Every finding on record at Pearl of Joliet, The

Based on observation, interview, and record review, the facility failed to assure the facility dishwasher consistently achieved the required temperature to disinfect facility dishware.This applies to all 125 residents that receive dietary service from the facility kitchen.Findings include:On 05/05/2026 at 3:24 PM, V1 Administrator stated 125 residents were receiving meals services at start of the survey.On 05/05/2026 at 10:25 AM, the kitchen tour began with V13 Regional Operations-Dietary and V22 Dietary Manager. V13 stared the dishwasher disinfected by temperature and the final rinse should be a minimum of 180 degrees Fahrenheit. Four dish load cycles were observed. The first final rinse temperature was 174 degrees Fahrenheit. The second final rinse temperature was 185 degrees Fahrenheit. The third final rinse temperature was 164 degrees Fahrenheit. The fourth final rinse temperature was 175 degrees Fahrenheit.V13 stated the dishes would need to be sanitized manually until the dishwasher is serviced.V14 Dishwasher stated she tested the final rinse that morning, but she didn't remember what it was. V14 stated she looks at the digital reading while she is doing the dishes and it was fine. V14 stated that when the dish machine is not working properly, she should inform her supervisor.On 05/07/2026 at 12:43 PM, V20 Maintenance Director stated he was notified by the kitchen staff that last month there was a problem with the dishwasher. The repair company came out to repair a steamer and a pilot on an oven and he mentioned the dishwasher to them at that time, but they are unable to complete the dishwasher repair until a part that was ordered is received. V20 stated he called the repair company to come out to make repairs and had no documentation of the call or their visits to the facility.On 05/07/2026 at 1:02 PM, V19 Dishwasher stated he had previously informed V20 of problems with the dishwasher but did not recall the specific date. V19 stated he was not informed that while the dishwasher is waiting to be repaired, he should be using the three-compartment sink to sanitize the dishes and utensils. The three-compartment sink has only been used for the pot and pans.The dish machine temperature logs were reviewed for February, March, April and May 2026. The digital readings were recorded every day for each meal. Everyday for breakfast lunch and dinner the recorded wash temperature was 160 degrees Fahrenheit. Everyday for breakfast, lunch and dinner the rinse temperature was 160 degrees Fahrenheit. Everyday for breakfast, lunch and dinner the final rinse temperature documented was 180 degrees Fahrenheit.The undated facility policy Dish Machine Temp states the dishes pots, pans, utensils, cups, mugs, bowls etc. will be washed using procedure, chemicals and equipment that result in clean, sanitized items. High temperature machine temperatures, as required by the manufactured are wash from 150-165 Final Rinse 180 to 195. If temperature reads incorrectly notify the department head and / or inform maintenance department (usually by work order form). If unable to repair the dish machine by the next meal the meal ay be served on disposable plates with plastic utensils OR the dishes and flatware maybe washed in the three-compartment sink following standard procedures.The undated facility policy Equipment Failure and Repair states dining services equipment shall be maintained in a good state of repair. Staff is trained to report equipment that does not work or is not functioning properly. Supervisor or staff member reports problem to maintenance department according to facility procedure giving as much detail as needed to describe the problem. Outside repair service is called if the problem cannot be corrected in a reasonable time frame by the facility maintenance staff.

Based on observation, interview, and record review, the facility failed to prevent and treat for an insect infestation in the kitchen area.This applies to all 125 residents that receive dietary service from the facility kitchen.Findings include:On 05/05/2026 at 3:24 PM, V1, Administrator, stated 125 residents were receiving meals services at start of the survey.On 05/05/2026 at 10:25 AM, the kitchen tour began with V13 (Regional Operations-Dietary) and V22 (Dietary Manager). Black flying insects were present at the kitchen sink. In the dry storage area of the kitchen, there was a swarm of flying black insects. V13 denied being informed of problems with flying insects in the kitchen area. V13 stated she was unaware if the pest control company had previously noted or treated for any flying insects.On 05/07/2026 at 12:36 PM, V21 (Dietary Aide) stated he has seen the flying bugs in the kitchen, but he did not mention it to anyone.On 05/07/2026 at 12:43 PM, V20 (Maintenance Director) stated pest control came out the day before for bugs seen in the kitchen, but they did not provide him with a report. V20 stated he had no documentation of the pest control visit.The service inspection report from the pest control company, dated 04/29/2026, lists a Norway rat found in the laundry room. No other pest activity is documented on the report. No product application was utilized in the facility to treat any pest activity.The facility policy Pest Control, dated 5/15/2025, states the intent is to provide a healthy environment for residents.The facility's pest control policy does not provide direction on what to do when pest activity is discovered.

Based on observation, interview, and record review, the facility failed to prioritize resident discharge goals and preferences and facilitate timely discharge.This applies to one resident (R8) reviewed for discharges in a sample of 30 residents.Findings include:On 5/5/26 at 12:58 PM, R8 said she has been trying to get discharged to another facility. R8 said every time she calls the outside facility, their Social Worker tells R8 she is waiting on documentation to approve the transfer. R8 said the outside facility told R8 they need documentation saying R8 is not contagious, and this is the only thing holding up R8's transfer. R8 said she has been working with V6 (Social Service Director) to get the requested documentation sent.R8's Discharge summary, dated [DATE] by V6 (Social Service Director), states R8 will be discharged to facility in (city, state) on 4/2/26 per the resident's request. V6 did not document any follow up note after 4/1/26 stating why R8 was not transferred.On 5/6/26 at 2:09 PM, V6 (Social Service Director) said R8 is not under isolation and is not contagious. V6 said the facility in (city) said they needed documentation to prove some type of test, that she could not recall the name of, was negative. V6 said she was told by V3 (ADON/Assistant Director of Nursing) the facility does not have any paperwork showing R8 is negative for this specific bacterium or that the bacteria was inactive/dormant. On 5/6/26 at 2:55 PM, V6 said she does not have any other documentation regarding R8's transfer/discharge planning since V6's Discharge Summary note from 4/1/26. V6 said she talked to V3 (ADON) and V3 told V6 the bacteria that R8 had tested positive for in the past was Candida Auris also known as C. Auris. V6 said V3 told her R8 will always show up positive for C. Auris and there is no testing the facility could do to provide the requested not contagious documentation to the facility in (city). On 5/6/26 at 3:21 PM, V6 said she last spoke to R8 on 4/20/26 and told R8 she was still trying to get the requested documentation. On 5/6/26 at 3:24 PM, V3 said she is not sure where R8 had Candida Auris in the past, but usually once you have it, you will always test positive for it. V3 said she did not know when R8 was last tested for Candida Auris.R8's EMR (Electronic Medical Health Record) shows documentation from 4/13/26 by V28 (Infectious Disease Nurse Practitioner) stating patient requested to be transferred to an outside facility but was rejected due to history of C. Auris. Patient tested positive for C. Auris in the urine in October 2024. She exhibits no acute symptoms of infection and is asymptomatic currently. R8's urinalysis, culture and sensitivity from 11/14/24 and 9/9/25 were negative for candidal growth. Patient is safe for discharge form Infectious Disease standpoint with no concern for acute candidal (C. Auris) infection.On 5/6/26 at 3:47 PM, V6 (Social Service Director) was asked if she had reviewed the Infectious Disease note from 4/13/26, and she said she did not think to look at the notes. V6 said she was going by what V3 was telling her. V6 said if she had seen the note, she would have sent it to outside facility to get R8 transferred. V6 said she should have documented follow up social work notes in R8's chart regarding the discharge planning, and she does not know what happened, sometimes she gets distracted. On 5/7/26 at 2:01 PM, V1 (Administrator) said it is important to document the discharge planning process in the resident's chart so that all staff know where the resident is at in the process to facilitate a successful timely discharge. V1 said it is a concern R8 had discharge clearance from Infectious Disease last month that was missed. V1 said R8's transfer to her desired facility could have and should have been arranged sooner.The facility's policy titled, Discharge Planning, last revised 12/2025, states, Policy Statement: It is the policy of the facility to provide an ongoing, resident-centered discharge planning process that focuses on the resident's goals, preferences, needs, strengths, and post-discharge care requirements to support a safe and appropriate transition form the facility to another level of care, community setting, or home environment. The facility will ensure that discharge planning begins upon admission, is reviewed throughout the resident's stay, and involves the resident, representative, interdisciplinary team, and other appropriate individuals as necessary.Purpose: The purpose of this policy is to: promote safe, timely, and appropriate discharge transitions.support residents rights, preferences, and informed choices.Policy Guidelines.2. Interdisciplinary Team (IDT) Participation: The discharge planning process will involve the interdisciplinary team. The team will collaborate to ensure continuity and coordination of care.8 Documentation Requirements: The medical record will include documentation of: discharge planning discussions, resident goals and preferences, participation of resident/representative, IDT involvement, referrals and arrangements made, education provided.communication with receiving providers/agencies.Procedure:.During Stay:.3. Necessary referrals and arrangements will be initiated timely.

Based on observation, interview, and record review, the facility failed to provide personal hygiene for residents who required assistance from staff.This applies to 3 of 3 residents (R93, R48, R34) reviewed for ADLs (Activities of Daily Living) in a sample of 30. The findings include: 1. On 05/05/26 at 10:08 AM, R93's nails were 1.5 cm (Centimeters) long and had brown substances underneath them. R93 said she could not see the dirt underneath her fingernails. On 05/07/26 at 12:37 PM, R93's nails were still 1.5 cm long and had brown substances underneath them. R93 said she did not like having dirt underneath her nails and asked who was going to clean them for her. R93's face sheet showed she was admitted to the facility with diagnoses including lack of coordination, cognitive communication deficit, emphysema, type 2 diabetes mellitus, dementia, and adjustment disorder. R93's MDS (Minimum Data Set), dated 03/21/26, showed R93 had mild cognitive impairment and required moderate assistance with personal hygiene. R93's Care Plan, dated 09/25/24, showed R93 has an ADL self-care performance deficit related to activity intolerance, fatigue, limited mobility, weakness, decrease strength, low activity tolerance. 2. On 05/05/26 at 10:15 AM, R48 had facial hair that was two inches long on her chin. On 05/07/26 at 12:50 PM, R48 still had facial hair that was two inches long on her chin. R48 said she did not like having facial hair and wanted it to be removed. R48's face sheet showed she was admitted to the facility with diagnoses including polyosteoarthritis, peripheral vascular disease, paranoid schizophrenia, and bipolar disorder. R48's MDS, dated [DATE], showed R48 had moderate cognitive impairment and required supervision for personal hygiene. R48's Care Plan, dated 05/05/20, showed Restorative Program: R48 is placed on dressing and grooming due to weakness at times and a Care Plan, dated 07/28/22, which showed R48 has an ADL self-care performance deficit [related to] decreased mobility and cognitive loss. On 05/07/26 at 12:40 PM, V10 (CNA/Certified Nurse Assistant) said facial hair and nail care were provided to residents on their shower days. V10 said the staff should clean underneath the residents' nails because they could scratch and get dead skin and dirt under their nails and could cause an infection, especially if the brown substances were feces. V10 said R93's nails should not have brown substances, and they should be clean. V10 said they would notify the nurse if the resident refused nail or facial hair care. At 12:52 PM, V10 said R48 would not refuse if asked if she wanted her facial hair removed. On 05/07/26 at 12:45 PM, V11 (CNA) said on shower days, she provided nail and facial hair care for the residents. V11 said if the residents wanted to keep their nails long, they would need to clean underneath the nails to make sure there were no substances underneath them, which could cause an infection. V11 said R93's nails should not have dirt underneath them. 3. On 05/05/26 at 12:44 PM, R34 was in bed. R34 had an accumulation of facial hair. R34's hair was long, greasy, and uncombed. R34 stated he had asked for a shave several times from the staff. R34 stated he had not gotten a shave in a long time. On 05/07/26 at 10:45 AM, R34's continued to have full and thick facial hair. R34's hair remained long, greasy and uncombed. R34 stated he told the staff he wanted to be shaven, and get his hair washed and trimmed. On 05/07/26 at 10:55 AM, V24 (Registered Nurse) stated R34's hair should not be greasy, long, and uncombed. V24 stated R34 should not have an accumulation of facial hair. V24 stated the staff should be assisting R34 with ADL care on shower days and as needed. On 05/07/26 at 9:58 AM, V2 (Director of Nursing) stated residents should not have full, long facial hair. V2 stated their hair should not be long, greasy, and uncombed. V2 stated it is expected that the staff will give showers and perform hygiene as ordered and as needed. R34 was admitted to the facility on [DATE], with multiple diagnoses which included chronic obstructive pulmonary disease, diabetes, end stage renal disease, major depressive disorder, and osteoarthritis. R34's ADL self-care performance deficit care plan, dated 11/15/23, showed, Deficit related to weakness, decrease strength, limited mobility, and low activity tolerance. R34's MDS, dated [DATE], showed R34 required partial to moderate assist with shower/bathing, and supervision or touching assistance with personal hygiene. The facility's Activities of Daily Living Support with Showers, date reviewed 01/18/26, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2) Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to provide foot care to a diabetic resident.This applies to 1 of 1 residents (R88) reviewed for podiatry services in a sample of 30.Findings include:R88's diagnoses include congestive heart failure, type two diabetes, muscle wasting and atrophy, morbid obesity, end stage renal disease, and bilateral osteoarthritis of knees. R88's face Sheet showed she was admitted [DATE].On 05/05/2026 at 12:16 PM, R88 was sitting on the side of her bed with bare feet exposed. R88's feet were dry and crusty. Her toenails were long and jagged. R88 toes had a black-tipped French polish that had grown out well past the nail bed. R88 stated she hadn't had her nails cut in about five months. R88 stated she had requested from multiple staff to see the podiatrist for some time and had not been seen. R88 stated her son would take her to the nail shop but she wouldn't be able to get in their chairs to put her feet in the bowls to have a pedicure.On 05/06/2026 at 4:02 PM, V16, C.N.A. (Certified Nursing Assistant), assigned to R88, stated he couldn't think of any of his residents that needed to be seen by the podiatrist. V16 stated he does not cut toenails; he marks on the shower sheets residents that need to have their nails cut. The shower sheet is signed by the nurse then submitted to the DON (Director of Nursing). V16 stated there is also a podiatrist list at the nursing station that residents' names could be added to.On 05/07/2026 at 10:44 AM, V18, LPN (Licensed Practical Nurse), stated in her experience the Social Worker usually sets up podiatry appointments. V18 stated no one informed her R88's toenails needed to be cut. R88's toenails looked like they had been growing longer than six months. V18 stated R88 is a diabetic and she could be seriously injured if one of her toenails was bumped and broke off and put her at risk of infection. R88 stated her toenails looked like she could use them to climb a wall.On 05/07/2026 at 11:04 AM, V15, C.N.A, assigned to R88 stated she has taken care of R88 before but had never looked at her toes. V15 stated she washes R88, changes her brief, but had not previously noticed her toes. V15 stated normally she would have reported the toenails to the nurse but had not reported that R88 needed her nails cut.On 05/06/2026 at 3:26 PM, V6 Social Services Director stated the nursing staff add residents' names to a list to be seen by the podiatrist that is kept at the nursing station. V6 stated sometimes she gives the list to the podiatrist and sometimes he takes the list from the station himself. V6 stated she had the current lists available but did not have the podiatry list from previous months. V6 stated the podiatrist comes to the facility once per month and the list is not a guarantee that all residents will be seen by the podiatrist for that month. V6 stated after the podiatrist sees the residents, he emails her his after-visit assessment. V6 stated R88 had not been seen by a podiatrist since her admission to the facility.On 05/07/2026 at 1:23 PM, V2, DON (Director of Nursing), stated toenails are a part of foot care. Diabetics toenails should be kept cut to prevent the development of an infection or ingrown nails.The podiatrist list for May 2026 did not have R88 listed. R88 did not have any shower sheet completed prior to survey indicating she required her toenails be cut.The facility policy Foot Care, dated 05/20/25, states it is the policy of the facility 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.

Based on observation, interview, and record review, the facility failed to assess a resident for limited ROM (range of motion) and implement interventions to prevent a decline in ROM. This applies to 2 of 6 residents (R90 and R113) reviewed for Range of Motion in a sample of 30.Findings include: 1.On 05/05/2026 at 12:30 PM, R90's right hand was formed into a tight fist. R90 stated he was unable to stretch or open his right hand due to a stroke. R90 stated he did not have any type of splint or anything being done to keep his hand from staying in the first position. On 05/06/2026 4:02 PM, V16, C.N.A. (Certified Nursing Assistant), assigned to R90, stated R90 did not have a splint for his right hand. On 05/07/2026 at 10:09 AM, V17 (Restorative Nurse) went to R90's bedside to do an assessment. V17 stated she had just started at the facility at the beginning of the week and had not seen R90 before. V17 stated R90 was being seen by Restorative Services for bed mobility and dressing. V17 stated R90's previous documentation showed he had moderate limitation of strength to his right side; no mention of limited ROM (Range of Motion) to right wrist and fingers. V17 stated assessing R90 at bedside, she was unable to extend his right hand and fingers past thirty degrees. Interventions that could have been put in place to prevent R90's decrease in range of motion could have been PROM (Passive Range of Motion) as tolerated or a palm splint. R90's mobility assessment, dated 03/24/2026, states he has full ROM to his right elbow, wrist, and fingers. R90's updated assessment, dated 05/07/2026, states R90's right elbow ROM flexion decreased to moderate and his right wrist and fingers flexion and extension were now poor. R90's current care plan states R90 had a Cerebral Vascular Accident (CVA / Stroke). The resident will be free from signs / symptoms of complications of CVA. Interventions include monitor / document mobility status. If the resident is presenting with problems or paralysis, obtain order for physical therapy and occupational therapy to evaluate and treat. 2. R113 was admitted to the facility on [DATE] with multiple diagnoses which included aphasia, Wernicke's' Encephalopathy, major depressive disorder, and neuromuscular dysfunction. R113's Minimum Data Set/MDS, dated [DATE], showed R113 was cognitively intact. The same MDS showed R113 had impaired functional limitation to both of her upper and lower extremities. R113's Order Summary Report for May 2026 showed, (R113) has a contracture to the right hand/wrist. R113 has slight contraction to middle finger on left hand. Apply palm protector/rolled towel to right and left hand daily. Check skin integrity periodically. May remove splint for ADL/hygiene tasks and NOC (night). Ordered 03/05/2025. R113's contracture care, plan dated 11/27/23, showed, (R113) has a contracture to right hand/wrist. (R113) will decrease further contracture risk by next review. Apply palm protector/rolled towel to right hand daily. May remove splint for ADL/hygiene tasks and NOC. R113's contraction to middle finger on left hand care plan showed, Preserve functionally in daily activities. Apply palm protector/rolled towel to left hand daily. May remove splint for ADL/hygiene tasks and NOC. 05/05/26 at 11:33 AM, R113 was sitting in a high back wheelchair. R113 was unable to open both hands. R113's first fingers were extended on both hands; all other fingers were in a closed position. R113 was not wearing a splint, palm protectors, or rolled up towels in her hands. R113 stated she does not wear a splint/palm protectors and does not receive any exercises to her hands. On 05/06/26 at 2:54 PM, R113 was in bed sleeping. R113 continued to not be wearing splints, palm protectors, or rolled up towels in her hands. Both of R113's hands remained in the closed position with the first fingers on each hand extended. On 05/06/26 at 3:16 PM, V26 (Director of Rehab) stated R113 was not receiving any services through therapy at the moment. V26 stated R113 had never been evaluated for OT (Occupational Therapy). V26 stated he was not aware of the NP (Nurse Practitioner) writing an order on 04/16/26 for OT. On 05/06/26 at 3:29 PM, V2 (Director of Nursing) stated when an order is put in for OT, the resident should be evaluated. V2 stated she had no knowledge of an order written by the NP for R113 to receive OT. V2 stated if an order is given to the nurse for therapy, it is the nurse's responsibility to notify therapy. V2 stated R113 is supposed to wear palm protectors. On 05/06/2026 at 3:42 PM, V17 (Restorative Nurse) stated it is expected that the splints and palm protectors are applied to the residents as ordered. V17 stated if they are not worn as ordered, residents can get a contracture or further decline to an existing contracture.\ On 05/07/26 at 1:43 PM, V27 (Licensed Practical Nurse) stated she received the order from the nurse practitioner for R113 to receive OT for a decrease in ADL's, trigger finger bilaterally. V27 stated she did not inform therapy of the order. V27 stated she never told the DON or ADON (Assistant Director of Nursing) about the order for OT. The facility's Managing Residents with Impaired Physical Mobility Policy, dated 06/20/2020, showed, Facility will provide care and management of physical mobility impairment based on cause and nature for deformity. Facility will provide programs to prevent contractures and or further decline. 2) Treatment of Contractures, a) Physical therapy and occupational therapy evaluation and treatment as indicated, b) Restorative program based on assessment, c) Medical devices. Supportive devices such as splints and casts may be applied to stretch the tissues of the affected body part based on therapy/MD (Medical Doctor) recommendations.

Based on observation, interview, and record review, the facility failed to assess and care plan for a resident to ensure he is a safe smoker and failed to ensure the resident did not keep his smoking materials unsecured.This applies to 1 of 2 residents (R32) reviewed for smoking in a sample of 30.The findings include:R32's face sheet documents he was admitted to facility on 6/17/25. Diagnoses include atherosclerotic heart disease, type II diabetes mellitus, hyperlipidemia, dementia, chronic obstructive pulmonary disease, hypertension, major depressive disorder, anxiety disorder, and delusional disorder. MDS (Minimum Data Sheet), dated 4/12/26, shows he has intact cognitive functions and is independent with transfers.On 5/5/26 at 10:41 AM, R32 was sitting on his rolling walker; he had a pack of cigarettes and a lighter on his shirt pocket. Three more packs of cigarettes were on a shelf on top of his nightstand. R32 said he had more lighters in his blue bag. He said his girlfriend brought him cigarettes and lighters. A review of R32's EMR (Electronic Medical Record) on 5/5/26 at 1:00 PM shows R32 was never assessed for safe smoking since he was admitted and R32 did not have a care plan for smoking.On 5/7/26 at 1:30 AM, V6 (SSD-Social Service Director) said she was in charge of assessing residents for safe smoking and said she has never done an assessment for R32 since admission. She said assessment for safe smoking is done upon admission, quarterly and as needed to know if a resident can smoke independently or not. She said R32 should not have more than a pack of cigarettes in his room. He said smokers must turn all their cigarettes and lighters to the receptionist at the end of the day after the last smoking time at night.The facility provided a Smoker's Program care plan for R32, which was created on 5/6/26. Facility's Smoking Policy, dated 11/20/23, documents the following: Independent Smoking: Residents on the independent smoking program will have the opportunity to smoke between the hours of 7:00 AM to 7:00 PM. Independent smoking is a privilege that can be earned or taken away by compliance (or non-compliance) in the following area: Ability to safely put out and dispose of smoking materials in appropriate receptacles and return all cigarettes and lighters to the front desk immediately when returning. Every resident that is newly admitted or re-admitted to the facility will be assessed and monitored for safe and responsible smoking guidelines.

Based on observation, interview, and record review, the facility failed to check for G-tube (Gastrostomy Tube) placement before flushing the gastrostomy tube and before providing tube feeding. This applies to 2 out of 2 (R6, R13) residents reviewed for feeding tubes in a sample of 30.The findings include:1. R6's face sheet documents he was admitted to facility on 2/19/26. Diagnoses include pleural effusion, gastrostomy, acute and chronic respiratory failure with tracheostomy and dependent on ventilator, dysphagia, diabetes mellitus, atherosclerotic heart disease, and cachexia. MDS (Minimum Data Sheet), dated 3/26/26, documents he has intact cognitive functions and is dependent on staff for eating. R6's POS (Physician Order Sheet) shows order for G-Tube feeding order for Glucerna 1.5 at 80 ml per hour for 20 hours, on at 12:00 PM and off at 8:00 AM with G-Tube flush of 300 ml per hour every six hours. R6 also had an order for Ferrous Sulfate Oral Solution, give 220 mg via G-Tube three times a day. On 05/07/26 at 12:10 PM, V7 (RN-Registered Nurse) said she was starting R6's G-Tube feeding. She said she also has to administer Ferrous Sulfate before starting the feeding. V7 proceeded to set the flow rate as ordered and primed the tubing. V7 went back to her medication cart to get R6's medication. V7 then proceeded to flush the tubing with water, administered the medication, and hooked up and started the feeding. V7 did not check for placement of the G-Tube prior to administering the medication and feeding.R6's care plan, created on 3/19/25 and revised on 4/28/26, shows R6 requires tube feeding related to dysphagia, swallowing problem, infection, weight loss and depression. Interventions included checking for tube placement, size of tube, and gastric contents/residual volume per facility protocol and record. 2. R13's face sheet documents she was admitted to the facility on [DATE]. Diagnoses include acute and chronic respiratory failure, chronic obstructive pulmonary disease, dementia, epilepsy, paraplegia, and presence of gastrostomy and tracheostomy. MDS dated [DATE] shows R13's Cognitive Patterns were not assessed and R13's eating ability was not applicable which means activity was not attempted and the resident did not perform this activity prior to current illness, exacerbation, or injury.R13's POS show order for G-Tube feeding of Jevity 1.5 at 60 ml per hour, on at 12:00 PM and off at 8:00 AM with G-Tube flush with 275 ml water every six hours.On 05/07/26 at 12:30 PM, R13's tube feeding machine was beeping. V7 went into R13's room. R13 had ongoing G-Tube feeding. V7 said the beeping sound means there is blockage and she needed to flush the tubing. V7 disconnected R13 from feeding machine and flushed R13's tubing with water. V7 then proceeded to set the flow rate as ordered and re-primed the tubing. V7 then re-started R13's feeding. V7 did not check for placement of G-Tube prior to flushing the tubing and re-starting feeding. R13's care plan, initiated on 4/7/26, shows R13 requires a feeding tube related to dysphagia. Intervention included checking tube placement and gastric contents/residual volume per facility protocol and record. On 5/7/26 at 12:45 PM, V7 said she forgot to check for G-Tube placement before flushing the tubing and before providing G-tube feeding. She said placement should be checked to prevent aspiration. On 5/7/26 at 1:30 PM, V2 (DON-Director of Nursing) said she expects all nurses to check for G-tube placement prior to flushing and feeding. She said not checking placement will put the resident at risk for aspiration.Facility's Policy titled Enteral Feeding Medication Administration, dated 1/20/21 and reviewed on 6/16/22, 6/15/23, 5/28/24, 4/18/25 and 4/15/26, documents: Procedure: Residents admitted to Facility With An Enteral Feeding Tube: 6. Prior to flushing of a feeding tube, the administration of medication via a feeding tube, or the providing of tube feedings, the nurse performing the procedure ensures the proper placement of the feeding tube by checking gastric aspirates/residual. Notify MD/NP if gastric residual exceeds 100 ml and above.

Based on observation, interview, and record review, the facility failed to ensure the treatment dressing on a venous access device (VAD) site was in place for resident on dialysis, and failed to ensure the dressing replacement was completed in a sterile manner. This applies to 1 of 1 residents (R9) reviewed for dialysis.The findings include:On 5/5/26 at 12:21 PM, R9 said her main concern is the effectiveness of hemodialysis as her health has been up and down in the past year. R9 was observed without a dressing covering her left chest venous access device (VAD) that is used for hemodialysis and redness at the insertion site. R9 said she has a history of MRSA (Methicillin Resistant Staphylococcus Aureus) infection of her hemodialysis site and she recently had her site changed from her right chest to her left chest. R9's MDS (Minimum Data Set) dated 4/10/26 shows her cognition is intact. R9's Physician Orders showed an order dated 4/17/26 for in-house renal dialysis 3 times a week.On 5/5/26 at 12:31 PM, V4 (RN/Registered Nurse) said she did not know when R9's VAD dressing came off. At 12:35 PM, V4 entered R9's room without washing her hands or putting on gloves and pulled back the neck of R9's shirt to assess her VAD site with her bare hands. V4 then left R9's room to gather supplies to place a new dressing over the VAD site. While sitting on the side of her bed, R9 removed her left arm from her shirt and left it hanging by the left side of her neck. V4 returned to R9's room with sterile dressing change kit. While placing a new sterile dressing over R9's VAD site, the tag of R9's shirt touched the gauze covering the insertion site and instead of changing the gauze, V4 placed the clear dressing on top of the compromised gauze. V4 did not wear a gown during the VAD sterile dressing change. While cleansing the VAD site with the chlorhexidine swab, V4 cleansed in a rainbow motion (side to side) over the superior aspect of the VAD and did not cleanse the inferior aspect of the VAD site.On 5/6/26 at 1:34 PM, V5 (Hemodialysis RN) said R9 has come to hemodialysis on multiple occasions without a dressing covering her VAD hemodialysis site. V5 said R9 came to dialysis two days earlier on 5/4/26 without a dressing on her site. V5 said hemodialysis VAD sites should always have a dressing covering them, because if bacteria enters the body through the VAD site, there is a greater risk for infection, including infection of the heart, that could be deadly for the resident. V5 said dressing changes of hemodialysis sites require full PPE including a gown and the chlorhexidine swab should be wiped in a full circular motion starting at the VAD insertion site and moving outwards. On 5/7/26 at 2:18 PM, V2 (DON/Director of Nursing) said hemodialysis sites always need to be covered with a dressing to prevent infection. V2 said hemodialysis VAD sites pose a greater risk for infection if they are not properly dressed because the line goes directly into the blood stream and it ends close to the resident's heart. V2 said hemodialysis residents are already at risk for infection due to their impaired kidney function, and having a central line puts them at greater risk. V2 said the field needs to be kept sterile during hemodialysis site dressing change. The hemodialysis provided policy titled, Vascular Access Care for Dialysis Patients, with origination date 8/2025, states, Purpose: To establish safe, evidence-based procedures for the monitoring and care of vascular access in dialysis patients.This policy ensures patient safety, early detection of complications, and proper coordination of care with dialysis partners.Scope: Those policy applies to all.dialysis units across skilled nursing facilities and contracted sites. Policy:.Central Venous Catheter: Dressing Care: dressing must remain clean, dry, and intact at all times.

Based on observation, interview, and record review, the facility failed to ensure that a resident was free from a significant medication error. This applies to 1 of 1 resident (R20) reviewed for significant medication errors in a sample size of 30. The findings include: R20 was admitted to the facility on [DATE] with multiple diagnoses which included dementia, diabetes, hypertension, and hyperlipidemia. The Order Summary Report for May 2026 showed Losartan 100 mg daily. The packing slip proof of delivery from the pharmacy showed on 04/08/26, the pharmacy delivered Losartan Pot tab 50 mg, quantity of 30. The MAR (Medication Administration Record) for May 2026 showed Losartan Potassium Oral Tablet 50 mg, give 100 mg by mouth one time a day for HTN (hypertension), start date 04/09/26. R20's altered cardiac function care plan date 02/27/26, showed Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Progress Notes dated 04/08/26 at 8:06 PM, showed, Patient seen today for follow up of hypertension. Blood pressure trends over the past several weeks reviewed. Readings have been variable ranging approximately from 110's to 160's systolic, with intermittent elevations in the 160's. Recent readings include 145/83, 158/101, 162/88, 154/74, and 140/72, demonstrating fluctuating control despite current regimen. Patient currently on multiple hypertensives including amlodipine, carvedilol, hydralazine, and losartan. Given persistent variability and intermittent elevations, losartan increased to 100 mg daily. Patient is at moderate to high risk for complications related to hypertension given variable blood pressure control requiring multi-drug therapy and recent medication adjustment.On 05/06/26 at 8:40 AM, V23 (LPN/Licensed Practical Nurse) prepared morning medications to be administered to R20. V23 placed one Losartan Pot 50 mg (milligram) tablet, one Amlodipine 10 mg tablet, one glipizide 5mg tablet, one Jardiance 10 mg tablet, and one Iron + Vitamin C 65-125mg tablet in a medication cup. Before V23 administered the medication to R20, V23 verified the total of pills. There was a total of five pills in the cup. During the medication reconciliation, the Order Summary Report Active Orders for May 2026 showed, Losartan Potassium Oral Tablet 50 mg, give 100 mg by mouth one time a day for hypertension. The label on the medication card showed Losartan Pot tablet 50 mg. Give one tablet by mouth daily for hypertension. The medication card had ten pills remaining after V23 administered the medication to R20. The medication room was checked by the surveyor and V23 to see if R20 had more Losartan. There was no extra Losartan for R20. On 05/07/26 at 9:58 AM, V2 (DON/Director of Nursing) stated the pharmacy delivered Losartan 50 mg, 30 tablets on 04/08/26. V2 stated R20's current orders are for Losartan 100 mg daily. V2 stated with the manifest from the pharmacy and the number of pills dispensed (30), R20 would not have any pills left if the nurses were administering Losartan 100 mg as ordered. V2 stated the nurses were only administering him Losartan 50 mgs daily as the card showed. V2 stated if the medications are not administered as ordered, R20's blood pressure could not be controlled. The facility's Medication Administration Policy, dated 03/20/2020, showed, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 5) Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 6) Read each order entirely. 8) If there is a discrepancy between the MAR and label, check orders before administering medications. 9) If the label is wrong, send medications to pharmacy for relabeling or call pharmacy to send a new label. If the MAR is wrong, reenter the order.

Based on observation, interview, and record review, the facility failed to follow infection control and prevention practices with PPE (Personal Protective Equipment) usage.This applies to 2 residents (R9 and R1) reviewed for infection control in a sample of 30 residents.The findings include: 1.On 5/5/26 at 12:21 PM, R9 said her main concern is the effectiveness of hemodialysis as her health has been up and down in the past year. R9 was observed without a dressing covering her left chest venous access device (VAD) that is used for hemodialysis and redness at the insertion site. R9 said she has a history of MRSA (Methicillin Resistant Staphylococcus Aureus) infection of her hemodialysis site and she recently had her site changed from her right chest to her left chest. R9's MDS (Minimum Data Set) dated 4/10/26 shows her cognition is intact. There was EBP (Enhanced Barrier Precautions) signage outside room with PPE cart. On 5/5/26 at 12:35 PM, V4 (RN/Registered Nurse) entered R9's room without washing her hands or putting on gloves and pulled back the neck of R9's shirt to assess her VAD site with her bare hands. V4 then left R9's room to gather supplies to place a new dressing. V4 did not wear a gown during the VAD sterile dressing change. On 5/6/26 at 1:34 PM, V5 (Hemodialysis RN) V5 said dressing changes of hemodialysis sites require full PPE, including a gown. On 5/7/26 at 2:18 PM, V2 (DON/Director of Nursing) stated the nurse needs to wear full PPE including a gown to prevent bacteria growth and central line infection. R9's Face sheet shows the following diagnoses: end stage renal disease, dependence on renal dialysis, complication of vascular dialysis catheter, and personal history of methicillin resistant staphylococcus aureus (MRSA) infection. Order dated 5/1/26 reads vancomycin 1250mg/250mL (milligrams/milliliter) intravenously every Monday, Wednesday, and Friday for infection. R9's Physician Order Sheet showed an order dated 4/12/26 for enhanced barrier precaution. R9's Care Plan last revised 12/9/24 states resident is on enhanced barrier precautions related to indwelling dialysis device. Interventions include: clean and wash hands before entering and when leaving resident's room, and wear gloves and gown for high contact resident care activities, including central line device care. Care Plan created 5/1/25 states resident has MRSA requiring contact isolation of dialysis site. 2. R1's face sheet document admission date of 4/9/26. Diagnoses include hemiplegia, type II diabetes mellitus, cerebral infarction, chronic respiratory failure, encephalopathy, dysphagia, hypertension, hyperlipidemia, anemia, presence of tracheostomy and presence of gastrostomy. MDS (Minimum Data Sheet) dated 4/13/26 documents she has moderate cognitive impairment and is totally dependent on staff for ADLs (Activities of Daily Living) and transfers. R1 is on contact isolation due to presence of tracheostomy. On 5/6/26 at 11:10 AM, V12 (R1's family member) was seen inside R1's room, sitting on a chair on the right side of R1's bed. He was not wearing any surgical mask, gown or glove. On 5/6/26 at 11:15 AM, R4 (RN- Registered Nurse) said visitors entering rooms with the Contact Isolation sign must wear gowns, gloves and surgical mask to protect the resident from infection because they come from the outside and might unknowingly be a carrier of infection. She said she did not educate V12 on use of proper PPE (Personal Protective Equipment) before he entered R1's room. On 5/6/26 at 1:14 PM, V8 (IP-Infection Preventionist) said all residents with tracheostomy are on contact isolation due to history of MDRO (Multidrug Resistant Organism) and to protect them from infection. V8 said visitors must also wear gowns, gloves and mask when entering a room on contact isolation to protect the resident from infection. She said R1 is currently on antibiotics for a urinary tract infection and positive sputum culture. R1's POS (Physician Order Sheet) documents she is currently receiving Cefuroxime Axetil oral tablet 500 mg , 1 tablet via G-tube every 12 hours for positive sputum culture for Proteus Mirablis for 7 days and Meropenem Intravenous Solution Reconstituted 1 GM, use 1 gm IV every 8 hours for UTI (Urinary Tract Infection)- Escherichia Coli and Proteus Mirabilis in sputum culture for 7 days . Both medications were started on 5/4/26. Facility's Policy titled Isolation- Categories of Transmission- Based Precautions dated 11/23/21 and reviewed on 6/2/22, 5/31/23, 5/31/24, 5/31/25 and 1/14/26 documents the following: Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. b. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on record review and interview, the facility failed to ensure a resident who was admitted with an unstageable pressure ulcer was seen by a wound care physician or nurse practitioner in a timely manner and failed to follow recommended wound treatment. This failure resulted in a resident (R1) to develop an infection in the wound and require surgical debridement.This applies to 1 of 3 residents (R1) reviewed for wound care in the sample of 3.The findings include:R1's electronic medical record (EMR) showed R1 was admitted to the facility on [DATE]. R1 was 75 years-old, who had multiple medical diagnoses including type 2 diabetes mellitus, pressure ulcer in the sacral region, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, necrotizing fasciitis, deep vein thrombosis, and hypothyroidism. On September 30, 2025, V3 (Wound Care Nurse) assessed R1 and noted R1 had an unstageable pressure ulcer to the sacral-coccyx area which measured as 1.5-centimeter (cm/centimeters) x 1.5 cm x 0 cm. (Length x Width x Depth). The wound surface was covered with slough and there was a moderate amount of serosanguinous exudate (drainage). This wound already existed prior to R1's admission to the facility. V3 noted the wound was clean, there was no odor, and no sign of infection. R1's Physician Order Summary (POS), dated September 29, 2025, shows R1 may be seen by a wound care physician.On September 30, 2025, the wound care treatment order showed: clean coccyx area, paint with skin prep, apply Medi honey, and fluff gauze, and cover with dry dressing three times a week and as needed. On November 19, 2025, the POS showed the wound treatment as : apply Dakin's (1/4 strength) External Solution to sacral wound topically one time a day from Monday through Friday for 14 days. On November 24, 2025, the POS showed the wound treatment as: apply Santyl External Ointment to sacral wound topically as needed. V3 continued to monitor and assess R1's wound and documented in the weekly wound assessment report. Assessments showed R1's wound remained unstageable; however, the wound size became bigger with each assessment. By November 1, 2025, the wound was measured as 4.3 cm x 3.80 cm. The wound was also noted with slight excoriation to surrounding wound bed which was fully covered with slough. The treatment administration record (TAR) for the month of November 2025, showed R1 continued to receive the same treatment of Medi honey three times a week. On November 5, 2025, V4's (Wound Specialist Nurse Practitioner/NP) documented R1 had an unstageable/unclassified pressure ulcer and has received a status of Not Healed. Upon initial wound encounter the wound measurements were 5.0 cm x 6.0 cm x 0.2 cm, with area of 30 square cm (cm2) and volume of 6 cubic cm (cm3). There was no tunneling, no sinus tract, and no undermining noted. There was a moderate amount of serosanguinous drainage, which has no odor. R1 reported wound pain of 0/10. The wound margin was attached to wound base. Wound bed has no granulation, it has 100% slough, no eschar and no epithelialization noted. The peri-wound color was normal. The temperature of the skin was within normal limits. The peri-wound did not exhibit signs and symptoms of infection. V4's recommended treatment was to clean the wound, apply Medi honey, calcium alginate, and cover with foam dry dressing three times a week and as needed. On November 8, 2025, V3's (Wound Care Nurse) documentation showed R1 was seen by V4 (Wound NP). Debridement procedure was discussed with V8 (R1's POA/Power of Attorney) and consent was obtained. Debridement was done to remove the slough and necrotic tissue. Slight debridement was performed using a curette stick at R1's bedside. The area was scored using sharps with intent for better penetration of Medi honey. According to V3, this debridement procedure happened on November 5, 2025. On November 12, 2025, V4's (NP) wound note showed R1's laboratory result were reviewed. R1's WBC (White Blood Cell) was high. R1 was receiving an antibiotic for an UTI (Urinary Tract Infection). Sacral x-ray was reviewed; its depth was seen. Adherent slough has softened and liquified. Sacral wound was unstageable/unclassified pressure ulcer and has received a status of Not Healed. The subsequent wound encounter measurements are 5.5 cm x 5.5 cm x 1.5 cm., with an area of 30.25 sq cm and a volume of 45.375 cubic cm. There was no tunneling, no sinus tract, and no undermining noted. There was a moderate amount of serosanguinous drainage noted, which has no odor. R1 reported wound pain of 0/10 (no pain). Wound bed has no granulation, it has 100% slough, no eschar and no epithelialization noted. There was no change in the wound progression. The peri-wound skin texture, moisture, and color are all normal. The temperature of the peri-wound skin is within normal limits. Peri-wound skin does not exhibit signs and symptoms of infection. V4 performed a skin/tissue level excision/surgical debridement to R1's sacral pressure ulcer. On November 12m 2025, the recommended wound order was to cleanse the wound with Dakin's solution 1/4 strength, to apply Dakin's wet to moist gauze, and to cover wound with foam dressing. Dressing change were to be done daily and as needed. On November 19, 2025, V4's wound notes showed R1's sacral wound was now categorized as a stage 4 pressure injury/ pressure ulcer and had received a status of Not Healed. The subsequent wound encounter measurements are 6.5 cm x 4.5 cm x 2.0 cm, with an area of 29.25 sq cm and with a volume of 58.5 cubic cm. There was no tunneling, no sinus tract, and no undermining noted. There was a moderate amount of serosanguinous drainage, which has odor. R1 reported a wound pain of 0/10. Wound bed has no granulation, it has 100% slough, no eschar and no epithelialization noted. There was no change in the wound progression. The peri-wound skin texture, moisture, and color are all normal. Peri-wound skin presents with signs and symptoms of infection. The temperature of the peri-wound skin is within normal limits. This same note showed, V4 ordered wound C&S (culture and sensitivity) and topical antibiotics. On November 19, 2025, the wound care order showed: cleanse wound with Dakin's solution 1/4 strength, apply Silvadene creme to wound, apply primary dressing calcium alginate, and cover with foam or dry dressing. The treatment and change of wound dressing were to be done daily and as needed.R1's wound culture results, dated November 23, 2025, showed R1 was positive for MRSA (Methicillin-resistant Staphylococcus aureus).On November 24, 2025, skin/wound notes showed the sacral wound culture result showed R1 was positive for MRSA. The wound was assessed; it was noted with black necrotic tissue and slightly odorous conclusive to necrotic tissue and active infection. Wound cleansed with Dakin's solution and treated as ordered. R1's Treatment Administration Record, dated November 2025, shows the following: On September 30, 2025: Clean coccyx area, paint with skin prep. Apply Medi Honey and fluff gauze and cover with dry dressing three times a week and prn (as needed). This order was d/c (discontinued) on November 19, 2025.On November 20, 2025: Clean coccyx area, paint with skin prep. Apply Medi-Honey, cover with fluff gauze, and cover with dry dressing three times a week and prn. This order was d/c on November 24, 2025.On November 20, 2025: Dakins (1/4 strength) External Solution. Apply to sacral wound topically once a day from Monday through Friday for 14 days. On November 22, 2025: Clean coccyx area, paint with skin prep, apply Medi honey and fluff gauze and cover with dry dressing 3x weekly and prn one time a day every Saturday and Sunday. This order was d/c on November 24, 2025.Hospital record showed R1 was admitted to the hospital on [DATE], and was discharged on December 5, 2025. History and physical, dated November 25, 2025, showed R1 was admitted to the hospital with worsening sacral pressure ulcer which was also positive for MRSA. The wound was noted with significant amount of necrotic tissue with foul smelling odor. This same hospital record showed a consultation note, dated November 25, 2025, which showed R1 had an infected sacral decubitus ulcer with osteomyelitis.On November 25, 2025, R1 underwent debridement procedure in the operating room due to diagnosis of infected stage 4 decubitus ulcer. Detailed description of the surgery showed excisional debridement of the skin, subcutaneous fat, muscle, and fascia of the decubitus ulcer. R1's MRI (Magnetic Resonance Imaging) of the sacrum, dated November 26, 2025, showed result of multiple impression including signs of osteomyelitis of the sacrococcygeal junction.On April 28, at 1:31 PM, V3 (Wound Care Nurse) stated R1 was admitted to the facility with unstageable pressure ulcer in the Sacro-coccyx area measuring 1.5 cm x 1.5 cm. R1's dressing change was three times a week every Monday, Wednesday, and Friday and as needed. The NP wound specialist (V4) visits once a week. V3 was unable to recall exact time when the wound started deteriorating, but that was when she called V4 to assess R1's wound. R1 was first seen on November 5, 2025, by V4. V4 debrided R1's pressure wound twice (November 5 and November 12, 2025). They were wondering why R1's wound continued to deteriorate and they tried to check all avenues to manage the wound. R1 had been off-loaded, she was turned side to side during incontinence care, she had the air mattress, the pressure relieving cushion in her wheelchair seat, and was given nutritional supplements as scheduled. R1 was debrided twice that's why the wound got bigger. The wound bed was covered with 80% soft necrotic and 20% slough. On April 29, 2026, at 4:11 PM, V3 stated the only time the treatment (Medi-honey) was changed when it was increased from three times a week to once daily and as needed. After the second debridement, it was changed to Santyl daily. The Medi honey was combatting the MRSA of the wound rather than the Silvadene. R1's wound was stable and was being treated. When V3 observed that the wound was deteriorating, that's when she recommended R1 to be seen by V4. On April 30, 2026, at 11:41 AM, V3 (Wound Nurse) said R1 received the first debridement procedure on November 5, 2025, and the second procedure on November 12, 2025. V3 usually receives verbal order from V4, and she recapped the order before V4 leaves the facility. V3 does not read V4's notes because it usually comes after two days. On April 29, 2026, at 10:16 AM, V4 (Nurse Practitioner/NP) stated when she first saw R1, she thought R1 was just recently admitted to the facility with community acquired pressure ulcer, because the size was big and it was unstageable. R1 had one pressure ulcer in the coccyx-sacral area. Upon her initial assessment, she observed R1 was receiving Medi honey and alginate treatment three times a week. R1 was a high risk for skin breakdown because she was not eating and she was non-compliant with repositioning and off-loading. The facility should have called for wound consultation right away when R1 was first admitted , because appropriate assessment and treatment could have been done sooner. V4 could have debrided the wound sooner by removing the dead tissues, so her wound could have had a higher chance of healing. V4 only ordered Dakin's solution treatment after the first debridement because it is a debriding agent and an antiseptic; it helps prevent infection. V4 ordered Dakin's solution and Silvadene ointment after the second debridement because she was worried about the potential infection. The Silvadene shield the wound from bacterial infection. V4 also said whatever she documented in the recommended treatment means that's what she ordered. If the Medi honey is not written in her notes that means it was discontinued. She ordered Dakin's to coccyx sacral wound daily and as needed. Treatment daily makes a big difference compared to three times a week. The Dakin's solution could have prevented the deterioration of the wound and potential infection. She reinforced to V3 the importance of the daily wound care to R1. V4 also stated all orders go under the primary care physician. As a wound consultant (NP) she can't enter her order directly into the facility's system, but she communicated with the wound care nurse her new wound care order or recommendation during the wound rounds. V4 gives verbal order to V3 and written report via email after her wound rounds containing her new wound treatment/care order, she does this before leaving the facility. Then V4 emails her completed wound notes after a day or two. The wound care nurse usually notifies the primary physician, and the primary physician usually approved V4's treatment recommendation. On April 29, 2026, at 1:17 PM, V7 (Primary Physician) stated he follows the recommendation of medical consultants because that's what they are here for. R1 was admitted with an unstageable pressure ulcer in the sacral-coccyx area. There was an admission order that R1 may be seen by a wound care physician. However, R1 was seen by a wound care specialist (V4) five weeks after she was admitted , after R1's wound continued to deteriorate. R1 received debridement procedure on November 12, and November 19, 2025. V4 gave an order to cleanse wound with Dakin's solution daily and as needed after the first debridement on November 5, and an order of Dakin's solution and Silvadene ointment daily and as needed after the second debridement was performed on November 19, 2025. However, R1's TAR showed that R1 continued to receive Medi honey treatment three times a week. Dakin's solution was applied to wound only on November 20, 21, and 24. There was no Silvadene treatment provided to R1. On November 19, V4 noted the foul odor from R1's wound, she ordered a wound culture, the result showed R1 was positive for MRSA. R1 was sent to the hospital after V8's (R1's POA) insistence where R1 was admitted for an infected stage 4 pressure ulcer with osteomyelitis and where she underwent surgical debridement. The Facility's Policy and Procedure for Wound Prevention and Healing with revision date of April 2026 shows:Intent: To provide wound care treatment/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician.Procedure:Goal will focus on the clinical status of the wound, guide the appropriate intervention for the wound, indicate that, if there is no change in wound status within a pre-determined timeframe, re-assess and alter the plan, monitor and evaluate overall client outcomes (progression or regression), and determine the effectiveness of treatment. Continued/Ongoing Treatmenta. Nurse will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment. The nurse will notify the physician for any change in the patient's condition or lack of progress. d. If the patient is not responding to established treatment regimen, the Wound MD/NP shall evaluate the need for treatment change. Wound Care and Treatment:a. Wound care treatments are provided within an individualized plan of care under the direction of the physician.

Based on observation, interview, and record review, the facility failed to maintain the head of bed at thirty degrees while a resident's tube feeding was infusing. This applies to 1 of 4 residents R1 reviewed for their tube feeding in a sample of 8.Findings include:On 10/15/25 at 10:33 AM, R1 was observed during care provision by V9 and V10, CNAs (Certified Nursing Assistants). While R1 was in bed, the head of the bed was in a flat position. The tube feeding of Nepro 1.8 Cal was infusing at 40 ML (Milliliters) per hour by a feeding pump. V10 CNA stated residents receiving their tube feedings only needed to have the head of bed elevated if the resident is being rolled side to side, otherwise it is ok for the resident to be flat with the tube feeding infusing.V9 CNA stated there was no problem with R1's head of bed being flat while her tube feeding was infusing if she was not being turned side to side as it may cause R1 to become sick.On 10/15/25 at 5:15 PM, V2, DON (Director of Nursing), stated the head of bed should be elevated when the tube feeding is infusing so that the resident does not vomit or aspirate.R1's physician orders tube feeding states may stop feeding during routine care, ADL's (Activities of Daily Living), bathing, notify nurse to restart. Every shift elevates head of bed 30 -45 degrees while feeding.The facility policy Tube Feeding, dated 11/2024, states the head of bed will be 30-45 degrees unless ordered differently.

Based on interview and record review, the facility failed to administer the ordered initial dose of an antibiotic. This applies to 1 of 4 residents R1 reviewed for antibiotic administration in a sample of 8.Findings include:V5, NP (Nurse Practitioner) progress note on 9/12/25 documents the plan for to treat a UTI (Urinary Tract Infection) with Levofloxacin IV (Intravenously). Levofloxacin 750 MG (Milligrams) to start on 9/13/25 and end 9/14/25. Levofloxacin 500 MG administered every 48 hours for 10 days starting 0 9/15/25 and ending on 9/25/25. Meropenem 500 MG intravenously daily for 7 days starting on 9/9/25.R1's MAR (Medication Administration Record) shows a missed administration of Meropenem 500 MG on 9/14/25 at 9am. There is no documentation for the administration of Levofloxacin 750 MG on R1's MAR on 9/13/25 or 9/14/25. V4, LPN (Licensed Practical Nurse) progress, note dated 9/14/25 at 3:25 AM, states call to pharmacy related to Levofloxacin would be delivered early in AM. A nursing progress note, dated 9/14/25 at 6:42 PM, states Levofloxacin 750 MG was not available and would be delivered that night. Calls placed to interview V5, NP, and V4, LPN, were unsuccessful.V2, DON (Director of Nursing), stated there was no documentation showing R1 received the Meropenem 500 MG on 9/14/25. V2 stated she did not receive any authorization requests from pharmacy for R1 to receive the one-time dose of Levofloxacin 750 MG. V2, DON, stated there was no documentation showing R1 received the one-time dose of Levofloxacin 750 MG.The facility policy Medication Ordering and Receiving from Pharmacy, dated November 2021, states a licensed nurse promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse / supervisor.

Based on interview, observation, and record review, the facility failed to maintain palatable and appetizing food temperature when serving meals. This applies to all 121 residents receiving meals from the facility. The findings include: The facility data sheet, dated August 4, 2025, documents 133 residents in the facility, with 121 receiving food from the Dietary department, and 12 residents on NPO (Nothing by mouth) status.From August 4 to August 6, 2025, R1, R4, R7, R10, R11, and R14 were observed at mealtime and interviewed about the facility's food service. R1, R4, R7, R10, R11, and R14 are assessed to be alert and oriented based on their most recent MDS (Minimum Data Set) assessments. R1, R4, R7, R10, R11, and R14 all stated the food was lukewarm or cold, and they would prefer that food be served warmer. R12 was a former resident from the facility. R12 was alert and oriented based on her last her last MDS prior to discharge. On August 4, 2025, at 1:15 PM, V17 (family member) stated R12 was always complaining to V17 the food in the facility was always served cold.On August 5, 2025, 11:35 AM, the lunch meal was observed on the second floor. There were a few residents in the dining room. A kitchen staff delivered the second food cart in the dining room. V20 (Dietary manager), V21 (Certified Nursing Assistant/CNA), and V22 (CNA) were setting up the trays and serving food in the dining room. At 11:41 AM, the third food cart was delivered. V22 started setting it up, she placed condiments and drinks in each tray. V23 (Wound Care Aid and Central Supply) and V24 (CNA) came in to help. The facility menu was roasted turkey with gravy, cornbread dressing, zucchini, and mandarin fruit for dessert. All the food carts were delivered with a plastic cover that was zippered closed on all the four corners of the carts. The staff unzipped all the four corners of the cover as they started to set up the trays placing condiments and drinks on each tray. The carts were not insulated, nor was a plate warmer in place to aide in maintaining temperatures. At 11:52 AM, the food cart was delivered to the hallway for residents eating in their rooms.On August 5, 2025, at 12:00 PM, R10's lunch tray was tested for food temperature. The cornbread dressing was 50.1 degrees/Fahrenheit (F), and the turkey with gravy was 50.3F.On August 5, 2025, at 12:04 PM, R11's lunch tray was tested for food temperature. The cornbread dressing was 107.6 F and the turkey with gravy was 115.7 F; the zucchini vegetable was 107.5 F. On August 5, 2025, at 12:42 PM, V20 (Dietary Manager) stated they check the food temperature prior to delivering food in the unit. V20 explained food is plated on a ceramic plate and covered with a plastic lid. The food temperature in the kitchen should be at least 135F. V20 added then the trays are placed on a cart, covered with a plastic zipped cover and delivered to each floor or unit. V20 stated the food holding temperature should be 135F. V20 has been a Dietary manager for 20 plus years. They deliver food through tray line. The staff would place food on the ceramic plate and would be covered with a plastic food lid, they deliver the meals via tall food cart which was covered with zippered plastic cover. The holding temperature for the hot food should be 135F, which means that when it's delivered to the residents it should be a little less than 135F. On August 6, 2025, at 12:20 PM, V20 (Dietary Manager) also stated she just started working in the facility on July 14, 2025. Ever since she started, there was no metal heating plate in the trays when they serve the food to the residents. The metal heating plate is important because it can hold the hot temperature longer. The Facility's Policy and Procedure for Food Palatability-Hot Food Temperatures shows:Policy: The healthcare community prepares and serves food and beverages that is palatable, attractive and at safe and appetizing temperature.The healthcare community makes every effort to take all factors into consideration to ensure that hot food and beverages are served at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to donning of gowns during provisions of care to residents who are on EBP (Enhance Barrier Precautions).This applies to 3 of the 4 residents (R1, R4, R5) reviewed for EBP in the sample of 14.The findings include: 1. On August 4, 2025, at 10:06 AM, there was an EBP signage outside R1's bedroom. V13 and V14 (Both Certified Nursing Assistants/CNA) were providing hygiene care to R1. Both staff were not wearing a gown during the provision of care. R1 is on the facility's EBP list for history of Candida Auris. 2. Face sheet shows tR4 is 77 years-old who has multiple medical diagnoses including end stage renal failure (ESRD). On August 5, 2025, at 12:51 PM, R4 was in bed receiving incontinence care. R4 has an AV (Arteriovenous) fistula in his left arm and an intravenous (IV) midline catheter in his right arm. V25 (Certified Nursing Assistant/CNA) was providing incontinence care to R4, who had a bowel movement. V25 did not wear a gown all throughout the incontinence care. There was a signage outside R4 door which shows R4 is on Enhance Barrier Precaution (EBP).On August 6, 2025, at 2:32 PM, V2 (Director of Nursing/DON) stated R4 is receiving IV antibiotic (Unasyn) for pneumonia. 3. Face sheet shows R5 is 69 years-old who has multiple medical diagnoses including spastic diplegic cerebral palsy, carrier of Carbapenem-Resistant Enterobacterales, and contact with and (suspected) exposure to other viral communicable disease. On August 4, 2025, at 10:19 AM, during environmental rounds, there was an EBP signage outside R5's bedroom. Upon inspection of the bedroom, V12 (Nurse) was inside R5's room, at R5's bedside, checking R5's vital signs (blood pressure and heart rate). V12 was not wearing a gown during the procedure. Facility's EBP list shows R5 was on the list due to wound, indwelling urinary catheter, and history of KPC (Klebsiella pneumoniae Carbapenemase). On August 5, 2025, at 1:57 PM, V16 (Infection Preventionist Nurse) stated the staff is expected to wear gown and gloves when providing high contact care such as dressing, bathing, showering, hygiene, incontinence care, and changing linens, for an EBP resident. It helps prevent resident from getting infection and prevents spread of infection. The EBP signage shows:Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. Facility's Enhance Barrier Precautions (EBP) Policy and Procedure with recent review dated of June 2025 shows:General: Enhance Barrier Precautions is an approach of targeted gown and glove use during high contact resident care activities, design to reduce transmission of S. aureus and Multidrug Resistant Organism (MDRO).

Based on observation, interview, and record review, the facility failed to complete a wound or skin event in risk management when a skin abnormality was found on a resident, failed to seek medical attention for a resident who developed rash-like skin redness, failed to monitor the skin rash/redness for improvement or worsening, failed to implement wound nurse practitioner's recommendations to keep the area clean and dry, and failed to implement wound nurse practitioner's recommendations for treatment of the rash. These failures resulted in R1 developing a rash/reddened area under her breasts that went without assessment or treatment, experiencing a rash/redness on her groin and buttocks that did not improve, and R1 expressing she experienced extreme pain and discomfort for many months due to the rash/redness. This applies to 1 of 3 residents (R1) reviewed for skin rashes in the sample of 3. The findings include: On April 16, 2025 at 9:18 AM, R1 was lying in bed. R1 had a tracheostomy in place and was unable to speak out loud, but was able to mouth intelligible words and make hand gestures. R1 said she was experiencing pain, and pointed to her perineal area and buttocks when asked where her pain was located. R1 was wearing an incontinence brief. The brief was closed at each side of R1's hip with the adhesive closures from the incontinence brief. R1 had an indwelling urinary catheter in place draining cloudy, yellow urine. On April 16, 2025 at 10:38 AM, R1 continued to be lying in bed. V10 (Mother of R1) was sitting at R1's bedside. V4 (CNA-Certified Nursing Assistant) and V5 (CNA) came to R1's room to provide incontinence care. V5 said she arrived at the facility at 6:00 AM and was assigned to care for R1. V5 continued to say she had not had time to check R1's incontinence brief or provide incontinence care since she started her shift over four hours earlier. V5 said R1 was wearing the incontinence brief from a previous shift. V4 and V5 unfastened R1's incontinence brief. V4 and V5 said they had not been instructed to leave R1's incontinence brief open. As V5 pulled back R1's incontinence brief, the brief had a strong odor and appeared wet, despite R1 having an indwelling urinary catheter. V5 said the catheter must have leaked. R1's front perineal area had a rash over R1's entire pubic area, along both groin areas, and extending to her inner left and right thigh, approximately six inches in diameter. The rash appeared as solid, bright red areas. As R1 was turned to her right side, R1's buttocks were exposed. The red rash encompassed R1's entire buttocks, approximately 12 inches in diameter and extended up her back, approximately six inches, on R1's right side. The rash on R1's buttocks was bright red and appeared as one solid red area. As the rash extended up R1's back, the rash appeared to be a spottier, red pattern. R1 flinched when V5 tried to use a disposable wipe to clean R1's buttocks. V4 and V5 said they did not have barrier cream to apply to R1's buttocks or groin area because they were not allowed to keep the cream in the resident's rooms, and they would have to ask V7 (LPN-Licensed Practical Nurse) to obtain the cream. V4 and V5 applied a clean incontinence brief to R1 and did not apply barrier cream and prepared to leave the room. V5 (CNA) said she has been assigned to care for R1 many times, and the rash on R1's perineal area and buttocks had been present since at least February 2025. V4 and V5 lifted R1's gown. R1 was not wearing a bra. V5 lifted R1's right and left breast. R1's skin appeared bright red under R1's right and left breasts, approximately one to two inches wide, and approximately 4 inches long. A white, pilled substance was under each breast and V5 speculated it was old powder. V5 used a disposable wipe to clean the white substance from under R1's breasts, and R1 flinched when V5 cleaned the area and indicated the area was painful by mouthing the words that hurts. As V4 and V5 were ready to leave R1's room, V7 (LPN) entered the room with a small medication cup filled with a white cream and a wood tongue depressor. V7 said the white cream was zinc oxide. V4 and V5 opened R1's incontinence brief and again turned her to her right side. V7 (LPN) used her gloved hand to smear the zinc oxide on R1's buttocks. V7 did not cover the rash on R1's upper back with the zinc oxide. R1 was turned to her back by V4 and V5. With approximately one teaspoon of zinc oxide left in the medicine cup, V7 (LPN) used the wood tongue depressor to smear the remaining zinc oxide to R1's front perineal area in a swiping motion. The remaining zinc oxide ointment did not cover all red areas of R1's front perineal area, or R1's inner thighs. V7 (LPN) said she would have to return with more zinc oxide ointment to cover the reddened areas. On April 16, 2025 at 11:11 AM, V10 (Mother of R1) remained at R1's bedside, and said V7 (LPN) had not returned to R1's room to apply zinc oxide ointment to R1's front perineal area. V7 also said no other facility staff had come to the room to apply the ointment. On April 16, 2025 at 11:45 AM, V10 (Mother of R1) remained at R1's bedside, and said V7 (LPN) had not returned to R1's room to apply zinc oxide ointment to R1's front perineal area. V7 also said no other facility staff had come to the room to apply the ointment. On April 16, 2025 at 11:50 AM, V7 (LPN) came to R1's room and applied zinc oxide ointment to R1's front perineal area, and said she was unable to do it sooner due to caring for other residents. V7 did not assess the skin under R1's breasts or apply the zinc oxide ointment. As V7 was ready to leave R1's room, V7 was asked what the treatment would be for R1's skin redness under her bilateral breasts, and V7 turned around and applied the remaining zinc oxide ointment to the area under R1's bilateral breasts. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including metabolic encephalopathy, pneumonia, UTI (Urinary Tract Infection), acute and chronic respiratory failure, COPD (Chronic Obstructive Pulmonary Disease), acute pulmonary edema, myotonic muscular dystrophy, ascites, dependence on ventilator, gastrostomy tube, tracheostomy, and intestinal obstruction. R1's MDS (Minimum Data Set), dated February 6, 2025, shows R1 is cognitively intact, requires partial/moderate assistance with oral hygiene, substantial/maximal assistance with bed mobility, and dependent on facility staff for all other ADLs (Activities of Daily Living). R1 has an indwelling urinary catheter and is always incontinent of stool. The MDS continues to show R1 receives 51 percent or more of her total calories from tube feeding. R1 had no unhealed pressure ulcers, rashes or MASD (Moisture-Associated Skin Damage) at the time of this MDS assessment. R1's care plan for potential/actual impairment to skin integrity, created on January 31, 2025, shows multiple interventions initiated on January 31, 2025 including, keep skin clean and dry. Identify/document potential causative factors and eliminate/resolve where possible. On January 31, 2025 at 6:46 AM, V6 (LPN) documented, [R1] buttock dry, redness, and flaky to touch V6's (LPN) Admission/Readmission Evaluation, dated January 31, 2025, shows R1 was readmitted to the facility with groin redness, redness on her inner thighs, and perineal area. The evaluation also shows R1 was high risk for skin breakdown. The EMR shows the following order, dated January 31, 2025: Zinc oxide external ointment 20 percent to groin, peri, and buttock topically every 12 hours for redness. The facility's Skin Monitoring/CNA Shower and Grooming sheets show the following for R1: January 21, 2025: Redness on R1's bilateral groin areas and redness on R1's buttocks. March 18, 2025: Redness under R1's right breast, and redness in R1's perineal area. April 1, 2025: Redness under R1's right and left breasts, and redness in R1's perineal area. The facility does not have documentation to show R1's physician was notified about the redness/rash on R1's skin, or that the redness/rash was assessed by nursing staff between January 31, 2025 and April 9, 2025. The facility does not have documentation to show the nurse assessed the reddened areas or completed a wound or skin event within risk management. The facility does not have documentation to show the wound care nurse checked risk management and proceeded with an assessment or investigation. On January 7, 2025, V9 (Wound Care NP-Nurse Practitioner) documented, Wound #2 groin is a partial thickness moisture associated skin damage and has received a status of not healed. Initial wound encounter measurements are 20 cm. (centimeters) length by 15 cm. width x 0.1 cm. depth, with an area of 300 square cm, and a volume of 30 cubic cm. There is a scant amount of serous drainage noted which has a mild odor. The patient reports a wound pain of level 3/10 (0/10 equals no pain, 10/10 most pain). The wound margin is undefined. Active problems, irritant contact dermatitis due to friction or contact with body fluids, erythema intertrigo (inflammatory skin condition caused by skin-to-skin friction). Wound orders groin: cleanse wound with wound cleanser, topical treatment: apply house stock antifungal cream twice a day. Follow-up: re-evaluation in 1 week. Incontinence/moisture management: barrier cream/ointment 3 x (times) per day and after incontinent episodes, recommend antifungal, keep area clean and dry, reduce briefs whenever possible. The facility does not have documentation to show R1 received the antifungal cream or barrier cream as ordered by V9 (Wound Care NP) on January 7, 2025. The facility does not have documentation to show R1 was re-evaluated in one week. The facility does not have documentation to show measurements were obtained after January 7, 2025 to determine if the rash area was improving or deteriorating. On April 9, 2025, V9 (Wound Care NP-Nurse Practitioner) documented, Patient being evaluated for skin assessment due to at risk conditions/Braden score for skin breakdown of 12. V9's documentation continues to show R1 had irritant contact dermatitis due to friction or contact with body fluids, and erythema intertrigo. V9's documentation continues to show, Incontinence/Moisture Management: Barrier cream/ointment 3 x (times) per day and after incontinent episodes, maintain prompt cleansing and moisture management to support skin health, use breathable alternatives to briefs when appropriate to promote skin integrity. The facility does not have documentation to show R1 received the barrier cream as ordered by V9 (Wound Care NP) on April 9, 2025. On April 16, 2025 at 1:16 PM, V9 (Wound Care Nurse Practitioner/NP) said he assessed R1 on April 9, 2025. V9 said the skin redness on R1's buttocks is due to MASD (Moisture Associated Skin Damage), and if there is moisture involved, R1 may also have a fungal rash. I was asked to see the resident because the rash was not improving and was getting worse. This skin condition can be handled by the nurses, and they can call me anytime, if the need arises. Last week when I saw her, she had dermatitis and the area had not spread up her back. I told them to apply barrier cream three times a day and after every incontinent episode. I was not notified by the facility before today that the rash looked worse. If they left her in feces or urine overnight or for a long period of time, it could go from zero to 100. It needs to be addressed immediately and appropriately. On April 17, 2025 at 11:11 AM, V9 (Wound Care NP) said, I saw [R1] on January 7, 2025. She had MASD in the groin area. We recommended house stock antifungal to the bilateral groin area twice a day and barrier cream three times a day. We did not specify a stop date. They should have put the antifungal cream and barrier cream order in place when I saw her on January 7, 2025. It is my expectation that they institute my recommendations. The skin issue will deteriorate if they do not do it. If it is a recommendation and it was never done, then I would say that is why the rash got worse. On April 17, 2025 at 2:55 PM, V11 (Physician) said, Based on (V9's, Wound Care NP) documentation dated April 9, 2025, there has been an acute change in (R1's) skin since last week, possibly caused by the antibiotic medication (R1) was taking. V11 said it would be his expectation that facility staff follow provider recommendations for wound care, and they should follow the facility's policy for nursing assessment of abnormal skin conditions and completing wound or skin events in risk management. The facility's policy entitled Wound Prevention Program, dated March 2025, shows, Purpose: The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure related wounds. Process: 1. Upon admission and in conjunction with the Resident Assessment Instrument, and when a significant change in the resident status occurs, the resident's skin will be evaluated head-to-toe by licensed nurse. 2. Weekly skin checks will be conducted by the licensed nurse. This will be documented in the resident's EMR. 3. Daily, during routine care, the CNA will observe the resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse and the licensed nurse will proceed as mentioned in step 2 and complete a wound or skin event within risk management. The wound care nurse will check risk management daily for any new wound/skin event and proceed with an assessment/investigation. The facility's policy entitled Wound Prevention and Healing, reviewed 06/01/2024, shows, Policy Statement: To provide wound care treatments/services using a multidisciplinary approach based on evidence-based standards of care under the direction of a physician. 1. Risk Assessment and Prevention: a. Braden Scale will be completed upon admission, readmission, quarterly, and when there is a change in condition by a licensed or registered professional nurse.c. Skin will be inspected during showers, following orders for daily and/or weekly skin checks as scheduled, and PRN (as needed).

Based on interview and record review, the facility failed to complete thorough abuse investigations to ensure abuse is recognized/identified and failed to maintain proof of thorough investigations. This has the potential to affect all residents in the facility. The findings include: The facility's 2/4/2025 CMS-671 Form showed 145 residents live in the facility. 1. On 2/6/2025 at 9:06 AM, V11, CNA (Certified Nursing Assistant), stated she remembered the incident between R81 and V33 LPN (Licensed Practical Nurse) on January 10th. V11 stated she heard V33 in R81's room and holler at him to Stop that and Shut up! when V33 went in his room to pass medication. V11 stated she did not see the interaction but overheard it because V33's voice was raised. V11 stated she didn't think anyone else was around to hear it. V11's abuse allegation statement showed, On Friday evening 01/10/2025 [V33] I overheard talking to [R81] disrespectfully. The nurse hollered stop that and then told resident to shut up! Loudly. The facility's Final Report for R81's abuse allegation showed, On 01/10/2025, [V11] alleged that she felt that the facility nurse was verbally discourteous to resident. The facility nurse suspended pending investigation. The abuse investigation is ongoing The Report ended with Patient is legally deaf when asked if [R81] heard or thought the nurse in question was rude to him, he responded no . the facility cannot substantiate mental abuse occurred. On 2/6/2025 at 1:25 PM, V1 (Administrator/Abuse Coordinator) verified there was no evidence R81 was ever interviewed. V1 stated R81 is deaf, but he can speak. V1 stated she personally interviewed R81 four days after the staff member reported the abuse allegation, but she did not write any of it down. (R81's 10/25/2024 MDS [Minimum Data Set] showed he is moderately cognitively impaired.) V1 also verified there was no written statement or interview from V33 regarding her side of the allegation. A second statement by V11 was included in the abuse investigation, as well as statements from V13 (CNA), V40 (Social Services), and V12 (Nurse), but V1 verified these statements were about a concurrent Human Resources incident regarding V33, rather than the abuse allegation investigation. V1 also provided seven pieces of paper with four questions on them, labeled Resident Interviews. The typed questions are: Do the nurses here take good care of you? Do you feel safe here in the facility? Do your CNAs assist with any issues? Are your medical needs met in a timely fashion? The papers are undated, no staff names are included to show who was asking the questions, and the papers do not show if any other questions were asked. On 2/6/2024 at 1:25 PM, V1 stated she thought that the Social Service Director and Social Services Assistant were the ones who asked the questions to the residents, and she stated she thought the interviews were completed on January 13th or 14th. V1 stated the residents interviewed were from throughout the building since V33 worked both floors. V1 stated she could not say if the residents were asked other questions more specific to the verbal abuse allegation made against V33. R81's Final Report showed, Interviewed other residents and they do not have any issues with that nurse. Spoke with R1 and he states he feels safe to be in the facility. At this time, the facility cannot substantiate mental abuse occurred. Investigation concluded. On 2/4/25 at 12:22 PM, V2, DON (Director of Nursing), said V33 works full-time on the overnight shift at the facility. V2 also said V33 works throughout the facility, and she has been assigned to all residents. 2. On 2/7/2025 at 1:30 PM, all of the evidence for the facility's 11/23/2024 abuse investigation for R29 was requested. V1 (Administrator/Abuse Coordinator) provided the Initial and Final Reports that were sent to the Illinois Department of Public Health (IDPH), their corresponding fax confirmations, and written statements from V37 and V38 (CNAs- Certified Nursing Assistants). V1 verified there was no documentation of an interview with R29 or any residents. R29's Final Report showed R29 was alert and oriented, and the Report references speaking with [R29] again, and later .spoke with [R29] . The Report also showed Spoke with random patients and staff on the unit regarding CNA and no one had complaints at this time . On 2/7/2025 at 1:46 PM, V1 stated the allegation was reported by a nurse, but she did not know who. V1 also stated she spoke with R29, but nothing was documented. V1 verified that the entire investigation had been provided. 3.On 2/7/2024 at 1:30 PM, all of the evidence for the facility's 11/10/2024 abuse investigation for R252 was also requested. V1 provided the Initial and Final Reports sent to IDPH and their corresponding fax confirmations. V1 verified there was no other investigatory evidence aside from the Initial and Final Reports. V1 stated, There were no staff interviews- it was all verbal. V1 stated, Social Services asked residents if they felt safe. There were no resident interviews included in the investigation. V1 stated R252 was hospitalized , and she was unclear who reported the allegation. R252's Final Report showed, Investigation included staff interviews (nurses and CNAs) in which no one reported patient saying he felt unsafe in any way. Random residents were asked if they felt safe with the nursing staff and if they felt safe in the facility. They all stated that they feel safe and have no issues at this time At this time, we are not able to substantiate any abuse. The Investigation section of the facility's Abuse Policy and Procedure (reviewed 9/5/2024) showed, As soon as possible after an allegation of abuse, mistreatment the administrator or designee will initiate an investigation into the allegation which may include the following elements: interviewing all persons who may have knowledge .including all persons who reported the suspicion, allegation or incident; the alleged victim (if the victim is unable to be interviewed, this should be documented); the alleged perpetrator .; any witnesses or potential witnesses to the alleged occurrence or incident; any staff having contact with the resident during the period of the alleged incident; roommates, other residents, family or visitors .; a review of the medical record, including care plan; a review of all circumstances surrounding the incident . The policy continued, The investigation shall conclude whether the allegation of abuse, neglect, mistreatment .can likely be substantiated. Records of the investigation shall be maintained.

Based on observation, interview, and record review, the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 133 residents in the facility receiving dietary services. Findings include: On 02/06/25 at 12:08 PM, V17, Dietary Manager, confirmed 133 residents were being served from dietary services. 1. On 02/04/25 at 10:15 AM, the vents located over the stove cooking surface were dusty. One of two red sanitizing buckets sanitizer tested at 500 ppm (Parts Per Million). The three-compartment sink sanitizing solution tested at 500 ppm. The dishwasher was being utilized to clean dishware. The temperature sensitive strips were run through the dishwasher and did not turn black to indicate the appropriate sanitizing temperature had been achieved. During the test run the digital reading highest temperature was 99-degree Fahrenheit. V17 stated the dishwasher disinfects by temperature and should have a final rinse of 180 degrees Fahrenheit. V19, Morning Cook, stated he last filled the sanitizing sink, and it tested at 300ppm. V19 stated the sanitizing solution is automated and dispense when he turns the dial. V19 wrote down 300ppm on the log, stating he forgot to write it down earlier. On 02/06/25 at 12:08 PM, V17 stated the red sanitization buckets and 3 compartment sink sanitization level should be between 200-400 ppm per the manufacturer. 300ppm is not a choice on the testing strips but if the color falls between 200 and 400 staff can guestimate. If the dishwasher doesn't reach 180 degrees Fahrenheit, they can't verify the dishes are sanitized. The sink could have been used, but the automated sanitizer dispenser wasn't working well either and the dishes would need to air dry before use. The undated facility provided policy 3 compartment sink states, check sanitization sink frequently using test strips to assure the level of sanitizing solution is appropriate. Follow chemical manufacturers' s guideline to prepare sanitizing solution. The undated facility provided policy Sanitizer Buckets states compare color test strip to manufacture's color chart to decipher if solution is the correct concentration. Record ppm on sanitization log. The sanitizer product information sheet states when used as directed the product is for use as a sanitizer on dishes glassware and utensils at 200-400ppm active quaternary without potable water rinse. It is a violation of federal law to use product in a manner inconsistent with its labeling. 2. On 02/04/25 at 09:37 AM, the walk-in cooler contained items that were not labeled to identify contents and had a single date. A block of yellow sliced cheese accessed and wrapped in plastic dated 2/3 Four small cups with pickles dated 1/30. Eleven cups identified by V18 as cottage cheese dated 2/1 and one cup dated 1/30. Peanut butter and Jelly sandwich dated 2/1 A sandwich bag identified by V18 as ham and cheese labeled with an S and dated 2/2 Eight cups identified by V18 as lactose free milk dated 2/2. Two rotten tomatoes one with black spots one with white spots. Eleven wrinkled and wilted green peppers. An accessed 5 lb. (pound) bag of cheddar cheese labeled use first dated 1/30 An accessed 5 lb. bag of cheddar cheese opened on 1/29 use by date 2/1/25 Manufacturer wrapped turkey breast stored over a metal facility pan identified as diced beets and dated 2/2/25. Meat wrapped in plastic identified by V17 as sliced turkey labeled use first dated 2/2 Two packages of meat wrapped in plastic identified by V17 as sliced ham dated 2/2 Meat wrapped in plastic identified by v 17 as sliced turkey dated 2/2. Twenty-eight bowls of salad dated 2/1 Eighteen containers identified a cottage cheese dated 2/1 and one dated 1/3. Seventeen sandwiches identified as ham and cheese dated 2/2 Metal tray containing sliced mushy tomatoes, lettuce, sliced onion and cheese slices date 2/4 A tray labeled employees food with a 2-liter bottle of ginger ale and an apple. On 02/06/25 at 12:08 PM, V17 stated food should be labeled when it was delivered, or the with the manufacture's use by date if it taken out of the original container and a use by date added. V17, Dietary Manager, stated it is ok for staff to keep their personal food in the kitchens refrigerator if it is labeled for staff, adding there is no eating or drinking in food prep area because there is a risk for contamination. The undated facility policy Labeling and Dating states leftovers and open foods shall be clearly labeled with date food item is to be discarded. Seven-day shelf life including date of preparation - label includes name of food item, discard date, some health departments also require preparation date. Thirty-day shelf-life label includes name of food item, discard date (i.e. opened date, discard date) The facility policy Food Storage (Dry, Refrigerated and Frozen), dated 8/12/2023, Refrigerated Foods states, open products are sealed, labeled and dated. Raw food is stored below cooked or ready to eat foods. The facility provided Proper Cold Food Storage shows ready to eat food stored above poultry. The facility policy Staff Personal Food Storage, dated 6/14/19, states food brought in by staff will be identified with name of owner and date placed in designated refrigerator. On 02/04/25 at 10:10 AM, the walk-in freezer contained a clear bag identified by V18 as pork patties, dated 1/26, and a clear bag identified as chicken nuggets open to air without a label or dates. The facility policy Food Storage (Dry, Refrigerated and Frozen), dated 8/12/2023, Frozen Foods states, if taken out the original packaging, product is labeled and dated. 3. On 02/05/25 at 02:39 PM, the first-floor resident refrigerator was reviewed with V4, LPN (License Practical Nurse). There was no thermometer in the refrigerator. The temperature log on front of the refrigerator was blank and the freezer section was built up with ice. There was a 240 ml (Milliliter) carton of chocolate milk with a sell by date of 1/27/25. There were two take-out containers containing spaghetti and meatballs with no labels or dates. On 02/05/25 at 02:43 PM, the second-floor resident refrigerator was reviewed with V23, RN (Registered Nurse). The refrigerator contained two take-out containers that were not labeled and dated. There were no thermometers in the refrigerator, and it felt warm and there was no temperature log. On 02/05/25 at 04:33 PM, V1, Administrator, stated there were no temperature logs for the resident refrigerators. The temperature checks are not being done. There should be a thermometer in all the refrigerators. The receptionists are responsible for checking both unit food refrigerators. V1 stated the refrigerator temperatures could not be checked without thermometers in place. On 02/05/25 at 05:12 PM, the first-floor resident refrigerator was observed with V26, Maintenance Director. There was no thermometer, and the temperature log was blank. At 05:21 PM, the second-floor resident refrigerator was observed with V26. There was now a thermometer the freezer section was 15-degrees Fahrenheit. The refrigerator was 50 degrees Fahrenheit. The facility did not provide a policy for resident unit refrigerators. The facility policy Food Storage (Dry, Refrigerated and Frozen), dated 8/12/2023, Refrigerated Foods states, foods are stored at 41 degrees Fahrenheit or below. 4. On 02/04/25 at 09:25 AM, the kitchen tour began with V17, Dietary Manager, and V18, Regional Director. The dry storage area contained dented cans stored on slanted shelves and were not marked as dented. Strawberry filling 7 lbs. (Pounds) Pumpkin puree 6lb 10oz (ounces) Sliced olives 3lbs 7 oz Sliced peaches 3lbs 10 oz Diced potatoes 6lbs 4 oz On 02/06/25 at 12:08 PM, V17 stated if a dented can is inadvertently used, there is a chance for botulism to develop and cause food borne illnesses. The undated facility provided policy Storage of Dry Foods states dented cans shall be stored separately or immediately returned to the food vendor. If dented cans are stored in the storeroom, they shall be clearly marked to prevent usage.

Based on observation, interview, and record review, the facility failed to provide assessment, treatment, services, devices, and care planning for residents with decreased ROM (Range of Motion). This applies to 5 of 5 residents (R114, R86, R46, R94, R99) reviewed for range of motion in a sample of 30. The findings include: 1. R114's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and weakness. R114's POS (Physician Order Sheet) showed an order to, [NAME] [Left] resting hand splint for contracture [management] daily, doff at [Night] and for hygiene, check skin integrity [Every] shift, starting 1/22/25. R114's MDS (Minimum Data Set), dated 12/20/24, showed R114 was cognitively intact. R114's MDS also showed R114 had an impairment on one side of the upper extremity. R114's care plan showed the resident has hemiplegia/hemiparesis [related to] stroke, but did not show the use of a resting hand splint. The care plan also showed Impaired mobility [Due to] hemiplegia/hemiparesis decreased ROM (Range of Motion) [related to] weakness, with a goal of [R114] will maintain ROM to BUE/BLE (Bilateral Upper Extremity/Bilateral Lower Extremity) through next review. On 2/4/25 at 10:37 AM, R114 was lying in her bed, and her left hand was closed into a fist. R114 said she had a stroke and was not able to move her left arm without the help of her right arm. R114 said she needed a splint/brace, and it was in the dresser. R114 said she was not able to put the splint on herself and would need help. On 2/4/25 at 12:48 PM, R114 did not have a splint on. On 2/5/25 at 1:14 PM, R114 did not have a splint on and said the staff did not put it on her. On 2/5/25 at 4:31, R114 still did not have a splint on her left arm. On 2/6/25 at 10:07 AM, R114 was in bed and did not have a brace on her left arm. On 2/6/25 at 2:31 PM, V10 (Director of Rehab) said R114 would use the right arm to lift the left arm. V10 said R114 would benefit from a splint and thought she had one. V10 said R114 should have the splint on her because it could cause a contracture if she did not use it. V10 said a splint was used if a resident did not have a lot of movement in their hand and it would help keep her hand open. On 2/6/25 at 2:22 PM, V9 (Restorative Aide) said R114's left side was impacted, and she was unable to open her hand. V9 said if the resident had an order for a splint, it should be applied. V9 said if the staff do not apply the splint, the hand could remain closed, get tighter, and could even hurt them if they try to put it on after waiting too long. 2. R86's face sheet shows he was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R86's POS shows an order, dated 1/19/22, for [Patient] to have resting hand splint to [Left] hand: don daily, doff at [Night] and during hygiene. R86's MDS, dated [DATE], shows R86 was cognitively intact. R86's care plan dated 11/27/23,, showed R86 will participate in splint/brace use to decrease contractures to left hand with interventions to Apply splint to left hand 6-7 days a week. On in the AM of at night as ordered. On 2/4/25 at 10:30 AM, R86 was lying in bed and there was a splint on R86's dresser table. When asked if R86 could open or wiggle his fingers, R86 was not able to open the last three fingers on his left hand. On 2/6/25 at 10:05 AM, R86 was sitting in his wheelchair, and he did not have his splint on his left arm. R86 said he needed help putting the splint on, and it had not been placed on him the whole day. On 2/6/25 at 2:19 PM, V9 (Restorative Aide) said the restorative staff put the splints on for all the residents in the facility, but she was made to work on the floor as a CNA (Certified Nursing Assistant), so was unable to apply the splints on the residents. V9 said no one was doing restorative therapy today. V9 said R86 needs to have a splint on every day and the CNA could apply it if restorative was unavailable. V9 said the splint should be applied when R86 wakes up. On 2/6/25 at 2:03 PM, V7 (CNA/Certified Nurse Assistant) said R86 was not able to open or close his hand, but she had not seen a brace. V7 said the restorative staff are the ones who apply the splints on the resident. On 2/6/25 at 2:11 PM, V8 (CNA) said she had not seen R86 wearing a splint recently. V8 said the CNAs can apply the splint on the residents. On 2/6/25 at 2:15 PM, V5 (LPN/Licensed Practical Nurse) said R86 would have a splint on the left hand and used to. V5 said restorative staff are the ones to put the splints on the residents. On 2/6/25 at 3:43 PM, V2 (DON/Director of Nursing) said the restorative CNAs should be putting the splints on the residents. The facility's Managing Residents with Impaired Physical Mobility policy, dated 3/16/24, showed Supporting devices such as splints and casts may be applied to stretch the tissues of the affected body part based on therapy/MD (Medical Director) recommendation. 31327 3. R46's face sheet shows an admitted [DATE]. R46's face sheet shows diagnoses of metabolic encephalopathy, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and facial weakness following cerebral infarction. R46's MDS (Minimum Data Set), dated 12/11/24, shows a blank score for the BIMS (Brief Interview for Mental Status). R46 was triggered as moderately impaired under cognitive skills for daily decision making. R46 has impairment on both sides of his upper and lower extremities. R46's POS (Physician Order Sheet) shows the following orders: [NAME] right rest hand splint for contracture management daily, doff at NOC (Night Shift/Nocturnal) and for hygiene, check skin integrity every shift. Apply cervical collar when up in the wheelchair, may remove for feeding, hygiene, check for redness, discomfort, and pain. R46's care plan documents he has impaired cognitive function/dementia or impaired though processes related to dementia and history of stroke. R46 has limited physical mobility related to weakness, confusion, physical limitation to bilateral upper and lower extremities. R46 will remain free of complications related to immobility including contractures .Interventions: monitor/document/report as needed any signs or symptoms of immobility and contractures forming or worsening, provide gentle range of motion as tolerated with daily care and provide supportive care, assistance with mobility as needed. Document assistance as needed. R46 requires AROM (Active Range of Motion). Staff will provide assistance with AROM to upper and lower extremities. On 2/4/25 at 1:25 PM, R46 was sitting on his reclined chair in his room. R46's hands were contracted. He did not have his splints on. He also was not wearing his cervical collar. On 2/4/25 at 2:41 PM, R46 was laying in bed. He did not have his splints on. On 2/5/25 at 8:47 AM, R46 was sitting on his bed. He did not have his splints on. On 2/5/25 at 12:34 PM, R46 was sitting in his reclined chair. He did not have his cervical collar or splints on. On 2/5/25 at 2:01 PM, R46 was sleeping in his bed. He did not have splints on. On 2/6/25 at 9:46 AM, R46 was sitting in his reclined hair. He did not have his cervical collar or splints on. R46 was unable to answer surveyor's questions regarding his cervical collar, splints, and contracted hands. He was nonverbal, and just grumbled something when surveyor attempted to talk to him. On 2/5/25 at 12:43 PM, V2 (DON-Director of Nursing) stated, It is the responsibility of the restorative aides to apply the splints on the residents who have orders for them. I believe the nurses are supposed to be putting the cervical collars on those residents who have the orders as well. They should be following physician orders. 4. R94's face sheet shows an admitted [DATE], and diagnoses of aphasia following unspecified cerebrovascular disease, Wernicke's encephalopathy, and personal history of other mental and behavioral disorders. R94's POS (Physician Order Sheet) show no orders for R94 to have a splint or other restorative device. R94's MDS, dated [DATE], showed she is moderately impaired in cognition and she has impairment in both sides of her upper and lower extremities. R94's care plans show the following: (R94) has limited physical mobility due to weakness, decrease strength, and low activity tolerance. Restorative: PROM (Passive Range of Motion) to bilateral upper and lower extremities x 10 repetitions. (R94) will have PROM to all planes with staff daily, 6 to 7 days a week as tolerated. (R94) is at risk for pain related to adult failure to thrive, generalized pain. (R94) has a contracture to right hand/wrist. Apply palm protector/rolled towel to right hand daily. May remove splint for ADL (Activities for Daily Living)/hygiene tasks. (R94) has aphasia related to cerebral vascular accident. On 2/4/25 at 11:00 AM, R94 was lying bed. Her hands were contracted and she was not wearing a splint. Surveyor asked her if she was given a splint or towel rolled up to put between her fingers and palm. R94 stated, They don't really put anything between my hands. Surveyor asked if the restorative aides do any exercises with her. R94 responded, They don't really do any exercises because they can't open my fingers. On 2/5/25 at 10:02 AM, R94 was not wearing a splint. On 2/6/25 at 10:27 AM, R94 was not wearing a splint. On 2/6/25 at 11:23 AM, V15 (LPN-Licensed Practical Nurse/ Restorative Nurse stated, I'm new. I started in November/December 2024. They are supposed to wear splints and cervical collars as ordered. I don't have (R94)'s assessment. I didn't get a chance to review her chart. The restorative aides are supposed to be doing exercises with the residents. I don't know if they are documenting. Sometimes they have to work on the floor as CNA's (Certified Nursing Assistants). Today, they are working as CNA's. So, the residents are not getting any restorative exercises. On 2/6/25 at 2:05 PM, V15 came back to surveyor and said, I just did (R94's) assessment and I ordered her palm protectors. She wasn't wearing the palm protectors, because it was never ordered. I don't have any documentation showing (R46) and (R94) got ROM exercises. Facility's policy titled Managing Residents with Impaired Physical Mobility (3/16/24) shows, 1. Mobility assessment will be completed by a nurse upon admission, quarterly, and as necessary. Treatment guidelines for contractures will depend on the cause of the deformity. The following maybe utilized in general: b. Restorative program on assessment. c. Medical devise. Supportive devices such as splint and casts maybe applied to stretch the tissues of the affected body part based on therapy/MD (Medical Doctor) recommendation. B. Facility will develop a plan of care to assess the patient's level of functional mobility and ability to perform ADL's. c. Staff will encourage the patient to perform range of motion (ROM) exercises in all extremities as recommended by therapist or restorative nurse . 48526 5. R99's Face Sheet showed she was admitted to the facility on [DATE], with multiple diagnoses which included hemiplegia and hemiparesis, adult failure to thrive, transient ischemic attack and cerebral infarction. R99's Order Summary Report for 02/2025 showed a current order for, DON (Put On) left upper extremity form progressive hand splint for contracture management daily, DOFF (Remove) at NOC (Night) and for hygiene, check skin integrity every shift. R99's MDS, dated [DATE], showed R99 was cognitively intact, and R99 had an upper extremity impairment on one side. R99's POC (POC/Point of Care) Response History showed restorative splint/brace task. No documentation of splint being applied in the last 30 days. On 02/04/25 at 10:28 AM, R99 was in bed, awake and alert. R99's left hand was in a closed-fist position. R99 was unable to open her left hand. R99 stated she wears a splint and is waiting on a new splint. On 02/05/25 at 1:52 PM, R99 remained in bed. R99's left hand remained closed without a splint. R99 stated the staff still had not applied her splint. She stated she would like to wear a splint because she does not want her hand to continue to worsen. R99 stated she could not remember the last time she had a splint on. On 02/06/25 at 2:20 PM R99 continued to not have a splint on to her left hand. On 02/06/25 at 2:20 PM, V15 (Restorative Nurse) stated R99 has orders for a splint to be worn during the day. The splint is off during the night and for hygiene. V15 stated R99 wears a splint for the contracture of her left hand. V15 stated R99 should have had the splint on today and the last three days. V15 stated R99's contracture can worsen if she does not wear the splint. Facility's policy titled Restorative Nursing Program (8/18/24) shows: 1. Each resident will be screened and or evaluated by the nurse designated to oversee the restorative nursing process for inclusion in the appropriate facility restorative nursing program. The designated nurse will be responsible for the following: a. Obtaining orders for the resident's restorative program b. Documentation on a monthly basis (at a minimum) and c. initiation and updating restorative care plans .

Based on observation, interview, and record review, the facility failed to identify a resident's skin breakdown. As a result of this failure, R7 developed a Stage 3 pressure ulcer. This applies to 1 of 1 resident (R7) reviewed for pressure ulcers in a sample of 10. The findings include: The EMR (Electronic Medical Record) shows R7 was admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis, bacteremia, dependence on respiratory status, hypertension, gastrostomy status, and tracheostomy status. R7's POS (Physician Order Sheet), dated December 24, 2024, showed an order for Daily skin check if moderate risk to high risk based on Braden scale- perform daily skin check if any skin issues are identified please complete the skin assessment form, every night shift for prevention, which was ordered on October 24, 2024. The POS also showed orders dated November 1, 2024 for Weekly skin check, complete weekly skin check in assessment one time a day every [Thursday] assessment and Weekly skin check, complete weekly skin check in assessment one time a day every [Tuesday]. R7's care plan, dated September 13, 2024, showed R7 has potential for impairment to skin integrity (related to) immobility and (respiratory) failure/hypoxia with a goal to maintain clean and intact skin by the review date. R7's Admission Assessment, dated September 11, 2024, showed R7 was at moderate risk for skin breakdown. R7 had no skin breakdown on his coccyx or buttocks upon admission. R7's Readmission Assessment, dated October 24, 2024, showed R7 was at a very high risk for skin breakdown. R7's assessment did not show any skin breakdown on his coccyx or buttocks. On December 24, 2024 at 10:50 AM, V22 (Wound Care Coordinator) said R7 did not have any skin concerns the wound team was seeing him for. At 11:47 AM, V22 did a skin observation. R7's incontinence brief was removed, and R7's skin on his buttocks had several areas of open, broken, and bloody skin. V22 said R7 did not have any skin issues before. V22 said the area needed to be treated, as it was a Stage 3 pressure ulcer and was draining a moderate amount of serosanguineous drainage. R7's buttocks did not have any dressings in place. On December 24, 2024 at 11:55 AM, V21 (CNA/Certified Nurse Assistant) said she had provided incontinence care for him earlier that morning, and she had not noticed anything when she was changing him, but was changing him very quickly. V21 said R7 did not have a dressing on the buttocks when she had previously cleaned him up. V21 said she should have told the nurse so they could put a dressing or apply a cream. V21 said the previous shifts had not reported any concerns about R7's skin. On December 24, 2024 at 12:23 PM, V25 (CNA) said she helped V21 provide incontinence care for R7 and had not noticed any issues with his skin. V25 said she was not the one wiping his perianal area. V25 said she had worked with R7 in the past week and had not seen any broken skin. On December 24, 2024 at 12:07 PM, V12 (LPN/Licensed Practical Nurse) said she had never seen him before and was not treating him for any skin concerns. At 12:13 PM, V12 measured the area of broken skin, which was nine by nine centimeters. V12 said there appeared to be seven areas with broken skin. R7's progress note, written by V22, dated December 24, 2024 at 1:18 PM, showed, Body assessment completed, multiple open areas noted, scattered to buttocks and coccyx area. Wound noted with dusky discoloration, granulation, epithelial and slough noted to wound bed. Wound clustered and measured as one. Resident noted alert and oriented +0 and [diagnosis] with [respiratory] failure with ventilation dependence, hemiplegia following [Cerebrovascular Accident], obesity, [Hypertension] and history of wounds. Alternating air mattress noted in place. [Power of Attorney] [name] called and wound to buttocks/coccyx communicated with intervention and treatment plan. No concerns voiced at this time. [Medical Doctor] called for orders, no answer at this time. [Nurse Practitioner] notified and orders received to clean wound and apply medihoney fiber sheets three times weekly and cover with adhesive foam. Will continue to monitor. On December 24, 2024 at 1:54 PM, V27 (NP/Nurse Practitioner) said she was made aware of the skin issues for R7 on December 24, 2024. When showed the wounds, V27 said R7's wounds would be something she would defer to the wound doctor. V27 said it was her expectation any increasing redness should be notified to the nurse or the wound care team. On December 26, 2024 at 1:40 PM, V2 (DON/Director of Nursing) said she would have expected the CNAs to notify the nurses and the wound care nurses. V2 said when the CNAs saw the skin breakdown, she would have expected the CNA to notify the nurse. On December 26, 2024 at 2:40 PM, V4 (Nurse Consultant) said the wound doctor would be seeing R7 tomorrow and might debride it. R7's Assessments were reviewed, and no assessments were completed for impaired or open skin since admission. The facility's Wound Prevention and Healing policy reviewed on June 1, 2024 showed Skin will be inspected during showers, following orders for daily and or weekly skin checks as scheduled, and PRN (As Needed).

Based on observation, interview, and record review, the facility failed to report a new skin alteration for a resident (R3) with a known history of a right hip pressure injury. This failure resulted in R3's right distal hip stage 3, and right proximal hip stage 2, new facility-acquired pressure injuries not being assessed and treated once identified. This applies to 1 of 3 residents (R3) reviewed for pressure wounds. The findings include: R3's EMR (Electronic Medical Record) showed R3 had multiple diagnoses including a history of pressure injuries, sequelae of cerebral infarction, traumatic subarachnoid hemorrhage, peripheral vascular disease, major depressive disorder, anxiety, dementia, neuropathy, cervical disc degeneration, hypertension, dysphagia, right eye blindness, and malnutrition. R3's MDS (Minimum Data Set), dated 7/04/2024, showed R3 was dependent on staff assistance for personal hygiene and required substantial to maximal two-staff assistance with bed mobility. R3's EMR showed R3 was at risk for developing pressure injuries because R3 had a history of a facility-acquired stage 3 pressure injury to her right hip. On 10/02/2024 at 10:10 AM, R3 was in bed on her right side. At 10:47 AM, R3 was still in the same position. Surveyor asked V5 (Certified Nurse Assistant/CNA) to do a skin check on R3. V5 initially said R3 had no wounds. Then V5 turned R3 on her left side, and R3 had uncovered open areas on her right hip. Then V5 said she had observed those new open areas on R3's hip earlier in the shift during care. V5 said her shift started at 6 AM. V5 continued to say she would now go notify V8 (Licensed Practical Nurse/LPN). At 11:07 AM, V8 (LPN) said she was not aware of R3 having wounds, and was just now notified by V5. V8 proceeded to assess R3's right hip wounds and said they were pressure injuries. V8 cleaned the wounds and covered them. V8 said V3 (Wound Care Nurse/WCN) was just now notified and would be coming to assess R3's wounds. R3 appeared uncomfortable and said her side was hurting. At 11:53 AM, V3 (WCN) and V4 (Wound Care Aide/WCA) assessed R3's right hip wounds. V3 said R3 had two newly acquired pressure wounds to her right hip, a stage 2 and stage 3 cluster. V3 said R3's skin had to be monitored because she had a history of a right hip pressure wound, and because she favored positioning on her right side. On 10/02/2024 at 4 PM, V3 (WCN) said she expects nursing staff to report any skin alterations immediately to the nurses on duty and complete the facility's skin reporting referral slip. V3 said, additionally, the nurses on duty were also responsible for contacting the physician and initiating wound care immediately. V3 said she had just educated the nursing staff on reporting newly identified skin alterations. On 10/03/2024 at 12:30 PM, V18 (Nurse Practitioner/NP) said she oversees R3's medical care. V18 said she expected facility staff to monitor residents' skin and report any skin alteration when identified to initiate treatment right away and monitor the wound's progress. On 10/02/2024 at 4:05 PM, V2 (Director of Nursing/DON) said she expects nursing staff to follow the facility's skin prevention process of assessing residents' skin and reporting any abnormalities immediately. R3's Wound Assessment Details Report, dated 10/02/2024, showed R3 had a Braden Score of 12 (High Risk) for pressure injuries completed on 8/15/2024. R3's Care Plan reviewed on 10/02/2024 showed R3 was at risk for developing pressure injuries to her right hip with a revised date of 3/18/2024. The care plan showed multiple interventions including, Follow facility policies/protocols for the prevention/treatment of skin breakdown initiated on 8/31/2022. R3's Order Summary Report, dated 10/02/2024, showed an order dated 11/23/2022 to, Assess skin for impairment daily. Notify wound care for any issues observed. The report also showed orders initiated on 10/02/2024 to, Clean Right trochanter distal wounds, paint with skin prep. Apply medi-honey fiber sheet. Cover with adhesive foam three times weekly and PRN and Clean Right (Trochantar) proximal wound, Paint with skin prep. Cover with adhesive foam three times weekly and PRN. R3's Wound Assessment Details Report, dated 10/02/2024, showed R3 acquired a stage 3 pressure injury to her right distal trochantar (hip). The report showed R3's wounds were clustered together and measured 1.6 cm (centimeter) in length x 0.7 cm in width x 0.1 cm in depth. The report showed R3's wounds had 50% slough (necrotic non-viable tissue), 10% pale pink non-granulating, and 20% epithelial tissues and had light serous drainage. R3's Wound Assessment Details Report, dated 10/02/2024, showed R3 acquired a stage 2 pressure injury to her right proximal trochantar (hip). The report showed R3's wound measured 0.4 cm in length x 0.4 cm in width x 0.1 cm in depth. The report showed R3's wound had 90% pale pink non-granulating and 10% epithelial tissues with light serous drainage. The facility's policy titled Treatment/Services to Prevent/Heal Pressure Ulcers, dated 6/16/2024, showed, 1. The facility will ensure that based on the comprehensive Assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . The facility's policy titled Wound Prevention and Healing dated 6/01/2024 showed, Policy Statement: To provide wound care treatments/services (using a multidisciplinary approach) .1. Risk Assessment and Prevention .b. Braden scale will be completed to determine the patient's level of risk and implement interventions to prevent development of pressure ulcers. c. Skin will be inspected during showers, following orders for daily and or weekly skin checks as scheduled, and PRN .12. Staff Education and Competency Testing .2. All nursing staff will complete competency assessments for basic wound care and prevention including other wound related topics that would be beneficial to patient care .

Based on observation, interview, and record review, the facility failed to monitor and check glucose blood sugar levels for a resident with a known history of Diabetic Ketoacidosis and elevated blood sugars. This failure resulted in R1 needing hospitalization for Diabetic Ketoacidosis (grossly elevated blood sugars). This applies to 1 of 3 residents (R1) review for Diabetes and blood glucose monitoring in the sample of 4. The findings include: Face sheet shows R1 is [AGE] years-old who has multiple diagnoses which include acute embolism and thrombosis of deep veins of upper extremity, bilateral, type 2 diabetes mellitus with ketoacidosis without coma, cardiac arrest due to other underlying condition, cardiac arrest, cause unspecified, diabetes mellitus due to underlying condition with ketoacidosis without coma, elevated white blood cell count, unspecified, schizoaffective disorder, bipolar type, acute kidney failure, unspecified, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, acute respiratory failure with hypoxia, unspecified protein-calorie malnutrition, anemia in other chronic diseases classified elsewhere, hyperkalemia, pneumonia due to streptococcus, group b, pneumonia due to klebsiella pneumoniae, sepsis, unspecified organism, acute diastolic (congestive) heart failure, metabolic encephalopathy, hypoxic ischemic encephalopathy, unspecified, acute metabolic acidosis, type 2 diabetes mellitus with hyperglycemia, essential (primary) hypertension, other hypotension, other symptoms and signs involving cognitive functions and awareness, relevant medical history is: CHF diabetes chronic renal failure/ESRD. Nurse Practitioner Notes, dated May 17, 2024, shows R1 is a [AGE] year-old male who was admitted to the facility on [DATE], after suffering a cardiac arrest and was resuscitated in the emergency room . R1 was also diagnosed with DKA (Diabetic Ketoacidosis), AKI (Acute Kidney Injury), EKG showed right bundle branch block, septal infarct, MI (Myocardial Infarction). In the ER, R1 became bradycardic and went into cardiac arrest. His blood sugar was 1229 mg/dL (milligram per deciliter). Medication Administration Record (MAR) showed R1's blood sugar level is to be monitored every 7:30 AM, 12:00 PM, and 4:30 PM. The same MAR shows Insulin Aspart 35 units was given twice a day (9 AM and 5 PM) and 15 units every 12 PM. Humalog Insulin sliding scale was also prescribed according to the blood sugar result every 7:30 AM, 12 PM, and 4:30 PM. R1's blood glucose monitoring log shows the following readings: 5/21/2024, at 1:14 PM- 400.0 mg/dL, 5/21/2024 at 5:04 PM- 345.0 mg/dL, 5/22/2024 at 9:20 AM- 400.0 mg/dL, 5/22/2024 at 4:33 PM- 350.0 mg/dL, 5/22/2024 at 4:34 PM- 399.0 mg/dL, 5/23/2024 at 6:15 AM- 600.0 mg/dL. R1's blood glucose monitoring from May 21 at 1:14 PM through May 22, 2024, at 4:34 PM showed his blood sugar level was consistently elevated, ranging from 345 mg/dL to 400 mg/dL, despite routine Insulin dose plus sliding scale order. The progress notes of the same dates lacked documentation the staff rechecked R1's sugar after dinner and at bedtime, or monitored R1 for change in condition. There was no documentation of notifying V4 (R1's Physician) of R1's consistent elevation of sugar level despite the insulin doses. On May 23 at 6:15 AM, R1's blood sugar level was 600 mg/dL. R1 displayed lethargy and slurred speech, resulting to being sent and admitted to the hospital with diagnosis of diabetic ketoacidosis (DKA). R1's health status notes, dated May 23, 2024 at 9:15 AM, shows R1was found on floor the floor lying on his back. R1 was lethargic with slurred speech. R1's blood sugar level reads high. R1 was given insulin coverage per V4's order. R1's glucose level was rechecked, results showed HI (High). R1 was sent the hospital emergency department via 911. Hospital Physician Endocrinology Report, dated May 24, 2024, shows R1 was seen in consultation for management of type 2 diabetes with hyperglycemia. R1 was brought into the hospital from the nursing home facility after an unwitnessed fall and altered mental status. Upon admission, R1's sugar was quite elevated, and he was acidotic. The same hospital record shows on May 23, 2024, at 9:47 AM, R1's blood glucose level was 810 mg/dL, his Ketones result showed 5.7 mmol/L, which was also very high. On May 28, 2024, at 4:00 PM, R1 was observed in the hospital. He was resting on his bed awake but confused. R1 was only oriented to himself and to his family. R1 was on 2-point soft restraint to his upper extremities only. V12 (Hospital Nurse) stated when R1 first got admitted to the hospital, his blood sugar was very high; he had DKA. R1 was initially placed in ICU (Intensive Care Unit) and was later transferred to the medical floor. On May 29, 2024, at 8:55 AM, V6 (Nurse) stated R1 got up from bed without calling for help and fell . V6 assessed R1 and checked his vital signs, including his blood sugar level. R1's sugar registered HI (High). When he fell , he did not sustain injury, he just said he was getting up. He was sent to the hospital because he had slurred speech. When V6 rechecked R1's sugar, it remained high despite being given Insulin (Humalog) 10 units. On May 29, 2024, at 1:55 PM, V4 (R1's Physician) stated, For brittle diabetics, the standard glucose monitoring is 3-4 times a day, and as needed. When R1's glucose level was consistently elevated despite administration of prescribed insulin, the staff should have rechecked the sugar 2 hours after dinner and rechecked it again at bedtime. If there was no order, the staff should have called me. V4 stated the staff should have reported R1's condition to him and he could have given new orders for care and review the medications and see if it needed adjustment. V4 added when the blood sugar is consistently elevated, the staff should follow up with the physician, and closely monitor resident's condition and sugar level.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from resident-to-resident physical abuse. This failure resulted in the facility seeking medical attention at the local hospital for R1, and R1 sustaining bruising and abrasions to her nose and face. This applies to 1 of 3 residents (R1) reviewed for resident-to-resident physical assault in the sample of 3. Findings include: On October 5, 2021 at 10:25 AM, R1 was lying in bed. R1 had dark blue to purple bruising over the bridge of her nose, extending under her lower right eye, and bruising and scabbed abrasions across her left lower jawline. Due to her cognitive impairment, R1 was unable to recall how she sustained the injuries to her face. R1 was alert and oriented to her name only. R1 touched the affected areas with her hand and said the areas were painful when she touched them. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in October 2018 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated June 24, 2021 shows R1 has moderate cognitive impairment, requires extensive assistance by two facility staff members for transfers between surfaces, extensive assistance by one facility staff member for bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene. R1 is totally dependent on facility staff for bathing. R1 uses a wheelchair for mobility and is always incontinent of bowel and bladder. On October 1, 2021 at 3:14 AM V4 (Licensed Practical Nurse/LPN) documented, CNA (Certified Nursing Assistant) observed [R1] was trying to get out of the bed, while her roommate (R2) was standing close to her bed with a shoe in her hand. [R1] stated her roommate [R2] is beating me up with her shoe. Resident was quickly removed from her roommate. Writer completed head to toe assessment to resident. Resident has a left cheek laceration, a bruise on her nose, a red face and resident stated she also hit me on my chest . On October 1, 2021 at 3:16 AM, V4 (LPN) documented R1 was sent to the local hospital via 911 paramedics. Hospital documentation by V5 (emergency room /ER Physician) dated October 1, 2021 shows: Primary Impression: Nasal Injury. [R1] presents for evaluation from SNF [Skilled Nursing Facility] after reportedly being struck to the face by her roommate. There is no other head injury or loss of consciousness. Patient is noted to have some mild ecchymosis to the nasal bridge area but no septal hematoma. Patient is in no acute distress. X-ray does not reveal acute fracture. At this time, we will plan for discharge back to her facility. On October 5, 2021 at 1:19 PM, V4 (LPN) said, I was finishing my med pass and I had an admission. I was called by the CNA who shouted my name. When I went to the room there were two CNAs in the room, and one was holding [R1] and the other was holding [R2]. [R2] was holding a shoe in her hand and said she had hit [R1] with the shoe. I assessed [R1]. She had a laceration on her left cheek and a bruise on her nose and she also stated she was hit on her chest. I made sure she was stable and safe. I rolled [R1] to another room and I called [V2] (Director of Nursing/DON) and I called the doctor and I received an order to send both residents out to ER via 911. The police came and did a report. I felt afraid of [R2] after she hit the resident. She was agitated and screaming. [R1] cannot walk and is confined to her bed or the chair. [R1] cannot fight back. She was upset and afraid. [R1] told the police, 'I was scared to death.' The police asked [R1] what was going on and [R1] said, 'She [R2] attacked me.' [R1] said she was hit on her chest, but I couldn't see anything on her chest. On October 5, 2021 at 1:49 PM, V6 (CNA) said, I wasn't assigned to care for [R1] or [R2] that night. Their assigned CNA was taking care of someone else's call light. She asked me to come down while she took care of the other resident. I went down to make sure [R1] was okay because she was trying to get out of bed and she never tried to do that. When I walked in [R2] was standing with a shoe in her hand over [R1]. Then the nurse came down and [R2] was still standing with a shoe in her hand and that's when the nurse noticed [R1] was hurt. [R1] said she was afraid. [R2] has been aggressive towards others; she does have an aggressive side to her. I have seen it. [R2] was confined to her room after the incident and said, I'll take my gun and shoot you [profanity]. On October 6, 2021 at 12:38 PM, V7 (Nurse Practitioner/NP) said, I am very familiar with [R1] and [R2]. I see them quite frequently at the facility. I was told by the facility [R2] hit [R1] with her shoe and both were sent to the hospital. [R1] is very frail and elderly. The wounds on her face were definitely caused by the shoe hitting her face. On October 6, 2021, V7 (NP) documented regarding R1, Patient unable to give complete, detailed or reliable history due to: Impaired memory or dementia. Was notified 10/01 that pt was struck by her roommate. A shoe was used to hit pt in the face. Pt was sent to ER, came back same day, no new orders. Her roommate was sent to hospital for psychiatric admission. Right peri-orbital area resolving ecchymosis, no redness, conjunctiva clear, stable peri-orbital [CONDITION(S)]. Left jawline-linear 'spots,' imprint of bottom of shoe? One line. Resolving. Not swollen. The facility's Incident Report Form dated October 5, 2021 shows, .On the night of 10/1/2021, at approximately 01:20 AM, [R1] was observed sitting at the side of her bed and [R2] was observed standing at the side of the bed with a shoe in her hand. [R1] stated that [R2] struck her. The residents were immediately separated and assessed for injury by nurse. Upon assessment, [R1] was noted to have a scratch on the left side of her face and bruise on her nose.After investigation, it has been determined that this incident could not have been predicted or prevented by staff. The MDS (Minimum Data Set) assessment for each resident show that there had been no aggressive behavior and that there was no significant risk of injury to those around them. The EMR shows R2 was admitted to the facility in May 2016. The EMR continues to show R2 was transferred to the local hospital under psychiatric petition on October 1, 2021. R2 has not returned to the facility. R2 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] shows R2 had moderate cognitive impairment, required extensive assistance with dressing and toilet use, limited assistance with personal hygiene and supervision with all other ADLs. R2 had adequate hearing, clear speech, and usually understood others. R2's MDS continues to show R2 had delusions, inattention, disorganized thinking, and wandering behaviors. The EMR shows the following documentation regarding R2: August 16, 2021 at 7:28 AM, V4 (LPN) documented: [R2] becomes more confused, forgetful and violent for the last couple of days. May 13, 2021 at 6:46 AM, V9 (LPN) documented: Writer observed this resident [R2] standing over [R1] while she was sleeping, redirected [R2] back to her side of the room, writer continued passing meds went back to check on resident the door was closed, writer open the door noted [R2] standing over [R1] again resident redirected to her bed, and was asked not to close the door. On May 5, 2021, V10 (Nurse) documented: Resident heard screaming in her room. CNA went in and observed [R2] with her shoe in her hand attempting to hit [R1], stating This is my apartment! On January 22, 2021, V8 (LPN) documented, [R2] started acting out because she wants the TV off in the room, while her [R1] is watching the TV. [R2] has a problem with sharing her room at times. Redirecting and talking to resident help at times. On January 21, 2021, V8 (LPN) documented, [R2] TV off in her room, but [R1] is watching TV with volume low. Resident started threatening to sleep in the hallway, tried to orientate her to time, its only 6:00 PM, and thought it was 1:00 AM. Resident continued to behavior of needing a place to sleep, she then put pillows on the floor to lay down. Another staff came to help me to encourage her not to lay on floor. On November 15, 2021, V10 (Nurse) documented: [R2] verbally aggressive towards CNA. Cursing at her and raising her middle finger. Threatening to break the TV [R1] is watching if it is not turned off right away. On October 5, 2021 at 10:13 AM, V8 (LPN) said, [R2] is out at the hospital. [R2] had an aggressive episode and hit her roommate. [R2] would have outbursts and have psychotic episodes and threaten to hit somebody or get verbally aggressive. She would go in other people's rooms. She would not wear her mask. People complained she was coming in their room without a mask. Her roommate (R1) is kind and frail and could yell stop but could not defend herself. On October 5, 2021 at 10:34 AM, R3 said, My room used to be on the same floor as [R2]. She frequently came into my room and never wore her mask, and it bothered me. If I asked her to leave or said put your mask on, she would make a fist at me in the air and shake her arm at me like she would hit me. It would scare me that she would hit me. I mentioned it to the facility staff, and I was told it was none of my business. Nothing changed after I said something. The EMR shows R3 was admitted to the facility in April 2018, and her MDS dated [DATE] shows R3 is cognitively intact. On October 6, 2021 at 9:50 AM, V12 (CNA) said, [R2] is pleasantly confused and has her moments at times. She is hard to give care to because she gets agitated and refuses care and calls us [profanity]. There have been a couple of times when I saw her shaking her fist at people giving a gesture like she wanted to punch them. On October 6, 2021 at 11:44 AM, V9 (LPN) said, Back in May 2021 I had seen [R2] standing over [R1] while [R1] was sleeping. I had not seen her hit or harm the resident, but I had an uneasy feeling. I had seen her being verbally aggressive before. On October 5, 2021 at 3:13 PM, V1 (Administrator) and V2 (DON) said R1 and R2 have been roommates dating back to April 2020. V1 said, I was not aware there was an incident back in May 2021 where [R2] was seen holding a shoe over [R1]. It wasn't reported to me, otherwise we would have investigated it. V2 confirmed the facility has nursing progress notes dating back to November 2020 showing multiple behaviors by R2 towards R1 and said the facility has never tried to move R1 to a different room, away from R2. On October 6, 2021 at 11:30 AM, V1 (Administrator) said, I was not aware of situations with [R1] and [R2]. I would assume since I didn't know about it, the family of [R1] was never told either. Had I known, we would have moved the residents to different rooms. The documentation regarding the situations would have been on the 24-hour report. I'm not sure how me or the DON missed it. On October 6, 2021 at 11:49 AM, V13 (Power of Attorney/Family Member of R1) said, I'm not happy about the situation with my mom (R1). They haven't given me a lot of information about the situation. I was contacted at 2:00 AM on October 1, when they sent her to the hospital. I don't want my mother back in the same room with that person. I've never complained about the care there but just too many things have been going on. My mother was a victim of battery and I said there better be a police report. I'm the one who said call the police. I have never been informed by the facility that my mom has had any other issues with this roommate. If I had ever been made aware of any other instances or problems between my mother and this roommate, I would have said separate them and keep that woman away from my mother. But I have never been told there were any other situations. The facility's Abuse Prevention Program-Policy, reviewed 1/2019 shows: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. .IV. Establishing a Resident Sensitive Environment. This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's concern identification procedures. Residents and families will be informed of the facility's concern identification procedures. An essential element of customer satisfaction is a timely response back to the family or resident to concerns expressed. At least quarterly, the reported concerns from residents and families, and the facility response, will be reviewed by the facility Quality Management committee to assure that individual concerns are being addressed and to assess any patterns that might indicate needed changes in facility practices. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Pattern Assessment: At least quarterly, the Quality Management committee will review concern identification reports, accident reports, incidents reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other unusual occurrences that may constitute abuse, neglect, mistreatment or misappropriation of resident property. Based on an assessment of the reports, the Quality Management committee will further investigate and/or determine whether a change in facility practices is warranted. V. Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer . Handout C: Abuse Prevention Program Training: Causes of Angry or Agitated Resident Behaviors: Signals That a Resident May Become Aggressive: Paranoia Hallucinations Delusions Change of mood Combativeness Stubbornness Pacing Restlessness Crying Suspiciousness Tension Repetitive questions or actions

Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-,[DATE]-NH revised on [DATE], Nursing Home guidance from the Centers for Disease Control (CDC), and observation, interview, and record review, the facility failed to prevent or contain the spread of COVID-19 as evidenced by failure to develop a process of ensuring that screening forms required for staff and others entering the facility were reviewed for completion and healthcare personnel (HCP) who documented positive signs/symptoms of respiratory infection in the screening form were properly assessed and not allowed to work. This failure represent Immediate Jeopardy (IJ) to the health and safety of all 77 residents in the facility due to the high likelihood of transmission of COVID-19 from staff to residents. The facility is in a county with high incidence of community based transmission and at the time of the survey the facility had 67 confirmed COVID-19 cases in residents and staff. The IJ began on [DATE] when Nursing Assistant (NA1), a deceased employee, was allowed to work from 2pm-10pm without clinical evaluation when on the screening form, NA1 indicated yes to the screening question I now have a new symptoms of a cold or flu. NA1 subsequently tested positive to [DIAGNOSES REDACTED]-CoV-2, the coronavirus associated with COVID-19, and was hospitalized and eventually NA1 expired on [DATE]. The facility had reported two staff COVID-19 related deaths, Employee (E1) and NA1, and 24 resident COVID-19 related deaths. At the time of the survey, the facility had 40 staff and 27 residents who tested positive for COVID-19. The Administrator was notified of the Immediate Jeopardy on [DATE] at 11:51am. Findings include: According to https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html updated on [DATE] revealed: Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. If infected with [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19, residents are at increased risk of serious illness. COVID-19 cases have now been reported in all 50 states and DC; with many areas having wide-spread community transmission. Given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from severe infections, hospitalization s, and death. Visitors and HCP continue to be sources of introduction of COVID-19 into nursing homes. To protect the vulnerable nursing home population, aggressive efforts toward visitor restrictions and implementing sick leave policies for ill HCP, and actively checking every person entering a facility for fever and symptoms of illness continue to be recommended . During the entrance interview on [DATE] at 10:15am, with the Administrator when asked if the facility had any confirmed cases of residents with COVID-19 or persons under investigation (PUI), the Administrator stated that they had active cases and PUIs placed in the designated unit on second floor. Review of the resident list, provided by the facility, revealed 27 positive cases and three PUIs in the facility. Review of the employee surveillance record revealed there were two staff deaths related to COVID-19. Both staff (NA1 and E1) had onset of symptoms dated [DATE]. The same form indicated E1's last day of work was on [DATE], called off work with onset of symptoms (fever, cough and shortness of breath) on [DATE], was hospitalized on [DATE] and expired on [DATE]. Review of the Resident Line List for COVID-19 Outbreaks in Long Term Care revealed the first confirmed COVID-19 case R1 (Resident 1) had onset of symptoms on [DATE], tested positive for COVID-19 on [DATE], was hospitalized and subsequently expired on [DATE]. Review of the facility's COVID-19 Screening Tool for Employees/Visitors, revealed the following questions needed to be answered with a yes or no prior to the start of the shift or prior to the entry to the facility: Within the past 14 days, I have traveled to a location where COVID-19 has been diagnosed or suspected. Within the past 14 days, I have been in close contact with persons who have traveled to a location where COVID19 has been diagnosed or suspected. Within the past 14 days, I have been sick with a cold or the flu. Within the last 7 days, I have had a fever. Within the last 7 days, I have had nausea and vomiting. Within the last 7 days, I have had diarrhea. I now have new symptoms of a cold or flu. I now have a new onset of fever. Within the past 14 days, I have been around people who have been or are sick with colds or flu. Within the past 14 days, I have been around people who were sick with colds or flu. I have been nauseated or have vomited or had diarrhea within the past week. IF YOU HAVE MARKED YES TO ANY OF THESE QUESTIONS, PLEASE SEE YOUR DON (Director of Nursing)/IP (Infection Preventionist), AND OR DESIGNEE FOR FURTHER ADVICE AND DIRECTIONS . 1. Review of the screening tools from [DATE] to [DATE] revealed the following: a. NA1's screening form dated [DATE] revealed a yes answer to the question I now have a new symptoms of a cold or flu. There was no evidence that NA1 was clinically assessed prior to starting the shift. Review of NA1's timecard reflected NA1 worked on [DATE] from 2pm-10pm. b. NA2's screening form dated [DATE] revealed a yes response to the questions: Within the past 14 days, I have been sick with a cold or the flu, within the last 7 days, I have had a fever . I now have new symptoms of a cold or flu . The form did not have a recorded temperature. There was no evidence that NA2 was clinically assessed prior to starting the shift. Review of the time card on [DATE] revealed NA2 worked 6am-2pm on that day. c. NA16's screening questions dated [DATE] were not answered except for a recorded temperature of 95 degrees Fahrenheit (F). The staffing sheet on [DATE] revealed NA16 worked 6am-2pm on that day. d. NA4's screening questions dated [DATE] and [DATE] were not answered except for a recorded temperature of 93.6 F. The timecard on [DATE] and [DATE] indicated NA4 worked 2pm-10pm on both days. e. NP1 (Nurse Practitioner1) screening questions dated [DATE] were not answered. There was no temperature recorded. f. E1 (Employee1) screening tool signed by the employee on [DATE] was not completed except for a recorded temperature of 93.6F. g. JM's (person initial) screening tool dated [DATE] was not completed nor was the temperature recorded. On [DATE] at 11am, when asked to identify JM, the Administrator stated she was not sure who the person was. During a telephone conference on [DATE] at 3:30pm with participation of the Administrator, Regional Nurse Consultant, Director of Nursing and Infection Control Preventionist, the facility confirmed that there was no evidence that clinical evaluation was conducted for the staff who answered yes to signs/symptoms of respiratory infections prior to allowing them to work. The Administrator confirmed that they are now looking at the screening tools to ensure they are reviewed for completeness and clinical evaluation as needed. 2. Review of the facility's COVID-19 Screening Tool for Employees, dated [DATE] to [DATE], and the facility's corresponding timecards revealed the following staff did not complete the screening questions prior to starting their shift: a. [DATE], eight staff did not complete the screening questions and were allowed to work: NA6, E3, E4, NA7, Licensed Practical Nurse (LPN1), NA8, E5, and the Maintenance Environmental Director. b. [DATE], 19 staff did not complete the screening questions and were allowed to work: E2, E6, NA9, NA5, NA10, NA11, LPN2, LPN3, NA12, E3, E5, E7, NA7, E8, E9, Registered Nurse (RN1), NA13, LPN4, and the Maintenance Environmental Director. c. [DATE], 11 staff did not complete the screening questions and were allowed to work: NA10, LPN5, NA14, RN2, E7, LPN4, E4, E5, E3, NA11, and E10. d. [DATE], 18 staff did not complete the screening questions and were allowed to work: NA10, NA5, NA11, NA15, NA16, RN1, NA17, E11, NA13, E5, NA18, RN1, E2, RN3, LPN1, E7, E8, and the Food Service Director. e. [DATE], nine staff did not complete the screening questions and were allowed to work: RN1, NA8, NA10, NA19, LPN1, NA8, NA7, LPN5, and the Food Service Director. Review of the facility's Report of Laboratory Results, dated [DATE] and [DATE], revealed that the following staff did not fill out the screening questions on the COVID-19 Screening Tool for Employees, dated [DATE] to [DATE], were allowed to work, and subsequently tested positive for COVID-19 on [DATE] and [DATE]: NA9, NA10, and RN1. During an interview on [DATE] at 10:30am, the Administrator was asked when the COVID-19 results were reported to the facility. The Administrator stated that the results were reported at various times during the day on [DATE]. When asked why RN1 whose COVID-19 positive result that was reported on [DATE], was still allowed to finish the shift until 9:23pm, the Administrator stated the [MEDICAL TREATMENT] company was unable to find a replacement. According to the Administrator, RN1 stated the screening forms were not completed because RN1 was in a hurry. Review of the QSO ,[DATE] revised on [DATE] Guidance for Limiting the Transmission of COVID-19 for Nursing Homes revealed: .Additional guidance: 2. Implement active screening of residents and staff for fever and respiratory symptoms . 4. Screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. If they are ill, have them put on a facemask and self-isolate at home. [DATE] Additional Considerations and Recommendations: While contact tracing and risk assessment, with appropriate implementation of HCP work restrictions, of potentially exposed HCP remains the recommended strategy for identifying and reducing the risk of transmission of COVID-19 to HCP, patients, and others, it is not practical or achievable in all situations. Community transmission of COVID-19 in the United States has been reported in multiple areas. This development means some recommended actions (e.g., contact tracing and risk assessment of all potentially exposed HCP) are impractical for implementation by healthcare facilities. In the setting of community transmission, all HCP are at some risk for exposure to COVID-19, whether in the workplace or in the community. Devoting resources to contact tracing and retrospective risk assessment could divert resources from other important infection prevention and control activities. Facilities should shift emphasis to more routine practices, which include asking HCP to report recognized exposures, regularly monitor themselves for fever and symptoms of COVID-19, use facemasks or cloth face coverings for source control, and not report to work when ill. Facilities should develop a plan for how they will screen for symptoms and evaluate ill HCP. This could include having HCP report absence of fever and symptoms prior to starting work each day . The Administrator was notified that the immediacy was removed on [DATE] at 11:27am after the removal plan was accepted. Removal of the immediacy was verified on [DATE] by the following: 1. Observation and interview of the receptionist/screener on [DATE] at 11am revealed a revised screening process in which the screener asked the surveyor questions and entered the answer in the screening form and at the same time recorded the temperature that was taken. The screener then provided the surveyor with a screening ticket that was dated and timed and initialed by the screener. According to the screener, this was the same process for anyone who would enter the facility. The screener stated that the employee is required to provide the screening ticket to the shift supervisor prior to work. The screener explained that any yes answer to the screening questions would require a notification to the clinical staff for assessment. When asked if the receptionist had received any yes answers since the change in the screening had been initiated, the receptionist responded, Yes. 2. Random review of staff screening forms based on staff schedule from [DATE] until [DATE] revealed forms were properly completed with only one staff who responded yes to the question Do you have a headache?. The facility provided a clinical assessment form that was completed for this particular employee with an appropriate explanation why the employee was still eligible to work. 3. Review of the in-service dated [DATE] provided to the designated screeners related to the revised screening process and screening tool and the notifications to the clinical staff for any needed assessments or follow-up. 4. Review of in-service dated [DATE] provided to the shift supervisors and all staff related to the screening process, the revised screening tool and the assessment/evaluation process for symptomatic staff. 5. Interviews were conducted to assess staff knowledge of the revised screening process and screening tool, signs and symptoms of respiratory infection that would require notification of the facility before reporting to work. After removal of the Immediacy, the non-compliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified.

Based on interview and record review the facility failed to implement preventative fall measures. This applies to two of four residents (R1, R4) reviewed for falls in a sample of 13. This failure resulted in R1 incurring a right femoral neck fracture and R4 incurring a left forehead laceration requiring sutures. Findings include: 1. The Admission Record dated June 18, 2016 documents R1 with [DIAGNOSES REDACTED]. The Progress Notes document R1 admitted to the facility on [DATE] at 6:10pm. R1's hospital Skilled Nursing Facility Communication Form dated June 18, 2016 documents R1 with discharge fall precautions recommended as to utilize a bed and chair alarm for safety measures. On June 1, 2017 at 8:59am E5 (Evening Nursing Supervisor) stated on June 18, 2016 E5 assisted with R1's admission to the facility. E5 stated hospital recommended fall interventions are initiated at the time a resident is admitted to the facility. The Fall Event form dated June 19, 2016 documents R1 as being found on the floor and as sitting just prior to the fall. R1 reported she was looking for a key to start the plane to fly and lost balance falling on right hip, knee and elbow. This form documents a bed alarm checked as an intervention for R1 and the chair alarm is not marked as in place. On May 31, 2017 at 2:05pm E7 stated E7 heard R1 fall and was the first responder to R1's room. E7 went to R1's room and found R1 on the floor. E7 stated no alarms were sounding in R1's room. On May 31, 2017 at 2:28pm, E8 (Nurse) stated E8 was R1's nurse during the day shift at the time of the fall on June 19, 2016. E8 stated R1 spent most of day in the bedroom and was confused and required assistance to ambulate. E8 stated R1 had to be re-oriented to the call light during the shift because R1 kept getting up unassisted. The Final Incident Report form dated June 24, 2016 documents on June 19, 2016 at 2:48pm, R1 was found on the floor in R1's bedroom. R1 was complaining of pain to the right hip, elbow and knee and was transferred to the hospital for evaluation. At the hospital R1 was diagnosed with [REDACTED]. This report also documents R1 with delusions, weakness and anxiety noted at the time of admission to the facility on [DATE]. This report documents R1 falling due to impulsive behaviors likely associated with worsening pneumonia. The report further documents if R1 returns to the facility R1 will be re-evaluated for the most appropriate assistive devices .as well as increase monitoring on her . On June 1, 2017 at 2:43pm, E1 (Administrator) stated if a resident is repeatedly non-compliant, making attempts to get up unassisted E1 expects staff to offer non-pharmacological interventions such as activities, place at nursing station for supervision, etc. E1 stated staff are to implement measures to keep residents safe. The hospital Orthopedic Consult dated June 20, 2016 documents R1 with a right femoral neck fracture. On June 1, 2017 at 1:06pm, E13 (Medical Director) confirmed the facility should implement measures to keep a resident safer and to additionally implement hospital discharge recommended fall interventions. 2. The Admission Record dated September 19, 2016 documents R4 as a [AGE] year old with [DIAGNOSES REDACTED]. The Brief Interview of Mental Status dated February 1, 2017 documents R1 as severely cognitively impaired. The Incident Report Form dated March 5, 2017 documents R4 was found on the floor near R4's bed at 5:25pm with a laceration to the left forehead. R4 was sent to the hospital and received 6 sutures to close the wound. R4 is documented as ambulatory with no assistive devices in this report. This report documents shortly before dinner a staff entered R4's room and R4 was walking around in the bedroom at the time the staff person entered. R4 was asked to come to the dining room and began following a staff member out of the bedroom; the staff member exited the bedroom and thought R4 was following. A few minutes later a different staff member noticed R4 wasn't present in the dining room prompting the staff to go to R4's room to get R4 again for dinner at which time R4 was found on the floor of R4's bedroom. R4's Occupational Evaluation and Plan of Treatment dated February 22, 2017 documents reason for referral as: Per nursing report of decline in self performance referred to therapy .patient referred to therapy due to exacerbation of decrease in strength, decrease in transfers, increased need for assistance from others, reduced static and dynamic standing balance . On June 1, 2017 at 11:18am, E9 (Certified Occupational Therapy Assistant) stated R4 was referred for services in February 2017 due to increased weakness of both upper and lower extremities, declining ambulation for long distances and cognitive decline requiring both verbal and tactile cues to push off and for hand placement to stand up. E9 stated at the time of R4's fall R4 required stand by assistance with a rolling walker and verbal cues by staff. On June 1, 2017 at 1:25pm, E2 (Director of Nursing) stated therapy recommendations are discussed and followed. E2 stated E2 was unaware therapy had made recommendations for R4 to be a stand by assist with a rolling walker for ambulation. The hospital emergency room Report dated March 4, 2017 documents R4 as being evaluated after a fall at the facility with a laceration requiring repair to the left forehead area. On June 1, 2017 at 1:06pm, E13 (Medical Director) confirmed staff should follow therapy recommendations to provide a safe environment for the residents. E13 stated, I am not sure where the communication breakdown occurred. The facility Fall policy dated August 2014 documents the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies and facility as safe an environment as possible.

Based on observation, interviews and record review the facility failed to ensure safety measures in the careplan were followed for R2, one of three sampled residents, R1, R2 and R3. This resulted in R2 falling out of bed and sustaining a cervical fracture at the C-6 level. Findings include: According to the medical record R2 is an [AGE] year old male with [DIAGNOSES REDACTED]. R2 is non-verbal, non-ambulatory and depends upon staff for all activities of daily living, including the assistance of two staff members for turning and repositioning in bed. R2 was first observed on 01/16/13 in his room. He was lying in a bariatric bed and wearing a cervical collar. A mattress was also observed on the floor next to his bed. According to an incident report form completed by E1, D.O.N. (Director of Nursing), on 12/28/12 at approximately 9:34pm R2 was found on the floor next to his bed by E3, his assigned C.N.A. (Certified Nurses Aid). R2 was lying on his right side and noted to be bleeding from a laceration above the right eye. R2 was assessed by E4, R.N.(registered nurse) who also noted a tooth on the floor. R2's position on the floor was maintained until paramedics arrived and transported him to the hospital. It was noted on the incident report the safety intervention of a mattress next to the bed was not in place and the bed alarm had not sounded. Upon interview E3 stated at 9:10pm she provided R2 with care, turned and repositioned him on his left side. E3 further stated she did not put any positioning devices in place to assist R2 in maintaining his side lying position. E3 also stated she did not place the extra mattress on the floor next to R2's bed. Upon further questioning E3 stated R2 may have been too close to the edge of the bed because she may not have positioned R2 in the center of the bed. E3 said R2's bed alarm had not sounded because the cord was too long. The facility's incident investigation included a written interview with E4 in which she was asked about the siderails on R2's bed. E4 stated the siderails were not in position (up) when she entered R2's room and the floor mattress was in the room but not in place next to R2's bed. R2's careplan for falls was updated on 10/09/12. The plan to prevent falls included an alarm to be placed on the bed, bed in lowest position, place resident in center of the bed, bathroom light on and extra mattress next to bedside when resting. R2's x-ray report of 12/29/12 noted the presence of fractures identified involving the lamina bilaterally at the C-6 level and extending through the base of the spinous process at the C6 level. E5, Administrator, confirmed on 01/16/13 the information obtained in the incident report was accurate and that R2's careplan was not followed on 12/28/12 when the fall occurred.

Based on record review and interview, the facility failed to ensure : The bed alarm was functioning for 1 of 3 sample residents reviewed for falls, (R2) who sustained a fractured femur after falling. Additional fall precautions were implemented, according to the plan of care, for 2 of 3 sample residents (R1, R2) reviewed with histories of falls. Findings include: According to the record, R2 is a [AGE] year old with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS), dated [DATE], states R2 needs one person assistance when ambulating. According to the safety assessment tool, dated 3/24/12, R2 is oriented to person only, is unsteady with ambulation, uses a wheelchair at times and has a history of falls. The careplan, revised on 3/20/12, states R2 requires, "Place bed alarm out of resident's reach. Apply sensor to bed." Incident reports reviewed from 12/1/2011, documented the following falls; 12/1/2011= fell in room. No injury. 3/27/2012= fell in room with resulting head scrape and elbow redness. Trying to remove alarm. Action taken included, "Place alarm out of resident's reach." 4/19/2012 = fell in room. No injury. 6/4/2012= fell in room. Fractured femur sustained. This resulted in a hospitalization and surgery for [REDACTED]. E3 (LPN) documented on the 6/4/12 incident report, "Discovered resident on the floor lying on left side. Resident was yelling out. Resident fell after walking across the room. Resident states she removed alarm. She unclipped her alarm." The incident / investigative report for the 6/4/12 fall did not address whether or not the resident's alarm was sounding or the proper alarm was used, however E2 (Director of Nursing) documented in the report, "Wrong alarm and placement. Staff education. Safety and alarm will be re-evaluated when she (R2) returns." E2 confirmed the incident report documentation on 6/13/12, at 2:10 PM. E3 (LPN) stated on 6/13/12, at 3:30 PM, R2 was assigned to her on 6/4/12, at 6:30 AM, the time R2 fell . She said R2 had both alarms on in bed, the clip-on and the sensor pad, because R2 tries to remove the clip alarm. E3 said she and the Certified Nursing Assistant (CNA) heard R2 yelling and found her on her bedroom floor. She said it appeared R2 had gotten out of bed, walked across the room, and fell near her roommate's bed. E3 said it appeared R2 had removed her clip alarm, but that the bed sensor alarm was not sounding. After finding R2 on the floor, E3 touched R2's bed sensor pad and it started alarming. R2 was observed with E2, on 6/13/12 at 1:30 PM. She was in bed with an alarmed mattress pad which was attached to the sound apparatus, positioned near R2's shoulder. R2's wheelchair had a clip alarm on it, but not a pad sensor. E5 (Rehabilitation RN/Director) was interviewed on 6/13/12, at 2:30 PM. She confirmed the investigative action plan was to re-evaluate R2's alarms and that she would be the person to do so. However, E5 said R2 had come back to the facility yesterday evening, 6/12/12, but E5 had not yet re-assessed the alarm usage. E5 said since R2 has disconnected her clip alarm in the past, she should have a pad sensor for the wheelchair, the clip alarm is not enough. E5 also said the sensor pad alarm can be disconnected from the sounding device, therefore R2's device should be positioned at the bottom of the bed, not at the top near the shoulder area. 2) According to the record, R1 has [DIAGNOSES REDACTED].= Resident fell in room, legs weak. Small abrasion right knee. Encourage to ask for staff help. 6/3/12= Resident fell in room. No injury. Reminded to ask for staff assistance. 6/12/12= Resident fell in room, going to toilet. Action taken; Pad alarm placed on wheelchair and bed. R1's careplan, revised 6/12/12, documented, "6/12/12 - Pad alarm placed on wheelchair and bed." R1 was observed with E2, on 6/13/12 at 1:45 PM. Neither R1's wheelchair nor bed were alarmed. E2 confirmed this during the observation. E5 (Rehabilitation RN/Director) was interviewed on 6/13/12, at 2:30 PM. She confirmed the investigative action plan was to place the alarms on R1's wheelchair and bed, however it had not yet been done.

Based on record review, interview and observation the facility failed to: - provide adequate and timely supervision and monitoring for two of five sampled residents (R1 and R8) identified as high risk for falls. - develop, implement, monitor effectiveness and modify interventions as necessary to prevent re-occuring falls with and without injuries for R1 and R8. - provide supervision and monitoring for one of one sampled residents assessed as unsafe cigarette smokers (R26)). - provide a safe environment and develop a plan of care to prevent multiple skin tears and injuries sustained during direct care for one of 26 sampled residents (R23). - provide necessary supervision and assistance per care plan for 1 of 26 sampled residents with swallowing precautions (R16). - (Failed to ensure hot water was not above 110 degrees Farenheit). These failures resulted in: - R8 experiencing five falls in the facility from 5/12/11 through 7/12/11, with resulting right hip fracture, laceration to forehead, hematoma to forehead and skin tears. - R1 having multiple fall incidents with and without injuries. - R26 reporting he dropped a cigarette onto his left thigh, which resulted in an opened skin wound, requiring treatment. Findings include: Review of Psychiatric Evaluation dated 5/9/11 states R8 is [AGE] years old and admitted to facility on 5/5/11 with [DIAGNOSES REDACTED]. A Social Service note dated 5/5/11 states R8 is upset and cannot express himself. R8 was observed on 7/26/11 at 10:45am sitting in an adult reclining chair wearing a helmet. R8 was unable to answer questions other than with a 'yes'. E20 (nurses aide) stated on 7/27/11 at 10:50am R8 utilized a cane for walking prior to his hip fracture (sustained in facility on 5/12/11) and had been a resident on the Alzheimer's Unit. Now, R8 is in an adult reclining chair most of the day because he still tries to get out of bed. E20 stated R8 is very demented and and wears the helmet because of his falls. E20 said R8 does not ask to go to the bathroom but would take off his clothes if he needed to go, he is very restless and scooting himself to the edge of the chair often. Review of facility incident/accident reports with accompanying investigations shows R8 sustained the following incidents: ? 5/12/11 3:35am R8 was observed sitting on side of bed and by the time the nurse returned to the desk, R8's roommate informed the nurse R8 was on the floor. R8 was sent to hospital. Review of hospital consult report from this incident states R8's "radiographs demonstrated a comminuted fracture of the right hip." ? 5/25/11 6:15am The investigation summary states R8 lowered himself to the floor. Two nurse's aides written statements state as they (aides) were getting ready to lay R8 down, R8 maneuvered himself from the edge of bed onto the floor. The follow-up action documented as part of this incident states to "place in visible area for staff monitoring. Continues to try to get out of bed or chair (due to) severe dementia." Psychiatric progress note dated 6/6/11 states R8 is "restless, anxious, kept on standing up from his wheelchair; yells, shakes the door. Not redirectable. Disoriented/demented." Physician ordered Ativan .5mg three times a day. ? 6/18/11 at 1135am Incident investigation of this occurrence states R8 was brought to the dining room for lunch by a nurse's aide who placed R8 at a table and left R8 unattended to get another resident. No other staff was present in the dining room, per bruise/skin tear investigative summary dated 6/18/11. Another staff responded to wheelchair alarm and found R8 lying on floor. R8 sustained a skin tear on the right arm and was taken to the hospital. The facility response was the same as the 5/25//11 incident: do not leave resident unattended. An intervention put in place by facility following this fall was to have Rehab assess R8 for an adult reclining chair, per Timeline of Incidents provided to surveyor and dated on 7/29/11. ? 6/19/11 at 4pm Incident Investigation and Follow-Up Action form related to this incident states R8 had received Ativan at 3pm for restlessness and was fidgeting with footrests, "swinging legs over chair attempting to stand and remove clothes. (R8) was with nurse and nurse walked away momentarily. Scooted to edge of chair and fell forward hitting head." R8 was sent to the hospital. Neurology consultation at the hospital dated 6/20/11 states R8 "was brought to the hospital for a second day in a row for a fall out of his wheelchair. ... He sustained a laceration to his left scalp." The intervention put in place by facility following this fall was to provide R8 with a helmet, per Timeline of Incidents provided to surveyor and dated on 7/29/11. ? 7/12/11 3:40pm Investigation and incident reporting of this 7/12/11 incident states R8 was sitting in the hallway in his adult reclining chair when staff observed a 5 x 3 cm bruise to the left forehead. Facility was unable to determine what happened and stated R8 "possibly hit himself in the forehead with an object during a behavior episode." R8 was sent to the ER. There was no documentation regarding this possible "behavior episode". The intervention put in place by facility following this fall was to provide R8 with a more padded helmet, per Timeline of Incidents provided to surveyor and dated on 7/29/11. Review of psychiatrist notes following visit dated 7/12/11 states "Despite the Haldol which he receives every day, twice a day, he continues to act inappropriately. Removes all of his clothing, yells, screams. Now, he's drooling.." The physician increased R8's Haldol to three times a day. Surveyor requested time line of events and interventions utilized in regards to R8's incidents and accidents and for facility to provide any additional information regarding action taken by facility in response to the incidents. E2 provided surveyor with a Timeline of Incidents to surveyor and dated on 7/29/11 which summarized the incidents and the interventions following each incident, as noted above. The care plan dated 5/6/11 states R8 is high risk for falls, is confused and wandering. The approaches on this care plan to achieve the goal of keeping R8 free from fall related injuries are not individualized to R8's needs and behaviors. R8's displays of agitated behaviors of physical displays of agitation, confusion and inability to express himself are not evaluated for specific interventions with measurable outcomes, including supervision interventions. The interventions that are listed are not evaluated for their effectiveness. Mood/Behavior Care Plan dated 5/19/11, 1 week after R8 sustained a fractured hip, lists an approach for staff to attempt to identify the cause of the mood/behavior indicators, and try to address by diversion, engaging R8 in therapeutic activity, assess for physical reason for indicators. Another approach is to "visit episodically 1 to 1 to address concerns and issues that arise. Another is to "Continue mood/behavioral tracking to assist with approach, ideas, and indicate outcome of approach." Facility did not provide any documentation supporting these approaches. According to documentation in the medical record R1 is a [AGE] year old female who was admitted to the facility from home on 05/16/11 with [DIAGNOSES REDACTED]. R1 has a history of multiple falls at home prior to her admission. R1 resides on the Alzheimer's unit and was first observed on 07/26/11. She was in the activity room of the unit and staff were observed interacting with her and other residents. According to progress notes in the medical record and review of incident reports since her admission R1 has experienced the following: On 05/19/11 R1 was summoned by the nurses aid to walk to the shower room. The aid who was walking in front of R1 heard a sound and turned around to find R 1 on the floor and her head had apparently hit the refrigerator. The staff member was counseled to walk side by side with R1 and a soft helmet was applied. On 06/06/11 nurses notes document R1 fell while on a home visit with her husband and scraped her shoulder. On 06/07/11 R1 fell again at home and was noted to have bruising to the left gluteal region. On 06/08/11 after return to the facility R1 was discovered to have bruising to the left hand. An x-ray was ordered and a fracture to the left 3rd finger was noted. The cause of the fracture was not known but the facility's investigation noted that it may have occurred when R1 fell at home. On 07/01/11 R1 was heard in her room yelling. She was found by the nurse alone on the floor of her room bleeding from her bottom lip. The facility's intervention was to place a mat on the floor of her room and place her on 15 minute checks. This incident was unwitnessed. On 07/12/11 another unwitnessed incident took place. Facility incident report completed by E2 (Director of Nursing)documents R1 was observed lying on the floor next to a clean linen cart in the hallway. E2 further documented "Possibly with the resident being confused and an unsteady gait the resident walked into the clean linen cart and fell ." R1 was sent to the emergency room where she received 5 sutures to the right eye brow. E3 ( Director of Alzheimer's Unit) was interviewed on 07/28/11 at approximately 3pm. E3 was asked about R1's multiple falls and interventions implemented since her admission. E3 stated interventions include a helmet, hipsters and a low-bed with floor mat in her room. E3 was asked if R1's level of supervision was increased at any time since her admission. E 3 stated the only increased supervision for R1 was placement on 15 minute checks after the incident of 07/01/11. However, E3 failed to produce any documentation that the 15 minute checks were being implemented. R1's care plan was reviewed but did not include the 15 minute checks. After the incident of 07/12/11 no further interventions were implemented to increase R1's supervision. -When two certified nurses aides (CNA's) took R26 to the bathroom on 7/28/2011, surveyor observed a dressing on his left thigh. When asked about the dressing, R26 told surveyor he burned himself, while smoking. R26 said he was smoking, when no staff was supervising him, and dropped a cigarette on to his thigh and "burned" himself. Later on 7/28/2011, surveyor observed the treatment nurse (E16) change the dressing on R26's left thigh. Surveyor observed the opened wound area to R26's thigh to be a perfect round shape and flat. E16 told surveyor that R26's wound was being treated with Silvadene. When asked what type of wound R26's was assessed to have, E19 (director of wound care) told surveyor R26's wound was not a pressure sore, so they were following what R26's stated happened. Later on 7/28/2011, R26 demonstrated he could hold his cigarette in his right hand. On 7/28/2011, the social services aide (E13) was interviewed in a second floor office. E13 told surveyor she was investigating R26's incident, which resulted in his wound on the left thigh. E13 stated R26 told her that he was smoking and a cigarette fell on to his thigh causing an opened wound. At the time of the interview, E13's concluded that the incident had happened. E13 told surveyor that the activity staff were responsible for supervising the at risk smoker. 7/28/2011, E7 (nurse) was interviewed in the social service office. E7 told surveyor R26 told the night nurse he had burned himself with a cigarette. E7 said that the activity aides are usually responsible for monitoring residents while they smoke. E7 said nurses, CNA's and other staff members will also monitor residents while they smoke. On 7/28/2011 at 2:40 PM, E11 (Social service aide working on the second floor.) was interviewed in her office. When asked, E11 told surveyor she monitored R26 while smoking. E11 said she had a smoking apron for R26 to use while smoking. E11 said she kept the smoking apron in her office. However, R26 came into her office and E11 prompted R26 to tell surveyor that he smoked, while using a smoking apron. But R26 told surveyors that he did not wear the fire apron. Surveyor asked where the smoking apron was kept. E11 reported that it was kept in her office. When asked, E11 told surveyor that the door to her office was kept lock, and the key was not readily available to staff. The activity aide (E10) for the second floor was interviewed on 7/28/2011 near the smoking room. E10 said she often monitored R26's while smoking. When asked, E10 stated she did not put a smoking apron on R26, and she did not think R26 needed to wear one. E10 told surveyor there was only one fire apron readily available, which another resident used. E10 was aware of another apron, but stated it was locked up in a room. Because she (E10) did not smoke, E10 said she did not sit in the smoking room with R26. E10 described monitoring R26 from outside of the smoking room by looking into the window of the smoking room. Two CNA's (E8 and E9) reported they provided care to R26 was interviewed. They reported that they were not aware that R26 needed to be supervised while smoking. Review of R26's Admission and Discharge Summary documented R26 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of R26's Skin Narrative Documentation had the following document: "Staff reported to this writer that on left thigh an open area 0.8 cm x 1 cm wound bed reddened peri wound normal no drainage." Review of R26's care plan documented the following in the care of R26: "Unsafe smoking habits. Resident (R26) needs supervision while smoking..." "Goals: Resident (R26) will exhibit safe smoking with staff assistance and supervision..." "Interventions: Provide cigarettes in smoking areas only under staff supervision... Resident (R26) needs to wear a smoking apron to prevent burning himself or his clothing while smoking." However, there is evidence to support R26 was not provided with the supervision he needed. R26's psycho-social smoking assessment was last completed in September 2010 and has not been re-evaluated since to date 7/26/11. - During the noon meal on 7/27/2011, surveyor observed R16 lying in bed eating his lunch. R16 told surveyor he had a peanut butter and jelly sandwich. No staff member was near by to supervise or monitor R16, or prompt him to sit up. Surveyor also observed multiple clear plastic bags containing a variety of snack foods. After leaving R16's room on 7/27/2011 at the noon meal, surveyor asked R16's nurse (E21) should he be eating lying down in bed. E21 told surveyor that R26 likes to eat in bed while lying down. But, surveyor did not observe E21 go into R16's room to redirect him to put his head of bed (HOB) up or monitor him. Z2 (speech therapist), who evaluated R16, was interviewed on 7/29/2011 at 2:30 PM. Z2 stated, "I was asked to evaluate him. He's noncompliant. Based on observation and chart review, he's not safe eating lying down. He has a history of aspiration and choking. I have concerns. It's not safe for anyone to eat lying down. The food is filling up his throat before swallowing... and puts him at risk... Eating while lying down puts him at risk for aspiration. Review of R16's prior Swallowing Evaluation, dated 9/01/2010-9/16/2010, documented and assessed R16 as having pharyngeal dysphagia. R16's evaluation documented that R16 could safely eat in bed, but he should have his "HOB up with all PO intake". R16's current Swallowing Evaluation, dated 7/28/2011, documented R16 as "unsafe" due to his noncompliance to eat with the HOB up. Review of R16's physician order [REDACTED]. R16's physician gave the following order for R16: "Head of Bed up at 90 degree angle with all PO (mouth) intake" However, surveyor did not observed following R16's physician order [REDACTED]. Review R16's care plan, dated 7/17/2011, documented the following care issue: "R16 is on a regular diet with thin liquids. He does have a history of swallowing difficulty. He eats in his room as he refuses to come out of his room for meals and refuses to get OOB (out of bed) at times." "Goals: R16 will tolerate diet without signs and symptoms of aspiration..." "Interventions: Remind R16 to alternate small bites and sips. Use a teaspoon for eating. Observed for swallowing difficulty and report to nurse. Instruct resident (R16) to eat in an upright position to eat slowly, and to chew each bite thoroughly. Keep HOB elevated 90 degrees during meal and thirty minutes afterwards. Monitor for shortness of breath, choking, labored respirations, lung congestion..." However, surveyor was not observed implementing these nursing measure for R16. R23 was observed in bed asleep on 7/28/11. E6 (nurse) on the unit stated R23 requires total care in all areas of and is not inteviewable due to severe Dementia. Interview with E2 (director of nurses) on 7/29/11 stated the resident was total care and required assistance from the staff in all areas of activity's of daily living. This was also verified through review of the Minimum Data Set (MDS) date 6/8/11. The following accident and incident reports were noted to have occurred to R23; 1.7/26/10 skin tear found after transferring with the mechanical lift,..probably hit her arm on the mechanical pad. (plan to throw away rough pad) 2. 12/20/10 at 2:30 p.m. skin tear to lower right shin 3.5 centimeters by 2.5 centimeters. The cause was unknown. 3.12/20/11 at 4:30 p.m. documented in the nurses notes at 4:30 p.m. during a transfer with a mechanical lift toenail bumped against the right third toenail and loosened the third right toenail. There was no incident report available for review when requested on 7/29/11. E2 presented a Bruise/Skin tear Investigation on 7/29/11. The date of the report 12/20/11 was changed to 12/30/11 4. 1/29/11 skin tear 0.53 by 3.6 centimeters on the abdominal fold...probable caused by plastic incontinent brief. 5. 3/17/11 skin tear right forearm, 2 centimeters by 2 centimeters occurred during a mechanical lift transfer. The cause...skin exposed. 6. 4/21/11, bruise to the right lower leg.. 1 centimeter 7. 7/5/11 skin tear to right shin found when returned from dining room 4.4 centimeters by .7 centimeters. A interview and record review was conducted with E2 on 7/29/11. The facility showed that an individualized care plan with specfic goals was not developed for the prevention of skin tears. On 7/28/11 during the general observation of the facility in the B Wing second floor shower room the hot water temperature at the sink was 118 degrees Farenheit. In the 2B second floor shower room the hot water temperature at the sink was also 118 degrees Farenheit. In this same shower room the hot water at the tub was 116 degrees Farenheit. Interviews with E14 (Director of Environmental Services) and E15(Maintenance Supervisor) on 7/28/11 noted both to say the water was too hot and needed to be adjusted.

Based on observation, interview and record review the facility failed to (1) complete an accurate and thorough assessment of factors/causes for R 26' s urinary incontinence. (2) Identify R 26' s type of urinary incontinence and analyze whether these were reversible or irreversible. (3) Develop a specific Bowel and Bladder program based on resident's individual assessment. (4) Develop a plan to promote dignity and to improve or maintain R 26's current bladder functioning. (5) Utilize the bowel and bladder diary to implement a specific program for R 26. (6) Develop and implement a bowel and bladder program. (7) Obtain doctor's order and insert correct catheter size as ordered. Provide medical justification for the use of the R 14's catheter. (8) Develop and implement interventions to minimize catheter related injury, accidental removal or obstruction of urine outflow for R14. (9) Assess factors affecting R 14's urinary function. (10) Attempt to remove R 14's catheter and document result. This is for two residents, R14 and R26, in a sample of seven incontinent residents. These failures resulted in psychosocial harm for R 26. R 26 was embarrassed and humiliated every time he wet himself. Findings include: 1) -On 7/28/2011, surveyor observed staff pushing R26 in his wheel chair. R26 was observed to tell staff he was wet and wanting to go to the bathroom. The surveyor observed R26 was wet from the groin area down to his lower thigh. When the CNA got R26 in the bathroom, R26 was transferred to the toilet. The surveyor observed R26 wearing cloth briefs. R26 told surveyor, "It's terrible and embarrasses me to wet on myself! I feel the urge to go." When asked why he did not tell staff he has to go to the rest room, R26 replied, "I won't tell anyone. No one will help me, when I ask. They just put me off." Later on 7/28/2011, R26 was lying in the bed, trying to call staff using his call light and his call light did not work. E12, E8 and E9 (certified nurses aides) were interviewed on 7/28/2011, because the surveyor observed them taking care of R26. When asked, E12, E8, and E9 told the surveyor R26 could tell staff he needed to go to the bathroom. E12 indicated R26 was on a prompting program. But E12, E8, and E9 were observed only changing R26 after being incontinent. E4 was identified as the restorative nurse. E4 was interviewed on 7/28/2011 in an office on the first floor. E4 told the surveyor R26 was on the prompting toilet program and should be wearing incontinent briefs. E4 could not explain why R26 was wearing cloth briefs. The surveyor asked E4 to review R26's care plan and tell the surveyor the interventions identified to keep R26 dry. After reviewing R26's plan of care to maintain his incontinence, E4 said R26 was being prompted to go to the bathroom. When asked for R26's toileting diary, E4 provided one. But, E4 did not tell surveyor how the diary was being used to analyze and develop a plan of care for R26 to address R26's incontinence. Review of R26's Bowel and Bladder Assessment documented R26 was not being assessed quarterly. R26 was assessed on 8/17/2010, 8/29/2010 and not again until 4/15/2011. This assessment failed to identify the reason for the urinary incontinence. Review of R26's care plan identified he had incontinence due to physical limitation, such as impaired mobility secondary to Cardiovascular Accident with left side weakness. The goal documented was for: "the resident (R26) will have fewer episodes of bladder/bowel incontinence..." However, staff failed to follow the nursing interventions, such as: "...Complete the bowel/bladders ...quarterly..." Toilet R26 at regular intervals per the resident's determined voiding pattern..." However, this was not observed being done and R26's toileting diary documented no reductions in episodes of incontinence. Review of R26's Prompted Voiding Toileting Plan documented far more incidents of R26 being incontinent and very little incidents of R26 being prompted. 2) On 07-26-11 at 10:40 AM, R 14 was observed sitting in her wheelchair in the dining room with an indwelling catheter tubing noted to be cloudy. R 14's Physician order [REDACTED]. E 2 stated " I think she has that catheter since admission. I think the indication is for [MEDICAL CONDITION]. I could check that from medical record. " R 14's indwelling catheter care plan showed: indwelling catheter due to [MEDICAL CONDITION], CKD ([MEDICAL CONDITION]) and renal cyst. Intervention includes: Catheter size 21 French/10 cc balloon. Review of the nurses notes dated 02-07-11 at 10:45 - catheter out, 22 French catheter inserted ...On 03-25-11 at 12:00 pm, catheter leaking- removed reinserted 24 French ... 06-11-11 at 10:30 am- catheter came out accidentally by the C.N.A- while changing the patient with slight blood clot on the catheter ... On 07-27-11 at 11:45 AM E 2 confirmed there were no urologist consultations found in R 14 ' s chart and said " I would check in medical records if there's any. " E 2 had not presented any documentation from the medical record. There were no documentation previous attempts to remove the catheter was made.

Based on record review, interview and observation the facility failed to evaluate and intervene with one resident (R9) who displayed behaviors of decreased social interaction and increased depressive behaviors. This failure resulted in R9 expressing feelings of despondency. This is for one of nine residents sampled for behaviors. Findings include: Interview and observation on 7/26/11 at 11:10am found R9 alert and oriented, lying in bed with her curtain drawn and the lights out. R9 stated other than [MEDICAL TREATMENT], "I stay in bed all day. I'm all alone. I don't have anything." When asked about what type of activities she does throughout the day, R9 stated "no one asks me what I would like to be doing." R9 stated she was awake most of the night and has difficulty sleeping every night. R9 also stated she is not allowed to eat anything by mouth and is having a hard time with that. R9 was observed to have a brown substance under her fingernail and all around the nail beds. R9 stated she does not get to wash her hands. Review of admitting Social Service note dated 5/13/11 states R9 has [DIAGNOSES REDACTED]. The next social service note dated 5/20/11 states R9 is alert and oriented, appears quiet and keeps to herself. The result of the Mood Interview as part of the MDS (minimum data set) indicates some sadness due to current situation and the loss of her son and husband one year ago. Review of psychiatric evaluation and [MEDICAL CONDITION] medication review/follow-up evaluation form dated 6/21/11 states that R9's [DIAGNOSES REDACTED]. It also states that R9's current symptoms include increased depression per family and R9. Review of initial Mood/Behavioral care plan dated 5/20/11 states R9 "appears to have some depression, has a recent loss of son and spouse. She has [MEDICAL TREATMENT] three times a week and indicates she is tired at times. She is quiet and usually keeps to self." The interventions listed are not goal oriented or specific and do not address R9's feelings of depression. There is no care plan addressing R9's [MEDICAL CONDITION]. Interview with E18 on 7/29/11 at 11:15am stated R9 told her (E18) she did not like to socialize and likes to be by herself. E18 said she was aware of R9's loss of her son and husband in the last year, and R9 was end stage [MEDICAL CONDITION], receiving [MEDICAL TREATMENT] three times a week and takes nothing by mouth. E18 stated her involvement with R9 was to pop in and say "hi". E18 confirmed she did not have any plan or goals for R9 and did not have any documentation showing contact with R9. E18 also stated as of 2 days ago, 7/27/11, R9 will be scheduled to be seen by the psychologist.