Every finding on record at Prairie Crossing LVG & Rehab

Based on observation, interview, and record review the facility failed to ensure food was labeled, the sanitation level on the dishwasher was at 50 ppm, dishware and flatware was not used until it was sanitized, and pureed food was at least 135 degrees Fahrenheit on the steam table. This applies to all 52 residents in the facility.The facility's Long Term Care Facility Application for Medicare and Medicaid form dated 1/27/26 showed a census of 52 residents. 1. On 1/27/26 at 9:35 AM, A sign on the refrigerator door stated, refrigerate for safety! cover, label, and date all items. The French toast sticks in the refrigerator were in a bag that was not sealed or labeled. There were 3 resealable storage bags with sliced yellow cheese and sliced ham wrapped in a clear wrap with no labels. There were plastic containers on two drink serving carts with thickener and hot chocolate powder in them that were not labeled. There were two separate plastic containers with lids that contained cereal that were not labeled. On a shelf in the dry storage area there were 4 plates with rice krispie treats wrapped in plastic with no labels. A 22-quart container of brown sugar, 3-liter plastic container of hot cereal mix, and 22-quart plastic containers were on the shelf and did not have labels.On 1/27/2026 at 9:48 AM, V8 Dietary Manager stated food is supposed to be labeled. The item should have the date it was made on it. The other stuff should have the date it was opened on it. V8 stated cheese and lunchmeat should have the best used by date on a label on them. V8 stated it was important to have labels on the food, so they know when it expires.A Daily Task List (no date) for the kitchen staff showed, Everything in the fridge/freezer/storage etc.must be labeled and dated.2. On 1/27/26 at 9:51 AM, V9 Dishwasher was at the low temperature dishwasher running dishes through. V8 Dietary Manager was present when V9 tested the sanitizer level in the machine. V9 used a chlorine test strip, and it showed the level at 10 ppm. V9 stated the chlorine level needed to be at 50 ppm; he stated he checked it that morning. The test was repeated, and the sanitizer level did not reach 50 ppm. V8 manually primed the dishwasher with sanitizer. V8 stated the machine automatically does this but they will manually prime it to get it up to where it needs to be. V8 & V9 tested the sanitizer level again and it did not show any chlorine on the strip. V8 stated he would put a work order in for the dishwasher. V9 continued to run silverware, bowls, and pans through the dishwasher. V6 Dietary aide put the dishes, silverware, and pans away for use.On 1/27/26 at 10:13 AM, the Dish Machine Monitoring Sheet on the clipboard in the kitchen showed the last time the sanitizer level was documented as checked was on 1/25/26 at lunch. There was no documentation for the chlorine on 1/27/26.On 1/27/2026 at 10:15 AM, V8 stated the log sheets should be checked every day and chlorine levels documented three times per day every day. The facility's Low Temp Dishwasher Guidelines (2010) showed, check low temp sanitizer level minimum once a day. Acceptable range 50-100 ppm chlorine. Check local regulations.The facility's Sanitation of Dishes/Dish Machine policy (2017) showed the final rinse sanitization was 50 ppm hypochlorite.The Cleaning Dishes/Dish Machine policy (2017) showed all flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing.3. On 1/27/26 at 12:30 PM, V8 checked the temperature of the pureed food on the steam table for the lunch meal. The sweet potatoes temperature was 131 degrees Fahrenheit - F. At 12:47 PM the pureed food including the sweet potatoes was served for lunch.On 1/28/2026 at 2:47 PM, V5 [NAME] stated the holding temperature for food on the steam table is 135 degrees Fahrenheit. The facility's Food Temperatures policy (2017) showed temperatures should be taken periodically to assure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the holding and plating process and until food leaves the service area. Food preparation and service areas will avoid the following methods: a. holding foods in the temperature danger zone (41 degrees to 135 degrees F).

Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were followed (R4), failed to ensure hand hygiene was performed during medication pass (R7, R22, R36, R37), and failed to ensure staff did not touch a resident's food with bare hands (R5) for 6 of 6 residents reviewed for infection control in the sample of 35. The findings include:1. R4's face sheet printed on 1/28/26 showed diagnoses including but not limited to senile degeneration of brain, traumatic brain injury, dementia, neuromuscular bladder, and history of urinary tract infection (UTI). R4's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance required for personal hygiene, dressing, and toileting. R4's January 2026 order summary report showed an order for an indwelling urinary catheter start dated 10/8/25. The same report showed R4 placed on enhanced barrier precautions (EBP) with the same start date of 10/8/25. R4's December 2025 medication orders showed an antibiotic start dated 12/5/25 for seven days due to ESBL/UTI infection (Extended-Spectrum Beta-Lactamases bacterial infection). R4's current care plan showed a focus area related to a history of urinary tract infections last revision dated 8/22/2019. The same care plan showed a focus area related to the use of EBP due to an indwelling catheter and a history of ESBL infection last revision dated 1/27/26 (day of survey). On 1/27/26 at 9:49 AM, a sign was posted on the door of R4's room. The sign had a dragonfly on it and handwriting with EBP Bed-1. A PPE bin (personal protective equipment) was located next to the door. R4 was lying in bed one with a blanket over her head. On 1/27/26 at 11:56 AM, this surveyor entered R4's room and V4 (Certified Nurse Aide) was in the process of changing R4's overnight catheter bag to a daytime leg bag. V4 was wearing gloves but not a gown. V4 stated R4 has used a catheter for a long time. It is switched back and forth between bags daily. V4 switched drainage bags then transferred R4 from the bed to the wheelchair. V4 leaned over R4's bed, touching it with her body, and straightening the bed linens. On 1/28/26 at 12:50 PM, V2 (Director of Nurses/Infection Control Preventionist) stated all residents with a catheter are on enhanced barrier precautions. Staff need to wear gowns and gloves during care. Those residents have a high risk of infection due to the opening of a device going into the body. The gowns & gloves are needed as an extra barrier of protection between staff clothing and openings into the body. The PPE stops germs from spreading between resident to resident or getting outside of the room. Staff know who is on EBP because there is a sign with a dragonfly on it and showing which bed is EBP. The facility's Infection Control-Enhanced Barrier Precaution policy last review dated 3/6/25 states: EBP are generally indicated for resident with.ii. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. The policy further stated: Personal Protective Equipment of gowns and gloves should be donned and worn after entering room and prior to the following high contact resident care activities.f. Device care or use. 2. On 1/28/26 at 7:31 AM, V3 (Licensed Practical Nurse) was observed while performing the morning medication pass for R7, R22, R36, and R37. V3 did not sanitize or wash his hands before the process. V3 did not sanitize or wash his hands between each resident's medication administration. While V3 was dispensing R22's medication, one tablet fell on top of the medication cart. V3 picked up the tablet with bare hands, placed it in the medication cup, and continued to give it to the resident. V3 did wash his hands after completing the medication pass for the four residents. V3 stated he uses soap and water at completion because he does not like to use the hand sanitizer, he hates it and never uses it. (Hand sanitizer was sitting on the medication cart). On 1/29/26 at 10:05 AM, V1 (Administrator/Register Nurse) stated hand hygiene needs to be done between each resident during a medication pass. Hand hygiene should be done anytime there is the risk of contamination. It prevents the cross contamination of any bacteria or other germs. V1 said medications should be replaced if they are dropped. Using bare hands contaminates the pill. V3 should have replaced the contaminated tablet rather than give it to the resident. V3 should be performing hand hygiene between each resident's medication pass. The facility's Hand Hygiene policy last review dated 3/21/25 states: All personnel working in the long-term care facility are required to wash or sanitize their hands before and after resident contact.after touching inanimate surfaces and objects in the immediate vicinity. The facility's Administering Oral Medications policy last review dated 3/21/25 states: 20. If a medication falls to the floor, discard and document per facility protocol. Repeat the preparation.23. Perform hand antisepsis. 3. R5's admission Record, provided by the facility on 1/29/2026, showed she had diagnoses including, but not limited to Alzheimer's disease, hallucinations, anxiety disorder, anemia, type II diabetes mellitus, heart failure, and chronic kidney disease stage 4. R5's Order Summary Report, provided by the facility on 1/29/2026, showed she was admitted to hospice on 8/6/2025. The report showed R5 had an order for a regular diet. R5's facility assessment dated [DATE] showed she had severe cognitive impairment and required setup or clean-up assistance with eating. R5's ADL (activities of daily living) care plan, with a revision date of 12/10/2025, showed R5 needs supervision to substantial assist with eating and the amount of assistance R5 needs varies. On 1/27/2026 at 1:18 PM, V12 (Certified Nursing Assistant) was setting up R5's lunch meal. V13 picked up R5's bun with his bare hand and covered the bun with mayonnaise. V13 placed the bun back on top of the sandwich and held the bun in place with his bare hand while cutting the bun in half. V13 asked V14 (Certified Nursing Assistant) if she would assist R5 with her meal. V14 pushed the chair she was on from the other side of the table over to R5, sat down and picked up half of the sandwich with her bare hand. V14 held the sandwich up to R5's mouth and R5 took a bite of the sandwich. V14 put the sandwich on the plate and assisted another resident to her right. V14 picked R5's sandwich up again with her bare hands and gave her another bite. On 1/28/2026 at 3:30 PM, V2 (Director of Nursing) said staff do not typically wear gloves when they are feeding the residents. V2 said staff should be cleaning their hands before touching the residents' food. V2 said if staff are moving chairs or feeding other residents, there is the potential for cross-contamination. At 3:47 PM V1 (Administrator) said staff should be using utensils, not their bare hands. For infection control. The facility's policy and procedure titled Assisting the Resident with Meals, with a review date of 3/21/2025, showed 11. Employees must wash their hands before serving food to residents. It is not necessary to wash hands between each resident tray; however, if there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash their hands before serving food to the next resident. The policy does not address directly touching the resident's food with bare hands.

Based on observation, interview, and record review the facility failed to provide pureed bread and margarine for the noon meal on 1/27/26 for 8 of 8 residents reviewed (R7, R33, R54, R4, R48, R37, R23, & R43) for dining in the sample of 35 residents.The findings include:The Week 3 Menu for Tuesday showed tater crusted chicken, smoked paprika sweet potatoes, green beans, bread/margarine, and fruit crisp for the noon meal.On 1/27/26 at 12:15 PM, V8 Dietary Manager stated they didn't have the breading to do the tater crusted chicken so the menu was changed, and it would be chicken breast on a bun. On 1/27/26 at 12:47 PM in the kitchen the purees were served up and placed on resident trays. There was no pureed bread placed on the trays.On 1/27/26 for the noon meal R7, R33, R54, R4, R48, R37, R23, & R43 did not receive pureed bread and butter. The residents on a general diet had chicken breasts on a bun.On 1/27/26 at 2:58 PM, V8 stated he forgot the pureed bread. V8 stated he normally would take bread and puree it for the residents and put it on the tray.The facility's Menu Planning policy (2017) showed menus will include at least three meals daily at regular times, in amounts consistent with nutritional needs.

Based on observation, interviews and record review, the facility failed to ensure that prescribed medications were safely administered to a resident as ordered by the physician. This failure affected 1 of 1 resident (R42) reviewed for medication administration in the sample of 35. The findings include:R42's face sheet documented last admission date of 02/04/2025 with a past medical history not limited to lack of coordination, history of falling, muscle weakness, need for assistance with personal care, hypertension, atrial fibrillation and congestive heart failure.On 01/29/2026 at 09:09 AM, entered R42's room and observed a small, clear plastic cup with resident's name written on the cup that contained four tablets. The med cup was on R42's bedside table that was next to his bed. R42 was initially asleep in bed upon entering the room but awoke when surveyor entered. When asked about the medications in the cup, R42 said they always leave my pills there and I take them when I feel like it. R42 then said he did not know what the medications were or why he takes them. R42 added, I should know but I don't. Review of R42's active orders on 01/29/2026 at 09:15 AM (previously requested and received from facility dated 01/28/2026) showed orders not limited to: empagliflozin oral tablet 10 milligram (mg) one tablet by mouth one time a day related to congestive heart failure ; furosemide oral tablet 40mg one tablet by mouth one time a day related to congestive heart failure; lisinopril oral tablet 2.5mg one tablet by mouth one time a day related to hypertension; and metoprolol tartrate tablet give 12.5mg by mouth one time a day for hypertension. Review of R42's electronic medication administration record (eMAR) on 01/29/2026 at 09:15 AM showed the above mentioned medications are scheduled for 08:00 AM daily and were documented as being administered by V11 (Registered Nurse).On 01/29/2026 at 09:19 AM, surveyor entered R42's room with V11 (RN) who said she brought R42 the medications earlier, but he was eating so she left them on the bedside table. V11 added that the medications were scheduled for 08:00 AM. V11 then said that R42 does not have an order to self-administer medications, and she should not have left them at the bedside.Review of R42's medical record showed no active physician's order, and no current assessment or care plan for R42 to self-administrator medications.On 01/29/2026 at 11:23 AM, V2 (Director of Nursing) said she would have to review the policy and procedures for a resident to self-administer medications which should also be care planned. V2 then said she is not aware of any resident who has been assessed to self-administer medications. V2 added that medications should not be left at the bedside because you don't know if the resident will reliably take them and indicated that wandering residents could also be a concern. On 01/29/2026, requested R42's active physician's order to self-administer, and assessment/care plan for medication self-administration from V2 (Director of Nursing) that were not received upon survey exit.Administering Oral Medications last reviewed 03/21/2025 provided by facility on 01/29/2026 reads in part: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Review the resident's care plan to assess for any special needs of the resident.place the MAR within easy viewing distance, check the label on the medication and confirm the medication name and dose with the MAR, check the medication dose then re-check to confirm proper dose, prepare the correct dose of medication.confirm the identity of the resident, explain the procedure to the resident.offer water to assist the resident in swallowing medications, allow the resident to swallow oral tablets or capsules at his or her comfortable pace.remain with the resident until all medications have been taken.document administration per policy.Self-Administration of Medications policy last reviewed 03/21/2025 provided by V2 (Director of Nursing) on 01/29/2026 reads in part:Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication, and the ability to recognize risks and major adverse consequences of his or her medications. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the facility or responsible party.The staff and practitioner will periodically revaluate a resident's ability to continue to self-administer medications.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed weekly for 1 of 2 resident (R18) reviewed for oxygen in the sample of 35.The findings include:On 1/27/26 at 11:16 AM, R18 had an oxygen concentrator in room. The oxygen tubing attached to the concentrator was dated 12/9/25. The humidification bubbler attached to the machine was not dated and half full. On 1/28/26 at 2:14 PM, V1 Administrator stated that oxygen tubing is to be changed weekly for infection control purposes. V1 stated the tubing is changed when the bubblers are running low because it is included in the set up.The Physician Orders dated January 2026 for R18 showed titrate oxygen to maintain oxygen saturation at or above 90%. May administer Oxygen for respiratory distress to maintain O2 saturation as tolerated. The original order was placed 11/19/24 and remained an active order.The Progress Notes for R18 from 12/31/25 through 1/28/26 showed use of oxygen via nasal canula on 12/31/25, 1/2/26, 1/5/26, 1/9/26, 1/12/26, and 1/22/26. On 1/28/26 at 7:41 AM showed the physician was contacted due to R18's continued use of as needed oxygen with desaturations at 87-88% on room air.The Oxygen Vital Sign Record for R18 from 12/16/25 to 1/27/26 showed R18 had oxygen on via nasal cannula on 12/30, 1/1/26, 1/2/26, 1/7/26, 1/9/26 - 1/12/26, 1/14/26, and 1/27/26.R18's Care Plan dated 1/9/26 did not show a plan in place for the use of oxygen including the maintenance of equipment/nasal cannula changes.On 1/28/26 at 2:14 PM, V10 Registered Nurse/Care Plan Coordinator stated if a resident uses oxygen, then they will have a care plan in place for it. V10 looked at R18's care plan and stated she missed putting an oxygen care plan in place for her.The Face Sheet dated 1/28/26 for R18 showed diagnoses including Alzheimer's disease, unsteadiness on feet, atherosclerosis, dementia, restlessness and agitation, hyperlipidemia, hypertension, delirium, and personal history of covid-19.The facility's Oxygen Administration and Storage policy (3/21/25) showed review the resident's care plan to assess for any special needs of the resident. Tubing: Oxygen tubing should be length sufficient to provide the resident with adequate oxygen levels while promoting maximum mobility. Tubing should be changed weekly. Nasal cannula tubing may need to be changed more frequently. Tubing should be kept clean and off soiled surfaces. If contaminated, tubing shall be replaced.

Based on observation, interview and record review the facility failed to ensure catheter tubing was cleansed prior to use (R4) and failed to ensure catheter tubing remained off the floor for 2 of 4 residents (R4, R26) reviewed for catheters in the sample of 35. The findings include: 1. R4's face sheet printed on 1/28/26 showed diagnoses including but not limited to senile degeneration of brain, traumatic brain injury, dementia, neuromuscular bladder, and history of urinary tract infection (UTI). R4's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance required for personal hygiene, dressing, and toileting. R4's January 2026 order summary report showed an order for an indwelling urinary catheter start dated 10/8/25. The same report showed R4 placed on enhanced barrier precautions (EBP) with the same start date of 10/8/25. R4's December 2025 medication orders showed an antibiotic start dated 12/5/25 for seven days due to ESBL/UTI infection (Extended-Spectrum Beta-Lactamases bacterial infection). R4's current care plan showed a focus area related to a history of urinary tract infections last revision dated 8/22/2019. The same care plan showed a focus area related to the use of EBP due to an indwelling catheter and a history of ESBL infection last revision dated 1/27/26 (day of survey). On 1/27/26 at 9:49 AM, a sign was posted on the door of R4's room. The sign had a dragonfly on it and handwriting with EBP Bed-1. A PPE bin (personal protective equipment) was located next to the door. R4 was lying in bed one with a blanket over her head. On 1/27/26 at 11:56 AM, this surveyor entered R4's room and V4 (Certified Nurse Aide) was in the process of changing R4's overnight catheter bag to a daytime leg bag. The leg type drainage bag was lying directly on the used bed linens. V4 wore gloves to disconnect the overnight drainage bag and connect the daytime leg bag. V4 did not sanitize the tubing prior to connecting each of the catheter tubes. V4 stated R4 has used a catheter for a long time. It is switched back and forth between bags daily. On 1/28/26 at 12:49 PM, V2 (Director of Nurses/Infection Control Preventionist) stated the aides should be wiping the tubing before connecting them. An alcohol swab should be used. It is important because it is a relatively sterile field. The alcohol helps to prevent any urinary tract infections. The facility's Urinary Leg Drainage Bags policy last review dated 3/21/25 states under the steps in the procedure section: 4. Wipe the Foley catheter/drainage tubing junction with alcohol wipe before disconnecting. 10. When the urinary leg drainage bag is no longer needed, wipe the catheter/drainage bag junction with alcohol wipe. 11. Wipe connection tip of straight tubing with alcohol wipe. 2. R26's admission Record, printed by the facility on 1/28/2026, showed he had diagnoses including, but not limited to dementia, chronic kidney disease stage 2, a history of urinary tract infections, sepsis, urine retention, and obstructive and reflux uropathy (a structural or functional blockage in the urinary tract that hinders the normal flow of urine and causes urine to flow backward from the bladder to the kidneys). R26's Order Summary Report, printed by the facility on 1/28/2026, showed an active order dated 1/3/2026 for an indwelling urinary catheter for system failure. R26's facility assessment dated [DATE] showed he has severe cognitive impairment, has a urinary catheter, and is frequently incontinent of bowel. The assessment showed R26 is dependent on staff for toilet hygiene and lower body dressing. R26's care plan initiated on 5/8/2025 showed he had a urinary catheter due to a diagnosis of obstructive and reflux uropathy. On 1/27/2026 at 1:08 PM, 1:38 PM and 3:37 PM, R26 was observed sitting in the north dining room at the table. During all three observations, R26's catheter tubing was touching the floor. On 1/28/2026 at 3:30 PM, V2 (Director of Nursing) said catheter tubing should not be touching the floor to prevent cross-contamination. For infection control. At 3:47 PM, V1 (Administrator) said the catheter tubing should not be touching the floor for infection control. The facility's policy and procedure titled Catheters, Emptying a Urinary Drainage Bag, with a review date of 3/21/2025, showed 8. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.

Based on interview and record review, the facility failed to consistently obtain daily weights for residents with congestive heart failure (R42, R3) and/or a blood pressure every shift as ordered by the physician following a fall incident (R42). This failure affected 2 of 2 residents (R42, R3) who were reviewed for quality of care in the sample of 35. The findings include: 1. R42's face sheet documented last admission date of 02/04/2025 with a past medical history not limited to fluid overload, frontotemporal neurocognitive disorder, congestive heart failure and history of falling. R42's care plan last reviewed 01/26/2026 showed a fall intervention to monitor blood pressure (b/p's) every shift and update cardiologist of B/P's date initiated 10/06/25. R42's active orders as of 01/28/2026 showed orders to obtain daily weight and notify the cardiologist or provider for weight gain of more than 2-3 pounds over night, or 5 pounds in one week (start date 3/21/2025) every day shift; and obtain blood pressure every shift (start date 10/06/2025). Review of R42's electronic medication administration record (eMAR) and weight/vitals log on 01/29/2026 from October 2025 to current showed the following: October MAR showed no weight documented for the 4th or 28th. October weight log showed no documented weight on the 4th. November MAR showed no documented blood pressure for day shift on the 26th or for the night shift on the 20th or 28th. November blood pressure log showed only one documented blood pressure on the 20th at 1313 and on the 26th at 2244, and only two documented blood pressures for the 28th at 0021 and 1314. December MAR showed no weight documented on the 3rd, 13th or for the 15th through the 17th; and showed no documented blood pressure for day shift on the 5th, 13th 18th and 19th. December weight log showed no documented weight on the 3rd, 13th, or the 15th through the 17th. December blood pressure log showed the same discrepancy on the 5th, 13th and 18th; and only one documented blood pressure on the 19th at 1814. January 2026 MAR showed no weight documented for the 1st, 17th, 20th, 22nd or 29th; and no documented blood pressure for day shift on the 21st or 24th and no documented blood pressure for the night shift on the 21st. January 2026 weight log showed no documented weight on the 1st, 17th, 20th, or the 29th. January 2026 blood pressure log showed the same discrepancy for the 21st, and only one blood pressure logged on the 24th at 1624. On 1/29/2026 at 09:09 AM, R42 was observed in bed. R42 said a few months ago, he was walking in his room with his wheelchair, and he became dizzy then lowered himself to the floor. R42 added that staff started checking his blood pressure 2-3 times a day since the fall. R42 then said he is a daily weight but they have missed a couple of days and they don't always check my blood pressure every shift. On 1/29/2026 at 11:28 AM, V2 (Director of Nursing) said after the nurse enters a weight or blood pressure into the resident's medication administration record (MAR), it will automatically transfer over to the resident's weights/vitals log in their electronic medical record then said, for the most part, R2's weights and blood pressures were logged daily but V2 acknowledged a few missing entries. V2 said is it important to obtain daily weights for a resident with congestive heart failure because we are looking for changes to report to the physician and fall interventions should be followed to prevent further falls. V2 added that it is her expectation that nurses follow physician orders and if resident information is not documented on the MAR, it could be possible that it was not done or was charted somewhere else. (No documentation regarding missing weights or blood pressures was provided) On 01/29/2026, survey team requested policy on obtaining weights for a resident with congestive heart failure and a policy on following physician's orders. Neither policy was received upon survey exit. Medication Orders policy last reviewed 03/21/2025 that was provided by the facility on 01/29/2026 reads in part: the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. 2. R3's admission Record, provided by the facility on 1/29/2026, showed he had diagnoses including, but not limited to heart failure, Parkinson's disease, dementia, anxiety disorder, depression, restlessness and agitation. R3 was observed on multiple occasions between 1/27/2026 through 1/29/2026. R3 was alert, oriented, and pleasant. No refusals of care were observed by R3. No signs of distress, shortness of breath, or edema noted for R3 during observations. R3's Order Summary Report, provided by the facility on 1/29/2026, showed an active order dated 11/7/2025 for daily weights on Monday, Wednesday, and Friday in the morning due to CHF (congestive heart failure). The order showed a start date of 11/10/2025. The order had no end date. Based on the order, 9 weights should have been entered from 11/10/2025-11/30/2025. Only 4 weights were entered during that time, and they were on 11/10/25, 11/14/25, 11/21/25, and 11/28/25. December should have had 14 weights entered. Only 3 weights were entered for the month of December 2025 and they were on 12/1/25, 12/5/25, and 12/19/25. As of 1/29/2026, 12 weights should have been entered into R3's electronic medical record. Only 1 weight was entered for January 2026 and that was on 1/2/26. R3's January 2026 medication administration record (MAR) and Treatment Administration Record (TAR) did not show any order for weights. On 1/29/2026 at 9:39 AM, V2 (Director of Nursing-DON) looked at R3's electronic medical record and said it looks like there are quite a few missing weights in his medical record. V2 said R3 is on weights three times a week for heart failure. It is important to do the weights as ordered to monitor for changes in edema and fluid buildup. V2 said the CNAs (Certified Nursing Assistants) working that floor the day the weights are scheduled are the ones that get the resident's weight. The nurse is also responsible for making sure the weight gets completed as ordered. V2 was asked to provide the facility's policy and procedure regarding obtaining resident weights/weights for residents with CHF. No policy was provided prior to exiting the facility. On 1/29/2026 at 10:18 AM, V11 (Registered Nurse) said the CNAs get the residents' weights and give the weights to the nurses on duty. The nurse enters the weights into the computer on the resident's medication administration record (MAR), and it automatically transfers over to the resident's weights/vitals tab in their electronic medical record.

Based on Observation, interview and record review the facility failed to cool a pork roast before freezing and failed to use serving utensils while serving food. This applies to all residents in the facility. The findings include: The CMS (Center for Medicare and Medicaid) 671 dated 1/10/24 shows there are 43 residents in the facility. On 10/1/2024 at 10:00 AM, a pork roast was observed in the refrigerator wrapped in aluminum foil with the date 9/18/2024 written on it. V3 Dietary Manager said the roast was cooked before for another meal and the leftovers were placed in the freezer. The roast was removed from the freezer on 9/18/2024 to thaw and will be used for a meal this week. V3 said they usually don't do this, that meals are prepared the day they are used, so a cooling log could not be provided. V3 said cooling logs should be used to reduce the risk of food borne illnesses. On 10/1/2024 at 1:26 PM, V4 [NAME] said when food is saved for leftovers the temperatures are checked but not logged anywhere, we just do it in our heads. On 10/2/2024 at 12:15 PM, V4 was observed serving the noon meal. V4 was wearing gloves and was observed placing garlic bread on the resident's plates with her gloved hands. V4 was also observed placing a slice of lasagna onto the plates using a spatula and using her hands to guide the lasagna onto the plates. V4 was observed while wearing the same gloves going to the storage room and into drawers for utensils. V4 did not change her gloves after leaving the work area. On 10/2/24023 at 1:16 PM, V3 said the cooks are supposed to be using utensils to plate the food and should not be using their hands. I expect the staff to use utensils to prevent cross contamination. The facility policy dated 2017 for Bare hand contact with food shows staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. The facility policy dated 2017 for general HACCP (Hazard Analysis Critical Control Points) shows to cool food 135 degrees Fahrenheit (F) to 70 degrees F in 2 hours and from 70 degrees F to 41 degrees F in 4 hours.

Based on interview and record review, the facility failed to ensure daily weights were obtained for a resident with a diagnosis of heart failure, and failed to notify the resident's doctor when weight gain was outside of the set parameters for 1 of 1 resident (R19) reviewed for congestive heart failure (CHF) in the sample of 15. The findings include: R1's Admission Record, printed by the facility on 10/2/24 showed he had diagnoses including, but not limited to, heart failure, dementia, Parkinson's disease, anxiety, depression, and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). R19's Order Summary Report, printed by the facility on 10/2/24, showed an order dated 5/14/24 for daily weights and to update V13 (R19's Cardiologist) if R19 had a gain of more than 2-3 pounds (lbs.) overnight or 5 pounds (lbs.) in a week. The report showed the order was still active on 10/2/24. R19's facility assessment dated [DATE] showed he had severe cognitive impairment, required partial/moderate assistance from staff for toileting, bathing, and transfers, and substantial to maximal assist for lower body dressing and putting on/taking off footwear. Section I of the assessment showed R19's primary medical condition was debility, cardiorespiratory conditions. R19's undated/untitled document, provided by the facility on 10/3/24 showed R19's weight on 6/30/24 was 201.6 lbs. R19's Weights and Vitals Summary, printed by the facility on 10/2/24, showed R19's weight on 7/1/24 was 204.9 lbs. (a 3.3 lb. gain in one day). R19's Weights and Vitals Summary, printed by the facility on 10/2/24, also showed the following: On 7/5/24 R19 weighed 200.6 lbs. On 7/6/24 R19 weighed 206.5 lbs. (a 5.9 lb. increase). On 7/24/24 R19 weighed 201.4 lbs. On 7/25/24 R19 weighed 208.3 lbs. (a 6.9 lb. increase). On 8/6/24 R19 weighed 199.9 lbs. No weight was entered for 8/7/24. On 8/8/24 R19 weighed 206.1 lb. (a 6.2 lb. increase). On 9/26/24 R19 weighed 198.5 lbs. On 9/27/24 R19 weighed 202.9 lbs. (an increase of 4.4 lbs.). On 9/29/24 R19 weighed 203.3 lbs. On 9/30/24 R19 weighed 206.6 lbs. (an increase of 3.3 lbs.). R19's Progress Notes from 7/1/24-10/2/24 were reviewed. The only documentation during that time period of V13 being notified regarding R19's weights was on 9/30/24. R19's Weights and Vitals Summary, printed by the facility on 10/2/24, showed no weights entered for the following days: 7/20/24; 7/27/24; 7/28/24; 8/3/24; 8/7/24; 8/13/24; 8/17/24; 9/8/24; 9/14/24; and 9/22/24. R19's July 2024-September 2024 Medication Administration Records showed no weights entered for the following days: 7/27/24; 7/28/24; 9/8/24; and 9/22/24. R19's care plan initiated on 7/3/24 showed he had a diagnosis of heart failure. The care plan showed Daily weight monitoring. The care plan also showed Monitor/document/report PRN (as needed) any (signs or symptoms) of Heart Failure .weight gain unrelated to intake . On 10/3/24 at 9:05 AM, V2 (Director of Nursing-DON) said R19's orders show to do daily wts and update (V13) if he has a 2-3 lb. weight gain. V2 looked through R19's electronic medical record for documentation that V13 had been notified on the dates in question while this surveyor waited. V2 said she did not see any documentation in R19's progress notes or in the electronic miscellaneous tab showing that V13 had been updated regarding R19's weights, other than on 9/30/24. V2 said R19 should have been reweighed and V13 should have been updated if there was that much of a difference in his weight. V2 said she did not see anything showing (V13) was updated until 9/30/24. It is important to notify the cardiologist. the resident could be having an exacerbation of CHF, that is what we are monitoring for when doing daily weights. V2 said she would continue to look and see if she could find any documentation showing that V13 was notified. At 10:51 AM, V2 said We looked for notification to the cardiologist and did not see anything. At 11:20 AM, V2 said R19 should have been weighed daily because there was an order for daily weights. The facility's policy and procedure titled Acute Condition Changes-Clinical Protocol, with a review date of 8/29/24, showed Notification: 1. The Nurse will notify the resident's Attending Physician or On-Call Physician when there has been .h. Instructions to notify the physician of changes in the resident's condition.

Based on observation, interview, and record review the facility failed to ensure a dependent residents was provided showers for 1 of 3 residents (R1) reviewed for activities of daily living in the sample of 7. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include sepsis, pneumonia, urinary tract infection, seizures, dysphasia, aphasia, peripheral vascular disease, pressure ulcer of right buttock, incontinence without sensory awareness, irritant contact dermatitis due to fecal, urinary, or dual incontinence. R1's facility assessment dated [DATE] showed R1 is dependent upon staff for all cares. R1's care plan initiated 3/21/2016 showed, [R1] has an ADL (activities of daily living) self-care performance deficit related to limited mobility and weakness secondary to cardiovascular accident with right hemiplegia and requires extensive assist with ADL's and dependent on staff for transfers . [R1] requires extensive assist of 2 staff with bathing/showering per should schedule and as necessary . On 7/31/24 at 11:30 AM, R1 was in her bed receiving incontinence care from staff. R1's hair appeared dirty and unkempt. R1's mouth was dry, and she had a thick layer of residue across her teeth. On 7/31/24 at 11:14 AM, V7 CNA (Certified Nursing Assistant) said showers are done for residents twice a week and completed on Monday through Friday. V7 said showers are not documented in the electronic record but are documented on shower sheets. On 7/31/24 at 11:19 AM, V4 RN (Registered Nurse) said shower sheets are completed by the CNAs, the nurses sign off on them, and then they are given to her as the Wound Care Nurse to keep records. V4 said showers are only documented on shower sheets. On 7/31/24 at 11:21 AM, V4 provided R1's shower sheets for July 2024. There were 2 shower sheets provided with one dated 7/17/24 showing R1 refused a shower and one 7/24/24 indicated the shower was completed. There was no evidence found that R1 had more than 1 shower given to her for the month of July. On 7/31/24 at 10:34 AM, V8 (Registered Nurse from Day Surgery at local acute care hospital) said R1 had been to their department on 7/30/24 for a procedure. V8 said when R1 arrived for the procedure she appeared unkempt, her hair appeared dirty, she was wearing a dirty, foul smelling hospital gown, and it appeared to have been quite some time since she received oral care because her teeth were covered in a thick layer of plaque or debris. On 7/31/24 at V2 DON (Director of Nursing) said she expects residents to receive at least one shower each week. V2 said the CNAs should offer the shower more than once and if they refuse the nurse should be notified of the refusal. The facility's policy and procedure for providing resident care and showers was requested. V1 (Administrator) said the facility does not have a policy regarding providing showers. The facility's policy and procedure titled Mouth Care showed, . the purposes of this procedure are to keep the resident' slips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .

Based on observation, interview, and record review the facility failed to have interventions in place to prevent resident to resident abuse. This applies to 3 of 3 residents (R1, R2, R3) reviewed for abuse in the sample of 3. This failure resulted in R1 being sent to the hospital, receiving a hematoma, and experiencing pain with activities of daily living. The findings include. R2's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include dementia with behavioral disturbances, depression, and anxiety. R2's 3/15/24 Admission Minimum Data Set (MDS) showed he had severe cognitive impairment with a brief interview for mental status (BIMS) score of 3 out of 15. The MDS showed he had physical behavioral symptoms directed towards others 1 to 3 days a week (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.) The MDS showed he had verbal behavioral symptoms directed towards others 4 to 6 days a week (e.g., threatening others, screaming at others, cursing at others.) The MDS showed he was independent in walking 150 feet, and he only needed setup assistance for eating, dressing, oral hygiene, and toileting hygiene. R2's 3/8/224 Behavior Note from 5:41 PM showed Per staff, when resident was informed that he would be spending the night he stated, then I'm gonna hurt people . R2's 3/10/24 Behavior Note from 5:34 PM showed, Resident opened window in the [dementia unit] sitting area and said, 'I'm going to climb out that window.' Staff stood in front of the window. Resident attempted to push staff away from the window x3 (three times) without success . R2's 3/13/24 Behavior Note from 1:45 PM showed, .resident had been entering resident rooms, breaking window blinds, and pulling curtains down throughout the [day] shift. Also received report from CNA (certified nursing assistant) that resident had taken his name tag off of his room door, then sunk his nails into her fingers when redirected . R2's 3/13/24 Behavior Note from 5:45 PM showed, .resident was noted trying to kiss another resident without success. Resident redirected. Residents kept apart. Subsequently holding another resident's hand and [walking] with her at times. Difficult to redirect .Admin (Administrator) notified. R2's 3/13/24 Behavior Note from 8:04 PM showed, Received report from CNA that resident had grabbed the back of her chair and tried to push her out of it. When this writer entered [dementia unit] to take the CNA's statement, she was noted in the corner of the hallway near the entrance. [R2] had his right fist cocked as if to punch her and was leaning and stepping toward her as if to punch her. He ceased this motion without [NAME] her when this writer stood between them. Admin notified . R2's 3/19/24 Behavior Note from 8:49 PM showed, CNA reported that resident came to her and poured a full container of water on her as well as the resident she was standing next to. The CNA was found with saturated clothing, trying to separate this resident from the area . On 4/2/24 at 2:06 PM, V9 CNA stated R2 had taken her water bottle and dumped it on her. V9 said R2 believed she was on fire. V9 said immediately after that R2 cocked his fist as if he was going to hit her. V9 said she turned her face away from R2 because she was certain he was going to hit her, however, he did not. R2's 3/20/24 Behavior Note from 6:00 PM showed, [R2] noted putting his fingers around another resident's left forearm. The other resident touched [R2's] abdomen with his left hand. [R2] then walked away. No apparent injury noted . R3's Face Sheet showed an original admitted [DATE] with diagnoses to include dementia with anxiety and agitation; delirium; and altered mental status. R3's 3/13/24 Admission Minimum Data Set showed moderate cognitive impairment with a BIMS score of 8 out of 15. The MDS showed no physical of verbal behavioral symptoms. The MDS showed R3 was independent in walking 150 feet and needed setup assistance for eating, dressing, oral hygiene, and toileting hygiene. The facility's 3/22/24 Final Incident report showed R2 and R3 were on the locked dementia unit. The incident showed R3 was near entry doors to the unit with his wife. The report showed R3 was attempting to leave the unit with his wife when staff redirected him away from the door. While staff were escorting R3 away from the unit, R2 was upset about the commotion and R2 pushed R3. R3 then attempted to push a wheelchair into R2; however, staff intervened. On 4/2/24 at 12:08 PM, V4 Licensed Practical Nurse (LPN) stated R3 was wanting to leave the unit with his wife. V4 stated she redirected R3 away from the door and was walking with him when R2 came out of nowhere. [R2] came behind and pushed [R3] from behind. He pushed him enough that he stumbled forward. V4 said R3 then attempted to pick up a wheelchair; however, staff intervened. On 4/2/24 at 12:51 PM, 3/22/24 security camera footage was reviewed for the dementia unit. The footage showed, on 3/22/24 at approximately 3:40 PM, V4 was escorting R3 away from the unit doors down the hallway when R2 shoved R3 from behind. R2 stumbled several feet forward, catching himself on a wheelchair in the hallway. R3 then grabbed the wheelchair and attempted to move it in the direction of R2; however, staff intervened. R2's 3/22/24 Behavior Note from 5:24 PM described the incident above. The note showed V1 Administrator was notified and staff were directed to contact psychiatric services. R2's 3/22/24 Nursing Note from 5:23 PM showed psychiatric services requested R2 be sent to the emergency department for evaluation. R2's 3/23/24 Nursing Note from 12:04 AM showed, Resident continues to have increasing agitation. Attempted to give resident Haldol [antipsychotic medication] .Resident took med cup and threw it down hallway. R2's 3/27/24 Behavior Note from 3:10 PM, showed R2's right fist was raised as if he was going to punch staff, he then crushed a bottle of hand sanitizer, and then grabbed a staff member's forearm. R2's 3/27/24 Nursing Note from 9:30 PM showed he was sent to a local inpatient psychiatric facility for an involuntary psychiatric admission. R3's 3/24/24 Behavior Note from 4:01 PM, showed Resident noted in his room, grabbing another resident by the shoulders and attempting to push him out of the room. Resident's separated .MD and Admin notified. (Note authored by V6 Registered Nurse (RN)) On 4/2/24 at 12:21 PM, V6 was unclear on the events leading up to the incident on 3/24/24; however, V6 stated R2 was in R3's room, R3 grabbed R2 by the shoulders and tried to push him out of the room V6 said, It was only R3 that R2 got agitated with. They would have words and push each other. It seemed like it happened every few days .I think they should be separated. In an ideal world, I would do that by putting them on a 1 to 1, at least one of them on a 1 to 1. I would do that so that the staff with them could make sure they don't get near each other and deescalate the situation. The facility's Incident Report from 3/26/24 showed, .At 3:40 PM, a resident was standing at the entrance to his bedroom conversing with another resident. A third resident approached and attempted to enter the bedroom which resulted in [R1] stumbling backwards into his garbage can and landing on his buttocks on the floor . On 4/2/24 at 9:32 AM, V3 Activities Director stated she heard a .commotion and went into the hallway . V3 stated she saw R2, R3, and V12 (R3's Spouse) in R3's room. V3 said the commotion was loud talking. V3 said she witnessed .[R2] pushed [R3], [R3] lost his balance and he fell into [R1] and [R1] I think his arm hit the garbage can. V3 stated V7 also responded to the incident. On 4/2/24 at 10:25 AM, V7 Activity Aide/Dietary Aide stated regarding the incident on 3/26/24, I was doing 1 on 1's with [R2] because of the issues [R2] was having. V7 said, He (R2) had been restless. They told me he needed extra watching. There was an incident that had happened a couple of days earlier .they told me to try and keep him (R2) away from [R3]. V7, while she was 1 on 1 with R2 on 3/26/24, she was not aware R2 had shoved R3 on 3/22/24. V7 said she would like to have known about the incident on 3/22/24 prior to being on a 1 to 1 with R2. V7 said, on 3/26/24 she was walking with R2 when R2 saw R3 and V12 in the doorway to R3's room. V7 said R2 pushed at him (R3). I'm not sure if he made contact. V7 said R3 bumped into R1. V7 said, in hindsight, she would not have done anything differently. R1's 3/26/24 Nursing Note from 6:34 PM showed, Resident with increased c/o (complaints of) pain in the lower back and upper hip. R1's 3/26/34 Nursing Note from 10:30 PM showed the Xray was completed and R1 had three compression fractures. The note showed R1 was sent to a local area emergency room . R1's CT scan from 3/26/24 showed the spinal fractures were most likely chronic fractures. R1's After Visit Summary (Hospital Discharge Orders) from 3/27/24 showed, The hematoma (a pool of clotted blood within the body) on the left will extend into the buttock and down the leg . R1's 3/28/24 Nursing Note from 11:34 AM showed, Resident monitored post fall. (R1's progress notes show no previous falls except for the incident on 3/26/24) He had tears in his eyes from pain while receiving AM (morning) cares. Pain is to his left side where his hematoma is. After breakfast, and AM medications, resident stated that the pain is worse with movement . R1's 3/29/24 Nursing Note from 4:25 PM showed, .Reports 5/10 (rating pain at a 5 out of 10) left hip pain. No new injury noted . R1's 4/1/24 Weekly Skin Observations note showed he had a 4-inch by 17-inch bruise to his left abdomen. The note showed he had a 11-inch by 23-inch bruise that extended from his left hip to left buttock. The note showed a third bruise to his left thigh which was 11-inches by 48-inches long. On 4/2/24 at 12:51 PM, video footage, provided by the facility, showed on 3/26/24 at approximated 3:45 PM, V3 walking quickly out of a resident room. V3 was walking down the hallway looking in resident rooms as if she was searching for something. When V3 reached R3's room, she immediately entered the room, and she was out of sight. Several seconds later, V7 (who stated she was on 1 to 1 supervision with R2) exited the dining room and entered R3's room. Several seconds after later, V3 exited the room and then nursing staff arrived. The footage provided by the facility did not show R2 entering R3's room or how long R2 was in the room. On 4/2/24 at 2:27 PM, V8 Licensed Practical Nurse (LPN) stated she was on the dementia unit nurse on 3/26/24. V8 said she was not aware of R2 being on 1 to 1 supervision on 3/26/24. V8 said she was not aware of any incidents between R2 and R3 prior to 3/26/24. V8 said, I would expect to be aware of any previous issues just so I would know what to look out for. I would follow whatever direction management provided as far as keeping them separated. That day (3/26/24) I had no direction from management about keeping them separated. On 4/3/24 at 11:45 AM, V2 Director of Nursing stated after incidents occur, such as the incident on 3/22/24, interventions are put in place to protect the residents. V2 said the interventions for R2 were mainly medications and psychiatric services. V2 said, In retrospect, we could have separated him sooner, but we were trying to work on medications. Medication changes can take a while to take effect. The orders we got were for long term medications (medications that take time before they reach full effect). V2 said, R2's interventions for safety should be in his care plan. V2 said, I would expect the nurse on the 26th to be aware of the previous incidents. I would want to know so I could keep an eye on them and try to keep them separated. V2 said, It wasn't me that put her (V7) on 1 to 1 (supervision) but it seems like it was a good idea. We were trying to keep extra staff back there [on the dementia unit] because of the issues we had back there with [R2]. V2 said R2 and R3 should not have been in the same room unsupervised. On 4/3/24 at 12:20 PM, V1 Administrator stated she was the abuse coordinator. V1 said abuse interventions are a team effort and all the interventions should be in the care plan. V1 said R2's abuse interventions were psychiatric services, medications, activities, and redirection. V1 said, There was never any interventions put in place to keep them (R2 and R3) separated. I don't think it would be an appropriate intervention to keep them separated. They had a lot of positive interactions together .I think they were reacting to the stimuli around them. I don't think it was directed behavior I think he was responding to the environment. I think the staff were aware of the incident on the 22nd (3/22/24) and they increased their supervision. On 4/3/24 at 10:15 AM, V10 R3's Power of Attorney/Daughter stated, They have called me twice about incidents with my dad and another resident. He was on memory care, my mom was visiting, he (R3) was following her to the door, and the resident shoved him, I believe. Dad defended himself and the nurse got between them and stopped it. Another incident they called, my mom was there, what they told me was a scuffle between the same resident and another resident, not my dad .There may have been a third time, it was kind of an on-going thing with this particular resident and my dad .He (R2) would have been upset over these incidents, he is more about protecting others than himself, he would defend himself. He would be more worried about others than himself. He was a teacher for [AGE] years, so he was always on the lookout for bullies. After the incident on the 22nd he would have wanted to stay away from him. He would have stayed away from him and just work to not interact with him .I think it would have been best to just keep them separated at all times, to keep them safe. R2's Care Plan showed R2 has a behavior problem. Becomes agitated quickly. He responds to a male staff member better than he does female staff members. (This care plan area was initiated on 3/27/24, two weeks after resident attempted to kiss another resident, several days after a raised fist at staff, 5 days after R3 was initially pushed, and the day he was sent out for involuntary psychiatric admission.) The interventions for this care plan focus area do not show close monitoring of R2 when he is around other residents, specifically R3. The interventions do not show to keep R2 separated from R3. R3's Care Plan showed no interventions for close monitoring when around R2 and/or interventions to keep them separated. On 4/3/24 at 11:30 AM, V11 Medical Director stated, based on the CT scans from the hospital the fractures may have been from a previous fall for R1. V11 said, Hematomas and bruising most definitely can be painful and that could be the source of his pain. Ideally, they would have interventions in place to keep them (R2 and R3) separated but on a locked memory care unit that can be difficult. Moving him (R3 was moved off the memory care unit following the incident on 3/26/24) off the memory care unit to be away from [R2] does seem like a good intervention to keep them separated. [R2]is non-compliant, which makes it difficult to manage those behaviors. The facility's Abuse Prevention Program policy (Reviewed 10/2023) showed, This facility affirms the right of our residents to be free from abuse . The policy continued, Resident Assessment: .staff will identify residents with increased vulnerability for abuse .Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis, and update as necessary . The policy showed, The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents. The policy showed, Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .

Based on observation, interview, and record review the facility failed to ensure a resident was transferred and ambulated in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. These failures resulted in R1 sustaining a fractured nasal bone, sutures to the forehead, and bruising. The findings include: R1's face sheet printed on 12/6/23 showed diagnoses including but not limited to Alzheimer's disease, dementia with agitation, anxiety disorder, wandering, impulsiveness, difficulty walking, muscle weakness, and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed severe cognitive impairment. The assessment showed substantial/maximal staff assistance needed for transferring from sitting to standing. The assessment showed partial/moderate staff assistance required for walking once standing. R1's fall risk assessment dated [DATE] showed a high risk for falls. R1's progress note dated 12/2/23 at 6:02 AM stated: Called to resident room for witnessed fall. Resident found on floor with laceration to forehead above right eyebrow. Assessed resident and call 911 for ER transport. Resident made comfortable with C spine supported until EMS arrived. Pressure applied to laceration with woven sponge . The note documented R1 was found on the floor at 4:39 AM and was sent to the local emergency room at 5:00 AM. The note was written by V4 (Registered Nurse). R1's progress note dated 12/2/23 at 6:20 AM stated: ED (emergency department) called with report, resident has fractured nasal bone, 3 stitches to laceration over right eyebrow-per report and will be returning to facility. MD notified, DON and administrator informed of fall, ED visit and pending return to the facility. On 12/6/23 at 9:00 AM, R1 was lying in bed dressed and covered with a light blanket. R1 had dark, purple crescent shaped bruises under both eyes and a 2x2 inch dressing on her forehead over the right eyebrow. R1's right arm was uncovered, and a quarter size dark purple bruise was on top of her right hand with scattered smaller bruises on her arm. R1 was awake but did not respond or react to any questions. R1's room was located on the dementia unit of the facility. On 12/6/23 at 11:15 AM, V8 (CNA-Certified Nurse Aide) assisted R1 out of bed and across the room to the bathroom. R1 was nonverbal and walked in a shuffling, unsteady manner. V8 used a gait belt to steady R1 and a walker during the transfer and while walking. At 2:10 PM, V8 stated the following: R1 needs help while getting out of bed and walking. R1 walks unsteady and cannot follow directions. R1 is confused and will walk away during care. R1 tries to walk while her pants are still at her ankles. R1 will just give up and plop herself down into the bed. R1 needs a walker and gait belt for safety. It provides R1 something to hold onto and she doesn't walk safely without both. On 12/6/23 at 10:40 AM, V3 (CNA) stated she was working the night shift on 12/2/23 and took R1 to the toilet at around 4:30 AM. V3 said she sat R1 at the side of the bed and directed R1 to grasp her around the waist, like a bear hug. V3 said she stood R1 up by holding her hands and placed the wheeled walker in front of R1. V3 said she walked R1 to the bathroom and changed her into day clothes while toileting R1. V3 said she had to close the bathroom door during care to prevent R1 from walking away from her. V3 said she directed R1 back across the room and to the bed side. V3 said she stood in front of the walker and pulled on it to guide R1 toward the bed. V3 stated she turned away from R1 to adjust the bed linens and R1 walked away from her, toward the closet door. V3 said R1 was walking by herself and out of grasp. R1 suddenly fell forward and pushed the walker to the side during the fall. V3 said R1 did not reach out with her hands and fell face first to the floor. V3 said she hit the floor full impact. V3 said R1 began bleeding and she immediately yelled for V4 (Registered Nurse). V3 was questioned if R1 was wearing a gait belt and if V3 holding onto it. V3 said, no. The thought never crossed V3's mind and V3 didn't have a gait belt with her at the time. V3 said R1 needs a gait belt and walker to be moved safely. V3 said she has cared for R1 in the past and was familiar with her mental confusion and unsteady walking. On 12/6/23 at 1:26 PM, V4 (Registered Nurse) stated she was working the night shift on 12/2/23 and heard V3 (CNA) yelling out for help around 4:40 AM. V4 said she went to R1's room and found R1 on the floor bleeding from the nose. V4 said she immediately called the physician and orders were received to send R1 to the emergency room . V4 said R1 was dressed in day clothes and her walker was near her. R1 was wearing anti-skid socks but not a gait belt. V4 said R1 is confused and has a weak gait. R1 needs staff help to stabilize her during transfers and walking to prevent her from falling. V4 said R1 returned to the facility the same morning and was diagnosed with a fractured nasal bone. R1 required stitches to her forehead and had bruising to her right arm and face. On 12/6/23 at 12:50 PM, V5 (Registered Nurse) stated R1's ambulation skills have been decreasing due to her disease progression. R1 is confused and will walk by herself if staff do not guide her. V5 said R1 needs more and more help to walk safely. V5 said R1 is becoming weaker and more unsteady and needs a wheelchair on her extremely weak days. V5 said R1 should always have a gait belt and walker with her to maintain balance. It is an extra way for CNAs to hold and stabilize R1. On 12/6/23 at 2:38 PM, V9 (Physical Therapist) stated he has worked with R1 in the past and was familiar with her needs. V9 said R1 needs a lot of help transferring and walking safely. Staff should be using a gait belt and standing at her side to guide her. Pulling the front of a walker to direct a resident is not appropriate. V9 said gait belts are required for any resident who is a high fall risk. On 12/6/23 at 11:35 AM, V2 (Director of Nurses/Fall Coordinator) stated prior to R1's 12/2/23 fall she was under standard fall interventions. V2 said R1 did not have gait belt use cared planned but they are required for any resident who is unsteady. V2 said, gait belts are used to have something to hold onto and staff can gently lower a resident to the floor if need be. At 12:11 PM, V2 was asked for the facility policy related to gait belt use. At 2:43 PM, V2 was asked for the facility policies related to resident transfers and resident ambulation. V2 stated the facility did not have any policies regarding the topics requested. R1's emergency room after visit summary dated 12/2/23 showed the reason for the visit was fall related. R1's resulting diagnoses showed a cut on forehead and a nose fracture. The facility's Fall Prevention and Management policy last review dated 9/29/23 states under the fall prevention section: 7. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. Staff will be educated on the fall reduction and prevention program.

Based on observation, interview and record review, the facility failed to supervise a resident at high risk for falls, with previous falls in the facility, and failed to supervise a resident with wandering behaviors for 2 of 8 residents (R41, R26) reviewed for safety and supervision in the sample of 14. This failure resulted in R41 falling, sustaining a hip fracture, and being sent out to a local hospital for evaluation and surgical treatment. The findings include: 1. R41's Admission Record, printed by the facility on 9/13/23, showed she had diagnoses including vascular dementia, severe, with behavioral disturbance, a history of falling, unsteadiness on feet, and abnormalities of gait and mobility. The Admission Record also showed a diagnoses added on 4/29/23 (upon readmission from a local hospital) of nondisplaced intertrochanteric fracture of left femur (left hip fracture). The Admission Record showed R41 resides on the dementia care unit of the facility. R41's progress note dated 4/21/23 showed 7:15 PM, V6 (Licensed Practical Nurse-LPN) heard a noise coming from the dementia care unit's dining room. Upon investigation, R41 was observed lying on the floor of the dining room. R41's progress note dated 4/22/23 at 6:00 AM showed R41's doctor was updated about R41 having increased pain during the night. R41 was able to bear weight but was refusing to take steps. The note showed R41 was favoring her left leg and knee. The note showed a new order was given to X-ray R41's left hip, femur and knee. R41's progress note dated 4/22/23 at 9:30 AM showed R41 had another fall in her room and was found lying on her left side on the floor. The note showed R41 was attempting to stand up unassisted and continued to put her left hand on her left thigh, saying Ouch when R41 attempted to take a step. The note showed the company that was notified to perform the X-ray was on the way to the facility. R41 was placed on one-to-one staff supervision at that time, due to attempts to self-transfer/ambulate. R41's progress note dated 4/22/23 at 11:58 AM showed R41's X-ray results showed an acute intertrochanteric hip fracture. R41's progress note dated 4/22/23 at 12:14 PM showed a new order was received from R41's Physician to send her to a local hospital's emergency department for evaluation and treatment of her left hip, due to X-ray results and signs of pain. The facility's document titled Incidents by Incident Type, printed by the facility on 9/13/23, showed between 7/25/22 - 9/13/23 R41 had 17 falls in the facility. The document showed 12 of R41's falls occurred before the fall resulting in a fracture that occurred on 4/21/23. The document showed R41's falls had occurred in the hallway, in the dining room, in R41's room, in R41's bathroom, and in the lounge area. R41's facility assessment dated [DATE] showed R41 had severe cognitive impairment, short-term and long-term memory problems, and continuous inattention. The assessment also showed R41 had falls in the facility and wandering behaviors. The assessment also showed R41 required supervision when walking. R41's Morse Fall Scale (a tool to determine a resident's risk for falls) dated 4/4/23 showed R41 had a high risk for falling. On 9/14/23 at 8:38 AM V6 (LPN) said she thinks R41 was in the dining room when R41 fell on [DATE]. V6 stated, she (R41) had so many falls, I (V6) think this is the one where she was in the dining room. V6 said she was in the hallway passing medications when she heard R41 fall. V6 said she went into the dining room and R41 was on the floor. V6 said R41 did not complain of pain at the time and was trying to get up on her own. V6 said no staff were in the dining room at the time of R41's fall, they were getting other residents up. V6 said there were other residents in the dining room at that time, however, she does not recall which residents. V6 said R41 had falls before that incident. V6 said R41 had been sitting up at a table in the dining room, prior to her fall. V6 said R41 would not stay anywhere, she was walking at the time and got up on her own. V6 said R41 was, and still is, restless and is constantly going. V6 said R41 was a fall risk. V6 said it is probably not a good idea to have her (R41) in the dining room with no staff present, considering she is a fall risk. On 9/14/23 at 12:28 PM, V13 (Certified Nursing Assistant-CNA) said the day R41 fell in the dining room and sustained a hip fracture, V13 was in another resident's room assisting the resident. V13 said by the time she got done assisting the other resident and went out of the room, R41 had already been assessed and was back up in her chair. V13 said V6 (LPN) informed her R41 had fallen. V13 said she did not consider R41 a fall risk, prior to that incident, because R41 had not had any falls on her shift. V13 said the only time she would consider R41 a fall risk was when she was agitated and pacing, but that did not happen very often. V13 said when she went through her initial training at the facility, she was told that staff should be in the dining room at all times when there are any residents in the dining room; regardless of whether it is when they are serving food or eating. V13 said she does not know if there were staff in the dining room at the time or not because was assisting another resident. On 9/14/23 11:00 AM, V16 (Psychiatric Nurse Practitioner) said R41 has dementia, wandering behaviors, and a history of falls and should not be left in the dining room unsupervised. V16 said she feels that no residents should be in the dining room unsupervised; whether it is during a meal, or before a meal, in case there is an emergency situation. V16 said there should be someone in the dining room when there are residents in there. Staff should respond as soon as they hear the sensor alarm going off. R41's care plan, with a revision date of 5/1/23, showed R41 is at risk for a decline in physical mobility due to Alzheimer's and a recent hip fracture with repair, significant mobility change. The care plan showed R41 was non-ambulatory with CNA and is totally dependent on one staff for locomotion, using a wheelchair. R41's care plan initiated on 6/15/22 showed R41 is at risk for falls related to cognitive deficit and poor safety awareness secondary to dementia. The care plan showed R41 wandered and had impulsive behaviors. The facility assessment dated [DATE] showed R41 requires extensive assist from two staff members for transfers. The assessment showed R41 had two falls in the facility since reentry or the prior assessment. R41's History and Physical documentation printed on 4/29//23 (the day R41 returned to the facility) showed, Assessment: 1. Left hip intertrochanteric fracture. 2. Advanced dementia .Plan: Case discussed with orthopedic surgery. Tentative plan for surgical fixation on Monday, 4/24/23. R41's progress note dated 4/29/23 showed R41 returned to the facility via ambulance post hospitalization for intertrochanteric fracture of left femur. Post-op dressing dry and intact to left hip surgical incision. On 9/12/23 at 9:39 AM, A bed alarm went off on the dementia care unit of the facility. The alarm was coming from R41's room. R41 was sitting up in bed. Her left leg was over the side of her bed and she was bringing her right leg over to the side of the bed. R41's hands were on the bed on both sides of her, like she was getting ready to push herself up to stand up. This surveyor cued R41 to stay in bed and wait for staff 3 times (whenever she was making the motion to attempt to stand up) between 9:39 - 9:42 AM. At 9:42 AM, V11 CNA came through the door of the memory care unit and went into R41's room. Just prior to R41's alarm sounding, V14 (CNA) had entered a resident's room next to R41's room and closed the door. On 9/13/23 at 2:16 PM, V4 (CNA) was asked what intervention were in place to prevent R41 from falling. V4 said she thinks the interventions in place are to her pull alarm and low bed right now. V4 said as soon as we hear her alarm, we come running. On 9/14/23 at 8:18 AM, V2 (Director of Nursing-DON) was asked which residents would be a candidate for a sensor alarm. V2 said residents who have fallen a million times. V2 said the alarm gives staff a little time to get to the resident before they fall on the ground. V2 said staff should respond to the alarm as soon as possible when the alarm goes off. On 9/14/23 at 11:00 AM, V16 (Psychiatric Nurse Practitioner) said staff should respond as soon as they hear the sensor alarm going off. The facility's policy and procedure titled Fall Prevention and Management, approved on 5/18/18, showed Fall Prevention: 1. Conduct fall assessments on the day of admission, quarterly, and review after each fall .7. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident . 2. R26's Admission Record, printed by the facility on 9/13/23, showed R26 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, restlessness and agitation, anxiety disorder, and major depressive disorder. R26's facility assessment dated [DATE] showed she had severe cognitive impairment and wandering behaviors. The assessment showed R26 required supervision of staff when walking in her room and in the corridor on the unit. R26's Wandering/Elopement assessment dated [DATE] showed she was able to be independently mobile and had a diagnosis of dementia/Alzheimer's/Confusion. The assessment showed R26 exhibited pacing, wandering, trying to get out of the door, find family or friend, and/or perceived the need to be doing something other than what they are doing (e.g., go to work, get home, fix supper, do chores). On 9/12/23 At 2:58 PM, R26 was not in her room, or in the dining room of the dementia care unit. This surveyor walked down the hall, looking into other resident rooms that had the door open. At 2:59 PM, V4 and V10 (Certified Nursing Assistants-CNAs) were coming out of another resident's room and were asked if they knew where R26 was. V4 and V10 said R26 was in the dining room coloring. V12 (Agency Manager) had just entered the dementia care unit and was informed that this surveyor was looking for R26. V12 looked in R26's room and knocked on the bathroom door in R26's room, with no reply. V12 told V4 and V10 to start checking the other residents' rooms. The rooms were searched and R26 was found in the bathroom belonging to R44 (a male resident). R26 said she was using the bathroom. R26's care plans were reviewed, showing no care plan that addresses R26's wandering behaviors. On 9/13/23 at 2:18 PM, V4 (CNA) said she did not see anything in R26's electronic charting about wandering behaviors. On 9/13/23 at 2:40 PM, V15 (MDS/Care Plan Coordinator) was asked to look in R26's care plans for one that addresses her wandering behaviors. V15 looked through the care plans and said she did not see anything in R26's Care plans about wandering/ elopement risk. Adding, Unfortunately. V15 said R26's facility assessment dated [DATE] showed she had wandering behaviors. V15 said We usually address that in the care plans. V15 brought up section V Care Area Assessment Summary (CAAs) and said the CAAS section of the 8/21/23 MDS (facility assessment) triggered for wandering under behaviors. V15 said a care plan should have been initiated. R26's progress note dated 8/15/23 showed R26 sometimes wanders into the wrong room but is easily redirected. R26's progress note dated 8/19/23 showed, R26 refusing to stay out of other residents' room. When redirected, R26 tells staff to shut up. R26 is restless and non-stop pacing the hall, entering other resident rooms. R26's behavior note dated 8/20/23 showed she was repeatedly trying to exit the building from any door possible. Pacing back and forth up and down the halls and taking things from other residents' rooms. The note showed, Resident requires constant supervision. Another behavior note dated 8/20/23 showed R26 eating other residents' food. R26's Care plan conference note dated 9/6/23 showed R26 does wander into other resident's rooms and gets in other residents' personal space. On 9/13/23 at 2:53 PM, V1 (Administrator) said the purpose of the care plans are so staff know how to care for a resident, and to put interventions in place to keep the residents safe. The facility's policy and procedure titled Resident Wandering and Elopement, with an approval date of 2/13/2019, showed 1. The staff will identify residents who are at risk for harm because of unsafe wandering) including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included. 4. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high-risk of elopement or other unsafe behavior.

Based on observation, interview, and record review the facility failed to cleanse a stage four pressure ulcer in a manner to prevent cross contamination and failed to ensure staff were knowledgeable in the use of a pressure reduction device for 1 of 2 residents (R42) reviewed for pressure in the sample of 14. These failures resulted in R42 being at an increased risk of infection and delayed wound healing. The findings include: R42's face sheet printed on 9/13/23 showed diagnoses including but not limited to Alzheimer's disease, chronic obstructive pulmonary disease, diabetes mellitus, protein-calorie malnutrition, chronic kidney disease, neuromuscular bladder, and stage 4 pressure ulcer of the sacral region (lower back/upper buttock area). R42's facility assessment dated [DATE] showed moderate cognitive impairment and extensive staff assistance required for bed mobility, dressing, toilet use, and personal hygiene. The same assessment total staff dependence required for transfers. The assessment showed a urinary catheter in use and R42 is always incontinent of bowel. R42's physician orders showed an order dated 9/12/23 to: Place calcium alginate into wound on sacrum, after cleansing the wound with N.S. (normal saline) .cover with protective dressing/bandage, every day shift related to pressure ulcer of sacral region, stage 4. The orders showed an additional order dated 9/12/23 to: Place pressure relieving device on bed and wheelchair. (Both orders were dated as of the day the survey). R42's Medication Administration Records (MAR) showed recent antibiotic use for wound infections. The August 2023 MAR showed documentation of tigecycline intravenous administered for ten days (8/4 to 8/13) for a MRSA wound infection. The MAR showed amoxicillin-pot clavulanate oral tablets administered for 10 days (8/25 to 9/4) for wound infection. R42's most recent weekly wound assessment dated [DATE] showed the stage 4 pressure ulcer to the sacrum present on admission. The assessment showed the wound was 4 cm long, 2 cm wide, and 1 cm deep (centimeters). Visible tissue was epithelial (pink) and granulated (beefy red). On 9/12/23 at 10:29 AM, R42 was lying in bed on her back and stated she has a sore on her butt. R42 said it has been there awhile and they put a dressing on it daily. A pressure reducing air mattress overlay was under R42. The dial on the machine showed it was set at just over the 120 mark. At 10:37 AM, V3 (WCN-Wound Care Nurse) and V4 (CNA-Certified Nurse Aide) rolled R42 to her side. A large white, damp dressing was hanging loosely off her sacral area. V3 stated there was a tele-visit scheduled with the wound doctor in approximately 15 minutes and she would apply a fresh dressing when she was done with the physician's visual assessment. R42's pressure reduction mattress pad was set at the 80 mark. At 10:53 AM, V3 (WCN) and V18 (Nurse Liaison) rolled R42 to her side. V3 removed the dressing and held a tele visit via cell phone with V17 (Wound Physician). V17 stated to continue with the daily cleansing and calcium alginate wound care treatments. On 9/12/23 at 11:24 AM, V3 (WCN) wore gloves and removed the damp dressing from R42's sacrum. A golf ball size open wound with reddened skin surrounding it was observed. V3 used a gauze pad soaked in normal saline and blotted randomly at the wound. V3 blotted up, down, in and out across the wound. V3 poured more saline solution onto the same gauze pad a second time and blotted the wound again. V3 wore the same contaminated gloves and placed a calcium alginate pad on the wound then used a cotton swab to push it down. V3 readjusted the calcium alginate pad with her finger while wearing the same gloves. V3 placed a bordered foam dressing over the wound while still wearing the same contaminated gloves. V3 did not change gloves or sanitize her hands during the dressing change. V3 said she does the dressing change each day and as needed during the week. The floor nurses do it over the weekends. R42's pressure pad dial showed it was just under the 60 mark. On 9/12/23 at 2:41 PM, R42 was lying in bed. The pressure pad dial showed a setting pass the 280 mark. V5 (CNA Supervisor) was questioned by this surveyor what the pressure reduction devices hanging on the foot of resident beds were used for. V5 said she did not know what the machine was and had no idea how they should be set up. V5 stated she needed to ask her DON (Director of Nurses). V5 and V2 (DON) returned to the unit together approximately five minutes later. V2 was shown the pressure reducing device and stated they are used to prevent skin breakdown. V2 observed the setting on R42's device and said it is set well beyond the 280 mark and is as firm as it can be set. V2 said she did not know how the mattress should be set and will need to look into it. On 9/12/23 at 3:01 PM, V1(Administrator/Registered Nurse) said the air mattresses are set based on resident comfort. If they say it feels fine, then we leave it alone. If the skin looks reddened, it should be turned to a softer setting. We look for facial grimacing if the resident is non-verbal or just looks uncomfortable. V1 said pressure ulcer mattresses are set based on a resident's individual preferences. We turn it softer or firmer based on how they look and what they report as to the feel of it under them. On 9/13/23 at 9:08 AM, R42 was in bed and the pressure reduction pad was set beyond the 280 mark. On 9/13/23 at 1:05 PM, V3 (WCN) stated she had no idea what R42's mattress setting should be at. V3 said she did not know who sets it or how it is set. V3 said she has nothing to do with the pressure device settings. V3 said wound treatments should be done in a manner to help healing. V3 said the wound should be cleansed as ordered and kept clean while doing the treatment. V3 said it is important not to infect the wound in anyway while doing the treatments. V3 said she starts with hand hygiene and a fresh pair of gloves. V3 said she keeps the same gloves on until she is done with the treatment. V3 did not mention any glove changes were necessary while doing wound treatments. V3 said she wipes the inside and outside of the wound in a blotting manner. V3 said a cotton swab is used to fit the calcium alginate into the wound and it is important nothing dirty touches the wound. It could become contaminated. V3 and the surveyor observed R42's pressure reduction device together. It was set at the 120 mark. V3 said she had no idea what the numbers represent and maybe V1 (Administrator) would know. On 9/13/23 at 2:15 PM, V1 (Administrator/RN) said gloves should be changed anytime they are contaminated. Wounds should probably be cleaned from the inner area to the outer area. Nurses should be doing the dressing changes per the facility policy and the wound care nurse is the one that knows the proper technique. It is important to prevent infection. Poor wound care can delay healing and lead to other complications. Infected wounds can become systemic and R42 had just completed a round of antibiotics related to a sacral wound infection. V1 said the point of the pressure reduction mattress is to reduce pressure. It is based on resident comfort. V1 said we stick our hand under the mattress to judge if it is too soft or too hard. Our technique is based on the manufacturer's instructions. At 2:38 PM, V1 and the surveyor observed R42's mattress setting at the 60 mark. V1 turned the dial to 180 and said, I have no idea how or why this dial setting works. On 9/14/23 at 4:33 PM, V17 (Wound Physician) stated R42 has a tricky sacral wound. It is a chronic problem and staff should be cleaning it according to the orders. Cleansing the wound bed should be done per the facility's protocol. A fresh gauze pad is needed for each wipe or each time it is touched. The area should not be blotted because that will not thoroughly clean the wound. Gloves should be changed between dirty and clean use. It is important before going on to any treatments. V17 said gloves should be changed after cleansing the wound. New gloves should be worn to apply the calcium alginate and another set of new gloves to put the dressing over the wound. V17 said hand hygiene should be done between glove changes. V17 said R42 was on an antibiotic recently and poor wound cleansing can increase her risk for another infection. V17 said R42's wound has the risk of decreased healing, increased pain, and a septic infection if wound care is not done properly. V17 said R42's pressure reduction mattress should be used per the manufacturer recommendations and staff need to know how to use it. It needs to be more than just comfort based. V17 said the standard is to set it at a level so the mattress sinks to about 20%. The facility should have a policy or procedure to explain to the staff how to use her pressure reduction mattress. Not knowing how to use it puts her at an increased risk for poor wound healing. The manufacturer instructions for R42's pressure reduction pad (undated) showed: 7. Please use pressure adjust knob to give maximum patient comfort. The facility was unable to provide any additional information related how to ensure it was providing the necessary pressure reduction or instructions on how to use the pad. The facility's Clean Dressing Change policy last review dated 7/28/2023 states under the purpose section: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. The policy states under the steps in the procedure section: 9. Loosen the tape and remove the existing dressing .10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze. 13. Measure wound using disposable measuring guide as indicated. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered .16. Secure the dressing.)

Based on observation, interview, and record review the facility failed to ensure catheter changes were performed as ordered and failed to ensure catheter care orders were in place for 2 of 3 residents (R6, R20) reviewed for catheters in the sample of 14. This failure resulted in catheters having a gray discoloration for residents with recurrent urinary tract infections (R6, R20), R6's urine was cloudy yellow with sediment, and R20's urine was thick, foul-smelling, and amber in color. The findings include: 1. On 9/14/23 at 10:05 AM, V10 and V11 (Certified Nursing Assistants - CNAs) transferred R6 to bed from the wheelchair. V10 and V11 laid R6 on her back and removed her pants and incontinence brief. R6 had an indwelling catheter inserted. The catheter was attached to a leg bag. The leg back was secured to R6's right inner leg. There was cloudy yellow urine, with sediment draining into the leg bag. V11 used a washcloth to cleanse R6's catheter tubing. The catheter tubing was discolored from the insertion site (nearest the body) to the Y in the tubing. (This type of indwelling catheter had a Y at the distal end of the tubing, one side connected to the drainage system and the other was used to inflate the balloon of the catheter). The catheter tubing from R6's body to the beginning of the Y was a dark gray discoloration. The tubing at the of the Y was a tan color (The original color of this type of indwelling catheter was tan). V10 and V11 provided catheter care, emptied R6's leg bag, and attached R6's regular drainage bag. R6's Face Sheet dated 9/14/23 showed diagnoses to include, but not limited to: TBI (traumatic brain injury), asthma, diabetes, generalized muscle weakness, diabetes, need for assistance with personal cares, difficulty walking, unsteadiness on feet, Extended Spectrum Beta Lactamase (ESBL) Resistance (a multi-drug resistant organism that causes bladder infections (UTIs), anxiety, history of bladder infections, neuromuscular dysfunction of the bladder, chronic obstructive pyelonephritis, retention of urine, vascular dementia, depression, and bipolar disorder. R6's facility assessment dated [DATE] showed R6 had long and short-term memory problems; required extensive assistance from staff for transfers, personal hygiene, and toilet use; and had an indwelling urinary catheter. R6's Physician Visit dated 8/10/23 showed R6 had recurrent UTIs. R6's Urology Visit Summary dated 4/26/23 showed R6 was seen for a UTI associated with an indwelling catheter and recurrent UTIs. R6's Lab Report dated 4/15/23 showed R6's Urine Culture was positive for ESBL. R6's Physician Order Sheet dated 9/14/23 showed R6 had an order for catheter care every shift. This document showed R6 had an order for Contact Isolation precautions (due to an UTI caused by ESBL), initiated on 4/20/23. R6 had an order a 16 French (catheter size), 10 cc balloon change monthly and as needed, to be initiated 4/20/23. R6's Treatment Administration Records (TARs) dated June 2023 through [DATE] were reviewed. R6's TARs showed R6's catheter had not been changed since 6/9/23 (3 months prior to this observation). R6's TARs showed that R6's indwelling catheter was not changed monthly, as ordered. R6's Progress Notes were reviewed from 6/10/23 to 9/13/23. There were no entries that showed R6's indwelling catheter had been changed. These progress notes showed R6 was hospitalized for ESBL from 4/14/23 - 4/20/23. R6's Progress Note dated 9/13/23 showed the facility had collected a urine specimen for urinalysis and culture and sensitivity. R6's Care Plan revised 1/11/23 showed R6 had an indwelling catheter related to a neurogenic bladder. The interventions included Change per MD orders. On 9/14/23 at 10:21 AM, V6 (Licensed Practical Nurse) said she was the nurse for R6's hall. V6 stated, I think the catheters are changed monthly and PRN (as needed). There should be a doctor's order for that. We (the nurses) should follow the physician's order. V6 said she thought the facility might have changed the policy and she wasn't sure exactly. V8 (RN) walked up to the nurses' station. V6 asked V8 what the policy was for changing the indwelling catheters. V8 stated, I know it has changed recently. I believe the catheter change is now PRN (as needed), but I would have to check our policy to be sure. V6 said some reasons to change an indwelling catheter PRN could be the catheter isn't flowing right, it's leaking, or it doesn't flush. The surveyor asked V6 if discoloration of the catheter tubing was an indication to change the catheter. V6 said she wasn't sure what that meant. The surveyor described the dark gray, discoloration on R6's tan catheter tubing. V6 replied, That would be concerning. They shouldn't change color. V6 said it is important the nurses change the catheter to ensure it is working properly and not building up infection. V6 said R6 has had UTIs. The surveyor asked how the nurse knows when the catheter was changed last. V6 said she would have to check the TAR. V6 reviewed R6's September TAR and stated, I don't see that the catheter was changed in September, but this order says to change it monthly. V6 reviewed R6's TARs until she found the last time R6's catheter change was documented. V6 stated, It looks like it wasn't changed since 6/9/23. That's not right. It should have been changed. V6 informed V7 (LPN in training), Let's get those sizes (of the catheters) written down. We'll need to change those. V6 said the facility's supply of catheters was kept on the front hall. On 9/14/23 at 10:40 AM, V1 (Administrator) said the facility has two types of catheters. The 100% silicone that R20 needs (this catheter tubing is clear) and the silicone coated one that has latex (this catheter tubing is tan). R6 used the tan catheter. The surveyor informed V1 that R6's catheter had a dark gray discoloration from the insertion site to the Y on the catheter. V1 replied, I will have to take a look. At 11:15 AM, V1 said she did see the discoloration on R6 and R20's catheters. V1 said both R6 and R20 were seen by urology. At 12:07 PM, V1 said the only policy related to catheters that the facility had was the Catheter Care Policy that was provided. (This policy did not contain any information regarding when to change the indwelling catheter.) On 9/14/23 at 1:20 PM, V9 (Urologist) said R6 was seen in his office, V9 does not go to the facility. V9 said he saw R6 in April 2023 for urinary tract infections. V9 said he expects the catheter to be changed monthly. V9 said he would expect the facility to follow the physician's orders. V9 said he had never heard of indwelling catheters being changed PRN. The surveyor informed V9 that R6's last catheter changed was 6/9/23. V9 replied, Well that's a month or two late. V9 said R6's catheter should not be discolored. V9 said that should be an indication to change the catheter, but it really should be done monthly and this wouldn't be an issue. The surveyor asked for a catheter policy. The facility provided Catheter Care Policy (reviewed 7/28/23). This policy does not include information regarding when to change an indwelling catheter. (V1 (Administrator) said this was the only policy the facility had for catheters. 2. On 9/14/23 at 9:39 AM, V10 and V11 (CNAs) transferred R20 from her wheelchair to her bed, using a total lift. R20 was laid on her back and her pants were removed. R20 had an indwelling catheter attached to a leg back. The leg back was secured to her right leg. There was dark amber urine in the leg bag. V10 and V11 provided catheter care. R20's catheter was gray from her body to the Y in the tubing. (R20's catheter color is normally clear). V11 emptied R20's leg bag. The urine was sluggish to drain. V11 stated, It gets like this from time to time. Her position doesn't help. R20 was lying on her back in bed with her right leg slightly bent. The urine wasn't flowing freely down to the drain spot. V11 moved R20's leg, so the urine could be drained. Thick, amber, foul-smelling urine slowly drained from the leg bag. There were strings of sediment that were hanging from the drain spot. R20's urine appeared thick and was sluggish to drain. V11 (CNA) said it gets like this sometimes. R20's Face Sheet dated 9/14/23 showed diagnoses to include, but no limited to: chronic pain syndrome, MRSA (Methicillin Resistant Staph Aureus) infection, multiple sclerosis, dysphagia, anxiety, depression, generalized muscle weakness, seizures, and bipolar disorder. R20's facility assessment dated [DATE] showed she had severe cognitive impairment; required extensive assistance for personal hygiene and bed mobility; was totally dependent on staff for transfers and toilet use; and had an indwelling catheter. R20's POS dated 9/14/23 showed orders for an indwelling catheter, size 16 French with a 10 ml balloon. Change PRN (as needed). R20 did not have orders of Catheter Care every shift. R20's July 2023 to [DATE] TARs were reviewed. The last documented catheter change was 7/25/23. There was no documentation of catheter care being provided every shift. On 9/14/23 at 10:21 AM, V6 (Licensed Practical Nurse) said she was the nurse for R20's hall. V6 stated, I think the catheters are changed monthly and PRN (as needed). There should be a doctor's order for that. V6 said she thought the facility might have changed the policy and she wasn't sure exactly. V8 (RN) walked up to the nurses' station. V6 asked V8 what the policy was for changing the indwelling catheters. V8 stated, I know it has changed recently. I believe the catheter change is now PRN (as needed), but I would have to check our policy to be sure. V6 said some reasons to change an indwelling catheter PRN could be the catheter isn't flowing right, it's leaking, or it doesn't flush. The surveyor asked V6 if discoloration of the catheter tubing was an indication to change the catheter. V6 said she wasn't sure what that meant. The surveyor described the gray, discoloration on R20's clear catheter tubing. V6 replied, That would be concerning. They shouldn't change color. V6 said it is important the nurses change the catheter to ensure it is working properly and not building up infection. V6 said R20 had a history of UTIs. The surveyor asked how the nurse knows when the catheter was changed last. V6 said she would have to check the TAR. V6 reviewed R6's September TAR and stated, I don't see that the catheter was changed in September. V6 reviewed R20's TARs until she found the last time R20's catheter change was documented. V6 stated, It looks like it wasn't changed since 7/25/23. That's not right. It should have been changed. V6 informed V7 (LPN in training), Lets write get those sizes (of the catheters) written down. We'll need to change those. V6 said the facility's supply of catheters was kept on the front hall. V6 said catheter care should be ordered every shift for all residents with catheters. V6 said she did not see catheter care orders for R20. V6 said catheter care is important to decrease the risk of infection. The surveyor described R20's urine as thick, amber, and foul-smelling. V6 replied, That could be a sign of an UTI. I don't see that she (R20) has had urinalysis done since May. On 9/14/23 at 10:40 AM, V1 (Administrator) said the facility has two types of catheters. The 100% silicone that R20 needs (this catheter tubing is clear) and the silicone coated one that has latex (this catheter tubing is tan). The surveyor informed V1 that R20's catheter had a gray discoloration from the insertion site to the Y on the catheter. V1 replied, I will have to take a look. At 11:15 AM, V1 said she did see the discoloration on R6 and R20's catheters. V1 said both R6 and R20 were seen by urology. At 12:07 PM, V1 said the only policy related to Catheters that the facility had was the Catheter Care Policy that was provided. (This policy did not contain any information regarding when to change the indwelling catheter.) On 9/14/23 at 1:20 PM, V9 (Urologist) said R6 was seen in his office, he does not go to the facility. V9 said he had not seen R20 since November 2022. V9 said he expects the catheter to be changed monthly and for catheter care to be ordered. V9 said he had never heard of indwelling catheters being changed PRN. The surveyor informed V9 that R20's last catheter change was 7/25/23. V9 said R20's catheter should not be discolored. V9 said that should be an indication to change the catheter, but it really should be done monthly and this wouldn't be an issue. The surveyor asked for a Catheter policy. The facility provided Catheter Care Policy (reviewed 7/28/23). This policy does not include information regarding when to change an indwelling catheter. (V1 (Administrator) said this was the only policy the facility had for catheters).

Based on observation, interview and record review the facility failed to sanitize resident equipment and failed to provide peri care in a manner to prevent cross contamination for 3 of 3 residents (R31, R39, R41) reviewed for infection control in the sample of 14. The findings include: 1. On 9/13/23 at 7:45 AM, V6 (Licensed Practical Nurse) used a glucometer to perform a blood sugar check on R31. V6 laid the glucometer on top of the medication cart after it was exposed to R31's blood. V6 did not clean or sanitize the device in any way. V6 completed the medication administration for R31, then continued onto the next resident's room to administer medications. The facility supplied a list of residents that V6 was administering blood sugar checks on for 9/13/23 and from the same medication cart. The list consisted of R31 and R39. On 9/13/23 at 3:13 PM, V6 stated she should have cleaned the glucometer right after use. It has germs on it that could be passed onto the next person. V6 said she should have rubbed it down with a sanitizing wipe and left if on for at least two minutes. There is the potential that germs could go from the glucometer to the top of the cart and then get passed onto the next resident when their medications are prepared. On 9/13/23 at 3:26 PM, V2 (Director of Nurses, Infection Control Preventionist) stated the glucometers need to be cleaned between residents and based on manufacturer instruction. It should be wiped off and left wet as long as the manufacturer shows. It should be done after each use. It comes in contact with blood and there is the potential for cross contamination between residents. Blood borne pathogens can be spread. The facility's Super Sani-Cloth germicidal disposable wipes instructions states: To disinfect nonfood contact surfaces only. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. The facility's Glucometer Disinfection policy last review dated 7/28/23 states: 5. The nurse shall use a surface disinfectant to wipe the surface of the glucometer. The surface shall include all areas of the meter excluding the read-out window. Follow manufacture guidelines for length of cleaning time. 34491 2. R41's Admission Record, printed by the facility on 9/13/23, showed she had diagnoses including vascular dementia, severe, with behavioral disturbance, generalized muscle weakness, and need for assistance with personal care. The Admission Record showed R41 resides on the dementia care unit of the facility. On 9/13/23 at 2:07 PM, V4 (Certified Nursing Assistant-CNA) was providing incontinent care for R41. V4 used one wash cloth to wipe R41's right groin area, folded the washcloth, and wiped R41's right groin a second time. Stool was visible on the washcloth at this point. V4 folded the washcloth again, then wiped R41's left groin area twice, folding the washcloth in between wipes. More stool was observed on the washcloth when V4 wiped R41's right groin area. V4 folded the washcloth a fourth time and then wiped down R41's middle, labial area. V4 placed the soiled washcloth in a garbage bag located on R41's chair. V4 picked up another washcloth to rinse, using the same technique. V4 placed that washcloth in the garbage bag and dried R41's front side with a towel. V4 rolled R41 onto her right side, then picked up the same visibly soiled washcloth she used to clean R41's front side and started cleaning stool from R41's buttocks. V4 folded the cloth and wiped again, then placed the soiled washcloth back into the garbage bag. V4 grabbed the washcloth that she had rinsed R41's front side out of the garbage bag and used it to rinse R41's buttocks. V4 then dried the area and placed a clean incontinent brief on R41 and pulled her pants up. On 9/13/23 at 2:55 PM, V1 (Administrator/Registered Nurse-RN) said she would think a washcloth should not be folded and used again after 2-3 times of folding the cloth. V1 said once the washcloth becomes soiled, a new washcloth should be used. V1 said it is important to do this so bacteria are not introduced into the opening of the body and to prevent UTIs (urinary tract infections). The facility's policy and procedure titled Perineal Care, approved on 7/1/2019, showed the purpose of the procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The policy showed 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back .(2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, and using downward strokes. Do not reuse the same side of washcloth to clean the urethra or labia.

Based on observation, interview and record review the facility failed to ensure staff wore PPE (personal protective equipment) when providing cares to a resident on contact isolation precautions. The facility failed to ensure staff wore eye protection during a time of high community COVID-19 transmission rate. The facility failed to perform hand hygiene during medication administration. These failures apply to 7 of 12 residents (R21, R39, R10, R2, R9, R4, R19) reviewed for infection control in the sample of 12. The findings include: 1. A facility list dated July 25, 2022 showed R21 was on contact isolation precautions due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On July 25, 2022 at 9:15 AM, a contact isolation sign hung on the door of R21's room. The sign showed staff/visitors should don PPE (personal protective equipment) including a mask, gloves, and gown prior to entering the room. An isolation cart with PPE was stationed outside of R21's door. V6 Certified Nursing Assistant (CNA) stood beside R21, in her room, wearing only a mask. V6 CNA wore no gloves or gown. At 9:20 AM, V6 CNA transferred R21 to the toilet and removed R21's incontinence brief that was soiled with urine, without donning gloves or a gown. While R21 sat on the toilet, V6 CNA then exited R21's room to don gloves and a gown and returned to assist R21 off of the toilet. On July 25, 2022 at 9:24 AM, V6 CNA stated, I should have worn a gown and gloves when I was in (R21's) room, especially when I helped her to the bathroom. On July 26, 2022 at 9:27 AM, V2 Director of Nursing stated staff should wear PPE including gloves, mask, and gown when toileting a resident on contact isolation for ESBL of the urine. The facility's Isolation-Categories of Transmission-Based Precautions policy dated July 20, 2022 showed, Implement Contact Precautions for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy showed staff should don a gown and gloves prior to entering a resident's room on contact isolation. 2. On 7/26/22 at 8:21 AM, V8 (Certified Nursing Assistant) was feeding R2 breakfast. V8 had no eye protection on. On 7/26/22 at 8:21 AM, V7 (Certified Nursing Assistant) was feeding R39 breakfast. V7 had glasses on but no eye protection. On 7/25/22 at 2:18 PM, V9 (Environmental Service Supervisor) was sitting within 6 feet of R10 and singing with her. V9 had glasses on but no eye protection. On 7/27/22 at 10:38 AM, V1 (Administrator) said that glasses are not considered eye protection. It has to be a face shield and goggles. V1 said that eye protection needs to be worn at all times. V1 said that the facility is currently in an outbreak and the county community transmission rate is high. The facility's Coronavirus-(COVID-19) Policy reviewed on 3/30/22 shows, PPE (Personal Protective Equipment) .For those residents not suspected to have COVID-19, HCP (Health Care Personnel) should use the community transmission levels to determine the appropriate PPE to wear. When community transmission levels are substantial or high, HCP must wear a well-fitted face mask and eye protection. The facility's Personal Protective Equipment-Using Protective Eyewear Policy reviewed on 6/24/21 shows, Personal eyeglasses should not be considered as adequate protective eyewear. The CDC (Centers for Disease Control) Data Tracker for 7/20/22-7/26/22 shows that the facility's county COVID transmission level is high. 3. On 7/26/22 at 8:21 AM, V4 (RN) prepared R9's medications at the medication cart in the hallway. V4 entered the dining room spoon fed R9's medications then left the dining room and did not perform hand hygiene before and after administering the medications. V4 continued to give medications to R4 and R19 and did not perform hand hygiene before and after administering the medications. (hand sanitizer was located on V4's medication cart). On 7/26/22 at 9:43 AM, V2 (DON) said staff should perform hand hygiene in between residents. The facility's Hand Hygiene Policy states, Proper hand hygiene practices reduce the transmission of pathogenic microorganisms to residents, visitors and other staff members .all personal working in long term care facilities are required to wash their hands before and after resident contact

Based on observation, interview and record review the facility failed to identify a wound prior to becoming infected. This applies to 1 of 12 residents (R19) reviewed for quality life in the sample of 12. The findings include: R19's face shows she is a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist with bed mobility transfers, toileting and is frequently incontinent. R19's Skin Braden Scale dated 2/23/22 shows she is at risk for developing pressure sores. The nurse's note dated 2/16/22 documents R19 skin is normal with no skin issues present. R19's nurse's note dated 2/21/22 documents at 2:40 AM, a large, raised area to the right of her coccyx was observed. The redness measured 10.0 cm (centimeters) x 9.0 cm with a dark area to the center measuring 1.0 cm x 1.0 cm. R19's Physician Wound progress note dated 2/21/22 documents R19 has a right buttock full thickness wound (wound that extends beyond the two layers of the skin) measuring 2 cm x 0.2 cm x 0.5 cm. There is moderate amount of drainage of the wound with 100% eschar. The same report showed an I & D (Incision & Drainage) was performed at the bedside with immediate release of purulent fluid (thick drainage indicating an infection). R19's Physician Wound progress note dated 2/28/22 documents R19 has a right buttock full thickness wound measuring 1.4 cm x 1.2 cm x 0.8 cm with moderate amount of drainage with no change to the wound progression. R19's nursing note dated 2/28/22 documents wound culture obtained of the right buttock and antibiotic initiated. R19's Laboratory Report showed the specimen was collected on 2/28/22 and the final wound report received on 3/3/22 showed heavy growth of [CONDITION(S)] (Staphylococcus aureus, [CONDITION(S)] resistant) in the buttock wound. On 7/25/22 at 9:07 AM, V7 (CNA) said R19 has a wound to her backside. R19 was lying on her back. A foam dressing was observed to the right coccyx/buttock. At 1:42 PM, R19 was observed lying on her back. On 7/26/22 at 12:18 PM, V11 (LPN) said on 2/21/22 she observed a dark area to her right coccyx with redness surrounding the area. V11 said R19 likes to lay on her back, and she needs assistance with bed mobility and transfers. V11 said the wound was not reported to her prior. On 7/26/22 at 9:44 AM, V4 (RN) said any new skin issues should be reported to nursing and assessed. On 7/26/22 at 10:36 AM, V2 (Director of Nursing) said R19's right buttock wound was infected with [CONDITION(S)]. On 7/26/22 at 12:00 PM, V14 (Director of Clinical Services) said she was not sure how R19 developed her wound on her right buttock. V14 said the wound was infected with [CONDITION(S)]. On 7/26/22 at 12:34 PM, V12 (Wound Physician) said infectious wounds take time to develop. The most recent Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The peri wound skin is exhibited with [CONDITION(S)] (redness). The same report showed debridement of the wound was performed. (The facility did not provide the wound progress notes from July 2022).

Based on observation, interview and record review the facility failed to ensure residents were transferred and ambulated in a safe manner for 2 of 12 residents (R35, R36) reviewed for safety and supervision in the sample of 12. The findings include: 1. R35's current care plan showed R35 was at risk for falls due to weakness, a gait balance problem, and her diagnosis of dementia with behaviors. The care plan showed R35 transferred and ambulated with the assistance of staff and a rolling walker. The facility's Incident/Accident Logs printed July 25, 2022 showed R35 had fallen 8 times in the facility from May 2022-July 2022. On July 25, 2022 at 8:50 AM, V5 Certified Nursing Assistant (CNA) transferred R35 out of bed, into a standing position, and began walking with R35, while holding onto the waistband of R35's pants. No gait belt was noted around R35's waist. 2. R36's current care plan showed R36 was at risk for falls related to weakness, deconditioning, pain to her lower extremities, and her history of previous falls. The care plan showed R36 transferred and ambulated with the assistance of one staff member. On July 25, 2022 at 8:54 AM, V5 CNA transferred R36 off of the toilet and ambulated R36 from the toilet to a recliner in her room, while holding onto R36's waist. No gait belt was noted around R36's waist. On July 25, 2022 at 9:02 AM, V5 CNA stated, Gait belts should be placed around the waist of residents and used whenever they are walked, transferred, or toileted. On July 26, 2022 at 9:27 AM, V2 Director of Nursing (DON) stated, Gait belts should be used whenever residents, that need staff assistance, are transferred and ambulated. Staff should be using gait belts with (R35 and R36). (R35) has had a lot of falls lately. The facility's Safe Lifting and Movement of Residents policy dated April 26, 2022 showed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .4. Gait belts shall be used on residents unless residents are independent with ambulation or contraindicated in the resident's care plan .

Based on observation, interview and record review the facility failed to apply an arm splint to a resident with a hand contracture for 1 of 5 residents (R15) reviewed for restorative care in the sample of 12. The findings include: R15's care plan dated July 14, 2022 showed R15 had a contracture to her right hand due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan showed facility staff were to apply a palmar (palm of the hand) splint to R15's right hand during the day and remove the splint at night. R15's resident assessment dated [DATE] showed R15 was severely cognitively impaired. On July 25, 2022 at 9:10 AM, V5 Certified Nursing Assistant (CNA) provided cares to R15 in her room. R15's right hand was contracted with the fingers of her right hand contracted/bent at the mid-knuckle area. No spontaneous movement of R15's right arm or leg were noted. No splint was noted to R15's right hand. An arm splint was noted in a storage container located directly across from R15's bed. On July 25, 2022 at 1:34 PM, R15 was asleep in bed. No splint was noted to R15's contracted right hand. On July 26, 2022 at 8:24 AM, R15 was lying in bed. No splint was noted to R15's contracted right hand. An arm splint was noted in a storage container located directly across from R15's bed. On July 26, 2022 at 9:48 AM, V5 CNA stated, I took care of (R15) yesterday. I didn't put a splint on her arm yesterday. I know she used to have a splint for her right hand, but I don't know if she still does. On July 26, 2022 at 9:52 AM, V7 CNA stated, I don't know if (R15) still has a splint for her right hand. I haven't offered it to her today or even looked for it. On July 26, 2022 at 9:57 AM, V3 Restorative Licensed Practical Nurse stated, (R15) has a splint for her contracture to her right hand. It should be in her room. CNA's are responsible for making sure it is applied. She has refused it in the past, but staff should attempt to offer it daily and document if she refuses. Staff should document her refusal under the restorative task charting in the computer. R15's Restorative Task report dated June 27, 2022-July 25, 2022 showed no documentation of R15 refusing to wear her right hand splint. On July 27, 2022 at 9:30 AM, V13 Regional Director of Operations stated the facility did not have a policy on restorative cares or the use of splints.

Based on observation, interview, and record review, the facility failed to provide services in a manner to maintain the dignity of a resident. This failure resulted in R4 being incontinent and feeling degraded and humiliated. This applies to 1 of 12 residents (R4) reviewed for dignity in the sample of 12. The findings include: R4's Minimum Data Set (MD) assessment of 8/28/18 shows she requires extensive assist of 2 staff members for transfers, bed mobility and toileting. The MDS shows R4 is cognitively intact and has bilateral range of motion limitations on her upper and lower extremities. The MDS shows R4 is always continent of bowel and bladder. On (MONTH) 11, (YEAR) at 6:30 PM, R4 was observed sitting in the dining room talking with her table mates at the supper table. R4 was alert, oriented and very social with the other residents. At 12:20 PM, R4 was observed in her room, lying in bed using a bed pan. R4 had 2 areas of darker skin on her coccyx area. V5 (Certified Nursing Assistant-CNA) said it was from a previously opened area, present on admit. On (MONTH) 11, (YEAR) at 7:57 PM, R4 was sitting in her wheel chair in her room. R4 said This last holiday weekend they (the facility) had the cluster mess of a century. R4 said there was just a couple of CNAs (Certified Nursing Assistants) working, that had to take care of everyone in the facility. R4 said it was 9:25 PM on 9/3/18 before she was removed from the dining room after supper and put into bed. R4 said she had been incontinent of urine because she could no longer hold her urine. I felt very degraded, humiliated and disgusted. R4 said not only was she tired and exhausted from sitting in the dining room that long but her tail bone hurt and she was incontinent. R4 said she has been in the facility for about three weeks and this is not the first time she had been incontinent due to not being able to hold her urine because staff were taking too long to assist her. R4 said sometimes she is left sitting in her pee for hours and hours. On (MONTH) 11, (YEAR) at 11:56 AM, V3 (Agency Certified Nursing Assistant-CNA) said she worked on (MONTH) 3, (YEAR) on the second and third shift. V3 said there was only herself and V4 (CNA) who were responsible for the residents located on the north and south halls. V3 said residents sat in the dining room for so long because her and V4 could not get to them. V3 said Everyone had to suffer and wait until we could get to them. V3 said some of the residents sat up in the dining room after supper until after 10:30 PM. V3 said she believes they laid the last resident down in bed at 11:15 PM that night. On (MONTH) 12, (YEAR) at 9:41 AM, V4 CNA said on (MONTH) 3, (YEAR), herself and V3 were responsible for the north and south halls and it was V3's first day in the facility. V4 said she felt so bad, The residents were so saturated by the time we laid them down. V4 said she stayed until 11:15 PM (an hour and 15 minutes past her shift) to help. V4 said the last resident was taken out of the dining room and laid down around 11:15 PM. V4 said They were sore from having to sit in urine because they had to sit there for so long. V4 said it was chaos. V4 said she was in tears that shift because she was so frustrated with the situation. V4 said she does not work at the facility any longer. That was my last night. I quit. The way management handled that, I was livid, it was like they just didn't care On (MONTH) 12, (YEAR) at 10:11 AM, V6 (Licensed Practical Nurse-LPN) said the residents were in the dining room very late on (MONTH) 3, (YEAR). V6 said I know when it was going on 10:00 PM there were residents still in the dining room from supper time. There was not enough staff that was a fact. On (MONTH) 11, (YEAR) at 1:10 AM, V2 (Director of Nursing) said a couple of times the facility has had to work one CNA on each hall. V2 added, That is not enough staff. The facility's undated Dignity policy shows The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on interview and record review the facility failed to allow a resident to return to the facility after being medically cleared by a facility physician. This failure resulted with a resident being displaced for 13 days into an emergency room setting unable to meet his long term care needs such as peer socialization and group activities. R1 was isolated to a single room and unable to freely move about independently. This applies to 1 of 5 residents (R1) reviewed for discharge in the sample of 10. The findings include: The July 18, 2016 MDS (Minimum Data Set) show R1 had physical behavioral symptoms directed towards others such as hitting, kicking, pushing and scratching 4 to 6 days of a 7 day period. The MDS shows this does not put the resident at risk for himself, but does put a risk of injury to others, and this behavior is worse than his previous admission assessment. The MDS section N (Medications) shows R1 did not receive any antipsychotic or antianxiety medications during the past 7 days. Section O (special treatments, procedures and programs) shows R1 was admitted to hospice services. Section Q (Participation in assessment and goal setting) shows R1 had no active discharge planning. The current MDS of April 5, 2017 shows R1 to have a decrease of his physical behavioral symptoms to 1 to 3 days, and still had no active discharge planning in place. The quarterly [MEDICAL CONDITION] drug assessments for February, March, and April 2017 show R1 to have behaviors such as striking out, refusing care, putting self on the floor, targeting other residents and being disruptive. The number of behaviors for each month shows R1 to have multiple episodes of each behavior except targeting other residents, of which he had none. The evaluation of whether the behavior causes the resident to present a danger to themselves or others or interfere with staff's ability to provide care was left blank. The form was not signed or completed by the physician regarding behaviors and medication management. The May 2017 behavior monitoring record list R1's behaviors as putting self on the floor and targets a specific resident. The total number of episodes for the month for putting self on the floor was 43 and the number of targeting behaviors documented was zero. R1 had no documented behaviors towards other residents. The nursing progress notes show on May 29, 2017, R1 began kicking the exit door near the south dining room at 2PM, after his family left from a visit. R1 continued this behavior until he was sent to the emergency room at 6:15 PM. The notes show R1 was allowed to return to the building at 9:55PM, and he was calm and cooperative. The notes do not indicate R1 was a harm or threat to other residents. The nursing progress notes for May 31, 2017 document at 6PM R1 scooted himself out to the south dining room and refused his evening meal. After refusing his meal, R1 moved to the glass exit door and began kicking the glass with his feet. The nurse attempted to redirect him but he yelled and kicked the door harder. The notes document R1 was given his scheduled medication at that time. The nurse documents E8 DON (Director of Nursing) arrived and attempted to redirect R1 without success, and when E8 stood in front of R1, he kicked at her. The notes show E1 (Administrator) was contacted and directed the nurse to send R1 out with involuntary discharge papers. The note shows Z11 (on call physician) was contacted and an order was received to send R1 to the emergency room due to uncontrolled behaviors. The notes show hospice was notified after the order was received to send patient to the emergency room . The notes show R1 became calm and transferred onto the gurney without difficulty and left the facility at 6:55 PM. The notes do not indicate any non-pharmacological interventions attempted/ failed, or the administration of additional medications ordered as needed for severe agitation. The hospice nurse progress note shows E6 LPN (Licensed Practical Nurse) called and informed the hospice nurse R1 was demonstrating dangerous behaviors. E6 told the hospice nurse because he is considered a danger to himself and others, he is being sent to the emergency room . Z12 (hospice registered nurse) documents E6 was told to wait and see what hospice could do to help keep R1 in the building and not send him out. E6 stated the ambulance was already at the facility to transport R1 to the emergency room and he was not going to be allowed back in the building. The notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents shows the facility transferred and discharged R1 due to the safety of individuals in the facility, and refers to the clinical record. The nursing notes for May 31, 2017 do not document R1 to be a harm to other residents in the facility, as he was kicking the glass door. On June 28, 2017 at 10:00 AM, E4 LPN said R1 had physical behaviors such as kicking and hitting the aides when they were trying to provide care. E4 said R1 was worse after his family would leave after a visit. E4 said R1 has had these behaviors since she started 8 months ago. On June 28, 2017 at 2:00 PM, E6 said R1 has not hurt any other residents, only had injured himself. E6 said she sent R1 to the emergency roiagnom on [DATE] and again on May 31. E6 said R1 was kicking at the window of the door and he would not stop, staff tried to move him but he just went back to the door and continued kicking. E6 said on May 31 the DON called E1 and was told to get an order for [REDACTED]. E6 said R1 calmed down when he saw the police, he was sent to the emergency room for evaluation, and no discharge notice was given when he had that behavior. E6 said she feels the facility would still be able to meet R1's needs, because when he returns from the emergency room he is more calm and cooperative. On June 28, 2017 at 2:45 PM, E1 said she was told R1 was kicking the door on May 31, same as he was on May 29. E1 said she had prepared the involuntary discharge papers on May 29, and was ready to give to R1 the next time he acted out and had behaviors. E1 said the staff was afraid R1 was going to put his foot through the glass door and injure himself. E1 said after R1 was sent to the hospital, they tried to send him back to the facility later that night, so she spoke with emergency staff and explained R1 was not to be allowed back in the building, and they informed her it was illegal and cannot refuse the resident, and E1 said under no circumstances was R1 going to ever be allowed back in her building. On July 6, 2017 at 9:00 AM, E8 DON (Director of Nursing) said she was in the facility on May 31, 2017 when R1 began kicking the door. E8 said she never witnessed R1 go after other residents, only tried to harm himself. E8 said she attempted to calm R1 and keep him from kicking the door, by stepping between him and the door, and was kicked. E8 said she had been told by E1 the next episode of behavior R1 has and is sent to the emergency room , to get the involuntary discharge papers from the administration office and send them with R1. On June 1, 2017 at 2:22 AM, the hospital documents R1 was back in the emergency room after the facility refused to take him back. R1 had been waiting in the ambulance while the police were talking to staff, and while he was in the ambulance he became agitated and was given [MEDICATION NAME] for anxiety. Once back in the emergency room , he was calm and cooperative. On June 1, 2017 at 3:43 PM, Z1 (social service) documents she was informed by E8 that R1 was aggressive and kicking the glass, and no other residents have been harmed, only staff and equipment. On May 31, 2017 at 8:05 PM, Z13 (emergency room physician) documents Z11 (facility on call physician) ordered R1 to be sent back to the facility, and R1 was not to be admitted to the hospital. On July 11, 2017 at 10:10 AM, Z9 (emergency room manager/ registered nurse) said R1 stayed in his room, only leaving the area for testing. Z9 said R1 was not able to get out of bed and move about (scooting) as he normally would in a long term care facility. Z9 said R1 did not have any socialization other than his sitter and the nurses caring for him. Z9 said a bed bath was given, not a shower. Z9 said R1 was in the department long enough for staff to become familiar with him and learn how to deal with his behaviors, and learn what agitated him. Z9 said R1 had only had baths, food and medications. Z9 said the medication R1 was given kept him calm but not sedated. Z9 said most patients are in the emergency room for 3 hours, they are in and out, the emergency room is not made for a long term stay. On July 12, 2017 at 2:30 PM, Z14 (visual monitor tech) said when R1 first arrived at the emergency room , he was monitored on video by the staff. Z14 said after the first day, he was constantly wanting to get out of bed and move on the floor (as he does at the facility), but he was not allowed to scoot on the floor. Z14 said when R1 would get out of bed; he would scoot toward the door, but did not exhibit any violent or aggressive behaviors. Z14 said R1 had a television in his room, but no other activities to keep him occupied. Z14 said R1 did not have visitors, and was not allowed to leave the emergency room . Z14 said when R1 was re-directed or attempts made to keep him confined to his room, R1 became very agitated. On July 5, 2017 at 12:15 PM, Z7 (R1's primary physician) said R1 would have received basic patient care while in the emergency room for 13 days. Z7 said R1 would not have received group activities or had any peer socialization, and would have been fed and watered while waiting for his discharge. Z7 said R1 had been discharged from the emergency room in stable condition on June 1, 2017, was denied re-admission to the long term care facility, and returned to the emergency room . On June1, 2017 at 2:22 AM, the emergency room nurse documented R1 had returned with the ambulance after the facility refused to take him back. R1 had remained waiting in the ambulance while the staff was discussing issue with the police. The nurse documented while R1 was waiting in the parking lot of his facility, he became agitated and required additional antianxiety medication. R1's hospital record shows he was in the emergency room awaiting discharge to a long term care facility from June1, 2017 to June 13, 2017. The facility's policy for involuntary discharge states residents are not subject to involuntary discharge unless: 1. Transfer or discharge is necessary for the resident's welfare and his/her needs cannot be met by the facility. In the event that emergency involuntary transfer/discharge becomes necessary the facility is responsible for: A. Notifying the appropriate physician (attending or psychiatrist) to discuss the appropriate immediate plan for the resident o protect the resident's safety and the health and safety of their individuals. The physician should order emergency transfer and enter a note explaining the situation. C. Document the reasons for emergency transfer in the resident's record.

Based on interview and record review the facility failed to identify triggers for adverse behaviors and develop effective management interventions. R1 demonstrated predicted aggressive behavior which the facility did not have a plan or intervention to address. These failures contributed to the transferring of R1 to the emergency room , and need for antianxiety medication. R1 was not allowed to return to his home, and was placed at a location far from his family. R1 was non-communicative and unavailable for interview, under the same circumstances a reasonable person would have felt rejected, sad, afraid, and anxious resulting in psychosocial harm. This applies to 1 of 5 residents (R1) reviewed for discharge in the sample of 10. The findings include: The facility admission contract for R1 shows he was admitted to the facility on [DATE]. The June 1, 2016 social progress note by E7(social services) documents R1 was admitted from the Department of Corrections with [MEDICAL CONDITION]'s disease, and had non-verbal communication and required a wheelchair for mobility. The May 4, 2016 Correctional Center outpatient progress notes document episodes of agitation/ sun downing. The July 18, 2016 MDS (Minimum Data Set) show R1 had physical behavioral symptoms directed towards others such as hitting, kicking, pushing and scratching 4 to 6 days of a 7 day period. The MDS shows this does not put the resident at risk for himself, but does put a risk of injury to others, and this behavior is worse than his previous admission assessment. The MDS section N (Medications) shows R1 did not receive any antipsychotic or antianxiety medications during the past 7 days. Section O (special treatments, procedures and programs) shows R1 was admitted to hospice services. Section Q (Participation in assessment and goal setting) shows R1 had no active discharge planning. The current MDS of April 5, 2017 shows R1 to have a decrease of his physical behavioral symptoms to 1 to 3 days, and no active discharge planning in place and remains on hospice care. On June 28, 2017 at 10:00 AM, E4 LPN (Licensed Practical Nurse) said R1 has had the same aggressive behaviors since she started working at the facility (8 months). E4 said R1 was difficult to re-direct, it varied as everyday was different on what would work and what did not calm him down. E4 said R1 had physical behaviors such as kicking; hitting or he would drop to his knees while the aides were walking him. E4 said R1 would target only 1 resident, but had not made contact with him or caused injury. E4 said R1 would scoot around on his buttocks out of his room and into dining room or shower room, because he did not want the staff to help him. On June 28, 2017 at 2:00 PM, E6 LPN said R1 normally keeps to himself in his room, and when he does come out, he scoots himself around on his buttocks. E6 said R1 would not stay in a wheelchair. R1's care plan includes being physically aggressive at times related to anger due to [MEDICAL CONDITION]'s disease, history of harm to others, poor impulse control. R1 uses [MEDICAL CONDITION] medication for behavior management, and is on hospice for end of life issues. The last update on R1's care plans was January 12, 2017, no new interventions identified or attempted for behavior management. The January 18, 2017 care plan shows R1 has a self- care deficit and requires extensive assist for activities of daily living (ADL's) including: limited to extensive assist of 2 for ambulation. The care plan does not include R1's scooting on the floor as his primary means of mobility. On June 28, 2017 at 9:15 AM, E7 (social service) said R1's behaviors are always worse after his family visits. At 10:00 AM, E4 said R1's behavior was better with medications, but always was worse when family would leave after a visit. At 2:00 PM, E6 said R1 would get upset after his family visits. On July 6, 2017 at 12:15 PM, E5 (care plan coordinator) said interventions for R1's behavior included using a communication board, providing consistent staffing, and letting him scoot on the floor for mobility. E5 said a special meeting was scheduled in April 2017 with hospice, the ombudsman, and R1's family, for R1's behaviors, but the family did not show for the meeting. E5 said the care plan committee was expecting the family to provide interventions for the facility to implement during R1's behaviors. R1's behavior care plan does not include his increase in agitation after family visits, and no personalized interventions for staff to implement for this known behavior. On July 5, 2017 at 2:00 PM, Z10 (R1's Power of Attorney) said he received the notice for a meeting in April just a day before the meeting or after the meeting, he said either way he was out of town for work, and unable to be on a phone conference for the care plan. Z10 said the facility made no attempts to reschedule the meeting. Z10 said himself and his family visited the facility multiple times and no staff had ever asked for any input on how to deal with R1's behaviors. Z10 said he felt the facility was meeting R1's needs and had planned on R1's long term placement. Z10 said now he has to drive into Chicago to visit R1 and the facility is difficult to get to, and there is very little parking, making it harder for the family to visit. The quarterly [MEDICAL CONDITION] drug assessments for February, March, and April 2017 show R1 to have behaviors such as striking out, refusing care, putting self on the floor, targeting other residents and being disruptive. The number of behaviors for each month shows R1 to have multiple episodes of each behavior except targeting other residents, of which he had none. The evaluation of whether the behavior causes the resident to present a danger to themselves or others or interfere with staff's ability to provide care was left blank. The form was not signed or completed by the physician regarding behaviors and medication management. On June 28, 2017 at 12:30 PM, E3 LPN said she monitors the behaviors and [MEDICAL CONDITION] medications with social service. E3 said the facility worked with hospice to make sure R1 was on the proper doses. The last quarter a behavior of targeting other residents was added, but does not know why the behavior was added because he had no occurrences of targeting other residents reported. The May 2017 behavior monitoring record for list R1's behaviors as putting self on the floor and targets a specific resident. The total number of episodes for the month for putting self on the floor was 43 and the number of targeting other resident's behaviors was documented as zero. On June 30, 2017 at 9:20 AM, Z4 Agency CNA (Certified Nursing Assistant) said she had no issues caring for R1, no hitting or kicking. Z4 said she witnessed R1 scoot around on the floor but not attack any residents. On June 28, 2017 at 10:45 AM, Z3 agency CNA, said she works full time at the facility and is familiar with R1 and his behaviors. Z3 said R1 was very difficult and would kick, hit and yell at staff. Z3 said when R1 had behaviors she would walk away and re-approach at a different time. On June 28, 2017 at 10:15 AM, Z2 hospice CNA said she would feed and shower R1 when he would allow. Z2 said she had done her own research on how to approach a patient with [MEDICAL CONDITION]'s. Z2 said over time she learned what events set him off, and what worked with him. Z2 said R1 would scoot around the facility but never witnessed him attack other residents. Z2 said R1 had no speech and it took months to understand him and his needs, it was a lot of work but could get him to cooperate. The nursing progress notes for May 31, 2017 document at 6PM R1 scooted himself out to the south dining room and refused his evening meal. After refusing his meal, R1 moved to the glass exit door and began kicking the glass with his feet. The nurse attempted to redirect him but he yelled and kicked the door harder. The notes document R1 was given his scheduled medication at that time. The nurse documents E8 DON (Director of Nursing) arrived and attempted to redirect R1 without success, and when E8 stood in front of R1, he kicked at her. The notes show E1 was contacted and directed the nurse to send R1 out with involuntary discharge papers. The note shows Z11 (facility on call physician) was contacted and an order was received to send R1 to the emergency room due to uncontrolled behaviors. The notes show hospice was notified after the order was received to send patient to the emergency room . The notes show R1 became calm and transferred onto the gurney without difficulty and left the facility at 6:55 PM. The notes do not indicate any interventions attempted/ failed, or the administration of additional medications ordered for severe agitation. R1's hospice care plan dated January 24, 2017 documents R1 had agitation, verbal and physical aggression on January 23, 2017 and the intervention is for the administration of as needed medications. On March 4, 2017 R1 continued with brief episodes of agitation and crawls into the hallway and will not allow staff to assist him to a safer area, the number of episodes duration and severity have improved. On May 30, 2017 documents R1 was sent to the emergency room for agitation following a family visit and R1 was attempting to leave the facility. The hospice interventions include providing emotional support post family visits, continue to assess for triggers of agitation and assess for pain. The emergency room record shows on May 31, 2017 at 8:05 PM, the physician spoke with Z11 and she was unaware that (R1) discharged from the nursing home and feels very unhappy this had occurred. Z11 requested the physician to evaluate (R1) and if medically cleared, send him back to the nursing home. At 11:40 PM, transport was called to return R1 to the facility. On June1, 2017 at 2:22 AM, the emergency room nurse documented R1 had returned with the ambulance after the facility refused to take him back. R1 had remained waiting in the ambulance while the staff was discussing issue with the police. The nurse documented while R1 was waiting in the parking lot of his facility, he became agitated and required additional antianxiety medication. R1's May 2017 behavior tracking form shows no behavior episodes. On June 28, 2017 at 12:30 PM, E3 said when R1 would have behavior; all non-pharmacological approaches would be tried first such as alternate staff. E3 said if nothing works then hospice should be called and if the resident has medication for anxiety or aggressive behaviors, it should be given before being sent out to the hospital. On June 28, 2017 at 1:50 PM, Z5 (hospice nurse) said she was contacted by Z12 (hospice nurse) regarding R1 being sent to the hospital, without waiting for orders or to see how hospice could help to keep R1 at the facility. Z5 said the nurse should have notified hospice first and wait for orders, and R1 should have received his medication for agitation. Z5 said hospice had offered to in-service the staff about R1 and his behaviors, and the DON at the time continually postponed the in-services and none were done. Z5 said R1's behaviors were compulsive, when he wanted something; he wanted it now and was not patient with waiting. Z5 said it was best to give R1 space and to re-approach at a later time and re-attempt care. The 2008 scope and limitations of hospice services list emergency room visits not arranged for or approved by hospice as a service not covered by hospice benefit. R1's hospice agreement signed July 11, 2016 shows hospice is to be called first for any emergency, before transporting out of the home, for any change of condition or before ordering any aggressive therapy. The contract states staff are available 24 hours a day/ 7 days a week, and a back-up number is also listed.

Based on interview and record review the facility failed to keep R2 free from mental abuse by E5 on May 14, 2017. This failure resulted in R2 being anxious and agitated throughout the day requiring an anti-anxiety medication to calm R2. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample of 19. The findings include: The facility's Final Report investigation dated May 17, 2017, shows E1(Administrator) was notified by E7(Licensed Practical Nurse) that R2 came out of her room yelling about her picture being taken and R2 did not like it. E7 approached R2 and R2 pointed at E5 (Certified Nursing Assistant) and said, She took pictures of me and I didn't like it, I don't look like a bunny, I don't like it! E5 stated she was using her phone and was showing R2 an application on her smart phone that made animal ears and faces appear on R2's face. On June 14, 2017 at 9:35 AM, E1 stated an allegation of abuse was reported to her on May 14, 2017. E7 reported R2 was upset about her picture being taken and her looking like a bunny. E5 was alleged to have taken the pictures of R2. On June 14, 2017 at 9:38 AM, E7 stated, about three weeks ago R2 came out of her room yelling, 'that son of a b**ch, that girl took pictures of me when I was in the bathroom. R2 was pointing at E5. E7 said she asked E5 if she was taking pictures of R2. E5 told her she was showing R2 what she would look like with bunny ears and a face using her smart phone. R2 was sitting on the toilet at the time. R2 remained upset and was telling everyone all day long that the girl took her picture on the toilet and she had bunny ears and did not like it. R2 was upset for awhile. E7 stated she reported the incident to E1 and E6 (CNA supervisor). On June 14, 2017 at 3:10 PM, E8 (CNA) stated she and E5 transferred R2 to the toilet on May 14, 2017. R2 was incontinent of stool. E8 left the bathroom with R2's wheel chair. E5 remained in the bathroom with R2. E8 cleaned R2's wheelchair of stool, located a brief and a clean pair of pants and returned to the bathroom. R2 was still on the toilet. R2 was upset and yelling that she did not like that a picture was taken of her. R2 was transferred to her wheelchair. R2 self propelled out into the hallway and was yelling to everyone about getting her picture taken on the toilet with ears. E8 stated E5 did have her cell phone but she did not see her take any pictures of R2. On June 14, 2017 at 5:50 PM, E6 (CNA supervisor) stated R2 was yelling that son of a b**ch girl took my picture with bunny ears while I was on the toilet. R2 was telling everyone that day. R2 told E6 she was upset that her picture was taken while she was on the toilet. R2 did not understand the smart phone application and believed that E5 had taken a picture of her on the toilet with bunny ears. E6 stated R2 was upset the entire day and 1:1 reassurance was offered. R2 was reassured that there was no picture. E6 stated she spoke with E5 that day about the incident. E5 told her she was using the camera on her smart phone and an application to put bunny ears and a face on R2 and showing the screen to R2 in the bathroom. R2 was sitting on the toilet. E6 said she told E5 that she could not do that with her phone especially when the resident was on the toilet. On June 15, 2017 at 9:45 AM, Z1 (State Guardian representative) stated she had known R2 for years. Z1 visits with R2 at the facility on a quarterly basis. Z1 stated R2 was angry about the incident. R2 would not be aware that the smart phone application was not a real picture. R2 would have been humiliated by the experience. R2's Minimum Data Set, dated dated dated [DATE], shows R2 has a [DIAGNOSES REDACTED]. R2 requires two persons for toileting and transfers. R2's face sheet dated June 15, 2017 shows R2 has an anxiety disorder. R2's Physician order [REDACTED]. R2's PRN (As needed) Medication Administration for May 2017 shows R2 received [MEDICATION NAME] 0.25 mls (0.5mg) on May 14, 2017 at 4:00 PM for increased anxiety and agitation with a helpful response. R2 only received the one dose of her anti-anxiety medication during the month of May 2017 the day of the incident with the smart phone in her bathroom. E5's Employees Warning report dated May 14, 2017 shows, E5 was reported for using her cell phone in a resident bathroom while toileting R2. R2 stated she (E5) was taking pictures of her on the toilet. E5 will be suspended while investigation is in progress. The facility's Abuse Prohibition and Reporting policy dated February 2017, shows, the facility actively prohibits abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source and exploitation . Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demeanor humiliate a resident(s).

Based on observation, interview and the record review the facility failed to have a wound care program to monitor residents skin, reduce pressure, protect the skin, identify causes of pressure and evaluate the effectivness of the interventions. These failures resulted in R3 developing an unstageable wound to the left posterior thigh. This applies to 3 of 4 residents (R1, R3, R4) reviewed for pressure ulcer management in a sample of 4. The findings include: 1. On 6/20/12 at 1:10 PM, R3 was transferred into bed using a mechanical lift by E11 and E14 (Certified Nursing Assistant - CNA). R3's legs and arms were in a contracted position. During personal care and repositioning, a wound was observed on the back of R3's left leg, in the mid thigh area. Through the center of the wound was a skin crease from the disposable incontinence pad she was wearing. The center of the wound was filled with black scabbed tissue. E11 and E14 both stated they were not aware she had a wound there. E11 stated, "She did have one on the coccyx, but I think it is healed". E11 stated, "We are to report open areas to the nurse", she was not aware if the nurse knew of this opening. No barrier cream was applied to R3's buttocks after incontinence care was completed. On 6/20/12 at 1:50 PM, E2 (Director of Nurses - DON) and E4 (Registered Nurse - RN) observed the wound on the back of R3's leg. E4 (RN) stated there was no treatment order for a wound on the back of R3's left leg. E4 stated she was not aware of the wound, nothing had been reported. E2 and E4 did not know the reason R3 could have developed a pressure sore on the back of her leg. E4 measured the opening 1cm x 0.5 cm and stated, "The black center is eschar, and the wound is unstageable". E4 stated she was not aware of any facility protocols for wound care. E4 stated the physician will give the treatment order. R3's shower sheets dated 6/8/12 and 6/19/12 do not identify the open area on the posterior left thigh. R3's pressure ulcer risk score was 12 on 4/2012, (greater than 8 is high risk for development of pressure ulcers). The treatment record for R3 dated 5/1/2012 shows on 5/8/12 a stage I area of non-blanchable redness was noted and "Skin Prep" treatment was ordered. On 5/17/12 the wound was assessed as healed. The treatment order for daily skin checks was documented on 9 of 31 days in May and 5 of 19 days in June. The nurses' notes for R3 from 2/29/12 through 6/20/12 do not identify any pressure concerns to R3's posterior thigh. R3's updated care plan dated 5/2/12 states R3 is non-ambulatory and dependent on staff for mobility. The care plan states R3 has no pressure areas. The source of pressure to R3's posterior thigh is not identified and no interventions are listed to prevent pressure on the area. The Physician order [REDACTED]. The physician orders [REDACTED]. On 6/26/12 at 9:25 AM, Z1 (Physician) stated, "The facility has wound care protocols." Z1 added he could not recall if the facility had notified him of an unstageable area on the left posterior thigh. Z1 stated, "The back of the thigh is an unusual area for pressure to develop, but the care plan should address what to do (to relieve the cause of the pressure)." R3's Minimum Data Set (MDS) of 4/24/12 shows she is at risk for skin breakdown and does not have any unhealed pressure ulcers. The (undated) facility policy for Pressure Ulcer Prevention and Care states inspection of the resident's skin should be included in the daily routine. Reporting of new wounds or a change in the resident's skin to the nurse is not included in the policy. E2 (DON) 2. The facility weekly skin report of Non-Pressure areas dated 6/19/12 shows R4 has 2 facility acquired wounds; one on her right lower back and the other on her midline back. The type of wound is listed as blister. On 6/20/12 1:40 PM, E4 (Registered Nurse - RN) stated R4 was receiving wound treatments for 2 blistered areas on her back. E4 stated she did not know how or what caused them. On 6/20/12 at 3:15 PM, E12 (Licensed Practical Nurse - LPN) turned R4 while in bed. Two adhesive dressings were observed across R4's lower back at the waistline area. An adhesive dressing was also observed on R4's right upper thigh. E12 stated the areas were blisters. E12 was not aware what caused R4 to develop the blisters. The nurses' notes dated 6/11/12 for R4 states, "Resident found with blisters to her low back. The right lower back noted to have broken open. Wound bed bright red and moderate amount of serous drainage. The lower left back with an intact fluid filled blister measuring 3.0 cm L x 1.0 cm W x undetermined depth." No assessment was done to determine the potential cause of the friction on her lower back. The wound documentation found on the back of the treatment record dated 6/11/12 for R4 states, "Stage II open blister to lower right back, 4.8 cm L x 7.0 cm W x <0.2 cm depth. (Wound) bed bright red moderate amount serous drainage, surrounding skin normal pink." The second area is described, "Left lower back with intact fluid filled blister 3.0 cm L x 1.0 cm W x undetermined depth, surrounding skin normal pink". A wound treatment order for [MEDICATION NAME] Cream 1% to the affected areas twice a day was obtained for R4. According to the treatment record documentation, the treatment started on 6/11/12. The treatment was applied twice a day on only 2 of the 9 days between 6/11/12 and 6/18/12. There was no treatment order or wound documentation for the wound on R4's right upper thigh. The care plan for R4 dated 11/23/11 and updated on 5/24/12 shows R4 is at risk for skin breakdown. The blister wounds on her back and upper right thigh are not included, and no causative factors are identified for R4's development of blisters on her back. R4's care plans also address a decreased ability to ambulate and impaired mobility. R4 requires transfer assistance of 1 or 2 staff using a gait belt. According to her care plan, R4's speech is nonsensical, and she is unable to make her needs known. The facility's undated wound staging cards state, "Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister". 3. The Physician order [REDACTED]. A wound treatment order dated 5/7/12 (date of admission) to cleanse wound (coccyx) with normal saline, apply ointment (debridement agent used to debride and heal wounds) and cover with foam border dressing daily until healed. The weekly pressure ulcer report dated 5/7/12 shows R1 was admitted with coccyx wound, with undetermined stage, measuring 1.3 cm L, x 0.4 cm W, no depth, moderate serous drainage and debridement agent initiated. The next pressure ulcer report on 5/12/12 shows the coccyx wound assessment as Stage II, measuring 1.0 cm L x 3.0 cm W, <0.2 cm depth. Comments include the area had declined with an increased size noted. The weekly pressure ulcer report dated 5/21/12 shows R1's coccyx wound as Unstageable, measuring 2.0 cm L x 0.6 cm W x 0.3 cm depth, with moderate serous drainage. Progress note states the wound size increased and was covered with 100% slough. The weekly pressure ulcer report dated 5/30/12 shows R1's coccyx wound again increased in size to 2.0 cm L x 1.0 cm L. No progress note is documented; no change in treatment orders are noted. The weekly pressure ulcer reports on 6/13/12 and 6/19/12 document R1's coccyx wound is unchanged in size and wound healing. The same treatment order since admission(debridement agent) is in place. There was no evaluation and treatment modifications regarding the lack of healing progress of R1's coccyx wound. The physician was not notified of the lack of healing. On 6/20/12 at 1:40 PM, E4 (RN) stated, "Each wing nurse does the weekly measurements and on puts them on the log. I'm not sure how the wound progress is evaluated. We have a (consulting) wound nurse but she does not see R1. We can ask her opinion about something, but the doctor gives the orders for wound care treatments." E4 was not aware if the facility had any standing orders or wound care protocols. The care plan dated 5/30/12 states R1 was admitted with 3 Stage II pressure areas, 2 pressure areas (heels) that are suspected to be deep tissue injury. Wound care interventions include update the doctor and wound care nurse if regression noted. The treatment record dated 5/7/12 for R1 shows the coccyx treatment was ordered daily. Between 5/7/12 and 5/31/12, the treatment was not provided on 8 of the 25 days in May 2012. On 6/20/12, E3 (RN) confirmed the blank entries on the treatment record for R1. E3 stated, "The blank spaces (on the treatment record) means the nurse forgot to sign off the treatment, it does not validate the treatment was done." The (undated) facility policy for Pressure Ulcer prevention and care does not address the monitoring process and wound healing evaluation procedure. The manufacturer's product information for application of Santyl (debridement agent) states Santyl ointment is indicated for [MEDICATION NAME] chronic dermal ulcers. Use of the ointment should be terminated when debridement is complete and granulation tissue is well established.