Every finding on record at Pekin Manor

Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development, conduct a pressure ulcer risk assessment once a week for four weeks after admission and then quarterly thereafter, update pressure ulcer care plans with pressure relieving interventions, and failed to provide a treatment as ordered by the physician for three of three residents (R1, R2, and R3) reviewed for facility acquired pressure ulcers in the sample of four. These failures resulted in R1 developing a stage four full thickness pressure ulcer to the medial heel that required surgical debridement, R2 developing an infected, painful stage four pressure ulcer to the left lateral ankle that required surgical debridement, and R2 developing a painful stage four pressure ulcer to the right lateral heel that required surgical debridement. Findings include: The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol dated 10-24-22 documents Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure injury will present as an open ulcer. The appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Principles: 1. A skin assessment (Braden Scale Pressure Ulcer Risk Assessment) is completed on all residents upon admission and weekly for the first four weeks after admission, quarterly, and whenever there is a change in the resident's condition. 2. An individualized plan of care will be developed for the resident following the guidelines of the assessment. 3. All high and moderate risk residents will be assessed for the needs of the items below. If the intervention is initiated, it will be added to the care plan. A. Special mattress and wheelchair cushions. B. PROMS (Passive Range of Motions). C. Protein and/or Nutritional Supplements. D. Turning and positioning schedule. E. Skin Checks. F. Elbow/heel protectors/bridging of heels. 6. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size, wound bed, drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissues, and pain at site. B. Determine the injury's current stage of development: Stage One Pressure Injury: Non-blanchable erythema of intact skin. Stage Two Pressure Ulcer: Partial thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not viable. Granulation (new tissue) tissue, slough (dead tissue in wounds), and eschar (black or brown hardened layer of dead tissue that forms over a wound) are not present. Stage Three Pressure Ulcer: Full thickness loss of skin, in which subcutaneous fat is visible in the ulcer and granulation tissues are epibole (rolled wound edges) are often present. Slough and or/eschar may be visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (dry, adherent, intact without erythema or fluctuance) should only be removed after careful consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue, this area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue, This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. C. Notify the physician of the above assessment and obtain orders for treatment of pressure ulcer/injury. If pressure ulcer/injury is showing no improvement, Physician will be notified so change of treatment may be obtained, E. Care plan will be established for treatment of existing pressure ulcers/injuries. G. For pressure ulcer with drainage the physician will be notified, and culture obtained if ordered. Pressure Injury and Treatment Protocol: H. Weekly measurements will be conducted and entered in the chart under wound management. J. Turning and repositioning assistance will be given to those residents that are unable to reposition themselves. K. Special devices will be used to relieve pressure, L. All treatment and charting of pressure ulcers/injuries will be done by licensed staff. 1. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses Muscle Weakness, Lack of Coordination, Cognitive Communication Deficit, and Vascular Dementia. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired, requires moderate assistance with personal hygiene and rolling left to right, is at risk for developing pressure ulcers, has one stage four facility acquired pressure ulcer, and is not on a turning and repositioning program. R1's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 6/17/25 Stage four pressure wound of right lateral ankle cleanse with wound cleanser, pat dry, apply hydrogel to would bed, cover with abdominal pad and kerlix (rolled gauze). Change dressing daily and as needed for impaired dressing integrity. R1's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 16 indicating R1 was at risk of development of pressure ulcers. This same Braden Scale documents R1 was chairfast, was slightly limited in mobility, and required minimum staff assistance in moving to prevent friction and shearing. R1's Medical Record dated 6/27/24 through 6/27/25 does not include any quarterly Braden Scale Pressure Risk Assessments except for the one completed on 12/26/24. R1's Wound Evaluation and Management Summary dated 3/12/24 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the right medial heel full thickness. Etiology: Pressure. Stage four. Duration: Less than 62 days. Wound Size: 5.0 cm (centimeters) by 5.3 cm by not measurable depth. Exudate: Moderate serosanguinous (pinkish drainage). Slough: 40 % (percent). Granulation tissue: 60 %. General Recommendations: Off-load wound, reposition per facility protocol, float heels in bed, and prevalon (heel floating cushioned) boots. Surgical Excisional Debridement procedure to remove necrotic tissue and establish the margins of viable tissue. R1's current Pressure Ulcer Care Plan does not include the interventions to ensure R1 is wearing heel pressure relieving boots and did not include pressure relieving interventions to prevent pressure to the heels prior to the development of R1's right medial heel pressure ulcer. On 6/26/25 from 11:00 AM through 11:45 AM R1 was sitting up in her wheelchair. R1 did not have heel protecting boots on, or a dressing covering the right outer heel wound. On 6/26/25 at 1:00 PM V16 (Wound Nurse) stated, I do not know why (R1) did not have a dressing on her right heel. On 6/27/25 at 9:35 AM R1 was lying on a low air-loss mattress. R1's heels were lying directly on the bed. R1 did not have pressure relieving heel boots on, or her heels off-loaded as ordered by the physician. R1's right foot was facing outward, putting pressure directly on the right ankle pressure wound. During this time, V17 (CNA/Certified Nursing Assistant) verified he did not know R1 was supposed to wear heel protector boots. On 6/27/25 at 9:30 AM V2 (DON/Director of Nursing) performed the wound treatment to R1's right outer heel. R1's right outer heel was covered in 40 percent slough and was approximately five cm round. On 6/27/25 at 12:00 PM V2 (DON) stated, (R1) has only had one Braden Scale Pressure Risk Assessment done within the last year. (R1) should have had Braden Scale Pressure Risk Assessments done quarterly. (R1's) pressure relieving heel boots are not on the care plan and (R1) did not have any pressure relieving interventions to the heels prior to the development of the pressure ulcer to the right heel. (R1's) wound to the right medial heel was caused by pressure. (V17/CNA) is new to taking care of (R1) and is probably not aware that (R1) needs a heel boot on. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Fracture of the Right Humerus, Osteoarthritis, Chronic Diastolic Congestive Heart Failure, Reduced Mobility, Stiffness of the Left Ankle, Left Knee and Right Ankle, Chronic Kidney Disease Stage Three, and Hypertension. R2's MDS assessment dated [DATE] documents R2 is cognitively intact, is dependent on staff for personal hygiene, rolling side to side, and transfers, is at risk of developing pressure ulcers, has one facility acquired stage three pressure ulcer, has one stage four facility acquired pressure ulcer, and is not on a turning/repositioning program. R2's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 5/6/25 Stage four pressure ulcer wound of left lateral ankle cleanse with wound cleanser, pat dry, apply xeroform (petroleum gauze) to wound bed, cover with abdominal pad, and [NAME] with kerlix once daily. Start Date: 6/14/25 Stage three pressure wound of right lateral heel cleanse with wound cleanser, pat dry, apply xeroform, cover with abdominal pad, wrap with kerlix and secure with tape daily and as needed. R2's Treatment Administration Record dated 6/1/25 through 6/27/25 documents R2's treatments to the right lateral heel pressure ulcer and left lateral ankle were not performed on 6/20/25. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 14 indicating R2 is at moderate risk of development of pressure ulcers. This same Braden Scale documents R2 is chairfast, is very limited in mobility, and requires moderate to maximum assistance in moving to prevent friction and shearing. R2's Medical Record dated 5/28/24 through 6/27/25 does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or quarterly except for the one assessment dated [DATE]. R2's Wound Evaluation and Management Summary dated 4/22/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than one day. Wound Size: 0.9 cm by 1.5 cm by non-measurable cm. Exudate: Moderate serosanguinous. Slough: 80%. Granulation tissue: 20%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. R2's Wound Evaluation and Management Summary dated 5/6/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than 15 days. Wound Size: 1.3 cm by 1.3 cm by non-measurable cm. Exudate: Moderate sero-sanguinous. Slough: 80%. Granulation tissue: 20%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Deep swab technique of stage four pressure wound of left lateral ankle demonstrates MRSA (Methicillin-Resistant Staphylococcus Aureus) and Proteus Mirabilis on 5/6/25. Start Bactrim DS (Double Strength) BID (twice daily) for 14 days. Probiotics daily for 30 days. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. Stage three pressure wound of the right lateral heel full thickness. Etiology: Pressure. Stage: Three. Duration: Less than one day. Wound Size: 2.0 cm by 1.5 cm by 0.4 cm. Exudate: Light serosanguinous. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Secondary dressing abdominal pad once daily and as needed. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. R2's Wound Evaluation and Management Summary dated 6/26/25 and signed by V14 (Wound Physician) documents, Stage four pressure wound of the left lateral ankle full thickness. Etiology: Pressure. Stage four. Duration: Less than 66 days. Wound Size: 0.8 cm by 0.5 cm by 0.3 cm. Exudate: Moderate sero-sanguinous. Slough: 30%. Granulation tissue: 70%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Sharp selective debridement procedure to remove biofilm and remove devitalized epidermis and/or dermis. Stage four pressure wound of the right lateral heel full thickness. Etiology: Pressure. Stage: four. Duration: Less than 52 days. Wound Size: 1.2 cm by 0.8 cm by non-measurable depth cm. Exudate: Moderate Serous. Slough: 100%. Dressing Treatment Plan: Xeroform gauze apply once daily as needed if saturated, soiled, or dislodged. Secondary dressing abdominal pad once daily and as needed. Surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, elevate legs, and float heels in bed. Specific to visit recommendations: Pressure off-loading boot-prevalon. Low air-loss mattress. R2's current Pressure Ulcer Care Plan does not include the interventions to ensure R2's low air-loss bed and did not include pressure relieving interventions to prevent pressure to the heels/ankles prior to the development of R2's right lateral heel and left lateral ankle pressure ulcers. On 6/27/25 at 9:48 AM V2 (DON) performed wound treatments to R2's left lateral ankle and R2's right lateral heel. R2's left lateral ankle wound was approximately 1.3 cm round and covered in 80 percent slough. R2's right lateral heel was approximately 2.0 cm by 1.5 cm with a slight depth and red in color. On 6/27/25 at 12:15 PM V2 (DON) stated, (R2) did not get the Braden Pressure Ulcer Risk Assessments done weekly for four weeks after admission or quarterly. The only Braden Pressure Ulcer Risk Assessment (R2) had done was on 6/24/25. (R2's) treatments to the left lateral ankle and right lateral heel were not done as ordered on 6/20/25. (R2's) wounds to the left lateral ankle and right later heel were caused by pressure. (R2) did not have pressure relieving interventions to the heels or ankles prior to developing the pressure ulcers. (R2's) care plan does not include (R2's) low air-loss mattress. 3. R3's Face Sheet documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of a Fracture to the Right Femur, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Major Depressive Disorder, Chronic Pain, Hypertension, Cognitive Communicative Deficit, and Hearing Loss. R3's admission Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 16 indicating R3 was at risk of development of pressure ulcers. This same Braden Scale documents R3 was chairfast, had no limitations in mobility, 3 and required moderate to maximum assistance in moving to prevent friction and shearing. R3's admission MDS assessment dated [DATE] documents R3 was significantly cognitively impaired, was dependent on staff for turning left to right, personal hygiene, and transferring to the chair. This same MDS documents R3 was at risk for developing pressure ulcers, had no pressure ulcers upon admission, and was not on a turning/repositioning program. R3's Significant Change MDS assessment dated [DATE] documents R3 is severely cognitively impaired, is dependent on staff for turning left to right, personal hygiene, and transferring to the chair. This same MDS documents R3 was at risk of developing pressures, had no pressure ulcers as of 4/25/25, and was not on a turning/repositioning program as of 4/25/25. R3's Medical Record dated 3/25/25 through 6/27/25 does not include any Braden Scale Pressure Risk Assessments weekly times four weeks after admission, or after a change in condition except for the one assessment dated [DATE]. R3's Progress Notes dated 6/14/25 at 4:59 AM and signed by V15 (LPN/Licensed Practical Nurse) document, Two cm open area noted to right ischium. Area cleansed and hydrocolloid applied. R3's current Physician's Order Sheets dated 5/26/25 through 6/26/25 document, Start Date: 6/14/25 apply hydrocolloid to right ischium every three days and as needed. R3's Treatment Administration Records dated 6/14/25 through 6/26/25 document R3 did not get a treatment performed as scheduled to the right ischium on 6/20/25. R3's Initial Wound Evaluation and Management Summary dated 6/19/25 and signed by V14 (Wound Physician) documents, Stage two pressure wound of the right ischium partial thickness. Etiology: Pressure. Stage two. Duration: Less than one day. Wound Size: 1.0 cm by 0.7 cm by 0.1 cm. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, and float heels in bed. Low air loss mattress. Dressing Treatment Plan: Hydrocolloid three times per week and as needed if saturated, soiled, or dislodged. R3's Wound Evaluation and Management Summary dated 6/26/25 and signed by V14 (Wound Physician) documents, Stage two pressure wound of the right ischium partial thickness. Etiology: Pressure. Stage two. Duration: Less than eight days. Wound Size: 1.0 cm by 0.7 cm by 0.1 cm. General Recommendations: Off-load wound, reposition per facility protocol, turn side-to-side in bed, and float heels in bed. Low air loss mattress. Dressing Treatment Plan: Hydrocolloid three times per week and as needed if saturated, soiled, or dislodged. R3's Care Plan dated 3/25/25 through 6/26/25 does not include the physician ordered pressure relieving interventions to provide a low air-loss mattress, off-load pressure to the wound, or float R3's heels while in bed. On 6/26/25 V2 (Director of Nursing) stated, (R3) has had no other Braden Scale Pressure Sore Risk Assessments since admission 3/25/25 and should have had a Braden Pressure Risk Assessment done weekly after admission and after a change of condition. On 6/26/25 from 11:35 AM through 2:00 PM and 6/27/25 at 9:15 AM R3 was lying in bed on her back, on a regular mattress (not low air-loss as ordered by the physician). R3's heels were lying directly on the bed. R3 did not have heel protection boots on, or her heels off-loaded as ordered by the physician. On 6/27/25 at 9:15 AM V2 (Director of Nursing/DON)) performed the wound treatment to R3's right ischium. When removing the hydrocolloid dressing, R3 was moaning and saying ouch. The right ischium wound was approximately 1 cm round pink with reddened skin surrounding the wound. During this time V2 stated, I do not know if (R3's) heels should be off-loaded or if (R3) is supposed to have a low air-loss mattress or heel boots. I will have to look at (R3's) orders. On 6/27/25 at 12:30 PM V16 (Wound Nurse) stated, I did not get (R3) a low air-loss mattress or pressure relieving boots. I do rounds with (V14) and have never looked at (V14's) recommendations. I will make sure I look now. (R3's) air-loss mattress and pressure relieving boots never got added to (R3's) care plan. The staff should always make sure (R3's) pressure is off (R3's) ischium wound and heels. On 6/27/25 at 10:30 AM V14 (Wound Physician) stated the facility should always off-load R3's heels to prevent pressure to the heels and the facility should have contacted hospice to order a low air-loss mattress and prevalon boots for the resident. R3's wound to the right ischium was caused from pressure. R1 and R3's wounds were caused from pressure according to my notes. V14 verified R1, R2, and R3 should have had pressure relieving interventions tried prior to development of pressure ulcers to prevent their (R1, R2, and R3's) pressure ulcers from developing.

Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions and contact precautions during wound and incontinence cares for four of four residents (R1-R4) reviewed for infection control practices in the sample of four. Findings include: The facility's Enhanced Barrier Precautions Policy dated 3/28/24 documents, It is the policy of the facility to use proper PPE (Personal Protective Equipment) during high-contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant Organisms) to staff hands and clothing. 1. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designated to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. 3. EBP are indicated for residents with any of the following: a. Infection or colonization with a targeted MDRO contact precautions do not otherwise apply. b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, or wound care. The facility's Infection Control Policy dated 12/17/19 documents gowns, gloves, and proper hand washing will be applied when entering the room and utilized during all cares with residents in transmission based precautions/contact precautions. 1. R1's current Care Plan documents R1 has ESBL (Extended-Spectrum Beta-Lactamase) of the urine and requires contact isolation. This same Care Plan documents R1 has a stage four pressure injury to the right lateral ankle and requires EBP during cares. On 6/27/25 at 9:30 AM R1 was lying in bed and had an enhanced barrier precautions sign, and a contact precautions sign posted on her door. V2 (Director of Nursing/DON) entered R1's room and performed a wound treatment to R1's right outer heel. During this wound treatment V2 did not wear a gown. 2. R2's current Care Plan documents R2 has MRSA of the wound and requires contact isolation. This same Care Plan documents R2 has a stage four pressure injury to the left lateral ankle and stage three pressure ulcer to the right heel that requires EBP during cares. On 6/27/25 at 9:48 AM R2 was lying in bed and had an enhanced barrier precautions sign, and a contact precautions sign posted on his door. V2 (DON) entered R2's room and performed a wound treatment to R2's left lateral ankle and R2's right lateral heel. During these wound treatments V2 did not wear a gown. During this same time V7 (CNA/Certified Nursing Assistant) assisted V2 with R2's wound cares and helped R2 to place his penis in a urinal. V7 did not wear a glove during wound cares or while helping R2 with the urinal. 3. R3's current Care Plan documents R3 has a stage two pressure injury to the right ischium that requires EBP during cares. On 6/27/25 at 9:15 AM R3 was lying in bed and had an enhanced barrier precautions sign posted on R3's door. V2 (Director of Nursing/DON) entered R3's room and performed a wound treatment to R3's right ischium. During this treatment V2 did not wear a gown. 4. R4's Physician's Orders dated 6/18/25 through 6/27/25 document, Start dated 6/18/25 EBP due to buttock wound. On 6/27/25 at 10:30 AM R4 was lying in bed and had an enhanced barrier precautions sign posted on her door. During this time R4 had feces down both of her legs and up her stomach. V19 (LPN/Licensed Practical Nurse) and V20 (CNA) provided R4 with incontinence cares. During R4's incontinence cares V19 and V20 did not wear a gown. On 6/27/25 at 10:00 AM V2 (Director of Nursing) stated, I should have worn a gown while doing wound cares with (R1, R2, and R3). Staff should wear gowns and gloves during wound cares and incontinence cares with all residents who are in contact precautions or enhanced barrier precautions.

Based on observation, interview, and record review the facility failed to answer a call light timely to provide timely incontinence cares and dressing, failed to maintain a resident's dignity for one of four residents (R4) reviewed for resident rights in the sample of four. Findings include: The facility's Resident Rights policy dated 11/28/17 documents, the resident has a right to a dignified existence, self-determination, and communication with and access to persona and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her qualify of life, recognizing each residents' individuality. The facility must protect and promote the rights of the resident. The facility's Call Light Policy dated 01/20024 documents, Answer a call light promptly. Listen to resident's request. Do not make him/her feel that you are too busy to help. Respond to request. Offer further assistance before leaving resident's room. R4's current Care Plan documents R4 needs one assistance of staff for incontinence cares. On 6/27/25 at 10:30 AM R4 was lying in bed. During this time R4 had on an adult brief and a gown that was soiled with feces and the feces was running down both of R4's legs and up R4's stomach. R4's call light was on. R4 stated, I have been waiting for someone to clean me up for over a half an hour. I had to go to the bathroom, and no one answered my call light in time. I am sorry. This is embarrassing. Over two hours ago I turned on my call light. I wanted to get up out of bed and get dressed for the day. (V20/CNA/Certified Nursing Assistant) came in earlier, shut off my call light, and said she would be back. (V20) never returned. I have a brace to my right knee and cannot get dressed or get up on my own. On 6/27/25 at 10:45 AM V20 (CNA) stated, I was passing hall trays earlier this morning when (R4) wanted to get up. I did not have time to get (R4) up at that time, so I did turn off (R4's) call light. On 6/27/25 at 12:15 PM V2 (Director of Nursing) stated R4 should not have had to lay in her own stool and R4's call light should have been answered quicker.

Based on interview, observation and record review, the facility failed to ensure the floor was free and clear of trip hazards for one of three residents (R1) reviewed for falls with injury in a sample of four. On 01/05/25, R1 fell at the facility after a cord on the floor of the walkway entering her room became trapped in the wheel of her walker. R1 sustained a laceration to her forehead requiring placement of nine sutures, a skin tear and bruising to her right third finger, and fractures to C1 (first cervical vertebrae) and C2 (second cervical vertebrae), requiring R1 to wear a hard cervical collar at all times. Findings include: R1's Fall Investigation (dated 01/05/25) documents the following: On 01/05/25, at approximately 03:10 PM, RN (Registered Nurse) was notified by CNA (Certified Nursing Assistant) resident (R1) had a witnessed fall. Resident was walking with her walker and assist of one CNA with gait belt in place to the bathroom when resident's walker caught on the bed remote causing resident to lose her balance and fall to her right side. Nurse immediately went to assess the resident upon notification of fall. The resident was observed lying on the floor near the end of her bed with a CNA holding a washcloth to resident's forehead, shoes on with laces tied, walker near feet lying on its side, gait belt in place. RN completed assessment and noted laceration to center of forehead, skin tear to middle finger of right hand with bruising and vitals WNL (within normal limits). Nurse noted resident pain to be a 6 out of 10. CNA continued to apply pressure to forehead and keep resident's head secured until (local ambulance transport service) arrived. Resident is current with hospice care. Resident was transported to (local emergency department) for further evaluation/possible treatment. POA (Power of Attorney), MD (Physician), Hospice, and (V2, Director of Nursing) were notified. Staff interviews conducted post event were completed. CNA stated at approximately 03:10 PM, she was walking resident to the bathroom with resident's walker and a gait belt in place when resident's walker caught on the bed remote causing the resident to lose her balance and fall to her right side. Resident was evaluated in (local emergency department). Resident returned to (facility) 01/05/25 for continued long term care. Diagnosis: Cervical Fracture of C1 & C2 (with Cervical Collar in place) and laceration to forehead with nine stitches. Resident POA (Power of Attorney) chose no surgical intervention at this time and to remain of hospice care keeping resident comfortable. Hospice adjusted pain medication to help ensure resident comfort. Family to provide more frequent monitoring. New interventions put into place, staff educated and care plan updated. POA and MD (Physician) notified and are in agreement with plan of care. R1's 01/05/25 Fall Investigation also documents the following: Evaluation Notes: (R1) is alert with confusion at baseline (Brief Interview of Mental Status score of 3, indicating severe cognitive impairment), (R1) had a witnessed fall in her bedroom while ambulating with CNA (V6, Certified Nursing Assistant), resident's walker got wrapped in the bed remote cord, this is believed to be the root cause of the incident. (R1) obtained C1 and C2 fracture, laceration and bruising as result from this incident. Care Plan reviewed, new intervention: bed remote control fixed to bed. On 02/05/25 at 01:25 PM, V5 (Certified Nursing Assistant) verified her written statement included in R1's 01/05/25 fall investigation and stated the following: I was right across the hall when (R1) fell . (V6, Certified Nursing Assistant) was walking (R1) into her room, and (V6) called out for help after the fall. The right front wheel of (R1's) walker ran over the loose cord that was on the ground in the walkway near the footboard of (R4's, R1's roommate) bed. The cord was hanging from (R4's) bed and it caused (R1) to fall after it got stuck in her walker's wheel. The cord connects to the bed remote, which (R4) cannot utilize due to her Dementia. The cord was still stuck around the right front wheel of (R1's) walker when I entered the room. (R4) had just moved back into that room a day or two before (R1's) fall. The bed remote cord must have become unsecured when (R4's) bed was moved. I went and got (V12, Registered Nurse), who responded to R1's room right away. On 02/05/25 at 03:50 PM, V6 (Certified Nursing Assistant) stated she was the staff member assisting R1 when she fell . V6 stated, The cord from the bed remote of (R4's) bed had came loose. It was dangling from the underneath of (R4's) bed and was sitting on the floor. I was walking with (R1) to the bathroom. She uses a walker when she walks, and I had a gait belt on her. She must have ran over the remote cord hanging from (R4's) bed while we were walking into the room. While we were walking, I felt (R1) suddenly jolt backwards. I'm guessing this is when the cord that was tangled in the wheel of her walker became taut, and this caused her to lose her balance and fall. I tried to stop her, but she just went down so quick. After she had fallen, you could see the cord from (R4's) bed was tangled in the right front wheel of (R1's) walker. She had a big cut in the middle of her forehead, and a skin tear on her right middle finger. (V5, Certified Nursing Assistant) was right across the hall in another resident's room, and I called her to come in the room for help. She came into R1's room, I explained what had just happened, and she immediately went and got (V12, Registered Nurse), who came in right away. On 02/05/25 at 02:30 PM, V9 (Certified Nursing Assistant) stated she was working when R1 fell on [DATE]. V9 stated, I last saw (R1) when she was in the day room. (V6, Certified Nursing Assistant) was walking with her when she fell . The cord from a bed remote got stuck in the wheel of her walker. I saw the cord stuck in the wheel when I entered the room after (R1) fell . On 02/10/25 at 08:30 AM, V12 (Registered Nurse) stated she was the nurse that responded after R1's 01/05/25 fall. V12 verified her written statement form R1's fall investigation, which documents the following: This nurse was called to (R1's) room by (V5, Certified Nursing Assistant) due to resident being on the floor. Resident observed on floor with another CNA (V6, Certified Nursing Assistant) holding wash cloth to resident's forehead, shoes on with laces tied, walker near feet lying on its side, gait belt in place. Upon inspection, resident observed to have a laceration to center of forehead, skin tear to middle finger of right hand with bruising and knot present. Fall witnessed by (V6, Certified Nursing Assistant). Pressure applied to forehead and sent to ER (emergency room ) for further evaluation. Hospice, MD (Physician), POA (Power of Attorney) and (V2, Director of Nursing) notified. V12 stated due to R1's extensive confusion, she estimated R1's pain to be a 6 out of 10 based on the Wong-Baker Faces Pain Scale (visual analog pain scale used to assess pain in children and adults). On 02/05/25 at 01:45 PM, R1 was reclined in a recliner with a blanket covering her lap near the nurse's station. R1's eyes were closed, and a hard cervical collar was in place around R1's neck. R1 appeared confused, did not open her eyes or respond to verbal stimuli, and was moaning incomprehensible phrases. A moon-shaped scar with well-approximated edges was present in the middle of R1's forehead. A small scabbed area with faint bruising was present on R1's right third digit. R1's (local hospital) emergency department medical record (dated 01/05/25) documents the following: HPI (History of present illness): Patient is a [AGE] year-old female who presents to the emergency department today for evaluation of injuries sustained from a ground level fall. She has a history of advanced dementia and resides at a nursing facility. She is currently enrolled in hospice but due to the size of lacerations involved she was sent here for evaluation and repair of the lacerations. It is reported that she fell forward. Sustained a large laceration to her forehead and a laceration to her right middle finger. (R1) Has also been complaining of some neck pain since the fall occurred. She is not on any form of blood thinners. She did not lose consciousness. She has not had any vomiting since injury occurred. This same medical record also documents, Skin: Positive for wound (large forehead laceration); Comments: 10 centimeter laceration to forehead with visualized portion of skull; Neck: Diffuse posterior neck tenderness; Musculoskeletal: 1.5 centimeter laceration to dorsal aspect of right middle finger. R1's same (local hospital) medical record documents the following: CT (computed tomography) Cervical Spine without Contrast: Cervical: There is an acute, obliquely oriented, complete type II fracture of the base of the dens (second cervical vertebrae). There is no displacement at the fracture site at this time. An acute, nondisplaced fracture of the right-sided posterior arch of C1 (first cervical vertebrae) is also present. R1's (local hospital) emergency department medical record also documents the following: Medical Decision Making: CT (computed tomography) of the head showed no acute fractures or bleeds. Unfortunately, CT of the cervical spine did show a nondisplaced type II dens fracture with a non-displaced posterior arch fracture of C1 on the right side. I did discuss patient's case with (V15, local Neurosurgeon) who was on on-call for Neurosurgery. He notes that this would usually require surgical repair. However, patient is a hospice patient with advanced dementia. Family is very reluctant to have her undergo surgery. (V15) notes if this is the case the only other alternative would be to place patient in (hard cervical collar). Patient's power of attorney had extensive discussion with other family members. It was decided by family and power of attorney that they would forego extensive trauma workup or surgical intervention. They would like patient to be kept as comfortable as possible. They do understand that if patient moves her neck in certain way could lead to neurological defects or death. They would like to respect her wishes and allow her to be discharged back to the nursing facility on hospice. We will provide her with a small amount of Lortab (pain medication) elixir. She tolerated suture procedure of her forehead very well. Dissolvable sutures were placed so she would not have to undergo suture removal. Well, the laceration on her finger could benefit from some sutures. The edges are well-approximated and attempting to repair it has caused her distress. Family is okay with just bandaging the finger for now and letting it heal. On 02/05/25 at 03:20 PM, V1 (Administrator) verified R1 fell as a result of her wheeled walker contacting a cord that was hanging from the foot of R4's bed. V1 verified that R1 has to ambulate past R4's bed to enter her bathroom. V1 verified that R1 returned to the facility after her evaluation in the local emergency department with a C1 and C2 fracture sustained during her fall on 01/05/25, requiring R1 to wear a hard cervical collar. V1 also verified R1 had 9 sutures placed to a large laceration in her forehead, and had a dressing in place on the skin tear sustained to her right third digit after her 01/05/25 fall.

Based on observation, interview, and record review, the facility failed to cover a urinary catheter bag with a privacy bag for one of 24 residents (R18) reviewed for dignity in the sample of 33 Findings include: The Resident Rights Booklet, dated 11/18, documents, Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike. R18's current computerized medical record documents R18 was admitted to the facility on [DATE], with diagnoses which included Neuromuscular Dysfunction of Bladder, Overactive Bladder, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Essential (Primary) Hypertension. R18's MDS (Minimum Data Set) Assessment, dated 8/29/24, documents a BIMS (Brief Interview for Mental Status) Score of 14/15, indicating cognition intact and has an indwelling catheter. R18's Care Plan, dated 8/18/21, documents R18 has a catheter related to neuromuscular dysfunction of bladder. R18's Physicians Order, dated 12/19/23, documents R18 has a (indwelling) catheter. On 9/23/24 at 12:20 PM, R18 was sitting in the dining room. R18's urinary drainage bag was not covered with a privacy bag. The urinary drainage bag was hooked under R18's chair, and the bag with urine was visible. R18 was asked if she would like the catheter bag to be covered. R18 stated she thought it was covered and if not, she would like it covered. On 9/23/24 at 12:25 PM, V4/Registered Nurse verified R18's catheter bag was not covered with a privacy bag, but should be. On 9/25/24 at 10:12 AM, V2/Director of Nursing stated catheter bags are to be covered with a privacy bag. V2 also stated, There is no policy for using a dignity bag to cover the catheter bag, but that is standard practice.

Based on interview and record review, the facility failed to notify the facility Ombudsman of Facility Discharges/Transfers, monthly, for two residents (R26 and R67) of 7 reviewed for discharges in the sample of 33. Findings include: 1. R26's current Medical Record, documents R26 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Anxiety, Vascular Dementia, Peripheral Vascular Disease, Fibromyalgia, Essential (Primary) Hypertension, and Severe Sepsis with Septic Shock R26's Nursing Note, dated 6/3/24 at 10:56 AM, documents R26 was taken to the hospital for evaluation. R26's Nursing Note, dated 6/3/24 at 11:13 AM, documents R26 was admitted to the hospital with a diagnosis of UTI/Urinary Tract Infection. R26's Social Service Note, dated 6/11/24 at 12:15 PM, documents R26 was back in the facility. R26's Nursing Note, dated 6/18/24 at 6:23 AM, documents emergency services were called to take R26 to the emergency room . R26's Nursing Note, dated 6/18/24 at 9:51 AM, documents R26 is being admitted to the hospital. R26's Nursing Note, dated 6/26/24 at 5:24 PM, documents R26 returned from the hospital. R26's Bed hold Notice, dated 6/4/24, documents R26 went to the hospital on 6/3/24 for a diagnosis of UTI/ Urinary Tract Infection. R26's Bed Hold Notice, dated 6/19/24 documents R26 went to the hospital for sepsis. The Admit/Discharge Report, dated 6/1/24 - 6/30/24, does not document R26 was discharged to the hospital on 6/3/24 and 6/18/24. On 9/25/24 at 10:37 AM, V5/Social Services stated R26 was not on the June 2024 list of admit/discharge that was provided to the Ombudsman. V5 also stated, The information was put in the system. I don't know why it didn't show up on the report. 2. R67's current Medical Record documents R67 was admitted to the facility on [DATE], with diagnoses which included Chronic Kidney Disease Stage 3, Sepsis, Anxiety, Essential (Primary) Hypertension, and Chronic Systolic (Congestive) Heart Failure. R67's Nursing Note, dated 1/9/24 at 4:46 PM, documents R67 was not responding to questions or stimuli. R67 was sent to the hospital for evaluation and treatment. R67 left the facility at 4:40 PM. R67's Nursing Note, dated 1/9/24 at 6:07 PM, documents R67 was admitted to the hospital with a diagnosis of UTI/Urinary Tract Infection. R67's Nursing Note, dated 1/13/24 at 1:46 PM, documents R67 returned to the facility. R67's Bed Hold, dated 1/10/24, documents that R67 went to the hospital on 1/9/24 with a diagnosis of UTI/Urinary Tract Infection. The Admission/Discharge Log, dated 6/1/24 to 6/30/24, does not document R67 was discharged to the hospital on 1/9/24. On 9/25/24 at 10:42 AM, V5/Social Services stated R67 was not on the January 2024 list of admit/discharge that was provided to the Ombudsman. V5 also stated, The information was put in the system. I don't know why it didn't show up on the report.

Based on interview and record review the facility failed to develop a Person Centered Care Plan for one resident (R67) out of 24 reviewed for Care Plans in a sample of 33. Findings Include: The Care Plan Policy, dated 6/1/22, documents, It is the policy of this facility to develop and implement a Base Line Care Plan, a Comprehensive Person-Centered Care Plan and conduct Care Plan Meetings as appropriate for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meter resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 6. The comprehensive care plan will be developed within 7 (seven) days after the completion of the comprehensive MDS (Minimum Data Set) assessment as outlined in the RAI (Resident Assessment Instrument) manual guidelines. Address other factors identified by the interdisciplinary team, or in accordance with the resident's preference, will also be addressed in the plan of care. 9. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. R67's current Medical Record documents R67 was admitted to the facility on [DATE], with diagnoses which included Chronic Kidney Disease Stage 3, Sepsis, Anxiety, Essential (Primary) Hypertension, and Chronic Systolic (Congestive) Heart Failure. R67's MDS (Minimum Data Set) Assessment, dated 1/20/24, documents R67 takes an anticoagulant. R67's Physicians Order for Eliquis 5 mg/Milligrams documents a start date of 1/13/24, Take Eliquis 5 mg twice a day. Care Plan, dated 9/24/24 at 3:59 PM, documents, (R67) uses an anticoagulant medication related to CHF (Congestive Heart Failure). On 9/26/24 at 9:32 AM, V10/MDS/Care Planner, stated R67 did not have a Care Plan for an anticoagulant until 9/24/24, although there should have been.

Based on observation, interview, and record review, the facility failed to change an oxygen tubing/humidifier bottle for one resident (R2) of two residents reviewed for oxygen therapy in the sample of 33. Findings Include: The Oxygen Therapy policy, dated 3/16/17, documents, To provide a source of oxygen to persons experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing) must be exchanged every 7 (seven) days. R2's current Medical Record documents R2 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with Hypoxia (Primary), Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypercapnia, and Shortness of Breath. R2's Care Plan documents R2 has COPD/Chronic Obstructive Pulmonary Disease, Chronic Respiratory Insufficiency, Obstructive Sleep Apnea, Restrictive Lung Disease, Recent Respiratory Acidosis, Recent Acute Hypercapnia, and Respiratory Failure. R2's oxygen setting is to be at three liters. R2's Physician Order, dated 3/30/24, documents oxygen at three liters continues every shift. R14's Physician Order, dated 3/12/24, documents oxygen at 2 (two) liters per minute by nasal cannula every shift. On 9/23/24 11:25 AM, R2 was sitting in her room wearing oxygen. It was connected to the humidifier bottle. The humidifier bottle was dated 8/18/24. On 9/23/24 at 11:26 AM, V4/Registered Nurse verified the date on the humidifier bottle was 8/18/24. V4 also stated the tubing and humidifier bottle is to be changed weekly on the night shift. On 9/25/24 at 10:12 AM, V2/Director of Nursing stated oxygen tubing and humidifier bottles are supposed to be changed weekly. The staff are to date the tubing and humidifier bottle when they are changed.

Based on observation, interview, and record review, the facility failed to document a diagnosis and monitor for specific adverse behaviors to warrant the use of an antipsychotic medications for one of five residents (R249) reviewed for unnecessary medications in a sample of 33. Findings include: The facility's Psychopharmacological Drug Usage Procedure, revised 10/18/17, documents the documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medications response and adverse consequences. R249's current Medication Administration Record documents to take Quetiapine (antipsychotic) 25mg daily for Alzheimer's disease, unspecified. On 9/23/24 at 10:30am, R249 was being assisted to his wheelchair, cooperative with care. On 9/24/24 at 1:30pm, R249 was sleeping in his wheelchair. On 9/25/24 at 10:30am, R249 was sleeping in his wheelchair. R249 was encouraged to lay in bed but refused. On 9/25/24 at 11:30am, V13, Certified Nursing Assistant, stated R249 does not show any signs of adverse behaviors. V13 verified R249 is cooperative with care. On 9/25/24 at 1:30pm, R249 was sleeping in his wheelchair in his room. On 9/25/24 at 11:45am, V6, Assistant Director of Nursing, verified R249 does not have any adverse behaviors or diagnosis for the use of an antipsychotic medication. V6 stated R249 shows signs of increase confusion in the evenings, but is easily redirected.

Based on observation, interview, and record review, the facility failed to provide nail care to 1 resident (R1) of 3 residents reviewed for nail care in the sample of 7. The Findings include: The Nail Care policy, dated 3/2004, documents to provide cleanliness and prevent infection the nails should be trimmed. The Personal Care of Residents policy, dated 12/2002, documents, It is the policy of the facility to provide a plan of personal care for residents. To provide that residents of the facility receive adequate care. Each resident shall have proper daily personal attention and/or care, including skin, nails, hair, and oral hygiene, in addition to treatments ordered by the physician. R2's Nursing Note, dated 2/6/24 at 12:50 PM, documents R2 was seen today by V6 (Advanced Practical Nurse) and received an order to provide nail care. R2's Nursing Note, dated 2/7/24 at 10:48 AM, documents R2 has received a shower today and no new skin concerns. Areas on the bilateral lower extremity/BLE shows self-inflicted scratches. R2's nails have been trimmed and triamcinolone cream applied to the BLE. On 3/4/24 at 2:55 PM, R2's fingernails were observed. The fingernails were jagged with some sharp edges. V1 (Administrator) was asked to look at R2's fingernails. V1 observed R2's nails and stated she would have the nails cut. On 3/5/24 at 10:00 AM, V3 (Assistant Director of Nursing) stated she looked at R2's fingernails on 3/4/24, and although they were short, they were jagged and sharp. V3 told V20 (Certified Nursing Assistant) to cut R2's fingernails, and V20 said he had recently cut them. V3 told V20 the fingernails were sharp, and to do it again. On 3/5/24 at 10:25 AM, V6 (Advanced Practice Nurse) state she had ordered R2's nails be cut because R2's left hand is contracted, R2's nails were long, and V6 was concerned the nails would dig into R2's hand. V6 also stated R2's nails did need to be addressed. On 3/6/24 at 12:29 PM, V19 (Assistant Occupational Therapist) stated she worked with R2 four times from February 8th to 3/6/24. (R2's) fingernails were not super long, but longer than they should have been.

Based on observation, interview, and record review, the facility failed to prevent misappropriation of property for 1 resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. The Findings include: The Abuse policy, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown sources, exploitation and use of any physical or chemical restraint not required to treat residents' symptoms. To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. The Final Investigation Report sent to the (State Agency), dated 2/13/24, documents a Drug Diversion Investigation. On 2/8/24, V2 (Regional Nurse Coordinator) notified V1 (Administrator) of a possible drug diversion for a bottle labeled Morphine Sulfate. During a routine medication cart audit by V4 (Pharmacy Nurse Consultant), V4 noted a bottle labeled morphine sulfate for R1. The bottle was stored in a zip lock bag along with the dosing syringe. The content of the bottle was gray in color. The morphine that is provided by the facility pharmacy is blue in color. V4 removed the bottle of morphine and the sign out sheet and took it to V5 (Previous Director of Nursing) due to her concerns. V4 left the bottle labeled Morphine for R1 containing the gray liquid, sign out sheet, and dosing syringe in V5's office. V5 and V3 (Assistant Director of Nursing) immediately initiated an investigation. After completion of interviews with all nursing staff, the time frame for this occurrence has been determined to be after 1/22/24. R1's Physician Order, dated 12/6/22, documents, Morphine Concentrate - Schedule II solution; 100 mg (Milligram)/5 ml (Milliliter) (20 mg/ml); Amount to Administer: 0.25 ml; oral. R1's Controlled Substance Record documents 30 ml of Morphine was delivered on 12/6/23. There was 27.5 ml remaining out of 30 ml. At the top of the sheet written in marker is Dark color - reported. R1's Medication Administration Record documents the last time R1 received Morphine was on 1/21/24 at 1:54 PM given by V16. On 3/5/24 at 10:56 AM, V3 had two bottles of Morphine. The bottles were white plastic with a clear area on the side where the medication could be seen and measured. The contents of R1's bottle was gray in color. The bottle had 27.5 ml of liquid in it out of the original 30 ml's. The unopened bottle of morphine was blue in color. R1's Morphine bottle had an expiration date of 7/25. On 3/5/24 at 11:21 AM, V1 (Administrator) stated V4 found a bottle of morphine for R1 that V4 thought had been tampered with during V4's medication audit. The bottle should have had a blue medication in it, but what was in the bottle was gray. An investigation was done, and the facility was unable to identify what happened to (R1's) medication. On 3/4/24 at 2:32 PM, V3 (Assistant Director of Nursing) stated when V4 was doing her medication audit, V4 found a bottle of Morphine that V4 questioned if it was really Morphine. V4 brought the bottle to V3 and V5 and said she thought the color was different than it should be. V3 and V5 agreed the medication did not look like the correct medication. The bottle was a white bottle with a strip on the side that the color can be seen through. The medication should have been blue but was gray. V3 also stated V16 (Licensed Practical Nurse) was the last person to give the medication to R1 on 1/21/24. V16 said the medication she removed from the bottle for R1 was blue. On 3/4/24 at 1:36 PM, V4 (Pharmacy Nurse Consultant) stated when she was doing the narcotic counts at the facility, V4 noticed a bottle of Morphine for R1 that was gray in color instead of blue. The Morphine looked as though it had been tampered with. V4 also stated she could not say what was in the bottle, but knew it was not Morphine.

Based on observation, interview, and record review, the facility failed to perform indwelling urinary catheter care according to facility policy and failed to keep the urinary bag below the bladder and off the floor for one (R7) of two residents reviewed for indwelling catheters in a sample of 26. Findings include: The facility's undated Catheter (Maintenance and Removal) policy documents Procedure: 2. Attach drainage bag to bed frame, below level of resident's bladder - not touching the floor. Key Points: To allow flow with gravity and to avoid backflow of urine, secure catheter to thigh/lower abdomen for men .Procedure: 7. Cleanse the meatus and adjacent catheter. (Follow 'Catheter Care' procedure.) The facility's undated Catheter Care policy documents Procedure: 4. Wash perineal area with soap and water or perineal cleanser. Begin cleansing from the cleanest area in front to the most soiled area in back .On a circumcised male resident, wash the skin folds at the top of the penis using a circular motion. Clean the meatus around the catheter first and work downward .Gently clean catheter tubing nearest the body, wiping away from where it enters the meatus. R7's current Physician Order Sheet/POS documents R7 has an indwelling urinary catheter with a diagnosis of Unspecified complication of genitourinary prosthetic device, implant, and graft. 1. On 11/01/23, at 2:05 pm, R7 was lying in bed with an indwelling urinary catheter draining into a catheter bag. V5, Certified Nursing Assistant/CNA, prepared supplies to empty R7's urinary catheter bag and perform catheter care. V5 held a graduate on the top of R7's bed and lifted the catheter bag over the graduate (above R7's bladder), and emptied the urine from the bag into the graduate. While lifted up, R7's catheter tubing was filled with cloudy urine, flowing towards R7's bladder, and was not emptied out at this time. V5 emptied the urine into the toilet, removed V5's gloves then re-applied gloves without hand sanitizing or cleansing. V5, CNA, then cleansed R7's catheter tubing with cleansing cloths from R7's penis down to the bag. No cleansing was completed of R7's penis or meatus. V5 removed V5's gloves, then with bare hands, V5 adjusted R7's bed height, finished tying the garbage trash liner, brought R7 his ice water pitcher, glass, remote, and basket of personal supplies to R7's bedside table. V5 put a new liner in the trash can. All of this was completed prior to washing hands. On 11/01/23, at 2:32 pm, V5, CNA, stated V5 should not have held the catheter bag above R7's bladder. I didn't know where to put it while you were here. I usually just hold it and I didn't want to spill it. V5 stated V5 did not use hand sanitizer after removing gloves or before putting clean ones on and should have. V5 also stated V5 did not cleanse R7's penis during the catheter and should have. I thought you wanted to see catheter care. 2. On 10/31/23, at 10:26 am, R7 sat in a wheelchair in his room with an indwelling urinary catheter bag hooked under R7's seat and touching the floor. On 10/31/23, at 10:39 am, V4, Certified Nursing Assistant/CNA, confirmed R7's catheter bag was touching the floor and should not be. On 11/2/23, at 10:09 am, V3, Infection Control Preventionist, stated, They should use hand sanitizer between glove changes and put on a clean pair of gloves. On 11/2/23, at 10:51 am, V2, Director of Nursing/DON, stated during catheter care, the staff should wash the head of the penis, penis, inner thighs and all down the tubing. V2 stated the urinary catheter bag should be always kept below the bladder and up off the floor.

Based on observation, interview, and record review, the facility failed to remove Personal Protective Equipment/PPE and perform hand hygiene upon exiting a COVID-19 positive resident room to prevent cross-contamination; failed to follow their COVID-19 policy regarding wearing masks for one resident (R79); and failed to perform hand hygiene during incontinence care for one resident (R7) of 19 residents reviewed for infection control in a sample of 26. Findings include: The facility's Standard Precautions policy, dated 08/09, documents Policy: Standard Precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard Precautions are based on the principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Objective: To prevent the spread of infectious agents among residents and healthcare personnel in the facility Procedure: 1. Hand hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent: or thoroughly applying an alcohol-based hand rub (ABHR) .c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedures on the same resident to prevent cross-contamination of different body sites 2. Gloves: c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments. The facility's undated Proper Hand Washing Procedure documents When to Wash Hands: Employee must wash their hands: After removing disposable gloves. After engaging in any activity that would contaminate hands. The facility's COVID-19 policy, dated 8/28/23, documents Policy: The Infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage and isolation of potentially infectious residents. Purpose: The purpose of this policy is to prevent/minimize the risk of COVID-19 from being introduced into the facility and provide care for resident suspected or confirmed to have COVID-19 .Prevention: Masking: 3. Facility will follow current CDC/CMS recommendations regarding masking while in an outbreak. The CDC's COVID-19 guidelines, provided by the facility and dated 5/25/23, documents The Core Principles of COVID-19 Infection Prevention: 6. Implement Source Control Measures: Source control refers to use of respirators or well-fitting masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .Source control is always recommended for individuals in health care settings who: Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 (Severe acute respiratory syndrome coronavirus-2) outbreak .If a facility is experiencing an outbreak of COVID-10 or other respiratory illnesses, at a minimum, HCP (Healthcare Personnel) must wear a well-fitted mask while on the unit or floor experiencing an outbreak. R79's current Physician Order Sheet/POS documents diagnoses including COVID-19 Acute Respiratory Disease (Primary). On 11/2/23, at 10:01 am, V3 Infection Control Preventionist/ICP stated that one or more COVID-19 positive is considered outbreak. V3 stated that staff who are working on that hallway where the COVID Isolation room is, have to wear a surgical mask when caring for the other residents on that hall. 1. On 10/31/23, at 11:34 am, V6, Floor Tech, donned a gown, gloves, N95 face mask, and face shield. V6 stepped inside R79's Isolation room and wiped the isolation garbage lid with a disinfectant spray. When finished, V6 placed the soiled cloth into a clear bag. V6 removed his gown and gloves. Without any hand hygiene and while wearing the same soiled N-95 face mask and face shield, V6 took the clear bag and disinfectant spray bottle, walked up the resident hall, around the corner past a small resident dining area, and down the next resident hall to the end passing by occupied resident rooms. V6 then stepped into the housekeeping office. V6 removed V6's face shield, put a glove on and placed the clear bag with the soiled cloth into another bag then stepped out and carried it to the dirty linen closet to dispose of it. Upon exiting the closet, V6 removed his soiled N-95 face mask. On 10/31/23, at 11:41 am, V6 stated V6 usually wears the mask and face shield clear through (the task). V6 stated, I should not have walked through the hall with it on and should have washed my hands right when I left the room. On 11/2/23, at 10:12 am, V3, Infection Control Preventionist/ICP, stated, It is not correct to be wearing the same face shield or the N95 beyond the COVID isolation room - it should be changed to a surgical mask. 2. On 10/31/23, between 9:30 am and 2:30 pm, R79 was in bed in a COVID-19 Isolation room. Staff noted to be working at various times on this hall were not wearing any face masks, and included V4, V8, and V9, Certified Nursing Assistants/CNAs. On 10/31/23, at 10:10 am, V9, CNA, was in between answering resident call devices on the COVID-19 hall. V9 was not wearing any face mask. On 10/31/23, at 11:27 am, V4, CNA, stood outside R79's Isolation room and handed supplies to V10, Registered Nurse/RN, who had donned PPE and entered R79's room. V4, CNA, was not wearing any face mask. On 11/1/23, at 2:18 pm, V8, CNA, now wearing a surgical face mask on the COVID-19 hall, stated V3, Infection Control Preventionist, told them today they are supposed to wear a surgical mask when working on this (COVID-19) hall. V8 confirmed V8 was not wearing one yesterday (10/31/23). On 11/2/23, at 10:01 am, V3, Infection Control Preventionist/ICP, stated staff who are working on that hallway where the COVID-19 Isolation room is, have to wear a surgical mask when caring for the other residents on that hall. 3. On 10/31/23, at 11:27 am, R79 was lying in bed in an Isolation room. V10, Registered Nurse/RN, donned PPE (Personal Protective Equipment) and entered R79's room to pass medications. After completion and removing V10's PPE at R79's doorway, V10 walked past occupied resident rooms (approximately 25 feet up the hall) then used hand sanitizer. On 11/02/23, at 10:09 am, V3, ICP, stated, Staff should be either washing their hands or using hand sanitizer as soon as they leave the room. Not to be walking up the hall to sanitize. 4. On 11/01/23, at 10:12 am, R7 sat in a wheelchair in his room. V5, Certified Nursing Assistant/CNA, assisted R7 to the bathroom to put lotion on R7's bottom per his request. As V5 pulled down R7's pants and brief, V5 noticed stool on R7's brief. V5 assisted R7 to sit back down into his wheelchair then gathered supplies for incontinence care. With gloved hands, V5 assisted R7 to stand, lowered and removed R7's soiled brief, and tossed it into the garbage can. V5 wiped stool from R7's bottom with cleansing wipes. With the same soiled gloves, V5 put a clean brief on R7, applied lotion to R7's thighs per his request, then assisted R7 to sit down in his wheelchair. V5 removed her soiled gloves, then with bare hands, adjusted the wheelchair pedals and removed the gait belt from R7. On 11/01/23, at 10:16 am, V5 stated V5 should have changed V5's gloves after cleaning (R7's) butt. On 11/2/23, at 10:09 am, V3, Infection Control Preventionist, stated, They should use hand sanitizer between glove changes. For incontinence care, they should use fresh gloves before start, and [NAME] soiled cloths into the bag, then dropping their gloves into the bag as well, and then sanitizing and putting on a clean pair of gloves.

Based on observation, interview, and record review, the facility failed to perform neurological (neuro) checks every four hours as directed by the facility's policy after a resident sustained a fall with a head injury for one of three residents (R2) reviewed for falls in the sample of three. Findings include: The facility's Emergency Care Procedure policy, dated 4-3-18, documents after a fall with a head injury neuro checks should be performed every four hours for twenty-four hours following the fall. On 8-22-23 at 10:30 AM, R2 was sitting in a wheelchair in the dining room. R2 had a quarter-sized hematoma above her left eye and had extensive yellowish-purplish bruising below the left eye that extended down into R2's left cheek and left chin and R2 had yellow-purplish bruising under the right eye. R2's Progress Notes, dated 8-6-23 at 11:07 PM and signed by V7 (LPN), document, Called to resident room by CNA (Certified Nursing Assistant). (R2) observed lying on left side next to bed. (R2) has four cm (centimeter) by four cm hematoma over left eye. Complaints of pain of hematoma. No other injuries noted. Moves all extremities per normal (R2) assisted back into bed. Bed lowered to floor and floor mats placed. Family and (V9/R2's Physician) notified. Ice pack applied to hematoma. R2's Electronic Health Record documents neurological checks were only performed on 8-7-23 at 2:43 AM and 8-7-23 at 3:23 PM (not every four hours as directed by the facility's policy). On 8-23-23 at 10:30 AM, V2 (Director of Nursing) stated, Neuro checks should have been done every four hours for twenty four hours after (R2) fell and hit her head on 8-6-23. There is no evidence that the nurses did (R2's) neuro checks every four hours after the fall on 8-6-23.

Based on interview and record review, the facility failed to revise a care plan for new onset of pain location, for one resident (R1) out of three residents reviewed for care plans in a sample of three. Findings include: The facility's Care Plan policy, dated 6/1/22, documents, 3. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, physical, mental or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. R1's physician visit summary, dated 6/19/23, documents, Seen today for follow-up-up service since recent admission to skilled nursing facility .(R1) reports pain to the right upper extremity as an 8-9, states she thinks her arm was strained during mobility or transfer recently. R1's physical therapy notes, dated 6/17/23, documents, (R1) stating her right arm hurts, states night male CNA (Certified Nursing Assistant) hurt it when transferring her out of her recliner to go to the bathroom last PM he didn't mean to, but pulled on it to help get me up. Took patient to floor nurse to give report of events. After, patient was given medication by nurse and agrees to do therapy. R1's medical record, dated 6/20/23, documents an X-ray was obtained for R1's right upper extremity due to new onset of shoulder pain. R1's physician visit note, dated 6/22/23, document,s Patient seen today for review of x-ray results and follow-up regarding right shoulder pain. R1's care plan does not address R1's onset of right upper extremity pain or interventions to address her right upper extremity pain. On 7/6/23 at 10:56 AM, V4, Advanced Practice Nurse (APN), stated, I followed up with (R1) on 6/22 and let her know her right shoulder pain was due to significant arthritis in that joint. She was still complaining of pain, so I gave a new order for some pain medications. I believe the pain was due to her therapy sessions. It's common to see an increase in pain in arthritic joints during therapy. That's why I wanted her to rest it a few days before trying any pain medications. On 7/8/23 at 12:27 PM, V1, Administrator, verified R1's new onset of right upper extremity pain was not added to the care plan.

Based on interview and record review, the facility failed to assess, investigat,e and notify the physician of a possible resident injury for one resident (R1) out of three residents reviewed for injury in a sample of three Findings include: The facility's Accident and Incident Report policy, dated 4/2/19, documents, Objective: 1. TO document all accidents/incidents occurring to resident's, visitors and employees. Resident: A. Provide necessary emergency care. B. Notify Charge Nurse, who then must notify Physician and family. C. If there has been no apparent injury, follow-up must continue for 24 hours. D. If there is apparent injury, follow-up must continue for at least 72 hours. E. Documentation must be on Resident Accident and Incident Report as well as in the Nurse's Notes. R1's minimum data set (MDS) documents a Brief Interview of Mental Status (BIMS) of 14. A BIMS of 12-15 indicates an individual in cognitively intact. R1's physical therapy notes, dated 6/17/23, documents, (R1) stating her right arm hurts, states night male CNA (Certified Nursing Assistant) hurt it when transferring her out of her recliner to go to the bathroom last PM he didn't mean to, but pulled on it to help get me up. Took patient to floor nurse to give report of events. After, patient was given medication by nurse and agrees to do therapy. R1's physician visit summary, dated 6/19/23, documents, Seen today for follow-up-up service since recent admission to skilled nursing facility .(R1) reports pain to the right upper extremity as an 8-9, states she thinks her arm was strained during mobility or transfer recently. R1's progress noted does not document a resident reported incident of injury. R1's medical record does not include an investigation into R1's reported incident of injury. On 7/6/23 at 9:03 AM, R1 stated, I'm not sure what day it was, but a staff member was trying to help me get out the recliner and I felt a pop in my shoulder, and it started hurting. I told the nurse when it happened.' On 7/6/23 at 10:56 AM, V4, Advanced Practice Nurse (APN) stated, I saw (R1) on 6/19. At that time, (R1) was complaining of pain to her right upper extremity (RUE). I ordered an X-ray to rule out any injuries. According to my notes, the facility never contacted me. I saw (R1) on 6/19 as part of a routine follow-up. I followed up with (R1) on 6/22 to let her know her right shoulder pain was due to significant arthritis in that joint. She was still complaining of pain, so I gave a new order for some pain medications. I believe the pain was due to her therapy sessions. It's common to see an increase in pain in arthritic joints during therapy. That's why I wanted her to rest it a few days before trying any pain medications. On 7/8/23 at 9:00 AM, V5, Licensed Practical Nurse (LPN), stated, I was working Monday (6/19) when I heard (V4, APN) tell the bridge nurse to put in an X-ray order for (R1)'s right upper extremity. I asked why they were putting in an order for it when she didn't say anything to me about any new pain. I was told that she hurt her arm over the weekend, possibly while therapy was working with her to get her out of her chair. From what I understand, therapy questioned (R1) about it, and (R1) said that it wasn't therapy, it was a male CNA that was trying to get her out of her chair and accidentally hurt her arm. On 7/8/23 at 12:24 PM, V2, Director of Nursing (DON), stated, In a situation like (R1)'s, the nurse should have done an assessment when it was reported to her on 6/17, documented the incident, started an incident report and notify the administration and physician. Unfortunately, it wasn't done.

Based on observation, interview, and record review, the facility failed to address a residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: The facility's [CONDITION(S)] (Nursing Management Of) policy, revised 02/04, documents Resident Care Plan: 1. Identify problem of seizures and underlying cause if known. 2. Establish measurable goal for [CONDITION(S)] control. 3. Medication as ordered. Provide calm environment. Avoid stimuli that cause seizures. Airway at bedside as needed. Observe at frequent intervals. Pad side rails and head of bed. Monitor blood level of medication. R3's medical record documents a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's current care plan does not include R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's medical record, dated 8/1/22, documents, Loud scream was heard from the residents room, this nurse and CNA (Certified Nursing Assistant) went to check on the resident, resident was found on the floor on a kneeling position with head bent down. Resident was assisted to the wheelchair and resident seizing after sitting on the wheelchair. It lasted for nine minutes. After regaining consciousness, resident was assisted to bed and oxygen was administered. After three to four minutes, loud noise was heard from resident's room, this nurse went to check on resident and observed resident starting to have a another [CONDITION(S)] which lasted seven minutes. Ambulance was called and arrived to facility and transported resident to hospital for further evaluation. R3's medical record, dated 8/22/22, documents, New orders per Advanced Practice Nurse (APN) -Neurological consult for increased [CONDITION(S)] activity per power of attorney's request. Orders processed scheduling notified. R3's medical record, dated 9/03/2022, documents, Resident observed on floor by the east side nurses station. When asked what resident was trying to do she states she feels sick. Resident appeared to be anxious and pre-[CONDITION(S)] like activity noted. No injuries noted. Resident assisted back to wheelchair then to bed. As needed [MEDICATION(S)] given for [CONDITION(S)] like activity. On 9/17/22 at 10:00 AM, V3, Assistant Director of Nursing (ADON), verified R3's bed does not have a bolster mattress or padded side rails and headboard. On 9/17/22 at 11:05 AM, V2, Director of Nursing (DON), verified R3's care plan does not address her seizures and stated, I don't know why (R3)'s [CONDITION(S)] precautions never made it to the care plan. It should have been on there because she's been here a while.

Based on observation, interview, and record review, the facility failed to implement identified fall interventions and [CONDITION(S)] precautions for one resident (R3) out of three resident reviewed for falls in sample of three. Findings include. The facility's [CONDITION(S)] (Nursing Management Of) policy, revised 02/04, documents, Resident Care Plan: 1. Identify problem of seizures and underlying cause if known. 2. Establish measurable goal for [CONDITION(S)] control. 3. Medication as ordered. Provide calm environment. Avoid stimuli that cause seizures. Airway at bedside as needed. Observe at frequent intervals. Pad side rails and head of bed. Monitor blood level of medication. R3's medical record documents a diagnosis of seizures. R3's current care plan does not address R3's seizures and precaution to take to ensure resident safety. R3's current care plan documents, Problem: Resident at risk for falling related to weakness, impaired cognition and new environment. (R3) has a diagnosis of spastic diplegic [CONDITION(S)] which results in spastic, uncontrolled, or unintentional overly exaggerated movements at times. Approach: staff to utilize two assist with resident when transferring with the stand aide, to ensure safety. Educate CNA (Certified Nursing Assistant) on proper transfer methods and how to find transfer status in matrix. non-slip pad put in chair. Non-slip placed under and on top of wheelchair cushion. Approach: Sent to hospital for evaluation due to increased [CONDITION(S)] activity. R3's medical record, dated 7/21/22, documents, called to room by CNA (Certified Nursing Assistant). upon entering room resident was lying on her back in front of her wheelchair with head resting on legs of wheelchair. pad from seat of wheelchair was under her head. looks like she slid herself off the seat to the floor. Range of motion and neurological check within normal limits for this resident. no complains of discomfort related to fall. R3's medical record, dated 8/1/22, documents, Loud scream was heard from the residents room, this nurse and CNA went to check on the resident, resident was found on the floor on a kneeling position with head bent down. Resident was assisted to the wheelchair and resident seizing after sitting on the wheelchair. It lasted for nine minutes. After regaining consciousness resident was assisted to bed and oxygen was administered. After three to four minutes, loud noise was heard from resident's room, this nurse went to check on resident and observed resident starting to have a another [CONDITION(S)] which lasted seven minutes. Ambulance was called and arrived to facility and transported resident to hospital for further evaluation. R3's medical record, dated 9/03/2022, documents, Resident observed on floor by the east side nurses station. When asked what resident was trying to do she states she feels sick. Resident appeared to be anxious and pre-[CONDITION(S)] like activity noted. No injuries noted. Resident assisted back to wheelchair then to bed. As needed [MEDICATION(S)] given for [CONDITION(S)] like activity. On 9/17/22 at 9:15 AM, R3 was sitting in dining room. R3 is in a standard wheelchair with no modifications, no anti-rollback bars, and without a non-slip pad under her. On 9/17/22 at 9:55 AM, V5, CNA, stated, I used the sit to stand to transfer her by myself. I'm the only one working this hall today. My help just got here. She's agency. On 9/17/22 at 10:00 AM, V3, Assistant Director of Nursing (ADON), verified R3's bed does not have a bolster mattress or padded side rails and headboard. On 9/17/22 at 10:05 AM, V3, ADON, with the aid of another staff member, observed lifting R3 out of her wheelchair with a sit to stand device. There are no non-slip pads in R3's wheelchair. V3, ADON, verified R3 did not have a non-slip pad on her wheelchair and stated, She's supposed to have one. The staff are also supposed to use a two person assist with (R3) when using the sit to stand.

Based on observation, interview, and record review, the facility failed to maintain a clean kitchen including can openers, refrigerators, ovens and fans; failed to label and or discard food items as needed, and failed to keep scoops out of food bins. This has the potential to affect all 90 residents living in the facility. Findings: The Food Storage and Labeling Policy, dated 10/21, states Keep all food covered in a resealable bag or container or the original container if applicable. Discard any food item past it's use by date or expiration date. Do not store any utensil in a container of food. The label should include: Product Name; Date; Discard Date; Staff Initials. Items left in their original containers should say Opened with the date. Gallons of milk should be labeled by the Open Date. The discard date is within seven days of the open date. If the expiration date is less than seven days, the milk should be discarded on the expiration date. All staff are responsible for monitoring and discarding outdated items. The Sanitation and Safety Policy, dated 9/10, stated, Can openers shall be cleaned daily. Stove tops will be cleaned daily as well as monthly. Refrigerators and Freezers will be cleaned on an assigned schedule. Foods under refrigerators and in freezers shall be inspected daily. Foods shall be labeled and dated. Once a week food will be removed from shelves which are cleaned with detergent. A cleaning schedule will be developed and posted by the (Dietary Manager) and posted. The schedule will include all items to be cleaned as used, on a daily, weekly or monthly basis. It will include the staffs name and will be checked when cleaned. On 9/12/22 at 10:05 AM, the outside and inside of the coolers, ovens, and storage drawers, had splashes, crumbs, and a build up of unknown food debris. The door handles were sticky. The grease pans under the range had not been emptied, one of the drawers would not open because of a build up of grease. Both large manual can openers had a black sticky, gooey substance, including on the table base. The wall fan that blows over a food preparation area had grime and dust hanging on the blades. The window air conditioner, located by the three compartment sink, has dust on the area where air blows out of the appliance. The air conditioner did not fit flush with the window frame, and there is one and a half inch by one half inch area open directly to the outside. Large scoops were in the large storage bins containing flour, sugar and oats. A gallon of skim milk that was in the milk cooler had a use by date of 9/03/22. The walk in cooler had two opened five pound bags of lettuce with 50 % used. The appearance of the lettuce was a darker green, watery and slimy. One bag of lettuce had no open date, and the other was dated 9/05/22. An opened 16 ounce bag of whipped topping, with 50 % used was not labeled. Four boxes containing two, 10 pounds each of hamburger, and, four, eight to ten pound raw turkey breasts thawing, were stored on a shelf above a 20 pound smoked, ready to eat ham, three 15 pound cases of bacon and two 10.7 pound boxes of peeled boiled eggs. The reach in cooler at the door by the dining room contained an opened 46 ounce container of undated or labeled tomato juice; one pound remaining of a five pound bag of shredded cheddar cheese; one pound remaining of a five pound bag of shredded blended cheese, both bags not sealed; Three pounds remaining in a five pound shredded cheddar cheese bag, no label; ten pounds of sliced bulk American Cheese, in a container without any wrapping or lid; six ounces remaining in a 32 ounce package of deli smoked ham, no open date; one half full pan of chicken noodle soup, uncovered and no label; two half pans, one full containing sliced onions and one with one cup of sliced pickles, uncovered, unlabeled;. In the stock room, an opened five pound bag, 50 % remaining of cornbread mix, dated 5/05/22; an opened five pound bag, 50 % remaining of a bag of basic muffin mix, dated 6/07/22, with a brown sticky substance on the outside of the package; and an opened five pound bag white cake mix, no label. On 9/12/22 at 11:10 AM, V1, Administrator, acknowledged the above items which were shown to her. V1 stated, This kitchen will be cleaned up. We have a new Certified Dietary Manager starting who will make sure the kitchen stays that way. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents' Report, form 672, dated 9/12/22 and signed by V2, Director of Nursing, documents at the time of the survey 90 residents live in the facility.

Based on observation, interview, and record review, the facility failed to ensure all staff was wearing required Personal Protective Equipment (PPE) according to Centers for Disease Control (CDC)guidelines. This failure has the potential to affect all 90 residents in the building. Findings include: The facility's COVID-19 policy, dated 1/19/2022, documents the following: The Infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage and isolation of potentially infectious residents. Prevention: 6. All employees must wear a well-fitted face mask while present in resident care areas. Other PPE (personal protective equipment) may be required. The facility's electronic records document R339 and R340 were diagnosed COVID-19 positive on 9/12/2022. On 9/13/2022 from 7:58 AM-8:20 AM and on 9/14/2022 from 9:25 AM-9:35 AM, V6, RN (Registered Nurse) had a face mask on that sat below her nose. On 9/14/2022 at 9:40 AM, V6, RN verified her mask was under her nose, and should be covering her nose. On 9/14/2022 from 9:25 AM- 9:35 AM, V5, LPN, (Licensed Practical Nurse) was sitting in the COVID-19 hallway with her facemask under her nose. On 9/14/22 at 9:35 AM, V4, ICP (Infection Control Preventionist) observed, and verified V5, LPN, was wearing her facemask under her nose while working in the COVID Unit. V5 verified there are two COVID Positive residents on the hall, and R339 and R340 tested positive for COVID-19 on 9/12/2022. V4, ICP stated, (V5, LPN) should have her mask covering her nose, as well as have a gown on.

Based on record review and interview, the facility failed to implement person centered fall prevention interventions and provide supervision to prevent a fall for one resident (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a fall . Findings Include: R1's Admission Nursing Notes, dated 12/3/21, document R1 was admitted to the facility from the hospital for Physical Therapy for strengthening, with plans to discharge to a lower level of care when possible. R1's Fall Risk Assessment, dated 12/6/21, documents R1 is High Risk for falling. R1's Fall Risk Assessment documents a diagnosis of Other symptoms and signs involving cognitive functions following other [CONDITION(S)] disease. R1's MDS (Minimum Data Set) Assessment, dated 12/10/21, documents R1's BIMS (Brief Interview for Mental Status) score of 5 out of 15, indicating severe cognitive impairment. R1's MDS Assessment also documents, Short term memory problem. R1's Care Plan, dated 12/3/21, documents, Staff to educate (R1) to ask for assist with mobility and ADLs (Activities of Daily Living) and Call Light Education. R1's Nurse's Notes, dated 12/14/21, document R1 was found on the floor in R1's room with a large bruise starting to form on the crown/back of R1's head. R1 was sent to the emergency room for evaluation. R1's Hospital Discharge Record, dated 12/15/21, documents, CT (Computed Tomography) Scan shows (R1 has) left Subarachnoid hemorrhage. On 12/22/21 at 9:00 A.M., R1 could not recall ever having a fall, or R1's fall on 12/14/21 specifically. On 12/22/21 at 9:15 A.M., R4 (R1's Room Mate) stated (R1) has been back from the hospital for 8 days now, she does not remember falling. She does not remember anything five minutes after you tell her. On 12/23/21, V3 (Social Services Director) stated, (R1) is severely cognitively impaired. She does not have the ability to retain information. She often times forgets family members names, or that they are her family. On 12/23/21 at 9:20 A.M., V7 (R1's Physician) stated, (R1) can not recall information. If she is told to use a call light multiple times throughout the day, she would still never remember to actually use it and get help before moving herself. She is a very high risk for injury because she no longer has safety awareness at all. On 12/23/21 at 9:40 A.M., V1 (Director of Nursing) stated, Those interventions on R1's Care Plan for falls are not appropriate at all due to her cognition decline.

Based on interview, record review and observation the facility failed to provide pain medication for two of 26 (R96 and R209) residents reviewed for pain management in the sample of 53. This failure resulted in R96 and R209 enduring pain at a severe level without timely intervention. Findings include: The facility policy for Pain Management last revised 9/2010 documents, The facility is dedicated to the philosophy that all residents should be as free from pain as possible, through a combination of medical interventions and functional therapy. The purpose: to identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve symptoms. Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in the resident's condition. A standardized 0-10 scale or Verbal Descriptor Scale will be utilized to determine pain intensity. 1. On 8/8/2019 at 11:20AM V16 License Practical Nurse (LPN) prepared to change a dressing to R96's right heel. V22 Certified Nurse Aide (CNA) held up R96's lower leg as V16 removed the soiled dressing. R96, who was lying in bed, pulled the covers up to her mouth and stated, It hurts when this is done then she started to moan and cry. V16 stated, I know, I will try not to hurt you. V16 stated, We are going to clean it now. R96 started to grimace cried out and pulled her foot away from the nurse when V16 cleansed her wound with the gauze and saline solution. V16 stated to R96, You poor thing. R96 stated, You are patting that awful hard as V16 patted the wound bed. V16 stated, I'm sorry. We are going to put some medicine on it then the worst will be over. R96 cried out No! and continued to cry while V16 finished the dressing change. R96 rated her pain for this surveyor at this point in the process. R96 stated her pain was at an 8. On 8/9/2019 at 12:20 V16 LPN stated, (R96) had a [MEDICATION NAME] for pain at 7:30AM. I guess I could have given her another one before her treatment or some Tylenol. I just didn't think about it. On 8/9/2019 at 9:30AM, V10 (Office Nurse) stated V11 (attending physician) would have ordered pain medication to pre-treat R96's pain before each dressing change if he had known she was experiencing that much pain. 2. On 8/6/19 at 1:30 pm, R209 was lying in bed on her back with head elevated with a distressed grimace to her face. R209 was rubbing her left leg from the upper lateral buttock down to her lateral knee. When questioned regarding her pain R209 stated I always have pain in my left leg. On 8/6/19 at 1:48 pm, R209 stated the facility messed up her pain medication last weekend and her pain was out of control. R209 stated she was told she only had two pills for the whole weekend and was asked how she wanted to take them. R209 stated she was awake all night and not able to eat much due to the pain. R209 stated she has Tylenol she can use in between the [MEDICATION NAME] but stated it does not help much. R209 stated therapy has offered her ice or heat to help with the pain but no one offered that this last weekend. R209 stated her pain ranged from seven through ten throughout the weekend. On 8/6/19 at 3:10 pm, V21 LPN (Licensed Practical Nurse) stated she personally notified the pharmacy that R209 was going to run out of her [MEDICATION NAME] during the weekend and was going to need some. V21 stated she notified pharmacy on Wednesday and Thursday and was off for the weekend and when V21 returned on Monday she noticed that R209's [MEDICATION NAME] had not come in so she called the Doctors office again. The current Care Plan for R209 documents (R209) is at risk for pain related to recent [MEDICAL CONDITION], spinal stenosis, and chronic pain and documents a goal of an acceptable pain level of three. This Care Plan documents the following approaches: Administer pain medication as ordered. Monitor for side effects. Assist resident with non pharmacological pain relief methods (ice, heat, repositioning.) The Physician order [REDACTED]. The Consolidated Delivery Sheets for R209, dated 7/30/19, documents there were 16 [MEDICATION NAME] 5 mg tablets delivered to the facility and as of Friday 8/2/19 at 9:25 pm R209 had five tablets remaining until Monday 8/5/19. The Individual Resident Controlled Substance Record for R209, dated 7/30/19, documents that on 8/2/19 at 9:30 pm there were a total of five [MEDICATION NAME] 5 mg for R209 to receive over the next 56 hours. In order for R209 to receive her [MEDICATION NAME] every four hours, as needed, there would have had to be a total of 14 tablets. The Medication Administration History for R209, dated 7/30/19 through 8/7/19, documents R209's pain scale ranged between 5 and 10 throughout the weekend.

Based on interview and record review, the facility failed to provide incontinence care in a timely manner for one (R85) of seven residents reviewed for incontinent care in a sample of 53. This failure resulted in R85 getting two open areas below the coccyx area. Findings include; Facility Job Description Certified Nurse's Aide (CNA), revised 4/30/18, documents To provide direct resident care as trained and specified in the job training. Assist residents with toileting, grooming, and return residents to bed as assigned, turning and positioning, and answer call lights as needed. Resident Progress Notes, dated 6/22/19, documents Two 1cm (centimeter) open areas noted on bilateral buttocks below the coccyx area. Area cleansed and Duoderm placed over area. R85's wound evaluation and management summary, dated 6/25/19 and 7/16/19, documents Intergluteal fold wound moisture related and Moisture Associated [MEDICAL CONDITION] to the buttocks has deteriorated. Advances in Skin & Wound Care Journal title Diagnosing and Treating Moisture-Associated Skin Damage, dated (MONTH) 2012, documents Perineal [MEDICAL CONDITION], diaper rash, incontinence-associated [MEDICAL CONDITION], or moisture-associated skin damage are all names used to describe damage to skin caused by moisture. Regardless of what the condition is called, this damage is painful and costly. Moisture can come from many sources, including perspiration or wound drainage, but fecal and/or urinary incontinence are the most common causes. R85's MDS (Minimum Data Set), dated 7/9/19, documents R85 is cognitively intact, totally dependent two person physical assist for toileting, extensive two person assist for personal hygiene, has no behavior or mood concerns, and no rejection of cares. R85's current care plan documents full mechanical lift with an assist of two, incontinent of bowel and bladder, and wears extra extra large depends. No documentation on care plan for rejection of cares. R85 TAR (Treatment Administration Record), dated 7/1-7/31/19 and 8/1-8/8/19, documents Venelex ointment three times a day. Dx: Diaper [MEDICAL CONDITION]. On 8/8/19 at 11:45am, R85 stated I put my call light on today at 11am and told them I needed changed. I wear incontinence briefs because I can be incontinent of bowel and urine. The staff came in and shut off my light and told me they would get me when they were finished taking care of someone and I am still waiting sitting in urine. I have a sore on my bottom that gets worse at times when I have to sit for a long time when I am wet. This happens frequently here because they tell me there is not enough staff or if there are only two CNAs scheduled they can't help me if one is on break because I require two to transfer. On 8/8/19 at 12:08pm, R85 was provided incontinence cares by V17 and V18 both CNAs and R85s bottom was bright red and his incontinence brief was soaked with strong smelling urine. On 8/8/19 at 2:00pm, V17 CNA I take care of resident needs depending on what the resident wants, and if they need changed or incontinent then I get to them first. We have an issue with our hoyer lift not holding a battery charge, so we had to wait for the battery to charge before we could get (R85) toileted. We need three CNAs down this hallway (500 hall) but today we do not and the residents have to wait. (R85's) bottom has a sore on his bottom that opens and closes. At that same time, V17 verified R85 had been waiting to get changed since 11am and V17 did not get to R85 until 12:08pm. On 8/8/19 at 2:00pm, V18 CNA stated There is only two of us working this hall and we have to use two people per lift. We try to get to residents as quick as possible but sometimes they have to wait. At that same time, V18 verified R85 was incontinent and had been waiting since about 11am and V18 did not get to R85 until 12:08pm.

Based on interview and record review, the facility failed to drain a chest tube for one of three residents (R1) reviewed for assistive devices/supplies in the sample of four. This failure resulted in R1 developing shortness of breath and being admitted to the hospital for [MEDICAL CONDITION]. Findings include: R1's Emergency Department (ED) record dated 3/3/19 documents the following assessment: 1. Acute on chronic [MEDICAL CONDITION]: Secondary to pleural effusion, possible pneumonia. 2. Bilateral pleural effusions: Left (chest tube) catheter has not been draining for several days now. Chest x-ray shows possible loculation on the left. Skilled nursing facility was unable to drain the right for 2 (two) days as they ran out of bottles. ED documentation on 3/3/19 at 10:03pm documents pulled off 800 cc (cubic centimeters) of fluid. R1's ED chest x-ray report dated 3/3/19 at 9:01pm documents 1. Findings suggesting interval development of a large right pleural effusion, 2. Left bibasilar infiltrate with mild subsegmental atelectasis in right midlung field. R1's Physician order [REDACTED]. Drain right chest tube daily and record output. R1's Treatment Administration Record documents R1's chest tubes were last drained 3/1/19. R1's Progress Notes dated 3/2/19 at 4:13pm document unable to drain right chest tube at this time due to supplies. On 3/03/2019 at 5:39pm, R1's Progress Notes document R1 complained of shortness of breath, oxygen saturation was 83% (per cent) on (six) liters of oxygen per nasal cannula, lung sounds diminished right upper and lower lobe with wheezing noted. 911 called to be transported to (local hospital). On 3/6/19 at 10: 15am, V2, Director of Nursing (DON) stated the drainage system (bottles) to drain R1's chest tube were not available on Saturday (3/2/19) or Sunday (3/3/19). V2 stated V9, (who orders supplies), was told the supply was getting low on Wednesday (2/27/19) and to order more, but she did not. V2 stated we again told V9 to order them on Friday (3/1/19) and have them delivered in 24 hours, but they did not arrive in 24 hours because they (medical equipment provider) do not do 24 hour deliveries on weekends. On 3/7/19 at 12:05pm, V5, Primary Care Physician, stated the failure to drain the chest tube certainly could have exacerbated R1's condition, and if they would have drained the chest tube on time, it would not have happened.

Based on interview, observation and record review, the facility failed to timely respond to a call light and ensure a call light was functioning for a resident that requires toileting assistance for one of three residents (R1) reviewed for falls in the sample of three. On 10/25/18, R1 was placed on the toilet by V4 (Certified Nursing Assistant) and remained on the toilet for an additional 25 minutes, resulting in R1 falling and sustaining a two centimeter [MEDICAL CONDITION]. R1 was then transported to a local hospital for treatment, and received four sutures to repair her [MEDICAL CONDITION]. Finding includes: R1's Brief Interview for Mental Status on the following dates document the following scores, all of which indicate R1 is cognitively intact: On 09/10/18, a score of 15; On 09/25/18, a score of 12; and on 11/02/18, a score of 14. The facility's Accident and Incident Report Log dated 10/23/18 - 10/29/18 documents R1 fell at the facility on 10/25/18 and sustained a laceration requiring sutures, swelling to her right hand, and a bruise to her left heel. R1's Nursing Progress Note dated 10/25/18 documents the following: (R1) observed lying on the floor on her right side, blood noted in front of the bathroom towards the foot of (R1's) bed, (R1) was fully dressed with no shoes or socks on. (R1) stated she was assisted to the restroom, where she had been for an extended amount of time and after yelling for help she decided to transfer herself back to bed when assistance did not arrive. (R1) stated she fell in the bathroom doorway and crawled to bedside. Hematoma with laceration noted to left/midline forehead superior to left eye, moderate amount of blood noted on face, hands, and floor. Injury noted to right index knuckle, thumb and posterior hand. (R1) stated pain in head, right hand, and left foot. Bruising noted to left heel, non[MEDICAL CONDITION] noted to left ankle. 911 called. Resident transported to (local hospital) for stitches and evaluation. Unable to contact Power of Attorney, message left for call back. Nurse Manager on call notified. On 12/03/18 at 03:08 PM, R1 was lying in bed watching television. R1 could recall her recent fall on 10/25/18. R1 stated, She put me on the toilet with that lift, and then left me. I pressed my call light, but no one ever came. I was yelling for help. I waited at least 25-30 minutes, and then decided I was going to get up myself. I ended up falling and hitting my head. R1 then pointed to the left side of her forehead and stated, I had to go to the hospital to get stitches. R1's local hospital emergency department record dated 10/25/18 documents the following: [MEDICAL CONDITION] 2 centimeters. Injected with [MEDICATION NAME] 1% without [MEDICATION NAME]. Cleaned, probed, no foreign body, sutured with 5.0 prolene. 4 sutures simple interrupted placed. Patient tolerated well. These same records document R1 was discharged on [DATE] with the following Diagnoses: [REDACTED]. On 12/04/18 at 10:35 AM, V1 (Administrator) stated that on 10/25/18, V4 (Certified Nursing Assistant) did place R1 on the toilet, then left R1 and provided cares to two other residents. V1 stated that V5 (Certified Nursing Assistant), Took a break during lay down time. Our practice is not to have anyone on break during this time. (V5) was on break at the time of (R1's) fall. V1 then stated that the facility was unable to determine the amount of time R1 remained on the toilet prior to falling. V1 stated When she was found, her call light was on. She said that she thought she could go down to her knees and crawl, but instead, she face-planted. R1's Abuse Investigation dated 10/25/18 documents an investigation was conducted in regards to length of time R1 reported being left on the toilet on 10/25/18, prior to falling. This investigation also documents V4 (Certified Nursing Assistant) received disciplinary action for the following: On 10/25/18, (V4) suspended for improper nursing care with placing resident on toilet and not returning timely. This investigation also documents V5 (Certified Nursing Assistant) was in-serviced on the following: Content discussed CNA (Certified Nursing Assistant) break times. (V5) was educated to not take breaks during increased time of resident cares. Get-up, meal times, and lay down. It was also discussed to continue to notify nurse and fell ow CNA's when taking break. On 12/4/18 at 01:40 PM, V1 (Administrator) stated that she ended up conducting an abuse investigation following R1's 10/25/18 fall because of the time R1 reported she was left on the toilet. We determined there was no willful intent, but V4 (Certified Nursing Assistant) should have stayed within an earshot of (R1) while she was in the bathroom. So after (R1's) fall, we disciplined (V4) and provided education. On 12/03/18 at 03:08 PM, R1 was lying in bed watching television. R1's call light was in reach and tied around the right upper side rail attached to R1's bed. R1 pressed her call light several times, and stated, I need to go to the bathroom. R1 continued to press her call light every few minutes, began to reposition and become restless in bed and stated, I've had my call light on since before 03:00 PM, and I'm going to wet the bed. R1 again pressed her call light several times. On this same date at 03:30 PM, V3 (Assistant Director of Nursing) was notified that R1 had pushed her call light multiple times and had been waiting approximately 30 minutes for toileting assistance. At 03:31 PM, V3 entered R1's room and verified that R1's call light was not working. On 12/3/18 at 03:35 PM, V6 and V7 (Certified Nursing Assistants) entered R1's room, assisted R1 to the bathroom with a sit-to-stand mechanical lift, provided perineal care to R1, and transferred R1 back into bed. V6 stated, The call lights can be temperamental sometimes. On 12/04/18 at 09:00 AM, V3 (Assistant Director of Nursing) stated, This building is old, and sometimes call lights will stop working. They can sometimes be temperamental. We call maintenance, and they come fix them.

Based on observation, interview, and record review the facility failed to provide pressure reduction interventions, provide a skin assessment every week for four weeks after admission, obtain a treatment for [REDACTED]. These failures resulted in R39's stage one pressure ulcer being left untreated, resulting in the stage one pressure ulcer worsening to a stage three pressure ulcer. Findings include: The National Pressure Ulcer Advisory Panel Pressure Injury Prevention Points dated 04/2016 documents, Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury on admission and weekly for fours weeks after admission for long term care residents. Turn and reposition all individuals at risk for pressure injury, avoid positioning the individual on the body areas with the pressure injury, and reposition weak or immobile residents in the chair every hour. The facility's Pressure Injury Prevention and Treatment Protocol dated 07/2016 documents, When a resident is admitted to the facility the following will occur: Assess the pressure injury for location, size, wound bed, drainage, odor, tunneling, wound edges, and pain. Obtain treatment. Assess and measure the pressure ulcer weekly. Stage Three Pressure Injury is a full thickness tissue skin loss with which fat is visible in the ulcer and granulation tissue is often present. A skin risk assessment (Braden Scale Pressure Sore Risk Assessment) is completed on all residents upon admission and weekly for the first four weeks after admission and quarterly thereafter. All high and moderate risk residents may have the following addressed on the care plan: Protein and/or nutritional supplements. Turning and positioning schedule, elbow/heel protectors/bridging of heels. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: Protein Supplement will be put in place. For those residents that cannot reposition themselves, transfer self out of bed, or cannot turn themselves in bed, staff will be responsible. R39's current Face Sheet documents R39 has the [DIAGNOSES REDACTED]. R39's Braden Scale for Predicting Pressure Sore Risk dated 6-12-18, documents is a Moderate Risk for developing pressure ulcers and is chair fast, is unable to bear own weight which requires staff assistance into chair or wheelchair, and is unable to make frequent or significant changes independently with change and body position. R39's Medical Record does not include a Braden Scale Pressure Risk Assessment since admission on 6-12-18. R39's Admission Body assessment dated [DATE] documents R39 has a 2.2 cm (centimeter) firm, red, non-blanchable spot on the left gluteal fold. R39's Medical Record does not include a treatment, pressure relieving interventions, or weekly measurements of the area to the left gluteal fold from admission (6-12-18), until 8-16-18 when it had advanced to a stage three pressure ulcer. R39's Initial Wound Evaluation and Management Summary dated 8-16-18 and signed by V14 (Wound Doctor) documents, (R39) presents with a wound on the left buttock. Stage three pressure wound of the left buttock of at least one day in duration. Etiology: Pressure. Wound size 1.0 cm (centimeters) by 0.4 cm by 0.3 cm. Apply Calcium Alginate once daily for 30 days and foam with border apply once daily for 30 days. Importance of wound off load and compliance with local wound care discussed with rounding nurse. Risk factors: Being confined to a wheelchair, immobility, urinary or bowel incontinence, poor nutrition, decreased sensation around affected areas, and recent surgery/illness. Preventions of a pressure ulcer; Reposition self while in bed at least every two hours and in chair at least every hour, elevate your heels off the bed using a pillow under your lower legs, and use a pressure relieving mattress or a cushion in your chair. R39's physician's orders [REDACTED]. R39's Minimum Data Set (MDS) Section G Functional Status dated 6-19-18, documents R39 is unable to ambulate and requires assistance of one staff for personal hygiene, toileting, transfers, bed mobility, and transfers. This same MDS Cognitive Patterns Section C documents R39 is cognitively intact. R39's Pressure Ulcer Care Plan dated 8-18-18 documents R39 has a stage three pressure ulcer to the left buttock with the following intervention: Assist resident with turning and re-positioning. On 08/19/18 at 09:42 AM and 2:50 PM, R39 was sitting up in the wheelchair with direct pressure to the left buttock pressure ulcer. R39 stated, I have had a sore on my bottom for about one week. I think the sore is from sitting up too long in my wheelchair. The staff does not really ask me to lay down off of the sore. On 08/20/18 at 8:45 AM, 10:30 AM, 12:00 PM, and 01:45 PM, R39 was sitting up in the wheelchair with direct pressure to the left buttock pressure ulcer. On 08/20/18 at 01:46 PM, V9 (Licensed Practical Nurse/LPN) provided wound care to R39's left buttock pressure ulcer. R39's left buttock pressure ulcer had a beefy red center with a white tissue surrounding and was draining a moderate amount or yellowish/pink drainage. V9 measured the wound being 2 cm (centimeters) by 1 cm by 0.5 cm depth. On 08/20/18 at 01:50 PM, V8 (CNA/Certified Nursing Assistant) stated, (V10/CNA) and myself are taking care of (R39) today. I am not sure what time (R39) got up today. I have not re-positioned (R39) out of the wheelchair or offered (R39) to lay down today. I am not sure if (R39) is to be re-positioned. I don't work with (R39) enough to know if (R39) needs re-positioned. I have not asked (R39) to lay down today. (R39) has been in the wheelchair since this morning. On 08/20/18 at 01:52 PM, V9 (Licensed Practical Nurse) stated, (R39) needs to be laid down off of the pressure ulcer, or the pressure ulcer will worsen, or R39 will develop additional pressure ulcers. (R39) has been up in the wheelchair since sometime this morning around breakfast. I have never known of (R39) refusing to lay down or re-position. On 08/20/18 at 02:07 PM, V10 (CNA) stated, I got (R39) up in the wheelchair around 7:15 AM today. I have not asked (R39) to lay down since 7:15 AM this morning. (R39) has been up in the wheelchair since 7:15 AM. On 08/21/18 at 11:19 AM, V3 (Assistant Director Of Nursing/ADON) stated, A Braden Skin Assessment is suppose to be done on admission and then weekly for the first four weeks. (R39) only had a Braden Skin Assessment done on admitted d 6-12-18. (R39) has not had a Braden Skin Assessment done since admission. (R39's) Stage three pressure ulcer was caused from pressure to the left buttock and could have been prevented had the Braden Skin Assessment been done and pressure relieved. (R39's) pressure ulcer should have been treated before it progressed to a stage three. (R39's Spouse) found the pressure ulcer on 8-16-18 and reported the wound to the nurse. (R39) should be turned and re-positioned every two hours out of the wheelchair. A dietician has not assessed (R39's) pressure ulcer and nutritional risks yet. On 08/21/18 at 02:08 PM, V14 (Wound Doctor) stated, (R39's) wound to the left buttock was due to pressure from sitting in the wheelchair too long. (R39) should be laid down to bed after every meal and at least every two hours, and (R39) should be positioned to the right side to keep pressure off of the wound. Pressure was the only contributing factor to the pressure ulcer development. On 8/22/18 at 2:55 p.m., V3 (ADON) stated, (R39) was admitted on [DATE] with a stage one pressure ulcer. The admission assessment wasn't marked as being a pressure ulcer, however the description of a non-blanchable area is a stage one pressure ulcer. It was not until 8/16/18 that they (facility staff) obtained a treatment order for the pressure ulcer, and it is now a stage three. Nothing was done with the stage one pressure ulcer when (R39) was admitted until 8/16/18.

Based on interview and record review, the facility failed to monitor and establish control of severe pain following a fall with suspected fracture for one of 16 residents (R69) reviewed for accidents in the sample of 27. These failures resulted in R69 experiencing uncontrolled severe pain for over 20 hours before receiving treatment/surgical repair for a left [MEDICAL CONDITION]. Findings include: The facility's Pain Management policy, dated 9/2010, documents, The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. The policy also documents, Purpose: To identify resident experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms. Residents will be monitored until pain is resolved or is under control and periodically thereafter. The facility's Emergencies policy, dated 4/3/18, documents, Immediate care of the Resident: Falls: Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives. The policy also documents, Acute Trauma: Fractures: Immobilize the joint above and below the fracture. Elevate extremity. Apply Ice. Notify doctor. Transport to hospital. Notify family. R69's Progress notes, dated 7/14/18 at 6:58 a.m., document, At 9:57 pm certified nursing assistants alerted this nurse that R69 was on floor in bathroom. Upon arrival, R69 was noted to be on her knees leaning over toilet while playing with the toilet water. Weight noted on left knee. R69 denied pain at that time and just wanted to be picked up off of the floor. R69 did complain of usual back pain prior to fall, however, res began to complain of left hip and left upper leg pain at 11:10 pm. R69 refusing to straighten out her left leg due to pain. No rotation noted. Unable to assess if there is shortening due to her position. Upon attempt to straighten out R69's left lower extremity, R69 screamed out in pain and moved back to bent position. R69 did not sleep at all throughout the night and continued to complain of pain. X-ray ordered at 11:27 pm for left hip and left femur to rule out injuries. As needed Tylenol administered between scheduled [MEDICATION NAME] doses. R69's Progress notes, dated 7/14/18, 3:42 p.m., documents, R69 complains of pain upon moving left leg. R69's Progress notes, dated 07/14/2018 06:17 PM, document, Mobile x-ray here x-rays completed. R69's Progress notes, dated 07/14/2018 08:30 PM, document, Hip X-Ray results = Left hip/pelvis-There is no prior study available for comparison. There is narrowing of the hip compartment consistent with [MEDICAL CONDITION]. There is an impacted acute or subacute subcapital [MEDICAL CONDITION] with varus alignment at the hip. Conclusion: [MEDICAL CONDITION]. 8:45 pm V3 (Assistant Director of Nursing) on call notified. 8:50 pm Power of Attorney notified of fall and x-ray results. Agreed to send to emergency room for evaluation and treatment. Message left for return call from doctor calling services. 911 notified of need for transport. R69's Medications Administration History, dated 7/1-7/31/18, documents that on 7/13/18's pain assessment severe pain to R69's left lower extremity was documented, and on 7/14/18's pain assessment pain at the level of a 9 all over was documented. The Medication Administration History also documents that R69 received a scheduled [MEDICATION NAME] 12 mcg (microgram)/hr (hour) patch on 7/13/18, from the time of the fall to being sent to the emergency room two scheduled doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 mg (milligrams) one tablet were administered, and two doses of as needed Tylenol 650 mg were administered on 7/13/18 at 11:04 p.m. and 7/14/18 at 7:23 a.m. The as needed dose at 11:04 p.m. was administered for general pain, and the 7:23 a.m. dose was administered for pain at the level of a 9 all over. Both as needed doses document the as needed results of the medication were not effective. R69's Progress notes, dated 07/15/2018 at 11:26 AM, document, Called local hospital R69 admitted , she will have surgery tomorrow for left [MEDICAL CONDITION]. R69's Serious Injury Incident Report, dated 7/18/18, documents, On 7/13/18 at approximately 9:57 p.m., R69 dementia resident who is one assist transfer attempted to self toilet was noted on her knees in her bathroom. During Initial Assessment, R69 had no complain of pain and wanting to go back to bed and was assisted by staff. Doctor notified, and left message for Power of Attorney. During another assessment around 11:00 p.m., R69 started to have complaint of pain to left hip region and documented limited ROM. X-ray order per standing orders. Results noted left fracture acute/subacute subcaptial region. POA answered and notified and doctor notified of X-ray results. R69 sent to hospital where she was admitted and had surgery scheduled for 7/16/18. R69's Emergency Report, dated 7/14/18, documents, Hip Injury Pain. Complaint injury. Onset 16 hours ago at the nursing home. R69's Operative Report, dated 7/16/18, documents, Pre-operative Diagnosis: [REDACTED]. Procedure: Left hip hemiathroplasty. On 8/22/18 at 1:15 p.m., V23 stated, I came in that morning (7/14/18) and the nurse told me that R69 had a fall the previous night. Then, we got her up for lunch because she wanted out of bed. She would complain when her left leg was moved. She was up in her wheel chair/ and she was toileted by staff. If we suspect a fracture after a fall it just depends if we send them out or not. I wasn't aware that the policy said if fracture is suspected to send to emergency room . On 8/22/18 at 1:30 p.m., V21 (Certified Nursing Assistant) stated, (R69) was complaining of pain more (7/14/18) than usual especially when (R69) was moved. On 8/22/18 at 1:30 p.m., V26 (Certified Nursing Assistant) stated, (R69) was in a lot of pain that next morning (7/14/18) with any kind of movement. We got her up for breakfast and lunch. We were also taking her to the restroom. She was a two person gaitbelt stand pivot transfer. She was babying and favoring that left leg. She would grab and guard her left hip saying 'oh oh' when we would move her. On 08/22/18 at 09:15 AM, V2 (Director of Nursing) stated, If R69's X-ray was ordered at 11:27 pm it should have been a stat X-ray that should be done within 4 hours especially with the increased pain. They should not have waited that long we could have sent her in to the emergency room for pain relief. On 08/21/18 at 09:49 AM, V19 (R69's Nurse Practitioner) stated, If the facility got the order to x-ray (R69's) hip around 11:00 pm I would have expected them to get the x-ray done within the hour not at 6:00 pm the following night especially with it actually being fractured. (R69) had to have been in pain.

Based on interview and record review, the facility failed to obtain an x-ray in a timely manner following a fall with suspected fracture for one of 16 residents (R69) reviewed for accidents in the sample of 27. This failure resulted in R69 waiting 19 hours to have an x-ray completed and receive emergency care/surgical intervention for a [MEDICAL CONDITION] hip. Findings include: R69's Progress notes, dated 7/14/18 at 6:58 a.m., document, At 9:57 pm Certified Nursing Assistants alerted this nurse that R69 was on floor in bathroom. Upon arrival, R69 was noted to be on her knees leaning over toilet while playing with the toilet water. R69 denied pain at that time and just wanted to be picked up off of the floor. R69 was resting in bed sleeping. R69 did complain of usual back pain prior to fall, however, R69 began to complain of left hip and left upper leg pain at 11:10 pm. R69 was refusing to straighten out her left leg due to pain. Upon attempt to straighten out left lower extremity, R69 screamed out in pain and moved back to bent position. R69 did not sleep at all throughout the night and continued to complain of pain. X-ray ordered at 11:27 pm for left hip and left femur to rule out injuries. R69's Radiology Order, dated 7/13/18 at 11:27 p.m., documents an order was obtained to x-ray R69's left hip and femur for pain. R69's Progress notes, dated 07/14/2018 06:17 PM, document, Mobile x-ray here x-rays completed. R69's Radiology Report, dated 7/14/18, documents, There is an impacted acute or subacute subcapital [MEDICAL CONDITION] hip with varus alignment at the hip. Conclusion: [MEDICAL CONDITION]. R69's Progress notes, dated 07/14/2018 08:30 PM, document, Conclusion: [MEDICAL CONDITION]. 8:45 pm V3 (Assistant Director of Nursing) on call notified. 8:50 pm Power of Attorney notified of fall and x-ray results. Agreed to send to emergency room for evaluation and treatment. Message left for return call from doctor calling services. 911 notified of need for transport. R69's Emergency Report, dated 7/14/18, documents, Hip Injury Pain. Complaint injury. Onset 16 hours ago at the nursing home. R69's Operative Report, dated 7/16/18, documents, Pre-operative Diagnosis: [REDACTED]. Procedure: Left hip hemiathroplasty. On 08/21/18 09:26 AM, V23 (Licensed Practical Nurse) stated, If we order a stat x-ray they are here immediately but otherwise it just depends on how busy they are. With (R69) falling and having concerns of a possible broken hip it should have been a stat x-ray. On 08/22/18 at 09:15 AM V2 (Director of Nursing) stated, If (R69's) X-ray was ordered at 11:27 pm it should have been a stat x-ray that should be done within four hours, especially with the increased pain. They should not have waited that long. We could have sent her in to the emergency room . On 08/21/18 at 09:49 AM, V19 (R69's Nurse Practitioner) stated, If the facility got the order to x-ray (R69's) hip around 11 pm I would have expected them to get the X-ray done within the hour not at 6 pm the following night, especially with it actually being fractured.

Based on record review and interview, the facility failed to utilize foot pedals on a wheelchair to prevent resident injury for one of one residents (R1) reviewed for a fracture, in a sample of four and failed to ensure residents were monitored by staff during toileting and investigate a resident fall, for one of two residents (R2) reviewed for falls, in a sample of four. This failure resulted in R1's right foot getting caught under a wheelchair, causing a right femur fracture. Findings include: 1. The Electronic Medical Record documents that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/19/15, Progress Notes document R1 complained of left knee pain and R1's (foot).had got caught under the wheelchair while it was moving. A Radiology Report, dated 5/19/15 documents an X-ray of left knee was obtained. On 5/25/15, a Radiology Report documents left knee medial fracture concyle fracture around a total knee arthroplasty component.difficult to appreciate if a new fracture or callous formation of old fracture. On 5/20/15, the physician's orders [REDACTED]. On 5/21/15, Progress Notes document E3 (Certified Nurse Aide/CNA) was pushing R1 in wheelchair down the hallway, when R1 lowered his right foot to the floor causing his right foot to be pulled under the chair. Progress Notes document an x-ray of the right knee was ordered, due to R1's complaint of pain. A Radiology Report of the right knee, dated 5/21/15, documents R1 sustained an acute right femoral sopracondylar fracture. On 6/10/15 at 1:05 p.m., E3 (CNA) stated (E3) was assisting R1 on 5/21/15, by pushing him in his wheelchair with the left leg elevated on a pillow on a foot pedal. E3 stated that there was not a pedal placed on the right side of wheelchair at that time. E3 confirmed that R1 dropped his right foot while (E3) was pushing the wheelchair, pulling the right foot underneath. E3 stated (E3) was not fully aware of circumstances of R1's incident on 5/19/15, in which R1's left foot was caught under the wheelchair. E3 stated, had I been aware of incident, I would have put a pedal on right side of (R1's) wheelchair. On 6/11/15 at 9:45 a.m., E2 (Director of Nurses) stated if a resident is known to have problems with their feet dropping to floor while being pushed in a wheelchair, it would be better to have pedals on the wheelchair. At 11:45 a.m., E2 stated all staff were inserviced on 5/27/15 regarding the need to place foot pedals on a wheelchair, when a resident is being pushed by staff to ensure resident safety. An Inservice Education/Meeting Report, dated 5/27/15, document staff were reminded that Residents who cannot propel themselves in their wheelchairs need to have foot pedals placed on their wheelchairs before being escorted. Residents who are determined to be independent in propelling themselves in their wheelchairs need to complete task independently. If the independent resident asks for assistance, then foot pedals are to be placed before assisting the resident. 2. The Electronic Medical Record Admission Summary documents R2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Minimum Data Set, dated dated [DATE], documents R2 requires the extensive assist of one staff while toileting. The current Plan of Care, dated 3/31/15, documents R2 is high risk for falls, related to weakness, cognitive impairment, Psychiatric Medication use, anxiety and requiring staff assistance to transfer. The Plan of Care also identifies R2 as being non-complaint with transferring at times. An Event in the Electronic Medical Record, dated 5/27/15, documents, Resident reported that she fell back onto the toilet in attempt to self-transfer to the wheelchair. Resident has a 5 cm (centimeter) round bruise on the left hip. The Electronic Medical Record did not contain documented evidence of an investigation into R2's 5/27/15 fall. On 6/10/15 at 2:34 p.m., E2 (Director of Nursing) stated the facility did not consider the 5/27/15 incident involving R2 an actual fall. E2 stated R2 had informed staff that R2 had partially stood up, in attempt to transfer self back to the wheelchair, and then went back down onto the toilet seat, causing her hip to bruise. E2 stated the fall was unwitnessed, because staff were going back and forth between residents and left (R2) alone on the toilet. E2 stated she had no documented statements or written investigation regarding the fall, other than the identification of the left hip bruise. According to E2, R2's current Plan of Care did not document any new fall prevention interventions after the 5/27/15 incident since it wasn't treated as a fall. The facility policy, titled Accident and Incident Report, documents in the event of an accident involving a resident, staff are required to document on Form-137 (Resident Accident & Incident Reports), as well as in the Nurses Notes.