Every finding on record at Radford Green

Based on observation, interview and record review the facility failed to provide timely incontinence care for residents who require extensive assistance with activities of daily living for 2 of 18 residents (R4 and R42) reviewed for activities of daily living in the sample of 18. This failure resulted in R4 developing MASD (Moisture Associated Skin Damage) with open wounds to the sacral area. The findings include: 1.R4's Minimum Data Set assessment dated [DATE] shows that his cognition is severely impaired, is always incontinent of urine and stool and is dependent on staff for toileting and personal hygiene. On 4/13/26 at 10:44 AM, V16 (Certified Nursing Assistant/CNA) went in to provide incontinence care to R4. R4's incontinence brief was saturated and the sheet underneath R4 was wet. R4's buttock was reddened and had multiple open wounds present. V16 said that R4 was last changed with the help of the night shift around 6:45-7:00 AM. On 4/14/26 at 2:06 PM, V17 (CNA) said that all incontinent residents should be checked and changed every two hours. R4's Skin Check from 4/7/26 shows that R4 has generalized redness to his coccyx but does not document any open wounds or MASD. R4's Wound Evaluation and Management Summary dated 4/15/26 shows that R4 has Moisture Associated Skin Damage measuring 7.0 centimeters (cm) x 6 cm x 0.1 cm (Surface Area of 42 cm squared) with open areas with exposed dermis of 21 cm squared.On 4/15/26 at 10:35 AM, V18 (Wound Physician) said that he just saw R4 and R4 has a cluster of wounds on his bottom that were caused by MASD. V18 said that they were not present when he saw him the week prior. V18 said that R4 is incontinent, and the wounds are caused by prolonged moisture. V18 said that the wounds could have developed from R4 being wet for a long period of time. V18 said that the facility needs to make sure that R4 is being provided incontinence care and repositioned frequently.2. R42's Minimum Data Set assessment dated [DATE] shows that she is cognitively impaired, incontinent of urine and stool and is dependent on staff for toileting and personal hygiene. On 4/13/26 at 2:58 PM, V16 (CNA) provided incontinence care to R42. R42's incontinence brief was saturated and the sheet under her was wet. R42's buttock was reddened and had an open wound present. V16 said that she last changed R42 at breakfast time. On 4/14/26 at 2:06 PM, V17 (CNA) said that all incontinent residents should be checked and changed every two hours. R42's current Care Plan shows, [R42] has bowel and bladder incontinence and is dependent on staff for toileting hygiene. Provide incontinence care in a timely manner.The facility's Activities of Daily Living Policy shows, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: hygiene.elimination.

Based on interview and record review the facility failed to ensure discharge MDS (Minimum Data Set) assessments were completed for discharged residents. This applies to 4 of 4 residents (R29, R54, R81, R83) reviewed for resident assessments in the sample of 18. The findings include: 1.R29's face sheet shows she was admitted to the facility on [DATE] and discharged on 12/28/25. On 4/15/26, R29's MDS shows her discharge assessment was not completed (greater than 100 days). 2. R54's face sheet shows she was admitted to the facility on [DATE] and discharged on 03/16/26. 3. R81's face sheet shows she was admitted to the facility on [DATE] and discharged on 3/20/26. 4. R83's face sheet shows she was admitted to the facility on [DATE] and discharged on 3/20/26. The facility's MDS report provided on 4/15/26, shows R54, R81, R83's discharge assessments were not completed/submitted within 14 days of discharge. On 4/15/26 at 10:05 AM, V10 (MDS Nurse) said the facility has certified 84 beds. If there are more residents listed in IQES it's probably because residents are not being discharged timely. We have to submit MDS discharge assessments within 14 days. There's been a miscommunication issue not discharging residents timely. She runs a monthly report of the missed assessments, and she is in the process of completing the missed discharge assessments. We have to be more diligent completing the discharge assessment in the MDS. V10 confirmed R54, R81 and R83's discharge assessments were not completed within 14 days of discharge and said she was not aware of R29's discharge not being completed. The facility's Discharge Assessments Policy dated 2023 states, A discharge MDS assessment is completed whenever a resident is physically discharged from the facility.a discharge assessment is completed when a resident is discharged from the facility and the resident is not expected to return.is completed within 14 days after the discharge date .

Based on observation, interview and record review the facility failed to identify, assess and implement treatment after a resident developed a stage two pressure ulcer, failed to ensure pressure ulcer prevention interventions were in place and failed to ensure low air loss mattresses were functioning and set to the appropriate settings for 4 of 7 residents (R1, R4, R11 and R42) reviewed for pressure ulcers in the sample of 18. The findings include: 1.On 4/13/26 at 2:58 PM, V16, (Certified Nursing Assistant/CNA) and V17 (CNA) went provided incontinence care to R42. R42 had an open wound on her coccyx. There was no dressing present on the wound or in the incontinence brief. On 4/14/26 at 2:00 PM, V21 (Registered Nurse) and V9 (Clinical Nurse Manager) went into R42's room to do a skin check. R42 still had the open wound to her coccyx with no dressing in place. V21 stated, That must be new because it was not there earlier. This surveyor notified V21 that it was there on 4/13/26. V21 stated, No one told me about it. There was no documentation regarding R42's coccyx wound from when it was first observed on 4/13/26 at 2:58 PM and when it was observed on 4/14/26 at 2:00 PM. R42's Hospice Notes dated 4/15/26 shows, Patient has new opening to coccyx or sacral region stage 2. Wound measures 1 cm (centimeter) x 3.5 cm x 0.1 cm, no drainage, 100 percent granulation tissue. On 4/15/26 at 9:50 AM, V2 (Director of Nursing) said that if a CNA sees a new wound, they should notify the nurse right away. V2 said that the nurse would then immediately assess the wound and call the provider for treatment orders. 2.On 4/13/26 at 10:03 AM, R4 was laying in bed sleeping. R4's heels were directly on the mattress and the bottoms of his feet were touching the foot board. R4's heel protector boots were sitting in a chair in R4's room. At 10:44 AM, R4 was in the same position and his heel protector boots were still on the chair. On 4/14/26 at 1:45 PM, V9 (Clinical Nurse Manager) said that R4 has a wound to his foot. V9 said that R4 is at risk for pressure and has pressure relieving boots that should be worn at all times when he is in bed. V9 said that R4 does not refuse to wear his pressure relieving boots. R4's Care Plan shows, [R4] is at risk for alteration in skin integrity due to bed-chair confinement, need for assistance with transfers/repositioning. off-load heels as applicable R4's Wound Evaluation and Management Summary dated 4/15/26 shows that R4 has a dry blister to his right lateral foot measuring 1.5 centimeters (cm) x 1.1 cm with an etiology undetermined or unknown. The same report shows that the support surface for R4's feet is off-loading. 3. R1's wound report dated 4/8/26 showed R1 had a stage 3 pressure injury to her left buttock and a stage 2 pressure injury to her right buttock. A physician order dated 3/11/26 showed an order for R1 to be on a low-air-loss mattress (LAL) due to her pressure injuries. On 4/13/26 at 9:36 AM, R1 was in bed, lying on a LAL mattress; however, the LAL mattress was powered off. The mattress appeared deflated. On 4/14/26 at 8:30 AM, R1 was asleep in bed. R1's LAL mattress was powered off and appeared deflated. On 4/14/26 at 8:45 AM, V8 (Licensed Practical Nurse/LPN) stated R1 requires a LAL mattress because of the pressure injuries she has to her buttocks. V8 stated nurses should be checking to make sure LAL mattresses are turned on and functioning every shift. V8 stated, If the mattress is not turned on, it's just a regular mattress. It won't off-load areas of pressure or take pressure off areas with injuries. The facility's Support Services Guidelines policy dated September 2025 showed, Redistributing support services are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. 4. On 4/13/26 at 9:51 AM, and again on 4/14/26 at 10:02 AM, R11 was lying in bed on top of a low air loss mattress. At the end of the bed was the mattress control box which controlled the mattress being on and off and the weight settings. R11's mattress was set for 200 pounds (lbs.) R11 presented as very thin and fragile. R11's care plan shows she has a pressure injury to her coccyx. R11's weight summary shows R11s weight on 3/7/26 was 76.2 lbs. On 4/14/26 at 1:39 PM, V9 (Clinical Nurse Manager) said the air mattress should be set to a residents weight and the nurses are the people responsible to make sure the settings are correct and the device is powered on. On 4/14/26 at 2:01 PM, V13 (LPN) said when the mattresses are put on, they are set up. And R11 is on hospice so the bed was set by them. V13 also said she knows nothing about the pressure reducing mattress settings.

Based on observation, interview and record review the facility failed to follow the menu during the noon meal for residents on a pureed diet. This applies to 5 of 5 residents (R11, R23, R42, R91 and R6) reviewed for dietary services in the sample of 18. The findings include: On 4/13/26 at 10:55 AM, V5 (Cook) prepared the pureed meal using the food processor including bean soup, BBQ chicken, cowboy beans, pea onion salad and coffee cake. On 4/13/26 at 12:38 PM, the lunch service began on the second floor. Staff came to the serving window and verbally requested a resident's tray (pureed/regular). V5 was plating and serving the meals. The puree residents were served BBQ chicken, cowboy beans and mashed potatoes. The puree soup was not served to all the puree residents. The puree pea salad and coffee cake were not served. The puree pea salad and puree coffee cake were sitting on the prep table behind the serving table with plastic wrap in place during the noon meal service. At 1:37 PM, V4 (Dietary Manager) said the puree meal should receive what's on the menu including puree soup, BBQ chicken, cowboy beans, pea salad and coffee cake. The soup and salad should be served first. Staff should automatically serve what is listed unless the resident requests something else. V5 confirmed the puree salad and dessert were not offered or served to the puree residents. On 4/14/26, a list provided by the facility shows R11, R23, R42, R91 and R6 on a puree diet. The menu dated 4/15/26 shows barley soup, green pea and red onion salad, BBQ chicken, cowboy beans and assorted desserts are listed for the noon meal. The facility's Dietary Services for the Health Care Policy dated 2015 states, The community will provide a comprehensive dining program to meet the resident's individual nutritional needs and enhance quality of life.

Based on observation, interview and record review the facility failed to ensure the puree noon meal was a smooth consistency for residents on a pureed diet. This applies to 5 of 5 residents (R11, R23, R42, R91 and R6) reviewed for therapeutic diets in the sample of 18. The findings include: On 4/13/26 at 10:55 AM, V5 (Cook) prepared the noon puree meal adding cubed chicken adding eight ladles of BBQ sauce, one ladle of hot water and unmeasured amount of thickener in the food processor and blended. V5 then placed the puree BBQ chicken in the steam pan it appeared thick and lumpy. V5 then pureed the cowboy beans in the food processor and added unmeasured amount of thickener. On 4/13/26 at 11:44 AM, V5 said the puree consistency should be smooth like pudding. If you add too much thickener, it will be thick. On 4/13/26 at 1:50 PM, this surveyor sampled the puree meal including the pureed BBQ chicken and cowboy beans. Both items appeared lumpy on the plate. The puree BBQ chicken and cowboy beans were not a smooth consistency. Small gritty pieces that required chewing were present. On 4/13/26 at 2:10 PM, V4 (Dietary Manager) said I can already tell what's wrong. V4 said the puree meals normally don't look like this. V4 sampled the puree BBQ chicken and cowboy beans and said it's not a smooth consistency. It should be smooth like pudding. On 4/14/26, a list provided by the facility shows R11, R23, R42, R91 and R6 are all on a puree diet. The facility's BBQ Chicken Quarters Recipes dated 2026 states, place the number of servings needed in the food processor and blend until smooth. check product consistency until smooth, lump free and extremely thick. The facility's Pureed Cowboy Beans recipe dated 2026 states, Place prepared beans and tomato juice in the food processor; blend until smooth.adjust liquid needed to create a smooth pudding consistency.

Based on observation, interview and record review the facility failed to ensure daily weights were performed as order for residents with congestive heart failure and failed to perform and document a wound assessment for a resident with a new wound. This applies to 3 of 18 residents (R4, R13 and R108) reviewed for quality of care in the sample of 18.The findings include:1.On 4/13/26 at 2:22 PM, R4 had a dressing on his upper back dated 4/13/26. R4's Nursing Notes dated 4/8/26 shows, Resident noted to have a small open area to midback. Cleaned with NS (normal saline), patted dry, covered with clean and dry dressing. Resident denies pain to area. The facility was unable to provide any additional wound assessment documentation for R4's back wound that provided characteristics of the wound and measurements. R4's Wound Evaluation and Management Summary dated 4/15/26 shows that R4 has a non-pressure wound of his left upper back measuring 0.6 centimeters (cm) x 0.6 cm x 0.1 cm with moderate serous exudate. On 4/14/26 at 1:45 PM, V9 (Clinical Nurse Manager) said that if a resident develops a wound at the facility, the nurse should assess the wound and call the provider for orders. V9 said that the documented assessment should include the characteristics of the wound and measurements. On 4/14/26 at 2:00 PM, V21 (Registered Nurse) said that if a resident develops a new wound, the nurse should assess the wound and call the provider for orders. V21 said that it should be documented in the resident's record. V21 said that she is not sure if they are supposed to do measurements. The facility's Wound Assessment Protocol shows, Nursing will complete and document a focused skin and wound assessment when concerns are identified and is clinically indicated which may include: Skin integrity status, including presence of open areas.wound location and general appearance.wound measurements.wound bed characteristics (e.g. granulation, slough, eschar, epithelialization), drainage characteristics.condition of surrounding skin.pain or discomfort.signs and symptoms of infection.Assessment findings will be documented at the time of the observation. 2. R13's admission record showed R13 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF). R13's April 2026 Summary Order Report showed R13 received a diuretic medication (Torsemide) once a day for treatment of CHF. A physician order dated 12/17/25 showed, Record weight daily. notify MD (physician) if difference is greater than 2 pounds in one day or 5 pounds in one week. On 4/13/26 at 9:46 AM, a sign that showed Daily Weight hung on the door frame to R13's room. R13 was in bed. When R13 asked when she had last been weighed, R13 stated, It's been a couple of days. I don't get weighed every day. R13's weight records dated March 2026-April 2026 showed R13 was not weighed on 4/2, 4/3, 4/5-4/7, 4/9, 4/11, or 4/12/26. R13 was not weighed on 3/1-3/3, 3/5-3/10, 3/15, 3/16, 3/18, 3/19, 2/23, 3/24, 3/26, 3/27, or 3/29-3/31/26. R13's current care plan reviewed on 4/13/26 showed no documentation of R13 refusing to be weighed. 3. R108's admission record showed R108 was admitted to the facility on [DATE] with diagnoses of respiratory failure and CHF. R108's April 2026 Order Summary Report showed R108 received a diuretic medication (Furosemide) once a day for treatment of CHF. A physician order dated 4/9/26 showed, Record weight daily. notify MD (physician) if difference is greater than 2 pounds in one day or 5 pounds in one week. On 4/13/26 at 10:00 AM, a sign that showed Daily Weight hung on the door frame to R108's room. R108 was in bed with supplemental oxygen in place to her nares via nasal cannula. R108 stated she had not been weighed daily while in the facility. R108's weight record dated April 2026 showed R108 was not weighed on 4/10, 4/11, or 4/12/26. 4/14/26 at 11:05 AM, V2 (Director of Nursing) stated residents should be weighed as per their physician order. V2 stated, Most residents are weighed once week but residents with CHF and that are on diuretics are weighed daily because that's how we monitor those residents for increased fluid retention which could mean their CHF is worsening.

Based on interview and record review the facility failed to ensure a resident was assessed by a dietician after a significant weight loss for 1 of 3 residents (R11) reviewed for weight loss in the sample of 18. The findings include: R11's face sheet shows she has diagnoses including Alzheimer's Disease with early onset and dysphagia. R11's current Care Plan shows she is dependent on staff for feeding assistance, she is at risk for nutritional deficit and should be seen by the dietician. The Care Plan also shows R11 has transitioned to hospice care. R11's weight summary shows she weighed 89.4 pounds (lbs.) on 1/28/26 and on 2/22/26 she weighed 83.0 lbs. which is a 6.4 lb. 7.16% weight loss in less than 1 one month.On 3/1/26 R11 weighed 87.6 lbs. and on 3/7/26 she weighed 76.2 lbs. which is a 11.4 lb. 13.01% weight loss in one week. On 4/14/26 and 4/15/26 all dietary notes and assessments for the past 6 months for R11 were requested. The facility provided dietary progress notes completed by V15 (Registered Dietician) which shows R11 was assessed on 10/24/25 and the next dietary/nutrition note was not done until 3/26/26 (5 months later). That note states, Pt. [Patient] is in hospice care r/t [related to] decline 2/2 [secondary] to Alzheimer's. Last known weight @ 76.2#. Remains on Pureed diet with (Brand name supplemental drink) TID [three times per day] as tolerated. CPM. The note does not address R11's significant weight loss or any recommendation that maybe implemented. On 4/14/26 at 11:46 AM, V15 said I see residents with significant weight loss, and with wounds, or that have tube feedings. I do admission and quarterly assessments, however, when a resident is on hospice I do not normally see them unless there is a consult request done. Usually hospice takes over, and even when I recommend a supplement it is often denied. On 4/15/26 at 9:55 AM, V2 (Director of Nursing) said assessments of residents with significant weight loss should still be done by the facility even if someone is in hospice care.On 4/15/26 at 11:55 AM, V14 (R11's hospice nurse) said We do not do nutritional assessments for residents with significant weight loss that should be done by the facility dietician unless they do not have one and then the facility can ask if they can consult our hospice dietician. V14 said R11 has been on hospice since 12/17/25 and the facility has not asked about consulting their dietician for the required assessments. V14 said R11 does currently receive (Brand name supplemental drink) but unfortunately due to her overall status and diagnosis, weight loss is probable. The facility provided Weight Assessment and Intervention policy dated 2001 identified significant weight loss as an unplanned and undesired weight loss of greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months. The policy also shows that the dietician will review residents with significant weight loss. R11's face sheet shows she has diagnoses including Alzheimer's Disease with early onset and dysphagia. R11's current Care Plan shows she is dependent on staff for feeding assistance, she is at risk for nutritional deficit and should be seen by the dietician. R11's weight summary shows she weighed 89.4 pounds (lbs.) on 1/28/26 and on 2/22/26 she weighed 83.0 lbs. which is a 6.4 lb. 7.16% weight loss in less than 1 one month. On 3/1/26 R11 weighed 87.6 lbs. and on 3/7/26 she weighed 76.2 lbs. which is a 11.4 lb. 13.01% weight loss in one week. On 4/14 and 4/15/26 all dietary notes and assessments for the past 6 months for R11 were requested. The facility provided dietary progress notes completed by V15 (Registered Dietician) which shows R11 was assessed on 10/24/25 and the next dietary/nutrition note was not done until 3/26/26.

Based on observation, interview and record review the facility failed to ensure a resident's head of bed was elevated while tube feeding was being administered for 1 of 3 residents (R4) reviewed for tube feeding management in the sample of 18.The findings include:On 4/13/26 at 10:44 AM, V16, (Certified Nursing Assistant/CNA) went into R4's room to provide incontinence care. R4 had tube feeding running. V16 lowered R4's head of the bed to a flat position. V16 then started incontinence care. At 10:49 AM, V16 left the room to get help with care and left R4's head of the bed lowered. At 11:04 AM, V16 returned to the room and continued providing incontinence care with the head of the bed still in the flat position and the tube feeding still running.On 4/14/26 at 2:06 PM, V17 (CNA) said that if a resident is getting tube feeding, the head of the bed should always be elevated. V17 said that if the head of the bed needs to be lowered to provide care, the CNA should notify the nurse so they can stop the feeding while the care is being provided. R4's Current Care Plan shows that he requires tube feeding with interventions of, The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feeding.The facility's Enteral Feedings-Safety Precautions Policy shows, Preventing aspiration.Always elevate the head of bed (HOB) at least 30-45 degrees during tube feeding and at least 1 hour after.

Based on observation, interview and record review the facility failed to ensure the required Personal Protective Equipment (PPE) was worn when providing care to residents on Enhanced Barrier Precautions (EBP) and failed to handle oxygen tubing in a manner to prevent cross contamination for 3 of 18 residents (R24, R4, R107) reviewed for infection control in the sample of 18. The findings include: 1. R24's face sheet shows she has diagnoses including dementia and dysphagia. R24's active Care Plan shows she is incontinent of both bowel and bladder and is dependent on staff for care. R24 has a pressure injury to her coccyx which requires wound care, and is on Enhanced Barrier Precautions due to having a wound. On 4/13/26 at 9:35 AM, there was a sign posted on R24's door indicating that providers and staff must wear gloves and gowns for high contact resident care including dressing, changing linen, providing hygiene and changing briefs. There was a plastic bin outside of R24's doorway that had PPE supplies inside including gowns and gloves. At 9:37 AM, V11 and V12 both Certified Nursing Assistants (CNAs) applied only gloves and entered R24's room with the surveyor. V11 and V12 used a mechanical lift and put R24 to bed. Once R24 was in bed and without ever applying gowns, they removed R24's incontinent brief and provided incontinence care to R24 and applied a new brief. There was a bandage on R24 lower back. V12 said that R24 is on EBP due to her having the pressure wound. On 4/14/26 at 9:19 AM, V13 (Licensed Practical Nurse/LPN) said that when a resident is on EBP precautions and direct patient care is being done staff are required to wear both gowns and gloves. The facility provided Enhanced Barrier Precautions policy dated March 22, 2024 shows that EBP precautions are used to prevent infection and to reduce the spread of drug resistant organisms to residents. The policy also identifies gloves and gowns should be worn during high contact care including changing linens and briefs. 2. On 4/13/26 at 10:44 AM. R4's room door had a sign on it that said, Enhanced Barrier Precautions, Everyone must:.Wear gloves and gown for the following high contact care activities.providing hygiene.changing briefs. On 4/13/26 at 10:44 AM, V16 (CNA) entered the room to provide incontinence care. V16 did not put a gown on. V16 cleaned R4's front perineal area. On 4/14/26 at 2:06 PM, V17 (CNA) said that if a resident is on enhanced barrier precautions, staff should wear a gown and gloves when providing care to the resident. R4's Current Care Plan shows, Potential for the spread of multi-drug resistant organisms (MDROs) to other residents or staff during high contact related to: feeding tube.Apply gloves and gown before performing the high contact resident care activity. 3. R107's admission record showed R107 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and COPD (chronic obstructive pulmonary disease). A physician order dated 4/3/26 showed R107 was prescribed one liter of continuous supplemental oxygen via nasal cannula related to her diagnoses. On 4/13/26 at 9:43 AM, V6 (CNA) provided cares to R107 in bed. R107's nasal cannula was off R107's face, lying on the bed next to R107. As V6 repositioned R107, R107's nasal cannula fell off the bed, onto the floor. V6 picked the cannula off the floor and immediately placed the cannula in R107's nares and secured it to R107's face. On 4/14/26 at 9:02 AM, V7 (CNA) stated staff are to immediately dispose of a resident's nasal cannula that appears dirty and/or falls on the floor because the nasal cannula is considered contaminated and could potentially cause an infection.

Based on observation, interview, and record review the facility failed to ensure a resident's safety while providing cares which applies to 1 of 4 residents (R1) reviewed for safety in a sample of 4. This failure resulted in R1 falling out of bed and receiving a fracture.The findings include:R1's admission Record printed on 3/30/26 showed R1 was readmitted to the facility on [DATE] with diagnoses which include hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility.R1's Minimum Data Set, dated [DATE] showed R1 has a cognitive deficit and needs partial to substantial assistance with activities of daily living (ADLs) of self-care. These areas of self-care include turning in bed, showering/bathing, toileting, dressing, and personal hygiene.The facility's Final Incident Report dated 3/8/26 Showed on 3/4/26 R1 was receiving incontinent care, turned to R1's right side away from the caregiver, and fell out of the bed. This report showed R1 was admitted to a local hospital with a diagnosis of a femur (large leg bone) fracture.On 3/30/26 at 9:40 AM, V11 (Certified Nursing Assistant/CNA) stated when providing peri-care to a resident you should make sure they are in the middle of the bed prior to having the resident turn or assist turning the resident to their side so they do not go too far and fall out of the bed.On 3/30/26 at 11:15 AM, V14 (CNA) stated she was performing peri-care to R1. V14 stated she had completed cleaning up R1's front and asked R1 to turn on her side. R1 turned on her right side, her legs went over the side of the bed, and R1 fell out of the bed.On 3/30/26 at 11:05, V8 (Registered Nurse) stated V14 told them R1 fell out of bed when cleaning R1 up and needed V8 to look at R1. After assessing and getting R1 back to bed R1 nodded when asked if R1 had pain. V8 stated R1 was sent out per V18 (R1's Power of Attorney) to their hospital of choice.On 3/30/26 at 12:30 PM, V17 (Nurse Practitioner) stated V17 saw R1 up in R1's wheelchair about 8:15 AM on 3/4/26. R1 was not showing signs of pain until V17 palpated R1's right hip and thigh. V17 stated V18 requested R1 to be sent to the hospital. V17 stated it was unusual to have a resident fall out of bed during peri-cares.R1's Hospital Record faxed on 3/31/26 showed R1 was admitted to the hospital on [DATE] with an intertrochanteric right femur fracture (a fracture to top end of the femur bone). This record showed R1 was transferred to a second hospital to receive surgery to fix the fracture.On 3/31/26 at 9:10 AM V3 (Medical Director) stated the type of fracture R1 received (intertrochanteric fracture) is associated with a traumatic event.

Based on observation, interview, and record review the facility failed to ensure a resident was free from misappropriation of funds. This applies to 1 of 3 residents (R1) reviewed for misappropriation of funds in the sample of 13. The findings include: The facility's reported incident: Misappropriation of Funds report dated March 7, 2025, shows, On 3/3/2025, R1 reported to the night nurse, during early morning rounds, that his (name of card) credit card was stolen The same report shows, both R1 and V24 (R1's son) were interviewed. The son (V24) stated that his father texted him early Saturday morning (3/1/25) to inform him that the credit card was missing. Resident (R1) told the son that he could not sleep so he was checking his accounts. The resident noticed that there was a charge on his (name of card) for $57.28. He immediately canceled the credit card and called (name of card) to inquire about the charge. The credit card company told him that the card was used for a purchase at a local liquor store in northern Illinois on 2/28/25. (Name of card) was unable to give a time the card was used. The resident told the son that he called the police to file a report. Police came to the facility early in the morning, around 7:00 AM R1 stated, The resident stated the same information that the son communicated earlier When asked if he had the card with him upon admission, the resident said that he did not. His son brought it to him on Saturday, February 22nd, 2025. The resident described the missing card being with a several other miscellaneous cards, including another credit card that were all wrapped in a rubber band. He put the bundle of cards in his night stand next to the bed. The other credit card was still in the stack and was not taken. He stated he was on isolation for influenza and did not leave his room until 2/25/2025. He stated while in his room, he did not see anyone go to the nightstand. On March 12, 2025, at 10:18 AM, V24 (R1's son) stated, R1 was not able to be interviewed because he was currently in the hospital on a ventilator. However, he stated the exact story the facility reported on 3/7/2025. He brought his dad his credit cards after he was admitted to the facility. His dad called him on 3/1/2025 saying his credit card was stolen. They reported it to the police department and the facility. The facility's reported incident: Misappropriation of Funds report dated March 7, 2025, shows, Addendum, submitted 4/25/25: On 3/12/25, (state surveying agency) surveyor conducted an FRI (facility reported incident) survey regarding the misappropriation of funds. Due to not having enough information, she closed the survey with no findings. On 04/25/2025, V25 (R7's wife) alerted V29 (Assistant Administrator) that during her visit the day before, on 4/24/25 during the timeframe of 3:10-3:50pm, she had money missing from her purse. She had left the purse on the recliner while her and her husband (R7) went outside. V11 (Certified Nursing Assistant/CNA) who was assigned to this wife's husband (R7) on 4/24/25 and was upstairs working. V29 (Assistant Administrator) identified that V11 (CNA) lived 4 minutes away from the (name of liquor store). V4 (Detective) took V11 (CNA's) picture to the local liquor store to identify her, and an employee confirmed that she frequented the store. V4 (Detective) and his partner V3 (Police Officer) interviewed V11 (CNA) and during this interview, V11 (CNA) confessed to taking and using the credit card at the local liquor store for the $57.28 purchase. V11's (CNA) employment was terminated, and V4 (Detective) along with his Partner (V3) and another attending officer, took her into custody. V11 (CNA) did not confess to taking the Visitor's V25 (R7's wife) money. Later this evening on 4/25/25 at 6:30pm, V4 (Detective) called V29 (Assistant Administrator), with V1 (Administrator) on the phone to report that V11 (CNA) had been charged with 3 felonies: 1) unlawful use of a credit card, 2) unlawful possession of a credit card without consent, and 3) theft Misappropriation of resident funds [was] substantiated. On April 29, 2025, at 9:31 AM, V1 (Administrator) and V2 (Director of Nursing) confirmed the information provided in the facility reported incident. V11 (CNA) confessed to stealing R1's credit card and was charged with 3 felonies. On April 29, 2025, at 5:02 PM, V4 (Detective) stated, the facility had called reporting another theft with a resident's wife. She (V25 R7's wife) was reporting about $800/$900 in cash was missing in a 40-minute timeframe. They were able to narrow it down to a CNA and a nurse. V11 (CNA) was the CNA. She also lives right next to the local liquor store where R1's credit card was used when stolen in February 2025. He went to the liquor store and showed the employee V11's (CNA) driver license and they confirmed she frequented the liquor store. He interviewed V11 (CNA) for about 3 hours at the facility. V11 (CNA) was adamant that she didn't steal the $800/$900 cash but confessed to stealing R1's credit card back in February 2025. She confessed to swiping the credit card and acknowledged it was stolen. She also offered to pay back the $57.00 and $500 of the cash (that she didn't take). She was charged with unlawful use, possession, and theft of a credit card. V4 (Detective) stated, there was not enough evidence to prove V11 (CNA) stole V25 (R7's wife) cash so no charges could be made for the missing cash. On April 29, 2025, at 11:34 AM, V11 (CNA) stated, she was set up and did not steal R1's credit card. She blamed it on an agency CNA working that night with her. The agency CNA gave her a ride home and asked if she wanted to get a drink before she left. They stopped at the local liquor store and the agency CNA handed her the credit card. She went in and used the card but didn't pay any attention to the name on the card or what kind of card it was. That was that. The agency CNA she named was not a CNA that worked on any of the days R1's credit card was stolen. The facility's schedules for February 27 & 28, 2025 both shows, V11 (CNA) worked 6:30 AM - 7:00 PM. They did not show a CNA by the name V11 (CNA) gave during her interview. On April 29, 2025, at 1:15 PM, V28 (Assistant Director of Nursing) confirmed there were no agency CNAs working by the name V11 (CNA) named during her interview. She also confirmed that V11 (CNA) clocked out on February 28, 2025, at 7:02 PM and R1's credit card was used shortly after at the local liquor store. V11's (CNA) facility employee notice of termination dated April 25, 2025, shows, Date of occurrence: February 28, 2025. Description of occurrence (list only facts): Misappropriation of funds occurred on February 28, 2025. Employee admitted to local law enforcement on April 25, 2025, that she used a stolen (R1) credit card to make personal purchases on February 28, 2025. Per the facility's employee handbook Stealing property or unauthorized use of property is grounds for immediate termination. The facility's abuse, neglect, exploitation, and misappropriation prevention program dated April 2021 shows, Policy statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; .

Based on observation, interview, and record review the facility failed to ensure resident coffee was served at a safe temperature. This failure resulted in R57 receiving second degree burns to her right arm. The facility also failed to ensure fall preventative measures were in place for a resident. This applies to 2 of 6 residents (R57 & R28) reviewed for safety and supervision in the sample of 34. The findings include: 1. The Nurse's Notes for R57 showed, 1/6/25 at 12:19 AM - This writer was called to resident's room by CNA (Certified Nursing Assistant). Resident had spilled coffee on right arm. Right arm noted to have 2 reddened area with shiny skin, no blisters noted. Right forearm open area 3 cm (centimeters) x 2 cm, right elbow 5 cm x 8 cm. Cool water applied to right arm. DON (Director of Nursing) and supervisor made aware. Spoke with .physician assistant. New orders given and endorsed. Tylenol given for pain. Dressing applied per order/change daily. 1/6/25 at 12:23 AM - Dressing clean, dry, and intact. New order per (V9 Nurse Practitioner/NP). Apply bacitracin to right arm burns, apply petroleum gauze, cover with rolled gauze, and change daily. Monitor for signs/symptoms of infection. Wound care consult. The Provider Progress Note dated 1/5/25 (should have been dated 1/6/25) for R57 showed, patient seen and examined in her room today at the request of nursing. Patient has a burn on her right forearm, second degree. No signs/symptoms of infection. The Initial Wound Evaluation & Management Summary dated 1/8/25 for R57 showed, Patient presents with wounds on her right forearm, right elbow. At the request of the referring provider .a thorough wound care assessment and evaluation was performed today. Focused wound exam (site 1) burn of right elbow; etiology - burn; further etiology detail - hot liquid. Wound size (L x W x D) 7.0 x 6.5 x 0.1 cm. Moderate serous exudate; 100% granulation tissue. Additional wound detail: burn at right elbow and forearm from patient spilling coffee on herself while in bed. Dressing treatment plan: silver sulfadiazine - apply once daily for 30 days. Abdominal pad - apply once daily for 30 days; gauze roll 3.4 apply once daily for thirty days. Focused wound exam (site 2) burn of right forearm; etiology - burn; further etiology detail - hot liquid. Wound size (L x W x D) 2.6 x 3.6 x 0.1 cm. Moderate serous exudate; 5% slough; and 95% granulation tissue. Dressing treatment plan: silver sulfadiazine - apply once daily for 30 days. Abdominal pad - apply once daily for 30 days; gauze roll 3.4 apply once daily for thirty days. On 2/19/25 at 12:17 PM, the floor where R57 resides had an automatic coffee machine dispenser in the dining room on the counter accessible to anyone. On 2/19/25 at 12:19 PM, V5 (Dietary Director) filled a cup with coffee from the automatic coffee dispenser machine on the floor where R57 resides dining room. The temperature of the coffee was tested by V5 at the request of the surveyor. The temperature of the coffee from the machine was 187.2 degrees Fahrenheit. V5 stated the coffee machines were installed a couple of months ago. V5 stated he doesn't check the temperature of the coffee from the machine on a regular basis. V5 stated the company that services the machine will check the temperature when they come in for a service call and he was unsure of the last time the company was in to provide service. V5 stated the normal temperature that coffee is served is at 180 degrees. V5 stated all coffee comes from the machine and is not made in the kitchen. V5 stated he was told about the incident where someone had burned themselves from the coffee. V5 stated he didn't know who it was that burned themselves. V5 stated he was not part of the correction process for that. V5 stated nursing was a part of the correction process and the dietary department did not do anything for correction. The last Field Service Update for the coffee machines was dated 7/24/24 and showed it was for the main kitchen machine and the water temperature for that machine was 180 degrees Fahrenheit. On 2/19/25 at 12:25 PM, V8 (Licensed Practical Nurse/LPN) stated R57 had a burn to her right elbow from coffee. V8 stated R57 asked for coffee and spilled the coffee in bed. V8 stated R57 doesn't have sensation to her right arm and keeps her right arm immobile. V8 stated R57 received a second degree burn from the spilled coffee. On 2/19/25 at 12:55 PM, V3 (Director of Nursing/DON) stated she received call from nurse and was told R57 was in her room, had finished dinner, and wanted coffee. The CNA went and got more coffee and added the coffee to R57's cup. R57 ended up spilling the coffee on herself. R57 had second degree burns from the coffee that were treated right away. V3 stated she had dietary check the temperature of the coffee and it was within normal range. V2 stated she did not know what the temperature of the coffee should be. V2 stated the dietary manager would have been notified by the dietary department. On 2/20/25 at 11:21 AM, V9 (Nurse Practitioner/NP) stated the facility called telehealth the evening that it happened and got a treatment order. V9 stated she saw R57 the following day. R57 had a second degree burn to her arm. V9 stated she ordered Silvadene. The family refused that treatment and wanted bacitracin because they had a doctor friend that told them that is what they use for burns. V9 state she was not sure if R57 needed assistance with meals; however, R57 had been declining. V9 stated she believed R57 needed assistance. V9 stated this could have been prevented from happening by checking the temperature of the coffee and making sure it is not too hot. The Care Plan dated 6/28/24 - Present for R57 showed, R57 is at risk for impaired skin integrity. Offer staff assistance with hot beverages. Encourage use of clothing protector to protect skin for accidental spills. Encourage resident to sit up right at a table while drinking hot liquids. Serve hot liquids in a cup with a lid. The Face Sheet dated 2/19/25 for R57 showed diagnoses including Alzheimer's disease, depression, osteoporosis, hypertension, atherosclerotic heart disease, spinal stenosis, gastro-esophageal reflux disease, anxiety disorder, edema, osteoarthritis, abnormal posture, and muscle weakness. The MDS (Minimum Data Set) dated 12/20/24 for R57 showed severe cognitive impairment; dependent for eating; substantial/maximal assistance needed for toileting hygiene, bathing, upper body dressing, and personal hygiene. The facility's Safety of hot Liquids policy (October 2014) showed, Appropriate precautions will be implemented to maximize choice beverages while minimizing the potential for injury. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in care plan. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include a. maintaining hot liquids serving temperature of not more than 180 degrees Fahrenheit: e. staff supervision or assistance with hot beverages. 34891 2. R28's face sheet printed on 2/20/25 showed diagnoses including but not limited to heart failure, chronic obstructive pulmonary disease, chronic kidney disease, anxiety, and dementia. R28's facility assessment dated [DATE] showed severe cognitive impairment. R28's fall risk assessment dated [DATE] showed a high risk of falls. The same assessment showed a history of falls in the last three months, weakness with gait and transfers, and forgets her limitations. R28's care plan showed a focus area related to the high risk for falls. Interventions included staff to place floor mats beside the bed and bed in lowest position when she is in it. On 2/18/25 at 12:27 PM, R28 was lying in bed with her eyes closed. R28's bed was low to the ground but there were no fall mats next to the bed. On 2/19/25 at 9:31 AM, R28 was in bed and was yelling out for help. R28 did not have any fall mats next to the bed. The mats were folded up and leaning against the wall at the foot of the bed. V7 and V10 (RN-Registered Nurses) responded to R28 and entered the room. V7 stated R28 has fallen out of bed in the past. About one month ago, she rolled out and hit her eye on the side rail. V7 was asked if the bed was in the lowest position and stated no. V7 lowered the bed further to the ground. At 9:54 AM, R28 was yelling out for help again and outwardly agitated. The fall mats were still not next to the bed and remained folded up against the wall. On 2/19/25 at 9:45 AM, V10 (RN) stated R28 has fallen out of bed several times in the past. She can get herself to the side of the bed and rolls herself out. She ends up on the floor. That is why the fall mats are important. V10 said R28 gets agitated and excited, like she is right now. She is highly confused and frequently ends up on the floor. On 2/19/25 at 12:06 PM, R28 was in bed and V11 (Certified Nursing Assistant) was in the room. The bed was not in the low position and the fall matts were folded up against the wall by the window. V11 stated she needs the mats next to her bed anytime she is in it. She falls out of bed a lot and they keep her from getting hurt. On 2/20/25 at 11:07 AM, V3 (Director of Nurses) stated R28 has had several falls out of bed related to her behaviors. She is confused, gets agitated, and rolls herself out of bed. She will try to get up by herself frequently. The low bed and fall mats need to be in place at all times. They both help minimize any potential for injury. She absolutely needs the interventions in place. The facility's Falls and Fall Risk Managing policy revision dated 3/2018 states: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on interview and record review the facility failed to ensure food temperatures were monitored for meals prior to service for all 76 residents residing in the facility. The findings include: The CMS (Centers for Medicare and Medicaid services) form 671, dated 2/18/25, documents 76 residents reside in the facility. On 2/18/25 at 10:00 AM, V7 (Dining Director) said the food temperatures are initially taken by the dietary aide in the kitchen. The food is then sent up to the 2nd and 3rd floors to be placed on a steam table and then plated directly before giving to the residents. V7 said the temperatures are logged into the book on each of the pantry log books and the temps are transferred to the main logbook. Each of the food items should have 2 temperature readings, one is done in the kitchen, and the second temperature from the pantry. The temperature monitoring sheets were reviewed for the week of 2/2/25 to 2/8/25 for the 2nd and 3rd floor pantries. The 2nd floor readings show on 2/2/25 only 1 temperature for dinner, 2/6/25 no dinner temperatures, 2/7/25 lunch 1 temperature, no dinner temperatures, and 2/8/25 no dinner temperatures recorded. The pantry floor 3 log shows on 2/2/25 dinner no floor temperatures, 2/4/25 no floor temperatures for lunch or dinner, 2/6/25 and 2/8/25 had no dinner temperatures recorded. On 2/18/25 at 10:15 AM, V7 said it is important for the temperatures to be taken before meals to ensure the food is cooked properly, no chance of food poisoning, and the residents are getting hot food. The facility's 2005 policy for food temperatures documents it is the policy of the community to ensure the proper serving temperature of food through the use of a temperature monitoring system. Procedure: 1. Hot food temperatures will be taken three times throughout each meal service. Hot food temperatures will be taken prior to leaving the heath center kitchen, prior to meal service, and after completion of meal service for each meal. Temperatures will be recorded each time in a temperature log form.

Based on observation, interview, and record review the failed to ensure controlled substances were disposed of in a safe manner for 3 of 3 residents (R22, R296, R297) reviewed for controlled medications in the sample of 34. The findings include: 1.) R296's face sheet documents she was admitted to the facility on [DATE] for aftercare following joint replacement. The February 2025 Physician Order Sheet shows and order for Tramadol (a controlled pain medication) 50 milligram (mg) tablet every 6 hours as needed for pain. R297's face sheet documents she was admitted to the facility on [DATE] for a fracture of unspecified part of the neck of the right femur. The February 2025 Physician Order sheet shows an order for oxycodone (a controlled pain medication) 5 mg every 6 hours as needed for pain. On 2/20/25 at 9:28 AM, the medication cart on 3 west was reviewed for narcotic controlled medications. V6 (Registered Nurse/RN) opened the locked narcotic box. Medication cards for R296 and R297 were observed to have controlled medications taped back into their medication cards. R296 had a card of Tramadol 30 tablets. The pill in the card in the number 30 bubble was taped in place. R297's controlled medication card of oxycodone, had a pill taped back into the card in the number 29 bubble. V6 said controlled medications should not be taped back into the bubble cards. If a resident refuses the medication, it should be destroyed. 2.) R22's face sheet documents she was admitted on [DATE] with multiple diagnoses including Alzheimer's disease, anxiety, and diarrhea. On 2/20/25 at 10:00 AM, the 2 west medication cart was reviewed with V7 (RN). The controlled medication/narcotic box had a card for R22 of diphenoxylate/atropine with 2 tablets remaining. The pill in the number 2 bubble on the card was taped back into place. V7 said the pill should have been destroyed, with 2 nurses and both nurses would sign the medication count sheet. She said the controlled medication should not have been taped back into the package. On 2/20/25 at 10:20 AM, V2 (Director of Nursing) said if a resident refused a narcotic medication, the nurses are to put it in the sharps box with 2 nurses to witness and sign the count sheet. The pill should never be taped back into the card because it is already dispensed. If the pill is not taken it should be destroyed. The facility's November 2022 policy for controlled substances documents the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Dispensing and Reconciling Controlled Substances: 6. Unless otherwise instructed by the director of nursing services, when a resident refused a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed and may not be returned to the container. 7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on observation, interview, and record review the facility failed to ensure PPE (Personal Protective Equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R28) reviewed for infection control in the sample of 34. The findings include: On 2/18/25 at 12:27 PM, R28 had signs on her door stating she was on droplet precautions. The signs showed full PPE was needed in the room including gowns, gloves, face shields, and N95 masks. The signs showed the correct manner to don and doff the PPE items. The signs stated to remove the gown, gloves, N95 mask, and eye protection after exiting the room. On 2/19/25 at 9:31 AM, R28 was in bed and yelling out for help. V7 and V10 (RN-Registered Nurses) donned gowns, gloves, face shields, and N95 masks then entered the room. R28 was confused and agitated. V10 exited room and removed her gown and gloves at the room door. V10 continued to wear her face shield and N95 mask down the hallway. V10 was interviewed while leaning on the wound treatment cart and again in the nurse's charting room. V10 stated R28 was on isolation for covid, and full PPE is needed whenever staff go into the room. V10 said the PPE should be removed and put into the red bins near the room exit. Wearing the dirty PPE outside of the room can contaminate things. On 2/20/25 at 11:07 AM, V3 (Director of Nurses) stated staff need full PPE when entering a resident room that is on isolation for covid. Staff need to remove the PPE when exiting the room to protect themselves and stop the spread of covid. There is the potential for the spread of germs between residents. PPE worn outside of the isolation room has the potential to contaminate the outside environment and common areas. Cross contamination to others is a definite concern. The facility's Coronavirus Disease (COVID-19)-Using Personal Protective Equipment policy revision dated 5/2023 states: Disposable respirators are removed and discarded after exiting the resident's room or care area and closing the door .Eye protection is removed after leaving the resident room or care area. .

Based on observation, interview, and record review the facility failed to assess and identify open areas to the right and left buttocks, this failure resulted in R1's open areas becoming full thickness for 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. The finding include: R1's Physician Order Sheet printed on 1/21/25 show R1 was admitted to the facility on [DATE] with diagnoses of pancreatic cancer, Type 2 diabetes, and chronic kidney disease. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. (BIMS-15) R1's Braden scale (predicting of risk of pressure injury) dated 12/20/24 show R1 is at risk to develop a pressure injury. R1's skin admission assessment dated [DATE] show R1 had redness to his bottom but no open areas. On 1/21/25 at 9:10 AM, R1 said he was having so much pain in my bottom, I was complaining about it, until they saw that I had an open sore while they were cleaning and changing me. R1 said he did not have any wounds on his bottom when he first came at the facility (12/13/24.) On 1/21/25 at 10AM, V9 (Wound Nurse) provided wound care to R1. V9 removed the soiled dressing from the right and left buttocks. There were open areas to R1's right and left buttocks. V9 said she was informed of R1's open areas on 1/9/25. V9 said she took pictures and sent them to V10 (Wound Physician). V10 was then at the facility last 1/15/25 and assessed R1's wounds. R1 had no other skin assessments in R1's medical record after R1's initial skin assessment (12/14/24). R1 had no skin assessments the week of: 12/16/24, 12/23/24 and 12/30/24 (no skin assessments for 3 weeks) prior to a progress note on 1/9/25 when the open wound to right and left buttocks were discovered. Skin opening noted to right and left buttocks . Area cleanse with normal saline . R1's Wound assessment dated [DATE] by V10 documents, initial wound assessments on the right buttocks-full thickness 5.0 centimeters (cm) x 3.5 cm x 0.1 cm. Initial assessments left buttocks-full thickness 3.5 cm x 1.5 cm x 0.1 cm treatment with date of order (1/15/25) to right and left buttocks-mupirocine 2% with santyl and lidocaine jelly with calcium alginate cover with foam dressing. On 1/21/25 at 1:30 PM, V2 (Director of Nursing/DON) said skin assessments should be done upon admission and then weekly. V2 said the skin assessments on 1/9/25 was when the open areas on right and left buttocks were discovered. V2 confirmed R1 no skin assessments were completed the week of: 12/16/24, 12/23/24 and 12/30/24. R1's care plan with a range date of 12/13/24 show R1 is at risk for impaired skin integrity related to weakness and occasional bowel and bladder incontinence with intervention to check skin for redness. Skin tears swelling or pressure areas.

Based on interview and record review the facility failed to ensure a resident's sink faucet was in working order for 1 of 3 residents (R1) reviewed for environmental services in the sample of 3. The findings include: R1's facility assessment dated [DATE] show R1 has no cognitive impairment-(BIMS of 15) On 1/21/25 at 9:10 AM, R1 was in bed alert and pleasant. R1 said it took the staff, days before they were able to fix his sink faucet. There was no water coming out since the faucet was broken. R1 said there was no water to brush his teeth. Staff had to get the water from outside. A document entitled Maintenance work order dated 1/10/25 (Friday)-Faucet in room XXX-Faucet is broken in the sink in room XXX. The same document show, Priority .same day. On 1/21/25 at 12:44 PM, V4 (Registered Nurse Weekend Supervisor) said last Saturday 1/11/25 it was reported to her that the faucet in R1's room was still broken. R1's wife was also in the room at that time and was asking when it will be fixed. V4 said she notified V3 (Assistant Director of Nursing/ADON). V4 also said she provided buckets of water to R1 to be used during care. On 1/21/25 at 12:52 PM, V3 (ADON) said when she was informed regarding R1's faucet sink not working, it was facilitated for the Maintenance of the Assisted Living to come over and fix R1's sink faucet. On 1/21/25 at 12:11 PM, V6 said he was the Maintenance at the Assisted Living. V6 said he was requested to go the Long Term to fix a faucet. He got the call on Saturday 1/11/25. V6 said he went to the Long-Term unit the next day (1/12/25 Sunday afternoon). R1 and his wife were in the room. The wife said it has not been working for days now. V6 said the faucet was broken. I explained that I cannot fix the faucet at that time. It will need a whole replacement. On 1/21/25 at 10 AM, V5 (Maintenance) said he fixed the faucet on 1/13/25 (Monday) first thing in the morning. V5 said he replaced the faucet, and it was now working fine. V5 said if V6 would have only called that weekend, I would have given him direction where to get the parts so it would have been taken cared of same day. The facility policy entitled Maintenance Service dated 12/2009 states, 1. The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner.

Based on observation, interview, and record review the facility failed to ensure staff safely assisted and supervised a resident while showering. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE]. R1's diagnoses including neoplasm of the brain, muscle weakness, aphasia, cognitive communication deficit, history of falling, cerebral infarct, and unspecified convulsions. R1's Minimum Data Set assessment dated [DATE] shows severe cognitive impairment, has limited range of motion with impairments to one side affecting his upper and lower extremity, and dependent on staff for showers/bathing. On 01/07/25 at 9:49 AM, R1 was observed in a high back wheelchair located near the nurse's station in the hallway. R1 was leaning forward and back repeatedly in his wheelchair. R1 was alert to self only. R1 said he fell but does not recall the details of the fall. On 01/07/25 at 9:52 AM, V3 (Registered Nurse/RN) said R1 is alert to self with right sided weakness. He leans forward when he is in his wheelchair this is normal for him. She was R1's nurse the on 12/27/24 when he fell in the shower room. She was notified by V4 (Certified Nursing Assistant/CNA), R1 fell in the shower room. V4 reported while he turned away from R1 to get his clothes, R1 fell forward out of the shower chair. R1 needs close supervision and should have two staff while showering R1. On 01/07/25 at 10:02 AM, V5 (CNA) said R1 has right sided weakness, he transfers and showers with two person assist. R1 is alert to self but does not answer questions appropriately or understand what you are saying. R1 has always been a two person assist during showers because he is weak, unsteady and at risk for falls When giving a resident a shower, staff should ensure items are within close reach. On 01/07/25 at 11:49 AM, V4 (CNA) said he was R1's CNA on 12/27/24. He was told R1 was a two person assist for showers, R1 was a newer admit and had not given him a shower prior. He transferred R1 from his bed to the wheelchair and wheeled him to the shower room. R1 was not steady during the transfer from the bed to the wheelchair. After showering R1, he turned his back away from R1 and reached for a towel and R1's clothing placed on the shower bench against the wall. When he turned around, R1 was leaning over in his shower chair and fell on the floor. He was cueing R1 directions to stay still, but he was not sure if R1 understood him. V4 said he used a regular shower chair and did not dry off R1 yet with the towel. V4 said he felt confident enough to give R1 a shower himself. V4 said he should have placed the items closer in reach. R1's current care plan shows he is at risk for falls with interventions to be assisted in shower x 2 until reclining chair is available. The facility's Final Investigation dated 12/28/24 documents on 12/27/24, (V4 CNA) was assisting a (R1) with a shower. (V4) turned to grab the clothes off the other chair when (R1) leaned forward and fell to the floor .due to weakness and trunk control resident will be assisted x 2 until a reclining shower chair is available. The facility's Falls Protocol undated policy states, the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on observation, interview, and record review the facility failed to notify a resident of a change of her medication to 1 of 3 residents (R1) reviewed for notification in the sample of 3. The findings include: R1's facility assessment dated [DATE] show R1 has no cognitive impairment. On 11/12/24 at 9:20 AM, R1 was sitting in her wheelchair with dressing on both of her lower legs. R1 said she always have pain due to chronic wounds since 2018. R1 said her choice of pain medication was Norco. Norco takes the edge off. R1 said around the first week of November was when she noticed some trembling after taking her pain medications. R1 said early morning (around three in the morning) she would ask for her pain medication and after taking her pain medication then she gets the trembling feeling again. R1 said she thought the nurse was substituting her Norco to extra strength Tylenol since they are both white and elongated in shaped. Finally, she asked the nurse-was she really being given Norco? That was when she was told the order was to give her Extra Strength Tylenol at 3AM. R1 said no one notified her of the order of extra strength Tylenol instead of Norco. I was probably having withdrawals from the Norco. R1 said she told the Director of Nursing she does not like to take Tylenol at all. R1 said she was told the issue will be taken care of. R1's November Medication Administration Record that was printed on 11/12/24 documents an order for acetaminophen (generic Tylenol) extra strength 500mg tablet (2) every 6 hours starting 10/30/24 and discontinued on 11/5/24. On 11/12/2024 at 10:00 AM, V2 (Director of Nursing) said R1 was not made aware of her being put on Tylenol extra strength every 6 hours given routinely at 9AM, 3PM, 9PM and 3AM. V2 said R1 should have been notified of any of her medication changes. V2 said she discontinued R1's Tylenol order on 11/5/24 per R1's request and just kept R1 on Norco as needed (PRN). On 11/12/2024 at 1:00 PM, V3 (Nurse Practitioner) said nurses were requesting for R1 to have a Tylenol order for her breakthrough pain. V3 said she did not tell R1 of the new order of Tylenol, she thought the nurses would do that. The facility policy under Resident's rights show, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: O. be notified of her medical condition and of any changes in her condition. p. be informed of and participate in her .treatment.

Based on interview and record review the facility failed to ensure a resident (R1) was assessed in a timely manner after being lowered to the ground during a mechanical lift transfer on 7/26/24 at 5:30 AM which resulted in a left hip fracture. The facility failed to notify the physician in a timely manner and provide ongoing nursing assessments from the time of the incident on 7/26/24 at 5:30 AM through 8/1/24 when R1 was transported to the emergency department for evaluation and treatment of a left hip fracture. These failures resulted in R1 not receiving required medical evaluations and treatment after being lowered to the ground when she was falling from a mechanical lift on 7/26/24. This applies to one of three residents (R1) reviewed for injury in the sample of three. The findings include: The facility face sheet for R1 shows diagnoses to include fibromyalgia, Atrial Fibrillation, congestive heart failure and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required maximum staff assistance with bed mobility and transfers. The final report dated 7/31/24 for a bruise of unknown origin shows upon further investigation it was discovered that the resident was being transferred by a sit to stand lift for a shower. During the transfer, R1 became agitated and began to come out of the sit to stand sling. The report shows this staff lowered the resident to the floor. The sling caused pressure to the left shoulder which developed into a bruise. An additional follow-up, post 5-day summary dated 8/2/24 shows R1 was noted with bruising to her left lower extremity and had an increase in pain. An x-ray revealed a fracture to the left distal femur. The undated facility final conclusion for bruise and fracture of unknown origin, upon completion of investigation shows it is believed that the left femur fracture is related to the reported incident of resident being lowered to the ground by staff on 7/26/24. On 8/7/24 at 3:00 PM, V5 (Certified Nursing Assistant/CNA) said he was the CNA caring for R1 on Friday 7/26/24. V5 said he was to give R1 a shower that morning. V5 said the shower began around 5:30 AM. After the shower was completed and he was preparing to transfer R1, she became agitated and resistive to having the lift sling placed under her arms. V5 said he proceeded with the transfer anyway and as the transfer was happening, she began to slide out of the lift sling. V5 said her legs were standing on the base of the lift and she never fell to the floor. V5 said he was alone during the transfer and knows he was to have assistance with the transfer. V5 said he did not report the incident to the nurse because R1 did not get hurt and he didn't feel he had to. V5 said R1 was lowered to the ground and a sling for the mechanical lift was placed under R1 as she lay on the floor, and she was lifted up off the floor into her wheelchair. On 8/7/24 at 6:39 PM, V6 (CNA) said on the morning of 7/26/24, at around 5:30 AM, she heard yelling from the shower room and noticed the door was ajar. V6 said when R1 gets a shower, she does yell out loudly. V6 said she wanted to close the door to avoid disrupting the other residents in the unit. V6 said she peeked in the room and saw R1 hanging from the sit to stand lift sling with her arms raised high and her legs dangling near the ground. V6 said R1 was not bearing any weight on her legs at the time. V6 said V5 (CNA) was just standing there looking at R1 with a shocked look on his face. V6 said V5 was not doing anything to help R1. V6 said she immediately went into the room, told V5 to grab R1 from behind and support her weight and V6 lowered the lift arm and detached the arm sling from R1 and V5 lowered R1 to the ground. V6 said V5 did not have the leg band secured around R1's legs. V6 said she went and got the mechanical lift and together her and V5 rolled R1 onto a sling and lifted her off the floor and into her wheelchair. V6 said she knew the incident should have been reported to the nurse and she assumed V5 would do that. On 8/8/24 at 9:45 AM, V3 (Director of Nursing) said a bruise of unknown origin was reported to her on 7/27/24 to R1's left shoulder. V3 said an investigation was started and it was discovered R1 was lowered to the ground on 7/26/24 in the shower room. V3 said bruising and resident complaints of pain were to her left shoulder only, until on 8/1/24 when bruising and limited range of motion was observed for R1. An x-ray revealed a fracture to R1's left femur. V3 said R1 was not complaining of any pain to her leg in the week between the incident and when the fracture was identified. V3 said she expects staff to have two CNA's present for all transfers involving a mechanical lift. V3 said this is for the safety of the resident. One staff to run the lift and another staff to guide and protect the resident. V3 said the staff should have gotten the nurse before moving the resident so an assessment could have been completed to check for injuries. On 8/8/24 at 2:13 PM, V10 (Advanced Practice Nurse) said when R1 was lowered to the ground on 7/26/24, it should have been reported to the nurse right away so an assessment for injuries could have been performed. V10 said she expects the staff to perform an assessment to check for any acute injuries and the resident should be closely monitored for at least 24 hours after an incident. On 8/8/24 at 5:27 PM, V13 (Orthopedic Surgeon) said R1 had very poor bone quality so being lowered to the ground during a transfer could have led to this type of fracture. V13 said R1 had a bad injury, and she should have been sent out to the emergency department after the incident for x-rays and treatment. The x-ray report dated 8/2/24 (seven days after the incident of being lowered to the ground) shows R1 had a fracture of the distal shaft (lower) of the left femur (thigh bone) with some overriding of the fracture fragments. The nursing progress note dated 8/1/24 at 12:55 AM, shows R1 was experiencing restricted range of motion to her lower extremities. R1 would scream in pain when leg was moved, substantial swelling to the entire leg and R1 not able to tolerate leg extension, flexion, or elevation. On the same day at 7:46 AM, it was documented in R1's records that R1 now had discoloration on the back of her leg and back of the knee. The hospital emergency department report dated 8/2/24 shows R1 had a fall reportedly one week ago and the details of the fall were unknown. R1's left leg was swollen with tenderness and bruising noted to the back of the leg and painful range of motion. The x-ray of the left leg showed a closed fracture of the distal end of the left femur. The hospital progress note dated 8/2/24 completed by the Orthopedic surgeon showed the left lower is shortened and R1 grimaces when the leg was palpated. The facility falls clinical protocol assessment and recognition revised March 2018 shows the nurse shall assess and document/report the following: vital signs, recent injury, observe for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, precipitating factors, details on how the fall occurred .

Based on interview and record review the facility failed to safely transfer a resident using a mechanical lift. This failure resulted on R1 sustaining a femur fracture requiring surgery. This applies to one of three residents reviewed for safety in the sample of three. The findings include: The facility face sheet for R1 shows diagnoses to include fibromyalgia, Atrial Fibrillation, congestive heart failure and dementia. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and required maximum staff assistance with bed mobility and transfers. The final report dated 7/31/24 for a bruise of unknown origin shows upon further investigation it was discovered that the resident was being transferred by a sit to stand lift for a shower. During the transfer, R1 became agitated and began to come out of the sit to stand sling. The report shows this staff lowered the resident to the floor. The sling caused pressure to the left shoulder which developed into a bruise. An additional follow-up, post 5-day summary dated 8/2/24 shows R1 was noted with bruising to her left lower extremity and had an increase in pain. An x-ray revealed a fracture to the left distal femur. On 8/7/24 at 12:55 PM, V1 (Administrator) said for the resident's safety during a mechanical lift transfer, there must be two staff present. On 8/7/24 at 3:00 PM, V5 (Certified Nursing Assistant/CNA) said he was the CNA caring for R1 on Friday 7/26/24. V5 said he was to give R1 a shower that morning. V5 said the shower began around 5:30 AM. After the shower was completed and he was preparing to transfer R1, she became agitated and resistive to having the lift sling placed under her arms. V5 said he proceeded with the transfer anyway and as the transfer was happening, she began to slide out of the lift sling. V5 said her legs were standing on the base of the lift and she never fell to the floor. V5 said he was alone during the transfer and knows he was to have assistance with the transfer. On 8/7/24 at 6:39 PM, V6 (CNA) said on the morning of 7/26/24, at around 5:30 AM, she heard yelling from the shower room and noticed the door was ajar. V6 said when R1 gets a shower, she does yell out loudly. V6 said she wanted to close the door to avoid disrupting the other residents in the unit. V6 said she peeked in the room and saw R1 hanging from the sit to stand lift sling with her arms raised high and her legs dangling near the ground. V6 said R1 was not bearing any weight on her legs at the time. V6 said V5 (CNA) was just standing there looking at R1 with a shocked look on his face. V6 said V5 was not doing anything to help R1. V6 said she immediately went into the room, told V5 to grab R1 from behind and support her weight and V6 lowered the lift arm and detached the arm sling from R1 and V5 lowered R1 to the ground. V6 said V5 did not have the leg band secured around R1's legs. V6 said she went and got the mechanical lift and together her and V5 rolled R1 onto a sling and lifted her off the floor and into her wheelchair. On 8/8/24 at 9:45 AM, V3 (Director of Nursing) said a bruise of unknown origin was reported to her on 7/27/24 to R1's left shoulder. V3 said an investigation was started and it was discovered R1 was lowered to the ground on 7/26/24 in the shower room. V3 said bruising and resident complaints of pain were to her left shoulder only, until on 8/1/24 when bruising and limited range of motion was observed for R1. An x-ray revealed a fracture to R1's left femur. V3 said R1 was not complaining of any pain to her leg in the week between the incident and when the fracture was identified. V3 said she expects staff to have two CNAs present for all transfers involving a mechanical lift. V3 said this is for the safety of the resident. One staff to run the lift and another staff to guide and protect the resident. On 8/8/24 at 5:27 PM, V13 (Orthopedic Surgeon) said R1 had very poor bone quality so being lowered to the ground during a transfer could have led to this type of fracture. The x-ray report dated 8/2/24 shows R1 had a fracture of the distal shaft (lower) of the left femur (thigh bone) with some overriding of the fracture fragments. The nursing progress note dated 8/1/24 at 12:55 AM, shows R1 was experiencing restricted range of motion to her lower extremities. R1 would scream in pain when leg was moved, substantial swelling to the entire leg and R1 not able to tolerate leg extension, flexion, or elevation. On the same day at 7:46 AM, it was documented in R1's records that R1 now had discoloration on the back of her leg and back of the knee. The undated facility final conclusion for bruise and fracture of unknown origin, upon completion of investigation shows it is believed that the left femur fracture is related to the reported incident of resident being lowered to the ground by staff on 7/26/24. The facility policy with a revision date of March 2024 for lifting machine, using a mechanical lift shows at least two nursing assistants or nurse are needed to safely move a resident with a mechanical lift.

Based on interview and record review the facility failed to supervise a cognitively impaired resident (R1) while being toileted which resulted in R1 falling off the toilet and requiring emergent transport to a local hospital where she was admitted with diagnosis of a basal ganglia hemorrhage (brain bleed) and a frontal scalp hematoma. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1's admission nursing note dated 4/26/24 showed R1 was admitted to the facility with a diagnosis of CVA (cerebrovascular accident/stroke) which resulted in weakness to R1's right arm and right leg. R1 was nonverbal due to her stroke. The note showed, Per POA (power of attorney), patient is a fall risk and will attempt to get out of bed. R1's nursing note dated 4/27/24 showed facility staff found R1 attempting to get out of bed without assistance. R1's care plan dated 4/26/24 showed R1 was at risk for falls due to her impaired cognition, poor safety awareness, overall weakness, and need for assistance with activities of daily living (ADLs). R1's resident assessment dated [DATE] showed R1 was dependent on staff for toileting and transfers. R1's nursing noted dated 5/7/24 showed R1 sustained a fall off the toilet after two staff members (V9 Certified Nursing Assistant/CNA and V12 Licensed Practical Nurse/LPN) left her unsupervised in the bathroom. R1 was found on the floor by staff, lying on her right side, with swelling and bruising noted to the right side of R1's forehead. R1 was emergently transported to a local hospital via ambulance. The note showed, Patient was admitted for intracranial bleeding. R1's hospital neurology progress note dated 5/9/24 showed R1 presented to the ER (emergency room ) on 5/8/24 after multiple falls. She sustained head contusion. CT head (computed tomography scan) showed hemorrhage in the left BG (basal ganglia) region . On 5/13/24 at 10:36 AM, V12 (LPN) stated she and V9 (CNA) placed R1 on the toilet on 5/7/24. V12 stated, I told (V9) to go get the shower chair. It was (R1's) shower day. I would stay with (R1) in the bathroom. I heard someone yelling in the hallway outside of (R1's) room. I ran out of (R1's) room to see what was going on. Just as I turned around to go back to (R1), I heard a thud. I found (R1) lying on her right side, on the floor next to the toilet. She was awake but had a large bump on her forehead . I shouldn't have left her alone. On 5/13/24 at 11:04 AM, V9 (CNA) stated, I had taken care of (R1) before. She was a fall risk. She isn't someone that can be left alone on the toilet. I didn't see her fall (on 5/7/24). I had left to go get the shower chair. V12 (LPN) was going to stay with (R1) while she was on the toilet. I came back to her room to find her on the floor with (V12) next to her. On 5/13/24 at 9:45 AM, V2 (Director of Nursing) stated due to R1 being at a high risk for falls, staff should not have left her on the toilet unsupervised on 5/7/24. On 5/13/24 at 11:00 AM, V11 (R1's Physician) stated, (R1) was here for more rehab. She had a history of a CVA with deficits to one side of her body. When I saw her, she was pretty weak all over. She couldn't walk. She was nonverbal but would occasionally shake her head yes or no when asked questions. It was hard to tell how cognitively intact she really was. No, she was not someone who should be left alone on the toilet. The facility's Safety and Supervision of Residents policy dated July 2017 showed, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the resident's assessed needs and identified hazards in the environment .

Based on interview and record review the facility failed to administer a resident's post-surgical pain medication as ordered for 1 of 7 residents (R326) reviewed for pain management in the sample of 18. This failure resulted in R326 experiencing severe pain overnight (approximately 7-10 hours) on 3/8/24-3/9/24. The findings include: R326's Face Sheet shows R326 has admitting diagnoses including fusion of spine in the lumbar region, encounter for surgical aftercare following surgery on the nervous system, presence of other vascular implants and grafts, spondylolisthesis in the lumbar region, spinal stenosis in the lumbosacral region, and low back pain. R326's hospital discharge paperwork dated 3/8/24 shows that R326 had an order for Oxycodone (narcotic analgesic) 5 mg every 4 hours for pain management. R326 last received 10 milligrams (mg) of Oxycodone at 5:15 PM on 3/8/24, before being discharged from the hospital. R326's Face sheet shows that R326 was admitted to the facility at 7:10 PM on 3/8/24. On 3/12/24 at 9:29 AM, R326 said she admitted to the facility on [DATE] following lower back surgery and that she was here to receive therapy and pain management. Overnight from 3/8/24 to 3/9/24, R326 said there was a mix up with her pain medication and she was in severe pain, stating pain was a 9 out of 10 and she did not receive pain medication to relieve the pain. R326 said she was only offered acetaminophen (Mild analgesic). On 3/13/24 at 11:17 AM, V17 (Registered Nurse/RN) said that she was the one who took report from the hospital regarding R326. V17 said that R326 was admitting following a L3 and L4 spinal nerve laminectomy and that she had a paper script sent with her for Oxycodone 5mg one tablet by mouth every four hours as needed for pain. V17 said she completed her shift around midnight on 3/8/24 and R326 had not requested pain medication during V17's shift. R326's Nurse's Note dated 3/9/24 at 9:54 AM, written by V18 (RN) states, . Slept on and off, c/o (complains of) severe back pain. PRN (as needed) Tylenol (acetaminophen) administered . Encouraged to reposition, refusing due to pain. Oxycodone not yet available from pharmacy overnight. On 3/13/24 at 11:26 AM, V18 was attempted to be contacted by phone and was unable to be reached. R326's Medication Administration Report for March 2024 shows that R326 did not receive Oxycodone 5 mg until 3/9/24 at 7:40 AM. (approximately 14 hours after the last documented dose from the hospital). This form also documents R326's pain as Bracing. On 3/13/24 at 12:00 PM, V19 (Licensed Practical Nurse/LPN) said that if the facility has not received the prescription and the time frame to receive the next dose has passed, the nurse on duty would call the pharmacy and go through the protocols to access and retrieve the medication from the locked medication dispenser in the nurse's station. V19 said if the pain level is a 9 out of 10, providing PRN acetaminophen is not going to be very effective. On 3/13/24 at 11:35 AM, V5 (LPN) stated a resident's pain is subjective to the resident. When a resident has pain, it needs to be addressed as soon as possible. On 3/13/24 at 9:31 AM, V16 (RN) said that the locked medication dispenser is there for when residents require PRN pain medications or antibiotics, and the facility has not yet received them from the pharmacy. V16 said to retrieve medications from the locked medication dispenser, the nurse on duty has to call the pharmacy, provide the paper script sent from the hospital, and they will receive a one-time code to access the medication to provide to the resident. V16 said that the facility had the paper script from the hospital and the nurse on duty would have been able to remove the medication from the locked medication dispenser on 3/8/24 or 3/9/24, when the medication was needed. Facility Active Inventory form (locked medication dispenser) shows Oxycodone HCL 5 mg tablet is available in the locked medication box in the nurse's station on the 3rd floor. On 3/13/24 at 1:12 PM, V20 (Nurse Practitioner) said that the facility had the medication available in the locked medication box. V20 would have expected the nurse on duty to retrieve the medication from the locked medication box to give to R326. The facility Pain Assessment and Management policy dated 10/22 states, . 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals . Monitoring and Modifying Approaches . 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.

Based on observation, interview, and record review the facility failed to ensure a resident received treatment in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. This failure resulted in R1 waiting for 4 days to receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: R1's Facesheet shows R1 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact and requires extensive assistance of two person for activities of daily living. R1's Nurses Note dated 9/1/21 shows R1 was admitted to the facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Event Report dated 9/4/21 (Saturday Night) at 6:25 PM, shows R1 was observed sitting on the floor by chair, states he slid off while trying to push away the table .resident tried to push away table with his body weight and slid off the sheet covered chair. This same document shows a skin assessment was done with no new injury noted, the x-ray is marked N/A and doesn't contain documentation that a hip assessment or range of motion was done. R1's Nurses Notes dated 9/4/21 shows patient observed sitting on the floor by the chair. He states that he slid off while trying to push away the table. No skin injury observed. Patient denies new pain. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nurses Note dated 9/6/21 at 1:56 PM, shows R1 stayed in bed all shift and refused to get up during physical therapy. R1's Nurses Note dated 9/6/21 at 11:14 PM, shows R1 complains of unrelieved pain. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physical Therapy Note dated 9/7/21 shows patient refused therapy in AM twice despite max encouragement. Patient was agreeable to do something light in late afternoon .Patient unable to stand longer than 10 seconds due to severe pain in the left hip .Patient reported he was getting dizzy from all the exertion and pain and requested to go back to bed. R1's Nurses Note dated 9/7/21 at 11:00 PM, shows R1 is very confused at bedtime making conversation that does not make logical sense. surgical site with moderate swelling. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nurses Note dated 9/8/21 at 2:42 PM, shows Left lower extremity swollen and resident complained of the same intensity of pain even after [MEDICATION(S)] pain medication 2 hours ago. Referred to V13 (Psychiatry MD), checked with order to do x-ray on left hip. R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient notes pain with movement does help to [MEDICATION(S)] but does not relieve thoroughly X-ray immediately ordered to check for possible hip dislocation Physical Exam: Upon closer examination of left hip patient does have shortening hip on the left with external rotation concerning a possible dislocation. R1's Left Hip X-ray Report dated 9/8/21 shows Examination reveals total left hip replacement prosthesis with dislocation and superior displacement of the metallic head prosthesis outside the confines of the metallic acetabular prosthesis .Impression Left Hip: Dislocated metallic hip prosthesis. R1's Nurses Note dated 9/8/21 shows R1 left facility at 5:20 PM via ambulance. admitted to hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/14/22 at 11:00 AM, V5 Physical Therapist said she remembered when she saw R1 he was in a lot of pain, and she reported to the nurse that R1's leg didn't look good, it was swollen and his pain was getting worse, something was not right. V5 said she asked can someone order an x-ray for unusual pain and the nurse told her no he was fine he has been cleared, go ahead with therapy. V5 said the next day she reported to V13 what was going on with R1 and he ordered an x-ray. V5 said she was told R1's foot slipped while using the commode, it was not really a fall. V5 was not aware R1 had had a fall and was found on the floor, she was only aware of the commode episode. V5 said if he did fall they should have done an x-ray right away. On 2/14/22 at 1:01 PM, V13 said when he came into the facility after the holiday weekend, therapy staff reported R1's pain and refusal of therapy and he ordered an x-ray. V13 said during his exam of R1 he noticed slight external rotation of the left hip. V13 said the x-ray technician, pulled him aside to show him the film. V13 said R1's x-ray showed rotation, the hip was dislocated. V13 stated I was upset, why did this take so long? I had a talk with the nursing staff that when the pain was reported why didn't they inform primary or get an x-ray right away especially with a history of a full hip replacement? This shouldn't have taken so long. This is a shame this happened. V13 said he was unaware of a fall, he was just told R1's leg slipped while using the commode. V13 stated if he did fall why didn't they follow some protocol and get an x-ray? During the fall, R1 could have flexed his legs and ended up dislocating his hip. On 2/14/22 at 12:47 PM, V12 Licensed Practical Nurse said she could not recall R1, but if after a fall, the patient (with hip replacement) was reporting increased pain, or increased swelling was noticed, and or if therapy was reporting a change she would notify the doctor right away and get an x-ray to see if the hip was dislocated. On 2/14/22 at 12:32 PM, V2 Director of Nursing said she didn't know the details of R1 or the fall, she only looked up R1's information after he was sent out. V2 said after a fall, nursing should monitor for changes in condition from baseline including: increased pain, increased swelling, behavior changes, or reports of change from therapy and should notify the doctor right away. On 2/15/22 at 11:20 AM, V14 (R1's wife) said R1 went to the facility on [DATE] after a left hip replacement for therapy. V14 due to COVID restrictions at the time, she was unable to visit but spoke with R1 on the phone daily. V14 said R1 didn't answer his phone all day on Saturday 9/4/21 but she was finally able to reach him on Sunday 9/5/21. V14 said R1 said he fell in the bathroom and was screaming he couldn't move his leg it was like a balloon, and he couldn't straighten it. V14 said he sounded drugged and not himself so she called the nurse. V14 said the nurse said nothing was wrong he was ok. V14 said on Monday 9/6/21 when she talked to R1 he said the therapist said something about inflammation in his leg. V14 said she again called the nurse and was told R1 was a liar and he didn't know what he was talking about. On 9/7/21, V14 said when she called R1 was talking about grasshoppers on the ceiling so she called the nurse again to tell them he was hallucinating. V14 said again the nurse said he was OK. V14 said on 9/8/21 she received a call from the facility around 6 PM, saying they were sending R1 to the emergency room . V14 said she called the emergency room as was told R1's left hip was extremely dislocated. V14 said she went to the hospital on 9/9/21 and R1's hip was externally rotated and his leg was 6 inches shorter according to the nurses. V14 said the orthopedic surgeon reported the hip had so much inflammation from waiting so long he couldn't be sure there wasn't a fracture. V14 said the orthopedic surgeon performed a closed reduction surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Falls Clinical Protocol dated 11/2011 does not address resident treatment/monitoring after a fall.

Based on interview and record review the facility staff failed to safely transfer a resident. The facility failure resulted in R1 sustaining a fracture of her right lower leg. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's admission facesheet dated 2/10/20 shows that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/10/20 at 9:23 AM, V3 (Physical Therapy) said that R1 came in for therapy due to previously using sit to stand lift machine at an assisted living facility and needed to be able to use it again before returning there. V3 said that during therapy R1 practiced with the sit to stand, but it was still not a safe way to transfer. R1 had limited range of motion to her upper extremities and was not able to bear weight because of pain in her feet. R1 was able to transfer safely with a slide board. On 2/10/20 at 9:00 AM, V2 (Director of Nursing) said that R1 is still in the hospital, and they have not gotten any updates on how R1 is doing. She said that R1 was originally admitted to the facility for a short term stay to work on building her strength. At 10:56 AM V2 said that the facility requires two staff to be present for sit to stand transfers. She said it is important that the resident be able to bear at least 50% of their weight, and they need upper extremity strength. V2 said that (Certified Nursing Assistants) can get information on a resident's transfer status from the nurse, the Resident Information Sheet which is updated one to two times a week by the Restorative Nurse, and nurses have to do a summary of the residents which CNA's can see on the computers. On 2/10/20 at 12:35 PM, V7 (CNA), said that her co-workers were busy with another resident so she used the sit to stand lift machine to change R1 by herself. V7 said when she started lifting R1, she slipped down onto the floor. R1 complained about pain to her back and neck from hitting the wheelchair during the fall. V7 said the nurse told her to use the sit to stand to transfer R1. On 2/10/20 at 11:20 AM, V6, Licensed Practical Nurse (LPN), Restorative Nurse, said that he updates the Resident Information Sheet, which includes information on how to transfer residents, once a week. R1 was not on the Resident Information Sheet because she was only at the facility less than a week. V6 said that if therapy has made recommendations on how to transfer a resident, therapy's recommendation should be followed. On 2/10/20 at 10:45 AM, V5 (LPN) said that when using any lift there should be two staff present. V5 said that CNA's can obtain direction on how a resident transfers from the nurse or from the Resident Information Sheet that is located at the Nurses Station. At 12:15 PM, V5 said that she was the nurse for R1 the day the accident occurred. She said that she knew V7 was going to need to transfer R1 soon and told her that she would help with the transfer. Next thing she knew, V7 came and told her that R1 had fallen. V5 said she walked in the room and R1 was on the floor on her back with her legs still strapped to the sit to stand lift machine. She was told that R1 hit her head and shoulder on the wheelchair during the fall. V5 said that she and therapy had practiced using the sit to stand with R1 on Monday 2/3/20, but R1 was not able to tolerate it for a long time. She said that therapy was considering using the sit to stand, but they (nursing staff and therapy) were still communicating to CNA's that the slide board was the preferred method of transfer for R1 for safety. On 2/10/20 V8 - V10, (CNAs) stated that they are supposed to use 2 people when using the sit to stand lifting machine. They are told how a resident transfers from the nurse, the Resident Information Sheet (located at the nurse's station), or the care plan. On 2/10/20 at 12:52 PM, V4 (Medical Doctor) stated that he has not seen R1 since she was sent to the hospital. R1 did sustain a right leg fracture, and it is his understanding that the facture was due to the fall that occurred on 2/4/20 at the facility. R1's x-ray results dated 2/4/20 showed acute fractures of the right tibia and fibula (lower leg bones). The Physical Therapy Evaluation and Plan of Care for R1, dated 1/29/20, shows that R1 was unable to tolerate the sit to stand lift machine to transfer from bed to wheelchair. The therapist decided to try the slide board technique for which patient was able to transfer from bed to the wheelchair with patient needing max assist. Physical Therapy notes dated 2/3/20 show that R1 was able to practice with the sit to stand machine but was not able to fully transfer from the wheelchair to another surface since patient was not able to support her weight through her feet. The Resident Summary dated 1/29/20 shows that the resident was a total assist by 2 people with a mechanical lift. The Resident Summary dated 1/31/20 shows that the resident was an extensive assist by two people (with no mention of using a lift or slide board). The instruction manual for the mechanical lift shows The intended use of this lifting device is for the safe lifting and transfer of an individual from on resting surface to another . recommends that the transfer of a patient is fully risk assessed and conducted safely ., and .is suitable for patients in the sitting position only who have a degree of weight-bearing ability . The facility's undated Competency for a sit to stand lift shows that skills demonstrated include 1. Employee able to verbalize . importance of 2 person assist when using the lift .