Every finding on record at Pearl of Crystal Lake, The

Based on observation, interview and record review, the facility failed to unload the clean dishes from the dishwasher in a sanitary manner and failed to document cooling temperatures. This applies to all the residents in the facility.The findings include:The CMS (Center for Medicare and Medicaid Services) 671 dated 6/2/26 shows there were 77 residents in the facility.On 6/2/26 at 9:24 AM, V4 [NAME] was observed wearing gloves and loading the dishwasher with the dirty dishes. V4 then rinsed her gloves off using the sink sprayer, then wiped them against her cloth apron and began removing the clean dishes from the dishwasher. (V4 did not remove her gloves or wash her hands prior to touching the clean dishes) V4 was observed again doing this at 9:28 AM.On 6/2/26 at 9:59 AM, a pan of cooked cut up chicken was observed in refrigerator with a prepared date of 6/1/26 label. V3 Dietary Manager said he cooked the chicken yesterday and cooled it by resting it in a pan of ice. V3 said he checked the temperatures as it was cooling. V3 said the facility does not use cooling logs or cooling stickers as most foods are cooked the day they are served.On 6/2/26 at 11:10 AM, V3 handed this surveyor a cooling log dated June 2026 showing the chicken was cooked and cooled on 6/1/26.On 6/2/26 at 2:00 PM, V3 said he was the staff that prepared the chicken on 6/1/26 and was doing this because he had some time and wanted to do some meal prep for the next day. V3 said he checked the temperature of the chicken as it was cooling, and he remembered them so he made a cooling log for the surveyor. V3 said the staff are to wash their hands or change their gloves when going between the dirty and the clean dishes.On 6/4/26 at 9:11 AM, V3 was asked for the cooling logs for the last 3 months and provided this surveyor with production logs which did not include any cooling temperatures. V3 said we usually cook food during the day of service.The undated facility policy for hand washing shows food services employees will practice safe food handling to prevent foodborne illness. Workers will thoroughly wash their hands with soap and water after touching anything unsanitary (garbage, dirty dishes).A policy for food cooling was requested, and the facility provided a cooling food log dated June 2026 that shows cool foods from 123 degrees F (Fahrenheit) to 70 degrees F within two hours or less and from 70 Degrees F to 41 degrees F in four hours or less.

Based on observation, interview, and record review, the facility failed to administer medications as ordered by a physician for 3 residents (R65, R100, R101), failed to safely administer medications to 1 resident (R38), failed to ensure medications were not left at the bedside for 2 residents (R41, R45). These failures apply to 6 of 6 residents reviewed for pharmacy services in the sample of 44. The findings include:1. R38's electronic face sheet dated 6/4/26 showed R38 has diagnoses including but not limited to end stage renal disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), and depression. R38's facility assessment dated [DATE] showed R38 has no cognitive impairment. R38's June 2026 physician's orders showed R38 receives duloxetine 30mg (milligrams), loratadine 10mg, and sevelamer 800mg at 8:00AM and Lyrica 50mg at 9:00AM. On 6/3/26 at 11:08AM, R38 was sitting up in her room preparing to go on an outing. R38 had a cup of pills in her room sitting on her nightstand. R38 stated, I was nauseous so I had the nurse leave the pills in my room so I can take them later. They are my morning medications. I told the nurse I would take them so it's fine. On 6/3/26 at 11:18AM, V6 (Registered Nurse-Agency) stated, (R38) said she would take her meds, I don't know if she is alert & oriented, but she seems fine to take them I don't have time for her to take them 1 by 1. I have given most all of morning meds, none left to give really. R38's electronic medical record showed no assessment or care plan present for R38 to self-administer her medications. On 6/4/26 at 11:29AM, V2 (Director of Nursing) stated, (R38) has no assessment for self-administration of medications so she should be supervised while taking her medications to ensure she takes them all. 2. R65's electronic face sheet dated 6/4/26 showed R65 has diagnoses including but not limited to dementia with behaviors, Alzheimer's disease, adjustment disorder, and vascular dementia. R65's facility assessment dated [DATE] showed R65 has severe cognitive impairment. R65's June 2026 physician's orders showed R65 receives Depo-Provera 225mg, aspirin 81mg and phosphatidylserine 1200mg at 8:00AM and tizanidine 4mg, guaifenesin 600mg, Colace 100mg, and ferrous sulfate 325mg at 9:00AM. On 6/3/26 at 1:47PM, V2 (Director of Nursing) stated, We are currently checking blood sugars & vitals on all residents who did not get their vitals done or who are late on meds, and we are informing their physician's. We know it's all late but all we can do is catch up now. I didn't realize our agency nurse was getting that far behind today. I still have a few residents to give medications to from this morning. (R65) and (R100) have not received their medications yet. R65's medication administration audit report dated 6/3/26 showed R65 received Depo-Provera 225mg injection and 2:53PM, aspirin 81mg and phosphatidylserine 1200mg at 2:49PM (over 6 hours past the ordered administration time). The facility's policy titled, Medication Administration dated 4/15/26 showed, 19. Scheduled medications will be given within an hour window before and after its scheduled and as preferred by resident. 3. R100's electronic face sheet dated 6/4/26 showed R100 has diagnoses including but not limited to chronic leukemia, acute kidney failure, pneumonia, chronic obstructive pulmonary disease, and emphysema. R100's June 2026 physician's orders showed R100 receives allopurinol 100mg, aspirin 81mg, escitalopram 10mg, folic acid 400mcg, Lasix 20mg, metoprolol 25mg, omeprazole 20mg, potassium chloride 10meq (milliequivalents), simvastatin 10mg, thiamine 100mg, diphenoxylate-atropine 2.5-0.025mg, and gabapentin 100mg at 8:00AM. R100's medication administration dated audit report dated 6/3/26 showed R100 received allopurinol 100mg, escitalopram 10mg, Lasix 20mg, metoprolol 25mg, and potassium chloride 10meq at 2:14PM, aspirin 81mg and omeprazole 20mg at 2:15PM, folic acid 500mcg at 2:16PM, Lasix 20mg and simvastatin 10mg at 2:27PM, thiamine 100mg at 2:11PM, diphenoxylate-atropine 2.5-0.025mg at 2:17PM, and gabapentin 100mg at 1:39PM. (over 5 hours past the ordered administration time). 4. On 6/2/26 at 10:09 AM, R45 was sitting in a wheelchair in her room. R45 had a bottle of Preservision (130 soft gels) on her tray table next to her Trelegy Ellipta inhaler. V9 Licensed Practical Nurse came into the room and was shown the medication at bedside. R45 stated she wasn't sure if the inhaler was left at the bedside because the resident has contact precautions in place. V9 left the room, went to her medication cart to review the resident's record with the surveyor. V9 confirmed there wasn't an order to leave the medications at the bedside or for self-administration of medication. V9 reviewed R45's care plan with the surveyor present and stated there wasn't a plan in place for self-administration of medications. The Physician Orders dated June 2026 for R45 showed an order was entered on 6/2/26 after the observation at 10:09 AM, for the Preservision Areds 2, 1 capsule by mouth two times a day – supervised self-administration. R45 had an existing order in place for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG (micrograms)/ACT (actuation)(Fluticasone-Umeclidinium-Vilanterol) - 1 puff inhale orally one time a day for COPD, rinse mouth after use, date and discard after 42 days. The order did not include self-administration or keeping it at bedside. The Care Plan dated 5/14/26 for R45 did not have a plan in place for self-administration of medication. On 6/3/26 at 2:58 PM, V1 Administrator/Registered Nurse stated for residents to self-administer medications there is a policy/process. The residents need to be educated on what the medications are for, when they are taken, etc. There needs to be a doctor's order and assessment for self-administration of medications before it can be done. The resident needs to have a care plan in place for self-administration of medication. The facility's Self Administration of Medication Program policy (4/25/25) showed it is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it's been deemed by the interdisciplinary team that it is clinically appropriate. The facility will allow the resident to self-administer drugs if the interdisciplinary team (IDT team), has determined this practice is safe. Nurse will complete a Self- Administration of Medication Assessment. The IDT team must also determine who will be responsible for storage (if medications are stored at the resident's bedside, a lockbox or locked drawer must be used to store medications). 5. On 6/3/26 at 10:27 AM, R41 was sitting in a wheelchair in his room. R41 had oxygen at 4 liters/min (minute) per nasal cannula. There was an albuterol inhaler lying on the tray table in his room. On 6/3/26 at 2:58 PM, V1 Administrator/Registered Nurse stated for resident to self-administer medications there is a policy/process. The residents need to be educated on what the medications are for, when they are taken, etc. There needs to be a doctor's order and assessment for self-administration of medications before it can be done. The resident needs to have a care plan in place for self-administration of medication. The Face Sheet dated 6/4/26 for R41 showed diagnoses including pneumonia, pulmonary embolism, acute on chronic systolic congestive heart failure, pleural effusion, paroxysmal atrial fibrillation, Guillain-Barre syndrome, type 2 diabetes mellitus, dyspnea, anxiety disorder, dependence on supplemental oxygen, burn of unspecified degree of abdominal wall, sacral pressure ulcer, deep vein thrombosis, major depressive disorder, hypotension, hyperlipidemia, atrial fibrillation, hypokalemia, depression, polyneuropathy, restless leg syndrome, and cardiomegaly. The Physician Orders dated June 2026 for R41 showed Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) MG/ML (milliliter), 1 dose inhale every morning and at bedtime for shortness of breath/wheezing. There were no orders for self-administration or storage at the bedside. The Care Plan dated 6/2/26 for R41 showed he has the potential for shortness of breath related to acute pulmonary embolism, congestive heart failure, pneumonia, and pleural effusion. The care plan did not show anything regarding self-administration of medication or storage of medication at bedside. 6. R101's admission Record (Face Sheet) showed an admission date of 6/1/26 with diagnoses to include but not limited to joint replacement surgery, high blood pressure, anxiety, and depression. R101's 6/1/26 Health Status note from 4:53 PM showed she arrived at the facility. The note showed she was oriented to person, place, time, and her current condition. On 6/2/26 at 11:35 AM, R101 stated the facility was given a list of her medications and the facility failed to enter them in time for her to receive her evening blood pressure medication. R101 said, I didn't get my blood pressure medication last night and this morning my blood pressure was 183 or something like that. Normally I'm 120. They really didn't care. The blood pressure thing scared me. R101's blood pressure documentation from 6/2/26 at 6:36 AM showed it was 175/80 (The upper limit of normal is 120/80). R101's blood pressure documentation showed her blood pressure at 10:08 AM was 145/78 (after her morning blood pressure medication was administered.) R101's June 2026 Medication Administration Record (MAR) showed and order for carvedilol (blood pressure medication) 25 milligrams to be given twice daily. The MAR showed the 5:00 PM dose on 6/1/26 was not given. 6/4/26 at 10:31 AM, V2 Director of Nursing stated medications are not ordered for a resident until they arrive to the facility. V2 said if an ordered medication is not available for a resident the staff should check the facility's supply and if it is not available the medication should be ordered stat from the pharmacy. The facility's Medication Administration policy (reviewed 4/15/26) showed, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. lf medication is ordered but not present check to see if it was misplaced and then call the pharmacy to obtain the medication. If available, obtain the emergency or convenience box.

Based on observation, interview, and record review the facility failed to ensure a resident's nebulizer was stored in a manner to prevent cross contamination for 1 of 1 residents (R41) reviewed for oxygen/respiratory treatments in the sample of 44.The findings include: On 6/3/26 10:27 AM R41 was sitting in a wheelchair in his room with oxygen on via nasal cannula. R41 had a nebulizer machine on his nightstand. The drawer to the nightstand was open and the face mask to his nebulizer machine was uncovered and laying in the drawer with other items. R41 had an albuterol inhaler and incentive spirometer on his tray table. R41 stated he would be okay if his breathing was better. R41 stated he was in the hospital for 26 days because of pneumonia and a blood clot. R41 stated during his hospitalization he spent time in the intensive care unit. R41 stated he was diagnosed with Guillain Barre in December 2025.On 6/3/26 at 2:58 PM, V1 Administrator/Registered Nurse stated the nebulizer mask should be stored in a bag and covered for infection control.The Face Sheet for R41 showed diagnoses including pneumonia, pulmonary embolism, acute on chronic systolic congestive heart failure, pleural effusion, paroxysmal atrial fibrillation, Guillain-Barre syndrome, type 2 diabetes mellitus, dyspnea, anxiety disorder, dependence on supplemental oxygen, burn of unspecified degree of abdominal wall, sacral pressure ulcer, deep vein thrombosis, major depressive disorder, hypotension, hyperlipidemia, atrial fibrillation, hypokalemia, depression, polyneuropathy, restless leg syndrome, and cardiomegaly. The Physician Orders dated June 2026 for R41 showed Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) MG (milligrams)/ML (milliliter), 1 dose inhale every morning and at bedtime for shortness of breath/wheezing. The Care Plan dated 6/2/26 for R41 showed he has the potential for shortness of breath related to acute pulmonary embolism, congestive heart failure, pneumonia, and pleural effusion. The Care Plan dated 6/2/26 for R41 showed he has oxygen therapy related to recent pneumonia, acute pulmonary embolism with acute respiratory failure, and pleural effusion. The Facilities Nebulizer Therapy policy (4/1/23) showed, store in a plastic bag.

Based on observation, interview, and record review the facility failed to ensure fall preventative measures were in place for a resident at high risk for falls for 1 of 4 residents (R45) reviewed for falls in the sample of 44.The findings include: On 6/2/26 at 10:09 AM, R45 was sitting in a wheelchair in her room. R45 had oxygen on via a nasal cannula. R45 had a small portable oxygen tank sitting on her dresser across the room. The oxygen tubing was coming from the portable tank on the dresser, draped across the bed and coiled on the floor in front of the resident. R45 stated she has been in and out of the facility for rehabilitation services and has had 17 falls in 6 months. R45 stated she is not supposed to get up on her own but has done so when waiting for help going to the bathroom. R45 stated she fell at the facility when trying to overstep the oxygen tubing and it got caught around her ankles.On 6/3/26 at 3:05 PM, V2 Director of Nursing stated R45 was at high risk for falling and the oxygen tubing should be out of the way and not laying on the floor; R45 could fall.The Face Sheet dated 6/4/26 for R45 showed diagnoses including fall on same level, chronic obstructive pulmonary disease, Type 2 diabetes mellitus, morbid obesity, long term use of anticoagulants, abnormality of gait and mobility, lack of coordination, anxiety disorder, rheumatoid arthritis, presence of left artificial knee joint, and dependence on supplemental oxygen.R45's Minimum Data Set, dated [DATE] showed no cognitive impairment.The SBAR note dated 5/13/26 at 7:49 PM for R45 showed the nurse was called to the resident's room and R45 was sitting on the floor at the toilet. R45 stated she was trying to untangle the oxygen tubing around her feet and landed on the floor.The Care Plan dated 5/9/26 for R45 showed she is at high risk for falls related to frequent falls at home, weakness/deconditioning due to bacteremia, urinary tract infection, and cholecystitis. R45's care plan showed she had an actual fall on 5/14/26.The facility's Fall Prevention and Management Policy (3/25/26) showed high risk residents and patients for falls will receive individualized interventions as appropriate to risk factors. Fall focus program will be implemented to all residents admitted to the facility regardless of risk scores. Fall Risk Program will be implemented to ensure purposeful rounding addresses residents positioning, pain, personal needs, personal items within reach, perils/safety hazards, and peaceful environment upon admission and throughout resident's stay.

Based on observation, interview, and record review the facility failed to ensure the transfer to the hospital was documented and the basis for transfer was documented for 1 of 1 resident (R77) reviewed for transfers in the sample of 44.The findings include:On 6/4/26 at 9:10 AM, R77 wasn't in her room and her belongings including wheelchair were in the room. V14 Registered Nurse was in the hallway and stated R77 went to the hospital after becoming unresponsive at dialysis the day before (6/3/26).The Progress Notes for R77 were reviewed for 6/3/26 and showed at 1:58 AM she had an episode of emesis. At 4:06 PM a skilled charting note was entered that showed vitals signs, mental status as alert and oriented x 3 (person, place, and time), and functional status. There was no note in R77's chart to show what happened, why the resident was sent out of the facility, or where she went.On 6/4/26 at 9:49 AM, V2 Director of Nursing stated R77 was at dialysis, and she wasn't responding like normal. R77 was not at her baseline; she had a change in condition. R77 was sent to the hospital. V2 stated normally an e-interact SBAR (situation, background, assessment, recommendation) is documented in the resident's record. The documentation for the resident was reviewed with V2 who confirmed that there was no note showing what happened to R77, where she went, why she was sent out, of follow up information.The Notification of Change in Condition, Discharge and Transfer policy (1/15/26) showed if a resident becomes unstable or deteriorates, the situation becomes urgent, and emergency procedures apply (emergency services may be called without waiting for orders). Document everything. All attempts to contact providers, the residents' status, and nursing actions must be documented.

Based on observation, interview, and record review the facility failed to provide nail care for a 1 of 1 residents (R9) reviewed for activities of daily living in sample of 44. The findings include:R9's admission Record (Face Sheet) showed an admission date of 11/5/24 with diagnoses to include but not limited to paralysis affecting his right side, dementia, and cognitive communication deficit.R9's 5/8/26 Significant Change Minimum Data Set (MDS) showed he had severe cognitive impairment with a Brief Interview for Mental Status score of 5 out 15. The MDS showed he required substantial/maximal assistance (helper does more than half the work) for both personal hygiene and showering/bathing. The MDS showed he had an impairment to one side of his upper body.On 6/2/26 at 11:13 AM, R9 was asleep on his back in bed. R9's right hand appeared stiff and contracted. R9's fingernails on both hands were dirty and approximately 0.25 inches past the cuticle bed.On 6/3/26 at 1:41 PM, R9 was up in his wheelchair. R9's fingernails were in the same condition as they were on 6/2/26. R9 said, My nails are long, they need to be trimmed. Would you be able to do that. R9 was asked if he would like this surveyor to find a staff member to trim his nails. R9 replied, Would you do that? I would appreciate it. R9 said he liked having his nails trimmed and I don't like them being long.On 6/3/26 at 2:01 PM, V8 Certified Nursing Assistant (CNA) stated, He (R9) needs assistance with pretty much all of his care. He can't move his right hand, but he does feed himself with his left hand. He works well with us; he doesn't refuse care. On shower day we do nails and shave. CNAs can do fingernails. Trimming nails is important for bacteria, it can prevent an infection. R9's fingernails were then observed with V8. V8 stated, It doesn't look like they have been trimmed in a while. They do need to be trimmed. V8 stated it was the end of her shift, and she would pass on R9's nail care to the next shift. On 6/4/26 at 9:24 AM, R9's nails showed they had been trimmed.On 6/4/26 at 10:56 AM, V2 Director of Nursing stated that nail care should be offered on shower days. V2 said nail care is important for hygiene and cross-contamination.The facility's Supporting Activities of Daily Living policy (reviewed 12/4/25) 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.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer prevention measures were in place for 2 of 7 residents (R62,R65) reviewed for pressure ulcers in the sample of 44. The findings include:1. R62's electronic face sheet dated 6/4/26 showed R62 has diagnoses including but not limited to displaced fracture of right femur, age-related osteoporosis, hypertension, pressure-induced deep tissue damage of right heel, pressure ulcer of sacral region-unstageable. R62's facility assessment dated [DATE] showed R62 has no cognitive impairment, is at risk for developing pressure ulcers, has one stage 1 pressure ulcer, and two unstageable pressure ulcers. R62's care plan dated 5/22/26 showed, (R62) has PUs (pressure ulcers) to her sacrum and right heel related to impaired mobility, fall with femur fracture and surgery, recent MASD (moisture associated skin damage) with incontinence, not repositioning much on her own in the bed .offload heels. R62's wound assessment dated [DATE] showed, right heel 5.40 x 4.00 x 0.10 (L x W x D) (present upon admission) deep tissue injury .Seen by wound nurse practitioner for the first time. The blister had opened prior to seeing today. On LAL (low air loss) mattress and reminded to use the heel protector boots while in bed. Skin prepped and bordered foam applied. No pain to site. Continuing with care. On 6/2/26 at 10:27AM, R62 stated, I'm not sure what all they are doing about my sores. They put the boots on my feet, I was getting sores on the back of my foot and those keep it from happening, I don't need them all the time, I shouldn't be in bed all the time. R62's pressure relieving heel boots were sitting in the chair next to her bed. On 6/4/26 at 11:10AM, R62 was laying in her bed with her heels flat on the bed. R62's pressure relieving heel boots were sitting in the chair next to her bed. On 6/4/26 at 11:16AM, V10 (Certified Nursing Assistant-CNA) stated, (R62) has a few pressure ulcer prevention measures in place. She uses an air mattress, heel boots, and side to side turning. She is compliant with everything. I'm not sure why she wouldn't have her heel boots on if she is in bed. She has no problem letting us put them on.On 6/4/26 at 11:29AM, V2 (Director of Nursing) stated, Pressure ulcer prevention measures are put in place to prevent a pressure ulcer. (R62's) interventions are a low air loss mattress and heel protectors while in bed. It seems like a contraindication for the prevention measures with the air mattress but if that is what is on their care plan then that is what we should be doing.2. R65's electronic face sheet dated 6/4/26 showed R65 has diagnoses including but not limited to frontotemporal neurocognitive disorder, dementia with behaviors, vascular dementia, peripheral vascular disease, anxiety disorder, and adjustment disorder. R65's facility assessment dated [DATE] showed R65 has severe cognitive impairment and is at risk for pressure ulcers. R65's care plan dated 2/10/26 showed, (R65) recently had discolorations to bilateral popliteal areas related to restless legs while up in chair and bumping wheelchair or (reclining wheelchair) arm rest, strap and bar .pillow or sheet between legs and wall to keep from bumping. R65's care plan dated 1/13/26 showed, (R65) has potential for impairment to skin integrity related to fragile skin, incontinence, glasses too tight or too loose sometimes causing irritation to nose, restless legs while in wheelchair and in bed- causing leg discolorations, history of falls, impaired mobility, MASD and scratches at skin- mostly buttock/groin .offload heels with pillows when in bed. On 6/2/26 at 10:18AM, R65 was laying down in his bed with the head of bed elevated approximately 30 degrees. R65 had no pillow between his legs and his knees were rubbing together. R65 was rubbing his feet/heels back and forth on his bed with no pressure relief device in place. A wedge cushion and knee separation cushion were located on R65's bedside table across the room. On 6/2/26 at 1:22PM, V17 (CNA) provided incontinence care to R65 and laid him down for the afternoon. V17 completed her care for R65 and put a blanket over him without elevating his heels off the bed. V17 stated R65 does not wear heel boots and will pull his feet up off the mattress every so often. On 6/4/26 at 11:09AM, R65 was lying in his bed with no pressure prevention device on his feet or between his knees. On 6/4/26 at 11:16AM, V10 (Certified Nursing Assistant-CNA) stated, (R65's) pressure ulcer prevention measures are an air mattress, laying down, repositioning, and pillows to elevate his heels. We put pillow in between his legs as well, so his knees don't rub together and create a sore. I'm not sure why his prevention measures are not in place right now because everything is in his room. On 6/4/26 at 11:29AM, V2 stated, (R65's) pressure ulcer prevention measures are a low air loss mattress and lamb's wool. I don't see anything else unless it's on his care plan but if has alternative measures on his care plan then that's what he should be getting. The facility's policy titled, Pressure Injury Evaluation, Assessment, Risk Reduction, and Long-Term Healing dated 4/2026 showed, 1. The facility will ensure that based on the comprehensive assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure injuries. b. A resident with a pressure injury receives necessary treatment and services, consistent with professional standards of practice, that are aimed to promote healing, minimize complications and prevent the development of further pressure injury .3. Interventions will be implemented in the resident's plan of care to prevent pressure injury development when the resident has no areas of concern .5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure injury .

Based on interview and record review the facility failed to notify a resident's provider when the resident's blood sugar was outside the specified parameters. This applies to 1 of 1 residents (R7) reviewed for notification in the sample of 44.The findings include:R7's admission Record (Face Sheet) showed she was a type two diabetic.R7's Order Listing Report showed an order with a last order date of 3/20/26 which showed .notify MD (medical doctor) if 2 consecutive blood sugars are greater than 349.R7's Blood Glucose documentation showed on 3/23/26 at 6:01 AM a blood sugar of 401, then at 8:24 AM a blood sugar of 390, and finally at 11:49 a blood sugar of 368.R7's Electronic Health Record (EHR) showed no documented communication between nursing staff and R7's provider.On 6/04/2026 at 10:47 AM, V2 Director of Nursing stated, staff should be following orders as written and notifying providers when ordered to do so. V2 states she was not able to find any documentation that R7's provider was notified of the three consecutive blood sugars being greater than 349. V2 stated the purpose of notifying the provider of these elevated values was to keep the provider informed and to possibly adjust R7's insulin dose.The facility's Notification of Change in Condition policy (reviewed 1/15/26) showed, It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The policy showed, after documentation the nurse will .Document the notification and record any new orders in the resident 's medical record.

Based on interview and record review the facility failed to provide pain medication for a resident prior to therapy. This applies to 1 of 1 residents (R101) reviewed for pain control in the sample of 44.The findings include:R101's admission Record (Face Sheet) showed an admission date of 6/1/26 with diagnoses to include but not limited to joint replacement surgery, right artificial knee joint, and type two diabetes. R101's 6/1/26 Health Status note from 4:53 PM showed she arrived at the facility. The note showed she was oriented to person, place, time, and her current condition.On 6/2/26 at 11:35 AM, R101 I asked if I could have my pain pill before therapy and that didn't happen. My therapy was at 10:00 AM. I asked for it earlier in the morning. I know they are busy but they act like they don't care. My therapy hurt this morning, the pain pill would have helped.On 6/2/26 at 1:42 PM, V7 Registered Nurse stated she was R101's nurse. V7 said, She had a right knee replacement. I gave her [hydrocodone/acetaminophen]. (A combination narcotic and over the counter pain medication, which comes in several different narcotic strengths.) I gave her the 10 milligram dose because she said her pain was bad. She didn't ask me for pain meds before therapy. I don't know when therapy is going to be done for the residents. For patients like her with knee replacements, therapy can be painful. Often times therapists will tell us they are going to take a resident and tell us to give them something for pain but they didn't this time. The therapists didn't tell me she was having pain either. Giving the pain medication before therapy can also be helpful to stay ahead of the pain and also it helps them do more with therapy.R101's 6/2/26 Health Status Note from 5:30 PM showed she left the facility AMA (against medical advice).On 6/4/26 at 11:06 AM, V11 Therapy Director stated prior to therapy the therapist will try and speak with the resident and tell them to request pain medication prior to therapy, if needed. V11 said residents with recent joint replacements can have pain with therapy. V11 said the pain medication can allow the resident to endure therapy and allow the resident to do more in therapy.R101's Medication Administration Record showed R101 was given a tablet of hydrocodone/acetaminophen at 11:07 AM on 6/2/26 for pain rating of 8 out of 10. (Given after R101 stated therapy had been done.)The facility's Pain Management policy (reviewed 10/30/25) showed The facility will provide adequate pain assessment and management to that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure a resident (R66) was free from a significant medication error. This applies to 1 of 1 residents reviewed for significant medication errors in the sample of 44. The findings include:R66's electronic face sheet dated 6/4/26 showed R66 has diagnoses including but not limited to congestive heart failure, hypertension, type 2 diabetes, and cirrhosis of the liver. R66's physician's orders dated 5/21/26 showed, Humalog 100 unit/mL (milliliter) Inject as per sliding scale subcutaneously with meals for diabetes mellitus. On 6/3/26 at 1:47PM, V2 (Director of Nursing) stated, It doesn't look like (R66) got her insulin at noon today with her lunch. We are currently checking blood sugars and vitals on all residents who did not get their vitals done or who are late on medications, and we are informing their physician's. We know it's all late but all we can do is catch up now. I didn't realize our agency nurse was getting that far behind today. R66's medication administration report showed R66 received her Humalog Insulin at 1:58PM. (1 hour and 58 minutes past the scheduled administration time). The facility's policy titled, Medication Administration dated 4/15/26 showed, 19. If the medication is given at a time different from the scheduled time, updated the MAR (Medication Administration Record) to reflect administration time. Scheduled medications will be given within an hour window before and after its scheduled and as preferred by resident .

Based on observation, interview and record review, the facility failed to puree foods following the recipe to maintain palatability of the food served. This applies to two of two residents (R9, R65) reviewed for puree foods in the sample of 44.The findings include:On 6/2/26 at 10:50 AM, V4 [NAME] was preparing the puree foods for lunch. V4 was pureeing the Asian fried rice and was adding plain hot water to the blender to puree the rice to the correct consistency. V4 and this surveyor tasted the mixture when she was done pureeing the rice and the rice had no flavor. V4 was told by V3 Dietary Manager (DM) to add some salt which she did.On 6/2/26 at 11:19 AM, V4 said the rice was cooked in chicken broth and that is why she used the water to help puree the rice to the correct consistency.On 6/2/26 at 2:00 PM, V3 DM said V4 should have used chicken broth as the liquid to puree the rice. V3 said he had started to boil a pot of water to make some broth, and V4 took the water before he could complete that.On 6/3/26 at 11:44 AM, V5 Dietician said if the recipe calls to add broth to the rice while it is being pureed, that is what the staff are to do. V5 said chicken broth would make the rice more palatable for the residents.The recipe for Asian Fried [NAME] shows to process the rice in food processer until smooth pudding like consistency is achieved. Add juice, milk or broth, whichever is most appropriate for the item being pureed, a little at a time to achieve desired consistency.The facility face sheet for R9 shows he was admitted to facility with diagnoses to include dementia and dysphagia (Difficulty swallowing). A Physician order dated 3/23/26 for R9 shows he is to have pureed foods.The facility face sheet for R65 shows he was admitted to the facility with diagnoses to include Alzheimer's Disease. A Physician order dated 3/5/26 shows R65 to be served pureed foods.The undated facility policy for Standardized Recipes shows the recipes are to be followed throughout production.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were followed for 1 of 7 residents (R21) reviewed for infection control in the sample of 44.The findings include:On 6/2/26 at 10:28 AM R21 had an enhanced barrier precautions (EPB) sign up on doorway to his room. R21 was in bed on his back with the head of his bed elevated. R21 had an air mattress in place on his bed and stated that his bottom hurt because it felt like the bed was inflated enough. R41 stated it felt like his bottom was touching the metal of the bed. V12 Certified Nursing Assistant came into his room, did not have gloves or gown on and removed his blankets, was touching/pressing all over the mattress to check the inflation. V12 moved the linen around on his bed to look at the mattress. At 10:46 AM V13 Restorative Nurse came into the room, put gloves on, did not have a gown on and on and started pushing on the mattress to check the inflation. V13 also put her hands and forearms under the resident to see if the mattress was flat under him. V12 and V13 were asked why the EBP sign was up and what it meant. V12 stated that R21 had surgery to remove his feeding tube and the site came open last week and was draining so that is why he was on the EBP. V13 stated EBP was for residents with a stage 3 or higher open wound and that is when the EBP has to be followed.On 6/2/26 at 11:07 AM, V12 looked at the EBP sign and stated she should have had gloves on when touching R21 and his linen because it was close contact.On 6/4/26 at 3:05 PM, V2 Director of Nursing stated staff should follow the EBP sign and do what it says. V1 was present and agreed that if the EBP sign is posted then it should be followed. They stated gown and gloves should be worn with the high contact care.The Physician Orders for June 2026 for R21 showed EBP precautions for surgical wound site.The Care Plan dated 6/1/26 for R21 showed he is on enhanced barrier precautions related to his surgical site. To alleviate and reduce further the spread of infection through early recognition and to allow prompt treatment. Clean/wash hands, including before entering and when leaving the room wear gloves and a gown for High Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene care, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, wound care: any skin opening requiring a dressing.The facility's Enhanced Barrier Precautions policy (1/14/26) showed enhanced barrier precautions is an approach of targeted gown and glove use during high contact resident care activities to reduce the transmission of staphylococcus aureus and multidrug resistant organisms. When a resident is placed in enhanced barrier precautions, gown and gloves will be used during high-contact resident care activities.

Based on observation, interview and record review the facility failed to ensure the menu was followed to meet the nutritional needs of residents on a pureed diet for 4 of 4 residents (R13, R49, R54 and R65) reviewed for menus and nutritional adequacy in the sample of 18. The findings include: The undated facility provided list of residents on a pureed diet shows that R13, R49, R54 and R65 are all on a pureed diet. The Menu Extension Sheet for 3/10/25 shows that residents on a regular diet were to receive sloppy joe on a bun, cucumber and tomato salad, french fries and mixed fruit for the noon meal. Residents on a pureed diet were to receive pureed #6 (5 1/3 ounces (oz)) scoop of sloppy joe, tomato juice 4 oz, #8 (4 oz) scoop mashed potatoes and pureed #8 scoop of mixed fruit. On 3/10/25 at 10:00 AM, the pureed sloppy joe was made for the residents on a pureed diet. Meat, thickening powder and water were added to the blender and processed. No bread serving was added to the meat. On 3/10/25 at 11:45 AM, R13, R49, R54 and R65's noon meal was plated. A #8 (4 oz) scoop of the pureed sloppy joe meat was provided. There was no additional bread serving provided. During continuous dining observations on 3/10/25 between 12:30 and 1:22 PM, R13, R49, R54 and R65 were not served pureed mixed fruit. By 1:22 PM, R13, R49, R54 and R65 all had exited the dining room. The Menu Extension for 3/11/25 shows that regular diet residents are to get strawberry jello cake. The sheet shows that pureed diet residents are to get pureed #10 scoop of strawberry jello cake. On 3/11/25 at 12:43 PM, R13, R49, R54 and R65 were in the dining room eating the noon meal. R13, R49, R54 and R65 did not have pureed strawberry jello cake present. On 3/11/25 at 2:17 PM, V15 (Dietary Manager) said that he used a #8 scoop for the pureed sloppy joe because he thought that is what the sheet said to use. V15 said that he did not serve the pureed diet residents any bread serving with the sloppy joe meat. V15 said that he did not serve the pureed diet residents pureed mixed fruit because he forgot since he was busy training someone. V15 said that he did not serve pureed strawberry jello cake to the residents because he read the sheet wrong. On 3/11/25 at 2:00 PM, V12 (Dietitian) said that the menus should be followed, and the spreadsheets should be followed using the appropriate scoop sizes to ensure each resident gets a balanced diet. The facility's Portion Control Chart shows that a #6 scoop is 5 1/3 oz, a #8 scoop is 4 oz, and a #10 scoop is 3 oz.

Based on observation, interview and record review the facility failed to put interventions in place for residents with pressure injuries to 3 of 8 residents (R127, R62, and R44) reviewed for pressure injuries in the sample of 18 The findings include: 1. R127's Physician Order Sheet (POS) printed on 3/10/25 show R127 has an order of LAL (lo air loss mattress) due to R127 being admitted to the facility with a stage 4 sacral area pressure injury with possible infection. The same POS show R127's wound treatment for the Stage 4 sacral wound included cleaning with skin prep peri wound. Apply Therahoney and lightly pack with Alginate tucked to tunnel and depth of wound. Cover with bordered foam. R127's wound assessment dated [DATE] show, pressure injury present on admission Stage 4 measuring 3.20 centimeters (cm) x 3 cm x 1.5 cm with undermining of 12 o'clock to 12 o'clock (2.60 cm) On 03/10/25 at 11:30 AM, R127 was in bed. R127 stated I am soaked and wet, I am lying on these wet sheets and my back is sore, I have been needing to be changed and turned. R127 was on a regular mattress. V8 (Registered Nurse-RN) who was in the room to provide incontinence care said R127 was admitted with a stage 4 pressure injury. V8 (RN) confirmed that R127 was on a regular mattress. On 3/10/25 at 12PM, V6 (Wound Nurse) who just completed a wound treatment to R127 said R127 was sent to the hospital due to seizures last Friday afternoon, (3/7/25). R127 was readmitted back to the facility Saturday afternoon (3/8/25). R127 was moved to another room that day (Saturday 3/8/25). R127 has a stage 4 wound. R127 needs the lo air loss mattress. This makes me upset. She should have been moved with her lo air loss mattress. R127's careplan dated 3/4/35 shows R127 has a pressure injury to her sacrum related to impaired mobility, incontinence and fragile skin. R127 requires pressure relieving surfaces to bed and wheelchair. 40085 2. On 3/10/25 at 9:39 AM, R62 was lying in bed asleep, both of his heels were resting against the mattress with no offloading. A green padded heel protector boot was sitting on his bedside across the room. R62 said he has a wound on his foot and cannot wait to get it healed so he can get out of here. On 3/10/25 at 12:15 PM, R62 was still lying in the same position with no heel protectors on and heels were not offloaded. R62's 3/4/25 Wound Assessment Details Report, shows he has a 1.40 centimeter (cm) x 1.70 cm. x 0.20 cm. stage 4 pressure injury to his right lateral foot. The report shows the current treatment plan is to wear heel protector boot in bed, and states, always when in bed. On 03/11/25 at 11:09 AM, V6 (Wound Care Nurse) said R62 should have heel (boot) protectors on when in bed and he has a pressure injury to his right foot. V6 said staff should be applying the heel boots and R62 generally does not refuse to wear them. R62's Pressure Injury Care Plan initiated on 10/7/2024, shows he requires pressure relieving devices and offloading while in bed. R62's pressure injury Care Plan does not address any refusals from R62 for applying heel protector boots. 3. On 3/10/25 at 9:25 AM, R44 was lying in bed, both of her heels were resting against the mattress. Her heels were not offloaded and there were no heel protectors seen at her bedside. R44's 3/4/25 Wound Assessment Details Report shows she has the following wounds: 1. A stage 3 pressure area measuring 1.90 x 1.50 x 0.30 cm. to her left heel. 2. A 3.10 cm. x 3.10 cm. x unknown unstageable pressure injury to her right heel. The plan of care identified for R44's heel show she should have her heels offloaded with heel boots when in bed. 3. A 5.80 cm. x 7.80 cm. x 3.00 cm. stage 4 pressure injury to her sacrum. R44's Pressure Injury Care Plan initiated on 1/23/25, shows R44 should have weight shifted and her heels offloaded. The Care Plan does not address any refusals from R44 for offloading or applying heel protectors. On 3/11/25 at 11:12 AM, V6 said offloading should be done when R44 is in bed. The facility provided Wound Prevention and Healing policy reviewed on 6/1/24 shows that residents will have interventions in place to prevent the development of pressure injuries.

Based on interview and record review the facility failed to ensure a resident received a pneumococcal vaccine for 1 of 5 residents (R52) reviewed for immunizations in the sample of 18. The findings include: R52's Face Sheet shows that she is [AGE] years old and admitted to the facility on [DATE] with diagnoses of: end stage renal disease, dialysis, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, congestive heart failure, dependence on supplemental oxygen and obstructive sleep apnea. R52's Pneumococcal Vaccine Consent form dated 10/14/24 shows that she gave consent to receive the pneumococcal vaccine. R52's Immunization Report printed 3/10/25 shows that she received a pneumococcal vaccine (Prevnar 13) on 12/1/2021 and no additional pneumococcal vaccines since then. On 3/11/25 at 1:04 PM, V3 (Infection Preventionist) said that the nurses ask residents upon admission about their immunization history and if they are due for a pneumococcal vaccine, she speaks with them, gets a consent and gives the appropriate vaccine. V3 said that she uses the table from the CDC (Centers for Disease Control and Prevention) to determine what pneumococcal vaccine is needed. V3 said that after reviewing the table, R52 should have received the Prevnar 20 vaccine a year after her Prevnar 13 vaccine. The CDC Pneumococcal Vaccine Timing for Adults table dated 10/2024 shows that adults [AGE] years of age or older that have had the Prevnar 13 vaccine only should receive the Prevnar 20 or Prevnar 21 vaccine one year later. The facility's Pneumococcal Vaccination Policy dated 6/20/21 shows, Administration of pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) for a resident on enhanced barrier precautions for 1 of 18 residents (R178) reviewed for infection control in the sample of 18. The findings include: R178's Order Summary Report printed on 3/11/25 showed R178 had an order to be on enhanced barrier precautions due to a wound and another order for PPE to be used during high contact resident care activities such as transferring the resident. The orders had a start date of 3/8/25. On 03/10/25 at 10:26 AM, V3 (Infection Control Nurse) put a sign on R178's door indicating R178 was on enhanced barrier precautions. V4 (Occupational Therapist) and V5 (Physical Therapist) were in R178's room assisting R178 to stand, walk across the room, and sit in a chair. V5 supported R178 to transfer by holding onto a gait belt. V4 and V5 had on gloves. V4 and V5 did not have on a gown. On 03/10/25 at 10:48 AM, V3 was asked what triggered her to place an enhanced barrier precaution sign on R179's door. V3 said R178 was a newer admission, and she just became aware of his wound. On 03/11/25 at 10:12 AM, V3 said for a resident on enhanced barrier precautions staff should wear gloves and gowns when assisting the resident to transfer. R178's Care Plan with an initiated date of 3/2/25 showed R178 was on enhanced barrier precautions due to a wound. Listed under interventions was for staff to wear gloves and gown for high contact resident care activities such as transfers. The facility's Enhanced Barrier Precautions policy with a revision date of 3/28/24 showed enhanced barrier precautions is an approach to targeted gown and glove use during high contact resident care activities. The policy listed transferring as a high contact resident care activity.

Based on interview and record review the facility failed to implement a care plan intervention for a resident at risk for malnutrition for 1 of 3 residents (R73) reviewed for nutrition in the sample of 18. The findings include: R73's face sheet shows she is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including: pressure ulcer of the sacral region, ascites, generalized edema, chronic kidney disease stage 4, unspecified severe protein-calorie malnutrition and history of gastric bypass surgery. R73's Nutrition Care Plan initiated on 2/12/25 shows she has the potential for nutritional problems and is at risk for malnutrition. Interventions for R73 identified in the Care Plan shows weights should be monitored as ordered. R73's Physician Order Summary shows an order for weight on day one (admission day) and day two then weight weekly for 4 weeks (record in the morning every Tuesday for 4 weeks.) R73's Weight Summary and Medication Administration Record both show R73 was weighed on 2/14/25 and not again until 3/3/25 (17 days later). On 3/12/25 at 9:00 AM, V12 (Dietician) said she was aware that R73 had lost weight when she ran a weight report on 3/4/25. V12 said R73 should have had weekly weights at minimum. V12 said that the nursing staff at the facility does not always notify her of weight loss immediately so she runs a weekly report herself. V12 said while it was expected R73 would lose some weight due to her overall medical conditions, but the weights should be done to identify weight loss sooner. On 3/12/25 at 8:50 AM, R73 was eating breakfast in her room. R73 said she only remembers the staff weighing her one time shortly after admission by a mechanical lift, but she never refused to be weighed with the lift. R73 said standing was an issue shortly after admission but the lift wasn't a problem, and she would let them weigh her. The facility provided Weight Management policy last reviewed on 8/20/24 shows that all residents will be weighed according to facility policy on admission day, on day two, and weekly for 4 weeks. The policy also says that weights should be documented in the resident's electronic medical record.

Based on observation, interview, and record review the facility failed to obtain treatment orders for a non-pressure wound and failed to obtain daily weights as ordered for a resident with congestive heart failure. This applies to 2 of 18 residents (R177 and R128) reviewed for quality of care in the sample of 18. The findings include: 1. On 03/10/25 at 10:14 AM, R177 was in bed. R177 had a tan foam dressing to her left forearm. The dressing was not dated. The dressing had shadow drainage that was smaller than a dime. The corners of the dressing were rolled up. On 03/11/25 at 10:18 AM, R177 had a different white dressing to her left forearm. The dressing had shadow drainage that was smaller than a dime. R177's Progress Note dated 03/08/25 showed R177 had a fall and two skin tears to her left forearm were found. One skin tear was 5-6 centimeters (cm), and the other was 3-4 centimeters. The same note showed the skin was cleaned and a dressing was applied. R177's Order Summary Report printed on 3/10/25 did not show a dressing/treatment order for R177's left forearm. On 03/11/25 at 10:54 AM, V6 (Wound Care Nurse) said she was not aware/informed R177 had a wound to her left forearm. V6 said the last time she saw R177 was on 3/6/25 and R177 did not have any skin tears to her left forearm. V6 said when a wound is found staff should obtain treatment orders. V6 said for a resident with a new wound she should be notified. V6 added she would assess the resident/wound to make treatment recommendations. R177's Skin/Wound Note dated 03/06/25 did not indicate R177 had skin tears to her left forearm. R177's Wound Assessment Detail Report dated 03/11/25 showed R177 had two skin tears to her left forearm. One skin tear measured 3 cm x 4.5 cm x 0.2 cm. The second skin tear measured 2.5 cm x 2 cm x 0.10 cm. The document indicated the wounds were facility acquired and identified on 3/11/25. The facility's Wound Prevention and Healing policy dated 10/9/21 showed wound care treatments are provided within an individualized plan of care under the direction of a physician. 33760 2. R128's Face Sheet printed on 3/12/25 show R128 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure (CHF) and chronic respiratory failure dependence on supplemental oxygen due to shortness of breath. On 3/10/25 at 9:10 AM, R128 was in bed with oxygen on via nasal cannula. R128 said she gets short of breath easily. R128's Physician's Order Sheet (POS) shows an order dated 3/5/25 for daily weights for a diagnosis of CHF. Notify Cardiologist/Primary MD/NP If weight increases by 3 pounds (lbs) in 1 day or 5 lbs in 1 week. The same POS shows another renewal order date of 3/10/25 for weight daily and record. R128's Weights and Vitals summary printed on 3/11/25 shows that between 3/5/26 (admission day) to 3/11/25, R128 did not receive a weight on 3/5, 3/6, 3/8, 3/9, and 3/10. On 3/11/24 at 12:30 PM, V2 (Director of Nursing) said residents with CHF should be weighed as ordered to assess for weight gain or fluid overload due to heart failure that can cause shortness of breath and complications.

Based on observation, interview and record review the facility failed to ensure a resident who is morbidly obese received the appropriate wheelchair for 1 of 18 residents (R128) reviewed for accommodation of needs in the sample of 18. The findings include: R128's face sheet printed on 3/12/25 shows R128 was admitted to the facility on [DATE] with a diagnosis that include fracture of left lower leg wearing a cast and morbid (severe), obesity due to excess calorie, and congestive heart failure (CHF) on oxygen. On 3/10/25 at 9:16 AM, V9 and V10 both Certified Nursing Assistants (CNA) were transferring R128 to her wheelchair via a mechanical lift. As R128 was being lowered and placed into the wheelchair, R128 was not positioned well in the wheelchair. V9 and V10 kept on trying to pull R128 back so R128 could fit in the wheelchair, but R128 was not moving an inch, since there was no space on either sides or back of the wheelchair. R128's midsection was wider than the wheelchair. R128 stated this is so tight, It's uncomfortable. R128 was trying to use her casted leg to push herself in the wheelchair. V9 and V10 were holding unto R128 so as not to slide down from the wheelchair. V9 and V10 continued trying to position R128 in the wheelchair. This surveyor had to ask for R128's nurse (V8 Registered Nurse) to come to R128's room. On 3/10/25 at 9:30 AM, V8 (RN) was in R128's room. R128 informed V8 she was not comfortable with the wheelchair. V8 said R128 barely fits in the wheelchair, the wheelchair is too small. R128 cannot sit back enough in the wheelchair. R128 needs to get back to bed for safety. R128 needs a wider chair. On 3/10/25 at 10:30 AM, V7 (Restorative Nurse) said the chair that the staff was using to R128 was a regular wheelchair. R128 should have a bariatric wheelchair. Therapy took R128's chair to ensure it was the right size of wheelchair. Therapy will provide a wheelchair for R128. On 3/10/25 at 10:44 AM, V11 (Therapy Director) said R128 needed at least a size 26 wheelchair (bariatric wheelchair-morbidly obese.) The right size wheelchair can provide comfort, prevent skin conditions and ensure residents safety. The facility policy entitled Accommodation of Needs dated 7/23/24 documents, The resident's individual needs and preferences will be accommodated to the extent possible except when the health and safety of the individual or other residents would be endangered.

Based on interviews and record review, the facility failed to prevent the theft of a resident's personal money for one of three residents (R1) reviewed for misappropriation of property. The findings include: The facility's final investigation report with incident date of 10/03/2024 indicated that R1 admitted to the facility on [DATE] with $75 that was documented on her admitting inventory sheet. R1 noticed the money was missing/stolen from her wallet on 09/27/2024. R1 thought her son had picked up the money but he confirmed that he did not take the money. The staff searched through R1's purse and room, as well as the garbage and laundry but were unable to locate the money. After staff, resident, and family interviews were conducted and video surveillance was reviewed, the facility could not ascertain where R1's money went or when it went missing. R1's medical record indicated the resident admitted to the facility on [DATE] with a past medical history not limited to: history of fall, weakness, cervical disk degeneration, age-related osteoporosis and bilateral hearing loss. R1 discharged to home on 10/08/2024. No contact number was noted on file. R1's son was not listed within her medical records, nor any contact information. R1's inventory sheet dated 09/24/2024 documented $75 son will take home tomorrow. Review of R1's admission note dated 09/24/2024 showed no documentation of the money or that R1's son would be picking it up the next day. R1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated R1 had no cognitive impairment and scored 15/15. The facility's grievance/concern/compliment logs showed an entry on 09/27/2024 documenting that R1 had missing money that son took home with a resolution on the same date. A second entry that was dated 09/30/2024 documented that R1 had missing money which her son did not take home and was reported with a documented resolution date of 10/04/2024. On 10/10/2024 at 09:54 AM, V1 (Administrator) said R1 admitted to facility on 09/24/2024 and the admitting nurse (V4-Registered Nurse) found that R1 had $75 in her wallet. R1 did not want the facility to secure this money then indicated that her son would pick it up the following day and was documented by V4 (Registered Nurse) on R1's admitting inventory sheet. V3 (Social Services Director) who was also present during interview said R1's son came to the facility on [DATE] and denied taking R1's money home. V1 added that a thorough search was conducted, staff and residents were interviewed, and video surveillance was reviewed for the three-day window from the time R1 admitted (09/24/2024) until when the money was alleged to be missing (09/27/2024). V1 added that the video surveillance showed staff were never present in R1's room without R1 and/or her roommate (R2) also present. V1 said there were no findings in the facility's investigation, so the incident was reported to public health and a police report was filed with the local department which they have not received to date. V1 (Administrator) and V3 (Social Services Director) both said that they believed R1's son took the money because they couldn't prove staff took the money and R1's son became defensive when confronted. When asked if the facility could provide evidence that a staff member did not take R1's money, V1 responded no. V1 (Administrator) provided documentation of her request to reimburse or credit R1 for the missing money that has not been provided to R1 as of current. On 10/10/2024 at 11:02 AM, V4 (Registered Nurse) said during R1's admission inventory, she asked R1 if she had any money on her person. R1 initially said no but V4 saw a blue purse and handed it to R1. V4 added that R1 took out some bills from the wallet then counted the money which totaled $75. V4 said R1 did not want her to secure the money and indicated that her son would pick it up the following day so R1 put the money back into the wallet. V4 said she wrote a note on R1's inventory sheet indicating the same and reported off to the oncoming nurse about the money and when R1's son would be picking it up. On 10/10/2024 at 11:39 AM, V7 (Certified Nursing Assistant) said he was working when R1 admitted and that V4 was the nurse. V7 added that R1 came with a clear plastic bag from the hospital that contained some personal belongings which he placed in the closet. V7 (Certified Nursing Assistant) then said he informed V4 (Registered Nurse) about the bag. He added that V4 and R1 began going through the bag, then he heard V4 say to R1, oh you have some money. V4 then told R1 that she would record the amount of money on her inventory sheet. V7 said he then left the room shortly after this encounter. On 10/10/2024 at 12:34 PM, V8 (Maintenance Director) said he reviewed video surveillance from R1's admission on 09/24/2024 until the time it was first reported missing on 09/27/24. V8 then said he only saw R1's son enter her room on 09/27/2024 and R1 was present. V8 added there was not a time when he could see on the video that R1's son was in the room alone without either R1 or R2 present. V8 also said that he did not see a time when staff were in the room without one or both residents being present. When asked if activity within the room could be visualized with the video surveillance, V8 said whatever occurred in the room is not visible on the video and that it could have been a staff member because he never saw the son in the room alone. On 10/10/2024 at 1:42 PM, V9 (Agency Registered Nurse) said she doesn't recall R1 specifically but does recall that she has never been informed about any resident at the facility having money on their person and/or that a family member would be picking up the money. On 10/10/2024 at 02:04 PM, V2 (Director of Nursing) said R1 informed her on 09/27/2024 that she had $75 missing. V2 then said R1 gave permission for V2 and V4 (Registered Nurse) to search her room but could not locate the money which V4 verified was present and counted on admission. When asked why the facility waited several days to report the incident to public health and/or the local police, V2 (DON) said R1 didn't allege that the money was stolen until 10/03/2024 and that's when V1 was informed, and a complete investigation was initiated. Prior to this date, R1 just said the money was missing. Reviewed facility's undated abuse prevention program policy that indicated the following: 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. The purpose of this policy and the abuse prevention program is to describe the process of identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by and not limited to: establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. No theft policy was provided by the facility during course of this investigation.

Based on observation, interview, and record review the facility failed to ensure a resident was not involuntarily transferred to another facility that provides the same level of care. R2 was transferred on 5/22/19 to another long term care facility against her wishes which resulted in psychosocial harm to the resident. This applies to 1 of 3 residents (R2) reviewed for transfer/discharge in the sample of 14. The findings include: The Progress Notes for R2 showed on 5/9/19 she was admitted from the hospital to the facility after a fall at home and concussion per report from the hospital nurse. R2's daughter indicated to the facility that R2 would no longer be able to live with her upon discharge because it would not be safe and they will be looking for nursing home placement. R2's Interim Care Plan dated 5/9/19 showed, Initial goals: possible nursing home placement. R2's Progress Notes showed, 5/10/19 at 7:37 AM - R2 took early morning medications. Fifteen minutes after, the patient became very agitated. Threatening to kill herself, trying to hit her head with her fist, trying to fling herself to the floor. Focused on harming herself. R2 wrapped a blanket around her neck. Requested certified nursing assistant (CNA) supervisor stay 1:1 with R2; At 8:23 AM - Spoke with the medical assistant for the doctor and okay to send R2 to the hospital for safety and evaluation. Communicated to next shift registered nurse (RN) and daughter; 4:46 PM - Director of Nursing (DON) and this nurse spoke to the case manager at the hospital, resident has been deemed clear by psych, not suicidal at this point and calm; states the resident was able to verbalize she was angry with her daughter. The DON and this nurse spoke to the daughter and requested a sitter; daughter advised cannot afford a sitter and cannot stay with the patient. This nurse reached out to a mental health hospital and spoke to a staff member that said if the resident has been cleared by psych at another medical center they cannot take the referral . The patient needs to be readmitted to our facility and if behavior continues we can make a referral at that time. The hospital Discharge Instructions dated 5/10/19 for R2 showed, Recurrent moderate/major [MEDICAL CONDITION] without [MEDICAL CONDITION]. No suicidal ideation. Mood disorder. Anxiety disorder. R2's Progress Notes from 5/11/19 through 5/22/19 were reviewed and did not show any behaviors or suicidal ideation. R2's Psychosocial Well Being -Behavior Management Follow Up forms dated 5/11/19 through 5/20/19 showed no behavior issues. On 5/22/19 at 9:23 AM, V1 (Administrator) stated, When R2 came to the facility her daughter said she wasn't going back home; there was a fight between R2 and her daughter. R2's goal was to go home with the daughter. R2 thought she was just coming here for therapy and that is how it all started. R2 woke up the next morning and wrapped a sheet around her head/neck and said she was going to kill herself. We sent her out and the hospital evaluated her. R2 said she only did that because she was mad at her daughter and was not suicidal. The hospital sent R2 back after a psychiatric evaluation at the hospital. A hospital with a mental health unit said they couldn't do anything because she was just seen and they couldn't admit her because she was evaluated by another hospital. They said if R2 had any further behaviors they would be able to evaluate her. R2 has been fine ever since. Another long term care facility was contacted because they have a behavioral unit. Our psych saw her here; I am not sure what they did. R2 is not an involuntary discharge; if she is stable we might just keep her. Now that she is stable I don't see why she needs to go anywhere else. R2 has stayed with us before and there were no issues. I need to see where we are at with her. R2's daughter was touring another facility this last weekend. We thought the behavioral unit there would better suit her needs. All of our rooms are dual certified; we take Medicare and Medicaid. On 5/22/19 at 10:05 AM, R2 was sitting in a wheelchair in her room. Resident was dressed and getting ready to leave via ambulance for another facility. R2 was asked if she was leaving the facility and she said, yes. When asked if she wanted to leave the facility to go to another facility she stated, No and then became visibly upset and started to cry. On 5/22/19 at 11:07 AM, V5 (R2's daughter) stated, We were not given the option for her to stay and they told me to look for another facility. They gave me the names of a couple of facilities to look at so I went with one. I was not aware this facility was a long term care facility or that they could have kept her. The move to the other facility is traumatic for her. They did not discuss any option of her staying there. They said this was a rehabilitation facility and she would need to go somewhere else for long term care. They told me about one close by and one in another town that had space for her. V6 the Social Worker told us that. I would have kept her there if I could. I told mom last night that she was going to move to another facility and she was upset and crying; she said she would rather die than move. I have a feeling it is going to be hard for her to get used to another place. The last time she was at this facility was in (MONTH) 2019 and she went home after her stay. She lived with me; she fell again and went to the hospital and from the hospital to the facility. The hospital said she had 40 days left of Medicare coverage and then she has medicaid. She had a problem one night when she first came in; I told her that I could not take care of her at home. I got a call from there and they said she was upset and said she would kill herself by not eating or taking medication. She was sent to the hospital and then sent back to the facility; they said she wasn't suicidal. They told me at the facility that if she could behave then she would not have to go anywhere else. She hasn't had any incidents since. They never said she wasn't behaving after that. I think it is why they are transferring her. She is going to a regular unit at the other facility and not the behavioral unit. On 5/22/19 at 11:50 AM, V1(Administrator) stated there are Medicaid certified rooms available at this time in the facility. She stated she would check on how many are available. R2's Social Service Notes showed, 5/16/19 - Phone call to R2's daughter regarding discharge plan. No longer looking at sending her mother to Florida. She will need to look for long term care in the area. Reviewed facilities that usually can accept long term Illinois Public Aide; 5/20/19 - Phone call to R2's daughter for follow up. R2's daughter has toured facility A and facility B and has chosen facility B. On 5/22/19 at 12:07 PM, V6 (Social Services Director) stated, R2 left because the daughter was looking for options for care in Florida to be closer to another sibling but changed her mind and decided that was not the best plan. V5 wanted R2 closer to her and she chose the other facility. It is 7 miles closer to her house. I did not give the daughter the option of R2 staying here. I don't remember telling the daughter that this is a rehabilitation only facility but I never gave her the option of staying here. R2 has not exhausted her Medicare days. We were initially concerned about her behavior but when she came back from the hospital her behavior was fine. My impression is that they wanted her closer and asked what other facility in the area accepted public aide. It's my understanding that in the last seven years this facility is mostly a short term rehabilitation facility; before that it was a long term care facility that did very little rehab. We are now accepting more long term care residents. The administration makes decisions on the admissions, transfers, and discharges. We don't meet as an interdisciplinary team regarding discharges. Admissions will screen residents and ask the patient what their plan is and what they need before they come to the facility. Initially R2 was coming here for rehab. The Face Sheet for R2 showed she was discharged from the facility on 5/22/19 to an assisted living facility; R2 went to another long term care facility. The Face Sheet dated 5/22/19 for R2 showed [DIAGNOSES REDACTED]. The Resident Profile in the Facility Assessment (2/13/19) showed the facility it is able to care for residents with psychiatric/mood disorders such as impaired cognition, depression, anxiety disorder and [MEDICAL CONDITION] and that it is some of the top common diseases and conditions that they serve. The facility assessment showed, Should an individual require care and services based upon [DIAGNOSES REDACTED]. The facility takes an interdisciplinary approach to making admission or continuing care decisions for persons that have [DIAGNOSES REDACTED]. The Facility Assessment also showed, The facility provides care and services based upon the needs of our resident population. Our facility embraces a person centered care culture in which we provide care and services based upon our resident population, including the following: Behavioral health - management of medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support residents with issues dealing with anxiety, care of someone with cognitive impairment, care of residents with depression, trauma/[MEDICAL CONDITION], and other psychiatric diagnosis. The facility's Transfer and Discharge policy (2/2016) showed, The facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless: The transfer or discharge is resident initiated; The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. The safety of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility or the facility ceases to operate.

Based on observation, interview and record review the facility failed to implement pressure relieving interventions for a resident with a Stage 2 pressure injury and for residents at risk for pressure injuries. The facility failed to ensure a pressure injury wound treatment was completed in a manner to prevent cross contamination. The facility failed to ensure residents' skin was kept free of biological irritants. These failures resulted in a resident's (R2) Stage 2 pressure injury declining to a unstageable pressure injury with a [DIAGNOSES REDACTED]. This applies to 3 of 3 residents (R1-R3) reviewed for pressure injuries in a sample of 4. The findings include: 1. R2's Resident Face Sheet printed (MONTH) 26, (YEAR) showed R2 was admitted to the facility on (MONTH) 9, (YEAR) for rehabilitation after sustaining a fall which resulted in a right femur fracture. R2's Minimum Data Set (MDS) dated (MONTH) 16, (YEAR) showed that R2 was cognitively intact and required extensive assistance of 2 staff for bed mobility and toileting. R2's Wound Assessment Report dated (MONTH) 10, (YEAR) showed R2 had a Stage 2 pressure injury to R2's coccyx measuring 0.6cm x 0.2cm x 0. The report also showed there were no signs of infection to R2's coccyx wound. The report does not show any wounds to R2's right heel. R2's Wound Assessment Report dated (MONTH) 18, (YEAR) showed R2's coccyx wound measurements had increased to 3.0cm x 1.5cm x unknown. The report also showed R2 had developed a new pressure injury to R2's right heel measuring 2 x 2 x 0. V7's (WNP) Wound Provider History and Physical Report for R2 dated (MONTH) 25, (YEAR) showed, I was asked to see this patient due to a worsening sacral wound .Wound nurse reports that the wound is deteriorating. This wound illustrates various levels of deterioration . The report showed R2's wound to measure 11cm x 10cm x 0.1cm R2's Wound Assessment Report dated (MONTH) 7, (YEAR) showed R2's coccyx pressure injury was as an unstageable wound. R2's right heel wound measurements had increased to 3cm x 4cm x unknown. R2's coccyx X-ray report dated (MONTH) 9, (YEAR) showed, Slight reactive bone changes at the posterior access of the coccyx in close proximity to the wound, suspicious for osteo[DIAGNOSES REDACTED] . On (MONTH) 26, (YEAR) at 9:45 AM, R2 was lying on R2's back in bed with a [DEVICE] in place to R2's buttocks. R2 stated, I got this [DEVICE] after I got here because the wound on my butt got worse. I also have a sore on my right heel that is new . I probably got it (coccyx wound) because I laid in my poop a lot. They don't always clean you up quickly . When R2 was asked why R2 had an intravenous needle (IV) in R2's right arm, R2 stated, I got an infection somewhere and need antibiotics .I think it might be in the wound in my butt . On (MONTH) 26, (YEAR) at 10:50 AM, R2 was repositioned on R2's right side, in bed, by V11 Registered Nurse (RN) and V12 Wound Nurse, R2 was incontinent of a moderate amount of stool with stool noted up between R2's buttocks, directly below R2's coccyx pressure wound, and on R2's incontinence brief. V12 attempted to tuck R2's soiled incontinence brief under R2's right hip but a piece of the brief, soiled with stool, was placed directly next to R2's wound. Without providing incontinence care and removing R2's soiled incontinence brief, V12 proceeded to remove R2's [DEVICE] and wound dressing from R2's coccyx wound. V12 then continued to place a new wound dressing and reattach the [DEVICE] to R2's wound while R2 was positioned on top of the brief soiled with stool. On (MONTH) 26, (YEAR) at 11:25 AM, V12 Wound Nurse stated, I don't know why (R2) wound (coccyx) got so bad .Yes, (R2) has been on IV antibiotics forever because of the osteo[DIAGNOSES REDACTED] from R2's wound. On (MONTH) 27, (YEAR) at 1:00 PM, V12 Wound Nurse stated, I asked (V7 WNP) to see (R2) on (MONTH) 24, (YEAR) because I felt like someone needed to see (R2) while (R2's) wound physician was gone on vacation. On (MONTH) 8, (YEAR), (V7 WNP) told me (V7) suspected (R2) had osteo[DIAGNOSES REDACTED]. On (MONTH) 26, (YEAR) at 12:15 PM, V7 WNP stated, I was asked to see (R2) by (V12 Wound Nurse) because (R2) had some concerns about R2's coccyx wound and (R2's) physician was gone. (R2's) coccyx wound went south really fast. I don't know why. Yes, when (R2) was admitted it was originally a Stage 2 but it got worse fast and (R2) developed osteo[DIAGNOSES REDACTED]. (R2) also developed a pressure wound to (R2's) right heel in the facility .If a resident is incontinent, incontinence care should be provided before changing a wound dressing to avoid contamination. R2's Physician order [REDACTED]. On (MONTH) 26, (YEAR) at 12:45 PM, V2 Director of Nursing (DON) was asked why R2 was not placed on a low air loss mattress on R2's admission to the facility on (MONTH) 9, (YEAR). V2 stated, If a resident is admitted with a Stage 2 pressure injury or higher, they get a low air loss mattress. I'm not sure why (R2) was not put on one when (R2) was admitted . 2. R1 was unavailable for observation as R1 was discharged from the facility on (MONTH) 4, (YEAR). R1's Physician order [REDACTED]. R1's Care Plan dated (MONTH) 2, (YEAR) showed R1 required maximum to extensive assistance with all ADL's (activities of daily living) including toileting and repositioning. The Care Plan also showed anticipate (R1's) needs - frequent repositioning, incontinence care and provide incontinence care after each incontinent episode . R1's Skin Risk assessment dated (MONTH) 13, (YEAR) showed R1 was at very high risk for developing a pressure injury. R1's Skin Observation Report dated (MONTH) 15, (YEAR) showed no open wounds to R1's buttocks. R1's Progress Note dated (MONTH) 16, (YEAR) showed, WCN (wound care nurse) notified spouse and daughter . of wound to bottom that was found today . R1's Wound Provider History and Physical Note dated (MONTH) 18, (YEAR) showed, During (R1's) stay at the (facility), the patient developed a DTI (deep tissue injury) of the sacrum. The Provider Note also showed R1 had a wound to (R1's) sacrum measuring 5.5cm (centimeters) x 3.0cm x 0 ). R1's Wound Provider History and Physical Note dated (MONTH) 1, (YEAR) showed that R1's sacral wound is deteriorating R1's sacral wound measured 6cm x 5cm x 0.1cm. The Provider Note showed that R1 had also developed a new area of incontinence associated skin damage . to (R1's) perianal area. On (MONTH) 25, (YEAR) at 11:30 AM, V4 (Daughter of R1) stated, My dad had no wounds to (R1's) buttocks until after (R1) got to the facility. (R1) was in there just 4 days when the nurse told me that dad developed a small blister to (R1's) buttocks. It wasn't a small blister, it was the size of a softball .Maybe it (wound) happened because my dad always had diarrhea and laid in poop. I always had to find staff to come clean dad up . R1's Physician order [REDACTED]. On (MONTH) 27, (YEAR) at 10:55 AM, V12 Wound Nurse stated, (R1) had no pressure wounds when (R1) was admitted . I'm not sure how it (R1's sacral wound) developed or why it got so bad. When V12 was asked why R1 was not placed on a low air loss mattress until after R1 developed the wound to R1's sacrum (on (MONTH) 16, (YEAR)), V12 stated, I don't have a good answer for that. I'm not really sure why we didn't. I guess I didn't realize or underestimated how immobile (R1) was. On (MONTH) 26, (YEAR) at 12:15 PM, V7 Wound Care Nurse Practitioner (WNP) stated, Anything that causes you to be immobile, like a stroke or someone who is a postsurgical [MEDICAL CONDITION], puts you at risk for a pressure injury. If a resident is high risk for pressure injuries or if a resident is admitted with a pressure injury, ideally they should be placed on a low air loss mattress upon admission to the facility .Yes, (R1) was admitted to the facility without any pressure injuries .I am not sure how (R1) wound developed . Frequent repositioning, turning, and incontinence care is key to preventing new wounds and the worsening of previous wounds for these residents. Repositioning and frequent incontinence care should be provided at least every 2 hours. 3. R3's Resident Face Sheet printed (MONTH) 26, (YEAR), showed R3 was admitted to the facility on (MONTH) 3, (YEAR) with [DIAGNOSES REDACTED]. R3's MDS dated (MONTH) 10, (YEAR) showed R3 required extensive assistance of 2 staff for bed mobility and toileting. R3's Skin Risk assessment dated (MONTH) 3, (YEAR) showed R3 was at a high risk for developing pressure injuries. R3's Care Plan dated (MONTH) 5, (YEAR) showed R3 was at risk for skin breakdown. The Care Plan showed, Provide incontinence care after each incontinent episode. On (MONTH) 26, (YEAR) at 9:45 AM, R3 was lying on R3's back in bed. V15 (Daughter of R3) was seated next to R3. V15 stated, I have a concern. (R3) has been here for 3 weeks. I have been times when (R3) has laid in (R3's) poop and pee for up to an hour There has also been times when (R3) has been sitting in (R3's) wheelchair for hours .(R3) is always on (R3's) back. I have never even seen them offer to reposition (R3) . On (MONTH) 26, (YEAR) at 10:30 AM, R3 was in bed, asleep on (R3's) back, with V15 at bedside. On (MONTH) 26, (YEAR) at 11:15 AM, , R3 was in bed, asleep on R3's back, with V15 at bedside. On (MONTH) 26, (YEAR) at 11:40 AM, V13 and V14 CNA's provided R3 with incontinence care. V14 repositioned R3 on R3's right side, as V13 removed R3's incontinence brief as R3 was incontinent of urine. R3 had long linear marks to both buttocks with redness and excoriation to the skin between R3's buttocks. V14 CNA stated, Those marks on (R3's) buttocks are from the creases in (R3's) brief or from (R3's) bedding. (R3) has been laying on (R3's) back for awhile. V14 CNA stated V14 last provided R3 with incontinence care at 8:15 AM on (MONTH) 26, (YEAR). On (MONTH) 26, (YEAR), V2 DON, V9 CNA, and V10 RN, each stated incontinence care and repositioning should be provided for residents every 2 hours. The facility's Pressure Ulcer Prevention Program Policy (undated) showed the facility shall provide care, treatment, and services to: promote the prevention of pressure ulcer development, promote the healing of pressure ulcers that are present, prevent development of additional pressure ulcers .Preventive interventions for all patients at risk: .Use pressure redistribution devices, i.e., .low air mattresses .Keep linen wrinkle-free to prevent uneven pressure distribution .Try to prevent any moisture, diarrhea, urinary incontinence and sweating because excretions may cause skin maceration .

Based on interview and record review, the facility failed to immediately notify a resident's physician when a resident's condition deteriorated on May 11, 2017. R1 was noted to be confused at 5:00 PM, increasingly lethargic at 6:30 PM, and was unresponsive at 7:00 PM, 7:30 PM, and 8:00 PM. The facility failed to report blood glucose values according to facility policy. This failure contributed to R1's continued deterioration and delay in emergency treatment. Emergency Medical Services (EMS) did not arrive until 8:44 PM to find R1 unresponsive, with cold, clammy skin, and in respiratory distress. R1 was hospitalized in a diabetic coma, with hypothermia and acute [MEDICAL CONDITION]. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: R1's electronic medical record showed she has a [DIAGNOSES REDACTED]. On May 19, 2017 at 2:25 PM, E8 (Dietician) stated a brittle diabetic means if a resident doesn't eat right or misses a meal, they can get [DIAGNOSES REDACTED] where their blood sugar goes down. On May 18, 2017 at 3:30 PM, E5 CNA (Certified Nursing Assistant) stated R1 was awake and responsive and talking before dinner on May 11, 2017. On May 18, 2017 at 1:55 PM, E3 (RN) stated she went into R1's room around 4:30 PM to get her blood sugar and the reading was in the 80s. E3 stated she gave R1 a yogurt. E3 stated she went back into R1's room around 6:30 PM and R1's dinner meal was on the tray uneaten. E3 stated she tried to wake R1 up and R1 said yeah, yeah I'll get up. E3 stated she went back into R1's room around 7:00 PM and R1 sounded like she was sleeping. E3 stated she reported to E2 (Director of Nursing) that something wasn't right, and E2 told her to do a sternal rub (with her knuckles on R1's chest) and continue to monitor R1. E3 stated R1 did not move when she performed the sternal rub. E3 stated R1's tongue was sticking out. On May 18, 2017 at 8:45 AM, Z1 (R1's family) stated he arrived at the facility on May 11, 2017, around 8:10 or 8:15 PM. Z1 stated R1 was in her bed in her clothes and sprawled out in a weird position . not in a way how she normally sleeps. Z1 stated her tongue was out of her mouth. Z1 stated he used his baseball stadium voice to scream in R1's ear and she did not respond. Z1 stated he asked E3 to take her blood sugar. E3 stated Z1 came to her and told her they couldn't wake R1 up. E3 stated she told Z1 she had not been able to wake R1 up since around 6:30 PM. E3 stated R1's tongue was still sticking out when family came to the facility. On May 18, 2017 at 1:55 PM, E3 stated when she went to tell E2 that Z1 wanted R1 sent to the hospital, it occurred to her R1 was diabetic. Blood glucose value entries for May 11, 2017 on R1's Vitals Report show 81 mg/dl at 5:05 PM, and 64 mg/dl at 8:38 PM. On May 19, 2017 at 3:10 PM, E3 stated I think I should have sent (R1) out way before I did. I should have called (physician) when I sent her out- I should have called him before and let him know the symptoms I was seeing and how she was difficult to arouse. E3 added I should have checked her blood sugar earlier- I should have done a lot of things differently. On May 18, 2017 at 11:45 AM, E4 (LPN) stated if a resident had a blood glucose level of 70 mg/dl and was symptomatic, she would notify the MD. On May 18, 2017, E2 RN (Director of Nursing) stated she did not visualize R1 for herself, and R1's physician was not called about transport to the ER. E2 stated R1's family was present and wanted her sent so she called for transport. E2 stated 911 was not called for R1, and they should have been. On May 19, 2017 at 12:35 PM, Z2 (Nurse Practitioner) stated she would expect a phone call when a change in a resident's condition is initially discovered. Z2 stated she would like to be notified so she could instruct staff what needed to be done for the resident, such as administer [MEDICATION NAME], or oxygen, or run the ABCs (airway, breathing and circulation assessments) with staff. R1's May 11, 2017 progress note from 9:17 PM showed Fax sent out to MD about transfer after Emergency Medical Services (EMS) transported R1 to the hospital. The purpose of the facility's Resident Examination and Assessment policy (revised April 2007) showed to examine and assess the resident for any abnormalities in health status . Steps in the procedure showed to examine and note . Neurological: alertness and orientation . strength and equality of hand grasps . and to document the date and time the procedure was performed. The Reporting section showed to notify the physician of any abnormalities, such as but not limited to Change in cognitive, behavioral or neurological status from baseline . The facility's Change in a Resident's Condition or Status policy (revised April 2007) showed Our facility shall promptly notify (a resident's) attending physician . of changes in the resident's medical/mental condition and/or status . Nursing interventions outlined in the policy for low blood glucose (70 mg/dl or below) and symptoms of severe [DIAGNOSES REDACTED] showed for licensed staff to notify the physician of blood glucose values.

Based on interview and record review, the facility failed to assess and thoroughly evaluate a resident's change in condition on a resident known to be a brittle diabetic. This failure contributed to the facility's inability to provide necessary emergency treatment when R1's blood glucose was low. R1's condition continued to deteriorate for approximately 90 minutes before the facility sought Emergency Medical Services (EMS). R1 was found to be unresponsive, with cold and clammy skin. As a result, R1 was hospitalized in a diabetic coma, with hypothermia and acute [MEDICAL CONDITION]. These failures apply to 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: R1's electronic medical record showed she has a [DIAGNOSES REDACTED]. R1's May 6, 2017 admission progress note from 10:53 PM showed R1 is a brittle diabetic . and has a supra-pubic catheter. On May 19, 2017 at 2:25 PM, E8 (Dietician) stated a brittle diabetic means if a resident doesn't eat right or misses a meal, they can get [DIAGNOSES REDACTED] where their blood sugar goes down. R1's May 11, 2017 progress note from 9:17 PM showed R1 was found confused at 5:00 PM, was verbally responsive and not moving at 6:30 PM, was not responding at 7:00 PM, and 7:30 PM, E3 stated Z1 (R1's family) came in the evening of May 11, 2017 around 8:00 PM and told her they couldn't wake up R1. E3 stated she told Z1 she had not been able to wake R1 up since around 6:30 PM. On May 18, 2017 at 3:30 PM, E5 (CNA) stated he cared for R1 the night she was sent to the hospital. E5 stated before dinner on May 11, 2017, R1 was awake and responsive and talking. E5 stated he saw R1's full dinner tray in her room around 7:00 PM and he tried to wake her up, and added he was not sure of the time. E5 stated R1 continued to snore and he tried to shake her right arm. E5 stated R1 moved her arm at him a little bit but her eyes were closed, she kept snoring and said no words. E5 stated he told the nurse he could not wake her up. E5 stated he went into R1's room a second time and he shook her left arm and poked at her left arm for one or two minutes and R1 kept on sleeping. E5 stated the second time he was in to try to wake R1 she did not resist at all and kept snoring. E5 stated he could not remember the time he was in the room. On May 18, 2017 at 1:55 PM, E3 (RN) E3 stated she went into R1's room on May 11, 2017 around 6:30 PM, and R1's dinner meal was on the tray uneaten. E3 stated she tried to wake R1 up and R1 said yeah, yeah I'll get up. E3 stated she went back into R1's room around 7:00 PM and R1 sounded like she was sleeping. E3 stated R1's tongue was sticking out. E3 stated she had reported to E2 RN (Director of Nursing) because something was not right. E3 stated she was instructed to do a sternal rub (with her knuckles on R1's chest) and continue to monitor R1. E3 stated R1 would not move when she did the sternal rub. On May 18, 2017, E2 RN (Director of Nursing) stated she did not visualize R1 for herself, and R1's physician was not called about transport to the ER. E2 stated R1's family was present and wanted R1 sent for evaluation so she called for transport. E2 stated 911 was not called for R1 and they should have been. On May 18, 2017 at 8:45 AM, Z1 stated he arrived at the facility on May 11, 2017, around 8:10 or 8:15 PM. Z1 stated R1 was in her bed in her clothes and sprawled out in a weird position . not in a way how she normally sleeps. Z1 stated her tongue was out of her mouth. Z1 stated he used his baseball stadium voice to scream in (R1's) ear and she did not respond. Z1 stated he asked E3 to take her blood sugar. On May 18, 2017 at 1:55 PM, E3 stated when she went to tell the E2 RN the family wanted R1 sent to the hospital, it occurred to her R1 was diabetic. E3 stated R1's tongue was still sticking out when family came to the facility. R1's Emergency Medical Services (EMS) Run form for May 11, 2017 showed an ambulance was not dispatched for transport until 8:23 PM and it arrived at 8:42 PM. R1 was unresponsive and her skin was cool, pale, and clammy. R1 had no verbal or motor response, and did not open her eyes. R1 had shallow, labored breathing. On May 18, 2017 at 8:45 AM, Z1 stated another EMS crew that happened to be in the building for another resident assisted R1's EMS responders. On May 18, 2017 at 11:45 AM, E4 (LPN) stated if a resident had a blood glucose level of 70 mg/dl and was symptomatic, she would notify the MD. E4 stated she would give glucose gel if a resident was not coherent and then recheck the blood glucose in five minutes. E4 stated if she used up all the gel, she would give glucose as an injection but she would never not react. On May 19, 2017 at 3:10 PM, E3 stated I think I should have sent (R1) out way before I did. I should have called (physician) when I sent her out- I should have called him before and let him know symptoms I was seeing and how she was difficult to arouse. E3 added I should have checked her blood sugar earlier- I should have done a lot of things differently. On May 19, 2017 at 12:35 PM, Z2 (Nurse Practitioner) stated she would expect a phone call when a change in a resident's condition is initially discovered. Z2 stated she would like to be notified so she could instruct staff what needed to be done for the resident, such as administer [MEDICATION NAME], or oxygen, or do the ABCs (airway, breathing and circulation assessments) with them. R1's May 11, 2017 progress note from 9:17 PM showed Fax sent out to MD about transfer after Emergency Medical Services (EMS) transported R1 to the hospital. R1's May 11, 2017 emergency room Triage Report from 9:05 PM showed patient was sent by private ambulance. Patient had been unresponsive since 6:30 PM. Blood sugar was 62 en route. Pt with very agonal breathing (gasping, labored) and nonresponsive .pink purulent drainage in foley (urinary catheter) tubing. A bear hugger was applied for a rectal temperature of 94 degrees Fahrenheit. R1's September 14, 2016 diabetes care plan (from previous admission) showed an intervention to Monitor for signs of [DIAGNOSES REDACTED] (blood glucose <60 mg/dl, sweating, cold, clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, faintness, dizziness). The facility's undated Diabetes Mellitus: Prevention and Emergency treatment of [REDACTED]. Observe daily for conditions which may predispose the resident to [DIAGNOSES REDACTED] on a daily basis: a. Too little food; 2. Skipping or delaying a meal or snack. The policy showed 2. Assess for symptoms of [DIAGNOSES REDACTED]. The policy described Severe [DIAGNOSES REDACTED] as disoriented behavior, loss of consciousness, inability to arouse from sleep, [MEDICAL CONDITION]. Nursing interventions outlined in the policy for low blood glucose (70 mg/dl or below) and symptoms of severe [DIAGNOSES REDACTED] showed elevate the head of the bed . ADMINISTER THE physician's orders [REDACTED]. The Reporting section in the facility's Resident Examination and Assessment policy (revised April 2007) showed .2. Notify the physician of any abnormalities, such as, but not limited to . 2.c. change in cognitive, behavioral, or neurological status from baseline .

Based on interview and record review, the facility neglected to follow its Resident Examination and Assessment policy when staff failed to assess a resident's condition when the resident had an obvious neurological status decline. The facility failed to follow its Change in a Resident's Condition or Status policy when the facility failed to notify R1's physician when R1 was found unresponsive on three separate occasions on May 11, 2017, beginning at 7:00 pm, again at 7:30 PM, and at 8:00 PM. The facility failed to follow their Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property policy by not providing medical help to R1 in a timely manner. These failures contributed to a delay in treatment for [REDACTED]. As a result, R1 was hospitalized in a diabetic coma, with hypothermia and acute [MEDICAL CONDITION]. This applies to 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: On May 19, 2017 at 12:35 PM, Z2 (Nurse Practitioner) stated she would expect a phone call when a change in a resident's condition is initially discovered. Z2 stated she would like to be notified so she could instruct staff what needed to be done for the resident, such as administer [MEDICATION NAME], or oxygen, or do the ABCs (airway, breathing and circulation assessments) with them. R1's May 11, 2017 progress note from 9:17 PM showed Fax sent out to MD about transfer after Emergency Medical Services (EMS) transported R1 to the hospital. On May 18, 2017 at 3:30 PM, E5 CNA (Certified Nursing Assistant) stated R1 was awake and responsive and talking before dinner on May 11, 2017. R1's Emergency Medical Services (EMS) Run form for May 11, 2017 showed an ambulance was dispatched for transport at 8:23 PM and arrived at R1 at 8:44 PM. R1 was unresponsive and her skin was cool, pale, and clammy. R1 had no verbal or motor response, and did not open her eyes. R1 had shallow labored breathing an oral airway was placed at 8:46 PM. On May 18, 2017 at 8:45 AM, Z1 (R1's family) stated another EMS crew that was in the building for another resident assisted R1's EMS responders. On May 18, 2017 at 1:55 PM, E3 (RN) E3 stated she went into R1's room on May 11, 2017 around 6:30 PM, and R1's dinner meal was on the tray uneaten. E3 stated she tried to wake R1 up and R1 said yeah, yeah I'll get up. E3 stated she went back into R1's room around 7:00 PM and R1 sounded like she was sleeping. E3 stated R1's tongue was sticking out. E3 stated she had reported to E2 RN (Director of Nursing) because something was not right. E3 stated she was instructed to do a sternal rub (with her knuckles on R1's chest) and continue to monitor. E3 stated R1 would not move when she did the sternal rub. E3 stated Z1 (R1's family) came in the evening of May 11, 2017 and told her they couldn't wake up R1. E3 stated she told Z1 she had not been able to wake R1 up since around 6:30 PM. On May 19, 2017 at 3:10 PM, E3 stated I think I should have sent (R1) out way before I did. I should have called (physician) when I sent her out- I should have called him before and let him know symptoms I was seeing and how she was difficult to arouse. E3 added I should have checked her blood sugar earlier- I should have done a lot of things differently. On May 18, 2017 at 8:45 AM, Z1 stated he arrived at the facility on May 11, 2017, around 8:10 PM or 8:15 PM. Z1 stated R1 was in her bed in her clothes and sprawled out in a weird position . not in a way how she normally sleeps. Z1 stated R1's tongue was out of her mouth. Z1 stated he used his baseball stadium voice to scream in (R1's) ear and she did not respond. Z1 stated he asked E3 to take her blood sugar. E3 also stated R1's tongue was still sticking out when family came to the facility. On May 18, 2017 at 1:55 PM, E3 stated when she went to tell the E2 RN (Director of Nursing) the family wanted R1 sent to the hospital, it occurred to her R1 was diabetic. R1's electronic medical record showed she has a [DIAGNOSES REDACTED]. On May 19, 2017 at 2:25 PM, E8 (Dietician) stated a brittle diabetic means if a resident doesn't eat right or misses a meal, they can get [DIAGNOSES REDACTED] where their blood sugar goes down. On May 18, 2017 at 11:45 AM, E4 (LPN) stated if a resident had a blood glucose level of 70 mg/dl and was symptomatic, she would notify the MD. E4 stated she would give glucose gel if a resident was not coherent and then recheck the blood glucose in five minutes. E4 stated if she used up all the gel, she would give glucose as an injection but she would never not react. R1's May 11, 2017 nursing progress note from 9:17 PM showed at 7:00 PM, writer went into the room again, not response from the patient. Writer went into the room again at (7:30 PM) resident was still not responding . The facility's undated Diabetes Mellitus: Prevention and Emergency treatment of [REDACTED]. Assess for symptoms of [DIAGNOSES REDACTED]. The policy described Severe [DIAGNOSES REDACTED] as disoriented behavior, loss of consciousness, inability to arouse from sleep, [MEDICAL CONDITION]. The policy showed Procedure: 1. Observe daily for conditions which may predispose the resident to [DIAGNOSES REDACTED] on a daily basis: a. Too little food; 2. Skipping or delaying a meal or snack. Blood glucose value entries for May 11, 2017 on R1's Vitals Report show 81 mg/dl at 5:05 PM, and 64 mg/dl at 8:38 PM. Nursing interventions outlined in the policy for low blood glucose (70 mg/dl or below) and symptoms of severe [DIAGNOSES REDACTED], showed elevate the head of the bed . administer the physician orders [REDACTED]. The Reporting section in the facility's Resident Examination and Assessment policy (revised April 2007) showed .2. Notify the physician of any abnormalities, such as, but not limited to . 2.c. change in cognitive, behavioral, or neurological status from baseline . The facility's Change in a Resident's Condition or Status policy (revised April 2007) showed Our facility shall promptly notify (a resident's) attending physician . of changes in the resident's medical/mental condition and/or status . Under Neglect in the facility's February 2014 Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property policy showed .2. a. Types of neglect may include: d. Employees did not provide medical help promptly .

Based on interview and record review the facility failed to implement resident specific interventions to prevent unstageable/deep tissue injury pressure sores. This applies to two (R1 and R4) of three residents reviewed for pressure sores. This resulted in R1 obtaining a deep tissue injury to unstageable pressure sore to her left heel on 5/6/15 measuring 2.9 cm x 1.3 cm. and an unstageable wound on the left ischium measuring 8.7 cm x 9.3 cm. on 5/30/15. The findings include: R1 was admitted to the facility on [DATE] from the hospital with an admitting [DIAGNOSES REDACTED]. R1's admission assessment on 4/22/15 documented R1 had 0 of 10 on the pain scale rating (0/10) and intact skin other than some bruising to extremities and no known history of pressure sores. On 6/25/15 at 1:15 PM, E4 (LPN,wound Nurse) stated R1 entered the facility on 4/22/15 with no pressure sores. On 4/23/15 the first Braden risk assessment for pressure sores was done by E4 and R1 was documented At risk. E4 stated interventions were moisture barrier after incontinence episodes and float heels in bed. On 4/29/15, R1's Braden risk assessment was still At risk no new interventions added. On 5/6/15, R1 developed deep tissue injury (DTI) to left heel, foam dressing added no new interventions. On 5/13/15 R1 began to develop reddened area to coccyx, barrier cream was already in use, no new interventions. On 5/24/15 R1 developed open, excoriated areas to the coccyx, E4 stated an antifungal moisture barrier cream was added, no other interventions. On 5/29/15, R1 developed an unstageable wound to the left ischium. New dressings were added. On 6/1/15, E4 stated she assessed R1's ischial wound and then initiated a low air-loss mattress, limiting time out of bed to one hour. On 6/25/15 at 10:45 AM, E4 stated she is the wound nurse in the facility and is not currently wound certified. E4 stated there was not a wound physician who follows the wounds in the facility and directs wound care. E4 stated the primary physician will direct care for the resident. E4 stated the physicians usually just defer to the wound nurse. E4 stated that R1 had developed redness and excoriated areas to the coccyx area but E4 had not been following that area on R1 as part of her wound care. even though R1 was documented and assesed to be high risk. E4 stated it wasn't a pressure sore. The May 2015 treatment assessment record documents that weekly skin assessments were being done by the nursing staff on the 11 PM -7 AM shift with the last weekly check being on 5/27/15 where the staff nurse documented multiple areas of bruising on R1 as well as small sores on the buttocks and the wound nurse was following. The May 2015 treatment assessment record also documents from May 5th 2015 to may 31, 2015 that each nursing shift confirmed the left heel dressing was intact and that proper offloading of the heel was done. On 6/1/15 when E4 (wound nurse) assessed R1's reported reddened coccyx area, E4 stated R1 was noted to have an 8.7 cm x 9.3 cm unstageable left ischial wound that is documented as 95% necrotic tissue, the peri wound is macerated and reddened with a moderate amount of malodorous serosanguinous fluid. E4 documented in the wound assessment notes that R1 had a decline in condition and per the floor staff R1 was frequently non-compliant with repositioning despite education and that the MD and family were notified by the floor staff. There s no documented education on the risks presented to R1. The may 2015 CNA documentation form documents refusal of shower 5/5/15 and multiple episodes of complaints of back pain that the staff nurse was notified about. There is no documentation of R1 refusing care such as repositioning or heel offloading. On 6/25/15 multiple CNA's who cared for R1 routinely were interviewed and stated when R1 complained of pain she didn't like to be moved. R1's careplan with a problem start date of 4/28/15 and interventions were dated at 6/16/15. On 6/25/15 at 10:45 E4 (Wound Nurse) stated that's the way the printed out but that the intervention were actually started on 4/28/15. No other care plans reviewed printed that way and no other problem areas other that pressure ulcers printed that way. The problem under pressure sore documents R1 is at risk for breakdown due to impaired mobility, non compliance with offloading, incontinence and co-morbidities including diabetes, chronic [MEDICAL CONDITION], fluid overload and dehydration. The intervention are non specific to R1. The interventions listed were: - assist/encourage repositioning as needed. There is scant documentation to support R1 refusing repositioning and staff being aggressive with it until R1 had an unstageable ischial pressure sore identified on 5/30/15. -elevate the head of the bed 30 degrees or less unless contraindicated. R1 had documented episodes of back and hip pain in the May 2015 nursing notes and was unable to tolerate laying down at times and would sit up for hours to be comfortable and this was not addressed in the plan of care. -monitor weights and labs as ordered. This was not consistently done. -nutritional supplementation per registered dietician. -observe and assess regularly. This is not clear on who should observe what and what assessment needs to be done for R1. -Registered Dietician consult. -serve diet as ordered. R1 was documented to have a consistent poor appetite. -Therapeutic surfaces to bed and wheelchair as appropriate. This is not clear as to what therapeutic surfaces are needed and appropriate for R1 to prevent and heel pressure sores. -weekly skin assessments. After this careplan was initiated by E4 (Wound Nurse) on 4/28/15, R1 developed two unstageable pressure sores while in the facility and the only interventions added to the care plan were Treatment as ordered. The facility policy title Skin Management with a revised date of 12/2013 documents that the facility will assess residents for risks of pressure sores by identifying the specific factors and initiate interventions based on those factors. R1 came into the facility high risk and remained high risk and subsequently developed two unstageable pressure sores where more aggressive interventions were not put into place until the second unstageable pressure sore had developed. The facility skin management policy also documents the Braden Scale is the designated risk assessment tool and tissue tolerance testing would be completed on residents who are unable to position themselves while lying or sitting. There is no documented tissue tolerance testing done on R1. There are no physician assessments of either wounds. Z1 (Primary Physician) had seen and assessed R1 on 5/13/15, 5/18/14, 5/26/15 and 5/29/15 and none of these assessments mentions R1s unstageable heel or ischial wound. On 6/25/15 at 12:15 PM, Z1 stated he does not recall R1 having a sacral or ischial wound. Z1 stated he was aware of the heel wound but was concerned with her fluid overload status when he had seen her. Z1 could not remember if he had seen R1's wounds. R1 was transferred to the hospital on [DATE] due to unresponsiveness and [MEDICAL CONDITION] and was found to have bactremia by positive blood cultures in the hospital. R4 has a medical hisotory of open reduction internal fixation of the right elbow, Guillan- Barre syndrome and chronic anxiety as documented on the June 2015 physician order [REDACTED]. R4's admission report from the hospital (undated) documents skin as left elbow elastogel and reddened buttocks.(R4 was admitted [DATE]). The facility admission assessment form dated 4/8/15 documents skin as: bottom of heels red. and a surgical incision., bruises. No pressure ulcers. The facility 4/8/15 treatment record documented, Right elbow incision healing, staples out, slightly red, no drainage. Both heels red, not open and blanches easily. There is no other documentation on R4's elbow. R4's surgical incision is distal to the bony prominence of the elbow. The facility nursing note dated 4/14/15 documents, Right elbow noted with blanchable dark [DIAGNOSES REDACTED], surgical site healed. Pt states she frequently rubs elbow against and presses elbow into the mattress. No interventions put in place to protect the elbows. R4's care plan titled Skin integrity. is undated and documents the problem as: R4 was admitted with surgical wound to rt elbow and deep tissue injury to right elbow. R4 is at risk for breakdown in skin integrity related to impaired mobility, incontinence and comorbidities. The inteventions listed are non specific and not individualized to the prevention and helaing of R4's unstageable right elbow pressure ulcer. The interventions listed are: -Weekly skin assessments -Monitor for changes -Moisture barrier cream -Elevate the head of the bed 30 degrees -Assist/encourage repositioning -monitor nutritional status -Hydration -Notify physician and family of change -Treatment as ordered -Assess an document weekly. There are no specific interventions to prevent pressure to the elbows / bony promineneces. On 6/30/15 at 10:00 Am E4 (Wound Nurse) stated she had thought R4 was admitted with the pressure ulcer but confirmed there was no documentation to support that. The facility Wound Rounds notes dated 4/9/15 documents R4 to have a Braden Score (Pressure ulcer risk factor assessment) of 14 being moderate risk. The preventive interventions listed were: Nutrition-none Friction and Shear- protect elbows if being exposed to friction There are no documented interventions put in place to prevent the elbows from friction and shearing. The first wound assessment detail report was done 4/17/15 and documents the wound was identifed 4/8/15 even though all supporting documentation stated R4 did not have a pressure sore on admission to the facility. The 4/23/15 documentation of the wound has the wound measured at 3.2cm x 2.6 cm and was described as, Boggy with deep maroon filled blister. Periwound noted with yellow discoloration and bogginess. Foam dressing was added at that time. On 5/17/15 the purple maroon discoloration is documented as improved and now draining. It is not documented if the physician or family was notified. On 5/19/15 the dressing treatment was revised. On 5/25/15 the wound was documented as opened with partial thickness tissue loss. On 6/1/15 the wound is documented to have 95% slough. moderate amount of seroussanguinous drainage and macerated periwound. Dressing again revised. The careplan interventions were not revised during this period.