Every finding on record at Pearl of Hinsdale, The

Based on observation, interview, and record review, the facility failed to safely transfer and reposition dependent residents. This failure resulted in R3 sustaining ongoing discomfort and pain to the right upper extremity with a possible right shoulder subluxation and/or right humerus fracture and a hematoma on her forehead.This applies to 2 of 4 residents (R3 and R7) reviewed for accidents.The findings include:1. R3's EMR (Electronic Medical Record) said she had multiple diagnoses including hemiplegia and hemiparesis affecting her right dominant side following a cerebral infarction, disorders of the musculoskeletal system and bone density, and history of falls. R3's mechanical lift care plan (created 2/3/2026) showed she required the use of a full-body mechanical lift with 2-staff assistance for her transfers with a goal for R1 to be transferred without injury. Interventions (also initiated 2/3/2026) included Use at least two trained staff members during mechanical lift transfers, per protocol, and Avoid placing pressure or strain on the affected (right lower) extremity during transfer. Support limb as needed.On 7/21/2026 at 10:55 AM, R3 was in bed and had bruising on the right side of her forehead and appeared to be in discomfort as she grimaced and guarded her right arm. R3's arm sling was on her bedside table. R3 was unable to provide details regarding her injuries and accident on 7/02/2026 (19 days earlier).R3's incident report dated 7/02/2026 said at 9:45 PM, V23 (Registered Nurse/RN) heard sudden yelp from another room. Went to check and observed resident on bed with [Certified Nursing Assistant/CNA-V10] on bedside. The Resident complaint that her head bump on the TV while transferring and her right wrist and arm hurts. Per Resident she was transferred by the CNA [V10] by herself which resulted to her head bump on the TV.On 7/21/2026 and 7/22/2026, V10 (Agency CNA) was contacted but was not available for an interview. V10's interview statement document showed she reported having transferred R3 from the wheelchair to the bed using a gait belt. The statement showed V10 reported that she instructed the resident to hold onto her with the resident's left arm during the transfer and in the process, her head accidentally made contact with the hanging television.On 7/22/2026 at 1:15 PM, V23 (RN) said R3 reported that V10 had transferred her from her wheelchair to the bed by herself, and during the transfer she was injured by the overhead television. V23 said R3 required the use of a total mechanical lift with 2-staff assistance for transfers. V23 continued to say R3 sustained a bruise to the right side of her forehead and the following morning reported acute pain in her right arm and left foot. V23 said she notified the physician and received orders for X-rays. R3's 1/19/2026 care plan showed R3 already had existing pain due to a history of a displaced tri-malleolar fracture (fractures of three different bones) of her left ankle (the side not affected by her stroke).On 7/22/2026 at 12:55 PM, V3 (Assistant Director of Nursing/ADON) said he investigated R3's incident and determined that V10 failed to safely transfer R3 as indicated in her plan of care, resulting in her sustaining an injury. R3's progress note dated 7/05/2026 at 2:16 PM said Pt. still c/o right arm pain, refusing to be touched by staff. Arm slightly swollen than usual. [Family Member] is in facility insisted to send patient to [Hospital] ER due to pain to be evaluated and treated.On 7/21/2026 at 3 PM, V2 (Director of Nursing/DON) said R3's portable x-rays done on 7/03/2026 did not show any acute injury to her right arm and left foot. V2 stated an X-ray of R3's shoulder, however, was not conducted in the facility on 7/3/2026. V2 said that R3 continued to complain of right arm pain, and after her family's request, she was sent to the hospital for a further evaluation on 7/05/2026. V2 said R3 had additional X-rays done to her right arm, including her shoulder, which showed a possible fracture to her right humerus. V2 said R3 returned from the hospital's emergency room that same day with orders to follow up with an orthopedic specialist. R3's emergency room (ER) Discharge summary dated [DATE] showed her right shoulder X-ray Impression as Severe osteopenia of proximal right humerus. A nondisplaced fracture of the proximal right humerus cannot be excluded as described. R3's ER right shoulder x-ray report noted patient was unable to move right arm for routine positioning. The Findings section showed subtle break in the cortex may be present along the neck of the right humerus by the greater tuberosity ad possibly in the head of the right humerus at the articulation with the bony glenoid. R3's ER imaging also listed a scalp hematoma superficial to the right frontal bone.R3's telehealth provider note dated 7/06/2026 said R3 had an ER visit and there was a possible nondisplaced fracture of the right humerus and an immobilizer was provided. The note said R3 was to follow with an orthopedic specialist.R3's Orthopedic consultation with V5 (Orthopedic Specialist/Surgeon) note dated 7/07/2026 maintained the fracture diagnosis and showed R3 reported She was being transferred with only 1 assist and patient feels like the nurse pulled her harder than usual.she continues to have discomfort in the right shoulder. The patient does have a history of stroke with right-sided paralysis. V5 noted X-rays of the entire right upper extremity were obtained at outside hospital and reviewed in clinic today by me, which demonstrate severe osteopenia throughout the right upper extremity. There is a possible nondisplaced greater tuberosity fracture of the right proximal humerus. On 7/22/2026, V5 was contacted but was not available for an interview.On 7/21/20226 at 3 PM, V2 continued and said R3 was seen by V5 (Orthopedic Surgeon) on 7/07/2026, where she was evaluated for her right arm pain and again diagnosed with a right humerus fracture. V2 stated the facility believed R3's diagnosis was incorrect and they consulted V4 (Physiatrist). V2 said V4 ordered repeat portable X-rays at the facility on 7/07/2026, which resulted on 7/08/2026. V2 stated R3's in-house X-ray showed R3 had a fracture but the fracture was not new. V2 said the facility did not contact V5 (Orthopedic Specialist) to discuss R3's plan of care but had a follow-up planned with V5 later for management of her right shoulder. V2 said she had also reviewed R3's EMR and was unable to locate any documented consultation visit from V4 (Physiatrist) after R3's incident.The results from R3's right shoulder X-ray performed in the facility on 7/7/2026 showed old fracture deformity of the greater tuberosity and possible subluxation of the humeral head with no evidence of recent fracture or dislocation. Clinical correlation is requested. R3's fracture care plan showed she has a nondisplaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing and was created on 7/9/2026. The care plan's goal was for R3 to report pain of less than 4 out of 10 after analgesic administration. Interventions (also created on 7/9/2026) showed to use a sling and to avoid rotation of her arm.On 7/22/2026 at 11:35 AM, V4 (Physiatrist) said he was unsure if R3's arm was pulled when she was transferred on 7/02/2026. V4 said R3 had a recent stroke and had developed subluxation of her right arm, and he was managing her pain. V4 said he reviewed R3's medical records and felt her right shoulder fracture was not acute and believed her pain was chronic. V4 said he did not have a peer-to-peer discussion with V5 (Orthopedic Surgeon) to review R3's right shoulder fracture diagnosis and pain. The facility's Initial 24-hour Notification for R3's 7/5/2026 incident (with report date 7/21/2026) showed Resident experienced a fall with concern for serious injury and was transferred for evaluation. A non-displaced fracture of the right proximal humerus was identified.The facility policy titled Free of Accidents Hazards/Supervision/Devices and Reporting of Accidents and Incidents dated 3/01/2026 said it was the facility's policy to ensure it identifies and provides needed care and services that are resident-centered, in accordance with the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. The facility will identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent accidents.2. R7's care plan said she was dependent on staff for her care, including mobility, and was at risk for falls.On 7/22/2026 at 9:45 AM, V8 (CNA) was rendering incontinence care to R7 in bed by herself. R7 was severely cognitively impaired and had splints on both hands. V8 was having difficulty redirecting R7 to safely remain positioned in bed when she turned her on her side (away from her) to change her brief. Then at 10:25 AM, V27 came to R7's bedside to assist V8 with her care. V27 said she routinely cared for R7, and she was dependent on all her care needs. V27 said she also had poor trunk control and, for her safety with positioning, required the assistance of 2 staff. R7 was not interviewable and unable to provide details regarding her witnessed fall on 7/15/2026.R7's witnessed fall incident report dated 7/15/2026 said that at 4:46 PM, she was sitting in her geriatric reclining wheelchair in the dining room when V28 (CNA) attempted to reposition and fell. The report said, Nursing Aide attempted to reposition patient in chair for dinner, met with resistance from resident chair when attempting to lower head of chair. Head of chair began moving forward and patient slid out of chair.On 7/22/2026 at 11:30 AM, V28 said she noticed R7 was sliding off her chair and there was no additional staff available to assist her with repositioning R7. V28 said she attempted to recline the chair back, but the head of the chair bounced forward, causing R7 to slide off her chair. V28 said she received education on how to use a geriatric wheelchair and obtaining additional assistance when repositioning R7.On 7/22/2026 at 12:20 PM, V13 (Restorative Nurse) said the facility's traffic light guide system was to ensure residents were being transferred safely as indicated in their plan of care. V13 said that when staff were to assist a dependent resident with mobility and repositioning, they were to provide 2-person assistance to ensure their safety, including for R7.

Based on observation, interview and record review, the facility failed to follow the menu spreadsheet to serve portion sizes as shown for the pureed diets and failed to serve mechanical soft consistency foods as shown on the menu spreadsheet and recipe. This applies to 10 of 10 residents (R12, R13, R60, R73, R81, R84, R85, R91, R173, R174) reviewed for mechanically altered diets in the sample of 34. The findings include: Facility week at a glance menu for Monday January 5, 2026, lunch meal, included chicken Fajita with peppers and onions, refried beans, mixed vegetables and Spanish rice. On January 5, 2026, at 11:43 AM, during lunch meal observations, V8 (Cook), was platting the food. 1. Menu spreadsheet for the above menu for pureed diets showed to serve pureed Fajita chicken with #10 scoop, pureed peppers and onions #8 scoop, pureed bread #16 scoop, pureed carrots #8 scoop, 4 oz seasoned cream of rice. Facility scoop equivalents showed that #12= 3-1/4 oz/ounces, #10 =3-3/4 oz, #8 = 4 oz and #16 =2-3/4 oz. V8 used #12 scoop to serve pureed chicken and pureed rice respectively and #8 scoop of pureed refried beans. V8 stated that the facility does not have a #10 scoop so he will use a heaped #12 scoop to serve the pureed chicken and the pureed rice respectively. V8 stated that he did not prepare the pureed tortilla. R12, R60, R73 and R81 received a heaped #12 scoop of pureed chicken and pureed rice respectively and a #8 scoop of refried beans. 2. Menu spreadsheets for above menu for mechanical soft diets included to serve course ground chicken fajita (#10 scoop) with ground peppers and onions (#8 scoop) on bread. The ground chicken with diced green peppers and onion mixture prepared and served for the mechanical soft diet, had large pieces of onions that were between 2 -3 inches long and appeared crunchy. This mixture was placed on a tortilla and served to the residents on mechanical soft diets along with sides of Spanish rice and black beans. R13, R84, R85, R91, R173 and R174 received the same. On January 5, 2025, at 11:59 AM, on request, V9 (Regional Director of Operation) provided the recipe of mechanical soft Chicken Fajita with Peppers and Onions. Recipe for the same included to follow the process shown on extension and production sheet for modified consistency diets. For the Ground consistency, the same recipe showed to process the number of servings of prepared Chicken Fajita with Peppers and Onions servings in a food processor until even ground texture is achieved with no pieces larger than 1/8 inch. On January 5, 2025, at 12:02 PM, V9 agreed that the onions that were in the ground chicken mixture for mechanical soft diets should have been less than 1/8th inch. When asked if residents on mechanical soft diets could have tortillas, V9 stated that tortillas are soft and that she would consider it odd to serve the chicken mixture on bread. V9 was requested to provide the facility policy for foods allowed for mechanical soft diets. Facility policy and procedure for Mechanical Soft Diet taken from 2025 edition of Diet Manual included as follows: The mechanical soft diet consists of foods that are in easy to chew form. The mechanical soft diet is indicated for residents with chewing difficulty, teeth loss, poor fitting dentures, mouth pain, or residents that require extensive time to complete a meal. Regular diet items should be mechanically altered, chopped or ground, so that it can be consumed by a resident with chewing difficulty. Food Characteristics included: Can be mashed/broken down with pressure from fork, spoon or chopsticks, bite size pieces (1/2 inch or less). Vegetables allowed: Vegetables that are cooked to a fork tender and mash able texture (no larger than 1/2-inch pieces). Starches: Foods to avoid included tortillas. On January 7, 2026, at 11:39 AM, V10 (Dietitian) stated that the facility should have followed the recipe to serve mechanical soft consistency chicken fajita with vegetables and foods allowed per policy. V10 stated that the scoop sizes for pureed diets should have been followed to provide adequate portions and nutrients for the meal. Facility Diet Order listing printed on January 5, 2026, included that R12, R60, R73 and R81 were on pureed diet and that R13, R84, R85, R91, R173 and R174 were on mechanical soft diet.

Based on observation, interview and record review, the facility failed to implement its policy regarding the management and care of PICC (Peripherally Inserted Central Catheter) lines, including measurement of arm circumference and ensuring that PICC insertion sites were assessed and monitored every shift for signs of symptoms of infection. This applies to 2 of 2 residents (R113 and R196) reviewed for PICC line in the sample of 34.The findings include: 1.R196's face sheet showed that she was admitted on [DATE], with multiple diagnoses including hemiplegia, unspecified affecting unspecified side, cervical disc disorder with myelopathy, unspecified cervical region, other staphylococcus as the cause of diseases classified elsewhere, enterococcus as the cause of diseases classified elsewhere, malignant neoplasm of spinal cord, encounter for surgical aftercare following surgery on the nervous system.R196's comprehensive MDS (minimum data set) dated January 5, 2026, showed that R196 was cognitively intact. R196's POS (Physician Order Summary) showed midline dressing change and measurement of Arm Circumference and length of exposed midline after every midline dressing change on admission and every 7 days. Document Insertion site appearance every shift.On January 5, 2026, at 12:29 PM, R196 stated I am on PICC line IV (intravenous) for antibiotics. They changed it yesterday and put a date on it. The nurse cleaned it today.R196's IV site on right arm had a clean transparent dressing (dated January 4, 2026) taped over a round dry patch that was covering the IV insertion tip. The area around the insertion site was not visible with the presence of the round dry patch. On January 6, 2026, at 2:33 PM, R196's IV site was checked in presence of V5 (Registered Nurse/RN). R196's IV site had the same transparent dressing dated January 4, 2026, which was taped over the round dry patch that was covering the IV insertion tip. V5 stated that R196 received normal saline via the IV site. When asked how she checks the insertion site, as per orders, V5 stated that she only checks around the area and not the insertion site. V5 stated that she was not the one who changed the dressing on January 4, 2026. R196's care plan, initiated January 5, 2025, included that R196 has a right arm-midline with a goal to maintain a patent midline without signs of phlebitis, infiltration, or deep vein thrombosis. Interventions included as follows for dressing integrity: Maintain a transparent semi-permeable dressing. Change it every 7 days, or immediately if it becomes damp, loose, or soiled and Midline dressing change and measurement of Arm Circumference and length of exposed midline after every Midline change on admission and every 7 days. 2. R113's face sheet showed that he was admitted on [DATE], with multiple diagnoses including osteomyelitis of vertebra, long term (current) use of antibiotics, thoracic region, other lack of coordination, unsteadiness on feet, encounter for adjustment and management of vascular access device, neoplasm of uncertain behavior of colon.R113's admission MDS dated [DATE], showed that R113 was moderately impaired in cognition. R113's POS showed that R113 was on antibiotic Vancomycin Hydrochloride Intravenous Solution 1250 milligram/250 ml/milliliter intravenously every 12 hours for Osteomyelitis until January 8, 2026. R113 was admitted with orders start date December 6, 2025, with IV PICC line, flush with 10 ml normal saline before and after medications. The same POS showed orders as follows: Left PICC line dressing change and measurement of Arm Circumference and length of exposed PICC line after every PICC line dressing change on admission and every 7 days every night shift every Wednesday and as needed, Document insertion site appearance every shift, Monitor for any signs of infection, Check for any redness, swelling, warmth, tenderness or bleeding, every shift for IV care.R113's care plan revised January 5, 2026, included that R113 has a PICC line for IV Antibiotic Infusion secondary to Osteomyelitis. R113's care plan created December 6, 2025, included that R113 has a PICC line or Mid-Line.Interventions for the above included: To assess the PICC/Mid-line insertion site for redness, tenderness, or swelling. To keep an eye on any swelling, the patient's arm circumference can be compared with the baseline measurement taken before PICC line insertion. Left PICC line dressing change and measurement of Arm Circumference and length of exposed PICC line after every PICC line change on admission and every 7 days, Monitor for signs and symptoms of infection. On January 6, 2026, at 2:04 PM, R113's IV site on left arm was checked in presence of V4 (Nurse Manager/RN). The IV site was covered over by a round dry patch with a transparent dressing taped over the patch and was dated January 5, 2026. V4 stated that the dressing is changed once a week. On January 6, 2026, at 2:28 PM, V6 (Licensed Practical Nurse) stated that the night nurse changes the dressing, and the policy is to check around the IV insertion site for drainage. V6 stated that she usually does not work in R113's wing and was not sure of where to find documentation of insertion site and dressing change. On January 6, 2026, at 2:49 PM, R196's and R113's EMAR (Electronic Medication Administration) and ETAR (Electronic Treatment Administration) and nurses progress notes were reviewed in presence of V4 and showed no documentation of monitoring measurement of Arm Circumference and length of exposed midline after every midline dressing change or description of monitoring the insertion site. V4 stated that the IV site has an antimicrobial patch at the insertion site and a transparent dressing taped over it and that the insertion should be checked every shift. V4 acknowledged that the IV tip was not visible when covered with the bio patch. V4 added that the arm circumference measurements should have been recorded in EMAR. On January 7, 2026, at 8:10 AM and 9:36 AM, V3 (Infectious Disease RN) stated that the night nurse changes the dressing per orders but does not write down the measurements and that he checks around the site for infection the next day and documents the same in progress notes. V3 stated that the nurse who changes the dressing should document the measurements. V3 added that this was not done as there is no area currently for nurses to document.On January 7, 2026, at 12:30 PM, V11(Chief Nursing Officer) stated that she understands that the orders to monitor the insertion site every shift will not be able if there is a covering over the site. V11 stated that the facility will review their orders to reflect the current practice. Facility policy for Central Line (reviewed April 15, 2025) included:d. Peripherally Inserted Central Catheter (PICC).9) Upper arm circumference should be measured on admission and weekly to monitor infiltration.10) External catheter length should be monitored on admission, and weekly to monitor for outward migration of the catheter. Facility did not have a policy for checking insertion site every shift.

Based on observation, interview, and record review, the facility failed to assess and report bleeding from a resident's dialysis access site. The facility also failed to reinforce dressing to a resident's dialysis access site. This applies to 2 of 7 (R14, R101) reviewed for dialysis in a sample of 34.The findings include: 1. According to the face sheet, R101 had multiple diagnoses, including end-stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis. R101's MDS (Minimum Data Set) dated December 26, 2025, showed R101 was cognitively intact, required maximum staff assistance for upper body dressing, and was dependent on staff for lower body dressing. R101's POS (Physician Order Summary) dated December 25, 2025, showed an order for renal dialysis at the facility's dialysis center every Monday, Wednesday, and Friday. The same POS also showed to check dialysis access site for bruit and thrill, record and report abnormalities immediately, every shift. Record, or notify the physician if absent, and may reinforce dressing to the dialysis site as needed. R101's care plan initiated on December 27, 2025, showed that R101 needs hemodialysis related to end-stage renal disease. Interventions for the same care plan included checking and changing dressing daily at access site and documenting. On Monday, January 5, 2025, at 11:57 AM, R101's left upper arm dialysis access site on her left upper arm was checked in the presence of V12 (Licensed Practical Nurse/LPN). V101's dialysis access site dressing was undated, completely saturated with dried dark brown drainage, and the tape was loose and almost falling off R101's arm. R101 said she gets dialysis treatment at the facility's dialysis center on Mondays, Wednesdays, and Fridays, and her dialysis access site dressing was bloody since Friday (her last day of dialysis). R101 also said she would be going to dialysis later the same day for her Monday treatment. V12 said she was the day shift nurse for R101. V12 said she started her shift at 7 AM, gave R101 her morning medications, and did not assess R101's dialysis access site. V12 removed the gauze dressing from R101's dialysis access site and the entire dressings was saturated with dried dark brown drainage. V12 said the dressing she removed from R101's dialysis site was most likely the same one she had from dialysis (since Friday). V12 said the dialysis center changes R101's dialysis site dressing, and nurses on the unit reinforce dressings as needed. V101's Dialysis Communication Report reviewed from December 24, 2025, to January 5, 2026. R101's Dialysis Communication Report dated Friday, January 2, 2026, showed R101 had a left AV (Arteriovenous Fistula) dialysis access site. The same report showed, Post Treatment Special Instructions: monitor for bleeding from access site. A review of R101's Nursing Progress Note, reviewed from Friday, January 2, 2025, to Monday January 5, 2025, did not show nursing documentation of R101's dialysis access site bleeding or notification to the dialysis center or physician. On January 7, 2026, at 10:35 AM, V2 (Director of Nursing/DON) said nurses are expected to assess the resident's dialysis access site for bruit and thrill by palpating the dialysis access site and listening with a stethoscope. V12 said the facility's nurses are expected to monitor and assess R101's dialysis access site before and after dialysis, and every shift for bleeding, and any signs of infection. V12 said if the resident's dialysis access site dressing is bleeding, the nurse must reinforce the dressing and notify the dialysis center. V12 also said if a resident's dressing is bleeding during the weekend when the facility's dialysis center is closed, the nurse must notify the physician, and the resident would be sent to the hospital if the bleeding persists. The facility's Dialysis Protocol Guideline, with the review date of March 2025, showed, General: To provide guidance to the facility on how to care for the dialysis resident. Responsible Party: Registered Nurse, LPN. 4. The dialysis site will be checked every shift for signs and symptoms of infection or bleeding. 5. The dialysis site will be monitored every shift for thrill and bruit. 6. Communication with the dialysis center will be done by nursing, dietary, and/or social services on an ongoing basis. 2.R14's face sheet included diagnoses of cerebral infarction due to thrombosis of right middle cerebral artery, dysphagia, oropharyngeal phase, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute kidney failure, chronic kidney disease, stage 4 (severe), dependence on renal dialysis. R14's POS (Physician Order Summary) showed that R14 received Renal dialysis at an offsite dialysis center once weekly. The same orders showed to check right Central Venous Catheter site daily and upon return from dialysis, include check that caps are secure, may reinforce dressing to dialysis site as needed. R14's quarterly MDS (minimum data set) dated November 21, 2025, showed that R14 was severely impaired in cognition and required substantial maximal assistance (helper does more than half the effort) for upper body dressing and was dependent on staff for lower body dressing and personal hygiene. On January 5, 2026, at 11:23 AM, during family interview, V7 (R14's family) stated that R14 goes once a week, every Wednesday to dialysis. On January 6, 2026, at 2:30 PM, R14's dialysis site on subclavian catheter was checked in presence of V5 (Registered Nurse). A gauze dressing was noted hanging loosely under R14's shirt with the dialysis site exposed to show dry crusted brownish substance around the insertion site. V5 stated that R14 goes out for dialysis once weekly, and the site was checked in the morning. V5 added that the dressing may have come off when the CNA (Certified Nursing Assistant) who worked the morning shift changed R14's clothes. R14's care plan created July 30, 2025, showed that R14 needs hemodialysis related to chronic kidney disease, stage 4 (severe) with Right Chest Central Venous Catheter. Interventions for the same included to check and change dressing daily at access site and document. On January 7, 2026, at 8:13 AM, V2 (Director of Nursing) stated that the dressing change at the catheter site is done at the dialysis center. V2 stated that if the dressing has come off, it should be reinforced by the nurse on duty. V2 stated that the catheter site should be always covered to prevent infection. Facility policy titled Dialysis Protocol (reviewed March 2025) included: General: To provide guidance to the facility on how to care for the dialysis resident. Guideline: 3. Any line dressings for dialysis residents will be done at dialysis unless specifically ordered to be done at the facility. The dressing, may however, be reinforced.

Based on observation, interview, and record review, the facility failed to provide resident wound treatments as ordered by physicians. This applies to 2 of 3 residents (R1 and R2) reviewed for wound treatments in a sample of 5. The findings include: 1. Face sheet, printed 5/13/25, shows R1's diagnoses included peripheral vascular disease, osteoarthritis, pain, chronic kidney disease, venous insufficiency, and mild protein-calorie malnutrition. On 5/13/25 at 11:07 AM, V3 (Wound Nurse RN - Registered Nurse) stated R1 had a physician order for wound treatments to be completed every Monday, Wednesday and Friday. V3 stated R1 should have received wound treatments the day prior, on Monday. V4 (Wound Tech CNA - Certified Nursing Assistant) stated she worked with V5 (Wound Nurse RN) the day prior and V5 and V4 did not complete wound treatments on R1's wounds. At 11:32 AM, V4 began to perform wound treatments on R1's wounds. On 5/14/25 at 9:54 AM, V5 stated on 5/12/25 she was being pulled in many directions, had an eye injury, and was unable to complete R2's wound treatments as ordered by the physician. V5 stated she had every intention of performing the wound treatments but was unable to complete them as ordered. Review of R1's TAR (Treatment Administration Record), printed 5/13/25, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, right lateral foot every Monday, Wednesday, and Friday. The TAR shows R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity, or right lateral foot on 5/12/25. Review of R1's TAR, dated 4/2025, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, and right lateral foot every Monday, Wednesday and Friday. The TAR showed R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity or right lateral foot on 4/7/25. Review of R1's TAR, dated 3/2025, shows R1 had physician orders for wound treatments to her right heel, right ischial tuberosity, and right lateral foot every Monday, Wednesday, and Friday. The TAR showed R1 did not receive any of the physician-ordered wound treatments to her right heel, right ischial tuberosity, or right lateral foot on 3/19/25. On 5/13/25 at 2:32 PM, V2 (Director of Nursing) stated the wound treatments for R1 should be performed every Monday, Wednesday, and Friday as ordered by the physician. Facility policy/procedure, reviewed 3/1/25, shows 1. Licensed Professional Nurses/Registered nurses will follow orders from physicians and documented in a timely manner 2. Face sheet, dated 5/13/25, shows R2's diagnoses included pleural effusion, peripheral vascular disease, protein calorie malnutrition, and chronic obstructive pulmonary disease. TAR, dated March 2025, shows R2 had physician orders for wound treatments for right lower extremities and left lower leg to be performed three times a week (every day shift every Monday, Wednesday, and Friday) and as needed. Review of R2's March 2025 TAR shows none of the wound treatments were performed on 3/10/25.

Based on observation, interview, and record review, the facility failed ensure that there are enough supplies of linens and towels to meet resident needs. This applies to 5 of 7 residents (R5, R6, R7, R8, R9) reviewed for linens and towel supply in the sample of 11. Findings include: On May 28 and 29, 2025, multiple observations of the linen closets in the first, second, and third floors of the facility were conducted. It was noted that their facility's linen closets were almost empty and were scarcely supplied with linens and towels. Multiple residents and staffs were interviewed with regards to towels and linens. 1. On April 28, 2025, at 12:55 PM, R5 said that frequently the facility ran out of towels, her mom brings towels from home for her so she could get showers as scheduled. 2. On April 29, 2025, at 9:39 AM, R7 stated that the staff gives her shower but there were times they would tell her to wait because there were no available towels. There was also a time that the staff gave her a shower and they dry her with 4 pieces of washcloths, and it started to get cold because the staff was drying her with only the washcloths. 3. On April 29, 2025, at 11:14 AM, R6 stated that there were days that he couldn't get a shower because they don't have enough supply of towels. 4. On April 29, 2025, at 1:21 PM, R8 stated the facility does run out of towels and she experienced twice not being able to shower because there was no available towel. On April 30, 2025, at 9:50 AM, R8 said her bed linen was last changed 2 weeks ago. 5. On April 29, 2025, at 1:25 PM, R9 said the facility always runs out of towels. There was a time that there were no towels available, and the staff could not shower her. R9 also stated that at times there was no linen, so the staff could not change her beddings. R9 also stated that one time that they gave her shower, and staff used a blanket to dry her because there was no available towel. On April 30, 2025, at 9:52 AM, R9 said it's been a while about 2-3 weeks ago, since her bed linens were last changed. On April 28, 2025, at 12:13 PM, V10 (Certified Nursing Assistant/CNA) stated that linens, towels and gowns are somewhat of a struggle for them to get. V10 showed the linen closet on the third floor, it showed shelves almost empty there were very few blankets, and linens, 11 towels and 8 gowns. There were 34 residents residing on this unit. On April 29, 2025, at 9:23 AM, V11 (CNA) stated that the facility frequently ran out of towels, sometimes there were totally no towels. The laundry staff would come in twice or three times, but they will give them 6 towels and linens for the whole unit, when there were lots of residents on the floor. On April 29, 2025, at 9:31 AM V12, V13, and V14 (All CNA) stated they ran out of linens and towels in general. There were days that they had difficulty arranging showers because there were no towels available. The laundry staff delivers 2-3 times, but it was not enough to meet residents' need. Laundry staff would deliver two to three pieces of linens, blankets, or towels, it just ranges but it was always not enough. V13 and V14 also said that it was so hard when they need to change the resident's linens because it was soiled and there was no linen available. On April 29, 2025, at 2:15 PM,V15 (Laundry Staff) was on the second floor ([NAME] Unit) delivering towels. V15 said they don't have enough circulating towels and linens in the whole facility, the number of towels and linens she delivers depends upon how much soiled towels and linens they collected from the units to wash. V15 also said they had to wait for towels and linens to be washed to distribute to the units. They only deliver what they have. There were 2 towels remaining and V15 delivered 9, making it 11 towels. There were a few linens and blankets on the shelves. On April 29, 2025, at 9:51 AM, on the second floor (Adam's Unit) there were seven remaining towels in the linen room and the laundry staff delivered 10 new towels. The linen room had shelves that were almost empty with scarce supply of linens and gowns. There were 54 residents residing on this unit. On April 29, 2025, at 9:57 AM, on the second floor ([NAME] Unit), the shelves in the linen closet looked almost empty there were 7 towels remaining and 12 new deliveries of towels, there were about 3 blankets and very few linens in the shelves. There were 53 residents residing on this floor. On April 29, 2025, at 2:39 PM, 2nd floor Dementia unit V16 (CNA) said there is shortage of towels and linens in the facility. Sometimes she couldn't give shower to residents because there was no towel at all. V16 continued, so far this is the most towels and linens that she had seen pointing at the almost empty shelves with linens and towels. On April 29, 2:47 PM, V17 (Activity Director) said the staffs frequently complaint of towel and linen shortage. V17 counted the linens and towels on the second floor Dementia unit. There were 24 towels, 4 blankets or big sheets, 11 drawsheets, 7 flat sheets. On April 29, 2025, at 2:53 PM, V18 (CNA) said they need more towels and sheets because it ran out quickly. There were times she goes to another floor, and they don't have linens and towel either. On April 29, 2025, at 4:04 PM, V1 (Administrator) stated they do purchase linens and towels, they need more in circulation. There's always linen available, it's just about having the right amount in circulation and the process of making sure that the linen room has enough supplies. They must figure out which they need to work on to, whether the purchasing or the process of distribution, but they will increase the circulation. V1 also stated they have no inventory of sheets and towels. On April 30, 2025, at 9:35 AM, V22 (Laundry Staff) stated all the linens that were in the laundry room were being washed. Surveyor observed linens being washed in the washing machine. V22 stated that presently all the linens and towels they have in the laundry room were in the washer. It will all be delivered in the units after it was laundered. They were waiting from the unit floors to get all the soiled linens and towels to be washed. It takes 45 minutes for the laundry to wash and 30 minutes to dry. If staff could only bring the soiled linen on time, it would be washed on time. Surveyor observed that there was no extra clean linen nor towel noted in the laundry room. V22 stated everything was already delivered to the units. On April 30, 2025, at 10:17 AM, V23 (Environmental Services Director) stated that they don't have enough circulating linens and towels.

Based on observation, interview, and record review, the facility failed to ensure that menus and dietary orders are being followed to meet resident's needs. This applies to 6 of the 6 residents (R4, R6, R7, R8, R9, R11) reviewed for meal portions in the sample of 11. Findings include: 1. On April 28, 2025, at 12:18 PM, R4 stated that he was supposed to received double portions with meals as ordered. Sometimes they don't give it to him. The double portion was recommended to him because he was losing weight. R4's Physician Order Summary with revision date of September 18, 2025, shows general diet, double portions with meals. R4's ticket menu which was in his tray showed that he was supposed to received Double Portions of 4 ounces (oz) mixed fruit, 4 oz meatloaf, 4 oz mashed potatoes, 4 oz green beans, 1 slice bread, choice of milk, 8 oz beverage. On April 28, 2025, at 12:35 PM, during lunch time, V4 received 2 slices of meatloaf, 1 slice of bread, 1 scoop of mashed potatoes, 1 scoop of green beans, 6 small pieces of pineapple chunks. There was no milk and no beverage in his lunch tray. 2. On April 29, 2025, at 9:39 AM, R7 said that she was not satisfied with the breakfast this morning, she felt that the meal portion was small. R7 said she was given one slice of bacon, a cup of oatmeal, cinnamon roll, milk, and juice. R7 also said she's supposed to received cheesy ham and egg but got one piece of bacon instead. It does not match the menu on her ticket meal. There was no sign of egg in R7's plate, there was a very small piece of leftover of the cinnamon roll on her plate, an empty small bowl with traces of oatmeal. R7's ticket menu for breakfast dated April 29, 2025, showed: Juice of choice, oatmeal or cereal, cheesy ham and egg scramble (3 oz), 1 slice of toast, milk of choice, hot tea or coffee. 3. On April 29, 2025, at 10:09 AM, R11 stated he has a cinnamon roll, a chocolate milk, 2 slices of bacon, coffee, and oatmeal. R11's menu ticket dated April 29, 2025, shows chocolate milk, oatmeal, cheesy ham and egg, 1 slice of toast with butter, and coffee. 4. On April 29, 2025, at 11:14 AM, R6 stated that he would like more available food. There were times the food served to them does not match the things listed on the menu. Sometime last week the menu showed chicken sandwich but what they served was a baked chicken breast only with no bread. R6 wished that they gave him bread to complete the meal. 5. On April 29, 2025, at 1:21 PM, R8 said that frequently the menu does not match what they were being served. This morning, she was given 2 eggs, 2 slices of bacons, cinnamon roll, coffee. R8 requested a cream of wheat but they did not give it to her. 6. On April 29, 2025, at 1:25 PM, R9 said there were times their menu was not accurate. There were circumstances when R9 ordered a ham sandwich, but they gave her a grilled cheese sandwich, and she was lactose intolerant. Another circumstance, R9 did not like the dinner they were serving so R9 ordered a hot dog sandwich, but they gave her a piece of toast. On April 29, 2025, at 3:28 PM, V6 (Dietary Manager) and V5 (Regional Director of Operations), both said that double portion means double of everything unless specified by the physician to give double protein only. Menu is supposed to be followed. V6 also said they dropped the pan of eggs this morning. They did not have enough fresh eggs and extra liquid eggs to serve for the whole building. They did not have enough time to serve the residents the eggs because the delivery truck came in at 9AM. They gave them 2 slices of bacon because they had to give them something at that moment. The Resident Council Minutes dated January 31, 2025, shows food items are not always on tray. Council minutes dated March 28, 2025, shows food is getting better but would like big portions.

Based on interview and record review, the facility failed to ensure nursing staff was trained and was able to demonstrate competency to care for residents with implanted cardiac LVADs (Left Ventricular Assist Devices). This applies to 4 of 4 residents (R1, R2, R3, and R4) reviewed for improper nursing care in the sample of 4. The findings include: Facility documentation shows R1, R2, R3, and R4 were admitted to the facility between November 5, 2024 and December 11, 2024. Facility documentation continues to show R1, R2, R3, and R4 had LVADs due to multiple cardiac diagnoses. On December 16, 2024, V2 (DON-Director of Nursing) provided a copy of the local hospital's LVAD training packet for subacute rehab facilities. The undated LVAD training packet shows the following information regarding an LVAD: A Ventricular Assist Device (VAD) is a continuous flow pump implanted (into a patient's heart) to assist a failing native heart by taking blood from the left ventricle, flowing through the pump into the outflow graft to the ascending aorta. The training packet continues to show, Who receives a VAD? A patient who has advanced heart failure with symptoms at rest, a patient who cannot come off the heart lung machine after open heart surgery, and a patient in cardiogenic shock. The VAD pump is surgically implanted and has a driveline/electrical line that communicates between the pump inside the patient and the controller outside of the patient. The driveline must ALWAYS be covered with sterile occlusive dressing. The pump is powered by large batteries or wall power. The facility's signed agreement between the facility and the LVAD hospital, signed by V2 (DON-Director of Nursing) on June 11, 2024 shows: Facility accepting patient will be responsible for the following: Superusers (Charge RN-Registered Nurse/Educators/DON/ADON-Assistant Director of Nursing) will come for initial and annual competency training by the referring implanting center. The training course will be offered monthly through [LVAD hospital]. All staff caring for VAD patient to have had initial competency completed and direct training from the implanting center staff. Training from industry personnel and/or online module training will be supplementary training, and not considered core competency. All staff must have annual competency by their designated Superuser, who must attend yearly training from implanting center. Facility responsible for keeping records of training and use of VAD trained RNs when making daily assignments. For all turn over or new staff hires it is the responsibility of the facility leadership to register staff for initial training and provide annual competencies On December 16, 2024 at 9:33 AM, V1 (Administrator) identified V2 (DON), V8 (ADON/LPN-Licensed Practical Nurse), and V11 (ADON) as LVAD superusers. On December 17, 2024 at 9:10 AM, V4 (LVAD Hospital Educator) said the LVAD contract shows in person training classes for the LVAD. V4 said since the onset of COVID, those classes have been held virtually, but are still required as the contract shows. V4 continued to say V2, V8 and V11 have not attended a training since March of 2023. V4 said, We require the superusers to attend training annually. Due to updates in medicine, things can change with LVADs, and we want the superusers to be up to date on those changes. We also want to know they are proficient in caring for the LVAD patients. We also allow the superusers, if proficient, to train the staff in their building. We would prefer the staff attend the online training, which is about four hours. We expect the nurses to know how to do troubleshooting of the LVAD, how to do the dressing changes, how to understand the readings and alarms on the LVAD machine, and how and when to notify the LVAD team. The facility did not have any LVAD residents until August when they got one patient. We recently sent three or four more. There have been some issues with those residents, and what you are seeing is the unacceptable side of the staff members not being competent. The facility needs to keep records of who has been trained and when. There is no way to do this training in under an hour. At the shortest, it takes three hours. There are concerns that the facility does not know what they are doing based on how we received [R1]. We were unaware (of the lack of training) when [R1] was over there. We will not send other patients to that facility unless they receive training. On December 17, 2024 at 11:17 AM, V2 (DON) said no superusers have attended LVAD training since March of 2023. V2 continued to say LVADs were covered at the annual skills fair at the facility but it was a basic 10-minute training. V2 said, We do not have anything to show the staff caring for the LVAD residents are competent to take care of them. On December 17, 2024 at 2:24 PM, V16 (RN) was assigned to care for R2, R3, and R4. V16 said he has not had training regarding LVAD patients for over two years. All I know is what I learned two years ago. There has been no training at the facility. I do not know who our superusers are. On December 17, 2024 at 3:59 PM, V7 (RN) said she is frequently assigned to care for LVAD residents. V7 said, I have not had LVAD training for at least 1.5 years. Two weeks ago, I had an agency nurse working with the LVAD residents and she asked me what the LVAD numbers meant and how to document them. I showed her after she asked me, but I had not provided her training before she cared for them. I do not know who our super users are. On December 17, 2024 at 4:02 PM, V17 (Physician/Medical Director) said, I was not aware the staff were not up to date on their LVAD education. They should have been compliant with that before they accepted LVAD residents. They have to dedicate staff to care for those residents. We need to find out where this fell through the cracks, including the DON not scheduling the training. On December 17, 2024 at 4:27 PM, V8 (ADON) went through all binders and materials at the nurse's station on the unit where R1, R2, R3, and R4 resided. V8 was unable to find an LVAD binder with education materials, or a binder with education materials for agency staff. Later V8 returned and said she was able to find the LVAD binder on another floor of the facility because the facility had previously had a resident on that floor, but as of December 17, 2024 the binder had not been available to the staff working on the unit with R1, R2, R3, and R4. The facility identified the following staff as staff who cared for R1, R2, R3, and R4 since December 1, 2024: V6 (LPN-Licensed Practical Nurse), V7 (RN), V10 (RN), V15 (RN), V16 (RN), V18 (Agency Nurse), V19 (Nurse), V20 (Nurse), V21 (Nurse), V22 (Nurse), V23 (Agency Nurse), V24 (Agency Nurse), V25 Nurse, V26 (Agency Nurse), V27 (Nurse), V28 (Agency Nurse), V29 (Nurse), V30 (Agency Nurse), and V31 (Agency Nurse). On December 17, 2024 at approximately 4:40 PM, V2 (DON) said, she was unable to provide documentation to show nursing staff were trained to care for LVAD residents or that they were competent to care for them. On December 18, 2024 at 9:50 AM, V4 (RN-LVAD Educator) said he works closely with the LVAD team at the local hospital. V4 said, We pulled [R2] out of the facility last night and had him return to our hospital because we were concerned about his care and the facility's lack of education regarding caring for LVAD residents.

Based on observation, interview, and record review, the facility failed to provide LVAD (Left Ventricular Assist Device) dressing changes as ordered by the physician. This applies to 3 of 4 residents (R1, R2, and R3) reviewed for improper nursing care in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 was sent to the local hospital on November 25, 2024, admitted to the hospital with shortness of breath, and returned to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on December 12, 2024 and did not return to the facility during this investigation. R1 had multiple diagnoses including acute on chronic combined systolic and diastolic congestive heart failure, chronic kidney disease, shortness of breath, klebsiella pneumoniae, difficulty walking, acute and chronic respiratory failure, cardiogenic shock, diabetes, chronic atrial fibrillation, pleural effusions, presence of automatic implantable cardiac defibrillator, long-term use of anticoagulants, and presence of an LVAD. R1's MDS (Minimum Data Set) dated November 9, 2024 shows R1 was cognitively intact, required setup assistance with eating, partial/moderate assistance with oral hygiene, personal hygiene, and bed mobility, substantial/maximal assistance with showering, and transfers between surfaces, and was dependent on facility staff with toilet hygiene, and lower body dressing. R1 had an indwelling urinary catheter and was always continent of stool. On December 16, 2024, V2 (DON-Director of Nursing) provided a copy of the local hospital's LVAD training packet for subacute rehab facilities. The undated LVAD training packet shows the following information regarding an LVAD: A Ventricular Assist Device (VAD) is a continuous flow pump implanted (into a patient's heart) to assist a failing native heart by taking blood from the left ventricle, flowing through the pump into the outflow graft to the ascending aorta. The training packet continues to show, Who receives a VAD? A patient who has advanced heart failure with symptoms at rest, a patient who cannot come off the heart lung machine after open heart surgery, and a patient in cardiogenic shock. The VAD pump is surgically implanted and has a driveline/electrical line that communicates between the pump inside the patient and the controller outside of the patient. The driveline must ALWAYS be covered with sterile occlusive dressing. The pump is powered by large batteries or wall power. The EMR shows the following order for R1 dated November 7, 2024 through November 18, 2024: 7. Remove old dressing and take off gloves and discard in trash. 8. Wash hands or use antiseptic cleanser. 9. Apply second pair of gloves using sterile technique. 10. Activate one Chloroprep swab and scrub/cleanse in spiral direction beginning at the exit site continuing down and away from the exit with one side of the swab and the other side of driveline with other side of swab discard allow skin to dry for 3 minutes before Sorbaview (do not fan area). Every day shift every Monday, Thursday 2 of 3 . On December 18, 2024 at 1:00 PM, V2 (DON-Director of Nursing) said R1's LVAD dressing order was entered incorrectly by the nursing staff on November 18, 2024. V2 said the facility has an LVAD dressing order set that is supposed to be entered when the facility receives an LVAD resident. V2 continued to say the LVAD dressing orders have multiple steps to be followed, and R1's dressing order was missing steps 1 through 6 and steps 11 through 12. V2 continued to say R1 should have had the following orders in the EMR for the nursing staff to follow so they were aware of the site where the dressing change needed to be done and that the entire procedure was under sterile conditions: 1. LVAD drive line dressing wet kit instructions. Prepare room. 1. Close window/door and turn off all fans. 2. Wipe down the table with antimicrobial wipe, place mask on all the individuals in room. 3. Wash hands for 20-30 seconds. 4. Open kit using sterile technique. 5. Apply gloves using sterile technique. 6. Prepare kit to use (pen packages onto sterile field). 11. Apply Algidex patch (antimicrobial patch) yellow side up. 12. Apply Sorbaview dressing. Additional tips: extra gauze can be used to hold/secure the driveline during cleaning. If you do not use extra gauze to hold driveline, it may be used to blot skin that's very hairy to improve drying ability. If dressing and or patch is saturated with drainage call the VAD team for additional orders. V2 also continued to say all of the sterile dressing orders should be entered into the computer as scheduled treatments as well as prn (as needed treatments) in case the resident's LVAD dressing becomes dirty or dislodged and requires changing between scheduled dressing changes. The facility does not have documentation to show the sterile dressing orders were followed as ordered by the physician from November 7, 2024 to November 18, 2024 for R1. R1's hospital LVAD discharge orders dated December 4, 2024 show: Wound Care: 1. Type of sterile driveline dressing change: sterile dry kit. 2. Frequency of sterile driveline dressing change: Every Monday and Thursday. The EMR shows the following order for R1 dated December 11, 2024: L Vab (sp.) dressing change weekly every night shift every Tue. The order was entered by V15 (RN). The order was discontinued on December 12, 2024 at 6:55 PM by V16 (RN). The facility does not have documentation to show the sterile dressing change orders were ever entered for R1 upon his return to the facility on [DATE]. The local hospital LVAD care instructions provided to the facility on [DATE] when R1 was transferred to the facility from the hospital show: LVAD Driveline Dressing Dry Kit instructions for SAR (Subacute Rehab): Prepare Room: Close windows/door and turn off all fans. Wipe down table with antimicrobial wipe, place mask on all individuals in room. Wash hands for 20-30 seconds. Open kit using sterile technique. Apply gloves using sterile technique. Prepare kit to use (open packages onto sterile field). Remove old dressing and take off gloves, discard in trash. Wash hands or use antiseptic cleanser. Apply second pair of gloves using sterile technique. Activate one Chloroprep swab and scrub/cleanse in spiral direction beginning at the exit site working outward up to 4 inches never return to the exit site with dirty swab then discard. Activate second Chloroprep swab and clean along driveline. Clean one side of driveline beginning at the exit site continuing down and away from the exit site with one side of swab and the other side of driveline with other side of swab. Discard. Allow skin to dry for 3 minutes before applying Sorbaview (do not fan area). Apply Algidex patch yellow side up. Apply Sorbaview dressing. Apply [name of indwelling catheter] anchor distal to the Sorbaview dressing). 2. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, acute on chronic combined systolic and diastolic congestive heart failure, lack of coordination, diabetes, chronic kidney disease, fluid overload, presence of heart assist device, encounter for adjustment and management of other part of cardiac pacemaker, epilepsy, long-term use of anticoagulants, presence of an LVAD, and depression. R2's MDS (Minimum Data Set) was not completed at the time of this investigation. The EMR shows an order dated December 9, 2024 to Apply Algidex patch during the LVAD dressing changes on Mondays and Thursdays. On December 16, 2024 at 10:23 AM, V2 (DON) and V8 (ADON-Assistant Director of Nursing) showed the dressing kits used for LVAD dressing changes. V8 said only one resident has orders for the antimicrobial patch. V8 was unaware the facility's standing LVAD dressing change orders show an antimicrobial patch as part of the order. V8 continued to show the antimicrobial patches are not kept in the dressing kits and she has the patches in her office. V8 said she places the patches in the medication room for the staff on dressing change days. At 10:50 AM, V8 walked to R2's room and showed R2's LVAD dressing site. V8 confirmed the LVAD dressing, and securement device were not dated. V8 palpated the gauze covering R2's LVAD driveline dressing site and said she did not feel an antimicrobial patch under the gauze dressing, as ordered. On December 16, 2024 at 2:00 PM, V7 (RN) was in R2's room. V7 said she was told to change R2's LVAD dressing. V7 said when she removed the dressing, there was no antimicrobial patch around R2's drive line as ordered. 3. The EMR shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, metabolic encephalopathy, parainfluenza pneumonia, acute respiratory failure, COPD (Chronic Obstructive Pulmonary Disease), emphysema, acute on chronic combined systolic and diastolic heart failure, atrial fibrillation, acute kidney failure, chronic kidney disease, history of falling, presence of heart assist device (LVAD), and long-term use of anticoagulants. R3's MDS was not completed at the time of this investigation. On December 16, 2024 at 9:45 AM, R3 was sitting up in his bed. R3 said he has had his LVAD for almost six years. R3 was visibly upset and said the facility staff does not know how to do a proper sterile dressing change. R3 said, They don't clean the wound correctly. The dressing was supposed to be changed the day I got here, which was Tuesday and didn't get changed until Thursday or Friday. They don't even give me a mask to wear. They leave my door wide open, and people walk in and out without masks. R3's hospital discharge orders, printed December 10, 2024 show the following order: Type of sterile driveline dressing change: Sterile wet kit. Frequency of sterile driveline dressing change: Daily. The EMR shows the following order for R3 dated December 12, 2024: L Vab (sp.) dressing change daily wet kit, every night shift. The facility does not have documentation to show the multi-step LVAD dressing change orders were entered by the nursing staff. On December 17, 2024 at 3:34 PM, R3's nursing orders and documentation were reviewed regarding R3's LVAD dressing with V2 (DON). V2 said the nursing staff failed to enter the correct LVAD dressing orders when R3 was admitted to the facility and based on the orders entered, would have no idea if the dressing was a sterile dressing based on what the EMR shows. On December 17, 2024 at 9:10 AM, V4 (Hospital LVAD Educator) said the SAR sterile dressing change orders, with the multiple steps should be followed for every LVAD patient, which is taught in the LVAD training classes.

Based on interview and record review, the facility failed to administer medications as ordered by the physician to residents with diagnoses of heart failure requiring the use of implanted LVADs (Left Ventricular Assist Devices). This applies to 2 of 4 residents (R2 and R4) reviewed for improper nursing care in the sample of 4. The findings include: 1. The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, acute on chronic combined systolic and diastolic congestive heart failure, lack of coordination, diabetes, chronic kidney disease, fluid overload, presence of heart assist device (LVAD), encounter for adjustment and management of other part of cardiac pacemaker, epilepsy, long-term use of anticoagulants, and depression. R2's MDS (Minimum Data Set) was not completed at the time of this investigation. The EMR shows the following order for R2 dated December 7, 2024: Milrinone Lactate (heart failure medication) Intravenous Solution. Use 20 mg. (Milligrams) intravenously every shift for heart failure 20 mg/100 ml (Milliliters), inject 34.725 mcg/minute. On December 10, 2024 at 9:46 PM, V9 (NP-Nurse Practitioner) documented, Primary Chief Complaint: Medication Given in Error. Nurse called to report that [R2] had been receiving another patient's bag of Milrinone. Nurse went to change the bag of Milrinone and noted that most of the bag had not infused the full volume as it should have. Nurse looked carefully at the bag she took down and noted that it had another patient's name on the bag. The concentration of the other patient's bag is (90 mg/112 ml x 24 hours) than [R2's] prescription (53 mg/66 ml x 24 hours) for Milrinone. [R2] is currently stable and has not had any change in condition. His vital signs are stable and consistent with his baseline. Of note, the other patient's Milrinone was to run at a higher rate of infusion than [R2's]. So, [R2] received a stronger concentration of Milrinone but at a lower rate of infusion. Nurse hung the correct bag at 7:20 PM. Diagnosis, Assessment/Plan: CHF (Congestive Heart Failure) acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (Primary). Condition is guarded. Vital signs every 1-hour x 4 times. If stable revert to vital signs every shift. Obtain a STAT EKG (Electrocardiogram). On December 10, 2024 at 11:33 PM, V10 (RN-Registered Nurse) documented, This writer observed a medication incident on this shift. The incident has been reported to management and [on call physician group]. This writer received orders to monitor vital signs every hour x 4 times and STAT EKG to be performed. The patient remains in a stable condition. No signs of irregular heartbeat, dizziness or chest pain observed. Nursing staff informed to monitor the patient and notified MD of any changes with his current health status. On December 18, 2024 at 9:56 AM, V1 (Administrator) and V2 (DON-Director of Nursing) said there was a medication error and R2 received a medication labeled with another resident's name. The medication was Milrinone. V2 said R2's new Milrinone bag was started on December 9, 2024 between 2:00 and 3:00 PM by V11 (RN). V10 (RN) found the wrong medication bag infusing into R2 on December 10, 2024 at 7:00 PM. V2 said, [R2] received the incorrect dosage of the Milrinone medication continuously for 27 hours. On December 18, 2024 at 9:11 AM, V12 (Pharmacist) said, This is the only facility that I currently oversee using Milrinone. The cardiologists want this intravenous drug for short-term use. It is a very risky drug. Especially if the resident gets an increased dose. The reason [R2] got a higher dose than ordered is because they gave the medication intended for another resident. This was a huge medication error with the potential for substantial consequences including cardiac consequences. 2. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including wedge compression fracture of first lumbar vertebra, difficulty walking, fracture of the superior rim of the right pubis, diabetes, chronic systolic heart failure, chronic pain syndrome, spinal stenosis, prostate cancer, colon cancer, bladder cancer, and presence of heart assist device (LVAD). R4's MDS dated [DATE] shows R4 is cognitively intact, is independent with eating, requires setup assistance with oral hygiene, partial/moderate assistance with toilet hygiene, showering, and lower body dressing, substantial/maximal assistance with transfers between surfaces, and is dependent on facility staff for bed mobility. R4 is occasionally incontinent of bowel and bladder. The EMR shows the following order for R4 dated December 3, 2024: Torsemide (diuretic) 10 mg. orally, daily. R4's December 2024 MAR (Medication Administration Record) shows R4 received Torsemide 10 mg. every day at 9:00 AM from December 3, 2024 through December 15, 2024. R4's hospital Summary of Discharge Medications dated December 2, 2024 at 2:24 PM shows the following order for R4: Torsemide 20 mg. by mouth daily. On December 17, 2024 at 3:34 PM, V2 (DON) said R4's Torsemide order was entered incorrectly when his orders were entered by the nurse at the facility. V2 also said she was unaware R4 was receiving the incorrect dosage of Torsemide since his admission to the facility 15 days earlier. On December 18, 2024 at 9:11 AM, V12 (Pharmacist) said, Torsemide is used as a diuretic, not urinary retention. [R4] has significant cardiac issues, and fluid overload, and shortness of breath are concerns for residents with LVADs and heart failure when they receive too low of a dose of Torsemide. LVAD residents can get fluid overloaded very easily and require hospitalization because of it. The incorrect dose of Torsemide can lead to significant consequences for LVAD residents. I do the medication review and compare the hospital records to the orders entered by the facility and look for discrepancies. I identified the medication error of the Torsemide being incorrectly ordered as 10 mg. when it should have been 20 mg. I sent an email to [V2] (DON), and also included [V11] (ADON-Assistant Director of Nursing), [V14] (Vice President of Clinical Services), and [V13] (Regional Consultant) on the email. The email was sent the day after [R4] was admitted to the facility, on December 3, 2024. On December 18, 2024 at 9:50 AM, V4 (RN-LVAD Educator) said he works closely with the LVAD team at the local hospital. V4 said all significant medication errors should be reported to the LVAD team. V4 continued to say, We pulled [R2] out of the facility last night and had him return to our hospital because we were concerned about his care and the facility's lack of education regarding caring for LVAD residents. The facility's policy entitled Medication Administration, reviewed on 8/01/24 shows: All medication are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Guideline: .5. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 6. Read each order entirely. 7. Remove medication from drawer and read label three times; when removing from drawer, before pouring, and after pouring.21. If medication error/s identified, notify MD/NP (physician/nurse practitioner). Monitor resident's condition as ordered by the physician/NP .

Based on the observations, interviews, and record reviews, the facility failed to return the heart monitor devices to the cardiology monitoring departments per physician orders and label instructions. This applies to 2 of 3 (R2 and R3) residents reviewed for heart monitoring devices in a sample of 7. Findings include: 1. The EMR (Electronic Medical Record) showed R3 was a [AGE] year-old female with diagnoses including congestive heart failure, chronic pulmonary edema, pleural effusion, coronary artery diseases, atrial fibrillation, presence of coronary angioplasty implants and grafts, end-stage renal disease with dependent on dialysis. R3's Minimum Data Set, dated dated dated [DATE] showed R3 cognitively intact. On 10/22/2024 at 12:30 PM, R3 was in bed and said a cardiac monitor patch was applied to her because she was feeling dizzy and has a history of atrial fibrillation. R3 said her heart monitor was removed a few weeks ago, and V9 (Nurse Practitioner Cardiology) could not find the result. R3's Physician order dated 09/13/2024 showed R3 to have a 14-day (Heart monitor patch), return on 09/25/2024, place all equipment in a self-addressed pre-paid box, mail it back, and check with V9 (Nurse Practitioner Cardiology) for any questions. On 10/23/2044 at 11:46 AM, V9 (Nurse Practitioner Cardiology) said R3 was ordered a (heart monitor patch) for syncope episodes during therapy, and R3 has a history of atrial fibrillation. V9 said the (heart monitor patch) detects irregular heartbeats in the Electrocardiogram (ECG) data and helps to have a plan of care. V9 said the heart monitor was supposed to be sent on 09/25/2024 to the heart monitor company, and V11 (Facility Nurse Practitioner) removed and packed it on the same day. V9 said she kept looking for the results and followed up with the cardiac department and came to know that they never received the heart monitor. V9 said she escalated to V2 (Assistant Director of Nursing) and V1 (Administrator) and was upset about the situation. V9 further said R3 has very complicated cardiac conditions with multiple medications, and unnecessarily, R3's plan of care was delayed. On 10/23/2024 at 12:10 PM, V11 (Facility Nurse Practitioner) said on 09/25/2024, she removed the (heart monitor patch) from R3, put it in the box, per return label instructions, sealed it, and handed it over to V12 (Receptionist) around 11:00 AM - 11:30 AM, and she came to know that the device is pending return from the facility. V11 said R3 has very fluctuating blood pressure and heart rate with a history of A-fibrillation, and it takes two weeks for the result, and the result is very important for the plan of care. On 10/23/2024 at 12:20 PM, V12 (Receptionist) and V13 (Payroll staff) said when V11 brought the packet, UPS had already left for the day, and V12 had left for vacation. The next day, when V13 (Payroll staff) was covering for V12, she did not find any packets by the reception area, so she assumed United Parcel Service (UPS) picked them up. V12 said recently, when it came to his notice, he researched, and there was no UPS tracking number available. On 10/23/2024 at 1:07, V1 (Administrator) and V2 (Assistant Director of Nursing) said they found the sealed packet in the 3rd floor nursing station. V2 said no one knew why it was there or why no one noticed. V1 and V2 said the facility should have sent the device in a timely manner. 2. The EMR (Electronic Medical Record) showed R2 was a [AGE] year-old male with diagnoses including congestive heart failure, hypotension, morbid obesity, arterial tortuosity syndrome (congenital connective tissue syndrome), which causes complications in medium-sized arteries including aorta, and acute kidney failure. R2's Minimum Data Set, dated dated dated [DATE] showed R2 cognitively intact, and R2 was discharged home on 09/28/2024. A physician order dated 04/03/2024 showed R2 having a [NAME] Monitor. R2's [NAME] monitor was returned to the cardiology company for the result without a cell phone, and R2 received a bill for the missing cell phone. On 10/23/2024 at 12:10 PM, V11 (Facility Nurse Practitioner) said all heart monitors come with a proper return label with instructions, and whoever removes one should follow the instructions. On 10/23/2024 at 2:00 PM, V1 (Administrator) said not all heart monitors come with a phone, and R2's device came with a cellphone. V1 and V2 said whoever removed the heart monitor did not pack the device with the cell phone to mail it. V1 said R2 called him about the concerns a week ago, and he found the cell phone today and said he would return it to the company. The facility policy titled Policy/Procedure dated 07/2020, with the subject Physician Orders, in part showed that Licensed Professional Nurses and Registered Nurses would follow orders from physicians.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated [DATE] documents the total census was 138 residents. On [DATE] at 11:33 AM, V12 (Dietary Manager) said there are 3 NPO (Nothing by Mouth) residents and the rest of the residents eat from the facility kitchen. On [DATE] starting at 10:24 AM, the facility kitchen was toured. Starting at 10:37 AM, V13 (Regional Dietary Manager) was present for the tour. The following was found: At 10:53 AM in walk-in cooler #1: 1. 2 large pork roasts, no label and no date 2. 5- 10 pound packages of 73% lean and 27% fat ground beef with best before or freeze by date of [DATE]. V13 (Regional Dietary Manager) said the staff told her the ground beef was thawed a couple days ago. The meat was all completely thawed and there was no other date on the meat besides [DATE]. 3. A 5 pound tub of cottage cheese with sell by date of [DATE]rd. V13 said cottage cheese was not safe to serve. 4. A meatloaf dated [DATE]. V13 said the meatloaf expired [DATE]. 5. 17 tomatoes that are soft/rotten with multiple black spots on them. V13 pointed to one of the tomatoes and said, this one is moldy. 6. A medium sized silver bin of marinara sauce dated [DATE]. V13 said the sauce was expired on [DATE]. 7. A 10 pound tub of potato salad with best before [DATE]. Expired. At 10:39 AM in walk-in cooler #3: 8. A crate of 27 4 ounce milk cartons that were warm to touch. Surveyor asked V13 to check the temperature of the milk and it showed 68 degrees. 9. A single mango sitting on wire rack. Mango is soft/mushy with the imprint of the wire rack on it when picked up and is sticky on the outside. V13 said she did not know where the mango came from because mangoes are not a part of their menu. 10. A plastic grocery store bag with partially thawed pork chops in it. Outside of the bag wet and sticky- resting on second from top rack above a cardboard box of hamburger buns. A staff member came into the cooler and told V13 the pork chops were his personal food items that he purchased for his home. V13 gave him the bag of meat. 11. A half loaf of raisin bread, firm to touch, dated [DATE]. At 10:27 AM in the dry storage: 12. ,d+[DATE] pound rainbow sprinkle cartons expired on [DATE]. 13. An opened 5 pound bag of instant dry milk crystals labeled ,d+[DATE] and use by ,d+[DATE]. 14. A large opened, not sealed bag of croutons. 15. An unlabeled opened/punctured 2 pound bag of what appears to be rice that is spilling out over the floor and has expiration date of [DATE]. 16. 3 unlabeled and undated medium sized plastic bags of brown powder- appears to be cake mix. At 11:15 AM in walk-in freezer: 17. 10 hamburger patties in plastic bag not sealed, hole ripped in bag. On [DATE] at 11:19 AM, V12 (Dietary Manager) said all the food items in the kitchen need to be labeled and dated for food safety. V12 said it is the policy that every food item coming into the kitchen needs to be labeled and dated to make sure the food is safe to serve the residents and does not cause foodborne illness. V12 said all food items need to be sealed properly to prevent contamination to the food item from environmental contaminants. V12 said expired items should be thrown away as soon as possible, by the expiration date. V12 said all items in the refrigerator should be kept below 40 degrees and milk that goes above 41 degrees is not safe to serve to the residents as it may cause diarrhea, stomach upset, or food poisoning. V12 said staff can absolutely not store their personal food items in food storage designated for residents because of the risk of foodborne illness/contamination to resident food. V12 said when kitchen staff move food items from the freezer to the cooler to thaw, they need to date the item with a thaw date so staff now how much longer the item is safe to serve. The facility's policy titled, Food Storage last reviewed [DATE] states, Policy: All food stock and food products are stored in a safe and sanitary manner. All food stock is dated . Procedure: .7. Food stock and prepared food products are stored at safe temperature ranges at all times. 8. All protein items (i.e. meat, poultry, fish) are defrosted under refrigeration on the bottom shelf. 9. All food stock and products are stored . covered, labeled as to contents, and dated . The facility's policy titled, Labeling and Dating Foods last reviewed on [DATE] states, Policy: To decrease the risk of food borne illness and to provide the highest quality, foods are labeled with the date received, the date opened and the date by which the item should be discarded. Procedure: Canned food and other than shelf stable items such as cake mixes are labeled with the date received. If the product does not have an expiration date, the product is labeled with a discard or use by date . The facility's policy titled, Personal Food Storage last reviewed [DATE] states, Policy: Food items brought in by staff shall be stored in designated areas only. Procedure: 1. Food brought in by staff will be identified with the name of owner and date placed in designated refrigerator .4. Placing personal food items in any area other than specific designated area shall be subject to progressive disciplinary policy .

Based on observation, interview, and record review, the facility failed to properly contain and cover garbage in the facility kitchen to control fruit fly population. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 10/15/24 documents the total census was 138 residents. On 10/15/24 at 11:33 AM, V12 (Dietary Manager) said there are 3 NPO (Nothing by Mouth) residents and the rest of the residents eat from the facility kitchen. On 10/15/24 at 10:24 a large black garbage can was observed uncovered in the main kitchen area with at least 2 fruit flies seen flying above the garbage can. On 10/15/24 at 11:19 AM in the Dish Room, a large black garbage can was seen uncovered with food debris in it and swarms of an estimated 10-20 fruit flies flying around it. No staff were doing dishes in the dish room at that time, the room was not occupied and garbage can was left with food in it, uncovered. V13 (Regional Dietary Manager) said we do have a problem with flies. This garbage can remained uncovered with fruit flies flying in and out and around and above it through 11:29 AM when surveyor and V13 left the dish room. On 10/16/24 at 11:07 AM, large black garbage can was seen in the dish room flipped upside down with no bag in it and no lid on it. An estimated 2-3 fruit flies were seen in the dish room at this time. On 10/17/24 at 11:19 AM, an estimated 2-3 fruit flies were seen flying in the hall right outside of the kitchen entrance. On 10/17/24 at 11:19 AM, V12 (Dietary Manager) said fruit flies had been a problem in the kitchen on and off for at least the past six months since she started working at the facility. V12 said garbage cans should be kept covered because garbage can release gas into the air, there could be splashes, and having an uncovered garbage can cause/attract more fruit flies. The facility provided Service Inspection Reports for Pest Control show that fruit flies were found in the main kitchen, the kitchen dish room or both places on 8/30/24, 9/19/24, 9/30/24, and 10/10/24. The facility's policy titled, Pest Control last reviewed on 6/20/24 states, 1. INTENT: Provide a healthy environment for residents. Typical pests include: .Other common pests found in long-term care facilities include: .flies .Interior .Cover and seal bulk food storage containers and garbage containers. Keep trash cans lined and empty them regularly . The facility's policy titled, Garbage and Rubbish Disposal last reviewed 9/3/24 states, Policy: Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Procedure: 1. All garbage and rubbish containing food wastes shall be kept in containers. 2. All containers shall be provided with tight fitting lids or covers and such containers must be kept covered when stored or not in use . The facility's policy titled, Garbage Cans last reviewed on 9/3/24 states, Note: Always cover garbage cans when not in use .

Based on observation, interview, and record review, the facility failed to implement fall precaution interventions for residents at risk for falls. This applies to 3 of 3 residents (R5, R103, and R87) reviewed for accidents and supervision in a sample of 28. 46003 1. R103 admitted to the facility with diagnoses of osteoarthritis of both knees, methicillin resistant staphylococcus aureus, morbid obesity, heart failure, lymphedema, hypotension, sleep apnea, chronic kidney disease, and hypertension. R103 current care plan states she is at risk for fall interventions include staff to assess the physical environment, device including furniture bed to ensure that they don't pose a safety hazard. Bed in a safe level position based on residents needs / risks. R103 MDS (Minimum Data Set) dated 9/28/24 shows she is dependent on staff for transfers and uses a manual wheelchair for mobility. On 10/15/24 at 11:08 AM, R103 was lying in bed with the bed and over-bed table in the highest position. R103 stated her bed was left in that position after her brief was changed. On 10/16/24 at 04:07 PM, R103 was lying in bed with the bed and over-bed table in the highest position. R103 stated her bed was raised to the high position so the CNA (Certified Nursing Assistant) wouldn't hurt his back and the nurse would be coming in at some time for the dressing change. On 10/16/24 04:07 PM, R20 CNA/ Wound Tech was called into R103's room. R20 stated the bed was not in a safe position. R103 could fall from the bed and be injured. The bed and table should have been left in a lower position. 2. R5 admitted to the facility with diagnoses that includes intervertebral disc degeneration, osteoarthritis, chronic respiratory failure, type 2 diabetes, morbid obesity, cervicalgia, chronic kidney disease, anemia, major depressive disorder, transient ischemic attack, blindness in one eye, lymphedema, dependence on supplemental oxygen, and obstructive sleep apnea. R5's current care plan states she is at risk for falls. Interventions include staff checking to ensure she is properly and safely positioned in bed. R5's MDS (Minimum Data Set) date 8/28/24 shows she uses a wheelchair for mobility and is dependent on staff assistance for transfers. On 10/15/24 at 12:15 PM, R5 was lying in bed with the bed and over-bed table in the highest position. On 10/16/24 04:17 PM, V19 CNA assigned to R5 stated she left R5's bed and over-bed table high after she took her vital signs and brought her water. V19 stated no one ever talked to her about the beds position when she leaves the resident's bedside. V19 stated no one ever told her R5's bed should not be left in a high position. On 10/17/24 at 01:25 PM, V2 DON (Director of Nursing) stated staff should make sure patients are safe. The bed should be in a low position if they are a high risk for fall and make sure fall interventions are in place. Staff should make sure the resident's belongings are in reach and bed is positioned safely. R103 is not able to self-transfer, and she is care planned as a fall risk. Her bed and table should be in the lowest position when staff walk away from her. R5 can have episodes of confusion. R5 is at risk for falls. V2 did not know of any occasion of R5 refusing to have her bed or over-bed table lowered. Staff should be lowering her bed and over-bed table. The facility policy Repositioning a Resident dated 7/15/24 states to lower the bed into safest and most comfortable position for resident. The facility policy Fall Prevention and Management dated 4/8/24 states all residents and patients will be considered at risk for falling, regardless of fall risk score. Universal fall precautions interventions will be implemented to all. 41384 3. On 10/15/24 at 11:23 AM, R87 was observed in his bed with his bed in a high position. Staff who only identified himself as PT (Physical Therapist) was in the room next to R87's bed but then left the room and left R87's bed in a high position. R87's 8/21/24 care plan showed that R87 is at risk for falls secondary to impaired balance, decreased strength and endurance, weakness, decreased cognitive and communication skills secondary to stroke with residual deficits, with diagnoses including altered Mental Status, CHF (congestive heart failure), seizures, and the use of hypoglycemic, and cardiac medications. The interventions include positioning, staff will check residents' location and activity to ensure resident is properly and safely positioned in bed or chair/wheelchair. On 10/17/24 at 02:05 PM, V3 ADON (Assistant Director of Nursing) said that her expectations are that residents' beds are not left in a high position because it is a fall risk. The facility's Fall Prevention and Management policy dated 4/8/2024 showed that the facility maintains a safe patient environment. The policy shows that interventions for High Risk Precautions included, interventions will be in place based on identified and assessed risk factor.

Based on observation, record review, and interview, the facility failed to complete accurate post-dialysis weights for residents on dialysis treatments. This applies to 5 of 7 residents (R41, R49, R91, R107, and R138) reviewed for dialysis in a sample of 28. Findings include: The dialysis service policy titled Monitoring and documentation pre, during, and post-treatment, dated 06/2018, in part, showed that the post-dialysis assessment would include post-dialysis weight. The registered nurse will do the post-dialysis assessment before the resident is discharged from the treatment area, and a copy of the completed dialysis communication form will be given to the unit staff after the resident's dialysis treatment. On 10/16/2024 around 11:00 AM, V21 (Registered Nurse dialysis) said staff either check the post weight at the dialysis unit or some time at the unit by the Certified Nursing Assistants, and staff let V21 know to complete the dialysis communication report, and then V21 provides the dialysis communication form to the unit nurse to enter the post dialysis weight readings in the EMR (Electronic Medical Record) 1. Observed R41 having dialysis on 10/16/2024 around 10:30 AM, and after the completion of the dialysis treatment, R1 was transferred to the unit without taking post weight. The review of the record for Resident 41 showed R41 had diagnoses including end-stage renal disease and dependence on renal dialysis, morbid obesity, pleural effusion, cardiac diseases, and dependence on oxygen. R1 was admitted on [DATE] with continuing dialysis treatment three times per week on Monday, Wednesday, and Friday. R41's Minimum Data Set, dated dated dated [DATE] showed that R41 is cognitively moderately competent and required one to two maximum assistances for daily living activities. During the interview, R41 said the facility staff weighed before transferring her to the dialysis treatment unit, and she was never weighed after the treatment either at the dialysis center or by the unit staff. 2. On 10/16/2024, around 4:30 PM, R138 was wheeled from the dialysis treatment to his room. R138 said the unit staff weighed him before the dialysis treatment, and he was never weighed after the treatment. The review of the record for R138 showed he had diagnoses including end-stage renal disease and dependence on renal dialysis, cardiac diseases, and HIV. R138's Minimum Data Set, dated dated dated [DATE] showed R138 cognitively competent and required one assist for daily living activities. 3. On 10/16/2024 observed R49 in her room after the dialysis treatment, and R1 was interviewable and said she was weighed before the dialysis treatment and never weighed either by the dialysis staff or the unit staff after the dialysis treatment. The review of the record for Resident 49 showed she had diagnoses including end-stage renal disease and dependence on renal dialysis, diabetes, and cardiac diseases. R49's Minimum Data Set, dated dated dated [DATE] showed R49 cognitively impaired and required one staff assist for the activities of daily living. V24(Licensed Practical Nurse) entered R49's weights from the communication form to the EMR. V24 said she was entering the numbers from the communication form and was unsure who was weighing residents' weights after the treatments. 4. On 10/16/2024, R107 was observed having dialysis treatment around 11:30 AM, and after the treatment, R107 was transferred to the unit without weighing post weight. R107 was interviewable and said she was weighed before the dialysis treatment and never weighed either by the dialysis staff or the unit staff after the dialysis treatment. The review of the record for Resident R107 had diagnoses that included end-stage renal disease and dependence on renal dialysis, diabetes, and cardiac diseases: morbid obesity and cirrhosis of the liver. The Minimum Data Set, dated dated dated [DATE] showed that R107 was cognitively intact and required one staff member to assist with daily living activities. 5. On 10/16/2024, R91 had dialysis treatment around 3:30 PM, and after the treatment, R91 was transferred to the unit without recording post-weight. R91 was interviewable and said she was weighed before the dialysis treatment and never weighed either by the dialysis staff or the unit staff after the dialysis treatment. The review of the record for Resident R107 had diagnoses that included end-stage renal disease dependence on renal dialysis and heart failure. Minimum Data Set, dated dated dated [DATE] showed R91 cognitively intact and required supervision from one staff assistant for the activities of daily living. On 10/16/2024, at 11:00 AM and 11:45 AM, V25 and V26 (Certified Nursing Assistants), who transferred residents from the dialysis unit, said they never weighed residents after the dialysis treatment. At 12:00 PM, V21 (Registered Nurse Dialysis) acknowledged she was subtracting Residents' weights from the set ultrafiltration goals on dialysis machines and added standard 500 ml saline prime, which is the practice. On 10/17/2024 at 9:53 AM, V5 (Registered Nurse) said Certified Nursing Assistants are responsible for weighing residents before the dialysis treatments unit nurses complete the dialysis pre-assessments in the communication form, and Dialysis nurse completes the post-assessment communication form, including post weights. V5 said she was unaware that residents were not weighed after the dialysis treatments. V5 said if the dialysis pre and post-weights are not accurate, renal residents can get into hypovolemia or fluid overload complications. On 10/17/2024 (the Director of Nursing) said she was unaware of who was weighing residents after the dialysis treatment. V2 said it is important to comply with policy and prevent post-dialysis-related complications.

Based on observation, interview, and record review, the facility failed to appropriately store and secure medications and biologics safely for 2 residents (R19 & R93) who were reviewed for medication storge in a sample of 28. Findings include: 1. On 10/15/24 at 01:38 PM 1 unopened package of albuterol sulfate 0.5% 2.5 mg / 0.5ml (milligram/milliliter), 1 albuterol sulfate 0.5% 2.5mg/0.5ml vial, not in the package, and 1 white pill in a medication cup was observed on R19's overbed side table. R19 said that the nurse had left the pill for her, and she did not know what the medication was for. Then R19 swallowed the pill. R19 said that the nurse leaves the albuterol sulfate for her every day, and she does the treatments herself. On 10/16/24 at 12:03 PM, a record review was done of R19's electronic health record, and it did not show any order to have medications at bedside, an assessment for self-medication, or an order to self-medicate. On 10/17/24 at 02:22 PM V3 ADON (Assistant Director of Nursing) said that R19 should not have medications left at her bedside because R19 doesn't have an order to self-medicate, and it is a safety issues. V3 said the facility cannot ensure that R19 received her medications as prescribed if the nurse does not give the medication to the resident. V3 said that there is a potential of someone else getting control of the medication because it is not being properly stored or secured. 46003 2. R93 admitted to the facility with diagnoses that includes chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and hypercapnia, emphysema, hypoxemia, hypertension, major depressive disorder, anemia, and nicotine dependence. R93 current care plan states the resident is at risk for adverse reaction related to medication error. Interventions include educate the nurse to observe the 6 rights of mediation administration. R93's MDS (Minimum Data Set) dated 9/27/24 indicates he is cognitively intact. On 10/15/24 at 11:32 AM, R93 had two ampules of duo-neb (Ipratropium - Albuterol) at his bedside. R93 stated he does his own nebulizer treatments three times per day. R93 stated the nurse gave him the duo-neb ampules. R93 stated the nurses don't follow up to see when he does his nebulizer treatment. R93 stated it is up to him to do administer them on his own. On 10/17/24 at 10:48 AM R93 stated he didn't have the duo-neb ampules anymore because he had used them. R93 he can have them every four hours as needed, and he last self-administered his duo-neb at 10pm the previous night. On 10/17/24 at 10:58 AM, V17 LPN (Licensed Practical Nurse) stated R93 can have his duo-neb every four hours as needed. When V17 reviewed the EMR (Electronic Medical Record) she was unable to find a current order for duo-neb. The medication cart had 9 ampules for R93 dated 6/25/24. V17 stated she never allowed R93 to self-administer his medication and she did not know who gave them to him. V17 LPN stated he did not have an assessment to keep medication at the bedside for self-administration. On 10/17/24 at 01:25 PM, V2 DON (Director of Nursing) stated R93 did not have an assessment to self-administer medications. R93 hasn't had an order for duo-nebs since August. The medications should not have been in his possession or still on the medication cart. V2 stated R93 is alert but did not have an order to self-administer medication and it should not have been in his possession. R93's order for duo-neb (ipratropium-albuterol) 0.5-2.5 (3) MG (Milligram)/ 3ML (Milliliters) 1 inhalation inhale orally every 6 hours as needed for SOB (Shortness of Breath) give over 10 minutes was discontinued 8/15/24. The facility policy Self- Administration of Medication dated 10/25/14 states for those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. The resident is asked to complete a bedside record indicating the administration of the medication if bedside storage is to be used. The facility policy Medication Administration dated 4/18/24 states medications will not be left at bedside unless with order from physician.

Based on observation, interview, and record review, the facility failed to follow its Enhanced Barrier Precautions (EBP) Guidelines and isolation policy by staff not wearing gowns during incontinent care for an EBP resident and having visitors visiting contact isolation residents without having gloves or gown. The facility also failed to maintain effective hand hygiene during resident care. This applies to 3 of 3 residents (R51, R80, and R87) reviewed for infection control practices in a sample of 28. The findings include: 1. R80 is a [AGE] year-old female admitted on [DATE]. As per the Minimum Data Set (MDS) dated [DATE], her cognition is intact. On 10/15/24 at 11:29 AM, R80's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. On 10/15/24 at 11:35 AM, the writer observed V27 (Certified Nursing Assistant / CNA) and V28(CNA) providing incontinent care without wearing a gown as per the EBP sign posted on the entry door. On 10/15/24 at 11:44 AM, V27 stated that R80 was not assigned to her and was not aware of EBP with R80. V27 added that she was just helping V28 to provide incontinent care. On 10/15/24 at 11:46 AM, V28 stated that she didn't know that she should have worn a gown during incontinent care to R80. On 10/15/24 at 11:39 AM, V29 (Licensed Practical Nurse / LPN) stated, R80 is on EBP due to extended-spectrum beta-lactamase (ESBL) in urine. Changing R80's incontinent brief is considered a touch activity, and staff should wear gowns and gloves while providing incontinent care. A review of the facility presented Enhanced Barrier Precaution Guidelines revised on 3/28/24 document high contact activities include changing brief or assisting with toileting. 2. R51 is a [AGE] year-old female with intact cognition as per the MDS dated [DATE]. On10/15/24 at 10:21 AM, R51 was observed in a contact isolation room with a care giver without having gloves or gown and touching/rearranging resident belongings at bedside. 10/15/24 10:47 AM, V29 (LPN) stated that R51 is on contact isolation due to extended-spectrum beta-lactamase (ESBL) in urine. Everybody goes in should wear gown and gloves. The care giver supposed to wear Personal Protective Equipment (PPE) when inside. On 10/15/24 at 02:25 PM, V2 (Director of Nursing / DON) stated that anybody going inside the contact isolation resident room including private care giver should wear PPE. Changing resident brief is considered a high contact activity and CNAs should have worn gown and gloves during incontinent care for EBP resident. A review of the facility presented isolation policy revised on 6/2/24 documented to provide and/or oversee the education of the resident, representative, and/or visitors regarding the precautions and use of PPE. 41384 3. On 10/15/24 at 11:22 AM R87 was in his bed and V25 & V30 CNAs (Certified Nurses' Assistants) were observed changing R87's soiled bedlinen. V25 said that the linen was soiled with urine and food. V25 said that R87 spilled urine in his bed from his urinal. V25 and V30 had gloves on their hands but were never observed cleaning their hands and changing their gloves when going from a dirty item/area to a clean item/area. V25 and V30 were observed removing the soiled linen and putting clean linen on R87 bed and on R87. V25 and V30 were observed touching R87's body, bed control, TV control, blanket and call light with their dirty gloved hands. V25 picked up a clean incontinence brief and handed it to R87 for him to put on himself with her dirty gloved hands. 4. On 10/15/24 at 12:00 PM V25 CNA, was observed with gloved hands providing incontinence care for R87. V25 was wiping stool from R87's buttocks, touching R87's blanket, removing his soiled brief and putting a clean brief on R87 without cleaning her hands in-between going from a dirty environment to a clean one. On 10/17/24 at 02:11 PM V3 ADON (Assistant Director of Nursing) said that the staff should have cleaned their hands and changed gloves when going from dirty to clean while providing incontinence care and changing linen for infection control. The facility's Incontinence Care policy dated 3/10/24 showed that staff should remove gloves and perform handwashing after removing soiled clothing and linen. The policy shows that after cleaning a resident during incontinence care staff is to remove their gloves and clean their hands then apply clean clothing and linen. The facility's Hand Hygiene Policy date 6/2/2024 showed that it is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Preventions and the World Health Organization.

Based on interview, observation, and record review, the facility failed to maintain residents' bed equipment. This applies to 2 residents (R87 & R123) reviewed for maintenance of furnishings and equipment in a sample of 28. The findings include: 1. On 10/15/24 at 11:28 AM, R87 was observed in his bed and his bed control had about 2 inches of exposed wires. On 10/17/24 at 10:11 AM, R87 was observed in his bed and his bed control was observed with about 3 inches of exposed wires. On 10/17/24 at 02:16 PM V3 ADON (Assistant Director of Nursing) said that R87's bed control should not have exposed wires because it is a safety issue. V3 said that it is her expectation for staff to report it. 2. On 10/15/24 at 12:23 PM, R123 was in his bed, and he said that his bed control has not worked since he was moved into the room [ROOM NUMBER] weeks ago and he reported it. V25 CNA (Certified Nurse's Assistant) said that she reported it the day before, and the Friday before that. R123 said that the bed can only be adjusted by the staff at the foot of the bed. R123 said that a man came in earlier that day and looked at the bed controller, but he could not get it to work. On 10/17/24 at 10:11 AM, R123 was observed in his bed with the head of the bed flat. R123 said his bed controller was still not working. He said that he is not able to raise the head of his bed. Then V6 (Janitor) came into the room and tested the bed control and confirmed that it was not working. R123's electronic health record showed that he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including acute pulmonary edema, emphysema, fluid overload, pleural effusion, pericardial effusion, hypertension, and end stage renal disease. R123's 7/26/24 care plan showed that R123 has fluid overload and potential fluid volume overload with interventions including raise HOB (head of bed) as needed to facilitate breathing and increase comfort. On 10/17/24 at 02:18 PM, V3 ADON (Assistant Director of Nursing) said that her expectations are that R123 have a working bed control because of his conditions. V3 said that the bed control should have been taken care of as soon as it was identified especially because of his condition. V3 said that the facility could have gotten R123 a different bed if they couldn't get the control to work. The facility's Space and Equipment policy dated 3/22/2024 showed that the facility will maintain all mechanical, electrical and patient care equipment in safe operating conditions.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for 3 residents (R87, R123, & R65) who are dependent on care for daily living in a sample of 28. The findings include: 1. On 10/15/24 at 11:19 AM, R87 was observed with long fingernails, about 1/4 inch over nailbed and a brownish blackish substance under the nails, and R87's legs were observed with dry flaking skin. At 12:15 PM V25 CNA (Certified Nurses' Assistant) brought R87 his lunch tray but did not offer to clean his hands or assist in cleaning them before serving him his food. On 10/17/24 at 10:23 AM, R87's fingernails were observed long and with a brownish colored substance under the nails. R87's 8/21/24 ADL care plan showed that R87 has an ADL self-care performance deficit related to an impaired balance, decreased strength and endurance, weakness, decreased cognitive and communication skills secondary to stroke with residual deficits with diagnoses including altered Mental Status, CHF (congestive heart failure), and seizure. R87's care plan showed interventions including staff will provide sponge bath when a full bath or shower cannot be tolerated. R87's 10/9/24 MDS (minimum data set) section C showed that R87's mental status is cognitively impaired. R87's 10/2/24 MDS section GG showed that R87's needs supervision or touching assistance with personal hygiene. On 10/17/24 at 11:30 AM a review of R87's last 30 days of progress notes did not show any documentation of R87 refusing ADL care including nail care. 2. On 10/15/24 at 11:36 AM, R123 was observed with his fingernails long, jagged, and with a brown substance under the nails. R123 said that the physical therapist clipped his nails a couple weeks ago. R123 said that when he moved into his room [ROOM NUMBER] weeks ago his personal nail grooming items were lost. On 10/15/24 at 12:28 PM, V25 gave R123 his lunch tray and did not offer to clean his hands. At 12:33 PM, R123 said he would have liked for the staff to offer to assist him in cleaning his hands before eating. R123 said that nobody has ever offered and thought that it would be automatic. On 10/17/24 at 10:21 AM, R123 was observed with his fingernails long and with a brown substance under the nails. R123's 8/6/24 MDS section GG showed that R123 needs partial/moderate assistance with personal hygiene. R123's 7/26/24 care plan showed that R123 has an ADL self-care performance deficit related to decreased balance, decreased gait, decreased strength and endurance, decreased activity tolerance following hospitalization with multiple medical conditions and comorbidities. The interventions include R123 will improve current level of function in hygiene through the review date. On 10/17/24 at 02:07 PM V3 ADON (Assistant Director of Nursing) said that she expects residents' nails to be cleaned, cut, and filed if needed, and resident's hands should be cleaned before eating. V3 said this should be done for cleanliness and infection control. The facility's Activities of Daily Living policy dated 7/20/2024 showed that the facility ensures that the residents receive ADL assistance and maintains resident's comfort, safety, and dignity. The policy showed that the facility will assist the resident to be clean, neat and well-groomed including nail care . as needed. 45906 3. On 10/15/24 at 12:24 PM, R65 said her whiskers on her chin bother her and she wants them removed. R65's chin hairs were a quarter inch to half an inch long and gray. R65 also had long dark nose hairs sticking out of her nostrils. R65 told surveyor that her chin hairs, bother the heck out of her because they are for men, not women. V1 (Administrator) was notified that R65 was requesting to have her chin hairs removed. On 10/17/24 at 11:46 AM R65 was observed lying in her bed, still with hairs on her chin. R65 said no staff had come in to help her remove her chin hairs and she still wanted the chin hairs taken care of. On 10/17/24 at 2:29 PM, V1 (Administrator) said he spoke to multiple staff members on 10/16/24 and R65's chin hairs had been removed. Surveyor told V1 that R65's chin hairs had not been removed. V1 and surveyor then walked together to R65's room and verified that R65 still needed her chin hairs removed. R65's Care Plan dated 8/11/23 shows she has a self-care performance deficit related to decreased strength and diagnosis of dementia.

Based on observation, interview and record review the facility failed to assure residents were not served food items to which they had allergies or sensitivities and follow up on a resident's food preferences. This applies to 2 of 4 residents (R40 and R30) reviewed for food concerns in a sample of 28. Findings include: 1. R40 admitted to the facility with diagnoses that includes atrial fibrillation, cognitive communication deficit, pneumonitis due to inhalation of food and vomit, anemia, anxiety, bipolar disorder and celiac disease. R40's MDS (Minimum Data Set) dated 7/27/24 indicates she has moderate cognitive impairment. R40's current diet order is general diet regular texture, regular consistency, gluten free / restricted. R40's current care plan states she has bowel incontinence related to celiac disease. R40 has a nutritional problem related to celiac disease. Interventions include to provide and serve diet as ordered. On 10/15/24 at 12:35 PM, R40's lunch meal ticket read: allergy red dye, gluten / wheat. Main menu vegetarian / vegan option, green peas, no sub found for apple crisp beverage of choice. R40's meal included a brown patty, green peas and a serving of apple crisp. On 10/17/24 at 12:27 PM, R40's meal included pork in gravy, rice pilaf, mixed vegetables, cranberry juice and red gelatin with fruit. While eating the gelatin R40 began coughing. V19 CNA (Certified Nurse Aide) came to R40 and looked at her meal ticket with surveyor. The meal ticket read allergy red dye, gluten / wheat. Pork chop no breading, rice pilaf, broccoli florets, no sub found for dinner roll no sub found for fruited gelatin beverage of choice. V19 took the gelatin and cranberry juice and gave R40 plain water. V19 stated she did not know if the gelatin and cranberry juice had red dye in them. On 10/17/24 at 01:08 PM, V12 Dietary Manager stated she did not have a recipe for the gravy that was served on the pork. The cook and three dietary aids plate the food and check the meal ticket for allergies. V12 stated that flour has gluten in it and the cook and staff are aware. V12 there is only one resident with a gluten allergy. V12 stated the gelatin did have red dye. If an allergy to gluten the resident should not get the gravy. If the resident has a red dye allergy, they should not get the gelatin. On 10/17/24 at 01:13 PM, V14 [NAME] stated the pork gravy was made from pork drippings, salt, pepper, garlic, flour and a little cold water. V14 stated he only made one type of gravy and did not make a special gravy for anyone. Review of the recipe for apple crisp lists all-purpose flour as one of the ingredients. Review of the gelatin product ingredients includes red 40 and red 40 lake. 2. R30 admitted to the facility with diagnoses that includes chronic obstructive pulmonary disease, dermatitis, hypertension, severe protein calorie malnutrition, gastro-esophageal reflux disease and adult failure to thrive. R30's MDS (Minimum Data Set) dated 9/13/24 indicates she is cognitively intact. The current care plan states R30 has abdominal pain related to an ileus. Interventions include to monitor, record and report to the nurse loss of appetite or refusals to eat. R30's current physician diet ordered is general diet mechanical soft texture, regular thin consistency, super cereal at breakfast, nutritional treat with lunch, pudding with dinner. Dietician to re-evaluate for food preferences. On 10/15/24 at 12:52 PM, R30 stated she got apple sauce, gelato and apple juice but she couldn't eat them because it would upset her stomach. She stated she is sensitive to dairy too. R30 stated if she told them she wouldn't get anything to eat or drink. On 10/17/24 at 10:29 AM, R30 stated got a banana for breakfast but gave it back to the CNA. R30 stated she had not seen the dietician at all this year as far she could recall. On 10/17/24 at 10:29 AM, V18 Family Member stated fruit doesn't agree with R30 as it gives her runny bowels / diarrhea. On 10/17/24 at 12:53 PM, R30 got gelatin with fruit, apple juice and milk on her lunch tray. On 10/17/24 at 10:54 AM, V16 CNA stated R30 did give her the banana back at breakfast. R30 will usually give the gelato and banana back and give the juice to the housekeeper. R30 mainly drinks coffee and water. V16 stated she didn't know why R30 sent the items back and she didn't want to know why. On 10/17/24 at 10:58 AM, V17 LPN (Licensed Practical Nurse) stated R30 did not have any food allergies on her chart. An order was entered on 4/9/24 for the dietician to see R30 for food preferences. V17 did not find any documentation that the dietician had seen R30 since the order was entered. On 10/17/24 at 01:25 PM, V2 DON (Director of Nursing) stated There was an order from April 2024 for the dietician to follow up with R30 for food preferences. If the dietician had seen her there would be a progress note or an assessment done. V2 did not find any progress notes or assessments by the dietician since the order was entered. V2 stated the nurse or nurse manager should have reached out to the dietician to follow up with the resident. On 10/17/24 at 02:22 PM, V15 Dietician stated she did not know at that moment if she or the aide had seen R30 or if she had been notified of a follow up. V15 stated nursing notifies her of new orders. V15 stated if she had been seen there would be a progress note or assessment documenting the follow up. The facility policy Food and Nutrition dated 4/17/24 states it is the policy of the facility to ensure that facility staff support the nutritional wellbeing of the residents while respecting an individual's right to make choices about his or her diet. The facility will provide each resident with a nourishing, palatable, well- balanced diet that meats his or her daily nutritional and special dietary, needs taking into consideration the preferences of each resident.

Based on observation, interview and record review, the facility failed to provide two person assistance during incontinence care and failed to implement a post fall intervention. This failure applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in the resident falling off the bed and sustaining a left femur and a right shoulder fracture. The findings include: R1's EMR (electronic medical records) showed that R1 was sent to the ER (emergency room ) on May 9, 2024 post fall and readmitted to the facility on [DATE] after hospital stay with diagnoses of unspecified fall, subsequent encounter, nondisplaced fracture of lateral condyle of right femur, subsequent encounter for closed fracture with routine healing, fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with routine healing, unspecified injury of head, subsequent encounter. R1's diagnoses prior to discharge to the hospital included morbid (severe) obesity due to excess calories, other idiopathic peripheral autonomic neuropathy. Initial Consultation at ED (Emergency Department) on May 9, 2024 included the following information: R1 is a [AGE] year old female presented to ED for further evaluation after mechanical fall out of bed at the nursing home. R1 is on Xarelto (blood thinner) and primarily complained of headache where she hit her head, right shoulder pain and left knee and hip pain. ED evaluation with X-ray to shoulder shows comminuted displaced right neck humeral fracture primarily involving the humeral neck which is displaced up to 1.7 cm (centimeters) and also involves the humeral head cortex and tuberosities, soft tissue edema present. CT (Computed Tomography) of left knee shows fracture of both medial and lateral distal femur essentially nondisplaced extending into the tibiofemoral articular surface as well as patellofemoral articular surface. Orthopedic surgery was consulted for further management. R1's quarterly MDS (minimum data set) dated March 5, 2024 showed that R1 was moderately impaired in cognition. The same MDS showed that R1 was dependent on staff for toileting hygiene. The MDS assessment showed that the term dependent included that helper does ALL of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. R1's Fall Risk assessment dated [DATE] showed that R1 was at high risk for fall with a score of 16. R1's EMR showed that R1 was 264.0 pounds on May 3, 2024. Facility Final Report of R1's fall incident dated May 9, 2024 to IDPH (Illinois Department of Public Health), included that during ADL (activities of daily living) care, R1 was repositioned on her left side and slid off bed. R1 complained of pain to right arm. Medical Doctor notified and R1 sent to ER via 911 for evaluation. R1 sustained injuries of right humeral fracture and left humeral fracture. The same report included that according to CNA (Certified Nursing Assistant) interview, she was on R1's right side and she assisted R1 to the middle of the bed so that she could clean her and change her linen and was unable to prevent R1 slipping off the edge of the bed. Nursing progress notes dated May 9, 2024 included that per investigation of above incident, there was only one person present during care. R1's care plan initiated December 23, 2020 included that R1 has ADL self care deficit related to obesity, muscle weakness which may lead to physical limitations low activity tolerance related to diagnoses of degenerative disease to left knee, and back, carpal tunnel, peripheral autonomic neuropathy. Intervention created and initiated on March 8, 2024 included for staff to provides extensive to total assist in bed mobility, transfer, toileting check and change . R1's care plan revised May 09, 2024 included that R1 had an actual fall related to poor balance. Interventions created and initiated on May 09, 2024 included to transfer to ER 911 for evaluation. Upon return bariatric bed will be provided and 2 staff will assist for ADLs. Interventions created and initiated on May 17, 2024 included : Protection /Safety Hazards/Peril: Staff will assess its physical environment, device, equipment, including furniture, appliances, beds, wheelchairs, etc. to ensure that it don't pose as a safety risk or hazard. On May 20, 2024 at 9:38 AM, R1 was seen lying in a regular sized bed and appeared morbidly obese and occupied the entire width of the bed and mattress with no extra space on either side. When asked if the bed/mattress size were adequate size for her, R1 remarked No, both are too small. R1 stated that she was in a similar sized bed when the fall incident occurred. Regarding the fall incident of May 9, 2024, R1 stated I fell when she (CNA) was changing me (providing incontinence care). She turned me towards the door (left side) to the edge of the bed and before you know it, I was on the floor. She was the only person changing me then. Now there are two. Happened after 5 (5:00 AM) in the morning. R1 stated that there were no side rails for her to hold on to while she was turned. R1 stated that she broke her right shoulder and left leg during the fall. R1 stated that the bedside table was there towards the left side during the fall. On May 20, 2024 at around 10:20 AM, facility was asked to provide measurements of R1's mattress and bed. On May 20, 2024 at 12:17 PM, V1 (Administrator) stated that R1 was on a 42-inch bed during her fall incident and was placed in a 42-inch bed when she was readmitted over the weekend. V1 stated that a 48-inch bed is considered a 'bariatric' bed. On May 20, 2024 at 12:39 PM, V5 (Assistant Director of Nursing) stated that she did the root cause risk analysis post R1's fall and had intervention in R1's care plan that she (R1) would have a bariatric bed on readmission from hospital. V5 stated that a bariatric bed is 6 inch wider than R1's previous bed. On May 20, 2024 at 1:04 PM, V6 (Maintenance Director) stated that around 10:30 AM that morning, he was told to change R1's both bed and mattress from a 42 inch to 48 inch bed and mattress. V6 stated, that the 42-inch bed is extendable to a 48-inch bed. V6 stated that he was not notified earlier to do the same. On May 20, 2024 at 2:15 PM, V3 (CNA) stated that she works the night shift and has always assisted R1 with incontinence care by herself. V3 stated that on May 9, 2024 at around 6:00 AM, while providing incontinence care for R1, she was on the right ride of R1 and turned R1 on to her left side towards the middle of the bed. V3 stated that the sheet underneath R1 was wet so she proceeded to change the whole bed and pulled the sheet from underneath R1. V3 stated that just as she turned to get the clean linen, R1 rolled off the bed on the left side towards the bedside table. V3 stated that she was unable to prevent R1 from sliding off the bed. On May 20, 2024 at 10:28 AM, V4 (CNA) stated that she usually works the day shift and has taken care of R1 prior to her fall incident. V4 stated I used to do her incontinence care by myself. I always pull her towards me and turn her so that she has more room. On May 20, 2024 at 2:55 PM, V8 (MDS Coordinator) stated that toileting hygiene includes wiping the resident during incontinence care. V8 stated that R1 is not able to wipe herself. V8 stated that the term 'dependent' usually involves two or more staff. On May 20, 2024 at 3:11 PM, V9 (R1's Physician) stated that the facility should follow their protocol regarding assistance or provide bariatric bed depending on whatever difficulty the patient has in bed. Facility Policy titled Fall Prevention and Management (last revised April 8, 2024) included as follows: Policy Statement: 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. Procedures: 2. Fall interventions: b) High Risk Precautions will be implemented to residents and patients whose scores on Resident Family/Notification screen shows high risk will be considered on this precaution. 4. Fall Response: Investigate fall circumstances. Initiate Risk Management/Fall Event. 2.m. Safety hazards 5. Implement immediate intervention post fall at least within same shift.

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for COVID-19 resident rooms. This failure has the potential to effect all residents in the facility and has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on August 16, 2021 when V3 (Licensed Practical Nurse/LPN) was observed in R32's room without an isolation gown or gloves on. The Immediate Jeopardy was identified on August 16, 2021. V1 (Administrator) was informed of the Immediate Jeopardy on August 17, 2021. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on August 17, 2021; however noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The CMS 672 form (Resident Census and Conditions Report), dated August 17, 2021 showed 129 residents in the facility. A list provided by the facility on August 16, 2021 showed 84% of residents and 74% of staff have been fully vaccinated against COVID-19. The facility Daily Census list dated August 16, 2021 showed R32 and R132 were on airborne/droplet transmission based precautions (isolation) and were considered to be PUI (patients under investigation), to rule out COVID-19. Outside of R32 and R132's rooms were isolation carts and isolation signage indicating R32 and R132 were each on droplet isolation/transmission based precautions. The droplet isolation signage showed any staff entering the room was required to wear a gown, N95 mask, gloves, and eye protection when in the room. R32's Order Summary Report dated August 10, 2021 showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 16, 2021 at 10:20 AM, R32 was observed lying in bed in her room. V3 LPN was standing directly next to R32, to the right of R32's bed. The door to R32's room was open. V3 LPN had no isolation gown or gloves on, only a N95 mask and personal eye glasses. A droplet isolation sign hung on the door frame outside of R32's room. At 10:21 AM, V3 LPN exited R32's room. Upon exiting R32's room, V3 LPN was asked if R32 was on isolation, V3 LPN stated, I don't know. On August 16, 2021 at 12:34 PM, V5 Certified Nursing Assistant (CNA) entered R32's room wearing only a surgical mask. R32 did not don an isolation gown, face shield, N95 mask, or gloves prior to entering R32's room. Upon exiting R32's room, V5 CNA was asked about R32's isolation precautions, V5 stated, We are supposed to wear a N95 mask, face shield, a gown, and gloves when going into (R32's) room. I was just moving too fast and forgot. On August 16, 2021 at 10:25 AM, V4 Registered Nurse (RN) stated, (R32) is on droplet isolation to rule out COVID-19 because (R32) was recently readmitted to the facility from the hospital. Staff must wear full PPE (personal protective equipment) when in her room which includes a face shield, gown, gloves, and a N95 mask. On August 17, 2021 at 8:25 AM, V7 (Licensed Practical Nurse/LPN) entered R32's room wearing only a surgical mask (not an N95), face shield, gown and gloves. Sitting on top of the medication cart that V7 was using, was a brand new N95 mask. At 8:35 AM, when V7 was asked by the surveyor what type of isolation R32 was on, V7 replied R32 was on contact isolation for an infection in a wound. V7 said this is her first day working at the facility and the report sheet that she was given does not list that R32 is considered a PUI or on isolation for anything else. V7 said she would have put on a N95 mask before she entered the room had she known that R32 was a new admission and on droplet isolation to rule out COVID-19. R132's Order Summary Report printed August 16, 2021 showed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On August 16, 2021 at 12:27 PM, R132 was lying in bed. The door to his room open. A droplet isolation sign hung on the door frame outside of R132's room. V5 CNA entered R132's room wearing a surgical mask, an isolation gown, and gloves. V5 CNA's surgical mask was down below her nose. V5 did not don a N95 mask or face shield prior to entering R132's room. On August 16, 2021 at 12:59 PM, V6 RN/Infection Preventionist stated, (R32) and (R132) are on droplet isolation to rule out COVID-19 because they are a new admission or readmission to the facility. All staff must wear a N95 mask, an isolation gown, a face shield, and gloves while in droplet isolation rooms. On August 16, 2021 at 2:00 PM, the Illinois Department of Public Health website was reviewed and showed the Dupage County COVID-19 positivity rate for the period of August 1, 2021 to August 7, 2021 (the most recent posting) to be 5%. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic last updated March 29, 2021 shows, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. The Centers for Disease Control Preparing for COVID-19 in Nursing Homes-Create a Plan for Managing New Admissions and Readmissions updated 11/20/2020 shows, HCP (Healthcare personnel) should wear an N95 or higher-level respiratory mask, eye protection, gloves, and gown when caring for new admissions and readmissions. The facility's Transmission-Based Precautions and COVID-19 policy dated July 1, 2020 showed, In our facilities, because aerosol generating procedures are rare, we are utilizing transmission based precautions in caring for known or suspected patients with COVID-19. Because the organism can be spread by droplets through the air, we are utilizing a combination of droplet and airborne transmission-based precautions. The same level of precautions are utilized regardless of whether the patient is on a special COVID-19 Airborne Isolation Unit (CAIU) or is in a private room with their own bathroom anywhere else in the facility. *N-95 respirator/mask *Eye protection (face shield, goggles, or safety glasses with attached side shields) *Gown *Gloves . The Immediate Jeopardy that began on August 16, 2021 was removed on August 17, 2021 when the facility took the following actions to remove the immediacy: 1. The DON (Director of Nursing), Unit Manager, Infection Preventionist, Transition Nurse, and Assistant Administrator will in-service all current staff and incoming staff prior to the beginning of their shift on when to wear and how to properly don and doff personal protective equipment per the CDC guidelines for a PUI and COVID patient and prevent possible exposure to COVID-19 by 8/24/21 and quarterly. 2. The DON, Unit Manager, Infection Preventionist, Transition Nurse, and Assistant Administrator will competency all current staff and incoming staff prior to the beginning of their shift on PPE donning and doffing. 3. The DON, Unit Manager, Infection Preventionist, Transition Nurse, and Assistant Administrator will audit and ensure that all PUI resident's for COVID-19/new admissions in airborne/droplet isolation cart outside their doors which will include extra N95's, protective eyewear, gloves, gowns, and appropriate PPE. 4. The DON, Unit Manager, Infection Preventionist, Transition Nurse, and Assistant Administrator will audit staff donning and doffing procedures and observe 5 observations daily for 5 days, then weekly on all shifts to ensure that policies and procedures are followed per guidelines. 5. Medical Director, has been notified on 8/17/21. 6. A Quality Assurance meeting was held 8/17/21 to review the findings of the IJ, to review the abatement plan, and review to determine future training and audit schedule.

Based on interview and record review the facility failed to identify a blister as a pressure ulcer, and failed to prevent a pressure ulcer from becoming infected. This failure resulted in R32 developing [CONDITION(S)] requiring surgery and a toe amputation. This applies to 1 of 10 residents (R32) reviewed for pressure in the sample of 26. The findings include: R32's active face sheet showed she was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's 3/5/2021 Minimum Data Set (MDS) showed that R32 was mildly cognitively impaired, she was not able to walk, she was remaining in bed most days and when she was up, she was using a wheelchair and needed staff to push her. The same MDS shows that she was requiring extensive assistance from staff with all of her Activities of Daily Living (ADL's). R32's skin integrity care plan showed she was at risk for impaired skin integrity, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan also showed an additional entry on 6/8/2021 indicating that R32 had a new skin alteration: blister to her right foot 1st hallux (big toe). A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care nurse is following the patient. There is no documentation in R32's nursing progress notes about a scab or any injury occurring for R32. A wound progress note for R32 completed by V15 (Wound Nurse Practitioner) on 4/26/2021, showed that R32 had a new skin alteration to her right foot 1st toe and stated, Patient has an acute blister to her right foot plantar 1st toe. Area has skin flap present to the area that is non adherent. Skin flap removed to reveal granular tissue. Moist wound bed with no [sign or symptoms] of infection noted. A nursing skin and wound evaluation completed on 4/26/2021 for R32 showed that R32 had a new blister on her right toe that is in-house acquired and measures 0.9 centimeters (cm.) long, x 0.8 cm wide, x 0.1 cm deep. A nursing skin and wound evaluation completed on 5/24/2021 showed the wound on R32's toe is 1.2 cm long, 1.4 wide, 0.2 deep. The same document says nursing was educated on the importance of wound care and hygiene, turning and repositioning, and R32 is being referred to a podiatrist. A wound progress note completed by V15 on 6/7/2021 states, Chronic blister to patients right foot plantar 1st toe remains open today and has slight increase in size noted today. Wound continues to have mostly granular tissue noted. Bone is palpable but not visible today. Small amount of slough noted to the wound bed today. Patient has small amount of bloody drainage from the area and small amount of purulent drainage from the medical aspect of the right foot great toe nail which is loose today. Patient reports moderate discomfort with wound care. A nursing skin and wound evaluation also completed on 6/7/2021 showed the wound is deteriorating with bloody drainage. A nursing progress note completed on 6/11/2021 showed R32 went out for a appointment with V16 (Podiatrist) and returned with orders to avoid pressure to wounds and [CONDITION(S)] control as well as dressing change orders. There is no mention in the progress note about an antibiotic or the wound being infected. A nursing progress note dated 6/12/2021 states, Continues PO (by mouth) ABT (antibiotic) for right great toe wound . The facility was asked by the surveyor for copies of the podiatrist consult report for this date, but were unable to locate or obtain one. A wound progress note completed on 6/14/2021 by V15 showed R32 was having purulent drainage from the toe wound and antibiotics will continue for 10 days total. A nursing progress note completed on 6/24/2021 showed R32 went to a out patient wound care appointment and needs debridement of the toe wound but it was not able to be done due to no power of attorney consent. A nursing progress note showed that R32 went for an out patient appointment on 7/15/2021 to see V16. A wound care initial visit report completed by V16 on 7/15/2021 states, Patient has a history of dementia and has an ulcer on the right great toe supposedly from trauma but no history provided. Unable to get history from {the facility}. Patient does not ambulate or stand. There is exposed bone that is palpable through the ulceration. The same report also says R32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The report shows that a wound culture was obtained, and surgical intervention would most likely be required due to exposed bone at the digit. There was no documentation in R32's medical record that the results of the wound culture results were obtained by the facility. Hospital records from a local community hospital show on 8/6/2021. R32 underwent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The same hospital records show a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] {Methicillin-resistant Staphylococcus aureus} X-Rays had shown erosion at the inner phalangeal joint consistent with [CONDITION(S)]. The hospital records also indicate the wound culture that was done on 7/15/2021 had shown MRSA to the wound. R32 was started on IV antibiotics, via a PICC line (peripherally inserted central catheter) and was readmitted to the facility on [DATE]. On 8/18/2021 at 9:28 AM, V14 (Wound Care Nurse) said she was not the wound nurse when the initial blister was discovered. She said that the blister to R32's toe just appeared and they were not sure how it happened but possible from friction. V14 said she was not able to find any injury as the cause of the blister. V14 said she was unable to find all of the consultation reports for R32's podiatrist appointments. She also said that between May and June R32's wound continued to deteriorate at the facility and ultimately R32 developed an infection and [CONDITION(S)], and R32 had to have her toe amputated. On 8/18/2021 at 10:17 AM, V15 said that she is unsure what caused R32's toe ulcer (blister) because it is not a usual place for friction to occur. V15 also said that R32 was typically in bed and should of had boots on her feet. She said she was unaware that the culture from R32's wound on 7/15/2021 was positive for MRSA. V15 said that [CONDITION(S)] to R33's bone would be caused from an infection in the wound. On 08/18/21 at 10:36 AM, V13 (R32's Physician) said he took over as R32's primary care physician shortly before her surgery and the toe amputation. R32 said basically this resident was bed bound and had some protein calorie malnutrition, and yes unfortunately this was a pressure injury that started as a deep tissue injury that never healed, became infected, developed [CONDITION(S)], and resulted in a toe amputation. V13 said even though she was wearing boots unfortunately that was not enough of an intervention to prevent the pressure ulcer. He said that the cause of R32's wound infection could be from bacteria exposure during the dressing changes.

Based on observation, interview and record review, the facility failed to implement interventions to prevent the development of facility acquired pressure ulcers for R2 and failed to promptly develop a care plan for R3 after R3 developed an acquired pressure ulcer.. This applies to two of three residents (R2, R3) reviewed for pressure ulcers in the sample of three. This failure resulted in R2 developing five facility acquired pressure ulcers, one of which developed in the facility, became unstageable and infected while R2 was in the facility requiring the resident to be hospitalized . The findings include: 1). R2 is an [AGE] year old woman, admitted to the facility on [DATE] " post left hip surgery after a fall " per the facility ' s nursing documentation dated 12/22/2014. R2 ' S electronic medical record (EMR) showed [DIAGNOSES REDACTED]. R2's was noted upon admission date of [DATE] with purple discoloration on her sacrum of 8 centimeters (cm.) x 6 cm. which then progressed to a 12.0 x 12.0 cm. unstageable pressure ulcer. In addition, R2 developed five facility acquired pressure ulcers which included two Stage I pressure ulcers; one on R2 ' s right trochanter measuring 6.5 cm. x 5.0 cm., and one on R2 ' s left lateral lower extremity measuring 6.0 cm. x 1.0 cm., and three unstageable pressure ulcers; one on R2 ' s left ischium measuring 8.5 cm. x 4.0 cm., one on R2 ' s right heel measuring 2.5 cm. x 5.0 cm., and one on R2 ' s left heel measuring 4.5 x 5.0., requiring hospitalization for wound infection. R2 ' s Minimum Data Set ((MDS) dated [DATE] showed R2 was moderately cognitively impaired with a score of 8 on her Brief Interview of Mental Status (BIMS). The MDS showed R2 required extensive assistance with transfers, dressing, eating, hygiene, and toileting. R2 had an indwelling urinary catheter, and was always incontinent of bowel. R2 ' s initial skin assessment signed on 12/23/2015 showed R2 had purple discoloration on her sacrum approximately 8 x 6 centimeters (cm.), front groin pelvic area purple bruising, and three left hip area intact/approximated incisions with staples in place. R2 ' s Braden Scale was 14 on admission, putting R2 at moderate risk for skin breakdown. On 1/14/2015, at 3:40 p.m., R2 was laying on her back in bed. R2 ' s bed had a low air, loss pressure relieving mattress in place. Z1 (R2 ' s family member) was seated at R2 ' s bedside. Z1 stated she had been sitting at the bedside since 1:30 p.m. and R2 had remained in the same position during that time period, and that no facility staff had been in the room to reposition R2. At 3:45 p.m., Z1 used the call light to call for staff assistance. Z1 explained to the facility staff she had been in R2 ' s room for almost three hours and had not seen R2 ' s position changed. Staff complied with Z1 ' s request and repositioned R2. On 1/15/2015 R2 was intermittently observed laying on her right side, between the hours of 8:30 a.m. and 11:55 a.m.; R2 was not repositioned. Z1 (R2 ' s family member) stated R2 ' s position " had not been changed all morning. " On 1/15/2015, at 12:30 p.m., E6 (CNA-Certified Nursing Assistant) said R2 ' s last incontinence care and position change was performed " between 6:30 and 7:00 a.m. this morning. " E6 stated she had not repositioned R2 since 7:00 a.m., " because I think the night shift nurse told me to keep R2 on her side. " E6 stated residents should be repositioned every 2 hours. On 1/15/2015, at 12:05 p.m., E3 (RN-Registered Nurse/Wound Care Nurse) changed R2 ' s pressure ulcer dressings. Loose, wet stool was present in R2 ' s incontinence brief and dried, crusty stool was stuck to R2 ' s buttocks. Incontinence care was performed on R2, prior to the dressing changes. Pressure ulcers were observed on R2 ' s sacrum, right trochanter, right heel, left ischium, left heel, and left lateral lower extremity. Immediately following the wound dressing change, E3 stated residents should be repositioned every two hours. E3 also stated that resident's care plans should be updated "right away" when a resident develops a pressure ulcer, but admitted she does not always do so. The facility ' s Cumulative Skin Report dated " Week of: 12/29//2014 " showed R2 had a 7.0 cm. x 7.0 cm. unstageable pressure ulcer on her sacrum. The facility ' s Cumulative Skin Report dated " Week of 1/12/2015 " showed R2 ' s sacral pressure ulcer measured 12.0 cm. x 12.0 cm., and five facility acquired pressure ulcers were present. These included two Stage I pressure ulcers; one on R2 ' s right trochanter measuring 6.5 cm. x 5.0 cm., and one on R2 ' s left lateral lower extremity measuring 6.0 cm. x 1.0 cm., and three unstageable pressure ulcers; one on R2 ' s left ischium measuring 8.5 cm. x 4.0 cm., one on R2 ' s right heel measuring 2.5 cm. x 5.0 cm., and one on R2 ' s left heel measuring 4.5 x 5.0. On 1/15/2015 at 11:05 a.m., E2 (DON-Director of Nursing) said residents should be repositioned every 2 hours. On 1/15/2015 at 1:15 p.m., E4 (RN-Director of Care Delivery, 1st Floor) said residents should be repositioned and checked for incontinence every 2 hours. On 1/15/2015 at 3:10 p.m., Z4 (MD-Primary Physician for R2) said he was aware of R2 ' s facility acquired pressure ulcers. Z4 said frequent repositioning of R2 was important to prevent pressure ulcers, and that not being respositioned could have played a role in the development of her pressure ulcers. Z4 said he is aware that R2 can be uncooperative with care, but R2 should still be repositioned every 2 hours. On 1/9/2015, E3 (RN/Wound Nurse) documented R2 acquired a pressure sore on her left ischium and left heel. On 1/13/2015, E3 (RN/Wound Nurse) documented R2 acquired pressure sores on her right ischium, right heel, and left lateral lower extremity. E3 created a care plan addressing R2 ' s pressure ulcer of the sacrum on 12/26/2014. Interventions initiated on 12/23/2014 included " encourage and assist as needed to turn and reposition, and special mattress/cushion on bed/wheelchair. " R2 ' s care plan was not updated after the initial care plan was created on 12/26/2014, as R2 ' s sacral pressure ulcer worsened, as noted in E3 ' s nursing documentation on 1/9/2015; " decline to sacral wound " and on 1/13/2015 "sacral unstageable pressure ulcer wound now 12.0 x 12.9 cm. " R2 ' s care plan did not address an alternate plan of care when R2 refused repositioning or dressing changes. The facility's nursing documentation dated 1/16/2015 at 11:27 a.m., showed R2 was sent to a local hospital due to her wounds after being seen by Z2 (MD-Wound Doctor) and Z4 (MD) on 1/16/2015. Follow up documentation on 1/16/2015 at 7:05 p.m. showed R2 was admitted to the hospital with [REDACTED]. The facility ' s policy entitled " Skin Practice Guide " dated 1/2013 showed: " Phase 3: Implement - Positioning, Mobility, Restraints . . . Minimize direct pressure over vulnerable areas and actual pressure ulcers, maintain head of bed elevation at less than 30 degrees, unless contraindicated, reposition frequently; use friction reducing devices for assistance, elevate or float heels, even if patient is on specialty support surface. " The facility ' s Skin Practice Guide also showed residents have " a right to refuse the care designed in the care plan. In this case, staff performs several tasks, including: designing an alternate plan, offering alternatives and documenting the patient ' s comprehension of options presented. This revised strategy needs to be described in the care plan and documented in the patient ' s medical record. Update the care plan to reflect any changes in the patient ' s risk status. " 2). R3 is an [AGE] year old woman admitted to the facility on [DATE] post left hip surgery for [REDACTED]. E3 ' s (RN/Wound Nurse) documentation on 10/23/2014 showed R3 was admitted to the facility with [DIAGNOSES REDACTED]. . . with scattered blanchable [DIAGNOSES REDACTED] to buttocks and sacral area. Patient at risk for skin breakdown, related to above comorbidities, limited mobility related to [MEDICAL CONDITION] and reluctance to be repositioned. " R3 ' s MDS dated [DATE] showed R3 was cognitively intact with a BIMS score of 14, and required extensive assistance with transfers, ambulation, dressing, hygiene, bathing and toileting. R3 was frequently incontinent of bowel and bladder. The facility ' s Cumulative Skin Report dated Week of: 12/08/2014 showed R3 had a facility-acquired Stage II pressure ulcer on her coccyx measuring 0.5 x 0.5 cm. E3 ' s nursing documentation showed R3 had developed a Stage II pressure ulcer on her coccyx on 12/08/2014. A care plan was created on 1/14/2015 by E3 to address R3 ' s coccyx pressure ulcer that developed a month earlier on 12/8/2013. Prior to 1/14/2015, there was no care plan in place to address R3 ' s pressure ulcer or risk for skin breakdown " related to recent hip surgery, diabetes, impaired mobility or incontinence. " The facility ' s " Skin Practice Guide " showed " Phase 2: Plan. . . When the interdisciplinary team designs the comprehensive care plan to address the problem(s) associated with potential or actual skin alteration, a measurable goal is developed and a target date is established. . . . Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient ' s condition and needs change. "

Based on observation, interview and record review, the facility failed to assess, develop and implement appropriate interventions, re-evaluate for the effectiveness of interventions, attempt alternative interventions and provide adequate supervision in order to minimize the risks for recurring falls and injury to two of three residents (R1 and R3) reviewed for falls. As a result of this failure, R1 sustained a left hip fracture and R3 had sustained multiple falls . Findings include: 1) Review of record showed that R1 was admitted to the facility on [DATE]. R1 is an [AGE] year old with [DIAGNOSES REDACTED]. Review of MDS(Minimum Data Set) dated 4/15/2011 showed that R1 was assessed as having a memory problem, some difficulty in decision making, has impairment in upper and lower extremities with range of motion. This assessment also showed that R1 requires extensive assistance with 1 to 2 person physical assist for transfers and bed mobility. Review of R1's nurses notes and occurrence reports showed that R1 had 3 falls/incidents from 3/2/2011 through 6/18/11. Occurrence reports showed the following fall incidents for R1: 3/2/11 - 12:15 P.M. - "(R1) got up from his wheelchair and sat in a regular chair then he (R1) got up 30 seconds later ambulated over to drinking fountain and fell to the floor hitting his head." 4/30/11 - 9:45 P.M. - "(R1) was found by aid sitting on the floor mat near his bed. (R1) stated he was going home." 6/18/2011 -2:10 P.M. - "(R1 ) stood up and attempted to walk and fell to the floor. (R1) complained of left hip pain." Review of R1's nurse's notes showed that R1 was sent to the local hospital precipitated by the fall of 6/18/2011. Hospital record dated 6/19/2011 showed that R1 sustained a left hip fracture from the fall. R1 had undergone a surgery(left hip arthroplasty) on 6/19/2011 to repair the fracture of the left hip. R1 returned to the facility on [DATE]. R1 was observed in the group activity on 8/9/2011 at 2:00 P.M. . R1 was observed with bouts of confusion and with left hand hemiparesis. Review of facility's investigation for the fall of 6/18/2011 showed that R1 was verbally abusive and physically aggressive towards other residents in the dining area . R1's aggression was noted after lunch which was prior to the fall incident. The facility investigation also showed that R1 was removed from the dining room to be separated from other residents. R1 was placed by the lounge area across the nurse's station. Few minutes after R1 was placed at the lounge area, R1 stood up, attempted to walk , then fell to the floor. E3 (CNA, certified nurse assistant) stated on 8/10/2011 at 12:20 P.M., that R1 was agitated, verbally abusive toward other residents in the dining room an hour prior to the fall incident of 6/18/2011 at 2:10 P.M. E2 (Assistant Director of Nurses) stated on 8/10/2011 at 10:45 A.M., that R1 has poor safety awareness, impulsive and has bouts of confusion. E2 further stated that R1 was verbally abusive and tried to swing at other residents prior to the fall incident of 6/18/2011. E2 further stated that there was no documentation to indicate that an assessment was done when R1 was identified with physical aggression. E2 also stated that there was no plan of care to address R1's physical aggression nor there were any alternative approaches tried after R1's fall incident of 4/30/2011. E5(Administrator) stated on 8/11/2011 at 9:35 A.M., that R1 is a high risk for fall. E5 also stated that approximately 30 to 45 minutes prior to the fall(6/18/2011), R1 was "a little bit of high energy" while at the dining room. E5 also stated that facility staff had intervened by separating R1 from other residents in the dining room. E5 further stated that R1 was placed at the lounge area across the nurse's station. E5 also added that around 5 minutes after R1 was placed at the lounge, R1 decided to stand up unassisted and fell to the floor. E5 also stated that facility "could have done a better assessment because I(E5) think he (R1) was tired, should have put him(R3) to bed and this could have prevented the fall. (R1's) family insisted that facility cannot put (R1) to bed before 2:30 P.M. and it was not 2:30 P.M. yet." Review of R1's nurse's notes and social notes showed no documentation that an assessment was done to determine appropriate intervention and monitoring to address R1's physical aggression/agitation. Review of R1's plan of care after the fall of 4/30/2011 showed no adjustment/revision or any attempts for alternatives in approaches, interventions, or goals prevent to further falls and/or injuries. E1(Director of Nurses) stated on 8/9/2011 that there was no revision of care plan when R1 had a fall incident on 4/30/2011. The failure for not doing an assessment on 6/18/2011 to address R1's aggression in order to determine appropriate intervention and monitoring resulted to a fall incident in which R1 had sustained a fracture of the left hip. Furthermore, there were no revisions or alternatives tried to prevent further fall occurrence after the fall of 4/30/2011. 2) Review of record showed that R3 is a [AGE] year old year old. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS(Minimum Data Set) dated 7/29/2011 and 8/1/2011 showed that R3 requires extensive assistance with 2 person physical assist for transfers and bed mobility. Review of R3's nurses notes showed that R3 is alert with bouts of confusion. Review of the occurrence reports showed that R3 had a total of 8 falls for a period of 17 days (from 7/23/2011 through 8/8/201). Occurrence reports showed the following fall incidents for R3: 7/22/2011 - 10:00 P.M. - "(R3) noted on floor next to low bed." 7/23/2011 - 12:14 A.M. - "(R3) rolled out of bed., 7/23/2011 - 2:27 A.M. - "(R3) noted laying on floor next to bed." 7/28/2011 - 4:00 P.M., -" After being left alone by physical therapy aide, (R3) slipped out of wheelchair onto the floor." 7/31/2011 - 9:30 P.M. - "(R3) was found on floor by CNA(certified nurse assistant). Informed by (R3), he was trying to go somewhere." 8/4/2011 - 1:30 A.M. - " Nurse noted (R3) laying on floor next to bed after hearing bed alarm. Nurse asked (R3) what happened. (R3) stated it was time to get up." 8/8/2011 -10:45 P.M. - (R3) was trying to get out of bed and fell on floor." Review of R3's plan of care after each fall showed no adjustment/changes in approaches, interventions, or goals prevent further falls and/or injuries to R3. E1 (Director of Nurses) validated above concern for no revision of care plan after each fall on 8/10/2011 at 4:00 P.M.