Every finding on record at Prairie Oasis

Based on observation, interview and record review facility failed to follow pressure ulcer policy and procedures by not sufficiently off-loading the sacral area at least every two hours, failed to ensure wounds were dressed as prescribed, failed to prevent wound exposure to urine/feces. This affected two of three residents (R4, R5) reviewed for pressure ulcer prevention and treatment. 1. R4 was admitted to the facility 7/17/2023. R4's diagnoses include cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis, toxic encephalopathy, chronic heart failure, acute kidney failure, malnutrition, aphasia, type two diabetes, respiratory failure, chronic kidney disease gastrostomy malfunction, myopathy, dementia, neuromuscular dysfunction of the bladder, paraplegia, morbid obesity.On 7/21/2026 R4's Brief Interview of Mental Status (BIMS) was one indicating severe cognitive impairment. Minimum Data Set (MDS) section GG identified toileting and personal hygiene as dependent. R4 has a present on admission stage four sacral pressure ulcer. On 8/26/2026 at 3:34 PM V16 (Certified Nursing Assistant) and surveyor observed R4 wearing a diaper. Upon removing the diaper and turning R4, V16 pointed to brown discoloration on R4's under pad and stated That is old. You can tell by the way that it is dried and smeared. Surveyor observed what appeared to be smudges of dried feces on the pad under R4. Wound dressing observed lying on the under pad adjacent and to the right of the wound not covering the wound.On 8/26/2026 at 3:35 PM V11 (Wound Nurse/Licensed Practical Nurse) described R4's wound as a stage four sacral wound. V11 stated the pressure injury was present on admission and has been like that for years. V11 stated R4 was sent to the hospital for debridement and the wound got bigger. V11 stated R4's pressure injury is to the bone.On 8/25/2026 and 8/26/2026 R4 was intermittently observed. At each observation, R4 was observed lying on R4's back. On 8/27/2026 at 7:28 AM R4 was observed lying supine in bed with head raised to between a thirty and forty-five degree angle. Continual observation of R4 was initiated.On 8/27/2026 at 8:10 AM V22 (Certified Nursing Assistant) was observed washing R4's face and applying lip moisturizer. R4 remained lying supine in bed with head raised to between a thirty and forty-five degree angle. On 8/27/2026 at 8:53 AM V11 (Wound Nurse) and V22 (Certified Nursing Assistant) changed R4's linens which were wet with urine. A new skin tear was observed by V11 and surveyor on R4's left lateral breast. V11 and V22 placed clean linens and returned R4 to a position of being supine in bed with head raised to between a thirty and forty-five degree angle.On 8/27/2026 at 11:15 AM V22 (Certified Nursing Assistant) and V23 (Certified Nursing Assistant) changed R4. R4 was observed to be wet. V22 stated the sacral wound dressing is wet from urine. V22 and V23 cleaned R4. V22 and V23 returned R4 to a position of being supine in bed with head raised to between a thirty and forty-five degree angle. On 8/27/2026 from 7:28 AM to 11:20 AM, R4 was not turned or repositioned other than to change soiled linens on the bed. At no time was R4 repositioned to off-load the sacral wound area. On 8/28/2026 R4's medical orders were reviewed and included Mesalt external pad (wound dressing - apply to sacrum topically every day shift for wound care. Cleanse area with normal saline, pat dry, and cover with bordered gauze every day and as needed. Bacitracin - Polymyxin B topical ointment - apply to left lateral breast topically every day shift for skin tear for seven days. Cleanse area with normal saline, pat dry, and cover with bordered gauze daily. 2. R5 was admitted to the facility 5/30/2024. R5's medical diagnoses include cirrhosis of the liver, hypertension, malnutrition, dementia, obesity, acute respiratory failure, altered mental status, dysphagia, hepatic encephalopathy, hypermetropia, metabolic encephalopathy, functional quadriplegia, viral hepatitis C and visual disturbances. R5's Brief Interview of Mental Status (BIMS) dated 5/1/2026 was 6, indicating significant cognitive deficit. Minimum Data Set (MDS) section GG documented toileting was dependent, and personal hygiene was substantial to maximal assistance needed. Rolling from left to right was partial to moderate assistance needed. R5 has a pressure injury to the left posterior upper thigh. R5 also has a cluster of four pressure injuries to the sacral area which the facility is classifying as one unstageable present on admission pressure ulcer to the sacrum. On 8/26/2026 at 3:06 PM V16 and surveyor observed R5 wearing a diaper. A dressing was observed to the left upper posterior thigh. As V16 removed R5's diaper, the sacral wounds were soiled with urine and feces. No dressing was in place on the sacral wounds. V16 stated This is ridiculous. They (off-going CNAs) just left. R5 should not look like that. V16 stated this is not uncommon for residents to be left soiled. People don't like to work. I am going to HR (Human Resources). Surveyor asked V16 about the missing dressing for R5's sacral wounds. V16 stated there is no dressing in the bed, around the bed or on the floor. V16 confirmed feces present in the sacral wounds. V16 used a wet washcloth to clean the wounds. R5 stated that hurts when V16 cleaned the sacral area. On 8/26/2026 at 3:14 PM V10 (Licensed Practical Nurse) stated there are four open areas on R5's buttocks. There is no dressing on the buttock wounds. V10 stated the risk to R5 with those wounds and no dressing is that the wounds won't heal or R5 could get an infection. V10 was unaware that there was no dressing on R5's sacral wounds. The CNAs did not tell me.ON 8/26/2026 at 3:24 PM V11 (Wound Nurse/Licensed Practical Nurse) stated the four wounds in the sacral area should have had a dressing. V11 stated the CNAs on day shift should have told the nurse that there was no dressing. If the dressing is soiled or missing, it should be replaced. The risk of no dressing, urine and/or feces in the wound is infection and the wound not healing or getting worse. V11 stated R5 experiences pain during dressing changes and will need pain medication before a new dressing is applied. On 8/26/2026 at 3:47 PM R5 stated to V11 (Wound Nurse/Licensed Practical Nurse), This is hurting as V11 cleansed the sacral wounds. V11 stated to R5, That is from the wounds. R5 yelled out as R5 cleansed the sacral wounds. V11 stated the dressing should not be off R5's sacral wounds. V11 will talk to the CNAs and set expectations. On 8/26/2026 at 6:04 PM V19 (Wound Physician) described R5's sacral rounds as a cluster of multiple openings still defining themselves. V19 stated, you could classify them as all in the sacral region, or you could say left, right and upper buttocks but because they are the same tissue type and the treatment is the same approach, the four wounds were clustered into one. If one of the wounds improves or worsens, we would say the entire cluster is improving or worsening. V19 stated the dressings for wounds should be on at all times other than showering. If wounds are undressed and/or exposed to feces or urine, it creates bacteria exposure to the wound. V19 stated, Infection is my biggest concern. If a resident has no dressing, it can cause the wound to decline and worsen.On 8/27/2026 at 7:13 AM V21 (Certified Nursing Assistant) and surveyor observed R5 lying in bed. Upon turning R5, under pad was observed to be folded in half and tucked under R5. When V21 unfolded the under pad, yellow stained liquid was observed in the folded under pad. When the under pad was removed, the bed sheet under the under pad and the mattress were both observed to be wet. The wet sheet under R5 extended from R5's shoulders to R5's posterior knees. V21 stated the whole bed is saturated. V21 stated, This is somebody being lazy. The whole bed is soaked, and this didn't just happen. Someone folded the wet under pad under R5. When asked how V21 knows this didn't just happen, V21 stated you can see that urine soaked through and around the under pad, all the way through the sheets and to the mattress. On 8/27/2026 at 9:53 AM V21 (Certified Nursing Assistant) stated there is no way R5 had just wet herself when V21 found R5 at 7:13 AM this morning. V21 stated, Did it look like that incontinence just happened? No. She was left like that. We are supposed to do rounds every two hours and check on residents. For as saturated as R5 was, there is no way they checked R5 every 2 hours last night. V21 stated it is not uncommon that residents are saturated or soiled at the start of the shift and it (the incontinence) did not just happen - the resident was left like that.On 8/28/2026 R5's medical orders were reviewed and included Medihoney Wound/Burn Dressing Topical Paste (Wound Dressings) - apply to sacrum topically every day shift for wound care. Cleanse area with normal saline, pat dry, and cover with bordered gauze daily and as needed. Hydrocol external pad - apply to left posterior thigh topically every day shift on Tuesday, Friday and Sunday. Cleanse areas with normal saline, pat dry, and cover every three times a week and as needed. Acetaminophen oral tablet three hundred twenty five milligrams- give two tablets by mouth every six hours as needed for pain. On 8/26/2026 at 4:01 PM V2 (Director of Nursing) stated pressure injury prevention includes staff to change residents to make sure they are clean and dry at least every 2 hours and as needed. Staff are supposed to turn and reposition residents every two hours. When V11 (Wound Nurse) puts on a dressing, the expectation is that the dressing stays on. If the dressing gets soiled or falls off, the Certified Nursing Assistant (CNA) should immediately tell the nurse so the dressing can be changed or replaced. V2 stated if a dressing gets soiled or falls off, the wound can be compromised so the dressing should immediately be replaced. If the dressing is not immediately replaced, the wound is compromised and the length of time the dressing was off doesn't matter. If a resident's wound is soiled, it can affect wound healing.On 8/27/2026 at 2:52 PM V26 (Assistant Director of Nursing) stated pressure injury prevention includes turning and repositioning residents at least every two hours. Certified Nursing Assistants (CNA) should be checking on residents and getting them off bony prominences and pressure injury areas at least every two hours. That means turning the resident to the right side, left side, and back alternating every two hours. V26 stated, You don't let anyone lay in one position for more than two, or three hours, max. We have diapers, but they should not be used if a resident has a pressure ulcer. We stress that all the time. CNAs should not be using diapers. V26 stated CNAs should be checking residents every two hours to make sure they are dry - no urine and no feces. CNAs should also be making sure that residents are checked at the end of their shift. During last rounds, the CNAs make sure every resident is clean and dry. V26 stated that when staff come in at 7 AM, all of the residents should be clean and dry. You may have an occasional resident with urine, but nobody should be soaked with urine at the start of a CNAs shift. A family may ask about using diapers, but we take the time to educate family about the risk of diapers. If a resident's family insists on using diapers, it will be care planned. If a wound is exposed to urine or feces or the proper dressings are not in place, the wound will increase in size and severity, not heal, infection could develop, or the resident could become septic. On 8/27/2026 at 3:05 PM V11 (Wound Nurse) stated turning and repositioning means every two hours residents should be turned. Turning and repositioning means residents are turned to their back, right side or left side every two hours. If a resident cannot fully turn to the right or left, the resident should be tilted or off-loaded using wedges or pillows to get pressure relief off the wound or bony prominences and to promote blood flow to the area. V11 stated that when the Certified Nursing Assistants (CNA) are providing incontinence care and turning the resident, it is not sufficient to tilt or turn the resident to change them and then return to their same position. That is not a long enough time to constitute off-loading the wound or the bony prominence. V11 stated changing a resident who is soiled during care of the incontinence provides range of motion, but it does not offload the area. The CNAs know they are supposed to turn and reposition and off-load every two hours. It is part of their CNA training, onboarding, and ongoing in services here at the facility. V11 stated R4 should have had a wedge in the room to move R4 to the left and right side and offload the sacrum. V11 stated V11 put a wedge in R5's room around 11:30 AM after staff noticed that surveyor was watching R4's room and R4 had not been turned, repositioned or the sacrum off-loaded in several hours. V11 stated V21 (CNA) told V11 about how R5 was found incontinent and saturated this morning. V11 stated, I was in disbelief. It was bad. V11 was told by V21 that R5 was soiled. The whole bed was wet. V11 stated based on what V11 has seen these past two days, V11 will be increasing the number of wedges in the facility and providing more in services reminding staff to call if dressings fall off, and in servicing staff about turning and repositioning expectations.On 8/28/2026 at 9:45 AM V31 (Medical Director) stated expectation in pressure injury prevention and treatment is that residents are turned and repositioned every two hours, dressings are maintained and wounds remain covered and intact, and that residents who are at high risk for pressure injury or have pressure injuries, are identified. If dressings are not maintained on an open wound, the concern is infection. If urine and feces is getting into open wounds, it is absolutely the source of infection. If residents are not being turned or repositioned, the concern is that the wound can worsen or extend to infection. On 8/28/2026 at 11:37 AM V2 (Director of Nursing) stated pressure injury prevention includes staff turning and repositioning every two hours and toileting residents to keep the skin clean and dry. Turning and repositioning means alleviating pressure points over bony prominences and relieving pressure to the buttocks and sacrum. If a certified nursing assistant (CNA) is cleaning a resident who is soiled with feces or urine, it is not sufficient to clean the resident and turn the resident to the same position, unless resident was repositioned within the hour and the CNA is returning the resident to the same position that the resident has been in for less than an hour. V2 stated, dressings over pressure ulcers should be changed by the wound nurse. If it becomes soiled, the CNA immediately tells the treatment nurse or assigned nurse so that the dressing can be replaced. It is never permissible for a CNA to fold a soiled under pad under a resident instead of changing the under pad and cleaning the resident. Facility policy titled Pressure Injury and Skin Condition assessment dated 9/2016 stated the purpose is to establish guidelines for assessing monitoring and documenting the presence of skin breakdown, pressure and other ulcers, and assuring interventions are implemented. Care givers are responsible for promptly notifying the charge nurse of skin observations, including, but not limited to, any type of lesion. Policy titled Pressure Injury Prevention dated 9/2014 stated the purpose is to prevent and treat pressure sores. Residents do not routinely wear diapers in bed as part of the prevention plan.Facility policy titled Activities of Daily Living (ADLS) dated 4/2014 stated the purpose is to preserve activities of daily living function, promote independence, and increase self-esteem and dignity. Interventions include grooming defined as maintaining personal hygiene. Bed Monitoring includes assisting residents to turn side to (side). Facility policy titled Residents' Rights for Peoples in Long Term Care Facilities with no date stated facility must provide services to keep a resident's physical and mental health and sense of satisfaction.

Based on observation, interview, and record review the facility failed to implement fall preventive measures for a resident who is a high fall risk. This deficiency affects one (R3) of three residents reviewed for Falls prevention program. Findings include:R3 is an [AGE] year-old admitted to facility on 7/3/19 with the following diagnosis: cerebral infarction, aphasia, dysphagia, essential hypertension, hyperlipidemia, secondary hypertension, anemia, age related osteoporosis without current pathological fracture, insomnia, presence of right artificial hip joint, dementia, depression, history of falling, low back pain, personal history of urinary tract infections.Facility reported incident indicates on 2/28/26 R3, upon rounds staff note resident sitting on her left side of the bed between the dresser and bed. The incident occurred during self-transfer from bed without assistance. She (R3) denies any pain no discomfort noted. She is able to move all extremities, and all limbs are in good alignment. She denies any pain no discomfort noted. The resident was assisted back to bed with assistance, and she has gait imbalance and unsteady call light within reach. The resident has a small hematoma to the right side of face and bruising. MD notified new orders given and carried out.On 3/21/26 at 12:50PM, R3 observed sitting in wheelchair with no shoes and regular socks on, room observed with bed next to furniture (nightstand dresser) to left side of bed.On 3/21/26 at 12:53PM, V3 (Licensed Practical Nurse) said R3 should have non-skid socks as her fall intervention, V3 said she is not sure about the bed next to furniture said she is unsure if that is R3 fall intervention.On 3/21/26 at 12:55PM, V5 (Certified Nurse Aide) said she dressed R3 and did not put on her non-skid socks on. V5 said she just did not put them on for no apparent reason.On 3/21/26 at 1:24PM, V2 (Director of Nursing) said her expectations for staff is to follow all fall interventions for all high fall risk residents, V2 said she was not in facility when R3 had a fall on 2/28/26, said she is not sure of the specific interventions, but staff should know where to locate interventions for high risk fall residents.On 3/21/26 at 2:59PM, V1 (Administrator) said her expectations for all staff is to implement fall interventions and make sure they are in place. Fall interventions are located in the residents point of care chart and also are communicated by the restorative staff.R3 Fall risk review dated 9/25/25 Admission/Readmission-indicated R3 high risk for falls.R3 Fall risk review dated 2/28/26- indicated R3 high risk for falls. R3 Risk for Falls related to Confusion, unaware of safety needs, unsteady gait, impulsiveness, history of fall- care plan interventions dated 1/1/24 intervention- Ensure the resident is wearing appropriate footwear (Specify and describe correct client footwear in example brown leather shoes, tartan bedroom slippers, black non-skid socks) when ambulating or mobilizing in wheelchair.R3 Risk for Falls related to Confusion, unaware of safety needs, unsteady gait, impulsiveness history of fall- care plan interventions dated 2/28/26 intervention- X-ray to rule out any fractures and Move furniture over from the bed. Facility Policy on Fall Prevention Program-revised 2/10/26Policy: it is the policy of this facility to have a fall prevention program to assure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision assistive devices are utilized as necessary. Quality assurance programs will monitor the program to assure ongoing effectiveness. This fall prevention plan is a site specific plan to eliminate or reduce the risk of falls.Responsibility: all facility staff. Teamwork between all staff is essential for fall preventionprogram contents:The fall prevention program includes the following components:Methods to identify risk factors.Methods to identify residents at risk.Assessment time frames.Use an implementation of professional standards of practice.Changes in interventions that were unsuccessful.Notification of physician family legal representative.Communication with direct care staff members.Documentation requirements.Adherence to manufacturers recommendation in use of alarm and medical devices and special care equipment.Care plan incorporates:identification of risk /issue.Interventions are reviewed and or changed with each file as appropriate.Preventative measures.Monthly risk management meeting agenda will include a discussion of:fall prevention surveillance activities.Recommendation for changes in the plan of care to minimize reoccurrence.Protocol compliance.Standards:A fall risk assessment will be performed by a licensed nurse at the time of admission the assessment tool will incorporate current clinical practice guidelines.A fall risk assessment will be performed at least quarterly with each significant change in condition and after any fall incident.Safety interventions will be implemented for each resident identify at risk using a standard protocol.The admitting nurse and assign CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Standard fall safety precautions for all residentsall staff will be oriented and trained in the fall prevention program.7. Residents will be observed approximately every two hours to ensure the resident is safely positioned in bed or a chair and provide care as signed in accordance with the plan of care. Rounds may be more frequent if deemed necessary.15. All nursing personnel will be informed of residents who are at risk of falling. The fall risk classification will be identified on the care plan.17. Footwear will be monitored to ensure the resident has proper fitting shoes or footwear is non-skid.

Based on observation, interview, and record review, the facility failed to provide a hazard free environment for two (R1, R5) of 4 (R1, R2, R4 and R5) residents reviewed for hazards/supervision. This failure resulted in R1 getting out of bed and falling on an uncovered radiator heater resulting in R1 suffering second degree burns to the right shoulder and right hip and admitted to the hospital's burn intensive care unit for evaluation and treatment of severe burns. This failure also resulted in R5 suffering a laceration to the left eye that required sutures, subdural hematomas that required R5 to be admitted to the hospital's intensive care unit and ultimately resulted in admission to hospice due to the subdural hematoma. The immediate jeopardy began on 2/07/2026 when R1 was found lying on an uncovered radiator heater. V1 (Administrator) was notified on 2/18/2026 at 11:02am of the Immediate Jeopardy.The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 2/19/2026, however noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: 1. R1's face sheet documents diagnoses that include but are not limited to Alzheimer's Disease, dementia, insomnia, palliative care, restlessness and agitation, and fall. R1's BIMS (brief interview for mental status) score, dated 11/11/25, is 7 which indicates R1's cognition is severely impaired. R1's FRI (facility reported incident), date and time of Occurrence: 2/7/26 at 5:15am, documents, in part, Describe Occurrence: Observe on the floor upon rounds (R1). Blistering to the right shoulder and right hip. Resident (R1) was transferred to hospital for evaluation of blistered right shoulder and right hip. First aid was rendered per nurse and medicated for pain as ordered per MD (medical doctor). Resident (R1) was admitted to the hospital. Record review of facility document titled, Attorney/Client Privilege, dated February 7, 2026, per V30 (Regional Nurse Consultant), documents, in part, Received call this morning from V2 (Director of Nursing/DON) that a resident (R1) was observed lying on radiator and subsequently has burns on right shoulder and hip. Met with and spoke with assigned CNA (certified nursing assistant/V8). According to V8, she (V8) made rounds on resident (R1) initially when she (V8) arrived for work but did not make another round on her (R1) til almost 5am. When asked why, she (V8) stated she (V8) was assisting V9 (certified nursing assistant/CNA with her (V9) residents in a certain room. Per punch time, CNA (V8) arrived to work at 10:55pm. CNA (V8) was very apologetic verbally and stated, I hate that happened to her (R1). Unaware how resident ended up on floor. According to 11-7 (11:00pm to 7:00am) Charge Nurse (V3/Licensed Practical Nurse/LPN), she (V3) observed Resident (R1) lying on floor on right side of bed near the head of bed on her right side after being alerted by V8. Stated (and demonstrated position and location) the floor heat radiator cover was off, and Resident (R1) was right side lying directly on the radiator wedged between the bed and the wall. Unsure of how long Resident (R1) had been there. Stated the V8 came to get her (V3) for help. States Resident (R1) tends to favor right side and therefore, had rolled bath blankets to form a wedge on Resident's (R1) right side of bed to prevent rolling off on that side. Unaware how resident ended up on floor. Noticed (V30) intact dressings to right shoulder and right hip (R1) areas with moderate amount of break-thru serous drainage to shoulder area and small amount to hip area. After examining sites, dressings changed. Right shoulder (R1) has multiple clear fluid intact blistered areas (and some of which had burst) along with areas of pink flesh and charred color skin in areas from outer shoulder to mid upper arm. Multiple areas of subcutaneous tissue noted. Right hip (R1) area presented with pink flesh and evident of burst blisters. Nurse (V3) stated that upon initial findings, the area had a large clear fluid filled blister that had burst. Multiple detached areas of skin sporadically noted at both sites' indicative of burst blisters and/or friction causing skin flaps. When repositioned resident (R1) moans and facial grimaces as if in pain. Charge Nurse (V3) stated she (V3) had given pain med already. Room observed upon entry. Radiator cover intact at that time, but Charge Nurse (V3) reports it wasn't at time of incident and that she (V3) replaced the cover. Rolled bath blankets to form a protective wedge noted on right side of bed with resident. Nurse (V3) stated she (V3) applied that after the incident in an effort to prevent further such incident. Probable cause is that Resident (R1) may have attempted to get out of bed alone from the right side, may have tripped and fell landing on the radiator, may have gotten wedged between bed and wall and could not get self-up. R1's hospital records, dated 2/7/26, documents, in part, Patient (R1) allegedly fell asleep on a heater. A [AGE] year-old female with dementia (R1) presented with thermal burns to the shoulder, hip, and arm, reportedly sustained after prolonged contact with a heater overnight. The history was obtained from a caregiver at the nursing home. Pain: Traumatic. She (R1) is nonverbal and only mumbles words-Examination revealed full thickness burns on the shoulder, a large but less deep burn on the hip, and burn extension down the arm R (right) shoulder and R (right) hip with partial deep and deep thickness burns with surrounding superficial burns. Dead skin present. Appears to be tender to palpation. Moans to pain. Presentation is most concerning for burns from falling asleep near heater. Will admit to burn ICU (intensive care unit) for resuscitation. Second degree burn of shoulder and upper extremity except wrist and hand, initial encounter. Surgical Procedure(s): Skin transplant; debridement of right shoulder and hip; possible allograft, autograft or synthetic material. Operative Procedure: The hip wound was excised tangentially down to punctate bleeding tissue. The arm was deeper, down to and through some of the deltoid muscle. There was a peninsula burn on the lower arm, which was excised and was able to be closed primarily with buried intradermal sutures. Thin split-thickness skin grafts were then harvested and carefully applied to the exact size and shape of the wounds. They were secured in place with staples. On the arm, a total of 400 cm2 of wound was excised with 150 cm2 from the right lower extremity and 250 cm2 from the right upper extremity. The deepest layer on the right upper extremity was muscle. The 400 cm2 of excised wound was closed with split-thickness skin graft, 150 cm2 to right lower extremity and 250 cm2 to the right upper extremity. Pt (patient/R1) nonverbal, does not follow commands, arms and legs stiff, strength 3/5. Pt moans and resists to pain. Poor tolerance to dressing change. Dressing: R Hip -Pink, moist, blanchable -moderate serous drainage, no odor -debrided, cleansed plus large burn. R shoulder/back -pink, red, white, serosanguinous drainage, no odor, mixed, some areas non blanching (center, white area), debrided/cleansed. R1's progress note, dated 2/07/26 at 5:15am, per V3 (Licensed Practical Nurse/LPN), documents, in part, Nurse (V3) was called in the room by V8 (Certified Nursing Assistant/CNA) when entering the room resident (R1) was on the right side of the bed lying on her (R1) right side next to the wall. Staff transferred resident (R1) back to bed with 2 assist and she (R1) was positioned in bed for comfort call light within reach. Resident (R1) has no verbal complaints of pain. Upon body assessment blistered area was noted to her right shoulder and her right hip. MD (medical doctor) notified of incident new orders given to transfer resident to ER (emergency room) for further Eval. (evaluation). Attempted to notify family with no answer. R1's progress note, dated 2/07/26 at 8:39am, per V4 (Licensed Practical Nurse/LPN), documents, in part, endorsed from previous nurse resident (R1) will be transferring to (hospital) for eval (evaluation) of impaired skin integrity (ambulance) currently in facility for departure. R1's progress note, dated 2/07/26 at 1:45pm, per V4 (Licensed Practical Nurse/LPN), documents, in part, writer contacted (hospital) and spoke with ER (emergency room) Nurse. Writer was made aware resident (R1) is being transferred to (another/different hospital). Please F/U (follow up). R1's progress note, dated 2/07/26 at 6:45pm, per V5 (Licensed Practical Nurse/LPN) documents, in part, Resident (R1) admitted to the (hospital) d/t (due to) severe burns on right shoulder and right hip. DON (Director of Nursing/DON) made aware. all personal belongings remains in room and Medications secured on med Cart. R1's Ambulance Run Record, dated 2/07/2026, documents, in part, AVPU (alert, verbal, pain, unresponsive): Painful, pain score of 5/10; Ambulance dispatched to (nursing home) for an emergency call due to a burn. The pt (patient) is a [AGE] year-old female (R1) getting transported to hospital ER (emergency room). The pt is in need of ambulance services due to having dementia, unable to ambulate, bed confined, and muscle weakness. R1's Transfers and Bed Mobility/Limited lift review (Nursing/restorative), dated 11/12/25, documents, in part, Bed Mobility: Roll left and right: Partial/Moderate assistance; Sit to lying: Substantial/Maximal assistance; and Lying to sitting on side of bed: Substantial/Maximal assistance. Transfer Ability: Sit to stand: Substantial/Maximal assistance; Chair/bed-to-chair transfer: Substantial/Maximal assistance. Ability to maintain standing balance: Poor; Recommendations for Transfers: Resident (R1) will be designated as Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; Recommendations for Bed Mobility Physical Assistance Needs: Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; and Bed Mobility Symbol Assignment: Residents requires a one person physical assistance from staff for bed mobility. R1's care plan, dated 8/11/25, documents, in part, (R1) is at risk for falls R/T (related to) impaired mobility, history of falls, with a goal that documents, in part, (R1) will have a safe environment maintained thru the next review, and with interventions that documents, in part, Anticipate and meet individual needs of the resident (R1). R1's care plan, dated 8/12/25, documents, in part, (R1) presents with poor balance, decreased strength & impaired ambulation secondary to: unspecified dementia, unspecified severity, with other behavioral disturbance, with a goal that documents, in part, (R1) will not sustain a fall related injury by the next review, and with interventions that documents, in part, Assist resident (R1) to a standing position. R1's care plan, dated 11/12/25, documents, in part, (R1) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Confusion, Dementia, Impaired Balance, Limited Mobility, with a goal that documents, in part, (R1) will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injuries through the next review, and interventions that documents, in part, Bed mobility - the resident (R1)requires (1) staff member(s) to turn and reposition. Transfer - the resident (R1) requires the assistance of (1) staff member(s) when transferring. R1's care plan, dated 11/12/25, documents, in part, (R1) has a Self-Care Deficit related to (Cognitive impairment, Limited Mobility, Dementia) and requires assistance with Bed mobility. Resident(R1) will benefit from participation in a Bed mobility program, with interventions that documents, in part, Assist the resident (R1) with turning/positioning and finding a comfortable position as needed. R1's care plan, dated 11/12/25, documents, in part, (R1) has been assessed and has been determined to need a mechanical lift for transfers R/t (related to): Will be designated as ONE PERSON ASSIST, as they (R1) require Limited Assist and up to Extensive Assist with no more than 25% wt. (weight) bearing assistance. 1 = One Person Assistance, Impaired Cognition, Impaired Communication, with interventions that documents, in part, Transfer with 1 staff assistance. R1's care plan, dated 10/01/25, documents, in part, (R1) terminal Illness - Alteration in Comfort R/T: Hospice, with interventions that documents, in part, Provide cares per resident(R1) &/or family wishes to achieve acceptable level of comfort. Provide re-positioning per skin care plan and PRN (as needed) for comfort. R1's care plan, dated 11/12/25, documents, in part, (R1) has limited physical mobility r/t Cognitive impairment, Limited Mobility, Dementia, with interventions that documents, in part, MOBILITY: The resident requires (1) staff participation for mobility. Provide supportive care, assistance with mobility as needed. Document assistance as needed. On 2/12/26 on 10:01am, V1 (Administrator) said, I was called early Saturday (2/07/26) in morning for a fall with injury and immediately came here (facility). It (fall with injury) was her (R1). She (R1) was going to be sent out. About 5:00am R1's fall with injury occurred. She (R1) was laying against the radiator, and the cover was knocked off. No, the cover to the radiator (R1's radiator heater) was not attached. I think it (radiator cover) came off when she (R1) fell out of bed. We (facility staff) completed a review of the whole facility's radiator heaters that day (2/07/26) and made sure all covers were secure. We (facility staff) did a FRI (facility reported incident). On 2/12/26 at 10:08am, with V1 (Administrator) and V2 (Director of Nursing/DON), the cover to the radiator heater in R9, R1, R11, R12)'s was observed not secured and partially coming off. V7 (Maintenance Director/Housekeeping Manager) was called to room this by V1 and V7 stated, Yeah, this (radiator heater cover in room [ROOM NUMBER]) is loose, it requires more screws (observed after V1 stated an audit of the whole facility's radiator covers was done). The boilers are set to bring out 30 degrees Fahrenheit and the PTAC units in the room are both a heating and cooling system. The PTAC units can change the temperature per the residents desire. On 2/12/2026 at 11:42am, V3 (Licensed Practical Nurse/LPN) said, Yes, I was the nurse (2/07/26, R1 fall with injury). Basically, I was called by CNA (V8/certified nursing assistant). The resident (R1) has a low bed and was found in between the bed and the heater. At the time when I entered the room, yes it (radiator heater cover) was off. I'm not sure if it (radiator heater cover) bumped off. V8 and I assisted R1 back to bed and I did a body assessment. It looked like blisters on the right shoulder and right hip. The skin (R1) was blistering up from shoulder going down. About 2x2 inches in size. The right hip was about 2x2 inches in size as well. I called the physician, got orders, applied dressings, and called an ambulance. R1 was sent to (hospital). I checked on her like 3:00am or 3:15am and she (R1) was sleeping. Yes, I actually seen her (R1). I can't remember if the curtain was closed. Yes, she (R1) can be very impulsive. She (R1) usually has someone (staff) with her (R1) all the time. R1 is at the nurse's station a lot. She's (R1) confused and not steady on her (R1) feet. On 2/12/2026 at 12:06pm, V8 (Certified Nursing Assistant/CNA) said, Yes, she (R1) was one of the patients I had. I did work that day (2/07/26, R1 fall with injury). When I discovered she (R1) fell, she (R1) fell between bed and heater, and was burned on her (R1) arm and hip. The side of her (R1) was laying on the heater. The heater did not have a cover on. I am so sorry that happened. I wish it didn't happen. It's (radiator heater cover) been off for some period of time. So many months back, it was over 9 months (radiator heater cover not secured). I don't know if anyone had reported it (radiator heater cover not secured). Another nurse V11 (Licensed Practical Nurse/LPN) can vouch for the radiator heater cover coming off all the time (prior to 2/07/26, R1 fall with injury). It (R1's burns) was nice size area (R1's burns). Sorta burned on both areas (right arm and right hip). Can't really give an approximate length. It happened around 5:15am (2/07/26). The last time I seen R1 before the fall was not at all. I didn't see her (R1) at all that shift. R1's curtain was pulled all the way across. My shift is from 11:00pm to 7:00am. Another CNA (V9/certified nursing assistant) asked me to help with another resident to put back to bed, and then I started doing POCs (point of care). We (night shift CNAs) come in at 11:00pm and are supposed to check on all the residents, but I didn't because I helped put another resident back to bed. I went back to my area, washed my hands, and started to put patient's POCs in the computer. I don't think there is enough staff to do everything we (staff) need to do. It probably took a good 30 minutes to help V9 get the resident back in bed. I was behind so I started on my POCs. Even if there is not a call off, which most of the time there is a call off, we (facility) could use another CNA, especially for the confused residents. I wanna say this here. When they (V2/Director of Nursing/DON) had called me and said they (V2) had to terminate me, I knew I should have done my rounds every 2 hours. I enjoyed working there. I was negligent, but the LPN is supposed to check them (residents) every 2 hours too. They (facility) terminated me because of this incident. V2 called me. There's not enough staff to take care of the confused residents. R1 should be a 1:1 all day and all night. She's (R1) confused and tries to get up all the time. No, she (R1) is not steady on her (R1) feet. Record review of V8's (certified nursing assistant/CNA) Corrective Action, dated 2/10/26, documents, in part, Reason for warning: CNA (V8) failed to make rounds every 2 hours as per facility protocol. CNA (V8) admits to rounding initially (11:00pm) and then again at 4:45am-5am. Resident (R1) on assignment fell causing multiple burns to body resulting in hospitalization. Relevant company/CBA policy violated: CBA pg. 38 #7 Physical or verbal abuse, neglect, or attempting to injure residents or other person Corrective action required: Termination. On 2/12/26 at 12:39pm, V7 (Maintenance Director/Housekeeping) said that there's no documentation that we (facility) check the radiator heaters regularly, but we (facility) did start documenting heater checks the day (2/07/26) R1 fell. I was never notified of the heater being broken prior to the incident (2/07/26, R1 fall with injury). I was involved in checking the radiator heaters throughout the whole facility. 2 screws on each end were needed to secure the heater's cover. Just 2 heater covers weren't secured, and the rooms were R1's and now R9, R10, R11, R12's room. I'm not sure how all the rooms radiator heater's cover were checked and R9, R10, R11, R12's cover was still loose and needed 2 more screws today (2/12/26). It (R9, R10, R11, R12's room radiator cover) could have just became loose since the inspection (2/07/26). On 2/12/26 at 1:01pm, V2 (Director of Nursing) said, I was not aware that it (R1's radiator heater cover) had been previously broken. V3 called me at 5:00a.m. (2/07/26) to inform me that the CNA (V8) admitted she (V8) did not complete her (V8) rounding. She (V8) is a good CNA. I would switch her (V8) with some of the younger staff members. There is no documented evidence that any staff member went in and seen R1 prior to her (R1) fall (2/07/26, R1 fall with injury). R1 is confused. The staff are good at watching her (R1). No, I don't think she (R1) required 1:1 supervision. Yes, she (R1) can be impulsive and a fall risk. On 2/12/26 at 2:05pm, V7 (Maintenance Director/Housekeeping Manager) said, Again, we (facility staff) were not documenting that we (facility staff) were checking the radiator heaters regularly, but we (facility) did start documenting heater checks the day R1 fell. We (facility staff) were just taking hot water temperatures, 6 rooms per week and the common area temperatures. Maintenance and housekeeping should be checking the radiator heaters daily, but there is no documented protocol for that until now. The facility has 2 types of heating systems. The radiators which is heated using 2 boilers, heats the whole facility. The boilers (two of them) are set at 72 degrees Fahrenheit, but the pressure is set let out 30 degrees Fahrenheit so when the boiler temperature reach the radiator, 30 degrees Fahrenheit is only let out. The PTAC unit subsidizes heat. The PTAC is forced air only and is thermostat controlled. On 2/12/26, V32, Physician said, They (facility staff) called me and said she (R1) was laying on a heater and developed blisters (2/07/26). I don't know, I'm not a specialist. Try calling the hospital where she (R1) is at about the burns. Burns from a heater all depends on nutrition, age, and comorbidities. I don't know. Talk with hospice regarding pain and burns. Hospice is really good at keeping resident's pain under control. On 2/13/26 at 11:35am, V15, Hospice Registered Nurse/RN said, Yes, I am familiar with R1. End-stage Alzheimer's disease was her (R1) hospice diagnosis. She (R1) is alert with reduced spontaneity and alert to self only. She (R1) has episodes of confusion, more so in the evening, during which she (R1) becomes agitated. She (R1) is at high risk for falls because she (R1) attempts to get up on her (R1) own. She (R1) believes she (R1) can do things independently but is unable to do so safely. She (R1) is a feeder and requires total care. She (R1) is on a pureed diet and is at risk for aspiration. She (R1) had a seizure a few months ago. Her (R1) skin is intact, and she (R1) is incontinent. She (R1) has never really expressed pain, though she (R1) occasionally demonstrates facial grimacing. Music therapy is used to help calm her (R1). She (R1) requires total care with ADLs (activities of daily living). On a couple of occasions, she (R1) fed herself and participated minimally in washing up. Her (R1) cognition is impaired. She (R1) responds to simple yes or no questions but does not provide details. She (R1) does not speak much. I (R1) saw her (R1) on the 6th (2/06/26) and had been following her (R1) since August 10, 2025. Most of the time, she (R1) is in the dining room or at the nurse's station with staff, especially in the evening when she (R1) sundowns. Not only was she (R1) transported by 911 to (hospital), but she (R1) was also admitted . Since we (hospice staff) did not know the reason for admission, we (hospice staff) had to discharge her (R1) from hospice so the hospital could complete any necessary interventions. On 2/13/2026 at 3:04 pm, V9 (Certified Nursing Assistant/CNA) said, Yes, V8 (certified nursing assistant/CNA) helped me put a resident back to bed that night (2/6/26) at the start of the shift. The resident was in a geri-chair attempting to get out; however, she (resident) did not fall out of the chair. I cannot remember which resident. The radiator cover (R1's) was not intact or secured, and it would come off before R1 fell and was burned (2/07/26). I really cannot recall the details because I am usually not assigned to that area. I cannot say how long it (R1's radiator heater cover) had been broken, but it was broken before that day (2/07/26). I'm sorry, I do not know for how long. On 2/13/26 at 1:16pm, V16, Hospice Physician said, R1 is a cognitively impaired patient with dementia. She (R1) speaks very little, and when she (R1) does, her (R1) speech is mostly nonsensical. She (R1) is prone to agitation, has impaired judgment, and demonstrates nonsensical speech. Her (R1) balance is poor, she (R1) experiences sleep disturbances, and she (R1) is at high risk for falls. Blistering of the skin can be painful and also places her at risk for infection. On 2/13/26 at 4:18pm, V11 (Licensed Practical Nurse/LPN) said, I work from 11:00 p.m. to 7:00 a.m. I did not work that day (2/6/26). I work every other weekend. Yes, I am familiar with her (R1). She (R1) was on hospice and would frequently attempt to get up and fall. I do not know why housekeeping did not notice the issue (R1's radiator heat covered not secured). It (R1's radiator heater) was in disrepair. I am not aware of whether anyone reported it (unsecured radiator heater cover in R1's room). To my knowledge, it (R1's radiator heat cover not secured) had been that way for at least a couple of months. Housekeeping staff come in and clean every day, and never did anything about the radiator. I have not been there recently, so I cannot provide additional information. On 2/14/26 at 11:34am, V7 (Maintenance Director/Housekeeping Manager), She's (R1) thin, and I believe she (R1) can fit right in between the radiator and the floor. Like nudged in between. I believe it was like a noodle, but not a wet noodle. A noodle is kinda thin, and if you lay it on the radiator, even if it's a 30 degree Fahrenheit it'll still burn the skin. The immediate Jeopardy that began on 2/07/2026 was removed on 2/19/2026 when the facility took the following actions to remove the immediacy: All resident rooms in facility, all units (Unit 100, 200, 300) were visited, and beds were rearranged as necessary to ensure no beds are pushed against the walls or close to heating units on February 7, 2026. Bedside cabinets/nightstands will be placed between bed and wall that houses the floor radiator to provide separation from bed to wall. This monitoring continued and completed on February 9, 2026. Any residents who resisted received education. This was completed by Maintenance Director. Surveyor verified that this was completed on 2/18/2026. Resident's (R1) bed was immediately removed from wall and heating unit on February 7, 2026, by llp-7a shift Charge Nurse. Surveyor verified that this was completed on 2/12/2026. On February 7, 2026, Nursing Staff (Nurses, CNAs) and Housekeepers that were on duty were in-service that no resident beds are to be pushed to walls or close to heating units. Bedside cabinets/nightstands were placed between bed and wall that houses the floor radiator to provide separation from bed to wall. This in-service from February 7, 2026, continued and completed on February 18, 2026, by Maintenance Director and Regional Director of Clinical Services. Surveyor verified that this was completed on 2/19/2026. On February 7, 2026, the facility began educating Staff (Nurses, CNAs, Housekeeping, Department Heads) verbally on safety protocol. This education continued on February9 through February 12, 2026. Education completed February 18, 2026. Focus of education: a. Abstaining from positioning beds against the wall b. Abstaining from positioning beds close to heating units c. Ensuring proper protection/covering of wall heating units. d. Importance of visual rounds; increased visual monitoring e. Consequences for Staff's noncompliance f. Bedside cabinets/nightstands will be placed between bed and wall that houses the floor radiator to provide separation from bed to wall g. Fall Prevention Program This was initiated by Maintenance Director and continued by Regional Director of Clinical Services. (All of number 5, surveyor verified that this was completed on 2/19/2026.) On February 9, 2026, incident with Resident (R1) was discussed with IDT as an impromptu QAPI with instructions to increase visual rounding on all units which has been ongoing. IDT Members included, but not limited to, Administrator, Asst Administrator, DON, ADON, Activity Director, PRSC, MOS, Restorative Director, Wound Care Nurse, Infection Preventionist Nurse, Dietary Manager, Maintenance Director, Scheduler, Therapy Director and Regional Director of Clinical Services. (see attached) Next QAPI scheduled for February 25, 2026, when incident will be discussed again. Surveyor verified that this was completed on 2/19/2026. On February 10 through February 12, 2026, Staff (Nurses, Housekeepers, Activities, CNAs) were in-service on hourly rounding and form created by Regional Director of Clinical Services. (see attached) Surveyor verified that this was completed on 2/19/2026. On February 18, 2026, Nurses and CNAs were in serviced verbally via phone conversation on items listed below. Abstaining from positioning beds against the wall b. Abstaining from positioning beds close to heating units c. Bedside cabinets/nightstands will be placed between bed and wall that houses the floor radiator to provide separation from bed to wall d. Ensuring proper protection/covering of wall heating units e. importance of visual rounds; increased visual monitoring f. Consequences for Staff's noncompliance g. Fall Prevention Program (All of number 9, surveyor verified that this was completed on 2/19/2026.) Surveyor verified that the following system was put into place on 2/19/2026. Maintenance Director and Asst Director will perform preventive maintenance rounds in all resident rooms. This was initiated February 7, 2026, and is continual daily when on duty. On weekends, each Housekeeper will be responsible for the rounds on their assigned units (all resident rooms located Unit 100, Unit 200, Unit 300). All needed repairs will be reported to the Maintenance Department immediately via TELS (maintenance work order system), in person or by phone. All Staff aware. In the event that a repair that may pose potential harm to a resident can't be repaired immediately, the resident will be placed in alternate room until repair is completed. On February 7, 2026, Maintenance Director checked Resident's (R1) heating unit in addition to all floor heating units for coverings. Heating units have proper protective cover in place and secure. This was completed on February 12, 2026. Maintenance Director and his assistant in addition to Weekend Housekeepers will monitor this daily. On February 12, 2026, hourly rounding with recordings initiated on all units. (see attached) Surveyor verified that this was completed on 2/19/2026. Administrator will be responsible for overall compliance to this removal plan in conjunction with Asst Administrator, Director of Nursing, Assist Director of Nursing and Maintenance Director by monitoring during routine rounds daily when on duty. Each Charge Nurse and Facility Manager on Duty as well as Weekend Housekeepers as assigned will be responsible for monitoring overall compliance in absence of Admin, Asst Adm., DON, ADON and Maintenance Director. The Quality Assurance Quality Improvement Team meets monthly. This event will be brought again to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly. Completion Date: February 19, 2026 2. R5's face sheet documents in part the following diagnoses: unspecified dementia, severe with other behavioral disturbance, traumatic subdural hemorrhage with loss of

Based on observation, interview and record review, the facility failed to have sufficient nursing staff to meet the resident needs and failed to ensure the facility was staffed in accordance with the facility assessment. This failure affects all 112 residents that reside within the facility. Findings include: Facility census (2/11/2026) documents in part that 112 residents reside within the facility. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact. Additionally, R4's minimum data set documents that R4 is dependent on staff for toileting assistance. On 2/13/2026 at 1:00 PM, R4 explained, Yes, the facility doesn't have enough staff. It takes forever for someone to help you sometimes like 3-4 hours. Back in October, I was left hanging on a Hoyer for over 3 hours in my own feces. I get left in my own urine and feces for hours like an animal. I'm not an animal; I don't deserve to be treated like that. I've told the administration of this facility about my problems and nothing changes, that's the problem. Yes, I am incontinent even right now and have been sitting in my urine for hours. No, I don't want them to change me, it's during lunch time, no one will come. R4's POC (Point of Care) Response History (2/17/2025) report does not document that R4 received assistance with toileting on the following dates: 1/19/2026 (11 PM-7 AM Shift), 1/21/2026 (3 PM-11 PM Shift, 11 PM-7 AM Shift), 1/24/2026 (11-7 AM Shift), 1/25/2026 (11 PM-7 AM Shift), 1/26/2026 (7 AM-3 Shift), 1/27/2026 (11 PM-7 AM Shift), 1/31/2026 (11 PM-7 AM Shift), 2/1/2026 (11 PM-7 AM Shift), 2/2/2026 (11 PM-7 AM Shift), 2/3/2026 (11 PM-7 AM Shift), 2/6/2026 (11 PM -7 AM Shift), 2/7/2026 (3 PM-11 PM Shift, 11PM -7 PM Shift), 2/8/2026 (3 PM-11 PM Shift, 11 PM-7 AM Shift), 2/9/2026 (11 PM-7 AM Shift), 2/10/2026 (7AM -3 PM Shift), 2/11/2026 (11PM -7 AM Shift), 2/12/2026 (7 AM-3 PM Shift), 2/15/2026 (7 AM -3 PM Shift). On 2/13/2026 at 1:28 PM, R4 affirmed R4 was aware of another resident being burned in the facility. R4 explained, Here's a perfect example of how the facility isn't ran right by the administration and how we don't have enough staff: There was a resident just a few days ago that fell out of bed and no staff checked on her for hours. She fell on to the radiator and suffered 3rd degree burns because they never checked on her. They clearly didn't do their job. I did not see the resident, and I am not familiar with which resident exactly, but it (the resident being burned) is all the staff are talking about. You can hear them talk about it all the time. They said her skin was burnt off. I really hope you guys (State Survey Agency) are looking into that incident—it's bad. On 2/13/2026 at 3:10 PM, V24 (Certified Nursing Assistant) stated, I have to be honest. I don't think we have enough people to meet the resident's needs. We are usually short. People are always calling in and it makes us run short. The managers try to call people in but there's usually not enough people to pick up. On 2/13/2026 at 3:22 PM, V5 (Licensed Practical Nurse) stated, I don't think there is enough staff overall. I mean, I am assigned to 42 residents on my own. I don't think that's safe. There's a lot of residents here with dementia and they require more care. R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. On 2/17/2026 at 10:16 AM, R8 stated, My roommates wait forever to get help from the staff. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. R3's Face Sheet documents in part the following diagnoses: hemiplegia affective left non-dominant side, bilateral cataracts, hypertension, type 2 diabetes mellitus, and depression. On 2/17/2026 at 10:21 AM, R3 stated, They don't have enough aides. I have to wait a long time to get help and sometimes don't get the help. They don't provide me with incontinence care, it's still a problem. Everything is short staffed here. R3's Minimum Data Set (11/25/2025) documents in part a BIMS summary score of 13, indicating R3 is cognitively intact and that R3 is dependent on staff for toileting assistance. R3's POC (Point of Care) Response History (2/17/2025) report does not document that R3 received assistance with toileting on the following dates: 1/19/2026 (3 PM-11 PM Shift), 1/20/2026 (3-11 PM Shift), 1/22/2026 (11 PM -7 AM Shift), 1/26/2026 (11 PM-7 AM Shift), 1/31/2026 (11 PM-7 AM Shift), 2/1/2026 (3 PM-11 Shift), 2/4/2026 (3 PM-11 Shift), 2/5/2026 (11 PM-7 AM Shift), 2/13/2026 (7 AM-3 PM Shift, 11 PM-7 AM Shift), 2/15/2026 (7 AM-3 PM Shift). On 2/18/2026 at 9:41 AM, V1 (Administrator) stated that V1 has not received any complaints about staffing in the facility. V1 stated, Of course they (staff and residents) are going to tell you there's not enough staff. You can ask anywhere if they need staff and they'll tell you yes, we need more staff. Everywhere is hiring. V1 stated there is no policy for staffing and that the facility uses the facility assessment to guide the staffing patterns in the facility. On 2/18/2026 at 10:24 AM, V39 (Scheduler/Central Supply/Medical Records) affirmed that V39 is responsible for scheduling the nursing shifts within the facility. V39 stated, I think we have sufficient staff, it's just the call ins. We have call ins almost every day. At times, yes, it has caused disruptions in the resident's care. When we have call-ins we try to call staff in or get people to stay. We staff the facility based on acuity. On 2/18/2026 at 10:05 AM, V2 (Director of Nursing) stated, I think we have enough staff. We do have a lot of call ins. I wouldn't say the call ins happen every day, but at least every other day. They call in saying their sick and I have to take their word for it. When people call in, we call staff members at home to get them to come in and work or offer staff overtime to stay. The only times when the call ins have affected the care of the residents is when we can't find staff to come in or we have to wait for them to come in. Then, more residents have to be assigned to each staff member to care for which can delay care. On 02/18/2026 at 12:10 PM, V39 reviewed the daily staffing assignment sheets (1/30/2026-2/13/2026). V39 confirmed that on 2/2/2026 there were 8 nursing assistants that worked 11 PM-7 AM shift, on 2/7/2026 there were 7 nursing assistants that worked 11 PM - 7AM shift, on 2/8/2026 6 certified nursing assistants worked the 11 PM-7 AM shift, on 2/9/2026 there were 7 nursing assistants that worked 11 PM- 7 AM shift, and on 2/13/2026 6 certified nursing assistants worked the 11 PM-7 AM shift. V39 affirmed that no other staff members came in those days to cover the shifts. V39 stated that the staffing would shift to 2-2-2 instead of 3-3-3 CNAs per each unit when there were only 6 certified nursing assistants. V39 stated that the facility's staffing plan is 11 nursing assistants on day shift (7 AM-3 PM), 10 nursing assistants on PM shift (3PM -11 PM) and 9 nursing assistants on NOC (11 PM-7 AM) shift. Record review of the facility's daily staffing assignment sheets (1/30/2026-2/13/2026) documents in part, on 1/30/2026, 3 call-ins (1 Nurse PM, 2 CNA NOC), on 1/31/2026 2 call-ins (1 CNA AM, 1 Nurse NOC), 2/1/2026 5 call-ins (2 CNA PM, 2 CNA NOC, 1 Nurse NOC), on 2/2/2026 2 call ins (1 Nurse PM, 1 CNA NOC), 2/5/2026 1 call-in (1 CNA PM), on 2/6/2026 4 call-ins (1 CNA AM, 3 CNA PM) , on 2/7/2026 2 no-call no shows (2 CNAs NOC), on 2/8/2026 3 call-ins (1 AM CNA, 2 PM CNA) and 1 no call no show (PM CNA), 2/9/2026 4 call ins (3 NOC CNA, 1 NOC Nurse), 1 removed from schedule (NOC CNA), 2/10/2026 1 call in (NOC CNA), 1 removed from schedule (NOC CNA), on 2/11/2026 1 call-ins (PM Nurse) 1 No Call-No Show (PM CNA), 2/12/2026 2 call-ins (PM CNA, NOC Nurse), 2/13/2026, 4 no call no shows (1 PM CNA, 3 PM NOC) and 1 call off (PM CNA). On 2/2/2026 there were 8 nursing assistants that worked 11-7 shift, on 2/7/2026 there were 7 nursing assistants that worked 11-7 shift, on 2/8/2026 6 certified nursing assistants worked the 11-7 shift, on 2/9/2026 there were 7 nursing assistants that worked 11-7 shift, and on 2/13/2026 6 certified nursing assistants worked the 11-7 shift. Facility census for 2/2/2026 documents 113 residents were residing within the facility. Facility census for 2/3/2026 documents 112 residents were residing within the facility. Facility census for 2/7/2026 documents 112 residents were residing within the facility. Facility census for 2/8/2026 documents 111 residents were residing within the facility. Facility census for 2/9/2026 documents 109 residents were residing within the facility. Facility census for 2/13/2026 documents 113 residents were residing within the facility. Record review of the facility assessment (2/12/2026) documents in part for the facility's staffing plan that that approximately 4 licensed nurses are needed per shift on 1st shift, 4 on second shift, and 3 on third shift. For certified nursing assistants, 11 are needed on first shift, 10 are needed on second shift, and 9 are needed on third shift to adequately meet the resident's care needs. Additionally, the facility assessment identifies an average census of 103.

Based on observation, interview, and record review, the facility failed to have sufficient dietary staff to meet resident needs and to serve meals timely. This failure affected all 106 residents that consume food from the facility's kitchen. Findings include:Facility census (2/11/2026) documents in part that 112 residents reside within the facility. Facility document titled RESIDENTS THAT ARE NPO (Nothing By Mouth) (2/2026) documents in part that 6 residents do not consume oral intake. This indicates that 106 residents consume food from the facility's kitchen. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact.On 2/13/2026 at 1:00 PM, R4 was observed eating lunch in R4's room. R4 stated that meals are generally served late and are sometimes cold. On 2/14/2026 at 11:37 AM, observed 1 cook and 2 dietary aides in the kitchen. V29 confirmed the observation and stated there was one cook and 2 dietary aides on duty. V29 (Cook) affirmed that the kitchen begins plating food at 12:00 PM and that lunch begins at 12:00 PM for the residents. V29 stated, I don't know if I would consider us (Dietary Department) short staffed. I know we are usually short on PM shift, I know we need help there. On 2/14/2026 at 11:59 AM, V29 stated, We haven't started plating the food yet because the dietary aides have not finished prepping the trays. Come back in like 25 minutes and we should be ready to plate the food then. I don't know why the aides aren't done plating.On 2/14/2026 at 12:30 PM, observed V29 in the kitchen plating the food for the first dining room. V29 was assisted by 2 dietary aides. V6 (Assistant Administrator, HR) was present in the kitchen. V6 stated that V6 came into the kitchen to see what was taking the food so long (to be distributed). V6 affirmed that lunch begins at 12:00 PM.On 2/14/2026 at 1:47 PM, observed the final tray served to the residents in the 300-dining room (indicating the final resident was served 1 hour and 47 minutes after the start of the lunch time).R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:16 AM, R8 stated, The food is never served on time. Just a couple nights ago, I was served dinner at 7:10pm. I was the last tray to be given. I am supposed to eat at like 5:00 o'clock pm. I didn't want to wait that long. They don't have enough help in the kitchen or in nursingR3's Face Sheet documents in part the following diagnoses: hemiplegia affective left non-dominant side, bilateral cataracts, hypertension, type 2 diabetes mellitus, and depression. R3's Minimum Data Set (11/25/2025) documents in part a BIMS summary score of 13, indicating R3 is cognitively intact and that R4 is dependent on staff for toileting assistance. On 2/17/2026 at 10:20 AM, R3 stated, Everything is short staffed here. Most of the meals here are served late. On 2/17/2026 at 10:24 AM, V35 (Dietary Manager) stated, I have been here (employed by the facility) about 2 months. Honestly, I don't want to throw anyone under the bus, but I do think we need more staff in the kitchen. I have tried my best to eliminate tedious tasks, like for example, I buy individual cartons of thickened liquids, so we don't have to make the thickened liquids in bulk. I try my best to streamline the processes, cut out any extra stuff that isn't crucial, but we still could use more. We are currently trying to hire for a part-time cook and part-time dietary aide. I try to help where I can but there are a lot of tasks in the kitchen to do. I have seen times where we have been late on serving meals. On 2/17/2026 at 11:45 AM, V37 (Registered Dietician) stated, I am the consultant dietician for the facility. To be honest, I am not sure how much staff are needed in the kitchen or what the regulatory requirements are related to kitchen staffing. On 2/17/2026 at 12:39 PM, V1 (Administrator) stated, There is no written policy for dietary staffing we follow the guidelines from state and federal of sufficient support personnel to meet the dietary needs of all persons eating meals in the facility. On 2/18/2026 at 9:53 AM, V1 stated, the purpose of the facility assessment is that it is a living, breathing tool, that identifies resources needed in order to care for the residents and in cases of emergency. The facility assessment was reviewed with V1 (Administrator). When asked if the facility assessment identifies the dietary department staffing needs, V1 replied, It says the dietary manager, we don't have to list cooks or dietary aides. That's not a requirement. We follow the federal regulation, which is: if you have enough staff to create the food and serve the food then you are meeting the needs of the facility. Review of facility working dietary staff schedules for 2/2026, documents in part that the facility usually staffs between 2-3 dietary aides between 6:00 AM - 8:00 PM with one cook working 6 AM-2 PM and a second cook working 12 PM-8 PM. On 2/1/2026, 2/3/2026, 2/13/2026, and 2/14/2026, there was only 1 dietary aide working the 4:00-8:00 PM shift. On 2/12/2026, only 1 dietary aide worked the 6:30 AM-2:30 PM shift. On 2/9/2026, only one cook worked from 12:00 PM-8:00 PM. The facility assessment (2/12/2026) does not indicate a dietary department staffing plan or how many/which type of staff members are required to meet the needs of the facility's dietary department. The Dietary aides and cooks are not identified within the dietary department staffing plan. Facility document titled, MEAL CART AND TRAY TIMES (Undated), documents in part that breakfast is served at 8:00 AM, 8:15 AM and 8:30 AM, lunch is served at 12:00 PM, 12:15 PM, and 12:30 PM, and supper (dinner) is served at 5:00 PM, 5:15 PM, and 5:30 PM in the 300-dining room, 200-dining room and main dining room, respectively.

Based on observation, interview and record review, the facility failed to ensure menu variety for dinner, failed to honor resident preferences and cultural/ethnic considerations, failed to follow recipes for the written menu, and failed to obtain dietician input for any substitutions made to the recipes/menu. This failure affected all 106 residents that consume food from the facility's kitchen.Findings include: Facility census (2/11/2026) documents in part that 112 residents reside within the facility. Facility document titled RESIDENTS THAT ARE NPO (Nothing By Mouth) (2/2026) documents in part that 6 residents do not consume oral intake. This indicates that 106 residents consume food from the facility's kitchen. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. On 2/13/2026 at 1:00 PM, R4 explained, The food here is terrible, barely edible. I am afraid to eat the entree a lot of the times because it gives me (diarrhea). One of the worst things about the food here is the lack of variety. Every single night we are served a sandwich of sorts. In my culture, you might not understand, but Sunday dinners are important to us. In the black community, we get together and have a nice Sunday dinner. Most of these residents are black, it's our culture. I usually get served a choke sandwich (dry, without condiments), piece of ham between two pieces of bread. That's it. That's not okay, dinner in general is always just sandwiches of some sort. It is so depressing. We deserve to have normal dinner items. On 2/13/2025 at 3:10 PM, V24 (Certified Nursing Assistant) affirmed V24 heard residents complaining about the taste of the food. V24 stated, They (residents) often complain about the food, it's about every day. They'll say it doesn't taste good or was cold. The residents will leave food on the tray or have us go get something else like a sandwich.On 2/14/2026 at 12:21 PM, observed V29 (Cook) taking food temperatures of the prepared lunch entrees and sides within the kitchen. V29 stated, The recipe for the stuffed peppers called for ground turkey, but we didn't have any of that. I don't think we ordered it. So, I called my manager, and we used ground beef to make it instead. When discussing the preparation for the mechanically altered foods, V29 stated, The menu today calls for creamed corn for mechanically altered residents, but we didn't have any of that, so I made carrots. I do not know why there was no creamed corn to serve the residents. On 2/14/2026 at 12:30 PM, the kitchen staff observed preparing lunch. Observed 4 tray racks within the kitchen that had trays with desserts and utensils. The desserts cups contained peaches and a nickel-sized dollop of whipped cream that was smashed into the plastic wrap covering the dessert which would transfer approximately 50% of the whipped cream to the plastic. There were no color change or any other indicators that would identify honey was mixed into the whipped topping. V38 (Dietary Aide) affirmed that V38 made the desserts, used a spray can of whipped cream, and then covered them with plastic. Surveyor inquired how much whipped cream is supposed to be on the dessert. V38 replied, Not much at all. Like a little squirt of it, maybe less than a half a second. V38 affirmed that the whipped topping was not made, it came from a can, and V38 sprayed the whipped cream directly from the can onto the dessert (indicating no honey was used). Observed V29 cutting the cornbread to be served, approximately a 9-10-inch diameter of the top of the cornbread was burnt. V29 stated, I'm not going to use that. V29 denied that there was any more cornbread to be served and no more cornbread was going to be made in response to the burnt portion of cornbread. On 2/14/2026 at 1:10 PM, observed V29 (Cook) placing plain pieces of wheat sandwich bread on each plate and omitting the corn bread. V29 stated, we ran out of cornbread. V38 (Dietary Aide) affirmed that at least 6 people were going to receive the plain sandwich bread in lieu of the cornbread on the menu. V29 affirmed that V29 did not notify the dietician prior to changing the menu for some of the residents. On 2/14/2026 at 1:49 PM, a test tray was provided to the survey team. The test tray consisted of corn, a plain piece of bread, and unidentifiable rice/meat mixture in a tomato-based sauce on a Styrofoam plate wrapped in plastic cling wrap. The rice/meat mixture smelled heavily of tomato, lacked the smell of any other spices, and lacked bell pepper. The cornbread, stuffed pepper, and spiced peach dessert were not provided. V29 (Cook) stated, We ran out of the stuffed peppers, so that is the inside of the stuffed pepper. It is what we used for the mechanical soft. We ran out of cornbread and the spiced peach dessert. R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:16 AM, R8 make a gagging noise and motion like R8 was throwing up. R8 stated, That's what I think of the food: nasty. They don't really have a lot of different options or variety. It's all nasty.R3's Face Sheet documents in part the following diagnoses: hemiplegia affective left non-dominant side, bilateral cataracts, hypertension, type 2 diabetes mellitus, and depression. R3's Minimum Data Set (11/25/2025) documents in part a BIMS summary score of 13, indicating R3 is cognitively intact and that R4 is dependent on staff for toileting assistance. On 2/17/2026 at 10:20 AM, R3 stated the food was alright, but it needs more variety. R3 affirmed that the facility serves a lot of sandwiches and would prefer other menu items. On 2/17/2026 at 10:24 AM, V35 (Dietary Manager) stated, I have been here (employed by the facility) about 2 months. I have noticed that there are a lot of sandwich items on our menu cycle. I thought it was interesting, I don't know why there are so many sandwich style items on the menu cycle. I don't make the menu, corporate makes the menu and it is approved by a dietician. Yes, menus should have variety, but again, I don't make the menu. V35 affirmed that V35 has received complaints about lack of flavor and palatability of the food from the residents and has implemented a food committee to try and better serve the residents' concerns. V35 provided resident council meeting minutes from 11/2025-present. V35 stated that V35 does not have documentation of the food committee meetings they get documented in the resident council meeting minutes. On 2/17/2025 at 10:27 AM, V35 (Dietary Manager) explained, I was not aware that (V29) used different meat when preparing the stuffed peppers. I don't know why (V29) didn't use the correct meat according to the menu, we had the meat thawing. Same with the cornbread, there was more cornbread that (V29) could have made. I don't know what was going on that day (2/14/2026), everything (ingredients) was here. V29 stated that the facility used a spray-form of whipped topping when making the spiced peach dessert, so there was no way we (staff) could measure the amount. V35 stated that the expectation is that staff should be following the recipes and the menus. On 2/17/2026 at 11:45 AM, V37 (Registered Dietician) affirmed V37 is the consultant dietician for the facility and was not aware of any ingredient substitutions or menu changes for 2/14/2026. V37 denied V37 gave any approvals to change any parts of the menu on 2/14/2026. V37 affirmed that the facility should be preparing food as directed by the recipe and menu. On 2/17/2026 at 11:45 AM, V37 (Registered Dietician) affirmed V37 is the consultant dietician for the facility and was not aware of any ingredient substitutions or menu changes for 2/14/2026. V37 denied V37 gave any approvals to change any parts of the menu on 2/14/2026. V37 affirmed that the facility should be preparing food as directed by the recipe and menu. On 2/17/2025, surveyor requested the recipe for all items served at lunch on 2/14/2026. The pureed carrot recipe was not provided prior to the exit of the survey. Resident council meeting minutes 11/2025-present documents in part on 12/30/2025, the resident council had concerns related to putting veggies on sandwiches. Comments (12/30/2025) were made by V35 (Dietary Manager) that indicated that the cook was in-serviced on making grits. There are no comments related to corrective action for the residents' wanting vegetables on their sandwiches and no further information was provided prior to the exit of the survey.The posting for the lunch menu (Prairie Oasis F/W 25/26 Dat at a Glance for General Week 4 Saturday) for 2/14/2026 documents in part that the lunch being served is Stuffed Pepper, Skillet Corn, Spiced Peach Parfait, Cornbread, MargarineRecord review of the recipe for stuffed pepper indicates the following ingredients: vegetable salad oil, ground turkey, medium green peppers, chopped onion, diced celery, Italian seasoning, garlic powder, salt, black pepper, tomato sauce, condensed cream of tomato soup and shredded cheddar cheese. The ground stuffed pepper with sauce instructs the staff to ground the stuffed pepper in an appropriate consistency in a food processor and top with sauce. Record review of the recipe for the spice peach parfait indicates the following ingredients: diced peaches, juice pack, brown sugar, cinnamon, whipped topping and honey. The recipe instructs staff to prepare whipped topping according to package instructions, add honey, and whisk to incorporate the honey into the whipped topping. Record review of the recipe for the whipped topping instructs the staff to mix whipped topping mix packages and ice-cold water into a mixing bowl and whip for approximately 5-10 until peaks form. There is no recipe to use spray-style whipped cream in place of this whipped topping mix. Record review of the current facility menu cycle indicates the following days where a sandwich (meat or other food item between bread/bun) is being served for dinner: Week 1: Tuesday (Grilled Cheese Sandwich), Thursday (Barbequed Chicken Sandwich), Friday (Chicken Salad Sandwich); Week 2 : Sunday (Grilled Ham and Cheese Sandwich), Monday (Alpine Burger with Bun), Tuesday (Turkey and Swiss Cheese Sandwich), Thursday (Bratwurst on bun), Week 3: Sunday (Turkey and Swiss Cheese Sandwich), Monday (Hot Dog with Bun), Saturday (BBQ Rib Patty on Submarine Roll), Week 4: Sunday (Sloppy [NAME] Sandwich), Monday (Tuna Salad Sandwich), Thursday (Cheeseburger with Bun), Friday (Bratwurst Sausage with Bun), Saturday (Breaded Fish Sandwich with Cheese on Bun). This indicates that a sandwich style entree was served for dinner on 3 days in Week 1, 4 days in Week 2, 3 days in week 3, and 5 days in week 5. Facility policy titled, Menu Changes (2017) documents, Menu Items will be served as planned whenever possible. Due to unavoidable circumstances, temporary changes may be made to the menu. Procedure: Changes will be indicated on the posted menu prior to the meal service. The menu change will be noted in a file kept for that purpose. The reason for change will be noted. Changes will be of similar nutritional value. Permanent changes must be approved by the dietician.Facility policy titled CYCLE MENU (2018) documents in part, .Procedure: Cycle Menus are planned by a dietician at least two weeks in advance. A variety of nourishing food is served three meals a day and an evening snack. Menus are different for the same day of consecutive weeks and seasonal foods are used. Menus reflect the religious, cultural and ethnic needs of the clients as well as the clients' food preferences .

Based on observation, interview and record review, the facility failed to serve food to residents in a manner that is palatable and attractive. This failure has the potential to affect all 106 residents that consume food from the facility's kitchen. Findings include:Facility census (2/11/2026) documents in part that 112 residents reside within the facility. Facility document titled RESIDENTS THAT ARE NPO (Nothing By Mouth) (2/2026) documents in part that 6 residents do not consume oral intake. This indicates that 106 residents consume food from the facility's kitchen. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact.On 2/13/2026 at 1:00 PM, R4 explained, The food here is terrible, barely edible. I am afraid to eat the entree a lot of the times because it gives me (diarrhea). The food tastes bad, looks bad, the only thing that tastes ok is the salad. All of the residents don't like the food here and most of them can't speak up because they got dementias or impaired cognition. On 2/13/2025 at 3:10 PM, V24 (Certified Nursing Assistant) affirmed V24 heard residents complaining about the taste of the food. V24 stated, They (residents) often complain about the food, it's about every day. They'll say it doesn't taste good or was cold. The residents will leave food on the tray or have us go get something else like a sandwich.On 2/13/2025 at 3:22 PM, V5 (Licensed Practical Nurse) affirmed V5 has had residents complain about the food. V5 stated, They (residents) will say they don't like it (the food) or it doesn't taste good. Or they order a certain meal, and they don't get what they ordered. On 2/14/2026 at 12:30 PM, observed kitchen staff preparing lunch. Observed 4 tray racks within the kitchen that had trays with desserts and utensils. The desserts cups contained peaches and a nickel-sized dollop of whipped cream that was smashed into the plastic wrap covering the desert which would transfer approximately 50% of the whipped cream to the plastic. V38 (Dietary Aide) affirmed that V38 made the desserts and covered them with plastic. Surveyor inquired how much whipped cream is supposed to be on the dessert and V38 replied, Not much at all. Like a little squirt of it, maybe less than a half a second. Observed V29 cutting the cornbread to be served, approximately a 9-10-inch diameter of the top of the cornbread was burnt. V39 stated, I'm not going to use that. V29 denied that there was any more cornbread to be served and no more cornbread was going to be made in response to the burnt portion of cornbread. On 2/14/2026 at 12:32 PM, observed V29 (Cook) plate a serving of pureed bell peppers, pureed carrots, and puree cornbread. The pureed items appeared thick, lumpy and unappetizing on the tray. The pureed carrots were a gelatinous texture and had a shine across the surface. On 2/14/2026 at 1:10 PM, observed V29 (Cook) placing plain pieces of wheat sandwich bread on each plate and omitting the corn bread. V29 stated, we ran out of cornbread. V38 (Dietary Aide) affirmed that at least 6 people were going to receive the plain sandwich bread in lieu of the cornbread on the menu. On 2/14/2026 at 1:49 PM, a test tray was provided to the survey team. The test tray consisted of corn, a plain piece of bread, and unidentifiable rice/meat mixture in a tomato-based sauce on a Styrofoam plate wrapped in plastic cling wrap. The rice/meat mixture smelled heavily of tomato and lacked the smell of any other spices. The cornbread, stuffed pepper, and spiced peach dessert was not provided. V29 (Cook) stated, We ran out of the stuffed peppers, so that is the inside of the stuffed pepper. It is what we used for the mechanical soft. We ran out of cornbread and the spiced peach dessert. On 2/14/2026 at 1:57 PM, V1 (Administrator) observed the test tray and affirmed that the test tray did not appear to be appetizing or palatable.On 2/17/2025 at 10:27 PM, V35 (Dietary Manager) stated that pureed carrots should have a texture that looks similar to mashed potatoes. V35 affirmed that pureed carrots should not appear gelatinous. V35 stated that the facility used a spray-form of whipped topping, so there was no way we (staff) could measure the amount. V35 affirmed that V35 has received complaints about lack of flavor and palatability of the food from the residents and has implemented a food committee to try and better serve the resident's concerns. V35 provided resident council meeting minutes from 11/2025-present. V35 stated that V35 does not have documentation of the food committee meetings they get documented in the resident council meeting minutes. R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:16 AM, R8 make a gagging noise and motion like R8 was throwing up. That's what I think of the food: nasty.On 2/18/2026 at 5:08 PM, V40 (Licensed Practical Nurse) affirmed that V40 no longer works at the facility but when V40 did work at the facility, V40 would often have residents complain about the food. V40 recalled, It was pretty much every day that residents would complain about it (food). They would say like, oh I don't want that, it looks gross or it doesn't have any taste or seasoning. Food being too bland was probably the most frequent complaint. Resident council meeting minutes 11/2025-present documents in part on 12/30/2025, the resident council had concerns related to grits needing to be cooked longer and putting veggies on sandwiches. Comments (12/30/2025) were made by V35 (Dietary Manager) that indicated that the cook was in-serviced on making grits. There are no comments related to corrective action for the residents' wanting vegetables on their sandwiches and no further information was provided prior to the exit of the survey. Facility policy titled, FOOD PALATABILITY- HOT FOOD TEMPERATURES (2018) documents in part, POLICY: The healthcare community prepares and serves food and beverages that are palatable, attractive, and at safe and appetizing temperature .

Based on observation, interview and record review, the facility failed to procure sufficient amounts of food ingredients to properly follow the written menu and failed to have enough food items to follow written menu/serve every resident according to the written menu. This failure affected all 106 residents that consume meals from the facility's kitchen. Findings include: Facility census (2/11/2026) documents in part that 112 residents reside within the facility. Facility document titled RESIDENTS THAT ARE NPO (Nothing By Mouth) (2/2026) documents in part that 6 residents do not consume oral intake. This indicates that 106 residents consume food from the facility's kitchen. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact.On 2/13/2026 at 1:00 PM, R4 explained, The food here is terrible, barely edible. I am afraid to eat the entree a lot of the times because it gives me (diarrhea). So, I ask for substitutes, which of course they run out of. When that happens, I pretty much just don't eat. They are always running out of food, substitute or the actual meal. On 2/13/2025 at 3:10 PM, V24 (Certified Nursing Assistant) affirmed V24 heard residents complaining about the taste of the food. V24 stated, They (residents) often complain about the food, it's about every day. There have been times where they didn't have enough of the main meal, so residents had to be served a sandwich or another substituteOn 2/13/2025 at 3:22 PM, V5 (Licensed Practical Nurse) affirmed V5 has had residents complain about the food. V5 stated, They (residents) will say they don't like it (the food) or it doesn't taste good. Or they order a certain meal, and they don't get what they ordered. I have seen times where they (staff) have run out of the entree or the substitute, and they (residents) had to be served something else. On 2/14/2026 at 12:21 PM, observed V29 (Cook) taking food temperatures of the prepared lunch entrees and sides within the kitchen. V29 stated, The recipe for the stuffed peppers called for ground turkey, but we didn't have any of that. I don't think we ordered it. So. I called my manager and we used ground beef to make it instead. When discussing the preparation for the mechanically altered foods, V29 stated, The menu today calls for creamed corn for mechanically altered residents, but we didn't have any of that, so I made carrots. I do not know why there was no creamed corn to serve to the residents. Observed V29 cutting the cornbread to be served, approximately a 9-10-inch diameter of the top of the cornbread was burnt. V29 stated, I'm not going to use that. V29 denied that there was any more cornbread to be served and no more cornbread was going to be made in response to the burnt portion of cornbread. On 2/14/2026 at 1:10 PM, observed V29 placing plain pieces of wheat sandwich bread on each plate and omitting the corn bread. V29 stated, We ran out of cornbread. V38 (Dietary Aide) affirmed that at least 6 people were going to receive the plain sandwich bread in lieu of the cornbread on the menu. On 2/14/2026 at 1:49 PM, a test tray was provided to the survey team. The test tray consisted of corn, a plain piece of bread, and unidentifiable rice/meat mixture in a tomato-based sauce on a Styrofoam plate wrapped in plastic cling wrap. The cornbread, stuffed pepper, and spiced peach dessert was not provided. V29 stated, We ran out of the stuffed peppers, so that is the inside of the stuffed pepper. The mechanical soft. We ran out of cornbread and the spiced peach dessert. On 2/14/2026 at 1:57 PM, V1 (Administrator) affirmed that the facility should be following the written menu and should be procuring all needed ingredients so the menu can be followed. R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:16 AM, R8 made a gagging noise and motion like R8 was throwing up. That's what I think of the food: nasty. They do be running out of things on the menu, and then they just give you a salad. A salad ain't enough.On 2/17/2026 at 10:27 AM, V35 (Dietary Manager) explained, I was not aware that (V29) used different meat when preparing the stuffed peppers. I don't know why (V29) didn't use the correct meat according to the menu, we had the meat thawing. Same with the cornbread, there was more cornbread that (V29) could have made. I don't know what was going on that day (2/14/2026), everything (ingredients) was here. On 2/17/2026 at 11:45 AM, V37 (Registered Dietician) affirmed V37 is the consultant dietician for the facility and was not aware of any ingredient substitutions or menu changes for 2/14/2026. V37 denied V37 gave any approvals to change any parts of the menu on 2/14/2026. V37 explained that the facility should be procuring enough ingredients and making enough food so that all residents can be served from the menu with some leftovers for seconds, if needed. V37 stated that the facility should be following the recipes and menus that are approved. The facility's policy for food ordering/procurement was requested on 2/17/2025.On 2/17/2026 at 12:51 PM, V1 (Administrator) stated, There is no policy for food procurement/ordering.Facility policy titled, Menu Changes (2017) documents, Menu Items will be served as planned whenever possible. Due to unavoidable circumstances, temporary changes may be made to the menu. Procedure: Changes will be indicated on the posted menu prior to the meal service. The menu change will be noted in a file kept for that purpose. The reason for change will be noted. Changes will be of similar nutritional value. Permanent changes must be approved by the dietician.

Based on interview and record review, the facility failed to address any ethnic, cultural or religious factors that may potentially affect the care provided by the facility, including but not limited to, activities and food and nutrition services and failed to identify a staffing plan for nutritional support staff. These failures have the potential to affect all 112 residents that reside within the facility. Facility census (2/11/2026) documents in part that 112 residents reside within the facility. R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. On 2/13/2026 at 1:00 PM, R4 explained, The food here is terrible, barely edible. I am afraid to eat the entree a lot of the times because it gives me (diarrhea). One of the worst things about the food here is the lack of variety. Every single night we are served a sandwich of sorts. In my culture, you might not understand, but Sunday dinners are important to us. In the black community, we get together and have a nice Sunday dinner. Most of these residents is black, it's our culture. I usually get served a choke sandwich (dry, without condiments), piece of ham between two pieces of bread. That's it. That's not okay, dinner in general is always just sandwiches of some sort. It is so depressing. We deserve to have normal dinner items. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact.On 2/14/2026 at 11:37 AM, V29 (Cook) affirmed that the kitchen begins plating food at 12:00 PM and that lunch begins at 12:00 PM for the residents. V29 stated, I don't know if I would consider us (Dietary Department) short staffed. I know we are usually short on PM shift, I know we need help there.Review of facility working dietary staff schedules for 2/2026, documents in part that the facility usually staffs between 2-3 dietary aides between 6:00 AM - 8:00 PM with one cook working 6 AM-2 PM and a second cook working 12 PM-8 PM. On 2/1/2026, 2/3/2026, 2/13/2026, and 2/14/2026, there was only 1 dietary aide working the 4:00-8:00 PM shift. On 2/12/2026, only 1 dietary aide worked the 6:30 AM-2:30 PM shift. On 2/9/2026, only one cook worked from 12:00 PM-8:00 PM. R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:16 AM, R8 stated, The food is never served on time. Just a couple of nights ago, I was served dinner at 7:10. I was the last try to be given. I am supposed to eat at like 5 o'clock. I didn't want to wait that long. They don't have enough help in the kitchen or in nursingR3's Face Sheet documents in part the following diagnoses: hemiplegia affective left non-dominant side, bilateral cataracts, hypertension, type 2 diabetes mellitus, and depression. R3's Minimum Data Set (11/25/2025) documents in part a BIMS summary score of 13, indicating R3 is cognitively intact.On 2/17/2026 at 10:20 AM, R3 stated, Everything is short staffed here. Most of the meals here are served late. On 2/17/2026 at 10:24 AM, V35 (Dietary Manager) stated, I have been here (employed by the facility) about 2 months. Honestly, I don't want to throw anyone under the bus, but I do think we need more staff in the kitchen. I have tried my best to eliminate tedious tasks, like for example, I buy individual cartons of thickened liquids, so we don't have to make the thickened liquids in bulk. I try my best to streamline the processes, cut out any extra stuff that isn't crucial, but we still could use more. We are currently trying to hire for a part-time cook and part-time dietary aide. I try to help where I can but there are a lot of tasks in the kitchen to do. I have seen times where we have been late on serving meals. On 2/18/2026 at 9:53 AM, V1 stated, the purpose of the facility assessment is that it is a living, breathing tool, that identifies resources needed in order to care for the residents and in cases of emergency. The facility assessment was reviewed with V1 (Administrator). When asked if the facility assessment identifies ethnic, cultural or religious factors, V1 replied, we (staff) ask about that stuff in resident council and the residents get to choose a meal of the month. I can adjust that. When asked if the facility assessment identifies the dietary department staffing needs, V1 replied, It says the dietary manager, we don't have to list cooks or dietary aides. That's not a requirement. We follow the federal regulation, which is if you have enough staff to create the food and serve the food then you are meeting the needs of the facility. Facility assessment dated (2/12/2026) documents in part, . Ethnic, cultural, or religious factors Describe ethnic, cultural, or religious factors or personal resident preferences that may potentially affect the care provided to residents by your facility. Examples may include activities, food and nutrition services, languages, clothing preferences, access to religious services, or religious-based advanced directives.Residents and/or resident representative will be interviewed to determine preferences with regards to daily schedules, waking/bedtime, special food preferences or restrictions, religious/spiritual needs, special communication needs, language barriers, etc. to meet the needs of the residentList any specific or unique Ethnic/ Cultural/ Religious factors affecting care provided, if any:Activity to discuss in resident council meetingPrairie Oasis has a population with an average age of 74 that should be considered when providing services .Staffing plan Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time .Other (department heads, quality assurance nurse, ancillary staff in maintenance, housekeeping, dietary, laundry, etc.) Customize to the staffing of your facility: 1 Director of Nursing 1 Assistant Director of Nursing MDS/Careplan Coordinators 1 Restorative Nurse 1 Treatment Nurse 1 Infectious Disease Nurse 1 Maintenance/Housekeeping Director 1 Dietary Director 1 Activity Director 1 Scheduler/Medical records 1 Social Service Director 1 PRSC 1 Admissions Director/Marketer 1 Assistant Administrator. The requisite number of cooks and dietary aides is not identified within the facility assessment. No ethnic, cultural or religious needs were identified within the facility assessment. Facility Assessment Tool Instructions (Undated) document in part, Requirement Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (S483.70(e)). Purpose The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Overview of the assessment tool The tool is organized in three parts:Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact careServices and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment)Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment .

Based on interview and record review, the facility failed to provide incontinence care for residents that were dependent on staff for incontinence care. This failure affected four (R1 R3 R4 and R5) of four residents reviewed for incontinence care. Findings include: R1's Face Sheet documents in part the following diagnoses: Alzheimer's disease, severe dementia with other behavioral disturbance, unspecified protein-calorie malnutrition, hypomyelination with atrophy of the basal ganglia and cerebellum, chronic kidney disease unspecified, adult failure to thrive, restlessness and agitation, cachexia, and unspecified convulsions. R1 Minimum Data Set (11/12/2025) documents in part that R1 dependent on staff for toileting assistance and is always incontinent of bowel and bladder.R1's care plan (revised 11/12/2025) documents in part that R1 has an activity of daily living (ADL) self-care deficit due to confusion, dementia, impaired balance and limited mobility, and indicates that R1 is totally dependent on staff for toileting. R1's POC (Point of Care) Response History (2/17/2025) report does not document that R1 received assistance with toileting on the following dates: 1/20/2026 (11 PM-7 AM Shift), 1/24/2026 (3 PM-11 PM Shift), 1/25/2026 (11PM -7 AM Shift), 1/29/2026 (3PM -11 PM Shift, 11PM -7 AM Shift), 1/31/2026 (7AM -3 PM Shift), 2/1/2026 (11PM -7 AM Shift), 2/2/2026 (11PM -7 AM Shift). R3's Face Sheet documents in part the following diagnoses: hemiplegia affective left non-dominant side, bilateral cataracts, hypertension, type 2 diabetes mellitus, and depression. On 2/17/2026 at 10:21 AM, R3 stated, They don't have enough aides. I have to wait a long time to get help and sometimes don't get the help. They don't provide me with incontinence care, it's still a problem. Everything is short staffed here. R3's Minimum Data Set (11/25/2025) documents in part a BIMS summary score of 13, indicating R3 is cognitively intact and R4 is dependent on staff for toileting assistance and is frequently incontinent of bowel and bladder. R3's POC (Point of Care) Response History (2/17/2025) report does not document that R3 received assistance with toileting on the following dates: 1/19/2026 (3 PM-11 PM Shift), 1/20/2026 (3-11 PM Shift), 1/22/2026 (11 PM -7 AM Shift), 1/26/2026 (11 PM-7 AM Shift), 1/31/2026 (11 PM-7 AM Shift), 2/1/2026 (3 PM-11 Shift), 2/4/2026 (3 PM-11 Shift), 2/5/2026 (11 PM-7 AM Shift), 2/13/2026 (7 AM-3 PM Shift, 11 PM-7 AM Shift), 2/15/2026 (7 AM-3 PM Shift). R4's Face Sheet documents in part the following diagnoses: rhabdomyolysis, fusion of spine (lumbar region), inflammatory spondylopathy lumbar region, type 2 diabetes mellitus with diabetic neuropathy, unspecified protein calorie malnutrition, neuromuscular dysfunction of the bladder, obesity, chronic obstructive pulmonary disease, and major depressive disorder without psychotic features. R4's Minimum Data Set (12/16/2025) document in part a brief interview of mental status (BIMS) summary score of 15, indicating R4 is cognitively intact. Additionally, R4's minimum data set documents that R4 is dependent on staff for toileting assistance and frequently is incontinent of bowel and bladder. On 2/13/2026 at 1:00 PM, R4 explained, Yes, the facility doesn't have enough staff. It takes forever for someone to help you sometimes like 3-4 hours. Back in October, I was left hanging on a Hoyer for over 3 hours in my own feces. I get left in my own urine and feces for hours like an animal. I'm not an animal; I don't deserve to be treated like that. I've told the administration of this facility about my problems and nothing changes, that's the problem. Yes, I am incontinent even right now and have been sitting in my urine for hours. No, I don't want them to change me, it's during lunch time, no one will come.R4's POC (Point of Care) Response History (2/17/2025) report does not document that R4 received assistance with toileting on the following dates: 1/19/2026 (11 PM-7 AM Shift), 1/21/2026 (3 PM-11 PM Shift, 11 PM-7 AM Shift), 1/24/2026 (11-7 AM Shift), 1/25/2026 (11 PM-7 AM Shift), 1/26/2026 (7 AM-3 Shift), 1/27/2026 (11 PM-7 AM Shift), 1/31/2026 (11 PM-7 AM Shift), 2/1/2026 (11 PM-7 AM Shift), 2/2/2026 (11 PM-7 AM Shift), 2/3/2026 (11 PM-7 AM Shift), 2/6/2026 (11 PM -7 AM Shift), 2/7/2026 (3 PM-11 PM Shift, 11PM -7 PM Shift), 2/8/2026 (3 PM-11 PM Shift, 11 PM-7 AM Shift), 2/9/2026 (11 PM-7 AM Shift), 2/10/2026 (7AM -3 PM Shift), 2/11/2026 (11PM -7 AM Shift), 2/12/2026 (7 AM-3 PM Shift), 2/15/2026 (7 AM -3 PM Shift). R5's face sheet documents in part the following diagnoses: unspecified dementia, severe with other behavioral disturbance, traumatic subdural hemorrhage with loss of consciousness, age related osteoporosis, altered mental status, unspecified fall, lymphedema, moderate protein calorie malnutrition, muscle wasting and atrophy, and vertigo. R5's Minimum Data Set (1/5/2026) documents in part that that R5 has a brief interview of mental status (BIMS) summary score of 5 indicating that R5 is cognitively impaired. Additionally, the MDS documents that R5 is dependent on staff for toileting and is frequently incontinent of bowel and bladder. R5's POC (Point of Care) Response History (2/17/2026) report does not document that R5 received assistance with toileting on the following dates: 1/22/2026 (11 PM-7 AM Shift), 1/23/2026 (3 PM-11 PM Shift), 1/25/2026 (3 PM-11 PM Shift, 11-7 AM Shift), 1/26/2025 (11 PM -7 AM Shift), 1/28/2026 (3 PM-11 PM Shift), 1/29/2026 (3 PM-11 PM Shift), 1/30/2026 (3 PM-11 PM Shift), 1/31/2026 (11 PM-7 AM Shift), 2/3/2026 (3 PM-11 PM Shift, 11 PM -7 AM Shift), 2/6/2026 (3 PM-11 PM Shift, 11-7 AM Shift), 2/8/2026 (11 PM-7 AM Shift), 2/11/2026 (11 PM-7 AM Shift), 2/13/2026 (3 PM-11 PM Shift), 2/15/2026 (7 AM-3 PM Shift, 3 PM -11 PM Shift). R8's Face Sheet documents in part the following diagnoses: trigeminal neuralgia, type 2 diabetes without complications, hypertension, and osteoarthritis. On 2/17/2025 at 10:16 AM, R8 stated R8's roommates (including R3) need incontinence care, and it is not regularly provided by staff. R8 stated, My roommates (R3) have to wait forever to get help from staff.R8's Minimum Data Set (12/24/2025) documents in part a BIMS summary score of 13, indicating R8 is cognitively intact. On 2/17/2026 at 10:35 AM, V34 (Restorative Nurse, Licensed Practical Nurse) affirmed that V34 is responsible for monitoring the resident's ADL status and ADL charting in the facility. V34 stated that the CNAs are expected to chart once per shift to document the highest level of care provided during that shift. V34 affirmed that R1, R3, R4, and R5 are dependent on staff for toileting. V34 reviewed R1, R3, R4 and R5's POC charting completed by the nursing assistants and confirmed that all residents were missing many shifts of ADL charting. V34 stated, this is the [NAME] of my existence, trying to get them to complete the charting. We were doing so well after we were cited (in December 2025) at ADL charting. I went on leave for a bit and the care plan coordinator was supposed to be monitoring all of this (the ADL charting). I don't know what happened, but they (care plan coordinator) no longer work for the facility. It's just so frustrating because, you know the golden rule of nursing: if it's not charted, it's not completed. No further documentation that indicates R1, R3, R4, or R5 was provided assistance with toileting/incontinence care prior to the exit of the survey. On 2/18/2026 at 10:05 AM, V2 (Director of Nursing) affirmed that staff are required to document the level of assistance provided with ADLs every shift. Facility policy titled INCONTINENCY CARE (9/2014) documents in part, Incontinent resident will be checked periodically every two hours and provided perineal and genital care after each episode . Perineal, genital and catheter care will be performed at least daily or more often as necessary during routine CNA care.Facility policy titled, ACTIVITIES OF DAILY LIVING (ADLS) (4/2014) documents in part, Purpose To preserve ADL function, promote independence, and increase self-esteem and dignity.

Based on interview and record review, the facility failed to ensure timely assessment and implementation of preventative measures to prevent the development of a pressure ulcer for one (R1) of three residents reviewed for pressure ulcers. This failure resulted in R1 developing a facility-acquired Stage 3 pressure ulcer to the coccyx.Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] to 11/13/25 with diagnoses including but not limited to: atrial fibrillation, seizure, hypertension, cerebrovascular accident, obesity, depression, cognitive and communication deficit, dementia, cerebral amyloid angiopathy, anxiety, history of encephalopathy, and coronary artery disease. R1's (MDS) Minimal Data Set assessment of 10/13/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 03/15 (severely impaired cognition). MDS of 10/13/2025, GG section R1 is dependent on self-care- Helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. R1 is dependent on mobility assistance and requires roll left and right, sit to lying tub/shower transfer: The ability to get in and out of a tub/shower. R1 requires helper does all of the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 2/7/2025 at 1:45 PM, V4 (Wound Care Nurse) said, (R1) had no wound impairment on admission and stage 2 on the coccyx area was noted on 10/31/2025. We have shower sheets and skin alteration sheets for the nursing assistants to fill out when they observe any skin impairment. The floor nurse will notify the physician and obtain orders if I am not in the building. I will add the resident to the wound physician for the weekly rounds and do the treatment for the residents when I am in the building. The nurses are expected to do treatment if I am not in the building. The surveyor requested shower sheets, skin impairment sheets, and nursing routine skin assessment but V4 said, the facility does not keep shower sheets or skin impairment sheets past a month per facility policy. V4 said, I assessed (R1) on 10/31/2025, called the physician, and added the air mattress, dietary supplements, and added (R1) to the list of the wound physician rounds. R1's physician's order dated 10/03/2025 reads in part, Skin assessment weekly on shower or bath day. Per record review: 10/3/25: admission, intact skin10/3-10/31: no documented weekly assessments10/31/25: Stage 2 identified11/11/25: Stage 3 documentedRecord review of 11/11/2025 V5 (Wound Care Physician) progress notes noted a stage 3 pressure ulcer to the sacrum measuring 4 x 5.5 x 0.1 cm with light sero-sanguinous drainage and fair healing potential and estimated time to heal 4 - 6 Months. On 2/7/2026 at 3:53 PM, V2 (Director of Nursing) said, nurses are expected to complete the skin assessment, check the shower skin assessment, and any skin impairment to be assessed, call the physician, and obtain orders. V2 stated, We have a wound care nurse who will complete the assessment and treatment. I cannot put a timeframe on when a wound will develop and turn into stage 2. I expected the nurses to turn, reposition, and keep residents dry and clean, and monitor the skin. Also, we take into consideration nutrition and keep residents hydrated. The surveyor requested skin assessments, shower sheets, and only received the skin assessment from admission on [DATE] and 10/31/2025, when R1 already had a stage 2 pressure ulcer to the coccyx area. V2 said the facility does not keep records of showers past the current month or the entire last month. V2 and V3 (Director of Clinical Service) both reviewed records for routine skin assessment under the electronic medical records with the surveyor, but none were found. V3 said skin assessments are expected to be added under the MAR (Medication Administration Records) for the nurses to complete. When questioned about how frequently V3 said per standard of care, on admission, and weekly for 4 weeks. During the records review with V2 and V3 of the MAR, no skin assessments were found as per the physician's order. Care plan and interventions updated on 10/31/2025 reads, skin will be checked during routine care on a daily basis, and during the weekly and biweekly bath or shower schedule. No additional assessments were provided by the facility at the time of this survey. In the absence of documentation, the facility failed to demonstrate that required skin assessments were completed or that the pressure ulcer was unavoidable in accordance with professional standards of practice and facility policy. On 2/7/2026 at 4:47 PM, V1(Administrator) provided the facility policy titled Pressure Injury and Skin Condition Assessment Policy dated 9/2016, reads:Purpose:To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure ulcers, assuring interventions are implemented.Standards:2-Residents identified by the Braden scale of being at high risk of skin breakdown will have a weekly skin assessment x4 by a licensed nurse.4-Each resident will be observed for skin breakdown daily during care on assigned bath day by the CNA (Certified Nursing Assistant). Changes shall be promptly reported to the charge nurse, who will perform the initial assessment.Wound Care Skin Inspection TableBath twice weekly or as necessary. Avoid hot water; use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleaning process, care should be taken to minimize the force and friction applied to the skin.Documentation of weekly head-to-toe assessment by the licensed nurse in the resident's chart or on the facility-approved form.Daily head-to-toe skin assessment by caregivers.

Based on interview and record review, the facility failed to maintain complete and accurate clinical records by not retaining skin assessment and skin monitoring documentation necessary to demonstrate compliance with physician orders as part of the resident's medical record. This failure applied to one (R1) of three residents reviewed for medical records. Findings include: R1 was admitted to the facility on [DATE]. A physician's order dated 10/03/2025 required weekly skin assessments on shower or bath day.Facility policy titled Pressure Injury and Skin Condition Assessment Policy dated 9/2016 required:Weekly head-to-toe skin assessments by a licensed nurse for residents at high risk;Daily observation for skin breakdown by certified nursing assistants;Documentation of skin assessments in the resident's medical record or on facility-approved forms.On 2/7/2026 at 1:45 PM, V4 (Wound Care Nurse) stated the facility utilized shower sheets and skin alteration sheets completed by nursing assistants to document skin observations. When requested to provide these records for R1, V4 stated the facility does not retain shower sheets or skin alteration sheets beyond one month per facility policy.On 2/7/2026 at 3:53 PM, V2 (Director of Nursing) confirmed the facility does not keep shower or skin assessment documentation beyond the current or previous month. V2 stated nurses are expected to complete skin assessments and monitor skin condition; however, when requested, the facility was only able to produce skin assessments dated 10/03/2025 (admission) and 10/31/2025 (after skin breakdown was identified).During record review conducted with V2 (Director of Nursing) and V3 (Director of Clinical Services), the surveyor was unable to locate documentation of routine weekly or daily skin assessments in the electronic medical record. V3 stated skin assessments were expected to be documented on the Medication Administration Record (MAR); however, review of the MAR revealed no documented skin assessments as required by physician order or facility policy.As a result, the facility failed to maintain complete, accurate, and retrievable clinical records necessary to demonstrate that required skin assessments and monitoring were performed. The facility's failure to retain clinical documentation prevented verification of compliance with physician orders, facility policy, and professional standards of practice.

Based on observation, interview and record review, the facility failed to prevent staff to resident physical abuse and neglect. These failures resulted in R1 sustaining a fractured left humerus and R3 sustaining moisture associated skin damage/skin breakdown. These failures affected two (R1 and R3) of six residents reviewed for abuse/neglect. Findings include:1) R3's face sheet documents, R3 is an [AGE] year-old resident and has diagnoses including, but not limited to: cirrhosis of the liver, unspecified supracondylar fracture of the left humerus, dementia without behavioral disturbance, unspecified protein calorie malnutrition, other disorders of bone density and structure, functional quadriplegia and metabolic encephalopathy. R3's minimum data set (MDS) dated [DATE], documents, R3 has a brief interview of mental status (BIMS) summary score of 3, indicating R3 has severe cognitive impairment. Additionally, the MDS documents indicates R3 requires assistance from staff with activities of daily living (ADLs), that R3's height is 65 inches and weighs 163 pounds. R3's care plan (6/19/2024) documents R3 is at risk of abuse/neglect and that symptoms of abuse may be manifested by verbal expressions of distress, generalized mood distress, and observable signs of distress. R1's MDS dated [DATE], documents R1 has a BIMS summary score of 13, indicating that R1 is cognitively intact. R2's MDS dated [DATE], documents R2 has a BIMS summary score of 15, indicating that R2 is cognitively intact. On 12/13/2025 at 10:27 AM, R1 stated, I have had issues with (V5, Certified Nursing Assistant) in that past. (V5) is very rude when (V5) is caring for people. She's lied on me saying I hit her, I never done anything like that. I wasn't in the room when it (the incident) happened, but I heard that (R3's) arm broke. On 12/13/2025 at 10:37 AM, R2 explained, About 4 or 5 days ago, I was sitting here in the room and V5 (Certified Nursing Assistant) was being really rough with (R3). (V5) was bossing her around, pulling on her by her clothes. (R3) doesn't talk much but (V5) was getting real smart, mouthy with her. I couldn't see exactly what happened because V5 was standing in-between me and (R3), but I heard a loud bang, and I think (R3)'s arm hit the side rail. (R3) cried out and screamed, B***h you broke my arm!. (R3) was screaming in pain after the incident. I told a nurse what happened, I can't remember exactly which one. (R3) is in a cast now. I don't recall (R3) having any recent falls. (V5) was acting real weird after the incident and kept asking me if I needed anything, which is not like her. She is normally very rude.On 12/13/2025 at 10:56 AM, R3 was observed sitting in a wheelchair with a splint/sling to R3's left arm. R3 stated, I don't know what happened, my arm, my arm broke. It hurts real bad. My arm hurts real bad. R3 was observed having difficulty answering questioning due to severe cognitive deficits. On 12/13/2025 at 11:37 AM, V5 (Certified Nursing Assistant) was unsure the cause of R3's fracture, denied witnessing any staff physically abuse any resident and denied hitting/handling R3 roughly. V5 stated, I don't yell at them (residents), but I am firm. I have boundaries, like when (R1) hit me in the head during the summer, I was real mad. I was so heated. I left the room and told social services, but I didn't hit her back. I didn't handle (R3) roughly, look at (R3's) size. I am small. Their weight versus mine. What could I do to (R3)? I couldn't hurt her. (R3) likes to put herself on the ground and is wiggly.Review of V5's healthcare worker background check form (3/16/2020) documents that V5 is 5 foot tall and weighs 134 pounds. On 12/13/2025 at 12:51 AM, V7 (R1's Family Member) recalled when visiting a few days prior, R2 had told V7 that V5 had hit R3's arm. V7 denied ever witnessing V5 hit another resident, but recalled during the summer one time, I recall (R1) telling me that (V5) got mad, raised her and raised her arm up like (V5) was going to hit (R1). (R1) said V5 called her a b***h. I am not sure if (V5) ever hit her. I have not personally seen (V5) hit any residents, but I know she refuses to care for (R1). On 12/13/2025 at 3:45 PM, V1 (Administrator) affirmed V1 is aware of R3's fracture and that the facility does not know how R3 got the fracture. V1 explained, (R3) wasn't able to say what happened, (R3) just kept saying 'woo'. (R2) had mentioned there was an issue between (R3) and (V5), but when I was asking what happened, (R2) stated that they were arguing and did not see anything else. (R2) stated she did not see her hit (R3). When I looked up the type of fracture, it said it was commonly from a fall. I was not aware of any allegation that (V5) hit (R3) or handled (R3) roughly until today but (V5) was suspended this morning pending the investigation. V1 affirmed that there was an active investigation into the fracture by V2 (Director of Nursing). On 12/15/2025 at 10:22 AM, V9 (Wound Care Nurse, Licensed Practical Nurse) denied knowing how R3 sustained the fracture. V9 stated V9 has not seen V5 ever abuse any residents but V5 is firm. V9 explained, Firm meaning like if a resident is able to do something, (V5) is not going to do that for them. Like she will tell them, no you need to wash your own private area or chest if they can.On 12/15/2025 at 11:00 AM, V10 (Certified Nursing Assistant) denied knowing how R3 sustained the fracture. V10 explained, I work part time. I was off for a bit but then when I came back, I saw (R3) was in the splint. Though, you really should talk to (R2). (R2) is sharp, writes things down. If something happened, (R2) would know. I would trust what (R2) says.On 12/15/2025 at 11:39 AM, V11 (Certified Nursing Assistant) recalled an incident occurring in the afternoon of 12/9/2025. V11 explained, I was at the nurse's station speaking with (V15, Dialysis Registered Nurse). I heard almost a crying sound; it got louder and louder and we went towards the noise. V4 (Social Services Director) heard too and came out of (V4's) office. It was coming from (R3's) room, it was (R3). (R3) was in bed and (V5) was standing at the foot of the bed, it looked like (V5) was performing care in the room. I saw (R3) in bed and not the floor, so I wasn't really concerned. I thought (R3) was crying from a fall. I didn't ask (R3) what was wrong, I left at that point. I can't say how it (R3's fracture) happened. I know there were issues with (R1) and (V5) in the past, but I don't know what it is. I think they had an argument or something. I try to keep everything together and make the work environment positive. I remember them hugging it out later on, I thought they were cool (with each other). I have not witnessed (V5) abuse any residents and I am not sure if (R2) was in the room at the time of the incident. I left pretty quick.On 12/15/2025 at 12:15 PM, V4 (Social Services Director) explained, Last Tuesday (12/9/2025) I was getting ready to leave around 4:15 PM. I heard noises from my office. Loud yelling, louder than normal. Loud enough for me to have concerns. I went out of my office; my office is a couple doors down from (R3's) room. V11 and V15 were also going to the room. I was in the doorway and saw (R3) lying in bed and it looked like (R3) was getting changed. (R3) was holding her left arm, the one that is broken. I asked (R3) what happened and (R3) told me (R3's) arm hurts. So, I told V16 (Licensed Practical Nurse). I don't really remember if there were other residents in the room at the time. (R2) told me on Thursday (12/11/2025) that she saw (V5) hurt (R3). I brought (R3) to (V2 Director of Nursing) and (V1 Administrator) was there. The story changed when (R2) was talking to (V1) and (V2) and (R2) stated that (R2) heard a loud bang and thought R1's arm hit the bed and that R2 couldn't see what happened because (V5) was standing in between. I would say that is an allegation of physical abuse. (R2's) cognition is intact, I would believe an interview from (R2). (R3's) cognition is in and out, some days (R3) can tell me things, other days (R3) can't. A fracture can be a sign of physical abuse.On 12/15/2025 at 12:31 PM, V1 (Administrator) affirmed that V1 is the abuse prevention coordinator, and that physical abuse includes hitting a resident or handling a resident roughly. V1 explained, (V4) came and got us (V2) and (R2) told us (R2) was in the doorway and witnessed (R3) screaming out and (V5) was in the room. (R2) said it was louder than normal. I asked what was going on and (R2) stated, I don't know I couldn't see. (V5) back was turned. (V4) told me that (R2) was in the DON office and wanted to talk to you. V4 never said anything about abuse between (R2) and (V5), I never received any allegation of abuse. On 12/15/2025 at 1:46 PM, V12 (Licensed Practical Nurse) recalled, On Thursday Morning (12/11/2025), I was assigned to care for (R3). A staff member, I can't remember who, told me something was wrong with (R3's) arm, (R3's) screaming. I went to the room, and it was pretty bad, swollen and (R3) was guarding the arm. V13 (Nurse Practitioner) was here, assessed R3, and gave orders for an X-ray and pain medication. Around 12:30 or 1 PM, I showed (V2) (R3's) arm and (V2) instructed me to send (R3) to the hospital. When I asked (R3) what happened, (R3) stated, That woman did this to me, that woman did this to my arm. I reported this to (V2). There was no fall, (V5) never said there was any fall. I was told on Thursday (12/11/2025) by (V11 Certified Nursing Assistant) that V5 was working a double on (12/9/2025) and (V11) gave me this look. I don't remember her exact words but (V11) told me that (V11) and (V15) were talking at the nurse's station and (V11) heard (R3) scream, This b***h broke my arm!. (V11) had concerns (V5) was being rough with (R3). On that same day, (R2) told me that (V5) was being rough with (R3), that (V5) snatched (R3's) arm and went bam bam bam hitting it on the rail of the bed. I told (V2) about it because I was shocked and (V2) was the closest staff that was there. I did not tell V1, I should have. I was very concerned after hearing (V11) tell me about (R3's) yelling and saying and then (R3) telling me a woman broke (R3's) arm, I was very concerned with physical abuse. I would think this fracture could be a sign (R3) was physically abused. I have not witnessed (V5) abuse any residents but (V5) has no patience for the residents. No fall caused this injury. (V1) called me in and asked if (R3) had fell and I told (V1) not to my knowledge. They (V1 and V2) are trying to put this on me that this was caused potentially by a fall-- it was not a fall. I told them it wasn't the fall. I told them my concerns, and they are going to pin this on me that I didn't chart a fall. No fall caused that fracture. Record review of corrective action given to V12 on (12/16/2025) documents that during an investigation for injury of unknown origin, V12 did not report, document, or inform the nurse manager of a fall by (R3) and, after 2 different witness statements given during the investigation then said the resident had a fall. On 12/15/2025 at 2:51 PM, V2 (Director of Nursing) recalled on 12/11/2025, I did go back and look at R3's arm. I didn't lift it because she was complaining of pain. It was more swollen more than normal. (V6) was in and had ordered pain meds and an Xray. She was in so much pain, so we sent her out. I asked (R3) what happened she didn't say anything about a fall. (R3) stated, She turned me too hard. (R3) couldn't say who did it. Her doctor had concerns about bone density. I don't know how (the fracture) happened. Yes, I remember being in the office with (R2) and (V1). I was working on many items and was in and out of the conversation. I heard (R2) say something about the CNA hurting (R3's) arm. (R2) said it was (V5). (R2) then said in the conversation (R2) heard a loud noise but didn't see what (V5) did. I did not report abuse to (V1), (V1) was there for that conversation.On 12/15/2025 at 3:41 PM, V13 (Nurse Practitioner) explained, I am (R3's) provider. I recall (on 12/11/2025) being notified by the nurse that her left upper extremity was swollen and painful. I went in and assessed her. It was swollen, it didn't look deformed though, it was tender to the touch. (R3) had very limited range of motion due to pain. (R3's) nurse at the time was unaware of any recent trauma or falls at that time. (R3) was alert times 1 (to self), (R3) could not report what happened to (R3's) arm. (R3) was sent to the hospital and diagnosed with a subcapital left humeral fracture. I was not told that there was any suspicion of abuse. I am not ortho, but that (a subcapital fracture) can be caused by trauma, it depends on how hard someone is hit against something. If (R3) was screaming, that isn't (R3's) baseline. It would make sense if it (the fracture) was related to trauma. It doesn't take a lot for an older adult to have a fracture. I did tell the facility they needed to investigate what happened, these fractures don't happen for no reason.On 12/17/2025 at 9:57 AM, V15 (Dialysis Registered Nurse) affirmed that V15 provides dialysis to the residents and is not an employee of the facility. V15 recalled, I was talking to another staff member, I can't remember who, when I was doing my rounds, and I heard someone scream. At least 2-3 times. I thought maybe someone had fallen. Once I had went there with the facility staff, I saw a CNA in the room with the resident standing by the resident who was lying in bed. It was not one of my dialysis residents, so I don't know the resident's name. The staff were talking to her, so I left. I heard an ahh sound, it sounded like the resident was in pain.During this survey, multiple attempts were made to contact V16 (Licensed Practical Nurse) during the survey but V16 was unable to be reached. Record review of facility final investigation (12/16/2025) completed by V2 (Director of Nursing) indicates that the facility believed the injury of unknown origin was caused by a fall that wasn't reported. V12 was terminated for not reporting the fall incident and V5 was terminated for discourteous behavior. Record review of facility witnesses' statements gathered to make the investigative outcome determine do not indicate evidence of a fall. V5's statement (perpetrator of abuse) states that V5 was told by V20 that R3 and fell and got R3 back into bed. Then before lunch, V5 observed R3 on the ground and the nurse (V12, Licensed Practical Nurse) assisted V5 in getting R3 back to bed. Then on second shift R3 was complaining of pain so V5 told V16 (Licensed Practical Nurse) about the pain. Interview statements from V12, V20, and V16 do not corroborate V5's statement and do not indicate that there was any observed fall, R3 on the ground, pain, or fall related injury. One witness statement submitted with no discernable staff/resident name, time, states, On 12/13/2025 (after the survey had begun), I was told by a (unknown) staff member that (they) were told (R3) had a fall earlier in the week. I am not aware of what day/time of the fall. Witness statements obtained by R2 do corroborate allegations of physical abuse. R2's witness statement(s) indicates that R2 saw V5 be rough with R3 and a loud bang was heard while V5 was providing care. These statements corroborate V4 (Social Services Director), V11 (Certified Nursing Assistant) and V15 (Dialysis Nurse, Registered Nurse) witness a loud noise and yelling while a CNA was in the room on 12/9/2025. There is no other evidence within the witness statements that indicate R3 had any fall. Review of R3's progress notes indicate that on 12/11/2025 at 10:10 AM, documents, CNA notified writer of resident complaint of pain at Lt arm. Upon arrival to resident's room, resident in lying in bed alert and oriented x 2. During assessment resident's Lt arm is swollen, painful to touch, and resident is yelling out in when she attempts to move Lt arm. No other apparent abnormalities noted. Writer gently placed Lt arm on pillow. T 98.1 P 65 R 20 BP 100/66 02 sat 95% RA. (V6) to be notified for pain medication orders. At 10:15 AM, R3 was seen by V13 (Nurse Practitioner) at the bedside. At 1:36 PM, R3 was sent to the hospital for evaluation and returned at 10:16 PM with a diagnosis of a closed supracondylar fracture of left humerus. There is no indication of a fall or any potential indicators of a fall or change of plane (e.g. R3 observed on the ground) within R3's progress notes reviewed since 10/1/2025-12/18/2025. Record review of R3's hospital records (12/11/2025) document, .presents emergency department today for arm pain. Per daughters at bedside, patient may have injured her elbow 2 days ago at the nursing home. They are unsure if somebody pulled out or if she hit her arm against something. Patient complains of pain to her left elbow. Denies any numbness or tingling. Limited history due to patient's history of dementia .XR HUMERUS 2 VIEWS LEFT (Final result) .FINDINGS/IMPRESSION: Advanced osseous demineralization. Interval closed reduction and splinting of a displaced transverse supracondylar fracture at the distal humerus. Persistent medial displacement of 2.5 cm and impaction up to 1.4 cm. Distal radius and ulna appear radiographically intact. Ulnotrochlear and radiocapitellar joints are in anatomic alignment. Mild associated osteoarthritis. Trace elbow effusion . XR ELBOW 3 VIEWS LEFT (Final result) . FINDINGS/IMPRESSION: Advanced osseous demineralization. Interval closed reduction and splinting of a displaced transverse supracondylar fracture at the distal humerus. Persistent medial displacement of 2.5 cm and impaction up to 1.4 cm. Distal radius and ulna appear radiographically intact. Ulnotrochlear and radiocapitellar joints are in anatomic alignment. Mild associated osteoarthritis. Trace elbow effusion .On 12/17/2025 at 10:30 AM, V18 (Physician) affirmed that V18 is the primary care physician for R3. V18 explained, I was at the facility and spoke with the facility/family after (R3) was in the hospital. We had a discussion for what possibly happened, I am not aware of a fall. There may be potential for some demineralization. I don't know what happened or how the fracture was caused. We call that type of fracture (R3) has an avulsion fracture. It is where the tendon gets ripped of the bone. I don't know if abuse is the cause, the fracture may be caused if it (the arm) was hit at a certain angle.On 12/17/2025 at 1:14 PM, witness statements for the allegation were reviewed with V2. V2 affirmed that the cause of the injury was a fall and that the only statement that mentioned a fall occurred was V5's statement (perpetrator of abuse). V2 stated that V12 told V2 there was a fall. V2 reviewed V12's witness statement and affirmed V12 statement does not include any documentation of a fall. V2 affirmed that V2 didn't get the other statement that (V12) made about the fall and surveyor observed V2 fabricate a statement. Surveyor requested any documentation that indicates R3's injury was caused by a fall or any evidence that a fall occurred. No documentation was provided that indicated R3 had a fall prior to the exit of the survey. Record review of the observed fabricated statement collected on 12/17/2025 (dated 12/18/2025) gives V2's statement that indicates, I was informed by administrator (V1) that (V12) informed (V1) that the resident (R3) did have a fall. (V12) was too busy and forgot to report the fall. (V12) said I'll take my hit for not reporting the fall.On 12/17/2025 at 2:04 PM, V19 (Medical Director) affirmed V19 is the medical director of the facility. V19 explained, Subcapital fractures, there is variability on how they are caused. In young people, it is nearly always caused by trauma. In the elderly, the majority of the time it is caused by trauma, but if the resident has osteopenia, a sudden movement or mobility change can cause that fracture. Suddenly twisting or putting a lot more pressure on an arm, or when an arm is stretched there is a potential. I believe it is roughly 10-12% of the time pathologically related. Physical abuse can cause fractures. I am aware of the incident; I was made aware by (V1 Administrator) and was told the statements were not corroborating enough. I heard there was another person, I am unsure if it was a roommate or staff, saw another staff member giving care but couldn't really see. If the resident fell, yes, that has to be documented. If this was caused by a fall or abuse, it would have been documented. Even if there was a fact (R3) was in pain, that would have to be documented and assessed when it happened. Even if (R3) was being combative at the time of the incident and there was a change in status, I would expect to see that (documentation). If the CNA actually abused (R3) with the fracture, it's hard to say. None of the actual statements really corroborated is my understanding. If (R3) was receiving care and then had pain, there should have been care provided right away. They (the facility staff) should have taken that more seriously. On 12/18/2025 at 2:19 PM, V20 (R3's Family Member) explained that on 12/9/2025 R3's roommates (R1, R2) left a voicemail on V20's sister's phone stating that a staff member was being rough with V3 and that R3 was in pain. V20's sister did not see the voicemail until 12/11/2025 when R3 was in the hospital. V20 recalled getting a call from the facility stating that R3 was being sent to the hospital for arm pain. V20 went to the hospital and R3's arm was in really bad shape. The emergency room doctor told me that this fracture is usually caused by someone pulling or twisting an arm too hard. V20 stated, (R3) can't speak for herself. (R3) couldn't defend herself against a staff member. If someone was rough with (R3), (R3) would probably start yelling or crying. Bottom line, (R3's) arm is broken and no one caught it till Thursday? How? There's a lot of incompetence up there at that facility.On 12/18/2025 at 2:46 PM, V19 (Certified Nursing Assistant) reviewed her witness statements and affirmed they were correct. V19 affirmed that R3 never had any fall. V19 recalled that V19 was the staff member that discovered R3's swollen arm. V19 stated, (R3's) elbow was swollen above the arm. When I asked what happened, (R3) was screaming, a female CNA broke my arm and that R3 wanted to go home. V19 explained, I went and immediately told (V12). (V12) came and I stepped out of the situation once (V12) took over. (V5) is very mean-spirited and verbally aggressive with the residents. It's very inappropriate. Like if someone needs help putting on their clothes, (V5) will help them, but the whole time (V5) will be like, Why can't you do that yourself? All nasty. V19 affirmed that V19 never picked R3 up off the ground, V12 was never told R3 fell, and that R3 has not had any falls. V19 denied R3 would be able to defend herself against physical abuse and that a fracture could be a sign of abuse. V19 affirmed that R2 does not make false allegations and would believe if (R2) made an allegation. During this survey, multiple attempts were made to contact V16 (Licensed Practical Nurse) for interview. V16 was unable to be reached for interview prior to the exit of the survey. Facility abuse policy (undated) documents , This policy affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .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 resulting in physical harm, pain or mental anguish . Physical abuse is the infliction of injury on a resident that occurs other than accidental means and that requires medical attention .2) R1's face sheet documents that R1 is a [AGE] year-old resident with a prior medical history including: hemiplegia affecting left side, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension. R1's MDS dated [DATE], documents R1 has a BIMS summary score of 13, indicating that R1 is cognitively intact. Additionally, the MDS indicates that R1 does not have any moisture associated skin damage at the time of the assessment. On 12/13/2025 at 10:27 AM, R1 affirmed that R1 is incontinent of bowel/bladder and explained, They (staff) never change me regularly. I have had open areas on my buttocks and thighs for about a week or two. I have told my daughter and the staff, I know my daughter has told the administration too about them not changing me. I am in a lot of pain on my butt, it's burning pain at like 7/10. Theres no dressing or treatment in place for my skin. R2's MDS dated [DATE], documents R2 has a BIMS summary score of 15, indicating that R2 is cognitively intact. On 12/13/2025 at 10:37 AM, R2 (R1's Roommate) affirmed that R1 regularly does not get incontinence care/changed by the facility staff and that R1 waits long periods of time to be changed by staff. On 12/13/2025 at 12:51 PM, V7 (R1's Family Member) explained, (R1) has not gotten a shower in a couple weeks maybe longer. I have to constantly remind them (staff) to give (R1) a shower, and they always blame other shifts. (R1) has breakdown on (R1's) bottom from sitting in urine and feces, the staff just blame the other shifts. (R1) keeps talking about being in pain and (R1's) butt burning. I came in a few days ago in the morning and (R1) was still in bed, soaked in urine. She is gotten up from the night shift, she should already be up and have had incontinence care provided by the time I get there. (V2, Director of Nursing) was made aware of these issues and (V2) apologized, I think this was Wednesday (12/10/2025) morning. It's constant incontinence care issues. It's becoming overwhelming to me that (R1) isn't receiving basic care. On 12/13/2025 at 1:16 PM, V2 (Director of Nursing) and V12 (Licensed Practical Nurse) denied knowledge of R1 having any skin impairment or breakdown. V2 recalled R1's family member coming to the facility and that the family member had concerns with incontinence care. V2 stated that V2 went with the family member and did observe R1 still in bed during day shift. V2 confirmed that R1 is a 3rd shift get up and should have been up by the time the family was in the facility. V2 reviewed the last 30 days of ADL charting within R1's electronic health record and affirmed that there are multiple shifts within the last 30 days where there is no documentation that R1 received incontinence care. V2 affirmed that if there is no documentation that the service was provided, then the care was not provided. Surveyor requested any additional documentation that confirms R1 received the needed care as identified within the care plan/MDS and no further evidence was provided prior to the exit of the survey. On 12/13/2025 at 2:12 PM, V2 stated, The staff just was in here, placed (R1) in bed and performed incontinence care. Observed R1 laying in left side-lying position with no pants or brief. V2 asked R1 to rate R1's current level of pain and R1 replied, 4/10, on my left side and butt. Observed V2 and V12 perform a skin check of R1's legs, peri-area and bottom. Observed V2 displace R1's buttocks and noted a large amount of feces covering the area between R1's buttocks. V2 (Director of Nursing) stated Oop (sic). Guess they didn't do it (peri-care) well, (the staff) left bowel movement. V12 observed and affirmed there was feces covering the area between R1's buttocks. Observed two 0.5x0.5x<0.1 cm open areas draining serosanguinous fluids on R1's left upper leg, near the buttocks with a red wound bed and intact edges. Measurements were confirmed with V2. When asked to describe the drainage coming from the open area, V2 replied, No, I think that's urine. R1 exclaimed and yelped in pain as the open areas were measured. V2 apologized. Surveyor asked V2 to continue to assess R1's skin. Observed one open area 0.2x0.5x<0.1 cm open area with a pink/red wound bed, intact edges and one open area 0.5x0.5x<0.1 cm open area with a pink/red wound bed and intact edges to R1's left buttock. Additionally, observed one 0.5x0.5x<0.1 cm open area with a pink/red wound bed with intact edges to R1's right gluteal fold. V2 educated R1 that R1 needed some cream on that (open areas). V2 placed the sheet over R1 and V2 and V12 left the room without providing R1 any peri-care after observing the feces between R1's buttocks. Record review of R1's toileting assistance provided 11/16/2025-12/15/2025 does not document that toileting assistance was provided on the following shifts: 11/17/2025 1st Shift; 11/21/2025 2nd shift; 11/22/2025 1st shift, 2nd shift; 11/29/2025 2nd Shift; 12/2/2025 1st shift; 12/5/2025 2nd shift; 12/10/2025 (into 12/11/2025) 3rd shift; 12/13/2025 2nd and 3rd shift (into 12/14/2025); 12/14/2025 1st, 2nd and 3rd shift. Record review of R1's shower sheets for 11/2025 through 12/2025 does not document that R1 had a shower between 11/30/2025 and 12/13/2025. This indicates that R1 did not have a shower for 13 days. Additionally, this indicates that R1 did not get showers as required until after the survey began and that the concerns within the grievance related to showers were not resolved. R1's care plan documents that R1 is totally dependent on staff for toilet use (3/17/2025), and instructs staff to: Toilet at regular intervals, such as following meals, as indicated (5/29/2024), Administer appropriate cleansing & peri-care after each incontinent episode 5/29/2024), Observe for signs of skin irritation &/or breakdown. Report irritation/breakdown to the physician. (5/29/2024), Evaluate side effects of prescribed medications to assess causes of incontinence. (5/29/2025). Additionally, the care plan identifies that the moisture associated skin damage was identified on 12/13/2025. R1's progress notes identify that R1 has a history of moisture associated skin damage and candidiasis and that it was healed on 10/21/2025. On 12/13/2025 at 14:53 PM, V9 documented, Resident noted with MASD to bilateral posterior thighs and buttocks continue nystatin cream as previously ordered, check and change and apply after incontinence episodes. Hydrocolloid applied to posterior thighs for MASD. On 12/15/2025 at 9:44 AM, V8 (Restorative Nurse, Licensed Practical Nurse) affirmed that staff are not required to document every episode of incontinence but are required to document the highest amount of care provided for the activity of daily living (ADL) that shift. If the resident has refused or if there is a reason that care was not provided, the nurse would complete a progress note. V8 stated, They (CNA's) are required to document every shift. V8 reviewed R1's incontinence care charting and confirmed that on multiple shifts that there is no documentation/evidence that R1 received incontinence care. V8 stated the standard of care is that incontinent residents are checked and changed if needed every 2 hours. V8 stated, If you are performing good peri-care, you wouldn't see any feces afterward. V8 stated, If incontinence care is not provided every 2 hours, skin breakdown can occur. Urine can eat away at the skin which causes burning. I was not that (R1) had any skin breakdown. V9, Wound Care Nurse, Licensed Practical Nurse monitors shower sheets and skin breakdown. Anytime there is moisture associated skin damage, (V9) is notified. On 12/15/2025 at 10:22 AM, V9 (Wound Care Nurse, Licensed Practical Nurse) affirmed that R1 had a history of moisture associated skin damage but we healed it out. V9 explained, (R1) had some when (R1) first admitted , (R1) is heavy wetting. (R1) was followed by the wound care doctor for moisture associated skin damage and we have been providing cream for a while. (R1) has a history of fungal yeast infections. We found the open areas yesterday. We have been creaming her for a while, (R1) should be getting cream every incontinence episode. You shouldn't see any feces after peri-care was completed. I went in after you (the surveyor) observed (R1), and the feces was still there when I completed a skin check. I found three open areas caused by moisture associated skin damage on (R1's) bottom. Surveyor informed V9 that there were five open areas discovered on R1's bottom and V9 replied, Oh, I didn't see those, I thought there was only three. V9 described R1's skin as wet, wrinkly and affirmed there was moisture present during ass[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide incontinence care and showers for one (R1) resident that was dependent on staff for ADL (activities of daily living) care. This failure affected one (R1) of six residents reviewed for ADL care. This failure resulted in R1 experiencing pain and development of moisture associated skin damage (open areas). R1's face sheet documents in part that R1 is a [AGE] year-old resident with a prior medical history including: hemiplegia affecting left side, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension. R1's MDS dated [DATE], documents R1 has a BIMS summary score of 13, indicating that R1 is cognitively intact. Additionally, the MDS indicates R1 did not have any moisture associated skin damage at the time of the assessment. On 12/13/2025 at 10:27 AM, R1 affirmed R1 is incontinent of bowel/bladder and explained, They (staff) never change me regularly. I have had open areas on my buttocks and thighs for about a week or two. I have told my daughter and the staff, I know my daughter has told the administration too about them not changing me. I am in a lot of pain on my butt, it's burning pain at like 7/10. Theres no dressing or treatment in place for my skin. R2's MDS dated [DATE], documents R2 has a BIMS summary score of 15, indicating that R2 is cognitively intact. On 12/13/2025 at 10:37 AM, R2 (R1's Roommate) affirmed R1 regularly does not get incontinence care/changed by the facility staff and that R1 waits long periods of time to be changed by staff. On 12/13/2025 at 12:51 PM, V7 (R1's Family Member) explained, (R1) has not gotten a shower in a couple weeks maybe longer. I have to constantly remind them (staff) to give (R1) a shower, and they always blame other shifts. (R1) has breakdown on (R1's) bottom from sitting in urine and feces, the staff just blame the other shifts. (R1) keeps talking about being in pain and (R1's) butt burning. I came in a few days ago in the morning and (R1) was still in bed, soaked in urine. She is gotten up from the night shift, she should already be up and have had incontinence care provided by the time I get there. V2, Director of Nursing was made aware of these issues and (V2) apologized, I think this was Wednesday (12/10/2025) morning. It's constant incontinence care issues. It's becoming overwhelming to me that (R1) isn't receiving basic care. On 12/13/2025 at 1:16 PM, V2, Director of Nursing and V12, Licensed Practical Nurse denied knowledge of R1 having any skin impairment or breakdown. V2 recalled R1's family member coming to the facility and that the family member had concerns with incontinence care. V2 stated, V2 went with the family member and did observe R1 still in bed during day shift. V2 confirmed that R1 is a 3rd shift get up and should have been up by the time the family was in the facility. V2 reviewed the last 30 days of ADL charting within R1's electronic health record and affirmed that there are multiple shifts within the last 30 days where there is no documentation that R1 received incontinence care. V2 affirmed that if there is no documentation that the service was provided, then the care was not provided. Surveyor requested any additional documentation that confirms R1 received the needed care as identified within the care plan/MDS and no further evidence was provided prior to the exit of the survey. On 12/13/2025 at 2:12 PM, V2 stated, The staff just was in here, placed (R1) in bed and performed incontinence care. Observed R1 laying in left side-lying position with no pants or brief. V2 asked R1 to rate R1's current level of pain and R1 replied, 4/10, on my left side and butt. Observed V2 and V12 perform a skin check of R1's legs, peri-area and bottom. Observed V2 displace R1's buttocks and noted a large amount of feces covering the area between R1's buttocks. V2 (Director of Nursing) stated Oop. Guess they didn't do it (peri-care) well, (the staff) left bowel movement. V12 observed and affirmed there was feces covering the area between R1's buttocks. Observed two 0.5x0.5x<0.1 cm open areas draining serosanguinous fluids on R1's left upper leg, near the buttocks with a red wound bed and intact edges. Measurements were confirmed with V2. When asked to describe the drainage coming from the open area, V2 replied, No, I think that's urine. R1 exclaimed and yelped in pain as the open areas were measured. V2 apologized. Surveyor asked V2 to continue to assess R1's skin. Observed one open area 0.2x0.5x<0.1 cm open area with a pink/red wound bed, intact edges and one open area 0.5x0.5x<0.1 cm open area with a pink/red wound bed and intact edges to R1's left buttock. Additionally, observed one 0.5x0.5x<0.1 cm open area with a pink/red wound bed with intact edges to R1's right gluteal fold. V2 educated R1 that R1 needed some cream on that (open areas). V2 placed the sheet over R1 and V2 and V12 left the room without providing R1 any peri-care after observing the feces between R1's buttocks. Record review of R1's toileting assistance provided 11/16/2025-12/15/2025 does not document that toileting assistance was provided on the following shifts: 11/17/2025 1st Shift; 11/21/2025 2nd shift; 11/22/2025 1st shift, 2nd shift; 11/29/2025 2nd Shift; 12/2/2025 1st shift; 12/5/2025 2nd shift; 12/10/2025 (into 12/11/2025) 3rd shift; 12/13/2025 2nd and 3rd shift (into 12/14/2025); 12/14/2025 1st, 2nd and 3rd shift. Record review of R1's shower sheets for 11/2025 through 12/2025 does not document that R1 had a shower between 11/30/2025 and 12/13/2025. This indicates that R1 did not have a shower for 13 days. Additionally, this indicates that R1 did not get showers as required until after the survey began and that the concerns within the grievance related to showers were not resolved. R1's care plan documents in part that R1 is totally dependent on staff for toilet use (3/17/2025) and instructs staff to: Toilet at regular intervals, such as following meals, as indicated (5/29/2024), Administer appropriate cleansing & peri-care after each incontinent episode 5/29/2024), Observe for signs of skin irritation &/or breakdown. Report irritation/breakdown to the physician. (5/29/2024), Evaluate side effects of prescribed medications to assess causes of incontinence. (5/29/2025). Additionally, the care plan identifies that the moisture associated skin damage was identified on 12/13/2025. R1's progress notes identify that R1 has a history of moisture associated skin damage and candidiasis and that it was healed on 10/21/2025. On 12/13/2025 at 14:53 PM, V9 documented, Resident noted with MASD to bilateral posterior thighs and buttocks continue nystatin cream as previously ordered, check and change and apply after incontinence episodes. Hydrocolloid applied to posterior thighs for MASD. On 12/15/2025 at 9:44 AM, V8, Restorative Nurse, Licensed Practical Nurse affirmed staff are not required to document every episode of incontinence but are required to document the highest amount of care provided for the activity of daily living (ADL) that shift. If the resident has refused or if there is a reason that care was not provided, the nurse would complete a progress note. V8 stated, They (CNA's) are required to document every shift. V8 reviewed R1's incontinence care charting and confirmed that on multiple shifts that there is no documentation/evidence that R1 received incontinence care. V8 stated that the standard of care is that incontinent residents are checked and changed if needed every 2 hours. V8 stated, If you are performing good peri-care, you wouldn't see any feces afterward. V8 stated, If incontinence care is not provided every 2 hours, skin breakdown can occur. Urine can eat away at the skin which causes burning. I was not that (R1) had any skin breakdown. (V9, Wound Care Nurse, Licensed Practical Nurse) monitors shower sheets and skin breakdown. Anytime there is moisture associated skin damage, (V9) is notified. On 12/15/2025 at 10:22 AM, V9, Wound Care Nurse, Licensed Practical Nurse affirmed that R1 had a history of moisture associated skin damage but we healed it out. V9 explained, (R1) had some when (R1) first admitted , (R1) is heavy wetting. (R1) was followed by the wound care doctor for moisture associated skin damage and we have been providing cream for a while. (R1) has a history of fungal yeast infections. We found the open areas yesterday. We have been creaming her for a while, (R1) should be getting cream every incontinence episode. You shouldn't see any feces after peri-care was completed. I went in after you (the surveyor) observed (R1), and the feces was still there when I completed a skin check. I found three open areas caused by moisture associated skin damage on (R1's) bottom. Surveyor informed V9 that there were five open areas discovered on R1's bottom and V9 replied, Oh, I didn't see those, I thought there was only three. V9 described R1's skin as wet, wrinkly and affirmed there was moisture present during assessment. When asked if V9 had measured the open areas, V9 replied, No, we (staff) don't measure MASD (moisture associated skin damage). That's not our policy. But I always thought that was weird because the wound care doctor does. So why wouldn't we?. V9 recalled notifying R1's nurse practitioner for orders and got orders to get a wound care consult. V9 recalled, When I told (R1's) family about the new open areas, the family said we were only calling because state was in the building. They (the family) were upset. (R1's) family has brought up concerns with showers, incontinence care, and not being gotten up on the night shift. I've offered to take (R1) off the night shift get up list, but it is (R1's) choice to get up then. If (R1's Family Member) comes in and sees R1 not out of bed in the morning, (R1's family member) gets mad. It is part of my duty to review and ensure shower sheets are completed. V9 reviewed R1's December 2025 shower sheet and affirmed that there was no documentation that R1 had a shower. V9 explained, The nurses fill out the top part for a skin assessment, but the bottom part is filled out by the CNAs to document the shower was given. The bottom part is blank. Well, textbook would tell you if it wasn't completed, it wasn't done. On 12/15/2025 at 12:31 PM, V1 (Administrator) affirmed that V1 is the abuse prevention coordinator for the facility. V1 stated, Skin breakdown occurs if incontinence care is not provided. V1 affirmed that once per shift CNAs are required to document the care provided. V1 stated, If there is no charting for the shift, I wouldn't assume the care was not provided. Like, if the patient didn't have a negative outcome that would trigger me to think they weren't cared for. When asked if moisture associated skin damage is a negative outcome, V1 replied, It might mean that they weren't changed timely but not that it wasn't received. On 12/15/2025 at 1:46 PM, V12, Licensed Practical Nurse recalled a few days ago that R1's family member was in the facility and upset. V12 explained, I don't know what (the family member) was upset about. But I know she talked to (V2) and (V2) went down there. I think the last time I saw R1's skin intact was maybe Monday (12/9/2025). The other day we assessed (R1's) skin with you (surveyor) and found multiple open areas. If (R1) was changed every 2 hours, we wouldn't have seen that. On 12/17/2025 at 2:04 PM, V19 (Medical Director) stated that signs of incontinence care not being provided is a rash in an area. Stool or urinary incontinence can cause skin breakdown. Not at all an acceptable level of care. MASD there is many factors, it depends on the level of incontinence and the frequency, some people are very incontinent going about every 20 or 30 minutes. MASD can be caused by not checking or changing diapers. Can be multiple factors. It would be documented if staff were providing incontinence care.Facility policy titled, Skin Care Dos and Don'ts (5/2014) documents in part that facility staff should observing skin during direct care, notifying the treatment nurse/charge nurse of any changes in skin breakdown/moisture associated conditions, completing peri-care with mild soap and water after each incontinence episode, using moisture barrier ointment to protect skin from incontinence and to document skin irritation in progress notes.

Based on observation, interview and record review, the facility failed to implement their abuse policy; failed to suspend a staff member pending an allegation of staff to resident physical abuse; and failed to prevent retaliation of a staff member after reporting abuse. This failure affects one (R3) of six residents reviewed for abuse and has the potential to affect all 118 residents that reside within the facility. Findings include: Facility census (12/13/2025) documents in part that 118 residents reside within the facility. Review of R3's progress notes indicate that on 12/11/2025 at 10:10 AM, documents in part, CNA notified writer of resident complaint of pain at Lt arm. Upon arrival to resident's room, resident in lying in bed alert and oriented x 2. During assessment resident's Lt arm is swollen, painful to touch, and resident is yelling out in when she attempts to move Lt arm. No other apparent abnormalities noted. Writer gently placed Lt arm on pillow. T 98.1 P 65 R 20 BP 100/66 02 sat 95% RA. (V6) to be notified for pain medication orders. At 10:15 AM, R3 was seen by V13 (Nurse Practitioner) at the bedside. At 1:36 PM, R3 was sent to the hospital for evaluation and returned at 10:16 PM with a diagnosis of a closed supracondylar fracture of left humerus. There is no indication of a fall or any potential indicators of a fall or change of plane (e.g. R3 observed on the ground) within R3's progress notes reviewed since 10/1/2025-12/18/2025. On 12/15/2025 at 12:15 PM, V4 (Social Services Director) explained, Last Tuesday (12/9/2025) I was getting ready to leave around 4:15 PM. I heard noises from my office. Loud yelling, louder than normal. Loud enough for me to have concerns. I went out of my office; my office is a couple doors down from (R3's) room. V11 and V15 were also going to the room. I was in the doorway and saw (R3) lying in bed and it looked like (R3) was getting changed. (R3) was holding her left arm, the one that is broken. I asked (R3) what happened and (R3) told me (R3's) arm hurts. So, I told V16 (Licensed Practical Nurse). I don't really remember if there were other residents in the room at the time. (R2) told me on Thursday (12/11/2025) that she saw (V5) hurt (R3). I brought (R3) to (V2 Director of Nursing) and (V1 Administrator) was there. The story changed when (R2) was talking to (V1) and (V2) and (R2) stated that (R2) heard a loud bang and thought R1's arm hit the bed and that R2 couldn't see what happened because (V5) was standing in between. I would say that is an allegation of physical abuse. (R2's) cognition is intact, I would believe an interview from (R2). (R3's) cognition is in and out, some days (R3) can tell me things, other days (R3) can't. A fracture can be a sign of physical abuse.On 12/15/2025 at 1:46 PM, V12 (Licensed Practical Nurse) recalled, On Thursday Morning (12/11/2025), I was assigned to care for (R3). A staff member, I can't remember who, told me something was wrong with (R3's) arm, (R3's) screaming. I went to the room, and it was pretty bad, swollen and (R3) was guarding the arm. V13 (Nurse Practitioner) was here, assessed R3, and gave orders for an X-ray and pain medication. Around 12:30 or 1 PM, I showed (V2) (R3's) arm and (V2) instructed me to send (R3) to the hospital. When I asked (R3) what happened, (R3) stated, that woman did this to me, that woman did this to my arm. I reported this to (V2). There was no fall, (V5) never said there was any fall. I was told on Thursday (12/11/2025) by (V11 Certified Nursing Assistant) that V5 was working a double on (12/9/2025) and (V11) gave me this look. I don't remember her exact words but (V11) told me that (V11) and (V15) were talking at the nurse's station and (V11) heard (R3) scream this b***h broke my arm!. (V11) had concerns (V5) was being rough with (R3). On that same day, (R2) told me that (V5) was being rough with (R3), that (V5) snatched (R3's) arm and went bam bam bam hitting it on the rail of the bed. I told (V2) about it because I was shocked and (V2) was the closest staff that was there. I did not tell V1, I should have. I was very concerned after hearing (V11) tell me about R3's yelling and saying and then (R3) telling me a woman broke (R3's) arm, I was very concerned with physical abuse. I would think this fracture could be a sign (R3) was physically abused. I have not witnessed (V5) abuse any residents but (V5) has no patience for the residents. No fall caused this injury. V1 called me in and asked if (R3) had fell and I told (V1) not to my knowledge. They (V1 and V2) are trying to put this on me that this was caused potentially by a fall, it was not a fall. I told them it wasn't the fall. I told them my concerns, and they are going to pin this on me that I didn't chart a fall. No fall caused that fracture.On 12/15/2025 at 2:51 PM, V2 (Director of Nursing) recalled on 12/11/2025, I did go back and look at (R3's) arm. I didn't lift it because she was complaining of pain. I was more swollen more than normal. (V6) was in and had ordered pain meds and an X-ray. She was in so much pain, so we sent her out. I asked (R3) what happened she didn't say anything about a fall. (R3) stated, She turned me too hard. (R3) couldn't say who did it. Her doctor had concerns about bone density. I don't know how (the fracture) happened. Yes, I remember being in the office with (R2) and (V1). I was working on many items and was in and out of the conversation. I heard (R2) say something about the CNA hurting (R3's) arm. (R2) said it was (V5). (R2) then said in the conversation (R2) heard a loud noise but didn't see what (V5) did. I did not report abuse to V1, V1 was there for that conversation. Surveyor inquired if V5 had continued access to R3 after the allegation was made. V2 responded, No, because I changed (V5's) assignment, (V5) wasn't over there anymore. Surveyor inquired why V2 changed V5's assignment. V2 responded, because there was an issue between (R3) and (V5). I see what you mean, (V5) should have been suspended pending investigation. Assignment sheets were reviewed with V2 from 12/9/2025 through 12/15/2025. V5 was not scheduled to work between 12/10/2025-12/12/2025 but was assigned to another unit (100) different from R3's unit (300) on 12/13/2025.On 12/15/2025 at 3:41 PM, V13 (Nurse Practitioner) explained, I am (R3's) provider. I recall (on 12/11/2025) being notified by the nurse that her left upper extremity was swollen and painful. I went in and assessed her. It was swollen, it didn't look deformed though, it was tender to the touch. (R3) had very limited range of motion due to pain. (R3's) nurse at the time was unaware of any recent trauma or falls at that time. (R3) was alert times 1 (to self), (R3) could not report what happened to (R3's) arm. (R3) was sent to the hospital and diagnosed with a supracondylar fracture left humeral fracture. I was not told that there was any suspicion of abuse. I am not ortho, but that (a supracondylar fracture) can be caused by trauma, it depends on how hard someone is hit against something. If (R3) was screaming, that isn't (R3's) baseline. It would make sense if it (the fracture) was related to trauma. It doesn't take a lot for an older adult to have a fracture. I did tell the facility they needed to investigate what happened; these fractures don't happen for no reason.Record review of facility final investigation (12/16/2025) completed by V2 (Director of Nursing) indicates that the facility believed the injury of unknown origin was caused by a fall that wasn't reported. (V12) was terminated for not reporting the fall incident. Record review of corrective action given to V12 on (12/16/2025) documents in part that during an investigation for injury of unknown origin, V12 did not report, document, or inform the nurse manager of a fall by (R3) and after 2 different witness statements given during the investigation (by V12) then said the resident had a fall. On 12/17/2025 at 1:14 PM, witness statements for the allegation were reviewed with V2. V2 affirmed that the cause of the injury was a fall and that the only statement that mentioned a fall occurred was V5's statement (perpetrator of abuse). V2 stated that V12 told V2 there was a fall. V2 reviewed V12's witness statement and affirmed V12 statement does not include any documentation of a fall. V2 affirmed that V2 didn't get the other statement that (V12) made about the fall and surveyor observed V2 fabricate a statement. Surveyor requested any documentation that indicates R3's injury was caused by a fall or any evidence that a fall occurred. No documentation was provided that indicated R3 had a fall prior to the exit of the survey. Record review of the observed fabricated statement collected on 12/17/2025 (dated 12/18/2025) gives V2's statement that indicates, I was informed by administrator (V1) that (V12) informed (V1) that the resident (R3) did have a fall. (V12) was too busy and forgot to report the fall. (V12) said I'll take my hit for not reporting the fall.On 12/18/2025 at 2:46 PM, V19 (Certified Nursing Assistant) reviewed her witness statements and affirmed they were correct. V19 affirmed that R3 never had any fall. V19 recalled that V19 was the staff member that discovered R3's swollen arm. V19 stated, (R3's) elbow was swollen above the arm. When I asked what happened, (R3) was screaming, a female CNA broke my arm and that R3 wanted to go home. V19 explained, I went and immediately told (V12). (V12) came and I stepped out of the situation once (V12) took over. (V5) is very mean-spirited and verbally aggressive with the residents. It's very inappropriate. Like if someone needs help putting on their clothes, (V5) will help them, but the whole time (V5) will be like, Why can't you do that yourself?! all nasty. V19 affirmed that V19 never picked R3 up off the ground, V12 was never told R3 fell, and that R3 has not had any falls. V19 denied R3 would be able to defend herself against physical abuse and that a fracture could be a sign of abuse. V19 affirmed that R2 does not make false allegations and would believe if (R2) made an allegation. Facility abuse policy (undated) documents in part, . NOTICE All employees of Prairie Oasis have the following responsibilities and rights under federal law . No retaliation Prairie Oasis cannot punish you or otherwise retaliate against you for reporting your reasonable suspicion of a crime against a resident or person receiving care from this facility. On 12/18/2025 at 3:16 PM, V21 (Regional Supervisor) affirmed that V21 oversees the administrator of the facility and is part of the facility's governing body. V21 was aware of the investigation of injury of unknown origin but was not aware that V12 was fired during the investigative process. V21 explained that the facility would never fire an employee for reporting abuse and that staff need an environment where they can freely report abuse without retaliation. If retaliation occurs, it makes an environment where staff wouldn't want to come forward with abuse which can affect the other residents. V21 referred the violation of whistleblower protections to the facility's legal department/lawyers for further action. On 12/17/2025 at 2:04 PM, V19 (Medical Director) affirmed that V19 is the medical director of the facility. V19 explained, supracondylar fractures, there is variability on how they are caused. In young people, it is nearly always caused by trauma. In the elderly, the majority of the time it is caused by trauma, but if the resident has osteopenia, a sudden movement or mobility change can cause that fracture. Suddenly twisting or putting a lot more pressure on an arm, or when an arm is stretched there is a potential. I believe it is roughly 10-12% of the time pathologically related. Physical abuse can cause fractures. I am aware of the incident; I was made aware by (V1 Administrator) and was told the statements were not corroborating enough. I heard there was another person, I am unsure if it was a roommate or staff, saw another staff member giving care but couldn't really see. If the resident fell, yes, that has to be documented. If this was caused by a fall or abuse, it would have been documented. Even if there was a fact (R3) was in pain, that would have to be documented and assessed when it happened. Even if (R3) was being combative at the time of the incident and there was a change in status, I would expect to see that (documentation). If the CNA actually abused (R3) with the fracture, it's hard to say. None of the actual statements really corroborated is my understanding. If (R3) was receiving care and then had pain, there should have been care provided right away. They (the facility staff) should have taken that more seriously. Facility abuse policy (undated) documents in part, This policy affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion .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 resulting in physical harm, pain or mental anguish . Physical abuse is the infliction of injury on a resident that occurs other than accidental means and that requires medical attention .V. Protection of Residents . Employees of this facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse, neglect or misappropriation of property shall not complete the shift as a direct care provider to the residents . NOTICE All employees of Prairie Oasis have the following responsibilities and rights under federal law . No retaliation Prairie Oasis cannot punish you or otherwise retaliate against you for reporting your reasonable suspicion of a crime against a resident or person receiving care from this facility.

Based on interview and record review, the facility failed to respond and resolve resident grievances in a timely manner. This failure affects one of six residents (R1) reviewed for grievances. Findings include: R1's face sheet documents in part R1 is a [AGE] year-old resident with a prior medical history including: hemiplegia affecting left side, type 2 diabetes mellitus, depression, hypothyroidism, and hypertension. Record review of grievances (5/5/2025, 7/3/2025, 11/11/2025) document, in part, concerns with R1 receiving showers. The grievance dated 11/11/2025 does not indicate if the grievance was resolved or unresolved, the complainant's response to the resolution or signature from the administrator. On 12/13/2025 at 10:27 AM, R1 stated R1 has complained about showers to R1's family members and staff and stated staff do not respond timely to concerns. R1 affirmed R1's family will also complain to staff about concerns and nothing gets resolved. R1 stated, I haven't had a shower in over a month. On 12/13/2025 at 12:51 PM, V7 (R1's Family Member) affirmed V7 has complained to many staff members including V2 (Director of Nursing) about not R1 not getting care. V7 affirmed R1 does not get showers regularly and the lack of care is still an issue after filing grievances. On 12/13/2025 at 1:16 PM, V2 (Director of Nursing) affirmed the facility staff are required to document showers on shower sheets. V2 stated if shower sheets are not complete, then there is no documentation the care was provided. V2 recalled V7 had brought up concerns related to R1's care in the past, including incontinence and peri-care. On 12/13/2025 at 3:45 PM, V1 (Administrator) reviewed the grievance dated 11/11/2025. V1 stated it appeared V17 (Care Plan Coordinator) forwarded the grievance to V4 (Social Services Director) to address and R1 received a shower. V1 affirmed the grievance documentation does not indicate if the grievance was resolved or unresolved, the complainant's response to the resolution or signature from the administrator. V1 affirmed all grievances are to be sent to the administrator for review where V1 would sign off they were complete. V1 stated, They (staff) must have just put this in the grievance binder and forgot to give it to me. On 12/15/2025 at 12:15 PM, V4 (Social Services Director) reviewed the grievance (11/11/2025) and recalled the grievance was received by R1's family member during a care plan meeting. V4 explained the family was upset R1 was not receiving showers on R1's shower day. V4 told nursing staff about the incident and recalled staff showered R1 day. V4 was unsure if there was any documentation of any other follow up, auditing, investigation for the validity of the complaint, or resolution/communication to R1's family about the concern being resolved. V4 affirmed the grievance should be considered incomplete because there is no documentation the grievance was resolved, communicated to the family or the administrator was aware/signed off. V4 explained the grievance process is V4 receives the grievances, follow ups with the appropriate department, communicates and documents the resolution with the complainant and then reviews with the administrator. After, it is filed in the grievance log. Record review of R1's shower sheets for 11/2025 through 12/2025 does not document R1 had a shower between 11/30/2025 and 12/13/2025. This indicates R1 did not have a shower for 13 days. Additionally, R1 did not get showers as required until after the survey began and the concerns within the grievance related to showers were not resolved. Facility policy titled, Grievances (6/2014) documents in part, . Purpose: to establish a formal system for documentation of grievances and system of resolution . 1. The director of social services will utilize the written concern form method to document concerns . all concerns will be reviewed and signed by the administrator. 8. Concern resolutions are expected within 72 hours unless further time is needed to resolve the concern (example: ordering an item) .Facility policy titled Bath/Shower Schedule (2/2014) documents in part, A bath or shower will be given to each resident by a Certified Nursing Assistant two times per week as scheduled and (as needed) . 3. Certified Nursing Assistant will give shower as scheduled . 6. Bath/shower sheets are to be completed by the Certified Nursing Assistant upon each bath/shower scheduled whether accepted or declined. Bath/shower sheets will be maintained by the facility for the current and entire last month and then may be discarded.

Based on interview and record review, the facility failed to report an injury of unknown origin to the state survey agency within 2 hours for one (R3) of six residents reviewed for reporting. This failure resulted in R3 experiencing left arm pain and swelling and being transferred to the hospital and diagnosed with closed supracondylar fracture of the left humerus.Findings include:Record review of initial report to the state survey agency (12/12/2025) documents in part, that on 12/11/2025 at 10:10 AM, R3's left arm was observed swollen and painful to the touch. At 22:16, R3 returned from the hospital with a diagnosis of closed supracondylar fracture of the left humerus. The facsimile transmission for the initial report documents in part, that the reportable was faxed on 12/12/2025 at 3:30 PM. On 12/13/2025 at 3:45 PM, V1 (Administrator) affirmed V1 is aware of R3's fracture and that the facility does not know how R3 got the fracture. V1 explained, (R3) wasn't able to say what happened, (R3) just kept saying [NAME]. (R2) had mentioned there was an issue between (R3) and (V5), but when I was asking what happened, (R2) stated that they were arguing and did not see anything else. (R2) stated she did not see her hit (R3). When I looked up the type of fracture, it said it was commonly from a fall . V1 affirmed the allegation was an injury of unknown origin. V1 reviewed the initial report and confirmed the facsimile was transmitted over 2 hours after the facility was made aware of the fracture. V1 stated, The facility thought it was a probably from a fall, so we treated it like reporting a fall with injury. V1 affirmed that allegations of abuse, including injuries of unknown origin, are to be reported within 2 hours of the allegation. On 12/15/2025 at 12:15 PM, V4 (Social Services Director) explained, Last Tuesday (12/9/2025) I was getting ready to leave around 4:15 PM. I heard noises from my office. Loud yelling, louder than normal. Loud enough for me to have concerns. I went out of my office; my office is a couple doors down from (R3's) room. V11 and V15 were also going to the room. I was in the doorway and saw (R3) lying in bed and it looked like (R3) was getting changed. (R3) was holding her left arm, the one that is broken. I asked (R3) what happened and (R3) told me (R3's) arm hurts. So, I told V16 (Licensed Practical Nurse). I don't really remember if there were other residents in the room at the time. (R2) told me on Thursday (12/11/2025) that she saw (V5) hurt (R3). I brought (R3) to (V2 Director of Nursing) and (V1 Administrator) was there. The story changed when (R2) was talking to (V1) and (V2) and (R2) stated that (R2) heard a loud bang and thought (R1's) arm hit the bed and that (R2) couldn't see what happened because (V5) was standing in between. I would say that is an allegation of physical abuse. (R2's) cognition is intact, I would believe an interview from (R2). (R3's) cognition is in and out, some days (R3) can tell me things, other days (R3) can't. A fracture can be a sign of physical abuse.On 12/15/2025 at 2:51 PM, V2 (Director of Nursing) recalled on 12/11/2025, I did go back and look at (R3's) arm. I didn't lift it because she was complaining of pain. It was more swollen more than normal. (V6) was in and had ordered pain meds and an Xray. She was in so much pain, so we sent her out. I asked (R3) what happened she didn't say anything about a fall. (R3) stated, She turned me too hard. (R3) couldn't say who did it. Her doctor had concerns about bone density. I don't know how (the fracture) happened. Yes, I remember being in the office with (R2) and (V1). I was working on many items and was in and out of the conversation. I heard (R2) say something about the CNA hurting (R3's) arm. (R2) said it was (V5). (R2) then said in the conversation (R2) heard a loud noise but didn't see what (V5) did. I did not report abuse to V1, V1 was there for that conversation.On 12/15/2025 at 3:41 PM, V13 (Nurse Practitioner) explained, I am (R3's) provider. I recall (on 12/11/2025) being notified by the nurse that her left upper extremity was swollen and painful. I went in and assessed her. It was swollen, it didn't look deformed though, it was tender to the touch. (R3) had very limited range of motion due to pain. (R3's) nurse at the time was unaware of any recent trauma or falls at that time. (R3) was alert times 1 (to self), (R3) could not report what happened to (R3's) arm. (R3) was sent to the hospital and diagnosed with a supracondylar left humeral fracture. I was not told that there was any suspicion of abuse. I am not ortho, but that (a supracondylar fracture) can be caused by trauma, it depends on how hard someone is hit against something. If (R3) was screaming, that isn't (R3's) baseline. It would make sense if it (the fracture) was related to trauma. It doesn't take a lot for an older adult to have a fracture. I did tell the facility they needed to investigate what happened, these fractures don't happen for no reason.Facility abuse policy (undated) documents in part, This policy affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion . VII. External Reporting of Potential Abuse. Initial reporting of Allegations. If mistreatment has occurred, the resident's representative and the department of public health shall be notified as soon as possible within 24 hours . If reasonable suspicion of a crime has occurred, the resident's representative and the department of public health shall be informed according to the following time frames: Serious bodily injury - Immediately, but not later than two hours after forming the suspicion.

Based on interview and record review, the facility failed to ensure that two-person assistance was utilized during resident care, as required by the resident's care plan, to maintain safety. This deficient practice affected one of three residents (Resident #13) reviewed for safety during care. As a result, Resident #13 fell from the bed during care, which led to the dislodgement of the resident's gastrostomy tube and required hospitalization for replacement. On 9/12/25 at 9:37 AM, R13 was observed able to nod head yes or no to questions asked. When questioned if able to raise arms off bed, R13 nodded head 'no'. On 9/9/25 at 4:00 PM, V2 DON (director of nursing) stated V2 wrote up V9 CNA (certified nurse aide) for improper care resulting in R13's fall out of bed. V2 stated R13 is a two-person assist with all care.On 9/11/25 at 12:08 PM, V10 RN (registered nurse) stated she worked night shift 11:00 PM 8/20/25 to 7:30 AM 8/21/25. V10 stated she had just changed R13 with the night shift CNA at 4:00 AM. V10 stated R13 is not able to assist with turning/repositioning. V10 stated R13 requires two-person assistance with all ADL care. V10 stated R13 fell out of bed and was on the floor on the side of bed furthest from the door; fell on left side of bed. V10 stated upon arrival to room, V10 observed R13's gastrostomy tube dislodged with balloon inflated resting on R13's stomach. V10 stated R13 was sent to the hospital morning for G-tube replacement because nursing staff cannot re-insert the tubing. V10 stated the day shift, V9 CNA (certified nurse aide,) was performing care without another staff member to assist. On 9/11/25 at 12:15 PM, V5 (restorative nurse) stated R13 is able to move hands. V5 stated R13 receives AAROM (active assisted range of motion) to both legs. V5 stated R13 can move legs side to side with staff holding leg off bed. V5 stated R13 can move her arms with AAROM. V5 stated R13 needs a lot of encouragement to participate in restorative therapy. V5 stated R13 is not able to turn self or hold self on side while staff provide care. V5 stated resident requires two-person assistance with all turning/repositioning and transfers. On 9/12/25 at 11:00 AM, V9 CNA (certified nurse aide) stated on 8/21, V9 was providing morning care to R13 by herself. V9 stated R13 is totally dependent on staff; not able to assist with turning. V9 stated typically V9 provides care for R13 by herself due to not enough staff present in facility to assist V9. V9 stated R13 is a two-person assist with all ADLs. V9 stated sometimes R13 will throw herself onto back when positioned on side during care. V9 stated this is not a new behavior for R13. V9 stated R13 was positioned on her left side facing window. V9 stated V9 was positioned on the right side of bed placing new linen on bed behind R13 when R13 fell off bed. R13's fall incident report, dated 8/21/25, notes V10 RN found R13 on floor near bed lying on her right side. V10 noted R13's gastrostomy tube dislodged. The conclusion: R13 slid to the floor during morning care. R13's ADL care plan, dated 9/3/23, notes R13 has performance deficit related to stroke with hemiparesis affecting left non-dominant side. Intervention, dated 2/28/25, notes R13 is totally dependent on staff for turning and repositioning in bed. R13's diet care plan, dated 7/18/23, notes R13 has a nothing by mouth diet and receives gastrostomy tube feeding of Glucerna 1.2 at 75ml (milliliters)/hour x 20 hours and 450ml water flush per shift. R13's MDS (minimum data set), dated 8/5/25, notes, in part, R13 is dependent on staff for bed mobility, toileting, hygiene, and bathing. Per section GG, dependent is defined as helper does all of the effort. R13 does none of the effort to complete the activity. Or the assistance of two or more helpers is required for R13 to complete the activity. R13's transfer and bed mobility review, dated 8/5/25, notes R13's mobility and balance - ability to turn side to side is poor. R13 requires two person physical assistance from staff for bed mobility. R13's side rail assessment, dated 8/5/25, notes R13 has moderately impaired cognitive skills for decision making. R13 has alterations in safety awareness due to cognitive decline. R13 will not use side rails at this time. The facility's fall prevention program policy, dated 2/28/2014, notes safety interventions will be implemented for each resident identified at risk using a standard protocol. All nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.

Based on observations, interviews, and record reviews, the facility failed to provide sufficient RN (registered nurse) coverage for the second quarter of 2025. Per PBJ (payroll based journal) requirements there should be an RN working 8 consecutive hours 7 days a week. This failure has the potential to affect all residents residing in the facility. Findings include:On 9/9/25 at 9:30 AM, there was signage posted at the main receptionist desk, dated 8/19/25, noting 'this facility did not meet the minimum staffing ratios required by law for the quarter ending March 31st, 2025.On 9/12/25 at 9:00 AM, V2 DON (director of nursing) stated that for 21 days during the second quarter PBJ report there wasn't an RN present for 8 consecutive hours 7 days a week.The facility's staffing sheets for January, February, and March were reviewed. Per V18 RN (registered nurse), V19 RN, V20 RN, V21 RN, and V22 RN time punches, the facility did not routinely have an RN present for 8 consecutive hours on New Year's Day, Saturdays, and Sundays:1/1/25 - RN time punch requested during survey but not made available for review.1/4 - RN time punch requested during survey but not made available for review.1/5 - V19 RN worked 7.9 hours1/11 - V20 RN worked 7.25 hours1/12 - V20 worked 7.25 hours1/18 - V19 worked 7.5 hours1/19 - V19 worked 7.8 hours1/25 - V18 RN worked 7.7 hours, V18 worked 7.8 hours, and V20 worked 6.5 hours1/26 - V18 worked 7.6 hours and V18 worked 7.7 hours, and V20 worked 7 hours2/1 - 7.75 hours and 6.5 hours2/2 - V21 RN worked 7.1 hours2/8 - V18 worked 7.25 hours2/9 - V18 worked 7.5 hours2/15 - RN time punch requested during survey but not made available for review.2/16 - V19 worked 5.9 hours3/1 - V19 worked 6.25 hours and V22 RN worked 7.75 hours3/2 - V19 worked 6.25 hours3/9 - V18 worked 7.5 hours3/16 - V22 worked 7 hours3/22 - V18 worked 7.25 hours3/23 - V22 worked 7.5 hours

Based on observation and record review, the facility failed to follow their recipe by not utilizing the appropriate serving size for zucchini, lettuce and cheese during lunch service. This has the potential to affect all 58 resident receiving regular diet. In addition, the facility, failed to provide pureed tortilla during lunch service for 20 of 20 residents receiving pureed diets.Findings include: On 9/9/25 at 11:49AM kitchen tray line observed with V13 (Cook). Lunch being served was beef taco on a tortilla with lettuce, cheese, onion and tomato with zucchini and refried beans. V13 said the mechanical soft diet is the same as regular but without lettuce. V13 observed using a tongs to serve the zucchini. No measurement or tools used for cheese, lettuce and tomatoes. V13 using gloved hand to place on cheese, lettuce and tomatoes the plates.Facility recipe for shredded lettuce with diced tomatoes and cheese documents to portion as garnish 1/2 cup of lettuce and tomato with tablespoon of shredded cheese.Facility recipe for seasoned zucchini documents to serve with #8 scoop to provide 1/2 cup vegetables per serving.Facility diet list dated 9/9/25 documents: 58 residents on regular diets.On 9/9/25 at 11:49AM kitchen tray line observed with V13 (Cook). Pureed food was identified as refried beans, beef and zucchini. Pureed food trays were given zucchini, beef and refried beans no other food was on the plate. No pureed tortilla was observed.Facility recipe for pureed tortilla document portion with #16 scoop.Facility diet list dated 9/9/25 documents: 20 residents on pureed diets.

Based on interviews and record reviews, the facility failed to complete a post fall assessment of a resident immediately following a fall; failed to ensure a resident's physician was notified after a fall; failed to ensure residents received medications as ordered by the physician; and failed to ensure the physician was notified of abnormal lab results. These failures applied to three of four residents (R3, R4, R5) reviewed for quality of care and resulted in R3 having a delay in care of approximately two days after a fall in which R3 was found to have a hip fracture that required surgical intervention. Findings include: 1. R3 is a [AGE] year-old male with a diagnoses history of COPD, Heart Failure, Unspecified Convulsions, and Alcohol Abuse who was admitted to the facility 08/14/2024. R3's Current Care Plan documents he is at risk for falls related to requiring assistance with activities of daily living and for transfers and mobility related tasks with interventions implemented 08/15/2024 including be sure call light is within reach and encourage the resident to use it for assistance as needed, staff to respond promptly to all requests for assistance, and complete the Fall Risk Review per the facility protocol. R3's progress note created by V18 (Licensed Practical Nurse) dated 2/15/2025 at 2:17 PM documents resident appears to be more confused in a.m. and not verbally understood by writer, refused to eat breakfast/lunch even with encouragement/setup, resident is also losing control of bowel/bladder, refuses to get out of bed to toilet self as he normally does or sit up to eat; Orders received to send resident out for altered mental status and failure to thrive; at 4:52 PM writer received call from the hospital charge nurse stated that resident is being admitted for left hip fracture, that left leg is inverted, rotated and shorten, she also stated that fracture appears to be 48 hours old. Resident is scheduled for surgery in a.m. R3's Fall Incident report dated 02/15/2025 documents he was sent to the hospital for evaluation and treatment due to change in condition and was informed by the hospital via phone on 02/15/2025 at approximately 4:52 PM that he had a left hip fracture. Unusual Occurrence Final Investigative Report dated 02/19/2025 documents on 02/15/2025 at approximately 2:17 PM, R3 was sent to the hospital for evaluation due to refusal of meals, incontinence of bowel and bladder, and refusal to get out of the bed which were acute change of condition per nursing assessment. The nurse was informed by the hospital nurse at 4:30 PM that R3 had a left hip fracture and will be admitted to the hospital. Undated witness statement from V7 (Licensed Practical Nurse) documents on 02/14/2025 at 3:45 PM she was off duty and returned to the facility because she forgot her phone and observed aides running to a room to assist R3 off the floor, she assisted the aides at this time to remove R3 off the floor, observed him, and no pain was observed. Witness statement from R12 dated 02/15/2025 documents he reported R3 had a fall trying to pick up a resident that fell in their room and aides assisted R3 from the floor; Witness statements from R13 dated 02/15/2025 documents he reported R3 fell . It was daylight at the time and aides assisted him from off the floor; Witness statement from V18 (Licensed Practical Nurse) dated 02/15/2025 documents she reported his roommates informed that he fell two days ago in their room and aides picked him up off the floor; Witness statement from V9 (Certified Nursing Assistant) dated 02/17/2025 documents she reported she worked from 3-11 PM on Friday and approximately between 3:30 - 4PM she observed R3 on the floor, the nurse checked him and helped place R3 on his bed. R3's roommates reported R3 was trying to help R9 up and fell . R3's hospital report dated 02/15/2025 documents he was admitted from the nursing home for lethargy but noted at baseline while at the emergency department and instead found to have a left thigh fracture and is unable to explain how he fell . R3 was assessed to have an acute fracture of the left hip and the circumstances of the fall are unclear; patient with a high level of risk based on: acute or chronic illnesses or injury which poses a threat to life or bodily function; he is a [AGE] year old male presenting with a fall at the nursing home and left thigh fracture and underwent surgical treatment for fracture on 02/16/2025; the etiology of the fall is unclear, suspect mechanical. On 02/25/2025 at 12:27 PM V2 (Director of Nursing) stated she completed the investigation on 02/19/2025 for R3's fall that occurred 02/15/2025. V2 stated there was confusion about his fall and they were trying to determine when R3 had a fall. V2 stated she concluded after the investigation that R3 had a fracture. V2 stated she wanted to go back to 02/14/2025 because someone said he fell two days ago but he was up and walking on 02/15/2025 so she said that couldn't be correct. On 02/25/2025 at 2:07 PM V2 (Director of Nursing) stated V7 (Licensed Practical Nurse) was suspended for three days because she did not complete an incident report for R3's fall because she said she was off the clock when R3 fell . V2 stated V7 assisted the aides with getting R3 up after he fell on [DATE] and then left the facility immediately after. V2 stated V7 should have let someone know R3 had a fall. V2 stated V7 will be terminated because she failed to inform anyone about a fall that resulted in an injury. V2 stated an injury could occur due to failure to report a fall or failure to properly assess a resident after a fall. V2 stated if you continue to put pressure on an injury after a fall that could result in harm. On 02/25/2025 at 2:52 PM V8 (Certified Nursing Assistant) stated at approximately 3:15 PM on 02/14/2025 as she was entering the unit where R3 's room was located V9 (Certified Nursing Assistant) observed R9 crawling on the floor. V8 stated V9 informed her of this as well as V7 (Licensed Practical Nurse). The nurse walked with her (V8) and V9 towards R9. V8 stated she found R9 crawling on all fours directly outside of R3 's room. V8 stated once they made it to the doorway of R3's room on the other side of the threshold, R3 was laid out parallel to the wall. V8 stated V7 stated R3's was on the floor too. V8 stated V7 then asked R3 if he was ok, what was he doing, asked him if he hit his head then answered for him no you didn't hit your head then instructed her (V7) and V9 to get him up. V8 stated V9 and V7 then assisted R3 off the floor, then she (V8) and V9 helped R9 up into her wheelchair and placed R9 at the nurses station. V8 stated V7 said she's not reporting it, she was ready to go, they didn't hit their head and they're alright. V8 stated V7 then sat at the nurses station until approximately 3:30 then left the facility. V8 stated V7 did not perform an assessment of R3 when he fell . V8 stated neither she nor V9 reported this to anyone else. V8 stated she was trained to report falls to the nurse and the nurse was present and aware of R3 's fall. On 02/25/2025 3:21 PM V9 (Certified Nurse Assistant) stated on 02/14/2025 at approximately 3:15 PM she was coming in from getting a linen bag then approached the nurses station and could see R9 sitting on the floor. V9 stated she informed V7 (Licensed Practical Nurse) that R9 was on the floor. V9 stated then she, V7 and V8 (Certified Nursing Assistant) approached the threshold of R3 's room and observed R3 was on the floor. V9 stated V7 said R3 is on the floor too and then immediately went to assess R3. V9 stated V7 assessed R3's body by patting him on his head, arms, legs, and back and then asked her (V9) and V8 to help R3 into bed. V9 stated she's unsure of R3's response while V7 was assessing him. V9 stated during this time she was observing R9 who was just sitting on the floor. V9 stated she remained standing in R3's doorway in between R9 and R3 while V7 assessed R3. V9 stated V7 asked R3 if he was ok and if anything hurt but she doesn't recall his response. V9 stated R3 looked like he was in pain and grunted when she, V7, and V8 picked him up and placed him in his bed. V9 stated after they placed R9 in the wheelchair, V7 stated she was getting ready to leave then went and got her bags and things and left. V9 stated R9 didn't have any injuries and didn't show any signs of pain other than grunting while being picked up. V9 stated she believes R3 stayed in his bed the remainder of the shift. On 02/25/2025 at 3:48 PM V2 (Director of Nursing) stated V7 (Licensed Practical Nurse) would have had a nurses note in R3 's medical records if an assessment was performed after he fell . V3 (Assistant Director of Nursing) stated a fall assessment, nurses note, incident report, and vital signs should all be documented in R3 's medical record along with notation of whether there was a loss of consciousness, complaints of pain, or changes in range of motion after a resident's fall. R3's medical records did not include documentation of a fall assessment, nurses note, or incident report that included his vital sign measurements, level of consciousness, pain status, or assessment of his range of motion, or physician notification after his fall on 02/14/2025. 2. R4 is an [AGE] year-old female with a diagnoses history of Dementia, Hallucinations, Stroke, Anxiety Disorder, Malignant Cancer of Left Breast, Metabolic Encephalopathy, and Repeated Falls who was admitted to the facility 09/02/2022. R4's Physician Order history includes an active order effective 10/12/2024 for 1 mg Anastrozole (Hormone Based Chemotherapy) Tablet to be given by mouth one time a day related to Breast Cancer. R4's February 2025 Medication Administration Record reviewed to document Anastrozole scheduled to be given once daily in the morning was not administered on 9 different days from 02/01/2025 - 02/11/2025. R4's medication administration progress note dated 2/1/2025 documents her Anastrozole Oral Tablet (Hormone Based Chemotherapy) to be given by mouth one time a day related to Breast Cancer is awaiting delivery. 3. R5 is a [AGE] year-old male with a diagnoses history of Quadriplegia, Heart Failure, End Stage Renal Disease, Chronic Kidney Disease, Dependence on Renal Dialysis, Urinary Tract Infection, Metabolic Encephalopathy, Partial Paralysis following Stroke, and Dehydration (02/15/2025) who was admitted to the facility 01/31/2025. R5's Physician Order history includes an order effective from 02/01/2025 - 02/26/2025 for one Lanthanum Carbonate Oral Tablet Chewable 1000 MG tablet to be given by mouth three times a day with meals to reduce Phosphates level, in kidney disease; and an order effective from 02/01/2025 - 02/13/2025 for 5ml Nystatin Mouth/Throat Suspension to be given by mouth four times a day for oral anti-fungal, swish and swallow for 10 days. R5's February 2025 Medication Administration Records documents his Lanthanum Carbonate Oral Chewable tablet to be given by mouth three times a day with meals was not administered as ordered from 02/01/2025 - 02/24/2025 and his Nystatin Mouth/Throat Suspension medication to be given by mouth four times a day for oral anti-fungal was not administered as ordered on multiple days across multiple shifts from 02/01/2025 - 02/09/2025. R5's medication administration progress note dated 2/3/2025 at 05:35 AM documents his Nystatin Mouth/Throat Suspension antifungal was on order. R5's Physician Progress Note dated 2/4/2025 at 12:15 PM documents his phosphorus levels were 3.8. R5's blood labs dated 02/04/2025 document abnormalities including high phosphorus levels at 6.9. R5's progress notes did not include documentation of physician notification of abnormal blood labs. On 02/26/2025 at 12:00 PM V2 (Director of Nursing) stated according to R4's February 2025 Medication Administration record she was not receiving her chemotherapy medication as ordered based on all the 9's documented. V2 stated she had to in-service V5 (Licensed Practical Nurse) on ordering and passing medications. V2 stated R5 should have received his Lanthanum Carbonate Oral Chewable 1000 MG (Phosphorus Lowering) tablet during dialysis. On 02/26/2025 at 1:16 PM V2 (Director of Nursing) stated since Lanthanum Carbonate (Phosphorus Lowering) and Nystatin Mouth/Throat Suspension (Antifungal) was ordered for R5 he should have received it however he didn't receive it. In response to being asked by surveyor what are the risks from R5 not receiving his Lanthanum medication, V2 replied abnormal labs and phosphorus levels. V2 stated R5's high phosphorus levels documented in his lab report dated 02/04/2025 could indicate he was not receiving dialysis, not being properly dialyzed, or not receiving his Lanthanum medication. V2 stated R5 was admitted to the facility on Friday 01/31/2025. In response to surveyor asking what the risks from R5 not receiving his Nystatin medication, V2 replied possibly thrush on his tongue. When asked by surveyor what are the risks of R4 not receiving her Anastrozole Oral Tablet (Hormone Based Chemotherapy), V2 replied R4 needs her chemotherapy medication for cancer but could not explain what the risks are from not receiving her chemotherapy medication. V2 stated everyone should receive their medications. V2 stated indications of dehydration include high BUN (Blood Urea Nitrogen) and High Creatinine levels. V2 stated R5's lab work from 02/04/2025 were obtained from the dialysis nurse and should have been reported to the floor nurse and urologist. V2 stated there should be follow up from abnormal labs including consulting with the physician to determine if additional labs should be repeated, if there any changes needed in medications or with dialysis treatment. On 02/26/2025 at 1:57 PM V2 (Director of Nursing) stated the dialysis nurse V17 (Registered Nurse) explained R5 did not receive his initial dialysis until Monday 02/03/2025. V2 stated the purpose of R5's Lanthanum Carbonate medication is to keep his phosphorus levels down and agreed his levels would elevate if he were not receiving his medications or not receiving dialysis. The facility's Fall Risk and Post Fall Assessment Policy and Procedures received 02/26/2025 states: The purpose of the policy is To conduct appropriate assessments after falls. Post Fall Assessment Procedures include: conduct physical and mental status assessment, assess resident's airway breathing and circulation, note level of consciousness and perform neuro checks whenever there is potential for actual head injury, assess limb strength and motion by asking the resident if he has pain and the location of said pain; ask if he can do active range of motion. The facility's Fall Policy and received 02/27/2025 states: Observed and reported by staff member. Licensed nurse should conduct assessment immediately, including events leading up to the fall to determine when possible causative factors. Assess for respiratory difficulties, bleeding and fractures. Additional Measures include: Notify Physician. Document all assessment findings and observations, physician and family notifications in the resident's clinical record in accordance with the assessment guidelines. The facility's Medication Administration Policy and received 02/26/2025 states: Medications must be administered in accordance with a physician's order. The facility's Physician Orders Policy received 02/26/2025 states: These guidelines are to ensure that: Changes in resident status/condition are assessed and physician notification is based on assessment findings; Any orders given by Physician are carried out. Any calls to physician will be documented in the nurse's notes indicating information conveyed and received.

Based on observation, interviews and record reviews, the facility failed to follow resident care assessment and plan in providing adequate supervision and monitoring of residents with severe cognitive impairment for two (R3 and R4) of four residents reviewed for accidents and supervision. This deficiency resulted in R4 had a fall in the dining room and sustained a comminuted and mildly displaced fractures of the left medial acetabular wall and root of the superior pubic ramus (hip/pelvic area). Findings include: 1. R3 is an [AGE] year old, female, admitted to the facility on [DATE] with diagnoses of Parkinson's Disease without Dyskinesia, without Mention of Fluctuations; Depression, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Mood Disturbance and Anxiety; and History of Falling. MDS (Minimum Data Set) dated 12/10/24 recorded R3 has BIMS (Brief Interview for Mental Status) score of 7 which means severe cognitive impairment. MDS dated [DATE] indicated R3 needs substantial/maximal assistance during chair/bed to chair transfer. R3's care plans documented the following: 1.Self-care deficit, initiated 04/10/23: Interventions: Provide assistance with all ADLs (activities of daily living) as required per resident's need dependence: eating, transferring, bed mobility, bathing, dressing, personal hygiene, ambulation and personal hygiene. 2. ADL self-care performance deficit related to disease process Parkinson, initiated 10/06/23: Interventions: Transfer (01/27/25): R3 requires the assistance of 1 staff member when transferring. On 02/04/25 at 10:35 AM, observed R3 was coming out from the dining room, in her wheelchair to hallway. There was an ongoing activity in the dining room and R3 was attending. R3 was using both feet in propelling her wheelchair. R3 went to her room and made several attempts to transfer self from wheelchair to a chair. Finally, R3 was able to transfer self to the chair without any supervision from staff. R3 was able to leave the dining room unnoticed. On 02/04/25 at 11:00 AM, V21 (Licensed Practical Nurse, LPN) was interviewed regarding R3 supervision, monitoring and transfer. V21 replied, She is alert, oriented to self and place, with periods of confusion. Sometimes when you speak to her, she will answer you but will start with something else. She is on a wheelchair and dragged her wheelchair using her feet to move around. She cannot transfer herself. We all have eyes on her. She will try to get up on her own. Monitor her every hour while in room. During activities, she is monitored. She tried to leave the dining room; staff usually call the nurse. We cannot leave her unsupervised. Fall risk review dated 01/31/25 recorded R3 is high risk for falls. R3's progress notes documented the following: 01/14/25: R3 was observed laying on the floor next to bed during rounds. 01/30/25: R3 was observed in the hallway sitting on the floor in front of her wheelchair. 01/31/25: R3 was found lying on floor with wheelchair on top of legs. On 02/04/25 at 2:13 PM, V2 (Director of Nursing/Fall Coordinator) stated, She (R3) is provided with supervision and monitoring by placing her at the nurses' station or in activities. We keep an eye on her. Since she came back from the hospital, she needs assistance during transfers, she needs help. 2. R4 is an [AGE] year-old, female, admitted in the facility on 11/02/2020 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; and History of Falling. MDS (Minimum Data Set) dated 12/02/24 recorded R4's BIMS (Brief Interview for Mental Status) score is 3 which means severe cognitive impairment. R4's care plans documented the following: 1.At risk for increasing confusion secondary to dementia, initiated 11/02/20: Interventions: Provide cueing and prompting PRN (when necessary). Involve in small group/low stress activities. Reality orientation as needed. Calm/quiet environment. 2.Self-Care Deficit, date initiated 11/12/202: Interventions: Provide assistance with all ADLs as required per the resident's need dependence: eating, transferring, bed mobility, bathing, dressing, personal hygiene, ambulation and personal hygiene. R4's progress noted dated 01/30/25 documented R4 was found sitting up on the floor mat sitting up on buttocks with heel protectors in place wrapped in bed sheet. No apparent injury noted. No new orders received at this time. Bed in lowest position. R4's care plan recorded the following: 1.At risk for falls related to resistive to care at times and history of fall, initiated 11/08/20: Interventions: Frequent room rounds when resident is in room. Gather information on past falls and attempt to determine the root cause of the fall (s). Anticipate and intervene to prevent recurrence. Fall Risk Review dated 01/06/25 indicated R4 had been determined not to be a high risk for falls. Fall incident report dated 01/22/25 documented that on 01/16/25 at approximately 2:04 PM, R4 had a fall in the 100-unit dining room. There were no open areas. The nurse assessed R4, noted to have facial grimaces when moving the left leg. R4 was sent out to the hospital as ordered for further treatment and evaluation. R4's CT (computed tomography) scan and X-ray of left hip and pelvis dated 01/16/25 performed in the hospital revealed the following results: CT pelvis without contrast: comminuted and minimally displaced anterior column fracture with incomplete nondisplaced posterior hemi transverse component. X Ray hip 2 views left and pelvis: comminuted and mildly displaced fractures of the left medial acetabular wall and root of the superior pubic ramus. On 02/03/25 at 11:31 AM, R4 was in the dining room, up in wheelchair. R4 is alert, oriented to self, confused. R4 was sitting at a table with other residents attending activities. R4 was asked regarding recent fall incident wherein she sustained fracture. R4 stated she does not know what happened and had no recollection of the fall incident. On 02/04/25 at 10:55 AM, R4 was in the dining room; up in wheelchair; attending activities. She is alert to self but did not respond when surveyor asked on how she was doing. On 02/04/25 at 11:24 AM, V15 (LPN) stated, R4 is alert and confused. She is dependent on staff. She uses a wheelchair. I was the nurse assigned to her on 01/16/25. I was coming in from break, the aide called me and told me that she (R4) had a fall in the dining room while I was on break. V20 was the CNA assigned in the dining room. Usually there is one CNA assigned every hour in the dining room with the usual of no more than 20-25 residents in the dining room for 1 CNA. There were about 20 residents that time. I did the assessment on R4, there was no apparent injury. Vital signs were normal. When I found her, she was laying on the floor opening graham crackers. She appeared to be herself. She cannot recall what happened. The CNA told me that she was attending to another resident, when she turned around, she saw R4 fell . She was the only CNA in the dining room at the time. She (R4) was assisted back to her chair. I called physician and told me to get an X-ray and she (R4) was later sent out. On 02/04/25 at 1:01 PM, V20 verbalized, On 01/16/25, I was in my dining room time. She (R4) does ambulate. I was keeping eye on another resident. On the other side. R4 was standing, it was fine because she ambulates, and she can walk. When I turned towards my left, I saw her (R4) going to the floor and fell . I was the only one in the dining room at the time. I believe it was after lunch. Usually, after lunch, there's only one CNA who rotates every hour for dining room supervision. There were 15 or slightly more residents at the time. Majority of residents were in wheelchairs. She (R4) was in the chair not in wheelchair because she can still walk. When I saw her fell to the floor, I called the nurse. V20 was asked what interventions should be implemented to prevent R4's fall. V20 mentioned, Close supervision, make sure she doesn't stand or ambulate. On 02/05/25 at 10:15 AM, V15 was asked regarding staff assignment for dining room supervision. V15 stated, We, nurses on the floor are the ones responsible for assigning a CNA to monitor the dining area. I'm on 100 unit. Only one CNA is assigned regardless of the number of residents in the dining room. The rotation is every hour. At 10AM to 11 AM and 2 PM to 3 PM, it is our activity time. Activity aides are assigned to conduct activities and there's no CNA assigned around this time. Between the hours of 3 PM to 4 PM, an activity aide and an assigned CNA should be in the dining room monitoring residents. This is the typical schedule for the day. R4 is in the 100 unit. I am her regular nurse. Per R4's incident report, she had a fall at approximately 2:04 PM. V15 stated that between 2 PM to 3 PM, it is scheduled activity time and activity aides should be conducting activities on resident. Facility was asked to provide schedule sheets for dining room supervision. V1 (Administrator) stated they don't document staff schedules. On 02/04/25 at 2:13 PM, V2 was asked regarding R4 and fall supervision and monitoring. V2 replied, Every hour, there could be one CNA assigned in the dining room. During monitoring of residents in the dining room, there should be one CNA assigned regardless of the number of residents present. Staff monitor residents, attend to their needs. For R4, we make sure she is clean, dry, fed, assisted with feeding, when she is up, she is in the dining. She can participate in activities, keeping her busy. She was not a fall risk before, she used to ambulate and still walking. I investigated her (R4) fall on 01/16/25. She had a fall in the dining room. She got up and she took some steps and lost her balance. She was sitting in the chair, stood up and fell on her left side. The nurse assessed her, and she was sent out. She sustained pelvic fracture. She was admitted for a few days and came back for readmission. She can get agitated, she can get impulsive, we try to approach her in a calm manner. She is confused. She likes to get up and move We have to bring her out to activities. We don't know exactly why she (R4) stood up but she had that fall. R4 is able to walk around, we just monitor her. We don't need to supervise her when walking, because she is able to walk around, prior to fall. R4's MDS dated [DATE] also recorded: Section GG - sit to stand: supervision or touching assistance; walk 10 feet: supervision or touching assistance. Supervision or touching assistance is coded as helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 02/04/25 at 1:14 PM, V22 (Physician) stated, I am her physician and been seeing her. I was notified that she had a recent fall. She is confused, walked around, and fell down, she had fracture in the pelvis. She just fell . For high risk residents for falls, I expect staff to constantly watch them. In the dining room, there should be close supervision. For a staff to be watching more than 15 residents in the dining room, and majority are in their wheelchairs, it is almost impossible to provide close supervision. If you are constantly looking into another resident and one resident may stand up, walk and fell , it's almost impossible. I expect staff to provide close supervision; eyes on them at all times and follow the facility fall protocol. Facility's policy titled Fall Prevention Program dated 2/28/14 documented in part but not limited to the following: Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Program contents: The Fall Prevention Program includes the following components: 4.Use and implementation of professional standards of practice. 5. Changes in interventions that were unsuccessful. 10.Care plan incorporates: b. Interventions are changed with each fall, as appropriate. c. Preventative measures. 11. Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care. Standards: 3. Safety interventions will be implemented for each resident identified at risk using a standard protocol. Safety Precautions for residents at risk: In addition to the use of Standard Fall Precautions, the following interventions will be implemented for resident identified at risk. 1.The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on interview and record review, the facility failed to identify and treat wounds on a resident (R1) before R1 was sent out to the hospital for one of three residents reviewed for wound care in a total sample of eight. This failure resulted in the unidentified wounds being present on R1's heels for an unknown amount of time without being treated. Findings Include: R1 is an [AGE] year old with the following diagnosis: type 2 diabetes, peripheral vascular disease (PVD), and rheumatoid arthritis. A Nursing note dated 11/3/24 documents R1 had a boil on the sacrum that burst and left an open area. The nurse practitioner was notified and ordered to cleanse the wound daily and apply a dry dressing. A Physician note dated 11/13/24 documents R1 currently has no concerns and is at baseline. The Treatment Nurse Initial Skin Alteration Review dated 11/4/24 documents a full thickness wound to the sacrum was identified on 11/3/24 and measured 0.3 cm x 0.3 cm x 1 cm. The wound bed had 100% granulation tissue with a small amount of serous drainage. R1 turns and repositions independently. A preventative measure includes daily skin checks during CNA rounds. On 12/24/24 at 12:37PM, V14 (Nurse) stated R1 was sent out the morning of 11/20/24 for altered mental status changes. V14 denied performing a skin assessment on R1 before leaving for the hospital because V14 was a newer nurse and wasn't aware V14 should do that. When asked why doing a skin assessment before a resident leaves the facility is beneficial, V14 reported the nurse needs to be responsible in being aware of what condition the resident left the facility in, so if anything comes up the facility can say who was at fault. On 12/24/24 at 2:12PM, V15 (Wound Care Nurse) stated R1 was being seen by wound care for a wound to the sacrum. V15 reported a full head to toe assessment must be performed daily on resident's with wounds. V15 stated V15 along with the CNAs and floor nurses are responsible for completing the daily skin assessments. V15 reported V15 likes to do a skin assessment before the resident leaves the facility so the facility knows what wounds occurred at the facility and what wounds did not happen at the facility. V15 denied being aware of any wounds to R1's ankle or heels. On 12/26/24 at 1:55PM, V16 (Wound Physician) stated a wound needs to be treated as soon as it develops because the wound could decline or not heal from not being treated. V16 reported the expectation of staff is to have due diligence in checking the skin if a resident is prone to developing the skin. V16 was unable to say how long the wounds on the left heel and left ankle took to develop. On 12/26/24 at 3:41PM, V18 (DON) stated R1 had a wound to the sacrum that was being treated at the facility. V18 reported if a wound develops in the facility, then staff need to identify the wound and treat it. The Weekly Skin Alteration Review dated 11/11/24 documents a full thickness wound to the sacrum that measured 0.3 cm x 0.3 cm x 0.8 cm. The wound bed had 100% beefy red granulation tissue with a small amount of serous drainage. The drainage had no odor. The wound is documented as improving as evidenced by decreased depth. The family was called and notified of the wound changes on this day. The Weekly Skin Alteration Review dated 11/19/24 documents a full thickness wound to the sacrum that measured 0.5 cm x 0.3 cm x 0.9 cm. The wound bed had 100% beefy red granulation tissues with a scant amount of serous drainage. The wound was stable due to no changes. The Wound Physician note dated 11/19/24 documents this was the initial evaluation by the wound care physician. R1 was in no acute distress. The wound on the sacrum is a full thickness wound that measured 0.5 cm x 0.3 cm x 0.9 cm. The wound is documented as being caused by an abscess that spontaneously drained. The dressing was changed to iodoform to be changed daily. There was no other documentation that R1 had any wounds to the left ankle or heel. The Bath and Skin Report Sheet dated 11/2024 documents skin assessments were completed on shower days on 11/2/24, 11/6/24, and 11/9/24 and the only documented wound is to the sacrum. A Nursing note dated 11/20/24 documents R1 showed signs of altered mental status and was sent out to the hospital. R1 was admitted to the hospital with a diagnosis of altered mental status and congestive heart failure. The Hospital Records dated 11/19/24 documents R1 presented from the nursing home with altered mental status. A skin assessment was performed by the wound care team. A full thickness wound to the sacrum was noted. The wound is down to the bone and has a foul odor. There is also dark discoloration to the left heel consistent with a deep tissue injury. The left lateral ankle and hallux has a small opening to the skin with eschar present. This is consistent with an unstageable pressure injury. R1 was admitted to the hospital with a diagnosis of sacral wound infection and altered mental status. The Care Plan dated 5/8/20 documents R1 is at risk for alteration in skin integrity due to skin being occasionally exposed to moisture due to incontinence and being at risk for friction/shearing. An intervention includes to check skin during routine care on a daily basis and during the bi-weekly bath or shower schedule. The Care Plan dated 4/17/23 documents R1 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to diabetes, anemia, abnormal posture, and peripheral vascular disease. An intervention includes to check skin during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. The Care Plan dated 12/1/23 documents R1 has PVD and is at increased risk of skin integrity issues with a potential for diminished blood flow to the lower extremities. An intervention includes to observe for discoloration for the skin. The policy titled, Pressure Ulcer Prevention, dated 09/2014 documents, Purpose: To prevent and treat pressure sores . Procedure: .2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures. The policy titled, Pressure Injury and Skin Condition Assessment Policy, documents, Purpose: To establish guidelines for assessing, monitoring, and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented .Standards: .4. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the Charge Nurse who will perform the initial assessment .6. Care givers are responsible for promptly notifying the Charge Nurse of skin observations, including but not limited to: A. redness/swelling B. bruises C. skin tears D. blisters E. excoriations F. wound drainage G. crusts H. scales I. any type of lesion J. skin discoloration K. bleeding L. changes in skin temperature The policy titled, Discharge/Transfer of Resident, dated 04/2014 documents, .7. Complete Transfer Form accurately and completely including vital signs. Ensure that resident's current physical and psycho/social assessment, medications, and current treatment is completely described and available to the receiving facility upon transfer .10. Thoroughly assess resident prior to discharge/transfer.

Based on interview and record review, the facility failed to monitor a high fall risk resident (R2) during a scheduled monitoring period for one out of three residents reviewed for falls in a total sample of eight. This failure resulted in R2 suffering a right fractured hip after falling from a chair while reaching out for a nearby object when unsupervised. Findings Include: R2 is an [AGE] year old with the following diagnosis: history of falling, dementia, and age-related osteoporosis. A Nursing note dated 12/8/24 documents it was reported by the CNA (V9) that R2 slid out of a chair attempting to reach for something that was in another chair. V9 reported R2 fell on to the right hip. R2 denied any pain upon assessment and was placed back into bed. X-rays of the hip/pelvis were ordered. R2 remains alert and oriented times one per baseline. The Unusual Occurrence Final Investigative Report Form dated 12/13/24 documents R2 slid out of a chair while attempting to reach for something that was in another chair. R2 fell on to the right hip. R2 was sent out to the hospital for evaluation. R2 returned from the hospital with a diagnosis of a closed femur fracture. A statement from V9 documents V9 was providing care to another resident in the room when R2 was noted reaching for an object in another chair. V9 reported the object was a few feet away from R2 and R2 fell on to the right side while reaching to get it. The Hospital Record dated 12/8/24 documents R2 presented to the hospital after a fall. R2 is alert and oriented times one per baseline. X-ray of the hip was consistent with a right femoral neck fracture. R2 was admitted and ortho was consulted for surgery. R2's admitting diagnosis was displaced fracture of the right femoral neck. On 12/20/24 at 1:59PM, R2 was sitting in a chair in R2's room. V2 (CNA) was sitting within arm's reach of R2. R2 was unable to answer any questions due to mental status. V2 reported R2 fell and broke the right hip but was not able to answer and detailed questions about the fall. V2 stated R2 has a behavior of constantly trying to get up without asking for assistance. V2 reported R2 is always confused and needs multiple attempts to redirect before R2 will listen. V2 stated one staff member is assigned to sit in the room to monitor residents due to being high fall risk. V2 reported if any other care tasks need to be completed while assigned to monitoring then another staff member must come and sit with the residents in the room to make sure they stay safe. On 12/24/24 at 10:10AM, V9 (CNA) stated V9 got R2 ready for the morning then sat R2 in a chair while V9 began providing morning care to R2's roommate. V9 reported there was linen sitting on another chair about three to four feet away from R2 and R2 began reaching for the linen. V9 stated by the time V9 looked up and saw R2 reaching that it was too late to tell R2 to stop because R2 was in the middle of falling. V9 reported R2 has a behavior of trying to get up unassisted and walk alone. V9 stated R2 is a high fall risk because R2 is confused and R2's gait is unsteady. V9 reported V9 should have gotten another staff member to watch R2 but V9 did not think R2 would try to get up unassisted at that time. V9 stated V9 was responsible for monitoring the residents in that room at the time R2 fell . On 12/24/24 at 10:24AM, V10 (Nurse) stated V9 came to the nurse's station and told V10 that R2 fell while reaching for something that was in another chair. V10 reported R2 is a high fall risk because R2 walks on R2's [NAME] toes and is only alert and oriented times one. V10 stated R2 needs constant redirection and supervision due to being impulsive. V10 reported a staff member is always sitting in R2's room monitoring residents. V10 reported if the person assigned to monitoring needs to take care of someone else then another staff should be notified so R2 can be monitored. V10 denied V9 asking for assistance the day R2 fell . V10 said, I was kind of shocked she fell with a CNA in the room with her. On 12/24/24 at 10:36AM, V11 (Former Restorative Nurse) stated V11 resigned before the fall but knows R2 is impulsive and has an unsteady gait. V11 reported the CNAs have monitoring schedules for that room because R2 is such a high fall risk. V11 stated staff switches out throughout the shift so R2 can be constantly monitored. V11 reported the only responsibility staff has during their monitoring time is to monitor the high fall risk residents to make sure they don't fall. V11 stated another staff should be notified to help watch R2 is the staff scheduled for monitoring needs to perform another task during that time. On 12/24/24 at 12:26PM, V13 (Therapy Director) stated R2 was discharged from therapy on 12/3 after reaching the highest performance level. V13 reported they were working with R2 because R2 is a high fall risk and very unsafe. V13 stated R2 has an unsteady gait and is impulsive. V13 reported R2 needs 1:1 supervision to maintain safety. On 12/26/24 at 3:11PM, V17 (Medical Director) stated R2 fell in early December and suffered a hip fracture. V17 reported R2 fell while reaching for something while in a sitting position. V17 stated R2 has severe dementia but is not lethargic. V17 reported being aware the CNAs having a monitoring schedule for R2. V17 stated staff needs to be monitoring residents and redirecting them when get up unassisted during the monitoring time. V17 reported if another resident is in need of care, then more staff need to be called into the room to monitor R2 to make sure R2 does not fall. V17 stated the main priority when staff is assigned to monitoring is to monitor the high fall risk residents and keep them from falling. On 12/26/24 at 3:41PM, V18 (DON) stated an intervention to help R2 from falling is to have staff in the room with R2 or have R2 sit at the nurse's station. V18 reported if the CNA responsible for monitor needs to leave the room or take care of another resident then a nurse or another CNA needs to be called into the room to make sure monitoring is continued. The Physical Therapy Discharge Summary dated 11/29/24 documents R2 resides in a long term care facility and 24 hour a day supervision is needed. R2 needs partial/moderate assistance with transfers and walking. The Daily Assignment Sheet dated 12/8/24 documents V9 was assigned to monitoring at 9AM until 10AM. V9 was also assigned to provide care for the room R2 resided in. The Fall Report dated 12/8/24 documents V9 reported R2 was reaching for an object in another chair and fell out of the chair hitting R2's right hip. Upon attempting to have R2 stand, R2 showed facial grimacing and was unable to stand. R2 is alert to person only. Predisposing physiological factors to the fall are documented as gait imbalance, impaired memory, incontinent, and agitation. Predisposing situation factors are documented as incident occurred during unassisted transfer. The Care Plan dated 1/1/24 documents R2 is high risk for falls related to confusion, being unaware of safety needs, unsteady gait, impulsiveness, and history of falls. The Care Plan dated 12/11/24 documents R2 fractured the right hip. Appropriate interventions are documented. The Minimum Data Set (MDS) dated [DATE] documents the Brief Interview for Mental Status score as five (severe cognitive impairment). Section GG of the MDS documents R2 needs partial/moderate assistance with bed mobility, transfers, and walking. The policy titled, Fall Prevention Program, dated 2/28/14 documents, It is the policy of the facility to have a Fall Prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary .In addition to the use of Standard Fall Precautions, the following interventions will be implemented for resident identified at risk. 1. The resident will be checked approximately every two hours, or as according to the care plan, to assure they are in a safe position. The frequency of safety monitoring will be determined by the resident's risk factors and the plan of care.

Based on interview and record review, the facility failed to follow their policy by failing to provide an individualized plan of care with effective interventions to prevent falls; the facility failed to provide supervision while walking in corridors per resident assessment. These failures applied to one (R1) of five residents reviewed for falls and resulted in R1 having three falls in the last three months and requiring hospital transfer for medical treatment of a laceration and hematoma after the last two falls. Findings include: R1 is [AGE] years old and has resided at the facility since 2022, past medical history includes Altered mental status unspecified, anxiety disorder, hallucinations, malignant neoplasm of unspecified site of female breast, metabolic encephalopathy, unspecified dementia, unspecified fall, unspecified protein calorie malnutrition, etc. 11/12/2024 2:15PM, R1 was observed in her room sleeping, bed not low and no floor mats on either side of the bed. Resident's walker was noted in the room but not close to the resident, no call lights noted and bedside table with an empty plastic cup was observed in front of resident's bed. Review of resident's health record showed R1 had 5 unwitnessed falls since 1/11/2024 (4 in the hallway and 1 in resident's room) and was sent to the hospital 4 times for medical management after the falls. Minimum Data Set (MDS) assessment dated [DATE] section C (cognition) scored R1 as a 4 for brief interview for mental status (BIMS). Section GG (Functional abilities and goals) coded R1 as requiring partial to moderate assistance for most activities of daily living (ADL). R1 was also assessed as requiring supervision or touching assistance for walking in the room or corridors. Fall risk assessment dated [DATE], 10/7/2024 and 10/13/2024 all documented R1 is a high risk for fall. Care plan initiated 9/3/2022, revised 7/23/2024 stated R1 is at risk for falls related to history of falls. Interventions include encourage resident to take frequent breaks from ambulating on the unit, redirect resident when up and ambulating with walker, gather information on past falls and attempt to determine the root cause of the fall, anticipate, and intervene to prevent recurrence, etc. Progress note dated 8/3/2024 states R1 had a fall in the 100-unit exit door while ambulating with her walker, no visible injury noted. Another note dated 8/5/2024 documented R1 was observed walking around the facility without walker, staff redirecting resident to use her walker. Facility reported incident dated 9/4/2024 stated R1 was ambulating with her walker down the hallway when another resident swung the dining room door open, hitting R1 who fell and sustained a laceration to the left side of her forehead. R1 was sent to a local hospital where her laceration was treated with derma glue. A reportable incident dated 10/13/2024 documented 2 staff nurses were called to the 200 unit for a fall, R1 was found in a sitting position with her walker in front of her, a large hematoma was noted to her left forehead, the incident was unwitnessed. R1 stated her head hurts and was sent to emergency room for further evaluation. 11/13/2024 at 12:43PM, V7 (Restorative Nurse) said R1 has a walker and ambulates by herself but still requires staff supervision. 11/13/2024 at 1:00PM, V4 (LPN) said the day R1 had a fall, V4 was paged to the front lobby. R1 was walking in the hallway by the main dining room, another resident was coming out of the dining room, opened the door and hit R1 accidentally. V4 added R1 was on the floor when she got to the scene, she noted some blood coming from a laceration above her right eye was about 2 centimeters in length. R1 was asked what happened and she stated she fell . V4 said no one witnessed the fall. V4 said R1 falls all the time. R1 walks with her walker but will discard the walker sometimes. Staff tries to redirect her. R1 is hard to monitor because she walks all the time and can be aggressive, and one time she tried to throw her walker to a staff. 11/13/2024 at 1:48PM, V8 (C.N.A) said she was assigned to R1 the day she had a fall. R1 likes to walk by herself with her walker and she is confused. V8 said she did not witness the fall; she was charting at the nursing station and was notified by another C.N.A R1 was on the floor. When V8 got there, R1 was sitting on her bottom with her walker in front of her. There was no staff at the nursing station where resident fell . 11/13/2024 at 2:50PM, V2 (DON) said R1 is alert with confusion, walks around with a rolling walker and will sometimes leave her purse and staff will bring it to her. V2 stated R1 requires supervision and her last 3 falls were unwitnessed. V2 said after the last 2 falls the only changes to resident's intervention is sending resident to the hospital, fall care plan should be individualized. R1 may need more supervision to avoid further falls with injury. 11/4/2024 at 3:53PM, V9 (C.N.A) said she was charting at the nursing station when R1 walked past her then she heard a thump and went to check it out. V9 saw R1 on the floor, and R1 said her head hurt. There were no visible injuries or bleeding noted. V9 said, R1 walks around all the time with her walker, staff tries to redirect her, but she does not listen. There was no body in the hallway when R1 fell . Fall policy dated 2/28/2014 presented by V1 (Administrator), stated in part it is the policy of the facility to have a fall prevention program to assure the safety of all residents in the facility, when possible. The program will include measures which determine individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Under safety precautions for residents at risk, the policy states in addition to standard fall precautions, the following interventions will be implemented for resident identified at risk: 1. The resident will be checked approximately every two hours, or according to the care plan, to assure they are in a safe position. The frequency of the checks will be determined by the resident's risk factors and plan of care. 2. In the event safety mentoring is initiated for 15-30 minute periods, a documentation record will be used to validate observations. Assigned nursing personnel are responsible for completing the safety checks ad documenting.

Based on interviews and records reviewed the facility failed to ensure one resident (R6) remained free from resident to resident sexual assault. This affected two of three residents (R6, R8) reviewed sexual abuse. This failure resulted in R6 being kissed in the mouth unwantedly by R8. R6 said she feels scared and on-guard when walking past R8. Findings include: Final Facility Incident Report shows R6 reported to facility that R8 kissed R6 on the lips. The following conclusion was determined about the allegation: abuse is founded. R8 has diagnosis including but not limited to Alzheimer's Disease, Dementia, Psychosis, Weakness, Cognitive Communication Deficit, Violent behaviors, and Homicidal Ideations. R8's cognitive assessment dated [DATE] indicates a score of 9, impaired. R6 diagnosis include but are not limited to Hemiplegia following Cerebral Vascular Infarction, Hypertensive Heart Disease, Dysphagia, Hyperlipidemia, Alcohol Abuse, and Cocaine Abuse. R6's cognitive assessment dated [DATE] indicates a score of 13, intact. On 5/30/24 at 9:40AM R8 was observed in his room, in bed, resting. The surveyor asked R8 where he is, and R8 responded 'in a hospital'. R8 said he does not know anyone here and has not made friends. R8 said he does not have a girlfriend or wife in the facility. R8 said he has never kissed any women in the facility. On 5/30/24 at 9:45AM R6 said, I was passing his (R8) room in the hallway, he was standing by his door, and he tapped me on the shoulder when I turned, he kissed me on the lips. I couldn't believe it. No, I didn't want him to kiss me. R6 said, When I see (R8), I feel scared he will try again. I'm 'on guard' now when he comes around me. There were two CNAs in the dining room, and they saw it and they said he has done it before. On 5/31/24 at 1:48PM V43, Nurse, said R6 reported R8 had tried to kiss R6 or R8 did kiss her. R6 said R8 was in the dining room. R6's Screening for Indicators of Aggressive and or Harmful Behaviors dated 5/1/24 documents, R6 has factors that increase vulnerability: yes. Review of R8's Progress notes dated 5/19/24 R8 observed being sexually aggressive towards 2 female residents, grabbing their faces and trying to kiss them. Both females were visibly upset. Review of R8's Progress notes dated 3/16/24 documents as follows: Resident received in bed, alert with confusion and aggressive behavior. R8 stated to CNA, I just want to beat her a-- !!. Resident has been noted to be aggressive when staff come in room, staff (nurse) are noticing aggressive behavior to increase, with attempt with aggressive physical contact with staff. Review of R8's care plan does not include interventions for aggressive behaviors. Review of police narrative states, on 5/19/24 R6 stated a male approached her, placed both hands on her face and kissed her upon the lips. The male was later identified as R8. R6 said she did not welcome or consent to R8 having kissed her. The facility undated Abuse Prevention Program Facility Policy states, in part, the facility affirms the right of our residents to be free from abuse.

Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 7. This failure resulted in R1 sustaining a fall which required emergency medical transport to a local hospital where she was admitted and diagnosed with a subdural hematoma (brain bleed). The findings include: R1's fall investigation report dated June 20, 2023, showed R1 sustained a fall when she was ambulating with the CNA (certified nursing assistant) to the bathroom. The report showed R1 fell back, hitting her head on the bathroom floor. A hematoma was noted to the back of R1's head after her fall. R1 was sent to a local hospital, by ambulance, where she was diagnosed with a subdural hematoma, as a result from her fall. R1's care plan revised May 11, 2023, showed R1 had diagnoses including dementia, altered mental status, anxiety, lack of coordination, and difficulty walking. The care plan showed R1 was at increased risk for falls due poor balance, impaired ambulation, and decreased safety awareness. R1's Restorative Nursing Review dated June 1, 2023, showed R1 required the extensive assistance of one staff for transfers. R1 was totally dependent on one staff for toileting/incontinence care. On July 27, 2023, at 11:55 AM, V16 Family of R1 stated, The nurse called me from the facility, on June 20, 2023, to tell me (R1) had fallen while she was being walked to the bathroom. I don't understand why they walked her to the bathroom. (R1) was wheelchair-bound at that time. She didn't walk anywhere. On July 28, 2023, at 8:50 AM, V9 CNA stated, I was taking care of (R1) when she fell . I was standing in front of her, holding her hands, as I helped her walk from her bed into her bathroom. I was walking backwards, facing (R1), as she tried to walk forwards. I didn't use a gait belt. I held onto both of her hands. We walked into the bathroom and there was stool on the toilet seat. (R1) saw the stool, got upset, and lost her balance. She fell back onto the floor, hitting her head. I couldn't catch her. I went and got the nurse right away. She wasn't bleeding but she had a medium sized lump to the back of her head . I should have wheeled her to the toilet, in her wheelchair, and then used a gait belt to transfer her from her wheelchair to the toilet. On July 28, 2023, at 9:22 AM, V10 Restorative Nurse stated, (R1) was wheelchair-bound. She couldn't walk on her own. She was at risk for falls. She had been on a walking program for restorative programming. Some days were good days and she could walk with our help. She could take 2-3 steps. Some days she couldn't walk even with our help. To ensure her safety when we walked her, one staff member would walk next to her, holding onto the gait belt, that was around her waist. Another staff member would walk directly behind (R1), with a wheelchair, in case she had to sit down. (R1) was also supposed to use a walker when staff ambulated her also. On July 28, 2023, at 10:45 AM, V4 Assistant Director of Nursing stated, (R1) was confused and wheelchair bound. She didn't really walk at all. She could pivot-transfer with one person assisting. Staff should have always used a gait belt when transferring her because of her being at risk for falling. On July 28, 2023, at 10:30 AM, V12 Physician stated, (R1) really didn't walk. She was primarily wheelchair bound. She needed assistance with all her ADLs (activities of daily living). Due to her being a fall risk, staff were supposed to use a gait belt when transferring her. The facility's Gait Belt policy dated June 2014, showed, Purpose: To provide support and safety during ambulation, lifting, or transferring residents. Place belt around resident's waist .Grasp belt webbing securely at resident's back and resident's right or left side to support resident balance during transfers .Stand slightly behind and to the side of the resident .

Based on observations, interviews, and record reviews, the facility failed to: (A) follow their wound prevention and management policy to ensure residents do not develop pressure sores for 3 [R55, R67 R74] residents; (B) ensure resident [R74] received prescribed amount of nutritional feeding via gastric tube; (C) assess resident [R67] for a new pressure ulcer and provide treatment and (D) ensure air loss mattresses were functioning properly and set according to manufacturer's instructions for 5 [R1, R24, R55, R130, R131] residents. These failures resulted in R55, R67, and R74 developing facility acquired pressure wounds; [R55] unstageable DTI [Deep Tissue Injury] (right hip) partial thickness, unstageable due to necrosis (sacrum) full thickness, [R74] unstageable DTI [Deep Tissue Injury] of the left ischium partial thickness, and [R67] two open beefy red, pink wound bed area on (right buttocks). Findings include: On 2/21/22 at 9:40 AM, surveyor and V17 [Licensed Practical Nurse] observed R55 lying in supine position in a deflated air loss mattress bed, flat to the metal frame. V17 stated, I gave R55 her medications this morning, but I did not notice the air loss mattress flat. I am not sure how long R55's mattress been flat. I don't know anything about these air mattresses, I'll get the housekeeper to fix the air mattress. On 2/21/22 at 9:55 AM, V18 [Housekeeper] stated, I'm not in charge of the air loss mattress, but I can usually get them back working. R55's air mattress will not turn on because it is unplugged from the outlet. Give it a few minutes to fill back up with air. On 2/21/22 R55's medical record documents in part; admitted on [DATE], medical diagnosis of dementia, quadriplegia, muscle wasting and atrophy, atherosclerotic heart disease, Alzheimer's disease, and weakness. R55's weekly wound assessment dated [DATE]- (right hip) facility acquired unstageable pressure DTI [Deep Tissue Injury] with partial thickness, measures [L-length, W-width, D-Depth] (L) 6.2 x (W) 4.8 x (D) not measurable cm and (sacrum) unstageable facility acquired pressure wound due to necrosis, full thickness (L) 9.0 x (W) 8.2 x (D) Not measurable cm. Weekly wound assessment dated [DATE]-stage 4, sacrum facility acquired pressure wound with full thickness measures (L) 8.5 x (W) 7.3 x (D) 0.7cm. On 2/13/23 last weekly wound assessment- stage 4 sacrum facility acquired pressure wound with full thickness measures (L) 9.0 x (W) 8.0 x (D) 0.8 cm. Care plan dated 12/13/22- facility acquired pressures wounds on sacrum and right hip. Interventions; low air mattress. Physician order dated 1/27/23 Calcium Alginate External, apply to sacrum topically every day shift, cleanse area with normal saline, pat dry, and cover with border gauze. Order dated 2/13/23, Dakin's 1/4 strength External solution 0.125%-apply to right hip topically every day shift, clean wound area with Dakin's pack wet to moist and Santyl cover with bordered gauze. On 2/22/23 at 8:15 AM, R55 was transferred to the hospital, surveyor unable to observe wound care. On 2/21/23 at 9:45 AM, surveyor and V17 entered R1's room and observed R1 lying in supine position in a deflated air loss mattress bed, flat to the metal frame. V17 stated, R1 sometimes refuse help, I am not sure why R1's air loss mattress is off and not working. The housekeeper will come and check on her bed. On 2/21/23 at 10:00 AM, V18 [Housekeeper] stated, R1's air loss mattress is plugged into the outlet, but I cannot get the air pump to turn on, I will change out the air loss mattress for another one. On 2/22/23 at 8:01 AM, surveyor observed R74 resting in bed with the port from the tube feeding laying on the floor. The Glucerna 1.2 bottle was labeled with R74's name, dated 02/21/2023 to run at 50 mL per hour, to start at 12:00 PM. Surveyor saw the tube feeding bottle was only missing 500ml out the bottle. On 2/22/23 at 8:31 AM, V7 (Licensed Practical Nurse) stated, I did not disconnect R74 from the gastric tube feeding because the night nurse disconnected her (R74) from the tube feeding machine at 7:30 AM this morning on 02/22/2023. V7 stated, the initials on the Glucerna bottle are mine and I started the infusion at 12:00PM yesterday (02/21/2023) and only 500mL was infused over 20hours. I'm not sure what happened after my shift. According to the order, R74 is supposed to receive 1000mL over 20 hours but she (R74) only received 500mL. R74's medical record documents in part; admitted on [DATE], medical diagnosis-protein calorie malnutrition, history of sepsis, essential hypertension, pressure ulcers, type II diabetes, depression, altered mental status, and anemia. R74's weekly wound noted dated 12/16/22-(left ischium) unstageable pressure wound DTI of the with partial thickness, measures (L) 2.9 x (W) 2.0 x (D) not measurable cm. Weekly assessment dated [DATE] noted the left ischium is not full thickness stage 4 pressure ulcer measures (L) 2.3 x (W) 2.5 x (D) 0.7cm. Care plan dated facility acquired Left ischium noted 12/16/22. Interventions; air loss mattress, nutritional supplements per dietician recommendations. Physician order dated 1/18/23- Enteral feed order every shift Glucerna 1.2 calorie at 50 ml/hour for 20 hours turn on at 12 noon, turn off at 8am. Treatment order dated 2/10/23 Calcium alginate external, apply to left ischium topically every day shift for wound care, cleanse the area with normal saline, pat dry, cover with bordered gauze. Treatment order dated 2/13/23- Collagen antimicrobial external sheet, apply to left ischium topically every dayshift for wound care, cleanse the area with normal saline, pat dry and cover with bordered gauze. On 2/22/23 at 10:35 AM, R67 stated, Please get the nurse, my butt is hurting and burning. On 2/22/23 at 10:40 AM surveyor and V15 entered R67's room to completed body check. V15 stated, R67 does not have any wounds, but we will continue with the body assessment. On 2/22/23 at 10:45 AM surveyor observed on R67's right buttock, 2 open beefy red, pink wound bed areas on (right buttocks). V15 cleans the area and measured the areas. V15 stated, The two areas equal together (L) 2.0 x (W) 0.6 x (D) not measurable. I do not measure each area separately, because they are close to each other. I don't feel these open areas are pressure ulcers, so at this time I will not complete a wound assessment, but I will place an order and notify the physician and family on a progress note. R67 medical record documents in part: admitted on [DATE], with medical diagnosis of hemiplegia with hemiparesis, essential hypertension, weakness, type II diabetes and acute kidney failure. No physician treatment orders noted. Care plan dated 9/12/22-R67 is at risk for skin integrity issues, Interventions: Skin will be checked during routine care on a daily basis. On 2/22/23 at 1:19 PM, V14 [Wound Care Physician] stated, I am the wound care physician and make rounds once a week. The air mattress should not be flat, the supporting mattress should be afloat with air. I will not say if a resident lays on a metal frame it could potentially cause a wound to worsen. However, I will say a resident with wounds should be on a group two mattress and has been set to appropriated manufactures recommendation and function properly. Group two mattress are low air mattress, and special memory foams to meet the requirements per manufacture manual to provide benefits. I last assessed R55's wounds on 2/13/23, during that time her [R55] wounds have gotten better, and over the last couple of months some of R55's wounds deteriorated but also gotten better, due to R55's medical diagnosis of anemia, and comorbidities. R74's wound assessment today, some of her [R74] wounds have deteriorated due to R74 not absorbing the enteral gastric nutrition, and failure to thrive. On 2/23/22 at 1:45 PM, V15 [Wound Care Nurse] stated, R55 developed a facility acquired right hip pressures ulcer and facility acquired sacrum wound noted on 12/12/22. The size of R55's wounds have decreased and increased over the past couple of months. The air loss mattress is an intervention to prevent and assist in wound healing. If the air loss mattress is not functioning properly or not turn on, it could potentially interfere with the wound healing process. R74 was admitted with a sacrum, left hip, right hip wounds. On 12/16/22 R74 developed a facility acquired left ischium wound. All R74's wounds have got better and worsen over the past few months, due to her malnutrition and her [R74] contractures. After R74 was admitted to the facility, R74 received an gastric tube placed to help with her malnutritional status. If a resident is not receiving their gastric tube nutrition as prescribed, it could potentially interfere with wound healing. On 2/23/22 at 2:15 PM, V3 [Director of Nursing] stated, Air loss mattresses are to be monitored by the staff nursing daily. The nurses upon making rounds, passing medication, and answering call lights are to monitor the air loss mattresses. If there are any problems, notify housekeeping, and me for further instruction. R55 and R1's nurse V17 [Licensed Practical Nurse] will be in-serviced regarding the air loss mattresses. The air loss mattress not being on at all, could potentially cause a pressure ulcer or worsening of a pressure ulcer due to the pressure on the metal frame. If a resident is not receiving the prescribed amount of gastric tube nutritional feeding it could potentially make the wound worsen or interfere with the wound healing process. When residents receive showers, bed baths, or incontinence care, the certified nurse assistance and nurses are to monitor the resident's skin and peri area for any sign of skin alterations. If any skin breakdown or alteration is noted, the staff should report it immediately to the nurse, and treatment nurse. Then the nurse would assess, clean, and place a bandage on the area. Notify the physician, family, wound care nurse and document the findings. If the protocol is not followed, the resident will have a delay in treatment. I will in-service the staff in regard to R67 new open areas found by the surveyor. On 2/24/22 at 11:12 AM, V21[ Dietician] stated, R74 was admitted to the facility under weight, the family finally agreed to a gastric enteral feeding tube to assist with R74's nutrition. R74 was to receive Glucerna 1.2 at 50ml per hour for 20 hours per day, equals 1000ml per day to meet R74's caloric needs. If R74 only received 500ml of the 1000mls ordered, it could potentially cause weight loss, and not provide sufficient amount of feeding to help with wound healing. Policy documents in part: Pressure Ulcer Prevention Handout dated 9/2014 -A pressure ulcer is defined as any lesion caused by unrelieved pressure that result in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degrees of tissue of tissue damage observed. -Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions revised those approaches as appropriate. -Stage II pressure ulcer- loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough or bruising - Skin assessments must continue on a daily basis for all residents that are at risk for skin breakdown. -Poor diet intake can play a role in pressure ulcer development and delayed healing -The important thing to check for when using a pressure reducing overlay or mattress is bottoming auf. Place your hand under the overlay at the point of the sacral contact. If the sacrum is making contact with the bed mattress the pressure relief is not being achieved. 45111 R24 is a [AGE] year-old individual admitted to the facility on [DATE]. R24's medical diagnosis includes but not limited to: paraplegia, unspecified, Chronic Obstructive Pulmonary disease, pressure ulcer of other site, stage 3, obstructive sleep apnea, other specified noninfective disorders of lymphatic vessels and lymph nodes, acute embolism and thrombosis of deep veins of the right upper extremity. R24's Brief Interview for Mental Status (BIMS) dated [DATE], document R24's BIMS as 12/15. R24's Activities of Daily Living (ADL) Assistance dated [DATE], documents R24's Bed mobility, Transfer, Toilet use, Personal hygiene as R24 needing extensive with two or more persons. R24's MDS section M (skin conditions) dated 2/14/2023 document R24 as having a pressure ulcer/injury, and skin treatments to include pressure reducing device for bed. On 2/21/2023 at 11:17am, R24 was observed lying on bed on a low air mattress. With V11 in R24's room, V11 was asked to check R24's weight setting on R24's low air mattress pump. V11 with surveyor checked the air pump and the weight on the pump was set at 540 lbs. V11 commented that R24's weight is way less than 540 lbs. V11 said that if R24's air mattress was not set using the correct weight for R24, then the air mattress is not therapeutic and can contribute to more pressure ulcers. V11 said that the wrong air pressure can make R24 very tired and uncomfortable. V11 said the air mattress needs to be set using R24's weight. 02/23/23 11:04 AM, V15 (Wound care nurse) said allow air mattress for R24 should be set on the correct weight to improve wound healing, for offloading and to provide the correct firmness to prevent pressure ulcers from developing or get worse. R24's physician orders dated 2/13/2023 13:27document R24's weight as 435.0 Lbs. R131 is a [AGE] year-old individual admitted to the facility on [DATE]. R131's medical conditions include but not limited to: Pressure ulcer of the sacral region, stage 4, cellulitis of the left external ear, pressure ulcer of the left buttock, stage 2, other, pulmonary embolism without acute cor pulmonale. R131's Brief Interview of Mental Status (BIMS) Activities of Daily Living (ADLs) is not completed at this time. On 2/21/2023 at 10:30am, R131 was observed lying on her bed. V11 (Licensed Practical Nurse) was observed in R131's room and stated she (V11) was checking on R131. Observed R131 laying on a low air mattress, pump setting for R131's weight set at 220 lb. V11 was asked what R131's weight was, and if the weight on low air mattress pump was correct. V11 said There is no way R131's weight is 220lbs. I will go and check on R131's chart. V11 came back to R131's room and stated that there were not weights on record for R131. V11 was asked how the setting on air low mattress was determined without R131's weight. V11 said V11 does not know who set R131's low air mattress. V11 said R131's mattress should be set according to R131's weight because the weight goes with the amount of pressure released from the air mattress. V11 said it is a problem to have the air mattress at the wrong setting because wrong setting means the air mattress is not therapeutic and can lead to pressure ulcers or worsening of the existing pressure ulcers. On 2/22/2023 at 2:40pm, V15 (wound care Nurse) said air mattress should be set at the right weight. V15 said if the air mattress weight is set at a higher weight than the resident's, then the mattress will be too firm, or uncomfortable for the resident. V15 further commented that air mattresses are used for offloading, wound healing and for preventive measures to prevent skin breakdown. R131's physician orders, dated 2/15/2023 document: Low air loss mattress R131 weights on 2/21/2023 12:25 document R131's weight as 133.7 lbs. R130 is an [AGE] year-old individual admitted to the facility on [DATE]. R130's medical diagnosis includes but not limited to: pressure -induced deep tissue damage of other site, difficulty in walking, not elsewhere classified, dysphagia, underweight, venous insufficiency(chronic)(peripheral). R130's MDS (Minimum Data Set) section C-Brief Interview for Mental Status (BIMS) dated [DATE]. R130's Activities of Daily Living (ADL) Assistance, dated [DATE], documents R130 is total dependence, two plus personal assistance with bed mobility, transfer, dressing, eating, and walking. R130's section M dated 1/13/2023 documents R130 has pressure ulcer injury, skin tear, pressure reducing device for bed and chair. On 2/21/2023 at 11:00am, R130 was observed lying in bed on a low air pressure mattress. Surveyor with V11 (Licensed practical Nurse-LPN) in R130's room observed R130's low air mattress pump set at weight of over 350 lbs. V11 said R130 is not over 350 lbs. I don't know who set it to over 350lbs. V11 said setting the weight at over 350lbs is not therapeutic for R130 and can cause pressure ulcers and discomfort to R130. V11 said for the air mattress to be therapeutic, it needs to be set at the right weight so that it can provide the correct amount of pressure therapeutic to R130. 02/23/23 11:04 AM V15(Wound Nurse) said some of R130's wounds are improving, and others are getting worse. V15 said allow air mattress for R130 should be set on the correct weight to improve wound healing, for offloading and to provide the correct firmness to prevent pressure ulcers from developing or get worse. R130's weight dated 2/17/2023 documents R131's weight as 83.6lbs. R130's physician orders dated 12/8/2022 document-Low Air Loss Mattress Facility provided manufacture's instructional manual for low pressure mattress, no title, no date under HOW TO USE, documents: position of knob pressure to correlate with weight to produce amount pressure related to weight. Facility Policy titled Low air mattress, no date, documents: Set device according to resident's weight.

Based on observations, interviews, and records reviewed the facility failed to ensure fall prevention interventions were in place. This affected 2 of 3 residents (R9, R3) reviewed for fall prevention interventions. This failure resulted in R9 falling from her wheelchair and sustaining a closed left [CONDITION(S)] that required surgical intervention. Findings include: 1. R9 is [AGE] years old with diagnosis including, but not limited to Dementia, Diabetes Mellitus, Low Back Pain, Hypertension, Muscle Wasting and Atrophy Right and Left Thighs, Major Depressive Disorder, [CONDITION(S)], History of Falling, Abnormal Posture, Weakness, and Repeated Falls. R9 fell on [DATE] in the facility and was sent to the hospital for evaluation. R9 did not return to the facility during the survey. On 10/25/22 at 12:27PM V25, Certified Nursing Assistant (CNA), said R9 was in another resident's doorway leaning forward in her wheelchair. V25 said when she saw R9 entering another resident's room she approached her and noticed R9 was sitting on the edge of the chair. V25 said R9 was pulling on the doorway to maneuver herself into the room and sliding herself out of the wheelchair. V25 said I was trying to get R9 to release her grip from the doorway and she was resisting, yelling, and saying no. V25 said R9 was not responding to redirection. V25 said R9 was leaning forward and then she leaned to the left and fell out of her chair. V25 said she did not see a nonskid pad in R9's wheel chair when R9 fell . V25 said I called the nurse when R9 was on the floor V25 said V13, CNA, the nurse, and myself picked R9 off the floor. V25 said we did not use a lift to get R9 off the floor, after the nurse checked her. V25 said R9 was picked up off the floor, assisted into the wheelchair, and then placed in her bed. V25 said she was not assigned to R9 on 10/10/22. On 10/25/22 at 12:45PM V13, CNA, said I was at the computer when R9 fell . V13 said I did not see her fall, but I heard V25, CNA, make a sound and when I turned my head towards the sound, I saw R9 was on the floor. V13 said I went to where R9 was to help. V13 said the nurse checked R9 and then said we could get her up. V13 said the nurse had touched R9's legs and straightened her legs out when she was on the floor. V13 said when R9 was on the floor she was in the hallway near a door. V13 said R9 fell out of the wheelchair and was laying on her side, but I don't recall which side. V13 said we picked R9 up by her arms and put her in the wheelchair. V9 said the other CNA and herself grabbed R9 by an arm to get her in the wheelchair, and the nurse was helping. V13 said when R9 was in the chair she was saying her leg was hurting. V25 said I did not put R9 into bed before I left that day. V13 said I was not assigned to R9 that day. V13 said usually R9 was monitored by staff in the hall, and she would make her needs known. On 10/25/22 at 1:33PM V26, Licensed Practical Nurse (LPN), said R9 was usually confused and pleasant. V26 said fall prevention interventions for R9 included a low bed. V26 said R9 did not have floor mats in her room. V26 said after R9 fell on [DATE] she was in the room providing care to R9 who was in the bed and there were no floor mats in place. On 10/25/22 at 1:53PM V4, Director of Nursing, said R3 is a high fall risk and we use a low bed, floor mats, and he sits near the nurses station when out of bed for observation by staff. V4 said R9 fell on [DATE]. V4 said she was told that R9 was trying to get into another resident's room. V4 said the CNA saw R9 and tried to redirect her and intervened. V4 said the CNA told her R9 was holding on each side of the door frame, and this prevented the CNA from repositioning R9 in her wheelchair. V4 said R9 then fell out of her wheelchair and onto her left side. V4 said the nurse told her that she assessed R9 and there was no injury or deformity. V4 said she was told that the staff got R9 off the floor using the full body mechanical lift. V4 said then R9 began having pain and an x-ray was ordered, but the radiology tech did not arrive, and the Nurse Practitioner was notified. V4 said the Nurse Practitioner said to send R9 to the hospital for evaluation. V4 said when someone falls on the floor, we are a non-lift facility, so the appropriate lift is used to get them off the floor. V4 said at the time of the fall R9 had been being monitored near the nurses' station, she had appropriate footwear on, and a pressure relieving cushion in her wheelchair. V4 said the identified safety devices are checked for placement once a week or every 2 weeks. V4 said we do rounds every day. We check for fall devices, low beds, and or call lights in reach. V4 said the facility uses the nonskid pads on the wheelchairs. V4 said the staff is made aware of safety interventions by checking the care plan and we verbally tell the staff. V4 said the Assistant Director of Nursing and I will implement the nonskid device, if needed. V4 said we have a big roll of the nonskid device in the office. V4 said I think the roll maybe green. V4 said not everyone automatically gets a nonskid device implemented. V4 checked the schedule and said V13 was assigned to R9 on 10/10/22. At 2:41PM V4 and the surveyor observed the roll of nonskid pad that is dark blue. On 10/26/22 at 8:59AM via phone interview, V27, LPN, said on 10/10/22 she was at the nursing cart in the hallway and when she turned around, she saw R9 on the floor and the CNA was with her. V27 said R9 was laying on her left side and was saying get me off the floor. V27 said I assessed R9's head and upper and lower extremity movements. V27 said when R9 was on the floor she said her left leg hurt. V27 said we got the full body mechanical lift and got R9 off the floor and moved her to her bed. V27 said she assisted the patient while her and the CNA transported R9 from the hall floor to her bed. V27 said the CNA steered the lift and operated the controls. V27 said she has worked at the facility for about 4 months and she has not been trained on the use of the facility's mechanical lift. V27 said R9 fell in front of the nurses' station. V27 said she called the DON, the doctor, and was given an order for an X-ray. V27 said she called to schedule the X-ray. V27 said R9 remained in the facility during her shift. Facility Incident Report dated 10/10/22 3:02PM written by V27 states R9 was being pushed to her room in her wheelchair and R9 fell on her left side to the floor. No injuries noted at this time. Head to toe assessment completed, R9 complained of pain in her left upper and lower extremities. R9's Progress Notes dated 10/22/22 at 2:46AM document R9 was transferred to hospital via 911 for complaints of pain to the left hip. R9's Progress Notes dated 10/18/22 document she remains in the hospital as she is a status post pinning of her left [CONDITION(S)]. R9's emergency room hospital record dated 10/11/22 documents Range of motion of the left leg is limited secondary to pain. R9's X-Ray pelvis dated 10/11/22 documents reason for exam: fall Findings: suspicious for impacted left femoral neck fracture. ED Course notes document X-ray of the pelvis suggests an impacted left femoral neck fracture. Clinical Impression: 1. Closed left [CONDITION(S)], initial encounter. Hospitalists History and Physical dated 10/11/22 documents Orthopedics consulted for subcapital femur fracture. R9's Monthly Summary dated 9/7/22 section 9 Safety Precautions notes at risk for falls. Floor mats and Low bed, and Protective gear are not marked. R9's cognitive assessment dated [DATE] score is 3, severely impaired. Functional Status dated 7/18/22 documents R9 requires extensive assist with transfers, total dependence for locomotion while in the unit (moving between locations in her room and adjacent corridors). Balance test documents R9 is only able to balance with assistance from staff when standing or during transfer. R9's care plan documents at risk for falls related to I may be unaware of safety limits due to diagnosis of dementia, I am using a wheelchair for mobility. I also have a history of falls. Interventions include, but not limited to revised on 4/22/22 Non-skid placed on top of wheelchair cushion to help prevent resident from sliding out of her wheelchair. Revised on 4/11/22 Floor mats at bedside. 2. R3 is [AGE] years old with diagnosis including, but not limited to Altered Mental Status, Dementia, [CONDITION(S)], [CONDITION(S)], and Unspecified fall. On 10/25/22 the surveyor toured the units. At 1:46PM the surveyor observed R3 in his bed. R3's bed was lower than normal height and no floor mat was observed. On 10/25/22 at 1:46PM V2, MDS Coordinator, was at the medication cart on R3's unit. V2 accompanied the surveyor to R3's room. V2 demonstrated the bed was in the lowest position. The surveyor asked V2 about the floor mats for R3. V2 responded I am looking for them. No floor mats were observed in R3's room. On 10/25/22 at 1:53PM V4, Director of Nursing, said R3 is a high fall risk. V4 said fall prevention interventions for R3 include a low bed, floor mats when in the bed, and observation at the nurse's station. R3's care plan revised on 7/12/22 documents he is at risk for falls. R3 has a behavior of getting out of bed and sitting on floor mattress. Review of the facility fall list documents R3 fell on [DATE]; 9/30/22; 10/7/22; and 10/9/22. The facility Fall Prevention Policy dated 2/18/14 notes the program will include measures which determine the individual needs for each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Standards 3. Safety interventions will be implemented for each resident at risk using a standard protocol. 4. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained.

Based on interview and record review, the facility failed to perform a daily skin assessment to assess for any new wounds and the facility failed to perform the dressing changes to the wounds as ordered. This affected 1 of 3 (R1) residents reviewed for pressure ulcer care. This failure resulted in the wounds not being treated as soon as they developed, and it resulted in the wounds deteriorating by increasing in size. Findings Include: R1 is an [AGE] year-old with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 07/01/22 documents R1 readmitted to the facility from the hospital. R1 has a skin tear to the right buttocks. The Treatment Nurse Initial Skin Alteration review dated 07/05/22 documents there is a partial thickness wound to the coccyx that was first noted on 07/01/22. R1 was admitted with this wound after a hospitalization . There's also a partial thickness wound to the right anterior thigh and a left heel deep tissue injury that were present on admission. The Bath and Skin Report Sheet dated 07/2022 documents R1 received skin assessments on 07/09/22 and no new areas of skin concerns are documented. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set, dated dated dated [DATE] documents R1 has 1 unstageable deep tissue injury at this time. The Braden Scale dated 07/08/22 documents a Braden score of 11 which indicates R1 is at high risk for developing pressure ulcers. A Nursing note dated 07/12/22 documents R1 continues with poor appetite and fluid intake. R1 exited the facility alert, clean, and dry. The Hospital Record dated 07/12/22 documents R1 was admitted for evaluation of failure to thrive. R1 was noted to have a urinary tract infection and was started on IV antibiotics. The family is still deciding on a G tube. R1 was noted to have a left hip deep tissue injury with a 3.5 x 5 cm blister. Also noted is a full thickness pressure injury (the wound extends through all layers of the skin into the subcutaneous tissue) on the left lateral ankle, a right heel deep tissue injury, and a right hip deep tissue injury are also noted. R1 readmitted to the facility from the hospital on 07/18/22. The Treatment Nurse Initial Skin Alteration Review dated 07/19/22 documents R1 has a stage 2 to the right and left hip, A non-stageable pressure injury to the left lateral ankle, a deep tissue injury to the left medial lateral foot. All staff teaching for each wound is documented that the nurse is to apply a new dressing per treatment orders. The Treatment Administration Record dated is 07/2022 documents the ordered dressing changes for the left and hip were not completed on 07/22/22, 07/24/22, and 07/30/22. The Treatment Administration record dated 09/2022 documents the ordered dressing change for the left heel, left lateral foot, left lateral ankle, sacrum and left and right hip were not completed on 09/03/22 and 09/04/22. The Weekly Skin Alteration Review dated 08/26/22 and 09/02/22 documents the wound to the left and right hip are now unstageable, have increased in size, and are worsening. On 09/28/22 at 3:01PM, V4 (Nurse) stated, I believe the one time I sent R1 out to the hospital it was for not eating and drinking. We do body checks before they leave the facility as long as it's not an emergency. No, I don't believe R1 went out via 911. If there was a wound already documented and been treated then I would not have charted it on the note for R1 going out. If I found something new on the skin assessment I did before R1 left then I would have documented it. Skin checks are done on shower days twice a week or when the CNA's change them. If the CNA see something abnormal then they come tell the nurse. We notify the wound care nurse and follow the treatment plan. If wound care nurse is not here then the floor nurses will do the treatment. We usually know who needs dressing changes from just being familiar with them. Otherwise, you can find that information in the TAR (Treatment Administration Record) and what to do for the wound when it needs to be changed. I know for sure when I sent R1 out that that R1 didn't have anything on R1's hips. On 09/28/22 at 4:33PM, V5 (Nurse) stated, Skin checks are scheduled for shower days and they are also done when wound care does their rounds. When wound care is not here to do the dressings then it is up to the staff nurses to complete those. You find the order in the TAR and do the treatment. It should come up on your screen in the computer that a resident has a dressing that needs to be changed. They should always be changed if they're ordered. On 09/29/22 at 9:57AM, V6 (CNA) stated, If something was new in those days that I worked with R1 then I would've told the nurse. I don't remember seeing any new wounds on R1 from when R1 got back (7/5/22) from the hospital until R1 went out again (7/12/22). Anytime you find something new the nurse should be told immediately. On 09/29/22 at 12:57PM, V10 (Wound Care Coordinator) stated, R1 went out in the beginning of July with COVID and came back a couple days later on 7/5. That time when R1 came back R1 had a stage 2 to the coccyx. R1 also had a right anterior thigh abrasion and a DTI to the left heel. R1 was sent out on 7/12 to get a G-tube placed for not eating. R1 came back on 7/18. When R1 came back R1 had a stage 2 to the right and left hip, a DTI to the left foot, and DTI to the left lateral ankle. For a couple weeks the wound were stable in the beginning of July but after that he had an overall decline which the wounds did not do well with. R1 was at risk (for developing wounds) after R1 came back from the first hospitalization with wounds. Skin assessments are done on shower days and when the CNA's are doing patient care. They do patient care whenever the resident needs to be changed so sometimes residents are being checked more than once a day. If anything new is found then it should be reported to me immediately. Skin assessments are also done before a resident goes out and when they come back. We do this to be sure they don't have anything new before leaving the facility. We make sure we're able to tell the difference between what wounds they got at the hospital and what they got here. As long as there's not a 911 call or a code the skin assessment should be done before they leave the facility. Whenever I am not in the building then the floor nurse does the dressing change. They could find how to do the dressing change in the TAR. A dressing change should always be done if there's an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/29/22 at 2:07PM, V2 (DON) stated, Skin checks are done with showers and during incontinent care. They are also done when they come back from the hospital to identify if they have any new ones. When V10 is not here, V10 leaves a list on the homepage so the staff nurses can see who needs wound care for that shift. There is no reason why the wound care should not be done. I know we've had to have talked with them about signing it off on the TAR like it is supposed to be done because if it's not signed off then it is considered not done. If any new areas are noted then V10 should be told immediately. Either the nurse or the CNA can tell V10. On 09/29/22 at 2:31PM, V11 (Wound Physician) stated, I do not advise to skip out on any treatments that are ordered because it has the potential for deteriorating the wounds. This also means if they were not doing the dressings as ordered then they weren't inspecting the wounds either. The wound should be inspected with each dressing change because if there are any changes to the wound then I need to be notified as soon as possible to make adjustments to the treatment if needed. When asked how many wound treatments are safe to skip, V11 responded, I can't give a specific number because I doubt there has been any clinical studies on it but in general no wound treatment should be skipped. The Care Plan dated 03/24/22 documents R1 is monitored for alteration and skin integrity. An intervention for this care plan is documented as the skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule. Any skin integrity issues/concerns will be conveyed to the charge nurse for further evaluation and/or treatment changes/new interventions and the physician will be called as needed. The Care Plan dated 07/05/22 documents R1 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to impaired cognition, incontinent of bowel, impaired nutritional status, decreased sensory perception, comorbidities, and cancer. The same interventions listed in the previous care plan are also documented for this care plan. The policy titled, Pressure Ulcer Prevention, dated 09/2014 documents, Purpose: To prevent and treat pressure sores. Procedure: .2. Inspect the skin several times daily during bathing, hygiene, and repositioning measures . Note: daily skin checks will be done by CNA's during routine care . The policy titled, Pressure Injury and Skin Condition Assessment Policy, dated 09/2016 documents, Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure and other ulcers and assuring interventions are implemented. Standards: .4. Each resident will be observed for skin breakdown daily during care and on the assigned birthday by the CNA. Changes shall be promptly reported to the charge nurse who performed the initial assessment .6. Caregivers are responsible for promptly notifying the charge nurse of skin observations, including but not limited to: redness swelling, bruises, skin tears, blisters, excoriations, wound drainage, crusts, skills, any type of lesion, skin discoloration, bleeding, and changes in skin temperature .16. Dressings which are applied to pressure injuries, skin tears, wounds, [CONDITION(S)] or incisions shall include the date of the procedure. Dressings will be checked daily for placement, cleanliness, and signs and symptoms of infection .22. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Other nursing measures not involving medication shall be documented in the progress notes .23. A licensed nurse shall observe conditions of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented .

Based on interview and record review the facility failed to prevent a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one of three (R4) residents reviewed for injury of unknown origin. This failure resulted in R4 being found with his leg contorted and was not assessed until 5 hours later with a right femur fracture. Findings include: R4 face sheet and care plan shows R4 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was admitted from (nursing home name) resident presents with Parkinson disease, diabetes, CAD, [CONDITION(S)], GERD, and adult failure to thrive. On examination resident is seen in lying in bed, he is alert and oriented 1-2, agitated but verbally responsive with periods of confusion and forgetfulness. Nurse reports that resident was seen walking out of his room with no clothes on. He was immediately helped back into his room and redirected. Psychologic: clear and lucid, insight impaired, cognitive status: forgetfulness, confused, dementia. Dementia: monitor for behavior changes, redirect when necessary, supportive care. R4 MDS dated [DATE], shows section G for functional status for self-performance with bed mobility, R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Transfer-R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Walk in room- not assessed. Walk in corridor- not assessed. Dressing-R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Eating- R4 requires limited assistance. Toilet use-R4 is total dependent (full staff performance every time). Section C for cognitive pattern shows R4 cognitive skills for daily decision making is moderately impaired. Review of R4 progress note dated 4/10/22, completed by V19 (RN), shows in-part late entry: note text: Writer called to residents' room by CNA, who informed that the resident was putting his right foot in his mouth. Upon entering the room, resident is noted to have his foot to his face while still talking to CNA. Resident showed no S/S of pain or distress at this time, such as facial grimacing or guarding extremity. Writer asked if resident had pain and he (R4) stated no. Assessment of area performed: he (R4) did not complain of tenderness or pain as he continued to talk clearly. Pain medication offered as a prophylaxis which he (R4) refused. Bed left in lowest position with call light in place. Writer then left resident room to continue work. Review of V19 progress note shows there is no documentation noted if R4 leg was externally or internally rotated. No documentation noted if there are any scratches or abrasions to the great toe. There is no documentation if there was monitoring put in place for R4. There is no documentation that R4 was redirected from bending his leg and putting his foot to his face and chewing on his toe. Facility incident report dated 4/10/22, completed by V18 (RN) at 11:03 a.m. shows in-part: writer called to room by CNA (certified nurse aide), upon entering room with co-nurse, resident (R4) noted in bed with head of bed elevated, complains of pain to right lower extremity, upon assessment, residents right knee noted to be swollen and externally rotated. Resident also noted with abrasion noted to right great toe area. Resident unable to explain nature of incident. Resident remains in bed. Physician notified of incident, T 97.5 P 72 R 18 B/P 134/74, new orders received to send to ER (emergency room ), abrasion to right great toe cleansed with normal saline and left open to air. 911 called. Resident transported to hospital in stable condition. Orientated to person, confused/ disoriented, abrasion- right knee. Predisposing physiological factors- confused, incontinent, impulsive, resistant care, impaired memory, decreased safety awareness and agitated /anxious. At approximately 5:00 am the 11-7 shift staff reported observing resident in bed with his right great toe in his mouth, chewing on it. Resident is very thin and appears to be flexible. No obvious injury to RLE (right lower extremity) was noted at that time. The 7-3 staff observed resident lying in bed with his right knee externally rotated. Resident admitted to hospital with a right femur fracture. No falls were noted or reported by staff. Staff reports the resident had been up and walking and was exit seeking during both the 3-11 and 11-7 shift. He was difficult to redirect. He is confused. On 7/6/22 at 11:06a.m. V3 (CNA) said he was working with R4 on 4/9/22 on the 11:00 pm to 7:00 am shift. V3 said around 4:00 a.m., he observed R4 standing in the doorway of his room, and he escorted R4 back to his bed, V3 said around 5:30 a.m., he observed R4 in his bed and R4 had his foot to his face and R4 was chewing on his right great toe. V3 said he was shocked to see R4 so flexible and limber, V3 said he summonsed V19 (nurse) to come and observe R4. V3 said V19 came to R4's room and that V3 walked away shortly after because he had to finish working. V3 said he did not redirect R4 to remove his foot from his face and his toe from his mouth. V3 said the way R4's leg was bent toward his face, it looked like something in a [MEDICATION(S)] act. V3 said R4's leg looked flimsy now that he thought about it. V3 said he mentioned that R4 was limber and V19 said to him that older people can be flexible like that. V3 said he did not report R4's behavior to the oncoming CNA, nurse, or the Director of Nursing. V3 said he does not know why R4 was chewing on his toe. On 7/8/22 at 9:20 a.m., V3 said the first time he changed R4's brief, R4 was lying in bed, and he turned R4 from side to side, V3 said around 4:00-4:30 a.m. he changed R4 again, V3 said he assisted R4 to a standing position at the bedside so that he could provide incontinent care to R4. V3 said R4 put R4's left arm on his (V3) shoulder for support. V3 said he had to bend down to put the brief through R4's legs and then fasten the brief. V3 said he did not get a report on how much assistance R4 needs for ADL (activity of daily living) care. On 7/6/22 at 11:16 a.m. V19 (Nurse) said around 5:30 a.m. on 4/10/22 she was summons to the room to observe R4 with his foot in his mouth. V19 said she observed R4 with his right great toe in his mouth. V19 said R4 continued to talk while he had his toe in his mouth and foot to his face. V19 said while R4 remained in that position she completed her assessment of R4. V19 said she touched R4 legs from his hip to his ankles. V19 said R4 denied pain and discomfort and she did not observe any deformities to R4 extremities. V19 said she could not tell if R4 leg was bent at the knee or above the knee. V19 said she did not check to see if R4's leg was internally or externally rotated. V19 said she did not look at R4 legs for asymmetries. V19 said after she assessed (touched R4 right leg from hip to ankle) R4 she left R4 in the room in the bed with his foot folded over his lap (V19 describe Indian style position). V19 said she did not redirect R4 from the observed behavior. V19 said she went to finish working because she had to work two halls (200 and 300 wing). V19 said she asked R4 was he okay and offered R4 something for pain. V19 said she saw R4 again at 6:30 a.m. and R4 was sleeping in the bed. V19 said that was the last she saw R4. V19 said she doesn't know what time she left the facility. V19 said she gave report on R4 behavior to a nurse, but she doesn't know who the nurse was. On 7/8/22 at 12:19 p.m., V19 said she did not document R4's behavior because she was not sure of the facility policy on documentation. V19 said she documented on 4/11/22 when she was asked to put a note in the electronic record. V19 said her handwritten statement is dated for 4/10/22 because that was the date of the occurrence, and she wrote the statement on 4/11/22. V19 said she assessed R4 and R4 did not have an abrasion or scratches to his right great toe. V19 said she does not know why R4 was chewing on his right great toe, she did not ask R4. V19 omitted initiating behavior monitoring for R4. On 7/6/22 at 11:32a.m V21 (CNA) said she was the assigned CNA for R4 on 4/10/22 for the morning shift. V21 said she got to work late that morning around 8-8:30 a.m. V21 said during her first rounds she passed a breakfast tray to R4. R4 was resting in bed with no complaints. V21 said she told R4 she will get him up during her second rounds. V21 said she did not provide any care to R4 at that time. V21 said she did not touch R4 at that time. V21 said at 10:30 a.m. when she went to get R4 up for the day, she asked R4 if he was ready to get up and R4 replied yea but I can't lift my leg. V21 said she thought that was odd because R4 was able to stand with assistance before. V21 said that when she pulled the sheet back and observed R4's knee, it did not look right. V21 said R4's right knee was rotated to the side. V21 said that's when she went and got the nurse. V21 said when she returned to the room with V18 (Manager on duty) she observed that R4 had scratches on his right great toe. On 7/7/22 at 1:30 p.m. V13 (CNA-Certified Nursing Assistance) said on 4/10/22 V21 got her attention when V21 said something was wrong with R4's knee. V13 said she went and looked at R4's knee and it looked bad. V13 said R4's right knee was rotated to the side and R4's right toe had scratches on it. V13 said no one reported to her that R4 was having behaviors of putting his foot in his mouth. On 7/7/22 at 11:40am V22 (Nurse) said she was working the other half of the 200 unit when V21 came and got her to look at R4 leg. V22 said when she looked at R4 leg, she had never seen anything like that in all her years of working as a nurse. (V22 would not describe what she saw) V22 said she told the aide to get the supervisor immediately. V22 said the night nurse (V19) did not give her report that R4 was having any behaviors of putting his foot in his mouth. On 7/6/22 at 12:26p.m V18 (Manager on Duty) said she was the manager on duty when the CNA came and got her to look at R4's leg. V18 said when she got to the room, she pulled the covers back and observed R4 knee looked dislocated and rotated, and R4 had an abrasion on his right great toe. V18 said she cleansed R4's toe and left it open to air, V18 said she notified the physician and orders were given to send R4 out to the hospital for further evaluation. V18 said she do not know who the assigned nurse was for R4. V18 said V19 did not report that R4 was having behavior early that morning and chewing on his right great toe. On 7/6/22 at 1:33p.m V2 (DON) said she conducted the investigation of R4's injury of unknown origin. V2 said she was not aware of R4 unusual behavior of putting his toe in his mouth initially. V2 said she was not made aware until V18 (manager on Duty/Nurse) informed her of the observation of R4's knee looking dislocated. V2 said that's when she called V19, and V19 informed her of R4 behavior that early morning. V2 said she wished V19 would have informed her of R4's behavior initially. V2 said she would have put monitoring in place for R4 and she would ensure the occurrence was documented. V2 said she would have notified the physician; informed the aides of the behavior so that they can observed for continued behavior and redirect the resident: the care plan would have been updated, and the guardian notified. V2 said she can't say what the frequency would be because again the behaviors were so unusual. V2 said a head-to-toe assessment should be conducted, making observation of all extremities. V2 said R4 is cognitively impaired, has poor safety aware and he does not understand that he could injury himself doing such behavior. V2 said no staff reported to her that R4 had a fall. V2 said if R4 had a fall from the bed that morning, there is no way that R4 would have been able to get himself off the floor independently with the extent of R4's injury. V2 said R4 would have needed some assistance to get off the floor. V2 said she and V1 (Administrator) viewed the facility video recording and verified V3's and V19's statements only. V2 was asked if she viewed the video to determine if any staff went into that room to pick R4 up off the floor. V2 continued to say the video was reviewed to verify what V3 and V19 had said only. V2 said she does not know if any staff went into R4's room between the time R4 was last observed in the bed and the time R4 was observed with the scratches to the great toe and the distorted knee. V2 said she believes the facility video recording records up to 24 hours. V2 continued to say no one reported to her that R4 had a fall. V2 also said no one reported to her, R4's behavior early that morning either, V2 said she had to call her staff and ask them what happened. V2 said her staff also did not document until she requested them to document their observation of R4. V2 said the staff should document on the resident behavior right away. V2 said R4's injury must have happened after the initial observation of R4 with his toe in his mouth. V2 said if V19 was not familiar with the facility policy and practice, V19 should have contacted her or the physician for directives. On 7/6/22 at 2:38 p.m. V20 (Therapy Director) said R4 was screened and evaluated by therapy. R4 has an unsteady gait, weakness. R4 is a fall risk. R4 could come to a sitting position and sit up for about 30 seconds. V20 said R4 should not be in a position where he has his right foot to his face and his great toe in his mouth. V20 said that position is not safe and R4 could roll out of the bed and cause an injury to himself. On 7/8/22 at 10:04a.m V24 (Physician) said she cannot say if the injury was a result of trauma because the facility does not have evidence that there was a fall or trauma. V24 said she has seen in her practice a few situations where a resident suffered a fracture without having trauma. V24 said R4 had to do some twisting because it's not easy to put the toe in the mouth without twisting of the extremities. V24 said twisting can cause spiral fractures. V24 said it's possible that R4 had a hairline fracture and suffered a comminuted fracture due to the twisting. V24 said she cannot say because she does not have the supporting evidence to say this fracture came from trauma or fall. On 7/8/22 at 3:05p.m. V9 (MDS coordinator) said R4 required weight bearing support from staff for bed mobility, transfers, toilet use, V9 said R4 was able to feed his self. V9 said she did not assess R4 for walking ability. On 7/08/22 the surveyor observed a photo of R4 lying in bed, with his right knee grossly deformed and twisted 90 degrees out of its normal position. R4 progress notes dated 4/10/22 at 6:20 p.m. shows resident was admitted to hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R4 hospital records dated 4/10/22, shows primary complaint: general medical complaint specific right knee deformity, pain unable to assess AMS (altered mental status), associated symptoms leg swelling, risk factors diabetes. 78 y/o male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per NH, no witness fall, it is unclear when it happened. NH also states that patient has been walking as of last night. HPI limited d/t AMS (altered mental status). Diagnostic impression-other distal femur fracture. ER Xray shows this is a severely comminuted displaced fracture involving the metadiaphysis of the distal right femur. Facility policy titled, Behavioral management for new or worsening behavior symptoms, dated 4/14 shows in-part: the purpose is to determine the cause of the behavior, to prevent the resident from harming self or others, to establish guidelines for reducing or preventing behaviors when possible. It is the policy of the nursing department to determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. In the event the behavior cannot be managed, staff will implement protocols to prevent the resident from harming self or others which may take precedents over the procedure as written. Procedures measure vital signs, review drug regime, review clinical record, observe body position and ROM( range of motion): (rational-protecting or guarding, neurological deficits, new asymmetries or swelling, pain or tenderness, fractures) , assess skin condition, assess body system, evaluate environmental changes, notify social services as soon as possible, perform depression assessment, initiate behavioral monitoring and intervention record, develop behavior management plan with interdisciplinary team members. Facility policy titled, Incident/accident reports, dated 9/14 shows in-part that an incident is defined as any happening, not consistent with the routine operation of the facility, event out of the ordinary that does not result in bodily or property damage. An accident is defined as any happening, unexpected, unintended event not consistent with the routine operation of the facility that can result in bodily injury other than abuse. Incidents of unknown origin are to be investigated thoroughly in an effort to rule out abuse. These are to be reported to Illinois Department of Public health.

Based on interview and record review the facility failed to conduct a thorough physical assessment of a resident after finding the resident with his right leg contorted with his foot in his mouth this failure affects 1 of 3 resident (4) reviewed for assessment of a change in condition. This failure resulted in R4 being left in this contorted condition without a thorough assessment, physician notification or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R4's face sheet shows R4 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 MDS dated [DATE], shows section G for functional status for self-performance with bed mobility, R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Transfer-R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Walk in room- not assessed. Walk in corridor- not assessed. Dressing-R4 is extensive assist (resident involved in activity, staff provide weight bearing support). Eating- R4 requires limited assistance. Toilet use-R4 is total dependent (full staff performance every time). Section C for cognitive pattern shows R4 cognitive skills for daily decision making is moderately impaired. On 7/6/22 at 11:06a.m. V3 (CNA) said he was working with R4 on 4/9/22 on the 11:00 pm to 7:00 am shift. V3 said around 4:00 a.m., he observed R4 standing in the doorway of his room, and he escorted R4 back to his bed, V3 said around 5:30 a.m., he observed R4 in his bed and R4 had his foot to his face and R4 was chewing on his right great toe. V3 said he was shocked to see R4 so flexible and limber, V3 said he summonsed V19 (nurse) to come and observe R4. V3 said V19 came to R4's room and that V3 walked away shortly after because he had to finish working. V3 said he did not redirect R4 to remove his foot from his face and his toe from his mouth. V3 said the way R4's leg was bent toward his face, it looked like something in a [MEDICATION(S)] act. V3 said R4's leg looked flimsy now that he thought about it. V3 said he mentioned that R4 was limber and V19 said to him that older people can be flexible like that. V3 said he did not report R4's behavior to the oncoming CNA, nurse, or the Director of Nursing. V3 said he does not know why R4 was chewing on his toe. On 7/8/22 at 9:20 a.m., V3 said the first time he changed R4's brief, R4 was lying in bed, and he turned R4 from side to side, V3 said around 4:00-4:30 a.m. he changed R4 again, V3 said he assisted R4 to a standing position at the bedside so that he could provide incontinent care to R4. V3 said R4 put R4's left arm on his (V3) shoulder for support. V3 said he had to bend down to put the brief through R4's legs and then fasten the brief. V3 said he did not get a report on how much assistance R4 needs for ADL (activity of daily living) care. On 7/6/22 at 11:16 a.m. V19 (Nurse) said around 5:30 a.m. on 4/10/22 she was summons to the room to observe R4 with his foot in his mouth. V19 said she observed R4 with his right great toe in his mouth. V19 said R4 continued to talk while he had his toe in his mouth and foot to his face. V19 said while R4 remained in that position she completed her assessment of R4. V19 said she touched R4 legs from his hip to his ankles. V19 said R4 denied pain and discomfort and she did not observe any deformities to R4 extremities. V19 said she could not tell if R4 leg was bent at the knee or above the knee. V19 said she did not check to see if R4's leg was internally or externally rotated. V19 said she did not look at R4 legs for asymmetries. V19 said after she assessed (touched R4 right leg from hip to ankle) R4 she left R4 in the room in the bed with his foot folded over his lap (V19 describe Indian style position). V19 said she did not redirect R4 from the observed behavior. V19 said she went to finish working because she had to work two halls (200 and 300 wing). V19 said she asked R4 was he okay and offered R4 something for pain. V19 said she saw R4 again at 6:30 a.m. and R4 was sleeping in the bed. V19 said that was the last she saw R4. V19 said she doesn't know what time she left the facility. V19 said she gave report on R4 behavior to a nurse, but she doesn't know who the nurse was. On 7/8/22 at 12:19 p.m., V19 said she did not document R4's behavior because she was not sure of the facility policy on documentation. V19 said she documented on 4/11/22 when she was asked to put a note in the electronic record. V19 said her handwritten statement is dated for 4/10/22 because that was the date of the occurrence, and she wrote the statement on 4/11/22. V19 said she assessed R4 and R4 did not have an abrasion or scratches to his right great toe. V19 said she does not know why R4 was chewing on his right great toe, she did not ask R4. V19 omitted initiating behavior monitoring for R4. On 7/8/22 at 12:19 PM V19 stated she did not document R4's behavior because she was not sure of the facility policy on documentation. V19 stated she documented on 4/11/22 when she was asked to put a note in the electronic record. V19 stated her handwritten statement is dated for 4/10/22 because that was the date of the occurrence, and she wrote the statement on 4/11/22. V19 stated she assessed R4, R4 did not have an abrasion or scratches to his right great toe. V19 stated she does not know why R4 was chewing on his right great toe, nor did she ask him.V19 omitted initiating behavior monitoring for R4. On 7/6/22 at 11:32a.m V21 (CNA) said she was the assigned CNA for R4 on 4/10/22 for the morning shift. V21 said she got to work late that morning around 8-8:30 a.m. V21 said during her first rounds she passed a breakfast tray to R4. R4 was resting in bed with no complaints. V21 said she told R4 she will get him up during her second rounds. V21 said she did not provide any care to R4 at that time. V21 said she did not touch R4 at that time. V21 said at 10:30 a.m. when she went to get R4 up for the day, she asked R4 if he was ready to get up and R4 replied yea but I can't lift my leg. V21 said she thought that was odd because R4 was able to stand with assistance before. V21 said that when she pulled the sheet back and observed R4's knee, it did not look right. V21 said R4's right knee was rotated to the side. V21 said that's when she went and got the nurse. V21 said when she returned to the room with V18 (Manager on duty) she observed that R4 had scratches on his right great toe. On 7/7/22 at 1:30 p.m. V13 (CNA-Certified Nursing Assistance) said on 4/10/22 V21 got her attention when V21 said something was wrong with R4's knee. V13 said she went and looked at R4's knee and it looked bad. V13 said R4's right knee was rotated to the side and R4's right toe had scratches on it. V13 said no one reported to her that R4 was having behaviors of putting his foot in his mouth. On 7/7/22 at 11:40am V22 (Nurse) said she was working the other half of the 200 unit when V21 came and got her to look at R4 leg. V22 said when she looked at R4 leg, she had never seen anything like that in all her years of working as a nurse. (V22 would not describe what she saw) V22 said she told the aide to get the supervisor immediately. V22 said the night nurse (V19) did not give her report that R4 was having any behaviors of putting his foot in his mouth. On 7/6/22 at 12:26p.m V18 (Manager on Duty) said she was the manager on duty when the CNA came and got her to look at R4's leg. V18 said when she got to the room, she pulled the covers back and observed R4 knee looked dislocated and rotated, and R4 had an abrasion on his right great toe. V18 said she cleansed R4's toe and left it open to air, V18 said she notified the physician and orders were given to send R4 out to the hospital for further evaluation. V18 said she do not know who the assigned nurse was for R4. V18 said V19 did not report that R4 was having behavior early that morning and chewing on his right great toe. On 7/6/22 at 1:33p.m V2 (DON) said she conducted the investigation of R4's injury of unknown origin. V2 said she was not aware of R4 unusual behavior of putting his toe in his mouth initially. V2 said she was not made aware until V18 (manager on Duty/Nurse) informed her of the observation of R4's knee looking dislocated. V2 said that's when she called V19, and V19 informed her of R4 behavior that early morning. V2 said she wished V19 would have informed her of R4's behavior initially. V2 said she would have put monitoring in place for R4 and she would ensure the occurrence was documented. V2 said she would have notified the physician; informed the aides of the behavior so that they can observed for continued behavior and redirect the resident: the care plan would have been updated, and the guardian notified. V2 said she can't say what the frequency would be because again the behaviors were so unusual. V2 said a head-to-toe assessment should be conducted, making observation of all extremities. V2 said R4 is cognitively impaired, has poor safety aware and he does not understand that he could injury himself doing such behavior. V2 said no staff reported to her that R4 had a fall. V2 said if R4 had a fall from the bed that morning, there is no way that R4 would have been able to get himself off the floor independently with the extent of R4's injury. V2 said R4 would have needed some assistance to get off the floor. V2 said she and V1 (Administrator) viewed the facility video recording and verified V3's and V19's statements only. V2 was asked if she viewed the video to determine if any staff went into that room to pick R4 up off the floor. V2 continued to say the video was reviewed to verify what V3 and V19 had said only. V2 said she does not know if any staff went into R4's room between the time R4 was last observed in the bed and the time R4 was observed with the scratches to the great toe and the distorted knee. V2 said she believes the facility video recording records up to 24 hours. V2 continued to say no one reported to her that R4 had a fall. V2 also said no one reported to her, R4's behavior early that morning either, V2 said she had to call her staff and ask them what happened. V2 said her staff also did not document until she requested them to document their observation of R4. V2 said the staff should document on the resident behavior right away. V2 said R4's injury must have happened after the initial observation of R4 with his toe in his mouth. V2 said if V19 was not familiar with the facility policy and practice, V19 should have contacted her or the physician for directives. On 7/6/22 at 2:38 p.m. V20 (Therapy Director) said R4 was screened and evaluated by therapy. R4 has an unsteady gait, weakness. R4 is a fall risk. R4 could come to a sitting position and sit up for about 30 seconds. V20 said R4 should not be in a position where he has his right foot to his face and his great toe in his mouth. V20 said that position is not safe and R4 could roll out of the bed and cause an injury to himself. Review of R4 progress note dated 4/10/22, completed by V19 (RN), shows in-part late entry: note text: Writer called to residents' room by CNA, who informed that the resident was putting his right foot in his mouth. Upon entering the room, resident is noted to have his foot to his face while still talking to CNA. Resident showed no S/S of pain or distress at this time, such as facial grimacing or guarding extremity. Writer asked if resident had pain and he (R4) stated no. Assessment of area performed: he (R4) did not complain of tenderness or pain as he continued to talk clearly. Pain medication offered as a prophylaxis which he (R4) refused. Bed left in lowest position with call light in place. Writer then left resident room to continue work. Review of V19 progress note shows there is no documentation noted if R4 leg was externally or internally rotated. No documentation noted if there are any scratches or abrasions to the great toe. There is no documentation if there was monitoring put in place for R4. There is no documentation that R4 was redirected from bending his leg and putting his foot to his face and chewing on his toe. R4 progress notes dated 4/10/22 at 6:20 p.m. shows resident was admitted to hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R4 hospital records dated 4/10/22, shows primary complaint: general medical complaint specific right knee deformity, pain unable to assess AMS (altered mental status), associated symptoms leg swelling, risk factors diabetes. 78 y/o male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per NH, no witness fall, it is unclear when it happened. NH also states that patient has been walking as of last night. HPI limited d/t AMS (altered mental status). Diagnostic impression-other distal femur fracture. ER Xray shows this is a severely comminuted displaced fracture involving the metadiaphysis of the distal right femur. On 7/8/22 at 10:04a.m V24 (Physician) said she cannot say if the injury was a result of trauma because the facility does not have evidence that there was a fall or trauma. V24 said she has seen in her practice a few situations where a resident suffered a fracture without having trauma. V24 said R4 had to do some twisting because it's not easy to put the toe in the mouth without twisting of the extremities. V24 said twisting can cause spiral fractures. V24 said it's possible that R4 had a hairline fracture and suffered a comminuted fracture due to the twisting. V24 said she cannot say because she does not have the supporting evidence to say this fracture came from trauma or fall. Facility incident report dated 4/10/22, completed by V18 (RN) at 11:03 a.m. shows in-part: writer called to room by CNA (certified nurse aide), upon entering room with co-nurse, resident (R4) noted in bed with head of bed elevated, complains of pain to right lower extremity, upon assessment, residents right knee noted to be swollen and externally rotated. Resident also noted with abrasion noted to right great toe area. Resident unable to explain nature of incident. Resident remains in bed. Physician notified of incident, T 97.5 P 72 R 18 B/P 134/74, new orders received to send to ER (emergency room ), abrasion to right great toe cleansed with normal saline and left open to air. 911 called. Resident transported to hospital in stable condition. Orientated to person, confused/ disoriented, abrasion- right knee. Predisposing physiological factors- confused, incontinent, impulsive, resistant care, impaired memory, decreased safety awareness and agitated /anxious. At approximately 5:00 am the 11-7 shift staff reported observing resident in bed with his right great toe in his mouth, chewing on it. Resident is very thin and appears to be flexible. No obvious injury to RLE (right lower extremity) was noted at that time. The 7-3 staff observed resident lying in bed with his right knee externally rotated. Resident admitted to hospital with a right femur fracture. No falls were noted or reported by staff. Staff reports the resident had been up and walking and was exit seeking during both the 3-11 and 11-7 shift. He was difficult to redirect. He is confused. Facility policy titled, Behavioral management for new or worsening behavior symptoms, dated 4/14 shows in-part: the purpose is to determine the cause of the behavior, to prevent the resident from harming self or others, to establish guidelines for reducing or preventing behaviors when possible. It is the policy of the nursing department to determine the cause of behaviors when possible and initiate interventions to reduce, control, or prevent identified behaviors. In the event the behavior cannot be managed, staff will implement protocols to prevent the resident from harming self or others which may take precedents over the procedure as written. Procedures measure vital signs, review drug regime, review clinical record, observe body position and ROM( range of motion): (rational-protecting or guarding, neurological deficits, new asymmetries or swelling, pain or tenderness, fractures) , assess skin condition, assess body system, evaluate environmental changes, notify social services as soon as possible, perform depression assessment, initiate behavioral monitoring and intervention record, develop behavior management plan with interdisciplinary team members. Facility policy titled, Incident/accident reports, dated 9/14 shows in-part that an incident is defined as any happening, not consistent with the routine operation of the facility, event out of the ordinary that does not result in bodily or property damage. An accident is defined as any happening, unexpected, unintended event not consistent with the routine operation of the facility that can result in bodily injury other than abuse. Incidents of unknown origin are to be investigated thoroughly in an effort to rule out abuse. These are to be reported to Illinois Department of Public health.

A. Based on observations, interviews, and records reviewed, the facility failed to prevent one resident (R2) who has a history of dementia, severely impaired cognition, and known elopement risk, from leaving the facility unsupervised. This failure resulted in R2 leaving the building without facility staff knowledge and being found by Police officers, sent to the hospital and treated for hypothermia and dehydration. B. Based on observations, interviews and records reviewed, the facility failed to develop an effective plan of care with interventions to prevent or reduce the risk of falling for one resident (R6) who has vision impairment, a history of [CONDITION(S)] with collapse, and a high risk for falls, from falling and hitting his head. This failure resulted in R6 hitting his head, being taken to the hospital, and being diagnosed with a brain hemorrhage. A. Findings include: Record review of R2 Face sheet documents an [AGE] year-old admitted to the facility with diagnoses that includes Dementia and Toxic [CONDITION(S)]. R2's Minimum Data Sheet (MDS) dated [DATE] section C documents R2's mental status as severely impaired as noted in the Brief Interview for Mental Status (BIMS) score of 3 out of 15. R2's Community Survival Skills assessment dated [DATE] documents R2 does not appear to be capable of unsupervised outside pass privileges at this time. On 3/8/22 at 3:31PM R2 in her room sitting at the side of the bed. R2 is alert to self and talks of random things. Unable to answer questions or respond appropriately. On 3/8/22 at 3:20 PM V5 (LPN) states R2 was a wanderer before she eloped on 2/14/22. On 3/8/2022 at 3:05 PM V4 (LPN) states R2, they just put precautions in place to watch R2. I've seen R2 on 100 and 200 unit. She has always wandered and is an elopement risk. On 3/8/2022 at 3:45 PM V1 states on 2/14/2022 R2 exited via a door where the door alarm was malfunctioning and did not alarm. V1 states when they checked the door after the elopement, it didn't alarm. V1 states R2 has been known to get agitated and will try to leave with family. V1 states R2 is confused. V1 states, she checked the cameras and R2 left at approximately 11:30AM on 2/14/2022. V1 states prior to the R2's elopement, the door alarms were being checked monthly. On 3/9/22 at 11:21 AM V13 (CNA) states she saw R2 in the morning of 2/14/22 before breakfast and at breakfast and when she picked up trays. V13 states R2 was not assigned to her. V14 states I knew she was wanderer. On 3/9/22 at 11:32 AM V14 CNA) states she was assigned to R2 on the morning of 2/14/22. V14 states she saw R2 last that day around 11:00 AM. V14 states R2 was a wanderer before this happened. V14 states if R2 tried to get out, we would take her back. V14 states, on 2/14/2022 R2 became abusive that day. V14 states, First, she was trying to get out the front door and administrator and R2's nurse was there at the front door dealing with the situation. V14 states, once a week she [R2] tries to get out. She wants to get out to get her money. V14 states, Normally we have 3 CNAs on 100, and normally 4 CNA's on the 200 unit. We were short one CNA on each unit on 2/14/2022. V14 states, they try to check on wanderers every hour. V14 states, I saw R2 around 11 AM and then I went to help two other residents that needed to be up for [CONDITION(S)]. When I finished getting one dressed for [CONDITION(S)] and put another one to bed, I went to check on R2 and her roommate. I had 4 [CONDITION(S)] residents and we were short a person. Normally, I would have had 2 [CONDITION(S)] residents. It is time consuming to get them ready. One of the people is a Hoyer lift. V14 sates, when she went to check on R2 and her roommate, R2's lunch was still on the table. When I went up front looking for R2, the police were there. Staffing sheet for the facility for 2/14/2022 documents unit 100 had 1 CNA call off and unit 200 had one call off and one no show. On 3/3/2022 at 12:10 PM V15 (Staffing Coordinator) states there should be a minimum of 3 CNA staffed on each unit on 7 AM to 3 PM shift. The facility's assessment tool documents: Total # of CNA's staffed per shift on average (includes Restorative Aides): 1st shift =6. On 3/9/22 at 1:15 PM V7 (LPN) states R2 was assigned to her on 2/14/2022. V7 states, the last time she saw R2 on the day she eloped was around 11:30 AM sitting at the front desk. V7 states she tries to check on residents every 2 hours to keep a close eye on them and if they wander she tries to check on them every hour. V7 states R2 was a wanderer before she eloped. V7 states R2 tried to go out of the door earlier in the day of the elopement and the administrator and activities director stopped her. V7 states, R2 tried to leave out with staff earlier that day. On 3/9/22 11:03 AM V12 (Maintenance Director) states the alarm on the door that R2 left out of was malfunctioning that day. I found out after the fact that it wasn't arming or alarming. On 3/11/2022 at 10:50 AM V17 states, she enters the behavior care plan. I believe someone who tries to elope should be care planned as soon as possible the same day. V17 states, she was familiar with R2's attempted elopements. V17 states she doesn't remember the days of R2's attempted elopements. V17 states, she was working on 2/11/2022 and staff made her aware of R2's attempted elopement that day. V17 states R2 went outside, and the staff was outside and they brought her back into the facility. V17 states, she should have done an elopement care plan for R2 before the day she eloped on 2/14/2022. V17 states, she did not know why she did not care plan R2's elopement attempts/wandering before R2 eloped. Review of R2 wandering care plan documents it was initiated on 2/15/2022. R2's care plan is absent of any care plan for wandering/elopement prior to 2/15/2022. On 3/15/2022 at 9:20 V22 (Police Officer) states that on 2/14/22 at 12:47PM a call came in from a neighbor who heard a woman screaming. V22 states, the caller stated that he saw a black female sitting in a snow bank along the river bed with no shoes on. V22 states there is little creek there and half way down the incline to the river is where R2 was found. V22 states he, went to talk to the administrator at the facility. V22 states he and the administrator reviewed the video and R2 walked out a door of what they call the back door. Right before she left an employee left who had emptied the garbage and did not rearm the door. V22 states, the administrator stated the door did not alarm when R2 went out. V22 states, that the administrator stated that it was not uncommon to deactivate the alarm to take out trash. V22 states, The person in charge of her (R2) that day, I'm not sure if it was the nurse or not, stated that she (R2) wasn't in her room and she (R2) was not fed lunch. V22 states R2 was outside for probably over hour. It was pretty darn cold that day. V22 states, the facility did not know where R2 was. Review of R2's progress notes document the following: 1/16/2022 resident exited out the unit 100 exit door to parking lot. Alarm sounded. Staff noticed resident exiting door unescorted. Staff immediately ran and caught her just as she got outside the door. 2/1/2022 resident seen at reception area attempting to leave the facility with her son. 2/11/2022 Staff noticed resident going out the front door without permission saying she was going with. Staff immediately ran and caught her just as she got outside the door and escorted her back with resistance and coaxing. 2/13/2022 R2 alert note documents: Saturday Feb. 13, 2022, resident attempted to go outside. I tried to redirect resident, but she was very agitated, cursing and resistant. I called resident's daughter to try to talk with her. Resident spoke to daughter which seem to calm her down. I did report incident to nurse. 2/14/2022 at 8:30 AM resident trying to exit out of main doors stating she is going home. Resident unable to be redirected. Resident yelling out and using profanity towards staff. 2/14/2022 at 1:48 PM nursing progress note documents: The police and paramedics arrived at facility with female in ambulance and was found in the snow at a nearby house. Review of the Facility Reported incident documents the resident was located sitting on the lawn next door to the facility on [DATE]. Review of the Facility Reported Incident Summary of Investigative Findings documents the following: Upon further investigation facility determined that the resident left the facility and was reported seen at the neighbors back yard. Facility was then notified by the fire department staff that resident was being taken to the ER for further evaluation. Hospital ER notes dated 2/14/2022 documents the following: Physician note documents Resident admitted with a diagnosis of hypothermia and dehydration. She was rewarmed in ER, hydrated with IV fluids for correction of dehydration, and discharged on [DATE]. . R2's vitals on 2/14/2022 at 1:25 PM documents the following abnormal vitals: Temperature 90.6 (97-100.4F) Pulse 104H (60-100) Blood Pressure 155/92H (90-140/60-90) Initial assessment documents: Resident arrived by EMS for outside cold exposure of unknown amount of time per EMS staff; EMS state that patient was found seated in a snow bank. Patient shivering, with cold skin and redness noted to left posterior thigh and left foot. ED nursing reassessment note documents: Resident verbalizes that I left trying to get home, but I was in the snow for a long time. ED Nursing Disposition note: Apparently, she wandered out of the nursing home and walked outside. She was found 20 minutes prior to the arrival to the ED lying in a snowbank across from the skilled nursing facility. Her left foot and leg apparently were submerged in a retention pond. Patient arrived complaining of her left leg feeling cold. Review of R2's elopement risk review dated 2/11/22 documents R2 has: 1) A history of wandering/elopement prior to admission. R2 has a diagnosis of Dementia 2) A) Reported/documented episodes of elopement and/or attempts to elope. B. signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place the resident at risk in the community. Place resident on the Elopement Risk Protocol. 6) Comments: R2 is at risk for elopement, she has attempted to exit the building. She was redirected by staff. Elopement Risk policy dated 7/2002 documents the following: It is the policy of the facility that all residents are afforded adequate supervision to meet each resident's nursing and personal care needs. All residents will be assessed for behaviors or conditions that that put them at risk for elopement. All Residents identified will have these issues addressed in their care plans and in the medical record. B. Review of R6 face sheet documents an [AGE] year-old, with diagnoses including: [CONDITION(S)] and Collapse, [CONDITION(S)] and Homonymous Bilateral Field Defects, Left side. R6's most recent completed Minimum Data Sheet (MDS) section GG dated 12/31/21 documents that R6 requires supervision or touching assistance with toileting and transfers. R6 care plan documents he is monitored for fall related injury and he is also legally blind and wear glasses and is able to see shadows per resident interview. Date initiated 12/15/2020. Facility reported incident dated 3/8/2022 documents the following: Nurse responded to yelling and observed the resident on the floor in his bathroom, lying on his left side between the toilet and the sink. Resident states he hit his head. Resident is independent in all transfers. 3/9/22 Summary of investigation: Patient with new diagnosis of [CONDITION(S)] and Collapse. Resident was admitted to the hospital with a diagnosis of intracranial Hemorrhage. Resident's plan of care will be updated upon his return from the hospital On 3/16/2022 3:47 PM R6 states he can't see. R6 states he can only see shadows. On 3/22/22 at 11:35 PM R6 states, he took himself to the toilet the day he fell and hit his head. R6 states I fell off the toilet. I don't know how I fell . R6 states, after he came from the hospital, they said someone needed to assist him when going to the toilet. There was no CNA there at all when I fell . I pulled the call light, and no one came so I started screaming. Nursing progress note dated 3/1/2022 at 10:15 AM documents the following: Resident observed sitting in wheelchair slumped over and staff called resident name and resident did not respond or open his eyes. Sternum rub performed by writer. Resident still did not respond. Nurse practitioner examined R6 at bedside and new order to send resident out to the hospital for further evaluation. Review of R6's hospital cardiology consult note dated 3/2/2022 documents R6 being seen for syncopal episode. Hospital discharge records dated 3/3/22 document R6 released with fall risk prevention information. R6 nursing note dated 3/4/2022 at 6:23 PM documents the following: Resident received from hospital with a diagnosis of [CONDITION(S)] and severe sinusitis. Review of R6's fall risk assessment dated [DATE] documents R6 as a High risk for falls. As of 3/16/2022 R6 fall risk care plan is absent of any new intervention related to syncopal episode on 3/1/22 or fall on 3/8/2022. R6 nursing progress note dated 3/8/2022 at 4:00 PM documents the following: Responded to yelling and observed R6 on the floor in the bathroom on left side between toilet and sink. Resident stated that he fell off the toilet. Resident stated he did hit his head a little. Resident was prepared to transfer to ER for evaluation. Review of R6's Computed Tomography (CT) scan of the head documents the diagnostic impression as other intracranial hemorrhage. R6's admission hospital records dated 3/8/222 at 5:22 PM documents R6 as a full admit to the Intensive Care Unit with diagnosis of intracranial hemorrhage. On 3/18/22 at 3:55 PM V28 (LPN) states, when she got in she rounded and saw R6 in a wheelchair and then 30 minutes later I heard screaming and R6 was on the floor in the bathroom. V28 states that R6 said he fell off the toilet and he said he hit his head. V28 states R6 is blind and but sees shadows. V28 states, I think R6 is to go to the bathroom with supervision. He should be supervised the whole time. V28 states, I have seen him getting out of the restroom and getting himself back to bed with no problems. V28 states, He (R6) will not pull call light all the time. I've frequently seen him coming out of bathroom and going to the bathroom on his own. V28 states, she remembers R6 had a diagnosis of [CONDITION(S)]. V28 states the nurse told me in report that R6 is in the hospital with a diagnosis of [CONDITION(S)]. V28 states, when she got report on 3/8/22, she was not made aware of any new fall precautions for R6. V28 states, that R6 understands but does not follow directions all the time. On 3/18/2022 4:34 PM V30 (CNA) states on the day R6 fell it was at the beginning of her shift. V30 states, The CNA helped him go to the bathroom her name is V14 maybe. V30 states, she is new hire and not familiar with everyone's name yet. V30 states, when she got to the unit, V28 (LPN) I believe is her name, asked me to check on R6 because he was in the bathroom and previous shift put him in there. V30 states, when she got to R6's room, R6 was on the toilet, and she asked if he was ok. V30 states R6, said he was okay. He said he needed more time and I told him I would step out and he needs to put on the call light on when he was done. V30 states, she was outside the bathroom door with the door cracked so that she could give R6 some privacy. V30 states, she was outside the bathroom door, and she heard R6 say help me. V30 states, she went in and he was on the floor on the left side. I called the nurse and CNA. I start screaming to get help. V30 states R6 said, I tried to get in my wheelchair and slipped. V30 states, she did not see R6 get up or fall. V30 states, even though we keep reminding him to pull the call light and let us know, he would still not call. Sometimes he does pull the light and sometimes he will try to do it himself. V30 states, she should have kept an eye on him while he was in the bathroom. On 3/22/22 at 11:35 PM R6 states, last night at around 3:00 in the morning I went to the bathroom by myself. I pulled the string, and no one came. I waited a long time, then I put my clothes and shoes on and got in the wheelchair and went to the bathroom. Then they came fussing and I fussed right back. I lay there a long time and my stomach started hurting. I had to get up and go. At night time they don't come to help me. They are asleep. They got to be asleep. I pulled that light and waited a long time. I know I'm not supposed to get up, but they don't come. They work like they want too around here. Sometimes they come and sometimes they don't. On 3/23/22 at 11:11 AM Surveyor and V5 (LPN) at the nurse's observed V26 (CNA) wheel R6 to the restroom in his room. V26 came out of the bathroom with R6, closed the door and left the room. V5 states V26 should not have left R6 in the restroom. V5 states V26 should stay in the room, tell R6 to pull the call light and watch R6 while he is in the restroom. On 3/22/22 at 12:10 PM V2 (DON) states her expectations staff to monitor residents who are fall risks. V2 states they are assisting R6 to restroom. V2 states, R6 is instructed to put on call light which he does. V2 states R6 was going to the restroom by himself. V2 states, they sent R6 out to the hospital and it was confirmed that he had a syncopal episode. Now with syncopal episode, we are no longer allowing him to transfer and toilet by himself. We watch him from outside the door to give him privacy. Facility reported incident root cause (because factor/conclusion) dated 3/9/2022 documents: Resident with a new diagnosis of [CONDITION(S)]; patient may continue to experience syncopal episodes at any time and could be at risk for falls and injury. The facility's fall Prevention Program documents the following: Policy: It is the policy of this facility to have a fall prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Standard fall/Safety Precautions for all Residents: 11. Residents who require staff assistance will not be left alone after being assisted to bathe, shower, or toilet.

Based on interview and record review, the facility failed to notify any other staff, a physician and/or family immediately after a resident had a fall for one (R1) resident out of three reviewed for falls in a total sample of six. This failure resulted in R1 not receiving medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R1 is an [AGE] year-old with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 1/13/22, documents the CNA (V3) notified the nurse (V4) post occurrence that R1 was self transferring from the toilet to the wheelchair. In an attempt to adjust herself (R1) onto the toilet, R1 began to slide off the toilet and required assistance from the CNA to be eased to the floor. R1 was assessed and transferred onto the bed. No injury was noted and R1 denied any pain at this time. The Nursing note dated 1/16/22 at 7:58AM, documents R1 complained of left knee and lower leg pain. Moderate swelling was noted, warm to touch. An X-ray of the left leg was ordered. R1 declined pain management at this time. R1's family was made aware of status. (Survey note: this was 3 days after R1's 1/13/22 fall). A Nursing note dated 1/16/22 at 10:48 PM, documents X-ray was done at 10:15 PM and showed a left femur fracture. The doctor was notified and ordered to send R1 to the hospital for evaluation. R1's family was notified. Pain medication was administered. (Survey note: this was 3 days after R1's 1/13/22 fall). The Unusual Occurrence 24-hour Report Form dated 1/16/22, documents R1 complained of left leg pain during the 11p-7a shift last night. A portable X-ray showed a left femur fracture. When asked, R1 endorsed not reporting the fall to anyone because R1 thought V3 (CNA) reported it. The X-ray of the left femur dated 1/17/22, documents an oblique distal fracture of the left femur. On 01/29/22 at 2:32PM, V3 stated, I was doing my rounds and I was coming down the hall and I heard (R1) yelling my name. I ran into the room and I didn't see (R1), so I went to the bathroom and (R1) is holding onto the side rail that's on the wall with (R1's) legs in between the toilet in the wall. (R1's) saying 'help me I'm going to fall.' I got in behind (R1) to try to sit (R1) down on the toilet but (R1) was slipping off the side, so I had to just lower (R1) down onto the floor. I did the best I could but (R1) did make a little thump when (R1) hit the floor. (R1's) legs kind of came up onto the toilet and (R1) landed on (R1's) left side. We got (R1) in the wheelchair and put (R1) back in the bed. (R1) didn't say (R1) was in any pain and it was a change of shift, so I left right after that. I don't remember telling anybody that (R1) fell . On 01/29/22 at 2:49PM, V4 (Nurse) stated, I didn't document it for a day or two later because I didn't consider it a fall. I let the DON know then too. After a fall you call the doctor in the family to let them know what happened. I think a fall is anytime resident ends up on the ground before it can be stopped. I don't remember if I told the next nurse or not and report that she had a fall. On 01/29/22 at 3:51PM, V2 (Acting DON) stated, They (nurses) notify the doctor, the family, and the DON. No one was notified with this fall. A fall is considered when you go from a higher plane to a lower plane. Yes, this should have been brought to the doctor's attention. When we asked R1, R1 didn't tell anyone because R1 thought V3 the CNA would tell someone what happened. On 01/29/22 at 4:23PM, V9 (Primary Physician) stated, When someone falls, they are supposed to examine them and report it to me. There's no reason I shouldn't be updated about a fall. It should be reported to me immediately. The policy titled, Fall Policy, dated 6/2014 documents . 3. Place (resident) in a position which is comfortable and will maintain an open airway. If head, neck, or back injury suspected, do not move unless it is necessary to maintain an open airway. Immediately call for an email to notify the physician . additional measures: document all assessment findings and observations, physician and family notification in the residence clinical record in accordance with the assessment guidelines. Document all assessment findings and observations, physician and family notifications in the resident's clinical record in accordance with the assessment guidelines. The policy titled, Change in Condition Physician Notification Overview Guidelines, dated 4/2014 documents These guidelines were developed to ensure that: 1. All significant changes in resident status are thoroughly assessed in physician notification is based on assessment findings and is to be documented in the medical record. 2. Medical care non-emergency problems are communicated to the attending physician and family in a timely, concise, and through manner (generally within 24 hours or sooner). The nurse should not hesitate to contact the attending physician at any time for a problem which is in his or her judgment requires immediate medical intervention.

Based on interview and record review, the facility neglected to follow their policy to notify physician and nursing staff of a residents fall incident for one (R1) resident out of three reviewed for notification of change in condition. This failure resulted in approx. a four-day delay of the physician being notified of R1's fall where R1 sustained a femur fracture. Findings Include: R1 is an [AGE] year-old with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 1/13/22, documents the CNA (V3) notified the nurse (V4) post occurrence that R1 was self transferring from the toilet to the wheelchair. In an attempt to adjust herself (R1) onto the toilet, R1 began to slide off the toilet and required assistance from the CNA to be eased to the floor. R1 was assessed and transferred onto the bed. No injury was noted and R1 denied any pain at this time. The Nursing note dated 1/16/22 at 7:58AM, documents R1 complained of left knee and lower leg pain. Moderate swelling was noted, warm to touch. An X-ray of the left leg was ordered. R1 declined pain management at this time. R1's family was made aware of status. (Survey note: this was 3 days after R1's 1/13/22 fall). A Nursing note dated 1/16/22 at 10:48 PM, documents X-ray was done at 10:15 PM and showed a left femur fracture. The doctor was notified and ordered to send R1 to the hospital for evaluation. R1's family was notified. Pain medication was administered. (Survey note: this was 3 days after R1's 1/13/22 fall). The Unusual Occurrence 24-hour Report Form dated 1/16/22, documents R1 complained of left leg pain during the 11p-7a shift last night. A portable X-ray showed a left femur fracture. When asked, R1 endorsed not reporting the fall to anyone because R1 thought V3 (CNA) reported it. The X-ray of the left femur dated 1/17/22, documents an oblique distal fracture of the left femur. The Hospital records dated 1/17/22 documents R1 presented with pain in the left lower leg after falling. X-ray of the left femur shortly distal fracture of the femur and a possible proximal fracture as well. R1's left leg was deviated externally when R1 was seen by the paramedics. R1 does have a lot of pain. R1 does have muscle pain and joint pain upon assessment. Bilateral pedal [CONDITION(S)] is noted with more over the left lower extremity. Left lower extremity is deviated outward and is shorter than the right. R1's family decided to proceed with an open reduction internal fixation surgery to repair the left distal femur fracture. On 01/29/22 at 2:32PM, V3 stated, I was doing my rounds and I was coming down the hall and I heard (R1) yelling my name. I ran into the room and I didn't see (R1), so I went to the bathroom and (R1) is holding onto the side rail that's on the wall with (R1's) legs in between the toilet in the wall. (R1's) saying 'help me I'm going to fall.' I got in behind (R1) to try to sit (R1) down on the toilet but (R1) was slipping off the side, so I had to just lower (R1) down onto the floor. I did the best I could but (R1) did make a little thump when (R1) hit the floor. (R1's) legs kind of came up onto the toilet and (R1) landed on (R1's) left side. We got (R1) in the wheelchair and put (R1) back in the bed. (R1) didn't say (R1) was in any pain and it was a change of shift, so I left right after that. I don't remember telling anybody that (R1) fell . On 01/29/22 at 2:49PM, V4 (Nurse) stated, I didn't document it for a day or two later because I didn't consider it a fall. I let the DON know then too. After a fall you call the doctor in the family to let them know what happened. I think a fall is anytime resident ends up on the ground before it can be stopped. I don't remember if I told the next nurse or not and report that she had a fall. On 01/29/22 at 3:51PM, V2 (Acting DON) stated, They (nurses) notify the doctor, the family, and the DON. No one was notified with this fall. A fall is considered when you go from a higher plane to a lower plane. Yes, this should have been brought to the doctor's attention. When we asked R1, R1 didn't tell anyone because R1 thought V3 the CNA would tell someone what happened. On 01/29/22 at 4:23PM, V9 (Primary Physician) stated, When someone falls, they are supposed to examine them and report it to me. There's no reason I shouldn't be updated about a fall. It should be reported to me immediately. The policy titled, Abuse Prevention Program Facility Policy, dated 2011 documents the facility affirmed the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment . Neglect means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident.

Based on interview and record review, the facility failed to conduct a comprehensive nursing assessment of a resident after a fall for one (R1) resident out of three reviewed for post fall assessment. This failure resulted in R1 not being assessed for injury post fall for approx. four days where R1 sustained a fracture of the femur. Findings Include: R1 is an [AGE] year-old with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 admitted to the facility on [DATE]. A Nursing note dated 1/13/22, documents the CNA (V3) notified the nurse (V4) post occurrence that R1 was self transferring from the toilet to the wheelchair. In an attempt to adjust herself (R1) onto the toilet, R1 began to slide off the toilet and required assistance from the CNA to be eased to the floor. R1 was assessed and transferred onto the bed. No injury was noted and R1 denied any pain at this time. The Nursing note dated 1/16/22 at 7:58AM, documents R1 complained of left knee and lower leg pain. Moderate swelling was noted, warm to touch. An X-ray of the left leg was ordered. R1 declined pain management at this time. R1's family was made aware of status. (Survey note: this was 3 days after R1's 1/13/22 fall). A Nursing note dated 1/16/22 at 10:48 PM, documents X-ray was done at 10:15 PM and showed a left femur fracture. The doctor was notified and ordered to send R1 to the hospital for evaluation. R1's family was notified. Pain medication was administered. (Survey note: this was 3 days after R1's 1/13/22 fall). The Unusual Occurrence 24-hour Report Form dated 1/16/22, documents R1 complained of left leg pain during the 11p-7a shift last night. A portable X-ray showed a left femur fracture. When asked, R1 endorsed not reporting the fall to anyone because R1 thought V3 (CNA) reported it. The X-ray of the left femur dated 1/17/22, documents an oblique distal fracture of the left femur. The Hospital records dated 1/17/22 documents R1 presented with pain in the left lower leg after falling. X-ray of the left femur shortly distal fracture of the femur and a possible proximal fracture as well. R1's left leg was deviated externally when R1 was seen by the paramedics. R1 does have a lot of pain. R1 does have muscle pain and joint pain upon assessment. Bilateral pedal [CONDITION(S)] is noted with more over the left lower extremity. Left lower extremity is deviated outward and is shorter than the right. R1's family decided to proceed with an open reduction internal fixation surgery to repair the left distal femur fracture. On 01/29/22 at 2:32PM, V3 stated, I was doing my rounds and I was coming down the hall and I heard (R1) yelling my name. I ran into the room and I didn't see (R1), so I went to the bathroom and (R1) is holding onto the side rail that's on the wall with (R1's) legs in between the toilet in the wall. (R1's) saying 'help me I'm going to fall.' I got in behind (R1) to try to sit (R1) down on the toilet but (R1) was slipping off the side, so I had to just lower (R1) down onto the floor. I did the best I could but (R1) did make a little thump when (R1) hit the floor. (R1's) legs kind of came up onto the toilet and (R1) landed on (R1's) left side. We got (R1) in the wheelchair and put (R1) back in the bed. (R1) didn't say (R1) was in any pain and it was a change of shift, so I left right after that. I don't remember telling anybody that (R1) fell . On 01/29/22 at 2:49PM, V4 (Nurse) stated, The CNA (V3) came and reported to me that V3 eased the resident (R1) down to the floor in the bathroom. I went in and assessed R1 and R1 said R1 was fine so we got R1 up to the wheelchair and back in bed. I asked R1 if R1 was any pain and R1 said no and I kind of looked to see if anything seemed off to R1 but it was ok. I didn't look at R1's leg once R1 got back in bed. I just asked R1 if she was in any pain. I assumed R1 wasn't hurting too bad because R1 was lower down to the ground. It happened towards the end of my shift so I only assessed R1 right then before I left. I didn't document it for a day or two later because I didn't consider it a fall. I let the DON know then too. After a fall you call the doctor in the family to let them know what happened. I think a fall is anytime resident ends up on the ground before it can be stopped. I don't remember if I told the next nurse or not and report that she had a fall. On 01/29/22 at 3:26PM, V6 (Nurse) stated, I know the CNA went in to do AM care and that's when R1 told us R1 had pain. R1 didn't even want to move R1's leg R1 was in so much pain. I went and I told the doctor and there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After every fall you should assess the residents and make sure there is no injuries, notify the doctor and the family, notify the supervisor or DON, and chart everything you did. You chart what happened during the fall, who you talk to notify the fall happened, what the residence pain level was and if there were any injuries, and what the plan will be after the fall. On 01/29/22 at 3:37PM, V7 (Nurse) stated, R1 started complaining of pain on the night shift on the morning of January 16th. The nurse (V6) who had R1 before me on day shift said R1 was doing fine with an X-ray was ordered of R1's left leg. They came around the x-ray at about 10:15PM. The technician came and showed me the x-ray and said that there was a femur fracture and he wanted to let me know now but it was going to take him about another hour or two to get back to the place where he had to go to upload it. I called the doctor right away and let him know and he said to send R1 out to the emergency room . On 01/29/22 at 3:51PM, V2 (Acting DON) stated, They (nurses) notify the doctor, the family, and the DON. No one was notified with this fall. A fall is considered when you go from a higher plane to a lower plane. Yes, this should have been brought to the doctor's attention. When we asked R1, R1 didn't tell anyone because R1 thought V3 the CNA would tell someone what happened. On 01/29/22 at 4:23PM, V9 (Primary Physician) stated, When someone falls they are supposed to examine them and report it to me. The nurse wouldn't have known this was a hip fracture without getting an x-ray. There could be classic signs like having one leg shorter than the other or the leg rotated out. A whole assessment of the body should be performed after a fall to see if there is something abnormal. There's no reason I shouldn't be updated about a fall. It should be reported to me immediately. The policy titled, Fall Policy, dated 6/2014 documents . 2. Assess for respiratory difficulties, bleeding and fractures, wear gloves in the presence of blood, open wounds or other body fluids. 3. Place (resident) in a position which is comfortable and will maintain an open airway. If head, neck, or back injury suspected, do not move unless it is necessary to maintain an open airway. Immediately call for an email to notify the physician . additional measures: document all assessment findings and observations, physician and family notification in the residence clinical record in accordance with the assessment guidelines. Document all assessment findings and observations, physician and family notifications in the resident's clinical record in accordance with the assessment guidelines.

Based on interview and record review, the facility failed to develop an effective plan of care to include monitoring and supervision for a resident identified to have weakness and at high risk for falls. This affected 1 of 3 residents (R1) reviewed for fall prevention protocol. This failure resulted in R1 sustaining an unwitnessed fall while attempting to transfer from the wheelchair to the toilet unassisted where R1 sustained a left femur fracture Findings Include: R1 is an [AGE] year-old with the following diagnosis: congestive heart failure, difficulty in walking, and lack of coordination. R1 admitted to the facility on [DATE]. A Nursing progress note dated 1/12/22 documents R1 was readmitted to the facility from the hospital with a diagnosis of rectal bleeding. Pitting [CONDITION(S)] that was painful to touch was noted to the bilateral lower extremities. A Nursing note dated 1/13/22, documents the CNA (V3) notified the nurse (V4) post occurrence that R1 was self transferring from the toilet to the wheelchair. In an attempt to adjust herself (R1) onto the toilet, R1 began to slide off the toilet and required assistance from the CNA to be eased to the floor. R1 was assessed and transferred onto the bed. No injury was noted and R1 denied any pain at this time. The Nursing note dated 1/16/22 at 7:58AM, documents R1 complained of left knee and lower leg pain. Moderate swelling was noted, warm to touch. An X-ray of the left leg was ordered. R1 declined pain management at this time. R1's family was made aware of status. (Survey note: this was 3 days after R1's 1/13/22 fall). A Nursing note dated 1/16/22 at 10:48 PM, documents X-ray was done at 10:15 PM and showed a left femur fracture. The doctor was notified and ordered to send R1 to the hospital for evaluation. R1's family was notified. Pain medication was administered. (Survey note: this was 3 days after R1's 1/13/22 fall). The Unusual Occurrence 24-hour Report Form dated 1/16/22, documents R1 complained of left leg pain during the 11p-7a shift last night. A portable X-ray showed a left femur fracture. When asked, R1 endorsed not reporting the fall to anyone because R1 thought V3 (CNA) reported it. The x-ray of the left femur dated 1/17/22 documents there was an oblique distal fracture of the left femur. The Hospital records dated 1/17/22 documents R1 presented with pain in the left lower leg after falling. X-ray of the left femur shortly distal fracture of the femur and a possible proximal fracture as well. R1's left leg was deviated externally when R1 was seen by the paramedics. R1 does have a lot of pain. R1 does have muscle pain and joint pain upon assessment. Bilateral pedal [CONDITION(S)] is noted with more over the left lower extremity. Left lower extremity is deviated outward and is shorter than the right. R1's family decided to proceed with an open reduction internal fixation surgery to repair the left distal femur fracture. On 01/29/22 at 2:32PM, V3 stated, (R1) had no issues transferring before (R1) went to the hospital. (R1) can get herself into the bathroom in (R1's) wheelchair and transfer to the toilet and transfer back to (R1's) wheelchair. (R1) was in the hospital for seven days and (R1) came back to us weaker because they don't let you get out of the bed too much in the hospital. I was doing my rounds and I was coming down the hall and I heard (R1) yelling my name. I ran into the room and I didn't see (R1) so I went to the bathroom and (R1) is holding onto the side rail that's on the wall with (R1's) legs in between the toilet in the wall. (R1's) saying help me I'm going to fall. I got in behind (R1) to try to sit (R1) down on the toilet but (R1) was slipping off the side so I had to just lower (R1) down onto the floor. I did the best I could but (R1) did make a little thump when (R1) hit the floor. (R1) doesn't walk but (R1's) able to transfer herself. You just have to kind of watch (R1) do it. We told (R1) when (R1) got back to not do that by herself because (R1) wasn't as strong. (R1) can follow directions but (R1) does like to be independent with some of (R1's) care. (R1) likes washing herself up at the sink in the morning and going to the bathroom herself. We did tell (R1) to call for help because (R1) was weaker from being in the hospital but (R1) didn't call this time. On 01/29/22 at 2:49PM, V4 (Nurse) stated, R1 never had a fall before and that's really what we base it on is R1's fall history. I don't think R1 had any fall interventions in place. R1 was able to transfer herself. I never got a report that R1 was weaker after coming back from the hospital. I assumed everything was fine. R1 does have daily moments of confusion but R1 is able to follow directions. On 01/29/22 at 3:51PM, V2 (Acting DON) stated, R1 is able to make transfers alone and R1 is able to follow directions. R1 recently went into the hospital for rectal bleeding and when R1 came back to us R1 was weaker due to not getting up in the hospital. A couple days later R1 complained of pain to the left leg and when the x-ray was taken and showed a fracture to the left femur. Fall Risk Assessment is done when a resident comes back from the hospital. It should tell use if there's anything different from before they went out, so we know if they is anything to be monitoring. On 01/29/22 at 4:23PM, V9 (Primary Physician) stated, I wasn't told they had any concerns with R1 when R1 got back. R1 does have chronic [CONDITION(S)] (swelling) so if R1 was not walking and just lying in bed in a hospital it could've gotten worse and decreased R1's mobility. The extra fluid in R1's legs could have made it harder to walk for R1. I would just say follow your policy for monitoring after they come back from the hospital to help prevent things like this. The Care Plan dated 1/25/19 documents R1 displays behavioral symptoms related to poor and/or ineffective coping skills and a history of non-compliance with recommendations from health care professionals - transferring self without support. There are no interventions related to R1 transferring without support. The Care Plan dated 2/7/20 documents R1 is monitored due to being at risk for falls related to injury due to assistance required for movements and transfers. The following interventions are documented: encourage R1 to call and ask for assistance with transfers and monitor R1 hourly and offer toileting assistance during hourly rounding. The Fall Risk Review dated 10/8/21 documents R1 is a high fall risk due to loss of balance while standing, use of an assistive device, and has a predisposing disease of circulatory/heart conditions. The MDS Section G dated 10/8/21 documents R1 needs a one person limited physical assist with transfers and a one-person physical assist with supervision for toilet use. When moving from a seated to a standing position R1 is not steady and only able to stabilize with staff assistance. The Fall Risk Review dated 1/12/22 documents R1 is not a high fall risk after returning from the hospital. The Management Incident Form dated 1/16/22 documents R1 is not identified as a fall risk, does display poor coordination/unsteady gait, and does have decreased strength. The policy titled, Fall Prevention Program, dated 02/28/14 documents, A Fall Risk Assessment will be performed by a licensed nurse at the time of admission. The assessment tool will incorporate current clinical practice guidelines. Residents who require assistance will not be left alone after being assisted to bathe, shower, or toilet. Residents at risk of falling will be assisted with toileting needs in accordance with voiding patterns identified on the care plan.

Based on observation, interview, and record review, the facility failed to keep a resident free from abuse by allowing a staff , V27 (Certified Nurse Assistant), to continue providing direct care to a resident who previously made allegations of abuse against the staff member. This failure applied to one of one (R1) resident reviewed for abuse and resulted in R1 experiencing continued emotional and mental anguish. Findings include: R1 is a [AGE] year old originally admitted on [DATE] with medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical records reads: R1 is alert and oriented X3, with Brief Interview for mental status (BIMS) score of 15, which means intact cognition. On 11/21/21 11:05 AM R1 was observed sitting in wheelchair, clean, dressed and in no apparent distress. R1 is watching television and is eager to speak with Surveyor upon introduction. R1 became tearful while expressing concerns regarding one staff member , V27 (CNA). On 11/21/2021 at 11:05 AM, R1 said I have reported verbal abuse regarding V27 (CNA). I reported it to the Director of Nursing that was here, and the Social Worker. V27 (CNA) would say something forceful, and slam my door. I suffered physical abuse at another nursing home before coming here. I feel like V27 (CNA) just taunts me and does things just to mess with me. Sometimes V27 (CNA) is on the phone and talking to others while providing care to me. V27 (CNA) gets me up in the sit to stand machine to wash me up and doesn't put lotion or cream on me. I have raw, pink skin on my bottom, but no sores. V27 (CNA) won't come and help me, and it makes me sad and makes me want to try harder to get out of here. I pray I can get out of here. On 11/23/21 11:05 AM, R1 stated V27 (CNA) didn't want to change R1 when R1 asked to be changed. This resulted in urine leaking through incontinence brief, saturating the wheelchair and leaking onto the floor. R1 said that V27 (CNA) was accusing R1 of purposely spilling water in R1's lap to make it appear that urine was on the floor. R1 told V12, Nurse, that this happens all the time and that V27 (CNA) lies about R1. On 11/23/21 at 11:30 AM, R1 is observed in room with V27 (CNA) and V12 (LPN), receiving incontinence care. V27 (CNA) left the room when Surveyor entered. Resident is visibly upset expressing concerns to V12, Nurse, regarding V27 (CNA). R1 said I don't want V27 taking care of me! I keep telling you all and nobody listens to me! At 11:35AM, V12, Licensed Practical Nurse (LPN), said I wasn't aware that there was any issue with V27 (CNA) and R1. I came in because V27 (CNA) said that R1 was upset while V27 (CNA) was providing care. At 11/23/21 11:37 AM ,V27 (CNA) said I take care of (R1) Monday through Friday. When I do take care of her, I try to have someone else with me, because I have had problems with her saying that I'm doing all kinds of stuff to her. I had a conversation with V1 (Administrator), and she gave me a choice to have someone go in with me, or find someone else to switch R1 with. V1 told me that I had to ask another (CNA) to take care of her on days that I worked. I last changed R1 2 hours ago, but I did not document that. V32 (CNA) helped me. At 11:45 AM, V32 (CNA) said I am helping with R1 to get cleaned up now, but I have not been in R1's room today, prior to this time. At 12:10 PM on 11/23/2021, V2, Acting Director of Nursing (DON), stated if a resident alleges abuse towards staff, it depends on the results of the investigation whether the staff would continue to care for that resident in the future. If the Resident complains, the resident says they are not safe or don't want that staff anymore they absolutely should not care for the resident again. On 11/23/21 01:50 PM, V1 (Administrator) said R1 reported to the past Director Of Nursing that there was an issue with V27 (CNA). As a result, V27 (CNA) was given a verbal disciplinary action which was documented on paper. One of the concerns was that V27 (CNA) wouldn't come prepared to care for R1with all the necessary care items and R1 felt as if R1 was waiting for long periods of time. V27 (CNA) would keep going in and out of the room to get things and left R1 half-dressed or exposed during care. That was the last time R1 expressed any issues, which was in October of this year. I am the abuse coordinator. The staff know to talk to me regarding any allegations of abuse. V1 (Administrator) stated on 10/8/2021, V27 (CNA) was given a teachable moment which is a sort of disciplinary write up. At the time, I did not consider the behavior of the V27 (CNA) as being abusive, I considered it being rude. R1 claimed that V27 (CNA) came into the room and demand that R1 get up and get dressed. It was explained to V27 (CNA) that we cannot demand anything from the residents because this is their home. If the residents decide they don't want to get up on a particular day that is their right. V27 (CNA) was written up for being rude to R1 but I didn't consider it to be abuse. The disciplinary action taken was the write up according to the union and the union employee conduct policy. On 11/23/2021 at 2:40PM V28 (LPN) said V12 has left for the day, so I am taking care of all the residents on the 100 and 200 unit until the next shift comes in. I wasn't aware of any staff that wasn't able to work with R1. I don't usually take care of R1, so I wouldn't know. The Director of Nursing, Assistant Director of Nursing or the Administrator would be the ones to let the nursing staff know if a CNA wouldn't be able to take care of a resident because the nurses are responsible for making the CNA assignment every shift. On 11/23/2021 at 2:45PM V3 (Care Plan Coordinator) said I am not aware of any allegations of abuse from R1. I don't have an abuse care plan in place for R1. On 11/23/2021 at 3:25 PM V7 (Social Worker) said I knew about the allegation regarding R1. I did a Screening assessment for Aggressive or Harmful Behaviors during the quarterly review this month and did not determine that R1 was at risk for abuse. No additional assessment for abuse has been conducted. In R1's facility assessment records, a Screening Assessment for Indicators of Aggressive and /or Harmful Behaviors conducted by V7 (Social Worker) dated 11/09/2021 indicated in Section D titled Abuse/Neglect Factors that R1 did not have a history of abuse, did not have any factors that would increase R1's vulnerability, such as weakness or poor ambulation and did not have a history of dysfunctional behaviors, such as aggressive, manipulative derogatory or disrespectful. V27 (CNA's) personnel filed reviewed, background and signs of misconduct. V27 received a Teachable Moment written notice which states details as Having inappropriate conversations with residents may be considered rude or abusive. V1 (Administrator) admitted to not following up this write-up as an abuse investigation, therefore none is available. V27 (CNA) received an additional written disciplinary action notice signed 10/11/2021 misconduct leading to Discourteous Behavior which reads as follows: R1 reported V27 (CNA) as being rude to R1 stating that V27 would not get R1 up this morning because R1 does not have a chair. No progress notes were available in regard to any complaints of abuse or neglect during this survey investigation. On 11/23/2021 at 4:04PM V1 (Administrator) presented undated policy titled Abuse Prevention Program Facility Policy which reads in part; The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse by: identifying occurrences and patterns of potential mistreatment, immediately protecting residents involved in identified reports of possible abuse, implementing systems to investigate all reports and allegation of mistreatment promptly and aggressively, making the necessary changes to prevent future occurrences and filing accurate and timely investigative reports.

Based on observation, interview and record review, the facility failed to provide supervision of residents assessed as high risk for falls; failed to formulate and implement individualized and measurable care plan interventions in preventing falls and failed to follow its policy related to fall investigation for four (R1, R25, R31 and R80) of four residents in a sample of 31 reviewed for accidents and supervision. These deficiencies resulted in R31 sustaining a pubic rami fracture after a fall incident. Findings include: R25 is a [AGE] year old, female, admitted in the facility on 05/28/21 with diagnoses of Unspecified Fall, Subsequent Encounter; Functional Quadriplegia; Alzheimer's Disease, Unspecified; Unspecified Lack of Coordination; Weakness and Age-Related Physical Debility. The following fall incident reports documented: 11/01/21 R25 was noted to be lying on the floor on right side wrapped in blanket. Small skin tear to right shoulder was noted. There were no other apparent injuries noted. R25 was sent to the hospital for further evaluation and treatment. 10/08/21 R25 was observed on the floor on left side next to her bed awake and alert wrapped in blankets. R25 could not recall what happened. Head to toe assessment completed. Alert and responsive. Denies hitting head. Verbally responsive. No signs and symptoms of pain were reported and no injuries noted. Sent to the hospital for evaluation and treatment. 08/16/21 -R25 was noted lying on right side on the floor wrapped in bedding, with head resting on right hand and arm. There were no injuries observed at the time of incident. Sent to the hospital for further evaluation and treatment. On 11/22/21 at 10:12 AM, R25 was observed in bed, asleep but can be awakened through verbal and tactile stimuli. R25 is able to talk, shakes head for a yes or no answer but unable to engage in a conversation. Bed in the lowest position and a fall mat was placed on the right side of bed. The head of bed was positioned at 30 to 45 degrees angle with body in a slight diagonal position with head leaning on the left side. A pillow was placed under lower extremities. On a low air loss mattress. The mattress is covered with a top white sheet. There was a disposable incontinent pad underneath R25's back. At 12:42 PM, V8 (Certified Nurse Assistant, CNA) was observed feeding R25 while in bed. During feeding, V8 elevated the head of (R25) bed at a 70 to 75 degrees angle. After (R25) finished eating meals, V8 placed back the fall mat on the left side of (R25) bed, took the food tray and left the room. On 11/23/21 at 10:56 AM, V13 (Minimum Data Set, MDS Coordinator) was interviewed regarding R25's fall incidents. V13 stated, On 10/08/21, yes, R25 had a fall. I was the floor nurse that day. R25 was on the floor by bed wrapped in blanket. Head to toe assessment done, no injuries but was sent out for further evaluation. When R25 had the fall on 10/08/21, maybe R25 attempted to roll and fell out of bed. Interventions that need to be implemented are the use of floor mats, more frequent rounds ensuring is positioned in the middle of the bed. When R25 was found that time, the bed was in lowest position, the head part of the bed was like 30-45 degrees. Was found wrapped with a flat sheet and the comforter. V3 (Care Plan Nurse) was also asked on 11/23/21 at 11:09 AM regarding R25's fall incidents. V13 verbalized, R25 had falls on 08/16/21; 10/08/21 and 11/01/21. There were no injuries noted on those fall incidents. R25 is generally alert, [AGE] years old. R25 never walks, been in the chair, up in a reclining chair and assisted by staff on all transfers. The fall incidents mentioned that was found on the floor wrapped in blankets. R25 is on low bed, does have the floor mats. R25 can move somewhat, move and position self As R25 was trying to reposition can make her roll, unaware of position on bed and be close to the edge and fall out of bed. R25 should be monitored for positioning while in bed, make sure R25 is at the center of the bed; needs to be frequently repositioned every one to two hours, make sure R25 is not entangled in a blanket; and bed should be in the lowest position with the head of the bed up around 30 degrees. According to R25's fall care plan with revision date of 10/15/21, the following interventions were documented: 10/8/21: Staff to ensure resident does not have too many blankets in bed while resting 10/8/21: Resident up during morning (7-3) shift and back down for 3-11 shift 08/16/21: Educate resident to use call light and call for assistance as needed 11/09/21: Ensure resident's bed is not left in upright position while in bed 11/09/21: Place resident in geri-chair (reclining chair) for meals 06/02/21: Be sure call light is within reach and encourage the resident to use it for assistance as needed. Staff to respond promptly to all requests for assistance. On 11/23/21 at 2:10 PM, V10 (Nurse Practitioner) was interviewed regarding her expectations on staff in fall prevention for R25. V10 replied, The bed should be in the lowest position, there should be floor mats at bedside and frequent rounding - at least see (R25) every hour, either CNA, nurse or staff member, by at least walking by the room to look at her. To physically see that she is not on the floor. She cannot be educated in calling for assistance or use the call light because she is not able to retain that information or recall. She is not able to demonstrate the use of call light. Per R25's MDS dated [DATE], R25's BIMS (Brief Interview for Mental Status) score was 3 which means severe cognitive impairment. R80 is a [AGE] year old, initially admitted in the facility on 04/20/21 with diagnoses of Unspecified Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Repeated Falls; Other Specified Disorders of Bone Density and Structure, Unspecified Site and Unsteadiness on Feet. R80's progress notes documented: 11/22/21 - observed R80 on floor in bathroom on back with head up against the wall. R80 denied any pain but states did hit his head. Sustained an abrasion on top of coccyx area, cleansed and band aid applied. Was sent to the hospital for further evaluation and treatment. 11/23 at 4:02 AM - returned to facility. No new orders. 72 hours neuro checks in progress. Will continue to follow plan of care. 11/10/21 at 11:00 PM - observed sitting on floor, no injuries noted, no pain. 11/09/21 at 3:05 PM - nurse walking past resident's room and heard resident yell out and discovered R80 on floor on left side with hand/arm curled under head. On 11/22/21 at 10:00 AM, R80 was observed in room, in bed. R80 is alert, verbal but confusion was noted during conversation. R80 talks about his previous occupation and suddenly jumps into a different topic about friends. R80 stated can go to the bathroom alone, and does not need staff assistance. On 11/23/21, V3 was asked regarding R80. V3 stated, R80 appears very alert, can tell you what (R80) wants to do, what R80 wants to eat, talks about past very well. But R80 is very resistive to people at times. R80 is alert, oriented to person, able to use the call light. Sometimes R80 yells if he wants something. But a lot of times, does not want to use the call light. His BIMS score was 3, which means cognitively impaired. With BIMS score of 3, probably not able to remember things. Of the 4 fall incidents, R80 was trying to go to the bathroom independently not asking for any assistance. R80 does have weak legs, can walk but with assistance. Unaware of safety issues, R80 is impulsive. According to R80's fall care plan dated 10/20/21, the following interventions were documented: 10/31/21: Continue to ask resident to call for assistance 11/23/21: Continue to encourage resident to call for assist with toileting during rounds at night, assist to toilet during rounds 08/11/21: Remind R80 to ask for assistance when needed 07/22/21: Encourage R80 to call for assistance with all transfers Per R80's MDS dated [DATE], he has a BIMS score of 3 which means severe cognitive impairment. Facility's policy titled, Fall Prevention Program dated 2/28/14 stated in part but not limited to the following: Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Findings include: On 11/22/21 at 11:12 AM, V5 CNA (Certified Nurse Assistant) was interviewed regarding R31's fall. V5 stated, I was the aide for day shift on 8/20/21. I saw R31's thumb was black and blue in the morning. I went to get V6, LPN. R31 told me and V6, she fell and went back to bed. R31 was limping when I tried to put her in the wheelchair. She gets up out of her wheelchair and wanders in her room, going through her closet. She wanders from unit to unit. We try to keep her at the nurses' station. V5, CNA was asked if R31 is mentally capable of using her call light? V5 stated, R31 was not able to use her call light. R31 has her call light pinned to her night gown during the night, but she's smart. She will take off the night gown. I've never seen her pull her call light. At 12:06 PM, R31 seen self-propelling wheelchair through the dining room. No fall prevention devices noted on wheelchair. R31 redirected back to h table a few times by staff , noted continuously rolling around. Upon R31's room observation, there were no fall prevention devices noted on bed or on the sides of the bed. At 12:45 PM, V6 LPN (Licensed Practical Nurse) was interviewed regarding R31's fall. V6 stated, R31 told me and demonstrated how she fell , she comes and goes. R31 self-propels in her wheelchair. She walks unassisted sometimes and we redirect her back to her chair. She has fallen before. We do rounds, keep bed in lowest position, and redirect her when she is up unassisted. She started favoring her hip that morning, so I sent her out. V6 LPN was asked if R31 is mentally capable of using her call light? V6 stated, I can't recall ever answering R31's call light. I don't think she can purposely use it. She doesn't have the wherewithal. Review of the facility incident report indicates: On 8/20/21, R31 walks and transfers independently. R31 reported to a CNA she fell forward, tried to catch herself using both hands during the night (8/19/21). R31 complained of left wrist pain, left hip and left knee. R31 was sent to the hospital, public guardian notified. The roommate stated she did not hear or see R31 fall. The facility falls list states: R31's last fall was 4/13/2020 with a fracture to finger of left hand. R31's current falls were 8/20/21 and 11/7/21. The care plan dated 6/10/21 indicates: R31 is at risk for falls related to unsteady gait. R31 may be unaware of safety limits due to diagnosis of Dementia and medication usage including antipsychotic medication. Goal: I will have a safe environment maintained thru the next review. Target date 12/19/21. Interventions include: Encourage R31 to call/wait for assistance when she wants to use the bathroom (3/25/20). Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence (10/28/19). Anticipate and meet individual needs of the resident (10/28/19). The current care plan dated 9/20/21 indicates: R31 had an actual unwitnessed fall in her room and sustained a fracture of the pelvis. Date initiated (8/20/21). Interventions include: Remind resident to ask for assistance when needed. Frequent monitoring. Date initiated (8/23/21). There is no documentation of staff responsible for monitoring or how often the frequent monitoring should occur. The root cause of R31's falls was not determined and individualized interventions were not implemented per facility policy. The MDS Minimum Data Set (Comprehensive Assessment) dated 6/10/21 indicates a BIMS (brief interview for mental status) score of 3. A score of 0-3 indicates the resident has severe cognitive impairment. R31's 6/10/21 fall risk review indicates: 1-2 falls in last 6 months, high risk for falls. The 6/10/21 MDS Section G for Functional Status indicates: B. Transfer- how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. 1. Self Performance= Limited assistance. 2. Support= one person physical assist. C. Walk in room- how resident walks between locations in his/her room. 1. Self Performance= Supervision. 2. Support= one person physical assist. There were no fall prevention devices in place at the time of the fall on 8/20/21. R31 was not on the falling star program due to not having a fall since 3/25/2020. On 11/23/21 at 1:03 PM, V3, Care Plan Coordinator, was interviewed regarding R31's care plan interventions and fall prevention devices. V3 stated, Interventions are updated to the care plan as soon as they have a fall. The DON (Director of Nursing) is responsible for the fall coordination, I just update the care plans. R31's BIMS (brief interview for mental status) score is 3 which means she is cognitively impaired. V3 stated, R31's not able to use the call light. We don't use alarms in this building. At 2:30 PM, V10, Nurse Practitioner, was interviewed regarding R31's falls. V10 stated, R31 is alert to herself only, dependent on staff. She can self-propel her wheelchair. She can stand and walk short distances, but she is extremely unsteady on her feet. R31 has a history of stroke, impulsivity, generalized muscle weakness, [CONDITION(S)] and dementia which all could contribute to falls. Interventions could be frequent rounding at least every hour with staff physically seeing the resident, resident being near the nurses' station and within sight. R31 has poor retention, she's unable to remember instructions. She'll be unable to retain information to use the call light. At 2:59 PM, V2, Acting DON (Director of Nursing),was interviewed regarding R31's interventions related to falls. V2 stated, The interventions should be determined related to the cause factor, they should be individualized, and the goals should be measurable. R31's BIMS score is low. The likelihood is she's not able to remember to use the call light. V2 inquired of the use of fall prevention devices. V2 stated, We use bed, chair alarms and wedges. The wedges prevent resident's from rolling out of the bed. The alarms remind and alert staff the resident is getting up, those who are impulsive and transfer themselves. The alarms will go off and give staff time to get to the residents. The devices are available, V1 (Administrator) can place an order and it can be shipped and here the next day. Review of the 8/20/21 hospital records indicates R31 was diagnosed with a Pubic Rami Fracture. The 2/28/14 Fall Prevention Program states: Policy: It is the policy of this facility to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Responsibility: Director of Nurses, licensed nurses, therapists, and all facility staff. The Fall Prevention Program includes the following components: 5. Changes in interventions that were unsuccessful. 10. Care plan incorporates: a. Identification of all risk/issue. C. Preventative measures. The 6/14 Fall Prevention Alarm Devices and Systems policy states: Purpose: To establish procedures for alerting staff members of a resident's attempt to stand or get out of bed unassisted and to prevent/reduce resident falls. Equipment: Motion alarms, Pressure alarms- chair/bed, Push/pull alarms, Sound monitors, Video systems. Responsibility: All Facility Staff Policy: It is the policy of the facility to use a variety of devices and systems to promote the safety of all residents and to help prevent/reduce falls and injuries. Procedure: 2. The assessment tool will include pertinent aspects of the resident's status and pre-admission information that is available. 6. Safety/movement devices will be used as an integral tool to prevent unassisted ambulation and to prevent/reduce resident falls. On 11/21/21 11:05 AM R1 said I had a fall a little while ago. I was trying to get out of bed on my own because the staff left me so long in my urine and feces that I had to get up. When I went to the hospital they found I had a urinary tract infection, and I complained of right shoulder pain and my ribs hurt on the right side. I got COVID last year and it caused decreased mobility, so I can't go to the bathroom on my own. I need help when I stand to pivot. On 11/21/21 02:27 PM V29, Physical Therapy Assistant, said R1 is not able to walk independently. I wouldn't say she could toilet without assistance. R1 should have a least one person for some physical assistance and supervision. It is not safe for R1 to toilet or ambulate independently. R1 is very cognitively aware. If R1 were to try to get up by themselves they know they may fall. 11/23/21 at 01:50 PM V1, Administrator, said I did not instruct the nurse to create a fall report because R1 has behavioral symptoms. R1 intentionally put herself on the floor because she wanted to leave the facility. I can't say why the nurse didn't assist R1 when they witnessed R1 moving from the bed to the floor. The nurse just stated to me that R1 was angry and was smearing feces on the wall. At that time, R1 called 911 herself, and they came and took R1 to the hospital. I can't say that she has done this before. R1 was in the hospital for about 4 days and was treated for a Urinary Tract Infection. Based on my administrative experience, R1's behaviors could have been compromised due to a urinary tract infection. R1 returned to the facility after the hospitalization and has not had any further incidences of falling or being on the floor. ' At 2:47PM , V13, MDS Coordinator, said Fall assessments are conducted quarterly and whenever a fall occurs. A fall is defined as any change in plane that is unassisted. Upon record review, no Fall Investigation was conducted for R1 on 10/23/2021 and is unavailable at the time of this investigation. Fall Risk Review dated 11/17/2021 determined that R1 was high risk for falling. R1 Progress note dated 10/23/2021 at 7:18PM said that two nurses observed R1's bed in the highest position, and was counseled on the risk of falls. Bed was returned to the floor and R1 was re-positioned. At 7:47PM, nurse writes that while passing medication, R1 was observed in bed at the highest position, saw R1 place herself on the floor and R1 begin to yell. When R1 was questioned about being on the floor, R1 stated to the nurse, I did not. I fell and you lying on me. It was at this time, the nurse was paged by the front desk and notified that R1 had called 911 and the ambulance was at the facility to transport. R1 was taken to a local Hospital emergency room for evaluation. On 10/27/2021 Nursing Progress Note written at 9:52PM said that R1 was readmitted to the facility with a diagnosis of Urinary Tract Infection. No injuries indicted at the time of admission.

Based on interview and record review the facility failed to follow its skin condition assessment policy by not completing daily assessments for 1 (R1) of 3 residents at risk for skin breakdown. This failure resulted in R1 having a bone protrude through a healed [MEDICAL CONDITION] resulting in R1 having to undergo a second amputation resulting in an above the knee amputation. Findings include: R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview For Mental Status score of fifteen which indicated intact cognition. MDS section G dated 5/13/2020 documents R1 required extensive assistance with bed mobility with one-person physical assist. Transfers from the bed to the wheelchair or a standing position did not occur. R1's lower extremity was impaired on both sides. R1's Braden risk assessment dated [DATE] documents R1 was at moderate risk for skin breakdown related to requiring moderate to maximum assistance being lifted, frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. R1 had a [MEDICAL CONDITION] (BKA) related to right foot gangrene about two years ago. R1 was seen in the hospital on [DATE] for acute ulcer skin, bone exposed in right BKA. R1 was not able to walk. On 10/28/2020 at 9:10am, V3 (Treatment Nurse) stated, The CNA (Certified Nursing Assistant) should notify the nurse of any skin alteration that is seen during care or with showers. The nurse must complete an assessment and put in an intervention/treatment in the computer. I would then follow up with the resident, adjust the treatment as needed after updating the wound doctor. The wound doctor makes rounds weekly. On 10/28/2020 at 3:45pm, V2 (Director of Nursing/DON) stated, When I heard about R1's wound, the bone was protruding. I told the nurse to send R1 out to the hospital. I did not look at R1 before she was discharged . R1 returned to the facility after she had the surgery. On 10/29/2020 at 9:30am, R1 stated, The prosthetic was too small. V20 (R1's Family Member) stated they took the prosthesis home in April 2020. On 10/29/2020 at 4:40pm, V3 stated, The Braden assessments are done with new wounds or quarterly; skin assessments are completed on the showers days. The floor nurse is responsible for completing a body assessment after every shower and signing the shower sheets. Residents get showers twice week and as needed. The high risk resident skin assessment is done on the shower days by the day/evening shift nurse. On 10/30/2020 at 10:58am, V2 (DON) stated, The Braden assessment is used to monitor resident who are at risk for skin breakdown. The certified nursing assistant checks residents' skin every two hours. The CNA should report any skin alterations to the nurse. The nurse will do an assessment and update me. The nurse and I will then approach and intervene as needed. The nurse should check the resident's skin with each shower. The CNA should complete the shower sheet and circle the area on the body figure on the sheet if there are any skin alterations. I expect all skin alterations to be documented. If the skin alteration is old, I expect the CNA/Nurse to document no new skin opening. I was not informed when R1 was initially noted with the wound on her stump. I did not get informed until R1's bone was protruding out of R1's stump. There should have been documentation and interventions put in place when R1 acquired the wound. On 10/30/2020 at 1:09pm, V19 (Wound Doctor) stated, R1 had a [MEDICAL CONDITION] in the past. R1's bone could be felt though the skin. R2's wound started developing on the top right portion on the stump. When I saw R1's stump on 7/10/2020 the wound was small and had 100% slough. I debrided it. The debridement was superficial. Routine skin assessments should be performed per facility policy. R1's wound was gradual. R1's wound did not happen overnight. The second time I saw R1's right stump on 7/17/2020, we discharged her to the hospital for a revision of the [MEDICAL CONDITION] to an above the knee amputation. R1's wound was so small and that is probably why staff missed it. R1's shower sheet dated July 2020 documents on 7/8/2020 R1 had an open area. Location of the open area was not identified. On 7/12/2020 there was no documentation. Shower signed by the nurse. On 7/15/2020 R1 had an open area documented on the shower sheets. Location of the open area was not identified. Skin/wound note dated 7/10 /2020 documents: R1 complains of pain to right BKA. R1 was assessed by V19 (Wound Doctor). Area cleansed with normal saline, patted dry and dressing applied with orders. R1's wound report dated 7/10/2020 documents right lower leg facility acquired wound was measured at 0.6cm length (L) x 0.5cm width (W) x 0.2cm depth (D). Treatment Nurse Initial Skin Alteration Review dated 7/10/2020 documents: R1's right lower leg stump, medical device related, facility acquired, stringy yellow slough (dead tissue) one hundred percent present. Based on the comprehensive assessment the probable or known cause of R1's skin alteration includes but not limited to diabetes, [MEDICAL CONDITION], dementia and medical device for a prosthesis leg for cosmetics as R1 is not ambulatory. Wound doctor note dated 7/10/2020 documents: R1 has a wound on the end of the BKA stump due to underlying bone. Recommend no use of prosthesis as R1 is not ambulatory. R1's wound report dated 7/17/2020 documents right lower leg facility acquired wounds was measured at 0.8cm (L) x 0.8cm (W) x 0.2cm (D). Weekly Skin Alteration Review dated 7/17/2020 documents: R1's right lower leg stump. Wound type: Medical related device. Five percent slough present with scant serous (clear) drainage. Wound healing process is worsening. R1's bone is exposed thought the right BKA/stump. R1 was placed on antibiotic for osteo[DIAGNOSES REDACTED] and ordered X-rays. Wound doctor note dated 7/17/2020 documents: Recommend appointment with the orthopedic surgeon to trim bone down and revise the BKA. Exposed bone with periwound [MEDICAL CONDITION]. Wound of the right lower leg deteriorated due to protruding bone. R1's right knee x-ray radiology report dated 7/17/2020 documents no evidence of recent fracture, dislocation or osteo[DIAGNOSES REDACTED]. Progress note dated 7/28/2020 documents R1 had a right AKA on 7/27/2020. Progress note dated 7/30 documents R1 was readmitted with revision of Right BKA leading to right AKA with 39 staples. Physician note dated 8/7/2020 documents, R1 was found to have right BKA site with ulcer exposing underlying bone. X-Ray knee did not show osteo[DIAGNOSES REDACTED]. Wound culture [MEDICAL CONDITION]. R1 underwent stump revision surgery and BKA was converted to above the knee amputation on 7/27/2020. R1's care plan goals initiated 9/19/2019 documents: R1's skin will be checked during routine care on a daily basis and during the weekly/bi-weekly bath or shower schedule. Hospital Paperwork dated 7/21/2020 documents: R1's [DIAGNOSES REDACTED]. Chief Complaint: R1's bone exposed in the right BKA. Pressure Injury and Skin Condition Assessment Policy: #4 Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the certified nursing assistant. Changes shall be reported to the Charge Nurse who will perform the initial assessment.

Based on interview and record review, the facility failed to provide staff supervision for one of six residents (R6) at risk for falls and with agitated behaviors reviewed in a total sample of 17 residents. This failure resulted in R6 falling on her face from her wheelchair, sustaining a laceration above her left eyebrow and requiring three sutures. Findings include: R6's [DIAGNOSES REDACTED]. Physical Therapy discharge summary dated 5/14/19 notes R6 requires moderate assistance with wheelchair mobility. R6's fall care plan notes she has a deficit related to functional limitations due to stroke with left sided weakness, has cognitive impairments and requires extensive assistance. R6 can become agitated and swing legs over bed and has poor safety awareness and reasoning skills, Interventions include to assistant with transfers, ensure proper positioning while in chair, if agitated and trying to move legs, to reposition her. 11/20/19 at 12:05 pm, V1 (Administrator) stated that R6 had a fall from her wheelchair on 11/17/19 in front of the nurse's station. There was nobody at the nurse's station at the time of the fall. V 14 (Licensed Practical Nurse, LPN) was assigned to R6 but was not on the unit when she fell . V4 (LPN) attended to R6 at first. She had a laceration on her head and was sent to the hospital where she was admitted with a head injury. 11/20/19 at 2:00 pm, V4 (LPN) stated that on Sunday, 11/17/19 around 8:30 am, I was monitoring residents in the dining room when V26 (Certified Nursing Assistant, CNA) yelled for me to come to the nurse's station. I was the only nurse on the unit at the time. R6 was laying on the floor and bleeding when I got to the nurse's station. I did not see her fall . V14 (assigned nurse) then came down the hall. V24 (CNA), V25 (CNA) and V26 (CNA) were with R6 when I arrived, and she was laying on the floor. V25's (CNA) written statement included in the facility investigation dated 11/17/19 notes, V25 got R6 up about 8:30 am and pushed her in the wheelchair to the desk (nurse's station). V24 and V26 were at the nurse's station. I went to get some socks. When I came back, R6 was on the floor. 11/21/19 at 10:30 am, V2 (Director of Nursing, DON) stated that I determined the cause of the R6's fall was that she was impulsive and agitated. V25 was taking care of her that day and stated V24 and V26 were at the nurse's station when she left to get her socks. I reviewed the video and saw R6 tried to stand up by herself. R6 has behaviors of agitation and tries to get up unassisted at times. 11/21/19 at 2:15pm, V24 (CNA) stated that V25 was assigned as R6's CNA and she brought her out in the wheelchair to the nurse's desk. V25 left the unit to get R6 socks. I went in my patient's room to care for her when R6 fell and did not see her fall. 11/25/19 at 9:45am, V26 (CNA) stated that V25 brought R6 out in a wheelchair to the nurse's station. She left the unit to get socks for R6. I was in my patient's room and when I walked out of that room, I saw R6's empty wheelchair and R6 on the floor. Nobody was with R6 or at the nurse's station when I found her on the floor. She was bleeding from her head. 11/21/19 at 2:10 pm, V28 (CNA) stated that R6 requires a mechanical lift for transfer and 2-3 staff members. She gets combative at times. I always keep her with me or supervised in activities in the day room. R6 needs constant supervision so she does not hurt herself or have a fall. She does lean to the sides in wheelchair and will propel herself in a circle with her right hand only. She slides forward sometimes when she does this also. 11/21/19 at 2:30 pm, V12 (LPN) stated that I would not leave R6 in the hallway or at the nurse's station because I may have to walk away and do something. R6 should always be supervised. She came back to facility with sutures to her eyebrow. 11/25/19 at 11:20 am, V2 (DON) stated that V25 (assigned CNA) said that several times she wheeled R6 to the nurse's station and when she went to walk away to get her socks, R6 would start to propel self with her right hand down the hall. V25 would get her and put her back in front of the nurse's station. Per V2, V25 stated she was afraid R6 would fall. This happened several times before she left to get R6 socks. V25 stated she left R6 at the nurse's station when V24 and V26 were there. V25 believed that V24 and V26 were supervising R6 at the nurse's station when she fell . Surveyor made V2 aware that per interview with V24 and V26, they both stated that they were in other resident rooms and not at the nurse's station when R6 fell . V2 then stated that R6 should have been supervised by staff when in the hallway. V25 should have specifically asked other staff to supervise R6 when she left the unit to get her socks. I did not see other staff in the video with R6 when she tried to get up by herself and fell . V2 (DON)'s investigation note dated 11/18/19 notes R6 is alert and oriented to name only with confusion. R6 is impulsive attempting to stand up with assist while in wheelchair and attempts to get self out of bed unassisted. Compulsive behavior, does not understand safety risks or preventative measures done to keep her safe. Redirection given by staff was unsuccessful. R6 stood from wheelchair unassisted losing balance and sustaining a fall. Staff at desk were unable to reach resident in time prior to falling per interviews. V14's incident report on 11/17/19 notes R6 was oriented to person and had a fall with laceration to her left forehead. R6 was in her wheelchair with predisposing factors of impulsiveness, gait imbalance, decreased safety awareness, combative behavior with the wheelchair wheels unlocked at time of fall. R6's functional status dated 10/21/19 notes she requires extensive assistance with one staff physical assistance for transfers and locomotion on the unit in her wheelchair. R6's cognitive function dated 10/21/19 notes a score of 3 out of 15 which indicates severely impaired. V12's readmission nursing screening dated 11/11/19 notes R6 requires total dependence with transferring and locomotion on and off unit with a wheelchair. V4's note (LPN) on 11/17/19 at 8:30 am, notes she was summoned to nurse's station and observed resident lying on her left side on the floor in front of her wheelchair. R6's left eye appeared to be bleeding from a laceration above her left eyebrow. V14 (Assigned LPN) note on 11/17/19 at 8:57 am, notes R6 observed on the floor near the nursing station around 8:15am, laceration observed on left eyebrow. R6 is alert and oriented to self. An ambulance was called, and she was sent to hospital for further evaluation. At 3:11 pm, R6 was admitted to hospital for head trauma. R6's hospital records documented on 11/17/19, R6 was in the emergency room with a laceration in the middle of her left eyebrow. V27 (Wound Care Nurse) progress notes on 11/20/19 at 8:34pm note that R6 was readmitted with three sutures in place over left eyebrow. Physician orders [REDACTED].

Based upon record review and interview the facility failed to assess pain level, failed to address resident change in condition, and failed to provide timely care/services for one of six residents (R1) in the sample. These failures resulted in R1 having pain that was not treated and a delay in treatment. R1's x-ray revealed fracture of distal tibia and fibula which required surgical intervention. Findings include; The (4/14) change in condition policy states; the Nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgment requires immediate medical intervention. The (9/14) incident/accident reports policy & procedure states; an incident report will be completed for all accidental/incidental unusual occurrences. R1's progress notes state; (9/23/19) 4:50pm, Resident reaching for CNA (Certified Nursing Assistant) when left leg is moved. Resident nod head when writer asked if she was in pain and she pointed to left leg (Physical assessment and/or pain level are not documented). (9/24/19) 7:33am, Resident made gestures of pain to left leg. When examined observed darkened circular area to left lower anterior leg. Tender to touch upon palpation (Pain level is not documented). Slight [MEDICAL CONDITION] is present. Doctor paged at this time. (There is no documentation that physician contact was made and/or incident report initiated). 4:45pm, upon making rounds CNA asked writer to come look at resident left leg. Assessment revealed left leg to be cool to touch, yellowish green in color with swelling. Resident whimper upon palpation. Doctor present during assessment gave orders for STAT x-ray. 6:13pm, X-ray done results pending. (9/25/19) 1:39am, X-ray results revealed fracture of distal tibia and fibula. On 10/2/19 at 2:18pm, Surveyor inquired if the Physician was paged at 7:33am (as stated in the progress note) V9 (Licensed Practical Nurse) replied That was actually a mistake with timing it was around 3:00am. I evaluated her at that time. On 10/2/19 at 3:01pm, surveyor inquired about R1's (9/24/19) injury V10 (Licensed Practical Nurse) stated About 4:30pm, the CNA told me to come and look at her. Surveyor inquired if she was aware of R1's change in condition at 3:00am, V10 responded No maam. I did not get report that day. The other nurse takes the report she didn't report anything to me. On 10/2/19 at 3:30pm, surveyor inquired about R1's injury V11 (Restorative Nurse) stated When I was doing rounds, the nurse (V9) was giving report to the dayshift Nurse (V12/Licensed Practical Nurse) and said her leg was red. On 10/2/19 at 3:52pm, V2 (Director of Nursing) stated (V9) said she paged the doctor at 3:00am on 9/24/19. I know she didn't get a response from the doctor cause the doctor said he kept calling and couldn't reach anyone. I did interview the dayshift Nurse (V12) she did not follow the change in condition notification policy. The (11/14) pain assessment policy states; documentation of each pain assessment will be recorded on the pain assessment form, in the nurses notes or on the MAR (Medication Administration Record). R1's (September 2019) MAR indicated [REDACTED]. Record actual score 0-10. (There are no pain assessments documented). [MEDICATION NAME] was administered for pain on 9/23 at 4:50pm, and 9/24/19 at 4:59pm however pain assessments are not inclusive. On 10/3/19 at 9:09am, V1 (Administrator) affirmed the facility does not have a policy for STAT turnaround time. On 10/3/19 at 9:41am, V2 stated For our STAT x-rays and labs we usually have procedures done and results within 4-5 hours. On 10/3/19 at 10:59am surveyor inquired about R1's status V14 (Hospital/Registered Nurse) stated On 9/25/19 at 5:23am she received [MEDICATION NAME] (Anti-[MEDICAL CONDITION]) 60mg (milligrams) IM (Intramuscular) and [MEDICATION NAME] (Opiod pain reliever used to treat severe pain) 50mg IM for pain. She had an ORIF (Open Reduction Internal Fixation) 2 days ago. On 10/3/19 at 11:19am, surveyor inquired about R1's (9/24/19) injury V15 (Physician) stated I came and seen her, the bones were unstable. Surveyor inquired what unstable means V15 responded That means there's probably a fracture. Surveyor inquired about R1's (9/24/19) pain level at that time V15 stated Pain rating it's difficult to say she had a stroke. She was kind of a making faces, grimaces. Surveyor inquired about the potential harm to R1 if pain medication was not administered as warranted V15 stated There's patient pain. Evidence shows that on 9/24/19 at 3:00am, swelling and discoloration of R1's leg was observed. The physician was not aware of R1's change in condition until 9/24/19 at 4:45pm (approximately 14 hours elapsed). Orders for STAT x-rays were received on 9/24/19 at 4:45pm however results were not obtained until 1:39am (approximately 9 additional hours elapsed) 9/25/19.

Based upon observation, interview and record review the facility failed to implement fall prevention interventions for three of five residents (R3, R4, R6) reviewed for falls. Findings include; The (2/28/14) fall prevention program states; safety interventions will be implemented for each resident identified at risk using a standard protocol. R3's (9/4/19) care plan states; at risk for fall related incidents due to history of falls and assistance required for movements/transfers. Interventions: ensure call light is within reach. On 10/1/19 at approximately 9:44am, R3 was lying in bed surveyor inquired if her call light was within reach V4 (Licensed Practical Nurse) stated At this time it is not. Surveyor inquired about the height of R3's bed V4 responded It's at working level, it's not low to the ground. R4's (7/30/19) care plan states; at risk for fall related incidents due to assistance required for movements/transfers. Intervention: encourage resident to refrain from putting bed in highest position. On 10/1/19 at approximately 9:58am, R4 was lying in bed in the high position. Surveyor inquired if R4's bed was in low position V4 responded It is not. R6's (9/26/19) care plan states; at risk for fall related injury due to medication usage. Intervention: be sure call light is within reach. On 10/1/19 at 10:35am, R6 was lying in bed her call light was on the floor. Surveyor inquired about the location of R6's call light V6 (Certified Nursing Assistant) stated It's kinda outta the way, behind the bed. V6 placed the call light on R6's bed and stated It's supposed to go here so she can reach it.

Based on observations, interviews and record reviews, this facility failed to identify environmental hazards and a resident's risk of potentially avoidable accident and implement interventions to reduce the resident's risk for injury for two residents (R2 and R3) in a sample of 4 residents reviewed for transfer technique in a sample of 7. This failure resulted in R2 sustaining a right great toe laceration and fracture and R3 sustaining a distal fracture of left tibia and fibula during transfer. Findings include: Review of R2's medical record notes R2 with [DIAGNOSES REDACTED]. On 10/24/17 at 3:15pm, E6 CNA (certified nursing assistant) stated that R2 was alert and oriented. E6 stated that this was E6's first time providing care for R2. E6 stated that the nurse and other CNAs working at the time informed E6 that R2 was able to stand and pivot to and from wheelchair with one person assist. E6 stated that there is a sign on the resident's footboard identifying how the resident transfers. E6 stated that while transferring, R2 became short of breath and E6 had R2 sit at edge of bed; E6 called for assistance. R2's nurse came and R2 was lowered to the floor. A mechanical lift was used to transfer R2 back into bed. E6 stated that after R2 was in bed, E6 noticed R2's right foot bleeding. Review of R2's admission assessment, dated 6/19/17, notes R2 has generalized weakness to lower extremities and requires extensive assistance of two staff members for transfer to and from bed/wheelchair. R2's initial restorative assessment, reassessment, progress notes, dated 6/26/17, notes R2 requires extensive assistance with transfers. Review of R2's admission MDS (minimum data set), dated 6/26/17, notes R2 requires extensive assistance of two + persons physical assist. Review of R2's fall occurrence report, dated 7/3/17, notes R2 was alert and oriented to person and place. R2's ambulatory status was chairbound. E5 reported to R2's nurse that R2's toe was bleeding when attempting to transfer R2 from wheelchair to bed. E5 stated I think R2 cut it on the wheelchair. R2 was assessed by the nurse and found to have a laceration to right great toe. R2's physician was notified and orders received to transfer to hospital for evaluation and treatment. R2's family member was notified. X-ray report notes diffuse soft tissue swelling in right foot and a small displaced intra-articular fracture of the first proximal phalanx base laterally. Review of R2's initial fall risk assessment notes R2 was at high risk for falls due to dementia, comorbidities, and medications. Review of R2's falls care plan notes R2 is at risk for falls related to history of falls prior to admission; impaired vision, R2 wears glasses but not with R2 at facility. Identified interventions include: ensure call light is within reach and encourage R2 to use it for assistance; physical therapy to improve strength and gait. Review of this facility's transfer technique/lift devices competency notes E6 was able to demonstrate competency of lift devices on 11/5/15. On 9/30/16, E6 was inserviced on this facility's resident handling policy, limited lift. Review of the medical record notes R3 with [DIAGNOSES REDACTED]. On 10/20/17 at 12:10pm, this surveyor observed E5 CNA (certified nursing assistant) transfer R3 from bed to wheelchair using a sit to stand mechanical lift device. On R3's footboard R3's method of transfer is identified as 'M'. On 10/20/17 at 9:55am, R3 stated I was getting ready for bed and I told Z5 CNA (certified nursing assistant) to get the lift, Z5 stated Z5 was too busy, Z5 dropped me and broke my leg. On 10/20/17 at 3:15pm, E4 (restorative nurse) stated that staff are inserviced and competencied upon hire and yearly. E4 stated that E4 performs the initial transfer assessment for residents admitted to this facility during the week and the nurse is responsible for this on the weekends. E4 stated that all residents are re-assessed quarterly, annually, and as needed. E4 stated at the foot of each resident's bed is a transfer symbol to alert staff to the transfer technique. E4 stated that '0' indicates the resident can transfer independently; '1' is one person assist with transfer; 'SSS' indicates the need to use the sit to stand lift device with standard sling; 'SSC' indicates the need to use the sit to stand lift device with a cradle sling; and 'M' indicates the resident requires the use of the mechanical lift device with two person assistance. Review of Z5's written statement of the event, dated 7/17/17, notes Z5 transferred R3 using body mechanics. Z5 stated I couldn't find a lift at the time so I transferred R3 the way I have been transferring residents for years. R3's transfer assessment tool, dated 9/27/16 and reviewed 11/4/16, 2/3/17, and 5/2/17, notes R3 requires a sit to stand lift device with a standard sling or a two person transfer. Review of R3's MDS (minimum data set), dated 5/2/17, notes R3 requires extensive assistance with transfers. Review of R3's most recent MDS, dated [DATE], notes R3 is total dependence on two staff members for transfers. R3's transfer assessment tool, dated 7/17/17, notes R3 requires a mechanical lift device for transfers. Review of R3's restorative nursing assessment, reassessment, progress notes, dated 9/27/16, notes R3 requires extensive assistance with transfers and uses the sit to stand lift device with one person assist. The most recent assessment, dated 8/1/17, notes R3 requires total assistance with transfers. R3 uses the mechanical lift device with two person assistance for transfers. Review of Z5's new hire orientation, dated 6/15/17, notes Z5 received training on lift devices and this facility's resident handling policy, limited lift. Review of this facility's resident handling policy limited lift, dated 11/2013, notes resident transfers will be designated into one of the following categories: 0 = independent; 1 = one person transfer (< or = 25 pounds of assistance from the caregiver); SSS = sit to stand device with standard sling; SSC = sit to stand lift device with carrier sling; and M = mechanical lift transfer with two caregivers. Resident transfer status will be tagged in the resident's room to inform the staff of the appropriate transfer to use. This policy is to be followed at all times.

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. This failure applies to 1 of 2 residents(R2), reviewed for quality of care, in the sample of 7. This failure resulted in a delay of treatment and services in association with a non-responsive resident(R2). Findings Include: R2 admitted to facility on [DATE] with [DIAGNOSES REDACTED]. POS(Physician order [REDACTED]. Progress note dated [DATE] at 1:15pm, R2 was having shortness of breath. R2 was given a treatment of [REDACTED]. R2 had a PRN order for the treatment in the case of shortness of breath. E4(Registered Nurse) notified Z1 (MD) of R2's condition. Z1 ordered Oxygen at 2 liters per nasal cannula. Progress note dated [DATE] at 1:30pm E4 took R2's Oxygen Saturation, temperature, pulse and blood pressure. Oxygen Saturation 97%,Temperature 98.0 ,Pulse 76 , Respirations 22 , Blood Pressure ,[DATE]. Progress note dated [DATE] at 2:15pm indicates that E4 entered R2's room and noted R2 was unresponsive,absence of breathing, unable to obtain blood pressure or/and pulse. Progress note dated [DATE] at 2:30pm indicates that Z1 was notified of R2's death. There is no documentation to indicate that CPR was initiated and that EMS(Emergency Medical Services) were notified. [DATE] at 4:40pm, E3(Registered Nurse) was interviewed. E3 said was working in another unit of the building when asked to come to the 100 unit concerning R2. E3 found R2 not breathing, no pulse, cool to the touch with grayish mottled skin. E3 documented in R2's progress notes what she found. E3 did not know what occurred before [DATE] at 2:30pm. E3 was asked if E3 heard a code Blue called. I don't know of any code 'Blue' being called. I had just returned from Lunch. Two nurses have to be present to assess whether or not a resident has expired and that's what I was there for. [DATE] at 2:15pm, Z1 (R2's Attending Physician) was interviewed by telephone. Z1 said that R2 should have been immediately sent out to the hospital, because of poor health associated with trouble breathing. Z1 also indicated that Z1 had repeatedly warned staff about R2's poor health. [DATE] at 3:45pm, E7 (Licensed Practical Nurse/LPN) was interviewed by telephone. The Daily Nursing Staffing Sheet dated [DATE] has E7 working the PM shift on the 200 wing. E7 said was giving a tour of the facility to family members, when E4 came out into the hallway and asked for help. Because, I was busy giving the tour, I(E7) asked E3 (Registered Nurse/RN) to help E4. E7 was asked if a code Blue was called. I don't recall hearing a code 'Blue'. Several attempts were made to interview E4. Policy-Emergency Procedure-CPR indicates the following: Initiating CPR-Begin CPR if the adult victim is unresponsive and not breathing normally(ignoring occasional gasps) without assessing victim's pulse. Initiate CPR Unless: It is known that a DNR(Do Not Resuscitate) order that specifically prohibits CPR ; or there are obvious signs of irreversible death(e,g., rigor mortis).

Based on observation, interview and record review facility failed to perform comprehensive pain assessments on (R1, R10, R11 and R21). Facility failed to implement a pain management plan of care for R1 on hospice care.This failure resulted in R1 experiencing unrelieved break through pain. The facility also failed to assess and monitor (R25) for an acute change of condition. This applies to 4 of 15 residents (R1, R11, R10 and R21) reviewed for pain management in the sample of 24 The Findings include; 1) On 9/29/2015 at 10:00AM, R1 was observed in bed with facial grimacing and complaining of severe pain. E12 (nurse), was present at R1's bedside during this observation. E12 stated R1's pain was probably due to wound treatments and dressing changes done early that morning. E12 told R1 you got Tylenol and your not due for the [MEDICATION NAME] until 2:00PM (4 hours from now). E12 then walked out of R1's room and proceeded with caring for other residents. R1 observed with bilateral hands contracted into fists and bilateral inner knees pressing against each other without protective padding between and with dressings in place. On 9/29/2015 at 10:10AM, E12 stated R1 is on hospice care and receives scheduled [MEDICATION NAME] 5 mg (milligram), every eight hours (6AM, 2PM and 10PM), daily and Tylenol extra strength for break through pain. On 9/29/2015 at 10:25AM, after several inquiries about R1's un-relieved pain, E12 stated I will call hospice about {R1's} unrelieved pain today. On 9/29/2015 at 3:10PM, Z2 (R1's hospice nurse), stated R1 was assessed 9/29/2015 to have break through pain. Z2 said R1's plan of care include physician orders [REDACTED]. Z2 stated E12 told Z2, he was not aware of R1's PRN [MEDICATION NAME] order, so E12 administered Tylenol for break through pain. Z2 said R1's scheduled [MEDICATION NAME] will be increased from 5mg to 7.5mg starting 9/29/2015. On 9/30/2015 at 9:30AM, R1 observed in bed. R1 stated she was not in any pain right now. R1 has [DIAGNOSES REDACTED]. R1 has a stage 4 infected large sacral pressure ulcer acquired at facility 5/11/2015. R1's hospice records include R1 was placed on hospice care 8/21/2015. R1's 9/14/2015 physician orders [REDACTED]. R1's September 2015 Medication Administration Record [REDACTED]. First dose administered was 9/29/2015 at 12:00PM for low back pain at a pain rating of 9 out of 10. R1's current care plan include problem : alteration for comfort due to moderate joint pain with [DIAGNOSES REDACTED]. Interventions include medicate as ordered. R1's hospice care plan include to medicate for pain as indicated, notify physician if pain medications are ineffective in controlling signs and symptoms of pain. R1's wound and pressure ulcer flow records include: - 9/29/2015 sacral pressure ulcer stage 4, 4.3 cm (centimeters) x 4.8cm x 3.2cm with undermining 6.8cm at 12:00 o ' clock. 100% loose gray yellow slough, moderate to heavy amount of drainage and dark, discolored tissue on peri-wound (area surrounding wound). This wound acquired at facility 5/11/2015. - 9/22/2015 acquired left medial knee fluid filled blister 1.5cm x 2.0cm - 9/29/2015 acquired right medial knee fluid filled blister 2cm x 1.5cm. R1's 9/22/2015 wound physician progress notes [REDACTED]. R1's 9/02/2014 comprehensive pain review does not indicate site or non-verbal pain indicators presented. R1's last pain review 7/17/2015 only documents R1 continues to complain of pain, not relieved with current regimen. Medications changed to help control pain. No further pain assessment completed after the 7/17/2015 review to present (9/29/2015). During a 10/01/2015 4:55 PM telephone interview, Z3 (R1's physician), stated R1's pain is probably related to her wounds. 2) R11 admitted to facility 01/21/2015. R1's medical records failed to include a comprehensive pain assessment. R11's 7/28/2015 minimum data set assessment (MDS), describes R11 unable to verbally communicate and severely cognitively impaired. R11's physician orders [REDACTED]. R21 has multiple medical [DIAGNOSES REDACTED]. R21 has been identified by the facility as having pain issues according to the CMS 802 Matrix provided by the facility. R21 is on a scheduled pain medication ([MEDICATION NAME] 50 mg BID-twice daily). R21's POS (physician's orders [REDACTED]. Prior to that, R21 was receiving [MEDICATION NAME] 25 mg twice a day, per Controlled Medication Prescription form dated 5/19/15. On 10/2/15 at 1:10 pm, E20 (Treatment Nurse) stated she obtained the order to increase R21's pain medication due to R21's complaints of breast pain, primarily on the evening or night shifts; she received this report from nursing staff on those shifts. R21 has [MEDICAL CONDITION] with a wound of her breast which requires treatment. Although R21 did not complain of pain during wound care, E20 stated because she did complain of breast pain at times, she thought her pain medication should be increased. R21's clinical record does not contain an initial comprehensive pain assessment. It does contain quarterly pain reviews from 12/13/14 through 7/24/15 . This pain review form only contains the space for the date and some blank lines where the author can write in whatever information they see fit. Although entitled Quarterly Comprehensive Pain Review, this is not a comprehensive evaluation. R21's quarterly assessments all contain a handwritten note indicating that R21 has no pain at the time of the assessment, . It does not assess the need for R21's scheduled pain medicine, nor does it address the level of pain when R21 does have pain. It does not address the need for the increase in R21's pain medication. R21's admitted was 7/23/14. R21's clinical record does contain a pain questionnaire date 7/23/14. At that time, R21 was scored a 3, which indicated no need for a comprehensive pain assessment. This assessment indicated routine medication for pain not ordered. The back of this form, entitled Comprehensive Pain Review, is blank. There was no Comprehensive Pain Review done for R21, either when her pain medication was originally ordered, nor when it was increased in June 2015 due to complaints of pain. Facility policy entitled 'Pain Screening and Management states , 5. Conduct a comprehensive pain screening upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is a consent of new pain or worsening of existing pain. This was not done for R21. Per R10's demographics, R10 is a [AGE] year old resident with multiple medical [DIAGNOSES REDACTED]. On 9/30/15 E16 (Nurse) gave R10 2 tablets of [MEDICATION NAME] 325 mg (650 milligrams) for pain at 10:10 AM and at 2:20 PM. E16 did not assess R10's pain (did not ask location, intensity, severity and type) prior to giving the pain medication. On 10/1/15 around 10:30 AM to 11:00 AM R10 stated, The pain medication they (staff) gave me does not work well. I am always in pain, I told them (staff) it doesn't work with me but I guess that's the only pain reliever they can give me The Face Sheet documents R25 was admitted on [DATE] with the following Diagnosis: [REDACTED]. The History and Physical Form dated 9/28/2015 states, R25 has a recent acute [MEDICAL CONDITION] episode before the nursing home admission. Physician order [REDACTED]. On 9/30/2015 at 8:33 AM, E5(Certified Nursing Assistant) brought R25 who was grunting, panting and wheezing into the dinning room. R25 had a portable oxygen tank on the back of the wheelchair with oxygen infusing via nasal cannula. E5(CNA) placed R25 at a table and asked R25 how are you doing? Before R25 could respond, E5 exited the dining room. R25 said not too good remained at the table in respiratory distress. R25 became progressively worse with panting, shallow breaths and grunting, attempted to eat and vomited her meal at the table. On 9/30/2015 at 8:39 AM, E6(CNA) brought R25 to her room and stated the nurse will be in shortly. While in the room R25 continued to pant, grunt and wheeze while intermittently exchanging slow shallow breaths. R25 gasped and slowly said I think I am dying. After inquiring about when the nurse would be in to check R25, E6(CNA) went to get the nurse. On 9/30/2015 at 8:40 AM, E10(Nurse) entered the room with E5. E10 assessed R25 and provided a nebulizer(breathing) treatment. E10 said E5(CNA) should have alerted me as soon as R25 experienced respiratory distress. On 9/30/2015 at 9:10 AM, E10(Nurse) said, R25 did not do well with her breathing treatment and is being sent out to the hospital. Nursing Progress Note dated 9/30/2015 states, R25 was admitted to the hospital with [REDACTED]. Acute Condition of Changes- Clinical Protocol revised 11/2013 does not address when direct care staff should notify the nurse of a change of condition.