Every finding on record at Nexus at Berwyn

Based on observation, interview, and record review the facility failed to protect the rights of 1 of 7 residents (R2) in maintaining the right to have a choice and preference about lighting in the room in the sample reviewed for resident rights. This failure affected R2, who did not want the window blind drawn for lighting in the room and denied the right to do so by staff. This has the potential to affect all 133 residents residing at the facility.Findings include:R2 is a [AGE] year-old male admitted to the facility on [DATE] per admission Record, with diagnosis list that includes but not limited to Osteomyelitis unspecified, morbid severe obesity, Type 2 diabetes mellitus without complications, muscle weakness, major depressive disorder, rash and other nonspecific skin eruption and chronic kidney disease unspecified.On 07/07/2026 at 3:37pm, R2 was observed in the room sitting on the bed and reading, R2 stated that on 05/20/26 during dinner time, V5 CNA (Certified Nurse's Aide) came into the room passing the food tray. R2 stated that after V5 left R2's tray on the bedside table, V5 went to the window and started to pull up the window blind and R2 told (V5) not to pull up the blind but V5 stated she cannot see. After insisting that V5 should put the light on instead of the blind, V5 said to R2 come and make me. Both R2 and V5 became loud and he told V5 to get the F*** out his room. R2 stated in part that V5 did not pull down the curtain, and he told V5 that this is my room and he (R2) has the right to do whatever he needs to do in my room since his roommate was not complaining about it. R2 stated he reported it to V10 LPN (Licensed Practical Nurse), and she told V5 to leave the room and that was it. R2 stated he was very angry and the food did not go down well (Loss of appetite).During the same interview, R3 who was in his bed with privacy curtain drawn stated in part that he cannot see anyway (Laughing) and it does not matter to him whether the window blind is drawn or not. R3 stated the staff (V5) no longer works here because V5 was fired, because she has not come to work since that day (05/20/2026).On 07/07/2026 between 2:48pm and 3:50pm, V9 RN (Registered Nurse), V11 LPN (Licensed Practical Nurse), and V12 (restorative aide/CNA) were interviewed and they all stated in part that the residents' rights must be considered and provided when it comes to choices and preferences with their care needs.On 07/7/26 at 4:03pm, V3 ADON (Assistant Director of Nurses/ Wound Care Director) also acknowledged that V5 (CNA) was one of the facility staff but had stopped coming to work a few months ago. V3 stated V5 only work at the facility for a few weeks.On 07/08/26 at 10:10am, V2 DON (Director of Nurses) stated that V5 no longer come to work at the facility and V10 LPN (Licensed Practical Nurse) did not report or make her aware of any incident with R2.On 07/08/2026 at 9:23am, V1 (Administrator) stated that V5 was not fired but requested to be off for a few days and never came back. V1 stated that the staff are to accommodate and provide residents with their needs considering the resident preference unless it is harmful to the resident or others. V1 presented V5's Employee timecard that showed that on 05/20/2026 and 05/21/2026 V5 worked 3pm to 11pm shift.On 07/08/2026 at 12:39pm, V16 RN (Registered Nurse) stated in part that the residents have the right to let the staff know about what they want about lighting in their room as long as it does not bother their roommate.On 07/08/2026 at 12:43pm, V17 stated that both R2 and R3 have never complained about each other and they are pleasant to work with. V17 stated the residents have the right to ask the (staff) about affording them their rights of choices and preferences. V17 stated that that is their room unless it is affecting their roommate or harmful to that resident or others.On 07/16/2026 at 11:02am, V21 (Assistant Social Service Director) stated in part that R2 keeps to himself, not needy in nature, very independent, easy to deal with and can always make his needs known. V21 stated in part that about two months ago in May (2026), R2 said an employee that does not work here (facility) anymore (referring to V5) during dinner time came to his room to pass food tray and pull up the window blind. When he (R2) asked (V5) not to pull up the blind, V5 told him that she can't see and needs some light. R2 said V5 told him that she can't see and that she does not have to close the blind. V21 stated that R2 said he told her (V5) that this is my room and (R2) have the right choice whether to keep the window blind up or down. The surveyor then asked did R2 told you (V21) how he felt about the incident, V21 stated that he (R2) felt uncomfortable and angry that he had to report the incident. The surveyor then asked V21 is it appropriate for staff to ignore/neglect residents' choices in their room. V21 stated, Absolutely not appropriate, the resident has rights and most of the time the health care workers don't understand resident's rights that they have the right to choice and preference. This can also lead to emotional abuse. R2 was very upset. When asked whether R3 had an issue with situation, V21 stated R2 and R3 are adaptive to each order and they get along well. R3 is easy to get along with both residents who have never complained about each order. R3 is blind and likes to tell jokes.On 07/16/2026 at 12:13pm, V22 CNA (Certified Nurse's Aide) stated in part that she usually works on this floor (first floor). V22 was able to verbalize types of abuse and will report immediately to V1 the abuse coordinator. V22 stated the resident rights, and safety should be considered in choice whether the widow blind should be up or down.On 07/16/2026 at approximately 12:35pm, during interview conducted with V4 (ADON) about resident's right, V4 stated that residents have their rights to choices and preferences and it must be respected by the staff and accommodated.As of 07/16/2026, during this investigation V5 and V10 could not be reached via telephone.The facility policy on Resident Rights with review date of 10/25 presented documents that the objective of the policy is to create an individualized home-like environment to maintain and/or achieve independent functioning, dignity and wellbeing to extent possible in accordance with the residents' own needs and preference. Listed procedure includes but is not limited to resident lighting to meet the resident's needs, resident preferences will be included when planning therapy scheduling whenever possible to meet the individual needs and requests of the resident and resident's environment will be maintained in a homelike manner.The State of Illinois Resident's Rights for people in Long-term Care Facilities Ombudsman Program pamphlet documents that the residents have the right to safety and good care and the facility must provide listed services that includes keeping resident's physical and mental health, and sense of satisfaction. Under the right to participate in your own care listed care-inclusive facility must make reasonable arrangements to meet your needs and choices.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly; failed to ensure that the outside dumpsters were closed; and failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. These failures have the potential to affect all 144 residents residing at the facility.Findings include:Facility census, dated 6/03/2026, documents 144 residents residing at the facility.On 6/3/26 at 11:02am, V3 (The City of Building Department [NAME] Inspector) said, Can you please come look at this garbage. It's (garbage) disgusting. I have been getting complaints for weeks from the residents and have talked with the facility multiple times to remove these mounds of trash. I keep getting the same response that the garbage is coming tomorrow. Tomorrow comes and the garbage is still there. Loads of it. I was first notified May 17th (5/17/26) and have been on them (facility) since to get this garbage out of here. They need to close this place down. The residents deserve better.On 6/3/26 at 11:06am, with V1 (Administrator) and V3 (The City of Building Department [NAME] Inspector), the 1 outside garbage dumpster, 2 outside recycling dumpsters, and the outside dumpster area were observed with the following:Upon approaching the rear waste disposal area, a strong, foul odor was immediately noticeable. The smell was heavy and pervasive throughout the area, resembling rotting refuse. The odor intensified closer to the overflowing dumpster and large piles of garbage bags stored outside of the waste containers. The offensive odor was detectable from several feet away and remained present throughout the inspection of the rear service area. Dozens of flies were visible flying around and landing on the overflowing garbage bags and exposed refuse. Flies were continuously swarming above the garbage accumulation and around the perimeter of the dumpsters. One large dumpster, with lids opened, overflowing with trash well beyond its intended capacity, with numerous garbage bags stacked several feet above the top rim of the container. The pile consists primarily of black and white trash bags, along with loose refuse and cardboard materials. Several bags of trash are protruding over the sides of the container, and one garbage bag is visibly hanging over the right side. The area surrounding the dumpster shows evidence of liquid runoff and staining on the pavement beneath and around the container. Two recycling dumpsters are overflowing with flattened cardboard and other recyclable materials. The cardboard extends significantly above the top edge of each dumpster and is protruding outward from the containers. Large amounts of cardboard and packaging materials have accumulated on the ground around the containers. Boxes and loose cardboard are visible adjacent to and beneath the dumpsters. A large area with a substantial quantity of garbage bags are observed outside of the dumpster and placed directly on wooden pallets and pavement. The refuse pile extends across a large section of the rear service area and reaches a height estimated to be approximately four to five feet in several locations. Dozens of black garbage bags are visible, along with numerous white bags intermixed throughout the pile.On 6/03/26 at 11:18am, V1 (Administrator) said, We (facility) haven't had the garbage picked up since the beginning of May (2026). I'm not sure the exact date. There's been billing issues since we had a change of ownership. I spoke with corporate about this and they (corporate) are working out the issues. I have e-mail too that show we (facility) are trying to get this (garbage disposal) taken care of. Yeah, there's a lot of garbage. The garbage should be in the dumpsters with the lid closed, but as you can see there is no room left. It's unsanitary and can attract mice.Record review of e-mails regarding the facility's garbage disposal concerns documents the following:On 5/28/26 at 11:40am, e-mail from V14 (Vice President of Physical Plant Operations) to V13 (Corporate Bookkeeper) documents, in part, (Facility) just got fined from the city for trash not being picked up. The dumpster is still overflowing. We (facility staff) need to give the city and update on when trash will be picked up. On 5/28/26 at 1:11pm, e-mail response from V13 (Corporate Bookkeeper) to V14 (Vice President of Physical Plant Operations) documents, in part, All invoices were received late, so they were only recently paid. On 6/03/26 at 11:29am, e-mail from V13 (Corporate Bookkeeper) to V14 (Vice President of Physical Plant Operations) documents, in part, I had already worked this out with V4 (Supervisor at Garbage Disposal Company) this morning, I believe all payments have been received and she (V4) already requested services to resume.Record review of facility policy titled, Disposal of Garbage and Refuse, dated 10/2025, documents, in part, The facility will dispose of garbage and refuse properly and in a timely manner. All garbage and refuse containers will be maintained properly and in a timely manner. The facility will assure all garbage and refuse containers are in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids and covered. Any loading docks, hallways, and elevators used for both garbage disposal and clean food transport are kept clean, free of debris and free of foul odors. Garbage storage areas are maintained in a sanitary condition to prevent the harborage and feeding of pests and rodents. Garbage receptacles will be covered when being removed from the kitchen area to the dumpster.Record review of facility policy titled, Resident Rights, dated 10/2025, documents, in part, The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The resident's environment will be maintained in a homelike manner.

Based on observations, interviews, and record review, the facility failed to initiate and continue cardiopulmonary resuscitation (CPR) for one resident (R1) who required resuscitative care until Emergency Medical Services (EMS) assumed resuscitative efforts. This failure has the potential to affect 106 residents that are identified as full code.The Immediate Jeopardy began on [DATE] when facility staff failed to ensure, CPR was conducted after R1 was found to be unresponsive and cold blue called. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:45pm. The surveyor confirmed by onsite observation, record review and interview that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings Include:Per the facility's video tapes on [DATE]:At 6:58 AM, V4 CNA (certified nurse aide) was seen entering one south nursing unit, walking directly to R1's room, open the door then immediately shut the door, and exit nursing unit.At 7:17:27 AM, V7 CNA (certified nurse aide) was observed opening R1's door, entering room, then exiting room to get V3 LPN (licensed practical nurse).At 7:17: 53 AM, V3 and V7 look in R1's room. V3 was observed walking away from R1's room while V7 enters R1's room.At 7:18:32 AM, V7 exits R1's room and exits nursing unit.At 7:20:06 AM, V6 CNA was observed entering R1's room.At 7:20:20 AM, V5 LPN was observed standing in R1's doorway looking into R1's room and then returning to nurses' station.At 7:20:34 AM, V6 CNA was observed exiting R1's room and calling for help.At 7:21:08 AM, V3 LPN was observed walking down hallway towards R1's room. V3 enters R1's room briefly then exits room. V8 RN enters R1's room briefly then exits the room and nursing unit.At 7:21:59 AM, V5 LPN was observed walking the emergency cart to R1's room and then walking to the nurses' station. There is no backboard observed on the emergency cart.At 7:23:04 AM, V8 RN (registered nurse) was observed entering R1's room.At 7:23:35 AM, V3 LPN was observed removing towels from linen room across from R1's room and handing to V8 who was standing in R1's doorway.At 7:25:20 AM, V3 was observed entering R1's room.At 7:25:34 AM, V11 CNA was observed bringing several clear large plastic bags to R1's room.At 7:25:44 AM, V3 was observed exiting R1's room with a large clear plastic bag with soiled linens. V3 exited nursing unit to dispose of bag.7:27:15 AM, staff exit R1's room. V3 LPN returns and stands by R1's doorway.7:29:05 AM, EMS crew arrive on unit.Between 7:21:59 until EMS crew arrived at R1's room at 7:29:14 AM, staff did not obtain a backboard. The manual resuscitation bag, oxygen tank, and the automated external defibrillator (AED) remained on the emergency cart. The facility's code blue documentation sheet (attached to crash cart) for [DATE] requested from V1 and V2. This sheet was not provided for review during this survey.On [DATE] at 3:00 PM, V4 CNA (certified nurse aide) stated that she worked [DATE] day shift. V4 stated that while she was rounding on the residents on the one north nursing unit, she heard a code blue announced overhead. V4 stated that she ran to the one south nursing unit. V4 stated that she was instructed to call EMS 911. V4 stated that she called 911 and waited in the main lobby for the ambulance crew to arrive. V4 stated that she did not return to the one south nursing unit to assist with CPR (cardiopulmonary resuscitation) efforts for R1.Per the facility's video surveillance tapes, V4 was seen entering one south nursing unit at 6:58 AM and walking directly to R1's room, open the door then immediately shut the door, and exit nursing unit. At 7:22:49 AM, V4 was observed returning to one south nursing unit with a large clear plastic bag and enter R1's room. At 7:23:26 V4 exits R1's room briefly then re-enters room. At 7:26:30 V4 was observed throwing soiled towels/linens into the large plastic bag then proceed to the nurses' station.On [DATE] at 3:15 PM, V5 LPN (licensed practical nurse) stated that on [DATE] she worked the day shift. V5 stated that as she was coming on shift, she heard a code blue called. V5 stated that she performed chest compressions. V5 stated that she switched off with V3 LPN. V5 denied observing any bowel movement on or around R1's bed.Per the facility's video surveillance tapes, at 7:20 AM, V5 was observed entering the one south nursing unit and walking directly to R1's room, opens door, looks in and then closes door. At 7:21 AM, V5 exits nursing unit. At 7:21:59 AM, V5 walks to R1's room with the emergency cart, places it next to room and walks away. V5 does not return to R1's room until 7:28:43 AM. V5 exits R1's room at 7:29:00 AM. On [DATE] at 2:35 PM, this surveyor attempted to interview V6 CNA, day shift CNA on [DATE], but was unsuccessful. V6's phone disconnected. This surveyor reviewed V6's employee file for additional phone number(s). There was one other phone number listed in V6's file from 2023. This surveyor was unsuccessful, no longer phone number for V6. On [DATE] at 3:10 PM, this surveyor attempted to interview V7 CNA, day shift CNA on [DATE], but was unsuccessful. V7 did not return my call. On [DATE] at 11:25 AM, V7 was interviewed. V7 stated that V7 was informed by the CNA on the previous shift that R1 was not changed during the night. V7 stated that when she went to R1's room at 7:17 AM, she observed R1's brief off and feces and urine in R1's bed.On [DATE] at 5:30 AM, V3 LPN stated that he saw R3 in R1's room. V3 stated that he was giving R1 and R3 private time and did not want to interrupt. V3 stated that at 6:30 AM, R3 was still in R1's bed. V3 stated that at 6:55 AM R3 exited R1's room. V3 stated that at 7:10 AM he went into R1's room, R1 was unresponsive. V3 stated that he called a code blue, initiated CPR, and called EMS 911 from the nurses' station phone. V3 stated that he is not sure who was performing chest compressions, he never went back into R1's room. V3 stated that he did not go into R1's room until the paramedics arrived. V3 stated that the crash cart was in R1's room, the manual resuscitation bag was in room, not sure if it was used. V3 stated that after he called 911, he printed R1's face sheet and e-interact form for the paramedics. V3 stated that the morning shift nurses responded to the code blue, does not know the names of staff. V3 is unable to state with certainty that chest compressions and rescue breathing were done since he did not go back into room.On [DATE] at 7:46 AM, V3 LPN stated that he was instructed to lie regarding this event involving R1. V3 would not state who informed him to lie. When questioned what the truth is, V3 stated that he wants to get his story straight before speaking any further to this surveyor.On [DATE] at 12:45 PM, V3 LPN stated that he went to R1's room at 6:30 AM and instructed R3 to leave R1's room. V3 stated that at 7:00 AM he saw R1 sleeping. V3 stated that at 7:15 AM, R1 was found unresponsive. V3 stated that there was dirty linen in R1's room. V3 stated that he was running around trying to figure out what to do. When questioned about chest compressions during a code blue, V3 responded you are not supposed to stop chest compressions before EMS crew takes over the care of the resident. V3 stated that there was feces on R1's bed and the floor and R1 was wet due to incontinence. V3 stated that towels were placed on the floor so staff would not step in the feces. V3 acknowledged cleaning the resident and/or floor does not take precedence over performing CPR.On [DATE] at 10:33 AM, V8 RN (registered nurse) stated that she worked on the one north nursing unit on [DATE]. V8 stated that when she arrived to work she went to the one north nursing unit to prep the medication cart and receive report from V3 LPN (night shift nurse). V8 stated that she heard staff calling V3 by name and then call a code blue. V8 stated that she ran to R1's room and found R1 unresponsive. V8 stated that the crash cart was brought to R1's room and CPR was initiated. V8 stated that she and another staff were performing CPR, she asked to switch, and left R1's room. V8 stated that she returned to R1's room and continued to perform CPR. V8 stated that she left R1's room because no staff were on the one north nursing unit. V8 stated that she does not know which other staff were present during CPR or performing CPR. V8 stated that she passed the EMS crew in the main lobby as they were entering facility.Per the facility's video surveillance tapes, V8 was observed at 7:21:31 AM entering R1's room; exiting room at 7:21:34 AM, and exiting the nursing unit at 7:21:45 AM. At 7:23:26 AM, V8 was observed standing in the doorway for R1's room. V8 is handed a stack of towels from V3 LPN and re-enters R1's room at 7:23:43 AM. At 7:25:24 AM, V8 exits R1's room. At 7:26:52, V8 obtains a large clear plastic bag and more towels. At 7:27:12 AM, V8 was observed standing in R1's doorway speaking with V3, briefly re-enters R1's room, and exits room at 7:27:50 AM and walks to nurses' station before exiting unit.On [DATE] at 12:52 PM, V9 (EMS paramedic) stated that when the crew arrived at R1's bedside, there was no medical equipment (backboard, manual resuscitation bag, oxygen tank) in room and V3 was the only person in R1 and R2's room and he was speaking with R2. V9 stated that the crew immediately placed backboard under R1 and placed manual resuscitation bag over R1's mouth and nose, CPR was initiated. V9 stated that a mechanical chest compression system was applied to R1 and R1 was placed on stretcher and transported to ambulance then hospital. V9 stated that CPR continued in ambulance and in hospital. V9 stated that there was no return of spontaneous circulation for R1. V9 stated that R1's jaw and right arm showed signs of rigor mortis (stiffening of the muscles) and right arm was cold to touch. V9 stated that R1's torso felt warm to touch so CPR was initiated.The EMS report, dated [DATE], notes dispatch was notified at 7:22:47 AM for a resident with breathing problems. The EMS crew arrived at facility at 7:27:31 AM; at R1's bedside at 7:28:26 AM. The EMS crew left the scene at 7:38 AM. The summary notes crew members were dispatched to the facility for a female resident not breathing. Upon arrival, crew was approached by nursing staff that informed crew that R1 was not breathing and informed crew they were performing CPR prior to EMS arrival. Staff also informed crew of finding R1 in the morning like that. Crew noted no CPR in progress upon arrival to R1. Crew noted R1 laying supine in bed, pulseless, apneic and unresponsive. R1 was alert and oriented x 0/4 with a glasgow coma scale of 3 out of 15. Crew began manually performing compressions. Crew placed the cardiac monitor defibrillation pads on R1. Crew analyzed rhythm and noted asystole (no ventricular contraction) on the monitor. Crew started to assist R1 with manual ventilations via manual resuscitation bag at 15 liters/minute of oxygen. Crew transferred R1 from R1's bed to the stretcher. While R1 was placed on the stretcher, crew placed the mechanical chest compression system on R1 and resumed CPR. Crew secured the patient's arms to the mechanical chest compression system and secured device to R1. Nursing staff gave all patient information to crew member. While moving R1 t to the ambulance, crew had mechanical compressions and ventilations continuing. Once in the ambulance, crew placed a device to maintain R1's airway and continued ventilation. Crew secured airway device and confirmed airway device was appropriately inserted. Crew established an IO (interosseous) catheter in R1's left humeral head with no complications. Crew administered the first round of Epinephrine 1:10 via IO. Crew then paused CPR for a rhythm and pulse check. Crew noted no pulse and R1 to remain in asystole. Crew resumed CPR and ventilations. Crew then secured R1 onto the stretcher and transported R1 to the closest hospital. En route, the hospital was contacted via telemetry and crew alerted the hospital of a cardiac arrest. R1 was transferred to a bed in the emergency department, and a handoff report was given to the primary Physician and primary nurse. R1's hospital record, dated [DATE], notes R1 presented to the emergency room at 7:41 AM, CPR in progress. Asystole noted entire time. Per EMS, R1 was found down at facility, unknown down time. R1 exhibiting rigidity of the right upper extremity and jaw on intubation attempt. R1 warm to touch. Pupils fixed and dilated. En route an airway device was inserted. In the emergency department, CPR continued. R1 was unresponsive, skin was cool and dry, pupils fixed and dilated. A rapid sequence endotracheal intubation was performed. R1 went through three rounds of epinephrine in the emergency room, five rounds total during her resuscitation. R1 remained asystole on the monitor on all pulse checks. On final pulse check, bedside echocardiogram performed which showed cardiac standstill. Time of death called at 7:56 AM.American Heart Association 2025 guidelines for adult CPR notes early high-quality CPR and prompt defibrillation are the most important interventions associated with improved outcomes in adult cardiac arrest. For adult cardiac arrest, rescuers should perform chest compressions with the patient on a firm surface. Start CPR until advanced care arrives. The adult BLS (basic life support) algorithm notes start with compressions, check for visible object in mouth before giving breaths, start CPR, begin bag-mask ventilation with oxygen. High-Quality CPR notes push hard (at least 2 inches [5 cm]), push fast (100-120/min) and allow complete chest recoil, minimize interruptions in compressions, avoid excessive ventilation, change compressor every 2 minutes, if no advanced airway, 30:2 compression-ventilation ratio. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following steps to remove the immediacy.PLAN OF REMOVALF678Affected resident corrective actions.R1 expired at the hospital [DATE].The facility failed to initiate and continue CPR for R1 who required resuscitative care until Emergency Medical services assumed resuscitative efforts.Immediate Actions and Actions to prevent recurrence. (Initiated on [DATE] at 4:45PM and will continue until all staff are in-serviced and trained prior to the start of their shift)The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. An In-service was conducted on performing CPR on residents who are full codes and in cardiopulmonary arrest/ requiring emergency medical attention, with emphasis on staff recognizing cardiac arrest and initiating CPR without delay, and staff understanding their roles and responsibility during a code event. Staff education has been conducted including documentation of who conducted the training and their title.(This immediate action was initiated and was completed on [DATE] at 4:45)A knowledge check and competency assessment completed immediately for all staff. Staff competence to initiate CPR has been verified utilizing a questionnaire for all nursing staff, competency test was conducted by DON/Designee.All staff currently on duty were educated and verified competent to provide CPR prior to resuming care.An audit of all residents' code status orders has been conducted to ensure they are accurate and readily available to staff.New hires will be in-serviced by the DON, or Designee on the facility's code blue policy.All staff members who are currently on vacation, or are not available, have received education on the facility's code blue policy via telephone, and will also receive the same education upon their return to work by DON/Designee.The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift.A crash cart audit was conducted by DON/ADON/Designee to ensure all resuscitation equipment, including a backboard and manual resuscitation device, is readily available, no concerns identified. (This immediate action was initiated and was completed on [DATE] at 4:45pm)The Medical Director, Administrator, DON and RNC reviewed the facility's policies which include but are not limited to the following. There was no revision required. Procedures on Code blue policy. 2) Emergency Cart Policy(This was initiated, reviewed and completed on [DATE] at 4:45pm)The DON/ designee will conduct code blue drills to identify any potential need for additional training. To ensure compliance, the results of the audit/drills will be reviewed after the drill by the DON, ADON, and the Administrator.(This immediate action was initiated on [DATE], and will be completed 2x a week, including weekends, for 4 weeks and then weekly for 8 weeks.)The DON/Designee will conduct random staff interviews for at least five (5) employees to gauge knowledge for retention and determine if additional training is required. (This immediate action was initiated on [DATE] and will be done weekly for 8 weeks.)Any identified concern will be addressed immediately. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and drills to determine if additional interventions are necessary to ensure compliance. (This immediate action was initiated on [DATE], then weekly for 8 weeks.) The Administrator, DON and Designee will monitor completion of this plan of removal.Date Facility Asserts Likelihood for Serious Harm No Longer Exists:Completion Date: [DATE]

Based on observation, interview, and record review, the facility failed to promote care for residents in a manner that maintains resident dignity and resident rights. This deficiency affects one (R5) of eight residents reviewed for Resident Rights. Findings include:On 1/27/26 at 12:55PM, observed V9 (restorative aide) feeding R5 while V9 was using her personal cell phone. On 1/27/26 at 12:55PM, V9 (Restorative aide) said she was feeding R5 and said she knows she is not supposed to use cell phone while providing patient care.On 1/27/26 at 1:30PM, V2 (Director of Nursing) said that staff should not be on their cell phones while feeding residents or providing any type of care.On 1/28/26 at 2:30PM, V19 (Human Resource Director) said that the staff is aware that no personal cell phone usage in the facility is allowed, unless they are on break and in designated area. V19 said upon hire they are given employee handbook and discuss the facility protocols, and they sign the back of the employee handbook as acknowledgment.On 1/29/26 at 10:39AM, V3 (Asst. Administrator) said that the facility has a no cell phone use while in the facility and no cell phone use while providing resident care.0n 1/29/26 at 11:41AM, V2 said that the facility does not have a policy on cell phone use and only has what is on the employee handbook, but staff is aware there is no cell phone use while in facility.R5 was admitted on [DATE] with diagnosis in part but not limited to unspecified dementia, abnormal posture, muscle weakness, unspecified abnormalities of gait and mobility, type 2 diabetes mellitus, essential hypertension, dehydration.Order summary report 1/2026- Diet order general Mechanical soft texture, thin liquids consistency.Care plan date 3/21/25 ADL Self Care Performance Deficit with intervention -Eating R5 is total assistance to eat.Facility Policy on Feeding Assistance-revised 10/2024General:To attempt to provide adequate nutrition to a resident who is unable to feed themselves by hand feeding the residents.Guidelines:Residents who are unable to feed themselves are encouraged, instructed, assisted and/or fed by a qualified staff member.Facility Policy on Resident Rights- revised 9/2024GENERAL:The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference.RESPONSIBLE PARTY: All StaffPOLICY:It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it would endanger the health or safety of the resident or other residents. Residents have the right to retain and use personal possessions to promote a homelike environment and to support each resident in maintaining their independence. The facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.PROCEDURE:1.The facility will assess and interview resident for the need to make reasonable accommodations such as:Room set-upPlacement of personal items and suppliesProtection of resident's personal items and supplies from loss or theftCall light in reach for room and bathroom and the correct type for resident useResident lighting to meet the resident's needsAdaptive devices necessary to maintain/restore resident at their highest level of functioningResident equipment to be maintained in proper working order2.The facility will assist the resident in attendance of family gatherings or community events of the resident's choosing when possible.3.Resident preferences will be included when planning therapy scheduling whenever possible to meet the individualized needs and requests of the resident.4. Resident preferences will be included when planning bathing schedules for the resident whenever possible.5.Resident will be provided access to use a telephone in a private area not overheard by others.6.Resident preferences for routines with daily care will be included in the individualized care plan process whenever possible.7.The residents' environment will be maintained in a homelike manner.8.The facility with make every effort to honor the residents' meal of choice monthly.

Based on interview and record review the facility failed to ensure a resident's right to be informed of their health status and participate in treatment decisions, the facility failed to honor a resident's request to be transferred to the hospital for evaluation of shortness of breath for one of one resident (R6) reviewed for resident rights.Findings include:On 1/28/2026 at 12:15 noon R6 said that on 1/12/2026 she was short of breath and coughing until her chest hurt and asked V17(Nurse) to send her to the hospital and V17 refused telling her she is in hospice care, R6 then had her roommate call 911.On 1/28/2026 at 12:20 noon R1 said that R6 was feeling short of breath and coughing, she asks her to call 911 because V17 would not, telling her she was in hospice care, and it was not that bad to go to the hospital.On 1/28/2026 at 1:00pm V17 said R6 was very uncooperative with staff and refusing care, she had a small cough and wanted to be transferred to the hospital , I informed her that she did not need to be transferred to the hospital for a cough, then shortly 911 arrived and said they had a 911 call and had to take R6 to the hospital. If a hospice resident had a change in condition, I should call hospice care, she had a cough and did not appear short of breath, I did not call hospice or emergency transfer, I tried to give R6 cough medication she wanted to go to the hospital.On 1/29/2026 at 10:30am V2 (Director of Nursing-DON) said I expect hospice to be called if a resident has a change in condition, I expect the nurse to administer all as needed medications and use all interventions, and if a Resident is insisting on going to the hospital it is their right to be transferred.An admission record dated 1/27/2026 indicates that R6 admission date was 1/15/2026 and an advance directive of DNR/Comfort care, a diagnosis of chronic kidney disease, diabetes, Gastroesophageal reflux disease-GERD, acute embolism and thrombosis, anxiety, and malignant pericardial disease, A order summary report that indicates R6 had an order for benzoate capsule 200mg, dextromethorphan-guaiphenesin 5mg and ipratropium-albuterol 4 times a day for Shortness of Breath. A care plan dated 1/9/2026 for hospice care for a terminal diagnosis related to diagnosis of Dementia, 1/16/2026 with an intervention to coordinate care and services between facility caregivers and hospice company to ensure all residents needs are met. A progress note dated 1/13/2026 at 0708 resident admitted to local hospital SOB-Shortness of Breath. A progress note dated 1/12/2026 at 19:50 son call and inform that resident call 911 and going to local hospital. On 1/13/2026 a hospital records acute COPD-chronic obstructive pulmonary disease with bilateral wheezing present on presentation.Facility Policy: Resident Rights revision 9/2024General:The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/ or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference.Responsible party: All staffPolicy:It is the facility's policy to identify and provide reasonable accommodation for resident needs and preferences except when it endangers the health or safety of the resident or other residents.

Based on interview and record review the facility failed to ensure family and hospice services were notified of a condition change for one of two residents (R6) reviewed for Hospice care.Findings Include:On 1/28/2026 at 12:15 noon R6 said that on 1/12/2026 she was short of breath and coughing until her chest hurt and asked V17(Nurse) to send her to the hospital and V17 refused telling her she is in hospice care, she only has a cough and is not short of breath. R6 then had her roommate call 911.On 1/28/2026 at 1:00pm V17 said R6 was very uncooperative with staff and refusing care, she had a small cough and wanted to be transferred to the hospital , I informed her that she did not need to be transferred to the hospital for a cough, then shortly 911 arrived and said they had a 911 call and had to take R6 to the hospital. If a hospice resident had a change in condition, I should call hospice care, the physician and family, she had a cough and did not appear short of breath, I did not call hospice or emergency transfer, I tried to give R6 cough medication she wanted only wanted to go to the hospital.On 1/29/2026 at 10:30am V2 (Director of Nursing-DON) said I expect hospice to be called if a resident has a change in condition, physician and family.An admission record dated 1/27/2026 indicates that R6 admission date was 1/15/2026 and an advance directive of DNR/Comfort care, a diagnosis of chronic kidney disease, diabetes, Gastroesophageal reflux disease-GERD, acute embolism and thrombosis, anxiety, and malignant pericardial disease, An order summary report that indicates R6 had an order for benzoate capsule 200mg, dextromethorphan-guaiphenesin 5mg and ipratropium-albuterol 4 times a day for Shortness of Breath. A care plan dated 1/9/2026 for hospice care for a terminal diagnosis related to diagnosis of Dementia, 1/16/2026 with an intervention to coordinate care and services between facility caregivers and hospice company to ensure all residents needs are met. A progress note dated 1/13/2026 at 0708 resident admitted to local hospital SOB-Shortness of Breath. A progress note dated 1/12/2026 at 19:50 son called and informed the facility that R6 called 911 and will be going to local hospital.Facility Policy: Change on Resident Condition 9/2025General:It is the facility policy, except in a medical emergency, to alert the resident, resident's physician and residents responsible party of a change in condition.Responsible Party:RN, LPN, Social ServicesPolicy:Nursing will notify the resident's physician or nurse practitioner when: B. There is a significant change in the residents' physical, mental or emotional status. D. The resident wants to be discharged or leaves AMA. E. It is deemed necessary or appropriate in the best interest of the residents. Hospice: 9/2024General: To provide guidance on how hospice services will be administered within the facility.Purpose: Ensure that the hospice services meet the professional standards and principles that apply to individuals who provide services in the facility and to the timeliness of the services.Protocol:5. A provision that LTC facility immediately notifies the hospice about the following:a. A significant change in residents' physical, mental social , or emotional status.c. A need to transfer the resident from the facility for any condition.

Based on observation, interview, and record review, the facility failed to ensure resident's personal privacy for medical records. This deficiency affects two (R9 and R10) of eight residents reviewed for Resident Privacy. Findings include:On 1/27/26, at 12:35PM, observed a report sheet on top of medication cart on the 1st floor north hallway, with R9 and R10 health information visible and uncovered. On 1/27/26 at 12:35PM, V7 (Certified Nurse Aide) made aware of findings and verified that the form does contain resident's information, the nurse on duty left to lunch. V7 said it contains information of two residents. V7 said she is not sure if the report should be placed on top of cart visible to others.On 1/27/26 at 12:50PM, V2 (Director of Nursing) made aware of above findings and verified that the report form on top of nurse's cart does contain resident information and should not be visible on cart for resident privacy. On 1/29/26 at 10:39AM, V3 (Asst. Administrator) said that resident records containing medical information should not be visible to other residents or visitors, all records should be covered to maintain privacy. V3 said the only policy on HIPAA is in the employee handbook.R9 was admitted on [DATE], with diagnoses listed in part but not limited to primary osteoarthritis, other specified site, type 2 diabetes mellitus without complications, acute and chronic respiratory failure with hypoxia, insomnia, due to other mental disorder, acute bronchitis, gastro-esophageal reflux disease without esophagitis, anemia, hyperlipidemia, bipolar disorder, depression, polyneuropathy, essential hypertension and atrial fibrillation. R10 was admitted on [DATE], with diagnoses listed in part but not limited to heart failure, pneumonia, atrioventricular block, type2 diabetes mellitus without complications, essential hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, muscle weakness, abnormal posture, dysphagia. Facility Policy on Resident Rights/ HIPAA/ Abuse and Neglect-Employee Handbook page 13 of 93. HIPAAThe facility treats as confidential residents medical and health information in accordance with the federal Health Insurance Portability and Accountability Act ( HIPAA) and its Standards for Privacy of Individually Identifiable Health Information ( Privacy Rule). The Privacy Rule requires the Facility to maintain the confidentiality of such medical records and other health information (referred to as protected health information or PHI) and defines and limits when and how PHI may be used or disclosed by the Facility, employees will have access to PHI. Employees must not use or disclose PHI, either directly or through others, in any manner that would violate the Privacy Rule. Any employee found to have violated HIPAA will be subject to disciplinary action, up to and immediate termination.

Based on observation, interview and record review the facility failed to ensure a dependent resident received assistance with ADL'S (activity of daily living) related to incontinence care for 1 of 3 residents ( R8) reviewed for ADL's.Findings include:On 1/28/2026 at 12:30pm this writer, V15(Rehabilitation Aide) and V16(Certified Nursing Assistant-CNA) observed R8 in bed with a urine soaked depend on causing the depend to separate when attempting to remove.On 1/28/2026 at 12:35pm V16 said that she's the CNA for R8 who is dependent on all care from staff, and she does resident rounds before breakfast and after lunch and that she has not made any rounds for R8 because V15 had made rounds earlier.On 1/28/2026 at 12:40pm V15 said she did incontinence care on R8 at 7:30am only, and that resident's rounds are every two hours and as needed, she assist the staff with morning care only.On 1/28/2026 at 1:30pm V2 (Director of Nursing-DON) said that she expects the CNA and nursing staff to do rounds every two hours and as needed, especially for dependent residents.An admission record dated 1/28/2026 indicates that R8 has a diagnosis of Alzheimer disease, encounter for palliative care, dysphagia. An order summary report for hospice care DX. Alzheimer's disease dated 4/22/2024. A care plan dated 11/7/2024 for potential for impairment to skin integrity with an intervention to keep skin clean an dry perform prompt toileting/incontinence care.Facility Policy: Activities of Daily Living Dependent Residents. 8/2024General A program of activities of daily living is provided to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis.Purpose: To ensure that dependent residents in the facility receive regular, safe, and respectful bathing assistance as part of their activities of daily living (ADL's), in alignment with their care plan, preferences, and clinical needs.Definition. Dependent resident: A resident who requires physical assistance or total care to complete the task bathing ADLs: Activities of daily living such as bathing, dressing, toileting, eating and mobility.Responsible Party:All nursing staff, certified nursing assistants (CNAs), and any other personnel involved in direct resident care.

Based on interview and record review, the facility failed to prevent a cognitively impaired resident (R2) from obtaining severe burns from a radiator heater connected to the wall after R2 rolled out of bed onto the radiator heater when R2's bed was pushed against the wall for one out of three residents reviewed for accidents and incidents in a total sample of seven. This failure resulted in R2 suffering a first degree burn to the right cheek and second and third degree burns to the right arm and right leg requiring an intensive care unit hospitalization on a burn unit for five days. The Immediate Jeopardy began on 12/13/2025, the administrator was notified at 10:54AM on 12/23/2025 and the Immediate Jeopardy was corrected on 12/24/2025 when the facility moved all bed away from the heating register, completed in-services with all departments regarding keeping all beds away from the wall and checking on the bed position during rounds, and created a monitoring tool that is completed daily to check on the position of resident beds. Findings Include:R2 is a [AGE] year-old with the following diagnoses: burn of third degree of right upper arm, dementia, heat failure, and cerebrovascular disease.On 12/23/25 at 11:05AM, R2 was sitting in a wheelchair at the dining room table. A gauze wrap was covering R2's entire left arm. The gauze was clean and dry. A yellow-colored dried blister was on R2's right cheek bone that was about the size of a quarter. R2 was able to verify name but unable to answer any other questions due to mental status. In R2's room, the bed was about two feet away from the radiator heater with a floor mat on that side of the bed and another floor mat folded up in the corner. A bedside dresser was placed in between the bed and the wall. Two small metal brackets were noted on the radiator heater. The cover to the radiator heater was properly in place and not able to be moved by the surveyor. The radiator was not hot to touch.On 12/23/25 at 12:39PM, V5 (Maintenance Director) stated the facility uses a radiator heating system throughout the rooms where hot water passes through the radiators from a boiler. V5 reported each temperature is set on a thermostat on each floor. V5 stated each floor 's temperature is set from 76 to 78 depending on how cold it is outside. V5 denied having any issues with the radiators needing to be replaced or being too hot. V5 denied checking the radiators unless staff report an issue. V5 denied being aware of any burn's residents suffered from being against the radiator. V5 reported completing an in-service recently but could not remember the topic of what in-service was. V5 denied being aware of any staff telling V5 that R2 was burned after being against the radiator.On 12/23/25 at 1:48PM, V11 (Restorative Nurse) stated R2 had a fall on 12/6 that was confusion related due to a urinary tract infection. V11 reported on 12/13, R2 was attempting to get out of bed or stand and fell or rolled out the side. V11 stated R2 was transferred to the hospital then to another hospital to an in intensive care unit due to having burns on R2's body. V11 stated R2 had R2's bed up against the wall originally, but the bed was moved away from the wall after R2 suffered the burns. V11 reported R2 is confused and can follow basic instructions. V11 stated V11 was unaware why the bed was up against the wall and reported that is the way the rooms are set up. V11 stated R2 fell in between the bed and the wall and laid on the heating portion of the wall. V11 denied being aware of how long R2 was on the radiator for. V11 reported R2 needs one person assist with bed mobility and transfers. V11 stated R2 needs monitoring due to attempts to try to get out of bed unassisted.On 12/23/25 at 2:13PM, V5 stated V2 (DON) told V5 to complete the in-service on 12/13/25 with staff. V5 reported that V2 told V5 that R2 fell out of bed against the radiator. V5 stated that R2's dresser was put in between the bed and the wall to mitigate the risk of R2 falling onto the radiator again. V5 reported beds were also damaging the outlets and the radiator covers when the beds were too close by knocking them loose. V5 denied checking again if beds were against the radiators after the in-service was given.On 12/24/25 at 10:23AM, V3 (Assistant Director of Nursing/ADON) stated R2 has a wound on the right cheek bone that is closed that is partial thickness or a first-degree burn. V3 reported all of the wounds to the right arm and right leg are full thickness or third-degree burns. V3 stated there are burns to the right forearm, above the right elbow, right shoulder, right thigh, and right lower leg. V3 reported dressing changes are performed as ordered by the wound care physician, which R2 is seen by once a week. V3 reported since R2 is older with frail skin, the skin can be damaged easier. V3 stated the bed is now moved away from the wall and floor mats are in place. V3 was unaware why the bed was up against the wall originally. V3 denied R2 had any wounds before the fall on 12/13.On 12/24/25 at 11:00AM, V2 (DON) stated V2 was notified around 3 AM that R2 fell out of bed. V2 reported the nurse told V2 that R2 had some redness and discoloration so R2 was sent out to the hospital. V2 stated the nurse told V2 that R2 fell on the side of the bed where the radiator was located. V2 reported when the nurse called to get a follow up report the hospital notified the facility that V2 had some burns and would be being sent to another hospital to a burn unit. V2 stated R2 returned to the facility five days later. V2 reported some of the wounds were full thickness, and others were partial thickness. V2 stated an investigation was started, and it was found that R2 was burned on the radiator after the covering of the heater fell off when R2 fell. V2 reported the facility assumed R2 was lying directly on the exposed radiator, which explained why the burns were so severe. V2 stated R2 is only alert to self and cannot follow directions. V2 reported R2 is able to move around the bed and will attempt to stand unassisted but does so unsafely. V2 stated a floor mat was placed on each side of the bed and the bed was moved away from the radiator after the fall. V2 stated maintenance fixed the radiator by putting brackets on the cover to nail it back into the wall and an in-service was given to staff on moving the beds away from the radiator in order to not damage the cover.On 12/24/25 at 4:36PM, V12 (Nurse) stated R2 was lying in bed after being changed by the CNA around 2:30AM. V12 reported the nurse and CNA found R2 around 3AM lying on top of the radiator. V12 stated R2 has a cognitive impairment so R2 cannot use the call light. V12 stated staff went into the room after hearing a loud noise like something was falling. V12 reported R2 can move back-and-forth in the bed but cannot stand up or walk. V12 reported R2 is a high fall risk because R2 tries to get up alone and the week prior had a fall out of bed. V12 reported the bed was pushed against the wall because it is a small room, and this is the way all rooms are set up with two residents. V12 stated the CNA and V12 got R2 up from the side of the bed and during the assessment, V12 saw some redness to the right side of the arm and leg. V12 reported the radiator was a little bit off the wall, but V12 did not notice if R2 was lying directly on the radiator. V12 stated R2 was sent to the hospital and then will send to another hospital for burns. V12 reported R2's bed is now moved away from the wall.On 12/26/25 at 10:17AM, V20 (Wound Physician) a second-degree burn is basically a blister and when the blister opens, it becomes a third-degree burn. V20 reported a first-degree burn is basically like a sunburn. V2 stated all wounds to the right arm and right leg are 3rd degree burns. V20 reported V20 was not in the building when this occurred, but the wounds are consistent with falling directly onto a radiator. V20 stated the timeframe of how long R2 was on the radiator is unknown. V20 reported since R2 is older the skin is very frail and it would only take a few minutes for a third-degree burn to occur. V20 stated R2 also has psychosis and dementia, which would contribute to not feeling pain of skin burning. V20 reported normal people would have reacted and pulled away immediately, but R2 might not have been able to do that with an impaired cognition.A Rehab Nurse Practitioner note dated 11/28/25 documents R2 needed assistance with basic self-care tasks but remains limited in advanced activities of daily living and ambulation. R2 is at risk for high falls. Plan to follow all facility precautions, environmental safety, and therapy to improve balance.A Nursing note dated 12/7/25 documents the CNA found R2 on the floor mat next to R2's bed. No injuries were noted.A Nursing note dated 12/13/25 at 5:53AM documents R2 was found on the floor mat between the bed and the wall around 3:15AM. R2 was alert and oriented times one. A head to toe assessment was completed and abrasions and burns were noted to the right arm and leg.A Nursing note dated 12/13/25 at 11:30AM documents the nurse in the emergency department provided an update that R2 was transferred to another hospital to an intensive care unit.A Nursing note dated 12/18/25 documents R2 returned from the hospital's burn unit with a diagnosis of full thickness burns. Skin alterations were noted to the right face, right arm, and right thigh that were all burn related.The Hospital Records from the burn unit dated 12/13/25 documents R2 presented with 5% total body surface area deep partial thickness and full thickness burns to the right lateral arm and upper right thigh after a fall on a radiator for an unknown duration. R2 was found between the bed and the radiator per nursing home report. R2 was admitted to the burn intensive care unit. Dressings were ordered and applied. R2 was treated with dressings changes and monitored for fluid/electrolyte imbalances for five days until R2 was discharged back to the facility.The Fall Report dated 12/6/25 documents R2 had a fall where R2 was found next to R2's bed on the fall mat. No injuries were noted. Predisposing physiological factors are confused, impaired memory, gait imbalance, and incontinent.The Fall Risk Evaluation dated 12/7/25 documents a score of 20 indicating R2 is at high risk for falls due to decreased mobility, impaired memory, history of falls, and incontinence.The Fall Report dated 12/13/25 documents R2 was found around 3AM after a noise was heard coming from R2's room. R2 was lying on the side near the radiator and was immediately removed. The CNA last saw R2 around 2:30AM when R2 was changed. Redness was noted to the right leg and right arm. The physician ordered for R2 to go to the hospital. Predisposing physiological factors are confused, impaired memory, and gait imbalance.The Wound Physician note dated 12/22/25 documents R2 was seen for initial evaluation of wounds with multiple third degree burns in multiple areas of the body. The first wound to the right forearm is a full thickness/third degree burn that measured 36cm x 5.2cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 40% granulation tissue and 40% slough. The second wound to the right shoulder is a full thickness/third degree burn that measured 0.9cm x 2.5cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 40% granulation tissue and 40% slough. The third wound to the right lateral thigh is a full thickness/third degree burn that measured 22cm x 7cm x 0.1 cm. Adipose tissue was exposed. The wound bed was 30% granulation tissue and 60% slough. The fourth wound to the right anterior lower leg is a full thickness/third degree burn that measured 10.5cm x 6cm x 0.1 cm. The wound bed has no granulation, slough, eschar, or epithelialization present. Healing is expected to be delayed due to dementia and mobility.The Care Plan dated 1/11/23 documents R2 has impaired cognitive function/dementia or impaired thought processes daily related to or as evidenced by a diagnosis of dementia, low BIMS score of 0, and becoming easily confused. The Care Plan dated 12/18/25 documents R2 has an actual impairment to skin integrity to the right shoulder, right upper arm, right thigh, right lower leg, and right side of the face. R2 is at moderate risk for skin impairment based on Braden score of 15. An intervention includes to identify/document potential causative factors and eliminate/resolve where possible. The Care Plan that is undated documents R2 is a high risk for falls related to current medication use, poor safety awareness, unsteady gait, and dementia. Interventions include: bed bolster upon return 12/13/25, ensure the environment is made free of clutter and hazardous items are away from R2, and floor mats 12/13/15. The Care Plan that is undated documents R2 has impaired mobility related to diagnoses. R2 is on a transferring program. An intervention includes to use a wedge while in bed for positioning and comfort. This care plan also documents R2 has an ADL self-care performance deficit and impaired mobility related to dementia. An intervention includes that R1 requires 1 staff assistance to turn and reposition in bed.The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as 00 (severe cognitive impairment). Section GG of the MDS documents R2 needs partial/moderate assistance with bed mobility where R2 does less than half the effort. The MDS dated [DATE] Section M documents R2 currently has burns that are second or third degree.An In-Service dated 12/13/25 documents V5 had an in-service on this day to discuss with staff to move beds off the wall and damage to heaters and outlets. This in-service was completed with 58 staff members from the nursing departments only.The policy titled, Fall Prevention and Management, dated 09/2025 documents, General: This facility is committed to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe and environment as possible.On 12/26/25, the surveyor verified by observation, interview, and record review the facility implemented the following to correct the immediacy:Plan of Removal Affected resident corrective actions. A. Resident R2's bed was moved away from the wall and heating unit. Immediate Actions and Actions to prevent recurrence. (Initiated on 12/24/2025 at 12:30PM and will continue until all staff are in-serviced and trained prior to the start of their shift) The facility took the following immediate actions to address the citation and prevent any additional residents from suffering an adverse outcome. A. The Maintenance director/Designee completed rounds to ensure that all heating units are working adequately, and all beds are moved away from the heating unit/Wall. There was no concern identified. (This immediate action was initiated and was completed on 12/24/2025 at 12:30) B. All staff were provided with education by the Maintenance director/ Designee, training including but is not limited to ensuring the positioning of beds are away from the heating unit/Wall. (This immediate action was initiated and was completed on 12/24/2025 at 12:30pm) C. The Medical Director, Administrator, DON and Maintenance director reviewed the facility's policies which include but are not limited to: Guidelines on preventative maintenance measures, no revision requiredThis was initiated, reviewed and completed on 12/24/2025 at 12:30 pm D. New hires will be in-serviced by the Maintenance, or Designee.All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. E. The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. F. The Maintenance director/ designee will conduct daily audits to identify any potential concerns related to this plan of removal. (This immediate action was initiated on 12/24/2025, daily for 4 weeks then weekly for 8 weeks.) G. During the weekends and holidays, the Maintenance director/Designee will conduct the daily audits, ensuring beds are away from the heating units. Any identified concern will be addressed immediately. (This immediate action was initiated on 12/24/2025 daily for 4 weeks then weekly for 8 weeks) H. To ensure compliance, the results of the audit will be reviewed daily during the meeting which is attended by the leadership which includes but is not limited to the: DON, ADON, Maintenance director and the Administrator/Designee. (This immediate action was initiated on 12/24/2025 daily for 4 weeks then weekly for 8 weeks) I. The Maintenance/Designee will conduct random staff interviews for at least 5 employees to gauge knowledge for retention and determine if additional training is required. (This immediate action was initiated on 12/24/2025 weekly for 12 weeks) J. Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI. The facility will reinforce the following process. K. All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held weekly to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance. (This immediate action was initiated on 12/24/2025, then weekly for 8 weeks) L. The Administrator, Maintenance director and Designee will monitor completion of this plan of removal. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: Completion Date: December 24, 2025

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to its residents by not cleaning up the mold in the shower room. This applies to 11 residents (R1-R11) reviewed for a safe, functional, and sanitary environment in a sample of 6.The findings include:R1 is a [AGE] year-old male having intact cognition as per the Minimum Data Set (MDS) dated [DATE] and was admitted with an admitting diagnosis including bipolar and anxiety.On 9/20/25 at 9:30 AM, observed R1 ambulate with a steady gate in his room and stated, Our common shower room is dirty with mold around it. I asked the housekeeping guy at the lobby to clean up and sanitize our shower room. V2 (Director of Nursing) said to me that there is no disinfectant available to clean up the shower room.On 12/20/25 at 10:05 AM, one south common shower room was observed with V6 (Licensed Practical Nurse / LPN). One south unit common shower room was observed with wet towels on the shower floor, with blackish colored mold buildup at the bottom of all four sides of the shower.On 12/20/25 at 10:05 AM, V6 stated that the housekeeping is supposed to clean up and sanitize the shower room. V6 also added that the maintenance department is responsible for replacing the broken hot water sink knob.On 12/20/25 at 10:30 AM, V2 (Director of Nursing / DON) stated, Our housekeeping is supposed to sanitize the shower rooms. Residents should have a mold-free environment.On 12/20/25 at 12:00 PM, V13 (Housekeeping Director) stated, My staff are supposed to clean the common shower room and sanitize. The shower room in one south unit had mold for a few weeks, and it was brought to my attention. We ordered disinfectant and are waiting for it to come to clean the shower room. R1 brought this issue to me on Thursday. The maintenance department is responsible for replacing the broken hot water sink knob in the common shower room in one south unit.On 12/20/25 at 9:10 AM, R2 stated, They need to clean up the shower room. Towels and linens were left in the shower room. Nobody is picking up.On 12/20/25 at 9:25 AM, R3 stated, They should clean up the mold in one south common shower room. They are not picking up the wet towels and linens from the shower room. We told the housekeeping, and they are not doing anything.A review of the facility presented an undated Daily Cleaning Procedure guidelines document:5. Disinfecting RestroomDisinfect sink and shower, including pipes under the sink, mirror, and light above the mirror.On 12/22/25 at 11:10 AM, V1 (Administrator) stated, We have 11 independent residents (R1-R11) who would be able to use the common shower room in one south unit.

Based on interview and record review, the facility failed to follow their Indwelling Catheter Care policy by not promoting comfort or cleanliness for one resident (R101) who was diagnosed with Neuromuscular Dysfunction of Bladder. This failure resulted in R101 being sent to the hospital with a fever, a grossly soiled indwelling catheter which was wrapped up in his gluteal (buttock) fold, around his leg with purulence (pus) drainage and tenderness noted to penis and lower abdominal. R101 was admitted with the diagnosis of Urinary Tract Infection associated with indwelling urethral catheter which required antibiotics for one of one reviewed for catheters. Findings Include: R101 was diagnosed with Neuromuscular Dysfunction of Bladder. Brief interview for mental status dated 12/3/25 documents a score of eleven which indicates moderate cognitive impairment. Care plan initiated 8/28/25 documents: R101 has a urinary catheter. R101 will be free from catheter related trauma. Care per order. Physician order dated 10/13/25 documents change indwelling catheter and drainage bag when non-functioning. On 12/10/25 at 4:31pm, R10's indwelling catheter drainage tube was observed with white partials covered the entire inside of the tube with cloudy urine in the bag. R10 was unable to report when the last time his indwelling catheter had been changed. On 12/12/25 at 10:55am, V2 (Director of Nursing) said, an indwelling catheter orders have been changed from monthly to change as needed. An indwelling catheter should be changed if it leaks, if the insertion tube looks gunky, dirty or has stuff (partials) all over it. If the drainage tube looks cloudy with condensation (white partials) on the inside. Patient's insertion tube should be cleaned daily. On 12/12/25 at 11:36am, R101 indwelling catheter drainage tube was observed with white partials covered the entire inside of the tube with cloudy urine in the bag. V31 (nurse) said, R101's had condensation in the tube, and his urine is cloudy. On 12/12/25 at 11:44am, V2 said, R101's indwelling catheter tube is cloudy due to the medication he was taking. V2 said, R101's indwelling catheter can be changed. On 12/11/25 at 11:05am, V11 (Hospital Personnel) said, R101 was sent to the hospital with soiled linen, sitting in brown liquid that was foul smelling, with an indwelling catheter that was crusty around the insertion tube with cloudy urine drainage in the bag. Hospital paperwork dated 10/10/25 documents: R101 presented to emergency room with fever. Indwelling catheter in place draining cloudy urine noted in bag along with yellow crust around tubing and yellow tinge stains around diaper and linen. R101 also found to be lying in soaked linen and strong foul smelling liquid around perineal area. The Indwelling catheter was grossly soiled and wrapped up in the gluteal fold and around R101's leg. Had some purulence when removed. emergency room diagnosis: Urinary tract infection associated with indwelling urethral catheter. Foley changed in emergency department. Bladder scanned due to catheter having minimal output and tenderness noted to penis and lower abdominal, post void residue eight hundred and eighty-eight (888) milliliters. Adjusted indwelling catheter, output flow improved. Vancomycin started. Nursing note dated 10/11/25 documents: R101 was admitted with catheter associated urinary tract infection. Indwelling Catheter Care dated 9/2025 documents: daily and as needed (PRN) catheter care will be done to promote comfort and cleanliness. Cleanse area of catheter insertion site, using soap and water or pre-moistened wipes. Being careful not to pull on catheter or advance further into urethra.

Based on interview and record review, the facility failed to follow its grievance policy and resolve a grievance within 7 days for one resident (R33) out of three reviewed for grievances in a sample of 58.Findings include:On 12/9/25 at 1:40 PM, R33 stated that R33's green personal phone has been missing for several months. R33 stated that he made staff aware, and the facility has not replaced R33's phone as of yet. R33 stated that the only phone number he remembers is his own. R33 stated that all his family contacts were stored in his phone. On 12/12/2025 11:04 AM V1 (Administrator) stated that she is not familiar with R33 or his missing phone grievance as she has only been in this position for one month. V1 reviewed R33's grievance form dated 6/13/25. V1 stated that she will have to find out if R33 was present at the meeting held with family and if R33 also chose not to replace phone. V1 acknowledged that if R33 is his own responsible party and is the person that expressed his concern to V3 SSD (social services director), then R33 should have been involved with resolving his concern. On 12/12/25 at 11:45 AM, V3 SSD (social services director) stated that R33 informed V3 of missing phone in June 2025. V3 stated that R33 informed him to deal with R33's family member regarding phone since R33's family member is the one that bought phone for R33. When questioned where this is documented in R33's medical record or grievance form, V3 responded that this was not documented. When questioned what that implies, V3 responded if not documented, it was not done. When questioned if R33 was present at care plan meeting with R33's family when decision was made not to replace R33's phone, V3 responded that R33 was made aware of R33's family member's decision after the meeting but it was not documented. When questioned regarding R33 was not involved in the decision, V3 responded that he will telephone R33's family member to see if the family wishes to buy R33 a new phone. On 12/12/25 at 12:00 PM, V1 stated that V1 will buy R33 a new phone. V1 acknowledged that it is not the responsibility of R33's family to replace a phone that was lost in this facility. R33's grievance, dated 6/13/25, notes R33 lost his cellular phone, pay as you go - green. The resolution documented by V3 SSD (social services director) notes care plan with R33's family to discuss need of a replacement phone. Discussed options to replace phone. R33's family does not wish to replace.R33's BIMS (brief interview of mental status) score, dated 5/2/25, notes R33's score is 11 out of 15.R33's medical record notes R33 is his own responsible party. R33 does not have a guardian or power of attorney.R33's community survival skills evaluation, dated 4/27/25, notes R33 is not capable of independent pass to go out into the community.R33's medical record does not note R33 went out of facility at any time from 6/1/25 - 6/13/25.R33's admission inventory of belongings, dated 4/25/25, does not note if R33 had a cellular phone or not. It does note R33 has a blue duffle bag and did not want staff searching through it at the time of R33's admission. There is no further inventory of R33's belongings.The facility's grievances/concerns policy, revision 09/2024, notes a grievance must be answered within seven days is required. The department head is responsible for investigating the grievances or concern and speaking with the resident who made the complaint regarding both the concern and possible resolution.

Based on observation, interview and record the facility failed to follow their fire prevention policy by not ensuring residents where free from hazardous fire conditions. This affected one of three residents (R9) reviewed for resident safety. This failure resulted in R9 having a refrigerator plugged into an unapproved, non-medical grade, surge protector which sparked and ignited a small fire leaving black smoke in the room and soot on the floor. This failure has the potential to affect all the twenty- two resident who reside on the units. The findings include:On 9/25/25 at 12:27PM, a code red (fire) to R9/R10's room was announced over the public announcement system during an interview with V1 (administrator). V1 left to attend to code.On 9/25/25 at 12:48PM, observations were made in R9's room of outlets near R9's bed. There was black soot noted on the floor. R9's nightstand was moved away from the wall. R9 had a mini refrigerator on top of the nightstand. There was burning smell present in R9's room.On 9/25/25 at 12:52PM, V7 (maintenance) said, there was smoke in R9's room. V7 said, he removed power surge device and thinks the smoke was from the mini refrigerator. Power surge was observed with 6 outlets plugs. Three of the six plug inserts were melted and shaped irregular. The side of the power surge near the red power button was melted area as well as a hole on the bottom of the power surge about size a nickel. V7 said, residents can have surge protectors but should not be used for medical devices.On 9/25/25 at 3:07PM, R9 who was alert and oriented x/times three at time of interview, was observed in her room. Mini refrigerator was removed from her room. R9 said, she was sitting on her bed near the window and heard a pop noise. R9 did not think anything of it but then she heard a pop again a few moments later. R9 said, she was not sure what it was, then began to smell burning and see black smoke. R9 said, she went to her refrigerator, looked on the sides behind the nightstand and saw small sparks coming from the power surge. R9 said, she observed a small flame near on the cord of refrigerator in the back. The flame was a little a larger that the flame on a lighter. R9 said, she yelled fire and went to get staff, who responded to the room. R9 said, the mini refrigerator was her own refrigerator. The power surge was in her room when she got there. R9's roommate R10 was alert and oriented at time of interview was also present, said she was in room at time of incident, R10 said she smelled something burning and heard R9 yell fire and they left the room. Staff came immediately.On 9/26/25 at 11:30am, V1 (administrator) said, there was a short circuit in the refrigerator compressor/motor. V1 said, the surge protector did its job, it melted with no fire. V1 said, the residents were not in the room. V1 said, we don't provide power surge protectors to the residents. If we provided a surge protector, it would have to be medical grade and approved by the maintenance director. On 9/26/25 at 1:45pm, V15 (fire department personnel) said, a refrigerator should not be plugged into a surge protector. The popping sound was the plastic on the conductor in the surge protector starting to fail. The refrigerator should have been plug into an outlet. All the manuals will document, to plug into an outlet.On 9/26/25 at 2:24pm, V7 said, he did not approve R9's surge protector. V7 said, he was not aware of R9 had a surge protector.Fire department report dated 9/25/25 documents: Upon arrival maintenance said R9's room had a surge protector started smoking. Maintenance quickly unplugged unit from wall. Fire Prevention Policy undated documents: It is the policy of the facility to make concerted efforts to protect persons and property of the facility from hazards related to fires through adherence to comprehensive safety policies, local, state and federal fire regulation and safe practices in all aspects of work performance and the resident's daily living activities. Electrical- ganged or multiple outlet plugs are not used.

Based on interviews and record reviews, the facility failed to protect a resident from physical abuse during resident-to-resident altercation. This deficiency affects one (R1) of three residents reviewed for abuse. Findings include:R1 is a [AGE] year-old male, admitted in the facility on 03/21/22 with diagnoses of Type 2 Diabetes Mellitus without Complications; Unspecified Mood (Affective) Disorder; Opioid Use, Unspecified, Uncomplicated; Compression of Brain; Alcohol Abuse, Uncomplicated; Traumatic Subdural Hemorrhage without Loss of Consciousness, Subsequent Encounter; and Personal History of Traumatic Brain Injury. MDS (Minimum Data Set) dated 06/21/25 documented R1's BIMS (Brief Interview for Mental Status) score is 11 which means moderate impairment in cognition. Facility's incident report dated 08/08/25 recorded: On 08/04/25 around 3:15 PM, R1 stated his roommate (R2) became upset about his closet space and became physical with him (R1). R1 was separated immediately and de-escalated. He (R1) stated the incident was unprovoked and didn't have any history of altercations with R2. R2 stated he thought his roommate (R1), was taking his belongings and he was looking for them in his (R1) closet. He (R2) did not find any of his personal belongings in R1's closet. R1 sustained a small cut inside his mouth. On 09/10/25 at 10:10 AM, R1 was in bed, taking a nap. R1 is alert and oriented, verbal, and able to ambulate without assistance. R1 was asked for any incident with R2 or previous roommate, or to any other resident in the facility. R1 stated, No, not that I know of. I did not have any altercation with any residents here. I was not hit. He (R2) did not hit me. There was no skin alteration in R1's mouth, lip or face as observed. R1 stated he does not have any problems with his mouth. On 09/10/25 at 9:56AM, R2 was observed in his room, sitting in a wheelchair. R2 is alert, oriented. He (R2) was asked regarding incident with R1 on 08/04/25. R2 verbalized, I didn't hit him (R1). I don't remember. I'm okay with other residents here. I don't remember having an altercation with other residents.R2 is a [AGE] year-old, male, admitted in the facility on 10/14/22 with diagnoses of Parkinson's Disease without Dyskinesia, without Mention of Fluctuations; Cognitive Communication Deficit; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Schizoaffective Disorder, Unspecified; and Brief Psychotic Disorder. MDS dated [DATE] recorded R2's BIMS score is 6, which means severe cognitive impairment. According to R2's care plan, he has history of aggressive/inappropriate behavior.On 09/10/25 at 10:52 AM, V6 Licensed Practical Nurse, LPN) was asked on what happened between R1 and R2 on 08/04/25 incident. V6 stated, I was at the nurses' station, I heard an argument. I went to see what was going on. When I entered the room, both (R1 and R2) were standing at the closet and were arguing. R2 swung his hand at R1. I tried to go between them. But R2 was able to hit R1 in the face. He (R1) had abrasion underneath the left eye with little bit of blood. I got him (R2) out of the room and called the CNA (Certified Nurse Assistant, CNA) to sit with him. I went back to room; I cleaned his (R1) abrasion. He didn't want to be touched and wanted to be left alone. I notified management, they came. R2 was sent out for psych evaluation. R1 refused to be sent out, physician was notified. I regularly work with them, and both have no prior behavior. They (R1 and R2) were arguing over a closet space and missing items. There was a confusion about which space belongs to who.On 09/10/25 at 11:08AM, V7 (CNA) was also asked regarding R1 and R2. V7 verbalized, On 08/04/25, I helped the nurse with 1:1 (one on one) monitoring of R2. When I went there, they were quiet. I did not witness anything. V5 (Social Services Director/Assistant Administrator) was interviewed on 09/10/25 at 11:32 AM regarding R1 and R2 incident on 08/04/25. V5 stated, I was notified of the incident immediately by V6. She informed me that residents (R1 and R2) had physical altercation. She found R1 on the floor in the room stating that his roommate (R2) had hit him in the face. Upon that point, she (V6) did a body assessment, moved R2 out of the room and placed him on 1:1. R1 did have some blood in the mouth, left inner portion. It was like a little blood. He (R1) had explained that R2 stated that he (R1) had his (R2) clothing and that was the reason why he (R2) was aggressive with him (R1). R2 has history of delusional processes, usually he believes he's at home. This is the first time he(R2) showed aggression towards a resident. He (R2) did hit him (R1) but there were no major injuries. R1 refused to go to the hospital. Physician was notified. R1 is alert, oriented, ambulatory. No violent or aggressive behaviors in the past. R2 is alert to self and place. He's been here for almost two years. He wanders in the facility, delusional behavior believing he is at home, or he wants to go home. R2 had no prior aggressive behaviors. They were separated, R2 was sent out for psych evaluation and admitted for about two weeks. R1 was placed on well-being check for three days and no concerns. Upon return from hospital, R2 was placed to another room in the other side of the unit. He (R2) was also placed on well-being check for two days with no concerns. On 09/10/25 at 11:51 AM, V1 (Administrator) was asked regarding R1 and R2. V1 verbalized, I am the Abuse Coordinator. I was notified of the incident on 08/04/25 regarding R1 and R2's incident. I oversee the abuse investigation, V5 helps me with the investigation. I was notified of the alleged incident. Staff overheard a commotion. The one resident is confused, R2. He (R2) was agitated, thought his roommate was rummaging his clothes. They had words, pushing each other. No one saw what happened. Nurses responded. R1 had abrasion or skin tear in the mouth. R2 was put into a 1:1 monitoring and was sent out for psych evaluation. There was no major injury on R1. He (R1) was not sent out to the hospital, he refused. There were no prior aggressive behaviors on these two residents. At the time of incident, there was nothing else we can do.Based on interviews with V5 and V6, R2 was able to hit R1 in the face, sustaining abrasion under left eye and presence of small amount of blood in the mouth. V6 witnessed R1's and R2's verbal altercation and when R2 swung his hand at R1. R1's care plan on abuse documented in part but not limited to the following:Interventions: Staff will intervene when they observe R1 in a verbal altercation with peer to assist in de-escalation (08/08/25). Facility's policy titled Abuse Policy and Prevention Program 2022 dated 10-2022 documented in part but not limited to the following:Abuse Policy: 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. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. This purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by:Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment.This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on interview and record review the facility failed to follow the physician ordered to ensure as needed pain medications (Norco, Tramadol, Gabapentin, and Tylenol) were administered to residents as prescribed. This affected two of three (R1, R2) residents reviewed pain management. This failure resulted in R1 suffering a psychosocial harm and stated that R1 endured excruciating pain due to not getting his pain medications. R2 said R2 needed pain medication, rated his pain as 8 on a scale of 1 to 10, but his medication was not available. Findings include: 1. R1 is [AGE] years old, admitted to the facility on [DATE], medical diagnosis includes, but not limited to Malignant neoplasm of bone and articular cartilage, secondary malignant neoplasm of other parts of nervous system, anemia, benign prostatic hyperplasia without lower urinary tract symptoms, low back pain, wedge compression fracture of first lumbar vertebrae, osteomyelitis unspecified, etc. On 6/23/2025 at12:20PM, R1 was observed in his room, awake, alert and oriented and stated that he is doing okay, he is managing to survive, but it could be better. R1 said that his pain is not being managed well because of how staff gives him his medicine, he would like to have something in between his Norco, staff always tells him that he is not due for Norco, and he cannot get anything else. They always run out of his lidocaine patch, he did not get any patch this morning, R1 said that the first week he was at the facility was hell, they took forever getting his medications and when they did, he was still not getting his medicine as he should, and he had to deal with excruciating pain. R1 said, imagine my medical condition and not having pain medications, the staff just don't understand, they think I was just asking for pain medicine for the heck of it. On 6/24/2025 at 9:40AM, R1 said that that he never received any anxiety medication or something for muscle pain, just the Norco. Active physician order summary for R1 showed the following: 1. Lidocaine External Patch 4 % (Lidocaine) apply to neck topically in the morning for Take off at 6p related to acute hematogenous osteomyelitis, multiple sites, order date 6/12/2025. 2.Hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 12.5 tablet by mouth every 8 hours as needed for Anxiety for 14 Days, order date 6/17/2025. 3.Gabapentin Oral Capsule (Gabapentin) Give 100 mg by mouth every 12 hours as needed for pain AND Give 200 mg by mouth every 24 hours as needed for Pain. Order date 6/12/2025. 4.Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain moderate to severe. Order date 6/12/2025, discontinue on 6/17/2025. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain moderate to severe. Order date 6/12/2025. 5.Acetaminophen Oral Tablet (Acetaminophen) give 650 mg by mouth every 6 hours as needed for Pain, order date 6/12/2025. Care plan initiated 6/13/2025 states the following: PAIN: Resident has an alteration in comfort r/t Advanced Disease process. Goal: Resident will not experience a decline in overall function r/t pain through next review. Interventions: Administer pain meds and treatments as ordered, assess effectiveness of pain medication, encourage to report any pain, Educate on non-pharmacological interventions such as heat, ice, massage, relaxation, and distraction techniques, etc. R1's Medication administration record (MAR) for the month of June 2025 showed the following documentations: Lidocaine patch was not signed as given on 6/14/2025, 6/20/2025 and 6/23/2025. Hydroxyzine signed out as given once, on 6/15/2025, Hydrocodone was signed as given on 6/15/2025, 6/16/2025, 6/18/2025, and 6/24/2025.Tylenol was signed as given on 6/13/2025, 6/17/2025 and 6/18/2025. Gabapentin was never signed out as given from the date it was ordered. On 6/23/2025 at 12:27PM, V3 (LPN) said that she is the assigned nurse for R1, he gets lidocaine patch for pain but not on her shift, it is usually given by the PM shift and removed in the morning by the AM shift nurse. V3 was asked if she removed any lidocaine patch from the resident this morning and she said no. V3 then said, we have some house stock, I can go give him one now. On 6/24/2025 at 2:47PM, V10 (LPN) said that R1 thought that he was supposed to be getting Norco and oxycodone at the same time, he wants pain medication all the time every hour. V10 said that she has not given R1 any other medication other than Norco for pain. She added that they are supposed to sign the narcotic sheet, document the pain scale, and sign the MAR whenever pain medication is given to a resident. On 6/24/2025 at 12:39PM, V6 (C.N.A) said that she is familiar with R1, he lets staff know when he needs anything. V6 said that R1 never complained of anything to her except one time he was asking V6 about getting more medication, stating that he is not getting all his pain medications. On 6/25/2025 at 11:15AM, V14 (pharmacy technician) said that they delivered 15 tablets of Norco for R1 on 6/13/2025, and then 30 tablets on 6/21/2025. V14 said that they also delivered 30 tablets of Gabapentin and 15 tablets of hydroxyzine for R1 on 6/13/2025.V14 added that that they did not supply any lidocaine patch for R1 because it is considered a house stock, they normally don't send it for individual residents, the facility uses their own supply. Review of manifest sheet from pharmacy confirmed that the above medications were delivered to the facility 6/13/2025 as stated by V14. On 6/25/2025 surveyor reviewed medication supply for R1 with V10 (LPN). There is 1 bingo card of Norco (30 tablets) delivered on 6/10/2025, resident have 15 tablets remaining. V10 was asked about resident's gabapentin and hydroxyzine, and she said that she could not find any, she will search more in the medication cart for it. At 2:18PM V10 told the surveyor that she did not find any gabapentin or hydroxyzine for R1. On 6/23/2025 at 2:00PM, V2 (DON) said that R1 he was getting his pain medications, the nurses are probably documenting only in the narcotic sheet and not in the medication administration record (MAR), medications are supposed to be signed out both in the narcotic count sheet and MAR when given. On 6/25/2025 at 3:11PM, V2 (DON) was presented with R1's missing gabapentin that was delivered but never signed out and she said that staff used all the gabapentin, and it is being reordered today. Surveyor asked V2 if she was aware that none of the medication was signed out as given to R1 in his MAR and she said yes. 2. R2 is [AGE] years old admitted to the facility on [DATE], medical diagnosis includes, but not limited to Unilateral primary osteoarthritis, right knee, generalized muscle weakness, unspecified abnormalities of gait and mobility, lack of coordination, essential primary hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, presence of right artificial knee joint, etc. On 6/23/2025 at 11:25AM, R2 was observed in his room, awake and alert and stated that he came to the facility after a knee surgery, the facility is not controlling his pain, he was supposed to be getting Norco for pain, but has not been getting it consistently, the last time he received his Norco was last Thursday, 6/19/2025. R2 was observed holding his right leg and grimacing, R2 said that he needs his pain medicine right now, have not received any today and rated his pain as 8 on a scale of 1 to 10. On 6/23/2025 at 11:30AM, surveyor inquired about the assigned nurse for R2 from V3 who was working on the same floor but was told that the nurse for R2 is on break. Surveyor asked V3 if she can give pain medication to R2, but she said that she does not have the narcotic key for the other cart and cannot tell if resident have had his pain medication today, she has to look in the narcotic book. On 6/23/2025 at 12:03PM, surveyor informed V2 (DON) that R2 has been waiting for pain medication and the other nurse on the floor said that his assigned nurse is on break. V2 said that she will follow up on that, the nurse should be returning from break shortly. On 6/23/2025 at 12:35PM, surveyor followed up with R2 who stated that he still did not receive any medication, no one has been to his room. Surveyor spoke to a staff who was sitting at the nursing station V4 (LPN), she said that she is the assigned nurse for R2, she was told that resident needed pain medication, she just spoke to the nurse practitioner who said that she will fax a new prescription for his Norco to pharmacy. V4 added that she will go and pull a dose for the resident from the emergency box. R2 has the following listed in physician order summary: 1. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain, order date 5/30/2025. 2.Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 5 mg by mouth one time only for severe pain for 1 Day. Order date 6/5/2025. 3.Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug*Give 1 tablet by mouth every 12 hours as needed for Pain, order date 6/23/2025. 4.Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain, order date 5/30/2025 discontinued 6/3/2025. Gabapentin Tablet 600 MG Give 1 tablet by mouth as needed for Pain related to presence of right artificial knee joint, three times a day. Order date 6/3/2025. Review of June MAR for R2 showed that his Norco was last given on 6/19/2025 as the resident said, there is no documentation that R2 was medicated for pain on 6/23/2025 for the pain scale of 8. R2's gabapentin 600mg was recorded as given once or twice some days, but not given at all on 6/3/2025, 6/4/3035, 6/6/2025, 6/8/2025. 6/9/2025, 6/15/2025, 6/18/2025 and 6/19/2028. There was no entry for tramadol in R2's MAR, or any documentation that R2 was receiving tramadol. On 6/23/2025 at 2:00PM, V2 (DON) said that R2 likes his pain medication, and he runs out, resident's pain medication is supposed to be reordered by the nurses. 6/23/2025 at 3:30PM, V2 said that the nurse practitioner gave the nurse an order to give R2 tramadol until his Norco is refilled. The NP faxed a new order to pharmacy on the 19th, not sure why it was not delivered. On 6/25/2025 at 11:35AM, surveyor presented R2's MAR to V2 (DON) that did not list any tramadol, and did not have any documentation that R2 was receiving any tramadol and she said, The nurse received an order to give resident tramadol when he ran out of Norco, she just forgot to put the order in or document it in the MAR. V2 was asked if the tramadol was delivered from the pharmacy and she said, no, it came from an outside source and we do not have any documentation of when it was received. V2 added that all medications residents receive are supposed to be documented in the MAR, and signed out when given, the nurse just forgot to do that. On 6/25/2025 at 12:29 PM V15 (Nurse Practitioner) said that R2 came to the facility from the hospital post right knee arthroplasty, he came with his own supply of Norco, Flexeril, gabapentin and tramadol, all to be taken a needed for pain. V15 did a script for his Norco to be refilled on 6/20/2025 and faxed it to pharmacy, not sure why the medication was not delivered. V15 gave an order to give resident tramadol until the Norco comes. Surveyor informed V15 that there is no documentation that R2 was receiving any tramadol in the medication administration record. She said, that part will be for the DON, I am just the NP, all resident medications are supposed to be documented in the medication administration record and signed out when given. Pain care plan for R2 initiated 6/2/2025 states: PAIN: Resident has an alteration in comfort r/t Advanced Disease process, Goal: Resident will not experience a decline in overall function r/t pain through next review. Interventions: Administer pain meds and treatments as ordered, assess effectiveness of pain medication, Educate on non-pharmacological interventions such as heat, ice, massage, relaxation, and distraction techniques, etc. Pain management policy revised 10/2024 states in part, to facilitate and provide guidance on pain observations and management, to facilitate resident independence, promote resident comfort and preserve resident dignity. This will be accomplished through an effective pain management program, ------------------- and enhance dignity and life involvement. Under guideline, the policy states as follows: The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exits whenever he or she says it does. Medication administration policy revised 4/2024 states in part: All medications are administered safely and appropriately to aid residents to overcome illness, relive and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. Under guideline, the policy states, #18 document as each medication is prepared in the medication administration record (MAR). #24, Document reason and response for any PRN medications. Job description for registered nurse and licensed practical nurse (undated) states in part: Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, -----------------, and adherence by staff members to facility policies and procedures. Essential duties #3, Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuous basis. #10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.

Based on observation, interview and record review, the facility failed to ensure that staff administer ordered pain medications to residents according to resident's needs and as outlined in their care plan and failed to ensure that resident's medications readily available. These failures affected two residents (R1 and R2) of four residents reviewed for pain management and have the potential to affect all 45 residents on the first floor of the facility. This failure resulted in R1 and R2 missed multiple doses of about 9 different pain medications while at the facility. Findings include: 1.R1's diagnosis includes, but are not limited to Malignant neoplasm of bone and articular cartilage, secondary malignant neoplasm of other parts of nervous system, anemia, benign prostatic hyperplasia without lower urinary tract symptom, wedge compression fracture of first lumbar vertebrae, osteomyelitis unspecified, etc. On 6/23/2025 at12:20PM, R1 was interviewed, and he said that his pain is not being managed because of how staff give his medications, he would like to have something in between Norco, staff always tell him that he is not due for Norco, and they cannot give him anything else. R1 said that they always run out of his lidocaine patch, he did not get any patch this morning, that is supposed to help with his neck pain. Active physician order summary for R1 showed the following: 1. Lidocaine External Patch 4 % (Lidocaine) apply to neck topically in the morning for Take off at 6PM related to acute hematogenous osteomyelitis, multiple sites, order date 6/12/2025. 2. Hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl) Give 12.5 tablet by mouth every 8 hours as needed for Anxiety for 14 Days, order date 6/17/2025. 3 Gabapentin Oral Capsule (Gabapentin) Give 100 mg by mouth every 12 hours as needed for pain AND Give 200 mg by mouth every 24 hours as needed for Pain. Order date 6/12/2025. 4. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain moderate to severe. Order date 6/18/2025. 5. Acetaminophen Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for Pain R1's Medication administration record (MAR) for the month of June 2025 showed the following documentations: Lidocaine patch was not signed as given on 6/14/2025, 6/20/2025 and 6/23/2025. Hydroxyzine signed out as given once, on 6/15/2025, Hydrocodone was not given on 6/12, 6/13, 6/14 and 6/17/, 6/19, 620, 6/21, 6/22 and 6/23/2025. Tylenol was given once on 6/13, 6/17 and 6/18/2025. Gabapentin was never signed out as given from the date it was ordered. On 6/23/2025 at 12:27PM, V3 (LPN) said that she did not remove any lidocaine patch from R1, the Surveyor informed V3 that R1 said he did not get his lidocaine patch this morning and does not have any on him right now. V3 then said, we have some house stock, I can go give him one now. On 6/23/2025 at 2:00PM, V2 (DON) was presented with all the days R1 did not get his pain medications and she said that R1 he was getting his pain medications, the nurses are probably documenting only in the narcotic sheet and not in the MAR, medications are supposed to signed out both in the narcotic count sheet and MAR when given. On 6/25/2025 surveyor reviewed medication supply for R1 with V10 (LPN) and noted that R1 did not have any gabapentin or hydroxyzine. V10 said that she could not find any, she will search more in the medication cart for it. At 2:18PM V10 told the surveyor that she did not find any gabapentin or hydroxyzine for R1. On 6/25/2025 at 3:11PM, V2 (DON) was presented with R1's missing gabapentin that was delivered on 6/13/2023, but never signed out as given in the MAR and she said that staff probably ran out, the medication is being re-ordered today. Surveyor asked V2 if she was aware that none of the delivered 30 tablets of gabapentin was signed out as given to R1 in his MAR and none is on hand at this time, she said yes. Facility could not provide any documentation that R1 received any gabapentin since it was ordered. 2. R2's medical diagnosis includes, but are not limited to Unilateral primary osteoarthritis, right knee, generalized muscle weakness, unspecified abnormalities of gait and mobility, lack of coordination, presence of right artificial knee joint, etc. On 6/23/2025 at 11:25AM, R2 was observed in his room, awake and alert and stated that he came to the facility after a knee surgery, the facility is not controlling his pain, he was supposed to be getting Norco for pain, but has not been getting it consistently, the last time he received his Norco was last Thursday, 6/19/2025. R2 said that he is in pain right now and rated his pain as 8 on a scale of 1 to 10. R2 have the following listed in physician order summary: 1. Hydrocodone-Acetaminophen Tablet 5-325 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for pain, order date 5/30/2025. 2.Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 5 mg by mouth one time only for severe pain for 1 Day. Order date 6/5/2025. 3.Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug*Give 1 tablet by mouth every 12 hours as needed for Pain, order date 6/23/2025. 4.Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for neuropathic pain, order date 5/30/2025 discontinued 6/3/2025. Gabapentin Tablet 600 MG Give 1 tablet by mouth as needed for Pain related to presence of right artificial knee joint, three times a day. Order date 6/3/2025. On 6/23/2025 at 12:03PM, surveyor informed V2 (DON) that R2 has been waiting for pain medication and the other nurse on the floor said that his assigned nurse is on break. V2 said that she will follow up on that, the nurse should be returning from break shortly. On 6/23/2025 at 12:35PM, surveyor followed up with R2 who stated that he still did not receive any medication, no one has been to his room. Surveyor spoke to a staff who was sitting at the nursing station V4 LPN) she said that she is the assigned nurse for R2, she was told that resident needed pain medication, she just spoke to the nurse practitioner who said that she will fax a new prescription to pharmacy. V4 added that she will go and pull a dose for the resident from the emergency box. Review of June MAR for R2 showed that his Norco was last given on 6/19/2025 as the resident said, there is no documentation that R2 was medicated for pain on 6/23/2025. R2's gabapentin 600mg was recorded as given once or twice some days, but not given at all on 6/3/2025, 6/4/3035, 6/6/2025, 6/8/2025. 6/9/2025, 6/15/2025, 6/18/2025 and 6/19/2028. There was no entry for tramadol in R2's MAR, or any documentation that R2 was receiving tramadol. On 6/23/2025 at 2:00PM, V2 (DON) said that R2 likes his pain medication, and he runs out, resident's pain medication is supposed to be reordered. 6/23/2025 at 3:30PM, V2 said that the nurse practitioner gave the nurse an order to give R2 tramadol until his Norco is refilled. The NP faxed a new order to pharmacy on the 19th, not sure why it was not delivered. On 6/25/2025 at 11:35AM, surveyor presented R2's MAR to V2 (DON) that did not list any tramadol, and did not have any documentation that R2 was receiving any tramadol and she said, The nurse received an order to give resident tramadol when he ran out of Norco, she just forgot to put the order in or document it in the MAR. V2 added that all medications residents receive are supposed to be documented in the MAR, and signed out when given, the nurse just forgot to do that. On 6/25/2025 at 12:29PM V15 (Nurse Practitioner) said that R2 came to the facility from the hospital post right knee arthroplasty, V15 did a script for his Norco to be refilled on 6/20/2025 and faxed it to pharmacy, not sure why the medication was not delivered. V15 gave an order to give resident tramadol until the Norco comes. Surveyor informed V15 that there is no documentation that R2 was receiving any tramadol in the medication administration record. She said, that part will be for the DON, I am just the NP, all resident medications are supposed to be documented in the medication administration record and signed out when given. Medication administration policy revised 4/2024 states in part: All medications are administered safely and appropriately to aid residents to overcome illness, relive and prevent symptoms and help in diagnosis. Licensed staff will administer medications as ordered by the physician. Under guideline, the policy states, #18 document as each medication is prepared in the medication administration record (MAR). #24, Document reason and response for any PRN medications. Job description for registered nurse and licensed practical nurse (undated) states in part: Under the direction of the physician, is responsible for total nursing care to all residents on assigned unit during the assigned shift including responsibility for delegation of duties, -----------------, and adherence by staff members to facility policies and procedures. Essential duties #3, Administer prescribed medications and treatments according to policy and procedure, evaluate treatment effectiveness on a continuous basis. #10. Document nursing care rendered, resident response, and all other pertinent and necessary data as outlined in facility's policies and procedures.

Based on observation, interview and record review the facility failed to ensure that resident personal washroom was equipped with toilet tissue/rolls in a timely manner in the resident's bathroom for personal hygiene. This failure affected 4 of 4 residents (R4, R6, R7 and R12) reviewed for personal hygiene equipment toilet rolls. Findings include: On 06/04/25 from 10:13am to 11:30am, the following observations were made: At 10:23am, R7's clothing noted on the bare floor R7 stated they are dirty clothes and stated he has no plastic bag to put the clothes Complain of not having toilet paper in the toilet for days at a time. At 10:42am, on the 1st floor, 1 south room [ROOM NUMBER], room floor noted with yellowish dry colored particles and orange peels. At 10:47am, V15 CNA stated the resident must have spill something, its dry possibly from previous shift. I am the CNA for this morning and the floor has been like that. On the 3floor at 10:54am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:56am, room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. At 10:58am, room [ROOM NUMBER], noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. In the same room garbage can with overflowing garbage and used adult incontinent diaper. room [ROOM NUMBER] noted with no toilet paper in the toilet. No extra paper tissue noted in the toilet. When all these observations were shown to V16 LPN (Licensed Practical Nurse) she stated that the housekeeping are responsible for replacing the toilet tissue and hopefully they will be getting to it, most of the garbage in the can are not from this shift. The surveyor asked who takes care of the garbage, V16 stated the housekeeping staff but those incontinent diapers should not be left in the room garbage. 06/04/25 at 11:03am, V18 (Housekeeping Director) stated that I (18) came in late this morning, but the rooms are supposed to be cleaned daily, and they are on it now. As for the toilet papers they (Housekeeping staff) are stocking up now. In no time now, all the rooms will be stocked. At 11:22am, in room [ROOM NUMBER] observed no tissue in the bathroom toilet. R4 noted sitting on the edge of the bed. R4 stated for two days now there was no tissue in the bathroom. They (housekeeping staff) came to clean it up but there is no tissue left. I don't know how they want us to wipe off our butt. room [ROOM NUMBER] shared the same bathroom with room [ROOM NUMBER]. On 06/04/25 at 2:06pm, V12 LPN (Licensed Practical Nurse) stated that the housekeeping staff usually are responsible for placing new tissue in the toilet room (washroom). V12 stated no extra tissue papers (rolls) are kept here (Nurse's station) but there should be plastic bags for room cabbage cans left at the Nurse's station. On 06/05/25 at 9:36am, V18 (Housekeeping Director) stated that the housekeepers are to stock up supplies during the cart preparations. The housekeeper for each floor is to stock up the rooms daily in the morning but sometimes they do and sometimes they do not. At times when budget run over it depends then I will put only one roll in the room. On weekends we leave supplies for the staff because I don't work on weekends. V18 stated I (V18) leave it on Friday before I leave. There are 96rolls in each box. The residents are not supposed to run short of toilet rolls, every room must have a supply very day. the surveyor asked do the staff that includes nursing staff have access to where toilet supplies are always kept. V18 stated only the housekeeping staff have access to the housekeeping storage unless there is a manager in the building. The surveyor then asked whether it Is appropriate for residents to be out of toilet tissue and what other plans are in place for them to clean up after using the bathroom. V18 stated logically they can use the towel (cloth towels) to wipe. V18 stated they (towels) are not stock in the bathroom for that purpose. 0n 06/05/25 at 1:49pm, V18 stated that there is no standard policy or SOP (Standard of Operation) given to us by the company, the only thing I (V18) have is the daily housekeeping check list from the hold company. Since the name change I (V18) don't have any policy on housekeeping from the new company. On 06/05/25 at 3:40pm V1 stated that the housekeeping keys will be left at the front desk so there should be no problem with the toilet roils any more, I know we should do better. We have problem with staff taken them home, we will do better.

Based on observation, interview and record review the facility failed to ensure that emergency cart, treatment cart was locked when not in proximity of the nurse and individual medications were locked up safely in the medication cart to prevent tampering and accidental hazard. This failure affected 2 of 2 residents (R3 and R1) in the sample reviewed for medication administration. Findings include: On 06/04/25 at 10:13am, the treatment cart noted in the hallway unlocked and unattended to by Room105. V7 LPN (Wound Care Nurse) confirm that it was the treatment cart stating that it is the treatment cart with treatment medications. V7 stated that the facility policy is to have it locked when not at eyesight level and not in use. At 10:40am, V2 (DON) stated that the treatment cart should be locked when not in visual contact of the nurse. V2 stated that V7 (treatment nurse) has told me about it (not locking the cart). I told her lock to the cart always when not in the eye contact with the cart. On 06/04/25 at 11:24am, crash cart noted in the hallway in front of the elevator unlocked with two plastic locks broken and left on the crash cart. When shown to V20 LPN (Licensed Practical Nurse). V20 stated the cart should be locked always with the red plastic lock so that no one can get into it. V20 stated I did not use the cart this morning and it should be locked; I turned the gray lock but that can be easily turned to unlock. The lock is to make sure that no one can get into its residents /visitors. On 06/05/25 at 11:03pm, R3 noted in the room in bed at the bedside noted 3pills in the medication cup at the bed side. R3 was unable to identify the pills. At 11:09am, from the hallway noted R11 had medication cup on the over bed side table. Upon entering the room there were 8pills noted in the medication cup. R11 stated that the nurse (referring to V9 (LPN) gave him the medications this morning and will have to take it later. At 11:11am, When the surveyor observations were shown to V9 LPN (Licensed Practical Nurse) and was asked about the facility policy for medication pass. V9 stated that the medications for R11 was this morning medication and while having conversation with R11 she forgot to give them to R11 and make sure he took them (Medicine). V9 stated that she should not have signed the MAR (Medication administration Record) has given. V9 checked the POS and the MAR with the surveyor R3's medication that was left at the bedside and told the surveyor that the medication found at R3 bedside is not left on the side table dresser by her and did not know how R3 got the medicines. V9 stated the medications look like tums and stool softener but R3 did not have any order for the medicines. And they should not be left at bedside unless ordered by the doctor to do so. On 06/05/25 at 11:24am, V10 (Nurse Supervisor) stated that we (nurses) not supposed to leave medication at bedside unless ordered by the doctor and the medication should not be signed out as given until after the resident has taken the medication. At 11:42am, V3 ADON (Assistant Director of Nurse's) stated that he cannot for word for word quote the facility policy, but the expectation is for the nurses to follow administration policy and one of it is to observe the patient (resident) take the medicine (Swallow) a document right after it is taken. V3 stated that no medication should be stored at bedside without an order and resident assessment that resident can self-administer. The facility policy on Crash Cart presented with revised date 04/2025 documented that in general the policy is to provide the staff with guidance on Crash cart contents and monitoring. Listed purpose indicated that the Crash Carts are set up for type of life-threatening event expected to occur in this facility (i.e., cardiac, anaphylaxis). Protocol listed includes crash cart will be checked daily by night nurse and department manager; verify the crash cart has not been opened since the previous day by verifying tag number against crash cart checklist. The facility policy Self-Administration of Medications and treatments presented with review date 12/2021 documented that self-administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Facility policy on Medication Storage in the Facility presented with review date 6/2024 documented in general that medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Responsible party listed nursing. Listed procedure includes but not limited to medication carts and medical supplies are locked or attended by person with authorized access that includes licensed nurses. Facility policy on Medication Administration presented with review date 3/2022 documented in general that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of responsible party are RN (Registered Nurse), LPN (Licensed Practical Nurse). Listed guidelines includes but not limited to remain with the resident to ensure that the resident swallows the medications.

Based on observations, interviews and record reviews, the facility failed to implement effective individualized fall interventions to prevent fall incidents and fall incidents with injury for residents identified as high risk for falls, with severe cognitive impairment and assessed with poor awareness. This affected two (R2 and R5) of three residents reviewed for incidents/accidents. This failure resulted in R2 having multiple falls with self-transfer attempts and R5 with history of wandering behavior, had a fall and found by the third floor exit door on 4/10/25. R5 transferred to local hospital for evaluation and returned with new diagnosis of closed nondisplaced fracture of proximal end of left humerus. Findings Include: R2 admitted in the facility on 9/16/24 with diagnoses of but not limited to: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Generalized Muscle Weakness, Abnormal Posture, Hypertension, Depression, Insomnia, Restlessness and Agitation, Cognitive Communication Deficit, History of Falling, Type 2 Diabetes, Muscle Wasting and Atrophy on Right Lower Leg and Abnormalities of Gait and Mobility. Section C of MDS (Minimum Data Set) dated 3/16/25, BIMS (Brief Interview for Mental Status) of 6/15, indicates severe cognitive impairment. Fall Risk Review dated 11/7/24 was 17 and 3/15/25 score was 20. R2 is High Risk for Fall. R2 is care planned for High Risk for falls related to current condition, medication use, Poor Safety Awareness, Unsteady Gait, Disease Process dated 1/23/25. Fall incident reviewed from January of 2025. R2 had multiple fall incident. One on 3/4/25 and another one on 3/15/25. R2's 3/4/25 fall incident at 1700, reads in part: R2 noted lying in-between bed and wheelchair on right lateral side. R2 tried to self-transfer from bed to wheelchair. R2 requires assistance with transfer. R2 stated R2 was trying to go to the living room to watch television. R2's 3/15/25 fall incident at 22:15, reads in part: Walking to the nurses station and heard R2 yelling, hey hey and upon entering room, R2 observed trying to transfer self from bed to wheelchair and slide down off the bed, landing in a sitting position on buttocks. On 4/15/25 at 11AM, observed R2 sitting in bed. Wearing AFO brace on right foot (white plastic brace with no socks or any footwear on bilateral feet. Feet touching the floor as R2 seats on his bed. On 4/16/25 at 9:30AM, R2 observed in bed, wearing gown and wearing regular socks. On 4/16/25 at 9:30AM, V7 (Restorative Aide/CNA) confirmed with V7 that R2 is currently wearing regular socks and not the non-skid socks. V7 stated that AFO brace is used at night, when he is in bed. R2 was able to put the AFO brace by himself, and that was the brace you have seen R2 was wearing yesterday. We are now keeping the brace in the bottom drawer, so R2 will not be able to put the brace on his own. R2 is not supposed to wear it during day time. For his safety. R2 requires minimal staff assist with transfer, can stand pivot safely with staff present. On 4/17/25 at 11:00AM, V2 (DON) stated that R2 should have and wear non-skid socks for safety because R2 is High Risk for Fall and history of fall with self-transfer. R2 wear AFO brace during night time and not during day time. AFO brace was recommended by outpatient therapy and we are in the process in getting more information into when and now long R2 needs to utilize it. CNA informed V2 that R2 puts on the AFO by himself, and so CNA working with R2 removes the brace and place it in the bottom drawer for resident safety. R5 admitted in the facility on 2/1023 with diagnoses of but not limited to: Fracture of Upper End of Left Humerus, Protein Calorie Malnutrition, Type 2 Diabetes, Hypertension, Fracture of Neck Left Femur, Mild Cognitive Impairment, Dementia, and History of Falling. Section C of MDS (Minimum Data Set) dated 3/17/25, BIMS (Brief Interview for Mental Status) of 4/15, indicates severe cognitive impairment. Fall Risk Review dated 3/17/25 was 10 and 4/10/25 score was 13. R5 is High Risk for Fall. R5 is care planned for at risk for falls related to: type 2 diabetes, history of falling, essential primary hypertension, dementia, and UTI, with a revision date of 11/18/24. R5 is care planned for Displays behavioral symptoms of unpredictable verbal aggression outburst towards peers with delusional statement of abuse, related to diagnosis of dementia, with a revision date of 3/17/25. R5's Wandering Risk Careplan dated 4/25/23 and revision date of 11/4/24, reads in part: R5 demonstrates movement behavior that may be interpreted as wandering, pacing and roaming. Pacing, roaming or wandering in and out of peers' rooms. R5 is a new admission and not familiar with her environment. R5 no longer exhibiting with behavior as of 11/4/24 and through this annual review period. R5's Social Services notes on 3/17/25, reads in part: R5 presents to be Alert & Oriented x1 with periods of confusion, disorientation, poor awareness, short-term memory loss, and/or forgetfulness. She has no challenges with the expression and comprehension of information at times when expressed to her to her understanding and knowledge. R5's Risk Management Fall Documentation dated 4/10/25 at 1400, reads in part: writer heard the alarm sound and immediately went to the door, upon observation writer noted resident alert and verbally responsive in the supine laying on the stairwell. 911 called due to anticoagulant therapy. Writer noted skin tear to left lower extremity. R5's Hospital record reviewed dated 4/10/25, reads in part: X-ray Left Shoulder: Comminuted fracture of left proximal humerus with varus impaction at the surgical neck. X-ray Left Humerus: Comminuted sub capital fracture with superior subluxation of distal fragment. Emergency Department diagnosis: closed nondisplaced fracture of proximal end of left humerus. On 4/16/25 at 9:40AM, V8 (LPN) stated R5 is high risk for fall due to R5's wandering behavior. R5 has a behavior of wandering the 3rd floor unit, baseline routine of R5 was up and uses her wheelchair as a mode of locomotion. Able to propel wheelchair with her hand on her own, but not now due to the left arm brace R5 is wearing now and the fracture on left arm. Staff usually redirect R5 when observed with wandering behavior. Staff would ask if R5 needs something, at times R5 would say R5 is looking for her room. V8 stated that V8 worked on 4/10/25, and was working the north side unit on the 3rd floor. Heard code yellow announced in the intercom. V8 stated he checked his unit for all his residents and after V8 went to 3rd floor south side unit. V8 heard an alarm coming from the south side exit door, there were already staff present at the exit door when he arrived in the area. V8 observed R5 outside the exit door, two steps away from the door, with R5 laying on the stairs floor, face up with the head towards two stair steps downward and feet placed upward, foot facing towards the door (body diagonally positioned) and wheelchair located at the middle part of the stairways. On 4/16/25 at 9:45, V8 demonstrates in opening the exit door. V8 pushed the door, loud alarm went off, however unable to open door for another 15 secs, as it is required to re-push for it to open. Need key for the alarm to stop sounding. Observed signage on the exit door stating push until alarm sounds, door can be opened in 15 seconds. R5 used to be on (3rd floor) south side unit by the exit door, passing an open area used to store unused wheelchair, Geri chair and mechanical lift, parked against the wall. On 4/16/25 at 12:25PM V9 (CNA) stated that R5 normal morning get up. R5's baseline routine in the unit, normally when V9 gets here R5 is usually already up in the dining room. Waiting for breakfast to come. Will do activity at times after and sometime will lay back down in her bed after the breakfast. Sometimes she needs redirecting as she forgets which side of the floor her room is on sometimes. Depend on her mood if she stays in the dining area after meals. When I redirect her, I will then take her to her room, when R5 seems kind of lost and can't find her room. On 4/16/25 at 12:50PM, V10 (CNA) stated that R5 gets up in the morning and that night shift get R5 up. R5 would be already ready be waiting for breakfast in the dining room. When too many people in the dining area, R5 sometimes would ask if she can go to her room. Most of the time R5 will ask. And there will be times, R5 will go in her room on her own. At times I see her and I will take her to her room. Sometimes R5 is confused and will not find her room. Sometimes she remembers her room number and sometimes she gets confused. On 4/16/25 at 1:05PM, V11 (CNA) stated R5 usually stays in the dining room for activity. R5 is fall risk, so R5 stays in the dining room, so staff would be able to monitor R5. To prevent fall and for her safety. One of the reason R5 stays in the dining room, so we can assist her at all times if R5 needs to go to the bathroom. R5 at times would try to go to the washroom and not able to find it unless assisted by the staff. Need assistance with staff in finding her room also. On 4/16/25 at 1:30PM, V12 (Wound Nurse), I was on the 2nd floor, Heard the alarm went off from the third floor. I ran south side stair exit coming from the 2nd floor. Office right by the 2nd floor exit door. When V12 went upstairs, observed R5 laying on the floor. On the first level, before the first two steps. Body started to continue to slide down further and so V12 assisted R5 further down the step, V12 does not recall the position of R5's head at the time. I do not recall where her wheelchair was. R5 was screaming and I was paying more attention to R5 at the time. People started coming maybe because of the alarm sounding at the time. 911(Emergency Response) was called and V12 stayed with R5 along with the other staff until taken by paramedics. V12 noted Skin tear on R5's Left leg lower shin area with partial skin flap. It was approximately 3x4 cm. STERI strips placed prior to the ambulance arriving in the facility and V12 was able to control the bleeding. Scant amount of bleeding. On 4/17/25 at 11:00AM, V2 (DON) stated that R5 was seen in her room prior to her fall. It just happened R5 fell trying to exit, R5 does not have an exit seeking behavior prior to this fall. Upon her returned in the facility, we placed her in a room closer to the nurse's station, and placed her in close monitoring. We are not aware of her wandering behaviors, management are all new in the facility. Fall Prevention and Management Policy with a review date of 8/2024, reads in part: This facility is committed to maximizing each residents' physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for fall, plan for preventative strategies and facilitate as safe as environment as possible. All residents fall shall be reviewed, and resident's existing plan of care shall be evaluated and modified as needed. A fall risk evaluation will be completed on admission readmission, quarterly, significant change and after each fall. Resident at risk for falls will have fall risk identified on the interim plan of care and the ISP with interventions implemented to minimize fall risk. A fall risk evaluation is completed by the nurse. A score of 10 or greater indicates the resident is at high risk for falls, a score of less than 10 indicates at risk for fall. Care plan to be updated with new interventions based on root cause analysis after reach fall occurrence.

Based on observation, interview and record review, the facility failed to maintain an available manual resuscitator and failed to provide timely suctioning care for two (R1 and R6) out of three residents with a tracheostomy. Findings include: According to the electronic health record, R1 has diagnosis including s/p tracheostomy, g-tube placement, hypertension, hyponatremia, anemia, sacral decubitus ulcer, chronic respiratory failure, and gastroparesis. R1 is nonverbal. On 3/21/2025 at 9:40 AM, R1 was observed asleep, tracheostomy attached to oxygen concentrator; tracheostomy collar appears clean and dry, no secretions present at the entrance of the tracheostomy tube observed. Manual resuscitator was not available at the bedside. V2, Director of Nursing (DON) confirmed that a manual resuscitator (a handheld medical device used to manually ventilate a patient who is not breathing or is breathing inadequately, often used in emergency situations like cardiac arrest or respiratory failure) was not available at the bedside. V2 further stated that there should be a manual resuscitator always at the bedside of residents with tracheostomies because in an event of an emergency the manual resuscitator is used to manually provide oxygenation to the resident. V2 stated that the facility also has a respiratory treatment cart that has a manual resuscitator and that she is not sure why R1's manual resuscitator is not at the bedside but that she will place a manual resuscitator in R1's room right away. On 3/21/2025 at 9:58 AM, V3, Licensed Practical Nurse, stated that lately she has noted that R1 has been having a lot of secretions so V3 has been suctioning R1 more frequently. V3 stated she had cleaned and changed R1's inner cannula, and that V3 had suctioned R1 once already today. V3 stated that she suctions R1 4 to 6 times during her shift at least. V3 stated that there should always be always a manual resuscitator available in R1's room because in an emergency, the manual resuscitator is used to provide oxygen to R1 for respiratory distress. According to the electronic health record, R6 has diagnosis including cerebrovascular accident, traumatic brain disorder s/p evacuation of subdural hematoma and left occipital lobe epidural hematoma, paraplegia, nonverbal, tracheostomy and gastrostomy tube in place. R6 is non interviewable and is nonverbal. R6's Physician Order Sheet includes a physician order dated 2/8/2025 that documents: Suction as needed. On 3/21/2025 at 2:50 PM, R6 was observed coughing and was noted with obvious thick secretions at the entrance of R6's trach(tracheostomy) tube. V6, Licensed Practical Nurse (LPN) was also at R6's bedside, cleaned the secretions around R6's trach tube but did not suction R6. On 3/21/2025 at 3:00 PM R6 was observed coughing again and additional thick secretions were noted at the entrance of R6's trach tube. V6 stated that she had just suctioned R6 around 11:00 AM and that she would have to check R6's suction orders but that she is pretty sure it is every 3 hours and as needed but not any sooner than every 3 hours. On 3/21/2025 at 3:11 PM, R6 was observed with thick secretions at the entrance of his trach tube. V6 was at the nurses' station and stated that she had not checked R6's orders for suctioning the tracheostomy. V6 stated she would go to the bathroom first and then check the order for R6. On 3/21/2025 at 3:18 PM, while waiting inside R6's room, R6 was observed coughing again and more thick secretions can now be observed at the entrance of R6's trach tube. On 3/21/2025 at 3:28 PM, V6, Licensed Practical Nurse, was observed walking in the hallway past R6's room. V6 did not check R6, nor did she suction R6. On 3/21/2025 at 3:30 PM, surveyor summoned V7, Nursing Supervisor to R6's room to check R6's SPO2 level. V7 stated R6's SPO2 (Saturation of peripheral oxygen which indicates how much oxygen your blood is carrying compared to its maximum capacity. A healthy SPO2 level is typically between 95% and 100%) is 89%. V7 affirmed that R6 needed to be suctioned. V7 affirmed that R6 had thick secretions at the entrance of R6's trach tube and needed to be suctioned. V7 stated that if there are secretions around and at the entrance of R6's trach tube, it is her expectation that the nurse would suction R6 right away since aside from the order for scheduled suctioning, R6 also has an order for PRN (as needed) suctioning. V2, Director of Nursing, also stated that it is her expectation that the nurse will suction the resident right away. V2 stated that she will suction R2 right now. Informed V2 that I have been observing R6 with thick secretions at the entrance of his trach tube since 2:50 PM and that V7 stated that R6's SPO2 level is now only 89%. V2 stated that the nurse should have suctioned R6 right away. Facility Tracheostomy Care policy dated 4/2019 documents in part: It is the policy of this facility that residents with tracheostomies receive routine care to maintain a patent airway, that aseptic technique is used during the dressing changes until the tracheostomy is healed, and a physician order is obtained for tracheostomy care.

Based on interview and record review, the facility failed to develop a fall care plan with interventions to prevent a fall of a resident (R1) who was assessed as high fall risk. These failures affected one (R1) of three residents reviewed for falls and resulted in R1 sustaining broken ribs, left shoulder out of socket and fluid in muscle as a result of a fall. Findings include: R1 is a [AGE] year-old male admitted to the facility on [DATE] with medical diagnosis that includes and not limited to Cerebral vascular accident, hemiplegia affecting the left side, respiratory failure, diabetes, and clostridium difficile. According to R1's progress notes dated 01/15/2025 at 9:15PM R1 was found by V3 (Licensed Practical Nurse) on the floor facing down next to the bed with an abrasion to left eyebrow and swelling to left hand. R1 was sent to a local hospital by ambulance for further evaluation. According to R1's progress notes dated 01/16/2025 at 4:16 AM V3 called the hospital and nurse on duty provided report that R1 had broken ribs, left shoulder out of socket and fluid in muscle and was transferred to another local hospital. On 01/21/2025 at 11:00AM V3 (Licensed Practical Nurse) said, R1 had his right leg dangling on the sides of the bed and assisted him back to bed while I finished passing medications for another resident and I parked the cart by the nursing station. About 9:00PM before going to my break time I completed a walking round in the unit. I observed R1 on the floor facing down and between the bed and the wall. I called V4 (Certified Nursing Assistant) who spoke Spanish and translated for me while I was doing R1 assessment. I sent R1 to the hospital and notified the family and director of nursing of the fall. I called the hospital four to five hours later; I received the information that R1's shoulder was out of the socket and had broken ribs. On 01/21/2025 at 11:47AM V4 (Certified Nursing Assistant) said, R1 was restless during the shift I changed R1's brief before the fall. Later while I was doing my rounds, I saw V3 in the room with R1 on the floor. On 01/21/2025 at 1:53PM V2 (Director of Nursing) said, I did not send a report to IDPH (Illinois Department of Health) because there is no report from the hospital, I am not going to report a fracture if I don't have the x-ray results and I am not going to rely on the progress notes from the nurse. On 01/21/2025 at 1:55PM reviewed records for R1 and noted that care plan did not include fall interventions for 01/14/2025 admission. On 01/22/2025 at 11:29AM V7 (Restorative Director) said, a restorative technician usually sees residents and completes an assessment and I will see the resident after the restorative technician. That is when I will add programs that the resident will benefit from. On my assessment for R1, he was lethargic and flaccid on the left side. I did not initiate or update any fall care plan, the nurses are expected to complete a fall evaluation on admission and if the score is above 10, a basic fall care plan should be entered by the admitting nurse with interventions to prevent falls. V7 stated that there is no fall risk care plan, but all residents have the call light within reach. On 01/21/2025 at 11:25AM V2 (Director of Nursing) said, the facility had no falls with injury since December of 2025. I expect the nurses to follow the facility fall policy, first assess the resident, call physician, and the notify family. Resident is placed on monitoring for 72 hours and update care plan and interventions. Any fall with injury I expect the nurses to notify the physician, administrator, and myself immediately. On 01/21/2025 at 1:50PM V2 (Director of Nursing) presented facility Policy Titled, Fall Prevention and Management (date reviewed 08/2024), which reads: General: The facility will identify and evaluate those residents at risk for falls, plan for a preventative strategy, and facilitate as safe and environment as possible. All residents' falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed. Guidelines: Upon admission: 1-A fall risk evaluation will be completed on admission, readmission, and quarterly, significant change after each fall. 2-Residents at risk for falls will have fall risk identified on the interim plan of care and ISP with the interventions implemented to minimize fall risks.

Based on interview and record review, the facility failed to identify and treat an open wound. This affected one of three residents (R1) reviewed for skin assessment and wound care. This failure resulted in R1 being admitted to the hospital where the open wound was found and treated for maggots present in the wound. Findings Include: R1 is a [AGE] year old with the following diagnosis: end stage renal disease with dependence on renal dialysis, type 2 diabetes, heart failure, and transient ischemic attacks. A General note dated 7/6/24 documents the nurse contacted the physician to inform them about R1's left leg swelling. Orders were put in to send R1 to the hospital for an evaluation to rule up blood clots. R1 was transported to the hospital at 12:06 AM. R1 was admitted to the hospital to a step down unit. The Hospital Records dated 7/7/24 document R1 presented to the emergency department with increased left leg swelling. R1 had a procedure on 6/17 where R1 underwent revascularization with a left vein angioplasty. R1 has required multiple veinoplasties in the past. Maggots were noted in the right plantar foot wound so a wound consult was ordered. The wound is on the plantar surface of the right foot and was noted to have maggots upon admission. On 7/9/24 at 2:00PM, V2 (CNA) stated R1 received bed baths daily due to being immobile and during the bed bath skin is checked for any issues. V2 denied being aware that R1's feet needed to checked or washed daily as part of the care plan. On 7/9/24 at 2:12PM, V3 (CNA) stated V3 worked with R1 the morning (7/6/24 7AM-3PM shift) before R1 left for the hospital. V3 reported giving R1 a bed bath on this day and denied seeing any open areas or new skin concerns that should have been reported to the nurse. V3 stated overall skins checks are performed daily on residents when care is being provided. V3 reported any concerns with the skin should be documented on the bath sheet and the nurse should be notified so wound treatments can be ordered. V3 reported seeing flies every now and then in the halls and that it is normal. On 7/9/24 at 2:44PM, V4 (Nurse) stated V4 did a full body skin assessment on R1 before R1 left for the hospital. V4 denied R1 having any open areas on the skin. V4 reported the skin has to be assessed before a resident leaves the facility so the facility is aware of how their skin looks before they leave and to give report to the location the resident is going on what was found. V4 stated the nurse must document a skin assessment was completed before the resident is discharged and what was found on the skin assessment. V4 reported if maggots were found in a wound then the skin would have to be open at least a couple days for the maggots to be there. On 7/9/24 at 3:11PM, V5 (DON) stated R1 previously had wounds that healed, but V5 was not aware of any wounds R1 had upon discharge to the hospital on 7/6/24. V5 confirmed R1 previously had a wound to the right foot that healed. V5 reported skin assessments should be completed when a resident is being bathed and as needed. V5 stated a skin assessment form needs to be completed with each bath given. V5 reported a skin assessment is not needed before going out to the hospital and the facility refers to the resident's last shower day to know what their skin was like when they left. On 7/9/24 at 3:26PM, V6 (CNA) stated V6 just arrived to the facility around 11PM and got R1 cleaned up to go to the hospital. V6 denied doing a complete skin assessment on R1 before leaving due to R1 having socks on. V6 reported R1 left the facility around midnight for the hospital. On 7/9/24 at 3:32PM, V7 (Wound Care Coordinator) stated R1 had pressure injuries on R1's heels when R1 was admitted but R1 did not have any current wounds. V7 reported skin assessments need to be completed on bath days and as needed. V7 stated staff did not bring any new skin concerns to V7's attention before R1 left for the hospital. V7 reported if a wound is left open and untreated then it runs the risk of becoming infected and declining. On 7/9/24 at 3:43PM, V8 (Nurse) stated R1's leg became swollen so V8 got orders to send R1 to the hospital for an evaluation. V8 denied assessing R1's skin before leaving for the hospital because because nothing was brought to my attention anything was wrong. When asked if residents are supposed to have a skin assessment before leaving the facility, V8 said, I don't know. On 7/12/24 at 10:32AM, R1 was interviewed at the hospital. R1 was alert and oriented times three when questioned the date, location, and president. R1 stated R1 came to the hospital due to the left leg swelling but was unaware why the leg was swelling. R1 reported in the emergency room maggots were found in a wound on R1's right foot. R1 was unaware R1 had a wound to the right foot. R1 stated there would be a fly in R1's room once or twice a week but it didn't stay all day. R1 reported R1 would go hours without seeing the fly then it would reappear later. R1 stated the fly would land on R1 and R1's belongings. R1 denied having any wound care to the feet within the last month. R1 reported the wound is still on R1's foot and was infected but is now healing. R1 was wearing a heel protective boot with a dressing to the right foot covered in gauze. The nurse at the hospital reported the dressing change was completed around 8AM that morning and the hospital would not be removing the dressing again for the surveyor to make an observation of the wound. On 7/12/24 at 1:55PM, V10 (Maintenance Director) stated staff notified V10 about a concern for flies downstairs on 7/8/24. V10 reported putting up two fly traps and reminding staff to close the door during deliveries because that is how flies get in the building. On 7/12/24 at 2:00PM, R5 resided in the room R1 resided in before R1 was sent to the hospital. R5 reported seeing a fly about once a week come into the room but was unaware of where the fly was coming from. R5 stated R5 thought the fly was coming from the hallway when the door was open because the window in the room did not open. R5 reported the fly would land on R5 as well as R5's belongings. R5 reporting making a comment to the flies coming in and out of the room to a staff member but R5 could not remember who the staff member was. R5 stated the flies having been coming in and out of the room all summer. On 7/15/24 at 12:37PM, V12 (Wound Nurse Practitioner) stated R1 was not being seen by V12's company due to R1;s wound healing earlier in the year. V12 reported the only way a resident is treated by V12 is if staff notify V12 that a resident has a skin concern. V12 stated R1 is at risk for developing wounds due to immobility, being incontinent, and previously having wounds in the past. V12 reported most facilities assess resident's skin at least on a weekly basis. V12 reported the wound care company should be notified immediately if there is any openings in a resident's skin so treatment can begin. V12 stated maggots get into a wound by a fly laying eggs in the warm moist environment. V12 said, I can't say exactly how long it takes for the fly eggs to become maggots, but I would say within a day or two. V12 reported in order to prevent maggots from entering a wound he area needs to clear of flies, which is difficult so the wound or any open areas of the skin should be covered to make sure the flies aren't laying eggs. V12 stated maggots can cause infection in a wound and cause the wound to decline and become worse. The SBAR Communication Form dated 7/6/24 documents R1 had swelling to the left lower extremity and was sent to the hospital. The skin evaluation documents there's only swelling to the left leg. There is no other indication that R1 has an open area to any part of the skin. The Hospital Transfer Form dated 7/6/24 documents R1 was sent to the hospital for new or worsening edema. R1 is at risk for pressure ulcers/injuries. The skin assessment documents R1 currently does not have any pressure ulcers or other wounds. The Braden Scale dated 6/8/24 documents a score of 15 indicating R1 is at risk for developing wounds due to being chair fast, very limited mobility, and slightly limited sensation. There is a wound documented that healed on the right plantar foot that was treated in the facility in 05/2024. The Bath Sheets for 07/2024 were reviewed. Per the documentation, R1 received a bed bath on 7/1/24 and 7/4/24 and had no new wounds present at the time of these assessments. There is no documentation of any daily skin checks to the feet were completed. The Care Plan was reviewed and does not document R1 having any current care plan for open wounds. The Care Plan dated 6/28/24 documents R1 is at risk for impairment to skin integrity with a Braden score of 15. An intervention includes to perform skin checks on bath days, report abnormalities to a nurse, and follow appropriate skin impairment protocols. The Care Plan dated 1/1/24 documents R1 has diabetes mellitus. An intervention for this care plan includes to wash feet daily with mild soap and water and inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness then report any issues to the nurse. The Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status score as a 14 (no cognitive impairment). Section M of the MDS documents R1 is a risk for developing pressure ulcers but currently does not have any unhealed pressure ulcers or other wounds present. The Physician Order Sheet was reviewed for all orders and there are no orders for wound treatments for be performed to the right foot. The Medication Administration Record for 06/2024 and 07/2024 were reviewed and does not document any dressing changes to the right foot. Per V1 (Administrator), there is no Treatment Administration Record for R1 for 06/2024 and 07/2024. The policy titled, Wound Prevention and Healing, dated 07/24/23 documents, Policy Statement: To provide wound care treatments/services based on evidence based standards of care under the direction of a physician. 1. Assessment and Prevention . c. Facility will inspect skin during showers, daily and or weekly skin checks as scheduled, and PRN .11. The Multidisciplinary Wound Care Team: 1. The wound care team is responsible for identifying problems, coordinating care, and promoting development of the team in the program. 2. Certified wound care nurses and trained nurses are responsible for oversight of wound care rendered to all wound care patients, including the patient assessments, evaluation, treatment, measurements, plans of care, care outcomes, and cost effective of the treatment plan of care.

Based on observation, interview, and record review, the facility failed to obtain consent for psychotropic medications prior to administering. This failure affected one of one (R2) resident reviewed for unnecessary psychotropic medications and resulted in R2 experiencing increased lethargy and concern from family members. Findings include: R2 is [AGE] years old and was transferred to the facility on [DATE]. Diagnoses listed for R2 include dementia, osteitis (inflammation of bone), convulsions and violent behavior. According to the Minimum Data Assessment of 4/19/24, R2 was assessed to have mild cognitive impairment. On 7/03/24, at 1:31PM R2 was observed in bed, dressed in a gown, and picking at lunch using fingers. R2 was conversational and alert. R2 also appeared lethargic, as evidenced by the slow movement of hands, low tone of voice and drooping eyelids. R2 expressed that they regularly received medications from the nursing staff but was unable to say what medications were being administered nor for what reason they were being administered. On 7/7/24 at 2:19PM V10 Family Member of R2 said, shortly after R2 came to the facility, R2 was noticed to have confusion, and hallucinations. V10 said when R2 transferred to this facility, R2 was lucid, but now R2 has become increasingly confused and V10 believed that R2 was being given too many medications that affect R2's mental capabilities and symptoms. V10 said that as a family, we think the facility nurses are deliberately trying to sedate R2. V10 continued to say, during a care plan meeting in May of 2024, concerns regarding medications were brought to the attention of the staff, however there was no suggestion or resolution to adjusting R2's medication regiment. V10 denied signing or giving consent for any medication R2 was receiving. V11 (Licensed Clinical Social Worker) was interviewed 7/8/24 at 10:59AM and said during the care plan meeting, V10 and another family member were given a medication administration record and they questioned the medications that R2 was taking. V11 said that we, (the interdisciplinary team) provided education regarding the medications and told them to continue educating themselves. As listed on the Physician order sheet active during this survey (July 2024), medications being administered to R2 include Olanzapine 15mg oral daily (ordered 6/24/24), Gabapentin 300mg two capsules every eight hours (4/9/24) for pain, Duloxetine 120mg daily for depression (4/9/24), Cyclobenzaprine 10mg every eight hours for muscle spasms (4/9/24), Hydrocodone-acetaminophen 5/325mg one tab every six hours as needed, and Lorazepam 2mg every night for sleep (4/9/24). On 7/8/24 at 1:42PM V12 Primary Physician said, olanzapine is an antipsychotic. Gabapentin is an anticonvulsant (anti-seizure) but can also be used as a mood stabilizer for the prescribed dose and unlikely used for pain for R2. Cyclobenzaprine is a muscle relaxer that can be used for muscle spasms, however if R2 is not complaining of cramps or muscle spasms, should not be taking as a scheduled medication because it can cause drowsiness and lethargy. V12 said, since R2 has other medications for pain such as ibuprofen and acetaminophen ordered, these should be used as a first option because hydrocodone as a narcotic has some sedating properties, while the other [aforementioned] medications do not. V12 said, that during previous visits, R2 did not complain of pain. Controlled drug administration record sheet for hydrocodone/acetaminophen 5/325mg indicated that this medication was dispensed for R2, in April, May and June of 2024, however, the pain assessments as listed in the Medication Administration record indicated that R2 did not complain of any pain in May or June. On 7/7/24 at 3:10PM V6 Director of Nursing said that the nurses were expected to document pain assessments when giving any medication specific to pain and that if R2 was not complaining of pain, they should not be given an as needed medication. On 7/8/24 at 3:47PM V13 Psychiatric PA (Physician's Assistant) said that they manage psychotropic medications for R2. On 6/6/24, V13 assessed R2 and made a recommendation to increase a medication Aripiprazole (antipsychotic) from 10mg to 15mg. When seeing R2 again on 6/20/24, V13 noted that the medication had not been entered on the Physician's Order Sheet and inquired about the order. V13 said that the nurses informed V13 that consent had not been given to administer the medication, and V13 also said that R2 was not believed to be decisional. V13 also said that olanzapine was not ordered or recommended for R2 by themselves, nor did V13 believe that the collaborating physician made the change from aripiprazole to olanzapine because it was not common practice. V13 explained that since both medications were in the same drug class, aripiprazole was less sedating than olanzapine. V13 said that when recommendations were given to adjust or order new medications, it was sent to the Director of Nursing and the Psychotropic Nurse to enter into the electronic health record, because consent is required prior to administering the medication. This practice was confirmed by V6 Director of Nursing on 7/8/24. V13 provided email documentation dated 6/6/24 sent to V6, the Assistant Director of Nursing and the Psychotropic Nurse which stated [R2]: increase [aripiprazole] from 10mg (every day) to 15mg (every day) (due to) psychotic (symptoms) that are causing distress. The facility provided psychotropic consents for lorazepam 2mg, duloxetine 120mg and apriprazole15mg which did not contain signatures from R2 or their representative. No consent was provided for olanzapine 15mg. Facility Policy PSYCHOTROPIC DRUG USE revised 1//21 states in part; General: The purpose is to promote the safe and effective use of psychotropic medications that are used in lowest possible dose and time frame and have indication for use that enhances the resident's quality of life. Guideline: Initiating the Use of Psychotropic Medications: 1. Prior to using any new Psychotropic medication, the staff will document the behaviors and any interventions that were attempted if appropriate. 3. The Health Care Provider/Psychiatrist may order psychotropic medications as indicated. 7. If an order is obtained for a Psychotropic Medication, the resident, family or POA must be informed of the risks and benefits of the medication. The facility must obtain an informed consent. If the family or significant other is not able to sign the consent, phone consent will be taken with by a nurse verifying the consent.

Based on observations, interviews, and record reviews, the facility failed to safely reposition a resident during direct resident care and failed to ensure supervision of residents with a history of aggression. This affected five of six residents reviewed (R3, R4, R7, R8, & R9) reviewed for supervision and safety. This failure resulted in R9 rolling from the bed while receiving incontinence care sustaining a laceration to the head and treated at the local hospital. The failure also resulted in R4 attacking R3 with a butter knife, and R8 throwing a walker and striking R7. Based on interview and record review the facility failed to follow their elopement policy by not contacting the local police for one resident. This affected one of three residents (R14) reviewed for resident safety. This failure resulted in R14 not returning from an independent community pass and the facility failed to notify the local police. Findings include: R9: On 4/2/24 at 1:00 PM, R9 was observed laying in bed. R9 was observed to have eyes open and is nonverbal. On 4/2/24, V18 (falls nurse) stated that all residents are assessed for their risk for falls upon admission and re-admission to this facility. V18 stated that staff will notify her if there is a resident fall incident. V18 stated that there is a falls binder at each nurses' station that identifies a resident's fall risk and interventions in place. V18 stated that she determines the root cause of the fall and reviews fall interventions currently in place and implements additional interventions as needed.V18 stated that R9 had a fall incident while receiving care. V18 stated that V19 CNA (certified nurse aide) did not project enough space between V19 and R9's bed. V18 stated that there were two CNAs providing care at the time of the incident. V18 stated that R9 sustained a laceration to head requiring sutures. On 4/4/24, V19 CNA stated that she and V20 CNA were providing incontinence care to R9 at the time of the incident. V19 stated that she was positioned on the right side of the bed. V19 stated that she and V20 turned R9 onto his right side. V19 stated that she misjudged the amount of bed space between her and R9; V19 thought there was enough room for R9 to be turned. V19 stated that she attempted to hold onto R9, but was unable to prevent R9 from falling. V19 stated that R9 rolled on top of her and hit his head on the night stand next to bed. V19 stated that V20 ran and got R9's nurse. V19 stated that R9 is totally dependent on staff for all ADLs (activities of daily living). V19 stated that a mechanical lift device was used to get R9 back in bed after nurse assessed him for injuries. V19 stated that R9 was transported to the hospital for further evaluation. On 4/5/24, V31 LPN (licensed practical nurse) stated that V31 was R9's nurse at the time of the fall incident. V31 stated that there were two CNAs providing care to R9 at the time of incident. V31 stated that V31, a co-worker, and V3 DON (director of nursing) were present near R9's room at the time of the incident. V31 stated that V20 notified her that R9 fell . V31 stated that she and V3 went to R9's room immediately. V31 stated that R9 was laying on his side next to his bed. V31 stated that she performed a head to toe assessment and observed R9 with a mid to left forehead laceration. V31 stated that R9's vital signs were stable and there was no change in level of consciousness. V31 stated that compression was applied to stop bleeding. V31 stated that R9 is unable to communicate due to his history of stroke. V31 stated that R9 did not grimace with pain upon palpation. V31 stated that the mechanical lift device was used to lift R9 into bed. V31 stated that R9 was transported to the hospital via EMS (emergency medical services) 911 for further evaluation. V31 stated that R9 returned to this facility later same day with sutures to forehead. On 4/9/24 at 4:26 PM, V20 CNA stated that he was called to assist V19 CNA with providing incontinence care to R9. V20 stated that he was standing on the side of the bed closest to the window (left side of bed). V20 stated that V19 CNA was standing on the right side of bed. V20 stated that they rolled R9 onto his right side and R9 continued to roll out of bed. V20 stated that V19 CNA attempted to catch R9, but was unsuccessful. V20 stated that R9 hit his head on the nightstand before landing on top of V19 CNA. V20 stated that he immediately looked outside R9's room and called for assistance. V20 stated that V31 LPN came to the room and he assisted V31 with rolling R9 off of V19 CNA and placing sling under R9. V20 stated that V31 assessed R9 and then R9 was lifted onto bed using the mechanical lift device. On 4/10/24 at 12:50 PM, V3 DON (director of nursing) stated that she was present on the nursing unit at the time of R9's fall incident. V3 stated that she responded with V31 LPN to R9's room. V3 stated that upon entering R9's room, R9 was observed laying on top of V19. R9 sustained a laceration to forehead. V3 stated that when R9 was being turned onto right side, V19 was unable to stabilize R9 on his side and R9 rolled out of bed. R9's ADL care plan, initiated 5/19/2020, notes R9 has an ADL performance deficit and impaired mobility related to paraplegia, gastrostomy tube, and tracheostomy. It notes R9 requires two staff participation to reposition and turn in bed. R9 has a self care deficit needing total assistance with all ADLs. R9's falls care plan, initiated 6/27/2019, notes R9 is at high risk for falls related to poor trunk control, paraplegia, and seizures. R3 and R4: On 3/29/24 at 1:10pm, R3 was assessed to be alert and oriented x 3. R3 stated that his previous roommate, R4, and he got into a verbal altercation over the volume of the television. R3 stated that R4 then picked up a butter knife and was swinging it at R3. R3 stated that R4 cut him on his head with the butter knife. R3 stated that he informed V24 (former administrator) of this incident. R3 stated that he and R4 were separated. R3 stated that he went to the dining area and R4 remained in R3 and R4's room until R4 was transported to the hospital for psychiatric evaluation. R3 stated that he informed his case manager of this incident on 7/26/23 and she reported it to facility. R3's BIMS (brief interview of mental status) score, dated 3/5/24, notes R3's score is 15 out of 15. R3 is cognitively intact and able to make needs known. This facility's investigation of the allegation of physical abuse involving R3 and R4, dated 7/26/23, notes R3 reported the incident involving R4 to his case manager on 7/26/23. R3 reported that he had a disagreement some months ago with his previous roommate, R4, regarding the volume of the television. During this disagreement R4 attempted to stab him. R3 stated that staff immediately separated both residents. Police were notified. V27 (former ADON - assistant director of nursing) was interviewed on 7/26/23. V27 stated she was made aware of the disagreement between R3 and R4 on 5/1/23. V27 stated when she arrived on the nursing unit, the residents were separated. R4 in room being monitored and R3 went to the common area. V27 stated R4 was delusional and not re-directable at that time. R4 went to hospital for psychiatric evaluation. V44 (agency nurse) was interviewed. V44 heard R3 yelling in his room 'R4 is stabbing me'. The report V44 gave to the emergency department was she was sending R4 out for aggressive behavior towards roommate, R3, and needed evaluation. The butter knife scraped R3 when she did the skin assessment. On 5/1/23 at 6:15 PM, R4 was petitioned out by V27 (former ADON) and V28 (former DON). R4's medical record notes the following: On 4/12/23 at 4:35 PM, V45 (former social services) notes V45 witnessed R4 expressing delusions and attempting to be aggressive with another resident. V45 re-directed R4, counseled on behavior and made staff aware. Staff will monitor for aggressive actions. On 5/1/23 at 6:39pm, V28 (former DON - director of nursing) noted R3 had dispute with roommate, R4, related to the volume of the television in the room. Staff responded to the dispute and separated the two residents. R4 received medication for agitation. Order received for R4 to be transported to hospital for psychiatric evaluation. Well-being check was conducted on R3. R3 currently in dining room watching television. On 5/8/23 R4 readmitted to facility. R4 and roommate, R3, not getting along and R4 requested a new room. Placed in room on another nursing unit temporarily until morning staff can change room. On 5/11/23 at 6:32 AM, V47 NP (nurse practitioner) noted per staff, R4 is a re-admit after becoming aggressive with staff and residents. He was sent out on a psychiatric evaluation and came back on more medications. R4 had to change room assignments on his first night back, 5/8, after becoming aggressive towards roommate (R3). R4's hospital record, dated 5/2/23-5/8/23, the psychiatric physician noted R4 with a long-standing history of very poorly controlled bipolar disorder and delirium. R4 presented to the emergency department on 5/1/23 after R4 grabbed a knife and threatened R3 with it. The facility feels R4 is in danger of hurting someone. R4 has a low threshold for confrontational behavior. R4's care plan for the presence of abuse and neglect factors, initiated 9/24/2020, notes R4 presents with a host of medical problems and psychiatric history. R4 presents with a risk for becoming a perpetrator of abuse. R4 is known to become upset/agitated and requires medication management and supervision/attention on the unit. R4's behavior symptoms/inappropriate boundaries care plan, initiated 2/3/2023, notes R4 has threatened physical aggression toward peers. R4's history of aggressive/inappropriate behavior care plan, initiated 9/24/2020, notes R4 has a history of aggressive, inappropriate, and/or maladaptive behavior. R4 has history of conflicts/altercations with others, exhibiting delusional behaviors toward others, and acting erratically. R7 and R8: On 4/2/24 at 1:15 PM, R7 was assessed to be alert and oriented x 3. R7 stated that R8 came to his room and began yelling at him. R7 stated that R8 then picked up his walker and threw it at R7. R7 stated that he raised his arms to block the walker from hitting him. R7 stated that the walker hit his left arm causing bruising. R7 denied any staff member being in R7's room at the time of this incident. R7 stated that he informed the V24 (former administrator) of the incident. The facility's abuse investigation, dated 8/6/23 at 6:55pm, notes R7 reported to V40 (manager on duty) that R8 entered his room and allegedly stated to R7 mind your f***ing business, you are always in my f***ing business and flung his walker at R7. R7 assessed and observed to have bruise to left arm. X-ray ordered. R8 was sent to the hospital for psychiatric evaluation. R8 placed on 1:1 monitoring until transported to hospital. R7 interview noted R7 was sitting on edge of bed with R7's walker in front of him. R8 picked up walker and threw it, R7 raised left arm to block walker causing bruise on left arm. CNA (certified nurse aide) in room at time of incident and responded immediately to separate residents. V32 CNA was interviewed at the time of this incident. V32 stated that he was in R7's room behind privacy curtain. V32 stated that he heard residents yelling at each other. V32 stated that he did not hear what they were saying. V32 denied witnessing R8 throw walker at R7. V39 (agency nurse) was interviewed at the time of this incident. V39 stated that she did not witness the alleged occurrence. V39 stated that she was informed that both residents were hollering at each other and it was a verbal disagreement. R7 reported incident to V40 during her rounds and V40 reported incident to V39. R7's medical records, dated 8/6/23 at 6:41 PM, V39 (agency nurse) noted V39 made aware by R7 that he was in a verbal altercation with R8 and stated that the R8 threw his walker at me. Head to toe assessment completed for injuries, dark red bruising and small skin tear with scant bleeding noted to the left lower arm. As needed acetaminophen given as ordered for comfort. Skin tear cleaned with normal saline solution and bacitracin ointment applied. Physician on call made aware and ordered for urgent x-ray for the lower left arm. R8's history of aggressive/inappropriate behavior care plan notes R8 has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior by becoming easily agitated and exhibiting poor impulse control, as evidenced by exhibiting with covert/open conflict, general intolerance and limited ability to deal with frustration and a history of substance abuse. R8's mood distress-conflict with other persons care plan, notes R8 displays conflictual, difficult behavior with peers and staff. R8 exhibits a difficult time adjusting to life in the long-term care facility, complaints/concerns about other residents, general intolerance and limited ability to deal with frustration and a history of substance abuse. 39340 R14 R14 was admitted to the facility on [DATE] with a diagnosis of cocaine dependence, schizophrenia, major depressive disorder, panic disorder, and depression. R14's brief interview for mental status score documents a score of 14/15 which indicates cognitively intact. R14's progress notes dated 10/15/23 at 10:47PM: R14 went out on pass and did not return at scheduled time. Writer and receptionist attempted to call patient and phone going straight to voicemail and unable to leave message. V42(MD), V22(previous DON) and V24 (administrator) made aware. There was no other notes on 10/15/23 documenting resident out on pass or any other details. On 4/9/24 at 4:01pm, V43(nurse)said when a resident does not return from pass, staff would call resident, family, police, management. V43 said she recall calling V24(former administrator) and she reported that R14 had done this before and not to call the police. V24 said they would handle the situation. V43 does not recall anyone saying the resident left against medical advice. R14's progress notes dated 10/16/23 at 6:06AM: The resident has not returned to the facility from being out on pass. Local hospital and emergency contacts were contacted by writer but no answer. There were no other progress notes documented in R14's medical record until 10/24/23. R14's progress notes dated 10/24/23 at 10:56AM: Writer attempted to contact emergency contacts on file in attempt to gather an update on resident. Writer unable to make contact or gather any information. Writer then proceeded to contact the V36(NP) letting her know that resident is still not back from being on independent pass and was given the directive to contact the police. Administration notified and verbalized that resident signed a release of responsibility form prior to leaving the facility and that there is no need to contact the local police. Resident was Alert and oriented x3 prior to leaving facility per staff. V36(NP) notified and in agreeance with carried out protocol. On 4/5/24 at 3:10Pm, V36(NP) said she was notified of the resident not returning from pass but unsure of the date called . She gave the initial order to call the police but after discussion with Director of nursing and administrator at that time they said the resident signed a responsibility for self paperwork prior to leaving and there was no need to call the police. If paperwork was not signed I would expect the facility to contact the police for a resident in case they are missing. On 4/10/24 at 10:36AM, V2(Assistant administrator) said that when residents leave on pass they sign a release of responsibility form. If a resident does not return, staff will attempt to call resident, family, hospitals, police and filing a missing person report within 24 hours of not returning. V2 was asked why the police were not contacted for R14 and said because R14 had contact with V24(Administrator) and expressed he was not going to return. V2 said that the information should be documented but it was a personal situation with V24(Administrator) and V24 was handling this situation. On 4/10/24 at 1:00PM, V1(Administrator) said they have no other documents related to R14. R14 said the release form is the same form former facility would have been utilizing and are unable to provide this document for R14. On 4/10/24 at 1:44PM, V24(former administrator) said if a resident does not return from pass, facility would attempt to reach out to resident, family, try to search area and contact the police to assist with the search. Due to R14's history of not returning from pass, he was considered leaving against medical advice and the police were not contacted. V24 said if the V36(NP) instructed staff to contact the police they should have been contacted. V24 was unable to answer why there was no other documentation from 10/16/23 to 10/24/23 in regards to R14. V24 said she was unaware of R14 whereabouts or location and did not have any contact with R14 after him not returning from pass.V24 was asked how did they determine the resident left against medical advice versus was not harmed while out of the facility. V24 said that she was new to facility and facility tried to locate R14. V24 said she reached out to R14 family and due to history of not returning he was considered leaving against medical advice. Facility elopement policy reviewed 8/1/23 documents: Facility intends to establish an organized approach to search for a resident who is potentially missing to ensure that if a resident is found to be missing that the appropriate authorities are notified. If search of rooms and grounds fail the following will be initiated: notify the police.

Based on interview and record review, the facility failed to protect a cognitively impaired resident from physical abuse from another resident with history of violent/criminal behavior. This failure affected one (R9) of 5 residents reviewed for abuse from the sampleof 29 residents This failure resulted in R9 falling to the ground after being violently pushed/assaulted by R10. R9 was emergently transferred to the hospital for her injuries of a femur fracture and with required pain management and surgical intervention. Findings include: R9 is a [AGE] year old resident with diagnoses listed in part with mild cognitive impairment, heart disease, hypertension, and fracture of the femur. R9's care plan dated 2/11/23 reads, Presence of abuse and neglect factors. The resident presents with a difficult or troubled past secondary to severe mental illness. (R9) presents with risk factors related to acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history and present mental health symptoms. The resident presents with behavioral symptoms including: (not listed) and may minimize his/her/my mental health and psychosocial issues. Goal: The resident will be treated with respect, dignity and reside in the facility free of mistreatment. Interventions: Conduct appropriate assessments to promote knowledge and understanding of the resident's past; Provide reassurance to the resident reminded him/her that he/she is safe and secure. On 5/22/23 at 11:50 AM, R9 was interviewed in her room and asked what happened to her, R9 stated, I was attacked by someone, I don't know who did it. Surveyor asked how she was feeling, R9 stated, I'm tired and want to get out the heck out of here. Can you take me home? Surveyor asked whether she could recall how she was hit, R9 stated, It was somebody out there (pointing outside the door). On 5/22/23 AT 12:00 PM resident (R10) observed in bed in fetal position, knocked on door and resident (R10) started swearing at surveyor to get the Fu*k out of the room. R10's care plan dated 12/29/22 reads, in all caps: HISTORY OF CRIMINAL BEHAVIOR / IDENTIFIED OFFENDER. The resident has a history of criminal behavior. The resident has demonstrated stability during the admission screening process, does not appear to present an unusual risk, and is therefore considered appropriate for admission. Has been arrested and convicted of a crime(s): Criminal Trespass to vehicle in 2001. She is identified as moderate risk. The resident will behave in a safe manner consistent with resident conduct policies through the next review. Refer the resident to a mental health professional including a consulting psychiatrist for evaluation if the resident's symptoms warrant further assessment and/or on-going management. Refer the resident for psychotherapy, as indicated. Give psycho-active medication as ordered. Record behavioral symptoms and side effects. Hospital records for R10 from the most recent hospitalization dated 7/27/22 reads in part, (R10) Patient with what appears to be stepwise decline in ADLs, in addition to increasing mood lability and behavioral agitation concerning for safety of self or others. Some of the behaviors noted by family prior to admission include run into traffic, running out of the apartment building, or posturing were making verbal threats when she does not get what she wants. During the hospitalization , patient with new baseline of significant aphasia and dysarthric speech with short phrases only.She is fixated on food and needs frequent toileting. She has significantly low threshold for agitation, and has had multiple episodes of behavioral disturbances such as running out of the room, screaming without apparent needs. She also declined care from primary team such as obtaining vitals or necessary labs/imaging. She was initially also difficult to redirect, requiring multiple as needed's that psychiatry had recommended for agitation, requiring vest restraint and security presence. Facility reported incident dated 4/22/23 written by V1 (administrator) shows in part (R9) walked into (R10) room and (R10) allegedly pushed her. Resident sent out for evaluation. MD and family notified. V3 (Agency LPN) wrote in a statement on the report: (R9) was leaving out of another resident's room and proceeded to walk in the hallway and fell . She fell on her left side. After assessing her, she complained of pain on her left elbow. She denied pain in any other part of body. I called 911 to send her to hospital for evaluation. Vitals were stable when paramedic left the facility. Interview with V3 (Agency LPN) on 5/14/23 at 2:00 PM stated, I didn't really see the actual fall happen, I just saw her already on the ground. Surveyor asked again to clarify whether she witnessed the altercation between the two residents, V3 stated, I did not. Surveyor asked whether R10 had any history of violent behavior or whether R9 and R10 should have been monitored, V3 stated, No one told me anything about either of these residents. I don't normally work there, I'm agency and I haven't worked back there ever since that incident. Progress notes written by V3 (Agency LPN) on 4/22/23 at 7:17 PM contradicts her interview and written statement and reads, Patient was in another residents room when resident pushed patient in back to get her out of her room. Patient landed on knees then laid on floor and turned her left arm while laying on floor and sustained abrasion to left elbow, cleaned and dry, bandaged. Patient states she wants to go to hospital says she cant get up off the floor. 911 called. en route. vital signs. Paramedics here, transporting to hospital ER follow up with admit diagnosis. Progress notes written by V37 (agency LPN) on 4/25/23, reads in part, 6:10 PM, Patient was transferred from hospital by ambulance via stretcher. Patient is a [AGE] year old female with past medical history: CAD, hypertension, type 2 diabetes, dementia, and recurrent urinary tract infection. Patient had a fall which she was admitted with acute mild displaced intertrochanteric fracture of proximal left femur. Patient noted with 5 staples intact to left femur and 4 more staples going down 2 centimeters to left hip. On 4/22/2023 at 14:29, V23 (Social Service Director) wrote, Social Service Note. Writer was made aware that (R10) became physically aggressive with peer (R9) when they wandered into her room. Writer met with her to counsel her on appropriate ways of dealing with issues. (R10) She expressed understanding. Staff will continue to monitor for aggression. V3 (Agency LPN) wrote in her statement to the facility (R9) was leaving out of another resident's room and proceeded to walk in the hallway and fell . She fell on her left side. After assessing her, she complained of pain on her left elbow. She denied pain in any other part of body. I called 911 to send her to hospital for evaluation. Vitals were stable when paramedic left the facility. Interview with V3 (Agency LPN) on 5/14/23 at 2:00 PM stated, I didn't really see the altercation or actual fall happen, I just saw her already on the ground. Surveyor asked again to clarify whether she witnessed the altercation between the two residents, V3 stated, I did not. R9's hospital records shows in part: Date of admission: 4/22/23. (R9) is a [AGE] year old female with primary medical history of CAD, hypertension, type 2 diabetes, dementia, who presented from the facility after a fall. History obtained from nurse at facility, son at bedside and patient. Patient reports that she had a fall and hence was brought to the Emergency Department. Per son, patient has history of multiple falls and she was walking when she had a fall. She denies hitting her head, but after the fall complained of left hip pain and hence brought here. Emergency Department course: X-Ray of hip showed intertrochanteric fracture of proximal left femur. Underwent open reduction and internal fixation of left hip fracture with cephalomedullary nail. Day 1 post op, on physical exam left lower extremity is edematous and tender. Facility policy titled Abuse and Neglect dated 10/24/22 reads in part: Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, other residents, state employers, family members, volunteers, students in an affiliated Nurse-training Program, students in affiliated academic institutions including therapy, social, and activity programs, guardian and other visitors. The general examples of physical altercations below illustrate possible cases that would likely NOT need to be reported, as long as it is not a willful action that results in physical injury, mental anguish, or pain per the new SOM: A resident lightly taps another resident to stop an irritating behavior or get attention, with no resulting physical injury, mental anguish, or pain. A resident who is slow, impedes the pathway of another resident, such as in the dining room, the other resident nudges the resident out of the way to get to his/her table faster, but there is no harm to the victim. A resident who swats at another resident who is trying to take some food off his/her plate, and no physical injury, mental anguish, or pain has occurred.

Based on record review and interview the facility failed to address a resident pain post fall for 1 of 1 resident (R5) reviewed for falls. As a result, the resident remained in pain for 8 hours after having multiple fractures post fall and was transferred to the hospital for treatment. Findings include: Reviewed fall list for last 6 months, R5 was not listed. Incident Summary dated 11/6/2022 00:15 showed resident was observed on the floor laying on her right side near the bathroom next to her bed. Complete body assessment given, no discoloration or skin tears noted at this time all skin is intact. Writer asked resident what happened, and she stated, I don't know I was leaving the bathroom and I just fell . Writer asked resident did she hit her head resident stated, No I did not hit my head. Resident was assisted into bed via staff. Resident stated she is experiencing pain in her right hip and right knee rating the pain on a 0-10 scale a 7. Progress Note dated 11/6/2022 00:21 showed: MD made aware of incident new order for STAT x-ray to the right knee and right hip per MD orders carried out. All stat portable phoned and STAT x-ray to the right hip and right knee scheduled for 11/6/22 morning, confirmation #236376730. Care dated 11/04/2022 showed R5 is a risk for falls. Fall risk assessment dated [DATE] showed score of 11 indicating she is a high fall risk. On 02/18/2023, R5's daughter was called at 11:33 AM by surveyor to inquire if facility contacts family after any incidents. No answer, message left. She called facility back at 12:00 PM and said she was notified of R5's fall and said at approximately 2 am on 11/06/2022, I called facility back and spoke with an agency nurse who said mom was given pain med and x-ray tech was on their way to the facility. I came into facility at 10 am, and mom was lying in bed, crying and said, they are lying, they're not doing anything to help me, and get me out of here, I'm in pain. R5 had not yet received an x-ray. I then said either you call 911 or I will. R5's daughter then said the agency nurse said she didn't know what to do and started calling to different floors. Finally, some facility staff came and showed her what to do and the agency nurse made the call to 911. R5's daughter also said that the agency nurse said they offered pain med (Tylenol) but R5 refused it then said the facility was not trying to do anything for her mother. R5 was admitted to hospital with multiple fractures to right lower extremity and did not re-admit to the facility. On 02/17/2023 at 3:38 PM, When asked how many staffing agencies are utilized, V3 said quite a bit and facility is trying to recruit nurses but it's been hard getting staff in here. V3 added new agency staff are given a quick rundown, plus there are agency binders with policies, how to use PCC (point click care), risk management, admission, order entry, important phone numbers, extensions, and infection control policy and procedures located at every nursing station. When asked what is done if there's a complaint regarding agency staff, V3 (Director of Nursing) said if it's a customer service complaint, they investigate and talk to the resident and staff. She continued saying if it's a poor customer service, safety concern, attitude, or affects mental well-being, they are DNR'd (do not return). On 2/18/2023 at 12:29 PM, V3 (Director of Nursing) unable to locate documentation of when portable x-ray came to facility and performed x-ray on R5. At 12:57 PM, V3 said she called diagnostic provider and was told they didn't have a tech that morning and facility does not use any other company. V3 added that R5 did not receive an x-ray until she was sent out to the hospital. When asked if the facility should have followed up with their diagnostic provider on day of incident rather then current date, V3 said yes. On 02/19/2022, reviewed incident reporting policy last revised 07/28/2022 that showed process of reporting to IDPH only. Reviewed fall occurrence policy last revised 05/17/2022 which indicated no process of notifying family or providing emergent care.

Based on interview, observation and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure affected 2 of 3 residents (R7, R6) both reviewed for pain management. This failure resulted in (R7) who was admitted following a surgical amputation being without pain medication for over 24 hours and reporting pain 8/10, and (R6) being without scheduled pain medications for 5 days with complaints of pain 7/10 in her back. Findings include: 1. R7 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Disc degeneration, [CONDITION(S)], acquired absence of right and left toes. On 6/14/22 at 2:55PM, R7 reported to surveyor pain 8/10 in bilateral feet. R7 said he has been without his pain medication for 24 hours. R7's medication administration details documents R7 received [MEDICATION(S)] on 6/13/22 at 8:54Am. There is no documentation of any pain medication received after that administration. On 6/14/22 at 300PM, R7's [MEDICATION(S)] medication was not available on the medication cart. On 6/17/22 at 133pm, observation of facility convenience box observed R7's [MEDICATION(S)] available for use. V4 (ADON) said that agency nurses do not have access to emergency box medications and would not be able to utilize it for medications not available. R7 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's care plan dated 6/10/22 documents R7 is at risk for pain related to [CONDITION(S)], posterior neck excoriation and transmetarsal amputation. Interventions dated 6/10/22 documents: I would like the staff to monitor/report to nurse any nonverbal signs/symptoms of pain or requests for pain treatment. R7's pharmacy notes dated 6/21/22 documents on 6/14/22 at 329PM, refill requested over the phone at 6/15/22 1243AM, 3 tablets were delivered. Facility Pain policy revised 7/28/21 documents: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. Under procedures: upon admission or readmission, the nurse will assess resident for pain. For those identified with pain upon admission, the nurse will assess for pain. For those identified with pain upon admission/readmission assessment, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident physician will be called to refer the lack of relief. Facility physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility shall ensure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. R6 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/22 at 3:10Pm, R6 said she was having back pain 7/10. R6 said she has been without pain medications for a few days because they need a prescription. R6 medication administration note for [MEDICATION(S)] 30mg document: 6/11/22 at 00:34 awaiting arrival from pharmacy; on 6/11/22 at 5:48 awaiting arrival from pharmacy; 6/12/22 at 12:25 needs prescription; 6/12/22 at 18:30 medication on order; 6/13/22 at 13:15 medication unavailable; 6/13/22 22:37 unavailable; 6/14/22 21:51 medication on order. R6's controlled drug administration sheet for [MEDICATION(S)] 30mg documents: last dose of medication was given on 6/10/22 at 1700. R6's care plan initiated 5/2/2022 documents: R6 is at risk for pain related to diabetes and generalized pain. Interventions initiated 5/2/22 document: R6 would like to receive pain relief upon request R6 pharmacy note documents a prescription for [MEDICATION(S)] was received on 6/14/22 and medication was delivered on 6/15/22 at 1243am. Pain policy revised 7/28/21 documents: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. Under procedures: upon admission or readmission, the nurse will assess resident for pain. For those identified with pain upon admission, the nurse will assess for pain. For those identified with pain upon admission/readmission assessment, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident physician will be called to refer the lack of relief. Facility physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility shall ensure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review that facility failed to implement effective fall prevention interventions to include monitoring/supervision to prevent or reduce the risk of falling for a resident identified to be high risk for falls. This affected 1 of 3 residents (R2) reviewed for falls This failure resulted in R2 falling in the dining room when staff was not looking, and R2 required hospitalization for a new brain bleed. Findings Include: R2 is a [AGE] year old with the following diagnosis: traumatic hemorrhage of the cerebrum, unsteadiness on feet, abnormalities of gait and mobility, [CONDITION(S)] following a cerebral infarction, and history of falls. R2 admitted to the facility on [DATE]. A Nursing note dated 4/9/22 documents at 9:35 AM, V8 found R2 on the floor flat on R2's back in the dining room, crying, saying R2's head hurt. R2 was unable to give a description of what happened prior to the fall. R2 is at baseline cognitive status. There was a new order to send R2 out of emergency room for evaluation. V8 contacted the hospital later that day and learned R2 was admitted to a different hospital in the neuro intensive care unit with a diagnosis of new intracranial hemorrhage. The Fall Event dated 4/9/22 documents at 9:35 AM, V8 found R2 on the floor in the dining room saying, my head hurts. V8 asked R2 what happened and R2 was unable to answer per baseline. There was a new order to send R2 to the ER for an evaluation. At the time of the fall R2 is alert and oriented to self only. The predisposing physiological factors are documented as confused, cognitive impairment, and impaired memory. The predisposing situation factor is documented as ambulating without assistance. The Facility Incident Report dated 4/15/22 documents R2 was noted on the floor in the dining room lying on R2's back next to R2's chair. R2 was unable to tell what happened, when asked if anything hurt R2 reported R2's head hurt. No visible injuries were noted and R2 was sent to the emergency room for an evaluation. Later that day the facility was notified by the hospital that R2 was admitted due to intracranial hemorrhage. The care plan will be updated once R2 returns to the facility. The Hospital Records dated 4/9/22 documents R2 presented to the emergency room with an unwitnessed fall at the nursing home. There is no visible trauma. Per the paramedics R2 was found on the floor. The physical exam shows R2's pupils are equal, constricted but responsive to light. The CT of the head shows a previously diagnosed left arteriovenous malformation brain bleed. There is a new area of 1.7 cm acute hemorrhage adjacent to the superior margin left brain bleed [CONDITION(S)]. A left to right midline shift measures approximately 0.5 cm. Previously measured 0.3 to 0.4 cm. Neurosurgery was consulted for new brain bleed. R2 will be transferred to a different hospital for a higher level of care. R2's diagnoses are fall and intracranial hemorrhage. On 5/5/22 at 2:40 PM, V4 (CNA), stated R2 couldn't talk and R2 stumbles a lot. That's what R2's wife told me. She also told me that the other nursing homes where R2 was at R2 was falling a lot. R2 was a former police officer so R2 would have a behavior of getting up and trying to search for an offender. Sometimes R2 would have the strength to stand all the way up but R2 would immediately sit back down because R2 couldn't stand that long. R2 was in a Geri chair. It was around 830 or 930 and I was sitting with R2 in the dining room. I was sitting right next to him. R2 was telling me that R2 was arresting someone. I heard another resident screaming down the hall that she wanted to get up. I turned and I told the nurse that I was going to start getting other people up for breakfast and I left the dining room. The nurse knew I was leaving. When I was coming out of that room people were telling me that R2 had fell . R2 was a High fall risk. R2 was high risk because R2 always tried to get up but R2 couldn't walk and R2's cognition was not there. R2 couldn't follow any directions from us. The only one that could get R2 to listen was R2's wife. For High fall risk people we do a lot of activities and watch TV in the dining room, eat snacks, and just keep them busy. If they keep trying to stand up and aren't listening and then we usually have two people try to walk up and down the halls with them to burn some energy. We couldn't leave R2 unattended. R2 was too much of a fall risk because R2 was so unsteady and couldn't listen. On 5/5/22 at 3:19 PM, V7 (Fall Coordinator) stated, From my interviews I found out R2 was in the dining room and was being watched by the CNA (V4). The CNA got up and R2 was then watched by the nurse (V8). I was told the nurse looked down for a second and when V8 turned back around R2 was on the floor. I don't know if R2 was getting up himself or if R2 fell over the side of the chair. I know the nurse said she asked R2 one time to sit back down in the chair. She was prepping medications for another resident. R2 was High fall risk when R2 first came in because of R2's medical diagnosis and unsteady gait. We put in place a low bed, locking his furniture, and having his belongings near him. His orientation was off and on. During the time of the fall, R2 was confused. R2 did have a previous brain bleed and the hospital was trying to figure out if there was a new one or not. High fall risk residents are rounded on every two hours, and if we find out they fall while we are still monitoring them then we put on a bed or chair alarm. These kinds of residents should not be left unattended. That is why they are a fall risk. R2 was very impulsive due to R2's diagnosis of a brain mass. On 5/5/22 at 3:39PM, V8 (Nurse) stated, R2 was a High fall risk. R2 had a one to one assist and was put in the dining room. The CNA left to go take care of someone else and told me to watch R2. I moved my med cart over closer to R2 to watch R2. No, I was not right next to R2. I turned my head to give meds to another resident and when I turned back around R2 was on the ground. I didn't see how R2 fell . R2 kept trying to stand up that morning and R2 was really confused. R2 could follow some directions that were basic. R2 kept trying to get up to go home. No, I never went closer to R2 when R2 was getting up. R2 had a very unsteady gait. R2 was a high fall risk because of R2's unsteady gait. The High fall risk residents usually have a one to one or someone within closer reach so we can keep an eye them at all times. These type of residents we should never leave unattended. On 5/6/22 at 10:40AM, V9 (Director of Rehab) stated, R2 was completely dependent on function, very impulsive, and needed max queuing to complete a task. R2 could do things like stand up or transfer or walk but it was very hard for R2 to follow directions. R2 was in a Geri chair because it was safer than R2 being in a wheelchair. In those type of chairs, the legs can go up and the patient can lean back so there was a safety concern with R2 being in a regular wheelchair. In a regular wheelchair, R2 could just stand up and take steps by R2's self but in the Geri chair if the leg part was up then R2 could take longer to stand up before someone noticed R2. A lot of times in therapy we would see R2 getting up before R2 was given any direction. We educated R2 all the time, but we didn't notice R2 carrying any of the education over. R2 could physically stand up and maybe take a couple steps but R2 was very unsteady. This made R2 a High fall risk. R2 lacked severe safety awareness. R2 was a one to one during therapy because R2 needed someone to be so close to R2. On 5/6/22 at 2:30 PM, V11 (Primary Physician) stated, I know R2 had a history of a hemorrhagic stroke. R2 did have a brain bleed before the fall. This is why R2 had a baseline of being very confused. R2 having a stroke increases R2's risk of falls. These residents are usually not left unattended. I was called and was told the nurse was giving meds or something to another resident and when V8 turned back around R2 was on the floor. R2 was very confused so I can see that happening. For residents like R2, you need to do more closely monitoring but we can't keep an eye them 24 hours a day. The brain bleed R2 had previously was from the hemorrhaging stroke. If they found new ones on the CT scans at the hospital those could have been from the fall or they could possibly be a new hemorrhagic stroke. It's hard to tell. The Admission Hospital Records dated 3/21/22 documents R2 presented to the hospital with frequent falls and recently diagnosed brain bleed prior to this admission. Multiple falls have occurred at the nursing home R2 was staying at. The CT scan showed two left occipital arteriovenous malformations with surrounding [CONDITION(S)]. R2 is alert and oriented times 0 and does not follow commands. While in the hospital on 4/6/22, R2 attempted to get up and struck R2's head on the side rail of the bed with experienced transit loss of consciousness for about 30 seconds. An emergency CT scan of the head was ordered and did not show any acute intracranial hemorrhage. R2 was ready for discharge at this time. The Nursing - Admission/Readmission assessment dated [DATE] documents the fall risk score as a five for R2 (low risk). R2 is documented as being alert but confused and a barrier to education is cognitive impairment. R2's response to training is documented as needing practice and/or reinforcement. The Care Plan dated 4/7/22 documents R2 is at high risk for falls related to hypo/hyper glycemia , [CONDITION(S)], use of antipsychotic medication, and use of cardiovascular medication's. The following interventions were documented on 4/7/22: keep all needed items within reach, keypad in the lowest position for safety, keep furniture in locked position during transfers and nursing care, and make sure the call light is within reach and encourage use for assistance when needed. The intervention put in place after the fall is documented on 4/19/22 and is bed/chair alarm. The Fall Risk Evaluation dated 4/9/22 documents a score of a 17. Anything that is an 8 or above means the resident is at high risk for falls. R2 is documented as being a High fall risk due to medications, unsteady gait, and having a memory problem. The Care Plan dated 4/10/22 documents R2 as an adult with impaired cognitive function, poor environmental awareness, and has difficulty with decision making tasks, responsibilities, and reality. R2 was unable to recall the year, month, day of the week, and is not able to recall the words in the assessment. It is best to provide R2 with cueing, prompts, and reminders when R2 becomes distracted and to return our tools focus to completing the task at hand. The care plan does not document any interventions or plan for R2's impulsive behavior or lack of safety awareness. An Admission summary dated 4/19/22 documents R2 was admitted to the facility from the hospital after a fall causing a brain bleed. R2 is an extremely high fall risk and will need a bed alarm. A Nurse Practitioner note dated 4/20/22 documents R2 suffered a fall at the facility and was readmitted to the hospital on 4/9/22. R2 is diagnosed with a new intracranial hemorrhage adjacent to known ateriovenous malformation. R2 underwent a diagnostic cerebral angiogram with coil/nBCA embo of the left middle cerebral artery branches x 2 on 4/10/22. Once R2 was stabilized, he was discharged back to the facility for further care. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as a 3 (severe cognitive impairment). Section G of the MDS documents R2 needs extensive two person physical assist with transfers, R2 needs extensive one person physical assist with bed mobility, total dependence one person physical assist with locomotion on unit and walking in room activity only occurred once or twice. R2's balance is documented as not steady, only able to stabilize with staff assistance when moving from a seated to a standing position, walking, and service to service transfers. The Policy titled, Fall Occurrence, dated 7/28/21 documents, Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. Procedure: . 2. Those identified for high risk for falls will be provided interventions to prevent falls.

Based on observation, interview and record review the facility failed to develop a plan to prevent a continued insidious unplanned weight loss for 1 of 3 residents R1 reviewed for unplanned weight loss. This failure resulted in R1 having continued weight loss for 30 days resulting in a significant weight loss of 8.29% in less than 1 month. Findings include: On 1/11/2022 at 12:59pm V6 (R1 family) V6 said R1 has lost 50 plus pounds since being in the nursing home. V6 said V15 (Nurse) called her and informed her that R1 has orders for nutritional supplements but the facility is not giving them to R1. V6 said the facility informed her that R1 failed a swallow evaluation. V6 said during a meeting at the facility, she was informed her that R1 will be getting supplements but R1 is not getting them, and R1 should not have lost so much weight. R1 face sheet shows R1 was admitted to the facility on [DATE]. R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/2022 at 10:10am R1 was weighed by V3 (Restorative Aide) using a chair scale, R1 was observed to weigh 112.8 pounds. R1 weight verified with V2 (Director of Nursing). At 12:12pm V4 (CNA) was observed assisting R1 with eating lunch. R1 ate 2 spoons of the chicken and dumpling, R1 drank 100% of med pass in 7ounce cup, 50% of orange juice in 4 ounce container, R1 ate 90% of magic cup in 4 ounce cup, and 10% of cranberry drink in 4 ounce cup, and R1 drank half cup of thicken water in 7 ounce cup. Review of R1 weight record, it's documented that R1 weighed 123 pounds on 12/03/2021, 122.7 pounds on 12/10/2021, and 118.6 pounds on 12/17/21. R1 monitoring record shows R1 weighed 118.6 pounds on 12/27/2021, 188.6 pounds on 01/03/2022, and 118.6 pounds on 01/10/2022. Review of R1 Monitoring Record it is documented in-part that R1 weight 118 pounds on 01/10/2022 documented by V8 (Registered Nurse), and on 01/03/2022 it's documented by V10 (Nurse) that R1 weighed 118.6 pounds. On 1/12/2022 at 9:08am V8 said he does not have anything to do with the resident's weight, when prompt to input the resident weight in electronic medical records (EMR), he clicks the button and it uploads the weight from the last weight documented in the EMR. V8 said no one gave him the weight to put in for R1 on 1/10/2022, V8 said he did not weight R1 on 1/10/2022, V8 continued to say the weight was uploaded from the last weight in the electronic records. V8 demonstrated how he click the box when prompted to input the resident weekly weight. V8 said he was not aware that R1 experienced a weight loss. On 01/13/2022 at 11:48am V10 said she's not sure if she entered R1's the weight from the previous weight or if the V3 (restorative aide) gave her a current weight to enter in the EMR. V10 said the weekly weigh is an order and the resident should be weighed weekly. R1 had an 8.29% weight loss since 12/03/2021. R1 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Med pass 2.0 three times a day for nutritional supplements 90 milliliters TID (three times a day). R1 POS shows orders for weight monitor dated 07/08/2021. On 01/13/2022 at 12:19pm V2 said weekly weights are an order and the weights should completed weekly, V2 said the nurse should not pull the weight from a previously documented weight record. V2 said monthly weights are completed by the restorative aides and they have a schedule for the monthly weights, and weekly weights are completed by the certified nursing aides( CNA), and the nurse have to inform the CNAs of who needs a weekly weight. On 1/13/2021 at 12:39PM V2 (Director of Nursing) said she notified V11 (Physician) on 01/12/2022 at 10:59am that R1 had a weight lost and now weighs 112.8 pounds and V11 said okay, with no new orders. V2 said she did not inform the physician of any prior weigh history because the admission weigh was struck out and that was a mistake on her part, V2 said she should have reviewed R1 weight history with the physician. At 1:30pm V2 (Director of Nursing) said there were no restorative aide working on the 3rd floor on 01/03/2022, and the regular restorative aide was off duty on 01/03/2022. On 01/12/2022 at 5:00pm V11 (Physician) said he was not aware that R1 had a significant weight loss and that he will see R1 when he visit the facility on the weekend. On 01/13/2022 at 1:13pm V11 said the facility made him aware of R1's weight loss and he ordered [MEDICATION(S)] an appetite stimulant, a calorie count, and dietitian consult. Review of R1 POS dated 01/13/2022 time stamped 1:19p.m does not show orders for [MEDICATION(S)] or calorie count. On 01/13/22 at 12:13pm V3 said she did not work on 01/03/2022 and she did not give V10 a weight for R1 on 01/03/2021. On 01/13/2022 at 1:34p.m V12 (CNA) said she worked on the 3rd floor on 01/03/2022 and she did not weigh R1 on 01/03/2022, V12 said she did not give the nurse a weigh for R1. On 01/13/2022 at 1:12p.m V9 (CNA) said she worked on the 3rd floor on 01/03/2022 and she did not weigh R1 on 01/03/2022, V9 said she did not give the nurse a weigh for R1. On 1/13/21 at 8:30am V15 denied telling V6 that the facility is not giving R1 her nutritional supplements. Review of R1 plan of care with print date of 01/13/2022 time stamp of 1:21pm, with initiated date of 01/12/2022 shows actual weight loss, R1 has experienced weight loss and is at risk for continued weight loss. Has experienced progressive weight loss, Increased risk for dehydration and/or malnutrition related to: history of positive COVID-19 status, R1 will consume > 50% , R1 will experience no further weight loss by next assessment, Dietary health supplements, as ordered, Encourage and praise the resident's attempts to follow the prescribed diet, Follow Speech therapist recommendations, Sit at 90 degree angle, no straw, small bits and sips, alternate solids & liquids, slow rate of food presentation, Make a referral to the MD/Registered Dietitian if there is a 5% weight loss over 30 days, or a 10% weight loss over 180 days, Weight will be obtained as ordered by MD (Medical Doctor). R1 plan of care does not address the calorie count ordered by V11. R1 progress notes dated 12/23/21, Nutrition/Wt ( weight) Review- Diet-Mech (mechanical) soft, NTL, Supplement-Med pass 2.0 90ml tid ( three times a day) Meds reviewed. Wts-12/17 118.6# 12/10 122.7# 11/16 121# 11/1 115.8# 10/9 122.4# 8/18 125# 7/9 162#, Ht-64, BMI-20.4 underweight status d/t age Appetite-fair, varies, Skin-intact, Labs-no current wt (weight) decrease of 4.1 lbs (3.3%) x 1 week and 5.8% x 3 months. Question accuracy of adm (admission). Wt (weight) of 162 lbs? Wt (weight) loss possibly r/t variable appetite and dysphagia hx (history), per meal documentation: appetite fair (50-75%). Needs encouragement with meals. Med pass provides an additional 540kcals/22.5gm pro if 100% consumed. On mechanically altered diet d/t dysphagia hx (history). No [CONDITION(S)] noted. Diet and supplements exceeding estimated nutritional requirements. Suggest add magic cup with lunch and dinner for additional calories to prevent further wt loss, wkly ( weekly) wt x 4 weeks. Monitor wts, labs, skin, po (by mouth) intake. Review of R1's document survey report for nutrition schedule dated December 2021 shows nutrition- amount eaten, there are 9 entries out of 124 available entries for the percentage of the meal eaten for December 2021. In the nine entries R1 ate 26%-50% once, 51%-75% six times, and 76%-100% two times. Review of R1's document survey report for nutrition schedule dated January 2022 shows nutrition- amount eaten, there was 1 entries for Tuesday January 4th. The entry shows R1 ate 51%-75% once. The print date for the record was 01/12/2022 time is 11:53am. On 01/13/2022 at 11:26am V5 (Restorative Nurse) said point of care charting is basic care charting for activities of daily living, the charting shows care given, V5 said the point of care charting is drawn into the MDS (Minimum Data Set), the information is used to show decline or improvement in function. V5 said the information is used for reimbursement, therapy, dietitian use the information to see if the resident is able to feed themselves, V5 said the information in the point of care charting paint a complete picture of the resident level of care.V5 said the point of care charting shows the eating habits for a resident that maybe losing or gaining weight, it's first thing we go to address the resident intake. V5 said point of care charting should be filled out every shift, but it's not always able to go that way, V5 said she prefer the aides provide care over documentation, V5 said 01/11/2022 the aides had a very busy day on the morning and evening shift doing room changes, V5 said she does not expect the aides to complete the documentation the next day. V5 said she can only speak about 01/11/2022 date, and she cannot speak to any other missing documentation. R1 dietary evaluation dated 01/09/2022 shows mechanical soft, regular, nectar thick liquids, no fluid restrictions, supplements - med pass 2.0 TID, recent weight 118.6 (date 12/17/2021), height 64.0 ( date 07/09/2021) laying down, loss of 5% or more in the last month or loss of 10% or more in the last 6 months-NO or unknown. Loss of 7.5% or more in the last 3 months-NO or unknown. Gain of 5% or more in the last month or loss of 10% or more in the last 6 months-NO or unknown. Gain of 7.5% or more in the last 3 months-NO or unknown. Is there an insidious weight loss or gain during this assessment-yes. Weight loss x 1 month of about 3-4 # noted. BMI, ideal for BMI, Ideal body weight 120#+/- 10%, usual body weight 118-124#. List of medication- see POS, yes -resident has more than % medications, no known allergies, current eating pattern- none of the above observed, on average, what is the resident overall intake of all meals- intake 26-75% of meal, on average, what is the resident overall intake of fluids-1000-1499 ml daily, does resident have functional problems that affect his/her ability to eat- no, does resident have cognitive, mental status and behavior problems that can interfere with eating- no, does resident have any dental/ oral problems-no. Risk factors- [CONDITION(S)], hypertension, [CONDITION(S)], dysphagia. Estimated of calorie needs- 1432-1718 kcal (25-30/kg), estimate protein needs- 57.3-68.7 grams (0.1/1.2/kg), estimate of fluids needs 1 ml/kcal), resident receive their nutrition orally, does resident have any skin alteration-no. Summary conclusion- Question accuracy of admission weight of 162# (struck out weight). Weights stable but showing some fluctuations. Estimated needs recalculated using 126#: 1432-1718 kcals (25-30/kg), 57.3-68.7 gm pro (1.0/1.2/kg), fluid: 1 ml/kcal. Per chart review oral intake varies 50-75% 76%-100% and is fair overall. Current diet Mechanical Soft/NTL appropriate secondary to dysphagia. Skin intact. Goal: Maintain weight within 1-3#. Continue to monitor. Med Pass, 120 ml TID to supplement oral intake at meals and aid in weight goal- continue as ordered. Current weight stable with supplement in place and current intake, expect some fluctuations with weights d/t (due to) [CONDITION(S)]. Facility clinical guidelines for Nutrition screening and assessment policy dated 05/2021 shows in-part to determine the current nutritional status of the resident through screening and assessment, on admission or readmission to the facility, nursing will weigh the resident and take their height to begin the nutrition screening process. Nursing will record the height and weight into the medical record. Facility policy titled Medical Nutritional therapy-weight management no date noted shows in-part resident will be weighed once a month on a predetermined schedule unless physician has ordered weekly weights. Significant change may be defined as a gain or loss of 5% in 1 month, 7.5% in 3 months, and 10% in 6 months. The physician, director of nursing, dietary manager, and consulting dietitian will be notified of change in weight. Facility policy titled care plans with last revision date of 07/27/2021 shows it is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. On 01/12/2022 V14 (MDS Nurse) said care plans are individualized according to the residents needs and should be updated whenever there's a change in resident condition, it could be daily, quarterly and or annually. Facility policy titled Notification for change in condition with review dated 07/28/2021 shows in part the facility will provide care to residents and provide notifications of resident change in status. The facility must immediately inform the resident, consult with the resident physician and if known notify the resident legal representative or an interested family member when there is a significant change in the resident physical, mental or psychosocial status. Facility Charting and Documentation Nursing Guidelines dated 05/05/2021 shows in-part the facility will ensure that all services provided to the resident, or any changes in the resident medical or mental condition, will be documented in the resident records. All observations, medications administered, services performed etc., must be documented in the residents clinical records. Entries may be recorded in the resident's clinical record by licensed personnel (Rn, LPN/LVN, physicians, therapist etc.) in accordance with state law and facility policy. Certified Nursing Assistance may only make entries in the resident's medical chart as permitted by facility policy. On 01/12/2022 at 11:15am V13 (Clinical Director for next level/ contracted company that provide dietitian services and environmental services) said she was made aware on 01/11/2022 that R1 had a weight change, V13 said R1 is seen by the company dietitian on 01/09/2022 for evaluation, V13 said R1 initial admission weight was struck out by the dietitian and she suspects there was some discrepancies with the weight. V13 said it is best practice for the facility to get an accurate weight on the resident upon admission and when weighing the resident. V13 said but things happen and if there suspicion of an inaccurate weight, the resident can be weighed again. V13 said R1 was seen by the dietitian on 01/09/2022 and R1 weight was stable with 3-4 pounds of insidious weight loss. V13 said the dietitian looks at the records to gather information during the evaluation, the dietitian can interview the staff and if they can communicate with the resident to gather information if the resident is able to communicate. V13 said the resident treatment plan is based on the information that's gathered during the evaluation. V13 said inaccurate documentation will make it more difficult to make accurate recommendations. V13 said R1 weight appeared to be stable based on the records and there were no concerns for weight loss on 01/09/2022. V13 said it is not impossible for a resident lose 6 pounds in 1 day if they are on a water pill, V13 reviewed R1 record, and R1 is not on a water pill. V13 said it is documented that R1 family had concerns about weight lost on 12/1/21, and the dietitian discussed po (by mouth) intake with the nurse and the nurse agreed to begin cueing the resident to eat at meal times and make [NAME] resident consumes med pass. V13 said the dietitian suggest adding magic cup for lunch and dinner for additional calories to prevent further weight loss, weekly weights for 4 weeks, monitor weights, labs, skin, and po (by mouth) intake.

Based on observation, interview and record review, the facility failed to treat and provide care in a respectful and dignified manner for 2 of 4 residents (R1, R2) sampled residents. This failure resulted in R1 and R2 from being subjected to a facility staff member (V4)who demeaned the residents causing psychosocial harm to the residents. Findings include: 1. Facility face sheet dated 12/18/21 show R1 as an alert and orient [AGE] year old resident with diagnoses listed in part (but not limited to) congestive heart failure, diabetes, and pressure sores. On 12/18/21 at 10 AM, R1 was observed in bed dressed in a hospital gown and stated to surveyor, I called about what happened to me about 2 weeks ago. the assistant administrator (V2) knows about it because I told him the following day. When I came back from a doctor's appointment, it was after 5 PM, I sat in my wheelchair for several hours waiting in my room and I was in pain because I was sitting so long. I asked this C.N.A.(certified nurses aide) (V4) who I never saw before because she is from an agency to put me back in bed. She had a nasty attitude and she said I was needy or something like that. I could not believe she spoke to me that way and it offended me She kept talking back to me and said in a nasty tone, What do you want? I told her I just wanted to be put back to bed and she goes off and has this nasty attitude and then walks out so I sat longer in the chair. I was afraid to call her back because she had such a nasty attitude. When she eventually came back several hours later, She's got this angry tone again towards me like she hates what she's doing. It made me feel helpless (R1 becomes teary-eyed) and I don't want to be in the situation that I'm in but it made me more depressed and I got afraid that no one was going to come help me. When she came back she continued to argue with me. She (V4) said What do you want first to be put back to bed or to to talk to the nurse? It confused me because why can't I have both? Why did I have to choose between one or the other? So she puts me back in the bed and I asked her if she could hang my coat and then she snaps back and says that it wasn't her job and do it myself. Surveyor asked R1 if she informed her nurse, R1 stated, No I didn't tell the nurse because I didn't know who it was and like what this CNA. said to me, Which do I want, to be put back to bed or talk to the nurse. She (V4) was just arguing with me, so I waited until the next day to tell administration. I even had to sleep in my street clothes because I was afraid she (V4) would come back and snap back at me again. I just didn't want her back so I didn't call for anyone else. She was the same way towards my roommate (R2). Facility face sheet records dated 12/18/21 show R2 is an alert and oriented [AGE] year old with diagnoses listed in part (but not limited to): [CONDITION(S)], heart failure and diabetes. 2. On 12/18/21 at 10:15 AM surveyor turned to R1's roommate and asked about the incident in question, R2 stated, Yes that C.N.A was pretty rude to me too. She didn't say anything directly to me but she said something she mumbled before she left the room but I still heard what she said and she was complaining about us was what she was saying. I heard her say we were difficult and needy and she wasn't very nice to my roommate (R1). She was just talking back at her and all she just wanted was to be put back in bed I saw it all happen and she (R1) can't do that herself. I dont know why these people work here when they don't want to work (referring to V4). Surveyor asked how V4 made her feel, R2 stated, I was just upset that this place would allow someone with such a nasty attitude like that to work here with us. Did she think we can't hear her say what she said so that upset me a lot and made me feel I didn't matter. On 12/18/21 at 11;30 AM, V2 (Assistant Administrator) stated upon interview, There was one incident where there were several residents, one or two, who didn't like the attitude of a C.N.A. Those residents were (R1 and R2). (R1) said it happened the day after this agency C.N.A. worked. I didn't catch her (agency C.N.A.) name but she worked on the 3-11 PM shift. I spoke to the staffing scheduler (V11) and told her to keep her away from the facility or away from that unit because they didn't care for her. To my knowledge she didn't help them (R1, R2) again. I think she worked maybe one more time but I'm not sure. (R1) said when this C.N.A. came in to their room, she'd just roll her eyes and her posture was like her hands were just on her hips. I asked them what else and and that was pretty much it. I did not investigate it or report it to public health because I didn't think there was any abuse. There was never any concern or abuse that would suggest that. Surveyor asked if he probed further with the nurse that evening or any other residents who were assisted by this agency C.N.A., V2 stated, No, I didn't interview or ask anyone else because there was nothing else they complained about. Surveyor asked if he didn't interview the nurse or any other residents regarding this agency c.n.a.'s care, how he determined there was no abuse, V2 stated, I guess but I asked R1 and R2 several times if there was anything else and they didn't say anything. Surveyor asked whether this C.N.A. worked again, V2 stated, I can't recall but maybe one other time but to my knowledge she (V4) worked one more time on a different floor. I texted the scheduler and I told her that we have some concerns about agency C.N.A. last night. Surveyor asked if he spoke to (R2), V2 stated, I spoke to her and she had issues about her (V4)'s attitude too. Surveyor asked if two residents complained about a staff's attitude whether he could have probed further, V2 stated, I guess so but in the future that is what I will do. Surveyor asked who the nurse on duty was the night of the incident, V2 stated, I don't remember who the nurse was either. Surveyor clarified whether he was the abuse prohibition coordinator, V2 answered, Yes. On 12/18/21 at 11:45 AM V3 (director of nursing) stated upon interview, I remember that the C.N.A (certified nurses aide) was (V4) she is from the agency. The agency staff had a bad attitude when I talked to her. So I called the agency and had her on the do not return list. She (V4) also called the scheduler (V11) and asked why she was canceled for the following shift because she was supposed to work another floor. She may have worked 3 or 4 more times before but I have to confirm that with you. (V2-assistant administrator) never mentioned anything to me about any problems with her except that she had an attitude towards him too. I didn't hear anything about any problems with the residents she took care of though, he never told me that. +

Based on observation, interview, and record review, the facility failed to keep residents free from neglect by failing to prevent residents from developing facility-acquired pressure ulcers and once residents acquired the new pressure ulcers, the facility failed to have nursing staff that were fully trained and able to immediately assess and implement interventions to prevent the worsening of the facility-acquired pressure ulcers; the facility also failed to ensure that staff who were competent in providing wound care treatments were available to perform the treatments as ordered by the physician. This failure applied to three of three residents (R1, R7, and R8) reviewed for pressure ulcers and resulted in R1 obtaining two Stage 4 pressure ulcers to the right hip and right heel, one Stage 2 pressure ulcer to the left medial knee, and a deep tissue pressure injury to the left hip; R7 developed a new facility-acquired Stage 4 pressure ulcer to the upper left buttock; and R8 developed a new facility-acquired, unstageable pressure ulcer to the right ischium; furthermore the respective wounds were not initially identified until they were already at Stage 4. Findings include: R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to local hospital on 10/7/21 and is not currently in the facility. On 10/22/21, R1 was discharged from local hospital to a long-term acute care hospital. R1's Admission MDS (Minimum Data Set) assessment dated [DATE] documents the following: Section C - Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 9, which indicates moderately impaired cognition Section G - Functional Status: total dependence, requires 2+ persons physical assist Section H - Bladder and Bowel: Urinary and Bowel Continence as Always Incontinent Section K - Swallowing/Nutritional Status: Weight is 147 pounds and Height is 63 inches, with no/unknown weight loss or gain within the past month or six months Section M - Skin Conditions-(including history of a pressure ulcers or pressure injuries), and pressure relieving devices: (1) Stage 2 Pressure Ulcer present upon admission and (1) Stage 4 Pressure Ulcer present upon admission; Zero documented Stage 1, Stage 3, unstageable pressure ulcers, or deep tissue injuries upon admission. Braden Score (for predicting pressure ulcer risk) is 13, indicating Moderate Risk of developing pressure ulcers. Full body assessment dated [DATE] 14:42 completed by V20 (Previous Wound Care Nurse) documents (upon admission): 1) area noted to coccyx 9.0 x 5.0 3.0 moderate serous exudate, 100% granulation. 2) area noted left lateral 1.5 x 4.0 leg 25% granulation, 25% slough, 50% necrotic light serous exudate. 3) area noted right bunion 0.2 x 1.5 DTI 100% deep maroon no exudate. 4) area noted to right heel 5.5 x 5.0 100% necrotic no exudate. 5) right ischial tuberosity 3.5 x 3.5 100% necrotic light serous exudate. 6) area noted left heel 3.5 x 5.0 100% necrotic no exudate tx implemented, heel protectors to be on at all times resident denies pain or discomfort prn pain meds given as needed. Physician treatment orders for July 2021 include: 1) coccyx: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift; Start Date: 7/17/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) left heel: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 3) left lateral foot: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 4) right bunion: cleanse with nss skin prep Iota QD/PRN every day shift; Start Date: 7/17/21; D/C Date: 9/01/2021 No documentation as to why this order was discontinued. 5) right heel: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 6) right ischium: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift; Start Date: 7/17/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 7) Right, lateral ankle skin prep LOTA qd/pm every day shift; Start Date: 7/24/21; D/C Date: 9/01/2021; No documentation as to why this order was discontinued. Physician treatment orders for August 2021, included the same orders as July 2021 with the addition of: 1) Dakins (1/2 strength) Solution 0.25% (Sodium Hypochlorite) Apply to left Ischium topically every day shift for Wound Care Cleanse with NSS, Pat dry and apply Dakins soaked gauze and cover with dry dressing; Start Date: 8/26/21 Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) left, medial knee clean with nss, wound cleanser apply [MEDICATION(S)] MWF/pm every day shift every Mon, Wed, Fri; Start Date: 8/02/21; D/C Date: 9/01/2021; No documentation as to why this order was discontinued. 8) right, medial shin clean with nss, wound cleanser apply [MEDICATION(S)] MWF/pm every day shift every Mon, Wed, Fri; Start Date: 8/02/21; D/C Date: 8/30/2021; No documentation as to why this order was discontinued. Progress Note created by V5 (Wound Care Nurse) dated 9/13/2021 12:15 documents that resident was seen by wound nurse and wound specialist V11 (Wound Care Doctor), r/t wound located on Coccyx, Right Ischium Right Hip, Left heel, Left Distal Lateral Foot, Right Medial Heel, Right distal medial Foot. Wound Improvements are documented. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Right Distal Medial Foot: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift to promote wound healing; Start Date: 9/13/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) Right Hip: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift for wound care; Start Date: 9/13/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 Review of R1's medical record documents four new facility-acquired pressure wounds: 1) Assessment date: 7/30/21, Date Identified: 7/28/21, Stage 2, left medial knee, 1x1x.10cm 2) Assessment date: 10/6/21, Date Identified: 10/6/21, Deep Tissue Pressure Injury, left hip, 4x3.5cm x unknown depth 3) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right heel, 5x3.5cm x unknown depth 4) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right hip, 5.5x4.2x2cm There is no documentation in R1's medical record to show that the new, facility acquired wounds were identified/assessed prior to Date Identified as Stage 2 and Stage 4, per documentation. Review of physician treatment orders for October 2021 do not include any new treatment orders prior to R1's transfer to local hospital on 10/7/21. Review of R1's care plans includes: Focus: Incontinent of bowel and bladder puts her at risk for infection, alteration in skin and complications associated. Date Initiated: 7/15/21; Interventions: None listed Focus: RD suggests 8/25/21 - Suggest add med pass 2.0 120ml tid, prostat awc 30 ml daily for additional kcals/pro; wkly wt x 4 weeks; Intervention: Prepare/serve the resident's nutritional diet as ordered. Monitor intake and record q meal. Date Initiated: 7/21/21 Multiple focus areas related to skin breakdown and pressure ulcers include interventions all with Date Initiated: 7/16/2021 - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - If resident refuses treatment, confer with IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. - Monitor/document/report to MD PRN changes in skin status, appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. - Notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, discoloration noted during bath or daily care. - Assess/record/monitor wound healing (FREQ). Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Review of R1's medical record does not include documentation to show that there was any concern with regard to resident refusing treatment or other explanation for the multiple dates of missed wound treatments. R1's medical record shows that on 10/7/21, R1 was transferred to local hospital. Hospital record documents: inpatient wound care consult report reads: lumbar sacral spine and right buttock, 4cmX6cmX1cm wound bed with sloughing, wound to the right buttock is extensive and dominated entire buttock, and there is exposed bone. Wound base right buttock wound extends to bone: breakdown forms a cavity around exposed ischium remainder of the injury is to the spine, there is slough under entire wound bed. There is considerable undermining along most edges of the injury. Right hip; both feet. Wound base right hip lesion is deeply tunneled lesion through which bone can be visualized. Wound area is foul smelling and much of the base appears necrotic. There are wounds to both feet which are similar appearance and involve lateral surfaces of the feet. 11/11/21 at 11:00am V5 (Wound Care Nurse) said, I do not remember R1, I will have to check the computer to refresh my memory. I do not think that R1 developed any wounds in house. R1 was admitted on [DATE] with wounds to Coccyx, left heel, right heel right ischium, right bunion and left foot. I cannot tell if the patient developed the wounds here or not. V5 did not provide any further information. 11/12/21 at 10:30am V2 (Director of Nursing) said, If the medication and or treatment record has any open spaces, it indicates to me that the nurses did not do the treatment or the medication was not given. This is not acceptable, but it happens. I know that we have some problems with the wound treatments during the week, we should not have any unsigned treatments because we do have the dedicated treatment nurse doing them. On weekends it's a different thing, the nurses are responsible for doing the treatments but more frequently than not, they do not do it because they have other things to do on the floor. I know the treatments on the weekend are not being done. It is not assigned to anyone when in particular when V5 is not here. The nurses do not document the sizes or measurements, the only thing they document is the location of the wound, and they are not trained on wounds. We are currently looking for a wound care coordinator. V5 (Wound Care Nurse) knows that she is only the wound care nurse, I do not think that she is ready for the coordinator position. I am not as involved with wound care cases because I have a lot of other duties that I am busy with. When asked what type of credentials and training the current wound care nurse has, V2 stated that she was hired because she knew her from another facility and was told that she (V5) was doing wound treatments at a previous job and she just assumed she knew what to do. V2 stated, I should have confirmed that information or looked into it more. Review of V5's (Wound Care Nurse) personnel file includes (but not limited to): Hire Date: 8/17/21, Wound Care Nurse Orientation and Onboarding Checklist dated 9/16/21 with more than 50% of the competency items not confirmed to be completed; Wound Care: Identification and Assessment training was completed on 10/12/21 and Wound Care Nurse Orientation and Onboarding Checklist dated 11/11/21 that is blank under, This employee has completed their orientation and has demonstrated reasonable command of each of the topics presented. Options include: PASS / FAIL 11/18/21 at 11:10am, V21 (Licensed Practical Nurse/ Restorative Director) said, I am working the floor when we have any call offs. I started here two months ago. If the Certified Nurse Assistant or I notice any new skin problems, I will let the treatment nurse/DON know and I will do a risk management form documenting the skin breakdown. Wounds are not my strong area, I know redness and abrasion, I cannot do staging; I will only describe what I see. I have not received any formal training since I came here. 11/18/21 at 11:20am, V22 (Licensed Practical Nurse) said, I am the regular nurse on the first floor. When I started working here, I had a wound care day training. I know that if we identify a wound I will need to let wound care know, do a risk management report of the new wound, call the doctor and let him know what I see and obtain an order and carry it out. I am not comfortable/good with staging, I will only document the appearance of the wound but I do not do any sizes or staging. I do the treatments if the wound care nurse is not here. 11/18/21 at 11:35am, V23 (Licensed Practical Nurse) said, I started here nine months ago. I am a floater. If we identify a new wound we make sure to call the doctor and let them know. I can describe how the wound looks like, I will not stage. I am not familiar with staging. I am not able to determine the stage or what kind of wound it is. I have not done any kind of wound training since I started working here. 11/18/21 at 11:45am V24 (Licensed Practical Nurse) said, I started working here six months ago. I am an as needed basis nurse. I have not had any wound care training, I only reviewed some slides (paperwork presentation). If the wound care nurse is not here, we are responsible for the dressing changes. If we identify a new wound, we document in the progress notes and do a risk management, call the doctor and get and order, once the treatment order is received I will implement it. I will describe the wound but I will not stage. 11/18/21 at 11:55am, V25 (Registered Nurse/ [CONDITION(S)] Nurse) said, I started working here three years ago. I work on the floor if we have a call off or if we are in need of a nurse. I will make sure to check the patient's skin after a shower and also after incontinence care. If the patient is identified with a wound I make sure to assess the patient, call the doctor and report what I see. I am not a wound care nurse, I will not stage. The best I can do is describe to the doctor that what I see on the wound and carry out the order that the doctor gives me. I have not had any wound care training here at the facility. We do online training on different topics. R7 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/11/21 at 11:10am R7 said, I developed the wound because they are very short staff here and many times I need to wait for them to come and change my diaper for hours and the urine [CONDITION(S)] my skin, now I cannot be out of the bed as frequent because I need not to put any pressure in my wound and I need to be in bed. I do not like to be in bed because I am losing my independence to be up and about in my electrical wheelchair, this is the result of them being short and not taking care of me as they should. V5 (Wound Care Nurse) said to (R7), I am here to do your wound care. R7 said I am soiled, I need to be cleaned first. Observed V5 and V7 perform incontinence and wound care with no concerns identified. At this time, V5 was asked if R7's wound was facility acquired and V5 stated, I am not sure if he developed it in the facility or not but based on (documentation), it appears that this is facility acquired. R7's Braden (Skin Risk Assessment) score dated 10/25/21 and 11/5/21 are 14 (Moderate Risk). R7's MDS (Minimum Data Set) assessment dated [DATE] documents that R7 is at risk for developing pressure ulcers/injuries (M0150) and that R7 does not have any unhealed pressure ulcers/injuries (M0210). Section M0300 is blank for Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Wound documentation for R7 includes pressure ulcer on the upper left buttock - Date Identified: 7/14/21 - Source: Facility-acquired - Most recent assessment history (at the time of this survey) includes: Date: 10/26/21 - Clinical Stage: Stage 4 - Exudate: Moderate, Serosanguinous - Wound measurements: 0.60x0.60x5.80cm - Wound Progress is documented as No Change on 11/8/21 Review of R7's current care plans include focus area of impairment to skin integrity (dated 9/9/21) with interventions put in place on 9/9/21. Interventions for skin impairment do no document any updates or modifications to the care plan since date initiated (9/9/21). R8 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/11/21 at 11:50am R8 said, I came here because I have a cancer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I think they are very short staffed and I have to wait for very long time for the C.N.A or even the nurse to come and take care of me. I am soiled in urine and feces for hours before they come and help me. It is very uncomfortable for me to be in bed all day long because I have wounds and I cannot be up in the chair as long as I want to be. I used to be a football coach for 30 plus years and I got sick and now I am at the mercy of others. I do not like that; they tell me I am not the only patient here that I need to wait. R8's Braden (Skin Risk Assessment) score dated 8/14/21, 9/15/21, and 10/26/21 are 16 (At Risk). R8's MDS (Minimum Data Set) assessment dated [DATE] documents that R8 is at risk for developing pressure ulcers/injuries (M0150) and that R8 has unhealed pressure ulcers/injuries (M0210). Section (M0300) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage lists: one Stage 4 pressure ulcer. Wound documentation for R8 includes pressure ulcer on the right ischium - Date Identified: 9/8/21 - Source: Facility-acquired - Most recent assessment history (at the time of this survey) includes: Date: 10/26/21 - Clinical Stage: Unstageable - Exudate: Moderate, Serous - Wound measurements: 1.00x4.00x4.00cm 11/11/21 at 1:00pm V5 (Wound Care Nurse) said, R8 developed a wound to the right ischium on 9/8/21, but I was not able to see R8's wound until 9/16/21 and it measured 5.5x3.0xUnknown, it was an unstageable pressure wound. Progree note dated 10/18/2021 18:46 reads, (R8) seen by V11 (Wound Care Doctor) observed Wound to Right ischium, Full Thickness: 1 x 4.3 x 4.5cm. Facility provided Skin Care Treatment Regimen (Revised date 7/28/21) includes: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Procedures (include but not limited to): 1. Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician . 4. TAR Nursing Documentation: a. Routine wound care completed by wound care nurse or designee . 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated . Facility Assessment Tool (Date of assessment or update: 8/3/21) documents . Staff Type (to include) Wound Care Nurses . Staff training/education and competencies: - Prior to hiring human resources audits credentials for applicable candidates. The HR Director tracks the licenses and certifications of the staff per discipline. The facility mandates training upon hire which covers company and facility's policies/procedures and Federal and State regulations. - Training and skill competencies are provided upon hire, annually and as needed by the facility. - While working, there is a minimum of monthly in service and education provided to direct staff including competencies . Training Topics: Licensed Nursing Staff . - Wound Care related to preventing facility acquired pressure ulcers including identifying high patients, conducting thorough assessments, nutritional approaches and equipment . Non-Licensed Nursing Staff . - Pressure Ulcer Prevention/Wound Care Related Competencies: Nurses .Initial Skin Assessment; Monitoring of Skin Condition; Turning and Positioning

Based on observation, interview, and record review, the facility failed to provide nursing services to prevent residents from obtaining new pressure ulcers or to heal existing pressure ulcers by not identifying new areas of skin breakdown in a timely manner, failing to conduct wound treatments as ordered by the physician, failing to ensure that dietary recommendations for wound management were carried out, and by failing to ensure that nursing staff were trained and competent in providing care for residents with pressure ulcers. This failure applied to three of three residents (R1, R7, and R8) reviewed for pressure ulcers and resulted in R1 obtaining two Stage 4 pressure ulcers to the right hip and right heel, one Stage 2 pressure ulcer to the left medial knee, and a deep tissue pressure injury to the left hip; R7 developed a new facility-acquired Stage 4 pressure ulcer to the upper left buttock; and R8 developed a new facility-acquired, unstageable pressure ulcer to the right ischium. Findings include: 1. R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to local hospital on 10/7/21 and is not currently in the facility. On 10/22/21, R1 was discharged from local hospital to a long-term acute care hospital. R1's Admission MDS (Minimum Data Set) assessment dated [DATE] documents the following: Section C - Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 9, which indicates moderately impaired cognition Section G - Functional Status: total dependence, requires 2+ persons physical assist Section H - Bladder and Bowel: Urinary and Bowel Continence as Always Incontinent Section K - Swallowing/Nutritional Status: Weight is 147 pounds and Height is 63 inches, with no/unknown weight loss or gain within the past month or six months Section M - Skin Conditions-(including history of a pressure ulcers or pressure injuries), and pressure relieving devices: (1) Stage 2 Pressure Ulcer present upon admission and (1) Stage 4 Pressure Ulcer present upon admission; Zero documented Stage 1, Stage 3, unstageable pressure ulcers, or deep tissue injuries upon admission. Braden Score (for predicting pressure ulcer risk) is 13, indicating Moderate Risk of developing pressure ulcers. Full body assessment dated [DATE] 14:42 completed by V20 (Previous Wound Care Nurse) documents (upon admission): 1) area noted to coccyx 9.0 x 5.0 3.0 moderate serous exudate, 100% granulation. 2) area noted left lateral 1.5 x 4.0 leg 25% granulation, 25% slough, 50% necrotic light serous exudate. 3) area noted right bunion 0.2 x 1.5 DTI 100% deep maroon no exudate. 4) area noted to right heel 5.5 x 5.0 100% necrotic no exudate. 5) right ischial tuberosity 3.5 x 3.5 100% necrotic light serous exudate. 6) area noted left heel 3.5 x 5.0 100% necrotic no exudate tx implemented, heel protectors to be on at all times resident denies pain or discomfort prn pain meds given as needed. Physician treatment orders for July 2021 include: 1) coccyx: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift; Start Date: 7/17/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) left heel: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 3) left lateral foot: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 4) right bunion: cleanse with nss skin prep Iota QD/PRN every day shift; Start Date: 7/17/21; D/C Date: 9/01/2021 No documentation as to why this order was discontinued. 5) right heel: cleanse with nss / wound cleanser apply [MEDICATION(S)] gauze cvr with abd pad wrap in kerlix M-W-F/PRN (as needed) every day shift every Mon, Wed, Fri; Start Date: 7/19/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/3, 6, 13, 15, and 29, 2021 and 10/6/2021 6) right ischium: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift; Start Date: 7/17/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 7) Right, lateral ankle skin prep LOTA qd/pm every day shift; Start Date: 7/24/21; D/C Date: 9/01/2021; No documentation as to why this order was discontinued. Physician treatment orders for August 2021, included the same orders as July 2021 with the addition of: 1) Dakins (1/2 strength) Solution 0.25% (Sodium Hypochlorite) Apply to left Ischium topically every day shift for Wound Care Cleanse with NSS, Pat dry and apply Dakins soaked gauze and cover with dry dressing; Start Date: 8/26/21 Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/2, 3, 4, 6, 11, 12, 13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) left, medial knee clean with nss, wound cleanser apply [MEDICATION(S)] MWF/pm every day shift every Mon, Wed, Fri; Start Date: 8/02/21; D/C Date: 9/01/2021; No documentation as to why this order was discontinued. 8) right, medial shin clean with nss, wound cleanser apply [MEDICATION(S)] MWF/pm every day shift every Mon, Wed, Fri; Start Date: 8/02/21; D/C Date: 8/30/2021; No documentation as to why this order was discontinued. Progress Note created by V15 (Consultant Registered Dietitian) dated 8/25/21 at 09:22 documents that R1 has Dx-severe pro calorie malnutrition; Diet-Mechsoft, thin liquids, no restrictions; Wt-8/18 112# 7/15 147#, Ht-63, BMI-19.8 underweight status d/t age, Appetite-good, Labs-no current .Per meal documentation: appetite improved, consuming 75-100% of most meals. Diet upgraded to mechsoft with good tolerance. Fed per staff .Suggest add med pass 2.0 120ml tid, prostat awc 30ml daily for additional kcals/pro., wkly wt x 4 weeks; Monitor wts, labs, skin, po intake. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/12/21 at 2:00pm, V2 (Director of Nursing) said, I was not able to see find any recommendations from the RD (Registered Dietician) noted or carried out. I do not know how the RD communicates the recommendations to the nursing department. If she sends e-mails I have currently 17,000 e-mails to review, in my opinion the RD needs to take the recommendations to the nurse and let me know of the recommendations. There is no specific protocol for carrying out the recommendations. 11/15/21 at 10:00am, V15 (Consultant Registered Dietitian) said, I was at the building, I do not remember the patient (R1) .I do write recommendations and e-mail them to the Director of Nursing, the Dietary tech and the dietary manager. I review to see of my recommendations are noted or carried out if I do not see any notes or new orders, I will submit the recommendations again. My expectation is that the recommendations are noted and carried out. 11/15/21 at 10:50am V1 (Administrator) said, the registered dietitian will make sure to give the recommendations to nursing and dietary manager, the Director of Nursing is responsible for making sure that the recommendations are noted and carried out. My expectation is that the doctor is notified of the RD recommendations, to input the order and to document in the patient medical record. All recommendations must be followed up on. The previous dietary manager is no longer here per mutual agreement and no contact information is available. During the course of this survey, upon request, facility did not provide any documented protocols, policies, or in-services to confirm the procedure for how dietary recommendations should be carried out. Progress Note created by V5 (Wound Care Nurse) dated 9/13/2021 12:15 documents that resident was seen by wound nurse and wound specialist V11 (Wound Care Doctor), r/t wound located on Coccyx, Right Ischium Right Hip, Left heel, Left Distal Lateral Foot, Right Medial Heel, Right distal medial Foot. Wound Improvements are documented. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1) Right Distal Medial Foot: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift to promote wound healing; Start Date: 9/13/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 2) Right Hip: cleanse with nss/wound cleanser skin prep periwound apply Dakins gauze cvr with dry drsg qd/pm every day shift for wound care; Start Date: 9/13/21 - Per TAR (Treatment Administration Record), treatments were not done on the following dates: 9/13, 14, 15, 19, 21, 23, 28, and 29, 2021 and 10/2, 3, 5, and 6, 2021 Review of R1's medical record documents four new facility acquired pressure wounds: 1) Assessment date: 7/30/21, Date Identified: 7/28/21, Stage 2, left medial knee, 1x1x.10cm 2) Assessment date: 10/6/21, Date Identified: 10/6/21, Deep Tissue Pressure Injury, left hip, 4x3.5cm x unknown depth 3) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right heel, 5x3.5cm x unknown depth 4) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right hip, 5.5x4.2x2cm There is no documentation in R1's medical record to show that the new, facility-acquired wounds were identified/assessed prior to the documented Date Identified as Stage 2 and Stage 4, per medical record. Review of physician treatment orders for October 2021 do not include any new treatment orders prior to R1's transfer to local hospital on 10/7/21. Review of R1's care plans includes: Focus: Incontinent of bowel and bladder puts her at risk for infection, alteration in skin and complications associated. Date Initiated: 7/15/21; Interventions: None listed Focus: RD suggests 8/25/21 - Suggest add med pass 2.0 120ml tid, prostat awc 30 ml daily for additional kcals/pro; wkly wt x 4 weeks; Intervention: Prepare/serve the resident's nutritional diet as ordered. Monitor intake and record q meal. Date Initiated: 7/21/21 Care plan includes multiple focus areas related to skin breakdown and pressure ulcers include interventions all with Date Initiated: 7/16/2021 and interventions including the following: - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - If resident refuses treatment, confer with IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. - Monitor/document/report to MD PRN changes in skin status, appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. - Notify nurse immediately of any new areas of skin breakdown, such as redness, blisters, bruises, discoloration noted during bath or daily care. - Assess/record/monitor wound healing (FREQ). Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Review of R1's medical record does not include documentation to show that there was any concern with regard to resident refusing treatment or other explanation for the multiple dates of missed wound treatments. R1's medical record shows that on 10/7/21, R1 was transferred to local hospital. Hospital record documents: inpatient wound care consult report reads: lumbar sacral spine and right buttock, 4cmX6cmX1cm wound bed with sloughing, wound to the right buttock is extensive and dominated entire buttock, and there is exposed bone. Wound base right buttock wound extends to bone: breakdown forms a cavity around exposed ischium remainder of the injury is to the spine, there is slough under entire wound bed. There is considerable undermining along most edges of the injury. Right hip; both feet. Wound base right hip lesion is deeply tunneled lesion through which bone can be visualized. Wound area is foul smelling and much of the base appears necrotic. There are wounds to both feet which are similar appearance and involve lateral surfaces of the feet. 11/11/21 at 11:00am V5 (Wound Care Nurse) said, I do not remember R1, I will have to check the computer to refresh my memory. I do not think that R1 developed any wounds in house. R1 was admitted on [DATE] with wounds to Coccyx, left heel, right heel right ischium, right bunion and left foot. I cannot tell if the patient developed the wounds here or not. V5 did not provide any further information. 11/12/21 at 10:30am V2 (Director of Nursing) said, If the medication and or treatment record has any open spaces, it indicates to me that the nurses did not do the treatment or the medication was not given. This is not acceptable, but it happens. I know that we have some problems with the wound treatments during the week, we should not have any unsigned treatments because we do have the dedicated treatment nurse doing them. On weekends it's a different thing, the nurses are responsible for doing the treatments but more frequently than not, they do not do it because they have other things to do on the floor. I know the treatments on the weekend are not being done. It is not assigned to anyone when in particular when V5 is not here. The nurses do not document the sizes or measurements, the only thing they document is the location of the wound, and they are not trained on wounds. We are currently looking for a wound care coordinator. V5 (Wound Care Nurse) knows that she is only the wound care nurse, I do not think that she is ready for the coordinator position. I am not as involved with wound care cases because I have a lot of other duties that I am busy with. When asked what type of credentials and training the current wound care nurse has, V2 stated that she was hired because she knew her from another facility and was told that she (V5) was doing wound treatments at a previous job and she just assumed she knew what to do. V2 stated, I should have confirmed that information or looked into it more. Review of V5's (Wound Care Nurse) personnel file includes (but not limited to): Hire Date: 8/17/21, Wound Care Nurse Orientation and Onboarding Checklist dated 9/16/21 with more than 50% of the competency items not confirmed to be completed; Wound Care: Identification and Assessment training was completed on 10/12/21 and Wound Care Nurse Orientation and Onboarding Checklist dated 11/11/21 that is blank under, This employee has completed their orientation and has demonstrated reasonable command of each of the topics presented. Options include: PASS / FAIL 11/18/21 at 11:10am, V21 (Licensed Practical Nurse/ Restorative Director) said, I am working the floor when we have any call offs. I started here two months ago. If the Certified Nurse Assistant or I notice any new skin problems, I will let the treatment nurse/DON know and I will do a risk management form documenting the skin breakdown. Wounds are not my strong area, I know redness and abrasion, I cannot do staging; I will only describe what I see. I have not received any formal training since I came here. 11/18/21 at 11:20am, V22 (Licensed Practical Nurse) said, I am the regular nurse on the first floor. When I started working here, I had a wound care day training. I know that if we identify a wound I will need to let wound care know, do a risk management report of the new wound, call the doctor and let him know what I see and obtain an order and carry it out. I am not comfortable/good with staging, I will only document the appearance of the wound but I do not do any sizes or staging. I do the treatments if the wound care nurse is not here. 11/18/21 at 11:35am, V23 (Licensed Practical Nurse) said, I started here nine months ago. I am a floater. If we identify a new wound we make sure to call the doctor and let them know. I can describe how the wound looks like, I will not stage. I am not familiar with staging. I am not able to determine the stage or what kind of wound it is. I have not done any kind of wound training since I started working here. 11/18/21 at 11:45am V24 (Licensed Practical Nurse) said, I started working here six months ago. I am an as needed basis nurse. I have not had any wound care training, I only reviewed some slides (paperwork presentation). If the wound care nurse is not here, we are responsible for the dressing changes. If we identify a new wound, we document in the progress notes and do a risk management, call the doctor and get and order, once the treatment order is received I will implement it. I will describe the wound but I will not stage. 11/18/21 at 11:55am, V25 (Registered Nurse/ [CONDITION(S)] Nurse) said, I started working here three years ago. I work on the floor if we have a call off or if we are in need of a nurse. I will make sure to check the patient's skin after a shower and also after incontinence care. If the patient is identified with a wound I make sure to assess the patient, call the doctor and report what I see. I am not a wound care nurse, I will not stage. The best I can do is describe to the doctor that what I see on the wound and carry out the order that the doctor gives me. I have not had any wound care training here at the facility. We do online training on different topics. R7 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/11/21 at 11:10am R7 said, I developed the wound because they are very short staff here and many times I need to wait for them to come and change my diaper for hours and the urine [CONDITION(S)] my skin, now I cannot be out of the bed as frequent because I need not to put any pressure in my wound and I need to be in bed. I do not like to be in bed because I am losing my independence to be up and about in my electrical wheelchair, this is the result of them being short and not taking care of me as they should. V5 (Wound Care Nurse) said to (R7), I am here to do your wound care. R7 said I am soiled, I need to be cleaned first. Observed V5 and V7 perform incontinence and wound care with no concerns identified. At this time, V5 was asked if R7's wound was facility acquired and V5 stated, I am not sure if he developed it in the facility or not but based on (documentation), it appears that this is facility acquired. R7's Braden (Skin Risk Assessment) score dated 10/25/21 and 11/5/21 are 14 (Moderate Risk). R7's MDS (Minimum Data Set) assessment dated [DATE] documents that R7 is at risk for developing pressure ulcers/injuries (M0150) and that R7 does not have any unhealed pressure ulcers/injuries (M0210). Section M0300 is blank for Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Wound documentation for R7 includes pressure ulcer on the upper left buttock - Date Identified: 7/14/21 - Source: Facility-acquired - Most recent assessment history (at the time of this survey) includes: Date: 10/26/21 - Clinical Stage: Stage 4 - Exudate: Moderate, Serosanguinous - Wound measurements: 0.60x0.60x5.80cm - Wound Progress is documented as No Change on 11/8/21 Review of R7's current care plans include focus area of impairment to skin integrity (dated 9/9/21) with interventions put in place on 9/9/21. Interventions for skin impairment do no document any updates or modifications to the care plan since date initiated (9/9/21). R8 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11/11/21 at 11:50am R8 said, I came here because I have a cancer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I think they are very short staffed and I have to wait for very long time for the C.N.A or even the nurse to come and take care of me. I am soiled in urine and feces for hours before they come and help me. It is very uncomfortable for me to be in bed all day long because I have wounds and I cannot be up in the chair as long as I want to be. I used to be a football coach for 30 plus years and I got sick and now I am at the mercy of others. I do not like that; they tell me I am not the only patient here that I need to wait. R8's Braden (Skin Risk Assessment) score dated 8/14/21, 9/15/21, and 10/26/21 are 16 (At Risk). R8's MDS (Minimum Data Set) assessment dated [DATE] documents that R8 is at risk for developing pressure ulcers/injuries (M0150) and that R8 has unhealed pressure ulcers/injuries (M0210). Section (M0300) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage lists: one Stage 4 pressure ulcer. Wound documentation for R8 includes pressure ulcer on the right ischium - Date Identified: 9/8/21 - Source: Facility-acquired - Most recent assessment history (at the time of this survey) includes: Date: 10/26/21 - Clinical Stage: Unstageable - Exudate: Moderate, Serous - Wound measurements: 1.00x4.00x4.00cm 11/11/21 at 1:00pm V5 (Wound Care Nurse) said, R8 developed a wound to the right ischium on 9/8/21, but I was not able to see R8's wound until 9/16/21 and it measured 5.5x3.0xUnknown, it was an unstageable pressure wound. 10/18/2021 18:46 Progress Note reads: (R8) seen by V11 (Wound Care Doctor) observed Wound to Right ischium, Full Thickness: 1 x 4.3 x 4.5cm. Facility provided Skin Care Treatment Regimen (Revised date 7/28/21) includes: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Procedures (include but not limited to): 1. Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician . 4. TAR Nursing Documentation: a. Routine wound care completed by wound care nurse or designee . 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated . Facility Assessment Tool (Date of assessment or update: 8/3/21) documents . Staff Type (to include) Wound Care Nurses . Staff training/education and competencies: - Prior to hiring human resources audits credentials for applicable candidates. The HR Director tracks the licenses and certifications of the staff per discipline. The facility mandates training upon hire which covers company and facility's policies/procedures and Federal and State regulations. - Training and skill competencies are provided upon hire, annually and as needed by the facility. - While working, there is a minimum of monthly in service and education provided to direct staff including competencies . Training Topics: Licensed Nursing Staff . - Wound Care related to preventing facility acquired pressure ulcers including identifying high patients, conducting thorough assessments, nutritional approaches and equipment . Non-Licensed Nursing Staff . - Pressure Ulcer Prevention/Wound Care Related Competencies: Nurses .Initial Skin Assessment; Monitoring of Skin Condition; Turning and Positioning

Based on interview and record review, the facility failed to maintain a residents nutritional status by not ensuring that nutritional recommendations were carried out and implemented for an underweight resident with multiple pressure ulcers, who was suffering from severe protein calorie restriction; the facility also failed to confirm and monitor the resident's weight as recommended by the licensed dietary nutritionist and ordered by the physician. This failure applied to one (R1) of three residents reviewed for weight loss and nutrition and resulted in R1 developing four (new) facility-acquired pressure ulcers and continuous weight loss during her stay in the facility. Findings include: R1 is a [AGE] year-old female originally admitted on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was transferred to local hospital on 10/7/21 and is not currently in the facility. On 10/22/21, R1 was discharged from local hospital to a long-term acute care hospital. R1's Admission MDS (Minimum Data Set) assessment dated [DATE] documents the following: Section C - Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 9, which indicates moderately impaired cognition Section K - Swallowing/Nutritional Status: Weight is 147 pounds and Height is 63 inches, with no/unknown weight loss or gain within the past month or six months Section M - Skin Conditions-(including history of a pressure ulcers or pressure injuries), and pressure relieving devices: (1) Stage 2 Pressure Ulcer present upon admission and (1) Stage 4 Pressure Ulcer present upon admission; Zero documented Stage 1, Stage 3, unstageable pressure ulcers, or deep tissue injuries upon admission. Braden Score (for predicting pressure ulcer risk) is 13, indicating Moderate Risk of developing pressure ulcers. Full body assessment (upon admission) dated 7/16/2021 14:42 completed by V20 (Previous Wound Care Nurse) documents six areas with pressure ulcers (coccyx, left lateral leg, right bunion, right heel, right ischial tuberosity, and left heel. Review of R1's care plans includes: Focus: RD suggests 8/25/21 - Suggest add med pass 2.0 120ml tid, prostat awc 30 ml daily for additional kcals/pro; wkly wt x 4 weeks; Intervention: Prepare/serve the resident's nutritional diet as ordered. Monitor intake and record q meal. Date Initiated: 7/21/21 Progress Note created by V15 (Consultant Registered Dietitian) dated 8/25/21 at 09:22 documents: (R1) Dx - severe pro calorie malnutrition Diet - Mechsoft, thin liquids, no restrictions Meds reviewed Wt - 8/18 112# 7/15 147# Ht - 63 BMI - 19.8 underweight status d/t age Appetite - good Labs - no current Wt decrease of 35 lbs (23.8%) x 1 month? Suspect scale error. Possibly incorrect adm wt? Request reweigh. Per meal documentation: appetite improved, consuming 75-100% of most meals. Diet upgraded to mechsoft with good tolerance. Fed per staff. Tx to multiple wounds - coccyx st 4, rt hip-uts, lt lat foot-diabetic, rt ankle-diabetic, rt shin-uts, lt med knee-st 2, lt heel-diabetic per 8/18 skin assessment. On MVI with min., Vit C and [MEDICATION(S)]. Suggest add med pass 2.0 120ml tid, prostat awc 30ml daily for additional kcals/pro., wkly wt x 4 weeks; Monitor wts, labs, skin, po intake. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - -Weight upon Admission x 3 days, then monthly every day shift for weight monitoring AND every day shift every Mon for weight monitoring weeklyx4, Order Start Date: 7/16/21, End Date: 10/29/21 - Weight weekly every day shift every Mon for weight monitoring, Order Start Date: 7/16/21, End Date: 10/29/21 There is no documentation in the medical record to indicate that the resident's admission weight was verified for accuracy (as recommended by RD) or that resident was being weighed per physician orders. Review of R1's medical record only includes the following documented weights: July 2021 - 147 lbs August 2021 - 112 lbs September 2021 - 107.5 lbs October 2021 - 101 lbs No other weights were provided for R1. Review of R1's medical record documents four new facility-acquired pressure wounds: 1) Assessment date: 7/30/21, Date Identified: 7/28/21, Stage 2, left medial knee, 1x1x.10cm 2) Assessment date: 10/6/21, Date Identified: 10/6/21, Deep Tissue Pressure Injury, left hip, 4x3.5cm x unknown depth 3) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right heel, 5x3.5cm x unknown depth 4) Assessment date: 10/6/21, Date Identified: 10/6/21, Stage 4, right hip, 5.5x4.2x2cm 11/12/21 at 12:20pm, V9 (Infectious Disease Nurse Practitioner) stated, I had seen that she had a lot of wounds. I was not aware that she lost any weight. I would have contacted the primary physician and requested for a g-tube placement sooner or other nutritional interventions. 11/12/21 at 2:00pm, V2 (Director of Nursing) said, I was not able to see find any recommendations from the RD (Registered Dietician) noted or carried out. I do not know how the RD communicates the recommendations to the nursing department. If she sends e-mails I have currently 17,000 e-mails to review, in my opinion the RD needs to take the recommendations to the nurse and let me know of the recommendations. There is no specific protocol for carrying out the recommendations. 11/15/21 at 10:00am, V15 (Consultant Registered Dietitian) said, I was at the building, I do not remember the patient (R1) but in the notes I documented that the first weigh that the facility documented was possibly incorrect. I do write recommendations and e-mail them to the Director of Nursing, the Dietary tech and the dietary manager. I review to see of my recommendations are noted or carried out if I do not see any notes or new orders, I will submit the recommendations again. My expectation is that the recommendations are noted and carried out. 11/15/21 at 11:50am, V16 (Consultant Diet Tech) said, I was at the building until September, I worked there for almost two years, once a week. I do not have access to the records anymore, I do not remember R1. I cannot check my documentation. The regular procedure was that the RD (registered dietician) would assess the resident and send the nutritional recommendations via e-mail to the DON, dietary manager and myself. The nurses were responsible for carrying out the orders out. The dietary manager and the director of nursing are responsible to follow up and see if the recommendation was noted. I would check to see if the care plan needed to be updated. The RD would see the high risk new admissions such as wounds, [CONDITION(S)], g tubes and any other compromised patients; I would follow up with patients that were more stable. The facility is responsible for doing daily weight for the first three days, then once a week for four weeks and then monthly or as frequent as the Medical Provider or the Registered Dietitian will recommends. 11/15/21 at 10:50am V1 (Administrator) said, the registered dietitian will make sure to give the recommendations to nursing and dietary manager. The Director of Nursing is responsible for making sure that the recommendations are noted and carried out. My expectation is that the doctor is notified of the RD recommendations, to input the order and to document in the patient medical record. All recommendations must be followed up on. The previous dietary manager is no longer here per mutual agreement and no contact information is available. During the course of this survey, request was made for facility to provide any documented protocols, policies, or in-services to confirm the procedure for how dietary recommendations should be carried out and/or weight monitoring and it was not provided. Facility provided Dietary Consultation Agreement (dated January 1, 2020), which includes: Consultant's duties may include: .2. To collaborate with the dietary department concerning the following areas: A. Nutritional assessment for residents referred by the facility which may include residents with: Enteral Feeding, Significant weight loss, Pressure ulcers, Poor nutritional intake renal [CONDITION(S)] . 3. Review and evaluate with the Administrator and Dietary Manager the progress of the Dietary Department . 7. Submit a consultation report after every consultation visit stating hours worked, nutritional assessments completed and other service performed . -Agreement is signed by V1 (Administrator)

Based on interviews and records reviewed the facility failed to follow physician orders to monitor one resident (R3) during the 11:00PM to 7:00AM shift by not having a nurse available to monitor his blood sugars, after reported low lab values and having possible pneumonia per chest X-ray. This failure resulted in R3 being transferred to the hospital after the day shift nurse assessed and reported his status to the Physician. This failure affected 1(R3) of 3 residents reviewed for monitoring. Findings include: R3 is [AGE] year old admitted to the facility on [DATE] with diagnosis including, but not limited to Cognitive Communication Deficit, Dementia, Hypertension, [CONDITION(S)], [CONDITION(S)], Heart Failure, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Chronic Kidney Disease, and Presence of Cardiac Pacemaker. R3's Brief interviews for Mental Status dated 9/18/21 has a score of 9, Moderately Impaired. R3 was transferred to the hospital on 10/13/21. On 10/13/21 at 2:39 V11, Scheduler, said the 1st floor is supposed to have 2 nurses scheduled on night shift. V11 said V19, Nurse, was supposed to come in. V11 said she was notified about 2:00AM that V19 did not come in. V11 said she called V2, Director of Nursing, when she found out there was not a nurse on the 1st floor and reported there was no nurse. On 10/14/21 at 10:57AM V4, Licensed Practical Nurse (LPN), said he worked nights on 10/12/21, V4 said he worked 2 shifts 3:00PM to 11:00PM and 11:00PM to 7:00AM. V4 said around 5:30AM on 10/13/21 he was called by the receptionist to work on the first floor. V4 said he did not assess R3. V4 said there is usually 1 nurse on each floor of the facility. On 10/14/21 at 11:21AM V16, Certified Nursing Assistant (CNA), said R3 would often move the head of bed flat down and I needed to reposition the head of the bed. V16 said R3 was on oxygen. On 10/14/21 at 12:12PM V13, Nurse, said she worked 3:00PM to 11:00PM on 10/12/21. V13 said she waited until 12:00AM or 12:30AM before she left, but V19, Nurse, did not arrive and there was no nurse on the unit when she left. V13 said during her shift she had relayed lab results to R3's doctor related to low hemoglobin and glucose levels. V13 said the doctor gave a new order to monitor R3. V13 said she last checked R3's blood glucose around 10:20PM and it was in the 70's. V13 said R3 had a poor appetite that evening and ate 25% of his dinner. V13 said the last physician order she received was to monitor R3. V13 said this means a nurse should be monitoring the resident for any changes. On 10/14/21 at 2:47AM V14, Physician, said when I tell them to monitor, I expect a nurse to check vitals and make sure the resident is stable and not in distress. I expect the nurses to be checking on the resident. When I gave the order to monitor, I expected the facility to have a nurse for the resident. V14 said R3 was started on antibiotics in the hospital and has been admitted . On 10/15/21 at 10:26AM V14 said if a resident has blood sugars in the 70s or 80s in the evening, I would order the nurse to recheck the blood sugar. In the evening the blood sugars should be around 100. On 10/15/21 at 12:07PM V18, CNA, said she did not have a nurse on the floor with her while she worked on 10/12/21 during the night shift. V18 said she did not do any vitals on any resident that shift. V18 said she is a CNA and can not assess and determine resident medical needs, that is the nurses job. V18 said I am not sure who R3 is. On 10/15/21 at 1:10 PM, V2, Director of Nursing, said symptoms of gastro-intestinal bleeding include coffee ground emesis, respiratory distress, blood pressure and vitals fluctuate. V2 said the nurses are trained to assess for this. V2 said a CNA can not call the doctor to report a change in resident condition. V2 said an order to monitor a patient means to check the resident, check oxygen levels, neurological function, vital signs, assess the resident, and document. On 10/15/21 at 9:52AM V10, LPN, said I came in on 10/13/21 about 6:30AM. V10 said she heard V4 say there was no night nurse on the first floor. V10 said that rang an alert for me because I knew we were waiting on R3's labs and x-ray results. I went into R3's chart and reviewed his labs and x-ray and saw the order that V14 gave to monitor R3. I saw the lab results were critical high or low and possible pneumonia. V10 said I noticed R3 was pale in his face and seemed more confused. V10 said I called V14 and I said Doctor, R3 needs to go to the hospital, something was not making sense. V10 said I felt we were unable to stabilize R3 by just monitoring him, he needed possible antibiotics and further testing. V10 said regularly R3 had to be monitored to be sure his head was elevated because he would lower it flat and he is on oxygen and needs his head of bed raised to facilitate breathing. V10 said a nurse should have been there to monitor the patient on the night shift. V10 said to monitor means check the resident, check vitals, and check his oxygen level, because he was on continuous oxygen. V10 said R3 is known to play with his remote and leave the bed flat down. R3's Progress Notes dated 10/11/21 at 12:18PM Notes R3 had 1 bloody emesis. Physician notified and ordered new medication for Gastroesophageal Reflux and to monitor R3. R3's Progress Notes dated 10/12/21 at 8:08PM state chest X-Ray results faxed to physician and he was paged. R3's Progress Notes dated 10/12/21 at 10:43PM states per physician continue to encourage oral intake and monitor for signs of bleeding. R3's Radiology Report dated 10/12/21 notes Impression: mild atelectatic changes/pneumonia at both lower lobe. R3's Lab Results Report collection date 10/12/21 at 2:00PM and Reported at 7:49PM note R3's Red Blood Cells and Hemoglobin and Hematocrit are Low. R3's Glucose notes LL (low level) in bold letters value is 26. The bottom of the report notes Critical Glucose and Hemoglobin reported to V13, Nurse, on 10/12/21 at 7:52PM. R3's Communication & Hospital Required Form dated 10/13/21 notes the change in condition, symptoms, or signs observed and evaluated is/are: abnormal labs and possible pneumonia, this started on 10/13/21. Section III Resident Evaluation states Increased confusion or disorientation. Increased confusion ad forgetfulness. R3's hospital records dated 10/13/21 note patient received D25 [CONDITION(S)] noted on labs. Emergency Department Diagnosis: [CONDITION(S)], Pneumonia, Gastrointestinal Hemorrhage, Nausea and Vomiting. R3's hospital lab results for Glucose noted 62 on 10/13/21 at 11:07AM The facility policy review date 7/28/21 for Notification for Change of Condition notes the facility will provide care to residents.

Based on interview and record review, the facility failed to ensure that a resident did not develop any new pressure ulcers while in the facility and failed to comprehensively assess, care plan, and prevent the worsening of a sacral wound noted upon admission to the facility for a resident assessed to be at risk for skin breakdown. This failure affected one (R2) of four (R1, R3, and R4) residents reviewed for pressure ulcers this failure resulted in R2 sustaining multiple new pressure sores on bilateral ankles, left foot, and worsening of a sacral wound. Findings include: R2 is a [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission summary dated 7/27/21, written by V6 (RN) reads: Resident presented to facility post fall with imaging notable for left greater trochanter fracture, unclear if acute or chronic. Resident arrived at facility from (hospital) via stretcher x2 escort. Head-to-toe assessment completed. Vital signs taken. Resident is alert and oriented times 2-3, occasionally forgetful at baseline. Resident noted with sacral wound, dressing is clean, dry and intact. MDS (Minimum Data Set) of 7/28/21 reveals contradictory information showing no pressure ulcers at the time of admission but documented that (R2) was at-risk for developing pressure ulcers/injuries. On 7/28/21, V6 (RN) performed a virtual (telehealth) examination with V8 (Doctor of Osteopathic Medicine-DO) to communicate health status of R2. There was no mention of a sacral wound to obtain orders for care documented in the medical record. Physician note dated 8/18/21, written by V9 (Attending Physician), reads: Patient seen and examined by me today as a staff reported patient has leukocytosis. Patient white blood count appears comfortable today. Patient is sitting in his room appears to be comfortable. Patient states that he is feeling good. Patient denies any fever, chills, nausea, vomiting. There was no documentation or assessment in the medical record written by V9 related to (R2's) sacral wound or other skin/pressure-related injuries. Review of R2's medical record has no other entries regarding the noted sacral wound. There were no doctor's orders for treatment documented nor assessment or plan of care pertaining to pressure related wounds or skin breakdown for R2 in the medical record. Nursing note dated 8/25/21 at 10:17 AM, written by V10 (Hospital Physician) reads: observed R2 with a change of condition and transferred the resident to the hospital where R2 was admitted for diabetic ketoacidosis. Documentation did not include any skin assessment or condition of (R2's) skin prior to the hospital transfer. Hospital record includes assessement documentation written by both V10 (Hospital Physician) and V11 (Hospital Physician) dated 8/25/21 at 10:46 AM, includes: Patient was found to have multiple pressure ulcers (5) on bilateral lower extremities and buttocks with gangrenous changes. Wound care consulted and daily dressing changes were performed. Hospital documentation further includes the following physician orders for wound care: 1. Sacrum: daily enzymatic debridement. Offload the area as much as possible. Patient may need sharp debridement (surgical removal of dead tissue) to assist with wound healing. 2. Left lateral foot proximal: Every 2 days and as needed application of a foam dressing. Change as needed if soiled. Offload the area as much as possible. 3. Left lateral foot distal: Every 2 days and as needed application of a foam dressing. Change as needed if soiled. Offload the area as much as possible. 4. Left lateral ankle: Every 2 days and as needed application of a foam dressing. Change as needed if soiled. Offload the area as much as possible. 5. Right lateral ankle: Every 2 days and as needed application of a foam dressing. Change as needed if soiled. Offload the area as much as possible. 9/15/21 at 12:40 PM, V3 (Director of Nursing) stated, I know that (R2) had a deep tissue injury on the sacrum when he was admitted . I do not know why they did not care plan for this but we should have if he came in with a pressure sore. We have a new wound nurse (V4, wound nurse/Licensed Practical Nurse) but she just started recently and can't answer any of your questions regarding R2 because he was in the hospital when she started. Surveyor asked who was responsible for conducting wound treatments in the facility and V3 stated, Just (V4), the floor nurses do not do wound care. Documentation provided by the facility during the course of this survey was reviewed and did not include any assessments, treatment orders, or care planning related to the prevention and/or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review the facility failed to implement its wound care prevention and management program policy by failure to provide ongoing clinical assessment, documentation, notification of physician for any skin changes to obtain appropriate treatment, wound pain assessment and care plan evaluation and revision. This failure resulting to necrosis/gangrene of bilateral feet and transfer to the hospital for further evaluation and treatment. This deficiency affects one (R1) of two residents reviewed for wound care management. Findings include: On 3/10/20 at 1:41pm, V3 (Family member) stated that she informed the nurse (she cannot remember the name but able to recognize her when she sees her) 2 weeks ago of R1's skin discoloration on right foot and nothing was done. Her both feet got worse and became necrotic/gangrene. No wound treatment/dressing was provided to R1. On 3/10/20 at 10:34am, R1 is lying across the bed with both lower extremities hanging from the bed and both feet touching the floor. No socks on right foot exposing 100% necrotic/gangrene great toe, 2nd and 3rd toes with dried open wound and with long toe nails. Foul smelling odor coming the gangrene toes. Right foot swollen/[MEDICAL CONDITION], reddened and dry skin. She is very sleepy unable to maintain conversation. V7 (Licensed Practical nurse) stated that she is not familiar with R1, she is floated to different units. She does not know if she has wound treatment. V7 assessed R1's necrotic/gangrene right foot. R1 complained of pain as she touches her right foot. V7 stated that she has 100% necrotic/gangrene tissues on Right great toe, 2nd and 3rd toes. Her entire right foot is cold to touch. Foul smelling coming from necrotic/gangrene toes. She removed the sock on her left foot and observed necrotic tissue on left great toe, 2nd and 3rd toe. No open wound noted. Left foot swollen. R1 complained of pain when she touches her left foot. She stated the left foot is cold to touch too. She stated that she will call V9 Wound care nurse. V7 LPN stated that she has not given her medication yet because she is lethargic. On 3/10/20 at 10:38am, V8 (Certified Nurse Assistant) stated that she is regularly taking care of her and has not seen her with bilateral feet dressing. Her black skin discoloration on her both feet/toes are the same no changes. She cannot remember when she developed it, but it has been there. On 3/10/20 at 10:51am, V7 (LPN) gave R1 her morning medications but was not given pain medication as needed. On 3/10/20 at 11:11am, V9 (Wound care Coordinator) stated that R1 was admitted on [DATE] with skin intact. She stated that she documented on 3/5/20 the necrotic/eschar 100% on right foot 2nd and 3rd digit tips. No other skin issues noted during assessment. She stated that she notified V12 (Nurse Practitioner) and informed V3 (Family member). Reviewed R1's medical record with V9 indicated re-admission comprehensive assessment dated [DATE] indicated skin assessment intact, podiatric- no problem with feet. No comprehensive skin evaluation was done on 3/5/20. On 3/6/20 R1's physician order [REDACTED]. with dry dressing once daily/PRN if loose or soiled every day shift to promote healing ordered by V13 (Primary care Physician). R1 was not seen by wound care physician. On 3/10/20 at 12:01pm, Observed V9 (Wound care coordinator) performed wound treatment to R1. She assisted R1 from sitting on bed to lying position. R1 complained of pain as she touches and position her both feet. She cleanses left foot with wound cleanser. She applied Vit A and D to dry skin of entire foot. R1 complained of pain and moans x 5, stating ouch. She wrapped the 100% necrotic/gangrene great toe, 2nd and 3rd toe with [MEDICATION NAME]-soaked gauze and wrapped it with dry gauze bandage. R1 complained of pain as she wrapped the left toes. She cleanses the right foot with wound cleanser. R1 complained of pain as she cleans the right toes. She applied Vit A and D ointment to dry skin of entire right foot. R1 complained of pain. She wrapped the 100% necrotic/gangrene right great toe, 2nd and 3rd with [MEDICATION NAME]-soaked gauze and wrapped it with dry gauze bandage. R1 complained of pain and moans x 6 as she applied the gauze, stated ouch. She positions R1 on sitting position and applied both socks. R1 complained of pain as she applied her socks. On 3/11/20 at 9:30am, V9 (Wound care coordinator) stated that she did not document wound assessment done with R1's yesterday and did not call V12 ( Nurse Practitioner) or V13 ( Primary care Physician) for new order of increased progress of 100% necrotic/gangrene tissues of Right foot to great toe, 2nd and 3rd; and Left foot great toe, 2nd and 3rd toe. No comprehensive skin evaluation was done. V7 (LPN) did not documented assessment done with R1 bilateral necrotic feet and did not call V12 or V13. On 3/11/20 at 9:58am, V12 (Nurse Practitioner) stated that she sees R1 for V13 Primary Care physician. She has seen R1 several times since admission. She comes to the facility on daily basis and will ask floor nurses if she needed to see assigned residents for any clinical conditions that needed to be addressed. She is not aware of R1's necrotic/gangrene toes on both feet. Reviewed R1's progress notes documented by V12 indicated that all her 12 visits from admission, she documented: Ext- no redness or swelling to feet, no BLE [MEDICAL CONDITION] and skin intact. She admitted she did not perform physical examination of R1's BLE. She was notified of her leg pain upon standing and addresses the concern when she visited her on 2/26/20. She did not assessed/examined R1's BLE but ordered doppler ultrasound for BLU. Reviewed R1's Arterial ultrasound of bilateral extremities dated 2/26/20 with V12 indicated: History: Swelling if limb. Impression: mild to moderate [MEDICAL CONDITION] without occlusion, bilateral lower extremities. Surveyor requested V12 and V9 (Wound care coordinator) to examine R1's bilateral necrotic/gangrene feet. On 3/11/20 at 10:17am, R1 lying on bed, undressed gown and loosen disposable brief but covered with blanket. She is sleepy but responsive. She complained of pain as V9 (Wound care coordinator) repositioned her on bed. V9 removed right sock, R1 complained of moans and flexed her right leg when she touched her. V9 removed right foot dressing. Observed necrotic/gangrene of right great toe, 2nd and 3rd toes 100% with dried open wound and with long toe nails. R1 moans and complained of pain as V12 (Nurse practitioner) assessed her right foot. V12 stated I was informed that she is in this condition. She stated that R1 has necrotic/gangrene on right great toe, 2nd and 3rd toes with dried open wounds and foul-smelling odor coming from the gangrene toes. Entire foot/ankle swollen, reddened and cold to touch. V9 removed left sock and wound dressing. Again, R1 moans and complained of pain as she touches her. V12 assessed R1's left foot and stated her great toe, 2nd and 3rd toes 100% necrotic/gangrene, no open areas and with long toe nails. Foot and ankle swollen, reddened and cold to touch. V12 stated that she will call V13 (Primary Care Physician) to update with R1's clinical condition. On 3/11/20 at 10:56am, R1 sleepy but responsive and stated that she has pain rate of 10/10 on her bilateral feet. She stated that she has not received yet her morning and pain medication. On 3/11/20 at 12:50pm, V12 Nurse Practitioner stated that she spoke with V12 Primary care physician and discussed R1's increased progression of necrotic/gangrene on both feet and order to send her to hospital for further evaluation and management. On 3/11/20 at 2:41pm, V9 Wound care coordinator stated that she does wound treatment for [REDACTED]. She stated that she asked both V7 (LPN) and V16 (RN), who worked on 3/10/20 and 3/11/20 to give R1 her pain medication 1-hour prior her wound dressing. When asked what time she asked V7 and V16 to give her medication, she stated she cannot remember for V7 but for V16 she asked around 8:15am. Reviewed R1's MAR ( Medication administration record) for March 2020 indicated that R1 was not given PRN ( as needed) pain medication . R1's physician order [REDACTED]. She stated that she will write a standing order for pain medication of R1, 1 hour prior to wound treatment. On 3/11/20 at 2:53pm, V13 Primary care physician stated that he expected that the nursing staff will call him for any changes in resident condition and follow the facility's protocol in wound management. He stated that R1's possible embolism of BLE causing occlusion. Her anti-coagulant aspirin and [MEDICATION NAME] were on hold due to recent subdural hematoma. He would like to see her in the hospital to evaluate the bilateral necrosis/gangrene of her feet. He will follow up with neurosurgery and vascular surgeon. On 3/12/20 at 10:52am, V17 (LPN) that on 2/20/20 she worked on 3-11 shift. V3 (Family member) at bedside and concern of R1's skin discoloration on 2nd digit/toe of right foot. R1's denied pain, no [MEDICAL CONDITION] and no open areas. She documented it but did not notify V13 (Primary Care Physician) or V12 (Nurse Practitioner). She wrote it to be follow up in 24-hour report. She notified V9 (Wound care Coordinator) the following day ( 2/21/20). She did not able to follow it up because she was floated to another unit. Reviewed of R1's progress notes dated 3/11/20 documented by V12 (Nurse Practitioner) indicated: R1 was examined for BLE (Bilateral lower extremities) necrotic toe. Ext: mild BLE [MEDICAL CONDITION]. SKIN: redness to bilateral feet with necrosis to left foot digits 1-3 and right foot digits 1-3. Review of R1's progress notes dated 3/8/20 indicated: No open area, redness or swelling noted. R1 has old scabs to both lower extremities. The documentation was deleted/strike out by V7 (LPN) on 3/10/20 at 12:52pm ( after surveyor observed her assessment of R1's bilateral necrotic/gangrene feet/toes on 3/10/20 at 10:34am) and she did late entry notes for 3/8 indicated: Open areas noted on left foot between great toe and 2nd toe. Toes noted to be dark in color, cool to touch. Facility's Wound Care Program Care guidelines revised date 7/3/19 indicated: Procedures: 1. Timely identification of residents assessed to be risk for skin breakdown. a) The Braden scale must be completed by a licensed nurse on admission/readmission and weekly for the first week of admission/re-admission in the facility. 2. Proper identification of risk factors that can impact in the development of unavoidable ulcer or may impede with healing process if resident does not have an ulcer. 3. Prevention of skin breakdown includes but not limited to: c) Inspection of skin every shift with care signs of breakdown. 5. Skin protection. 7. Pain a) Observe and assess for indication of pain and or discomfort. b) Manage pain by controlling source of pain. d) offer/administer [MEDICATION NAME], if ordered prior to dressing changes. 9. Documentation. c) The care plan shall be evaluated and revised based on resident's response to treatment; treatment goals and outcomes. d). The resident's skin alteration/breakdown (pressure ulcer, arterial, diabetic, venous ulcers and etc ) shall be documented in the resident's clinical records in accordance to the facility's policy and in compliance to current regulatory standards. 11. Wound assessment for pressure, diabetic, venous and arterial wounds: documentation shall include but not limited to: type of wound and or ulcer, location, date, stage ( if applicable), length, width and depth; wound bed description, wound edge description and if present, exudates, undermining, tunneling and wound related pain. Facility's Skin care treatment regimen revised date 8/2/19 indicated: it is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for [REDACTED].

Based upon observation, interview and record review the facility failed to document an initial wound description, failed to conduct weekly wound assessments, failed to transcribe wound care orders on the TAR (Treatment Administration Record) and failed to document treatment administration for one of five residents (R66) in the sample. R66 acquired a stage 3 sacral pressure ulcer on or about 4/5/19 which became necrotic and required surgical intervention 4/24/19. Findings include; R66's (4/5/19) POS (Physician order [REDACTED]. R66's (April 2019) TAR does not include said order therefore treatments were not documented. The (undated) pressure ulcer report (received 4/23/19) affirms R66 has a (stage 3) sacral wound measuring 5 x 2.5 x 0.3. On 4/24/19, R66's (March/April 2019) wound assessments were requested. On 4/24/29 at 3:31pm, V2 (Director of Nursing) presented R66's (3/13/19) admission assessment which does not include wounds, (3/21/19) skin evaluation which does not include wounds and (4/5/19) readmission assessment which includes a coccyx skin impairment, however type, length, width, depth, and stage are not inclusive. Surveyor inquired about R66's weekly wound assessments (4/5/19, 4/12/19, and 4/19/19) V2 stated That's everything I have. Surveyor inquired about the required frequency for wound assessments V2 responded Wound assessment is done weekly. On 4/25/19 at 1:05pm, V2 stated The patient (R66) was seen yesterday by the wound doctor for the first time and presented his (4/24/19) physician initial wound evaluation which includes the following; unstageable deep tissue injury sacrum. Etiology pressure. 5 x 2.5cm (centimeter) x not measurable. 20% slough. Surgical excisional debridement procedure; remove necrotic tissue and establish the margins of viable tissue. Curette was used to surgically excise 2.5cm of devitalized tissue. Dressing treatment plan: [REDACTED]. Foam with border apply once daily for 30 days. (On 4/25/19 at 10:12am, V27 applied hydrogel, dry gauze and border dressing to R66's wound which was not the treatment plan). On 4/25/19 at 10:40am, V12 (Assistant Director of Nursing) presented R66's current wound care orders, Leptospermum honey and foam border dressing x 30 days were not inclusive. The skin care treatment regimen policy & procedure (reviewed 2/20/17) states; it is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [REDACTED]. Charge nurses must document in the nurse's notes and/or the wound report form any skin breakdown upon assessment and identification.

Based on observation, interview and record review, the facility failed to ensure that a pressure sore did not increase in size/decline, failed to ensure that wound care treatments were performed according to facility practices, facility failed to ensure that physicians were notified of change in condition of wound status, failed to ensure that a low air loss mattress was functional, failed to ensure that staff obtained wound treatment orders upon admission to the facility, failed to ensure that staff did not place multiple linens on the low air loss mattresses and failed to follow medication orders to promote wound healing which affected four residents (R52, R61, R64, R86) of six residents reviewed for pressure sores in a sample of 22. These deficient practices resulted in worsening of pressure sores for R52, R61, R64 and R86 and caused R52's right and left buttock wounds to develop into Stage 3 pressure ulcers. Findings include: 1. R86's Resident Face Sheet documents a medical history which includes Non-pressure chronic ulcers of foot and thigh but does not include R86's [DIAGNOSES REDACTED]. On 3/19/18, the facility submitted a wound care list which documented that R86 was admitted to the facility with a right buttock unstageable pressure sore. On 3/18/18 at 12:45pm, R86 was laying on R86's back on a low air loss mattress. R86's air mattress was deflated and R86 indicated that the mattress was uncomfortable. R86 stated, I'm sinking. The air mattress had multiple layers of linen: thin sheet, thick cloth incontinence pad, thin blanket folded into fourths and an incontinence brief. On 3/19/18 at 9:44am, V21 (CNA-Certified Nurse Assistant) changed R86's soiled incontinence brief. V4 (Wound Care Nurse) was asked what stage R86's right buttock wound was and V4 stated, It's a cavity. You'll see when we get in there. This surveyor asked the stage of the wound again and V4 did not answer. As V21 turned R86, it was noted that R86's low air loss mattress was padded with a thin sheet, thin blanket folded into fourths and two thick cloth incontinence pads which were doubled up under R86's right buttock area. V21 finished cleaning up R86's bowel movement. V21 did not remove V21's soiled gloves. As V21 folded one of the thick incontinence pads under R86, it smeared with stool. V21 did not remove the incontinence pad. It remained under R86 during the wound treatment. V21 turned R86 to R86's right side so that V4 could begin treatment on R86's buttock wound. V4 squeezed two small vials of normal saline into R86's right buttock wound. V4 stated, This is how I do. I squeeze the two vials into the cavity. V4 and V21 then tilted R86 back towards R86's left and laid R86 flat on the soiled incontinence pad. R86's right buttock wound came in contact with the soiled incontinence pad. V4 stated, We let the water run out. After patting the wound dry, V4 applied hydrogel inside the buttock wound using a tongue depressor, then on the peri wound area and then inside the buttock wound again. V4 used the same tongue depressor. At this point, R86 was turned to R86's right side and the air mattress was visibly deflated. At 10:05am, V4 confirmed that the mattress was deflated and stated that one of the air cells was the problem. V21 stated It's fine. It was visible that the low air loss mattress was not supporting R86's weight. R86's Physician order [REDACTED]. Pat peri wound dry. Apply hydrogel to area, then loosely pack with sterile roll gauze every day and PRN (as needed) if loose or soiled. This wound care treatment order does not indicate to apply hydrogel to the peri wound area. It indicates to pat the peri wound area dry. On 3/19/18 at 11:00am, V15 (Environmental Manager) indicated that he called the rental company for a new mattress because of the problem with the mattress. V15 stated, It's deflated and not inflating properly. When asked who sets the air mattress up, V15 stated, The company places the frame and the air mattress in the room. And then the wound care nurse goes in and sets up the machine for the weight and the types of settings for the resident specific wound. I don't have that knowledge. On 3/19/18 at 12:50pm, V4 (Wound Care Nurse) confirmed R86's settings for R86's low air loss mattress. R86's weight setting was set to 300 pounds. V4 stated, Yea, that's about right. (R86) looks about 300 pounds. V4 pushed the up button and demonstrated that the resident's weight could be set at five pound increments. V4 stated, Now that he's out of it, the mattress looks better. I think the mattress cannot handle all the weight in the middle. V4 stated, The purpose of the (air) mattress is to provide pressure reduction. If functioning, it prevents wounds from getting worse. I think his weight was just not distributed. On 3/20/18, the facility submitted a document which indicated R86's weight as 408.2 pounds. On 3/19/18 at 1:32pm, V22 (Mattress Technician) stated that the setting should be within five to ten pounds of resident's actual weight. V22 stated, If weight is not set within range, air cells will not expand. Increased weight, cells expect certain amount of pressure. (Air) cells won't expand due to wrong weight. V22 delivered a new bed frame and new air mattress. On 3/19/18 at 2:10pm, V23 (Customer Service Representative Air Mattress) stated, Padding? Top cover works like a sheet. Do not tell the facility to use multiple layers. Generally, tell people just one thin sheet. Multiple layers will impede the air from circulating around the resident. V23 indicated that if settings on bed were at 320 for a 350 pound resident, then the resident will bottom out and air mattress will deflate. V23 indicated that if the settings are input incorrectly then the pressure redistribution would not occur. On 3/20/18 at 10:24am, R86 was lying in bed on R86's back with multiple layers of linen underneath R86: two thin sheets, two thick cloth incontinence pads and a thin blanket folded in fourths. R86 stated, I feel the difference in the mattress. It feels more firms. I feel more support. And it feels like less strain on my backside. When the mattress wasn't as full, it felt like more pressure on the backside. Like I could feel the frame of the bed. I feel the air circulating now. It feels more like a pillow. R86 indicated that R86's mattress has felt bad for about 3-4 weeks and the facility was aware. On 3/20/18 at 2:20pm, V21 (CNA-Certified Nurse Assistant) stated, We were trained only one flat sheet on the air mattress. R86 alert so he wants things done R86's way which is different from everyone else. I let the nurse know. R86's wound care plan does not reflect R86's behavior regarding requesting extra linen on R86's air mattress. R86's right buttock pressure sore was detected upon R86's return from a local hospital on [DATE]. R86's Resident Progress Notes indicate that orders for wound treatment for [REDACTED]. Initial wound care for R86's right buttock pressure wore sore were not performed until 10/24/17. V4 measured the right buttock wound on 10/23/17: Stage 2 pressure ulcer 3.0 centimeters (cm) length by 6.5 cm width by 0.1 cm depth. It is not signed off on the Treatment Administration Record (TAR) or documented in R86's Progress Notes that wound treatment was performed to the right buttock pressure ulcer. R86's Wound History documents that the right buttock pressure sore declined on four separate occasions: 11/2/17: 3.0 cm length by 3.5 cm width by 0.1 cm depth. It is documented that the tissue was [MEDICATION NAME]. 11/8/17: 2.5 cm by 1.5 cm by unable to determine (UTD) depth. The character of the wound changed to slough. The facility documented that R86's wound care was performed daily. There is no documentation indicating that V6 (Physician) was notified from 11/2/17 - 11/8/17 for a change in wound treatment. R86's TAR documents that he continued to receive the same wound care treatment until 11/8/17. 11/8/17 - 11/16/17: 10.5 x 8.3 x UTD. R86's wound size increased by 8 centimeters in length. V7 (Wound Care Physician) was not consulted for a wound evaluation until 11/15/17. There is no documentation that V6 was notified to change the treatment. R86 received the same wound treatment until 11/15/17. On 11/30/17, R86's right buttock wound measured: 6.5 cm x 8.0 cm x 0 cm. 12/8/17: it increased in size to 10 cm x 8.0 x UTD. There is no documentation that V6 or V7 was notified regarding the decline in the wound. On 3/20/18, V4 indicated that V4 could not locate V7's wound care notes for the time between 11/15/17 and 12/6/17. V4 indicated that V4 was on vacation and that V7 was possibly on vacation as well. There is no change in R86's wound care orders for that timeframe. On 3/8/18: 1 cm x 1 cm x 2 cm with undermining of 4.5 cm. On 3/14/18: It increased in size to 1.3 cm x 1.4 cm x 7 cm. There is no documentation that V6 or V7 were notified regarding the decline of R86's wound. On 3/20/18 at 11:20am, V4 measured R86's right buttock wound and stated that the length of the wound was 1.3 cm. This surveyor indicated that she saw the wound extend past 1.5 cm. V4 stated, That's just fat. The width of the wound measured 0.8 cm in width and 2.5 cm in depth. The undermining was measured at 7 cm. There is no documentation that V6 or V7 were notified regarding the decline of R86's wound. On 3/20/18 at 2:47pm, V7 was asked, If the facility is utilizing the air mattress correctly and notifying a physician when the wound worsens, would your expectation be that the wound would heal? V7 stated, If the mattress is not set to the correct weight and if there are multiple layers of linens, then the wound will not heal whether avoidable or unavoidable. Sure, this can contribute to the deterioration of the wound. V7 indicated that either she or the primary physician should be notified if a wound declines so treatments can be changed accordingly. On 3/21/18 at 10:36am, V6 (Physician) stated, I am the primary physician. I go to see (R86) every month. They are supposed to notify me if the wound gets worse. They have never notified me regarding (R86's) wound. I did not know that (R86's) pressure sore got worse. Nurses should be notifying me all the time so I can arrange for treatments or to go to the hospital for debridement. I did not give them an order for [REDACTED]. On 3/21/18 at 11:14am, V3 (ADON-Assistant Director of Nursing) stated, The expectation is that when the wound is discovered, nurse will identify the site and call the physician for initial wound care treatments. Nurse should so it as soon as the wound is identified. V1 (Administrator) stated, If wounds change, they are assessed daily by the wound care nurse. She's changing the wound every day. Wound care nurse visually notices the decline in the wound. Wound care nurse should not wait a week for a change in the wound to be addressed by (V7). On 3/21/18 at 11:20am, V2 (DON-Director of Nursing) and V3 indicated that a resident's wound should never come in contact with soiled sheets and that a pressure sore should always be cleaned from the inside to the outside to prevent cross contamination. R86's wound care plan documents: Approach: Apply dressings per (doctor) order. The facility submitted a document on pressure sores that list the expectations of the Wound Care Group: Contact your physician if your wound site becomes painful, odorous, larger, or if the amount of fluid coming from the wound increases. The manufacturer specifications for the low air loss mattress indicates that it can handle a weight up to 500 pounds. This pamphlet also documents: The electronic controller provides a real time display of the air pressure for both the inflated and deflated air cells. The deflated cells provide pressure relief, while the inflated air cells support the patient's weight. The amount of pressure needed to support a patient can be set automatically, based on the patient's weight, or can be set manually through custom configurations in Advanced Settings. Troubleshooting guide: 3. Patient is sinking or bottoming out: The pressures may be set too low for the patient's weight. a) Verify weight setting in Patient Setup. See Section 4.4.2. Adjust if set weight is not accurate to the patient's actual weight. 2. R61 is a [AGE] year old, male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R61's MDS (Minimum Data Set) dated 01/29/2018 documented: Sec. C - BIMS (Brief Interview for Mental Status) score of 10 which means moderately impaired cognition Sec. G - Needs extensive assistance from two persons physical assist during transfer, dressing, hygiene and toileting. R61 is using wheelchair for locomotion. Sec. H - Incontinence of bowel and bladder Sec. M - 0150: R61 is at risk of developing pressure ulcers; R61 has one Stage 4 pressure ulcer present upon admission into the facility. Sec. M - 1200: Skin and Ulcer Treatments - pressure reducing device for bed; pressure ulcer care. R61's POS (Physician order [REDACTED]. Site: Coccyx - cleanse wound with normal saline solution or wound cleanser. Pat peri wound dry then apply collagen. Cover with foam dressing daily and PRN (when needed) if loose or soiled once a day. R61's Care Plan on Pressure Ulcer dated 12/6/2016 documented intervention: Pressure reduction mattress. R61's Wound History documented: Pressure sore on the coccyx area was first observed on 12/06/2016, categorized as Unstageable, and was present upon readmission from hospitalization . R61's Wound Care Specialist Initial Evaluation dated 12/07/2016 documented: Unstageable (Due to Necrosis) Coccyx measuring 6cm (centimeters) x 7cm x 0.2cm. Additional Information: Wound not acquired in house, patient returned to facility with wound, per chart review patient recently hospitalized for [REDACTED]. A surgical excisional debridement of subcutaneous tissue was performed. Treatment - santyl once daily, dry protective dressing once daily; Recommendations: low air loss mattress; off-load wound, reposition per facility protocol. Further review of R61's wound history revealed: 12/08/2016 - Unstageable pressure wound on the coccyx measuring 6cm x 7cm; treatment - santyl ointment 12/29/2016 - Unstageable pressure wound on the coccyx measuring 6.4cm x 7.5cm x 2.0 cm; treatment - santyl ointment 04/20/2017 - Stage 4 pressure wound on the coccyx measuring 3.4cm x 2.5cm x 1.6cm; treatment - silver alginate with foam dressing 04/27/2017 - Stage 4 pressure wound on the coccyx measuring 4cm x 2cm x 1cm treatment - silver with foam dressing 05/26/2017 - Stage 4 pressure wound on the coccyx measuring 3cm x 1.5cm x 1.7cm; treatment - silver alginate with foam dressing 06/01/2017 - Stage 4 pressure ulcer on the coccyx measuring 3.3cm x 1.6cm x 0.5cm; undermining depth 1.5cm location 3 o'clock; treatment -silver alginate with [MEDICATION NAME] 08/25/2017 - Stage 4 pressure ulcer on the coccyx measuring 2cm x 1.5cm x 0.60cm; undermining depth 1.5cm location 0.6 o'clock 08/31/2017 - Stage 4 pressure ulcer on the coccyx measuring 2.5cm x 1.5cm x 0.6cm; undermining depth 1.0 cm location 3 o'clock; treatment - collagen with foam dressing 09/20/2017 - Stage 4 pressure ulcer on the coccyx measuring 2cm x 0.9cm x 0.5cm; undermining depth 1cm location 3 o'clock; treatment -collagen 10/02/2017 - Stage 4 pressure ulcer on the coccyx measuring 2.5cm x 1.4cm x 0.5cm; undermining 1cm. location 3 o'clock; treatment - collagen with foam dressing 10/27/2017 - Stage 4 pressure ulcer on the coccyx measuring 2cm x 1.2cm x 0.4cm; undermining depth 1cm location 3 o'clock; treatment - collagen with foam dressing 11/02/2017 - Stage 4 pressure ulcer on the coccyx measuring 2.5cm x 1.5cm x 0.4cm; undermining depth 1cm location 3 o'clock; treatment - collagen with foam dressing 11/16/2017 - Stage 4 pressure ulcer on the coccyx measuring 2.7cm x 1.5cm x 0.3cm; undermining depth 1cm. location 3 o'clock; treatment - collagen with foam dressing 11/29/2017 - Stage 4 pressure ulcer on the coccyx measuring 3cm x 2cm x 0.3cm; undermining depth 1cm location 3 o'clock; treatment - collagen with foam 01/12/2018 - Stage 4 pressure ulcer on the coccyx measuring 3.2cm x 1.5cm x 0.4cm; treatment - collagen with foam dressing 03/08/2018 - Stage 4 pressure ulcer on the coccyx measuring 1.8cm x 1cm x 0.4cm; undermining depth 1cm location 3 o'clock; treatment - silver alginate 03/16/2018 - Stage 4 pressure ulcer on the coccyx measuring 2cm x 1cm x 0.4cm; undermining depth 1cm. location 3 o'clock; treatment - collagen with silver alginate R61's Wound Care Specialist Evaluation Notes documented the following: 02/02/2017 - Stage 4 pressure ulcer on the coccyx measuring 5cm x 7cm x 3cm; Wound progress - Deteriorated; Surgical excisional debridement was performed; treatment - santyl once daily, dry protective dressing once daily, calcium alginate once daily; Recommendations - off-load wound, reposition per facility protocol. 11/15/2017 - Stage 4 pressure ulcer on the coccyx measuring 2.7cm x 1.5cm x 0.3cm. Wound progress - Deteriorated Treatment - dry protective dressing once daily, foam once daily; silver collagen once daily Recommendations - Continue off-load wound, reposition per facility protocol, low air loss mattress, multivitamin once daily PO (by mouth). 01/10/18 - Stage 4 pressure ulcer on the coccyx measuring 3.2cm x 1.5cm x 0.4cm; Wound progress - Deteriorated; Surgical excisional debridement was performed on the wound; treatment - dry protective dressing once daily, collagen dressing once daily; Recommendation - Continue reposition per facility protocol, off-load wound. 02/14/2018 - Stage 4 Pressure Wound Coccyx with measurements: 2cm x 0.8cm x 0.4 cm; undermining 1cm. at 3 o'clock. Surgical excisional debridement was performed; treatment - Dry protective dressing - once daily, silver alginate - every two days 02/21/2018 - Stage 4 Pressure Ulcer Coccyx with measurements: 2cm x 1cm x 0.4cm; undermining 1cm at 3 o'clock; surgical excisional debridement was performed; treatment - dry protective dressing, once daily, silver alginate every two days. Wound progress noted as Deteriorated. Assessment and Plan of Care Recommendation documented Stage 4 Pressure Wound Coccyx Deteriorated due to surface area, inflammation, incontinence 02/28/2018 - Stage 4 Pressure Ulcer Coccyx with measurements: 1.8cm x 1cm x 0.4 cm; undermining 1cm. at 3 o'clock; treatment - dry protective dressing, once daily, silver alginate and every two days 03/07/2018 - Stage 4 Pressure Wound Coccyx with measurements: 1.8cm x 1cm x 0.4cm; undermining 1cm at 3 o'clock; treatment - dry protective dressing, once daily, silver alginate every two days; Wound progress - no change 03/14/2018 - Stage 4 Pressure Wound Coccyx with measurements: 2cm x 1cm x 0.4cm; undermining 1cm at 3 o'clock; treatment - dry protective dressing apply once daily for 30 days, silver collagen apply once daily for 30 days; recommendation - off-load wound, reposition per facility protocol, low air loss mattress; Wound Progress documented Deteriorated. On 03/18/18 at 11:58 AM, R61 was observed in bed, on low air loss mattress; mattress was covered with white sheet as top sheet. A cloth underpad was placed under R61's buttocks and hip area. R61 was wearing an incontinent brief. R61 was asked regarding any pressure sores present on R61's back. R61 verbalized that R61 has a wound on R61's lower back. R61 stated, Staff cleans my wound every day and they change me regularly but my wound makes me feel messed up. I cannot do anything and I need assistance from staff. On 03/19/18 at 10:00 AM, R61 was observed lying on bed, on low air loss mattress. The mattress is covered with a white blanket sheet. On top of the blanket sheet was a cloth underpad placed under R61's lower back. On top of the cloth underpad, an incontinent brief was also observed laid under R61's lower back. R61 was also wearing an incontinent brief. At this time also, V4 (Licensed Practical Nurse, LPN/Wound Care Nurse) is about to do wound care treatment on R61. V4 removed R61's incontinent brief. There was no dressing observed on R61's wound on the coccyx area. V11 (Certified Nurse Aide, CNA) stated that when R61 did the morning care on R61, the wound dressing fell off because it was soaked with feces. V11 was asked if V11 reported it to V4 or to the charge nurse. V11 stated, I just saw V4 right now. No, I didn't tell her or to the other nurse. I know, I am supposed to tell the wound care nurse or to the nurse on duty. V4 continued doing the wound treatment. V4 cleansed R61's wound with saline, applied the ordered treatment then covered with foam dressing. The wound on the coccyx area is open, beefy red in appearance, with moderate amount of serous discharges. On 03/20/18 at 11:38 AM, Wound Care was again observed on R61 performed by V4 assisted by V11. Wound measurements were taken by V4 showing 2.0cm x 1.5cm x 1cm undermining 0.8cm about 1:00 o'clock. Wound care was performed afterwards. V11 was asked regarding linen covers for R61's mattress. V11 stated, Should be one top sheet only. At this time, it was observed that R61's mattress was covered with only one sheet. V11 was asked regarding yesterday's bed coverings. V11 stated, Yesterday was different, I know, I put so many sheets but today is only one sheet. We need to put only one top sheet because this is a special mattress. On 03/21/2018 at 10:10 AM, V11 was also interviewed regarding R61's pressure sore. V11 stated, He (R61) needs to be reposition every two hours, change incontinent brief every two hours and during changing of the brief, skin assessment is done and if there is a skin breakdown, the nurse need to be notified. We document skin assessment in the shower sheet. (R61) air mattress should be covered with one large sheet only. 3. R64 is a [AGE] year old, female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] Section M showed that R64 has no pressure ulcer at the time of admission in the facility. R64's MDS dated [DATE] documented: Sec. C - BIMS score of 3 which means severely impairment cognition. Sec. G - total dependence from two persons physical assist during transfer, dressing, toileting, hygiene and bathing; R64 uses wheelchair for locomotion due to impairment on both upper and lower extremities Sec. H - R64 has an indwelling urinary catheter and incontinent of bowel Sec. M - M0150 - R64 is at risk for developing pressure ulcers; R64 has one Stage 4 pressure ulcer Sec. M - 1200 - Skin and Ulcer Treatments - pressure reducing device for chair; turning/repositioning program; application of ointments/medications other than feet. R64's Wound History notes dated 08/17/2017 documented that a wound pressure on the coccyx was first observed on 08/15/2017, facility acquired and was categorized as Unstageable, with measurements 4.0cm x 3.0 cm; treatment: santyl ointment with foam dressing. R64's Resident Progress Notes dated 08/15/2017 documented: Resident (R64) is with sdti (suspected deep tissue injury) 4.0cm x 3.0 cm. utd (unable to determine) depth with blancheable redness to surrounding tissue with small excoriated area to left buttock, 0.3cm. x 0.3cm and informed new order written, low air loss mattress ordered revised turning schedule posted in room, vitamins and labs ordered, bolsters requested for bed to protect resident with positioning. R64's POS dated 08/15/2017 - 08/17/2017 documented: Site coccyx - cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Apply foam dressing to wound bed. Cover with border gauze daily and PRN if loose or soiled. R64's Care plan dated 08/23/2017: assess the pressure ulcer for stage, size, presence/absence of granulation tissue and epithelization, and condition of surrounding condition; Keep clean and dry as possible. Minimize skin exposure to moisture; Administer vitamins and minerals per MD orders. Further review of R64's wound history of pressure ulcer on the coccyx revealed: 11/23/2017 - Stage 4; measurements: 2.4 x 1.5 x 1.5; undermining depth 2.5 cm. location 12 o'clock; treatment - [MEDICATION NAME] with calcium packing 11/29/2017 - Stage 4; measurements: 3 x 2 x 2; undermining depth 2cm location 12 o'clock; treatment - [MEDICATION NAME] with calcium and foam 01/04/2018 - Stage 4; measurements: 1.5 x 1.0 x 0.80; no undermining; treatment - calcium alginate foam dressing 01/12/2018 - Stage 4; measurements: 2.5 x 1.5 x 0.8cm; undermining depth 2.0 cm location 12 o'clock 03/08/2018 - Stage 4; measurements: 0.8 x 0.5 x 0.6; undermining depth 2cm location 12 o'clock; treatment - calcium alginate with foam 03/16/2018 - Stage 4; measurements: 3 x 2 x 0.8; undermining depth 2cm location 12 o'clock; treatment - honey, calcium and foam R64's Wound Care Specialist Evaluation Notes dated 03/14/2018 documented: Wound size: 3cm x 2cm x 0.8cm; undermining 2cm at 12 o'clock; Surgical excisional debridement was performed on R64's wound on the coccyx. Wound progress - Deteriorated Dressing Treatment Plan - Foam apply once daily for 30 days, calcium alginate apply once daily for 30 days, leptospermum honey apply once daily for 30 days Recommendations - Off-load wound, reposition per facility protocol, Multivitamin once daily PO; Vitamin C 500mg. twice daily PO. POS dated 03/16/2018: Site -coccyx - cleanse wound with normal saline solution or wound cleanser, pat dry, apply [MEDICATION NAME] with calcium alginate, cover with foam dressing daily and PRN if loose or soiled once a day. Further review of POS dated 08/15/2017 showed that R64 has orders for MVI 1 tablet PO (by mouth) every AM (morning) once a day and Vitamin C 250 mg. (milligrams) PO every AM once a day. On 03/18/18 at 10:58 AM, R64 was observed lying in bed. R64 was turned to the left side. R64 is using a low air loss mattress; the pump indicated a static mode. The mattress was covered with a top sheet. Under R64's lower back area, a white sheet folded into fourths was observed placed. R64 was wearing an incontinent brief. On 03/19/18 at 10:12 AM; R64 was again observed lying in bed, awake. The mattress was covered with a top sheet. Under R64's lower back area, a white sheet folded into fourths was placed. R64 was also wearing an incontinent brief. A wedge pillow was placed under R64's left shoulder. R64 was turned to right side. The pump for the mattress indicated a static mode. V12 (Restorative Aide/CNA) and V13 (Certified Nurse Aide, CNA) was about to reposition R64 to the left side when V13 checked R64's incontinent brief was already wet with urine. Incontinence care was observed. After performing incontinence care on R64, V12 started to change the bedding linens. V12 placed the top sheet covering the mattress; a white blanket folded into fourths was placed underneath R64's lower back and put on a new diaper on R64. Afterwards, V12 placed a wedge pillow on the right shoulder and turned R64 to the left side. At 11:30 AM, Wound Care was observed as performed by V4 assisted by V13 on R64. V4 washed hands then donned gloves. V4 removed old dressing. The wound was open, deep and necrotic with serous discharge noted. V4 started to cleanse the wound with saline, removed gloves and washed hands. V4 donned gloves, applied the [MEDICATION NAME] with calcium alginate, and then covered with foam dressing. At 02:05 PM, R64 asked V4 regarding static mode indicated on R64's pump for the mattress stated, Static mode is non-alternating. The mode of the pump should be in alternating mode. On 03/20/18 at 03:05 PM, V12 was asked regarding beddings for low air loss mattresses. V12 stated, We need to put a top sheet, then a draw sheet or a flat sheet and adult brief on residents. We were trained by V4 to put a top sheet, a draw sheet plus of course resident wearing the incontinent brief. 4. R52 is an [AGE] year old, male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] documented the following: Sec. C - BIMS score of 10 which means moderately impaired cognition. Sec. G - needs extensive assistance from two person physical assist during transfer and dressing; needs extensive assistance from one person physical assist during provision of hygiene, toileting and bathing. R52 uses wheelchair for locomotion due to impairment on lower extremities. Sec. H - has indwelling urinary catheter and is frequently incontinent of bowel Sec. M - M0150 showed that R52 is at risk of developing pressure ulcers; M0210 showed that R52 has no pressure ulcers. M1200 skin and ulcer treatments - pressure reducing device for chair, turning/repositioning program, application of ointments/medications other than to feet. R52's Resident Progress notes dated 01/30/2018 documented: R52 is with abraded tissue to right buttocks measuring 1.5cm x 1.3cm x 0.1cm over previously damaged tissue, dressing applied, tolerated well. R52's Resident Progress notes dated 02/06/2018 documented: R52 is with abraised area of skin to left buttocks 1.5cm x 3.0cm, new order in place. R52's Wound Care Specialist Evaluation Notes documented the following: 02/07/2018 - Shear Wound of the Left Buttock measuring 2.5cm x 3 x 0.1; treatment - collagen dressing every three 3 days, [MEDICATION NAME] every three days; Shear Wound of the Right Buttock measuring 2 x 2 x 0.1; treatment - collagen dressing every 3 days, [MEDICATION NAME] every three days. 02/21/2018 - Shear Wound of the Left Buttock measuring 10 x 5 x 0.1cm. Wound progress - Deteriorated; Surgical Excisional debridement was performed on R52's left buttock wound; treatment - calcium alginate once daily, dry protective dressing once daily, santyl once daily. 03/14/2018 - The shear wound on the right and left buttocks were now categorized as Stage 3 Pressure Wound. R52's POS dated 03/16/2018 documented: Site Right buttock - cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Apply santyl to wound bed. Cover with 4x4 and border every other day and PRN if loose or soiled. (MONTH) use foam with dressing once a day; Site Left buttock - cleanse wound with normal saline or wound cleanser. Pat peri wound dry. Apply santyl with calcium alginate to wound bed. Cover with 4x4 and border gauze daily and PRN if loose or soiled. R52's care plan dated 01/05/2017 related to Pressure Ulcer documented interventions: Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences; Keep bony prominences from direct contact with one another with pillows; Keep linen clean, dry and wrinkle free; Keep clean and dry as possible. Minimize skin exposure to moisture. On 03/18/18 at 01:46 PM, R52 was observed lying in bed, awake, on low air loss (LAL) mattress. The mattress is covered with a top sheet. R52 was wearing a diaper. Under R52's lower back, a cloth underpad was placed. 03/19/18 at 10:03 AM, R52 was observed asleep on bed; on LAL mattress. The mattress was covered with a top sheet. A white sheet folded into fourths was placed under R52's lower back. R52 was wearing an incontinent brief. R52 was turned to left side. 03/19/18 at 11:40 AM, Wound care was observed as performed by V4 assisted by V14 (CNA) on R52. V4 removed the old wound dressing. R52 removed gloves and washed hands. V4 donned gloves,

Based on interview and record review, the facility failed to follow their fall prevention program for one resident (R460) in a sample of 22 residents reviewed for falls by not assessing or putting interventions in place for a resident with a history of falls in the facility. Furthermore, the facility failed to communicate and coordinate care with the resident's physician and hospice service related to the resident's history of falls in the facility and injuries obtained. This failure resulted in R460 having to be emergently transferred to local hospital with an abrasion, contusion, and small laceration on the face. Findings include: Physician order [REDACTED]. R460 was admitted to hospice services on [DATE] and expired in the hospital on [DATE]. Emergency Medical Services report dated [DATE]: BLS Unit 32 dispatched to an emergency fall. Upon arrival, the [AGE] year old male patient was found in semi-fowlers position. Patient had an abrasion, contusion, and small laceration on the right side of the face near the eye. Patient complained of pain in the foot but that the pain existed before the fall. emergency room Patient Discharge Transition Record dated [DATE] states, Chief Complaint: Fall. Primary Diagnosis: [REDACTED]. Physician order [REDACTED]. Review of facility hospice records show no evidence of facility documentation notifying the hospice agency of the three separate fall incidents that occurred to coordinate care with the hospice agency. When interviewed on [DATE] at 11:00am, V2 (Director of Nursing), was asked about the lack of communication with the hospice agency, V2 stated, They (nurses) should be informing the hospice staff of everything going on with (R460) .They have a separate binder (regarding documentation), they don't document in our electronic system. V2 was asked to find any communication between the facility and hospice agency about the three separate fall incidents to coordinate care. V2 stated, I'm still looking but I can't find any notes on it. Hospice record dated [DATE] titled, Interdisciplinary Care Plan states, (R460) has the terminal condition of cerebral vascular disease. His son placed (R460) and his step mother into a retirement community last year when he observed them becoming more forgetful and falling-especially (R460). No documentation was provided from the facility of a care plan for R460 related to falls or behaviors. [DATE] interview at 10:00 am with V10 (family member) states, I placed my dad in the facility so he can be taken care of with dignity and respect at the end of his life. Instead they managed to let him fall three times and they tell me because he's been agitated or something. If that's the reason, then why didn't they watch him closer so he doesn't fall and hurt himself? I was told that putting him on hospice, he'd get more care and people to care for him but instead he's being found on the floor all the time. That's not being cared for if you find my dad on the floor all the time. [DATE] interview at 3:15 pm with V9 (Attending Physician) states, Yes, I'm the doctor for (R460) he was on hospice and had history of [MEDICAL CONDITION] and had [MEDICAL CONDITION]. (Review of facility and hospital records show no diagnoses of history [MEDICAL CONDITION] or [MEDICAL CONDITION].) V9 was asked if she was informed about (R460) expiring, V9 stated, No but I didn't need to be informed because he died on hospice and died in the hospital. When asked if she was informed about the falls that occurred in the nursing home V9 stated, Either myself or my nurse practitioner is called, but I can't tell you for sure. V9 was reminded that R460 sustained three un-witnessed falls in the facility and asked her expectations of staff in carrying out doctors orders, V9 replied, Well (R460) is a hospice resident, I don't normally order anything, but if you ask my expectations, then I can tell you I expect that the staff keep him from falling by having fall precautions in place because he shouldn't be falling. He's hospice and he's dying, why is he falling? All MDS (Minimum Data Set) from [DATE] through [DATE] (Section E: Behaviors) R460 is assessed with [REDACTED]. Facility policy and procedure dated (MONTH) (YEAR) titled, Falls Prevention Program, states: Fall prevention program will be implemented to assure that safety of all residents in the facility whenever possible. This program should include measure which determines the individual needs of each resident by assessing the risks for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. As part of the initial assessment, identify individuals with a history of falls and risk factors for subsequent falling. Identify the root causes of the fall incident which could be related to resident's current or declining medical condition or worsening behavior. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction or if the individual continues to fall despite attempted interventions, notify the physician. Collect and evaluate any information until either the cause of the falling is identified, or can be speculated as to what was the resident trying to do causing the fall, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Additional policy and procedures titled, Hospice and Nursing Facility Services Agreement, states, Coordination of Services: In order to ensure that the needs of Hospice Patient are addressed and met twenty-four (24) hours a day, Nursing Facility, through its Administrator and/or designated representative shall coordinate, communicate, and document their activities hereunder with the Hospice Administrator and/or designated representative. Nursing facility shall immediately notify the Hospice upon occurrence of any of the following events: (i) A significant change in Hospice patient's physical, mental, social, or emotional status; (ii) Clinical complications appear that suggest a need to alter the Plan of Care. (iii) A need to transfer a hospice patient from the nursing facility, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related to conditions; or (iv) A hospice patient dies.

Based on interview and record review, the facility failed to follow their fall prevention program for one resident (R460) in a sample of 22 residents reviewed for accidents by not assessing or putting interventions in place for a resident with a history of falls in the facility. Furthermore, the facility failed to communicate and coordinate care with the resident's physician and hospice service related to the resident's history of falls in the facility and injuries obtained. This failure resulted in R460 having to be emergently transferred to local hospital with an abrasion, contusion, and small laceration on the face. Findings include: Physician order [REDACTED]. R460 was admitted to hospice services on [DATE] and expired in the hospital on [DATE]. Emergency Medical Services report dated [DATE]: BLS Unit 32 dispatched to an emergency fall. Upon arrival, the [AGE] year old male patient was found in semi-fowlers position. Patient had an abrasion, contusion, and small laceration on the right side of the face near the eye. Patient complained of pain in the foot but that the pain existed before the fall. emergency room Patient Discharge Transition Record dated [DATE] states, Chief Complaint: Fall. Primary Diagnosis: [REDACTED]. Physician order [REDACTED]. Review of facility hospice records show no evidence of facility documentation notifying the hospice agency of the three separate fall incidents that occurred to coordinate care with the hospice agency. When interviewed on [DATE] at 11:00am, V2 (Director of Nursing), was asked about the lack of communication with the hospice agency, V2 stated, They (nurses) should be informing the hospice staff of everything going on with (R460) .They have a separate binder (regarding documentation), they don't document in our electronic system. V2 was asked to find any communication between the facility and hospice agency about the three separate fall incidents to coordinate care. V2 stated, I'm still looking but I can't find any notes on it. Hospice record dated [DATE] titled, Interdisciplinary Care Plan states, (R460) has the terminal condition of cerebral vascular disease. His son placed (R460) and his step mother into a retirement community last year when he observed them becoming more forgetful and falling-especially (R460). No documentation was provided from the facility of a care plan for R460 related to falls or behaviors. [DATE] interview at 10:00 am with V10 (family member) states, I placed my dad in the facility so he can be taken care of with dignity and respect at the end of his life. Instead they managed to let him fall three times and they tell me because he's been agitated or something. If that's the reason, then why didn't they watch him closer so he doesn't fall and hurt himself? I was told that putting him on hospice, he'd get more care and people to care for him but instead he's being found on the floor all the time. That's not being cared for if you find my dad on the floor all the time. [DATE] interview at 3:15 pm with V9 (Attending Physician) states, Yes, I'm the doctor for (R460) he was on hospice and had history of [MEDICAL CONDITION] and had [MEDICAL CONDITION]. (Review of facility and hospital records show no diagnoses of history [MEDICAL CONDITION] or [MEDICAL CONDITION].) V9 was asked if she was informed about (R460) expiring, V9 stated, No but I didn't need to be informed because he died on hospice and died in the hospital. When asked if she was informed about the falls that occurred in the nursing home V9 stated, Either myself or my nurse practitioner is called, but I can't tell you for sure. V9 was reminded that R460 sustained three un-witnessed falls in the facility and asked her expectations of staff in carrying out doctors orders, V9 replied, Well (R460) is a hospice resident, I don't normally order anything, but if you ask my expectations, then I can tell you I expect that the staff keep him from falling by having fall precautions in place because he shouldn't be falling. He's hospice and he's dying, why is he falling? All MDS (Minimum Data Set) from [DATE] through [DATE] (Section E: Behaviors) R460 is assessed with [REDACTED]. Facility policy and procedure dated (MONTH) (YEAR) titled, Falls Prevention Program, states: Fall prevention program will be implemented to assure that safety of all residents in the facility whenever possible. This program should include measure which determines the individual needs of each resident by assessing the risks for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. As part of the initial assessment, identify individuals with a history of falls and risk factors for subsequent falling. Identify the root causes of the fall incident which could be related to resident's current or declining medical condition or worsening behavior. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction or if the individual continues to fall despite attempted interventions, notify the physician. Collect and evaluate any information until either the cause of the falling is identified, or can be speculated as to what was the resident trying to do causing the fall, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as a late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Additional policy and procedures titled, Hospice and Nursing Facility Services Agreement, states, Coordination of Services: In order to ensure that the needs of Hospice Patient are addressed and met twenty-four (24) hours a day, Nursing Facility, through its Administrator and/or designated representative shall coordinate, communicate, and document their activities hereunder with the Hospice Administrator and/or designated representative. Nursing facility shall immediately notify the Hospice upon occurrence of any of the following events: (i) A significant change in Hospice patient's physical, mental, social, or emotional status; (ii) Clinical complications appear that suggest a need to alter the Plan of Care. (iii) A need to transfer a hospice patient from the nursing facility, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related to conditions; or (iv) A hospice patient dies.

Based on interview, observation, and record review the facility failed to implement fall precautions and supervision for one of three residents (R1) identified as a fall risk and the facility failed to adequately supervise and ensure elopement prevention measures were functioning for one resident (R5) with advanced dementia out of five residents reviewed for elopement. This failure resulted in R5 leaving the facility unnoticed, without a coat and hat (sometime between 10:46 pm and 11:45 pm on 1/15/14). R5 was found 5 blocks away from the facility by the police department. Accuweather.com identifies temperatures for January 15 as high 22F (degrees Fahrenheit) with lows of 16F, and on Jan. 16 Highs 35F and lows of 20F. The facility has 4 residents in the supplemental sample who are ambulatory, diagnosed with [REDACTED]. Because the facility staff were not aware that R5 had eloped during freezing weather conditions, which created a potential for harm, and due to inadequate facility safety features to prevent an elopement, an Immediate Jeopardy was called. E1 (Administrator) was notified on 1/31/14 at 4:35 pm Findings include: 1) Face sheet documents R5 as a [AGE] year old with [DIAGNOSES REDACTED]. At the time of this incident R5 was a resident of the 3rd floor. R5 ' s psychosocial well-being Elopement Risk Observation, with a completion date of 12/17/13, was scored as 6. Score of 4 or more indicates elopement risk and requires interventions/care plan. Psychosocial well-being/elopement risk assessment dated [DATE] notes R5 as " moderately impaired-decisions poor; cues/supervision required. " Nursing progress notes describe R5 as: 1/5/14 12:00 am, document R5 is at times " adjusting objects that aren ' t present. " 1/6/14 11:22 am " very confused. " 1/7/14 3:40 am " Resident observed wandering through unit and attempted to get out from the unit through the emergency fire exit, writer immediately removed resident ... " and " ...closely monitored by staff due to high risk of elopement. " 1/7/14 11:16am " Resident observed attempting to open emergency exit door but was deterred per this writer he requires a lot of redirection at this time per staff and is unsuccessful due to confusion. This writer was informed per staff of resident being redirected after being inside a peer ' s room he became physically aggressive with staff picking up objects no one was injured. He is extremely confused ... " Z2 (physician) writes on 1/13/14 at 12:52 pm, " 1. Advanced Dementia with behavioral issues: mild delusional on and off. On 1/16/14 at 1:33 am E10 (Registered Nurse for 1/15/14 11:00 pm until 1/16/14 7:00 am) writes, " Upon nursing rounds around 11:45 writer noticed resident (R5) is not in his bed, staff searched the floor but was nowhere to be found ... " Police Department CAD call logs document the police department received a call on 1/16/14 at 11:47:46 (13 minutes to midnight or approximately 1 hour after R5 was noticed missing by nursing facility. Nursing note of 1/16/14 at 1:33 continues, " police notified and search was initiated. At about 1:15 police brought the resident to the facility stating that he was found at 31st and Harlem Ave. sitting in front of a house, resident was sent to ER (emergency room ) due to extreme cold and O2 (oxygen) saturation of 77% RA (room air, Normal reading 90 ' s) per MD orders. VS (vital signs): BP124/75 T (temperature) 96.9, P(pulse)81, Respirations 22; Administrator, DON (Director of Nursing) and family made aware. " On 2/4/14 at 10:38 pm Z3 (Police officer who found R5) stated, " I don ' t know exact time he was found but once we received call he was found 10 - 15 minutes later. He was found at 31st and Harlem on the Riverside. He had to cross railroad tracks; crossing Harlem Ave. He did not have a coat on; no hat; shoes on backward (left shoe on right foot). " For [DATE] accuweather.com reports a high temperature of 22F and low of 16F. R5 was released from the emergency room back to the facility without injury " ...returned to the floor by 2 EMTs (emergency medical technicians) as per nursing note of 1/16/14 at 5:44am. On 1/31/14 Z1 (Attending for R5) stated, " (R5 has) advanced dementia. Last 1 to 2 months more behavioral issues. Outside alone, yes, potential harm. " On 1/28/14 at 3:00 pm E11 (Certified Nursing Assistant) stated, " In the past he has waited for the elevator. No not able to get on elevator. Get his luggage and stand by elevator or standing by stairs on 3 South. From time I worked there on 3rd floor I saw him standing there. He told me once he wanted to leave. This happened over 2 month period. " On 1/28/14 at 3:00 pm E13(Registered Nurse) who worked on 3rd floor 3pm - 11pm shift on 1/15/14 stated, " Noticed (R5) missing at 11:45 pm. Nothing open. Opened door 3 South and 3 North and they both alarmed. Sometimes (R5) wait for elevator to jump. No visitors on unit. When making rounds not one visitor. " On 1/28/14 at 3:15 pm E14 (Certified Nursing Assistant for 3 South) who was scheduled 11:00 pm to 7:00 am 1/15/14 stated, " I arrived late almost 12:00 midnight. " On 1/28/14 at 9:00 am E2 (Director of Nursing) stated, " (R5) only privilege (pass privilege) if with family however, no one picked him up and he eloped. Front lobby stops when doors locked at 8:00 pm. No receptionist. Have to use code to get out front door. Exit in basement has alarm. It wasn ' t alarming so he got out front door. Someone gave him code. He ' s not alert and oriented. He has advanced dementia. He doesn ' t know how to press 1, 2, 3, 4 code. Someone let him out. " According to E1 (Administrator) per conversation on 1/28/14 at 9:35 am, " Stairwells are alarmed from 3rd floor. Elevators need key. The charge nurse is to have key on her at all times. Front lobby locked at 8:00 pm. I went to visitor log. Last visitor (illegible) signed out at 7:51 pm and 8:15 pm. Some visitors with no sign out. I asked ...They all said no visitors on 3rd floor. E12 (charge nurse 3 - 11pm) said saw him in dining room on 3rd floor 10:45 pm to 10:50 pm. No witnesses saw him leave. I guess what happened. Investigation done 11 pm - 7 am staff came off elevator. There ' s 8 - 9 second delay due to American with Disabilities act so doors remain open. He got on during lapse of time. Doors in lobby locked at 8:00 pm (receptionist leaves). If want to leave must call charge nurse (or 1 South Nurse). Only charge nurse (supposed to have code) has code. Operational since September. During in-service (found out) everyone knows code. Visitors know code. I ' m thinking visitor let him out. Staff told me visitor knows code. Cameras were not recording at that time. " On 1/31/14 at 1:15 pm, E1 (Administrator) reported the front lobby area had no written instructions for visitors when entering or exiting the facility related to residents. E1 (administrator) didn ' t think there would be an issue so no procedure in place. In addition E1 (administrator) acknowledged no quality assurance process was in place prior to 1/16/14 to ensure elopement preventive mechanisms in place were functioning as intended. On 1/28/14 at 3:45 pm while on tour with E1 (Administrator) and E9 (maintenance) basement door was found unalarmed. R5 care plan with target date of 9/25/13 documents a problem as: " Resident has exhibited behaviors that show a risk for elopement. Approach is " to continue to reside on a secured unit to be monitored. " R6 through R9 were all identified on list titled, " Elopement Risk Residents " as being ambulatory, diagnosed with [REDACTED]. The immediate jeopardy was determined to have begun on 1/15/14 when R5 was discovered missing. E1 was notified on 1/31 at 5:15pm that the abatement plan had been accepted. The facility took the following actions to reduce the IJ to severity Level 2: 1. On January 16, 2014 in middle of the night E1 (Administrator) reported to the facility to assist in the search for R5. 2. R5 was assessed for injury, although no injuries were noted, the resident was transported to the hospital for further evaluation on 1/16/14. 3. Facility identified all residents at risk for elopement and wandering. The facility elopement/wandering book has been reviewed to assure that all residents are accurately identified. Completed 1/15/14 4. The front sliding glass exit doors are monitored 24 hours a day, seven days a week by facility staff. This will remain in effect until the new electronic system is installed and operating. Started 1/15/14 and is ongoing. 5. The front door deactivation code was changed on 1/16/14. Only authorized staff have been given this new code. First floor south Nurses have been counseled about keeping the code secure. Completed 1/16/14. 6. R5 was placed on 1:1 observation that early morning of 1/16/14 until effective monitoring approaches are implemented. 7. On 1/16/14 at 2:00 am staff were in-serviced on " monitoring/rounding on residents; missing resident policy/procedure/reporting to administration and signs/symptoms of wandering behaviors. " 8. Facility administrative consultant has in-serviced the DON (Director of Nursing), ADON (assistant director of nursing) and Administrator regarding the importance of maintaining, monitoring and testing the facility ' s wandering/elopement system, policies and procedures. This includes: (1) evaluating, monitoring and testing existing preventative environmental safety (e.g. door locks, code access, door alarms, camera equipment); (2) Evaluating, monitoring and testing internal prevention procedures (e.g. resident assessment for risk, care plan development, interventions and approaches); (3) Evaluation, monitoring and testing staff adherence to policies and procedures regarding elopement/wandering prevention (e.g. care plan review, timeliness of assessments, timeliness of interventions and changes of approaches when warranted, post drill analysis and assessment). Completed 1/28/14. 9. Additional video monitoring cameras are being installed to better monitor resident and staff movement throughout the facility. Bidding requests started 1/16/14. Anticipated installation February 7, 2014. 10. On 1/16/14 at 1:00 am E15 (Maintenance Director) written statement notes, " Came in on January 16, 1:00 am. Did tour of building. Checked all alarms on every floor; opening door and resetting alarms. All alarms were working properly with no problems. 11. The facility sought and accepted a proposal for a new 8 channel DVR system with cameras with beginning installation on January 16, 2014. 12. Signage has been placed near the front entrance and front reception desk alerting visitors of the facility ' s policies and procedures regarding wandering residents and elopement risks. Signage will specifically instruct all visitors to not allow any residents from exiting with them and to seek staff assistance as needed. Completed 1/28/2014. 13. Random, unannounced elopement/wandering resident drills are held weekly to include all shifts at varied times. Started 1/16/14 and ongoing. 14. New alarm panel was installed for lower level exit door with 2 new auditory sirens on the evening of 1/28/14. 15. Additional quote is being sought for monitors for each nursing station on each floor. The abatement plan was accepted on 1/31/14 at 6:15 pm. 2. Facility Progress Note dated 12/16/13 at 10:27 pm reads: Resident (R1) observed lying down on the floor, after writer and staff heard a sound coming from resident's room, immediately vital signs, neuro-checks, physical and pain assessment were initiated, upon no apparent injury resident was placed on bed to be observed, writer contacted medical doctor. incident was explained and give the order of if any apparent injury, mental status change, of abnormal vital sign, to be sent to emergency room for further examination. Resident was reassessed and a small bump was noted on occipital, cold compresses and as needed medication were given for pain with positive outcome, transportation was set up, family notified about incident and doctors orders. On 12/27/13 at 12:58 pm E2 (director of nurses) stated "He (R1) was in the fall prevention program. He had floor mats, bed bolsters, alarm on bed and chair. The alarm has been in place since May 2013. On 1/3/14 at 3:29 pm E5 (licensed practical nurse) stated "I was in a room right in front of his (R1). I heard a sound like something hit over something, like metal over wood. I sent the CNA (certified nurses assistant) to see what happened. He (R1) said he went to the washroom and when he was coming out of the washroom, he tripped over the wheel. The CNA was (E8). When I did my rounds, I'm pretty sure I saw the alarm but I never saw the alarm when he fell . The alarm wasn't there. He had bed bolsters but was able to get over the bed bolsters. He was very independent." On 1/3/14 at 3:38 pm E8 (certified nurses assistant) stated "I was taking care of another resident across the hall. I heard a thud and went to see what happened. He (R1) was on the floor with his head against the closet door. There was no alarm. I called for the nurse. I worked with him before and he didn't have an alarm. I don't remember mats on the floor or any other fall precautions." Facility Occurrence Report dated 12/16/13 reads: Nurse narrative of occurrence: Resident was ambulating with walker from washroom to bed. He stated that he tripped with walker's wheel and fell and hit his head against closet door. Facility Care Plan with a problem start date of 10/11/13 reads: Resident has been identified as a high fall risk. Resident will be placed on fall prevention program. Goal target date 1/4/14, Resident will remain injury free. Approach start date 10/11/13, Make staff aware of residents placement of falling star program; Place icons on doors and mobile devices to alert of fall risk factor; keep fall precautions in place. Facility Current Orders sheet with a print date of 12/27/13 reads: Start date: 5/4/12 bed bolsters when in bed for safety precautions every shift, end date: open ended; 5/4/12 floor mats when in bed every shift, end date: open ended; 5/4/12 mobility alarm to be on all times in bed and/or wheelchair every shift, end date: open ended; 9/20/13 initiate falls prevention program, end date: open ended; 10/11/13 place resident on fall prevention program, monitor for safety, end date: open ended. Facility Fall Log dated December 2013 reads: 12/16 Root cause: staff error, not doing rounds. On 12/27/13 at 12:58 pm E2 stated "I complete the fall log. That was my own opinion. I tell them to do rounds all the time. The nurse and the CNA were in the same room with another patient. The log is just the conclusion for me. I didn't see why the CNA was in the same room with the nurse. They could have taken turns so that one would be on the floor." Facility Falls and Fall Risk, Managing policy reads: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 6. In conjunction with the Attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment or osteoporosis, as applicable) to try to minimize serious consequences of falling.