Every finding on record at Mount Sterling Health and Rehab Center

Based on Interview and Record Review, the facility failed to ensure a resident with a new onset of low heart rate was assessed for blood pressure and heart rate before administering Metoprolol (beta-blocker, antihypertensive medication) and ensure residents with diagnoses of Hypertension and Heart disease were provided care plans and interventions to promote safe, comprehensive care for three of three residents (R1, R2, R3) reviewed for Hypertension in the sample of three.Findings include:The facility's Facility Assessment, dated 9/2018, documents It is facility practice to provide sufficient staff with the appropriate competencies and skill sets to provide care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility population.The facility's Care Plan policy, dated 7/1/23, documents To provide guidance to the facility in developing, implementing and communicating the individualized plan of care of residents. Our facility's care plan/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.The facility's Medication Administration Procedure policy, dated 11/7/19, documents Purpose: To ensure proper administration of oral medications. Observe the individual and obtain any requires vital signs prior to medication administration. If any results are out of range, hold the medication and report to the physician.The National Library of Medicine/ National Center for Biotechnology Information, located at https://www.ncbi.nlm.nih.gov/books, last updated 2/29/24, documents Metoprolol is a beta-blocker medication that requires careful monitoring in patients with various cardiovascular conditions. The following parameters should be monitored when a patient is on metoprolol: Blood pressure and heart rate. Metoprolol can lower blood pressure and heart rate by blocking the effects of adrenaline on the heart and blood vessels. The blood pressure and heart rate should be measured at rest, during exercise, and before and after taking metoprolol.1. R1's Care Plan, dated 5/13/26, documents R1 has diagnoses including Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery, and Chronic Atrial Fibrillation. This care plan does not address R1's Hypertension or provide interventions for monitoring/ treating R1's blood pressure.R1's Nursing Progress note, dated 6/25/26 at 11:20 AM documents R1's blood pressure was assessed to be 94/66 and R1's heart rate was 40. This note documents R1's provider (V10, Physician) was notified. R1's Nursing Progress note, dated 6/25/26 at 12:45 PM documents Fax received from (V10) with new orders: Hold Metoprolol Friday, Saturday, & Sunday. (V6, Advanced Practice Nurse (APN)) will see on Monday.R1's Medication Administration Record (MAR), dated June 2026, documents R1 had an order for Metoprolol Tartrate Oral Tablet 25 MG (milligrams). Give 1 tablet by mouth two times a day for Essential Hypertension. Start Date 3/4/26. Hold Date from 6/25/26 12:47 PM to 6/29/26 6:00 AM. This MAR documents R1's doses of Metoprolol were held from 6/25/26 until 6/29/26 when it was given by V5 (Registered Nurse (RN), Minnimum Data Set (MDS) assessment coordinator) at 8:00 AM.R1's Vital Signs Summary for blood pressure and heart rate, dated 7/13/26, documents R1's heart rate was assessed on 6/27/26 at 9:50 AM and not again until 6/30/26 at 3:18 PM. This same summary also documents R1's blood pressure was recorded to be 94/66 on 6/25/26 at 1:04 PM and was not recorded again until 6/30/26 at 3:18 PM.R1's Nursing Progress note, dated 6/29/26 at 11:26 AM, and entered by V5 (RN/MDS coordinator), documents After (V6, APN) assessed resident she wanted (R1) sent out due to a heart rate of 32. 911 call and in transit.R1's Nursing Progress note, dated 6/29/26 at 11:35 AM, documents EMS (emergency medical services) arrived, and resident was hooked up to cardiac monitor. Resident remains in AFib (atrial fibrillation) with a blood pressure of 100/60 and pulse 40. This note documents R1 was taken to the hospital for further evaluation.R1's emergency room summary, dated 6/29/26 at 12:50 PM, documents (R1) is a [AGE] year-old male who presents for evaluation of bradycardia. He was sent to the emergency department for evaluation and assessment after being noted to be bradycardic with a heart rate in the 30s during a routine check at his nursing home. He has underlying dementia and no significant history. He does have a history of hypertension, hyperlipidemia, and chronic atrial fibrillation. He takes metoprolol and did get that dose this morning by history from the nursing home.On 7/13/26 at 11:37 AM, V7 (hospital Registered Nurse) confirmed taking care of R1 on 6/29 when he was sent to the emergency room. V7 stated I talked to EMS (emergency medical services) staff when they brought (R1) in and they reported that the facility nurse stated she gave (R1) metoprolol after not being able to find his heart rate.On 7/13/26 at 1:32 PM, V5 (RN/MDS coordinator) stated she sometimes works the floor, and she was the one who passed medication to R1 on 6/29 before he was sent to the hospital. V5 stated I know that his blood pressure medication was held over the weekend because (R1) had a low heart rate the week prior. It was stopped until Monday morning (6/29) and then it was on my MAR to administer. There was not a hard stop (forced vital sign entry) on his order to enter vitals, and I did not assess his heart rate or blood pressure before giving the medication. So, when V6 (APN) saw him later, after the medication was given, his heart rate was really low, and she wanted him sent to the hospital. We should have hard stops on all of the heart medications for this reason.On 7/13/26 at 2:20 PM, V2 (Director of Nursing) confirmed blood pressure and heart rate should be recorded before giving hypertensive medications. V2 stated Especially beta-blockers, blood pressure and heart rate assessment should be completed and recorded before ever administering the medication. I am not sure why that safeguard wasn't in place prior. Those vitals should be completed as part of the nursing assessment during medication administration. 2. R2's current Physician Order summary, dated 7/13/26, documents R2 has a diagnosis of Essential (Primary) Hypertension and a physician order for Metoprolol Tartrate Oral Tablet 25 MG to be given two times a day. This order documents apical pulse and blood pressure prior to administering.R2's current Care Plan, dated 5/15/26, does not contain a plan of care or interventions to treat and monitor R2's Hypertension or the administration of R2's beta-blocker medication. 3. R3's current Physician Order summary, dated 7/13/26, document R3 has a diagnosis of Essential (Primary) Hypertension and a physician order for Metoprolol Succinate Oral Tablet Extended Release 24 Hour 25 MG to be given in the morning related to essential hypertension. R3's current Care Plan, dated 4/13/26, does not contain a plan of care or interventions to treat and monitor R3's Hypertension or the administration of R3's beta-blocker medication.On 7/13/26 at 3:15 PM, V1 (Administrator) confirmed that residents with a diagnosis of hypertension should be care planned for the diagnosis and medications used to treat hypertension, as part of a comprehensive plan of care and to ensure adequate interventions and monitoring for the disease process are being followed.

Based on observation, interview, and record review the facility failed to assess safety risks and provide supervision for one (R1) of three residents reviewed for falls in a total sample of six. Findings include:The facility's Transportation Policy dated 7/1/23 documents It is the facility's responsibility that any resident being transported by the facility vehicle will have a safe and secure transport.R4's medical record documents R4 was admitted to the facility on [DATE] with diagnoses to include Repeated Falls, Chronic Kidney Disease, Bipolar Disorder, Anxiety, Major Depression, and Intrahepatic Bile Duct Cancer. R4's Skilled Care assessment dated [DATE] at 1:56 PM documents R4 is alert and oriented to person and place, her memory is OK and she is able to recall the current season and she is in a facility.R4's care plan documents interventions dated 3/3/26 include Keep environment free from clutter, Reinforce use of assistive devices, Observe for unsteady gait and balance, and Instruct to avoid sudden position changes. R4's Physical Therapy Treatment Encounter dated 3/3/26 documents R4 required a front wheeled walker and contact guard assist for ambulation. R4's Health Status Note dated 3/4/26 at 1:10 PM documents V7 (Transportation Director) took R4 to R4's apartment to pay her rent. R4 said she would use her walker in the apartment and left her wheelchair in the hallway. R4 had to be prompted to stand up to the walker. R4 asked V7 to remove the boxes from her bedroom doorway so she could get into her bedroom to find her clothes. V7 started moving the boxes and R4 got up and took a couple of steps without using her walker and fell to the floor and had a laceration above her right brow.R4's Verification of Incident Investigation/Administrative Summary dated 3/3/26 documents R4's fall and V7 (Transportation Director) called EMS (Emergency Medical Services) to have R4 transported to the emergency room for evaluation and returned to facility after evaluation. On 3/25/26 at 10:41 AM V7 (Transportation Director) reported she took R4 to her apartment on 3/4/26 to get her checkbook. R4 wanted to use her walker in the apartment so she left her wheelchair in the hallway. V7 reported R4's apartment was unsanitary with dried feces, gloves and empty packages on the floor from a previous EMS (Emergency Medical Services) call. V7 reported R4 was sitting in her recliner sorting through papers so V7 started moving boxes away from the bedroom doorway so R4 could go into her bedroom. R4 stood up and took a couple of steps without her walker and fell. R4 received a laceration above her right brow. V7 reported she applied pressure to the laceration and called EMS to transport R4 to the emergency room for an evaluation.On 3/25/26 at 11:56 AM R4 was sitting in a wheelchair self propelling in the Main Dining Room. R4 stated I fall all the time. The doctor put me here for physical therapy. R4 reports she uses both a walker and a wheelchair.On 3/25/26 at 12:58 PM V2 (DON) reported R4 is very impulsive. V2 reported V7 (Transportation Director) used to be a CNA, but she is no longer certified. On 3/25/26 at 2:21 PM V1 (Administrator) reported R4 left in a wheelchair and the expectation was that R4 would stay in her wheelchair during home visit. V1 reported R4 can be impulsive. V1 reported R4 required assistance with ambulation. V1 verified R4's apartment had not been assessed for safety prior to R4 going on the home visit and the facility should have sent a certified/licensed staff member for the visit as well as the transportation driver.On 3/26/26 at 11:13 AM V17 (Occupational Therapy Assistant) reported she would not recommend R4 ambulate without assistance with walker.

Based on observation, interview, and record review the facility failed to de-escalate a resident's behaviors and protect a cognitively impaired resident from staff-to-resident physical abuse for one of three (R1) residents reviewed in the sample of four. These failures resulted in a staff member (V4/Registered Nurse) kicking a resident (R1), who has a diagnosis of Dementia and known physical behaviors, three times above the left hip on 11/1/25 after R1 exhibited behaviors towards V4, which caused R1 to experience psychosocial and physical harm of fear, mental anguish, and pain.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/3/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Abuse Policy dated 2/2025 documents, To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. The administrator and/or designee is the facility abuse coordinator for the facility. It is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. It is all staff responsibility to report any allegation or witnessed abuse immediately to the administrator. This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. Procedure: Orientating and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property. Establishing and environment that promotes resident sensitivity, resident security, and prevention of mistreatment. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish to a resident. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attentions. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.The facility's Employee Handbook dated 11/1/25 documents, Section 5-General Standards of Conduct: (The facility) endeavors to maintain a positive work environment. Each employee plays a role in fostering this environment. Accordingly, we all must abide by certain rules of conduct, based on honesty common sense, and fair play. Because everyone may not have the same idea about proper workplace conduct, it is helpful to adopt and enforce rules all can follow. Unacceptable conduct may subject the offender to disciplinary action, up to and including discharge, in the facility's sole discretion. The following are examples of some, but not all, conduct which can be considered unacceptable: 9. Fighting, threatening, or disrupting the work of others or other violations of the facility's workplace violence policy.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired, has physical, verbal, and other behaviors, and requires partial/moderate assistance of staff for transfers.R1's current Care Plan documents R1 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Profound Intellectual Disabilities, Depression, Traumatic Brain Injury, and Vascular Dementia with Agitation. This same Care Plan documents R1 is independent with transfers, but at times requires one-person physical assistance, has a history of trauma with an intervention of the care plan team to meet to take into account strategies to provide R1 with a safe, secure, trustworthy and transparent environment through peer support, and has childlike behaviors that require staff reassurance to help R1 feel safe and secure. This care plan documents R1 will set himself on the floor and tell staff he fell in attempts to get his mother to come to the facility to see him.R1's Progress Note dated 11/1/25 at 4:23 PM and signed by V4 (RN/Registered Nurse) documents R1 put himself on a floor mat and was re-approached several times. This same note documents R1 became aggressive and pinched staff while trying to place a mechanical lift sling and (V4) called the medical Doctor and an order was given to let R1 sit on the floor to de-escalate and do 20 minutes safety checks until R1 is agreeable to get up. The facility's Incident Investigation/Administrative Summary dated 11/4/25 and signed by V1 (Administrator) documents on 11/1/25 a CNA (Certified Nursing Assistant) witnessed another staff member (V4/Registered Nurse/RN) make contact with R1's left upper leg with V4's foot, after R1 either pinched or hit V4 while staff were attempting to de-escalate R1's behaviors and assist in a transfer.V21's (CNA/Certified Nursing Assistant) written statement dated 11/1/25 documents, Today at approx. (approximately) 4:15 PM I was asked by (V4/RN/Registered Nurse) to help assist with a resident (R1) that had sat himself on the floor. She (V4) had a (mechanical lift) sling in her hand and stated that we (facility staff) would attempt to get (R1) in his chair with a (mechanical sling) from the floor. We walk in (R1's) room and (R1) immediately yelled no at (V4). (V4) approached (R1) while (R1) was yelling no at her. (V4) approached (R1) while he was yelling no and (R1) pushed (V4) aways three separate times. (V4) than in turn after the third one kicked (R1) three times while (R1) was sitting crisscross on the floor. (R1) started to cry and yelled you (V4) kicked me. I said that (V4) needed to leave (R1) alone, (V4) got frustrated at (me/V21) because I refused to put a sling under (R1) while he was being combative. I stated that it was dangerous and did not feel comfortable doing it.V23's (CNA) written statement dated 11/1/25 documents, I went into (R1's) room around 4:15 PM to help (V4) and (V21) was also in (R1's) room. (R1) was on the floor and they both were trying to get a (mechanical lift) pad underneath (R1). (R1) was agitated yelling, hitting at whoever was in front of (R1) which happened to be (V4). At one point (R1) had reached up and pinched (V4) in the leg. After (R1) did that (V4) proceeded to kick (R1) with the side of her shoes three times. (V4) was very stern in her communication with (R1) which I believe caused (R1) to be more agitated. (V21) did speak up and (told) (V4) that (R1) is very agitated, and we should not be trying to put (R1) in a sling which we then decided to leave (R1) be. I went back later maybe like ten minutes and sat down on the floor and talked to (R1) to see if I could get (R1) closer to his bed, which (R1) did end up closer. (R1) did state that he didn't like (V4) or want (V4) in his room and to shut his door so (V4) couldn't come back in.V4's Employee File documents V4 was hired on 1/30/2008.V4's Termination Form dated 11/7/25 documents V4 was terminated due to discourteous or inappropriate behavior or language to a resident (R1).On 11/2/26 at 10:30 AM R1 was sitting in bed confused and unable to answer questions appropriately.On 1/2/26 at 9:30 AM V21 (CNA) stated, On 11/1/25 sometime between lunch and supper (R1) was on the floor on a floor mat. (R1) frequently sits on the floor and plays and is usually a staff assist of one with a gait belt for transfers. (V4/RN) came to me and said she needed my help to get (R1) in a (mechanical lift sling) so we could get (R1) off the floor and into bed. (R1) was being very combative and did not want to be put in a sling. I did not feel comfortable with pushing (R1) to get into a sling, but (V4) kept insisting we put (R1) into a sling so we could lift (R1) into bed. (V23/CNA) was also in the room helping. While (R1) was being combative, (R1) pushed (V4) in the inner thigh and (V4) kicked (R1) three times pretty hard above the left buttock. (R1) yelled ouch and yelled at (V4), You kicked me? Get out of here! (R1) was crying and had visible tears. I made (V4) leave (R1's) room. I told (V4) no title gives you the right to kick a resident and treat a resident like that. (V4) said to me it was just a reaction to (R1) pinching her. I told (V4) kicking him three times is excessive. Kicking (R1) was definitely abuse and should not have happened. (V4) should not have kept trying to make (R1) get in a sling. That just escalated (R1's) behaviors and there was no reason for it. (V23) witnessed this too.On 1/2/26 at 10:45 AM V23 (CNA) stated, On 11/1/25 around 4:30 PM (V4) came and got me and said (R1) was sitting on the floor and (V4) needed my help to put a sling under (R1) and get him into bed. (V4) stated she was stressed earlier that day and appeared frustrated and overwhelmed. Me, (V21), and (V4) tried to put a sling under (R1) and that was making (R1) very combative. (R1) normally only requires one to maybe two staff to transfer. Instead of stepping away (V4) kept insisting we put a sling under (R1). (R1) reached out and pinched (V4) in the inner thigh. (V4) then kicked (R1) three times on the left hip. (V21) told (V4) she needed to leave (R1's) room after (V4) kicked (R1). (V4) said she kicked (R1) due to a reaction from (R1) pinching (V4). (V4) kicked (R1) kind of hard and I felt like three times was a little excessive. It was physically abuse to (R1). (R1) was crying afterwards and yelled, Ouch! She (V4) kicked me! Get her out of here! (R1) was crying and appeared to be in pain.On 1/2/26 at 11:45 AM V24 (R1's Power of Attorney) stated, (V1/Administrator) called me and reported (R1) was on the floor and a staff member reported to (V1) that the other staff member kicked (R1). (R1) puts himself on the floor at times. I have been really stressed about the situation. I was told (R1) pinched (V4) and (V4) kicked him back. (V4) and all the staff should know how to deal with difficult residents. That is why (R1) is there. (V4) should not have kicked (R1). I feel like that is physical abuse and it would have hurt (R1's) feelings and make (R1) cry, lash out, or try to defend himself. That has happened a few months ago and since then (R1) has said to me She is an idiot which I am guessing is referring to the staff member that kicked (R1). On 1/2/26 at 12:22 PM V1 (Administrator) stated, I called (V4) with the intent to terminate (V4) for acting inappropriate towards (R1). (R1) should have reapproached when (R1) was agitated and should not have kicked (R1). If (R1) was kicked three times that is considered physical abuse, even though it was a reaction from (R1) pinching (V4).On 1/2/26 at 12:26 PM V4 (Registered Nurse) stated, On 11/1/25 I had a really rough day and was very busy. When I went to (R1's) room sometime after lunch, (R1) was wet and scooting on the floor which is not abnormal. I had not worked on the unit for about a month before that. (R1) was safe and sitting on a mat. I asked the CNA's (V21 and V23) to help me, and I got a (mechanical lift) sling to get (R1) off the floor. (R1) pinched me and I brought my knee up and hit (R1) in the left hip. (V21) started to yell at me, You kicked him! This is unsafe! (R1) has behaviors and told me to go away. Looking back with (R1's) behaviors I should have left (R1) on the mat. I know (R1) had a urinary tract infection and was having behaviors.The Immediate Jeopardy started on 11/1/25 after V4 (RN) kicked R1 in the left hip three times, causing R1 to experience psychosocial and physical harm of fear, mental anguish, and pain.V1 (Administrator) and V25 (Corporate Nurse Consultant) were notified of the Immediate Jeopardy on 1/2/26 at 2:30 PM. On 1/4/26 this surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1.V4 was suspended immediately and then terminated from employment on 11/7/25.2.V2 (Director of Nursing) completed skin assessments on R1 post incident on 11/1/25, 11/10/25, and 11/17/25 with no signs of injury related to the incident.3.V28 (Social Service Director) completed trauma risk assessments on R1 on 11/1/25, 11/7/25, 11/10/25, 11/14/25, 11/17/25, 11/19/25, 11/24/25, and 11/25/25 to ensure R1 had no concerns post incident.4.On 1/2/26 V1 and V25 (Corporate Nurse Consultant) completed all staff in-servicing regarding abuse and de-escalation training including contracted staff.5.On 1/3/26 all staff were in-serviced prior to their shift on stress management, caregiver strain, and burnout.6.On 1/2/26 the QAA (Quality Assurance and Assessment) team completed a full QAA identification and QAPI (Quality Assurance and Performance Improvement) plan of correction for R1's incident (11/1/25).7.R1's Care Plan was updated by V2 on 1/3/26 with interventions to instruct staff on what to do if R1 chooses to sit on the floor.Completion date: 1/3/26

Based on observation, interview, and record review the facility failed to ensure physician ordered pressure ulcer treatments were transcribed to the treatment administration records and provided as ordered by the physician for one of three residents (R2) reviewed for pressure ulcers in the sample of four.Findings include:The facility's Pressure Ulcer Prevention, Identification, and Treatment Policy dated 10/16/23 documents, Purpose: To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. Policy: The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. Responsibility: It is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. Procedure: When a pressure ulcer is identified whether in-house, or upon a resident's admission, the area will be assessed using the skin and wound assessment and initial treatment started per physician's orders.The facility's Physician Orders Policy dated 7/1/23 documents, Policy: This facility will obtain, process, and implement physician orders given by a Licensed Physician and received by a licensed nurse. Treatment Orders-When recording treatment orders, specify the treatment, location, frequency, and duration of the treatment.R2's re-admission Skin Inspection assessment dated [DATE] and signed by V32 (Agency LPN/Licensed Practical Nurse) documents R2 was re-admitted to the facility from the hospital with pressure ulcers to the right toes, left toes, coccyx, right buttock, and left buttock.R2's Hospital Discharge Orders dated 12/22/25 document orders to paint R2's bilateral toe ulcers with betadine daily, apply offloading pressure relieving boots to the feet, apply alginate and foam to all buttock ulcers and change every three days, and reposition R2 every two hours using a wedge for effective off-loading.R2's Treatment Administration Records do not include documentation of R2's pressure ulcer physician ordered treatments dated 12/22/25 being transcribed or provided to R2's bilateral buttocks, coccyx, right toes, or left toes until 12/30/25 (eight days after re-admission).On 1/2/26 at 10:50 AM R2 was lying on a low air loss mattress. V3 (Wound Nurse) provided wound cares to R2 during this time with no concerns observed during wound cares. R2 had approximately one cm (centimeter) open ulcers to the left and right buttock with redness surrounding the areas. V3 applied zinc 40 percent to the bilateral buttock areas. R2's toes had dark brown scabs to the right great toe tip, left great toe tip, left great middle toe, and the knuckle of the right big toe. V3 applied skin preparation to those areas. R2's coccyx wound was unstageable and covered in slough (dead tissue). R2's coccyx wound had a moderate amount of yellowish-reddish drainage and measured approximately four cm long by 1.8 cm wide. V3 applied a sodium hypochlorite solution soaked gauzed to the coccyx wound and covered with a dry dressing.On 1/9/26 at 1:30 PM V2 (Director of Nursing) stated, I helped (V32) with (R2's) re-admission orders on 12/22/25. It is partly my fault that (R2's) pressure ulcer treatments were missed. I did not put any treatments to (R2's) pressure ulcers on (R2's) treatment administration records. It looks like (R2) did not receive treatments to (R2's) pressure ulcers until 12/30/25. Someone should have noticed this and made sure (R2's) pressure ulcers were being treated upon re-admission [DATE]).

Based on interview and record review the facility failed to provide activities on weekends and evenings. This failure has the potential to affect all 67 residents residing within the facility. Findings include:The Administration Code Section 300.1410 Activity Program (undated) documents a) The facility shall provide an ongoing program of activities to meet the interests and preferences and the physical, mental, and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment. The activities shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents. g) The facility shall provide a specific, planned program of individual (including self-initiated) and group activities that are aimed at improving, maintaining, or minimizing decline in the resident's functional status, and at promoting well-being. The program shall be designed in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background, interests, capabilities, and tolerance. Activities shall be daily and shall reflect the schedules, choices, and rights of the residents (e.g., morning, afternoon, evenings, and weekends). The residents shall be given opportunities to contribute to planning, preparing, conducting, concluding, and evaluating the activity program.On 8/21/25 at 5:18 PM, V1/Administrator stated, We work off of an administrative code in place of a policy.The facility's Daily Census form, dated 8/20/25, indicates that 67 residents are currently residing in the facility.The Activity Calendars for June, July, and August 2025 document that there are no activities after 3:30 PM Monday through Friday. They also document there are no scheduled activities on Saturdays or Sundays. On 8/21/25 at 9:55 AM V1/Administrator stated that there are no activities in the evenings and on weekends. There are two activity calendars one for the North Unit and one for the South Unit. The North Unit is the Special Care Unit where the residents have Dementia or Alzheimer's. The South Unit calendar lists independent activities for the weekend. The North calendar lists family visits, music and snacks, and television time. V1 also stated the activities listed for the weekend on the South Unit and North Unit are not structured and V1 cannot say that any activities are being done. On 8/20/25 at 11:30 AM, V7/Activity Director stated that there are no structured activities on evenings or weekends. V7 also stated he would like to do activities in the evenings and on weekends but does not have the staff to do it. On 8/20/25 at 4:04 PM, R6/Resident Council President stated that there are no activities on evenings or weekend. R6 also stated There is nothing to do on evenings and weekends. It would be nice if there were activities.On 8/25/25 at 11:07 AM, R7 stated that she would like activities on the weekends because there is nothing to do. On 8/25/25 at 11:11 AM, R8 stated I enjoy going to activities. Sometimes in the evenings I'm tired so I don't know how much I would go to evening activities, but I would like activities available on the weekends. On 8/25/25 at 11:20 AM R9 stated I go to activities with (R10/R9's Family Member). There are no activities in the evenings or weekends, and it makes it a long weekend. Having activities on weekends would especially help (R10). When (R10) gets bored he starts talking about wanting to go home. Activities would take (R10's) attention off wanting to go home. On 8/25/25 at 11:28 AM R11 stated That he likes to go to activities. I would go on the weekends if they had them.

Based on interview and record review the facility failed to respond to resident call lights in a timely manner for nine of 11 Residents (R2, R3, R4, R5, R7, R8, R9, R10 and R11) reviewed for call light response in a sample of 11. Findings include: Facility Call Light Guidance Policy, dated 7/1/23, documents: to provide guidance to all Facility staff on the use, response and placement of call lights; Resident call lights shall be responded to within a reasonable amount of time; it is the responsibility of all staff to respond to call lights; and if responding staff is unable to meet the request/need of the Resident, staff shall leave the light on and elicit the assistance of appropriate staff. Facility Certified Nursing Assistant/CNA Job Description, undated, documents: the CNA provides each assigned resident with routine daily nursing care and services in accordance with the Resident's assessment and care plan; and will be accountable for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures; and follow assigned tasks in accordance with the facilities established policies and procedures and as instructed by supervisors. The Facility Grievance Log, dated 1/1/25 through 4/4/25, documents a complaint on 1/29/25 for R3's concern for call bell response time. Facility Resident Council Minutes, dated 1/2/25, document Resident nursing concerns about beds not being made at all and about having to wait too long when they turn their call light on, which Resident's stated happens mainly between 6:00 pm and 9:00 pm. Facility Resident Council Minutes, dated 2/6/25, document Resident nursing concerns with water not being refilled. Concerns about not being able to reach call lights. On 4/2/25 at 12:57 pm, R3 stated, They easily most of the time take about an hour to answer my call light, and sometimes it has been up to an hour and a half. They also are good about coming in and shutting off the call light and saying that they will be back, and never come back. On 4/2/25 at 12:59 pm, R5 stated, They do not mean to hurt me intentionally, but they take a really long time to answer my call light and a lot of time they just come in, shut off my call light, and say they will be back with help. They usually need two people because I use a (mechanical lift) to help me transfer, and it always takes them forever to get two people, so I sit here for a long, long time waiting. On 4/3/25 at 2:30 pm, R2 stated, They could be better with answering call lights. On 4/4/25 at 1:00 pm, R8 stated, I go to Resident Council meetings, and we always have complaints about our call lights. On 4/4/25 at 1:05 pm, R9 stated, We always have complaints about the call lights not getting answered. Sometimes it takes a long time for them to get answered. On 4/3/25 at 1:20 pm, R10 stated, We get complaints every month in Resident Council that the call light response is an issue. On 4/3/25 at 1:41 pm, R11 stated, We get complaints with call lights not getting answered almost every month. They say they will look into it. On 4/4/25 at 12:45 pm, R7 (Resident Council President) stated, We turn our problems with the call lights in to them and tell us that they follow-up on it every month, but we continually have problems with the call lights not getting answered. On 4/5/25 at 12:46 pm, V1 (Administrator) stated, I know Resident Council does have complaints about the call lights, I am going to try and figure out the best way to resolve these issues.

Based on observation, interview, and record review the facility failed to ensure trash cans were emptied daily and resident rooms, floors, and bathrooms were clean and free of stains and debris for four of four residents (R1-R4) reviewed for housekeeping services in the sample of four. Findings include: The facility's Housekeeping Vendor's Deep Cleaning Procedures policy (undated) documents, Clean restroom by moving in a clockwise rotation from the restroom door. h. Toilet-Scrub and disinfect toilet bowl. Remove all stains and build-up. n. Remove all build-up from floor around bowl, door frame, corners, and edges. Dust mop and damp mop entire room. The facility's Resident Council Minutes dated 8-1-24, 9-5-24, and 10-3-24 document, Concerns that the rooms are not being cleaned well. Concerns about having to take out their own trash. On 10-4-24 at 9:10 AM, R1 and R3's floor in-between R1 and R3's beds had two golf-ball sized areas of dried feces. R1 and R3 had clothes and a four-by-four gauze with dried brown drainage lying on their closet floor. R1 and R3's corner of the closet had unpainted drywall that was missing two foot of cove base. R1 and R3's bathroom floor had scattered used paper towels and brown debris. On 10-4-24 at 9:20 AM, V5 (CNA/Certified Nursing Assistant) verified R1 and R3's room had dried feces, a dirty gauze, clothes, debris, and paper towels on the floor. On 10-4-24 10:15 AM, R2 and R4's toilet riser had splattered dried feces around the rim and on the seat. The toilet had a dried brown ring around the rim and on the bottom. The caulking around the floor of the toilet had a black stain. On 10-4-24 at 10:30 AM, R2 stated, Housekeeping needs to improve here. My trash does not get taken out daily. I have to take my own trash out at times. The toilet riser is always dirty with dried BM (Bowel Movement). The toilet and floors are dirty too. On 10-4-24 at 10:35 AM, V5 (CNA/Certified Nursing Assistant) confirmed R2 and R4's toilet riser, toilet, and caulking around the floor of the toilet were dirty and stained. On 10-4-24 at 12:15 PM, V1 (Administrator) stated, I agree. The housekeeping services need to improve here. We (the facility) use an outside vendor for housekeeping services and use their policies. The trash should be taken out at least daily.

Based on interview and record review the facility failed to follow PASARR (Preadmission Screening and Resident Review) requirements for one resident (R29) of three residents reviewed for PASARR in a total sample of 20. Findings Include: R29's Level II PASARR (Preadmission Screening and Resident Review) dated 8/8/23 documents You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is: A serious mental health condition. At this time, you meet PASRR inclusion criteria. You have a Level II PASRR condition of Depression Disorder which has impacted your functioning and need for ongoing treatment support. You also have the diagnoses of Anxiety Disorder, PTSD (Post Traumatic Stress Disorder) and Narcolepsy. Rehabilitative services: You will need to be provided the following services and/or supports Provision of a structured environment for those individuals who are determined to need such structure: Individual, group and family psychotherapy. R29's Care Plan dated 03/01/23 documents I suffered a traumatic life event. I was physically assaulted which resulted in bodily harm. I require ongoing support and intervention with a counselor. On 2/25/24 at 10:30 AM R29 stated I haven't had counseling in quite a while, I think it would help me a lot. R29's Medical Record did not contain any therapy or counseling progress notes. On 2/27/24 V2 (Director of Nursing) confirmed that R29 had not received any therapy or counseling services since her last outpatient session in July 2023. (R29) should have been getting counseling.

Based on observation, interview and record review the Facility failed to perform hand hygiene and prevent cross contamination, for three separate wounds, during wound/skin care for one of five Residents (R37) reviewed for wound/skin care in a sample of 20 Findings include: Facility Dry Dressing Policy, dated 7/2/23, documents: the purpose is to provide guidelines for the application of dry, clean dressings; perform hand hygiene, put on clean gloves, loosen tape and remove soiled dressing; pull glove over dressing and discard into plastic bag; perform hand hygiene, open dressing equipment using clean technique, place on clean field, perform hand hygiene and put on clean gloves, cleanse wound with ordered cleanser, if using gauze, use clean gauze for each cleansing stroke, clean from the least contaminated area to the most contaminated area; discard disposal items into the designated container; remove disposable gloves and discard into designated container; and perform hand hygiene. Facility Hand Washing Policy, dated 7/1/23, documents: to provide guidelines for adequate hand washing in order to reduce the transmission of organisms from Resident to Resident, Staff to Resident and Resident to Nursing Staff; the Facility considers hand hygiene the primary means to prevent the spread of infections and all staff will properly wash hands after direct contact with any contaminated substance, after direct Resident care, and as instructed; it is the responsibility of all staff to ensure that they properly wash their hands after direct contact with Resident, contaminated substances, and as needed; must wash their hands for fifteen to twenty seconds using antimicrobial, or non-antimicrobial soap and water after contact with blood, body fluids, secretions, mucous membranes or non-intact skin; and after handling items potentially contaminated with blood, body fluids or secretions. R37's Physician Order Sheet/POS, dated 2/27/24, documents diagnoses including Type Two Diabetes Mellitus with Foot Ulcer, Non Pressure Chronic Ulcer of Right Heel and Midfoot Limited Breakdown of Skin. R37's POS also documents wound/skin treatment orders for the following: apply skin adhesive ointment (Skin Prep) to Right Heel, then border gauze daily at night (HS) and as needed for dry eschar; cleanse Left Heel with wound cleanser, apply medicated cream (Calcium Alginate), then cover with a four by four (gauze) and cling wrap daily and as needed; and cleanse Right First Metatarsal with wound cleanser, apply medicated cream (Calcium Alginate) to wound bed, cover with dressing and change daily and as needed. On 2/27/24 at 11:07 am, V5 (Infection Preventionist/Wound Nurse) was performing Diabetic Ulcer wound care to R37's Left Heel, Right Heel and Right First Metatarsal. V5 removed R37's heel protector boots. R37 did not have a dressing on R37's Right Heel and Right First Metatarsal. V5 removed R37's Left Heel soiled dressing, and the medicated cream covering (Calcium Alginate), was still adhered to R37's Left Heel. V5 then applied wound cleanser to a stack of four-by-four gauze pads and cleansed R37's Right Heel, and with the same soiled gauze pads, cleansed R37's Left Heel. R37's Left Heel medicated cream pad (Calcium Alginate) fell on to R37's bed sheet. V5 picked up the medicated cream pad (Calcium Alginate) with the stack of cleansing four by four gauze pads and continued to cleanse R37's Left Heel and Right First Metatarsal. V5 did not use separate clean cleansing gauze pads, remove gloves, or perform hand washing between the wound care for R37's three diabetic wounds. On 2/27/24 at 12:45 pm, V2 (Director of Nursing) stated, (V5) is fairly new to this position and (V5) told me that (V5) was extremely nervous during (R37's) wound care. (V5) should have used different gauze pads to clean each individual wound, and also (V5) should have done hand hygiene and put on new gloves between each wound, so they would not get cross contaminated.

Based on interview and record review the Facility failed to investigate a fall for one of four residents (R50) reviewed for falls in a sample of 20. Findings include: Facility Policy Accidents and Incidents, dated 07/01/23, documents: all accidents/incidents involving a Resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions; Section Responsibility documents it is the responsibility of the Charge Nurse to complete the accident and incident in (a computerized charting system), notify attending Physician and responsible parties and document accordingly. It is the responsibility of the DON/Director of Nursing/Designee to investigate and ensure appropriate completion, notification, and follow-up on all accidents and incidents; Section Procedure: Reporting documents Accident and Incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an accident/incident report should be completed on the shift that the accident or incident occurred; Section titled Medical Attention documents the charge nurse shall examine all accident/incident victims and the Medical Director or resident's personal Physician shall be notified of the accident/incident; Section Investigate and Follow Up Action documents the charge nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties, the accident/incident report must be completed, charge nurse will place the residents name on the 24-hour report summary, the DON, Interdisciplinary Team and/or designee will conduct an investigation of the accident/incident as well, findings will be indicated in the appropriate area, the Interdisciplinary Team/IDT will review within 24 hours or next business day and discuss and attempt to find out the root cause and implement an appropriate intervention to attempt to prevent further falls. R50's progress notes for 12/22/23 have no notes regarding R50's fall. R50's Progress Note, dated 12/23/23 at 7:25 pm, document: Staff were changing resident due to incontinence. Resident had five-inch-long x three-inch-wide bruise on left outer Thigh/Hip and (R50) was unable to verbalize how the bruise appeared. R50's Progress Note, dated 12/24/2023 at 8:35 am, written by V1 (Administrator) and linked to the 12/23/23 bruise note documents that R50 had a fall on 12/22/23 and was found on floor at bedside leaning to left side. There was no documentation of R50's fall prior to this progress note. On 12/24/2023 at 8:58 am, R50's progress note documents: that R50 has had no signs or symptoms of pain from previous fall on 12/22/23; noted dark purple bruise on left hip area; able to stand without any grimacing or yelling; no shortening of left leg or visual deformity noted or reported; and will notify Hospice Physician and Power of Attorney. On 02/26/24 at 11:23 am, V1 (Administrator) stated that, I was made aware of (R50's) fall as I received shift report on 12/23/23 at 6:00 am. V1 was unaware there had not been documentation on R50's fall. V1 began the reporting and investigation of R50's fall on 12/24/23. On 02/27/24 at 12:28 pm, V1 confirmed R50's fall had not been promptly documented in Risk Management, recorded in the computerized charting system, reported to R50's physician or power of attorney or investigated. V1 confirmed there was no documentation for R50's assessment, investigation, interventions or follow up documented until V1 began an investigation on 12/24/23. V1 stated (R50's) fall on 12/22/23 occurred at approximately 11:30 pm. V1 confirmed that R50's medical record did not document R50's 11/22/23 fall, examination or investigation until 12/24/23, and that R50's Physician was not immediately contacted.

Based on record review and interview the facility failed to provide any treatment or counseling for a residnet with a diagnosis of PTSD (Post Traumatic Stress Disorder) and failed to identify triggers for PTSD for one resident (R29) of three residents reviewed for PTSD in a total sample of 20. Findings Include: The Facility's undated Trauma Informed Care Procedure documents Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. R29's Care Plan dated 03/01/23 documents I suffered a traumatic life event. I was physically assaulted which resulted in bodily harm. I require ongoing support and intervention with a counselor. R29's Care Plan does not address any triggers or any situations for staff to avoid related to R29's PTSD. R29's Care Plan dated 09/01/23 documents This resident has a history that indicates they may have experienced significant trauma during their lifetime. Specifically, trauma related to unexpected loss of a loved one. On 02/27/24 at 9:00 AM, R29 stated I would feel triggered if I were alone with a man because of the history of my attack. My friend dying, I don't have any specific triggers, the grief comes in waves. On 02/26/24 at 1:30 PM, V2 (Director of Nursing) confirmed that R29 has no identified triggers for her PTSD diagnosis and has not been seen by a counselor since July 2023.

Based on observation, interview and record review the facility failed to wash their hands and change gloves between two different residents (R8 and R33) of four residents reviewed for personal cares in a total sample of 20. Findings Include: The Facility's Standard Precautions Policy dated 6/19/22 documents Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. On 2/26/24 at 1:30 PM, V4 (Certified Nurse Aide) rolled R33 to his side, touched his buttocks while pointing out multiple small open areas. V4 then rolled R33 to his back and used both gloved hands to roll back the foreskin on R33's penis and repeatedly touched the tip of the penis while indicating where small open areas were on the penis. After V4 covered R33 back up, she went directly to R8's bed without changing gloves or sanitizing hands in any way, rolled R8 to his side and pulled down R8's skin folds to the back of the right thigh to indicate multiple small open areas. On 2/26/24 at 2:00 PM, V4 confirmed that she did not wash her hands or change her gloves between R33 and R8. V4 stated Oh yeah, I should of changed gloves and washed my hands.

Based on observation, interview, and record review, the facility failed to ensure antipsychotics were utilized as abuse incident interventions without behaviors to warrant the use and obtain a stop date for a PRN (as needed) antipsychotic for one of one resident (R1) reviewed for antipsychotics in the sample of five. Findings include: The facility's Psychotropic Medications Policy, dated 7/1/23, documents, In accordance with federal and state regulations, it is the facility's policy that residents will not be given unnecessary medications. Residents shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. On 12/18/23 at 12:45 p.m., R1 was alert sitting up in her low bed with her husband at her bedside feeding her lunch. R1 would periodically stop and start clapping her hands together. R1 interacted with V13 (R1's POA-Power of Attorney) appropriately, but confused. R1 was holding V13's hands. At no time did R1 become aggressive with V13. V13 stated, I've never witnessed (R1) get really aggressive towards other residents or sexually inappropriate. She grabs at staff and yells bad words at them when they try to take care of her, but she doesn't do anything to hurt anyone. When she is walking or in her wheelchair she is constantly reaching out wanting to grab onto things and when she reaches for people she usually wants to hold their hand. V13 also stated, I'm not worried about any of the incidents. With each time something has happened the facility has changed her medicine. I don't think they know what they're doing. So, today I'm having her enrolled with hospice. I'm hoping they can get more of a handle of things when it comes to her medicine. On 12/20/23 at 11:44 a.m., R1 was alert sitting up in her recliner with a flat effect not exhibiting any behaviors. The facility's Report to the State Agency, dated 11/1/23, documents, On 10/28 /2023 (7:30 p.m.) (V11 Licensed Practical Nurse-LPN) reported to Administrator an allegation of inappropriate contact between residents. Comprehensive investigation initiated immediately. On interview, (V11) reported to the administrator that she stepped out of the med room and (R1) was standing in front of (R2) who was seated on the couch in the common area. (R1) then leaned over with her hands behind her back and kissed (R2) on the face. Nurse immediately intervened separating residents and assisting (R1) to her room. Both residents have the diagnoses of dementia and reside on the dementia unit. Neither resident appeared to be upset by the incident and neither resident had any memory of it when questioned. Upon further investigation with (R1's) husband said this is how (R1) typically acts when she is 'mothering' someone. R1 always has felt the needed to assist and take care of or 'mother other people'. Both residents continue at baseline. Investigation concluded that allegation of willful abuse unsubstantiated related to investigation findings that (R1) was trying to show motherly affection to (R2). Follow Up Action Taken: (R1) was placed on 1:1. Care plan reviewed and updated. Medication review completed, new medication added. On 12/20/23 at 11:12 a.m., V11 stated she witnessed (R2) sitting on the couch, and (R1) bent over and kissed (R2). She had never witnessed (R1 & R2) be affection towards each other or any other residents. V11 also stated that she didn't think (R1) purposely was trying to be affectionate in an inappropriate way. R1's Nurses' notes, dated 10/30/23 at 1:28 p.m., documents, Nurse Practitioner here to see resident. New order Risperdal (antipsychotic) 0.5 mg (milligrams) at HS (bedtime). Diagnosis: Dementia with inappropriate behaviors. The facility's Report to the State Agency, dated 11/17/23, documents, On 11/14/2023 (9:23 a.m.) a verbal resident to resident allegation was reported to the administrator. Residents were immediately separated, and investigation initiated. Investigation concluded that (R1) was using profanity at the dining room table, staff present attempted to verbally redirect her and (R1) picked up a piece of toast and tossed it across the table. The toast landed in front of (R3) who picked it up and tossed it back towards (R1). Neither resident was hit by the toast. (R1) continued to use foul language and staff were able to encourage (R1) to leave the dining room where staff provided 1:1 until behavior subsided. (R1) could not recall the incident during investigation interview related to cognitive deficits associated with diagnosis of Dementia with behavioral disturbances and a BIMS of 3 (Severely Cognitively Impaired). (R3) was unable to recall any events that occurred related to the incident due to cognitive deficits associated with diagnosis of Dementia and a BIMS of 4 (Severely Cognitively Impaired). (R1) and (R3) have remained at baseline and show no signs of mental anguish. The facility finds the allegation of willful abuse unsubstantiated. Follow-Up Actions Taken: Both Residents plan of care have been updated. The facility will continue to monitor residents as needed. Doctor increased (R1's) Risperdal and added Sertraline (antidepressant). R1's Nurses' notes, dated 11/14/23 at 3:45 p.m., document, Physician here to see resident. New order to increase Risperdal to 0.5 mg, BID (twice a day AM & HS). Sertraline 25 mg daily for dementia and behaviors. The facility's Report to the State Agency, dated 12/15/23, documents, A comprehensive investigation was initiated and found that on 12/12/23 at approximately 2:30 p.m. (V12 Activity aide) witnessed a physical interaction between two residents. During the interview (V12) stated that (R1) was in the dining room attending an activity with other residents. She suddenly started to try to back away from the table and when she was unable to she started flailing her arms around and made contact with (R4's) right upper arm. (R1) could not recall he incident during investigation interview related to cognitive deficits associated with diagnosis of Dementia with behavioral disturbances and a BIMS of 3 (severely cognitively impaired). (R1 and R4) have remained at baseline and show no signs of mental anguish. The facility finds the allegations of willful abuse unsubstantiated. Follow-Up Actions Taken: Both residents plan of care have been reviewed. The facility will continue to monitor residents as needed. Doctor increased (R1's) Risperdal. Facility interviews, dated 12/12/23, document, (V12) stated that she was hosting an activity with the recollections residents in the dining room doing puzzles. (V12) was going around the table providing oversite. (R1) was seated with (R4) to the left of her. (R1) who had been sitting at the table clapping hands and observing all of the sudden tried to back away from the table. She was unable to get away from the table because another resident wheelchair was blocking her. At this point, (R1) started swinging her arms around making contact with open hands to (R4's) upper right arm. R1's Nurses' notes, dated 12/12/23 at 6:00 p.m., document to increase R1's Risperdal to 1 mg by mouth twice a day. R1's Nurses' notes, dated 12/13/23 at 9:13 a.m., document, Reached out to (V13 R1's POA-Power of Attorney) to update on (R1) and that we are trying to keep resident in house while we wait to see if the medication for UTI (Urinary Tract Infection) was causing the increase in behaviors. While on the phone with (V13) staff from the unit came and let me know that resident behaviors were further elevated and they were having to be 1:1 with her in the activity room . (R1) has not approached any co-residents this morning but is striking out at staff and making threats. (V13) did agree for us to send to hospital for evaluation and treatment. R1's Nurses' notes, dated 12/13/23 at 3:06 p.m., document, Resident returned to facility via ambulance. New orders include Seroquel (antipsychotic) 25 mg BID (twice a day), may increase to 50 mg BID after 2 days for delirium. Haldol (antipsychotic) 2 mg IM (intramuscularly) PRN up to two times daily for severe agitation. R1's Nurses' notes, dated 12/13/23 at 5:17 p.m., document, New order given to discontinue Risperdal due to resident starting Seroquel. R1's Order Summary Report, dated 12/18/23, documents that as of this date R1 has orders to receive Haldol 2 mg IM every eight hours as needed for severe agitation related to diagnosis of Dementia and Seroquel 50 mg twice a day for delirium related to Dementia. R1's Behavior Monitoring, dated 10/1/23-12/18/23, document that R1 is being monitored for the behavior of change in mood with one episode of being angry/annoyed occurring for the month of October and two for the month of December. On 12/18/23 at 1:15 p.m., V14 (Registered Nurse) stated that she had never seen (R1) have any type of altercations with (R1) and any other residents. (R1) can be combative with staff, but not residents. I've never witnessed her have any sexually inappropriate behaviors either. On 12/20/23 at 12:15 p.m., V2 (Director of Nursing) stated that profanity, yelling and having a hard time resting were the behaviors that she has exhibited as to why the facility started R1 on the Risperdal, and the diagnosis of Dementia with behaviors. On 12/20/23 at 11:35 a.m., V6 (Minimum Data Set Coordinator) stated that (R1's) behaviors are yelling out and cursing and she's grabby. She likes to grab staff hands and rub them or kiss them. It's not always aggressive. I have not seen any sexually inappropriate behaviors from her. With the kissing incident, she is known to try to kiss staff on the cheek being affectionate and telling them she loves them. On 12/20/23 at 12:15 p.m., V2 (Director of Nursing) stated that (R1) was admitted on [DATE]. She's been using profanity mainly. She can be very affectionate and maternal she likes to hug and kiss staff. She likes to hold hands as well. We've tried giving her a fake cat to take care of. Profanity, yelling, and having a hard time resting were the behaviors that she has exhibited as to why we started the Risperdal, and the diagnosis of Dementia with behaviors. V2 also confirmed that R1's Haldol should have a stop date of no longer than 14 days from when it was started on her PRN Haldol. On 12/20/23 at 12:30 p.m., V1 (Administrator) stated that on 10/28/23, (V11) was very clear that (R2) was seated and (R1) was talking to him standing over him with her hands behind her back and leaned over and kissed him. It was nothing sexual. Which was behaviors that she had displayed with the other staff and wanting to be motherly. The incident (11/14/23) with (R3) was basically (R1) tossed her toast and it landed in front of (R3). (R3) then picked it up and tossed back across the table. The way it (12/12/23 incident) was presented to me she was sitting in activities, she's impulsive, she attempted to back up and she couldn't back up because a wheelchair was behind her and she got frustrated. Once she hit that wheelchair and couldn't get away she felt trapped she started flailing her arms. Her arms flailing was not directed at (R4). We called the doctor about the incident, and she wanted the medication increased. The next day she woke up mad and we had to keep staff with her. She was being really threatening and aggressive towards the staff. So, we sent her to the hospital to get medical clearance. I've recommended against the Haldol. I think she would need to be unable to redirect anyway shape or form in order to give her the Haldol PRN. I'm not ok with them giving it. She would really have to be going after residents and unable to be redirected. When we started the Risperdal, (R1) was showing more elevated behaviors, for instance the clapping, and we were trying to calm her. She was having a lot of verbal behaviors and frustrated with staff. If you spend time with her, she was not being hateful she just wasn't good on the inside.

Based on interview and record review the facility failed to maintain privacy and confidentiality of personal and health information for two residents (R8 and R9) of 4 residents reviewed for medical records in the sample of 10. Findings include: R8's Assessment signed by V13 (Nurse Practitioner) dated 7/1/22 at 1:52 PM, documents R8's personal information was uploaded into R1's electronic medical record. The information included the following: R8's date of birth, address, and phone number. It included that R8 has dementia due to Parkinson's Disease without behavioral disturbance, Anxiety, Chronic Diastolic Congestive Heart Failure, Diabetes Mellitus Type 2, and a Urinary Tract Infection. The record also went on to state that R1 was a new resident and included additional information concerning R8's plan of care, active problems, and physical exam. (This information was included with R1's electronic records that were to be sent to a facility R1 requested to transfer to.) On 9/19/23 at 11:23 AM, V2 (Director of Nursing) and V12 (Regional Support Nurse) came in with a laptop computer and showed that there was information about R8 in R1's electronic medical records. On 9/19/23 at 11:23 AM, V1 (Regional Director of Operations) stated that the uploaded progress notes that were in the history for R1 included documents in the file that were for R8. This is the file that the corporate office could have sent to V9 (R1's Power of Attorney). V1 also stated, We cannot prove or disprove it was sent to V9 (R1's Power of Attorney), but there is the possibility. On 9/19/23 at 12:58 PM, V9 (R1's Power of Attorney) stated that in with R1's paperwork that V9 received from the facility was information about a catheter for (R9) and it was signed by a doctor. V9 emailed the above-mentioned records that were included in R1's records and review indicted the paperwork was a Physician Notification Form that was sent to V10 (R9's Primary Care Physician) dated 8/05/22, which documented (R9) requests SP (Super Pubic) catheter be changed on routine basis. Need orders please for SP cath (catheter) change and how often. On 9/19/23 at 1:12 PM, V2 (Director of Nursing) stated Evidently we do have an issue with confidentiality of resident's medical records that we need to figure out. On 9/20/23 at 12:12 PM, V2 (Director of Nursing) stated that each resident is given a copy of their rights upon admission, and they are told in Resident Council Meetings about their rights. They are aware their information is to be confidential. On 9/20/23 at 1:41 PM, V2 (Director of Nursing) stated that she assumes the mix up (with R9's records) happened on the fax/printer machine. The paperwork for R9 was probably on the machine when R1's papers were printed for V9 (R1's Power of Attorney). As far as how R8's medical records were in with R1's electronic record is unknown. V2 also stated We all agree there is a problem. The Resident Rights Booklet dated 11/18, documents You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Your facility may not give information about you or your care to unauthorized persons without your permission unless you are being transferred to a hospital or to another health care facility. The Electronic Medical Records policy dated 7/1/23, documents Purpose: To provide guidance to the facility regarding the use and storage of electronic medical records. Responsibility: It is the responsibility of the Administrator, or designee, to understand and ensure compliance of the facility of the electronic medical records policy. Policy: Electronic medical records may be used in lieu of paper records when approved by the Administrator and stored/maintained as required. Policy Interpretation and Implementation 2. the administrator, in conjunction with the quality assessment and assurance committee, shall review requests for and the implementation of our electronic medical records system. 8. Our electronic medical records system has safeguards to prevent unauthorized access of electronic protected health information (e-PHI). These safeguards include administrative, technical and physical safeguards that are appropriate for: a. the probability and criticality of risks to e-PHI based on a thorough risk analysis conducted by this facility; b. the size, complexity and capabilities of this organization; and c. the technical infrastructure, hardware, software and security capabilities. The Employee Handbook on page 45, documents, Section 5-21 Patient [NAME] of Rights, We firmly believe that each resident should expect and receive the highest quality of personal and professional care. In keeping with our philosophy, we are committed to supporting and adhering to the Patient's [NAME] of Rights. The Patient's [NAME] of Rights, in part, states that a resident: Will be assured confidential treatment of his/her personal and medical records. We expect the actions and conduct of our employees to be in compliance with the Patient's [NAME] of Rights. Section 5-22 Health Insurance Portability and Accountability Act (HIPAA) We are committed to complying with all applicable laws and regulations pertaining to Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a broad law that governs whom we give access to patient data as well as how we transmit, retain and safeguard residents and employees Protected Health Information (PHI).

Based on observation, interview and record review the facility failed to accurately assess residents for the use of bed rails and ensure bed rails were not left in the up position for residents who could not turn or reposition independently in the bed for five of five residents (R21, R1, R22, R26, R18) reviewed for bed rail safety in a sample of 19. Findings include: A Bed Rails policy dated as revised 1/10/18 states that bed rails may be used under certain circumstances which includes to, Assist in transfer into and out of their bed. To enable the resident('s) ability to independently make subtle position changes for comfort and pressure relief. To enable the residents (') ability to participate with staff in assistance to turn and reposition. This policy does not address residents who cannot independently utilize bed rails to reposition, or other safety concerns including impaired cognition or residents' individualized entrapment risks. 1. A list of R21's current diagnoses includes Down's Syndrome, Generalized Muscle Weakness, Muscle Wasting and Atrophy, and Major Depressive Disorder. R21's Minimum Data Set (MDS) assessment dated [DATE] documents that R21 is severely cognitively impaired, requires extensive assistance of two people for bed mobility, transfers, dressing and toilet use; and is always incontinent of bowel and bladder. This same MDS documents R21 requires substantial/maximal assistance from staff to roll to R21's side and roll to R21's back again. In addition, this MDS documents an attempt to walk R21 during this assessment was not made due to R21's medical condition or a safety concern. R21's care plan intervention dated 10/11/21 states, (R21) requires assist x (times) 2 for bed mobility. (R21) is not able to use his bed rails due to cognition. R21's Bed Rail Evaluation dated 12/1/22 documents R21 uses one-quarter side rails on both sides of R21's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R21) is unable to assist staff with his bed mobility without the rails. (R21) is able to grasp the side rail with verbal cues and hand guidance from staff to hold onto. The use of side rails promotes independence allowing (R21) to participate in his own mobility. R21's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R21's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R21's Bed Rail Evaluation describes how the use of bed rails increases R21's ability to function or improve R21's quality of life as, Side rail use promotes independence with (R21's) bed mobility and allows him to assist staff. On 12/12/22 at 11:18 AM R21 was lying in bed with one-quarter bed rails in the up position on either side of R21's bed. V5 (Registered Nurse) and V6 (Certified Nurse Aide) were providing R21 with extensive assistance to reposition in the bed. During this process, R21 did not reach for the side rails or provide any assistance with repositioning. 2. R1's list of current diagnoses includes Severe Intellectual Disabilities and Spastic Hemiplegic Cerebral Palsy. R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is severely cognitively impaired, is totally dependent on two people for bed mobility, transfers, dressing and toilet use; has functional limitation to both R1's upper and lower extremities, and is dependent on staff to roll to R1's side and roll to R1's back again. In addition, this MDS documents an attempt to walk R1 during this assessment was not made due to R1's medical condition or a safety concern. This same assessment documents R1 is always incontinent of bowel and bladder. R1's care plan focus dated 12/23/16 states R1 has an activities of daily living self-care deficit related to Cerebral Palsy which gives R1 little control over the movements of R1's extremities. This same care plan documents R1 has extreme difficulty at times carrying out verbal cues. In addition, this care plan states that staff will provide R1 with verbal cues to assist in bed mobility by pushing up with his feet. R1's care plan does not indicate that R1 has bed rails kept in the up position on his bed or under what circumstances bed rails will be used. R1's Bed Rail Evaluation dated 8/29/22 documents R1 uses one-quarter side rails on both sides of R1's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R1) uses side rails to perform bed mobility by grasping onto the side rail when staff assisting rolling from side.) Resident hangs onto the side rail much of the time while he is in bed. Without the use of side rails (R1) is no longer able to assist with these actions. (R1) is unable to use trapeze bar or bolster mattress due to limited ROM (range of motion) and decreased upper body strength. R1's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R1's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R1's Bed Rail Evaluation describes how the use of bed rails increases R1's ability to function or improve R1's quality of life as, (R1) uses side rails to assist in independent bed mobility and as security while in bed. On12/12/22 at 2:34 PM R1 was lying in bed with one-quarter bed rails in the up position on each side of R1's bed. R1 was grasping both bed rails with R1's hands but not turning or repositioning himself in the bed. V15 (Certified Nurse Aide/CNA) and V13 (CNA) entered R1's room to provide R1 with incontinence care. R1 let go of the bed rails while V15 and V13 physically turned and repositioned R1 from side-to-side during incontinence care. R1 did grasp the bed rails during R1's care but did not use them to assist with any aspect of turning or repositioning. R1 also did not use his legs to help V15 and V13 boost R1 up in bed. On 12/13/22 at 1:30 PM V13 stated that R1 likes to hold onto the bed rails while in bed or while receiving care but that R1 cannot use the bed rails for independent bed mobility. 3. R22's list of current diagnoses includes Osteoarthritis, Neurocognitive Disorder with Lewy Bodies, Depression, Insomnia, Anxiety Disorder, History of Falling. R22's Minimum Data Set (MDS) assessment dated [DATE] documents R22 is severely cognitively impaired, requires extensive assistance of two people for dressing and bed mobility, is totally dependent on two people for transfers and toilet use; and is always incontinent of urine and occasionally incontinent of bowel. R22's MDS documents that walking R22 was not attempted due to R22's medical condition or safety concerns. R22's care plan focus dated 8/26/22 documents that R22 has, both short and long-term memory deficits and confusion. (R22 is) able to make simple daily decisions with verbal cues and supervision to ensure (R22) make(s) the safest most appropriate decisions. R22's care plan does not indicate R22 has bed rails attached to R22's bed, is able to use bed rails independently or requires staff supervision while using bed rails for bed mobility. R22's Bed Rail Evaluation dated 11/14/22 documents R22 uses one-quarter bed rails on both sides of R22's bed. This evaluation documents under alternatives attempted prior to using bed rails as, (R22) is unable to use trapeze to help with turning and getting out of bed due to lack of upper arm strength and body size. (R22) uses bed rails to assist staff with turning and repositioning. R22's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R22's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R22's Bed Rail Evaluation describes how the use of bed rails increases R22's ability to function or improve R22's quality of life as, (R22) is able to complete bed mobility independently with the bed rails up. When bed rails were lowered (R22) had a hard time turning. (R22) maintains more independence with her ADLs (activities of daily living) with the use of bed rails. On 12/12/22 at 11:12 AM R22 was lying in bed with one-quarter bed rails in the up position on both sides of the bed. R22 stated she could use her bed rails to help her turn and reposition in the bed. At 11:22 AM V17 (Certified Nurse Aide/CNA) and V6 (CNA) entered R22's room to provide incontinence care. V17 and V6 instructed R22 that they needed to turn R22 to her right side. Only after R22 was turned to the right did she grab onto the bed rail to help keep herself on her side. Once R22 was repositioned onto her back, R22 stated that she could grab onto the bed rails to hold on once she was turned by staff to the side, but that R22 could not reach across her chest to grab the bed rail to independently turn to her side. On 12/13/22 at 1:30 PM V13 (CNA) and V14 (CNA) stated they were R13's CNAs for that day. V13 and V14 stated that R22 has bed rails in the up position on her bed but that R22 is unable to use the bed rails without staff assistance. 4. R26's list of current diagnoses includes Polyosteoarthritis and Scoliosis. R26's Minimum Data Set (MDS assessment dated [DATE] documents that R26 is cognitively intact, requires extensive assistance of two people for bed mobility, transfers, and toilet use, and has a functional limitation in both upper and lower extremities. This same MDS documents R2 is always incontinent of urine, occasionally incontinent of bowel, and requires substantial/maximal assistance from staff to roll to R26's side and roll to R26's back again. In addition, this MDS documents an attempt to walk R26 during this assessment was not made due to R26's medical condition or a safety concern. R26's care plan intervention dated 12/27/21 states, BED MOBILITY: (R26) needs staff assistance to turn and reposition in bed encourage her to use her bed rails to assist with turning. R26's Bed Rail assessment dated [DATE] documents R26 uses one-quarter side rails on both sides of R22's bed. This evaluation documents under alternatives attempted prior to using bed rails as, Due to limited ROM (range of motion) in upper arms (R26) is unable to use trapeze or bolster mattress to pull herself up or over in bed. Bed rails were lowered, and resident was a total assist for bed mobility and to sit up on side of bed. Bed rails were raised, and resident was able to use rails to help turn and sit on side of the bed. R26's Bed Rail Evaluation's bed rail risk section with boxes to check for all of R26's risks for using bed rails including incontinence, reduced range of motion, decreased ability to ambulate or perform routine activities, symptoms of withdrawal/depression/reduced social contact, skin integrity issues, and entrapment was left blank. In addition, R26's Bed Rail Evaluation describes how the use of bed rails increases R26's ability to function or improve R26's quality of life as, Bed rails enables resident to help staff turn and reposition self in bed and sit up on side of bed. Resident is unable to use any other alternatives due to limited ROM and pain. On 12/13/22 at 1:22 PM R26 was seated in a wheelchair in her room. R26's bed had one-quarter bed rails on either side of R26's bed in the up position. R26 stated that she is unable to use the bed rails independently and that she requires staff to assist her to turn and reposition while in the bed because of pain and upper and lower extremity weakness related to Osteoarthritis. On 12/14/22 at 11:50 AM V8 (MDS/ Care Plan Coordinator) stated she is also the facility's Restorative Nurse and is new to the position. V8 stated, as part of her restorative duties, she performs residents' bed rail assessments. V8 stated that residents whose Bed Rail Evaluations don't have any risks marked in the check boxes don't have any of the conditions which might place them at risk. V8 stated that R26 is cognitively intact and can accurately describe her bed mobility limitations. V8 stated that she thought once staff turns R22 to her side and R22 holds onto the bed rail, that indicated R22 could use the bed rail independently. V8 stated that R1 likes to hold onto the bed rail while he is in bed because it makes him feel secure. V8 verified that R21 was assessed as being unable to use the bed rails without staff assistance for verbal cues and guidance. V8 also verified that R21's care plan states R21 is unable to use bed rails due to R21's cognitive status. 31682 5. R18's Bed Rail Evaluation dated 11-1-22 and signed by V8 (MDS/Minimum Data Set) Assessment documents, Type of bed rail ordered: 1/4 (One-Quarter) side rails. Indications for use: 1. Enhanced bed mobility/comfort positioning. 2. Provide comfort for fear of falling/injury. 3. Serve as a reminder not to get up without assistance if unsafe to do so. 4. Decrease physical and/or cardiac exertion. 5. Promote independence and positive self-esteem. 6. Decrease exertional pain. Risks for bed rail use: (Section not completed). Resident Evaluation: Is the resident physically able to release bed rails? No. Resident Cognition: Confused. Mobility in and out of bed: Partial dependence on staff with or without assistive devices. Resident has been determined to be a fall risk based on the fall assessment: Yes. Continence with bladder and bowel? Incontinence. Ability to toilet self safely: No. R18's MDS (Minimum Data Set) assessment dated [DATE] documents R18 is severely cognitively impaired and requires extensive assistance of two staff physical assistance for bed mobility, toilet use, personal hygiene, and dressing, and extensive assistance of one staff physical assistance for eating. R18's current Plan of Care does not include a plan of care regarding R18's use of side rails along with risks and interventions to reduce those risks associated with side rail use. On 12/13/22 at 10:30 AM R18 was lying in bed with bilateral one-quarter length side rails in the raised position. R18 was confused at this time. V6 (CNA/Certified Nursing Assistant) asked (R18) to use grab the side rail to turn herself. R18 was unable to understand V6's request and unable to use the side rails. On 12/13/22 at 10:35 AM V6 (CNA/Certified Nursing Assistant) stated, (R18's) side rails are always raised when she is in bed. (R18) cannot use her side rails on her own. On 12-14-22 at 11:00 AM V2 (Director of Nursing) stated, (R18's) bed rail evaluation is inaccurate and does not identify (R18's) entrapment risks and other risks associated with bed rail use. On 12/14/22 at 11:44 AM V8 (MDS/Minimum Data Set) Assessment stated, (R18) would have a risk of entrapment since she is cognitively impaired and cannot use her side rails on her own. The bed rail assessment is inaccurate and should have had risks identified with the use of side rails.

Based on record review and interview the facility failed to complete a comprehensive MDS (Minimum Data Set) assessment within 14 days following a significant change in condition for one of one residents (R18) reviewed for change in condition in the sample of 19. Findings include: The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Manual dated 10-1-19 documents, A significant change in status assessment must be completed no later than 14 calendar days from determining a significant change in a resident's status occurred. A significant change in assessment is required when the resident has an improvement in more than one area of health status or a decline in more than one area of health status that is not expected to resolve within two weeks. A significant change in status assessment is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (example, two areas of ADL (Activities of Daily Living) decline or improvement). R18's MDS (Minimum Data Set) assessment dated [DATE] documents R18 required limited assistance of one staff physical assistance for bed mobility, toilet use, and personal hygiene, limited assistance of set-up only for eating, and extensive assistance of one staff physical assistance for dressing. R18's MDS assessment dated [DATE] documents R18 had a decline in ADL's (Activities of Daily Living) since the last MDS assessment dated [DATE] to requiring extensive assistance of two staff physical assistance for bed mobility, toilet use, personal hygiene, and dressing, and extensive assistance of one staff physical assistance for eating. On 12/13/22 at 11:55 AM, V2 (Director of Nursing) stated, A significant change MDS should have been completed within 14 days of (R18's) decline of ADL's that was identified on (R18's) MDS dated [DATE]. One was not completed that I am aware of. The facility uses the RAI manual to determine when a significant change assessment should be completed. Any decline in two areas of ADL's requires a significant assessment to be done.

Based on observation, interview, and record review the facility failed to develop and implement restorative programs and a plan of care to treat R18's decline in Activities of Daily Living (ADL's) for one of one resident (R18) reviewed for ADL decline in the sample of 19. Findings include: The facility General Requirements for Nursing and Personal Care policy dated 6-29-11 documents, The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive care plan. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. Restorative measures shall include, at a minimum, the following procedures: All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's abilities to bathe, dress, and groom, transfer and ambulate, toilet, eat, and use speech, language, or other functional communication systems. R18's MDS (Minimum Data Set) assessment dated [DATE] documents R18 required limited assistance of one staff physical assistance for bed mobility, toilet use, and personal hygiene, limited assistance of set-up only for eating, and extensive assistance of one staff physical assistance for dressing. R18's MDS assessment dated [DATE] documents R18 had a decline in ADLs since the last MDS assessment dated [DATE] to requiring extensive assistance of two staff physical assistance for bed mobility, toilet use, personal hygiene, and dressing, and extensive assistance of one staff physical assistance for eating. R18's MDS Assessments dated 8-4-22 and 11-1-22 document R18 does not receive therapy or restorative nursing programs to address R18's decline in bed mobility, toilet use, personal hygiene, dressing, and eating. On 12/12/22 from 12:28 PM to 1:15 PM V7 (R18's Family Member) was observed feeding R18 in the dining room. During this time staff did not do any restoratives with R18 to maintain or increase her functional status while eating. On 12/13/22 at 10:35 AM V6 (CNA/Certified Nursing Assistant) stated, (R18) does not get any therapy or restoratives. We (the staff) just do everything for (R18). (R18) has required a lot more assistance lately. On 12/13/22 at 10:42 AM V1 (Administrator) stated, We (the facility) do not have a restorative aide or nurse at the moment. On 12/13/22 at 11:55 AM, V2 (Director of Nursing) stated, There should have been a restorative program developed for all of R18's declines in ADL's. According to (R18's) record I do not believe (R18's) ADL declines have been addressed and (R18) has not had a care plan developed to address (R18's) ADL decline. We have not had a restorative nurse or aide for a little while now.

Based on observation, interview and record review the facility failed to ensure a resident's toenails were trimmed for one of two residents (R21) reviewed for activities of daily living (ADL) care in a sample of 19. Findings include: A facility General Requirements for Nursing and Personal Care policy (undated) states, Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident, and A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal hygiene. In addition, this policy states, Each resident shall have proper daily personal attention, including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician. A list of R21's current diagnoses includes Down's Syndrome, Generalized Muscle Weakness, Muscle Wasting and Atrophy. R21's Minimum Data Set (MDS) assessment dated [DATE] documents that R21 is severely cognitively impaired, requires extensive assistance for personal hygiene and is totally dependent on staff for bathing. On 12/13/22 at 9:51 AM R21 was lying in bed. V5 (Registered Nurse) entered R21's room to evaluate the condition of R21's feet and toenails. R21's toenails were a grayish discoloration with R21's great toe on each foot having an approximate one-quarter inch thick nail rising above the top of the great toe which were also approximately one-quarter inch in length. R21's remaining toenails were long and misshapen. V5 stated that R21's Nurse Practitioner, V16, had just evaluated R21 and wrote an order for R21 to see a podiatrist as soon as possible. V5 stated, It's been a while, since R21 had his toenails trimmed and that a podiatrist would normally do this procedure. R21's physician's orders dated 12/12/22 documents, Needs podiatrist ASAP (As soon as possible). R21's practitioner's progress notes dated 12/12/22 and documented by V16 states, Needs podiatrist for long, thick toenails as soon as possible. On 12/14/22 V2 (Director of Nurses) stated, If a residents' toenails need trimming, the nurse should have done that. V2 also stated that a Podiatrist has not visited the facility in several months.

Based on observation, interview, and record review the facility failed to prevent the development of a Deep Tissue Injury (DTI) for one of one resident (R21) reviewed for pressure ulcers in a sample of 19. Findings include: A Wound and Ulcer Policy and Procedure dated as revised 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management, and All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale-Ulcer Risk Assessment. This policy states that protocols for pressure ulcer prevention are, based upon the needs and condition of the resident. In addition, this policy defines a DTI as, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear, and The wound may further evolve and become covered by thin eschar (devitalized tissue). R21's Minimum Data Set (MDS) assessment dated [DATE] documents R21 is severely cognitively impaired and requires extensive assistance from staff for bed mobility, transfers, and dressing. R21's Braden Scale for Predicting Pressure ulcer Risk dated 11/7/22 documents R21 is at risk for the development of pressure ulcers. R21 has risk factors which includes R21 is chairfast with his ability to walk severely limited or non-existent, cannot bear weight and/or must be assisted into a chair or wheelchair, and makes frequent though slight changes in body or extremity position independently. On 12/13/22 at 9:51 AM R21 was observed lying in bed. R21's ankles appeared to be weak causing R21's feet to drop downward in a foot drop position. V5 (Registered Nurse) entered R21's room to assess a new pressure wound which had developed on R21's left great toe. R21 proceeded to examine the tip of R21's left great toe which had an intact blood-filled blister to the outer edge which measured approximately 2.3cm (centimeters) long x 2.0cm wide. V5 stated that R21 has a new wheelchair which has one solid foot plate which both feet rest on when R21 is up in the wheelchair. V5 stated that R21 normally does not wear shoes while he is in his wheelchair. V5 stated she noticed that R21 presses his feet and toes against the foot plate of his wheelchair. V5 stated she believes R21's pressure ulcer developed because of that pressure from his toe on the foot plate of the wheelchair. V5 stated that V16 (R21's Nurse Practitioner) examined R21's wound yesterday and called it a blood-filled blister. V5 demonstrated how R21's wheelchair has a single hard foot pedal on the bottom of R21's specialized wheelchair where R21 rests both of his feet. R21's physician's orders sheet (POS) dated 12/13/22 states, Monitor and apply betadine to blood blister on left great toe. Keep pressure off. R21's practitioner's progress notes dated 12/12/22 and documented by V16 states, OT (Occupational Therapy) to evaluate proper positioning in wheelchair. On 12/13/22 at 12:30 PM R21 was seated in the dining room in a specialized wheelchair. R21 was not wearing any shoes and R21's feet and toes, including where R21's pressure ulcer was located, appeared to be pressing against the single foot pedal of R21's wheelchair.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one residents (R26) reviewed for range of motion in a sample of 19. Findings include: A Restorative Program Checklist dated 6/26/13 states, A restorative assessment is completed prior to implementing the (restorative) program and at least quarterly thereafter, and Measurable objectives & interventions are documented in the care plan and clinical record. A Contracture Prevention Program policy dated 1/15/11 gives as its objectives, 1. To maintain residents at the highest level of physical functioning possible. 2. To stimulate circulation and prevent edema. 3. To prevent fixation of a joint for long periods of time. 4. To prevent atrophy of muscles. In addition, this policy states, The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing a contracture may include goals, positioning aids, treatment plans and potential for improvement. R26's Minimum Data Set (MDS) assessment dated [DATE] documents R26 requires extensive assistance of two people for transfers, bed mobility, dressing, toileting and personal hygiene. This same MDS documents that R26 has a functional limitation in range of motion to both R26's upper and lower extremities but is not receiving any range of motion nursing restorative programs. R26's current care plan does not include interventions to address R26's decreased range of motion to her upper and lower extremities. R26's physician's orders sheet (POS) dated 11/21/22 documents R26 was ordered to have Occupational Therapy (OT) dynamic activities including the use of balance strategies, strengthening and range of motion techniques to improve performance of a functional task or activity three times weekly for 30 days. On 12/12/22 at 10:41 AM R26 was observed seated in a wheelchair in her room. R26 stated that she has a decrease in range of motion because of severe Osteoarthritis to her arms, legs, and fingers. R26 stated that she does not receive any range of motion exercises to her upper and lower extremities from the facility's nursing staff but does receive therapy to her upper extremities from the OT department. R26 stated she is unable to move her legs and hips very well and requires the use of a mechanical sit/stand lift for transfers and requires extensive assistance from staff to move in her bed. On 12/14/22 at 2:30 PM V19 (Occupational Therapy Aide) stated that R26 was referred for Range of motion exercises and to evaluate for the need of adaptive equipment such as specialized eating utensils because of R26's severe Osteoarthritis. V19 stated that Osteoarthritis has affected R26 everywhere. However, V19 stated she is only providing therapy to R19's upper extremities. V19 stated that she gave R26 a choice of what part of her body she wanted to do therapy to and that R26 chose to work on just her arms. V19 stated that R26 said she didn't think she would benefit from therapy to her legs. On 12/14/22 at 9:30 AM V2 (Director of Nurses) stated that although R26 uses a sit/stand mechanical lift for transfers, that type of transfer provides some weight bearing for R26 but no lower extremity range of motion benefit. V2 stated the facility has just hired a new Restorative nurse who has not been there long enough to evaluate residents for their range of motion needs. On 12/14/22 at 10:33 AM V6 (Certified Nurse Aide) stated that R26 is not on a range of motion program from nursing staff.

Based on record review and interview the facility failed to allow a resident (R1) to return to the facility after being sent to the hospital for an acute behavioral and medical condition, failed to document all measures the facility took to meet R1's needs that could not be met by the facility along with developing and implementing a care plan to meet those needs, failed to involve R1, R1's Power of Attorney (POA), and the Ombudsman to develop a plan to meet R1's needs, failed to notify the resident, resident's representative, and long term care Ombudsman in writing and verbally of R1's discharge, including notification of appeal rights, and failed to establish and follow a written policy on allowing a resident to return to the facility after hospitalization for one of three residents (R1) reviewed for discharge in the sample of three. These failures resulted in R1 remaining in the hospital for 46 additional days after being medically cleared by the hospital physician to return to the facility resulting in R1 being placed in another facility in Norridge, Illinois (approximately 253 miles) from the facility in which was R1's home for two years and seven months. V7 stated R1 would be more confused, scared, and have increased behaviors due to being unaware of his surroundings, staff and not being able to see his friends. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-29-22, the facility remains out of compliance at a severity Level II as the facility continues to educate current and new staff on resident transfer, discharge, re-admission requirements, resident behavioral needs, audit behavioral needs of the residents, update the resident's care plans as needed to reflect those needs, and continues to implement their re-admission to the facility after discharge/therapeutic leave policy. Findings include: The Facility Assessment Tool revised on 1/27/21, documents the following: Part 1: Our Resident Profile- Indicate if you may accept residents with, or your residents may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management-diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Management of Medical Conditions- Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions. The Facility's New (Federal Regulations) for Involuntary Discharge/Transfer (date unknown), states Prior to involuntary discharge/transfer, the facility must document steps that were taken to avoid discharge/transfer. This should include a meeting with the resident and, if applicable, the resident's representative. The notice of an involuntary discharge/transfer must now be served at least 30 days before the effective date of the discharge/transfer in a language and manner understood by the resident. The following must be included in the notice: The reason for the involuntary discharge/transfer; The effective date of the discharge/transfer; The location where the resident will be discharged /transferred; A hearing request form and a pre-addressed, stamped envelope to mail the form. Note that a request for hearing will stay with the involuntary discharge/transfer; The name, mailing address, and telephone number of the person responsible to supervising the transfer; The name, mailing address, and telephone number of the Office of the State Long Term Care Facility Ombudsman; and if the person has intellectual/developmental disabilities or serious mental illness, the name, mailing address, email address, and telephone number of Equip for Equality. A copy of the notice must be mailed to the Department, and the State Long-Term Care Ombudsman or Equip for Equality. The involuntary discharge or transfer must be documented in the resident's record, including the following: The basis for the discharge/transfer; Needs that cannot be met by the facility, the steps taken to meet those needs, and needs that can be met by the new facility, as documented by the resident's physician; Physician documentation that the resident no longer needs long term care services; and Documentation of the danger that failure to discharge/transfer would pose. At a minimum, the following information must be provided to the receiving facility: Resident's physician and contact information; Resident Representative and contact information; Advance directive, if any; All special instructions or precaution; Care Plan goals; Discharge/transfer summary; and All other necessary information to ensure a safe and effective transition of care. On 8/24/22 at 12:02PM, V1 (Administrator) verified that the Facility Assessment last revised on 1/27/21, documents the most current assessment data. The Facility's Behavior (Serious Behavior) Emergency policy dated 9/2011, states The facility will ensure that a resident who displays a serious behavior emergency, (that is to say) any suicide attempts or threats, any physical acts which cause injury or potential injury to the resident, employees, visitors, or other residents, and any behavior exhibited which requires constant staff intervention will receive appropriate referral, treatment and services. Guidelines: 1. Any staff member, who suspects a resident is experiencing a serious behavior emergency which threatens the health, safety or welfare of the resident, employees, visitors, or other residents, shall report the problem to the charge nurse immediately. 2. The charge nurse shall promptly examine the resident. If it is determined that a serious behavior emergency has occurred, the charge nurse shall notify the resident's own physician and/or psychiatrist or psychologist. 5. If the resident's own physician, and/or psychiatrist or psychologist cannot be reached, the charge nurse is to call the facility's medical director and notify of the serious behavior emergency. 7. Upon assuring the resident's safety, the nurse will document the sequence of events outlining the serious behavior emergency, the interventions taken and outcome. The facility CMS (Centers for Medicare and Medicaid Service) Form 672 dated 8-24-22 and signed by V1 (Administrator) documents 12 residents that reside within the facility have psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same form also documents eight residents have behavioral healthcare needs, but only two of these residents have a care plan to support the behavioral healthcare needs. R1's Pre-Admission Hospital Geriatric Psych (Psychology) Discharge Summary dated 1-22-20 documents, admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . History and Hospital Course (R1) was brought into (hospital) emergency department after he was seen waiving a loaded revolver at his neighbors. The police were called in. There had been deterioration in his ability to function independently in his ability to complete his basic and advanced activities of daily living. His house was in poor condition, and he had not been bathing. (R1) was unable to recall the incident leading to this admission. The patient was admitted to the inpatient psychiatric unit for safety and stabilization. Provider reviewed current [CONDITION(S)] medication regimen and made adjustments as clinically indicated. Impulse Control is impaired. Insight is impaired and judgement is impaired. Assessment: Dementia and Depression single episode. (R1) is glad to be going to long term care in Mount Sterling as this is close to his friend who lives in Mount Sterling. Transfer instructions: [MEDICATION(S)] one mg (milligram) and 0.5 mg at bedtime daily. [MEDICATION(S)] 50 mg every night at bedtime. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired, has verbal and other behaviors, and requires extensive assistance of two staff for bed mobility, dressing, and personal hygiene. This same MDS documents R1 requires supervision for transfers and locomotion on the unit. R1's Order Summary Report dated June 1, 2022, documents R1 has the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same Order Report documents [MEDICATION(S)] 12.5 mg at bedtime for [CONDITION(S)] related to Circadian Rhythm Sleep Disorder, [MEDICATION(S)] 2.5 mg at bedtime for [CONDITION(S)], [MEDICATION(S)] 25 mg daily for Major Depressive Disorder, and [MEDICATION(S)] 2.5 mg daily for sexual behaviors. R1's Physician/Notification Clarification Form dated 6-13-22 documents, (R1) very disruptive yelling most of day. Cursing at staff. Unable to figure out what (R1) is needing. Kicking at staff when attempting to get vital signs. Roaming in and out of other rooms. Just FYI (For Your Information). (V6/R1's Physician) Comment: Monitor perhaps sitting in the hallway. R1's Progress Notes dated 6-21-22 at 7:53 AM and signed by V5 (RN/Registered Nurse) documents, (R1) required encouragement to feed self this morning, (R1) had been given food that was cut up, a spoon, fork, and drinks. (R1) yelled out for another spoon. This nurse brought resident a spoon. (R1) continued to yell out for a spoon, while becoming verbally aggressive and calling people a f***ing b***h. (R1) threw food across room. Will continue to monitor. R1's Physician/Notification Clarification Form dated faxed on 6-21-22 at 5:16 PM and signed by V5 (RN/Registered Nurse) documents, (R1) has been having behavioral yelling all day. (R1) won't feed self, or sit up on own, (R1) has a glazed look about eyes, but says he's not in pain, left fist is clenched. (R1) won't feed self and requires being fed, but if not fed in a timely manner throws food across the room. Can't get vitals. Won't cooperate. This same information is not documented in R1's Progress Notes and R1's Medical Record does not contain a follow-up from (R1's) physician. R1's Progress Note dated 6-22-22 at 7:53 AM and signed by V5 (RN/Registered Nurse) documents, (R1) was yelling in the north dining room about shooting. (R1) stated he was hungry. Peanut butter sandwich given. (R1) was asked to scoot butt back in wheelchair. (R1) refused and slid out of wheelchair onto the floor. (R1) did not hit his head. Skin tears were acquired on right arm. Two CNA's (Certified Nursing Assistants) and this RN used (mechanical lift) to get (R1) off the floor. (R1) wanted coffee. Coffee given to (R1). (R1) then tried to throw coffee on another resident and run resident over with wheelchair. (R1) removed from environment to another hallway. MD (Medical Doctor/V6) notified, and 5 mg (milligrams) [MEDICATION(S)] injected into resident's right deltoid per order. (R1) continued to hit staff and yell out because (R1) wanted a cup of coffee and his cart to place his coffee on, (R1) placed in room with cart and coffee. (R1) continues to scream. Will continue to monitor. R1's Progress Notes do not include any documentation of R1 being sent to the emergency room for evaluation. R1's Care Plan dated 4/7/22, documents R1 exhibits verbal and physical behaviors due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This same care plan does not include any updated interventions related to R1's behaviors on 6/21/22 and 6/22/22. R1's Care Plan dated 4/7/22, has not had any behavioral interventions updated since 10/19/21. R1's Ambulance Care Record dated 6/22/22, states EMS (Emergency Medical Services) called for an [AGE] year-old male patient (R1) who had fallen. When EMS arrived (R1) was sitting on the edge of bed in care of (facility staff). Staff stated (R1) had fallen twice this morning, not witnessed by staff. (R1) had a small hematoma on forehead. (R1) had a skin tear on left forearm. (R1) alert to normal status per staff. (R1) has a history of Dementia. (R1) can become violent with staff and other residents of facility. (R1) had bruising to his arms from falling. (R1) moved to stretcher by EMS crew. (R1) secured to stretcher with five straps. (R1) rested comfortably enroute to hospital. EMS crew had no difficulty with (R1 having) violent outburst. EMS kept (R1) calm by talking with (R1). (R1's) care turned over to (local hospital Emergency Department). R1's Hospital Emergency Department records dated 6/22/22, documents the following: R1 arrived via ambulance with a primary complaint of hitting his head during a fall. R1 received an [MEDICATION(S)] (antianxiety medication) 2 milligram injection intramuscularly on 6/22/22 at 11:13AM. R1's CT (Computed Tomography) dated 6/22/22 at 10:12AM, states Findings are overall concerning for infarct (Stroke). No acute [CONDITION(S)]. R1's laboratory (lab) results document the following: BNP (Brain Natriuretic Peptide/lab used to diagnose heart failure) dated 6/22/22 at 12:10PM, documents R1's BNP was 262 picograms per milliliter with the normal range of 0-99 picograms per milliliter. This same lab result states Note: 201-400 picograms per milliliter: Likely moderate (Congestive Heart Failure); Glucose 170 milligrams (mg)/deciliter (dl) with a normal range of 83-110 mg/dl. R1's Ultrasound of bilateral carotid arteries dated 6/22/22, states Indications: Stroke. Cardiovascular Accident ([CONDITION(S)]/Stroke) with fall today. R1's local hospital admission record dated 6/22/22, documents R1 was admitted for a Stroke and worsening mental status and deterioration. R1's local hospital Inpatient physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) was given [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (since arriving at the Emergency Department). Plan: Worsening mental status-Overmedication with [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] versus Worsening [CONDITION(S)]. Transferring to a larger hospital for Intensive Care Unit admission. R1's local hospital Initial Interview form dated 6/23/22, documents R1 was admitted to this local hospital on 6/22/22 at 1:35PM with chief complaint of fall and admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was discharged to a larger hospital for intensive care on 6/23/22 at 12:25AM R1's Progress Notes dated 6-22-22 at 12:22PM and signed by V5 document, Nurse with (hospital) called with update on (R1). MRI (Magnetic Resonance Imaging) showed possible stroke. (Hospital) is admitting (R1). R1's Hospital Stroke Consult Progress Note dated 6-23-22 at 1:15PM documents, (R1) is an [AGE] year-old male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) was last known well at 6-22-22 (unknown). (R1) went to outside emergency room for fall. (R1) was found on the ground with bruises on his arm. Incidentally, non-contrast CT (Computed Tomography) head was done due to the fall and showed wedge shaped right parietal lobe infarct appears subacute to chronic. (R1) showed agitation and received IV (Intravenous) [MEDICATION(S)], IV [MEDICATION(S)] in IV [MEDICATION(S)]. After that, (R1) was found to have an agonal breathing and sonorous respirations, (R1) was transferred to (another hospital) for further evaluation of the stroke and ICU (Intensive Care Unit) level cares. Assessment: Right parietal lobe infarct. R1's Hospital Discharge Planning Notes dated 6-30-22 document, Received message from (facility) stating that patient has been denied due to inability to meet needs. Spoke with (V4/Hospital Liaison) to see how long patient will need to be on good behavior before returning and she states they have denied, aware of the repercussions. R1's Hospital Discharge Planning Notes dated 7-6-22 and 7-7-22 document, 7-6-22 at 4:21PM: Received in a basket to send referral to facility and message left with (V4) if need referral re-sent and to call back concerning if (R1) can return to facility after medically ready since (R1) has been there (at the long-term care facility) as a custodial for two to three years. 7-7-22 at 1:53PM: Spoke with (V4). Facility still declined inability to meet (R1's) needs. 7-7-22 at 2:06PM received secure chat from (V11/R1's Hospital Physician) asking if facility would review if behavior improved. Spoke with (V4) who stated at this time the facility stated this is their final decision. (V4) stated if (R1) did improve greatly she would see if facility would review referral again. Team notified by chat. R1's Hospital Discharge Planning Notes dated 7-26-22 at 11:24AM document, Reached out to (V4) to look at referral. V4 replied with, 'I just had a chance to review. (R1) needed a bedside sitter yesterday. (R1) is still yelling out, restless, uncooperative, agitated, and combative. We cannot meet (R1's) needs and we will be declining and that regional leadership also replied and approved denial. R1's Hospital Interdisciplinary Notes dated 8-8-22 document, Discharge Placement Request-(Facility) denied-unable to meet (R1's) needs. 8-4-22 (R1) more towards baseline, now out of restraints and no longer has sitter. Does continue to yell. Ombudsman called to file complaint by V3 (R1's Hospital Case Manager) for hospital dumping. IDPH (Illinois Department of Public Health) made aware and will open a formal investigation. Hospital and (R1) has not received Discharge notice from (facility). 8-5-22 (R1) now had not been combative since 8-2-22. 8-8-22 Specialist consulted for assistance with placing (R1) at long term care facility. (R1) has not been in restraints or had sitter since 7-22-22. No chemical restraints since 8-2-22. [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] orally. R1's Progress Notes dated 8-12-22 and signed by V8 (R1's Hospital Physician) document, (R1) has remained in hospital due to need for placement. Case Management is following. Psychiatry last saw a couple weeks ago. (R1) has not been combative with staff since 8-2-22 per notes. (R1) has been out of wrist restraints. (R1) appears to be closer to his baseline on the new medications that are being prescribed. (R1) does yell out when he needs something. It is my opinion that (R1) could be easily cared for at a skilled nursing facility at this point. R1's Hospital Interdisciplinary Notes dated 8-9-22, 8-10-22, 8-11-22, and 8-13-22 document, Discharge Placement Request-(Facility) denied-unable to meet (R1's) needs. R1's Hospital Discharge Readiness Note dated 8-15-22 documents, Discharge to Norridge Gardens in Norridge, Illinois. R1's Progress Notes/Medical Record does not include any further documentation about R1's discharge, needs that could not be met by the facility preventing the facility from re-admitting R1 from the hospital, or notification to the resident, resident's representative, and long-term care ombudsman in writing or verbally of R1's discharge, including notification of appeal rights. On 8-23-22 at 11:20AM V5 stated, I have worked with (R1) for quite a while as a CNA before I became a nurse. (R1) would refuse cares at times and yell if he wanted coffee. On 6-22-22 in the morning, (R1) started to refuse to sit up in his wheelchair and would not let the staff re-position him. (R1) threw his coffee and almost hit a resident. (R1) slid to the floor and got skin tears. (R1) would not let me take care of the skin tears and was screaming loudly. I called (V6) and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I gave (R1) [MEDICATION(S)] 5 mg (milligram) IM (Intramuscularly) into the right arm. (R1) continued to fight us (facility staff) and refused to get off of the floor. We had to use the (mechanical lift) to get him up off of the floor and take him to his room. I was running behind on my medication pass already and (R1) kept screaming loudly from his room. The staff could not get (R1) to quit screaming. I went and got (V2/Director of Nursing) and told her I needed help as I did not have time to do medication pass and deal with (R1). (V2) came to help and was unable to get (R1) calmed down. (V2) had me call (V6) and report that (R1) still would not quit screaming. (V6) gave me an order to give (R1) more [MEDICATION(S)]. I told (V2) about the order for more [MEDICATION(S)], and (V2) said we were just going to send (R1) to the emergency room for evaluation because (V2) did not feel comfortable with giving (R1) more [MEDICATION(S)]. I did not call 911 or give the hospital or paramedics report. I am not sure who did. I did not document in (R1's) medical record that (R1) was sent to the emergency room , and I did not fill out an occurrence report as I am a new nurse and did not know that I had to. I filled out an occurrence report three days later. I also did not send anything to the hospital about what interventions we had tried with (R1). On 8-23-22 at 11:30AM V10 (Geriatric Care Specialist) stated, (R1) had behavior of just yelling out, 'Come here. Come here.' I never really had any issues with (R1) having physical behaviors. I am not completely sure why the facility could not re-admit him. On 8-23-22 at 9:00AM V3 (Hospital Case Manager) stated, The facility would not accept (R1) back even after (R1) was stabilized. The facility never did issue the hospital or (R1) a discharge letter. The facility just dumped (R1) on the hospital to find placement. (R1) had to be transferred to a facility up by Chicago, Illinois. On 8-23-22 at 9:30AM V4 (Hospital Liaison) stated, I have nothing to do with whether the facility can re-admit (R1). I was just told by the facility that (R1's) needs could not be met and I would relay that information to the hospital. On 8-23-22 at 12:00 PM V1 (Administrator) stated, The IDT (Inter-Disciplinary Team) met several times about (R1) being readmitted to the facility. At first, we did not re-admit him because he needed soft wrist restraints and sitter. The last time we denied him was because he still had a few episodes of agitation. (R1's Physician) was not notified about the facility refusing to take him back and we did not document an assessment or reason why the facility could not meet (R1's) needs in (R1's) medical record along with care plan interventions attempted. We did not notify the resident, resident's representative, or long-term care Ombudsman in writing or verbally of the facility's refusal to allow R1 to be readmitted to the facility. I was not the Administrator at the time (R1) was admitted originally to the facility after being in a psychiatric unit. The facility does not have a policy on re-admitting residents to the facility after a therapeutic leave or transfer to the hospital. On 8-23-22 at 12:00 PM V9 (Regional Ombudsman) stated, I did not receive a notice of discharge from the facility when the facility decided to deny (R1) re-admission after hospitalization . I also was not involved with developing a plan of care to meet (R1's) needs to return to the facility. It is always in the best interest of the resident to return to the facility. On 8-23-22 at 1:00 PM V7 (R1's Power of Attorney) stated, The facility did not notify me that they sent (R1) to the hospital and did not notify me that they were not going to take him back. I never received anything about (R1's) discharge. The Peoria hospital called me and informed me that (R1) was there, and the facility would not take him back. The hospital told me they were going to send (R1) to a facility in Chicago. I do not even know the name of the facility in Chicago, and that facility has not called me about how (R1) is doing, I know (R1) has to be scared, confused, and upset that he does not know anyone in Chicago and would not like living that far away from his home. (R1) will probably have more behaviors. I am not able to visit (R1) that far away. I would like to see the facility re-assess (R1) and take him back. The facility knew when they admitted him that he had mental problems and behaviors. On 8-24-22 at 8:30AM V2 (Director of Nursing) stated, I have worked at the facility since December 2020. (R1) has a very 'jarring' voice. (R1) had never been disruptive or have physical behaviors like he had on 6-22-22. (R1) would always repeat himself by saying 'Hey. Hey. Come here.' We could intervene and usually stop (R1's) behavior. I heard loud arguments and went to the unit (Dementia unit) to find out what was going on. (V5) told me that (R1) had fell out of the wheelchair and got skin tears. (V5) had already gave (R1) IM [MEDICATION(S)]. I told (V5) to leave (R1) alone in his room since he was not in 'grave condition.' (R1) was in his room and was safe. (R1) kept screaming loudly and most of the residents were wondering what was wrong. We had already dealt with (R1's) behaviors for over 45 minutes and did not have time to deal with (R1) any longer. I told (V5) to call (V6) again and let her know that (R1) continued to yell loudly. (V6) wanted (V5) to administer another dose of IM [MEDICATION(S)]. I told (V5) that unless (V6) wanted to assess (R1) and give (R1) the [MEDICATION(S)] herself, that we were not giving (R1) anymore [MEDICATION(S)]. I decided to have (V5) send (R1) to the hospital for evaluation. I did not give the hospital or paramedics report on what interventions had been attempted with (R1). I know the hospital had sent referrals wanting the facility to re-admit (R1) several times and I know the hospital physician had noted (R1) was stable and back to his baseline, but I had noticed (R1's) pulse had dropped to below 34 once and did not feel comfortable with him coming back to the facility. I did call the hospital nurse to see why his pulse had dropped and she reported that on occasion (R1's) pulse does drop. I made the decision that (R1) could not be readmitted to the facility because our facility is not close enough to a hospital in-case (R1) needed medical help. I did not document anything in (R1's) medical record about the facility refusing to re-admit (R1) or give (R1) or (R1's POA) a discharge letter as to why the facility cannot handle (R1). On 8/24/22 at 1:00PM, V2 stated she is currently responsible for care plan duties. V2 stated R1's care plan was not updated with R1's worsened behaviors on 6/21/22 and 6/22/22. V2 stated I did not add any new interventions to (R1's) care plan. R1 is one of those people that has a loud, jarring voice. It's hard to say whether he was yelling or if it was just his loud voice. On 8-24-22 at 1:00 PM V6 (R1's Physician) stated, I was not made aware that the facility refused to re-admit (R1). I never did an assessment, review (R1's) records, or document anything about (R1) or why the facility could not meet (R1's) needs to return to the facility. The Immediate Jeopardy was identified on August 25, 2022, to have started on June 30, 2022, when the hospital sent a notice of R1 being medically cleared for discharge to the facility, and the facility refused to re-admit R1 without developing a plan of care to meet R1's behavioral and medical needs, without documenting all measures the facility took to meet R1's needs, and without sending a notice of discharge to R1, V7, and V9 which resulted in R1 remaining in the hospital for 46 additional days after being medically cleared by the hospital physician to return to the facility, and then being placed in another facility approximately 253 miles from this facility in which was R1's home for two years and seven months. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 8-26-22 at 12:00 PM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V12 (Regional Director of Operations) and V13 (Regional Field Nurse) in-serviced the IDT team members including V1, V2, V14/Social Service Director, V15/Office Manager, V16/Activities Director, V17/Dietary Manager, and V18/Maintenance Director on 8/26/2022 and all other staff by 8-29-22 regarding ensuring appropriate processes and policies are followed in regard to resident discharges, notifications, rights to appeal, emergency behaviors, services and cares the facility is able to provide based on resident needs and diagnosis, discharge/transfer procedures, re-admission procedures, and documentation of resident needs that cannot be met. 2. The facility IDT members reviewed, discussed, evaluated, and assessed the facility's ability to re-admit R1 to the facility based on R1's behaviors and medical needs. 3. The IDT team contacted R1's POA, the Regional Ombudsman, and R1's physician to discuss the results and collaborate further considerations for a plan for R1. 4. The facility developed a policy for permitting re-admission of residents after hospitalization , transfer, or therapeutic leave to ensure appropriate review and consideration for readmission 5. The IDT team completed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. V12 and V13 updated the facility's assessment regarding services and cares the facility is able to provide based on resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 7. V12 (Regional Director of Operations) and V13 (Regional Field Nurse) in-serviced the IDT team and all other staff on proper documentation, reporting of behaviors, documentation of behaviors, care planning behaviors, and appropriate process for addressing behaviors or needs that are unable to be met within the facility. 8. V12 and V13 in-serviced the IDT regarding all residents that are sent to the hospital or allowed therapeutic leave and have had a change in condition that the facility identifies there to be a possibility that the facility will not be able to meet the resident's needs, the facility shall thoroughly evaluate and complete a collaborative discussion with the resident's POA, Regional Ombudsman, and resident's physician to ensure that all possibilities to develop a plan to meet the residents needs have been discussed, evaluated, and assessed. 1 will discuss all components of the plan with the V12 for a final determination of outcome. 9. On 8-29-22 the facility issued a Notice of Involuntary Transfer/Discharge to R1, V7, V9, and the Illinois Department of Public Health along with appeal rights. This notice documented, Your (R1) welfare and needs cannot be met in this facility, as documented in your clinical record by your physician. Completion Date: 8-29-22

Based on observation, record review and interview, the facility failed to ensure two qualified staff were present to assist a resident with bed mobility, dressing, transfer and a gait belt was utilized according to facility policy, for one of three residents (R1) reviewed for falls, in a sample of three. These failures resulted V4 (Certified Nursing Assistant) independently dressing R1 and attempting to transfer R1 without a gait belt resulting in R1 falling to the floor sustaining an Acute Displaced Right Distal Femoral Periprosthetic Fracture. Findings include: The facility policy, titled Fall Assessment and Management Policy (revised 4/2019), documents It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. The facility policy, titled Safe Resident Handling Program (revised 3/18/18), documents Gait belt usage is mandatory for all resident handling with the exception of mechanical lift use, bed mobility & medical contraindications. The gait belt will be considered a part of the certified nursing assistant's uniform. On 7/25/22 at 10:17 am, R1 was sitting in a high back reclining wheelchair on the Memory Unit. R1 did not have the cognitive ability to be interviewed. R1's right leg was in an immobilizer and elevated on the footrest out in front of her. The Electronic Medical Record documents R1 has the current diagnoses of Muscle Weakness, Advanced Atrophic No Exudated [CONDITION(S)], Anxiety and Dementia without Behavioral Disturbances. Minimum Data Set assessments completed over the last year, on 9/08/21, 12/09/21, 1/11/22, 4/13/22 and 7/14/22, all document R1 requires the extensive physical assistance of two or more staff for bed mobility, dressing and transfers. R1's current Plan of Care, dated 7/14/22, documents I am at risk for a fall related to confusion, incontinence, poor communication/comprehension and TRANSFER: (R1) requires two assist to transfer. A Morse Fall Scale (determines a resident's fall risk), completed on R1 6/05/22, identified R1 as High Risk for Falling due to a history of falls, impaired cognition, and overestimating or forgetting her limitations. A Report to Illinois Department of Public Health, dated 7/15/2022 at 7:30 am, documents Nurse called to R1's room observed resident on buttocks on floor at bedside. CNA (Certified Nursing Assistant) reported R1 was sitting on the side of her bed while CNA assisted her with putting her shirt on. R1 scooted quickly toward the edge of bed and slid down to the floor. R1 complained of pain during initial assessment but was unable to describe exact location of pain. Power of Attorney and Medical Doctor notified, and an order was given to obtain an x-ray in house. While on site on 7/15/22, the x-ray company had technical issues with the mobile x-ray machine and was unable to obtain imaging. On 7/16/22 at 10:44 am, imaging was obtained, and an Acute Displaced Right Distal Femoral Periprosthetic Fracture was discovered. R1 sent to hospital for evaluation and treatment. The Report further documents, R1 will re-admit 7/19/22 to the skilled nursing unit for skilled therapy close monitoring, and transfer status will be re-evaluated. There is no surgical intervention indicated for the fracture. R1 will be readmitting with full knee immobilizer. On 7/25/22 at 12:47 pm, V4 (Certified Nursing Assistant) stated on the morning of 7/15/22, she had gone into R1's room to get her up and dressed for the day. V4 stated V8 (Unit Assistant) was in R1's room at the time and (R1) is a two person assist, definitely. V4 stated she got R1 dressed and was getting ready to transfer her to her wheelchair. V4 stated R1 did not have a gait belt around her waist at the time. V4 explained that V8 was on one side of R1, and she was on the other, when R1 just didn't have the strength as we were getting her up. V4 stated R1 went limp, like dead weight and her legs went out to the side. V4 explained that she used her legs to direct R1's fall, so R1 wouldn't fall forward onto both knees. After the fall, V4 stated she left V8 with R1 and went to the Charge Nurse, V3 (Licensed Practical Nurse), for further assistance. On 7/25/22 at 11:40 am, V3 stated she was summoned to R1's room on the morning of 7/15/22, because R1 had fallen. V3 stated, when she walked in R1's room, V8 was on the ground with R1, trying to calm her. V3 stated R1's right knee was swollen, and she described R1 as uncomfortable. V3 stated two staff are required to assist R1 with ADLs (Activities of Daily Living) and transfers, as R1 can be unpredictable and make quick movements. On 7/25/22 at 1:11 pm, V8 (Unit Assistant) stated 7/15/22 was his first day working as a Unit Assistant in the facility. V8 stated he was in R1's room as V4 got R1 positioned onto the side of the bed and put R1's shirt on. V8 stated he is not allowed to perform direct patient care as a Unit Assistant, so he was just observing V4. V8 stated as V4 was getting ready to transfer R1 from the bed to the wheelchair, R1's legs just went out from under her and she fell to the ground. V8 stated he did not participate in assisting to transfer R1, as that is not something he is trained to do, but he was standing off to R1's side as V4 assisted R1. V4 demonstrated with an empty resident bed where he was standing in relation to R1 during the incident, and it was approximately two feet away from her. On 7/25/22 at 11:48 am, V1 (Administrator) stated Unit Assistants are not qualified to participate in direct resident care, which includes transfers and dressing. V1 stated a Unit Assistant is not allowed to be the second person to assist in a two-person resident transfer. On 7/25/22 at 2:00 pm, V2 (Director of Nursing) stated when she interviewed V4 for her investigation into R1's 7/15/22 fall, it was not fully explained to her that V4 had started to try and transfer R1 when R1 fell . V4 stated, regardless, R1 is a two person assist for dressing, bed mobility and transfers, and a Unit Assistant does not count as a second staff person for that type of assistance, because they lack the necessary training. V4 stated a gait belt is always to be used, during any pivot transfer, to ensure resident safety.

Based on interview and record review the facility failed to revise pressure relief measures or change treatment orders for one of three residents (R1) reviewed for pressure ulcers in a sample of three. These failures resulted in R1 developing a stage four pressure ulcer to the coccyx with wound infection, a deep tissue injury (DTI) to the right heel and a stage three pressure ulcer to the left heel which required hospitalization . Findings include: A Wound & Ulcer Policy and Procedure dated 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. This policy states, All residents will be assessed to determine the degree of risk of the developing a pressure ulcer using the Braden Scale-Ulcer Risk Assessment. This policy states, Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. This policy states that residents with moderate or high risk for developing pressure ulcers will have pressure reduction approaches placed on their care plans. In addition, this policy states, Orders for Vitamin C 500mg (milligrams) and/or [MEDICATION(S)] 220 mg daily and /or MVI (multivitamin) daily may be requested in addition to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy also states, When an existing or newly developed pressure ulcer(s) is present, a skin assessment (skin check) will be documented each shift to monitor the individual resident's tolerance to the current positioning schedule (tissue tolerance) and the facility will re-evaluate the frequency of repositioning if indications of further breakdown occur. This policy also states that a Suspected Deep Tissue Injury (DTI) is a Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. This policy documents that for a DTI the facility protocol is to treat the DTI using protectant wipes and a dry dressing. R1's list of current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 was admitted to the facility on [DATE], is moderately cognitively impaired, requires extensive assistance of two people for bed mobility, transfers, dressing, toilet use, personal hygiene, and uses a wheelchair for mobility with the extensive assistance of one. This MDS assessment also documents R1 is always incontinent of bowel, has an indwelling urinary catheter in place, is at risk for the development of pressure ulcers, and at the time of the assessment, R1 had developed a stage two pressure ulcer. R1's Care Area Assessment (CAA) Summary signed 4/7/22 documents R1 has identified care area problems that need to be addressed in R1's care plan. These care areas include, (R1) has a stage two pressure ulcer to (R1's) right buttock. This same CAA Summary documents as an analysis of factors putting R1 at risk for pressure ulcers includes pressure to the area, immobility, altered mental status, cognitive loss, incontinence, poor nutrition; diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R1's CAA Summary documents R1's Pressure Ulcer will be addressed in R1's care plan with the overall objective to slow or minimize decline, and Maintain current level of functioning. R1 Braden Scale for Predicting Pressure Ulcer Risk dated 4/1/22 documents R1 is at risk of developing a pressure ulcer because R1 is occasionally moist, requiring an extra linen change approximately once per day; R1 is bedfast but has no limitation to mobility, R1's food intake is probably inadequate, and has the potential for friction and shear because R1 moves feebly or requires minimum assistance, during a move; R1's skin probably slides to some extent against the sheets, chair, restraints, or other devices, and occasionally slide down. This same pressure risk document contains a list of clinical suggestions which could be initiated or added to R1's plan of care to reduce R1's pressure ulcer risk, however, none of the clinical suggestions are checked off. R1's Braden Scale for Predicting Pressure Ulcer Risk dated 4/8/22 documents R1 is at moderate risk for developing a pressure ulcer because R1's sensory perception is slightly limited, R1 is occasionally moist, requiring an extra linen change approximately once per day; R1 is bedfast and only makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, R1's food intake is probably inadequate, and has the potential for friction and shear because R1 moves feebly or requires minimum assistance, during a move; R1's skin probably slides to some extent against the sheets, chair, restraints, or other devices, and occasionally slide down. This same pressure risk document contains a list of clinical suggestions which could be initiated or added to R1's plan of care to reduce R1's pressure ulcer risk, however, none of the clinical suggestions are checked off. R1's Braden Scale for Predicting Pressure Ulcer Risk dated 5/1/22 documents that R1 is at moderate risk for developing a pressure ulcer because R1's sensory perception is slightly limited, R1 is occasionally moist, requiring an extra linen change approximately once per day; R1 is chairfast with ability to walk severely limited or non-existent and cannot bear own weight and/or must be assisted into chair or wheelchair, R1's food intake is probably inadequate, and has a problem with friction and shear because R1 requires moderate to maximum assistance in moving which make lifting R1 without sliding against the sheets impossible. This same pressure risk document contains a list of clinical suggestions which could be initiated or added to R1's plan of care to reduce R1's pressure ulcer risk, however, none of the clinical suggestions are checked off. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's POS documents R1 was prescribed a right buttock stage two pressure ulcer treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS documents that on 4/18/22 a new order for Triad Hydrophilic paste wound dressing was ordered to treat an open area to R1's Coccyx (base of the back) which was discontinued on 5/2/22. R1's POS documents that on 5/2/22 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This same order was discontinued on 5/5/22. R1's POS documents that on 5/5/22 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued 5/12/22. R1's POS documents that on 5/12/22 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order has no discontinuation date. In addition, R1's POS documents that a specialized pressure reduction cushion and to float R1's heels was not ordered until 5/2/22, and a specialty pressure reduction air mattress was not ordered until 5/5/22. R1's POS does not include any wound culture orders. A facility wound log dated 3/2022 to 5/18/22 and listing V2 (Director of Nurses/ DON) as the documents scribe, documents that R1 developed a stage two pressure ulcer to the right buttock on 3/31/22, six days after R1 was admitted to the facility, which was measured on 4/1/22 as 0.3cm (centimeters) long x 0.3 cm wide x 0.1cm depth. The wound log documents the treatment ordered for R1's wound as of 3/31/22 was Triad cream with a [MEDICATION(S)] dressing. The wound log documents that on 4/8/22 R1's right buttock stage two pressure ulcer had increased in size to 2cm long x 1.4cm wide x 0.1 cm depth with the treatment orders remaining unchanged. The wound log dated 4/15/22 documents R1's stage two pressure ulcer measured 2cm long x 1.5 cm wide x 0.1cm depth on that date with the treatment orders remaining unchanged. The wound log dated 4/22/22 documents R1's wound was 2cm long x 1.4cm wide x 0.1 cm depth with the treatment orders remaining unchanged. The wound log dated 4/29/22 documents R1's stage two pressure ulcer was 2cm wide x 1.4 cm long x 0.1cm depth with the treatment orders remaining unchanged. The wound log dated 5/5/22 documents R1's stage two pressure ulcer had increased in size on that date measuring 2.4cm long x 2.0cm wide x 0.2cm depth with the wound bed a pink color and containing slough (dead tissue). V2's note on R1's 5/5/22 wound documentation stated that V10 (Nurse Practitioner) was concerned R1 had a fistula or anatomy issue. The 5/5/22 wound log does not indicate what treatment was being used at that time. The wound log dated 5/12/22 documents R1's coccyx pressure ulcer was downgraded to a stage three pressure ulcer with deeper edges that were healing but with slough within the wound. The 5/12/22 wound log also documents R1 was prescribed oral liquid protein in addition to dressing changes to R1's wound using the medicated wound treatment Santyl. R1's care plan initiated 3/29/22 documents the facility developed a plan of care with interventions to address R1's risk for impaired skin integrity. This same care plan does not document any additional care plan interventions or revisions were made after R1 developed a stage two pressure ulcer to the right buttocks on 3/31/22, after that pressure ulcer increased in size, or when R1 developed an additional stage three pressure ulcer to the coccyx until 5/18/22. R1's Registered Dietitian notes document that no dietary recommendations were made for R1 until 4/19/22 at which time R1 was ordered to have the dietary supplement Med Pass 60ml two times daily. R1's progress notes dated 5/1/22 and entered by V7 (Licensed Practical Nurse/LPN) documents that R1's coccyx wound was 3.2cm long x 3.0cm wide with a wound bed containing white slough tissue and with some bruising around the edges of the irregularly shaped wound. This same nursing progress note documents R1 had developed a bruise measuring 1.0cm wide x 1.0cm long on R1's right heel. R1's nursing progress note dated 5/15/22 and entered by V7 documents that R1 had also developed an open and draining blister to the left heel which measured 0.4cm in diameter. This note documents R1's physician was notified, and the wound was wrapped with gauze for protection. R1's nursing progress note dated 5/16/22 and entered by V2 (Director of Nurses/DON) documents, V10 in house-checked (R1's) bottom. She would like (R1) sent to ER (emergency room ) for evaluation and treatment due to drastic change in the appearance of the wound. R1's ER records dated 5/16/22 document R1 arrived at that facility at 1:33p.m. and was transferred out to another hospital because of needing a higher level of care at 4:10p.m. that same date. This same ER record documents R1's level of care was Urgent. During R1's emergency room admission, a wound culture and sensitivity was performed to R1's buttock wound and showed R1's wound contained the infection causing organism Proteus Mirabilis. R1's hospital physician's consultation notes dated 5/17/22, after R1 was transferred for a higher level of care, document R1 was found to have a stage four pressure ulcer to R1's coccyx, a stage three pressure ulcer to R1's left heel, and a deep tissue injury to R1's right heel. This physician's note documents that Where the wound is located and the continued soilage from her stool make this next to impossible for (R1) to overcome. This note documents that R1 was not a surgical candidate to repair her coccyx wound and was recommended for palliative care. On 5/19/22 at 1:26p.m. V10 stated that she is a Nurse Practitioner for V12 (R1's physician). V10 stated she had been providing care for R1 since her admission to the facility 4/25/22. V10 stated that she first evaluated R1 on 4/28/22 at which time there was no documentation of R1 having any wounds. V10 stated that R1 developed a stage two pressure ulcer to the right buttock on 3/31/22. V10 stated that although the facility documented the wound had a length and a width, when she examined the wound, it was a superficial circular wound which measured 0.3cm in diameter. V10 stated that the facility has a protocol to use Triad paste for that type of wound until V10 can examine it. V10 stated that she did not examine R1's wound until 4/7/22. V10 stated she continued the Triad paste for R1's wound following that visit. V10 stated that she did not examine R1 again until 4/21/22. V10 stated that during that visit R1 was seated in the dining room so she only examined R1's legs for [CONDITION(S)]. V10 stated that sometime in 4/2022, R1 also developed a wound to her coccyx area. V10 stated that R1 still had the right buttock stage two pressure ulcer, but it became a satellite wound to R1's new coccyx wound. V10 stated that she did not examine R1 again until 5/5/22 when she noted R1's coccyx wound had worsened. V10 stated that in early 5/2022 R1's right buttocks wound resolved and she discontinued treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V10 stated that on 5/2/22 V10's office received a fax from the facility notifying V10 that R1's coccyx wound had a white slough in the wound bed and that R1 had also developed a bruise to R1's right heel. V10 stated that R1's right heel bruise was actually a DTI pressure wound. V10 stated that on 5/2/22 is when she ordered for R1 to start using a pressure relieving air mattress and a pressure relieving cushion for her chair. V10 stated the cushion R1 was using prior to V10's order was not really for pressure relief. V10 stated she did not examine R1 on that date, but she gave temporary orders until the next time she visited the facility. V10 stated that R1 was already wearing some padded boots prior to developing the right heel DTI, but that those boots do not provide much pressure relieve because R1's heel rested against the fabric of the boot. V10 stated that she prefers the pressure relief boots that have the heels cut out which provides better heel pressure prevention. V10 stated she does not think this facility uses that kind of pressure relief boot. V10 stated that she did not refer R1 to see a wound specialist, but instead, V10 spoke with a wound specialist on the phone for recommendations on treating R1's coccyx wound. V10 stated that the wound consultant did not come into the facility to examine R1's wound. V10 stated that based on their recommendations, V10 made several wound treatment changes from 5/5/22 until R1 was sent to the hospital 5/16/22. V10 verified that she did not change any of R1's coccyx wound treatment orders until 5/2/22 despite R1's wound increasing in size from the time it was being called a stage two pressure ulcer to the right buttock until 5/2/22 after the wound had enlarged to include the coccyx and the right buttock became a satellite wound to the coccyx. V10 stated R1's wound worsened very quickly. V10 stated she thought R1's wound might be a Kennedy Terminal Ulcer which is a pressure wound which develops rapidly when someone is at the end of life. V10 stated that R1 also had an interesting anatomy where there was not much distance between R1's rectum and the area around R1's vagina. V10 stated that R1 also had a problem with continuous oozing stool after she had developed her wound to the right buttock which continued until R1 went to the ER. V10 stated that on 5/10/22 she ordered for R1 to have a fiber supplement to bulk up her stools. V10 stated that on 5/9/22 facility staff notified her (R1) was still having pasty stools which was making it difficult to keep R1's wound clean. V10 stated that on 5/11/22 she ordered for R1 to have a rectal tube placed to aide in wound healing. V10 stated the facility did not get the rectal tube from their supplier before R1 went to theER on [DATE]. V10 stated that from 5/2/22 until 5/16/22 R1's coccyx wound worsened from a large wound with yellow slough to a big hole in her coccyx. V10 stated that on 5/16/22 when she examined R1's coccyx wound, the wound had, opened up into a big hole with bone visible in the wound. V10 stated, I could smell it when I went into (R1's) room. V10 stated that during her examination of R1 on 5/16/22, R1 had developed a new wound to her left heel. V10 stated the wound was macerated all around the wound bed because a dressing which holds moisture close to the wound instead of wicking it away was used by facility staff to cover R1's left heel wound. V10 stated that if the facility had put all possible pressure relief measures in place upon R1's admission to the facility, R1's pressure ulcers could have been prevented. On 5/19/22 at 10:16a.m. V11 (Hospital Wound Nurse) stated that she is the hospitals Wound Clinic Case Manager and evaluates hospital patients for wound care treatments and recommendations. V11 stated that she was referred to evaluate R1 when she was admitted to the hospital on 5/16/22. V11 stated during her examination of R1, V11 noted that R1 had a large unstageable pressure ulcer to R1's coccyx which measured 8.9cm long x 6cm wide x 2.9 cm deep. V11 stated bone could be visualized within the wound. V11 stated R1's wound bed was covered with black eschar (devitalized tissue), yellow and brown slough. V11 stated R1's wound had undermining all around the edges of the wound. V11 stated she did not belief R1's wound was a Kennedy Terminal Ulcer (KTU)meaning a wound that quickly develops during the dying process. V11 stated R1's wound did not have the butterfly shape which wraps around the coccyx which is typically associated with a KTU. V11 stated that R1 still had a small stage two pressure wound to her right buttocks which was a separate wound than the coccyx wound. V11 stated that R1 was referred to a colorectal surgeon (V14) and his Nurse Practitioner (V15) because R1's coccyx wound was so close to the rectum that for the wound to heal it would require diversion of her bowel with a [CONDITION(S)] to keep R1's coccyx wound clean during the healing process. V11 stated that it was determined that surgery was not going to be possible and R1 was referred for palliative care instead. V11 stated that R1's wounds were avoidable. V11 stated there were multiple measures the facility could have tried to prevent the development of R1's coccyx, buttock, and heel wounds including turning and repositioning more frequently, additional nutritional measures, wedge pillows and more. On 5/18/22 at 11:45a.m., on 5/19/22 at 2:11p.m., and on 5/20/11 at 8:42a.m. V2 stated that R1 was admitted to the facility on [DATE]. V2 stated that R1 had poor nutrition and weight loss prior to her admission which put R1 at risk for pressure ulcers. V1 stated that R1's advanced age and other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 stated she assumed the role as the facility wound nurse on 4/1/22. V2 stated that as the wound nurse she evaluates residents' wound once per week including measuring the wounds, writing out a description of the wounds, and contacting physicians when there is a change in the wound. V2 stated that R1 developed a stage two pressure ulcer to the right buttock on 3/31/22 which V2 assessed and measured on 4/1/22 as 0.3cm long x 0.3cm wide x 0.1cm depth. V2 stated that when the wound was found the facility made sure R1 was being turned and repositioned every two hours and as needed, encouraged R1 to go to the dining room for meals and that R1 was provided with puffy cloth boots for pressure relief to her heels. V2 stated that R1 was already using a pressure relieving foam mattress which is standard on all residents' beds and is rated as helping to prevent up to a stage two pressure ulcer. V2 stated she did not assess R1's tissue tolerance to determine how often R1 should be turned and repositioned. V2 stated that R1 received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated that she next assessed and measured R1's wound on 4/8/22. V2 verified that on that date R1's wound had increased in size measuring 2cm long x 1.4cm wide x 0.1cm depth. V2 stated that V10 ordered to discontinue R1's foley catheter at that time because she thought the catheter made R1 stay in bed too much. V2 stated that she did not make any recommendations to V10 to change R1's wound treatments or add any additional treatments, nor did V2 assess R1's tissue tolerance to determine if she needed turned and repositioned more frequently than every two hours. V2 stated she next assessed and measured R1's wound on 4/15/22. V2 verified R1's wound had increased in size measuring 2cm long x 1.5cm wide x 0.1cm depth. V2 stated that by that time, R1's wound had grown to include the coccyx area. V2 stated that at that time she requested a change in treatment orders from V10. V2 stated that V10 instructed for R1 to continue with the same wound treatment orders. V2 stated she did not re-evaluate the pressure relieving interventions already being used for R1. V2 stated there were no new interventions attempted to prevent worsening of R1's coccyx wound at that time. V2 stated she assessed and measured R1's coccyx wound on 4/22/22 at which time R1's wound measured 2cm long x 1.4cm wide x 0.1cm depth. V1 stated that R1's treatment orders for Triad paste with [MEDICATION(S)] dressing remained unchanged. V2 stated at that time V2 did not reevaluate R1's current pressure ulcer prevention measures or make change of treatment recommendations to V10. V2 stated she assessed and measured R1's coccyx wound on 4/29/22 at which time R1's wound measured 2cm long x 1.4cm wide x 0.1cm depth. V2 stated she did not make recommendations to V10 for change of treatment orders for R1's coccyx wound to help with wound healing and did not re-evaluate the pressure ulcer prevention measures that were in place. V2 stated that on 5/1/22 a bruise was found on R1's right heel. V2 stated she did not evaluate R1's right heel until 5/5/12 when she assessed and measured R1's coccyx pressure ulcer. V2 stated that R1's right heel bruise was actually a Deep Tissue Injury which is another type of pressure ulcer. V2 stated that R1's DTI was not listed on the facility's wound log because she only logs open wounds and not DTIs. V2 stated that since R1 was already wearing pressure relieving boots, the intervention was to float her heels on pillows. V2 stated that on 5/5/22 R1's coccyx wound measured 2.4cm long x 2.0cm wide x 0.2cm depth. V2 stated that at that time V10 ordered for R1 to have a pressure relieving chair cushion and a pressure relieving air mattress. V2 stated that R1 did not have a pressure relieving seat cushion until V10 ordered one on 5/5/22. V2 stated that early 5/2022 is when V10 changed R1's coccyx wound treatment orders and consulted with a wound care specialist. V2 stated that she assessed and measured R1's coccyx wound on 5/12/22 at which time R1's wound measured 3.2cm long x 3.0cm wide x 0.2cm depth and with slough covering the wound bed. V2 stated it was on that date that V10 downgraded R1's coccyx pressure ulcer to a stage three pressure ulcer. V2 stated she assessed R1's coccyx wound again on 5/16/22. V2 stated R1's wound was much larger on that date. V2 stated that V10 evaluated R1's wound and said R1 needed a higher level of care. V2 stated that R1 was sent to the hospital for evaluation and treatment. V2 stated that R1 had also developed a new wound to R1's left heel which appeared to be an open blister. V2 stated that R1 had oozing stool coming from her rectum from the time R1 developed the right buttock pressure ulcer until she was sent to the hospital 5/16/22. V2 stated the oozing stool only became a problem after R1's wounds became larger causing R1's wound to become frequently soiled with stool. V2 stated that V10 discussed inserting a rectal tube for R1 to aide in wound healing. V2 stated V10 ordered for R1 to have a rectal tube on 5/12/22 but that the facility did not receive the tube from their supplier until 5/16/22 after R1 was sent to the hospital. V2 stated that normally there is a wound consultant who comes to the facility, assesses wounds and advises practitioners on appropriate wound treatments. V2 stated that the wound consultant has been unavailable to come to the facility until after R1 left for the hospital. V2 stated R1's pressure ulcers could have been prevented or delayed if, We could have put some of (R1's) interventions in place sooner as opposed to waiting.

Based on observation, record review, and interview, the facility failed ensure skin protective interventions were utilized and failed to ensure safe transfer while using a mechanical lifting device for one of three residents (R1) reviewed for safe transfer in a sample of four. This failure resulted in a large skin tear leaving a layer of fatty tissue exposed without skin cover on the forearm. Findings include: R1's Progress Note dated 7/01/18 at 5:07 p.m., written by V11 (LPN - Licensed Practical Nurse) documents a CNA (Certified Nursing Assistant) came to V11 and reported R1 had received a skin tear during a transfer. V11 (LPN's) Progress Note states, Noted a very large skin tear down to the fatty tissue on left forearm measuring approximately 10 cm (centimeter) by 8 cm. Pressure applied until (Physician) could be notified. On 7/11/18 at 9:20 a.m., V11 (LPN) stated V3 (CNA) and V13 (CNA) were transferring R1 from the bed to the chair with a mechanical lift when V4 (CNA) came from R1's room and stated V11 (LPN) needed to come to R1's room Right now!'. V11 (LPN) reported R1 was already in the chair when V11 arrived in R1's room. V11 indicated R1 had R1's left arm down in between (R1's) side and the wheelchair arm and was bleeding. V11 (LPN) stated both V4 and V13 (CNAs) reported R1 was cooperative with the transfer and they were not sure what happened but the injury to R1's left arm happened during R1's transfer. V11 indicated R1 has very fragile skin and gets frequent skin tears. V11 (LPN) stated, It was pretty large. Ten centimeters right on top of the left forearm. I held pressure on it. Cleaned it and called the doctor. I (used adhesive wound closure strips) the best I could and wrapped it. (V16 - Medical Director/R1's Attending Physician) said (V16) would be in (to see R1's arm). On 7/11/18 at 12:13 p.m., V4 (CNA) stated V4 was working with V13 (CNA) to clean and dress R1 before R1 was transferred from the bed to a wheelchair. V4 stated, (R1's a mechanical lift). (V13 CNA) and I put (R1) in the (mechanical lift) sling. (V13 CNA) ran the machine and I was behind the wheelchair with the back (of the wheelchair) laid back. When we got (R1) moved to the wheelchair I raised up the back of the wheelchair and went around to the front and seen that (R1's) (left) arm was between the wheelchair arm and (R1's) body. We didn't have the (geri) sleeves (arm protectors). We looked and looked all day and we couldn't find them. We looked in the closet, the bed, the dresser. Just couldn't find them. I went immediately and got the nurse (V11 LPN) and the nurse took over after that. On 7/11/18 at 12:51 p.m., V13 (CNA) stated, We were getting (R1) up for supper. We put the sling on and I was standing in front of (R1). We lifted (R1) up and transferred (R1) over to the chair. We put (R1) down in the chair. (V4 CNA) pushed the back of (R1's) wheelchair up and when she did that (R1's) arm got caught or something and (R1) made a face. We both looked and noticed (R1's) arm was crumpled up under (R1). It was big horrible mess. (R1's) skin was torn between (R1's) elbow and wrist. On 7/12/18 at 12:10 p.m., V16 (Medical Director/R1's Attending Physician) stated, (R1's) skin is paper thin. Typically, (R1's geri sleeves) have been on. I'm not sure why they weren't then. The nurse did a good job (using adhesive wound closure strips) and saving what was there. Some of the skin was completely gone. A physician progress notes [REDACTED]. It is not clear now this occurred. Nursing (used adhesive wound closure strips) the approximated parts, but large defect without skin. Large skin tear with denuded (area stripped of skin) fat-exposed layer of the left forearm. The distal and proximal forearm with skin tear, but these edges re-approximated with (adhesive wound closure strips). There is nothing to repair on the denuded portion. (Occlusive dressing), (adhesive wound closure strips) to the approximated edges. Wound cleanser each day. It will take a while to heal. On 7/11/18 at 9:35 a.m., V8 (LPN) provided wound care to R1's left forearm. R1's left forearm wound measures 10 cm by 8 cm with approximately sixty percent of the wound bed denuded (without a skin covering) with fatty tissue exposed. The proximal and distal ends of the wound have some skin covering with adhesive wound closures still in place. R1 grimaced slightly as V8 (LPN) cleansed the wound. R1's care plan dated 6/13/18 documents R1 has very fragile skin and is prone to getting skin tears. The care plan interventions to address this concern is an entry dated 8/22/18 stating, Please apply (R1's) geri sleeves to (R1's) arms and legs daily to help prevent skin tears. On 7/12/18 at 9:30 a.m., V1 (Administrator) reported R1 has geri sleeves available and provided purchase orders dated 6/06/18 and 6/13/18 indicating protective arm sleeves were purchased for R1 on both dates. The manufacturer's information sheet for the protective arm sleeves states the product provides Superior pressure and shear relief. On 7/11/18 at 2:59 p.m., V2 (DON - Director of Nursing) stated, I was told (R1) did not have geri sleeves on. There is an extra pair.

Based on observation, interview, and record review the facility failed to properly assess, provide pressure relief, properly reassess pressure ulcer risk and ensure hand hygiene was performed during a pressure ulcer dressing change for one of three residents (R14) reviewed for pressure ulcers in a sample of 13. These failures resulted in R14 developing a stage two pressure ulcer that regressed into a stage three pressure ulcer. Findings include: A Wound and Ulcer Policy and Procedure dated 3/31/16 states, A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear .residents will be assessed to determine the degree of risk .using the Braden Scale- Ulcer Risk Assessment. Residents with existing ulcers will be scored at high risk automatically. Skin contact surfaces may be padded to protect boney prominences. Assessment of progress toward healing is completed at least weekly and the physician is notified at least monthly of progress toward healing. If there is regression, the physician is notified of the condition change. A Hand Hygiene Technique Policy dated 3/1/10 documents hand hygiene should be performed, To prevent the spread of infection. The policy also documents an indication for hand hygiene as, After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. R14's care plan dated 12/7/16 documents R14 has [DIAGNOSES REDACTED]. R14's care plan dated 5/10/16 documents R14 has, .Stooped posture and history of chronic pain. I also have increased weakness. I no longer feel safe walking by myself and at times, I do not feel safe walking at all. I now use a wheelchair for the majority of my mobility. R14's nurses' note dated 8/1/16 documents R14 has Kyphosis (rounded or hunchback). R14's Skin Risk Assessment (Braden) dated 8/1/16 documents R14 was at low risk for developing a pressure ulcer. R14's weight log dated 2/2016 to 8/2016 documents R14's weight remained stable between 121 pounds and 123 pounds. R14's Restorative Progress note dated 8/17/16 documents R14 is [AGE] years old, . with some general forgetfulness and periodic minimal confusion R14 suffers from Kyphosis .has a recliner in her room which R14 sits in during the day . R14's Activities progress note dated 8/23/16 documents, .resident is now a significant change due to her decline with her ADL's (Activities of Daily Living). R14's nurses' note dated 8/24/16 at 3:01p.m., documents, .An open area to the coccyx, was noted and that a pressure relieving cushion was placed in R14's recliner, .this nurse explained that R14 needs a pressure relieving cushion to prevent pressure. R14's Ulcer/Wound Documentation dated 8/24/16 documents a stage two pressure ulcer was identified on that date measuring 1.5cm (centimeters) long x 1.3cm wide x 0.3 cm deep. R14's wound documentation indicates R14's pressure ulcer developed as the result of, Kyphotic back causing pressure to coccyx area when sitting. R14's Skin Risk Assessment (Braden) dated 8/24/16 documents R14 remains at Low Risk for developing a pressure ulcer. R14's Ulcer/Wound Documentation dated 10/5/16 indicates R14's pressure ulcer had regressed to a stage three pressure ulcer on that date and measured 2cm long x 1.8cm wide x 0.7cm deep. R14's nurses' note dated 10/5/16 entered by E2 (Director of Nurses) documents, Z2 (R14's primary care physician) updated as area has shown very little improvement. Awaiting new treatment orders. R14's physician's orders [REDACTED]. R14's physician's orders [REDACTED]. On 12/19/16 at 1:55p.m. E6 (Registered Nurse) was at R14's bedside preparing to change R14's pressure ulcer dressing. While E6 was placing R14's dressing supplies on the chair next to R14's bed, E6 dropped the container of alginate fiber absorbing fiber wound treatment on the floor two times. E6 proceeded to apply gloves, remove R14's soiled dressing, then remove the soiled gloves before performing hand hygiene. R14's wound was a round wound approximately 2cm long x 1cm wide x 0.2 cm deep with a reddish pink wound bed. E6 applied clean gloves before opening the soiled container of alginate fiber wound treatment, then without changing gloves or performing hand hygiene, E6 applied the dressing to R14's stage three pressure ulcer. On 12/19/16 at 2:05p.m. E6 verified dropping R14's container of alginate absorbing fiber wound treatment two times on the floor prior to changing R14's wound dressing. E6 also verified wearing the same gloves to apply R14's wound treatment that E6 used to open the soiled container. On 12/21/16 at 9:15a.m. E2/DON verified R14 developed a stage two pressure ulcer to the coccyx on 8/24/16 which regressed to a stage three pressure ulcer on 10/5/16. E2 stated that at the time R14's pressure ulcer developed, R14 would sit for long periods of time in the chair next to the bed in R14 room. E2 stated that the pressure from the chair against the curvature of R14's back caused the stage two pressure ulcer to develop to R14's coccyx. E2 stated R14's chair was not assessed as needing pressure relieving equipment prior to R14's developing the pressure ulcer. E2 verified that R14's pressure ulcer treatment was not changed for six weeks after the initial development of the pressure ulcer, when it had regressed to a stage three pressure ulcer. E2 stated that the facility should have notified R14's physician for a change in wound treatment orders within two to three weeks after R14's stage two pressure ulcer was not improving. E2 stated, Normally we wait two to three weeks to see if a wound treatment is working before we change it to a new treatment. Actually, we call the physician and ask for new wound treatment orders. Not changing R14's wound treatment for [REDACTED]. On 12/20/16 at 11:25a.m., Z1 (also R14's primary care physician) stated that because R14's pressure ulcer risk was assessed by the facility as low risk for the development of pressure ulcers, and R14's weight was stable, and despite R14's advanced age, R14's stage two pressure ulcer which regressed to a stage three pressure ulcer was avoidable.