Every finding on record at Pearl at the Tillers

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents who require extensive assistance for ADL (Activities of Daily Living). The facility also failed to assist a resident who is totally dependent on staff for transfers to get up to a wheelchair. This applies to 3 of 18 residents (R4, R57, and R63) reviewed for ADLs in the sample of 18. Findings include: 1. According to the EMR (Electronic Medical Record), R63 had multiple diagnoses, including Parkinson's disease, polyarthritis, other chronic pain, and encounter for attention to gastrostomy. R63's MDS (Minimum Data Set) dated March 23, 2026, showed R63 had severe cognitive impairment. The MDS also showed that R63 was dependent on staff for toileting hygiene. On April 4, 2026, at 9:12 AM, V17 (Certified Nursing Assistant/CNA) went into R63's room to perform morning care. R63 was lying in bed. V17 pulled back R63's covers and blankets, and there was a large amount of pasty and formed stool that had leaked out of R63's incontinence brief. R63's incontinence cloth pad was grossly soiled and saturated with brown stains, extending across the mid and lower portions of the incontinence cloth pad. The back side of R63's upper thighs was covered with stool. V17 said R63 was last checked for incontinence care during the last shift of CNA's rounds around 5:30 AM. R63's care plan, initiated on July 11, 2024, showed that R63 was incontinent of bowel. The care plan interventions included staff checking R63 as required for incontinence. On April 8, 2026, at 1:15 PM, V2 (DON) said CNAs are required to check residents every two hours for incontinence care. The facility's policy titled, Supporting Activities of Daily Living (ADL) with a review date of December 12, 2025, showed, Policy Statement: 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. 2. The EMR (Electronic Medical Record) showed R57 was admitted to the facility on [DATE], with multiple diagnoses including cerebrovascular disease, type 2 diabetes mellitus, chronic kidney disease, unspecified dementia with other behavioral disturbances, congestive heart failure, obstructive sleep apnea. R57's MDS (Minimum Data Set) dated March 7, 2026, showed R57 was cognitively impaired. The MDS continued to show R57 was dependent on facility staff for toileting hygiene and was always incontinent of bladder and bowel. R57's care plan dated February 13, 2026, showed R57 has impaired mobility due to decreased range of motion. Care plan continued to show R57 has an ADL self-care performance deficit, decreased self-bed mobility and requires assistance with toileting. On April 7, 2026, at 11:51 AM, V21 (family member) and V22 (family member) said they have found R57 lying in a soiled urine-soaked incontinence brief full of feces and in uncomfortable positions on multiple occasions. V21 and V22 said R57 had a CVA (Cerebrovascular Disease) so she cannot take care of herself and requires more assistance from staff related to toileting and ADLs (Activity of Daily Living). V21 said she found R57 lying flat on her back on multiple occasions in soiled urine-soaked clothing. V21 said while in room of R57 she noticed feces on the blanket of R57 and V14 took the blanket and threw it on the chair. V21 said she has been at the facility since 9 AM today and the CNA did not come in until 11 AM to provide a diaper change. On April 7, 2026, at 12:19 PM, V14 (Certified Nursing Assistant, CNA) said she came in at 6 AM for the start of her shift. V14 said she checked R57 at 6 AM and 8 AM and R57 was dry both times. V14 said she checked R57 again at 11 AM to provide incontinence care and saw stool and brown substances on blanket the size of her fist. On April 7, 2026, at 1:18 PM, V15 (Staffing Coordinator) said V14 (CNA) asked her to help change R57 she saw brown stains but did not know what it was. V15 said V21 and V22 were in the room during incontinence care. V15 said it was 11am when they provided ADL care for R57. On April 8, 2026, 10:17 AM, V2 (DON/Director of Nursing) said residents who are incontinent of bowel and bladder should be checked to see if they require incontinence care at least every two hours. V2 said R57 should have been provided with incontinence care sooner than over two hours, especially if brief was saturated and clothing was wet with urine. V2 said her expectation is for CNAs to provide incontinence care when residents are wet with urine upon rounds. The facility policy titled Supporting Activities of Daily Living (ADL) dated December 4, 2025, showed 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, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (Bathing, dressing, grooming, and oral and nail care: .2. Mobility (turning, re-positioning, transfers, ambulation, including walking.3. Elimination (toileting). 3. R4's electronic medical record showed that she was admitted to the facility with diagnoses that included cerebral infarction, type 2 diabetes mellitus, abnormal posture, acute pulmonary edema, retention of urine, anxiety, and hypertension. R4's Minimum Data Set, dated [DATE], showed that R4 was dependent on staff for transfers. On April 6, 2026, at 11:04 AM, R4 was lying in bed and stated that the staff doesn't want her to sit up in a wheelchair because they think she will fall out of the wheelchair. R4 stated she would like to get up in the wheelchair. R4 stated it had been a long time since she was out of bed. On April 7, 2026, at 9:40 AM, R4 was observed lying in bed with television on. V16 (CNA) was getting R4's roommate up with a whole-body mechanical lift. On April 7, 2026, at 10:04 AM, at 12:36 PM, and at 2:20 PM, R4 was observed lying in bed. On April 7, 2026, at 3:19 PM R4 observed lying in bed and stated that no one offered to get her out of bed today. R4 stated she would have liked to get up during the day. On April 8, 2026, at 9:31AM, R4 was lying in bed with her television on. R4 stated no one has asked her if she would like to get out of bed. R4 stated she would like to get out of the bed and wheel down the hallway in her wheelchair. On April 8, 2026, at 10:07 AM, V27 (CNA) stated she has worked with R4 but has never gotten her up out of bed. V27 stated she charts (documents) when a resident refuses to get up out of bed, and she informs the nurse. On April 8, 2026, at 10:13 AM, V25 (CNA) stated R4 was alert and oriented and requires a whole-body mechanical lift to be transferred. V25 stated it is part of her routine to get residents up in morning. If the resident refuses to get out of bed, they tell the nurse and the therapist. V25 stated she has taken care of R4 but has never gotten her up into a chair. V25 started at the beginning of R4's stay at the facility over a year ago R4 used to get up, but she has not seen R4 up out of bed for at least the last 6 months. On April 8, 2026, at 3:57 PM, V16 (CNA) stated she has worked at the facility for 2.5 years. V16 stated she was assigned to care for R4 yesterday morning. V16 stated she got R4's roommate out of bed with a whole-body mechanical lift, and V16 stated, I did not ask her (R4) if she wanted to get out of the bed, and I know I should have asked her. V16 stated she did not get R4 out of bed yesterday. R4 stated in their computer system they document how a resident transfers, refusals, and is not applicable if the resident did not get up. On April 8, 2026, at 1:44 PM, V28 (CNA) stated that R4 requires a whole-body mechanical lift. V28 stated she has cared for R4 before but has never gotten her out of bed and has not ever seen R4 out of bed. On April 9, 2026, at 10:48 AM and at 11:09 AM, V2 (Director of Nursing) stated staff should be encouraging R4 to get up out of bed and ask R4 daily if she wants to get up. V2 stated they should encourage R4 to get up because it is R4's right to get up and socialize as part of activities and ADL care. V2 stated staff should be charting in the medical record if the resident refuses to get up. V2 stated the nurses should chart in the progress notes and EMAR (Electronic Medication Administration Record) and the CNAs should chart in the point of care tasks if the resident refuses to get out of bed. R4's progress notes and point of care tasks from March 9, 2026, to April 7, 2026, were absent of any mention of R4 refusing to transfer out of bed. Furthermore, R4's EMAR for March and April of 2026 showed the following: Monitor/record if targeted behavior of resisting care occurs every shift indicate if behavior occurred by indicating the number of times observed. There was no such behavior documented. The facility's Activities of daily living (ADL) policy dated December 4, 2025 showed the following: Appropriate care and services will be provided for resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with.mobility (turning, re-positioning, transfers and ambulation, including walking).

Based on interview, and record review the facility failed to follow physician orders and facility policy for the care and maintenance of PICC (Peripherally Inserted Central Catheters) lines or Midline Intravenous access devices.This applies to 3 of 3 residents (R3, R6, R9) reviewed for intravenous medication administration in the sample of 9.Findings include:1. R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, giant cell arteritis with polymyalgia rheumatica, chronic diastolic congestive heart failure, type 2 diabetes, chronic pain, and surgical wound right lower leg. R6's MDS (Minimum Data Set) dated November 19, 2025, showed R6 was moderately cognitively impaired and required assistance with ADL care including set up assistance for eating and oral hygiene and was dependent on staff assistance for toileting, dressing, bathing, bed mobility and transfer. R6's physician order dated December 3, 2025, showed Non-Valved Midline, flush with 10 ml NS (Normal Saline) before and after med. There was an order for IV medication initiated on December 4, 2025, that showed cefazolin sodium Injection Solution Reconstituted 1 GM (Cefazolin Sodium) Use 1 gram intravenously every 8 hours for RLE shin wound abscess until December 16, 2025. There were no orders for the care and maintenance for the midline catheter, no order for dressing changes, nor measuring arm circumference or measuring external catheter length as required per facility policy. R6's physician order initiated on December 15, 2025, showed change PICC line dressing, measure circumference and length exposed and document in progress note every day shift every 7 day(s) for change PICC line dressing, measure circumference and length., start date December 16, 2025. There was no documentation to indicate if a new IV line had been placed or if this order was for the midline IV catheter already in use. R6's MAR (Medication Administration Record) for December 16, 2025, entry for the PICC line dressing change scheduled that day showed documentation of code 9. The legend on the MAR showed code 9 stood for other and to refer to the progress note. There was no progress note regarding R6's PICC line dressing had been changed and no documentation of arm circumference or external catheter length measurements. R6's MAR showed R6 had been administered IV medication from December 4 through December 21, 2025, with no indication that an IV insertion site dressing change had been done or monitoring IV catheter for potential migration or infiltration had been done. On December 23, 2025, V6 (RN) stated R6's midline catheter had been removed on December 22, 2025, and stated R6 had a midline and not a PICC line in use for IV medication administration. R6's care plan did not address the care and maintenance of an IV or use of IV antibiotics. 2. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis, cognitive of communicative disorders, Barrett's Esophagus dysplasia, acquired absence of left leg below the knee. R3 was transferred to the hospital on November 12, 2025, and had not returned to the facility. R3's MDS (Minimum Data Set) dated November 10, 2025, showed R3 had moderately impaired cognition. R3's care plan showed R3 has a PICC line for IV antibiotic for infusion, interventions included assess for redness, tenderness, or swelling and to keep an eye on swelling, check the arm circumference against baseline, change dressing weekly or as needed. R3's hospital records showed R3 was admitted to the ER (Emergency Room) on November 12, 2025. V10 (Nurse) reported R3's PICC line dressing was dated October 31, 2025. On December 22, 2025, at 3:47 PM, request the facility to provide R3's physician order for PICC line care and required interventions. At 4:03 PM, V2 (DON) provided an order showing PICC line dressing change and measurement of arm circumference and length of exposed PICC line after PICC line dressing change done on admission and every 7days. V2 said when the order was entered, the category chosen was other and so it did not transfer onto the MAR (Medication Administration Record). V2 was not able to find any documentation that dressing had been changed or measurements taken of the arm circumference or exposed PICC line. 3. R9's EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis of vertebra lumbar region, infection and inflammatory reaction due to other internal joint prosthesis, Methicillin Resistant Staphylococcus Aureus site unspecified, acute osteomyelitis left ankle and foot, malignant neoplasm of larynx. R9's MDS (Minimum Data Set) dated November 16, 2025, showed R9 was cognitively intact. R9's care plan did not address the care and maintenance of his Midline catheter. R9's POS (Physician Order Set) showed an order to change PICC line dressing on admission and every 7 days and measure arm circumference and length of exposed PICC line. R9's MAR (Medication Administration Record) showed R9's dressing was changed on November 17, November 24, December 1, and December 8, 2025. R9's progress notes were reviewed and showed on November 17, 2025, the dressing change was completed, no signs/symptoms of infection, line patent and flushing appropriately, Length 16 cm and circumference 35 cm. On December 1, 2025, the dressing change was completed, no signs/symptoms of infection, line patent and flushing appropriately, Length 17 cm and circumference 35 cm. The facility was unable to provide progress notes showing the length of catheter or the arm circumference were measured when dressing was changed on November 24, or December 8, 2025. R9's Midline catheter was discontinued on December 10, 2025. On December 23, 2025, at 10:07 AM, R9 said he had an PICC line and staff changed the dressing a couple of times but was unsure if they measured his arm. On December 23, 2025, at 9:50 AM, V2 (DON/Director of Nursing) said when R3 came to us, he had an infection and was admitted here for IV (Intravenous). R3 was admitted with his PICC line in place. V2 further stated R3 had a PICC line and R9 had a Midline IV catheter. Facility provided their policy dated November 2022, and titled, Peripheral and Midline Intravenous Catheter Care and Dressing Changes showed, the dressing needs to be changed if loose, soiled, or damp and at least every 7 days with a transparent semi-permeable membrane dressing. If it is a midline catheter, the arm circumference needs to be measured and compared to baseline when indicated to assess for swelling and possible deep-vein thrombosis (blood clot). Facility provided their policy dated November 2022, and titled, Central Venous Catheter Care and Dressing Changes, showed, the dressing needs to be changed if loose, soiled, or damp and at least every 7 days for a transparent semi-permeable membrane dressing. The length of the external central vascular access device should be measured with each dressing change or if the catheter dislodgement is suspected and compared with the length documents at insertion. For PICC line, the arm circumference should be measured and compared to baseline when assessing for swelling and possible deep-vein thrombosis.

Based on observation, interview, and record review, the facility failed to protect a resident from misappropriation of resident property when a staff member removed a resident's cellular telephone from the facility and later disposed of the cellular telephone in a trash receptacle at a local park. This applies to 1 of 3 residents (R1) reviewed for theft in the sample of 3. Findings include: The facility's final report to the State Survey Agency dated April 21, 2025 shows, Brief description of incident: R1 family stated R1's cell phone is missing from facility. R1 unable to identify any staff member that could be involved but an immediate search was completed. Disposition: R1's family called the facility and stated they have a phone tracking application downloaded on R1's phone and they were notified that R1's phone left the facility. R1's family retrieved the phone and returned it to R1. Upon interview with [V3] (CNA-Certified Nursing Assistant), she stated she accidentally grabbed R1's phone. [V3] stated she realized on her drive home that she had two phones and panicked. [V3] stated she was scared and threw the phone into a trash can at a nearby park. [V3] acknowledges she should have returned the phone to the facility, but she states she didn't know whose phone it was. [V3] apologized for her behavior The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, non-rheumatic aortic valve stenosis, difficulty walking, unsteadiness on feet, abnormal gait, COPD (Chronic Obstructive Pulmonary Disease), asthma, diabetes, morbid obesity, atrial fibrillation, congestive heart failure, heart disease, lymphedema, and osteoarthritis. R1's MDS (Minimum Data Set) dated April 1, 2025 shows R1 is cognitively intact, requires setup assistance with eating and oral hygiene, supervision with personal hygiene, partial/moderate assistance with showering and lower body dressing, and substantial/maximal assistance with toilet hygiene, bed mobility, and transfers between surfaces. R1 is occasionally incontinent of urine, and frequently incontinent of stool. On April 28, 2025 at 10:03 AM, V1 (Administrator) said, [R1's] family had an app to track [R1's] cell phone. The app showed the phone left our facility between 3:10 PM and 3:15 PM on April 20, 2025. I looked at timecards and narrowed it down to who had just left the facility. The family tracked [R1's] cell phone to a trash can at a park. They went and retrieved the cell phone from the garbage can. [V3] (CNA) claims that she was burnt out and tired and she grabbed it and panicked and threw it out. On April 28, 2025 at 10:15 AM, R1 was sitting on the side of his bed. R1 was holding a cellular telephone in his hand. R1's cellular telephone had a heavy-duty, black protective case covering the telephone. R1 said he has had the protective case for his telephone for many years. R1 said, On April 20, I set my cell phone on my bedside table and went to lunch. When I came back, the cell phone was missing. I asked another resident to call my cell phone so I could find it. He called the cell phone, and we could not hear it ringing, so I knew it was missing. My family tracked the cell phone with the app on my phone and found it in a garbage can at the park, about two or three miles from here, and returned it to me. They told the facility, and they determined someone from here took my phone and then threw it away in the park a little while later. R1 continued to say he did not give anyone permission to use his cell phone. On April 28, 2025 at 10:56 AM, V6 (Daughter of R1) said, on April 20, 2025 her niece called to say Grandpa is missing from the nursing home. He is at some park close by. V6 continued to say the family did some quick investigating and found R1 was safely in the facility but his cell phone had been taken from the facility and then disposed of in the trash can at the local park. V6 said the facility did some investigating and found a staff member had taken R1's cell phone from the facility. On April 28, 2025 at 11:56 AM, V3 (CNA) said, It happened on a Sunday. I was overwhelmed and burned out and I didn't have anything to eat, and I was not feeling good, and I was running from room to room. I put the cell phone in my pocket. I didn't realize until I got home. It looked like my phone. My cell phone is black like [R1's] but does not have a protective case on it. I didn't know whose it was or where it came from even though, I had not been anywhere but work and my car to drive home. It would have been obvious that it was from work. I can't explain it. We are not supposed to take anyone's personal things. I stopped at a park and threw the cell phone in a garbage can. I should have returned the cell phone. I knew it had to be from work, I just didn't know where it came from. I know what I did was wrong. Facility documentation shows the local police department was notified. On April 28, 2025 at 6:42 PM, V7 (Police Officer) said he was the officer who responded to the call and investigated the incident. V7 said, [V3] admitted taking the cell phone and said it was a combination of panic and lack of time. [V3] admitted she threw the cell phone in the trash can. Had she just said she picked up the cell phone on accident and returned it to him, she would have been fine, but when she deprived [R1] of his cell phone by throwing it in the trash can, that shows intent to keep the phone from [R1]. The facility's undated Abuse Prevention Program - Policy shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Definitions: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the facility kitchen and during meal service. This applies to 58 residents that received foods prepared in the facility kitchen. Findings include: The facility's Long Term Care Facility Application for Medicare and Medicaid dated March 3, 2025 showed the facility census was 59 residents. The facility provided information that there was one resident on NPO (nothing by mouth) status. On March 3, 2025 starting at 9:15 AM, during initial tour of the facility kitchen the following observations were made: The sanitizer bucket (that was placed on the kitchen counter) when tested with a QUART (Quaternary Ammonium) test strip by V6 (Food Service Manager), the test strip remained white color showing 0 ppm (parts per million) on the color scale of the test strip. V7 (Cook) stated that he had just filled the bucket a few minutes ago at the 3-compartment sink. V6 stated that V7 is new and that the color on the test strip should change from white to orange/green registering between 150-200 ppm. V8 (Dietary Aide) was at the dish machine washing dishes at the soiled side of the machine. The gauge on the dish machine showed between 150-155 degrees Fahrenheit at the wash setting and 130 degrees Fahrenheit at the Rinse setting. V6 who had come into the area confirmed that it is a high temperature dish machine. When asked why the rinse setting shows 130 and not 180 degrees Fahrenheit, V6 stated that the dish machine works fine and that it's the gauge that was not working. V6 added that the piping connection at the base of the dish machine was also loose, and he had notified the dish machine services regarding the same about a week ago. V6 stated that the facility uses the 180-degree test strips to test the sanitation of the high temperature dish machine. When a test strip was ran through the machine, the black line on the test strip turned dark gray and V6 gave the impression that since the color had changed, it was sufficient. V6 was showed the instructions on the test strip that the line should change from black to bright orange. On request, V6 sent the test strip once again through the dish machine and the test strip remained black. V6 was notified that the dishes that were just washed were not able to be used for meal service as there was no proof of the dishes being sanitized with the gauge not working and test strip not changing color. V6 stated that he will notify the services for dish machine maintenance. On March 3, 2025 at 3:58 PM, V9 (representative of Dish Machine Service Company) was seen working on the dish machine. V9 stated that he was made aware a week ago about the loose drain body pipe at the base of the dish machine. V6 stated that during his visit to the facility thereafter, he noted that the drain body pipe was stripped, so the pipe will not stay connected long and that he placed an order for the same. V6 stated that the loose connection mainly affects the water drainage as the leaked water will seep into the dish area. V6 stated that he was not aware of the gauge not working. V6 stated that for high temperature dish machines, most facilities depend on the gauge to show that the temperature has reached 180 degrees Fahrenheit [for sanitation of the dishes]. Facility dish machine logs for breakfast, lunch and dinner for the past one week (February 24 to March 2, 2025) and March 3, 2025 breakfast recorded Wash/Rinse as 160/180 Fahrenheit. Signatures for most of these dates that were shown on the logs of these recordings were that of V10 (Dietary Aide). On March 3, 2025 at 4:01 PM, V10 stated that she starts at 8:00 AM. When V10 was asked how she recorded 160/180 when the gauge was not working during the past one week and whether the test strip had changed color during the dish washing procedure. V10 stated that she does not use the test strip and only looks at the gauge. V10 stated that she assumed that the temperature was 160/180 as she thought that it was the gauge that was not working and not the dish machine. On March 3, 2025 at 1:14 PM, two free standing carts with room trays were seen parked next to the nursing station. These carts did not have a cover over it and the dessert (fruit cup) was seen open to air. The tray card tickets showed that the meal trays belonged to R25, R29, R30, R69, R173, R174 and R274. Multiple staff and visitors were seen walking by the carts. V1 (Administrator) who was also walking past the carts was notified of the open carts. On March 3, 2025 at 1:17 PM, V6 stated that it is the responsibility of the dietary staff to cover the meal cart before delivery to the nurses station. On March 4, 2025 at 11:20 AM, the facility walk in Freezer (located outside) was noted to have ice built up over prepared foods stored in pans that were covered with a silver foil wrap. Parts of the silver foil on the pan were broken in showing ice seeping onto the food inside. There was ice built up on the floor at the base of these pans which included formation of a vertical shaft of icicle that was about a foot tall. These pans were inspected in presence of V6 and contents identified by V6 as follows: a large pan contained cooked ribs dated 12/16 (December 16, 2024), another pan contained bratwurst dated 1/17 (January 17, 2025), a pan contained fish that was completely covered with ice and no label was therefore visible. V6 stated that these dates were when the food was prepared. V6 stated that the recent weather fluctuations in the last two weeks triggered the condensations drips and ice built up. Facility Policy titled Cloths, Pads, Mops and Buckets (undated) included as follows: Policy: Cleaning tools will be maintained in clean, fresh, odor free condition. Procedure: 2. Cleaning cloths should be kept in a container of clean sanitized solution between uses. Facility Policy titled Sanitizer-Strength and Immersion Times (undated) included as follows: Procedure: 3. Quaternary Ammonium a. 150-200 ppm Facility Policy titled Dish machine Temp (undated) included as follows: Policy: Dishes, pots, pans, utensils, cups, mugs, bowls, etc will be washed using procedures, chemical and equipment that results in clean, sanitized items. Procedure: Machine Washing 3. Dish machine temperatures are logged at after each meal on the Dish machine Temperature Log. a. High temperature machine: Temperatures as required by the manufacturer. WASH 160, Rinse 180, Final Rinse 180-195. -If temperature reads incorrectly: Notify Department head and/or inform maintenance department (usually by work order form). - maintenance will determine if the malfunction is repairable -If unable to repair, maintenance will contact customer service company to schedule a date to properly restore operation of machine - If unable to repair dish machine by next mealtime the meal maybe served on disposable plates with plastic utensils OR the dishes and flatware maybe washed in the 3-compartment sink. Dishwasher temperature test strips for single use Food and Drug Administration (FDA) Food Code Compliance 180 degrees Fahrenheit/82 degrees Celsius included the following directions in summary: Attach the test strip to utensil or rack. Wash the item. If color bar has turned bright orange the dishwasher is maintaining the correct temperature. Facility Policy titled Freezers (undated) included as follows: Policy: Freezers will be defrosted monthly or as needed (when frost is 1/4 inch thick, freezer should be defrosted). Procedure: Remove all food from the freezer. Sort out and throw away all that is not usable .

Based on observation, interview, and record review, the facility failed to provide pureed corn bread as per planned menu to residents on pureed diets. This applies to 4 of 4 residents (R7, R15, R24, R273) reviewed for pureed diets in the sample of 16. Findings include: Facility Week at a Glance menu showed that the lunch meal for March 3, 2025 included Country Chicken and Dumplings, Glazed Carrots, Cornbread and Diced Pears. Facility Menu Extension sheet for pureed consistency included 2 #8 scoops of Country Chicken and Dumplings, #8 scoop of Glazed Carrots, #16 scoop of Cornbread, and #8 scoop of Diced Pears. Facility Dipper/Ladle Equivalents chart showed that #8= 4 fluid oz/ounce, #16 =2 fluid oz. On March 3, 2025 at 12:32 PM, the pureed meal preparation by V6 (Food Service Manager) was observed in the facility kitchen. V6 pureed the cooked Country Chicken and Dumplings first and then the cooked Glazed Carrots and transferred the items to pans to be placed at the steam table. During this pureed meal observation, the corn bread was not pureed. On March 3, 2025 at 12:41 PM, during meal service, R7, R15, R24 and R273 received 8 oz of pureed Country Chicken and Dumplings, 4 oz of Glazed Carrots, 4 oz of apple sauce (given on request). R7, R15, R24 and R273 did not receive pureed cornbread. V6 was made aware and he acknowledged that the pureed corn bread was not served. On March 5, 2025 at 3:20 PM, V11 (Dietitian) stated that she had originally worked with the menu's and signed off the adequacy of the same to provide daily nutrients for the day. V11 stated that the facility should provide the serving portions as shown on the spreadsheet or else the nutrition adequacy will not be met. V11 stated that the pureed cornbread provided the bread serving for the meal. The Facility resident listing of diet orders showed that R7, R15, R24 and R273 receive a pureed diet.

Based on observation, interview, and record review, the facility failed to perform urinary catheter and perineal care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 3 residents (R13, R18) reviewed for incontinence and catheter care in the sample of 16. Findings include: 1. R18's Care Plan shows: R18 has an indwelling catheter due to obstructive uropathy. The same care plan shows multiple interventions which include the following: Catheter care provided during routine peri-care. Keep urine collection container below bladder level at all times to prevent reflux or stasis of urine. On March 4, 2025, at 1:34 PM, R18 was lying in bed which was wet with urine due to leaking indwelling urinary catheter. R18 stated that she has not been changed all day. On March 4, 2025, at 1:50 PM, V13 (Certified Nursing Assistant/CNA) provided perineal care to R18. V13 cleaned R18's peri-area but did not clean the indwelling urinary catheter tube. The anchor was almost detached from R18. As R18 turned on to her left side the anchor completely detached and the urinary bag slipped, and was hanging loosely at the foot of the bed, causing the catheter to pull during provision of care. While R18 was turned from side to side during provision of care V13 lifted the urinary bag multiple times above the bladder, causing some of the urine with sedimentation to backflow towards R18's bladder. The incontinence brief was saturated with urine which turned dark brown and had strong urine odor. V13 stated that she (V13) was busy the whole shift and she last checked R18 to see if she was dry at the beginning of her (V13) shift. 2. On March 5, 2025, at 9:35 AM, V13 and V14 (CNAs) provided incontinence care to R13 who was wet with urine and had a bowel movement. V14 wiped R13's outer labial in a downward stroke on the left and right side twice then she asked R13 to turn on her right side. V14 continued to clean the back peri-area. V14 completed the care without cleaning R13's abdominal folds, inner groin, and labial folds. On March 5, 2025, at 2:34 PM, V2 (Director of Nursing) stated that when providing peri-care the staff must clean from front to back. For female resident wipe the labia, labial folds, inner groins, pubic area, and abdominal folds to prevent a Urinary Tract Infection (UTI.) If a resident has indwelling urinary catheter the staff must clean/wipe the catheter tube near the peri-area away from the body, the tube must always be secured, the catheter must always be below the bladder to prevent backflow which can cause infection. Facility's Policy and Procedure for Perineal Care with review date of April 18, 2024, showed under intent, Perineal care is provided to clean the perineum, prevent infection and odors, and provide comfort. The same policy under guideline showed, 7. Ensure [indwelling] catheter is positioned correctly and secured. Wipe down tubing using downward stroke with a clean cloth. Support and secure tubing during procedure.

Based on observation, interview and record review, the facility failed to evaluate and manage a resident's chronic pain. This applies to 1 of 1 resident (R26) reviewed for pain management in the sample of 16. Findings include: R26's Physician's (V5) progress notes dated November 22, 2024 showed that the resident has diagnosis of trigeminal neuralgia. R26's quarterly MDS (minimum data set) dated January 16, 2025 showed that the resident was cognitively intact. On March 3, 2025 at 10:24 AM, R26 was in bed, alert and oriented. While rubbing on her right cheek, R26 complained that she has nerve pain on the area. R26 stated that she last had her pain medication Tramadol at 9:00 AM and wanted to be given pain medication because she was still in pain. R26 scored her pain to be 8 out of 10 (10 being the worst). V15 (Registered Nurse) was notified of R26's complaint of pain. R26's active order report showed multiple orders including an order dated September 20, 2024 for, Gabapentin 100 milligrams (mg), to give 200 mg by mouth two times a day for nerve pain. An order dated December 23, 2023 for, Tramadol HCl (hydrochloride), to give 1 tablet by mouth every 6 hours as needed for moderate to severe pain and an order dated February 2, 2024 for, Acetaminophen 500 mg, to give 1000 mg by mouth every 8 hours as needed for pain. R26's medication administration audit report for March 3, 2025 showed that the ordered Gabapentin 200 mg for nerve pain scheduled to be administered at 9:00 AM, was administered at 10:31 AM by V15. This medication was administered after R26 was observed at 10:24 AM and one and a half hour after the scheduled administration time. On March 4, 2025 at 11:09 AM, R26 was in bed, alert and oriented. R26 was rubbing her right cheek and stated that she had pain. R26 scored the pain on her right cheek to be 10 out of 10 (10 being the worst). According to R26 she had received Tramadol medication between 9:00 AM and 9:30 AM. V4 (Licensed Practical Nurse) was immediately notified of R26's complaint of pain. At 11:10 AM, R26 told V4 that she has pain on her right cheek while rubbing the area. R26 again scored her pain to be 10 out of 10. V4 stated that R26, received her ordered Tramadol and Gabapentin that morning at around 9:30 AM. V4 offered Tylenol medication to R26 for her right cheek pain and the resident stated that Tylenol does not work to relieve her nerve pain. V4 offered to give R26 cold water but resident refused stating that her mouth hurts when she would open it. V4 told R26, that she (V4) will wait for 15 minutes and go back to the resident, to again assess the pain. On March 4, 2025 at 11:30 AM, with V2 (Director of Nursing) present by the hallway, V4 was asked if she had re-assessed R26 for pain on her right cheek, since she stated that she will go back to the resident after 15 minutes to re-assess. V4 stated that she had not re-assessed R26 yet. V2 and V4 went inside R26's room. V2 asked R26 how she was doing, and the resident was observed rubbing her right cheek and verbalized that she was in pain. V2 asked the resident to score her pain and R26 stated 10 out of 10. R26 was again offered Tylenol, and the resident stated. It does not work for me. V2 stated that the facility will call the Physician to inform of the right cheek pain and to obtain any other additional orders. While walking out of R26's room, V2 was told that according to V4, the resident had received her ordered Tramadol and Gabapentin that morning at around 9:30 AM. V2 stated that V4 should have called the Physician earlier and did not have to wait to reassess R26's pain after 15 minutes when the resident complained of 10 out of 10 pain because the resident already verbalized not being relieved of pain after receiving her ordered medications earlier. R26's printed MAR (medication administration record) dated March 4, 2025 showed that R26 received her ordered Gabapentin at 9:00 AM. The March 4, 2025 pain assessment during the day shift showed a score of 10. The same MAR showed that the Tramadol 50 mg, one tablet was administered at 9:30 AM and there was no documentation of the effectiveness of the medication. The MAR was printed by the facility on March 4, 2025 at 10:38 AM. R26's progress notes dated March 4, 2025 at 9:30 AM showed that the Tramadol medication was administered due to face pain. R26's active care plan last revised by the facility on January 28, 2025 showed that the resident was at risk for alteration in comfort. With generalized aches and pains, and reported pain on her lower back, facial, and general aches and pains. The care plan showed that R26 was receiving scheduled Tylenol and as needed pain medication. The same care plan showed multiple interventions including, administering of medication as ordered and to monitor for effectiveness of relief and screen for pain when conversing with resident. On March 4, 2025 at 12:35 PM, V2 stated that if a resident complained of pain, ordered PRN (as needed) pain medication should be administered and she expects the nurses to reassess the resident for the effectiveness of the PRN pain medication, after 15 to 30 minutes, then document. V2 added that non-pharmacological interventions should also be offered such as positioning, ice pack or warm pack to be applied on the area. If the resident declined and the resident was not relieved of the pain after 15-30 minutes of administering the PRN pain medication post re-assessment, the Physician should be notified for further orders or any additional intervention, because the goal is to manage and/or relieve the resident of pain. V2 stated that when R26 complained of right cheek pain at 11:10 AM that morning, and after V4 offered to give Tylenol which according to the resident does not help, V4 should have called the Physician to obtain further orders, especially when R26 verbalized that her pain was 10 out of 10 on her right cheek, even though she had previously received pain medication (Tramadol) and Gabapentin at around 9:30 AM. According to V2 she spoke to R26's primary care physician (V5) about the resident's right cheek pain, at around 12:00 noon that day. V5 informed her that R26 had chronic trigeminal neuralgia, and that Tramadol pain medication does not relieve nerve pain. V2 stated that V5 increased R26's current scheduled order of Gabapentin from 200 mg twice a day to 300 mg twice a day and added an order to give Gabapentin 300 mg, right away as one dose for pain on the right cheek. On March 5, 2025 at 2:24 PM, V5 (Physician) stated that R26 have chronic right sided pain on her face due to trigeminal neuralgia. V5 stated that R26 was started on a low dose of Gabapentin and had gradually increased the dosage due to the resident's complaint of increasing pain. According to V5, R26's trigeminal neuralgia pain cannot be completely rid of, because only surgery could help but because of R26's age, it was not recommended. V5 stated that Tramadol pain medication is not the recommended medication for nerve pain because it is not 100% effective and that Gabapentin is the effective and appropriate treatment to manage the increasing pain of R26 due to trigeminal neuralgia. According to V5, R26's action of rubbing the right side of her face probably meant that the pain was severe and to help manage the nerve pain on her face she ordered to increase the Gabapentin from 200 mg twice a day to 300 mg twice a day and also ordered to give one time dose of Gabapentin 300 mg on March 4, 2025 when she was informed of R26's 10 out of 10 pain on her right face. The facility's pain management policy last reviewed by the facility on December 17, 2024 showed, The facility shall provide adequate management of pain to ensure that resident's attain or maintain the highest practicable physical, mental and psychosocial well-being. The pain management policy showed in-part under procedure, 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: . e. Bracing, guarding or rubbing. 3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. b. Review of the resident's diagnoses or conditions and any additional factors that may be causing or contributing to pain. 4. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. 12. If when re-evaluation, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene and gloving during provisions of ADL (activities of daily living) care. This applies to 2 of 16 residents (R13, R27) reviewed for infection control in the sample of 16. Findings include: Facility's Hand Hygiene Policy and Procedure with review date of June 2, 2024, showed, It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health organization. The same policy under procedure showed, Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g., when soap and water is not indicated) Hand hygiene is to be performed: .c. When moving from one contaminated body site to a clean body site such as when changing brief or wound dressing. d. After caring for a resident including after removing gloves. 1. On March 3, 2025, at 2:35 PM, V12 (Certified Nursing Assistant/CNA) performed perineal care to R27. V12 cleaned R27 from front to back, changed incontinence brief, repositioned R27, adjusted the pillow under his head, and the pillow under his lower extremities, and straightened his clothes, while wearing the same soiled gloves. On March 5, 2025, at 2:28 PM, V2 (Director of Nursing) stated that staff must perform hand hygiene and change gloves before starting care, from dirty to clean task, after care or before leaving the resident's bedroom, to prevent spread of infection. 2. On March 5, 2025, at 9:35 AM, V13 and V14 (both CNAs) rendered incontinence care to R13 who was wet with urine and bowel movement. V13 and V14 assisted R13 to wash her face and upper trunk and assisted in dressing her. After completing the task V14 removed her gloves, picked up the soiled items and carried it to the hallway without performing hand hygiene. On March 5, 2025, at 2:28 PM, V2 (Director of Nursing) stated that staff must perform hand hygiene and change gloves before starting care, from dirty to clean task, after care or before leaving the resident's bedroom, to prevent the spread of infection.

Based on interview and record review the facility failed to follow physician's order for oxygen administration. This applies to 1 of 3 residents (R1) reviewed for oxygen use in the sample of 4. Findings include: R1's EHR (Electronic Health Record) documents R1 is a [AGE] year old female who was admitted to the facility on [DATE], with diagnoses that include Chronic Respiratory Failure with Hypoxia, Morbid obesity, Muscle Weakness, Heart Failure, Obstructive Sleep Apnea, shortness of Breath and Pulmonary Arterial Hypertension. R1's MDS (Minimum Data Set) dated September 30, 2024, shows R1 is alert and oriented and was cognitively intact. R1's EHR also shows a physician's order dated September 27, 2024, to administer Oxygen 2 Liters continuously for hypoxemia. On October 8, 2024, at 9:52 AM and October 9, 2024, at 3:30 PM, R1 stated on the day she was admitted to the facility, the oxygen concentrator they had for her did not work properly so they put her on a portable oxygen tank. R1 stated, the oxygen tank ran out of oxygen in a couple hours, and someone came and put her on a second oxygen tank. In the meantime, another concentrator was delivered. R1 stated that the second oxygen tank was running out and the nurse needed to come and put her on the oxygen concentrator. R1 stated V3 (Certified Nursing Assistant/CNA) could not hook her up to the oxygen concentrator. R1 stated she could not get up to do it by herself. R1 stated the CNA (V3) was very nice and kept telling the nurse that the oxygen was going to run out and eventually it did. R1 stated, the nurse still did not come. R1 stated she panicked because she did not have oxygen for over 2 hours. R1 stated she then called a family member who lives nearby and asked him to come over to put her oxygen on and he did come around 9:00 PM. R1 stated her family member took the concentrator out of the wrapping, adjusted the settings, switched her nasal cannula from the portable oxygen tank to the oxygen concentrator, and plugged it into the wall. R1 stated V4 (her assigned nurse) did not come in until after her family had left. On October 8, 2024, at 12:17 PM and on October 9, 2024, at 3:30 PM, V3 (CNA) stated she remembers R1 and the issue with her oxygen on October 9, 2024. V3 stated R1 needed some oxygen. V3 stated the CNAs are not allowed to do anything with the oxygen, they can't turn on or adjust it. V3 stated she told V4 (Registered Nurse) and V5 (Nursing Manager) several times that R1 needed oxygen. They both said they will go do it, but they never did. V3 stated she felt bad for the resident and kept checking on R1. V3 stated R1's oxygen was off for a long time, but she was not sure for how many hours the oxygen was off. V3 stated later that evening a gentleman came in to see R1. V3 stated he came and put R1's oxygen concentrator on. V3 stated, he said he just unwrapped it and plugged it in. V3 stated that the oxygen concentrator that her family put on her worked fine. R1's grievance dated September 28, 2024, showed that R1's oxygen concentrator that was ordered was not functioning properly, and R1 was put on an oxygen tank. On October 8, 2024, at 5:15 PM, V2 (Director of Nursing) stated they she expects staff to follow the physician's orders.

Based on interview and record review, the facility failed to ensure a resident was free from financial abuse. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: The facility's June 12, 2024 State Report showed Upon interviews with the policy and facility, [V8- CNA/Certified Nursing Assistant] stated she was providing care to R1 on 6/10/2024 around 5:15 AM. [V8] stated that she and R1 began talking about [V8's] current financial hardships. [V8] stated that R1 said the word 'check' so [V8] provided R1 with her checkbook and then allocated a check written to her [V8] and signed by R1 in the amount of $4000. [V8] states that R1 stated she 'wanted to help.' [V8] stated she placed the checkbook back into R1's purse and completed her shift. [V8] relayed that she then took the check to her bank and deposited [it] into her account on 6/10/2024. [V8] came to the facility on [DATE], provided facility with the original check . On 6/22/24 at 9:50 AM, R1 stated, she had lost $ 4000.00. R1 stated, V8 (CNA-Certified Nursing Assistant) went into her purse and wrote a check for herself worth $ 4000.00. R1 stated, she also took cash $21.00. R1 stated, the bank called her daughter and that's when the theft was brought to light. On 6/22/24 at 11:30 AM, V1 (Administrator) stated, on 6/12/24, R1's daughter had called V9 (Facility Business Office Manager) and wanted to confirm if one of the facility employees had written out a check for $4000.00 from R1's checkbook. V1 (Administrator) stated, on investigation, it was found that V8 (CNA) had taken the check from R1. V1 (Administrator) stated, V8 (CNA) was terminated immediately. V1 stated, the facility is waiting for the bank to process and reinstate that amount back into R1's account. V1 (Administrator) stated, if the bank failed to do so, then the facility will reimburse $4000.00 to R1 and any fees associated with it. V1 (Administrator) stated, facility had reimbursed the $21.00 to R1. The facility employee handbook was reviewed and it showed, acceptance of gifts from residents is strictly prohibited. The facility complaint log for last 3 months was reviewed and it included R1's grievance of losing $ 4000.00. The facility's Abuse Prevention Program policy (11/22/17) showed, Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of resident's belongings or money without the resident's consent.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience. This applies to 1 of 2 residents (R18) reviewed for dignity in a sample of 69. The findings include: On 2/6/24 at 12:16 PM (during lunch), in the dining room, R18 was sitting in a motorized wheelchair. Both of her hands were contracted. She was unable to talk. R18 was sitting at the same table as R34. At 12:18 PM, V3 (CNA-Certified Nursing Assistant) placed 2 glasses of juice and 2 small bowels of banana pudding on the table for R18 and R34. R18 was not able to hold the glass of juice and bowel of banana pudding by herself. R34 was able to drink the juice and eat her banana pudding independently, which she was doing in front of R18. There were several other residents in the dining room that were drinking their juice and eating their banana pudding independently. V3 did not assist R18 with drinking her juice or eating her banana pudding. At 12:20 PM, V3 gave R34 a tray of scrambled eggs and bread. R34 started eating her food in the presence of R18 who did not get her tray. Surveyor asked R18 if it bothered her that she didn't get her tray, even though R34 did. R18 did not reply because she was nonverbal and just stared at R34. At 12:35 PM, R18 received her tray of pureed food and was finally fed by V3 at 12:38 PM. On 2/7/24 at 12:28 PM, R18 was sitting in the dining room. She was sitting at a table by herself for a few minutes alone. At 12:30 PM, staff passed out juice to R18 and other residents in the dining room. No one assisted R18 to drink her juice. It was not until 12:41 PM that V4 (CNA) came and assisted her with feeding and helped her drink the juice. On 2/7/24 at 3:14 PM, V1 (Administrator) stated, They (residents) need to eat together so that's why they should be served at the same time. It's a dignity issue. A resident shouldn't just watch while another resident is eating or drinking while waiting for their tray. R18's face sheet shows an admitted [DATE]. R18's face sheet shows the following diagnoses: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, degenerative disease of nervous system, stiffness of left/right hand, polyneuropathy, and polyosteoarthritis. R18's POS (Physician Order Sheet) shows an order of General diet, Pureed texture, Regular (Thin) consistency. R18's MDS (Minimum Data Set) dated 1/9/2024 shows a blank score for her BIM's (Brief Interview for Mental Status) score because she is rarely or never understood. It also shows that she is severely impaired in making decisions. She has impairment on both sides of her upper and lower extremity. Under eating she is dependent on staff to use utensils to bring food and/or liquid to her mouth and swallow food and/or liquid once the meal is placed before R18. R18's care plans show that she is nonverbal, has a swallowing problem related to holding food in her mouth/cheeks (pocketing) and intervention to assist resident with feeding. Facility's policy tiled Meal Service (12/2023) documents the following: 9. Trays are delivered to the residents at the same table at the same time. 11. Residents are encouraged to eat by all facility staff. If a resident needs to be fed, they are fed.

Based on observation, interview and record review, the facility failed to ensure that anti-contracture devices were applied as ordered. This applies to 1 of 3 residents (R34) reviewed for anti-contracture devices in a sample of 23. The findings include: On 2/6/24 at 10:18 AM, R34 was sitting in the wheelchair by the window in her room. R34's left hand was on her lap, and it was contracted into a fist. No device was in place. R34's 1/18/2024 MDS (Minimum Data Set) showed that her cognition was intact. R34 said that she fell at home, and she hurt her arms and legs. At 12:50 PM, R34 was observed eating lunch in the dining room. Her left hand remained in a fist position, and no device was in place. On 2/7/24 at 9:51 AM, R34 was sitting in her wheelchair in room. R34's left hand continued to be in fist position without a device in place. At 2:16 PM, R34 was sitting up in bed, still with her left hand in fist position and no device in place. R34 said staff does not provide any exercises for her left hand. R34 stated she used to have a splint on the left hand, but she has not had one on for months. On 2/8/24 at 9:20 AM, R34 was sitting up in bed with her left hand contracted and no device. R34 said her left hand feels weak, and staff cannot find the splint for her hand. R34's EMR (Electronic Medical Record) shows the following diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R34's February 2024 POS (Physician Order Sheet) showed an order for a cone splint to her left hand when she is up in a chair. Review of R34's February 2024 MAR (Medication Administration Review) showed that staff were documenting they were applying R34's cone splint every shift. On 2/7/24 at 2:17 PM, V4 (CNA/Certified Nurse Aide) said she is not aware of R34 having a splint, and she does not have one on when she works with R34. On 2/7/24 at 2:40 PM, V12 (Restorative Aide) said R34 is not currently on any restorative programs. V12 stated R34 used to be on a passive range of motion program, but since they switched companies, residents are no longer on any restorative programs except for ambulation. V12 said R34 has a cone splint for the left hand, and the CNAs are supposed to put it on her when she's sitting up in the chair. On 2/7/24 at 2:51 PM, V1 (Administrator) provided surveyor the list of residents that use anti-contracture devices. R34 was on the list. On 2/8/24 at 11:25 AM, V2 (DON/Director of Nursing) said R34 has a cone splint for her left hand, and she should have it on when she's up in the chair. The splint is used to prevent contractures or worsening of contractures. The facility's Managing Residents with Impaired Physical Mobility policy (review date 3/16/23) states that the facility will provide care and management of physical mobility impairment and will provide programs to prevent contractures and or further decline.

Based on observation, interview, and record review, the facility failed to position indwelling urinary catheters in a manner to prevent leakage, failed to cleanse urinary catheter tubing after residents are incontinent, and failed to ensure incontinent residents were changed in a timely manner to prevent infections. This applies to 3 of 5 residents (R3, R23, and R25) reviewed for bladder and bladder incontinence care in a sample of 23. The findings include: 1. The EMR (Electronic Medical Record) showed R3 had multiple diagnoses including neuromuscular dysfunction of the bladder, chronic kidney disease, and chronic pain. The MDS dated [DATE] showed R3 was cognitively intact, incontinent of bowel, and had a urinary indwelling catheter. The MDS continued to show R3 was dependent on staff with toileting hygiene and required substantial to maximal assistance with bed mobility from facility staff. On 2/07/2024 at 11:34 AM, R3 was in bed. V9 (Wound Care Nurse) and V12 (CNA) were positioning R3 after completing wound care. R3's incontinence brief was soiled with urine and her urinary catheter was positioned underneath her leg, unsecured. V12 said R3's urinary catheter was leaking urine. V9 started to provide incontinence care to R3, and wiped R3's perineal area from front to back. Then V9 and V12 turned R3 on her right side and continued to wipe R3's buttock area, and turned R3 on her back and applied a new incontinence brief. Urinary catheter care was not performed and R3's urinary catheter tubing was left positioned underneath her leg and unsecured. 2. The EMR showed R23 had multiple diagnoses including urogenital implants, urinary tract infections, hydronephrosis with renal and ureteral calculous obstruction, neuromuscular dysfunction of the bladder, and multiple sclerosis. The MDS dated [DATE] showed R23 was cognitively intact, incontinent of bowel, and had a urinary indwelling catheter. The MDS showed R23 was dependent on staff for toileting and hygiene and required substantial to maximal assistance with bed mobility from facility staff. On 2/07/2024 at 3:18 PM, R23 was transferred into bed by V17 (CNA) and V18 (CNA). When V17 and V18 pulled down R23's pants down, the pants were stained with fecal material and R23's incontinence brief was saturated with stool. V17 started to provide incontinence care to R23 and wiped R23's perineal area. Then V17 and V18 turned R23 on her right side and continued to wipe R23's buttocks area, then turned her on her back and continued to clean R23's perineal area again. V17 and V18 applied a new incontinence brief and did not provide urinary catheter care. 3. The EMR showed R25 had multiple diagnoses including recurrent urinary tract infections, calculus of the kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023 showed R25 was cognitively intact and had urinary and bowel incontinence. The MDS to showed R25 was dependent on staff for toileting hygiene and required substantial to maximal assistance with bed mobility. On 2/07/2024 at 9:54 AM, R25 was in bed. R25 said she was last changed around 6:00 AM and needed to be changed again. At 11:35 AM V8 (Infection Preventionist Nurse) and V11 (Certified Nursing Assistant Supervisor/CNA) entered R25's room to provide incontinence care. V14 and V11 started to provide incontinence care, and R25's incontinent brief was saturated with urine. They proceeded to turn R25 on her right side, and R25 had two incontinent cloth pads underneath her. The top pad was soiled with urine. On 2/08/2024 at 9:39 AM, V2 (Director of Nursing/DON) said nursing staff should change residents after each incontinence episode to prevent infections and skin breakdown. V2 continued to say those residents with urinary catheters should be provided catheter care if visible soiled after each incontinence episode. V2 said when nursing staff provide catheter care, they should use wipes to clean the catheter away from the urethra, and when done, they should place the urinary catheter over the resident's leg below the bladder and secure it with an anchoring device. V2 said failure to provide proper catheter care can also lead to urinary tract infections. The facility's Perineal Care policy with a review date of 5/21/2023, showed Intent: Perineal care is provided to clean the perineum, prevent infection and odors, and provide comfort .Guideline: 1. Perineal care is done daily and for all residents requiring assistance and/or those residents with a Foley catheter .4. Wash perineal area and around catheter (if applicable) with Peri wash and water using a washcloth .7. Ensure foley catheter is positioned correctly and secure. Wipe down tubing using downward stroke with clean cloth. Support and secure tubing during procedure .

Based on observation, interview, and record review, the facility failed to ensure emergency tracheostomy supplies were available and failed to maintain sterile handling of a resident's sterile tracheostomy supplies. This applies to 1 of 2 (R38) reviewed for tracheostomy care. The findings include: The EMR (Electronic Medical Record) showed R38 was admitted to the facility on [DATE] with diagnoses including tracheostomy, acute and chronic respiratory failure with hypoxia, pneumonia, acute bronchitis, chronic obstructive pulmonary disease with acute exacerbation, and history of COVID-19. The MDS (Minimum Data Set) dated 1/16/2024 showed R38 was cognitively intact. The MDS continued to show R38 required respiratory treatments of continuous oxygen and tracheostomy care. On 2/06/2024 at 10:22 AM, R38 was sitting up in her wheelchair in her room. R38 was receiving six liters of oxygen therapy via her transtracheal catheter. R38 had a clear container box with opened sterile transtracheal kits that contained transtracheal catheters and cleaning rods on top of her bedside table. The box also contained other non-respiratory personal items. R38 also had an uncovered nebulizer mask connected to a nebulizer machine on top of her nightstand table. R38 said she had her trach for a few years and cares for it herself at the facility. On 2/08/2024 at 9:18 AM, R38 was in bed and her bedside table still had the clear container box with opened transtracheal sterile kits. There were trach cleaning rods mixed in with non-respiratory personal items. R38 said she cleans her trach by squirting saline inside it and using the rod cleaner from her transtracheal kit to get out mucous plugs. R38 said she changed her transtracheal catheter a week ago by herself without any staff supervision. R38 said she used the transtracheal supplies she brought from home and does not think the facility could provide them. R38 continued to say she was started on an antibiotic for a lung infection. On 2/08/2024 at 9:24 AM, V2 (Director of Nursing/DON) said she completed a resident and family education with R38 regarding her transtracheal care on 2/07/2024 (during the survey). V2 said R38 takes a normal saline bullet and squirts it inside and then clears any occlusions or mucous. V2 said facility staff does not supervise R38 when performing her trach care. V2 said R38 was instructed to alert facility staff if any concerns. V2 said to her knowledge, R38 does not change her own trach catheter. V2 continued to say they provide R38 with saline and were not aware if R38 required other supplies for her trach care. V2 said the respiratory therapist evaluates R38's respiratory care. On 2/09/2024 at 8:56 AM, V2 said she was not aware R38 was exchanging her transtracheal catheter and R38 does not have an order for the catheter exchange. V2 continued to say the facility does not have transtracheal catheters or kits that R38 requires, and she was going to investigate what trach supplies R38 was using and how she was storing them in her room. On 2/08/2024 at 9:24 AM, V15 (Respiratory Therapist) said R38 was totally independent with her trach care because she has had the trach stoma for years. V15 said she tells R38 the process of flushing the trach. V15 said she was aware of R38 keeping the sterile saline and transtracheal kits in a plastic container in her room but has not looked at them recently. V15 said she thought the last time R38 exchanged her transtracheal catheter was before her last discharge to home and was not aware she recently exchanged it. V15 continued to say improperly stored respiratory equipment must be discarded, including sterile respiratory supplies. R38's EMR progress note dated 2/01/2024 at 7:02 AM, showed at 5:00 AM, R38 was complaining of shortness of breath and her oxygen saturation dropped to 79% while receiving four liters of oxygen via her transtracheal catheter. R38's progress note continued to show that R38 received an as needed breathing nebulizer treatment and inhaler, and her oxygen was increased to six liters. R38's oxygen saturation increased between 86-92%. The progress note continued to show the nurse notified the telehealth physician and received orders to keep R38 on six liters of oxygen. R38's EMR progress note dated 2/01/2024 at 9:07 AM, showed R38's physician was updated on R38's status and ordered an immediate (STAT) chest x-ray and laboratory testing. R38's Radiology Results Report dated 2/01/2024, showed R38 had early interstitial infiltrates in the right lung base. R38's EMR progress note dated 2/01/2024 at 5:04 PM, showed R38's physician reviewed the chest x-ray results and ordered R38 to continue with the antibiotic treatment. R38's EMR respiratory note dated 2/02/2024 at 6:58 PM, showed a respiratory assessment was done and a chart review which showed a new diagnosis of bronchitis. The respiratory note continued to show R38 was reiterated on breathing and cough techniques to help open her airway and no new recommendations. R38's care plan dated 2/08/2024, showed a focus problem for tracheostomy and for R38 to perform trach care and staff assist as needed. The care plan had multiple interventions including Oxygen (O2) @ 4Liters/Minute per transtracheal tube .Transtracheal care-may irrigate as needed, irrigation may be performed with either saline or sterile water to dislodge any mucus occlusion. The care plan did not show any interventions for providing, storing, or maintain tracheostomy supplies, transtracheal catheter exchange, or resident education process on maintain proper care of a transtracheal tracheostomy. The facility's Transtracheal Catheter policy undated, showed Purpose: This policy outlines the guidelines and procedures for the insertion, maintenance, and removal of transtracheal catheters to ensure patient safety and quality of care. Scope: This policy applies to healthcare providers involved in the placement and management of transtracheal catheters within the facility .Procedure: .3. Monitoring and Maintenance: .-Educate patients on proper care, including cleaning and securing the catheter. 5. Staff Training: -Ensure that healthcare providers involved in transtracheal catheterization are adequately trained and competent in the procedure. 6. Equipment and Supplies -Maintain a sufficient supply of sterile equipment and ensure proper function of oxygen delivery systems. 7. Documentation: -Thoroughly document all aspects of transtracheal catheterizations, including patient assessment, procedure details, and follow-up care. The facility's Care and Cleaning of Respiratory Equipment policy with a review date of 12/18/2023, showed Equipment Change .Procedure: .IX. Tracheostomies A. Tracheostomy tubes will be changed every 90 days, per physician order and per manufacturer recommendations .XII. Additional equipment .Respiratory tubing, catheters, masks, cleaning kits will be secured or placed in a container, original package or bag. Facility policies for tracheostomy care did not provide guidance on resident education on self-management of transtracheal for residents with tracheostomy.

Based on interview and record review, the facility failed to prevent the use of unnecessary antibiotic medications. This applies to 1 of 4 residents (R25) reviewed for antibiotics in a sample of 23. The findings included: The EMR (Electronic Medical Record) showed R25 had diagnoses including recurrent urinary tract infections (UTI), calculus of the kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023 showed R25 was cognitively intact. The MDS showed R25 was receiving a high-risk drug of antibiotic. R25's Order Summary Report dated 2/07/2024, showed an order for an antibiotic Macrodantin Oral Capsule 50 MG (Nitrofurantoin Macrocrystal) to give 50 mg by mouth (PO) one time a day for recurrent UTI with no stop date. R25's Care Plan dated 2/07/2024, showed R25 was receiving antibiotic therapy Macrobid (Nitrofurantoin) related to recurrent UTIs for indefinite time, prophylactically. The care plan showed multiple interventions, including reporting pertinent lab results to the physician. R25's Medication Administration Record (MAR) for November 2023, showed R25 was started on Macrobid (Nitrofurantoin) antibiotic on 11/30/2023 for urinary discomfort and UTI for seven days. R25's 11/29/2023 urinalysis laboratory results (reported 12/05/2023) showed the urine culture grew Citrobacter freundii bacteria, which was sensitive to Nitrofurantoin, and Providencia rettgeri bacteria, which was resistant to Nitrofurantoin. R25's MAR for December 2023 showed R25 received Nitrofurantoin until 12/05/2023. The MAR showed R25 received three doses of Invanz intravenous (IV) antibiotic starting on 12/7/2023 for the abnormal urine culture. R25's 12/12/2023 urinalysis laboratory results (reported 12/16/2023) showed the sample did not grow significant bacteria required for a culture. R25's December MAR showed R25 was restarted on Nitrofurantoin 12/27/2023 for recurrent UTI, and R25's January 2024 MAR showed R25 received Nitrofurantoin antibiotic until 1/31/2024 for recurrent UTI. R25's 11/11/2024 laboratory urinalysis results (reported 1/15/2024) showed the urine culture grew Proteus mirabilis and Providencia rettgeri bacteria, which were both resistant to Nitrofurantoin antibiotic. R25's 2/5/2024 urinalysis laboratory results (reported 2/08/2024) showed the urine culture continued to grow Proteus mirabilis bacteria and was resistant to Nitrofurantoin antibiotics. R25's MAR for February 2024, showed R25 continues to receive Nitrofurantoin antibiotic for recurrent UTI. On 12/08/2024 at 9:35 AM, V2 (Director of Nursing/DON) and V8 (Infection Preventionist Nurse) said R25 was receiving a Macrobid antibiotic prophylactic because she was prone to getting UTIs. They said R25 was being treated by the Infectious Nurse Practitioner and they were aware R25 was now resistant to the antibiotic Macrobid. They continued to say they did not agree with R25 antibiotic treatment. On 12/08/2024 at 9:45 AM, V14 (Infectious Nurse Practitioner) said she was treating R25 for recurrent UTIs. V14 said she uses urine culture results and allergies to determine which antibiotic to prescribe, but with R25 it was difficult. V14 said R25 refused to take any other antibiotic except Macrobid. V14 said her goal for treating R25 was to reduce her UTIs, and the treatment selected might not be ideal, but they are working with what they have. The facility document titled Infection Control ABT monitoring form dated 12/26/2023, showed R25 was started on Macrobid for an indefinite time for recurrent UTI prophylaxis. The document continued to show R25's antibiotic treatment did not meet the McGreers Criteria for antibiotic use and the physician was not notified of the identified inappropriate use of the antibiotic. The facility's Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes policy with a review date of 4/18/2023, showed Procedure: .2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: 1. The organism is not susceptible to antibiotic chosen; 2. The organism is susceptible to narrower spectrum antibiotic; 3. Therapy was ordered for prolonged surgical prophylaxis; or 4. Therapy was started awaiting culture, but culture results and clinical findings do not indicate continue need for antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings

Based on observation, interview and record review, facility failed to contain, handle, and transport soiled linen in a manner to prevent cross-contamination. This applies to 2 of 2 (R55 and R25) residents reviewed for infection control in a sample size of 23. Findings include: 1) On 2/6/24 at 11:15 AM, observed V7 (CNA-Certified Nursing Assistant) changing the bed linen for R55. She threw the dirty linen on the floor, wiped down the bed, changed her gloves, and put fresh linen on the bed. V7 picked up the loose soiled linen, unbagged, and carried it to the soiled linen room. V7 (CNA) stated, that's what she always does and that she didn't know she had to bag the dirty linen before transporting it to the soiled utility room. On 2/7/24, observed V5 (CNA) in the hallway, holding unbagged soiled linen that was touching her body and transported it to the dirty utility room. V5 (CNA) stated, she bags the soiled linen when resident is in isolation, otherwise she just rolls it up and takes it to the soiled utility room. V5 (CNA) stated, this is how they are taught in the in service. V5 (CNA) agreed that holding the soiled linen close to her body could cause contamination / infection to herself and others. On 2/7/24 at 9:42 AM, V6 (LPN) stated, Soiled linen should be bagged before bringing it out of the resident's room and taken to the dirty utility room to avoid cross contamination. On 2/8/24 at 10:43 AM, V2 (DON-Director of Nursing) stated, soiled linen should not be placed on the floor. It must be put into a plastic bag and be bagged before transporting it to the soiled utility room. 48944 3. The EMR (Electronic Medical Record) showed R25 had multiple diagnoses including recurrent urinary tract infections, calculus of the kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023 showed R25 had urinary and bowel incontinence. The MDS continued to show R25 was dependent on with toileting hygiene and required substantial to maximal assistance with bed mobility from facility staff. On 2/06/2024 at 12:55 PM, V10 (Certified Nurse Assistant/CNA) was leaving R25's room and walking down the hallway towards the soiled utility room. V10 was holding a soiled incontinence cloth pad with an ungloved hand and the pad was not bagged. V10 proceeded to enter the soiled utility room and dispose of the soiled incontinence cloth pad. V10 said she performed incontinence care for R25 and had just disposed of the R25's soiled incontinence cloth pad in the soiled utility room. On 2/08/2024 at 9:39 AM, V2 (Director of Nursing/DON) said soiled items should be bagged and disposed of accordingly, and soiled items should be handled with gloved hands for infection control. The facility's Linen Management policy with a review date of 5/18/2023, showed It is the policy of the facility to ensure linens are handled in a way to prevent cross contamination and the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure .6. Dirty linens are contained in a closed container or bag. 7. Dirty linen are not to come in contact with staff clothing. The facility's Handwashing/Hand Hygiene policy with a review dated 4/18/2023, showed This facility considers hand hygiene the primary means to prevent the spread of infection .9. Single-use disposable gloves should be used: Before aseptic procedure; When anticipating contact with blood or body fluid .

Based on observation, interview, and record review, the facility failed to have functional call lights. This applies to 2 of 3 residents (R8 and R266) reviewed for call lights in a sample of 23. The findings include: On 2/6/24 at 10:51 AM, R266 was in bed watching TV. R266 said he needed to be changed and asked Surveyor to change him. Surveyor asked R266 to use his call light to call facility staff; R266's call light did not light up outside R266's room. At 10:57 AM, Surveyor pushed R266's call light and it still did not light up outside the room. At 11:00 AM, V12 (Restorative Aide) was walking down the hallway, Surveyor asked which CNA (Certified Nurse Aide) was assigned to R266 and that the call light was not working, V12 was not aware that R266's call light was not working. V12 said she would inform the CNA assigned and would check on the call light. V10 (CNA) came in to R266's room and said she was not aware that the call light was not working. V12 returned to R266's room, said Maintenance staff said there's a bell in the room for the resident to use. V10 and V12 searched for the bell in R266's room and found it in the bedside drawer. V10 and V12 were not aware that the bell was in R266's room. R8 was R266's roommate and when Surveyor pushed R8's call light, that call light did not work either. R8 had a call bell on his bedside table and the bedside table was not within R8's reach. On 2/7/24 at 9:53 AM, R266's and R8's call lights were still not working. R266 was sitting in his wheelchair with the call bell on his bedside table, within reach. R266's call light was on the bed. R266 said he knew how to use the call light but was not aware of why there was a call bell on his bedside table. R8 was in bed resting at this time. R266's MDS (Minimum Data Set) of 2/1/24 shows that R266's cognition was moderately impaired. R8's MDS of 12/30/23 shows that R8's cognition was severely impaired. On 2/7/24 at 3:41 PM, V1 (Administrator) said the call light should be in working condition and residents should be educated on how to use the bell or alternate call system when the call light is down so residents can notify staff when they need help. The facility's Call Light Use policy (reviewed date 7/6/23) states the call system is utilized to alert staff of resident's needs.

Based on observation, interview, and record review, the facility failed to ensure resident rooms were maintained as sanitary, odor-free, and homelike environments. This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for dignified care in a sample of 4. Findings include: 1. On 3/22/23 at 9:20 AM, R1 was on his bed with a urinal with urine on the bedside table. R1 stated, The urinal with urine was sitting there for more than 30 minutes, causing the smell. On 3/22/23 at 9:30 AM, V4 (R1's Nurse) stated, The urinal with urine shouldn't be on the bedside table We will continue to educate residents not to put them on the bedside table 2. On 3/22/23 at 9:55 AM, R2 was on his bed. An uncovered, foul-smelling urinal with no date/label was on his bedside table near a glass of juice and a coffee mug. At 9:58 AM, R2 stated that he doesn't recall how long he has been using that urinal. R2 drank from the juice glass, stating I have my medication in it. 3. On 3/22/23 at 10:20 AM, R3 was on his bed. A strong odor of urine was present upon entering R3's room. At the surveyor's request, V7 CNA (Certified Nursing Assistant) checked on R3 for incontinence. R3 was wearing two incontinence briefs. The inner brief was soaked with urine, causing a strong urine odor. V7 stated that she would change R3, and he should not be wearing two incontinence briefs. 4. On 3/22/23 at 12:50 PM, R4's call light was going off and a urinal with urine was on the bedside table. R4 stated he had been waiting more than ten minutes for staff to empty his urinal. On 3/22/23 at 10:45 AM, V2 (Director of Nursing) stated, The urinals shouldn't be on the bedside tables .they should be on the side rails. We are educating residents not to put urinals on the bedside tables .The residents should have an odor-free environment .and it's not acceptable to have double briefs on residents. The facility presented guidelines on Disposable Patient Care Items document : 2. Bedpans and urinals will be emptied and rinsed out after each use. They will be replaced as needed.

Based on observation, interview, and record review the facility failed to serve food in a sanitary manner to prevent cross contamination. This applies to all 70 residents that consume meals orally. The Findings include: The facility census list of January 9, 2023, documents 71 residents in the facility. V2 (Director of Nursing/DON) stated during an interview of January 12, 2023, at 3:55PM that only one resident is NPO (Nothing Per Oral) in the facility. On January 9, 2023, at 12:09 PM, V16 (Cook) was observed preparing and plating food from the steam table. The menu was Tuscan chicken breast, spaghetti noodles, mixed vegetables, garlic toast. V16 was observed using tongs for the spaghetti noodles and then using his gloved hand to place noodles on the plate. At times V16 was noted to use his gloved hands to pick up the chicken and move the noodles onto to the plate. V16 was observed to garnish the plate of chicken, noodles, and vegetables by dipping his hand into the container of parmesan cheese. V16 would wipe his gloved hands on his soiled apron and adjust his facial mask throughout the lunch meal. V16 did not change his gloves or wash his hands during this observation. V15 (Food Service Director) confirmed during interview of January 11, 2023, at 12:50 PM that when serving food, staff must use serving utensils for each food item to prevent cross contamination. V15 also added that using gloved hands to serve food in not an appropriate technique.

Based on observation, interview, and record review the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 6 of 6 residents (R9, R13, R15, R35, R42 and R264) reviewed for ADL (activities of daily living) in the sample of 19. The findings include: 1. R9 has multiple diagnoses which includes chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, osteoarthritis, Parkinson's disease and dementia without behavioral disturbance, based on the face sheet. R9's quarterly MDS (Minimum Data Set) dated November 10, 2022, showed that the resident is moderately impaired with cognition. The same MDS showed that R9 required extensive assistance from the staff with most of her ADLs, including personal hygiene. On January 9, 2023, at 12:21 PM, R9 was in bed, alert and verbally responsive. R9's fingernails were long with black substances underneath. R9 stated that she wants the staff to clean and trim her fingernails. V4 (LPN/Licensed Practical Nurse) was informed of the condition of R9's fingernails. V4 stated, Resident would scratch herself, she should have her fingernails short. R9's active care plan showed that the resident has an ADL self-care performance deficit. 2. R13 has multiple diagnoses which includes senile degeneration of brain and osteoarthritis, based on the face sheet. R13's significant change in status MDS dated [DATE], showed that the resident is severely impaired with cognition. The same MDS showed that R13 required extensive assistance with most of her ADL, including personal hygiene. On January 9, 2023, at 10:56 AM, R13 was sitting in her wheelchair inside her room. R13 was alert but confused and would respond to simple questions only. R13's fingernails were long, jagged with black substances underneath. V5 (CNA/Certified Nursing Assistant) was present during the observation. R13's active care plan showed that the resident has an ADL self-care performance deficit. 3. R15 has multiple diagnoses which includes chronic diastolic (congestive) heart failure, dysphagia (oral phase), protein-calorie malnutrition, developmental disorder of scholastic skills, cerebrovascular disease and dementia without behavior disturbance, based on the face sheet. R15's significant change in status MDS dated [DATE], showed that the resident is severely impaired with cognitive skills for daily decision making. The same MDS showed that R15 required extensive assistance from the staff with most of her ADLs including personal hygiene. On January 9, 2023, at 11:18 AM, R15 was in bed, awake but non-verbal. R15's fingernails were long, jagged and with black substances underneath. V4 (LPN) who was present during the observation stated that R15's fingernails needed cleaning and trimming. R15's active care plan showed that the resident has an ADL self-care performance deficit. 4. R42 has multiple diagnoses which includes type 2 diabetes mellitus with diabetic nephropathy, giant cell arteritis with polymyalgia rheumatica and morbid (severe) obesity due to excess calories, based on the face sheet. R42's annual MDS dated [DATE], showed that the resident is cognitively intact. The same MDS showed that R42 required extensive assistance from the staff with most of his ADLs, including personal hygiene. On January 9, 2023, at 10:44 AM, R42 was in bed, alert and verbally responsive. R42's fingernails were long, jagged with black substances underneath. R42 stated that he wants the staff to clean and trim his fingernails. V3 (Assistant Director of Nursing) was informed of R42's fingernails and the request of the resident. R42's active care plan showed that the resident has an ADL self-care performance deficit. On January 11, 2023, at 11:14 AM, V2 (Director of Nursing) stated that it is part of the facility's nursing care to clean and trim all residents' fingernails, especially for those residents' needing assistance, to maintain personal hygiene. The facility's fingernail care guideline dated September 2013 showed in-part, 1. Resident fingernails will be inspected during morning and evening ADL care, for cleanliness, length, and that no sharp or jagged edges are present. 2. Hand hygiene will be performed with ADL care and as needed to ensure nails are clean. 3. If nails are long or have sharp/jagged edges, the nails are to be trimmed.6. Clean the resident's nails. 45303 5. The EMR (Electronic Medical Record) showed R35 was admitted to the facility on [DATE], with multiple diagnoses including dementia, dysphagia, and pubic fracture. R35's MDS (Minimum Data Set) dated November 9, 2022, showed R35 has severe cognitive impairment and required extensive assistance from facility staff for personal hygiene. On January 9, 2023, at 10:37 AM, R35 was sitting in her wheelchair in her room. R35's nails were long, cracked, and jagged. R35 said I do not like my nails long, I would like them cut. On January 10, 2023, at 3:50 PM, R35 was sitting in her wheelchair in the hallway. R35's nails were long, cracked, and jagged. R35 said, I got my hair washed, but my nails are not cut. 6. The EMR showed R264 was admitted to the facility on [DATE], with multiple diagnoses including morbid obesity, diabetes, congestive heart failure, lymphedema, and cellulitis of buttock. R264's MDS dated [DATE], showed R264 was cognitively intact. The MDS continued to show R264 has a limitation in range of motion on both lower extremities, was not steady and only able to stabilize with staff assistance when making surface-to-surface transfers and uses a wheelchair for mobility. The MDS showed R264 required extensive assistance of facility staff for personal hygiene and bathing did not occur during the MDS observation period. On January 9, 2023, at 11:08 AM, R264 was in his room, lying in bed. R264 appeared unkempt and R264's hair had a wet, greasy appearance. R264 said, My hair is not wet, it is greasy. I do not get showers, I get bed baths, and they have a hard time washing my hair when I am in bed. I do not get bed baths twice a week and sometimes I do not get them once a week. I would like to be bathed at least twice a week, I am supposed to get them on Wednesdays and Saturdays. I would like to take a shower, but I was told I cannot get into the shower room because I require a [full body mechanical lift]. On January 11, 2023, at 1:02 PM, V2 (DON/Director of Nursing) said, [R264] can have a shower if he wants one, there is no reason he cannot have one. The facility provided documentation dated January 11, 2023, to show R264 received baths on the following dates: October 26, 2022 November 2, 2022 November 5, 2022 November 9, 2022 November 18, 2022 November 23, 2022 November 26, 2022 November 30, 2022 December 7, 2022 December 10, 2022 December 20, 2022 December 21, 2022 December 24, 2022 January 4, 2023 January 7, 2023 The facility does not have documentation to show R264 received two showers and/or bed baths a week as per the facility policy and as per R264's preference. The facility policy titled, BATHING, revised on 5/21 showed Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse), and Certified Nursing Assistant. Guideline: 1. All residents are given a bath or shower at least once per week, based on resident preference, by the Certified Nursing Assistant. 2. If a resident requires a bed bath, a complete bed bath is given two times per week, and a partial bed bath the other days.

Based on observation, interview and record review, the facility failed to ensure a resident identified as an elopement risk was provided adequate supervision to prevent elopement from the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on May 25, 2021 when R1 eloped from the facility without being witnessed by facility staff. This applies to 1 of 4 residents (R1) identified by the facility as high risk for elopement in the sample of 8. V1 (Administrator), V2 (DON-Director of Nursing), and V12 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on June 3, 2021 at 11:55 AM. Although the immediacy was removed on June 3, 2021 at 4:45 PM, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of new policies and procedures and Quality Assurance monitoring. The findings include: The facility's initial incident report dated May 25, 2021 shows, Description of Occurrence: On 5/25/2021, at approximately 10:45 PM, staff observed [R1's] empty wheelchair at the nurse's station. Staff began search for the patient and found patient outside in front of the building in the parking lot lying down face up. Head to toe assessment was completed with no apparent injury. Resident did not have signs of any bleeding. Resident complained of bilateral knee and right hip pain. MD was notified and 911 was called. Patient was transferred to [Local Hospital]. Resident returned with no injuries. The facility's final incident report dated May 31, 2021 shows: Investigation and Conclusion: Based on all the evidence and staff reports, it is most likely that a staff member must have disarmed the alarm at the nurse's station instead of going to the front door to check if it was a staff member since it was during the change of shift. The facility is located on Illinois Route 71, a four-lane highway. The distance from the front door to the highway is approximately 160 feet. On June 1, 2021 at 10:37 AM, R1 was lying in his bed fully dressed. Attempts to interview R1 were unsuccessful due to R1's confusion. R1 does not recall leaving the facility on May 25, 2021, falling in the parking lot, or going to the local hospital. V2 (DON) was standing outside of R1's room and said the resident has a history of trying to leave the building and frequently states he is going out to look for his wife in his van. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, dementia, cognitive communication disorder, Alzheimer's Disease, history of falling, PVD (Peripheral Vascular Disease), major depressive disorder, history of TIA (Transient Ischemic Attack), hypertension, and [CONDITION(S)] (Chronic Obstructive Pulmonary Disease). R1's MDS (Minimum Data Set) dated May 12, 2021 shows R1 has severe cognitive impairment, requires supervision with locomotion off the unit and eating, is totally dependent on facility staff for bathing, and requires extensive assistance with all other ADLs (Activities of Daily Living). R1 has no functional limitation in range of motion on the upper or lower extremities, and normally uses a wheelchair for mobility. R1 is frequently incontinent of bowel and bladder. R1's elopement screenings dated November 11, 2020, February 5, 2021, and May 6, 2021, show R1 is an elopement risk. Nursing documentation shows multiple concerns regarding R1's wandering/elopement behavior including: April 6, 2021 at 6:23 AM, nursing documented, Resident was up on and off the whole night with very little sleep. He was restless, looking for his wife. Reoriented and assisted to bed multiple times this shift. He attempted to go out the back door twice. April 27, 2021 at 4:02 AM, R1 was seen wandering up and down the hallway. Staff found the resident coming out of another resident's room. On June 1, 2021 at 10:07 AM, V1 (Administrator) stated that all employee badges used to swipe in and out of the facility through locked doors had been disabled to ensure staff entered and exited through the front door. V1 stated badges had been disabled since March or April 2020 because of COVID screening procedures. V1 stated that since the badges are disabled, employees now set off the door alarm if they open the front door between 8:00 PM and 7:30 AM because the doors are automatically locked by the alarm system. V1 continued to say, The alarm was not sounding at the time the resident was outside the building, so someone shut it off at the nurse's station and didn't go check the door. That is the only conclusion I could come to. On June 1, 2021 at 10:47 AM, observations of the door alarm system were made with V11 (Environmental Services Director). Every exit door in the facility was observed. V11 demonstrated how the facility has multiple alarm keypads throughout the facility. V11 said any sounding door alarm can be disabled from any keypad throughout the facility without physically going to the alarming door to investigate the reason for the sounding alarm. On June 1, 2021 at 11:48 AM, V5 (LPN-Licensed Practical Nurse) said, I was not assigned to care for [R1] on May 25, 2021. [R1] likes to roam around. I was at the end of the 100 hallway working and kept him with me for a while. He is a huge exit seeker. He can self-propel his wheelchair. He doesn't use his arms; he uses his feet and goes all over the place. I last saw him around 10:00 PM, sitting at the nurse's station with [V6] (RN-Registered Nurse) and [V7] (RN). I would say that after I did all my tasks, I got back to the nurse's station around 10:45 PM, and that was when I saw [R1's] wheelchair sitting at the nurse's station empty. [V3] (CNA-Certified Nursing Assistant) and [V4] (CNA) were sitting at the computers doing their charting. I did not see [the Nurses]. I said to the CNAs where is [R1]? His wheelchair is here but he's not. The CNAs said they did not know where he was. Sometimes [R1] will get up and he will try to walk. We started looking all over for the resident. [V7] (RN) went out the front door to look for [R1] and found him lying in the parking lot. The resident was found about 1-1/2 to 2 feet away from the rocks. Next is a small strip of grass, then the sidewalk, and then the highway. It was drizzling out, but it wasn't a downpour. His back was all wet, but he was not drenched. He was lying face up and the front of his body was damp from the rain. It was chilly. He was fully dressed. The front door always alarms once the receptionist leaves at 8:00 PM. The alarm is constantly going off. Could it have gone off? Yes. With the shift change, I truly believe we've become complacent with the alarm keypad code. I believe someone hit the code and didn't know [R1] went out. None of the cameras were working at the desk that night. They would rotate and it would just keep flip-flopping so we could see main areas like the lobby, front entrance, or parking area. At the end of every hallway there's a keypad that disables any door alarm. I have not received any elopement training or door alarm training since the incident on May 25, 2021. On June 1, 2021 at 12:24 PM, V4 (CNA) said, I was assigned to [R1's] hallway the night of May 25. I started working at 10:00 PM that night. I saw him sitting with the nurse at the nurse's station. I was answering the call lights for 200 and 300 hallways. I went and answered some call lights. When I returned the empty wheelchair was sitting there and [V3] (CNA) asked me who's wheelchair was sitting there. [R1] likes to roam around. When we knew it was [R1's] we started looking for him. One of the nurses found the resident outside in the parking lot on the ground. I am not sure why the alarm didn't go off that night. There was no alarm sounding saying the door had opened when we saw the empty wheelchair. Sometimes if you put the code in the keypad, it will disable the alarm. After this happened there was no training that I'm aware of regarding alarms or anything. I only had to write out a statement of what happened. We've never been assigned to make sure the front door is locked. On June 1, 2021 at 12:47 PM, V6 (RN) said, I was in charge of the hallway where [R1] resides. That evening I was at the nurse's station with [V7] (RN). [R1] was sitting there too. He was right next to my chair. It's the only way I can keep my eye on him. It was between 10:00 PM and 11:00 PM. It's a busy time. I hadn't had a break that night, and I was behind. I had to leave the nurse's station to look for a medication that needed to be given to another resident. When I left the station [V7] was sitting there. I did not ask him to supervise [R1] while I was away from the nurse's station. I went to the medication cart and then I went to the resident's room to give the medication. When I came back, the CNA said another resident wanted her [CONDITION(S)] (Continuous Positive Airway Pressure) machine so I had to go to that room. That resident asks a lot of questions and I ended up being in the room for a long time, putting her laptop away and doing other things for her, and then her roommate also wanted her [CONDITION(S)] machine put on so I had to do that. It took me a long time to get both residents on the [CONDITION(S)], and then I heard the other nurses saying [R1] was missing and only his wheelchair was left. I don't recall hearing the alarm. I have no idea how he got out the front door. The resident room I was in is all the way down at the end of the hallway and far from the front door. No one on our shift checks the front door to make sure the alarm is turned on at 8:00 PM. Since the resident eloped, I have not received any additional training on door alarms or elopement. On June 1, 2021 at 1:06 PM, V2 (DON) said, facility staff must enter and exit through the front door of the building to ensure employees complete COVID screening prior to the start of their shift. Employee swipe cards were deactivated sometime in March or April 2020, but the door alarms are still working. After the receptionist leaves at 8:00 PM, the front doors automatically lock. I have no idea how [R1] got out of the building. No one saw him leave. My first call I received was from [V7] (RN) saying the resident was outside in the parking lot. The front door does not have to be in direct visual sight to be disabled. It can be disabled from any keypad in the building. No one is assigned to go around and make sure the doors are locked. Since the elopement of [R1] we have not done any training for facility staff regarding the procedure for door alarms when they are sounding or disabling the door alarms and ensuring all residents are accounted for. On June 1, 2021 at 5:05 PM, V7 (RN) said, I was sitting at the nurse's station with [V6] (RN). I was focusing on my charting and did not notice [R1] sitting there. I was doing my admission on the computer. [V6] left the nurse's station. She did not ask me to supervise [R1] during her absence. I left the nurse's station to use the restroom near the nurse's station. I heard the staff calling out for [R1] and looking for the resident. I immediately went outside because I had a suspicion. I did not hear any sounds or the door alarm before I went outside. When I went out the front door, the alarm sounded. When I looked in the parking lot, I saw someone waving at me in the lying position. I knew it was him. I called for help. Usually when a staff member leaves the building after their shift, we tell someone we are leaving, and that person will reset the door alarm. If no one says they are leaving, and you hear the alarm we should have a protocol. Possibly I think the alarm could have malfunctioned, I am not sure. It is possible I, or anyone, could have pushed the button to disable the alarm, I don't remember. The responsibility belonged to [V6] to watch the resident. He was assigned to her. I stick to the 400 hallway and I'm not familiar with him. Since the elopement, they reactivated our swipe cards, so the door alarms don't sound anymore when employees leave the building. I don't know why they didn't do that before. When you have call lights going off all the time and the alarms going off all the time and no receptionist, there's no way we can do it all. There just aren't enough of us. On June 1, 2021 at 06/01/2021 2:57 PM, V10 (Service Technician) said he was called to the facility on [DATE] for service. They wanted a hard box over the keypad that is mounted to the wall behind the nurse's station. That way the staff would have to physically go to the doors to disable the alarm and not use the keypad at the nurse's station. They were having their maintenance guy put the cover over the alarm keypad is what I was told. They wanted to disable the keypad, so the staff physically must go to the front door to check the alarm. I did not disable the keypad. I did not check to see if the front door alarm was working properly. They told me the alarm was functioning completely and was disarmed by the staff, so I never had to check to see if the alarm was working. At no time did I check the door to make sure it was working. The facility staff should be checking the functionality of the door alarms that automatically lock. Especially after time changes. The keypad behind the nurse's station was observed on June 1, 2021. No clear cover was observed over the keypad. On June 1, 2021, the facility identified R1, R2, R3, R4, R5, and R6 as residents at risk for elopement. On June 8, 2021, V2 (DON) stated R4 and R5 were no longer considered to be elopement risks and would be removed from the elopement risk list. The facility's guideline entitled Elopement dated 8/05 and reviewed on 7/17 shows: II. Elopement Risk Guideline: .8. Residents at risk to elope will be checked at least every two hours or more based on needs and risks. 10. Access doors on each unit are alarmed so that staff can secure the environment rather than the resident and can intercede when a resident wants to leave the unit. 11. All facility staff are responsible for responding to a door/elevator alarm immediately. This response will include visual check of the immediate vicinity surrounding the door/elevator that tripped the alarm, including the stairwells and outside area. Elopement Procedure: .3. When the resident is found: .d. Upon return of the resident to the facility, the nursing department will: Examine the resident for injuries. Appropriately document the event and update the care plan. Review the event with all staff who participated to ensure readiness for any future elopement. Institute a monitoring schedule for the resident. Through observation, interview and record review conducted on June 7, 2021, the surveyor confirmed that the facility took the following actions to remove the immediacy of the situation: Education/training was provided to all staff regarding supervision and staff accountability of residents identified as elopement risk. Education was completed by midnight on June 4, 2021. New hires will be educated during core orientation process, prior to starting. Staff on FMLA (Family and Medical Leave Act) and vacation will be made to educate prior to midnight on June 4, 2021. If unable to reach employee, the employee will not be allowed to return to work until education is completed. Education will be completed weekly for four weeks, and then monthly for three months. Facility documentation provided on June 7, 2021 shows four employees are currently on FMLA, and five employees are currently on vacation. Education/training was provided to all staff on the process of door alarms sounding. Education was completed by midnight on June 4, 2021. New hires will be educated during core orientation process, prior to starting. Staff on FMLA and vacation will be made to educate prior to midnight on June 4, 2021. If unable to reach employee, the employee will not be allowed to return to work until education is completed. Education will be completed weekly for four weeks, and then monthly for three months. Alarm keypads were secured at eight locations, except for the front desk, where the alarm will be shut off only after the site where the alarm is sounding is cleared. The clear securement devices are locked. Keys will be held by the maintenance director and Administrator. This was completed by June 4, 2021. Functionality of door alarms on doors with automatically timed locks (front door, boiler room door, kitchen door, and delivery door) were checked starting June 3, 2021 at 8:03 PM. This will be done weekly for four weeks, and then monthly thereafter. Log sheets were checked to ensure compliance. Interior doors to the kitchen will be checked every night prior to end of shift at 8:00 PM by the receptionist. Log sheets were checked to ensure compliance. An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held on June 3, 2021. Attendance log was reviewed. .

Based on observation, interview, and record review the facility failed to obtain physician ordered resident weights, ensure residents received dietary supplements, and failed to offer a planned menu for a resident receiving finger foods. This failure resulted in R1 experiencing a 23 pound weight loss over a 4 week time period and voicing concerns about experiencing weakness due to his weight loss. This applies to 3 of 4 residents (R1, R2, R4) reviewed for weight loss in the sample of 4. The findings include: 1. On (MONTH) 6, 2019 at 9:40 AM, R1 said, I've only been here about a month and I've lost so much weight. I feel like losing all this weight is just making me weaker and weaker. It is hard to feed myself with the tremors I have in my arms and hands. No one has asked me what I would like that would make me eat more. I do like bananas. They never bring me a banana. The dietitian said she would have them bring me a banana for breakfast today but they did not. I did not get yogurt with my breakfast yesterday or today, and I did not get the (nutritional frozen dessert) yesterday or today. I really don't like the super cereal, but no one from the kitchen has asked me what I would like instead of that. On (MONTH) 6, 2019 at approximately 1:00 PM, R1 was sitting in his bed. R1 was feeding himself a cheeseburger. R1's diet ticket showed R1 receives a general diet, and should have received a nutritional frozen dessert, Greek yogurt, weighted utensils, and offer sandwich and finger foods R1 said he did not receive the nutritional frozen dessert, Greek yogurt or any other foods with his hamburger. R1 said he was not offered the menu items of carrots, pineapple or dinner roll. On (MONTH) 6, 2019 at 1:35 PM, V10 (FSD-Food Service Director) said R1's breakfast tray and lunch tray was plated by V11 (CNA-Certified Nursing Assistant) and not the food service staff, so he could not say why the resident was not served all menued and physician ordered items. The facility Daily Spreadsheet for (MONTH) 6, 2019 showed residents on a general diet should have received honey glazed carrots, pineapple tidbits, a dinner roll and margarine in addition to the main entree of chicken and dumplings for lunch. R1 did not receive the carrots, pineapple tidbits or dinner roll with his hamburger. On (MONTH) 6, 2019 at 9:25 AM, V11 (CNA-Certified Nursing Assistant) said, I am frequently assigned to (R1) during the day shift, which ends at 2:00 PM. He feeds himself but I stay close by in case he needs help. He likes to eat bacon and cranberry juice for breakfast. At lunch I usually get him a peanut butter and jelly sandwich or grilled cheese. He's never had super cereal or (nutritional frozen dessert) or Greek yogurt from me. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on (MONTH) 5, 2019 with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 12, 2019 shows R1 is cognitively intact, requires supervision with one person physical assistance for eating, extensive assistance with dressing, transferring between surfaces, bed mobility, personal hygiene, and bathing, and is totally dependent on facility staff for toilet use, and locomotion on and off the unit. R1 has impairment on both sides of his lower extremities and uses a wheelchair. R1 has an indwelling urinary catheter, and always has bowel incontinence. R1's Order Summary Report dated (MONTH) 5, 2019 to (MONTH) 6, 2019 shows an order dated (MONTH) 5, 2019 for weekly weights x 4 every day shift every Monday for four weeks. Facility documentation shows R1 was weighed on admission on (MONTH) 5, 2019 and his weight was 165.9 pounds. The facility did not obtain R1's next weight until (MONTH) 15, 2019, at which time R1 weighed 153.2 pounds; a 7.66 percent weight loss in ten days. R1 was next weighed on (MONTH) 31, 2019, at which time R1 weighed 142.2 pounds; a 14.29 percent weight loss since R1's admission 26 days earlier. The facility did not have documentation to show R1 was weighed every week as ordered by the physician. On (MONTH) 6, 2019 at 1:01 PM, V10 (FSD) said, When we get a new resident, the dietitian usually comes to see them within the next week and does their nutritional evaluation. We don't go to the resident's rooms to ask about their food likes and dislikes or dietary preferences. We used to have someone here who did that, but we haven't had that person since late last year, so no one from our kitchen staff really addresses the resident's food preferences. On (MONTH) 7, 2019 at 10:25 AM, V11 (Cook) said, If a resident has a diet with finger foods, we can do several things, including dicing up the meat here in the kitchen before the food goes out to the room, or serving something like chicken tenders. (V10) usually talks to the resident. He can take the weekly menu into the resident's room and go over the menu with the resident and see what changes they want to make to the menu so that we know what the resident wants to eat. We have several residents here that he has done that for, but I don't have anything that shows that was done for (R1). On (MONTH) 5, 2019 at 1:45 PM, V4 (Dietitian) said she had added super cereal and (nutritional frozen dessert) for R1's meals and that facility staff should be checking the ticket when they provide meals to R1 and making sure the items are on his meal tray. V4 said, The main reason (R1) was losing weight was his medication and diarrhea. His daughter made some suggestions. We agreed to do a (liquid nutritional supplement) in addition to the other items. Today he agreed to have (liquid nutritional supplement) three times a day. The tremors, diarrhea, and antibiotics contributed to his weight loss. The facility has a dietary manager, but he doesn't get dietary preferences from residents. They are between people, but they haven't been doing that for residents. On (MONTH) 7, 2019 at 3:45 PM, V10 (FSD) said the facility does not have a planned menu for R1's finger food diet. The facility's Menu Handbook, revised in (MONTH) (YEAR) shows: General Diet - The General Diet is planned according to the USDA MyPlate and HCFA guidelines. Three meals per day and a night snack are provided, with a minimum of the following foods: 6 ounces of meat or meat substitute, 5 fruit and vegetable servings, 6 bread or other grain servings, and two 8-ounce servings of milk. Finger Foods is a meal plan that includes foods that are easily picked up with fingers. This includes items served in a bowl, mug or cup that can be picked up. The Food Guide Pyramid Guidelines are followed, as able, on this diet. The Finger Foods diet can be modified for additional calorie and protein needs of the residents. On (MONTH) 6, 2019 at 12:17 PM, V7 (Physician) said, They never called me about (R1's) weight loss. That is a significant weight loss. It's fair to say his weakness can be attributed to his weight loss. 2. R2 was reviewed for weight loss during record review. The EMR shows R2 was admitted to the facility on (MONTH) 9, 2019 with multiple [DIAGNOSES REDACTED]. R2 was discharged from the facility on (MONTH) 5, 2019 at 11:55 AM. R2's MDS dated (MONTH) 18, 2019 shows R2 is cognitively intact, is able to eat with supervision and set up help only, and requires extensive assistance for all other ADLs. R2 is frequently incontinent of urine and always incontinent of stool. R2's Order Summary Report dated (MONTH) 9, 2019 to (MONTH) 5, 2019 shows an order dated (MONTH) 9, 2019 for daily weights every day shift. The facility documentation shows R2 refused to be weighed on (MONTH) 10 and 11, 2019. The facility did not have documentation to show R2 was weighed on (MONTH) 12, 13, 14, 15, 17, 20, 21, 22, and 25, 2019. R2's weight on admission was recorded at 187.6 pounds. On (MONTH) 6, 2019 at approximately 4:00 PM, V2 (DON-Director of Nursing) said R2's weight on admission was entered into the EMR incorrectly by the facility nurse because she used the documented weight from the hospital which is not acceptable to use as an admission weight. V2 said the first weight obtained for R2 at the facility wasn't until (MONTH) 16, 2019, which was 173.2 pounds, a week after the resident was admitted . On (MONTH) 23, 2019 R2 weighed 162.6 pounds, a 10.6 pound weight loss or 6.12 percent. R2 weighed 162.8 pounds when he discharged from the facility on (MONTH) 5, 2019. Facility documentation shows V4 (Dietitian) saw R2 on (MONTH) 11, 2019 and recommended 80 ml (milliliters) of 2 calorie/ml supplement, three times a day. The medical record shows the supplement was not started until (MONTH) 24, 2019. 3. On (MONTH) 6, 2019 at 1:10 PM, R4 was sitting in her room. R4 said, I have lost a lot of weight since I came here. I talked to the dietitian about it a little over a week ago. She said she was going to start me on some supplements, but that never happened. I asked the nurse about it, and she said it was never ordered. Now all of a sudden today it started. On (MONTH) 5, 2019 at 1:45 PM, V4 (Dietitian) said, she completed R4's initial dietary assessment on (MONTH) 31, 2019 and recommended two nutritional supplements, including 30 ml of protein supplement daily and 80 ml of a house supplement three times a day. As of (MONTH) 5, 2019 at 4:00 PM, the facility did not have documentation to show the dietary recommendations for R4 had been addressed or ordered. V4 said, I give all of my recommendations to the DON on the same day I'm here and I wrote that. It's up to her to follow through with the physician to get the orders. The EMR shows R4 was admitted to the facility on (MONTH) 22, 2019 with multiple [DIAGNOSES REDACTED]. R4's MDS dated (MONTH) 29, 2019 shows R4 is cognitively intact, requires supervision with set up only for eating, limited assistance for all other ADLs, and was not rated for bathing due to that activity not taking place. R4 is occasionally incontinent of bladder, and was not rated for bowel continence. R4's Order Summary Report dated (MONTH) 22, 2019 to (MONTH) 6, 2019 shows an order dated (MONTH) 22, 2019 for weekly weights x 4 every day shift every Monday for 4 weeks. The EMR shows R4's weight on (MONTH) 22, 2019 was 163.8 pounds. The facility did not have documentation to show the facility followed the physician's orders [REDACTED]. Facility documentation shows R4 weighed 153.8 pounds on (MONTH) 5, 2019, a difference of 10 pounds or 6.11 percent. The facility's Nutrition Assessment Policy dated (YEAR) shows: Dietary personnel including director of food and nutrition services, diet technicians and diet clerks provide initial nutrition assessments, quarterly nutritional assessments and annual nutrition assessments. The consultant dietitian provides in-dept nutrition assessments for clients whose medical condition(s) may place them at nutrition risk. Procedure: Nutrition assessment data may include body mass index, usual body weight, height, weight, diagnosis, diet, level of mobility, self-help required, vision, oral status, alertness, food preferences, nutrition-related lab values, skin condition, client's appearance and an estimation of needs. The dietitian will provide random checks of the nutrition screens/assessments completed by dietary personnel and this will be noted on the dietary consultant report. The facility's Dietary Recommendation Policy dated (YEAR) shows: Policy: Recommendations made by the dietitian for change(s) in a diet order will be followed up as soon as possible. The dietitian may make a recommendation or the dietary recommendation form is submitted to the director of nursing, the nursing supervisor or person in charge. Nursing is responsible to forward the dietary recommendation to the physician for approval. The facility's Interventions for Weight Loss Policy dated (YEAR) shows Policy: Interventions are provided to address a decline in a client's appetite and food intake, a significant weight loss or an insidious weight loss trend. Procedure: Nutrition interventions can be initiated prior to assessment of the client's nutrition status by the dietitian. Nutrition interventions the diet tech, the director of food and nutrition services or the nurse may initiate include: Give the client their favorite foods even if it means sacrificing variety and a balanced diet. Add ice cream, yogurt, whole milk or fortified foods to the tray if the client will accept extra items. Offer snacks between meals. Request an order for [REDACTED]. The facility's Weight Monitoring Policy dated (YEAR) shows: Policy: To ensure the client maintains acceptable parameters of nutritional status unless their clinical condition demonstrates that this is not possible, the client's body weight is monitored. Procedure. The client is weighed on admission or readmission. Admission weight may be compared to the client's usual body weight if the usual body weight is known. New admissions may be weighed weekly for the first four (4) weeks. Significant weight change is defined at 5% in one month, 7.5% in three months, and 10% in six months.

Based on record review and interview, the facility failed to provide adequate supervision for a resident (R1) at high risk for falls. This failure resulted in R1 falling and sustaining a traumatic brain injury/acute subdural hemorrage requiring emergent craniotomy surgery. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. Findings include: The Face Sheet documents R1 is [AGE] years old with the following Diagnoses: [REDACTED]. The H&P (History and Physical) from the discharging hospital dated 3/19/17 documents: R1 has Parkinson's disease with (status [REDACTED]. R1 has worsening headaches after suffering multiple falls at home. After admission, the patient was discovered with a right frontal ICH (Intracranial hemorrhage) that was treated with a right frontal craniotomy for evacuation of ICH. Cardiology service recommended that the patient be restarted on therapeutic anticoagulation due to a history of mitral valve repair. At this time, the patient has been started on therapeutic bridge with Lovenox with titration of Coumadin. Functional History: has been falling approximately 2x/week recently per wife. The Nurse's Notes and Admission Assessment 4/13/17 completed by E4 (Nurse) documents that R1 was admitted to the facility because of multiple falls. The Interim Care Plan 4/13/17 documents: history of falls, increased weakness; interventions- fall protocol, safety alarms as indicated; goal- will be free from serious injury from falls during stay. Fall Risk Screen documented by E4 (nurse) did not correlate with R1's medical records/documented history. The screen was completed as follows: -Date of admission-over 3 months (score 0); less than 3 months (score 2). E4 checked over 3 months even though R1 was just admitted that day. -History of Falls within last six months- 1-2 times (score 2), Multiple falls (score 5). E4 checked 1-2 times even though she documented on the admission assessment and nursing notes that R1 was admitted for multiple falls. The Incident/Accident report sent to the state surveying agency documented: On 4/13/17 around 11:30PM, staff attended to the alarm that went off and noted patient on the floor with bleeding on patient's head. The statement documented by E3 (CNA/Certified Nursing Assistant) reads: I heard alarm sounding, so I went to the room right away and as I was turning off the alarm, (patient fell backward) bathroom door opened up and pt fell backward to the floor. The Fall Event documents R1 fell on [DATE]. What was resident doing just prior to fall-sitting on the toilet seat in the bathroom. Resident was transported to local medical center due to visible bleeding from the back of the head. The POS (physician's orders [REDACTED]. On 10/26/17 at 10:37am, E3 stated when she came on duty for night shift, she received report and was told R1 was a little confused and continent. E3 stated I did not know if R1 could ambulate, so the instructions were to use a wheelchair. We were not to walk R1. E3 stated she did not see a wheelchair in R1's room; E3 stated when she heard R1's alarm sounding she went to the room. E3 stated By the time I got there R1 had gotten out of bed and was on the toilet. E3 stated I entered the room and noticed R1 wasn't in bed, so I opened the bathroom and saw R1 on the toilet. I said stay right there, pull the cord when you're finished. E3 stated as she was in R1's room turning off the alarm R1 fell backwards out the bathroom door and hit R1's head on the floor. E3 stated E3 did not stay near the door while R1 was in the bathroom. E3 also stated I did not see R1 stand, I closed the door. I did not latch it. I don't know if R1 was trying to flush the toilet but R1 fell out of the bathroom. I did not latch the door. E3 stated she could not see R1 in the bathroom. E3 did not see R1 stand/fix R1's clothing. E3 stated I don't know if R1 was a fall risk, honestly I don't remember. They said he was a little confused. When asked about R1's alarm E3 replied Normally alarms are on residents that are fall risk. I was not told about supervision or monitoring. I did what I normally do if I see residents on the toilet. I gave R1 privacy, R1 looked stable. I had known R1 not even 30 minutes. On 10/26/17 at 11:20am, E4 (Nurse) stated she admitted R1 with [DIAGNOSES REDACTED]. E4 stated she got R1's medical history from the discharging hospital records and R1's spouse. E4 added So I put the alarm right away. When asked when she last saw R1, E4 replied At 7:00PM. R1 was in bed. R1 was really a high fall risk. I asked the aide to make multiple rounds and treated R1 as a high fall risk. E4 stated R1 needs assistance moving from one place to another, so someone should be with R1. We could not leave him in 1 place without anybody there. I told this to the oncoming nurse, they need to make frequent rounds because R1 is high fall risk with a head injury. E4 stated that with R1 being high fall risk someone should've stayed by the door (bathroom). If you stay by the door, that would be fine. Per facility protocol you must stay with the resident at all times, which means by the door. But I reported to the next nurse that R1 was high fall risk. E4 also stated R1 was really, really high fall risk. On 10/26/17 at 3:13pm, E5 (CNA) stated she worked with R1 during PM shift on 4/13/17. E5 documented that R1 urinated 3 times her shift. When asked about where R1 urinated/assistance provided, E5 stated she doesn't remember. E5 stated the facility doesn't document whether the resident used the commode, bed pan or incontinent brief. E5 stated that's how it's in the system, we just document how many times. On 10/26/17 at 11:39am, E2 (Director of Nursing/Falls coordinator/Quality Assurance Director) stated the protocol for high fall risk is to assess the environment and add interventions. E2 stated the policy is to make frequent rounds and frequent checks if the resident requires assistance to toilet. E2 stated R1 was seated when E3 came in. If R1 was standing, I would advise her to be with R1. E2 stated R1 had not had physical/occupational therapy evaluation as of yet. On 10/26/17 at 1:03pm, Z1 (Nurse Practitioner/Provider) stated R1 had multiple medical comorbidities. Z1 stated R1 was not stable to be in the bathroom alone and needed 24 hour care, a sitter. It takes like seconds for people to fall. I think in the back of R1's head, R1 just wanted to get up and go. H&P (History and Physical) received from the local hospital documenting the events relating to the fall/injury R1 sustained on 4/13/17 read: - this is a [AGE] year old patient with past medical history significant for Parkinson's disease. Also history of mechanical aortic valve replacement on chronic Coumadin therapy. Also history of right subdural hematoma after patient sustained a fall in March 2017. Was treated and discharged to the facility for further rehab. The patient subsequently fell again. Patient was brought to emergency room and noted to have a laceration to the back of the head. The CT (Computed Tomography) scan of the brain showed a 1.7cm acute subdural hemorrhage with effacement of the ventricles. INR was reversed. Neurosurgery was consulted. (R1) became less responsive. (R1) was unable to protect (R1's) airway and therefore intubated. (R1) had elevations of blood pressure to systolic blood pressure in the 200s. (R1) underwent emergent evacuation and underwent a craniotomy. (R1) also had a feeding tube placed. On 10/26/17, the facility was asked to provide their Falls policy. The facility's policy titled Falls read: A Fall risk will be completed on admission, readmission, and quarterly, with each significant change and after each fall. -Residents at fall risk will be identified for staff awareness The policy did not address how to care for residents that are high risk for falls.

Based on record review and interview, the facility failed to complete a comprehensive pain assessment for a resident injury. The facility failed to notify the physician of x-ray results and obtain timely transfer orders. This failure resulted in R3 receiving a delay in treatment after falling in the facility and sustaining a fractured left wrist. This applies to 1 of 3 (R3) residents reviewed for falls with injury in a sample of 19. Findings include: The facility's Face Sheet for R3 documents R3 was admitted [DATE] at the age of 92. The Face Sheet lists the following Diagnoses: [REDACTED]. R3's H & P (History and Physical) from the discharging hospital documented: history of dementia. Had a fall. Radiographs reveal pubic rami fracture. The facility's Event Investigation for R3 dated March 25, 2017 reads: E6 (Licensed Practical Nurse/LPN) - I admitted her around 2:40pm. Around 7:30pm, E7 (Certified Nursing Assistant/CNA) stated she heard moaning, so she went to the room and stated she noted pt (patient) on the floor. The written statement by E6 (Licensed Practical Nurse/LPN) documents: Noted small amount of blood on floor next to res (resident) head, noted small laceration 1cm on eyebrow area. Res complained of (c/o) left wrist and left pelvic pain. Noted bruising to left wrist with no swelling. Left wrist did appear to be slightly deformed in alignment. Z12 (Family Member) entered room. Resident immediately asked Z12 to get resident up. The Fall Event form dated March 25, 2017 documents: Resident response to name and pain. Extremity movement/grasp- weak (all 4 extremities), location of pain- left wrist and pelvic. Positioning of extremities- Rotation/deformity of upper left extremity. Nursing Progress Notes documents: March 25, 2017 20:10 Z2 (Medical Doctor) aware of fall and res c/o left wrist and pelvic pain w/ new orders for x-rays. Portable x-ray report: March 26, 2017 2:32am Possible displaced fracture noted involving distal radius. Nursing progress notes: March 26, 2017 03:20 POA was called to let him know the x-ray results. No answer. Message was left for POA. There was no documentation on this shift that Z2 was notified of the x-ray results. On March 31, 2017 at 1:10pm, E4 (Quality Assurance Coordinator/Falls Coordinator) stated that she worked the night of March 25-26, 2017. E4 stated that she received x-ray results for R3 around 3:00am March 26, 2017. E4 stated she did not call Z1 (Medical Doctor/MD) or E2 (Director of Nursing). E4 stated she instead sent them a text message. E4 stated I didn't want to wake E2 because she had been at the facility all afternoon. E4 stated that R3's x-ray showed a possible fracture. E4 stated she did not do any pain assessment for R3. E4 stated she did not speak to Z1 or relay the x-ray results. On April 6, 2017 at 2:11pm, E2 stated the policy for change in condition is to call the physician. E2 stated no specific time frame but as soon as possible. When you get the radiology report. Once you get hold of the results, call the doctor. E2 also stated the Comprehensive pain assessment is done on admission and after the fall. E2 stated R3 triggered for pain, so she has a comprehensive pain assessment. That's why she got an order for [REDACTED]. She finished it at 11:07pm (hours after the fall). She left it open. E2 stated E6 left the assessment open because she had to pass medications. E2 stated the nurses have to do a pain assessment each shift and document on the MAR (Medication Administration Record). The pain assessment for R3 by E6 reads: March 25, 2017 18:05, Do you have pain? No; Have you recently been medicated for pain? No; Have you experienced pain in the last 3 months? No; Are you receiving routine or PRN (as needed) pain medications? Yes. Pain location- Groin. Complete pain assessment quarterly, with significant change, resident self reports of pain, and/or day of discharge. This was the only comprehensive pain assessment in R3's medical record. There was no comprehensive assessment for R3's wrist. On April 6, 2017 at 12:36pm, Z2 (Medical Doctor) stated the facility notified him that R3 had fallen. Z2 stated I sent her to the emergency room for x-rays. On April 6, 2017 at 2:50pm, E1 (Administrator) stated E4 did not call the physician with the x-ray results because it read possible fracture. E1 stated R3 did not complain of pain. E1 also stated E4 did not complete a pain assessment. When asked about the policy for pain assessments, E1 replied I don't have all of them memorized. E1 stated the policy for physician notification with acute change in condition is to email, text or phone him. Z2 keeps his phone right next to him. That's what I was told. I don't sleep with him so I don't know for sure. The Nursing Progress Notes March 26, 2017 10:09am reads: Z2 notified of x-ray results of left wrist with possible mildly fracture. Patient with swelling, bruising and moderate to severe pain with movement/touch to left wrist. Also pt with BP's in the 180's. Send to ER for further eval. The Nursing Progress Notes dated March 26, 2017 documents: Resident taken at 11:00 by ambulance to local hospital for further evaluation on left wrist. The resident is AO X 1, weak. Pain on left wrist 8/10, ice pack used and Tylenol given, not effective. BP 180/85 early morning. E4 did not notify Z2 when she received the portable x-ray results. Z2 was notified on the next shift after the blood pressure is 180s, wrist with bruising and pain severity increasing (nearly 15 hours after the fall/injury). On April 6, 2017 at 5:13pm, Z12 (Family Member) stated he was at the facility on March 25, 2017 (7:30pm) and saw R3 on the floor. Z12 stated R3 was screaming in pain, stating her wrist was broken and was asking him to get her up. R3's discharge summary dated March 26, 2017 at 18:14 documents: admitted to local Medical Center. Hospital admission Diagnoses: [REDACTED]. The facility's policy titled Physician Notification documents: In a non-emergent, but acute medical situation the physician will be paged and if there is no return call in 15minutes, the physician will be notified again. If there is no return call in 5 minutes, the Medical Director will be notified. The facility's policy for Pain Management documents: Pain management is a multidisciplinary care process that includes the following- Observing for the potential for pain Effectively recognizing the presence of pain Addressing the underlying causes of the residents pain

Based on record review and interview, the facility failed to implement fall prevention/safety measures for a resident who was high risk for falls. The facility failed to follow their policy for Fall management. This failure resulted in R3 falling and sustaining a fractured wrist. This applies to 1 of 3 residents (R3) reviewed for falls/injuries in a sample of 19. Findings include: The facility's Face Sheet for R3 documents that R3 was admitted on [DATE] at the age of 92. The face sheet documents the following Diagnoses: [REDACTED]. R3's H & P (History and Physical) from the discharging hospital prior to the facility documents: March 22, 2017 History of dementia; Had a fall; Radiographs reveal pubic rami fracture. The Interim Care Plan for R3 dated March 25, 2017 at 18:26, by E6 (Licensed Practical Nurse/LPN) documents: Potential for fall related to increased weakness; Interventions- Fall protocol. R3's admission assessment by E6 dated March 25, 2017 at 18:29pm documents: Reason for admission- pelvic fracture, UTI (urinary tract infection); Lower extremity movement-weak; device- wheelchair; Risk alerts- Falls; Impairment- cognitive, vision. The call light ability screen for R3 dated March 25, 2017 documents that R3 was unable to follow instructions on how to use call light and unable to return demonstration on how to use call light after 5 minutes. Nursing Notes: March 25, 2017- admitted to facility at 1440 via stretcher. 1935-Grandson here, aware of fall. The facility's Event Investigation for R3 dated March 25, 2017 reads: E6 (Licensed Practical Nurse/LPN) - I admitted R3 around 2:40pm. Around 7:30pm, E7 (Certified Nursing Assistant/CNA) stated she heard moaning, so she went to the room and stated she noted pt (patient) on the floor. Post Fall Huddle/Investigation- Alert and Oriented X 1. The written statement by E6 (Licensed Practical Nurse/LPN) documents: Noted small amount of blood on floor next to res (resident) head, noted small laceration 1cm on eyebrow area. Res complained of (c/o) left wrist and left pelvic pain. Noted bruising to left wrist with no swelling. Left wrist did appear to be slightly deformed in alignment. The Fall Event form dated March 25, 2017 documents: Res said res was trying to get up out of bed and res foot slipped out from underneath res. Resident response to -name and pain. Extremity movement/grasp- weak (all 4 extremities), location of pain- left wrist and pelvic. Positioning of extremities- Rotation/deformity of upper left extremity. The nurse notes for March 25, 2017 documents that Z2 ordered an x-ray of R3's left wrist. The radiology report reads- Possible displaced fracture noted involving distal radius. The nurse's notes then documents that Z2 gave orders to send R3 to the emergency room . On March 31, 2017 at 10:28am, E7 (Certified Nursing Assistant/CNA) stated she was assigned to care for R3 on March 25, 2017. E7 stated she was confused. She didn't know where she was. She wanted to get a hold of her husband. E7 stated she noticed R3 lying on the floor, away from her bed, by the T.V. and dresser. E7 stated apparently she was ambulatory. E7 stated she thinks R3 had a wheelchair. E7 stated she had no information related to R3 being a fall risk prior to the fall. E7 added there were no fall interventions prior to then that I know of. I saw R3 laying (sic) on the floor. E7 stated she went and got E6 and they rolled R3 over and there was blood on the floor. E7 stated R3's arm was behind R3. R3 said R3's arm hurts. R3 was laying on it. E7 stated when staff knows residents are a fall risk, they will place an alarm. E7 stated we put the alarm on the bed after the fall. On March 31, 2017, E6 stated she admitted R3 around 2:40pm. E6 stated at 7:30pm, E7 called her to the room and R3 was lying on R3's left side near the foot of the bed. E6 stated R3's left arm was bent behind R3 and R3 was lying on it. Blood was on the left side of R3's head, on the floor. E6 stated R3 sustained a laceration. E6 stated that R3 requires assistance with ambulating. E6 stated she was not aware of R3 being a fall risk. E6 stated there were no fall prevention measures prior to the fall. R3 complained of left wrist pain, head ache and left pelvic. E6 stated R3 was admitted to the facility because she fell and sustained a fractured pelvis. E6 stated the fall protocol is If I know they are fall risk, they get an alarm. If they are confused, they would get an alarm. R3's Fall Risk Screen dated March 25, 2017 at 18:40 (approximately 1 hour prior to the fall) completed by E6 documents that she scored 23, category: high risk. History of falls within last six months- 1-2 times, Vision pattern- inadequate; unable to independently come to a standing position, requires hand-on assistance to move from place to place, uses an assistive device, decrease in muscle coordination. On March 31, 2017 at 1:10pm, E4 (Falls Coordinator/Quality Assurance Registered Nurse/RN) stated the fall protocol is If we know they are high risk for falls, we give alarms. We didn't know R3 was high risk until the grandson said something after the fall. I didn't realize R3 had fallen at home until after the fall. Staff are supposed to do fall risk assessments on admission. R3 didn't trigger high on fall risk assessment. We didn't know R3's history. If we had known, R3 would've been closer to the front of the hall. That's protocol if high risk. R3 has dementia, but with what was documented and what the CNA said, R3 didn't seem confused. On March 31, 2017 at 8:17am, E2 (Director of Nursing) stated the nurses are not used to the term high fall risk. On April 5, 2017 at 2:11pm, E2 stated E6 completed R3's fall assessment prior to her having a fall. The fall assessment score read 23, high risk. At 4:09pm, E2 stated fall interventions are added for all residents at risk for falls. If they come in and they had a fall, we give interventions. E4 and the corporate nurse are working on our fall program. I will have to look closely at our falls. On April 6, 2017 at 12:36pm, Z2 (Medical Doctor) stated he was not R3's primary MD, and did not get to see her because everything happened in one day. Z2 stated the facility notified him that R3 fell . Z2 stated and I sent R3 to the emergency room for x-rays. Z2 stated he was made aware that R3 sustained a fractured wrist. On April 6, 2017 at 5:13pm, Z12 (Family Member) stated he was at the facility on March 25, 2017 (7:30pm) and saw R3 on the floor. Z12 stated R3 was screaming in pain, stating her wrist was broken and was asking him to get her up. R3's discharge summary dated March 26, 2017 at 18:14 documents: admitted to local Medical Center. Hospital admission Diagnoses: [REDACTED]. The facility's policy for Falls documents: Fall Prevention Guidelines for all residents upon Admission/Re-Admission: -A Fall Risk will be completed on admission, readmission, quarterly, with each significant change and after each fall. -Residents at fall risk will be identified for staff awareness. -Residents at risk for falls will have Fall Risk identified on the interim plan of Care with interventions implemented to minimize fall risk.

Based on record review, interview and observation the facility failed to prevent the development of an unstageable pressure ulcer to one of two residents (R13) in the sample of 15 with acquired pressure ulcers by not implementing individualized interventions and evaluating and revising R13's care plan based on appropriate interventions and monitor for the effectiveness of the interventions. These failures resulted in the decline of R 12's redness to pressure ulcers on her coccyx to Stage II and then further decline to an unstageable pressure ulcer. The findings include: Review of the most recent MDS (minimum Data Set) dated 7/5/14 shows R13 is [AGE] years old with multiple [DIAGNOSES REDACTED]. Per this MDS, R13 does not have any cognitive impairment, scoring a 15 on the BIMS. Also per MDS, R13 requires extensive physical assistance for bed mobility and transfers and has no pressure ulcers identified. E10 (nurse) stated on 8/1/14 at 9:50am R13 gets up for meals and therapy via a sit--to-stand lift. R13 may be incontinent of bowel sometimes but will ask to use the bathroom for the most part. E10 said R13 utilizes a catheter. R13 was observed on 7/30/14 at 2:00pm to be lying in bed, alert and oriented. Z1 (wound doctor) and E5 (staff nurse) were present. R13 stated the wound to her coccyx was new in the past week or so and developed in the facility. Z1 stated this is the first time he is evaluating R13. Upon observation of R13's wound Z1 stated this wound contains an unstageable pressure ulcer to the coccyx. Z1 stated there is an area of this wound that is slough and the depth is unable to be determined. The edges are irregular and the unstageable area needs to be debrided. Z1 said there were other stage II areas present but he (Z1) was going to identify this area as one pressure ulcer since the areas of pressure breakdown were in such close proximity and measured the wound as 4 x 3.2 cm. E4 (wound nurse) stated on 7/31/14 at 2:15pm that R13 was admitted with redness to the buttocks on 5/16/14. R13 returned from the hospital on [DATE] with an order for [REDACTED]. When asked to provide interventions to remove or alter this as a factor, E4 stated R13 is kept clean and dry. The nursing readmitted d 6/9/14 documents redness to the buttocks and coccyx. E4 said the coccyx was identified as a stage I at that time. The care plan of 6/9/14 identifies this same assessment of the coccyx. The intervention listed on this care plan is to "provide weekly assessment and measurement. Measure length, width and depth where possible." E4 stated there is no documented monitoring/assessment of this area until she (E4) assessed it as a stage II on 7/25/14. The weekly pressure ulcer record completed by E4 and dated 7/25/14 shows R13 has a stage II pressure ulcer measuring 4 x 3 cm with scant drainage and mild excoriation. The narrative portion states R13 with "new order for a [MEDICATION NAME] dressing, assessed due to previous excoriation. Open area noted. Will get orders to consult with (Z1, wound doctor)." When asked if R13's tissue tolerance had been analyzed in order to develop and implement a more specific repositioning plan to promote healing, E4 stated the facility does not perform tissue tolerance analysis. Review of facility policy and procedure regarding the treatment of [REDACTED]. ..." E4 confirmed on 7/31/14 at 2:15pm there was not daily monitoring of the pressure ulcer from 7/24/14 until 7/30/14, when it was identified as an unstageable ulcer by Z1. E4 stated she has not had formal training in the management of pressure ulcers. E4 stated she made the referral to Z1 on 7/29/14 and Z1 assessed R13 on 7/30/14. Z1's documentation from this assessment dated [DATE] states R13 "...now presents with lower back and buttocks pressure ulcer. The patient is reported to have history of sacroccygeal pressure ulcer, which resolved." Z1 identified the ulcers as: 1. Decubitus ulcer of lower back (primary) 2. Pressure ulcer of buttock 3. Pressure ulcer, unstageable 4. Pressure ulcer stage II Notes: Right buttocks and Sacrococcygeal Pressure ulcer; stage II, and a few small/satellite unstageable areas. Most of (R13's) wound surface is stage II; and the remainder is unstageable, covered with eschar, thus unable to assess the depth of soft tissue involvement. Review of the pressure ulcer record completed by E5 (nurse) who was present during Z1's assessment on 7/30/14 incorrectly documents the wound as a stage II and the wound bed as pink.

Based on staff interviews and record review, the facility failed to ensure one resident (R17 outside the sample of 16 residents and one resident out of the three allegations of abuse reviewed.), remained free of physical, verbal and mental abuse. This failure resulted in R17 being unprotected from abuse and repeatedly abused by her daughter ( for approximately 45 minutes), without any staff intervention. Findings include: Review of the facility's abuse allegations/investigations revealed a substantiated occurrence of physical, verbal and mental abuse of R17, which was witnessed by facility staff June 13,2011 starting at approximately 4:15 PM. Z1 (visitor) was observed to deliberately toss water into R17's face and front of the resident's shirt and say: "How does that feel? Now you know how I feel!... Now you can just eat dinner in wet clothes". Z1 then pushed R17 into the dining room. Staff did not intervene. Next on 6/13/11 at approximately 4:30 PM, staff heard Z1 yelling at R17 in the resident's room. Z1 was overheard telling R17 to open her eyes. Z1 complained about R17's urinary incontinence. Staff then witnessed R17 coughing and observed Z1 grabbing R17's neck from behind while telling the resident to cover her mouth while coughing. Staff still did not intervene. Then on 6/13/11, at approximately, 5:00 PM, while in the dining room, staff observed Z1 hit R17 on the arm and to "be aggressive" with R17. Staff also observed Z1 speaking to R17 in an "aggressive tone". Z1 was heard to say to R17 "Cover your mouth when you cough, you are embarrassing, how rude of you". Again, staff did not intervene to ensure the safety of R17. Review of the Final Investigative Report Summary of Investigative Finding of Incidents Involving R17, dated June 21, 2011, had documentation to support that R17 was abused by her daughter: "...attempted to interview the resident (R17), however, she was unable to recall any of the alleged incident due to the resident's (R17's) level of cognitive impairment... The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with the resulting physical harm, pain or mental anguish. It seems clear that the daughter's actions were clearly intimidating in nature. While it may be argued that these alleged incident, it seems clear that at the the very least they resulted in mental anguish to the resident... More specifically, "verbal abuse" is defined in the polices and procedure as any use of oral, written, or gesture language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. On three separate occasions on June 13, resident's daughter used what could be characterized as verbally abusive language directed to her mother that could be considered derogatory in nature. The daughter's tone of voice when speaking to her mother was described as loud, inappropriate, scolding and condescending. Each of the witnesses felt that the daughter's behavior and tone of voice were not normal or typical... Mental abuse is defined in the policies and procedure as, but not limited to, humiliation, harassment, and threats of punishment or withholding of treatment or services. The terms humiliation and harassment could be used to characterize the daughter's actions as well as her statements to her mother. It was not only what was said, but rather the manner in which it was said that caused the staff to be concerned combined with the daughter's actions directed towards her mother. The fact that three incidents occurred on the same day within a short time span only adds to the level of concern... Based on the findings of this investigation, we conclude that some form of verbal, physical and/or mental did occur..." On 9/9/11 at 2:15 PM E8 (Dietary Aide) was interviewed regarding R17 and the abuse allegation. E8 stated on the day in question (June 13, 2011), she was walking from the kitchen and observed R17 coughing. E8 said she observed Z1 to hit R17 "real mean" on the arm. E8 described Z1 was overly aggressive and mean. E8 stated she didn't tell anyone right away although she was aware she should have, saying she had been doing a lot of things (multitasking) and working. E8 informed someone the next day, 6/14/11, as soon as she arrived at work. On 9/9/11 at 3:25 PM, E11 (nurse) was interviewed regarding allegation of abuse involving R17 and her daughter. E11 stated she didn't actually see the incident occur, but was told of the abuse by E10. E11 said she went over to R17 and Z1 and asked if everything was OK; Z1 said yes. When asked, E11 stated R17 had seemed a little nervous. E11 informed the surveyors she continued on with passing medications, and did not report doing anything to protect R17. E11 was unsure if Z1 stayed at the facility or left. On 9/9/11 at 3:15 PM, E10 (Certified Nursing Assistant) was interviewed. As stated by E11, E10 said she observed Z1 put her hands around R17's neck from behind. Also, E10 told surveyor she observed Z1 shake R17. E10 stated she thought that the behavior was inappropriate and told E11 (Nurse). E10 continued on to say that she had heard Z1 and R17 arguing in the room. But, E10 said she continued getting residents up for supper. E10 reported that Z1 stayed with R17 for supper. The director of social service, E5, was interviewed by phone on 9/09/2011. E5 told surveyor that staff did not asked Z1 to leave, when they observed her (Z1) being abusive toward R17. E5 also reported staff did not immediately report the abuse to administrative staff, and waited to the next day on June 14, 2011. The abuse coordinator (E1/administrator) was interviewed on 9/09/2011 at 11 AM. E1 told surveyor that staff did not inform him in a timely about the abuse of R17. E1 stated: "It involved more than one episode with in two to three hour time frame... I can recall the staff did not ask the daughter to leave on June 13, 2011... Completed Final Investigation June 21, 2011. We concluded it was abusive behavior. Verbal, some physical and mental abuse because of the dialog. We informed daughter of our findings. We had a discussion with the medical director. We put restriction on her (Z1's) visitation with R17." However, the facility's staff failed to immediately protect R17 from her daughter and allowed the repeated abuse of R17.