Every finding on record at Park Place Transitional Care and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for mobility assistance were turned and repositioned every two hours or as needed to prevent the development of pressure injuries for 3 (#s 2, 3, and 9) of 9 sampled residents. Findings include:1. During an observation on 7/21/26 at 10:52 a.m. resident #2 was seated in her wheelchair. At 2:03 p.m., the resident was still up in her wheelchair. At 4:14 p.m., resident #2 was observed in bed with the head of the bed elevated. Resident #2 did not have her feet elevated off the bed. During an observation on 7/22/26 at 9:53 a.m., resident #2 was in bed with the head of the bed elevated. The resident was awake, and family was in the room. At 1:04 p.m., the resident was still lying in bed with the head of the bed elevated. Resident #2 was not observed out of her room at any time during that time period.Review of resident #2's care plan, with a revision date of 1/5/26, for activities of daily living, showed the resident needed substantial assistance for transfers and turning and repositioning. The care plan showed the resident was to be wearing heel protector boots at all times. Based on observations, the care plan was not followed for the heel protector boots.Interventions included:- checked and changed per routine nursing plan- bilateral half rails to aid in my bed mobility and repositioning- cares in pairs when catheter care is being performed- supervision to substantial staff assistance with bed mobility.During an observation on 7/22/26 at 1:04 p.m., resident #2 was lying in bed with the head of the bed elevated. The resident had no covers on and appeared to be sleeping. Heel protectors were not observed.During an interview on 7/22/26 at 1:08 p.m., staff members E and I stated resident #2 was out of bed for breakfast and was placed back in bed at 10:30 a.m. The resident had been assisted to her bed at 10:30 a.m., and was found in the same position at 1:04 p.m.During an interview on 7/23/26 at 5:46 a.m., staff member G stated the night shift completed 5 to 6 checks and changes for residents that needed assistance. During the night hours, staff rounded every two hours on all the residents on the units. Staff member G stated there were times when she would come on shift in the morning, and some residents' briefs were wet from the night shift due to not being changed when incontinent. During an interview on 7/23/26 at 3:48 p.m., staff member L stated resident #2 had a pressure ulcer on her right heel which reopened after 3-6 months of being closed. Staff member L stated the resident was to have heel protectors on at all times, but during this surveyor's observation (s), they were not in place. During an interview on 7/23/26 at 4:15 p.m., staff member C stated resident #2 was a focus for the facility, and they were currently completing audits for staff completion of ADLs. Staff member C stated there were no concerns, but when they identified a concern, they educated staff in real time. Review of resident #2's skin issue progress notes, dated 7/8/26, 7/13/26, and 7/20/26, showed the resident had a Stage III pressure ulcer to her right heel. Interventions for skin issues included a turning/repositioning program, positioning wedge, pressure-reducing device for the wheelchair, heel suspension, and pressure-reducing device for the resident's bed. Resident #2 was to be turned every two hours.Review of resident #2's Quarterly MDS with an ARD of 6/8/26, section GG, showed the resident was dependent on staff for hygiene, upper and lower body dressing, and substantial/maximal assistance for rolling right and left. The resident required a Hoyer (full body) lift for transfers. The resident was in a wheelchair while out of bed.Review of resident #2's Medication Review Report dated 7/1/26 through 7/22/26 showed a physician's order for turning and repositioning of both lower extremities for resident #2, with incontinence care every two hours for impaired skin integrity. The Physician orders were not followed per this surveyor's observations.2. During an interview on 7/22/26 at 3:14 p.m., NF 1 stated that when day shift started, there were some residents with wet briefs and their bedding was wet. NF1 stated some days there were two CNAs and some days there were two nurses and one CNA working on the 400 unit. The 400 unit had 54 residents. NF1 stated resident #3 was still in the hospital gown, and the resident's brief and bedding were wet on 6/27/26 and 6/28/26. NF1 stated staff members N and O were going to change resident #3 when they showered her on her regular shower day which was on Saturdays. NF1 stated the resident had not been fed, changed, or repositioned prior to 3:00 p.m., while the resident was waiting to be showered by staff, which was 9 hours after the day shift staff took over care. NF1 stated this happened two days in a row for resident #3, and when her skin was assessed, the resident had developed a blister.A review of resident #3's medical record showed no evidence of a blister. During an interview on 7/22/26 at 3:50 p.m., staff members A and C stated angel rounds were done daily to assess the care the residents received. Staff member C stated staffing levels are based on the acuity of the residents' care needs. Staff member C stated staffing is complex, and there are a lot of variables contributing to the needs of the residents. Staff members A and C stated they had not identified any concerns during angel rounds that needed to be addressed. During an interview on 7/23/26 at 5:46 a.m., staff member G stated there have been occasions when the residents were wet (incontinent) when she came on shift. Staff member G stated most of the time there was enough staff, and stated, If I don't get something done, I stay late and finish it, inferring the night staff did not do that. During an interview on 7/23/26 at 5:53 a.m., staff member H stated they (the staff) do rounds on the residents to check and change them. Staff member H stated she does not feel rushed on her shift.During an observation on 7/23/26 at 12:53 p.m., resident #3 was seated in her wheelchair in the common area. At 2:33 p.m., resident #3 was still seated in the common area in her wheelchair. At 2:53 p.m., resident #3 remained seated in her wheelchair in the common area. During an observation on 7/23/26 at 3:00 p.m., resident #3 was in her wheelchair in the common area. Review of resident #3's Quarterly MDS, with an ARD of 6/19/26, section GG showed the resident was dependent on staff for all ADLs, including mobility, hygiene, transfers, bathing, dressing, and rolling right and left. The resident could not reposition herself.Review of resident #3's comprehensive care plan showed the resident had a self-care performance deficit. Interventions included peri care after each incontinent episode and as needed, and the resident was dependent on staff for toileting needs. The resident's care plan showed she was at risk for impairment to skin integrity. The medical record did not show documentation of scheduled turning and repositioning for relief of pressure on the resident's skin/body when up in her chair. 3. During an interview on 7/23/26 at 3:20 p.m., staff member F stated he received a call at 1:30 p.m. on 6/28/26 to report resident #9 was wet (incontinent of urine), and all the resident's bedding was wet due to staff not providing care. Staff member F stated he spoke to the nurse and received information on the incident. Staff member F stated resident #9 was in the shower when he arrived at the facility at 2:00 p.m. Resident #9 and her roommate stated staff had been in and out of the room that day. Staff member F stated staff members N and O said the resident had been wet, but the bedding was not wet. Staff member F stated NF1 appeared overwhelmed and was communicating with staff inappropriately, including sending controversial notes to staff on shift about the incident due to being upset.Review of an incident report, sent to the State Survey Agency, on 6/28/26, showed NF1 phoned facility management to report care not being provided for resident #9. The incident showed the resident had not received incontinence care, and the bedding and the resident's brief were wet. The report showed the resident had not received care for approximately seven hours. When management arrived at the facility at 2:00 p.m., the resident had already had a shower, and her bedding had been changed. The resident was left in an incontinent brief for an extended period of time, as staff waited to bathe the resident rather than change the resident to a new brief, which compromised the resident's skin integrity.Review of resident #9's comprehensive care plan, with a revision date of 7/6/26 for ADLs, showed the resident had a self-care performance deficit. Interventions included peri care after each incontinent episode and, as needed, the resident needed to be checked/changed per routine nursing plan, and to assist with ADLs as indicated, and it showed avoid doing for me what I can do for myself. Review of resident #9's MDS, with an ARD of 5/21/26, section GG, showed the resident was substantial/maximal assistance with dressing and could do some ADLs with staff set up or touch assistance.

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents and hazards, failed to provide supervision necessary to prevent accidents related to falls, and failed to thoroughly investigate (including interviewing resident #129) and identify the direct root causes of falls for future fall prevention, for 4 (#s 5, 45, 156, and 160) of 29 sampled residents, and the falls resulted in resident #160 sustaining a hip fracture, resident #45 had a closed head injury, and #156 had a laceration above the eye; and the facility failed to ensure interventions and safety assessments were in place for a resident who was smoking on facility property, and who kept his smoking materials, and the facility reported they were a non-smoking facility, for 1 (#86) of 29 sampled residents. This deficient practice had the potential to place resident #86 or other residents at risk due to unsafe smoking practices and a lack of supervision. Findings include: 1. During an observation on 4/6/26 at 1:33 p.m., resident #160 was lying in bed on top of an air mattress with the bed in a high position. During an observation on 4/7/26 at 9:05 a.m., resident #160 was lying in bed, on top of an air mattress, with the bed in a high position. During an interview on 4/9/26 at 9:19 a.m., staff member L stated resident beds should not be left in a high position due to safety concerns and should only be elevated during care and returned to the low position when care is completed. During an observation and interview on 4/9/26 at 10:40 a.m., resident #160 was lying in bed on top of an air mattress; the bed was in the lowest position. Resident #160 stated that a couple of weeks ago, she fell out of bed because she had been repositioned too close to the edge of the bed, and the bed was high in the air. Resident #160 stated she sustained a hip fracture from the fall and spent three days in the hospital. Resident #160 stated she was quadriplegic and was dependent on staff for care. Review of the incident report and root cause analysis dated 3/27/26 at 6:40 a.m., showed staff identified the bed too high/low contributed to the fall. Review of resident #160's Interdisciplinary Team Risk Management Follow up, notes dated 3/27/26 at 2:20 p.m., showed: . Root Cause: resident fell out of bed onto the floor, . New interventions: resident placed on fall program; staff education on bed positioning . There was no documentation in the medical record of a fall program or implementation of other interventions for safety related to falls, and the resident's bed remained in a high position. 2. During an observation and interview on 4/6/26 at 2:45 p.m., resident #45 was lying in bed, and his bed was in a high position. Resident #45 had a bruise noted on his left forehead and eye area. The bruise was yellow and light green around the edges, with a lighter brown color near the forehead and eye. Resident #45 stated he sustained the bruise from his fall back in February. Resident #45 stated he was taken to the hospital for an evaluation at the time of the fall. During an observation on 4/8/26 at 10:03 a.m., resident #45 was lying in bed, and the bed was again in a high position. Review of resident #45's emergency room note dated 2/9/26 showed a diagnosis of a fall and a closed head injury; no fractures were noted. Review of resident #45's fall assessment dated [DATE] showed the resident scored a 35, a moderate risk for falls. During an interview on 4/9/26 at 2:10 p.m., staff member C stated it was the resident's preference to have the bed in a high position. Review of resident #45's Interdisciplinary Team Risk Management Follow-up, notes dated 2/9/26 at 4:15 p.m., showed: . Root Cause: resident fell out of bed . New interventions: PT to eval for side rails . [sic] There was no documentation in the medical record of other interventions implemented for safety related to falls for resident #45. 3. Review of resident #5's nursing note, dated 2/4/26, showed: Resident assisted back to bed, bed placed into the lowest position. During an interview on 4/7/26 at 2:11 p.m., NF5 stated resident #5's bed was often way too high when she would visit resident #5. NF5 stated that she was often scared that he might fall out of bed. NF5 stated that the day the facility called to tell her resident #5 fell out of bed, she said, I was so mad. NF5 stated the night nurse called NF5 to report the incident, and stated resident #5 had been leaning out of bed, and the night nurse had been helping another resident when resident #5 had fallen out of bed. NF5 stated she was unsure why a fall mat or bed rails were not utilized for the resident's safety if he was prone to falling out of bed. During an interview on 4/8/26 at 8:47 a.m., staff member T stated a nightshift nurse had not repositioned resident #5 to neutral as they were supposed to because resident #5 naturally shifted to his left side. Staff member T stated, I was quite angry (that resident #5 fell out of bed). Staff member T stated they thought resident #5 could have had a spasm, which could have contributed to his falling out of bed, but staff member T stated if resident #5 had been repositioned properly, he would not have fallen out of bed. Staff member T also stated the facility then got resident #5 a bariatric (wider) bed after the fall. Staff member T stated, Thankfully, he fell on his left side because his right skull is missing. Staff member T stated it was more common sense to reposition him more neutral because he would naturally shift to the left side. Staff member T stated a fall mat and bed rails had been talked about by administrative and facility staff, but nothing was ever implemented before his fall. Staff member T stated a fall mat was not used because of the high number of IV poles around resident #5's bed, and the fall mat had gotten in the way of the equipment. During observations of resident #5 (on 4/7/26 at 9:24 a.m. and 4/8/26 at 8:47 a.m.), no fall mat or bed rails were utilized. Review of resident #5's fall incident report, dated 2/4/26, showed: Resident assisted back to bed, bed placed into the lowest position. resident sent to ER for further evaluation . A request was made for resident #5's fall document to include root causes, IDT notes, the full investigation, interventions, and neuros. The facility provided an interview with resident #5 concerning questions if the resident felt safe and felt comfortable asking for help, but there was no documented attempt to ask the resident what occurred during the fall. No staff interviews were conducted. In the incident report, bed position was shown to be the only predisposing environmental factor. Also, the bed too high/low was shown to be a predisposing factor. The root cause documented on the IDT paperwork showed: resident slid out of bed onto the floor. The intervention implemented after the fall was a bariatric mattress. During an interview on 4/8/26 at 5:04 p.m., staff member C stated resident #5 did not have bed rails because of a concern of safety when the resident had spasms. Staff member C stated the facility was aware of the concern with resident #5 falling out of bed and had tried many interventions, and their resolutions had been working until this point. 4. Review of a staff interview of resident #156's fall on 3/27/26 showed, At around 10:25 a.m. resident's roommate yelled for help . Documentation was requested for the root cause, IDT, full investigation, interventions, neuros for [resident #156] . The documentation received by the facility showed predisposing factors included poor safety awareness. The facility failed to show a root cause, but rather explained the situation as Resident was discovered on the floor, on the left side of the bed. Resident was lying on the left side, head towards the head part of the bed near the bedside table. Resident had her left hand under her head, noted laceration top of left eyebrow. Upon nursing evaluation, EMS notified for resident to be transferred to a higher level of care. [sic] Resident interviews were included concerning if the residents felt safe in the facility, and one staff interview was conducted, which referred to the roommate. The roommate (resident #129) was not interviewed, and the roommate shared with the surveyor that four staff members responded to the incident. The roommate also shared that two hours prior to resident #156's fall, resident #156 showed possible symptoms of a TIA, and there had been a staff member in the room at that time. During an interview on 4/8/26 at 10:18 a.m., resident #129 (the roommate) stated she was getting care from a staff member when resident #156 fell in their room. Resident #129 stated resident #156 had mumbled muuu mu mu jelly two hours before the fall. Resident #129 stated she felt resident #156 had a little TIA. Resident #129 stated she had heard the thump when resident #156 fell. Resident #129 stated she was not asked by facility staff members what happened to resident #156. Review of a facility policy, titled Abuse Investigation and Reporting, revised 7/17, showed: . d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); . g. Interview staff members (on all shifts) who have contact with the resident during the period of the alleged incident . j. Review all events leading up to the alleged incident. Review of a facility document titled Fall and Fall Risk, Managing, undated, showed: . the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize the complications from falling. . 11. The facility can use the following interventions, but not limited to these interventions for the resident. Fall matt, 1:1, bed in the lowest position, .placing the resident on a fall program, or other interventions that are resident centered. [sic] 5. During an observation on 4/6/26 at 4:06 p.m., resident #86 left the facility in an electric wheelchair and went around to the back of the facility. Resident #86 was seen by a large blue dumpster and was observed to be smoking. During an observation on 4/7/26 at 10:45 a.m., resident #86 exited the facility in his electric wheelchair and went around to the back of the facility. Resident #86 was seen smoking a cigarette by a large blue dumpster near the back of the facility. During an interview on 4/7/26 at 11:03 a.m., resident #86 stated he was a smoker. Resident #86 stated that when he was admitted to the facility, he signed a form notifying him he could not smoke on the property, but went back by the blue dumpster because no one could see him there. Resident #86 stated he kept his cigarettes and lighter either on him or in his room. Resident #86 stated he did not sign out every time he left the facility, and stated he only signed out if he was going out with family or to the grocery store. Resident #86 stated the facility was aware he was smoking and told him he had to smoke off the property. During an observation on 4/7/26 at 1:37 p.m. and 4:05 p.m., resident #86 was smoking by the blue dumpster. During an interview on 4/7/26 at 4:15 p.m., staff member F stated residents were to sign out when they were leaving the facility or the property. During an observation on 4/8/26 at 9:25 a.m. and 10:30 a.m., resident #86 was smoking by the blue dumpster. Review of resident #86's resident sign-out log showed the last entry was on 3/30/26 at 12:45 p.m. During an interview on 4/8/26 at 3:18 p.m., staff member A stated the facility was a non-smoking facility, and resident #86 signed the acknowledgement upon admission. During multiple observations throughout the duration of the survey, resident #86 was observed leaving the facility unattended, smoking on facility property by a dumpster, and not signing out or back in when he returned. Facility staff were unaware of when the resident was outside smoking on facility property or when he left the facility. Review of resident #86's physician's orders dated 10/2025 - 4/9/26 showed no orders for smoking or smoking cessation options. Review of resident #86's comprehensive care plan showed no focus, goals, or interventions for smoking. Review of resident #86's admission or quarterly evaluations completed by nursing staff showed no completed assessments or evaluations related to smoking safety. Review of a facility policy titled Smoke Free Facility, undated, showed: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees. Therefore, this facility is a Smoke Free Facility. - This policy applies to all residents residing in the facility. - Smoking is prohibited in all areas of the facility. - Residents will be informed of the facility's Smoke Free Policy. and will be required to sign an acknowledgement of the policy upon admission. . 5. Residents with a history of smoking will be further assessed to determine whether or not interventions are needed . 6. Residents who smoke will be offered supportive materials regarding smoking cessation. . 8. Residents that are found smoking on facility grounds could be subject to discharge. Review of a facility policy titled, Resident sign out policy, undated, showed: . 2. Residents (or their representatives) must notify the unit nurse or charge nurse for short outings. . 4. All sign-outs and leaves of absence will be documented on the facility Sign-Out Logs, which includes resident name, date/time out, and signatures. [sic]

Based on observation, interview, and record review, the facility failed to ensure dietary staff in the kitchen preparing and serving food during meal service wore beard coverings, and failed to ensure kitchen refrigeration temperature logs were monitored and maintained. This deficient practice increased the risk for residents receiving food and meals which were prepared, served, and stored in the kitchen to experience negative food service safety outcomes. Findings include:During an observation on 4/6/26 at 1:02 p.m., staff member Y was preparing sandwiches in the kitchen, not wearing a beard net with visible facial hair.During an observation on 4/6/26 at 1:14 p.m., staff member X was in the kitchen serving food onto resident trays from behind a steam table. Staff member X did not have a beard net covering his facial hair.During an interview on 4/8/26 at 2:18 p.m., staff member W stated dietary staff working in the kitchen were expected to wear facial coverings if they had a grown beard or mustache. Staff member W stated she spoke with staff members X and Y about wearing a covering over their facial hair while working in the kitchen, after the surveyor observed them not wearing the facial coverings. Staff member W stated that staff members X and Y agreed to wear beard nets instead of shaving their facial hair. Staff member W stated she kept logs of daily refrigerator and freezer temperatures, which were monitored each month. Staff member W stated she did not know why two of the daily logs for refrigerators in the kitchen did not have any temperatures written for a couple of weeks in March (2026). Staff member W stated she thought the temperature logs had gotten misplaced somewhere. Review of a facility document titled Daily Freezer/Refrigerator Temperature Log, dated March (2026), showed that refrigerator R1 had a note of Lost these ones in the section for days 1-15. There were no twice-daily temperature checks written on the log for days 1-15.Review of a facility document titled Daily Freezer/Refrigerator Temperature Log, dated March 2026, showed that refrigerator R4 had a note of Lost these ones in the section for days 1-15. There were no twice-daily temperature checks written on the log for days 1-15.Review of a facility policy titled Dietary Employee Personal Hygiene, undated, showed: . It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. 4. Hair Restraintsa. All dietary staff must wear hair restraints (e.g., beard restraint) to prevent hair from contacting food.Review of a facility policy titled Monitoring of Cooler/Freezer Temperature, undated, showed: . It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit.a. Temperatures will be checked and logged at least twice per day by designated personnel.3. All refrigerated storage must be maintained at or below 41 F, unless otherwise specified by law.

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed by protecting patient health information from visitors for 3 (#s 79, 121, and 134) of 29 sampled residents and failed to ensure medication carts were locked when unattended. Findings include: 1. During an observation on 4/6/26 at 4:27 p.m., the medication cart on the 100 hall was not locked. No staff member was present at this time.During an observation and interview on 4/8/26 at 8:32 a.m., staff member Z left the medication cart open after medications were prepared for a resident and staff member Z entered the resident's room to administer the medications. After returning to the hallway, staff member Z stated the medication cart should always be locked to ensure a visitor or resident could not take medications in the cart. Staff member Z also stated the medication keys should be in her pockets at all times to prevent a visitor or resident from getting into a medication cart or rooms. Staff member Z stated the medication cart should always be locked if she was not near the cart and this was a skill that she learned in her training at school. Staff member Z stated this was not a skill that the facility provided, but was an overall expectation of all nurses, medication techs, or anyone administering medications.2. During an observation on 4/8/26 at 8:41 a.m., the computer monitor on hall 500 was unattended and patient information was clearly viewable.During an observation on 4/8/26 at 8:41 a.m., there were four boxes with patient information on the 500 hall medication cart without a staff member present.During an interview on 4/8/26 at 8:47 a.m., staff member T stated the four boxes (fluticasone for resident #134, diclofenac gel for resident #79, calcitonin spray for resident #121, and formoterol spray for resident #121) were to be disposed of, but staff member T had not gotten time to do this yet. Staff member T stated patient information should not be out for any visitors to see.During an interview on 4/8/26 at 5:04 p.m., staff member C stated patient health information should not be easily accessible to visitors. Staff member C also stated medication carts should be locked at all times when a staff member was not present and the medication keys should never be located on top of the carts.Review of a facility policy, titled Medication Storage, no date, showed: . All drugs and biologicals will be stored in locked compartments .

Based on interview and record review, the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) in accordance with the Resident Assessment Instrument (RAI) Manual for 1 (#126) of 29 sampled residents. This deficient practice had the potential to affect quality measures, and care planning related to diabetes management. Findings include:Review of resident #126's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/23/26, showed under Section N (Medications), item N300 (number of injections received in the last 7 days) was coded as 7, and item N350 (number of days insulin injections were received) was coded as 7.Review of resident #126's physician's orders, dated 1/23/26, showed, Victoza Subcutaneous Solution Pen-injector 18 MG/ML (Liraglutide) Inject 0.6 mg subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS. [sic] Victoza is a GLP-1(Glucagon Like Peptide-1), which is a hormone that is used for weight loss and diabetes and is not considered insulin.During an interview on 4/9/26 at 11:12 a.m., staff member F stated she was responsible for completing section N of the MDS and recognized she coded Victoza as insulin because the diagnosis on the order was for Diabetes Mellitus Type II, but did not verify the medication class. Staff member F stated she had training on MDS completion and was familiar with the RAI Manual.Review of the MDS 3.0 RAI Manual, with a revision date of 10/2025, Chapter 3, Section N, showed: . 1. Review the resident's medication administration record for the 7-day look back period.2. Determine if the resident received insulin injections in the look back period.

Based on observation, interview, and record review, the facility failed to include interventions related to catheter care on the care plan for 1 (#6) of 29 sampled residents. Findings include:During an observation and interview on 4/7/26 at 11:37 a.m., resident #6 was sitting in her wheelchair in her room and an indwelling catheter tube was coming out of the bottom of her pajama pants. NF3 stated the facility was continuing catheter use for resident #6 due to incontinence and the resident wanted the catheter due to convenience.During an interview on 4/9/26 at 9:25 a.m., staff member D stated catheter interventions should be on a resident's care plan.Review of resident #6's care plan, dated 3/11/26, reflected a lack of catheter care interventions.

Based on interview and record review, the facility staff failed to review and revise the comprehensive care plan to reflect changes in resident conditions for 1 (#91) of 29 sampled residents. This deficient practice increased the risk of staff not monitoring or providing cares related to resident #91's treatment for pneumonia with an antibiotic. Findings include:During an interview on 4/9/26 at 11:09 a.m., staff member N stated she had a list of residents taking antibiotics used to treat infections. Staff member N stated she would update a resident's care plan with problems and interventions when a resident was identified to have an infection. Staff member N stated resident #91 had enhanced barrier precautions as an intervention in her care plan. Staff member N stated enhanced barrier precautions would cover part of the droplet precautions to use for a resident diagnosed with pneumonia. Review of resident #91's provider progress notes, dated 3/24/26, showed: . Patient experienced 2 episodes of emesis on March 24, 2026, with 4 hours of nasal congestion since this morning. Patient afebrile. Chest x-ray ordered to rule out pneumonia.Review of resident #91's provider progress notes, dated 3/25/26, showed: . Physical examination revealed mild crackles in left lower lobe on exam. Effusion being monitored in context of pneumonia treatment. Will continue supportive care and reassess response to antibiotic therapy.Lobar pneumonia. Chest x-ray obtained March 24, 2026 showed left lower lung infiltrate and/or atelectasis consistent with likely early development of pneumonia. Based on normal renal function and amoxicillin allergy, levofloxacin 500 mg by mouth once daily for 7 days was ordered. [sic]Review of resident #91's comprehensive care plan, revised 1/5/26, showed, - An intervention for Enhanced barrier precautions due to having catheter. Gowns and gloves required for all contact cares, and- A problem of RESPIRATORY: . at risk for respiratory decline and infection related to chronic obstructive pulmonary disease, recent pneumonia infection, history of pulmonary embolism, dysphagia, and multiple sclerosis.Resident #91's care plan failed to include revisions for a problem, goal, or interventions related to antibiotic treatment for pneumonia initiated on 3/25/26 for seven days, and did not include updates to transmission-based precautions to use when caring for resident #91.Review of a facility policy titled Comprehensive Care Plans, revised 4/5/26, showed: . 3. The comprehensive care plan will describe, at a minimum, the following:. a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. h. Any infection control interventions/guidelines established by the CDC deemed appropriate as indicated by resident condition/status. 9. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview, and record review, the facility failed to complete a reweight with a resident having a 22% weight loss (severe weight loss) after one week for 1 (#72), and failed to complete monthly follow ups with a resident who voiced concern about her consistent low weight for 1 (#110) of 29 sampled residents. Findings include:1. Review of resident #72's EHR showed an initial weight of 207.8 pounds (on 2/10/26). Resident #72's next weight (on 2/22/26) was 170 pounds. This is a 22.2% weight loss in a week.Review of resident #72's Care Plan, revised 2/21/26, showed: . Notify registered dietician and medical provider of weight loss greater than 5 pounds.During an interview on 4/9/26 at 7:50 a.m., staff member BB stated a fifty-pound weight loss in a week was most likely due to an incorrectly obtained weight, such as from equipment.During an observation and interview on 4/9/26 at 7:52 a.m., staff member AA stated resident #72 had come into the facility with a wheelchair from the hospital. Staff member AA stated that those wheelchairs almost always weighed about 50 pounds. Staff member AA stated the process for obtaining a weight was to get the weight with the wheelchair and the resident, then to get the weight of just the wheelchair, so the weight of the resident could be calculated. Staff member AA weighed resident #72's current wheelchair and showed the weight to be 53.1 pounds.2. During an observation and interview on 4/6/26 at 2:22 p.m., resident #110 stated she would like to gain weight and stated her clothes were starting to get too big on her. She stated the facility did not offer her any snacks that she enjoyed. Resident #110 stated the facility offered pudding and Jello, but resident #110 did not consider this to be a snack for her. Resident #110 stated she had her family and friends bring in snacks because she did not like the snacks offered. Resident #110 stated she liked sweet snacks such as ice cream but often stated that by the time the facility delivered the ice cream, it was melted. No snacks were observed at her bedside.During an interview on 4/9/26 at 8:58 a.m., resident #110 stated she was offered snacks a few times, but they were usually late at night (after 9:00 p.m.) when she did not want any and was already asleep.Review of resident #110's EHR showed a nightly snack was offered, but the resident was documented as being unavailable nine out of thirty days. Refer to the dates and times listed below:-3/10/26 at 9:07 p.m.,-3/13/26 at 8:49 p.m.,-3/14/26 at 8:53 p.m.,-3/18/26 at 10:33 p.m.,-3/19/26 at 9:05 p.m.,-3/24/26 at 10:02 p.m.,-3/27/26 at 9:29 p.m.,-4/6/26 at 10:20 p.m., and-4/7/26 at 9:53 p.m.Resident #110's current weight (on 4/7/26) was 77 pounds. From 3/5/25, resident #110's weight had averaged 70 to 80 pounds.A request was made for documentation related to any notes, care plans, etc., related to . [resident #110]'s weight loss. The following was found:Review of resident #110's dietician's note, dated 1/10/26, showed: . Dietician to revisit with her if her weight is down again.Review of resident #110's dietitian's note, dated 4/3/26, showed: . 6.25% weight loss in less than 1 month. There was no dietitian documentation in February or March 2026.During an interview on 4/8/26 at 4:00 p.m., staff member Q stated resident #72 was on the hall that she did not cover, but stated after the large difference between the admission and second weight, there should have been a reweight. Staff member Q stated for resident #110, there should be at least monthly evaluations, notes, or care plan meeting notes because staff member Q was meeting with her that frequently. Staff member Q stated monthly meetings were required for a resident who had weight loss or if weight was a concern. Staff member Q stated resident #110 was a picky eater, and finding foods that she enjoyed was a challenge. Staff member Q stated fortified foods were not implemented for resident #110, as staff member Q stated resident #110 did not want to gain weight. Staff member Q stated resident #110 was on a regular diet and stated the facility did have products such as a high-calorie dense pudding, but resident #110 was not receiving items like this.

Based on observations and interview, the facility failed to ensure appropriate and safe PEG tube practices were followed for 1 (#5) of 29 sampled residents. Findings include:During an observation on 4/7/26 at 9:24 a.m., resident #5's PEG tube was unclamped and unhooked from any tubing.During an observation and interview on 4/8/26 at 8:47 a.m., resident #5's PEG tube was unclamped, and still hooked up to the kangaroo pump with the enteral nutrition not running. Staff member T stated the kangaroo pump had been turned off at 6:30 a.m. and the tubing should have been flushed, clamped, and unhooked from the resident. Staff member T looked at resident #5 and stated, She got me there. Staff member T had been referring to the PEG tube being incorrectly still being hooked up and unclamped. Staff member T stated they did not worry about a clogging PEG tube as often with this resident due to the larger circumference of the PEG tubing.According to the University Hospital PEG tube feeding guidelines, a PEG tube should be clamped after being flushed with water (University Hospitals, 2025). References:University Hospitals. (2025, June). PEG Feeding Tube Guide. Retrieved from https://www.uhhospitals.org/-/media/files/services/cancer/patient-education/peg-tube.pdf

Based on observation, interview, and record review, the facility staff failed to adhere to nationally recognized standards of hand hygiene when passing meal trays for 2 (#s 85 and 92) of 2 supplemental residents sampled for infection control during meals. This deficient practice had an increased risk of transmitting infections to all residents who received meals in the dining room. Findings include:During an observation on 4/8/26 at 12:05 p.m., staff member K obtained a meal tray from the kitchen and placed it on a dining room table without performing hand hygiene. Staff member K removed the plate cover and left the area. Staff member K walked back to the kitchen and obtained another meal tray and delivered it to resident #85 without performing hand hygiene.Staff member K walked over to resident #92 and grasped the wheelchair handles and pushed her to the dining room table where the uncovered meal tray had been placed and proceeded to handle resident #92's silverware without performing hand hygiene between contact with the wheelchair and the meal tray items.During an interview on 4/8/26 at 12:20 p.m., staff member K stated he was a new employee and had been educated on hand hygiene prior to starting his first shift. Staff member K stated he should have completed hand hygiene between residents and meal trays.Review of a facility document titled, Hand Hygiene, undated, showed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.1. Staff will perform hand hygiene when, indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. [sic]Review of a facility document titled, Hand Hygiene Table, undated, showed:In the column under Condition showed . Between resident contacts, . After handling contaminated objects and . when in doubt. an X was placed showing Either Soap and Water or Alcohol Based Hand Rub.

Based on observation, interview, and record review, the facility failed to ensure current, readily available results of surveys completed by the State Survey Agency were located in a publicly accessible area. This deficient practice increased the risk of residents to be uninformed of oversight agency findings as required by the rights of long-term care residents. Findings include:During an observation and interview on 4/8/26 at 11:22 a.m., a wall-mounted file holder labeled Survey Results was located by the entrance of the building near the reception desk. The holder had a binder with documents inside that contained State Survey Agency survey reports. The binder failed to include a report for the 2025 recertification survey. Staff member N walked towards the hallway next to the wall where the survey results binder was located. Staff member N stated she would check to see why last year's survey results were not in the binder.During an interview on 4/9/26 at 11:43 a.m., staff member A stated she did not know why the survey results binder did not include survey results from last year. Staff member A stated she was not sure why the survey report and plan of correction for 2025 had been removed. Staff member A stated she usually checked the binder closer to annual survey time, maybe two weeks before the time of the survey, to see that results were there. Staff member A stated the same thing happened last year during the annual survey.Review of a facility document titled Resident Rights, not dated, showed: . 6. Information and Communication. k. The resident has a right to:i. Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility.

Based on observation, interview, and record review, the facility failed to ensure a system was in place, so grievance forms were readily accessible without staff needing to assist in the provision or acceptance of a grievance form, and that grievances received were secured to maintain confidentiality. The deficient practice was widespread and may affect any resident, family member, or visitor who wishes to complete and or submit grievances without staff assistance or maintain confidentiality. Findings include:During an observation on 4/7/26 at 9:10 a.m., the door to the social services office was closed, and residents and staff members were passing through the hallways near it. A wall-mounted file holder was located on the wall outside the door to social services. Grievance forms were inside the holder, with writing and completed forms that showed resident names and information. The folder holding the completed forms was not secured to maintain confidentiality. During an observation on 4/8/26 at 10:18 a.m., residents and staff members on the 400 unit were moving through the common area near the nurses' station and down hallways. There was no visible holder or signage for grievance forms on any walls or throughout the unit.During an observation and interview on 4/9/26 at 10:51 a.m., staff member R was sitting with another staff member at the nurses' station at the end of the 200 unit. Staff member R stated residents would have to ask staff for a grievance form to fill out. Staff member R stated that grievances were kept in a desk at the nurses' station. Staff member R stated if a resident had a question about a grievance, they could be directed to the social services office at the end of the unit. There were no grievance forms readily available on the unit for residents to access without staff having to assist. During an observation and interview on 4/9/26 at 11:08 a.m., staff members S and T were sitting at the nurses' station on the 500 unit. Multiple staff members were present and walked through the hallways of the unit. There were no visible holders or signs for grievances in the unit. Staff member T stated she would look to see where grievance forms were when asked for one. Staff member T looked through some drawers of a desk at the nurses' station to find forms. Staff member S stated residents on the 500 unit could bring grievances to the drop box outside of social services. Staff member S stated if residents could not get to the social services office, staff could bring their grievances down to drop them off for them. During an interview on 4/9/26 at 11:34 a.m., with staff members A and V, staff member V stated he was the grievance official for the facility. Staff member V stated residents could fill out grievances, or staff could assist them. Staff member V stated that residents could verbally give information for grievances to be filled out. Staff member V stated residents could put completed grievances in the box on the wall outside of his office (which was not secured for confidentiality). Staff member V stated residents could also push grievance forms through the bottom opening of the door on the floor to the social services office. Staff member A stated that the box on the wall outside the social services office was not locked. Staff member A stated the facility did not have any locked drop boxes for grievances in the building.Review of a facility document titled Resident and Family Grievances, not dated, showed: . It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. 2. Social Services Department is responsible for . maintaining the confidentiality of all information associated with grievances. 7. Information on how to file a grievance or complaint will be readily available throughout facility. 9. A grievance may be filed anonymously.10. Procedure:. iii. All staff involved in the grievance investigation or resolution will take steps to preserve the confidentiality of files and records relating to grievances . [sic]

Based on observations, interviews, and record review, the facility failed to ensure a resident with a history of elopements had a Wander guard in place and doors were secured for 1 (#1) of three sampled residents with elopements; and failed to ensure staff were aware of and employing appropriate fall interventions for 1 (#3) of 5 sampled residents with fall risks. Findings include:1. Review of a facility reported incident investigation indicated resident #1 eloped from the facility on 6/23/25 at approximately 8:00 p.m. and was found 7 blocks away and returned to the facility. A BIMS was completed and indicated resident #1 had a BIMS of 4/15, severely impaired. Review of resident #1's EHR reflected that resident #1 was admitted on [DATE] at 10:38 a.m. and had an elopement risk score of 1.0.Review of resident #1's nursing progress note, dated 6/23/25 at 3:15 p.m., reflected that a wander guard was placed on resident #1's left ankle. Review of resident #1's Baseline Care Plan, dated 6/23/25, reflected that resident #1 was not an elopement risk.Review of resident #1's referral notes, faxed 8/3/25, reflected that resident #1 had made little progression at [Facility Name] and had agitation, aggression, and continual exit-seeking behaviors. The referral also reflected the referring facility had a wander guard in place.During an interview on 8/5/25 at 10:50 a.m., staff member B stated resident #1 was not wearing a wander guard on admission because the facility's process required the resident to show a risk for elopement after admission, rather than based on a history of elopement. Staff member B stated that admission nurses were not given the opportunity to review the referral documents because the facility did not want the nurses to enter the admission assessments based on bias from the resident's history. During an observation and interview on 8/6/25 at 9:40 a.m., staff member M stated he was doing his weekly checks of the door alarms. The following observations were made during the walk-through:The 300-hall exit door alarmed when opened but was so quiet, the alarm could not be heard down the hallway.The 400B-hall exit door did not turn on. The alarm had been turned off.The 400A-hall exit door did not turn on. The alarm had been turned off.The 500-hall exit door by therapy did not have a lock. The door remained open to the public for therapy services.The back kitchen door was propped open with a rock, and a staff member was smoking outside the door.Staff member M stated that the nurses repeatedly unlock the alarms to go outside and smoke. Staff member M stated the facility had taken the keys away from the nurses because they left the alarms off, but then were receiving too many calls at night for alarms, so the keys were given back. Staff member M stated that a sign-out sheet was in the storage room for staff to get the key. Staff member M stated, They just need to take the keys away again. Staff member M then went to the nurse's station and notified the nurse that the doors were unlocked. Staff member H stated, Ok and returned to her computer work. Review of the Emergency Exit Key Sign-Out Log, not dated, reflected only one sign out on 7/18/25 to the 400B hall, and the signature was illegible. During an interview on 8/6/25 at 10:35 a.m., staff member A stated the keys had been taken away because nurses were unlocking the alarms and not relocking them. Staff member A stated she thought the problem had been addressed and only the nurse had access to the key. Staff member A stated she was not aware of the sign-out sheet. Review of the facility's policy, Elopements and Wandering Residents, no date, reflected: - This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.- a. Residents will be assessed for risk of elopement and unsafe wandering upon admission .2. During an interview on 8/5/25 at 12:10 p.m., staff member E stated the 300-hall only had four residents at high risk of falls. Staff member E stated he would know who a high fall risk was based on whether the resident had a mat next to their bed. Staff member E stated all residents at risk of falls receive a fall mat next to their bed. When asked about interventions for each resident, staff member E stated he follows the same interventions for all fall risks, including transfer based on care plan, shoes or socks for all, and toileting during rounds. Staff member E stated he was not aware of individual interventions for residents in their care plans.Review of the roster for 300-hall, not dated, reflected eight residents with a High fall risk.3. Review of the roster for 400-hall reflected 38 residents with, High fall risk.During an interview on 8/6/25 at 7:45 a.m., staff member G stated all residents were at risk of a fall. Staff member G stated he would look up each resident on the computer to determine what their care plan says, so he just keeps an eye on them all to help stop falls. Staff member G stated he only knew of one resident who was a high fall risk. Staff member G stated he was not aware the roster showed 38 high fall risks on the hall and did not know what their individual interventions included.During an interview on 8/6/05 at 8:00 a.m., staff member H stated she thought a sign or something else was on the door if the resident was a high fall risk. Staff member H stated that the only resident on 400-hall that she knew was a high fall risk was the second door down the hall. Staff member H stated that the resident had a low bed, but staff member H did not know of any other interventions for her or the other high fall-risk residents on the unit. 4. During an observation on 8/6/25 at 8:08 a.m., resident #3 was in her bed yelling and trying to get out of bed, with her feet tangled in the sheets. Nurses and CNAs were gathering residents and setting them up in the dining area next to resident #3's room. During a 37-minute observation period no one entered resident #3's room. Resident #3 continued to yell and cry out. Resident #3 untangled her feet and stood up between the bed and the wheelchair. Resident #3 stood and stared at the wheelchair while yelling out. At 8:45 a.m., resident #3 turned herself and sat in the wheelchair. During an interview on 8/6/25 at 8:46 a.m., staff member G stated that resident #3 yelled out all the time. Staff member G stated she (resident #3) just yells throughout the day and night, but she can get up on her own. During an interview on 8/6/25 at 8:55 a.m., staff member A stated she had heard resident #3 yelling, and she and a CNA assisted her to get dressed and ready for the day just before this interview. Staff member A stated resident #3 did yell throughout the day, and the staff had a hard time differentiating between her calling for help and her calling out at the hallucinations she had throughout the day. During an interview on 8/6/25 at 11:52 a.m., staff member B stated the resident rosters were completed by the unit managers and given to staff, so the CNAs and nurses were aware of the resident's fall risks, infection risks, and code status. Staff member B stated that the nursing staff should know which resident was a fall risk and what fall interventions were in place. Staff member B stated no signs were on the doors or in the resident rooms for showing who was a fall risk, due to resident dignity. Review of the 400-hall roster reflected that resident #3 was a high fall-risk.Review of the Incidents Fall report, dated 2/5/25 to 8/5/25, reflected that resident #3 had four falls in the past four months. Review of the facility's policy, Fall Prevention Program, not dated, reflected:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment in resident rooms for 2 (#11 and 15); ensure the proper-storage and emptying of full urinals for 2 (#s 16 and 17); and ensure proper disposal of trash/recycling for 2 (#s 4 and 5) of 22 sampled residents. Findings include: 1. Recycling:a. During an observation on 8/6/25 at 11:10 a.m., resident #4 had nine soda pop cans on the floor, next to the bed, which were empty. Resident #4 was unable to answer questions as to why the empty cans were on the floor. b. During an observation and interview on 8/6/25 at 11:41 a.m., resident #5 had nine empty bottles of soda and 11 empty cans of soda pop on the floor, next to his bed, which were empty. Resident #5 stated he did not know where the recycling was located, so he left the items on the floor. A trash/recycling policy was requested on 8/6/25 at 12:55 p.m. Staff member A stated the facility did not have a policy specific to trash/recycling and cleaning of resident rooms. 2. During an observation and interview on 8/6/25 at 12:05 p.m., resident #11 had a suction machine on the floor between her bed and her nightstand. Resident #11 stated that the staff recently used the suction machine when she was having trouble breathing.Review of resident #11's nursing progress notes, dated 7/17/25, reflected respiratory therapy and the notes showed, .orally suctioned (with a yanker) for a large amount of thick white yellow secretions.3. During an observation and interview on 8/6/25 at 12:07 p.m., resident #15 had an incentive spirometer on a tabletop, sitting on his bed, with a partially filled urinal touching the mouthpiece of the incentive spirometer. Resident #15 stated he used the spirometer during the day. Resident #15 had a cup of water on the table. When asked how he had his urinal emptied, he stated he would have it emptied by the staff when he sees them. During an interview on 8/6/25 at 11:45 a.m., staff member K stated that respiratory therapy was responsible for checking respiratory machines, changing cannulas, and humidifiers. Staff member K stated the suction machine should never be stored on the floor.Review of the facility's policy, Cleaning and Disinfection of Resident-Care Equipment, no date, reflected: .f. For durable medical equipment, such as feeding pumps, staff shall store used/dirty equipment in the soiled utility room. The central supply clerk shall be responsible for terminal cleaning/disinfection in designated locations, covering the equipment to prevent dust and other contamination, and storing in the clean utility or other designated storage rooms.4. During an observation on 8/6/25 at 12:09 p.m., resident #16 had a full urinal sitting on the heater in his room. Resident #16 stated he did not want to be interviewed. 5. During an observation and interview on 8/6/25 at 12:12 p.m., resident #17 had a full urinal on the floor next to his bed, and there was urine spilled on the floor. Resident #17 stated he assumed someone would empty the full urinal, but did not know who or when it would be emptied. Review of the facility's policy, Disinfection of bedpans and urinals, no date, reflected:3. If the resident uses the bedpan and urinal at will, do not allow placement on the floor or on a bedside table that is used for eating or drinking.During an interview on 8/6/25 at 12:15 p.m., staff member C stated the resident should call and notify of the assistance needed, and the CNAs should be emptying the urinals immediately; they should be stored in a bag in the resident's nightstand, and urinals should not be on a table with an incentive spirometer and drinks. Staff member C stated that respiratory equipment should not be stored on the floor or near a urinal. Staff member C stated she was not aware of residents keeping empty soda pop cans in their rooms.

Based on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure ulcer did not develop a pressure ulcer for 1 (#10) of 2 sampled residents with pressure ulcers. Resident #10 was admitted with intact skin on the sacrum and developed a Stage III pressure ulcer which progressed to a Stage IV with healing not achievable. The resident did have refusals of care, and the facility implemented interventions for wound prevention, but failed to identify the wound timely and prevent further deterioration or infection, of the wound, and implement and monitor sufficient intervetnions for healing, or resolve the resident's concerns with refusals and pain management which hindered wount healing. Findings include: During an observation on 4/21/25 at 2:32 p.m., resident #10 was seated in her wheelchair. Review of resident #10's Care Plan, initiated 3/31/25, showed the resident was to be in her wheelchair for only one hour, three times daily, at meals. Review of resident #10's turn and turn and reposition task documentation, dated 3/26/25 through 4/24/25, had not shown documentation for repositioning every two hours. During an interview on 4/24/25 at 8:48 a.m., staff members H and P stated resident #10 was dependent on staff for all her care needs. Staff members H and P stated the resident's son came in daily to assist her with meals. Staff member H stated skin interventions for resident #10 were an air mattress, reposition every hour, use a wedge behind her when in bed, and a cushion in the resident's wheelchair. Staff member H stated the resident sometimes refused to be repositioned. Staff member H stated she made rounds frequently to ensure the resident was being repositioned. During an interview on 4/24/25 at 9:23 a.m., staff member EE stated resident #10 went to the wound clinic. Staff member EE stated resident #10 had refused turning and repositioning, occasionally. Staff member EE stated the resident was at higher risk for pressure ulcers because of the resident's medical co-morbities. Review of resident #10's Nursing-Clinical Admission Evaluation, dated 7/8/24, showed a scar on the resident's coccyx, a pressure wound to the right ankle, and a pressure wound to the right gluteal fold. The resident did not have a pressure wound on her sacrum, per the clinical admission evaluation. Review of resident #10's Skin and Wound Evaluations, dated 8/29/24 through 4/21/25, showed the following: - On 8/29/24 a Stage III pressure wound to the resident's sacrum was identified. Measurements were 1.3 cm x 1.5 cm x 0.2 cm (length x width x depth) - From 9/10/24 through 12/10/24 the resident's pressure wound was documented as a Stage III, which began undermining on 11/11/24, and as of 11/18/24, the Stage III pressure wound was undermining and measuring 1.5 cm and tunneling, measuring 2.0 cm. - On 12/18/24, the pressure wound was classified as a Stage IV with undermining. Measurements were 2.8 cm x 1.8 cm x 2.3 cm, with 3.0 cm of undermining, showing interventions were not successful for helping prevent further deterioration of the wound, and on 12/23/24, the pressure wound was classified as a Stage IV measuring 3.0 cm x 2.4 cm x 2.0 cm with 2.8 cm of undermining. From this date to 2/24/25, the wound measurements varied, but staff were not consistent on the wound documentation related to the status, size, and tunneling. - On 4/21/25, the pressure wound measured 2.2 cm x 1.3 cm x 1.3 cm with 2.3 cm of undermining. - Review of resident #10's Skin and Wound Evaluations showed inconsistent measurements and failed to identify undermining and tunneling consistently. Review of resident #10's wound care orders and TARs showed the dressing changes were to be done either daily, or every other day, depending on the order at the time. It was found not all changes occurred as ordered by the physician. Review of resident #10's TAR showed dressing changes were not documented for 8/28/24, 8/29/24, 10/9/24, 10/19/24, 10/23/24, 10/25/24, 11/11/24, 1/7/25, 1/15/25, 1/26/25, 2/5/25, 3/14/25, 4/7/25, 4/15/25, and 4/19/25. From 8/20/24 through 11/11/24, dressing changes were to be done one time daily, but did not occur at least 6 times. The TAR reflected incomplete information related to the treatment of the wound. Review of resident #10's Skin and Wound Evaluation, dated 10/28/24 showed the provider identified an infection in the resident's wound. Review of resident #10's MAR, dated 10/2024 through 12/2024, showed the following orders for antibiotics: - 10/22/24, Bactrim DS 800-160 mg two times daily for 20 days for sacral wound with cellulitis - 10/25/24, metronidazole 500 mg three times daily for cellulitis/sacral ulcer for 14 days - 10/28/24, Ampicillin-sulbactam sodium intraveneously every six hours for cellulitis/sacral wound infection for seven days - 11/30/24, Bactrim-DS 800-160 mg two times daily for 10 days for sacral wound infection. Review of resident #10's Care Plan, with an initiation date of 10/25/24, showed the resident had a wound, but it was not identified where the wound was on the resident's body, nor was the severity of the wound. The Care Plan showed the following interventions for skin integrity and alteration in skin integrity: - Administer treatment as ordered. Initiated on 10/25/24. Revised on 10/28/24 - Air mattress. Initiated on 7/25/24. Revised on 1/20/25 - Turn and reposition every two hours. Initiated on 7/25/24. Revised on 1/20/25 - Assess, record, and monitor wound healing. Initiated on 10/25/24. Revised on 10/28/24 - Cushion in chair. Initiated on 11/14/24. Revised on 4/22/25 - Positioning wedge while in bed. Initiated on 3/25/25. - Assess the level of pain and administer pain medication prior to dressing changes, initiated on 10/25/24 and revised on 4/22/25 Review of resident #10's Progress Note, dated 3/25/25, showed the resident refused Ultramist treatments, due to pain during and after, the procedure. There were no documented pain management interventions prior to the wound treatment procedures. Review of resident #10's Physician Progress note, dated 1/27/25, showed the resident was to have hydrocodone, as needed for pain, especially with dressing changes. During an interview on 4/24/25 at 11:14 a.m., staff member Y stated resident #10 was to be repositioned every two hours. Staff member Y stated she checked on the resident at the start of every shift. Staff member Y stated the resident did not normally refuse to be turned. During an interview on 4/24/25 at 11:18 a.m., staff member Z stated she made sure the resident was turned and repositioned on time. Staff member Z stated the resident was usually turned every one to two hours. Staff member Z stated a wedge was used to keep the resident in position. Staff member Z stated the resident had an air mattress. Staff member Z stated if the resident refused it was documented and she would notify the nurse.

Based on observation, interview, and record review, the facility failed to properly store, label, date, and discard food items by the use by date, in the backroom cooler in the kitchen; and failed to monitor refrigerator and freezer temperatures, in the refrigerator next to the juice dispenser, in the kitchen. These failures may affect any resident using or receiving items from the refrigerator or freezer. Findings include: 1. During an observation on 4/21/25 at 12:50 p.m., the following items were observed in the back room cooler in the kitchen: - tortillas opened and wrapped in cellophane with a use by date of 10/18/24, - a food item which resembled a potato, wrapped in aluminum foil, not labeled or dated, - a stainless-steel pan labeled beef was not dated, - mushrooms in a plastic bag were not labeled or dated, - hotdog's, in a stainless-steel pan, were opened and not covered, labeled, or dated, - a food item which resembled cooked, ground beef, stored in a stainless-steel pan, was not labeled or dated, - an item labeled deli ham stored in a stainless-steel pan was not dated, - sausages stored in a stainless-steel pan were labeled 4/7, and - a food item labeled chicken was dated 4/9 and 4/13. During an interview on 4/21/25 at 12:53 p.m., staff member V stated the use by date was seven days after the food item was opened. Review of the facility's policy and procedure titled, Food Safety Requirements, with a revision date of 1/14/25, showed: .Policy Explanation and Compliance Guidelines: . 3. Facility staff shall .ensure timely and proper storage. c. Refrigerated storage . Practices to maintain safe refrigerated storage include: . iv. Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen (where applicable)/discarded . 2. During the initial observation in the kitchen on 4/21/25 at 12:58 p.m., the refrigerator, located to the left of the juice machine, did not have a temperature log monitoring temperatures in the refrigerator and the freezer. During an interview on 4/23/25 at 12:15 p.m., staff member U said the refrigerator temperatures should be monitored for all refrigerator units. Review of the facility's policy and procedure titled, Food Safety Requirements, with a revision date of 1/14/25, showed: .Policy Explanation and Compliance Guidelines: . 3. Facility staff shall .ensure timely and proper storage.c Refrigerated storage . Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation .

Based on observation and interviews, the facility failed to provide a home like setting and correct and control odors emanating on the 400B hallway, for 2 (#s 114 and 130) of 39 sampled residents. This deficient practice affected those residents who resided on the 400B hallway and their visitors, due to the unpleasant odors. Findings include: During an observation on 4/21/25 at 3:24 p.m., there was a strong smell of urine observed in the 400B hallway. During an observation on 4/22/25 at 9:43 a.m., an overwhelming, undesirable smell of urine was present throughout the 400B hallway. During an interview on 4/23/25 at 4:20 p.m., NF4 stated resident #114 had always kept a clean and tidy home before her dementia diagnosis. NF4 stated the strong smell of hallway 400B would not have been tolerated by resident #114, but due to the diagnosis of dementia, she was not the same person. During an interview on 4/23/25 at 4:24 p.m., NF3 stated he had a concern when his mother, resident #114, was moved to the 400B hallway due to the overwhelming strength of the smell. NF3 stated a room replacement was discussed with social services, but this room was the only option. NF3 commented, You can smell it when you come down the hall. NF3 stated the facility sprayed odor ban in the room before she moved in, and they over did it and caused a negative effect of coughing for resident #114. NF3 stated he brought in a bottle of air freshener, but I can't help the whole building. NF3 further stated he brought in a fan and planned to bring an air purifier to help with the smell. During an interview on 4/23/25 at 4:40 p.m., resident #130 stated, sure stinks in here. During an observation on 4/24/25 at 8:58 a.m., the malodorous smell was again observed throughout 400B hallway.

Based on observation, interview, and record review, the facility failed to ensure safe and effective blood-draw practices were utilized by contracted staff to reduce the potential for cross-contamination and contamination from blood-borne pathogens when attempting to draw a resident's blood in the dining room, for 1 (#39); failed to implement the appropriate use of TBP for droplet precautions for 1 (#7); and contact precautions for 1 (#52) of 39 sampled residents; and failed to ensure proper hand hygiene was followed related to glove use in the kitchen. These deficient practices had the potential to increase the risk of infection related to blood-borne pathogens, and the risk of spread of infection for all residents. Findings include: 1. During an observation on 4/22/25 at 8:26 a.m., resident #39 was sitting at a table in the main dining room eating his breakfast. There was another resident sitting at the table with resident #39. NF1 and NF2 were attempting to obtain a blood sample from resident #39's right arm. During an interview on 4/22/25 at 8:30 a.m., NF1 and NF2 stated they did not work for the facility. They stated they were there to draw resident #39's blood per a physician's order for blood work. NF1 stated a staff member told them they could draw the resident's blood in the dining room if the resident did not mind. They stated they had asked resident #39 if he minded if they drew his blood in the dining room, and he had told them he did not mind. NF1 and NF2 stated the concern with drawing a resident in the dining room would be related to blood-borne pathogen exposure and infection to the resident and other residents exposed. They stated they received training on blood-borne pathogen exposures from their facility but had not received any additional training at this facility. During an interview on 4/22/25 at 8:46 a.m., staff member J stated when staff from other facilities were at this facility to draw blood they were expected to follow this facility's guidelines for safe infection control practices. They were expected to check in with the staff prior to obtaining the blood sample for the resident and they were not to draw a resident's blood in a common living area such as the dining room. Staff member J stated drawing blood in the dining room had the potential for cross-contamination of blood-borne pathogens. Staff member J stated they had not provided any additional training for the contracted staff to ensure they were aware of the facility's expectations and process for drawing labs and preventing the spread of blood-borne pathogens. During an interview on 4/22/25 at 11:55 a.m., staff member B stated drawing labs on a resident in the dining room was an infection control concern and had the potential to spread blood-borne pathogens. Staff member B stated the contracted staff were expected to follow the facility's infection control guidelines and were not to draw a resident's blood in the dining room. He stated it was an issue that needed to be addressed on our side. During an interview on 4/22/25 at 3:42 p.m., staff member R stated the two lab technicians had inquired with her about finding resident #39 for his blood draw. She stated he was in the dining room and told them to ask him for permission before drawing his blood. She stated she did not realize they were going to draw his blood in the dining room. She stated she did not stay to assist them or the resident. A review of the facility's policy and procedure titled, Specimen Collection, with a revision date of 1/21/25, reflected: - . 2. The staff will be educated on the proper collection techniques, handling, and storage of specimens, ensuring proper infection control practices are used . 49554 2. During an observation on 4/22/25 at 8:13 a.m., resident #7's door was closed. A yellow circle was on the doorjamb. No other signage was on the door. Inside the room were protective goggles place on the back of a chair, protective goggles, and used PPE were in the trash. A hanging storage container with PPE was hanging on the bathroom door. Resident #7 was lying in his bed sleeping. During an observation and interview on 4/22/25 at 10:16 a.m., staff member CC stated, [Resident #7] is on droplet precautions for pneumonia and on EBP because he has a catheter. We use the yellow dot system for EBP. When we go into his room, we wear goggles, gowns, and gloves. All the PPE for us (staff) to use is in his room hanging on the bathroom door. We enter the room, don the PPE, and then doff the PPE before we exit the room. During an interview on 4/24/25 at 10:30 a.m., staff member J stated, There should be signage on the outside of the door if they are on droplet precautions. The PPE should also be on the outside of the room so staff can don PPE prior to entering the room. I track the infection to determine when to release them (resident) from isolation. For droplet precautions, it would be seven days from the time of symptom onset. Review of resident #7's MAR, with a revision date of 4/21/25, showed an active order for droplet precautions due to parainfluenza. Review of resident #7's discharge summary, dated 4/21/25, showed: . -Discharge Diagnosis: Parainfluenza virus pneumonia . Review of resident #7's infection progress note, dated 4/23/25, showed: Note Text: Resident shows no signs or symptoms of parainfluenza. No fever over last 48 hours. (see chart) droplet precautions ended today, Resident remains on EBP for wounds/cath. Will be moved back to his own room today as isolation for virus is complete. [sic] Review of the facility's document titled, Transmission-Based (Isolation) Precautions, dated 1/14/25, showed: - Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy . Policy Explanation and Compliance Guidelines: 1. Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. - 9. Initiation of Transmission-Based Precautions (Isolation Precautions) . e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. [sic] 3. During an observation on 4/21/25 at 3:51 p.m., resident #52 had a PPE caddy hanging on the bathroom door, inside the room. During an observation on 4/22/25 at 8:51 a.m., the PPE caddy was hanging on the outside of resident #52's room door. During an observation on 4/23/25 at 8:11 a.m., staff member W was in resident #52's room assisting the resident, but was not wearing PPE. During an observation and interview on 4/23/25 at 4:08 p.m., a contact precautions sign was observed on the outside of resident #52's door. Staff member X stated resident #52 was on contact precautions due to an MSSA, staph infection. Staff member X said the PPE should be donned before entering the room. During an interview on 4/24/25 at 11:21 a.m., staff member J stated resident #52 was on contact precautions due to the MSSA diagnosis. Staff member J said the contact precautions were removed today (4/24/25) from resident #52's room because she was at the end of her treatment date, and she was now on enhanced barrier precautions. Review of resident #52's medical diagnosis showed METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AUREUS INFECTION, UNSPECIFIED SITE. It was categorized as an acute infection on admission. Review of a facility's document titled, Case detail - Quick view, showed, Resident - [#52], . admitted : 4/10/25, Status: Confirmed (P), Infection Details - Onset Date 4/10/25, .Infection Site - Breast - Left, Organism - Methicillin-susceptible Staphylococcus aureus, .Isolation and Precaution Details - Isolation Requirement Yes, Isolation Precaution Contact, Isolation Start Date 4/10/25 . Review of the facility's policy and procedure titled, Transmission-Based (Isolation) Precautions, with a revision date of 1/14/25, showed, .Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. .Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions, Infection/Condition - Staphylococcal disease, Precaution - Contact . 10. Contact Precautions- .d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens . 4. During an observation on 4/23/25 at 12:15 p.m., staff member BB was observed using a broom to sweep the floor with gloved hands. Staff member BB was then observed picking up a head of lettuce and did not change her gloves in between sweeping with the soiled broom and touching the head of lettuce. During an interview on 4/23/25 at 12:17 p.m., staff member U stated gloves should be changed between each task (soiled to clean) in the kitchen. During an observation on 4/23/25 at 12:20 p.m., staff member AA was observed wearing gloves assembling food trays. Staff member AA used his gloved hands to pick up meat from the steam table and placed the meat on a resident's tray. Staff member AA was then observed touching a soiled piece of cardboard which covered the garbage can, to throw an item away with gloved hands. He did not change the gloves and returned to handling food from the steam table. Staff member AA, wearing the same gloves, reached into a bag of hot dog buns, grabbed a bun, then he opened a plastic container containing yellow cheese, picked up the yellow cheese with his gloved hands, and returned to the steam table. Staff member AA did not change his gloves or wash hands for the duration of the observation. Review of the facility's policy and procedure titled, Food Safety Requirements, with a revision date of 1/14/25, showed, .Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: .f. Employee hygienic practices. 7. Staff shall adhere to safe hygienic practices to prevent contamination of food from hand or physical objects . .f. Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. .h. Gloves will be worn when directly touching ready-to-eat food and when serving residents who are on transmission-based precautions. [sic]

Based on observation, interview, and record review, the facility failed to assist a resident with obtaining clothing that fit, and change the clothing she had regularly, are attempt to obtain clothes she could use that fit, so the resident did not need to re-wear the same shirts each day. This failure did not enhance enhance the resident's dignity as how she dressed was important to her, and she became teary discussing it, for 1 (#52) of 39 sampled residents. Findings include: During an interview and observation on 4/21/25 at 3:51 p.m., resident #52 was very tearful and stated she had few clothes of her own at the facility, and the clothes were either way too big, or way too small. Resident #52 said she had some very nice clothes at the assisted living, and she had asked staff to get clothing from the assisted living where she resided. Resident #52 was observed in a multicolored, short sleeve, floral shirt and gray sweat pants which were knotted at the waist. There were no clothes hanging in resident #52's closet. There were three items of clothing in the middle drawer of the bedside stand which she identified as her own. There was one item of clothing in the top drawer of the bedside stand which she stated was given to her by the facility and did not fit. During an interview on 4/22/25 at 3:39 p.m., staff member W stated there was a linen closet with spare clothing for residents if needed. Staff member W stated they used spare clothing for residents quite a bit because they came to the facility from the hospital. Staff member W said social services would contact the resident's family for more clothing when there was a need. During an interview on 4/22/25 at 3:47 p.m., staff member Q stated he had not requested additional clothing from resident #52's assisted living facility. During an observation on 4/22/25 at 4:04 p.m., resident #52 was observed in the same multicolored, short sleeve, floral shirt as the previous day. During an observation and interview on 4/23/25 at 8:11 a.m., resident #52 was observed in the same multicolored, short sleeve, floral shirt she wore on 4/21/25. Resident #52 stated, I don't know who brought my clothes to me, they don't fit me at all. Staff member W said, I thought someone brought you clothes, they must have brought the wrong clothes. During an interview on 4/23/25 at 10:14 a.m., staff member DD stated staff does assist with getting residents proper clothing and it is a task of the social service department. Review of resident #52's Admission MDS, with an ARD of 4/17/25, showed it was very important for resident #52 to choose what clothes to wear. Her BIMS score showed she was a 13, cognitively intact. Review of resident #52's Inventory of Personal Effects, undated, showed, 1- blouses, multi-colored short sleeve, 1- Shorts, yellow & white, - Dentures: Upper, - 02 tank & holder, - 3 - Bracelets (2 beaded) (1 grn & clear stone). Review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, with a revision date of 1/7/25, showed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: .9. Groom and dress residents according to resident preference.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment, services, and assistive devices to maintain optimal visual abilities for 1 (#42) of 39 sampled residents. Findings include: During an observation and interview on 4/22/25 at 9:04 a.m., resident #42 was sitting in his room attempting to watch television. He was wearing glasses. The resident stated he could not see well even with the glasses he had on, and he was frustrated because he had been asking to see the eye doctor for over a month, and the facility told him he had to wait because they did not have a ride for him. During an observation and interview on 4/22/25 at 3:03 p.m., resident #42 was sitting in his room attempting to read his bible. The resident stated he was frustrated because he could not see well even with his glasses. The resident repeated he had been asking the facility to make an eye appointment for him, but he was frustrated because he had been asking for a while, and they still had not made him an appointment. Review of resident #42's Social Services Progress Note, created by staff member S, dated 2/6/25, showed, . Speech therapist approached me, and reported that resident is complaining about his vision, and requesting follow-up with ophthalmologist. Could you help arrange this appointment? Review of resident #42's Social Services Progress Note, dated 2/17/25, showed, . Vision and hearing adequate, wears glasses . There were no additional Social Services Notes which showed the physician requested eye exam was scheduled for resident #42. Review of resident #42's Health Status Note, dated 3/29/25, showed, . Note to social services for eye doctor appointment requested by resident. He states he doesn't have prescription glasses anymore and can't see well. This nurse did look and found only simple 'reader' glasses. Review of resident #42's Progress and Social Service notes did not show an eye appointment was scheduled for the resident from this request. Review of resident #42's Health Status Note, dated 4/3/25, showed, Resident magnifying glass has been dropped and taped several times. Contacted his sister and she is going to get him a new one as soon as she can. During an interview on 4/23/25 at 8:59 a.m., resident #42 expressed again how important it was for him to see the eye doctor because he could hardly see anything. He stated the current glasses he had were not helping. During an interview on 4/23/25 at 9:21 a.m., staff members H and P, both stated resident #42, did not have an eye appointment scheduled. Staff member H stated the eyeglasses the resident was currently wearing were magnified eyeglasses his sister brought in for him last weekend. She stated they realized that he only had readers available. Both staff members stated they were aware the resident was still having difficulty seeing even with the magnified eyeglasses provided by his sister. Staff members H and P stated staff member Q was responsible for scheduling the eye appointments for residents. During an interview on 4/23/25 at 9:24 a.m., staff member Q stated resident #42 did not have an eye exam scheduled. He stated he was aware the resident was having difficulty seeing and had spoken to staff member S about scheduling an eye exam for the resident but did not know if anything would help due to his glaucoma. A review of resident #42's Progress Notes, Physician Notes, and Provider Orders did not show any documentation to discontinue the request for obtaining an eye exam for resident #42. A referral for an eye exam was made by the provider on 2/6/25. As of 4/24/25, no eye exam had been scheduled for resident #42. During an interview on 4/24/25 at 9:36 a.m., staff member A stated it was the expectation to set up an eye appointment more often than yearly when a resident was actively having difficulty with their vision, or there was a change in the resident's visual health. A review of the facility's policy and procedure titled, Hearing and Vision Services, with a revision date of 1/14/25, reflected: . 1. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: c. Ongoing monitoring of sensory problems; . e. Evaluation. 2. Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee. 3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources (e.g. Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs. 4. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation .

Based on observation, interview, and record review, the facility failed to identify a discrepancy in weight recordings which would have identified a severe 16% weight loss in two weeks, for 1 (#40) of 1 dialysis resident sampled for weight loss. Findings include: Review of resident #40's Dialysis Communication Records, dated 3/18/24 - 4/3/24, showed an average of 2.06 lbs. of fluid removal at each dialysis treatment. The resident never had body or fluid weight gain between dialysis treatments, instead each pre-dialysis treatment record showed a consistently downward trending weight loss of one to four pounds. This loss of body weight represented a severe 16.27% weight loss in two weeks: - 3/18/24 pre-dialysis weight 205.48 lbs. Post dialysis weight was 200.6 lbs. The treatment resulted in 4.88 lbs. of fluid removal. - 3/20/24 pre-dialysis weight was 200.6 lbs. The resident had not gained any weight between treatments. Post dialysis weight was 199.54 lbs. The treatment resulted in 1.06 lbs. of fluid removal. - 3/22/24 pre-dialysis weight was 196.9 lbs. The resident had lost 2.64 lbs. between treatments. Post dialysis weight was 196.9 lbs. The treatment did not perform any fluid removal. - 3/25/24 pre-dialysis weight was 195.14 lbs. The resident had lost 1.76 lbs. between treatments. Post dialysis weight was 192.94 lbs. The treatment resulted in 2.2 lbs. of fluid removal. - 3/27/24 pre-dialysis weight was 191.62 lbs. The resident had lost 1.28 lbs. between treatments. Post dialysis weight was 189.64 lbs. The treatment resulted in 1.98 lbs. of fluid removal. - 3/29/24 pre-dialysis weight was 185.02 lbs. The resident had lost 4.62 lbs. between treatments. Post dialysis weight was 182.6 lbs. The treatment resulted in 2.42 lbs. of fluid removal. - 4/1/24 pre-dialysis weight was 179.08 lbs. The resident had lost 3.52 lbs. between treatments. Post dialysis weight was 177.32 lbs. The treatment resulted in 1.76 lbs. of fluid removal. - 4/3/24 pre-dialysis weight was 172.04 lbs. The resident had lost 5.28 lbs. between treatments. Post dialysis weight was 169.84 lbs. The treatment resulted in 2.2 lbs. of fluid removal. Review of resident #40's weekly weight summary in PCC showed: - 3/15/24 - 201.74 lbs. via wheelchair scale, - 3/22/24 - 196.9 lbs. via wheelchair scale, - 3/31/24 - 193.8 lbs. via mechanical lift scale. The facility's weight of 193.8 lbs., on 3/31/24, was 8.78 lbs. over the dialysis weight of 185.02 lbs. and two days prior on 3/29/24, and 14.72 lbs. heavier than the dialysis weight of 179.08 lbs. one day later on 4/1/24. The facility weight was the weight used at the IDT weight meeting, dated 4/5/24, that did not identify the resident as having a weight loss. During an interview on 4/25/24 at 8:46 a.m., staff member M stated resident weights were monitored by the electronic health record dashboard or if nursing brought up concerns to her. The dashboard showed weights entered as seen on the vitals page in PCC. Staff member M stated when she saw resident #40 on 4/7/24, she had observed muscle and fat loss and initiated a weight loss warning. The weight loss was later deemed unavoidable as the resident had been hospitalized [DATE] and transitioned to comfort care for other comorbidities. During an observation and interview on 4/25/24 at 9:09 a.m., staff member I stated to weigh a resident with the mechanical lift scale you would first zero it out, and then lift the resident to be weighed. Staff member I performed the zero task (adjusting scale to a weight of zero) and then raised a resident out of bed. The scale showed the resident as weighing 11.5 lbs. staff member I stated that was not correct, and she didn't know why the scale wasn't working. During an interview on 4/25/24 at 9:45 a.m., staff member A stated maintenance had a schedule where the scales would be calibrated.

Based on interview and record review, facility staff neglected to assess and monitor a new admission, and ensure antibiotic medications were provided properly and documented, for 1 (#2) of 4 sampled residents, whose condition deteriorated over a weekend. The facility terminated two staff involved, but did not report the event as resident neglect. The resident was later transferred to the hospital and passed away. Findings include: During an interview on 12/4/23 at 12:00 p.m., staff member D stated new admissions had a skilled daily charting note completed each day by the nurse. Staff member D also stated residents would have daily vital signs taken. During an interview on 12/4/23 at 2:45 p.m., staff member B stated it was the expectation that all new admissions for skilled nursing had a daily skilled note completed and vital signs taken. Staff member B stated the facility had terminated a nurse, and an on-call manager, in October, after it was noted that a resident went the weekend without his medical assessments, or admission orders completed. Review of resident #2's EMR, accessed 12/4/23, showed the resident was admitted to the facility on [DATE] with a respiratory infection, and transferred back to the hospital on 10/23/23 for worsening respiratory status. During the four-day period the resident was at the facility there was: - Only one daily skilled note done by a nurse. - One day where no vital signs were documented on a resident admitted with respiratory concerns. - Two days without any nursing progress notes on the resident's condition, respiratory status, or general wellbeing. - One nursing progress note detailing a missed hand off of responsibilities that led to the resident's physician/care orders not being checked for completeness and accuracy. Review of resident #2's hospital discharge summary, dated 10/20/23, showed the resident was discharged to the facility with, Albuterol nebulization around-the-clock and orders to monitor his respiratory status. He was also discharged with orders for two antibiotics and a corticosteroid [Prednisone]. Review of resident #2's MAR showed he resident recieved his Albuterol inhalations every four hours for shortness of breath over the weekend [10/21/23 & 10/22/23]. There were no notes about his respiratory effort, oxygen saturation, or response to treatment in the medical record. Review of resident #2's MAR showed he recieved one of the ordered antibiotics over the weekend [10/21/23 & 10/22/23].The second antibiotic and corticosteroid were not started until Monday, 10/23/23 after the transcription error was caught. Review of resident #2's nursing progress notes, dated 10/23/23, showed the resident was having shortness of breath, severe congestion on lung auscultation, and needed an increase in his oxygen from four liters to five to increase his respiratory saturation above 75%. He was sent to the hospital where he passed away the next day, 10/24/23. During an interview on 12/4/23 at 3:07 p.m., staff member A stated the staff members who had been terminated had simply not done their jobs and that everyone was aware of the process for new admissions. Staff member A stated they had not investigated the incident as neglect of care.

Based on interview and record review, the facility failed to identify signs and symptoms of infection which led to septic shock and admission to the hospital, with subsequent surgery and the placement of a Vacuum Assisted Wound Closure system for 1 (#1) of 3 sampled residents. Findings include: During an interview on 10/23/23 at 6:23 p.m., NF1 stated resident #1 had MRSA in his leg wound. NF1 stated the resident was in septic shock when he arrived at the hospital and he was very confused, had not known who the family member was or who he was. NF1 stated the facility staff told the family to wait until the next day because he would just have to sit in the ER. NF1 stated the family wanted the resident sent out right away. NF1 stated the resident was to return to the surgeon on 9/12/23 and the surgeon would remove the staples from the resident's right stump, but the facility had the nursing staff remove the staples off of the resident's incision on the stump. During an interview on 10/23/23 at 7:05 p.m., NF2 stated because of the additional removal of the leg on 10/19/23, resident #1 was no longer a candidate for prostheses and would never walk again. NF2 stated the family wanted to know why wound care care was not being done. NF2 stated when resident #1 entered the facility he was independent in some activities of daily living, and needed some assistance with other activities of daily living. NF2 stated the facility took the staples from the surgical incision out in the resident's room. NF2 stated the facility wanted to wait until the next day because the in-house provider had ordered urine collection for the evaluation of a UTI. NF2 stated the resident had been confused for approximately two to three days. NF2 stated the family wanted the resident sent to the hospital and requested the facility call for an ambulance, however the facility discouraged the request and wanted to wait until morning for labs. NF2 stated NF3 called the facility and requested an ambulance be called, but the facility provider stated there was no infection. NF2 stated the facility called for a non-emergent ambulance after talking to NF3. NF2 stated the resident was in septic shock when he got to the hospital and had very low blood pressures. During an interview on 10/24/23 at 8:15 a.m., staff member C stated the facility handled the situation appropriately and was in contact with staff member D. Staff member C stated the leaking of the wound had started on night shift. Staff member C stated the day had been a very hectic one. Staff member C stated there was one staple left in the resident's incision because it was too deep to remove. Staff member C stated the facility consulted with staff member D to remove the staples. Staff member C stated it was not common for facility staff to remove staples, but nursing staff were capable of doing the task. Staff member C stated they thought the family was picking at the remaining staple, but had no way to prove it was occurring. During an interview on 10/24/23 at 12:28 p.m., NF3 stated the surgeon was supposed to take the staples out of resident #1's right leg, but one of the nurses at the facility took the staples out and left one staple in. NF3 stated staff member D sent a picture and it appeared red and swollen. NF3 stated the resident had a staple left in and a scab had formed over the staple. NF3 stated a picture of the resident's leg was sent by NF2, and showed a big puddle of blood and pus on the floor. NF3 stated resident #1 was no longer a candidate for prostheses due to the loss of four inches more off of the resident's right leg. NF3 stated staff member C apologized for the lack of care. NF3 stated resident #1 had approximately four more inches removed from his right leg on 10/19/23. During an interview on 10/24/23 at 2:28 p.m., NF4 stated resident #1 was very sick when he was readmitted to the hospital on 10/16/23. NF4 stated the resident had a AKA, and then went to rehab. NF4 stated he saw resident #1 in the office on 9/26/23, and all but one of the staples had been removed, which he thought was strange. NF4 stated the staples are usually left in longer to hold the incision together. NF4 stated the resident had a few scabs and the staple that was left in. NF4 stated since then the resident was in the hospital again and needed additional amputation of the leg. NF4 stated it was very unusual for someone to take another doctor's staples out. NF4 stated If they had called me, I would have said no. NF4 stated he was easily reachable. During an interview on 1/25/23 at 9:55 a.m., staff member D stated resident #1 had an AKA. Staff member D stated the resident had cellulitis when he was admitted to the facility on [DATE], and was taking an antibiotic. Staff member D stated the resident began to look sick and was more confused. Staff member D stated the incision and surrounding skin looked more red and puffy, but was not leaking at the time of assessment on 10/16/23. Staff member D stated someone must have picked the scab off and then it started leaking. Staff member D stated there was one staple left in, and stated it happens. Staff member D stated there was no urgency to take the staples out. Staff member D stated the resident was treated for the cellulitis successfully, and the infection must have been deeper than just the cellulitis. During an interview on 10/25/23 at 11:45 a.m., staff members A and B stated resident #1 had a change in mentation, and was more confused on 10/16/23. Staff members A and B stated the resident picked at the scabs on his leg. Staff member A and B stated staff member D looked at resident #1 on 10/16/23 due to change in condition of the resident's right leg. Staff members A and B stated the wound appeared pink and was light warm to the touch. Staff members A and B stated the wound was not oozing when it was observed on 10/16/23. Staff members A and B stated the nurse had seen the resident picking at the incision and it started oozing. Staff members A and B stated the resident had a history of infection. Review of resident #1's physician order, dated 9/12/23, showed the resident had a scheduled follow up with NF4 for right AKA staple removal on 9/26/23. The facility removed the staples without consulting the surgeon on 9/22/23, 4 days before the resident was to have a follow up appointment to remove the staples. Review of resident #1's physician progress note, dated 10/16/23, showed the following: - Resident had an acute altered mental status for two to three days. - More recently, some concerns have arisen about patient being more confused, and some swelling on the right AKA stump. - There was one retained staple that needed removed . - There is a bit of edema (swelling) involving the distal stump, and erythema (reddening of the skin) along the incision line, but no induration, and minimally tender on palpation . - Increasing edema raises concern for infection versus subcutaneous fluid collection. Review of resident #1's Weekly Skin Check, dated 9/16/23, showed right above the knee amputation, staples intact, slightly red around the incision, no drainage noted-MD notified and assessed. Review of resident #1's Weekly Skin Alteration (non-pressure) Evaluation, dated 9/26/23, showed the R AKA stump site. Staples removed 9/22/23. Review of resident #1's Care Plan, dated 9/24/23, showed the resident was to have staples removed per MD (medical doctor) appointment on 9/26/23. The facility failed to follow physician's orders for removal of the staples. Review of resident #1's Weekly Skin Alteration (non-pressure) Evaluation, dated 10/10/23, showed reddened areas across the wound site where edges are healed. The facility failed to identify reddened areas as a sign of infection. Review of resident #1's Nursing Progress Note, dated 10/16/23, showed an order was received to send the resident out to the ER via non-emergent ambulance due to worsening of wound. Review of resident #1's Progress Note, dated 10/16/23, showed Nursing observations, evaluation, and recommendations are: After review and consult with provider, Resident was determined to be stable during the day shift with no s/sx (signs and symptoms) to go to the ER for possible severe wound infection. Appropriate lab orders were placed to test for infection and treat in-house if needed. Due to worsening of wound and exudate on evening shift, provider made decision to send in to ER for further evaluation and higher level of care. Review of resident #1's emergency room Record, dated 10/16/23, showed the following: - family noted increasing redness from his right stump 2 days ago. This evening, the wound opened up and started draining purulent material. Patient has been more altered and confused over the past day. Medics were called to the house and found him hypotensive in the 70s systolic. - Under physical exam, extremities showed Right AKA. The distant end of the stump is draining purulent and bloody material. Some swelling in the extremity and is quite tender to the touch. - On arrival, he is hypotensive and somewhat confused. Leg wound as described above is very concerning for infection. The residual staple was removed. Patient immediately given 1 L NS, imipenem and vancomycin (antibiotics). - CT scan showed fluid collection measuring 6.0 x 3.3 x 1.2 consistent with abscess. - General surgery will evaluate tomorrow. - The wound is actively draining right now and there is no indication for emergent drainage at this time. Review of resident #1's Operative Report, dated 10/19/23, showed the following: - The original procedure was performed over two months ago, and the resident was mostly healed from the resident's surgery. - He was readmitted to the hospital with signs of sepsis and the resident was treated with antibiotics and IV fluid resuscitation. - I (surgeon) evaluated resident #1 on the day of admission, 10/16/23, and performed a bedside drainage procedure to temporize and potentially treat the infection. - The following day, 10/17/23, there was increased erythema. - Due to the increased erythema and lack of soft tissue coverage over the femur, it was decided to proceed back to the OR for semi-urgent debridement, revision, and all indicated procedures. Review of resident #1's Infectious Disease Consult, dated 10/23/23, for a stump infection showed the following: - Resident #1 was admitted to the hospital on 10/16/23 with septic shock secondary to SSTI involving AKA stump and osteomyelitis (infection of the bone) of the distal femur. - Resident #1's family noted redness around the AKA stump approximately two day duration followed by dehiscence and drainage. - The resident was found to be hypotensive and was admitted to the intensive care unit and started on antibiotics. - CT scan showed right lower extremity fluid collection within the anterior tissue and appeared edematous measuring approximately 5.5 cm x 1.0 cm. - The resident underwent bedside irrigation with cultures positive for growth of MRSA. - On 10/19/23 resident #1 underwent revision of the right AKA with debridement of skin, subcutaneous tissue, muscle, and fascia and resection of approximately 10 cm of the distal femur.

Based on observation, interview, and record review, facility staff failed to identify, prevent, and treat pressure ulcers which led to the development of two Stage IV pressure ulcers which required hospitalization , and wound clinic management for 1(#4); and failed to identify, prevent, and treat pressure ulcers which led to the development of 3 Stage II, and 1 Stage III, pressure ulcers, for 2 (#s 98 and 194) of 5 sampled residents. Findings include: 1. During an observation on 4/24/23 at 3:36 p.m.,., resident #4 was lying on his bed with an air mattress. The bed was in the flat position, and the resident was on his back with no cushions or pillows in use for pressure offloading. During an observation on 4/25/23 at 11:09 a.m., resident #4 was asleep, lying on his bed with an air mattress. The head of bed was slightly elevated and only one pillow was observed with the resident's left arm resting on it. No other pressure offloading devices were in use. During an observation and interview on 4/26/23 at 5:45 a.m., staff member G stated she was unable to complete the dressing change for resident #4 as she did not have the supplies to complete the dressing. Staff member G walked around going through cabinets and drawers stating, I don't really know what these items are that are listed on the order. Staff member G was asked to notify the oncoming nurse so the dressing change could be observed when supplies become available. During an interview on 4/26/23 at 6:35 a.m., staff member F stated she was not notified the dressing change for resident #4 needed to be observed. Staff member F stated, [staff member D] had already completed the dressing change moments ago and that supplies were here all along, but the night nurse just didn't know what she was looking for. During an observation and interview on 4/26/23 at 9:44 a.m., staff members A and D returned to complete the dressing change for resident #4. Staff member A was using a cell phone with a movie playing to distract resident #4. Staff member D stated the distraction was necessary to prevent resident #4 from hitting during the dressing change. Staff member D changed dressings for two Stage IV pressure wounds on the resident's left hip and right buttock. Staff member D showed all of resident #4's skin except the spine and back due to contractures. Staff member A stated she would ensure CNAs notified this surveyor when they were getting resident #4 up for lunch, as this was the best time to see resident #4's back. By the end of the survey on 4/27/23, the surveyor was not notified or present for the resident's care and was unable to observe the resident's back. During an interview on 4/27/23 at 9:51 a.m., staff member F stated resident #4 was totally dependent on staff for cares, and the resident had an air bed for pressure relief. Staff member F stated the nursing staff were to turn resident #4 every two hours, use a wedge cushion, and pillows to offload pressure to the resident's skin, as he could not turn himself. Staff member F stated resident #4 currently was going to the wound clinic for pressure ulcer treatment, in addition to wound care by facility nurses. Staff member F stated before the wound clinic, resident #4's pressure ulcers were full of eschar and gross. Staff member F stated the floor nurses completed the wound care, except for when the wound nurse did his wound rounds. Staff member F stated the wound care orders were updated by the wound clinic, entered by the wound nurse in the resident's EHR, and staff member F had never had an issue with supplies for resident #4's wound care. During an interview on 4/27/23 at 10:09 a.m., staff member H stated resident #4 was completely dependent on staff for cares. Staff member H stated the nursing staff were to turn resident #4 every two hours and use a wedge cushion behind his back, a pillow between his legs, and a pillow in front of his chest for offloading pressure. During an interview on 4/27/23 at 10:33 a.m., staff member O stated she had been working with the facility for two months. Staff member O stated there should have been pressure offloading and turning every hour for residents with pressure ulcers. Staff member O stated resident #4 was an impossible, unfixable situation as of now. Staff member O stated since resident #4 was so thin there was no way for him to not have a bony prominence without pressure. Staff member O stated she attempted to get resident #4 on end-of-life care, but his family was not agreeable. Staff member O stated the facility had a wound nurse that should have been doing weekly wound rounds and monitoring residents. Staff member O stated she had a visit with resident #4 when she first started at the facility. Resident #4 had just returned from a hospitalization for wound debridement, as that was what happened when wounds were not paid attention to. Staff member O stated at his 30-day visit the wound was purulent and had necrotic tissue at the time. Staff member O stated resident #4 was now being seen by the wound clinic, and they were rotating treatments using a wound vac and specific dressing changes to treat his pressure ulcers. Staff member O stated the wound clinic was utilized to assist with wound care to help resident #4 become stable, even though his wounds would never heal. Review of the second roster matrix provided by the facility, on 4/25/23 at 12:21 p.m., showed resident #4 had a Stage III and a Stage IV pressure ulcer. Neither notated if they were facility acquired. The second roster matrix was needed as the initial roster matrix did not have any of the facility residents pressure ulcers listed. Review of resident #4's hospitalization discharge records, on 2/13/23, showed: -Right sacral decubitus pressure stage III concern for necrotizing fasciitis infection s/p debridement . - found to have a right wound buttock with dermal ischemia overlying his right ischial tuberosity . - wound cultures grew multi microbial organisms Proteus mirabilis, E. Coli, Enterococcus, Peptoniphilus and Bilophilia Wadsworhti. He went back to the OR on 2/8 for further debridement of his right buttock ulcer. Per operative report there was superficial necrosis that was cleared from the wound bed, - completed 13 days of IV/PO antibiotics -There is an ulcerative wound overlying the right ischium that contains fluid and air. Patient is incontinent of fecal material. Distinction between fecal material and any dressings overlaying the wound . not distinguishable on CT images. [sic] Review of resident #4's assessments showed no skin assessment completed between 1/3/23 and 1/17/23. The skin assessment on 1/17/23 showed a new open wound, with no measurements. Review of resident #4's treatment administration record showed the first order for the right ischium pressure ulcer was entered on 1/25/23 as prn wound care. Review of resident #4's most recent wound clinic visit on, 4/25/23, showed, R ischium .stage 4 .moderate amount of serosanguineous exudate draining . the ulcer bed has exposed bone . and, Left hip .stage 4 .large amount of serosanguineous exudate draining .has exposed bone tissue . Procedures performed were debridement of subcutaneous tissue of both wounds and measurements. 48261 2. During interviews on 4/24/23 at 2:50 p.m., resident #194 and NF6 were in resident #194's room. NF6 stated resident #194 was unable to sit in his recliner due to the pain from his buttocks. NF6 stated resident #194 had bed sores on his buttocks, from when the resident was in the hospital. Resident #194 stated the bed sores were painful. During an interview on 4/24/23 at 3:01 p.m., staff member J stated he was not aware of any wounds for resident #194. Staff member J checked resident #194's EMR, and stated the admission assessment, dated 4/21/23, showed no wounds were present. During an observation on 4/24/23 at 3:15 p.m., staff member J assessed the buttocks of resident #194, and found his buttocks were caked with a thick cream that was dried and difficult to remove. Once cleaned, staff member J stated he found a Stage II, and Stage III, pressure ulcers of the following sizes: -two 2 cm x 2 cm, -one 3 cm x 3 cm, and -one 3.5 cm x .25 cm. Review of resident #194's EMR failed to show any orders for wound care. Resident #194's hospital admission orders, dated 4/21/23, showed, Wound consult needed. No wound consults notes were available in resident #194's EMR as of 4/24/23. Review of resident #194's care plan failed to show any focus, goals, or interventions for wound care for the four pressure wounds. Review of resident #194's weekly skin assessment, dated 4/23/23 (admission), reflected no skin changes, ulcers, or injuries. Resident #194 was discharged from the hospital and admitted to facility on 4/21/23. A copy of the discharge summary was not provided as of the end of the survey on 4/27/23, as to determine wounds present prior to the hospital discharge. 3. During an observation and interview on 4/27/23 at 6:42 a.m., staff member D completed wound care for resident #98. Staff member D prepared to change resident #98's wound by washing his hands, gloving, repositioning, and then rolled resident #98 to remove a bandage. Per staff member D, a Stage II wound was present with drainage. Staff member D cleaned the wound with saline spray, and started to scrub an area on the resident's right buttock stating, Its just BM, as he started to pull what appeared to be a black scab off the wound. Resident #98 started to yell out in pain and pulled his buttock away from staff member D. Staff member D apologized stating It's BM, and scrubbed again, then pulled again on what appeared to be a black scab, which caused the wound to bleed. Resident #98 again yelled out in pain. Staff member D asked to turn on another light, then stated, Oh, its not BM. Staff member D stated, It's a Stage II (pressure ulcer) 0.1 cm x 1 cm pressure wound. I will have the physician look at it later today. Staff member D asked the resident if he was still in pain after bandaging the pressure wounds. Resident #98 stated he was ok. Review of resident #98's TAR (treatment administration record), dated April 2023, showed one wound care order for the resident's sacrum, and the order was dated 4/21/23. The weekly skin assessment was completed on night shift on 4/26/23, and failed to identify the new wound on resident #98's buttock. The failure of the facility staff to identify and treat the second pressure wound allowed resident #98's skin to further deteriorate causing pain for resident #98. Record review of facility policy, Skin Care Policy, dated April 2002, showed, 1 . All newly admitted residents will have a complete body check upon admission or readmission to identify potential or existing skin problems ., and .4. Skin problems will be monitored weekly to ensure proper treatment, and to determine the need for treatment revision. The Director of Nursing or designee will evaluate the skin problems weekly to ensure proper management of the skin care in the facility.

Based on interview and record review, the facility failed to identify, follow up, and notify the physician when 1 (#195) admitted to the facility, and the resident's vital signs were identified to be out of range, and not addressed by the facility as a concern, out of 1 sampled resident. Findings include: Record review of resident #195's electronic medical record showed she was admitted to the facility on [DATE] with multiple comorbidities, to include: Chronic Kidney Disease; Stage 5, Type II Diabetes Mellitus, Heart Failure, Hypertension, and Chronic Obstructive Pulmonary Disease (not all inclusive). Review of resident #195's medical record showed staff identified resident #195's blood pressure on the day of her admission as: - [DATE] at 3:45 p.m., the resident's blood pressure was ,d+[DATE] mmHg, and her pulse was 114. There was no documentation showing the physician was notified of the elevated blood pressure reading. Vitals were taken again at 4:57 p.m., and found to be ,d+[DATE] mmHg, and her pulse was 114. There was no documentation showing the physician was notified of the resident's elevated blood pressure reading. - On [DATE] at 7:40 a.m., the resident's blood pressure was ,d+[DATE] mmHg, and her pulse was 100. There was no documentation showing the physician was notified of the elevated blood pressure reading. - [DATE] at 1:53 p.m., was ,d+[DATE] mmHg, there was no documentation showing the physician was notified; and, - [DATE] at 11:30 a.m., was ,d+[DATE] mmHg, there was no documentation showing the physician was notified. Review of the American Heart Association website, for blood pressure reading levels, showed a Normal reading would be less than 120 (systolic) and less than 80 (diastolic). Anything above that is considered to be Elevated or High Blood Pressure, either Stage 1 or Stage 2; and, if a blood pressure reading is higher than 180 (systolic) and/or higher than 120 (diastolic) it is considered to be a Hypertensive Crisis, and the physician should be consulted immediately (https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings). Review of resident #195's electronic medical record showed on [DATE] at 1:05 p.m., resident #195 had a fall from the recliner, in her room. Staff member P found her and assessed her at that time. The nurse documented contributing factors included shortness of breath and fall(s). Review of resident #195's nursing progress note, dated [DATE], showed resident #195 was found on the floor in her room, deceased . During an interview on [DATE] at 9:47 a.m., staff member K stated resident #195 was .coughing up quite a bit of mucous . but since she was on an expectorant, they (staff) contributed the coughing and mucous to the use of the expectorant. Staff member K stated resident #195 was having a lot of weakness and anxiety, and she was using a C-pap at night. Staff member K stated staff should get a set of vital signs each shift. During an interview on [DATE] at 9:47 a.m., staff member L stated resident #195 was using her C-pap during the day because she was short of breath. There was no documentation which showed the shortness of breath had been communicated to resident #195's doctor. During an interview on [DATE] at 10:33 a.m., staff member P stated resident #195 was .a very sick lady . Staff member P stated resident #195 came into the [provider name] with new renal failure and came to the facility for therapy. Staff member P stated resident #195 had severe bleeding from a renal biopsy attempt before being discharged from the hospital. Staff member P stated, It may not have been realistic for her to be able to go home. She felt that resident #195 was overloaded with fluid. Staff member P stated initial vital signs should have triggered closer monitoring.

Based on observation, interview, and record review, the facility failed to identify and act timely to address and attempt to prevent a high number of resident falls occurring at the facility, month over month, with the intent of reducing the fall rate and protecting the residents. This failure resulted in new and repeated resident falls, to include with and without injury, for 5 (#s 3, 5, 11, 12, and 13) of 8 sampled residents; and, the facility failed to address concerns sufficiently for a resident (#2) who sustained an injury during a care session, or concerns brought forth by resident #19 during the investigation for resident #2's injury, pertaining to the pace of the staff during care, for 2 (#s 2 and 19) of 2 sampled residents. Findings include: Resident Fall Concerns A review of the Facility Reported Incidents, submitted to the State Survey Agency, by the facility, identified frequent falls as a concern. Due to this, falls and the prevention of falls was investigated during the complaint survey. A record review of the facility QAPI information, for September 2022, showed the facility had 83 falls from 6/1/22 to 9/7/22. Fifty three of the falls were identified to have occurred with the same residents, and they fell more than one time. Some of the falls included: - A review of resident #12's fall history documentation over the last year showed he had 26 falls from 3/24/22 to 8/11/22, and then on 8/16/22, the resident fell and sustained a [CONDITION(S)] when he was trying to dress himself. The resident's EHR showed he had not called for assistance when the fall occurred, and had a history of not calling staff for help. - A record review of resident #13's nursing notes and documentation in the EHR showed the resident had two falls, the first in January 2022, and the 2nd in August 2022. For these two falls, the nurse on duty at the time failed to comprehensively fill out all of the required documentation related to the fall. For the fall on 8/27/22, the nurse documented the resident was found on the floor, he had hit his head, and this caused lacerations and bleeding. The fall investigation information showed the resident had no injury observed at the time of the incident. The IDT Risk Management Follow up notes showed minimal information for the fall. There were no Environmental Factors documented on the event report completed by the nurse, eventhough nursing notes showed the resident got his electric wheelchair wedged and stuck in the doorway, and he was trying to free himself, and fell . For the resident's mental status, the nurse checked the resident was oriented to person, but in the comment section documented the resident had lacerations, and the treatment for them, but did not document detail on his mental status any further. There were no predisposing Environmental Factors, Psychological, or Predisposing situational factors checked or acknowledged in any way on the investigation form. The lack of accurate and concise documentation would prevent others from knowing correct details, contributing factors, or potential risks related to the fall. - A review of resident #11's EHR fall documentation showed she had a fall on 5/23/22. She reported a man was standing in her room, and she was reaching for a coke. At the time, there was not a man in her room, but rather the resident was hallucinating. The fall investigation form, which included mental status options, did not address the mental status at the time, but the nurse noted the resident was confused and had been for a week. Further review of the resident's medical record showed the resident fell on [DATE], from her bed, and her call light was not on. The resident stated she was reaching for something and fell . No injuries were observed. The mental status section was blank on the fall investigation form, as well as for the Physiological Factors and Situational Factors. The resident had two falls, three days apart, and for both she was reaching for something. - A record review of resident #3's baseline care plan, initiated on 6/14/22, showed he had a recent fall with [CONDITION(S)] (prior to admission), but there were no goals specifically related to falls or interventions for fall safety until the comprehensive care plan was completed. The resident's mental status, confusion, fluctuations, or hallucinations were not identified or addressed on the baseline care plan for staff to know how to care for the resident properly, or as needed related to his safety, until the comprehensive care plan was developed and finalized with a date of 7/2/22. The resident's falls included: a. Fall #1 - A record review of resident #3's EHR nursing notes showed the resident had a fall on 6/19/22. The resident was found laying on the floor and his bedside table was tipped over. The resident was trying to go to his farm. Resident #3 complained of .severe left hip pain when assessed, was unable to dorsiflex foot or move toes on left leg, leg appeared inward turned . The resident was sent to the ER for further evaluation and treatment. The nurse did not document how future falls would be prevented at the time. The IDT Risk Management Follow Up for the fall, dated 6/20/22, showed the resident would be toileted and up in the wheelchair for meals, and the resident had increased confusion. Included in the resident's EHR notes, it showed the resident's Fall Risk Assessment score was an 8; at risk for falls. The witness statements for the fall on 6/19/22 showed a staff member said the resident was trying to introduce the staff member to his wife, but his wife had passed away previously, and the nurse at the time said the resident was confused. A record review of the [Hospital Name] emergency room report, dated 6/19/22, showed two weeks prior the resident had a [CONDITION(S)] (prior to the admission to the nursing home). Resident #3 had hip pain and an abrasion on his elbow. There was no new evidence of a fracture from the fall on 6/19/22. The Additional Instructions showed, Please use caution when ambulating to help prevent falls. The Physical Exam section showed, under Psychiatric, Conversation is confused. A review of resident #3's social service, psychological evaluation notes, dated 6/20/22, showed the resident was alert and oriented and could make his needs known. The resident scored a 14/15 on his BIMS; cognitively intact. The notes showed the resident could use the call light, appropriately, tried to be independent. A record review of resident #3's provider notes, dated 6/14/22, showed the resident was admitted for aftercare for a fall with a fracture. On 6/22/22, the provider documented the resident had a fall with left [CONDITION(S)] with ORIF, and the resident had mild dementia. The evidence in the resident's record showed the resident's mental status was contributing to his ability to be safe and free from falls. b. Fall #2 - A record review of resident #3's nursing note on 6/29/22 showed the resident was witnessed falling out of his wheelchair. He had no injury. The eInteract Change of Condition Evaluation showed the resident was assisted up into his wheelchair. No interventions for prevention of future falls was documented at the time of the fall by the nurse. c. Fall #3 - A record review of resident #3's nursing notes on 7/22/22, showed the resident had a fall and was found sitting on the floor. He had no injury, and he was reaching for socks, but there were no socks on the floor. A record review of QAPI data and information showed Staff member B began employment in August of 2022. Upon review of clinical systems, it was noted the facility had many resident falls. Staff member provided QAPI with resident fall information. After review, the QAPI team implemented a plan of improvement for the goal of decreasing resident fall numbers in August 2022. QAPI was continuing to review and provide oversight for the plan to reduce falls, but the facility had not yet sustained the corrections. The following was found: During an interview on 10/26/22 at 12:29 p.m., staff member B stated her employment started in August 2022, and right away she noticed nursing staff was not always completing the fall documentation or tasks required when a resident fall occurred. She also found the facility resident fall rate was very high. Due to this, she immediately began the development and plan of improvement for decreasing resident falls. Each day, staff member B would follow up on any resident who had a fall, by pulling up the electronic health record risk management system, to view the fall information, and ensure tasks were completed as needed. She stated she would contact a nursing manager to follow up with a nurse who was working at the time of a fall to complete any tasks not finished. She said she was constantly reminding staff of the importance of fall prevention, although the work had improved. Staff member B stated resident #12 had not had a fall since August of 2022, but prior to that, he had many. She stated he tended to get up on his own, and staff watched that very closely. The resident was more agreeable to calling for help since he had his hip injury. Staff member B stated the nursing management team, to include herself, completed rounds consistently to identify and address fall concerns. She stated fall prevention was ongoing, and the unit managers would continue this plan and tasks related to it, if she was not present. A record review of the QAPI fall prevention information showed: - Staff member B reviewed fall data and identified there was a high rate of resident falls. She developed a plan to provide to QAPI for corrective action. Statistics on resident falls was gathered and documented, which was then brought forth to the QAPI committee. - In September 2022, the facility had 83 falls from 6/1/22 to 9/7/22. Fifty three of those falls were identified to have occurred with the same residents, and this was an average of 26 falls a month. - The facility QAPI committee also trended the days, locations, and shifts in which the falls occurred. It was found 66% occurred in resident rooms. The facility then addressed concerns identified related to fall management. - In September 2022, 24 resident falls occurred 25 falls occurred. - From October 1st to the 26th, the last day of the survey, there had been 12 falls in the month, which was approximately a 50% decrease from the prior month. The education provided to staff, and the measures taken by the facility for fall prevention, were showing the fall rate was decreasing, and the number of resident falls significantly declined, but resident falls continued to be a concern, and the corrections put in place by QAPI for preventing falls had not been sustained. On 10/25/22 at 10:39 a.m., observational rounds and interviews were completed and the following was found: a. At 10:40 a.m., resident #5's room had several pieces of furniture. This included her bed, dresser, bedside table, crafting supplies, table, her wheelchair, which she was in at the time, and some storage bins. In order to speak to the resident, this surveyor had to maneuver around the items to reach her. Resident #5 stated she had fallen the week prior while at the facility, with no injury. She said she believed staff did what they could to assist her with fall safety. When she had fallen the prior week, she stated it was because she was attempting to get up on her own to use the restroom, and fell . b. At 10:50 a.m., resident #12 was in bed, and stated he had multiple falls. He said he had injured himself in a fall early in the year and fractured his hip. It was noted the resident had two adhesive grip strips alongside the bed, on the floor. The bed had been lowered, and was not the normal height, but it was not all the way down to the floor. The resident stated he did not fall for several months, which he was thankful for, because he did not want to get hurt again. Resident #12 stated the staff reminded him to use his call light, and said, I don't always use the light, but I should, and they have me do as much as I can when care was provided. During an interview on 10/25/22 at 2:15 p.m., staff member G stated resident #12's bed should be lowered, only when he is in it, for fall safety. The staff should use the mechanical lift for transferring the resident, and he was able to bear weight, but had weakness. Staff reminded resident #12 to use the reacher to get his things so he was not reaching so far and falling. Staff member G stated resident #12 could stand when he wanted to transfer himself, and he could pivot transfer, but he was not always compliant when asking for help. Review of resident #12's care plan information, which was undated, showed many interventions to address his fall risks and safety, to include having a low bed. c. At 11:10 a.m., it was observed resident #11 had two adhesive grip strips on the floor, on the right side of the bed. The strips were under the bed, rather than off to the side of the bed. The resident was in her electric wheelchair sitting by the window. She moved to the right side of the bed, and showed the surveyor how she could reach the call light, which was hooked to her bedside dresser. Resident #11 explained she had fallen prior, and had an injury. The resident said she had a fall mat, but the facility decided it was not safe, and therefore removed it. The resident had many large items in the room, and it appeared cluttered. She stated she could usually get around in the room ok. Resident Injury A record review of resident #2's EHR event report, dated 8/6/22, showed the resident complained to the nurse of left shoulder pain. The resident told the nurse two CNAs went into her room to provide care, earlier in the morning, and moved the resident in bed and her shoulder popped. The resident did not want to get anyone in trouble, and she did not feel the CNAs were trying to hurt her intentionally. The document showed the resident was oriented to person, place, time, and situation. A record review of a Facility Reported Event (FRI), submitted to the State Survey Agency on 8/11/22, showed resident #2 was sent to the emergency room for left shoulder pain. The report showed there was no fracture, and the Resident stated pain started early in the morning when toileting with a bed pan but did not report pain until 7:00 a.m. The resident stated, staff was not being mean or hurtful and pain occurred during routine care. A record review of a facility Resident Interview form, related to the shoulder injury for resident #2, showed the resident reported the staff were, . just being to quick during care, and they were trying to be quick and efficient (during care tasks), and when the injury occurred. A review of resident #2's Admission assessment, dated 7/27/22, showed the resident scored a 15 on her BIMS; cognitively intact. Section G of the MDS, showed resident #2 was coded as being extensive assist of two person physical assistance for the majority of her ADL cares. A record review of a facility Additional Resident Interview form, for Physical or Verbal abuse, related to resident #2's shoulder injury, showed resident #19 voiced concerns related to care provided by staff, and the resident stated, Some are a little rough. I don't think they are malicious. A record review of resident #19's MDS Admission assessment, dated 8/18/22, showed the resident scored a 15 on her BIMS assessment; cognitively intact. Resident #19 also needed extensive assistance of two person assist with the majority of her ADL cares. Further record review of the investigation information for resident #2's injury showed the facility had not acted on the concern related to the staff providing care quickly, to a point that it caused a shoulder injury and pain for resident #2, and the investigation notes had not shown any actions taken for resident #19's concerns. A record review of resident #2's care plan, revised on 10/20/22, showed an intervention for staff to allow the resident to take time to complete her own care needs independently, but the plan had not addressed the pace of the care the staff provided or safety measures to be taken to ensure no future injuries occurred to resident #2 during care sessions. A record review of an IDT Risk Management Follow Up note, dated 8/8/22, showed the IDT put an intervention into place for resident #2's shoulder injury, which was to Ensure a draw sheet available on bed to assist with bed mobility. The IDT did not address the pace of the care being provided to the resident, or show it was identified as part of the concern for the accident.

Based on observation, interview, and record review the facility failed to prevent and provide timely treatment for a resident who fell , was not sent for treatment for several hours, and was found to have sustained multiple fractures, for 1 (#5), and failed to provide supervision of a resident to prevent a fall that resulted in head and facial bruising for 1 (#77) of 4 sampled residents. The facility failed to provide supervision during meals for 2 (#28 and #73) out of 2 sampled residents who were at risk for aspiration. Findings include: 1. During an observation and interview on 5/10/22 at 8:28 a.m., resident #5 was observed in bed on her back with a sheet pulled over her. Resident #5 stated she had gone to the hospital recently after she had a fall and swiped her hand along her arm in several places. She explained she had a cast for breaking her arm in several places. She requested to just have the lights off and door closed and to stay in bed as she mostly did now. During an interview on 5/12/22 at 9:15 a.m., staff member E stated, when a fall happened on a unit the staff made sure the resident was safe and would proceed with the process of evaluating the resident. If the fall was unwitnessed or the resident hit their head the nurse would start neuros. He stated the nurse would treat any minor injury but if there was any concern for further injury they would get an order from the doctor if possible, to send the resident to the emergency room for further treatment to make sure, even if it was just x-rays. Staff member E stated, he always erred on the side of caution to rule out injury. The nurse would complete the electronic medical record documentation including the post fall event form, neuros, and a progress note describing everything that transpired regarding the fall. The next day the interdisciplinary team would review to determine the root cause and implement interventions immediately, which would be added to the care plan at the time of the meetings. During an interview on 5/12/22 at 1:11 p.m., staff members A and B stated, for a fall the nurse would assess the resident and document the details in a progress note in the electronic medical record. Staff member B stated it was a no lift facility but could not say how resident #5 was transferred from the floor to bed when she fell . Staff member B stated the nurse would have documented in the physician binder for notification of the fall if it was minor but since she was sent out later in the shift they would not have the documentation to show it. Staff member A stated the facility staff did as they were supposed to and read an employee written statement. The written statement showed the residents range of motion was getting worse on the neuro/after fall report so they requested the on call doctor to give an order to send the resident to the hospital for evaluation, and the resident was transferred at 1:45 a.m. and the transfer was charted at 2:15 a.m. The resident only had skin tears treated with multiple steri-strips and the arm was tender, but the resident did not want a pain medication at the time. Staff member B stated for interventions upon return to the facility therapy was ordered but staff member B could not speak to any other interventions. Review of resident #5's SBAR Communication Form eInteract tool for the fall showed a pain level of 8 out of 10, and pain is sharp./Left shoulder (front). The non-verbal pain signs was not completed. The notification section showed the physician was notified at 2:00 a.m. for a hospital evaluation for an x-ray and other with no description. The form provided did not have a date and time of completion. Review of resident #5's Post Fall 72-Hour Monitoring Report, for a fall on 1/15/22 showed, time of the fall as 10:05 p.m. Pain was circled Y for yes for the initial check but left blank for the rest of the follow up, and the location listed under the chart was blank. The ROM for all extremities were documented consistently the same for each timeframe. Specifically, the left arm at L/2 nine times meaning limited range of motion with severe weakness. The left leg was documented as F/3 nine times meaning full range of motion with mild weakness. Review of resident #5's nurse progress note for the fall was written on 1/16/22 at 3:50 a.m., and showed, Resident fell and shoulder appears to be out of socket. Called Dr got order to send to hospital at 0120 [1:20 a.m.]. Vitals with in her norm. She reports pain only when moving the left shoulder. Swelling in left shoulder. Skin tear in left are steri strips applied. Ambulance arrived at about 200. [2:00 a.m.] resident left at about 0225. [2:25 a.m.] [sic] Review of resident #5's hospital records discharge document, dated 1/24/22, showed, Patient's shoulder x-ray showed displaced fracture, elbow x-ray showed olecranon fracture . CTA chest abdomen pelvis was done which showed right sided pulmonary embolism, acute left humeral head and neck fracture, acute left superior and inferior pubic rami fractures. [sic] Review of resident #5's Care Plan provided on 5/11/22, showed a focus area with, I am at risk for falls/trauma due to recent and history of falls, weakness, impaired balance and endurance, cognitive deficits with poor safety awareness, does not use call light consistently, medication use [sic] with an initiated date of 3/10/2020 and revised date of 1/17/22. The Interventions/Tasks area for falls showed items initiated on 1/17/22 as, Anticipate needs, Give reminders for call light use before exiting the room/providing cares. An intervention added on 7/9/2021 as, I rarely use call light due to cognitive status. Staff needs to check with me frequently for care needs. All other interventions were added on 3/10/2020, none were specific to the resident's fall with fractures on 1/15/22. Review of staff member X's handwritten witness statement, dated 1/15/22, for resident #5's fall showed, .Range of Motion in Right Arm FULL. Range of Motion in Left Arm was Good But Resident Complained of Pain with Arm extended above her shoulder .Wounds on Left Arm closed with steri strips. [sic] Review of staff member X's 1/16/22 handwritten statement for resident #5's 1/15/22 fall showed, Range of motion and Range in Right Arm Good. Range in Left Limited. Resident stated pain only when Arm is Moved. [sic] Review of staff member Y's handwritten witness statement, dated 1/15/22, for resident #5's fall showed, L [left] arm had 3 big skin tears and the resident said her shoulder was hurting, nurse and I examined resident, we did notice the L[left] shoulder was a little swollen and resident was not able to lift L(left) arm very much. [sic] 46400 2. During an observation and interview on 5/9/22 at 3:33 p.m., resident #77 was in her wheelchair by the nurses' station. She had dark bruising covering her face and extending down her neck. Staff member K stated resident #77 had fallen over the weekend. During an interview on 5/11/22 at 10:09 a.m., staff member D stated she was the nurse on duty when resident #77 had her fall. She stated residents are only sent out for evaluation if the doctor wants that and in this case he did not. The doctor told them to monitor the resident for changes. During an observation on 5/12/22 at 10:22 a.m., resident #77 was slumped over in her wheelchair alone at the nurses' station. During an observation on 5/12/22 at 11:01 a.m., the unit hallways were empty. Resident #77 continued to be alone at nurses' station without supervision. During an interview on 5/12/22 at 10:00 a.m., NF1 stated there were some concerns with care at the facility. Resident #77 was admitted with a history of falls and labeled a high fall risk. There were no interventions put in place for resident #77 upon admission. NF1 was told the interventions could not be implemented until Monday (5/9/22) due to the resident being admitted on a Friday (5/6/22). Resident #77 fell the day of her admission. NF1 stated, I can see there's only a couple people [working].NF1 stated a staff member told me, 'Two of us for twenty-two patients' . Probably one of the reasons she fell . I texted the doctor and then the next day there were three other helpers. NF1 reported family has found resident #77 slumped over in her wheelchair at the end of the hallway almost falling out of her chair. NF1 stated, They seem to be reactive instead of proactive. Unless you say something, they won't do anything. NF1 acknowledged that the people who work there do seem to care they just don't have enough help. NF1 stated, I knew they were short staffed. I wanted [resident #77 name] to go somewhere else because of this. Measures should have been in place. Now she's declining. She was not given a chance to get better. Review of resident #77's nurse progress note dated 5/6/22 at 3:06 p.m., showed, Resident was found laying on the floor in the bathroom by therapy. Head to toe assessment was completed. Resident did hit her forehead on the ground and now has 2 golf ball size bumps on her forehead. Vitals were taken and are WNL. Resident stated she hit her knee on the ground as well, ROM performed with no pain voiced by resident. Assisted resident off the floor and place her back in her wheelchair. CNA offered to take her to the restroom and resident refused. [son's name] has been notified. Spoke with [staff member U's name] and he stated just monitor resident at this time and notify him of any change in condition. Resident is sitting in her wheelchair at the nurses station for monitoring. [sic] 3. Review of resident #73's Care Plan, initiated 4/20/22, showed, Due to my swallowing difficulty, I will be monitored for signs/symptoms of aspiration: choking, coughing, loss of liquids from mouth, recurrent heart burn, hoarseness, sensation of food getting stuck in the throat or chest or behind the breastbone, unexplained weight loss, regurgitation, difficulty controlling foods in mouth, difficulty starting the swallowing process, pocketing of foods, avoidance/anxiety with meals, and complaints of difficulty. Review of resident #73's Speech Therapy evaluation dated 4/21/22 showed, Swallow abilities mild. recommendations: supervision for oral intake; close supervision. Due to the documented physical impairments and associated functional deficits the patient is at risk for aspiration. During an observation on 5/12/22 at 7:02 a.m., resident #73 was eating breakfast alone in his room which was the last one at the end of the hallway, furthest from the nurses' station. While attempting to grab a beverage, resident #73 knocked his tray off of the table causing food and liquids to be scattered across the floor in his room. Review of resident #73's provider note, dated 5/11/22, showed the resident needed, Extensive assist with ADLs. During an observation on 5/12/22 at 1:04 p.m., resident #73 was sitting alone in his room with his lunch tray in front of him. No staff were visible in either hallway for interview regarding resident #73's aspiration risk status and supervision. 40068 4. During an observation on 5/11/22 at 12:05 p.m., resident #28 was served a pureed diet by staff member N. Staff member N set the tray on resident #28's bedside table and left the room. During an observation on 5/11/22 at 12:11 p.m., resident #28 was in her room, with the door cracked, eating her lunch and coughing. Resident #28 was not being supervised. During an interview on 5/11/22 at 12:42 p.m., staff member J stated resident #28 usually prefers to eat in her room. Staff member J stated she was only on a pureed diet because that was her preference. Staff member J stated, I don't think she is at risk of aspiration because she would need to eat in the dining room, and she eats trail mix often. Review of resident #28's care plan with a revision date of 12/22/20 showed, .history of swallowing difficulty and aspiration .Due to my history of swallowing concerns, I will be monitored for signs/symptoms of aspiration: choking, coughing, loss of liquids from mouth, recurrent heartburn, hoarseness, sensation of food getting stuck in the throat or chest or behind the breastbone, unexplained weight loss, regurgitation, difficulty controlling foods in mouth, difficulty starting the swallowing process, pocketing of foods, avoidance/anxiety with meals, and complaints of difficulty . Review of resident #28's Speech Therapy Evaluation dated 1/6/21 showed, Tx R13.12 Dysphagia, oropharyngeal phase 1/1/21 .Reason for Referral: Patient referred to ST due to new onset of decreased oral/pharyngeal function, increased s/s dysphagia, risk for aspiration and dysarthria indicating the need for ST to assess/evaluate least restrictive oral intake, analyze oral/pharyngeal function, minimize aspiration/risk of and develop & instruct compensatory strategies .Overall Abilities Swallowing Abilities = Min/Close Supervision .Assessment Summary Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: aspiration.

Based on observation, interview, and record review, the facility staff neglected to properly transfer a resident which caused the resident fear, for 1 (#15) of 1 sampled resident; neglected to provide necessary and timely care for a resident who had a fall and sustained significant injuries, for 1 (#5) of 3 sampled residents; and, facility staff neglected to ensure availability of glucogon in the medication cart(s) and access it from the emergency medication stock, for a resident who had a hypoglycemic event; and facility management neglected to ensure a sufficient oversight system was in place and followed for glucogon when an emergency occurred, for 1 (#57) of 1 sampled resident. Findings include: 1. During an interview on 5/9/22 at 2:07 p.m., resident #15 stated she was a two-person assist and the facility was not using two people to help get her out of bed. She stated this was very scary because she knew if she fell and only one person was there helping, they would drop her. During an interview on 5/11/22 at 8:35 a.m., staff member I stated resident #15 usually got up at 9:30 a.m. and then laid back down after lunch at 1:30 p.m. Staff member I stated he usually put her back in bed at 1:30 p.m. before he left. Staff member I stated resident #15 was a one-person physical assist to get out of bed. He stated he pulled her legs off the side of the bed then lifted her torso, so she was seated on the side of the bed. Then sometimes she could lift herself out of bed into her chair. He stated it depended on how she was feeling. During an interview on 5/11/22 at 9:00 a.m., staff member J stated resident #15 was a two-person assist to get out of bed, but often the facility just had one person do it, neglecting her need of a two-person assist. Staff member J stated it depended on the size of the CNA if they needed two people to help the resident out of bed. During an observation and interview on 5/11/22 at 12:15 p.m., resident #15 stated only one staff member helped her get out of bed that morning. She stated it was scary. She stated, I know they will not be able to help me if I fall. They should be using two people for me but there is not enough staff for that. Review of resident #15's care plan, with a revision date of 9/29/20, showed, Transfers: All transfers should be completed using Hoyer lift with bariatric sling and 2 person assist. 41952 2. Review of resident #5's SBAR Communication Form eInteract tool for the resident's fall, which occurred on 1/15/22, showed a pain level of 8 out of 10 and, pain is sharp./Left shoulder (front). [sic] The non-verbal pain signs section of the form was not completed. The notification section showed the physician was notified at 2:00 a.m. of the need to send the resident to the hospital for an evaluation for the fall, an x-ray, and other with no description. The form provided did not have a date and time of completion. Staff neglected to ensure documentation and services were provided timely for the resident. During an interview on 5/12/22 at 9:15 a.m., staff member E stated when a fall happened on a unit the staff made sure the resident was safe. The nurse would proceed with the process of evaluating the resident. The nurse would treat any minor injury. If there was any concern for further injury, the nurse would get an order from the doctor, if possible, to send the resident to the emergency room for further treatment, even if it was just x-rays. Staff member E stated he always erred on the side of caution to rule out injury. Review of resident #5's Post Fall 72-Hour Monitoring Report, for a fall on 1/15/22, showed the time of the fall as 10:05 p.m. Pain was circled Y for yes for the initial check but left blank for the rest of the follow up, and the location of pain listed under the chart was blank. The range of motion for all the resident's extremities were documented consistently the same for each timeframe. Specifically, the left arm was documented as L/2, nine times, meaning limited range of motion with severe weakness. The left leg was documented as F/3, nine times, meaning full range of motion with mild weakness. Review of staff member Y's handwritten witness statement, dated 1/15/22, for resident #5's fall showed, . L [left] arm had 3 big skin tears and the resident said her shoulder was hurting, nurse and I examined resident, we did notice the L [left] shoulder was a little swollen and resident was not able to lift L[left] arm very much. [sic] Review of resident #5's nurse progress note for the fall on 1/15/22, was written at 3:50 a.m. on 1/16/22, and showed, Resident fell and shoulder appears to be out of socket. Called Dr got order to send to hospital at 0120 [1:20 a.m.]. Resident #5 was not sent out for a higher level of care for evaluation and treatment for several hours after her fall, which was at 10:05 p.m. in which she sustained multiple fractures on the left side of her body. Review of resident #5's hospital discharge documents, dated 1/24/22, showed, Patient's shoulder x-ray showed displaced fracture, elbow x-ray showed olecranon fracture . CTA chest abdomen pelvis was done which showed right sided pulmonary embolism, acute left humeral head and neck fracture, acute left superior and inferior pubic rami fractures. [sic] 45447 3. During an interview on 5/11/22 at 8:55 a.m., staff member D stated during the incident with resident #57 on 3/8/22, where the resident's blood sugar was 38 (hypoglycemic) and he was non-responsive, she was unable to find glucagon in the medication cart. Staff member D stated when she asked the other nurses in the facility, they stated there was no available glycogon on their units either. Staff member D stated there was glycogen in the Cubex (location with emergency medication), but she did not have access at the time of the incident, and still did not have access on the day of the interview, which was over six months after the event with resident #57. Staff member D stated there should have been glucagon in the medication cart, and she had not received education in the facility about the protocol for a resident during a hypoglycemic event or other emergency protocols. During an interview on 5/11/22 at 11:11 a.m., staff member B stated she was aware of the incident with resident #57's hypoglycemic event on 3/8/22, and stated the floor nurses were to ensure glucagon was available in the medication carts. Staff member B stated staff member D should have retrieved another nurse to login to the Cubex (emergency medication) system to obtain the resident #57 needed. During an interview on 5/11/22 at 3:05 p.m., staff member D stated she did not ask another nurse to access the Cubex system during the incident with resident #57 on 3/8/22 because she did not know there was a Cubex system or other emergency medication location in the facility. Staff member D stated she had her orientation to the facility in November 2021. The event occurred with resident #57 several months later. During an interview on 5/11/22 at 3:25 p.m., staff member E stated he did orient staff member D to the Cubex system. Staff member E stated he showed staff member D how to access the system, but never watched her open it, and trusted her when she said she knew how to access it. During an interview on 5/11/22 at 3:38 p.m., staff member B stated she gave verbal education on 3/9/22 to staff member D after the hypoglycemic incident with resident #57. Review of a facility document signed by staff member B reflected, Hypoglycemic incident reviewed in daily clinical on 3/9. Cubex checked to verify availability of glucagon. Glucagon noted to be available and in stock. [Staff member D] verbally educated on availability of emergency medications and how to access them on 3/11 by the SDC under the direction of the DON.

Based on interview and record review, the facility failed to ensure a system was in place for the provision of emergency medication/treatment during a hypoglycemic event, when a resident had a hypoglycemic event, which put other residents at risk due to the failed system, for 1 (#57) of 1 sampled resident. Findings include: During an interview on 5/11/22 at 8:55 a.m., staff member D stated if a resident was hypoglycemic (had low blood sugar) and non-responsive, the staff was to administer an intramuscular injection of glucagon from the medication cart. Staff member D stated if there was no glucagon in the cart, the staff member was to call the doctor. Staff member D stated all nurses on the units were responsible for ensuring there was glucagon available in the medication carts. Staff member D stated during the incident with resident #57 on 3/8/22, where the resident's blood sugar was 38 (hypoglycemic) and he was non-responsive, she was unable to find glucagon in the medication cart. Staff member D stated when she asked the other nurses in the facility, they stated there was no available glucagon on their units either. Staff member D stated there was glucagon in the Cubex (location with emergency medication), but she did not have access at the time of the incident, and still did not have access on the day of the interview. Staff member D stated there should have been glucagon in the medication cart, and she had not received education in the facility about the protocol for a resident during a hypoglycemic event or other emergency protocols. During an interview on 5/11/22 at 11:11 a.m., staff member B stated she was aware of the incident with resident #57's hypoglycemic event on 3/8/22, and there was no documentation of a formal root cause analysis for the incident. Staff member B stated it was her expectation the floor nurses ensured glucagon was available in the medication carts, and she ensured all staff were registered and could access the Cubex system monthly. Staff member B stated staff member D should have retrieved another nurse to login to the Cubex system to obtain the glucagon during the incident. Staff member B stated she did not provide training to staff on hypoglycemic protocols because there were protocols ordered in the chart for the nursing staff to follow. During an interview on 5/11/22 at 3:05 p.m., staff member D stated she did not ask another nurse to access the Cubex system during the incident with resident #57 on 3/8/22 because she did not know there was a Cubex system or other emergency medication location in the facility. Staff member D stated she was not made aware of the system during her orientation to the facility in November 2021. Staff member D stated she trained with staff member E for a week and then worked on the floor. During an interview on 5/11/22 at 3:25 p.m., staff member E stated he oriented new staff to the medication carts, computer system, and the Cubex. Staff member E stated staff are normally given access to the Cubex system during orientation, and he did orient staff member D to the Cubex system. Staff member E stated he showed staff member D how to access the system, but never watched her open it, and trusted her when she said she knew how to access it. During an interview on 5/11/22 at 3:38 p.m., staff member B stated she gave verbal education on 3/9/22 to staff member D after the hypoglycemic incident with resident #57. Staff member B stated she did not have staff member D sign the verbal education sheet because it was not a formal conversation. Staff member B stated she had the staff complete a competency checklist upon hire, and it was communicated where the Cubex system was during the overview of the facility's floor plan, as the location of the Cubex was not on the checklist. Review of a facility document signed by staff member B reflected, Hypoglycemic incident reviewed in daily clinical on 3/9. Cubex checked to verify availability of glucagon. Glucagon noted to be available and in stock. [Staff member D] verbally educated on availability of emergency medications and how to access them on 3/11 by the SDC under the direction of the DON. There was no signature of staff member D on the document. Review of a facility document titled, [Facility name] Licensed Nurse Clinical Competencies, dated 4/19/22, did not show a competency option or completion related to emergency medications, hypoglycemic protocol, or Cubex access for staff member D.

Based on observation, interview, and record review the facility failed to provide dignity and respect for 1 (#62 ) of 24 sampled residents, and the resident felt humiliated, hopeless, harassed, abused, and violated, and this negatively effected her mood, and the resident was assessed to have a deterioration in mood per the Minimum Data Set Assessment over the last year. Findings include: During an observation and interview on 6/7/21 at 2:40 p.m., resident #62 said she needs extensive assist to transfer from the bed to the chair, and is a cares in pairs (two staff) for assistance. Resident #62 said she was weighed with one gown on and her butt hanging out. Resident #62 said she felt humiliated. Resident #62 said she had reported this to staff member B and C. Review of resident #62's Quartery MDS, with an ARD of 5/21/21, showed the resident had a BIMS of 14, which showed she was cognitively intact. During an interview on 6/8/21 at 10:50 a.m., resident #62 said when staff members D, H, and J work, she dreads it. Resident #62 said when staff member D worked days, she told resident #62 I'm still here and did not get terminated. Resident #62 stated there was a picture of her with staff members D and J holding my arm against me because I would not go along with their schedule change, such as only being able to use my call light once during the day. Resident #62 said this had made her depression twenty times worse, and I start shaking. Review of resident #62's Annual MDS, with an ARD date of 8/27/20, Section D-Mood, D0300, showed a Total Severity Score of 5. Review of resident #62's Quarterly MDS, with an ARD date of 11/18/20, Section D-Mood, D0300, showed a Total Severity Score of 16. Review of resident #62's Quarterly MDS, with an ARD date of 2/18/21, Section D-Mood, D0300, showed a Total Severity Score of 13. Review of resident #62's Quarterly MDS, with an ARD date of 5/21/21, Section D-Mood, D0300, showed a Total Severity Score of 17. A review of the MDS PHQ9 (Section D of the MDS) scoring results showed: - 5-9: mild depression - 10-14: moderate depression - 15-19: moderately severe depression Per the resident's MDS assessments, the resident's mood deteriorated from the mild depression (low-range), to moderate severe depression (mid-range) in nine months. During an interview on 6/8/21 at 11:06 a.m., resident #62 said staff member J finds it funny to drop my gown on the floor and let me walk around naked in the bathroom. Resident #62 said staff were told to have 4 staff for her showers. Resident #62 did not know why the increase in staff for showers. During an interview on 6/8/21 at 11:14 a.m., resident #62 said she feels humiliated, hopeless, harassed, and abused. During an interview on 6/10/21 at 10:45 a.m., NF1 said resident #62 told her she felt violated with four people giving her a shower. Staff did not cover her properly when going in and out of the bathing room. During an interview on 6/10/21 at 1:25 p.m., staff member J said, that more staff were used with residents that make allegations against them.

Based on interview and record review, the facility failed to protect residents from abuse by staff members for 2 (#s 42 and 62) of 34 sampled and supplemental residents. This failure caused ongoing feelings of anger, frustration, defensiveness, hopelessness, and humiliation. Findings include: 1. During an interview on 6/7/21 at 2:40 p.m., resident #62 said four staff members blocked the entrance to her room and she was told by staff member D that she did not get fired and she was still here. Resident #62 said staff member D told her I win. Resident #62 said she had reported it to staff members B and C. The resident said she felt harassed, and abused. During an interview on 6/8/21 at 10:50 a.m., resident #62 said staff member D was a nurse that worked days. Resident #62 said she reported, that four staff members blocked her doorway, to the floor nurse and CNA on that day. Resident #62 also stated the harassment and abuse started about a month ago, April 2021 to current. The resident said she saw a picture showing staff members D and J were restraining her by holding her arms against her. Resident #62 said the staff restrained me because I would not go along with their schedule change. Resident #62 said one of the schedule changes was that I could only use my call ligt once during the day. During an interview on 6/8/21 at 11:14 a.m., resident #62 said staff respond to my call light, with 2 staff, cares in pairs and staff said for the shower, there is to be four staff, and that's what they were told to do. Resident #62 did not say who told them that. During an interview at 6/8/21 at 4:03 p.m., staff member C stated that resident #62 had reported more than weekly with allegations. Resident #62 did not always report to staff member C. Staff member C said resident #62 accused him of abuse. Resident #62 accused staff member C of yelling and slamming the door in her face. During an interview on 6/8/21 at 5:06 p.m., staff member A, B, and K stated they were unaware of abuse allegations made by resident #62. An investigation into the allegation of abuse reported by resident #62 was not initiated until after this interview, and was reported to the State Survey Agency on 6/8/21 at 7:40 p.m. During an interview on 6/9/21 at 9:58 a.m., NF1 said she has heard of resident abuse in the past, had gone to the facility, and the facility placed the blame back on the residents. NF1 said there was no supervisory oversite, and no documentation of incidents of abuse. During an interview on 6/10/21 at 10:45 a.m., NF1 said resident #62 felt violated with four staff members in the shower room, and not being covered properly. NF1 stated resident #62 was told by staff member D if she fell on the floor, they would leave her on the floor until the fire department came. During an interview on 6/10/21 at 11:18 a.m., resident #62 said she was aware of the three staff working her wing today. Resident #62 said it made her uncomfortable, it was just more retaliation, and they got away with it. Resident #62 said no staff member came in and asked her if she would be comfortable with these staff working her wing today. 2. During an interview on 6/7/21 at 3:05 p.m., resident #42 stated he had been verbally abused by staff member D. Resident #42 raised his voice during the interview, was visibly agitated, and stated staff member D was his only issue. Resident #42 stated he reported the abuse to staff members B and C. During an interview on 6/8/21 at 9:08 a.m., staff member C stated resident #42 had behaviors in the past and targets staff. Staff member C stated he had not documented each incident that resident #42 reported, and his documentation was based on resident #42's reaction, if he continued to talk about it, and if he apologized the next day. During an interview on 6/8/21 at 10:54 a.m., staff members E, F, and G stated they had received de-escalation skills training. Staff member E stated if resident #42 had a concern, he sometimes wanted to talk to someone higher up, such as staff member B or C. During an interview on 6/8/21 at 2:30 p.m., resident #42 stated about a month ago he had asked for help from staff member D and was told, You can help yourself and do it yourself. Resident #42 stated he then had cursed at staff member D. Resident #42 stated staff member D replied f*** you and then flipped me off, more than once. Resident #42 stated, She was abusive. Resident #42 stated the things staff member D said to him made him feel angry, frustrated, and defensive, and he did not want to face her again. Resident #42 stated, I'm not the only one, she does this to other people. During an interview on 6/8/21 at 4:04 p.m., staff member C stated repeat allegations may not be documented in the electronic record, and it is a difficult balance for people that have a history of allegations. When asked how the facility protects residents from abuse, staff member C stated if he felt there was a legitimate allegation, then staff would not work while the incident was investigated. Staff member C stated when there was actually an allegation of abuse, the facility would do incident reports. Staff member C stated staff member B is aware of the incidents reported by these individuals with a history of allegations, and they were reported to staff member A. During an interview on 6/8/21 at 5:06 p.m., staff member A, B, and K stated they were unaware of abuse allegations made by resident #42. An investigation into the allegation of verbal abuse reported by resident #42 was not initiated until after this interview, and was reported to the State Survey Agency on 6/8/21 at 7:40 p.m. Review of resident #42's Quarterly MDS, with an ARD of 5/5/21, showed: -Section C - BIMS score of 13, and -Section I - Anxiety Disorder, [CONDITION(S)], [CONDITION(S)]. During an interview on 6/8/21 at 3:30 p.m., staff member I said the last abuse training was completed in April 2021. Abuse training was completed every quarter for staff. Staff member I said the different types of abuse were reviewed. Staff member I said that any type of abuse was reported to staff member C within two hours. During an interview on 6/8/21 at 3:45 p.m., staff member Z said she had abuse training, and that staff member I goes over this every month. Staff member Z was able to recite the types of abuse. Staff member I said if she witnessed abuse, she would report it to the nurse and call staff member C within two hours. During an interview on 6/10/21 at 1:25 p.m., staff member J said she received abuse training once a month. Staff member J was able to recite the different types of abuse. Staff member J said if she witnessed abuse, she would report it to her charge nurse and then it was reported to staff member C within two hours. Staff member J said the staff do cares in pairs. Staff member J said sometimes they bring in a third staff to help if a resident was accusing staff of anything. Review of the All - Staff training in April 2021, showed, Quarterly Abuse ED (education) was completed by staff. Review of the facility policy titled, Abuse Prevention Program, last revised 12/16, showed: -6. Identify and assess all possible incidents of abuse, -7. Investigate and report any allegations of abuse within timeframes as required by federal requirements, and -8. Protect residents during abuse investigations. Refer to F550 related to Dignity and Respect for resident #62.

Based on observation, interview, and record review, the facility staff, to include multiple disciplines and shifts, failed to identify and provide necessary medical interventions for a resident who had an accident, in which the resident sustained [REDACTED]. not be repaired, therefore, the resident had all medications stopped and was receiving end of life care, for 1 (#7) of 7 sampled residents. Findings include: During an observation on 12/26/18 at 2:37 p.m., resident #7 was observed sitting in her wheelchair, with a white towel placed underneath her. She was wearing blue pants which covered her knees, but exposed the remainder of her legs. A large hematoma was observed on her left calf. Several other small bruises were observed on both of her lower legs. During an interview on 12/26/18 at 2:39 p.m., staff member H stated she was not sure why resident #7 was sitting on a white towel, but she would go and get one of her staff to determine why the towel was placed under the resident, and then assist the resident. During an observation and interview on 12/26/18 at 2:43 p.m., staff member E was observed approaching resident #7. He stated he was not sure why she had a towel placed underneath her, but he would get another staff member to help him remove it. Staff member E pushed resident #7 to the nurse's station of the 400 wing. During an observation on 12/26/18 at 2:44 p.m., staff members E and D were observed trying to lift resident #7 from her wheelchair so they could remove the white towel from her chair that was placed underneath her. Resident #7 yelled out Ouch, don't touch me! It hurts so bad! Staff member D removed the white towel, even though the resident was voicing the pain when touched/moved. During an observation and interview on 12/26/18 at 2:45 p.m., staff member D and E were observed taking resident #7 to her room. Staff member E stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. During an observation and interview on 12/26/18 at 2:46 p.m., staff member C entered resident #7's room. She stated she had not worked the last two days, and she was not aware that resident #7 had been complaining of right hip or leg pain. Staff member C instructed staff members D and E to transfer the resident to her bed. Staff member E was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and E continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six, on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. Staff member C stated, Let me go call the doc. She exited resident #7's room at 3:03 p.m. During an observation on 12/26/18 at 3:07 p.m., staff member B was observed entering resident #7's bedroom. She began asking the resident questions about where her pain was, and what the source of the pain was. While completing a nursing assessment of the resident's right leg, staff member B placed her hands on the resident's right knee. Staff member B attempted to lift resident #7's pant leg up above her knee but was unable to, due to resident #7's complaints of pain. When staff member B attempted to move resident #7's right leg, resident #7 yelled out, It hurts so bad! Staff member B asked resident #7 if she would like medication to manage her pain. Resident #7 responded, I'm afraid I'm gonna go downhill (decline in health/mobility). She stated, I'm scared something is gonna happen to me, and I'm not ready to go yet. During an observation on 12/26/18 at 4:38 p.m., resident #7 had been removed from her bed, although the resident had voiced the prior complaints of pain with her hip/leg, and the resident was observed sitting in her wheelchair in her room. Resident #7 appeared groggy. When greeted, she opened her eyes, responded, then appeared to fall asleep. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. She stated the technician who took the x-rays stated there appeared to be a right distal femur fracture. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. Staff member B stated the resident had been transferred from the bed, to the wheelchair, by the hoyer lift. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today. During an interview on 12/26/18 at 8:15 p.m., staff member E stated resident #7 had been in bed the last three shifts he had worked. He stated resident #7 had, Complained of a lot of pain all three days. Staff member E stated he worked on 12/21/18, 12/24/18 and 12/25/18. He said he was not scheduled to work on 12/22/18 and 12/23/18. Staff member E stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated she had not received any reports of resident #7 having had any falls or incidents in the last week. She stated, On the 23rd she refused her pain medications although she did complain of pain in her leg. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. Staff member L said she was informed that resident #7 was transferred to the hospital for a suspected fracture when she arrived for her shift. During an interview on 12/27/18 at 8:30 a.m., staff member N stated she had been told in report that morning that resident #7 had been in bed for, Four days straight. Staff member N stated to staff member G that they should, Get (resident #7) up. Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 transferred from her bed into her wheelchair okay with the assistance of one staff. Staff member N stated resident #7 initially refused to transfer from her wheelchair to the toilet. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:13 a.m., staff member C stated she worked on 12/21/18, 12/22/18, and 12/23/18 from 6:00 a.m. to 6:00 p.m. She was not scheduled to work on 12/24/18 or 12/25/18. She stated when she came back from lunch on 12/21/18, staff member M told her about the incident that occurred with resident #7. She stated staff member M told her she did an assessment, the resident was in pain, and she gave the resident a PRN pain medication. Staff member C stated she did not complete an assessment of resident #7 because she was told staff member M did one. She stated staff member M should have completed a nursing assessment. Staff member C stated she did not call the doctor or the family to report the incident. She stated staff member M should have notified both parties. When asked if resident #7 received a PRN medication to treat her pain following the incident, staff member C stated, Based on the documentation on the MAR, no PRN was administered. She stated nursing staff should document on the MAR all medications that are administered. Staff member C stated she was not aware that resident #7 remained in bed for several days following the incident. She stated, She refused to get up two days for me. Staff member C stated resident #7 did not get out of bed on 12/22/18 or 12/23/18. She stated prior to the incident on 12/21/18, resident #7 had never complained of right leg pain. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday. Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. Review of resident #7's narcotic medication log showed staff member M removed a [MEDICATION NAME] tablet from resident #7's medication card on 12/21/18 at 1:30 p.m. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed, no documentation that a PRN pain medication was administered to resident #7, or that a pain assessment was completed for the resident on 12/21/18 at 1:30 p.m. During an interview on 12/27/18 at 9:51 a.m., staff member B stated she was made aware of the incident that occurred on 12/21/18 with resident #7 at 5:00 p.m. the previous day (12/26/18). She stated there was no nursing assessment completed for resident #7 following the incident on the 21st, and stated, Whoever assessed the resident should have wrote an assessment. Staff member B stated, Pain assessments should be made and documented, if a PRN pain medication is given to a resident. She said when a PRN pain medication is administered, the computer system prompts staff to complete a pain assessment. Staff member B stated it is not acceptable practice for a nurse to sign out a narcotic medication and administer it to a resident without signing the residents MAR. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. She stated she worked from 6:00 a.m. to 6:00 p.m. on 12/24/18 and resident #7 did complain of pain that day. Staff member B stated she administered a PRN Tylenol to resident #7, and the documentation could be found on her MAR. She stated resident #7 refused to get out of bed that day, but she did take all her medications. When asked if staff member G should have placed resident #7's foot pedals on her wheelchair prior to transporting her on 12/21/18, staff member B stated, I would have preferred it. Staff member B stated that all incidents involving residents in the facility should be documented. She stated nursing staff should complete a nursing note and document their assessments. She stated incidents are reviewed the following day by the IDT. Staff member B stated notifications of incidents should be reported to the doctor, the family, and she would, Prefer to be notified. She stated her phone number is posted all over the building. When asked if she had received an updated report from the hospital, staff member B stated resident #7 had a right femur fracture. She stated resident #7 was admitted to the hospital, and, We just don't know the plan yet. During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. Staff member F stated she documented this information in resident #7's nursing progress notes. She stated she placed a copy of the note in the doctor communication book, and staff member S read and signed the note on 12/26/18. Staff member F stated she did not notify the doctor of her findings on 12/25/18. Review of resident #7's progress notes, dated 12/25/18, showed, Resident does complain of right knee pain. Knee has continuous selling, (sic) does not seem worse today. No redness or warmth to the area. CNA's report that resident does not bear weight well even with stand up lift. The note was signed by staff member S. During an interview on 12/27/18 at 10:52 a.m., staff member A stated that he was made aware of the incident that occurred on 12/21/18 with resident #7 on the previous day (12/26/18). He stated, I learned about it yesterday afternoon. You would think that someone would have reported it (prior). During an interview on 12/27/18 at 11:10 a.m., staff member G stated she worked on 12/26/18. She stated she was informed that resident #7 had been, In bed for four days, when she got her morning report. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Staff member S stated she could not provide any additional information about resident #7 or her medical status without having her chart available. She stated she would follow-up with a phone call on 12/28/18. No follow up phone call was received from staff member S regarding the resident. Review of resident #7's physician progress notes [REDACTED]. No documentation of a resident assessment was completed after that date. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. Review of resident #7's pain evaluation assessment, completed on 12/13/18, showed, resident #7 did not verbalize or exhibit non-verbal symptoms of pain. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments were documented, on a scale of 0-10, as follows: -12/21/18- 0; -12/22/18- 0; -12/23/18- 0; -12/24/18- 7; -12/25/18- 7; -12/26/18- 8. Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's transferring with staff. Review of resident #7's progress notes, dated 12/26/18, showed, Spoke with ER. Nurse stated res (sic) is going to be admitted to the hospital for a Tib and Fib (sic) fracture. No other information was given. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated the facility had called her the afternoon prior (12/26/18), to inform her that her mother was going to be sent to the emergency room for a suspected injury to her leg, but she had not had any communication with anyone from the facility since that time. NF1 stated she had spent her morning talking to several doctors at the hospital. She stated she was told that her mother's femoral fracture was, So severe that the bone was shattered. NF1 stated, The doctor's said that my mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Review of the facilities Abuse and Neglect policy, revised (MONTH) (YEAR), showed, Neglect is defined as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Section Assessment and Recognition of the policy showed, 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment .b. Pain assessment .2. The nurse will report findings to the physician .

Based on observation, interview, and record review, the facility failed to assess, identify, thoroughly investigate, and act on a resident's injury and medical condition timely, and the injury occurred during an accident at the facility. The failure caused a delay in treatment for [REDACTED].#7) of 7 sampled residents. Findings include: During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday. Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. During the survey, the following was identified, showing concerns were present, but not identified and acted upon adequately, following the resident's accident: a. Care After Accident - Care Plan Modification During an observation and interview on 12/26/18 at 2:45 p.m., staff member E stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. No changes were made to address the resident's plan of care by this date. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today. During an interview on 12/26/18 at 8:15 p.m., staff member E stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated she had not received any reports of resident #7 having had any falls or incidents in the last week. She stated, On the 23rd she refused her pain medications although she did complain of pain in her leg. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. Staff member L said she was informed that resident #7 was transferred to the hospital for a suspected fracture when she arrived for her shift. During an interview on 12/27/18 at 8:30 a.m., staff member N stated she had been told in report that morning that resident #7 had been in bed for, Four days straight. Staff member N stated to staff member G that they should, Get (resident #7) up. Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 transferred from her bed into her wheelchair okay with the assistance of one staff. Staff member N stated resident #7 initially refused to transfer from her wheelchair to the toilet. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments from 12/21/18 - 12/23/18 were documented with 0's until 12/24/18, which is when the pain increased to a 7 or 8 out of 10. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's safe transferring with staff members. b. After Surveyor Involvement, the following occurred: During an observation and interview on 12/26/18 at 2:46 p.m., staff member C was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and E continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. She left to notify the physician, which was now five days after the accident occurred. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. During an interview on 12/27/18 at 9:51 a.m., staff member B stated she was made aware of the incident that occurred on 12/21/18 with resident #7 at 5:00 p.m. the previous day (12/26/18). She stated there was no nursing assessment completed for resident #7 following the incident on the 21st. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. When asked if staff member G should have placed resident #7's foot pedals on her wheelchair prior to transporting her on 12/21/18, staff member B stated, I would have preferred it. Staff member B stated that all incidents involving residents in the facility should be documented. She stated nursing staff should complete a nursing note and document their assessments. She stated incidents are reviewed the following day by the IDT. Staff member B stated notifications of incidents should be reported to the doctor, the family, and she would, Prefer to be notified. c. Provider and Radiology During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. Staff member F stated she documented this information in resident #7's nursing progress notes. She stated she placed a copy of the note in the doctor communication book, and staff member S read and signed the note on 12/26/18. Staff member F stated she did not notify the doctor of her findings on 12/25/18; verbally. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated, My mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Refer to F600 for Neglect, F658 Professional Standards, and F697 Pain, related to this event.

Based on observation, interview, and record review, the facility staff failed to sufficiently assess and provide timely and suitable interventions for a resident who had an unidentified leg fracture and the resident had a change in pain and comfort level, and staff were aware of the changes, which included increase in pain intensity, change of pain location, pain when touched, she refused to get out of bed for four days, and had a change in her transfer ability. The resident's care plan was not modified during this time period to address the pain and care related to it; and, staff did not adequately communicate the resident's ongoing pain and condition related to the pain, to ensure a comprehensive nursing assessment and ongoing monitoring occurred so the pain could be actively addressed timely with the provider, for 1 (#7) of 7 sampled residents. Findings include: a. Accident and initial assessment - Start of increased pain complaints During an interview on 12/27/18 at 8:52 a.m., staff member G stated she worked on 12/21/18. She stated around 1:00 p.m., she was asked to take resident #7 out of the dining room. Staff member G stated, I asked (resident #7) to lift up her legs. She stated when she went to move her wheelchair, resident #7 dropped her right leg, and it got caught under her wheelchair. Staff member G stated resident #7 screamed, Ouch! She stated, I grabbed her foot pedals. She stated, I lifted her left leg first, nothing. Then, I lifted her right leg and she screamed. Staff member G stated, I pushed resident #7 to the nurse's station. She stated the nurse on her wing was on break so she went to get staff member M. She stated she told staff member M exactly what happened. Staff member G said she reported that resident #7 was in extreme pain. Staff member G said that she observed staff member M looking at resident #7's right knee. She stated she was not sure if staff member M completed a nursing assessment and was not sure if staff member M gave resident #7 any pain medication. Staff member G stated staff member M told her to take resident #7 to her room and lay her down in her bed. She stated when she transferred resident #7, she Screamed and told me not to move her leg. Staff member G stated she reported the incident to staff member C around 2:00 p.m., and she reported the incident to the oncoming shift. During an interview on 12/27/18 at 9:24 a.m., staff member M stated she worked on 12/21/18. She stated staff member G, Came to get me. She came to my office panic stricken. Staff member M stated staff member G told her resident #7's right foot got caught underneath her wheelchair. She stated staff member G told her resident #7 yelled out in pain. Staff member M stated she completed an assessment of resident #7's right leg. She stated, There was no swelling in the right leg, or in her right knee. Staff member M stated, (Resident #7) told me the pain was in her right lower leg. She stated resident #7 said she wanted pain medication and she, Gave her a [MEDICATION NAME]. Staff member M stated she did not sign the MAR when she administered the medication. She stated, I signed out the medication in the NARC book. When asked if she should have signed the MAR, staff member M stated, Yes of course I am supposed to sign the MAR. Staff member M stated she did not document her assessment of resident #7's right leg, and stated, I am supposed to. She stated she gave staff member G permission to put resident #7 in her bed. She stated she did not hear resident #7 scream out in pain when she was transferred. Staff member M stated she reported the incident to staff member C when she returned from lunch. Staff member M stated she did not report the incident to resident #7's family or doctor. She stated she was not aware that resident #7 spent several days in bed following the incident. Staff member M stated, I have heard that (resident #7) has a femur fracture. She stated, (Staff member B) told me yesterday (12/26). Staff member M stated staff are supposed to be placing a resident's feet on the foot pedals of their wheelchairs before transporting them. The resident's injury/fracture was not identified after the accident and initial nursing assessment was done, and care continued with no changes to the resident's care plan. Review of resident #7's pain evaluation assessment, completed on 12/13/18, showed, resident #7 did not verbalize or exhibit non-verbal symptoms of pain. The evaluation was completed prior to the injury occurring. Review of resident #7's Medication Administration Record for (MONTH) (YEAR), showed resident #7's pain assessments were documented, on a scale of 0-10, as follows: -12/21/18- 0; Staff voiced resident had pain throughout day (content below) -12/22/18- 0; Staff voiced resident had pain throughout day (content below) -12/23/18- 0; Staff voiced resident had pain throughout day (content below) -12/24/18- 7; -12/25/18- 7; -12/26/18- 8. b. Staff awareness of pain During an observation and interview on 12/26/18 at 2:45 p.m., staff member E stated resident #7 had recently been complaining about pain in her right hip and leg. He stated resident #7 had difficulty transferring recently, and he reported both the pain and transferring issues to the nursing staff. During an interview on 12/26/18 at 8:10 p.m., staff member D stated he worked on 12/22/18 and 12/23/18 from 2 p.m. to 10 p.m. He stated resident #7 was in bed and remained in bed both days for the entirety of his shifts. Staff member D stated, She wouldn't get up. She complained of pain whenever she was repositioned. He stated he did not work on 12/24/18 or 12/25/18. Staff member D stated resident #7, Complained of a lot of pain today (12/26). During an interview on 12/26/18 at 8:15 p.m., staff member E stated resident #7 had been in bed the last three shifts he had worked. He stated resident #7 had, Complained of a lot of pain all three days. Staff member E stated he worked on 12/21/18, 12/24/18 and 12/25/18. He said he was not scheduled to work on 12/22/18 and 12/23/18. Staff member E stated he had to use the sit to stand hoyer lift for resident #7 on 12/25/18. He stated, She wouldn't bear weight, and I needed enough time to do peri care. During an interview on 12/26/18 at 8:30 p.m., staff member L stated she worked 6 p.m. to 6 a.m. on 12/21/18, 12/22/18, and 12/23/18. She stated that resident #7 remained in her bed the entirety of all three of her scheduled shifts. Staff member L stated, (Resident #7) was hollering with pain and did eventually take her meds. During an interview on 12/27/18 at 8:30 a.m., Staff member N said resident #7 complained of her body hurting more than usual during care. She stated resident #7 eventually agreed to the transfer and stated, Ow, ow, ow, during the transfer. Staff member N stated she then went to get another CNA to assist her. Staff member N said she did not report this information to the nurse. During an interview on 12/27/18 at 9:51 a.m., staff member B stated Whoever assessed the resident should have wrote an assessment. Staff member B stated, Pain assessments should be made and documented, if a PRN pain medication is given to a resident. She said when a PRN pain medication is administered, the computer system prompts staff to complete a pain assessment. Staff member B stated it is not an acceptable practice for a nurse to sign out a narcotic medication and administer it to a resident without signing the residents MAR. Staff member B stated she was not aware that resident #7 had remained in bed for several days following the incident that occurred on 12/21/18. During an interview on 12/27/18 at 10:25 a.m., staff member F stated resident #7 told her that she was having right knee pain on 12/25/18. She stated CNA's had informed her that the resident would not bear weight well, even while using a stand up lift. She stated she placed a copy of the note in the doctor communication book. Staff member F stated she did not notify the doctor of her findings on 12/25/18, which was now four days after the accident occurred. Review of resident #7's progress notes, dated 12/25/18, showed, Resident does complain of right knee pain. Knee has continuous selling, (sic) does not seem worse today. No redness or warmth to the area. CNAs report that resident does not bear weight well even with stand up lift. The note was signed by staff member S. Review of resident #7's Care Plan, last updated 12/18/18, showed she has alterations in her physical mobility. Section Interventions showed, I want to (sic) licensed unit nurse to intervene when I decline to ambulate. I want them to investigate my reasons and resolve the core issue I identify and document as appropriate .Monitor/document/report to my MD as needed signs/symptoms of immobility . c. Failure to identify root cause of pain increase and provide intervention. During an observation on 12/26/18 at 2:44 p.m., staff members E and D were observed trying to lift resident #7 from her wheelchair, and resident #7 yelled out Ouch, don't touch me! It hurts so bad! Staff member D removed a white towel from under the resident, even though the resident was voicing the pain when touched/moved. This surveyor had questioned why a towel was under the resident, and staff did not have knowledge of why the towel was placed on the chair. During an observation and interview on 12/26/18 at 2:46 p.m., staff member C entered resident #7's room. She stated she had not worked the last two days, and she was not aware that resident #7 had been complaining of right hip or leg pain. Staff member C instructed staff members D and E to transfer the resident to her bed. Staff member E was observed touching resident #7's right leg to lift the right foot pedal of the resident's wheelchair. Resident #7 screamed, Stop! Staff members D and E continued to prepare resident #7 for a transfer to her bed. Due to the resident's heightened pain complaints, with resident #7 observed yelling out in pain every time the staff members touched her right leg, Staff member C was asked if a nursing assessment should be done prior to resident #7 being transferred to her bed. Staff member C stated, Oh yes, and she approached resident #7 and began asking her questions about where her pain was. Resident #7 stated, to staff member C, pain was a six, on a scale of one-to-ten. The resident was observed holding the middle portion of her right upper leg with both hands, and would not let go. Resident #7's right knee was swollen, and there was an old vertical scar observed. Resident #7 could not recall how her leg was injured, and stated, Moving it causes terrible pain. Staff member C stated, Let me go call the doc. She exited resident #7's room at 3:03 p.m. During an observation on 12/26/18 at 3:07 p.m., staff member B was observed entering resident #7's bedroom. She began asking the resident questions about where her pain was, and what the source of the pain was. While completing a nursing assessment of the resident's right leg, staff member B placed her hands on the resident's right knee. Staff member B attempted to lift resident #7's pant leg up above her knee but was unable to, due to resident #7's complaints of pain. When staff member B attempted to move resident #7's right leg, resident #7 yelled out, It hurts so bad! Staff member B asked resident #7 if she would like medication to manage her pain. During an interview on 12/26/18 at 4:40 p.m., staff member B stated resident #7 had an X-ray completed of her right leg. Staff member B stated the portable X-ray tech arrived to do resident #7's x-rays and the facility was waiting for the x-rays to be read. She stated the technician who took the x-rays stated there appeared to be a right distal femur fracture. Staff member B stated resident #7's doctor had requested that she be sent to the emergency room for further evaluation, and she had arranged for a transfer. Staff member B stated the resident had been transferred from the bed, to the wheelchair, by the hoyer lift. During an interview 12/27/18 at 12:27 p.m., staff member S stated she was at the facility on 12/26/18. Staff member S stated she signed the nursing progress note that was placed in the physician communication log for resident #7 (by staff member F). She stated she did not assess resident #7 while at the facility that day, and stated she had not assessed the resident in the last week. Review of resident #7's radiology report, dated 12/26/18, showed resident #7 was diagnosed with [REDACTED]. Findings showed, Comminuted periprosthetic [MEDICAL CONDITION] femur with half shaft width posterior displacement of the arthroplasty at the fracture line and posterior angulation approaching 90 degrees. Indications section of the report showed, Fall. Review of resident #7's medical chart showed no nursing assessment was completed for the resident following the incident that occurred on 12/21/18, and the record failed to show the resident #7's right foot was caught under her wheelchair. No interventions were implemented for future prevention of similar events, to address pain, or the resident's transferring with staff. Review of resident #7's progress notes, dated 12/26/18, showed, Spoke with ER. Nurse stated res (sic) is going to be admitted to the hospital for a Tib and Fib (sic) fracture. No other information was given. During an interview on 12/27/18 at 1:58 p.m., NF1 stated resident #7 was admitted to the hospital and sustained a substantial fracture to her right femur. She stated the facility had called her the afternoon prior (12/26/18), to inform her that her mother was going to be sent to the emergency room for a suspected injury to her leg, but she had not had any communication with anyone from the facility since that time. NF1 stated she had spent her morning talking to several doctors at the hospital. She stated she was told that her mother's femoral fracture was, So severe that the bone was shattered. NF1 stated, The doctor's said that my mom is too fragile and would not be able to survive the surgery to fix her leg. She stated she and her family had made the decision to pursue hospice care for her mother due to this, and stated, We are going to take her off all of her meds. She's in so much pain. After this, all we want to do is keep her comfortable. She just wants to die. Review of the facilities Abuse and Neglect policy, revised (MONTH) (YEAR), showed, Neglect is defined as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Section Assessment and Recognition of the policy showed, 1. The nurse will assess the individual and document related findings. Assessment data will include: a. Injury assessment .b. Pain assessment .2. The nurse will report findings to the physician .

Based on interview and record review, the facility failed to prevent verbal abuse, resulting in psychosocial harm for 2 (#s 22 and 82) of 35 sampled and supplemental residents. Findings include: 1. During an interview on 6/26/18 at 1:31 p.m., resident #82 stated there is a staff member who is disrespectful towards him. He said it was more than being disrespectful, adding, She is just mean. Resident #82 stated the staff member scolded him when he put on his call light to use the bathroom, and yelled at him if he bumped into things while wheeling himself in the hallway. He stated the way she treated him made him feel, less than human. During the interview, resident #82 raised his voice and became agitated and tearful. During an interview on 6/27/18 at 8:17 a.m., staff member K stated staff member L had an irritated attitude when interacting with residents. She stated she heard staff member L talk to residents as if they were a burden. Staff member K stated she heard staff member L scold resident #82 for activating his call light. She stated the issue was beyond poor customer service and a lack of respect. She stated it was more like abuse. Staff member K stated she has reported staff member L's behavior in the past, but not recently. She stated she did not know why she did not report the abuse this time. Staff member K said she didn't work this hall often or work with staff member L very often. During an interview on 6/27/18 at 4:00 p.m., staff member N stated on 6/26/18, NF1 told her resident #82 had complained to him of a CNA who mistreated him. She stated NF1 reported resident #82 said she made him feel bad about needing to use the toilet. She stated when she interviewed resident #82 he told her staff member L did not treat him like a human being. During an interview on 6/28/18 at 1:17 p.m., staff member O stated the facility had no assessment to determine if a resident was at risk for abuse, but she does consider risk factors when she develops the care plan. She stated she had not considered resident #82 at risk because he was so quiet and easy to deal with. She stated he did have a whiny tone, and she may need to expand what risk factors she considers. During an interview on 6/28/18 at 1:29 p.m., staff member I stated resident #82 told her that he was being mistreated by another CNA. She said he had told her that every Monday, when she comes back after her days off, for three or four weeks. Staff member I stated resident #82 said the CNA was mean to him, and said she's evil, asking why staff member L had not been fired. She stated he could not tell her what staff member L did, just that she was mean to him. Staff member I said resident #82 never said he was being physically abused, and she never saw any signs of physical abuse. She stated she had not noticed any behavior changes. During an interview on 6/28/18 at 2:09 p.m., staff member E stated about two weeks ago NF1 told her that resident #82 had told him a CNA named (alleged staff name) spoke roughly to him while she assisted him with toileting. She stated she told NF1 there was no CNA named (alleged staff name), but she would tell staff member N about the concern. Staff member E stated she had reported the concern to staff member N approximately two weeks ago, but she was uncertain of the timeframe. She stated she did not follow-up with resident #82, and she did not ask any other residents if they had been mistreated. Staff member E said she thought staff member N would conduct the investigation. She said she received abuse training in April, and the training included what should be reported, and to whom to report. Staff member E stated she would not do anything differently. She said she felt she had received adequate information from NF1, and did not feel she needed to talk to resident #82. Staff member E stated resident #38 had voiced concerns to her about the treatment of [REDACTED]. She stated resident #38 said they were not as nice as they should be when taking him to the bathroom. She stated she did not know if resident #38 reported to her before or after NF1 reported, but both reports were about two weeks ago. Review of an investigation provided by the facility, dated 6/27/18, showed the following statements by resident #82: - If I say anything to her she says I am whimpering. - She grabs ahold of me like a stick of wood. - She slams me into it, referring to the grab bar next to the toilet. - I would rather die than have her handle me. - I feel abused . Review of an investigation provided by the facility, dated 6/27/18, showed the following statements by staff member L: - Resident #82 has complained about the way she assisted him to use the toilet. - He tells me that I am trying to kill him because I am being rough with him. - She gets frustrated with resident #82 and stated he would feel like she was scolding him. - She stated she was, short and abrupt. During an interview on 6/28/18 at 1:44 p.m., staff member M stated staff member L had been terminated as a result of the allegation of abuse being substantiated. 2. During an interview on 6/25/18 at 11:20 a.m., resident #22 stated he was treated well by everyone, except for one CNA. He stated she used, abusive speech when talking to him, telling him not to question her and that she would do things her way. Resident #22 stated she had a, stinking rotten attitude. He said staff member L was the CNA. He stated he had discussed the issue with staff member N, and staff member L was being reassigned. During an interview on 6/25/18 at 3:25 p.m., resident #22 stated he was happy staff member L would no longer be assigned to assist him, because the way she talked to him made him feel abused. During an interview on 6/27/18 at 8:02 a.m., staff member E stated staff member L was no longer allowed to provide showers for resident #22 due to his complaints. She stated staff member L did not engage with residents, but rather just tells them what to do. She stated she felt the situation was a personality conflict. Review of a Grievance Form, dated 6/20/18, showed resident #22 was the resident voicing the concern. The forms showed resident #22 stated the following regarding staff member L: - she made him uncomfortable by using her cell phone while assisting him with toileting - she was very short with him - she made him feel bad if he asked for anything - she said he always complains - he was afraid to ask to pick out his own clothes - he was in fear of her getting angry at him During an interview on 6/27/18 at 4:00 p.m., staff member N stated there was no documentation of interviews with residents or staff regarding resident #22's complaint because she viewed it as a grievance, rather than an allegation of abuse. She stated she did not ask what his fear was or what he feared she would do. Staff member N stated when an abuse investigation is done, she asks residents if they feel safe. She said she did ask resident #22 that question, in this case. She said she did not consider the situation as abuse, so she did not question the resident in that manner. She stated resident #22 did not use the term abuse, and a full investigation was not conducted. She stated she wished she had questioned him more thoroughly. Review of an abuse investigation provided by the facility, dated 6/27/18, showed staff member L stated she has had quite a few conflicts with resident #22. Four out of five staff statements, other than staff member L, showed resident #22 had complained about treatment by staff member L. During an interview on 6/28/18 at 2:25 p.m., resident #22 stated he dreaded having staff member L as his CNA. He said there was always a battle, and if he tried to ask for her to honor his requests a war would start. Resident #22 said she made him fee like, crap. He said his interactions with her would, suck the life out of me.

Based on interview and record review, the facility staff failed to thoroughly investigate an allegation of abuse after it was reported resulting in 1 (#82) of the 35 sampled and supplemental residents, and being exposed to further psychosocial abuse by a staff member. Findings include: During an interview on 6/26/18 at 1:31 p.m., resident #82 stated there is a staff member who is disrespectful towards him. He said it was more than being disrespectful, adding, She is just mean. Resident #82 stated the staff member scolded him when he put on his call light to use the bathroom, and yelled at him if he bumped into things while wheeling himself in the hallway. During an interview on 6/27/18 at 8:17 a.m., staff member K stated staff member L had an irritated attitude when interacting with residents. She stated she heard staff member L talk to residents as if they were a burden. Staff member K stated she heard staff member L scold resident #82 for activating his call light. She stated the issue was beyond poor customer service and a lack of respect. She stated it was more like abuse. Staff member K stated she has reported staff member L's behavior in the past, but not recently. She stated she did not know why she did not report the abuse this time. Staff member K said she didn't work this hall often or work with staff member L very often. During an interview on 6/28/18 at 1:29 p.m., staff member I stated resident #82 told her that he was being mistreated by another CNA. She said he had told her that every Monday, when she comes back after days off, for three or four weeks. Staff member I stated resident #82 said the CNA was mean to him, and said she's evil, asking why staff member L had not been fired. She stated she had not reported the allegations because she could not figure out who he was talking about. She stated he could not tell her what staff member L did, just that she was mean to him. She stated about a week ago she had figured out it was another day shift CNA, but she still did not report it because resident #38 told her he had reported the situation to the nurse. She stated she should have said something in the beginning, even without knowing who it was. Staff member I said resident #82 never said he was being physically abused, and she never saw any signs of physical abuse. She stated she had not noticed any behavior changes. Staff member I stated there are mandatory staff training twice a month which include dementia training, and abuse prevention. She said she could not say when she had last received training regarding reporting abuse. She stated she was not aware she was a mandatory abuse reporter, but said it just seemed like common sense to report. During an interview on 6/28/18 at 1:44 p.m., staff member M stated there was a culture in the facility, developed under the previous management, that discouraged reporting abuse. Staff members M and A stated they were aware of barriers to abuse reporting in the facility and had addressed the issue with a QAPI plan. Staff members M and A stated the plan included initiating Angel Rounds. They stated the Angel Rounds involved asking residents if they had any concerns. Staff member M said the rounds do not include asking the resident if they have been abused. He stated his expectation was for staff to report allegations of abuse. During an interview on 6/28/18 at 2:09 p.m., staff member E stated NF1 told her that resident #82 had told him a CNA named (alleged staff name) spoke roughly to him while she assisted him with toileting. She stated she told NF1 there was no CNA named (alleged staff name), but she would tell staff member N about the concern. Staff member E stated she had reported the concern to staff member N approximately two weeks ago, but she was uncertain of the timeframe. She stated she did not follow-up with resident #82, and she did not ask any other residents if they had been mistreated. Staff member E said she thought staff member N would conduct the investigation. She said she received abuse training in April, and the training included what should be reported, and to whom to report. Staff member E stated she would not do anything differently. She said she felt she had received adequate information from NF1, and did not feel she needed to talk to resident #82. Staff member E stated resident #38 had voiced concerns to her about the treatment of [REDACTED]. She stated resident #38 said they were not as nice as they should be when taking him to the bathroom. She stated she did not know if resident #38 reported to her before or after NF1 reported, but both reports were about two weeks ago. Review of an abuse investigation provided by the facility, dated 6/27/18, showed statements by two staff members who stated they were aware of the allegations of abuse by resident #82. One of the statements showed the allegation was reported to staff member N the previous week. During an interview on 6/28/18 at 2:40 p.m., staff member N stated she had not investigated an allegation of abuse of resident #82 prior to 6/25/18, because she had not received a report of an allegation of abuse regarding resident #82 at any time before 6/25/18, when NF1 brought the allegation to her attention. She stated she did not recall staff member E reporting anything about resident #82 to her two weeks ago, or at any other time.

Based on observation, interview and record review, the facility failed to prevent the development of 3 Stage II pressure ulcers, the worsening of pressure ulcers, the development of 2 Unstageable pressures ulcers, and a wound infection for 1 (#13) of 17 sampled residents. The facility failed to prevent the development of an Unstageable pressure ulcer for 1 (#6) of 17 residents. Findings include: 1. Review of the Admission MDS, with the ARD of 5/24/16, showed resident #13 came to the facility with 2 Stage II pressure ulcers. Review of the BWAT forms, dated 5/18/16, showed resident #13 had a Stage II pressure ulcer on the left gluteal fold, and 2 stage II ulcers on the left buttock. Review of the BWAT, dated 6/1/16, showed the resident's left gluteal fold ulcers had healed. Review of the BWAT, dated 6/3/16, showed the resident's new development of a Stage II ulcer to the left heel. Treatments included Rook Boots, and heel protectors. Review of the BWAT, dated 6/14/16, showed the resident's left buttock ulcer had healed. Review of resident #13's Progress Note, dated 6/16/16, showed the left heel was healing well. Review of the BWAT, dated 6/22/16, showed the heel had developed into an Unstagable pressure ulcer. The ulcer was covered with eschar. During an interview on 4/20/17 at 1:20 p.m., staff member B stated she did not know what had happened to worsen the heel pressure ulcer. She stated his heels were floated, and the strap on the back of his wheel chair was removed because it may have caused the blister. Review of resident #13's Progress Note, dated 6/28/16, showed NF2 had requested the appointment for the foot doctor on that day. Review of resident #13's Progress Note, dated 8/3/16, showed (Family member) continues to want to go to resident's podiatrist. During an interview on 4/11/17 at 1:30 p.m., NF2 stated she had to fight to get the facility to send resident #13 to the foot doctor. Review of resident #13's Progress Note, dated 8/17/16, showed out to (Podiatrist) yesterday. Continuing with [MEDICATION NAME] washes. Review of resident #13's physician order, dated 8/24/16, showed must wear boot we dispensed last week to protect heel. During an interview on 4/11/17 at 1:15 p.m., NF2 stated the boots were not on resident #13 during visits. Review of the resident's Physician Order, dated 9/2/16, showed Boot to off-weight heel to be worn at all times. Grey boot goes on L foot. Review of the resident's Progress Note, dated 10/4/16, showed Left heel has been grafted and has a non-removable dressing in place. Has specialty mattress, heel pro, and heel lift boots. Review of the resident's Progress Note, dated 12/18/16, showed the resident was sent to the ER related to a fall out of bed. Review of the resident's Hospital Notes, dated 12/19/16, showed resident #13 had Right heel has intact bullous lesion with bone palpated beneath it suggestive of suspected pressure stage 2. Left heel has dry crusted lesion with bone palpated beneath it suggestive of unstageable suspected pressure ulcer. During an interview on 4/21/16 at 1:20 p.m., staff member B stated she had not looked at resident #13's heel, since 11/8/16. She was not aware the pressure ulcer was still on the heel. 2. Review of resident #13's Progress notes showed he discharged from the facility on 7/12/16, with a UTI, and readmitted on [DATE], with a Stage II pressure ulcer on the sacrum, and an Unstageable area on the left buttocks. Review of the Progress Notes for resident #13, dated 7/27/16, showed the left buttock was now a Stage II, and the sacrum remained a Stage II. Review of the Progress Note, dated 8/10/16, showed resident #13's left buttock ulcer had healed, and the pressure ulcer to the sacrum running across both buttocks, had resolved. Has (new) abrasion to left buttock that appears to be from armrest of chair when transferred with mechanical lift. Review of the resident's Progress Note, dated 9/6/16, showed the abrasion to the left buttock continued. An abraded area was also noted to the scrotum, and some excoriation, lower down the left buttock. During an interview on 4/20/17 at 4:25 p.m., staff member B stated the open areas were identified as injuries, and not pressure ulcers. She stated the treatment would not have changed if the areas had been identified as pressure. Review of the resident's physician's orders [REDACTED]. Review of the resident's Progress Note, dated 11/1/16, showed bilateral buttocks are very macerated. Skin is white and peeling away. Believe this is from too much moisture with current treatment. Some bleeding noted. Right buttock measures 4.3 x 3.2 cm, and left buttock measures 5.9 x 3.8 cm. Will request orders for [MEDICATION NAME] q shift and to wear tape attends products to assist with moisture issues. Review of the resident's Progress Note dated, 11/8/16, showed [MEDICATION NAME] noted at 50% of wound bed. Scrotal area with new skin damage. Has appearance of being torn, maybe by adjusting of attends or pants. Scabbed over. Will continue use of antifungal powder/Vaseline mix to soften scab. Resident continues to be non-compliant with turn and repositioning. Review of resident#13's Significant Change MDS, with the ARD of 10/18/16, showed the resident required extensive assist of two people to reposition in bed. Review of the resident's Progress Note, dated 11/14/16, showed Injury to left ischium and across to scrotum covered with necrotic tissue now. Unable to use tape on this resident as his skin reacts. MD notified and that wound has progressed and is now a pressure ulcer. Have PT to debride and treatment. Airbed orders and will be delivered within 24 hours. Review of the last physician visit provided by the facility, dated 11/14/16, showed the resident had Fever above 102 several days. New decubitus of buttocks. Culture if temp. A review of resident #13's Progress Note, dated 11/15/16 showed he had a temperature of 100.2. Review of resident #13's Progress Note, dated 11/20/16, showed a new open area on the coccyx. Review of resident #13's Wound Clinic Report, dated 11/29/16, showed an Unstageable pressure ulcer of the left buttock. Review of resident #13's Progress Note, dated 12/1/16, showed he was now being treated at the wound clinic. Review of resident #13's Progress Note, dated 12/4/16, showed, Resident appetite poor @ lunch. Lethargic @ times & slow to respond to staff questions .temp decreased to 98.4 with prn Tylenol Review of resident #13's Progress Note, dated 12/5/16, showed IDT review r/t fall out of bed this past weekend. Resident is on air mattress with a low bed. This is an isolated incident. Resident was running an increased temperature and more lethargic than usual. ? (sic) infection r/t wound. Will have MD assess resident. During an interview on 4/20/17 at 2:50 p.m., staff member K stated resident #13's wound care was managed by the wound clinic, when asked about wound cultures for non-healing pressure ulcers. Review of resident #13's Wound Clinic Report, dated 12/6/16, showed the left buttock wound site was larger, with a new sacral ulcer; Stage III. Review of resident #13's IDT note, dated 12/8/16, showed injury with added pressure to sacrum to ischium. Wife continues to place an extra cushion in wheelchair under ROHO (a cushion). Education provided but she continues to direct and provide husbands care. Wound is followed by wound clinic. Wound is worsening. Resident is up for meals only. During an interview on 4/20/17 at 1:40 p.m., staff member B stated she had never personally seen the wife place the cushion on the chair. During an interview on 4/11/17 at 1:35 p.m., NF2 stated she visited resident #13 on 12/11/16, and he did not appear to be his usual self, and did not eat or speak much. Review of resident #13's Progress Note dated 12/15/16 showed the Foley catheter was blocked. New catheter inserted using sterile technique, balloon inflated with 8cc sterile water, 900 cc dark cloudy fluid return. Afebrile. During an interview on 4/18/17 at 1:00 p.m., staff member E stated she notified the physician by putting the above note in the MD book. No further documented assessment was completed for the resident's temperature, wound or urinary status. Review of resident #13's Vitals tab, in the electronic record, showed no temperature had been recorded since 12/8/16. During an interview on 4/20/17 at 8:40 a.m., staff member A stated there was nothing going on with the resident to warrant recorded temperatures. 3. Resident #13 was discharged to the hospital on [DATE], after a second fall out of bed. Review of resident #13's ER admission note, dated 12/18/16 at 1:43 a.m., showed (physical exam in the ED has revealed what I can only describe as significant neglect resulting in serious ulceration, possible perirectal fistula and even ulceration and swelling of the posterior scrotum. There was stool packed into his wounds. His urinalysis shows significant infections. Skin break down was noted on both heels, pressure sore with damage down to the fascia on the scrotum and pressure sore on coccyx with damage down to the muscle. Review of the resident's hospital notes, dated 12/25/16, showed the resident had septic shock secondary to urinary tract infection present on admission; stage IV decubitus ulcer, which was noted to have stool inside the wound at admission. A culture, dated 12/19/16, showed drainage from the penis had E. coli, and Proteus Mirabilis. The two urine cultures were contaminated with the same 2 organisms. The left ischial necrotic tissue had the same two organisms, plus Pseudomonas aeruginosa. The bone culture also had [MEDICAL CONDITION][MEDICATION NAME]. Resident #13 had surgery for [REDACTED]. He was placed on Hospice 12/28/16. The resident passed away on 12/29/16. 4. Review of resident #13's Progress Note, dated 6/22/16, showed his penis was swollen and macerated. Review of resident #13's Progress Note, dated 6/22/16, showed he had a small amount of thick green drainage from the open area on the penis. Will request orders for antibiotic ointment. During an interview on 4/19/17 at 3:00 p.m., staff member B stated she determined the open area was an injury related to the Foley catheter and resident rubbing penis back and forth. She stated it did not look like a pressure ulcer, and she determined it as an injury. Review of resident #13's Progress Note, dated 6/29/16, showed Catheter is rubbing penis and causing drainage. Review of resident #13's Physician order, dated 7/19/16, showed Apply [MEDICATION NAME] BID to open area of penis. Review of resident #13's electronic record showed the resident was discharged to the hospital on [DATE] for a urinary tract infection. Review of resident #13's physician progress notes [REDACTED]. Review of resident #13's Progress Note, dated 10/18/16, showed he continued to have an open area to foreskin. Staff report continued stimulation to area. Resident denies manipulation. Review of resident #13's Progress Note, dated 12/18/16, showed he fell out of bed on his face. He was taken to the ER. Review of the resident's Discharge summary from the hospital, prior to admit to ICU, at a second hospital, showed pus in the Foley catheter and around the urethral meatus. There was a small skin ulceration with pus at the foreskin area. During an interview on 4/20/17 at 8:45 a.m., regarding the UTI and pus, staff member A stated the facility could not be responsible for what happens at the hospital. During an interview on 4/20/17 3:40 p.m., staff member D stated resident #13 fell out of bed. She sent him to the ER. She could not remember whether he had a boot on (for wound). She thought the staff took vitals, but they were not recorded. She did not notice anything out of the ordinary. 5. Resident #6 was admitted with [DIAGNOSES REDACTED]. Review of resident #6's Quarterly MDS, with an ARD of 3/3/17, showed the resident had a BIMS of 6, showing severely impaired cognition. The Quarterly MDS showed the resident was a two-person extensive assist for bed mobility and total dependence for toilet use. The MDS showed the resident was always incontinent of bowel. The Quarterly MDS showed the resident was a high risk for pressure ulcers and had a unhealed pressure ulcer noted on the last OBRA. The Quarterly MDS showed there were no current pressure ulcers for the resident. Review of resident #6's most current Braden scale showed the resident was a high risk for pressure ulcers. During an observation on 4/19/17 at 3:43 p.m., staff member L told staff member B resident #6 had a new red open area on his coccyx. During an observation on 4/19/17 at 4:49 p.m., staff member B performed wound care to resident #6's coccyx and back. The area was approximately 1 cm by 1 cm of reddened tissue with approximately 50% slough and open in center with a dark red dot in the middle. During an interview on 4/19/17 at 4:49 p.m., staff member B stated the area on the coccyx was a new pressure ulcer, and she would put the resident on pressure ulcer precautions, and get an order from the physician. Staff member B stated she was just notified of the skin change on resident #6's coccyx. Staff member B stated she had not been informed of any skin changes for resident #6 prior to this wound care. Review of resident #6's CNA Skin Observation documentation record, from 4/1/17 to 4/19/17, showed red area, documented on the following dates, but there was no indication on the CNA documentation record of where the red area was noted: - 4/8/17 - 4/9/17 - 4/10/17 - 4/11/17 - 4/14/17 - 4/15/17 - 4/16/17 - 4/17/17 - 4/19/17 Review of resident #6's Weekly Skin Check, dated 4/14/17, showed heels are clear, coccyx is reddish but CR is STAT. Turned to side with pillows placed to avoid pressure on coccyx. Skin warm and dry turgor good no tenting. This was a new area of redness and was not indicated as such on the Weekly Skin Check sheet. Review of patient #6's nursing notes did not show any further skin assessments to check the reddish area on the coccyx and the wound care nurse was not notified of the change to the resident's skin until 4/19/17. Review of resident #6's Weekly Pressure Ulcer BWAT Report, dated 4/19/17 showed, Weekly Pressure Ulcer BWAT Report Completed. Site information: Coccyx-Pressure: Length 0.5, Width 0.5, Depth, unstageable. Date of initial observation: 4/19/17. BWAT score 28.0. See progress note assessment for more details. Noted new open area to coccyx, Measurements are 0.5 x 0.5 with yellow center that covers approximately 50% of the wound. Unstageable. secondary to slough. there is no odor, no drainage, and no surrounding redness noted. Painful to touch. Will request new orders for ulcer care to area change Wednesday and Saturdays. Ulcer care placed. Will update guardian and MD in AM. Will place ROHO as soon as one available. Request pain medication prior to treatment. Refer to dietary. Turn and reposition per plan. During an interview on 4/20/17 at 11:34 a.m., staff member K stated the CNAs Skin Observation Documentation record, did not allow the CNAs to make a note to where the red area was observed. She stated it would be the expectation of the CNAs to let the floor nurse know of any new findings to the resident's skin. It would then be the nurse's responsibility to monitor the patient's skin for changes, and notify the wound nurse of any new areas of skin breakdown or ulceration. Staff member K stated it was the expectation of staff to notify the wound nurse as soon as the area was noted. The nurse would make a note in the Weekly Skin Check which would indicate the area is new and this alerts the wound nurse. Staff member K stated the weekly skin check on 4/14/17 should have been noted in the documentation as a new area, and it was not. During an interview on 4/20/17 at 12:00 p.m., staff member B stated she was not notified of the skin change to resident #6's coccyx. She stated had she been notified of the change, she would have assessed the area immediately and implemented an appropriate treatment. The staff member stated, had she not been available, there was a secondary nurse that could be notified for wound management on the weekends.

Based on record review, interview, and observation, the facility failed to identify the root cause and analyze risk factors to prevent falls with injury; failed to implement interventions, monitor for effectiveness, and modify interventions as needed for 2 (#9 and #13) of 17 sampled residents. Findings include: 1. Review of resident #9's Quarterly MDS, with the ARD of 12/8/16, showed he required supervision and 1 person assist for transfers, and was cognitively intact. Review of resident #9's Care Plan, dated 5/20/14, showed he had a recent fall with fractures, was non-weight bearing, and had poor safety awareness. The interventions included: check ammonia levels if altered mental status is present; Ensure brake extensions are in place to wheelchair; Ensure fridge is stocked to decrease risk for falls; Monitor, cue as needed and minimize clutter. Review of the resident #9's Care Plan, dated 2/27/17, showed Impaired communication, cognition and impaired thought process related to exhibits poor safety awareness, impulsive actions, requires frequent verbal cues for safety and care needs, hearing impaired, forgetful, and easily confused. (Resident) inconsistently uses his call light due to cognition. Review of resident #9's Post Fall Investigations reports showed 13 unwitnessed falls from 4/16/16 through 4/17/17. The 12th fall resulted in a non-displaced trochanter fracture and right inferior pubic ramus fracture. Review of resident #9's Post Fall Investigation, dated 4/16/16, showed he slipped on the skid strips (used to prevent falls.) He stated he was using the urinal and got dizzy. He stated his pain was at a 10 and his knees gave out on him. The intervention implemented was Physical Therapy from 4/19/16 through 6/7/16. The dizziness was not addressed. Review of resident #9's Post Fall Investigation, dated 6/16/16, showed he was found in the bathroom, sitting upright. There was feces on the floor and he had poor footing while walking. Contributing causes included non-compliance. No documented interventions were implemented to prevent further falls. Review of resident #9's Post Fall Investigation, dated 7/15/16, did not describe the fall, but showed he was found in his room, laying on his back, with legs stretched outward, next to his bed. No investigation or analysis was completed regarding the cause of the fall. Review of resident #9's Post Fall Investigation, dated 8/23/16, showed he was sitting on the floor, on his bottom, with his back against the bed. He stated he dropped his medications on the floor and was bending over to pick them up. He had a red bruise/abrasion between his brows and tender to touch. No new interventions were implemented; interventions in place were not evaluated for effectiveness. Review of resident #9's Progress Note, dated 8/29/16, showed he had a fall out of bed, trying to find his cell phone. A Fall Investigation report was not provided. The new intervention was to place a call sign to remind resident to call before reaching items. During an observation on 4/18/17, 4/19/17 and 4/20/17, no sign was visible in resident #9's room to remind the resident not to reach for items without calling for assistance. Review of resident #9's Post Fall Investigation, dated 9/01/16, showed the resident was lying on his back, 5 to 7 feet away from the bed. He was reaching for a coke from the refrigerator in his room. His pain level was a nine. No further analysis was completed for a root cause for the fall, or new interventions. Documentation showed, Resident has fallen 6 times since March. Will monitor. The monitoring was not measurable, or clear enough to show what staff were to monitor for. Review of resident #9's Post Fall Investigation, dated 10/24/16, showed the resident was found in the bathroom, on the floor, with his call light on. I slipped in these socks. Review of an IDT note for resdent #9, dated 10/27/16, showed Resident reminded to either wear non-skid socks or shoes during ambulation. Although the resident did not have good recall for calling for assistance, staff continued to use the intervention to remind the resident. Review of an IDT note for resident #9, dated 12/20/16, showed review related to fall last week. Resident slid off the edge of bed while trying to get to bathroom He has non-skid strips beside bed and slippers with good soles. He was incontinent of bowel and appears to have slid in it (feces). Resident is independent with ambulation. Isolated incident. No further interventions needed. No Post Fall Investigation was provided. The facility did not address the resident's potential need for more assistance relating to bowel and bladder deficits. Review of resident #9's Post Fall Investigation, dated 12/22/16, showed the resident was found on the floor of his bathroom, and stated he lost his balance. A contributing cause was listed as non-compliance. The loss of balance was not addressed. Review of resident #9's Post Fall Investigation, dated 1/10/17, showed a CNA found him lying on the floor. He stated he was looking for stuff in the bottom of his closet and I got dizzy. Review of resident #9's IDT note, with no date, showed a review of the 12/22/16, and 1/10/17 falls: Resident is independent with ambulation in room. Does use walker. Nonskid strips beside bed and in bathroom. Room was changed to allow easy access to his fridge and other items he uses frequently. Resident has a history of balance issues which does affect him when bending down or reaching for items, causing a loss of balance, resulting in a fall. PT has worked with resident in the past with good results. Takes Meclizine for dizziness. Resident will call for assistance if not feeling well but not for simple tasks that he believes he can do on his own. Plan: therapy to review Berg Balance Scores from recent therapy session to see if an improvement in noted with therapy if balance remains unchanged. Will review to determine if further therapy is indicated. The IDT note, addressed factors from the 12/22/16 fall that may have prevented the fall from occurring on 1/10/17, but the IDT did not address these until after 1/10/17, which was at least 20 days after the 12/22 fall. During an interview on 4/20/16 at 8:20 a.m., staff member A stated PT was initiated for resident #9 on 1/13/17. Review of resident #9's Post Fall Investigation, dated 2/10/17, showed he was found sitting on the floor by the bed. He stated he was walking back to his bed from the bathroom. A team huddle (IDT huddle meeting and discussion) was documented after the fall, but no analysis, root cause, new interventions, or evaluation of the effectiveness of current interventions was documented in the resident's medical record. Review of resident #9's Post Fall Investigation, dated 2/19/17, showed he was found on his back, his feet toward the bathroom door, head against his hallway door, and he was incontinent of bowel and bladder. A contributing cause was listed as non-compliance. Review of resident #9's Progress note, dated 2/27/17, showed he had sustained two fractures from the fall on 2/19/17; a hip and pelvic fracture. The resident was now non-weight bearing. Review of resident #9's Significant Change MDS, with the ARD of 2/27/17, showed he now required two person extensive assist with all his ADLs except for eating. A Foley catheter was placed for bladder incontinence related to immobility. During an interview on 4/17/17 at 1:00 p.m., resident #9 stated he stayed in bed now, and did not get dressed. He said he would shower if he wanted. He said he was now afraid of falling. I fell , and I fell , and I fell . He stated he didn't use his call light because They don't care about me. During an interview on 4/20/17 at 8:40 a.m., staff members A and C stated the facility did have a fall prevention program in place, and that team huddles were conducted with each fall. The team huddle answered the 10 questions (for falls) to determine the root cause. Staff member C stated the facility did not keep this document, because it was a working tool, therefore the root cause analysis was not documented in the resident's medical record. One of 15 falls had documentation from the team huddle for resident #9's falls. Staff member C also stated the resident had the right to fall. 2. Review of resident #13's progress note, dated 5/23/16, showed a Post Fall Investigation was completed for a fall on an unidentified date. See investigation for details. No Post Fall Investigation was provided by the facility. Review of resident #13's Admission MDS, with the ARD of 5/24/16, showed he had a history of [REDACTED]. Review of resident #13's IDT note dated 5/23/16, showed a review of the falling star program (fall program). Resident is not impulsive and will call for assistance when needed. Will remove from falling star program. Review of resident #13's Post Fall Investigation, dated 12/5/16, showed he was found lying on the floor by his bed. Review of resident #13's IDT note, dated 12/5/16, showed Resident is on an air mattress with a low bed. This is an isolated incident. Resident was running an increased temperature and more lethargic than usual. ? (sic) infection related to wound. Will have MD assess resident. Review of the Physician visits for resident #13 showed no visit or assessment was completed after 11/14/16. During an interview on 4/11/17 at 1:35 p.m., NF2 stated she visited resident #13 on 12/11/16, and he did not appear to be his usual self, and did not eat or speak much. Review of resident #13's Post Fall investigation, dated 12/18/16, showed he had fallen out of bed, onto his face, and sustained a large hematoma over right eyebrow. During an interview on 4/11/17 at 1:40 p.m., NF2 said the hospital called her the night of 12/18/16, and asked Do you know how sick (resident #13) is? Review of resident #9's Progress Note, dated 12/18/16, showed he was discharged to the hospital. The resident was admitted , and the resident had an infection in the wound of the buttock. (Refer to F314) Review of resident #13's Care Plan, dated 7/19/16, showed no new interventions were implemented to prevent falls after each of the three falls. The investigations did not include the root cause analysis of the falls, monitoring, or evaluation of the resident's individualized risk factors.