Every finding on record at Pleasant View Luther Home

Based on interview and record review, the facility to ensure licensed staff dispensed physician-ordered medications for one of three residents (R1) reviewed for medication administration in a sample of three. Findings include: The facility's Medication Administration General Guidelines, dated 02/26, documents that medications are administered as prescribed in accordance with the manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. This form also documents that medications are prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state regulations to prepare medications. V4's, Certified Nursing Assistant, Termination Detail, dated 4/16/26, documents involuntary gross misconduct and breach of policy/procedures. V5's, Registered Nurse, Termination Detail, dated 4/16/26, documents involuntary gross misconduct for termination.R1's current Physician Order Sheet documents that R1 can take Tylenol (analgesic) 325mg 2 tabs every six hours as needed for pain. V1's, Administrator, Interview Notes, dated 4/16/26 at 10:55am, documents that V5 was asked if she had ever given a medication to a CNA (Certified Nursing Assistant) to administer. V5, Registered Nurse, stated yes the other night when (R4) was in pain. V5 gave a Norco to ( V4) to give to him (R4). Asked (V5) what she was doing and why she did not give the med herself. (V5) stated that she was on the phone with the pharmacy. (V1) asked if there were any other times that she had given a medication to a CNA to administer, and she said yes, it was months ago when she had a gas leak at her apartment. She gave (V4) a Tylenol for (R1). This form documents that V5 was notified that it was not OK to give a CNA any medication to administer, that they are not licensed to do so, and that this was a huge policy violation, along with putting her own license at risk.On 5/12/26 at 2:00pm, V4, Certified Nursing Assistant, stated that V5, Registered Nurse, handed her a cup with two pills in it to give to R1. V2 stated that she thought that it was 2 Tylenol (analgesic). V4 stated that V5 was busy with another resident and could not get to R1, so she gave her the medications to help V5. V4 stated that she also gave another resident pain medication, but could not remember who the resident was. On 5/12/26 at 2:30pm, V1, Administrator, stated that it was brought to her attention that V5 gave V4 medications to pass. V1 stated that she spoke with V5, and she confirmed that she gave V4 Tylenol to give to a resident. V1 stated that V5 told her that she was on the phone with the pharmacy and could not get away to give R1 her medications, so she had V4 give them to her. V1 verified that both V4 and V5 were terminated for gross misconduct.

Based on observation, interview and record review, the facility failed to ensure refrigerator and freezer temperatures were monitored and expired food products were discarded and not available for resident use. This failure has the potential to affect all residents who reside in the facility with a current census of 68 residents. Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 1/27/26, were reviewed. The Census Roster documented 68 Residents resided in the Facility.The Storage Procedures policy documents refrigerated storage temperature will be at 41 degrees Fahrenheit or below and frozen storage temperatures will be 0 degrees Fahrenheit or below. Temperatures will be recorded on the refrigerator and/or freezer log at least twice daily. The Date Marking policy dated 11/20/25 documents items will be marked using the attached food shelf life and dating guidelines. If a food hasn't been opened check the manufacturers date to ensure it hasn't expired. If expired discard and report to manager. The Ice Cream Freezer Temperature Log dated 09/2025, 11/2025, 12/2025 and 01/2026; the 3 Door Freezer Temperature Log dated 10/2025; the Beverage Cooler Temperature Log dated 09/2025, 10/2025 and 01/2026; and the Dairy Cooler Temperature Log dated 09/2025, 10/2025, 12/2025 and 01/2026 were not completed twice daily. During the initial tour on 1/27/26 at 10:45 AM, the refrigerator/cooler in the dish storage area contained four Ready Care thickened Orange Juice 46 fluid ounces per container. Three of the containers expired 2/2/26 and one expired 11/27/25. On 1/27/26 at 11:05 AM, V9 (Dietary Manager) agreed the logs were not completed twice daily and should have been. On 1/29/26 at 2:30 PM, V1 (Administrator) stated all 68 residents that reside in the facility have diet orders and consume food stored and prepared by the facility.

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 4 of 6 residents (R3, R19, R40, R55) reviewed for transmission based precautions in a sample of 33.The facility's Enhanced Barrier Precautions (EBP) Policy, dated 4/15/2025, documents EBP refers to an infection control intervention that employs targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug resistant organisms (MDROs). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are to be posted on the door or wall outside the resident room indicating the type of precautions and (Personal Protective Equipment) PPE required as well as ensure PPE is available outside of the resident rooms. 1. R3 is an [AGE] year-old resident admitted to the facility on [DATE] with a diagnosis of Displaced Intertrochanteric Fracture of Left femur with surgical intervention on 1/2/26. On 1/29/26 at approximately 1:35pm clear signage with instructions for Enhanced Barrier Precautions was posted outside R3's room including the use of protective gowns when providing close contact cares. PPE/Personal Protective Equipment was present in a cabinet marked PPE inside R3's door stocked with protective gowns, gloves and masks for use by staff and visitors. The facility's January Wound List identifies R3 has an in-house acquired Stage 3 sacral area pressure ulcer. R3's current Physicians Order Sheet includes the following wound care orders for R3's Stage 3 Pressure ulcer dated 1/27/26 by V18/Wound Care Physician: Coccyx-cleanse with wound cleaner, pat dry, apply calcium alginate with silver over open area, cover with foam dressing every 6 hours as needed for wound care. On 1/29/26 at approximately1:50pm V8 RN/Registered Nurse and V12 CNA/Certified Nursing Assistant entered R3's room without donning protective gowns. V12 turned R3 in bed and held R3 on her side while V8 performed wound care for R3's Stage 3, right sacral pressure. The pressure ulcer measured approximately 1.5cm long by 1.5 cm wide and o.1 cm deep with a wound bed of approximately 20% slough (non-viable yellow tissue) and 80% granulation tissue. V8 removed the dressing, with moderate serous drainage, sprayed the wound with wound cleanser, patted the area dry, placed the medicated dressing over the wound followed by a foam dressing. On 1/29/26 V4 LPN/Licensed Practical Nurse stated EBP includes the use of protective gowns when performing pressure ulcer wound cares for R3. 2. R19 was admitted on [DATE] with diagnoses of Hypoxemia, Urinary Tract Infection, Hematuria, Severe Sepsis, Chronic Atrial Fibrillation, Obstructive and Reflux Uropathy and Presence of Urogenital Implants. R19's Baseline Care Plan dated 1/16/26 documents R19 has an indwelling urinary catheter. On 01/27/2026 at 10:30 AM, R19 was observed to have an indwelling urinary catheter. R19's room did not have an Enhanced Barrier Precaution sign nor Personal Protective Equipment available for use. On 1/27/26 at 10:33 AM, V11 (R19's family member) stated staff did not wear gowns when conducting cares including catheter cares. 3. R55 was admitted on [DATE] with diagnoses of Retention of Urine, Gross Hematuria, Severe Protein-Calorie Malnutrition, Esophageal Obstruction, Unstable Angina, Malignant Neoplasm of Prostate Obstructive Uropathy and Urogenital Implants. R55's Current Care Plan documents R55 has an indwelling urinary catheter. On 01/27/2026 at 10:00 AM, R55 was observed to have an indwelling urinary catheter. R55's room did not have an Enhanced Barrier Precaution sign nor Personal Protective Equipment available for use. On 1/27/26 at 10:05 AM, R55 stated staff did not wear gowns when conducting cares including catheter care. On 1/29/26 at 2:30 PM, V2 (Director of Nursing) stated R19 and R55 should have had a Physician's Order for Enhanced Barrier Precautions (EBP), staff should have utilized EBP's during cares and an Enhanced Barrier Precautions sign should have been posted at the resident's door and Personal Protective Equipment available for staff use due to having an indwelling urinary catheter. 4. R40's skin/wound note, dated 1/2/2026 at 6:45pm, documents R40 has a tissue growth on their left buttock. The tissue growth appears to have opened and is red and beefy in appearance and is draining a yellow tinted fluid. R40's hospice nurse gave orders to cleanse the wound with wound cleaner, pat dry, and apply a bordered foam bandage. R40's Hospice Updated Comprehensive Assessment Encounter, dated 01/06/2026, documents R40 has a partial thickness wound to her left buttock measuring 2cm (centimeters) by 2.5 cm by 0.3cm. The encounter also documents the wound was identified on 1/6/2026. R40's skin/wound note, dated 1/20/2026 at 7:39pm, documents R40's wound has yellow drainage and foul-smelling odor. R40's skin/wound note, dated 1/21/2026 at 9:47am, documents resident has wound on left buttock which is beefy red and has not changed in size. The wound has foul smelling drainage. R40's skin/wound note, dated 1/21/2026 2:57pm, documents R40 has new order for this wound. Augmentin (antibiotic) 500-125mg (milligrams) 3 times daily by mouth. On 01/27/2026 at 12:30 PM, R40's door did not have EBP signage posted nor any PPE readily available in or outside of R40's room. On 1/28/2026 at 1:20pm, R40 had a circular shaped open area on R40's left buttock. The open area had a beefy dark red wound bed. On 01/27/2026 at 12:35 PM, V5, RN (Registered Nurse) stated R40 has a wound on her left buttock that is actively draining, and she is currently receiving an antibiotic for a potential wound infection. When V5 is doing R40's wound care, V5 only utilizes gloves for PPE and does not wear an isolation gown. V5 also stated R40 should be on EBP because of the wound and she should have PPE outside her door and EBP signage on her door, however, she does not. On 1/29/2026 at 2:30pm, V2 (Director of Nursing/Infection Preventionist), confirmed (R19, R40, R55) should be on EBP.

Based on interview and record review, the facility failed to ensure a psychotropic medication was necessary based on an appropriate diagnosis, associated behaviors, non-pharmacological intervention were care planned nor was the resident or resident representative informed in advance of the risks and benefits the medication, the treatment alternatives or other options for 1 of 6 residents (R61) who receive psychotropic medications.Findings include:The Psychotropic Medication Management System policy, dated 10/26/22, documents a psychotropic drug includes anti-depressants. Behavior monitoring involves identifying behaviors, the number of behavior episodes and success of interventions. A care plan is developed to reflect specific non-pharmacological approaches to care to meet the individual needs of a resident. Prior to administration of a psychotropic medication, the following must be documented: any new antipsychotic medication order will be discussed and reviewed by the Interdisciplinary Team; must have an appropriate supporting diagnosis as an indication for use; target behaviors will be identified with supporting documentation; environmental modifications and non-pharmacological approaches; consent for the medication; and a plan of care will include treatment goals, evaluation of any precipitating factors and non-pharmacological interventions.R61 was admitted on [DATE] with diagnoses of Muscle Weakness, Need for Assistance with Personal Care, Lack of Coordination, Repeated Falls, Parkinson's Disease, Dyskinesia, Hematuria, Generalized Anxiety Disorder, Insomnia and Malignant Neoplasm of Prostate. The Minimum Data Sets dated 6/17/25, 9/9/25 and 12/2/25 documents in section I that R61's mood assessment scored a 00 (no depression) therefore a PHQ-2 9 (Patient Health Questionnaire (Depression Screen) was not completed.A physician's order dated 6/18/25 ordered Mirtazapine (antidepressant) oral tablet 15 MG (Milligrams) give one tablet by mouth one time a day for Depression.The monthly Medication Administration Records dated May 2025 through January 2026 documents R61 received Mirtazapine daily. although specific depression behaviors were not documented. The current care plan does not include a Depression diagnosis, the use of psychotropic medication and/or non-pharmacological interventions related to depression.R61's record did not include a signed psychotropic use consent to demonstrate risks and benefits, treatment options or other option were explained to the resident or resident's representative. On 1/27/26 at 11:45 AM, V20 (R61's family member/Power of Attorney) stated she had not signed a consent form explaining the risks and benefits and other treatment options related to R61's antidepression medication use. R61 stated she had not discussed R61's use of antidepression medication with the Interdisciplinary Team.On 1/29/26 at 1:20 PM, V10 (Social Worker) stated R61 did not have a Depression diagnosis, and his behaviors were typical for a resident with Parkinson's Disease. V10 stated I think he was on the medication (Mirtazapine) prior to admission, and we just continued it. V10 agreed the care plan did not include the use of the anti-depression medication or non-pharmacological interventions for the management of Depression.

Based on interview and record review, the facility failed to have a PASRR Level I (Pre-admission Screening and Resident Review) re-evaluated with a new psychotic diagnosis for one of one resident (R9) reviewed for PASRRs in the sample of 33.R9's admission record documents R9 was admitted to facility on 2/18/23.R9's PASRR Level I screening, dated 2/6/23, documents, PASRR Level I determination: No Level II required - No SMI/ID/RC (Serious Mental Illness/Intellectual Disease/Related Condition). Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R9's Diagnosis Report dated 1/28/26 documents R9 was newly diagnosed with psychotic disorder on 2/28/23. Then on 4/1/23, R9 was newly diagnosed with Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, and Visual Hallucinations.As of 1/28/26, R9's medical record had no documentation of a new PASRR Level I screening being completed after the addition of R9's new SMI/ID/RC diagnoses on 2/28/23 and 4/1/23.On 1/28/26 at 2 PM, V1 (Administrator), stated no PASRR Level I was completed for R9 after the addition of R9's new SMI diagnoses.

Based on interview and record review, the facility failed to develop a plan of care to address resident specific concerns for three of twenty residents (R5, R9 and R28), reviewed for care plans, in a sample of 33. The facility policy, Person- Centered Care Plan, dated (revised) 11/28/2017 directs staff, Person- centered care means to support the resident in making their own choices and having over their daily lives. The Person- centered care plan is in accordance with professional standards of practice and includes the resident's choice. The plan of care addresses the following: Identification of resident areas of needs, problems, strengths, goals, life history and preferences. 1.R5's Physician Order Sheet, dated January 2026 includes the following medications and diagnosis: 1/22/26 Cipro Oral Tablet 500 MG (milligrams) (antibiotic). Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 7 Days. A review of R5's current Care Plan, dated 2/14/2025 includes no documentation of R5's current urinary tract infection. On 01/29/2026 at 11:00 A.M., V4/Care Plan Coordinator stated she should care plan a resident's active infection, but she had not care planned R5's current urinary tract infection. 2. R28's Physician Order Sheet, dated 11/18/25, documents to discontinue R28's urinary drainage tube. R28's current physician order sheet documents for R28 to take Quetiapine (antipsychotic) 25mg (milligrams) by mouth daily. R28's current Diagnosis Sheet documents a diagnosis of Alzheimer's Disease, Dementia, and Vascular Dementia. R28's current care plan documents that R28 has an indwelling catheter with goals and interventions. R28's care plan does not address current bowel and bladder concerns. R28's care plan does not address R28's antipsychotic medication or a Dementia plan of care. On 1/27/26 at 11:45am, V5, Registered Nurse, verified that R28 has not had an urinary catheter for quite some time. V5 stated that he took it out himself and refused to have it replaced. On 1/29/26 at 11:00am, V4, Minimum Data Set/Care Plan Director, verified that R28's care plan was not updated with the antipsychotic medication or a specific Dementia care plan. V4 also stated she did not discontinue R28's urinary catheter and add interventions for his bowel and bladder 3. R9's Diagnosis Report dated 1/28/26 documents R9 was newly diagnosed with psychotic disorder on 2/28/23. Then on 4/1/23, R9 was newly diagnosed with Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, and Visual Hallucinations. R9's current care plan dated 11/17/25 has no documentation of a comprehensive care plan addressing R9's diagnoses of Psychotic Disorder, Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, and Visual Hallucinations. On 1/29/26 at 11 AM, V4 (Minimum Data Set Coordinator) stated R9's current care plan does not have a comprehensive care plan addressing R9's diagnoses of Psychotic Disorder, Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, and Visual Hallucinations.

Based on observation, record review, and interview, the facility failed to administer medications as ordered by the physician to two (R26 and R60) of nine residents reviewed for medication pass. This failure resulted in two errors out of twenty-eight opportunities for a 6.9 percent medication error rate.Findings include:The facility's Medication Administration policy, undated, documents in section 7.1, page 3, that medications are administered in accordance with written orders of the prescriber.The facility's Medication Ordering and Receiving From Pharmacy Provider policy, dated 1/25, documents that all medications shall be reordered in advance by writing the medication name and prescription number or applying the peel-off bar coded labeled from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacyR26's Physician Order Sheet documents for R26 to take Cetirizine HCL Oral tablet 10MG (milligrams) one time a day for allergies.On 1/28/26 at 8:10am, V7, Registered Nurse, prepared all R26's scheduled 9:00am medications except for the Cetirizine 10mg tablet. V7 verified that R26's Cetirizine was not available and has to be ordered.R60's current Physician Order Sheet documents for R60 to take Ferrous Fumarate 324mg, one tablet by mouth daily for iron deficiency.On 1/28/26 8:35am, V8, Registered Nurse, prepared R60's physician-ordered 9:00am medications except for the Fumarate 324mg tablet. V8 stated that R60's Fumarate tablet is not available and has to be re-ordered.

Based on interview and record review, the facility failed to implement safety interventions for a resident at moderate risk for falls while on the toilet for one (R2) of three residents reviewed for falls in a sample of three. The facility's Mechanical Lift policy, reviewed 5/23/25, documents for the Power Stand-Up Lift Procedure: Assemble all supplies within reach, including lift and lift harness. b. Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). c. Securely fasten the harness safety strap around the resident's chest. This form documents that when lifting a resident from a wheelchair or other chair, secure the harness loops onto the lift. b. Secure the shin straps around the resident's legs. The facility's Falls Prevention and Post-Falls Management policy, reviewed 9/6/25, documents that the staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence, and cognition. R2's Fall Risk Assessment, dated 10/13/25, documents that R2 is at moderate risk for falls. R2's Incident Description, dated 10/11/25, documents that R2 had been transferred via sit-to-stand mechanical lift to the toilet. V8, Certified Nursing Assistant, removed the lift sling and raised the enabler bar to perform personal hygiene. R2 was unable to maintain posture and balance on the toilet and fell to the floor. This form documents V4, R2's Spouse, requested to take R2 to the emergency room. The root cause analysis determined that R2 had impaired mobility and poor sitting/standing balance. R2 was unable to maintain posture or balance on toilet during personal hygiene care. R2 leaned to one side and fell off the toilet to the floor. Team member (V8) had placed the enabler bar in upward position to provide more room during personal hygiene cares and was unable to prevent fall. Team member education provided regarding use of enable bars and safety awareness when providing cares for resident with impaired sitting/standing balance. On 11/15/25 at 10:45 a.m., V6, Certified Nursing Assistant, stated that the enabler bars in the bathrooms are used by residents who are able to stand independently but may need some assistance with standing and balancing. On 11/15/25 at 11:45am, V8 stated that he assisted R2 to the toilet with the sit-to-stand lift. V8 stated that he unhooked R2 from the mechanical lift to clean him up V8 stated that he raised the enabler bar to provide incontinence care V8 stated that he put R2's pull-up and pants back on, then lifted his feet to put them on the sit-to-stand, and R2 fell off the toilet. V8 verified that he put R2's feet onto the sit-to-stand first instead of applying the top harness. V8 stated that he should have applied the top harness, then attached it to the lift before lifting his feet on the foot pedal. V8 verified that R2 was unable to balance or stand without assistance.

Based on interview and record review, the facility failed to implement psychosocial service interventions for one of three residents (R1) reviewed for social services in sample of three. Findings include:The facility's Behavioral Health policy, reviewed 12/18/24, documents that the organization will provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This form documents that behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care, and residents who exhibit signs of emotional/psychosocial distress receive services and supportthat address their individual needs and goals for care. On 11/15/25 at 8:45am, R1 stated that he and his wife lived in an apartment in the assisted living portion of the facility. R1 stated that he and his wife had separated and are getting divorced after 40-plus years of marriage. R1 stated that he was moved to the long-term part of the facility because of the divorce and he can not be around his wife. R1 stated that he feels very depressed and will act out at times, because he does not know how to handle the personal situation he is going through. R1 stated that the only time V9, Social Service Director or any other staff, speaks to him is when he is in trouble. R1 stated that she, nor anyone else, ever asked him what he might be feeling or going through. On 11/15/24 at 12:40pm, V9 verified that R1 is not in any psychosocial programming. V9 stated that she has not assessed or asked him about his feelings concerning his divorce. V9 also verified that she does not have any psychosocial programs within the facility. V9 stated that the residents go to activities.

Based on observation, interview, and record review the facility failed to follow the recommended guidelines to properly treat and disinfect a resident room with suspected bed bugs to prevent the spread of bed bugs for 2 of 3 residents (R1, R2) reviewed for infection control in the sample of 3. The findings include: On 6/27/25 at 9:33 AM, R2 was in him room, sitting in his wheelchair. R2 said the staff reported bed bugs were found in this room on 6/23/25. R2 said they bagged his clothing this time on 6/24/25 (Tuesday) and he moved to another room and came back to his room on 6/26/25. On 6/27/25 at 9:47 AM, R1 was in his wheelchair out of his room on the computer in the lounge area. R1's hair was past his shoulder, long, scraggly, greasy and matted in the back. R1 had a long facial beard approximately 3 inches past his chin. R1 said on 6/23/25, the staff found a bed bug on his blanket near his leg. R1 said he stayed in his room until 6/26/25, when his room was sprayed by a pest exterminator. R1 said when they were treating his room, he was placed in the dining room for several hours. R1 said when he came out of his room on 6/26/25, he did not receive a shower. R1 said about a month ago, they found a bed bug, they took his clothes but left his roommate (R2's) clothes in his closet, this time they bagged both of their clothing. On 6/27/25 at 9:55 AM, R1's top dresser drawer had multiple items including, shirt, multiple pairs of socks, slipper socks, gauze wraps, knee brace, and toiletry items. A pair of shoes were in his armoire and wash bin of personal items located on top of the armoire. There were no items bagged in his room. R2 had personal items stored in drawer and wash bin of personal items on the top of his armoire. On 6/27/25 at 9:57 AM, V4 (Licensed Practical Nurse-LPN) said last month R1's room was being treated for bed bugs. At that time R1 and R2 could not leave the room, until they treated the room and went back to the same room after 3-4 hours. They did not remove all the clothing or items in the drawers at that time. We questioned if the proper treatment was done, but we were told the pest exterminator decides the type of treatment. It was frustrating clearly it was not done properly because another live bed bug was found on 6/23/25. On 6/23/25, staff reported they saw a bed bug on him. We were told the pest exterminator was supposed to come that day to treat the room, but they did not come until 6/26/25. R1 was isolated to his room, and they moved R2 to a different room. On 6/26/25, R1 was out in the common area while his room was being treated. He was supposed to get a shower before leaving his room but that did not happen. On 6/27/25 at 10:06 AM, V5 (Certified Nursing Assistant-CNA) said on 6/23/25, the staff found a bed bug on R1. R1's roommate (R2) refused to go back into that room, and we moved him to different room. R1 was placed on isolation. On 6/24/25, R2 was in the same clothes as the day before and she gave R2 a shower. R1's shower day is on Wednesdays, she worked on Monday, Tuesday and Friday this week. By looks of R1 he did not receive a shower this week. I'm not sure what they did to solve the problem with the bed bugs. She was told R1 should have received a shower before leaving him room. This is horrible for the residents and staff. On 6/27/25 at 1:09 PM, V6 (CNA) said she was R1's CNA on 6/25/25 and 6/26/25. She did not know R1's room had bed bugs; staff did not report anything to her. R1 told me the staff found a bed bug on his blanket on Monday 6/23/25. On 6/26/25, his room was sprayed, and she placed R1 in the dining room. She did not shower him before he left the room. No one educated us on what to do if bed bugs are found. V6 said R1's brother passed away and the family brought his clothing to him and his brother's home had bed bugs, she thinks that's where the bed bug came from. On 6/27/25 at 10:41 AM, V7 (Pest Exterminator) said if bed bugs are found all clothing should be bagged, removed, and laundered. All drawers should be emptied, and he recommends a decontamination room where the resident can go while the room is being treated. The day of treatment the resident should be cleaned before leaving the room. On 6/27/25 at 9:24 AM, V3 (Building Service Director) said about a month ago, R1's room was treated for bed bugs. On 6/23/25, another bed bug was found on R1. R1's room was treated yesterday, and we bagged and removed all of R1 and R2's clothing. V3 said they only bagged clothing and not personal items. V3 said he handles the environmental treatment of bed bugs and V2 (Director of Nursing) handles the clinical side of treatment. V3 said he did not keep a record of timing in May 2025 when bed bugs were found in R1's room. On 6/27/25 at 11:15 AM, V2 (DON) said if bed bugs are found residents should be isolated until the room is treated by the exterminator. Clothing should be bagged, removed, and washed. I don't understand why the resident should be showered before leaving their room. V2 said clothing may be potentially infected with bed bugs and that makes perfect sense. At 1:45 PM, V2 confirmed education was provided to staff on how to handle bed bugs, she was not familiar on the guidelines for treatment of bed bugs. V2 confirmed there was no documentation in R1 and R2's medical records regarding the treatment of bed bugs. R1's electronic health records for May to June 2025 does not show documentation of bed bugs found and the treatment provided. The facility provided a timeline on 6/27/25, it shows on 6/23/25, a bed bug was reported in room [ROOM NUMBER] and clothing items removed (there is no mention of bagging personal items) and 6/26/27 the room was treated. The facility's Treatment for Bed Bugs undated Policy states, Bed bugs can travel in clothing, bags, and can hide in small places, including under carpeting in drawers, light switches, electronic plugs, picture frames, padding, cervices, and screw holds in furniture, mattresses .cell phones, laptops, books. Bed bugs can live for over 1 year without feeding, so they can survive even if a room or apartment is not occupied .Suspected Steps to be taken if bed bugs are suspected or seen: contract with a professional pest control company that will treat the problem with an integrated pest management approach .all actions should be performed in the room to prevent the spread of bed bugs to other rooms. Assist the resident to showered, dress in clothing from the outside the room, including shoes, socks and transfer to another room. Personal belongings, equipment and furnishings including beds should not leave the room until they have been thoroughly inspected and determined to be bed bug free .bag clothing in room in plastic bags, tie bag tightly. Wear PPE (personal protective equipment) including gown, and gloves. Bag everything in the closet, under the bed, in dresser drawers .Shoes and non-washable items should be bagged and left in the room for the professional pest control management.

Based on observation, interview and record review the facility failed to identify environmental hazards and implement fall prevention interventions for a resident who has a history of falls. This failure resulted in R1 tripping over a resident's wheelchair, falling and hitting his head on the floor sustaining a C1 (neck) fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5. Findings include: R1's Final Incident Report dated 4/14/25 shows (R1) is alert to self only. He requires the assistance of one caregiver to complete activities of daily living. He ambulates with his walker. On 4/10/25, (R1) finished breakfast in the dining room and began ambulating back to his room when he tripped and fell to the ground .(R1) complained of right shoulder pain and head pain. (R1) had a vomiting episode and superficial abrasion to right side of forehead he was transferred to the ER for evaluation. (R1) had imaging performed in the ER that showed a C1 fracture. R1's face sheet shows he is an [AGE] year-old male with diagnoses including Alzheimer's, vascular dementia, type 2 diabetes, muscle weakness and hypertension. R1's Fall Risk assessment dated [DATE] shows he is a HIGH fall risk, has a weak gait and overestimates or forgets limits. On 5/7/25 at 11:53 AM, the dining room table where R1 sat shows a wall behind the chair and a water cooler stand to the left. The space behind the chair was narrow, this surveyor could not walk through the space going forward, this surveyor turned her body to the side to fit through the space. R5 was sitting at the table on the opposite side of the table away from water cooler, she was sitted in a recliner chair with oversized wheels. On 5/7/25 at 9:32 AM, V13 (Certified Nursing Assistant-CNA) said she was R1's CNA on 4/10/25. During the breakfast meal, she was sitting at the back table feeding other residents. R1 was sitting in the middle of the table with one resident to the right of him and R5 was sitting next to him on the left. She heard R1 fall, R1 was laying on the floor on his right side he had a gash to his forehead, and he threw up immediately after falling. R1 was trying to leave the table going from the left side and there was not enough room for him to go through, he tripped over the wheelchair. R5's wheelchair wheels are huge when she sits on the side of the table where the wall is there her there is not enough room to get by. R1 is alert, he self-transfers, we encourage him to use his walker and he can get up independently. On 5/7/25 at 9:55 AM, V12 (CNA) said on 4/10/25 she was in the dining room during the breakfast meal. She was sitting at the table assisting another resident with feeding. R1 was sitting in the middle with one resident to his right and R5 to his left. She saw R1 get up from this table and he stepped over R5's wheelchair, tripped and fell landing on his right side. R1 threw up right away after falling and had a cut on the side of his head. R5's wheelchair wheels stick out a lot in the back, her wheels were almost touching the water cooler located behind her. There was not enough room for him to walk through. R1 is a fall risk and is supposed to use a walker when ambulating, he walks independently. Since the incident we place R5 on the opposite of the table so she's not blocking the space. On 5/7/25 at 11:18 AM, V15 (CNA) said on 4/10/25 she was in the dining room assisting with feeding. R1 tripped leaving the dining room, because R5's wheelchair was in the way. R1 is supposed to use the walker when he gets up but does not like to use it. On 5/7/25 at 10:10 AM, V11 (RN) said on 4/10/25, R1 was in the dining room sitting at the table he was in the middle between two residents. There is a resident (R5) who has a larger wheelchair sitting to his left, R5's wheelchair was positioned at an angle, R1 tried to go over R5's wheelchair and he was not able to get through without stepping over her the wheelchair wheel. R1 fell on his right side hitting his head on the floor, he had a good size abrasion to his forehead. There is wall behind his chair and a water cooler to the left side. R1's walker was against the wall, there was not enough space behind his chair for R1 to use his walker. R1's had numerous falls, he does not pay attention, he shuffles when he walks, is impulsive and gets up by himself. R1 should have been placed at the end of the table where he had room to use his walker when he got up, he used to sit at the end of the table. R1 had a previous incident of tripping over a chair. R1's Fall Incident Reports shows he had a fall on 1/23/25, 2/3/25, and 3/20/25. R1's current care plan initiated on 3/24/23 shows he is at risk for falls related to confusion and history of prior falls. R1's fall interventions include anticipate the needs of the resident, ensure appropriate footwear, resident to use rolling walker for support and balance with all transfers and ambulation, skilled therapy evaluation. The care plan shows the last fall intervention was on 12/20/24. R1's care plan shows he transfers with limited extensive assist. R1's Fall Prevention and Post-Falls Management Policy revised 2025 states, The nursing staff, in conjunction with the attending physician .and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Fall Risk Factors: environmental factors that contribute to the risk of falls obstacle's in the footpath .the staff will seek to identify environmental factors that may contribute to falling such as lighting or room layout .

Based on interview and record review the facility failed to notify a resident's representative of a change on resident's anti depressant medication to 1 of 5 residents (R2) reviewed for notification of change in the sample of 5. Findings include: R2's electronic face sheet printed last 5/7/25 show R2 has diagnoses of dementia and major depressive disorder. The face sheet show V14 (R2's Daughter) is R2's power of attorney (POA). On 5/7/25 at 12PM, V14 said R2's antidepressant medication's dose (Zoloft) was decreased without the facility notifying her. V14 said when she came back from vacation last March 2025, she noticed R2 was being tearful and emotional. V14 said she requested a copy of R2's medication record and found out that R2's dose of Zoloft was decreased from 75 milligrams (mg) to 50 mg. V14 said she did not consent to the dose change. V14 said she informed V4 that she would have not given permission of R2's antidepressant dose decreased. R2's electronic medical record (EMAR) documents that from 12/24 to 1/22/25, R2 was on Zoloft 75 mg. On 1/23/25, R2 was put on Zoloft 50 mg which V14 said she did not consent to. R2 was on 50 mg of Zoloft from 1/23/25 to 3/21/25 (almost 3 months). On 3/22/25, R2 was put back to 75 mg per V14's request. On 4/9/25 and up to present, R2 was now on 100 mg which V14 have also consented. R2's Psychotropic Consent form documents that on 5/31/23 to 3/18/25, R2 was on 75 mg of Zoloft. The form show that V14 signed the consent. On 4/9/25, R2's Zoloft was increased to 100 mg (50 mg in AM and 50 mg in PM) which V14 also consented. The psychotropic form did not show that R2 was put on 50 mg from from 1/23/25 to 3/21/25. The psychotropic form also did not show that V14 consented to the decrease of R2's 50 mg dose. On 5/7/25 at 1:06 PM, V4 (Resource Nurse) said when there is a change of resident's medication, the POA should be notified of the medication changes and a consent should be obtained from the resident or resident's representative.

Based on interview and record review the facility failed to notify a resolution of a grievance to 1 of 5 residents (R2) reviewed for grievances in the sample of 5. Findings include: On 5/6/25 at 1:30 PM, V14 (R2's POA and daughter) said on 4/16/25 while she was at the facility, she sent an electronic communication (text) with V4 (Resource Nurse) letting her know that she wanted to file a grievance regarding R2. V14 said she arrived at R2's room close to 10AM last 4/16/25. Upon opening R2's door, R2's room was with strong urine odor. R2 was in bed, soaked and wet with urine, R2 had not been gotten up and had not eaten her breakfast. V14 said she wanted V4 to come to R2's room and see what was going on. V14 said she saw V4 in the elevator and said to V4, I hope you are figuring out what happened this morning (with R2) and get back to me. V14 said she had not heard from V4 or any staff from the facility regarding the findings of her grievance regarding R2's issue, it's almost a month now. On 5/6/25 at 10:30 AM, V4 (Resource Nurse) said on 4/16/25 around 10AM, she received a text from V14 (R2's daughter) that she needed her to go to 2nd floor. V14 said V4 sounded upset about R2's care. V4 said when she was at the 2nd floor elevator, she saw V14 and R2. V14 was loud, yelling you need to find out what happened! V4 said she asked V14 if they can discuss in private and to refrain from yelling. V4 said another family member of R2 also called the facility to follow up since R2's POA (V14) was upset of what happened with R2 earlier (R2 was not up for breakfast and R2 was soaked and wet) . V4 said she informed the family member that they are looking into the situation and will educate staff. V4 confirmed that up to this time, she had not spoken to V4 regarding the grievance last 4/16/25. V4 said within 24 hours there should be an update to the grievance resolution. On 5/7/25 at 10:05 AM, V6 (Social Service) said on 4/16/25 she witnessed how V14 was so upset about R2's care. V6 said she filled out R2's grievance form but she did not notify V4 of the facility's response or findings to R2's grievance. R2's grievance/concern form dated 4/16/25 under concern show, Incontinence Care which was signed off by V6 (Social Service) and V1 Administrator. Under Response: (Family member) stated that POA is stressed and wanted to follow up (with)-nurse supervisor, explained all steps to resolve complaint to team members. The grievance response did not include that V14 who is R2's POA was informed of the result of the investigation and resolution of the grievance. On 5/7/25 at 10:15 AM, V1 said they will get hold of V4 (R2's POA) today to give an update of the grievance resolution. The facility policy on Grievance Resolution dated 7/25/24 show, all grievances and complaints filed by a resident/her representative, family member will be investigated and corrective actions will be taken to resolve the grievance. 7. The resident, or person acting on behalf of the resident will be informed of the findings of the investigation as well as the corrective actions recommended within 7 working days of the filing of the grievance or complaint.

Based on interview and record review the facility failed to provide incontinence care to a resident that need extensive assist with Activities of daily living (ADL) to 1 of 5 residents (R2) reviewed for incontinence care in the sample of 5. Findings include: R2's facility assessment dated [DATE] show R2 is frequently incontinent of urine and need assist with toileting and transfers. On 5/6/25 at 12:30 PM, V14 (R2's daughter) said last 4/16/25 she arrived at the facility almost 10AM. R2's room was permeating with strong urine odor. R2 was still in bed, she was soaked and wet. R2 was trying to get up from bed, her foot was already dangling at the side of the bed. V14 said she was very upset, R2 was not toileted. On 5/7/25 at 2:30 PM, V16 (Certified Nursing Assistant-CNA) said she was R2's CNA the night shift from 4/15/25 going to 4/16/25. R2 went to bed at 11:30 PM. V16 said at around 2:30 AM, she went to R2's room and offered R2 to be toileted but R2 refused. At 7AM, V16 said she did not go and check on R2 again but gave report to V7 (day CNA). V16 said the last time R2 was toileted was at 11:30 PM (4/15/25) when R2 was put to bed. On 5/6/25 at 11:16 AM, V7 (CNA) said on 4/16/25 she came in at 5AM, she was R2's CNA on day shift. V7 said the night shift CNA (V16) gave report that R2 was fine. V7 said she peeked in R2's room at around 6:30ish that morning, R2 was asleep. V7 said she did not check on R2 if she was wet and did not asked R2 if she needed to go to the bathroom. At 7:30 AM, she went again to R2's room, I just opened the door and peeked, [R2] was still asleep. Again, V7 said she did not go and check if R2 was wet and did not offer for R2 to use the bathroom. V7 said at 8:45 AM, she saw the nurse coming out from R2's room so V7 said she did not go to R2's room. V7 said she went on break around 9:15-9:30 AM. V7 said by the time she got back to the floor, R2's daughter (V14) was in R2's room, V14 was very upset that R2 was soaked and wet. On 5/6/25 at 11:54 AM, V8 (CNA) said on 4/16/25 at around 10AM, R2's call light was on. V8 said she went to R2's room, V14, R2's daughter was in the room, R2 was in the bathroom, V14 was very upset, she said R2 was still in bed when she arrived, R2 was soaked and wet with urine. On 5/7/25 at 2:45 PM, V2 (Director of Nursing) said all residents including R2 should be checked and change to keep them dry and prevent skin breakdown. R2's careplan dated 2/24/25 documents R2 has occasional bladder incontinence r/t Confusion, Dementia, Impaired Mobility, will remain free from skin breakdown due to incontinence and brief use. With intervention to include: Approach resident in a manner of lets go to the restroom or lets get changes instead of asking do you need to be changed?

Based on observation, interview, and record review, the facility failed to ensure the staff completely covered hair in a sanitary manner while in the kitchen; failed to ensure food items were stored and labeled with dates and identification, and failed to ensure chemical product was not stored in the facility's Dry Food Storage Room. These failures have the potential to affect 76 of the 77 residents who consume food in the facility. Findings include: The facility's Use of Hair Restraints Policy dated 1/17/25 documents: Culinary employees will practice safe food handling to prevent food borne illness. The organization has strict requirements regarding hair restraints: A. Employees will wear hairnets or ball caps that completely cover the hair while in the kitchen or service food. If hair hangs below the ball cap, a hairnet must be worn. B. Beards and mustaches must be covered with effective hair restraint if longer than one-half inch in length, otherwise neatly trimmed close to the face. The facility's Storage Procedures Policy dated 1/17/25 documents: Food and supplies shall be properly stored to keep foods safe and preserve flavor, nutritive value and appearance. A. Food storage areas are used for food and paper supplies. Chemicals/poisonous items are not stored in food storage area. F. Open packages are labeled, dated and covered. The facility's Date Marking Policy dated 1/17/25, documents: All prepared foods that are stored will be properly dated to ensure food safety. Special Notes: 1. All items should include name of product, and two dates as indicated above. On 2/25/25 at 9:15am, V20 Culinary Services Director was noted in the kitchen with a hair bonnet on with hair not completely covered, tendrils of hair hang down on both sides of her face and the nape of her neck. V21 Dietary Aide was noted wearing a cap while doing dish washing task in the kitchen. V21's hair was not covered at the back of his head and sides of his face. V21 stated that he was given a choice to wear a cap or hairnet, and he chose a cap. V22 Dietary Aide had a hairnet on her head that covered all her hair except the entire bangs at the front of her head. V22 stated that she covered her hair but the bangs slide out when I am working. On 2/25/25 at 9:15am, the kitchen staff stated that all their hair was supposed to be covered while in the kitchen. On 2/25/25 at 11:25am while in the kitchen V23 [NAME] wore a cap; V23's hair showed at the front of his head from underneath the cap and his sideburns and beard were not covered. V23 had a surgical mask on; and wore a beard hairnet that was not in place. The beard hairnet was located beneath his chin. On 2/24/25 at 11:35am, V24 Prep [NAME] did not have his hair completely covered while in the kitchen. At this same time, V20 Culinary Services Director stated, All the hair for the kitchen staff should be covered. On 2/24/25 at 9:25am, a pan of individually wrapped meat loaf portions in the facility's Freezer were not labeled or dated; a half full 50 pound bag of rice in the Dry Food Storage Room was not labeled or dated; a half full pitcher of lemonade with a use by date of 2/24/25 was in the Walk-in Cooler (V20 Culinary Services Director stated that the lemonade should not be in the Walk-in Cooler); a pan of sliced potatoes in the Walk-in Cooler was not labeled or dated, ten containers with sub sandwiches on a rolling cart were not labeled or dated in the Walk-in Cooler; and three medium sized bags of chopped red potatoes in the Walk-in Cooler were not labeled or dated. At this same time, V20 Culinary Services Director stated that labels and dates should be on all the food items. On 2/25/25 at 9:45am, in the facility's Bakery Freezer, a bag of peanut butter cookies and two bags of sugar cookies had no labels or dates. At this time, V25 Kitchen Manager stated, I don't know how old they (cookies) are. On 2/25/25 at 9:50am, a full container of Sanitizer chemical used for dishes was in the facility's Dry Food Storage Room. V25 Kitchen Manager stated that the Sanitizer should not be in the Dry Food Storage Room but should be in the chemical's storage area. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 2/25/25, documents 77 residents reside in the facility.

Based on interview and record review, the facility failed to ensure facility staff were educated and competent in providing Hospice and End of Life Care for Hospice Residents for nine of nine residents (R14, R23, R40, R43, R51, R52, R61, R62, R65) reviewed for Hospice services in a sample of 38 residents Findings include: The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services dated 8/10/16 documented 4.6 Experience and Competence. It and its employees and personnel providing services pursuant to this agreement are (i) familiar with the administrative and patient care needs associated with hospice patients, (ii) competent in the care of terminally ill persons and in recordkeeping, and (iii) otherwise fully capable of performing its and their obligations hereunder in accordance with generally recognized professional standards of care. The facility's current Matrix 802 documents R14, R23, R40, R43, R51, R52, R61, R62, and R65 receive Hospice care. On 2/26/25 at 12:10 PM, V5 (Registered Nurse/ Date of Hire: 5/14/24) and V9 (Licensed Practical Nurse/Date of Hire: 1/15/25) Training Transcripts did not indicate Hospice or End of Life education had been completed. On 2/26/25 at 12:10 PM, V1 (Administrator) stated I thought End of Life training was completed on all new hires, but I don't see that it was assigned or completed for either of these two (V5 and V9) upon their hiring. On 2/27/25 at 1:28 PM, V5 stated she had not received Hospice or End of Life training since her date of hire.

Based on observation, interview, and record review the facility failed to perform hand hygiene, glove changes and perform pressure ulcer dressing change in a manner to prevent cross contamination for one (R48) of four residents reviewed for pressure ulcers in the sample of 38. Findings include: The facility's Infection Prevention and Control Program, dated 7/19/25, documents: Good hand hygiene is a requirement of Standard Precautions. Hand hygiene is performed before and after each care contact for which hand hygiene is indicated by acceptable professional practice, utilizing designated time frames and products. Alcohol based hand rub (ABHR) is the preferred method, however, hands should be washed with soap and water when they are visibly soiled, before or after eating or handling food, after using the restroom and after caring for a resident with known or suspected clostridium Difficile or norovirus infection. Standard Precautions are designed to reduce the risk of transmission of blood borne and other significant pathogens. Standard Precautions apply to all contact with any blood, body fluid, secretion and excretion, except for sweat, from any human being, regardless of diagnosis or presumed infection status. Standard Precautions means that contact with any blood, body fluid, secretion and excretion except for sweat should be avoided. This also includes any items soiled with body substances or fluids. Wear gloves when touching or handling: Blood; All body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood; Non-intact skin; Mucous membranes; Surfaces and equipment visibly soiled by these body substances . Gloves should be removed promptly after use and hands should be washed or sanitized to avoid transfer of microorganisms to other individuals or the environment. The facility's Clean Wound Care Treatment Technique, dated 10/11/24, documents guidelines of cleaning a wound and applying dry dressing. These guidelines document the following: Perform hand hygiene and put on PPE, if indicated; Prepare for dressing change; Put on clean, disposable gloves and remove old dressing; After removing dressing, remove gloves and dispose, perform hand hygiene and apply new gloves; Once the wound is cleaned and dry, remove gloves, perform hand hygiene, and apply new gloves; apply treatments with date and time; Remove and discard gloves and perform hand hygiene, remove all remaining equipment and adjust resident position, bed position, remove any remaining PPE and perform hand hygiene. The Order Summary Report for R48, dated 2/28/25, documents the following 1/30/25 physician order as: Coccyx cleanse open area with wound cleanser, pat dry, apply medical honey, calcium alginate, and secure with bordered foam dressing. On 2/27/25 at 9:28 am, V19 RN (Registered Nurse) stated R48 has a small pressure ulcer located in the crease of buttocks coccyx area, treatment is done daily, and R48 goes to the local wound clinic every couple of weeks for follow up. On 2/27/25 at 10:50 am, V18 RN and V19 RN entered R48's room, performed hand hygiene and applied PPE (personal protective equipment). V19 RN set up supplies on an overbed table as V18 RN assisted R48 to stand at her walker. R48 pulled her pants down revealing a superficial open area to R48's buttock crease. V19 RN cleansed R48's coccyx wound. With same soiled gloves V19 RN applied physician ordered ointment, absorbent dressing, and foam dressing. V19 RN removed her soiled gloves and without performing hand hygiene, donned gloves, reached in (V19's) uniform pocket and retrieved a black marker, pulled off the marker cap, signed and dated R48's coccyx wound dressing, and placed marker back into (V19's) uniform pocket. V19 RN then removed her soiled gloves and without performing hand hygiene, applied a new pair of gloves, gathered R48's treatment supplies, placed treatment supplies back into R48's closet, reached back into R48's closet for antiseptic wipe, wiped (V19's) soiled scissors, placed scissors in her uniform pocket, and wiped off the overbed table using same soiled wipe. With same soiled gloved hands V19 RN shoved soiled treatment supplies down into the garbage bag, pulled bag from garbage can and tied it up, and placed new garbage bag. V19 RN proceeded to walk out of R48's room with soiled gloves, carrying garbage in her left hand while pushing overbed table into the hall with her right hand, walked across the hallway, opened and entered the soiled utility room to throw garbage bag away and continued to move overbed table down the hallway into another resident room without performing hand hygiene. On 2/27/25 at 3:00 pm, V2 DON (Director of Nursing) confirmed hand hygiene is to be done in between going from soiled to clean, any time after removing gloves, and V19 RN should not have touched anything in the room with soiled gloves or prior to performing hand hygiene.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing and humidifier bottles were dated and changed per policy for two (R25 and R127) of four residents reviewed for respiratory care in the sample of 38. Findings include: The facility's Oxygen Policy, dated 3/8/24, documents Oxygen tubing will be changed routinely. 1. The current Order Summary Report for R25, documents the following physician orders dated 1/14/25: O2 (oxygen) 1-3 LPM (liters per minute) per nasal cannula continuously to maintain O2 saturation greater than 90% every shift; and to change and label oxygen tubing and humidifier bottle weekly every Sunday night shift. On 2/25/25 at 10:15 am, R25 was sitting up in a wheelchair with oxygen infusing at 1.5 liters via nasal cannula, by way of oxygen concentrator. A humidifier bottle dated 2/16/25 was attached to the concentrator and there was no visible date on R25's oxygen tubing. 2. The current Order Summary Report for R127, documents the following dated physician orders: 2/23/25 O2 at 2 LPM per nasal cannula continuously to maintain O2 saturation greater than 94% every shift, 3 LPM if needed; and 2/21/25 Change and label O2 tubing and humidifier bottle weekly every Sunday night shift. On 2/25/25 at 10:48 am, R127 was sitting up in recliner in her room with oxygen infusing at 2 liters via nasal cannula by way of oxygen concentrator. A humidifier bottle was attached to the concentrator. The humidifier bottle and R127's nasal cannula were undated. On 2/28/25 at 3:00 pm, V2 DON (Director of Nursing) stated oxygen tubing and humidifier bottles are to be dated and changed weekly.

Based on interview and record review, the facility failed to ensure Hospice providers provided the facility with written physician orders for one of three residents (R42) reviewed for Hospice services in a sample of 38 residents. Findings include: The Hospice's Agreement for Nursing Facility, Inpatient and Inpatient Respite Services dated [DATE] stated Appendix C Facility Services 1.4 Physician Orders: To the extent permitted by applicable law, rules, and regulations, (Hospice) nurses may receive and transcribe physician orders in the Facility's clinical records for any Residential Hospice Patient. Such physician orders will be countersigned by Facility's Director of Nursing or other Facility nurse. The Physician Orders-Obtaining and Transcribing policy dated [DATE] documented 1. All orders for medications, tests and treatments shall be written on the physician's order form and signed by the physician or physician extender unless entered into EHR (Electronic Health Record). R42's Care Plan documented R42 was admitted to Hospice services on [DATE] with a terminal prognosis related to Advancing Alzheimer's Disease and Severe Protein Malnutrition. R42 expired on [DATE]. On [DATE] at 10:30 AM, V1 (Administrator) stated after R42 expired that the Facility requested R42's Hospice records from the Hospice Agency. V1 stated We didn't have much information (Hospice documentation) in our records. The Hospice record (received post R42's expiration) dated [DATE] documented adjusted meds (medications); [DATE] cut Morphine (medication for pain and restlessness) dose to half 2.5 mg (milligram); [DATE] Aspiration Risk, increase Morphine 0.125 ml (milliliter) every four hours and Morphine 0.125 ml every three hours as needed; [DATE] discontinue oral medications; and [DATE] Morphine every four hours scheduled, as needed Ativan increased to every four hours. R42's Order Summary did not include medication order changes dated [DATE]; did not include an order for Aspiration Risks on [DATE]; did not include an order to discontinue oral medications on [DATE]; nor an order to crush Ativan (antianxiety medication) with instructions on how to administer the medication. The Medication Administration Record dated [DATE] through [DATE] documented R42 received Ativan and Morphine orally [DATE] through [DATE]. On [DATE] at 2:22 PM, V6 (Hospice Nurse) stated R42's Ativan should have been crushed, mixed with water and administered between the gum and cheek for optimal absorption. V6 stated When a resident cannot swallow anymore, the facility nurses should be administering medications between the gum and cheek. Orders are given to the facility nurse's verbally and it's up to them (nurses) to enter the orders into their (facility's) EMR (Electronic Medical Record) and ensure nurses know what routes to use when administering medications. On [DATE] at 11:47 AM, V26 (Registered Nurse) stated Hospice orders are received verbally from the Hospice nurse and the Facility's nurse enterers the order into the Electronic Health Record. V26 stated orders are every once in a while faxed to the facility but rarely and the Hospice Nurses do not leave their Progress Notes or Plan of Cares at the facility. On [DATE] at 12:00 PM, V2 (Director of Nursing) stated the Hospices sometimes write the orders and sometimes verbally give the orders. V2 agreed the facility nurses are taking verbal orders from the Hospice nurses without written documentation of the order and who the prescribing physician was. On [DATE] at 1:28 PM, V5 (Registered Nurse) stated I didn't know to crush (R42's) Ativan and how to administer it. The (physician) orders did not include an order that (R42) was not to have medications orally and we don't have records (Hospice) available to verify what the Hospice has changed. The Hospice nurses do not have access to our records (Electronic Medical Record/EHR). I've entered orders (into the EHR) the Hospice nurse has given me verbally, but I now understand that is not safe. They should be in writing. That's nursing 101.

Based on interview and record review, the facility failed to document clinical rationale for extending PRN (as needed) psychotropic medication for one (R6) of two residents reviewed for psychotropic medications in a sample of 38. Findings include: The facility's Psychotropic Medication Management System policy, dated 10/26/24, documents (Named facility) has developed a system to ensure a resident is not given psychotropic medications unless a comprehensive assessment identifies clear indications and parameters for their use, based upon regulatory compliance and best practice. With administration of a psychotropic medication, the following will be documented: PRN orders are limited to 14 days unless the prescriber believes it is appropriate to extend the order beyond 14 days and documents their rationale in the clinical record and indicates the duration for the PRN order. R6's current Physician Order Statement/POS, dated 2/5/25, documents an order for Alprazolam (psychotropic) oral tablet 0.5mg (milligrams) give one tablet by mouth as needed for Anxiety for 30 Days TID (three times per day). On 2/27/25, at 1:45pm, V16 Licensed Practical Nurse/LPN/Resource Nurse stated We use the 14 days only if there is no stop date. (R6's) order was written by the prescriber to extend out to 30 days instead of 14. When asked if there is a written rationale V16 stated No, it is not written and it is probably so that it doesn't drop off (after 14 days). R6's clinical record does not include a documented rationale for R6's Alprazolam to be extended to 30 days.

Based on observation, interview, and record review the facility failed to protect a demented resident (R1) from sexual abuse by R2 with dementia and a known history of pacing, wandering, disrobing, and violence/aggression towards staff/others. This failure resulted in R2 placing his hand down R1's pants and performing repeated aggressive up and down sexual type motions. This failure resulted in R1 feeling frightened and requiring hospital examination where a minor tear near R1's vagina was noted. This failure has the potential to affect R1 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/18/24 the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The Immediate Jeopardy began on 12/12/24 at 7:15pm when the facility failed to protect a demented resident (R1) from alleged sexual abuse by R2. The facility's Abuse and Neglect of a Resident policy, last revised 6/16/23, documents Policy Statement: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse - is non-consensual sexual contact of any type with a resident, including but not limited to, assault, rape, or sexual harassment. Examples are: exhibitionism by the service provider, forcing the individual receiving services to view pornographic material, intimate touching of the individual receiving services by the service provider during bathing, molesting the individual receiving services. Capacity and Consent - residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps will include evaluating whether the resident has the capacity to consent to sexual activity. Policy Implementation: Procedures for Detection and Prevention: 5. Establishment of a Resident Sensitive Environment and Prevention: The facility will establish a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and have policies and protocols in place for preventing sexual abuse. The Residents' Rights for People in Long Term Care facilities, undated, documents Your right to safety - You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is severely cognitively impaired. R1's current Face sheet documents R1 has diagnoses including but not limited to Alzheimer's Disease with late onset; Anxiety Disorder; Depression; Unspecified Dementia, mild, with Agitation. R1's current Care Plan documents R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. R2's MDS, dated [DATE], documents R2 is moderately cognitively impaired. R2's current Face sheet documents R2 has diagnoses including but not limited to Vascular dementia, Unspecified dementia, Anxiety disorder, and Major Depression disorder. R2's current Care plan includes but is not limited to a focus of (R2) uses psychotropic medications related to Behavior management and an intervention including but not limited to Monitor/record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. The facility's Alleged Abuse incident report, dated 12/12/24, documented by V1 Administrator CNA (Certified Nursing Assistant) (V4) was performing beginning of shift rounds and entered (R2's) room. (R2) was seen lying in bed behind (R1). Both residents had their clothing on. (R2) had his hand in (R1's) pants. (V4) CNA separated both residents and walked (R1) back to her room. During separation, (R1) stated to (V4) 'thank you I was so scared - he is so much older than me.' (R1) was unable to recall any further details. Mental Status - oriented to person. The local police department report, dated 12/12/24, documents V13 local police officer was called to the facility for an incident between two residents (R1 and R2). This report documents the following: (V4 CNA) advised she was doing routine room checks at approximately (7:20pm). (V4) said upon entering (R2's) room, (V4) observed (R2) and (R1) lying on the bed together in a 'spooning position', with (R2) laying behind (R1) facing the same direction. (V4) said she saw (R2's) hand down the front of (R1's) pants and appeared to be using his fingers to enter (R1) aggressively. (V4) said she then separated them both and returned (R1) to (R1's) room. (V4) said while asking (R1) if she was okay, (V4) said (R1) appeared afraid and told (V4) 'Thank you so much. He was older than me.' (V4) said (V4) asked for additional staff because (R2) became upset and kept trying to enter (R1's) room again. (V4) said approximately one month ago (V4) walked into (R2's) room and observed (R2) attempting to pull the shirt off (R1) before (V4) intervened. (V4) said (V4) reported this to the nurse (V5 Registered Nurse/RN) on the floor and was concerned since (R2's) and (R1's) rooms are only two doors away from each other. V12 (R1's Family Nurse Practitioner's/FNP) note, dated 12/13/24, documents History of Present Illness: (R1), [AGE] year-old female is seen today for follow-up dementia and vaginal abrasion. I was notified by social worker at nursing home that (R1) was found yesterday evening by a staff member having a sexual experience with another resident. The patient was brought to the emergency department due to concerns for sexual assault. (R1) reported no recollection of the encounter. The reports and emergency room were reviewed. The patient and her son who is the Power of Attorney/POA declined a SANE (Sexual Assault Nurse Examiner) exam. The exam did reveal a 0.5 cm vaginal abrasion. (R1) was discharged back to the unit following the examination. (R1) is in her room this morning with a CNA (Certified Nursing Assistant). (R1) has no recollection of this encounter. (R1) reports some pain and burning in her mouth. Oral mucosa is dry and erythematous. There are no open lesions or abrasions noted. (R1) otherwise offers no information regarding the history of this visit. F03.C0 - Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety: Patient seen for follow-up of dementia. No recollection of recent sexual encounter, raising concerns about capacity to consent. V12's (R2's FNP) note, dated 12/13/24, documents the following: R2 is a [AGE] year-old male seen in the office for follow-up dementia and weakness. V12 was notified by V3 Social Service Director/Abuse Officer that an incident had occurred last night where V4 found R2 with his hand down another resident's pants (R1) in a sexual manner. On 12/13/24, at 1:40pm, R1 ambulated into R1's room and sat in a chair. This writer noted that R2's room is two doors down from and on the same hall as R1's room. R1 answered questions in a quiet voice by stating the following: R1 has no friends here or enemies. Has no gentleman friend. Feels safe. Denies being touched inappropriately. When R2's name was mentioned R1 said she's known R2 a long time, that they are the same age and we have just stayed on as friends. It is better than being married. I shouldn't say that. He is nice and I like him but not to go too far. He holds my hand but no more than that. R1 denies ever lying in bed with R2 and quietly stated I don't want that. Denies ever being intimate with R2 and stated, I think of him as one of my best friends. On 12/13/24, at 2:00pm, R2 was in his room. R2 answered questions by the following: When asked if he liked living here, he said there are too many rules. R2 confirmed he knows R1 and that R1 is his girlfriend and has been since R2 got here. R2 confirmed R1 was in R2's room last night in bed with him. R2 denied any inappropriate touching and stated I don't think she'd let me get in her pants. I tried. R2 confirmed that a staff member came in. R2 said the staff member was mad and said out. R2 thinks the staff member was mad because it is their rule. R2 could not state what rule he was referring to. R2 denies doing anything wrong. R2 denies having any other girlfriends but R1. I like everything about her. I think she chose me. R2 confirmed that R1 has been in his room before and other than last night. On 12/13/24, at 2:50pm, V4 CNA stated the following: Last night I got in to work at 7:05pm, got report and cart ready. I started room checks about 7:15pm. (R1's) is the first room and she wasn't in there, but she is a wanderer. I kept going and got to (R2's) room. When I opened (R2's) door they (R1 and R2) were in a like a spooning position. They were facing the door and (R1) was in front with (R2) behind (R1). One of his hands was holding (R1's) shoulder under (R2's) neck. (R2's) right hand was down (R1's) jeans in the front. (R2) was making some pretty aggressive motions and it was like (R2) was penetrating (R1). (R1) looked very scared with wide eyes and holding herself very tightly like hugging herself. (R2's) expression was just focused. (R2) did not stop when I walked in. As I led (R1) out (R2) started following us and into (R1's) room. (R2) got kind of aggressive and was refusing to go back into his room. (R1) said 'thank you so much, I was so scared - he is much older than me.' It happened before about a month or so ago. I had opened the door to (R2's) room during room checks and I saw (R1's) breasts were exposed, (R1's) shirt was up and (R2's) pants were zipped down. On 12/17/24, at 2:18pm, V5 Registered Nurse/RN stated that during nursing shift report V4 and V9 CNAs came in and reported that V4 walked in and saw (R1) laying on the bed in (R2's) room; (R2) had his hands down (R1's) pants and (R2's) hand was moving. On 12/17/24, at 2:20pm, V5 RN stated there was another time when R2 had his shorts unbuttoned with R1 alone in (R2's) room. That was told to me, but I don't remember the exact details. It was not definitive of sexual activity. They (R1 and R2) had a semi-romance and would hold hands. V5 confirmed that if they had not been walked in on it could have led to more. Who knows how many episodes we may not have encountered. On 12/17/24, at 4:03pm, V4 CNA verified that the prior incident (when R1's shirt was up and R2's pants were unzipped) had occurred the night V4 worked a half shift with V5 RN on 9/1/24. V4 stated (V5 RN) has a different thought process on residents doing these things and in (V5's) mind (V5) thinks (R1 and R2) can consent. Maybe I should have known (V5) would not have taken it seriously. On 12/18/24, at 7:15am, V9 CNA confirmed that on 12/12/24 V4 CNA came up to V9 and said that R2 had his hands down R1's pants. V9 stated that after they were separated R2 was agitated. V9 said I asked what was going on and (R2) said 'I just want to be with her.' On 12/18/24, at 9:05am, V1 Administrator stated (as far as the incident last week 12/12/24), I was told that (V4 CNA) had walked into (R2's) room doing rounds. (V4) found (R1) and (R2) lying in bed together. That (R2) was behind (R1) both with clothing on but (R2's) hand was in (R1's) pants. V1 denied any awareness of the 9/1/24 incident between R1 and R2. On 12/20/24, at 11:15am, V1 Administrator produced the facility's Final Report dated 12/20/24. This report documents The facility finds resident to resident contact was substantiated. Consent is unable to be determined based on the cognition of both residents. Neither resident is able to recall an event has taken place nor has expressed harm, pain, or mental anguish, therefore the facility cannot definitively substantiate abuse at this time. The facility will take the course of higher scrutiny and act as if abuse has been substantiated. On 12/18/2024 at 10:30am V1 was notified of the Immediate Jeopardy. On 12/20/2024 it was confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2. 2. Local police were contacted. 3. R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion. 4. R2 was maintained on 1:1 monitoring. 5. Head-to-toe assessments were completed for each female resident residing on the memory care unit with no findings. 6. Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents. 7. 12/16/24 R1 was moved to a new room on a different floor. 8. 12/18/24 Care plan training for IDT (Interdisciplinary Team) for care planning requirements for actual/potential resident to resident abuse completed. 9. 12/18/24 Care plan updates completed on R1 and R2. 10. 12/18/24 Head to toe assessments conducted on all residents for signs and symptoms of abuse. 11. 12/18/24 Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse. 12. 12/13/24 - 12/18/24 training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed 12/18/24 in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed. 13. Administrator or designee will randomly interview four residents four times a week for any potential abuse allegations for one month; then three days a week for one month; then two times per month for three months. 14. Administrator or designee will interview four staff members four times a week for one month to verify their understanding of the identification and reporting of abuse requirements then four staff member two times a month for three months. 15. Results from the interviews will be reviewed by the QAPI (Quality Assessment and Performance Improvement) Committee on a regular basis for any additional recommendations.

Based on interview and record review, the facility failed to ensure resident safety during assisted ambulation for one (R1) resident of four reviewed for falls in a sample of four. This failure resulted in R1 receiving a fractured femur followed by a decline in condition and subsequent death. Findings include: The facility's Falls Prevention and Post-Falls Management policy, dated [DATE], documents Policy: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. This policy also states Resident-Centered Approaches to Fall Risk Assessment: 5. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, Excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. The facility's Gait Belt/Transfers policy, dated [DATE], documents All staff members who assist resident to transfer or ambulate will be required to use a gait belt during these procedures. In implementing this policy, the following shall apply .B. Gait belt must be used with all assisted transfer or ambulating procedure. R1's current Physician Order Sheet/POS documents diagnoses including but not limited to Alzheimer's Disease with late onset, General Anxiety Disorder, Chronic Kidney Disease, Muscle Weakness (generalized), and Displaced Intertrochanteric Fracture of Left Femur. R1's Minimum Data Set/MDS assessment, dated [DATE], documents R1 with moderately impaired cognition, requiring partial/moderate assistance for ambulation of 10 feet and 50 feet with two turns, and substantial/maximum assistance to walk 150 feet. R1's Fall Risk Assessment, dated [DATE], documents R1 as a moderate risk for falling. R1's Facility Reported Incident, dated [DATE], documents Resident was ambulating with CNA (Certified Nursing Assistant) and wheeled walker when she tripped over her feet. Sent to ER (emergency room ) for evaluation, found to have left hip fracture. R1's Hospital records include an x-ray of R1's left hip with pelvis, dated [DATE], with a radiology report that documents Impression: 1. Intertrochanteric fracture of the left femur as described. On [DATE], at 2:41pm, V3 Registered Nurse/RN stated the following: That day I remember it was dinner time around 6pm and I was on the other side in the other dining room. I heard some commotion on the other side, so I ran over to the other dining room. Then I saw (R1) on the floor. So, I assessed (R1) and then noticed she had limited movement on her left side. That night she was talking but had pain. I had asked (V4 Certified Nursing Assistant/CNA) what happened. There was one other person in dining room at the time. (V4) was the one walking with (R1). (V4) said (R1) was walking and (R1) tripped over the little threshold portion of the floor between the carpet and flooring. I asked more questions like was she by her and she said yes. Then later one of the CNAs (does not recall name) said (V4) was on her phone. Once we got (R1) in the chair we noticed she couldn't put weight on her leg. I asked (R1) what happened. (R1) is very outspoken. (R1) said something along the lines of 'She wasn't walking with me. She was on her phone.' I saw that (R1) did not have a gait belt on. (R1) was a one assist with stand-by so (V4) probably should have had one (gait belt) on her. (R1) just had her walker. On [DATE], at 3:42pm, V2 Director of Nursing stated I know (R1) did walk most times to the dining room with a CNA. Not sure if (V4 CNA) used a gait belt. I know that is our standard. That is what is expected. I don't remember asking (V4) if she used one. On [DATE], at 2:15pm, V4 CNA stated that R1 tripped over a rubber piece of the floor while V4 was walking with R1 to the dining room. V4 stated I did not have a gait belt on her at that time. I should have, but for the most part she was independent, and she was coming out the door and I didn't grab it quick enough, and we just kept going. This writer asked V4 what V4 could have done differently that might have prevented the fall and V4 stated Obviously used a gait belt. R1's clinical record documents the following: Progress Note, dated [DATE], states R1 returned from the hospital after surgery for her fractured femur; R1 has confusion, which was a new level of impaired cognition, and now requires cueing. Progress Note, dated [DATE], stated R1 was lethargic and unable to take medication. Physician Order Sheet/POS documents an order, dated [DATE], for R1 to be admitted to Hospice. Progress Note, dated [DATE], documents R1 expired with family at her bedside. R1's Death Certificate documents cause of death: Aspiration Pneumonia due to Congestive Hypertensive Cardiovascular Disease; Significant Conditions Contributing to Death: Fracture of the Femur due to a fall and Chronic Kidney Disease. On [DATE], at 10:20am, V7 (R1's physician) stated the following: No question about it that (R1's) fall with fracture exacerbated her decline and subsequent death. She was so frail. V7 also stated With her age, long bone fracture, and a surgical procedure, (R1's) mortality risk was high within the first six months for complications, including death. Even without surgery her risks were high.

Based on interview, observation and record review, the facility failed to perform skin risk assessments, implement additional pressure relieving interventions after a change in condition, and identify a pressure ulcer prior to its status worsening to a Stage III for one of three residents (R9) reviewed for pressure ulcers in the sample of 38. This failure resulted in R9's pressure ulcer worseing without new interventions implemented. Findings Include: The facility's Pressure Injury Prevention policy (revised 01/10/24) documents the following: The community must ensure that : A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This policy also documents, Each resident is formally assessed for risk of developing pressure injuries using the Braden Scale completed upon admission, quarterly, significant changes, and after developing pressure injury. This same policy documents, Inspect the skin when performing or assisting with personal cares or ADLs (activities of daily living.); Evaluating condition of skin (skin color, moisture, temperature, integrity, and turgor) at least weekly, or more often if indicated, such as when the resident is using a medical device that may cause pressure. This policy also documents, Care Plan documentation: Care Plan will be revised quarterly and as needed. R9's medical record documents R9 was admitted to the facility on [DATE] with a Stage III pressure ulcer present on her sacrum, and physician orders are in place for daily wound care and dressing changes to R9's sacral wound This same medical record documents R9 developed a Stage III pressure ulcer on the right side of her lower thoracic area (middle back) on 08/22/23. R9's current Physician's Orders document the following Physician's Order for R9's lower thoracic pressure ulcer: Lower back - cleanse with wound cleaner, pat dry, cover with bordered gauze every night shift every Tuesday, Thursday, and Saturday. R9's Braden Scale for Predicting Pressure Sore Risk Assessment (dated 06/28/23) documents a score of 17, indicating R9 is at risk for pressure ulcer development. R9's next Braden Scale for Predicting Pressure Sore Risk Assessment was not completed until 12/01/23 and also documents a score of 17, indicating R9 is at risk for pressure ulcer development. R9's monthly Treatment Administration Record (dated 07/2023 - 01/2024) documents R9 has received weekly skin checks during this time frame. R9's Treatment Administration Record (dated August 2023) documents R9 received a skin check on the following days: 08/01/23, 08/08/23, 08/15/23, 08/22/23 and 08/29/23. R9's Wound Evaluation (dated 08/22/23) documents a Stage III pressure ulcer (full-thickness skin loss) measuring 2.5 cm (centimeters) by 2.5 cm by 0.1 cm with the presence of slough tissue was discovered on the right side of R9's lower thoracic area. According to the Pressure Ulcer Prevention & Prevention Treatment Clinical Practice Guideline, Slough tissue: Soft, moist, devitalized (avascular) tissue. It may be white, yellow, tan or green, and it may be loose or firmly adherent. (www.npuap.org). R9's care plan documents, (R9) has actual impairment to skin integrity of both ankles and sacrum. All were present on admission. This current care plan has no mention of R9's current right lower thoracic area Stage III pressure ulcer, or R9's risk for skin impairment. On 01/31/24 at 09:55 AM, R9 was lying in bed covered with a blanket watching television. R9 smiled and stated she would be getting her shower soon, I am going to get my hair washed today. V4 (Care Plan/Minimum Data Set Coordinator/Wound Nurse) entered R9's room to provide wound care to R9's pressure ulcers. V4 removed the current dressing in place to R9's right lower thoracic area, and an oval-shaped red, open area approximately 3 cm (centimeters) by 2 cm was present with areas of eschar (brown scabbed) tissue present . V4 cleansed R9's pressure ulcer with wound cleanser and applied a new dressing. On 01/31/24 at 11:00 AM, V4 (Care Plan Coordinator/Wound Nurse) stated that R9's Braden Scale Assessments were not completed quarterly as directed by the facility's Pressure Ulcer Prevention policy. V4 stated R9 had a change in condition around the time her pressure ulcer developed and was admitted under the care of hospice services shortly after. V4 verified no Braden Scale Assessment was completed at that time. V4 also confirmed that no additional pressure relieving interventions were implemented at the time of R9's decline. V4 then stated that R9 should have been considered a high risk for pressure ulcer development, since R9 had a Stage III pressure ulcer on her sacrum upon admission. V4 stated that R9 should have been receiving daily skin checks, and the development of R9's right lower thoracic area pressure ulcer that had progressed to Stage III upon discovery could have been avoided or discovered before progressing to a Stage III if daily skin checks were being completed, Someone should have seen it while (R9) was receiving daily cares. V4 also confirmed that R9's current care plan had no mention of R9's lower thoracic area pressure ulcer.

Based on interview and record review, the facility failed to ensure resident safety during van transport for one (R1) of four residents reviewed for falls in a sample of three. This failure resulted in a 5th metacarpal fracture of R1's hand. Findings include: R1's current clinical record documents R1 is cognitively intact, and has diagnoses including generalized muscle weakness, low back pain, history of falls, and a left artificial hip joint (since 05/2023). R1's Incident note, dated 11/21/23, by V9, Licensed Practical Nurse/LPN, documents Resident slid from w/c (wheelchair) while exiting transport van. Small abrasion to forehead. Bleeding stopped and no c/o (complaint of) pain elsewhere. Neuros (neurological signs) WNL (within normal limits). On blood thinner. Witnessed by (V4, CNA/Certified Nursing Assistant). Ambulance call for transport to ER (emergency room ) further evaluation. R1's Incident note, dated 11/21/23, by V8, LPN, documents Resident returned from (named ER/emergency room ) due to fall. CT (Computerized Tomography) was normal. Multiple abrasions on left hand/knuckles, right kneecap, and top of head. No complaint of pain. R1's Medication Administration Record/MAR, dated November 2023, documents, Monitor laceration to top of scalp, left hand/knuckles and left kneecap - report any redness, warmth, or drainage to NP (Nurse Practitioner) or MD (Medical Director) every shift for monitoring for 7 days. Start date 11/22/23. D/C (Discontinue) Date 11/24/23. R1's Radiology Report, date of service 11/24/23, documents, Hand 2V (two views), Left Results: There is a fracture involving the 5th metacarpal with minimal callus and mild displacement. There is associated soft tissue swelling .Conclusion: Left hand fracture as described. This radiology report documents a report date of 11/25/23 at 1:02 AM. R1's written Physician Progress Notes, dated 11/27/23, documents Needs a brace for left hand - 5th metacarpal fracture. Please schedule and appointment with orthopedics for left hand fracture and was noted by V5, Registered Nurse/RN on 11/27/23 a 1:24 PM. R1's Physician Progress Note, dated 11/28/23 and signed by V11n R1's physician, documentsn Diagnosis and all orders for this visit: Closed displaced fracture of neck of fifth metacarpal bone of left hand, initial encounter. History of Present Illness: fell during transport, injured right (left) hand. Had an x-ray at the facility that shows a metacarpal fracture right (left) hand. R1's Discharge Instructions, dated 11/29/23, documents, Follow up with ortho (orthopedics) and keep splint on nwb (no weight bearing) to left hand. This document is signed by R1 and e-signed by V8, LPN. On 01/10/24, at 10:07 AM, V10 R1's family member stated R1's left hand was fractured in two places after his last fall on 11/21/23. V10 stated R1's left hand is his prominent hand and he can't do anything with a brace on. At this time, V10 confirmed (R1) is seeing an orthopedic doctor and had a second x-ray which showed that one bone is healing, but the other one isn't. On 01/10/24, at 3:07 PM, V4, CNA/Transportation Driver, stated the following: I picked (R1) up from hospital (on 11/21/23). When we pulled up to the front door entrance, I lowered the ramp down. I told (R1) to keep his feet up so we could get him down, and he said 'yeah yeah' sarcastically. When we started going down slowly he started to try to put his hands on the wheels to try to help and I said 'no no gotta keep your hands up.' As soon as I said that he put his feet down where the end of the ramp met the ground. Then he fell forward and fell on his forehead. The first point of contact was his head. V4 continued to state, During the wheelchair going down residents have to keep their feet up. He didn't have any footrests or a bag on the back of his wheelchair. I am prn (work as needed) and not sure if he was supposed to have footrests on his wheelchair. He needed constant reassurance to keep his feet up. If residents are unable to keep feet up at times you might have to incline them up so their foot pedals aren't hitting against the ramp. I did not tilt him back. Regardless if able to keep feet up or not everyone should have footrests on their wheelchairs. He could keep his feet up, but wanted to help. If he would have had footrests, he would have had his feet up, and I would have only had to watch his hands which were easier to stop and less likely to incur injury. I am not the typical transport person and was filling in for (V7, Main Transportation Driver). On 01/11/24, at 9:19 AM, V7, Main Transportation Driver/CNA, stated V7 does the training for the van and their bus. V7 stated, I show them how to manually lower the ramp on the van. I tell them to line it (the wheelchair) up with the ramp and to go slow. I ask the resident to keep their hands on their lap and their feet on the foot pedals. We have foot pedals for every wheelchair. They should have them on during transport, but some do refuse. (If refuse) I definitely tell them they will have to keep their feet up and watch that they do. When going down the ramp, I have them lift their feet up. I have transported (R1) before and no problems. I know he self propels and will put his feet down, so I have to watch for it. He might have refused the pedals that day. I don't know why there weren't foot pedals on that day since I wasn't here. (R1) probably put his feet down .The safety of our residents is number one priority. It is important to watch their hands and feet and go slow. On 01/11/24, at 3:30 PM, V2, Director of Nursing/DON, stated, A couple of different possibilities (that may have caused R1's hand fracture) - he did land on his left side when he was with therapy. It was the only fall he specifically landed on the left side. The last fall during the transport, I was told he landed more face first and got the abrasions. The radiology report doesn't say it is acute. I am not sure when if first occurred. The Nurse Practitioner documented left hand edema but no pain on 11/24/23. During the fall, it was reported to me that he did not have footrests on the wheelchair. He self propelled often, so don't believe he had them on. At this time, V2 confirmed it is the transportation driver's responsibility to keep residents safe during transfer. V2 stated it is not V2's expectation for residents to self-propel out of the van. On 01/11/24, at 4:06 PM, V11 R1's physician stated, I looked at the films at that visit. I agree the quality of the film isn't great. It is not possible to know whether it (the fracture) is new or old. (R1) was asymptomatic enough to have no concern about his hand. He had no complaint of pain only swelling when Nurse Practitioner ordered the x-ray. My sense is that it is subacute whether than acute. I can not be certain of when the fracture occurred, but it most likely happened with a fall. The facility's Wheelchair Leg Rests policy, dated 8/5/23, documents, Policy Statement: It is the intent of this policy to allow residents/patients to be transported safely in wheelchairs. To this end, wheelchairs will be equipped with leg rests that fit the wheel chair properly and are accessible for use at all times. Procedure: 3. Wheelchair leg rests are to be in position on the wheelchair in the following situations: a. The patient is being propelled by employees, family members, volunteers, therapists, etc .5. General safety precautions when using wheelchair leg rests: c. Once the patient is seated in the wheelchair, make certain the footrests are lowered and secured with the resident's feet in place before releasing the brakes and moving the wheelchair. The facility's Job Description Certified Nursing Aide, undated, documents Primary Responsibilities: Use proper techniques for resident escort and transfer. The facility's Falls Prevention and Post-Falls Management policy, dated 8/8/23, documents, Resident-Centered Approaches to Fall Risk Assessment: 8. In conjunction with the attending physician, staff will identify and implement relevant interventions (for example hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. The facility's van Installation Instructions manual, undated, documents Other items to consider when determining floor anchorage placement: Tiedowns should have a clear path from floor anchorages to the wheelchair frame without infringing on any parts of the wheelchair (E.g. (for example) footrests). This Instruction manual includes numerous photos of a manikin sitting in a wheelchair. All of the photos show the manikin's feet resting on the wheelchair footrests.

Based on interview and record review, the facility failed to initiate interventions to address a resident's risk for falls and failed to complete neurological assessments as required for a resident (R1) who had sustained an unwitnessed fall with head trauma. These failures resulted in R1 experiencing a fall with serious injury, which contributed to R1's death. Findings include: The facility Fall Reduction Protocol policy, dated (revised) [DATE], directs staff, The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); Evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s); and Monitoring for effectiveness and modifying interventions when necessary. All residents will be assessed upon admission, following a fall, quarterly, or if the IDT (Intra Disciplinary Team) recognizes a significant change in resident condition. All residents are assessed on admission using the Admission Nursing Evaluation. Residents identified as being at risk for falls will have individualized care plan interventions. The facility Neurological Assessment and Flow Sheet policy, dated (revised) [DATE], directs staff, The neurological flow sheet shall be initiated when indicated by resident assessment and/or Physician order including but not limited to the following situations: Following a fall with a witnessed head injury; Following an un-witnessed fall of a resident taking anticoagulants; Following an un-witnessed fall of a resident with high-suspicion of a head injury. The neurological assessment will be completed every fifteen minutes for the first hour, every thirty minutes for the next hour, every one hour for the next two hours and then every twelve hours for the next seventy two hours. Neurological assessment and documentation on the flow sheet shall include: Date and time of assessment, Vital signs, Level of consciousness, Pupillary response and Limb response. The nurse shall document and report any pertinent changes in the resident's neurological status immediately to the physician. Significant changes in condition per the neurological assessment may result in transfer to the hospital for further evaluation and treatment. R1's Hospital Transfer Sheet, dated [DATE] documents that R1 was discharged from a local hospital on [DATE] after a 2 day hospital stay for Influenza A and Pneumonia and admitted to the facility. Additionally, R1's diagnoses included: Atrial Fibrillation, Hypertension, Muscle Weakness and Need for Assistance with Personal Care. R1's Admission Progress Notes, dated [DATE] at 4:20 P.M., document, (R1) arrived (at) approx (approximately) 3:40p (P.M.) today via bus. Droplet precautions x 24 hours as long as remains afebrile, then can d/c (discontinue) iso (isolation) after the 24 hours. PT/OT (Physical Therapy/Occupational Therapy) aware of (R1's) arrival. (R1) hard 1 assist transfer with gait belt. Alert and oriented. R1's facility Fall Risk Assessment, dated [DATE], documents R1's Fall Risk as Moderate Risk due to fall(s) in the past 3 months, secondary diagnoses (atrial fibrillation, weakness and requires assistance with activities of daily living), use of wheelchair and (requires) staff assist for ambulation, a weak gait, and overestimates or forgets limits. R1's facility Baseline Care Plan, dated [DATE], documents, Safety Risks: (R1) has a history of falls. No interventions to address R1's fall risk are documented on R1's baseline care plan. R1's Physical Therapy Plan of Care, dated [DATE] and signed by V8 (Physical Therapist/PT) documents, Functional Decline - (R1) presents to therapy with a decline in transfers and ambulation due to weakness and SOB (Shortness of Breath) due to influenza. Nursing has noticed a decrease in self care abilities resulting in decreased safety and an increased need for assistance. (R1) requires skilled physical therapy in order to improve safety and function. Without therapy (R1) at risk for falls and debility. R1's Occupational Therapy Plan of Care, dated [DATE] and signed by V9 (Occupational Therapist/OT) documents, Evaluation examination identified deficits of dressing, toilet hygiene, mobility, transfers. Therapy is necessary to address deficits and improve function. Without therapy (R1) at risk for falls, further decline in in functional status. R1's Nursing Progress Notes, dated [DATE] at 9:30 A.M. document, CNA (Certified Nursing Assistant) called writer into (R1's) room. (R1) in bathroom, lying on his back on the floor. States was going into the bathroom to use the toilet when his 'bad knee' (left) gave out and he fell backwards, hitting head on bathroom wall. No shoes on, (R1) in only socks. Rollator walker in front of toilet. Reminded (R1) he is still weak from hosp (hospital) stay and influenza, to please call for help. (R1) alert, denies pain other that soreness from lying on floor. Noted bleeding from top of head, R (right) wrist and R (right) forearm. PERRL (Pupils Equal and Reactive to Light). ROM (Range of Motion) done to all extrem (extremities). Denied pain other than to left knee, which he states he cannot bend all the way anyway, old surgical scar to left knee present. States no increased pain to knee post fall, states it is his norm (normal). Bleeding had already subsided to top of head. Up to w/c (wheelchair) with 3 assist and gait belt. Top of head left with abrasion and laceration within abrasion. Abrasion meas (measures) 5.0 x 1.8 cm (Centimeters) x 0.1 cm. Laceration within meas (measures) 4.0 x 0.3 cm x 0.2 cm. Top of head Right with abrasion meas (measures) 3.0 cm x 2.5 cm x 0.1 cm. R (right) wrist skin tear meas (measures) 2.0 cm x 0.3 cm x 0.1 cm v-shaped. R (right) forearm skin tear meas (measures) 3.4 cm x 2.0 cm x 0.1 cm. All areas cleansed with normal saline, TAO (Triple Antibiotic Ointment) and multiple steri strips applied. NP (Nurse Practitioner) updated when arrived and saw (R1). Oozing small amt (amount) of blood to frontal aspect of left head laceration. New order to send to ER (emergency room ). 911 called. Message to son with cond (condition) report. Transferred to ER. ER called with update. Rec'd (Received) call from ER approx (approximately) 4:30p (P.M.) that (R1) will be returning to facility. They gave him a tetanus shot, CT (Computerized Tomography) of head neg (negative), steri-strips left in place and small pressure dressing applied over top of laceration as still oozing small amt (amount) of blood. Rec'd (Received) call this afternoon from son, updated. States his dad 'very stubborn.' PT (Physical Therapy) updated earlier today re (in reference to): fall. R1's emergency room Notes, dated [DATE] document, (R1) with past medical history of Atrial Fibrillation on Eliquis (Blood thinner), difficulty ambulating who presents to emergency department after sustaining a mechanical fall. Per EMS (Emergency Medical Staff) nursing home staff stated (R1) is a 3-person lift assist and should not be ambulating by himself. (R1) attempted to ambulate by himself, fell hitting head against the wall. (R1) sustained an abrasion/small superficial laceration to top of head, was bleeding, therefore EMS was contacted and (R1) was transferred to the emergency department. (R1) did not have any LOC (Loss of Consciousness). CT (Computerized Tomography) of Cervical Spine and Head are negative. Clinical Impression: Closed Head Injury, Laceration of Scalp. R1's Neurological Checks, dated [DATE] document that neurological checks were initiated on R1 at 9:30 A.M. Subsequent neurological checks were completed at 9:45 A.M., 10:00 A.M., 10:15 A.M.,10:30 A.M., 11:00 A.M., 11:30 A.M., 1:15 P.M.,1:15 A.M. on [DATE]. R1's neurological assessment and vital signs are incomplete for the next required assessment on [DATE] at 1:15 P.M. R1's Nursing Progress Notes, dated [DATE] at 7:10 A.M. document, Writer called to (R1's) room by CNAs (Certified Nursing Assistants). CNAs report that they entered (R1's) room and (R1) in bed with lg (large) amount of emesis. They assisted (R1) into chair, when (R1) went unresponsive for approx (approximately) 5 sec (seconds), then came around. (R1) sitting upright when writer entered room. Awake, answering questions, but slowly. Color pale, skin warm/dry. Arms and hands mottling. O2 (oxygen) sat (saturation) 90% RA (Room Air). Initiated O2 (oxygen) at 3L Liters)/nc (nasal cannula). (Vital signs) ,d+[DATE], R (respirations) 28, P (pulse) 110. Loud audible congestion. Accucheck 258. Emesis was brown with mucus. Called 911 for transport to ER. Writer called ER with report and called son with cond (condition) change update, states will meet (R1) at hosp (hospital). Writer called ER at 1p (P.M.) to check on (R1's) status, ER nurse states they are transferring (R1) to (Trauma Center) with dx (diagnosis) of T9 (Thoracic) fx (fracture), R (right) hemothorax, L (left) rib fractures, and left pelvic fx (fracture). NP (Nurse Practitioner) updated. DON (Director of Nurses) updated. R1's (hospital) Discharge (Death) Summary, dated [DATE] documents, (R1) resident at (facility) with a brief episode of loss of consciousness and vomitus visible on his clothing. EMS brought (R1) to the emergency department. Found to have audible airway noise, tachypnecic and hypoxemic with 4 liter/minute oxygen flow rate. Chest x-ray showed opacification right hemothorax. CT scan confirmed a large amount of pleural fluid, rib fractures and thoracic vertebral fracture, unstable. (R1) had been evaluated by ED staff 4 days prior after fall at the same facility. (R1) has not had any additional falls since this injury. (R1) was lucid, alert during this ED evaluation and son and daughter-in-law at the bedside. All affirmed (R1's) wish for no invasive interventions. Neurosurgery was consulted regarding (R1's) vertebral fracture and felt that it was unstable and required evaluation for operative fixation. Likewise chest tube/thoracotomy would be necessary to evacuate the pleural effusion. Transfer and evaluation for these procedures was ruled out by (R1) and his family. (R1) was admitted to the medical unit. Within a few hour's time (R1) expired peacefully. R1's Certificate of Death, dated [DATE] documents, Influenza, Pneumonia, Multiple Chest Injuries Due to a Fall. On [DATE] at 10:40 A.M., V2 (Director of Nursing/DON) stated, (R1) was at risk for falls from admission as he had fallen previously and was very weak due to recent Influenza and hospitalization . (R1's) Fall Risk Assessment was completed on admission and showed him at risk. A care plan should have been instituted upon admission with interventions to prevent falls. His baseline care plan was completed on [DATE] by V6 (Assistant Director of Nursing/ADON). (R1) did not have a care plan for falls started on admission or upon completion of the baseline care plan (on [DATE]). R1 did not have a plan of care initiated until after his fall on [DATE]. Neuro (logical) Checks include a neurological assessment and vital signs. They are to be completed per the scheduled times. At that time, V2 (DON) verified the missing neuro checks for R1. On [DATE] at 10:54 A.M., V4 (CNA) stated, I have been a CNA for the past [AGE] years, at this facility. I remember (R1). He needed help walking to the bathroom and his walker. He was weak and unsteady. I don't recall any specific interventions for him due to being at risk for falls. I don't recall ever reading (R1's) care plan. On [DATE] at 11:19 A.M., V3 (Registered Nurse/RN), Previous Employee, stated, I was recently an employee of the facility for the past [AGE] years. I have since taken a new position. I worked fulltime on the 4th floor, where (R1) was a resident. I remember (R1). I remember when (R1) was admitted to the building. I admitted him. I didn't start a care plan on admission for him. The MDS (Minimum Data Set) person (EMPLOYEE) usually does that a couple of days after admission. (R1) came from the apartments, here on campus. (R1) had lived there for many years. (R1) had also been a resident here previously and I was his nurse. When (R1) came to us from the hospital, (R1) was very weak due to his hospitalization and his diagnosis of influenza. (R1) was definitely at risk for falling. (R1) had frequently fallen at his apartment. I had spoken with his son many times and he told us from the start that (R1) was very stubborn and independent. (R1) needed one, sometimes two staff members to get him up and ambulate with him to the bathroom, due to his weakness. From the very beginning of his stay, we had caught him a couple of times trying to get up on his own. (R1) was very independent and private. (R1) was a proud man and didn't want to ask for help to use the bathroom. (V4/CNA) came to get me the morning (R1) fell in the bathroom and told me (R1) was on the floor. (R1) had not put his call light on and (R1) was wearing socks. (R1) was on the floor just inside the bathroom door, but his walker was across the room, near the toilet. You could tell where (R1) had fallen against the wall because there was dried blood on the wall behind (R1). (R1) had skin tears on both arms and an abrasion with a laceration to the top of his head. We assessed (R1) and then me, (V4) and another one of the CNAs got (R1) up into his wheelchair. I got (R1's) skin tears cleaned up and bandaged, but (R1's) head wound kept oozing blood. (R1) was on Eliquis. The facility NP (Nurse Practitioner) was in the building, and I had her come up and look at (R1). She said since (R1) had an unwitnessed fall and was on Eliquis, (R1) needed to go to the ER and be checked out. I called (R1's) son and then we transferred (R1) to the ER. (R1) came back later that afternoon. They said they did a CT Scan in the ER and it was negative, and they applied a pressure dressing to (R1's) head wound and left the bandage I had placed, in place. I was also here on the 23rd when we found (R1) that morning with the large red/brown emesis and in respiratory distress. We sent (R1) immediately to the ER. On [DATE] at 12:50 P.M., V7 (ADON/MDS Coordinator) stated, I was the ADON previously, but have been transitioning into the MDS position. We found the previous MDS person was not completing her work. Our nurses don't do a care plan on admission. They do the Fall Risk Assessment on admission. But a care plan is completed with the Baseline Care Plan, which is typically done 48 hours after admission. I don't know why (R1's) Baseline Care Plan does not include any interventions for R1's fall risk. (R1's) Fall Risk Care Plan was not initiated until [DATE], the day after (R1) fell . On [DATE] at 2:30 P.M., V8 (PT) verified he evaluated R1 on [DATE] and his concern was for R1's safety as R1 was at high risk to fall due to his weakness from his recent illness. On [DATE] at 9:51 A.M., V10 (CNA) stated, I remember (R1). (R1) was weak and sometimes it took two of us to get (R1) up and walk him to the bathroom. (R1) was caught a few times trying to get up by himself. I don't recall what (R1's) care plan was. On [DATE] at 9:57 A.M., V9 (OT) stated, I was R1's therapist. I evaluated (R1), two days after he was admitted . (R1) was alert, cooperative, but very weak. (R1) had been hospitalized with a respiratory infection and (R1) was still recovering. (R1) was very insistent that he wanted to go back to his apartment, here on campus. I documented on my report that (R1) was a high risk for falls due to all of those things, plus (R1) was impulsive. On [DATE] at 11:19 A.M., V11 (R1's Power of Attorney/POA) stated, I admitted (R1) to the facility on [DATE]. I was not with (R1) when he admitted but spoke with the facility on the telephone. I told them at that time that (R1) was stubborn and independent and had fallen many times at his apartment.

Based on observation, interview, and record review the facility failed to use proper transfer technique, identify root cause, and ensure fall interventions were provided and implemented for resident falls for two (R19 and R32) of eight residents reviewed for falls in the sample of 27. These failures resulted in R32 having pain and sustaining a lumbar fracture. Findings include: The facility Fall Reduction Protocol, Revised 1/5/2021, documents Policy Statement: The intent of the requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); Evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s); and Monitoring for effectiveness and modifying interventions when necessary. Procedures following fall . includes the completion of . E. Review and Update Plan of Care. 1. The current Care Plan for R32 includes the following diagnoses: Muscle weakness, Wedge compression fracture of fourth lumbar vertebra, [CONDITION(S)], and Chronic [CONDITION(S)] with [CONDITION(S)]. Congestive heart failure, and Supraventricular [CONDITION(S)]. This same Care Plan documents R32 is a high risk for falls related to confusion, gait/balance problems, poor communication/comprehension, and unaware of safety needs. This Care Plan includes the following interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach, encourage use and answer promptly. For no apparent acute injury, determine and address causative factors of the fall. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes. If resident is a fall risk, initiate fall risk precautions. The Quarterly MDS (Minimum Data Set) Assessment for R32, dated 10/22/22, documents R32 with impaired cognition with periods of wandering behavior, requires extensive assist of two staff for bed mobility, transfers, dressing and toileting and requires total assist of two for bathing. This same MDS documents R32 has functional limitations in range of motion to both upper and lower extremities. The Fall Risk Evaluations for R32, dated 7/1/22, 7/14/22, 7/29/22, and 8/3/22 all document R32 is At Risk for falls. R32's Fall Risk Evaluation, dated 9/5/22 documents NA (not applicable) for risk of falling. All of these evaluations document R32 with history of falls during last three months, balance problem while standing and walking and requires assistive device for gait and balance. R32's un-witnessed fall reports dated 7/8/22, 7/11/22, and 7/14/22 document R32 had falls. These reports did not document a root cause or intervention to prevent further falls. R32's un-witnessed fall reports dated 7/29/2022, 8/23/2022, 9/5/2022 and 9/28/2022 document R32 had falls. These reports do not document a root cause for the falls. The #70 Un-Witnessed fall report for R32, dated 7/2/22 at 2:30 am, documents Resident found lying on the floor, right side of bed. Resident was laying on his right side with right arm under head, left arm at side and both legs extended out in front of him. Resident stated, I rolled out of bed. This report documents R32 received an abrasion to left elbow and front of left knee and bruise to left elbow. This investigative report does not include a completed root cause analysis or fall intervention to prevent further falls. The #104 Un-witnessed fall report for R32, dated 8/3/22 at 1:20 pm, documents Staff member alerted resident was observed laying on floor, he was on L (left) side, skin tear to R (right) forearm . Call light was on floor next to w/c (wheelchair), it was not on . There were numerous papers and newspapers on the bed he was attending to during cleansing of wound and dressing of wound. Other documentation included Footwear was on but one shoe not tied up, off heel upon observation and assessment. This investigative report does not include a completed root cause analysis or fall intervention to prevent further falls. The #114 Un-witnessed fall report for R32, dated 8/7/22 at 9:00 am, documents Resident observed on floor. Res unable to give description. This report documents R32 received a skin tear to his left elbow. This investigative report does not include a completed root cause analysis or fall intervention to prevent further falls. The #173 Un-witnessed fall report for R32, dated 9/25/22 at 11:45 pm, documents Entering room resident was found laying up against wall behind door. Right shoulder resting on floor, back up against wall and legs extended out in front of him. Resident stated, 'I was going out to put the mail on the chair.' This report documents R32 received a skin tear to the back of his left hand. This investigative report does not include a completed root cause analysis or fall intervention to prevent further falls. The #209 Un-witnessed fall report for R32, dated 10/25/22 at 11:30 pm, documents Resident was found on the floor next to the bed at 2330 (11:30pm) (Urinary) catheter is pulled out with missing tip. Resident is sent to ER (emergency room ) for potential injury in the urinary tract. This investigative report does not include a completed root cause analysis or fall intervention to prevent further falls. The Skilled Nursing Visit for R32, dated 9/28/22 documents R32 was seen by V17 PCP (Primary Care Physician). V17 PCP documented (R32) stumbled and fell while (at facility). Within 48 hours began having more severe lumbosacral pain. History of lumbar stenosis with previous laminectomy (back surgery) May 2022. Imaging here suggested mild compression deformity L1 that is probably acute on CT scan. Patient's pain was reasonably well controlled with Tylenol alone, though at times he had some spasms of pain. [MEDICATION(S)] low-dose to be added for pain control in addition to Tylenol. (Family) at the bedside and (Family) was brought up-to-date on diagnosis, prognosis, treatment plan. (R32) will return to the facility in improved condition. Assessment by problem: 1. Vertebral fracture, mild compression deformity L1 vertebrae, with good pain control with Tylenol at present though he has spasms of pain at times. Scheduled Tylenol 650 mg qid (four times a day). Add [MEDICATION(S)] 100 mg TID (three times a day). Return to the nursing facility and begin PT/OT. The Skilled Nursing Visit for R32, dated 10/27/22 documents R32 was seen by V16 APRN (Advance Practice Registered Nurse). V16 documented R32 was admitted to the local hospital from 9/27/22 to 9/28/22 for a closed compression fracture of L1 (first vertebra of lumbar spine) after a fall. (R32) was sent to (local) ER with c/o (complaints of) back pain after a recent fall. Found to have an acute compression deformity of L4 with grade 1 (mild degree) retrolisthesis (vertebra slip backward on one another and graded 1-4 based on percentage of backward displacement) at L3-L4. CT (computed tomography) showed no evidence of instability. Started on [MEDICATION(S)] and scheduled Tylenol due to occasional pain spasms in back. History of laminectomy in May 2022 due to lumbar stenosis. discharged back to (facility) for rehab (rehabilitation). Assessment/Plan: documents Compression fracture: Conservative treatment, PT/OT (Physical and Occupational therapy), Continue scheduled Tylenol and [MEDICATION(S)]. Consider starting [MEDICATION(S)] (treats bone loss) for [CONDITION(S)]. On 11/01/22 at 11:35 AM, R32 was lying in bed on his back, head of bed elevated, mats on the floor to both sides of R32's bed. R32's bed was elevated in a high position up off the floor, R32 sat up on the side of the bed, looked toward the open bedroom door, yelled out for help and then laid back down on his bed. There were no staff noted near R32's room or in the hallway at this time. On 11/02/22 at 09:21 AM, R32 was lying in bed on his left side with blue and purple bruising to his left forearm and left healing with a healing skin tear to his left elbow. R32 stated I fell down a while ago. I don't know how many times. On 11/3/22 at 11:50 AM, R32 was lying in bed on his right side with his eyes closed. R32's call light was behind R32, hanging over the headboard out of R32's reach. The floor mats were not on the floor next to R32's bed. The floor mats were folded up and in between the dresser and the closet in R32's room. On 11/4/22 at 10:00 AM V2 DON/Director of Nursing confirmed that R32 was a high risk for falls, mats should have been on the floor next to R32's bed, R32's bed should have been lowered to the floor, and R32's fall investigations did not include a completed root cause analysis or did not have a fall intervention put into place to prevent further falls. V2 also confirmed R32 did complain of back pain after his fall on 9/25/22 and R32 was sent to the local hospital and returned with a diagnosis of lumbar fracture. 2. The Diagnosis Report for R19 includes the following diagnoses for R19: Fracture of lower end of left tibia, Open wound left lower leg, History of falling, and [CONDITION(S)]. The Witnessed fall report #154 for R19, dated 9/16/22 at 1:48 pm, documents Two nurse's aides were assisting to get resident up in w/c (wheelchair) for physical therapy. Resident stated she didn't want to have the mechanical lift for transfer. Stated she's been using the slide board approved by PT (Physical Therapy). While resident was transferring, she wasn't properly on the slide board for her transfer. The nurses aides lowered her to the floor. Resident didn't hit her head and left leg was supported. Resident description: Resident stated she was transferring into w/c with slide board and wasn't properly on the slide board for transfer. This report documents R6 RN/Registered Nurse prepared the fall report and V7 CNA/Certified Nursing Assistant, and V8 CNA witnessed the fall. On 11/02/22 at 10:37 AM, R19 was lying in bed with a metal surgical rod extending out of her left leg. R19 stated she fell at home, broke her leg, came to the facility for therapy and is not to bear any weight on her left leg. R19 stated on 9/16/22 the staff were transferring her with a sliding board, weren't listening to her, the wheelchair wasn't positioned right, and she ended up on the floor. On 11/03/22 at 11:41 AM, R19 stated I haven't used the sliding board since I fell . The staff use the mechanical lift to get me up. Only Therapy uses the sliding board with me. On 11/03/22 at 2:05 PM V7 CNA stated on 9/16/22 V7 and V15 CNA were transferring R19 from her bed to her wheelchair with a sliding board. V7 stated she told R19 she didn't feel good about using the sliding board to transfer R19 but R19 kept saying therapy said she could use it and cleared her to use it. After R19's fall, V7 stated that (V7) asked V8 PT/Physical Therapist about using the sliding board and V8 PT said he did not release R19, and we should be using the mechanical lift. V7 CNA stated R19 was not sitting right on the board, has an air mattress and moved too fast, and was lowered to the floor. On 11/03/22 at 2:10 PM V6 RN stated she was the Nurse for R19 on the day R19 fell . V6 RN stated the CNA's used a transfer sliding board, on R19's air mattress, and R19 started sliding before V7 and V15 (CNA's) were ready and they had to lower R19 to the floor. On 11/03/22 at 2:19 PM, V8 (PT) stated therapy has been working with R19 on sliding board transfers in therapy only and no one should have been transferring her with the sliding board except therapy. Sliding boards are not to be used on air mattresses and R19 should have been a mechanical lift for transfers. On 11/3/22 at 2:30 pm, V2 DON/Director of Nursing confirmed V7, and V15 CNA's should not have been using a sliding board while transferring R19 from her bed to the wheelchair.

Based on interview and record review, the facility failed to notify the physician of a significant weight gain for one (R39) of three residents reviewed for weights in a sample of 32. This failure resulted in R39 experiencing a heart failure exacerbation and subsequently being hospitalized for [REDACTED]. Findings include: The facility's Notification of Changes policy dated 11/22/16 documents a facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is the following. A significant change in the resident's physical, mental, or psychosocial status. A need to alter treatment significantly. The facility's Weight policy dated 3/11/14 documents, The individuals physician will be notified of significant weight changes greater than five percent in one month, greater that 7.5 percent in three months and greater than 10 percent in six months as as warranted outside those parameters. The facility's Care Path Symptoms of [MEDICAL CONDITION] dated 2014 documents, weight gain of greater than five pounds (lbs) in a week, notify physician. R39's physician's orders [REDACTED]. Call doctor's (V10, R39's Cardiologist) office if weight gain greater than three pounds overnight or five pounds in one week. R39's medical record dated 11/21/19 documents R39's weight at 1[AGE].00 lbs and on 11/23/19, R39's weight at 203 lbs. On 02/27/20 12:26 PM V2, Director of Nursing (DON), stated when a resident has a significant weight change the physician should be notified. On 2/27/20 at 02:39 PM V2, DON, verified there were no physician notifications or new orders addressing R39's significant weight gain on 11/23/19 until physician communication was sent on 12/7/19. V2, DON, stated (R39) was sent to the hospital on [DATE] directly from the cardiologist's office for a 20 lbs weight gain. On 02/27/20 at 02:38 PM V3, Assistant Director of Nursing (ADON), verified there was no physician notification for R39's significant weight gain on 11/23/19 until 12/7/19. On 02/27/20 at 12:27 PM, V3, ADON, stated (R39) was sent to the hospital from the cardiologist's office on 12/11/19 for fluid gain and was put on an intravenous (IV) [MEDICATION NAME] (diuretic). R39's nursing note dated 12/11/19 documents resident (R39) is staying at hospital for observation due to a 20 lb weight gain and high blood pressure. R39's hospital record dated [DATE] document R39 was admitted on [DATE] and discharged on [DATE]. R39's hospital record documents between 12/11/19 and [DATE] (R39) was admitted to hospital for heart failure exacerbation and was treated for [REDACTED]. On 02/28/20 at 09:55 AM, V9, Medical Director (MD), stated I should have been notified of his (R39) significant weight gain on the 23rd (11/23/19). Something should have been done. Had I been notified, I would've evaluated him and added a diuretic to his orders or increased his diuretic and put him on a fluid restriction. His hospitalization potentially could have been prevented if I had been notified when he (R39) had the significant weight gain.

Based on interview and record review the facility failed to identify and prevent worsening of a pressure ulcer for one (R215) of four residents reviewed for pressure ulcers in a sample of 66. This failure resulted in the development, decline and increase in size of a stage three pressure ulcer. Findings include: Facility Policy and Procedures, revised 12/4/17, documents that any resident admitted without a pressure ulcer/injury will not develop a pressure ulcer or a resident who has a pressure ulcer/injury will receive care, services to promote healing and prevention of additional pressure ulcer/injury; prevention of pressure ulcers/injury will be through assessment, care plans, evaluation and monitoring of the resident; a pressure injury present as intact skin and may be painful; a pressure ulcer will present as an open ulcer, as a result of intense/prolonged pressure or presence the tolerance for soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition and co-morbidities; avoidable pressure ulcer- means the resident developed a pressure ulcer/injury and the facility did not define and implement interventions that are consistent with the resident needs, resident goals and professional standard of practice, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate; and additional clinical condition - utilize additional information for risk analysis including impaired mobility, co-morbidities, continence status, medications and nutritional status. R215's Physician order [REDACTED]. No coccyx pressure ulcer issues or treatments are documented. R215's current Care Plan, dated 10/20/17, documents incontinence care, assessment of skin and perineal area and change padding/toilet or give proper hygiene and that R215 requires limited to extensive assistance with activities of daily living. No coccyx pressure ulcer issues or interventions are documented. R215's Admission Nursing Evaluation, dated 10/12/17, documents that R215 had a large bruise to neck, posterior right hip, redness to bilateral heels, hematoma to center of forehead and two small abrasions to bilateral collar bones. The Admission Nursing Evaluation documents that R215 is continent of bowel and bladder and does not document any issues with R215's coccyx. R215's Nursing Note, dated 10/12/17, documents that R215 was admitted to the facility with no complaints of pain and that R215 ambulates with stand-by-assistance with one staff member. R215's Scale for Predicting Pressure Ulcer Risk, dated 10/12/17, documents that R215 was a mild risk for skin breakdown. R215's Minimum Data Set/MDS assessment, dated 10/19/17, documents under H0200 (Urinary Toileting Program), that R215 was occasionally incontinent of urine and frequently incontinent of bowel. The MDS assessment also documents under section J0100 (Pain Management), that R215 had pain in the last five days and received/or was offered pain medication. The MDS assessment documents under section M0900 (Skin Conditions) that R215 had no pressure ulcers but was at risk for pressure ulcers. R215's MDS assessment, dated 10/26/17, section M0900 (Skin Conditions) documents an unhealed stage three or four pressure ulcer measuring 2.5 centimeters/cm X 1.2 cm with no depth. R215's MDS assessment, dated 11/8/17, documents under section J0300 (Pain Management) that R215 had pain rated at an eight, on a scale of one to ten; under section G0110 (Activities of Daily Living) R215 requires staff assistance to toilet, and that R215 had an indwelling catheter. Section M0900 (Skin Conditions) documents an Unhealed Stage Three or Four Pressure Ulcer measuring 4.4 cm X 4.2 cm X 2.8 cm. R215's Nursing Note, dated 10/24/17, documents that R215 complained of pain on coccyx and staff identified a new stage three wound measuring 2.5 cm X 1.2 cm X 0.5 cm. The wound presented with maceration, swollen edges, no drainage and slough in the wound bed. R215's Nursing Note, dated 10/26/17, documents that R215's laboratory [MEDICATION NAME] level was low (2.8), a fair nutritional intake (an average intake of 60% at mealtimes) and resident needing increased nutrients. R215's physician progress notes [REDACTED]. R215's Progress Notes, dated 10/20/17, document that V6 (R215's Nurse Practitioner) did not document any pressure ulcer issues. V6 documents that R215's briefs have been wet. R215's Progress Notes, dated 10/24/17, document that V6 (R215's Nurse Practitioner) provided services to evaluate R215's coccyx wound. V6 documents that (R215) complained of sore bottom and had large open area on coccyx, with white center and no drainage. R215's Nursing Notes, dated 10/30/17, documents an appointment, on 10/31/17, with V5 (R215's Surgeon) for surgical debridement of the coccyx pressure ulcer. R215's Nursing Note, dated 10/30/17, documents the coccyx dressing falls off several times a shift, slough now fibrous with opening and large amounts of foul drainage, noted tunneling. R215's Nursing Note, dated 10/31/17, documents a new order for an indwelling catheter to be inserted due to the coccyx wound. On 12/6/17, at 11:15 am, V9 (R215's family) stated that (R215) admitted on [DATE], with a pressure sore that she got from the hospital. By the time they found it on 10/24/17, it got worse and required surgery. (R215) came into the nursing home needing a little help to use the toilet, and because they took so long to answer call lights, eventually they started putting (R215) in diapers. I think the moisture from the diapers made her tailbone worse. I would come in many times and the diaper was wet. On 12/7/17, at 11:55 am, V6 (R215's Nurse Practitioner) stated, I was notified on 10/24/17 of the pressure ulcer and made a referral to a surgeon because at that time it was a suspected deep tissue injury. The development of this pressure ulcer was a sudden thing. The facility should put preventative measures in place for at risk residents, so skin issues do not develop or get worse. On 12/7/17, at 2:27 pm, V7 (R215's Wound Consultant) stated, I assessed the pressure ulcer on 10/26/17, and it was an unstageable pressure ulcer with slough. Pressure ulcers can develop, due to many issues, such as co-morbidities and nutritional status. Nurtional status plays a huge role in skin issues. It declined so fast, it could have started as a deep tissue injury. An indwelling catheter was eventually inserted, due to the skin being exposed to incontinence and causing skin breakdown and to promote the healing of the pressure ulcer. It is the facility's responsibility to assess new admissions for pain related to pressure points, nutritional interventions and adequately put additional interventions into place to avoid a pressure ulcer or deterioration of a pressure ulcer. If the facility adequately assesses and follows the pressure ulcer/skin policy, I would expect an ulcer to heal. On 12/7/17, at 10:30 am, V9 (R215's Surgeon's Nurse) stated, (R215's) notes from the 11/2/17 appointment document that when the pressure ulcer was first observed on 10/24/17, it measured 2.5 cm X 1.2 cm X 0.5 cm, and on the 11/2/17 appointment, the measurements were 4.0 cm X 3.0 cm and redness with local [MEDICAL CONDITION] and that (R215) was scheduled for surgical debridement on 11/13/17.

Based on interview and record review, the facility failed to notify the physician of a change in condition for one of one resident (R1) reviewed for physician notification, in a sample of three. This failure resulted in R1 experiencing a delay in treatment which ultimately led to R1's death. FINDINGS INCLUDE: The facility policy, Change of Condition and Emergency Evaluation of Resident, dated (revised) [DATE] directs staff, Change in Condition: Immediate Notification, Any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. R1's Nurse's Notes, dated [DATE] (no time stamp) document, (R1) continues to c/o (complain of) right flank pain from fall recently. V/S (vital signs) WNL (within normal limits) on room air. Assisted in repositioning to improve breathing. R1's Skilled Daily Nursing Note, dated [DATE] documents, Pain, Origin: Fall, Location: Right Lateral Back, Intensity: 6:10. SaO2 (arterial oxygen saturation) 90% (normal 100%). R1's Nurse's Notes, dated [DATE] at 0350 (3:50 A.M.) documents, (R1)'s temperature (is) 99.6. SPO2 on room air 92%. (R1's spouse) came to the nurse's station and said she could hear (R1) breathe. Audible wheezing noted. Auscultation reveals upper and lower expiratory wheezes. R1's Nurse's Notes, dated [DATE] at 8:00 P.M. document, Color pale, T (temperature) 99.4, Resp (respirations) 32 (normal ,[DATE]/minute). O2 (oxygen) at 4 liters/nasal cannula, SPO2 (pulse oximetry) 88%. R1's Nurse's Notes, dated [DATE] at 12:00 A.M. document, (R1) short of breath. Restless. SPO2 74% on O2 at 4 liters/ nasal cannula, respirations 38. Send to ER (emergency room ) for evaluation and report. On [DATE] at 1:25 P.M., E3/Registered Nurse stated, On [DATE], I worked day shift. (R1) was complaining of pain in the right rib cage/side when (R1) would breath. I listened to (R1)'s lungs, they were diminished in the bases. I didn't think this was an emergency. On [DATE] at 7:15 A.M., E7/Licensed Practical Nurse stated, On [DATE] at 8:00 P.M., I went into (R1)'s room and (R1) had oxygen on. That was new. (R1)'s color was pale. (R1) had a low grade temperature. (R1)'s respirations were 32, they were elevated. I checked (R1)'s pulse ox (oxygen) level, it was 88%. I did not listen to (R1)'s lungs. I did not notify the doctor at that time. I had been told the doctor was aware. On [DATE] at 10:00 A.M., E8/Registered Nurse stated, I worked [DATE]. I guess an elevated temperature, audible wheezing and expiratory wheezing on auscultation would constitute a change in condition. No, I did not call (R1)'s doctor. On [DATE] at 12:45 P.M., E9/Medical Director stated, The standard treatment for [REDACTED]. If (R1) had received hospital or emergency treatment earlier than (R1) did, (R1) shouldn't have died . R1's emergency room report , dated [DATE] documents,Diagnosis: [REDACTED]. In the hospital (R1) was kept comfortable . (R1)'s condition deteriorated and (R1) died .

Based on interview and record review, the facility failed to recognize, assess and address a continuing decline in a resident's condition after a fall, for one of one residents (R1) reviewed for falls, in a sample of three. These failures resulted in R1 developing a life-threatening condition, subsequent hospitalization and death. FINDINGS INCLUDE: The facility policy, Change of Condition and Emergency Evaluation of Resident, dated (revised) [DATE] directs staff, Change in Condition: Immediate Notification, Any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. It is the policy of the community to seek immediate evaluation for residents with a change in condition. R1's Physician order [REDACTED]. This same document includes the following medications: [REDACTED]. R1's facility Admission Nursing Evaluation, dated [DATE] documents R1's skin on admission as, Redness to bottom and scattered bruising on arms. R1's Fall Risk Evaluation, dated [DATE] documents R1's fall risk as a 22. A resident who scores a 10 or higher is at risk (for falls). R1's Incident Report, dated [DATE] at 11:30 P.M. documents, Bed alarm sounding. (R1) sitting on the floor next to bed with back against the wall and walker in front of (R1). Able to move all extremities WNL (within normal limits). Denies pain. Red mark noted to right upper back below shoulder. R1's Nurse's Notes, dated [DATE] (no time stamp) document, (R1) having c/o (complaints of) pain to lower back from falling on [DATE]. SNF (Physician) notified via fax asking for order for PRN (as needed) Tylenol. R1's Nurse's Notes, dated [DATE] (no time stamp) document, (R1) continues to c/o (complain of) right flank pain from fall recently. V/S (vital signs) WNL (within normal limits) on room air. Assisted in repositioning to improve breathing. R1's Skilled Daily Nursing Note, dated [DATE] documents, Pain, Origin: Fall, Location: Right Lateral Back, Intensity: 6:10. SaO2 (arterial oxygen saturation) 90% (normal 100%). R1's Nurse's Notes, dated [DATE] at 0350 (3:50 A.M.) documents, (R1)'s temperature (is) 99.6 (degrees fahrenheit). SPO2 on room air 92%. (R1's spouse) came to the nurse's station and said she could hear (R1) breathe. Audible wheezing noted. Auscultation reveals upper and lower expiratory wheezes. R1's Nurse's Notes, dated [DATE] (no time stamp) documents, N/O (new order) chest X-RAY today (due to) SOB (shortness of breath), low O2 (oxygen) sats (saturations) and right rib pain. On this same date at 8:00 P.M., R1's Nurse's Notes document, Color pale, T (temperature) 99.4 (degrees fahrenheit), Resp (respirations) 32 (normal ,[DATE]/minute). O2 (oxygen) at 4 liters/nasal cannula, SPO2 (pulse oximetry) 88%. R1's Chest X-RAY report, dated [DATE] and time stamped as 9:11 P.M. as being faxed to the facility, documents, Impression: Infiltrate and/or atelectasis (a complete or partial collapse of a lung or a lobe of a lung) is noted in right lower lobe in addition to a moderate sized right pleural effusion (excess fluid that accumulates in the pleural cavity). R1's Nurse's Notes, dated [DATE] at 12:00 A.M. document, (R1) short of breath. Restless. SPO2 74% on O2 at 4 liters/ nasal cannula, respirations 38. Send to ER (emergency room ) for evaluation and report. R1's emergency room report , dated [DATE] documents,(R1) with a past medical history of [REDACTED]. Per (R1) family, (R1) has increased confusion and shortness of breath throughout the day yesterday. Nursing home reports (R1) had a chest X-RAY which showed a new pleural effusion. Vital signs in the emergency room showed oxygen saturation of 76% on room air, pulse of 111 and respiratory rate of 36. EKG (electrocardiogram) showed [MEDICAL CONDITION]. CMP (complete metabolic panel) showed low [MEDICATION NAME] and elevated total bilirubin, mildly elevated glucose and BUN (blood urea nitrogen). Chest X-RAY showed a right hydro pneumothorax. ED (emergency department) was unable to place a chest tube because of low blood pressure. (R1) family decided to go with comfort measures. (R1) was admitted to the floor for comfort measures. Palliative care consultation was called. In the hospital (R1) was kept comfortable . (R1)'s condition deteriorated and (R1) died . Diagnosis: [REDACTED]. R1's Death Certificate (dated [DATE]) documents R1's date of death was [DATE]. This record documents a cause of death was [MEDICAL CONDITION] with other significant conditions contributing to death as hypertensive cardiovascular disease and hemopneumothorax. On [DATE] at 1:25 P.M., E3/Licensed Practical Nurse stated, I was (R1)'s nurse on [DATE] (day shift). (R1) was complaining of pain in (R1)'s right rib cage or side when (R1) would breath. I put pillows under (R1)'s arms, sat (R1) up starlight and sent a fax for some Tylenol. I didn't think this was an emergency. On [DATE] at 2:05 P.M., E4/Certified Nursing Assistant stated, (After the fall) (R1) complained of right rib pain. (R1) said (R1)'s body hit something when (R1) fell and it didn't feel right. You could tell (R1) was a lot weaker. (R1)'s transfers were a lot more difficult. (R1) had a huge turn around. (R1) was very different. (R1) had been a one assist with supervision (for transfers) and (R1) was becoming a heavy assist of two (staff). (R1) was weak after the fall. (R1)'s (spouse) said (R1) had started yelling and cussing, which was new for (R1). The nurse was aware of (R1)'s condition. We had discussed (R1). On [DATE] at 2:20 P.M., E5/Certified Nursing Assistant stated, I was working the night (R1) fell . Me and (E6/Certified Nursing Assistant) went to (R1)' s room due to the alarm sounding. (R1) was sitting on the floor, next to the wall. There was a red spot on (R1)'s back. On [DATE] at 3:00 P.M., E6/Certified Nursing Assistant stated, I was working the night (R1) fell . We heard (R1)'s alarm sounding and went running to (R1)'s room. We got to (R1)'s room about the same time. (R1) was sitting next to the wall, (R1)'s back was against the wall. (R1)'s walker was next to (R1). (R1) must have fallen from a standing position and hit (R1)'s walker or the bed frame because (R1) had quite a red mark on (R1)'s right shoulder. I didn't work again for a few days, but when I did, there was a huge difference in (R1). Even (R1)'s (spouse) said (R1) was different. (R1) was very pale by then, (R1) was not talkative. Infact, (R1)'s (spouse) said (R1) was crabby. (R1) also now required extensive assist of two (staff) for all transfers. (R1) was in pain and kept saying (R1)'s back hurt. I told my Nurse (E7). (R1) went to the hospital around midnight and (R1) never came back. (R1) was having a real hard time breathing by then. I hear (R1) died . On [DATE] at 7:15 A.M., E7/Licensed Practical Nurse stated, I was working the night (R1) fell . When I got to the room, (R1) was sitting on the floor, next to the wall. I returned to work on [DATE]. I went into (R1)'s room, (R1) had oxygen on, (R1)'s color was pale, (R1) had a low grade temperature, (R1)'s respirations were 32, they were elevated. I checked R1's pulse ox (oxygen) , it was 88%. I did not listen to (R1)'s lungs. Around midnight, I called the On-Call Practice because (R1) was a lot worse and needed to be sent out (to the hospital). (R1) left around midnight, (R1) looked really bad. I guess (R1) died at the hospital a few hours later. On [DATE] at 10:00 A.M., E8/Registered Nurse stated, I worked the night of [DATE]. (R1)'s wife summoned me to (R1)'s room. She said she could hear (R1) breathing. (R1)'s lungs had expiratory wheezes bilaterally. (R1)'s temperature was 99.6 (degrees fahrenheit) and (R1)'s (oxygen) sats (saturations) were 92%. Our policy is to notify the doctor if there is a change in condition. I guess an elevated temperature, audible wheezing and expiratory wheezing on auscultation would constitute a change. No, I did not call (R1)'s doctor. On [DATE] at 2:05 P.M., Z1/Occupational Therapist stated, Yes, I was (R1)'s therapist. When I came back to work on that Monday after (R1) fell ([DATE]), there had been a significant change in (R1). (R1) was extremely short of breath and in pain. (R1) was complaining of pain in (R1)'s right ribs. We pulled up (R1)'s shirt and (R1) had bruising about sixteen to eighteen inches covering (R1)'s posterior rib cage. I was so concerned, I recommended that staff use a mechanical lift for (transfers) because (R1) was so weak. Nursing was aware of my findings. On [DATE] at 12:45 P.M., E9/Medical Director stated, Nursing Home staff should call me or the On-Call doctor if a resident has a change in condition, such as increasing shortness of breath and decreasing blood oxygen levels. The standard treatment for [REDACTED]. If (R1) had received hospital or emergency treatment earlier than (R1) did, (R1) shouldn't have died . By the time (R1) got to the hospital, (R1)'s lung was full of blood. We could have stopped the bleeding with Vitamin K.

Based on interview, observation, and record review the facility failed to protect two residents (R1 and R3) from verbal and physical abuse by staff members (E3 and E18) for two of three abuse allegations reviewed. This resulted in R1 being subjected to physical and emotional abuse by E3 causing bruising and fear to the point of shaking. Findings include: 1. On 8/10/16 at 3:00 pm, Z1 (R1's family) stated the following: I put the audio/video camera in (R1's) room after (R1) made comments that (E3/Certified Nursing Assistant/CNA) was not helping (R1) wipe, stand up, or dress; (R1) told Z1 that (E3) was not nice and made (R1) sit in the dining room for hours in the morning; E3 washed (R1's) genitals and stuck the washcloth in (R1's) face and then (E3) laughed at (R1); I (Z1) changed out the camera card everyday and looked at it after about a week of recording; on the video I (Z1) saw (E3) not helping (R1) and (R1) fall back into a chair hard; I also saw (E3) come rushing up to (R1) and flipped (R1) off; the video on 7/14/16 night shift going into 7/15/16 morning showed (E4 /CNA) was in (R1's) room and (E3/ CNA) told (R1) that (R1) hit (E3) and that was when I (Z1) called the police; on the video I saw (E4) roll eyes at (R1); and E3 was aggravated on the video and (R1) was heard saying 'Why do you hate me' on the video. On 8/10/16 at 10:40 am, R1 stated (R1) had diarrhea and needed help in the bathroom and E3/CNA refused to help (R1) and told R1 to clean up (R1's) own mess. R1 stated (R1) is unable to get up unassisted but did the best I could. R1 also stated this made (R1) feel pretty bad. R1 stated (R1) raised (R1's) fist but didn't hit (E3) because she is a lady. R1 stated E3 treated (R1) like a sack of potatoes frequently and has grabbed (R1's) arms causing bruising. On 8/11/16 at 1:00pm, E1/Administrator stated the following: (E1) was unaware there was a problem with E3, E4, and R1 until the police came to the facility on [DATE]. E1 also stated Z1 provided an edited video tape on 7/29/16 showing E3 and E4 as being physically, mentally and verbally abusive to R1. On 8/10/16 at 10:40 am, (R1) had a furrowed brow and (R1) raised (R1's) voice at times when talking about (E3). R1 also raised (R1's) fist during the interview while talking about wanting to hit (E3). The Nurses Notes for R1, dated 7/19/16 documents R1 with multiple bruises of unknown origin to the following areas: right arm, right elbow, back of right hand, left arm, upper tricep area, back of left elbow, back of left hand, left upper arm bicep area and to right bicep area. The local Police Department Incident Report # 1856, documents an audio/visual recording showing some of the evidence of E3 CNA (Certified Nursing Assistant) abusing R1. This report documents that on 6/16/16 at 8:56 pm, (R1) fell back into the bed from a standing positioning, and (R1's) head went back and over the other side of the bed. (E3) stood next to the bed and did not help (R1) up. The report documents that on 6/26/16 at 4:45 am, (E3) approached (R1) quickly, got in (R1's) face, and extended her index finger in front of (R1's) face. The report documents that on 6/26/16 at 9:01 pm, (R1) fell into (R1's) wheelchair while (E3) stood next to (R1). (R1) struck (R1's) left arm on the arm of the wheelchair and is in apparent pain. The report documents that on 6/30/16 at 4:25 am, The view of the camera is blocked by a sheet, but (E3's) right arm jabs in a punching motion toward (R1). (R1) is heard moaning immediately after the movement. (E3) stepped back, then made two more quick punching motions toward (R1) with her left arm. The report documents that on 7/9/16 at 4:51 am, (E3) approached (R1) quickly, got in (R1's) face, and extended her middle finger in front of (R1's) face. This report also documents that on 7/9/16 at 4:52 am, (E3) approached (R1) with a white towel in her hand, and attempted to roughly wipe (R1's) face. (R1) raised (R1's) hands to stop her and their was a struggle in front of (R1's) face where (R1) repeatedly said, No. The local Police Department Incident Report # 1856, documents (R1) told us that (E3) would be cleaning (R1's) testicles and would be very rough with (R1). (R1) went on to explain that (E3) would sometimes clean (R1's) privates with a rag and then wipe (R1's) face with the same rag. (R1) said this happened a few times that (R1) could recall. (R1) said (R1) would sometimes yell from the pain and (E3) would put her finger to her lips and tell (R1), 'Shhhh.' (R1) said (E3) would also squeeze (R1's) testicles too. (R1) said (R1) would tell (E3) not to do these things, but she did not listen. (R1) said there were times where (E3) would make a mean face at (R1) as well. (R1) said when (R1) would call for help and saw (E3) come in the room (R1) would shake because (R1) was so afraid. (R1) said (R1) kept these things to (R1's) self because (R1) was afraid to tell anyone. The local Police Department Incident Report # 1856, also documents E3 CNA was arrested on 7/28/16 for two warrants: The first warrant was for Aggravated Battery and the second for Abuse of a Long-term Healthcare Facility Resident. 2. The facility's Preliminary Incident Investigation Report, dated 2/11/16, documents On 2/5/16 at approximately 11:45 am, two CNA's (E18 and E19) were completing a transfer with (R3). E19/CNA reported an allegation of excessive use of force and profanity by E18 CNA. The facility's Initial Report to the State Agency, dated 2/11/16, documents E19 CNA (Certified Nursing Assistant) reported that E18 CNA used excessive force while using a mechanical lift to transfer R3. This report documents (E19) reported observing (E18) force (R3's) foot down with her foot, while pulling the strap to the lift with excessive force. During that time, (E18) used profanity saying, 'Come on, what the f***!'. E19 said when completing the transfer, E18 pulled (R3's) hand forcefully off of the lift. The facility's corrective Action Document for E18 CNA, dated 2/10/16, documents E18's employment was discharged for specific policy violations as listed: Conduct and Behavior, Employee Guidebook-Employee Guiding Concepts & Practices, and for Abuse & Neglect. On 8/11/16 at 1:30 pm, E1/ Administrator stated that E18 CNA was put on administrative leave on 2/5/16 and her employment was terminated on 2/10/16.

Based on observation, interview and record review the facility failed to prevent one of five sampled residents (R1) from developing two facility acquired stage II pressure areas to the right outer foot/ankle area in a sample of 17. The facility also failed to have qualified staff to evaluate and implement the proper treatment to prevent the pressure ulcers. This failure resulted in R1 acquiring two stage II pressure areas which were regressing in condition, including inflammation/antibiotic use and severe pain during treatment of [REDACTED]. Findings include: The face sheet dated 6/22/2011 states R1 admitted to facility with following [DIAGNOSES REDACTED]. The Braden Scale for Predicting Pressure Ulcer Risk dated 11/5/2013 documents R1 is a high risk for skin break down. The Minimum Data Set ((MDS) dated [DATE], states R1 requires extensive assistance of two staff for bed mobility, transfer, dressing,toileting and bathing. R1's nursing progress note dated 10/9/2013 at 6:30 PM states "1.5 centimeter (cm) by 1.5cm by 0.1 cm open area to right outer ankle bone. 1.5 cm by 1 cm open area to the border of the right foot noted. Apparent pressure ulcers. Cleanse with normal saline apply PolyMem with silver, [MEDICATION NAME]. Will change treatment every three days and as needed. call to physician and power of attorney." On 1/29/2014 at 10:15 AM, E10 (Licensed Practical Nurse) put on a pair of gloves and removed the dressing from R1's right lateral foot and ankle pressure area. E10 then washed her hands putting on a new pair of gloves. E10 then measured the areas and placed the measuring tool which had touched the dirty wound back into the tub with the clean dressings, cleaning solution, scissors and tape. E10 then cleaned the wound with normal saline. E10 washed her hands, changed gloves and used scissors to cut the PolyMem Silver placing this over both the right lateral foot wound and the right outer ankle wound. E10 then taped the PolyMem Silver in place removing her gloves and again washing E10's hands. E10 then placed the container with the rest of the clean dressing supplies and the contaminated measuring tool back in the treatment cart in the treatment room. On 1/29/2014 at 10:15 AM, E10 measured the right lateral ankle wound as 1.7 centimeters (cm) by 1.4cm with a depth of less than 0.1 cm the wound bed was yellow in color with the surrounding tissue red and inflamed. R1 began screaming "It hurts to much, It hurts" when E10 cleaned the area. E10 continued to clean and treat the area. E10 measured the right lateral foot wound as 0.4 cm by 0. 5 cm with no depth. On 1/29/2014 at 10:20 AM, E10 stated R1 receives Tylenol for pain. E10 stated "I did not pass R1's medications this morning but I'm sure the other nurse gave ( R1) her the Tylenol for pain." E10 stated the pain medication should be given to a patient at least 30 minutes before a treatment is completed. E10 stated R1 never yells or acts like R1 is in pain when her treatment is done. E10 also stated the ankle area appears to be red and inflamed today. E10 stated the area also appears bigger in size than when E10 measured the area on 1/26/2014. R1s physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The physicians orders also show no current treatment orders for pressure ulcer treatment of [REDACTED]. The Wound Evaluation Flow sheet dated 1/17/2014 shows R1 is to have the following preventative measures in place: pressure reduction mattress, elevate legs, and eggcrate foam boot. R1 was observed on 1/28/2014 at 10:00 AM and 1/29/2014 at 10:30 AM, 12:30 PM and 1:30 PM sitting in her wheelchair with both legs in a downward position with stocking feet resting on the foot rest and no eggcrate foam boat on the right or left foot. R1's wheelchair had stationary foot rest in place. The wheel chair foot and leg rest were not able to be elevated. On 1/30/2014 at 10:15 AM, E8 (Certified Nurses Aide) stated R1 usually has a brown foam boot on her right foot. E8 stated the boot was to help relieve pressure on R1's foot. E8 then went to R1's room finding the eggcrate foam boot on the floor of R1's closet under a bag of pillows. E8 placed the boot back in the closet leaving R1's room. E8 did not take the boot to the day area where R1 was sitting and place the boot on R1's foot. On 1/30/2014 at 9:30 AM, E2 (Director of Nursing) stated "I review the pressure ulcer logs on a weekly basis. I do not routinely look at pressure ulcers, the floor nurses measure the wound, get the treatment orders and put the interventions in place. The same nurse does not always measure the wound each week. The floor nurses receive inservices on wound care. I am not wound care certified, but one of the floor nurses on the third floor is. The facility does not utilize the third floor nurse as a wound care nurse. The facility provides all of the wound care supplies as stock supplies therefore each resident does not receive a labeled supply of treatment supplies from pharmacy. Each resident should have a current physicians order for any wound treatment ordered. The floor nurse is to fax these orders to the pharmacy so that the order is placed on the printed physicians order sheet." E2 also stated the facility does not have a system in place to track, trend or analyze the progress of pressure ulcers nor is this a part of the quality assurance process. On 1/30/2014 at 11:00 AM, Z1 (R1's primary physician) stated "(R1) can't move herself so the pressure ulcer occurred one of two ways, (R1) either bumped (R1) self or (R1) lays on the right side too much. Clinically when I assessed (R1) today (R1) may have [MEDICAL CONDITION]. I couldn't feel good pedal pulses in the feet. I am going to order a Doppler study of (R1's) legs and an X-ray to make sure there is no Osteomylitis of the right lower extremity. As far as (R1's) pain goes, (R1) is very unpredictable and hard to assess for pain." The Physicians progress note dated 1/30/2014 states "Left ankle ulcer: poorly healing, check arterial Doppler of lower extremities to evaluate circulation, check x-ray of the right ankle to rule out Osteomylitis, start Bactrim DS, continue wound dressing and give as needed pain medication." The Physicians order dated 1/30/2014 states the following: Arterial Doppler of lower extremities, X-ray of the right ankle to rule out [DIAGNOSES REDACTED], Bactrim DS one tablet twice a day, [MEDICATION NAME] 5/325 every eight hours as needed for pain and elevate right leg when in bed. The Facility Infection Control Policy stated hand washing is to occur before a treatment, after removing or touching soiled material and after a treatment is completed.