Every finding on record at Meadowbrook Manor - Naperville

Based on observation, interview and record review the facility failed to perform laboratory testing for residents with new respiratory illness symptoms. The facility also failed to follow their water management plan.This applies to all 212 residents residing in the facility.The finding include:The facility's Long-term Care Facility Application for Medicare and Medicaid dated [DATE], showed the facility census of 212 residents. 1. On [DATE], at 11:28 AM, R164 and R209 were residing in a room together. The sign outside of R164 and R209's room showed contact and droplet isolation. The signs did not show an N95 mask was required to enter the room. The EMR (Electronic Medical Record) showed R164 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, nasal congestion, and cough. A progress note dated [DATE], at 1:01 AM by V17 (Nurse) showed Resident coughing, complained of sore throat and has raspy voice. Residents remain on [oseltamivir], Nurse Practitioner updated Daughter/POA (Power of Attorney) updated. As of [DATE], at 4:00 PM the facility did not have documentation to show a rapid COVID-19 test, COVID-19 PCR (Polymerase Chain Reaction) test, or a respiratory quad panel was performed. 2. The EMR showed R209 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, Alzheimer's disease, dementia unspecified severity. A progress noted dated [DATE], at 10:41 AM by V18 (LPN/Licensed Practical Nurse) showed Resident was noted with respiratory symptoms. Nurse practitioner notified and advised resident to have stat CBC (Complete Blood Count) with Differential/CMP (Comprehensive Metabolic Panel) and chest x-ray. Orders carried out. Family here at facility and notified of symptoms. As of [DATE], at 4:00 PM the facility did not have documentation to show a rapid COVID-19 test, COVID-19 PCR (Polymerase Chain Reaction) test, or a respiratory quad panel was performed. 3. The EMR showed R142 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease with acute exacerbation, asthma, congestive heart failure, dependence of supplemental oxygen. On [DATE], at 10:09 AM ,the sign outside of R142's room showed contact and droplet isolation. The signs did not show an N95 mask was required to enter the room. On [DATE], at 12:28 PM a facility staff member entered R142's room wearing a surgical mask. V12's (Infectious Disease Nurse Practitioner) progress dated [DATE], at 3:45 PM showed R142 had a possible upper respiratory infection with the occasional cough. As of [DATE], at 4:00 PM, the facility did not have documentation to show R142 had a rapid COVID-19 test, COVID-19 PCR test, or a RSV (Respiratory Syncytial virus) test. 4. The EMR showed R85 was admitted to the facility on [DATE], with multiple diagnoses chronic congestive heart failure, Alzheimer's disease, dementia, personal history or COVID-19. V19's (LPN/Licensed Practical Nurse) progress dated [DATE], at 2:44 PM, showed Resident noted coughing. she is place on isolation for coughing. POA notified. will continue to monitor. As of [DATE], at 4:00 PM, the facility did not have documentation to show R85 had a rapid COVID-19 test, COVID-19 PCR (Polymerase Chain Reaction) test, or a respiratory quad panel test. 5. The EMR showed R188 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease. A progress note dated [DATE], by V12 (Infectious Disease Nurse Practitioner) showed R188 had a cough and was tested for flu, RSV and a rapid covid test on [DATE]. As of [DATE], at 4:00 PM, the facility did not have documentation to show R188 had a rapid a COVID-19 PCR test. On [DATE]:33 PM, V5 (IP/Infection Preventionist) said the facility was in a influenza A and RSV outbreak so residents with respiratory illness symptoms were no longer being tested for acute respiratory illness. On [DATE], at 1:58 PM, V2 (Director of Nursing) said residents who test positive for COVID-19 are on a different isolation than residents with influenza or RSV. V2 said there is different antiviral treatment for residents who test positive for COVID-19. On [DATE], at 2:50 PM, V12 said residents with respiratory symptoms should have a respiratory quad panel conducted to test for influenza, RSV and COVID-19. On [DATE], at 4:09 PM, V2 (Director of Nursing) said if a resident has respiratory symptoms, and the COVID-19 rapid test was negative then a COVID-19 PCR test should have been done. V2 said the facility should be following CDC guidelines in regard to testing for respiratory illnesses. The CDC's (Centers for Disease Control and Prevention) Viral Respiratory Pathogens Toolkit for Nursing Homes dated [DATE], showed .Test colon test residents and healthcare providers with new respiratory illness signs or symptoms. Selection of diagnostic test will depend on the suspected cause of the infection and if the results will inform clinical management. At a minimum, testing should include SARS-Cov2 and influenza virus with consideration for other causes (e.g. RSV) . 5. The facility's Water Management Plan dated [DATE], showed .2.1 Scope: the water management plan outlines procedures for minimizing the risk of Legionnaires' disease for persons at [the facility]. The water systems are described in tables and flow diagrams; the systems requiring control measures are noted in the Hazard Analysis. Although Legionella is not the only organism that can cause disease in a building environment, or the only pathogen associated with building water systems, it is the best pathogen on which to base water management procedures and to validate a water management program because it is the only one that meets the following criteria: causes numerous cases of severe illness; entirely environmental; almost entirely airborne; primarily building water related; detectable in water via reliable methods; extensively studied in both laboratory and field settings. The defined scope of the WMP (Water Management Plan) is limited to Legionella even though some control measures included may protect against other pathogens as well as chemical hazards. Many control measures that are effective in minimizing Legionella bacteria may be effective for other [NAME] of waterborne bacteria (e.g. mycobacteria avium; pseudomonas aeruginosa) that multiply in biofilms within a proximal temperature range. There are exceptions, however, so one cannot assume that Legionella control measures will be thoroughly effective against other waterborne pathogens.Control Measures; the facility shall manage the water system to maintain operation within these limits. If a limit is exceeded a corrective action show be implemented to control the growth or spread of Legionella in the water system. Control Measure: Hot water generation and storage temperature, Control Limit: greater than 140 degrees Fahrenheit, Monitoring Method: Record the temperature at each hot water tank after a 60 second flush, Frequency: Weekly; Control Measure: Distal site temperature, Control Limit: Hot: greater than 105 degrees Fahrenheit, Cold: less than 77 degrees Fahrenheit, Monitoring Method: Flush outlet for 60 seconds. Record the temperature. Take temperature from a minimum of 10 outlets representative of each hot water system. Frequency: Quarterly. Control Measure: Thermostatic mixing valve temperature, Control Limit: greater than 110 degrees Fahrenheit, Monitoring Method: Record the temperature from the mixing valve prior to supply into building. Document temperature from gauge. Frequency: Quarterly. Preventative Maintenance and Operation Procedures: Potable Water Equipment Preventative Maintenance. Frequency: Daily, Task: Pump Operation, Procedure: Perform a visual check of all components to ensure pumps are operating correctly. Perform maintenance on the pumps according to the manufacturer's recommended frequency and guidelines. Maintain documentation. Frequency: Weekly, Task: Emergency Eyewash and showers flushing, Procedure: In accordance with ANSI (American National Standards Institute) Z358.1-2009 Standard, flush the stations for one to three minutes to verify operation and ensure that flushing fluid is available. Maintain documentation. 7. Documentation: A written record to document monitoring, compliance with control limits, performance of corrective actions, and WMP validation. Maintain water testing documentation to be retrievable for at least three years. A master document providing the location of all program documents shall be maintained. Maintain the following minimum documentation for this WMP. Logs required for normal operation and system maintenance shall continue to be maintained: Temperature (heaters, return, distal outlets, mixing valve logs), Maintenance and Operation Procedures, Flushing Logs, System service/modification records, Bacteriological analysis records, Episodic water event and action logs, Corrective action records. On [DATE], at 1:33 PM, V16 (Maintenance Director) said for the facility's water management plan V16 documents his monitoring of the water management plan in a computerized building management platform. V16 said he does not do anything with the hot water return pumps. V16 said he was unsure what the plan meant when it referred to a pump. V16 said he thinks a company comes out annually to inspect a pump. V16 said he documents inspection of the eyewash stations weekly and checks random water temperatures throughout the facility daily. On [DATE], at 10:26 AM, V1 (Administrator) provided handwritten documentation from V16 regarding water management plan documentation. On [DATE], at 11:40 AM, V1 said the provided documentation from V16 was re-created documentation from V16's memory, including the water temperature results. V1 said his expectation is V16 documents monitoring of the facility's water systems in real time. The facility does not have documentation to show real time monitoring of quarterly distal site temperatures were obtained, weekly hot water generation and storage temperatures were obtained, daily inspection of the pump operation, hot water return temperature was obtained, and quarterly thermostatic mixing valve temperatures were obtained. On [DATE], at 2:41 PM, V1 said V16 should be following the water management plan for Legionella.

Based on observation, interview, and record review, the facility failed to document the narcotic medication that were removed from its container for resident administration to ensure accurate count of the controlled medication. This applies to 10 of 10 residents (R2, R18, R34, R55, R58, R109, R126, R141, R145, R74) reviewed for controlled medication count in the sample of 35. The finding include:On January 14, 2026, at 10:00 AM, narcotic count was conducted with V7 (Nurse) in the facility's memory care unit. 1. R55's Lorazepam 0.5 milligram (mg) tablet's log sheet showed 3 remaining tablets, however the actual count showed 2 tablets remaining. 2. R126's Alprazolam 0.5 mg tablet's log sheet showed 29 tablets, but the actual count showed 27 tablets remaining. 3. R145's Lorazepam 0.5 mg tablet's log sheet showed 9 remaining tablets, but the actual count showed 8 tablets remaining. 4. R74's Lorazepam 1 mg tablet log sheet showed 48 remaining tablets, however, actual count showed 47 tablets remaining. On January 14, 2026, at 10:16 AM, the narcotic count for 2B medication cart was conducted with V8 (Nurse) and the following were observed: 5. R18's Hydrocodone-Acetaminophen 10-325 mg tablet's log sheet shows 61 remaining, but the actual count showed 60 tablets were remaining. R18's Pregabalin 100 mg capsule's log sheet showed 35 capsules remaining, but the actual count showed 34 capsules were remaining. 6. R34's Hydrocodone-Acetaminophen 5-325 mg tablet's log sheet shows 2 tablets remaining, but actual count showed 1 tablet was remaining. 7. R141's Hydrocodone-Acetaminophen 5-325 mg tablet's log sheet showed 23 tablets remaining, but the actual count showed 22 tablets were remaining. On January 14, 2026, at 10:37 AM, narcotic count was conducted for the 2A medication cart with V9 (Nurse). 8. R109's Lorazepam 0.5 mg tablet's log sheet shows 21 remaining, but the actual count showed 20 tablets were remaining. 9. R58's Oxycodone-Acetaminophen 5-325 mg tablet's log sheet shows 27 remaining tablets; however, the actual count shows 26 tablets were remaining. 10. R2's Alprazolam 0.25 mg tablet's log sheet shows 6 tablets remaining, but the actual count shows 5 tablets were remaining. On January 14, 2026, at 12:10 PM, V2 (Director of Nursing/DON) stated the nurses are supposed to count the narcotics during shift change and they are to document/sign the narcotic sheet every time they pull out a narcotic medication to ensure accuracy of and accountability for the narcotic count. Facility's Policy and Procedure for Controlled Medications dated April 2025, shows controlled substances are reconciled upon receipt, administration, disposition, and at the end of the shift. This same policy shows that upon administration the nurse administering the medication is responsible for recording the resident receiving the medication, quantity of the medication remaining, and signature of the nurse administering the medication.

Based on interview and record review the facility failed offer the 2025-2026 Covid-19 vaccination to residents.This applies to 5 of 5 residents (R48, R71, R142, R162, and R164) reviewed for immunizations in the sample of 35.The findings include:1.The EMR (Electronic Medical Record) showed R48 was an [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including sleep apnea, hypertensive heart disease.R48's Immunization Report dated January 14, 2026, did not show R48 had received or offered the updated 2025-2026 COVID-19 vaccine.The facility did not have documentation to show R48 was offered the updated 2025-2026 COVID-19 vaccine.2. The EMR showed R71 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including transient ischemic attack, stroke and epilepsy.R71's Immunizations Report dated January 14, 2026, did not show R71 had received or offered the updated 2025-2026 COVID-19 vaccine.The facility did not have documentation to show R71 was offered the updated 2025-2026 COVID-19 vaccine3. The EMR showed R142 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses chronic obstructive pulmonary disease with acute exacerbation, asthma, congestive heart failure, dependence of supplemental oxygen.R142 Immunizations Report dated January 14, 2026, did not show R142 had received or offered the updated 2025-2026 COVID-19 vaccine.The facility did not have the documentation to show R142 was offered the updated 2025-2026 COVID-19 vaccine.4. The EMR showed R162 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses essential hypertension, venous insufficiency, personal history of COVID-19.R162 Immunizations Report dated January 14, 2026, did not show R162 had received or offered the updated 2025-2026 COVID-19 vaccine.The facility did not have the documentation to show R162 was offered the updated 2025-2026 COVID-19 vaccine.5. The EMR showed R164 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy.R164 Immunizations Report dated January 14, 2026, did not show R164 had received or offered the updated 2025-2026 COVID-19 vaccine.The facility did not have the documentation to show R164 was offered the updated 2025-2026 COVID-19 vaccine.On January 13, 2026, at 2:33 PM, V5 (Assisted Director of Nursing/Infection Prevention Nurse, ADON/IP) said he follows the CDC guidelines for COVID-19 vaccinations.On January 14, 2026, at 12:07 PM, V5 said R48, R71, R142, R162 and R164 were not offered the 2025-2026 COVID-19 vaccine. V5 said for residents to be up to date on the COVID-19 vaccine they should receive the 2025-2026 COVID-19 vaccine.On January 15, 2026, at 1:16 PM, V2 (DON/Director of Nursing) said the expectation is for V5 to follow the facility policy for COVID-19 immunizations. V2 said residents are up to date on their COVID-19 immunizations when they receive the 2025-2026 COVID-19 Immunization. V2 said R48, R71, R142, R162 and R164 should have been offered the vaccine already. The facility's policy titled COVID Vaccination dated November 27, 2025 showed General: To ensure the health and safety of all residents, staff and visitors, the facility shall implement and maintain a COVID-19 vaccination policy in alignment with the latest guidance from the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization practices (ACIP), and applicable state and local health authorities . Policy: All eligible individuals, including residents and staff, are encouraged to receive the most recent seasonally updated COVID-19 vaccine, as appropriate based on age, prior vaccination history and immunocompromised status.Facility leadership is responsible for: ensuring timely access to COVID-19 vaccinations.Guidance: 3.COVID-19 vaccination is recommended for the prevention of COVID-19 disease and its complications as follows.a. Adult ages 65 years and older: Vaccination based on individual-based decision making (also known as shared clinical decision making).The CDC's Recommended Adult Immunization Schedule for Ages 19 Years or Older dated October 7, 2025, showed adults 65 years or older are recommended to receive two or more doses of 2025-2026 COVID-19 vaccine

Based on observation, interview, and record review, the facility failed to provide a dining experience in a manner that would promote dignity. This applies to 6 of 16 residents (R12, R42, R80, R138, R191, R199) reviewed for dining experience in the sample of 35. The findings include:On January 12, 2026, at 12:23 PM, during lunch time in the 3rd floor dining room there were several dining tables with group of residents sitting each table. Some of the residents were eating, and some were waiting for their trays to be served to them.1. A table by the TV area had a group of 5 residents sitting around including R42 and R191. R42 and R191 were waiting for their trays to be served and watching the other 3 residents who were already eating. At 12:41 PM, R42 and R191 received their trays while the other 3 residents were halfway through their meals. Though R42 and R191 received their lunch tray only R42 started eating because R191 needed assistance to eat. At 12:45 PM, a staff sat down by R191 and started setting up her tray to feed her, and as soon as R191 saw it, R191 tried to grab the food in front of her as if she was very hungry and has been waiting to eat. 2. In a corner of the dining room near the exit door, R80 was sitting in her wheelchair alone. R80 was about 4 feet away from a table with a group of residents who were all eating. R80 was on and off watching people around her eating. At 12:43 PM, R80 was served lunch and fed by V14 (Certified Nursing Assistant/CNA) who stated that R80 has good appetite. 3. At the same time (12:23 PM) at another table there were 6 residents sitting around including R138. Four of the residents were served their food and were eating while R138 was waiting for the food. At 12:34 PM, two of the residents at this table finished eating, while R138 was still waiting for her tray. At 12:52 PM, R138 finally received her tray and was fed by V15 (CNA), while the rest of the other residents at her table were almost done eating. 4. On January 12, 2026, at 12:38 PM, at another table by the window, there were 4 residents seated including R12. Three of these residents were all eating while R12 was waiting for her meal and watching them eat. R12 suddenly grabbed one of her table mate's tray to get the food, a staff intervene to prevent it. At 12:43 PM, R12 was served her food tray, however, she had to wait until 12:45 PM for staff to come and feed her. Throughout this meal, it was observed that there were tables with residents who can feed themselves seated together with residents who require feeding assistance. The staff were noted serving lunch tray first to those who can feed themselves and not ensuring that residents who sits at the same table were served at the same time so they could eat together. 5. On January 14, 2026, at 11:40 AM, R199 was in the dining room waiting for lunch to be served. V11 (Clinical Manager) approached R199 to put a clothing protector on R199. R199 protested and told V11 not to put it on him because he is 88 years-old and it makes him feel like a baby. V11 kept insisting that R199 needed it to keep his clothes clean, then she proceeded to put it on R199. While doing so, R199 continued to protest and raised his hands and wrists to block the clothing protector from being fastened around his neck, when V11 continued to fasten the clothing protector, R199 attempted to pull it off to no avail. Despite the protest, V11 fastened the clothing protector around R199's neck and walked away. Facility's policy and procedure for Assistance with Meals dated April 2025 shows: Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. On January 14, 2026, at 2:02 PM, V2 (Director of Nursing) stated that during mealtime the staff must serve table by table to ensure that everyone at each table is served and have a meal at the same time to ensure resident's dignity. V2 also stated, resident may use clothing protector as requested by resident and/or family to keep clothes from becoming soiled or stained. If a resident refuses to wear a clothing protector, the staff must respect resident's request.

Based on observation, interview and record review the facility failed to provide assistance in cleaning and trimming nails to residents that needed extensive assistance for personal hygiene.The applies to 3 of 5 (R1, R97, R108) residents, reviewed for ADL (Activities of Daily Living) in the sample of 35. The findings include:1. R1's face sheet showed multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, moderate, with other behavioral disturbance, aphasia following cerebral infarction, unsteadiness on feet, cognitive communication deficit, personal history of other diseases of the musculoskeletal system and connective tissue.R1's quarterly MDS (minimum data set) dated January 1, 2026, showed that R1 was cognitively intact and required substantial maximal assistance (helper does more than half the effort, Helper lifts or holds trunk or limbs and provides more than half the effort) in personal hygiene. On January 12, 2026, at 11:58 AM, R1 was seated in a wheelchair and noted to have most nails on left hand with blackish substance underneath the nails, some of them that were long (about half centimeter beyond fingertips). R1's right hand was in a splint, and nails were not visible. R1 spoke haltingly and stated that he feeds self with left hand. On January 13, 2026, at 12:36 PM, R1 was eating in dining room and feeding self with left hand. R1's nails on left hand remain long with blackish substance underneath the nails. R1 right hand was without a splint and noted to have long nails that were digging into his palm with blackish substance underneath some of the nails. R1 stated that he would like to have his nails cut and cleaned. On January 13, 2026, at 12:42 PM, V4 (Restorative Aide) stated that the restorative aides put the splint on daily after providing PROM (passive range of motion) exercises. V4 was notified that R1 would like to have his nails cut and cleaned.R1's care plan revised July 31, 2024, showed that R1 has an ADL Self Care Performance Deficit and requires substantial to dependent assistance for mobility. Interventions in R1's care plan showed that R1 requires substantial assistance of one staff participation with personal hygiene. 2. R97's face sheet included multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, unspecified severity, with other behavioral disturbance, Alzheimer's disease, cognitive communication deficit, unsteadiness on feet, other lack of coordination. R97's admission MDS dated [DATE], showed that R97 had severely impaired in cognition and was dependent ((Helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for personal hygiene.On January 12, 2026, at 10:15 AM, R97 's nails were very long (about one centimeter beyond fingertip) with many jagged and broken with some having blackish substance underneath. R97 stated that he would like to have them clipped.On January 12, 2026, at 10:19 AM, V3 (Registered Nurse) was notified of R97's request. On January 12, 2026, at 2:35 PM, R97 was with V10 (R97's family member) in the dining room and his nails remained long with many of them jagged and broken with blackish substance underneath most nailbeds. R97 stated that the staff haven't gotten to his nails yet. Restorative care plan-initiated January 6, 2026, showed that R97 has an ADL Self Care Performance Deficit including limited mobility. Interventions showed that R97 requires substantial staff participation with personal hygiene. 3. R108's face sheet included multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction, contracture, left hand, Parkinson's disease without dyskinesia, without mention of fluctuations R108's quarterly MDS dated [DATE], showed that she was cognitively intact and required substantial maximal assistance in personal hygiene. On January 12, 2026, at 10:51 AM, R108 was lying in bed and although her nails were short, they had extensive blackish substance underneath the nails. R108 remarked They are filthy. I keep asking them to clean it. The last time I told them was when I was going out with my son on December 29th, 2025, for my birthday. I was so embarrassed to have them that dirty. After that they haven't cleaned it. They are so busy. On January 12, 2026, at 10:56 AM R108's request was related to V3 (Registered Nurse).R108's restorative care plan revised October 5, 2024, showed that R108 has an ADL Self Care Performance Deficit including limited mobility. Interventions showed that R108 requires substantial of one staff participation with personal hygiene. On January 13, 2026, at 3:32 PM, V2 (Director of Nursing) stated that the CNA's are responsible for cutting and cleaning the nails mostly on shower days and as needed. Facility policy for Activities of Daily Living (revised July 2025) included: 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, including appropriate support and assistance with:1.Hygiene (bathing, dressing, grooming, oral care and nail care).A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) the following MDS definitions:Extensive Assistance-While resident performed part of activity over the last 7 days, staff providing weight bearing support.Total Dependance- Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period.

Based on interview and record review, the facility failed to keep a resident free from chemical restraint. This applies to 1 of 5 residents (R11) reviewed for unnecessary medications in the sample of 35. The findings include:R11's EMR (Electronic Medical Record) showed R11 was admitted to the facility on [DATE], with diagnoses that included dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbances, major depressive disorder, and adjustment disorder with anxiety. R11's MDS (Minimum Data Set) dated November 26, 2025, showed R11 had moderately impaired cognition. R11's MDS showed R11 takes and antipsychotic and antidepressant. R11's care plan showed R11 uses psychotropic medications (See MAR, Medication Administration Record) related to MDD (Major Depressive Disorder) and adjustment disorder with anxiety. The intervention included consult with pharmacy, MD (Medical Doctor) to consider dosage reduction when clinically appropriate at least quarterly. R11's January MAR showed Aripiprazole (antipsychotic medication) oral tablet 2 mg. Give 0.5 tablet by mouth one time a day at 5:00 PM for MMD. Mirtazapine (antidepressant) oral tablet 7.5 mg. Give one tablet by mouth at bedtime related to major depressive disorder, recurrent, mild. On January 13, 2026, at the end of the day, V2 (DON/Director of Nursing) was asked to show evidence that a GDR (Gradual Dose Reduction) was completed or attempted for R11. On January 14, 2026, at 12:37 PM, V2 provided a pharmacy Consultation Report dated May 1, 2025, to May 31, 2025. The Consultation Report showed, [R11] has received an antipsychotic, Aripiprazole 1 mg, every night for MDD since April 2024, in addition to Mirtazapine 7.5 mg, every bedtime. Please attempt a gradual dose reduction of the aforementioned V2 said she was able to get the Consultation Report for the GDR by calling pharmacy but unfortunately it was not addressed by psychiatrist. The facility provided their policy titled, Gradual Dose Reduction of Psychotropic Drugs. The policy was last reviewed in April 2025. The policy showed, Definitions: 'Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. 'Psychotropic drug' or 'psychotropic medication' is defined as any drug that affects brain activities associate with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, antianxiety, and hypnotics. Compliance Guidelines: .3. The timeframes and duration of attempts to taper any medication shall depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications .c. Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or otherwise modified include: During the monthly medication regimen review by the pharmacist .

Based on observation, interview and record review the facility failed to provide adequate staffing to meet the care needs of residents. Staffing was insufficient to provide residents with assistance with incontinence care, preventing the development of pressure wounds, assisting with care needs, answering the call light and screams for help.This applies to 4 residents R1, R2, R3 and R6 in a sample of 6. Findings include:1.On 9/2/25 at 11:48 AM, R1stated she had recently admitted , and had a pressure wound on her buttocks and UTI (Urinary Tract Infection) since arriving to the facility. R1 stated the facility is short staffed. R1 stated on a few occasions she had called for incontinence care and left waiting for hours. R1 stated on one occasion she called V8 (Family Member) requesting he call the nursing station after waiting hours to be cleaned up of urine and feces. On 9/2/25 at 11:55 AM, V6 (CNA -Certified Nursing Assistant) and V13 (PT -Physical Therapist) came to R1's bedside for skin and brief observation. R1's undergarment was dry with a large streak of dried feces. Dried caked feces were between the gluteal fold. R1's labia and gluteal fold was reddened. R1 had a small open area on her coccyx.On 9/2/25 at 12:32 PM, V6 CNA stated her shift started a 6AM, but she had not provided incontinence care or turned R1 prior to 11:55 AM. V6 stated the wound nurse provided incontinence care and repositioned the resident during her dressing change.On 9/2/25 at 12:42 PM, R1 stated V6 had not provided any incontinence care during her shift and repositioned her at 11:55 with the physical therapist.On 9/2/25 at 3:10 PM, V8 Family Member stated R1 had called a few times with request for him to call nursing station for assistance. V8 stated on one of the calls R1 had complained of being left in soiled brief for over two hours.On 9/2/25 at 3:18 PM, V9 RN (Registered Nurse) stated R1 was on antibiotics for a UTI and had a pressure wound on her coccyx. On 9/2/25 at 6:17 PM, V1 Administrator stated should not need to call their family members to obtain staff assistance.2. On 9/2/25 at 10:50 AM, R2 was screaming for help. The call light was on and visible in the hall. Staff were observed walking past R2's room without addressing the calls for help. R2 stated she vomited earlier in the morning and had continued nausea. R2 also stated her bilateral knee braces were causing her discomfort because they were on too tight, and she wanted them loosened. R1 stated her room was too hot and wanted the temperature decreased. R2 stated she request V5 LPN (Licensed Practical Nurse) for assistance but did not receive it. R2 stated there isn't enough staff to complete the work needing to be done including providing her assistance. R2 stated she had been waiting since before 7AM for nausea and vomiting medication and hadn't gotten anything. During R2's interview staff were observed passing R2's room without addressing her call light.On 9/2/25 at 11:13 AM, V7 CNA (Certified Nursing Assistant) answered R2's call light stating she would let the nurse know a third time about R2's nausea.On 9/2/25 at 11:31 AM, V5 stated R2 complained of nausea not vomiting. V5 stated Ondansetron was ordered for R2's nausea but she had not given her any. On 9/2/25 at 3:26 PM, V10 Nursing Supervisor stated if the CNA reports resident concern to the nurse, the nurse should go to the resident right away or as soon as possible. R2's MDS (Minimum Data Set) dated 6/16/25 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) Score of 15. The facility policy Call Light Response dated April 2025, states answer the patient or resident's call as soon as possible. Listen to the patient / resident's request.3. On 9/2/25 at 2:58 PM, V12 (Family Member) stated staffing was insufficient and if she didn't visit the facility regularly nothing would get done for R3. V12 stated she arrived at approximately 11:55 AM. R3's undergarment was soaked through her clothing, and the staff didn't come and provide incontinence care until about 1:00 PM. V12 stated that the floor was dirty and R3's laundry hamper was overflowing with urine-soaked clothing.4. On 9/2/25 at 12:16 PM, R6 stated she didn't believe there was enough staff. R6 stated she has been told by staff they are working short of staff. R6 stated it can take ten minutes to three hours for the call light to be answered. R6 stated if staff are feeding other residents she must wait for incontinence care. R6 stated she put her call light on at about 8:30 AM to get dressed and out of bed but was not gotten up until 11AM.On 9/2/25 at 12:07 PM, V7 CNA (Certified Nursing Assistant) stated she sometimes has 17 to 20 residents to care for. V7 stated sometimes she is unable to complete like resident showers. Residents must sometimes wait a long time to have their call light answered. What we don't get done we inform the scheduler, and the task is passed on to the next shift or the next day. Some residents aren't happy when they're not showered when it's scheduled.On 9/2/25 at 3:50 PM, V11 CNA stated when there is a staffing shortage the residents may miss getting showered. If there is staffing shortage and no one picks up it's expected the CNAs working will make up the shortage.On 9/2/25 at 4:26 PM, V4 Scheduler stated if there is a staffing shortage the managers and restorative aids should fill in and assist but aren't taking a full team. V4 stated she was a CNA able to fill in on the floor if needed.On 9/3/25 at 3:50 PM, V4 Scheduler stated staff are to initial on the schedule when they work. A check mark by nursing staff names mean they did not initial but they were working and accounted for. If there is no initial or check mark by the staff name that means they called off. Names that are lined out means that staff member was reassigned to another unit. V4 stated the staffing ratios for the 1st floor AM and PM shifts should have 3-4 nurses and 4-5 CNAs. The 1st floor night shift should have 2 nurses and 3 CNAs. The 2nd floor AM and PM shifts should have 3 nurses and 5-6 CNAs. The Night shift 2nd floor should have 2 nurses and 4 CNAs. The 3rd floor AM and PM shifts should have 2 nurses and 3 CNAs. The 3rd floor night shift should have 1 nurse and 2 CNAs. The memory care unit AM and PM should have 1 nurse and 2-3 CNAs. The memory care unit night shift should have 1 nurse and 2 CNAs.The staffing schedule for August 2025 and September to date were reviewed. The facility had 22 shifts that worked with less than the required number of nurses or CNAs as determined by the facility for August 2025.On 9/2/25 at 6:17 PM, V1 Administrator stated there was no facility policy for staffing.

Based on observation, interview and record review the facility failed to provide personal care to a resident with a pressure ulcer. This applies to 1 of 4 (R1) residents reviewed for pressure wounds in a sample of 6.Findings include:On 9/2/25 at 11:48 AM, R1stated she had recently admitted , but had developed a pressure wound on her buttocks and UTI (Urinary Tract Infection) since arriving to the facility. R1 stated the facility is short staffed. R1 stated on a few occasions she had called for incontinence care and left waiting for hours. R1 stated on one occasion she called V8 Family Member requesting he call the nursing station after waiting hours to be provided care. On 9/2/25 at 11:55 AM, V6 CNA (Certified Nursing Assistant) and V13 PT (Physical Therapist) came to R1's bedside for skin and brief observation. R1's undergarment was dry with large streak of dried feces. Dried caked feces were between the gluteal fold. R1's labia and gluteal fold was reddened. R1 had a small open area on her coccyx.On 9/2/25 at 12:32 PM, V6 CNA stated her shift started a 6AM, but she had not provided incontinence care or turned R1 prior to 11:55 AM. V6 stated the wound nurse provided incontinence care and repositioned the resident during the dressing change.On 9/2/25 at 12:42 PM, R1 stated V6 had not provided any incontinence care during her shift and repositioned her at 11:55 with the physical therapist.On 9/2/25 at 3:10 PM, V8 Family Member stated R1 had called him a couple of times with request for him to call nursing station for assistance. V8 stated on one of the calls R1 had complained of being left in soiled brief for over two hours.On 9/2/25 at 3:18 PM, V9 RN (Registered Nurse) stated R1 was on antibiotics for a UTI and had a pressure wound on her coccyx. On 9/2/25 at 4:50 PM, V3 Wound Nurse stated V3 stated R1 is obese and unable to reposition without the assistance of two staff members. R1 is incontinent of bowel and bladder moisture is a contributing factor to skin break down. V3 stated nursing staff is responsible for repositioning and providing incontinence care for R1.On 9/2/25 at 6:17 PM, V1 Administrator stated should not need to call their family members to obtain staff assistance.The facility policy Wound Care Prevention dated April 2025 states, all residents will receive appropriate care to decrease the risk of skin break down. The nursing department will review all new admissions / readmissions to put a plan in place for the prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. Clean skin at time of soiling and at routine intervals.The facility policy Incontinence Care dated April 2025 states, incontinence care is provided to keep residents as dry comfortable and odor free as possible. It also helps in preventing skin breakdown. On 9/2/25 at 11:48 AM, R1stated she had recently admitted , but had developed a pressure wound on her buttocks and UTI (Urinary Tract Infection) since arriving to the facility. R1 stated the facility is short staffed. R1 stated on a few occasions she had called for incontinence care and left waiting for hours. R1 stated on one occasion she called V8 Family Member requesting he call the nursing station after waiting hours to be cleaned up of urine and feces. On 9/2/25 at 11:55 AM, V6 CNA (Certified Nursing Assistant) and V13 PT (Physical Therapist) came to R1's bedside for skin and brief observation. R1's undergarment was dry with large streak of dried feces. Dried caked feces were between the gluteal fold. R1's labia and gluteal fold was reddened. R1 had a small open area on her coccyx.On 9/2/25 at 12:32 PM, V6 CNA stated her shift started a 6AM, but she had not provided incontinence care or turned R1 prior to 11:55 AM. V6 stated the wound nurse provided incontinence care and repositioned the resident during the dressing change.On 9/2/25 at 12:42 PM, R1 stated V6 had not provided any incontinence care during her shift and repositioned her at 11:55 with the physical therapist.On 9/2/25 at 3:10 PM, V8 Family Member stated R1 had called him a couple of times with request for him to call nursing station for assistance. V8 stated on one of the calls R1 had complained of being left in soiled brief for over two hours.On 9/2/25 at 3:18 PM, V9 RN (Registered Nurse) stated R1 was on antibiotics for a UTI and had a pressure wound on her coccyx. V9 did not see any documentation of a pressure wound or UTI prior to or on admission.On 9/2/25 at 4:50 PM, V3 Wound Nurse stated there was no documentation of a coccyx pressure wound on 8/27/25 when R1 was admitted to the facility. V3 stated there was no documentation of a coccyx pressure wound was in R1's hospital discharge records. V3 stated she discovered and documented R1's wounds on 8/29/25 during the skin assessment. V3 stated the coccyx wound measured 2.0 cm (centimeters)x 0.2 cm x 0.2cm. V3 stated R1 is obese and unable to reposition without the assistance of two staff members. R1 is incontinent of bowel and bladder moisture is a contributing factor to skin break down. V3 stated nursing staff is responsible for repositioning and providing incontinence care for R1.On 9/2/25 at 6:17 PM, V1 Administrator stated should not need to call their family members to obtain staff assistance.The facility policy Wound Care Prevention dated April 2025 states, all residents will receive appropriate care to decrease the risk of skin break down. The nursing department will review all new admissions / readmissions to put a plan in place for the prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. Clean skin at time of soiling and at routine intervals.The facility policy Incontinence Care dated April 2025 states, incontinence care is provided to keep residents as dry comfortable and odor free as possible. It also helps in preventing skin breakdown.

Based on interview and record review, the facility failed to supervise a resident with high risk for falls. This failure resulted in the resident falling and requiring hospitalization for acute traumatic brain injury, seizures, and altered mental status. This applies to 1 out of 3 residents (R1) reviewed for accidents. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including history of falls, traumatic subdural hemorrhage, hydrocephalus with presence of cerebrospinal fluid drainage device, hallucinations, vascular dementia with moderate agitation, abnormalities of gait and mobility, unsteadiness on feet, difficulty in walking, cognitive deficit, and hearing loss. R1's EMR did not show a history of seizures. R1's MDS (Minimum Data Set) dated 8/22/2024 said R1 was severely cognitively impaired and required staff assistance with transfers. On 6/30/2025 at 3:15 PM, V9 (Nurse) said on 10/23/2024 at 12:30 PM, R1 was observed sitting on the floor in front of his wheelchair in his room. V9 said R1 was at a high risk for falls because he had a known history of falls, was confused, and impulsive. V9 said he assessed and initiated neurological checks for R1 after his unwitnessed fall. V9 said R1's neurological assessment was normal and did not appear to have any injury or change in condition. V9 said staff then assisted R1 into his wheelchair and transported him to the main dining area for lunch, where he was supervised. On 6/30/2025 at 1:50 PM, V2 (Director of Nursing/DON) said R1 was monitored after his fall per protocol, and at 3:15 PM, he was noted with a bump to his head. V2 said V5 (Nurse Practitioner/NP) was updated and gave orders to send R1 to the hospital for further evaluation. V2 said routine paramedics then transferred R1 into the ambulance when he started to have a massive seizure. V2 said the paramedics then contacted the emergency paramedics for additional support, and R1 was transferred to the hospital. V2 said R1 was admitted for altered mental status, seizure, and traumatic brain injury. V2 said the facility felt they could not determine if R1's acute change in medical condition was related to his fall incident because the facility elected to admit R1 into inpatient hospice care and not proceed with additional diagnostic testing. V2 said R1 had a known history of recurrent falls and head trauma with an intracranial bleed. V2 said fall incidents were investigated and fall prevention interventions were implemented in the residents' plan of care. On 6/30/2025 at 3:50 PM, V5 (NP) said she expected facility staff to complete a root cause analysis after a resident's fall to investigate the cause and then implement interventions to prevent reoccurrences. R1's fall care plan report initiated on 3/08/2024 said R1 was at risk for falls related to his confusion, deconditioning, gait and balance problems, poor comprehension, unaware of safety needs, dementia, hallucinations, and recurrent falls. R1's care plan included multiple fall interventions, including conduct rounds, toilet resident and place in dining room, hallways or nurses' station for more visual supervision, and increase supervision in the room. Monitor any attempt of self transfer. R1's fall incident reports showed he had 8 unwitnessed falls in his room prior to 10/23/2024. Falls had occurred on 3/12/2024, 4/13/2024, 5/28/2024, 7/17/2024, 8/11/2024, 8/23/2024, 8/23/2024, and 8/30/2024. The fall incident reports showed R1 falls occurred because he was trying to self-transfer in and out of his wheelchair. R1's fall incident report dated 10/23/2024 said R1 had another unwitnessed fall in his room after attempting to stand up from his wheelchair unassisted. The report said R1 was observed at 12:35 PM sitting on the floor facing his wheelchair with his legs flexed and holding on to his wheelchair. The report said after R1's fall assessment, he was then transported to the main dining room for his lunch. The report continued to say at 3:15 PM, a bump was noted to R1's right side of the head, and when being transported by medical paramedics to the hospital, he had a seizure. The report said emergency paramedics were then contacted for additional support, and R1 was transported to the hospital for further management. V17's (R1's assigned Certified Nurse Assistant/CNA) incident statement dated 10/23/2024 said, When the incident happened, I did not witness it happening. I was helping in the dining room with passing trays and feeding residents. V9's (R1's assigned Nurse) incident statement dated 10/23/2024 said, At the time of fall, I was at the nurse's station. Fall not witnessed. R1's hospital notes dated 10/24/2024 said R1 was admitted post-fall with a suspected significant head trauma likely subdural hematoma, acute encephalopathy, seizures, and dilated left pupil and flaccid left side. The note said R1 remained unresponsive and family elected for hospice care. The facility's policy titled Falls and Fall Risk, Managing undated, said Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors(s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .

Based on observation, interview, and record review, the facility failed to ensure a diabetic resident's feet were monitored to prevent complications. This failure resulted in the resident acquiring a necrotic diabetic ulcer on her left heel. This applies to 1 out of 3 residents (R5) reviewed for foot care. The findings include: R5's EMR (Electronic Medical Record) showed R5 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, diabetes, stenosis, and vascular disease. R5's EMR said she was dependent on staff assistance with her mobility and hygiene care, and at risk for developing ulcers. On 6/30/2025 at 9 AM, V24 (Wound Care Nurse/WCN) changed R5's left heel wound dressing. R5's wound was open with serosanguinous drainage. V24 said R5's diabetic wound was acquired on 3/31/2025, and now required an outpatient vascular consultation for possible vascular surgical intervention because of her wound. V24 said nursing staff was expected to perform and document routine resident skin checks, including their feet. V24 said CNAs (Certified Nurse Assistants) were also expected to check residents' skin daily when providing care and report changes such as redness or discoloration. V24 said R5's heel wound was acquired with 100% hard eschar (necrotic) tissue measuring 4.5 centimeters (cm) x 4.5 cm x depth unknown. V24 said R5's wound should have been identified prior to becoming necrotic or at a smaller size. On 6/30/2025 at 3:25 PM, V10 (Nurse) said on 3/28/2025 she assessed R5's heel. V10 said R5's heel did not appear normal because it had a hard, black wound. V10 said R5 was new to the unit, and it was unclear when she acquired the wound. V10 said CNAs were expected to complete skin checks during routine care and report any changes to prevent skin complications. On 7/01/2025 at 12 PM, V6 (Podiatrist) said her team provided routine foot care services and facility foot care recommendations. V6 said residents with diabetes and vascular disease were at a higher risk for skin deterioration to pressure point areas because of their impaired circulation and sensation. V6 said facility staff was required to check skin routinely and report any changes to the providers because residents with these comorbidities were at a higher risk for accelerated skin deterioration and complications. R5's care plan initiated on 10/29/2024, said she was at risk for developing skin breakdown due to her immobility, diabetes, impaired circulation, and altered neurological status. R5's care plan included multiple skin monitoring preventions including Inspect foot/ankle/calf skin per facility protocol/as provider orders for changes; maceration (white, wrinkly, moist), redness, purple tinge, blue, rust coloring, weeping, edema, puffiness, tenderness, area with no sensation. R5's podiatry consult note dated 3/04/2025 said R5's skin on her feet was noted dry. The consultation included general foot hygiene recommendations, including daily look for swelling in the feet and ankles, use lotion daily, and reviewed the importance of getting regular foot care. R5's new skin condition note dated 3/28/2025 said R5's left heel was noted with hard, dry discoloration and swelling. R5's daily skin monitoring log from 3/01/2025-3/31/2025 showed no skin alterations were observed on her feet. R5's Skin Monitoring: Comprehensive CNA Shower Review sheets provided by the facility, dated 3/17/2025, 3/21/2025, and 3/24/2025, showed no skin alterations were observed. R5's Wound Assessment Details Report dated 3/31/2025 said R5 was at high risk for skin breakdown and had a newly acquired diabetic ulcer to her left heel. The report said the wound measured 4.5 cm length x 4.5 cm width x unknown depth, with 100% necrotic, hard, firm adherent tissue. R5's Wound Assessment Details Report dated 6/24/2025 said R5's left heel wound now measured 4.5 x 4 x 1.5 cm with 50% bright beefy red and 50% necrotic soft adherent tissue. The facility's policy titled Foot Care dated 03/2018, said Residents will receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g., diabetes, peripheral vascular disease, etc.). The facility's policy titled Prevention of Pressure Injuries dated 04/2020, said Skin Assessment .2. During the skin assessment, inspect: a. Presence of erythema; b. Temperature of skin and soft tissue; c. Edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels .). Monitoring 1. Evaluate, report and document potential changes in the skin.

Based on interview and record review, the facility failed to follow insulin administration instructions for a diabetic resident. As a result of this failure, R4 had an acute episode of hypoglycemia, which required the administration of emergency reversal-medications by emergency paramedics. This applies to 1 out of 3 residents (R4) reviewed for diabetes management. The findings include: On 6/30/2025 at 11:45 AM, V11 (Nurse) said she administered R4's scheduled insulin on 6/17/2025. V11 said insulin was administered based on the order. V11 continued to say that if a resident refuses to eat, they should not receive their fast-acting insulin because their blood sugar would drop. V11 said she believed residents with diabetes required an active order for emergency glucagon for emergency episodes of hypoglycemia. On 6/30/2025 at 12 PM, V18 (Certified Nurse Assistant/CNA) said on 6/17/2025, R4 refused his breakfast and lunch meals. V18 said she was concerned R4's blood sugar would drop and informed the nurse on duty and V18 documented R4's meal refusals. On 6/30/2024 at 11:50 AM, V12 (Nurse) said on 6/17/2025 at approximately 4 PM, he noticed R4 was in a deep sleep, not responding to physical stimuli, and had abnormal breathing. V12 said emergency paramedics were called, and they checked R4's blood sugar. V12 said R4's blood sugar was 22, and they administered emergency intravenous fluids and glucagon. V12 said he was not aware of the facility's hypoglycemic protocol. V12 said if he had been informed of R4's insulin administration and meal refusals, he would have monitored his blood sugar closely. V12 said R4 was transferred to the hospital for further evaluation. On 6/30/2025 at 3 PM, V5 (Nurse Practitioner/NP) said she expected nurses to administer insulin as ordered and use clinical judgment when administering short-acting insulin for residents who refused their meals. V5 said she believed the facility's hypoglycemic protocol was standard of care for diabetic residents. R4's Medication Administration Record (MAR) for June 2025 said on 6/17/2025, R4 was administered Humalog insulin (fast-acting) 2 units at 9 AM and Fiasp insulin (fast-acting) 28 units at 8 AM and 12 PM. The MAR included specific instructions for the administration of Humalog, to administer with meals. R4's nutritional intake log for 6/17/2025 showed R4 refused his breakfast and lunch meals. R4's Order Summary Report dated 6/30/2025 did not have an active order for Glucagon emergency injection for hypoglycemia. R4's diabetic care plan initiated on 6/26/2024 said Monitor/document/report to MD PRN s/sx of hypoglycemia and Diabetes medication as ordered by doctor. R4's hospital note dated 6/17/2025 said R4 received treatment for hypoglycemia. The note said, He received insulin this morning and this afternoon. Did not have lunch. Was found to be less responsive later this afternoon. EMS was called he was hypoglycemia with a sugar of 22. Was given glucagon and D10. The facility's document titled Hypoglycemia Protocol undated, said residents needed to be assessed for their level of consciousness, pulse, blood pressure, and respirations. The document provided instructions of nursing inteventions for the management of residents with acute episodes of hypoglycemia. The facility's policy titled Insulin Administration dated 09/2014, said Purpose To provide guidelines for the safe administration of insulin to residents with diabetes .3. The type of insulin, dosage, requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use .Rapid-acting Onset 10-15 min Peak 0.5-3 hrs .

Based on interview and record review, the facility failed to assist a resident with his social services needs. This applies to 1 out of 3 residents (R4) reviewed for social service needs. The findings include: On 6/30/2025 at 1:10 PM, R4 was fatigued in bed. R4 at times during the interview became frustrated and showed signs of impaired memory. R4 said V8 (Family Member) was no longer his Power of Attorney (POA) for health and finance. R4 said he believed V7 (Family Member) was now his assigned POA for health and finance. On 6/30/2025 at 10:45 AM, V2 (Director of Nursing/DON) said on 4/23/2025, V7 (R4's Family Member) called informing the facility that R4 was seeking legal aid to assist him in revoking his POA and divorce from V8. V2 said she informed V3 (Social Services/SS). On 6/30/2025 at 2:30 PM, V3 (SS) said residents were provided with social services, and if needed outside, referrals were made. V3 said R4 was a long-term care resident at the facility. V3 said she followed up with R4 on 4/25/2025, and he verbally revoked his financial and health POA from V8. V3 said R4 continued to say he wanted to proceed with his divorce and wanted V7 to be his POA. V3 said she believed V7 had POA documents indicating R4's directives. V3 said R4 was informed that it was expected he obtain his POA documents from V7 (who was out-of-state) to provide to the facility and proceed with his divorce on his own. V3 said she was unsure if V26 (Ombudsman) was assisting R4 with his legal aid request. On 6/30/2025 at 3 PM, V5 (Nurse Practitioner/NP) said R4 had recently started to decline physically and cognitively. V5 said R4's cognition was impaired and unable to make decisions on his own now. V5 said R4 was now physically impaired and dependent on staff for his care. On 6/30/2025 at 11:40 AM, V27 (Ombudsman) was called and said no referral was received for R4. R4's progress note dated 4/23/2025 said Received a call from [V7] .wanted to inform the facility that the resident was seeking legal aid to assist him with a divorce and with revoking his current POA for financial and healthcare . The facility's policy titled Social Services dated 10/2010, said Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being .Making referrals to social service agencies as necessary or appropriate .

Based on observation, interview, and record review, the facility failed to ensure the pressure ulcer intervention of a pressure-relieving mattress was working for a resident with known multiple pressure wounds. This applies to 1 out of 3 residents (R4) reviewed for pressure wounds. The findings include: On 6/29/2025 at 9:45 AM, R4 said he had pain all over his back. R4 was in bed on an air-loss mattress, with a beeping alarm. V20 (Certified Nurse Assistant) turned R4 in bed, and R4 was lying on two overlapping cloth pads and a sheet, which were bunched up together. V25 (Wound Care Nurse/WCN) said R4 was recently readmitted with multiple pressure wounds and required the use of an air-loss mattress. V25 changed R4's dressing to his left posterior lower leg vascular wound and pressure wounds to his bilateral mid buttock, coccyx, and right lateral buttock. At 10:15 AM, V20 and V25 finished providing care to R4's wounds. The beeping alarm on R4's mattress continued and the mattress was not inflated because the mattress was disconnected from the pump. V25 said she believed R4's mattress was working properly. On 6/30/2025 at 1:20 PM, V24 (WCN) said R4 had a facility-acquired deep tissue injury to his left buttock that was new. V24 said R4 had a history of non-compliance with skin management and required the use of an air-loss mattress to assist in relieving pressure. V24 said staff was expected to respond and troubleshoot medical equipment alarms, including air-loss mattresses to prevent bottoming out. R4's skin care plan initiated on 6/18/2025 said R4 was at risk for developing further skin breakdown. The care plan included multiple interventions, including Pressure reducing mattress provided for pressure relief and prevention. R4's Order Summary Report dated 6/30/2025 had an active order for Pressure Reducing Mattress to Bed: Ensure Placement and Functionality. Every shift for Prevention of developing/worsening pressure injury initiated on 6/19/2025. R4's Wound Assessment Details Reports dated 6/29/2025 said R4 had unstageable pressure injuries to bilateral buttocks and coccyx and a deep tissue injury to his right buttock. R4's Wound Assessment Details Report dated 6/30/2025 said R4 had a newly acquired deep tissue pressure injury to his left buttock on 6/30/2025. The wound measured 1.3 centimeters (cm) length x 1 cm width x unknown depth, with 100% deep maroon tissue. On 6/30/2025 at 4:30 PM, V2 (Director of Nursing/DON) said the facility did not have a specific policy regarding air-loss mattresses. The facility's policy titled Prevention of Pressure Injuries dated 04/2020, said The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Provide support devices and assistance as needed .

Based on interview and record review, the facility failed to investigate and report an allegation of financial abuse by a family member. This applies to 1 out of 3 residents (R4) reviewed for financial abuse. The findings include: On 6/30/2025 at 1:10 PM, R4 was fatigued in bed. R4 at times during the interview became frustrated and showed signs of impaired memory. R4 said V8 (Family Member) had stolen his money from his bank account. R4 was unable to provide details of when it occurred and how much money he believed was stolen. R4 said after the alleged incident, he made sure V8 no longer had access to his bank account. R4 said he also removed V8 from his financial power of attorney (POA). On 6/30/2025 at 3 PM, V5 (Nurse Practitioner/NP) said R4 had recently started to decline physically and cognitively. V5 said R4's cognition was impaired and unable to make decisions on his own now. On 6/30/2025 at 10:45 AM, V2 (Director of Nursing/DON) said on 4/23/2025, V7 (R4's Family Member) called the facility, alleging R4 informed her V8 was stealing from his bank account. V2 said she informed V3 (Social Services/SS). On 6/30/2025 at 10:25 AM, V28 (Business of Manager) said V8 (Family Member) had contacted the facility on 6/30/2025, requesting assistance in obtaining a new financial POA because she was informed by R4's bank that it was invalid. On 6/30/2025 at 2:30 PM, V3 (SS) said residents were assessed for their risk for abuse and care plans are updated. V3 said she followed up with R4 on 4/25/2025, and he verbally revoked his financial POA from V8. On 6/30/2025 at 2 PM, V1 (Administrator) said he was the facility abuse coordinator. V1 said he was aware of V7's financial abuse allegation involving R4. V1 said he did not report or further investigate the allegation because he believed it was a misunderstanding on R4's behalf. R4's care plan initiated on 6/18/2024, said he was at risk for abuse. The care plan had multiple interventions, including Report issues pertaining to potential abuse/neglect situations per policy. R4's progress note dated 4/23/2025 said Received a call from [V7] .indicated that her father has indicated that his current wife/POA along with his daughter [daughter] have been stealing his money from his bank account. The facility did not have any abuse allegation/investigation Illinois Department of Public Health eportable incident for R4's allegation of financial abuse by his family member from 4/23/2025. The facility's policy titled Abuse Prevention Program undated, said This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded .Internal Reporting Requirements and Identification of Allegations .Protection of Residents .Internal Investigation 1. Incidents will be reviewed, investigated, and documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected .External Reporting .Public health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated .

Based on observation, interview, and record review, the facility failed to use a two-person transfer with a gait belt, as shown in the EMR (Electronic Medical Record), for a resident with a history of multiple falls. This applies to 1 of 3 residents (R2) reviewed for accidents and supervision in the sample of 3. The findings include: On June 12, 2025, at 11:21 AM, V3 (CNA-Certified Nursing Assistant) transferred R2 from the wheelchair to the toilet. No other staff were present. V3 said R2 was wearing regular socks and did not have shoes. V3 tightly held R2's waist band of her pants and R2's incontinence brief to lift the resident from the wheelchair to the toilet. V3 did not use a gait belt. As V3 was attempting to stand R2, R2's knees were buckling and R2 was unable to bear her full weight as she was being transferred to the toilet. R2 was unable to follow V3's instructions due to her cognitive status. V3 said R2 needed a new incontinence brief due to R2's previous incontinence brief being torn after it was used to lift the resident during transfer. V3 obtained a new incontinence brief and instructed R2 to hold the handrail and the handle of her wheelchair. As R2 reached for the handrail, a yellow plastic wrist band was visible on R2's right wrist. V3 said when a resident is wearing a yellow wrist band, it means the resident is a high fall risk. V3 again attempted to lift R2 without using a gait belt. V3 was able to lift the resident from the toilet to a standing position. As V3 attempted to place the clean incontinence brief on R2, R2's knees began to buckle and V3 had to lower R2 back down to the toilet. A pair of shoes was in a clear bag next to R2's bed and V3 said she was not aware R2 owned shoes. V3 placed the shoes on R2's feet. V3 left R2 unattended and left the bathroom to find another CNA to help her. V3 returned to the bathroom with V6 (CNA). V3 applied a gait belt to R2. V3 and V6 completed R2's toilet hygiene, applied a new incontinence brief, and transferred R2 back to the wheelchair. V6 said the type of transfer a resident requires is shown in the EMR and each CNA should carry their own gait belt, which is a required part of a CNA's uniform. The EMR shows R2 was admitted to the facility on [DATE], with multiple diagnoses including, acute kidney failure, anxiety disorder, hypertensive heart and chronic kidney disease, gastro-esophageal reflex disease, history of falling, sensorineural hearing loss, dementia, chronic kidney disease, depression, Alzheimer's disease, benign paroxysmal, vertigo, localized edema, visual loss, history of cancer of large intestine, anemia, history of breast cancer, essential tremor, and irritable bowel syndrome. R2's MDS (Minimum Data Set) was not completed at the time of this investigation. R2's care plan for ADL (Activities of Daily Living) self-care performance deficient, initiated on June 12, 2025, shows multiple interventions initiated on June 12, 2025, including, Transfer: Requires dependent of 2 people with transfers. The EMR shows the following special instructions for R2, Transfer code: dependent assist of 2 (mod A x 2) (Moderate Assistance with two people) stand pivot transfer. The EMR shows R2 sustained falls at the facility on June 8, 9, 10, and 11, 2025. On June 12, 2025, at 1:25 PM, V4 (Risk Management RN-Registered Nurse), said R2 has severe cognitive impairment and has impulsive behaviors. R2 is a two person transfer assist. All CNAs should use a gait belt when transferring residents. V4 continued to say the resident's transfer status is shown in the EMR and each CNA is required to know the transfer status of the resident they are caring for before transferring the resident. V4 said R2's four recent falls at the facility were due to poor safety awareness due to cognitive impairment and anxiety disorder. The facility's undated policy entitled, Resident Transfer Protocol shows: Statement of policy: It is the policy of [the facility] to attempt to protect both its residents and employees from injury in the course of transferring patients/residents. Procedure: .3. The transfer technique that is appropriate for each resident will be listed on the Special Instructions in [EMR] and a transfer code will be posted on the resident's foot board. 4. No resident is to be transferred without first verifying the transfer technique assigned to that resident to know what type of transfer is required by that resident on that day. The facility's undated policy entitled, Gait Belt Usage shows: Statement of Policy: It is the policy of the facility that all residents and staff are safe from injury during all transfers. It is the policy of this facility that a gait belt will be used when performing transfers or when ambulating a resident unless contraindicated or resident refuses. Procedure: 1. Gait belts are a part of the staff's uniform; all staff has to have individual gait belts with them during the entire shift that they are scheduled to work. 2. When transferring a resident (sit to stand, bed to chair, chair to bed, chair to toilet, toilet to chair), a gait belt must be used unless contraindicated or refused.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers were repositioned at regular intervals as ordered by the physician, received timely incontinence care, and received wound care treatments to ensure wounds are clean, as ordered by the physician. This failure resulted in delayed healing of R1's facility-acquired pressure ulcer. This failure applies to 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 6. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025 and returned to the facility on [DATE]. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region, weakness, dementia, hearing loss, history of falling, and acquired absence of right leg above the knee. R1's MDS (Minimum Data Set) dated November 4, 2024 shows R1 is cognitively intact, is dependent on facility staff for transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. R1's pressure ulcer care plan, created on July 11, 2024 shows, Reopened Stage 3 pressure injury on the coccyx with treatment in place and rendered. September 2, 2024: Wound on coccyx is now Stage 4 pressure injury. R1 has multiple care plan interventions, including, Get up in the wheelchair during lunchtime and be back in bed after 2 hours or when requested to go back to bed initiated on September 27, 2024. Turn/reposition resident at regular intervals and as needed initiated on September 28, 2024. On January 27, 2025 at 9:36 AM, R1 was lying in bed. R1 was lying on his back with one pillow behind his head. No other pillows or positioning wedges were visible in R1's room. On January 27, 2025 at 10:44 AM, R1 was lying in the same position in his bed, with one pillow behind his head and no other pillows or positioning wedges in the room. V5 (Spouse of R1) was sitting at R1's bedside. V5 said, she came to the facility around 9:45 AM. V5 said R1 was lying on his back when she arrived, and no facility staff had been in the room to change his position. On January 27, 2025 at 12:05 PM, R1 was lying in his bed, covered by a top sheet. A large bulge was visible on R1's lower abdomen, through the top sheet of the bed. V5 (Spouse of R1) pulled back the top sheet and showed R1 was wearing an incontinence brief. V5 opened R1's incontinence brief. Inside R1's incontinence brief was a folded bath towel and a second incontinence brief. Loose stool was present between R1's legs and covering his scrotum. The folded bath towel was wet, and a urine odor was present. R1 continued to be lying on his back, with one pillow behind his head, and no other pillows or positioning wedges visible in the room. V5 said no facility staff had been in the room to reposition R1 since she arrived at 9:45 AM. On January 27, 2025 at 12:31 PM, R1 remained lying on his back, with one pillow behind his head. V7 (CNA-Certified Nursing Assistant) said, I changed [R1's] incontinence brief at 8:00 AM. I have not had time to do it again. V7 continued to say she had not repositioned R1 since 8:00 AM. V7 was asked if there were additional pillows or positioning wedges for R1 and V7 said, What would I need those for? R1 was turned to his left side by V7 (CNA) while V4 (WCN/LPN-Wound Care Nurse/Licensed Practical Nurse) cleaned stool from the area of R1's pressure ulcer and provided wound care to R1's sacral pressure ulcer. A four-inch by 5-inch dressing was covering R1's sacral pressure ulcer. An area approximately 1.5 inches in diameter of dark red drainage was visible on the dressing before the dressing was removed from R1's sacrum. V4 (WCN/LPN) removed the dressing and cleaned the wound with normal saline. The wound appeared to be approximately two inches in diameter. V4 was able to insert her gloved fingers approximately 1.5 inches into the wound and demonstrated the area of the wound where tunneling was present. V4 packed the wound with two calcium alginate/silver foam dressings, and then covered the wound with a four-inch by 5-inch dressing. V4 said R1 should be getting up to the chair every day and should be turned at regular intervals. V4 continued to say if R1 was in the same position since 8:00 AM, he was not being repositioned often enough. V4 said the pressure ulcer was identified on July 11, 2024 as an unstageable pressure ulcer and is now a Stage 4 pressure ulcer. V4 also said R1's pressure ulcer was assessed by V6 (Wound Care NP-Nurse Practitioner) at approximately 8:00 AM that same day and the wound measurements were 5.1 cm. (centimeters) long by 3.1 cm. wide by 3.6 cm. deep, with tunneling from 11 o'clock to 5 o'clock at a depth of 6.3 cm. On January 28, 2025 at 10:48 AM, V10 (Physician) documented, Sacrum and Coccyx: Stage 4 pressure injury to coccyx. Wound measures as 5.1 cm. by 3.1 cm. by 3.6 cm. with 6.3 cm. undermining from 12 o'clock to 5 o'clock. Wound with 100 percent granulation tissue. Moderate serosanguineous exudate. Deteriorated surface area. Due to patient's multiple comorbidities, patient is at high risk for developing new and worsening wounds. To reduce risk for developing new and/or worsening wounds, recommend turning repositioning to relieve pressure on areas at risk and to maintain general skin integrity. Recommend to offload bilateral heels at all times. Case discussed with the members of wound care team. We will re-evaluate patient during the next visit. Patient seen and examined during wound rounds today. Case discussed with [V6] (Wound Care NP). Agree with documentation and plan as outlined. The EMR shows the following order for R1 dated November 4, 2024 and discontinued on December 16, 2024: Dakin's (1/4 strength) External solution (antiseptic solution). Apply to coccyx topically two times a day for wound care. Cleanse with normal saline, pat dry. Loosely pack soaked roll gauze to 1/4 strength of Dakin's solution and cover with dry dressing. R1's TAR (Treatment Administration Record) shows R1's wound care was scheduled at 5:00 AM and 5:00 PM daily. The facility does not have documentation to show R1 received the wound care treatment as ordered by the physician on the following dates and times: November 7, 2024 5:00 PM November 8, 2024 5:00 AM, 5:00 PM November 9, 2024 5:00 AM November 11, 2024 5:00 AM, 5:00 PM November 15, 2024 5:00 PM November 16, 2024 5:00 AM, 5:00 PM November 17, 2024 5:00 PM November 18, 2024 5:00 AM November 21, 2024 5:00 PM November 22, 2024 5:00 AM November 23, 2024 5:00 PM November 24, 2024 5:00 AM, 5:00 PM November 25, 2024 5:00 PM November 26, 2024 5:00 PM November 27, 2024 5:00 PM November 28, 2024 5:00 PM November 29, 2024 5:00 AM November 30, 2024 5:00 AM, 5:00 PM December 4, 2024 5:00 PM December 5, 2024 5:00 PM December 6, 2024 5:00 AM, 5:00 PM December 8, 2024 5:00 AM, 5:00 PM December 9, 2024 5:00 PM December 11, 2024 5:00 PM December 13, 2024 5:00 PM December 14, 2024 5:00 AM The EMR shows the following order for R1 dated December 17, 2024 and discontinued on January 3, 2025: Dakin's (1/4 strength) External Solution. Apply to coccyx topically every day shift for wound care. Cleanse with 1/4 strength Dakin's solution, pat dry and apply alginate Ag and cover with dry dressing. The facility does not have documentation to show R1 received the wound care treatment as ordered by the physician on December 21, 28, and 31, 2024. The EMR shows the following order for R1 dated January 11, 2025: Coccyx cleanse with normal saline, pat dry. Loosely pack silver alginate to wound and cover with dry dressing every day shift for wound care. The facility does not have documentation to show R1 received the wound care treatment as ordered by the physician on January 18, 19, and 26, 2025. 2. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, multiple sclerosis, hypertension, dysphagia, open left leg wound, PVD (Peripheral Vascular Disease), weakness, cognitive communication deficit, hydronephrosis, history of falling, right buttock pressure ulcer, and anemia. R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, substantial/maximal assistance with toilet hygiene, showering, dressing, personal hygiene, and bed mobility, and is dependent on facility staff for transfers between surfaces. R2 has an indwelling urinary catheter and is frequently incontinent of stool. R2's care plan created on September 23, 2022 shows, Resident developed unstageable pressure injury on the sacrum. R2's care plan was revised on October 14, 2024 to show, 10/14/2024 sacrum extending to right buttock Stage 4 pressure injury. R2's care plan shows multiple interventions created on September 23, 2022 including, Treatment done per M.D. orders. On January 27, 2025 at 11:57 AM, R2 was lying in bed in his room. R2 did not wish to be interviewed regarding his wound care treatments. On January 27, 2025, V10 (Wound Care Physician) documented, Sacrum and coccyx: Wounds to coccyx and right buttock are now coalesced into one contiguous wound. Stage 4 pressure injury to coccyx extending to right buttock. Reopened. Wound measures as 1 x 0.6 x 0.1 cm. with 100 percent granulation tissue. Scant serous exudate. Deteriorated surface area. The EMR shows the following order for R2 dated November 12, 2024, and discontinued on December 9, 2024: Sacrum, extending to right buttock. Cleanse with normal saline, pat dry. Apply alginate then cover with foam dressing. Apply triad to periwound every day shift for wound care. The facility does not have documentation to show R2 received the wound care treatment as ordered by the physician on December 7 or 8, 2024. The EMR shows the following order for R2 dated December 10, 2024 and discontinued on January 6, 2025: Sacrum extending to right buttock. Cleanse with normal saline, pat dry. Apply silver alginate then cover with foam dressing. Apply triad to periwound every day shift for wound care. The facility does not have documentation to show R2 received the wound care treatment as ordered by the physician on December 21, 22, 28, 29, 30, and 31, 2024, and January 4 and 5, 2025. The EMR shows the following order for R2 dated January 14, 2025: Sacrum extending to right buttock. Cleanse with normal saline, pat dry. Apply alginate and cover with foam dressing every day shift for wound care. The facility does not have documentation to show R2 received the wound care treatment as ordered by the physician on January 18, 19, and 26, 2025. On January 27, 2025 at 1:42 PM, V6 (Wound Care NP) said she assesses the residents with pressure ulcers every Monday and provides her notes to V10 (Wound Care Physician). V10 then provides written notes to the facility of V6's examination. V6 (Wound Care NP) said, I expect the facility staff to provide the wound care treatments as ordered, and as needed with incontinence episodes. The wounds need to be kept clean. [R1] needs to be turned at regular intervals, based on his tolerance. Four or five hours in the same position is too long for him. I was not aware he was missing wound treatments, not receiving timely incontinence care, and not being repositioned. All those failures are contributing factors as to why his pressure ulcer isn't healing. On January 28, 2025 at 12:10 PM, V2 (DON-Director of Nursing) said, The standard of care is to reposition residents every two hours. No resident should be lying in the same position for hours at a time. No resident should be wearing two briefs or not receiving timely incontinence care. Residents should get their wound care treatments as ordered by the physician. I was not aware we were having a problem with that. [V6] (Wound Care NP) sees the residents every week and submits a report to me. [V10] (Wound Care Physician) submits his progress notes to us for downloading into the medical record, but [V6] is the one who actually sees the residents. The wound care IDT (Interdisciplinary Team) has fallen by the wayside. We have not been meeting about pressure ulcers. The facility's policy entitled Prevention of Pressure Injuries, revised April 2020 shows: Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Mobility/Repositioning: 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical guidelines. The facility's policy entitled Wound Care, revised October 2010 shows: Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure . Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition.8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the wound care .

Based on observation, interview, and record review, the facility failed to follow their policy to ensure residents received timely incontinence care, showers, oral care, and assistance with shaving. This failure applies to 5 of 6 residents (R1, R2, R3, R5, and R6) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 6. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025 and returned to the facility on [DATE]. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region, weakness, dementia, hearing loss, history of falling, and acquired absence of right leg above the knee. R1's MDS (Minimum Data Set) dated November 4, 2024 shows R1 is cognitively intact, is dependent on facility staff for transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. R1's care plan initiated on February 5, 2020 shows R1 has an ADL Self-care performance deficit due to decreased strength and decreased functional mobility. Care plan interventions, initiated on February 5, 2020 include, Bathing: Resident requires total assistance of 2 people using full lift machine with bathing transfer. Resident requires substantial assistance of 1 person with bathing. Resident requires substantial people to turn and reposition. Resident requires substantial assistance of 1 person with personal hygiene/oral care. Resident requires dependent assistance of 2 people using full lift machine with transfers. On January 27, 2025 at 9:36 AM, R1 was lying in bed. R1 had facial hair stubble, and his teeth had visible debris. On January 27, 2025 at 10:44 AM, R1 was lying in the same position in his bed. V5 (Spouse of R1) was sitting at R1's bedside. V5 said, I came in this morning and shaved him and brushed his teeth. If I don't come in and do it every day, it doesn't get done. He never receives showers anymore, just bed baths. He really enjoys getting showers, and never refuses. R1 appeared clean-shaven. R1 said no facility staff had helped him brush his teeth or shaved him. R1 continued to say he wants to get a shower and does not understand why the facility only gives him bed baths when he prefers showers. On January 27, 2025 at 12:05 PM, R1 was lying in his bed, covered by a top sheet. A large bulge was visible on R1's lower abdomen, through the top sheet of the bed. V5 (Spouse of R1) pulled back the top sheet and showed R1 was wearing an incontinence brief. V5 opened R1's incontinence brief. Inside R1's incontinence brief was a folded bath towel and a second incontinence brief. Loose stool was present between R1's legs and covering his scrotum. The folded bath towel was wet, and a urine odor was present. On January 27, 2025 at 12:31 PM, V7 (CNA-Certified Nursing Assistant) said, I changed [R1's] incontinence brief at 8:00 AM. I have not had time to do it again. There are still people I haven't been able to get to. I have 20 patients to take care of today. No one is getting showers today! We usually shave people during their showers. I did not have time to brush teeth or shave anyone. On January 27, 2025 at 2:21 PM, V5 (Spouse of R1) said, I gave him a bed bath because the CNA said he will not be getting a shower today. If I don't do it, no one else will. The facility's undated Assignment Sheet shows R1 should receive showers on Mondays between 6:00 AM and 2:00 PM, and Fridays between 2:00 PM and 10:00 PM. The facility's Skin Monitoring: Comprehensive CNA Shower Review sheets for R1 show R1 received a bed bath on January 13, 2025, January 15, 2025, and January 24, 2025. The facility does not have documentation to show R1 received his scheduled shower or a bed bath on January 10, 2025, January 17, 2025, or January 20, 2025. The facility does not have documentation to show R1 receives daily oral care. 2. On January 27, 2025 at 11:57 AM, R2 was lying in bed. R2's teeth appeared caked with a black debris. R2 said he had not received oral care by facility staff, nor had facility staff brought him a toothbrush with toothpaste to do his own oral care. R2 said, I can't get out of the bed, so how am I supposed to get toothpaste onto my toothbrush to brush my teeth. The facility does not have documentation to show R2 received oral care by facility staff. The EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including, multiple sclerosis, hypertension, dysphagia, open left leg wound, PVD, weakness, cognitive communication deficit, hydronephrosis, history of falling, right buttock pressure ulcer, and anemia. R2's MDS dated [DATE] shows R2 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, substantial/maximal assistance with toilet hygiene, showering, dressing, personal hygiene, and bed mobility, and is dependent on facility staff for transfers between surfaces. R2 has an indwelling urinary catheter and is frequently incontinent of stool. 3. On January 27, 2025 at 12:02 PM, R3 was lying in bed. R3 had long facial hair. R3 said, I need a shave. On January 28, 2025 at 9:31 AM, R3 was lying in bed, fully dressed. R3 continued to have long facial hair and debris in his teeth. The EMR shows R3 was admitted to the facility on [DATE]. The EMR continues to show R3 was transferred to the local hospital on January 2, 2025 with altered mental status and returned to the facility on [DATE]. R3 has multiple diagnoses including metabolic encephalopathy, hemiplegia affecting the left non-dominant side, multiple sclerosis, heart disease, spinal stenosis, anxiety disorder, delirium, major depressive disorder, weakness, muscle disorder, hematuria, restlessness and agitation, epilepsy, and urinary tract infection. R3's MDS dated [DATE] shows R3 is cognitively intact, requires setup assistance with eating, supervision with oral hygiene, substantial/maximal assistance with dressing and bed mobility, and is dependent on facility staff for toilet hygiene, showering, and transfers between surfaces. R3 has an indwelling urinary catheter and is frequently incontinent of stool. R3's care plan for ADL self-care performance deficit due to decreased strength, created on February 28, 2020 shows multiple interventions created on February 28, 2020, including, Resident requires dependent of 1 person with bathing. Personal hygiene/oral care: Resident requires substantial of 1 person with personal hygiene. The facility's Assignment Sheet shows R3 should receive showers on Tuesdays between 6:00 AM and 2:00 PM, and Saturdays between 2:00 PM and 10:00 PM. The facility's Skin Monitoring: Comprehensive CNA Shower Review sheets show R3 refused a shower on January 14, 2025 and January 17, 2025. The shower sheets show R3 received a shower on January 24, 2025. The facility does not have documentation to show R3 received his scheduled showers on January 18, 2025 or January 21, 2025. The facility does not have documentation to show R3 received oral care or assistance with shaving. 4. On January 27, 2025 at 9:15 AM, during initial tour of the facility, R5 and R6 were observed with long facial hair. R5 and R6 are male residents. R5 and R6 said they do not like having long facial hair and would like facility staff to assist them with shaving. R5's MDS dated [DATE] shows R5 requires setup assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, substantial/maximal assistance with bed mobility and transfers between surfaces, and is dependent on facility staff for toilet hygiene, showering, and dressing. R6's MDS dated [DATE] shows R6 is dependent on facility staff for transfers between surfaces and requires substantial/maximal assistance with all other ADLs. On January 28, 2025 at 12:10 PM, V2 (DON-Director of Nursing) said, Showers should be given twice a week. Unless their preference is a bed bath, then the resident should get a shower. [V5] (Spouse of R1) told me in early January that she was upset [R1] wasn't receiving showers. I don't know why he still isn't getting showers. There is no reason for any resident not to get their showers. V2 continued to say no residents should be wearing double briefs or have a bath towel folded inside their incontinence brief and residents should receive incontinence care every two hours. V2 also said there was plenty of staff in the facility on January 27, 2025 to assist V7 (CNA) if she was falling behind with her residents. The facility's policy entitled, Supporting Activities of Daily Living revised March 2018 shows: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: .2. 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, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). .4. If residents 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. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate.

Based on interview and record review, the facility failed to follow their policy to immediately notify a resident's representative when a resident had a change in condition requiring transfer to the local hospital. This applies to 1 of 3 residents (R1) reviewed for change in condition notification in the sample of 6. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on January 2, 2025, and returned to the facility on [DATE]. R1 has multiple diagnoses including, acute encephalopathy due to sepsis, acute respiratory failure with hypoxia, diabetes, multiple sclerosis, paraplegia, major depressive disorder, PVD (Peripheral Vascular Disease), heart disease, idiopathic neuropathy, cognitive communication deficit, dysphagia, severe sepsis with septic shock, pneumonitis due to inhalation of food and vomit, hydronephrosis, Stage 4 pressure ulcer of the sacral region, weakness, dementia, hearing loss, history of falling, and acquired absence of right leg above the knee. R1's MDS (Minimum Data Set) dated November 4, 2024 shows R1 is cognitively intact, is dependent on facility staff for transfers between surfaces, and requires substantial/maximal assistance with all other ADLs (Activities of Daily Living). R1 is always incontinent of bowel and bladder. On January 2, 2025 at 8:37 PM, V3 (LPN-Licensed Practical Nurse) documented R1 had three episodes of vomiting and was clammy, with an elevated heart rate. V3 documented, she notified R1's doctor and family and he was sent to the local hospital at 8:30 PM. On January 27, 2025 at 12:05 PM, R1 was lying in bed in his room. V5 (Spouse of R1) was sitting at R1's bedside. V5 said, R1 was sent to the local hospital on January 2, 2025. V5 said, No one called me to tell me my husband (R1) was sent to the hospital. I had no idea. The next morning the hospital calls me and tells me [R1] was being rushed to surgery. I didn't even know he was at the hospital, and I didn't get to see him before he went to surgery. This was very upsetting to both of us. We have been married over [AGE] years, and I would have wanted to be there for him. He ended up with a kidney stone and other problems, and he ended up in intensive care. I was told by [V2] (DON-Director of Nursing) that the nurse called the wrong number when she tried to call me. She used the wrong area code. My number is in the chart. There is no reason for this. They also have his sister's phone number, and our daughter's phone number. Why didn't they try to call someone else if they weren't able to reach me? Instead, they left a message on a total stranger's telephone about my husband. On January 27, 2025 at 11:23 AM, V3 (LPN) said, [R1] was clammy, and his heart rate was elevated. I called the NP (Nurse Practitioner) and she said to send him out to the hospital. I thought I called the family, but I called the wrong area code, so I never spoke to the wife. I did not try to call the wife again. I did not try to call his other emergency contacts. On January 28, 2025 at 12:10 PM, V2 (DON) said, The nurse called the wrong number when [R1] went to the hospital, and never spoke to a family member. She should have kept trying to call the spouse, and if she wasn't able to reach her, then reach out to one of the other two contact numbers we have for his other family members. The wife did call me and tell me she was very upset about not being notified by us. No one wants to hear from the hospital that their family member has been there overnight and is going to surgery when they thought they were here sleeping in their bed. The facility's policy entitled Notification of Change in Condition, Discharge, and Transfer, created October 9, 2021 shows: Policy Statement: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Procedure: 1. The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following (list is not all inclusive): .b. A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication.d. A decision to transfer or discharge the resident from the facility.

Based on observation, interview and record review, the facility failed to provide wound treatment as ordered. This applies to 1 of 7 residents (R112) reviewed for pressure ulcer prevention and treatment in the sample of 35. This failure resulted in the worsening of an acquired pressure ulcer wound from a stage 2 to an unstageable wound. The findings include: R112's EMR (Electronic Medical Record) showed R112, was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, age related osteoporosis, unspecified macular degeneration, cognitive communication deficit, adult failure to thrive and mild protein-calorie malnutrition. R112's MDS (Minimum Data Set) dated September 10, 2024, showed R112 had severe cognitive impairment and required assistance with ADLs (Activities of Daily Living) including substantial assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and bed mobility and was dependent on staff for transfer. R112's wound assessment dated [DATE], showed R112 had developed newly acquired pressure wounds on the sacrum and right buttock identified on October 6, 2024. The pressure wound on the sacrum measured 3.00 cm (centimeter) x 1.50 cm (centimeter) with a surface area of 4.5 cm and was identified as unstageable. The pressure wound on the right buttock measured 1.0 cm x 1.0cm x 0.10 cm depth with a surface area of 1.00 cm and was identified as a stage 2 wound with 100% (percent) pink tissue in the wound bed. On October 9, 2024, at 9:52 AM, V32 (Licensed Practical Nurse-Wound Care Nurse) and V14 (Registered Nurse- Unit Manager Third floor) performed wound care to the pressure wounds on the sacrum and right buttock. Upon removing the disposable brief, there was no dressing covering the right buttock wound present. V32 was asked if there should be a dressing covering the right buttock wound and V32 responded yes. V32 stated the right buttock wound was now worse and now an unstageable wound with 100% slough covering the wound bed. V32 stated the last time she saw the wound was October 7, 2024, when she assessed the wound and did the treatment. On October 9, 2024, at 2:24 PM, V18 (Nurse Practitioner) stated R112, right buttock wound, if left uncovered without a dressing, would leave the wound exposed to urine and fecal contamination and that exposure could cause the wound to get worse. V18 also stated unrelieved pressure would contribute to pressure wound development but was not sure if R112 had unrelieved pressure from sitting in the wheelchair. R112's October 2024, TAR (Treatment Administration Record) showed an order for the right buttock wound initiated October 7, 2024, Right buttock cleanse with normal saline pat dry. Apply hydrocolloid dressing as needed for wound care. There is no documentation that this treatment had been administered on October 7, 8, or 9th. There also was an order initiated and discontinued on October 9, 2024, that showed right buttock cleanse with normal saline pat dry. Apply hydrocolloid dressing every day shift Mon, Wed, Fri for wound care. There is no documentation this treatment was administered. On October 9, 2024, at 11:10 AM, V33 (CNA/Certified Nursing Assistant) stated she was the primary CNA assigned to R112 on the day shift and often worked the evening shift as well. V33 stated she was present on October 6, 2024, when the wounds to the sacrum and right buttock were discovered and informed V14. V33 stated that R112's normal routine was to get up on the night shift, maybe around 5:00 AM and was up already when V33 arrived to work at 6:00 AM. V33 stated R112 required a full mechanical lift for transfer and R112 would remain sitting in the wheelchair until after lunch when V33 would put R112 back to bed and change her incontinent brief. When asked if R112 had been repositioned while seated in the wheelchair from early morning until after lunch, V33 replied that R112 did not wet the brief very much because R112 would not drink much and did not need changing very often. During intermittent observations on October 7, and October 8, 2024, R112 remained seated in the high back wheelchair in the dining room. R112's care plan for risk for developing unavoidable skin breakdown-initiated February 12, 2024, showed an intervention to turn and reposition resident at regular intervals and as needed. There is no intervention to identify for staff how to reposition R112 while seated in the wheelchair. On October 10, 2024, at 11:30 AM, V2 (DON) stated it is the expectation if a new wound is discovered that the CNA would report to the Nurse and the Nurse would assess the wound, contact the Physician, obtain a treatment order, and notify the wound team for follow up. V2 stated upon observation of a wound dressing missing, the CNA should report the missing dressing to the nurse and the nurse would replace the wound dressing in accordance with the Physician orders. V2 stated residents should be repositioned in accordance with clinical standards of practice, every 2 hours. The facility's policy title Wound Care dated October 2010, showed . Purpose .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .and .Preparation .1. Verify that there is a Physician's order for this procedure. The Facility's policy titled Prevention of Pressure Injuries dated April 2020, showed Mobility/Repositioning .1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team.

Based on observation, interview the facility failed to ensure that sanitary practices are maintained to prevent cross contamination during dishwashing procedure and storage of dish rags. This applies to 199 residents that receive foods prepared and served from the facility kitchen. The findings include: The facility provided information that on October 7, 2024 the facility census was 203 residents with 4 residents on NPO (nothing by mouth) status. On October 7, 2024 at 9:20 AM, during initial tour of the kitchen, multiple rags that were both dry and wet/dirty were seen strewn on free standing carts. On October 7, 2024 at 9:24 AM, during the dishwashing procedure at the high temperature dish machine, V10 (Dietary Aide), who was wearing gloves, was observed washing and rinsing dirty dishes prior to loading them on racks to send through the dish machine for sanitation. V10 was then seen going to the clean side without changing her gloves or washing her hands and unloading cleaned water pitchers and a plate guard and put them away on a shelf. V11 (Dietary Aide) was seen walking in from outside the kitchen and without washing hands or putting on gloves, put away some of the cleaned cups that were air drying after being washed. V11 left the dish room for a few minutes and then came back again and put away more cleaned dishes. When asked where he came from, V11 stated that he had gone upstairs to bring down the carts with the used tableware after breakfast. V11 was asked why he did not wash his hands before touching the cleaned dishes and V11 then proceeded to go to the hand sink. V9 (Director of Dining Services) was notified of the observations and relayed that the dishes that were touched by both V10 and V11 will have to be rewashed. V9 agreed and stated that V10 should have stayed in the dirty side of the dish washing area and V11 should have washed his hands prior to putting away the cleaned dishes. On October 9, 2024 at 12:10 PM, V9 added that the clean dish rags should have been placed in a bucket assigned for wash and/or with sanitizing solution and the dirty rags in a separate container for dirty linen. V9 stated that the facility does not have a policy for the same. Facility also did not have a policy for dishwashing procedures that included directives about cross contamination.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse. R6 was found with R7 in his closed bedroom with a chair placed to block the door. R6 is severely cognitively impaired and she was sitting on R7's bed, exposed, with her pants and incontinence brief around her ankles. R7 was naked from the waist down. Staff also failed to identify R7's behaviors (getting into a female resident's bed and disrobing in the hallway) as potentially sexually inappropriate behaviors, and failed to report those behaviors. This applies to 2 of 4 residents (R6, R10) reviewed for abuse. As a result, this type of inappropriate, nonconsensual sexual contact would reasonably cause psycho-social harm, and it can be determined that a reasonable person in R6's position would have experienced psycho-social harm (such as humiliation and fear) as a result of the sexual abuse. This failure resulted in an Immediate Jeopardy (IJ). The IJ began on December 24, 2023 when R7 (male resident) climbed into the bed with R10, a female resident. V1 (Administrator) was notified of the Immediate Jeopardy on January 16, 2024 at 12:40 PM, and V1 was provided an IJ template which outlined the failure. While the immediacy was removed on January 18, 2024 at 4:00 PM, the facility remains out of compliance at Severity Level 2 because additional time is needed to evaluate the implementation of the in-service training and auditing the effectiveness. The findings include: The facility's initial January 8, 2024 IDPH (Illinois Department of Public Health) Reportable Event from R6's Electronic Medical Record (EMR) showed On 1/8/2024 [no time] staff reported seeing [R6] to be sitting by the side of her bed with her undergarments down to her ankles and [R7, a male resident] was by the side of the bed and pulling his pants up On January 10, 2024 at 03:02 PM, V8 (Activity Aide) said that around lunch time on January 8, 2024, she left R6 and R7's unit (locked dementia unit) to do the lunch trays in the dining room outside the unit. V8 said before she left, R6 and R7 were sitting together by a window. V8 said when she returned, R6 and R7 were no longer in the dining room and she started gathering residents for lunch. V8 said when she arrived at R7's room, his door was closed, and no one answered when she knocked. V8 said when she opened the door, a chair fell that was being used to block the closed door. V8 said she saw R6 sitting in the middle R7's bed with her pants and incontinence brief around her feet. V8 stated R7 was standing about a foot away from R6, wearing no pants or incontinence brief. V8 stated I saw them both with no bottoms on and told R6 she had a phone call and needed to go eat lunch, and ran to get the nurse (V6, RN/Registered Nurse). V8 stated she did not take R6 with her. V8 said she went to get the nurse and R7 covered his perineal area with clothing. V8 said R7 was confused and had a behavior of going to other residents' rooms. V8 continued, R7 is one of our newest residents from the beginning of December. V8 said he walked independently. V8 stated R7 gets confused so sometimes he goes to another room, sees it's not his and then goes back to his room. V8 stated R6 has been at the facility for a while, and she doesn't have that behavior. V8 stated R6 follows directions, and she has never seen her having this behavior. V8 stated for R7's first few weeks, R7 was getting adjusted, so he was alone and would sit by the TV or in the dining room or would walk in the hallways. On January 10, 2024 at 2:00 PM, V6 (RN/Registered Nurse) said on January 8, 2024 when V8 went to deliver R7's tray, R7 had put a chair on the back of the door and when she tried to open the door, the chair fell . V6 stated when she got to R7's room, R7 told her that R6 needed help with something and that was why he had brought her into his room. V6 stated she completed a full body assessment, including checking for semen between R6's legs, and everything was ok. V6 stated when she asked R6 about the incident, R6 was sitting on the bed and smiling, and R6 told her R7 had brought her to his room. V6 stated R6 likes to sit with people, rub their hands and she wanders. V6 stated R6 does not know what room she is going into, but R6 and R7 can both walk. V6 stated R7's pants were completely off, but he covered himself with clothes, leaving his buttocks exposed. V6 stated R6's pants and brief were down, and she thought staff caught them in the process before anything happened. V6 stated R6 and R7's families were told that based on their assessment, it was probably going to happen that they were going to have sex. On January 11, 2024 at 10:22 AM, V6 stated R6 is a very pleasant lady. V6 added R6 has not had issues with the male residents. R6's medical record showed she was admitted with diagnoses including dementia, Alzheimer's, restlessness and agitation, delirium, and altered mental status. R6's October 16, 2023 Minimum Data Set (MDS) showed she is severely cognitively impaired. On January 10, 2024 at 2:50 PM, R6 was sitting in the dining room flipping through a magazine. R6 said she was doing good and said she ate her lunch when she was asked about it. R6 laughed inappropriately during the conversation with Surveyor. R6 was unable to answer questions regarding incident on January 8, 2024. On January 10, 2024 at 2:19 PM, V12 (CNA) stated R7 needs to be watched for wandering. V12 stated sometimes she has seen R7 go into other residents' rooms, but she redirects him. V12 stated when R6 moves, it is because she needs to use the bathroom. On January 11, 2024 at 11:28 AM, V9 (CNA) stated she worked on January 8, 2024. V9 stated R6 is nice, and she doesn't know what she is doing. V9 stated R6 is able to walk by herself and she does not go into other residents' rooms. V9 stated R7 walks by himself, and he is always walking. V9 stated R6 and R7 did not have a relationship and she did not get any special instructions about R7 and did not know what happened on January 8, 2024. R6's Care Plan listing does not include any care plan that shows she is at risk for abuse. R6's impaired cognitive function/dementia or impaired thought processes related to Alzheimer's care plan (revised January 30, 2022) showed a goal to be able to communicate basic needs. Interventions include to ask her yes/no questions and cue, reorient, and supervise as needed. R6's other impaired cognitive function or impaired thought processes care plan (revised February 4, 2022) included a focus of Difficulty making decisions, impaired decision-making related to dementia. Interventions include to engage in simple, structured activities that avoid overly demanding tasks. R6's Activities of Daily Living care plan (revised January 10, 2024) showed a February 4, 2022) intervention that showed DRESSING: Requires substantial [assist] of 1 staff participation to dress. There is no evidence that showed R6 is able to consent to any sexual activity. On January 19, 2024 at 12:40 PM, R6 was sitting in the dining room. When asked, R6 introduced herself and said she was [AGE] years old and then her speech became unintelligible. R6 was able to stand up and walk without staff assistance. R7's Admission Record showed he was admitted to the facility on [DATE] with diagnoses of liver abscess and urinary tract infection. A diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance was added on January 9, 2024. R7's December 5, 2023 MDS showed he was severely cognitively impaired. On January 11, 2024 at 12:03 PM, V10 (CNA) stated she had worked in the locked memory unit on January 8, 2024 and was on break when R6 and R7 were found in R7's room. V10 stated the nurse did not tell her what had happened but told her to keep an eye on R7. V10 stated she had never received report about R7 sleeping in another resident's bed or to continue monitoring for the behavior. On January 11, 2024 at 01:09 PM, V7 (R7's POA-Power of Attorney) said on January 8, 2024, she was told R7 was caught attempting to have sexual intercourse with a female resident. V7 said R7 had dementia and would only be able to identify himself and close family members. V7 said this was the second incident that was reported to her, with the first occurring on December 24, 2023 where she was told by V5 (LPN) that he had found R7 attempting to have sexual intercourse with R6. V7 said when she came to the facility after Christmas Eve, V5 pointed out R6 to her. V7 said she was told for the first incident, V5 found R7 taking his pants off. V7 said when she was notified of the second incident, she was told by staff that R7 was pulling his pants up. V7 said after the second incident on January 8, 2024, she was told the facility was increasing R7's medications and adding an estrogen-based medication to lower his testosterone. V7 said the social worker told her they were labeling R7 as hyper-sexual due to the two incidents. R6's Family was unable to be reached during the survey. Prior to the January 8, 2024 incident, R7's December 24, 2023 V5's (LPN/Licensed Practical Nurse) nursing progress note from 8:43 PM (23 days after R7's admission) showed Resident climbed into another female resident bed to sleep while she was in bed. Resident was educated that he [cannot do] that. Resident got agitated with the nurse screaming to the nurse to get out. Nurse [calmed] down resident and got him out of the room. [V7, R7's POA] notified of resident behavior. On January 10, 2024 at 2:28 PM, V5 LPN (Licensed Practical Nurse) stated there was one time he found R7 sleeping in another resident's bed, stating it was R10's bed. V5 stated he didn't take it as anything .most of them go sleep on somebody else's bed- it's a dementia unit, but I did chart it. V5 said he did not notify R10's POA. R10's December 24, 2023 progress notes showed no specific mention of the event, and instead showed a December 24, 2023 entry from 8:39 PM that showed Nurse called [local] hospital to follow up with resident and was told the resident is been admitted . However, the receptionist could not give diagnosis. R10's and R6's Census in their EMRs showed R10 and R6 shared a room prior to R10's discharge. No documentation was present in either R6's or R10's progress notes regarding the December 24, 2023 incident. On January 11, 2024 at 12:20 PM, V5 was again asked about the incident on December 24, 2023 where R7 was in R10's bed. V5 stated he notified R7's Power of Attorney (POA) and the Social Workers and he did not talk to R10's POA. V5 stated he told the on-coming night shift agency nurse to monitor him, but not about what happened, adding I didn't see it as any big issue. V5 stated I said to keep an eye on him because he might go sleep in someone else's bed. On January 11, 2024 at 12:40 PM, V32 (Social Services) said she was told R7 wandered frequently and went into another resident's room and got into another resident's bed on Christmas Eve. V32 said she was told R7 was the only one in the room and she updated R7's care plan. V32 said R7 is more agitated in the evenings and interventions were for staff to monitor him and to redirect him into activities. V32 said the next incident she had heard was from January 8, 2024 when R7 was found halfway unclothed with R6. V32 said there had been miscommunication about what happened on Christmas Eve and she had only read the progress note on January 10, 2024, and she did not know who that resident was from the earlier incident. V32 stated if R7 had the behaviors, he should have been more closely monitored so the incident on January 8, 2024 would not have occurred. V32 said residents on the memory care unit for the most part are not able to make decisions for themselves, including R6 and R7. V32 said when she read R7's progress notes from December 24, 2023 and January 8, 2024, they were different stories than what she had received. V32 said it was not made clear that R7 was climbing into bed with another resident already in the bed, and if she had known, a room change would have been done on December 24, 2023. R7's Behaviors care plan (initiated December 28, 2023, four days after the incident with R10 and written by V32, Social Services) showed On occasion, [R7] is seen displaying inappropriate behaviors such as climbing into other residents' beds. As well as yelling/screaming at staff. Goals include attempting to follow staff redirections and refraining from going into other resident rooms and beds. The only intervention listed is [Interdisciplinary Team] will monitor, which was revised on January 16, 2024 (during the survey), from [Social Services] will monitor. R7's December 26, 2023 Nurse Practitioner (NP) progress note showed Nurse reported some behavior concerns/agitation. Patient went into another resident's bed the other night and was removed by staff. In house psych to follow- agitation in hospital and had been on Seroquel .Nurse reports overnight patient agitated removing clothes and wandering hall. On January 11, 2024 at 02:45 PM, V14 (Psychiatric NP) said he saw R7 for the first time on January 8, 2024 for hyper-sexual behaviors and Alzheimer's dementia with behavioral disturbances. V14 said the staff told him R7 made a lot of sexual comments and would speak to females in a flirtatious manner. V14 said he went to the facility on [DATE], and the staff told him they had caught R7 attempting to perform some type of sexual activity with a female resident. V14 said when he came to evaluate R7, he saw R7 speaking to a female CNA and could tell R7 was flirting with her. V14 said R7 should not be left alone with female residents. V14 stated he increased R7's antidepressant medication to reduce his sexual behaviors. On January 18, 2024 at 02:10 PM, V14 said he would expect the staff to report resident behaviors to the NP or the Physician- behaviors like going into other residents' rooms, sexual acts, groping, being sexually threatening, making sexual comments or specific comments about a resident's breasts or genitalia, taking one's clothes off in public places, touching their own genitalia in public places, having an erection in the middle of interacting with someone, and climbing into another resident's bed with another resident in the bed. V14 said if a resident appeared to be fixated on another resident, he would have told the staff to keep monitoring the resident and to separate them from one another. V14 said he was not notified R7 had climbed into another resident's bed on December 24, 2023. V14 said if he had known of the incident on December 24, 2023, he would have increased R7's psychotropic medications then and ordered behavioral monitoring to ensure he was not left alone with female residents. V14 said the residents on the memory care unit cannot make decisions for themselves, and none of them would be able to consent to sexual contact. On January 11, 2024 at 11:42 AM, V13 (CNA) stated staff monitor R7. V13 stated she never received any instructions about R7. V13 stated R6 is always sitting in the dining room, and she will ask staff to use the bathroom. V13 stated she has never seen R6 have any inappropriate behaviors with other residents. V13 stated when she came back to work after Christmas, she was told she needed to watch [R7]. V13 stated they said something happened, but I don ' t know what. The facility's January 12, 2024 final IDPH Reportable Event for the January 8, 2024 abuse allegation notification showed .Investigation shows that both residents [R6 and R7] had no malicious intent towards each other there would not have been any time for either resident to have touched each other in any sexual manner It is obvious to staff that they had a liking to each other, took a walk and may have wanted a nap as husband and wife .The allegation of sexual abuse is unsubstantiated . The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy (revised November 1, 2021) defined Sexual abuse as non-consensual sexual contact of any type with a resident. The facility's 11/01/2021 Abuse Policy showed It is the policy of [Facility] that each resident will be free from 'Abuse.' Abuse can include .sexual . No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection . Under Resident Assessment in the Procedure section, the policy showed Every resident is unique and may be subject to 'abuse' based on a variety of circumstances, including .the resident's health, behavior, or cognitive level . Under 4. Population, the policy showed a. The facility's population presents the following factors, which could result in maltreatment of residents: The assessment, planning of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of cognitive deficits, sensory deficits, aggressive behaviors, residents who have behaviors such as entering other residents' rooms, wandering behaviors .socially inappropriate behaviors, verbal outbursts, residents with communication disorders, those who are nonverbal .b. The facility will ensure a comprehensive dementia management program to prevent resident abuse . Under Identification, the policy showed .It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns, and trends that may constitute abuse will be investigated . The first immediacy removal plan presented by the facility on January 16, 2024 at 4:00 PM was rejected, and the revision presented at 7:34 PM was also returned. The second revision submitted on January 17, 2024 at 10:40 AM was rejected. The third revision of the immediacy removal plan was submitted on January 17, 2024 at 12:50 PM and it was accepted. Based on interview, and record review, the Surveyor determined immediacy was removed on January 18, 2024 at 4:00 PM after the facility: Removed R6 from the dementia unit Assigned ongoing 1:1 supervision for R7 Care plans were updated for R6 and R7 All facility staff were trained on Recognizing the Signs of Potential Sexual Activity with the Dementia Population, reporting the behaviors, and notifying staff of resident behaviors that put others at risk, and documentation in the Electronic Medical Record All facility staff were in-serviced on the need to ensure residents who are cognitively impaired and cannot make decisions for themselves are free from abuse

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when a nurse refused to provide R1 with feeding assistance while administering crushed medications to the resident. This failure resulted in psycho-social harm for the resident, when R1 said she felt anxious at the thought of not receiving her medications, was unable to sleep, and felt powerless to help herself. This applies to 1 of 4 residents (R1) reviewed for improper nursing care in the sample of 4. The findings include: On June 29, 2023 at 9:33 AM, R1 was sitting at the side of her bed. R1 was attempting to eat her breakfast. R1's hands appeared shaky, and all of her finger joints appeared swollen. R1 said she has arthritis in her hands, making simple tasks difficult for her. R1 said, There were three different times recently when [V3] (LPN-Licensed Practical Nurse) refused to help me take my medications. I get my medications crushed with pudding or applesauce. All of the other staff crush the medications and then feed them to me with a spoon or using a tongue depressor. Three different evenings, [V3] refused to give me my medications. She said she would not feed the medications to me, and if I wanted the medications, I would have to feed myself. She crushed the medications, put them in a little cup and left them on the bedside table for me to take. I asked her to feed them to me and she refused to feed me. I was unable to take the medications. Look at my hands! I have arthritis so bad that I cannot hold that tiny cup in my hand and feed myself. I can barely feed myself my meals as it is. Not only that, but I broke a bone in my left hand recently, and it is painful. [V3] refused to give me the medications and walked away. It made me feel very upset. I have anxiety, and that kind of thing makes me nervous. It was evening, right before bedtime, and then I could not sleep all night because I was so upset that she treated me that way. I felt totally helpless. I was not able to take my medications. I was powerless to help myself, and my only option was to call my daughter and ask her to intervene on my behalf. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, osteoarthritis, chronic DVT (Deep Vein Thrombosis) of the lower extremity, atrial fibrillation, heart failure, cardiomyopathy, dyskinesia of the esophagus, aortic aneurysm, left shoulder rotator cuff tear, anxiety, presence of a cardiac pacemaker, presence of an artificial hip joint, hearing loss, and mitral valve prolapse. R1's MDS (Minimum Data Set) dated April 26, 2023 shows R1 is cognitively intact, is able to eat with supervision, and requires extensive assistance with all other ADLs (Activities of Daily Living). R1 is frequently incontinent of bowel and bladder. R1's left hand Radiology Results Report dated June 6, 2023 shows R1 has Diffuse soft tissue swelling and acute fracture of the proximal phalanx of the fourth digit (ring finger). On June 16, 2023 at 8:45 PM, V3 (LPN) documented, 8:00 PM nurse passing medications to resident, and resident states that nurse is supposed to feed the medications to her and if you do not I'm going to tell [V8] (ADON-Assistant Director of Nursing) that you left my medication at my bedside. I know you are not supposed to leave it here. Nurse asked the resident are you going to take your medication? If not I will get rid of them. Nurse replied, I'm not supposed to feed you the medications because you can use your hands and you can feed yourself food, which is why you can take your medications yourself. Resident replied, no I'm not going to take them. On June 16, 2023 at 9:26 PM, V3 (LPN) documented, At 9:05 resident's daughter (V5) called the facility to speak with the nurse. She wanted to know why resident did not get her medications. Nurse explained to her as to what happened during the 8:00 PM medication pass, and the family understood and asked nurse if she can please make more medication to give to her because there were important meds she had to take, nurse replied yes that would be no problem. Medications were made over, and nurse gave resident her medications to take. On June 17, 2023 at 8:37 PM, V3 (LPN) documented, 8:00 PM nurse passing medication to resident, medication was given resident states, I want you to feed it to me. Nurse replied, we went through this yesterday concerning your medications (you can do this yourself). Resident was again educated on taking her medication, when nurse gave her the meds in the cup, resident says, leave them here. The nurse states I can't do that. Nurse also states can I have them back if you are not going to take them as nurse began to pick them up resident grabbed from my hand. The other nurse [V10] (LPN) was across the hall and resident says I want her (V10) to feed them to me. Nurse asked [V10] can she please give resident her meds and she replied, yes. On July 3, 2023 at 1:32 PM, V10 (LPN) said, I was passing my meds and I overheard the conversation between [R1] and [V3]. [R1] was very upset. I am very familiar with [R1's] preferences. She has preferences as to how she takes her medications and getting the care she needs. I feed her the medications every time I administer them. Ever since I've known [R1] she has been particular. Also, she was recovering from a fractured finger, she has a lot of pain, and it is hard for her to reach her arms above a certain point due to bursitis in her shoulders. It is easier for her if we feed the medications to her, and how she prefers it. I don't know why [V3] (LPN) wouldn't just give the medications. [V3] kept trying to explain to the resident that she is in rehab, and she should be able to feed herself, and [R1] couldn't understand why she could not have her medications fed to her. I was out in the hallway passing medications to the residents assigned to me, and I could see [R1] kept looking at me to help. I didn't want [R1] to miss her medication, and for that reason I offered to assist her. I stepped in and gave the medications because [V3] refused to. On June 24, 2023 at 8:47 PM, V3 (LPN) documented, 8:30 PM nurse asked the other nurse to give resident her medications D/T (due to) resident not wanting to take meds from her nurse. Medications was given to resident to take, resident states to the nurse, You are supposed to feed me the medication because it is a matter of life and death! Nurse replied, That is why you should take your medication. Nurse went to her med cart and came back 10 minutes later, and resident had medication on the table. Nurse asked, Why you didn't take your medicine? Resident states, It will stay here until someone feeds it to me. Nurse says, The medication cannot stay here, I will return in 1/2 hour and if the medication is still here I will get rid of it because I can't leave medication at the bedside. Nurse informed [V5] (Daughter/POA-Power of Attorney of R1) about situation. On June 29, 2023 at 3:32 PM, V3 (LPN) said, I used to work at the facility and then I left for a year or so When I used to take care of [R1], she could feed herself. We are a rehab facility. She wanted me to feed her the medications and I told her she could do it herself. She told me she wanted me to feed her the medications and I told her no. I left the medications in her room and thought she would try to feed herself the medications, but she did not. She kept telling me she wanted me to feed them to her. I was not going to do that because I don't want her to get weaker. She wanted me to feed her, and I said no. I left the medications on her bedside table. Later the CNA (Certified Nursing Assistant) came to me and said she helped the resident take her medication. I did not see the resident take the medications. V3 was asked if the nurse sees a decline in a resident, such as not being able to feed themselves as they did in the past, is the nurse supposed to refer the resident to restorative therapy or to the rehab department, but still provide the resident care, and V3 responded, yes. On July 3, 2023 at 9:27 AM, V5 (Daughter/POA of R1) said, The first time [V3] refused to feed the medications to my mom (June 16, 2023), my mom called me and said [V3] won't give me my medications. All of the staff know she needs her medications crushed and put in pudding and fed to her. She has arthritis in her hands and a fracture in her left hand. This nurse (V3) refused to feed it to her and left the medication sitting there. [R1] called me and told me about it. I called and spoke to [V3] and [V3] said she would not feed the medication to my mom. The second time [V3] called me and told me my mom refused to take her medication. It really was a matter of [V3] telling my mom to take it yourself, you are capable, and my mom being unable to feed herself. I said to the nurse, come on, can you please just give the medication to her, and she responded, I won't do it. [R1] did the best she could, and she had to have an aide help her, but she could not do it unassisted. After the first incident on June 16, I spoke to [V8] (ADON) and she said she spoke to [V3], and the situation was taken care of. I assumed the facility would not have [V3] care for my mom again. That did not happen, because I got a second phone call on June 17. I had assumed the nurse was reassigned to other residents, and theoretically she will never work with my mother again, but that would mean she will be able to do that to other residents. [R1] was very upset because she did not understand why every other staff member has no problem feeding her the crushed medications, but [V3] refused to. She was very anxious. This place is her whole world. It just upset her. When she becomes anxious, then her hands get shaky, and it makes it worse, and harder for her when it comes to feeding herself, and her blood pressure typically goes up because that has always been her response to stressful situations. She said she felt powerless, and indeed she was powerless, and unless I am standing there, I cannot help her. This really created a lot of anxiety for my mom. Then she couldn't sleep because she was so upset. I am not aware there was a third instance on June 24, 2023. On June 29, 2023 at 11:30 AM, V8 (ADON) said the first time V3 (LPN) refused to feed medication to R1 was on June 16, 2023. On the second occasion, (V10) (LPN) separated R1 and V3 and spoke to V3 off the unit and said residents should not be spoken to the way she heard V3 speak to R1. V8 continued to say she was contacted by V5 (Daughter/POA of R1) regarding the issue with V3 refusing to feed medications to R1. V8 said, [V3] was refusing to place the medications in [R1's] mouth because she said [R1] could do it herself. The facility's policy entitled Administering Oral Medications, revised October 2010, shows: 12. Place medications on the bedside table or tray. 15. Offer water to assist the resident in swallowing medications. 16. Allow the resident to swallow oral tablets or capsules at his or her comfortable pace. 20. Remain with the resident until all medications have been taken.

Based on observation, interview, and record review, the facility failed to implement infection control policies and procedures per facility and CDC (Centers for Disease Control) guidelines regarding the isolation of Covid-19 positive residents, and for the use of Personal Protective Equipment (PPE) when interacting with residents who test positive for Covid-19. This failure has the potential to affect 35 residents (R4, R6, R17, R23, R28, R30-31, R33-34, R39, R47-49, R54-55, R63, R65, R68, R72, R75-76, R79, R86-88, R93, R97, R108, R127, R130, R140, R160, R165, R170 and R173) on R168's unit who were not already Covid-19 positive on 1/12/2022, or who had recovered from Covid-19 in the 90 days prior to 1/12/2022. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/08/2022 at 9:30 PM when the lab that tested R168's specimen notified the facility by phone that R168 tested positive for Covid-19. The Immediate Jeopardy was identified on 1/12/2022 at noon. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/20/2022 at 10:50 AM. Although the immediacy was removed on 1/21/2022, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies and procedures, audits, and Quality Assurance monitoring. The findings include: On 11/19/22 at 11:35am, V3 (Assistant Director of Nursing/Infection Preventionist) stated that since the facility has been in Covid outbreak status, the staff was already instructed to wear N95 masks and face shields in the facility. V3 stated the first case of Covid-19 in the facility in the last 90 days was identified on 12/27/2021, adding there were no resident Covid-19 cases for October or November 2021. On 1/20/2022, the facility provided a list that showed 8 of the residents on R168's unit (aside from R168) were positive for Covid-19 or recently recovered from it by 1/12/2022. R168's Face Sheet showed she was admitted to the facility on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R168's Covid-19 Real-Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) lab test (collected on 1/07/22 at 6:00 AM) showed R168 tested positive for Covid-19, and the result was reported on 1/08/2022 at 8:19 PM. On 1/13/2022 at 2:15 PM, V26 (Licensed Practical Nurse- LPN) stated she worked the evening shift on 1/08/2022 (Saturday) and was assigned to R168. V26 stated she received a phone call from the lab around 9:30 PM that night to notify her that R168 had tested positive for Covid-19. V26 stated she reported it to V28 (Agency RN- Registered Nurse), who came in to work the night shift. V26 stated she did not notify R168's Physician or family about R168's positive Covid-19 result, and she did not call the Director of Nursing. V26 stated she did not post Isolation signs on R168's door, nor did she place an Isolation cart (with PPE) for persons who enter R168's room. V26 stated she did put a small table in front of R168's room with some isolation gowns on it, but the Isolation carts and signs are kept in the Central Supply Room and she does not have access to it. V26 stated that if a resident tested positive for Covid-19, the resident must be isolated immediately. On 1/14/2022 at 9:13 AM, V28 (Agency RN) stated that V26 (LPN) did not tell him during report on 1/08/2022 that R168 tested positive for Covid, and further, that another nurse told him residents who had tested positive for Covid had been moved downstairs. V28 stated if the lab had called V26 and told her R168 tested positive for Covid, V26 should have called the doctor and family, isolated the resident, and set up the Isolation kit at that time. V28 stated he could not remember if he went into R168's room the night of 1/08/2022, but if he had known R168 was positive, he would have definitely informed his CNAs (Certified Nursing Assistants) and taken vitals on R168 every four hours. V28 stated he had not received any training from the facility on what to do if a resident tested positive for Covid, but he did receive training from another facility he works at. On 1/14/2022 at 2:36 PM, V31 (Agency CNA) stated she worked with R168 on the evening shift of 1/08/2022. V31 stated she remembered pushing R168 in her wheelchair and she was not wearing an isolation gown. V31 stated that later in the shift, V26 (LPN) told her R168 had tested positive for Covid and to put R168 back in her room. V31 stated she grabbed an isolation gown from R58's Isolation cart, put on gloves, and wheeled R168 into her room and assisted her to bed. V31 stated We didn't put the isolation flyers or signs or PPE bin outside [R168's] door because we couldn't find it. R168's 12/10/2021 Minimum Data Set (MDS) showed she requires extensive assistance from one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. The same MDS showed she is moderately cognitively impaired, and she needs limited assistance of one person to eat. On 1/13/2022 at 2:34 PM, V2 (RN, Director of Nursing) stated the staff does have access to Central Supply on the weekends and all staff have been told this, then described where the key was located. V2 stated when a nurse finds out from the lab that a resident is Covid positive, they need to notify me, the Doctor, and family or Power of Attorney .they need to isolate residents . V2 stated In this case, [V26] is a regular nurse (meaning facility staff). She should have done everything following our Covid protocol instead of endorsing it to an Agency Nurse on a different shift. On 1/11/22 at 11:00 AM (three days after the lab notified the facility of R168's positive Covid-19 test result), the surveyor's initial tour was conducted on R168's floor. At 11:50 AM, the surveyor asked V27 RN (Registered Nurse) if there were any residents on isolation and if so, why. V27 stated that there was only one resident using Isolation precautions and it was R168, and it was because R168 had tested positive for Covid. R168 had an Isolation cart with PPE in it outside of her room and Isolation signs were present for Contact and Droplet Isolation. No table or Isolation cart was present outside of R168's room, and there were no signs for Contact or Droplet isolation posted on R168's door. On 1/12/2022 at 10:26 AM, again there were no signs on R168's door that indicated she was on any type of Isolation precautions, and no Isolation cart containing PPE was present by her doorway. R168 was in bed with her eyes closed. At 12:00 PM, the surveyor was in the dining room and saw a staff member in full PPE (gown, gloves, N95 mask, and face shield) in R168's doorway. Contact and Droplet Isolation signs were present on R168's door and an Isolation cart with PPE was outside R168's room. When asked why R168 was on Isolation, V27 (RN) stated They tested [R168] yesterday (1/11/2022) and the result came today that showed she is positive for Covid-19. On 1/13/2022 at 1:49 PM, V3 (Infection Control Nurse) confirmed that R168 actually had tested positive for Covid-19 on 1/08/2022, four days earlier. V3 stated the lab is connected to the facility's electronic medical record system and she can access lab results. V3 stated the lab typically calls the nurse on duty about positive Covid-19 results or other abnormal lab results, then the nurse should follow protocol and notify the Physician and family. V3 stated she checks the lab system Monday through Friday and she is unclear who is responsible to check lab results on the weekends. V3 stated it should be a Nurse Manager or the Manager on Duty that should check the lab values on the weekend I don't have a policy on who is responsible for this. In this case, [R168] tested positive for Covid on 1/08/2022, and she should have been isolated. On 1/14/2022 at 2:00 PM, V27 (RN) stated she worked a double shift on 1/9/2022 (mornings and evenings), and she did not know R168's positive Covid-19 result came in the night before. V27 stated she also worked 1/10/2022 on the evening shift, and then worked another double shift on 1/11/2022 (mornings and evenings) and was unaware R168 was Covid positive the whole time. V27 stated she did not know R168 was Covid positive until around noon on 1/12/2022, and she had only been wearing an N95 and a face shield when she was around R168 the previous three days. V27 stated she did not wear a gown or gloves when she gave R168 her medications. V27 stated if nurses find out that a resident has tested positive for Covid-19, they should immediately notify the Infectious Disease Physician, the Director of Nursing, and the resident's Power of Attorney. V27 stated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V27 stated that Isolation carts, PPE, and Isolation signs are in the Central Supply room. V27 described where the Central Supply room key was located on the first floor, stated she would place Isolation signs and supplies outside the resident's room, and would notify her staff that are caring for the resident. On 1/16/2022 at 10:20 AM, V33 (RN) stated she worked the night shift on Sunday, 1/09/2022. V33 stated she did not receive anything in report that R168 tested positive for Covid. V33 stated there was no Isolation cart with PPE or signs on her door to notify staff of R168's Isolation needs. V33 stated she was in R168's room every two hours for pain assessments wearing an N95 mask and face shield, and she had not worn gloves or an isolation gown. On 1/16/2022 at 12:17 PM, V37 (Agency LPN) stated she worked on 1/10/2022 and 1/11/2022 and gave R168 her medications. V37 stated if there was no Isolation cart outside a resident's room and there were no signs, then she would not think the resident required Isolation precautions. V37 stated she probably just walked into R168's room with only an N95 and face shield on. V37 stated she does not know where the Isolation carts and signs are at the facility, and never had any facility training on what steps to take when someone tests positive for Covid-19. V37 stated she would call the Physician and set up an Isolation kit. On 1/14/2022 at 1:34 PM, V29 (Agency CNA) stated she has never received training from the facility on what staff should do if a resident tested positive for Covid-19. At 1:45 PM, V30 (Agency CNA) stated this nursing home has never told us anything about what to do when someone becomes Covid positive. I just got some training from our Agency. V30 continued If someone is Covid positive, you need to isolate that resident, put signs on the door, and use full PPE like gowns, gloves, face shield, and N95. You need to also set up the isolation cart in front of the resident's room. On 1/19/2022 at 9:36 AM, V39 (Infectious Disease Nurse Practitioner) stated she has worked for a year and a half at the facility under the guidance of V38 (Infectious Disease Physician). V39 stated when a nurse learns that a resident tested positive for Covid-19, the nurse should notify them so there are orders for isolation. V39 stated she expected the nurse to put isolation signs on the resident's door and an isolation cart with PPE outside the Covid-19 positive resident's room. V39 stated the nurse should notify the resident, family/Power of Attorney, floor manager, CNAs, and other staff of the resident's Covid result. V39 stated that if staff do not post isolation signs and set up an isolation cart outside a Covid positive resident's room, then staff will not be reminded to wear the proper PPE, which includes an N95 face mask, face shield, isolation gown, and gloves. V39 stated with staff who worked with R168 and did not use the full PPE, there is a possibility they could spread Covid to other residents and other parts of the building, especially if staff members work in different parts of the building. V39 stated if R168 tested positive on 1/8/2022 and was not put in isolation for four days, then it is bad because the risk of transmission is high, and it could spread throughout areas where the potentially infected staff member traveled. On 11/19/22 at 11:35AM, V3 (Infection Preventionist) stated her expectation is that when a nurse receives a positive Covid-19 test result, the nurse needs to notify her and V2 (Director of Nursing), the Physician, resident, family/Power of Attorney, and the rest of the staff. V3 stated the nurse has to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated when she came in on Tuesday (1/11/22), she became aware that R168 tested positive for Covid-19. V3 stated she did not know that the nurse on 1/8/22 failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated the floor nurse has the responsibility to act on positive Covid test results on the weekends. V3 stated if staff were not wearing full PPE for four days in [R168's] room, then there is a potential for someone to get infected with Covid and a possibility of a facility wide infection, depending on who they come in contact with and where they are traveling or working in the facility. V3 again stated when going to a Covid19 resident's room, you have to be in full gear, which means you need to wear N95 face mask, face shield, gloves, and gown. On 1/19/22 at 11:45am, V40 (Medical Director) stated he could not recall exactly when he was notified that R168 tested positive for Covid-19. V40 stated when a nurse finds about a resident's positive Covid status, his expectation is that he/she notifies him or the Infection Preventionist. V40 stated that signs should be posted and a PPE cart should be set up. V40 stated he did not know what happened in this case. V40 stated if someone goes to R168's room without proper PPE, then they could potentially spread it, adding it all depends on several factors-how far away was the staff member from the Covid positive resident . Was it less than 6 feet . Was the staff member vaccinated . Did they have Delta or Omicron variant V40 stated the risk is low to transmit Covid-19 to residents who have tested positive in the last 90 days because they already build up antibodies, adding but if they have different variants, then they could possibly transmit the infection. On 1/19/2022 at 1:42 PM, V38 (Infectious Disease Physician) stated Yes, they dropped the ball . they should have put [R168] in isolation . Under GUIDELINES in the facility's Covid-19 Policy/Procedure (revised 10/21/2021), it showed a Core Principle of COVID-19 Infection Prevention as Infection prevention and control education and competency. Section 6 under GUIDELINES showed Universal PPE for HCP [Health Care Practitioners] a. HCP will wear N95 respirator, eye protection, gown, and gloves if a resident is suspected or confirmed to have COVID-19 Table 6 under 20. Management of Residents-Updated showed Residents with Confirmed Covid-19 Transmission-based precautions: Isolate: Contact and Droplet Transmission-based precautions (TBP) . Monitoring: Every 4 hours PPE: N95, respirator, gown, gloves, eye protection . The Centers for Disease Control and Prevention (CDC) website guidance entitled Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/2021), showed 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection . Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) -------------------------- The Immediate Jeopardy that began on 1/08/2022 was removed on 1/21/2022 when the facility took the following actions to remove the immediacy: 1. V26 (LPN) was disciplined and all licensed staff were re-inserviced on the proper protocol on what to do when they receive a positive Covid test result for a resident. 2. A QAPI meeting was conducted on 1/20/22 to discuss Infection Control and the F880 IJ Abatement plan with V40 (Medical Director) and all department heads. 3. New work tasks were implemented for V3 (ADON/Infection Preventionist) and the Nurse Manager on Duty where they will be assigned specific days and shifts (including the weekend) to monitor and check all lab results 7 days/week to ensure the physician, POA/family, DON, ADON, and/or Manager on Duty are aware. Nurse will obtain a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All nurses were re-educated that they must document what was completed in their progress notes. Isolation signs will be posted for both Contact and Droplet Precautions on all Covid positive residents' rooms and in the front entrance of the Covid Unit. Isolation kits will be set up. 4. Staff was educated that the location of the key to the Central Supply Room is in the first floor medication room, and if PPE not available, staff are to go to the Central Supply Room in the basement and obtain PPE from there. 5. A list of residents testing positive for Covid19 is in a binder in the first floor nursing station. This is checked by the supervisor or manager on duty every day and updated. 6. Audits were conducted on all newly diagnosed Covid positive residents to ensure orders and equipment were in place according to their Infection Control Policy and CDC guidelines. -------------------------------------------------------------------------------------------------------------- B. Based on observation, interview, and record review, the facility failed to sanitize glucometers in a manner to decrease cross-contamination. This applies to 1 resident (R167) reviewed for glucometer use. The findings include: On January 12, 2022 at 9:06 AM, V11 Agency RN (Registered Nurse) went into R167's room. V11 checked R167's blood glucose using the facility's glucometer. V11 brought the glucometer and placed in the top drawer of medication cart and sanitized his hands. V11 failed to sanitize the glucometer after use. When questioned, V11 said he disinfected the glucometer prior to using it, but did not disinfect it after use. V11 said he should have used the disinfecting wipes to clean the glucometer after use. On January 12, 2022 at 2:03 PM, V2 DON (Director of Nursing) said, the nurse should use bleach wipes to disinfect the glucometers and let it air dry after each use. Manufacturer's guidelines documents, wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for 30 seconds for bacteria, 1 minute for viruses, 3 minutes for blood born pathogens, parovoviruses, fungi. Let it air dry. The facility's policy titled Cleaning and Disinfecting of Resident-Care Items and Equipment (November 2021) under Procedure states: 1. d. Reusable items are cleaned and disinfected or sterilized between residents (stethoscope, durable medical equipment). 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.

Based on interview and record review the facility failed to provide supervision in the Memory Care dining room for 1 confused resident with a history of falls known to have impulsive behavior. This failure affected 1 resident (R193) out of 7 reviewed for falls out of a sample of 35. This failure resulted in a fall ,after R193 was left alone in the dining room, resulting in a fractured right hip. Findings include: R193 is an [AGE] year old female originally admitted to the facility 6/30/17 with numerous [DIAGNOSES REDACTED]. R193 resides in the locked memory care unit. Incident report for R193 dated 3/13/18 timed at 6:00 AM documents that R193 was observed in the dining room lying on the floor on her back. She complained of pain to her right hip and limited range of motion was noted. Post Fall Report of the same date documents that R193 sustained a fractured right hip as a result of this fall. Page 1 of the incident report contains a section which reads, Initial intervention to prevent recurrence. The handwritten response to this query reads, place in area with increased staff supervision, Page 1 of the Post fall report indicates the following regarding R193 and her fall: fall was unwitnessed; attempting self-transfer; last observed at 5:50 AM and last toileted at 5:45 AM; when last observed she had been sitting in a chair. R193 was described as impulsive requiring assistance but not asking for assistance. She was described as alert, oriented to person, confused and forgetful. At time of fall, post fall report form indicates R193 was alone/unattended. At 11:45 AM on 10/30/18, V24 (Fall Coordinator) stated that as fall coordinator, part of her role is to monitor the residents who fall and make sure their care plans get updated after a fall. She looks into the circumstances of the fall to try to determine the cause. With regard to the fall for R193 in March, she recalled that the CNA observed R193 trying to get out of bed early in the morning. The CNA toileted R193. Because R193 had a history of [REDACTED]. The CNA then took R193 to the dining room. The CNA told R193 she would be back. CNA left to get another resident up. A few minutes later, the CNA heard the alarm sounding and went to investigate. She found R193 on the floor in the dining room. She is aware residents are to be supervised in the dining room The night nurse was not in the unit at the time. The night nurse was covering both the memory care unit and the unit outside of the memory care unit, which is the remainder of the third floor. On 10/31/18 at 12:30 PM, V19 (CNA) stated that she recalled the incident back in (MONTH) with R193. She recalled R193 was trying to get out of bed around 5:30 AM. V19 was doing rounds and heard R193's alarm. She went to check on R193. V19 found V1936 still in bed but trying to get up. V19 got R193 up and toileted. After dressing R193, V19 took her to the dining room. V19 stated that she didn't want to leave R193 alone in her room since she was known to try to get out of bed. V19 placed her in the dining room and continued doing rounds. V19 can't recall who, if anyone, was in the dining room. At that point in time, on the night shift, the usual staffing was either 1 or 2 CNAs (certified nursing assistants) in the alzheimer's unit and 3 outside of the unit on third floor. That night there had been a call off for the Memory Care Unit leaving V19 as the only CNA. Help would come from the CNAs outside the memory unit if needed. While doing rounds V19 heard R193's alarm and went to check on her in the dining room. She found R193 on the floor next to her wheel chair. At the time, the nurse was outside of the unit, proiding coverage on the rest of the 3rd floor. R193 was awake and talking. V19 went and called the nurse who came to assess R193. R193 couldn't stand and the ambulance was called. On 10/31/18 at 12:35 PM, V20 (RN), stated that she vaguely recalls the incident back in (MONTH) with R193. V20 recalled the fall happening at the end of the night shift,. At that time, she was covering both the memory care unit and 3rd floor which is outside the memory care unit. Currently the nursing supervisor helps cover the units, but there was no nursing supervisor that night. V20 stated she was pretty sure she was outside the unit when the CNA came to get her to tell her that R193 fell . She did not witness the fall. She went in to the unit to assess R193. She thinks the resident was sitting on the floor. R193 was awake and talking. she can't recall if they got her up. On 10/31/18 at 10:25 AM, V26 (scheduler) stated that there was a time when the night nurse assigned to the Memory Care unit would also cover the third floor unit outside the memory care unit. After reviewing the schedule for the night shift for 3/12/18, V20 stated that V25 would have been the CNA who would have helped out on the memory care unit. On 10/31/18 at 4:10 PM, V25 (CNA) stated that she didn't recall an incident with a resident falling in the memory care dining room. V25 denied being present or witnessing any resident fall in the Memory care dining room in March. V25 has been assigned in the past to the outside unit and been asked to assist in the memory care unit because of a call in. When a CNA from the Memory Care unit calls in, one of the outside CNAs go in to help out but that person does not remain in the unit; she floats between the 2 units. Sometime the nurse would cover both third floor units. On 11/1/18 at 11:00 AM, V21 (LPN) stated that she recalled the morning that R193 fell , although she did not witness it. V21 stated she worked days that day, and started work at 6:00 AM. When she was just arriving to the unit, she saw the night nurse also outside of the unit. As soon as V21 entered the memory care unit V19 told her that R193 had fallen and was on the floor. V21 stated that both she and the night nurse assessed R193. On 11/1/18 at 10:30 AM V2 (Assistant Administrator) stated that the facility does not have a formal policy on supervision in the dining room, but stated that their practice is to assign staff to the dining room on a rotating basis. There is to be supervision when residents are in the dining room at all times. On 11/1/18 at 12:15 PM, V22 (Nurse Practitioner) for R193 stated she recalled being called when R193 fell . The staff told her that it was obvious she had a fracture, so she ordered R193 to be evaluated at the hospital. V22 stated she believes the facility's policy is to provide supervision in the dining room and thinks that the facility should follow their policy. On 11/1/18 AT 12:35 V23 (MD for R193) stated that he does follow R193 and saw her about a month ago. He does recall that R193 sustained a [MEDICAL CONDITION] as a result of her fall. The type of fracture she had is consistent with a fall. R193's fall care plan created on 7/12/17 indicates she is at high risk for falls and indicates that R193 has poor safety awareness. Nursing notes of 3/13/18 timed at 6:00 AM states Found on floor by CNA in dining (room) in front of w/c (wheel chair). Chair alarm in use. W/C unlocked. Resident was unsupervised at time of fall . R193's BIMS score (Brief Interview for Mental Status) dated 3/26/18 indicates R193 has a score of 3, reflecting severe cognitive impairment.

Based on interview and record review, the facility failed to ensure staff properly cared for a resident with severe contractures. This failure resulted in R1's sustaining a acute, severely anterolaterally displaced, [MEDICAL CONDITION] proximal left femur. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origins in a sample of 3. This applies to: Face sheet, dated (MONTH) 21, (YEAR), shows R1's [DIAGNOSES REDACTED]. MDS, dated (MONTH) 17, (YEAR), shows R1 was moderately cognitively impaired. PT (Physical Therapy) Plan of Care, dated (MONTH) 8, (YEAR), shows R1 was non-ambulatory, required total assistance from staff for all ADLs and mobility, used a mechanical lift for transfers, and required pillows to position R1's BLE (Bilateral Lower Extremity) due to contractures. The note shows R1 was referred to therapy per family request to re-assess R1's contractures. PT evaluation revealed severe multiple contractures of BLE joints as well as UE (Upper Extremity) joints, increased muscle tone, impaired muscle strength, decreased cognition and impaired sitting balance/trunk control which affects all ADLs (Activities of Daily Living)/mobility and sitting/bed positioning. Patient is at high risk for falls, developing further skin breakdown and joint contractures Skilled PT is medically necessary on a trial basis to address above stated problems, focusing on contracture management, proper positioning, with appropriate positioning devices and caregiver training to prevent further skin breakdown and joint tightness/contractures. PT progress note, dated (MONTH) 23, (YEAR), shows Caregiver education/training initiated with nursing staff focusing on the use of pillows to properly position patient in and in (high) chair focusing on pressure relief between BLE, preventing skin to skin contact, and maintaining current available range on BLE The note shows R1 had .severe tone on BLE and multiple joint contractures Facility inservice sign in sheet, dated (MONTH) 21, (YEAR), shows V10 (Physical Therapist) provided education to five nurses, two restorative staff, and one CNA on proper positioning for R1 using pillows only when in bed and (high) chair. The summary of topic presented shows, Pillows need to be placed between knees/legs to prevent skin-to-skin contact Nursing note written by V8 (LPN - Licensed Practical Nurse), dated (MONTH) 23, (YEAR) at 9:17 AM, shows, Called to room because CNA (Certified Nursing Assistant) noticed when he removed blanket that the resident's left leg was in a different position than usual. Upon evaluation no swelling, redness or tenderness to touch. Resident showed no signs of pain but when asked stated he had pain but unable to rate. V/S (vital signs) WNL (within normal limits). MD (Medical Doctor) prescribed pain medication given and paged NP (Nurse Practitioner). POS (Physician order [REDACTED]. POS, dated (MONTH) 23, (YEAR), shows R1 was sent to the emergency room for further evaluation. Radiology Report, dated (MONTH) 23, (YEAR), shows R1 had mild osteopenia, and acute [MEDICAL CONDITION] proximal left femur. The fracture is severely anterolaterally. Mild DJD ([MEDICAL CONDITION] joint disease) of both knees and ankles On (MONTH) 27, (YEAR) at 3:15 PM, V4 (LPN) stated she worked on (MONTH) 22, (YEAR) from 6:00 AM-10:00 PM with R1. V4 stated the last time she saw R1 was at approximately 9:00 PM and R1's legs were in his usual, contracted position which was R1's left leg crisscrossed over R1's right leg. V4 stated R1 had a pillow between his legs and his pants were off. V4 stated V5 (Agency CNA) came into the room to change R1's brief and V4 exited the room. V4 stated R1 was showing no signs of distress during her shift. On (MONTH) 27, (YEAR) at 10:00 AM, V5 stated he worked on (MONTH) 22, (YEAR) from 2:00-10:00 PM with R1. V5 stated he had worked with R1 before and knew he needed to move R1's legs carefully. V5 stated he removed R1's pants to get R1 ready for bed prior to V4 coming in the room. V5 stated he changed R1's incontinence brief after V4 left the room, placed a pillow between R1's legs, did not replace R1's pants, and then covered R1 with a blanket for the night. V5 stated when V5 last saw R1 at approximately 9:45 PM, R1's legs were still in his usual, crisscrossed position and R1 had the blanket over his legs. V5 stated he remained in the facility until approximately 10:30 PM to complete charting. At 2:15 PM, V5 stated he very carefully placed the pillow between R1's legs. V5 stated he did not attend the PT inservice on (MONTH) 21, (YEAR) regarding R1's positioning, nor did he receive any verbal or written information regarding the information presented at the inservice. On (MONTH) 27, (YEAR) at 12:50 PM, V6 (RN - Registered Nurse), stated she worked on (MONTH) 22-23, (YEAR) from 10:00 PM - 6:00 AM with R1. V6 stated when she arrived for her shift R1 had a blanked over R1's legs, had a pillow between his legs, and R1 was sleeping. V6 stated she was new to the floor and had not worked with R1 before. V6 stated she performed rounds every two hours on her residents and did not notice R1 in distress. V6 stated she had a bit of a conversation with R1 at 6:00 AM when she performed a vitals check and R1 did not complain of any pain. V6 stated she got no report regarding R1 from V7 (CNA). V6 stated she never moved R1 on her shift. On (MONTH) 27, (YEAR) at 2:49 PM, V7 (CNA) stated he worked on (MONTH) 22-23, (YEAR) from 10:00 PM - 6:00 AM with R1. V7 stated he first saw R1 at approximately 10:45 -11:00 PM and R1 was asleep, was not covered with a sheet, and there was a pillow between R1's legs. V7 stated usually R1's legs are crisscrossed, however V7 stated at that time R1's legs were unusually uncrossed and both R1's right and left knees were facing the same direction toward the door. V7 stated this position was not normal for R1 and that V7 had never seen R1's legs like that before. V7 stated the position was unusual to me but R1 was not showing any discomfort or pain. V7 stated he thought the previous shift would have noticed R1's legs unusually positioned so V7 thought he did not have to report the change. V7 stated he readjusted R1's position at 1:30 AM, checked R1's brief, and R1 expressed no signs of discomfort. V7 stated the last time he saw R1 was at 4:30 AM when he checked R1's incontinence brief. On (MONTH) 27, (YEAR) at 3:00 PM, V7 stated he did not attend the PT inservice on (MONTH) 21, (YEAR) regarding R1's positioning, nor did he receive any verbal or written information regarding the information presented at the inservice. On (MONTH) 27, (YEAR) at 1:50 PM, V9 (CNA) stated he worked on (MONTH) 23, (YEAR) from 6:00 AM-2:00 PM with R1. V9 stated he went to R1 after the wound nurse completed assisting R1 to perform ADL care. V9 stated R1 had debris on his face and V9 wiped R1's face. V9 stated he then pulled R1's sheet back and was shocked. V9 stated R1's legs were uncrossed which was abnormal. V9 stated he called V8 (LPN) immediately. V9 stated he did not get any report from the previous shift regarding anything unusual regarding R1. V9 stated R1 had no signs of pain or discomfort. V9 stated R1 could normally verbalize if he was in pain. On (MONTH) 27, (YEAR) at 12:58 PM, V8 stated she worked (MONTH) 23, (YEAR) from 6:00 AM -2:00 PM with R1. V8 stated she performed rounds at the beginning of her shift and R1 was awake but showed no signs of distress. V8 stated she did not pull R1's cover down and did not see R1's legs. V8 stated the next time she saw R1 was when V9 alerted her that R1's legs were unusual and uncrossed. V8 stated she assessed R1 and when she touched R1's hip, R1 stated the hip hurt. V8 stated she called R1's nurse practitioner right away, and X-ray was ordered, and R1 was sent to the emergency room before the results were received because R1's pain was not resolving. On (MONTH) 27, (YEAR) at 3:10 PM, V11 (Wound Nurse-RN) stated she performed wound treatment on R1 at approximately 5:40 AM on (MONTH) 23, (YEAR). V11 stated she did not remove R1's sheets and V11 did not see R1's legs. V11 stated she did reposition R1 however R1 showed no signs of distress during the repositioning. V11 stated she noticed nothing unusual regarding R1. On (MONTH) 28, (YEAR) at 9:30 AM, V10 stated she performed physical therapy on R1 and provided training to the staff regarding R1's positioning and use of pillows between his legs. V10 stated R1 had had contractures for some time and had severe tone. V10 stated his tone in his legs varied between relaxed (R1's left calf was crossed over R1's right thigh), to increased tone when R1 would become more contracted. V10 stated during the staff training she instructed the staff how to safely and correctly place the pillow between R1's legs - including telling R1 to relax his legs, instructing staff not to push R1's legs, and how to gently place the pillow between R1's legs where the legs meet. V10 stated the staff who attended the training were expected to endorse the information to the following shifts' staff. V10 stated if R1's contracted legs were forced to straighten, the force would cause a fracture or dislocation. On (MONTH) 28, (YEAR) at 1:31 PM, V12 (Physician) stated he saw R1 on (MONTH) 23, (YEAR) at the facility prior to leaving for the emergency room . V12 stated R1's legs looked not usual and R1 was showing no signs of trauma other than the unusually positioned lower extremities. V12 read the X-ray report he obtained from the hospital and stated R1 had a severely displaced fracture. V12 stated the new intervention the facility was providing was training for use of the pillow between R1's legs. V12 stated, If a someone is all contracted and forces a pillow, then you are opening with a force. V12 stated nothing other than a force caused R1's fracture. V12 stated the [DIAGNOSES REDACTED]. V12 also stated turning/repositioning would not have caused R1's fracture. V12 stated, It's an oblique fracture, not straight - something is pulling . someone is trying to separate the knees with force.

Based on record review and interview the facility failed to ensure proper transfer technique for a resident who is totally dependent for transfer and requiring assistance of two staff. This incident resulted in the resident sustaining laceration to the right leg which required thirteen staples. This applies to 1 of 3 residents (R4) reviewed for incident with injuries in the sample of 13 residents. The findings include: R4 is an [AGE] year old who has multiple medical [DIAGNOSES REDACTED]. Incident report and progress notes dated 1/27/18 showed: R4 was being assisted by V11(CNA-Certified Nurse Aide) to bed, as R4 was approaching the bed R4's knees buckled causing R4's right lateral leg to hit the side rail/frame of the bed. The incident resulted to a laceration in the right lateral leg which measured as Length (L) 8.0 centimeter (cm) x Width (W) 2.0 cm x Depth (D) 0.5 cm. R4 was sent to the hospital for further evaluation and returned from the hospital with 13 staples in the right lateral leg. On 2/28/18 at 10:17 AM, V11 (Certified Nursing Assistant/CNA) gave the following statement: R1 was sitting in her wheelchair when she requested to go back to bed. V11 assisted R4 to get up and as R4 was getting up, R4 leaned forward, then swayed unsteadily to her right side. R4's knees buckled which resulted to R4's right leg hitting the bottom of the side rail of the bed which cut her skin. V11 checked R4's care card prior to assisting R4's transfer. There were two instructions in the care card; one with use of a mechanical lift. The other instruction was one staff assistance with one staff on standby, with the former crossed with a pen. V11 assumed that since the one with mechanical lift was penned across, she used the one staff assistance with a standby. There was another CNA staff on standby at the time of the incident. On 2/28/18 at 1:07 PM V13 (Nurse Practitioner/Health Provider) gave the following statement: R4 has a [DIAGNOSES REDACTED]. Incident could have been prevented if the staff used mechanical lift for transfer. R4 would not have been caught in the bed frame and would have been transferred safely on top of the bed. On 2/28/18 at 1:35 PM V15 (Nurse) stated, R4's laceration had a slight bleeding at the time of the incident. There was more fluid secretion related to R4's [MEDICAL CONDITION]. The wound was open and showed the layers of the skin, tissues and fats. V15 provided the first aid treatment and sent R4 to the hospital for further evaluation. V15 received the report from the hospital the facility that R4 was heading back to the facility with 13 staples to her wound. Facility's Transfer Protocol dated 7/22/15 showed: Policy: It is the policy of the facility to attempt to protect both its residents and employees from injury in the course of transferring residents. Procedure: - The transfer technique that is appropriate for each resident will be listed on the Special Care Needs Sheet and posted on the inside door of the resident's wardrobe. - No resident is to be transferred without first verifying the transfer technique assigned to that resident to know what type of transfer is required by that resident on that day.

Based on observation, interview and record review the facility failed to identify, treat and notify the physician of a facility acquired wound. This failure affects one resident (R2) of three residents reviewed for wounds and resulted in R2 acquiring one Stage 3 buttock pressure ulcer with surrounding Deep Tissue Injury and one Stage 3 gluteal fold wound. The facility also failed to implement interventions, preventative measures and initiate a skin impairment care plan for one resident (R4) of three residents reviewed for wounds. Findings include: physician's orders [REDACTED]. POS dated 1/19/18 indicates to discontinue [MEDICATION NAME] and foam dressing and start Phytoplex Z-Guard (hydrating skin cream) to peri-area and buttocks daily. Nurse Progress Notes dated 1/26/18 at 3:35pm indicates R2 has an open area on her left buttock due to MASD (Moisture Associated Skin Damage). POS dated 1/26/18 indicates orders received to Apply [MEDICATION NAME] (moisture barrier cream) to left buttock daily and as needed. POS dated 1/31/18 indicates Apply [MEDICATION NAME] Cream Daily and as needed to buttocks. No other nursing progress notes, assessments, monitoring or tracking of this open area identified on 1/26/18 were found or provided. On 2/7/18 at 1:45pm R2 was observed in bed. V8, CNA (Certified Nurse Assistant) stated that she was R2's assigned CNA for the day but did not actually see R2's skin because Hospice Aide took care of R2 on that day. V8 stated that R2 was already up in her chair when she started her shift at 6am. V8 stated the Hospice Aide told her and V9, LPN that R2 had open areas on her buttocks and that V9 put cream on R2's wounds. At that time R2 was noted to have an oval-shaped ulcerated open wound with scattered slough throughout the wound bed on left inner buttock. Wound noted with dark red/purple non-blanchable discoloration surrounding entire ulceration. Right inner buttock was noted with crescent-shaped, non-blanchable light purple/red discoloration directly opposite left buttock wound. Right gluteal fold was noted with irregular-shaped open area/wound bed covered with approximately 75% slough and reddened edges. R2's wounds were again observed on 2/8/18 with V6, Wound Care/LPN (Licensed Practical Nurse) and V10, RN (Registered Nurse/Wound Care Nurse). At that time V6 stated that the wound on R2's left buttock was a Stage 3 and the wound on right gluteal fold was caused from the elastic from the incontinent brief constricting on the skin and due to moisture. V6 stated That's why (R2) shouldn't have diapers on, shouldn't be sitting up for more than 2 hours and shouldn't be on the early get up list. On 2/8/18 at 1:30pm V9, LPN (Licensed Practical Nurse) stated that (on 1/7/18) she was told about R2's open areas by R2's Hospice Aide. V9 stated that she checked the treatment book, saw a treatment and applied it to R2's open areas. V9 stated that she later talked with V6, Wound Care Nurse about R2's wounds because I really thought maybe something else should be put on them (besides [MEDICATION NAME]). V9 stated that V6 told her they were not new wounds and that she had seen them earlier that day. On 2/8/18 at 1:50pm V10, RN stated that she initially found the area on R2's left buttock (on 1/26/18) and that it was superficially open; Not like now. V10 agreed that the wound found on 1/26/18 and the left buttock wound were in the same location. V10 stated she does not know how the wound on R2's right gluteal fold was not noticed. V10 stated that nurses and CNA's should be looking at R2's skin everyday and report any new wounds or changes. No assessments of wounds, physician notification or treatments were initiated despite Hospice Aide notifying V9, LPN and who discussed R2's wounds with V6, Wound Care Nurse on 2/7/18. No care plan was initiated on 1/26/18 or anytime after for left buttock skin impairment. On 2/8/18 at 10:50am V6, LPN/Wound Care Nurse stated that when there is a new wound or if a wound changes the care plan should be initiated or revised immediately. Wound Assessment Details Report dated 2/8/18 at 12:09pm indicates: Facility Acquired right gluteal Stage 3 pressure ulceration (identified on 2/8/18) 75% slough; light serous exudate and [DIAGNOSES REDACTED] (red) surrounding wound. Facility Acquired left buttock wound identified on 1/26/18; partial thickness wound 50% pink/red, 40% slough. Skin/Wound Note dated 2/8/18 at 12:27pm indicates open area noted to (R2) left buttock Stage 3 pressure area due to incontinence of bowel/bladder and right gluteal due to mechanical force of diaper irritation. On 2/8/18 at 1:30pm V6, LPN stated that both wounds were classified as Stage 3 and only pressure wounds can be staged. On 2/8/18 at 2:37pm V5, Wound Care Physician stated Really all wounds are avoidable. 2) Nursing Admission assessment dated [DATE] indicates R4 was admitted with no skin issues. Skin Observation Report dated 5/21/17 indicates no sacral skin impairments. Nurse Note dated 7/5/17 at 11:45am indicates open area to buttocks, was reddened over the weekend and opened up on Tuesday (7/4/17). Note indicates wound consult ordered and seen by V5, Wound Physician on that date with new treatment initiated. Skin/Wound Problem: Irritation - Weekly Progress Report dated 7/4/17 indicates redness to buttocks due to incontinence, barrier cream applied. Report dated 7/12/17 indicates redness to buttocks, cream applied and staff to continue monitoring. Report does not indicate size/extent, response to treatment, preventative measures or reason incontinence is cause of irritation since R4 required an indwelling urinary catheter during stay at faciliy from 5/16/17 to 7/14/17. No Care Plan for skin impairment was found or presented. On 2/21/18 at 1:45pm V6, Wound Care Nurse stated that she was new to Wound Care when R4 developed his wound and was unfamiliar with documenting wound specifics. V6 stated that the buttock irritation came from stool incontinence - either frequent stools or stool left in contact with the skin too long. V6 stated she did not do care plans at that time and wasn't really sure who did them. On 2/21/18 at 10:25am V18, Care Plan Coordinator stated that until approximately (MONTH) (YEAR), Wound Treatment team was doing own care plans - preventative and active skin problems. Physician Wound Care note dated 7/5/17 indicates nursing reported R4 with sacral ulcer and area opening on Tuesday (7/4/17). Note indicates Irritation of buttocks - sacrum closed, ischium closed. On 2/21/18 at 11:00am V5, Wound Care Physician stated that R4 had irritation from scooting or shearing on the buttocks. V5 stated not sure where moisture would be coming from if R4 had an (indwelling) catheter. V5 stated that the only time she saw R4 was on 7/5/17 and anything can happen in 10 days (referring to allegation of Stage 3 pressure ulcer on 7/14/17). Facility Policy Pressure Sores dated/revised 10/2010 indicates: 4. Wound Care nurses will perform weekly skin assessments and will document their assessment on the reverse side of Treatment Administration Record. 5. CNA will report to nurse if any skin issues or skin breakdown are noted during routine care, showers. 6. Interdisciplinary Team will develop a comprehensive plan of care based on assessments and clinical condition of the resident. 10. Skin abnormalities such as skin tears, abrasions or other minor skin issues noted when providing routine care will be addressed and interventions done immediately using clinical standards of nursing practice.

Based on observation, interview and record review the facility failed to use the required number of staff and the required device to reposition residents. This applies to 1(R1) of 4 residents reviewed for injuries of unknown origin/reportable events. As a result of these failures R1 sustained a right arm fracture and can no longer use the right arm for activity of daily living skills. The Findings Include: On August 3, 2017 at 9:39 AM, R1 was sitting in an adult reclining chair in the dining room with a mesh sling on the right arm, restraining the right arm close to the body. E9(Certified Nursing Assistant, CNA) brought R1 to a private area and interpreted Spanish for R1. R1 said he was good but did not respond to what happened to his right arm. On August 3, 2017 at 1:04 PM, E10(CNA, Certified Nursing Assistant) and E11(Restorative Aide) repositioned R1 from the adult recliner to the bed using a mechanical lifting device. E10 and E11 provided a pillow for R1' right arm to rest upon after R1 was placed into bed. R1's right arm had a mesh black sling, restraining the right arm close to the body and a 2 by 2 dressing to the lower forearm underneath the mesh sling. Minimum Data Set, dated dated dated [DATE] states: R1 is totally dependent on staff with 2 plus persons to assist with transfers from the bed, chair, wheelchair and standing. The bathing section was coded: extensive assist with 2 persons. Resident Transfer Protocol Policy last reviewed July 22, 2015 states, All residents will be assigned a transfer technique that identifies the kind of transfer that is appropriate for their individual needs according to the following: Total mechanical lift (2 person assist). The policy states that staff should be aware of the assigned transfer technique and follow it. The policy states that employees that do not follow the protocol will be subject to immediate termination whether or not the transfer resulted in an injury to the resident. Restorative Care Plan dated August 2,2017 states, Bathing: R1 requires extensive assistance of 2 people with bathing. Transfer: R1 requires total assistance of 2 people using a mechanical lifting device for transfers. Nursing Progress Note dated July 29, 2017 at 10:35 AM: Received R1 in adult recliner sitting at the nursing station with a blanket on him. After R1 received his shower, I went to the shower room to assess his body and noticed a skin tear with fresh blood to the right elbow 2 cm and a fresh greenish bruise that is warm to touch. CNA stated the skin tear happened when she removed the mechanical lifts' sling from underneath his body. CNA stated she noticed the bruise when she removed R1's shirt. Paged medical doctor and received a Stat order for an x- ray of R1's right arm. Notified family. X- ray completed, awaiting results. Endorsed to PM nurse to follow up with x- ray results. July 29, 2017 at 6:30 PM: Received x- ray results; right fracture of the neck of humerus, medical doctor paged and gave orders to put fractured arm into a sling, no weight bearing and schedule an orthopedic appointment next week. Vitals signs are: blood pressure( 150/88), pulse (76), respirations( 19) and oxygen saturation (96%). Family and Director of Nursing informed. Scheduled Tramadol administered and well tolerated, all orders carried out. July 29, 2017 at 7:30 PM: R1's arm is swollen and residents vitals are: blood pressure (177/98), respirations (20), Pulse (76), temperature (98.6) , oxygen saturation ( 95%), medical doctor paged and ordered R1 to be sent out to the hospital for further management. Family and Director of Nursing aware of R1's transfer to the hospital. At 8:35 PM, Paramedics arrive and R1 is transferred to the hospital. July 30, 2017 at 12 PM, R1 was admitted to the hospital with [REDACTED]. On August 3, 2017 at 10:40 AM, E3(Interim Director of Nursing, Nurse Consultant/ DON) said the investigation for R1's right arm fracture (injury of unknown origin) is still on-going. E3 said so far a CNA has been suspended for improper transfer which was discovered during an interview with other staff. E4(CNA) transferred R1 from the bed to the chair by picking R1 up with E4's hands without a mechanical lifting device. E3 said R1, at one point ,said he fell during the process of being transferred by E4 but did not re-state it again. On August 3, 2017 at 11:11 AM, E4 said via telephone interview that he worked with R1 on the night of July 29, 2017. E4 said he got R1 up using my hands from the bed and put R1 into the adult recliner because we were short of slings. E4 said this was 4:30 AM and then he placed R1 at the nursing station. E4 said it was an error to transfer R1 without the mechanical lifting device and without 2 staff. E4 said he transferred R1 one other time the same way and R1 was fine and that he is aware that R1 has sensitive skin. E4 said if there was a problem with the transfer R1 would have complained on the day shift. E4 said he went home on the day shift and returned to work the evening shift and R1 was in bed and we were waiting on x- ray results. Something must have happened to R1 during the shower. On August 3, 2017 at 12:07 PM, via telephone, E6(CNA) said R1 was in the dining room at 6 AM. E6 said she assisted R1 to eat. E6 said she noticed that R1 was holding the cup with his left arm and guarding the right arm. This was unusual. After R1 ate, E6 said she took R1 to get a shower and upon taking off R1's shirt , R1 complained of pain and continued to guard the right arm. E6 said she noticed that R1 did not have a sling underneath and R1 requires a mechanical lift. E6 said she went to R1's room and got the sling out of the closet and returned to transfer R1, using the sling and the mechanical lifting device alone. E6 said we are not supposed to transfer residents with a lifting device alone, but I could not find anyone to help me. During the rolling process of R1, he got a skin tear. E6 said when R1 had all clothing off she noticed a bruise, but continued the shower and notified the nurse after the shower was complete. E6 said the nurse came in and said that is a fresh bruise, the arm may be broken we will get an x- ray. On August 3, 2017 at 11:27 AM, E8(Nurse) said she came in after E6 had given R1 a shower and saw the right arm bleeding. skin tear and a bruise on the right arm noticed. E8 said E6 told me that R1 was guarding the arm before the shower was given and that the skin tear happened upon placing the sling underneath R1 for transfer. E8 said the bruise was fresh and R1 is a dependent resident who requires assistance with everything. E8 said she notified the doctor and the doctor ordered an x- ray. E8 said E6 should have notified me prior to giving R1 a shower about the guarding the right arm and pain. On August 3, 2017 at 11:40 AM, E5(Nurse) said on July 29, 2017 she worked that afternoon and R1 had an x- ray. E5 said the results came back and it read fractured right humerus, the doctor was notified. E5 said swelling continued and R1 was sent out to the emergency room for further management. On August 3, 2017 at 12:08 PM, E7(CNA) said R1 was fine the evening before the fracture. E7 said R1 was able to use both hands to wipe his face and eat prior to the fracture. On August 3, 2017 at 2:38 PM, via telephone, Z2(Medical Doctor) said R1's right arm fracture was not pathologic. Z2 said an improper transfer could cause the fracture that R1 sustained. Z2 said at one point R1 said he fell during the improper transfer and that can cause a fracture as well.

Based on interview and record review the facility failed to assess and implement specific safety interventions for showering one resident (R3) with a [DIAGNOSES REDACTED]. This failure resulted in R3 falling on wet tile and fracturing the left hip requiring surgical intervention. This failure applied to one resident (R3) out of three reviewed for falls. A facility incident accident statement form showed that while R3 was cleaning her private parts E7 was holding the shower head to R3 for rinsing when R3's left foot slipped forward on the wet floor and R3 landed in a seated position on the floor R3 was admitted to the facility December 3, 2016 per the admission face sheet. The physician order [REDACTED]. The facility summary log for falls for the Month of December showed that R3 fell on [DATE]. The log showed that R3 went to the hospital for treatment and was hospitalized . The log showed that R3 had a fracture and had risk factors of behaviors and safety. Nursing admission assessment showed that R3 was restless and agitated. The assessment showed that R3 wore glasses and was ambulatory with or without assistance. The admission assessment did not address showering R3. A history and physical dated December 8, 2016 by R3's physician showed that R3 used a walker for ambulation and had no prior falls. Under review of systems the physician documented that R3 had confusion, poor safety awareness and gait disturbance. The review of psychiatric system showed that R3 was not oriented to time, place, person or situation and had poor judgment and insight. Care plans initiated December 13, 2016 showed that R3 was at risk for falls due to confusion, gait balance, impaired judgment, poor safety awareness, wandering and psychotropic use. The care plan showed that R3 required extensive one person assist to dress, a safe environment with even floors free from spills and or clutter and hand rails on walls. The care plan also showed that the staff was to ensure that R3 was wearing non skid shoes or socks when ambulating or mobilizing in wheelchair. The care plan did not have an assessment for showering under fall prevention. The fall risk assessment dated [DATE] showed that R3 required the assistance of a device such as a cane, walker wheelchair or furniture. The assessment showed that R3 had taken psychotropic's during the last seven days. An assessment dated [DATE] showed that R3 had an alteration in safety awareness due to cognitive decline and that R3 was using the side rail in bed for support. A physician order [REDACTED]. An Occupational therapy note dated December 21, 2016 showed that R3 needed contact guard assist during bathing due to resident unsteadiness especially for the lower body. An incident report dated December 22, 2016 showed that 10:00 am R3 was found in the shower room sitting on the floor with E7 CNA (certified nursing assistant) supporting the upper torso. The report showed that R3 stood up from the shower chair to wash private parts and that E7 held onto the shower chair and held shower head to R3 to rinse. The note showed that R3 slipped on the wet floor and landed on the buttocks. The note showed that the physician and Power of attorney were notified. The note showed the facility called 911 and R3 was sent to the hospital at 11:00 am per ambulance. The note showed that R3 was admitted to the community hospital with a left hip fracture. A nursing note dated December 22, 2016 showed that R3 got off the shower chair while E7 was holding the shower chair when the resident slid and fell . On December 28, 2016 at 3:50 PM in the conference room E4 LPN (Licensed Practical Nurse) Restorative Nurse said that a rolling walker should have been used in the shower for R3. E4 stated, R3 should have used the hand bars while showering. E4 said that this should be reflected on the care plan. E4 said that all new admissions are assessed for fall risk. On December 28, 2016 at 4:08 PM in the conference room E5 Physical Therapist said that for lower body care R3 needed to be sitting or staff needed to have contact assist. E5 said that R3's goals were not met with physical therapy and that she still required supervision and standing assist. E5 stated, I think hand bars would have helped steady R3 for her task. If we know a resident is having trouble we would recommend staying in the chair if the balance is less than fair, or to use a grab bar or walker. On January 3, 2017 at 10:15 am E6 LPN said via telephone that R3 was found on the shower room floor in the sitting position with E7 CNA supporting R3's trunk. E6 could not recall if there was a rubber mat on the floor but did recall Lots of towels and bath blankets on the wet tile floor. E6 could not recall if the shower chair was locked. E6 said that there were hand bars in the shower room. On January 3, 2017 at 10:44 am in the conference room E7 CNA said that R3 got up from the shower chair and started to wash her private parts. E7 said that she was holding the shower head to rinse R3's back side when all of a sudden R3's left foot slid forward and R3 fell to the floor in the sitting position.

Based on observation, interview, and record the facility failed to failed to conduct comprehensive assessment and evaluate the root cause for the development of the facility acquired pressure ulcers for R 1 and R 15. Failed to evaluate and implement an individualized repositioning plan for R 1 and R 15 and to revise plan of care to promote healing and prevention of of development of additional pressure injury in the facility. The facility failed to implement interventions to prevent the worsening of pressure injuries to the left elbow and left buttock areas and failed to follow the doctor's orders for the treatment of [REDACTED]. The facility also failed to develop and implement individualized interventions including turning and repositioning, use of positioning devices as a measure to prevent the development of Deep Tissue Pressure Injury for R20. These failure resulted in: (1) R 1 acquiring a left ischial Stage IV pressure injury, multiple Stage 2 pressure injuries on the sacrum and a left and right buttock ' s Deep Tissue Pressure Injury that the facility was not aware. (2) R 15 acquired multiple areas of Stage 4 (Sacral, right and left ischium and left hip). (3) R13's pressure injuries worsened to her elbow and left buttocks area. (4) R20 acquired two Deep Tissue Pressure Injuries (DPTI) to her left heel and one DPTI to her right heel. This applies to 4 of 4 residents ( R 1, R 15, R13, R20 ) reviewed in the sample of 30 residents for pressure injuries. The findings include: 1. R 1 admission record shows R 1 was admitted to the facility with [DIAGNOSES REDACTED]. On December 13, 2016 at 10:35 AM, R 1 was noted lying flat in bed, non-verbal, with oxygen via nasal cannula and a gastrostomy tube feeding. On December 14, 2016 at 9:25 AM, R 1 was noted in bed lying on his back, at 10:40 AM and at 11:25 AM R 1 remained in the same position. On December 15, 2016 at 12:20 PM, E 37 (Certified Nursing Assistant) stated, I had him (R 1) yesterday (December 14, 2016), I worked from 6 AM through 2:00 PM, I usually check him (R 1) around 7:30 AM, empty his urinary bag and at 8:30 AM, I clean him up. When I cleaned him up, I saw a little bleeding on his buttocks, I told the Nurse, she said she would tell the wound team. I went back and check on him around 12:00 PM. On December 14, 2016 at 11:40 AM, during treatment observation with E 6 (Treatment Nurse) and E 36 (Certified Nursing Assistant), E 6 identified a Stage IV pressure injury on R 1 ' s left ischium, measured at 1.5 cm X 0.5 cm X 1.0 cm. E 6 explained, It was staged at IV because I can feel the bone. R 1 ' s most current weekly pressure ulcer progress report presented by E 5 (Wound Nurse Director) showed that on December 8, 2016 this pressure injury (Left ischium) was measured at 1.0 cm X 0.7 cm X 0.4 cm. During this observation, a dried blood approximately 3.0 cm X 6.0 cm was noted on R 1 ' s sacral area. E 6 cleansed the sacral area and identified multiple stage II ' s. R 1 was also noted with two areas of Deep Tissue Pressure Injury described by E 6 as deep dark purple in color on the right buttocks measuring 5.0 cm X 3.5 cm and on the left buttocks measuring 3.0 cm X 3.0 cm. On December 15, 2016 at 10:50 AM, E 5 (Wound Nurse Director) explained that the facility has no comprehensive assessment to analyze and identify the root cause of R 1 ' s development of pressure injury on the left ischium. E 5 explained, R 1 is totally dependent on staff with activities of daily living and repositioning. E 5 reviewed and presented R 1 ' s wound care plan and explained, This wound was initially identified on January 1, 2016 and it was a Stage IV already. R 1 ' s Stage IV (pressure injury) care plan showed the following interventions: Assess for pain prior to dressing changes; Wound MD to evaluate; Low air loss mattress; monitor for sign and symptoms of infection; prostat 30 cc; roho cushion while on wheelchair; treatment done per order and wound documentation in place and updated weekly as needed. E 5 also explained that the facility uses the Braden scale, the weekly pressure ulcer progress report; the doctor wound progress notes and the care plan to document the progression of wounds. R 1 ' s progress notes showed that the wound doctor last saw R 1 on October 3, 2016. On December 15, 2016 at 11:50 AM via phone, Z 5 (Nurse Practitioner) stated, I was informed this morning that they found new areas on his (R 1) buttocks. They should be repositioning him at least every two hours to prevent pressure and to promote healing. As a rule it should be every two hours but again it depends on the skin condition of the patient, some might need more frequent turning and positioning. 2. On December 13, 2016 at 10:20 AM, R 15 was in bed lying on his back sleeping. R 1 was noted with a splint on the left arm and with an indwelling urinary catheter. On December 14, 2016 at 9:35 AM, R 15 was observed lying flat in bed, E 42 (Nurse) described, He had a stroke with left side weakness, feeder and he stays in bed most of the time. He has a big wound on his sacrum. R 15 ' s admission record shows R 15 was admitted at the facility on July 26, 2016 with [DIAGNOSES REDACTED]. R15 ' s wound report/ documentation dated December 9, 2016 showed R 15 has a Stage IV on the right ischium (0.5 cm X 0.8 cm X 0.5 cm) and left ischium (0.5 cm X 0.7 cm X 0.3 cm) and a Stage III on the sacrum (8.0 cm X 7.0 cm X 1.0 cm). On December 14, 2016 at 10:10 AM, during treatment observation with E 6 and E 5, both E 6 and E 5 stated, All of R 15 ' s pressure ulcers are acquired from the facility. E6 identified the following: Sacral Stage IV measuring 9.5 cm X 9.0 cm X 1.2 with undermining at 12 o ' clock 1.2 cm, 1.7 cm at 1 o ' clock, 1.2 cm at 2 o ' clock, 2.5 cm at 9 through 11 o ' clock, 1.7 cm at 11 through 12 o ' clock and 1.5 cm at 7 o ' clock. Left ischium Stage IV measured at 1.0 cm X 0.5 cm X 0.7 cm Right ischium Stage IV measured at 0.5 cm X 0.5 cm X 0.5 cm I can feel the bone. Left hip Stage III, E 6 described, This was Stage III but now there is a thick eschar (75 %) covering the wound so it would be Unstageable. This pressure injury was measured at 1.5 cm X 1.3 cm. R 15 ' s pressure injury on the sacrum and left ischium increased in size. There was no wound progress report/ documentation found on R 15 ' s wound on the left hip. E 5 explained, there was no comprehensive assessment to evaluate R 15 ' s root cause for the development of multiple areas of pressure injury. R 15 ' s skin alteration care plan was not individualized based on R 15 ' s needs. 3. On December 13, 2016 at 10:15 AM, R13 sat in her wheelchair in the dining area. E38 (Registered Nurse-RN/Care Plan Coordinator) said R13 has a pressure wound to the left elbow and left buttock areas. There was no protective pad seen under the left elbow. The left elbow was pressed against the wheelchair arm rest. E38 said the elbow wound came from pressure when the resident pushes her elbow against the bed. R13's POS (Physician order [REDACTED]. On December 14, 2016 at 12:11 PM, E6 (Registered Nurse-RN Treatment Nurse) started the wound treatment to R13's left elbow pressure injury. There was no elbow pad seen to protect the area. E6 said there was an order for [REDACTED]. E6 described the left elbow area as a stage IV pressure injury, reddish around the wound bed with the tendons exposed. E6 removed the dressing to the left buttock pressure injury. E6 described the left buttock area as an unstageable wound covered with 100% eschar. E6 measured the pressure wound to the left elbow area as 4.5 cm (centimeter) in length, 5 cm in width and 0.5 cm in depth. There was undermining at 4 o'clock and 9 o'clock. The undermining at 4 o'clock to 8 o'clock was measured at 1.5 cm and the 9 o'clock undermining was measured at 1.0 cm. E6 measured the pressure wound to the left buttock area as 7.5 cm in length, 7.0 cm in width and with no depth. On December 15, 2016 at 12:20 PM, E5 (LPN-Licensed Practical Nurse/ Treatment Nurse) said the facility's Braden Scale Assessment (used to assess risk for pressure injury) is done upon Admission and for the succeeding 4 weeks and then Quarterly. R13's Braden Scale document shows R13 was assessed as High Risk for Pressure Sore (score of 12) on August 3, 2016, October 29, 2016 and November 24, 2016. The facility's undated Protocols for At Risk Residents document shows, Interventions are directed toward minimizing and/or eliminating the effects of the causal/contributing factors: pressure, moisture, friction/sheer and nutrition. E5 stated there should be off-loading for any pressure. E5 (LPN/Treatment Nurse) explained R13's pressure injuries were community-acquired when R13 returned from the hospital on August 4, 2016. R13's Shower/Skin Observation Report dated August 4, 2016 showed Left elbow healing wound 3.5 x 1.5 centimeters. The same document showed, Left buttock redness, Blanchable There were no documentation presented regarding the left elbow and left buttock pressure injuries from the time it was first documented on August 4, 2016 until November 7, 2016. E5 stated treatments were done by the wound treatment staff and when there was no improvement seen, the in-house wound doctor was reached out with new orders. There was no documentation, measurements presented regarding the pressure injuries from the time it was first noticed on August 4, 2016 until a weekly pressure ulcer progress report was done in November 7, 2016. The facility's Weekly Pressure Ulcer Progress Report showed only the measurements and status of the left elbow pressure injury on November 7, 2016-stage IV, 3.3 x 3.1 cm; November 21, 2016-stage IV, 3.5 x 3.5 cm; November 28, 2016-stage IV, 3.0 x 3.0 cm; December 5, 2016-stage IV, 5.0 x 3.0 cm and December 12, 2016- stage IV, 5.4 x 3.0 cm. There was no measurement and documentation presented regarding the pressure injury on the left buttock. R13's care plan with the initiated date of November 7, 2016 did not show any specific interventions for her left buttock pressure injury. The same care plan talked only about the left elbow with no specific interventions. It was also written on the same care plan that R13 was placed under hospice care on November 11, 2016. E5 said there were no other documentation of the status of the pressure injury to the left elbow and left buttock other than the ones the wound doctor wrote starting after the referral was done on November 9, 2016. R13's Progress Note from the wound doctor dated November 9, 2016 showed, Left buttock severe excoriation,10 cm. The same document showed, left elbow pressure area measured at 4 cm x 3 cm x [MEDICATION NAME] filled/slough filled bed. R13's Progress Note from the wound doctor dated December 5, 2016 showed, Left ischium area 8 cm x 7 cm with thick eschar. The same document showed, left elbow-area exposed bone at 3 cm x 3 cm. 4. On December 15, 2016 at 11:25 AM E18 (Nurse) went to R20's room to administer medication via gastrostomy tube. R20 was lying in her bed in supine position, her legs were crossed left over right, her heels were pressing against the mattress and she had no foot wear or socks. R20 was also incontinent of bowel and bladder. E18 summoned E17 (Certified Nurse Aide - CNA) to provide incontinence care. When E17 turned R20 to her side lying position, it was observed that R20's heels had deep tissue pressure injury (DTPI) with dark black discoloration and did not blanche even after relieving pressure for more than 15 minutes. R20's left medial heel skin was mottled. R20's left and right medial buttocks had dark black discoloration which did not blanche even after relieving pressure for 15 minutes. E18 and E19 (Nursing Care Plan Coordinator / Supervisor) verified R20's skin condition and DTPI and they summoned E5 (Pressure Injury Treatment Nurse) to evaluate R20's skin condition and DTPI. E6 (another pressure sore treatment nurse) presented R20's DTPI report dated December 15, 2016 which read as under: Left lateral heel DTPI 1.0 cm (centimeter) x 3.0 cm dark brown area nonblanchable. Left medial heel DTPI 2.0 cm x 2.5 cm area dark brown non-blanchable. Right medial heel DTPI 2.0 cm x 1.5 cm area dark brown non-blanchable. On December 15, 2016 at 12:15 PM E5 stated she was not aware of R20's DTPI, she said she will do the assessment of the R20's pressure injury. E5 also said R20's should be elevated on pillows to relieve pressure. E5 confirmed R20 is at high risk for the development of pressure injury and should be turned and repositioned at least every two hours, she should also use heel protectors and will order special mattress. On December 15, 2016 at 12:05 PM E17 stated she positioned R20 at 8:00 AM on her back in supine position and since then she has been on her back. E17 also said she should have elevated R20's legs on pillows. R20's October 17, 2016 Minimum Data Set (MDS) showed she needs extensive assistance of one person for her activities of daily living, frequently incontinent of bowel and bladder. R20's July 20, and October 17, 2016 Braden Scale for Predicting Pressure Sore Risk showed she is at risk for acquiring pressure injury. The pressure sore risk factors included: limited sensory perception, constant moisture, chairfast, very limited mobility and friction and shearing. The facility did not analyzed these risk factors to develop individualized pressure injury prevention interventions. The facility also did not conduct a tissue tolerance test to develop turning and repositioning schedule. R20's preventative pressure injury plan of care dated May 4, 2016 which was updated on July 20, 2016 and October 17, 2016 interventions are generalized and vague. The examples of such interventions are: observe skin routinely, preventative skin products. There are no interventions to use positioning devices to relieve pressure on her heels.

Based on interview and record review, the facility failed to provide physical assistance and or supervision during meal-time as care planned for a resident with a known feeding deficit. As a result the resident (R1) choked on a ,[DATE] inch piece of hot dog while feeding himself and had to be sent to an area hospital where he was diagnosed with [REDACTED]. Immediate Jeopardy was identified on [DATE] at 1:00 PM. The facility's Administrator (E1) and the Director of Nursing (E2) were informed on [DATE] at 2:16 PM. The Immediate Jeopardy began on [DATE] when R1 was given his meal tray in his room and allowed to feed himself despite his care plan intervention for extensive physical assist with meals. This applies to one (R1) of three residents reviewed for Activities of daily living (ADLs) help, in a sample of three. The findings include: R1 is a [AGE] year old resident originally admitted to the facility on [DATE]. At the time of his admission R1 was alert and oriented. Admitting [DIAGNOSES REDACTED]. According to a facility self-reporting incident sent to the state survey agency on [DATE], R1, while feeding himself in his room choked on a three inch piece of hot dog. At the time of the incident there was a Certified Nurse's Assistant/CNA (E8) in the room feeding R1's roommate. The facility report stated when the CNA heard R1 choking he ran to get a nurse. A code blue was subsequently called and CPR initiated. When the hot dog was removed from R1's airway he was found to be unresponsive. After being revived by paramedics R1 was taken by ambulance to an local hospital where he was admitted . According to emergency department records ([DATE]) obtained from the treating hospital, R1 was diagnosed with [REDACTED]. R1 has since been admitted to an unknown facility and placed on hospice care. Review of multiple documents found in R1's medical record, including ADL functional assessment ([DATE]), Minimum Data Set ([DATE]), Dietary care plan (,[DATE]), self-care deficit for eating care plan ([DATE]), Nursing admission/re-admission assessment ([DATE]) and Restorative nursing assessment ([DATE]) all indicated R1 required extensive physical assistance during meals. On [DATE] at between 3:15 PM and 4:05 PM the nurse (E4) assigned to provide care for R1 stated during interview, "I have never known this resident to be fed by staff." E4 also stated he wasn't aware of R1's care plan that required R1 to received one person extensive physical assistance with meals. On [DATE] at 2:58 PM, the CNA (E8) who heard R1 choking stated during interview, when he heard R1 choking he was feeding R1's roommate behind a pulled privacy curtain. He stated he was never directed or assigned to feed or supervise R1 on [DATE]. He stated R1 usually ate in his room alone and unsupervised. On [DATE] at 4:13 PM, on interview the facility's Director of Nursing (E2) stated, "I just started in this facility. I' am not aware of his (R1) assistance with feeding." E2 stated, "For a resident who requires assistance with feeding her understanding is to have someone provide a hand over hand assistance from start to finish." E2 stated there was no formal list of residents requiring assistance with feeding who eat in their rooms. She also stated the facility had no policy or procedure for feeding residents in their room. During her investigation E2 stated she only spoke to the nurse (E4) assigned to R1 on the evening of [DATE] and read a written statement by the CNA (E8) present in the room feeding R1's roommate. There were no other interviews conducted although there were ten other nursing staff members working on the unit that evening. Following this incident, the facility did not implement any new policies or interventions to prevent future occurrences of residents choking while eating in their rooms. There are 11 other residents currently residing in the facility who require physical assistance with meals and eat in their rooms. On [DATE] at 12:50 PM, R1's physician, stated during interview that he hadn't been informed by the facility that R1 required extensive assistance during meals. He volunteered additional information, stating he also was not informed by the facility, until recently R1 had a habit of "force feeding" himself large amounts of food at one time. He stated, " I saw the picture of the hot dog taken from his mouth. It was about 4 inches. " " It was obscene. " He went on to say if the hot dog would have been cut into a smaller piece R1 probably wouldn't have choked. The physician stated swallowing difficulty (dysphasia) can be a complication of advanced MS, the resident's primary diagnosis. On [DATE] at 1:10 PM, the facility's in-house speech pathologist (E11) stated he had performed a dysphasia evaluation on R1 in January of 2012. He stated the results of the evaluation were R1 was capable of eating all food consistencies with thin liquids using a straw and following safe swallow strategies and aspiration precautions (90 degree position during meals and for 30 minutes after, chin tuck, double swallow and sips of thin liquids). E11 stated some time later he found out from CNAs and nurses R1 was not following aspiration precautions during meals. He stated he also heard the resident was putting large bites of food into his mouth, eating at a rapid rate and refusing to maintain appropriate positioning during meals. E11 stated, " Based on R1's non- compliance following safe swallowing strategies to avoid risk of aspiration; supervision during meals/assistance would be helpful to avoid aspiration risk. On [DATE] at 12:45 PM, R1's Social Services Designee (E3) stated although she was assigned to R1 for the past three years and attended his care plan meetings, she was not involved in any formal or informal discussions regarding the safety of R1 eating in his room. On [DATE] at approximately 3:45 PM, E1 presented the facility's abatement plan. According to the abatement plan the facility will take the following steps to abate the Immediate Jeopardy: 1. A policy and procedure related to resident eating in their rooms has been implemented. This was initially done on [DATE] by the Director of Nursing. On [DATE], the policy and procedure was revised and staff will be inserviced on the new Policy and procedure beginning [DATE] and will be completed on [DATE]. 2. Staff education was completed as follows: - [DATE] - Providing assistance and supervision during mealtimes - [DATE] - Room tray monitoring and physical assistance during meals. - [DATE] - Room tray policy and procedure; Quality assurance for room trays and residents who need assistance during meals 3. Review listing of all residents to determine which residents eat in their rooms either at all times or occasionally. 4. Develop from the review of #3 above, a listing of those residents who eat in their rooms. The listing will include the resident's name, room number, diet, assistance required, and any other pertinent information related to meal service. This listing will be maintained on each nursing unit. 5. Restorative department reviewed and updated the special needs care sheets for all residents who eat in their rooms to ensure that ADL eating status and assistance required are reflected for staff reference. 6. A resident room tray quality assurance tool was developed and implemented on [DATE]. CNAs/Nurses have been assigned to monitor residents who eat in their rooms and require more than set-up help and to complete this tool to verify that all required areas are being addressed regarding resident's meal service safety. This tracking tool will be returned to the nursing supervisor who will submit to the Administrator or Director of Nursing. 7. The facility has begun re-screening those residents who eat in their rooms. These screenings will continue to be conducted by the facility's Speech Therapist. Re-screening of these individuals began on [DATE] and will be completed [DATE]. 8. Additionally, the facility is implementing a quality assurance (QA) tool to verify that all aspects of resident eating are consistent. This will include a review of the physician order [REDACTED]. This tool will be completed by the Administrative staff to ensure that all documentation for these individuals is consistent 9. If an individual with difficulty in swallowing or with [DIAGNOSES REDACTED]. - Provide education to the resident as to the risk involved if resident would continue to eat in his/her room; - Solicit assistance from family members to encourage the resident to eat in the dinning room to ensure safety; - The Interdisciplinary team will meet with the resident and/or family member to reinforce the safety issues involved with resident eating in his or her room; - Contact the physician to discuss the risk of eating in the room with the resident and/or family members. 10. Interdisciplinary team members will receive additional instruction in accurate coding and assessment of residents. This will be completed by [DATE] and quarterly or as needed thereafter. The facility's abatement plan was accepted on [DATE] at 8:30 PM. All elements of the abatement plan were initiated prior to its acceptance and completion has been verified.

Based on record review, observation and interview, the facility failed to complete a comprehensive assessment after each fall occurrences for two residents (R6 and R30), and do an analysis of the root causes for one resident multiple falls (R6), with re-evaluation of interventions for their effectiveness. This failure resulted in R6 experiencing multiple (26) falls between 1/29/12 and 9/22/12, and sustaining facial fractures. This is applies to 2 of 5 residents (R6 and R30) reviewed for incidents of falls in the sample of 30 residents. Findings include: 1. Review of Minimum Data Set (MDS), dated [DATE], shows that R6 is [AGE] years old with [DIAGNOSES REDACTED]. R6 requires limited, hands on assistance of one person for ADL ' s (activities of daily living) including all mobility issues. But R6 is documented as continent of bladder and bowel. E16 (nurse's aide) was interviewed on 10/31/12 at 3:00 pm. E16 stated R6 does not speak English other than to say "perfect", and give the OK sign. E16 said there is no one in the facility who can speak R6's native language of Romanian. E16 reported R6's family comes in to visit about once every two weeks. E16 said R6 is mostly oriented as far as he can tell. E16 said the thing most important to R6 is that she not be incontinent. E16 stated R6 will take herself to the bathroom at any cost so staff tries to respond immediately when they hear her alarm. Observation of R6 on 10/30/12, 10/31/12 and 11/1/12 found her to be alert and in her wheelchair, out and about on the third floor unit. Several attempts were made to interview R6. But, R6 was observed unable to converse in English. R6 was unable to respond other than with a smile and a nod to all simple questions (such as: having pain, having to use the bathroom or wanting something to eat). R6's response was the same no matter what was asked. Review of Interdisciplinary Care Plan Update dated 2/3/12 states R6 has had multiple falls in the last two weeks. The following is documented: R6 "continues to take alarm off, hiding it or becoming very agitated when placed on her. Continues to stand and transfer without assist ...Will keep in visible area of staff at all times when up in wheelchair and close supervision when in bed. " The next entry is 2/6/12, " Daughter stated mom is depressed because she is not as independent as she once was. Said alarm (loud noise bothers her mom.) ...Many falls have been while attempting to go to washroom. " E2 (director of nursing) stated on 10/31/12 at 2:40 pm she was not aware the alarm was annoying to R6. E2 stated that R6 had a significant change in January 2012 in which R6 was taking herself to the bathroom much more frequently and this was the reason for most of the falls. Review of incident reports and fall care plan documents R6 had 26 falls between 1/29/12 and 9/22/12. Review of the investigations of the falls shows that in 12 of those falls, R16 was found in the bathroom or near the bathroom. Review of medical record (nurse's notes between 6/2012 and incident investigations between 2/2012 and 9/2012) shows R6 repeatedly removed alarms, wheeled herself out of the dining room to the bathroom unsupervised. R6 is documented sustaining the majority of her falls (22) in her room/bathroom, and at all hours of the day. Review of the Incident Report dated 6/13/12 shows R6 sustained a laceration to the right knee and hematoma to the right side of the head. The fall on 9/22/12 at 3:20 am resulted in " minimally displaced fractures involving the anterior and lateral walls of the maxillary sinus and the floor of the left orbit extending through the left infraorbital canal " This was confirmed per CT scan of brain dated 9/22/12, which was obtained when R6 was sent to the hospital. Also reviewed from this hospital visit was the "Impressions/Plans" of the physician dated 9/22/12 . R6's Impression/Plan documented R16 with a left arm contusion, facial contusion and dehydration. Review of " Interdisciplinary care plan update " dated 8/7/12 (after R6 was found on floor next to the bed) states that staff will educate R6 to ask for assistance with toileting. It is unclear how this is an appropriate intervention for R6. R6 does not speak English. R6 has been assessed to have poor safety awareness as stated on her cognition care plan dated 2/10/12. Other interventions listed in R6's care plan is to continue all personal alarms and toileting schedule. But, the interventions have not been re-evaluated for their effectiveness since being put in place in February 2012, even as R6 continued to fall. E3 (director of nursing) stated on 10/31/12 at 10:40 am R6 has had several urinary tract infections (UTI) over the past several months. E3 confirmed on 10/31/12 at 2:40 pm that as part of evaluating the circumstances surrounding R6's falls and UTI's, a complete urological workup should be done, but had not been performed. E3 said the effect of the loud alarms on R6's and her (R6's) reaction and removing the alarms had not been addressed, nor had the communication barrier evaluated as a factor in R6's falling. So, The interventions to prevent R6 from possible falls are not individualized and specific because the circumstances surrounding R6's falls have not been analyzed. 2. Review of R30 ' s Admission Face Sheet documented R30 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the facility ' s Incident Reports documented the following falls for R30: " 9/02/2012 at 5 PM ...NURSE'S AIDE heard a voice: " Please help, please help " and noted resident in sitting position on floor by the door of her bathroom and said, " I slipped and fell ... " " 9/03/2012 at 9:30 PM ...Noted resident (R30) laying flat or in supine position in her doorway ... As per resident (R30) she hit her head on the floor upon assessment noted skin tear on left elbow and bump on left lateral head. " " 9/07/2012 ... Dietary staff observed R30 walking in the hallway, ...when she turned her head R30 was on the floor ... R30 who was lying on her back on the floor in the hallway between nurse ' s station and doorway. R30 complained of pain to her left upper extremities and unable to move it ... R30 was sent to emergency room for further evaluation and treatment of [REDACTED]. The Incident Report, dated 9/30/2012, documented that R30 tried to get up and fell from a recliner. R30 was sent to the hospital for evaluation and treatment. However, she did not return to the facility. However, review of the assessments completed after R30 ' s fall occurrences that happened on 9/02/2012 and 9/3/2012 were not comprehensive. There were no detail reviews of all the factors that impact R30 ' s ability (such as use of psychoactive medications, to safely walk to ambulate until after the fall) with the fracture on 9/07/2012. The assessment was a check list of factors without analysis of the effect on the resident, which would help staff target appropriate/effective interventions. Review of the Fall Investigation Follow Up, dated 9/02/2012, documented the following recommendations/new interventions: Walk fast, gait unsteady, repeatedly to bathroom. The interventions identified were for staff to monitor R30 and put pad alarms on her. On 11/02/2012, the assistant director of nursing (E25) was interviewed. E25 described R30 as alert to self, but confused. E25 stated that R30's fall risk assessment done 8/17/2012 documented she was at high risk for falls. When asked about the comprehensive fall assessment conducted after each of R30's fall, E25 did not report reviewing R30's medications, labs and referral to physical therapy until after her fall occurrence on 9/07/2012.

Based on observation, record review and interview the facility failed to: (1) Monitor a resident (R1) in wheel chair, who has cognition impairment, from wandering out through the facility front exit / entrance door and falling in drive way. (2) Have an effective policy and procedure to monitor the whereabouts of residents who are at wandering /elopement risk. As a result: On 7/4/11 R1 in wheel chair wandered out through front entrance / exit door unnoticed by the facility staff. While she was in the wheel chair, the wheel chair slid through the entrance /exit drive way slope and hit the curb. R1 while she was in wheel chair fell to the ground and hit her left side of the head. At the hospital it was determined that R1 sustained acute left parietal subdural hematoma. This is for one of four residents (R1) in the sample of four who are identified as wanderers. Findings include: On 7/26/11 R1 was in her wheel chair, alert, pleasant, confused and disoriented. R1 could not recall any of the fall incident content that occurred on 7/4/11. The facility reported, 7/4/11 incident involving R1 wandering out through front door, to the Department and conducted the investigation. The investigation report indicated the activity staff brought R1 from the second floor where she lives, to the first floor to attend a singing activity entertainment conducted by an individual from out side the facility. The investigation report also indicated the security camera review showed R1 wheeled herself out of the dining room and into the hallway. A family member went out the front door and R1 followed her out the door, while the activity was still going on and the activity aides were busy attending to other residents. The receptionist at the front desk was helping another resident at the time R1 left. The report also noted R1 is able to wheel her wheel chair around the unit but made no previous attempt to leave her floor on her own or to leave the building. On 7/26/11 from 2:15 pm to 2:50 pm interviewed the facility employees (E4 to E8). E4, one of the second floor activity aide stated, she wheeled residents including R1 from the second floor at 1:45 pm to attend activity on 1st floor. The other activity aide (E6) assisted to place residents in the circle. E4 remained on second floor to work with other residents. E6 stated, after she seated the residents, she went to the kitchen to help serving nourishments to the residents participating in the activity and she did not notice R1 leaving the activity. E5 and E7 who are also activity aides from the third floor stated they were monitoring their residents from the third floor and did not notice R1 leaving the activity. All E4, E5, E6, and E7 stated they do not receive help from other staff such as Certified Nurse Aides when the activities are conducted for the residents. E8, the receptionist stated, he was helping another resident at the receptionist desk. He had his head down writing and he missed R1 wheel herself pass him. On 7/26/11 at 3:30 pm R2 who is alert, oriented to time, place and person was interviewed. R2 stated, she was in her motorized wheel chair stationed inside the facility near front entrance / exit door. R2 stated she saw R1 to pass the sliding door along with other people. R2 saw R1's chair slide through the slope like a thunder and hit the curb and fell while R1 was still in the chair. R2 alerted E8 at the receptionist desk and the staff took care of the situation. As a result R1 wheeled herself from the activity unnoticed by the activity staff, passed the nurses station rotunda, passed receptionist desk and went through two sliding glass doors, slid through sloped drive way hit the curb and fell . The distance from front door to the curb side is 8 yards. The facility identified R1 to be not at risk for elopement for the quarters 7/23/10, 10/18/10, 1/16/11 and 4/11/11. On 5/24/11 5:00 am R1's Nurses Notes noted she was found on floor beside her bed. The notes also read R1 reported 'this building on fire.' On 6/16/11 7:00 am R1 was observed on lateral side on bed side mat on the floor she said 'I want to get out of here.' On 7/26/11 E3, the Assistant Director of Nurses; E2 the Director of Nurses stated the nurse who documented these entries did not make them aware of R1's behavior. However, E2 and E3 insisted R1 was not at risk for purposeful elopement at the time (7/4/11) she wandered out through front door. The facility as of 7/21/11 identified 27 residents at risk for elopement including R1. The policy and procedure for elopement is not inclusive to have a system monitor and document the where about's of these residents.

Based on record review and interview the facility failed to adequately supervise 1 of 1 resident in the facility, R2, who was assessed as a high risk for falls. The facility also failed to initiate changes to R2's care plan after the second of three documented falls. After the third fall R2 suffered a subdural hematoma and a fractured right elbow. Findings include: According to the initial admission sheet dated 06/18/08 in the clinical record R2 was a [AGE] year old female with [DIAGNOSES REDACTED]. R2 ' s most current Fall Risk Assessment in the record dated 08/05/10, (4 days prior to the fall) notes that R2 was unable to ambulate without holding onto anything, her vision status was rated as poor and she was disoriented to person, place and time. R2 ' s total score of 16 represented a high risk for falls. An incident report dated 08/09/10 prepared by E1, RN (Registered Nurse) was reviewed. E1 documented that R2 was found by the nurse, (E1), sitting at the side of her bed at 9:07 PM stating she had to go to the bathroom. R2 was placed back in bed by E1 who then conveyed this information to E2, CNA, (Certified Nurses Aid) who was assisting a resident in the next room. E1 told R2 that the CNA, (E2) would come to help her, to not attempt to get up on her own. E1 then left R2 alone. Three minutes later at 9:10 PM a loud thud was heard from R2 ' s room. R2 was found face down on the floor parallel to the bed with her head turned to the right side. R2 was initially unresponsive but began to moan while being examined. A preliminary investigation report dated 08/09/10 at 9:00 PM was completed by E3, DON,(Director of Nurses). E3 documented that upon initial assessment R2 was noted to have slurred speech and a non-reactive right pupil. R2 was also noted to have a left facial droop. R2 was then sent by Emergency squad to the hospital for further treatment. E3 further documented on 08/13/10 that R2 was diagnosed with [REDACTED]. On 12/01/10 at approximately 2:00 PM, E4, (Administrator) was interviewed. E4 stated that after the incident was investigated E1 received disciplinary action because she should have taken R2 to the toilet and should not have left R2 alone after she was first observed sitting on the side of her bed. E1 was not interviewed because she was not on duty during the survey and could not be reached by phone. E2 is no longer working at the facility and could not be reached for interview. Further review of the nurses' notes and a care plan form related to falls indicate that R2 sustained a total of 3 falls since the beginning of the year. On 01/20/10 a nurses note reflected that at 2:15 AM R2 was found on the floor of her room. R2 stated that she was looking for her shoes and slipped on the floor. On 06/18/10 a nurse ' s note reflected that at 6:30PM R2's body alarm was going off and R2 was found in her room, on the floor on her right side. When asked how she came to be on the floor she stated, " I don ' t know. " R2 complained of right hip pain but had no signs of serious injury. Review of R2 ' s care plan noted that after the fall on 06/18/10 there was no action taken by the facility to address the falls. The care plan contained no new interventions until after R2 fell on [DATE] and sustained the subdural hematoma and elbow fracture. E4 was asked on 12/01/10 if any interventions were put in place after each of R2's previous falls. E4 stated that if there were any changes to the care plan they would have been in the record.

Based on Observation, Record Review , and Interview the facility failed to assess, and implement measures to prevent the development of pressure ulcers and also prevent the worsening of pressure ulcers for two ( R6 and R4) of five residents reviewed for pressure ulcers in a sample of 30 residents. This failure resulted in R6 developing a facility acquired stage III pressure ulcer on the right ischium and an unstageable pressure ulcer on the right trochanter. Examples include: 1. R4's physician's orders [REDACTED]. He was admitted to the facility on [DATE]. R4's weekly skin documentation denotes stage I pressure ulcer to the left heel on 04/09/10. He also had a history of [REDACTED]. On 08/03/09 a stage II pressure ulcer was noted on the Right Ischium. A stage II pressure ulcer was noted on the Left Ischium on 12/08/09. Currently the Ischium pressure ulcers are stage IV. On 11/16/10 at 10:35am R4's ulcers were observed with E9, the wound treatment nurse. The wounds were stage IV. The right ulcer had no slough and the base was red with granulation tissue present . The Weekly Wound Documentation for the week of 11/15/10 measured the wound as 0.8cm,length width 1.8cm and depth as 3.2cm. The left Ischium measured 0.7 length, 2.1, width, and 3.8cm in depth. The facility failed to fully document what measures were initiated prior to 12/08/09 to prevent the occurrence of new pressure ulcers between admission and the acquired Ischial pressure ulcers. On 11/18/10 at 10:30am E3, the Assistant Director of Nursing stated that R4 had a regular mattress until after 08/03/2009. R4 had a history of [REDACTED]. 2. R6 is a [AGE] year old resident with multiple [DIAGNOSES REDACTED]. Review of the record showed that R6 had no history of pressure ulcers prior to developing them in October 2010. Assessment showed R6 not to be high risk for pressure sore development, however on 10/12/10 nurses notes document that a Stage III sore was found on the R ischium. This was followed by the discovery of an Unstageable wound on the R trochanter 10/27/10. R6 has been eating well and has maintained his weight. On 11/17/10 the treatment nurse E9 was observed doing R6's dressing change. On interview E9 acknowledged that R6 has the risk factors of aging and incontinence, but that his weight has been stable. There is no assessment stating or documenting whether the pressure sores were avoidable or unavoidable. After the decubitus was acquired an adjustment to the care plan was made that included use of a low air loss mattress and nutritional supplementation. Review of the careplan in the clinical record documents the approach that R6 should be :"up in chair only during meals and back to bed after." R6 was observed during the survey on 11/16 and 11/17 to be seated in a wheel chair up in the dementia unit with the other residents for meals and activities. R6 currently lives on other area of the third floor and goes to the dementia unit for 'day care' and then returns to his room on the other side after lunch to lay down. E9 is currently not utilized to assess the skin of newly admitted or high risk residents prior to the development of pressure sores. She is made aware only after they have developed and there is an order for [REDACTED].

Based on observation, interview and record review the facility failed to ensure that one resident (R1) maintained acceptable parameters of nutritional status such as body weight even though receiving tube feedings assessed as meeting nutrition adequacy. This failure resulted in one resident (R1) who had a significant weight loss. Findings include: During record review of resident R1 it was noted that over the last year R1 has lost weight steadily from 134 pounds in January down to 109 pounds for November. R1 is documented as having a Stage IV to the sacrum and eating difficulties requiring placement of a Gtube for nutrition. R1 has orders for pleasure feeds only, otherwise she is NPO (nothing by mouth). The tube feeding was placed in September after an 11% weight loss that occurred from June to July and then was followed by a 7.5% loss from August to September. On 11/15/10, R1's weight was recorded as 109 on the resident weight record form in her chart. The dietician assessed R1 on 9/20/10 as receiving greater than 100% of her caloric needs from the tube feeding [MEDICATION NAME] 1.5 at the rate of 50cc an hour for a total of 1000 cc per day. The rate was increased to 65cc/hr on 10/15/10. In November the weight dropped to 109. The record lacks documentation of why a resident with tube feedings lost weight. R1 was observed on 11/15/10 and 11/16/10 to not have any tube feeding running during the day. The floor nurse was asked about when the tube feeding was to run for R1. She stated that it is hung at 5pm on the evening shift. Documentation was requested to show when the feeding was hung , how long it ran, how much feeding was consumed, and how it was tolerated by the resident. The nurse stated that the MAR (medication administration record) shows when it was hung. The MAR indicated [REDACTED]. The nurse was asked if intake and output (I&O) sheets were kept for the tube feedings. She said they were not. Nurses notes were checked and found to not have documentation of the Tube Feeding infusing at night on a consistent basis. The nurse was again asked if she documented anywhere, when she removed the tube feeding. She said that she did not. On 11/18 at the daily status meeting E2 the DON was asked to provide the facility policy regarding tube feedings. She presented an "Enteral Feeding Protocol" she had developed. In the first line of the protocol it states residents will be assessed to ensure adequate nutrition and hydration. It does not provide how this will be accomplished. E2 later returned with two other documents. One titled "Checkpoints for Enteral Feeding" that says "Record intake and output". Based on the lack of documentation the facility is unable to verify that the proper amount of feeding was infused. This is accompanied by the fact that R1 was continuing to loose weight even though the dietician assessed the caloric need as being exceeded by the feeding being received. This put R1 at risk of delayed healing of her pressure sores and presented the potential for allowing R1 to develop further breakdown if not receiving adequate nutrition.