Every finding on record at Miller Health Care Center

Based on observations, interviews, and record review, the facility failed to ensure that a resident did not develop an avoidable pressure injury from wearing an abdominal binder.This applies to 1 of 4 residents (R4) reviewed for Quality of Care/Treatment in a sample of 4.The findings include:R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE]. The EMR showed that R4 had multiple diagnoses, including unspecified dementia, personal history of traumatic brain injury, gastrostomy status, epileptic seizures related to external causes, not intractable, with status epilepticus, functional quadriplegia, constipation, sepsis unspecified organism, type 2 diabetes mellitus, and heart failure unspecified, R4's MDS (Minimum Data Set) dated June 7, 2026, showed R4 had cognitive impairment, required maximum assistance with personal hygiene, and was dependent on staff for toileting and bathing.R4's POS (Physician Order Set) dated March 4, 2026, showed an order for Abdominal binder: resident must wear abdominal binder at all times, every shift to keep g-tube (gastrostomy tube) secure, every shift.On June 22, 2026, V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) said the residents receive showers or bed baths once or twice weekly, and that the Certified Nursing Assistants/CNAs report any observed skin abnormalities to the nurses. V2 and V3 also said the nurses perform G-tube care every shift and as needed. V2 said nurses are expected to perform skin inspections beneath R4's abdominal binder during G-tube care every shift. V2 said she was confident the nursing staff was checking R4's armpits when they put the abdominal binder on R4. V2 said the nurses had to lift up R4's arms to place the abdominal binder, and the nursing staff would have seen if R4 had any skin breakdown in his armpits. R4's bed bath sheet documentation for May and June 2026 was reviewed. No abnormal skin condition was documented by the nursing staff. R4's last documented bed bath sheet before his transfer to the hospital on June 8, 2026, was on June 2, 2026.R4's care plan showed that R4 required tube feeding due to the diagnosis of dysphagia. Care plan interventions documented on January 13, 2026, included the resident wears an abdominal binder at all times. Ensure applied correctly and snugly. Check skin under binder daily for irritation, redness, or breakdown. As of June 22, 2026, there was no documentation to show that the skin under the abdominal binder, including R4's armpits, was checked after June 2, 2026.R4 was transferred to the ED on June 8, 2026, at approximately 1:08 AM according to the nursing progress note. R4's hospital wound care progress note dated June 8, 2026, at 9:49 AM showed, Consultation for wound care to see wound bilateral underarms present on admission. patient noted with a large abdominal binder applying pressure to his underarms. Wound 1 Pressure Injury Axilla Right: Shape: linear. Measurement: 1.2 cm (centimeters) by 3.5 cm by 1.7 cm (Length by Width by Depth), odor: none, Pressure Injury Stage: 3. Wound 2: Pressure Injury Axilla Left. Shape: linear. Measurement: 1.6 cm (centimeters) by 4.4 cm by 0.7 cm (L by W by D), odor: none, Pressure Injury Stage: 3. R4 returned to the facility on June 10, 2026.On June 22, 2026, at 10:44 AM, V4 (Wound Care Nurse) said V4 R4 was not being seen by the wound care team for any wounds prior to R4's hospitalization on June 8, 2026. V4 said she found out that R4 had wound to his bilateral axilla after R4 returned from the hospital on June 10, 2026. V4 said she assessed the resident's wound for the first time on June 11, 2026. V4 said wounds can develop very quickly due to moisture and other risk factors. V4 said she could not say for sure if R4 had something starting in his armpit to have developed stage 2 and stage 3 pressure ulcers during his two-night stay at the hospital. V4 said her assessment of R4's wound on June 11, 2026, showed that R4 had a stage 3 left front axilla MDRPU (Medical Device Related Pressure Ulcer/injury) and a stage 2 right front axilla MDRPU, and they were both present upon R4's readmission to the facility on June 10, 2026. V4 said wound treatment began immediately after the assessment on June 11, 2026. V11(Wound Care Physician) also assessed R4's wound the same day.

Based on observation, interview and record review the facility failed to provide interventions to prevent the development and worsening of skin breakdown. This failure resulted in two residents developing pressure ulcer (also known as a bedsore or pressure wound is an injury to the skin and the tissue below the skin that are due to pressure on the skin for an extended period). This applies to 2 residents, R1 and R2 reviewed for facility acquired pressure ulcers in a sample of 8.Findings include:1.R1 was admitted to the facility on [DATE] with diagnoses that include disease of the spinal cord, cervical radiculopathy, chronic obstructive pulmonary disease, acute respiratory failure, pneumonia, morbid obesity, muscle wasting and atrophy, major depressive disorder, and diaper dermatitis. R1's EMR (Electronic Medical Record) documents she was sent to the local emergency room for rectal bleeding on 03/04/26.On 04/14/26 at 9:20 AM, V18 Family Member stated R1 developed multiple bedsores while in the facility because the staff was not turning R1. V18 stated R1 was chair bound and required total care assistance from the staff. V18 stated R1 did not have any open wounds when she came to the facility.On 04/15/26 at 1:30 PM, V13 Wound Nurse stated R1 was chair bound and was able to feed herself but required staff assistance to move her legs and incontinence care. R1 admitted to the facility with a left gluteal skin tear, bilateral upper extremity bruising, a skin tear on her left forearm, a fungal rash to her back and posterior arms MASD (Moisture Associated Skin Damage) to gluteal fold and hyperkeratosis to her bilateral lower extremities. V13 stated R1 developed a cluster wound on her left gluteal area that measured 0.58 cm x 0.56 cm x 0.1 cm (Centimeters) documented on 2/26/26. V13 denied classifying any of R1's wounds as pressure related. V13 stated the floor nurses would be responsible for documenting the daily skin assessments and prescribed treatments ordered by the physician. The CNAs (Certified Nursing Assistant) are required to document any skin concerns noted during care and care activities in the tasks section of the EMR (Electronic Medical Record). The CNAs should verbally inform the nurse of any new skin concerns.On 04/14/26 at 2:51 PM, V13 Wound Nurse stated nystatin was ordered for R1's fungal rash and Silvadene cream was ordered for hyperkeratosis to the bilateral lower extremities daily. V13 stated the triad cream was an order that came with R1 from the hospital for incontinence, but the facility would does not supply triad cream the remedy protect zinc cream is used instead.On 04/15/26 at 4:48PM, V2 DON (Director of Nursing) stated the admitting nurse will do an initial skin assessment and implement a baseline care plan. The wound care nurse will see the resident by the next business day if they are admitted after hours. The wound nurse stages wounds not the floor nurse. V2 stated V13 Wound Nurse saw R1 on 2/17/26 the fourth day after her admission. V2 stated the triad cream would have been sent from the pharmacy. V2 acknowledged there were missed skin assessments and administrations of the triad cream on R1's TAR (Treatment Administration Record). V2 stated missing prescribed treatments could lead to the worsening of skin breakdown. V2 stated there are multiple interventions that could be implemented to prevent skin breakdown. V2 stated the CNAs should document skin issues and notify the nurse of skin concerns. Upon reviewing EMR V2 could not locate CNAs care documentation in the EMR (Electronic Medical Record).On 04/16/26 at 4:00 PM, V10 RN (Registered Nurse) stated she did not recall R1 having a pressure ulcer on admission. V10 stated if there was a pressure wound on admission she would have messaged the wound nurse for follow up. V10 stated she did not recall the topical treatments ordered for R1, but triad cream would have been sent from the pharmacy.On 04/17/26 at 10:35 AM, V12 NP (Nurse Practitioner) stated she recalls R1 having complaints of pain related to her neck but was unaware of her skin breakdown. V12 stated R1 was care dependent. V12 stated she expects CNAs to provide incontinence care and turning assistance for care dependent residents to prevent skin breakdown and report new skin concerns to the nurse. V12 stated she expects the staff to follow the facility policy to prevent skin breakdown. V12 stated she would have expected the wound doctor to see R1 prior to 2/26/26. V12 stated missing ordered treatments can lead to the worsening of skin breakdown worsening. V12 stated she had never heard of cluster used to classify the type of wound.On 04/14/26 at 4:45 PM, during record review the CNAs documentation for R1 was not accessible in the EMR. R1's TAR documentation had missing physician ordered skin assessment documentation and missing documentation of triad cream application.On 04/15/26 at 7:07 PM survey records were requested again from V1 Administrator including the nursing TAR documentation and CNAs care documentation for R1. The TAR and CNAs documentation was not provided.The pharmacy requisition for medication delivered to the facility for R1 was requested from V1 Administrator.On 04/17/26 at 2:51 PM, V1 stated she could not provide a requisition documenting triad cream being delivered for R1. V1 stated there was no requisition in the facility and none was provided by the pharmacy. V1 stated she was informed by the wound doctor that the remedy protect cream is used in place of the triad cream. V1 stated a new order should have been obtained if a different product was being used.R1's admission wound documentation on 2/13/26 completed by V10 documents MASD (Moisture Associated Skin Damage) The admission documentation entered by V10 RN on 2/13/26 did not document any pressure ulcer in the admission note or skin assessment.The product information for triad states it is a hydrophilic wound dressing that adheres to wet or irregular surfaces with pressure injuries, broken skin in the presences of urinary incontinence, macerated skin, and facilitates autolytic debridement of necrotic skin. Remedy skin protectant zinc oxide product information states it protects and helps relieve chapped or cracked skin and seals out moisture.R1's Physician orders dated 2/13/26 include skin assessment every shift for 3 days skin risk assessment weekly for 4 weeks starting one week after admission. Wound care bilateral ischial and coccyx after providing skin hygiene apply Triad cream to open wound beds ad silicone barrier cream to intact skin twice daily and as needed for incontinence.R1's care plan includes wound management dated 02/18/26 wound will show signs of improvement. Notify provider if there is no sign of improvement on current wound regimen. Provide wound care per treatment order.The facility provided a list of residents with pressure ulcers from February and March 2026. R1 was not identified as having a pressure ulcer.R1's emergency room records dated 03/04/26 documents stage 2 injury (pressure injury with partial thickness skin loss with exposed dermis) of sacral region. 2.On 04/14/26 at 1:36 PM, R2 was assisted to bed by V4 CNA (Certified Nursing Assistant). Incontinence care was observed for R2. R2 had a regular mattress in place on her bed. V4 stated R2 did not have any pressure ulcers and her skin was intact. When R2's brief was removed she had an open area on her sacral coccyx area. The peri wound, buttocks and perineum were beet red. R2 did not have any visible protective cream in place or dressing in place.On 04/14/26 at 3:14 PM, V6 RN (Registered Nurse) assigned to R2 stated she did not have any residents with a pressure wound. V6 stated she did not receive any notification from V4 CNA of R2 having skin break down or wounds.On 04/15/26 at 1:18 PM, V13 Wound Nurse stated she saw R2 on 04/14/26 for a stage 3 (pressure injury full thickness skin loss) pressure wound on her sacral area. V13 stated there was no previous documentation of pressure wound prior to then. V13 stated the staff should have identified the skin breakdown prior to it developing to stage 3. V13 stated as far as she can see that all facility acquired wounds are avoidable.On 04/17/26 at 10:35 AM, V12 NP (Nurse Practitioner) stated she was not made aware of R2's stage 3 pressure wound. R2 requires staff assistance for care. V12 stated she would have expected staff to notice R2's skin before it became a stage 3 pressure wound. V12 NP stated pressure wounds can be painful and can lead to infection.On 04/17/26 at 12:12 PM, V13 Wound Nurse stated a low air loss mattress is a pressure relieving device. V13 stated the facility does have some low air loss mattresses, but when they are all in use they go to an outside vendor to provide them. V13 stated she should have obtained the low air loss mattress for R2, but she had not.R2's care plan initiated on 01/11/26 states R2 has potential for pressure ulcer development related to incontinence of bowel and bladder. The resident will have intact skin, free of redness, blisters or discolorations. Interventions include educating the resident / family / caregiver as to the cause of skin breakdown including transfers /positioning requirements; importance of taking care during ambulating / mobility, good nutrition and frequent repositioning. Follow the facility policy / protocols for the prevention / treatment of skin breakdown. Pressure relieving devices to bed and chair.A progress note entered by V6 RN dated 04/14/26 at 5:24 PM states around 2pm R2 observed to have a skin issue on her coccyx area. Redness found and non-blanchable. R2 felt pain when touched 4/10.The facility policy Pressure Injury dated 01/2026 states the pressure ulcer prevention protocol on the resident's plan of care includes the following in an attempt to stabilize, reduce or remove underlying risk factors. Nursing judgement may be used to determine what preventative measures are to be used for each resident: manage moisture, manage friction and shearing, reduce pressure optimize nutrition / hydration status. The skin risk assessment is to be completed on admission and weekly for four (4) weeks for all new residents, and quarterly thereafter or upon severe deterioration change in condition or sever deterioration in physical activity. Residents who have wounds on admission would have the skin risk assessment completed on admission and staff are to document on the wound assessment progress flow sheet weekly until healed. TAR (Treatment Administration Record) is considered part of plan of care.The facility policy Wound assessment dated 01/2026 states it is the policy of the facility to do a systemic, ongoing wound assessment on all wounds I order to determine the response to care and treatment modalities.

Based on interview and record review the facility failed to provide 2 assists for a full mechanical lift transfer in accordance with their policy. This applies to 1 of 3 residents (R1) reviewed for full mechanical lift transfer in the sample of 5. The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged from the facility on February 14, 2026. R1 was admitted with multiple diagnoses including quadriplegia C6-C7 incomplete, post laminectomy syndrome, muscle wasting, chronic venous insufficiency, cellulitis of the right lower leg and stage 4 pressure ulcer of the sacral region. R1's MDS (Minimum Data Set) dated February 3, 2026, showed R1 was cognitively intact and required assistance with ADLs (Activities of Daily Living) including independent with eating, set up assistance with oral hygiene and personal hygiene, partial assistance with upper body dressing, substantial assistance with bathing and bed mobility and dependent on staff for lower body dressing, toileting and transfer. R1 had an indwelling urinary catheter and was incontinent of bowel. The facility list of fall incident reports showed R1 had witnessed fall on February 6, 2026, at 11:40 AM. The post fall huddle report, undated, showed during a transfer at R1's bedside, R1 had slid forward in the chair. V3's (Certified Nursing Assistant, CNA) written statement dated February 6, 2026, showed V3 transferred R1 to the motorized wheelchair and R1 started to slide out and V3 had to leave the room to get help. On February 20, 2026, at 10:42AM V8 (LPN) stated while walking in the hall outside of R1's room, V8 saw V3 (CNA) coming out of R1's room asking for assistance. V8 stated V8 and V3 went into R1's room and V8 saw R1 sliding out of the chair with her legs extended in front of R1 on the floor. V8 stated the mechanical lift was in the room. V8 reported the top part of the sling was attached to the lift hooks but the bottom part of the sling was not underneath R1 and not attached to the lift. V8 reported V3 stated she had transferred R1 from the bed to the chair using the full mechanical lift by herself (with only V3 as the assistant). V8 stated V3 had attempted to move R1 up in the chair herself with the sling when the sling came out from underneath R1. V8 stated later she and V3 were in the room with R1 and R1's two daughters and witnessed V3 tell the family that V3 could not find anyone to assist with the transfer. On February 19, 2026, at 3:40 PM, V4 (Restorative RN) stated V4 instructs new staff on transfer techniques and the policy of the facility is to have 2 assists when using the full mechanical lift. On February 19, 2026, at 4:00 PM, V2 (Interim DON) stated the expectation for staff when using the full mechanical lift is for 2 staff to provide assistance. The facility's policy titled Lift-Mechanical dated January 2026, the policy statement showed Two staff members are required during a full body lift transfer.

Based on interview and record review, the facility failed to assess a resident after CNA (Certified Nurse Assistant) was unable to obtain resident's blood pressure or heart rate and failed to document resident's code status in the medical record.This failure resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on [DATE] around 6:30 AM when V33 (Agency RN) did not assess R18 after V35 (CNA/Certified Nurse Assistant) notified V33 that she was unable to obtain a blood pressure or heart rate on R18. Around 7:45 AM, V33 (Agency RN) found R18 unresponsive and left R18 to find V16 (RN/Registered Nurse). V16 said V33 told her she thought R18 expired and R18 was DNR (Do Not Resuscitate). Around 8:00AM, R18 was found unresponsive by V41 (Respiratory Therapist) and V3 (LPN/ Acting ADON/Assistant Director of Nursing) and CPR (Cardio-Pulmonary Resuscitation) was initiated. 911 was called at 8:33 AM by V42 (Dietary Aide/CNA). Per ambulance run report, Paramedics arrived on scene at 8:38 AM and resuscitative efforts including intubation attempts ceased at 8:59 AM and R18 was pronounced deceased . This applies to 1 resident (R18) reviewed for emergency response and code status availability in medical record and has the potential to affect all residents in the facility.V1 (Administrator) was notified of the IJ on [DATE] at 12:01 PM and the IJ template was provided.The facility presented an Immediacy Removal Plan on [DATE] at 2:45 PM that was returned for revisions at 3:57 PM. The second Removal Plan was accepted on [DATE] at 6:12 PM.The surveyor confirmed the immediacy was removed on [DATE] at 2:49 PM; however, the facility remains out of compliance at a severity level II due to the need to evaluate the new agency orientation checklists for completion including initiation of CPR and code status documentation, all staff reeducation on Change in Resident Condition Policy, Emergency response escalation, CPR Policy, DNR Order Policy, nurse responsibilities for new admissions, and Quality Assurance Monitoring.The findings include:On [DATE] at 3:46 PM, V33 (Agency RN) said on the morning of [DATE] around 6:30 AM, V35 (CNA) told her that she could not get a blood pressure or heart rate for R18. V33 said she continued to pass her morning medications to other residents and around 7:45 AM when she went in to give R18 medications, she found R18 unresponsive. V33 said she then attempted, unsuccessfully, to recheck R18's vital signs with the vitals machine and listened for R18's heartbeat with her stethoscope, but found R18 did not have a heartbeat. V33 said she then left R18's bedside and went to find V16 (RN), who was working a different hall. On [DATE] at 1:24 PM, V33 (Agency Nurse) said she was R18's admission nurse and V12 (LPN) took report from the hospital on R18 for V33. V33 said V12's report paper had R18's code status on it, but V33 didn't remember what the code status was. V33 said it is the admission nurse's responsibility to enter the resident's code status in the electronic medical record. On [DATE] at 11:17 AM V16 (RN) said V33 came to her on the morning of [DATE] during her medication pass and told her, I think my patient expired. V16 said she then asked V33 what R18's code status was and while walking away from V16, she heard V33 say DNR. V16 said she then went to R18's room to verify she had expired and noted that R18 was pale with bluish lips, but still warm to touch. V16 said she listened to R18's chest with her stethoscope and did not hear a heartbeat and then she felt for a carotid pulse and felt nothing. V16 said she was then called back to attend to her residents, so she left R18's bedside. On [DATE] at 5:06 PM V4 (Social Service Director) said on the morning of [DATE] around 8:00AM he was walking past R18's room and saw R18 slumped to the side in bed and V16 (RN) and V44 (CNA) in R18's room. V4 said he overheard V44 (CNA) say they could not get vitals on R18. V4 (Social Service Director) said he then walked to the nearest clinical staff near a computer, V41 (Respiratory Therapist), and V4 asked V41 to look up R18's code status in the medical record. On [DATE] at 12:13 PM, V41 (Respiratory Therapist) said when V4 asked her to look up R18's code status, she checked R18's medical record and did not see any order for code status, including DNR. V41 said she then asked V4 why he was asking and V4 told V41 R18's CNA was unable to get vitals on her. V41 said she then went right to R18's room, assessed that R18 was not breathing and did not have a pulse, so V41 started chest compressions. V41 said V3 (LPN/Acting ADON) was next to enter R18's room and he took over chest compressions while V41 placed the AED (Automated External Defibrillator) on R18. V41 said she then started ventilating R18 with oxygen and bag valve mask. On [DATE] at 2:37 PM, V42 (Dietary Aide/CNA) said she was called into R18's room by V3 (Acting ADON) to help with CPR efforts and after she completed 2 rounds of chest compressions, V41 (Respiratory Therapist) and V3 (Acting ADON) were trying to figure out who R18's nurse was to find out why 911 assistance had not yet arrived. V42 said V33 (Agency RN) then came into the room and said she called 911 but, they said they can't come. V42 (Dietary Aide/CNA) said she then called 911 from her personal phone, inside R18's room. V42 said 911 assistance arrived within 10 minutes of her call and took over CPR. On [DATE] at 4:50 PM, V33 (Agency Nurse) said she called the universal number that is used for ambulance transport. V33 was then asked, When a patient is unresponsive, do you call for ambulance transport, or do you call 911? and she replied, I am not sure.On [DATE] at 1:42 PM, V47 (Assistant EMS Coordinator of Kankakee Dispatch) said all 911 calls go through his dispatch center and they only received one 911 call on [DATE] regarding R18, and that took place at 8:33AM, and the caller was V42.R18's ambulance run report dated [DATE] shows 911 was called for cardiac arrest, ambulance was en route at 8:34 AM, on scene at 8:38 AM, and at R18's bedside at 8:39 AM. Ambulance crew took over R18's care at 8:39 AM, using an external plunger device for CPR. At 8:46 AM, 8:50 AM, 8:54 AM, and 8:58 AM, Epinephrine was administered through IO (Intraosseous) line that was inserted by the crew at 8:44 AM. At 8:48 AM, orotracheal intubation was attempted multiple times but complicated by patient vomiting and was unsuccessful. At 8:52 AM iGel was used to establish a supraglottic airway for ventilation. R18 remained in asystole (without a cardiac rhythm) throughout code and crew terminated ALS (Advanced Life Support) efforts at 8:59 AM. R18 expired.On [DATE] at 10:46 AM, V4 (Social Service Director) said when R18 was found unresponsive and without a code status or advanced directives, he first consulted the admissions team who has access to the hospital chart to try to obtain the code status from the hospital documentation. V4 said the admissions team told him they did not have anything logged for R18's code status. While staff were performing CPR, before the ambulance arrived, V4 spoke to V45 (R18's Son) who told V4 he knew R18 did not want extensive measures, including intubation, but to continue chest compressions.On [DATE] at 2:09 PM, V45 (R18's Son) said he received a call from V4 (Social Service Director) on [DATE] at 8:28 AM. V45 said he told V4 he knew R18 did not want to be intubated and her living will said no extreme measures. V45 said he never had the conversation with R18 about CPR, so he told V4 to go ahead with CPR, but not to intubate her. V45 reiterated again, R18 did not want to be intubated or placed on mechanical ventilation.R18's hospital orders show her last code status update in the hospital prior to her admission to the facility was partial code as of [DATE]. In the hospital, prior to R18's admission to the facility, her code status order showed: No Mechanical Ventilation with Intubation, Selective Cardio Resuscitation, No Chest Compressions, and No Defibrillation/Cardioversion.R18's Face sheet shows she was admitted to the facility on [DATE] with primary diagnosis of Acute Respiratory Failure with Hypoxia and she had no Advance Directive or code status listed. R18's POS (Physician Order Sheet) shows she had no physician order for code status. R18 had been admitted to the facility for approximately 16 hours at the time of her code blue and she did not have any nursing assessment documented or vital signs.On [DATE] at 10:24 AM V2 (DON) said if the CNA notifies the nurse they could not obtain a blood pressure and heart rate on a resident, the nurse should assess that resident immediately. V2 said if a resident is found unresponsive and there is no code status listed in the medical record, the staff should immediately proceed with compressions. V2 said timely initiation of CPR is important because there is a short period of time the staff have to get the resident back and they want to minimize any damage to the organs caused by lack of blood flow and oxygen. V2 said every minute is detrimental once the resident is found unresponsive. On [DATE] at 3:17 PM, V2 (DON/Director of Nursing) said the resident's code status should be entered into the computer right when the resident arrives when they are entered into the computer system. V2 said the code status needs to be entered right away so staff do not have to spend time looking for the resident's code status in the event of an emergency, and this is important because they want to honor the resident's wishes if they are found unresponsive. On [DATE] at 5:08 PM, V1 (Administrator) verified R18's facility record did not show any advance directive or code status. V1 said the resident's code status should be obtained first thing when a new admission comes, before any other parts of the admission are done. V1 said she was not aware V45 (R18's Son) told V4 R18 did not want to be intubated. On [DATE] at 1:16 PM, V43 (Admissions Director) said a resident's code status should be obtained before the admission comes and if there isn't a code status on file, there should be a physician order entered saying full code so the nursing staff know how to proceed until social services is able to discuss Advance Directives with the resident. V43 said she cannot locate any documentation showing that R18 wanted to be a full code. V43 said in R18's hospital chart it said she was a partial code, and that was not discovered until after she had died.The facility's policy titled, Resident Admissions last revised 5/2024 states, .Procedure: The admitting nurse shall use the PCC (PointClickCare) EMR (Electronic Medical Record) system admission process for all resident admissions. These processes include, but are not limited to the following tasks within the system: A. Add resident/Patient B. Create admission C. Assign Bed D. Advance Directives.The facility's policy titled, Advance Directives- [NAME] last revised 1/2020 states, Policy: [NAME] Rehabilitation supports the right of all residents to participate in their own health care decision making including the right to decide whether they wish to accept or refuse life-prolonging measures or other treatments. [NAME] Rehab also supports the right of residents to prepare an Advance Directive declaration or statement which clearly expresses the resident's wishes regarding the use of life-prolonging procedures and designating another person to make treatment decisions in the event that the resident becomes incapable of communicating his or her choices or wishes. Procedure: A. Upon admission, written information will be provided to residents informing them of their rights under State law regarding health care decision-making, including the right to prepare advance directives. A signed acknowledgement that such information has been received will be required, and notation will be made in the resident's medical record as to whether or not an advance directive has been prepared and presented.The facility's policy titled, Cardio-Pulmonary Resuscitation (CPR) last approved 01/2026 states, Policy: Basic life support is an emergency first aid procedure that consists of recognizing respiratory and cardiac arrest and starting the proper application of cardio-pulmonary resuscitation to maintain life until the resident recovers sufficiently or until advanced life support is available. This includes the C-A-B steps of CPR: A. Circulation B. Airway C. Breathing Any trained staff members should initiate basic life support immediately upon recognition of the need to do so.The IJ that began on [DATE] was removed on [DATE] at 6:12 PM when the facility took the following actions to remove the immediacy:Audit of resident code status was completed, to ensure all current residents had a code status.V3 provided education on code status and emergency response expectations were reinforced with all nursing staff.Cessation of any practice of delaying CPR due to verbal assumptions of DNR status.The facility implemented a directive that all residents will be treated as full code unless a valid physician DNR order is present and accessible in the medical record.100% audit of all current resident charts was completed to verify presence of physician code status orders.V3 provided an audit to ensure the DNR status was accurately reflected on nursing shift to shift reports and matching the DNR status in the chart.Emergency code status roster placed at all nurse's stations for rapid access.New language added to the facility's change in condition policy: Nursing staff must immediately assess when vitals signs cannot be obtained. Nurse must not delay in assessment of escalation.Nursing leadership will educate all staff, including agency, on shift by 6PM on the following policies: Do not Resuscitate Order Policy, Cardio-Pulmonary Resuscitation (CPR) Policy, and Change in Resident Condition Policy. Nursing leadership will educate all remaining staff prior to their next worked shift.Nursing staff will be reeducated on rooming responsibility for new residents including: clinical assessment completion within 2 hours of patient's arrival to the building, and completion of a move-in note. This will be audited daily by DON.Implement checklist for admissions including DNR status to validate patient wishes prior to arrival. Director of Sales and Marketing to audit daily.Immediate requirement for licensed nurse assessment without delay upon inability to obtain vital signs or change in condition.Immediate re-education of staff that CPR must be initiated unless a physician DNR order is confirmed.Verified all current agency staff have completed orientation checklist prior to taking an independent patient assignment.QAPI Action Plan to be completed including the following audits: admission code status complete upon admission, admission checklist with code status known prior to admission, nursing assessment completion within 2 hours of admission by admitting nurse, nursing completion of move-in note upon admission, agency checklist completion audit for new agency staff-checklist complete prior to taking full assignment, Mock CPR code completion weekly on each shift.

Based on interview and record review, the facility failed to implement fall precautions for a high fall risk resident admitted with a history of fall and left hip fracture.This failure resulted in R5's fall in the facility on 12/25/25, transfer to the hospital, and diagnosis of right hip fracture.This applies to 1 resident (R5) reviewed for falls with injury in a sample of 3.The findings include:R5's Face sheet shows she was admitted to the facility on [DATE] with primary diagnosis of fracture of left pubis. R5's other diagnoses include: unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit, dizziness, osteoarthritis, and falls.On 1/28/26 at 2:35 PM, V40 (LPN/Licensed Practical Nurse) said she was the nurse taking care of R5 on 12/25/25 when she fell. V40 said she heard R5 yelling and found her lying on the floor at the foot of her bed on her right hip and supporting herself with her right hand. V40 said R5 was confused and tried to stand up to walk to her closet and told V40 she was trying to get her clothes to go home. V40 said she was not aware of any fall precautions that R5 had in place at the time of her fall.V39 (Agency LPN) completed R5's admission Fall Risk Evaluation on 12/17/25 which documented R5 had a history of 1-2 falls in the past 3 months, was incontinent, had 1-2 predisposing conditions, had recently been hospitalized , and had taken 1-2 medications currently or within the previous 7 days that put her at greater risk for falls. The score of V39's Fall Risk Evaluation showed R5 was a high fall risk. V39 did not trigger/implement any fall precautions from this evaluation. On 1/28/26 at 11:41 AM V39 said if a resident is high fall risk, certain precautions should be implemented such as bed alarm or chair alarm, fall mats, and/or frequent rounding. V39 said she remembered R5 getting more confused the longer she was in the facility, then looked through her documentation on R5 and verified that she did not add any fall precautions/interventions after she completed R5's Fall Risk Evaluation. V39 said R5 was a high fall precaution because she had a history of falls but she did not implement any fall interventions because she didn't know R5 very well. V39 then stated based off R5's fall risk score she could have implemented something.R5's Care Plan initiated 12/25/25, after her fall in the facility, states the resident has had an actual fall with serious injury related to unsteady gait. The goal of this Care Plan states the resident's right hip fracture will resolve without complications and interventions include: call don't fall sign placed in room, one time order to send the resident to the emergency room for evaluation and treatment, and continue interventions on the at-risk plan.On 2/2/26 at 2:04 PM, V3 (Acting ADON/Assistant Director of Nursing) said the facility completes a fall risk assessment as part of their standard admission, which highlights anything that puts the resident at greater risk for fall. V3 said a history of falls and a recent hospitalization both put a resident at greater risk for falls. V3 said after the initial fall risk screen is done, if the resident is showing they are at risk for falls, the nurse will be prompted to add a fall risk care plan and fall interventions to help reduce or prevent any future falls from happening. V3 then looked through R5's electronic health record and said V39 (Agency LPN) never implemented any fall precautions when prompted and V29 (RN/ADON) initiated R5's Fall Care Plan on 12/25/25 after her fall and wrote to continue interventions in her at-risk plan, but there was never any interventions documented in the at risk plan. V3 said there were not any fall precautions/interventions in place prior to R5's fall in the facility on 12/25/25. V3 said if a resident comes to the facility for rehab after hip fracture from a previous fall, the first thing that should be implemented for the resident's safety is fall precautions, to prevent any future injuries or falls.On 2/2/26 at 1:07 PM, V48 (NP/Nurse Practitioner) said it is the facility protocol to put fall precautions in place for any resident admitted and assessed to be high fall risk, and this should have been done for R5. V48 said fall precaution implementation is essential for any resident admitted post fall and hip fracture to prevent another fall or injury and for all staff to know the resident is a fall risk for safety.R5's emergency room X-ray hips 2 views bilateral with pelvis imaging dated 12/25/25 at 9:43 PM shows: Impression: Acute right intertrochanteric hip fracture. The facility's policy titled, Fall Risk Prevention/Reduction last revised 7/2025 states, Policy: Riverside [NAME] Rehabilitation will provide a safe environment by taking actions to reduce the risk of falls during a resident's stay.Procedure: A. On admission a fall risk assessment will be completed.Any resident at high risk of falls will be put on fall risk precautions.C. If a resident is at risk for falls, then the interdisciplinary team will initiate the following protocol: 1. Place a yellow dot on the resident's door and chart to identify fall risk precautions 2. Place the bed in the lowest position and lock the wheels 3. Place the call light within reach of the resident at all times 4. Assess the resident's environment for any hazards and remove them promptly 5. Provide appropriate supervision/assistance while ambulating or transferring 6. Keep environment well lit in the room, bathroom and resident areas 7. Document interventions in the clinical record.11. Complete fall intervention checklist.

Based on interview and record review, the facility failed to assess and notify the provider of changes in a resident's condition after fall incident with injuries and pain for R2 and R6. This resulted in a delay of treatment for R2 and R6 for pain and a fracture from a fall incident. The facility failed to notify the provider of R4's change of condition that included vomiting blood and black tarry stools that resulted in the need for hospitalization and blood transfusions. This applies to 3 of 3 residents (R2, R4, and R6) reviewed for resident injury and improper nursing. The findings include: 1. R2 was admitted to the facility on [DATE] with multiple diagnoses which included mesothelioma, peripheral vascular disease, neoplasm-related pain, muscle weakness, difficulty in walking, osteoarthritis, and periprosthetic fracture around internal prosthetic right hip joint per the EMR (Electronic Medical Record). R2's Progress Note, Late Entry, created on 06/02/24 at 2:25 PM, effective date of 05/29/24 at 2:12 PM, showed On 05/29/24 about 1650 (4:50 PM) I witnessed/heard alarm as R2 got up from recliner in the day room and started to walk. I was at the nurses station and went to stop him. Before I could reach him, he fell forward hitting the right side of his head on the table, and he started to bleed. I applied pressure to the wound while (Nurse) did vitals, called family, physician, and sent him to the hospital for eval. On 01/21/26 at 2:33 PM, V8 (RN/Registered Nurse) stated on 05/29/24, during shift change, R2 had a fall. V8 stated she did not witness the fall but assisted the nurse who witnessed the fall. V8 stated she obtained R2's vitals and waited with R2 until EMS (Emergency Medical Services) arrived to transport R2 to the ER (Emergency Room). V8 stated R2 returned to the facility from the ER the same night. V8 stated R2's return from the ER was not documented in the medical record. V8 stated after a resident has a fall, the nurses complete a three-day, head-to-toe assessment on the residents. V8 stated if a resident reports new pain after a fall, the provider should be notified. V8 stated the provider should have been notified of R2's complaints of pain in the right thigh. V8 stated R2 should have had x-rays after the fall on 05/29/24. On 01/21/26 at 3:35 PM, V9 (RN) stated R2's wife informed her that R2 had fallen a few days ago and had been complaining of pain in the right leg and foot. V9 stated she noticed R2 did not get an x-ray of the right leg or hip when he fell a few days prior and went to the hospital. V9 stated if a resident falls and is complaining of a new onset of pain, the provider should be contacted. On 01/21/26 at 11:09 AM, V7 (Physical Therapy Assistant) stated R2 was evaluated for therapy on 05/23/24. V6 stated upon evaluation, R2 was able to ambulate 200 feet without pain. V7 stated R2 was seen again for physical therapy on 05/24/24, 05/27/24, 05/28/24, and 05/30/24 without complaints of pain. V7 stated on 05/30/24, a change with R2's gait was noticed. V7 stated there was no documentation of the nurse being notified of the change in gait. V7 stated on 05/31/24 R2 was seen for physical therapy. V6 stated while R2 was ambulating, R2 presented with an antalgic gait pattern (painful, slow gait speed, and decreased stance on his right lower extremity). V7 stated R2 described the pain level as five out of ten to the right lower extremity. V7 stated when residents have a change in their gait or complaints of pain, the nurse should be notified of the change in condition. On 01/27/26 at 3:40 PM, V2 (DON/Director of Nursing) stated the nurses are expected to document on falls for 72 hours after the fall. V2 stated if there are any changes with pain, new symptoms, or new injuries, the doctor must be notified. On 02/02/26 at 1:30 PM, V49 (MD/Medical Doctor) stated the nurses should immediately report to the medical providers caring for the residents when there is new pain after a fall. V49 stated he expects the nurses to thoroughly assess the residents, monitor new symptoms, and notify the provider of changes. V49 stated if they are not notified, more injuries could occur.R2's EMR (Electronic Medical Record) showed: Vitals and Pain only note dated 05/30/24 at 12:47 AM, showed, Vocal complaints of pain. New location: right thigh generalized. Pain socre:2. Skilled Evaluation dated 05/30/24 at 3:56 AM, showed, Pain: Right thigh generalized. Pain core 2. Advanced Skill Evaluation dated 05/30/24 at 11:53 PM, showed, Pain: Right thigh generalized. Pain score: 2. Advanced Skilled Evaluation dated 05/31/24 at 11:31 PM, showed, Pain: Right thigh generalized. Pain score: 2. Advanced Skilled Evaluation dated 06/01/24 at 9:30 PM, showed, Pain: Right thigh generalized. Pain score: 5. Aching. R2's Progress Note dated 06/02/24 at 1:06 PM, showed, Patient complaining of right hip pain and states he is unable to move right foot. Patient wife reports that patient was sent to (Hospital) ER on 05/29 from a fall here at (Facility). Patient's chart from (Hospital) shows head CT, results were negative, but no Xray of right hip. MD paged at this time. Progress Note dated 06/02/24 at 1:38 PM, showed, MD (Name) called back. Stated reasonable to send patient to ER for Xray. Ambulance called and arrived to (Facility) at 1:30. Patient left via ambulance at 1:35, wife accompanying. Report called to (Hospital) ER. Progress Note dated 06/02/24 at 4:36 PM, showed, Writer checked Epic for update on patient. Results are periprosthetic fracture of hip. On call nurse, (Name), called and informed.R2's MAR (Medication Administration Record) for May 2024 showed prior to R2' fall on 05/29/24, R2 had active orders for Oxycodone 5 mg. The same MAR showed R2 did not take any Oxycodone in May 2024. R2's progress notes and skilled evaluation notes showed no complaints of pain to the right thigh or leg prior to the fall on 05/29/24. R2's progress notes and assessments showed no documentation of notifying any provider of the change in R2's gait, or the onset of pain to R2's right extremity until 06/02/24. R2's (Hospital) Emergency Department Provider Notes dated 05/29/24 at 10:37 PM, showed, Patient is an [AGE] year-old male who presents to the emergency room, chief complaint of head injury. Patient states that he hit the back of his head, states that he otherwise had no injury anywhere else. Patient denies any pain throughout any other aspect of his body, states that he had cut to the back of the head, which has since stopped bleeding. Musculoskeletal: Negative for neck pain. and neck stiffness. Injury to the back of the head. Head: Normocephalic. Comments: Patient has a laceration on the right parietal aspect of the head; however, laceration is shallow and is not bleeding at time of assessment. Medical Decision Making: patient presents to the emergency room, chief complaint of head injury, this time CT (Computed Tomography) head will be obtained. Throughout the rest of his exam, there is no evidence of trauma or injury. Patient CT head is negative. Patient is provided fluids and is then discharged home. (Hospital) Healthcare Emergency Department Provider Notes dated 06/02/24 at 5:15 PM, showed, R2 is an [AGE] year-old male with a history of CAD (Coronary Artery Disease), mesothelioma, hyponatremia presenting for right hip pain after a ground-level fall 2 days ago. Patient was seen in the ER at that time, however, did not have hip pain, and complained of head pain, and a had laceration which was repaired in the ER. Patient had a CT of his brain at that time which was also unremarkable. Patient discharged back to the facility where he even completed a day of physical therapy. He was transferred back to the facility that he was in. Musculoskeletal: Limited range of motion of right hip due to discomfort. Full range of motion of hip flexion extension of left hip. Patients notably have minimal discomfort with passive range of motion of the right hip. There is questionable shortening of the right hip approximately 1 cm (centimeter). X-ray hip right 2 views: Final Result, Findings/Impression: The bones are demineralized. Status post right hip arthroplasty with an acute comminuted periprosthetic fracture through the proximal diaphysis extending to the level of the tip of the femoral stem. Fracture also involves the base of the lesser trochanter, which is distracted by at least 8 mm (millimeter). Additional displaced fracture component through the greater trochanter. Clinical impression: Periprosthetic fracture of hip. Medical Decision Making: Discussed with our orthopedic surgeon as well as orthopedics who state they do not have the ability to repair this type of fracture. Discussed with (Hospital) Ortho who are agreeable to transfer at this time for likely operative fixation. Family notified of the plan to transfer to (Hospital). (Hospital) Encounter Summary, Orthopaedic Surgery Progress Note dated 06/07/24, showed, Underwent ORIF (Open Reduction and Internal Fixation) R femur with Doctor (Name) on 06/03/24. Progress Notes dated 06/08/24 at 12:00 PM, showed, Patient returned to facility per vehicle in wheelchair. Vital signs stable, reports not happy to be back. Family in to see. No report received from (Hospital). Orders entered. Progress Note, Medical Professional Note, dated 06/10/24 at 1:36 PM, R2 is an [AGE] year-old male who is admitted to (Facility) for further rehabilitation needs, he previously had a witnessed fall at the end of May. He was found to have difficulty moving right leg and complained of right hip pain. He was further evaluated in the ER and was found to have acute comminuted periprosthetic fracture through the proximal diaphysis extending to the level of the tip of the femoral stem. Fracture also involves the base of the lesser trochanter, which is distracted by at least 8 mm. Patient was then transferred to (Hospital) for further management. He underwent ORIF of the right femur on 06/03/24. R2's EMR showed no documentation of the medical provider or nurse practitioner being notified of right lower extremity pain that occurred after R2's fall on 05/29/24. R2 had complained of pain to the right thigh and/or leg beginning 05/30/24 which was not reported to the provider until 06/02/24. 2. R4 was admitted to the facility on [DATE] with multiple diagnoses which included acute kidney failure, end stage renal disease, malignant neoplasm of colon and rectum, melena, and gastrointestinal hemorrhage per the EMR. R4's Progress Notes dated 11/29/25 at 11:44 AM, showed, Resident complained of feeling nauseated since early this morning and did not eat her breakfast. Message sent to (Doctor) re: (regarding) this matter and to obtain anti-nausea meds. Awaiting return call. On 01/22/26 at 1:05 PM, V15 (CNA) stated he was the CNA taking care of R4 on the night of 11/28/25. V15 stated R4 vomited three times during the night. V15 stated the vomit had blood and blood clots in it. V15 stated R4 had a bowel movement that was dark in color. V15 stated the vomit was dark red and had an odor. V15 stated he informed the nurse of the vomit and bowel movement. V15 stated the nurse did not immediately go into the room to assess R4. V15 stated he was not sure if the nurse went in the room at all to assess R4. On 01/23/26 at 10:31 AM, V18 (RN) stated she took care of R4 during the night on 11/28/25. V18 stated R4 did not say she was sick or nauseated. V18 stated V15 did not tell her that R4 was vomiting blood or had black stools. V18 stated R4 was new, and the facility did not know much about R4. On 01/27/26 at 3:40 PM, V2 (DON) stated if a resident is throwing up and has black tarry stools, the CNA should report a change in condition to the nurse. V2 stated after it is reported to the nurse, the nurse should notify the doctor. V2 stated if the nurse does not notify the doctor, the resident could have abnormal lab values, a health decline, or death can occur. V2 stated the nurses should report to the provider immediately if a resident has a change in condition. On 02/02/26 at 1:30 PM, V49 (MD) stated it is expected that the nurses immediately assess residents with changes in condition, monitor new symptoms, and immediately report to him or any other providers caring for the residents when there is a change in condition. V49 stated if the providers are not notified, more injuries can occur. R4's Progress Notes dated 11/29/25 at 11:02 PM, showed, Gastrointestinal: Abdomen is non tender. Complaint of nausea. Progress Notes dated 12/01/25 at 7:44 AM, showed, Received call from lab with critical hgb (hemoglobin) 3.8 and hematocrit 12.4. Placed call to resident's nurse (Name) RN to notify. Progress Notes dated 12/01/25 at 8:42 AM, showed, Critical hgb 3.8, b/p (blood pressure) 106/44, hr (heart rate) 61, 91% 2L (Liters), resp even & non labored, t (temperature) 98.0, lightheaded, sent AM (American Messaging) to (Doctor) at 0755, no response. Called answer service and had him paged at 8:05, no response. Prior to EMT (Emergency Medical Technician) arriving, had large bloody stool. Notified ADON (Assistant Director of Nursing) at 8:06 that this nurse is sending patient to ER (Emergency Room) and why. Gave report to (Hospital) ER RN (Name) at 8:10. Notified son (Name) at 8:15, dialysis notified at 8:17. R4's (Hospital) Order Tracking, Complete Blood Count final result dated 12/1/25 showed the lab was ordered on 12/1/25. Red Blood Cells 1.24 (normal range 4.00-5.20), Hemoglobin 3.8 (normal range 12.0-16.0), Hematocrit 12.4 (normal range 36.0-46.0). Lab ordered on 11/27/25 showed, Red Blood Cells 2.66, Hemoglobin 8.1, and Hematocrit 25.4. Hospital Blood Bank Results showed R4 had a blood transfusion on 12/01/25. Three units of packed red blood cells leukoreduced transfused. R4's ED (Emergency Department) Triage Notes dated 12/1/25 at 8:49 AM, showed Assessment & Plan showed Reports persistent vomiting of blood when first transferred to the facility, subsided over the last few days. Zofran started at the facility, helped tolerate pills. Imaging normal. Hemoglobin low. Differential Diagnosis; Gastrointestinal bleed: vomiting blood, low hemoglobin. Plan: Admit to IMCU (Intermediate Care Unit), GI (Gastrointestinal) consult, possible endoscopy, colonoscopy, hemoglobin stabilization, monitoring, PPI (Proton Pump Inhibitor) drip started. Three units of blood ordered. R4's MDS (Minimum Data Set) dated 01/06/26 showed R4 was cognitively intact. R4's EMR showed no documentation of the physician or the nurse practitioner being notified of R4 vomiting blood or having black tarry stools on 11/28/25. R4's order Summary Report for November 2025 showed R4 had an order for Ondansetron 4 mg (milligrams) by mouth every four hours as needed for nausea and vomiting written on 11/29/25. R4's Order Administration Note dated 11/30/25 at 8:00 PM, showed, R4 complained of nausea/vomiting and received Ondansetron 4 mg. R4's EMR showed no notification of the provider being notified of the nausea/vomiting. 3. R6 was admitted to the facility on [DATE] with multiple diagnoses which included encounter for surgical aftercare following surgery on the digestive system, pneumonia, muscle wasting and atrophy, muscle weakness, cognitive communication deficit, difficulty in walking, chronic kidney disease per the EMR. R6's Progress Notes dated 09/17/25 at 6:15 PM, showed CNA called for nurse to come to patient's room. CNA had already assisted patient up off of the floor and into her recliner. CNA had been transferring the patient with her walker. Patient lost her balance and fell onto the floor with guided assistance from the CNA. Patient's family member was in the room when I entered the room. Patients appear to be shaken up from the fall. Denies any new pain. Patient denies hitting her head. Pink mark noted to middle of back and right upper shoulder. Dr. (Name) notified of fall. On 02/02/26 at 4:09 PM, V32 (CNA) stated she was taking care of R6 when she fell. V32 stated R6 lost her balance while standing, fell backwards, and was guided to the floor. V32 stated V30 (RN) assessed R6 while on the floor and was lifted off the floor by V32 and V30. V32 stated R6 did not complain of pain at the time of the fall. V32 stated R6 was a stand pivot with transfers. On 01/27/26 at 12:00 PM, V30 stated R6 had a witnessed fall on 09/17/25 around 6:15 PM. V30 stated when she went in the room to assess R6, V32 had already assisted R6 back in the chair. V30 stated R6's family assisted with helping to get R6 off of the floor with V32. V30 stated she should have assessed R6 first before being lifted from the floor. V30 stated R6 denied pain initially at the time of the fall but had a pink mark in the middle of her back and to her right upper shoulder. V30 stated V32 told her R6 had hit her back on the dresser when she fell. V30 stated she did not consider the pink marks to her back and shoulder an injury because it was not open or an abrasion. V30 stated on 09/17/25 at 6:37 PM, she administered Tylenol 650 mg for back pain. I don't think that I should have informed the doctor of back pain after I gave her the medication. V30 stated on 09/17/25 at 8:04 PM, she administered Tramadol for left hip pain. V30 stated she did not update the doctor that R6 was having pain in her hip or back after the fall. On 01/27/26 at 12:37 PM, V31 (Rehab Director) stated on 09/18/25 during therapy, R6 complained of back pain, five out of ten. V31 stated R6 stated her pain was due to a fall the previous day. V31 stated on 09/19/25, R6 complained of pain again with movement, and the nurse was notified. V31 stated on 09/21/25, R6 complained low back pain, seven out of ten. V31 stated therapy would have been on hold if they knew R6 had fractures to her back. V31 stated R6 was discharged to the hospital. On 01/27/26 at 3:40 PM, V2 stated residents should not be lifted from the floor after a fall until the nurses assess them. V2 stated R6's pink mark to her shoulder and her back could have been an injury related to the fall on 09/17/25. V2 stated the doctor should have been notified sooner of the pain to R6's back related to the fall. On 02/02/26 at 1:10 PM, V48 (Nurse Practitioner) stated she was not aware of the increasing pain that R6 was experiencing to her back and hips after the fall. V48 stated the providers should have been contacted about the increasing pain sooner. V48 stated x-rays could have been obtained earlier. V48 stated if the providers are not notified of a change in a condition, the problem could get worse and go in the wrong direction. V48 stated it is expected the nurses to notify the providers immediately with changes in pain after a fall or any other changes in condition for all residents. R6's Progress note- Administration Note dated 09/17/25 at 6:37 PM, showed Acetaminophen Oral Tablet 325 mg, give 650 mg by mouth every six hours as needed for pain-back. Progress note- Administration Note dated 09/17/25 at 8:04 PM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for pain moderate (4-6) severe (7-10). Progress note- Administration Note dated 09/18/25 at 10:05 AM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for pain moderate (4-6) severe (7-10). Progress note- Administration Note dated 09/18/25 at 9:00 PM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for pain moderate (4-6) severe (7-10). Progress note- Administration Note dated 09/19/25 at 8:36 PM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for moderate pain (4-6) severe (7-10). Progress note- Administration Note dated 09/20/25 at 11:04 AM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for pain moderate (4-6) severe (7-10). Progress note- Administration Note dated 09/20/25 at 7:35 PM, showed Tramadol HCL oral tablet 50 mg, give one tablet by mouth every six hours as needed for pain moderate (4-6) severe (7-10). Progress Note- Adv Skilled Evaluation dated 09/21/25 at 10:42 AM, showed, Pain: Indicators of pain: Vocal complaints of pain. Pain issue: 001: New: Location: Lower back. Pain score: 6. Pain Note: 8. Progress Note dated 09/21/25 at 9:29 PM, showed Patient c/o (complaints of) right hip and right low back pain increasing since fall on 09/17/25. Increase in pain with movement. Foot is not externally rotated. Does not want to go to the ER. Paged on call Doctor (Name). Order for x-ray of right hip and CT scan w/o (without) contrast of lumbar spine. Patient prefers (Hospital). Explained to her the caravan can take her tomorrow. But, if the CT scan cannot be scheduled tomorrow, she needs to go to the ER to be evaluated, so physical therapy will not be delayed. Call patient's sister, (Name), and informed her. (Sister) lives 45 minutes away if she needs to accompany the patient to the appointment. Progress note dated 09/22/25 at 5:42 AM, Patient decided to go to (Hospital) ER for right hip pain. Doctor (Name) notified, sister, notified. Ambulance left at 5:00 AM. Progress note 09/22/25 at 9:29 AM, Family here to pick up some of patient's belongings. Stated she was admitted to (Hospital) for hypoxia. X-ray and tests were okay. Progress note dated 09/26/25 at 4:00 PM, showed, Patient returned from hospital. Imaging there showed an acute L2 (Lumbar) fracture. Patient to wear TLSO (Thoracolumbar Sacral Orthosis) brace during ambulation, can remove when sitting and laying down. Hospital Diagnostic Imaging, MRI (Magnetic Resonance Imaging) of the lumbar spine without contrast, dated 09/23/25, showed, Clinical History: low back pain. Status post fall. Findings: There is an acute to subacute compression fracture of the L2 vertebral body with approximately 45 % height loss. There is no significant posterior retropulsion into the spinal canal. Chronic compression deformities of the L1 and L3 vertebral bodies. R6's EMR showed no documentation of notification to the providers regarding the increasing back and lower extremity pain after the fall. R6 was administered pain medication on different dates for pain related to the fall with no notification of the provider. R6 was not assessed by a provider after the fall until the hospital admission on [DATE]. The facility's Change in Resident's Condition Policy, last revised 01/2026 showed, Policy: It is the responsibility of the nursing staff to report any significant change in a resident's condition to the physician in order to provide continuity of care, and to the responsible family member. A change in condition may include the following but is not limited to: C. Persistent vomiting and/or diarrhea. E. a fall or other injury. F. Any other unusual symptoms.

Based on observation, interview, and record review, the facility failed to provide mechanical soft diet as per physician orders.This applies to 1 of 3 residents (R11) reviewed for safe diet consistency in a sample of 23 residents.On 1/21/26 at 11:58 AM, R11 was observed in the dining room, being fed lunch by V28 (CNA/Certified Nurse Assistant). R11's plate had the following on it: sauteed broccoli, mandarin oranges, chicken salad sandwich, potato chips, and nectar thick root beer.R11's POS (Physician Order Sheet) shows an order dated 1/24/25: regular diet, mechanical soft texture, nectar/mildly thick liquid consistency. R11's Care Plan created 4/4/23 and last revised 2/3/25 states resident is at risk for alteration in nutrition/hydration status secondary to frequent propelling, coughing/choking episodes, increased lethargy, and need for feeding assistance. Interventions include: provide and serve diet as ordered .Resident is receiving mechanical soft, nectar thick liquids.On 1/21/26 at 12:11 PM, V20 (Dietician) said potato chips are not appropriate for a resident on a mechanical soft diet because they have a crunchy texture and a resident on a mechanical soft diet needs to receive all soft foods. V20 said serving potato chips to a resident on a mechanical soft diet poses a risk of difficulty chewing and choking. V20 said if a family member fills out a menu for the resident on a mechanical soft diet and wants chips, the facility should offer the resident mashed potatoes instead because potato chips are not safe to serve. V20 said R11 should not have received potato chips and the kitchen staff should not have served R11 chips. On 1/21/26 at 1:32 PM, V26 (Dining Room Supervisor) said R11's daughter fills out her menus for R11 in advance and V26 just transcribed what R11's daughter requested. V26 said she did not realize she was making a mistake when she wrote chips on R11's menu. On 1/21/26 at 1:38 PM, V27 (Dining Room Service Director) said she is the second set of eyes in the kitchen during meal service that double checks to make sure what is plated is appropriate for the prescribed diet, but she missed R11's tray being plated incorrectly. V27 and V26 said potato chips should not have been served to a resident on mechanical soft diet because chips are a choking hazard.The facility's policy titled, Oral Nutrition & Feeding Assistance last revised 01/2026 states, .Policy: It is the policy of [NAME] Healthcare to ensure that all residents receive required oral nutrition and hydration in a safe, dignified manner that minimizes discomfort, fatigue, and risk of aspiration. Feeding assistance shall be provided in accordance with the resident's comprehensive care plan, diet order, swallowing precautions, and guidance from the interdisciplinary team, including Dietary and Speech Language Pathology.

Based on interview and record review, the facility failed to obtain consent prior to a wound procedure of a cognitively impaired resident. This failure resulted in the facility obtaining a wound biopsy without consent from R2's family.This applies to 1 of 1 (R2) resident reviewed for resident's rights.The findings include:R2 was [AGE] years old. R2 had multiple diagnoses which included hemiplegia and hemiparesis, aphasia, dysphagia, acute and chronic respiratory failure, and lobar pneumonia per the Face Sheet. R2's MDS (Minimum Data Set) dated 06/06/25 showed R2 had severe cognitive impairment.R2's Specialty Physician Wound Evaluation & Management Summary dated 07/10/25 showed, Skin tear wound of the left shoulder, full thickness. Wound size 1.7 x 1.5 x 0.1 cm. Moderate serous exudate. 100% granulation tissue. Wound progress not at goal due to suspicious non healing lesion. Procedure: Biopsy of a skin tear wound of the left shoulder. Consent for procedure: The rationale for biopsy, alternative options, and procedure risks were explained on 07/10/2025 to the patient who indicated agreement to proceed with the procedure.On 08/22/25 at 12:40 PM, V2 (Registered Nurse/Wound Care) stated R2 was admitted to the facility with a left shoulder skin tear. V2 stated on 07/10/25 the left shoulder skin tear was biopsied by the wound care doctor. V2 stated R2 shook his head and gave verbal consent for the procedure. V2 stated I don't recall if the biopsy was discussed with the family before it was done.On 08/22/25 at 1:55 PM, V3 (Social Worker) stated R2 was not able to make decisions or give consents for care or procedures. V3 stated R2's family also did not want decisions made without them being present. On 08/22/25 at 3:26 PM, V7 (family member) stated R2 cognitively was unable to give verbal consent for biopsy. V7 stated verbal consent was not obtained from R2's wife or daughter before the biopsy. R2's EMR (Electronic Medical Record) was reviewed. There was no documentation of verbal consent for the biopsy of the left shoulder given by R2's wife or daughter.

Based on observation, interview, and record review, the facility failed to safely store resident medications and properly assess resident for self-administration of medications. This applies to 1 resident (R52) reviewed for self-administration of medications in a sample of 22. The findings include: R52's Face Sheet shows diagnoses of chronic respiratory failure with hypoxia, atrial fibrillation, heart failure, dyspnea, weakness, reduced mobility, dependence on supplemental oxygen, and history of falling. R52's POS (Physician Order Sheet) shows an order dated 4/25/25 for Albuterol Sulfate (Ventolin) HFA 2 puff inhale orally every 6 hours as needed for wheezing. On 6/10/25 at 1:08 PM, R52's Ventolin inhaler was observed sitting on her bedside table next to her. R52 said she was feeling anxious and her stomach was bothering her and was observed with shaky hands. R52 said she takes the inhaler as needed and she did not know how often that was. R52 said she uses the inhaler when she gets short of breath which she estimated to be less than 10 times a day. When asked how often she can take the inhaler R52 said, I don't know how many times a day or how many times an hour, it just depends on my movements. R52 said she was diagnosed with Atrial Fibrillation, a heart arrhythmia, after she started taking the inhaler. R52 said she gets jumpy like this after taking her inhaler and pointed out her shaky hands. No assessment could be found in R52's record showing the resident is safe to self-administer her inhaler. On 6/12/25 at 1:01 PM, V2 (DON/Director of Nursing) said she did not know if an assessment was done to see if R52 was safe to self-administer her inhaler. V2 said side effects of over use of a Ventolin inhaler are increased heart rate and the resident could get shaky. V2 said Ventolin is an inhaled steroid/bronchodilator and a resident could have cardiac side effects from inhaled steroids. V2 said the inhaler should not be taken 10 times in a day, that is too frequent. R52's Care Plan initiated on 5/6/25 states R52 has altered respiratory status/difficulty breathing related to COPD (Chronic Obstructive Pulmonary Disease). Interventions include Administer medication/puffers (inhalers) as ordered. Monitor for effectiveness and side effects. R52's Care Plan does not say she has been assessed to be able to self-administer medications. The facility's policy titled, Self- Administration of Medication approved 07/24 states, Policy: Residents may administer their own medications, if requested, once their ability to do all functions of administration have been determined using the following established guidelines: .B. A Folstein Mini-Mental Test is obtained on admit. C. The resident must be able to demonstrate an ability to dispense the medications from the receptacle. D. The resident must be able to come to the nursing station to obtain the medications. Procedure: . D. Medications must remain secured at the nursing station. E. Nursing remains responsible for: .3. monitoring for effects and side effects .F. Self- administration of medication should be addressed in the care plan with an established plan for continuing to monitor ability to self-administer drugs on an ongoing basis, including reliability in following the program and reassessment of functional ability.

Based on observation, interview, and record review, the facility failed to implement fall interventions for a high fall risk resident with history of fall. This applies to 1 resident (R21) reviewed for fall interventions in a sample of 22. The findings include: R21's Face Sheet shows personal history of traumatic brain injury, paraplegia, and hemiplegia and hemiparesis following cerebral infarction. R21's MDS (Minimum Data Set) dated 5/12/25 shows a mental status assessment could not be completed because resident is rarely/never understood and he has a short term and long term memory problem. R21's Incident note dated 4/9/25 at 10:07 AM states the resident was observed on the floor at 0745 by dietary staff. R21 was on the floor on his back with his feet on the bed. R21's Fall Risk Evaluation documented on 4/9/25 at 10:12 AM shows his Fall Risk Score of 11. R21's Incident note dated 4/9/25 at 10:53 AM states the Interdisciplinary Team reviewed R21's fall and the root cause was determined to be restlessness and resident slid out of bed. New intervention: thick floor mats ordered. R21's Fall Risk Evaluation dated 4/9/25 at 10:12 states if the resident's total fall risk score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented in the Care Plan. R21's Care Plan initiated on 5/24/23 states the resident is High risk for falls related to balance problems, unaware of safety needs, and a history of falls. Intervention initiated on 4/9/25 shows thick floor mats. On 6/10/25 at 11:37 AM, R21 was observed lying in bed, restless and yelling unintelligible words. A thick fall mat was observed on one side of his bed standing on its side, parallel to the mattress, not lying flat on the floor. The other side of the bed had R21's bedside table pushed up to the side of the bed, no floor thick mat on the floor. On 6/12/25 at 11:24 AM, R21 was again observed lying in his bed on his right side, asleep. He again had a thick floor mat standing on end on his left side, parallel to the bed, not lying flat on the floor. The other thick floor mat was observed folded in half and up against the wall on his right side by the head of the bed, not in use. R21's bedside table was pushed up next to his right side of bed. For both of these observations on 6/10 and 6/12, R21 was not eating and did not have food tray on his bedside table. On 6/12/25 at 11:25 AM, V9 (CNA/Certified Nurse Assistant) said she is taking care of R21 and he has 2 thick fall mats. V9 said because there are two beds in R21's room, the staff stand his fall mat up on its side instead of laying the mat on the ground. V9 said the thick mat on the other side of R21's bed should be put down unless it is meal time. V9 said she doesn't know what would happen if R21 rolled out of the left side of the bed with the mat standing upright. V9 said if the mat is flat on the floor, it fits between both beds. On 6/12/25 at 11:42 AM, V8 (LPN/Licensed Practical Nurse) said she is taking care of R21 and his thick fall mats are supposed to be lying flat on the ground. V8 then observed R21's mat standing upright parallel to the bed and she said the mat always has to be flat on the ground and she doesn't know who placed it upright. On 6/12/25 at 1:01 PM, V2 (DON/Director of Nursing) said R21's thick fall mats should be positioned on both sides of his bed lying flat on the ground, not standing up on its side. V2 said the thick fall mats should be lying flat because if the resident were to fall with the mats upright, the fall mat might not work correctly and the resident could fall on the floor instead of having the protection of the thick mat. V2 said both mats should be in place on the floor next to R21's bed unless he is eating. The facility's policy titled, Fall Risk Prevention/Reduction last revised 01/2021 states, Policy: . will provide a safe environment by taking actions to reduce the risk of falls during a residents stay .Procedure: .D. The following additional measures may be implemented for the resident to promote fall prevention. Each resident will be assessed for individual needs .4. Fall mat next to bed .F. Investigation after event: 1. Each event will be reviewed by a member(s) of the care plan and multidisciplinary fall team in attempt to identify potential cause or risk and to implement appropriate interventions most likely to decrease future falls .G. Recognition and Prevention: .2. Communication or interventions/strategy in attempt to reduce the individuals risk and or cause based on the investigation will be entered into the resident plan of care . Safety Guidelines for Preventing Falls: .Use proper equipment recommended for you, including proper seating and assistive devices .

Based on observations, interviews, and record reviews, the facility failed to ensure proper positioning of indwelling catheters. This applies to 2 of 2 residents (R58 & R68) who were reviewed for catheter care in a sample of 22. The findings include: 1. On 06/10/25 at 12:03 PM, R68 was observed in her wheelchair in the dining room and her catheter bag and tubing were on the floor. At 12:27 PM, R68 was observed leaving the dining room and her catheter bag and tubing was dragging on the floor. R68's electronic health records showed that she has diagnoses including acute kidney failure, disorders of the kidneys and ureter and neuromuscular dysfunction of the bladder. 2. On 06/10/25 at 12:13 PM, R58 was observed in her wheelchair in the dining room, and her catheter bag and tubing were observed on the floor. R58's electronic health records showed that she has diagnoses including a history of urinary tract infections and retention of urine. R58 10/3/24 care plan shows a focus of a risk for infection with interventions including staff to follow standard precautions. On 06/12/25 at 11:48 AM, V2 DON (Director of Nursing) said that catheter bags and tubing should be up off the ground for infection prevention. The facility's Urinary Catheter Insertion and Removal policy dated 02/2021 showed that the collecting bags are always off the floor.

Based on observations, interviews, and record reviews, the facility failed to properly store medications for 2 out of 2 residents (R1 & R131) reviewed for medication storage in a sample of 22. The findings include: 1. On 06/10/25 at 11:21 AM, there was one 60-gram bottle of Nystatin powder and one 16-ounce bottle of Betadine solution on R1's bed side table. R1 said that the Betadine solution is used for his wound on his leg. R1's physician orders showed: 10/31/24 Change dressing daily right anterior lower leg, cleanse with normal saline cover wound with betadine dampened gauze secured with paper tape. 6/4/24 Nystatin external powder, apply to groins/testicles topically 2 times a day for fungal rash. 2. On 06/10/25 at 12:52 PM, two 10ml bottles of Systane eye drops were observed on R131's over the bed side table. R131 said that she gives herself the drops twice a day once in the morning and once in the evening. R131's electronic records did not show an order for the Systane drops. R131's 5/27/25 Care Plan showed a focus on documented safety concerns with a goal of resident will remain safe, and interventions including safety measures including strategies to reduce the risk of infection, falls and injuries. R131's Care Plan had a focus on knowledge deficit with interventions including provided education regarding medical devices and therapies . R131 Care Plan had a focus for impaired cognitive function dementia or impaired thought processes related to Alzheimer's. R131's electronic health records showed on 6/5/25 that her cognition is moderately impaired. On 06/12/25 at 11:48 AM, V2 DON (Director of Nursing) said that no medications should be in the residents' room, they should be secured in locked container so nobody can pick them up. V2 said that if the medications are not secured properly, it is a safety issue, it could possibly cause a wrong administration of medication. On 6/12/25 at 3:23 PM, V2 said that the facility does not have a policy on how to securely store medications.

Based on observations, interviews, and record reviews, the facility failed to provide proper hand hygiene while providing resident care for 3 out of 3 residents (R14, R36, and R235) reviewed for infection control in a sample of 22. The findings include: 1. On 06/10/25 at 12:30 PM, V4 CNA (Certified Nurse's Assistant) was observed during lunch feeding R14 and R36 using his right hand and never cleaning his hands between each resident. R14 was on V4 left side at the table and R36 was at V4 right side. V4 with his right hand put food in R36's mouth, and then put a spoonful of pureed pork in R14's mouth, then picks up R36's napkin with his right hand and wipes R36's mouth and then goes back and picks up R14's spoon with his right hand and puts a spoonful of food in R14's mouth. Then V4 picks up R36's coffee cup and uses his right hand to put a straw in it, and then he goes back to R14 and gives her a spoonful of pureed soup with his right hand. Then V4 picks up R14's cup of a red drink with his right hand and gives R14 a drink and then picks up R36's fork with his right hand and puts a piece of cake into R36's mouth. V4 continued feeding R14 and R36 until they were done with lunch, and he never stopped to clean his hands in-between feeding them. R36's electronic health records showed a diagnosis of lack of coordination, and his 5/28/25 Care Plan showed a focus of a risk for infections and a focus of risk for nutrition with interventions including assist with feeding. R36's 4/18/25 electronic health records showed that his cognition is severely impaired. R14's electronic health records showed diagnosis of Alzheimer's disease, dementia, and personal history of traumatic brain injury. R14's 10/03/24 Care Plan showed a focus of an ADL self-care performance deficit related to poor posture with interventions including the resident requires assistance by 1 staff to eat. On 06/12/25 at 11:48 AM, V2 DON (Director of Nursing) said that her expectations are for staff to use hand hygiene between each resident and before and after feeding, for infection control and to eliminate cross contamination. The facility's Handwashing /Hand Hygiene policy dated 06/2022 showed hand hygiene should be done between contacts with different patients. 2. On 06/12/25 at 10:21 AM, during the wound care of R235. V10 wound Nurse closed the room door and turned on the room light wall switch using her gloved hand then touched the resident and his bedding in preparation of his dressing change. After washing her hands V11 Wound Doctor retrieved key from her pocket to give V10 Wound Nurse. V11 held her hands up in front of her waving them stating she was letting them air dry before donning gloves. On 06/12/25 at 02:28 PM, V10 wound Nurse stated hand hygiene should be done before entering the room, before exiting, before giving care, changing from clean to dirty, if you touch something in the environment you should clean your hands before touching the resident. On 06/12/25 at 03:28 PM, V18 Infection Preventionist stated to prevent the spread of infection hand hygiene should be done before and after touching a resident, after removing gloves or going from dirty to clean care. If you touch a door handle you should clean your hands before touching the resident. If you put your hands in your pocket, you should sanitize your hand before touching the resident.

Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 5 of 5 residents (R1-R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R1 was a [AGE] year-old male admitted on [DATE] and having severe cognitive impairment as per the MDS dated [DATE]. On 8/31/24 at 11:00 AM, V1 (Administrator) stated that she heard about the incident and that the ambulance people were complaining that R1 was not clean when they picked him up on 8/24/24 to the hospital. On 8/31/24 at 12:20 PM, V8 (R1's certified nursing assistant / CNA) stated, I heard that EMS (Emergency Medical Service) was complaining that R1 was not super clean at the time of pick up at around 1:45 PM on 8/24/24. I didn't see any bowel movement when EMS picked him up, and I was with another resident. He didn't have a bowel movement for the last 3-4 days. On 8/31/24 at 11:00 AM, V2 (Assistant Director of Nursing / ADON) stated, I was not here when EMS picked up R1 on 8/24/24. When they picked him up, I heard that R1 was a big mess with bowel movements. He ended up having a gastrointestinal (GI) bleed. 2. R2 is an [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. MDS also documented that R2 is dependent on toileting hygiene and showering/bathing. On 8/31/24 at 9:55 AM, R2 stated, They didn't change me today. They changed me last night; the girls might be too busy. On 8/31/24 at 9:55 AM, as per the writer's request, V3 (Registered Nurse / RN) checked on R2, who was observed with a urine-soaked brief and an intense urine smell. On 8/31/24 at 10:00 AM, V4 (Certified Nursing Assistant / CNA) stated, I started my shift at 5:00 AM. I changed R2 early morning, and I am going to change her now. A review of the care plan documents that R2 was care planned for functional bladder incontinence, with interventions including checking every two hours for incontinence. 3. R3 is a [AGE] year-old female with mild cognitive impairment as per the MDS dated [DATE]. MDS also documents that R3 is dependent on toileting hygiene. On 8/31/24 at 10:20 AM, R3 was observed with a urine-soaked brief with mild discoloration (light black). On 8/31/24 at 10:20 AM, V6, CNA stated that she didn't get a chance to change her. 4. R4 is a [AGE] year-old male with cognition intact as per the MDS dated [DATE]. MDS also documented that R4 is dependent on toileting hygiene. On 8/31/24 at 10:05 AM, V10 (R4's wife) stated, R4 was not changed yet. I was giving him a urinal, but still, he is wet. On 8/31/24 at 10:05 AM, as per the writer's request, V5, CNA checked on R4 and observed with a urine-soaked brief. On 8/31/24 at 10:05 AM, V5 stated, I have two halls, and I haven't changed him yet. A review of the care plan documented that R4 was care planned for the risk of impaired skin integrity, with interventions including providing skin care per facility guidelines and as needed (PRN). 5. R5 is a [AGE] year-old male who was readmitted on [DATE]. On 8/31/24 at 10:35 AM, he stated that he had been changed in the early morning and was wet then. On 8/31/24 at 10:40 AM, as per the writer's request, V7 (CNA) checked on R5, and R5 was observed with a soaked brief. On 8/31/24 at 10:40 AM, V7 stated, I changed him around 8:00 AM. He has a colostomy. I am going to change him again. On 8/31/24 at 11:00 AM, V2 added, Residents are supposed to be checked on every two hours for incontinent care. The facility presented an incontinence policy approved on 07/2024 document: Policy: Residents who are incontinent of urine, feces, or both are kept clean, dry, and comfortable while maintaining their dignity. Residents with an incontinence problem are checked for toileting and changing per bladder monitoring pattern.

Based on observation, interview, and record review the facility failed to manage a resident's pain during bathing and wound care. This applies to 1 of 2 residents (R36) reviewed for pain management in the sample of 19. This failure resulted in R36 crying in pain during bed bath, wound treatment, and repositioning. Findings include: According to the face sheet R36 was admitted to facility on April 2, 2024, with multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity and end stage renal disease with dependence on renal dialysis. R36's MDS dated [DATE], shows resident has moderately impaired cognition, and is totally dependent on staff to complete most ADLs (Activities of Daily Living). On July 16, 2024, at 1:08 PM, V7 and V8 (Certified Nursing Assistants, CNAs) gave R36 a bed bath. R36 complained of pain, flinched, and grimaced throughout process. During perineal care R36 cried out multiple times during cleaning of abdominal folds. These areas were visibly reddened and tender. While cleaning R36's right foot, V8 noticed right toes were reddened and extremely tender, R36 flinched and cried as V8 attempted to clean between toes. An object was removed from between toes during process. R36 was not offered pain medications at any time during bathing process nor was the bathing process stopped. V8 was then prompted to stop manipulating R36's toes. On July 16, 2024, at 2:09 PM, V9 (wound care nurse) entered R36's room and started wound dressing preparation. V9 began the treatment process for multiple pressure ulcers. V8 notified V9 that R36 had issues with pain throughout bed bath and that there was a wound or injury to right foot. V9 continued with treatment. V9 applied dressings to pressure wounds, during which R36 continued to complain of pain during treatment and repositioning. V9 began to inspect R36's right foot, R36 complained and cried in pain during V9's initial examination. V9 then moved to obtain saline and gauze pads. V9 then stated she was going clean and examine R36's right foot and toes, at that point V9 was prompted to discontinue procedure until the assigned nurse was notified and R36 was assessed for pain and pain medication was administered. R36's Medication Administration Record (MAR) dated July 2024 shows the following physician's orders for pain medications: 1. Two tablets of acetaminophen 325 mg available every 6 hours and, 2. One tablet of Tramadol HCL 25 mg available every 12 hours for right leg pain. The most recently recorded administration of Tramadol was May 18, 2024 (prior to the incident mentioned above). On July 17, 2024, at 10:51 AM, V2 (Director of Nursing) stated that if staff becomes aware of resident being in pain, then staff should immediately notify the assigned nurse to have resident evaluated or have pain medication administered. Also, that if a procedure is causing resident pain, then that procedure should be paused until pain is relieved either by non-pharmacological methods or available pain medication because resident should not be in unnecessary pain. On July 17, 2024, at 12:59 PM, V21 (Nurse Practitioner) stated he was not aware of R36 having any pain during ADLs and wound treatment. Facility pain management policy dated July 2024 shows A. Each individual with pain, whether it be acute or chronic, has the right to obtain optimal pain relief .

Based on observation, interview, and record review, the facility failed to ensure carrots had smooth consistency for residents who required a pureed diet. This applies to 4 of 4 residents (R16, R20, R38, and R47) reviewed for dietary needs in the sample of 19. The findings include: R16's EMR (Electronic Medical records) showed R16 had multiple diagnoses including vascular dementia, and dysphagia. R16's active order summary report showed an order dated November 16, 2023 for regular diet, pureed texture. R20's EMR showed R20 had multiple diagnoses including Alzheimer's disease, dementia, and traumatic brain injury. R20's active order summary report showed an order dated August 21, 2023 for regular diet, pureed texture. R38's EMR showed R38 had multiple diagnoses including Alzheimer's disease, dementia and feeding difficulties. R38's active order summary report showed an order dated March 22, 2024 for regular diet, pureed texture. R47's EMR showed R47 had multiple diagnoses including cerebral atherosclerosis and metabolic encephalopathy. R47's active order summary report showed an order dated March 22, 2024 for regular diet, pureed texture. On July 15, 2024 at 10:39 AM, V18 (Cook) was observed preparing pureed meals. V18 did not follow any recipes for pureed food. V18 blended a full #6 container (about 8 cups) of carrots and a half cup of thickener. After blending the carrots, V18 put it in a container for serving. The blended carrots looked chunky and not smooth. The blended carrots was tasted and it had hard chunks throughout. V18 took the temperature of the blended carrots, and it was not hot enough, so he placed it inside the steamer until it was time for it to be served. On July 15, 2024 at 11:31 AM, V18 took the container of blended carrots out of the steamer and placed it in the steam table for serving. V18 and V23 (Dietary Manager) were asked if the blended carrots were ready to be served and both V18 and V23 responded, yes. The blended carrots were again tasted. There were still hard chunks of carrots throughout, and the consistency was not smooth. V18 and V23 were asked to try the blended carrots and were asked, what they thought of the texture. V23 stated that the carrots needed to be cooked some more. V18 stated the carrots were chunky and that it needed to be blended some more. The facilities modified texture foods policy dated January 2024 showed that the foods requiring a modification to a puree texture will have a smooth texture.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of ADL (activities of daily living) care and wound care. In addition, the facility failed to ensure that a urinary catheter bag was not placed on the floor. This applies 5 of the 19 residents (R26, R36, R39, R40, R53) reviewed for infection control in the sample of 19. The findings include: 1. R26 was on Enhance Barrier Precaution (EBP) due to gastrostomy tube according V11 and V17 (both Certified Nursing Assistants, CNA). On July 16, 2024, at 12:15 PM, V11 and V17 (Both CNA/Certified Nursing Assistants) provided grooming care to R26. After V11 completed the care, she removed her gloves and sanitized her hands, then she carried R26's soiled gown with her bare hands without a plastic linen bag and carried it through the hallway into the soiled linen room. 2. On July 16, 2024, at 2:19 PM, V17 and V20 (Both CNAs) assisted R40 to the toilet. After R40 used the toilet, V20 wiped R40's perineum. V20 removed her gloves and without hand hygiene, put the incontinence brief and pulled the pants back on to R40. Then V17 and V20 transferred R40 back to the wheelchair via the sit to stand mechanical lift without V20 performing hand hygiene. On July 17, 2024, at 11:48 AM, V2 (Director of Nursing) stated staff must wash their hands before and after care and perform hand hygiene and change gloves in between task. Soiled linen or items are to be placed in a plastic bag when bringing it from the resident's room to the soiled utility room, to prevent infection or spread of infection. 50501 3. R36 was admitted to facility on April 2, 2024, according to resident face sheet, with multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity, and end stage renal disease with dependence on renal dialysis. R36's MDS (Minimum Data Set) dated July 9, 2024, shows that resident has moderate cognitive impairment, and is totally dependent on staff to complete most ALDs (Activities of Daily Living). R36's care plan dated July 16, 2024, requires EBP (Enhanced Barrier Precautions) due to hemo dialysis access port and multiple pressure ulcers. An enhanced barrier precautions sign was posted on R36's door. On July 16, 2024, at 1:30 PM, V7 and V8 (CNAs) prepared R36 for bed bath by transferring R36 to bed using the mechanical lift. Both V7 and V8 were only wearing gloves. Then R36 was undressed, V7 and V8 were in the process to start giving R36 a bed bath, at this point V7 and V8 were prompted to put the gown on. Once bed bath was completed V9 (wound care nurse) was notified. On July 16, 2024, at 2:09 PM, V9 entered R36's room put on gloves and began preparing materials for wound care. V9 performed hand hygiene and put on clean gloves and stated she was going to start the dressing change, at this point she was prompted to put on the gown. On July 17, 2024, at 10:51 AM, V2 (DON) stated that if staff are preparing to conduct any high contact resident care on a resident with EBP, gown and gloves are to be worn by all staff. V2 further stated the high contact resident care activities included dressing, bathing, transferring, device, and wound care. Facility EBP policy dated July 2024 shows . 2. EBPs employ targeted gown and glove use during high contact resident care activities .a. gloves and gown are applied prior to performing the high contact resident care activity .3. Examples of high contact resident care activities include .b. bathing and showering .c. transferring .g. device care and .h. wound care . 5. EBPs are indicated . for residents with wounds and/or indwelling medical devices. 4. R39's Face sheet shows diagnoses including neuromuscular dysfunction of bladder. R39's care plan dated March 24, 2024, shows R39 has indwelling supra pubic catheter. On July 16, 2024, at 12:55 PM, R39 was sitting in a chair in a reclined position, at 1:10 PM, V5 (CNA) unhooked the urinary collection bag and placed the bag on the floor during repositioning R39 for his meal. The urinary bag remained on the floor V6 (Nurse) was notified about the issue, then V5 with her bare hands (without wearing gloves) hung the urinary collection bag on the side of chair but it remained in contact with floor. On July 17, 2024, at 11:03 AM, V2 stated that no staff member should handle resident devices (catheters) without first putting on gloves, and that drainage bags should never be on the floor for any reason. Facilities Urinary Catheter Insertion and Removal policy dated July 2024 shows .L. To achieve free flow of urine .4. Collecting bags are always off the floor . 41855 5. R53's EMR (Electronic Medical Record) showed R53 was admitted to the facility on [DATE]. R53's diagnoses included pressure ulcer stage 4 of sacral region, pressure ulcer stage 3 of other region, paraplegia, major depressive order, peripheral vascular disease, and diabetes type 2. R53's MDS dated [DATE], showed R53 had moderately impaired cognition. On July 17, 2024, at 9:29 AM, V10 (LPN/Licensed Practical Nurse) was preparing to provide wound care to R53. After supplies were gathered, hand sanitizer was used, gown and gloves were donned. V10 said R53's coccyx dressing had already been removed because he had just had a bowel movement. V10 picked up gauze she had soaked with normal saline and cleaned the wound in a circular motion. V10 removed gloves, used hand sanitizer, and put on new gloves. V10 picked up rolled gauze and wet it with a wound solution and packed the wound using a sterile cotton tipped applicator. V10 used her fingers to put zinc around the wound. V10 removed the glove from the hand that had the zinc on it and put on a new glove without using hand sanitizer. V10 covered the area with a bordered silicone super absorbent dressing. V10 moved to the left lower leg wounds. She removed her gloves, used hand sanitizer, and put on new gloves. V10 removed the soiled dressing from the left lower leg proximal wound and then the left lower distal leg wound. With the same gloves, V10 put some gauze over each wound and said she just puts it there because he usually bleeds. V10 picked up new gauze that was wet with normal saline and cleaned the proximal wound and then covered with a bordered silicone super absorbent dressing. With same gloves, V10 picked up another gauze wet with saline and cleaned the distal wound and covered the wound with a bordered silicone super absorbent dressing. V10 removed her gloves, used hand sanitizer, and put on new gloves. R53 was repositioned to expose the right lower leg wound. V10 removed gloves, sanitized her hands, and put on new gloves. V10 then removed dressing from the wound and with the same gloves picked up gauzes soaked with normal saline and cleaned the entire wound. V10 removed gloves, sanitized her hands, and put on new gloves. V10 soaked gauze with wound solution and placed on wound, covered with bordered dressing. On July 17, 2024, 10:07 AM, V10 said she changes her gloves after she cleans the wound because the dressing, she removes is dirty and until she cleans the wound, the wound is also dirty and that is why she removed her gloves and used hand sanitizer after cleaning the wound and putting on new gloves to do the cleaning, treatment, and dressing. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said before starting the procedure, the staff will hand hygiene and don gown and/or gloves. The old wound dressing should be removed, and then the gloves should be discarded, hand must be sanitized, and new pair of gloves must be donned. With the new gloves on, the treatment can be applied if ordered. If the nurse did not use a tool (cotton tipped applicator, tongue depressor) and instead used a gloved hand to apply the treatment, then the gloves get removed, hands must be sanitized, and new gloves should be donned before applying the outer dressing. Facility provided policy titled, Standard Precautions with revision date of May 2017 showed B. Handwashing. 1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether gloves are worn or not 3. Also wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites .C. Gloves . 3. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. 4. Removed gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Facility provided policy titled, Dressing- Clean Technique with revision date of February 2021 showed Procedure .I. remove soiled dressing J. Remove gloves, perform hand hygiene, apply new gloves L. Clean wound P. Remove gloves, perform hand hygiene, apply new gloves R. Apply prescribed topical agent to wound. S. Apply wound dressing.

Based on observation, interview, and record review, the facility failed to assist a resident that was assessed to require assistance with ADLs (Activities of Daily Living). This applies to 1 of 1 resident (R436) in the sample of 19. The findings include: R436's EMR (Electronic Medical Record) showed R436's most recent admission to the facility was on July 10, 2024. R436's diagnoses included generalized muscle weakness, Alzheimer's with late onset, dementia, polyneuropathy, and ESBL (Extended Spectrum Beta Lactamase) in his urine requiring him to be in contact isolation. R436's MDS (Minimum Data Set) dated July 16, 2024, showed R436 had severe cognitive impairment. R436 was recently discharged from this facility on February 2, 2024. His MDS was incomplete at the time of the survey due to recent admission. On July 15, 2024, at 11:02 AM, R436 was in bed asleep. He was unshaven and his nails were noted to be reaching out past the end of his fingers and were uneven and jagged. On July 16, 2024, at 11:45 AM, R436 was sitting up in his room, he said he would like to be shaved and have his fingernails cut. He was wearing facility sweatshirt and sweatpants. On July 16, 2024, at 11:55 AM, V11 (CNA/Certified Nurse Assistant) showed surveyor the shower book at the nurses' station and V11 said R436 should be showered today. V11 said residents in isolation are done at the end of the day and showers are disinfected once done to prevent the spreading of infection. On July 17, 2024, at 10:02 AM, R436 was sitting in his wheelchair wearing the same clothes as yesterday. There was a white substance down the front of his facility sweatshirt and a musty foul odor was noted. His hair was uncombed. R436 said he really wants a shave and wants to have his nails cut. On July 17, 2024, at 11:09 AM, V2 (DON/Director of Nursing) said residents should be offered hygiene care daily regardless of isolation status. Hygiene care would include oral care, shower if preferred or bed bath/wash up at sink, shaving, nail care, and clean clothes. Facility provided their policy titled, General Requirements for Nursing and Personal Care- [NAME] with revision date of February 2011. The policy showed .5. Personal care shall be provided on a 24-hour, seven day a week basis. This shall include but not be limited to the following a .daily personal attention including skin, nails, hair, and oral hygiene . b. each resident shall have at least one complete bath and hair wash weekly .c each resident shall have clean suitable clothing in order to be comfortable, sanitary, free of odors, and decent appearance .

Based on interview and record review, the facility failed to offer and administer the pneumonia vaccines to new and current residents residing in the facility. This applies to 3 of 6 residents (R29, R53, R286) reviewed for immunizations in the sample of 19. The findings include: 1. R29's Electronic Medical record (EMR) showed R29 was admitted to the facility on [DATE]. The medical record failed to show R29 had received any pneumonia vaccines. The medical record failed to show that the facility had offered any type of pneumonia vaccine to the resident. 2. R53's EMR showed R53 was admitted to the facility on [DATE]. R53 received the pneumococcal conjugate 13-valent vaccine prior to his admission on March 25, 2021. R53 would have been eligible for the PPSV-23 (Pneumococcal polysaccharide vaccine) one year later. R53's medical record failed to show the facility offered the PPSV 23 vaccine to the resident. 3. R286's EMR showed R286 was admitted to the facility on [DATE]. There wasn't any documentation to show R286 had received any pneumonia vaccines. The medical record failed to show the facility had offered R286 any pneumonia vaccines. On July 17, 2024, at 2:26 PM, V12 (Vice President of Post-Acute Care) said she was unable to locate any pneumonia vaccine record for R29 and R286. On July 16, 2024, at 2:19 PM, V4 (Infection Prevention Nurse) said pneumonia vaccines should be offered to all new admission, and those that need the vaccine. The staff will document in the progress notes what vaccine was given, and it will also be documented under the immunization tab in the electronic medical record. Consents get scanned into the medical record and if the resident refuses, then there should be a progress note documenting the refusal and any education provided to the resident and/or their family members about the risks and benefits of receiving the vaccine. On July 17, 2024, at 10:53 AM, V3 (Assistant Director of Nursing) said she was not sure who is offering the vaccine to the residents, she said she believes it is to be offered on admission, and one staff member gets the consent, while someone else is responsible for looking up historical records. V3 was not sure what pneumonia vaccine was available to be given to the residents. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said it is her understanding that all nurses are to offer the pneumonia vaccines to all new admission (Influenza offered during October to March). This is being discussed each morning in the morning meeting. If the resident has not had the vaccines, it is the expectation that the vaccines are offered. If it is offered, there should be a progress note showing it was offered, consented, or refused. If consented, it would be documented under the immunization tab. The facility policy titled, Pneumococcal Immunization, with revision date December 2019 showed, The purpose is to reduce the overall incident of pneumococcal by providing the pneumococcal vaccine to the residents [AGE] years of age and older and to others at high risk.

Based on interview and record review, the facility failed to offer the Covid-19 vaccine to new and current residents residing in the facility. This applies to 2 of 6 residents (R286 and R437) reviewed for Covid-19 immunizations in the sample of 19. The findings include: 1. R286 was admitted to the facility on [DATE]. There wasn't any documentation to show R286 had been offered the Covid-19 vaccines. The medical record showed R286 had received one dose of the Covid-19 vaccine on September 20, 2021 and the medical record failed to show the facility had offered R286 the Covid vaccine on or after his admission to this facility. 2. R437 was admitted to the facility on [DATE]. The medical record showed she had not received any Covid-19 vaccines. The medical record failed to show that the facility offered the Covid-19 vaccine to R437. On July 17, 2024, at 2:26 PM, V12 (Vice President of Post-Acute Care) said she was unable to locate any other vaccine record for R286. On July 16, 2024, at 2:19 PM, V4 (Infection Prevention Nurse) said Covid-19 vaccines should be offered to all new admission, and those that need the vaccine. The staff should document in the progress notes of the resident what vaccine was given, and it should also be documented under the immunization tab in the electronic medical record. Consents get scanned into the medical record and if the resident refuses, then there should be a progress note documenting the refusal and any education provided to the resident and/or their family members about the risks and benefits of receiving the vaccine. On July 17, 2024, at 10:53 AM V3 (Assistant Director of Nursing) said she not sure who is offering the vaccine to the residents, she said she believes it is to be offered on admission, and one staff member gets the consent, while someone else is responsible for looking up historical records. V3 said the facility should offer the Covid-19 vaccine, but if the resident wants to have it, they will need to go to the local pharmacy because you have to order the vaccine in bulk, and it would be too costly. On July 17, 2024, at 10:15 AM, V2 (Director of Nursing) said it is her understanding that all nurses are to offer the Covid-19 vaccines to all new admission. This is being discussed each morning in the morning meeting. If the resident has not had the vaccines, it is the expectation that the vaccines are offered. If it is offered, there should be a progress note showing it was offered, consented, or refused. If consented, it would be documented under the immunization tab. Facility policy titled Covid Immunization with revision date of July 2024 showed the facility will encourage residents, staff, and families to remain up to date with Covid-19 vaccinations, including all eligible boosters. Nursing staff is responsible for the administration and assessment of the vaccine per the order of the physician, if not contraindicated or refused. Resident concerns will be obtained prior to the administration and then scanned into the resident's medical record.

Based on interview and record review the facility failed to ensure safety interventions were in place for a resident with a history of multiple falls. This failure resulted in R1 falling in her room and found on the floor and sustained a left [MEDICAL CONDITION]. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. Findings include: The Final Incident Report dated June 23, 2020 documents R1 has [DIAGNOSES REDACTED]. On June 19, 2020 at 3:30 PM, staff heard an alarm sounding and found (R1) on the floor in between her wheelchair and the doorway. (R1) has a history of multiple falls and her last fall was on June 15, 2020 (4 days prior). (R1) has a history of anxiety and can appear guarded and paranoid. (R1) was sent to local hospital and the imaging results showed R1 had left [MEDICAL CONDITION]. (R1) underwent surgical intervention. R1's hospital records dated June 19, 2020 documents R1 comes in for a fall she sustained while trying to hang her menu on the door, when she slipped on the floor on her left leg. R1 states she in in severe pain. The x-ray report dated June 19, 2020, showed R1 has left [MEDICAL CONDITION] and underwent surgical intervention on June 20, 2020. The Minimum Data Set assessment dated [DATE] shows R1's cognition is impaired and requires assistance with transfers. R1's Fall Risk assessment dated [DATE] shows a score of 40. A score of 10 or more puts the resident at a high risk for falls. R1's Fall Review dated June 5, 2020 documents R1 spilled her drink while eating and attempted to get up without assistance. R1 was found on the floor laying at the foot of her bed. Skin tears to her left eyebrow, left knee and shoulder. R1 told staff she was crawling to get help. R1's physician progress notes [REDACTED]. R1 fell sometime over the weekend and hit her face and sustained a small laceration over her left eyebrow. Bruising is noted to her left eye. R1 is impulsive and has poor recall and needs constant reminding to ask for help. R1's physician progress notes [REDACTED]. R1 is impulsive and does not ask for help. R1's physician progress notes [REDACTED]. R1 appeared guarded and somewhat paranoid. R1 exhibits anxiety, paranoia, impulsive, she is forgetful and has poor recall. R1's Fall Report dated June 19, 2020 documents the nurse heard a chair alarm sounding and upon entering the room (R1) was found lying on her back between the wheelchair and the doorway to the hallway. The nurse attempted to do a head to toe assessment on R1, but she was complaining of pain to her left hip and thigh. R1 was wearing plain socks and not non-skid footwear. Staff were uncertain if the wheelchair had been in a locked position. R1 had been impulsive several times during the day needing frequent redirection. X-ray films revealed a left [MEDICAL CONDITION]. R1 had surgical intervention on June 20, 2020. R1's Fall Huddle Form dated June 19, 2020 documents R1 had a fall at 3:30 PM, she is alert to person and does not know the month, R1 stated is was winter (during the month of June). R1's type of footwear worn at the time of the fall were socks and her safety interventions included to be seated in the dayroom for closer observation. On December 11, 2020 at 10:40 AM, V4 (Restorative Nurse) said she conducted R1's fall investigation and it was discovered R1 was not wearing non-skid footwear and her wheelchair was not locked when she fell on [DATE]. V4 said R1 had a history of [REDACTED]. V4 said R1 should have been placed on closer supervision especially that day due to her increased behaviors. On December 11, 2020 at 11:45 AM, V3 (Assistant Director of Nursing) said R1 was very impulsive. V3 said staff should implement the fall interventions in place for a resident. V3 said fall interventions should be updated after each resident's fall. On December 12, 2020 at 9:45 AM, V5 (Registered Nurse) said she was R1's nurse the day she fell on [DATE]. V5 said I guess her fall interventions are in the care plan. V5 said she does not look at the care plan and stated I don't know how to access the care plan. R1's Care plan shows at risk for falls with interventions include to assist resident to wear non-skid footwear and place R1 in a recliner in the dayroom for closer observation when she is up. R1's care plan does not include new interventions after her fall on June 5, 2020. The facility's Fall Risk and Prevention/Reduction Policy revised Policy dated February 2018 states, Riverside Miller Rehabilitation will provide a safe environment by taking actions to reduce the risk of falls during a residents stay .If a resident is at risk for falls, then the interdisciplinary team will initiate the following protocol .provide appropriate supervision .document interventions in clinical record.

Based on record review and interview the facility failed to ensure proper use of hot pack; the facility also failed to develop/implement policy and procedure for use of a hot pack. This failure resulted in a second degree burn on a resident who was given a hot pack to relieve pain. This applies to 1 of 3 residents (R2) reviewed for incident with skin injury in the sample of 8. The findings include: R2 is an [AGE] year old who has multiple medical [DIAGNOSES REDACTED]. R2's Minimum Data Set ((MDS) dated [DATE] showed that he requires extensive assistance for bed mobility. Physician order [REDACTED]. Call physician if there's no improvement. R2's incident report dated 12/13/18 at 7:45 AM showed: While providing shower to R2 CNA staff noticed an open area to R2's upper back region. Staff notified the nurse. R2 reported to V7 (Wound Care Nurse) that he fell asleep with the hot pack on his neck which was ordered by V9 (Nurse Practitioner/NP). R2 stated it was wrapped in a towel and when he rubbed the area because it was hurting a bit the roughness of the towel broke open the skin. V7 is treating topically and will monitor for full healing. Family and physician are aware of the issue. Comprehensive Wound assessment dated [DATE] showed: R2 sustained partial thickness burn in the left upper scapula which measured as Length (L) 6.0 centimeter (cm) x Width (W) 3.5 cm. According to the wound care RN (Registered Nurse) progress note from the local hospital on [DATE], R2 underwent debridement of the mid upper back. On 1/15/19 at 11:26 AM, V7 (Wound Care Nurse) stated V2 had an application of warm pack and he said he fell asleep with the warm pack still in place on his back. The warm pack was wrapped in a towel and he guessed that he rubbed himself against it. Warm pack was used for pain. It looked like it had formed a blister as evidenced by the skin flap which was open. The wound bed was granular and moist. V7 described it as a partial thickness burn or a second degree. V7 notified V12 (Wound Care Physician) and she ordered a Versatel Contact Layer and [MEDICATION NAME] dressing to apply daily and as needed. The wound was healing then R2 went out for hospital leave and when R2 came back it was dry and he had eschar covering the wound. The presence of eschar showed that the wound deteriorated. V7 had talked to the granddaughter with regards to his wound. On 1/15/19 at 1:45 PM V9 (Nurse Practitioner/NP) stated, R2 complained of having stiffness in his neck. V9 ordered to apply icy hot cream and warm pack to apply three times a day as needed. This is to loosen up the stiffness in his muscle. V9 did not indicate the length of time the warm pack is to be applied on to R2. V9 was not sure what the facility uses for warm pack and concluded that they would follow the facility protocol for application of warm pack. V9 added warm packs usually don't stay warm for too long. On 1/15/19 at 2:35 PM V10 (Certified Nursing Assistant/CNA) stated, she (V10) wet a washcloth and placed washcloth in the microwave for 30 seconds and when she felt that it was not warm enough she put the washcloth back into the microwave and warm it up for another 30 seconds then when V10 felt that it was warm enough she placed it in a plastic bag and placed it inside a pillow case. V10 also stated she tried to cool it off for a certain period of time (V10 was unsure how long she cooled it off) prior to application. V10 was not sure what the temperature of the warm compress, not sure how long it stayed in R2's neck and who removed it. On 1/15/18 at 3:42 PM V2 (Director of Nursing/DON) stated she (V2) facility does not have a specific policy for the use of hot pack. V2 is not sure if staff had specific education pertaining to hot pack use prior to R2's incident. On 1/16/19 at 11:20 AM V12 (Physician) stated she was made aware of the incident on 12/14/19 and ordered to apply Versatel and [MEDICATION NAME] dressing to R2. R2 is an old man with a very thin/fragile skin. The component of this incident was the length of time, the heat and the pressure of lying on it that caused the burn. Facility does not have any definitive protocol for application of heat pack such as; the temperature of the heat pack, the length of time applied to resident's skin and monitoring while the heat pack is on resident.

Based on interviews and record reviews, the facility failed to keep residents free from abuse by certified nursing assistants (CNA). This failure resulted in R1 experiencing psychosocial harm, anger and frustration when E5 (Certified Nursing Assistant) provided rough and rude treatment and when E5 failed to provide personal care for R1. This applies to 2 out 4 residents (R1 and R4) reviewed for abuse from a total sample of 6. Findings include: 1) On August 17, 2017, the facility submitted their final Abuse Investigation Report to the Illinois Department of Public Health concerning an incident involving R1 and E5 (CNA). In this report R1 complained that E5 was rough and rude. The report documents that R1 complained (on August 14, 2017) that E5 ripped off my clothes, caused my glasses to fall off, and would not do my oral care. This report also documents that R1 has a BIMS (Brief Interview Mental Status) Assessment of 14(able to be interviewed), and did not have a history of prior complaints. This report included documentation that E5 was terminated from the facility due to inappropriate treatment of [REDACTED]. R1 was interviewed on August 22, 2017 at 9:15 AM. R1 sat in R1's wheel chair, alert and oriented. R1 recalled the following from the incident occurring with E5: The aide (E5) was rough with me. E5 said, Get out of bed and sit down! E5 talked to me in a rough and real mean way. The other girls were nice and made me feel comfortable. Not E5.I told E5 I needed to go to the bathroom first. E5 said you should have told me that in the first place. E5 talked rough and mean to me. I had to go to the bathroom by myself. I usually go to the bathroom with assistance. E5 acted like E5 was in a hurry, and ripped the blanket off me. I got to the end of my fuse .it was E5's attitude.I needed assistance getting out of bed and on the toilet. E5 did not give me the assistance I needed. E5 was rough and mean from start to finish. E5 was rough and not gentle. E4 (assistant director of nursing) was interviewed on August 22, 2017 at 2:30 PM. E4 said E4 helped with the investigation into R1's allegations regarding E5. E4 stated E4 talked with R1 on August 15, 2017, after R1 made R1's initial complaint to staff (on August 14, 2017). E4 described R1 as alert and oriented. E4 said: I went in and had R1 tell me what happened. R1 talked about a CNA (E5) being rude, demanding and pushy. E5 made R1 feel afraid to say anything.The CNA (E5) was terminated because of this investigation. E5 was terminated because E5 was rough and rude to R1, which can be considered abusive. The evening supervisor (E7) was interviewed on August 22, 2017 at 2:51 PM. E7 said the nurse caring for R1 told me on August 14, 2017 that R1 was unhappy with R1's care given by E5. E7 stated: R1 was upset. R1 said R1 had to go to the bathroom and E5 would not assist R1. E5 did not do R1's oral care. I had to do it . I got R1's teeth (dentures) out and helped R1 finish going to bed. R1 was agitated. R1 said E5 made me uncomfortable and I made E5 uncomfortable . R1 said R1 told E5, R1 needed to go to the bathroom, but E5 made E5 feel bad for asking. R1 asked for help with R1's dentures, but E5 did not assist R1. R1 still had R1's dentures in, so I helped R1 with that. R1 likes to have R1's dentures removed at night. E7 stated E5 had been the subject of a prior abuse investigation in June of 2017, and was found to be rough and rude while giving care to residents. E7 said E5 completed in-service and training. During the interview with E4 (Assistant Director of Nursing) on August 22, 2017 at 2:30 PM, E4 also said E4 was involved in a June 2017 Abuse Investigation involving E5. E4 stated that R6 (former resident) complained about E5 and the way E5 cared for R5 (roommate of R6). E4 said a resident, R6, complained R6's roommate (R5) received rude and rough care from E5. E5 was given additional training on August 11, 2017 covering [MEDICATION NAME] approach and communication with residents to improve E5's service to residents. 2) There were other abuse investigation reports describing staff as rude and rough in giving care to residents. Abuse 24 Hour Incident showed: August 9, 2017 at 10 AM, R4 complained the aides were being abrupt and not showing [MEDICATION NAME] when getting patients ready for the morning. The finial Abuse Investigation Report of R4's allegations, dated August 14, 2017, showed: R4's allegations involved the care from three CNA's. This report documents: R4 said two CNA's (E17 and E18) took her to the shower and were rude and mean. During the investigation of R4's abuse allegations involving E17 and E18, interviews with staff were conducted on August 9- August 11, 2017. The finial Abuse Investigation, dated August 14, 2017, included these written statements from staff. One nurse's statement was: E17 and E18 have horrible attitudes. Armpits are not getting washed. Deodorant and lotion is not being applied. Hair is not getting washed . Shower book is not being filled out. E17 and E18 disappear and take excessive breaks. If a patient refuses, then staff is not made aware, nor do they come back to ask the patients a second time or inquire as to why they are refusing . Another nurse gave the following written statement: E17 and E18 never report anything to her. She did not know who had a shower or who has refused. If a patient refuses and the staff is notified we could find out why or be able to chart a note regarding the refusal. Sometimes the nurse can talk to the patient and get them to shower versus refusing . A certified nurse's aide gave this written report: E17 and E18 will tell the patient that they will get a shower the next day and then the patient does not get a shower at all. The Abuse Investigation Finial Report, dated August 14, 2017, also documented that R4 was alert and oriented and able to answer questions. R4's care plan, dated August 14, 2017 with goal dated of November 14, 2017, showed R4 had [DIAGNOSES REDACTED]. The Human Resource Coordinator (E9) was interviewed on August 23, 2017 at 2 PM. E9 said E5 had no disciplinary/corrective action in E5's personnel file. But there should have been documentation of corrective actions in E5's personnel file because of multiple residents' complaints. E9 stated E16 received corrective action for failure: to make sure residents are assisted, and for not getting help to transfer residents. E9 stated E16 was suspended because E16 was rude to a resident in August of 2017. E9 said E17 had corrective actions in the past, and was terminated in August of 2017 because of the way E17 treated a resident. E18 was also terminated in August 2017 because of E18's inappropriate treatment of [REDACTED]. The administrator (E1) was interviewed on August 22, 2017 at 4:55 PM. Later E1 and E2 (director of nursing) were interviewed on August 23, 2017 and August 25, 2017. E1 and E2 said they found evidence that the CNA's were rude, rough and sometimes did not provide the care residents requested. The facility's Abuse and Neglect Policy, dated February 2017 and August 22, 2017, showed: .Abuse includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental, and psychosocial well-being. Abuse also includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on interview and record review the facility failed to provide nursing services by not assessing and monitoring R1's right foot vascular wound until day 5 of admission to facility. Facility failed to obtain timely wound care evaluation and medical intervention and to notify physician of decline in wound status. Facility also failed to follow their wound management protocol. These failures resulted in 1 of 3 sampled residents (R1), reviewed for wound management, wound status to decline. R1's right foot vascular wound developed necrotic tissue over 60% of the wound surface and required surgical intervention to remove the necrotic tissue. The Findings include; R1 was admitted to facility [DATE] at 2:32PM from the hospital. R1's hospital records document, R1 was hospitalized [DATE] through [DATE]. R1's [DATE] hospital history and physical report includes: chronic wound on the top of right foot that has been worsening. medical history of [REDACTED]. Z4 (Infectious disease physician), [DATE] consult report documents presence of a "4cm x 4cm x 0.2cm deep with exposed fascia, tendons and muscle. It is unclear if there is any portion of the bone exposed." Z4 also documented; R1 was found to have an occlusion and underwent a revision of her bypass graft on [DATE]. The patient has a right chronic dorsal wound with exposed tendons and the tissue appearing healthy. Z6 (Vascular physician), ,[DATE] and [DATE] progress notes include "Right foot with open dorsal wound, clean base with exposed tendons and healthy appearing tissue." R1's ,[DATE] and [DATE] hospital nursing skin integrity assessment includes, presence of an "ulceration", "non intact open, pink, red, other: tendon." Facilities wound management protocol includes: - Residents admitted with wounds are to be assessed on admission and weekly until healed. Document wound assessment on wound assessment progress flow sheet. A copy of residents wound assessments are to be provided to the wound care team. - Document dressing changes / wound care on treatment administration record (TAR). Note type of dressing or topical applied, note weekly status to assess the progress toward healing and impact of interventions being implemented. - Existing wounds are to be described by location, type, stage, depth, length, width, tunneling/undermining, color/ type/ amount of drainage, odor, presence of infection, appearance of peri-wound and pain. - Wound Care Team Consultation may be ordered by physician for evaluation and treatment. Any treatment recommendations made by the wound care team are based on the clinical guidelines outlined in the "AHCPR" (agency for health care policy and research, with the department of human services), manual for treatment of [REDACTED]. - Treatment protocol includes monitoring skin condition for signs of healing and signs of increased involvement and deterioration of area. On [DATE], at 9:30AM, E1 (Administrator) and E2 (Director of nurses), stated that facility wound care team consist of E3 (wound certified physical therapist), E6 (wound nurse) and Z2 (wound certified physical therapist). E2 said that E3 and E6 are full time employees and Z2 is in facility 3 days per week. R1's [DATE] physician orders, include right foot wound treatment of [REDACTED]." R1's ,[DATE] TAR includes Wet to Dry dressings with Hydrogel to be administered 3 times / day. R1 was administered these treatments [DATE] at 7:30PM, [DATE] and [DATE] at 10:30AM, 2PM and 7:30PM, [DATE] at 10:30AM, [DATE] at 2PM and 7:30PM and [DATE] at 10:30AM. During individual interviews on [DATE] of E3 at 10:00AM, E6 at 11:04AM and E2 at 11:30AM the following information obtained: E2, E3 and E6 said R1's right foot wound was not assessed [DATE] admission through [DATE]. R1's right dorsal foot wound was initially evaluated on [DATE], by E6 and assessed by Z2 on [DATE]. E2, E3 and E6 also said that facility nursing staff do residents wound treatments but they do not assess, measure and document wound status. E3 and E6 do all the wound assessments in facility. E6 said she does wound assessments on Mondays and the rest of the week works as a staff nurse on the floor. E2 and E3 said E3 was off sick ,[DATE] through [DATE] and E6 was not working that weekend. E3 does physical therapy as well as wound treatments for skilled care residents. R1's [DATE] right foot wound assessment includes 5.9 cm X 8cm X 0.2cm, moderate amount of serous drainage, 40% visible tendons and 60 % black eschar, rolled pink edges and puffy dark brown peri wound. R1's physician orders [REDACTED]. clean and dry right foot wound, apply "No sting" to peri-wound area and apply gel cover with [MEDICATION NAME], every other day and as needed. This wound treatment change was ordered after initial wound assessment by E3. R1 was initially evaluated by Z2 on [DATE]. Z2 changed wound treatments. On [DATE] Z2 changed R1's wound treatment after assessing the wound to Regenecare and [MEDICATION NAME] to right foot every other day and to soak dressing with Saline prior to removing as needed. On [DATE] at 9:45AM, Z2 said, R1's admission wound treatment of [REDACTED]. This type of treatment can cause more damage to the tendons. Z2 also said , "I see medicare patients after they are evaluated by therapy and follow-up visits every 1 ,[DATE] weeks. I ' m a consultant, not the primary physician." Z2 said, she assists E3 and E6 as needed but does not just care for wounds. Z2's [DATE] progress note includes tendons visible and eschar present on right dorsal foot wound and surrounding [DIAGNOSES REDACTED]. During telephone interview [DATE] at 9:45AM, Z3 (R1's attending physician), stated, Z3 did not see R1 while a resident at facility ([DATE] - [DATE]). R1 was not evaluated by the wound care team until [DATE], due to the wound care nurse being off for the holiday. R1 does have very poor circulation. Z3 said "I heard from R1's family that the residents wound deteriorated at the facility." Z3 said upon review of R1's medical records, timely wound assessments were not documented. Z3 also said the facility failed to notify Z3 of the 5 day delay of wound care team evaluation by the wound care specialist and of deterioration of R1's right dorsal foot wound. On [DATE] at 10:10AM, E5 (admission nurse director), said on [DATE], R1 was admitted to facility for wound care and strengthening. R1 and her daughter thought facility was going to provide Hyperbaric wound treatments and became upset when told facility does not provide this therapy. R1 was so upset, she wanted to be discharged . E5 said "I explained to the resident and her daughter that facility will provide wound care for her foot." E5's [DATE] progress note included; R1 was upset about inability to get Hyperbaric treatments at facility while an in-patient. R1 wanted to leave facility related to, the rational for her admission was for Hyperbaric wound treatments. E5 reviewed treatment plan with R1 and daughter and told them, R1 would receive therapy and wound care from facilities wound care team. R1's [DATE], 3:47AM progress note includes, R1 very upset about inability to receive "proper wound care (Hyperbaric treatments)," while in facility. R1's [DATE] 1:25PM progress note includes R1's daughter requesting out patient wound care referral for Hyperbaric treatments. R1's [DATE] progress note and 2:00PM physician order [REDACTED]. R1's Wound Measurement Flow sheet includes; [DATE] "The tendons continue exposed. The black, tough eschar remains 66% or greater of the wound." R1's [DATE] progress notes include; 11:23AM out to Z1 (Cardio vascular surgeon), follow-up appointment. 4:47PM, R1's daughter called with many concerns about wound care provided and saying the wound is black. Daughter said R1 was being readmitted to the hospital for possible right foot amputation. 5:28PM, R1's daughter called , saying Z1 told her R1's right foot should have never gotten as bad as it has and that proper wound care was not provided at facility. R1's [DATE] progress notes include, on [DATE], R1 was readmitted to hospital for right foot wound debriedment.

Based on interview and record review the facility failed to ensure the proper use of a mechanical lift device for one of three sampled residents, (R2) and 9 supplemental residents who are transferred using the lift. This failure resulted in an injury to R2 after sustaining a fall while being transferred in the device. Findings include: According to the medical record R2 is an [AGE] year old female with [DIAGNOSES REDACTED]. The facility's incident investigation noted on 06/25/11 at 7AM E3, CNA (Certified Nurses Aid) was using a mechanical lift device to transfer R2 from the bed to a wheelchair. E3 stated in the report as she began to move R2 from the bed, R2 fell from the device onto the floor. R2 sustained a laceration to the left side of the head. R2 was transferred to the hospital and required 8 sutures to the forehead. E2,(CNA) was interviewed on 07/21/11 and stated on 06/25/11 she heard a loud noise and scream from R2's room. When she went to investigate she saw E3 in the room and R2 lying on the floor. E2 further stated apparently E3 was trying use the mechanical lift to transfer R2 by herself. When asked, E2 stated the mechanical lift device requires two persons to operate it while transferring a resident. E1(Director of Nursing) confirmed on 07/21/11 that E3 was operating the mechanical lift by herself while attempting to transfer R2. The facility's policy on the use of the mechanical lift last modified on 02/23/11 notes at least two people are required to be present while transferring a resident. E4 and E5 (CNA's) were interviewed and stated two people are required to be present when using the mechanical lift.