Every finding on record at Quincy Healthcare & SR Living

Based on record review and interview the facility failed to administer physician ordered medications for one of three residents (R1) reviewed for significant medication errors in the sample of three.Findings include:The facility's Adverse Consequences and Medication Errors policy dated 6/25 documents, A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer's specifications, or accepted professional standards and principles of the professionals providing services. Example of medication error include: Omission-a drug is ordered but not administered.R1's Physician's Order Sheets and Medication Administration Records dated 6/1/26 through 6/30/26 document the following orders: Famotidine 20 mg (milligrams) give two times daily at 8:00 AM and 4:00 PM for the diagnosis of GERD (Gastro-Esophageal Reflux Disease), Memantine 10 mg give two times daily at 8:00 AM and 4:00 PM for the diagnosis of Parkinson's Disease, Potassium Chloride ER (Extended Release) 10 MEQ (Milliequivalent) give two tablets two times a day at 8:00 AM and 4:00 PM for the diagnosis of Hypokalemia, Deep Sea Nasal Spray Solution one spray in both nostrils four times daily at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM for the diagnosis of Allergies.R1's Medication Administration Record (MAR), dated 6/28/26 at 4:00 PM and signed by V9 (RN/Registered Nurse), documented that the physician-ordered Famotidine 20 mg, Memantine 10 mg, Potassium Chloride ER 10 MEQ (two tablets), and Deep Sea Nasal Spray Solution were not administered because R1 was hospitalized .R1's Health Status Note dated 6/28/26 at 3:08 PM and signed by V9 (RN) documents, (R1) returned from the ER (Emergency Room) at 2:44 PM via personal transport, accompanied by (V5/R1's Family Member).On 7/16/26 at 1:30 PM V9 (RN) stated, I was taking care of (R1) on 6/28/26 and (R1) had went to the hospital. I started my medication pass at 3:00 PM and did not give (R1's) scheduled 4:00 PM medications because I thought (R1) was in the hospital. I did not realize (R1) has returned to the facility at 2:44 PM. That was my mistake.On 7/16/26 at 4:40 PM V5 (R1's Family Member) stated, I was with (R1) when (R1) returned from the hospital on 6/28/26. I never did see a nurse give (R1) his medications that were scheduled to be given at 4:00 PM.

Based on interview and record review, the facility failed to ensure residents were provided scheduled showers for one of three residents (R1) reviewed for ADLs (Activities of Daily Living) in the sample of three.Findings include:The facility's Bath, Shower/Tub policy, dated 2/18, documents The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.The facility's Resident Council minutes for April, May and June 2026 all document that resident showers are not being given twice a week and the issue remains on-going.The facility's Shower Schedule indicates R1 should receive a shower twice weekly on Sundays and Wednesdays.R1's current Care Plan documents, Bathing/Showering: (R1) requires partial/moderate hands on assist by one staff for bathing/showering. Shower two time a week and as necessary.R1's Shower/Bath Skin Assessment sheets dated 5/31/26 through 6/30/26 do not include evidence of R1 receiving showers as scheduled on every Sunday and Wednesday on 5/31/26, 6/3/26, 6/7/26, 6/10/26, and 6/14/26.On 7/16/26 at 10:10 AM V4 (Ombudsman) stated, (R1) has not been getting his showers twice weekly.On 7/16/26 at 4:40 PM V5 (R1's Family Member) stated, (R1) wants to have showers at least twice a week or more and (R1) has not been getting them.On 7/17/26 at 2:10 PM V1 (Administrator-In-Training) stated, (R1) is supposed to get showers every Sunday and Wednesday. According to (R1's) Shower Sheets (R1) did not get his scheduled showers on 5/31/26, 6/3/26, 6/7/26, 6/10/26, or 6/14/26.

Based on record review and interview the facility failed to ensure a call light was in working order and able to be used by the resident to prevent a fall for one of three residents (R1) reviewed for falls in the sample of three.Findings include:The facility's Answering the Call Light policy dated 10/22 documents, Be sure the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly.The facility's Fall-Clinical Protocol policy dated 3/18 documents, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling go consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches.R1's current Care Plan documents, (R1) will be free of falls through next review. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.R1's Fall Incident Reported dated 5/12/26 documents R1 slipped out if his chair and was found lying in front of his recliner with hi hands behind his neck. R1 stated his call light was not working.The facility's Maintenance Request Order dated 5/12/26 document R1's call light was broken and was not fixed until 5/13/26.On 7/16/26 at 4:40 PM V5 (R1's Family Member) stated, (R1) had a fall on 5/12/26 because he could not use his call light for help. (R1's) call light was not working.On 7/17/26 at 11:00 AM V15 (Maintenance Director) stated, I did not know until 5/13/26 that (R1's) call light was not working on 5/12/26, so (R1's) call light did not get fixed until 5/13/26.

Based on Interview and Record Review, the facility failed to ensure residents were provided adequate bathing/showers to maintain proper hygiene and skin care for two of three residents (R1, R2) reviewed for showers in the sample of three.Findings include:The facility's Bath, Shower/Tub policy, dated 2/2018, documents The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.The facility's Resident Council minutes for April, May and June 2026 all document that resident showers are not being given twice a week and the issue remains on-going.1. R1's Physician Order Sheet, dated 5/15/26, documents R1 was admitted to the facility on [DATE] and has diagnoses including Morbid Obesity, Heart Failure, Peripheral Vascular Disease, Methicillin Resistant Staphylococcus Aureus infection and Cellulitis of the left lower limb.On 6/23/26 at 11:05 AM, V5 (local hospital Registered Nurse) confirmed caring for R1 when she transferred to the hospital on 5/20/26. V5 stated (R1's) labia and groin were my biggest concerns. (V12, R1's Power of Attorney) told us she felt like R1 was not getting cleaned adequately or showered very often. (R1) kept saying she was sore down there. We (emergency room staff) cleaned bloody yeast from her groin, and it took about 45 minutes. Her wounds weren't cared for and her hygiene was not adequate to prevent infection.R1's Shower/Bath Skin Assessment sheets for April and May 2026 document R1 went from 4/2 to 4/12 (10 days) between showers and went from 4/19-5/3 (14 days) between showers.2. R2's Physician Order Sheet, dated 6/23/26, documents R2 was admitted [DATE] and has diagnoses including Vascular Dementia, Osteoporosis and Chronic Pain. This same order sheet documents R2 has an order for (mechanical lift) for all functional transfers.R2's Skin Monitoring shower sheets for May and June 2026 document R2 was given a shower 5/23, 5/26 and 5/30/26. R2's medical record does not contain any other shower sheets for those months.On 6/23/26 at 2:30 PM, V2 (Director of Nursing) confirmed staff are supposed to document bathing and skin conditions on the facility's shower and skin sheets. V2 confirmed they only have three shower sheets for R2 and agreed there are large gaps in time for R1's showers. V2 stated This is all of the documentation I could find.

Based on Interview and Record Review, the facility failed to ensure a resident was monitored and assessed for skin injuries after falling and ensure a post fall risk assessment was completed for one of three residents (R1) reviewed for Falls in the sample of three.Findings include:The facility's Assessing Falls and Their Causes policy, dated 3/2018, documents After a Fall: Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/ consciousness and overall function. Note the presence or absence of significant findings. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty at the time and submitted to the director of nursing services. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. When a resident falls, the following information should be recorded in the resident's medical record: Assessment data, including vital signs and any obvious injuries. Completion of a fall risk assessment.R1's Progress Notes, dated 5/15/26 at 11:00 AM and completed by V7 (Registered Nurse) documents (R1) was assisted to the bathroom, then when she was ready to get off the toilet, she slid down to the floor. This note also documents No injury noted. Got (R1) off the floor via (mechanical lift) to wheelchair.R1's electronic medical record does not document any skin assessment, post fall assessment, or updated fall risk assessment.On 6/23/26 at 2:00 PM, V7 (Registered Nurse) confirmed taking care of R1 the day she suffered a fall from the toilet. V7 stated I was the one who lowered (R1) to the floor on 5/15/26 after the incident. V7 then stated he did not document a fall note, fall assessment, skin assessment or update her record to reflect a fall because he lowered her to the ground and it wasn't a fall in his opinion. On 6/23/26 at 2:40 PM, V2 (Director of Nursing) confirmed that being lowered to the floor on 5/15/26 was a fall for R1 and stated a fall assessment, skin assessment, post fall monitoring and fall risk updates should have been conducted at that time.

Based on Interview and Record Review, the facility failed to report a new injury of unknown source to the abuse coordinator for one of three residents (R1) reviewed for Abuse in the sample of three.Findings include:The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy, dated 4/2021, documents Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations.The facility's Investigating Resident Injuries policy, dated 4/2021, documents All resident injuries are investigated. The director of nursing services or a designee assesses all resident injuries and documents findings in the medical record. The medical director or attending physician shall review and verify conclusions about the possibility of a medical or other similar cause of the findings. If nursing and medical assessment determines an injury of unknown source the investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. Injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time; or the incidence of injuries over time.R1's Nursing Progress Notes, dated 5/18/26 at 1:19 AM and completed by V6 (Registered Nurse), documents (R1) taken to the restroom CNA (Certified Nursing Assistant, unknown) reports blood in the toilet. (V6) assessed (R1) noting dark discoloration to back of her legs and a small open area 0.5 centimeters by 0.5 centimeters on right labia.R1's Skin Check, dated 5/18/26 at 3:32 AM and completed by V6, documents Skin impairment site groin, description: small area to right labia. R1's electronic medical record dated 5/18/26-5/20/26 does not document any further notes or assessment of R1's open area to her labia. This record does document R1 was admitted to the hospital on [DATE].On 6/23/26 at 11:30 AM, V1 (Administrator in Training) stated she does not have any injury of unknown source investigations for the past three months and that none of those have been reported to her.On 6/23/26 at 1:50 PM, V6 (Registered Nurse) confirmed she was the nurse working on 5/18 when it was noted that R1 had blood in the toilet. V6 denied notifying anyone of the new finding after filling out a skin observation for the right labial tear. V6 stated It was a small laceration to her labia. I might've said something to the nurse in report. I did not call the doctor or notify anyone at one in the morning.On 6/23/26 at 2:40 PM, V1 and V2 (Director of Nursing) both denied knowing that R1 had a labia tear discovered prior to her hospitalization. V1 stated I thought that was after she went to the hospital. V1 confirmed she is the facility's abuse coordinator, and she should have been notified so she could complete an investigation. V2 confirmed that the open area is in a location that would require some investigation. V2 stated she was not made aware of R1 having a labia tear and stated it should have been reported immediately.

Based on Interview and Record Review, the facility failed to ensure a physician was notified of a residents change in skin conditions when new concerns were identified for one of three residents (R1) reviewed for Change of Condition in the sample of three.Findings include:The facility's Change in Resident Condition or Status policy, dated 2/2021, documents Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a (an): accident or incident involving the resident; discovery of injuries of an unknown source; significant change in the resident's physical/ emotional/ mental condition. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.The facility's Skin Tears- Abrasions and Minor Breaks policy, dated 9/2013, documents When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated or not associated with significant trauma. Notify the physician of any abnormalities (i.e., excessive bleeding, localized swelling, redness, drainage, tenderness, pain etc.). Report other information in accordance with facility policy/guideline and professional standards of practice.R1's Care Plan, dated 5/19/26, documents R1 was admitted to the facility on [DATE] and has left and right lower extremity venous stasis ulcers due to disease processes. This care plan does not document R1 has any other wounds.R1's Nursing Progress Notes, dated 5/18/26 at 1:19 AM and completed by V6 (Registered Nurse), documents (R1) taken to the restroom CNA (Certified Nursing Assistant, unknown) reports blood in the toilet. (V6) assessed (R1) noting dark discoloration to back of her legs and a small open area 0.5 centimeters by 0.5 centimeters on right labia.R1's Skin Check, dated 5/18/26 at 3:32 AM and completed by V6, documents Skin impairment site groin, description: small area to right labia. This same form documents the skin area is new, a treatment was not obtained and R1's care plan was not reviewed or updated.R1's electronic medical record does not document that a physician or the Director of Nursing (V2) were ever notified of R1's newly discovered labial tear.On 6/23/26 at 1:50 PM, V6 (Registered Nurse) confirmed she was the nurse working on 5/18 when it was noted that R1 had blood in the toilet. V6 denied notifying anyone of the new finding after filling out a skin observation for the right labial tear. V6 stated It was a small laceration to her labia. I might've said something to the nurse in report. I did not call the doctor or notify anyone at one in the morning.On 6/23/26 at 2:40 PM, V2 (Director of Nursing) stated she was not made aware of R1 having a labia tear and stated it should have been reported immediately to her and a physician.

Based on Interview and Record Review, the facility failed to properly assess a resident's new skin condition and ensure identified wounds were evaluated and obtain treatment orders for one of three residents (R1) reviewed for wounds in the sample of three.Findings include:The facility's Skin Tears- Abrasions and Minor Breaks policy, dated 9/2013, documents The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Obtain a physician's order as needed. Document physician notification in medical record. An abrasion is an area on the skin that has been damaged by friction, scraping, rubbing or trauma. A skin tear is the disruption of epidermis resulting in a lifting or friction of the skin. If the wound is bleeding, gently apply a compress with pressure over the wound and reinforce the compress as needed to control any bleeding. If the bleeding persists after efforts to stop it, or an object is embedded into the abrasion, or other medical attention is needed, notify the physician. This policy also documents Record the following information in the resident's medical record: Complete in-house investigation of causation. Generate Non-Pressure form. Document physician and family notification, and resident education (if completed) in medical record. How the resident tolerated the procedure. Any problems or resident complaints related to the procedure. Any complications related to the abrasion (e.g., pain, redness, drainage, swelling, bleeding, decreased movement). If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Interventions implemented or modified to prevent additional abrasions (e.g., clothes that cover arms and legs). When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if the abrasion is uncomplicated or not associated with significant trauma. Notify the physician of any abnormalities (i.e., excessive bleeding, localized swelling, redness, drainage, tenderness, pain etc.). Report other information in accordance with facility policy/guideline and professional standards of practice.R1's Care Plan, dated 5/19/26, documents R1 was admitted to the facility on [DATE] and has left and right lower extremity venous stasis ulcers due to disease processes. This care plan does not document R1 has any other wounds.On 6/23/26 at 2:00 PM, V7 (Registered Nurse) confirmed taking care of R1 the day she suffered a fall from the toilet. V7 stated R1 did not have any lacerations to her private area, labia or groin at that time and stated she has had redness in the past on her backside but on 5/15, she did not have bruising or discoloration to her back or the backs of her legs.R1's Bath Skin Assessment sheet, dated 5/17/26 and signed off by V9 (Registered Nurse) documents that new skin areas were identified during R1's shower on 5/17/26. This sheet documents R1 has slight redness in the front vaginal and perinium area and inside red and skin peeling open areas to R1's buttock area. R1's Skin Check, dated 5/18/26 at 3:32 AM and completed by V6 (Registered Nurse), documents Skin impairment site groin, description: small area to right labia. This same form documents the skin area is new, a treatment was not obtained and R1's care plan was not reviewed or updated. R1's electronic medical record, dated 5/15/26-5/20/26, does not document any new wound assessments, treatment orders or any updates to R1's Care Plan upon discovery of R1's new skin conditions. This medical record does document R1 was transferred to the local hospital for lower extremity weakness and admitted to the hospital.On 6/23/26 at 1:50 PM, V6 (Registered Nurse) confirmed she was the nurse working on 5/18 when it was noted that R1 had blood in the toilet. V6 denied notifying anyone of the new finding after filling out a skin observation for the right labial tear. V6 It was a small laceration to her labia. (R1's) back of her legs were discolored. V6 also stated I did not call the doctor or notify anyone at one in the morning. I am not aware if it was told to V1 (Administrator in Training) or V2 (Director of Nursing), or if an order for treatment was ever obtained.R1's Hospital emergency room Progress note, dated 5/20/26 at 11:42 AM, documents Skin: Scattered abrasions on the back laterally both sides, likely from gait belt. Open areas from excoriation and lower abdominal fold and up on labia, minor bleeding noted.On 6/23/26 at 11:05 AM V5 (local hospital Registered Nurse) stated I took care of (R1) in the hospital. (R1's) labia and groin were my biggest concerns. (R1) kept saying she was sore down there. (R1's) had a slit in her groin and another on her labia that were both untreated. Her groin wound was deep, and she had blood in her underwear. These wounds weren't cared for, and her hygiene was not adequate to prevent infection. I did talk to someone from the facility, but I am not sure who. I told them about (R1's) wounds and they acted surprised to hear about them.On 6/23/26 at 2:40 PM, V2 (Director of Nursing) stated she was not made aware of R1 having new skin concerns in the days before she was transferred to the hospital and was not aware of a labial tear. V2 confirmed that if new skin conditions are discovered they should be reported to her, and the physician should be notified to get treatment orders.

Based on record review and interview the facility failed to complete treatments for two residents (R3, R4) of three reviewed for wound care in a total sample of four.The facility's Documentation Policy dated July 2017 documents Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed. R3's EHR (Electronic Health Record) documents R3 was admitted to the facility 3/9/23 with diagnoses to include Multiple Sclerosis, Spinal Stenosis, Poly-osteoarthritis, Fibromyalgia, Bipolar Disorder, hypertension, and Depression. R3's Physicians Order dated 2/3/26 documents a treatment order for (Hydrophilic) paste and Silicone Foam Border dressing to right inferior gluteal fold every other day. R3's Physicians Order dated 4/7/26 documents a treatment order for (Hydrophilic) paste and Silicone Border Dressing to right posterior thigh. R4's EHR documents R4 admitted to the facility on [DATE] with diagnoses to include Atrial Fibrillation, Pulmonary Hypertension, and Hypothyroidism. R4's Physician's Order dated 5/4/26 documents a treatment order for Xeroform to wound bed, cover with silicone border dressing to left heel daily. R4's Physician's Order dated 5/4/26 documents a treatment order for Skin-Prep daily to right elbow. R3's May 2026 TAR (Treatment Administration Record) does not have documentation for the administration of (Hydrophilic) paste and Silicone Foam Border dressing to right inferior gluteal fold seven times in May 2026 (May 4, 6, 8, 12, 14, 18, 26). R3's May 2026 TAR does not have documentation for the administration of (Hydrophilic) paste and Silicone Border Dressing to right posterior thigh seven times in May 2026 (May 3, 7, 11, 13, 17, 19, 27). R4's May 2026 TAR does not have documentation for the administration of Xeroform and silicone border to left heel 12 times in May 2026 (May 6, 7, 8, 11, 12, 13, 18, 19, 21, 25, 26, 27) R4's May TAR does not document R4 received Skin-Prep to right elbow 12 times in May 2026 (May 6, 7, 8, 11, 12, 13, 14, 18, 19, 21, 25, 27). On 6/11/26 at 12:25 PM V3 ADON (Acting Director of Nursing) confirmed treatments that are completed are to be documented. On 6/16/26 at 8:48 AM V3 confirmed R3 and R4's treatments for May 2026 are not documented for each day the treatments were to be completed.

Based on observation, interview, and record review the facility failed to follow infection control precautions for one (R2) of three resident reviewed for wound care in a total sample of four. The facility's Enhanced Barrier Precautions Policy dated March 2024 documents Policy Interpretation and Implementation: 2. EBP (Enhanced Barrier Precautions) employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: a. dressing' b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use; h. wound care (any skin opening requiring a dressing).R2's Electronic Health Record documents R2 was admitted to the facility 2/28/24 with diagnoses to include Parkinsonism, Diabetes, and Hypertension.R2's Wound Assessment and Plan dated 6/9/26 documents R2 has a stage 4 (Full thickness) pressure ulcer on right buttock. R2's Care Plan documents Use enhanced barrier precautions during high contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or central lines, urinary catheter, feeding tube, tracheostomy, and wound care.On 6/16/26 at 8:55 AM V3 ADON (Acting Director of Nursing) and V4 APRN (Advanced Practice Registered Nurse/wound consultant) were assessing and providing wound care for R2. R2's room did not have signage indicating R2 was on EBP (Enhanced Barrier Precautions). V3 donned gloves only. V4 donned gloves and gown. V3 cleansed R2's wound, removed gloves and performed hand hygiene. V3 went to the treatment cart inside the doorway and gathered treatment supplies. V3 donned gloves and applied wound treatment as ordered.On 6/16/26 at 9:03 AM V3 (ADON) confirmed that R2 is on EBP. V3 verified that R2 did not have EBP signage on her door and confirmed that V3 should have been wearing a gown for R2's wound care.

Based on observation, interview, and record review the facility failed to ensure a resident's call light was answered promptly and the resident received timely incontinence care for one of three residents (R3) reviewed for dignity in the sample of five. These failures resulted in R3 sitting in urine for an extended period of time, experiencing feelings of disgust and anger, feeling insulted and uncomfortable, and experiencing pain and burning to her buttocks. Findings include:The facility's Resident Rights policy dated 2/21 documents, Employees shall treat all resident with kindness, respect, and dignity.The facility Dignity policy dated 2/21 documents, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents for example: Promptly responding to a resident's request for toileting assistance.The facility's Residents' Call System policy dated 9/22 documents, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Calls for assistance are answered as soon as possible, but no later than 20 minutes, Urgent requests for assistance are addressed immediately.The facility's Resident Council Minutes dated 4/7/26 document, Residents had concerns about call lights not getting answered in a timely manner. Issue was not resolved.The facility's Resident Council Minutes dated 5/5/26 document, Resident still have concerns about call lights in a timely manner.R3's Order Summary Report dated 6/5/26 documents R1 is a [AGE] year-old with the diagnoses of Multiple Sclerosis and Spinal Stenosis and uses a sit-to-stand mechanical lift for transfers.R3's MDS (Minimum Data Set) assessment dated [DATE] documents R3 is cognitively intact, dependent on staff for toileting hygiene and toileting transfers, and is always incontinent of urine.R3's Alarm Response Report dated 5/29/26 through 6/5/26 documents R3's call light was on for over 20 minutes before being answered on nine different occurrences.R3's Alarm Response Report dated 6/5/26 documents R3's call light was turned on at 10:15 AM and was not answered by staff until 11:07 AM (51 minutes later).On 6/7/26 at 10:30 AM R3's call light was on. R3 stated she has been waiting for staff to answer her call light for over 15 minutes. R3 stated she had wet herself and needed to be changed.On 6/7/26 at 11:50 AM R3 was sitting in the dining room. R3 stated, One thing that makes me so mad is my call light does not get answered for over 20 minutes a lot of times when I need changed. I have to have staff change me. I cannot do it myself. Today it was an hour before my call light got answered and I got changed. I just recently had a sore on my bottom that healed. Today I sat in a soaked (adult brief) for an hour. I felt disgusted, insulted, and uncomfortable. The urine was burning my butt so badly I could not stand it. It hurts terribly and makes me feel cold.On 6/7/26 at 2:10 PM V10 (CNA/Certified Nursing Assistant) stated, I answered (R3's) call light sometime after 11:00 AM. (R3) stated she had her call light on for an hour and was needing changed. (R3) seemed upset and disturbed. When I changed (R3's adult brief) the brief was very heavy and soaked in urine. There was so much urine that (R3) had soaked through her pants. I had to completely change (R3's) brief and pants.On 6/5/26 at 2:00 PM V1 (Administrator-In-Training) stated, A call light should be answered promptly within eight to ten minutes. (R3) should not have had to wait as long as she did to get changed. That is unacceptable. V1 confirmed that according to the facility's Alarm Response Report R3's call light was on for 51 minutes on 6/5/26 before staff responded.

Based on interview and record review the facility failed to notify the residents representative and physician of an injury for one of three residents (R1) reviewed for Quality of Care in the sample of three. Findings include:The Change in a Resident's Condition or Status policy dated 2/2021, documents Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. (example), changes in level of care, billing/payments, resident rights, etc. (et cetera). Policy Interpretation and Implementation 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 5. Except in medical emergencies, notification will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.R1's computerized Medical Record documents that R1 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included Contracture of Muscle, Left Upper Arm, Type 2 Diabetes Mellitus, Dysphagia, Chronic Kidney Disease (Stage 3), Anemia, Vitamin D Deficiency, Atelectasis, Soft Tissue Disorders, Muscle Wasting and Atrophy.R1's Nursing Note written by V9/Registered Nurse/RN dated 3/12/26 at 5:30 AM, documents (R1) lying in bed when this nurse entered room (R1) noted to have dark purple bruising to inside of left arm, (R1) noted to have yellow discoloration to left side of chest with dark purple bruising by (R1's) nipple.R1's Nursing Note written by V2/Director of Nursing/DON dated 3/13/26 at 1:05 PM, documents This nurse observed yellow bruising to (R1's) chest and sides. This nurse also observed purple bruising to the resident's left side near ribcage. Xiphoid process noted to be protruding. (R1) denies pain or discomfort at this time.R1's Nursing Note written by V15/Assistant Director of Nursing dated 3/16/26 at 4:42 PM, documents a 15 inch by 19 inch yellow bruising to R1's upper chest, 1 inch by 1.5 inch, purple bruising noted to R1's Xiphoid process, 3 inch by 3 inch dark purple bruising to R1's right iliac crest, and 1 inch by 4.5 inch dark purple bruising to R1's left lateral ribs. R1's Nursing Note written by V12/Licensed Practical Nurse dated 3/16/26 at 5:06 PM, documents that V14/R1's Power of Attorney was made aware of R1's bruises and stated V14 would go to the emergency room to see R1.On 5/11/26 at 12:28 PM, V5/Nurse Practitioner stated that when she was first made aware of R1's bruising (3/16/26) there was no known incident of a fall or accident so V5 sent R1 out to be evaluated to check R1 for a GI (Gastrointestinal) Bleed. On 5/13/26 at 9:27 AM, V14/R1's Power of Attorney/POA stated that she was not made aware of R1's bruising to his chest until R1 was sent to the hospital (3/16/26). V14 also stated that she was told by staff that R1 had the bruising for a couple of days before R1 was sent to the hospital. V14 stated that she would have liked to have been notified when the bruising was found.On 5/14/26 at 12:20 PM, V9/RN stated that she worked the night shift and had seen some bruising on R1's chest on 5/12/26 and passed the information to the next shift. V9 also stated that she told the DON but did not do an incident report, call the doctor, or R1's POA.On 5/14/26 at 12:45 PM, V1, Administrator stated that as soon as the bruises were seen on 3/12/26 an incident report should have been filled out, the bruises should have been documented with measurements, and the family and physician should have been notified at that time. V1 also stated I was not notified until 3/16/26 and that is when the investigation was started.

Based on observation, interview, and record review, the facility failed to identify and provide necessary treatment and services to promote healing and prevent worsening of pressure injuries, assess and document wound conditions, perform weekly wound assessments with measurements, notify the physician of wound progression, administer the correct treatment per the physician's order, and failed to properly apply a wound vacuum for three of four residents (R26, R53 and R62) reviewed for pressure ulcers. These failures resulted in R26, R53 and R62, experiencing deterioration of their pressure injuries without timely or appropriate clinical response.Findings include:The facility's Pressure Injuries Overview policy dated 3/2020 documents Pressure ulcers/injuries occur because of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. 1.) R53's current care plan dated 01/15/25 documents R53 has redness to the coccyx, a stasis ulcer to the left chin, and a scabbed area on the right great toe. Despite this, R53 was assessed as low risk for skin breakdown, and the care plan was not updated to reflect increased risk or wound progression.R53's Physician Orders document a hydrocolloid dressing was ordered on 05/01/25 for coccyx redness. R53's electronic medical record does not contain documentation of weekly skin assessments or measurements to R53's coccyx. R53's Bath Skin assessment dated [DATE] documents small pinhole open areas on the coccyx. R53's electronic medical chart does not contain documentation of an assessment to R53's coccyx on or after 6/15/25. R53's Minimum Data Set (MDS) dated [DATE] documents R53 is cognitively impaired. On 07/09/25 at 09:28 AM, V4 (Registered Nurse) assessed R53's coccyx as red, macerated, and open, identifying it as a Stage 2 pressure ulcer. V4 stated that weekly wound monitoring was not being conducted and that V6 (Nurse Practitioner) had not been notified. V4 applied an absorbent foam dressing, which was not the dressing ordered by V6.On 07/09/25 at 10:32 AM, V6 confirmed by assessment that R53 had a Stage 2 pressure ulcer and that the incorrect dressing had been applied. V6 stated the wound progression was not reported, and that V6 was unaware of the development of the Stage 2 ulcer. V6 added that weekly monitoring and provider notification should have occurred, and that V6's office had no documentation of the ulcer.On 7/9/25 at 1:00 PM, V3 (Infection Preventionist) stated V3 was not aware of R53's Stage two pressure ulcer on her coccyx. V3 stated the staff should have been doing a weekly skin assessment on R53. 2. R62's Current Care Plan, dated 7/9/2025, documents, I require extensive assistance from 2 staff member to move about in bed, I require assistance with my ADL's (Activities of Daily Living). I am at risk for loss of movement in my joints due to dementia, general weakness.The Facility Wound Log dated 6/5/2025 documents, (R62) Right Buttock. The Facility Weekly Wound Tracking Log dated 7/8/2025 documents, (R62) stage four, location, right buttock. On 7/8/25 at 2:15 PM, V10 (Wound Nurse Practitioner) stated This facility needs lots of training on wound vacuums. The facility should not accept new residents with wound vacuums until they have received training. V10 stated Two residents seen today for wound services both have had their wound vacuums applied incorrectly, which then caused worsening of the wounds and further skin breakdown. V10 stated that the foam which was to be inserted in the wound bed was touching healthy skin, this caused the peri wound to worsen and be macerated. V10 further stated (R62's) wound looks worse than last week because the foam to R62's wound bed was touching the peri wound and the outer skin, the foam has caused the skin surrounding the wound bed to become macerated.On 7/8/25 at 2:25 PM V3 (Infection Preventionist) stated There was no drape applied to R62's skin surrounding her wound bed and the foam which was inserted in the wound bed was touching healthy skin and caused the skin surrounding the wound bed to be redder and more excoriated. V3 stated The wound vacuum was not applied per the physician's order which caused the wound to worsen.On 7/9/2025 V3 (Infection Preventionist) stated Weekly skin assessments, documenting wound conditions and measurements, and notifying the physician of wound progression was not done or documentation was not found prior to June of 2025 for R62.3. R26's Current Care Plan, dated 7/9/2025, documents, I am at high risk for skin breakdown. I require limited/extensive assistance from one staff member/ two staff members to move about in bed.The Facility Wound Log dated 6/5/2025 documents, (R26) left lateral leg, right lateral leg, left medial leg, right medial leg, right upper buttock, intragluteal left middle, right buttock.On 7/9/2025 V3 (Infection Preventionist) stated Weekly skin assessments, documenting wound conditions and measurements, and notifying the physician of wound progression was not done or documentation was not found prior to June of 2025 for R26.

Based on observation, interview, and record review the facility failed to educate residents on what a grievance is, provide grievance forms, and provide a clear and noticeable destination for grievances to be submitted. This failure has the potential to affect all 71 residents who reside in the facility.Findings Include:The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/7/25 and signed by V5/Chief Operating Officer documents 71 residents currently reside within the facility.The facility Grievance/Complaints, Filing policy dated April 2017 documents, Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/representative. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board.On 7/8/2025 at 10 AM during a Resident Council meeting, R11, R28, R38, R48, and R64 all confirmed they did not know what a grievance was or how to file a grievance. On 7/9/2025 at 11 AM, V7 (Social Service Director) stated I have not had a grievance filed since August of 2024.On 7/9/2025 at 11:15 AM, The facility's Chapel room, on the opposite side of the pews and located in the right corner of the room were several boxes in front of a small table. V7 removed 3 boxes then revealed that the table had pens and several pieces of blank paper. There was a black box labeled grievances. On 7/9/2025 at 11:20 AM, V1 (Administrator) confirmed that the current grievance process was not acceptable and that V7 needed to educate all residents on what a grievance was and how to file a grievance.

Based on Observation, Interview and Record Review, the facility failed to ensure a resident call system was effective to directly alert staff of a resident's need for assistance. This failure has the potential to affect all 71 residents residing in the facility.Findings include:The facility's Resident's Call System policy, dated 9/2022, documents Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately.The facility's Resident Council minutes, dated 12/3/24, document six residents attended the meeting and stated call lights are not getting answered in a timely manner.The facility's Resident Council minutes, dated 2/4/25, document eleven residents attended the meeting and stated call lights not being answered in a timely manner is still an issue.The facility's Resident Council minutes, dated 4/1/25, document eight residents attended the meeting and stated residents in the 100/200 hall and the 300/400 hall voiced call lights are not being answered in a timely manner.The facility's Resident Council minutes, dated 5/6/25, document eleven residents attended the meeting and stated call lights not being answered in a timely manner is still an issue.The facility's Resident Council minutes, dated 7/1/25, document ten residents attended the meeting and stated call lights not being answered in a timely manner is still an issue. This meeting record documents Residents had concerns about call lights not being answered in a timely manner and going to the bathroom and staff not answering the call light to get them out of the bathroom.On 7/7/25 at 9:53 AM, R24 stated I have to wait for (staff) help for a long time.On 7/7/25 at 10:35 AM, R29 was sitting in her room and stated Often call light wait times are way too long. At times they take 30 to 60 minutes which is just too long if you have to go to the bathroom. The call lights do not alarm. They show on a board, I think at the nurses station. So if they (staff) aren't around they may not even know when (call lights) are going off. I have called the facility before after waiting too long, and asked for the specific nurses station and told them to get someone down here because I need help!On 7/7/25 at 10:30 AM, the facility's 300/400 hall nurses station was empty with no staff present. At the end of the 400 hall an electronic scrolling board was positioned just below the ceiling and listed room numbers of call lights scrolling laterally from right to left.On 7/7/25 at 11:14 AM, R42 stated residents have to wait long periods for staff to answer call lights.On 7/7/25 at 11:18 AM, R43 stated We have to wait for long periods of time for help.On 7/8/25 at 10:00 AM a Resident Council meeting was conducted. During this group meeting, R28 and R48 stated wait times after pushing their call lights are really long. R11, R28, R38, R48, and R64 all stated that call light wait times are always too long, at varying times of the day.On 7/8/25 at 1:00 PM, V1 (Administrator) confirmed the facility's call light system is silent and does not light up outside of the resident's rooms. V1 stated There is no way to know if a call light is on when staff are in a resident room, away from the nurses' station or when standing in the hallway unless you look at the scrolling board. V1 confirmed this scrolling board does not indicate who pushed their call light first and is not accessible unless staff stand in front of the screens to view.On 7/8/25 at 1:10 PM, the facility's 300/500 hall nurses station was empty with no staff present.On 7/8/25 at 1:14 PM, the facility's 300/400 hall nurses station was empty with no staff present.On 7/8/25 at 1:15 PM V12 (Restorative Certified Nursing Assistant) confirmed the facility's call system is silent and does not light up by resident rooms. V12 stated Residents complain about call light wait times a lot. Not one resident in general. (Staff) just frequently hear complaints about call light wait times. I have to stand in the hall and look at the scroll to see what lights are going off. There is no way to see the order of who's light went off first unless you go to the nurses' station where there is a monitor. There isn't an alarm to notify a call light and there are no lights in the hall or outside of resident rooms. It's not a direct notification to staff when a resident hits their call light because there isn't always staff at the nurses' station. The only way staff are notified is if they are by the monitor at a nurses' station or looking up at the scroll in the hallways.On 7/8/25 at 1:18 PM, the call light monitor at the 300/500 hall nurses station displayed four active call lights were triggered and remained unanswered in the 100 and 300 halls. These call lights were triggered at 11:40 AM, 12:31 PM, 12:33 PM and 12:52 PM. V12 confirmed that those lights either were not shut off or not answered and that is why they are showing up on the monitor at the nursing station. V12 stated Those call lights are still going off and I have no way to know if they were not shut off in the resident room when answered, or if they have been going off the entire time. If a resident is in the bathroom and hits their call light it is the same way. It does not alarm and does not light up. On the scroll it will say the room number and bathroom beside the room. If we have a power outage or generator surge the system will stop, shutdown and reset. Then you have to stand and wait until it starts scrolling again. Basically, if staff are not staring at the screen there is not immediate notification that a call light is going off. We don't know until we are able to go check the scrolling screen again. I'm sure it's why we can't keep wait times low and respond quickly. There's no way to know if someone needs help when busy providing resident care unless you're up in front of the monitor.The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 7/7/25 and signed by V5 (Chief Operating Officer), documents 71 residents reside within the facility.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) were provided and completed a minimum of 12 hours of training that includes Dementia and Abuse over a 12 month period. This failure has the potential to affect all 71 residents residing in the facility.Findings include:The facility's Facility Assessment, dated 7/5/24, documents the facility cares for residents with Cognitive loss/ Dementia. This assessment also documents CNA's (Certified Nursing Assistants) receive yearly competency and on hire. This assessment documents required yearly trainings for CNAs will include Dementia and Abuse/Neglect training.On 07/9/25 at 9:40 AM, V1 (Administrator) confirmed she does not have proof that CNAs working in the facility have had 12 hours of training, including Abuse and Dementia training, in the past year. V1 stated I am not able to locate any training for the CNA's. In January 2025 the training system changed over, and it is now on the computer. I am unable to locate any training for the past 12 months.The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 7/7/25 and signed by V5 (Chief Operating Officer), documents 71 residents reside within the facility.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and humidification supplies were dated, changed weekly, and maintained in a sanitary condition for 6 of 6 residents (R7, R15, R43, R46, R53, and R61) reviewed for oxygen therapy in the sample of 34.Findings Include:The facility's Oxygen Administration policy dated 2001 documents, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol. Nasal cannula, nasal catheter, mask (as ordered). After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record, the date and time that the procedure was performed for oxygen administration.1. On 7/7/2025 at 10 AM, R7 was sitting in her room, in her recliner chair with oxygen flowing 2 liters per nasal cannula. R7's oxygen tubing was not dated, and the humidification bottle was not labeled. R7's Physician Order Sheet, dated 7/9/2025, documents oxygen therapy at 2 liters per minute per nasal cannula.2. On 7/7/25 at 1:30 PM, R15 was in her room, in her chair, with oxygen flowing at 2 liters per nasal cannula, oxygen tubing not dated, humidification bottle not labeled. R15's Physician Order Sheet, dated 7/9/2025, documents oxygen therapy at 2 liters per minute per nasal cannula. On 7/9/2025, at 12 PM, V2 (Director of Nursing) confirmed R7 and R15's oxygen tubing and humidification bottle attached to oxygen therapy should always be dated. 3.) On 07/07/25 at 11:16 AM, R43's oxygen tubing was not dated. R43's electronic chart did not contain documentation of when R43's oxygen tubing was last changed. R43's current Physician's Orders documents oxygen tubing to be changed weekly and as needed. 4.) On 07/07/25 at 9:47 AM, R46's oxygen tubing and humidification bottle were not dated. Staff were unable to verify the last change date at the time of observation.R46's current Physician's Orders documents oxygen tubing to be changed weekly and as needed.5.) On 07/07/25 at 10:08 AM, R53's oxygen tubing and humidification bottle were not dated. R53's tubing was attached to an in-use oxygen concentrator. No documentation or labeling was present to show the last replacement date.R53's current Physician's Orders documents oxygen tubing to be changed weekly and as needed.6.) On 07/07/25 at 11:25 AM, R61's oxygen tubing and humidification bottle were not dated, and the tubing was observed lying directly on the floor in R61's room. R61's current Physician's Orders documents oxygen tubing to be changed weekly and as needed.On 07/09/25 at 11:09 AM, V2 (Director of Nursing/DON) stated oxygen tubing should be changed weekly and dated.

Based on Observation, Interview and Record review, the facility failed to ensure a resident's call light was answered timely to provide toileting assistance for one of 18 residents (R29) reviewed for call lights in the sample of 34.Findings include:The facility's Dignity policy, dated 2/2021, documents Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident's request for toileting assistance.The facility's Resident's Call System policy, dated 9/2022, documents Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered as soon as possible. Urgent requests for assistance are addressed immediately.R29's current care plan, dated 6/23/25, documents I (R29) require assistance with ADL's (Activities of Daily Living) due to recent surgery to left shoulder. I require extensive assistance from one staff member/ two staff members to move about in bed. I require limited/extensive assistance to transfer with assist of one (staff) with front wheeled walker.On 7/7/25 at 10:35 AM, R29 was in her room sitting in electric wheelchair. At this time R29 stated Often call light wait times are way too long. At times they take 30 to 60 minutes which is just too long if you have to go to the bathroom. I have wet myself before waiting for them to answer my call light. Of course, that isn't enjoyable when you know you need help and can't transfer on your own. If I am on the toilet and need taken off it is way too long to sit and wait also. You're at their (staff) mercy in that situation and it's been a problem for a long time.On 7/8/25 at 1:00 PM, V1 (Administrator) confirmed that call light wait times have been an ongoing issue for the facility and that 30-60 minutes is not acceptable for someone who needs to go to the bathroom or get taken off of the toilet.

Based on interview and record review, the facility failed to ensure a Level II PASARR (Preadmission Screening and Resident Review) evaluation was completed for a resident who required further review after the Level I screen. The facility also failed to ensure staff responsible for PASARR coordination had adequate knowledge of PASARR requirements for one (R32) of three residents reviewed for PASARR's out of a sample list of 34.Findings include:The facility's admission Criteria policy revised 3/2019 documents the facility admits only residents who's medical and nursing care needs can be met. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD. The social worker is responsible for making referrals to the appropriate state-designated authority.R32's Level I PASARR screening, completed on 01/04/24, documented that R32 required referral for a Level II onsite evaluation, indicating possible serious mental illness and/or intellectual disability requiring further assessment.R32's Medical Diagnosis List documents R32 has Unspecified Dementia, Paranoid Schizophrenia, Depression, and Anxiety Disorder.On 07/07/25 at 12:15 PM, V7 (Social Services Director) stated that a Level II PASARR was not completed for R32. V7 stated she was not aware of what a Level II PASARR meant and did not know the process for initiating or completing it.On 07/07/25 at 2:21 PM, V1 (Administrator) confirmed that several PASARRs were found to be incomplete or improperly processed. V1 acknowledged that V7 requires additional training in PASARR requirements and responsibilities.

Based on observation, interview and record review, the facility failed to ensure a resident's call light was answered timely to provide toileting assistance for one of three residents (R1) reviewed for call lights in the sample of three. This failure resulted in R1 soiling herself while waiting for assistance and sitting for several hours and causing her emotional distress. Findings include: The facility's Resident Rights policy, dated 2/2021, documents Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity. The facility's Dignity policy, dated 2/2021, documents Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: promptly responding to a resident's request for toileting assistance. The facility's Resident's Call System policy, dated 9/2022, documents Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. R1's current electronic medical record documents R1 has diagnoses of Urinary Tract Infection, Chronic Diastolic (congestive) Heart Failure, Acute and Chronic Respiratory Failure, Morbid obesity and Chronic Kidney Disease stage 3. R1's current Care Plan, dated 4/24/25, documents (R1) will remain in homelike atmosphere at (the facility) and continue to have her needs met. (R1) will be continually monitored for safety and assisted so that her needs are met. R1's Toileting assessment, dated 4/21/25, documents R1 requires assistance of one staff for toileting. R1's current Brief Interview for Mental Status assessment (BIMS), dated 4/7/25, documents R1 has a BIMS of 14 indicating R1 is cognitively intact. On 4/25/25 at 12:45 PM, R1 was sitting in her room in a wheelchair. R1 stated sometimes she has to wait a while for her call light to be answered. R1 stated I need assistance to get up and when using the toilet. Last night I had to go to the bathroom and a CNA (Certified Nursing Assistant, unknown) came in at supper time and I told her that I needed to use the toilet. The CNA said she would go get someone to help her transfer me, but she never came back. I hit my call light, but I didn't see anyone until 11:30 PM. I had already soiled myself because I couldn't hold it that long. I can't transfer safely because my legs get wobbly, so I need help with going to the bathroom, so I just had to sit in the mess and wait. When the staff came in at 11:30 PM, they helped get me cleaned up. I don't know if it was a staffing problem or what. While waiting for someone to come I just felt very dirty. I was so upset that it happened, and I wish it didn't. On 4/25/25 at 12:55 PM, V8 (Certified Nursing Assistant) confirmed she is working on R1's hall. V8 stated (R1) was very upset this morning when I came in the see her. She said first thing when I entered her room that last night, she had a CNA (unknown) that told her she would come back and help her but never did. She said she ended up wetting herself and that she didn't receive help with getting cleaned up for several hours. (R1) is a nice resident and rarely pushes her call light because she doesn't want to bother. I felt bad for her because I could tell it made her so upset and she had it on her mind throughout the night. I am not sure how many were here at that time yesterday, but she needed assistance to the bathroom and was upset that she couldn't hold it. On 4/26/25 at 2:45 PM, V1 (Administrator in Training) stated he is handling nursing and nursing assistant concerns right now due to the facility not having a Director of Nursing or Interim director in that role, currently. V1 stated he was unaware that R1 waited several hours for toileting assistance or that she had an incontinent accident as a result. V1 confirmed waiting even one hour to receive assistance is not acceptable.

Based on observation, interview, and record review, the facility failed to remove a resident's wheelchair pedals during a sit to stand transfer from the wheelchair to the recliner for one of four resident (R52) reviewed for accidents in the sample of 33. This failure resulted in R52 hitting her left outer calf on the wheelchair pedal during the transfer, resulting in R52 sustaining a seven cm (centimeter) long full thickness, painful, gaping laceration of the left, lower leg requiring R52 to be transferred to the emergency room to received internal and external sutures of the laceration. Finding include: The facility's Using a Mechanical Lifting Machine policy dated July 2017, states The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. This same policy states 4. Prepare the environment: a. Clean an unobstructed path for the lift machine; b. Ensure there is enough room to pivot. R52's Minimum Data Set assessment dated [DATE], documents R52 is cognitively intact with a Brief Interview for Mental Status of fifteen out of fifteen. R52's Plan of Care dated 8/31/23, states My (R52) transfer status is to stand lift with two staff assist. R52's Plan of Care also documents R52 is on anticoagulant therapy and staff are to use caution to avoid bumping or scraping (R52's) skin. On 10/30/23 at 11:40 a.m., R52 had a 4 inch by 4 inch bandage on her left outer calf. R52 stated she had a laceration on her left outer calf that had 15 stitches on the outside and two on the inside. R52 stated this laceration resulted from staff not removing the foot pedal from her wheelchair before transferring her with the sit to stand mechanical lift. R52 stated when the injury occurred there were large puddles of blood and R52 sent to the local emergency room . R52 stated It hurt like crazy. R52's Accident Report dated 10/24/23 at 4:15 p.m., documents Outcome-Deep Laceration. R52's nurse was called into R52's room by two Certified Nurse Aides (V8 and V9) due to a laceration on R52's left lower extremity caused by the wheelchair pedals during a transfer. R52's nurse noted a moderate amount of bleeding coming from R52's laceration to lower left leg. Pressure was applied to laceration and area cleansed the best possible to assess the wound. R52 was sent to the local Emergency Department for evaluation and treatment. This same report documents Contributing Factors: Wheelchair pedals were not removed from wheelchair prior to (sit to stand mechanical lift transfer). Corrective Actions Taken: Education was provided to both (V8 and V9) Certified Nurse Aides involved regarding the importance of removing the wheelchair pedal prior to transfers. V8's Statement dated 10/24/23, states (V9/Certified Nurse Aide) and I were transferring (R52) with sit to stand lift from wheelchair to recliner when her left leg caught on her wheelchair foot pedal. We noticed bleeding and I went to get the nurse. The local Hospital Emergency Department Note dated 10/24/23 at 6:38 p.m., states (R52) presents with a 7 centimeter long full thickness, stellate gaping laceration of the left, lower leg. The area was draped and prepped per norm. Closure was achieved with two 3.0 running (2 running stitches, approximately 15 total tosses) Ethilon sutures in the skin. On 11/1/23 at 1:30 p.m., V7 (Infection Preventionist) removed the bandage from R52's laceration/wound on the left outer calf area. Under the outer bandage was another type of dressing that was sticking to R52's sutures. V7 was able to count multiple stitches but did not want to pull on the bandage that was stuck to the sutures. V7 stated the facility's Nurse Practitioner is scheduled to remove R52's sutures early next week. V7 stated R52's laceration was caused when R52's wheelchair pedals were not removed prior to a sit to stand mechanical transfer when the pedal caught her leg. R52 stated the staff were educated the staff should always remove the pedals. On 11/1/23 at 2:00 p.m., V1 (Administrator) stated R52's laceration to her lower left leg was caused by the staff (V8 and V9) not removing the wheelchair pedals prior to transferring R52 from her wheelchair to the recliner. V1 stated V8 and V9 were educated to always remove wheelchair pedals prior to transferring residents to prevent injuries.

Based on interview and record review the facility failed to ensure staff were knowledgeable about an implanted urinary sphincter device, assessing for low urine output, sudden weight gain, and development of edema for one of three (R1) residents reviewed for competent nursing staff in a sample of three. These failures resulted in R1 requiring hospitalization where R1 was diagnosed with not having R1's bladder drained enough, with 2 (two) liters of urine found on ultrasound in R1's bladder, a weight gain of 35 pounds in four days, Congestive heart Failure (CHF) and small pleural effusions. Findings include: An Admission Criteria policy dated as revised 3/2019 states, Our facility admits only residents who's medical and nursing care needs can be met. A RN/LPN (Registered Nurse/Licensed Practical Nurse) job description policy dated 4/2022 summarizes a nurse's job as, provides direct nursing care to the resident and supervises the day-to-day activities performed by CNAs (Certified Nurse Aides) in accordance with current Federal, States, and local standards-of-care and as required by the DON (Director of Nurses). This policy also includes in the nurses' duties, Provide treatments as necessary and appropriate, and Communicate with direct care staff the needs of the residents, and Monitor significant weight loss/gain, alerting the physician and family as appropriate. In addition, this policy states that nursing staff must have, the ability to take initiative, make independent judgements, and promote teamwork is required to successfully fulfill this job's responsibilities. An Admission Assessment and Follow up: Role of the Nurse policy dated as revised 9/2012 states, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set). In addition, this policy instructs nurses to, Notify the supervisor and the Attending Physician of immediate needs that the resident may have, and Report other information in accordance with facility policy and professional standards of practice. A Weight Assessment and Intervention policy dated as revised 3/2022 states, Resident weights are monitored for undesirable or unintended weight loss or gain. R1's hospital Discharge Orders and Summary dated 7/14/23, which was in R1's facility medical records, describes R1's hospital course as having been admitted to the hospital following a fall at home and was found to have had a Myocardial Infarction (Heart Attack) with Acute on Chronic systolic heart failure (CHF). This summary includes that R1 was admitted with an artificial urethral sphincter for emptying urine from R1's bladder because of urinary incontinence. This summary documents R1 was assessed for dementia and scored as moderately cognitively impaired. R1's physician's orders dated 7/14/23 document R1 has diagnoses including Acute on chronic systolic (congestive) heart failure, non-st elevation Myocardial Infarction. These same orders include instructions for R1 to be weighed daily between the hours of 6:00a.m.- 2:00p.m., and to be administered the diuretic Spironolactone 25mg (milligrams) once daily. R1's admission referral from the hospital record dated as printed 7/13/23 by V2 (Director of Nurses) documents R1 was accepted for admission to the facility by V1 (Administrator) as of 7/12/23. This same referral record includes a physician's progress note that documents R1's most recent hospital recorded weight at the time of the referral was 209lbs and 14 oz (ounces) and that R1 had medical history of Type 2 Diabetes Mellitus, Prostate Cancer with Prostatectomy, and Neuropathy. In addition, R1's hospital physician's progress note dated 7/12/23 documents that R1 had no swelling or peripheral edema. R1's nursing progress notes dated 7/14/23 at 5:43p.m. documents the facility received a nursing report on R1's condition prior to R1's admission which included that R1 had a prosthetic urinary sphincter in place. This nursing progress note does not indicate R1 was admitted with any edema. R1 does not have any other nursing progress notes documented until 7/16/23 at 7:13p.m which state, (R1's) Family came to this nurse with concerns regarding resident's current weight of 232.8lbs. Family stated (R1's) abdomen is more distended than normal and has some swelling to his feet and legs. This nurse assessed (R1). (R1) reported he wasn't having any pain. Heart and lungs WNL (within normal limits). Obtained 80ml of yellow urine. Abdomen non-tender but distended. Bowel sounds normal. (R1's family) requested that (R1) be sent to ER for evaluation and would not like to hold the bed. At 7:32p.m. R1's nursing progress note documents that R1 was transferred via ambulance to the hospital. R1's care plan does not include interventions to address how to care for R1's implanted urinary sphincter. R1's hospital emergency room physician's progress note dated 7/16/23 at 7:48p.m. states, (R1) presents to the ED (emergency department) c/o (complaining of) edema onset a few days. (R1) was just admitted to (the Facility's) acute rehab. (R1) reports sx (symptoms) of LE (lower extremity) edema and sits in a chair for prolonged periods without feet elevated. (R1) has a prosthetic urinary sphincter and reports that the nursing home staff was not assisting with draining his bladder. (R1) has had a 35-pound weight gain in the last 4 days. This same progress note documents that upon the emergency room physician's assessment of R1's genitourinary area they found that R1 had lower abdomen tenderness and distention. R1's emergency room physician's emergency department course progress note dated 7/16/23 states, (R1) presents to the emergency department for severe edema, not having his bladder drained enough, concerning for fluid overload with potential for acute renal failure secondary to obstructive uropathy. Bedside ultrasound performed by me had approximately 2L of urine in the bladder. (R1) has mild AKI (Acute Kidney Injury) and mild evidence of CHF with fluid overload including small pleural effusions (fluid around the lungs). Given his 35-pound weight gain, (R1) would be admitted for IV (intravenous) diuresis (increasing urine production to rid body of excess fluid) and will require frequent manual decompression of the bladder with his prosthetic sphincter. On 7/24/23 at 9:51a.m. V9 (R1's Family) stated that R1 was admitted to the facility for therapy after he fell at home and had some cardiac issues. V9 stated that R1 has a prosthetic urinary sphincter which must be manually released for R1 to urinate. R1 stated that because R1 was on a diuretic, he had received a large amount of fluids in the hospital, had new onset heart issues, and because he had to have his prosthesis manually released to urinate, R1 was supposed to receive daily weights and be closely monitored by nursing staff. V9 stated nurses did not assess R1 after he was initially admitted on [DATE] until V9 complained to CNA staff that R1 was not being weighed daily or having his urine output monitored. V9 stated that on 7/16/23 during the late afternoon, she asked R1's CNA (Certified Nurse Aide) if R1 had been weighed for the day yet. V9 stated the CNA said R1 had not been weighed yet and that there was no documentation that R1 had been weighed the previous day. V9 stated that facility nurses and CNAs were not familiar with R1's prosthetic sphincter and did not know how to care for it or engage it manually as it was supposed to be. V9 stated that when R1 was initially admitted to the hospital, the hospital nurses were not familiar with the type of prosthetic sphincter that R1 has, so those nurses looked on the internet to learn about how the sphincter works and how to care for it. V9 stated that none if the facility's nursing staff were knowledgeable about R1's prosthetic sphincter. V9 stated that the CNA's were the ones caring for R1's prosthetic sphincter and she does not believe they knew how to care for it appropriately. V9 stated that she was shocked and upset when she came to the facility to visit R1 on 7/16/23 and noted he had severe swelling to his legs and feet and his abdomen was also swollen. V9 stated that when the CNA weighed R1 he weighed 232 pounds which was about 30 pounds or more than his last weight in the hospital prior to his discharge on 7/14/23. V9 stated that given R1's extreme weight gain, nursing staff could not have been properly assessing R1 for edema, weight, or urine output. V9 stated that on the afternoon of 7/16/23, when R1 had such a dramatic weight gain, she insisted that R1's nurse send R1 to the hospital for evaluation. V9 stated that the nurse tried to convince her that R1 should stay at the facility and be evaluated by the facility's physician the next day on Monday. V9 stated that she insisted R1 go to the emergency room . V9 stated that once R1 was in the emergency room , the physician performed an ultrasound on R1's bladder and found that R1's bladder was in danger of rupturing because it contained 2 liters of urine. V9 stated the emergency room physician stated that R1's bladder could not have been emptied appropriately for it to contain that much fluid. V9 stated the 2 liters of urine were removed from R1's bladder and R1 was admitted to the medical floor of the hospital for treatment. On 7/24/23 at 10:59a.m. V1 (Administrator) stated that if a resident is admitted to the facility and requires an unusual treatment or has an unusual appliance, the facility has education staff and an education consulting group who can train nursing staff on how to manage the care of that resident. V1 stated that the facility's nursing staff are very vocal about when they need education. V1 stated, We haven't' had to do any training for an unusual appliance or unusual resident needs recently, or for any new resident. On 7/24/23 at 12:31p.m. V4 (Registered Nurse/RN) stated that he was R1's nurse on 7/15/23 and 7/16/23 day shift. V4 stated that, (R1) had some sort of urinary sphincter device, but that V4 didn't know anything about it. V4 stated, The CNA's took care of it. V4 stated he did not know if R1 was supposed to have his urine output monitored but that R1's weight was supposed to be checked every day. V4 stated that he was planning to look up some information on how to care for R1's urinary sphincter device the next time he was R1's nurse, but R1 was discharged before V4 worked again. V4 stated it was V5 (Certified Nurse Aide/ CNA) who knew how to take care of R1's urinary sphincter. V4 stated that R1 was somewhat confused and became more confused as the day went on. V4 stated that R1 did not have very much urine output when he cared for R1. V4 stated he did not think R1 ever emptied his own bladder by manually engaging R1's urinary sphincter. V4 stated he didn't think R1 could urinate without the sphincter button being pushed. V4 stated, Why did they (facility) admit someone with something like that if no one knows how to use it? Did they know he had that when they admitted him? On 7/24/23 at 12:52p.m. V5 stated she was one of R1's CNAs from 8:30a.m to 9: 00a.m on 7/15/23. V5 stated she had never been taught how to use a manual urinary sphincter device. V5 stated nursing staff did not instruct her on how to empty R1's urine using this device. V5 stated R1 showed her how to push an area on the left side of R1's scrotum which opened the sphincter and allowed urine to empty from the bladder. V5 stated that R1 instructed her to push on the area again to re-engage the sphincter so urine didn't leak out. V5 stated that was the only time she cared for R1 but also stated she demonstrated to V6 (CNA) how to use the device since V6 was one of R1's day shift CNAs. On 7/23/23 at 1:00p.m. V6 (CNA) stated that she took care of R1 on 7/15/23 and 7/16/23 during the day shift. V6 stated she did not open R1's urinary sphincter to empty urine from R1's bladder during her shift. V6 stated that V5 was the only CNA to empty R1's bladder. V6 stated there was no schedule for emptying R1's bladder and that CNA staff only went into R1's room when he used his call light. V6 stated, But he could urinate around it (sphincter). V6 stated she knew he could urinate around the sphincter because she could hear some urine dribble into the toilet when she took R1 into the bathroom for a bowel movement. V6 stated she had never heard of a device like R1's urinary sphincter before. On 7/24/23 at 1:43p.m. V2 (Director of Nurses) stated she did not know about R1's implanted urinary sphincter which required manual manipulation to empty R1's bladder until today. V2 stated she reviewed R1's nursing documentation from the day R1 was admitted [DATE] and noted that the nurse who took report from the hospital documented R1 had this device. V2 stated she would have expected nursing staff to relieve R1's bladder on a schedule to make sure R1's bladder was appropriately emptied. V2 stated she does not believe residents have their output monitored unless they have the diagnosis of CHF or other similar diagnosis. On 7/24/23 at 2:10p.m. V1 (Administrator) stated that she is also a nurse, and it was V1 who accepted R1 as a new resident at the facility. V1 stated that she did not know R1 had an implanted urinary sphincter which required staff to manually open the sphincter to drain R1's urine from R1's bladder. V1 stated she does not know much about this device. V1 stated that when R1 was admitted , R1's nurses should have informed her they did not know how to manage R1's sphincter device. On 7/24/23 at 2:51p.m. V7 (Licensed Practical Nurse/LPN/ Evening Supervisor) stated that on 7/16/23 she was working as a floor nurse on another hall when staff told her that R1's family had concerns about R1's feet being swollen. V7 stated that R1 had only one compression stocking because the other stocking was cut off at the hospital. V7 stated that she gave R1 a new compression stocking so he would have one for each leg. V7 stated that R1's family mentioned R1 had a urinary sphincter device. V7 stated, I said we would make sure the nurses would show the CNAs how to care for it. I told V4 to show the CNAs how to use it at around 11:30a.m. on that date. V7 stated that V4 told her V4 knew how to use the device. V7 stated that the CNAs told V7 that R1 knew how to use the device himself. V7 stated that later in the day, V8 (LPN) told her that R1's family wanted R1 sent to the hospital because of R1's edema. V7 stated that V8 told her R1 had no signs of CHF exacerbation and that V8 thought R1's edema was no different from when he was first admitted . V7 stated that she and V8 went to R1's room and attempted to empty R1's bladder by pushing on R1's sphincter device. V7 stated that V8 was only able to get around 100ml of urine to drain from R1's bladder. V7 stated she and V8 did not attempt to open R1's sphincter a second time to see if more urine would drain out. V7 stated that she didn't know anything about how R1's urinary sphincter worked. V7 stated, I didn't read up on it and I'm not sure if (V8) did. On 7/24/23 at 4:39p.m. V8 stated she took care of R1 only one time from approximately 2:30p.m.-6:00p.m. on 7/16/23. V8 stated she was not R1's admitting nurse and didn't know anything about R1 before 7/16/23. V8 stated she had never used a urinary sphincter device before and did not know anything about how it worked. V8 stated she did not receive any instruction from the facility on how to manage this device. V8 stated that at first R1 seemed a little confused but she thought he may not have understood what she was asking him when she asked about the sphincter device. V8 stated that she initially checked on R1 because R1's family was concerned that R1's weight had not been monitored and they did not believe the weight the CNA recorded for that day was accurate. V8 stated she reweighed R1 and the weight V8 recorded was within 0.2 pounds of the CNAs weight. V8 stated she looked through R1's medical records and could not find documentation that R1 had been weighed the day before. V8 stated that when she and V7 attempted to empty R1's sphincter device, only 80ml of urine drained from R1's bladder. V8 stated R1 was visibly edematous to his legs and his abdomen. V8 stated R1's bladder was firm. V8 stated she and V7 did not attempt to drain R1's bladder a second time to ensure it was empty. V8 stated R1 was sent to the hospital shortly after she drained the 80ml of urine from R1's bladder.

Based on record review and interview, the facility failed to ensure a resident identified as a significant fall risk was adequately supervised, wearing the proper footwear and failed to follow the facility's policies regarding post fall resident assessments, for one of three residents (R1) reviewed for falls in a sample of three. These failures resulted in R1 falling on 9/07/22 and sustaining an Acute Subdural Hemorrhage, Pubic Ramus Fracture and Left Femur Fracture. Findings include: The facility policy, titled Assessing Falls and Their Causes (revised March 2018), documents, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy also documents, After a fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate timeframe. a. When a fall results in a significant injury or condition change, notify the practioner immediately by phone. The facility policy, titled Falls - Clinical Protocol (revised March 2018), documents, Monitoring and Follow-up - 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The Electronic Medical Record Documents R1 was admitted to the facility on [DATE] with the diagnoses of Unsteadiness on Feet, Osteoarthritis, Cognitive Communication Deficit, Muscle Weakness and Congestive Heart Failure. A Plan of Care, dated 5/06/22, documents R1 as being high risk for falls based on his Fall Risk Assessment. An Accident Report, dated 5/15/22, documents R1 was found on the floor of his room and R1 indicated to staff that he was attempting to go to the bathroom by himself. Documentation in the Accident Report indicates Contributing Factors to R1's fall being confusion, his wheelchair being next to the bed for easy access and R1 not wearing gripper (non-skid) socks. The Accident Report further documents, Measures to Prevent Recurrence (of R1 falling): Gripper socks to be worn while in bed. R1's Plan of Care documents it was updated under Fall Risk, on 5/15/22, instructing staff to ensure R1 is wearing non-skid footwear. Additional Accident Reports, dated 5/23/22, 7/01/22 and 8/17/22 document R1 was found on the floor of his room without injury after attempting to ambulate/transfer himself independently. An Accident Report, dated 8/25/22 at 8:15 am, documents R1 was found on the floor of his room with a large laceration on the back of his head and R1 was transferred to the local hospital for treatment. A Long-Term Care Serious Injury Incident Report, dated 8/25/22, documents R1 received seven staples to the posterior aspect of his scalp as a result of the fall. This report also documents, Plan upon readmission to facility was to move (R1) to a room closer to nurse's station for closer supervision. Nursing Notes dated 8/30/22, document R1 returned to the facility from the hospital and was relocated to a room next to the Nurse's Station. R1's Plan of Care was updated on 8/25/22, under Fall Risk, instructing staff Move my room closer to the nurse's station for close monitoring. A Fall Scene Investigation Report, completed 9/08/22 at 12:00 am by V3 (Registered Nurse), documents R1 was found on the floor of his room after an unwitnessed fall at 8:00 pm on 9/07/22. According to the report, R1 was noted to be aggravated and frustrated that evening of the fall and R1 informed staff that he was attempting to urinate (with the urinal) and slipped off the edge of the bed onto the floor. The report also documents staff were unsure of the last time R1 was toileted and R1 was only wearing socks at the time of the fall, so non-skid socks applied. The conclusion of the Fall Scene Investigation Report documents What appears to be the root cause of the fall? (R1) does not wait until someone can help him. Call light was in hand. Describe initial interventions to prevent future falls - Make sure (R1) has non skid socks on. A Neurological Assessment Flowsheet documents on 9/07/22 at 8:00 pm routine vitals were taken, along with assessment of consciousness, pupil response and motor function. There was no corresponding nursing note at the time of R1's 9/07/22 fall to document additional details, initial or ongoing nursing assessments of R1's physical condition or if R1 sustained an injury after the fall. The next documentation in R1's electronic medical record was the morning of 9/08/22, at 7:30 am, when V4 (Licensed Practical Nurse) documented in Nursing Notes, Call placed to (Nurse Practitioner's) office regarding (R1's complaint of) severe (left) hip/leg pain and inability to stand with 3 person assist. Therapy informed this nurse that they were trying to work with him and had 3 people in there and they could not stand him. Upon this nurse's examination resident's leg did look externally rotated and appeared shorter than the (right) leg. Order given by (Nurse Practitioner) to send resident to (emergency room ) for (evaluation and treatment). Resident's wife notified and agreed to bed hold. Resident left facility at 8:00 am by ambulance to (emergency room ). A late entry Nursing Note, two days later, by V3 (Registered Nurse), documents 9.09.22 5:01 am - Was summoned to resident's room (on 9/07/22) by CNA (Certified Nursing Assistant). Upon entering (R1) was on the floor laying on left side along side his bed. Head was facing toward the head of the bed . (R1's) head was bleeding from the area of where his staples presented. All staples intact. Bleeding was controlled with pressure to the area . (R1) was able to move all extremities . (R1) was assisted to a standing position with the use of gait belt and 2 staff members. (R1) was assisted to his bed . Pressure was applied with dressings and ice pack applied to the area of the staples. Neuros (neurological assessments) and (vital signs) initiated. A Long-Term Care Serious Injury Incident Report, dated 9/08/22 at 5:45 pm, documents (R1) had slid off the edge of his bed on 9/07/22 at approximately 8:00 pm. At time of incident, he was assessed per nurse on duty, no injury noted at that time and he denied pain until this morning (9/08) when morning nurse assessed him. Sent to ER (emergency room ) for further testing. Noted to have fractured pelvis. 5 day (investigation) to follow. The Five Day Final Long-Term Care Serious Injury Incident Report, dated 9/13/22, documents Detailed Incident Summary (Who, What, When, Where, Why) - On 9/07/22 (R1, who has a medical history including cognitive deficit, chronic pancytopenia and heart failure) was attempting to self transfer out of bed and 'slid to the floor' per investigation and self report from him. Assessed per nurse on duty at time of incident (V3) - No injuries noted or complaints of pain/discomfort voiced by (R1). On the morning of 9/08/22, (R1) was unable to sit up the assist of 1 staff member as per his norm, as physical therapy was attempting exercises. Staff attempted with 3 staff and he was still unable to sit on side of bed. (R1) Immediately indicated pain with movement. Assessed per nurse (V4), noted left leg to appear shorter than right and internally rotated. (V10 - Nurse Practitioner) notified - orders received to send to (Hospital) for further evaluation. (R1) transported from home facility to (Hospital) via (ambulance). Per x-ray and CT (Computed Tomography Scan) noted several subdural hematomas (very small) and fracture of left femur. (R1) was then airlifted to (different Hospital) due to his chronic health concerns and lack of trauma surgeons in our area. Further examination at (receiving Hospital) indicated that (R1) had a subdural hematoma on each side of his head (old appeared to be from previous injury/fall), sub-arachnoid hemorrhage, fractured right hip and left femur fracture. Determined that based on his chronic illness, age and other comorbidities, he is not a surgical candidate. (R1) returned to this facility on 9/13/22. Plan: Enrolled into Hospice care upon his readmission and going forward he is to remain in room closest to the nurse's station, continued high frequency rounding, as well as maintaining comfort. On 9/21/22 at 12:37 pm, V3 (Registered Nurse) stated on the night of 9/07/22, R1 had been on his light, wanting out of bed and help with his urinal all night. V3 stated R1 was unpredictable and needed to be closely monitored. V3 stated it is difficult to supervise everyone, with only two people staffed on that hallway. It's only me and a CNA. V3 indicated R1 had recently been relocated to a room near the nurses station for increased supervision due to a previous fall with injury, so she was aware R1 needed increased supervision. V3 stated, around 8:00 pm, she was summoned into R1's room, by a CNA (Certified Nursing Assistant), who had found R1 lying on the floor. V3 stated when she entered the room, R1 was on the floor bleeding from his head where the staples were from the previous fall, so V3 assumed R1 hit his head. V3 stated R1 was able to bend his knees upward and she conducted a neurological assessment, which was normal. V3 stated another staff member got ice for R1's head, she stopped the bleeding and assisted R1 to a sitting position. V3 then stood R1 up with the assistance of V11 (Registered Nurse) and a gait belt, and sat R1 in his wheelchair. According to V3, R1 was alert per his normal. R1 told V3 that he was sitting on the edge of his bed and fell trying to reach the urinal, as he needed to urinate. V3 stated R1's call light was on the bed, but not on and he was wearing regular socks, not non-skid socks. V3 and V11 assisted R1 back to bed. V3 stated she did not contact the physician or the nurse practitioner at that time to notify them that R1 had fallen, even though R1 had bleeding from his head. V3 stated we typically don't call the physician if someone falls and is uninjured. V3 stated she did neuro (neurological) checks on (R1) throughout the night and they were normal. V3 indicated R1 remained in bed for the remainder of her shift, without complaint. On 9/22/22 at 3:45 pm, V11 (Licensed Practical Nurse) stated she was called into R1's room on the evening of 9/07/22 after he fell . According to V11, R1 had obviously hit his head, as there was blood coming from the area where he had staples and blood was all over the floor. V11 stated she observed V3 assess R1's legs and bend his knees upward. V11 indicated R1 did not express symptoms of pain and denied any pain during the assessment; however, V11 thought R1's left leg was turned inward somewhat, and V11 questioned V3 regarding that, but V3 said R1's leg looked fine. V11 stated she told V3 she thought R1 needed to go to the emergency room , but again, V3 told her he didn't and insisted he was fine. V11 and V3 got R1 up with a gait belt and V11 stated he was a total lift, and it was difficult. V11 stated R1 continued to deny any pain, so I went with what (V3) said regarding not sending him out. (V3) was the RN (Registered Nurse) on duty and I'm just an LPN (Licensed Practical Nurse. On 9/21/22, at 3:30 pm, V1 (Administrator) confirmed that at the time of R1's 9/07/22 fall, he should have been wearing non-skid socks as a fall prevention intervention, as outlined in R1's Plan of Care. On 9/21/22 at 11:58 am, V5 (Certified Nursing Assistant) stated on the night of 9/07/22 R1 had been using his call light frequently wanting his urinal. V5 stated, around 8:00 pm, she and another CNA observed R1 on the floor of his room. According to V5, R1 stated, I was trying to go pee and insisted his call light was on, when it was not. V5 was uncertain the last time R1 had been toileted, but indicated he had a urinal next to his bed. V5 stated R1 was attempting to get up off the floor, but couldn't. V5 summoned assistance and V5 and another nurse came in to assess R1, who kept telling staff just get me up! V5 observed V3 do a neurological assessment and R1 denied pain at that time when questioned by staff. V5 stated V3 and two other staff helped get R1 up off the floor and into his wheelchair using a gait belt. V5 saw R1's head bleeding and there was blood on the floor. V5 stated, I told (V3) that I thought (R1) should go to the ER (emergency room ) after the fall, but (V3) said 'no'. V3 stated she gave report to the day shift CNAs at approximately 6:30 am and advised them R1 had fallen earlier that night. On 9/21/22 at 12:29 pm, V4 (Licensed Practical Nurse) described R1 as very impatient and if you didn't help him right away, he'd try to do whatever he was trying to do by himself. V4 stated she started her shift on 9/08/22 at 6:30 am. V4 stated she was given report from the night nurse and was advised that R1 had fallen and had sustained some bruising, but V3 did not tell her where the bruising was. According to V4, V3 also did not tell her R1 had hit his head and was bleeding after the fall. Shortly after V4 received report, the CNAs and Therapy Staff told her they could not get R1 to stand up to get him ready for breakfast. V4 assessed R1, who was alert and only expressed pain if they moved him. Therapy staff told V4 that they saw bruising and swelling on R1's backside, but V4 was unable to assess the area since R1's pants were on. V4 noted at that time, R1's left leg was rotated and slightly shorter than the right leg. It was then, the decision was made to send R1 out to the emergency room . On 9/21/22 at 2:45 pm, V7 (Certified Occupational Therapist) stated she had worked with R1 on several occasions with a goal of making him a little more independent with ADLs (Activities of Daily Living). V7 stated R1 was very guilty of not using his call light and was very impulsive. V7 indicated she would catch (R1) walking to the bathroom by himself and he needed a lot of supervision. According to V7, the morning of 9/08/22 at approximately 6:30 am, V8 and V9 (Certified Nursing Assistants) told her they were trying to get R1 up for breakfast and R1 couldn't stand. V7 entered R1's room and found him sitting on the side of his bed. V7 noted R1's left hip to have a very noticeable bruise, between the size of a golf ball and a softball and the skin surrounding the bruise was swollen and tight to the touch. V7 observed R1's left leg to be rotated. V7 stated R1 cried out in pain as they tried to get him positioned on the bed and pull pants on him. V7 stated she immediately went to V3, who was near the end of her shift and reported to her that she observed R1's left gluteal area bruised and swollen, along with the external rotation of the left leg. V3 indicated to V7 that R1 always had bruising in that area, which V3 argued, as she got him dressed in the mornings on many occasions and never witnessed bruising in that area before. According to V7, she told V3 that R1 needed to go out to the emergency room , but V3 kept advising her He's (R1) fine, when V7 (I) observed he clearly wasn't. V7 then reported R1's assessment findings to V4, because she was the oncoming nurse, and V4 agreed R1 needed sent to the emergency room right away. On 9/21/22 at 1:44 pm, V2 (House Support Nurse) stated all disciplines met to discuss R1's increasing number of falls after the 8/25/22 fall that resulted in injury. According to V2, was decided that R1 needed to be closer to the nurse's station so he could be more easily observed. V2 stated, staff were told to keep a close eye on him and check on him more frequently, as he needed increased supervision. On 9/21/22 at 1:13 pm, V6 (Nurse Practitioner) stated R1 had been declining the last several weeks prior to the 9/07/22 fall and was lacking safety awareness. According to V6, R1 almost needed 1:1 supervision after the 8/25/22 fall when he hit his head and needed staples. V6 stated, after a fall, nursing staff should be documenting any injury and a findings associated with a full physical assessment. V6 indicated that, since R1 did hit his head and was bleeding after the fall, she would have expected staff to immediately notify herself or the physician, so a determination could be made if R1 needed to be sent out to the emergency room for an evaluation at that time.

Based on observation, interview and record review, the facility failed to identify risk factors and implement measures to prevent the development of pressure ulcers for one of four residents (R26) reviewed for pressure ulcers in a sample of 25. These failures resulted in R26 developing an unstageable pressure ulcer to the left heel and a stage two pressure ulcer to the coccyx. Findings include: A Prevention of Pressure Injuries policy dated as revised 4/2020 states, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. This policy instructs to, Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge, and Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team, and Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. R26's Minimum Data Set (MDS) assessment dated [DATE] documents R26 is moderately cognitively impaired with inattention and an altered level of consciousness. In addition, R26's MDS assessment documents R26 requires extensive assistance of two people for bed mobility, transfers, toilet use, personal hygiene, and is unable to walk. In addition, R26's MDS assessment documents R26 is at risk for developing pressure ulcers and has had a weight loss of 5% (percent) or more in the last month or a loss of 10% or more in the last six months. R26's Braden Risk for pressure ulcer development dated 4/19/22 documents R26 is at moderate risk for developing a pressure ulcer because R26 has very limited sensory perception, is chairfast, probable inadequate nutrition, is occasionally moist and has the potential for skin breakdown related to friction and shear. R26's Wound assessment dated [DATE] to 8/7/22 documents R26 developed an unstageable pressure ulcer to the left heel which measured 6 cm (centimeters) long x 6cm wide which was white in appearance on 7/2/22. This same assessment documents that over the course of the next four weeks R26's left heel wound increased in size measuring 7.4 cm long x 6.8 cm wide when last measured on 8/7/22. R26's Wound assessment dated [DATE] to 8/6/22 documents R26 developed a stage two pressure ulcer to the coccyx on 7/24/22 measuring 1.4 cm long x 1cm wide x 0.2cm deep which had a pink center with scant drainage. R26's Nurse Practitioner's (NP) Progress Note (dated 4/22/22), the first practitioner's assessment since R1's admission, documents R26 had a red area to her buttocks at the time of the assessment. This note also states that R26 was confused and weak; had a poor appetite and would spit out food. R26's Clinical Monitoring Detail Report dated 4/18/22 to 8/2/22 documents R26's admission weight was 232 lbs. (pounds). This same report documents that over the course of the next 10 weeks following R26's admission to the facility she suffered a 20.13% (percent) weight loss. On 4/25/22, R26's weight dropped to 223.6lbs, a 3.62% weight loss. On 4/29/22, R26's weight dropped to 217.6, a 6.21% weight loss. On 5/24/22, R26's weight dropped to 201.4lbs, an 11.47% weight loss. On 6/7/22, R26's weight dropped to 202.4lbs, a 12.76% weight loss. On 6/14/22 R26's weight dropped to 197, a 15.09% weight loss. On 6/21/22, R26's weight dropped to 196.7 lbs, a 15.17% weight loss. On 6/28/22 R26's weight dropped to 190.4 lbs, a 17.93% weight loss. On 7/2/22, R26's weight dropped to 185.3lbs, which is a 20.13% weight loss. R26's care plan dated 4/19/22 documents one of the focus areas of R26's care plan is for skin integrity concerns and states, I am at high risk for skin breakdown. This same care plan includes interventions dated 4/19/22 which instruct, Please help me to reposition frequently to help relieve pressure to my skin, and Please ensure I have a pressure relieving mattress on my bed, and cushion in my wheelchair, and Apply preventive barrier cream to my skin after cleansing me, and as needed. This care plan does not include any revisions for the prevention of skin integrity issues, such as pressure ulcers, until 7/5/22 which is after R26 developed the unstageable pressure ulcer to her left heel. R26's care plan intervention dated 7/5/22 states, Apply heel protectors to both my feet and off load my heels when I lay down. This care plan does not include any additional interventions were added after 7/5/22 until 8/2/22, which is after R26 developed the stage 2 pressure ulcer to her coccyx on 7/24/22. R26's care plan intervention added as of 8/2/22 states, I take high protein supplements to help my skin heal. On 8/9/22 at 10:30a.m. R26 was seated in a recliner in her room with her feet elevated on a footrest. There were fabric quilted boots on R26's feet with cut out areas in the heels leaving the heels exposed. R26's heels were resting on the footrest of the recliner without any part of the boot protecting R26's heels. R26's left foot appeared to be bent abnormally forward indicating R26 had foot drop. R26 was also seated directly on her buttocks/coccyx without a pressure relief cushion in place. There was a high-backed wheelchair in the corner of R26's room which also did not have a pressure relieving cushion in place. V3 (Certified Nurse Aide/CNA) and V4 (CNA) entered R26's room and proceeded to transfer R26 to the bed using a mechanical lift. Once R26 was lowered to the bed, V3 and V4 provided total assistance to turn R26 from side to side while they performed a skin observation and incontinence care. V3 verified R26 did not have a pressure relief cushion in her recliner stating that R26 has never had a cushion in her recliner since R26's admission to the facility. V3 also verified R26 did not have a cushion to her wheelchair stating that R26 currently does not sit in her wheelchair anyway. R26 had an open wound without a dressing to the top of R26's left buttock which was approximately 1.5cm long x 0.8cm wide x 0.2 cm deep with a pale pink wound bed. R26's left heel was covered with a gauze dressing. V3 and V4 completed R26's incontinence care, and without applying protective cream to R26's buttocks area, V3 and V4 reapplied R26's incontinence brief and covered R26 with a blanket. Before leaving the room V3 placed a pillow under R26's feet. R26's legs weighed down the pillow making R26's left heel rest on the mattress. V3 stated R26 was not able to move very much when she was first admitted to the facility but is now able to move her right leg and foot. V3 stated R26 is not able to move her left foot very well and that R26's left foot has a foot drop. V3 and V4 left R26's room, with R26's left heel wound resting on the mattress and R26 laying on her back with R26's weight on her coccyx wound. At 11:10a.m. V5 (Registered Nurse) entered R26's room to perform dressing changes to R26's left foot and left buttock wound. V5 stated R26's left buttock wound is considered a stage 2 coccyx pressure ulcer and R26's left heel is considered an unstageable pressure ulcer. When V5 removed the soiled dressing from R26's left heel, R26's entire heel, approximately the size of a baseball, was covered in black/brown tissue. On 8/9/22 at 12:36p.m. and on 8/11/22 at 2:25p.m. V1 (Administrator) stated she is a member of the interdisciplinary team (IDT) and a nurse. V1 stated that all residents are turned and repositioned every two hours. V1 stated that the facility and IDT did not assess R26's tissue tolerance to see if her individualized turning and repositioning schedule should be more frequently than every two hours. V1 verified that no additional pressure ulcer prevention measures were put into place after the initial interventions were added 4/19/22 until after R26 developed a left heel unstageable pressure ulcer on 7/2/22. V1 verified no new pressure ulcer preventive measures were added after R26 developed her left heel pressure ulcer and before she developed the stage 2 pressure ulcer to her coccyx 7/24/22. V1 stated that R26's weight loss was addressed by the facility's Registered Dietitian, but no new pressure relief interventions were implemented based on R26's increased risk for the development of pressure ulcers as a result of significant weight loss. V1 verified that R1's pressure relief boots were not implemented until after R1 developed the unstageable pressure ulcer to her left heel. V1 stated that R26 did not use a pressure relief cushion in her recliner because it made R26 sit too high and increased her fall risk.

Based on record review and interview, the facility failed to promptly address inadequately controlled pain and notify the attending physician for reconsideration of approaches and management for one of three residents (R1) reviewed for pain management in a sample of three. This failure resulted in escalation of pain symptoms to the point of requiring hospitalization for severe back pain. Findings include: A policy titled Pain Assessment and Management dated (MONTH) (YEAR) states, 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Monitoring and Modifying Approaches: 4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain; 3. Prolonged, unrelieved pain despite care plan interventions. A policy titled Administering Pain Medications dated (MONTH) 2010 states, Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose; 4. Route of administration; and 5. Results of the medication (adverse or desired). A policy titled Pain - Clinical Protocol dated (MONTH) 2013 states, Monitoring: 3. The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. R1's electric record accessed on 10/30/18 documents R1 was admitted on [DATE] after experiencing a fall at home and a brief hospitalization [DATE] through 10/02/18. An Emergency Department Assessment dictated by V32 (emergency room Physician) dated 9/30/18 reports R1's Pain is sharp and 8 out of 10 increased with movement. While lying down and resting comfortably is 2 out of 10. A History and Physical dictated by V33 (Hospital Physician) dated 9/30/18 documents R1 has [DIAGNOSES REDACTED]. A Discharge Summary from the local hospital dictated by V33(Hospital Physician) dated 10/02/18 states R1 had paraspinal (area surrounding the spine) tenderness along L3-L4 (the third and forth lumbar disc of the lower back) with no [MEDICAL CONDITION]. This discharge summary reports R1 was treated with a [MEDICATION NAME] (to numb the area/relieve pain) and [MEDICATION NAME] (a muscle relaxant) and recommended for rehabilitation in a nursing home. Radiology reports dated 9/30/18 of the lower and mid-back both state No acute abnormality identified. The Discharge Summary indicates the discharge [DIAGNOSES REDACTED]. A Progress Note written by V26 (LPN - Licensed Practical Nurse) dated 10/02/18 documents for mobility R1 required assistance of one with a walker. Progress Notes written by V8 (RN - Registered Nurse) dated 10/09/18 at 6:31 a.m., document R1 complained of stomach pain on the right side, upper and lower abdomen and a call was placed to V14 (R1's Nurse Practitioner), A Progress Note written by V8 (RN) dated 10/09/18 at 11:19 a.m., indicates R1 was transferred to the local emergency room for evaluation and treatment. An Emergency Department Note dictated by V34 (emergency room Physician) dated 10/09/18 documents R1's pain level was zero out of 10 and that R1 complained of diarrhea times six days and lack of appetite times two days but denied pain. This Emergency Department Note states R1 was kept for observation over night at the local hospital. A hospital nursing assessment written by V35 (Hospital RN) dated 10/09/18 documents R1 complained of back and abdominal pain with cramping on a scale of 4 out of 10 (with 10 being the worst pain). Discharge Orders and Summary dictated by V33 (Hospital Physician) dated 10/10/18 document R1's discharge [DIAGNOSES REDACTED]. R1 was discharged with orders of [MEDICATION NAME] 5 percent topical patch (to back) once daily and [MEDICATION NAME] 500 mg three times daily as needed for back pain. A 10/10/18 Progress Note written by V36 (RN) at 7:11 a.m. states R1 continued to complain of pain in R1's left side/flank. On 10/10/18, R1's Physician orders [REDACTED]. The 10/10/18 Progress Note written by V36 (RN) at 7:11 a.m., documents R1's pain was not controlled and on 10/10/18 a new order for [MEDICATION NAME] (a narcotic for treatment of [REDACTED]. A Progress Note written by V28 (LPN) dated 10/11/18 at 3:54 p.m., documents R1 was experiencing back pain of 8 out of 10 and appeared to be having muscle spasms with tremors of the legs. This Progress Note documents V14 (R1's Nurse Practitioner) was contacted and V14 reported R1's complaints of flank pain and lower back pain were related to muscle spasms of the lower back and the recent [DIAGNOSES REDACTED]. R1's Physician order [REDACTED]. of pain/muscle spasms: The MEDICATION ORDERS FOR [REDACTED] 10/02/18 -[MEDICATION NAME] 650 mg every 4 hours as needed - (MAR shows administered 6 times from 10/02/18 through 10/10/18) 10/02/18 - [MEDICATION NAME] 5 percent topical patch daily - on in AM off in PM - (MAR shows administered 7 times from 10/02/18 through 10/10/18) 10/02/18 - [MEDICATION NAME] 500 mg 3 times daily as needed - (MAR shows administered 3 times from 10/02/18 through 10/10/18) The MEDICATION ORDERS FOR [REDACTED] 10/10/18 - [MEDICATION NAME] 50 mg every 6 hours as needed - (MAR shows administered 6 times from 10/10/18 through 10/15/18) 10/10/18 - [MEDICATION NAME] 650 mg every 4 hours as needed - (MAR shows administered 6 times from 10/10/18 through 10/15/18) 10/10/18 - [MEDICATION NAME] 500 mg 3 times a day as needed - (MAR shows administered 4 times from 10/10/18 through 10/15/18) 10/10/18 - [MEDICATION NAME] 5 percent topical patch daily - on in AM off in PM - (MAR shows administered 3 times and refused by R1 twice from 10/10/18 through 10/15/18) The MEDICATION ORDERS FOR [REDACTED] 10/15/18 - [MEDICATION NAME] (non-steroidal/anti-[MEDICAL CONDITION] medication) 1 percent topical gel 3 times daily-(MAR shows administered 6 times, refused once from 10/15/18 through 10/17/18) 10/15/18 - [MEDICATION NAME] 50 mg twice daily - (MAR shows administered 4 times and refused once by R1 from 10/15/18 through 10/17/18) 10/15/18 - [MEDICATION NAME] 650 mg twice daily - (MAR shows administered 4 times and refused once by R1 from 10/15/18) The MEDICATION ORDERS FOR [REDACTED] 10/17/18 - [MEDICATION NAME] 5 mg - [MEDICATION NAME] 325 mg (an opioid pain medication) every 4 hours as needed (MAR shows R1 received 2 dose from 10/17/18 through 10/24/18) 10/17/18 - [MEDICATION NAME] 5 mg - [MEDICATION NAME] 325 mg 3 times daily - (MAR shows R1 received 19 of 21 doses from 10/17/18 through 10/24/18) 10/17/18 - [MEDICATION NAME] 500 mg twice daily - (MAR shows R1 received all scheduled doses from 10/17/18 through 10/24/18) 10/17/18 - [MEDICATION NAME] 500 mg once daily as needed. (MONTH) be given one time between scheduled doses - (MAR shows R1 received 2 dose between 10/17/18 and 10/24/18) R1's MAR from 10/02/18 through 10/24/18 documents R1 refused [MEDICATION NAME] 1 percent topical gel 11 times from 10/15/18 through 10/24/18 and refused [MEDICATION NAME] 5 percent topical patch 4 times from 10/14/18 through 10/24/18. On 11/01/18 at 10:10 a.m., V3 (DON - Director of Nursing) stated the reason R1 was refusing the [MEDICATION NAME] and [MEDICATION NAME] was (R1) had gotten into a comfortable position and didn't want to move. The MAR from 10/02/18 through 10/24/18 documents R1 rated R1's pain from none at all to a range of 3 to 6 on a scale of 0 to 10 with 10 being the worst pain. The worst documented pain on R1's MAR indicated [REDACTED]. On the following dates, R1's pain was not rated with the numeric pain scale on the MAR indicated [REDACTED] On 10/31/18 at 1:15 p.m., regarding R1's care on 10/20/18, V13 (Physical Therapy Aide) stated, I worked with (R1) once (since admission on 10/02/18) when (R1) was much higher functioning. On 10/20/18, (R1) was telling me (R1) had a lot of pain. A CNA (Certified Nursing Assistant) was in there (R1's room) and said the day before they had to lower (R1) to the floor (during a transfer). So I tried to imitate a sit to stand transfer just to see how he was. It was just horrendous for (R1). It was just too much. I talked to the nurse about the pain. R1's MDS (Minimum Data Set) assessments for pain were completed by V37 (RN) on 10/09/18, 10/16/18, and 10/22/18. On 10/09/18, R1 reported R1 was frequently having pain rated at 5 out of 10 that made it hard for R1 to sleep and limited R1's day-to-day activities. On 10/16/18, R1 reported R1 was rarely having pain but rated pain as moderate and 7 out of 10. On 10/22/18, R1 reported having severe pain almost constantly. A Daily Medicare assessment dated written by V30 (LPN) on 10/23/18 documents, (R1) remains on (medication) for (Back) strain. Continues to work with therapy. Continues with uncontrolled pain. (As needed) and scheduled pain medication given as well as repositioning and heat and cold pack. All have been non-effective. R1's care plan dated 10/02/18 states, I have pain because of back strain/sprain related to recent falls. Goals: My pain will (be) at a tolerable level. All the interventions to address R1's pain are dated 10/02/18 and include: Monitor and assess me for episodes of pain as needed; Administer pain medications as ordered by my doctor. Refer to PO (Physician Order) sheet, MAR (Medication Administration Record), TAR (Treatment Administration Record); Notify my doctor if my pain is not relieved by my current medications; Position me for comfort to help relieve my pain; Allow me to have rest periods as needed during my ADL (Activities of Daily Living) tasks; Offer me other forms of comfort to promote decreased pain such as food, drink, heat, cold, fluids, repositioning, etc.; Monitor me for non-verbal signs of pain such as facial grimacing, moaning, guarding, or increased behaviors which may indicate pain; Refer me to PT/OT (Physical Therapy/Occupational Therapy) to help with pain control; and ask me every shift if I am having pain and document my responses for tracking. R1's care plan has no new interventions added to address pain since 10/02/18. On 10/30/18 at 2:50 p.m., V8 (RN - Registered Nurse) reported We had been really concerned about (R1's) pain control and had been reaching out to the provider. (After R1 fell on [DATE]) We were able to reach out even more because we felt if (R1) had better pain control (R1) would be more active. (On 10/24/18) (R1) was up in the chair in the dining room yelling and we were not seeing any improvement so we sent him back to the hospital. On 11/01/18 at 12:00 p.m., V8 (RN) stated, I called (V15's - R1's Attending Physician) office (on 10/24/18) ant told the nurse if (R1) couldn't be seen that today (R1) needs to go to the hospital. (V14 Nurse Practitioner) was making changes but it wasn't effective (to address R1's pain). A Progress Note dated 10/17/18, written by V14 (R1's Nurse Practitioner) states, (R1) was discharged on [DATE] back to (the long term care facility). Once back to the nursing home (R1) had increasing in severity of pain and bilateral knee pain (R1) was started on [MEDICATION NAME] and as of today appears to have been non-effective. (R1) is being seen during physical therapy where (R1) is expressing a lot of bilateral knee pain and lower paraspinal spasms and discomfort. On 11/01/18 at 9:35 a.m., regarding R1's pain, V14 (R1's Nurse Practitioner) stated, First [MEDICATION NAME] was started. I don't like to start routine stuff on people when they are not use to taking it. I evaluated (R1) one day in Physical Therapy and changed the muscle relaxer to scheduled (doses). (R1) appeared to be having spasms as well, so pain or spasms or both at the same time. It's hard to tell. After that (10/17/18) I was not notified of any pain issues. I round once a week there and they call if they need anything but after 10/17/18 there was nothing about pain. They called (V15 - R1's Attending Physician) about (R1's) pain and (R1) was sent to the hospital (on 10/24/18). The last SBAR (Situation, Background, Assessment, Recommendation form for communication to doctors/nurse practitioners) addressing R1's pain prior to R1's hospitalization on [DATE] was dated 10/18/18 and faxed to V14 (R1's Nurse Practitioner). The 10/18/18 SBAR stated, Resident appears to be in severe pain with any movement and cries/moans loudly with any movement. V14's hand written response on the form states, Noted: Continue with current meds (medications and) treatments. Continue to offer (as needed) medications. Continue with current ice pack/warm packs. On 11/01/18 at 10:10 a.m., regarding R1's pain management, V3 (DON - Director of Nursing) stated, We felt like we weren't getting answers. (V14 - R1's Nurse Practitioner) called, I'm not sure of the date and was upset about the frequency of SBARs to the office regarding (R1's) pain. (V14) said (R1) needed to continue to get up and move and to continue with Physical Therapy and it was going to take time to heal. (V14) said we needed to allow time for the medication changes to take affect. Even before (R1) was lowered to the floor (an Accident report On 10/19/18 states R1 was lowered to the floor during a gait belt transfer) (R1) was screaming out in pain, refusing meals, refusing [MEDICATION NAME] gel because (R1) didn't want to be repositioned once comfortable in bed. (R1) had severe pain here and yes, it got worse. V3 (DON) indicated neither R1's Attending Physician V15 nor V25 (Medical Director) was contacted about R1's uncontrolled pain until V8 (RN-Registered Nurse) called V15's office on 10/24/18. A Progress Note written by V8 (RN) dated 10/24/18 at 8:37 a.m., states, Spoke with (V15's office) related to severe pain (10 out of 10) that is difficult to manage (back, abdomen, sides). (R1) hollers out in pain, refuses to turn and re-position due to pain, developing pressure injuries, refusing medications, meals and fluids at times. Received okay to send to emergency room for pain management. On 11/01/18 at 10:30 a.m., V15 (R1's Attending Physician) stated on 10/24/18 R1 was Crying out in pain the day they called (10/24/18). (R1) needed sent to the emergency room for evaluation. It sounded awful to me. V15 indicated V14 (Nurse Practitioner) does not work directly with V15 but works in collaboration with V25 (Facility's Medical Director). A History and Physical dictated by V31 (Hospital Physician) dated 10/24/18 states, (R1) was hosptalized on [DATE] in observation unit following a fall (R1) had sustained at home. Was sent to skilled nursing facility for rehab. At that time no vertebral (back bone) fracture were identified as per (back) x-rays. It appears about a week ago (R1) sustained a fall at the nursing facility when (R1) was being transferred from the bed. MRI (Magnetic Resonance Imaging) of the spine done today has shown (bone in the spine between the shoulders and the lower back) T11 vertebral fracture with (Spinal cord narrowing), (Spinal) cord compression, (Spinal) cord [MEDICAL CONDITION]. (R1) appears to be in intractable (hard to control) pain in mid back. Admitting to hospital as an inpatient for pain control.

Based on observation, interview and record review the facility failed to prevent staff to resident mental abuse for one of four residents (R43) reviewed for abuse in a sample of 23. This failure resulted in V19 purposefully slapping the baby doll of a severely cognitively impaired resident in order to rile up the resident causing R43 to suffer emotional distress and agitation. Findings include: An Abuse Prevention Program policy dated 12/2016 states, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. An Abuse and Neglect Prevention Program employee education booklet dated 6/26/18 states, Any employee who becomes aware of perceived, possible or actual abuse/neglect of a resident shall immediately protect the resident from further harm and summon help if needed. Immediately report the incident to Administrator. R43's Minimum Data Set (MDS) assessment dated [DATE] documents that R43 is cognitively impaired. R43's current care plan states, I have confusion/short and long term memory impairment that affects my daily functioning. Provide me comfort and support my current thoughts in a soothing manner, and ensure my safety. I have a baby doll in my room that I like to take care of. Don't touch or rearrange any of my personal items. Provide me with emotional support and reassurance when I am upset. On 8/6/18 at 1:41p.m. R43 was seated in her room in a chair next to her bed. R43 was holding two baby dolls in her arms and a third baby doll was laying on top R43's bedside table. When asked about her baby dolls, R43 became agitated and pulled the baby dolls closer to her body and moved the table with the third doll closer to herself in a protective gesture . R43's abuse investigation dated 6/26/18 documents that on 6/24/18 at 7:00p.m. V20 (Certified Nurse Aide/CNA), V21 (CNA) and V19 (CNA) were in R43's room when V19 stated, Every once in a while I like to rile her up, then proceeded to pick up R43's baby doll and strike it. The investigation states that V43, Was visibly upset, and proceeded to say, No, put it down now. Stop It. The investigation documents that once V1 (Administrator) was notified, an abuse investigation was initiated which substantiated mental abuse to R43 by V19. On 8/8/18 at 3:10p.m. V20 stated that on the evening of 6/24/18 V20, V21, and V19 were in R43's room assisting R43's roommate with care. V20 stated that before they left the room V19 said, Watch this, then V19 proceeded to slap R43's baby doll. V20 stated that R43 has dementia and all staff are aware that V43 considers her three baby dolls her children and doesn't want anyone to touch them. V20 stated that when V20, V19, and V21 left R43's room, V20 asked V19 why she would do such a thing. V20 stated that V19 told V20, She (V19) does it all the time. V20 stated that after V19 slapped R43's doll, R43 was, Very distressed and angry. V20 stated that R43 also became agitated and rocked her baby dolls. V20 stated that she did not report witnessing V19's mental abuse to R43. V20 stated that V19 continued to provide care to residents until the end of her shift at 10:45p.m. On 8/9/18 at 9:10a.m. V21 stated that 6/24/18 was only the second evening he had worked at the facility. V21 also stated that the evening of 6/24/18 was the first time he had met V19. V21 stated that V19 was rude and seemed like, She didn't really want to be here at work. V21 stated that at approximately 8:00p.m. V19, V20, and V21 entered R43's room to provide care to R43's roommate. V21 stated that while they were in R43's room, V19 started discussing, How to keep from being bored during a shift. She looked at R43's baby doll on her box of tissues, which is R43's favorite. R43 says it's too beautiful to touch, and R43 never holds it because she thinks it's so beautiful. R43 has severe dementia and she is very particular about her environment. V21 stated, (V19) said something like,' Every once in a while I like to rile her up,' then she held (R43's) baby doll in her hand and smacked it's head in front of (R43). (R43) said 'Don't do that' and 'No' very sternly. (R43) grimaced and reached for the baby doll. (V19) put the baby doll back down and said to (R43), 'You're fine.' (R43) rocked and coddled the baby doll. That's the only time I've ever seen (R43) hold that baby. I was flabbergasted, astounded someone could do that. I felt horrible for not saying anything, to stop V19. In V19's abuse allegation interview dated 6/25/18 documents that during the interview V19 stated, Oh. Sometimes we toss her dolls on her (R43's) bed and it riles her up. It's kind of cute, but probably not to the resident. Then we have to fix them for her. On 8/9/18 at 11:55a.m. V26 (R43's family) stated that R43 has severe dementia and doesn't even remember the names of R43's children. V26 stated, Those baby dolls are her (R43) everything. Those baby dolls are her children. I know this (slapping the baby doll) would have really disturbed her. She thinks those baby dolls are her babies. On 8/9/18 at 12:39p.m. V2 (Director of Nurses) stated, All staff know (R43) has dementia and considers the dolls as her children. V19 made the decision, even after having dementia training, to say she likes to rile (R43) up by hitting her baby dolls. V2 verified that hitting R43's baby dolls to rile up R43 is mental abuse.

Based on observation, interview, and record review the facility failed to demonstrate staff competency and skill to implement individualized approaches for understanding, prevention and relief of resident stress associated with dementia for one of five residents (R43) reviewed for dementia care in a sample of 23. These failures resulted in R43 suffering emotional distress and agitation when V19(CNA/Certified Nurse Aide) slapped the resident's cherished baby doll in order to purposefully rile her up. Findings include: A Quality of Life- Dignity policy dated 8/2009 states, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall speak respectfully to residents at all times. A Facility dementia training booklet (undated) instructs staff, Reassure her (resident) with words and touch. Being with a person with dementia means understanding things from his or her unique prospective. It is important for us as caregivers to have empathy. Empathy is having awareness of or insight into, the feelings, emotions and behaviors of another person and their meaning and significance. Empathy builds trust; decreases anxiety; restores dignity. when residents feel they are being accepted and acknowledged for what ever the feelings are, anxieties tend to decrease. R43's Minimum Data Set (MDS) assessment dated [DATE] documents that R43 is moderately cognitively impaired. R43's list of current [DIAGNOSES REDACTED]. R43's current care plan states, I have confusion/short and long term memory impairment that affects my daily functioning. Provide me comfort and support my current thoughts in a soothing manner, and ensure my safety. I have a baby doll in my room that I like to take care of. Don't touch or rearrange any of my personal items. Provide me with emotional support and reassurance when I am upset. On 8/6/18 at 1:41p.m. R43 was seated in her room in a chair next to her bed. R43 was holding two baby dolls in her arms and a third baby doll was laying on top R43's bedside table. When asked about her baby dolls, R43 became agitated and pulled the baby dolls closer to her body and moved the table with the third doll closer to herself in a protective gesture . R43's abuse investigation dated 6/26/18 documents that on 6/24/18 at 7:00p.m. V20 (Certified Nurse Aide/CNA), V21 (CNA) and V19 (CNA) were in R43's room when V19 stated, Every once in a while I like to rile her up, then proceeded to pick up R43's baby doll and strike it. The investigation states that V43, Was visibly upset, and proceeded to say, No, put it down now. Stop It. The investigation documents that once V1 (Administrator) was notified, an abuse investigation was initiated which substantiated mental abuse to R43 by V19. On 8/8/18 at 3:10p.m. V20 stated that on the evening of 6/24/18 V20, V21, and V19 were in R43's room assisting R43's roommate with care. V20 stated that before they left the room V19 said, Watch this, then V19 proceeded to slap R43's baby doll. V20 stated that R43 has dementia and all staff are aware that V43 considers her three baby dolls her children and doesn't want anyone to touch them. V20 stated that when V20, V19, and V21 left R43's room, V20 asked V19 why she would do such a thing. V20 stated that V19 told V20, She (V19) does it all the time. V20 stated that after V19 slapped R43's doll, R43 was, Very distressed and angry. V20 stated that R43 also became agitated and rocked her baby dolls. V20 stated that she did not report witnessing V19's mental abuse to R43. V20 stated that V19 continued to provide care to residents until the end of her shift at 10:45p.m. On 8/9/18 at 9:10a.m. V21 stated that 6/24/18 was only the second evening he had worked at the facility. V21 also stated that the evening of 6/24/18 was the first time he had met V19. V21 stated that V19 was rude and seemed like, She didn't really want to be here at work. V21 stated that at approximately 8:00p.m. V19, V20, and V21 entered R43's room to provide care to R43's roommate. V21 stated that while they were in R43's room, V19 started discussing, How to keep from being bored during a shift. She looked at R43's baby doll on her box of tissues, which is R43's favorite. R43 says it's too beautiful to touch, and R43 never holds it because she thinks it's so beautiful. R43 has severe dementia and she is very particular about her environment. V21 stated, (V19) said something like,' Every once in a while I like to rile her up,' then (V19) held (R43's) baby doll in her hand and smacked it's head in front of (R43). (R43) said 'Don't do that' and 'No' very sternly. (R43) grimaced and reached for the baby doll. (V19) put the baby doll back down and said to (R43), 'You're fine.' (R43) rocked and coddled the baby doll. That's the only time I've ever seen (R43) hold that baby. I was flabbergasted, astounded someone could do that. I felt horrible for not saying anything, to stop V19. In V19's abuse allegation interview dated 6/25/18 documents that during the interview V19 stated, Oh. Sometimes we toss her dolls on her (R43's) bed and it riles her up. It's kind of cute, but probably not to the resident. Then we have to fix them for her. On 8/9/18 at 11:55a.m. V26 (R43's family) stated that R43 has severe dementia and doesn't even remember the names of R43's children. V26 stated, Those baby dolls are her (R43) everything. Those baby dolls are her children. I know this (slapping the baby doll) would have really disturbed her. She thinks those baby dolls are her babies. On 8/9/18 at 12:39p.m. V2 (Director of Nurses) stated, All staff know (R43) has dementia and considers the dolls as her children. V19 made the decision, even after having dementia training, to say she likes to rile (R43) up by hitting her baby dolls. V2 verified that hitting R43's baby dolls to rile up R43 is mental abuse.

Based on observation, interview, and record review, the facility failed to monitor and implement interventions to promote the healing of pressure ulcers and prevent development of new pressure ulcers for one of two residents (R2) at risk for developing pressure ulcers in the sample of fifteen. This failure resulted in the pressure ulcer on R2's heel progressing from a Stage II to Stage III pressure ulcer. Findings include: R2's medical record documents R2 has the current [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) Assessment, dated 5-30-14, documents R2 requires extensive assist of two for bed mobility and is totally dependent on staff for transfers and ADL's (Activities of Daily Living). R2's Braden Skin Assessment, dated 1/15/14, documents a Braden score of 13 ( moderate risk). R2's Progress Note dated 10/4/13, documents R2 was noted to have a new open area on left coccyx that measures 3.8 cm x 3.3 cm and the facility failed to identify the Stage of the wound. R2's Plan of Care fails to document the development of new interventions to prevent further skin breakdown, until 10/30/13, when R2 visited the Wound Clinic and added a nutritional supplement. The facility's Progress Note for R2 dated 5-2-14 documents, R2 developed a skin tear on the left heel. The facility's Wound assessment dated [DATE] documents, R2's skin tear had developed into a Stage II pressure ulcer to left inner heel measuring 1.2 cm x 1.5 cm x 0.5 cm. A Wound Clinic Report dated 6-25-14, documents R2's coccyx wound as increasing in size and Stage, from a Stage III with no tunneling on 10/30/13, to a Stage IV with tunneling of 2.3 cm on 6/25/14. The Wound Clinic Report dated 6/25/14 also documents (R2) as very debilitated and incontinent, secondary to advanced dementia and describes R2's wound as "deteriorating." The Wound Clinic Report dated 6/25/14 documents R2's left heel wound as a Stage III. R2's Plan of Care failed to document the development of any interventions to prevent R2's wounds from worsening, after the 6/25/14 Wound Clinic visit which identified the coccyx wound as "deteriorating." On 7-1-14 at 11:30 am, R2 received incontinence care and has a small open area with evidence of tunneling on the left coccyx. Also R2 has an open wound on R2's left heel. On 7-2-14 at 11:00 am, E10 (MDS/Minimum Data Set Coordinator) verified R2 started out with a skin tear to the left heel which has now resulted in a pressure ulcer. On 7-3-14 at 9:30 am, E11 (RN/Registered Nurse, Quality Nurse) indicated R2 did not eat well and was receiving supplements, and described R2 as being contracted and unable to reposition independently. E11 indicated these issues have made R2's pressure ulcers unavoidable. However, R2's weight monitoring for the last 12 months documents R2's weight as being stable at 123 pounds. R2's Care Plan for Impaired Skin Integrity documents R2 is to be turned side to side every two hours. E11 was unable to provide documentation that R2 was turned side to side every two hours as instructed on R2's care plan. On 7-2-14 at 3:15 pm, Z1 (Wound Physician) stated, "(R2) has Senile Dementia and is bedridden" and had no other explanation to suggest R2's pressure ulcers were unavoidable. Z1 also verified R2's wound to R2's coccyx has worsened from a Stage III to a Stage IV and R2's heel wound was now a Stage III Pressure Ulcer. A Pressure Ulcer Prevention and Management Policy dated 5/28/14 documents, "(The facility) actively intervenes to prevent/limit the development of pressure ulcers and to promote and maintain skin integrity."

Based on observation, record review and interviews, the facility failed to use two staff members to assist with a mechanical lift transfer as required by the resident ' s care plan and facility policy for one (R1) of five residents utilizing mechanical lifts for transfer. R1 was transferred using a sit-to-stand mechanical lift and slipped off the platform on two separate occasions, the second occurring two days after the first. This failure resulted in an immediate jeopardy. R1 sustained severe back pain and an overall decline in function. While the immediacy was removed on [DATE], the facility remains out of compliance at severity Level Two. Additional time is needed for the facility to complete staff education and re-education on transfer status policy and procedure and care plan familiarization, change and review and for the facility to monitor effectiveness of the plan. Findings include: The facility policy titled, " Limited Lift Resident Transfers " and revised [DATE], states, " Nursing staff will transfer residents according to their transfer status as assessed by therapy or neighborhood coordinator. 3. resident's transfer status will be posted in the resident's room on the inside foot board of their bed. Resident transfer status is to be checked before every transfer is initiated. Transfer is to be completed according to the resident transfer status. Transfer status will also be listed on the care plan and in the CNA(Certified Nurse Aide) instructions. If no transfer status is posted or if transfer status is uncertain in any way caregiver is to check with the nurse first, before initiating transfer. 12. This policy is to be followed at all times. Failure to adhere to the policy will result in disciplinary action by the criteria below unless the Administrator/DON deem the situation requires further immediate disciplinary action. The facility policy, titled " Incident Reports " and revised [DATE], states, " Incident reports will be completed on residents when the following have occurred either in-house or off the campus: 1. Falls, witnessed or unwitnessed ...4. Any behavior, situation or injury with possible indicator of abuse, or anything out of the ordinary for the resident. PURPOSE: to document the details of the incident, to ascertain the root cause, and to prevent recurrence. PROCEDURE: 1. Complete incident report: Provide and accurate description of the incident along with any witnesses. Interview staff, residents, or any that may have knowledge of incident. Complete report thoroughly, with no missing info. Document thoroughly in the progress notes matching the incident report. Place resident on focus charting for at least three days. R1's MDS (Minimum Data Set) Assessment, dated [DATE], documents R1 to be [AGE] years of age with [DIAGNOSES REDACTED]. The MDS noted R1 at six feet two inches tall, 241 pounds, to be non-ambulatory, requiring extensive two plus person physical assist for bed mobility, dressing, bathing, toileting and transferring. R1's care plan, dated [DATE], documents R1's transfer status required a sit to stand device plus two-person assist. R1's care plan also includes the problem of pain due to Osteoarthritis in the knees, lower back and shoulders. There are no Nursing Notes in R1's medical record from [DATE] to [DATE]. Nursing Note, written by E4 (RN/Registered Nurse) and dated [DATE] at 7:45 AM, states, "As (R1) was being transferred from sit to stand onto bed, his legs slipped off lift. Assisted with staff times three to correct position of legs back onto lift to complete transfer. Resident assessed, no reddened areas noted to upper or lower back and legs. (R1) complain of lower back pain, scheduled pain meds administered with relief noted. (R1) said (R1) felt better after lying down. Will continue to monitor." The note states it is a late entry for [DATE]. The facility incident/investigation, dated [DATE], includes the following documentation by (E2/DON/Director of Nursing), "Talked with (E8/CNA) regarding episode on the 29th of October with (R1). At approx. ,[DATE] pm (R1) was in bathroom with (sit to stand mechanical lift). (R1) is a two-person assist. (E8) 'Did not look where (R1's) feet placement was' or know that (R1) was a two person assist. 'I (E8) did not look at the end of the bed.' When (E8) got (R1) to the center of the bed, (R1's) feet slipped off back of lift, leaving (R1) semi hanging on the lift and feet (toes) on the floor. (E8) immediately yelled for help, the two nurses (E4/RN and E5/LPN/Licensed Practical Nurse) assisted (E8) with helping (R1) into bed. (R1) had no injuries, but did complain of (R1's) underarms hurting. Slight redness noted but no skin abrasions. (R1) had no other pain at that time." On ?????????????????[DATE] at 10:35 am, E2 confirmed that E8 was the only person interviewed by E2 regarding the incident involving R1 on [DATE]. At 1:50 pm on [DATE] E4 (RN/Registered Nurse) stated the following in regards to the [DATE] approximately 8:30 pm incident with (R1), "(E8/CNA) yelled my name from (R1's) room. I and (E5/LPN/Licensed Practical Nurse) went up the hall. (R1's) feet had slipped off and he was hanging by the handrails. (E5) and I got his feet back on while (E8) ran the lift. (R1's) care plan says two-person assist for transfer with the lift. The belt was still on and the straps were still connected. (R1) was complaining of back pain at that time. There should have been three-day focus charting for that incident. I noticed that I forgot to chart so I did that back note on the 31st for the 29th." On [DATE] at 3 PM, E2 (DON/Director of Nursing) stated, "This is the room and the bed (R1) was using during the [DATE] transfer incident. The foot of the bed was marked transfer with two right here. (E8/CNA) didn't look here to see (R1) was a two-person transfer. (E8) hadn't worked with (R1) for a long time. They don't have to look at the care plan. They just have to look at the foot of the bed." The sticker that documented that R1 required the assistance of two people for the mechanical lift transfer remained on the footboard of the bed in the room once occupied by R1. On [DATE] at 3:10 pm, E5 (LPN) stated, "I was going down the hall when I and (E4/RN) heard (E8/CNA) yell. We both went to find (R1) hanging off the lift with the belt up around under (R1's) armpits. We maneuvered his feet back on. One side at a time. There was a red mark under his left arm." The statement was in regards to the [DATE] incident involving R1. On [DATE] at 3:18 PM, E8 (CNA) stated, "I took (R1) to the bathroom on the sit to stand lift and was coming back to the bed when his foot slipped off and continued to go on when the other foot started to go off, too. The nurses came to help as (R1) was hanging on the lift. The lift pad was under his armpits instead of around his waist. It was tight. (R1) was a one-person assist as far as I knew. The DON (E2) talked to me a couple of days later that (R1) was a two person. First time I worked with him in about a year. Yes, it is marked on the bed. The last time I was over there, he was a one person. I can look on the care plan system but some areas are restricted. CNA's pass that information on. Usually. That was the only night I worked there." Nursing Note in R1's medical record, dated [DATE] at 2:00 PM states, "Note: (R1) has continued to complain of low back pain. Had scheduled pain pills this /AM. Pain meds help, as long as (R1) doesn't move any. CNAs stood (R1) up with sit to stand, I ((E12/LPN/Licensed Practical Nurse) happened to walk into room during transfer with (R1) on sit to stand. (R1) standing very poor....Knees were buckled, feet with one on top of other, and arms with elbows pointing towards the ceiling. Talked with E20 (RN/Restorative) suggested we use (full mechanical) lift for transfers at this time. (E11/R1's Medical Doctor in a meeting) (Z2/E11's nurse) Will call back if (E11 available). " The note is signed by E12 (LPN). On [DATE] at 10:25 AM, E12 (LPN) stated, "They were standing (R1) up with the sit to stand and (R1) had no strength. (R1) couldn't tolerate it. His elbows were pointing at the ceiling, not holding on to the handles. His knees were buckled," in regards to the incident on [DATE]. On [DATE] at 10:30 am, Z2 (E11/nurse at R1's Medical Doctor's office) stated, "I don't have any record of a call from the facility on the 29th. Facility called here on [DATE] and left message that (R1) was having a lot of lower back pain. When I called back, they mentioned (R1) was on a sit-to-stand lift and R1 ' s feet had slipped off and jarred him, possibly hurting it then, and now is leaning to one side. Did not say when that happened. Is on Norco and Fentanyl patch. No calls about [DATE] that I know of. No. No mention of a second incident." On [DATE] at 1:55 PM, E10/CNA reported the following in regards to the incident of [DATE] involving (R1): "(E13/CNA) and I were transferring (R1). I recall (R1) was hooked up fine but when we started to raise the sling (R1) started to slide. The sling slid up. We tried to tighten/shorten the strap and that is when the nurse stopped by. (R1) said, 'You're hurting my back.' I didn't know about any previous incident with the lift. I didn't notice where his feet were. But, I did see his elbows go up. I knew he (R1) wasn't holding on. (R1) was like, too weak to bear weight. Then, I guess his knees did buckle. He was dangling for a second until we got him set back down. That's when the nurse (E12/LPN) decided to change him to a (full mechanical lift)." R1 ' s care plan includes no new interventions related to transfers on or after [DATE]. On [DATE] at 2:15 pm, E2 stated, "No, I don't have an investigation for the [DATE] incident involving R1, but I will make you one if you want me to." R1's CNA notes document R1 was not transferred from his bed after [DATE] at 5:06 pm. After that date, R1 was only turned and repositioned in the bed. R1's Nursing Notes document the following: [DATE] at 3:25 am, (R1) refused shower due to lower back pain; [DATE] at 6:28 pm, (R1) didn't eat dinner after given 4 units of insulin, had poor appetite, stomach appeared distended; [DATE] at 1:54 pm, Urine is cloudy, greenish-gray, foul odor, with sediment present, start Levaquin 250 milligrams once daily times ten days; [DATE] at 2:45 am (R1) fidgety and restless, increased confusion, stated water's running out of the toilet onto the floor, explained to resident there wasn't any water on the floor; [DATE] at 11:02 am called to doctor about restlessness, continued wheezing and confusion, sweating, and distended abdomen; [DATE] 2:47 pm Dr (doctor) orders for IV fluids; [DATE] at 3:16 pm vomited minimal amount; [DATE] at 3:40 pm increasing temperature and minimal vomiting; [DATE] at 3:03 am complain pain to back and legs, Morphine given; [DATE] at 6:51 pm resident placed on comfort care; [DATE] at 9:20 am atropine drops due to heavy secretions; [DATE] at 12:39 am (R1) expired. On [DATE] at 9:00 am, an Immediate Jeopardy was identified to have begun on [DATE] at approximately 8:30 pm when facility staff failed to follow facility policies and R1 ' s care plan related to mechanical lift transfers. In addition, the facility did not reassess R1's transfer status to identify new interventions to prevent further similar incidents. The failures resulted in R1 having another incident regarding a mechanical lift transfer two days later and experiencing severe back pain and a decline in condition. E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 1:50 pm. The surveyor confirmed through observation and record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1. A review of policy and procedure concerning lifts and resident transfer status. Completed [DATE] by the Director of Nurses. 2. All Nursing staff will be educated and re-educated on transfer status policy and procedure and care plan familiarization, change and review. Initiated [DATE]. Responsible staff include Staff Educator, Quality Assurance Nurses, Director of Nurses and the Charge Nurses. 3. Nursing staff will be checked on a random basis, once per day for the next two weeks for proper knowledge of the care plan and proper transfer status and lift usage with return demonstration. Initiated: [DATE] Responsible staff: DON 4. Nursing staff will be checked on a random basis, once per week for the next two months for proper knowledge of the care plan and proper transfer status and lift usage with return demonstrations. Initiated: [DATE] 5. Education on transfer status policy and procedure and care plan familiarization, change and review will be included as part of the annual in-service and orientation for nursing employees. Initiated: [DATE]Responsible staff: DON

Based on record review and interview, facility staff failed to follow proper transfer guidelines for utilization of a mechanical sit-to-stand lift for one of five residents (R1) reviewed for transfers using a mechanical lift. This failure resulted in an Immediate Jeopardy. R1 slipped off the platform and sustained severe back pain and an overall decline in condition as a result. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at severity Level Two. Additional time is needed for the facility to complete staff education and re-education on transfer status policy and procedure and care plan familiarization, change and review. Findings include: The facility policy titled, " Limited Lift Resident Transfers " and revised [DATE], states, " Nursing staff will transfer residents according to their transfer status as assessed by therapy or neighborhood coordinator. 3. resident's transfer status will be posted in the resident's room on the inside foot board of their bed. Resident transfer status is to be checked before every transfer is initiated. Transfer is to be completed according to the resident transfer status. Transfer status will also be listed on the care plan and in the CNA (Certified Nurse Aide) instructions If no transfer status is posted or if transfer status is uncertain in any way caregiver is to check with the nurse first, before initiating transfer. 12. This policy is to be followed at all times. Failure to adhere to the policy will result in disciplinary action by the criteria below unless the Administrator/DON deem the situation requires further immediate disciplinary action: 1st violation- written warning, which may include suspension dependent on the circumstance and discretion of DON. Any staff member not reporting a violation will also receive this disciplinary action. 2nd violation-will result in termination-NO EXCEPTIONS." The facility policy, titled " Incident Reports " and revised [DATE], states, " Incident reports will be completed on residents when the following have occurred either in-house or off the campus: 1. Falls, witnessed or un-witnessed, any behavior, situation or injury with possible indicators of abuse, or anything out of the ordinary for the resident. PURPOSE: to document the details of the incident, to ascertain the root cause, and to prevent recurrence. PROCEDURE: 1. Complete incident report: Provide and accurate description of the incident along with any witnesses. Interview staff, residents, or any that may have knowledge of incident. Complete report thoroughly, with no missing information, document thoroughly in the progress notes matching the incident report. Place resident on focus charting for at least three days. The facility incident report for R1, dated [DATE], states, "(8:30 pm, Estimated) Accident Reason: Misuse of Equipment........Details: (R1) is transfer assist of 2 with sit to stand. During transfer with 1 CNA (Certified Nursing Assistant), (R1's) feet came off of platform. (R1) holding on to hand grips with sling around upper chest/waist. Responsible party: (E8/CNA/Certified Nurse Aide) Statements: (E4/RN/Registered Nurse) 'I was down hall when I heard someone yelling my name. As I approached (R1's) room (E8) said she needed help. (R1's) feet slipped off the platform of the sit to stand lift. (R1) was in front of bed, sling in place, (R1 ' s) hands on grips of lift. I and (E5/LPN/Licensed Practical Nurse) assisted (E8) in positioning (R1) feet on platform correctly while (E8) ran lift. After (R1) was positioned on bed, no bruising or red areas noted to upper and lower extremities. (E11/R1's Medical Doctor) notified [DATE], (Z5/POA/Power of Attorney) notified [DATE]." There are no Nursing Notes in R1's medical record from [DATE] to [DATE]. Nursing Note, written by E4 (RN/Registered Nurse) and dated [DATE] at 7:45 AM, states, "As (R1) was being transferred from sit to stand onto bed, his legs slipped off lift. Assisted with staff times three to correct position of legs back onto lift to complete transfer. Resident assessed, no reddened areas noted to upper or lower back and legs. (R1) complain of lower back pain, scheduled pain meds administered with relief noted. (R1) said (R1) felt better after lying down. Will continue to monitor." The note states it is a late entry for [DATE]. At 1:50 pm on [DATE] E4 (RN/Registered Nurse) stated the following in regards to the [DATE] approximately 8:30 pm incident with (R1), "(E8/CNA) yelled my name from (R1's) room. I and (E5/LPN/Licensed Practical Nurse) went up the hall. (R1's) feet had slipped off and he was hanging by the handrails. (E5) and I got his feet back on while (E8) ran the lift. (R1's) care plan says two-person assist for transfer with the lift. The belt was still on and the straps were still connected. (R1) was complaining of back pain at that time. There should have been three-day focus charting for that incident. I noticed that I forgot to chart so I did that back note on the 31st for the 29th. On [DATE] at 3:10 pm, E5 (LPN) stated, "I was going down the hall when I and (E4/RN) heard (E8/CNA) yell. We both went to find (R1) hanging off the lift with the belt up around under (R1's) armpits. We maneuvered his feet back on. One side at a time. There was a red mark under his left arm." The statement was in regards to the [DATE] incident involving R1. On [DATE] at 3:18 PM, E8 (CNA) stated, "I took (R1) to the bathroom on the sit to stand lift and was coming back to the bed when his foot slipped off and continued to go on when the other foot started to go off, too. The nurses came to help as (R1) was hanging on the lift. The lift pad was under his armpits instead of around his waist. It was tight. (R1) was a one-person assist as far as I knew. The DON (E2) talked to me a couple of days later that (R1) was a two person. First time I worked with him in about a year. Yes, it is marked on the bed. The last time I was over there, he was a one person. I can look on the care plan system but some areas are restricted. CNA's pass that information on. Usually. That was the only night I worked there." On [DATE] at 3 PM, E2 (DON/Director of Nursing) stated, "This is the room and the bed (R1) was using during the [DATE] transfer incident. The foot of the bed was marked transfer with two right here. (E8/CNA) didn't look here to see (R1) was a two-person transfer. (E8) hadn't worked with (R1) for a long time. They don't have to look at the care plan. They just have to look at the foot of the bed." At that time the sticker that documented that R1 required the assistance of two people for the mechanical lift transfer remained on the footboard of the bed in the room once occupied by R1. R1's MDS (Minimum Data Set) Assessment, dated [DATE], documents R1 to be [AGE] years of age with [DIAGNOSES REDACTED]. The MDS noted R1 at six feet two inches tall, 241 pounds, to be non-ambulatory, requiring extensive two plus person physical assist for bed mobility, dressing, bathing, toileting and transferring. R1's care plan, dated [DATE], documents R1's transfer status required a sit to stand device plus two-person assist. R1's care plan also includes the problem of pain due to [MEDICAL CONDITION] in the knees, lower back and shoulders. Nursing Note in R1's medical record, dated [DATE] at 2:00 PM states, "Note: (R1) has continued to complain of low back pain. Had scheduled pain pills this /AM. Pain meds help, as long as (R1) doesn't move any. CNAs stood (R1) up with sit to stand, I ((E12/LPN/Licensed Practical Nurse) happened to walk into room during transfer with (R1) on sit to stand. (R1) standing very poor....Knees were buckled, feet with one on top of other, and arms with elbows pointing towards the ceiling. Talked with E20 (RN/Restorative) suggested we use (full mechanical) lift for transfers at this time. (E11/R1's Medical Doctor in a meeting) (Z2/E11's nurse) Will call back if (E11 available). " The note is signed by E12 (LPN). On [DATE] at 10:25 AM, E12 (LPN) stated in regards to the incident on [DATE], "They were standing (R1) up with the sit to stand and (R1) had no strength. (R1) couldn't tolerate it. His elbows were pointing at the ceiling, not holding on to the handles. His knees were buckled." On [DATE] at 10:40 am, E2 stated, "No, I don't have an investigation for the [DATE] incident involving R1, but I will make you one if you want me to." E2 also stated that if a resident is using the lift, the resident ' s elbows can ' t point up if he/she is holding on to the handles because the handles point down. On [DATE] at 10:30 am, Z2 (E11/nurse at R1's Medical Doctor's office) stated, "I don't have any record of a call from the facility on the 29th. Facility called here on [DATE] and left message that (R1) was having a lot of lower back pain. When I called back, they mentioned (R1) was on a sit-to-stand lift and R1 ' s feet had slipped off and jarred him, possibly hurting it then, and now is leaning to one side. They did not say when that happened. Is on [MEDICATION NAME] and [MEDICATION NAME]. No calls about [DATE], that I know of. No. No mention of a second incident." E2 (DON) stated on [DATE] at 10:35 pm, "We are supposed to notify the Doctor and the family right away when there is an incident. If the 31st is what the report says, then I don't know why they waited until the 31st for (R1's) incident of the 29th. I don't know why." On [DATE] at 1:55 PM, E10/CNA reported the following in regards to the incident of [DATE] involving (R1), "(E13/CNA) and I were transferring (R1). I recall (R1) was hooked up fine but when we started to raise the sling (R1) started to slide. The sling slid up. We tried to tighten/shorten the strap and that is when the nurse stopped by just as (R1) said, 'You're hurting my back.' I didn't know about any previous incident with the lift. I didn't notice where his feet were. But, I did see his elbows go up. I knew he (R1) wasn't holding on. (R1) was like, too weak to bear weight. Then, I guess his knees did buckle. He was dangling for a second until we got him set back down. That's when the nurse (E12/LPN) decided to change him to a (full mechanical lift)." R1 ' s care plan includes no new interventions related to transfers on [DATE]. On [DATE] at 3:10 pm E3 Care Plan Coordinator confirmed that R1 ' s care plan was not updated after the first incident and stated, "The only change is after the second incident (on [DATE] at 2:00 pm) when we asked to change to the (full mechanical lift)." R1's CNA notes document R1 was not transferred from his bed after [DATE] at 5:06 pm. After that date, R1 was only turned and repositioned in the bed. R1's Nursing Notes document the following: [DATE] at 3:25 am, (R1) refused shower due to lower back pain; [DATE] at 6:28 pm, (R1) didn't eat dinner after given 4 units of insulin, had poor appetite, stomach appeared distended; [DATE] at 1:54 pm, Urine is cloudy, greenish-gray, foul odor, with sediment present, start [MEDICATION NAME] 250 milligrams once daily times ten days; [DATE] at 2:45 am (R1) fidgety and restless, increased confusion, stated water's running out of the toilet onto the floor, explained to resident there wasn't any water on the floor; [DATE] at 11:02 am called to doctor about restlessness, continued wheezing and confusion, sweating, and distended abdomen; [DATE] 2:47 pm Dr (doctor) orders for IV fluids; [DATE] at 3:16 pm vomited minimal amount; [DATE] at 3:40 pm increasing temperature and minimal vomiting; [DATE] at 3:03 am complain pain to back and legs, [MEDICATION NAME] given; [DATE] at 6:51 pm resident placed on comfort care; [DATE] at 9:20 am [MEDICATION NAME] drops due to heavy secretions; [DATE] at 12:39 am (R1) expired. The facility incident/investigation, dated [DATE], includes the following documentation by (E2/DON/Director of Nursing), "Talked with (E8/CNA) regarding episode on the 29th of October with (R1). At approx. ,[DATE] pm (R1) was in bathroom with (sit to stand mechanical lift). (R1) is a two-person assist. (E8) 'Did not look where (R1's) feet placement was' or know that (R1) was a two person assist. 'I (E8) did not look at the end of the bed.' When (E8) got (R1) to the center of the bed, (R1's) feet slipped off back of lift, leaving (R1) semi hanging on the lift and feet (toes) on the floor. (E8) immediately yelled for help, the two nurses (E4/RN and E5/LPN/Licensed Practical Nurse) assisted (E8) with helping (R1) into bed. (R1) had no injuries, but did complain of (R1's) underarms hurting. Slight redness noted but no skin abrasions. (R1) had no other pain at that time." On [DATE] at 3:10 PM, E2 confirmed that E8 was the only person interviewed by E2 regarding the incident involving R1 on [DATE]. On [DATE] at 9:00 am an Immediate Jeopardy was identified to have begun on [DATE] at 8:30 pm when E8/CNA ignored the intervention notice taped to the end of R1 ' s bed and transferred R1 alone rather than obtaining assistance in order to have two staff members to do the transfer, as outlined in R1 ' s care plan and on the notification on R1 ' s bed. The situation continued when facility staff failed to follow facility policies related to incident reporting and care plan updates. In addition, the facility did not reassess R1's transfer status to identify new interventions to prevent further similar incidents. The failures resulted in R1 having another incident regarding a mechanical lift transfer two days later and experiencing severe back pain and a decline in condition. E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 1:50 pm. The surveyor confirmed through observation and record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1. A review of policy and procedure concerning lifts and resident transfer status. Completed [DATE] by the Director of Nurses. 2. All Nursing staff will be educated and re-educated on transfer status policy and procedure and care plan familiarization, change and review. Initiated [DATE]. Completed [DATE]. Responsible staff include Staff Educator, Quality Assurance Nurses, Director of Nurses and the Charge Nurses. 3. Nursing staff will be checked on a random basis, once per day for the next two weeks for proper knowledge of the care plan and proper transfer status and lift usage with return demonstration. Initiated: [DATE] 4. Nursing staff will be checked on a random basis, once per week for the next two months for proper knowledge of the care plan and proper transfer status and lift usage with return demonstrations. Initiated: [DATE] 5. Education on transfer status policy and procedure and care plan familiarization, change Initiated: [DATE] and review will be included as part of the annual in-service and orientation for nursing employees.