving narcotics.This applies to 2 out of 3 residents (R11 and R34) reviewed for narcotics in a sample of 30.Findings include:1. On 7/23/2025 at 10:40 AM, R11's Tramadol 50 mg (milligrams) medication punch card was observed with no tablets available. R11's Controlled Substances Proof of Use sheet for Tramadol showed R11 had 1 tablet remaining for use. R11's Pregabalin 75 mg medication punch cards were observed with 30 capsules available. R11's Controlled Substance Proof of Use sheet for Pregabalin showed R11 had 31 capsules remaining for use. The Pregabalin punch cards showed #5, #8, #14, and #16 medication punch slots were torn with loose capsules inside, not secured. V3 (Assistant Director of Nursing/ADON) was present during the observations and said she was not sure why the medication logs were inaccurate. V3 said controlled medications had to be logged when removed and if not properly secured they had to be reconciled and discarded appropriately. R11's Order Summary Report dated 7/23/2025 showed active orders for Tramadol HCI Oral Tablet 50 MG and Pregabalin Oral Capsule 75 MG.2. On 7/23/2025 at 10:50 AM, R34's Tramadol 50 mg medication punch card was observed with 1 tablet available. R34's Controlled Substance Proof of Use sheet for Tramadol showed R34 had 2 tablets remaining for use. V3 remained present for R34's observation. On 7/23/2025 at 10:45 AM, V12 (Registered Nurse/RN) said she had administered R11 and R34's scheduled controlled medications as ordered at 8 AM on 7/23/2025. V12 said she did not log R11 and R34's removed narcotics. R34's Order Summary Report dated 7/23/2025 showed an active order for Tramadol HCI Oral Tablet 50 MG.On 7/24/2025 at 1:30 PM, V2 (Director of Nursing/DON) said nurses were expected to ensure proper storage, disposition, and logging of controlled medications to prevent discrepancies and maintain accurate counts.The facility's policy titled Controlled Substances dated 04/2025 said 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.14. Policies and procedures for monitoring controlled medications to prevent loss, diversion, or accidental exposure.

Based on observation, interview, and record review, the facility failed to ensure a resident's equipment and environment were free from accident hazards, and failed to ensure a resident with known wandering habits was supervised to prevent a fall. This failure resulted in the emergent transfer to the hospital for 2 residents due to fall incidents. This applies to 2 of 2 residents (R25 and R36) reviewed for accidents and supervision in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25’s MDS (Minimum Data Set) dated May 5, 2025, shows R25 is cognitively intact, non-ambulatory, and requires total assist with transfers with 2 staff members via Hoyer lift. R25’s latest fall risk assessment (prior to fall on June 13,2025) dated January 25, 2024, states R25 has a history of multiple falls and is in the high-risk category for falls. On July 22, 2025, at 10:02 AM, R25 said on June 13, 2025, she was in her room at around 4:00 AM, about to be wheeled downstairs to dialysis. After being transferred to her dialysis chair/ “geri-chair” (geriatric chair), staff stepped away from her to get something when R25 felt the backrest of her chair falling backwards and then felt the chair “give out” from underneath her. R25 said she hit her right temporal area and right shoulder on the wall. Per R25, she was in pain from being “wedged between the dialysis chair and the wall.” R25 stated nursing staff used the Hoyer lift to get her up from the floor and she felt intense neck pain during the transfer since her head was not supported by the mechanical lift sling. R25 said 911 paramedics arrived after she staff assisted her up to transfer her to the ER (Emergency Room) for evaluation. V45 LPN (Licensed Practical Nurse) completed R25's Post Fall Observation assessment form at 4:15 AM on June 13, 2025. V45’s progress noted dated June 13,2025, states she saw R25 “tipped back against the wall with her legs in the air and her head tilted to the right against the wall.” Per V45, “leaving her (R25) on the floor was not an option due to the [full-body mechanical life] lift being stuck under the geri-chair.” R25’s June 13, 2025 “Post-Fall Observation” assessment form showed that resident sustained a fall in her room and was sent to the ER for evaluation. R25’s “After Visit Summary” from states that resident had a fall resulting in closed head injury, strain of neck muscle, and contusion of right shoulder. On June 24, 2025, 5:20 PM, V2 (Director of Nursing) stated that she did not investigate or report R25's fall. A Grievance/Concern Form written by V2, dated 6/13/25, showed that R25's “dialysis chair malfunctioned while R25 was being transferred from bed to dialysis chair. Facility’s policy titled, “Fall Prevention and Management” dated June 2025, states it is the duty of the facility to ensure and maintain a safe environment for residents to reduce the risk of falls, including those resulting in harm. 2. On July 23, 2025 at 2:27 PM, V43 (Firefighter) said the fire department was dispatched for a call regarding a person who had fallen. V43 said when they arrived at the facility, there was a staff member waiting at the elevator to lead the team to the emergency egress stairwell on the second floor. V43 said the emergency egress stairwell was behind an alarmed emergency door that would need to be pushed and held for 10 to 15 seconds to open the door. V43 said the resident was lying on the floor on the top of the stairs and her wheelchair was at the base of a flight of stairs below. V43 said when they had arrived, the emergency door was propped open, and the alarm was sounding. V43 said the facility staff had reported to him they had last seen her 15 to 20 minutes prior. On July 23, 2025 at 12:52 PM, V5 (RN/Registered Nurse) said she was R36’s nurse when R36 had a fall on July 21, 2025. V5 was working on the second floor, which was the floor R36 resided on for long term care. V5 said she was working the 2 to 10 PM shift and was in another patient’s room when she heard the door alarm sounding off. V5 said she told V4 (CNA/Certified Nurse Assistant) to make sure the resident she was working with was ok and went to the alarming door and saw R36 outside the emergency exit door on the floor. V5 said it was around 7:10 PM. V5 said R36’s body was facing the wall, and her feet were facing the door. V5 said she could not remember where the wheelchair was. V5 said R36 complained of pain to her hips and her head was on the floor. V5 said R36 was not oriented and was confused. V5 said R36 was able to get around in the wheelchair. V5 said she had last seen R36 was in the TV room speaking to V4. V5 said residents that wander were placed at the nurse’s station and in the TV room and a CNA was always watching them as they could not be left unattended. V5 said the wandering residents need to be redirected. On July 23, 2025 at 1:26 PM, V4 (CNA) said he worked on July 21, 2025 until 10 PM. V4 said he had just finished his shift supervising the TV room when he saw the flashing light above the nurse’s station. V4 said he was not sure if the light was from the door or a resident pulling the call light out of the wall. V4 said V5 came to him at the nurse’s station and told him to check on the resident she had been working with and V5 went to address the flashing light. V4 said after he checked on the resident, he went to the stairwell where V4 was attending to R36, who had fallen. V4 said he had last seen R36 before 7 PM when she had come to the TV room asking for the exit. V4 said R36 told him she was looking for the police and asking about her dad. V4 said R36 wandered a lot and went into other residents’ rooms. V4 said R36 was by the nurse’s station, asking the other nurses if she could get out. V4 said they keep the residents in the TV room to keep an eye on them. V4 said if residents were out of their room, they should be in the TV room. V4 said if a wandering resident leaves the TV room, they should be redirected and put back in the TV room. R36’s face sheet showed she was admitted to the facility with diagnoses including dementia and a history of falling. R36’s MDS (Minimum Data Set) dated July 2, 2025 showed R36 had severe cognitive impairment and used a wheelchair for mobility. R36’s care plan dated January 17, 2025 showed the resident is an elopement risk [due to] [diagnosis] dementia, cognitive deficit and wandering behavior with interventions including Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? The care plan dated December 30, 2021 also showed [R36] is at risk for falls due to decreased mobility, weakness. R36’s Progress Note showed the following: A late entry progress note written by V5 (RN) dated July 21, 2025 showed “Staff responded to the door alarm; resident was observed by staff on her left side on the floor next to the exit door. Resident is alert, on her baseline stating, 'get me up.' Able to move extremities but complain of a little pain to her left hip, otherwise no pain to the rest of her body. No visible injury noted. Resident was observed by staff wheelchair her wheelchair by the nurses’ station about 10 mins ago. Head to toe assessment without visible injury. ROM (Range of Motion) within baseline, no internal external rotation, no shortening. 911 was called to transfer resident to the ER (Emergency Room). MD (Medical Doctor) and family made aware of incident and transfer.” R36’s Elopement Risk assessment dated [DATE] showed R36 was At Risk for Elopement. The facility’s Wandering and Elopements Policy dated April 2025 showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If an employee observes a resident leaving the premises, he/she should 1. Attempt to prevent the resident from leaving in a courteous manner; 2. Get help from other staff members in the immediate vicinity, if necessary; and 3. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises.

Based on observation interview and record review the facility failed to provide incontinence care for a dependent resident.This applies to 1 of 9 residents (R11) reviewed for ADL (Activities of Daily Living) in a sample of 30 .Findings include:On 07/24/2025 at 12:29 PM, a head-to-toe skin check for R11 was conducted with V40 RN (Registered Nurse). V40 RN stated R11 sacral area was a little red due to frequent stooling related a chronic infection. V40 stated to minimize the irritation R11 is cleaned frequently, and barrier cream is applied. Before V40 started the skin assessment R11 requested butt cream be applied. When V40 RN pulled R11 blanket and top sheet back, her undergarment was saturated and soaked through to her bottom sheet. R11 had stool up through her vagina and her buttocks were reddened. No barrier cream was noted on R11.On 07/24/2025 at 12:44 PM, V41 CNA (Certified Nursing Assistant) assigned to R11 stated her work shift started at 06:00 AM. V41 stated the last time she provided incontinence care to R11 was between 08:00 and 08:30 AM. V41 stated she saw R11 at 10:00 AM to pick up her meal tray but did not provide incontinence care.On 07/24/2025 at 2:45 PM, V2 (Director of Nursing) stated R11 is incontinent and should be visually checked for incontinence every two hours and R11 is not a reliable historian. On 07/24/2025 at 3:24 PM, V32 (Wound Nurse) stated she had just left R11. R11 told her not to mess with her cream. V32 stated she had to show R11 she had a bowel movement because she did not know she had gone.R11 was admitted to the facility with diagnoses that includes cerebral infarction, aphasia, dysphagia, pressure ulcer, hypertension, and anxiety disorder. R11's MDS (Minimum Date Set) dated 6/9/25 shows she is cognitively impaired and completely dependent on staff for incontinent care and at risk for developing pressure ulcers / injuries. R11 physician orders includes house stock moisture barrier, and the CNA may apply it and leave it at bedside. R11's care plan includes an impairment to skin integrity and potential for further impairment to skin integrity. Interventions includes use of house stock barrier cream. R11 has bladder incontinence due to impaired mobility. Interventions include change disposable brief upon rising, after meals, before bed and as needed. Check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episode.The facility policy Activities of Daily Living dated April 2025 states, appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. If a resident with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care.

Based on observation, interview, and record review, the facility failed to review and revise resident care plans to reflect significant incidents/changes in condition. This applies to 2 of 2 residents (R25 and R36) reviewed for care plans in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25 had a fall incident on June 13, 2025 at 4:15 AM per V45’s (LPN/Licensed Practical Nurse) “Post Fall Observation” assessment form. V45’s progress noted dated June 13,2025, states she saw R25 “tipped back against the wall with her legs in the air and her head tilted to the right against the wall.” Per V45, “leaving her (R25) on the floor was not an option due to the Hoyer lift being stuck under the geri-chair.” V45’s “Post-Fall Observation” assessment form dated June 13, 2025, states that resident sustained a fall in her room and was sent to the ER for evaluation. R25’s fall care plan accessed on July 23,2025 still states resident is “at risk” for falls due to weakness and impaired mobility and does not reflect resident’s actual fall incident on June 13, 2025. On June 24, 2025, 5:20 PM, V2 (Director of Nursing) stated that R25’s incident is not considered a fall, so it was not investigated or reported as such. 2. R36’s face sheet showed she was admitted to the facility with diagnoses including dementia and a history of falling. R36’s MDS (Minimum Data Set) dated July 2, 2025 showed R36 had severe cognitive impairment and used a wheelchair for mobility. R36’s care plan dated January 17, 2025 showed the resident is an elopement risk [due to] [diagnosis] dementia, cognitive deficit and wandering behavior with interventions including Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book. Identify patterns of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? R36’s care plan dated July 24, 2025 (during the survey) showed R36 had the potential for injury [marked by] wandering and exit seeking behavior dementia [with] decreased focus and safety awareness with interventions including hourly visual checks and record, monitor for [signs and symptoms] elopement: increased agitation, hanging around exits, increased pacing and stated desire to leave, redirect [resident] as needed- utilize activities as therapeutic distraction, and respond promptly to all door alarms. The care plan dated December 30, 2021 also showed [R36] is at risk for falls due to decreased mobility, weakness. R36’s care plan did not show any updates regarding R36’s fall on July 21, 2025 and interventions to prevent falls. Facility’s policy titled, “Fall Prevention and Management” dated June 2025, states the facility’s fall response includes updating residents’ care plans including the development of fall interventions plan based on results of the fall assessment as well as investigation of all circumstances and related resident outcomes. Multi-disciplinary discussion regarding such interventions is expected to adjust the care plan as needed.

Based on interview and record review, the facility failed to facilitate non-discriminatory discharge planning that meets the resident's preferences by allowing the resident to remain in the facility and paying privately for a bed.This applies to 1 resident (R5) reviewed for discharge planning in a sample of 30 residents.Findings include:On 7/22/25 at 11:53 AM, R5 and V31 (R5's Son-in Law) said they are concerned because they want R5 to be able to remain in the facility, but they were told R5 is going to be transferred to another facility on 7/29/25 when her Medicare days run out. V31 said they had a meeting with the facility staff and told the staff they want to remain in the facility after the 29th as private pay, but the staff said they will not have a room for R5 after 7/29/25.V1's (Administrator) progress note dated 7/10/25 at 9:12AM states V2 (DON/Director of Nursing) and V1 met with R5's POA (Power of Attorney) and son to discuss discharge planning. Progress note states R5's 100th day is on 7/29/25 and V1 explained to POA that at this time the facility does not have long term care bed availability. V28's (Social Service Director's) Progress Note dated 7/7/25 at 1:49 PM states a Care Plan meeting was held with R5, R5's son, and R5's daughter and Social Services went over a discharge plan. V28's progress note states R5's discharge date is 7/29/25, her 100th Medicare day and this note also states R5 would like to pay for a little bit.On 7/24/25 at 12:34 PM V28 (Social Service Director) said R5's discharge plan is to be discharged on 7/30/25 to an undetermined facility. V28 said she knows R5 wants to stay in the facility as private pay, but it has been explained to R5 and her family that the facility does not have a long term bed right now. V28 said she knows they do not have a long term bed because V1 (Administrator) told V28 there is no long term bed available for a private pay resident. V28 said she does not know how bed availability is determined, but V1 has the final say. V28 said R5 was accepted at another facility, but R5's daughter said she is uncertain if she wants her mom to go to that facility because R5 might need dialysis and she doesn't know if R5's primary physician goes to that facility like he does this facility.On 7/24/25 at 1:54 PM, V1 (Administrator) said the facility has 140 certified beds for Medicaid/Private Pay residents. V1 said based on that 140 certified bed allowance and the facility census of 130 residents, they do have a bed available for R5. V1 said R5 and her family were told there was no bed available because V1 was told by the facility's CFO (Chief Financial Officer) to only accept 82 long term care residents. V1 said the only long term care residents that she has accepted since she started at the facility in May 2025 have been Hospice or Respite. V1 was asked if the facility is licensed and certified for 140 Medicaid/Private Pay beds, why would the CFO tell her to only accept 82 residents and V1 replied, It is for profit. V1 said the facility does have the bed available for R5 to stay in the facility after 7/29/25 based on their certification status, but they told R5 and her family they did not have a bed for her. V1 said when the facility is accepting residents into their beds, V1 and V30 (Admissions Director) reference an email dated 3/13/2020 sent by the Bureau of Long Term Care Chief. This email states, Dear Administrator, The Department of Public Health notified my office of an increase in the Medicaid distinct part unit effective October 1, 2019. Of the 197 licensed beds, 140 of these beds are certified in the Medicaid program. On 7/24/25 at 2:57 PM, V30 (Admissions Director) said she does not know how many beds the facility has for Private Pay or Medicaid residents. V30 said all Long-Term Care admissions need to be approved by V1. V30 then provided surveyor a document showing all beds that were available on 7/22/25 and are still available to accept a Medicaid or Private Pay resident. V30 said there are 29 available Medicaid/Private Pay beds.R5's Care Plan initiated on 6/19/25 states the resident has a psychosocial well-being problem related to recent admission. Interventions include increase communication between resident/family/caregivers about care and living environment: Explain all. changes, rules, options and provide opportunities for the resident and family to participate in care.The facility provided brochure titled, Residents' Rights for People in Long-term Care Facilities dated 4/24 states, You have the right to keep living in your facility.

Based on observation, interview and record review the facility failed to provide maintenance services for a safe, comfortable and homelike environment. This applies to 1 of 1 (R48) resident reviewed for safe home like environment, in a sample of 30Findings include:On 07/22/2025 at 10:37 AM the molding of R48's cardiac table, stationed next to R48's bed, was broken and hanging downwards. R48 stated it had been broken for more than two weeks, that he had asked them to repair it and it was not done yet. On 7/23/25 at 2:15 PM the molding of R48's over bed table was still broken and hanging to the floor. R48 stated he had told multiple nursing staff about it.On 7/24/25 at 1:10 PM the molding around R48's cardiac table next to R48's bed was still broken and hanging downwards. On 7/24/25 at 1:10 PM, V5 (RN-Registered Nurse) stated, resident could scrape his skin due to the broken over-bed table.On 7/24/25 at 1:30 PM V29 (Maintenance Director) stated, he did not know about the broken table and that nobody had informed him about it. V29 stated, it could be a cause for potential injury to R48. V29 stated, he doesn't have a log of the work orders. Usually, the staff either call him or text him when an item need to be repaired and he fixes it. Facility policy on maintenance services dated 5/25/25 showed maintenance department is responsible for maintaining the equipment in a safe and operable manner.

Based on observation, interview and record review, the facility failed to ensure a resident identified with confusion, poor safety awareness, ambulatory, and had verbalization of wanting to exit the facility, was provided supervision to prevent elopement from the facility. The facility also failed to ensure the door on the ground floor leads to courtyard and main street was in good repair and had a working alarm system to alert facility staff of a resident attempting to exit the facility. This failure resulted in R1 eloping from the facility without being witnessed by facility staff during the early hours on December 29, 2024. This applies to 1 of 7 residents (R1) reviewed for risk of elopement in the sample of 7. R1 was found standing on the sidewalk of a local street near an intersection with 4 traffic lanes, which was approximately 183 feet from the entrance of the facility by a bystander, who alerted the police on December 29, 2024, at 5:14AM. The local police and fire department found R1 wet, with no shoes and wearing only a pair of socks and pajamas. R1 had skin injury due to a fall occurred during the elopement. The weather showed at time of occurrence was 46 degrees Fahrenheit and raining. R1 was taken to the nearby hospital by paramedics. The hospital record dated December 29, 2024, showed R1 was diagnosed with cold exposure, small bump to left side of head with dried blood and laceration. The hospital's ED (Emergency Department) report dated December 29,2024 showed (R1) arrives to ED via EMS (Emergency Medical Serves) after being found outside by police across street from the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on December 29, 2024 at 5:14 A.M. when R1 was found by a bystander who then alerted the police. V1 (Administrator) was notified of the Immediate Jeopardy on January 3, 2025 at 1:02 P.M. The Immediate Jeopardy was removed on January 04, 2025, at 11:00 A.M. Noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the removal plan. The findings include: The EMR (Electronic Medical Record) shows R1 was originally admitted to the facility on [DATE]. R1, an [AGE] year old with multiple diagnoses including adrenal insufficiency, type 2 diabetes mellitus, laryngeal cancer with status post laryngectomy and tracheostomy, coronary artery disease with status post x4 (coronary artery bypass graft on 2020), hypertension, gangrenous cholecystitis with status post insertion of irrigation drain, and insertion of gastrostomy tube (on October 2024), clostridium difficile infection, hard of hearing, unsteadiness on feet, lack of coordination, major depressive disorder, adult failure to thrive and spinal stenosis. R1's MDS (Minimum Data Set) dated November 25, 2024 shows R1 had moderate cognitive impairment with BIMS (Brief Interview Mental Status) score of 9/15. On December 31, 2024 at 11:00 A.M., together with V3 (Assistant Director of Nursing), the facility's nine exit doors were checked. Two doors on the ground floor which lead to courtyard and main street were not in good repair. The first door by TV lounge/ground floor was observed with a non-functioning alarm. This door leads towards the courtyard and main street. This door would not close shut, and door remained a few inches ajar. There was a panel alarm next to this door. The alarm did not sound off when opening and closing this door. The door and the alarm were not in working condition. V3 said the door should always be closed, and alarm should sound when opening or closing the door for the staff to be alerted and checked to ensure no resident/s was outside unsupervised. V3 said the alarm should continue sounding off without staff reactivating the code of the alarm. V3 added, both the door and alarm were not in working condition and no alarm had sound off when the door was open. V4 (Director of Maintenance) came to the TV lounge door with surveyor and V3 present. V4 said the door and alarm were non-working condition, and the alarm panel was not sensing the alarm by the mother board above the door. V4 said the alarm should sound off when the door opens and closes for the staff to be alerted. V4 said since the door was not latching and not totally closing, the alarm will not sound off. V4 said, This door (TV lounge) was not locked for quiet sometime now, and anyone can come and go, especially those who smoke. V4 said he cannot remember when the TV lounge door/alarm was last checked to ensure its functionality. V4 said he was informed on December 31, 2024 sometime in the morning that R1 eloped from the TV lounge door. V4 said he will call V18 (Regional Head for the Maintenance) to help fix the non-functioning alarm and door. V4 said he checks the doors and alarms randomly but does not document what doors were last checked since it was done in random. Observation continued by touring the facility with V3. The defective TV lounge door leads to an open courtyard and to a main street. There was a pathway in the courtyard that went steep down and then inclined. Upon walking this walkway, caution and foot brakes were needed to avoid stumbling or falling. From the pathway, there was the access to the main street. There was an intersection between main street with four lanes of traffic from north and south direction of the facility. The second door by the library room on the ground floor also leads to the courtyard and to the main street. The alarm was not sounding and was not in good repair. V1 (Administrator) came and explained the alarm by the door in the library room was not functional and said the library door was locked at nighttime around 8:00 P.M. There was no documentation/log the library door was locked every 8:00 P.M. On December 31,2024 at 12:00 Noon, R1 was sitting in a regular chair in his room. R1 had a tracheotomy that was capped. R1 speaks with slow raspy voice. R1 was noted to be hard of hearing. During this time, V16 (R1's spouse) was at bedside. V16 said, I was called by the staff here (R1) had left the facility without them knowing it. They said he exited by the door from the TV lounge. They told me he was found by the police and their staff across the facility's main street. I know it, that TV lounge door was always unlocked, people go in and out to smoke. That door/TV lounge was close to my husband's room. I went to the hospital at once when the staff called me around 5:20 A.M. on December 29,2024. When I went to the hospital with my daughter, and saw him (R1), he was only wearing cotton pajama, socks no shoes, no jacket and the weather was cold, was raining and was still dark. I asked him what happened, and he said, I want to go home; then when I asked him again what he was doing outside the facility he said, I do not know. I was told he fell while he left the facility. Look at this, (V16, pointing skin injuries) he got a cut on the right eyebrow, left side of forehead, and bruises on knees and ankles. He was so impulsive, weak and does not know where to go especially when he needs to go to bathroom. Since that TV lounge door was always unlock and no alarm, he left without staff knowing it. (R1) had been saying he wanted to go home. I told him to get stronger, there was a nurse who heard this conversation, and this was like a month ago. I don't remember the name of the nurse. R1 said I don't know and responded he does not remember being out of the facility and was alone during the early morning of December 29, 2024. V16 assisted R1 to the bathroom with a walker device. R1's gait was observed to be unsteady. V16 said R1 was weak, and at facility for therapy. V16 said R1 is confused at times and had said his desire to go home but does not know how to get home. On January 2, 2024 at 10:30 A.M., together with V2 (Director of Nursing), the facility's video surveillance was reviewed for the date of December 28,2024 at 11:00 P.M. going to 5:12 A.M. of December 29, 2024. The video surveillance showed R1 came out of his room at 4:05 A.M. V7 (LPN/Licensed Practical nurse) started to look for R1 at 4:53 A.M. Several staff: V8 (CNA-Certified Nurse Assistant), V10 (RN/Registered Nurse), V5 (CNA) went out the main entrance at 5:12 A.M. and all came back to the facility. V2 said, They must have found (R1) was why they all were back to the facility and R1 was taken to the hospital by paramedics. The video surveillance showed no staff went inside R1's room to check from 11:00 P.M. of December 28, 2024 through 4:53 A.M. of December 29, 2024. On December 31,2024, multiple interviews were held with the staff worked on December 28-29, 2024, from 11:00 P.M. though 7:00 A.M and assigned to R1. On December 31, 2024, at 2:08 P.M., V6 (CNA) said she took care of R1 the evening shift (3-11 P.M.) on December 28, 2024. V6 said R1 was restless, confused, impulsive and was not aware of his safety. V6 said during the evening shift on December 28, 2024, the shift prior to R1's elopement, R1 had exhibited and repeatedly verbalized wanting to go home. V6 said R1 was cued, reoriented and was assisted to go back to bed. V6 said few moments later, R1 was verbalizing again he wanted to go home. V6 said she continued to work for the next shift which was the night shift. V6 said she was on the same unit where R1 resides, but it was V5 (CNA) who was assigned to R1. V6 said R1's room was next to the TV Lounge Room that had the defective door, and the alarm was not sounding off. V6 said, The door by the TV lounge has been like that, not locking, no alarm sounding off and people including residents go in and out to smoke. We sit by the lounge area whenever we get a chance, but taking care of residents especially early morning was busiest time. Nobody was supervising or monitoring that unlocked, no alarm door and we do not know if any residents go out without us knowing. (R1) must have exited that door. There was no other door he can leave the facility being undetected. V5 (CNA) said at 2:17PM on December 31, 2024, the TV lounge door was unlocked, without an alarm and no supervision from staff. V5 stated the TV lounge lacks supervision when staff is providing care to residents. V5 said R1 must have exited the malfunctioning door/alarm since no one had heard any alarm sounding off. V5 said R1kept saying he wanted to go home. V5 said she saw R1 at 3:30 A.M. prior to elopement. Review of the facility's video surveillance indicated staff was not seen checking R1 from 11:00PM December 28, 2024, until he was noted missing on December 29, 2024, by V7 (LPN-Nurse) at 4:53AM. V7 said when she went out of the facility to look for R1 at around 5:12 A.M., she saw R1 standing by the sidewalk across the street from the facility. V7 stated R1 had passed by the main street. V7 said a bystander had called the police. V7 said R1 was wet, was wearing pajamas and socks, weather was cold, and it was still dark at the time R1 was found. On December 31, 2024, at 4:20 P.M., V10 (RN/night supervisor) said she was called by V7 when R1 had eloped from the facility on December 29, 2024, early morning. V10 said R1 was found across the street from the facility. V10 said R1 was taken by the paramedics when found. On December 31, 2024, at 1:50 P.M., V8 (CNA) said the TV lounge was not latching, and no alarm was sounding off. V8 said she did not hear alarm when R1 had eloped from facility. On December 31, 2024 at 2:37 P.M., V11 (PT/Physical Therapist/Director of Rehabilitation) said R1 was receiving skilled therapy for deconditioning since R1 was weak. V11 said R1 needed his walker device with staff supervision for safe ambulation. V11 said R1 is with bouts of confusion with poor safety awareness. On January 2,2025 at 1:00 P.M., V13 (CNA), V15 (CNA) and V14 (LPN) said doors have access to outside to the facility going to street should be locked and always alarmed. They said there was no recent training to monitor the doors/alarms. V19 (CNA) said the TV lounge door has always been unlatched, was not closing properly and alarm was not sounding when the door was fully open nor when the door was closed. V19 said residents go in and out to unlock/unalarmed door to smoke. On January 2,2025 at 12:30 P.M., V17 (R1's family member) said they thought R1 left the building through the door by the ground floor and TV room. V17 added they never heard an alarm. V17 said R1 wanted to return home but he needed to recover and was weak. V17 was upset R1 was able to exit the building and was found outside wearing only socks and pajamas. V17 stated R1 can be confused and does not know his own safety. On January 2,2025 at 2:06 P.M., V18 (Regional head of Maintenance department) said the TV lounge door exit to the courtyard and to the main street was not in working order. V18 said the sensor board above the door was short circuited, and it does not give signal to the alarm panel. V18 said he was only informed by the V1 regarding the malfunction doors and alarms on December 31, 2024 at around 1:30 P.M. V18 explained the pathway route where R1 exited had a steep pathway sloped down to at least 20-degree angle and inclined after to another 20-degree angle. The care plan dated December 29,2024 showed non-specific interventions regarding supervision and monitoring of R1's elopement risk. Review of the facility's policy dated December 2007 for Elopement showed there were no preventative measures to prevent elopement, no process for monitoring alarm doors to prevent elopement there was no procedure identify and address assessment of residents for elopement risk. The facility presented an Immediate Jeopardy removal plan on January 3, 2025; however it was returned. The second version of the plan was approved at 7:30PM, January 3, 2024. Through observation, interview and record review conducted on January 4, 2025, the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: -R1 was re-assessed for Elopement risk as of January 3, 2025 to complete accurate assessment. -R1's care plan was reviewed and updated as of January 3, 2025 to include: R1 placed on monitoring while out of resident's room; R1 placed on hourly monitoring. There will be a sign off sheet to reflect his behavior, what he is doing, how is acting if he is verbalizing wanting to leave while his family is not in the facility. Wife is in the facility daily from 8 am - 2 pm. R1's wife was educated to share with the staff to alert the staff when leaving. -Facility initiated in-service on R1's direct care staff on plan of care to address elopement risk and precautions. This will continue until all direct care staff for R1 have been provided with in-service. The staff will not be allowed to work the shift without being In-serviced prior. Facility Scheduler, Nurse Supervisor, Administrator, and/or Designee will check if in-services are all completed prior to beginning of the shift. -All residents in the facility who have cognitive impairments have scored moderate BIMS and are at risk high risk for elopement have the potential to be affected by the same deficient practice, initiated January 3,2025. -All residents are being reassessed for elopement. The facility will monitor any resident that is at moderate and high risk and will make sure proper care plan is in place and will monitor resident for any significant changes. -The measures the facility will take or systems the facility will alter to ensure the problem will be corrected and not recur: Facility initiated a binder with photos of residents who are at risk of elopement and will be checked weekly and as needed by Social Service and/or Designee. This will be on an ongoing basis. Facility DON and/or Designee will conduct a daily audit of all admissions and readmissions to ensure the elopement assessment has been completed. If a resident is at high risk for elopement, DON and/or Designee will ensure elopement precautions are in place and implemented. This will be conducted daily and will be ongoing. Facility initiated the audit of resident elopement assessments of residents who are at risk of wandering and elopement and residents with cognitive impairments to ensure proper care plan is in place. Facility removed door lever as well from the problem doors, to ensure doors are locked until alarm company will provide the sensor board. The sensor company will be at the facility Monday (January 6, 2025) to assess the problem in the motherboard. Door alarms will be checked daily to be completed by Maintenance, or the Designee or the MOD and audited by Administrator or designee. Latch to the door was lubricated and noted functional day of the survey. Facility having door alarms modified to continuously alarm so staff would physically have to go to the location to reset the alarm in the event the alarm triggers. Facility initiated in-service on direct staff on Monitoring the Exit Doors, Assessing for Resident Departure, and Reporting to Maintenance Malfunctioning Equipment. -Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed. Facility has contacted low voltage repairer to come to the facility to repair the motherboard on the courtyard doors. Facility initiated in-service on direct care staff on residents identified at risk for Elopement along with Elopement Policy. Any staff member who has not received in-service education by the completion date will be in-serviced before the start of their next shift. Continuing education will be provided on these policies and procedures as needed. -Facility may utilize verbal and in-person methods for in-services. -The facility has an Elopement Binder with policy and list of residents' high risk for elopement/wandering to ensure appropriate training and in-service is provided. -Facility will schedule a Resident Council Meeting on January 6, 2025, at 2:00 PM to discuss facility's policy on going out on pass, utilization of back patio (i.e., smoking, including signing in and out when exiting the building through the front door) and when courtyard patio would be utilized by residents. -Facility held an emergency QAPI meeting. Medical Director informed of the plan. Done January 3,2025. -Receptionist received in-service education to ensure all residents who go in and out of the facility follow the sign-in and out protocol. -Staff to conduct head count on assigned residents during rounds. -Staff will be assigned to monitor and supervise residents when out in the front of the facility and/or courtyards. -Quality Assurance plans to monitor facility performance to make sure the corrective actions are achieved and permanent: Administrator will review audits weekly to ensure compliance with the measures put in place to address the safety of residents at high risk for Elopement. Administrator will ensure the Abatement Plan will be implemented and completed until compliance date and as indicated. QAPI was initiated on January 3,2025 to discuss with QA Committee the Abatement Plan and ensure all corrective actions and safety measures are consistently implemented. Medical Director notified via phone of the plan.

Based on observation, interview, and record review, the facility failed to ensure residents who developed facility-acquired pressure ulcers were assessed by the wound care physician/NP-Nurse Practitioner; failed to ensure the residents received nutritional interventions to promote wound healing; failed to put interventions in place to prevent pressure ulcers from deteriorating; failed to provide wound care treatments as ordered by the physician; and failed to follow their policy to do a root cause analysis for residents with facility-acquired pressure ulcers. This failures resulted in R1's facility-acquired pressure ulcer increasing in size, and R1's DTI (Deep Tissue Injury) progressing to an unstageable pressure ulcer. This applies to 3 of 3 residents (R1, R2, R3) reviewed for facility-acquired pressure ulcers in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including nondisplaced fracture of the right great toe, COPD (Chronic Obstructive Pulmonary Disease), OSA (Obstructive Sleep Apnea), Type 2 diabetes, cataract, hypertension, lymphedema, history of breast cancer, heart failure, morbid obesity, altered mental status, major depressive disorder, insomnia, muscle weakness, difficulty walking, lack of coordination, need for assistance with personal care, shortness of breath, and dementia. R1's MDS (Minimum Data Set) dated October 17, 2024 shows R1 has moderate cognitive impairment, requires setup assistance with eating, supervision with oral and personal hygiene, bed mobility, and transfers between surfaces, and substantial/maximal assistance with toilet hygiene, showering, and lower body dressing. R1 is occasionally incontinent of urine, and frequently incontinent of stool. The MDS continues to show R1 was at risk of developing pressure ulcers and did not have pressure ulcers at the time of her admission to the facility. On November 25, 2024 at 10:26 PM, V11 (Nurse) documented, Writer made aware of open area to heel left foot. Upon further assessment, writer observed open area on left heel. Writer cleaned area with normal saline, dried with sterile gauze and applied 4x4 to area. Provider and family is aware. Wound care is aware. New orders for protein and to keep foot elevated and Podiatry consult. Staff to continue to follow up. On November 26, 2024 at 9:40 AM, V3 (WCN/RN) documented, Was notified that a wound was found on [R1's] left heel. Upon assessment, she has a Stage 3 pressure ulcer there. She was also found to have a small DTI (Deep Tissue Injury) on her right heel. She spends little time in bed, but she may have pressure from the back of her shoes. Her daughter and MD were notified. On November 25, 2024 at 1:40 PM, V1 (Administrator) documented, I saw [R1] at lunch time propelling herself to the dining room using her heels. I asked [R1] if she wanted help, she stated no she was fine. On December 4, 2024 at 9:15 AM, R1 was lying in bed in her room, sleeping. R1 was not covered by a sheet or blanket and her legs were visible. R1's heels were resting on the mattress. R1 was not wearing foam heel boots. No pillows were present in R1's bed to offload her heels from the mattress. R1 did not have a low air loss mattress. On December 4, 2024 at 9:28 AM, V10 (CNA-Certified Nursing Assistant) entered R1's room and said, I had to wake her up this morning. She likes to sleep late. R1 attempted to make position changes in her bed but found it difficult to change positions in bed without the assistance of V10. V10 was unable to find foam heel boots or other pillows in R1's room to elevate R1's heels off the bed. R1 was wearing a nightgown and short socks in bed. V10 removed R1's socks. R1 had a dressing over the back of her left heel. The dressing had peeled away from R1's skin and was bunched up over the back of her ankle. The wound on R1's heel was exposed. The wound on R1's heel appeared approximately 1 inch in diameter. The wound appeared crater-like, dry, and with some redness in the center of the wound. R1 also had a dressing over her right heel, and the wound was not visible. V10 assisted R1 with dressing herself and placed R1's shoes on her feet. On December 4, 2024 at 9:40 AM, V3 (WCN-Wound Care Nurse/RN-Registered Nurse) said she believes R1's pressure ulcers were caused by R1's shoes. V3 said, [R1] uses her feet to propel herself around in her wheelchair. She has a Stage 3 pressure ulcer on her left heel and a DTI (Deep Tissue Injury) on her right heel. Both wounds were found on November 26, 2024. We have two wound NPs (Nurse Practitioners) who come to the facility weekly. [R1] has not been seen by either wound care NP. I don't think we have a protocol for when the residents should be seen by the wound care NP. I don't think we have a protocol for when residents should be put on a low air loss mattress. Usually, we only use a low air loss mattress when the resident is immobile and has a Stage 2 or higher pressure ulcer. V3 entered R1's room at 9:45 AM. R1 was sitting up in her wheelchair fully dressed, including wearing her shoes. V3 told R1 she was surprised to see R1 wearing her shoes. V3 removed the dressing on R1's left heel. V3 noted the dressing was not covering R1's pressure ulcer. V3 said the dressing should be covering R1's pressure ulcer. V3 said, On November 26, 2024, R1's left heel wound measurements were 1.2 cm. (centimeters) long by 0.8 cm. wide, by 0.3 cm. deep. Today the measurements are 1.5 cm. long by 1.8 cm. wide, by 0.2 cm. deep. The wound is getting wider/bigger. V3 removed the dressing on R1's right heel and said, The DTI area has now turned to a scab. I am going to discontinue putting any dressing on this and leave it open to air. During the wound care treatment, R1 stated she has very little feeling in her feet due to her diabetes. R1 said she can feel something is there but could not say exactly what she was feeling. On December 4, 2024 at 11:26 AM, V8 (WCN/LPN-Licensed Practical Nurse) said, I am responsible for arranging all wound care visits between our wound care providers and the residents. The other wound care nurses notify me who needs to be seen and I arrange it. The wound care physician and NPs come to the facility on Mondays and Tuesdays, and I round with them. We were never notified [R1] needed to be seen by the wound care physician or NP, so we did not see that resident. It could have happened right away if [V3] (WCN/RN) would have made the referral and added [R1] to the list. V8 continued to say when a resident has a DTI and the DTI develops a scab over the area, the pressure ulcer would be considered an unstageable pressure ulcer. As of December 5, 2024 at 4:00 PM, the facility did not have documentation to show R1 was assessed by the wound care physician or NP since the development of her pressure ulcer on November 25, 2024. The facility does not have documentation to show R1 was encouraged not to wear her shoes or to stop using her heels to self-propel her wheelchair. The facility does not have documentation to show R1 was educated regarding her pressure ulcers. The facility does not have documentation to show R1 was assessed by the dietitian following the development of her pressure ulcers until December 4, 2024. V5 (Dietitian) documented R1 has Increased protein needs related to increased demand for healing as evidenced by skin impairments. The facility does not have documentation to show orders for protein supplements were ordered until December 4, 2024. R1's care plan for potential for pressure ulcer development/impaired skin integrity was created on September 24, 2024 by V12 (MDS Nurse). R1's care plan does not show R1's care plan interventions were updated after the development of her left heel Stage 3 pressure ulcer, or her right heel DTI. On December 4, 2024 at 3:24 PM, V12 (MDS Nurse) said, I was aware [R1] developed pressure ulcers. I did not update the care plan interventions. [R1's] care plan interventions were not updated after she developed pressure ulcers. The facility does not have documentation to show a root cause analysis was completed after R1 developed pressure ulcers at the facility, as shown in the facility's policy for facility-acquired pressure ulcers. On December 4, 2024 at 3:24 PM, V9 (NP) said, I was aware [R1] developed pressure ulcers. I believe they automatically have the wound NP look at the resident. I usually just have the wound care nurse address it unless it gets worse. Then we must take more invasive steps. I was not notified that [R1's] wound was larger as of today. The wound nurse told me the shoes were rubbing on her heel. It would be my expectation that they put interventions in place to prevent the wound from getting worse. On December 4, 2024 at 4:17 PM, V13 (Primary Care Physician) said, The last time I saw [R1] was October 22, 2024. I was called and told [R1] had a pressure ulcer last week. They told me it was because of the shoes she was wearing. Of course, I would expect them to stop putting those shoes on her if that is what caused the pressure ulcers. I would have expected them to have her seen by the wound care doctor or nurse practitioner, and make sure she was evaluated by the dietitian. If she had a DTI and it now has a scab on it, that wound is considered an unstageable pressure ulcer, so that wound is worse. If the Stage 3 pressure ulcer measurements are bigger, then that wound got worse also. Of course, they should put new interventions in place once they find someone has a pressure ulcer. I would say her pressure ulcers got worse because they did not do anything to prevent that from happening. 2. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, right lower limb cellulitis, chronic lymphocytic leukemia, dementia, muscle weakness, difficulty walking, falls, idiopathic neuropathy, atrial fibrillation, acquired absence of right toe, and major depressive disorder. R2's MDS dated [DATE] shows R2 is cognitively intact, requires supervision with eating, partial/moderate assistance with oral hygiene, bed mobility, and transfers between surfaces, substantial/maximal assistance with personal hygiene, and is dependent on facility staff for toilet hygiene, showering, and dressing. R2 is frequently incontinent of bowel and bladder. R2's MDS continues to show R2 was at risk for developing pressure ulcers and did not have any pressure ulcers at the time of the MDS assessment. The facility's wound report dated December 4, 2024 at 10:22 AM shows R2 developed a facility acquired deep tissue pressure injury to his anterior left malleolus on November 20, 2024, and a facility-acquired unstageable pressure ulcer to his right heel. The facility does not have documentation to show a care plan was initiated after R2 developed a facility-acquired pressure ulcer. On December 4, 2024 at 3:40 PM, R2 was sitting up in his wheelchair in his room. R2 had a dressing on his right foot. R2 had difficulty answering questions about his wound due to his cognitive status at the time. On December 5, 2024 at 12:33 PM, R2 was sitting up in his wheelchair in his room. R2 was wearing non-skid socks. Two visitors were present in the room and R2 did not want to be disturbed at that time. On December 4, 2024 at 2:29 PM, V12 (MDS Nurse) said R2 does not have a care plan or interventions in place for his facility-acquired pressure ulcers. The facility does not have documentation to show a root cause analysis was completed to determine the cause of R2's facility-acquired pressure ulcers as shown in the facility's policy. The EMR shows the following order for R2 dated November 22, 2024: Right heel cleanse with house stock wound cleanser. Paint/swab with betadine and cover with dry dressing three times per week and as needed. The facility does not have documentation to show R2's wound treatments were administered as ordered on November 25, 27, and 29, 2024. The EMR shows the following order for R2 dated November 22, 2024: Left malleolus anterior, cleanse with house stock wound cleanser. Paint/swab with betadine and cover with dry dressing three times per week and as needed, every Monday, Wednesday, Friday. The facility does not have documentation to show R2's wound treatments were administered as ordered on November 25, 27, 29, 2024. On December 5, 2024 at 12:33 PM, V15 (Physician) said, [R2's] debility puts him at an increased risk for the pressure ulcers. It is standard protocol to initiate interventions to prevent pressure ulcers. It is my expectation that wound care treatments be administered as ordered. 3. The EMR shows R3 was admitted to the facility on [DATE] with multiple diagnoses including, idiopathic progressive neuropathy, Alzheimer's disease, major depressive disorder, personal history of cerebral infarction, history of breast cancer, and hypertension. R3's MDS dated [DATE] shows R3 has moderate cognitive impairment, requires supervision with eating and oral hygiene, substantial/maximal assistance with showering, personal hygiene, and bed mobility, and is dependent on facility staff for toilet hygiene, lower body dressing and transferring to and from the bed to the chair. R3 is always incontinent of bowel and bladder. R3's MDS continues to show R3 is at risk for developing pressure ulcers and did not have any pressure ulcers at the time of the MDS assessment. On October 9, 2024 at 1:54 PM, V3 (WCN/RN) documented R3 had a facility-acquired Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 1.70 cm. long by 1.20 cm. wide by 0.10 cm. deep. Wound status: active. On October 16, 2024 at 9:10 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, The wound to [R3's] sacrum has closed. She reports intermittent pain in the area relieved with position changes. Wound care provided, tolerated well. On October 24, 2024 at 10:07 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with small open area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. Wound care performed, tolerated well. V3's documentation does not show the measurements for R3's open wound. On November 4, 2024 at 9:59 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with wound area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. Wound care performed, tolerated well. V3's documentation does not show the measurements for R3's wound area. On November 13, 2024 at 10:54 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 0.00 cm. long by 0.00 cm. wide by 0.00 cm. deep. Wound status: closed. V3's documentation continues to show, [R3] continues with some redness to her sacrum . V3's documentation does not show the measurements for R3's reddened area. On November 21, 2024 at 9:22 AM, V3 (WCN/RN) documented R3 had a Stage 2 pressure ulcer of the sacrum. The pressure ulcer measurements were 1.80 cm. long by 1.00 cm. wide by 0.00 cm. deep. Wound status: active. V3's documentation continues to show, [R3] continues with open area noted to her sacrum. She reports intermittent pain in the area relieved with position changes. She is resistant to being on her side and spends much of her time on her back, not allowing this wound to improve much. She was left on her side after this visit. Wound care performed, tolerated well. R3's care plans were reviewed. As of December 4, 2024, the facility did not have documentation to show a care plan was initiated following the development of the facility-acquired pressure ulcer on October 9, 2024. The facility does not have documentation to show a root cause analysis was completed to determine the cause of R3's facility-acquired pressure ulcers as shown in the facility's policy. The EMR shows the following order for R3 dated October 18, 2024 and discontinued on November 13, 2024: Wound care to sacrum. Cleanse with normal saline, pat dry, apply triad to wound area and cover with dry dressing three times weekly and as needed if dressing becomes soiled, every Monday, Wednesday, Friday. The facility does not have documentation to show the wound treatment was administered as ordered on, October 18, 21, 23, 25, 28, 30, 2024, and November 1, 6, 8, 11, 13, 2024. The EMR shows the following order for R3 dated November 14, 2024: Wound care to sacrum. Cleanse with normal saline, pat dry and apply hydrocolloid dressing two times weekly and as needed if dressing becomes soiled or dislodged every Monday, Thursday. The facility does not have documentation to show the wound treatment was administered as ordered on November 28, 2024 or December 2, 2024. On December 4, 2024 at 9:15 AM, R3 was lying in bed. R3 refused to get out of bed and stated she had a sore butt. On December 5, 2024 at 2:13 PM, V2 (DON-Director of Nursing) said she was confused by V3's (WCN/RN) documentation of R3's wounds. V2 confirmed V3's documentation showed the wound was closed on October 24, 2024 but later in her documentation V3 documented the wound was open and no measurements were documented. V2 also confirmed on November 4, 2024, V3 documented R3's wound was closed but then documented a wound area was noted to R3's sacrum and no measurements were documented. V2 (DON) said, [V3's] (WCN/RN) documentation is inconsistent and does not make sense. [R3] had active orders for wound care treatments. Those treatments were not documented as being administered as ordered. Every resident who has a pressure ulcer should be referred to the wound care doctor/NP. That did not happen for [R1] and [R3]. Every resident who develops a pressure ulcer in the facility should have a root cause analysis completed so we can individualize their care. That is our policy. That did not happen for [R1], [R2], and [R3]. All residents with pressure ulcers should have their nutrition assessed by the dietitian to see if they need protein supplements for wound healing. That did not happen either. We have three wound care nurses who work here and are exclusively assigned to wound care, seven days a week. Plus, we have two wound care doctors who visit this facility, twice a week. None of this should have happened. The facility's policy entitled Skin Management: Dressing Application, revised on 10/16 shows: General: Dressings are changed as ordered by the physician or NP. Guideline: .8. Dress wound as directed in the physician orders.11. Document on treatment sheet that dressing was completed, measure and describe wound weekly, and document any pertinent findings or communication with physician/nurse practitioner in the medical record. The facility's policy entitled Skin Management: Pressure ulcer, lower extremity ulcer evaluation and documentation, revised 7/14 shows: General: To report and gather data for the purpose of planning and implementing wound care treatment procedures. To evaluate outcomes in terms of wound management. Responsible Party: Wound Care Team. Guideline: .4. Pressure ulcers will be evaluated, a picture taken, and the following areas documented weekly: Location, Stage, Size: perpendicular measurement of the greatest extent of length and width of the ulcer using a disposable measuring device. Depth, presence and location.10. Wounds will be measured on a weekly basis The facility's policy entitled, Unavoidable Evaluation, reviewed 10/16 shows: Guideline: To provide a process for reviewing a pressure ulcer to determine the root cause. Responsible Party: Wound Care Team. Guideline: 1. When a resident develops an in house acquired pressure ulcer or the pressure ulcer deteriorates, the facility will do a root cause analysis to determine the reason.7. Once the evaluation is completed, the facility will consult with the physician and determine if the wound was unavoidable. If the resident's wound was unavoidable the physician will be asked to document such in the medical record.

Based on observation, interview, and record review, the facility failed to safely transfer a resident while using a mechanical lift. As a result of this failure, R1 sustained a laceration to the head and fracture of the thoracic 8 and 12 vertebral bodies after falling. R1 was transferred to the local hospital and received 2 staples to the back of R1's head. This applies to 2 of 6 residents (R1 and R7) reviewed for falls and accidents. The findings include: On 10/22/24 at 11:15 AM, R1 was observed in bed in her room. R1 said fall incident happened on a Thursday, which was her shower day. R1 said 2 Certified Nurse Aides (CNAs) transferred her using the mechanical lift from the bed to the shower chair and gave her a shower. R1 has a shower in her room. R1 said after the shower, the same CNAs were transferring her back to the bed using the mechanical lift. R1 said while they were attempting to put her back in bed, she fell to the floor on the bathroom side of her bed. R1 said she hit her head and there was some bleeding, and the staff called the ambulance, and she was sent to the hospital. R1 said had staples on her head and was at the hospital for 7 days. R1 said she is still experiencing pain on her middle and lower back from the fall. On 10/23/24 at 11:20 AM, R1 said she has not been out of bed since she returned from the hospital. R1 said she now requires a back brace when she is out of bed. R1 said she is not sure when she will get out of bed, adding being in the mechanical lift sling would cause her more pain and her body would be limp since there is no support with the sling. On 10/22/24 at 12:58 PM, V8 (CNA) said on the day of the incident, she assisted V11 (CNA) with giving R1 a shower. V8 said they transferred R1 using the mechanical lift and a shower sling. V8 said after R1's shower while transferring her to the bed, R1 slipped out of the shower sling and fell . V8 said the incident happened so quick, there was no time to catch R1. V8 said R1 landed on top of the legs of the mechanical lift. V8 stated R1 has a tendency of leaning towards her left side. V8 said she was guiding R1 during the transfer while V11 was maneuvering the mechanical lift. V8 said after the fall they notified the nurse, and the nurse assessed R1. V8 stated they called the ambulance and R1 was sent to the hospital. On 10/22/24 at 3:26 PM, V11 (CNA) said they used a mechanical lift to transfer R1. V11 said on the day of the incident after she and V8 had given R1 a shower, they were transferring her back to bed, and right before they got to R1's bed, R1 slipped out of the sling and fell . V11 said she was the one maneuvering the mechanical lift while V8 was guiding R1. V11 said the incident happened fast. V11 stated R1's body shifted left out of the sling and R1 landed on top of the legs of the mechanical lift. V11 said after the fall she called the nurse to assess R1 while V8 stayed with R1. V11 said R1 was taken to the hospital. On 10/23/24 at 10:02 AM, V12 (Licensed Practical Nurse/LPN) said she was informed by the CNA that R1 had a fall. V12 said when she got to R1's room, R1 was on the floor and had a laceration to her head. V12 stated she said she assessed R1 and R1 complained of pain in her back. On 10/22/24 at 2:50 PM, V3 (Director of Nursing/DON) said she was informed R1 slipped from the mechanical lift shower sling during a transfer after her shower. V3 said R1 was sent to the hospital after the fall, where she had 2 staples to her head, and the X-ray report showed there was a fracture to T8 and T12. V3 said when she investigated the incident, she found that the shower sling strap was giving way. V3 stated there was a small tear at the top blue part by the loops that is hooked onto the mechanical lift. On 10/23/24 at 2:14 PM, V1 (Administrator) said they do not have a time frame for replacing resident's mechanical lift slings; if it does not look good, they replace it. V1 said she purchased R1's shower sling and full body sling a year ago because R1 was complaining that her sling was missing. V1 said that it was R1's personal sling. R1's Fall Incident Report of 10/3/24 stated, On 10/3/24 during the morning care, the resident slipped with the presence of the staff inside the resident room. Analysis is maybe the blue strap starting to give away and the resident body shifted, slipped and fell . The sling used for R1's transfer had already been thrown away. R1's Face Sheet shows that the following diagnoses of wedge compression fracture of unspecified thoracic vertebra initial encounter for closed fracture, quadriplegia, disorder of bone and multiple sclerosis. R1's Restorative Evaluation of 10/14/24 shows that R1 is dependent on staff for transfers. R1's hospital records of 10/4/24 stated R1 was sent to the hospital following a fall; R1 was being bathed earlier in the morning, when resident was being placed back into the bed, the transfer device sling broke and she slipped to the ground. R1 hit back of head and dropped on her back. R1 had laceration repair to the scalp and was noted with thoracic vertebral fractures/closed fracture of thoracic vertebra. R1's CT (Computed Tomography) scan of 10/3/24 shows there are fractures of the T8 and T12 vertebral bodies which appear acute and subacute and there is minimal compression of the T9 vertebral body. The facility's Safe Lifting and Movement of Residents policy (revised July 2017) states that resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.

Based on interview and record review, the facility failed to follow the plan of care regarding the required number of staff assistance during bed mobility of a resident. This failure resulted in R1 sustaining an acute closed displaced supracondylar fracture of the distal end of the right femur after R1 fell off the bed during care on 11/4/2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 as an [AGE] year-old resident, with diagnoses included multiple sclerosis, idiopathic gout, quadriplegia, atherosclerotic heart disease, chronic obstructive pulmonary disease, periprosthetic fracture around internal prosthetic right knee, vitamin D deficiency, vitamin B12 deficiency, anemia, polyneuropathy, anxiety disorder, major depression, insomnia, hyperlipidemia, osteoporosis, and osteoarthritis. The EMR also showed R1 had a history of right knee arthroplasty. The MDS (Minimum Data Set) 7/21/2023 showed R1 as cognitively intact. The functional status regarding bed mobility showed R1 required extensive assistance of 2 plus staff members. The care plan dated 10/19/2023 showed two-person assistance was required for R1's bed mobility. The care plan also showed R1 requires the use of mechanical transfer lift device and two-person assistance for transfer. The progress notes dated 11/4/2023 showed, NOD (Nurse on Duty) called writer attention that (R1) fell on floor this morning during care by CNA (Certified Nurse Assistant) on duty and (R1) complain on right knee pain. Writer went immediately and noted (R1) in bed, alert and oriented, noted to complain of right knee pain also mentioned to writer she hit her head during the fall. Writer assessed head, no skin discoloration noted, very small bump noted. (R1) denies any pain or discomfort. R1 stated only her knee right is painful. On scale 0-10, R1 stated 8, offered pain medication. R1 stated NOD already give her pain medication before a few minutes. Informed MD .and updated. MD stated to send (R1) via 911 for evaluation. The progress notes also showed a follow up call was made to the hospital later the evening of 11/4/2023 and that R1 was admitted for right femur fracture. Hospital note dated 11/4/2023 showed, R1's x-ray result was closed displaced supracondylar fracture of distal end of right femur without intercondylar extension. Ortho on consult. Continue conservative management, pain control, DVT (deep vein thrombosis) prophylaxis, PT/OT (Physical/Occupational Therapy eval . will be back to skilled facility . R1 returned to the facility on [DATE]. The admission assessment dated [DATE] showed R1's diagnoses of right femur fracture. On 11/15/2023 at 11:00 A.M., R1 was lying in bed. R1's bed mattress was an air loss pressure reducing device. R1 said on 11/4/2023 around 9:00 A.M., V4 had given her a shower. R1 said there was no problem with shower, however, when she (R1) was put back to bed, V4 had turned her (R1) to the right side to dry her (R1's) back. R1 said during the turn, she (R1) landed on the floor. R1 said V4 was by herself when she (R1) was turned while in bed. R1 was observed with an ace wrapped around from right mid-thigh to mid-calf area. On 11/15/2023 at 1:52 P.M., V4 (CNA) said she had provided R1 a shower morning of 11/4/2023. V4 said R1 was put back to bed after the shower. V4 also said, (R1) was upset because she wanted a longer shower that last more than an hour and her shower lasted around 30 minutes. (R1) was very particular with care, demands a lot of things at the same time, and I try to please her by following her demands immediately. That morning, (R1) said to dry her back, so I turned her to her right side, then she rolled out of bed. I immediately called the nurse and she was sent out to the hospital. I felt bad what happened. All I want is to give her care at once so she would not get upset. On 11/15/2023 at 1:32 P.M., V9 (LPN/Licensed Practical Nurse) said sometime in the morning of 11/4/2023, she was called because R1 was on the floor. V9 said she immediately assessed R1. V9 said immediate care was provided to R1 and R1 was sent to the hospital via 911.

Based on observation, interview and record review, the facility failed to follow plan of care regarding needed assistance for a resident requiring 2 plus person physical assist. The facility also failed to ensure that a bed rail was in functioning order when used as an enabler to ensure resident's safety. This applies to 1 of 3 residents (R2) reviewed for falls. These failures resulted in R2 sustaining a laceration to his head and left eyebrow requiring sutures and staples at the hospital. The findings include: The EMR (Electronic Medical Record) shows that R2, a [AGE] year-old with diagnoses that includes hemiplegia and hemiparesis due to effect of cerebral infarction, right above knee amputee, malignant neoplasm of left lung, tonsil, larynx, diabetes mellitus, peripheral autonomic neuropathy, PVD (peripheral vascular disease), COPD (coronary obstructive pulmonary disease), AHSD (atherosclerotic heart disease), atrial fibrillation, weakness and major depression. R2's original admission to the facility was on 8/1/2016 with most current reentry on 2/27/2023. On 3/13/2023 at 10:30 A.M., R2 was observed lying in bed. R2's bed mattress was an air loss pressure reducing device. R2's upper bed rails were on upward position. R2 was wearing a left-hand splint due to a hand contracture. R2 did not verbally response when conversation was initiated. R2 was connected to a gastrostomy feeding. R2 was also connected to an oxygen tubing. R2 was positioned in the middle of the bed. It was observed that there was approximately 4-6 inches width distance from R2's body to the edge of the bed. R2 was observed with multiple staples to the scalp between the middle and right side of the head. R2 also was noted with several small sutures to the left upper eyelid. V2, DON (Director of Nursing) was present during this time. V2 said that the staples and sutures were the lacerated wounds acquired by R2 from the fall of 2/22/2023. V2 said that R2 fell to the floor on 2/22/2023 during the provision of care by V5 (CNA). The incident report dated 2/22/2023 shows R2 fell to the floor from bed, during provision of care by V5. R2 was noted with bleeding on the face, head and was sent to the hospital. R2 was admitted with diagnoses of fall and hypoxia. R2 returned to facility on 2/27/2023 with staples on the middle of the head and sutures to left upper eyelid. On 3/13/2023 at 3:23 P.M., both V4 (Nurse) and V5 (CNA) were interviewed in the facility's conference room. V5 said R2 fell from bed to the floor on 2/22/2023 when he was providing care to R2. V5 said that it was only him and no other staff assistance when he turned R2 to the left side of the bed and R2 was holding unto the left side bedrail that was on upward position. V5 said he turned his back to get a bed sheet from R2's drawer, which was just next to R2's bed. V5 said the upper left bed rail went to the downward position, because the screws that attached to the bed were loose, and (R2) fell to the floor. V5 said V54 changed R2's incontinence brief and noted the bed sheet was soiled. V4 said she immediately went to R2's room when V5 called for help. V4 said she saw R2 lying on the floor, with bleeding from the head and left lower eyebrow. V4 said the left side of the upper bed rail was on downward position. V4 said, I assumed the screws that attached to the bed were loose because it did not hold to the intended and secured position, which was supposed to be upward. This was why maintenance had replaced the bed. (R2) is a big guy. When turning (R2) to the side while in bed and there was not enough bed space and (R2) lying on an air loss mattress, which can be slippery, it would be like a water wave. Gravity will pull him 9R2) down. This is what caused (R2) to end up on the floor. On 3/13/2023 at 3:45 P.M., V6 (Maintenance Director) said he inspected R2's bed the next day after the fall. V6 said that due to (R2) being a big guy. The screws from the bed rail that attached to the bed frame came loose and did not hold secured position. The bed rail went to downward position. R2's most recent MDS (Minimum Data Set) was 1/3/2023 which was the most recent assessment prior to R2's fall on 2/22/2023. The MDS indicated R2's functional assessment as follows: R2 with extensive assistance with 2 plus person physical assistance for bed mobility. The MDS described bed mobility as how resident moves to and from lying position, turns side to side, and positions while in bed. R2 was assessed as extensive assistance with 2 person plus physical assistance for toilet use. The MDS described toilet use as when a resident uses toilet, commode, bed pan, urinal, cleanses self after toilet use or elimination, including changing incontinence pad. Review further of R2's MDS assessment shows that R2 has mood disorder exhibited by low interest in activity, feeling empty, has trouble concentrating, feeling tired and low energy level. R2 also has limited range in motion on one side of upper extremity (left hand contracture) and one side of the lower extremity (right above knee amputee.). Review of R2's most recent care plan dated 1/3/2023, shows that there were no revised interventions to prevent further falls. The history of care plan shows that it was on 7/23/2020 that R2 was assessed for risk for fall; with intervention for education to staff for safety; 8/9/2020; staff education for safety; 3/26/2023 for dycem (non-skid seat cushion). R2 had histories of falls. R2 was sent out for CT (Computerized Tomography) of the head on 7/23/2020. The hospital admission record dated 2/23/2023 shows R1 was seen and treated for fall and hypoxia. The record also shows that due to the fall incident, R2 sustained a laceration to the left side of his scalp and a laceration below left eyebrow that were stapled and sutured.

Based on interview and record review, the facility failed to transfer residents with a mechanical lift according to their policy and in a safe manner. This failure resulted in R4 sustaining a [MEDICAL CONDITION] and lacerations to the face and head following a fall from a mechanical lift. This applies to 5 of 5 residents (R4, 5, 6, 7 and R8) reviewed for mechanical lift transfers, in the sample of 8. The findings include: On (MONTH) 19, 2019, the facility reported to the Department they had begun an investigation of a resident fall from a mechanical lift that resulted in the resident sustaining a right [MEDICAL CONDITION] and lacerations to the face and back of head. On (MONTH) 2, 2019, the facility provided a list showing the 5th floor housing 64 residents including 25 residents requiring a 2 person mechanical lift to transfer. On (MONTH) 3, 2019 at 4:24pm, V4 (private care giver) stated, prior to V4's fall, she had retrieved the mechanical lift from outside the room across the hall while V9, CNA (Certified Nurse Assistant) was working in the room across the hall. V4 stated V9 saw her take the mechanical lift. V4 stated she was transferring R4 with the mechanical lift from the bed to the motorized wheelchair. She raised R4 over the space past the foot of the bed, then turned away from R4 to move the wheelchair into position and when she turned back, R4 was on the floor, bleeding from the top of his head. V4 stated, she just does not know what happened, did not hear R4 fall and does not understand how the lift sling came to be detached from the lift. Additionally, V4 stated she has been performing transfers with the mechanical lift for R4 since she began caring for him in the facility in 2008. V4 stated no staff in the facility had ever objected and it was not often that staff would assist in the transfers. V4 stated, she had never met the Director of Nurses before this incident. V4 went on to explain, she immediately bent down to R4 on the floor to tend to him, pressed a towel to his head and at that time, V9 entered the room. V4 stated she had not yet called anyone to help. V4 stated she believed V9 came to get the mechanical lift to use for another resident. On (MONTH) 2, 2019 at 2:18pm, V9 stated he was the first one in the room and saw R4 on the floor and V4 was kneeling down with him wiping blood from his head and the floor. I went for the Nurse right away. On (MONTH) 4, 2019 at 2:18pm, V9 stated he had never known V4 to ask for assistance with transfers. V9 stated V4 had been working with R4 in the facility since long before he started working in the facility. V9 stated, on the day of the fall (March 19, 2019), he was in the room across the hall from R4's room working with another resident and did see V4 retrieve the mechanical lift from outside the room he was working in. V9 stated, he went to R4's room to retrieve the mechanical lift and assist if needed, at which time he saw R4 on the floor. V9 stated, it is not for me to say if any CNA's in the facility operate mechanical lifts by themselves without help. On (MONTH) 2, 2019 at 12:16pm, R4 stated (through a typed message on a communication device) V4 has been transferring him for years by herself. R4 stated he doesn't like waiting for the staff as they sometimes take a long time to arrive. R4 stated that one staff sometimes transfers him. V13 (CNA) often transfers him by herself in the morning when he gets up. The facility face sheet shows R4 was admitted to the facility (MONTH) 2005. R4's most recent MDS (minimum data set) dated (MONTH) 1, 2019 shows a BIMS (brief interview for mental status) score of 15 (memory and cognition fully intact). Also, MDS shows R4 requires 2 persons to provide extensive assistance for all transfers. On (MONTH) 2, 2019 at 11:54am, R5 was in a motorized wheelchair. R5 stated she has been in the facility for 3 years and is transferred only with a mechanical lift. R5 stated in the morning, getting out of bed, a mechanical lift is used and in the afternoons she is able to use a mechanical sit-to-stand lift. R5 stated that 2 staff usually transfers her, but sometimes it is only one. The facility face sheet shows R5 was admitted to the facility (MONTH) (YEAR). R5's most recent MDS dated (MONTH) 28, 2019 show a BIMS score of 15 (memory and cognition fully intact). Also, MDS shows R5 requires 2 persons to provide extensive assistance for all transfers. On (MONTH) 3, 2019 at 10:40am, R6 was in bed. R6 stated she is transferred using the mechanical lift. R6 stated, staff does sometimes perform the transfer with only one staff in the room. R6 stated it had been several days since the last time one staff performed the transfer. R6 stated, she would prefer not to name any staff. The facility face sheet shows R6 was admitted to the facility (MONTH) (YEAR). R6's most recent MDS dated (MONTH) 25, 2019 show a BIMS score of 15 (memory and cognition fully intact). Also, MDS shows R6 is totally dependent and requires 2 persons to provide extensive assistance for all transfers. On (MONTH) 3, 2019 at 11:55am, R7 was in bed, turned to her right side. R7 stated all transfers are done by staff using the mechanical lift and staff assists with positioning. R7 stated usually 2 staff perform the transfer, but occasionally just one is there. R7 stated she knows which CNA's are good at it and let's them perform the transfers, but will not allow newer or unfamiliar staff to perform transfers by themselves. The facility face sheet shows R7 was admitted to the facility (MONTH) 2009. R7's most recent MDS dated (MONTH) 18, 2019 show a BIMS score of 15 (memory and cognition fully intact). Also, MDS shows R7 is totally dependent for and requires 2 persons to provide extensive assistance for all transfers. On (MONTH) 4, 2019 at 12:50pm, R8 was in the facility hallway propelling a motor wheelchair. R8 stated she is always transferred with a mechanical lift and it is usually done by 2 staff. R8 stated, sometimes she is transferred by only one staff. R8 added that she was transferred by one staff that morning. The facility face sheet shows R8 was admitted to the facility (MONTH) (YEAR). R8's most recent MDS dated (MONTH) 18, 2019 show a BIMS score of 9 (memory and cognition mildly to moderately impaired). Also, MDS shows R8 is totally dependent for and requires 2 persons to provide extensive assistance for all transfers. On (MONTH) 2, 2019 at 10:30am, V2 (Director of Nurses) stated she had not met V4 and was surprised that V4 would be doing mechanical lift transfers by themselves. V2 stated, an in-service was done following the incident, re-enforcing the strict requirement that 2 staff must always be present during any mechanical lift transfer. On (MONTH) 3, 2019 at 3:49am, V3 (Medical Doctor) stated she had been working with R4 for many years and was aware of V4 for many years. V3 stated she was aware there was a strong bond between R4 and V4. V3 stated she believed, but did not know, that V4 was performing transfers for V4 for years and was sure the fall was simply an accident. On (MONTH) 3, 2019 at 9:05am, V11 (Registered Nurse and Floor Supervisor) stated she was in the facility and was called to V4's room at the time of the fall. V11 stated she had seen V4 before, but did not know her and could not say how she came to performing a mechanical transfer by herself. On (MONTH) 3, 2019 at 9:20am, V10 (Registered Nurse) stated she was the Nurse for V4 the day of the fall. V10 stated she did not know V4, but had seen her here now and then. V10 stated she did not see her retrieve the mechanical lift and was unaware if the CNA's assisted V4 with transfers. The facility policy titled Safe Patient Lifting Policy, dated (MONTH) 10 (YEAR) shows, Purpose: The Safe Patient Lifting Policy exists to ensure a working environment for resident handlers. The policy is to be reviewed & signed by all staff that perform or may perform resident handling. - the transfers will be designated into one of the following categories: SSS= Sit to Stand with Standard Sling with 2 caregivers (Extensive Assist 2 people) SSC= Sit to Stand with Carrier Sling with 2 caregivers (Extensive Assist 2 people) H= Total Lift Transfer (HoyerTM type) with 2 caregivers (Total Assist).

Based on interview and record review the facility failed to have a side rail, used as a safety device, in a correct position to prevent a resident from falling out of a bed during care. This failure applies to one of three residents (R1) reviewed for falls in a sample of three. As a result, E1 (certified nurse aide) rolled R1 to the side during incontinence care and R1 fell on to the floor. R1 sustained a laceration to her forehead and experienced a Subarachnoid hemorrhage. Findings Include: Facility's fall prevention program (bee safe program) undated denotes for high fall risk resident, the following interventions: 1. Monitor and assist following daily schedule routine. 2. Supervise and or assist bedside sitting, personal hygiene and toileting as appropriate. 3. Keep safety device in place and functioning. 4. Staff to check for proper placement and function of safety devices every shift. R1's care plan initiated 4-7-15 denotes the resident is high risk for falls related to decreased mobility and cognition. Interventions included all staff to provide safe environment and educate family and staff on the importance of keeping safety device in place and functioning. An incident report dated 5-4-15 denotes CNA (certified nurse aide) called nurse to R1's room observed R1 on floor face down with acute bleeding to right forehead. CNA stated she turned R1 and she rolled off the bed. Steps taken to prevent recurrence: take more precautions when turning residents, use side rail down when turning residents. R1' s minimum (MDS) data set [DATE] denotes for bed mobility ( how resident turns side to side and positions body while in bed or alternate sleep furniture) requires extensive physical assistance by two or more person. On 5-13-15 at 3:00 pm E1 (Certified Nurse Aide) stated she went in to assist R1 with her ADL (activity of daily living) and was changing her incontinent brief. E1 stated R1 was facing the window leaning on her right side and holding the side rail on the right side of the bed. E1 stated she was standing behind R1 on the opposite side (left side). While she was removing the incontinent brief, R1 let go of the raised side rail and rolled off the bed and hit the floor. E1 stated called for help and the nurse (E2) came. E1 stated they did not remove R1 and ambulance attendants came shortly and put her on the stretcher. E1 stated when the side rails are not being used by a resident they are in the up position. E1 stated she will now make sure the side rail is down before repositioning or changing any resident for now on. On 5-13-15 at 3:30 pm E2 (Licensed Practical Nurse) stated she was in hallway on 5-4-15 doing medication pass when CNA (E1) called for assistance in R1's room. She went and saw R1 on the floor on the right side of her bed. E2 stated she noted that R1 was bleeding and the side rail was up in the air. E2 stated she got a 4 x 4 gauze and applied pressure to her head. E2 further reported, E1 informed her that she was getting ready to get R1 up for breakfast. She (E1) rolled R1 on her side and R1 fell out of the bed. E2 stated when the side rails are not being used they are in the up position. E2 stated they are supposed to pull the side rails down so they are in place so the residents can grab them, when they are repositioning or changing them. E2 stated R1 is very dependent and weak and needs staff to assist all her ADLS. R1's hospital record dated 5-4-15 denotes Computed Tomography (CT) Scan impression: new 4 x 3 area of high density at right frontal cortex, consistent with a small hemorrhagic contusion. Comment: There are some linear areas of high density within the Subarachnoid space adjacent to right frontal/temporal lobes. Admission physical exam forehead lacerations currently sutured. On 5-13-15 at 4:45 pm Z1 (Doctor) stated, R1's fall caused R1 to sustain the laceration to her forehead and the trauma of the fall contributed to her subdural bleed. On 5-13-15 at 3:50 pm E3 (Director of Nursing) stated E1 should have had R1's side rail down when she was providing care to R1 on the day (5-4-15). She (R1) rolled out of the bed. When the side rail is up, it is much shorter than when it is down. E3 believes the cause of R1's fall was that the CNA did not have the side rail down and R1 rolled out of the bed.

Based on interview and record review, the facility failed to ensure that identified fall prevention interventions were implemented for 1 of 3 residents reviewed for falls (R1). These failures resulted in R1 sustaining a fractured left femur and subsequent hospitalization . Findings Include: Facility ' s fall risk assessment policy denotes residents will be assessed for risk factors that increase their potential for falls in order to identify the need to initiate additional safety measures. Residents who scores 0-11 shall be considered at risk for falls and have general resident safety interventions implemented. R1 ' s fall risk assessment dated [DATE] denotes R1 had total score of 8. R1 ' s initial care plan denotes R1 has potential for falls related to dementia with decreased focus and safety awareness, interventions included ensure that resident (R1) is wearing appropriate footwear (shoes, bedroom slippers, nonskid socks) when ambulating or up in wheel chair, increase redirection of the resident for safety and initiate falling prevention protocol. R1 ' s nurse note dated 1-25-14 denotes R1 in/out of residents ' room wearing their shoes. R1 ' s nurse notes dated 1-30-14 and 2-6-14 denotes R1 in other resident s rooms taking their personal belongings. R1 ' s nurse note dated 2-12-14 R1 continues to ambulate and wanders in and out of other residents rooms, takes their belongings, clothes shoes redirection given. E2 (Certified Nurse Aide) stated on 3-18-14 at 11:20 AM was working on 2-14-14 and assigned to R1. E2 stated saw R1 with a pair of black shoes (clogs) on earlier at the beginning of her shift (2-10). E2 stated she did not know if they were her shoes and did not check. E2 stated was later told by the nurse that R1 had fallen. E2 stated was not told by the nurse to make sure R1 had the appropriate foot wear on. E2 stated she did know that R1 would go into other residents ' room and take their clothes but did not know R1 would put the other resident ' s clothes/shoes. E4 (Assistant Director of Nursing) stated on 3-18-14 at 2:00 PM " clogs " are not appropriate foot wear for the residents. E4 stated staff is responsible to make sure residents have on the appropriate foot wear and their own shoes/clothes on. E1 (Licensed Practical Nurse) stated on 3-18-14 at 1:10 PM worked on the Dementia unit for 5 years. E1 stated on 2-14-14 was sitting at the nurses ' station next to the TV room when the CNA (E3) told her that R1 had tripped and fallen. E1 stated she went to R1 and assessed her, called doctor and R1 denied any pain. E1 stated she noticed that R1 had on another resident black shoe (clogs) on. E1 stated R1 does not have black shoes (clog), she has a pair of gym shoes. E1 stated the black shoes (clogs) that R1 was wearing are not appropriate shoes. E1 stated all the staff is responsible to make sure the residents have the appropriate footwear on but the CNA assigned to R1 was to make sure R1 had the appropriate footwear. E3 (Certified Nurse Aide) stated on 3-18-14 at 11:30 AM was sitting in the TV room on 2-14-14 when R1 got up and walked out. E3 stated she called for R1 and asked her to come back in the TV room. E3 stated as R1 was turning around she got tripped over her feet and fell . E3 stated she immediately got E1 and saw that R1 had black shoes that belonged to her roommate. E3 stated part of the CNA duties is to a make sure the resident they are assigned to have on the right shoes. R1 ' s nurse note written at 4: 00 PM dated 2-14-14 denotes informed by CNA R1 on the floor in a sitting position. R1 assessed able to move all extremities. R1 observed to have another residents shoes-clog on at time of fall. Doctor notified and ordered X-ray. R1 ' s nurse note dated 2-14-14 written at 7:00 PM denotes X-ray done results pending. R1 ' s nurse note dated 2-15-14 written at 12: 50 AM denotes X-ray results fracture of the left femur, doctor notified and ordered to send R1 to hospital. R1 ' X-ray dated 2-14-14 denotes impacted transcervical fracture of the neck of the left femur. R1 ' s hospital record dated 2-15-14 denotes R1 in emergency room and X-ray showed a left femur fracture admitted for further management. Date of surgery 2-16-14 preoperative [DIAGNOSES REDACTED]. Procedure performed: Placement of bipolar femoral endoprosthesis at left hip. Z1 (Doctor) stated on 3-18-14 at 1:00 PM R1 had Dementia but able to walk without staff assistance. Z1 stated R1 did sustain a fracture of her left hip from the fall and needed a rod placed in her left hip to stabilize it. R1's post fall assessment dated [DATE] denotes footwear at the time of the fall were clogs foot wear. E5 (Restorative Nurse) stated on 3-18-14 at 12:30 PM did R1's fall post assessment. E5 stated R1 fell because she had on the wrong shoes at the time according to the nurses.

Based on record review and interview, the facility failed to ensure proper reconciliation of the Medication Administration Record (MAR) and Physicians' Order Sheet (POS) for 1 (R5) of 10 residents reviewed for [MEDICAL CONDITION] medications in a sample of 12. The facility also failed to establish an effective policy for reconciling the MAR and POS. This failure led to R5 receiving an excessive dose of [MEDICATION NAME] and being sent to the local emergency room with a [DIAGNOSES REDACTED]. Findings include: R5 is a [AGE] year old female admitted to the facility with the following Diagnoses: [REDACTED]. The facility's incident report for R5 dated 3/21/13 documents that R5 was sent to the local hospital via 911 for possible [MEDICAL CONDITION] activity and possible drug toxicity. The final report documents that R5 had returned back to the facility with a [DIAGNOSES REDACTED]. The report further documents that R5 had received the wrong dose of [MEDICATION NAME] ([MEDICATION NAME]). R5 had several Physicians' Order Sheets (POS) on the POS labeled #1, the following orders were noted: R5's POS labeled #2 documented the following orders: 2/24 [MEDICATION NAME] 100mg, 3 tabs (300mg) oral daily- 9:00am 2/24 [MEDICATION NAME] 25mg, 3 tabs (75mg) oral at HS (bedtime) - 9:00pm 2/25/13 [MEDICATION NAME] 100mg tablet, take 3 tablets (300mg) w/75mg (Dose=375mg) by mouth every evening- 9:00pm; 2/25/13 [MEDICATION NAME] 25mg tablet, take 3 tablets (75mg) w/300mg (Dose=375mg) by mouth every evening- 9:00pm Both orders had been crossed out with the word " Chg (change) 2/24 " written across them. R5's Telephone Order Sheet (TOS) dated 3/8/13 documents the following order: Increase [MEDICATION NAME] to 400mg oral QHS (at bedtime). R5's Medication Administration Record for the week of 3/13/13 - 3/20/13 documents that R5 received 300mg of [MEDICATION NAME] at 9:00am and 400mg at 9:00pm indicating a total dose of 700mg on several days. R5's medical records dated 3/21/13 documents: 2:00 am (Nurse's Notes) - noted spastic movements to upper and lower extremities 6:30am (Nurse's Notes) -MD (Medical Doctor) here and alerted this writer that R5 was unresponsive. 6:45am (TOS) -Send out to local emergency room to rule out [MEDICATION NAME] toxicity/[MEDICAL CONDITION] activity. 12:00 pm (Nurse's Notes) -Received R5 via ambulance, some jerky movements still noted due to diagnosis. 2:10 pm (Nurse's Notes) - [MEDICATION NAME] put on hold, DX (Diagnosis): [DIAGNOSES REDACTED]. R5's laboratory report dated 3/21/13 documents the following lab value: [MEDICATION NAME] ([MEDICATION NAME]) -955 *Critical R5's care plan for [MEDICATION NAME] dated 11/1/12 documents: Administer [MEDICAL CONDITION] medication per MD order. The next care plan for [MEDICATION NAME] was dated 4/3/12. On 5/1/13 at 2:53pm, E2 (Director of Nursing) stated that R5 was [DIAGNOSES REDACTED]. The facility's Medication Policy did not contain documentation on reconciling the MAR and POS. However, E2 stated that both the facility and pharmacy nurses are required to reconcile the POS and MAR when the new sheets are printed. E2 stated that R5's order for [MEDICATION NAME] was improperly documented when the POS and MAR for Mar/2012 was reconciled. On 5/2/13 at 11:48am, Z3 (Registered Pharmacist) stated that [DIAGNOSES REDACTED] can be caused by [MEDICATION NAME]. On 5/2/13 at 12:07pm, Z1 (Medical Doctor) stated that she visited R5 on 3/21/13 and noted R5 to be weak and tired. Z1 stated that according to R5's medical record, Z2 (Psychiatrist) had increased R5's dose of [MEDICATION NAME], and the facility gave R5 a higher dose than what was ordered. On 5/2/13 at 12:16pm, Z2 stated that R5's [MEDICATION NAME] dose was supposed to be increased by 25mg. Z2 stated "I don ' t know what happened, I just told them to increase it 25mg and somehow they added those 400mgs." Z2 stated "I believe the medication most likely caused her to have a [MEDICAL CONDITION]." R5's emergency room report from the local hospital documents: History and Present Illness- character of symptoms is patient has muscle twitches. Risk factors consist of multiple medications. Reevaluation- Appears to be having any [MEDICAL CONDITION] activity. Some of the muscle twitches is likely secondary to her psychiatric medications. R5's discharge instructions from the hospital documents: Drug reaction- dystonic. You are having a muscular reaction to a drug you have taken. The facility's policy for General Dose Preparation and Medication Administration documents: Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following- The facility should verify each time a medication is administered that it is the correct medication at the correct dose.

Based on observations, interviews and record reviews, the facility failed to effectively assess the strength of the mechanical lift sling used for transferring 1 resident (R2) and failed to assess 1 resident (R1) for strength and mobility in the lower extremities from a sample of 3 who were observed for mechanical lift transfers. This failure resulted in R2 falling and sustained left rib fracture. Findings include On 12/13/11 at 10 AM, R2 had an appointment with the dentist. R2 was being transferred from his bed to a cardiac chair via mechanical lift by E5(CNA) and E8(CNA), when one of the upper straps of the full body sling in the mechanical lift snapped/ broke. R2 slid off from the sling and fell on to the floor. R2 was evaluated. Physician and R2's family notified of incident. R2 was sent to the hospital. At 2:00 PM the same day, R2 returned to the facility. Alert and oriented complaining of pain in his left side. R2 was diagnosed with [REDACTED]. On 2/16/12 at 3:00 PM, R2 stated, he was on a mechanical lift being transferred to a cardiac chair when the strap of the sling in his left arm broke. R2 fell all the way down to the floor at the foot of the mechanical lift. There were 2 staff (E5 and E8) with R2 at the time of incident. R2 added he couldn't breath and staff rolled him in his right side. Facility called 911 right away. R2 was told by the hospital staff that he has a broken rib cage and the hospital can't do anything about it. R2 added, he wondered if facility had used the right sling on him. On 2/16/12 at 2:17 PM, E1 (Director of Nursing ) stated, facility usually had the laundry staff to check on the slings before placing it on the unit for used. E1 added facility follows manufacturer's recommendation for individual size, weight and color coding of the sling to use. E2 presented a copy of the manufacturer's recommendation that indicated the following: Weight Sling Size Strap Color 0-100 lbs. Small Black 100-200 lbs. Medium Blue 210-310 lbs. Large Yellow 310-450 lbs X- Large White 450-1000 lbs Bariatric Purple On 2/17/12 at 3:15 PM, E11 (Laundry Aid) stated, laundry staff checked the sling after they washed it. They also give it to E1 to check. E11 added they make sure it's not broken, that there's no tear and it could hold well. On 4/6/12 at 12:40 PM, E5 stated, that particular day E5 was just assisting E8 for transferring R2. E8 brought the sling to the room. E5 stated, he inspected the sling and did not see anything unusual with it. E5 added staff determine what sling to use through resident's care card. E3 (Restorative Nurse Director) usually assessed the residents and decides what type of sling or harness is to be used for individual resident. E5 added , he determined the effectiveness of the sling through its wear and tear, and by rip and sheer. On 4/6/12 at 5:45 PM, E8 stated, she determined what type of sling to use for a resident through the resident's care card. E8 confirmed she checked the sling before she used it to R2 . E8 added she determined the sling's effectivity if she doesn't see any tear, holes, or rips in the sling. R2 was about 390-391 lbs at the time of the incident. The white strap sling was used on him,however, it was observed that the sling used for R2, was already very worn and thin. Facility was unable to present evidence that they have been checking the sling prior to the incident. Facility started logging it in (sling check), after the incident happened. Based on the above, the facility failed to effectively assess the sling that was used on R2. The sling broke, causing R2 to fall and sustained left broken ribs. Further observations were made regarding transfers. On 2/16/12 at 12:15 PM, R1 was transferred via sit to stand mechanical lift from chair to bed. E13 and E14 rendered incontinent care while R1 was in the the sit to stand. R1 was observed hanging precariously, clutching tightly on to the metal handle of the sit to stand lift, with no support from her lower extremities. E13 and E14 stated they can do incontinent care while resident was in the sit to stand. On 2/16/12 at 2:17 PM, E1 stated, sit to stand is being used for residents who can bear their own weight. Staff can do incontinent care while resident is standing in the sit to stand lift. The facility also failed to properly assessed R1's strength and mobility to the lower extremities which could have potentially caused harm to R1.