Every finding on record at Pearl of Hillside,The

Based on observation, interview, and record review, the facility failed to provide appropriate footwear as a fall prevention intervention for a cognitively impaired resident with a history of repeated falls. This failure affected one resident (R72), reviewed for fall prevention in a total sample of 68 residents.Findings include:R72's face sheet documents diagnoses which include but are not limited to Dementia, Repeated Falls, Osteoarthritis, and Adult Failure to Thrive.Fall assessment dated [DATE] showed that R39 is at risk for falls.BIMS (Basic Interview for Mental Status) did not have a score due to Severe Cognitive Impairment. Care plan dated 10/3/24 showed in part that R72 is at risk for falls due to impaired mobility, confusion, gait balance problems, incontinence, psychoactive drug use, unaware of safety needs and diagnosis of Dementia. Intervention states in part to follow facility fall protocol.MDS (Minimum Data Status) Section GG dated 3/27/26 showed that R72 requires assistance for functional abilities and R72 uses a wheelchair.On 6/22/26 at 10:45am, R72 was observed in the activity room sitting in the wheelchair at table with other residents during activities. R72 was wearing a pair of socks with blue and black color that was smooth on the bottom, not nonskid. Again, on 6/22/26 at 12:05pm, R72 was in the same position with the same pair of smooth bottom socks. At this time, V25(Activity staff) stated the name of the resident and checked the bottom of R72's socks and confirmed that the socks R72 was wearing had smooth bottom and were not non-skid. V25 and V6 (Activity Director) stated that they would inform the CNA (Certified Nurse Assistant) and Nurse to find nonskid socks for R72.On 6/23/26 at 11:20am, the surveyor asked V2(Director of Nursing) why a resident at risk for falls needed to wear nonskid socks or appropriate nonskid footwear. V2 stated nonskid socks are important to prevent falls and that she(V2) would remind staff to ensure that residents wear nonskid socks. V2 Added that she(V2) is relatively new at the facility, but she believes that nonskid socks are available in storage, and she would ensure that the socks are available in residents' rooms.Facility's policy titled Fall Prevention and Management with latest revision date 3/25/2026 states: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. #1d: High risk residents and patients for falls will receive individualized interventions as appropriate to risk factors.

Based on observation, interview, and record review, the facility failed to follow the standard of practice and physician orders for the care of urinary catheters. This applies to 2 of 3 residents (R2 and R4) reviewed for catheter care in a sample of 6.The findings include:1.R2 is an [AGE] year-old female admitted on [DATE], having severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE].On 3/7/26 at 10:05 AM, R2 was observed on her bed with her spouse (V10) at bedside. V10 stated, My wife was sent to the local hospital due to a severe infection. They are not changing gloves between care, which is causing infection.On 3/7/26 at 10:40 AM, observed V12 (Certified Nursing Assistant / CNA) providing urinary catheter care for R2 with stool on catheter. V12 provided urinary catheter care by wiping the catheter toward the urethra and then away from it.On 3/7/26 at 2:10 PM, V2 (Director of Nursing / DON) stated, As per standard of practice, the catheter itself should be wiped from the insertion site outward to prevent infection. I will conduct an in-service to educate staff on providing catheter care.A review of the health status note dated 12/1/25 documented that R1 was admitted to the local hospital for urinary tract infection (UTI) and sepsis. A further review of the health status note dated 2/12/26 and 1/7/26 documented that R2 was admitted to the local hospital on 2/12/26 and 1/7/26 due to sepsis.2.R4 is a [AGE] year-old male with intact cognition per the Minimum Data Set (MDS) dated [DATE].On 3/7/26 at 11:25 AM, R4 was observed in his bed with his suprapubic catheter site dirty and dry blood almost four inches around the insertion site.A review of R4's physician order sheet (POS) document: Cleanse suprapubic catheter insertion site daily and as needed (PRN). Use soap and water, as needed, unless otherwise ordered.On 3/7/26 at 2:10 PM, V2 added that the suprapubic catheter should have been kept clean to prevent potential infection.

Based on the interview and record review, the facility failed to follow its appointments and transportation policy by not arranging transportation for outside appointments. This applies to 1 of 3 residents (R1) reviewed for appointments and transportation in a sample of 6.The findings include:R1 is a [AGE] year-old male with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. A review of the MDS also documented that R1 was admitted with an admitting diagnosis including malignant neoplasm of the mouth.On 3/7/26 at 9:15 AM, R1 was observed in his bed with swollen lips and was unable to communicate effectively.On 3/6/26 at 2:15 PM, V8 (Oncology Clinic Nurse Practitioner) stated, I am R1's oncology clinic nurse practitioner. R1 missed so many appointments, I would say around five appointments, between other care providers and us. R1 said he missed his appointments due to a lack of transportation, communication, and not writing it down in the records for staff to follow up after setting transportation. R1 is at high risk for relapse if he misses his oncology appointments.A review of the clinical physician orders documented that R1 was scheduled for a cardiology appointment on 2/4/26 at 9:05 AM, an oncology appointment at 12:00 PM, and an infusion appointment at 2:00 PM.A review of the transportation schedule for 02/2025 and nursing progress notes from 2/1/26 through 2/6/26 documented that R1 was sent only for cardiology appointments, not for oncology or infusion appointments.A further review of the January transportation schedule and nursing progress note from 1/25/26 through 1/30/26 documented that R1 was not sent for the oncology appointments on 1/27/26 at 11:40 AM.On 3/7/25 at 2:10 PM, V2 (Director of Nursing / DON) stated, I can't remember exactly why he missed appointments. The resident has the right to go for an appointment, and we are supposed to set it up.A review of the facility's appointments and transportation policy, reviewed on 4/16/2025, documented that when a resident has an appointment outside the facility, staff will make the transportation arrangements unless the responsible party chooses to make them themselves.

Based on interview and record review the facility failed to protect and prevent one (R1) of three residents from injury of unknown origin. This failure resulted in R1 sustaining multiple fractures, left subdural hematoma, right parietal subarachnoid hemorrhage, anterior wall bruising, and left shoulder bruising. This failure affected R1 and has the potential to affect all 163 residents residing at the facility. Findings include:R1's admission Record documents initial admission as 2/28/25 and latest admission as 7/05/25.R1's electronic medical record admission Record documents diagnose that includes but not limited to Unstable burst fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing, altered mental status unspecified, unspecified fall subsequent encounter, unspecified cirrhosis of liver, hepatic encephalopathy, other pancytopenia, major depressive disorder, single episode moderate and alcohol dependence uncomplicated.R1's primary language is SpanishFacility Reported Incident dated 1/27/2026 at 3:50pm final report documents in part: Incident Date 1/27/2026 Time 3pm, R1 alert and oriented times 3 with a BIMS of 15 with no diagnosis of dementia or cognitive impairment. On 1/27/26 resident complained of left shoulder pain, receive pain medication that was not effective nurse placed a call to DR. New order to send patient to ER for evaluation. When asked if someone hurt him, R1 responded that no one hurt him. When asked if he felt safe at the facility, R1 responded yes I feel safe here. Hospital informed facility of multiple fractures with some being acute and chronic, intraabdominal hemorrhage, intracranial hemorrhage. Brusing noted to anterior chest wall and left shoulder. V25, Facility Liaison, interviewed R1 at hospital on 1/28/2026. V25 stated she was there to interview him to see if he remembers anything from the day that he was sent out. R1 stated that he was doing exercises in bed, and he felt stronger than normal. He wanted to walk, and he attempted to get out of bed. When he attempted, he fell to the side that was close to the window. R1 stated that a staff member assisted him back to bed and at that time R1 did not have pain. R1 stated that he doesn't want anyone to get in trouble, and he felt he could walk but he knows he can't now. R1 was asked why he didn't share this information with the hospital or the police, and he stated that he did not feel comfortable because they kept coming in and out and he didn't know them. Resident interview was not witnessed.R1's Emergency Medical Run sheet dated 1/27/2026 at 8:26.54 documents in part, Patient Evaluated, and care provided. Primary Symptom: Pain Narrative: 49yo male (R1) with numbness and pain to his left shoulder. Upon arrival crew found the pt laying semi-Fowlers in bed, aox4, in no distress, holding his left wrist. Pt informed crew that his left shoulder and left hip hurt. Pain began last night and has not gone away. Pain starts at shoulder down to elbow and from his feet up to his knee. Pt. Denies falls/trauma.R1's medical record showed that R1 was sent to the local hospital ER (Emergency Room) on 01/27/2026 for complaint of pain in his left arm. R1's hospital record 1/27/2026 showed that R1 had Multiple fractures that include Acute comminuted and displaced Left humeral head fracture and displaced left humeral head fracture, bilateral sub capital femoral neck fractures, minimal displaced bilateral sacral body insufficiency type fracture at S2, minimal displaced right L4 transverse process fracture, small left subdural hematoma, right parietal subarachnoid hemorrhage, anterior chest wall bruising, left shoulder bruising, bruising is 3 to 4 days old.R1's hospital record 1/27/2026 documented in part that He (R1) at one point accepted that somebody hurt him, however (R1) is reluctant to give information about fear of police involvement or other social reasons.R1's MDS (Minimum Data Set) dated 12/05/2025 coded BIMS score as 15 indicating that R1 is cognitively intact. Section GG under GG0115 functional limitation documents under range of motion that R1 has no impairment. R1 uses wheelchair for ambulation, for transfer needs supervision or touching.R1's plan of care documents that R1 is unable to leave the facility independently on community pass. R1 cannot go out without an escort for appointments.R1's plan of care documented that R1 has self-care performance deficit and for transfer needs sit to stand transfer device ADLs (Activity of Daily Living).R1's fall assessment dated [DATE] R1 was categorized as a low risk for falls with a score of 11.0 and on 1/28/2026 a score of 10.0 indicating low risk for falls. V19, Registered Nurse (RN) documented that the patient (R1) complained of extreme pain and numbness in the left upper extremity. Limited mobility noted in the left arm and leg. Vitals are listed: B/P-120/ 54, pulse (Pulse) 60, O2% 95, RR (Respiration Rate) 15. AOx3. MD (Medical Director) paged. Orders received to send to ER (Emergency Room) to rule out stroke. Orders carried out. Patient (R1) sent to ER via 911.On 01/29/2026 at 9:12am, V1, Administrator stated, I think this visit will be about (R1) because the hospital already told us they called it in to IDPH (Illinois Department of Public Health). At 9:42am during conference meeting with V1 and V2, Director of Nursing (DON), both stated that R1 did not fall. V1 further stated, I have interviewed the staff and they all said R1 did not fall.On 01/29/2026 at 10:00am, V1 stated, R1 is one of the residents that was admitted on a contract from a local hospital to be housed and care for because they have medical needs with their care.On 01/29/2026 at 10:04am, V3, emergency room Registered Nurse (RN) stated that she received R1 via ambulance from the facility with complaints of left shoulder pain and arm. V3 stated, R1's left shoulder was bruised and R1 could not lift his arms and there was visible bruising. R1's X-Ray showed both hips broken (fracture), Acute left shoulder fracture, C-T scan done and it showed that he had peritoneal hematoma, head and neck showed subdural bleeding on the left side. V3 stated that (R1) is alert, speaks Spanish and I am Spanish, so I was able to communicate in Spanish with R1. R1 said he did not remember what happened and that he had been living in the facility for eight to nine months. (R1) is bed bound, and he can only sit in bed when the head of the bed is raised.On 01/29/2026 at 2:31pm, V18, Certified Nurse's Aide (CNA) stated, she is familiar with R1, and she worked with R1 on 01/26/26 but was not his direct CNA for 01/27/26. V18 stated, she speaks Spanish so R1 likes to talk with her. V18 stated in part that on 1/26/26 there was no abnormal incident with R1. He was sitting in bed with his phone watching video on his phone. V18 explained that on 1/27/2026 R1 had his call light on so when I went into the room, he said he could not move and was in pain because he slept on his left side for a long time. R1 asked me to help him to turn on his back. I (V18) just helped by pulling his incontinent clothing pad under him to get him off his side. R1 kept complaining of pain to the left side holding his left arm saying it is painful. I let the nurse (V19) know, he said he could not move the left arm while complaining of pain. V18 stated in part that we (facility nursing staff) use a transferring Device to move R1 with 2 people's assistance. R1 is on fall risk, with his bed most of the time on low setting. V18 was asked if R1 fell on 1/27/2026. V18 stated, Not that I know off.On 1/29/26 at 1:15pm, V17, Certified Nurse's Aide (CNA) stated that she was assigned to R1 on 1/27/26 morning shift. V17 stated she is familiar with (R1). V17 stated that on 1/27/26 she was late to work arriving at 8:00am and when she walked into his room to check on him, he (R1) was showing sign of pain groaning, and I could tell from his face expression that he was in pain. V17 further stated, I (V17) asked him if he was in pain and he said yes using head gestures to point to his left arm which was kind of swollen. V17 said as she was about to leave the room she saw V18 and V19 come into the room, as they walked into R1's room V18 translated what R1 was saying to V19. R1 said he did not know what happened, he said he had been laying on the left side on his arm for a long time. V19 then called the physician, and he was sent out because I did not see him for the rest of the day.On 01/29/2026 at 2:59pm, V19 Registered Nurse (RN) stated, she was the nurse that sent R1 out to the ER (Emergency room) and she worked from 7am to 3pm on 1/27/29 and she was familiar with R1. V19 stated, R1's call light was going off and V18 came out of R1's room telling me (V19) that R1 was complaining of pain. V19 stated, I went to assess him and V18 helped in translating. R1 complained of pain to left arm and left leg with limited mobility. R1 could not move. I (V19) called V34, Nurse Practitioner (NP) and V34 ordered to send R1 to the hospital to rule out stroke. V19 stated, the night nurse did not report any incidents with R1 and did not report that R1 fell and R1 did not say he fell.During the same interview V19 stated that I have worked with R1 before (01/27/2026). Normally he is in bed and will not go to the dining room to eat. He does not get up in wheelchair. I have never seen him out of bed. V19 stated, she has never seen him get out of bed by himself. V19 stated that (R1) needs staff to assist him using a transfer device if he needs to get up in a wheelchair or for any transfer. V19 stated that R1 needs two people's assistance for transfer.On 02/03/2026 at 11:17am, R1 was observed in bed. During interview with R1 with V3, Assistant Director of Nurses (ADON) present and on-line video Spanish interpreter, V23 (interpreter). R1 stated to interpreter, in part that he did not know what happened to him. He woke up and was in pain and was being sent to the hospital. R1 was asked if he fell. R1 stated, he did not remember falling and he did not remember telling anyone that he fell. R1 stated that he told them he was in pain.On 02/03/2026 at 11:36am, V22, Therapy Director stated in part that R1 was not currently getting PT/OT (Physical Therapy/ Occupational Therapy). V22 checked the computer and stated in part that R1 had PT from 07/10/25 to 07/23/25 and OT from 07/11/2025 to 7/23/2025. V22 stated, R1 is now in facility restorative program. V22 further stated R1 cannot transfer from bed to chair or vice versa independently. PT discharge instructions for R1 with supervision/touch assistance, a staff must be with resident because it documented maximum assistance that means staff helping with transfer 75% and R1 helping at 25%. OT with personal hygiene documented that R1 upper body with set up only and with lower body maximum assistance, staff must assist.R1's PT (Physical Therapy) discharge summary presented with dates of service from 7/10/2025 to 7/23/2025 documented under Functional Skills Assessment that bed mobility roll left and right =setup or clean-up assistance, sit to lying=supervision or touching assistance, lying to sitting on side of bed = supervision or touching assistance, Transfer sit to stand=substantial/maximal assistance. Mobility score Mobility function score (ranges from 0-12; 12 being the highest function) = 0, Mobility Performance raw score = 1. On 02/03/2026 at 2:15pm, V20, Physician stated, that R1 is one of my patients he came to us (facility) from the hospital after a fall. R1 has alcoholic history, fracture of the spine. He was seen by neurosurgeons and was sent to the facility for rehab (rehabilitation) since I met him, he has not been able to walk any more. He has no place to go. He has memory change; he cannot recall things, repeats himself. He (R1) had therapy for about a year with no change. When I talk to nursing (staff), they say he does not get out of bed and is not able to walk. That became his (R1)'s new baseline. V20 stated that he last saw R1 in December 2025, and V34 I saw him on 23rd of January 2026. V20 stated that R1 cannot walk independently. He cannot and has never tried to walk before as far as I know. R1 needs supervision in getting up with assistance from staff. V20 further stated in part, I looked at the hospital's report with the fractures, the injury was on the left side. It is very possible he fell, R1 is a high risk for falls. V20 stated that R1's injuries are consistent with falls. The surveyor asked if it is appropriate to rate R1 as a low risk for fall. V20 stated that R1 should never have been a low fall risk from admission. V20 stated in my professional opinion with transfer, I would recommend two people assist with device.On 2/11/2026 at 12:10pm V29, Certified Nurse's Aide (CNA) stated, R1 did not fall, and I did not pick up R1 off the floor. V29 further stated he will deny any accusation that he picked R1 off the floor. V29 worked 1/26/2026 into 1/27/2026.On 2/11/2026 at 12:38pm V1 (Administrator) stated, V29 has been suspended from the facility pending investigation after the facility was made aware of the allegation but was not reported to IDPH as fall with injury because V29 denies that R1 fell during his shift.On 02/11/2026 between 2:09 to 2:17pm, V34 NP (Nurse Practitioner0stated in part that she has been following him (R1) since last year. V34 said on the day he was sent out, the nurse called me to say that he was having severe pain in the left side unable to move so I told them (nurse) to send him to the (Hospital) for workup (evaluation and treatment) to rule out stroke. The work up came out that R1 has multiple fractures, bleeding in the brain and abdomen. The surveyor asked V34 whether it is possible for R1 to walk independently, get up from the bed or dangle feet exercising. V34 explained that R1 has not being able to walk since admission to the facility (February 2025). Movement to lower extremity is slow and weak, the right side has been weaker. The nurse (referring to V19) did not say R1 fell, and V2 DON (Director of Nurse's) told me that R1 did not fall.During this investigation V31 LPN (Licensed Practical Nurse) was contacted via telephone without success. V2 DON (Director of Nurse's) stated that she had tried to contact V31 several times without success.The facility as at 3:00pm on 2/11/2026 could not present any fall incident report. V2 stated that because the staff that worked did not report any fall incident and that none of the staff knows what happened to R1 and the cause of injury.According to facility investigation, the facility staff interviewed on 1/27/2026 and 1/28/2026 V5, V18, V28, V29, V30, V32, V35, V36, V38, V39, V40, V43, V44, V48, V49, Certified Nursing Assistants, V13, V14, V31, V47, Licensed Practical Nurses, and V37, V41, V46, V50, Registered Nurses did not know what happened to R1 and denied that R1 fell and was picked up off the floor.On 02/11/2026 at10:34am, V5 stated that (R1) cannot sit on the edge of the bed or scoot down the bed. R1can only turn to side with the (staff) assistance because we (staff) must help him move his legs and feet. He (R1) lays on the bed playing with his phone. V5 stated R1 speaks only Spanish language.On 02/11/2026 at 10:36am, V12 stated that (R1) only move in bed by sitting up and turning with incontinent care with staff assistance. I have never seen R1 get up or stand up. (R1) needs 2 people's assistance if he must get up. We (nursing staff) just raise the head of the bed up. He (R1) cannot scoop to the edge of the bed, and I have never seen him done that. V12 stated that I have not seen him even trying to get off the bed.On 02/11/26 at 12:25pm, V1 stated in part that none of the staff interviewed knows what happened to R1. When pictures of the night CNAs on 01/26/2026 were shown to R1, R1 identified (V29) that it was him who picked him off the floor.Facility Abuse prevention policy presented under definitions documents in part that the federal and state laws and regulations mandate that a nursing home resident has the right to be free from abuse. Injury of unknown source are injuries for which both of the following condition are met one the source of injury was not observed by any person, or the source of injury could not be explained by the resident and two the injury is suspicious because of the extent or location of the injuries observed at one point, or the incidence of injuries overtime.

Based on interview and record review, the facility failed to ensure a thorough and credible investigation was conducted for 1 of 3 residents (R1) reviewed for abuse. Specifically, the facility's investigative process failed to: 1) Reconcile conflicting evidence between a staff member's motive and the resident's initial allegation of being 'hit'; 2) Include critical witness testimony from the first clinician on the scene (V4 Agency RN) in reports provided to law enforcement; 3) Conduct a clinical review to assess the feasibility of a catastrophic orbital globe rupture and depressed fracture being caused by a minor 'accidental' strike; and 4) Factor the resident's Mild Alzheimer's and high-risk use of Eliquis into the evaluation of the incident and subsequent 'recantation.' As a result of this incomplete investigative process, the facility provided a medically implausible and incomplete narrative to law enforcement, which contributed to the premature closure of an abuse investigation into a life-altering injury. Review of the facility's undated policy titled Abuse Prevention Training Program, stated in part but not limited to: Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. The policy further states that Abuse is most likely to happen in situations that result in frustration, annoyance, and anger, and directs staff to manage these situations with self-control and to remove themselves from the situation when in doubt. Review of the facility's final investigative file regarding the incident on 11/08/25 revealed that the facility neglected to document or include critical testimony and clinical evidence: During an interview on 01/16/26 at 11:55 AM, V4 Agency RN stated he was the first clinician on the scene and documented R1's immediate allegation that the CNA hit me. V4 also observed the CNA's agitated state and perceived anger toward R1 over a broken necklace as a possible motive. V4 stated he reported these findings to the Administrator and management, yet the facility's formal report to Law Enforcement did not include these observations and the fact that a staff member had reported the incident as an assault via a 911 call. The facility concluded R1's injury was accidental, suggesting the resident's eye was struck by the resident himself and did not include the possibility that the necklace chain or pendent may have been the contributing blunt object. Review of the hospital discharge summary confirmed a depressed orbital floor fracture and left orbital globe rupture requiring emergent surgical intervention. There was no evidence the facility consulted a medical professional to determine if a swinging pendant or a self-inflicted blow from an elderly resident with Mild Alzheimer's could generate the force required to fracture the bony orbit. There was no evidence that R1's use of Eliquis (Apixaban) and the associated risk of hemorrhage were evaluated. Clinical literature indicates that geriatric patients on anticoagulant therapy are at an increased risk for sight-threatening retrobulbar hemorrhages following blunt trauma. Despite R1 requiring emergent surgery for severe hemorrhaging, the facility did not conduct a clinical review to reconcile how a minor accident could lead to such a catastrophic emergency. Review of Police Report #25-002908 indicated the Administrator (V1) provided a statement asserting the resident recanted the allegation. However, the facility's records do not indicate that R1's cognitive impairment (Mild Alzheimer's) or potential suggestibility following traumatic injury were considered when evaluating the validity of this recantation. Furthermore, the facility did not demonstrate that a neutral advocate or social worker was present during the interview where the recantation occurred. A review of the facility's internal abuse investigation procedures revealed that the facility lacked a thorough and complete investigative process as required by Federal regulations. Specifically, by omitting documented allegations of physical assault from the formal report and failing to clinically validate the feasibility of the injury, the facility lacked a thorough implementation of a system that ensures residents are protected. This facility's investigative process mischaracterized a major physical assault as an accident, resulting in profound clinical and legal consequences for R1. The resident sustained a permanent left orbital globe rupture and total loss of vision in the affected eye. Additionally, the apparent incomplete narrative provided to law enforcement resulted in the closure of the criminal investigation without charges, depriving a resident with Mild Alzheimer's of the legal recourse and protective oversight necessary following a life-altering injury.

Based on interview and record review, the facility failed to follow their fall focus program for one resident who was identified as moderate risk for falls, by not ensuring the resident's entire bathroom floor was dry prior to assisting him with care. This affected one of three residents (R1) reviewed for safety during care. This failure resulted in R1 sustaining a witnessed fall resulting in an impacted intertrochanteric fracture of the proximal right femur (right hip fracture).Findings include:R1 was admitted to the facility on [DATE] with a diagnosis of down syndrome, severe intellectual disabilities, mood disorder and osteoarthritis. R1's brief interview for mental status score dated 9/26/25 documents a score of 8/15 which indicates mildly impaired. R1's functional abilities dated 9/26/25 documents supervision or touching assistance for personal hygiene, shower transfer, putting on/taking off footwear, upper and lower body dressing. Under shower/ bathe self documents: R1 requires partial/moderate assistance.R1's fall assessment dated [DATE] documents moderate risk for falls. Under gait analysis documents: unable to independently come to standing position, exhibits loss of balance while standing, decrease muscle coordination and strays off straight path of walking.R1's incident report dated 10/13/25 documents: Resident was taking a shower had a slip and hurt his buttocks area. The fall was witnessed no injury to head. Resident reports pain to right leg. Under predisposing environmental factors wet floor is marked.On 10/28/25 at 2:06pm, V4 (CNA/Certified Nurses Assistant) said she was passing by R1's room and heard the water. V4 said she entered the room and observed R1 undressed in his bathroom with wet towels. R1 was soaking the towels in the sink with water and then going to shower and squeezing the water onto himself because the shower head was turned off and only had a small amount of water coming from the shower head. V4 said she tried to convince R1 to come out of the bathroom, but he was refusing. V4 said there was water all over the floor. V4 said the floor was still wet with puddles where R1 was standing but had dried the other half of the floor. V4 said, V5 (CNA) heard them and came into the room to assist. V4 said R1 started listening to V5 and V4 was able to dry off R1 and assisted him to get dressed with cueing. R1 had a shirt, pants, shoes on and was reaching to put on his sweater that V5 was holding. V5 and V4 were walking out of the bathroom to try to get R1 to come out to put his sweater on when R1 slipped and fell to his buttocks. On 10/29/25 at 12:21pm, V5 (CNA) said on day of incident he was in the hallway and heard R1. He went into R1's room to assist. R1 was already out of the shower and had pants and shoes on. The floor was wet because R1 had a cup that he was filling with water at the bathroom sink and bringing to the shower to bathe. R1 needed to get his shirt on and was assisted by staff V4 who was in the room as well. R1 was not being resistive with care at that time. V5 said he had R1's sweater and when R1 went to grab it he slipped and started to fall. V5 said he tried to stop him from falling but R1's weight took him down and the position he was in due to the toilet being in the way.R1's right femur x-ray report dated 10/13/25 documents: an impacted intertrochanteric fracture of the proximal right femur with varus deformity.Facility Fall prevention and management policy revised 3/31/25 documents: The facility is committed to its duty of care to residents and patients in reducing risk, the number of consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Universal fall precautions will be implemented to all residents admitted to the facility regardless of risk scores. Fall focus program will be implemented to ensure purposeful rounding addresses residents positioning, pain, personal needs. personal items within reach, safety hazards and peaceful environment upon admission and throughout resident stay.Facility fall focus program undated under protection/safety hazards documents: Staff will assess its physical environment, device, equipment, including furniture, appliances, beds, wheelchairs etc to ensure that it don't pose a safety risk or hazard. Rooms and hallways should always be clutter free. Floors and surfaces should be clean and dry.

Based on observation, interview and record review, the facility failed to implement an effective pest management program. This affected two of four (R5, R6) residents reviewed for pest. This has the potential to affect all 154-resident having their meals prepared in the kitchen. This failure resulted in gnats being observed in R5, and R5 rooms and observed in flying in the kitchen dish area.Findings Include:On 9.23.25 there were currently 154 residents residing in the facility that utilize the kitchen to have their meals prepared. On 9/23/25 at 12:15pm, R5's room was observed with two trash cans with lids near his entry way. Multiple gnats were observed flying around the two trash cans when surveyor entered R5's room. More than ten gnats were crawling on the outside of R5's white trash can. R5 was observed in bed asleep with a few gnats on his bed sheet resting above R5's head.On 9/23/25 at 12:18pm, R6 was observed resting in bed. R6 was assessed to be alert and orient to person place and time. Three gnats were observed flying around R6's bed and bedside table. R6 said, she has been having a problem with gnats. R6 said, it's nasty to have gnats flying around.On 9/23/25 at 12:19pm, V4 (maintenance director) said, there are gnat in R5's entry way surrounding the trash cans and in R5's trash can. R5's white trash can was observed full with trash. V4 said, the gnats are in the trash due to the certified nursing assistance (CNA) not emptying R5's trash. On 9/23/25 at 12:48pm, R5 was observed awoke in bed and eating lunch. R5 said, he has had a problem with gnats. On 9/23/25 at 12:51pm, V3 (unit manager) said, she saw one gnat around R5's bed. V3 said, R5 cannot swat the gnats away. On 9/23/25 at 1:06pm, during the tour of the kitchen, three to four gnats and one large mosquito were observed flying in the corner near the handwashing sink. V6 (dietary manager) identified the insect flying around as gnats and a mosquito. V6 said, this is the dish washing area. V6 said, she has not seen any gnats prior to today.Service Inspection Report dated 9/24/25 documents: Main Kitchen Area: Comments: Fruit flies were present during the time of service. Kitchen floor needs to be regrouped to prevent fruit flies from breeding.On 9/23/25 at 3:43pm, R5 was observed with a partially open bag of restaurant food on his bedside table with seven or more gnats crawling around top, inside and on the outside of his food bag. Three gnats were resting on R5's wall near his bedside table. V4 said, there are gnats in and around R5's food bag. V4 said, there are gnats on the wall. Pest control Policy dated 3/22/21 documents: Provide a healthy environment for residents. Mosquitoes-they not only bite patient and cause allergic reaction at times but also carry disease like [NAME] Nile virus. Often, elderly patient is more susceptible to this infection when compared to younger population and have more difficulty recovering. Keep trach cans lined and empty them regularly.

Based on observation, interview and record review, the facility failed to check and provide incontinence care at least every two hours for one resident who was identified as dependent on staff for toileting. This affected one of three residents (R3) reviewed for incontinence care. This failure resulted in R3 being saturated with a urine filled adult brief for over four hours. Findings Include:R3 was diagnosed with Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage affecting left dominant side. R3's care plan dated 3/28/24 documents: provide incontinence care after each incontinent episode. Section C (cognitive patterns) dated 6/20/25 documents a score of twelve which indicated moderate cognitive impairment. Section GG (functional abilities) documents dependent with toileting hygiene. Section H (bladder and bowel) documents: urinary continence always incontinent.On 9/23/25 at 12:53pm, R3 said, he needed changed. V3 (unit supervisor), checked R3's adult brief. R3's entire brief was saturated with urine. V3 asked, R3 when was he changed last. R3 replied at 7:30am or 8:00am. V3 said, residents should be provided incontinence care every two hours and as needed. V5 (certified nursing assistant/cna) said, she was R3's assigned cna. V5 said, she last provided care for R3 at 9:00am. R3 was observed with a brief full of yellow urine, with a large yellow irregular ring on his bed pad and a smaller irregular shaped ring on his fitted sheet. V5 said, R3's bed pad is wet with urine. R3's sheet has a dried urine stain. V5 said, residents should be changed every two hours. V5 said, R3 is a heavy wetter.Urinary Continence and Incontinence-Assessment and Management dated 2/13/25 documents: Staff will ensure that incontinence care needs are met.

Based on interview and record review, the facility failed to develop a plan of care with increased monitoring /supervision for a resident identified to have safety awareness of urinating in a trash can, resident had a history of falls and unsteady gait. This affected one of three residents (R1) reviewed for falls, supervision and safety awareness. This failure resulted in slipping his own urine falling to the floor sustaining a bump to the head and change in consciousness.Findings Include: R1 was admitted on [DATE] with the diagnosis of abnormal gait and mobility, lack of coordination, dizziness and giddiness, hypotension, cerebral infraction due to embolism of left middle cerebral artery and aphasia following a cerebral infraction. Care plan initiated: 09/03/2025 documents: Resident (R1) has potential for falls secondary to functional deficits, fluctuating blood sugars, cognitive deficits. Care plan initiated 9/04/2025 documents: resident has an ADL self-care performance deficit related to right side weakness, hypotension. Unwitnessed fall report dated 9/5/25 documents: R1 urinated on the floor, he also was laying on the floor on his back, a bump was noted on the back of his head. R1 complained while touching that area. Unable to give any statement resident does not speak English. Predisposing environment factors: wet floor. Other information: R1 urinated on the floor then he fell. Fall event dated 9/5/25 documents: Mental status: Lethargic/drowsy- does not perceive the environment fully, responds to stimuli appropriately slowly and with a delay. Was there a deviation from usual mental status? Yes, drowsier. Left/right upper and lower extremities: weak. Nursing note dated 9/5/25 documents: This AM (morning) I/(V8) Nurse, was getting a nurse's report, The activity aide (V14) came to us to let us know that the resident was walking in the room, we went into the room, we noticed that the resident urinated on the floor, he was laying on the floor on his back, able to move all four extremities, a bump was noted on the back of his head, resident complained of pain while touching that area, resident was assisted back to his bed, MD aware with an order to send the resident to the ER via 911. admitted to hospital with the diagnosis of intracranial bleeding.On 9/24/25 at 10:46am, V2 (Director of Nursing/DON) said, R1was a new admit. V14 walked past R1's room and saw R1 standing at the doorway. V8 and V14 returned to R1's room. R1 was laying in the floor. R1 urinated on the floor, sipped in the urine and fell backwards. R1 had a bump on the back of his head and started blinking. On 9/24/25 at 11:15pm, V8 (nurse) said, R1 was on the respiratory unit. V8 said, R1 should have been on the transitional care unit. V8 said, he was getting report from the nurse when V14 (activity aide) reported that R1 walking in his room and trying to urinate in the red isolation container/trash can. V8 said, R1 urinated on the floor and slipped in his urine. R1 only spoke mandarin. V8 said, R1 sustained a lump on the back of his head. V8 said, R1 had decreased motor functioning and had increased confusion after the fall. R1 was discharged to the hospital via 911. On 9/24/25 at 11:25, R1 was interview via V7 (translator). R1 was unable to answer the orientation questions. V7 said, R1 could only answer simple things. V7 said, R1 reported he just fell down. V7 said, R1 reported he fell down before he arrived at the facility. V7 said, R1 was unable to recall the details if his fall at the facility. R1's witness statement dated 9/5/25 documents: R1 was standing at the door of room, lost balance and fell backwards. Why do you believe the event occurred: blood pressure dropped. On 9/24/25 at 11:41am, V2 (DON) said, R1 had a fall in the community. R1 was found down. V2 said, she is not sure where R1 was found. On 9/25/25 at 10:22am, V14 (activity aide) said, V14 said, she was walking, reporting to work with her bags on her shoulders and she walked past R1's room. V14 said, R1 was urinating in the trash can. V14 said, she walked to the nurse station to inform the nurse. V14 said, when she and the nurse returned to R1's room, R1 was on the floor. V14's witness statement dated 9/5/25 documents: time of event 7:30am. Type of event: fall. Walking down hall seen R1 up went to get the nurse. R1 was on the floor when nurse came back. Lying on his back. On 9/25/25 at 12:06pm, V2 said, the day shift CNA for R1's unit was in another resident's room. On 9/25/25 at 12:42pm, V2 said, R1's did not have a fall care plan implemented upon admission. V2 said, when a resident does not have a fall care plan staff follows the facilities fall focus system. Fall focus system no date documents: (6 pearls)- personal needs: staff will assess and anticipate resident's personal and activity for daily living (ADL) needs such as toileting, incontinent care during rounds. Staff will attend to needs as they are identified.Hospital paperwork dated documents: CT scan of the head showed multiple rounded areas of hemorrhage in left cerebral hemisphere representing intraparenchymal contusion with hemorrhagic conversion. It also shows extensive edema involving left parieto-occipital region and left temporal region with associated internal hemorrhage. MRI of the brain shows subacute infarct with hemorrhage and associated surrounding edema involving left basal ganglia, temporal lobe and parietal occipital lobes.Fall Prevention and Management dated 10/29/21 documents: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained.

Based on observation, interview, and record review the facility failed to provide a functional sanitary environment for one (R1) of three residents reviewed functional and comfortable environment. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: diabetes, congested heart failure, atrial fibrillation, hypertension, acute kidney disease, osteomyelitis, right leg amputated on 10/7/2024 and left leg amputated on 2/22/2025. On the (MDS) Minimal data Set assessment of 5/1/2025 section C the BIMS (Brief Interviewed Mental Status) score was 15/15 and indicates cognitive intact. On MDS of 5/1/2025 GG section R1 can wheel 50 feet with two turns: Once seated in a wheelchair/scooter, the ability to wheel at least 50 feet and make two turns with Partial/moderate assistance. On 7/8/2025 at 2:41 PM, R1 said, my bathroom sink has been leaking for two weeks and staff placed a gray bucket under the sick because it was leaking on the floor. I notified the staff to call maintenance to get it fixed, but nothing was done. I cannot remember who I had notified. R1 accompanied the surveyor to the room. A gray bucket was ½ full of dirty water under the sink was observed. When the faucet is opened and the water is running, a few drips are observed dripping into the gray bucket under the sink. On 7/8/2025 at 3:43 PM, I asked V5 (Wound Care Nurse) to walk to R1's room to check the sink when V6 (Maintenance Director) was already in the room and started to fix the sink. V6 said, that once I get notified of anything that is not working or broken, I usually can fix it right away. I was just notified that the sink was leaking, and I am fixing it now. On 7/8/2025 at 4:38 PM V1 (Administrator)said, I was not notified of the sink leaking until today and staff can add a work order online and the maintenance director checks it daily and can fix broken equipment or leakages like the sink. I do not know why the staff did not report it. On 7/9/2025 at 2:30 PM V2 (Director of Nursing) said, I was not aware that R1's sink was leaking for two weeks, staff can add a work order for V6 (Maintenance Director) to fix. I will provide education for the staff to add work orders as soon as they are aware of anything requiring repair. On 7/9/2025 at 2:03 PM V1(Administrator) provided a policy titled, Work Orders, Maintenance review date 6/1/2025. Which reads in part (but not limited to): 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. 3. QR codes are placed throughout the facility to scan and place work orders. 4. Emergency requests will be given priority in making necessary repairs.

Based on observation, interview and record review, the facility failed to safely handle foods for all 144 residents receiving food from the kitchen. The facility also failed to ensure resident refrigerators are clean and the temperatures are monitored for two of two residents (R23, R46) reviewed for food safety in a sample of 31. Findings include: 1. On [DATE] at 10:15AM during initial kitchen tour with V8 (Food Service Director) and V21 (Regional Director of Operations), reach-in cooler had a gallon of 2% milk with sell date of [DATE], and walk-in cooler had an opened, undated half gallon of orange juice and an open box of bagels with dates [DATE] and [DATE] written on it. On [DATE] at 10:18AM during interview with V8, V8 stated that the gallon of 2% milk with sell date of [DATE] should have been discarded, the half gallon of orange juice should have been dated when it was opened. On [DATE] at 10:18AM during interview with V21, V21 stated that box of bagels was frozen when it was delivered and should be pulled out from the freezer to the cooler to thaw 48 hours before it has to be used so there should be a clear date when it was pulled out from the freezer to the cooler to know when the bagels should be used. Review of facility's policy entitled Food Storage (Dry, Refrigerated and Frozen) reviewed on [DATE] indicated the following: Policy: Food storage areas will be clean, dry and maintained at temperatures as required to ensure food safety. Procedure: 7. Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded. 8. All out-dated goods will be discarded the day after expiration. Refrigerated Foods c. Open products are sealed, labeled and dated. Review of facility's policy entitled Labeling and Dating Foods reviewed [DATE] indicated the following: Policy: To decrease the risk of foodborne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded. Procedure: - Packaged or containerized bulk food may be removed from the original package and stored in an ingredient bin labeled with the common name of the food, the date the item was opened and the date by which the item should be discarded or used by. 2. On [DATE] at 11:14AM during unit rounds, R23 had a personal refrigerator in the room without a temperature log. On [DATE] at 9:48AM during observation with V24 (Licensed Practical Nurse), R23 had personal refrigerator in the room without a temperature log, and the food items include 3 undated glasses of milk, undated resealable bag of fries, undated mixture of food in a glass, and opened, undated package of pancakes. On [DATE] at 9:48AM during interview with V24, V24 stated that night shift usually checks the resident's refrigerator temperature and should be cleaning it out too. V24 also stated that food items in the refrigerator should be dated. V24 stated that there should be a temperature log to record the temperature of the refrigerator daily. On [DATE] at 10:25AM during interview with V8 (Food Service Director), V8 stated that the glass of milk comes from the kitchen, and it should not be kept in the residents' refrigerator. Review of R23's Order Summary Report dated [DATE] indicated admitted [DATE] and diagnoses of not limited to Major Depressive Disorder, Chronic Kidney Disease Stage 3B, Heart failure and Mixed hyperlipidemia. 3. On [DATE] at 11:15AM during unit rounds, R46 had personal refrigerator in the room without a temperature log. On [DATE] at 9:49AM during observation with V24 (Licensed Practical Nurse), R46 had personal refrigerator in the room without a temperature log or thermometer inside the refrigerator. On [DATE] at 9:48AM during interview with V24, V24 stated that night shift usually checks the resident's refrigerator temperature and should be cleaning it out too. V24 stated that there should be a thermometer and temperature log to record the temperature of the refrigerator daily. Review of R46's Order Summary Report dated [DATE] indicated admitted [DATE], and diagnoses of not limited to nicotine dependence, cigarettes, and other seizures. Review of facility's policy entitled Food Storage reviewed on [DATE] indicated the following: Policy Statement: To ensure safe and sanitary storage of food in compliance with Illinois Department of Public Health (IDPH) regulations and federal food safety guidelines while allowing residents to keep personal food in designated areas, including their personal refrigerators. Procedure: 1. General Food Storage Guidelines - Refrigerators: at or below 41F (5C), Freezers: at or below 0F (-18C) - Expiration dates must be checked weekly; expired food must be discarded. - Label all food with resident's name and date of storage 2. Resident-Specific Food Storage (Resident Refrigerators) - Personal refrigerators must be checked at least weekly for safety. - All food must be labeled with the resident's name and storage date. - Perishable food must be discarded within 3 days unless frozen. - Staff must check resident refrigerator temperatures weekly. 3. Enforcement & Compliance - Regular weekly inspections will be conducted by staff. - Spolied, expired, or improperly stored food will be discarded immediately.

Based on observation, interview, and record review, the facility failed to ensure that necessary treatment and services to promote healing and prevent development of pressure injury are implemented for 5 of 12 residents (R53, R117, R127, R136, R151) reviewed for pressure injury in a sample of 31. Findings include: 1. On 03/25/2025 at 11:30AM during unit rounds, R127's air mattress light indicator is on the 6th light indicating the weight setting of the air mattress is between 210-320 lbs (pounds). On 03/26/2025 at 9:32AM during unit rounds with V12 (Wound Care Coordinator/WCC), R127's air mattress light indicator is on the 6th light indicating the weight setting of the air mattress is between 210-320 lbs. V12 then proceeded to change the setting to the 5th light indicator. On 03/26/2025 at 9:32AM during interview with V12, V12 stated that R127's weight is 183 lbs so the air mattress setting should be adjusted to the 5th light indicator. V12 also stated that air mattress settings should be according to R127's weight. Review of R127's Order Summary Report dated 03/26/2025 indicated admitted [DATE] and diagnoses of not limited to dependence on respirator (ventilator) status, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R127's Monthly Weight Report dated 03/27/2025 indicated R127's weight in March 2025 is 183.7 lbs. Review of R127's Patient Risk Profile indicated R127 was assessed for risk for acquiring pressure wounds on 03/13/2025 and scored 10 which is high risk. Review of R127's Wound Assessment Details indicated R127 has active sacral pressure ulcer on assessment date 03/25/2025. 2. On 03/25/2025 at 11:08AM during unit rounds, R136 was observed with air mattress. R136 had a flat sheet, folded linen, and reusable pad between R136 and the air mattress. R136 was also wearing disposable briefs. On 03/26/2025 at 9:27AM during unit rounds with V12 (WCC), R136 was observed with air mattress. R136 had a flat sheet, folded linen, and reusable pad between R136 and the air mattress. R136 was also wearing disposable briefs. On 03/26/2025 at 9:27AM during interview with V12, V12 stated that R136 should only have the flat sheet underneath her with disposable briefs on. Review of R136's Order Summary Report dated 03/26/2025 indicated R136 was admitted on [DATE] with diagnoses of not limited to morbid obesity due to excess calories. Review of R136's Patient Risk Profile indicated R136 was assessed for risk for acquiring pressure wounds on 01/24/2025 and scored 16 which is at risk. 3. On 03/25/2025 at 11:34AM during unit rounds, R151's air mattress light indicator is on the 7th light indicating the weight setting of the air mattress is between 260-400 lbs (pounds). On 03/26/2025 at 9:32AM during unit rounds with V12 (WCC), R151's air mattress light indicator is on the 7th light indicating the weight setting of the air mattress is between 260-400 lbs. V12 then proceeded to changing the setting to the 2nd light indicator. On 03/26/2025 at 9:32AM during interview with V12, V12 stated that R151's weight is 105 lbs so the air mattress setting should be adjusted to the 2nd light indicator. V12 also stated that air mattress settings should be according to R151's weight. Review of R151's Order Summary Report dated 03/26/2025 indicated admitted [DATE] and diagnoses of not limited to focal traumatic brain injury and traumatic subdural hemorrhage. Review of R151's Monthly Weight Report dated 03/27/2025 indicated R151's weight in March 2025 is 104.4 lbs. Review of R151's Patient Risk Profile indicated R151 was assessed for risk for acquiring pressure wounds on 03/24/2025 and scored 10 which is high risk. Review of facility's policy entitled Skin Management: Specialty Mattress reviewed on 06/2024 indicated the following: Guidelines for the Use of Specialty Mattresses: The following are guidelines for the use of specialty mattresses; however, the facility Wound Care Nurses, DON (Director of Nursing) and Physician will continue to use their professional judgement to determine the type of mattresses most appropriate for the individual resident. Procedure: 1. As per manufacture guideline, no more than 1 piece of linen will be placed between the mattress and the resident. 39781 4. On 3/25/25 at 10:30AM, Observed R117 lying in bed with Low air loss (LAL) mattress uncovered. She is alert, responsive and pleasantly confused. Observed fitted sheet covering the LAL mattress with cloth pad over the mattress. R117 wears disposable briefs. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that resident with LAL mattress should only have flat sheet over the mattress. On 3/25/25 at 10:34AM, Observed V12 (WCC) prepare wound treatment/medication for R117's sacral wound, she left the treatment cart opened and unlocked In front of R117's room. V12 went inside the room and closed the door. No visual access of the treatment cart. V12 assessed R117 for pain. R117 said, she has on pain at her back with rate of 10/10. V12 said she will have the floor nurse administer R117's pain medication before she will perform wound care. Informed V12 of observation that she left the treatment cart opened and unlocked. V12 said, treatment cart should be closed and locked when not in use. On 3/25/25 at 11:41AM, Observed V12 (WCC) reposition R117 to her side and removed sacral wound dressing. Observed moderate amount of serosanguineous wound drainage. V12 cleansed the sacral wound with wound cleanser and gauze. V12 said R117 has a stage 4 pressure ulcer on sacrum with 20% yellowish greenish slough and 80% granulation tissue. V12 applied Medi honey and calcium alginate, then covered with dry dressing. R117 has an admitted [DATE] with diagnosis listed in part but not limited to Encephalopathy, Chronic kidney failure, Human Immunodeficiency Virus, Hospice care. Active physician order sheet indicated Wound care: Sacral /coccyx - cleanse with Dakin's, wound cleanser or Normal saline, pat dry skin prep peri wound skin cover with honey and alginate and dry dressing every day shift and as needed. On low air loss mattress to prevent pressure ulcers. Wound assessment report dated 3/26/25 indicated Stage 4 Sacrum active pressure ulcer present on admission on 3/22/24 measures 2.2 centimeters (cm) x 6cm x 0.1cm. 90% bright beefy red and 10% necrotic soft adherent. Moderate amount of serosanguineous drainage. Comprehensive care plan indicated she has pressure ulcer related to disease process, history of ulcers, immobility. She has an ADL self-care performance deficit secondary Impaired mobility, decreased in ADL, Physical limitations. Braden scale/Skin assessment indicated that she is at risk for impairment. On 3/26/25 at 10:10AM, Informed V12 (WCC) that she did not follow R117's physician wound care treatment order when providing wound care to R117 yesterday. Informed V12 that she did not cleanse R117's sacral wound with Dakin's solution in addition to wound cleanser as indicated in physician order. V12 said that she forgot the Dakin's solution. V12 said they are expected to follow physician order in performing wound care. On 3/27/25 at 9:30AM, Reviewed R117 physician order sheet, indicated Dakin's solution for cleansing wound as part of wound treatment for R117 was discontinued. On 3/25/25 at 10:42AM, Observed R53 lying in bed with low air loss mattress with flat sheet and cloth pad over the mattress. He wears disposable briefs. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that residents on LAL mattress should only have flat sheet over the mattress. R53 has a re-admitted [DATE] with diagnosis listed in part but not limited on Stage 4 pressure ulcer sacral region, Type 2 Diabetes Mellitus with diabetic neurological complication and diabetic neuropathy, Morbid obesity, Peripheral Vascular disease, Congestive heart failure, Paraplegia. Active physician order sheet indicated Wound care: Sacrum cleanse with normal saline solution or wound cleanser, apply Hydrofera blue covered with dry dressing as scheduled every day shift MWF (Monday/Wednesday/Friday) and as needed. Comprehensive care plan indicated he has alteration in skin integrity/pressure injury. Intervention: Apply specialty mattress when in bed. No documentation in care plan that he is noncompliance with LAL mattress management of avoiding multi layers of linens over the mattress. Braden scale/Skin assessment indicated that she is at risk for impairment. On 3/27/25 at 9:54AM, Reviewed R53 and R117's medical records regarding wound care management with V12 (WCC). Informed concerns identified with R53 and R117. On 3/27/25 at 12:19PM, Informed V2 DON (Director of Nursing) of above concerns. V2 said that only flat sheet is placed over the LAL mattress as manufacturer's recommendation, no multi layers of linens. They are expected to follow physician orders in performing wound care to resident. Facility's policy on Skin Management: Specialty Mattress review date 6/2024 indicated: Low Air Loss: Stage 3, Stage 4, Unstageable, DTI to the buttocks, Multiple Stage 2, very high risk with multiple co-morbidities or residents who need this type of mattress for comfort. Procedure: 1. As per manufacture guideline, no more than 1 piece of linen will be placed between the mattress and the resident. Facility's policy on Wound Prevention and Healing reviewed on 6/1/2024 indicated: Policy statement: To provide wound care treatments/services (using multidisciplinary) based on evidence-based standards of care under the direction of a physician. 2. Wound assessment and documentation tool b. Goal will focus on the clinical status of the wound, guide the appropriate intervention for the wound. 9. Continued/Ongoing treatment a. Nurse/Therapist will provide wound care per physician order.

Based on interview and record review, the facility failed to re-screen residents with mental disorder for two of five residents (R95, R105) reviewed for pre-admission screening in a sample of 31. Findings include: 1. R95 is a [AGE] year-old male initially admitted in the facility on 04/20/2024 with diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. R95's Notice of PASRR (Pre-Admission Screening and Resident Review) Level I Screen Outcome dated 04/12/2024 indicated R95 is authorized to stay in the NF (nursing facility) 30 days or less. It also indicated that re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. On 03/26/2025 at 11:35AM during interview with V20 (Regional Director of Social Work), V20 stated that a new screening should have been requested for R95 before the 30 days had ended. Review of R95's Admission Record dated 03/27/2025 indicated R95 was initially admitted on [DATE]. Review of R95's Order Summary Report dated 03/26/2025 indicated diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. Review of facility's policy entitled Admission Criteria reviewed on 04/18/2024 indicated the following: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Procedure: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorder (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. The State PASARR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlines in the evaluation. f. Once a decision is made, the State PASARR representative, the potential resident and his or her representative are notified. 45316 On 03/26/25 at 11:35 AM, review of R105 PASRR LEVEL I SCREEN indicated that R105 PASARR level I was completed on April 11, 2022. The outcome determination was that no level II PASARR was required. On 3/30/2023, R105 was readmitted to the facility with a diagnosis of unspecified psychosis not due to a substance or known psychological condition. With this new diagnosis, the facility did not obtain a new PASARR Level I to determine if R105 will need PASARR Level II. On 03/26/2025 at 12:16PM, V18 (MDS Coordinator) stated she answers the questions in MDS section A and section I. V18 also stated that it is her responsibility to inform the Social Service if the resident needs a new PASARR. R105 is a [AGE] year old male with original admitted [DATE]. R105 PASARR level 1 on 4/11/2022 prior to R105 admission indicated no Level II PASARR needed. R105 has diagnosis not limited to unspecified psychosis, major depressive disorder, vascular dementia, type 2 diabetes, and hypertensive heart failure. Document Reviewed: Face sheet; MDS: Section A - Identification of Information A1500 & A1510; A1600 Section I - Active Diagnosis Psychiatric Mood Disorder 15800 - Depression (other than bipolar) 15950 - Psychotic Disorder (other than schizophrenia)

Based on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 3 of 5 residents (R34, R87, R91) reviewed for PASARR in a total sample of 31. Findings Include: On 3/26/2025 at 10:30AM, V20 (Regional Director of Social Work) stated there was no PASARR completed for R87 prior to admission. A Level I was requested this morning. On 3/27/2025 at 9:30 AM, V1 (Administrator) stated PASARR needs to be completed prior to resident admission and if Level I is positive, Level II will have to be completed to ensure residents will receive appropriate services. R87's Admission Record indicated an admitted [DATE]. Diagnosis Information include Schizoaffective Disorder, Unspecified. Care Plan report state, Focus: R87 uses psychotropic medications r/t (related to) Behavior management, dementia, schizoaffective disorder. Review of Notice of PASARR Level I Screen Outcome, Notice date: March 26,2025 PASARR Level I Determination: Refer for Level II Onsite Policy and Procedure: Policy: Admission Criteria, Reviewed 4/18/2024 Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Procedure: 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the level I screen indicates the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 38796 R34 face sheet shows diagnosis of schizophrenia. 3/27/25 V20 (Consultant) said R34 has SMI (Serious Mental Illness) diagnosis, V20 said R34 was not referred for PASARR level one or level two assessment. R34's MDS (Minimum Data Set) dated 1/2/25 section I denotes diagnosis of schizophrenia. Section A 1500 denotes 0 for No for resident being considered by state for PASARR LEVEL 2 or related condition, section A1510 for level 2 preadmission screening nothing is checked for serious mental illness. R91's face sheet shows diagnosis of bipolar, major depression disorder, anxiety, and unspecified psychosis not due to substance. 3/27/25 V20 (Consultant) said R91 has SMI (Serious Mental Illness) diagnosis, V20 said R91 was not referred for PASARR level one or level two assessment. R91's MDS dated [DATE] section I denotes active diagnosis anxiety disorder, depression, bipolar disorder, and psychotic disorder. Section A 1500 denotes 0 for No for resident being considered by state for PASARR level 2 or related condition, section A1510 for level 2 preadmission screening nothing is checked for serious mental illness.

Based on observation, interview, and record review the facility failed to ensure to provide nail and foot care to dependent resident. This deficiency affects three (R60, R117, and R130) residents in the sample of 31 reviewed for Activities of Daily Living (ADL) Program. Findings include: On 3/25/25 at 10:30AM, Observed R117 lying in bed uncovered. Fingernails on both hands are long and dirty with black matter inside the fingernails. Toenails on both feet are long, curved, and have thick yellowish-brown discoloration. Bilateral lower extremities have dry scaly skin. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that Certified Nurse Assistants (CNAs) should provide nail care as part of ADL care. R117 has an admitted [DATE] with diagnosis listed in part but not limited to Encephalopathy, Chronic kidney failure, Human Immunodeficiency Virus, Hospice care. Comprehensive care plan indicated she has an ADL self-care performance deficit secondary Impaired mobility, decreased in ADL, Physical limitations. She has a terminal prognosis, in hospice care. No indication in care plan that resident refused nail and foot care. She is alert, responsive and pleasantly confused. On 3/25/25 at 10:45AM, Observed R60 up in wheelchair in activity room. He is awake but nonresponsive. He has contractures on his right hand. Both fingernails on both hands are long and dirty with black matter underneath the nails. Showed observation to V10. V10 said that CNAs should provide nail care as part of ADL care. R60 has an admitted [DATE] with diagnosis listed in part but not limited to end stage renal diseases, Type 2 Diabetes Mellitus with diabetic neuropathy, Aphasia following cerebrovascular disease, Dementia. Comprehensive care plan indicated he has an ADL self-care performance deficit secondary to impaired mobility, decrease in ADLs, physical limitations, and medical diagnosis. Has impaired cognitive function and thought processes. No indication in care plan that he refused nail care. On 3/27/25 at 1:07AM, V2 Director of Nursing (DON) said that CNAs and nurses are responsible for providing nail care to residents as part of the ADL program. The nurses should inform social services if a resident needs to be seen by the podiatrist. Social services is responsible for scheduling residents to be seen by the podiatrist. The podiatrist comes to the facility monthly. Facility's policy on ADL reviewed 7/20/2024 indicated: Policy statement: Facility ensures that residents receive ADL assistance and maintain resident's comfort, safety, and dignity. The goal is to maximize the residents and staff safety, confidence, independence, and ability to handle everyday activities. Procedures: 6. Assist the resident to be clean, neat, and well-groomed including nail care and having finger and toenails will be cut on shower days and as needed. Facility's policy on Foot care reviewed 5/2024 indicated: General: Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown, and promote healing. Guideline: 1. Foot care is provided routinely with the bath and PRN. It may also be done more frequently with a physician or nurse practitioner order. 8. Never cut toenails of resident with diabetes and circulatory disorders. 9. Residents with diabetes and circulatory disorders will be referred to the podiatrist as necessary. 49871 On 3/25/2025 at 10:33 AM, R130 is in bed and able to hold conversation. R130's fingernails were long. R130 said he would want his nails trimmed if there is someone who can do it. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) stated R130's fingernails were long and V25 will have the CNA assigned trim R130's fingernails. On 3/26/2025 at 8:55 AM, V2 (Director of Nursing) stated resident fingernails should be trimmed when long as this is part of their ADL care. V2 said staff should follow through. Review of R130's Care Plan (Revision date: 1/22/2025) read: R130 has ADL self-care performance deficit r/t (related to) dx (diagnosis) of dementia, lack of coordination, and muscle d/o.

Based on observation, interview, and record review the facility failed to ensure comprehensive restorative nursing evaluation and ongoing assessment is completed for a resident with limited range of motion/ contractures to upper extremities. This deficiency affects two (R60 and R79) of three residents in the sample of 31 reviewed for Restorative program. Findings include: 1. On 3/25/25 at 10:45AM, Observed R60 up in wheelchair in activity room. He is awake but nonresponsive. He has flexion contractures on his right hand. No splint applied. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said she does not know if he has an order for a splint. R60 has a re-admitted [DATE] with diagnosis listed in art but not limited to End stage renal disease, dependence on renal dialysis, Type 2 Diabetes Mellitus with diabetic neuropathy, Aphasia following cerebrovascular disease, Cerebral infarction, Memory deficit, Anorexia. Physician order sheet indicated Caregiver will don/doff palm protector with rolled hand towel for right upper ordered 3/25/25 pending confirmation. No Comprehensive restorative assessment/Functional abilities were done for 2024 and 2025. Restorative assessment/Functional abilities completed on 9/30/23, 6/20/23, 2/20/23 and 1/31/22. MDS/resident assessment dated [DATE] indicated Section GG0115 Functional limitation in Range of Motion- 0 no impairment. Section GG0130 Self-care - Shower/Bathe, Upper and lower body dressing, putting on /taking off footwear and personal hygiene were marked 2 Substantial/maximal assistance. Toileting- was marked 1 Dependent. Eating was marked Supervision or touching assistance. On 3/27/25 at 11:07AM, V13 (Restorative Nurse) said that she has only been working in the facility for 2 months. She said that restorative assessment/functional abilities are done upon admission, quarterly assessment, annually and significant change of condition. Based on assessment the resident is placed on appropriate restorative program. R60's medical records were reviewed with V13. Informed V13 that R60 did not have restorative assessment for 2024 and 2025. The last restorative assessment done for R60 was 2023. V13 said that she has not uploaded her assessment due last month (2/20/25). R60's physician order sheet indicated order of splint to right hand (observed R60 with no splint). R60 was placed on bed mobility and splint program without having a comprehensive assessment. R60 was not evaluated for appropriate program based on comprehensive assessment. On 3/27/25 at 12:19PM, Informed V2 Director of Nursing (DON) of above concerns. V2 said that restorative nursing assessment is completed for resident upon admission, quarterly assessment, annually and significant change of condition. They (Restorative Nurse) are expected to follow their policy on Restorative Nursing program. On 3/28/25 at 9:55AM, Reviewed R60's MDS (Minimum Data Set)/Resident assessment Section GG Functional abilities and O Special treatments, procedures and programs dated 2/20/25 with V1 (Administrator), V2 (DON) and V13 (Restorative Nurse). R60 was marked for functional limitation in range of motion 0 -no impairment. All agree that R60 has impairment on his right arm due to contractures and will correct the MDS assessment. Informed V1 and V2 that no restorative assessment/functional abilities was done for 2024 and 2025. Most recent quarterly restorative assessment done on 9/30/23. Facility's policy on Restorative Nursing program reviewed on 8/18/24 indicated: Intent: It is policy of the facility to assist each resident to attain and or maintain their individual highest most practicable functional level of independence and well-being, in accordance with State and Federal Regulations. Procedure: 1. Each resident will be screened and or evaluated by the nurse designated to oversee the restorative nursing process for inclusion into the appropriate facility restorative nursing program when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program. 3. The facility restorative nursing program will include but not limited to the following programs: b. Mobility- transfer and ambulation, including walking, prosthetic and or splint application with or without active and or passive range of motion, bed mobility. 4. The above program will be documented on the facility designated restorative care forms/tools in the resident's electronic medical records. 6. The designated nurse will be responsible for the following: a. Obtaining orders for the resident's restorative program b. Documentation on a monthly basis (at a minimum) and c. Initiation and updating restorative care plans. 7. Once in an appropriate restorative program, the designated nurse will continue to monitor the resident's progress. 8. The designated nurse will evaluate the restorative documentation monthly to determine if there are any changes needed to the existing program and make a monthly progress note, in the resident's electronic medical record related to this evaluation. Facility's policy on Managing resident with impaired physical mobility reviewed 3/16/2023 indicated: Policy statement: Facility will provide care and management of physical mobility impairment based on cause and nature of deformity. Facility will provide programs to prevent contractures and or further decline. Guidelines: 1. Mobility assessment will be completed by nurse upon admission, quarterly and as necessary. 2. Treatment of contractures: a. Treatment guidelines for contractures will depend on the cause of the deformity. The following may be utilized in general. b. Restorative program based on assessment. b. Facility will develop a plan of care to assess the patient's level of functional mobility and ability to perform ADLs, assist the patient during exercises and when performing ADLs. 46560 2. On 03/25/2025 at 11:10AM during unit rounds, R79 had contractures on both of his upper extremities, without any brace, splint or carrot on. On 03/26/2025 at 9:43AM during unit rounds with V13 (Restorative Nurse), R79 had contractures on both of his upper extremities, without any brace, splint or carrot on. On 03/27/2025 at 11:27AM during record review with V13, R79 did not have a restorative nursing assessment. On 03/27/2025 at 11:27AM during interview with V13, V13 stated R79's restorative nursing assessment should be done quarterly to capture any changes within the quarter. V13 stated that restorative nursing assessments are done upon admission, quarterly, significant change and annually. On 03/27/2025 at 12:45PM V2 (DON) stated that restorative nursing assessments are done upon admission, quarterly, significant change and annually. Review of R79's Order Summary Report dated 03/26/2025 indicated admitted [DATE] and diagnoses of not limited to left hand contracture, other sequelae of cerebral infarction and right elbow contracture.

Based on observation, interview and record review, the facility failed to ensure that the resident's environment is free of accident hazards and failed to perform ongoing smoking assessments for a smoking resident for two of three residents (R46, R95) reviewed for accidents in a sample of 31. Findings include: 1. R46 is a [AGE] year-old female initially admitted in the facility on 03/03/2023 with diagnoses of not limited to Nicotine Dependence, cigarettes, and other seizures. R46's most recent smoking risk assessment was completed on 08/09/2024. On 03/27/2025 at 9:45AM during record review with V3 (Social Worker), R46's most recent smoking risk assessment was noted on 08/09/2024. On 03/27/2025 at 9:45AM during interview with V3 (Social Worker), V3 stated that R46's smoking risk assessment should have been completed quarterly and should have a smoking risk assessment on November 2024 and February 2025. V3 stated that smoking risk assessment is done to determine if the resident is still safe to smoke independently and to capture if there are any changes in their smoking behavior. On 03/27/2025 at 10:15AM during interview with V20 (Regional Director of Social Work), V20 stated that smoking risk assessment should be completed upon admission, quarterly, annually, and as needed. Review of R46's Minimum Data Set (MDS) Section J dated 02/21/2025 indicated R46 currently uses tobacco. 2. R95 is a [AGE] year-old male initially admitted in the facility on 04/20/2024 with diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. On 03/25/2025 at 10:58AM during unit rounds, R95 has a 2-socket extension cord with the socket head placed on top of the right side of the head of the bed and is connected to the wall outlet. The extension cord has 2 plugs plugged into it. On 03/26/2025 at 10:50AM during observation with V6 (Maintenance Director), R95 was again observed with a 2-socket extension cord with the socket head placed on top of the right side of the head of the bed and is connected to the wall outlet. The extension cord has 2 plugs plugged into it. On 03/26/2025 at 10:50AM during interview with V6, V6 stated that R95 should not have an extension cord at bedside and should have not placed it on top of the bed because it is a fire hazard. On 03/26/2025 at 11:40AM during interview with V1 (Administrator), V1 stated that extension cords are not allowed in the resident care areas. On 03/28/2025 at 10:40AM, V1 stated that all staff should be aware that extension cords are not allowed in the resident care areas, and should report any fire safety concerns to any department heads if the resident refuses to remove it. Review of facility policy entitled Fire Safety and Prevention dated 06/01/2024 indicated the following: Intent: It is the policy of the facility to provide care and services related to Fire Safety and Prevention in accordance to State and Federal regulation. All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. It is the policy of this facility that personnel will follow facility established fire safety precautions in order to provide safety to all concerned.

Based on observation, interview, and record review the facility failed to follow physician oxygen orders for 1 of 2 residents (R141) reviewed for oxygen administration in a total sample of 31. Findings Include: On 3/25/2025 at 10:30 AM, R141 is laying flat in bed with oxygen on per nasal cannula. R141 stated he likes to lay flat in the bed even with oxygen on. Oxygen concentrator positioned at bedside with a setting of 4 liters (L)/minute. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) checked R141's physician order and indicated Oxygen (02) @ 2 Liters/Minute per nasal cannula/mask. V25 proceeded to R141's room and adjusted oxygen concentrator setting from 4L to 2L. V25 stated R141 should be on 2L per physician order. On 3/26/2025 at 9:00 AM, V2 (Director of Nursing) said oxygen administration should be followed according to physician order and raised head of bed at least 30 degrees. Review of Admission Record (date: 2/8/2025) Diagnosis Information include CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), UNSPECIFIED, CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE, DEPENDENCE ON SUPPLEMENTAL OXYGEN Review of Care Plan indicate Focus: COPD: Noted to have an active diagnosis of COPD and avoids lying flat due to shortness of breath. Oxygen is in use to assist with symptoms of COPD. Interventions: Administer oxygen as ordered. Elevate the head of bed to promote optimal breathing and comfort. Policy and Procedure: Oxygen Therapy, 1/24/2021 Policy: Oxygen therapy is the administration of a FiO2 greater than 21% by means of various administration devices to: Raise the resident's PaO2 to an acceptable baseline using the lowest FiO2. To treat arterial hypoxemia. To decrease work of breathing. To reverse and prevent tissue hypoxia, and or to decrease myocardial work. Procedure: 1. Review physician's order 11. Start O2 flowrate at the prescribed liter flow

Based on observation, interview and record review the facility failed to follow their medication storage facility policy for 2 of 6 residents (R115, R79) reviewed for medication labeling and storage. Findings include: 1. R79 physician order sheet shows orders for Xalatan ophthalmic solution 0.005% (latanoprost), instill one drop in both eyes at bedtime related to glaucoma, order start date 6/7/2023. On 3/26/25 at 11:46am during a survey tour of the medication cart on the (unit) assisted by V2 (Director of Nursing), medication latanoprost 0.005% noted with R79's name, the box had one date of 3/15/25. V2 stated that 3/15/25 was the open date for the eye drops, V2 said the eye drops should be labeled with a second date for expiration. V2 said eye drops expire 30 days after opening. 2. R115 physician order sheet shows orders for Lokelma oral packet 10 GM (grams), give one packet by mouth one time a day for hyperkalemia, order start date 5/2/2024. On 3/27/25 at 8:22am during medication administration observation with V31 (Licensed Practical Nurse-LPN), V31 prepared and administered medication Lokelma 10 grams for R115, there was not a pharmacy label noted on the clear package, there was no label with R115's name, there was no instructions noted for administration. V31 did not respond when asked if the medication should have a pharmacy label. Facility policy titled Medication Storage In The Facility dated November 2021 denotes in-part medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications. The provider pharmacy dispense medication in containers that meet the regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kelp in these containers. Nurses may not transfer medications from one container to another or return partially used medications to original container. Expiration dating (beyond-use date), expiration dates (beyond-use date) of dispense medication shall be determined by the pharmacist at the time of dispensing. Drugs dispensed in the manufactures original container will be labeled with manufactures expiration date. Certain medication or package types, such as IV solutions, multiple dose injections vials, certain ophthalmic (per manufactures specifications; example latanoprost) nitroglycerin tablets, blood sugar testing solutions and strips, once opened, requires an expiration date shorter than manufacture's expiration date to insure medication purity and potency. Facility policy titled medication ordering and receiving from pharmacy dated November 2021 denotes in part each prescription label includes, resident name, specific directions for use, including route of administration, medication name, strength of medication, prescriber's name, date dispensed, quantity of medication, beyond use date (or expiration) date of medication, name address of dispensing pharmacy, and prescription number.

Based on interview and record review, the facility failed to grant the resident or his or her representative the right to rescind the arbitration agreement within 30 calendar days of signing it. This failure affected three (R7, R37, R67) out of three residents reviewed for arbitration agreement in the sample of 31. Findings include: On 03/27/25 at 10:30 AM, V4 (Business Office Manager), said that all residents are offered arbitration upon admission. Surveyor reviewed the facility arbitration agreement with V4. V4 said that according to the facility arbitration agreement in section five, residents may cancel the agreement within seven (7) days. V4 said that after seven days, the agreement becomes binding. Review of the signed arbitration agreement by R7, R37 and R67 indicated that on section five: right of cancellation, these residents were only granted the right to rescind the agreement only within seven (7) days instead of 30 calendar days. R7 is a [AGE] year old male admitted on [DATE] with diagnosis not limited to Parkinson's disease, asthma, type 2 diabetes, and primary hypertension. R37 is a [AGE] year old male admitted on [DATE] with diagnosis not limited to vascular dementia, anxiety, major depression, and primary hypertension. R67 is an [AGE] year old female with original admitted [DATE] and diagnosis not limited to primary generalized osteoarthritis, vascular dementia, psychotic disturbance, mood disturbance, anxiety and primary hypertension. Policy: Health Care Arbitration Agreement Section Five. Right of Cancellation The health care arbitration agreement may be canceled by any signatory within seven (7) days of its execution.

Based on interview and record review, the facility failed to supervise/monitor resident during smoke break. This affected one of three residents (R1) reviewed for monitoring and supervsion. This failure resulted in R1 having a face forward fall sustaining an open fracture of nasal bone and a nasal laceration requiring four sutures. Findings Include: R1 was admitted with Schizophrenia, Dementia with behavioral disturbance, restlessness, agitation and generalized anxiety. Brief interview for mental status dated 2/8/24 documents a score of six out of fifteen which indicates severe cognitive impairment. Fall assessment dated [DATE] documents: high risk for falls with a score of 17.0. On 7/27/24 at 2:56PM, V5 (ADON) said, V7 (nurse) took R1 to smoke. V7 is not a smoker. V7 stepped one arm length away from R1 while R1 was smoking. R1 dropped his cigarette, reached down to pick it up and fell face forward out of his wheel chair. V7 could not reach R1 before his fall. R1 sustained a fractured nose. V5 said, R1 has poor safety awareness related to his impulsiveness but he is able to comprehend. R1 was given a Reacher after his first fall On 7/27/24 at 1:35PM. V7 (nurse) said, he took R1 to smoke. V7 said, he was not at smoker. V7 said, he stood inside the entrance/exit smoking patio door monitoring, looking and checking on R1 via the opened door. V7 said, R1 was on the patio just pass the call bell sitting at the table and he stood inside the door. V7 said, the door and where R1 was sitting was one to two steps away. V7 said, he saw R1 bending and picking up something from the floor. V7 said, he attempted to reach out and grab R1 but R1 was on the floor already. V7 said, he was able to grab R1's jacket which slid off. On 7/27/24 at 2:21 PM, State Surveyor along with V2 (DON) measured the distance between the smoke patio door and the resident outside call bell to be seven feet and seven inched apart. On 7/27/24 at 2:45PM, V2 (DON) said, the patio is concrete. Nursing note dated 3/26/24 documents: R1 was noted reaching forward for his cigarette on the floor. R1 was noted falling face forward from his chair. Writers tried to hold on to the resident jacket to prevent him from hitting the floor. R1 moved too fast. R1 was on the floor with abrasion to his left fore head and sustained an injury to his nose bridge. Fall event dated 3/26/2024 documents: Smoking Area: The resident stated, he was trying to pick up his cigarette from the floor and fell out of the chair. Health care note dated 3/27/24 documents: IDT (interdisciplinary team) met to discuss resident's recent fall, R1 was attempting to reach for something on the ground while on the smoke patio and slid from his chair, staff unable to assist him however was there to supervise smoke time, R1 unaware of safety boundaries and is impulsive, he is instructed to ask staff for assistance and Reacher given to R1. Health care note dated 4/7/24 documents: R1was noted reaching forward for his cigarette on the floor and fell out the chair. Health care note dated 3/29/24 documents: Resident remains on PO ABT (by mouth antibiotic) therapy for open fracture of nasal bone. Health care note dated 4/7/24 documents: R1 was noted reaching forward for his cigarette on the floor and fell out the chair. Health care note dated 4/12/24 documents: IDT team met to discuss resident's recent fall, resident was attempting to reach for something in front of him and slid out of the chair, staff able to assist him back to his chair, resident unaware of safety boundaries, he is instructed to allow staff to assist him when items are needed off of the floor continues to educate to utilize Reacher to aide resident. On 7/27/24 at 1:25PM V9 (nurse) said, V9 educated the agency staff (CNA) who took R1 to smoke to stay within arm's length of R1. The agency staff personnel reported to V9 that R1 dropped his cigarette, reached for it and fell before the agency staff could reach R1. R1 kept his Reacher on the side of his wheelchair. V9 also stated that R1 was able to use the Reacher at the point of education but forgets. R1 said, he forgot to use the Reacher after his second fall. MDS (Minimum Date Set) assessment dated [DATE] shows that R1 has a BIMS (Brief Interview for Mental Status) score of 6 which means severe cognitive impairment prior to R1's first fall on 3/26/24. Hospital record dated 3/27/24 reads in part: Clinical impression: Open fracture of nasal bone, initial encounter. Facial laceration, initial encounter. Injury of head, initial encounter. Physical exam: Head 2cm vertical laceration noted over the bridge of the nose. Slightly gaping laceration. Tenderness to palpitation to bilateral maxillary areas. The wound repaired with 6-0 nylon sutures x 4. Hospital discharged medication clindamycin 300mg by mouth three times daily for 7 days. Fall Prevention and Management policy with a revised date of 4/8/24, reads in part: The facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting harm and ensuring that a safe patient environment is maintained. All residents and patients will be considered at risk for falling, regardless of fall risk score. Universal fall precaution (facility protocol) interventions will be implemented to all. High Risk residents and patients for fall will receive individualized intervention appropriate to risk factors. Development of the fall interventions plan is based on results of the Falls Assessment as well as investigation of all circumstances and related resident outcomes. Include multidisciplinary discussion of interventions that did not work in the past and is currently effective at the moment. Adjust care plan after careful review. If necessary, fall assessment and fall interventions will be reviewed, revised and update as necessary.

Based on observation, interview, and record review, the facility failed to protect a resident from physically abused by another resident; and failed to have abuse risk assessments, including plans of care and interventions in place for R1 and R2. These failures applied to two (R1, R2) of four residents reviewed for abuse, and resulted in R1 sustaining a right arm fracture after being found being pulled by R2 across room floor. Findings include: Facility Reported Incident of 02/13/2024 10:15 PM reds in part, (V20, Certified Nursing Assistant) was walking passed R1's room while completing rounds and saw (R1) on the ground. (R1) complained of pain to the right shoulder and right arm. (R2) was noted in (R1's) room holding onto (R1's) arm. (R2) stated that she thought (R1) was in her room. 1. R1 is an [AGE] year old female admitted to the facility on [DATE], with diagnoses including but not limited to Dementia; Unspecified Hearing Loss; Hypothyroidism; and Encounter for Palliative Care. R1's MDS (Minimum Data Set) assessment, dated 12/22/2023 under section C, documented R1 displays problems with Short and Long Term Memory, and R1's Cognitive Skills for Daily Decision Making are moderately impaired. R1's MDS (Minimum Data Set) assessment, dated 12/22/2023 under section GG, documented R1 completes Rolling left and right and Lying to sitting on side of bed with Partial/moderate assistance. R1's Fall Assessment, dated 01/02/2024, shows R1 is at high risk for falls. R1's Abuse care plan, dated 02/14/2024 was developed and implemented the day after incident of 02/13/2024, and there was no Abuse care plans provided during the course of this survey that were created/implemented in order to address risk of abuse or interventions for R1 prior to incident of 02/13/2024. Progress note, dated 02/13/2024 at 10:15 PM written by V15 (Licensed Practical Nurse), reads, It was reported to this writer, (R1) was observed on the floor in the side lying position in bedroom near doorway. (R1) accompanied by peer, peer noted to be holding (R1) left arm at the time of occurrence. (R1) assessed for any apparent injuries, AROM/PROM (active range of motion/passive range of motion) performed on extremities x4. (R1) c/o (complained of) pain to Right Shoulder and Right Arm. (R1) is alert & oriented x2, with confusion. Bruise noted on Left Forearm. (R1) offered PRN pain medication, (R1) refused. (R1) denies hitting head. Writer contacted EMS (Emergency Medical Services) to transfer the resident to (local) Hospital for evaluation. ADON (Assistant Director of Nursing)/ADMINISTRATOR/ DON (Director of Nursing) made aware of transfer. Writer attempted to contact (family), no answer at this time. Hospital record, dated 02/14/2024, reads, (R1) presents with fall. (R1) on (anticoagulant) and it her head. Physical exam: Extremities: right shoulder tender with limited ROM (Range of Motion). X-Ray right shoulder: Acute impacted humeral neck/proximal humeral fracture. 2. R2 is a [AGE] year old female admitted to the facility on [DATE], with diagnoses including but not limited to Dementia; Adjustment Disorder with Mixed Disturbance of Emotions and Conduct; Insomnia; Major Depressive Disorder; and Hypertension. R1's MDS (Minimum Data Set) assessment, dated 01/12/2023 under section C, documented R2 has BIMS (Brief Interview of Mental Status) score of 8, indicating moderately impaired cognition. Progress note, dated 11/22/2023 at 12:13 PM written by V23 (Registered Nurse), reads, It was reported to this writer by the witnesses that (R2) was getting out of her room and another resident questioning that this is my room - (R2) approached the other resident angry trying to run her over with her wheelchair and quickly hit the other resident on the top of other resident's head. R2's care plan, dated 01/05/2024, reads, (R2) presents with short and long term cognitive deficits, hx (history) of Dementia with aggression. Progress note, dated 01/09/2024 at 1:29 PM written by V22 (Advanced Practical Nurse), reads, (R2) has frequent behavioral disturbances at last facility. R2's Wandering and Behaviors care plan, dated 02/14/2024 was developed and implemented the day after incident of 02/13/2024, and there was no Wandering and Behavior care plans shown that were created/implemented in order to monitor R2 prior to incident of 02/13/2024. Progress note, dated 02/19/2024 at 1:59 PM written by V13 (Primary Care Provider Advanced Practical Nurse), reads, (Nurse) reports that (R2) is very agitated at night and noted aggressive with other patients and difficult to redirect. R2's physician order sheet, dated 02/19/2024, reads, Trazodone HCL tablet 50 MG Give 1 tablet by mouth at bedtime for depression and anxiety. Progress note, dated 02/26/2024 at 9:35 AM written by V14 (Psychiatric-Mental Health Nurse Practitioner), reads, Notified by nurse last weeks that (R2) with aggressive behaviors noted, order given to add (psychotropic medication). On 03/21/2024 at 1:52 PM, Surveyor attempted to interview R1. R1 did not respond to questions. R1 observed sitting up in the bed with her eyes closed. R1 noticed to look frail and vulnerable. On 03/25/2024 at 11:15 AM, Surveyor observed R2 laying on the bed in a random room. According to facility's census, dated 03/21/2024, R2's room was listed to be two rooms down from where surveyor found her. R2 stated, I don't remember pulling any resident out of their bed. On 03/25/2024 at 11:19 AM, V11 (Agency Registered Nurse) stated in summary: R2 is sleeping in an empty room right now. It is not currently occupied, but she resides in another room. On 03/25/2024 at 11:22 AM, V10 (Certified Nursing Assistant) stated in summary: R2 is confused. She goes back and forth to different rooms. When R2 wanders around the unit, we redirect her. I wasn't here during the incident involving R1 and R2 on 02/13/2024, but I heard R2 pulled R1 out of bed. Maybe R2 thought it was her bed. On 03/25/2024 at 2:00 PM, V13 (Primary Care Provider Advanced Practical Nurse) stated in summary: I follow up medical conditions and only know of any resident behaviors from nurses' report. On 02/19/2024, I was notified that R2 was agitated and aggressive. My assessment from 02/19/2024 was done in connection to the incident involving R2 and R1 on 02/13/2023. I just overheard that R2 pulled R1 out of bed, but not sure about circumstances of the incident. Around the same time, psychiatry saw R2 and started her on new psychotropic medication. R2 has extensive psychiatric history but none of her medical condition would aggravate her behavior. On 03/25/2024 at 2:08 PM, V14 (Psychiatric-Mental Health Nurse Practitioner) stated in summary: I only saw R2 couple of times. On 02/19/2024, I was notified that R2 was having agitation and behaviors. I prescribed a new psychotropic medication at the time, and I followed up on 02/26/2024, R2 was calm and had no behaviors. R2 was not followed by psychiatry before 02/19/2024; therefore, I don't know if R2 had any behaviors before then. On 03/25/2024 at 3:30 PM, V1 (Administrator/Abuse Coordinator) stated in summary: Since 01/05/2024, the day of R2's admission, R2 was involved in only one incident that occurred on 02/13/2024. That's when R2 was found in R1's room. I got a call from V15 (Licensed Practical Nurse/LPN), that R2 was found in R1's room, holding and pulling R1's left arm. Because R1 was found on the floor and has history of falls, we concluded, it was an unwitnessed fall. I did the investigation and interviewed directly involved staff. There were no residents present in the hallway at the time of the incident. The following morning, I spoke to most interviewable residents on the unit and they denied hearing any incident or loud noises form the night before. Based on lack of aggressive behaviors during R2's stay in the facility, it was concluded, R2 was trying to help resident get up from the floor. On 03/26/2024 at 11:18 AM, V9 (Social Worker) stated in summary: A vulnerable resident is someone who has dementia or is unable to communicate clearly. I create and initiate abuse care plans on as needed basis. I develop abuse care plans for residents who experienced previous trauma or abuse. Demented residents are not necessarily at risk for abuse even though they are vulnerable. On 03/26/2024 at 11:45 AM, V20 (Certified Nursing Assistant) stated in summary: I was making rounds on the evening of 02/13/2024, and saw R2 in R1's room. R1 was already on the floor and R2 was holding and pulling R1's arm. Both of them were right by R1's bed, and R2 was pulling R1 away from the bed, towards the doorway. R2 kept saying, Get out of my room repetitively. I called V19 (LPN), we redirected R2, and she was escorted back to her room. Sometimes R2 is hard to redirect due to her confusion, she wanders into other residents' rooms. R2 was monitored as per protocol, every two hours, on daily basis. On the day of the incident, I saw R2 right after dinner, around 8:00 PM, and then, at the time of the incident that occurred around 10:30 PM. On 03/26/2024 at 1:43 PM, V15 (Licensed Practical Nurse) stated in summary: I was on my lunch break during the incident involving R1 and R2. R1 was my patient that night (02/13/2024). When I return back to the facility from the lunch break, V19 (LPN) informed me that V20 (CNA) noticed R1 was on the floor and R2 was in the room holding on to R1's arm. They were both confused. That was the report I received. I assessed R1. R1 complained of pain, so I notified the doctor and received an order to send R1 out to the hospital, where R1 was diagnosed with right arm fracture. I spoke to both R1 and R2 after the incident. R2 was in a very confused state, but she was able to communicate that she wandered in to R1's room. It was her typical behavior, R2 wandered into other residents' rooms. R1 didn't really give a description of what happened, she just complained about right arm pain. We kept R2 under direct supervision, checked on her every 15 minutes after the incident. R2 was normally encouraged to stay in the dining room or ambulate in the hallways to stay visible to staff, but we monitored her as any other resident, every two hours. Sometimes R2 gets aggressive with staff when redirected. On 03/26/2024 at 3:10 PM, V19 (Licensed Practical Nurse) stated in summary: I was in the nursing station when V20 (CNA) called me into R1's room. When I came in, R2 was holding on to R1's arm and they both kept saying, This is my room. R2 was trying to pull R1 out of the room. We had to redirect R2 and she was escorted to her room. Prior to the incident, R2 was asleep in her room. R2 must have gone unnoticed into R1's room and tried to pull R1 out of there. I worked with R2 before, R2 needed to be redirected while wandering around the unit. The facility Abuse Prevention policy (no date) reads, The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by: establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Serious Bodily Harm is defined as an injury involving extreme physical pain, substantial risk of death, protracted loss, or impairment of the function of a body member, organ, or mental faculty, or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation.

Based on observation, interview, and record review, the facility failed to implement and/or provide proper staff assistance and supervision when providing care to a resident (R1) who was completely dependent on staff for Activities of Daily Living (ADL's), at high risk for falls and known to require at least two staff members while care is being provided and with bed mobility, for 1 of 3 residents reviewed for falls and safety (R1,R2 and R3). This failure caused R1 to have a fall out of bed where resident sustained lacerations to his right eyebrow and to his right lower extremity that required emergent transfer to a local hospital for sutures to R1's facial lacerations. Findings include: R1's face sheet indicated resident admitted to facility on 06/06/2023, and has a past medical history not limited to: cerebral infarction, adult failure to thrive, seizures, extrapyramidal and movement disorders, and contractures to bilateral open extremities. R1's admission fall assessment, dated 06/07/2023, indicated R1 was a high risk for falls. Minimum Data Set (MDS),dated 06/21/2023 and 09/13/2023, both indicated R1 required extensive assistance and required two person physical assistance for bed mobility. R1's care plan, date initiated 10/31/2023, indicated R1 has ADL's deficit related to limited mobility and movement disorders, totally dependent on two staff for bed mobility/repositioning/turning, and requires two persons assist at all times with ADL's. R1 facility mobility assessment, dated 10/30/2023 (Section C: Mobility and Balance), indicated R1's ability to roll side to side is poor, (Section D: Transitional Movements) unable to perform transitional movements (Section E: Weight Bear) and/or bear weight per self. Facility provided post fall counseling, dated 10/30/2023, indicated V4 (Certified Nursing Assistant) and V5 (Agency Licensed Practical Nurse) were both in-serviced on correct/proper assistance for transfers and ADL cares. Fall list, dated 11/01/2023, indicated R1 had a witnessed fall on 10/29/2023 at 9:55 PM. Progress note completed by V5 (Licensed Practical Nurse), dated 10/29/2023 2250 (10:50 PM), documented R1 was observed lying on floor next to bed with visible laceration to right side of face that required emergency medical transfer to local hospital. Progress note, dated 10/30/2023 at 07:39 AM, indicated R1 was admitted to local hospital with trauma and lacerations to head/face. R1's hospital records, dated 10/30/2023, indicated R1 sustained lacerations to his forehead and right lower extremity status post fall at facility that required sutures to close. Page ten of same hospital records indicated R1 required two person physical assist for bed mobility. R1's active physician orders read is part: wound care to forehead, cleanse with normal saline, pat dry, leave open to air, monitor suture sites for signs/symptoms of infection every shift daily; and may remove facial sutures on 11/6 with wound care. On 11/01/2023 at 12:47 PM, V3 (Restorative Nurse) said regarding R1's incident, she was informed that during care, R1 was near the edge of the bed with his back towards the aide (V4) when he experienced a tremor and/or uncontrollable body movement then proceeded to roll out of bed because the aide was unable to stop R1 from rolling out of bed. She then said, prior to the incident, R1's bed mobility status was one to two persons assist, but then stated she believed R1's bed mobility status was for one person assist in bed. She added a resident's bed mobility is determined by the resident's diagnosis along with their overall type of assistance needed and fall interventions post incident include: floor mats, scoop mattress, and two persons assist for all ADLs. On 11/01/2023 at 1:18 PM, V2 (Assistant Director of Nursing) said R1's admission fall assessment was scored high due to R1 being a new admit, and facility was unable to determine the number of previous falls. She added she had not seen any irregular body movements with R1, and R1 requires two persons assistance for ADLs after his fall incident. On 11/01/2023 at 2:01 PM, R1's bed was at waist level height, with R1 turned onto his left side in bed while incontinence care was being provided by V7 (Certified Nursing Assistant). At 2:03 PM, a second staff member entered room and assisted V7 boost R1 up in bed. Intact sutures were noted to R1's right brow area. At 2:07 PM, V7 said R1 is a two person staff assist with ADL's including bed mobility since his recent fall incident. When asked why she did not obtain assistance to provide care for R1, V7 said help is limited. On 11/01/2023 at 2:20 PM, V1 (Administrator) and V2 (Assistant Director of Nursing) both informed surveyor V7 (Certified Nursing Assistant) was in serviced on same day regarding R1's bed mobility status upgraded to two persons physical assist, then informed surveyor V7 was suspended due to not following this intervention during surveyor's observation and provided documentation of their corrective action. On 11/02/2023 at 1:48 PM, V4 (Certified Nursing Assistant) said regarding R1's fall incident, while providing care to R1, he had an involuntary body movement to his right leg that caused him to roll off the bed. She added she then went to the resident's side and could see blood coming from the top of his head, so she placed a pillow under his head, went to the hall and yelled to the nurse R1 had a fall, call 911 and come assist. Fall Prevention and Management policy last reviewed 10/30/2023 reads: Policy Statement: Facility is committed to its duty of care to residents and patients in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained. Procedures: 1. Fall Risk Screening a. Fall risk screening will be used on admission or readmission to the facility, following a fall, following any change of status, and quarterly. c. All residents and patients will be considered at risk for falling, regardless of fall risk score. Universal fall precaution *(facility protocol) interventions will be implemented to all. d. High risk residents and patients for falls will receive individualized interventions as appropriate to risk factors. 2. Fall Interventions a. Universal Fall Precaution/Facility Fall Protocol will be implemented in addition to High-Risk Fall Precaution Interventions. b. High Risk Precautions will be implemented to residents and patients whose scores on resident/family notification risk screen shows high risk will be considered on this precaution. a. Universal Fall Precautions/Facility Fall Protocol will be implemented in addition to High-Risk Fall Precaution Interventions. c. Some of these interventions may include but not limited to: assess need for appropriate assistive device for mobility and locomotion, restorative program: ambulation, transfers, bed mobility. 4. Fall Response 7. Develop plan of care 8. Monitor staff compliance and resident response 7. Fall Interventions Monitor a. Facility will initiate monitoring of interventions for residents who fall in the facility and with history of fall, who trigger the Falls CAA, and when a resident falls. Frequency and duration of monitoring of interventions will be based on current risks. Supporting Activities of Daily Living (ADL) policy last reviewed 03/20/2023 reads: Policy Statement: 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. Procedure: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with and not limited to: mobility (transfer and ambulation, including walking). 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. Repositioning a Resident policy last reviewed 07/20/2023 reads: Policy Statement: Facility will provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Procedure: 1. Preparation a. Review the resident's care plan to evaluate for any special needs of the resident. 3. Interventions a. Resident will be assessed, and care plan developed and implemented as necessary for a turning/repositioning, changing the resident's position and realigning the body. This will be approached specific to individual resident. 5. Review the resident's care plan to evaluate for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure that two person assist was provided per care assessment for one (R2) of three residents reviewed for falls and injuries. This failure resulted in R2 sliding off the bed during incontinence care and landing on the floor; R2 subsequently complained of pain on the right knee and was diagnosed with a right distal femur fracture. Findings include: R2 is a [AGE] year old, female, admitted in the facility on 02/25/2022, with diagnoses of Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side; Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing (4/14/23), and Morbid (Severe) Obesity Due to Excess Calories. R2's MDS (Minimum Data Set), dated 04/01/23, documented: Section C - BIMS (Brief Interview for Mental Status) score of 8, which means moderate impairment in cognition. Section G - bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture): needs extensive assistance from two persons' physical assist. Incident report, dated 04/11/23, recorded on 04/07/23, R2 was receiving ADL (activities of daily living) care. She was repositioned to right side and slid from the air loss mattress towards the wall. Nurse on duty heard R2 yell out and came into the room. R2 was noted on the floor. R2 was assessed, with no complaint of pain. On 04/11/23, R2 reported she was having right knee pain. An X-ray was done, but result was inconclusive. A repeat X-ray was performed. On 04/12/23, X-ray report showed right femur fracture. R2 was sent to the hospital for further evaluation and treatment. Hospital Records, dated 04/12/23, documented the following: Chief Complaint: Patient presents with fracture; leg pain HPI (History of Present Illness): presented to ER (emergency room ) for evaluation of right distal femur fracture following fall from bed at nursing home. X-ray shows acute mildly displaced distal femoral fracture. X-ray right knee (04/13/23): Acute mildly displaced obliquely oriented fracture of the distal right femoral diaphysis demonstrating intra-articular extension and associated lipohemarthrosis. X-ray right Femur (04/13/23): Mildly displaced acute obliquely oriented fracture of the distal right femoral diaphysis with intra-articular extension. Progress notes, dated 04/15/23, documented R2 came back in the facility with right long leg splint. On 07/17/23 at 2:00 PM, R2 was observed in bed, alert, verbal, on low air loss mattress, and had an ongoing oxygen treatment via nasal cannula at 2 liters per minute. R2 was asked regarding falls. R2 replied, I had a fractured hip. I fell on the floor. Supposedly two CNAs (Certified Nurse Assistant, CNA) should be changing me, but there was only one CNA at that time. When the CNA turned me, I slid off the bed and fell to the floor. On 07/18/23 at 1:13 PM, V11 (Licensed Practical Nurse, LPN) was asked regarding R2's fall incident. V11 stated, That time of incident on 04/07/23, the agency CNA was in her room, changing her and she said, 'Come, come, she (R2) is going to the floor.' I heard the CNA. I went to the room, and I saw (R2) sliding out of bed. We assisted her (R2) to the floor. She was between the bed and the wall, sliding out. The CNA was the only one changing her at the time. We got the lift and put her back to bed. All I know was the CNA was trying to change her, and the bed slipped on her. The CNA was supposed to call somebody before she changed (R2). I tried to tell her at the beginning of the shift the she is a two person assist; she is a big lady. On 07/18/23 at 3:46 PM, V2, Director of Nursing, stated, On 04/07/23, Agency CNA, (V18), turned her (R2) to her left side; she was using a low air loss mattress and she rolled onto the floor. It happened when she (V18) was changing her. She was the only one at the time, changing her (R2), supposedly two CNAs. When we questioned her (V18), she said she was waiting for the nurse, but she couldn't wait any longer, so she just went on and cleaned her and she rolled over. She fell to the floor. Her bed was by the wall, and she slid out of bed and landed on the floor. She (V18) was not able to catch her. She (V18) called for the nurse, (V11), and she (V11) assessed her (R2). There was no complaint of pain at the time. On 04/10/23, she (R2) complained of pain on the right lower leg. X-ray was ordered and resulted to fracture. On 07/18/23 at 3:38 PM, V17 (Fall Coordinator) stated, If it's a two person assist, two persons need to be providing the care or incontinence care. If it's in the care assessment that it should be two person assist, then two staff is needed during provision of care. On 07/19/23 at 10:18 AM, V19 (Licensed Practical Nurse, LPN) stated, When doing ADL care, she is a two person assist. She is a big lady and needs two staff assistance. On 07/19/23 at 3:02 PM, V24, Physician, stated, I remember she rolled out of bed, had a fracture. She is morbidly obese. Falls should not happen. Every fall is preventable, even if its during activities or changing. Her fall is preventable because the fall happened during changing, and an appropriate number of staff should have been provided. Facility's policy titled Fall Prevention and Management, reviewed date 11/10/2022, stated in part but not limited to the following: Policy Statement: Facility is committed to its duty of care to residents and patient in reducing risk, the number and consequences of falls including those resulting in harm and ensuring that a safe patient environment is maintained.

Based on observation, interview, and record review, the facility failed to provide effective pain management, failed to identify signs and symptoms of pain, and failed provide appropriate and adequate pain relief for one (R3) of three residents reviewed for pain in the sample of 17 residents. This failure resulted in R3 experiencing severe prostate pain for several months without adequate and appropriate pain relief. Findings include: On 7/18/2023 at 9:29 AM, R3 stated last night at approximately 8:30 PM, he asked for his Norco pain medication, and an agency nurse gave him 3 pills that were round and looked nothing like his Norco medication. R3 stated he told her those were not his pills, and so he refused them. R3 stated after arguing back and forth with the nurse, she finally pulled out his Norco medication, and asked if it was his name on the package. R3 stated those were in fact his Norco pills, but at this point, he did not want her to pass him any medications, due to his distrust of the nurse. R3 stated one of the CNA's/Certified Nursing Assistants called an offsite staff to complain about him protesting with the nurse about his medications. R3 stated he reported this to V2 (Director of Nursing) that a staff member would complain about him just asking for the correct pain medications. R3 stated when he was admitted , his prostate was 180% enlarged, and now it has enlarged so much, his physician says it's the largest he's ever seen. R3 stated his prostate hurts so severely, that it makes him fall down due to the pain. R3 stated he's in the facility because he is unable to get up to the 3rd floor stairs of his home because of his prostate pain. Asked how long he's been dealing with his severe pain, R3 indicated it was over several months, but has given up and felt helpless. On 7/18/2023 at 2:34 PM, V2 (Director of Nursing) stated this morning around 7:30 AM, R3 reported when he asked the night nurse for his Norco medication, she brought him his Norco pills in a cup, and when he looked in the cup, the pills were not Norco medications. V2 stated R3 reported the pills in the cup were round, and he told the agency nurse it wasn't his Norco medication, because he knew how they looked. V2 stated R3 explained to the agency nurse he had one Norco from when he went out on pass, and only wanted the 2nd one, and she responded what she gave him in the cup was his Norco. V2 stated R3 showed the agency nurse what his Norco medication looked like, and the agency nurse then went back to the medication cart, pulled out R3's Norco, and asked if that was his name on his Norco medication. V2 stated when R3 confirmed with the agency nurse it was actually his Norco, then the agency nurse then offered him his Norco from the medication cart. V2 stated R3 reported to her the agency nurse tried to give him Tylenol instead of his Norco. V2 stated she requested the nurse be DNR'd (Do Not Return) because she was agency and did not feel safe being under the care of this nurse. V2 stated the incident was investigated, and when she interviewed the agency nurse, she reported she did give R3 a Tylenol when he requested his Norco, because he didn't express any specific pain. Records reviewed showed there were no doctors orders for Tylenol to be administered for R3. May, June and July MAR's (Medication Administration Records) all show Norco medications were given with no evaluation of pain relief, and given inappropriately, even when R1 exhibited no pain, mild pain, or moderate pain. On 7/19/2023 at 10:30 AM, R3 came to the conference room where surveyors were present. R3 appeared agitated, and asked if he could file a grievance with the surveyors regarding his treatment at the facility. R3 indicated he again had issues with his pain medications and getting a nurse to respond to his pain. Surveyors asked if he was in pain, R3 affirmed he was, and he had severe pain in his prostate area, pointing to his groin area. On 7/19/23 at 2:15 PM, V24 (Physician) indicated Norco should only be given when the resident's pain level is either a 7 and higher. V24 acknowledged Norco was prescribed as PRN (as needed), and if it was being administered daily, then he should have been informed, so R3 could have a scheduled pain medication. V24 indicated no one from the facility informed him R3 was in severe pain, nor that it was not being managed properly. Surveyor asked whether it was the facility's obligation to inform him of any pain issues with R3, V24 affirmed the nurses needed to let him know of these issues, but did not. Surveyor asked if he ever did an in-service with the nurses in the facility, but V24 indicated he could not recall when he did one. V24 acknowledged he was going to conduct one soon. Surveyor asked how nurses should treat pain management for R3 and other residents, V24 stated, The nurses need to assess whether they (residents) are truly in pain or not. Pain is very subjective. If the resident has been using this pain medication for a long time or is aggressive about obtaining pain medications, this becomes a challenge. If the resident is always in pain, and is not enough to relieve the pain, and asks for more soon after. This becomes a challenge for the nurses, but we cannot assume they are faking, and we are obligated to assess and treat the pain immediately. Sometimes these types of patients, such as (R3), have more pain at night, and sometimes it can be truly worse at night. At night, the autonomic system starts to work and blood flow decreases, and so they will complain more pain. Again, this needs to be assessed quickly and thoroughly in order to provide good pain relief. Surveyor asked if the nurses at any time informed him of the lack of pain relief R3 was obtaining. V24 stated, No. V24 stated he was going to examine R3, and the orders given and would re-evaluate R3's current pain medication regimen. On 7/19/23 at 11:55 AM, V2 (Director of Nursing) stated, I expect that the nurses will document if the resident refused to take a medication. If the resident refuses 3 consecutive days, the nurses should report this to me and to the doctor so we can either adjust or discontinue the medication. The nurses should also come back later and try to administer the medication if the resident refused it originally. As far as pain goes, residents need to have their pain assessed and when they administer pain medications, they should go back and evaluate whether the pain was relieved or not. Pain policy, dated 10/22/2021, reads in part, The facility will provide adequate pain assessment and management to the residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Procedure: Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status. Pain assessment will be performed by a nurse, MD, NP or any licensed clinician. Assessment maybe performed by: Asking the patient to rate the intensity of higher pain using a numeric scale; identifying key characteristics of pain; obtaining descriptors of the pain; Determining factors that make the pain better or worse.

Based on interview and record review, the facility failed to provide care and services to adequately care for and manage the treatment of one resident (R1) admitted to the facility with a left arm soft cast. This failure resulted in R1 being found to have a pressure wound above the soft cast in the outer aspect of the left arm, that required surgical debridement upon being taken to local emergency room by family upon discharge from the facility. Findings include: R1 is an [AGE] year old male, originally admitted on [DATE], with medical diagnosis that include and are not limited to: fracture of the lower end of left radius, anxiety disorder, dementia and diabetes. R1's Minimum Data Set (MDS), dated [DATE], reads BIMS (Brief Interview for Mental Status) 99, unable to be complete the interview due to cognitive deficit. Section M (skin condition) reads, no open wounds; section G reads, R1 needs extensive assistance of two staff members for personal hygiene, toileting two staff members for personal hygiene, toileting, dressing, bathing, locomotion in the unit and bed mobility. R1 was discharged home on 1-22-2023. On 2-3-2023 at 2:30pm, V3 (emergency room Nurse) said, I remember (R1). On 1-22-2023, the family came to the emergency room after (R1) was discharged from the long-term care facility. (R1) had on the left arm above the elbow an open wound, no dressing in place, no obvious protection in place. The open area was 2X1cm, it was caused by pressure from the edge of the soft cast. (R1) had a debridement done to the area; we gave him two different antibiotics to control the infection. On 2-3-2023 10:40am V4 (Wound Care Coordinator) said, I remember (R1). He was on the second floor, confused, Spanish speaking. I assessed the patient after admission. I remember he was combative and refused for me to remove the soft cast and check his skin. I did not remove the cast while he was here at the facility. My expectation is that the floor nurse and the Certified Nurse Assistant monitor the patient skin and let me know if there is any new open area, any redness or any issues with the skin. I do not have any other patients with cast currently. We need to monitor the skin surrounding the cast to make sure no skin issues are developing. V4 presented a document titled: quickshot, dated; 1-7-2023 at 8:22pm, reads: order in place do not remove. V4 said, I just put in the order; no doctor gave me that order. I never talked with the orthopedic doctor. On 2-3-2023 at 2:55 pm, V1 (Director of Nursing) said, (R1) was admitted to the 2nd floor. He was Spanish speaking only. Any residents that are admitted in the facility needs to be evaluated within 24 hours of admission to see if they have any skin impairments. Any residents that have any cast or splint we need to make sure we check for circulation, movement, and I do not remember what the S stands for? We need to make sure to talk to the ortho doctor for orders. At 4:00pm, V1 presented document titled Admission/readmission evaluation, dated: 1-7-2023. V1 said, We do not have a complete nursing assessment for (R1). I printed it shows that is blank, it was not completed. The wound Care Nurse should evaluate the patient upon admission and weekly for 4 weeks. On 2-4-2023 at 1:15pm, V22 (Medical Doctor) said, My nurse practitioner was the one that took care of (R1). (R1) had a soft cast after a fall at home. My expectation is that the nurse checks every day the extremity for circulation, movement , swelling, any skin breakdown, decreased in range of motion, pain or increased in pain. The nurse needs to report to us, and to the orthopedic doctor, if a clarification of orders are needed. Any patient that comes with any cast they need to make sure to obtain orders from the orthopedic doctor for removal and care. I do not usually give orders for orthopedic care. Record review conducted; unable to find a cast care plan. On 2-4-2023 at 12:10pm, V4 (Wound Care Coordinator) said, The care plan for cast care is not in place, I did not develop one, I do not know how to write a care plan I am learning. My expectation is that the admitting nurse completes a body assessment and documents. I do not see any documentation in the admission form. The nurse needs to complete the assessment, call the medical doctor, get orders and carried them out. Nothing is filled out in the admission for (R1). I did not do any discharge planning for (R1). I was not a part of his discharge planning. My mistake is that I did not document the care I provided to (R1). I do not know when was the last day I saw (R1's) skin. R1's Physician Orders Sheets, dated: January 2023, reads: monitor left arm cast every shift. According to document presented by V1 (Director of Nursing), there is no documentation on the following days: 1-8-2023 night shift, 1-11, 1-13, 1-14,1-15, 1-16,1-18, 1-20 and 1-22-2023 during day shift. Policy titled: wound prevention program, dated: October 2022, reads: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and prevention of pressure ulcers as well as, non-pressure related wounds. Upon admission the resident's skin will be evaluated head to toe by licensed nurse. Provide padding for cast, splints and braces and check for redness .

Based on observations, interviews, and record reviews, this facility failed to provide the restorative nursing care, failed to assess and identify a decline, and develop a plan to implement interventions, and evaluate the effectiveness of interventions for one of three residents (R2) reviewed for mobility and range of motion. This failure resulted in a decline in range of motion in R2's left hand out of three residents reviewed for a decline in functional abilities in a sample of 3. R2 has developed a contracture of left hand and is unable to extend fingers. Findings include: On 4/25/22 at 9:30am, R2 was observed not wearing left hand splint. On 4/25/22 at 2:00pm, R2 was observed not wearing left hand splint. On 4/26/22 at 1:00pm, R2 was observed sitting in a high back wheelchair. R2 was observed not wearing left hand splint. R2 stated that R2 does not know what happened to R2's left hand. R2 stated that R2 currently is not able to move fingers or hand independently. R2 was observed with left fingers bent onto palm of hand and hand flexed towards wrist. R2 was observed extending left hand with right hand. R2 was not able to extend left fingers with right hand. R2 was observed only able to perform AROM (active range of motion) with right arm. R2 stated that it is painful to move R2's left hand. R2 stated that R2 did not wear the left-hand splint yesterday or today. R2 stated that V14 OT (occupational therapist) will be back tomorrow and V14 will put the splint on for me. On 4/25/22 at 10:50am, V2 DON (director of nursing) stated that there is no restorative nurse at this time. V2 stated that there is a part time restorative nurse that helps with MDS (minimum data set). V2 stated that V2 is unsure how long the facility has been without a restorative nurse. On 4/25/2022 at 11:01am, V4 (restorative aide) stated that V4 is familiar with R2. V4 stated that R2 has been on a restorative's AROM (active range of motion) program. V4 stated that R2 receives AROM for 15 minutes a day. V4 stated that if the resident complains of pain during AROM, therapy is stopped, and the resident's nurse is notified. V4 stated that V4 does not know when R2's left hand became contracted. V4 stated that contractures can develop when there is a stiffness of bone when not moving; range of motion is done to prevent this. V4 stated that V4 is unsure how long there has not been a restorative nurse at this facility. V7 stated that currently R2 needs a lot of assistance, moderate to maximum assistance with transfers with two staff members assisting. V7 stated that R2 is not safe to transfer by himself, V7 has another staff member assist with transfer. V7 stated that when R2 was seen by physical therapy July 2021, R2 required supervision with bed mobility, moderate assistance with transfers. V7 stated that when a resident is discharged from PT to the restorative program, a therapy to nursing recommendations form is completed and given to the restorative nurse. V7 stated that there is no restorative nurse at this time. V7 stated that the previous restorative nurse left last summer. On 4/26/2022 at 1:35pm, V10 (attending physician) stated that in March 2022 V10 noted R2's left hand contracture. V10 stated that V10 ordered an orthopedic physician consult regarding left hand and ordered a splint. V10 stated that R2 needs intervention with splint to prevent contracture from progressing. Review of V13's (rehabilitation physician) note, dated 4/12/2021, notes V13's assessment/plan: mobility and ADL (activities of daily living) dysfunction secondary to ADL and mobility impairment. R2 admitted to subacute rehabilitation with PT (physical therapy) and OT (occupational therapy). PT will work on strengthening, endurance training, neuromotor training, gait training, and balance training. OT will work on ADL and functional mobility training. Deconditioning/Gait instability - R2 is at high risk for functional impairment without therapy and adequate pain control. R2 has high risk for developing contractures, pressure ulcers, poor healing or falls if not receiving adequate therapy and pain control. On 4/26/2022 at 2:00pm, V3 (rehabilitation director) stated that R2's splint is a resting hand splint. V3 stated that this splint is used for effective contracture management. V3 stated that this splint should be worn daily. V3 stated that if R2 does not wear this splint daily it would not be an effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of V10's progress note, dated 3/15/2022, notes R2 complaining of ongoing left-hand weakness, bilateral lower extremity stiffness. Weakness, muscle stiffness-will order head CT (computerized tomography) scan, will ask therapy to recommend a brace. R2's BIMS (brief interview of mental status) score is 15 out of 15. R2 is able to make needs known. There is no documentation found noting this facility scheduled a CT scan of R2's head related to weakness. There is also no documentation found noting R2 has been seen by an orthopedic physician related to left hand contracture. Review of R2's joint mobility documentation, dated 4/26/22, notes R2's left-wrist severe (0-25% available ROM); left fingers moderate/severe (26-50% available ROM); left wrist noted at a downward flexed position. There is no documentation found noting R2's joint mobility was assessed quarterly since R2's admission to this facility on 1/19/2021. Review of R2's mobility assessment, dated 10/15/21, notes R2 had full flexion and extension of both hands and fingers. There is no documentation found noting a mobility assessment was completed quarterly since R2's admission to this facility on 1/19/2021. Review of R2's restorative AROM program documentation notes R2 has received 15 minutes of AROM (active range of motion) by restorative therapy. There is no documentation noting what extremities received AROM. There is no documentation of when R2 developed contracture to left hand. There is no documentation noting R2's complaints of left-hand pain with extension. Review of R2's nurses' documentation does not note any documentation regarding left hand weakness, left-hand contracture, or left-hand pain with movement. Review of R2's OT (occupational therapy) note, dated 4/7/22, notes R2 given left hand splint. R2 requires total assistance of staff to apply and remove splint. Review of R2's OT (occupational therapy) assessment while in hospital, dated 1/13/2021, notes good AROM and strength noted in R2's arms and legs. Review of this facility's activities of daily living (ADL) policy, revised 11/10/21, notes residents will be provided the care, treatment, and services to ensure their activities of daily living do not diminish. Care and services to prevent and/or minimize functional decline will include appropriate pain management. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. Review of this facility's active and passive range of motion protocol, undated, notes a joint mobility form is completed for all residents with their comprehensive assessment. It is reviewed on a quarterly basis. If decreased range of motion or voluntary movement is present, then passive range of motion is initiated. If the resident complains of pain during range of motion, the CNA will stop and notify the nurse. If there is any change in condition with the resident including but not limited to increased pain or decreased range of motion the physician or nurse practitioner will be notified. The restorative director will document progress and update the care plan on a quarterly basis. Review of this facility's specialized rehabilitative and restorative services policy, dated 3/7/21, notes the facility will provide restorative services such as but not limited to range of motion.

Based on interview and record review, the facility failed to immediately initiate CPR (cardiopulmonary resuscitation) or call a code blue for a full code resident (R3) after the resident was found unresponsive. This failure affected one resident in a total sample of seven. This failure resulted in CPR not being initiated on R3 until paramedics arrived to the facility approximately 9 minutes after R3 was found without a pulse or not breathing. R3 was pronounced dead after not being able to be revived by paramedics. This situation was identified as an Immediate Jeopardy. The immediate jeopardy began on [DATE]. The Interim Administrator was notified of Immediate Jeopardy on [DATE] at 11:36AM The deficiency remains at a level 2 harm until the facility can evaluate the effectiveness of the implementation of their removal plan. Findings Include: R3 is a [AGE] year old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 admitted to the facility on [DATE]. A Nurse Practitioner note, dated [DATE], documents R3 is a full code. (A resident being a full code means in the event a resident's heart stops beating and/or breathing stops, then all efforts of resuscitation will be provided to keep them alive.) A Nursing progress note, dated [DATE], documents at 9:05 PM, the CNA (Certified Nursing Assistant) (V5) called the nurse (V13) into the room. The nurse noted R3 was unresponsive while lying in the bed with foam in R3's mouth. The CNA stayed with R3 and the nurse called 911. The nurse was about to start to do CPR (cardiopulmonary resuscitation) when the paramedics came into the room and took over. The paramedics left the facility unable to revive R3. The time of death is recorded as 9:36 PM and was called by the physicians at the hospital through the paramedics. The Fire Department Report, dated [DATE], documents the paramedics were dispatched to the facility due to R3 being found unresponsive. While in route to call, dispatch notified the crew (paramedics) over the radio that CPR had been declined. The crew was led to R3 and upon arrival, no one was in the room doing CPR. R3 did not have a valid DNR (Do Not Resuscitate). There was another staff member on scene who said he (V13) was not the nurse. R3 is unresponsive, apneic, and pulseless, and is warm to touch. CPR was initiated by the crew and continues throughout the call without interruption. R3 remained in asystole (no heart beat) during resuscitation efforts. After working on R3 for 20 minutes the hospital was contacted and given report. The physician at the hospital ordered to seize any further resuscitation attempts and noted the time of death as 9:36 PM. The crew was dispatched at 9:08 PM, they were in route at 9:09 PM, they were on scene at 9:11 PM, and they were at R3's bedside at 9:14 PM. On [DATE] at 2:22PM, V5,Certified Nursing Assistant/CNA stated, I was her (R3) CNA that night. I don't remember the last time I saw her because we are in and out of rooms all the time checking on people. I went in to round on her and I saw she wasn't responding to me. I didn't check for a pulse and I can't remember if she was breathing or not. She just looked asleep and wasn't responding to touch. I went and told the nurse. The nurse came in the room and went to call 911. I don't remember what we did after that. I can't say if we did CPR or not. If you see something wrong with someone then you go tell the nurse and start CPR right away. Someone calls 911 and then you just keep doing CPR until they get there. On [DATE] at 10:43AM, V6 (Paramedic) and V7 (Paramedic) were interviewed together via phone call. V6 stated, While we were en route to the facility, we got notified by the dispatcher that CPR had been declined. We asked if they were a DNR and the dispatch told us no. I asked why CPR hadn't been started and whoever called in said because no one else was able to open the door for us while they did CPR. V7 stated, A man opened the door for us but told us that he wasn't her nurse. He directed us down to the room and no one else was in there; only the woman (R3) in the bed. I immediately checked for a pulse and breathing which both were absent. Another worker said she last saw her alert at around 7 PM. She still felt a little warm and was not stiff in any areas that I could tell so we ran the protocol for a full arrest. A full arrest protocol is starting CPR and getting sometime of airway in the patient to get the oxygen and try to get IV access to give medications. We also put the AED (automated external defibrillator) to see if there was any heart activity but we never got any. After doing 20 minutes of the full arrest we called the emergency medical response team at the hospital and they told us to end it because she couldn't be revived and there was no changes after the 20 minutes of us working on her. Anyone who gets CPR training knows that when you find anyone not responding and doesn't have a pulse to start as fast as you can while calling for help. On [DATE] at 1:23 PM, V10 (CNA) stated, The person who finds them like that is responsible for doing CPR and calling for help. It can be the CNA, nurse, doctor, or anybody. You start doing chest compressions first and then 2 breaths when you are done with those. You don't stop until 911 comes. If they are a full code, then CPR needs to be done. On [DATE] at 1:27 PM, V11 (Agency Nurse) stated, If I find someone down I start doing CPR as I'm yelling out for other people to come help me or I hit the code alarm. When someone comes into the room, I let them know I need the crash cart and to call 911. Once I get the cart in the room, I get the board under the resident and keep doing compressions while someone else give them breaths. It is 30 compressions then 2 breaths and start over again. You never should leave the person alone and never stop until the paramedics get there. You don't start CPR if they are a DNR but if they are a full code then CPR has to be done as soon as you realize they are unresponsive without a pulse. On [DATE] at 1:57 PM, V13 (Nurse) stated, I came in early that night around 7 PM. I was assigned on Parkview 1 and she (R3) was in the TCU so I was not her nurse. I don't believe there was a nurse over there. The CNA (V5) summoned me that I needed to go check on her because she wasn't responding. She (V5) came to get me down the hall on the other side because that is where I was assigned. I ran down to her (R3) room and she was not responsive. I checked for vital signs and she had none. I went to call 911 out at the nurse's station. I spoke with the dispatcher and she told me to start CPR and I told her I was going to as soon as I was off the phone with her. The CNA (V5) didn't start CPR. I don't know why she didn't start. When I got off the phone, I went back into the room and the CNA was cleaning her mouth because it had foam in it. I went to start doing CPR and that is when the paramedics got there. It was maybe like 5 minutes after I saw her before they arrived. I don't know how they got in the facility. I never seen her (R3) before this happened so I can't tell you what she was like before. I wasn't assigned to her. The CNA came to get me right after 9 PM. She was still warm when I was checking her. It was like it just happened because she wasn't cyanotic or anything. There was no time to call a code or bring in the crash cart because the paramedics got there as soon as I was off the phone. She was a full code. I didn't start CPR because I was the only nurse over there so I had to call 911. On [DATE] at 3:55 PM, V14 (Medical Director) stated, The first thing you do when someone is unresponsive is check for a pulse and if they are breathing. If they do not have either of those then you start CPR immediately. If you find them cold and clammy then that means they are already expired and there is no point to start CPR. If they are still warm, cardiac arrest just happened so immediate CPR should be performed. If the time they have been down is questionable but they still feel warm then you still do CPR. The benefit of doing CPR immediately is to bring circulation of blood back to the brain so it lessens the likelihood of significant brain damage. Blood flow to the brain means a better chance of recovery. One person can perform CPR until the ambulance arrives but two people are better. With two people one can do compressions while the other does breaths but one person alone can do both breaths and compression during CPR. The only reason you shouldn't do CPR is if someone is cold because there's no chance at reviving them or if they are a do not resuscitate. A full code means the patient still request chest compressions, intubation, medications, basically everything to save them. There's no reason CPR should not be started if they are a full code and still warm. A lot of these residents have a lot of comorbidities so their likelihood of surviving through this type of event is decreased but ethically to honor their decision we have to continue with CPR until we are sure they are unable to be brought back. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was ordered on [DATE]. The policy titled, Code Policy, dated [DATE] documents, A code is initiated for all residents requiring emergency medical attention. Procedure: 1. Upon finding a person without respirations and/or a pulse, have another staff member check the code status while the person finding the resident initiate CPR . 3. If the resident is not a DNR, than a cold blue or rapid response should be called. 4. When announcing a cold blue, state the unit, room number or place. 5. The crash cart which is located on each floor, is brought to the area where the code is occurring. 6. As staff arrive, the DON or designee, should assign staff to the following items: someone to call 911, someone to assist with CPR, someone to notify the physician in family, someone to start the transfer form, get the paperwork together and notify the hospital, someone to hold the elevator on the first floor, if applicable, and someone to remove other residents from the area to ensure there is a clear path for the paramedics. 7. Once the resident is taken to the hospital, document the events leading up to the cold, as well as action taken during the cold, and the nursing notes. The policy titled, Resident Right - Advance Directive Tracking Program, dated [DATE] documents, In the event a resident experience is cardiopulmonary arrest, the nurse on duty shall immediately determine the resident's status as a code or no code. If the person is a full code, the nurse or designee shall begin cardiopulmonary resuscitation and direct someone to call 911. The policy titled, Emergency Procedure - Cardiopulmonary Resuscitation, dated [DATE] documents, Procedure: 1. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS: Initiate CPR unless it is known that a do not resuscitate order that specifically prohibit CPR in or external defibrillation exists for the individual or there are obvious signs of irreversible death (e.g., rigor mortis) 4. Emergency procedure-cardiopulmonary resuscitation if an individual is found unresponsive, briefly sauce for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or coach status of the individual. Initiate the basic life support sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Chest compressions: follow initial assessment, begin CPR with chest compressions; push hard to a dust of at least 2 inches at a rate of at least 100 compressions per minute; allow full chest recoil after each compression; and minimize interruptions in chest compressions. Airway: tilt head back and live chin to clear airway. Breathing: after 30 chest compressions provide 2 breaths via Ambu bag or manually (with CPR shield). All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuer should also provide ventilation's. The AED arrives, assess for need and follow AED protocol as indicated. Continuous CPR/BLS until emergency medical personnel arrive. The surveyor confirmed via observation, record review, and interview, the facility did the following to remove the immediacy: 1. Corrective actions which will be accomplished for those residents found to have been affected by the deficient practice In-services on the CPR Policy was initiated on [DATE] on facility staff. In-service on CPR policy was continued on [DATE] to all staff working on all three shifts. In-service was conducted by Interim DON (Director of Nursing) and Regional Nurse Consultant. In-services will be on-going for six weeks on all shifts. The target goal date is [DATE]. In-service and training will be conducted by Interim DON, Nurse Manager, and Regional Nurse Consultant. In-services on the CPR Policy was initiated on [DATE] with agency staff present at the facility. This in-service was conducted by Interim DON and Regional Nurse Consultant. In-services will be on-going for six weeks on all shifts. The target goal date is [DATE]. In-service and training will be conducted by Interim DON, Nurse Manager, and Regional Nurse Consultant. 1:1 in-service on CPR Policy and Procedure was conducted with the CNA and nurse who were assigned to the patient on [DATE]. Another 1:1 in-service was provided to nurse assigned to the patient on [DATE]. Code Blue Policy was immediately sent to all staff in the building via CareFeed on [DATE]. Code Blue Policy was immediately sent to all staffing agencies contracted by the facility via email on [DATE]. A mock code blue drill was conducted on [DATE] by Interim DON, Registered Nurse/RN, and Regional Nurse Consultant, RN on am and pm shifts and was participated by clinical staff, including two agency nurses present in the building. Mock code blue will continue to be conducted by Interim DON, Nurse Manager, and RN and Regional Nurse Consultant every shift, once a week for six weeks an continue with new hires, annually and when needed. If all clinical staff have been trained and educated on CPR policy and Mock Code Blue on certain shift, in-service and training will not be necessary. QAPI meeting was conducted on [DATE] attended by Facility Department Heads to discuss F600 and F678 citations and plan of removal. Medical Director was informed of Immediate Jeopardy on [DATE]. Medical Director met with Administrator to discuss citations and plan of removal. o Attendees: Administrator Interim DON Regional Nurse Consultant Social Service Director HR Director Activity Director Wound Director Director of Special Projects Admissions Director Administrator in Training Rehab Director Business Office Manager Medical Director-Virtual Facility reviewed all Full Code status patients and list was put in a binder and placed on all crash carts. Full code binder will be reviewed and updated with all new admissions, re-admissions and any changes with POLST status. 2. The facility will identify other residents having the potential to be affected by the same deficient practice All 47 residents with a Full Code status have the potential to be affected by this alleged deficient practice. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and not recur In-service on CPR policy will be ongoing for six weeks. CPR Policy In-service will be given to facility and agency staff. The goal date will be on [DATE]. In-services will be conducted by Director of Nursing and Regional Nurse Consultant. In-service to agency nurses and C.N.A's on CPR Policy will be ongoing as long as facility utilizes agency staff in the facility. CPR and Code Blue Policy was created on [DATE] and revised on [DATE] to show an ongoing process to train and educate on CPR protocol, including rapid response to Code Blue. Agency nurses will receive in-service and training on CPR Policy and Code Blue within their shift and will be conducted by Interim DON, Nurse Manager, or Regional Nurse Consultant. The Director of Nursing or Regional Nurse Consultant will continue to educate and re-educate the facility new hires and new agency staff on the code blue and CPR policies and procedures on an ongoing basis on all shifts. This will begin on [DATE]. New hires will be trained and competencied during orientation and annually by the Director of Nursing, nurse manager, or Regional Nurse Consultant beginning ,d+[DATE]. Agency staff will be provided the Code Blue and CPR policy placed in binder located on TCU and Heritage Nurses Station. Facility will ensure that new hires have CPR certification. CPR certification will be completed during orientation, if employee has no current CPR. The DON and Social Service Director will continue to audit patient and resident's code status weekly to include POLST form, orders, and care plans. Clinical education will be provided on change in condition to nursing staff, including agency. Cardiologist and Respiratory Therapist to begin clinical education on [DATE]. Cardiologist will provide education regarding identifying changes in clinical condition, conducting clinical head to toe assessment, interventions, and cardiac system overview, change in condition on critically ill patients. Respiratory Therapist will provide education regarding changes in respiratory conditions, respiratory system review, [CONDITION(S)], [CONDITION(S)]/AVAP/[CONDITION(S)], and oxygen use. Facility will ensure that all CNA's and Nurses both facility and agency staff will be educated. This will be presented in a classroom type of setting using visual aids and handouts and will be held in the facility's conference room. The goal date for completion will be on [DATE]. 2022. This clinical education on change in condition will be provided during new hire orientation, annually and as needed. Facility and Agency staff who have not attended the clinical education during scheduled classes in the facility will receive education using online portal. This presented by cardiologist and respiratory therapist will complete requirements during not educated on Change in Condition will report to DON office prior to start of shift. The DON, Nurse Manager, or Regional Nurse Consultant will conduct competencies on Mock Code Blue upon new hire, annually, and as needed beginning on [DATE]. 4. Quality Assurance plans to monitor facility performance to make sure that the corrective actions are achieved and permanent: Administrator will utilize a QA tool to ensure compliance with this Plan of Removal, to include completion of In-services on CPR policy on all staff, including agency staff, Mock Code Blue for clinical and agency staff, clinical education on change in condition for all C.N.A's and nurses, including agency, audit tool for full code status. DON and Social Service Director will utilize a QA tool to ensure that the DNR POLST form, orders, and care plans are accurate and up to date weekly. Audit will be ongoing beginning [DATE]. DON and charge nurse will utilize the Code Blue Checklist Observation tool during actual Code Blue. Any identified opportunity will be addressed and appropriate in-service will be conducted to correct practice. Competencies on Code Blue will be reviewed by Director of Nursing monthly on an ongoing basis to ensure that all staff have completed training and competency annually and as needed. The results of the monitoring and audits done under this will be submitted to the QAPI Committee for review and follow up monthly. QAPI monthly meeting will be attended by all Department Managers to include: Administrator Interim DON/DON/Nurse Manager Regional Nurse Consultant Social Service Director HR Director Activity Director Wound Director Admissions Director Administrator in Training Environmental Service Rehab Director Business Office Manager Medical Director-Virtual Completion Date: [DATE]

Based on interview and record review, the facility failed to prevent one resident (R2) who was dependent on staff for turning, repositioning, and incontinent cares, and at risk for developing pressure ulcers, from developing an unstageable pressure ulcer on sacrum. This failure resulted in R2 being admitted to the hospital for [CONDITION(S)] secondary to urinary tract infection and sacral wound. This failure affected 1 (R2) of 3 residents reviewed for pressure ulcers. Findings include: R2 is [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted to the facility on [DATE], and transferred and admitted to the hospital on 10/27/21. Review of R2's Assessment, dated 8/26/21, note R2's cognitive status is moderately impaired. Functional status notes R2 requires total dependence from staff for bed mobility, toilet use, and extensive assist for dressing. R2 is documented to have limitation in range of motion to one side. Skin conditions notes R2 is at risk for developing pressure ulcers and does not have pressure ulcers on or before 8/26/21. Review of R2's Risk Assessment for skin breakdown from 8/19/21 thru 10/5/21, all indicate a score of 13, Moderate Risk. R2's care plan, initiated on 8/30/21, notes R2 has activity of daily living self care performance deficit related to [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction. The intervention notes R2 requires extensive assistance to turn and reposition in bed frequently and as necessary. Review of R2's progress notes, dated 10/3/21, note R2 crying. R2's daughter reported R2 is weak. Review of Follow Up Question Report, dated 10/6/21, notes V20 documented a new skin condition. Review of R2's Progress Notes on 10/6/21 do not include a skin condition. No Assessment is in the electronic record for 10/6/21 related to R2's skin. Review of R2's progress notes, dated 10/6/21, note R2's daughter stated she planned to visit R2 more often since R2 is not feeling well. Review of R2's Wound Assessment, dated 10/12/21, notes at 10:00AM, R2 has a pressure ulcer on sacrum 85% Slough, measured 8.0cm length x 10.0cm wide. Review of R2's care plan intervention, initiated on 10/12/21, notes encourage small frequent position changes. However, staff and assessments indicate R2 was dependent on staff for positioning. R2's Assessment, dated 10/12/21, notes R2's cognition is severely impaired, and R2 requires extensive assist from staff to turn and position. Review of V21's Wound Care Notes, dated 10/27/21, measured R2's wound as 7.5cm length x 10cm width and the wound is deteriorating. Sacral debridement was performed. R2's Orders (provided in screen shot format by facility) note on 10/27/21, Send (R2) to emergency room for altered mental status and leukocytosis. Review of R2's hospital record Progress Notes, date of admission is 10/27/21, and Reason for Admission is [CONDITION(S)] secondary to urinary tract infection and sacral wound. Emergency Department course: patient was febrile with temperature 101, [CONDITION(S)]. On 11/5/21 at 12:53PM, V11, Wound Nurse, said, A Certified Nursing Assistant (CNA) asked me to look at R2. When I looked, R2 had an unstageable wound on (R2's) bottom. It had slough and I could not see past the slough to know the depth. On 11/5/21 at 3:02PM, V15, Certified Nursing Assistant (CNA), said R2 was totally dependent on staff for cares, and needed to be repositioned by staff. V15 said R2 stayed in bed and was incontinent of urine. On 11/9/21 at 10:25AM, V17, CNA, said V17 was assigned to R2 on 10/12/21, and was turning R2 and saw R2 had a patch on R2's bottom and it was soiled. V17 said, The patch looked like a dressing and it was soiled and I took it off. V17 said V17 then went to get the nurse, and reported the wound. V17 said, This is the first time I had seen this area on R2. V17 said R2 was being turned every 2 hours. V17 said 2 hours is the standard for repositioning residents. On 11/9/21 at 10:45AM, V18, Licensed Practical Nurse, said on 10/11/21, V18 worked the night, 11:00PM- 7:00AM shift, and checked R2's skin. V18 said R2's skin was clear when V18 checked R2, and there was not a dressing on R2's bottom. V18 said it is rare to see an unstageable ulcer develop in just a few hours. On 11/9/21 at 11:57AM, V11 said on 10/12/21, V11 did not see a dressing on R2, and the CNA did not tell V11 she removed a dressing on R2. V11 said if a resident begins to fail, they can develop a wound quickly. V11 said the standard to turn and position a resident is every 2 hours. V11 said after R2 developed the wound, R2 could have been turned more frequently. On 11/9/21 at 12:51PM, via phone interview, V20, CNA, said V20 documents resident's skin condition in the computer charting system. V20 said on 10/6/21, R2 had a small scratch or something on R2's back side, and that was why V20 documented yes for new skin area. On 11/9/21 at 1:38PM, V2, Director of Nursing, said I called (V20) today. (V20) said no one talked to (V20) prior to today about (V20's) documentation on 10/6/21 for (R2). On 11/9/21 at 1:50PM. via phone interview. V21, Wound Nurse Practitioner, said slough is soft necrotic tissue. V21 said a pressure ulcer can develop in a couple of hours. V21 said R2 was anemic based on lab results from 10/3/21. and R2 had a low [MEDICATION(S)] protein level lab on 10/4/21. V21 said low labs levels contribute to skin breakdown. V21 said with incontinent care, the staff may have noticed skin breakdown prior to it becoming sloughed. V21 described the wound as bigger than a ping pong ball and smaller than a baseball. V21 said V21 first saw R2's wound on 10/14/21 and it measured 7.0 cm length x 8.5 cm width. On 11/9/21 at 2:18PM, via phone interview, V22, MDS Nurse, said R2's status was discussed because of R2's intravenous fluid status on 10/6/21, and (R2) seemed more depressed. We decided to do a significant change assessment on (R2). V22 said, During the assessment period, we found (R2) had declined cognitively, as well. V22 said on 10/12/21, the Assessment Reference Date, it was reported R2 had a pressure ulcer. The facility provided policy titled Comprehensive Resident Centered Care Plans, review date 3/20/21, states Developing Care Plan: 3c. Each planned intervention will be specific and include parameters for frequency and time schedules. The facility provided policy titled Wound Prevention, review date 3/20/21, states The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as, non pressure related wounds.

Based on interview, and record review, the facility failed to follow their weight policy by not monitoring a residents weight following a food intake decline that persisted for over one month and failed to reevaluate the effectiveness of interventions, or attempt alternative interventions to prevent further weight loss for one (R377) of seven residents reviewed for nutrition. This failure resulted in the resident experiencing a significant weight loss of 15.77 percent in 2 months. Findings include: R377 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R377's monthly weight report dated January 2020 to May 2020 documents the following weights; January 154 lbs, February 152.4 lbs, March 152.2 lbs, April no weight documented, and May 128.2. A significant weight loss of 15.77 percent from March to May. On 10/8/20 at 11:45pm, V8 (dietary tech) said, she was not made aware of any further changes with R377 appetite or intake after 4/14/20 . If there were any changes reported she would have discussed with the Dietician and made adjustments including discussion with family, weekly weights, 3day calorie count and updating food preferences. On 10/8/20 at 1109AM Director of Nurses (DON) said weights should be completed monthly and as ordered to ensure that the resident's weight is stable and there is no significant change in the weight. If change in weight is noted we would notify family, physician, and follow the nutrition protocol. On 10/7/20 at 12:16PM, V10 (restorative nurse) said they are responsible for monthly weights. No weights were done in April due to COVID-19. We would notify DON of any changes in weight and reweight prior to documenting the final weight in electronic medical record. V 10 said unaware of any weight loss or changes in appetite. On 10/9/20 at 331PM, V29 Nurse Practitioner (NP) said for concerns related to nutrition they would monitor labs, do a calorie count, monitor weights more frequently and refer to dietician. V29 was unsure why weights were not monitored and referred to facility for any further information related to 377s weight monitoring. If a resident was not eating family would need to decide if they want feeding tube or palliative care. V29 was unable to give a time frame when feeding tube discussion would be had with family, but said R377 was referred to palliative care. R377's hospital record dated 5/19/20 under physical exam documents emaciated. Under assessment and plan documents anorexia, dysphagia, severe protein calorie malnutrition, failure to thrive and currently requesting feeding tube. Gastrostomy tube placed 5/23/20. R377's progress note document poor appetite on the following days 5/19/20, 5/18/20, 5/15/20, 5/14/20, 5/12/20, 5/11/20, 5/10/20, 5/9/20, 5/8/20, 5/7/20, 5/5/20, 5/1/20, 4/25/20, 428/20, 4/12/20, 4/11/20, 4/7/20, 3/17/20. R377's progress note dated 5/19/20 by V28 (APN) documents: In past 4 weak, the nursing staff has observed worsening appetite and has required IV fluids. R377 has been refusing to open his mouth to accept food or fluids from staff since Friday (5/15/20). Under general appearance documents severe clavicular wasting. Appetite has declined over past 2months. Weight was fluctuating and progressively decreasing between 152- 155 in the past 6 months with a sharp decrease in the past 2 months. Current weight 128.6. a reweigh is expected but consistent with his appearance. Goals of care comfort focused vs gastrostomy. R377's progress note dated 4/14/20 documents referral to dietician due to poor intake. Resident eating 25 to 50 % of meals with no significant weight changes. Under plan increase supplement to 120 ml three times a day and add magic cup with lunch. There are no other dietician notes after 4/14/20. R377's progress notes document V29 ( NP) did virtual visit on 4/23/20 with no new orders noted. R377's physician order [REDACTED]. R377's care plan initiated on 5/7/2020 documents Resident has nutritional problem or potential nutritional problem related to possibly chewing issues and history of low body mass index. The following interventions were initiated on 5/7/20, Feed and assist during meals, monitor/ document/ report to MD as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, observe intake and record every meal, provide and serve diet as ordered; Dietician to evaluate and make diet changes recommendations as needed. R377's diet order documents dated 7/11/19 mechanical soft diet, super cereal at breakfast, double portions. R377's diet order 4/15/20 documents pureed diet, super cereal at breakfast, double portions magic cup at lunch. R377's dietary profile dated 5/7/20 documents Body max index of 25 within normal limits with a weight 152 from March 6 2020. Under comments refer to social service and restorative progress notes weights reviewed with no significant changes at this time; may weight pending current diet meet estimated needs. Currently with varied appetite recorded no dietary suggestions at this time. Facility policy titled weight revised on 7/14 document weekly weights will done with significant change of condition, food intake decline that has persisted for more than week. On 10/9/20 at 400pm, V3 Assistant Director of Nurses (ADON) said the facility did not have any policy on significant weight loss.

Based on observation, interview, and record review, the facility failed follow their policy on Skin Care Prevention by not ensuring daily skin assessments were completed for a resident who was scored as at risk for skin breakdown and provide necessary treatment. This affected 1 o 6 residents (R3) reviewed for skin breakdown and diabetic ulcers. This failure resulted in R3 being observed with (2) untreated ulcers to the lower extremity. Finding Includes: R3 has the [DIAGNOSES REDACTED]. R3's brief interview for mental status (BIMS) was scored a fifteen which indicates R3 is cognitive intact. Section G documents: R3 is total dependence for bathing, requires extensive assistance with two person physical assist with bed mobility and the inability to walk. Section M documents: R3 is at risk for developing pressure ulcers. R3's care plan initiated 12/12/19 documents: R3 is at risk for impaired skin integrity based on the Braden At Risk score. R3 has arterial/ischemic ulcer of the right foot related to [MEDICAL CONDITION]. Intervention dated 12/12/19: Inspect feet daily. Report changes to the nurse. R3's Braden score skin assessment dated [DATE] (a standardized tool used to assess a resident risk for skin breakdown) documents a sixteen (at risk range is 15-18) which indicates R3 as at risk for skin break down. On 10/1/2020 at 10:56 am, Surveyor asked V19 Certified Nurse Aide (CNA) to remove R3's sock. Surveyor observed, R3's sock stuck to the bottom of R3's foot as V19 (CNA) was taking it off. R3's left foot was observed with dried, flaky, beige and brown loose stuck on thick skin falling out of R3's left footie, onto R3's right foot wound dressing, and on the bed linen. R3's left ankle, and lateral anterior foot was covered with patches of dried flaky stuck on skin, thick beige and brown skin spreading from the ankle to the top and bottoms of R3's foot and toes. R3's posterior left foot was observed with an open area that was covered with a yellow shiny covering the entire open area with a hardened dried beige raised area in the center. The open area was observed on the upper middle portion of the bottom R3's foot. The open area was just a little smaller than a nickel. R3 has another open area on the bottom of his left big toe. The area had a yellow shiny coat of fixed skin. The open area was the size of a green pea. R3 said, I had a bed bath on Friday but staff did not take my sock off or wash my left foot. V5 (Treatment Nurse) did my wound care for my right foot yesterday and she didn't look at or touch my left foot. I get a new bandage of my right foot and staff don't do anything else. It doesn't make me feel good when I don't get the care I need. I feel neglected. On 10/01/2020 at 11:06am, V18 (Nurse) said, I don't know how many wounds R3 has. On 10/01/2020 at 11:09 am and 1:43pm, V 5 (Treatment Nurse) said, R 3 has [MEDICAL CONDITION] with a right foot wound and a left abdominal surgical wound. R 3 don't have another wounds. R 3 is at risk for skin break down. I would say R3's left foot was not cleaned on his last shower day this week. I did not know R3 had a wound on his left foot. R3's feet should have been inspected twice a week by the nursing staff. On 10/01/2020 at 11:29 am, V4 (Wound Coordinator) said, I put ointment on R3's left foot on Sunday. This dried skin can't be removed. V4 rubbed a glove hand on R3's brown and beige patchy, flaky skin to demonstrate that the dried skin could not be removed. Surveyor observed, some of R3's flaky, patchy skin was being removed with V4 rub and falling off onto the linens. V4 said, R3 is not getting any treatments for this foot. Wound Care note dated 10/1/2020 documents: R3 is diagnosed with [REDACTED]. Slough tissue noted. Drainage noted. R3 has a diabetic ulcer on left great toe. Pink granulation with slough tissue noted. Drainage noted. Wound assessment dated [DATE] documents: R2 had a Braden score of sixteen which indicated R3 is at risk for skin break down based on comorbidities. R3 has a facility acquired diabetic ulcer on the left great toe with slough tissue present. Left great toe wound measurements were documented as length 1.00 centimeter (cm) x width 1.00 cm x depth 0.10cm. R3 also has a facility acquired diabetic ulcer on the left plantar with slough tissue present measurement were documented as length 1:50cm x width 1.50 cm and depth 0.00. Progress note dated 9/11/2020 and 9/23/2020 documents: R3 was given a bed bath, skin intact and no new skin issues. Wound Report dated 9/29/2020 did not document anything related to R3. Physician order [REDACTED]. Apply medi-honey wound/burn dressing paste to left foot and great toe every day related to type two diabetes. On 10/01/2020 at 2:19pm, V2 (Director of Nursing) said, I expect the nurses to follow the R3's individualized care plan as outlined and the guidelines for skin assessments. The guidelines are to complete body assessment with showers, looking for abnormalities or anything new on the skin and report to the nurse. The skin abnormalities should be documented in the progress note. The treatment nurse and doctor should be notified. Staff did not assess his foot on his last shower day. Skin Care Prevention Policy dated 11/03 revised 12/19: General: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline#3: All resident will be observed will be observed daily for changes in their skin condition.

Based on interviews, and record reviews, this facility failed to assess and report the acuity of the assessment to the physician to obtain orders for an x-ray of the left shoulder after a fall incident and new onset of pain for 1 of 3 residents (R5). This failure resulted in R5 continued complaints of pain and being assessed by the physician 2 days post before an x-ray was ordered with results of an acute complete fracture of distal left clavicle. Findings include: On 3/21/19 at 3:45pm, V5 LPN (licensed practical nurse) stated that V5 did not witness R5's fall out of wheelchair on 3/2/19 but heard R5 call out for help. V5 stated that R5 does not have any upper body strength, can't support self, if R5 leans forward in wheelchair R5 will fall. V5 stated that head to toe assessment was done, R5 complained of left shoulder pain after the incident and the following day. On 3/22/19 at 9:30am, V8 (attending physician) stated that V8 was informed R5 complained of shoulder hurting but wasn't clear on which shoulder was injured. V8 stated that V8 spoke with R5's nurse the following day regarding R5's arm. V8 stated R5 is using arm, it did not sound like a big deal. V8 stated that V8 assessed R5 on 3/4/19 and ordered x-ray of left shoulder, and narcotic pain medication. V8 stated that R5 refused to go to [MEDICAL TREATMENT] on 3/4/19 due to left shoulder pain. On 3/22/19 at 4:00pm, V7 LPN stated that R5 complained of left shoulder pain after the incident. V7 stated that V7 notified V8 (attending physician) regarding fall, and requested x-ray of left shoulder. V7 stated that V8 stated V8 would be in facility the following day to assess R5 and decide at that time if x-rays were needed. Review of R5's fall event, dated 3/2/19, notes at 5:28pm R5 was riding in motorized wheelchair in the hallway and was observed bending over and fell out of wheelchair. Assessment notes weakness to both upper extremities. R5 complained of pain to left shoulder. ROM (range of motion) painful. It also notes 'nothing relieves the pain'. R5's physician was notified, an x-ray was requested due to pain in left shoulder, orders received for INR (international normalized ratio) only. Review of R5's medical record notes the following: On 3/2/19 at 5:48pm, V5 LPN (licensed practical nurse) informed V7 (LPN) that R5 fell out of wheelchair. R5 stated tried to pick something off floor and lost balance and landed on left shoulder and left arm. R5 complained of left shoulder pain upon movement. V8 (attending physician) notified, asked if x-ray to be done, V8 stated get [MEDICATION NAME] time and INR (international normalized ratio) tomorrow and call results to V8, and V8 will then decide on x-ray of left shoulder and arm. On 3/3, R5 complained pain in left arm and shoulder. V8 stated V8 will be in facility to evaluate R5 tomorrow and assess whether R5 needs to have an x-ray done. On 3/4 at 3:43am, R5 refused to go to scheduled [MEDICAL TREATMENT] appointment. On 3/4 at 10:44am, V8's documentation notes R5 fell two nights ago and must have struck left shoulder because it hurts. It has continued to hurt since then. R5 did not go to [MEDICAL TREATMENT] today because of shoulder pain. On exam, R5's left lateral clavicle very tender. Left shoulder abduction (movement of arm away from body) is limited to 80 degrees. Right arm abduction extends to 90 degrees. On 3/4/19 at 2:00pm, STAT x-ray done, and results faxed over to V8. Review of R5's medical record, dated 3/4/19, notes R5 was seen by V8 (attending physician) with order to obtain x-ray of left arm, and shoulder STAT (emergently). R5 continued to complain of pain to left upper extremity. X-ray notes an acute complete fracture of distal left clavicle. V8 made aware with order for scheduled [MEDICATION NAME]/[MEDICATION NAME] (pain medication) and continue to monitor for pain. Review of R5's hospital medical records, dated 3/4/19, notes R5 arrived at hospital at 9:46pm. X-ray of R5's left shoulder notes vertical [MEDICAL CONDITION] third left clavicle.

Based on interview, and record review, the facility failed to ensure that fall interventions were implemented for one of three residents (R2) with history of multiple falls, reviewed for falls in a sample of 8 residents. This failure resulted in R2 falling from bed, sustaining an injury to forehead which required stitches at community hospital. Findings include: R2 is a [AGE] years old admitted to facility on 2/26/2016 with [DIAGNOSES REDACTED]. R2's mental status was severely impaired and required minimum assistance for all Activities of Daily Living Skills(ADLS) Fall incident report for R2 dated 3/16/2018 noted R2 fell in dining room from chair with no injuries. No fall preventive interventions documented. On 8/8/2018 at 6:30AM, R2 was found on right side on floor in room next to bed. She sustained a laceration to right side of the head. She was sent out to the community hospital and was kept overnight. No fall prevention interventions documented. On 10/26/2018 at 8:30 PM, R2 was found on left side on floor in room next to bed with laceration to left side of forehead. She was sent to Community hospital where she received stitches to forehead area. Interview with V8(Restorative Nurse) on 11/13/18 at 12:55 PM, I was not employed when the resident fell on [DATE] and 8/8/18. If the facility had put interventions in place after the 8/8/18 fall; resident may have not fell again. I implemented fall preventions after the fall of 10/26/18. Facility's policy on Falls dated 8/2014 documented,The facility will identify and evaluate those residents at risk for falls, plan for preventative strategies and facilitate as safe an environment as possible and, All resident falls shall be reviewed and the residents' existing plan of care shall be evaluated and modified as needed.

Based on observation, interview and record review, the facility failed to conduct a comprehensive assessment; develop and implement individualized interventions to attempt to stabilize and reduce the underlying risk factors; and failed to implement an individualized repositioning plan to promote healing. This resulted in the development of facility acquired pressure ulcers to: (1) R 15 an Unstageable pressure ulcer on the sacrum; (2) A Stage III pressure ulcer on R 1 ' s right buttocks; and (3) A sacral Stage II pressure ulcer on R 4 ' s sacrum. This applies to 3 of 3 residents (R 15, R 1 and R 4) reviewed for pressure ulcer in the sample of 25 residents. The findings include: (1) R15 admitted to facility on 7/16/2015 with multiple pressure ulcers to include a sacral stage 2 pressure ulcer 0.5 cm (centimeters) X 0.5 cm. This wound was healed 7/30/2015. . R15's 7/16/15, 7/23/15, 7/30/15, 8/06/15 and 8/25/15 Bradon scores were 13, only moderate risk for skin breakdown. R15's 7/22/2015 minimum data set assessment (MDS), include requires 2 person assist with bed mobility and total assist by staff with transfers, ambulation, hygiene, bathing and toileting. R15 is assessed with [REDACTED]. R15's 7/22/2015 Care Area Assessment (CAA), include R15 is at risk for skin breakdown, totally dependent for all areas of activities of daily living (ADL's) and is always incontinent of bladder and frequently incontinent of bowel. R15's 8/25/2015 wound progress note documents initial observation of an acquired unstagable 8.0 cm X 6.0 cm X 0 sacral pressure ulcer. E21's 8/25/2015 progress note of R15's sacral wound include: at 1:54 PM, upon observation, R15 observed to have an unstageable sacral wound, with a heavy amount of drainage but no odor. Bradon score reassessed at 13 (moderate risk for skin breakdown), due to comorbidities of cognition deficit, dementia, [MEDICAL CONDITION], muscle weakness, mixed hyperlipidemeia, hypertension and closed fracture. Facilities 8/25/2015 picture of R15's newly acquired sacral wound presents with boggy, necrotic soft adherent black colored thick tissue covering 100 percent of the wound opening and a heavy amount of purulent drainage. R15's care plan for skin breakdown, did not include any individual interventions to prevent acquired wounds and promote healing of existing pressure sores. On 02/10/2016 at 10:00 AM, E1 (Administrator) and E2 (Director of nurses) provided a document understanding the Kennedy terminal ulcer. This document include that the wound usually starts out as a blister or a stage two and can rapidly progress to a stage three or four. There is no documentation of any sacral skin changes between 7/31 - 8/25/2015 observation of the unstagable large necrotic sacral wound. During 02/10/2016, 11:00 AM interview, E21 (wound care coordinator), stated E21 would not call R15's stage 4 sacral wound as a Kennedy Terminal Ulcer. E21 also stated R15 required at least every two hour repositioning and incontinence care. During 02/11/2016 1:00 PM telephone interview, Z1 (wound care physician), stated when Z1 first observed R15's sacral wound (8/26/2015), Z1 felt the wound was unstageable due to 90% dark yellow slough covering the wound base. Z1 said R15 's sacral wound is most likely due to lower extremity contractures causing increased pressure on sacrum. Z1 does not want to call R15's 8/25/2015 acquired sacral pressure ulcer a Kennedy terminal ulcer. Z1 stated R15 would benefit from more frequent position changes (more than every two hours). On 02/08/2016 at 12:42 PM, 02/09/2016 at 9:30 AM, 10:15 AM and 2:10 PM and 02/11/2016 at 10:14 AM R15 observed wearing a disposable incontinence brief and lying on top of a thick incontinence pad that was between R15's skin and the low air loss mattress. On 02/11/2016 at 10:14 AM, R15 observed in bed with bilateral lower extremity flexion contractures of knees and hips. R15's inner knees were touching together without padding. R15 has a history of left inner knee skin break down (7/16 - 7/30/15). R15's head of bed was elevated to a 45 degree angle, causing increased pressure on sacral wound. R15 also observed with a wet incontinence brief in place. On 02/11/2016 at 10:20 AM, E6 (nurse aid), observed to change R15's urine soaked incontinence brief without cleansing the entire perineum and buttocks with soap and water prior to applying another incontinence brief. E6 only used a water wet towel and wiped off the supra perineum and buttocks but not inside his groin area. While E6 turned R15 in bed, the lower half of R15's sacral wound dressing observed with large amounts of serous drainage soaked through the dressing. (2) On February 8, 2016 at 8:20 AM, R 4 was sitting in the dining room with a trunk restraint (lap belt); at 9:00 AM R 4 breakfast tray was served; at 11:00 AM an activity program was started (sit and fit) R 4 was noted to be sleeping at this time. At 12:30 PM, R 4 ' s lunch tray was served at 1:30 PM. R 4 was not repositioned or taken to the toilet from 8:20 AM through 1:30 PM. On February 09, 2016 at 8:20 AM, R 4 was sitting on a wheelchair in the dining room with a trunk restraint and a chair alarm. At 8:45 AM, R 4 ' s breakfast tray was served followed by activities at 10:20 AM in which R 4 was not actively participating. R 4 stayed in the dining room from 8:20 AM through 12:35 PM without being repositioned or toileted. On February 09, 2016 at 12:45 PM during treatment observation with E 21 and E 22 (Treatment Nurses) showed R 4 pressure ulcer on the sacrum and explained this area was noted at Stage II acquired in the facility. E 22 measured the wound at 1.0 cm X 0.5 cm. On February 03, 2016 R 4 wound assessment details report showed this wound was only 0.30 cm in length X 0.3 cm in width and with 0.2 cm depth. The wound assessment details report dated February 03, 2016 this wound was measured at 0.30 cm in length X 0.3 cm in width and with 0.2 cm depth. At 2:09 PM, E 22 explained that the facility has no comprehensive assessment to analyze whether this pressure ulcer was avoidable or unavoidable. E 22 said the facility comprehensive assessment is the wound doctor ' s weekly note (wound assessment details report). R 4 ' s quarterly Minimum Data Set with Assessment Reference Date of January 02, 2016 showed R 4 has severe impairment in cognition (scored at 3) and needs extensive assistance with one physical assist for activities of daily living. On February 9, 2016 at 9:23 AM E 14 (Certified Nursing Assistant/Restorative Aide) described R 4 as confused, will cry occasionally to get attention especially if she needs to go to the bathroom. E 14 stated, No, she (R 4) is unable to reposition herself when in chair or in bed. R 4 ' s pressure ulcer plan of care dated January 17, 2016 to reposition R 4 every two hours was not followed on February 8, 2016 from 8:20 AM through 1:30 PM and on February 9, 2016 from 8:20 AM through 12:35 PM. 3) R1's Face Sheet documents R1 was admitted on [DATE] with the following [DIAGNOSES REDACTED]. On 2/8/2016 starting at 8:15 AM during the initial tour R1, obese and laying on an low air loss mattress. R1 was alert and oriented to person, place and time. R1's heels were not elevated, there were flat on the bed with no heel protectors on them. On 2/9/2016 at 9:48 AM, E24 (CNA) and E25 (CNA) transferred R1 from bed to chair using a mechanical lift. E24 (CNA) said R1 is incontinent of bowel and bladder and is dependent on staff for transfers and personal care. Braden Risk Assessment History was reviewed from 4/5/2015 through 1/4/2016. All 10 assessments dated (4/5/2015, 4/19/2015, 4/26/2015, 7/28/2015, 10/5/2015, 12/02/2015, 12/09/2015, 12/16/2015, 12/23/2015 and 1/4/2016) rate R1 at risk for pressure ulcer development. In these assessments problems noted were chairfast activity and very limited mobility. Potential problems were friction and shearing, occasionally moist and limited sensory ability. The Risk Assessments rates did not change in any of the assessments. Wound Assessment Detail Reports were reviewed from 12/2/2015 through 12/22/2015. The reports document R1 acquired an unstageable right buttock pressure ulcer on 12/2/2015 measuring 2.5 cm in length by 2.0 cm in width an undetermined depth and on 12/3/2015 (the following day) the pressure ulcer was classified as a healing stage 3 right buttock pressure ulcer. The Notes also document that the stage 3 right buttock pressure ulcer healed on 12/22/2015; 20 days after the initial breakdown. The Notes contained no documentation of a decline in R1's clinical condition during the time of the pressure ulcer development. On 2/10/2016 at 11:50 PM, E21(Wound Care Nurse Coordinator) and E22(Wound Care Nurse) both said the comprehensive assessments consist of Braden Scales and measurements for development of pressure ulcers. E21 and E22 said they do not do tissue tolerance test for residents and they do not implement interventions for residents at risk for pressure ulcers. Neither E21 or E22 could answer how they manage R1's tissue load without doing tissue tolerance testing and they could not answer if the pressure was avoidable. E21 said the facility discovered R1's pressure ulcer on 12/2/2015. E21 and E22 had no explanation for why R1's right buttock pressure ulcer was discovered at unstageable/stage 3 and R1 is dependent on staff for incontinent care. E21 and E22 said R1 did not see the wound care physician because R1's stage 3 right buttock pressure ulcer healed on 12/22/2015 within 20 days. On 2/11/2016 at 8:52 AM, R1 was laying in bed. Both of R1's feet were flat on the bed, no offloading and no heel protectors. R1 said they do not elevate my feet unless they are swollen, I would not mind it someone elevated them. R1 said I do not remember much about when the pressure ulcer developed, I remember a itching and burning sensation for a while to my buttock area. R1 said after a while R1 told someone about the itching and burning and they treated the pressure ulcer. R1 did not know why it was not discovered until it was a stage 3, R1 said I can not use the bathroom with out help, they should be checking my skin in the back. On 2/11/2016 at 10:00 AM, E24(CNA) said she is familiar with R1. E24 said R1 is incontinent and dependent on staff for personal care. E24 said she did not work with R1 during the month of December but an unstageable/ stage 3 buttock pressure ulcer should have been discovered before it got that size it the staff were doing the skin assessments on R1's skin. On 2/11/2016 at 12:48 PM, E24(CNA) said she was familiar with R1 and had worked with R1 during the month of December 2015. E24(CNA) said R1 is dependent on staff for care and can not move without staff. E24 said a stage 3 right buttock pressure ulcer should have been discovered before it reached a stage 3, R1 is total care dependent on staff and doesn't walk. Alteration in Skin Integrity Care Plan initiated on 12/2/2015 does not address tissue tolerance or interventions for decreased sensory ability. There is no intervention or physician order [REDACTED]. There was no avoidable/unavoidable assessment. Skin Risk Assessment Policy dated 11/03 states, To identify residents with potential risk for impairment of skin integrity and ensure that the proper measures are instituted based on the residents condition. A care plan is then developed based on the residents identified risk factors. Facility Policy: Management of Wounds undated does not address tissue tolerance test for managing tissue loads or avoidable/non avoidable assessments.

Based upon observation, interview and record review the facility failed to implement fall prevention interventions to reduce/prevent the risk of falls and/or injury for 2 of 4 resident reviewed for fall preventions, the facility also failed to follow their fall prevention policy and conduct fall risk assessments for 2 of 4 residents reviewed for fall risk assessments post fall. Theses failures resulted in R3 being involved in a fall incident and and being taken to the hospital and treated for [REDACTED]. Findings include; R3's [DIAGNOSES REDACTED]. Incident report (12/5/15) denotes that R3 was observed on the floor at bedside with laceration to the back of her head. R3 was subsequently transferred to the hospital for evaluation and admitted with subdural hematoma. Per electronic fall events R3 sustained a total of seven (7) falls in the past 4 months. R3's fall risk care plan includes but not limited to the following; Interventions: (9/1/15) Sensory alarm provided for safety. (10/19/15) Brand name/non-skid pad to wheelchair staff to ensure that pad is in her wheelchair at all times. (12/8/15) Low bed with floor mat. On 12/29/15 at 2:35pm, R3's room was observed there were no floor mats in place. Surveyor inquired about R3's fall prevention interventions post recent fall, E3 (CNA/Certified Nursing Assistant) responded I wasn't aware that she fell cause I don't work this side. She's an assist. Surveyor inquired if R3's floor mats were in place while in bed, E3 responded Floor mats? No. At approximately 2:40pm, R3 was in a wheelchair, there was no alarm in place. Surveyor inquired about R3's alarm, E2 (Assistant Director of Nursing) stated Let me look in back. E2 proceeded to search behind R3's wheelchair and was unable to locate an alarm. Surveyor inquired if R3 uses an alarm while up in the wheelchair, R3 responded Alarm on the chair? No. It's on my bed. Surveyor inquired about R3's (Brand Name) non-skid pad to wheelchair E2 assisted R3 to stand and stated You don't have a (Brand Name) on. R4's [DIAGNOSES REDACTED]. Incident report (11/25/15) denotes that R4 was about on the floor with a superficial abrasion atop of the left hand. X-ray affirmed rib fracture(s). R4's fall risk care plan includes but not limited to the following; Interventions: (3/19/15) Encourage and assist as needed to wear non-slip footwear. (3/24/15) Sensory alarm while in wheelchair and bed. Resident continues to remove sensory alarm from her wheelchair despite redirection. (11/28/15) Sensory alarm reissued, resident encouraged to use alarm at all times for safety. On 12/29/15 at 2:51pm, surveyor inquired about R4's fall prevention interventions, E2 responded I'll have to look in the records. R4 was lying in bed there was no alarm in place. During inquiries regarding the alarm, R4 responded Bathroom. E2 proceeded to search for R4's alarm on the bed, wheelchair, in the top dresser drawer and the bathroom to no avail. R4's feet were unclothed, E2 stated She's got shoes right here. Surveyor inquired about R4's fall prevention interventions, E5 (CNA) responded As far as the fall, I can't really say but I can tell right now she's a fall risk. So I keep her bed lower to the ground. Surveyor inquired about an alarm in use for R4, E5 stated Not at the moment. I haven t seen any alarms. Surveyor inquired about R4's non-slip footwear, E5 responded I keep shoes on her whenever transporting her. When we get her up we put her shoes on. Surveyor inquired if R4 gets out of bed without assistance, E5 stated She'll try. E5 searched R4's dresser drawers and presented one pair of white socks. Surveyor inquired if R4's socks were non-slip, E5 replied No ma am. Surveyor inquired if the facility had non-skid socks available, E5 responded We have non-skid socks. Surveyor inquired if white socks (without non-skid) were appropriate attire for R4, E5 stated Yeah. R2's fall events were documented on 12/26/15 and 12/27/15, fall risk assessments were not conducted post fall(s). R4's fall risk assessment was not conducted post 11/25/15 fall. On 12/31/15 at approximately 10:20am, E9 (Care Plan Nurse) affirmed that E7 (Fall Nurse) is responsible for conducting fall risk assessments. The facility's fall prevention policy and procedure (revised 7/14) includes but not limited to; This facility is committed to maximizing each resident's physical, mental and psychosocial well being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident's falls shall be reviewed and the resident's existing plan of care shall be evaluated and modified as needed. A fall risk will be completed on admission re-admission and quarterly with each significant change and after each fall. Residents at fall risk will be identified for staff awareness. Residents at risk will have fall risk identified on the interim plan of care with interventions implemented to minimize fall risk.

Based on interview and record review the facility failed to follow the falls policy and implement appropriate interventions to prevent falls for 2 out of 3 residents (R1 and R3) reviewed for falls in a total sample of 8. This failure resulted in R1 falling on 1/24/14 and sustaining a fracture to the left hand, and falling on 1/27/14 and sustaining a fracture to the left hip. Findings Include: 1. The face sheet documents that R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission Falls Risk Assessment documents that R1 was at risk for falls and the resident was placed on the falls prevention program. The Occurrence Report dated 1/4/14 at 10:30pm documents that R1stood up from the wheel chair quickly and the resident lost balance resulting in a fall. There were no documented injuries, the care plan was updated on 1/7/14 and a self-releasing belt with alarm was implemented for the resident while sitting in the wheelchair. The Occurrence Report dated 1/24/14 at 3:57am documents that the nurse on duty was in another resident's room during rounds when she heard the belt alarm beeping and found R1 sitting on the floor next to the wheelchair. On 2/18/14 at 3:45pm E7 (nurse) stated in part that the belt is used to make the resident aware when trying to get up, and if the resident tries to get up the belt alarms. This night the resident was a little anxious and sitting in the wheelchair with the belt on. E7 was in another room and heard the belt alarm. When E7 got to the resident, R1 was sitting on the floor. The Progress Note dated 1/24/14 documents that at 10:00am the resident was observed with swelling to the left hand and wrist. An x-ray was done and showed a fracture to the 5th finger and R1 was sent to the local hospital for evaluation and treatment. The Progress Note dated 1/25/14 documents that R1 returned to the facility with a splint to the left hand and arm. The care plan documents that on 1/24/14 a rolling belt was implemented and was to be placed on the resident while sitting in the wheelchair. The Occurrence Report dated 1/27/14 documents that R1 was observed lying on the floor on the left side with complaints of left leg pain. The MD was notified and R1 was transferred to the local hospital and diagnosed with [REDACTED]. On 2/18/14 at 3:50pm E8 (nurse) stated in part that R1 sits at the nurse's station because she's high risk for falls so that staff can monitor the resident. E8 stepped away from the nurse's station and when she came back to sit down she heard a thump and the resident was on the floor. The resident had a roll belt on with no alarm. Prior to this fall the resident had an alarm but this night it was not on. The progress notes dated 1/24/14 documents that R1 was placed on hourly monitoring for fall prevention. The progress notes dated 1/26 and 1/27/14 documents that R1 was non-compliant with interventions due to Alzheimer's disease and R1 was observed removing the self-release belt and the rolling belt. There were no new interventions in place to address this behavior. 2. The face sheet documents that R3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The care plan dated 12/22/13 documents that R3 should have a sensory pad alarm. On 2/13/14 at 12:00pm R3 was observed lying in bed with a sensory pad alarm that was unplugged and not turned on. On 2/13/14 at 12:05pm E4 (ADON) stated "it should be plugged in". The Fall Program Policy documents that after a fall a root cause analysis should be done and a care plan update should be completed immediately. Staff should review, evaluate and apply specific and additional fall interventions noted on the care plan.

Based on interview and record review, the facility failed to accurately reinsert a [MEDICAL CONDITION] tube and failed to obtain a physician order [REDACTED]. These failures resulted in stomach swelling, extensive gas and contrast material in the subcutaneous tissues associated with migrated [MEDICAL CONDITION] tube, abnormal labs, and hospitalization . Findings Include: R4 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. POS (Physician order [REDACTED]. The [MEDICAL CONDITION] tube is described as being a 18 french with 15 cc size balloon. Nurses notes dated 10/16/12 at 6:00 AM indicates that the [MEDICAL CONDITION] tube ([DEVICE]) replaced by E16 (Nurse Supervisor/Licensed Practical Nurse) g - tube size 18 french. Placement was verified by [MEDICAL CONDITION] contents and per auscultation. [MEDICAL CONDITION] tube feeding resumed. Review of the October 2012 POS (Physician order [REDACTED]. On 10/16/12 at 5:45 PM, nurse's notes describe R4 as being diaphoretic, lethargic but responsive. The [MEDICAL CONDITION] tube feeding is infusing at 50 cc's per hour. Resident is also of short of breath. The nurse's note further describes R4's LUQ (Left Upper Quadrant), LLQ (Left lower Quadrant) of the abdomen to be swollen; also swelling of the LUE (Left Upper Extremity). Z4 (Physician) was notified. Orders included to send out to the hospital for an exam. R4 was admitted to the hospital with [REDACTED]. Review of hospital records show a discharge Summary dated 10/26/12 which indicates that R1 was found to have a migrated [DEVICE]. physician progress notes [REDACTED]. physician progress notes [REDACTED]. Extensive gas and contrast material in subcutaneous tissue consistent with misplaced [DEVICE] and subsequent feedings. Interview with Z4 (Physician) on 1/31/12 at 1:00 PM, " I was not notified of the [MEDICAL CONDITION] tube being out and replaced with one in the facility. In my opinion, once it was discovered that the [MEDICAL CONDITION] tube was out; the resident should be evaluated by a [MEDICATION NAME] for accurate assessment and tube replacement. If notified, I would have ordered that the resident be sent out to the hospital; not to reinsert the [MEDICAL CONDITION] tube in the facility. Perhaps the placement was not accurate; KUB (Kidneys Ureters Bladder) X-Ray is the most accurate test to determine placement. " Interview with E16 on 1/31/13 at 1:30 PM, " I examined R4 and noted that the tip of the [MEDICAL CONDITION] tube was not in the stoma; the bulb was deflated. I clipped the sutures that anchored the bumper to the stomach followed by inserting a [DEVICE] size 18 french. I checked the placement by air/auscultation followed by aspiration of stomach contents. I did not resume the feeding; R4 was without distress. " Nurse's notes dated 10/16/12, from 6:00 AM thru 5:45 PM documents that the [MEDICAL CONDITION] tube feeding was infusing. There is no documentation that the physician was notified of the problem with the [DEVICE] or its reinsertion. Review of facility policy regarding gastrostomy tube replacement states that "a gastrostomy tube can only be replaced with a physician or nurse practitioner order". It further states that "after placement of the [MEDICAL CONDITION] tube, staff should communicate with the physician". The policy does not require [MEDICAL CONDITION] tube placement confirmation by KUB .

Based on interview and record review, the facility failed to implement elopement risk prevention involving 1 of 3 residents (R4) reviewed for accidents/supervision of a sample of 10 residents. This failure resulted in R4 exiting from the window resulting in a fall of 14 feet and sustaining a fractured right wrist. Findings include: R4 is a [AGE] year old admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. At the time of admission, R4 was determined to be at risk for falls and elopement. R4 was placed on the dementia unit which is a secured unit. Review of nurses notes indicates the following: 1. 10-18-11 8:00 AM-resident attempted to elope times two. Elopement guard wrist device not present. Notified DON (Director of Nursing), unit manager and nurse supervisor. All parties made aware. Endorse to 3-11 shift to monitor. 2. 10-19-11 8:00 AM-up ambulating the hall. Will continue to monitor. 3. 10-23-11 3:55 PM-resident attempted to get on elevator to go down stairs. Stated she wanted to ride the elevator and go up and down for a ride. She was redirected and went back to her room. Staff will continue to monitor. 4. 10-23-11 10:45 PM-said writer(E7) was informed by the CNA(Certified Nurses Aide) that one of the employee's husband came to the door and stated that R4 had jumped out the window and once outside, found R4 lying in the bushes. R4 was alert and oriented, no complaint of pain or in distress. R4 stated she was trying to go to the store. 911 was called. R4 was taken to the local hospital and was diagnosed with [REDACTED]. careplan review indicated that R4 was at risk for falls and elopement. R4 never previously attempted to elope from the window. R4 resided in room 219. R4's fall was 14 feet from window to ground (landed in bushes). The window that R4 exited from had two safety features: flip lock and a screw that was supposed to be drilled into the lower frame to prevent the window from opening wider than an estimated 8 inches. The screw in the window frame is a safety intervention on the dementia unit used to reduce the risk of possible elopement by way of the window. the window opens from left to right which may be at 3 feet in the total open position. R4 was able to climb up on a chair, open the window (was found to be open at 18 inches), push out the screen and jump out from the window, landing in the bushes. there is no evidence to indicate if perhaps another resident opened the window for R4. Review of the local police department report dated 10-23-11 at 10:43 PM indicates the following: the window is supposed to have a special screw to prevent the window from opening too far. The screw for R4's window was missing. It is unknown if R4 removed it or if it was previously missing. R4 is a petite woman and did not need to open the window very much to fit through. Evidence indicates that at the time of R4's exit from the window, the screw was not secured to prevent the window from opening 8 inches. Review of a monitoring form dated 10-23-11 indicates that R4 was visually monitored every hour but does not include checking the window for security. Interview with E6 (Licensed Practical Nurse) on 2-23-12 at 12:30 PM stated that all residents at high risk for elopement are monitored every hour. Interview with E7(Dementia Unit Coordinator) on 2-23-12 at 11:30 AM stated that monitoring of the high risk elopement residents does not include checking the security of the windows, only a visual of the resident and that R4 was monitored hourly on 10-23-11. Interview with E5 (Maintenance Director) on 2-23-12 at 12:30 PM stated that the screws are secured into the frame of the window on the dementia unit to prevent the windows from opening no more than 8 inches. E5 also stated that the screws can only be removed by a screw driver. E5 also stated that in October of 2011, the checking of the windows was only twice weekly. E5 also stated that the window was discovered to have been opened at about 18 inches on the time after R4's exit from the window. Interview with E1(Administrator) on 2-23-12 at 3:00 PM stated that he was not the administrator at the time of the incident, but the maintenance department duties now include documenting all window checks for proper locking capabilities including screw placement. Policy review regarding falls and elopement indicates the following: the facility is to act in a proactive manner to identify and assess those residents at risk for falls/elopements and plan for preventive strategies and facilitate as safe an environment as possible and that all high risk elopement residents are to be monitored every hour. Review of the facility elopement policy does not indicate that the windows are to be checked hourly or any mention of window security.

Based on interview and record review the facility failed to properly transfer 1of 5 residents (R19) at risk for falls in a sample of 27. This failure resulted in R19 sustaining a fracture to her left proximal fibula. The findings include: R19 is a [AGE] year old female resident with [DIAGNOSES REDACTED]. Nursing note dated 11/19/2011 at 8 pm documents the following: " This writer was notified by CNA, (Certified Nurse Aide) that pt (patient) is complaining of left leg pain and left foot. Writer checked the patient, and patient is able to move left lower leg and left foot but with pain. Left leg is also noted swollen, notified MD (physician) of patients complaints of pain and accompanying symptoms. MD ordered X-ray of left lower leg and left foot. " Nursing note dated 11/20/2011 at 1:30 pm documents: " admitted to (local hospital), admitting [DIAGNOSES REDACTED]. X-ray report dated 2/21/2011 documents, " Proximal fibula fracture " . Interview with E1, Administrator, E2, ADON (Assistant Director of Nursing), and Z2, Corporate Nurse on 3/10/11 at 3:40 pm stated, " The investigation could not substantiate that any abuse had occurred but two CNA ' s were terminated for improperly transferring R19. " E2 further stated, " R19 was a 2 person assist for transfers before this incident and now she is a mechanical lift. " E1 provided a copy of E18 ' s, (CNA) employee report dated 11/22/10 documents the following, " Resident in room 122-a sustained a fracture of the left lower leg due to staff failure to use proper lift as noted in patients record and in the room. Failure of an employee to follow the reasonable instructions of her/his supervisor - Discharge. "