Every finding on record at Paul House & Health CR CTR

Based on observation, interview, and record review, the facility failed to ensure the call-light system on the Two [NAME] unit was functioning properly to provide an audible alert at the nursing station when resident call lights were activated. This failure had the potential to affect all 48 residents residing on the Two [NAME] unit. Findings include: On 8/19/26 at 11:34 AM, R101's call light was observed activated. The visual indicator was illuminated on the call-light panel at the Two [NAME] nursing station. On 8/19/2026 at 11:41 AM, V29 (Licensed Practical Nurse/LPN) who was seated at the nursing station across from R101's room, stated she did not hear R101's call light. V29 stated the call-light panel should provide an audible alert at the nursing station when a resident activates a call light. V29 stated the panel was illuminating to indicate activation; however, it was not producing an audible alert. V29 further stated maintenance should be notified if the call-light panel was not functioning properly.On 8/19/2026 at 11:54 AM, V23 (Maintenance Director) stated the Two [NAME] call-light system would occasionally produce a low audible ding at the nursing station when a resident activated a call light and that the corresponding room number would illuminate on the panel. V23 stated replacement parts for the system were difficult to obtain. V23 stated nursing staff could frequently monitor the call-light panel or walk the unit to visually identify activated call lights when the audible alert could not be heard. On 8/19/2026 at 11:57 AM, V23 activated R101's call light in the presence of the surveyor. The call-light panel at the Two [NAME] nursing station visually indicated that R101's call light had been activated; however, the panel did not produce an audible alert. On 8/19/2026 at 2:37 PM, V2 (Director of Nursing/DON) stated the call-light panel should produce an audible alert when a resident activates a call light. V2 stated nursing staff were responsible for notifying maintenance when the call-light panel was not functioning or when the audible alert could not be heard. V2 stated a malfunctioning call-light system presented a safety risk because staff may not be aware when a resident activates a call light requesting assistance. On 8/19/2026 at 3:08 PM, V1 (Administrator) stated staff should be able to hear the call-light alert at the nursing station when a resident activates a call light. V1 stated that if staff could not hear the alert, staff were expected to notify the Administrator and submit a maintenance work order. V1 stated the Maintenance Director was responsible for repairing the call-light system and that a malfunctioning call-light system was a resident safety concern.On 8/19/2026 at 3:18 PM, maintenance work orders related to the Two [NAME] call-light system were requested from V1; however, no work orders were provided. Review of the facility's undated Maintenance Service policy documented that maintenance services were to be provided to facility equipment. Review of the facility's Answering the Call Light policy, reviewed 02/2025, documented that the purpose of the procedure was to ensure timely responses to residents' requests and needs and directed staff to ensure call lights were plugged in and functioning at all times.

Based on observation, interview, and record review, the facility failed to ensure residents' call lights were readily accessible and responded to in a timely manner for 3 of 3 residents (R55, R81, and R101) reviewed for call-light use in a sample of 70 residents. Findings include: 1) On 8/19/2026 at 10:56 AM, R81's call light was observed activated, with the red visual indicator blinking for four minutes without staff response. On 8/19/2026 at 11:02 AM, R81 stated she activated the call light to determine whether staff had collected her laundry so it would be available later that day. R81's electronic health record documented diagnoses including repeated falls, type 2 diabetes mellitus, unspecified fracture of shaft of right femur, unspecified glaucoma, and unspecified lack of coordination. R81's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. 2) On 8/19/2026 from 11:34 AM through 11:39 AM, R101's call light was observed activated and visibly blinking. During the five-minute observation, V29 (Licensed Practical Nurse/LPN) was seated at the nursing station across from R101's room and did not respond to the activated call light. On 8/19/2026 at 11:40 AM, R101 stated, I pulled my call light about 10 to 15 minutes ago to request my soup and sometimes staff take longer than 15 minutes to answer my call light. On 8/19/2026 at 11:41 AM, V29 stated call lights should be answered promptly to address residents' needs and concerns. V29 stated she had not observed R101's call light and had not heard an audible alert. On 8/19/2026 at 2:37 PM, V2 (Director of Nursing/DON) stated all staff were responsible for responding to resident call lights and that call lights should be answered when activated. V2 stated failure to respond to call lights in a timely manner could place residents at risk because staff may not be aware that a resident needs assistance. On 8/19/2026 at 3:08 PM, V1 (Administrator) stated call lights should be answered by all staff as soon as the visual indicator is observed or the audible alert is heard. V1 stated failure to respond to resident call lights in a timely manner was a resident safety concern. R101's electronic health record documented diagnoses including dementia, chronic obstructive pulmonary disease-unspecified, type 2 diabetes mellitus with hyperglycemia, anemia, and essential hypertension. R101's MDS dated [DATE], documented a BIMS score of 12 indicating intact cognition. 3) On 8/17/26 at 11:22 AM, R55 was observed seated in a recliner with the call light positioned on top of the nightstand and outside of R55's reach. R55 stated she wanted to be repositioned and attempted to locate the call light to request staff assistance but was unable to reach it. On 8/17/26 at 11:32 AM, V11 (Certified Nursing Assistant /CNA) entered R55's room at the surveyor's request. V11 located R55's call light on the nightstand and handed it to R55. V11 acknowledged that the call light had been outside R55's reach and stated the purpose of the call light was to allow residents to obtain staff assistance when needed. On 8/19/26 at 12:45 PM, V2 stated any staff member could answer a resident's call light and that call lights should remain within reach of all residents, so residents are able to request assistance. V2 stated that when a call light is outside a resident's reach, the resident is unable to use it to call for help. R55's electronic health record documented diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left on-dominant side, type 2 diabetes mellitus with diabetic neuropathy, epilepsy-unspecified, unspecified glaucoma, and primary insomnia and R55's MDS dated [DATE], documented a BIMS score of 9 which, indicating moderate cognitive impairment. The MDS further documented that R55 required substantial/maximal assistance with mobility. R55's care plan documented the need for a working and reachable call light. Review of the facility's Answering the Call Light policy, reviewed 01/2025, documented that the purpose of the procedure was to ensure timely responses to residents' requests and needs. The policy directed staff to ensure call lights were plugged in and functioning at all times and, when a resident was in bed or confined to a chair, to ensure the call light was within easy reach of the resident.

Based on interview and record review the facility failed to provide adequate supervision for a resident with a known elopement risk. This failure resulted in R2 exiting the facility and falling near the exit door sustaining an abrasion to the nose and bilateral knees with swelling to the left forehead. The facility also failed to revise R2's care plan after the elopement and fall that occurred on 06/15/26.Findings Include:R2 was admitted to the facility on [DATE] with diagnosis not limited to Metabolic Encephalopathy, Depression, Altered Mental Status, Vascular Dementia, Mild, with Mood Disturbance, Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Cognitive Communication Deficit, Dysarthria and Anarthria, Muscle Wasting and Atrophy, Lack of Coordination, Abnormalities of Gait and Mobility, Cognitive Social or Emotional Deficit Following Cerebral Infarction, Major Depressive Disorder, Recurrent, History of Falling, and Disorder of the Autonomic Nervous System. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 04 indicating severe cognitive impact.Progress notes dated 06/15/26 04:05 documents in part: Alert Note Text: The patient wandered off the unit and ended up in the Assisted living area. ADON (Assistant Director of Nursing) notified, and she obtained an order for Lorazepam 2 mg IM q 6 hours prn agitation. Administered in L Deltoid area. Progress note dated 06/15/26 06:00 documents in part: Nurse Note Late Entry: Note Text: Staff heard the front exit door alarm activate. Staff immediately responded to the alarm and observed resident (R2) outside the facility on his knees. Resident is a poor historian and unable to provide clear description of events. Resident was noted with an abrasion to the nose and bilateral knees and swelling to the top of the head. No acute change in mental status was observed from baseline. The resident was transferred to the emergency department for further evaluation. Progress note dated 06/15/26 17:29 documents in part: Order Note Text: Resident return from Hospital via Ambulance Transportation service via stretcher. Noted with superficial scratches to both knees bilateral, superficial scratches located on nose. Hematoma located on the left side of head.Hospital Record dated 06/15/26 documents in part: Diagnosis Fall, initial encounter and Somnolence.R2's care plan documents in part: Focus: Movement | Wandering | Elopement Risk I am an adult living with dementia & mental health concerns. I have experienced health decline & I am diagnosed with several comorbidities. There is movement behavior on the unit consistent with anxiety and disorientation. My boundaries are poor, and my behavior may be interpreted as intrusive by my peers. I may wander on the unit, not able to comprehend the safety precautions that staff continually share/address. My awareness/insight may fluctuate with some lucid moments, but generally I do not follow safety guidance. My behavior may include motivation/desire to leave the facility unauthorized, and I am monitored to deter exit seeking. Date Initiated: 05/25/26. Goal: I will remain safe with no exit seeking behavior through the next review. Date Initiated: 05/25/26 Revision on: 07/08/26. Interventions: Reducing elopement risk. Establish a system for observing/monitoring the residents and whereabouts. Place picture at the nursing station and front door reception desk. Use electronic devices (e.g., Wander Guard) and as indicated, camera/video monitoring. The individual is identified on the elopement potential list to mitigate unsafe departure from the care unit. Date Initiated: 05/25/26. Falls: The resident is at risk for falls r/t (Related to) weakness. Resident requires substantial/maximal assistance from staff for transfers and toileting. Resident has poor balance present and utilizes wheelchair. Resident requires cueing and encouragement to complete tasks. Date Initiated: 02/03/26.Initial Reportable 06/15/26 at 10 PM documents in part: On 06/15/26 at approximately 5 am, staff heard the front exit door alarm activate. Staff immediately responded to the alarm and observed the resident (R2) outside the facility on his knees. Resident was noted with an abrasion to the nose and bilateral knees and swelling to the top of the head. No acute change in mental status was observed from baseline. The resident was transferred to the emergency department for further evaluation.Follow Up Investigation report dated 06/20/26 at 1 am documents in part: Conclusion: On 6/15/26 at approximately 4 am R2 with a documented history of vascular dementia, diabetes, hypertension and depression was observed to be confused and exhibiting increased wandering and exit seeking behaviors. Staff attempted verbal redirection: however, the resident was unable to follow cues or remain safely within designated area. At approximately 5 am, the staff noted that the resident was no longer visible on the unit. Upon discovery of the elopement, a rapid search of the immediate area was initiated. During this time, staff discovered that the resident had exited the building through the front exit area. At approximately 05:05 am the resident was located by staff at the front of the building on his knees. The resident was noted with abrasion on the nose and bilateral knees and small swelling on the top of head. The incident involving R2 was the result of acute confusion and impaired judgement. The resident eloped from the facility after leaving his assigned area and was unable to be redirected. Additional safety measures, care plan adjustment and environmental controls have been implemented.Signed interview statement dated 06/15/26 V2 (Director of Nursing) statement documents in part: V7 (Agency Registered Nurse) informed writer that R2 had not slept throughout the night and was agitated. V7 also informed this writer that R2 had escaped to the assisted living area earlier and was re-directed back to the unit.Interview statement dated 06/15/26 V7 (Agency Registered Nurse) statement documents in part: At about 4 am R2 was still agitated and wandered off the unit and ended up in the Assisted Living area. During my med pass around 5 am, I was informed by one of the Certified Nurse Assistant that R2 was seen outside. I went outside the front of the building and observed R2 on the floor on his knees.On 07/12/26 at 09:00 AM V22 (Receptionist) stated There is a white alarm box to the right side of the front door for the wander guard. The front doors are locked from 8 pm - 8 am. The assisted living area is located after passing the chapel and there are stairs to get to assisted living.On 07/12/2026 at 09:20 AM per telephone interview V7 (Agency Registered Nurse) stated At 3 am and 5am V12 (Agency Certified Nurse Assistant) and V13 (Certified Nurse Assistant) were asleep and that is when R2 eloped. The last time I saw R2 before R2 was outside was at about 04:30 am. I put R2 in the wheelchair and sat him next to my medication cart. I was able to keep a watch on R2 but when I went into a room to do an IV, I came out of the room and R2 was gone. We went through the hallway calling R2's name. R2 got outside and had a skin scrape on his nose and a lump on the left side of his head. R2 left the unit because the certified nurse assistants that were supposed to be watching R2 were not watching him. At around 04:00 am V14 (Assistant Living Certified Nurse Assistant) brought R2 back from the assisted living unit. I did not even know the R2 was gone. R2 was overactive and had pulled the fire alarm when he was on the assisted living unit. The wander guard R2 had on was not working. It is supposed to alert us that R2 left the unit. There was no alarm to let us know R2 left out of that door. I don't know what door R2 left out. I did not know R2 was an elopement risk and had a wander guard on. R2 was at the nurse station because he was a fall risk and was in the wheelchair before 04:00 am. The certified nurse assistants had to do their rounds so I said that I am going to watch R2 while you do your rounds. When I came out of the room within 5 minutes, R2 was found outside on his knees. That was the second time he had got away.On 07/13/26 at 12:34 PM Per telephone interview V12 (Agency Certified Nurse Assistant) stated I had R2 on 06/14/26 night shift and I kind of knew how he was. The first time I had him I was assigned to watch him all night. On 06/15/26 R2 was talking and moving about a lot. I was making rounds and R2 was sitting in his wheelchair by the nurse station. When I went on break V7 (Agency Registered Nurse) was watching him and that is the first time R2 escaped to the assisted living unit. V7 let R2 wander around and I don't know how long R2 was gone. The second time R2 left the unit and was found outside on the ground I was making my rounds so I gave R2 to V7 and sat him next to her medication cart. I was checking on him as I came out of the resident's room and I saw that R2 had disappeared. Me and V13 started searching for R2 and V7 did not assist us. R2 was found outside of the front door and had fallen when V7 said she would watch him. R2 can walk a little but he is not stable.On 07/11/26 at 06:14 PM Per telephone interview V13 (Certified Nurse Assistant) stated I worked 06/14/25 7 pm - 7am. On 06/15/26 is the day that R2 had eloped. R2 got out of the building. The first time that morning R2 got to the assisted living unit. The nurse or a certified nurse assistant came to let us know R2 was over there. The second time I found R2 in front of the building. V7 (Agency Registered Nurse) and V12 (Agency Certified Nurse Assistant) could not find R2. R2 can walk, when he got out the door he was on his hands and knees. R2's forehead had a lump, and his knees were scraped up. I can't give you the exact time. I thought V7 and V12 had a team plan, and they were taking turns watching R2. When R2 was outside on the ground I helped him up, let him stand for a few seconds the sat him on the bench. I put R2 in a wheelchair, brought him in the building and V7 was kind of frustrated.On 07/12/26 at 10:12 AM V21 (Licensed Practical Nurse) stated R2 walks but cannot pivot. When R2 came back from the hospital he had a scrape on his knee and on the left forehead had a bump.On 07/12/26 at 11:26 AM V2 (Director of Nursing) stated V12 (Agency Certified Nurse Assistant was assigned to R2 and could not give me a valid answer. I got here at 05:45 am and I asked why R2 was outside without anyone's knowledge. V12 said she was making rounds. V7, V12 and V13 said that R2 was agitated earlier, and they tried to redirect R2. V7 reported that R2 did not sleep all night, and I asked why she did not page the doctor if the resident was agitated. That is a change in condition. R2 can walk with assistance and R2 wandered off the unit to the assisted living unit. V7 told me she went and got R2, and he had pulled the fire alarm. V14 (Assistant Living Certified Nurse Assistant) on the assistant living side brought him back to this side. V7 said she started passing medication. V13 said she saw R2 outside. They heard the alarm but there was no video surveillance. To open the front doors when they are locked you will have to forcibly pull the door open. For R2 to walk from over there (the first-floor unit) will take time. V7 expected V12 and V13 to watch the resident. V7 and V12 were watching R2 between the two of them. R2 escaped and V7 did not report a resident change in condition to the doctor. We staff based on census. R2 is an elopement risk and should be in the elopement book. The care plan social services deal with the elopement and restorative deals with the falls. There are no updated interventions on R2's care plan. The definition of elopement is a resident that gets outside of the building that is not safe without a doctor order and nurse awareness. The residents want to leave and try to escape and it is not safe. I thought when R2 left the building it was elopement. It is the nurse's responsibility because they are the supervisor of the floor to direct the certified nurse assistants. The nurse's responsibility to the residents is to keep the residents safe. V7 failed to keep R2 safe. At the exit doors and the elevator, they are automatic, and they lock at 8 pm and unlock at 8 am. V1 (Administrator) said if you press on the front door for 15 seconds the door will open. We do not have video surveillance. My expectation is to report to me and the doctor, do documentation and monitor R2 more.On 07/12/26 at 01:22 PM V1 (Administrator) stated When R2's elopement was reported to me R2 was observed outside and R2 had a fall. R2 wanders and we still do close observations. R2 leaned on the door, it opened and R2 was able to get out. R2 was sent to the hospital and R2 came back on the same day. The care plans is a work in progress, and we have to work on them to catch up on the care plans.Document titled Job Description, Certified Nursing Assistant documents in part: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents.Document titled Job Description, Registered Nurse (RN) documents in part: The RN is responsible for providing direct nursing care to the residents, performing evaluations and or assessments, and to supervise the day-to-day clinical care performed by nursing assistants and other nursing staff. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times.During the facility tour to access the Assisted Living unit surveyor exited the first-floor unit, walked past the reception desk, entered a short corridor, past the chapel then walked through a long common area. After walking through the common area there are stairs leading up to the assisted living unit.Policy:Titled Safety and Supervision of Residents reviewed 09/01/24 documents in part: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Facility-Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; 3. When accident hazards are identified, the QAPI (Quality Assurance and Performance Improvement)/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: b. Assigning responsibility for carrying out interventions; d. Ensuring that interventions are implemented; and e. Documenting interventions. c. Modifying or replacing interventions as needed; Systems Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 1. Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: c. Falls; e. Unsafe wandering.Titled Wandering and Elopements reviewed 09/01/24 documents in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises.Titled Care Planning - Interdisciplinary Team reviewed 09/01/24 documents in part: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation.

Based on observation, interviews and record review, the facility failed to ensure that one totally dependent resident (R1) with skin breakdown was repositioned every two hours. This failure has the potential to affect eight residents with pressure ulcers. Findings include:R1 is [AGE] year-old with diagnosis including but not limited to: Hemiplegia and Hemiparesis following cerebral infarction, vascular dementia, pressure ulcer of sacral region stage three, frontotemporal neurocognitive disorder and hypertensive heart disease.On 3/23/26 at 3:26 pm, R1 was observed lying in bed on his right side and with the head of the bed elevated.At that time, V10 (R1's Family) stated the following, My brother has been lying on his right side since this morning around 10:00 am. I've been here with him (R1) and waiting on someone to come and help me turn him because he already has a pressure sore.On 3/23/26 at 3:45 pm, V7 (CNA/ Certified Nurse Assistant) stated the following, I'm assigned to R1 today. I've been here since 7:00 am. I believe the last time that I repositioned R1 was at 9:00 am. We have been really busy because we only have three CNAs on the unit (two west) and we usually have four. I cannot reposition him (R1) by myself and I cannot always find someone to help me reposition him. I didn't know that his sister (V10) would help reposition him. He should be repositioned every two hours to prevent pressure ulcers. He has a wound on his heel.On 3/23/26 at 3:50 pm, V6 (LPN/ Licensed Practical Nurse) stated the following, R1 is my patient today. I'm not sure when he (R1) was last turned. V7 (CNA) is the person that repositions R1.On 3/24/26 at 10:00 am, V2 (DON/ Director of Nursing) stated the following, He currently has one wound on the left heel that we are monitoring and trying to heal. It is expected that R1 is turned and repositioned every two hours to maintain his skin integrity. He (R1) is not able to turn himself.R1's Wound Report dated 3/24/26 documents a left heel wound.R1's care plan documents, R1 is at risk for alteration in skin integrity; R1 is at high risk for developing skin breakdown; R1 requires total care with dependent assistance for personal care and mobility; R1 should be repositioned every two hours and as needed.Facility Pressure Injury Prevention policy documents, reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team.

Based on observations, interviews, and record reviews, the facility failed to ensure that one (R504) resident who depends on staff assistance for ADL (Activities of Daily Living) care was provided incontinence care and transfer assistance in a timely manner, demonstrating inadequate care in a sample of 55 residents. This failure resulted in R504 suffering psychosocial harm stating feelings of humiliation and embarrassment. Findings include: On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an hour with sitting in urine would probably make a resident mad and sad. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed date9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident .

Based on observations, interviews and record reviews, the facility failed to provide clean bed and bath linens for residents with the need of assistance with daily hygiene, bathing, or showers. This failure affected two residents (R96, R504) out of three reviewed in the final sample of 55 residents, however, this failure has the potential to affect all 93 residents living in the facility. Findings include: On 6/2/2025 the Census sheet provided by the facility showed 93 residents. On 6/2/2025 at 11:00 AM, observed R504 sitting on the side of the bed, holding a walker. Underneath the bed, observed a fresh urine-like spot on the floor and on the resident's left foot. R504 stated, that it has been over an hour, that someone came in to help to transfer R504 from bed to the chair. R504 could not wait longer and tried to use the urinal, could not reach it in time and had an accident. R504 stated that R504 felt embarrassed, humiliated, and angry and did not have any clean towels or washcloths to use. On 6/2/2025 at 11:05 AM V11 (Certified Nurse's Aide/CNA) stated the resident's wait for help for a long time sometimes because the patient load is heavy because many of the residents require increased surveillance and two people assistance. V11 stated that the facility is always out of towels and washcloths and many times V11 had to use blankets to give residents bed baths. V11 stated that to cover the urine spot until cleaned, blanket must be used, because there are no towels available on the unit. 6/2/2025 at 11:10 AM, in the 2 East Unit's Clean Linen Room, observed no towels or washcloths on the linen carts. On 6/2/2025 at 11:30 AM R96 stated that sometimes the facility runs out of towels and washcloths and pillowcases and must use blankets instead when receiving a shower. R96 receives showers twice a week on Wednesday and Saturday. R96 had to take towels or a pillowcase from a cart when available, because the facility is often short of linens. R96 stated that sometimes she uses her own linens. On 6/3/2025 at 11:45 AM in the Facility's Laundry room observed with V22 (Laundry Aide), Observed on the top of the clean linen folding table, a total of eight towels and eight washcloths. Next to clean linen folding table, observed three full bins of clean linen (blankets, gowns, sheets, chucks,) and one empty linen cart with a pink cover attached to it. Surveyor observed additional room with clean linen storage area, with four carts of clean linen on the carts, covered with pink covers. No additional towels or washcloths observed in the additional clean linen storage room. No towels or washcloths observed in the four working dryer machines or the clean bins. V22 stated that there is a certain amount of linen placed on the linen carts for each unit specifically, and then the carts get distributed to each unit at 7am and again in the evening. The amount of linen varies per unit and is written on a paper form on the bulletin board in the laundry room. Surveyor observed, written in permanent black marker on each unit's linen cart, the amount of linen each unit is dispersed (the same amounts that are written on the paper form on the bulletin board in the laundry room). Evidence shows that the amount of linen that is dispersed to each unit is less than the number of residents on each unit. V22 said, sometimes V22 does not have clean towels and other linens ready, because V22 is the only one laundry aide until 2pm. V22 said, that another laundry aide comes in at 2pm and works until 8pm. V22 does not have enough time or help to wash and sort, fold, and disburse all linen in a timely manner. V22 said, that the reason why the towels and wash cloths are not visible in the laundry room, is that a full cart of fresh linen, was delivered at 7am to each unit and the dirty linen is still being washed. On 6/3/2025 at 11:55 AM Laundry's room bulletin board sign for distribution of linens showed linen placement as follows but not limited to 1 East 13 towels, 15 wash cloths; 2 East morning linen 10 towels, 15 wash cloths, 2 East night linen 6 towels, 10 wash cloths; 2 [NAME] linen Morning 12 towels, 20 washcloths, Night 6 towels, 20 wash cloths. 2 East Unit on 6/3/2025 at 12:07PM, V12 (LPN), stated that current census for the unit is 24 residents. 2 East Unit's Linen Room on 6/3/2025 at 12:08 PM, observed NO towels or washcloths on linen carts. On 6/3/2025 at 12:10 PM V13 (Certified Nurse's Aide/CNA), stated that since the new management took over, there has been many changes in laundry practices. V13 stated at 7am V13 removed four washcloths and two towels from the delivered linen cart and the other aide took the rest, which was about the same number of towels and washcloths. V13 affirmed that the facility is often short on linens, especially towels and washcloths and that since the new changes in laundry staff (now only one person working), it got worse. V13 must often call for more linens, sometimes must leave the unit and go to the laundry room and try to obtain more linens. V13 also stated that a few times, when V13 went to obtain more linens from the laundry room, the laundry room did not have the linens needed. On 6/3/2025 at 14:34 PM, V1 (Administrator) stated that there should be clean linen observed and available on every unit. V1 wasn't aware of not having towels or washcloths available. Observed two linen carts brought up by the maintenance personnel by the conference room. One cart was half empty with clean linen, including five towels and four washcloths, the second cart had only sheets, blankets, and gown on it, halfway full. When asked about the number of available towels and washcloths for residents on the clean linen carts coming from laundry, V1 stated that the amount gets refilled as needed, the laundry aide delivers more linen to the units, when needed. On 6/4/2025 at 11:19 AM V1 (Administrator) stated, that, the bulletin board signs used for stocking the linen carts in the laundry room, were made prior V1's start at the facility. V1 was not aware that the linen carts were stocked with the limited number of towels and other linens as shown on the bulletin board signs in the laundry room. V1 stated that each resident should be provided two towels and two washcloths. V1 provided document that listed linen inventory summary as of 6/4/2025. On 6/4/2025 at 12:10 PM V2 (Assistant Director of Nursing/ADON) stated that to provide a resident with a bed bath, a minimum of four bath towels and four washcloths are necessary to use. There should be a separate washcloth used for face and arms and resident's chest and lower extremities. V2 stated that the linen gets delivered in the morning, but there is not enough to give bed baths for all the residents. On 6/4/2025 at 14:20 PM V24 (Maintenance Director), stated that when more linen is need, the staff should call the maintenance, or the laundry and the linen would be brought up to the unit. V24 also stated that often the linen gets discarded to trash bins and therefore some linen gets locked in the storage room. V24 was not aware of no towels and washcloths not available on 6/2/2025. On 6/4/2025 at 15:00 PM V1 affirmed that according to the inventory document provided, the facility does not have enough towels to provide minimum of two towels for 93 residents. Facility's Linen Inventory Document provided by facility dated 6/4/2025 showed in part 120 towels in circulation and 60 towels in storage, which equals to a total of 180 towels in the building. R96's Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 12 which indicates moderate cognitive impairment. R96's Diagnosis included but not limited to palliative care, interstitial pulmonary disease, chronic obstructive pulmonary disease, chronic respiratory failure, anxiety disorder, hypothyroidism. R96's Care Plan Report (POC) initiated on 5/28/2025, showed in part that R96 is on hospice care and the staff should meet R96's comfort needs and provide support and comfort care (pg. 3 of POC). POC also showed in part that R96's palliative care status prioritizes comfort. (pg. 7 of POC) R504's Minimum Data Sheet (MDS) dated [DATE], in Section C- Cognitive Patterns documents Brief Interview for Mental Status (BIMS) Summary Score of 15 which indicates intact cognitive function. R504's Diagnosis included but not limited to history of unsteadiness on feet, acute thrombosis of veins, falls, aftercare following joint replacement surgery, presence of left artificial hip joint, major depressive disorder, benign prostatic hyperplasia R504's Care Plan Report (POC) initiated on 5/24/2025, showed in part that R504 had surgery on left hip and needs assistance in hygiene when there is an episode of incontinence, needs assistance to toilet in the morning, before or after meals, before bed and as needed, provide peri care, Activities of Daily Living (ADL's) self-care deficit. (pg4, 5, 7,11) Facility's Laundry Aide Job Description documents in part, that the laundry aide is responsible for ensuring that all resident linens and facility laundry are properly cleaned, sanitized, folded, and returned in a timely and efficient manner. Facility's Certified Nursing Assistant (CNA) Job Description documents in part, that the CNA is responsible for providing resident care and support all activities of daily living and ensures the health, welfare, and safety of all residents. The document also states in part, that CNA should aid in all activities of daily living including but not limited to personal hygiene by giving bedpans, urinals, baths, backrubs, shampoos, and shaves, assisting with showers and baths; provide for resident comfort by utilizing resources and material. Facility's Assistant of Director of Nursing (ADON) Job Description documents in part, that the one of the purposes of ADON is to direct the day-to-day functions of the Nursing Department and ensure that the highest degree of quality care is always maintained. Facility's Administrator Job Description documents in part, that some of essential duties and responsibilities expectations are to plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board, to develop and implement strategies to improve the quality of care of the residents. Administrator ensures that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. Facility's Policy titled Resident Rights, documents in part that federal and state laws guarantee certain basic rights to all residents of this facility. These rights include but not limited resident's right to: be treated with respect, kindness, and dignity. Facility's Policy titled Homelike Environment presented 6/5/2025, revised 9/1/2024, showed in part that residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management should maximize, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics including but not limited to clean, sanitary, and orderly environment; clean bed and bath linens that are in good condition. Illinois Long-Term Care Ombudsman Program Resident's rights booklet, dated 11/18, states in part that the facility must be safe, clean, comfortable, and homelike. The residents should receive the services and/or items included in the plan of care.

Based on interview and record review, the facility failed to ensure a Registered Nurse was scheduled for 8 consecutive hours daily, 7 days a week. This failure affected one (R504) resident reviewed for Registered Nurse coverage and has the potential to affect all 93 residents at the facility. Findings include: The (06/02/2025) facility census was 93. The (undated) Residents on IVABT (intravenous antibiotic) in MAY 2025 to present include R504. R504 ' s (printed: 06/05/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) infection and inflammatory reaction due to internal joint prosthesis. Status. Discontinued. Order Summary Cefazolin Sodium injection solution reconstituted 2 grams (GM), use 2000 milligram intravenously every 8 hours for prophylaxis for 7 days. Order Date: 5/24/2025. End Date: 06/01/2025. R504 (Active Order as Of: 06/05/2025) Order Summary Report documented, in part Status: Active. Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2000 mg intravenously, every 8 hours for prophylaxis for 8 Days. Order Date: 05/31/2025. End Date: 06/08/2025. Status: Active. PICC Line: Measure external length of catheter once each week. every day shift every Tue for PICC Line. Order Date: 06/03/2025. End Date: 06/10/2025. R504 ' s (05/28/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R504 ' s mental status as cognitively intact. Section O. Special Treatment, Procedures, and Programs. O0110. H1. IV medications. A. On admission and b. while a resident. H3. Antibiotics. A. On admission. R504 ' s (05/2025) Medication Administration Record documented the following: 5/25/2025 at 21:17 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 06:28 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 13:41 V12 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/26/2025 at 23:28 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 05:32 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 14:16 V12(Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/27/2025 at 04:06 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/28/2025 at 06:13 V30(Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/28/2025 at 14:15 V12 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/28/25 at 22:19 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/29/2025 at 05:11 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/29/2025 at 15:20 V31 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/29/2025 at 00:11 V32 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 05:38 V32 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 15:46 V33 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/30/2025 at 22:13 V30 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously 5/31/2025 at 22:00 V34 (Licensed Practical Nurse) administered Cefazolin 2 GM Intravenously On 6/4/2025 review of documents titled, Department Of Financial Regulation Nursing License shows that V12, V30, V31, and V32 all have an active Licensed Practical Nurse (LPN) license which will expire January 31,2027. On 6/4/2025 review of documents titled, Nurses Quick Confirm, Quick Confirm License Verification Report shows that V33 and V34 have an active Licensed Practical Nurse license which will expire January 31, 2027. On 6/3/2025 at 9:36 am, V18 (Nursing Scheduler) stated I have two master schedules for nurses that are color coded, the blue coded schedules consist of mostly registered nurses (RN) and the yellow coded schedules has most of the LPN ' s scheduled. V18 stated currently on yellow coded schedule there are no RN 's scheduled and I (V18) am not sure why but that this is how the schedule has been since I started working on schedules, and if a nurse calls off to the nursing director, I (V18) place a call to the Agency staffing to come in and work the shift. On 06/05/2025 at 1:56pm, V20 (Registered Nurse) stated I have not monitored or supervised a Licensed Practice Nurse administer an IV (intravenous) antibiotic. On 06/05/025 at 2:21pm, V5 (Registered Nurse) stated I only work on 1East. I never work on the other floor. I have never monitored or supervised an LPN hanging an IV antibiotic for him (R504). On 6/3/2025 at 10:11 am, V2 (Assistant Director of Nursing) stated there are no LPNs in the facility that are certified to administer intravenous medications. On 06/04/2025 at 9:47am, V2 stated LPN can administer IV medications in the presence of a Registered Nurse. It is not in the scope of their practice. All our LPNs are not certified to administer IV medications. I know the regulation states that we are supposed to have an RN (Registered Nurse) coverage for 8hours daily, seven days a week. I cannot lie to you; you have a copy of our schedule and there are days we don't have an RN on our schedules. On 06/03/25 9:36 AM V18 Staffing coordinator reported that she schedules staff by teams blue or yellow, and that Licensed practical nurses are staffed on yellow team and on those days Licensed practical nurses are scheduled she does not have Registered nurses scheduled. Staff calls off to assistant director of nursing and then the assistant director then calls V18 and informs her that she needs a nurse to replace the shift, V18 states she is able to replace the shift quickly because she has prn staff who give their availability and are able to work when called. The facility nursing staff work 12 hour shifts and each unit is staffed as below. Some days there is no RN scheduled 7am-7pm: First floor- two nurses, two nursing assistants Second floor east wing- two nurses, 2 nursing assistants Second floor west wing-two nurses, 3 nursing assistants 7pm-7am: First floor-one nurse, two nursing assistants Second floor east wing- one nurse, 2 nursing assistants Second floor west wing-two nurses, 3 nursing assistants The (05/2025) Facility Nursing Staffing indicated no Registered Nurse working in the units on May 02, 03, 04, 08, 18, 22, 27, and 31. The (06/04/2025) email correspondence with V1 (Administrator) documented, in part It is our expectation that we have RN coverage daily. The (3/25/2016) Registered Nurse (RN) Job Description documented, in part Summary: The RN is responsible for providing direct Nursing care to the residents, evaluations and OR assessments, and to supervise the day-to-day clinical care performed by other nursing staff. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility., and ask may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and responsibilities. Administer clinical care according to the standard of care and in accordance with local, state, federal and facility policies and procedures. The (09/01/2024) Staffing documented, in part Policy Statement. Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation. 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care.

Based on observation, interview, and record review the facility failed to ensure foods were stored and labeled according to standards, failed to monitor refrigerator, freezer, and cooler temperatures daily; and failed to maintain dishwashing sanitizing water concentrations. This failure has the potential to affect all 93 residents residing at the facility. Findings include: On 6/2/2025 at 10:03 am, during the initial tour of the kitchen, the following was identifed: the refrigerator, freezer, cooler lacked June temperature logs. May temperature logs were taped to the refrigerator, freezer, and cooler with several missing temperature checks. All foods in the refrigerator, cooler, and freezer lacked open and expiration dates, except potentially hazardous foods in particular; Tuna Fish, [NAME] Slaw Salad Dressing, Cottage Cheese, and Bacon with past due expiration dates. Ice cream freezer lacked monthly temperature tracking sheet. On 6/2/2025 at 10:26 am, surveyor observed Low Fat Cottage Cheese dated 5/15/2025. V3, (Dietary Manager-(DM) stated the date on the Low-Fat Cottage Cheese is the opening date. V3 stated when the dietary department receives a food delivery, the receiving date is applied to each food item. V3 stated, I will throw away the cottage cheese dated 5/15/2025 out. V3 stated residents can get sick from outdated perishable foods. On 6/2/2025 at 10:29 am, surveyor and V3 observed a box of bacon in a plastic bag unsealed and open to air. The bacon contained no open or expiration date. On 6/2/2025 at 10:31am, Surveyor and V3 observed a container labeled Tuna Salad with a date of 5/25/2025. Surveyor and V3 observed a large jar of [NAME] Slaw Salad Dressing with receiving date of 10/30/24. V3 affirmed bacon in plastic bag open to air, tuna salad with written date of 5/25/25, and [NAME] slaw salad dressing with a receiving date of 10/30/2024. V3 stated , I just started here, and I haven't had a chance to inspect the entire kitchen. V3 stated residents can get food poisoning from outdated meat, tuna, and salad dressing. Facility Policy titled Food Receiving and Storage with a revised date of October 2017 documents in part: Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods. On 6/4/2025 at 9:44 am, V27, (Cook) conducted a critical control points test on the sanitation bucket 1 at the 3-compartment sink. V27 affirmed the results was 300 ppm. V27 stated the critical control points range is 200ppm. V27 stated when the results is out of range, the dishes aren't clean and is not safe. On 6/4/2025 at 9:51 am, V26, (Dishwasher) performed a critical control points test on the sanitation bucket stored by the dishwashing machine. V26 stated the sanitation bucket is used to sanitize the silverware. V26 performed a critical control points test on the sanitation bucket stored on the dishwasher and the results were 100 ppm. V26 stated the critical control points normal range is 200ppm to 300ppm. V26 stated the critical control points test is performed on the sanitation buckets to make sure the silverware are clean to prevent residents from getting sick. Facility Policy titled Food Receiving and Storage with a revised date of October 2017 documents in part, Foods shall be received and stored in a manner that complies with safe food handling practices and All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Facility Policy titled Refrigerators and Freezers with a revised date of September 20, 2024 documents in part: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 2. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 3. Food Service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. Facility Policy titled Preventing Foodborne Illness-Food Handling with a last reviewed date of 9/1/24 documents in part: I. Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. II. This facility recognizes that the critical factors implicated in foodborne illness are: a. Contaminated equipment b. Unsafe food sources III. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents.

Based on observation, interview, and record review the facility failed to maintain garbage waste with a closed lid to prevent pest infestation and foul odor. This failure affects all 93 residents residing in the facility. Findings include: Facility's Census dated 6/2/2025 documents 93 residents are residing in the facility. On 6/2/2025 at 11:04am, a garbage can stored near the dry storage room was observed without a lid giving off a foul smell and several small black insects flying around the opening. On 6/2/2025 at 11:06 am, V3, (Dietary Manager-(DM) stated, this has been a problem since I started working here, this is fruit fly central. V3 affirmed the garbage can had a foul odor, did not have a lid on it was filled with garbage and black insects flying in and around the garbage can. V3 stated pest control treated the kitchen for fruit flies 3 weeks ago. Facility Policy titled Waste Disposal with a reviewed date of September 1, 20124 documents in part, All infectious and regulated waste destined for disposal shall be placed in closable leak-proof containers or bags that are color-coded or labeled as herein described.

Based on interview and record review, the facility failed to complete a thorough and accurate facility assessment. This failure has the potential to affect all 93 residents that reside within the facility. Findings include: Record review of facility census documentation provided on 6/2/2025 documents in part that 93 residents reside within the facility. Record review of the document titled Facility Assessment Tool for [NAME] House 6/2024 though 7/2025 documents in part the following: A) no resident/resident family member input in the completion of the facility assessment B) no direct care staff input in the completion of the facility assessment c) no specific staffing needs based on shift and unit D) no plan developed/maintained to maximize recruitment/retention of staff E) no Informed contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care F) Describe your plan to recruit and retain enough medical practitioners (e.g., physicians, nurse practitioners) who are adequately trained and knowledgeable in the care of your residents/patients, including how you will collaborate with them to ensure that the facility has appropriate medical practices for the needs and scope of your population. - This section is left blank G) Describe how the management and staff familiarize themselves with what they should expect from medical practitioners and other healthcare professionals related to standards of care and competencies that are necessary to provide the level and types of support and care needed for your resident population. For example, do you share expectations for providers that see residents in your nursing home on the use of standards, protocols, or other information developed by your medical director? Do you have discussions on what providers and staff expect of each other in terms of the care delivery process and clinical reasoning essential to providing high quality care? - This section is left blank. H) List (or refer to or provide a link to inventory) physical resources for the following categories. Review the resources in the example below and modify as needed. If applicable, describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents- This section does not indicate the process to ensure adequate supply, appropriate maintenance, replacement as applicable I) List health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. Consider including a description of a) how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility; b) how downtime procedures are developed and implemented; and c) how the facility ensures that residents and their representative can access their records upon request and obtain copies within required timeframes. - This section is left blank. J) Describe how you evaluate if your infection prevention and control program includes effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards. This section is left blank. K) .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require . On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed that V1 completed the facility assessment with V21 (Infection Preventionist, Registered Nurse, Nurse Consultant), V2 (Assistant Director of Nursing) and the governing body of the facility. V1 denied that input was obtained by residents and families when completing the facility assessment, and added, other facilities I have worked with have done that. Facility assessment was reviewed with V1 and V1 affirmed that there is no contingency staffing plan or a system for recruitment/retention of the facility within the facility assessment. When asked why sections of the facility assessment was not completed or left blank, V1 replied, it is because those sections are not required. V1 affirmed that the purpose of the facility assessment is to analyze and identify the overall needs of the facility, its staff/residents and to address the identified needs.

On 06/02/25 at 11:17 am, R86 was observed in bed awake and alert with feeding tube feeding in place running at 40 ml (milliliter) per hour and wound care dressing to R86's left ischium and sacral region. R86's door did not have an Enhanced Barrier Precaution (EBP) sign on R86's door or wall outside of R86's room. On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with feeding tubes and wounds should have EBP signs on the residents door. V16 stated that if a resident who requires EBP does not have a EBP sign on the residents door then staff will not know to wear Personal Protective Equipment (PPE) (gown and gloves) when providing care to the resident and can transmit bacteria to residents and staff. V16 stated, I (V16) thought she (R86) had a sign on her (R86) door. On 06/03/25 at 12:57 pm, V21 (Infection Preventionist, IP) stated residents tube feedings, indwelling catheters, receiving dialysis and residents with wounds require Enhanced Barrier Precautions (EBP) to prevent the staff from passing Multi Drug Resistant Organisms (MDRO's) and bacteria to other staff and residents. V21 stated that residents who require EBP, the staff should be wearing gown and gloves when performing high contact resident care. R86 has a diagnosis which includes but not limited to gastrostomy status, and dysphagia oropharyngeal phase. R86 has a Brief Interview for Mental Status (BIMS) dated 05/19/25 a BIMS score of 2 which indicates that R86 has some cognitive impairments. R86's Physician Order Sheet shows active orders as of 06/03/25 shows orders for Enhanced Barrier Precautions for wound care. Gloves and gown to be worn during wound care and prolonged contact activity. R86 Enteral Feed Order every 4 hours flush 140 ml Q4 (every four). Enteral Feed Order every shift (enteral) flush feeding tube with 20-30 ml (milliliter) of water before and after medication administration . Site: Left Ischium cleanse with NSS (Normal Saline Solution) apply /cover with Ca+ (calcium alginate) silver, cover with bordered foam dressing as needed for wound care. Site Sacral cleanse with NSS APPLY Bordered foam dressing as needed for wound care. The facility's document dated 06/02/25 shows a list of residents in the facility who require EBP and that R86 requires Enhanced Barrier Precautions at the facility. The facility's undated policy titled Enhanced Barrier Precautions documents in part: Policy Statement: Enhanced Barrier Precautions are used in the care for residents with wounds requiring dressings or indwelling medical devices and successfully admit and care for those residents with XDRO (Multi drug resistant organism, MDRO) or epidemiologically important MDRO . 2. Enhanced Barrier Precautions is to be implemented in conjunction with Standard Precautions . 4. Evidence Based Precautions will be implemented for residents with wounds that requiring dressing changes (e.g. (example) pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and only when the wound drainage is contained. 5. Evidenced Based Precautions will be implemented for residents with indwelling devices. Based on observation, interview, and record review the facility failed to perform hand hygiene in between residents while passing food trays for 4 residents (R21, R42, R48, and R77); failed to ensure a resident (R86) with an indwelling catheter and wounds was placed on Enhanced Barrier Precautions (EBP); failed to provide easily accessible areas/supplies to perform proper hand hygiene on 2 East; and failed to properly bag and secure soiled linen that is put down the laundry chute. These failures have the potential to affect R21, R39, R42, R48, R77, R86; all 24 residents residing on 2 East; and all 93 residents residing at the facility reviewed for infection control. Findings include: On 6/02/25, V1 (Administrator) stated that there are total of 93 active residents residing at the facility. On 6/2/2025 at 11:20am, with V11(CNA/Certified Nursing Assistant), during observation of the soiled utility room on 2 East, surveyor and V11 observed a brown substance on the walls of the laundry chute. V11(CNA/Certified Nursing Assistant) stated, that soiled linens get thrown into a laundry chute without being put in a plastic bag. On 6/3/2025 at 10:44am, V21 (Infection Preventionist/IP) stated, Soiled linen gets bagged and sent down a laundry chute in the dirty utility room. All resident's laundry bins should have a bag in them. Soiled linen is bagged and contained to prevent the spread of infection. On 6/3/2025 at 11:47am, while in the Facility's Laundry room with V22 (Laundry Aide), an opened bag of visibly soiled linen was on the floor under the laundry chute with multiple articles of visibly soiled linen on top of the bag not contained. V22 said, The linen should come down the chute in a bag. Sometimes the bag gets caught on this (V22 pointed to a metal piece at the end of the laundry chute) and rips open. Sometimes linen comes down the chute without a bag but most of the time the linen is bagged. Facility policy titled, Departmental (Environmental Services) - Laundry and Linen, reviewed date 9/01/24, documents, in part, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Consider all soiled linen to be potentially infectious and handle with standard operations . If laundry chutes are used, only closed and leak resistant bags will be put into the chute. Loose items will not be placed in the laundry chute . Facility policy titled, Laundry and bedding, soiled, reviewed date 9/01/24, documents, in part, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . all used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing .Contaminated laundry is placed in a bag or container at the location where it is used . Facility policy titled, Infection Prevention and Control Program, reviewed date 9/1/24, documents, in part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . instituting measures to avoid complications and dissemination; educating staff and ensuring that they adhere to proper techniques and procedures. On 6/2/2025 at 12:07 p.m, V13, a Certified Nursing Assistant (CNA), was passing residents' lunch trays in the hallway. V13 pulled a lunch tray from the dietary cart and headed toward R77's room. After exiting R77's room, V13 removed her hair from her face while walking down the hallway, then took the lemonade pitcher from the cart and began pouring lemonade into a cup, without using hand sanitizer. There were no hand sanitizer dispensers available in the hallway of the unit. V13 then rolled the dietary cart down the hall and removed another lunch tray, and placed it on R42's bedside table. V13 opened food items on R42's tray but exited the room without performing hand hygiene. V13 then took another tray from the cart and proceeded to R48's room, placing the tray on R48's bedside table. Again, V13 removed her hair from her face in the hallway, took another tray from the cart, and handed it to another staff member in the dining room. V13 pushed the dietary cart down the hall without using hand sanitizer. V13, removed R21's from the dietary cart and placed the lunch tray on R21's bedside table. V13 did not practice hand hygiene after delivering the lunch tray to R21. On 6/2/2025 at 12:23pm, V13 stated I wash my hands after I pass the trays. V13 was asked if V13 uses hand sanitizer when passing trays. V13 stated I used hand hygiene. V13 was made aware V13 was observed passing several residents trays without using hand sanitizer. V13 stated hand hygiene is used to prevent infection. On 6/3/2025 at 12:07PM, V12 (Licensed Practical Nurse/LPN), stated that current census for the 2 East unit is 24 residents. On 6/2/2025 at 10:55am, surveyor observed no hand sanitizer: on or in any of the PPE (personal protective equipment) bins outside resident's room, on the walls in the hallway, on the 2 East Unit nurse's station, or in the resident's room. On 6/2/2025 at 11:05am V11 (Certified Nurse's Assistant/CNA) stated that the facility does not provide them with enough hand sanitizers, usually only one bottle placed at the nurse's station and the facility also tends to be out of hand soaps in the resident's bathrooms often. On 6/3/2025 at 10:44 AM, V21 (Infection Preventionist/IP) stated that hand hygiene is an ongoing project, facility has monthly meeting and IP is part of morning clinical huddles. Expectation for staff is to use hand gel sanitizer or soap and water, and wash hands between residents. Hand gel sanitizers should be on the PPE carts, and at nurse's station, and the smaller pocket size bottles should be available for the staff to carry in pockets. V21 said that hand sand sanitizer and hand hygiene stations should be readily accessible for the employees and visitors to prevent the spread of infection. On 6/3/2025 at 12:10pm, V13 (Certified Nurse's Assistant/CNA), stated that the facility does supply hand sanitizer but is only one small bottle per nursing station that is located so far from the end rooms, that the hand washing is harder to do. The facility does not provide hand sanitizers inside the PPE carts nor pocket size for employees to carry with them. On 6/4/2025 at 12:15pm, V2 (Assistant Director of Nursing/ADON) stated that hand sanitizing gel should be provided by the facility when needed, but sometimes when ordered, the supplies are not received. Occasionally the staff will have to purchase hand sanitizing gel themselves in the store nearby. V2 stated that the facility used to carry hand sanitizers on the walls of the facility but were removed due to malfunction and breakage. V2 stated that there is usually one bottle of hand sanitizing gel in the nursing station, and the staff can wash the hands in the washroom. V2 affirmed that sometimes it is very inconvenient to not have the ability to have handwashing supplies nearby and it makes it more challenging for staff to perform hand hygiene if they need to perform care in rooms on the far end of the hallways. V2 stated that the lack of supply could lead to spread in infection due to staff not washing their hands as often. Facility policy titled, Handwashing/Hand Hygiene, reviewed date 9/1/24, documents, in part, Policy statement . to prevent the spread of infection . importance of hand hygiene in preventing the transmission of health-care associated infections . hand hygiene products and supplies (sink, soap, towels, alcohol based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . the following equipment and supplies are necessary for hand hygiene: alcohol-based hand rub containing at least 62% alcohol; . Soap .

Based on observation, interviews and record reviews, the facility failed to clean the lint screens thoroughly, to provide a safe environment for the residents of the facility. This failure has the potential to affect all 93 residents living at the facility. Findings include: On 6/2/2025 the Census sheet provided by the facility showed 93 residents living in the facility. On 6/3/2025 at 11: 50 AM a tour of facility's Laundry room was completed with V22 (laundry aide) and follow observations were noted: Dryer #1 had copious amount of white fluffy lint on the floor, underneath the filter trap. The filter was bulging and overfilled with lint. Dryer #2 had also overfilled lint trap and some white fluffy lint on the floor underneath the trap. Dryer # 3 was not in use and out of order, but it did contain a full lint trap. Dryer #4 lint filter was overfilled with lint and bulging, and white fuzzy lint was on the floor underneath the lint trap. On 6/3/2025 at 11:55 AM V22 stated, that the lint traps should be cleaned twice on his shift at 11 AM and 2PM and again, when the next laundry aide comes and cleans the traps around 5pm. V22 stated that V22 did not get chance to clean the lint traps today. V22 affirmed that cleaning of the lint traps under the dryers is important, so clothes would dry better and because the trapped lint could be a potential hazard for a fire. 6/4/2025 at 14:20 PM V24 (Maintenance Director), stated that V24 is responsible for maintaining and supervision of laundry machines working properly. The laundry aides are responsible for cleaning the dryer's lint traps and V24 provides education and training for them. V24 stated that the lint traps should be cleaned daily at 11am and 2pm by the day shift and 8pm by the evening shift laundry aide. The cleaning of the lint tramps is important because the accumulation of the lint could potentially cause a fire and put the whole facility and all residents in danger. Also, empty lint trap helps with proficiency and effective drying of laundry. On 6/5/2025 at 11:13 AM V1 (Administrator) in the email stated that all equipment are covered under our maintenance policy as provided. Facility's Laundry Aide Job Description documents in part that, the laundry aide is responsible for ensuring that all resident linens and facility laundry are properly cleaned, sanitized, folded, and returned in a timely and efficient manner. The document shows in part that the aide is responsible for operating washers, dryers, and other laundry equipment according to manufacturer instructions and maintain laundry area cleanliness and report equipment malfunctions. Facility's Administrator Job Description documents in part that Administrator should ensure that all facility personnel, follow established safety regulations such as fire protection/prevention, smoking regulations, infection control etc. Administrator ensures that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such deities/services Facility's policy titled Maintenance Services, revised April 01,2020, showed in part that purpose of maintenance services is to protect the health and safety of residents, visitors, and facility staff. Policy also stated that the maintenance department maintains all areas of the building, grounds, and equipment. The policy further stated in part, that the Director of Maintenance is responsible for conducting regular inspections that may include but are not limited to laundry.

Based on observation, interview, and record review the facility failed to maintain an effective pest control that eliminated black flying insects in the kitchen. This failure has the potential to affect all 93 residents in the facility. Findings include: On 6/2/2025 at 11:04am, a garbage can stored near the dry storage room was observed without a lid giving off a foul smell and several small black insects flying around the opening. On 6/2/2025 at 11:06 am, V3, (Dietary Manager-(DM) stated, this has been a problem since I started working here, this is fruit fly central. V3 affirmed the garbage can had a foul odor, did not have a lid on it was filled with garbage and black insects flying in and around the garbage can. V3 stated pest control treated the kitchen for fruit flies 3 weeks ago. On 6/4/2025 at 12:14 pm, V1 (Administrator) stated the Facility's Maintenance Director is responsible for pest control. V1 stated V1 was not aware of a pest control problem in the kitchen until yesterday when it was brought to his attention by the Dietary Manager. V1 stated V1 provided the pest control reports to the survey team. V1 stated V1 was not aware. V1 stated pest control services are provided to the facility once a week for preventive measures. On 6/4/2025 at 1:26pm V24 (Maintenance Director) stated pest control comes out every 2 weeks or twice a month on a regular basis regardless of if there is a pest control problem within the facility. V24 stated no one has brought it to his attention regarding fruit flies in the kitchen. V24 stated V24 noticed some fruit flies primarily in the dish room but no one has brought it to V24's attention of sightings of fruit flies anywhere else in the building. V24 stated I know that fruit flies are annoying and are a nuisance. V24 stated V24 honestly don't know how long the fruit flies has been a problem here. V24 stated V24 thinks the facility probably needs to be a little more aggressive treating the fruit flies. Facility's Pest Control Service Inspection Report from Sentry Pest Control does not document any treatment for fruit flies, gnats, or any flying black insects on the following preventive service dates: 1/17/2025, 1/23/2025, 2/5/2025, 2/21/2025, 3/6/2025, 3/10/2025, 4/16/2025, 4/30/2025, 5/12/2025, and 5/27/2025. Facility's Policy titled Pest Control with a revision date of April 1, 2020, documents in part, The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests.

Based on interview and record review, the facility failed to provide QAPI (Quality Assurance Performance Improvement) training to the staff. This failure has the potential to affect all 93 residents that reside within the facility. Findings include: On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on QAPI. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to QAPI was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to QAPI training. V1 stated that direct care staff do not get trained on QAPI but if they have a concern, they can tell their supervisor and they can bring it to the QAPI committee. V1 stated that the direct care staff would not know how to submit things to the QAPI committee because our chain of command is to tell the supervisor. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant and provides multi-facility oversight. V21 stated that the facility might have documentation of QAPI training in the director of nursing's office. Surveyor observed V21 and V2 (Assistant Director of Nursing) search the office and V21 stated, we don't have any other documentation. V21 denied that there is a training schedule for required in-services and stated, we are currently working on that. On 6/5/2025 at 10:21 AM, V21 affirmed that there was no further documentation that the facility could produce regarding QAPI training. V21 explained, The purpose of QAPI is to analyze our facility systems/processes and improve or fix them if appropriate. QAPI is a driving force for improving care and the direct care staff should be involved too. Direct care staff know a lot more about system processes and what is working or what is not working. They would also be responsible for driving the needed change identified within the QAPI committee. No further documentation was provided related to QAPI in-services prior to the exit of the survey. Record review of facility assessment (6/24 through 7/25) does not identify a training need for QAPI training. Record review of job description titled Certified Nursing Assistant documents in part Essential Duties and Responsibilities: . Involved in yearly mandated education according to local, state and federal laws .

Based on interview and record review, the facility failed to provide compliance and ethics training to the staff. This failure affects has the potential to affect all 93 residents that reside within the facility. Findings include: On 6/4/2025 at 10:39 AM, surveyor requested documentation for staff training on compliance and ethics. On 6/4/2025 at 1:39 PM, V1 (Administrator) provided surveyor with 2 binders labeled In-services 2025 and In-services 2024 and stated, all of our in-services are within that binder, if we in-serviced on it, it would be in there. Record review of in-servicing binders for 2024 and 2025 was completed and no training related to compliance/ethics was observed completed for staff. On 6/4/2025 at 3:37 PM, V1 (Administrator) affirmed there is no further documentation that the facility can produce related to compliance or ethics. V1 produced a binder labeled compliance and ethics program and affirmed that the facility does have a compliance and ethics program. V21 (Infection Preventionist, Registered Nurse, Nurse Consultant) stated that V21 is the nurse consultant and provides multi-facility oversight (4 facilities). V21 stated that the facility might have documentation (on ethics or compliance) in the director of nursing's office. Surveyor observed V21 and V2 (Assistant Director of Nursing) search the office and V21 stated, we don't have any other documentation. V21 denied that there is a training schedule for required in-services and stated, we are currently working on that. On 6/5/2025 at 10:21 AM, V21 affirmed that there was no further documentation that the facility could produce regarding compliance/ethics training. V21 explained, In our company, we have a compliance and ethics program for our staff members. Any staff member can call a hotline to our company and report ethical concerns. It could be things like not following regulations or other ethical issues like accepting bribes or tips. It is important because we can become aware of issues that affect the resident's care and staff need to know that they can report ethical issues without fear of retailation. If they don't report it, the issues could continue. No further documentation was provided related to compliance/ethics in-services prior to the exit of the survey. Record review of facility assessment (6/24 through 7/25) does not identify a training need for compliance and ethics training. Record review of job description titled Certified Nursing Assistant documents in part Essential Duties and Responsibilities: . Involved in yearly mandated education according to local, state and federal laws .

Based on interview and record review, the facility failed to ensure care plan meetings were conducted and failed to ensure residents/resident's family members participated in the development of the comprehensive care plan. This failure affects 4 residents (R49, R65, R83, and R354) out of a sample of 55. Findings include: R65's minimum data set (5/16/2025) documents in part a brief interview of mental status summary score of 12, indicating that R65 has moderate cognitive impairment. On 6/2/2025 at 11:09 AM, R65 stated that R65 was not familiar with R65's plan of care and denied ever receiving a copy of R65's care plan. R65 denied that R65 has attended a plan of care meeting. R65 stated, I would want to go if there were meetings about me like that. R65's progress notes indicate that on 4/26/22, R65's was scheduled for a care plan meeting on 5/4/22. No further documentation of care plan meetings or care plan participation was observed in R65's medical record. R49's minimum data set (5/7/2025) documents in part a brief interview of mental status summary score of 9, indicating that R49 has moderate cognitive impairment. On 6/2/2025 at 11:33 AM, R49 denied knowledge of what a care plan was and denied that R49 had ever attended a plan of care meeting. R49 stated, Well, yeah, of course I would want to go to a care plan meeting if they were having them. I really don't remember ever having one. Review of R49's progress notes does not document any care plan meeting participation or resident input in development of R49's plan of care. R354's minimum data set (4/6/2025) documents in part that R354's cognition was unable to be assessed due to being rarely/never understood. On 6/2/2025 at 11:40 AM, V29 (R354's Family Member) stated that R354 is on hospice services and has difficulty communicating/impaired cognition. V29 could not recall the last time R354 had a care plan meeting. Review of R354's progress notes documents in part that R354's last care plan meeting was held on 10/5/2023 prior to discharge. R354 was readmitted on [DATE] and no care plan meeting documentation or participation was noted in the medical record. R83's minimum data set (5/9/25) documents in part a brief interview of mental status summary score of 15, indicating that R83 is cognitively intact. On 6/2/2025 at 11:50 AM, R83 explained that R83 has a lot going on right now with a lot of different health issues and wants to be discharged to a lower level of care (such as supportive living or a community apartment) but doesn't know where we (the facility) are at with that. R83 stated that R83 has not had a care plan meeting but would like to be invited to participate if the facility was conducting them. R83 stated that R83 never got a copy of R83's care plan since being a resident of the facility. Review of R83's progress notes does not document any care plan meeting participation or resident input in development of R83's plan of care. On 6/4/2025 at 10:43 AM, V19 (Registered Nurse, MDS Coordinator) stated that residents get care plan meetings quarterly and with significant changes. V19 affirmed that social services and nursing conducts the care plan meetings in accordance to the minimum data set (MDS) schedule, quarterly, annually and with any signficant change, about a week after the MDS. V19 denied that members of the dietary department or certified nursing assistants participate in the development of a resident's plan of care and that the nurse usually covers all that (dietary/certified nursing assistant). V19 affirmed that residents have the right to participate in the development of their plan of care. On 6/4/2025 at 1:51 PM, V35 (Social Services Director) stated that V35 could not find any documentation that indicates that R49, R83, and R65 received care plan meetings. V35 affirmed that the last documentation that R354 had a care plan meeting was in 10/2023. V35 affirmed that the care plan meetings are conducted quarterly for residents. No further documentation was provided prior to the exit of the survey. Facility policy titled Care Planning - Interdisciplinary Team (undated), . 3. The resident, the resident's family and/or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 4. Every effort will be made to schedule care plan meetings at the best time of day for the resident and family 5. The mechanics of how the interdisciplinary team meets is responsibilities in the development of the interdisciplinary care plan (e.g. face-to-face, teleconference, written communication, etc.) is at the discretion of the care planning committee.

Based on observation, interview, and record review, the facility failed to ensure the nasal cannula was labeled with the date changed for 1 (R26) resident; failed to follow the prescribed oxygen flow rate for 2 (R26 and R42) residents; and failed to ensure oxygen was delivered to 1 (R12) resident. These failures affected 3 (R12, R26, and R42) residents reviewed for oxygen therapy in the total sample of 55 residents. Findings include: On 06/02/2025 at 11:41am, R12 was using a nasal cannula, the tubing was connected to a humidifier bottle via an oxygen concentrator. The humidifier bottle was filled with water. No bubbles noted in the humidifier bottle. The concentrator regulator was set at 3liters per minute. This was pointed out to V6 (Agency LPN/Licensed Practical Nurse). V6 stated she (R12) is not assigned to me. V6 checked the humidifier bottle and stated there is no bubbles because the oxygen tubing is not screwed tightly to the humidifier bottle. V6 was then observed unscrewing and screwing the oxygen tubing to the humidifier bottle with multiple attempts until bubbles appeared in the humidifier bottle. V6 stated now it is fixed. No bubbles in the humidifier bottle means no oxygen is delivered to the resident. On 06/04/2025 at 9:45am, V2 (Assistant Director Of Nursing) stated we use humidifier when we administer oxygen via an oxygen concentrator. The humidifier bottle should have bubbles to ensure oxygen is delivered to the resident. if there is no bubbles, it means no oxygen was delivered to the resident. R12's (Active Order as Of: 06/02/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) dependence on supplemental oxygen, COPD (Chronic Obstructive Pulmonary Disease), respiratory failure with hypoxia. Order Summary. Oxygen 3/lnc (liters nasal cannula) continuously. Order Date: 08/26/2024. R12's (03/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 11. Indicating R12's mental status as moderately impaired. Section O. - special treatments, Procedures, and Programs. O0110. C1. Oxygen therapy. B. While a resident. R12's (Target Date: 02/09/2025) COPD: The resident has COPD/Acute respiratory failure with hypoxia, on continuous oxygen inhalation 2-3L. via NC (nasal canula). The resident will display optimal breathing patterns daily. The (undated) Oxygen Administration documented, in part Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure: 11. Check the humidifying jar they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. On 6/02/25 at 12:06pm, R26 was observed in the day area, across from the nurse's station, sitting up in a wheelchair with oxygen being administered at 2 liters and the oxygen tubing was not labeled. On 6/03/25 at 12:21pm, R26 was again observed in the day area, across from the nurse's station, sitting up in a wheelchair with oxygen being administered at 2 liters and the oxygen tubing was not labeled. R26 was unable to be interviewed due to altered mental status. R26's face sheet documented diagnoses that include but are not limited to chronic obstructive pulmonary disease, emphysema, dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. R26's Brief Interview of Mental Status (BIMS) score, dated 4/2/25, documents, in part, a BIMS score of 00 which indicates R26's cognition is severely impaired. R26's Order Summary Report, dated 6/4/25, documents, in part, Oxygen Continuous 41iters per minute Via Nasal Cannula every shift. Oxygen Tubing: Date tubing and Change Weekly and as needed, every night shift every, Sunday change all tubing and label and date new tubing every week on Sundays. R26's care plan, date revised 3/31/25, documents, in part, Resident has 02 (oxygen) per NC (nasal cannula). On 6/04/25 at 12:01pm, V2 (Assistant Director of Nursing/ADON) said, Oxygen tubing should be changed every week and labeled with a date and time that way we (staff) know when to change it (oxygen tubing). It (oxygen tubing) needs to be changed at least weekly because boogers get in there and for infection control. I (V2) expect the oxygen to be running at the rate the physician ordered it to run. R42's Face Sheet documents a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Asthma, Respiratory Failure with Hypercapnia, Paroxysmal Atrial Fibrillation, Heart Failure, and Congestive Heart Failure. R42's Physician Order Sheet documents an active order for Oxygen at 3 Liters Per Minute Continuously with a start date of 4/24/2025. R42's Minimum Data Set Section O dated 2/21/2025 documents in part, R42 is receiving oxygen therapy. On 06/02/25 11:39 AM, surveyor observed R42's oxygen concentrator set at 4 liter per minute continuously in progress. On 06/02/25 at 11:42 AM, V12, (Licensed Practical Nurse-(LPN) affirmed V42's oxygen concentrator was set at 4 liters per minute continuously in progress. V12 verified R42 has a active physician's order for Oxygen 3 liters per minute continuously via Electronic Health Record. V12 stated nurses should follow the physician's order to prevent a resident from developing hypoxia instead of Hyperoxia. On 6/4/25 at 3:36pm, V2, (Acting Director of Nurses-(ADON) stated the nurses are responsible for assessing resident's oxygen is set according to the doctor's orders. V2 stated, nurses should assess if the residents' oxygen concentrator is set at the correct setting every time the nurse pass medication and when the nurse checks the residents' pulse oxygenation. V2 stated residents can experience retention of Carbon Dioxide, especially for residents with a diagnosis of Chronic Obstructive Pulmonary Disease.

Based upon observation, interview, and record review the facility failed to ensure that sufficient nursing staff were available to meet the needs for one residents (R504) in the sample of 55 residents. These failures have the potential to affect all 24 residents on 2 East. Findings include: On 6/3/2025 at 12:07PM, V12 (LPN/Licensed Practical Nurse), stated that current census for the 2 East unit is 24 residents. On 06/02/25 at 11:00am, R504 was observed, in his (R504) room, sitting on the side of bed with a walker in front of him, and R504's call light was wrapped on the bedside table behind R504 not within reach of R504. Surveyor observed urine on the floor below R504 with his (R504) foot lying in the puddle of urine. R504 stated, It has been over an hour that I (R504) have been waiting for help to get to chair and get cleaned up. A nurse came in, helped me sit on the side of the bed, and said that he (nurse) would be back once he (nurse) could find another nurse to help him (nurse). I'm sorry. This is humiliating. I'm (R504) so embarrassed. R504's face sheet documents diagnoses that include but are not limited to need for assistance with personal care; muscle weakness; fall; other abnormalities of gait and mobility; unsteadiness on feet; and periprosthetic fracture around internal prosthetic left hip joint. R504's Brief Interview of Mental Status (BIMS) score, dated 5/16/25, documents, in part, a BIMS score of 15 which indicates R504 is cognitively intact. On 6/2/2025 at 11:05am, V11 (Certified Nurse's Assistant/CNA) stated, My resident's load is heavy because many of them require increased surveillance and two people assistance, and they are always short staffed. I (V11) already waited for over an hour for another CNA to help me (V11) to move the resident from bed to chair. There is only one nurse and one other CNA working this unit. I (V11) will not risk the resident falling by moving him (R504) by himself (V11). On 6/3/2025 at 12:10pm, V13 (Certified Nursing Assistant/CNA), worked at the facility for 2 years, stated that since the new management took over, there has been many changes in laundry, supplies, staffing. V13 stated that this morning there are two CNA's working and two nurses on the unit with 24 residents, but it is not the standards. It is because the agency (Illinois Department of Public Health) is in the building. Normally there would be only one nurse. The two aides must work together effectively to help residents as much as they can, but sometimes the residents will have to wait for a long time for help. It might be even longer than an hour of wait on occasion. V13 stated that the work would be much better if there were three aides and two nurses, because the units are spread into three different hallways and sometimes it's hard-to-get help. On 6/4/25 at 12:01pm, V2 (Assistant Director of Nursing/DON) said, 2 East should always have 2 nurses and 2 CNAs for at least am shift (AM: 7:00am to 7:00pm) Sometimes, it is hard to find coverage, especially when there is a call off. Sometimes, we (nurses/CNAs) work short. I (V2) have to fight with the owner to raise the hourly rate to get agency nurses to pick up shifts. Any staff can help a resident. Physical therapy, social workers. You (staff) do not have to be a nurse. An hour is too much for a resident to get assistance. Right away. Assist them (residents) right away. Waiting for an hour with sitting in urine would probably make a resident mad and sad. Facility documents titled Nursing Staff Schedule, documents, in part: May 1, 2025: 1 LPN and 2 CNAs for am shift. May 2, 2025: 1 LPN and 2 CNAs for am shift. May 3, 2025: 1 LPN and 2 CNAs for am shift. May 4, 2025: 1 LPN and 2 CNAs for am shift. May 5, 2025: 1 LPN and 2 CNAs for am shift. May 6, 2025: 1 LPN and 2 CNAs for am shift. May 8, 2025: 1 LPN and 2 CNAs for am shift. May 9, 2025: 1 LPN and 2 CNAs for am shift. May 10, 2025: 1 LPN and 2 CNAs for am shift. May 11, 2025: 1 LPN and 2 CNAs for am shift. May 12, 2025: 1 LPN and 2 CNAs for am shift. May 13, 2025: 1 LPN and 2 CNAs for am shift. May 14, 2025: 1 LPN and 2 CNAs for am shift. May 15, 2025: 1 LPN and 2 CNAs for am shift. May 16, 2025: 1 LPN and 2 CNAs for am shift. May 17, 2025: 1 LPN and 2 CNAs for am shift. May 18, 2025: 1 LPN and 2 CNAs for am shift. May 19, 2025: 1 LPN and 2 CNAs for am shift. May 20, 2025: 1 LPN and 2 CNAs for am shift. May 22, 2025: 1 LPN and 2 CNAs for am shift. May 23, 2025: 1 LPN and 2 CNAs for am shift. May 25, 2025: 1 LPN and 2 CNAs for am shift. May 26, 2025: 1 LPN and 2 CNAs for am shift. May 27, 2025: 1 LPN and 2 CNAs for am shift. May 28, 2025: 1 LPN and 2 CNAs for am shift. May 29, 2025: 1 LPN and 2 CNAs for am shift. May 30, 2025: 1 LPN and 2 CNAs for am shift. May 31, 2025: 1 LPN and 2 CNAs for am shift. Evidence shows that 28 days of 31 days in the month of May 2025, 2 East am shift worked short 1 nurse. Facility policy titled, Staffing, reviewed date 9/01/24, documents, in part, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Facility policy titled, Activities of Daily Living (ADLs), Supporting, reviewed date 9/01/24, documents, in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including . hygiene; . mobility (transfer and ambulation, including walking); elimination (toileting) . Facility policy titled, Answering the Call light, reviewed date9/1/22, documents, in part, . When the resident is in the bed . be sure the call light is within easy reach of the resident . Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike . Facility job description titled, Certified Nursing Assistant, revised date 3/24/16, documents, in part, .is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents .Provides assistance in all activities od daily living including but not limited to; personal hygiene by giving bedpans, urinals, baths, .; assisting with ambulation to the bathroom; assisting with showers and baths. Provide assistance in ambulation and movement including but not limited to; turning, and positioning residents, transferring residents from bed to chair.

Based on observations, interviews, and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change; failed to ensure administration of controlled medication was documented; failed to ensure that the medication refrigerator had a temperature log sheets; and failed to ensure that staff do not store personal food items inside the medication refrigerator used for residents medication storage. These failures affected two residents (R99 and R104) and have the potential to affect all 47 residents on the 2 [NAME] unit. Findings include: On 06/02/25 the V1(Administrator) provided a facility census of 47 residents on the 2 [NAME] unit. On 06/02/25 at 11:00 am, during the controlled medication count of R104's Pregabalin 150 mg (milligrams) 150 mg capsule, surveyor and V5 (Registered Nurse, RN) observed 52 tablets left in R104's Medication Dispensing Card however, R104's Controlled Drug Record/Disposition Form's last entry was on 06/01/25 at 5:00 pm and amount of Pregabalin 150 mg was observed with 53 capsules. V5 (Registered Nurse, RN) stated, I (V5) gave one this morning. I did not sign it out yet. V5 stated that narcotic medications should be signed out when given so that the medication count can be accurate. On 06/02/25 at 12:14 pm, during the 2 [NAME] Team 1 cart narcotics count review Surveyor and V14 (Licensed Practical Nurse, LPN) observed the 2 [NAME] Narcotic Accountability sheet not signed for the on-coming nurse for June 1, 2025. V14 (LPN) stated, I don't know who should have signed there. That is not me. At 12:15 pm, Surveyor and V14 observed R99's Briviact Oral Tablet 10 mg (milligram) (Brivaracetam) Give 1 tablet by mouth two times a day for seizures 60 tablets repackaged in increments of ten inside six medication pill sleeves. V14 stated, I didn't do that. That was like that when I came. I'm not sure if we can do that (referring to the repackaging of medications for R99. I don't know who did that. On 06/02/25 at 12:17 pm, Surveyor and V14 (Licensed Practical Nurse, LPN) observed 2 [NAME] with two medication refrigerators inside of the 2 [NAME] Medication room with one medication refrigerator without a temperature log sheet and the other medication refrigerator with the facility's document dated May 2025 and titled Nursing Unit Daily Refrigerator Temperature Log posted. V14 stated that there should be a daily refrigerator log for June 2025 posted for both medication refrigerators so that the medication refrigerator can be monitored for a safe range in temperature for medication storage. V14 stated that if the medication refrigerator is not being monitored medication can possibly be stored at an unsafe temperature range. At 12:18 pm, Surveyor and V14 observed a sandwich package labeled Uncrustables in the freezer section of the 2 [NAME] medication refrigerator without a temperature log. V14 stated, That is the staffs. That should not be in there because it can grow mold and bacteria and harm the residents medication. On 06/03/25 at 10:04 am, V2 (Assistant Director of Nursing, ADON) stated that when a nurse administers a narcotic the narcotic should be signed out immediately upon administration. V2 explained that it is important for narcotic medication to be accurately signed during the narcotics count and when medications are administered so that double doses are not administered to residents and to ensure the narcotics count is accurate. V2 explained if a narcotic is not signed out there is no evidence that the resident received the medication. V2 further explained that medication should be administered from the medications original packaging. V2 stated that each medication refrigerator should have a refrigerator temperature log sheet to monitor the temperature of the medication and so that the medication will not lose its potency. R99's Physician Order Sheet (POS) dated active orders as of 06/04/25 shows that R99 has orders for Briviact Oral Tablet 10 mg (milligram) give 1 tablet by mouth two times a day for seizures. R99's Controlled Drug/Receipt/Record/Disposition Form dated received on 05/13/25 shows that R99 has Briviact Oral Tablet 10 mg (milligram) BID (twice a day) quantity received 60 tablets. R104's POS dated 05/28/25 shows that R104 has orders for Pregabalin Oral Capsule 150 MG (Pregabalin) *Controlled Drug* Give 1 capsule by mouth two times a day for Pain Take 1 capsule by mouth 2 times daily. The facility's document dated June 2025 and titled Controlled Substance Verification Sheet shows Nurses Station: 2 [NAME] Team with missing signatures for June 1, 2025 on the 7:00 am -7:00 pm on coming shift. The facility's documented dated received 05/29/25 and titled Controlled Drug Record shows that R104 has 53 tablets of Pregabalin 150 mg (milligrams)150 mg capsule left to dispense however, Surveyor and V5 (Registered Nurse, RN) observed R104's medication dispensing card for Pregabalin 150 mg (milligrams)150 mg capsule with 52 tablets left to dispense. The facility's undated policy titled Controlled Substances documents, in part: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation: .8. 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . 9. Upon Receipt: . b. Both individuals sign the controlled substance record of receipt . 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength, and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of the medication remaining; and (6) signature of nurse administering medication . 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The facility's undated policy titled Storage of Medications documents, in part: Policy heading: The facility stores all drugs and biological in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biological's are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. The facility's undated policy titled Labeling of Medications Containers documents, in part: Policy Statement: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Policy Interpretation and Implementation: 3. Labels for individual resident medications include all necessary information, such as: a. the resident's name . h. the expiration date when applicable. The facility's undated policy titled Refrigerator and Freezers documents, in part: Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.

On 6/2/25 at 11:15am, R104 was observed in bed with the indwelling urinary catheter drainage bag without privacy bag. The urine bag was hung on the side of the bed visible to anyone walking down the hallway when the door is not closed. On 6/2/25 at 11:18am, R18 was observed in bed with the indwelling urinary catheter drainage bag without privacy bag. The urine bag was hung on the side of the bed visible to anyone walking down the hallway when the door is not closed. On 6/2/25 at 12:05pm, both residents still had the urine bags without privacy bags. V5 (Registered Nurse) was notified and V5 stated that she (V5) would ensure to put the urine bags in privacy bags. Based on observation, interview and record review, the facility failed to ensure the indwelling catheter drainage bag was covered for three residents (R18, R51 and R104) reviewed for dignity in the sample of 55 residents. Findings include: On 06/02/25 at 11:19 am, R51 was observed in bed with indwelling catheter bag hanging on the bottom of R51's bed, visible to the doorway and not covered in a privacy bag. R51 stated that R51 has been at the facility for several months and has never had a privacy bag for R51's indwelling catheter. On 06/02/25 at 11:22 am, V16 (Licensed Practical Nurse, LPN) stated that residents with indwelling catheters should have a privacy bag to cover the residents indwelling catheter. V16 stated that if a residents indwelling catheter bag is not covered then the facility is not protecting the residents privacy. On 06/04/25 at 9:35 am, V2 (Assistant Director of Nursing, ADON) stated that indwelling catheters should be in a privacy bag for the residents dignity. V2 explained if the indwelling catheter should be placed on the side of the bed not visible to the hallway so that no one can see the residents indwelling catheter and to protect the residents dignity. R51's face sheet shows that R51 has a diagnosis which includes but not limited to indwelling and inflammatory reaction due to indwelling urethral catheter, initial encounter, hydronephrosis with ureteral stricture, and benign prostatic hyperplasia with lower urinary tract symptoms. R51's Brief Interview for Mental Status (BIMS) dated 03/24/25 shows a BIMS score for R51 of 15 and indicates that R51 is cognitively intact. R51's physician order sheet (POS) show active orders dated 06/03/25 shows that R51 has orders for indwelling catheter care every shift. The facility undated policy titled Dignity documents in part: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered. The facility's undated policy and titled Resident Rights documents, in part Policy Statement: Employees shall treat all resident with kindness, respect, and dignity.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff are aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that LALM checks were conducted, failed to ensure the LALM is on the correct setting/mode, failed to implement care plan interventions, failed to turn/reposition dependent residents every 2 hours, failed to ensure that wound assessments were accurate & staged correctly, failed to follow physician orders, and/or failed to ensure that treatments were administered as ordered for four of four residents (R1, R2, R3, R4) reviewed for pressure ulcers. These failures resulted in R1 sustaining a (facility acquired) infected large sacrum decubitus which required surgical intervention and osteomyelitis (bone infection) of the sacrum/coccyx. These failures also resulted in R3's (stage 3) sacrum pressure ulcer declining to (stage 4). Findings include: 1. On 10/8/24 and 10/18/24, IDPH (Illinois Department of Public Health) received allegations that the facility failed to provide timely/adequate care to prevent stage 4 wounds. (R1) sustained a stage 4 infected wound that required surgery. R1's wound was down to the bone. R1's diagnoses include but not limited to obesity, generalized muscle weakness, hypertensive heart disease, and congestive heart failure. R1 was admitted [DATE] transferred to the hospital on 9/21/24 and did not return to the facility. R1's (12/22/23) risk for skin integrity impairment assessment determined a score of 12 (High Risk). R1's (9/13/24) functional assessment affirms resident is dependent on staff for toileting hygiene and requires substantial/maximal assistance for rolling left and right (turning/repositioning). R1's care plan includes (12/25/23) Resident has alteration of bowel & bladder functioning due to weakness and decreased mobility. (9/16/24) MASD (Moisture Associated Skin Damage) sacrum area. Interventions: perform skin at risk assessment per facility protocol. Notify MD (Medical Doctor) of significant changes. Identify potential causative factors and eliminate/ resolve when possible. Keep skin clean and dry. Turn and reposition every 2 hours. On 10/28/24 at 1:05pm, surveyor inquired about R1's (facility acquired) skin integrity impairment, V2 (Director of Nursing) presented R1's (2/23/24) initial skin alteration record and (3/21/24) weekly skin alteration record and stated 2/23 is when the MASD started and 3/21 is when the MASD got resolved. Then, the 9/16 (2024) MASD was identified next. R1's (9/16/24) initial skin alteration record states sacrum MASD. 7 x 4.5 x 0cm (centimeters). Wound margins/edges: erythema (redness). Peri -wound area erythema, warm to touch, cracked/excoriation. No pain verbalized or observed during treatment. Assist to reposition totally dependent. Preventive measures daily skin checks during CNA routine rounds, reposition every 2 hours and PRN (as needed), moisture barrier, incontinence care. R1's POS (Physician Order Sheets) include (3/7/24) Air loss mattress checks for function every shift. Turn and reposition every 2 hours. (9/16/24) Medihoney apply to sacrum daily for excoriating/MASD. Cover with foam dressing. R1's (9/16/24) progress notes state wound care provided. R1's (September 2024) TAR (Treatment Administration Record) affirms Medihoney to sacrum was not documented (blank spaces noted) on 9/17, 9/18, 9/19, 9/20, and 9/21 (5 days). R1's (9/13/24) BIMS (Brief Interview Mental Status) determined a score of 12 (cognition intact). R1's (9/21/24) ER (emergency room ) progress notes state patient herself reports pain in her butt with pressure ulcer noted to her sacrum. Dressed with white substance and dressing on arrival [Medihoney which was prescribed - is not a white substance]. R1's (9/21/24) history and physical states patient presents to ER, patient is complaining of butt pain. Musculoskeletal: positive for back pain. Skin: Findings: Lesion present. Comments: Large sacral decubitus. Patient does endorse back pain near butt. Patient has large sacral decubitus. Differential diagnosis includes infection. R1's surgical consults state (9/24/24) wound appears likely to involve muscle and likely periostium (membranous tissue that covers the surface of bone). Recommend MRI (Magnetic Resonance Imaging) to evaluate bone involvement. (9/26/24) Patient was noted to have sacral decubitus ulcer on admission with imaging/MRI (Magnetic Resonance Imaging) confirming osteomyelitis of the sacrum and coccyx. Seen by surgery and plan for debridement today. R1's (10/3/24) discharge summary states wound cultures resulted pseudomonas (Bacteria) and VRE (Vancomycin-Resistant Enterococci) faecium (Bacteria). On 10/28/24, surveyor requested credentials for the facility Wound Care Nurse. At 12:05pm, V1 (Administrator) stated that the facility employs two wound care Nurses (V8 & V10) however only presented V10's (Wound Care Nurse) wound care certification. Surveyor inquired when V10 was hired V1 responded He (V10) started last Monday so that would be on October 21st [7 days prior]. On 10/28/24 at 12:47pm, V1 stated that (V8/Wound Care Nurse) Does not have wound care certification and subsequently affirmed in writing that V8 does not possess the WCC (Wound Care Certified) certification. This employee (V8) was hired on September 18, 2023 (over 1 year ago). On 10/29/24 at 12:11pm, surveyor inquired who's responsible for wound care at the facility V11 (ADON/Assistant Director of Nursing) stated I troubleshoot for the facility just to do the dressing when the wound care is not here and affirmed that when V8 (Wound Care Nurse) is not working she (V11) provides wound care. Surveyor inquired when V8 works at the facility V11 responded Friday, Saturday, Sunday and Monday. Surveyor inquired if V11 is wound care certified V11 replied No, I'm not. Surveyor inquired about R1's cognitive and functional status V11 stated She is bedridden. She's incontinent both of urine and stool. She's alert 2-3, she can tell you change me, or I have poop. Surveyor inquired about R1's skin integrity impairment (prior to 9/21/24) hospital transfer V11 responded she (R1) has excoriation because she is incontinent of urine and stool. Surveyor inquired what causes excoriation V11 replied Urine and stool, urine is very corrosive and stool. Surveyor inquired what blank spaces on the TAR indicates V11 stated That they didn't do anything. Surveyor inquired if R1's Medihoney treatment/dressing was documented on the (August 2024 TAR) V11 reviewed R1's EMR (Electronic Medical Records) and responded Nobody sign it or it means it's not there 5 days, the blank one. The Nurses on the floor should be doing this. Surveyor advised that V11 affirmed that she (V11) and V8 were responsible for wound care (in prior statement) V11 replied I (V11) know, but if I cannot do it, I told them (assigned Nurses) that they have to do it. Surveyor inquired about potential harm to a resident if skin integrity impairments are not treated (as ordered) V11 stated Well, it will just deteriorate with the stool and urine there. You need to clean it and put another dressing. On 10/30/24 at 12:59pm, surveyor inquired about staff requirements for resident change in condition re: sacrum Decubitus V14 (Medical Director) stated I would expect that the staging is done properly, the dressing requirements are very clear in the wound care plan, and the offloading mechanisms such as the low air loss mattress is ordered, and as a Physician or in-house Nurse Practitioner, there's a rounding and we treat infection if there's infection. Surveyor inquired about potential harm to a resident if treatments are not administered as ordered V14 responded So there is potential for serious harm, the wound can become infected, and the resident can become septic. Surveyor inquired how osteomyelitis occurs V14 replied It is a progression of any skin or soft tissue infection or trauma, the deeper the wound goes there's muscle and facia. The deeper the wound goes; it can involve the bone and it can be an infection which is osteomyelitis. On 10/30/24 at 1:32pm, V13 (Agency Licensed Practical Nurse) affirmed that she was assigned to R1 on 9/21/24. Surveyor inquired about R1's sacrum skin integrity impairment V13 stated That I'm not too familiar with it because I know that someone is there doing wound care [R1's TAR affirms that wound care was not documented for 5 days]. I'm not sure what kind of wound that (R1) had. V13 affirmed that V15 (CNA/Certified Nursing Assistant) was also assigned to R1 on 9/21/24. On 10/30/24 at 2:15pm, surveyor inquired about R1's sacrum wound, V15 (Certified Nursing Assistant) stated When I changed her, (R1) had like a patch on her butt and we (staff) usually put the zinc on it, it was just red. Surveyor inquired if R1 reported pain V15 replied She might say that she is uncomfortable, so we just turn her side to side. 2. R3's diagnoses include Parkinson's disease and reduced mobility. R3's (9/3/24) risk for skin integrity impairment assessment determined a score of 12 (high risk). R3's (10/3/24) functional assessment affirms resident is dependent on staff for rolling left and right. R3's (4/4/24) initial skin alteration record (admission) includes (stage 3) sacrum pressure ulcer. R3's (10/24/24) weekly skin alteration record includes (stage 4) sacrum pressure ulcer [therefore wound declined]. R3's POS includes (4/5/24) turning and repositioning every 2 hours. (4/9/24) air loss mattress check function every shift. (7/23/34) Calcium Alginate apply to sacral daily for stage 4 pressure ulcer after cleansing with NSS (Normal Saline Solution) and cover with dry dressing. R3's care plan includes (4/5/24) high risk for alteration in skin integrity, Interventions: identify potential causative factors and eliminate/resolve when possible. LALM (Low Air Loss Mattress) check for function every shift. On 10/23/24 at 3:44pm, R3 was lying on a LALM, and the setting was on static mode (therefore providing a firm surface). Surveyor inquired about R3's current LALM settings V5 (RN/Registered Nurse) stated Usually it's preset. Surveyor inquired what static mode means V5 responded I'm not familiar with this machine. R3 was noted to be lying on a white flat sheet, a thick blue folded sheet (8 layers), and folded bath blanket (4 layers). V5 counted the layers beneath R3 (as requested) and affirmed that there were 13 excluding the brief (therefore a total of 14 layers placed beneath the buttocks). Surveyor relayed concerns with all the linens placed between R3 and the LALM V5 replied It should only be one, otherwise this one (LALM) won't work. V5 then proceeded to cover R3 with the blanket and left the room, V5 did not remove any of the sheets and/or blanket beneath R3 at this time. R3's (October 2024) TAR affirms for low air loss mattress checks (blank entries) were noted on 10/5, 10/6, 10/8, 10/19, 10/23, 10/24, 10/25, and 10/27. For Calcium Alginate treatments 9 is documented on 10/6, 10/14, 10/17, 10/20 and 10/28. For turning/repositioning every 2 hours blank spaces were noted on 10/3, 10/5, 10/6, 10/7, 10/8, 10/9, 10/19, 10/20, 10/23, 10/24, 10/25, 10/27 and 10/28. On 10/29/24 at 12:45pm, surveyor inquired why 9 was documented on R3's (October 2024) TAR, V11 (ADON) stated I don't know why they (Nurses) do this number nine. 10/6 (2024) it says done by wound nurse (referring to R3's progress notes). 10/8 says done by wound nurse. 10/14 says done by wound nurse. 10/20 is done by wound nurse. 10/24 will be done by wound nurse. Surveyor inquired if Nurses should be charting wound care for other staff V11 responded No, they have to chart when they are doing it, the dressing and everything. Surveyor inquired what mode the LALM should be in while a resident is lying in bed V11 replied The mattress should just stay in alternating because that is where the cell is alternating, go up and go down the bed, so the patient should be floating in the mattress. Surveyor inquired if several linen layers were placed under R3's buttocks while lying on a LALM is the mattress effective V11 stated No, it has to be one layer only because the air can go to the patients skin. 3. R4's diagnoses include Parkinson's disease, generalized muscle weakness, and protein calorie malnutrition. R4's (10/12/24) Braden determined a score of 11 (high risk). R4's (9/13/24) initial skin alteration record was signed on 9/15/24 (2 days after assessment). Site: Abdomen. Description: Sacral wound stage 4 [the description is incongruent with the site]. Preventive measures: redistribution mattress. R4's (10/12/24) re-admission skin alteration record states site: abdomen. Description: sacral wound stage 4. [again, the description is incongruent with the site]. R4's (10/24/24) weekly skin alteration record states sacrum stage 3 [therefore back staged]. R4's (9/13/24) POS states cleanse sacral wound with NS, apply Alginate, cover with dry dressing daily and as needed. R4's (October 2024) TAR affirms sacral treatment was not documented (blank entries) on 10/4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/15, 10/17, 10/18, 10/19, and 10/22. Low air loss mattress checks were initiated on 10/24 (1.5 months after implementation). On 10/23/24 at 3:55pm, inquired if R4 has a wound V6 (RN) stated It's on the back, he (R4) was just turned by the CNA. R4's (10/15/24) BIMS determined a score of 9 (moderate impairment). On 10/23/24 at 3:57pm, surveyor inquired if R4's dressing was changed today R4 replied Uh um nodded his head no and affirmed that it was not. R4 was lying atop of a LALM, surveyor inquired about the current settings on R4's LALM, V6 (RN) stated Unfortunately I (V6) was not told as to what setting he (R4) should be in. Right now, the setting is at 250 (pounds) I wound say however R4 appeared to be about half that weight. Surveyor inquired how much R4 weighs R4 responded 122 pounds. Surveyor requested to inspect R4 at this time. V7 (Certified Nursing Assistant) removed R4's incontinence brief which was dry however a dressing was not present and white cream was noted on the open sacral wound. Surveyor inquired about R4's exposed wound, V6 replied I see a wound on the tailbone, it is an open wound. Surveyor inquired what was on R4's (stage 4) sacrum wound V6 stated Zinc oxide. Surveyor inquired if a dressing was supposed to be on R4's sacrum V6 responded Yes. On 10/28/24 at 10:36am, surveyor inquired why R4's initial wound assessment states stage 4 and the current wound assessment states stage 3, V2 (Director of Nursing) stated Good question. Surveyor inquired about staging wounds, V2 responded When staging from a stage 4 going to a stage 3, if the wound is getting better by the week-by-week assessment of the wound nurse. Surveyor inquired if back staging of wounds is appropriate V2 replied Don't we indicate if its progressing or getting better? Surveyor inquired if V2 was familiar with staging wounds V2 stated No. [The National Pressure Ulcer Advisory Panel advises against reverse staging of pressure ulcers, or bedsores, because it doesn't accurately reflect the healing process]. On 10/29/24 at 1:07pm, surveyor inquired why R4's initial sacral wound assessment (dated 9/13/24) was documented/signed on 9/15 (3 days after admission). V11 (ADON) stated (R4) was admitted on the 12th and the assessment was done the next day. When you do it on the day it will give you the day that you did the assessment. If I do the assessment today, I have to sign the assessment for today. Surveyor inquired about concerns with R4's (9/13/24) initial wound assessment, V11 responded The site says abdomen how can you put abdomen when the site is sacrum. 4. R2's diagnoses include dementia, type II diabetes mellitus, protein calorie malnutrition, and generalized muscle weakness. R2's (10/12/24) risk for skin integrity impairment assessment determined a score of 10 (high risk). R2's (10/12/24) initial skin alteration record (admission) includes left buttock stage 4 pressure ulcer and sacrum MASD. R2's (10/24/24) weekly skin alteration record includes sacrum stage 4 [incongruent with the initial assessment] and buttocks MASD [incongruent with the initial assessment]. On 10/29/24 at 12:28pm, V11 (ADON) affirmed that (V8/Wound Care Nurse) documented R2's (10/12/24) and (10/24/24) wound assessments. Surveyor inquired why R2's (10/12/24) initial wound assessment includes left buttock stage 4 (black/eschar tissue) however the (10/24/24) assessment (conducted 12 days later) states buttocks MASD, V11 stated (R2) cannot have MASD because (R2) is not eating. That cannot be, you cannot come back and change that to MASD. Stage 4 cannot go back to MASD. The documentation was not entered properly. R2's (10/23/24) POS states cleanse sacral 1/2 strength Dakins, pat dry, apply metrocream, cover with dry dressing daily. R2's (October 2024) TAR affirms the sacral treatment was not documented (blank entry) on 10/26/24. The (7/2023) low air loss mattress policy states the purpose is to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity of the skin. Low air loss mattresses will be utilized for residents with stage III and IV pressure ulcers of the trunk as well as residents with multiple stage II pressure ulcers. The low air loss mattress will be checked on a regular basis to ensure that all cells of the mattress are functioning appropriately. Any resident on a low air loss mattress will have a single non-fitted sheet which may be used for assistance with repositioning. The management of wounds policy (revised 12/31/23) states it is the policy of this facility to manage tissue load and improve tissue tolerance to pressure, friction, and shearing forces. This will be accomplished through the use of appropriate positioning practices, positioning devices, and support services. It is the policy of this facility to treat the wound according to the guidelines of the Agency for Healthcare Research and Quality (AHRQ), National Pressure Ulcer Advisory Panel, and current standards of clinical practice. According to the AHRQ, Care of the ulcer itself involves debridement of necrotic tissue, cleansing of the wound at initial examination and at each dressing change, and using a dressing that keeps the ulcer bed continuously moist but the surrounding intact skin dry. The following policies and procedures will be utilized: wound cleansing policy and procedure and wound dressing policy and procedure.

Based on interviews and record review, the facility failed to properly assess one resident (R1) for skin breakdown; and failed to prevent, recognize and treat a new wound that was acquired in the facility for 1 resident (R1) out of 7 residents reviewed for nursing care. This failure resulted in R1 being sent out to the hospital on 5/29/24 for altered mental status in which it was discovered R1 had a unstageable wound to the sacrum and again R1 was evaluated in the hospital on 6/5/24 where R1's sacral wound extended to the anus and required surgical debridement. Findings include: R1 is an [AGE] year old with diagnosis including but not limited to: Muscle weakness, abnormalities of gait and balance, cognitive communication deficit, cerebral infarction, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. On 7/01/2024 at 10:10 AM, V1 (Administrator) said, R1 has been discharged from the facility. He went to the hospital on 6/5/2024 and the family decided to take him home from the Hospital. (R1 was sent on 6/5/24 to the hospital for wound evaluation) On 7/1/2024 at 10:15 AM, V6 (R1's family) said, There have been times that I have gone to visit my dad (R1) and noticed that he smelled of urine and feces. He (R1) had a rash and wound on his scrotum. He (R1) had developed a wound on his back that spread to his anus. It was so deep that he had to have surgery and also had a colostomy bag placed. He (R1) had necrotic tissue that had to be removed and he also had formed infections in the wound. He (R1) is still not completely healed from the wound. My dad (R1) did not have any wounds when he was admitted to the facility on [DATE] and now he (R1) has an unstageable wound from which he (R1) is having many complications. The facility didn't prevent my dad's pressure wound from forming and did not treat my dad (R1's) wound until it was too late. He (R1) developed the pressure ulcer in the facility, before he was even hospitalized . He (R1) then got a wound infection in the facility and went back out to the Hospital for the infection. On 07/02/2024 at 1:12 PM, V14 (ADON/ Assistant Director of Nursing) said, I help with wounds sometimes when the wound nurse is not here. On 07/02/2024 at 1:12 PM, V14 said, R1 was incontinent. He (R1) was not alert and oriented and will not call for help if he is wet. For incontinent patients, they are usually rounded on every two hours to reposition and change. I was not in the facility on the day that R1 was readmitted to the facility. I live close by, so I have no problems coming into the facility to assess a wound. I was not aware of R1's wound. I (V14) am not sure why the wound care orders were not entered until 6/2/2024 because he (R1) came back to the facility on [DATE]. I was not aware of R1 having any skin breakdown. On 07/02/2024 at 1:12 PM, V14 (ADON) said, If a patient has a wound upon admission, wound care team is notified to assess the patient and implement treatment. We (wound team) will call the Doctor to get orders for a wound to ensure that it is treated. A patient can have skin breakdown within 24 hours because the skin is very tender and older patients are more prone to skin breakdown. For wound prevention, we use air mattresses, zinc oxide to protect the skin and we reposition and change the patients every two hours. The wounds can quickly worsen without treatment. My expectation is that there are no wounds developed or worsening in this facility. On 07/02/2024 at 1:14 PM, V14 (ADON) said, There can be many complications from a pressure ulcer including: sepsis (blood infection) or skin infections such as cellulitis. On 7/3/2024 at 1:50 PM, V18 (LPN/Licensed Practical Nurse) said, I readmitted R1 back to the facility. I don't recall any further orders for wound care at the time of R1's admission. I'm sure that I notified the nursing manager and I did document my findings of the open area on the skin. I am not sure what was done after that. On 7/3/2024 at 2:24 PM, V19 (Nurse Practitioner) said, If I saw the patent (R1) after re-admission to the facility, I would have definitely entered orders for wound treatment. Ideally, the nurse would call the primary Doctor and the wound care consult is ordered for assessment on the next day. The purpose of the treatment would be to heal the wound and to prevent it from worsening. Facility Census report documents, R1 was admitted to the facility on [DATE]; R1 was admitted to the Hospital on 5/29/2024; R1 was readmitted to the facility from the Hospital on 5/31/2024; R1 was discharged from the facility on 6/5/2024. Facility Admission Summary note dated 4/26/2024 documents, head to toe assessment done with no skin issue noted. Facility Admission Screener dated 4/26/2024 documents, R1 does not have impaired skin integrity upon admission. R1's Interim Care Plan dated 4/26/2024 documents, R1 is at risk for altered skin integrity related to incontinence and decreased mobility. R1's MDS (Minimum Data Set) - Section M dated 5/1/2024 documents, the resident (R1) is not at risk for developing pressure injuries/ulcers; the resident (R1) has no unhealed pressure injuries/ulcers. R1's MDS (Minimum Data Set) - Section H dated 5/1/2024 documents, R1 has occasional urinary and bowel incontinence; trial of a toileting program has not been attempted; No toileting program currently being used. Hospital Emergency Department Nurse note dated 5/29/2024 and written by V17 (Hospital Nurse) documents, Patient (R1) has wound on the sacrum, partial thickness. R1's (6/5/24) hospital record documents in part: R1 was sent for sacral wound evaluation. Wound measured 9 cm x 9 cm, base: moist, necrotic, extends to the anus. Hospital Discharge instructions dated 5/31/2024 documents a new order for miconazole nitrate ointment. Facility Nurse Progress note dated 5/31/2024 documents, body assessment completed, patient (R1) has open area on sacrum, dressing is covering the area, and R1 has noted irritation to penis area. Medical Doctor made aware R1 has returned. Orders are to stay the same. Facility Admission Screener dated 5/31/2024 documents, R1 has impaired skin integrity upon admission (R1 was readmitted to the facility from the hospital). R1's MDS (Minimum Data Set) - Section H dated 5/29/2024 documents, R1 is always incontinent. R1's MDS (Minimum Data Set) - Section M dated 6/5/2024 documents, R1 has one or more unhealed pressure ulcers. R1's Physician Order Summary Report documents wound care orders for treatment of buttock and sacrum entered on 6/2/2024; orders for LALM (Low Air Loss Mattress) entered on 6/3/2023; orders for treatment of perianal/ scrotum entered on 6/5/2024; turn and reposition orders entered on 6/5/2024; and order for wound cream entered on 6/5/2024. R1's Physician Order Summary Report documents no order for miconazole nitrate ointment. R1's Treatment Administration Record (TAR) documents, no treatments implemented for R1's wounds on 5/31/24, 6/1/24 or 6/2/2024. Hospital summary dated 6/12/2024 documents, R1 was seen for sacral wound cellulitis and osteomyelitis; R1 will also need a diverting colostomy, sharp excisional debridement of sacral decubitus on 6/7/2024, post operation day one. Facility policy titled Pressure Ulcer Treatment and Management documents, Residents with pressure ulcers will have a physician's order for treatment; residents with pressure ulcers will be determined to be at high risk for pressure ulcer prevention and all components of the At Risk Protocol will include; pressure relieving devices, nutritional support, assistance with mobility including repositioning and ROM (range of motion) as outlined in the At Risk Protocol. Facility policy titled Pressure Ulcer Prevention protocol documents, Daily skin checks conducted by either the CNA (Certified Nurse Assistance) or Licensed Nurse to ensure early identification of potential problem areas. Facility policy titled Pressure Ulcer Risk Assessment documents, to implement a standardized plan of pressure ulcer prevention based upon a reliable and valid assessment of pressure ulcer risk.

Based on observation, interview, and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for four of four residents (R1, R2, R3, R4) reviewed for ADL care. This failure resulted in R1 expressing feelings of shame. Findings include: On 10.21.2023 at 11:33 AM, R1 was observed awake, alert, lying in bed. R1 said he was soiled. 1) R1's medical record (Face Sheet) documents R1 is a [AGE] year-old admitted to the facility on 2.20.2020 with diagnoses including but not limited to: Parkinson's Disease, Venous Insufficiency (Chronic) (Peripheral), Acute Kidney Failure, and Weakness. R1's MDS (Minimum Data Set of 7.23.2023) documents R1 is cognitively intact, requires extensive assistance/two + persons physical assist with bed mobility, transfers, and toilet use; R1 is frequently incontinent of urine and stool. 10.21.2023 at 11:33 AM, R1 was observed sitting up in bed. A blue brief was observed sticking out from the top of R1's yellow brief. R1 said staff double diapered him (on the night shift). R1 said, I don't like it. They do that so that they don't have to change me so much. It's my fault because I wet so much. R1 appeared sad (sad facial expression) as he told the Surveyor about the double diapering. At 11:37 AM, V5 (Agency CNA-Certified Nursing Assistant) entered R1's room to provide incontinent care. R1's blue brief and back of R1's yellow brief were saturated with urine; a pungent odor was noted. R1's draw sheet was saturated with urine; a dark ring was noted on R1's fitted sheet. 2) R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on 1.16.2020 with diagnoses including but not limited to: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Diastolic (Congestive) Heart Failure, and Hyperlipidemia, Unspecified. R2's MDS (Minimum Data Set of 7.11.2023) documents R2 is severely cognitively impaired, requires extensive assistance/two+ persons physical assist with bed mobility, total dependence/two+ persons physical assist with transfers and toilet use; R2 is always incontinent of urine and stool. 10.21.2023 at 10:38 AM, R2 is sitting up in bed with eyes closed, non-verbal. V4 said this is the first time I'm seeing him (to provide incontinent care); I did feed him earlier. V4 lowered the head of R2's bed and undid his brief. Surveyor observed a blue brief (with flaps removed) inside R2's outer brief. R2's blue brief was saturated with urine, the back of R2's yellow brief was saturated with urine. V4 said the line down the front of R2's yellow brief will change color when the resident is wet, however because R2 was double diapered (blue brief inside of yellow brief) the line on the outer brief will not change color even though resident is wet. 3) R3's medical record (Face Sheet) documents R3 is an [AGE] year-old admitted to the facility on 2.10.2022 with diagnoses including but not limited to: Radiculopathy, Lumbar Region; Muscle Weakness (Generalized), Fusion of Spine, Lumbar Region, and Thoracoabdominal Aortic Ectasia. R3's MDS (Minimum Data Set of 8.13.2023) documents R3 is severely cognitively impaired, requires extensive assistance/one-person physical assist with bed mobility and transfers, total dependence/two+ persons physical assist with toilet use; R3 is always incontinent of urine and stool. 10.21.2023 at 10:50 AM, with V4 (CNA-Certified Nursing Assistant) and V5 (Agency CNA-Certified Nursing Assistant), R3 was observed awake and alert lying in bed, R3 did not respond to Surveyors questions. R3's brief was saturated with urine. R3's incontinent pad was wet with urine; a dark ring was noted as well. R3's fitted sheet was wet with urine. 4) R4's medical record (Face Sheet) documents R4 is a [AGE] year-old admitted to the facility on 2.20.2018 with diagnoses including but not limited to: Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Hyperlipidemia, Unspecified; Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, and Major Depressive Disorder, Single Episode, Unspecified. R4's MDS (Minimum Data Set of 8.13.2023) documents R3 is cognitively intact, requires extensive assistance/two+ persons physical assist with bed mobility, total dependence/two+ persons physical assist with transfers, total dependence/one-person physical assist with toilet use; R4 is always incontinent of urine and stool. 10.21.2023 at 11:06 AM, with V4 (CNA-Certified Nursing Assistant), R4 was observed awake and alert, sitting up in bed. R4 said she was changed once on the night shift but was currently wet. Surveyor observed a blue brief with flaps removed) inside R4's outer brief. R4's blue brief was saturated with urine, the back of R4's yellow brief was saturated with urine. The line down the front of R4's brief had not changed color. A folded bath blanket and an incontinent pad were observed under R4. The bath blanket was wet with dark urine; dark rings were noted on the bath blanket, incontinent pad, and fitted sheet.

Based on observation, interview and record review the facility failed to follow abuse policy as follows: Preventing a resident (R2) with cognitive impairment from entering another resident's room without her (R1's) consent and supervision. Resident (R1) has physical limitations and was unable to avoid physical contact. Failures involved 2 out of 3 residents (R1 and R2) for a total of 3 residents reviewed for abuse. These failures resulted to R1 experiencing fear and was placed in a threatening environment. R1 called for help, no staff came to assist before R2 was bitten and pushed off the bed by R1. Findings include: Facility abuse policy not dated in part reads: Policy Statement: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse it the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Willful means the individual mush have acted deliberately, not that he / she must have intended to inflict injury or harm. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment such as: pushing, slapping, hitting, shoving, shaking, striking with or without object. Mental abuse is an emotional or psychological abuse. The verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering. On 6/16/2022 at 9:51 AM V2 (Licensed Practical Nurse) stated that R2 was with a nursing assistant performing bedside care. V2 stated that R2 uses a wheelchair because he needs extensive assistance with transfers and ambulation. R2 can answer questions but often times is confused. V2 further stated that R2 only ambulates with a walker if accompanied by a therapist. V3 (Registered Nurse) stated that R1 does not ambulate on her own, R1 uses a wheelchair. R1 is alert and oriented times 3 and cognition is intact. On 6/16/2022 at 10:05 AM R1 was seen sitting in her wheelchair, R1 was alert and able to express her thoughts well. R1 was asked about the incident that happened related to R2. R1 said, It was breakfast around 7:30 AM, nobody came to see me or get me up that day. I always want to sit up when eating breakfast. I don't believe in breakfast in bed. Around quarter to eight, I used my bell (pointing to a metal bell on the edge of the bed) to call but nobody came. Around 8:15 AM, I was informed that someone will bring breakfast but never came. So, I settled back to bed and fell asleep. I can't stand, I can't walk so I just slept. When I woke up, I saw R2 at the foot of the bed. I told him (R2) to get out because this is my room. R2 told me that this was his room too. I am fully awake now and yelled at him because he moved closer to me. I called for help and used the bell, [NAME]! [NAME]! [NAME]! He (R2) leaned with his chest on my face so that I could not breathe. I was able to push him with his back facing me. I think I bit him (R2) twice. He (R2) said, Aw! Then he kind of sat up on the edge of the bed. So, I pushed him, and he fell on the floor. Meantime, I was still yelling but nobody came. It was V4 (Maintenance) who first saw us. Stuff on my tray was knocked off onto the floor. R2 was moving up and down the hall with his wheelchair mostly asking for food. Just yesterday, I saw him going inside two rooms of other residents. R2 is confused. I was really scared and afraid. If only somebody on the staff would have been there, these things would not have happened. R1 stated, I bit him (R2) on the upper back. R1 was seen very tense and often upset during the interview. On 6/16/2022 at 10:27 AM. R2 was in the hallway fronting the Nurse's Station sitting in a wheelchair. V2 was requested to bring R2 to his room. R2 knows the place but cannot tell the name of V2 or the date as of today. R2 said, I walk but need somebody to help me. I don't know R1 or anything about R1. On 6/16/2022 at 10:45 AM. V1 (Administrator) stated that I believe that what R1 was saying was true, that R2 went inside R1's room. But I don't think R2 knows what he was doing. We don't document incidents on the progress notes, but I have an incident report. V1 then presented an incident report document dated 5/8/2022. V1 was asked about the timeliness of reporting incident to State Agency since it was reported on 5/9/2022. V1 said, I did not know it until 5/9/2022. At 12:45 PM, V1 was informed that per V4's statement, R1 informed him (V4) that she hit and bit R2. V1 was asked if V4 should have informed him or his designee. V1 did not answer but said, I know you have concern about timely reporting of abuse. R1's full care plan was presented by V1 after request. Care plan was then reviewed with V1. V1 was asked why abuse was not included on R1's care plan. Then V1 called V9 (Minimum Data Set/MDS Coordinator) that later presented R1's abuse care plan. V1 was then asked about the incident on 5/8/2022, when R2 went into R1's room without her consent and was unsupervised. V1 said, I am not blaming R1 for the incident. I know it was wrong. And again, as I said, I believe R1 was telling the truth. On 6/16/2022 at 12:20 PM. V9 (Minimum Data Set Coordinator) said that R2 ambulates but with one-person extensive assistance. V9 said, R2 can ambulate but needs a walker. Like 10 feet ambulation, R2 needs extensive assistance. V10 (Restorative Nurse) said, I don't think R2 can ambulate by himself without falling. On 6/16/2022 at 12:36 PM. V4 (Maintenance Assistant) said, When I was passing by the hallway, I heard someone shouting, help! When I went into R1's room I saw R2 on the floor. R1 was screaming I hit him and bit him. I know it was Sunday. I reported it to V5 (Director of Nursing). I was not given abuse training. But I know abuse is when someone is trying to beat someone. Yes, it seems like it will fall within abuse because R1 told me she bit R2. On 6/16/2022 at 1:04 PM. V5 (Director of Nursing) said, It was V6 (Registered Nurse) who was on duty on that floor on 5/8/2022. That was Sunday that R2 fell because he was looking for food. V6 said R2 lost his balance. V6 did not witness it, so I don't know why she did not talk to R1 and know what really happened. I know if she (V6) just talked to R1, R1 would have told her about R2. As you can see R1 is very oriented and can tell you clearly her thoughts. V4 did not inform me until 5/9/2022 (Monday) about the incident between R1 and R2. Then R1 told me that R2 came inside her room. She (R1) was feeling suffocated when R2 fell on her face, so she bit him (R2). V4 also stated that R2 was on top of her (R1). R1 also told V3 (Registered Nurse) that he (R2) climbed up on to her (R1's) bed. On 6/17/2022 at 8:47 AM. V6 (Registered Nurse) said, I was working that Sunday when the incident happened between R1 and R2. I guess R2 wandered in her (R1's) room. All the stuff on the table was scattered on the floor. R1 was so upset. I called V5 (Director of Nursing) but I cannot remember giving to her a written statement or giving a statement on 5/9/2022 at 11:03 AM because I was not working in that facility at that time. I also do not remember R2 saying that he wants to go to the hospital. I cannot remember R1 telling me that R2 was on her bed, and I did not witness the whole incident. I don't remember if R2 was already on the floor or slid onto the floor. But I know I did not witness it. Oh yes, now I remember. R1 was very upset and told me that R2 was trying to get into her bed. There were other staff that went inside R1's room before me. I cannot remember if V4 (Maintenance) came in before me. V6 was informed about V6's statement related to what R1 told V4. V4 said, I think I remember now, R1 said R2 was trying to get into her (R1's) bed. If that happened to me, waking up with a man inside my room I would be petrified and scared, not being able to move away from that man. On 6/17/2022 at 9:35 AM. V8 (Certified Nursing Assistant) said, I was working on 5/8/2022 passing out trays. Then I was informed to help out R3 because that day she also had a fall. While helping R3, a nurse told me to also help R2. I cannot remember her name (the nurse), but R2 was already on the floor when I came in to R1's room. R1 was very scared. R1 was saying that she (R1) was frightened by him (R2). I know R2 can walk but is very unsteady. I think that was possible for R2 to walk after R1 pushed him out of the bed. That makes sense, if R1 pushed him out of the bed. Then it is but natural for R2 to be moving himself away from R1. If I put myself in R1's situation, I would have been very frightened and scared. I understand that for the residents, their room is their home. I did not see her after the incident. But any female will feel traumatized if male stranger goes inside their room without consent. R1 is [AGE] years old, initially admitted on [DATE] in the facility. R1's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's brief interview for mental status (BIMS) score dated 4/1/2022 was 15. That means R1 has full cognition or intact cognition. R1's functional status assessment dated [DATE] documents the following: R1 needs one-person extensive assistance on bed mobility or how resident moves to and from lying position, turns from side to side, and positions body while in bed. R1 needs one-person extensive assistance on transfers or how resident moves between surfaces including to or from: bed, chair, wheelchair. R1 was not ambulatory and uses wheelchair for mobility devise. No incident report related to R1 was provided by facility. R2 is [AGE] years old, initially admitted on [DATE] in the facility. R2's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's brief interview for mental status (BIMS) score dated 3/31/2022 was 8. That means R2 has moderate cognitive impairment. R2 needs one-person extensive assistance on bed mobility or how resident moves to and from lying position, turns from side to side, and positions body while in bed. R2 needs one-person extensive assistance on transfers or how resident moves between surfaces including to or from: bed, chair, wheelchair. R2 walks in his room or corridor two or fewer times on the period of review. Balance not steady, only stabilize with staff assistance. R2 uses wheelchair for mobility devise. R2's care plan dated 5/8/2022 documents that R2 was reported to have entered a female resident's room in the middle of the night and laid in bed. Female resident in the said room was still asleep. R2's incident report by V5 (Director of Nursing) documents that R2 was inside R1's room on the floor. R2 was asking for food and was also asking to be taken to the hospital.

Based on observation, interviews and record review the facility failed to follow their pressure injury policy in relation to performing treatment as ordered by physician, documentation on treatment administration record (TAR), and failed to assess newly identified skin opening areas for 2 out of 2 residents (R10 and R71) reviewed for pressure injuries prevention and treatment. These facility failures resulted in R10's facility acquired sacral pressure ulcer reopening and increased from stage 2 to stage 3 and lack of assessment of R71's newly identified skin opening. Findings include: On 05/10/2022 at 12:40 PM, R10 was seen in her room alert and verbally responsive. R10 was able to express her thoughts well during conversation. R10 said that she has wound on her back and that the wound had been there for quite some time. On 05/12/2022 at 12:01 PM, V13 (Wound Nurse Coordinator / Registered Nurse) stated that she started in March 2022 and was trying to keep updated of all the resident wounds in the facility. V13 stated that R10 has 2 pressure injury sites: Left lower leg and sacrum. Both are stage 3 and the dressing treatment was changed on 5/11/2022 from Santyl to Calcium Alginate with Silver. V13 said that V24 (Nurse Practitioner/ Wound) came to see R10 on 5/9/2022. V13 could not answer why the wound assessment done by V24 dated 5/9/2022 the treatment performed and recommended by V24 was Santyl for 30 days. V13 was asked about R10's Treatment Administration Record (TAR) related to multiple treatment orders that was not documented as being performed on multiple dates. V13 was not able to address the question. V2 then stated that R10's sacral pressure wound started with an abrasion and later increased to stage 3. Both V13 and V2 (Director of Nursing) said that if a treatment was not documented it was not performed. V13 stated that pressure injury/wound treatment and dressing changes must be followed to facilitate healing. V13 further stated that lack of following treatment orders will lead to pressure injuries not healing. On 05/12/2022 at 3:13 PM, R10's sacral pressure injury was observed with V2 (Director of Nursing), the approximate size measured 3 X 2 X 1.0 centimeters (Length X Height X Depth) which fits the description of a Stage 3 pressure injury. Fatty tissue can be seen and slough about 5% at the center of the wound. V2 said, Yes, I agree this is stage 3. The left lower leg pressure injury was observed with slough at the center of the area. Per facility assessment dated [DATE], R10's facility acquired sacral pressure injury was first identified on that same date. R10's sacral pressure injury was staged as 2 (which defines as breaking of the skin top layer) with measurement of 1.8 X 1.0 X 0.1 centimeters with serous drainage. Based on the (TAR) for March 2022, R10 has the following orders to apply [MEDICATION(S)] sheet dressing 3 times per week, and as needed after cleansing with normal saline one time a day for coccyx wound. Treatment Administration Record (TAR) documents that on 3/2, 3/3, 3/7, 3/8, 3/15, 3/16, & 3/17/22 (3/17/22 the day sacral pressure injury reopened and was first identified), 3/23 & 3/25/22 treatments was not documented as completed. Per facility assessment dated [DATE], R10's sacral pressure injury increased from stage 2 to stage 3 with increase in measurement of 2.0 X 1.5 X 0.1, serous drainage, 75% yellow slough. For the month of April 2022, the same treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment order was discontinued on April 8, 2022, after R10 was seen by V24 on 4/7/2022. The treatment order was changed to [MEDICATION(S)] dressing from 4/9 to 4/20/22. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 15th to the 20th [MEDICATION(S)] Antibiotic ointment was added as an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 21st to the 27th the treatment order was changed to Santyl Ointment and was not documented as being done for 4/22, 4/26, & 4/27/22. Multiple dates on both the March and April 2022 TAR were not documented as being performed. The most current wound assessment by V24, dated 5/9/2022: Stage 3, size 3.3 X 3 X 0.5 centimeters an increase in size and staging. 5/13/2022 at 9:38 AM. V24 (Nurse Practitioner/Wound) stated that R10 has two pressure injury sites on the sacral area and left lower leg. Per treatment records there are multiple orders for treatment and must be performed as ordered. V24 said, When the treatment is not performed as ordered, the pressure ulcer will be become worse, and infection will happen. V24 said that the first time he saw R10's sacral pressure injury was on 4/7/2022. When V24 comes and assesses R10, V24 performs treatment and dressing change. V24 said, R10 sometimes does not want to be turned at the beginning of the dressing change. In my experience once you explain to her and do health teaching, R10 allows you to do treatments. Yes, during all my visits the treatment was performed to R10. V24 further said, Infection can set in because of the proximity of R10's sacral pressure injury with her anus (rectum) that is why I ordered [MEDICATION(S)] antibiotic ointment. They need to resolve this issue of treatment not being performed as documented. Because if not documented it was not performed. R71 was [AGE] years old, admitted to hospice with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/10/2022 at 12:38 PM. R71 was lying on a low air loss mattress with multiple sheets. R71 was alert and verbally responsive. R71 seemed uncomfortable turning her head from side to side. On 05/11/2022 at 1:26 PM. With V13 (Wound Nurse Coordinator / Registered Nurse) assisted by V16 (Registered Nurse) performing treatment or dressing change to R71. R71 has 2 wound sites: Sacral and left dorsal foot. During dressing change of the mid-sacral area pressure injury, another site was identified approximately 2 centimeters lower left from the mid-sacral pressure injury. The newly identified opening was reddened and open superficially to the skin with small bleeding. V13 was asked if the opening was new or if it was there prior. V13 stated that it was not there before. V13 then covered both areas with the same dressing. During the dressing change R71 was screaming repeatedly, Water! Water! I need water. There was no pitcher, no glass or cup available in the room. V13 stated that she will bring R71 water after dressing change. Then R71 started grimacing and again turning her head from side to side. R71 said repeatedly, It hurts, don't be rough even when V13 was not or barely touching R71. V13 told R71 that she will give R71 pain medication after the treatment. After the treatment was completed V13 went to R10's room for another Treatment scheduled at 2:00 PM. V16 went back to the Nurse's Station and sat in the chair. None of the staff gave R71 water as requested. On 05/12/2022 at 12:01 PM, with V13 (Wound Nurse Coordinator / Registered Nurse) and V2 (Director of Nursing). V13 stated that she did not assess that newly identified opening near R71's sacral pressure injury. V13 was asked the reason why an assessment was not completed upon identification of wound, no information was given. V13 stated that she will assess it today. R71's Facility Wound assessment dated [DATE] notes the sacral pressure injury was first identified in the facility on that same date. Measurement 3 X 2.5 X 0.1 centimeters. Assessments dated 4/28/2022 and 5/6/2022 documents that R71 was in pain during assessment. The care plan for pain with target date 7/7/2022 documents: Administer analgesia (Tylenol / [MEDICATION(S)]) as per orders. Give 30 minutes before treatment or care. R71's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Facility policy on Pressure Ulcer Treatment and Management not dated. Reads in part: Objective is for residents who receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy on Wound Cleansing not dated. Reads in part: It is the policy of this facility to cleanse all wounds in order to clear exudates, bacteria contamination, and debris from the wound bed. This process is done since optimal healing cannot proceed until the inflammation-producing substances are removed from the wound surface. Wound cleansing will be done as indicated in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility policy on Pressure Ulcer Risk Assessment Policy and Procedure not dated. Reads in part: It is the policy of this facility to assess all residents for additional factors that place them at risk for developing pressure ulcers.

Based on interview and record review facility's pharmacy did not follow the terms of the Pharmacy Services Agreement Contract by not rendering services safely to one resident (R1) out of three residents reviewed for intravenous care. This failure resulted in R1 sustaining Upper Bilateral Humeral Fractures during the insertion of a PICC line (peripherally inserted central catheter) by the subcontractor. Findings Include: R1' medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Communication - with Family/NOK (next of kin)/POA (Power of Attorney) Text dated 1/21/2022 18:15 (6:15pm) states: Spoke with POA and informed about Doctor order for [MEDICATION(S)] (antibiotic) and that resident will need a PICC line. POA Agreed and gave consent for the PICC line. R1's Health Status Note Text dated 1/21/2022 at 17:45 (5:45pm) states: Spoke with Doctor and he ordered to start [MEDICATION(S)] 500mg IVAB (Intravenous antibiotic) every 8hrs x 2weeks. Contacted Vascular for PICC line insertion. R1's vascular access treatment form dated 1/21/22 at 21:50 (9:50pm) denotes three attempts. Right basilic vein, catheter size 4 lumen 1 used. R1's Health Status Note Text dated 1/25/2022 5:52am states: Resident is on bolus feeding connected to G-tube, patent and feeding tolerated well. With scheduled IV ABT [MEDICATION(S)] 500mg every 8 hours via PICC line infusing well, no adverse reaction noted during and after med. administration. Wound dressing with tx (treatment) done. Kept cleaned (sic) and dry. R1's vascular access company dated 1/27/22 denotes swelling at arm with PICC line, arm measured 31cm, placement checked line in correct position, recommend doppler to rule out DVT (deep vein [CONDITION(S)]). R1's Health Status Note Text dated 1/27/2022 at 17:00 (5pm) states: Received resident in bed alert and awake. Not in any form of respiratory distress. Vitals as follows: BP 124/8, temp 98.7, PR 105, RR 18, O2 sat 94% at room air. Writer noted resident's right arm where the PICC line site is swollen. Notified DON and supervisor. Supervisor came to check. Notified, resident's niece. Vascular access notified and said that there is no available IV nurse at the moment, unable to tell when the nurse can come. Notified MD and said will talk to, resident's niece. MD called back with order to send resident to hospital. Called ambulance and per ambulance will be available to pick up resident at 5PM. Report given to Hospital ER nurse. Niece notified the pickup time. At 3:10PM IV nurse came and checked the PICC line site and said that the PICC line is in place but there is DVT noted. At 5PM resident was picked up by ambulance per stretcher. R1's Health Status Note Text dated 1/27/2022 20:20 states: Spoke with Hospital ER nurse and inquired about resident's status and per nurse resident has 2 fractures -Upper Bilateral Humeral Fractures. R1's hospital radiology report dated 1/27/22 denotes lateral x-ray right humerus. Findings minimally displaced fracture through the right femoral neck (right upper arm fracture). Impression proximal right humeral fracture. R1's x-ray left humerus denotes minimally displaced fracture through the left humeral neck. Impression: Proximal humeral fracture (left upper arm fracture). V18 (Medical Director) stated on 2/4/22 at 12:00 pm that the older you get the [CONDITION(S)] response takes longer to come up. V18 stated that it is common with older residents that it took a few days for the swelling to appear. V18 stated depending on the side that R1 favored or laid on, the overall swelling would be more and/or less. V18 stated the area that was fractured in R1's case is under the shoulder, which is called the Proximal area. V18 stated in a contracted resident like R1 if you pull the arms away from the body it can cause a break in proximal area. V8 (Doctor) stated on 1/28/22 at 2:30 pm R1 and R3 have been under his care for a while. V8 stated if the x-ray from the hospital showed displaced fracture it means that some type of force was applied that would cause a break. According to the hospital x-ray R1 had displaced fracture to her left and right humeral neck. V8 stated if forced movement is done on a contracted extremity, it can cause a fracture, and in his medical opinion the fractures were unintentional. V8 stated R3 is alert, credible, and can remember things and tell the history of an event. R3 stated on 1/28/22 at 2:00 pm that she (R3) was awake and resting in her bed which is next to her daughters (R1's) bed when V2 (Vascular Registered Nurse) came into their room. R3 stated V2 was making her nervous because she kept going back and forth around R1's bed looking at R1's arms. R3 stated it took V2 about 1 ½ hours to get the IV in her daughters' (R1) arm. R3 stated she spoke to V2 before V2 left the room and V2 told her that she had trouble getting the IV in R1's arm but was able to get it. V6 (Certified Nurse Aide) stated on 1/28/22 at 11:40 am that he works with R1 often and R1 needs an adult diaper change a couple of times and would slowly turn. V6 stated R1 does not resist care and since her hands and arms are contracted, she does not move. V6 was working on the pm shift on 1/21/22 and at that time R1 and R3 were in their room. V6 stated R3 is R1's mother and always on the lookout to make sure R1 is getting taken care of. V6 stated V6 saw when V2 went into their (R1, R3's) room and remembered that she was there a long time, over an hour. V3 (Vascular Lab Owner) stated on 1/28/22 at 10:45am when a facility requests an PICC line insertion they confirm the orders. V3 stated it is not necessary to view both arms because they prefer the right arm. V3 stated the only reason to look at the left arm is if you're looking for a better vein for access. If the right arm shows good access there is no reason to go back and forth to the other side of the person's body unless you're looking at the other arm to find a vein. V3 stated the arm needs to be positioned so they can see the bottom part of the arm near the elbow during line placement. V3 stated ideally would like the resident to extend the arm but if the resident is contracted, they can't. V3 stated they assess the arm with ultrasound and once they find a good vein they proceed. If no problems occur it would take about 45 minutes to an hour to establish a PICC line. V2 (Vascular Registered Nurse) stated on 1/28/22 at 10:15 am she's been doing PICC (peripherally inserted central catheter) for one year. V2 stated before starting a PICC line it requires a doctor's order, face sheet and consent. V2 stated she got to the facility last week and R1's primary nurse gave her R1's face sheet, the order, and a consent. V2 stated she reviews the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated when she went into R1's room and observed that R1 was very contracted. V2 stated they like to use the right arm because it has better access to the central veins. V2 stated she pulled R1's arm out slowly away from her body at about 45 degrees to get the ultrasound probe on the arm. V2 placed the probe on R1's upper right arm and was able to see the image of R1's vein. V2 stated once she located a good vein, inserted the needle with a guide wire but had to keep R1's arm at 45-degree angle while inserting the PICC because the vein has to be straight so the PICC can go in correctly. V2 stated once the PICC line was inserted, required to aspirate for blood return, and then attaches the (name of machine, used to visualize line placement) machine to the shoulder and underneath the breast that tells her that the PICC line is in the correct vein, the superior vena cava (large vein that returns blood to the top right of the heart). V2 stated she did not move/touch R1's other (left) arm while she was there. V2 stated there was no one else in R1's room when she placed the PICC line, and after she finished R1 went to sleep. V2 stated she had no trouble putting the PICC line in R1's arm and did not go on the other side of R1's bed to look at her left arm. V11 (Licensed Practical Nurse) stated on 2/1/22 at 1:15pm that she was assigned to R1 when V2 came to the facility to insert the PICC line. V11 stated R1s' roommate (R3) was in the room when V2 was there. V11 did think that V2 was in R1's room a long time and even asked an aide to go check to see if V2 was still there. V11 stated V2 finally came out of R1's room and mentioned that the PICC line was in and could be used. V11 stated she did not have to touch R1's arms because the order to start antibiotics was not until the next shift. V11 mainly provided R1 with gastric tube care and proper repositioning. V5 (Registered Nurse) stated on 1/28/22 at 11:20 am that she been a nurse for ten years and took care of R1 while she was at the facility. V5 stated R1 was transferred to her side on Sunday (1/23). V5 stated on Wednesday she took care of R1 and used the PICC line to give her antibiotics and did not have to move her arm to connect the IV tubing to the porta cath. V5 stated she did not have to move R1's left arm at all during her care. V5 worked 7am-7pm on Thursday (1/27) and when about to give R1's antibiotic noticed that R1's right arm was swollen. V5 stated called DON (Director of Nursing) and the supervisor (V7) who came in to check R1's arms. V5 stated she called the doctor and that he would call her back. V5 stated called the vascular contractor to come and they came out that afternoon. V5 stated the vascular nurse came and checked the patency of the PICC line. V5 stated the vascular nurse told her that the site was patent but that it might be a DVT. V5 stated she called the doctor back and the doctor ordered R1 to be sent to the hospital to be evaluated. V7 (Registered Nurse Supervisor) stated on 1/28/22 at 12:00 pm that V5 informed her that R1's right arm was swollen. V7 went to R1's room, assessed R1's right arm and noticed that right arm was swollen. V7 tried to move R1's arm to observe site, but R1 grimaced in pain. V7 looked at R1's left arm to compare them and noticed that R1 had some discoloration inside the upper aspects of her left bicep. V7 stated she noticed a small needle prick inside the discoloration part of R1's left arm. V7 stated from her experience it looked like someone had tried to start an IV on R1's left arm but was unsuccessful. V14 (Director of Nursing) on 2/1/22 at 2:15 pm, stated she been an Registered Nurse for over twenty years. V14 stated V5 told her about R1's arm swelling and received a call from R1's family member to check on R1's arms. V14 went to R1's room and looked at the right arm at the PICC line site and noticed that it was red and swollen. V14 stated she then assessed R1's left arm and saw some discoloration and a needle prick inside the area of discoloration on R1's left arm. V14 stated she was puzzled because it looked like someone tried to start an IV in R1's left arm. V14 stated she convinced R1's family member to send R1 to the hospital because thought they should rule-out a Deep Vein [CONDITION(S)] (DVT) or [CONDITION(S)]. V1 (Administrator) stated on 1/28/22 at 10:00 am that he was told by nursing that R1 had a PICC line for antibiotic infusion, and staff noted that R1's arm was swollen. V1 stated the vascular company came to the facility last week to insert the PICC line. V1 stated from talking to V14 and V7 he was made aware that vascular tried to put the PICC line in both arms but was only successful with the right arm. V1 stated R1's arm is contracted and the vascular nurse probably moved R1's contracted arms to far to put the PICC line in. V1 stated they are cancelling their contract with the lab company. Facility's Pharmacy Service Agreement denotes Pharmacy shall provide the services set forth in this Agreement to Client and persons in care of the Customer (the Residents or Patients) in accordance with the terms and conditions of this Agreement, and any Schedules, 2. Obligations of the pharmacy A. Pharmacy shall provide to Client and deliver to the Customer prescription and non-prescription drugs, biologicals, and intravenous solutions, supplies and equipment (the Products or Medications), and Services as set forth in this Agreement, in accordance with the orders of the Residents' licensed prescribers as provided to Pharmacy by Customer, and Customer's own orders. I. Select and prepare [MEDICATION(S)] Products, as appropriate, and maintain IV administration Products for IV drug therapy. Section E. Subcontract. Pharmacy has the right to subcontract its duties hereunder, however, Pharmacy will remain liable for all performance under this Agreement. Therapy/Service peripheral, midline and PICC IV insertions and clinical support. This contract automatically renews successive on 1/31/21 for one year unless otherwise terminated.

Based on interviews and record review, the facility failed to timely send a resident out for evaluation and treatment of [REDACTED]. This failure resulted in R4 remaining in the facility for eight days with a dislocated hip joint before reduction treatment was provided in the hospital. Findings include: R4's [DIAGNOSES REDACTED]. On 9/16/2020 at 10:39 am, V23 (LPN) stated that on 2/19/2020, she called V37 (POA) to remind her about R4's orthopedic appointment on 2/20/2020 at 12:05 pm. V23 stated that V37 wanted to cancel the appointment. V23 stated that she then notified V10 (NP) that V37 needed to cancel R4's orthopedic appointment, and V10 ordered for an X-ray of R4's right hip. V23 added that if a family member or POA cannot come with a resident to a medical appointment, then the facility will offer an escort to accompany the resident. V23 could not recall if she offered V37 an escort for R4's orthopedic appointment. On 9/15/2020 at 9:33 am, V15 (Scheduler) stated that if there's no family member available to go with a resident to a medical appointment, the nurse will call her to set up an escort. Facility document, titled Escort for Patients/Residents and dated February 2020, documents, in part, that V37 (POA) is R4's escort for the 2/20/2020 orthopedic appointment with V21 (Orthopedic Surgeon). R4's portable X-ray results of right hip from 2/19/2020 at 8:56 pm, document, in part, Acute posterior dislocation of femoral head prosthesis with inward rotation of femur. On 9/17/2020 at 6:31 am, V19 (RN) stated that when she received R4's first right hip X-ray result on 2/20/2020 at 12:45 am, she called V17 (NP) with the results, and V17 replied that she wanted R4 to attend his orthopedic appointment scheduled on 2/20/2020 and to inform V10 (NP) of this right hip X-ray result for R4. V19 stated that V17 did not give an order at this time to transfer R4 to the hospital for the right hip dislocation. Furthermore, V19 stated that on 2/20/2020 at 4:32 am, when R4's right femur and lumbar spine X-ray results came in, she called V27 (Former Employee, NP) and read him the results. V19 stated that she informed him that she had already communicated to V17 the results of R4's first right hip X-ray and that she had ordered for R4 to attend the orthopedic appointment scheduled on 2/20/2020 and that V19 would be notifying V10 of R4's X-ray results in the morning. V19 stated that V27 did not give an order at this time to transfer R4 to the hospital for the right hip dislocation. V19 continued to state that on 2/20/2020 at 6:45 am, she called V10 (NP) and relayed R4's right hip X-ray results to her, and that V10 ordered for R4 to go to the scheduled orthopedic appointment on 2/20/20 and for V19 to call V37 (POA) to inform her of this order. V19 stated that she phoned V37 and left this new order from V10 on V37's voicemail. V19 stated that V10 did not give an order at this time to transfer R4 to the hospital for the right hip dislocation. On 2/20/2020 at 8:00 am, V36 (RN) documented, in part, that V37 (POA) wanted to reschedule V4's orthopedic appointment due to being sick. On 2/20/2020 at 10:00 am, V36 documented, in part, that R4's rescheduled orthopedic appointment was made for 2/27/2020 at 12:05 pm, and V37 and V10 (NP) were made aware of the new orthopedic appointment date. On 9/17/2020 at 6:31 am, V19 (RN) stated that she on 2/20/2020 at 7:45 pm, she witnessed R4 standing up from R4's wheelchair and fell to the floor. V19 stated that she immediately went to R4 while calling of help and then assessed R4. She stated that R4 complained of right hip pain and upon checking for range of motion, R4 had limited movement of the right leg. V19 stated, I didn't force the movement. (R4) had limited movement because of pain. V19 stated that she informed V27 (Former Employee, NP) of R4's fall and complaints of right hip pain, and he gave orders for X-rays of R4's right hip, femur and spine. V19 stated that on 2/21/2020 at 3:00 am, when she faxed R4's X-ray results to V27, she spoke to V27, and that he concluded that R4's new X-ray results from 2/20/2020, when compared to the previous X-ray results from 2/19/2020, were almost the same and ordered to send both sets of R4's hip X-rays results with R4 to the orthopedic appointment scheduled on 2/27/2020. V19 stated that V27 did not give an order at this time to transfer R4 to the hospital for the right hip dislocation. R4's portable X-ray results of right hip from 2/20/2020 and reported on 2/21/2020 at 12:04 am, document, in part, Examination reveals total right hip replacement prosthesis with subluxation of the metallic head prosthesis outside confines of the metallic acetabular prosthesis. On 9/17/2020 at 6:31 am, V19 (RN) stated that on 2/21/2020, she notified V37 (POA) of R4's X-ray results and said that V37 stated that she would be able to transport R4 to the 2/27/2020 orthopedic appointment. On 9/14/2020 at 11:23 am, V8 (LPN) stated that on 2/21/2020, she set up transportation with a non-emergency transportation provider company for R4 to go to the 2/27/2020 orthopedic appointment at 12:05 pm. On 2/14/2020 at 1:19 pm, V10 (NP) was shown R4's right hip and femur X-ray results that were performed on 2/19/2020 and 2/20/2020, and V10 stated, Oh my God, (R4) should have been sent out. V10 stated that R4 should have been sent out to the hospital with a dislocated hip. V10 stated that she cannot manually adjust a dislocated hip joint and that this treatment has to be done in the hospital. On 9/16/2020 at 10:39 am, V23 (LPN) stated that on 2/24/2020, V23 (LPN) stated that she received a new order from V10 (NP) for scheduled [MEDICATION NAME] twice a day for R4's right hip pain. V23 stated that due to R4's dementia, R4 wouldn't complain of any pain and would not request any pain medication. V23 stated that [MEDICATION NAME] was ordered twice a day for R4 for right hip pain relief coverage. On 2/24/2020 at 4:43 pm, V10 (NP) documented, in part, that R4 was examined, complained of right hip pain with a history of a recent fall with right hip dislocation and not taking any whenever (PRN). R4's Order Summary Report, with an order date of 2/25/2020, documents, in part, [MEDICATION NAME] 325 mg, Give 2 tablets by mouth every 12 hours for right hip pain. On 9/15/2020 at 4:16 pm, V21 (Orthopedic Surgeon) stated that he has seen R4 on several occasions for he met R4 for the first time during R4's orthopedic office visit on 2/27/2020. V21 stated that he immediately could see that R4's right leg was contracted. V21 said that he immediately performed an X-ray in his office which showed that R4's right hip was dislocated. V21 stated that he attempted to pop it back in, but that R4 was already in pain and that it's difficult to do without sedation. V21 stated that when he asked R4 how long R4's right hip has been like this, R4 said that R4 had no idea. V21 stated that he sent R4 emergently to the nearest hospital emergency room to reduce and relocate R4's right hip joint. After this surveyor read V21 (Orthopedic Surgeon) the right hip and femur X-ray results for R4 that were taken in the facility on 2/19/2020 and 2/20/2020, V21 stated that R4's confirmed right hip dislocation on 2/19/2020 needed to be evaluated and treated in a hospital emergency room . On 9/15/2020 at 4:16 pm, V21 stated that R4 suffered harm caused by the facility's delay to send out R4 for treatment at a hospital for eight days, from 2/19/2020 to 2/27/2020. V21 stated, With the nature of R4's hip being out for over a week, it makes it difficult to put back in, harder to keep it in the socket and increased R4's chances of future dislocations. V21 said that artificial parts don't get damaged with a dislocation, but that it is R4's soft tissues surrounding the hip joint that get damaged the longer it stays dislocated. Lastly, V21 added that since R4 has dementia and can't always make needs known to staff, R4 must have experienced right hip pain during the facility's delay in sending R4 out to the hospital. R4's Order Summary Report, with an order date of 3/6/2020, documents, in part, If (R4) dislocates hip, call 911 and go to hospital by ambulance. R4's emergency department hospital records on 3/11/2020 to 3/12/2020 revealed that R4 had another dislocated right hip and received intravenous sedation to reduce and set R4's right hip joint.

Based on observation, interview, and record review the facility failed to: assess and manage pain, medicate a resident for pain before wound care treatment, and ensure that a resident did not experience pain during wound care treatment according to facility policy for pain management. This deficient practice affected 2 residents (R2, R6) out of 11 residents (R1 thru R11) reviewed for pain in a sample of 18. Findings include: R6's Profile Face Sheet documents a readmission date of [DATE]. The following medical [DIAGNOSES REDACTED]. On 7/24/17, the facility submitted a pressure sore list that indicated R6 was admitted to the facility with a Stage 2 sacral pressure sore. R6's Skin Evaluation Form dated 7/21/17 documents a Stage 2 coccyx pressure sore which measured 1.0 centimeter in length, 1.1 centimeter width and 0.01 centimeter depth. R6's Physician order [REDACTED]. R6's initial pain evaluation documents that R6 has chronic intermittent pain in R6's legs. This form also documents that possible indicators of R6's pain are as follows: Nonverbal sounds-crying, whining, gasping, moaning and groaning) and Vocal complaints of pain (that hurts, ouch, stop). R6's Medication Administration Record [REDACTED]. E12 (RN-Registered Nurse) indicated that the pain pill was initially given in preparation for R6's wound treatment but physical therapy came to work with R6. R6's MAR indicated [REDACTED]. On 7/25/17 at 2:45pm, E12 stated, I gave (R6) one tablet of [MEDICATION NAME] at 12:30pm. I'm not so sure if it wore off. E12 proceeded to explain the wound care procedure to R6. E12 did not ask R6 if R6 was in any pain. E12 and E22 (CNA-Certified Nurse Assistant) turned R6 onto R6's right side. It was visible that R6 was experiencing discomfort with the position change. E22 stated, I'm sorry. E12 started to peel off the adhesive dressing that covered R6's coccyx wound. R6 stated, Ouch. Oh my god, ouch. E12 apologized and continued to slowly remove the dressing while R6 continued to be verbal about the pain. E22 rubbed R6's left arm in an attempt to comfort R6. As E12 continued to peel back the dressing, E22 encouraged R6 to, Hang in there. R6 started to moan and cry. E12 stated, I'm sorry. I wish I could hurry. R6 stated, It hurts so much. E12 apologized again. As E12 cleansed R6's pressure sore with normal saline, R6's body tensed up as she audibly groaned. When E12 applied the hydrogel to the wound, R6 covered R6's mouth with R6's left hand and started to cry. E12 asked E22 how R6 was. E22 stated, She's hurting to which E12 responded, Almost done. R6's initial MDS (Minimum Data Set) dated 6/27/17 documents a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicates that R6 is cognitively intact. On 7/25/17 at 3:10pm, R6 stated, Usually, it hurts that much (when they do the dressing). Right now pain is 7-8. During the procedure, it was 9. Hurt most when she pulled dressing off. But also hurt a lot when they were cleaning the wound. That's why I hate having it changed. For that reason. On 7/25/27 at 3:35pm, E12 stated, I usually do the wound care for (R6). She went to the hospital with Stage 1in sacrum. Came back with Stage 2. Gave [MEDICATION NAME] at 12:30pm. Should have stopped the treatment and addressed her pain. Provide comfort measures or offer more pain medications. E12's Interdisciplinary Note dated 7/25/17 denotes that R6 complained of pain during wound care treatment despite administration of pain medication. R6's Care Plan regarding pressure ulcers documents, in part: Approach: Give PRN (as needed) pain medication prior to dressing change. A Care Plan addressing Comfort/Pain reads, in part: Approach: Administer PRN and scheduled pain medication as ordered. Evaluation: Will monitor and inform MD (Medical Doctor)/NP (Nurse Practitioner) if resident does not express relief with current pain. Approach: Anticipate needs. Administer PRN pain medication before doing wound care. A policy dated 3/25/14 and titled, Pain Management documents, in part: We will achieve these goals through: Recognizing and evaluating the resident for pain to determine causes and characteristics of the pain as well as factors influencing the pain. Recognizing and providing measures to minimize or prevent pain for situations where pain could be anticipated. Monitoring the effects of interventions and modifying the approaches as needed. R2 is an [AGE] year old resident admitted to the facility on [DATE] per facility face sheet dated 7/24/17 and [DIAGNOSES REDACTED]. Physician order [REDACTED]. Care Plan for R2 dated 6/5/17 states in part, Goal: Resident will not develop further pressure sore. Approaches: Assess skin daily during care--if open or bruised areas noted, report to Nurse, MD and responsible party. Evaluation: Resident at times screams during dressing change when being asked if she's ok but is redirectable. Per wound nurse, resident noted with screaming during dressing changes at times but not daily. Staff to monitor for pain during treatments and provide PRN meds if needed prior to procedure. MDS (Minimum Data Set) dated 5/26/17 shows R2 unable to complete the brief interview for mental status indicating cognitive impairment. R2's bed mobility shows that she requires extensive assistance during self performance and actual one person physical assistance. All other activities of daily living show that R2 being total dependence on staff for toileting, eating and transferring. The pain assessment interview section in the same MDS (section J0200) is left blank or scored zero for no pain exhibited by R2 however a care plan presented shows R2 screams during wound care. The CAA (Care Area Assessment) summary of the MDS dated [DATE] states in part, Pain: Resident noted with no complaints of pain at this time, with facial grimace at times but denies pain, with [DIAGNOSES REDACTED]. On 7/25/17 at 8:40AM, during R2's wound care observation performed by E6 (LPN-licensed practical nurse) with the assistance of E9 (c.n.a.- certified nurses aide), the following was noted: E9 removed R2's incontinence brief revealing moist and macerated skin around R2's reddened sacral pressure ulcer. Neither E6 nor E9 asked R2 whether R2 was ok or not. E6 proceeded to cleanse the pressure ulcer with saline solution whereupon, R2 screamed, Ow,ow,ow,ow, ow five times while E6 continued on with the procedure and did not stop. E6 then placed medication cream around the pressure ulcer whereupon R2 recoiled back and grimaced with discomfort. Again, E6 continued on with the treatment without stopping nor asking R2 whether E6 should continue or not. After the procedure, E6 placed an incontinence brief back on R2 and proceeded to place R2 on R2's back but did not inform R2 they were done nor asked how R2 was feeling. E6 was asked whether R2 was given any pain medications before performing the treatment, E6 stated, No, sir. She used to have pain medications when she was on hospice but she doesn't get them anymore. Asked when R2 was discharged from hospice, E6 stated, I think in May. Asked whether R2 gets any pain medications before wound care treatments, E6 responded, No, sir. Asked why E6 didn't stop the procedure when R2 exhibited pain several times during the procedure, E6 stated, Well, she's usually like that, but she's not in pain. Interview with E2 (DON-director of nursing) on 7/25/17 at 10:00 AM states in part, Pain should be assessed every shift and as needed. Staff should provide pharmacological and nonpharmacological ways to alleviate pain. They should ask if they (residents) have pain on a pain rating scale, validate the pain and it's severity that has to be intervened so you can provide the necessary measures. Asked if staff informed E2 about (R2) experiencing pain during R2's wound treatment, E2 remarked, Yes they told me about it. We called the physician and he ordered pain medication for her now. Asked about the facility pain management flow sheets presented, E2 commented it's from 7am to 7pm and form 7pm to 7am the next morning. Facility pain management flow sheets show for 3 months, R2 exhibited no signs or symptoms of pain for 24hours for 3 months. Asked how (R2) with a stage 4 pressure ulcer on her sacral area can show no signs of pain for 3 months or longer, E2 commented, I don't know. Telephone interview on 7/26/17 at 2:30PM with Z2 (Physician) stated in part: Yes I am the physican attending to (R2). I was at the facility yesterday and what was mentioned to me was she was having pain during therapy so I ordered Tylenol. Z2 continued on, I've had her for two months as there was another physician before I took over for her when she was on hospice at the time. So I've just had her recently as my patient. Asked if he was informed of R2's pain during wound care, Z2 stated, I don't recall getting a call about that. I thought it was pertaining to her physical therapy but I may have gotten mixed up. Asked how staff should treat pain experienced by patients based on Z2's expectations, Z2 stated, It should be brought to my attention immediately. Pain should be reported immediately and they should be able to characterize pain a little bit and that would allow me to provide an order or not. Z2 was told that during the wound treatment, R2 was recoiling and screaming. Z2 stated, I was not informed of that specifically but that should be enough for staff to stop what they're doing as yes that would certainly indicate pain. Z2 added, Like I said I'm in the facility often and I will see (R2) when I come in and also confer with the wound care nurse. Review of Treatment Administration Records dated 7/1/17 show orders for dressing changes but no orders to premedicate or assess for pain before, during or after the treatments. Facility policy and procedure dated 3/25/14 titled Pain Management states in part, The intent of this policy is to facilitate resident independence, promote resident comfort and preserve resident dignity through an effective pain management program. We will achieve these goals through: Recognizing and evaluating the resident for pain to determine causes and characteristics of the pain, as well as factors influencing the pain. Developing and implementing interventions for pain management for a resident experiencing pain, consistent with the resident's goals, risks, and current standards of practice. Recognizing and providing measures to minimize or prevent pain for situations where pain could be anticipated. Monitoring the effects of interventions and modifying the approaches as needed. This same policy goes on and states, A standard format for assessing, monitoring, and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. For the purposes of this policy, pain is defined as unpleasant sensory and emotional experience that can be acute, recurrent or persistent. Following are descriptions of several different types of pain: Acute pain is generally pain of abrupt onset and limited duration. Breakthrough pain refers to an episodic increase in pain in someone whose pain is generally being managed by his/her curent medication regimen. Incident pain refers to pain that is typically predictable and is related to a precipitating event such as movement (e.g. walking, dressing) or certain actions (e.g. wound care). Procedure: Upon admission, all residents and families will receive the facility handout, About Pain Management, encouraging residents to report pain early so pain management can be more effective. Physician Communication and Involvement: Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. Through communication with the physician will ensure an appropriate pain management plan.

Based on observation, interview, and record review, the facility failed to follow their pressure ulcer prevention policy and procedures by failing to prevent the development of a new pressure ulcer and the healing of a current pressure ulcer for 1 high risk resident (R2) of 4 residents (R1, R2, R4, R6) reviewed for pressure ulcers in a sample of 18. Findings include: R2 is an [AGE] year old resident admitted to the facility on [DATE] per facility face sheet dated 7/24/17 and [DIAGNOSES REDACTED]. Physician order [REDACTED]. Care Plan for R2 dated 6/5/17 states in part, Goal: Resident will not develop further pressure sore. Approaches: Assess skin daily during care--if open or bruised areas noted, report to Nurse, MD and responsible party. Evaluation: Resident at times screams during dressing change when being asked if she's ok but is redirectable. Per wound nurse, resident noted with screaming during dressing changes at times but not daily. Staff to monitor for pain during treatments and provide PRN meds if needed prior to procedure. MDS (Minimum Data Set) dated 5/26/17 shows R2 unable to complete the brief interview for mental status indicating cognitive impairment. R2's bed mobility shows that she requires extensive assistance during self performance and actual one person physical assistance. All other activities of daily living show that R2 being total dependence on staff for toileting, eating and transferring. Section on skin conditions (Section M) of the same MDS shows resident at risk of developing pressure ulcers and shows one stage 4 pressure ulcer that is unhealed and present upon admission of 1/13/17. Skin and ulcer treatments for R2, show resident on a pressure reducing device for chair, bed; a turning and repositioning program, nutrition and hydration intervention, pressure ulcer care, application of nonsurgical dressings, and application of ointments/medications. Facility skin assessments provided by E8 (Wound care nurse) show initial assessment of wound upon 1/13/17 admission with the pressure ulcer measuring 1.5cm length X 1.2 cm width X 0.3 cm. Proceeding skin assessment dated [DATE] show the wound worsening and increasing in size and depth to 3.0cm length X 2.5 cm width X 0.6 depth. Skin assessment dated [DATE] show the pressure ulcer worsening again in width from an original 1.2 centimeters to 1.5 centimeters. Skin assessment dated [DATE] show the depth of the pressure ulcer worsening from an original 0.3 centimeters to 0.7 centimeters. During initial tour with E6 (LPN-licensed practical nurse) on 7/24/17 at 10:09AM, R2 was laying in bed asleep on R2's back. At 11:30 AM, R2 was still in bed asleep in the same position laying on R2's back. At 12:45PM, R2 did not change positions, remained asleep, and still flat on R2's back. From 1:30 through 3:00 PM, no staff entered R2's room and was observed still in the same position on R2's back. R2 was awake and had R2's eyes open. Surveyor went to nursing station and asked E6 if (R2) would be gotten up today, E6 responded, She is only gotten up from bed on Tuesdays, Thursdays, and Saturdays. Asked if R2 has an order for [REDACTED]. Asked if the family was ever educated on the risks for remaining in bed, E6 responded, I'm not sure sir. Review of records show no patient or family teaching referring to days R2 would be gotten up from bed. Request for records showing any care plan conference indicating family preference for R2 to remain in bed revealed no evidence to show such request. Interview with Z6 (R2's power of attorney) 7/27/17 at 10:45AM states in part: Asked if their preference was for (R2) to be gotten up from bed every other day, Z6 stated, No. We never would say that. In fact when I do visit along with my other sister, we tell them to get her out of the room so she can experience another environment. This is upsetting to hear. Asked if they were educated at all on the risks of remaining in bed, Z6 stated, Well I already know that, but like I said I would not want my sister (R2) to be in bed all day, every day, so there would be no reason for them to tell me the risk, but no I was not informed of that either. Asked if Z6 was informed of a newly developed pressure ulcer on R2's back, Z6 stated, No, I was not told. On 7/25/17 at 8:15 AM, R2's wound care observation noted the following: E6 (licensed practical nurse) went into R2's room to wash E6's hands in the bathroom and proceeded to walk out of the room and gather E6's supplies to perform the wound care treatment. E6 opened up the treatment cart with E6's washed and ungloved hands, grabbed several supplies out of the cart, closed the cart, flipped through the treatment book, then re-entered R2's room without rewashing E6's hands. E9 (c.n.a.-certified nurses aide) came into the room donning gloves and did not wash E9's hands prior to handling R2. E9 placed both unwashed and gloved hands on R2's hips to turn R2 and removed R2's incontinence brief revealing a very moist and macerated skin around R2's reddened sacral pressure ulcer. Neither E6 nor E9 asked R2 whether R2 was ok or not. E6 proceeded to cleanse the pressure ulcer with saline solution whereupon, R2 shouted, Ow,ow,ow,ow, ow five times while E6 continued with the procedure and did not stop. E6 then placed medication around the pressure ulcer whereupon R2 recoiled back and grimaced with discomfort. Again, E6 continued on with the treatment without stopping nor asking R2 whether E6 should continue or not. After the procedure, E9 placed an incontinence brief back on R2 and proceeded to place R2 on her back until the surveyor asked both E6 and E9 to stop what they were doing to point something observed on R2's spine area. E6 remarked, Oh I see that, it's new sir, I didn't see that before. E9 stated, It looks fresh. I never saw that before either. Asked to describe the new sore, E6 stated, It looks new, reddened, maybe a skin tear, I'm not sure because we cannot stage it sir, but I will inform the woundcare nurse. Asked whether it is located on a bony prominence, E6 stated, Yes its right on her spine area. Asked whether a sore acquired on a bony prominence would be considered a pressure ulcer, E6 stated, yes I think so. Asked about whether E6 washed E6's hands coming back in the room, E6 stated, Yes I should have washed my hands before I came back in to the room. E9 was also asked why E9 didn't wash E9's hands at all when entering the room, E9 stated, I'm sorry sir, I forgot, but I used my gloves though. E6 was asked whether R2 was given any pain medications before performing the treatment, E6 stated, She used to have pain medications when she was on hospice but she doesn't get them anymore. Asked why E6 didn't stop the procedure when R2 exhibited pain several times during the procedure, E6 stated, Well she's usually like that sometimes. Signed interview on 7/25/17 at 10:00 am with E2 (DON-director of nursing) states in part, My expectation is that we don't expect to acquire pressure ulcers so we work to ensure we implement our skin prevention protocols for all avoidable pressure ulcers. We do skin assessments upon admission, weekly and as needed. We use pressure relieving devices as needed, pressure ulcer mattresses, elevating of heels or cushion devices. Staff reports skin and referrals as needed to the wound nurse and doctor, referrals to the dietician. E2 continued, We do regular incontinence care, check and change when wet, getting them up in the morning before and after lunch, in the afternoon and evaluate them. If they are heavy-wetter's we change them every 2 hours. Staff should not be double padding the bed. Asked why E2 brought up double padding of beds, E2 responded, They (the staff) told me you saw that on some residents. That is not acceptable. We have inserviced the staff again about that. Telephone interview with Z2 on 7/26/17 at 2:30PM conducted in the marketing office states in part: Asked if Z2 was the attending physician to R2, Z2 stated, Yes, I am. Z2 continued on, I've had her for two months as there was another physician before I took over for her when she was on hospice at the time. So I've just had her recently as my patient. Asked if Z2 received a call from the facility, Z2 responded, I was at the facility yesterday and it was mentioned to me about (R2) experiencing pain during therapy. The surveyor clarified with Z2 that the pain R2 experienced was during wound treatment and if Z2 recalled that particular call. Z2 replied, No I don't recall that it was about that. Asked if Z2 was informed about a newly developed pressure ulcer on Z2's visit or via phonecall Z2 stated, No. Asked if a newly acquired pressure ulcer would qualify as a change of condition, Z2 stated, Yes, it does. Asked if Z2 was informed of R2's pain during woundcare, Z2 stated, I don't recall getting a call about that. I thought it was pertaining to her physical therapy but I may have gotten mixed up. Asked how staff should treat pain experienced by patients based on Z2's expectations, Z2 stated, It should be brought to my attention immediately. Pain should be reported immediately and they should be able to characterize pain a little bit and that would allow me to provide an order or not. Z2 was told that during the wound treatment, R2 was recoiling and screaming. Z2 stated, I was not informed of that specifically but that should be enough for staff to stop what they're doing as yes that would certainly indicate pain. Asked if Z2 was informed of that (new pressure ulcer) Z2 stated, I'm usually informed but I don't recall being told of that. I come to the facility almost daily for a variety of reasons, they usually speak to me about it in person and I was not notified of that however. Z2 was told that the facility wrote a telephone order for a pain medication for R2 and asked again if Z2 remembers being informed about the change of condition of a new pressure sore, Z2 stated, No I was not informed of that. Actually you're just telling me that now. As for telephone orders, I'm not usually called, they just wait till I sign it when I come in. Asked what Z2's expectation is related to pressure ulcer prevention, Z2 commented, I usually speak on a normal basis with the wound care nurse at the facility and she usually updates me of any changes of condition or any new deep tissue injuries. Asked again if Z2 was informed of the a new tissue injury, Z2 again responded, Correct, she did not tell me. Z2 continued, Well they communicate with me and I speak to the wound care nurse and we decide if the wound care physician needs to be involved and she(wound care nurse) discusses what her recommendations are for wound management. Asked to comment further on Z2's expectations on pressure ulcer prevention, Z2 continued,We monitor nutritional status, monitor any changes in weights, new injuries are reported, areas should be off-loaded, we sometimes order off-loading mattresses, I expect frequent repositioning and frequent checks on the resident. Telephone interview on 7/27/17 at 10:45AM with Z6 (R2's sister and power of attorney) states in part, I was contacted yesterday about getting pain medication but the young man I spoke to didn't mention she was in pain during woundcare. Asked if Z6 was informed about a new pressure sore, Z6 responded, No they didn't tell me that. Z6 continued, I know she has one above her butt but is this a new one? Surveyor clarified with Z6 who responded again, Well, no they did not tell me that at all. Facility policy on pressure ulcer prevention dated 4/6/17, titled, Skin Conditions-Prevention, Assessment, and Treatment, states in part: Any resident who is admitted without a pressure ulcer/pressure injury will not develop a pressure ulcer/pressure injury unless clinically unavoidable and a resident who has a pressure ulcer injury will receive care, services to promote healing, and prevention of additional pressure ulcers/pressure injury. In implementing this guideline, the faollowing shall apply: 1. Prevention of pressure ulcers/pressure injury will be through assessment, care plans, evaluation and monitoring of the resident in accordance with best practice standards. Definitions: A pressure ulcer is any lesion caused by unreleived pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of presure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. Avoidable means that the resident developed a pressure ulcer and that facility did not do one or more of the following: evaluate the resident's clinical condition and pressure, or pressure in combination with shear and/or friction.