Every finding on record at Parc Joliet

Based on observations, interviews and record reviews, the facility failed to protect a resident's right to be free from abuse. This failure applies to 1 of 3 residents (R1) reviewed for abuse. This failure resulted in R1 experiencing inappropriate physical assault when a visitor entered her room, unzipped his pants, and placed an item into her mouth and resulted in R1 experiencing inappropriate physical contact and assault. The findings include: R1's electronic medical records show she is a [AGE] year-old female with diagnoses and conditions including early onset Alzheimer's disease, anxiety disorder and impaired communication who was admitted to the facility May 11, 2024.On June 23, 2026, at 11:00 AM, R1 was lying in her bed in her room unable to speak, with her upper and lower extremities contracted. R1 was clinching her teeth and opened her eyes wide in response when spoken to. R1 had an anxious expression on her face while observing the surveyor walking near or around her bed.R1's current care plan-initiated May 13, 2024, shows she is totally dependent on staff for all activities of daily living, requires two staff to turn and reposition, is non-ambulatory, and is non-verbal.On June 24, 2026, at 9:54 AM, V13 (Registered Nurse/Restorative) and V14 (Restorative Aide) said R1 is fully dependent on staff for mobility and all activities of daily living, is unable to move at all on her own. V13 and V14 said R1 is fully contracted in her upper and lower extremities, is non-verbal, and clinches or grinds her teeth frequently. V14 said no oral devices are used by R1.On June 23, 2026, at 12:20 PM, The facility's camera footage showed on June 10, 2026, at 2:20 PM, V7 (Visitor) entered the facility, approached the reception desk, spoke to the receptionist, wrote on the visitor log, walked through the reception area doors, and began heading down the hall towards the residents' rooms.On June 23, 2026, at 11:16 AM, V5 (Licensed Practical Nurse) said sometime in the afternoon on June 10, 2026, she saw V7 (R1's visitor), a man she did not recognize, walking down the hall towards R1's room. V5 said she kept an eye on him and saw him go into R1's room and wondered if he went into the wrong room. V5 said she realized he wasn't coming out of the room and her gut told her to go and check on R1. V5 said R1's room door was partially closed, and the curtain was pulled halfway closed so you could not see R1 from the hallway. V5 said she opened the room door and pulled the curtain back and saw V7 standing at R1's bedside with his back to the door. V5 thought this was odd behavior so she stood and watched him for a few minutes. V5 said V7 said Hi, do you remember me? to R1, which creeped her out. V5 said there was loud talking out in the hallway, and V7 turned to look, and this was when he saw V5 was in the room. V7 walked to other side of R1's bed and was now facing the door. V5 said she left R1's room and headed directly to V4 (Receptionist) and asked her who was V7. V4 said she had never seen him before. V5 asked V4 to check the sign in sheet. V5 said V4 checked the sign in sheet and there was an identifiable signature. V5 said she asked V4 to call social service and ask them if they can take a look and see if they can identify this man. V6 (Social Services Assistant) did not know who this person was and was only able to get his name and relationship to R1. V7 said his name was [first name], and he was a family member. V6 said that it was weird because the curtain was pulled when V6 went into the room. V6 said she would call the POA (Power of Attorney) to confirm who V7 was. V5 stayed at the reception area for a few seconds then walked over to V6's office and asked if everything was ok. V6 informed her that she called the POA but was unable to leave a voice message. V5 went down to R1's room again, the door was open but the curtain by the door was completely closed. V5 said she pulled the curtain back and V7 was unaware of her presence. V7 he was standing on the right side of R1's bed facing the door, had his pants zipper down, his hand was by his penis, he was smiling as he adjusted the device in R1's mouth. V5 said she could see a white string coming from R1's mouth and she said, hey what's going on? V7 zipped up his pants and began yanking on the string in R1's mouth to remove the object he had placed there. V5 said there was a mouth guard in R1's mouth to keep her mouth open. V7 pulled three times on the string real hard and couldn't get the device to come out of R1's mouth. V7 put his hand on R1's forehead, pushed her head into the mattress as he yanked on the string attached to item that was in her mouth and ran into the bathroom. V5 said she stepped out of the room yelling for help, and a second later V7 came out of bathroom, and pushed her out of the way. V5 said she kept yelling for help and for someone to stop him as he headed down hallway. V5 said she later identified V7 to the police. On June 23, 2026, at 1:28 PM, V5 (Licensed Practical Nurse) said R1 never wears mouth guards.R1's progress note dated June 10, 2026, shows she was admitted to the hospital for possible assault.R1's progress note dated 06/11/2026 shows family proceeded to have a rape kit completed, which included the oral and upper portion of the rape kit.On June 23, 2026, at 10:37 AM, V4 (Receptionist) said she has worked at the facility for 4 years, all visitors check in and out at the front desk and sign the visitor log. V4 said all residents' profiles are checked for new visitors to screen for restrictions. V4 said if someone new visits a resident who is vulnerable the receptionist calls the nurse and asks if the resident is able to receive that visitor safely. On June 10th, V4 said she briefly greeted the man that visited R1 (V7). V4 said she is required to ask all visitors who they're seeing at the facility, but she couldn't recall if she asked V7 who he was here to see or what his response was. V4 was unable to recall her communication with him. V4 said there were two people coming into the building at the same time when V7 entered the building and she was speaking with both of them so she couldn't recall the exact communication. V4 confirmed the illegible signature on the sign in sheet dated June 10, 2026, with missing information of what room number was being visited and the time in and out was V7's writing. V4 said she was not familiar with V7. On June 24, 2026, at 3:43 PM, V6 (Social Services Assistant) said on June 10th she didn't know who V7 (Visitor) was and called the family for confirmation that this person was ok to be at the facility visiting R1 since R1 was not able to give consent. V6 said she was unable to reach the V8 (POA/Power of Attorney) at that time. V6 said residents who can't give consent would need to have a visitor confirmed with the family listed in their profile. V6 said on June 10th she told V5 to just keep an eye on the situation while she contacts R1's family. V6 said she was not aware V7 (Visitor) had not signed in when he entered the facility. V6 said she would have talked to the family first before having the visitor sign the book and allowing him to enter R1's room. On June 23, 2026, at 1:59 PM, V8 said V7 is a family member. V8 said she is concerned about what happened to R1 on June 10th at the facility during V7's visit. V8 said the nurse at the hospital told her a nurse at the nursing home walked in on V7 with his pants down, and a curtain closed while in R1's presence after V7 illegibly wrote his name in the guest book and a staff member noticed he seemed suspicious. On June 23, 2026, at 2:29 PM, V8 said she is concerned about the incident that occurred at the facility. V8 said although V7 has been arrested and has received three aggravated battery charges. V8 said the very nature of what V7 did was sexual assault, and V7 went to the facility for the sole purpose to do what he did. V8 said R1 can't speak but she can speak for R1. V8 said she plans to have sexual assault charges added to the aggravated battery charges for V7. V8 said she had never been asked to identify who can visit R1 and who cannot, prior to June 10th. V8 said she is unaware of V7 ever visiting R1 while at this facility. V8 said she knows V7 made an attempt to conceal his identity on June 10th when he came into the facility because he scribbled his name down on the visitor log. V8 expressed that what happened to R1 was very upsetting.The police report for R1 dated June 10, 2026 shows police were sent to the facility regarding a unknown male visitor that put an unknown object inside a female patients mouth and then fled the facility; staff handed the officer a plastic bag with a black object in it that was attached to a white string and it was obtained as evidence; V5 reported to the officer when she walked in on V7 while he was in the room with the female patient (R1) the curtain was pulled closed and when she opened it, she saw V7 with his pants unzipped, his hand near his penis, a black object in the female patient's mouth and a white string hanging from it; the staff reported when she saw V7 he became startled, yanked extremely hard on the rope three times (same motion as trying to start a lawnmower) to try and remove the object but was unable to; V7 then had to grab the female patient by her forehead and hold her forehead down and then was able to yank the object out of her mouth. The reporting officer described the black object placed into evidence as a garage plug and rope from V7s garage, and a spacer to keep a mouth open.On June 24, 2026, at 4:16 PM, When asked how might R1 have reasonably felt about V7's behavior of putting a guard in R1's mouth and pulling it out aggressively, V2 (Director of Nursing) responded R1 didn't feel good about it. When asked how might R1 have been affected or reasonably felt if R1 had been sexually assaulted, V3 (Assistant Director of Nursing) said it's reasonable that R1 may have felt violated, shamed or afraid. On June 23, 2026, at 1:30 PM, V1 (Administrator) said visitors check in at the front desk, notify the receptionist who they are visiting and their room number, the receptionist will check to see if the resident has any restricted visitors, and the visitor signs in on the sign in sheet on the clip board at the reception desk. V1 said if a visitor is exhibiting suspicious behavior, the staff that observes the suspicious behavior needs to alert other staff to assist. V1 said if a staff observes a visitor exhibiting suspicious behavior the resident should not be left alone with the visitor. V1 said if the visitor fails to document on the visitor log who they're visiting the receptionist should fill that information in, and this information should be confirmed before the visitor is allowed past the doors at the receptionist area that leads to the resident's room. V1 said if the visitor has already entered the resident area and the receptionist notices that the visitor didn't document who they were visiting at the facility nor does the receptionist know who the visitor is there to see, the receptionist should notify management or nursing staff and have the visitor removed from the resident's room.The facility provided their policy titled, Abuse Prevention Program Facility Policy and Procedures with a revision date of January 4, 2019, showed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation. irrespective of any mental or physical condition, cause physical harm. It includes sexual abuse, physical abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately. The facility final investigation showed, Based on a thorough investigation, there is no credible evidence that abuse occurred.

Based on observations, interviews, and record reviews, the facility failed to submit an accurate and complete abuse investigation report to the state agency.This failure applies to 1 of 3 residents (R1) reviewed for abuse.The findings include:R1's electronic medical records show she is a [AGE] year-old female with diagnoses and conditions including early onset Alzheimer's disease, anxiety disorder and impaired communication who was admitted to the facility on [DATE].On June 23, 2026, at 11:00 AM, R1 was lying in her bed in her room unable to speak, with her upper and lower extremities contracted and clinching her teeth in response when spoken to. R1's eyes widened in response to being spoken to and had an anxious expression on her face while observing the surveyor walking near or around her bed. On June 23, 2026, at 11:16 AM, V5 (Licensed Practical Nurse) said sometime in the afternoon on June 10, 2026, she saw V7 (R1's visitor), a man she did not recognize, walking down the hall towards R1's room. V5 said she kept an eye on him and saw him go into R1's room and wondered if he went into the wrong room. V5 said she realized he wasn't coming out of the room and her gut told her to go and check on R1. V5 asked V4 (receptionist) and V6 (social services) and no one could identify this visitor. V5 said V7 kept closing the room door most of the way, and/or pulling the privacy curtain so R1 was not visible from the hallway. V6 was calling V8 to see if she could identify V7. V5 went down to R1's room again, the door was open but the curtain by the door was completely closed. V5 said she pulled the curtain back and V7 was unaware of her presence. V5 said V7 was standing on the right side of R1's bed facing the door, had his pants zipper down, his hand was by his penis, he was smiling as he adjusted the device in R1's mouth. V5 said she could see a white string coming from R1's mouth and she said, hey what's going on? V7 zipped up his pants and began yanking on the string in R1's mouth to remove the object he had placed there. V5 said there was a mouth guard in R1's mouth to keep her mouth open. V7 pulled three times on the string real hard and couldn't get the device to come out of R1's mouth. V7 put his hand on R1's forehead, pushed her head into the mattress as he yanked on the string attached to item that was in her mouth and ran into the bathroom. V5 said she stepped out of the room yelling for help, and a second later V7 came out of bathroom, and pushed her out of the way. V5 said she kept yelling for help and for someone to stop him as he headed down hallway. V5 said she later identified V7 to the police.R1's progress note dated June 10, 2026, shows she was admitted to the hospital for possible assault.On June 24, 2026, at 11:33 AM, V15 (Insurance Care Manager) said she saw R1's emergency room doctors' notes for the incident that occurred June 10th that stated the nursing home suspected sexual abuse.R1's progress note dated June 11, 2026, shows family proceeded to have a rape kit completed, which included the oral and upper portion of the rape kit.On June 23, 2026, at 2:29 PM, regarding R1's incident at the facility on June 10th, V8 (Power of Attorney/Family Member) said she did have a rape kit done for R1 and felt it was V7's full 100% intent to sexually assault R1.The police report for R1 dated June 10, 2026, shows police were called to the facility for a staff member (V5) walking in on a male visitor (V7) in the room of a female resident (R1) and saw V7 with his pants unzipped, his hand near his penis, a black object in R1's mouth with a white string hanging from it and V7 forcefully removing the object from R1's mouth.On June 24, 2026, at 2:09 PM, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) said V2 is the designated abuse coordinator when V1 (Administrator) is unavailable. V2 said she submitted the final abuse investigation report for R1 to the state agency and all pertinent information to an abuse allegation should be included in the investigation report provided to the state agency. V2 said she was advised not to include the information regarding V7's pants zipper being down while at R1's bedside in the report provided to the state agency. When asked if police reports are used in abuse investigations, V2 said she's never had to request a police report for a reportable and V16 (Activities Director) attempted to request the police report but had not been able to obtain it.The facility's final abuse investigation report dated June 16, 2026, sent to the state agency shows on June 10, V5 (Licensed Practical Nurse) reported an allegation of V7 (Visitor/Family Member) possibly being inappropriate with R1 and did not include information regarding V7 standing at R1's bedside with his pants unzipped and his hand near his penis while putting something in R1's mouth. The report also did not include information regarding R1's family requesting a rape kit nor R1 being admitted to the hospital for possible assault. The facility's final investigation showed, Based on the thorough investigation, there is no credible evidence that abuse occurred.The facility's Abuse Prevention Program Facility and Procedure with revision date of January 4, 2019, shows.Employees are required to report any incident, allegation or suspicion of abuse. immediately to Administrator. or designee in administrators absence. Final investigation report shall contain the following. Facts determined during the process of the investigation. If there is a police report, attach the police report.

Based on observations, interviews, and record reviews, the facility failed to provide evidence to the state agency that an allegation of abuse was thoroughly investigated.This failure applies to 1 of 3 residents (R1) reviewed for abuse.The findings include: R1's electronic medical records show she is a [AGE] year-old female with diagnoses and conditions including early onset Alzheimer's disease, anxiety disorder and impaired communication who was admitted to the facility May 11, 2024.On June 23, 2026, at 11:00 AM, R1 was lying in her bed in her room unable to speak, with her upper and lower extremities contracted and clinching her teeth in response when spoken to. R1's eyes widened in response to being spoken to and had an anxious expression on her face while observing the surveyor walking near or around her bed.R1's current care plan-initiated May 13, 2024, shows she is totally dependent on staff for all activities of daily living, requires two staff to turn and reposition, is non-ambulatory, non-verbal.On June 23, 2026, at 2:29 PM, regarding R1's incident at the facility on June 10th, V8 (Power of Attorney) said although V7 has been arrested and received three aggravated battery charges, she said the very nature of what V7 did was sexual assault, V7 went to the facility for the sole purpose of what he did and V8 plans to have sexual assault charges added to V7's charges. V8 said she did have a rape kit done for R1.The facility's final abuse investigation report dated June 16, 2026 that was sent to the state agency shows on June 10, V5 (Licensed Practical Nurse) reported an allegation of V7 possibly being inappropriate with R1 and did not include information regarding V7 standing at R1's bedside with his pants unzipped and his hand near his penis while putting something in R1's mouth. The report also did not include information regarding R1's family requesting a rape kit nor R1 being admitted to the hospital for possible assault. The report shows the facility concluded that based on their investigation there is no credible evidence that abuse occurred.R1's progress note dated June 10, 2026, shows she was admitted to the hospital for possible assault.On June 24, 2026, at 11:33 AM, V15 (Insurance Care Manager) said she saw R1's emergency room doctors' notes for the incident that occurred June 10th that stated the nursing home suspected sexual abuse.On June 23, 2026, at 11:16 AM, V5 (Licensed Practical Nurse) said on June 10, 2026, she observed V7 (Visitor) standing on the right side of R1's bed facing the door. He was smiling while adjusting the device in R1's mouth, with his pants zipper down, and his hand near his penis before he realized she was in the room. V5 asked V7 what he was doing, but he would not answer and ran into the bathroom. The police report for R1 dated June 10, 2026 shows police were sent to the facility regarding a male that put an unknown object inside a female patients mouth and then fled the facility; the staff at the facility reported to the officer when she walked in on V7 (Visitor/Family Member) while in the room with the female patient and saw V7 with his pants unzipped, his hand near his penis, and a black object in the female patient's mouth with a white string hanging from it; V7 held down R1's head while aggressively pulling the object out of R1's mouth; and V7 was arrested for aggravated battery of a senior citizen and a person with physical disability.On June 24, 2026, at 2:09 PM, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) said V2 is the designated abuse coordinator when V1 (Administrator) is unavailable. V2 said she submitted the final abuse investigation report for R1 to the state agency and all pertinent information to an abuse allegation should be included in the investigation report provided to the state agency. V2 said she was advised not to include the information regarding V7's pants zipper being down while at R1's bedside in the report provided to the state agency. V2 said there is no way to prove abuse occurred for R1 on June 10th. When asked if police reports are used in abuse investigations, V2 said she's never had to request a police report for a reportable and V16 (Activities Director) attempted to request the police report but had not been able to obtain it. V2 said the facility did investigate the abuse allegation for R1 on June 10th for any form of abuse that may have occurred. V2 said she doesn't believe the way V7 pressed down R1's forehead and pulled out the guard is considered assault. The facility provided final investigation report showed, Based on the thorough investigation, there is no credible evidence that abuse occurred.The facility's Abuse Prevention Program Facility and Procedure with revision date of January 4, 2019, shows.Employees are required to report any incident, allegation or suspicion of abuse. immediately to Administrator. or designee in administrators absence. Final investigation report shall contain the following. Facts determined during the process of the investigation. If there is a police report, attach the police report.

Based on interviews and record reviews, the facility failed to report a resident's injury of unknown origin within required timeframes.This applies to 1 of 3 residents (R1) reviewed for abuse concerns.The findings include:Camera footage from [DATE] showed around 7:35 PM, R1 and V4 (Certified Nursing Assistant) were standing in front of the elevators, the doors opened, and R1 pushed V4 into the elevator. The footage showed that V4 grabbed R1's right arm and then jerked R1's right arm, pulling R1 into the elevator. The footage then showed R1 was transported to the hospital around 8:01 PM. R1's [DATE] emergency room records showed that R1 arrived at the hospital with a swollen upper lip and dried blood on his lip. On [DATE] at 1:15 pm, V8 (CNA) said that she saw blood on R1's mouth after the incident but she did not know where the blood was coming from.On [DATE] at 2:48 pm, V3 (Nurse), who was R1's nurse at the time, said that she saw blood on R1's lip after the incident but she did not attend to or assess R1. R1's [DATE] Minimum Data Set showed that his cognition is severely impaired. R1's [DATE] 8:17 PM progress notes showed that R1 was being aggressive towards a nurse and a CNA and he was transported to the local community hospital for psychological evaluation. R1's [DATE] 1:08 AM progress note showed that R1 returned from the hospital. On [DATE] at 4:17 PM, V2 DON (Director of Nursing) said that she was not informed that R1 was found with blood on his mouth.On [DATE] at 4:30 pm V15 ADON (Assistant Director of Nursing) said that he was unaware of R1 having blood on his mouth.On [DATE] at 4:05 pm, V1 (Administrator) said that she did not investigate the incident involving R1 on [DATE]. The facility was unable to provide documentation that showed the facility notified the Illinois Department of Public Health that an investigation had been opened into the cause of R1's bloodied and swollen lip on [DATE]. The facility's 1/2024 Abuse Prevention Program policy showed V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation, or suspicion of potential abuse.they observe, hear about, or suspect, to the administrator immediately or to an immediate supervisor, who must then report it to the administrator.reports should be documented and a record kept of the documentation.The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises, lacerations, or other abnormalities as they occur. The policy's section VIII. External Reporting showed 1. Initial Reporting of Allegations-.Public Health shall be informed that an occurrence of potential abuse.is being investigated. 2. Five-Day Final Investigation Report- within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation.will be sent to the Department of Public Health.

Based on interviews and record reviews, the facility failed to investigate the cause of a resident's injury.This applies to 1 of 3 residents (R1) reviewed for unknown injury.The findings include:R1's 4/11/26 Minimum Data Set showed that his cognition is severely impaired.R1's 5/6/2026 8:17 PM progress notes showed that R1 was being aggressive towards a nurse and a CNA (Certified Nursing Assistant) and was transported to the local community hospital for a psychological evaluation.On 5/14/2026, the facility's camera footage of 5/6/26 from 4:00 pm to 8:05 PM was reviewed. The footage from 7:35 pm to 7:59 PM showed R1 was attempting to leave the facility by means of the elevator and the stairway and staff were intervening. The footage showed that around 7:35 PM, R1 and V4 CNA were standing in front of the elevators when the doors opened, and R1 pushed V4 into the elevator. The footage showed V4 grabbed R1's right arm and then jerked it, pulling R1 into the elevator. On 5/14/26 at 1:15 pm, V8 (CNA) said afterwards she saw blood on R1's mouth but she did not know where the blood was coming from.On 5/14/26 at 2:48 PM, V3 (Nurse), who was R1's nurse at the time, said that she saw blood on R1's lip after the incident but she did not attend to or assess R1. R1 was sent to the Emergency Room.R1's 5/6/2026 emergency room records showed that R1 arrived at the hospital with a swollen upper lip with dried blood present. R1's 5/7/2026 1:08 AM progress note showed that R1 returned to the facility. On 5/14/26 at 4:17 PM, V2 DON (Director of Nursing) said that she was not informed that R1 had blood on his mouth and did not investigate any injury to R1. On 5/14/26 at 4:30 PM, V15 ADON (Assistant Director of Nursing) said that he was unaware of R1 having blood on his mouth and did not investigate R1 for an injury.On 5/14/26 at 4:05 PM, V1 (Administrator) said that she did not investigate the incident involving R1 on 5/6/26. The facility was unable to provide any documentation of an investigation conducted for R1 that related to injuries incurred during the 5/6/2026 incident.The facility's 1/2024 Abuse Prevention Program policy showed .Incidents, will be reviewed, investigated and documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of residence property occurred, was alleged or suspected. Incidents or allegations.will be reviewed by the administration and shall be investigated For resident injuries not involving an allegation of abuse or neglect the administrator will appoint a person to gather further facts to make a determination as to whether the injuries should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because the extent of the injury or the location of the injury. If the cause of an injury of unknown, the person gathering facts will document the injury.The investigator will attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable.

Based on observation, interview, and record review, the facility failed to ensure residents' medical records contained documentation to support new diagnoses of schizophrenia.This applies to 2 of 4 residents (R1, R3) reviewed for behavior documentation.The findings include:1. R3's Face Sheet showed she is a [AGE] year-old female who was admitted to the facility 12/09/2024 with diagnoses that include bipolar disorder and alcohol abuse. The Face Sheet showed a diagnosis of generalized anxiety disorder was added to R3's diagnosis list on 10/7/2025, and a new diagnosis of paranoid schizophrenia was also added on 2/17/2026. R3's March 2026 Medication Administration Record (MAR) showed a 12/9/2024 order for 300 mg (milligrams) of quetiapine (an anti-psychotic medication) to be given at bedtime for bi-polar disorder. The order was discontinued on 2/17/2026. The same MAR showed the same medication at the same dosage was to be given at the same time, but for a diagnosis of paranoid schizophrenia, starting 2/17/2026. On March 12, 2026 at 11:45 AM, R3 was in her room lying in her bed showing no signs of abnormal behavior. R3 was fairly groomed and had good hygiene. R3 described the medications she was taking. R3 said V5 (Psychiatric Nurse Practitioner) wanted to take her off quetiapine and clonazepam and mentioned something about those drugs being banned. R3 said V5 told her they changed the rules about the drug and unless she had a diagnosis of paranoid schizophrenia, she wouldn't be able to take it anymore. V5's 2/17/2026 Psychiatric follow-up note showed a Chief Complaint of I think people are out to get me and that's why you always want to take my medication away. The note showed R3 was being seen for medication management. R3's note showed she was well-groomed and appropriate and calm, had a clear and normal rate, tone and volume of speech, her thought process was linear, her associations were intact, and her mood was upset. R3's current care plan initiated 12/11/2024 shows she has a history of substance abuse and has potential complications of mood or behavioral disturbance. The care plan showed R3 requires psychotropic medication, including antipsychotics and antianxiety medications, to help manage and alleviate depression, mood swings, anxiety, and neurosis. Interventions include recording and documenting on a behavior tracking form if behavioral symptoms are observed. On March 17, 2026 at 11:16 AM, V2 (Director of Nursing/Registered Nurse) said residents receiving psychotropic medications or with diagnoses of dementia or other behavioral health disorders receive behavior monitoring. V2 stated all behavior monitoring should be documented in the resident's medical records, which include a progress note, a behavior template available in the medication administration records, and therapy and psychiatric reports. R3's monthly Medication Administration Records (MAR) from December 2024 to March 2026 (15 months) all showed a 12/09/2024 order for behavior monitoring. R3's MARs showed no observations of behavioral symptoms of being withdrawn or depressed, false beliefs, hallucinations, paranoia, delusions, or mood changes during the previous 15 months. The MAR asked for this information daily for each shift. On March 19, 2026 at 11:46 AM V28 (Psychiatric Physician) said they assess patients at every visit for what diagnosis they have, and use the DSM-V (Diagnostic and Statistical Manual of Mental Disorders-V) criteria. V28 stated the individual needs to have at least two of five core symptoms of delusions, hallucinations, disorganized thoughts/behaviors, and paranoia, and for a prolonged period of time. V28 stated there can't be just one delusion once in your life; it has to be a longer pattern, and therefore it's really hard to make the diagnosis. V28 said you want to make sure that if you're observing symptoms for schizophrenia it's recorded, especially when the symptom was happening. V28 said not everyone has all of the symptoms of schizophrenia all of the time, as some symptoms are present at different times. V28 said individuals with dementia can have disorganized behavior, delusions, paranoia too. On March 16, 2026 at 11:48 AM, V6 (Licensed Practical Nurse) said the only behaviors she has observed for R3 were anxiousness and excitability. On March 16, 2026 at 12:10 PM, V13 (Certified Nursing Assistant) said she has worked for the facility for 2 years, she has not observed R3 with hallucinations, paranoia, or delusions. On March 16, 2026 at 12:43 PM, V15 (Social Services Director) said she has never observed R3 having delusions, paranoia, or hallucinations. V15 stated that on 02/17/2026, R3 came to the social services office because she was upset because she believed her medication would be taken away and she didn't want it discontinued. R3 was concerned that if she was taken off her medications she may get kicked out because of behaviors. 2. R1's Face Sheet showed she is a [AGE] year-old female who was admitted to the facility 07/26/2025 with diagnoses including history of unspecified dementia with behavioral disturbance, bipolar disorder, delusional disorders, recurrent major depressive disorder, generalized anxiety disorder, and shared psychotic disorder. R1's Face Sheet showed a new diagnosis of paranoid schizophrenia was added to her diagnosis list on 2/11/2026. R1's current care plan initiated 08/05/2025 and last reviewed 01/08/2026 shows she is receiving psychotropic medication to help manage and alleviate bipolar, dementia, delusional disorder, recurrent depression, and anxiety, with interventions including to record and document on behavior tracking form. R1's March 2026 Physician Order Sheet (POS) includes a 7/28/2025 order for behavior tracking, including to monitor for behaviors of depression, being withdrawn, false beliefs, hallucinations, paranoia, delusions, and mood changes. R1's Medication Administration Records MAR) from September 2025 to March 2026 showed no behavioral symptoms of being withdrawn, false beliefs, hallucinations, paranoia, or delusions daily across all shifts. On March 16, 2026 at 1:17 PM, V15 (Social Services Director) and V16 (Social Services Assistant) said they have not observed R1 with any delusions, hallucinations, or paranoia. V16 said R1 worries about her health regarding dementia and this is why she writes everything down. V15 added she has only seen R1 experience anxiety.

Based on interview and record review, the facility failed to transfer a resident safely with a mechanical lift. This failure resulted in a resident sustaining an 8 cm (centimeter) laceration, requiring 11 sutures.This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3.The findings include:On 2/11/26 at 10:21, V4 (CNA/Certified Nurse Assistant) said she transferred R1 from his wheelchair to his bed with mechanical lift by herself on 1/15/26 when he sustained a skin tear. V4 said R1 has always had extreme anxiety with patient care and he freaks out when he is transferred with mechanical lift. V4 said, I am thinking maybe when I transferred him, from him freaking out and shaking, he might have bumped his leg on the bed at that point. V4 said she was taught there should be two staff when transferring a resident with a mechanical lift, but she did it by herself because she thought R1 was so light and easy to do. V4 said there should always be two staff for safety precautions when transferring a resident with a mechanical lift; one staff member is supposed to control the remote, and the other staff member focuses on the resident and positioning their body during transfer.The Facility Reported Incident Final Report done by V2 (DON/Director of Nursing) dated 1/23/26 states, [R1] has very fragile skin.On 1/15/26, [V4] was transferring [R1] from his wheelchair to his bed and [V4] discovered [R1] inadvertently acquired a skin tear. [R1] was sent to the ER (Emergency Room) for further evaluation and treatment per physician's orders. Facility nurse called for an update and was notified the skin tear required sutures.R1's ER Physician Report dated 1/15/26 states, R1 has an 8 cm left leg laceration.wound closure was performed with 11 sutures after local anesthesia.On 2/11/26 between 1:30 PM-3:40 PM, V2 (DON), V3 (ADON/Assistant Director of Nursing), V9 (Restorative/Quality Assurance Nurse), V5 and V6 (LPNs/Licensed Practical Nurse), and V7 and V8 (CNAs) said when transferring with mechanical lifts, two staff are required to ensure resident's safety. V9 (Restorative Nurse) said one staff member works the lift remote, and the other staff member is there to support the resident and prevent them from bumping into anything. V8 (CNA) said many of the residents have fragile skin and one staff cannot do the mechanical lift transfer by themselves because there are too many risks of resident injury.On 2/11/26 at 4:02 PM, V10 (Mechanical Lift Customer Service Representative) said two caregivers are required to safely operate a mechanical lift for patient transfers; one person operates the lift and the second person guides the patient.R1's Face Sheet shows he has the following diagnoses: muscle wasting and atrophy, abnormalities of gait and mobility, lack of coordination, chronic heart failure, peripheral vascular disease, osteoarthritis, end stage renal disease, and a history of falling. R1's MDS (Minimum Data Set) dated 1/6/26 shows he is completely dependent on the assistance of 2 or more helpers to transfer to/from chair/bed. R1's Nursing Progress Note dated 1/15/26 at 2:23 PM states, The CNA was transferring the resident from the wheelchair to the bed. In the process, the resident hit the. lower leg on the bed and had an open laceration that measures about 7cm long.the NP (Nurse Practitioner) ordered the resident to be sent out for evaluation. R1's Restorative Assessment documented on 1/5/26 shows he is fully dependent on staff for chair/bed-to chair transfer and he uses mechanical lift.The facility's undated policy titled, Limited Lifting Resident Handling Policy states, Purpose: To protect the safety and well-being of the staff and residents, and to promote quality care, this facility will use mechanical lifting devices for the lifting and movement of residents. Responsibility: Licensed Nurse, CNA, Restorative, Therapy Policy: 1. Mechanical lifting devices shall be used for any resident needing a two person assist.

Based on observation, interview and record review, the facility failed to ensure that a resident was not physically abused by a staff.This applies to 1 of 10 residents (R6) reviewed for physical abuse in the sample of 10.The findings include:R6 was admitted to the facility on [DATE]. R6 had multiple diagnoses including bipolar disorder, conduct disorder, anxiety disorder, restlessness and agitation, and severe dementia with agitation, based on the face sheet.R6's admission MDS (minimum data set) dated October 1, 2025 showed that the resident was severely impaired with cognition. The same MDS showed that R6 required moderate to maximum assistance from the staff with most of her ADLs (activities of daily living).On November 21, 2025 at 11:28 AM, R6 was inside the first-floor dining room, her head resting on the dining table. R6 responds inappropriately when talked to. R6 was confused. Sitting beside R6 was V17 (CNA/Certified Nursing Assistant). V17 stated that the staff takes turn providing 1:1 supervision of R6 because the resident is very confused and would constantly attempt to get up and ambulate without assistance.The facility's initial report sent to the State Regulatory Agency, showed that on November 17, 2025 a Resident reported an allegation of staff member's conduct not meeting facility standards while providing care to resident [R6]. Alleged staff member was sent home pending investigation. Head-to-toe assessment completed. [Physician], POA (Power of Attorney) and police notified. Investigation was initiated.The facility's final report sent to the State Regulatory Agency on November 20, 2025 showed that on November 17, 2025 around 9:00 PM, R1 (another resident) reported to V16 (RN, Registered Nurse) that he was walking by R6's room and observed V14 (CNA, Certified Nursing Assistant) holding a pillow and that the pillow made physical contact with R6's face. R6 was immediately separated for safety and V14 was sent home pending investigation. The report documented that R6 was unable to recall any inappropriate situation occurring and was mentally and physically stable at baseline when interviewed. R6 had no skin abnormalities when assessed. R6 had no complaints of pain and mental anguish. R6 was evaluated by the in-house Nurse Practitioner and had documented that the resident had no apparent distress, was calm and cooperative. The report showed that the camera footage of the alleged incident was reviewed on November 17, 2025 at 9:40 PM and The footage did not show any improper staff behavior, CNA [V14] was not assigned to [R6], and was not present in her room at the time of the alleged incident. The report documented that the police arrived at the facility at around 9:50 PM and was shown the camera footage and deemed there was no further reason to investigate. On November 17, 2025 at 11:28 PM, V16 reported that according to R1, the alleged incident happened in the dining room earlier, around dinner time. The report documented that R1 was interviewed and stated that the facility has cameras, so he shouldn't need to make an official statement. V14 was interviewed by the facility and stated that she was in the dining room with R6, [R6] stood up from her wheelchair, and she saw that she was sitting on a pillow. [V14] grabbed the pillow to take it out due to it being a safety issue and when she did, [R6] also grabbed the pillow. [V14] said she let go of the pillow and then [R6] sat back down in her wheelchair. She said the pillow did not make contact with [R6]. V15 (CNA) was interviewed by the facility and stated that around dinner time, V14 came into the dining room while she (V15) was sitting behind R6 and [V14] came up, grabbed the pillow from the table, and the pillow made contact with [R6]. The report documented that the facility reviewed the dining room camera footage from November 17, 2025 and showed that at 6:19 PM, [R6] was sitting at the dinner table. [V15] was sitting behind her, and [R1] was standing nearby. [V14] approaches the table where [R6] is sitting, she grabs a pillow from the table, and the pillow makes contact with [R6]. The facility again called the police after the camera footage review and eyewitness interview to make another report. V14 and V15 were terminated by the facility due to failure to follow facility protocols and the abuse prevention program. The facility's final report concluded that, there is credible evidence that [V14] was holding a pillow, and that the pillow made contact with [R6].On November 21, 2025 at 11:16 AM, R1 stated that on November 17, 2025 sometime at night, he reported to a male nurse that V14 (CNA) hit R6 on the face with a pillow and to look at the camera because he does not want to give an official statement. According to R1, the incident happened inside the dining room, around dinner time. R1 stated that V14 no longer work at the facility.On November 22, 2025 at 3:35 PM, V16 (RN) stated that on November 17, 2025 he started his shift at 7:30 PM, and between 8:00 PM and 8:30 PM while passing medications, R1 came to him and started asking him questions like, How would you feel if your family member was hit with a pillow by somebody at the facility? V16 stated that he asked R1 what he was talking about for clarification and during the conversation, R1 mentioned R6 and V14's (CNA) names but did not really explain what had occurred and/or gave further information but instead said that he will call the State. According to V16, upon hearing what R1 shared, he immediately called V2 (DON (Director of Nursing)) to report the potential abuse and because R1 did not give him full information, he (V16) assumed and reported to V2 that R1 saw V14 hit R6 with a pillow inside the resident's room. According to V16, he assessed R6 without any injuries or complain of pain and made sure that the resident was safe. V14 was sent home by V2 that night. V2 came to the facility and the police also came and talked to V2. During the same interview, V16 stated that at around 11:20 PM, after V2 and the police had left the facility, R1 again came to him and told him (V16) that he saw V14 hit R6's face with a pillow inside the dining room, earlier that night. V16 stated that after talking to R1 with more information, he immediately called V2 to report.On November 21, 2025 at 4:21 PM, V2 (DON) stated that she received a call from V16 (RN) on November 17, 2025 at 9:15 PM and was informed that R1 reported that he saw V14 (CNA) hit R6 with a pillow inside the resident's room. V2 instructed V16 to immediately assess R6 and to make sure that the resident was safe, and then she called V14 on her cellular phone. She asked V14 about the incident and she told V14 to go home and that she was suspended pending investigation of the alleged abuse. According to V2, she then called the police to make a report and then drove to the facility since it was only about five minutes away. V2 stated that when she arrived at the facility, she immediately reviewed the November 17, 2025 afternoon to nighttime hallway camera footage of where R6 resides, and she did not see V14 going to the said hallway or inside R6's room. V2 stated that when the police came to the facility on November 17, 2025, she showed the camera footage, and the police told her that they (police) have no further reason to investigate because V14 did not appear on the footage and the police left the facility. According to V2, when she talked to V14 prior to sending her home, she asked V14 if she hit R6 with a pillow, V14 denied ever hitting R6 with a pillow and stated that she was not assigned to R6, and she (V14) also did not work at the same hallway where R6 resides. V2 added that on November 17, 2025 at 11:28 PM, she again received a call from V16 and was informed that R1 again came to him and told him that the incident between V14 and R6 happened in the dining room, earlier that night. V2 stated that upon further investigation of the alleged abuse, V15 (CNA) stated on an interview that during dinner time on November 17, 2025, she was sitting behind R6 monitoring the resident, V14 came towards the table where R6 was sitting, V14 grabbed the pillow from the table and the pillow made contact with R6. According to V2, the facility also reviewed the dining room camera footage for November 17, 2025 and showed that V14 approached the table where R6 was seated, V14 grabbed the pillow from the table and the pillow made contact with R6. During the same interview, V2 stated that V14 and V15 were terminated by the facility on November 20, 2025 after completion of the investigation. V15 was terminated because she did not report the abuse incident immediately and V14 was terminated because the abuse allegation was substantiated as confirmed by V15 and the camera footage.On November 21, 2025 at 4:09 PM, V1 (Administrator) stated that when the incident occurred between V14 (CNA) and R6 on November 17, 2025, she was on vacation. According to V1 after the facility's full investigation, V14 was terminated. The facility had reported the incident to the police and a copy of the camera footage, was also given to the police as part of the evidence because the facility had filed charges against V14 for physical abuse towards R6. V1 added that the facility would also report the incident to the State Nurse Aide Registry.On November 21, 2025 at 12:20 PM, V1 showed the first-floor dining room camera footage of November 17, 2025. During the observation of the footage, V1 zoomed to clearly see R6 sitting in her wheelchair inside the dining room, while V15 (CNA) was seated behind R6, assisting the resident to sit down when R6 attempted to stand. The footage showed that at 6:19 PM, R1 could be seen standing nearby. V14 (CNA) walked towards the table where R6 was seated. While V15 was present, V14 grabbed the pillow that was on the table and swung the pillow towards R6 hitting the resident's face, then V14 left. R6 remained seated.The facility's policy and procedure regarding Abuse Prevention Program dated January 2024 showed in-part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The policy showed, The facility prohibits abuse, neglect, misappropriation of property, and exploitation of its residents, including verbal, mental, sexual or physical abuse; corporal punishment; and involuntary seclusion. The facility has a no tolerance philosophy; persons found to have engaged in such conduct will be terminated. The procedure under internal reporting and identification of allegations, showed that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about or suspect to the administrator immediately or to an immediate supervisor.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical and mental abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. 1. R2's EMR said he was 70 y.o. with medical diagnoses of right knee osteoarthritis, unspecified intellectual disability, and impaired mobility. R2's EMR said he was cognitively intact and required substantial staff assistance with transfers.On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation started to scratch his face. R2 said he yelled for help. R2 said facility staff intervened and escorted R3 out of his room. R2 said he feared R3 would return to his room but felt safe now that R3 was discharged from the facility. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said she immediately responded to R2's call for help. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said she was informed of R2 and R3's incident. V11 said R3 was observed prior to the incident, violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said she went to assess R2 after the incident, and R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. The facility's investigation report dated 10/31/2025, said on 10/27/2025 at 3:30 PM, R3 entered R2's room. R2 said he was sleeping when he sustained scratches under his right eye from R3. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified. 2. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter, but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.3. R4's EMR said he was 71 y.o. with medical diagnoses of left ankle and foot osteomyelitis, falls, and impaired mobility. R4's EMR said he was cognitively intact and supervision with ambulation with the use of an assistive device.On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym. R4 said he tried to block R3, but he sustained minor scratches under his right eye. R4 said the therapy staff was present and escorted R3 out of the gym. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 made physical contact with R4, and R4 sustained scratches under his right eye. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.The facility's investigation report dated 9/17/2025, said on 9/11/2025, R3 approached R4 with his arms. After their brief physical contact staff intervened. R4 sustained scratches under his right eye. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified.On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if R3's 1:1 supervision intervention had been maintained. V3 also said in retrospect, R2's incident could have also been prevented if R3's continuous 1:1 supervision would have been reimplemented after his known ongoing aggression. On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in the incident investigations involving R2 and R4. V2 said the facility determined the physical abuse allegations could not be substantiated. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations, and together they determined if abuse was substantiated based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her, but was not investigated because it was reported staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. V1 said they did not substantiate R2 and R4's incidents because she felt R3's physical contact was a result of his behavior of reaching out with his hands to get attention. V1 said she did not believe R3's behavior towards others was willful because of his medical condition of autism. V1 continued to say R3's unpredictable and unprovoked behaviors towards others were ongoing, and the facility had difficulty managing him. V1 said R3 was discharged to the hospital for behavioral management after R2's incident. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others, of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's policy titled Abuse Prevention Program Policy Definition dated 12/21/2019, said residents had the right to be free from abuse, including physical and mental abuse. The policy defined physical abuse as the infliction of injury on a resident that occurs other than by accidental means. Mental abuse is defined as verbal or nonverbal conduct that has the potential to cause intimidation and fear, which can include yelling or hovering over a resident. The policy also defines abuse as willful infliction of injury resulting in physical harm or mental anguish to a resident, irrespective of any mental or physical condition. The policy said, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review, the facility failed to report a resident's allegation of abuse by another resident (R3).This applies to 1 out of 5 residents (R1) reviewed for resident-to-resident abuse.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago, at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said all abuse allegations were to be reported to V1. V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.On 11/04/2025, the facility did not have an incident investigation regarding R1's abuse allegation. On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if his 1:1 supervision intervention had been maintained.On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in investigating the facility's abuse allegations. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations and reporting based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her but was not investigated or reported because it was reported that staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. The facility's policy titled Abuse Prevention Program Facility Policy and Procedure dated 01/04/2019, said the facility desired to prevent abuse by establishing a resident-sensitive environment, following up with identified concerns, and pattern assessments. The policy also said staff were required to report any incident, allegation, or suspicion of potential abuse to the administrator. And for the safety of others, they would take the following steps to protect residents who alleged abuse; initiate an internal investigation and external reporting of all allegations of abuse, including physical and mental.

Based on interview and record review, the facility failed to thoroughly investigate residents' allegations of abuse by another resident (R3). This applies to 3 out of 5 residents (R1, R2, and R4) reviewed for resident-to-resident abuse.The findings include:1. On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation started to scratch his face. R2 said he yelled for help. R2 said facility staff intervened and escorted R3 out of his room. R2 said he feared R3 would return to his room but felt safe now that R3 was discharged from the facility. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said she immediately responded to R2's call for help. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said she was informed of R2 and R3's incident. V11 said R3 was observed prior to the incident, violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said she went to assess R2 after the incident, and R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's investigation report dated 10/31/2025, said on 10/27/2025 at 3:30 PM, R3 entered R2's room. R2 said he was sleeping when he sustained scratches under his right eye from R3. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified. 2. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. R1 said she felt that R3 placed his hands on her throat, trying to choke her. R1 said the incident in her room was not witnessed, but staff responded to her screams. R1 said she was extremely scared that evening because she feared R3 would return to her room. R1 said she reported the incident to facility management staff, but was never formally interviewed by management. R1 said she requested a room change and was moved to another unit on a different floor. R1 said she felt safe now because R3 was finally discharged from the facility.On 11/04/2025 at 2 PM, V17 (CNA) said she immediately responded to R1's call for help. V17 said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter, but was not. V17 said R1 was emotionally startled and scared after the incident. On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. V16 said R1 was extremely scared after the incident. V16 said she was never interviewed by management regarding the incident involving R1.On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset, that she brought her to the nurse's station for the remainder of the shift (till 10:30 PM) to comfort her and reassure her of her safety. V9 said R1 continued to say R3 had attacked and choked her. V9 said R1 did not have any injury, and she reported the incident to V1 (Administrator) and V2 (Director of Nursing/DON). V9 said the following days she checked in on R1 because she was still concerned for her wellbeing, and R1 was still upset but felt better because she was moved to another unit. R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.R1's progress note dated 10/18/2025 (after the incident) said R1 was displaying increased anxiety in the AM, and the provider was contacted for an as-needed anxiolytic.On 11/04/2025, the facility did not have an incident investigation regarding R1's abuse allegation. 3. On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym. R4 said he tried to block R3, but he sustained minor scratches under his right eye. R4 said the therapy staff was present and escorted R3 out of the gym. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 made physical contact with R4, and R4 sustained scratches under his right eye. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.The facility's investigation report dated 9/17/2025, said on 9/11/2025, R3 approached R4 with his arms. After their brief physical contact staff intervened. R4 sustained scratches under his right eye. The report said the allegation of physical abuse was not substantiated because no credible evidence that abuse occurred was identified.On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said she assisted in the incident investigations involving R2 and R4. V2 said the facility determined the physical abuse allegations could not be substantiated. V2 said V1 was the abuse coordinator and made the determination if abuse was determined. V2 said she was notified on 10/17/2025 of R3's behavior and did not interview or investigate R1 regarding her alleged statement. V2 said based on the facility staff statements, they did not believe R1's statement regarding the incident had occurred. On 11/04/2025 at 1:25 PM, V1 (Administrator) said she was the facility abuse coordinator. V1 said the facility management team was involved in abuse allegation investigations, and together they determined if abuse was substantiated based on the facility's policy. V1 said they investigate all types of abuse allegations, including physical and mental. V1 said R1's incident was reported to her, but was not investigated because it was reported staff had intervened. V1 said she did not follow up with R1 after the incident and was not aware she was fearful to return to her room after the incident. V1 said R1 was moved to another floor as requested days after the incident. V1 said they did not substantiate R2 and R4's incidents because she felt R3's physical contact was a result of his behavior of reaching out with his hands to get attention. V1 said she did not believe R3's behavior towards others was willful because of his medical condition of autism. V1 continued to say R3's unpredictable and unprovoked behaviors towards others were ongoing, and the facility had difficulty managing him. V1 said R3 was discharged to the hospital for behavioral management after R2's incident. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.The facility's policy titled Abuse Prevention Program Facility Policy and Procedure dated 01/04/2019, said the facility desired to prevent abuse by establishing a resident-sensitive environment, following up with identified concerns, and pattern assessments. The policy also said staff were required to report any incident, allegation, or suspicion of potential abuse to the administrator. And for the safety of others, they would take the following steps to protect residents who alleged abuse; initiate internal investigation and external reporting of all allegations of abuse, including physical and mental. The policy said the facility investigation procedure included interviewing the person who reported the incident or anyone likely to have direct knowledge of the incident. And the final investigation report's conclusion would be based on known facts, Facts determined during the process of investigation, review of medical record, and interview of witnesses. And after the investigation was completed, the facility would initiate a Quality Management Review with the goal of enhancing the living environment of the resident population.

Based on observation, interview, and record review, the facility failed to implement safety monitoring interventions for a resident with known aggressive behaviors towards others. This applies to 1 out of 4 residents (R3) reviewed for safety and supervision.The findings include:R3's EMR (Electronic Medical Record) said he was a 35 y.o. (year old) who admitted to the facility on [DATE]. R3's medical diagnoses included autism, schizophrenia, anxiety, and lack of expected normal physiological development in childhood. R3's EMR said he was non-verbal and ambulatory. R3's EMR continued to say that he required supervision for safety due to aggressive behaviors of throwing items, scratching, and hitting others. R3's care plan initiated on 8/14/2025 said family reports known aggressive behavior towards others, of throwing, scratching, and hitting others. The care plan said the family to provide a 1:1 sitter. R3's reviewed and updated behavior care plan dated 9/22/2025 said his behavior intervention still required a 1:1 Companion.R3's admission care plan progress note dated 8/26/2025, said R3's family informed the facility of R3's known aggression towards others. The note said, Brother states he is very weak right now, but when he feels better he will get aggressive.1. R4's EMR said he was 71 y.o. with medical diagnoses of left ankle and foot osteomyelitis, falls, and impaired mobility. R4's EMR said he was cognitively intact and supervision with ambulation with the use of an assistive device.On 11/04/2025 at 11:30 AM, R4 was interviewed over the telephone because he had been discharged home on 9/26/2025. R4 said on 9/11/2025 at approximately 10 AM, R3 physically attacked him in the therapy gym, unprovoked. On 10/31/2025 at 3 PM, V7 (Physical Therapist Assistant/PTA) said she brought R3 to the therapy gym. V7 said R3 tried to grab her arms, but she avoided contact by walking away. V7 said R3, then turned towards R4 and tried to grab him. V7 said R3 was then escorted back to his room and placed on 1:1 for safety monitoring.2. R1's EMR said she was 81 y.o. with medical diagnoses of a right wrist fracture, falls, anxiety, and impaired mobility. R1's EMR said she was cognitively intact and required the use of wheelchair. On 10/31/2025 at 10:40 AM, R1 was in her wheelchair. R1 said a few weeks ago at approximately 6-7 PM, she encountered R3 in the hallway. R1 said R3 was throwing furniture in the hallway when he then followed her into her room. R1 said she was extremely scared as R3 started to attack her. On 11/04/2025 at 2 PM, V17 (CNA) said she intervened before R3 made physical contact with R1. V17 said R3 was supposed to be monitored by his 1:1 sitter but was not. V17 said she then provided 1:1 supervision for R3 till the end of her shift at 10:30 PM. V17 said R3 no longer had an assigned sitter for the NOC shift (10:30 PM-6 AM).On 11/04/2025 at 11:15 AM, V16 (CNA) said she was R3's assigned sitter on the evening of 10/17/2025. V16 said R3's behaviors were escalating; he was throwing furniture in the hall and trying to attack her. V16 said she stepped away from R3, and he was left unsupervised when he entered R1's room. On 10/31/2025 at 12:50 PM, V9 (Nurse) said she was discussing R3's 1:1 sitter intervention with V16 when R3 started to charge at R1 and followed her into her room. V9 said staff intervened and stopped R3 from making physical contact with R1. V9 said R1 was extremely upset and continued to say R3 had attacked and choked her. V9 said R3 only had an assigned 1:1 sitter for the AM and PM, not the nighttime shift.R3's progress note dated 10/17/2025 said Resident observed displaying aggressive behaviors, attempting to harm self and others.On 10/31/2025 at 1:45 PM, V15 (CNA) said on 10/21/2025 she was R3's 1:1 sitter on the PM shift when he started attacking her. V15 said R3 was throwing furniture in his room and was difficult to redirect. V15 said R3 then pulled her hair so harshly it caused her severe neck and back pain. V15 said she had to scream for staff assistance because R3 could not be controlled. V15 said she was currently still out on medical leave due to her sustained injury from R3. 3. R2's EMR said he was 70 y.o. with medical diagnoses of right knee osteoarthritis, unspecified intellectual disability, and impaired mobility. R2's EMR said he was cognitively intact and required substantial staff assistance with transfers.On 10/31/2025 at 11:10 AM, R2 was in bed and had linear scratch marks under his right eye. R2 said on 10/27/2025 at approximately 3 AM, R3 came to his room and, without provocation, started to scratch his face. R2 said R3 had a known history of aggression towards other residents and staff. On 10/31/2025 at 1 PM, V14 (Certified Nurse Assistant/CNA) said R3 had known behaviors of throwing furniture and hurting others. V14 said R3 required constant supervision and had a 1:1 sitter for all shifts, days prior, but recently the intervention was changed to only AM and PM shift. V14 said on 10/27/2025, R3 was throwing furniture in the hallway and then entered R2's room. V14 said R3 was attacking R2, and R2 sustained scratches under his right eye. V14 said she then escorted R3 back to his room.On 11/05/2025 at 9 AM, V11 (Nurse) said on 10/27/2025, R2 said R3 attacked him. V11 said R2 reported R3 had scratched his face and tried to choke him. V11 said prior to the incident, R3 was observed violently throwing furniture in the hallway. V11 said R3 no longer had a 1:1 sitter during the night shift because it was determined he was usually sleeping. V11 said R3 did continue to have a sitter during the AM and PM shifts for his known behaviors of aggression. On 11/04/2025 at 10:30 AM, V3 (Assistant Director of Nursing/ADON) said R3 had recently admitted to the facility and required behavior management after he started to display behaviors of throwing items and aggression towards others. V3 said R3 required 1:1 continuous supervision after his aggressive behaviors started to escalate. V3 said R3's behaviors were unprovoked and unpredictable. V3 said R1's incident could have been prevented if R3's 1:1 supervision intervention had been maintained. V3 also said in retrospect, R2's incident could have also been prevented if R3's continuous 1:1 supervision would have been reimplemented after his known ongoing aggression. On 11/04/2025 at 11:50 AM, V2 (Director of Nursing/DON) said R3's family reported they were unable to manage R3's behaviors at home. V2 said the facility became concerned for the safety of others because R3's behaviors were escalating. V2 said the facility then decided to implement a 1:1 sitter for all shifts on 9/22/2025 because they were unable to manage his behavioral needs. V2 said on 10/10/2025 administration decided to remove his assigned nightshift sitter because it was reported he was sleeping despite knowing that R3's behaviors were difficult to redirect and unpredictable. V2 said in retrospect, R3's 24-hr 1:1 sitter should have continued for the safety of himself and others. V2 said R3 was discharged on 10/27/2025 for behavior management after R2's incident. R3's behavior monitor log for October 2025 said R3 displayed behaviors of screaming, yelling, danger to others/self, and physical aggression on the nightshift on 10/04/2025, 10/10/2025, and 10/12/2025.R3's Social Service progress note dated 10/27/2025, said the facility discharged R3 because he exhibits behaviors, bangs his own head against the wall and the back of his headboard, throws remotes, chairs, and anything he can get his hands on, has injured a staff member, and had become physically aggressive with two residents without provocation.The facility's policy titled Behavior Management dated 01/2024, said the facility would determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. In the event the behavior cannot be managed, staff will implement protocols to prevent the residents from harming self or others, which may take precedents over the procedures as written. The facility will initiate behavior monitoring and recording to provide a pattern of behaviors and responses to planned interventions when applicable. The facility to continue with 1:1 until dangerous symptoms are reduced and aggressive acts have been minimized, and no longer harm to self and others.

Based on observations, interviews, and record reviews the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This failure applies to 144 residents who are served food from the kitchen. Findings include:On September 25, 2025, at 3:59 PM, V1 (Administrator) stated out of 147 residents in the facility, there are 144 residents receiving food from the kitchen.On September 23, 2025, at 10:39 AM, Upon entering the kitchen V15 (Cook) was standing at the food prep table handling food prep items then donned gloves without performing hand hygiene.On September 23, 2025 at 10:41 AM In the kitchen, V16 (Dietary Aide)collected and rinsed soiled dishes, placed them in a dish rack and into the low temp dishwasher, then collected clean dishes from the dishwasher without performing hand hygiene; after pulling a rack of clean dishes from the dishwasher V16 grabbed a towel from the top of a box of latex gloves sitting in a part of the dish washing machine, wiped the water out of multiple bowls and placed them back inside the dish rack, then placed the towel back on top of the box of latex gloves. V16 collected the dish rack containing the bowls V16 wiped and several other clean bowls and placed the rack on top of two other dish racks sitting on a roller base that contained heavy presence of visible debris and particles and left them to dry. Several dish racks used to clean dishes and for storing clean dishes were heavily stained with a film and substance that was removable when rubbed. The mugs and cups stored in several dish racks contained visible particles. A silverware [NAME] container filled with napkins that were placed on residents' meal trays contained heavy presence of visible stains and film all throughout the upper edges of the container. V14 (Dietary Manager) grabbed napkins from the silverware [NAME] and placed them on multiple trays being prepared for residents. V17 (Dietary Aide) and V18 (Dietary Aide) were performing kitchen duties with their hair exposed and not completed covered by their hairnets.On September 22, 2025, at 11:57 AM, V18 (Dietary Aide) was working in the kitchen with her hair not completely covered and exposed from the sides of her hairnet.The freezer was noted with a sticky spilled substance on the surface of a box of multiple frozen pizzas, the inside and outside of the plastic bag covering the pizzas contained a thick sticky layer of a spilled substance. V14 stated the substance appeared to be soda.On September 23, 2025, at 11:06 AM, Car keys and an eyeglass case were sitting on the bottom level of the food prep table next to a large box of potatoes. A bowl containing white powdered residue was sitting on top of the container of thickener powder, V15 (Cook) stated the bowl was used to scoop thickener from the container; the exterior of the container of thickener contained stains of a sticky yellow substance.On September 23, 2025, at 12:25 PM, in the first and 2nd floor dining rooms nursing aides were serving coffee and juice from large beverage dispensers. The dispensers that contained a heavy presence of dark and red stains covering the rubber lining inside the lids of the dispensers and the surface of the dispensers contained pink stains and sticky dark stains in various areas. Underneath the carts holding the beverage dispensers were two dish racks filled with mugs. These mugs had visible drops of water on their surface and the dish racks storing the mugs contained patches of thick film stains throughout the surface. The beverage carts holding the dispensers contained visible pink stains, particles, and sticky substances on various areas of the surface.On September 23, 2025, at 12:50 PM, A small refrigerator in the kitchen (used for storing multiple yogurts, sandwiches, and juice boxes) contained visible food particles, a thick sticky substance on the inside upper surface, and heavy presence of dark substance buildup on the rim of the door. V14 (Dietary Manager) said the food items in the refrigerator were being used for residents.On September 24, 2025, at 12:28 PM, V14 (Dietary Manager) said that staff should let dishes air dry. A rag to dry dish wear should not be used to prevent contamination. V14 also said that storing a dry towel on a box of gloves is not sanitary and they should be stored in a bucket of solution or a sealed plastic bag on the tray line. V14 confirmed that items used to store clean dishes should be clean and free of debris and the beverage carts should not have any buildup of substances or stains. V14 also added that dietary staff should not have exposed hair while working in the kitchen and staff should wash hands between tasks. The small refrigerator holding cold items to be served to residents should be wiped down daily and the small refrigerator should be cleaned. The facility's Food Safety and Sanitation policy on Tray Service received from the facility September 24, 2025 shows in part: Employees will use measures to ensure the sanitation and safety of food provision on the tray line, transportation of meals, and tray delivery. Proper procedures are used so that measured temperatures are accurate, and contamination is prevented:b. An alcohol swab is used to sanitize the thermometer between uses at one meal. Food will be delivered to the residents in a sanitary way to prevent food-borne illness.The facility's Food Safety and Sanitation policies on Cleaning Schedules received from the facility September 24, 2025, documents in part:The purpose of the policy is To assure the kitchen is kept clean and meets state regulations monthly. The cleaning schedule will be used by all staff to assure that the kitchen is maintained with cleanliness and sanitized as needed. The food service department will be cleaned and sanitized on a routine basis according to written cleaning schedules. The facility's Food Safety and Sanitation policy on Storage of Dry Food received from the facility September 24, 2025 states in part: The facility will follow safe handling and storage of dry foods and supplies. Storage bins used (for dry foods) will be kept clean. The facility's Food Safety and Sanitation policy on Handwashing received from the facility September 24, 2025 states in part: Employees will use proper hand washing techniques to prevent the spread of infection, cross contamination, and germs. Employees are required to wash hands:k. After handling soiled dishes and utensils.The facility's Food Safety and Sanitation policy on Employee Health and Personal Hygiene states in part: Personal items will be placed in a designated area away from food preparation.

Based on observation, interview, and record review, the facility failed to ensure that residents shower room was free of black substances and failed to ensure that a resident's toilet was in good repair.This applies 16 of 16 residents (R24, R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164) reviewed for homelike environment in the sample of 29. Findings include:1. On September 22, 2025 at 10:20 AM, R58 was in her room alert and oriented and stated that the exhaust fan in the shower down the hall from her doesn't work, and she saw sparks come from it a month ago. R58 stated that there is also mold in the same shower all along the edge of shower. On September 23, 2025 R58 stated she told a Certified Nursing Assistant (CNA) about the mold and the shower but she doesn't know their name. R58 stated the sparks had been there 4-5 months. R58 stated, because the fan hasn't been fixed yet, R58 tells all the staff not to turn on the fan when they help her with a shower. On September 22, 2025 at 10:50 AM, in the shower room down R58's hall, there is a strong musty foul smell odor when you enter the shower room. V33 (CNA) stated each hall on the 2nd floor has its own shower. R58 showed surveyor the 2400 wing shower room. There were small 1x1 inch white tiles in the shower that cover the floor and up to the edges that meet the walls. There was a black substance along the wall and covering caulk and cracks in the tiles. On September 22, 2025 at 10:52 AM, V34 (Housekeeper) stated that he is not assigned to clean that particular shower room and he was not sure what the black substance was. On September 22, 2025 at 11:01 AM, V35 (Director of Maintenance) came into the 2400 wing shower room. V35 turned on the fans. One of the two fan mad a loud screeching sound. V35 went over and looked at it and said that it was broken. Surveyor asked V35 what the black substance was along shower floor and going up the wall. V35 examined the black substance and said, It's mold. I'm not going to lie to you. V35 stated he is responsible for removing mold, but housekeeping is responsible for cleaning the shower room daily. V35 stated someone should have done a work order and V35 would have come up right away and taken care of the mold. V35 stated he has not received a work order for the mold in the shower. On September 23, 2025 at 10:53 AM, V35 stated, he treated the mold yesterday with a specific mold treatment. V35 stated he believed the cause of the sparks that R58 mentioned that were coming from the fan, was the heating element in the fan. R58 stated, he clipped and capped the wires to the heating element in the fan so that shouldn't happen again. R58 stated the fan is very old. The fan was then turned on by V35 and it was still very loud. V35 stated they are going to replace the fan and heating element together. On September 23, 2025 at 3:30 PM, V3 (Assistant Director of Nursing) stated that all the residents that reside in the 2400 wing where R58 reside use the shower in that hall. V3 provided a resident listing report of the residents who use the shower on the 2400 hall and it included the following residents: R47, R58, R85, R92, R101, R103, R104, R105, R138, R140, R144, R149, R150, R156, and R164. 2. On September 22, 2025 at 11:40 AM, R24 was alert and stated his toilet has been leaking urine and water since it was replaced 6 months ago. On September 22, 2025 at 11:46 AM, V33 (CNA) showed surveyor R24's bathroom where the floor was wet with some slightly brown fluid in front of the toilet and on the right side of the toilet. R24 said to V33, My toilet has been leaking. On September 23, 2025 at 9:09 AM, with V30 (Infection Preventionist) observed R24's bathroom floor was wet in front and on the right side of the toilet. On September 23, 2025 at 2:07 PM, V35 (Maintenance Director) and his only assistant, stated that they had not received any work orders for R24's toilet. On September 24, 2025 at 1:14 PM, V2 (Director of Nursing) stated she expects staff to fill out a maintenance ticket and let the manager know if there is mold in the shower room or a leaking toilet.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and bed bath or shower.This applies to 6 of 7 residents (R6, R38, R49, R50, R52 and R137) reviewed for ADL (activities of daily living), in the sample of 29.The findings include:1.According to the Electronic Medical Records (EMR), R137 has multiple diagnoses including cerebrovascular disease (Stroke) with right side paralysis affecting dominant side, abnormality of gait and mobility, Alzheimer's disease and dementia. The (MDS) Minimum Data Set, dated [DATE], showed R137 had severe cognitive impairment and required assistance for personal hygiene, and dressing. R137's Care Plan for (ADL) Activities of Daily Living self-care deficit initiated on March 24, 2025, showed R137 requires moderate to maximum assistance with dressing and grooming tasks. On September 22, 2025, at 11:07 AM R137 was sitting in the dining room in her wheelchair. R137's shirt had crumbs of food, and her fingernails had brown and black substances underneath them. On September 22, 2025, at 12:28 PM, V 19 cut up the food when assisting R137 with her lunch tray set up. R137 picked up the chicken and chocolate brownie with her left hand which had brown and black substances underneath the fingernails. On September 23, 2025, at 12:05 PM AM R137 was sitting in the dining room in her wheelchair. R137's fingernails had brown and black substances underneath. 2. Face sheet shows that R52 is 68 years-old who has multiple medical diagnoses including morbid obesity, and muscle wasting and atrophy, not elsewhere classified, multiple sites. R52's Minimum Data Sheet (MDS) dated [DATE], shows R52 is alert and oriented and requires assistance with activities of daily (ADL) care. On September 22, 2025, at 10:35 AM, R52 was resting in bed resting. R52 appear unkempt and disheveled with overgrown, unruly/unkept mustache and beard and long, uneven, jagged, dirty fingernails (with accumulations of black/brown substances underneath his nails). R52 wants his nails clipped but does not want his facial hair trimmed. On September 23, 2025, at 9:36 AM, R52 was resting in bed. R52 remained unkempt and disheveled looking with long dirty fingernails (with accumulated black/brown substances underneath nails) and untidy mustache and beard. The fitted sheet was soiled with debris of dead skin and other unidentified substances. It was also stained with dry yellow substance which V6 (Certified Nursing Assistant/CNA) identified as fluids that were secreting from R52's skin. V6 provided incontinence care to R52 who was wet with urine. R52's skin has multiple clumps of dead skin spread/scattered all over his back and buttocks which V5 (Wound Care Nurse) described as lump of mixed dead skin, sweat, and previous barrier and other treatment cream. 3. Face sheet shows that R50 is 65 years-old who has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R50's Minimum Data Set (MDS) dated [DATE], shows that R50 is alert and oriented and requires assistance with activities of daily living (ADL) care. On September 22, 2025, at 10:56 AM, R50 was in his bedroom. R50 had overgrown facial hair and overgrown, uneven, jagged and dirty fingernails (with black/brown substance underneath fingernails). R50 stated that it's been a while since they last clipped his nails and shaved his facial hair. On September 23, 2025, at 9:13 AM, R50 was in his room and was noted with overgrown facial hair and long, jagged, uneven, dirty fingernails. On September 24, 2025, at 3:53 PM, R50 remained with overgrown, uneven, jagged, dirty fingernails. R50's facial hair was shaven, he stated that they gave him a shower earlier, however, they did not clip his nails. R50 said wants his nails clipped. V29 (CNA) confirmed that it needed to be clipped. On September 25, 2025, 09:56 AM V2 [NAME] (DON) stated that bed bath and shower are provided twice a week and as needed to keep resident clean and comfortable. This shower and bed bath also include nail care and facial hair care (shaving, trimming, cleaning). 4. R38 had multiple diagnoses including, Parkinson's disease without dyskinesia and without mention of fluctuations, and muscle wasting and atrophy, based on the face sheet. R38's quarterly MDS dated [DATE], showed that the resident was cognitively intact and required assistance with personal hygiene. On September 22, 2025 at 11:51 AM, R38 was in bed, alert and oriented. R38's fingernails were long with black substances under some of the nails. R38 stated that she wants the staff to trim and clean her fingernails. On September 23, 2025 at 9:37 AM, R38 was in bed, alert and oriented. R38's fingernails were long with black substances under some of the nails. In the presence of V2 (Director of Nursing), R38 stated that she wants the staff to trim and clean her fingernails because it looks very nasty. According to R38 she had requested the staff multiple times for nail care assistance, but no one listened to her request. V2 acknowledged that R38 requires the assistance of the staff for nail care because the resident's fingernails were long with black substances under the nails. R38's active care plan in place last revised on May 21, 2025 showed that the resident has ADL self-care deficit. The same care plan showed multiple interventions including one staff assistance with hygiene tasks and provision of moderate to maximum assistance with grooming tasks. 5. R49 had multiple diagnoses including, Huntington's disease, based on the face sheet. R49's annual MDS dated [DATE], showed that the resident was severely impaired with cognition. The same MDS showed that R49 had functional limitation in range of motion to her bilateral upper extremities and required total assistance from the staff with personal hygiene. On September 22, 2025 at 2:13 PM, R49 was sitting in a reclining wheelchair in-front of the first floor nursing station. R49 was awake but non-verbal. R49 had constant involuntary movement of her bilateral arms and legs. R49's fingernails were long, and some were jagged. On September 23, 2025 at 9:32 AM, R49 was in bed, awake but non-verbal. R49 had constant involuntary movement of her bilateral arms and legs. R49's fingernails were long, and some were jagged. V2 who was present during the observation acknowledged that R49's fingernails were long. According to V2, R49 requires the assistance of the staff for nail care. R49's active care plan in place last revised on July 8, 2025 showed that the resident had ADL self-care deficit. The same care plan had multiple interventions including, Resident is dependent with ADL care; provide total assistance in all aspects of hygiene/dressing. 6. R6 has multiple diagnoses including unspecified intellectual disabilities and muscle wasting and atrophy, based on the face sheet. R6's quarterly MDS dated [DATE], showed that the resident was cognitively intact and required assistance with personal hygiene. On September 22, 2025 at 2:23 PM, R6 was sitting in his wheelchair inside the first floor dining room. R6 was alert and oriented. R6 had accumulation of long facial hair. R6 stated that he wanted to be shaven because his facial hair is long. On September 23, 2025 at 10:19 AM, R6 was inside the therapy room, participating in therapy. R6 had accumulation of long facial hair. R6 stated that he wanted the staff to shave him. V2 who was present stated that R6 needs the assistance of the staff with shaving. R6's active care plan last revised on May 17, 2025 showed that the resident has ADL self-care deficit. The same care plan under interventions showed, 1 assist with dressing/hygiene task and moderate to max assist with dressing/grooming tasks. On September 24, 2025 at 8:47 AM, V2 stated that it is part of the facility's care and service to provide assistance to all residents needing assistance with ADL care, including shaving and nail care. V2 stated that assistance with ADL care should be provided to maintain resident's grooming and hygiene.

Based on observation, interview, and record review, the facility failed to ensure that residents who smoke and require supervision for smoking were monitored closely during smoking period. In addition, facility also failed to ensure that residents are not keeping their own cigarette lighters. This applies to 6 of 8 residents (R26, R71, R75, R110, R151, R164) reviewed for smoking in the sample of 29. The findings include:On September 23, 2025, at 3:35 PM, V23 (Activity Aide) was in the dining/dayroom near the door of the back patio handing cigarettes to residents during smoke time. V23 was the only staff supervising the smoking period. Glass windows/walls with horizontal window blinds separated the dayroom from the back patio area. However, V23 was only intermittently looking outside through the glass window to monitor the residents who were smoking. R110 was observed in the back patio smoking and carrying a lighter. R110 lit up another cigarette with this lighter and then put the cigarette lighter in her pocket when she finished smoking and walked back inside the facility without surrendering the cigarette lighter to V23.On September 23, 2025, at 3:42 PM, after R110 went back inside the facility, V23 said that residents are not allowed to keep cigarette and cigarette lighter with them or in their bedroom. After this statement, V23 was notified that R110 had a lighter with her, but V23 did not say anything about it.On September 23, 2025, at 3:46 PM, R110 was in her room, she showed her cigarette lighter and said, All the residents have their own lighter. On September 24, 2025, at 9:45 AM, smoking observation was conducted. V24 (Activity Aide) was handing passing cigarettes to residents. There were several residents who were smoking in the back patio including R26, R71, R75, R151, R164. Upon approached, these residents all stated that they keep their own lighters.At 9:51 AM, R164 said that he lights his cigarettes with his own lighter and showed that he was keeping it in the pocket of his pants.At 9:54 AM, R75 said sometimes he needs to bring his own lighter to light his cigarette.At 9:56 AM, R26 has his own lighter. R26 stated he keeps it in his room and use it mostly to help light other people.At 9:57 AM, R71 was smoking and has a lighter with him.At around 10:00 AM, R151 was sitting on his wheelchair, he had a plastic bag with him which contained his lighter. R151 stated that he lights his own cigarette. R151 showed the lighter that was inside the plastic bag.Upon entering the dayroom, V24 was observed away from the back patio entrance and window and was not continuedly observing the residents who were smoking. There was no staff directly monitoring the back patio.At around 10:05 AM, R151 went back inside the dayroom and continued to propel himself to his bedroom without surrendering the lighter to V24.On September 24, 2025, at 10:22 AM, V25 (Activity Director) stated residents are not allowed to keep their lighter with them for safety concerns like potential burning. They don't want residents to be tempted or to try smoking in their bedrooms. The staff should monitor the residents. The facility is supposed to have 2 staff monitoring the residents during smoke time one staff passing the cigarette while the other would be directly monitoring in the patio. However, there were times when there was only 1 staff. Staff should be lighting the cigarettes for the residents. The lighters are to be lock in the cigarette cart.On September 24, 2025, at 10:29 AM, V25 opened the cigarette cart for inspection. There were only 2 lighters in the cart which belonged to R37 and R163. These two residents were not included among the 6 residents that were observed smoking with lighters.The updated smoking assessments of R26, R71, R75, R110, R151, 164, showed that these residents may not be capable of handling/carrying any smoking materials and require supervision when smoking.R26's, R75's, R110's, 164's, most recent smoking care plan showed, Potential for safety hazard and/or injury related to smoking. Resident is non-compliant with turning in smoking materials.R71's and R151's most recent smoking care plan showed, Resident is non-compliant with turning in smoking materials.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene during range of motion assessments and administration of insulin. In addition, the facility failed to wear complete PPE (Personal Protective Equipment) during provision of wound treatment and administration of intravenous (IV) medication for residents who are under Enhance Barrier Precaution (EBP). This applies to 5 of 6 residents (R9, R29, R50, R135, R163) reviewed for infection control in the sample of 29. The findings include: 1.According to the face sheet, R163 has multiple diagnoses including, cellulitis of right lower limb, local infection of skin and subcutaneous tissue, quadriplegia and history of other venous thrombosis and embolism. R163's POS (Physician Order Sheet) dated September 22, 2025, showed an active order for a (PICC) Peripherally Inserted Central Line Catheter to (RUE) Right Upper Extremity. On September 23, 2025, at 9:02 AM, V22 (Registered Nurse) was preparing R163's (IV) intravenously medication, Ceftriaxone Sodium Solution on the medication cart in front of R163's room. V22 connected the IV tubing to the IV bag, part of the tubing dropped and touched the floor while V22 was holding the IV bag. V22 proceeded to enter R163' room without replacing the tubing. There was an (EBP) Enhanced Barrier Precaution sign on R163's door which showed that providers and staff must wear gloves and gown when providing high-contact resident care activities including central line device care or use. V22 wore gloves and failed to wear a gown before entering R163's room. V22 primed the medication tubing, cleaned R163's IV access port with an alcohol wipe, flushed and connected the IV tubing to R163's IV access on his right upper extremity. 2.According to the face sheet, R135 has multiple diagnoses including, hypertension, hyperlipidemia, and arthritis. R163's POS (Physician Order Sheet) dated February 28, 2025, showed an active order for Humalog Injection solution (Insulin Lispro), inject per sliding scale subcutaneously for times a day for diabetes Mellitus. On September 23, 2025, at 9:17 AM, V22 drew up R135's insulin in a syringe in front of the resident's room. V22, failed to pull up the needle safety cap built in with the syringe, left the needle exposed and proceeded to enter R135's room. V22 held the insulin syringe with the exposed needle in her hand while she waited for R135 to take his other oral medication. V22 then proceeded to administer R135's insulin. On September 24, 2025, at 11:50 AM, V2 (Director of Nursing) said V22 should have worn gloves and gown before entering the room to administer IV medication to the resident on EBP, and V22 should have gotten a new tubing if the IV tubing touches the floor to prevent infection. V2 also added that V22 should have pulled up the syringe safety cap after drawing up the insulin until when ready to administer the insulin to prevent infection and accidental needle stick that can occur from touching the needle. The facility's Policy and Procedure for Administering Medications revised January 2025 showed, Procedure: .12. Adherence to established facility infection control procedures shall be followed during the administration of medications. 3. On September 23, 2025, at 10:43 AM, V4 and V5 (Both Wound Care Nurses) provided wound care to R29 who has a stage 4 pressure to the sacrum. Both nurses wore gloves during the provision of care, however, they did not wear a gown during the wound treatment. There was a signage posting of EBP (Enhance Barrier Precaution) on R29's door. 4. On September 23, 2025, at 2:36 PM, V7 (Occupational Therapist/OT) assessed R50's left hand for range of motion (ROM). V7 touched R50's left hand without wearing a pair of gloves and without hand hygiene prior to assessment. After assessment she went to see R9 (another resident) without hand hygiene. 5. On September 23, 2025, at 2:41 PM V7 (OT) went to see R9 to assess R9's left and right hands for ROM. V7 touched R7's hands during assessment without hand hygiene and without wearing gloves. On September 24, 2025, at 1:00 PM, V30 (Infection Preventionist Nurse) stated the staff must wear PPE (Personal Protective Equipment) if they are providing wound care, administering IV medications. When a staff is assessing a resident, the staff must perform hand hygiene before and after tasks and in between residents, to prevent spread of potential infection. The Enhance Barrier Precaution (EBP) signage posting shows: Wear gloves for the following High-Contact Resident Care Activities; Bathing/Showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, wound care, devices such as central lines. Facility's Policy and Procedure for Hand Hygiene dated November 8, 2022, shows: Purpose: To provide guidelines on proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infection.

Based on observation, interview, and record review, the facility failed to prevent a demented male resident from kissing a demented female resident. This applies to 1 of 1 resident (R148) reviewed for abuse in the sample of 29.Findings include: R148's admission record showed her to be a [AGE] year-old female with diagnoses that included unspecified severe dementia with mood disturbances, depression, anxiety and congestive heart failure. R148's Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated July 22, 2025 showed her to be severely cognitively impaired with a BIMS score of zero. R148's care plan showed the following: R148 is disoriented to person, place and time related to dementia diagnosis. R73's admission record showed him to be [AGE] years old with diagnoses that include dementia, bipolar, traumatic brain injury, paranoid schizophrenia. R73'BIMS score of 1, showed him to be severely cognitively impaired. R73 criminal background checks showed he had a history of aggravated domestic battery. On September 23, 2025, at 1:59 PM, R73 walled over to R148 and kissed R148 repeatedly. R148 was seated at a table with two other residents in the dining area. R148 just looked up at R73. V28 (LPN-Licensed Practical Nurse) told R73 to stop and then removed R73 from the area. On September 24, 2025, at 2:18 PM, V26 (Certified Nursing Assistant/CNA) staid she has worked at the facility for over a year and mostly works on the floor where R73 and R148 reside. V26 said that R73 kisses R148 all the time. V26 said that she has never seen R148 initiate a kiss with R73. V26 stated that sometimes R73 will grab R148's head (and she demonstrated on her own head) and force her head to turn with his hand and then kiss her. V26 stated R73 will even go into R148's room and kiss her while she is sleeping. V26 stated that they try to separate them but, we were told they are demented and there is nothing we can do. On September 24, 2025 at 2:27 PM, R148 was asked if she knew who R73 was. R148 said, No, Who is that? Tell me who that is. On September 24, 2025 at 2:31 PM, V27 (CNA) stated she doesn't work often up on the floor where R148 and R73 reside but has been up on the floor for the last couple of weeks. V27 stated that she sees R73 kissing R148 and she will stop it when she sees it. V27 stated she has never seen R148 initiate a kiss with R73. V27 stated that R73 is always initiating kissing R148. While V27 and surveyor were talking at the nurse's station, R73 went over to R148 and started kissing her again on the lips. V27 said, there he goes again, and she went over and separated them. On September 24, 2025 at 3:57 PM, V3 (Assistant Director of Nursing) stated that a person with a Brief Interview for Mental Status (BIMS) score of zero would not be able to consent to sexual or intimate contact. On September 24, 2025 at 4:15 PM, V8 (Social Services) stated they do not have an assessment for the ability to consent for intimate behaviors for R148. V8 stated they would just make that determination based on the residents BIMS score.On September 24, 2025, at 9:39 AM, V1 stated that no one had reported any incidents with R73 to her. On September 25, 2025 at 8:47 AM, V1 (Administrator/Abuse Coordinator) stated that R73's behavior of kissing R148 has been going on for longer than a month. V1 stated she will check the notes to see how long it has been going on. She doesn't know from the top of her head. As of September 23, 2025, at 2:27 PM, R148 did not have a care plan that addresses her risk for being abused, nor was there a care plan addressing her being consistently kissed by R73. R148 also did not have an assessment for a risk for vulnerability to abuse. On September 25, 2025, at 11:01 AM, V31 (Nurse Practitioner) stated that R148 is not able to consent to being kissed. Furthermore, neither is R73. V31 stated this is the first time she has ever heard that R73 is kissing R148, and she has been working at the facility for 4 years. R73's point of care behavioral charting showed he was sexually inappropriate on September 9, 2025 (V32 documentation) and September 24, 2025. On September 25, 2025, at 11:49 AM, V32 (CNA) stated the R73 has a thing where he likes to get up and kiss other residents specifically to R148 and R85. R85's room is near his. V32 stated, R148, R85, and R73 have dementia. I stop them because I know they aren't supposed to be doing that. V32 stated R148 comes out of his room and looks for R148 and when he doesn't find R148 then he goes to R85 and kisses her. V32 stated she has witness R73 kissing residents since she started in December 2024. V32 stated, R73 tries to kiss R148 and or R85 every day she is working on the floor R73 resides. V32 said, V32 believe that R73 is seeking R148 out when he is awake. V32 said R73 wanders throughout the night. V32 stated she has seen him go into to R85's bedroom and another time in the dining room and kissed her. V32 stated she does not believe R148 nor R85 is able to consent to being kissed. The facility's Abuse prevention policy dated October 2023 showed the following: Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property or who have needs and behaviors that might lead to conflict. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax.

Based on interview and record review, the facility failed to ensure that updated PASRR (Preadmission Screening and Record Review) referrals were completed when new psychiatric diagnoses were identified after admission.This applies to for 3 of 3 residents (R10, R35, R61) reviewed for PASRR compliance in the sample of 29.The findings include: 1.R61 was admitted on [DATE]. The PASRR Level I, dated October 30, 2023, indicated: No Level II Required - No SMI/ID/RC (Severe Mental Illness/Intellectual Disability/Related Condition.) The rationale stated: There is no evidence of a PASRR condition. If changes occur or new information refutes these findings, a new screen must be submitted.Review of medical diagnosis showed diagnoses of bipolar disorder, Schizophrenia, and Depression were created on November 03, 2025. No updated PASRR referral was completed.The resident's care plan dated March 18, 2025, showed, Resident is an adult living with chronic mental illness. Resident has been screened through the outside screening agency and found to need long-term care placement/services. History includes anxiety. However, anxiety was not listed in the EMR diagnoses, and the PASRR documentation did not reflect the later diagnoses of bipolar disorder, schizophrenia, or depression.Email correspondence dated November 02, 2023, between marketing and admissions specifically requested that a new PASRR be completed prior to November 05, 2023; however, no referral was submitted.2. R10 was admitted on [DATE]. PASRR Level I, dated October 28, 2022, determined 'No Level II Required - No SMI/ID/RC. EMR (Electronic Medical Record) showed new diagnoses: Unspecified Dementia added October 31, 2022, Major Depressive Disorder, recurrent, mild added May 07, 2025, and Dementia in other diseases classified elsewhere added May 12, 2025. Review of the care plan showed no focus, goal, or interventions addressing the new psychiatric/behavioral diagnoses.No updated PASRR referral was submitted following these diagnoses.3.R35 was admitted [DATE]. PASRR Level I, dated February 15, 2023, determined 'No Level II Required - No SMI/ID/RC,' with instructions to submit a new referral if new diagnoses were identified. EMR showed diagnoses of Major Depressive Disorder, recurrent severe and Generalized Anxiety Disorder were entered on January 17, 2024.PASRR documentation did not include these diagnoses or any recommendations for services. An updated PASRR referral was not completed.On September 23, 2025, at 10:37AM with V13 (Medical Records Director) confirmed that PASRR referrals are generated through an outside agency responsible for PASSR screenings when notified by MDS of a new diagnosis. V13 stated she relies on consultants or notification to initiate a new referral.On September 23, 2025, at1: 1:32PM V9 (MDS) confirmed that diagnoses are entered into the EMR (electronic Medical Records) by herself or V20 (Care Plan Coordinator) and that all new diagnoses are communicated in daily meetings attended by department heads, including V13. Despite this process, no updated PASRR referral was initiated for R61, R10, R35.

Based on observation, interview, and record review, the facility failed to thoroughly cleanse a resident's skin prior to application of skin treatment and failed to ensure that psychotropic medication was administered as ordered. This applies to 2 of 2 residents (R52, R121) reviewed for quality of care in the sample of 29. The findings include:1. On September 23, 2025, at 9:36 AM, V4 (Wound Care Nurse) assessed R52's skin while V6 was providing incontinence care. There was multiple striation of redness all over on R52's backside and buttocks. There was a yellow stain noted on the fitted sheet right by R52's upper back. V6 said that the stain came from the fluids that was secreting from R52's skin. There were also clumps of dead skin scattered all over R52's backside and buttocks. V4 said that R52 has history of fungal rash on his back that's why he is receiving Nystatin ointment. V4 applied the Nystatin ointment without ensuring that R52's back was cleansed. On September 23, 2025, at 10:06 AM, V4 and V5 (Both Wound Care Nurses) assessed R52's skin. V4 said R52 was admitted with redness and fungal rash. The Nystatin cream is used to treat his skin because of history of fungal rash. V5 on the other hand stated the small clumps on his skin were dead skin, sweat, and old cream, from previous application, it should have been cleansed more, because it's defeating the purpose of the treatment. R52's physician order summary dated July 16, 2025, shows: Nystatin External Cream 100000 unit/gram. Apply topically to back, buttocks, and groin, for redness. Medication Class: Antifungal. 2. R121 is a [AGE] year-old female with a diagnoses history of schizoaffective disorder and anxiety disorder who was admitted to the facility 03/21/2012. On September 22, 2025 at 10:59 AM, R121 stated she didn't receive her Lorazepam for 6 days, when it was delivered it was the wrong dose and she had to wait until this was fixed, then she finally received it; she has asked the facility not to delay giving her this medication because it messes with her and makes her anxious and angry. On September 23, 2025 at 10:02 AM, R121 stated in the past she had to be put in straight jacket because she was off her medications, and expressed concerns about the consequences of not receiving her psychotropic medications. On September 24, 2025 at 2:07 PM, V2 (Director of Nursing) stated if R121 has an order for Lorazepam it should have been administered as ordered; the facility does keep an emergency supply of Lorazepam and if it was in stock it should have been given to R121; the Lorazepam should have been reordered within a few days of running out. R121's current physician orders document an active order effective 11/17/2022 for one .5 mg Lorazepam tablet twice daily for anxiety. R121's progress notes dated 09/10, 09/11, 09/14, and 09/15 document her prescribed Lorazapam was not available for administration. R121's September medication administration record documents Lorazepam was not administered as ordered from 09/10 - 09/12 and 09/13 - 09/15. The facility's list of emergency medications received September 24, 2025 from the facility includes .5 mg of Lorazepam. The facility's policy on Administration of Medications received from the facility September 24, 2025 states in part: Medications should be administered within one (1) hour of the prescribed times.

Based on observation, interview, and record review, the facility failed to safely transfer a resident from the bed to the chair. This failure resulted in R4 experiencing a right humeral neck fracture when the mechanical lift R4 was attached to tipped over and R4 struck the wall in her room. This applies to 1 of 3 residents (R4) reviewed for accidents in the sample of 33. The findings include:On August 25, 2025, at 10:25 AM, R4 was sitting in the chair with an ice pack over her right shoulder area. R4 said, The other day I was up in the sling of the mechanical lift. The staff were transferring me to the dialysis chair from my bed when the entire [mechanical lift] tipped over with me in it. I slammed into the wall in my room hard, then the chair, and then the floor. My whole body ended up on the floor, still attached to the [mechanical lift]. I had very bad pain in my right shoulder. The [mechanical lift] machine also fell on one of the staff and she was pinned under the lift and my whole body. I went to the hospital, and they said I broke my arm by my shoulder. The facility's incident report dated July 28, 2025 shows, Floor nurse entered the resident's room. Three CNAs (Certified Nursing Assistants) present. Resident was lowered to the floor by staff. Resident stated she hit her shoulder and head on the wall during transfer. The incident report continues to show R4 was alert and oriented to person, place, time, and situation. Predisposing environmental factors included clutter. Predisposing situation factors included incident occurred during staff assist with transfer to/from chair and the resident's weight. The EMR (Electronic Medical Record) shows R4 is a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses including, end-stage renal disease, hypoxemia, right shoulder fracture, chronic respiratory failure, generalized anxiety disorder, insomnia, panic disorder, dependence on renal dialysis, heart failure, Type 2 diabetes, major depressive disorder, neuropathy, and hypertension. R4's MDS (Minimum Data Set) dated August 8, 2025 shows R4 is cognitively intact, requires setup assistance with eating, partial/moderate assistance with oral and person hygiene, and is totally dependent on facility staff for all other ADLs (Activities of Daily Living). R4 is always incontinent of bowel and bladder. Dialysis documentation dated August 1, 2025 shows R4's weight as 385 pounds. On July 29, 2025, at 2:56 AM, V8 (LPN-Licensed Practical Nurse) documented the following progress note for R4 effective July 28, 2025, at 5:15 AM: The writer was in the hallway and heard CNAs (Certified Nursing Assistants) yelling. The writer witnessed the resident on the floor attached to the [mechanical lift]. There were three CNAs present which stated the [mechanical lift] tipped over in the process of transferring the resident. V8's progress note was struck out by V18 (Restorative Nurse) on August 4, 2025 at 3:41 PM and labeled incorrect documentation. On July 29, 2025, at 2:57 AM, V8 (LPN) documented the following progress note with an effective date of July 28, 2025, at 5:15 AM: [R4] stated she hit her head and had right shoulder pain. She also stated the [mechanical lift] tipped over in the process of the transfer and she did not want to go to the hospital. V8's progress note was struck out by V18 (Restorative Nurse) on August 4, 2025 at 3:41 PM and labeled incorrect documentation. On July 29, 2025, at 2:58 AM, V8 (LPN) documented the following progress note with an effective date of July 28, 2025, at 5:15 AM: The writer called for help and called 911 for help getting the resident up from the floor. [R4] did not want to go to hospital. Writer explained since she hit her head she had to. The fire department arrived in 10 minutes and resident was taken to [local hospital] . V8's progress note was struck out by V18 (Restorative Nurse) on August 4, 2025 at 3:41 PM and labeled incorrect documentation. On August 25, 2025 at 2:01 PM, V8 (LPN) said, I was notified by the CNAs that the [mechanical lift] tipped over and they lowered [R4] to the ground. The resident was still connected to the [mechanical lift] when I came to the room, and we had to disconnect her and lift the [mechanical lift] off of the CNA (V7). I assessed [R4], and she complained of right shoulder pain. On August 25, 2025, at 6:09 PM, V8 (LPN) said, I wrote very detailed notes of what I saw and what I assessed. My notes are accurate. I did not go into the EMR and strike out my notes and label them as incorrect documentation. My documentation is accurate as to what happened. On August 26, 2025 at 10:04 AM, V1 (Administrator) and V2 (DON-Director of Nursing) said V8's documentation was inadvertently struck out when changes were made to the risk management report attached to this incident. V1 (Administrator) said, [V8's] notes are her story, and we will have to go back in and figure out a way to rewrite them. On August 25, 2025 at 1:36 PM, V7 (CNA) said, I was getting [R4] up for dialysis on July 28, 2025. Another CNA was with me. We used the [mechanical lift] and raised [R4] up off the bed with the full-body sling attached to the [mechanical lift] to get her weight reading. We were pulling the legs of the [mechanical lift] out from under her bed and we turned the [mechanical lift] and [R4's] weight shifted, and the whole [mechanical lift] tipped over. It looked like the wheel had broken off and it pulled her and the lift over. As we were turning the [mechanical lift] the support legs of the lift were opening and closing. The support legs are supposed to stay in a locked position, but the shifter lever on the [mechanical lift] has been broken since I started working at the facility in January 2025, and we were not able to keep the legs in a locked position. [R4] was in the [mechanical lift] sling, attached to the [mechanical lift] when it tipped over. The [mechanical lift] tipped over and I was pinned between the wall, the resident, and the [mechanical lift]. [R4's] head hit the foot of the chair. Her right shoulder caught the corner of the wall in her room. [R4] never fell out of the [mechanical lift] sling. The bar that was holding all of [R4's] weight was completely in my rib cage. I still have bruises from the incident on my ribs. The support legs to the [mechanical lift] were completely pinned under the bed. There was too much clutter in the room, like cases of water, boxes of personal belongings, and bags of her stuff, to easily transfer her. There wasn't room for us to turn the [mechanical lift] because of the clutter. We had to stop and turn, stop and turn a little more, and when we went to turn the [mechanical lift] again, it seemed like the wheel broke and it just tipped over. On August 25, 2025 at 2:49 PM, V6 (CNA) said, They were getting [R4] up using the [mechanical lift], and the [mechanical lift] tipped over and the lift and [R4] hit the wall hard. The wall is what kept the whole [mechanical lift] and [R4] from falling all the way to the floor. [V7] (CNA) was pinned between the lift, the resident, and the wall. The [mechanical lift] with the resident still attached to the lift had to be lowered to the ground. The legs of the [mechanical lift] got stuck under the resident's bed. Even when the fire department came, it took six of them to get [R4] up off the floor. I have worked at the facility since May 2025, and that particular [mechanical lift] has been broken the whole time I have worked here. The support legs won't stay locked in a fixed position. They move in and out when you are trying to move the lift with the resident. They said it had been reported already that the [mechanical lift] needed to be fixed, so I never filled out a repair ticket. On August 25, 2025, at 6:16 PM, V5 (CNA) said, They were transferring [R4] to the dialysis chair using the [mechanical lift]. I was holding the dialysis chair, and [V6] and [V7] were using the lift to get [R4's] weight reading from the lift before they started moving the lift away from the bed, with [R4] in the sling attached to the lift. The whole [mechanical lift] started to lean, and I was yelling to them to guide the lift, and I was screaming, it's leaning, it's leaning, but the resident was already in motion. The entire [mechanical lift] fell over with the resident attached to the lift, and the resident hit the wall hard, and it pinned [V7] (CNA) up against the wall. [R4] hit the corner of the wall, right by the bathroom door. [R4] hit the wall hard with her arm. We had to lower the resident and the lift to the floor at the same time, and the nurses came and started helping us move the chair and then we were able to lift the [mechanical lift] off of [V7]. It took a lot of paramedics to lift [R4] up the ground. R4's hospital records dated July 28, 2025 show, This is a [AGE] year-old female who presents with trying to be transferred from bed to chair. They were trying to use the [mechanical lift] when the [mechanical lift] fell, and she fell and hit her back of the head on a chair and hit her right should on the chair. She is complaining of headache as well as right shoulder pain. R4's right shoulder X-ray dated July 28, 2025 shows, Findings are suggestive for a mildly impacted right humeral neck fracture. R4's right humerus X-ray, dated July 28, 2025 shows, Impression: Impacted right humeral neck fracture. On August 26, 2025, at 10:09 AM, V16 (NP-Nurse Practitioner) said, '[R4] was being transferred from the bed to the chair, and during the transfer, there was an arm injury, and she was sent to the hospital where she was found to have an arm fracture. She does not have fragile bones or any other medical condition that would have caused the fracture. It is safe to say the incident where the mechanical lift tipped over and she hit the wall caused the arm fracture. On August 25, 2025 at 10:53 AM, V13 (Maintenance Director) showed the mechanical lift device involved in R4's incident on July 28, 2025. The mechanical lift was sitting outside next to the facility's dumpster. V13 said the mechanical lift was taken out of service and placed in the trash. The mechanical lift device had a property identification sticker affixed to it identifying the lift as lift number 107. V13 demonstrated how the shifter lever on the mechanical lift is used to open and close the legs of the mechanical lift base for stability when lifting and transferring the resident. V13 said, The shifter lever is broken. The shifter lever comes right off in your hand, which it is not supposed to do. Also, the shifter lever does not stay in the locked position because it is broken, so facility staff are unable to lock the legs of the base in place before moving the resident. The lift is so old, we just decided to throw it away after the incident. V13 demonstrated how the support legs of the mechanical lift would not stay in a locked position and how unstable the mechanical lift became when being moved with the support legs unlocked. V13 said the mechanical lifts in the facility are supposed to be inspected monthly. V13 said he started working at the facility on July 1, 2025 and had not inspected the mechanical lifts until July 30, 2025. V13 provided documentation to show the lift involved in the incident with R4 on July 28, 2025, lift number 107, had not been inspected since March 5, 2025. On August 26, 2025 at 1:00 PM, V1 (Administrator) said facility staff should inspect the mechanical lift prior to using it and remove the mechanical lift from service if the mechanical lift is in need of repairs. The undated mechanical lift User Manual provided by V1 (Administrator) shows, the shifter handle must be locked when transferring the resident. Maintenance of the mechanical lifts should include an initial inspection, and monthly inspections and adjustments when used in an institutional setting. The facility's policy entitled Limited Lifting Resident Handling, revised on 1/25 shows: Policy: This facility will use mechanical lifting devices when lifting and moving the residents when indicated and as ordered by the physician. Purpose: To protect the safety and well-being of the staff and residents. Procedure: .4. Mechanical lift equipment shall undergo routine maintenance checks and be accessible to staff 24 hours a day.8. The policy will be followed at all times. Failure to comply will result in disciplinary action at management's discretion. The facility's undated Validation of Competency - Total (Full Body) Mechanical Lift Transfer shows the facility's expected performance criteria. The Validation of Competency shows facility staff are expected to know a mechanical lift pre-operations check should be completed including, checking the weight limit of the mechanical lift and the sling size/style to verify they are appropriate for the resident, confirm the battery is charged, inspect the lift condition and check the operation, inspect slings for frays, tears, or other signs of wear, and state the reason and process for removing lift equipment and slings from service. The staff competency also shows facility staff are expected to know to clear a pathway to allow the lift to pivot and move freely.

Based on interview and record review, the facility failed to supervise a resident with impaired cognition while drinking a hot beverage. This failure resulted in the resident spilling the hot beverage, sustaining burns to her bilateral thighs and was transferred to hospital for treatment of the same. This applies to 1 of 3 residents (R1) reviewed for accidents and supervision in the sample of 3. The findings include: R1's face sheet showed that R1 was admitted to the facility on [DATE] with multiple diagnoses including Multiple Sclerosis, Dysarthria and Anarthria, Hereditary Spastic Paraplegia, Muscle Wasting and Atrophy, Anxiety Disorder, Insomnia, Diseases of Spinal Cord. R1's quarterly MDS (minimum data set) dated February 28, 2025 showed that R1 was severely impaired in cognition and required supervision or touching assistance for eating. Facility Incident logs showed that R1 had a hot liquid burn on March 10, 2025. Facility discharge records and nurses progress notes showed that R1 was discharged to the hospital to the burn center on March 13, 2025. Hospital patient information records showed that R1 was admitted to Burn stepdown unit on March 13, 2025. Hospital Burn Attending Physician history and physical progress note dated March 14, 2025 included that R1 presents with 5% scald burns: full thickness wounds accounting for 1.5 TBSA [total body surface area] to bilateral thighs . Occupational Therapy Assessment at hospital dated March 14, 2025 included that R1 is a [AGE] year old female with diagnosis of Burn who presents impairments in range of motions, strength, gross motor coordination, fine motor coordination, bilateral coordination, activity intolerance, safety awareness, balance motor planning, manual dexterity and self help skills. Performance deficits include difficulty in ADLS [activities of daily living] including feeding. Facility Change of Condition progress note dated March 13, 2025 included as follows: Resident has a second degree wound and blister wound on both thigh that needs attention as resident has been refusing care . Assessment for the same showed to send to the hospital for further care. Facility nursing progress notes dated March 10, 2025 included as follows: Resident sitting in hallway across from nurses station after shower for monitoring at 1515 (3:15 PM) resident yelled out CNA (Certified Nursing Assistant) went to assist resident noted resident had spilled drinking cup over, CNA took resident to room to change wet clothing summons this writer to resident room, this writer noted both thighs were reddened with blistered area on bilateral thighs, wound care nurse informed area addressed per wound care protocol . On March 28, 2025 at 9:52 AM, V5 (Licensed Practical Nurse) stated that on March 10, 2025, she was R1's nurse and V6 (CNA) had brought R1 out to the nurses station after a shower and placed her in a geri (recliner with wheeled bases) chair and given her something warm to drink. V5 stated that it was around the change of shift in the afternoon. V5 stated that she believes that V6 had heated up some water with a tea bag and set it on a bed side table and R1 knocked it off. V5 stated that V6 took R1 to her room to change her wet clothes and that's when she noticed that the area around R1's upper thighs were reddened. V5 stated that she notified V3 (Wound Care Nurse) and since V3 was leaving for the day, she applied the treatment based on V3's suggestion and endorsed to the night nurse. On March 28, 2025 at 2:25 PM, V6 (CNA) stated that she works the afternoon shift on March 10, 2025 and the routine was that when she comes in she gets her assignments and gives residents their showers. V6 stated that she gave R1 a shower with the assistance of V13 (CNA) and after changing her, they transferred her to a geri chair and placed her by the nurses station. V6 stated that R1 was cold and asked for tea. V6 continued I made the tea by getting a tea bag from the kitchen and I got water from the faucet and heated to about 1 to 1 1/2 minutes and gave it to her on a bedside table [that was by the geri-chair]. I had to help other residents and I walked away to help V13 with the showers. When I was down the hallway in the 2400 unit, she said 'Ahh' and the nurse [V5] told me to check her. I bring her to the room and pulled out her pants and showed it [reddened area] to the nurse who applied some ointment. She [R1] is always a challenge and moves around. When asked, what cup she used to heat the water, V6 stated that it was a Styrofoam disposable cup. On March 28, 2025 at 10:12 AM, V3 stated that she was working as a floor nurse on March 11, 2025 and was asked to take a look at R1 while they were providing care. V3 stated Upon laying eyes on her, I can tell that it had blistered and the skin was pretty exposed. V3 clarified that there was a very large intact blister on one thigh/leg and on the other thigh/leg the blister was partially ruptured. V3 stated that the staff who were changing R1 told her that there was a dressing on the partial blistered area but R1 had ripped it off as she was very agitated which must have caused the blister to be ruptured. V3 also added that lately, the staff had to assist and cue R1 with eating, more so because of her mental than physical decline. On March 28,2025 at 12:45 PM, V7 (Restorative Aide) stated that R1 has good and bad days and that on some days she was able to feed herself and other days the staff provided assistance in eating. V7 added that R1 had a tendency to lean forward if she was tired or not feeling well. On March 28, 2025 at 12:47 PM, V8 (CNA) stated that she has taken care of R1 and that for most part, R1 usually ate in the dining room by herself. V8 stated that R1 would sometimes spill food and drinks. On March 28, 2025 at 2:11 PM, V14 (R1's Power of Attorney) stated You don't give a person hot tea without a lid knowing her condition. This particular CNA [V6] knows her behavior. R1's restorative care plan dated January 20, 2023 showed that R1 has a self-care deficit (ADLs/Mobility) secondary to her diagnosis of multiple sclerosis and paraplegia. Interventions included intermittent supervision with meals and encourage to finish food for adequate nutrition, assist as needed. R1's nursing care plan revised January 15, 2023 showed that R1 demonstrates physical & emotional impairment secondary to neurological disease/damage caused by: multiple sclerosis and paraplegia. Interventions for the same included to provide assistive/adaptive devices to help the resident do as much for himself as possible. R1's behavior care plan initiated April 18, 2024 showed that R1 has potential to demonstrate physical behaviors or aggressive behaviors towards staff including yelling, knocking stuff down and throwing objects related to multiple sclerosis. Interventions included to assess and anticipate resident's needs

Based on observation, interview, and record review, the facility failed to have a system in place to launder and maintain the mechanical lift slings per manufacturer guidelines to prevent material breakdown and maintain the integrity of the lift slings for safe use. The facility failed to serve hot water at a safe temperature to a resident with upper extremity impairments. This failure resulted in a sling breaking while R1 was being transferred with the mechanical lift, causing R1 to sustain a right humerus fracture. R1 also incurred a 3rd degree burn after spilling hot water on herself after being served hot water by facility staff. This applies to 1 of 7 residents (R1) reviewed for accidents and incidents in a sample of 10. The findings include: R1's Admission Record dated 5/9/2023 documents R1 with diagnoses to include right sided Hemiparesis and Hemiplegia (weakness and paralysis) following a stroke affecting the dominant (right side), Bipolar Disorder, and morbid obesity. The Brief Interview of Mental Status dated 4/27/2023 documents R1 as cognitively intact. 1. On 5/5/2023 at 9:50 AM, R1 was in bed with a sling to her right arm. R1 stated last week, she fell from the mechanical lift while being transferred. R1 stated two nursing assistants took her from the bed to shower, brought her back to bed to get dressed, and as she was being transferred from her bed to her electric wheelchair, the strap snapped- causing her to fall onto the floor and breaking her right arm. R1 stated, They did everything right, but the sling busted. R1's 4/25/23 Radiology Report of Right Humerus, Shoulder and Elbow shows R1 with a fracture of her right humerus. On 5/5/2023 at 1:40, V6 (Nursing Assistant) stated on 4/25/2023, V6 and V7 (Nursing Assistants) got R1 up with the mechanical lift, showered her, and transferred her back to bed to get her dressed. V6 stated when she and V7 began to transfer R1 from the bed to her electric wheelchair, the sling loop on the upper left side broke, causing her to fall to the floor. V6 stated R1 always had her own sling, and it is laundered by the Laundry Department when soiled, then returned to her once it is cleaned. A facility Investigative Report dated 4/25/2023 documents during a transfer, the left loop on the mechanical lift sling broke, causing R1 to fall to the floor and incur a right humerus fracture. R1 was sent to the hospital and returned with a right arm sling. On 5/8/2023 10:18 AM, V15 (Restorative Nurse) stated prior to R1's falls, soiled slings were sent to laundry for washing. After the fall it was identified improper laundering can cause deterioration of the sling material if not washed properly. V15 stated manufacturer's guidelines showed the slings are supposed to be dried without heat or air dried and washed without using bleach. On 5/5/2023 1:20 PM, V14 (Laundry Director) stated prior to the fall, there was no specific process to launder lift slings. V14 stated lift slings were sent to the laundry to be washed and dried on the regular (hot) cycle in the dryer. V14 stated three are two cycles on the washing machines and depending on which cycle was chosen by the staff washing the laundry, bleach would be automatically added to one of the two cycles. V14 stated now the facility is washing the slings in cold water and air drying them per the manufacturer's guidelines. On 5/9/2023 at 11:45 AM V4 (Medical Director) stated he expects the facility to follow manufacturer's guidelines for the care of slings to maintain the integrity of the equipment for the safe provision of care. R1's Care Plan for fall risk dated 12/30/2016 documents R1 as a mechanical lift for transfers. On 5/8/2023 at 10:55 AM, V15 (Restorative Nurse) provided the manufacturer's guidelines for the care and use of the slings being utilized by the facility on 4/25/2023, the date of the occurrence. The undated manufacturer's Full Body Sling Instruction Manual documents washing instructions as wash in warm or cold water, air dry or tumble dry at cool. Do not tumble dry at high temperatures, and do not use bleach. Bleached, torn, cut, frayed or broken slings are unsafe and could result in injury and should be discarded immediately. The undated manufacturer's Guideline for Identifying Deteriorated Slings documents slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition, but the actual tensile strength of the material may be compromised and poses a safety risk and should not be used for lifting a resident. 2. On 5/10/2023 at 9:30 AM, R1 stated she spilled hot water on herself on 4/24/2023 at an unknown time and did not realize she burned herself. R1 stated V6 and V7 (Nursing Assistants) identified the burns while she was being showered on 4/25/2023. R1 stated she requests staff to provide hot water from the kitchen because the hot water from the plastic thermal dispensers sometimes has a coffee taste. R1 stated on this day, she had an unknown Nursing Assistant bring her water in her personal thermal cup, which was bedside during this interaction, placed in a larger silver thermal container. She said the water was so hot she let it sit for 2-3 hours before she went to drink it. She then realized she had not put the tea bag in the cup before giving it to staff to fill as she usually does. R1 pointed to the smaller thermal cup that was bedside, stating she opened it up to put the tea bag in and spilled some of the hot water on her right side. On 5/10/2023 at 10:05 AM, V18 (Nurse) pulled back R1's gown, and a few small tan pea-sized spots on her right upper thigh which were superficial and almost healed. V18 peeled back a small dressing to R1's lower right abdominal area to reveal one small irregular quarter-sized red open area. On 5/10/2023 at 11:36 AM, V6 (Nursing Assistant) stated on 4/25/2023, she noticed a red spot on R1's abdomen and leg while showering her and the areas looked fresh. R1 reported to V6 she had spilled tea on herself the day before. V6 stated R1 always uses her own personal thermos for water but staff always put the lid on it for her. V6 further stated, I would not trust her to be able to take a cup/thermos of hot water and put the lid on by herself safely. I would be afraid she would burn herself. On 5/10/2023 at 12:22 PM, V27 (Therapy Director) stated R1 has decreased sensation on her right side and no fine motor skills to her right hand. R1 has received therapy to learn how to compensate with her right hand and can function fairly independently with her right arm and hand after her stroke years ago. V27 stated R1 would be able to drink hot water safely after she is set up but would require assistance to safely open and manipulate the screw top of the thermal cup. The facility incident report titled Hot Liquid Burn for the incident discovered 4/25/2023, documents R1 reporting she was pulling the lid off of the coffee cup to put a tea bag inside when she lost balance of the cup and spilled some liquid. R1 was identified with redness and 2 quarter-sized blisters. R1's Care Plan for skin alterations dated 12/30/2016 documents R1 with a history of spilling hot water on herself with an intervention dated 6/24/2021 to not give her boiling hot liquids. On 5/10/2023 at 9:50 AM, V30 (Dietary Manager) checked the temperature of the hot water dispensing from the coffee/hot water machine in the kitchen. The hot water temperature coming from the dispenser was at 170 degrees and steam could be seen rising from the cup of hot water after it was dispensed. On 5/11/2023 at 10:12 AM, V28 (Nurse Practitioner) stated R1 incurred 3rd degree burns to her right thigh and abdomen from a hot liquid spill. V28 stated he ordered Silvadene after the incident. V28 further stated he expects the facility to serve her hot water at a temperature safe enough for her to handle it. The website ameriburn.org, for the American Burn Association, documents a third-degree burn can occur in one second with liquids at 155 degrees.

Based on interview and record review, the facility failed to ensure a resident was free from neglect when it did not have the structures and processes in place to ensure a newly admitted resident was assigned to the care of a nurse. This failure resulted in R1 residing at the facility for 18 hours without receiving glucose monitoring and scheduled insulin, sustaining a blood sugar reading greater than 600 mg/dL (milligram per deciliter), not receiving scheduled medications, including antihypertensives, diuretic medication, cardiac medications, and scheduled nursing staff denying responsibility for the care of the resident. The Immediate Jeopardy was noted to begin on [DATE], when the facility failed to ensure a newly admitted resident was assigned to the care of a nurse and provided care and services to ensure physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) and V16 (ADON-Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 11:15 AM. The surveyor confirmed by observation, interview, and record review 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 plan of correction, including in-service training of staff, regarding admission process, neglect, and administration of medication as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] at 5:45 PM and expired at the facility on [DATE] at 1:09 PM. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) was not completed at the time R1 expired at the facility due to the resident residing at the facility for less than 24 hours. On [DATE] at 5:30 PM, V7 (RN-Registered Nurse) documented the following regarding R1: 8:30 AM - call light on, resident awake, asking for her tray reassured 10:00 AM - resident awake and verbally responsive skin warm dry respiration unlabored, O2 on via nasal cannula 12:10 PM - resident due for [glucose check], noted resident not responding to verbal and tactile stimuli, vitals not appreciated BP (Blood Pressure) ,d+[DATE], PR (Pulse Rate) 0, RR (Respiratory Rate) 0, no rise and fall of chest noted, Code Blue called, CPR (Cardio-Pulmonary Resuscitation) initiated, 911 notified by another staff. CPR continued. 12:20 PM - 911 paramedics arrived and took over CPR. 13:03 PM (1:03 PM) - Resident expired pronounced by [local fire department] paramedics. The local fire department paramedic documentation for R1 dated [DATE] shows at 12:38 PM, paramedics assessed R1 with no blood pressure, no pulse, or respirations. R1's blood glucose reading on the paramedic glucometer read as high. Paramedic documentation continues to show: Crew called to the nursing home for the person not breathing (R1). Upon arrival found crew on scene providing manual CPR. Patient was last seen normal by staff at 10:30 this morning with no medical complaints. Staff found the patient not breathing and pulseless, began CPR and called 911. [Crew] has been on scene for approximately ,d+[DATE] minutes prior to [second crew], and obtained an asystole rhythm on the monitor, and has begun obtaining an ET (Endotracheal Tube) 7.0. Patient has no signs of trauma, and no signs of obvious death. Patient is still warm to the touch. Crew places patient on the [automated cardiopulmonary resuscitation device] for continuous CPR, and we obtain the intubation and IO (Intra-Osseous) IV. Crew hangs fluids at wide open. We administer Epi 1:10,000 as directed, with regular pulse checks. Patient remains in asystole except for one pulse check, which was PEA (Pulseless Electrical Activity). Patient's next pulse check returned back to asystole. Crew contacts medical control with full progress report. [Local hospital] confirms to terminate resuscitation attempts in the field at 13:06 (1:06 PM). On [DATE] at 8:49 AM, V9 (Paramedic) said, If we get a blood sugar reading of high on our glucometer, it means the blood sugar is over 600 [mg/dL]. All of our glucometers are the same on all of our frontline equipment. The State of Illinois, Certificate of Death Worksheet, dated [DATE] shows R1 expired at the facility on [DATE] at 1:09 PM due to an acute MI ([CONDITION(S)]). The death certificate is signed by V4 (Physician). R1's hospital discharge medication orders dated [DATE] at 3:52 PM show dietary orders, and multiple medications orders, including: [MEDICATION(S)] (blood pressure and cardiac medication) 5 mg. (Milligrams) orally daily. [MEDICATION(S)] (blood pressure and cardiac medication) 25 mg. orally twice daily with meals. [MEDICATION(S)] (blood pressure medication) 0.3 mg. orally three times daily. [MEDICATION(S)] (diuretic) 40 mg. orally daily. [MEDICATION(S)] (anti-diabetic medication) 2 mg. orally every day with breakfast. [MEDICATION(S)] (blood pressure medication) 100 mg. orally three times a day. Insulin [MEDICATION(S)] (diabetes medication) 20 units SQ (Subcutaneously) every day Insulin [MEDICATION(S)] (diabetes medication) 14 units SQ at bedtime Sliding scale Insulin [MEDICATION(S)] (diabetes medication) SQ four times a day based on blood sugar test results. [MEDICATION(S)] (blood pressure and cardiac medication) 20 mg. orally daily. [MEDICATION(S)] (anti-diabetic medication) 1000 mg. orally twice daily with meals. [MEDICATION(S)] 0.5 mg. orally daily. On [DATE] at 12:14 PM, V2 (DON-Director of Nursing) said, None of R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For some reason the resident never got entered into our computer system so the staff could not put in the orders or document anything about this resident. The resident was admitted to the facility on [DATE] around 6:00 PM, and it wasn't until the next day, starting around 10:00 AM when V6 (RN-Registered Nurse/Care Plan Coordinator) was able to get the resident admitted into our computer system and start entering all of the orders. It is my expectation the nurse will do a head-to-toe assessment and vital signs on admission and get all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:42 PM, V5 (RN) said, I received report from the hospital around 4:30 PM on [DATE] for R1. The agency nurse was taking the resident but was not in the facility yet. I did not care for this resident the rest of my shift, which ended around 11:00 PM. The agency nurse did not let me know R1 was not entered into the [EMR] until she left for the night around 11:00 PM. I tried to call a few different people to put her in the system but was not able to follow through with that because I was dealing with other issues. I only took telephone report on this resident. I did not obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:40 PM, V14 (Agency Nurse) said, R1 was not my resident. I was supposed to work on [DATE] from 2:00 PM to 10:00 PM. The resident belonged to V5 (RN), not me. I told V5 I would look over the resident's skin and I would let her know what I saw. That was it. I did not care for the resident the rest of my shift. I did not call the physician to obtain orders. A few days later the DON called me and asked me to fill out the admission assessment. I told her I did not take care of this resident and they shouldn't be calling me. Here this resident had been in the building for several shifts, and five days later they are calling me to document on her? They asked me to chart what I saw on the resident. I reached out to a corporate nurse and said that I did not think that was okay because the resident was never mine. The resident fell into my assigned area, but because it was my first time in the building, V5 was going to do her admission. On [DATE] at 12:29 PM, V11 (Registered Nurse/RN) said, I started work on [DATE] at 11:00 PM. There were two nurses on the unit: me and an agency nurse. R1 was not on the facility census list. R1 was assigned to the agency nurse. The agency nurse was also working in the COVID unit. The resident had not been entered into the system, and there were no orders put in for her. I did not call the doctor to obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:38 PM, V15 (Agency Nurse) said, I worked at the facility on the night of [DATE] starting at 11:00 PM. I did not care for R1 at all that night. When I work with V11(RN), she makes it very clear she does not want to work on the COVID unit, so I take that unit. The hallway R1 resided in belonged to V11. Every time I come to that facility I ask for a resident census and I do my rounds and see if the resident is actually in the room. The census sheet is always messed up. As an agency nurse, I have never had to put the medication orders into the computer. I would remember if they gave me a resident who needed to have her medications entered. I did not care for R1 that night. I did not call the doctor to get admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 9:09 AM, V7 (RN) said, I worked the day shift on [DATE], starting at 6:00 AM. I came in that morning and R1 was in the building, but not in our computer system. I did not call the NP (Nurse Practitioner) or the doctor to get admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . We did not establish who was going to take care of R1. I guess that's where we dropped the ball. The nurses on the two shifts before us didn't get orders for this resident either, so they dropped the ball too. It wasn't until around noon when I went in to take a blood sugar on R1 that I found her unresponsive and called a code blue. I had not given her any medications that day, checked her vital signs or assessed her. On [DATE] at 10:19 AM, V12 (LPN-Licensed Practical Nurse) said, I remember a little about [DATE]. I was working the day shift with V7 (RN). I was assigned to the COVID unit. If there was something outside of the COVID unit, then V7 took care of it. I did not call the NP or the physician for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is very unusual that no one did her admission on the other shifts. It's a 24-hour facility. Nursing is a 24-hour job. On [DATE] at 11:20 AM, V6 (Registered Nurse/ RN) said, Normally when a resident is a new admission or a readmission, the admitting nurse is the one putting in the orders on the day the resident is admitted . I was the Manager on Duty on Saturday, [DATE]. I noticed when I came in that morning R1 was admitted the evening before but was never entered into the computer system. I looked at her admission paperwork and saw none of her admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If she was admitted on Friday evening, the nursing staff on that shift should have gotten the orders and entered them into the system. Whoever was assigned to that resident should have put everything in on that day. I think because the resident was never entered into our computer system, no one did her admission. I started putting in her orders around 10:00 AM on [DATE]. I wasn't even finished putting in all the orders and they called a code blue on her, and the paramedics came. I'm not sure if the nurse notified the doctor, none of her medications had been given. On [DATE] at 4:24 PM, V10 (NP-Nurse Practitioner) said, I was on call the weekend R1 was admitted to the facility. No one ever called me for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 2:06 PM, V4 (Physician) said, It is my expectation that the facility staff administer the medications as ordered and on time. The orders should have been carried through from her discharge from the hospital to her admission at the facility right away. On [DATE] at 1:54 PM, V13 (Pharmacist) said, They could have gotten all of R1's medications with stat delivery or evening delivery and R1 would not have had to miss her medications if they would have notified us. The facility's policy entitled; Medication Reconciliation dated [DATE] shows: Purpose: Verify the resident's current medication regimen upon admission and/or readmission to the facility and provide an updated medication list to the next service provider at the time of discharge/transfer from this facility. Procedure: At the time of each admission and/or readmission to the facility, the charge nurse will review the list of medications/orders (including prescription and OTC) with the physician or physician extender, noting any discrepancies with the name of the drug, dosage, route, frequency, and reason for administration. Through observation, interview, and record review conducted on [DATE], the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All nursing and management staff were educated on ensuring that all new residents are assigned to the care of a nurse and provided care and services, free of neglect. Education was also provided to ensure physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This training included the process of Quick ADT (Admission/Discharge/Transfer) and notification of the DON (Director of Nursing) and/or ADON (Assistant Director of Nursing) for any issues encountered. Initial education was completed on [DATE] by the ADON, nurse managers, and Social Services. Education was provided to all licensed staff and is on-going. Newly hired employees will be educated on the process during the facility orientation process. Education was also provided to ensure physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . All new admission/readmissions are audited, as they are admitted , for three months to ensure compliance and the audit tool presented to monthly QAPI (Quality Assurance Performance Improvement) meetings. A new process for new admissions/readmissions has been put into place. A resident entry audit tool was initiated. Marketing Liaison/DON/ADON will ensure the new admissions are entered into the EMR (Electronic Medical Record). DON/ADON will audit, upon admission, to ensure that the new admissions/readmissions are in the EMR and will complete a new audit tool that was created to ensure the process is followed. The DON/ADON will audit every new admission/readmission, as they admit to the facility. Audits will include physician verification of orders, orders being entered upon admission, including glucose monitoring, cardiac and insulin medications, oxygen, and dietary orders to ensure residents receive immediate care after being admitted to the facility and free of neglect. The audits will continue for three months to ensure compliance. Audits will be reviewed in monthly QAPI. The DON/ADON will ensure that new resident's orders are entered upon admission, residents are assigned to the care of a nurse, and provided care and services, free of neglect. Admission/readmissions will be outlined on daily assignment sheet to designate the assigned nurse. All staff educated via telephone were educated with the same training as the staff educated in person, however, the staff who received training over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked, additionally. Any staff that is unreachable will be educated prior to their next scheduled shift. The DON/ADON will ensure upon completion of this in-person training, staff will sign education sheets prior to next scheduled shift. Evidence for education that took place over the telephone is provided by specifying the name of the employee educated, the time the employee educated was called, and who conducted the training. All newly hired nurses and management staff will be educated during orientation, upon hire, by the Administrator or Designee, prior to starting on the floor. Education was also provided to ensure physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An audit tool to ensure all newly hired nurses and management staff receive training will be completed by the DON/ADON for three months to ensure compliance. An emergency QAPI meeting was held on [DATE] with the IDT (Interdisciplinary Team). Copy of the QAPI minutes was shared with the Medical Director for review. Measurable goals were established to ensure new residents are entered into the system on the day of admission, are assigned to the nurse, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Audits will continue for three months. At that time, the QAPI committee will determine if adjustments need to be made. The expectation is 100 percent compliance in following the admission process. Non-compliance will result in on-the-spot training and disciplinary action, if warranted. Licensed nursing agency staff are educated by the DON/ADON prior to the start of the shift to ensure the resident is assigned to the appropriate nurse, the nurse acknowledges responsibility for the resident's care in writing, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The QAPI committee will determine if audits should continue after three months.

Based on interview and record review, the facility failed to ensure a newly admitted resident received physician-ordered cardiac and diabetes medications as shown on the physician's hospital discharge medication orders. This failure resulted in R1 residing at the facility for 18 hours without receiving glucose monitoring and scheduled insulin and sustaining a blood sugar reading greater than 600 mg/dL (milligram per deciliter). This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 5. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] at 5:45 PM and expired at the facility on [DATE] at 1:09 PM. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) was not completed at the time R1 expired at the facility due to the resident residing at the facility for less than 24 hours. On [DATE] at 5:30 PM, V7 (RN-Registered Nurse) documented the following regarding R1: 8:30 AM - call light on, resident awake, asking for her tray reassured 10:00 AM - resident awake and verbally responsive skin warm dry respiration unlabored, O2 on via nasal cannula 12:10 PM - resident due for [glucose check], noted resident not responding to verbal and tactile stimuli, vitals not appreciated BP (Blood Pressure) ,d+[DATE], PR (Pulse Rate) 0, RR (Respiratory Rate) 0, no rise and fall of chest noted, Code Blue called, CPR (Cardio-Pulmonary Resuscitation) initiated, 911 notified by another staff. CPR continued. 12:20 PM - 911 paramedics arrived and took over CPR. 13:03 PM (1:03 PM) - Resident expired pronounced by [local fire department] paramedics. The local fire department paramedic documentation for R1 dated [DATE] shows at 12:38 PM, paramedics assessed R1 with no blood pressure, no pulse, or respirations. R1's blood glucose reading on the paramedic glucometer read as high. Paramedic documentation continues to show: Crew called to the nursing home for the person not breathing (R1). Upon arrival found crew on scene providing manual CPR. Patient was last seen normal by staff at 10:30 this morning with no medical complaints. Staff found the patient not breathing and pulseless, began CPR and called 911. [Crew] has been on scene for approximately ,d+[DATE] minutes prior to [second crew], and obtained an asystole rhythm on the monitor, and has begun obtaining an ET (Endotracheal Tube) 7.0. Patient has no signs of trauma, and no signs of obvious death. Patient is still warm to the touch. Crew places patient on the [automated cardiopulmonary resuscitation device] for continuous CPR, and we obtain the intubation and IO (Intra-Osseous) IV. Crew hangs fluids at wide open. We administer Epi 1:10,000 as directed, with regular pulse checks. Patient remains in asystole except for one pulse check, which was PEA (Pulseless Electrical Activity). Patient's next pulse check returned back to asystole. Crew contacts medical control with full progress report. [Local hospital] confirms to terminate resuscitation attempts in the field at 13:06 (1:06 PM). On [DATE] at 8:49 AM, V9 (Paramedic) said, If we get a blood sugar reading of high on our glucometer, it means the blood sugar is over 600 [mg/dL]. All of our glucometers are the same on all of our frontline equipment. The State of Illinois, Certificate of Death Worksheet, dated [DATE] shows R1 expired at the facility on [DATE] at 1:09 PM due to an acute MI ([CONDITION(S)]). The death certificate is signed by V4 (Physician). R1's hospital discharge medication orders dated [DATE] at 3:52 PM and the hospital MAR (Medication Administration Record) show the following medication orders and last administered doses for R1: [MEDICATION(S)] (blood pressure and cardiac medication) 5 mg. (Milligrams) orally daily. Last dose administered at hospital on [DATE] at 10:05 AM. [MEDICATION(S)] (blood pressure and cardiac medication) 25 mg. orally twice daily with meals. Last dose administered at hospital on [DATE] at 4:41 PM. [MEDICATION(S)] (blood pressure medication) 0.3 mg. orally three times daily. Last dose administered at hospital on [DATE] at 12:55 PM. [MEDICATION(S)] (diuretic) 40 mg. orally daily. Never given in oral format at hospital. Last IV (Intravenous) dose on [DATE] at 9:53 AM. [MEDICATION(S)] (anti-diabetic medication) 2 mg. orally every day with breakfast. No documentation to shows if ever administered to resident at hospital. [MEDICATION(S)] (blood pressure medication) 100 mg. orally three times a day. Last dose administered at hospital on [DATE] at 12:55 PM. Insulin [MEDICATION(S)] (diabetes medication) 20 units SQ (Subcutaneously) every day. No documentation to shows if ever administered to resident at hospital. Insulin [MEDICATION(S)] (diabetes medication) 14 units SQ at bedtime. No documentation to shows if ever administered to resident at hospital. Sliding scale Insulin [MEDICATION(S)] (diabetes medication) SQ four times a day based on blood sugar test results. Last dose of sliding scale Insulin [MEDICATION(S)] (diabetes medication) administered 6 units SQ at the hospital on [DATE] at 12:57 PM. [MEDICATION(S)] (blood pressure and cardiac medication) 20 mg. orally daily. Last dose administered at hospital on [DATE] at 10:03 AM. [MEDICATION(S)] (anti-diabetic medication) 1000 mg. orally twice daily with meals. No documentation to show if ever administered to resident at hospital. R1's hospital discharge instructions continue to show: Heart Failure - Medication Information - Take medications as prescribed by your physician. DO NOT STOP taking your medication even if you begin to feel better. Facility documentation by V14 (Agency Nurse) dated [DATE] at 5:03 PM shows the following vital signs for R1: Blood pressure ,d+[DATE], pulse rate 76 beats per minute, respirations 18 breaths per minute, and oxygen saturation of 97 percent. On [DATE] at 1:40 PM, V14 said the vital signs she documented on [DATE] were the vital signs she obtained from R1 at the time of her admission on [DATE]. V14 said she did not obtain a blood glucose level for R1 at the time of her admission to the facility or any time during V14's shift, ending at 10:00 PM, on [DATE]. The facility does not have documentation to show the facility obtained R1's blood glucose readings on [DATE] or 22, 2022. The facility does not have documentation to show R1 received any of the cardiac or diabetes medications, including insulin, shown on R1's hospital discharge medication instructions from the time of her admission to the facility on [DATE] at 5:45 PM through her time of death at the facility on [DATE] at 1:09 PM. On [DATE] at 2:06 PM, V4 (Physician) said, I signed R1's death certificate and put the cause of death as acute MI ([CONDITION(S)]). She had a lot of cardiac issues. She had respiratory failure, [CONDITION(S)], diabetes, you name it. She was bound to have heart disease. As a general statement, if you are supposed to take the medications, then you should be taking them. Missing all of those medications could have contributed to her expiring. It is my expectation the facility staff administer the medications as ordered and on time. The orders should have been carried through from her discharge from the hospital to her admission at the facility right away. I would expect them to contact me and let me know she had missed all of those medications. They did not notify me. On [DATE] at 1:54 PM, V13 (Pharmacist) said, Can we say any harm was caused by this resident not taking the medications? I cannot say missing all of her medications caused her death. Is there a possibility she walked around with elevated blood pressure? We can pretty much say that happened. Can we say missing her insulin would cause elevated glucose levels? We can say that happened. We do put insulin in the refrigerator at the facility to be used as an emergency until the resident's medications arrive. They could have gotten all of these medications with stat delivery or evening delivery and the resident would not have had to miss her medications if they would have notified us. The facility's policy entitled; Medication Reconciliation dated [DATE] shows: Purpose: Verify the resident's current medication regimen upon admission and/or readmission to the facility and provide an updated medication list to the next service provider at the time of discharge/transfer from this facility. Procedure: At the time of each admission and/or readmission to the facility, the charge nurse will review the list of medications/orders (including prescription and OTC) with the physician or physician extender, noting any discrepancies with the name of the drug, dosage, route, frequency, and reason for administration.

Based on observation, interview, and record review, the facility failed to ensure that residents were free from neglect when it failed to provide structures and processes to care for residents with pressure ulcers. The facility neglected to follow their assessment policy for pressure ulcers. Multiple failures based on the policy were identified including failing to do an individual wound assessment when a pressure ulcer was identified by the wound nurse or licensed nurse, failing to stage and measure pressure ulcers and document in the medical record. The facility neglected to ensure a resident admitted to the facility with pressure ulcers received assessment and treatment by the wound care physician or podiatrist and neglected to ensure physician-ordered pressure ulcer treatments were administered as ordered. The facility neglected to ensure wound care was provided in manner to prevent infection. The facility neglected to provide nursing staff to perform wound care on the holiday weekend and weekends. The facility was cited for staffing issues on August 30, 2021 that included issues with meeting and providing wound care on weekends. The facility neglected to take measures to ensure residents received wound care the holiday weekend of September 4, 5, and 6, 2021. This resulted in R4, R5, R6, and R7 not receiving prescribed wound care. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on July 30, 2021 when R1 was admitted to the facility and facility staff failed to ensure pressure ulcer wound care orders from the local hospital were continued at the facility. V7 (Assistant Director of Nursing/ADON) and V7 (Nurse Consultant) were notified of the Immediate Jeopardy on September 15, 2021 at 10:37 AM. While the immediacy was removed on September 21, 2021 at 6:22 PM, the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. These failures apply to 5 of 5 residents (R1, R4, R5, R6, and R7) reviewed for pressure ulcers in the sample of 7. Findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged from the facility on August 24, 2021 to the local hospital due to pressure ulcer wound concerns including purulent drainage, significant foul smelling odor, and [CONDITION(S)]. R1 required hospitalization for pressure ulcer treatment with surgical intervention, intravenous antibiotics, and possible [CONDITION(S)]. R1 did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 30, 2021 at 11:36 PM, V10 (Nurse) documented: [R1] received approximately 6:00 PM via stretcher accompanied by two attendants .Resident has two pressure ulcers, one on sacrum, one on left hip. Resident is dependent on staff for repositioning and transfers . Hospital documentation for R1 dated July 26, 2021 shows a left trochanter pressure ulcer, left and right knee abrasions, right breast [CONDITION(S)], and denuded skin of the left and right groin. The hospital's Skilled Nursing Facility Communication Form for R1, dated July 30, 2021 shows: Decubiti Wound/Tx (treatment): Left trochanter and left ischial - daily cleanse with saline, triad at wound base, cover with {Brand Name} (absorbent, gelling) dressing and {Brand Name} (absorbent foam) dressing every other day. V2 (Director of Nursing/DON) confirmed on September 13, 2021 that orders sent from the hospital were not carried out for R1. V10's (Nurse) Admission/Readmission Skin Integrity Review dated July 30, 2021 at 11:10 PM shows: Left trochanter (hip): pressure. Sacrum: pressure. V10 did not document the appearance of R1's pressure ulcers, including measurements, pressure ulcer stage, drainage present, or wound appearance. The facility did not have documentation to show V10 notified R1's physician of the presence of pressure ulcers upon admission or ensured treatment orders from the hospital were continued at the facility. On September 13, 2021 at 12:35 PM, V10 said, I admitted [R1] on July 30, 2021. It was a crazy day. I did not receive report from the hospital before [R1] arrived at the facility. I did my own full body assessment on her when she arrived, and I documented she had two pressure ulcers upon admission. Usually the facility does not have us do the wound measurements or put a stage of the pressure ulcer in our notes. The wound nurse comes in on Monday and does all of that. I was helped with the admission by another nurse who said he would put the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I don't remember seeing any orders for wound care from the hospital. Both of R1's buttocks wounds had dressings on them. I took the dressings off and looked at the wounds and put the dressings back on. I documented they were pressure ulcers because they were over a bony prominence and they looked like pressure to me. I did not notify the wound care nurse or the physician the resident was admitted to the facility with any wounds. Documentation in the EMR dated August 2, 2021 by V5 (Wound Nurse) shows V5 documented all the wounds R1 was admitted with as skin tears/abrasions. V5 did not have documentation to show R1 had any pressure ulcers as of August 2, 2021. V5's documentation dated August 2, 2021 shows an Initial Wound Care Nurse Assessment of the left trochanter. V5 documented: Left trochanter: Present on admission. Skin tear/abrasion. Partial thickness. Scabbed area 1.3 cm x 1.0 cm x 0.0 cm. The area of the Initial Wound Care Nurse Assessment shows treatment plan. The area under treatment plan was left blank by V5. No treatment plans for R1's wounds were documented by V5. The facility does not have documentation to show V5 or any other nursing staff obtained wound care orders for R1 upon admission. The facility does not have documentation to show R1 received any wound assessments or treatment from July 30, 2021 until R1 was treated by V12 (Wound Physician) on August 9, 2021. On August 9, 2021, V12 (Wound Physician) documented: At the request of [V13] (Attending Physician), a thorough wound care assessment and evaluation was performed today. Site 1: [R1] has an unstageable DTI (Deep Tissue Injury) of the right proximal buttock for at least 4 days duration. Etiology: Pressure. Wound Size: 6.5 cm x 2.5 cm. x not measurable. Stage: Unstageable DTI with intact skin. V12's treatment orders included: Santyl (Wound Care Medication) apply once daily for 30 days. The order for Santyl to be applied to the right proximal/distal buttock was changed on August 10, 2021 to apply leptospermum honey daily due to insurance coverage for the Santyl medication. The wound treatment with leptospermum honey was not administered as ordered on August 14, 15, or 21, 2021. Recommendation: low air loss mattress, Multivitamin daily, Vitamin C 500 mg. twice a day, and [MEDICATION(S)] [MEDICATION(S)] 220 mg. orally for 14 days. A review of the EMR shows the facility did not initiate V12's (Wound Doctor) orders for supplements on August 9, 2021 as ordered. The daily multivitamin ordered on August 9, 2021 was not started until August 13, 2021, four days after being ordered by V12. The [MEDICATION(S)] 500 mg. ordered twice daily was never started. An order dated August 19, 2021 for [MEDICATION(S)] 500 mg. once daily was started on August 19, 2021, ten days after being ordered by V12. The [MEDICATION(S)] sulfate 220 mg. daily was not started until August 19, 2021, ten days after being ordered by V12. Site 2: Unstageable DTI of the right distal buttock. Etiology: Pressure. Wound Size: 10.5 cm x 3.1 cm x not measurable cm. Unstageable DTI with intact skin. Site 3: Pressure wound of the left buttock. Etiology: Pressure. Wound Size: 2.5 cm x 2.1 cm. x 0.2 cm. Stage 3. Exudate: Moderate Serous. Slough: 100%. treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Gauze island with border apply once daily for 30 days. Facility documentation shows the wound treatment was not administered on August 14, 15, or 21, 2021, as ordered by the physician. V12 performed surgical excisional debridement of the left buttock pressure wound on August 9, 2021 and documented: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Site 4: Stage 3 Pressure wound of the left thigh. Etiology: Pressure. Wound size: 0.5 cm. x 0.5 cm. x 0.2 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: Gauze island apply once daily for 30 days. V12 also performed surgical excisional debridement on August 9, 2021. Facility documentation shows the wound treatment was not administered on August 14, 15, or 21, 2021, as ordered by the physician. The facility provided documentation to show the low air loss mattress was not delivered to the facility until August 18, 2021. The low air loss mattress was ordered by V12 (Wound Physician) on August 9, 2021. On September 7, 2021 at 1:34 PM, V5 (Wound Nurse) said, [R1] came into the facility and she had scabs on her buttocks, her hips and her knees. Because she was incontinent, they deteriorated because she was wet all the time. The wounds were over a bony prominence, but they were scabbed over, so I called them abrasions. I did not classify them as pressure ulcers. I did not obtain any wound care orders either. I am not good at classifying wounds. I haven't had training in identifying and staging pressure ulcers since I was in nursing school many years ago. I've only been doing wound care at the facility for about a month. The wounds deteriorated and when [V12] (Wound Physician) came to the facility on [DATE], I had her see the resident. That was when the wound doctor [V12] told me the wounds weren't abrasions, they were pressure ulcers, and [V12] gave orders to treat the wounds. [V12] ordered supplements for the resident to help with wound healing, like multivitamins, Vitamin C, and [MEDICATION(S)]. [V12] ordered those supplements for [R1] on August 9, 2021. [R1] did not receive the supplements as ordered until about a week later because I did not get around to entering the orders into the computer. It was my fault the orders didn't get started. [R1] and the other residents at the facility with wounds missed wound treatments on the weekends. The facility is aware we have a problem with that. I have given training to the staff. Plain and simple, wound care is not getting done on the weekends when I am not here to do it. On September 8, 2021 at 12:05 PM, V5 said, I have trained the staff to do wound care when I am not here, and they have turned to me and said, 'I don't do wound care'. [V2] (Director of Nursing/DON) knows that. Lack of staff caused the wound care to not be done. The supplements were missed because I missed those orders. I had two days of training to be a wound nurse at another facility where I shadowed the wound nurse. On August 24, 2021 V12 (Wound Physician) documented concerns regarding R1's pressure ulcer and ordered for R1 to be sent to the local hospital. V12 documented: Patient has significant purulent discharge. Wound culture was done. Recommend ID (Infectious Disease) consult. Also, significant foul smelling with [CONDITION(S)] - likely will need aggressive surgical debridement and IV (Intravenous) antibiotics. At the time of V12's wound assessment on August 24, 2021, V12 documented R1's right proximal buttock pressure ulcer measured 9.5 cm x 2.3 cm x not measurable. On August 24, 2021 at 1:54 PM, V14 (Wound Nurse) documented: Wound MD here to assess wound. Upon bedside debridement resident wound was noted with pus foul smelling drainage. Surrounding wound is reddened. Verbal order for ER eval and treat was given. Son notified of mother's wound status. He will visit mother at hospital. Ambulance called. On August 24, 2021 at 2:58 PM, V16 (emergency room /ER Physician) documented the following regarding R1: Skin: Warm, dry. 7x5 cm. right-sided sacral decubitus ulcer with foul smelling pus and surrounding redness and [CONDITION(S)]. Impression: Primary Impression: [CONDITION(S)]. Additional Impression: Sacral decubitus ulcer. A CT (Computed Tomography) scan of R1's abdomen and pelvis dated August 24, 2021 shows R1 was admitted to the hospital with a right sacral decubitus ulcer. Results of the CT scan showed: Large soft tissue ulcer along right buttock and sacrum .containing fluid and [CONDITION(S)]. On August 25, 2021 at 2:56 PM, V15 (Surgeon) documented: Post-operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure performed: Excisional debridement of large sacral decubitus ulcer. There are 2 very large skin defects separated by a thin skin bridge with extensive necrotic tissue throughout both wounds which communicate under the skin bridge. Copious amounts of necrotic tissue were removed. At the completion of debridement, the wound was irrigated. The wound is then measured and found to be 12 cm. x 8 cm. x 3.5 cm in size with undermining from 11:00 to 6:00 with the greatest area of undermining at 5:00 measuring 7 cm. in depth. On September 7, 2021 at 2:56 PM, V12 (Wound Physician) said, I saw [R1] for the first time on August 9, 2021. [V5] (Wound Nurse) incorrectly assessed [R1's] wounds as abrasions; [R1's] wounds on her buttocks were pressure ulcers. When I assess a resident, my notes are immediately available to the facility, and it is my expectation that my orders are initiated immediately. They cannot wait a week or more until they are started. I was never told by the facility that my orders were not started immediately, or wound care was not getting done on the weekends. Not receiving incontinence care, not changing positions, not getting any treatments for the first nine days she resided at the facility all contributed to the wounds getting worse. Those nine or ten days she went without the wound treatment when she first came definitely added to the deterioration of the wounds. Not receiving treatments on the weekends added to the deterioration of [R1's] pressure ulcers. Wounds don't take off on the weekends. They will continue to deteriorate. On September 9, 2021 at 1:57 PM, V12 (Wound Physician) continued to say, Low air loss mattresses are the backbone of wound care. I expected the facility to start using the low air loss mattress immediately. The same with the supplements and the wound care. No one told me it was another nine days before the facility obtained the mattress or that the supplements did not start right away. I was never notified of this. I know when I saw [R1] on August 16, she still did not have the low air loss mattress in place, and I documented that in my notes. Not doing the wound care, not starting the supplements, not offloading the wound all contributed to the wound getting worse. [V5] (Wound Nurse) is a complete novice when it comes to wound care. The wound deteriorated to the point of pus and foul-smelling drainage. The wound needed immediate medical attention in the hospital setting and I told the facility to call 911. 2. On September 7, 2021 at 2:06 PM, R4 was lying in bed waiting for wound care. V5 (Wound Nurse) removed R4's incontinence brief. Stool was present in R4's incontinence brief and a pressure ulcer on his buttocks was covered in stool. No dressing was covering R4's pressure ulcer. V5 said, I came to do [R4's] wound care today because none of the staff did his wound care yesterday and it is supposed to be done every Monday, Wednesday, and Friday. V12 (Wound Physician) documented on August 30, 2021 R4 has a Stage 3 pressure ulcer of the left buttock measuring 2.9 cm x 1.7 cm. x 0.2 cm. The EMR shows the following order dated September 1, 2021: Wound to left gluteal fold, cleanse with NSS (Normal Saline Solution). Apply hydrogel on gauze and cover with border gauze three times a week. Facility documentation shows R4 did not receive pressure ulcer dressing changes as ordered by the physician on September 6, and 9, 2021. 3. On September 9, 2021 at 10:50 AM, R5 was sitting up in a chair in her room. R5's right lower leg was red and inflamed. Open areas were noted on R5's right lower leg. R5 said her leg was very itchy and she had been scratching her leg to the point of causing open areas on her lower leg. R5 said she notified the nurse who cared for her the night before, as well as her current nurse, and both nurses told R5 to tell the wound care nurse of her leg redness when wound treatment took place. R5 said she has a history of [CONDITION(S)] on her lower legs, and the redness and itching she was experiencing was like other times when she had experienced [CONDITION(S)]. R5 said, I am really worried about this. Most weekends they don't do my wound care. They tell me there isn't enough staff here to do get the wound care done, so over the Labor Day weekend, I did not receive dressing changes for my wounds on Saturday, Sunday, or Monday. V5 (Wound Nurse) donned clean gloves and removed dressings from R5's right ankle and toes. A yellowish drainage was present on the ankle dressing. V5 exposed an open wound on R5's right inner ankle approximately 1 inch in diameter. R5 said the wound on her right ankle was caused by pressure from a brace she had worn on her right leg. The ankle wound appeared yellow in color, with redness around the outside of the wound. R5's toes appeared dry with copious amounts of flaking skin. V5 removed [MEDICATION(S)] soaked gauze from between R5's toes. V5 did not assess the wounds between R5's toes. With the same gloved hands used to remove the soiled wound dressings, V5 touched R5's open wound on her ankle multiple times. With the same gloved hands, V5 continued to touch R5's lower leg and wounds. With the same gloved hands, V5 used scissors to cut a square of {Brand Name} blue dressing material into a one-inch square. V5 set the square of dressing material directly on R5's bare, reddened shin and moistened the dressing material with normal saline solution. V5 removed the dressing material from R5's shin and applied the dressing material, which had been making direct contact with R5's inflamed right shin, directly to R5's open ankle wound. V5 removed her gloves and donned a clean pair of gloves without performing any hand hygiene between glove changes. V5 applied [MEDICATION(S)] soaked gauze between each of R5's toes on her right foot without assessing the pressure ulcers present between R5's toes. V5 removed her gloves and applied new gloves without performing hand hygiene. V5 used her gloved hands to apply Vitamin A and D ointment over R5's bilateral lower legs and feet stating, I always do this for her because her skin is so dry. V5 removed her gloves, did not perform hand hygiene, and continued to touch R5's bilateral lower legs with both hands. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS dated [DATE] shows R5 is cognitively intact and was admitted with three Stage 3 pressure ulcers and an open lesion on her foot. Facility documentation shows R5 was to be seen by the podiatrist in his office on July 29, 2021. The facility does not have documentation to show R5 was ever seen by the podiatrist as ordered. The facility does not have any documentation to show R5 was seen by V12 (Wound Physician) for assessment and wound treatment. On July 28, 2021, V14 (Wound Nurse) documented R5 was admitted to the facility with a left ankle partial thickness wound measuring 2.5 cm x 0.5 cm. x 0.1 cm. V14 also documented Stage 3 pressure ulcers of the left toes measuring 0.4 x 0.5 x 0.1 cm, 0.6 x 0.6 x 0.1 cm, and 0.2 x 0.2 x 0.1 cm. The facility does not have any documentation in the medical record to show when R5 developed the right ankle pressure ulcer. The facility does not have documentation to show weekly assessment of R5's pressure ulcers, as shown in the facility's pressure ulcer policy. An order dated July 28, 2021 for R5 shows: {Brand Name} blue 4x4 pad apply to right medial ankle topically one time a day for wound care. NSS (Normal Saline Solution) cover with 4x4 gauze and [gauze] roll daily. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, and 6, 2021. An order dated July 29, 2021 for R5 shows: Wound left 3rd toe interspace, clean with NSS, pat dry, apply [MEDICATION(S)] dressing daily one time a day. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, 6, 2021. An order dated July 29, 2021 for R5 shows: Wound left 4th toe interspace clean with NSS, pat dry, apply [MEDICATION(S)] dressing daily one time a day for wound. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, 6, 2021. On September 9, 2021 at 12:25 PM, V12 (Wound Physician) said, I was never notified of [R5's] pressure ulcers. Had the facility notified me of R5's pressure ulcers, I would have seen her right away. I never refuse to see any resident. I have never heard of this resident. [R5] developed a Stage 3 pressure ulcer on her right ankle. They should have notified me. As soon as I saw the pressure ulcers, I changed the treatments they were doing since her admission. I don't understand why I was not told about this resident sooner. [R5] should not have gone that long without seeing a physician, especially when her podiatrist appointments did not happen. No physician was looking at [R5's] wounds and seeing if the wound care was appropriate. Also, if [V5] touches a resident's pressure ulcer or any wound with soiled gloves, or does not perform hand hygiene between glove changes, this puts the resident at risk for cross-contamination of the wounds, which could result in severe infection for the resident. I have never watched [V5] (Wound Nurse) do wound care, so I was not aware she was touching wounds with dirty gloves or not performing hand hygiene. On September 13, 2021, V12 (Wound Physician) documented the following: Site 1: Stage 3 pressure wound of the right medial ankle full thickness. Etiology: Pressure. 1.0 x 1.5 x 0.2 cm. Moderate serous exudate. Patient states happened from her boot. Surgical excisional debridement was done. Site 2: Stage 3 pressure wound of the right fourth toe full thickness. Etiology: Pressure. 0.6 x 0.3 x 0.2 cm. Site 3: Stage 3 pressure wound of the right third toe full thickness. Etiology: Pressure. 0.2 x 0.2 x 0.1 cm. On September 9, 2021 at 11:00 AM V5 (Wound Nurse) said she did not obtain a wound care consult for R5 since her admission to the facility. V5 replied, I don't know when asked why R5 had not been seen by V12 (Wound Physician) since her admission to the facility on [DATE]. V5 also stated, I don't know when asked why she had not documented assessments of R5's pressure ulcers, including pressure ulcer measurements, appearance, and drainage, since R5's admission to the facility on [DATE]. On September 14, 2021 at 2:06 PM, V2 (DON) said the facility staff should refer any resident with a pressure ulcer present on admission or acquired at the facility to the wound care physician immediately. V2 said physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On September 9, 2021 at 10:20 AM, V5 provided wound care to R6's pressure ulcers. V5 said R6 did not receive daily wound care over the previous Labor Day holiday weekend. The EMR shows R6 was admitted to the facility in March 2021. R6 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR shows the following order dated August 4, 2021: Sacrum, cleanse with NSS (Normal Saline Solution), pat dry, apply collagen powder, calcium alginate rope, cover with border dressing daily until healed. Facility documentation shows wound care was not provided to R6 as ordered by the physician on August 1, 7, 8, 21, 2021 and September 4, 5, 6, 2021. 5. On September 9, 2021 at 10:30 AM, R7 was lying in bed. V5 (Wound Nurse) provided wound care to R7. V5 said R7 did not receive wound care over the previous weekend. The EMR shows R7 was admitted to the facility in March 2020 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MDS dated [DATE] shows R7 is cognitively intact and continues to show R7 has one Stage 3 pressure ulcer. The EMR shows the following order for pressure ulcer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show R7 received pressure ulcer treatment on September 4, 5, and 6, 2021 as ordered by the physician. The facility's Pressure Ulcer and Skin Condition Assessment Policy dated 10/2020 shows: Policy: It is the policy of this facility that pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and recorded on the facility approved wound assessment form. Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions are implemented. Standards: 1. The skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission. 2. An individual wound assessment will be initiated when pressure and/or other ulcers are identified by the wound nurse or licensed nurse. 4. At the earliest sign of a pressure ulcer or other skin problem, the resident, legal representative, and attending physician will be notified. The Director of Nursing will also be notified. The initial observation of the ulcer or skin breakdown will also be described in the clinical record. 5. Pressure ulcers and other ulcers will be measured at lease weekly and documented in the medical record. Only pressure ulcers will be staged. 6. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. 7. A notation will be made in the nurse notes, treatment administration record. On September 8, 2021 at 12:33 PM, V2 (DON) said, We were recently cited for not providing wound treatment as ordered by the physician, and it's been something I've been working on. These are issues that are unfortunate. The plan of correction we had established we would have two full-time wound care nurses, but that did not work out. The QA audit tool we were using was not capturing the wound care treatments that weren't getting done on the weekend. On September 13, 2021 at 12:08 PM, V2 (DON) said, I made arrangements for [V9] (Licensed Practical Nurse/LPN) to do all wound dressing changes over the Labor Day weekend (September 4, 5, 6, 2021). On Sunday, she was pulled from wound care to work on the floor due to lack of staff to care for residents. I reached out to the nurses working at the facility and the manager on duty to make sure wound care was rendered until I could find extra help to do the treatments. I had no success. Wound care was not provided over the weekend due to the lack of staff. On September 9, 2021 at 2:33 PM, V1 (Administrator) said, We lost one of our wound care nurses to [illness]. We are training and cross-training other staff. But lack of staff bleeds over into other things. If a nurse only has time to pass medications, then the nurse must make a choice, and other things, like wound care, might not get done. We had deficiencies on recent surveys regarding wounds. We put steps in place that are obviously not enough. Through observation, interview, and record review conducted on September 22, 2021, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All staff was re-educated on ensuring residents are free from neglect by following the assessment policy for pressure ulcers, a resident admitted to the facility with a pressure ulcer receives assessment and treatment by the Wound Care Physician or Podiatrist, and that physician-ordered pressure ulcer treatments are provided as ordered. This training included conducting an individual wound assessment when a pressure ulcer is identified by the wound nurse or licensed nurse, staging and measuring pressure ulcers and documenting in the medical record (at least weekly), including nurse's notes and treatment administration record. Education also included following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A new process was put in place for new admissions/re-admissions. A new tool was developed. Admission Nursing Department Communication Tool is completed by marketing and emailed to the internal admissions department. The new tool will identify wound concerns. The tool is printed and handed to the admitting nurse for follow through and comparison with a full body check. The results of the body check are documented in the electronic medical record. The Admission Nursing Department Communication Tool is disseminated to Administration and clinical managers to enhance communication. The wound team will ensure dressings/treatments are completed, including any dressings on weekends and holidays. Weekly skin sweeps will be conducted by the wound team/designee for 4 weeks. After 4 weeks DON in conjunction with Medical Director will determine if the plan should be modified. A baseline skin sweep was completed on September 20, 2021. Any new areas were addressed by DON/ADON. A new Admission/Readmission Wound Protocol Newly Identified Wound Protocol is being used to guide the nursing staff on wound care follow through. The revised, more comprehensive, Quality Assurance/QA audit tool is completed weekly on all identified pressure ulcers/wounds by the DON or designee. The QA tool audits all pressure ulcers (new and existing), documentation, following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Baseline audits available in IJ binder. All staff educated via phone were educated with the same training as the staff educated in person, however, the staff who received training over the phone were notified that they will also be required to attend an in-person training prior to the beginning of the next shift worked. Upon completion of this in-person training, staff will sign education sheets. Evidence for education that took place over the phone is provided by specifying the name of the employee educated, the

Based on observation, interview, and record review, the facility failed to identify pressure ulcers in a resident, initiate and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to ensure residents received pressure ulcer treatment as ordered by the physician. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on July 30, 2021 when R1 was admitted to the facility and facility staff failed to ensure pressure ulcer wound care orders from the local hospital were continued at the facility. V7 (Assistant Director of Nursing/ADON) and V7 (Nurse Consultant) were notified of the Immediate Jeopardy on September 15, 2021 at 10:37 AM. While the immediacy was removed on September 21, 2021 at 6:22 PM, the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. These failures apply to 5 of 5 residents (R1, R4, R5, R6, and R7) reviewed for pressure ulcers in the sample of 7. Findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged from the facility on August 24, 2021 to the local hospital due to pressure ulcer wound concerns including purulent drainage, significant foul smelling odor, and [CONDITION(S)]. R1 required hospitalization for pressure ulcer treatment with surgical intervention, intravenous antibiotics, and possible [CONDITION(S)]. R1 did not return to the facility. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated August 6, 2021 shows R1 had moderate cognitive impairment, was able to eat with limited assistance, was totally dependent on facility staff for transfers between surfaces, and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. R1 was always incontinent of bowel and bladder. On July 30, 2021 at 11:36 PM, V10 (Nurse) documented: [R1] received approximately 6:00 PM via stretcher accompanied by two attendants .Resident has two pressure ulcers, one on sacrum, one on left hip. Resident is dependent on staff for repositioning and transfers . Hospital documentation for R1 dated July 26, 2021 shows a left trochanter pressure ulcer, left and right knee abrasions, right breast [CONDITION(S)], and denuded skin of the left and right groin. The hospital's Skilled Nursing Facility Communication Form for R1, dated July 30, 2021, shows: Decubiti Wound/Tx (treatment): Left trochanter and left ischial - daily cleanse with saline, triad at wound base, cover with {Brand Name} (absorbent, gelling) dressing and {Brand Name} (absorbent foam dressing) dressing every other day. On September 13, 2021 at 12:08 PM, V2 (Director of Nursing/DON) said, The purpose of the Skilled Nursing Facility Communication Form is continuity of care. The form comes with the resident from the hospital and can contain physician referrals, medication or treatment orders, or antibiotic orders to be carried out here at the facility. It gives us a picture of the resident. If there are orders on the form, all the orders should be clarified with the physician when the resident is admitted and ensure the orders are carried out. The orders on the form sent with R1 from the hospital were not carried out from the time of [R1's] admission on July 30, 2021. V10's (Nurse) Admission/Readmission Skin Integrity Review dated July 30, 2021 at 11:10 PM shows: Left trochanter (hip): pressure. Sacrum: pressure. V10 did not document the appearance of R1's pressure ulcers, including measurements, pressure ulcer stage, drainage present, or wound appearance. The facility did not have documentation to show V10 notified R1's physician of the presence of pressure ulcers upon admission or ensured treatment orders from the hospital were continued at the facility. On September 13, 2021 at 12:35 PM, V10 (Nurse) said, I admitted [R1] on July 30, 2021. It was a crazy day. I did not receive report from the hospital before [R1] arrived at the facility. I did my own full body assessment on her when she arrived, and I documented she had two pressure ulcers upon admission. Usually the facility does not have us do the wound measurements or put a stage of the pressure ulcer in our notes. The wound nurse comes in on Monday and does all of that. I was helped with the admission by another nurse who said he would put the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I don't remember seeing any orders for wound care from the hospital. Both of R1's buttocks wounds had dressings on them. I took the dressings off and looked at the wounds and put the dressings back on. I documented they were pressure ulcers because they were over a bony prominence and they looked like pressure to me. I did not notify the wound care nurse or the physician the resident was admitted to the facility with any wounds. Documentation in the EMR dated August 2, 2021 by V5 (Wound Nurse) shows V5 documented all the wounds R1 was admitted with as skin tears/abrasions. V5 did not have documentation to show R1 had any pressure ulcers as of August 2, 2021. V5's documentation dated August 2, 2021 shows an Initial Wound Care Nurse Assessment of the left trochanter. V5 documented: Left trochanter: Present on admission. Skin tear/abrasion. Partial thickness. Scabbed area 1.3 cm x 1.0 cm x 0.0 cm. The area of the Initial Wound Care Nurse Assessment shows treatment plan. The area under treatment plan was left blank by V5. No treatment plans for R1's wounds were documented by V5. V5's documentation dated August 2, 2021 shows an Initial Wound Care Nurse Assessment of the right iliac crest rear. V5 documented: Right iliac crest rear, partial thickness, present on admission, skin tear/abrasion. 1.0 cm. x 7.0 cm. x 0.0 cm. The area of the assessment under treatment plan was left blank by V5. V5's documentation dated August 2, 2021 shows an Initial Wound Care Nurse Assessment of the right buttock. V5 documented: Right buttock: Present on admission. Skin tear/abrasion. Partial thickness. 1.0 cm. x 1.0 cm. x 0.0 cm. The area of the assessment under treatment plan was left blank by V5. The facility does not have documentation to show V5 (Wound Nurse) or any other nursing staff obtained wound care orders for R1 upon admission. The facility does not have documentation to show R1 received any wound assessments or treatment from July 30, 2021 until R1 was treated by V12 (Wound Physician) on August 9, 2021. On August 9, 2021, V12 (Wound Physician) documented: At the request of [V13] (Attending Physician), a thorough wound care assessment and evaluation was performed today. Site 1: [R1] has an unstageable DTI (Deep Tissue Injury) of the right proximal buttock for at least 4 days duration. Etiology: Pressure. Wound Size: 6.5 cm x 2.5 cm. x not measurable. Stage: Unstageable DTI with intact skin. V12's treatment orders included: Santyl (Wound Care Medication) apply once daily for 30 days. The order for Santyl to be applied to the right proximal/distal buttock was changed on August 10, 2021 to apply leptospermum honey daily due to insurance coverage for the Santyl medication. The wound treatment with leptospermum honey was not administered as ordered on August 14, 15, or 21, 2021. Recommendation: low air loss mattress, Multivitamin daily, Vitamin C 500 mg. twice a day, and [MEDICATION(S)] [MEDICATION(S)] 220 mg. orally for 14 days. A review of the EMR shows the facility did not initiate V12's (Wound Doctor) orders for supplements on August 9, 2021 as ordered. The daily multivitamin ordered on August 9, 2021 was not started until August 13, 2021, four days after being ordered by V12. The [MEDICATION(S)] 500 mg. ordered twice daily was never started. An order dated August 19, 2021 for [MEDICATION(S)] 500 mg. once daily was started on August 19, 2021, ten days after being ordered by V12. The [MEDICATION(S)] sulfate 220 mg. daily was not started until August 19, 2021, ten days after being ordered by V12. Site 2: Unstageable DTI of the right distal buttock. Etiology: Pressure. Wound Size: 10.5 cm x 3.1 cm x not measurable cm. Unstageable DTI with intact skin. Site 3: Pressure wound of the left buttock. Etiology: Pressure. Wound Size: 2.5 cm x 2.1 cm. x 0.2 cm. Stage 3. Exudate: Moderate Serous. Slough: 100%. treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Gauze island with border apply once daily for 30 days. Facility documentation shows the wound treatment was not administered on August 14, 15, or 21, 2021, as ordered by the physician. V12 (Wound Physician) performed surgical excisional debridement of the left buttock pressure wound on August 9, 2021 and documented: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Site 4: Stage 3 Pressure wound of the left thigh. Etiology: Pressure. Wound size: 0.5 cm. x 0.5 cm. x 0.2 cm. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: Gauze island apply once daily for 30 days. V12 also performed surgical excisional debridement on August 9, 2021. Facility documentation shows the wound treatment was not administered on August 14, 15, or 21, 2021, as ordered by the physician. The facility provided documentation to show the low air loss mattress was not delivered to the facility until August 18, 2021. The low air loss mattress was ordered by V12 (Wound Physician) on August 9, 2021. On September 7, 2021 at 1:34 PM, V5 (Wound Nurse) said, [R1] came into the facility and she had scabs on her buttocks, her hips and her knees. Because [R1] was incontinent, they (R1's wounds) deteriorated because [R1] was wet all the time. The wounds were over a bony prominence, but they were scabbed over, so I called them abrasions. I did not classify them as pressure ulcers. I did not obtain any wound care orders either. I am not good at classifying wounds. I haven't had training in identifying and staging pressure ulcers since I was in nursing school many years ago. I've only been doing wound care at the facility for about a month. The wounds deteriorated and when [V12] (Wound Physician) came to the facility on [DATE], I had her see the resident. That was when the wound doctor told me the wounds weren't abrasions, they were pressure ulcers, and [V12] gave orders to treat the wounds. [V12] ordered supplements for the resident to help with wound healing, like multivitamins, Vitamin C, and [MEDICATION(S)]. [V12] ordered those supplements for [R1] on August 9, 2021. [R1] did not receive the supplements as ordered until about a week later because I did not get around to entering the orders into the computer. It was my fault the orders didn't get started. [R1] and the other residents at the facility with wounds missed wound treatments on the weekends. The facility is aware we have a problem with that. I have given training to the staff. Plain and simple, wound care is not getting done on the weekends when I am not here to do it. On September 8, 2021 at 12:05 PM, V5 said, I have trained the staff to do wound care when I am not here, and they have turned to me and said, 'I don't do wound care'. [V2] (Director of Nursing/DON) knows that. Lack of staff caused the wound care to not be done. The supplements were missed because I missed those orders. I had two days of training to be a wound nurse at another facility where I shadowed the wound nurse. On August 24, 2021 V12 (Wound Physician) documented concerns regarding R1's pressure ulcer and ordered for R1 to be sent to the local hospital. V12 documented: Patient has significant purulent discharge. Wound culture was done. Recommend ID (Infectious Disease) consult. Also, significant foul smelling with [CONDITION(S)] - likely will need aggressive surgical debridement and IV (Intravenous) antibiotics. At the time of V12's wound assessment on August 24, 2021, V12 documented R1's right proximal buttock pressure ulcer measured 9.5 cm x 2.3 cm x not measurable. On August 24, 2021 at 1:54 PM, V14 (Wound Nurse) documented: Wound MD here to assess wound. Upon bedside debridement resident wound was noted with pus foul smelling drainage. Surrounding wound is reddened. Verbal order for ER eval and treat was given. Son notified of mother's wound status. He will visit mother at hospital. Ambulance called. On August 24, 2021 at 2:58 PM, V16 (ER Physician) documented the following regarding R1: Skin: Warm, dry. 7x5 cm. right-sided sacral decubitus ulcer with foul smelling pus and surrounding redness and [CONDITION(S)]. Impression: Primary Impression: [CONDITION(S)]. Additional Impression: Sacral decubitus ulcer. A CT (Computed Tomography) scan of R1's abdomen and pelvis dated August 24, 2021 shows R1 was admitted to the hospital with a right sacral decubitus ulcer. Results of the CT scan showed: Large soft tissue ulcer along right buttock and sacrum .containing fluid and [CONDITION(S)]. On August 25, 2021 at 2:56 PM, V15 (Surgeon) documented: Post-operative Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure performed: Excisional debridement of large sacral decubitus ulcer. There are 2 very large skin defects separated by a thin skin bridge with extensive necrotic tissue throughout both wounds which communicate under the skin bridge. Copious amounts of necrotic tissue were removed. At the completion of debridement, the wound was irrigated. The wound is then measured and found to be 12 cm. x 8 cm. x 3.5 cm in size with undermining from 11:00 to 6:00 with the greatest area of undermining at 5:00 measuring 7 cm. in depth. On September 7, 2021 at 2:56 PM, V12 (Wound Physician) said, I saw [R1] for the first time on August 9, 2021. [V5] (Wound Nurse) incorrectly assessed [R1's] wounds as abrasions; [R1's] wounds on her buttocks were pressure ulcers. When I assess a resident, my notes are immediately available to the facility, and it is my expectation that my orders are initiated immediately. They cannot wait a week or more until they are started. I was never told by the facility that my orders were not started immediately, or wound care was not getting done on the weekends. Not receiving incontinence care, not changing positions, not getting any treatments for the first nine days [R1] resided at the facility all contributed to the wounds getting worse. Those nine or ten days she went without the wound treatment when she first came definitely added to the deterioration of the wounds. Not receiving treatments on the weekends added to the deterioration of [R1's] pressure ulcers. Wounds don't take off on the weekends. They will continue to deteriorate. On September 9, 2021 at 1:57 PM, V12 (Wound Physician) continued to say, Low air loss mattresses are the backbone of wound care. I expected the facility to start using the low air loss mattress immediately. The same with the supplements and the wound care. No one told me it was another nine days before the facility obtained the mattress or that the supplements did not start right away. I was never notified of this. I know when I saw [R1] on August 16, she still did not have the low air loss mattress in place, and I documented that in my notes. Not doing the wound care, not starting the supplements, not offloading the wound all contributed to the wound getting worse. [V5] (Wound Nurse) is a complete novice when it comes to wound care. The wound deteriorated to the point of pus and foul smelling drainage. The wound needed immediate medical attention in the hospital setting and I told the facility to call 911. 2. On September 7, 2021 at 2:06 PM, R4 was lying in bed waiting for wound care. V5 (Wound Nurse) removed R4's incontinence brief. Stool was present in R4's incontinence brief and a pressure ulcer on his buttocks was covered in stool. No dressing was covering R4's pressure ulcer. V5 said, I came to do [R4's] wound care today because none of the staff did his wound care yesterday and it is supposed to be done every Monday, Wednesday, and Friday. The EMR shows R4 was admitted to the facility in September 2013. R4 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's MDS dated [DATE] shows R4 is cognitively intact, requires supervision with eating, extensive assistance with bed mobility, dressing, and personal hygiene, and is totally dependent on facility staff for transfers between surfaces and toilet use. R4 is always continent of bowel and bladder. V12 (Wound Physician) documented on August 30, 2021 R4 has a Stage 3 pressure ulcer of the left buttock measuring 2.9 cm x 1.7 cm. x 0.2 cm. The EMR shows the following order dated September 1, 2021: Wound to left gluteal fold, cleanse with NSS (Normal Saline Solution). Apply hydrogel on gauze and cover with border gauze three times a week. Facility documentation shows R4 did not receive pressure ulcer dressing changes as ordered by the physician on September 6, and 9, 2021. 3. On September 9, 2021 at 10:50 AM, R5 was sitting up in a chair in her room. R5 right lower leg was red and inflamed. Open areas were noted on R5's right lower leg. R5 said her leg was very itchy and she had been scratching her leg to the point of causing open areas on her lower leg. R5 said she notified the nurse who cared for her the night before, as well as her current nurse, and both nurses told R5 to tell the wound care nurse of her leg redness when wound treatment took place. R5 said she has a history of [CONDITION(S)] on her lower legs, and the redness and itching she was experiencing was similar to other times when she had experienced [CONDITION(S)]. R5 said, I am really worried about this. Most weekends they don't do my wound care. They tell me there isn't enough staff here to do get the wound care done, so over the Labor Day weekend, I did not receive dressing changes for my wounds on Saturday, Sunday, or Monday. V5 (Wound Nurse) donned clean gloves and removed dressings from R5's right ankle and toes. A yellowish drainage was present on the ankle dressing. V5 exposed an open wound on R5's right inner ankle, approximately 1 inch in diameter. R5 said the wound on her right ankle was caused by pressure from a brace she had worn on her right leg. The ankle wound appeared yellow in color with redness around the outside of the wound. R5's toes appeared dry with copious amounts of flaking skin. V5 removed [MEDICATION(S)] soaked gauze from between R5's toes. V5 did not assess the wounds between R5's toes. With the same gloved hands used to remove the soiled wound dressings, V5 touched R5's open wound on her ankle multiple times. With the same gloved hands, V5 continued to touch R5's lower leg and wounds. With the same gloved hands, V5 used scissors to cut a square of {Brand Name} blue dressing material into a one-inch square. V5 set the square of dressing material directly on R5's bare, reddened shin and moistened the dressing material with normal saline solution. V5 removed the dressing material from R5's shin and applied the dressing material, which had been making direct contact with R5's inflamed right shin, directly to R5's open ankle wound. V5 removed her gloves and donned a clean pair of gloves without performing any hand hygiene between glove changes. V5 applied [MEDICATION(S)] soaked gauze between each of R5's toes on her right foot without assessing the pressure ulcers present between R5's toes. V5 removed her gloves and applied new gloves without performing hand hygiene. V5 used her gloved hands to apply Vitamin A and D ointment over R5's bilateral lower legs and feet, stating, I always do this for her because her skin is so dry. V5 removed her gloves, did not perform hand hygiene, and continued to touch R5's bilateral lower legs with both hands. The EMR shows R5 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS dated [DATE] shows R5 is cognitively intact, is independent with eating, and requires extensive assistance with bed mobility, transfers between surfaces, toilet use, and bathing. R5 is always incontinent of bowel and bladder. R5's MDS continues to show R5 was admitted with three Stage 3 pressure ulcers and an open lesion on her foot. Facility documentation shows R5 was to be seen by the podiatrist in his office on July 29, 2021. The facility does not have documentation to show R5 was ever seen by the podiatrist as ordered. The facility does not have any documentation to show R5 was seen by V12 (Wound Physician) for assessment and wound treatment. On July 28, 2021, V14 (Wound Nurse) documented R5 was admitted to the facility with a left ankle partial thickness wound measuring 2.5 cm x 0.5 cm. x 0.1 cm. V14 also documented Stage 3 pressure ulcers of the left toes measuring 0.4 x 0.5 x 0.1 cm, 0.6 x 0.6 x 0.1 cm, and 0.2 x 0.2 x 0.1 cm. The facility does not have any documentation in the medical record to show when R5 developed the right ankle pressure ulcer. The facility does not have documentation to show weekly assessment of R5's pressure ulcers, as shown in the facility's pressure ulcer policy. An order dated July 28, 2021 for R5 shows: {Brand Name} blue 4x4 pad apply to right medial ankle topically one time a day for wound care. NSS (Normal Saline Solution) cover with 4x4 gauze and [gauze] roll daily. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, and 6, 2021. An order dated July 29, 2021 for R5 shows: Wound left 3rd toe interspace, clean with NSS, pat dry, apply [MEDICATION(S)] dressing daily one time a day. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, 6, 2021. An order dated July 29, 2021 for R5 shows: Wound left 4th toe interspace clean with NSS, pat dry, apply [MEDICATION(S)] dressing daily one time a day for wound. Facility documentation shows R5 did not receive the physician-ordered treatment on August 1, 2, 7, 8, 21, 29, 2021 and September 4, 5, 6, 2021. On September 9, 2021 at 12:25 PM, V12 (Wound Physician) said, I was never notified of [R5's] pressure ulcers. Had the facility notified me of R5's pressure ulcers, I would have seen her right away. I never refuse to see any resident. I have never heard of this resident. [R5] developed a Stage 3 pressure ulcer on her right ankle. They should have notified me. As soon as I saw the pressure ulcers, I changed the treatments they were doing since her admission. I don't understand why I was not told about this resident sooner. [R5] should not have gone that long without seeing a physician, especially when her podiatrist appointments did not happen. No physician was looking at her wounds and seeing if the wound care was appropriate. Also, if [V5] touches a resident's pressure ulcer or any wound with soiled gloves, or does not perform hand hygiene between glove changes, this puts the resident at risk for cross-contamination of the wounds, which could result in severe infection for the resident. I have never watched [V5] (Wound Nurse) do wound care, so I was not aware she was touching wounds with dirty gloves or not performing hand hygiene. On September 13, 2021, V12 (Wound Physician) documented the following: Site 1: Stage 3 pressure wound of the right medial ankle full thickness. Etiology: Pressure. 1.0 x 1.5 x 0.2 cm. Moderate serous exudate. Patient states happened from her boot. Surgical excisional debridement was done. Site 2: Stage 3 pressure wound of the right fourth toe full thickness. Etiology: Pressure. 0.6 x 0.3 x 0.2 cm. Site 3: Stage 3 pressure wound of the right third toe full thickness. Etiology: Pressure. 0.2 x 0.2 x 0.1 cm. V12 ordered new wound care treatments for all of R5's pressure ulcers, including hydrogel impregnated gauze, and alginate calcium. On September 9, 2021 at 11:00 AM V5 (Wound Nurse) said she did not obtain a wound care consult for R5 since her admission to the facility. V5 replied, I don't know when asked why R5 had not been seen by V12 (Wound Physician) since her admission to the facility on [DATE]. V5 also stated I don't know when asked why she had not documented assessments of R5's pressure ulcers, including pressure ulcer measurements, appearance, and drainage, since R5's admission to the facility on [DATE]. On September 14, 2021 at 2:06 PM, V2 (DON) said the facility staff should refer any resident with a pressure ulcer present on admission or acquired at the facility to the wound care physician immediately. V2 said physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 could not say why R1's orders were not initiated on August 10, 2021 after R1 was seen by the wound care physician. V2 said she did not know why the low air low mattress ordered for R1 on August 10, 2021 did not arrive at the facility until August 18, 2021. V2 said R5 should have been referred to V12 (Wound Physician) upon admission to the facility due to her pressure ulcers present on admission. 4. On September 9, 2021 at 10:20 AM, V5 (Wound Nurse) provided wound care to R6's pressure ulcers. V5 said R6 did not receive daily wound care over the previous Labor Day holiday weekend. The EMR shows R6 was admitted to the facility in March 2021. R6 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS dated [DATE] shows R6 has moderate cognitive impairment, requires supervision with eating, is totally dependent on facility staff for toilet use, and requires extensive assistance with bed mobility, dressing, and personal hygiene. R6 is always incontinent of bowel and bladder. R6's MDS continues to show R6 has one Stage 4 pressure ulcer. The EMR shows the following order dated August 4, 2021: Sacrum, cleanse with NSS (Normal Saline Solution), pat dry, apply collagen powder, calcium alginate rope, cover with border dressing daily until healed. Facility documentation shows wound care was not provided to R6 as ordered by the physician on August 1, 7, 8, 21, 2021 and September 4, 5, 6, 2021. 5. On September 9, 2021 at 10:30 AM, R7 was lying in bed. V5 (Wound Nurse) provided wound care to R7. V5 said R7 did not receive wound care over the previous weekend. The EMR shows R7 was admitted to the facility in March 2020 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MDS dated [DATE] shows R7 is cognitively intact, is independent with eating, is totally dependent on facility staff for bathing, and requires extensive assistance with bed mobility, transfers between surfaces, dressing, toilet use, and personal hygiene. R7 has an indwelling urinary catheter and is frequently incontinent of stool. R7's MDS continues to show R7 has one Stage 3 pressure ulcer. The EMR shows the following order for pressure ulcer treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility does not have documentation to show R7 received pressure ulcer treatment on September 4, 5, and 6, 2021 as ordered by the physician. The facility's Pressure Ulcer and Skin Condition Assessment Policy dated 10/2020 shows: Policy: It is the policy of this facility that pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven days by a licensed nurse and recorded on the facility approved wound assessment form. Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure, and other ulcers and assuring interventions are implemented. Standards: 1. The skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission. 2. An individual wound assessment will be initiated when pressure and/or other ulcers are identified by the wound nurse or licensed nurse. 4. At the earliest sign of a pressure ulcer or other skin problem, the resident, legal representative, and attending physician will be notified. The Director of Nursing will also be notified. The initial observation of the ulcer or skin breakdown will also be described in the clinical record. 5. Pressure ulcers and other ulcers will be measured at least weekly and documented in the medical record. Only pressure ulcers will be staged. 6. When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. 7. A notation will be made in the nurse notes, treatment administration record. On September 13, 2021 at 12:08 PM, V2 (DON) said, I made arrangements for [V9] (Licensed Practical Nurse) to do all wound dressing changes over the Labor Day weekend (September 4, 5, 6, 2021). On Sunday, she was pulled from wound care to work on the floor due to lack of staff to care for residents. I reached out to the nurses working at the facility and the manager on duty to make sure wound care was rendered until I could find extra help to do the treatments. I had no success. Wound care was not provided over the weekend due to the lack of staff. On September 9, 2021 at 2:33 PM, V1 (Administrator) said, We lost one of our wound care nurses to [illness]. We are training and cross-training other staff. But lack of staff bleeds over into other things. If a nurse only has time to pass medications, then the nurse must make a choice, and other things, like wound care, might not get done. Through observation, interview, and record review conducted on September 22, 2021, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: All staff was re-educated on ensuring residents receive wound care by following the assessment policy for pressure ulcers, a resident admitted to the facility with a pressure ulcer receives assessment and treatment by the Wound Care Physician or Podiatrist, and that physician-ordered pressure ulcer treatments are provided as ordered. This training included conducting an individual wound assessment when a pressure ulcer is identified by the wound nurse or licensed nurse, staging and measuring pressure ulcers and documenting in the medical record (at least weekly), including nurse's notes and treatment administration record. Education also included following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A new process was put in place for new admissions/re-admissions. A new tool wa[TRU

Based on observation, interview, and record review, the facility failed to monitor therapeutic drug levels for [MEDICATION(S)] and [MEDICATION(S)]. The facility also failed to provide positioning needs per standard of practice for a gastrostomy tube (GT) feeding resident. These failures have the potential to affect 2 of 3 residents (R26 and R68) reviewed for therapeutic drug level and positioning needs in a sample of 36. Finding include: Record review on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/29/21 at 01:00 PM, V2 (Director of Nursing) stated, We should have monitored [MEDICATION(S)] and [MEDICATION(S)] drug levels. I don't have any lab/blood work available to show you the therapeutic drug level for [MEDICATION(S)], and [MEDICATION(S)] was monitored. The physician didn't order to monitor those drug levels. On 07/29/21 01:30 PM, V25 (Pharmacist) stated, Therapeutic drug levels for [MEDICATION(S)] and [MEDICATION(S)] should be monitored upon initiation of drug and periodically as per physician order. Too much drug levels can cause liver and kidney failure. Record review on POS indicates no blood draw was ordered to monitor therapeutic drug level for [MEDICATION(S)] and [MEDICATION(S)] until 7/29/21. On 7/29/21 at 1:50 PM, V26 (Attending Physician) stated, I am not sure what happened. Yes, the drug level should have been monitored. I don't have an answer for why it wasn't monitored. R26 is going to see the neurologist, and the neurologist should have ordered the blood draw to monitor those drug levels. Facility presented Medication Management policy (dated 10/25/2014) which documents: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant-pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. On 07/27/21 at 12:14 PM, surveyor observed R68 lying flat across the low bed with lower extremities dangling off the bed while GT feeding was infusing. On 07/28/21 at 10:10 AM, V2 stated, Staff should check on (R68) frequently to ensure (R68's) head of the bed remains elevated with GT feeding. Resident's lower extremities should not dangle from bed, and staff should have pulled him up when he comes to the bottom of the bed.

Based on observation, interview and record review, the facility failed to provide the ordered treatment to a resident's burn wounds. This applies to 1 of 2 residents (R9) reviewed for burn incidents in the sample of 11. This failure resulted in the delayed healing of R9's burn wounds. Findings include: R9 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's quarterly MDS (Minimum Data Set) dated 5/21/21 shows that the resident is cognitively intact. R9's MDS shows that the resident would require extensive assistance from the staff with bed mobility and toilet use, total assistance from the staff during transfer and bathing/sponge bath, and supervision during eating and personal hygiene. On 7/21/21 at 9:41 AM, R9 was in bed, alert, oriented and verbally responsive. R9 was clean and without odor. R9 stated that either on 6/21 or 6/28 (a Monday) she requested one of the staff (does not remember who) to warm up the water that she has inside her white disposable cup because it was cold for her tea. According to R9 when the staff came back with the hot water, the staff offered to transfer the hot water into her (R9) insulated water container. R9 stated that she told the staff that she will transfer it herself because her insulated water container still has some water in it, and she does not want it mixed. R9 stated that she told the staff to place the disposable cup with hot water on top of her over bed table. R9 stated that she waited at least more than 30 minutes and when she was ready to transfer the hot water into her insulated cup, she moved her over bed table towards her and placed the said over bed table directly on top of her abdominal area. As she was attempting to transfer her hot water from the disposable white cup into her empty insulated cup, the over bed table moved that caused the hot water to spill on her, saturating her blankets and hospital gown. R9 stated that she started screaming and V6 (CNA/Certified Nursing Assistant) came in her room and saw what had happened. R9 stated that V6 immediately called V7 (Infection Control Nurse) who came in her room and assessed her. According to R9 she sustained [CONDITION(S)] on her stomach area, and on both her left and right thighs. R9 stated that V7 immediately applied cold towels on her abdominal area and on her thighs and both V6 and V7 changed her hospital gown and beddings. R9 stated that sometime in the afternoon of that same day (6/21 or 6/28/21) V5 (Wound Care Nurse) applied an ointment/cream (does not know what type) on her abdominal area and thighs. According to R9, the burn on her abdominal area had healed, but the burn on her thighs are still present and is giving her pain when the dressing is not present because the area gets wet from her urine. R9 stated that she does not receive the treatment on her burn areas consistently. According to R9 if V5 is not working, no treatments are applied to her wounds. On 7/21/21 at 10:04 AM with V5 (Wound Care Nurse), V7 (Infection Control Nurse) and V8 (Wound Care Nurse in Training), R9 agreed to show the condition of the burn areas in her abdomen and thighs. R9's abdominal area had no redness, no open wound, no blister and/or any scar formation. V5 stated that the blister sustained from the burn on R9's abdominal area had healed (does not remember when). R9's left thigh was observed with a slightly discolored dressing (yellowish) in place. After V5 removed the dressing, a small wound without drainage or odor was noted. According to V5, when the burn incident happened R9 sustained two blisters on her left thigh and one of the blisters is already healed leaving only the site that had the dressing. R9's right thigh was observed with two small wounds without drainage or odor. These two wounds had no dressing in place. R9 stated that the dressing on her right thigh came off on 7/20/21 and that V9 (CNA) was aware of it. R9 stated that no one did the treatment on her thighs on 7/20/21. According to V5 when the burn incident happened, R9 sustained two blisters on her right thigh. R9's progress notes dated 6/21/21 (9:05 AM) shows, Resident explained she had 'spilled hot water on herself when moving her tray table.' Upon examination, abdomen and inner (right) and (left) thighs were red. Cold wet compress were applied to area. Wound nurse consulted for further examination and possible treatment. R9's weekly skin alteration review dated 6/21/21 (12:23 PM) created by V5, shows that redness measuring 13.5 cm (centimeters) x 11 cm was measured on the resident's abdominal area with a blister measuring 1.4 cm x 1.5 cm. No drainage and no pain documented. The same skin alteration report indicated Current treatment orders - [MEDICATION(S)] ointment. R9's weekly alteration review dated 6/21/21 (12:41 PM) created by V5, shows that the resident had a blister measuring 2 cm x 3 cm on the right front thigh. No drainage and no pain documented. The same skin alteration report indicated Current treatment orders - [MEDICATION(S)]. R9's weekly skin alteration review dated 6/21/21 (12:45 PM) created by V5, shows that the resident had a blister on the left front thigh, but no measurement was documented. There was also no documentation of drainage or pain. The same skin alteration report indicated Current treatment orders - [MEDICATION(S)]. R9's physician order report for the month of June 2021 and the TAR (Treatment Administration Report) for the months of June and July 2021 shows no documentation of the [MEDICATION(S)] treatment order and there was no documentation that the [MEDICATION(S)] treatment was applied to R9's abdominal area, and bilateral thighs from 6/21/21 through 7/5/21. R9's order summary report shows an order dated 7/6/21 for wound- abdomen/upper thighs, clean with NSS (Normal Saline Solution) pat dry. Apply [MEDICATION(S)] daily until healed, one time a day for burn. This treatment order was scheduled to be administered at 8:00 AM. Review of R9's TAR for the month of July 2021 starting 7/6/21 shows no documentation that the [MEDICATION(S)] treatment order to the abdomen and thighs were applied as ordered on 7/10, 7/11, 7/17, 7/18 and 7/20/21. On 7/21/21 at 12:00 noon, V5 stated that when she saw the burn wounds of R9's abdomen and bilateral thighs on the afternoon of 6/21/21, she called the primary physician's office and got the order to treat the burn sites with [MEDICATION(S)] as documented on R9's weekly skin alteration review dated 6/21/21. V5 stated that about 2 days after the liquid burn incident, all of R9's blisters (abdomen and bilateral thighs) popped. According to V5, based on her review of R9's weekly skin alteration sheet dated 7/16/21, the one popped blister on the left thigh became two separate open wounds located on the resident's left inner upper thigh and left inner lower thigh, and the one popped blister on the right thigh also became two separate open wounds located on the resident's right inner upper thigh and right lower thigh. V5 was asked why there was no documentation that the ordered [MEDICATION(S)] treatment was applied to R9's abdominal and bilateral wounds from 6/21/21 through 7/5/21. V5 responded that she forgot to place the [MEDICATION(S)] treatment order in the electronic order record and because of that no treatment administration record was generated for the nurses document treatments. During the same interview V5 stated that on 7/10, 7/11, 7/17, 7/18 and 7/20/21 she was not working and during those days no one provided treatment on R9's wounds as ordered. On 7/21/21 at 12:30 PM, V2 (Director of Nursing) stated that if the [MEDICATION(S)] treatment order was not transcribed in the electronic order record, the TAR will not reflect the treatment order to apply the [MEDICATION(S)] to R9's abdomen and bilateral thighs. V2 stated that if there was no documentation on the TAR that the [MEDICATION(S)] treatment were applied, the ordered treatments were not administered. R9's progress notes dated 7/9/21 shows, Liquid burn wound to abdomen resolved. Skin intact. R9's weekly skin alteration review dated 7/16/21 shows that the resident has two open wounds on the left thigh. The left thigh wounds were documented as, left inner lower thigh, measuring 0.3 cm x 0.7 cm x 0.1 cm with small serous drainage, with pain during treatment, rated at 3 (0-10) and the current treatment orders - [MEDICATION(S)] and left inner upper thigh-liquid burn open blister, measuring 0.5 cm x 1 cm x 0.1 cm with small amount of serous drainage with pain during treatment, rated at 3 (0-10) and the current treatment orders - [MEDICATION(S)]. Further review of R9's weekly skin alteration review dated 7/16/21 shows that the resident has two open wounds on the right thigh. The right thigh wounds were documented as: Right inner thigh upper- liquid burn measuring 0.5 cm x 3 cm x 0.1 cm with small amount of serous drainage with pain during treatment, rated at 3 (0-10) and the current treatment orders - [MEDICATION(S)] and Right lower thigh, measuring 2 cm x 1 cm x 0.1 cm with small amount of serous drainage with pain during treatment, rated at 3 (0-10) and the current treatment orders- [MEDICATION(S)]. R9's progress notes dated 7/21/21 shows, Liquid burn to the left lower thigh resolved, skin intact, discoloration to the area surrounding the lower part of the thigh. R9's weekly skin alteration review dated 7/21/21 shows that the resident's left upper inner thigh-liquid burn measured 2.5 cm x 0.5 cm x 0.1 cm with small amount of serous drainage with pain during treatment as manifested by resident moaning. R9's left upper inner thigh wound had increased in size compared to the 7/16/21 assessment. Further review of R9's weekly skin alteration review dated 7/21/21 shows that the resident's right inner upper thigh - liquid burn measured 1.7 cm x 1.7 cm x 0.1 cm with small amount of serous drainage with pain during treatment as manifested by resident moaning, and the right lower inner thigh- liquid burn measured 0.4 cm x 0.7 cm x 0.1 cm with small amount of serous drainage with pain during treatment as manifested by resident moaning. Review of the facility policy and procedure regarding administration of medications with current issue date of 1/1/2020 shows in-part, 11. Topical medications used in treatments shall be recorded on the resident's treatment record. On 7/22/21 at 3:00 PM, V18 (Nurse Practitioner) stated that if an order was obtained to treat R9's burn wounds with [MEDICATION(S)], the treatment order should be followed because if the treatment order was not administered, there will be a delay in the healing process of the wounds. V18 added that if the [MEDICATION(S)] treatment was applied, it should be documented in the resident's record based on the facility policy.

Based on interview and record review, the facility failed to supervise a resident identified as high risk for fall according to the plan of care. This applies to 1 of 3 residents (R1) reviewed for fall in the sample of 11. This failure resulted in R1's unwitnessed fall with injury requiring hospitalization . Findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included dementia without behavior disturbance, anxiety disorder, [CONDITION(S)] without [CONDITION(S)] pectoris, hypertensive [CONDITION(S)] with heart failure, polyosteoarthritis, history of TIA (transient ischemic attack) and cerebral infarction without residual deficits, and history of falling, based on the face sheet. R1's admission MDS (Minimum Data Set) dated 7/7/21 shows that the resident is severely impaired with cognition and would require limited assistance with most of her ADL (Activities of Daily Living) including bed mobility, transfer, dressing, toilet use and personal hygiene. R1's fall risk review dated 6/27/21 shows that the resident is a high fall risk. R1's progress notes dated 6/30/21 (2:40 AM) shows that the nurse heard the resident crying from her room. R1 was found on the floor beside her bed. The resident verbalized that she was trying to go to the bathroom when she fell . R1 was assessed by the nurse and was found to have a hematoma on the left side of her forehead. R1 was assisted back to bed and an ice pack was applied to the hematoma. R1 was taken to the hospital for evaluation. The resident returned to the facility from the hospital that same day (6/30/21). R1's fall incident report dated 6/30/21 (2:40 AM) shows that the resident had an unwitnessed fall related to unassisted self-transfer from bed. This incident report shows predisposing physiological factors of the fall identified by the facility to include, confusion and gait imbalance. R1's fall risk review was updated by the facility on 6/30/21 post fall incident, which indicated that the resident remained a high fall risk. R1's care plan initiated on 6/28/21 indicated that the resident is at risk for injury related to falls secondary to history of falls, cognitive impairment, unsteadiness on feet, lack of coordination, history of TIA and cerebral infarction. The same fall care plan shows that new interventions were initiated on 6/30/21 (post fall) which included, Observed frequently and placed in supervised area when out of bed. R1's progress notes dated 7/9/21 (7:52 PM) created by V13 (LPN/Licensed Practical Nurse) shows, 6:55 pm Nurse walking past resident's room, observed resident on floor by (wheelchair) with large wound on left dorsal hand, moderate bleeding noted. Left arm elevated, pressure dressing applied, 911 called for transport. 7:00 pm Resident's daughter informed of fall and injury and transfer to ER (emergency room ). (Physician) informed of fall and injury. R1's incident report dated 7/9/21 shows that the resident had an unwitnessed fall in her room. The report shows in-part, Nurse walking by resident's room, saw resident on floor, her (wheelchair) behind her on the door, noticed large wound to left hand. Resident does not know how or why she fell . This incident report shows predisposing physiological factors of the fall identified by the facility to include, resident's confusion, incontinence, impulsiveness, gait imbalance, impaired memory and decreased safety awareness and decreased strength/ endurance. R1's emergency department physician report dated 7/9/21 shows that the resident sustained a V-shaped laceration on the left hand, approximately 10 cm (centimeters) in total length with mild active bleeding. The subcutaneous tissue was exposed but no bone exposure or tendon exposure. A total of 10 simple interrupted sutures were placed. The emergency department physician report also shows, The first digit at IP (interphalangeal) joint appear retracted, possibly dislocated. With application of manual pressure to joint, remainder of digit extends into anatomic appearing position, however, retracts again upon release and does not stay in anatomic position. On 7/19/21 at 11:22 AM, V19 (CNA/Certified Nursing Assistant) stated that she was the assigned staff for R1 on 7/9/21 from 2:00 PM through 10:00 PM. V19 stated that R1 had dinner inside the second-floor dining room between 5:00 PM and 5:30 PM. According to V19 on 7/9/21 at around 6:20 PM she informed V13 (LPN/Licensed Practical Nurse) that she was going to the first floor to get more linens. V19 stated that before going back to the second-floor unit she also went to use the restroom. According to V19 when she left the second-floor unit, R1 was still inside the dining room and when she came back, R1 already had a fall inside her room. V19 stated that when she saw R1 on the floor inside her room, V13 was already checking the resident. V19 does not know who took R1 from the dining room to her room. According to V19, R1 was confused but was able to wheel herself to go to the dining room and back to her room. V19 stated that she was aware that R1 was high risk for fall and needs to be in a visible area when she is not in bed, which is why before she left the second floor unit to go the first floor she informed V13 to keep an eye on the residents inside the dining room, including R1. On 7/19/21 at 11:45 AM, V13 stated that on 7/9/21 sometime after dinner (does not remember exact time), V19 informed her that she (V19) will go to the first floor to get more linens. V13 stated that because V19 left the unit, I was monitoring the dining room because I know that (R1) was inside the dining room with other residents and I know that she can wheel her chair on her own. According to V13 she was aware that R1 was high risk for fall which is why she was monitoring the dining room until V19 comes back, but she got distracted. V13 was asked why she got distracted and V13 responded, I am not sure; probably another resident asking for her medication. According to V13 the other resident who asked for her medication was not in any pain or in any distress. V13 stated that because of the distraction she did not notice that R1 had wheeled herself out of the dining room to her room. V13 stated that at around 6:55 PM on 7/9/21 while walking past R1's room she noticed the resident on the floor inside her room approximately 3-4 steps away from the door, with her face and both hands down on the floor and her wheelchair behind her. V13 stated that while R1 was on the floor she noticed that blood was coming out from the resident's left hand. According to V13 she immediately called for staff assistance and another nurse (V20) came and helped with assessing R1 and putting the resident back to her wheelchair. V13 stated that pressure was applied on R1's left hand, 911 was called and while waiting for the EMS (Emergency Medical Service) personnel to arrive, R1 was placed by the nursing station for close monitoring. According to V13, R1's physician and daughter were informed of the fall and injury. On 7/26/21 at 3:29 PM, V3 (Assistant Director of Nursing) measured the distance from the second floor dining room to the room where R1 was found on the floor, using a measuring wheel. The distance was measured as 60 feet. On 7/19/21 at 12:15 PM, V21 (Nurse Practitioner) stated that she saw R1 once at the facility on 7/7/21 because the resident was a new patient. V21 stated that she saw R1 at the dining room with fading bruises on the left side of her face which according to the staff was from her previous fall at the facility. V21 was asked about R1's progress notes dated 7/7/21 which she documented, Unsteady gait. Maintain fall precautions all the time. V21 responded that it is standard to document fall precaution on the resident's record especially since R1 had history of fall prior to admission to the facility and another fall while at the facility, and because R1 was confused due to dementia. V21 was aware that R1 was sent to the hospital on 7/9/21 after another fall with injury at the facility. V21 was informed that post fall on 6/30/21, the facility added an intervention to place R1 in supervised areas when out of bed. V21 stated that the mentioned intervention is part of the facility's fall precaution plan and should be followed to prevent R1's fall and injury.

Based on observation, interview and record review the facility failed to provide physician ordered medications for pain management as prescribed. This applies to 1 of 3 residents (R3) reviewed for pain medications in a sample of 16. This failure has resulted in R3 experiencing exacerbations of pain. Findings include: R3's Admission Records document R3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/23/20 at 10:10 am R3 was observed in his room with the door closed to his room. R3's room was dark, the blinds were closed and R3 had a towel covering the upper portion of his head. R3 stated he was experiencing pain at a 7 but had just taken some pain medications. R3 stated his pain has not been controlled well since admission to the facility because the facility has not been consistently providing his physician ordered pain medications. R3's April and May 2020 Medication Administration Record [REDACTED]. These MAR's document R3 as not receiving 18 doses of [MEDICATION NAME] between April 18 - May 5, 2020 with entries documented in the eMAR Progress Notes (Electronic MAR indicated [REDACTED]. R3's April 2020 MAR indicated [REDACTED]. This MAR indicated [REDACTED]. R3's June 2020 MAR indicated [REDACTED]. This MAR indicated [REDACTED]. R3's June 2020 MAR indicated [REDACTED]. This MAR indicated [REDACTED]. R3's July 2020 MAR indicated [REDACTED]. This MAR indicated [REDACTED]. On 7/29/20 at 3:08 PM V13 (Nurse) stated R3's pain medications were sometimes not available. V13 stated when the medication was not administered R3 would state he would have an increase in his generalized pain and headaches. V13 stated when R3's medications were not available it would be documented on the eMAR. On 7/31/20 at 12:08 PM V12 (Pain Physician) stated it is very important R3's medication regimen is provided as ordered due to progressive Chronic Regional Pai[DIAGNOSES REDACTED] (CRPS) with nerve root issues. R3 receives a combination of [MEDICATION NAME]-[MEDICATION NAME], and [MEDICATION NAME] to manage his pain caused by the CRPS. V12 stated without a consistent pain medication regimen R3's symptoms worsen causing exacerbations of pain. V12 stated he has continued to see V12 regularly with the last visit on 7/8/20. V12 stated since his admission to the facility R3's pain is not as well controlled as it had been prior to admission. V12 stated the facility should be providing the appropriate medication regimen as prescribed to manage R3's pain and prevent exacerbations of uncontrolled pain. R3's Pain Consultation completed by V12 (Pain Physician) dated 7/8/20 documents treating R3 for greater than [AGE] years. V12 documents R3 with development of a [DIAGNOSES REDACTED] (CRPS) that has progressively spread over time to all extremities with an associated chronic neuropathic pai[DIAGNOSES REDACTED] and cervical, [MEDICATION NAME] and lumbosacral symptoms. V12 documents his overall impression for the visit on 7/8/20 as R3 currently has an exacerbation of the [MEDICATION NAME] radicular symptoms due to poor pain management. The facility policy Pain assessment dated ,[DATE] documents to administer pain medication in accordance with the physician order.

Based on observation, interview and record review the facility failed to ensure residents are free from physical abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 17. This failure resulted in R1 sustaining a broken tooth with bruising and abrasions to his face during an altercation with a staff member. Findings include: On 7/30/2019 at 9:27AM, R1 was laying in bed with the right eye swollen, red/blue in color and multiple red abrasions above the right eye. R1 opened his mouth and was pointing to his tooth while speaking Spanish. V3 (Nurse) entered the room to translate Spanish to English. V3 said she only speaks a small amount of Spanish. V3 said she was on duty early Sunday morning, 7/28/2019 when the incident happened but she did not witness it. V3 said V6 (Nurse) came and got her and reported that R1 attacked her. V3 said V6 did not say what happened to R1's face. V3 said she was present in R1's room when the paramedics took R1 to the hospital and said R1 had blood on his face. V3 said R1 has never been combative and she could not believe what V6 told her about R1 attacking. V3 exited the room. V3's (Nurse) Abuse Investigation statement dated (MONTH) 28, 2019 states, V6 informed (V3) that R1 attacked V6 and V6 said 'I had to defend myself.' On 7/30/2019 at 9:44AM, V4 (Nurse) entered R1's room to translate Spanish to English. Per translation, R1 said he went to his friends' rooms (R8 and R9) to get the nurse. R1 said the nurse pushed him into the bed and got on top of him and started hitting him in the face with keys. R1 said there were two of them and he only saw the one hitting him in the face. R1 said she was a black female and she put keys in R1's mouth. R1 opened his mouth and pointed to a cracked tooth on the lower left side. R1 said he was hit with an oxygen tank in his back. R1 pulled up his shirt to expose his back; the left lower side was swollen and R1 screamed upon touch. V4 (Nurse) said, We ordered an x- ray and are waiting on the results. V4 said she was not on duty when this happened and that R1 is not combative. On 7/30/2019 at 10:00AM V7 (Hospital Nurse) said he had concerns because the resident reported that he was looking for the nurse who was in his friends' room to ask for medication. V7 said R1 reported upon finding the nurse, he was pushed, hit in the face and choked by the nurse. V7 said upon emergency room visit R1 had a right black eye, bruising and scrapes around the right eye. V7 said R1 had lower left jaw swelling and a lower left bottom molar chip. V7 said he spoke with V2(Director of Nursing) at the facility and informed her that he was reporting this to the State agency. V7 said V2 was concerned about missing medication cart keys which R1 did not have on his person. V7 said he is familiar with R1, who comes into the emergency room a lot for kidney issues and has never been combative. V7 said R1 does not have Alzheimer's or dementia. V7 said, R1 entered the emergency room scared like a child with bruising and they reported to me bite marks on the staff's finger. V7 said, Well I would bite too if someone was holding my mouth opened with keys. V7 said x- rays of head and back were done with no fractures. Hospital Record dated 7/28/2019 at 1:50AM documents, Staff at Nursing Home stated R1 was aggressive and attacked staff at the nursing home and was exhibiting aggressive behavior. R1 was calm and cooperative with EMS staff. R1 states, he was looking for the RN at the nursing home to request [MEDICATION NAME], patient states he saw the RN in the room of his friends at the nursing home. R1 states that the RN at the nursing home shoo'ed him out of the room and that the RN followed him back to his room and pushed him down onto his bed, punched him in the face while holding keys in her hand as well as kicked him. R1 said the keys in the RN's hand entered the left side of his mouth and he is now having pain in that area as well . R1 said it was two staff, one staff stayed with him while the one who hit him ran off to hide. R1 said he is having severe lower back pain as well as where he was hit in the face and mouth. R1 has small cuts to the right side of his face with small amounts of dried blood as well as bruising noted around his right eye. R1 has small cuts on the bottom left lip as well as lip swelling. R1 has a broken molar tooth near the area where he says pain primarily is on the bottom left jaw . tooth break appears unhealed and fresh. R1 is alert and oriented to person, place and time answering questions appropriately, moving all extremities without difficulty. R1 is visibly upset but is completely cooperative with this RN and staff in room with no aggression noted. emergency room Physicians Report Dated 7/28/2019 states, [AGE] year old male presents with reportedly being assaulted by nursing home staff Staff kicked resident in the back, threw keys at R1s' face and allegedly had the keys shoved into his mouth and was struck in the face. No clear indication that the resident was being aggressive to staff. On 7/30/2019 at 3:43PM, R11 said R1 came into her room and complained about heart burn the night of the incident. R11 said she told R1 to go and find the nurse and ask for some [MEDICATION NAME]. R11 said she did not witness anything but in the morning, R1 told her a nurse beat him up. The Abuse Investigation dated 7/28/2019 was reviewed. Correspondence to the Receptionist dated 7/29/2019 states, R1 came to report that he was attacked by a nurse on 7/27/2019. It was translated by R11 that a nurse hit him in the face with an oxygen tank and keys and put her fingers in his mouth and scratched the inside. And that the nurse got on top of him at some point during the attack. R1 said he was in R9's room. Grievance Concern Dated 7/30/2019 documents R1 claimed he was attacked by employees. R1 said he asked for antacid for stomach pain and 2 nurses put a beating on him. R1 said keys were thrown at him and R1 was struck in the face. Nursing Progress Note dated 7/28/2019 at 1:16PM documents, R1 complained of back pain, refused as needed pain medication. No combativeness this shift. Ambulates with steady gait and rolling walker. Discoloration noted to right eye with scratches, discoloration to right forearm outer area and right lumbar area will continue to monitor . The Facility's Abuse Prevention Policy dated (MONTH) (YEAR) states, The facility affirms the right of residents to be free from abuse The facility therefore prohibits abuse . On 7/30/2019 at 10:45AM, V2 (Director of Nursing/DON) said she came to the facility and interviewed V6. V2 said V6 had bite marks on her fingers with no bruises/scratches on her face. V2 said R1 has no history of aggressive behavior. V2 said in situations like this staff should remove themselves and keep the resident safe. On 7/30/2019 at 11:03AM, R3 said he wanted to report that a staff nurse abused R1. R3 said R1 is very nice and not combative. On 7/30/2019 at 11:51AM, V3 (Nurse) said she is not familiar with V6 (Nurse) because V6 (Nurse) was recently hired. V3 said when V6 told her R1 attacked her I had to absorb that; I did not see what happened. V3 said, I am only saying what V6 reported to me. R1 had blood on his face and V6 had bite marks on her fingers. V6 said patient safety is number one. Staff should never hit residents. Again V3's witness statement documents that V6 said she had to defend herself. On 7/30/2019 at 12:13 Noon, V6 (Nurse) said R1 attacked her. When asked how R1 sustained the black eye and scratches, there was no response. V6 said, No one assessed R1 after the incident. I had to hold his hands to get him off of me. V6 (Nurse) witness statement dated 7/28/2019 states, V6 said 'I had to defend myself.' On 7/30/2019 at 12:56PM, R17 said she did not witness anything. R17 said R1 is mild mannered and not combative with anyone. On 7/30/2019 at 2PM, V5 (Nurse) said she came on duty to relief V6 the night of the incident. V5 said, I saw V6 and V6 had bite marks on the fingers and V6 told me R1 attacked her but there were no bruises or scratches on V6. R1 is never combative; he is the nicest male I know. I could not believe R1 attacked V6; he walks slow with a walker and has never been combative. On (MONTH) 30, 2019 at 2:31PM, R10 said he did not witness anything but R1 is not combative. R10 said R1 helps everyone. On (MONTH) 31, 2019 at 3:51PM, V10 (CNA) and V11 (CNA) said, Have you seen R1? He is not strong enough to throw a rollator. They both said they were in shock when they heard R1 attacked a nurse. They both said R1 is the sweetest, nicest and most helpful man with not a mean bone in his body. On 7/31/2019 at 11:31AM, V1 (Administrator) said the abuse investigation was ongoing. Care Plans were reviewed from 5/1/2019 to 7/28/2019. R1 had no care plans for behaviors. Minimum Date Set dated (MONTH) 11, 2019 document R1 has rejection of care, but no behaviors. BIMS (Brief Interview for Mental Status) dated 7/11/2019 for R1 documents an 11 indicating mild cognitive impairment. R1's progress notes reviewed from 10/1/18 through 7/28/19 show no combative behaviors.

Based on observation, interview and record review the facility failed to ensure transfer of 1 resident (R8) with two assistants and failed to provide supervision for 1 resident (R7) at risk for falls while ambulating. This applies to 2 of 3 residents (R7 and R8) reviewed for falls. This failure resulted in R8 fracturing R8's right femur. The findings include: 1) R8 was admitted to the facility (MONTH) 15, 2010 per the admission face sheet. The physician orders [REDACTED]. The fall risk assessment dated (MONTH) 19, (YEAR) showed that R8 was at high risk for falls. The MDS (Minimum Data Set) dated (MONTH) 19, (YEAR) showed that R8 was mildly cognitively impaired. The record showed that R8 was a two person assist with transfers and not able stabilize self without staff assistance. An incident report sent to the Illinois Department of Public Health dated (MONTH) 15, (YEAR) showed that R8 was toileted by staff members. The report showed that during the transfer R8's knee buckled and R8 was assisted to the floor. Staff interview post incident dated (MONTH) 15, (YEAR) showed that R8 was on the floor in front of the bathroom door. The report showed that R8 reported that he lost his balance. The report showed that R8 was not crying so he was returned to his wheelchair. Fall event report dated (MONTH) 15, (YEAR) showed that the fall was witnessed by staff and that R8 lost his balance. The report showed that R8 was assisted by one staff member. The report showed that R8 had no injury and had range of motion to all four extremities. The report showed that R8 had no pain and that no medical care was required after the fall. The report showed that interventions put in place were to increase supervision or monitoring. The report further showed nursing notes for (MONTH) 16, (YEAR) at 2:44 pm R8 complained of pain to the right knee. The report showed an x-ray was ordered. The note showed that the results were obtained by 10:02 pm and the Nurse Practitioner was notified. The report showed a note dated (MONTH) 17, (YEAR) 5:15 am that R8 was admitted to the community hospital with a fracture to right femur. With the incident report was an in-service training record for one CNA (Certified Nursing Assistant) dated (MONTH) 16, (YEAR). The topic discussed for the in-service was carrying out care per the activities of daily living care plan and transfer sticker. X-rays from the community mobile service dated (MONTH) 16, (YEAR) at 9:04 pm showed that there was evidence of an impaction [MEDICAL CONDITION] distal femur. Documents from the community hospital dated (MONTH) 17, (YEAR) showed that R8 had a fall at the nursing home. The operative report dated (MONTH) 17, (YEAR) showed that R8 had a closed displaced periprosthetic [MEDICAL CONDITION] femur. Care plans for self care deficit dated (MONTH) 18, (YEAR) showed that two staff was to assist with transfers and toileting. On (MONTH) 1, (YEAR) at 12:07 pm in the conference room V3 Director of Nursing said that R8's fall was self reported by the facility for an improper transfer by staff. V3 said that the staff was in-serviced on using the transfer information provided for each resident. V3 stated, R8 should have been a two assist transfer. The CNA (Certified Nursing Assistant) transferred R8 independently. 2) R7 was admitted to the facility (MONTH) 21, (YEAR) per the admission face sheet. The physician order [REDACTED]. On (MONTH) 28, (YEAR) at approximately 9:40 am R7 was observed walking with an unsteady gait up and down the hallway on the 2200 wing of the second floor. R7 was disheveled and was wearing a plastic brace to the torso. R7's pants were falling down to the mid buttock area. There was no staff assisting R7 throughout the observation until approximately 9:45 am. R7 was not able to say the day of the week or time of day. R7 did speak some Spanish. The MDS (Minimum Data Set) dated (MONTH) 24, (YEAR) showed that R7 was moderately cognitively impaired. The MDS showed that R7 required set up help with locomotion. An incident report dated (MONTH) 17, (YEAR) showed that R7 was noted with an inability to stand. The report showed that on (MONTH) 17, (YEAR) x-rays were obtained of the lumbar and coccyx area. The report showed that on (MONTH) 18, (YEAR) the negative results of the x-rays were called to the physician. The report showed that R7 was sent to the community hospital on (MONTH) 19, (YEAR). The report showed on (MONTH) 20, (YEAR) the hospital notified the facility of a fracture to [MEDICATION NAME] vertebrae 12. Nursing notes dated from (MONTH) 19, (YEAR) through (MONTH) 7, (YEAR) showed no nursing assessment information. There was no documentation regarding falls or incidents. A nursing note dated (MONTH) 10, (YEAR) showed that R7 had pain in the lower back and was requesting pain medication. R7's clinical record showed no more complaints of lower back pain until (MONTH) 17, (YEAR) at 11:21 am. The note showed that per the CNA, R7 was in pain and struggling to ambulate and had been worsening over the past few days. The nursing staff did call the physician for new orders. There were no nursing assessments or vital signs documented during this time. The nursing notes showed that R7 was not sent out to the hospital until (MONTH) 19, (YEAR). There continued to be no nursing assessment. From (MONTH) 17, (YEAR) through (MONTH) 19, (YEAR) R7 continued to need pain medication for pain. The Computerized Tomography report of the [MEDICATION NAME] spine from the community hospital dated (MONTH) 20, (YEAR) showed that R7 had a moderately severe compression fracture to the [MEDICATION NAME] 12 vertebrae. The community hospital records from the emergency room department dated (MONTH) 20, (YEAR) showed that R7 reportedly had a fall at the nursing home days before. Skilled nursing communication discharge/transfer report from the community hospital dated (MONTH) 22, (YEAR) showed that R7 required maximum assist with transfer and ambulation and required the use of a walker. Fall risk observation assessment showed that R7 was at high risk for falls. The assessment showed that R7 was on the fall prevention program. Fall risk observation assessment dated (MONTH) 24, (YEAR) (post injury) showed that balance and gait were not assessed. The assessment showed that R7 was unable to ambulate without assistance. The report showed the care plan was not updated and to continue with present care plan. The current care plan for fall prevention in R7's clinical record showed that R7 required the assistance of staff for ambulation. Some of the interventions added for fall prevention were not individualized to meet R7's abilities such as comprehending education and remembering instructions. Interventions in the care plan dated (MONTH) 28, (YEAR) showed that 1 staff were to assist R7 with transfers and have R1 use a wheelchair. On (MONTH) 1, (YEAR) at 3:50 pm V7 LPN (Licensed Practical Nurse) said that R7 was very mobile. V7 said R7 liked to dance and that R7 was usually put around other residents. V7 stated, R7 needs to be watched all the time. On (MONTH) 1, (YEAR) at 12:07 pm V3 DON (Director of Nursing) stated, R7 is supervision with limited assistance. V3 said the family reported the fall. V3 said that prior to the injury/fall R7 was able to ambulate without assistance.

Based on observation, interview and record review the facility failed to monitor a resident's status after a change in condition and failed to perform a thorough skin assessment upon re-admission to the facility. This applies to 1 of 4 residents (R7) reviewed for status changes in a sample of 19. This failure resulted in R7 receiving a delay in treatment and being hospitalized [MEDICAL CONDITION], Urinary Tract Infection, and Acute [MEDICAL CONDITION]. Finding include: R7's Resident Face Sheet dated October 27, 2017 documents R7 as an [AGE] year old readmitted to the facility on [DATE] after being hospitalized beginning October 17, 2017. R7 has [DIAGNOSES REDACTED]. R7's Resident Progress Notes dated October 12, 2017 documents labs results returned and Z7 (Nurse Practitioner) contacted. The October 12, 2017 Laboratory Report documents R7 with an elevated White Blood Cell Count (WBC) of 18 (Normal 4.8-10.8). R7's Resident Progress Notes document on October 13, 2017 at 10:19 am, . (R7) noted to be a little restless and tired. Vital checked, heart rate and temp (temperature) elevated. (Z7) in the facility, orders given to do a stat CXR (Chest X-Ray), and continue monitoring (R7). (Z7) also stated if symptoms worse to send to ER (emergency room ). The next computerized entry in R7's Resident Progress Notes is dated October 16, 2016 at 5:13pm documenting, (R7) noted to be lethargic. (R7) noted to have a temp of 100.2. Chest X-Ray noted to be negative and relayed to (Z7). New orders obtained There is no further assessment or vitals documented after this entry on October 16, 2017. These notes then document October 17, 2017 at 3:55am, labs received and Z8 (Physician) contacted with critical labs for sodium, blood urea nitrogen (BUN) and elevated WBC. At 5:04am, these notes document R7 being sent to the hospital. The Laboratory report dated October 18, 2017 for the specimen collected October 17, 2017 at 7:21pm documents R7's serum sodium at 165 (Normal 131-145), BUN 82 (Normal 5.0-28), creatinine 2.3 (Normal 0.6-1.2) and WBC 19.2 (Normal 4.8-10.8). The hospital ER Physician Documentation dated October 17, 2017 documents R7 being admitted with the Clinical Impression of [MEDICAL CONDITION] (elevated sodium), Acute [MEDICAL CONDITION], Fever, UTI, [MEDICAL CONDITION]. The Critical Care Consultation dated October 17, 2017 documents R7 with [MEDICAL CONDITION] from a urinary source, [MEDICAL CONDITION] due to volume depletion and [MEDICAL CONDITION] related [MEDICAL CONDITION] vs. volume depletion. The facility computerized Vitals Report for October 2017 does not document any vitals October 12, 2017 through October 17, 2017. On October 26, 2017 at 11:25am, E2 (Director of Nursing) confirmed there is no evidence nursing staff monitored R7 between October 12, 2017 until October 16, 2017. E2 stated R7 should have been monitored including vital signs, assessments and any changes communicated to the physician. On October 31, 2017 at 2:50pm, Z7 (Nurse Practitioner) stated the facility knew something was going on with R7 and should have been monitoring R7. Z7 stated if R7 had been started on an antibiotic a day or two earlier it may have made a difference. Z7 stated the elderly can turn septic at the drop of a hat and should be monitored and the facility should have evidence they monitored R7. The Minimum Data Set, dated dated dated [DATE] documents R7 with moderate cognitive impairments. On October 25, 2017 at 11:35am, R7 had a dressing to the left anterior leg/upper shin dated October 22, 2017. On October 25, 2017 at 12:59 pm, E10 (Nurse) stated, I have no idea what that bandage is for. At 1:25pm, E10 stated R7 was in the hospital on October 22, 2017 and that dressing should have been removed upon re-admission. On October 25, 2017 E11 (Wound Nurse) removed the dressing to the left anterior leg exposing a pea sized open area with yellow slough. The Skin Integrity form dated October 25, 2017 documents the first assessment of this wound after R7's return from the hospital on October 23, 2017. This assessment documents R7 with a left anterior leg/uper shin skin tear with yellow slough measuring 0.7 by 0.7 by 0.1 centimeters. On October 26, 2017 at 11:25m, E2 (Director of Nursing) stated residents are to have a complete skin assessment upon admission by the admitting nurse and then again shortly after re-admission, either the day of admission or the following day. The facility policy Pressure Ulcer/Skin Breakdown dated January 2017 documents examine the skin of a new admission for any alterations in skin integrity.

Based on interview and record review, the facility failed to provide a safe environment during the transfer of a resident. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in a fall in which the resident sustained [REDACTED]. Findings Include: R1 is a [AGE] year old resident admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. According to facility documentation, including the initial incident report, nurse's notes and the final investigative report, R1 sustained a fall on 3/8/13 while being transferred by a Certified Nurses' Assistant (E3). After complaining of persistent pain in her right leg following the fall, R1 was subsequently transferred to a local area emergency department (ED). Hospital X-rays showed a right impacted distal femur fracture. According to the post fall investigation report and E3's signed statement, E3 transferred R1 alone to the bathroom using a gait belt. The fall occurred while R1 was being transferred back from the bathroom. The facility's Interdisciplinary Resident Rehab screen completed on 2/22/13, recommended that R1 be transferred using a mechanical lift. R1's care plan (Initiated 1/12/13) also indicated that R1 was a 2 staff assist with mechanical lift for transfers. R1's most resent Minimum Data Set (MDS) completed on 1/3/13 indicated that R1 requires extensive assistance for transfers. The MDS section G item A2 was scored (3) as a 2+ person physical assist for transfers. On 3/12/13 at around 3:00 pm E2 (Director of Nurses) stated "on 3/8/13 CNA (E3) took upon herself to transfer resident from the recliner to the toilet without following protocols that she is well aware of." Statements obtained from the facility's Administrator (E1) on 3/12/13 at between 3:00 PM and 4:00 PM confirm the events surrounding R1's fall on 3/8/13. E1 and E2 also verified the validity of the post fall investigative report and all witness statements there in, including that R1 was transferred manually by a single Certified Nurse's Aide (E3)

Based on observation, record review, and interview the facility failed to: 1. Assess residents' bowel and bladder functions. 2. Develop and implement a bowel and bladder program to improve and/or maintain bowel and bladder continence. 3. Provide incontinence care in a timely manner to residents who are incontinent. Due to these failure residents: 1. remained incontinent of bowel and bladder. 2. Developed pressure sores and/or had pressure sores worsen due to their incontinence. 3. Remained in urine saturated bed/chairs for long period. This is for nine of 13 sampled residents investigated for incontinence in the total sample of 33 (R2,R20, R6 R7, R9, R18, R8, and R14) and one resident in the supplemental sample. (R34) The findings include: R 2 is a [AGE] year-old male. The clinical record lists multiple [DIAGNOSES REDACTED]. R2 sustained three falls on 1/3/2012 resulting in R2 being hospitalized with Septic shock from urinary tract infection, [MEDICAL CONDITION], dehydration and worsening [MEDICAL CONDITION] On 12/6/2011 at 2:50pm, R2 is found on floor. The incident report states was trying to dress himself and was incontinent of urine while lying in bed. The plan of care does not address the incontinence for R2. Review of the Management incident /Skin Tear/Bruise investigation form for interventions states: to circle the number for interventions and remember to start with the least restrictive intervention. This section is not complete. The incident dated 12/14/11, R2 was found on the floor lying on right arm with only pull-ups on no time given. Incident not identified on log report. No evaluation of the fall is available. On 1/2/2012, R2 sustained three falls resulting in R2 being sent out to the hospital The 1/2/2012 report documents at 1:40am, R2 fell in front of his closet. R2 is anxious and incontinent. Then at 2:20pm, staff yells from hallway, " He fell again. " R2 is found lying on the floor and has a laceration to the occipital lobe of head. R2 is irritable and anxious. At 2:45pm, R2 is found in his room on the floor. R2 is identified to be continent of urine and continent of bowel according to his 12/1/2010 Minimal Data Set(MDS) from closed record review and plan of care dated 12/15/11 R2 is incontinent of bowel and bladder and requires staff assistance with his toileting and incontinent needs. R2 is now using adult briefs. Interview with (E1) Administrator and (E3) on 4/5/12 about a bowel and bladder program They stated they do not have a program at the facility. Residents are not assessed for the type and reasons for incontinence. A review of the facility's Management Incident/SkinTear/Bruise investigation Form that were to be completed each time R2 had a fall list as an intervention to obtain orders for urine analysis to rule out infection. This was not done for R2's fall of 1/2/2012 and R2 was admitted to hospital with septic shock from urinary tract infection. 2. On 4/5/12 at 2:15 p.m., R34 was observed resting in bed in her room. The urine odor permeated R34's room. R34 stated, "I haven't been changed or repositioned since 2:30 a.m. I was checked at 6:00 a.m. and I was not wet but no one has checked me since then." R34 then pulled her top bed linens back to reveal her gown and bottom bed linens. R34's gown was soaked with urine from the waist down. The bottom sheet was soaked with brown stained urine. R34 was noted with multiple bath towels folded and placed between her legs. The towels were saturated with brown stained urine. R34 stated, "They don't have diapers large enough for me so they put these towels here and leave me in bed." Nurse staffing showed E11 (CNA) had been assigned to care for R34 from 7:00 a.m. to 1:00 p.m. E12 (CNA) had been assigned to care for R34 from 1:00 p.m. to 3:00 p.m. R34 stated neither CNA had checked, changed, or repositioned her. At 3:15 p.m., E13 (CNA) was observed providing incontinence care on R34. When E13 turned R34 to her side, R34 was observed with two large linen pads beneath. Both pads were saturated with brown stained urine. The fitted bottom sheet was saturated with brown stained urine. A linen pad was under the fitted sheet, which was saturated with brown stained urine, and the mattress beneath this pad was wet with urine. R34 was noted with four stage II open areas on her left buttock, sacrum, and coccyx area. Three of these areas were identified as avoidable pressure sores. One site was identified as an open area that had worsened. Interview with E13 at this time noted E13 to say, "I work 5 days a week and I usually work down this hallway. I always find R34 in this condition. She is always soaked with urine. I have to change the entire bed and wipe down the mattress." Interview with R34 noted R34 to say, "They have never tried to do a bladder diary or do scheduling on me to try and identify when I urinate so they can catch it and keep me dry." R34 further stated, "I asked for a catheter so I can get out of bed, heal my bottom, and be functional." Review of R34's last plan of care dated 1/26/2012 addressing skin integrity showed approaches for incontinence that included: -Check at regular intervals for any incontinent episode and assist with any incontinent needs promptly. -Keep skin clean and dry. -Moisture barrier to buttocks/peri area after incontinence. 3. On 4/5/12 at 12:10 p.m., R20's room was noted with the door closed. While standing outside of R20's room a pungent urine smell was noted. Upon entering the room, a very strong urine smell permeated the room. R20 was noted sitting on the side of his bed. R20's was observed wearing a gown that was urine soaked. R20's bottom bed linens were saturated with brown stained urine. During interview with R20 at this time noted R20 to say, "No one cleaned me up or helped me to the bathroom today. I try to do things for myself. I need help sometimes. I have been sitting here wet for a long time, probably all morning." R20 admitted no one has assessed him for a bowel or bladder program. Interview with E11 (CNA) on 4/5/12 at 12:15 p.m. noted E11 to say, "I cleaned R20 up this morning. We always have to talk him in to letting us do things for him." As noted above, R20 stated no one cleaned him or helped him to the bathroom today. Review of nurse ' s notes and incident report dated 4/1/12 showed R20 had a fall at the facility on 4/1/12 and sustained a right [MEDICAL CONDITION]. Review of R20's plan of care addressing falls included approaches for CNA to assist with ambulating, transferring and toileting. On 4/4/12 at 11:30 a.m. E1 (Administrator) and E3 (Assistant Director of Nurses) admitted they had no bowel and bladder programs at the facility. At this time, E3 stated, "Without a bowel and bladder program we can't guarantee residents won't decline." . 4.R22 is identified from the 1/10/12 Minimal Data Set (MDS) for urinary continence as occasionally incontinent. The care assessment dated [DATE] notes R22 has [MEDICAL CONDITION] bladder with [MEDICAL CONDITION]. There is no indication how the facility obtained this bladder information. Interview with R22 he is alert and oriented. R22 states he knows when he has to go to the bathroom. R22 states sometimes he does not get to bathroom in time and he will wet himself. R22 states he wears adult briefs and uses a wheeled chair for ambulation. Interview with (E1) administrator and (E2) assistant director of nursing the facility currently did not have bowel and bladder program. E2 states the restorative nurse had left the week before the survey. The facility does not conduct voiding patterns nor determine the type of incontinence residents have. 5). On 4/5/12 at 3:35PM R18 was observed as the resident sat in a wheelchair in the second floor dayroom. There was a strong urine odor noted upon approach to the resident which became stronger when the resident stood up. R18 was observed to be wearing a disposable diaper. When asked, R18 stated that the current diaper had been put on by staff that morning" when staff got me up out of bed this morning. They will put on a new diaper tonight when they put me to bed." The resident stated that she can feel the urge to go to the bathroom, but is unable to get to the bathroom on her own and sometimes, the nurses are so busy they can't take me quickly enough. R18 stated "they take good care of me". R18 stated that staff had not checked her for incontinence since she got up that morning. The resident was unable to remember the time that staff had gotten her up; only able to say it was before breakfast. E51 (CNA) was identified as the staff assigned to care for R18 and provided incontinent care to R18. During this time, when R18 stood up from the wheelchair she required hands on assistance by staff and the use of a walker. Upon standing, the urine odor was noted to be even stronger when the diaper was taken off. The diaper was so saturated with urine, that it had soaked through the resident's clothing and onto the incontinent pad that the resident had been sitting on. When interviewed, E51 stated that his shift had started at 2:00PM and admitted that he had not checked R18 for incontinence as of 3:35pm. Review of R18's record revealed that the resident was incontinent of urine and stool and required extensive assistance to use the toilet. The incontinence care plan required staff to check the resident for incontinent episodes at regular intervals and to assist with incontinent care promptly. CNAs were instructed to check the resident at regular intervals such as upon awakening, before and after meals, at HS (bedtime) and as needed. There was not any Bowel and Bladder Assessment available for R18, nor any indication of a toileting assessment having been initiated by the facility. 6). R6, R7 and R9 each had decubiti and each were incontinent. When interviewed 4/17/2012 E5 (Treatment Nurse) verified that each resident was incontinent. R6, R7 and R9 were assessed as confused and in need of staff assistance in toileting. There were not any Bowel and Bladder Assessments, nor any type of toileting assessment available for any of these residents. 7). R8 was interviewed in the hospital on [DATE] in the emergency room . R8 told surveyor that it took staff a long time to answer his call light, especially on the night shift. R8 said I have to wait 1 ? to 2 hours for someone to come and assist me. I want staff to help me with using my urinal. When I cant ' get help R8 said he used the bathroom in his bed. R8 said, I ' m left wet and cold. " -Review of R8 ' s Admission Face Sheet documented that R8 is a [AGE] year old male with [DIAGNOSES REDACTED]. Review of Bowel and Bladder Assessment, dated 2/09/2012 and 1/23/2012, documented that R8 was assessed to be bed ridden as a factor causing his incontinence. In the area of Elimination staff documented that R8 had " Incontinent-multiple daily episodes " , and used incontinent pad and briefs. The Urinary Function and Bowel Function were documented as: " Incontinent-multiple daily episodes. Functional Assessment/Mobility documented that " resident (R8) is a check and change " . The recommendations identified for R8: " use of inconstancy products, bedpan-urinal, with the resident to be check and change. " However, this assessment had no documentation of a toileting diary, or any observations of R8 ' s voiding pattern that would support these assessments of R8 ' s voiding pattern. The recommendations were inappropriate for R8 who is alert and able to report when he can go to the bathroom. Based on observation, record review, and interview the facility failed to: 1. Assess residents' bowel and bladder functions. 2. Develop and implement a bowel and bladder program to improve and/or maintain bowel and bladder continence. 3. Provide incontinence care in a timely manner to residents who are incontinent. Due to this failure residents: 1. Remained incontinent of bowel and bladder. 2. Developed pressure sores and/or had pressure sores worsen due to their incontinence. 3. Remained in urine saturated bed/chairs for long period of time. This is for 8 of 13 sampled residents investigated for incontinence in the total sample of 33 (R20, R6 R7, R9, R18, R8, and R14) and 1 resident in the supplemental sample. (R34) The findings include: 1. On 4/5/12 at 2:15 p.m. R34 was observed resting in bed in her room. The urine odor permeated R34's room. R34 stated, "I haven't been changed or repositioned since 2:30 a.m. I was checked at 6:00 a.m. and I was not wet but no one has checked me since then." R34 then pulled her top bed linens back to reveal her gown and bottom bed linens. R34's gown was soaked with urine from the waist down. The bottom sheet was soaked with brown stained urine. R34 was noted with multiple bath towels folded and placed between her legs. The towels were saturated with brown stained urine. R34 stated, "They don't have diapers large enough for me so they put these towels here and leave me in bed." Nurse staffing showed E11 (CNA) had been assigned to care for R34 from 7:00 a.m. to 1:00 p.m. E12 (CNA) had been assigned to care for R34 from 1:00 p.m. to 3:00 p.m. R34 stated neither CNA had checked, changed, or repositioned her. At 3:15 p.m. E13 (CNA) was observed providing incontinence care on R34. When E13 turned R34 to her side R34 was observed with 2 large linen pads beneath. Both pads were saturated with brown stained urine. The fitted bottom sheet was saturated with brown stained urine. A linen pad was under the fitted sheet which was saturated with brown stained urine and the mattress beneath this pad was wet with urine. R34 was noted with 4 stage II open areas on her left buttock, sacrum, and coccyx area. Three of these areas were identified as avoidable pressure sores. One site was identified as an open area that had worsened. Interview with E13 at this time noted E13 to say, "I work 5 days a week and I usually work down this hallway. I always find R34 in this condition. She is always soaked with urine. I have to change the entire bed and wipe down the mattress." Interview with R34 noted R34 to say, "They have never tried to do a bladder diary or do scheduling on me to try and identify when I urinate so they can catch it and keep me dry." R34 further stated, "I asked for a catheter so I can get out of bed, heal my bottom, and be functional." Review of R34's last plan of care dated 1/26/2012 addressing skin integrity showed approaches for incontinence which included: -Check at regular intervals for any incontinent episode and assist with any incontinent needs promptly. -Keep skin clean and dry. -Moisture barrier to buttocks/peri area after incontinence. 2. On 4/5/12 at 12:10 p.m. R20's room was noted with the door closed. While standing outside of R20's room a pungent urine smell was noted. Upon entering the room a very strong urine smell permeated the room. R20 was noted sitting on the side of his bed. R20's was observed wearing a gown which was urine soaked. R20's bottom bed linens was saturated with brown stained urine. During interview with R20 at this time noted R20 to say, "No one cleaned me up or helped me to the bathroom today. I try to do things for myself. I need help sometimes. I have been sitting here wet for a long time, probably all morning." R20 admitted no one has assessed him for a bowel or bladder program. Interview with E11 (CNA) on 4/5/12 at 12:15 p.m. noted E11 to say, "I cleaned R20 up this morning. We always have to talk him in to letting us do things for him." As noted above, R20 stated no one cleaned him or helped him to the bathroom today. Review of nurses notes and incident report dated 4/1/12 showed R20 had a fall at the facility on 4/1/12 and sustained a right [MEDICAL CONDITION]. Review of R20's plan of care addressing falls included approaches for CNA to assist with ambulating, transferring and toileting. On 4/4/12 at 11:30 a.m. E1 (Administrator) and E3 (Assistant Director of Nurses) admitted they had no bowel and bladder programs at the facility. At this time E3 stated, "Without a bowel and bladder program we can't guarantee residents won't decline." .

Surveyor: RELFORD, THERESSA Based on observation, record review, and interview the facility failed to ensure: 1.)Residents did not develop avoidable pressure sores while at the facility 2.)Residents' with existing pressure sores had pressure sores that did not worsen. 3.) Staff consistently documented on pressure ulcers once they developed. 4.)Facility follows it protocol for healed wounds to prevent reopening of wounds 5.)the facility comprehensively assess the development of pressure sores As a result of this failure four residents (R12,R34, R9 and R7) developed avoidable pressure sores while at the facility and 2 residents (R8 and R6) had pressure sores that worsened while at the facility. This is for eight of eight residents investigated for pressure sores in the sample of 33 (R34,R12,R10,R8, R9, R6 and R7) and 1 resident in the supplemental sample. (R34) The findings include 1. R34 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R34's admission CAA (care area assessment - no date) addressing pressure sores showed the following: "She has a decrease in her functional ability and requires staff assistance with bed mobility and positioning of her lower extremities. She is incontinent of bowel and bladder. She presents with her skin intact at this time. She scored a 14 making her at risk for skin breakdown. She is morbidly obese...and is able to help with turning in bed. Staff to keep her turned and repositioned. Keep her clean and dry. Assist with ADL (activities of daily living) care and incontinence care. (CNA) Certified Nursing Assistant to observe skin with each shower and with ADL care and report any skin concerns to the nurse on duty. Nurse to monitor skin weekly and report any skin concerns to the MD. On 4/5/12 at 2:15 p.m., R34 was observed in bed in her room. R34 was alert, oriented, and verbally responsive. R34 was very poorly positioned in bed with her upper body leaning to the right side. R34's room had a very strong urine smell that permeated the room. Interview with R34, "I have not been changed or repositioned since 2:30 a.m. I have not been checked for incontinence since 6:00 a.m. I was not wet then. Observation of R34's bottom bed linens showed the bed linens to be saturated with brown stained urine. R34 was asked if she had any open areas on her buttocks and she stated, "Yes." On 4/5/12 at 3:15 p.m., R34's buttocks were examined and assessed by E5 (Wound Care Nurse). When R34 was turned to her right side for pressure sore assessment R34 ' s bottom bed linens were noted saturated with urine. R34 was observed with four stage II open areas: two to her left buttock, one to her coccyx, and one to her sacral area. The site to R34's sacral area measured 0.8 cm x 0.2 cm x 0.1 cm. The coccyx site measured 3.1 cm x 0.5 cm. The left buttock site measured 3.4 x 3.1 cm and the left outer buttock site measured .6 cm x 2.1 cm. All of the sites were reddened, opened, and presented with the appearance of stage II. Interview with E5 at this time noted E5 to say, " R34 already had the site to the left outer buttock which was healing but now the site has reopened and worsened. The other 3 sites are new." Documentation on the Facility Wound Investigation Report done by E5 (LPN - Wound Care Nurse) dated 4/5/12 showed documentation that these wound were avoidable with the causing factor as "Resident was left wet and unturned for a prolonged period of time." Review of R34's latest plan of care addressing skin integrity dated 1/26/12 included approaches for the CNA to: -Observe skin daily during routine ADL's and report any changes to the nurse promptly. -Bathe/shower 2 x weekly and prn. -Assist with reposition at regular intervals. -Check at regular intervals for any incontinent episode and assist with any incontinent needs promptly. -Apply barrier cream after any incontinent episode. The skin integrity plan of care included approaches for nurses to: -Assess skin condition. -Keep skin clean/dry. -Reposition/turn at least every 2 hours. -Observe skin condition for any new areas of redness and/or skin breakdown and report immediately to MD. Further interview with R34 noted R34 to say, "I want a urinary catheter put in me so I can get out of bed, heal my bottom, and be functional." 2. A review of the closed record for R12 the face sheet states, R12 was originally admitted to the facility 12/11/2011 with multiple [DIAGNOSES REDACTED]. A review of the clinical record with (E5) LPN, treatment Nurse, and review of the 12/18/2011 Minimal Data Set ((MDS) dated [DATE], R12 did not have any skin ulcers or pressure sores on admission to the facility. On 12/ 21/2011, the nursing documentation at 9:49pm: R12 is noted to have redness to groin and abdominal folds. Bilateral reddened calluses with blisters to the left heel dark purple in color non blanchable. There are no open areas to heel. R12's right toe has a small cut covered with a bandage dark purple bedding with sanguineous draining. On 12/22/2011, the treatment writes blacken area noted to left heel during routine Cna care. Deep tissue injury (DTI) 2.5cm x 3.0cm there is no assessment of how or why R12 developed the DTI. On 1/30/2012, The treatment nurse documents R12 complained of pain to the right outer ankle this morning during routine wound care, upon assessment to the site aforementioned noted a non-stage open area to the location. The wound measured 1.5cm x 2.0cm. The wound bed is yellow black with 20 % slough and 80% necrotic tissue surrounding tissue is reddened /[DIAGNOSES REDACTED] /indurations with pain. The pressure ulcer facility acquired non-stageable. A review of the 1/30/2012 Facility Acquired Wound Investigation Report for R12 states: The acquired date is unknown. The report states that R12 prefers to lie on the right side with ankle rotated toward the mattress. On 2/16/2012, the treatment nurse documents an open area is noted on R12 ' s right lower buttock. There is no assessment available why R12 developed this new sore. On 3/15/2012, R12 is noted to have abrasions to bilateral shins, redness and excoriation noted to inner buttocks new open area to sacrum and left upper inner buttock. There is no evaluation why a new sore developed. Interview with (E1) Administrator and (E3) Assistant Director of Nursing if the Quality Assurance (QA) had evaluated the cause of the Acquired Pressure sore. They stated the facility did not have evaluation from QA about R12 ' s sores. 3. R10's original admission to the facility 7/12/2011 with multiple [DIAGNOSES REDACTED]. From closed record review, on admission R10 is identified to have no skin problems or pressure sores. R10 was admitted to the hospital 8/25/2011 upon return to the facility 9/23/2011, R10 had an open area to the right mid buttock and left mid buttock measurment to the coccyx is 0.5cmx 0.5cm x 1.0cm from review of R10 ' s record, The coccyx area were healed by 10/3/2012. The 10/6/2011 the coccyx area had reopened review of the clinical record the coccyx area would heal and reopen thru the date of 2/23/2012. Interview conducted with (E5) treatment nurse if facility has interventions for newly healed skin. E5 presented documentation Nurses Wound care Orders Guide. For prevention/ protection/healed areas [MEDICATION NAME] (no cover dressing) to be applied every seven days and as needed. This treatment was not initiated for R10 this was verified with E5. : 2). R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. When admitted , the resident did not have any open or reddened areas on his body. The resident was assessed as ambulatory and incontinent of urine and stool. The first mention of any open area on R7's body was documented on 8/12/11. There was not any description of the size or appearance of the wound, nor was there any documentation of treatment(s) being done to the area. The next documentation of any wound at all was not until 10/22/11. At that time staff staged the wound as stage III and described the wound as full thickness of the skin missing exposing subcutaneous tissue and presenting as a deep crater. After repeated requests, the facility failed to present any Wound Investigation Report(s) for R7 and failed to provide treatment orders and or Treatment Records that addressed the wound care having been done. The care plan for R7 requires nursing staff to assess R7's skin daily, reposition the resident every two hours and provide incontinent care as needed. There is not any consistent documentation verifying that this was done. 3). R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was incontinent of bowel and bladder. There is documentation of the resident having been incontinent of bowel and bladder, but no consistent documentation of incontinent care having been performed, nor is there clear and consistent documentation of the resident being repositioned. When initially admitted , R6 had a stage 3 open area on the right lower buttock that measured 6.0cm x 5.0cm x 0.8 cm. On 2/27/12 a second (new) pressure ulcer was noted on the sacral area which measured 4.5cm x 4.0cm x 0.1cm. The next day, 2/28/12, a second nurse measured R6's sacral wound and measured 6.5cm x 14.5cm x 0.1cm. On 3/4/12 a third pressure ulcer , stage 2, was noted on R6's left upper buttock which measured 0.6cm x 0.7cm x 0.1cm . On 3/5/12 the sacral pressure ulcer was documented as extending to both the left and right buttocks and having a yellow center. The measure was 8.0cm x 8.0cm and "unknown depth". There was necrotic slough in the center which measured 3.5cm x 3.7cm with 40% slough. Review of Wound Care Assessments by Z7 revealed that on 3/6/12 Z5 documented the following regarding R6's right lower buttock: "Wound now with large area of thick necrosis at coccyx. Pressure component involved...wants to sit up long periods of time...spends long hours in chair without cushion at [MEDICAL TREATMENT]. REC GEL CUSHION TO CHAIR DURING [MEDICAL TREATMENT]. Limit sitting up to 60 minute intervals if possible. Z7 recommended a dressing of calcium Alginate, Foam, Santyl, Skin Prep once daily. Z7 also recommended that staff off load the wound, a gel cushion to chair, limit sitting to 60 minutes and reposition per facility protocol. There is not any further descriptive documentation of R6's wound prior to the resident's discharge to the hospital on [DATE]. Hospital History and Physical dated 3/11/12 documented that "recently" the resident was noted to have a foul smelling odor from the stage 4 decubitus ulcer and was started on [MEDICATION NAME] (antibiotic) which did not improve her symptoms. The hospital Oncology/Hematology Consult also dated 3/11/12 documented that R6 was brought to the hospital because of "foul smelling decubitus ulcers stage 4 with weakness, fatigue, tiredness". When the facility record was reviewed, there is not any mention of R6 having any odor from any wound nor was there documentation of her wounds having increased in size from a stage 3 as assessed by Z7 on 3/6/12 to a stage 4 nor were any of her pressure ulcers staged. R6's care plan does not identify the presence of pressure ulcers nor mention locations of pressure ulcers, nor does it address stages, or number of pressure ulcers. 4). R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. When admitted , the resident did not have any open areas. Staff failed to address/assess the presence of redness, nonblanchable areas on R9's right posterior thigh until 1/31/12 at which time the area was assessed as stage 2 measuring 2.1cm x 2.0cm x 0.2cm and with 80% granulation tissue and 20% slough tissue. Wound edges were unattached. Z7's Wound Care Notes 2/7/12 assessed R9's right buttock as unstageable due to necrosis as described the wound as DTI (Deep tissue Injury). Subsequent Wound Care notes by Z7 assess the resident's wound as having necrotic tissue. The facility notes by E5 failed to mention any eschar or necrotic tissue in the wound. Wound Nurse's note of 2/11/12 changed the identification of the right posterior thigh wound to the right buttock. The wound bed was described as pink through out subsequent entries from 2/11/12 to 3/2/12. Facility staff failed to provide appropriate documentation of the appearance of R9's wound. R9's care plan does not identify the presence of pressure ulcers nor mention locations of pressure ulcers, nor does it address stages, or number of pressure ulcers. 4. Review of R8 ' s Admission Face Sheet documented that R8 is a [AGE] year old male, who was readmitted from the hospital back to the facility on [DATE] after sustaining a [MEDICAL CONDITION] leg. Review of R8 ' s readmission nursing notes, dated 1/23/2012, documented that R8 had generalized blister sores on his right leg. However, the nursing documentation was not very specific to the location of the blisters on R8 ' s leg. The nursing note documented the following: " Noted with multiple non measurable blisters to the anterior right lower leg. Some of the blisters filled with serosanguinous fluid, and few are ruptured with similar drainage. " 2/05/2012, 2/07/2012, 2/14/2012 Nursing Note continued to documented that R8 had blister on his anterior right leg. The only Predisposing Risk Factors identified is " Fractures " . The only preventative identified was: " ... Skin treatment per order ... Action: Continue to observe ... " 2/21/2012, 2/28/2012, nursing note documented that R8 ' s blisters on his right leg became opened lesion (s). The wound bed is described as reddened deep purple with [MEDICATION NAME] tissue. 3/27/2012 the nursing notes documented that R8 ' s right leg still had [MEDICAL CONDITION] located on right leg, dorsal right foot and Achilles. But there is no specific assessment about the [MEDICAL CONDITION] cause or prevention plan. Review of the nursing note dated 4/03/2012 and 4/04/2012 documented that R8 ' s opened [MEDICAL CONDITION] in the area of R8 ' s right leg, dorsal foot and Achilles blacken with 60 percent narcosis. But the nursing notes continued to lack a comprehensive nursing assessment. There was no measurements documenting the size of these wounds or change in nursing interventions. So, review of R8 ' s nursing notes from readmission on 1/23/2012 to 4/04/2012, had no documentation of a comprehensive assessment of R8 ' s pressure sore on his right lower leg to identify all possible risk factors and interventions to prevent the deteriorate of R8 ' s skin on the right leg. Review of R8 ' s care plan did not have documentation of appropriate and comprehensive nursing interventions (such as daily skin checks and plan to relieve pressure from the right leg) being implemented until late (By March, which was appropriate one and half month into R8 ' s experiencing poor skin integrity on the right leg) in the care of R8 ' s opened wounds on the right leg. R8 was sent to a local hospital on [DATE], which was located appropriately less then .25 miles away or 5 minutes. Facility's staff reported sending R8 to the hospital for generalized pain and lethargy. Review of R8 ' s clinical record at the hospital documented the following regarding R8 ' s wounds on his right leg: "4/06/2012 I (Z5 wound care nurse) saw patient to assess right calf and right wounds ... was in a leg brace at bedside, at nursing home. Right foot (dorsal and in step area) wound 14.5 x 5 x 0.3 cm, 80% black, 20% red and white. Right upper calf (anterior) wound-2.7 x 3 x 100% black, small amount serosanguinous drainage. Other wounds with moderate serosanguinous drainage. Etiology-probably pressure ulcers from leg brace, all unstageable pressure ulcers ... Patient education done: turn so off right lateral calf wound, elevate leg, healthy eating. " On 4/06/2012, the hospital wound care nurse (Z5) was interviewed at the community hospital. Z5 reported that she had examined and assessed the wounds on R8 ' s right leg. Z5 stated, " I don't think the blisters caused R8 ' s wounds. The cause of R8 ' s pressure sores was pressure from the leg brace. The brace needed to be taken off and his skin inspected daily. My understanding is he had right lower extremis fracture and that ' s why they put him in the brace... They (the wounds) did not happen in the last few days. I can ' t say how long ago. They should have been caught earlier. " Z5 said the standard of care was to monitor for early signs such as change in skin color (redness, purple or blacken skin) and put interventions in place to relive the cause of the pressure. When asked if R8 ' s wound could be the cause of pain for him, Z5 replied, they ' re (R8 ' s wounds) deep enough. " However, R8 ' s experienced changes in his right leg ' s skin color and no comprehensive assessment or nursing interventions was provided to R8 to identify and relive pressure to his leg. The facility treatment nurse, who provided R8 ' s care at the nursing home, was interviewed on 4/06/2012 at 11:25 AM. E5 stated that R8 was readmitted on [DATE] from the hospital with a leg brace and blister on his right leg. E5 said she notified that R8 ' s leg redden to deep purple in the color. R8 was getting [MEDICATION NAME] treatment, but no other changes were done. By 2/07/2012, R8 ' s right leg was purple in color. R8 went out to see an ortho doctor, who did not make any changes in his care. E5 said she did not inform R8 ' s primary physician about the change in his skin condition. When asked, E5 said the primary physician or wound care specialist [MEDICATION NAME] R8 as his wound change. Later on , E5 reported R8 ' s skin condition deteriorated by and the dressing change were done every other day. So, E5 did not perform the daily assessment of R8 ' s skin condition that was required. When asked, E5 only identified the pressure sores on R8's right leg as being caused by blisters and not his leg brace. Review of the facility's policy on Pressure Ulcer Recommended Treatment Protocol documented the following: "Recommended Treatment Options: Eliminate or reduce sources of pressure, friction, and shear" for all stages of pressure sores. However, facility nursing staff did not ensure this was done for R8 and his skin condition deteriorated to unstageable pressure sores. , Based on observation, record review, and interview the facility failed to ensure: 1. Residents did not develop avoidable pressure sores while at the facility. 2. Residents' with existing pressure sores had pressure sores that did not worsen. As a result of this failure 3 residents (R34, R9 and R7) developed avoidable pressure sores while at the facility and 1 resident (R8) had pressure sores that worsened while at the facility. This is for 3 of 8 residents investigated for pressure sores in the sample of of 33 (R34, R9, and R7) and 1 resident in the supplemental sample. (R34) The findings include: Review of R34's admission face sheet showed R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R34's admission CAA (care area assessment - no date) addressing pressure sores showed the following: "She has a decrease in her functional ability and requires staff assistance with bed mobility and positioning of her lower extremities. She is incontinent of bowel and bladder. She presents with her skin intact at this time. She scored a 14 making her at risk for skin breakdown. She is morbidly obese.....and is able to help with turning in bed. Staff to keep her turned and repositioned. Keep her clean and dry. Assist with ADL (activities of daily living) care and incontinence care. CNA to observe skin with each shower and with ADL care and report any skin concerns to the nurse on duty. Nurse to monitor skin weekly and report any skin concerns to the MD. On 4/5/12 at 2:15 p.m. R34 was observed in bed in her room. R34 was alert, oriented, and verbally responsive. R34 was very poorly positioned in bed with her upper body leaning to the right side. R34's room had a very strong urine smell that permeated the room. Interview with R34 at this time noted R34 to say, "I have not been changed or repositioned since 2:30 a.m. I have not been checked for incontinence since 6:00 a.m. I was not wet then. Observation of R34's bottom bed linens showed the bed linens to be saturated with brown stained urine. R34 was asked if she had any open areas on her buttocks and she stated, "Yes." On 4/5/12 at 3:15 p.m. R34's buttocks were examined and assessed by E5 (Wound Care Nurse). When R34 was turned to her right side for pressure sore assessment R34's bottom bed linens were noted saturated with urine. R34 was observed with 4 stage II open areas; two to her left buttock, one to her coccyx, and one to her sacral area. The site to R34's sacral area measured 0.8 cm x 0.2 cm x 0.1 cm. The coccyx site measured 3.1 cm x 0.5 cm. The left buttock site measured 3.4 x 3.1 cm and the left outer buttock site measured .6 cm x 2.1 cm. All of the sites were reddened, opened, and presented with the appearance of stage II. Interview with E5 at this time noted E5 to say, " R34 already had the site to the left outer buttock which was healing but now the site has reopened and worsened. The other 3 sites are new." Documentation on the Facility Wound Investigation Report done by E5 (LPN - Wound Care Nurse) dated 4/5/12 showed documentation that these wound were avoidable with the causing factor as "Resident was left wet and unturned for a prolonged period of time." Review of R34's latest plan of care addressing skin integrity dated 1/26/12 included approaches for the CNA to: -Observe skin daily during routine ADL's and report any changes to the nurse promptly. -Bathe/shower 2 x weekly and prn. -Assist with reposition at regular intervals. -Check at regular intervals for any incontinent episode and assist with any incontinent needs promptly. -Apply barrier cream after any incontinent episode. The skin integrity plan of care included approaches for nurses to: -Assess skin condition. -Keep skin clean/dry. -Reposition/turn at least every 2 hours. -Observe skin condition for any new areas of redness and/or skin breakdown and report immediately to MD. Further interview with R34 noted R34 to say, "I want a urinary catheter put in me so I can get out of bed, heal my bottom, and be functional."

Based on observation, record review, and interview the facility failed to provide supervision to prevent injuries to five of five identified residents with falls in a total sample of 33. As a result of this failure: R5 had falls and sustained an abrasion to her elbow, bruises to her arms and legs, lacerations to her forehead and nose, and a possible fracture to her cervical spine. R20 had falls and sustained a lumbar strain and a fracture to the right hip. R7 fell and was sent to hospital with right shoulder pain. R9 fell and was sent to ER with [DIAGNOSES REDACTED]. R2 had three falls on 1/3/12 and was sent to the hospital with [DIAGNOSES REDACTED]. The findings include: 1. Review of R5's admission face sheet showed R5 is an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R5's CAA (care area assessment) addressing falls/adl's showed R5 has impaired cognition, decreased function range of motion, and in need of limited to extensive assist of 1 staff member for adl's (activities of daily living). Nursing documentation showed R5 was a high risk for falls. Review of the facility's incident tracking logs showed R5 had four falls from 9/30/11 to 2/15/12 (9/30/11, 11/29/11, 2/3/12 and 2/15/12). Three of the four falls occurred in R5's room. With two of the four falls, R5 sustained injuries. On 9/30/11 R5 fell in her room and sustained an abrasion to her elbow (which elbow not specified). On 2/3/12 at 9:45 a.m. incident report documentation showed R5 was being transported to the activity room by the activity aid when R5 stood up unexpectedly, fell to the side and hit her head. Nursing documentation showed R5 sustained a hematoma and lacerations to her forehead and nose. Nursing documentation showed R5 was sent to a nearby hospital emergency room and admitted to the hospital with [REDACTED]. R5 was admitted to the hospital from 2/3/12 to 2/7/12. Hospital history and physical dated 2/3/12 showed R5 presented crying in pain and complaining of neck pain. Hospital CT (computerized tomography) of the cervical spine at C2 dated 2/3/12 did identify R2 with a fracture of the cervical spine but the age of the fracture was indeterminate. Nursing documentation showed R5 returned to the facility on [DATE]. Nursing documentation showed the laceration to R5's forehead had been "glued" and R5 had staple sutures to the laceration on her nose. There was also documentation that R5 had bruising to her face, arms, and legs. There was no descriptive documentation of the extent of R5's injuries. Nursing documentation showed no description of the lacerations and surrounding areas such as swelling, redness, color of bruising, the number of sutures to R5's nose, whether the sutures were intact etc... There was no description of the amount of bruising, size of bruises, color of bruises etc...to R5's face, arms, and legs. In addition, the preliminary and final reports to IDPH for R5's fall on 2/3/12 had no mention of R5's cervical fracture. Review of R5's plan of care addressing falls did not include interventions for closer monitoring of R5 while in her room and there was no intervention instructing staff to have hands on contact with R5 to prevent her from standing while transferring R5 in her wheel chair. Interview with E2 (Director of Nurses) on 4/6/12 noted E2 to say R5 did fall and had lacerations to her forehead and nose. E2 did not mention the possible fracture R5 sustained or any further interventions to prevent further falls for R5. 2. Review of incident reports for R20 showed R20 had 4 falls at the facility from 2/9 to 4/1/12 (2/9, 2/14, 2/15, and 4/1/12). With two of the four falls, R20 sustained injuries. On 2/9/12, R20 fell in the hallway and complained of severe back pain. R20 was sent to a nearby hospital emergency room and was diagnosed with [REDACTED]. Review of a Fall CAA (care area assessment) for R20 dated 10/2011 showed "R20 has lower extremity weakness from an old CVA (cerebral vascular accident) and uses a rolling walker for ambulation. R20 walks slowly and has a leg brace on his left leg. He is receiving medications that have potential side effects that increase his risk for a fall." The Activities CAA dated 10/2011 showed, "Resident has a fear that others will bump into him which will make him fall." With three of the four falls, R20 fell backwards and/or complained of dizziness and fell backwards. Interview with R20 on 4/5/12 noted R20 to be confused at times and answer questions inappropriately. R20 had recently returned from the hospital where he was admitted on [DATE] with [DIAGNOSES REDACTED]." Continued interview with R20 said he needed help with ambulation with his roller walker. Interviews with E14 (LPN) and E11 (CNA) on 4/5/12 noted both to say R20 likes to stay in his room. Observation of R20's room showed R20's room to be nearly at the end of the hallway: far away from the nurses ' station. Further interview with E14 noted E14 to say, "I didn't know R20 had a fracture. No one told me he had a fracture." Review of R20's plan of care addressing falls showed to "monitor closely, when using walker." There was no time frame documented as to how often to monitor R20. There were also no interventions to place R20 closer to the nurses ' station or attempt to have R20 out of his room for closer monitoring. 3. R2is a [AGE] year-old male. The clinical record lists multiple [DIAGNOSES REDACTED]. A review of the closed record R2 sustained seven falls from the period of 12/6/11 thru 1/2/2012. Three of the falls on 1/3/2012 resulting in R2 being hospitalized with Septic shock from urinary tract infection, hypotension, dehydration and worsening renal insufficiency A review of the incidents reported dated11/1/11, R2 is found at 2:00am sitting on the floor in his room. The facility ' s Management Incident report documents R2 is more confused and the interdisciplinary (ID) team signed off. There were no interventions to address the confusion. On 12/6/2011at 2:50pm, R2 is found on floor. The incident report statesR2 was trying to dress himself and was incontinent of urine while lying in bed. The plan of care does not address the incontinence for R2. Review of the Management incident /Skin Tear/Bruise investigation form for interventions states: to circle the number for interventions and remember to start with the least restrictive intervention. This section is not complete. The incident dated 12/14/11, at5:30pm., R2 attempted to get up from bed per self and fell . The report documents R2 has been anxious /agitated recently related to issue with his foot and pain. The intervention identified is to provide a low bed. The anxiety, agitation and pain are not address by the ID team. The incident dated12/14/11, R2 was found on the floor lying on right arm with only pull-ups on no time given. Incident not identified on log report. No evaluation of the fall is available. The incident dated 12/14/2011, a post interview report states R2 fell 15 minutes after he returned from the hospital. No time is given. This fall is not identified in the incident log report. No investigation is available for this fall. On 1/2/2012, R2 sustained three falls resulting in R2 being sent out to the hospital The 1/2/2012 report documents at 1:40am, R2 fell in front of his closet. R2 is anxious and incontinent. Then at 2:20pm, staff yells from hallway, " He fell again. " R2 is found lying on the floor and has a laceration to the occipital lobe of head. R2 is irritable and anxious. At2:45pm, R2 is found in his room on the floor. A review of a corrected charting that is not kept as part of R2 ' s clinical record. The charting is changed and the 1/2/2012 incidents are recorded for 1/4/2012. A 1/2/2012 notation that was " discontinued " the nurse documents R2 fell at 2:50pm. When the nurse was informed, she saw R2 sit back in wheelchair. R2 was cussing and very irritable. R2 was given Xanax 25mg. The nurse informed the restorative nurse and sent the restorative aide to grab a floor mats. The nurse charts that as she was making a call toR2 ' s family R2 fell again. R2 is noted with a hematoma and laceration to occipital lobe of his head. R2 complained his head hurt and toes hurt. And sent R2to the hospital. This information was discontinued and re-charted on 1/4/2012 leaving out the second fall. Interview with (E1) administrator and (E3) Assistant Director of nursing about the investigation s of R2 ' s falls and his change of mental status, They said they could not find recommendations of the Quality Assurance meeting addressing R2 falling. 4). R9 has [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], assessed the resident as having short and long term memory problems, as moderately impaired cognitive skills for daily decision making (poor decisions and supervision required). R9 was assessed as totally dependent in and was nonambulatory. The MDS also assessed the resident as having functional limitations in range motion in bilateral upper and lower extremities and required a wheelchair for mobility and as incontinent of bowel and bladder. Section I: Active [DIAGNOSES REDACTED]. After this R9 fell twice on 10/16/11 and 10/21/11. The bed was lowered , floor mats placed and bed bolsters were initiated as interventions. On 1/10/12 at R9 is documented alert but confused and spending most of the day wandering halls in her wheelchair occasionally wandering into other resident rooms. At 7:38PM R9 rolled her wheelchair into a hallway wall. The only interventions implemented post fall were "Monitor and chart on resident for 72 hr" and the bed was lowered a floor mat was added and call light put into reach. As a result of the fall a Fall Care Plan was initiated. One of the interventions listed was to implement fall precaution procedures as per facility protocol. The facility failed to evaluate and effectively implement or revise R9's care plan after each fall when it became apparent the interventions were not effective. For example when R9 fell out of the wheelchair on 1/14/12,the facility implemented a bed alarm and floor mat, but failed to assess for the need to use measures to keep the resident in the chair. On 2/20/12 at 8:00AM R9 fell out of the wheelchair while in the hall. Staff documented "Heard a noise and resident had fallen forward out of her wheelchair onto floor...resident is nonverbal, last time seen was 7:45AM in wheelchair around nurses station". R9 continued to be assessed as confused at all times. The fall investigation indicated that the resident was not aware of safety needs, but no restraints or safety devices were in place to prevent falls. The only intervention initiated after this fall was the placement of a Sensi pad to the wheelchair. After the fall of 2/20/12 R9 was transferred to the hospital for evaluation. When the paramedics arrived at the facility staff informed them that staff had seen the resident fall out of the wheelchair, break her fall with her hands and hit her head. paramedics secured R9's head with a headroll and tape and secured the resident to a backboard prior to transport to the hospital. The Clinical Finding/Assessment was identified as " Fall/ W/C (Wheelchair) Hematoma FH (forehead)". The 2/20/12 hospital emergency room Record for R9 assessed the resident as having had a fall with a closed head injury (CHI). The resident had a cervical collar and a bruise to the upper mid forehead. A Cat Scan (CT) of the head and neck was done and showed no hemorrhage or fracture. The resident was transferred back to the facility. The facility's Fall Prevention Program does not address interventions to be initiated when a resident falls and doesn't address the evaluation of interventions in place when a resident does fall. 5). R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as severely impaired in cognitive skills for daily decision making as well as being inattentive, confused and having disorganized thinking. R7 was also assessed as in need of extensive assistance with transfers, dressing hygiene and bathing. R7 was assessed as at risk for falls. R7 is documented as having fallen 11 times on: 3/20/11, the day after admission, 8/2011, 9/2011 10/15/11 11/17/11, 12/25/11, 12/27/11 ,12/29/11, 1/2/12, 1/21/12, 3/3/12 and 3/5/12. On 7/31/11 R7 was observed to drink liquid soap. On 7/31/11 after drinking the soap, R7 was sent to the hospital for evaluation. After the fall of 10/15/11, R7 was sent to the hospital with complaints of right shoulder pain. The fall of 1/2/12 resulted in the resident having a bruise and redness on the left temple. On 12/4/11 the resident was noted to have a skin tear on the left lower leg. R7's care plan instructs staff to initiate fall interventions after falls. This was done, but staff failed to evaluate and change those interventions when it became obvious that they were ineffective. Based on observation, record review, and interview the facility failed to provide supervision to prevent injuries to 6 of 6 identified residents with falls in a total sample of 33. As a result of this failure: R5 had falls and sustained an abrasion to her elbow, bruises to her arms and legs, lacerations to her forehead and nose, and a possible fracture to her cervical spine. R20 had falls and sustained a lumbar strain and a fracture to the right hip. R8 fell and sustained a fracture to the right tibia. R7 fell and was sent to hospital with right shoulder pain. R9 fell and was sent to ER with [DIAGNOSES REDACTED]. R2 had 3 falls on 1/3/12 and was sent to the hospital with [DIAGNOSES REDACTED]. The findings include: 1. Review of R5's admission face sheet showed R5 is an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R5's CAA (care area assessment) addressing falls/adl's showed R5 has impaired cognition, decreased function range of motion, and in need of limited to extensive assist of 1 staff member for adl's (activities of daily living). Nursing documentation showed R5 was a high risk for falls. Review of the facility's incident tracking logs showed R5 had 4 falls from 9/30/11 to 2/15/12 (9/30/11, 11/29/11, 2/3/12 and 2/15/12). Three of the 4 falls occurred in R5's room. With 2 of the 4 falls R5 sustained injuries. On 9/30/11 R5 fell in her room and sustained an abrasion to her elbow (which elbow not specified). On 2/3/12 at 9:45 a.m. incident report documentation showed R5 was being transported to the activity room by the activity aid when R5 stood up unexpectedly, fell to the side and hit her head. Nursing documentation showed R5 sustained a hematoma and lacerations to her forehead and nose. Nursing documentation showed R5 was sent to a nearby hospital emergency room and admitted to the hospital with [REDACTED]. R5 was admitted to the hospital from 2/3/12 to 2/7/12. Hospital history and physical dated 2/3/12 showed R5 presented crying in pain and complaining of neck pain. Hospital CT (computerized tomography) of the cervical spine at C2 dated 2/3/12 did identify R2 with a fracture of the cervical spine but the age of the fracture was indeterminate. Nursing documentation showed R5 returned to the facility on [DATE]. Nursing documentation showed the laceration to R5's forehead had been "glued" and R5 had staple sutures to the laceration on her nose. There was also documentation that R5 had bruising to her face, arms, and legs. There was no descriptive documentation of the extent of R5's injuries. Nursing documentation showed no description of the lacerations and surrounding areas such as swelling, redness, color of bruising, the number of sutures to R5's nose, whether the sutures were intact etc... There was no description of the amount of bruising, size of bruises, color of bruises etc...to R5's face, arms, and legs. In addition, the preliminary and final reports to IDPH for R5's fall on 2/3/12 had no mention of R5's cervical fracture. Review of R5's plan of care addressing falls did not include interventions for closer monitoring of R5 while in her room and there was no intervention instructing staff to have hands on contact with R5 to prevent her from standing while transferring R5 in her wheel chair. Interview with E2 (Director of Nurses) on 4/6/12 noted E2 to say R5 did fall and had lacerations to her forehead and nose. E2 did not mention the possible fracture R5 sustained or any further interventions to prevent further falls for R5. 2. Review of incident reports for R20 showed R20 had 4 falls at the facility from 2/9 to 4/1/12 (2/9, 2/14, 2/15, and 4/1/12). With 2 of the 4 falls, R20 sustained injuries. On 2/9/12 R20 fell in the hallway and complained of severe back pain. R20 was sent to a nearby hospital emergency room and was diagnosed with [REDACTED]. Review of a Fall CAA (care area assessment) for R20 dated 10/2011 showed "R20 has lower extremity weakness from an old CVA (cerebral vascular accident) and uses a rolling walker for ambulation. R20 walks slowly and has a leg brace on his left leg. He is receiving medications that have potential side effects that increase his risk for a fall." The Activities CAA dated 10/2011 showed, "Resident has a fear that others will bump into him which will make him fall." With 3 of the 4 falls R20 either fell backwards and/or complained of dizziness and fell backwards. Interview with R20 on 4/5/12 noted R20 to be confused at times and answer questions inappropriately. R20 had recently returned from the hospital where he was admitted on [DATE] with [DIAGNOSES REDACTED]." Continued interview with R20 noted R20 to say he needed help with ambulation with his roller walker. Interviews with E14 (LPN) and E11(CNA) on 4/5/12 noted both to say R20 likes to stay in his room. Observation of R20's room showed R20's room to be nearly at the end of the hallway; far away from the nurses station. Further interview with E14 noted E14 to say, "I didn't know R20 had a fracture. No one told me he had a fracture." Review of R20's plan of care addressing falls showed to "monitor closely, when using walker." There was no time frame documented as to how often to monitor R20. There was also no interventions to place R20 closer to the nurses station or attempt to have R20 out of his room for closer monitoring.

Surveyor: Lilibeth Lazaro-Camp Based on interview and record review the facility failed to honor resident's (R 1) wish for Do Not Resuscitate (DNR). (2) Failed to follow facility policy and procedure to document the DNR order/status on the physician order [REDACTED]. This was for five (R 1, R4, R5, R6 and R 7 ) of five residents with DNR status. These failures resulted in R 1 being resuscitated against her wishes in the hospital on [DATE] and expired on the same day. Findings include: (1) R1's Uniform Do- Not- Resuscitate (DNR) Advance Directive form, signed by the Health Care Power of Attorney and R 1's attending physician dated [DATE] was found in R 1's clinical record. This form showed: in an event of: (1) FULL CARDIOPULMONARY ARREST (When both breathing and heartbeat stop): Do Not Attempt Cardiopulmonary Resuscitation (CPR) (2) PRE- ARREST EMERGENCY (When breathing is labored or stopped, and heart is still beating): Do Not Attempt Cardiopulmonary Resuscitation (CPR). The facility Do Not Resuscitate policy and procedure reads: #2 A valid DNR order shall be written on the POS (Physician order [REDACTED]. #4. When faced with the possible DNR situation: (e) attach a copy of the DNR order to the transfer order, should the physician order [REDACTED]. Facility personnel will be oriented to the provisions of this policy upon hire and at least annually. R 1's code status (DNR) was not written on R 1's POS and this was confirmed by the DON (Director of Nursing)/E2 on [DATE] at 11:05 AM. E 2 also stated, " the nurse didn't copy the DNR form, so it was not sent during the transfer. She was disciplined with that. " Review of the nurse (E 4) employee report dated [DATE] reads: staff nurse failed to send copy of current DNR with resident (R 1) to the hospital ... On [DATE] at 9:50 AM via phone interview with Z1 disclosed " her ( R 1's) family was very upset and said they put her mother in so much more suffering because the most important documentation was not sent with her during the transfer (to the hospital). " Z1 stated R 1 expired the same day at night time. Review of senior services documentation from the hospital dated [DATE] showed: R 1 -has [MEDICAL CONDITION] that was almost completely clogged and was admitted into the hospital because she was unable to breathe. Although the facility had copy of her (R 1) DNR, they (facility) had neglected to send it along with her in the hospital, so they (hospital staff ) were forced to resuscitate her (R 1) ... (2) A DNR list was presented on [DATE]. The list include R 4, R 5, R 6 and R 7. Review of their clinical records showed R 4, R 5, R 6 and R 7 have Uniform Do- Not- Resuscitate (DNR) Advance Directive form signed by the Health Care Power of Attorney and their attending doctors, but this information was not documented in the physician order [REDACTED]. On [DATE] at 1:45 PM, the nurses/ E 5 and E 6 stated "we are not aware that we need to write it on the POS."

Based on interview and record review the facility failed to provide a written notice of transfer or discharge to a resident for which the facility feels they could no longer meet her needs. This is for one (R 3) of four residents in the sample. This failure resulted in R3's emotional and psychosocial harm. R3's started to exhibit behavioral changes as evidenced by being very upset, unable to sleep at night and crying. R 3 was admitted to the hospital on 11-18-11 for suicidal ideation. Findings include: R3's resident information sheet showed R3 was admitted to the facility on [DATE] and was discharged on [DATE] to another nursing home. On 11-17-11 at 10:00 AM, the Administrator/E 1 stated R 3 " was discharged to our sister facility. We cannot meet her needs here. There's no programming we can provide and get for her. No, we didn't give her a written 30 days notice. " At 1:45 PM, the Social Service Director/E 3 confirmed the facility had not issued R 3 a written notice for transfer or discharge. E 3 stated " I talked with her (R 3) and explained to her we can't keep her here. We can't get any programming for her. No one wants to accept her. She wanted to move to a nursing home where she was before but they would not accept her back. " This nursing home was called and I spoke with the Admission Director (Z 5 claimed " the facility didn't call me. It's the patient's family from Florida that called me inquiring if we can take her back. " On 11-23-11 at 12:05 PM, R 3's sister/Z 2 stated, " she was very- very shocked with the transfer. She doesn't want to be transferred. She had been in that nursing home for a long time (2005). They transferred her to another nursing home she didn't like to go. She was doing so well in that nursing home, no behavior problem. She was very- very good for a long time until now. She was very upset, unable to sleep at night and crying on the phone all the time. They transferred her again to another nursing home closer to us on 11-10-11 but she remains upset. She had a breakdown. The transfer just rattled her and she tried to commit suicide. She is now in the hospital." The ADON (assistant Director of Nursing) at R3's current nursing home stated on 11-23-11 at 1:30 PM R 3 was discharged to the hospital for suicidal ideation, asking staff for their gait belt so she can hang herself. At 1:45 PM, the hospital social worker (Z 4) stated the patient (R 3) was in the hospital's Psych Unit for behavior monitoring/ suicidal ideation. On 11-18-11 at 10:30 AM, E 1 stated " we ' re trying to be SMI (serious mental illness) free we got five to six more residents left. "

Based on interview and record review the facility failed to obtain a consent prior to administration of antipsychotic medication for one ( R 2) of four residents in the sample. The facility also failed to provide a medical justification or indication for the use of this medication, monitor for presence of adverse consequences /side effect and to develop a plan for gradual dose reduction. These failures resulted in R 2's admission to the hospital on 11-07-11 with [DIAGNOSES REDACTED]. Findings Include: R 2's nurse's notes for the month of October 2011 ([DATE], 5, 6, 9, 10, 17 and 19) showed R 2's alert and oriented, cooperative and quiet until 10-21-11. The facility preliminary 24 hour incident investigation report reads: 10-21-11 approximately 6-6:30 PM, Ist floor dining room R 2 became physically aggressive with another resident and put the resident in a " head lock. " On 11-17-11 at 2:20 PM, the ADON (Assistant Director of Nursing)/E 7 said " there were two residents who were having a verbal altercation. R 2 didn't like what the other patient said to the other guy. R 2 went to the other resident and put the resident in head lock. " When E 7 was asked what was the facility intervention that was implemented E 7 stated " we separated them. The two patients having the altercation were sent back to second floor. We sent R 2 to the hospital but was sent back right away. " E 7 confirmed there were no orders from the hospital so the facility staff called R 2's attending physician and obtained an order for [REDACTED]." R 2 ' s October 2011 MAR (Medication Administration Record) showed R 2 was given an antipsychotic medication, [MEDICATION NAME] 0.5 mg, twice a day, from 10-21-11 thru 10-30-11(10 days). There was no indication for the use of this medication, no consent, no monitoring for the possible adverse side effects and no plan of care developed for the use of the antipsychotic medication or plan for gradual dose reduction. These findings were confirmed by the DON (Director of Nursing) on 11-17-11 at 1:00 PM. Hospital transfer form (page 2 of 2) showed: reason for admission- altered mental status, allergies [REDACTED]. Review of [MEDICATION NAME] indication and side effects thru Midline Plus (U.S. National Library of Medicine thru the Internet) reads: (1) Background [MEDICATION NAME] ([MEDICATION NAME]) is an antipsychotic medication used to treat mental illnesses including [MEDICAL CONDITIONS] disorder, and irritability associated with autistic disorder. (2) IMPORTANT WARNING: Studies have shown that older adults with Dementia ( a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics such as [MEDICATION NAME] have increased risk for death during treatment. R 2 has a [DIAGNOSES REDACTED].? Drowsiness, dizziness, diarrhea, stomach pain, vision problem. Some side effects can be serious. If you experience any of the following symptoms or those listed call your doctor immediately.

Based on observation, interview and record review, the facility failed to: (1 ) Identify the indications for use or administration of anti psychotic medications for two (R 45 and R 48) of 9 residents in the sample. (2 ) Obtain consent prior to administration of antipsychotic medication ([MEDICATION NAME]) to one (R 45) of 9 residents in the sample. (3 ) Document the clinical rationale for the benefit of, or necessity for, the use of multiple anti depressant medications for one resident (R 48) of 9 residents in the sample. (4 ) Monitor the effects & potential adverse consequence of the medication regimen for two of (R 48 and R 45) nine residents in the sample. Findings include: (1) Review of R 48's most current Physician order [REDACTED]. On 12-15-11 at 1:05 PM, R 48 stated " I don't know why they're giving me antipsychotic or anti depressant. I didn't' even know I'm taking those medications. I'm not crazy or depressed. I get mad once in a while because they will not give me my pain medication. " On 12-15-11 at 1:50 PM, the Nurse E 13 stated " he's alert and oriented times three. He can verbalize his needs. He doesn't have any behavior problem. He's not inappropriate, very pleasant and appropriate all the time. I'm not sure why he's on antipsychotic or antidepressant. " Review of R 48's showed no indication for the use of these multiple (three) antidepressant and the use of the antipsychotic for R 48. There's no behavior monitoring sheet or assessment that was conducted and that the possible side effects were monitored. Review of R 48's nurse's notes showed R 48 had an incident of fall on 12-14-11 and 11-22-11. (2) R 45 physician order [REDACTED]. The only consent found in R 45 's clinical record was dated 12-15-11; the medication was administered since 10-23-11. The behavior notes were presented by E 2 on 12-16-11 at 11:00 AM and showed the facility had documentation of R 45's behavior only from 10-05-11 thru 10-19-11. This documentation showed R 45's mostly " quiet " except on two occasions, on 10-05-11 and on 10-16-11: where R 45 was " combative " . There were no documentation's found in R 45 ' s clinical record that the facility evaluated the cause of R 45 ' s behavior or implemented non pharmacological interventions. On 10-19-11 at 1:29 PM behavior notes reads: resident (R 45) up in chair with lap restraint in place for most of shift. Resident did well at first and then, began to start fidgeting and move the restraint. PRN (as needed) [MEDICATION NAME] (an anti anxiety medication) given per Medication Administration Record [REDACTED] On 12-15-11 at 1:05 PM, the Care Plan Coordinator/E 12 stated " I don't believe he displays any behavior. He's on hospice care. " This statement was confirmed by the Nurse/ E 10 at 1:10 PM. These findings were discussed with the Director of Nursing/E 2 on 12-16-11 at 3:20 PM, E 2 stated " the psychiatrist was here today, since there ' s no behavior problem he (psychiatrist) discontinue the use of [MEDICATION NAME] and the [MEDICATION NAME]. " E 2 claimed that the Assistant Director of Nursing monitors the [MEDICAL CONDITION] medications but she was fired so the nurses are now in charge with it. The Psychiatrist documented on 12-16-11: on hospice, exhibiting no behavior, no [MEDICAL CONDITION], no depressed mood, no anxiety, no SI (serious mental illness).

Based on observation, record review, and interview the facility failed to: 1. Provide supervision to residents to prevent falls, serious injuries, and/or fractures. This occurred for 4 of 24 sampled resident (R10,R17,R19 and R20) and 4 residents in the supplemental sample. ( R26, R86, R138, R91). 2. Provide supervision and develop effective interventions to prevent residents in the sample with tracheostomies from consistently extuba- ting themselves. (R10 and R19). 3. Develop, implement, and maintain a system to track residents' falls, failed to identify the circumstances why falls occurred, and failed to analyze patterns and trends of falls and incidents occurring at the facility. As a result of these failures: 1. R26 had 3 falls from 7/25 to 8/8/11 and sustained a fracture to his lumbar spine. 2. R86 had 2 falls on 7/10 and 8/14/11 and sustained a closed head injury and fracture to the left shoulder. 3. R138 had a fall on 8/27/11 and sustained a fracture to the left hip. 4. R91 was injured while being transferred to bed and on 8/4/11 hospital documentation showed R91 had sustained a torn meniscus and fracture to the left knee. 5. R20 had several falls and incidents and sustained a bruise to his back. 6. R10 was noted to have extubated himself 13 times from 7/13 to 9/19/11. 7. R19 was noted to have extubated himself 3 times from 7/18 to 8/2/11. 8. R17 fell twice within two days of admission to the facility, hit her head on the second day of admission and was admitted to an area hospital, to the Intensive Care Unit with [DIAGNOSES REDACTED]. The findings include: 1. Review of R26's admission face sheet showed R26 has [DIAGNOSES REDACTED]. Nursing documentation showed R26 had history of falls. During review of the facility's incident reports R26 was noted with 3 incidents/falls from 7/25/11 to 8/8/11. Incident documentation showed on 7/25/11 at 9:40 a.m. R26 attempted to transfer himself from the toilet back into his wheel chair and fell . Incident documentation showed R26 started complaining of severe back pain on 7/27/11 and was sent to a nearby hospital for evaluation. R27 was admitted to the hospital with [REDACTED]. Review of CT (computerized tomography) from the hospital dated 7/27/11 showed the following: R26 had a "moderate to marked compression fracture of the L1 vertebral body which does have a diffuse increased density. This may be possibly subacute in nature. There is, however a question of some mild paraspinal soft tissue edema at this level which could have a recent component associated with it There is a faint line projected through the right-sided posterior margin of the L1 vertebral body with the pedicle consistent with a non displaced fracture line at this level. " The CT scan also showed R26 "had slight wedging of the L2 and mild loss of height of the L3 vertebral body with mild impressions noted in the endplates at L4 and L5. Varying degrees of disc space narrowing noted, most pronounced at L5-S1." R26 was readmitted to the facility on [DATE]. Nursing documentation showed R26 complained of moderate pain during therapies and during care. Nursing documentation also showed R26 MUST WEAR BACK BRACE WHEN UP. Review of R26's plan of care for falls presented with the incident follow up report showed no intervention for R26 to wear his back brace. The follow up report notes, "Facility will continue to monitor and provide safety according to Plan of Care." Nursing documentation and incident documentation showed R26 had a fall in his room on 8/6/11 and a fall in the bathroom on 8/8/11. Documentation for the fall of 8/8/11 showed R26 put himself on the toilet, fell back against the toilet tank completely breaking the tank. R26 was sent back to the hospital for x-rays and admitted to to the hospital with [DIAGNOSES REDACTED]. R26 was readmitted to the facility again on 8/11/11. Observation of R26 9/23/11 at 10:20 a.m. noted R26 to be sitting in his electric wheel chair in the second floor dining room. R26 was noted with a Velcro wrap back support in place. Interview with R26 at this time noted R26 to say, "I think that I fell out of bed when I fractured my back. The second time when I fell and had to go to the hospital I was trying to go to the bathroom. I don't remember what happened." As mentioned above; review of R26's plan of care addressing falls showed no intervention which included wearing a back brace. There was no description of R26's back brace and no instructions on how the brace is to be applied. The fall plan of care showed no intervention for more frequent observation of R26 in an attempt to try to prevent further falls/injuries. The fall plan of care showed an intervention that R26's room should be moved closer to the nurses station. R26's room was observed to be approximately half way down the hallway where he resides. 2. Review of incident reports for R86 showed on 7/10/11 R86 was in the bathroom, got dizzy, fell , and hit his head on the toilet. R86 was sent to a nearby hospital where he was admitted with [DIAGNOSES REDACTED]. Nursing documentation showed R86 experienced pain "if he tried to walk." Further nursing documentation showed R86 had NO HISTORY OF FALLS (PAST 3 MONTHS) even though R86 had fallen on 7/10/11 (approximately 3 weeks prior) and sustained a closed head injury. Further review of incident reports showed on 8/14/11 at 2:30 PM R86 reported he had fallen in his room while transferring back to bed. R86 complained of pain to the left shoulder. Stat x-rays were taken of R86's left shoulder with results which showed "Non displaced fracture of the greater tuberosity and suspicious fracture of the neck of the left humerus." R86 was admitted to the hospital with [REDACTED]. R86's plan of care addressing falls includes "monitor for any evidence of hypotension." 3. Review of R138's closed record and incident report dated 8/27/11 showed conflicting information on the incident report and nurses notes. The incident report dated 8/27/11 showed time of occurrence at 11:00 p.m. and noted during rounds the nurse found R138 on the floor. Review of nursing note documentation showed on 8/27/11 at 5:15 p.m. R138 fell in his room while transferring to a chair. Nursing documentation showed NO APPARENT INJURY even though skin tears were documented and x-ray of the left hip and femur were ordered. Initial facility x-rays of the left hip and femur were negative. Facility incident report goes on to note R138 saw an outside physician on 9/2/11 and was found to have a hairline fracture of the greater trochanter. Review of a hospital x-ray dated 8/30/11 showed R138 was identified with a left hip fracture on 8/30/11 not 9/2/11. The hospital x-ray showed "There appears to be fragmentation and slight linear lucencies extending through the greater trochanteric of the left femur. Configuration raises the possibility of cortical fractures about the greater trochanter left femur." Further review of nursing documentation for R138 showed on 8/26/11 at 11:00 p.m. R138 fell in his room while transferring to bed. At this time R138's blood pressure was noted at 94/66. On 8/27/11 at the time of R138's fall his blood pressure was documented at 100/58. No plan of care was presented to address R138's hypotension and prevention of falls. 4. Review of an incident report for R91 and interview with E2 (Director of Nurses) showed conflicting information. Incident report review showed R91 had an incident (date unknown) while being transferred to bed R91's knee was hit on the bed frame. Incident documentation showed R91 stated this happened one week before she was hosptalized on [DATE]. Review of the incident follow-up report dated 8/17/11 showed R91 returned to the facility on [DATE], had follow up appointment in 1 week with ortho, and had no change in functional status. On 9/22/11 at approximately 2:30 p.m. E2 (Director of Nurses) was questioned regarding the incident with R91 bumping her knee while being transferred to bed. E2 stated R91 went to the hospital for a medical problem and they checked her knee there. E2 stated, "R91 didn't have any fracture, she had an effusion." On 9/23/11 at 11:00 a.m. R91 was observed receiving dialysis in the facility's dialysis unit. R91 was alert and verbally responsive. During interview with R91 at this time about the incident with bumping her knee R91 started, "I have an electric wheel chair. When the CNA was putting me to bed she didn't turn off the wheel chair. It got away from her and it jumped and my knee hit the bed rail. It hurt bad. They did x-rays at the hospital but the MRI showed I had a hairline fracture and something else wrong with my knee." R91's MRI results were requested and reviewed. R91's MRI results were dated 8/8/11. Review of the results showed documentation of the following injury: Impression: 1. Tear in the posterior horn and body of the lateral meniscus. 2. Nondisplaced fracture within the lateral tibial plateau which extends to tibial spine and visualized proximal tibial shaft. The most distal aspect of the fracture component is beyond the border of these images. In addition, there is about a 2 mm impaction of the fracture along the anterior aspect of the lateral tibial plateau. During interview with R91, R91 stated, "My knee still hurts sometimes and I still have to take pain pills for the pain." Review of R91's plan of care showed no interventions regarding instructions on operating R91's wheel chair when transferring R91 to and from the wheel chair. E2 also did not note that staff had been inserviced/trained on operating R91's wheel chair to prevent further accidents. 5. Review of incident reports for R20 showed R20 had 7 falls from 4/14/11 to 9/21/11. During most of R20's falls there is documentation that R20 is in his recliner chair in his room and is found on the floor. With one fall R20 is noted with bruising on his back. Confidential interview on 9/22/11 notes that R20 is usually put in his recliner chair with the feet elevated so "he can't get up." Also noted with R20's falls his blood pressures vastly fluctuates from 115/59 to 161/115. Review of R20's plan of care shows no follow up in evaluating R20's blood pressure fluctuations in an attempt to determine R20's falls. The plan of care also does not address positioning of R10 in his recliner chair or other interventions to prevent R20 from falling out of his recliner chair. 6. Observation of R10 on 9/22/10 at 10:20 a.m. noted R10 to be resting in bed. R10 was observed with a tracheostomy in place connected to a trach cuff and oxygen at 5L/min. R10 was in contact isolation for MRSA (methicillin resistant staph aureus). R10 also had a gastrostomy tube, and an indwelling catheter. Nursing documentation dated 7/22/11 on the CAA's (care area assessments) showed R10 has history of depression and has voiced suicidal thoughts. Review of nursing documentation from 7/13 to 9/19/11 showed R10 had pulled his tracheostomy tube out 13 times. During some of the times R10 had extubated himself, he had also pulled out and/or pulled on his gastrostomy tube and indwelling catheter. R10 was observed to be wearing hand mitts on 9/22/10. Review of R10's plan of care showed interventions that R10 had hand mitts ordered at times and wrist restraints ordered at other times. On 8/18 and 8/22/11 R10 also had an intervention for R10 to be monitored every 30 minutes. Review of nurses notes showed R10 had extubated himself 6 times after the intervention was developed to monitor him every 30 minutes. No other successful interventions were addressed/developed to prevent R10 from pulling on his tracheostomy to prevent him from extubating himself or from pulling on his gastrostomy tube and indwelling catheter. During interviews with E1 (Administrator) and E2 (Director of Nurses) on 9/23/11 both admitted that the facility does not keep a tracking log to track individual resident's falls/incidents. Both admitted the facility has no Fall Committee to address resident falls and both admitted no one is analyzing or identifying the circumstances for why the falls are occurring. The facility is not identifying whether there are fall patterns and/or trends of resident falls and incidents. E1 and E2 did present Incident/Accident Report Summaries for July and August 2011. These reports showed numbers and data collection but no individual analysis or summary of conclusion to identify an individual decrease in falls/incidents for any resident. Further review of these summaries showed they were not accurate/complete. The July 2011 summary sheet included a section identifying "Residents involved in more than one (1) incident this month." This section had initials of residents who had more than 1 incident in July. R20 had 2 documented falls in July. R20's initials were not included on this summary sheet. 7. Review of R19 Admission Face Sheet document R19 is a [AGE] year old male with [DIAGNOSES REDACTED]. Review of R19's Nursing Notes documented that R19 pulled out his tracheostomy tube several times. The nursing notes document the the following: 7/18/2011 6:35 PM Alert, oriented to time... person... to place... staff assist needed... pulls at tubes at time...has difficulty making decision in new situation. 6:44 PM Level of Consciousness/Mental Status Intermittent Confusion, chair bound, legally Bind... 9:30 PM Called to resident's room, has pulled out trach tube. Reinserted... small amount of bleeding noted." 7/19/2011 12:35 PM Decreased range of motion. Decline in muscle strength. Resident restrained for: behavioral symptoms: trying to pull out tracheostomy tube. Restraint prevented behavior from occurring. Contributing problems: confusion... Use bilateral mitts at all times... Resident has a life threatening condition..." 7/21/2011 11:11 PM Pulled out trach from site... Interventions: transferred to emergency room ..." 7/27/2011 12:05 AM... Trach out... Resident room...Resident in bed" R19's Nursing Notes also documented that R19 had 7 falls between 7/18/2011 to 8/25/2011. The nursing notes documented that R19 fell on the following days: 7/18/2011, 7/21/2011, 7/27/2011, 7/31/2011, 8/02/2011, 8/17/201, 8/21/2011, 8/22/2011 and 8/25/2011. The facility incident report that documented R19 pulling out his trach and falling on 7/21/2011 was reviewed. This was after R19 demonstrated he was confused and had exhibited the behavior of pulling out his tracheostomy tube. Staff interviews documented that they walked into R19's room around 7 PM and noticed R19's trach was out. Staff stated R19 could remove his mitts. Also, all staff interviewed noted that they last observed R19 approximately an hour ago (5:30 PM or 6:15 PM). This indicated R19 was not being closely monitored for the behavior of extubating himself. On 9/22/2011 at 10 AM, E9 (nurse) was accompanied to R19's room to observe what interventions were in place to prevent R19 from falling. E9 stated that R19 was at risk for falls. E9 also stated R19 had mats on the floor, boosters in the bed, and chair and bed alarms to prevent him from falling. However; R19 was observed in his wheel chair, sitting alone in his room, with no chair alarm attached. When asked about the absence of the chair alarm, E9 stated R19 should have one. R19 stated he did not need the chair alarm. The CNA for R19 entered the room. When asked about the absence of R19's chair alarm, the CNA stated, "R19 told me not to put it (chair alarm) on." This showed the nursing interventions identified to prevent R19 from falling were not being consistently implemented. E21 (nurse) was identified as taking care of R19 on 7/21/2011, when R19 pulled out his tracheostomy tube. E21 was interviewed on 9/27/2011 at 11:39 AM. When asked, E21 stated R19 has removed his tracheostomy "a couple of times". E21 also stated, "R19 did not want it in and he pulled it out. We've had to put his trach tube back in before. A couple of times, we sent him out to the hospital to get it back in." E22 (nurse) was identified as caring for R19 on 7/27/2011, when he removed his tracheostomy tube. E22 was interviewed on 7/27/2011 at 11 AM. E22 stated, "I went in there and it was out. At times he could get his mitts off. I just remember I went in there and it was out. I think there's been a few times he went to the hospital because it could not be reinserted". Review of R19's plan of care addressing R19's tracheostomy showed there was no consistent and effective interventions in place to prevent R19 from pulling his trach tube out (extubating himself) to prevent bleeding and irritation to the trach tube site. 8. R17's closed record was reviewed. R17's admission face sheet showed R17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R17 was admitted to this facility from another area nursing facility. The transferring facility sent background information about R17's illness and the course of care that R17 had received at the prior facility. Information sent with R17 from the previous nursing facility clearly documents R17's dementia, inability to follow commands, poor cognition, confusion and disorientation, Cerebral Vascular Accident (CVA), and Muscular Disuse Atrophy. E17 Certified Nursing Assistant (CNA) had been assigned to provide care to R17 during R17's short stay at the facility. E17 described R17 as "very confused and disoriented with a contracted left leg." "R17 was not ambulatory and needed a mechanical lift to transfer." Review of nurses notes and facility incident reports showed on 9/2/11 at 11:43PM, (the day after R17 was admitted to this facility), "R17 was found on the floor. R17's mental status [REDACTED]. On 9/3/11 R17 was found on the floor again. On this date E17 (CNA) found R17 on the floor. According to E17 on 9/3/11 while doing rounds E17 walked into R17's room and found the resident on the floor with the wheelchair behind her. R17's legs were underneath the wheelchair. R17 was not unconscious, but was not responsive to verbal stimuli. E17 returned the resident to bed. R17 would squeeze E17's hand and look at her, but not talk. E17 stated, "This is a change in mental status from the day of R17's admission." When found on the floor R17 was bleeding from her forehead. E17 stated she never observed R17 in the wheelchair. E17 stated, "On 9/1/11 R17 stayed in bed until therapy could assess her. On 9/2/11 I was off work and on 9/3/11 I found R17 on the floor." E17 continued to say when R17 was first admitted they (CNA's) were told R17 was confused and to "watch her" and to keep an eye on her. E17 stated that CNAs get report on residents, then they do rounds. E17 stated, "There was not any special information provided on R17 other than the fact that R17 was up in the chair." E18 (nurse) also cared for R17 during her stay. E18 stated she worked 6:30AM to 3:00PM on the day that R17 was found on the floor (9/3/11) . E18 also described R17 as having contracted bilateral knees and totally dependent for mobility. Regarding R17's mental status, E18 stated R17 would only look at her, nothing more. E18 stated, "On 9/3/11 R17 was not very alert in the morning but was more alert in the afternoon. R17's son came to visit at 2:30PM and brought R17 lunch. The son was surprised at the level of R17's alertness. R17 was sitting in the wheelchair." E18 stated R17 was cognitively and physically unable to propel herself in the wheelchair and wasn't ambulatory at all. E18 stated she had just finished report when she heard E17 say that R17 was on the floor. When E18 saw R17, R17 was laying face down on the floor bleeding from the middle of her forehead. R17 was nonverbal and looking around aimlessly. CNAs got the mechanical lift to return R17 to bed. Facility nurses notes and fall assessment both assess R17 as having difficulty walking and with poor balance. The nurses notes and fall assessment also showed R17 as having both short and long term memory problems, severely limited ability to walk, unable to bear weight or communicate, being immobile, and with a wheelchair as the primary mode of locomotion. Facility staff also assessed R17 in need on one staff to transfer. The initial fall care plan for R17 was initiated 9/1/11 and assessed R17 as high risk for falls. The listed interventions included instructions to: 1. Ask for assistance prior to attempting to transfer or walk. 2. To place the call light within easy reach 3. Encourage R17 to use the call light prior to attempting to walk or transfer. These interventions were not realistic, but were implemented even though the facility's own staff had assessed R17 as as having difficulty walking and with poor balance, as having both short and long term memory problems, as having severely limited ability to walk, not being unable to bear weight or communicate, being immobile, and with a wheelchair as the primary mode of locomotion. R17 was also in need on one staff to transfer. Further review of R17's incident report for 9/3/11 showed at 3:35 p.m. R17 was found on the floor with a laceration (no area specified). Incident documentation showed R17 was sent to a nearby hospital where she was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. Based on observation and interview the facility failed to place shower call light strings in such a manner that they were easily able to be used by residents. This failure affected 6 of 24 sampled residents, R1,R4, R11, R12, R14 and R24 and multiple residents in the supplemental sample. Findings include: During the survey on 9/21/11 and 9/22/11 the call light strings in the shower rooms on 200 wing, 300 wing, 500 wing, 2400 wing, 2500 wing and room 402 were tied to the grab bars and could not be pulled if the call string was grabbed below the grab bar. Residents interviewed stated that they were not able to activate call lights in the shower room. Residents that could be impacted by these call lights are R25, 28, 24, 11, 49, 51, 60, 64, 74, 80, 12, 100, 108, 111, 114, 117, 125, 128, 124, 32, 27, 35, 19, 50, 55, 66, 79, 87, 99, 124, 14, 62, 63, 70, 71, 72, 83, 89, 93, 102, 105, 107, 126, 129, 132, 29, 33, 42, 43, 44, 46, 61, 67, 4, 75, 77, 87, 91, 96, 97, 101, 120, 131, 135, 6, 31, 37, 38, 39, 40, 1, 52, 56, 69, 92, 113, 133 and 136.

Based on observation, record review and interview, the facility failed to: 1) Assess and implement interventions to address pain, and 2) Evaluate and modify approaches for pain when interventions were ineffective. This is for 2 residents (R1 and R9) in a sample of 24. These failures resulted in R1 experiencing frequent episodes of avoidable pain due to ineffective management and R9 experiencing frequent pain without evaluating the effectiveness of the interventions. . Findings include: 1. On 9/20/11, during the initial tour R1 was observed crying, groaning and complaining of pain. R1 complained to E3 (nurse) that she had pain. E3 administered [MEDICATION NAME] 0.5 ml via G tube to R1 without assessing the severity or location of the R1's pain. On 9/21/11 R1 was observed lying in bed. R1 stated that she was still in pain. R1 stated "the pain is in my abdomen." On a scale of 1 - 10 R1 rated the pain at a "10." During an interview on 9/21/11 at approximately 11:30 AM, E23 (nurse) stated that R1 receives her pain medication every 6 hours, and that R1 had her last dose at 8:00 AM. Review of the Medication Administration Record (MAR), verified R1 received the pain medication at 8:00 AM, but R1 also had other pain medication ordered. E23 had not re-assessed R1 to ensure the pain medication was effective nor did E23 offered additional pain medication to decrease R1's level of pain. Review of R1's Physician order [REDACTED]. Neither Nurses Notes nor MARs for August, 2011 and September, 2011 consistently document the severity of R1's pain when medications where administered. Nor is there documentation of the [MEDICATION NAME] having been applied as ordered. R1's care plan for pain listed interventions such as "note characteristics of respirations, instruct to rate pain if she can on a scale from 1-10 ...document pain level, administer pain meds, monitor/record med effectiveness, and side effects. Teach pain relievers: massage/ice exercise...assess for pain, response to pain medication/prn use or need to adjust dose and discuss with MD". None of these listed interventions were followed on a consistent basis, nor were other interventions initiated when the current interventions were ineffective. Review of R1's Controlled Drug Form for August,2011-Sept, 2011 documented the frequent administration of [MEDICATION NAME] Solution 0.5 ml (10 or 15 mg) sublingually every 2 hours as needed for pain or air hunger. This medication was administered 50 times between 8/9/11 and 9/24/11. Further review of R1's POS revealed that there was no order for the [MEDICATION NAME] to be administered every 2 hours. As noted above, R1 had physician's orders [REDACTED]. During an interview with E2 (DON), regarding the discrepancies of the [MEDICATION NAME] administration, E2 stated "That was an error, I was hoping that you would not catch that." Review of nursing documentation did not indicate that R1 was assessed for break through pain or alternative interventions in an attempt to minimize her pain. 2). Current physician's orders [REDACTED]. Nursing documentation shows R9 frequently complains of pain. The physician orders [REDACTED]. Review of the MAR and Nurses notes verified that nurses do not consistently document R9's location, characteristic, or severity of pain. According to the MAR, R9 received [MEDICATION NAME] 325/7.5 mg for pain on 8/25/11. Nurses notes for the day do not mention R9 having pain. There is also no documentation of location, characteristics or severity of R9's pain. According to the August 2011 MAR, R9 again received [MEDICATION NAME] 325/7.7. Again the nurses, did not assess R9's pain On 9/22/11 while in R9's room with Z1, E3 entered the room. R9 told E3 that he was in pain. E3 obtained [MEDICATION NAME] liquid and administered the [MEDICATION NAME] without assessing R9's location, characteristic or severity of pain. Review of nursing documentation showed a pattern of lack of assessment of R9's pain. The facility has also developed a care plan for R9 which addresses his pain. Interventions of : --teaching R9 pain relievers, --massage/ice /exercise, --document pain level, --note characteristics of pain, --assess the resident for pain, --response to pain medication/prn use or need to adjust dose and discuss with MD. These interventions for R9 have not be been consistently implemented by nursing staff.

Based on interview and record review, the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) for one resident (R5) who was found unresponsive and who was identified as a full code. ( R5 expired on [DATE]) This is for 1 of 3 residents reviewed for abuse/neglect concerns in the sample of 11. As the result of this failure, R5 was denied immediate resuscitation procedures and/or appropriate emergency treatment that could have prevented his death. The findings include; During an interview with E8 (CNA) on [DATE] at 12:11 P.M., E8 stated "on [DATE] at approximately 12:10 A.M., I provided incontinent care to R5. I noticed that he (R5) was drooling, gargling and was full of feces from his mid back all the way to his knees. I finished approximately around 12:36. It did not sit right with me when I looked at him (R5). He (R5) was not responding verbally and he was drooling with foamy secretions coming from his mouth. I immediately reported this to E5 (RN) and I told her about R5's change. I did not see E5 go into R5's room. At 2:02 A.M., I went to check on R5, and R5 was still not responding. His skin tone color had changed to yellow from a light/fair complexion and he had brown vomitus all over the top of his chest area and mouth. I yelled loudly in a panic voice for E5 to see R5 right away. E5 came to the room and E5 stated she was not sure of what to do. I told her(E5) to check his (R5) vital signs. E5 went out of the room to the nurse's station to get a stethoscope and called E6 (another nurse from the first floor). E5 came back to the room, listened to R5's breathing and stated that he (R5) is not breathing and that R5 had already passed away. E6 joined us in R5's room. Neither one of the nurses initiated CPR. I asked if they were going to do anything? E5 stated what was the point of doing CPR, he (R5) is already gone and would not be revived. E6 stated to call 911 and bring the emergency cart into R5's room. Both nurses told me {what happened does not leave this room. They are not going to know CPR was not done} I did not do CPR because I am a CNA not a nurse. I reported this to E7(DON) about 4 days after this happened. I then went on vacation, and when I came back nothing was done so that's when I reported this to E4(Human Resource Director)." R5 was found unresponsive at 2:02 A.M. on [DATE] . No resuscitative efforts were initiated by facility staff. The failure of staff to further assess, monitor and evaluate emergency medical needs for R5 placed other residents in the facility at risk. An Immediate Jeopardy was identified and called to the facility's E1(Administrator) on [DATE] at 4:20 PM. The Immediate jeopardy began on [DATE] when the facility did not initiate CPR on R5 who was a full code. While the immediacy was removed on ,[DATE] /2011, the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures, reinservicing staff for emergency preparedness and providing recertification for staff for CPR competency. R5 was a [AGE] year old male with [DIAGNOSES REDACTED]. R5 was admitted to the facility on [DATE] from another facility. Review of R5's physician transfer order dated [DATE] showed that R5 was a full code status. Review of clinical chart showed that R5 has an advance directives dated [DATE] indicating that R5 had requested to have Cardiopulmonary Resuscitation (CPR) in the event that R5's heart or breathing stop and that any and all measures will be taken to revive R5. Review of death certificate showed that R5 had expired at the facility on [DATE] at 2:30 A.M. There was no documentation in the clinical record to indicate R5 was assessed, monitored and how R5's medical condition that precipitated his death. On [DATE] at 9:55 A.M., Z1(attending physician) stated that R5 had multiple medical problems. Z1 also stated that R5 was a full code and should have been given CPR when he was found not breathing and without a pulse on [DATE]. Z1 further stated that he should have been notified when R5 was noted with significant medical changes, when R5 was noted drooling and with foamy secretions around the mouth area on [DATE]. During an interview with E1 (administrator) on [DATE] at 2:40 P.M., E1 stated that R5 expired on [DATE] at the facility. As E1 added, E5 and E6 were terminated on [DATE] and [DATE] for not providing CPR to R5 on [DATE] at 2:00 A.M. E1 also added that E7 was terminated on [DATE] because E7 failed to follow facility's policy to address and investigate E5 and E6's failure to provide CPR to R5. E1 also added that E4 was terminated on [DATE] for not reporting immediately the improper care to E1. E1(administrator) was informed of the Immediate Jeopardy related to not performing CPR on [DATE] at 4:20 P.M. The surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A) Social Service Director will identify resident with DNR status in place and apply armband by [DATE]. B) Inserviced training was was performed with staff nurses on "Presumed Death Policy versus CPR". C) The facility had mandated all nursing staff to become certified within the month. Those non-compliant will be removed from schedule. D) Human Resource Director will monitor all future new hires as well as updates to ensure continued compliance with CPR on ongoing basis. D) Facility staff has been re-inserviced on Abuse/Neglect on [DATE] and [DATE]. E) Human Resource Director will be responsible for initiating abuse training for all new hires during orientation period. F) The Administrator and Director of Nursing shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of this plan of abatement.

Based on interviews and record review, the facility failed to provide any care or services to one resident (R5) of three sampled for appropriate care, after he was observed with a significant change of condition. The lack of timely evaluation and provision of regular and emergency medical interventions resulted in further significant change in R5's condition on [DATE]. He was later found unresponsive and without a pulse. The facility also failed to initiate emergency medical procedures (CPR-Cardiopulmonary Resuscitation). R5 was a full code status. Review of death certificate showed R5 expired on [DATE] at 2:30 A.M. These failures of staff to monitor, timely evaluate and provide emergency and regular medical care to R5 placed other residents in the facility at risk. An Immediate Jeopardy was identified and called to the facility's Administrator on [DATE] at 4:20 P.M. The Immediate jeopardy began on [DATE] when the facility did not initiate CPR on R5 who was a full code. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures, reinservicing staff for emergency preparedness and providing recertification to the facility staff for CPR competency. Findings include: R5 was a [AGE] year old male with [DIAGNOSES REDACTED]. R5 was admitted to the facility on [DATE] from another facility. Review of R5's physician transfer order dated [DATE] showed that R5 was a full code status. Review of clinical chart showed that R5 has an advance directives dated [DATE] indicating that R5 had requested to have Cardiopulmonary Resuscitation (CPR) in the event that R5's heart or breathing stop and that any and all measures will be taken to revive R5. E8 (CNA, certified nurse assistant) stated on [DATE] at 12:11 P.M. that on [DATE] from the hour of approximately 12:10 A.M. to 12:36 a.m., E8 provided care to R5 by cleaning and changing bedding. As E8 indicated, R5 was found to be drooling and gargling in the mouth. R5 was full of bowel movements from upper mid back all the way to the knees. E8 also stated that it was already 12:36 a.m. when she was done cleaning R5. E8 indicated that when she looked at R5, it did not sit right with her because R5 was not responding verbally and was drooling with foamy secretions coming from his mouth. As soon as E5 left R5's room E8 immediately went to E5, (nurse on the floor) and told her regarding R5's significant change. E8 stated , she did not see E5 go to the room to check and assess R5. E8 also stated that definitely R5 had a significant changed in medical condition since R5 had been alert and verbally responsive from previous nights. E8 indicated that at 2:02 A.M., E8 went back to check R5. At this time, E8 stated she observed that R5 was still not responding, skin tone color had changed to yellow from a light/fair complexion and that R5 had brown vomitus all over top of chest area and mouth. E8 then came out and yelled in the hallway at E5 to come check R5. E5 responded she was passing medications and cannot leave medication cart. E8 then yelled loudly and in a panic voice for E5 to see R5 right away. As E8 added, E5 proceeded to come to the room and was not sure of what to do. E8 verbalized that she told E5 to check R5's vital signs (temperature/ pulse/blood pressure). E8 stated that E5 did not check pulse but went out of the room to the nurse's station, get a stethoscope, called E6 via phone (registered nurse assigned from the first floor) and checked clinical chart if R5 was a Do Not Resuscitate status or a Full Code. E8 added that E5 then came back to the room, listened to R5's breathing and stated that R5 was not breathing and that R5 had passed away. E6 who came from first floor joined E5 and E8 in R5's room . As E8 indicated, E5 and E6 were not doing CPR, so E8 asked what the facility's protocol was and why CPR is not initiated. As E8 stated, E5 responded "what was the point of doing CPR, he (R5) is already gone and would not be revived." As E8 added, she informed E5 and E6 that they do not know what time exactly that R5 passed away and that CPR should be done. As E8 indicated, E6 stated to call 911, bring the emergency cart into R5's room. E8 added that she was asked by E5 to leave the room to make some copies of R5's record for the paramedics. As E8 stated, she was told both by E5 and E6 that "this (incident) will not leave this room (R5) that they did not do CPR. They are not going to know CPR was not done, there will be no autopsy." E8 also added that she did not do CPR to R5 because she was a CNA and was under E5 and E6. As E8 added, she had reported this improper care to E7 (Director of Nursing) around 4 days after it had happened ([DATE]). E8 added, that on [DATE], E7 had not investigate fully the situation. As E8 added, she then informed the situation to E4 (Human Resource Director) when E7 did not investigate the situation. E8 also stated that she does not want to cause trouble to anyone, however felt that nurses should be trained and know facility's protocol for providing CPR. On [DATE] at 9:55 A.M., Z1 (attending physician) stated that R5 had multiple medical problems. Z1 also stated that R5 was a full code and should have been given CPR when he was found not breathing and without a pulse on [DATE]. Z1 further stated that he should have been notified when R5 was noted with significant medical change when R5 was noted drooling and with foamy secretions around the mouth area on [DATE]. Review of death certificate showed that R5 had expired at the facility on [DATE] at 2:30 A.M. There was no documentation in the clinical record to indicate that R5 was assessed, monitored and how R5's medical condition was that precipitated his death. Review of facility's protocol for "Presumed Death Policy" showed that assessment should be done to determine if CPR or no CPR is indicated. Further review of the policy showed that two nurses should determine and verified the presence of the following: ---Pupils fixed and dilated ---no spontaneous respiration ---mottled discoloration of the body ---no spontaneous movement ---absence of vital signs (apical pulse and blood pressure) The policy also showed that above findings should be documented in nursing notes alone with the names of both nurses. Facility could not show any documentation that protocol was followed. Staff did not assess R5 on [DATE], when found unresponsive at 2:02 A.M. There was no documentation that vital signs were taken, nor checked for viability. On [DATE] at 2:40 P.M., E1(administrator) stated R5 had expired on [DATE] at the facility. As E1 added, E5 and E6 were terminated on [DATE] and [DATE] for not providing CPR to R5 on [DATE]. E1 also added that E7 was terminated on [DATE] because E7 failed to follow facility's policy to address and investigate E5 and E6's failure to provide CPR to R5. E1 also added that E4 was terminated on [DATE] for not reporting immediately the improper care to E1. On [DATE], surveyor asked E1 the list of nursing staffs with all their current CPR cards. E1 stated on [DATE] at around 3:45 P.M. that facility is currently arranging a class for staffs to renew their CPR cards. On [DATE], E1 provided the list of licensed staff who do not have current CPR recertification. There were 46 that do not have current CPR cards. After surveyor's prompting, 21 staff were recertified on ,[DATE] and [DATE] and 25 nursing staff are still needed to be recertified. On [DATE] at 4:20 P.M., E1(administrator) was informed of the Immediate Jeopardy for not assessing, monitoring and providing CPR to R5. The surveyor confirmed the facility took the following actions to remove the immediacy of the situation: A) Social Service Director will identify resident with DNR status in place and apply armband by [DATE]. B) Inserviced training was was performed with staff nurses on "Presumed Death Policy versus CPR". C) The facility had mandated all nursing staff to become certified within the month ([DATE]). Those non-compliant will be removed from schedule. D) Human Resource Director will monitor all future new hires as well as updates to ensure continued compliance with CPR on ongoing basis. D) Facility staff has been re-inserviced on Abuse/Neglect on [DATE] and [DATE]. E) Human Resource Director will be responsible for initiating abuse training for all new hires during orientation period. F) The Administrator and Director of Nursing shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of this plan of abatement.

Based on observation, interview and record review, the facility failed to respond appropriately to resident's behavior in a timely manner, provide appropriate interventions and adequate supervision to prevent resident to resident physical abuse . This is for 2 of 5 residents reviewed for abuse concerns in the sample of 11(R3 and R4). This failure resulted in R3 being physically attacked by R4 with a metal object. R3 sustained multiple lacerations on the head area, multiple contusions and bruises on different parts of her body. R3 was sent to the hospital after physically attacked for medical treatment. Findings include: A review of the facility's incident report on 6/15/11 indicated that on 6/8/11 at 2:15 P.M., R4 asked R3 to come inside his room(2311). Inside the room, R4 started accusing R3 of having sexual affairs with another resident(R11) and the son of another resident at the facility. When R3 denied the accusations, R4 started hitting R3 all over her face and body with a metal object. (The metal object was identified by the facility staff as a metal table container for condiments from the first floor dining room.) At 2:20 P.M., the facility's staff (E10, E9 and E3) heard R3 scream for help inside R4's room. The staff found R3 with a large amount of blood all over her face and floor. (R3 sustained multiple injuries: bruising on the face, left arm, hand, lacerations on the head, left side of face and left hand hematoma.) R3 was sent to a nearby acute facility where she (R3) received staples and stitches to her lacerations and a dose of tetanus [MEDICATION NAME]. R3 returned to the facility on the same day. Meanwhile, R4 was removed from the facility by the police department. A review of the facility's progress notes dated 1/22/2011 showed that R3 is a [AGE] year old female with [DIAGNOSES REDACTED]. Record showed that R3 is alert and oriented times 3, has history of loss of independence, loss of control, inability to cope, impaired judgement, poor self image and altered thought process On 6/15/2011 at 2:00 P.M., R3 was observed with multiple bruises on her head, face, hands and arms. R3 was wearing an immobilizer on the left hand, (her left hand was observed to be swollen.) R3 was observed with 6 staples on top of her head, and 6 stitches on left side of her head. During an interview on 6/15/11, R3 stated "I was (R4's) fiancee. (R4) asked me (R3) to come to his room on the second floor on 6/8/2011 at around 2:00 P.M., then he (R4) started accusing me of having a sexual affairs with (R11) and a son of another resident at the facility. I denied his (R4) accusations and he (R4) started hitting me with a metal object. I screamed for help and staff had stopped him (R4). He( R4) was in a jealous rage because I had been talking to R11 and I (R3) offered (R11) a lemonade 2 days prior to the incident. Two days before the incident of 6/8/2011, he (R4) made me put my hand on the bible and made me (R3) swear not to talk to (R11) again. I (R3) did what he (R4) demanded in order to please him (R4). He (R4) is sometimes verbally aggressive with other residents at the facility including (R11)." Review of record showed that R4 is an [AGE] year old male with [DIAGNOSES REDACTED]. Record showed that R4 was seen by the psychiatrist averaging monthly and by psychologist averaging weekly. Review of the psychiatrist progress notes dated 6/6/2011 (2 days before incident on 6/8/2011) indicated that "(R4) is upset thinking that other patient is after his girlfriend and other residents steals from him." This record indicated that R4 has increased paranoia, increased [MEDICAL CONDITION] and with poor insight. It was also indicated that one of the interventions for R4's increased paranoia and [MEDICAL CONDITION] is for a psychotherapy follow up. Review of psychotherapy follow up dated 6/7/2011 showed that R4 was not seen by the psychotherapist because "(R4) with peers/will check next visit." There were no further/revised interventions found in the clinical record to direct staff on what to do when R4 is not seen by the Psychotherapist. On 6/28/2011 at 2:35 P.M., R11 was interviewed in his room. R11 was observed to be a pleasant man and oriented x 3 . R11 stated " a few days prior to the incident of 6/8/2011, he (R4) made a racial slur toward me (R11). There was a verbal altercation between the two of us (R4 and R11). He (R4) strongly prohibited me (R11) to talk, play cards or mingle with (R3). I will kick his a--once he (R4) calls me a n-----. Staff were aware of the verbal altercation prior to incident of 6/8/2011 because he (R4) had chased me (R11) towards the nursing station on the first floor." On 6/16/2011 at 1:35 P.M. E9(Social Service Director) stated "R4 has paranoia thinking that other residents steals from him. On 6/6/2011, (R4) was very upset and had a verbal altercation with (R11) because (R4) was jealous when (R3) gave (R11) lemonade . The psychiatrist had seen (R4) on 6/6/2011 and an intervention was a medication changed and a follow up with a psychotherapist. The psychotherapist has not seen (R4) because (R4) was with other residents during the time the psychotherapist was in the facility on 6/7/2011." E9 confirmed that there were no revised interventions when R4 was not seen by the psychotherapist on 6/7/2011 to address his jealousy with R11 and R3. On 6/16/2011 at 1:10 P.M., E10 (registered nurse on duty on 6/8/2011 for 7-3 shift on the second floor) stated "I was one of several staff who came to rescue R3. The scene was like what you see in a movie, "full of blood." R3 was unrecognizable because she (R3) was full of blood. I was not aware of R4's jealousy with R11 and R3." Review of the facility's investigation report of 6/8/2011 read "after R4 physically attacked R3 , R4 came out of the room with a calm demeanor and stated that (R3 deserved everything she got.) (R4) stated (R3) was giving (R11) a b--- j-- and f------ them. I (R4) hit her(R3) a bunch of times to kill her, no not to kill her but to deform her for the rest of her life for what she (R3) did to me."

Based on observations, interviews and record reviews, the facility failed to put in appropriate and implement interventions, including adequate supervision/monitoring in order to prevent injuries/physical altercations for 4 (R3, R4, R1 and R2) of 6 residents reviewed for fall/injuries in the sample of 11. This failure resulted in R3 being physically attacked by R4 with a metal object. R3 sustained multiple lacerations to her head area,multiple contusions and bruises on different parts of her body. R3 was sent to the hospital after physically attacked by R4 for medical treatment. Findings include: 1 ) Review progress notes record dated 1/22/2011 showed that R3 is a [AGE] year old female with [DIAGNOSES REDACTED]. Record showed that R3 is alert and oriented times 3, has history of loss of independence, loss of control, inability to cope, impaired judgement, poor self image and altered thought process. Review of facility's incident report indicated that on 6/8/2011 at 2:20 P.M., R3 was hit by R4 multiple times with a metal object. This metal object is a container for table condiments that R4 had obtained from the first floor dining room. Further review of incident report indicated that R4 asked R3 to come inside his room(2311) on the second floor on 6/8/2011 at around 2:15 P.M. Inside the room, R4 started accusing R3 of having sexual affairs with another resident (R11) and also the son of another resident at the facility. When R3 denied the accusations, R4 started hitting R3 all over her face and body. R3 sustained the following multiple injuries: bruising on the face, left arm, and hand, lacerations on the head, and left side of face and left hand hematoma. R3 was sent to the hospital after physically attacked and had received staples and stitches to her lacerations and also had a dose of tetanus toxoid. Meanwhile, R4 was taken by the police department after the incident. As indicated in this incident report, staff had heard R3 screamed for help inside R4's room and found R3 with large amount of blood all over her face and on the floor. R3 returned back to the facility after receiving treatment from the hospital on [DATE]. On 6/15/2011 at 2:00 P.M., R3 was observed and interviewed. R3 was noted with multiple bruises on the head, face, hands arms. R3's left hand was swollen and that R3 was wearing an immobilizer on the left hand. R3 has 6 staples on top of her head, and 6 stitches on left side of head. R3 stated that she was R4 fiancee. As R3 stated, R4 asked R3 to come to his room on the second floor on 6/8/2011 at around 2:00 P.M., then R4 started accusing her of having a sexual affairs with R11 and a son of another resident at the facility. R3 added that she denied R4's accusations and then R4 started hitting her with a metal object. R3 added that she then screamed for help and that staff intervened timely and appropriately. R3 also stated that R4 was in a jealous rage because R3 had been talking to R11 and that R3 offered R11 a lemonade 2 days prior to the incident. As R3 added, 2 days before the incident of 6/8/2011, R4 made R3 put her hand on the bible and made her swear not to talk to R11 again. R3 added that she abided to R4's demands in order to appease R4. R3 further stated that R4 is sometimes verbally aggressive with other residents at the facility including R11. Review of record showed that R4 is an [AGE] year old male with [DIAGNOSES REDACTED]. Record showed that R4 was seen by the psychiatrist averaging monthly and by psychologist averaging weekly. Review of the psychiatrist progress notes dated 6/6/2011 (2 days before incident on 6/8/2011) indicated that "(R4) is upset thinking that other patient is after his girlfriend and other residents steals from him." This record indicated that R4 has increased paranoia, increased delusions and with poor insight. Further review of this record also showed that R4 was assessed to have [DIAGNOSES REDACTED]. It was also indicated that one of intervention for this R4's increased paranoia and delusions is for a psychotherapy follow up. Review of psychotherapy follow up dated 6/7/2011 showed that R4 was not seen by the psychotherapist because "(R4) with peers/will check next visit." Further review of the clinical chart showed that there was no further or revised intervention when R4 was not seen for a follow up by the psychotherapist on 6/7/2011 to address R4's increased delusions and paranoia . On 6/28/2011 at 2:35 P.M., R11 was interviewed in his room. R11 is oriented x 3 . During the interview, R11 was noted to be pleasant. However, R11 had stated that few days prior to the incident of 6/8/2011, R4 had made racial slur to R11. As R11 added, there was a verbal altercation between the two(R4 and R11). R11 also stated that R4 strongly prohibited R3 to talk, play cards or mingle with R11. As R11 added, " I will kick his a-- once (R4) calls me a n-----." R11 also added that staff were aware of the verbal altercation prior to incident of 6/8/2011 because R11 had chased R4 towards the nursing station on the first floor while playing cards. On 6/16/2011 at 1:35 P.M. E9(Social Service Director) stated that R4 has paranoia thinking that other residents steals from him. E9 also added that on 6/6/2011, R4 was very upset and had verbal altercation with R11 because R4 was jealous when R3 gave R11 a lemonade . E9 added that the psychiatrist had seen R4 on 6/6/2011 and an intervention was a medication changed and a follow up with a psychotherapist. E9 further stated that psychotherapist had not seen R4 because R4 was with other residents during the time the psychotherapist was at the facility on 6/7/2011. E9 confirmed that there was no revised intervention when R4 was not seen by the psychotherapist on 6/7/2011 to address his jealousy with R11 and R3. Review of R3, R4 and R11's care plan showed that there was no specific intervention that includes monitoring to address R4's jealousy between R3 and R11. As record indicated, R4 had physically attacked R3 multiple times on 6/8/2011 at around 2:20 P.M. in R4's room. On 6/16/2011 at 1:10 P.M., E10 (registered nurse on duty on 6/8/2011 for 7-3 shift on the second floor) stated that she was one of the several staff who came into rescue when R4 physically attacked R3 multiple times. As E10 added, the scene when R4 attacked R3 was like "only see in a movie, full of blood." As E10 added, R3 was unrecognizable because R3 was full of blood. E10 further stated that she was not aware of R4's jealousy with R11 and R3. As E10 added, there was no special monitoring with regards to R4 to ensure R3 or R11 are free from any type of possible altercation or abuse in case R4 will have a jealous rage. As E10 further stated, R4 was in a jealous rage when E10 came to the rescue on 6/8/2011 at 2:20 P.M. Review of the facility's investigation report of 6/8/2011 indicated that after R4 physically attacked R3 , R4 came out of the room and has a calm demeanor and had stated that "(R3) deserved everything she got. (R4) stated (R3) was giving (R11) a b--- j-- and f------ them. I (R4) hit her(R3) a bunch of times to kill her, no not to kill her but to deform her for the rest of her life for what she (R3) did to me." 2) Review of facility's incident report dated 6/9/2011 showed that R1 feel from her wheelchair when R1 tried to pushed back from dining table to get farther away from R2 who was kicking R1. This incident happened on the second floor dining room while waiting for dinner. R1 was sent to the hospital precipitated by this fall for further medical evaluation because R1 is a high risk for bleed due to anticoagulant medication. As E1 (administrator) stated on 6/27/2011 at 2:40 P.M., this incident was not intentional and that R1 was just trying to get away from R2 when R2 had accidentally kicked R1. Review of current care plan for R1 and R2 showed a revised intervention to prevent further fall incident was for R1 and R2 to be separated and be seated in different dining table during meals. R1 and R2 was observed during lunch time at intervals on 6/27/2011 at 11:30 a.m., 12:50 p.m., and 1:30 p.m. seated next to each other sharing the same dining table on the second floor. When interviewed at time of observation, E11 and E12 (CNA-certified nurse assistants) stated that they were not aware that R1 and R2 cannot be seated next to each other to prevent possible accidents.

Based on observations, interviews and record reviews, the facility failed to respond appropriately to resident behavior in a timely manner, provide appropriate nursing interventions and adequate supervision to prevent resident to resident verbal, physical and mental abuse/altercation. This is for 3 residents inside the sample of 12 (R4, R5, and R6) and 3 residents on the supplemental sample (R28, R64 and R54). This failure resulted in R5 attacking R4 with physical abuse and residents complaining that they felt angry, belittled and threatened by R5's [MEDICAL CONDITION] of verbal abuse. Findings include: Review of an Abuse Investigation, involving R4 and R5, documented on 3/26/2011 that R4 and R5 got into a physical altercation. R4 was playing cards with some residents on the second floor. R4 made negative comments regarding R5's friend. Then, R4 called R5 a racial slur. R5 responded by bursting into an angry out-burst and grabbing R4 around the neck. R5 put R4 in a head hold. Staff were present but could not calm R5 down. R4 lives on the second floor, R5 lives on the first floor, but is often seen on the second floor. On 4/12/11 at 3:15 PM on 1st floor four residents (R64, R84, R6, and R26) were playing cards at a table. At 3:20 PM R6 left to go to 2nd floor because her son was visiting her. R132 wheeled himself to play in place of R6. R64 objected to have R132 at the table. At this time R5 (a [AGE] year old male) went in defense of R132 began yelling loudly at R64 (a [AGE] year old male) and became physically aggressive, then ran into the hall way screaming threatening loudly in a challenging manner as why he or R132 could not play with them. R5 immediately turned around from the hallway returned to the dining room to the table went toward R64 challenging him face to face and ran to the patio. R64 continued to say back to R5 in a hostile manner. No staff intervened until this point of the time. At this time E26 the Activity Director who was away from the table in the dining room came to R64 and said 'you all need to stop.' But no staff attempted to de-escalate R5's verbal and potential physical aggression. Review of R5's Admission Face Sheet documented that R5 is a [AGE] year old male. R5 was admitted to the facility with a [DIAGNOSES REDACTED]. R5 had no documented psychiatric [DIAGNOSES REDACTED]. Review of R5's care plan identified behavior as a concern on the care plan of 3/26/2011. The behavior was not addressed until after the altercation with R4. The nursing interventions were not specific in addressing the need to supervise, monitor, and intervene when R5 exhibited abusive behaviors toward peers. R5's plan of care did not address his [MEDICAL CONDITION] of anger or verbal abuse of peers. Review of R5's Social Service Notes only documented providing interventions after 3/26/2011 and did not address any of his anger issues or verbal abuse of peers. During an interview with R5 on 4/8/11, R5 stated "no one told me that I should not go to the second floor. I go up there all the time, I was up there this morning. I do see R4 when I go upstairs, R4 is always making negative or racial comment to me and other residents." Review of R4's Admission Face Sheet documented that R4 is a [AGE] year old male with [DIAGNOSES REDACTED]. R4's care plan and social services notes address his potentially abusive behaviors of being verbally hostile and threatening to other residents. Nursing note documentation showed R4 had altercations and conflicts with other residents however; R4's care plan documented no revisions to his plan of care after nursing interventions were shown not to be effective. During an interview on 4/8/11, R4 reported that R5 made comments in anger and staff was not addressing R5's behavior. E1 (administrator) and E3 (director of nursing) were interviewed on 4/08/2011, 4/12/2011, 4/13/2011. E1 and E3 told the survey team that one intervention put into place was R4 and R5 were being kept away from one another. E1 and E3 reported that after the physical altercation on 3/26/2011 R5 was not allowed to go to the second floor where R4 lived. However, they were not aware that R5 was being verbally abusive toward other residents and that R5 continued to visit the second floor where R4 lived. E5 (director of social service) was interviewed on 4/12/2011 at 11:07 AM. E5 reported that R4 had poor impulse control, and could be verbally hostile at times and make inappropriate statements. E5 described R5 as being depressed. E5 was not aware of R5 having any problem interactions with other residents. E5 told the surveyor that R5 was not allowed on the second floor with R4. When asked, E5 stated she had only verbal redirection and interaction with R4 and R5. E5 did not report a consistent and organized plan of care to address R4 and R5's abusive behaviors. Several alert and oriented residents (R4, R6, R28 and R54) were interviewed on 4/08/2011, and reported that R5 was still coming on the second floor. R4, R6, R28 and R54 complained that R5's behavior was explosive, loud and angry. R4, R6, R28 and R54 also expressed concerns that staff were not able to address R5's behavior. R28 and R54 felt R5 verbally attacked them and belittled them because they were seniors. E24 (nurse) was interviewed on 4/12/2011. E24 also reported that R5 had an [MEDICAL CONDITION] that was hard to address. Several nurses (E17 and E15), who were working on the evening shift, were interviewed on 4/12/2011. E17 and E15 told the surveyor they were not aware that R5 was not allowed to come on the second floor. E17 reported that R4 and R5 are verbally and mentally abusive toward other residents. E17 said she just talk to R4 and R5 to redirect their behaviors. However, E17 and other nursing staff stated verbal redirection was not working because R4 and R5 continued to display the behavior and threaten the mental well being of other residents. E20, E22, and E15 are certified nurses aides that worked on the second floor. E20, E22 and E15 said they were not aware that R5 could not come on the second floor. So, they did not know R5 needed to be monitored and supervised. Residents in group meeting and alert and oriented individual interview expressed concerns stating R5 is nice but, quick to go off the handle, become explosive, verbally and physically aggressive. The residents also stated the staff is aware of R5's explosive behavior, but he does what ever he wants in the facility especially when the other residents do not go along with what he says. R64 a [AGE] year old male stated he is not here in the facility to get beat up, R5 and R132 are intimidating to others. R64 added some times it is chaotic, especially in the evening. R28 and R54 expressed their concerns on 4/8/11 that staff were not able to address R5's behavior. R28 and R54 felt R5 verbally attacked them and belittled them because they were seniors. All reported that R5 was still coming to the second floor.

Based on observations, interviews and record reviews, the facility failed to respond appropriately to resident's behavior in a timely manner, provide appropriate nursing interventions and adequate supervision to prevent resident to resident physical abuse . This is for 2 of 5 residents reviewed for abuse concerns in the sample of 11(R3 and R4). This failure resulted to R3 being physically attacked by R4 with a metal object. R3 sustained multiple lacerations on the head area, multiple contusions and bruises on different parts of her body. R3 was sent to the hospital after physically attacked by R4 for medical treatment. Findings include: Review progress notes record dated 1/22/2011 showed that R3 is a [AGE] year old female with [DIAGNOSES REDACTED]. Record showed that R3 is alert and oriented times 3, has history of loss of independence, loss of control, inability to cope, impaired judgement, poor self image and altered thought process. Review of facility's incident report indicated that on 6/8/2011 at 2:20 P.M., R3 was hit by R4 multiple times with a metal object. This metal object is a container for table condiments that R4 had obtained from the first floor dining room. Further review of incident report indicated that R4 asked R3 to come inside his room on 6/8/2011 at around 2:15 P.M. Inside the room, R4 started accusing R3 of having sexual affairs with another resident (R11) and also the son of another resident at the facility. When R3 denied the accusations, R4 started hitting R3 all over her face and body. R3 sustained the following multiple injuries: bruising on the face, left arm, and hand, lacerations on the head, and left side of face and left hand hematoma. R3 was sent to the hospital after physically attacked and had received staples and stitches to her lacerations and also had a dose of tetanus [MEDICATION NAME]. Meanwhile, R4 was taken by the police department after the incident. As indicated in this incident report, staff had heard R3 screamed for help inside R4's room and found R3 with large amount of blood all over her face and on the floor. R3 returned back to the facility after receiving treatment from the hospital on [DATE]. On 6/15/2011 at 2:00 P.M., R3 was observed and interviewed. R3 was noted with multiple bruises on the head, face, hands arms. R3's left hand was swollen and that R3 was wearing an immobilizer on the left hand. R3 has 6 staples on top of her head, and 6 stitches on left side of head. R3 stated that she was R4 fiancee. As R3 stated, R4 asked R3 to come to his room on the second floor on 6/8/2011 at around 2:00 P.M., then R4 started accusing her of having a sexual affairs with R11 and a son of another resident at the facility. R3 added that she denied R4's accusations and then R4 started hitting her with a metal object. R3 added that she then screamed for help and that staff intervened timely and appropriately. R3 also stated that R4 was in a jealous rage because R3 had been talking to R11 and that R3 offered R11 a lemonade 2 days prior to the incident. As R3 added, 2 days before the incident of 6/8/2011, R4 made R3 put her hand on the bible and made her swear not to talk to R11 again. R3 added that she abided to R4's demands in order to appease R4. R3 further stated that R4 is sometimes verbally aggressive with other residents at the facility including R11. Review of record showed that R4 is an [AGE] year old male with [DIAGNOSES REDACTED]. Record showed that R4 was seen by the psychiatrist averaging monthly and by psychologist averaging weekly. Review of the psychiatrist progress notes dated 6/6/2011 (2 days before incident on 6/8/2011) indicated that "(R4) is upset thinking that other patient is after his girlfriend and other residents steals from him." This record indicated that R4 has increased paranoia, increased delusions and with poor insight. Further review of this record also showed that R4 was assessed to have [DIAGNOSES REDACTED]. It was also indicated that one of intervention for this R4's increased paranoia and delusions is for a psychotherapy follow up. Review of psychotherapy follow up dated 6/7/2011 showed that R4 was not seen by the psychotherapist because "(R4) with peers/will check next visit." Further review of the clinical chart showed that there was no further or revised intervention when R4 was not seen for a follow up by the psychotherapist on 6/7/2011 to address R4's increased delusions and paranoia . On 6/28/2011 at 2:35 P.M., R11 was interviewed in his room. R11 is oriented x 3. During the interview, R11 was noted to be pleasant. However, R11 had stated that few days prior to the incident of 6/8/2011, R4 had made racial slur to R11. As R11 added, there was a verbal altercation between the two(R4 and R11). R11 also stated that R4 strongly prohibited R3 to talk, play cards or mingle with R11. As R11 added, " I will kick his a-- once (R4) calls me a n-----." R11 also added that staff were aware of the verbal altercation prior to incident of 6/8/2011 because R11 had chased R4 towards the nursing station on the first floor while playing cards. On 6/16/2011 at 1:35 P.M. E9(Social Service Director) stated that R4 has paranoia thinking that other residents steals from him. E9 also added that on 6/6/2011, R4 was very upset and had verbal altercation with R11 because R4 was jealous when R3 gave R11 a lemonade . E9 added that the psychiatrist had seen R4 on 6/6/2011 and an intervention was a medication changed and a follow up with a psychotherapist. E9 further stated that psychotherapist had not seen R4 because R4 was with other residents during the time the psychotherapist was at the facility on 6/7/2011. E9 confirmed that there was no revised intervention when R4 was not seen by the psychotherapist on 6/7/2011 to address his jealousy with R11 and R3. Review of R3, R4 and R11's care plan showed that there was no specific intervention that includes monitoring to address R4's jealousy between R3 and R11. As record indicated, R4 had physically attacked R3 multiple times on 6/8/2011 at around 2:20 P.M. in R4's room. On 6/16/2011 at 1:10 P.M., E10 (registered nurse on duty on 6/8/2011 for 7-3 shift on the second floor) stated that she was one of the several staff who came into rescue when R4 physically attacked R3 multiple times. As E10 added, the scene when R4 attacked R3 was like "only see in a movie, full of blood." As E10 added, R3 was unrecognizable because R3 was full of blood. E10 further stated that she was not aware of R4's jealousy with R11 and R3. As E10 added, there was no special monitoring with regards to R4 to ensure R3 or R11 are free from any type of possible altercation or abuse in case R4 will have a jealous rage. As E10 further stated, R4 was in a jealous rage when E10 came to the rescue on 6/8/2011 at 2:20 P.M. Review of the facility's investigation report of 6/8/2011 indicated that after R4 physically attacked R3 , R4 came out of the room and has a calm demeanor and had stated that "(R3) deserved everything she got. (R4) stated (R3) was giving (R11) a b--- j-- and f------ them. I (R4) hit her(R3) a bunch of times to kill her, no not to kill her but to deform her for the rest of her life for what she (R3) did to me."

Based on observations, interviews and record reviews, the facility failed to provide 1 (R-6) residents in a sample of 12 with restorative nursing care and services to maintain/improve her independence in mobility, walking, use of wheel chair and toileting. This failure resulted in a decline in R6's mobility in her wheel chair, walking, standing and use of the bathroom independently at night. Findings include: On 4/08/2011 and 4/13/2011, R6 was interviewed. R6 reported her motorized wheel chair was out of service for appropriately one week. R6 complained that staff made no effort to get a replacement battery. R6 told surveyor that the restorative nurse gave her a wheel chair to use. But, R6 said this wheel chair had a screw which struck her in her ankle, causing a bruise and pain. She (R6) said it's difficult getting around in this wheel chair, because it was hard for her to push it forward. R6 stated this inability to easily move her wheel chair caused pain in her hands and did not help her get around independently. R6 stated she was loosing her ability to walk independently because none of the restorative aides were available to walk her or provide her restorative care. R6 said she came to the facility to receive care to increase her strength to walk. Because of her lack of care, R6 expressed fear and disappointment that she walked less distance than when admitted to the facility. R6 cried and described being left wet at night because no one could assist her to the bathroom. R6 said she could not use the toilet in the bathroom because hand rails did not support her weight, while getting up. So, restorative staff provided a bedside commode. But, R6 said she needed help to get up from her bed to the commode, during the night. Since there were not enough staff to assist her at night, they gave her a bed pan to use. R6 complained that she was left cold and wet for hours, while looking at the clock in front of her bed and waiting on staff. R6 cried as she told staff she would wet the diaper a second time and no one came to help her. On 4/12/2011, surveyors observed two restorative aides (E11 and E12) on duty. E11 and E12 were interviewed. E11 and E12 reported that they could not do the restorative care with residents. They were doing basic nursing care, because other certified nurses aides had called off duty. E11 and E12 stated that they were pulled to do CNA duties a lot and therefore could not perform the restorative programs with the residents. On 4/13/2011, the restorative aide (E12) assigned to walk R6 was interviewed. When asked, E12 reported that she often could not walk R6, because of bring reassigned to wash and bathe residents. E12 said this was due to certified nurses aides/CNA calling off. E12 said she was assigned to walk R6 today. But the second restorative aide called in and there was no one to assist her in walking R6. E12 said that R6's ability to walk a certain distance had declined. When asked, E12 could only remember walking R6 once since her admission to the facility. Review of R6's Admission Face Sheet documented that R6 is a [AGE] year old female, who was admitted to the facility in June of 2010, with [DIAGNOSES REDACTED]. Review of R6's Restorative Care Plan documented that she was to receive: daily walking for a distance of 25 feet. However, in the last 4 months, staff documented that R6 had only been walked one time. Active ROM (range of motion) to upper and lower extremities were to be done twice a day for R6. But, this was also documented as not being done by the restorative nursing staff. During the meeting with administrative staff E1 (administrator) and E3 (director of nursing), the survey team expressed concerns that R6 and other residents were not getting the restorative care they were assessed as needing. The team also expressed concerns that R6 was in a wheel chair that was not appropriate for her, while she waited a prolonged time for a replacement battery. After prompting from the survey team, E1 obtained a replacement battery for R6's motorized wheel chair. But, E1 could not explained what staff member was responsible or what process was in place to ensure that resident used appropriate wheel chair in good condition. Also, E3 provided no evidence that R6 was getting the restorative care and services she needed. Surveyors reviewed the documentation for the other 40 residents identified as needing restorative nursing care and services. Review of these forms showed that there was no documentation that resident's restorative care was not being done consistently, and according to the resident's assessed needs. This was verified through interviews with the restorative aides (E11 and E12).

Based on observation, record review, and interview the facility failed to provide the necessary care and services to prevent the development of facility acquired pressure ulcers for two residents (R1 and R2), and failed to develop a comprehensive assessment with interventions for these pressure ulcers. As a result of this failure R2 developed a painful, un-stageable pressure sore to her right heel and R1 developed a stage II pressure sore to her left buttock. This is for 1 of 5 residents identified with pressure sores (R2) and 1 resident who was not identified with a pressure sore (R1). The finding includes: 1. Review of R2's admission face sheet and current physician's orders [REDACTED]. R2 was admitted to the facility with NO pressure sores. Review of the facility's Pressure Ulcer Report for April 2011 showed R2 had acquired a stage I pressure sore to her right heel on 3/23/11. Pressure Ulcer Report documentation for 4/1 and 4/8/11 showed R2's pressure sore to her right heel was a stage I and showed the site was reddened. On 4/12/11 at 11:00 a.m. E6 (LPN - Treatment Nurse) was observed performing pressure sore treatment on R2 in R2's room. E9 (CNA) was in the room for standby assist. Observation of R2's right heel, showed the pressure sore site had blackened (eschar) tissue with a scab in the center of the blackened tissue. The site measured 3.5 cm x 3.0 cm. R2 complained of pain to touch when E6 was cleaning and dressing the site. During interview with E6, E6 was questioned about the stage of the pressure sore. E6 stated, "This is a stage II because it was a blister." When E6 was asked why/how R2 developed this pressure sore E6 stated, "I don't know how R2 got the pressure sore. The CNA's (certified nurses aides) just told me she had a blister on her heel." Review of R2's Admission (14 day) MDS (minimum data set) dated 1/17/11 showed R2 was at risk of developing pressure sores but no comprehensive assessment was done. The MDS of 1/17/11 showed R2 was at risk of developing pressure sores but the CAA (care area assessment) for pressure sores was not done until 2/18/11 (a month after R2 was identified at risk of developing pressure sores) . Review of the CAA documentation did not include the risk factors and/or complicating factors which would place R2 at risk of developing pressure sores. 2. On 4/12/11 at 11:45 am R1's skin condition checked in the presence of the facility pressure sore Nurse (E18). R1 had a stage II pressure on her left buttocks which measured 0.5 x 0.3 cms that the facility was not aware. E18 stated this is new and no staff reported to her. At this time R1's diaper was wet with urine, her healed pressure sore sites (coccyx and buttocks) were reddened. R1 who is alert and oriented stated she usually gets up for breakfast and does not go back to bed until after lunch. On 4/12/11 R1's Certified Nurse Aide (CNA) stated R1 has been in her wheel chair since 7:45 am. R1 is obese, incontinent, dependent on staff and she uses sit to stand lift to transfer her from bed to chair and chair to bed. R1's 3/24/11 pressure sore (Braden Scale) risk factors scored "15" which indicates R1 is at minimal risk for acquiring pressure sores. Even though R1 was identified at minimal risk, R1 acquired two stage II pressure sores (one on coccyx and one on buttocks) in the facility which resolved on 3/14/11. R1's pressure sore risk factors were reviewed with the facility consulting staff (Z2) and determined the Braden Scale score should have been a "10" which places R1 at high risk for developing pressure sores. R1's 7/6/10 Minimum Data Set (MDS) triggered problems which included pressure sores. There was no comprehensive assessment to show why R1 is at risk for acquiring pressure sores. R1's Resident Assessment Protocol (RAP) summary noted R1 acquired pressure sores secondary to her incontinence, her [MEDICAL CONDITION], and her needing assistance with mobility. There was no determination to show if the these risk factors could be modified to prevent acquiring pressure sores or determine if the pressure sore was preventable or not. R1's 3/24/11 plan of care pressure interventions were not specific to her medical condition. For example: implement incontinent protocol, this intervention was not specific; check for comfort every two to three hours and toilet, this intervention was not implemented on 4/12/11. Z2 the facility consultant staff stated staff reported R1 is not compliant with turning and repositioning, but there was no documentation to reflect R1's refusal of treatment.

Based on observations, interviews and record reviews, the facility failed to accurately assess and put in appropriate interventions to prevent falls, and provide supervision/monitoring for 2 residents (R12 and R10)on a sample of 3 reviewed for falls. This failure resulted in R12 sustaining a cervical fracture and R10 sustaining a clavicle fracture. Findings include: 1. R12 was interviewed in the dining room on 4/13/2011. R12 was observed sitting in a motorized wheel chair and wearing a neck brace. During an interview with R12, R12 stated that he had gotten up during the night, walked into a door, fell on the floor and broke his neck. R12 stated that he now has a chair and bed alarm to remind him not to get up without assistance. Before the incident, R12 said he had nothing in place to remind him not to get up by himself. E23 (nurse) was working on the night that R12 fell on [DATE]. E23 was interviewed on 4/13/2011 at 2:43 PM, and stated "Before he (R12) fell , he kept getting out of his wheel chair to plug in his (motorized) wheel chair. R12 has a prosthetic leg and can't walk right. His gait is not right. He stands humped over. He was more confused that night (4/02/2011). So, I thought he had a urinary tract infection. I told him to hold on and went to get a cup for a specimen. When, I came back with the cup, R12 had went in the urinal. I needed to get him back to bed, so I call for the CNA's (certified nurse aides)." E23 said the two CNA's were in rooms with other residents. E23 said, "I hooked R2 up to the oxygen and told him to wait a few minutes". Then, E23 said that she left R12 alone, confused and unsupervised. E23 said she went to the patio to smoke. When she came back, E23 said she found R12 on the floor yelling for help. When asked, E23 told surveyor that R12 was not at risk for falls. E24 (nurse) also who worked with R12 before he fell on [DATE]. E24 was interviewed on 4/13/2011 at 12:01 PM. E24 said, "Before he broke his neck, they (nursing staff) say he (E12) was getting too confused." Before the day of R12's accident, E24 described R12 as as confused. E24 said, "You have to remind him, he was not to get up. He needs supervision to remind him not to get up. We have to still remind him not to get up now." E24 said that before R12 fell , he (R12) was not on fall precautions. After R12 fell , E24 told surveyor that an alarm was put on his bed and chair. During a meeting on 4/14/2011 with E1 (administrator) and E3 (director of nursing), the survey team expressed concerns that R12 had mental and physical limitations that put him at risk for falls. However, staff failed to identify and implement appropriate fall precautions until after R12 fell and sustained a Cervical 7 Fracture. E1 nor E3 provided any evidence to support that R12 was assessed appropriately or given nursing interventions/use of safety devices to prevent R12 from falling. E3 told surveyor that she just started a log to monitor and analyze residents falls in the last 3 months. E3 did not give any evidence to support that R12's fall assessment was correct and an appropriate plan of care implemented. Review of R12's MDS (Minimum Data Set) Assessment, dated 2/11/2011, document that R12 is a [AGE] year old male, with [DIAGNOSES REDACTED]. Review of R12's Fall Risk assessment dated [DATE] documented that R12 was assessed at risk for falls. However, review of R12's Fall Assessment did not identify all the factors that could lead to a fall, such as: -additional gait/balance problems -use of more than 1-2 medications that put him at risk for falls, such as: Hypertensive, Diuretic, Insulin and Psychoactive Medications -more than 2 medical diagnosis (Hypertension, Diabetes, Generalized Muscle Weakness and Amputation). These factors put R12 at a higher risk for falls, and there was no evidence they were considered. 2. Review of an incident/accident report for R10 dated 11/29/10 at 6:15 p.m. showed R10 was getting up from his chair in the dining room, got dizzy, and fell . Incident report documentation showed R10 was sent to a nearby hospital and admitted with [DIAGNOSES REDACTED]. Hospital CT (computerized tomography) scan of R10's head dated 11/29/10 showed results of a "moderate - sized hematoma along the right side of the scalp - right side of face." Diagnostic imaging of R10's right shoulder dated 11/29/10 showed results of "Evidence for acute minimally angulated fracture through the lateral margin of the clavicle". Review of R10's prescribed medications prior to this fall showed R10 was receiving 18 medications which included antihypertensives, antipsychotics, hypoglycemics, antidepressants, antianxiety, and pain medications. There was no documentation found in R10's medical record which showed R10's medications had been assessed as a possible cause of R10's dizziness and fall. Interview with E3 (Director of Nurses) on 4/13/11 verified that R10's medications had not been reviewed to see if they could have caused R10's fall. Review of R10's plan of care for falls dated 9/13/10 showed an approach which included "nurses to assess/review resident's medications for side effects i.e. hypotension, impaired balance, lethargy, etc..and report any evidence to M.D." During review of R10's nursing notes R10's blood pressure readings were noted to fluctuate drastically between 96/62 to 158/92. At the time of R10's fall R10 was ambulating with a cane. Interview with R10 on 4/13/10 at 11:30 a.m. noted R10 to say, "When I fell I was using a a cane. After I fell they gave me a roller walker to use." Review of R10's plan of care for falls dated 12/9/10 and 3/7/11 still showed approaches to "Ensure resident ambulates with use of a cane." There was no documentation on R10's fall plan of care showing R10 uses a roller walker for ambulation. Nursing documentation dated 3/30/10 also showed, "R10 using his cane to assist with his ambulation." Review of R10's fall assessment dated [DATE] showed R10's fall assessment was incorrect. R10's fall assessment was scored as a 5 with noted documentation that R10 was not at risk for falls. Upon review of R10's fall assessment it showed R10's assessment should have scored a 10 or more which would have placed R10 at high risk for falls.