Every finding on record at Regency Care

Based on interview, observation and record review, the facility failed to complete timely and complete incontinent care for 3 of 4 residents (R3, R6, R9); reviewed for bowel/bladder incontinence in a sample of 11. This failure resulted in R6 and R9 having feelings of embarrassment and helplessness.Findings include:1.R9's Facesheet with a print date of 7/30/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus, and major depressive disorder.R9's Minimum Data Set (MDS) dated [DATE] documented he is moderately cognitively impaired. MDS dated [DATE] documented he was dependent on staff for toileting hygiene and toileting transfers. On 8/10/26 at 11:12 AM, V1 stated R9 refused to answer BIMS (Bried Interview for Mental Status) questions on 6/15/26 and attached the previous BIMS which does have answers (3/18/26).R9's Care Plan revised on 1/13/26 documented he is at risk for further skin integrity impairment related to disease process with an intervention initiated on 4/28/25 for staff to provide incontinence care after each episode according to facility protocol. R9's Care Plan revised on 4/28/25 documented he has bowel and bladder incontinence with interventions of, in part, for staff to offer toileting routinely and as needed, and to provide peri care as needed.On 7/29/26 at 9:29 AM, R9 was waiting right outside his doorway in the hallway stating he was waiting for V10 (certified nursing assistant/CNA) to come back and help him to the bathroom. R9 stated he had been waiting for about 10 minutes now and ended up soiling himself. R9 stated it makes him feel bad because he has a call light on that is not being answered and makes him think they forget about him. R9 stated V10 saw him with his light on even before she started helping the other lady. R9 stated this makes him feel helpless because he would go to the bathroom himself if he could walk.On 7/29/26 at 9:34 AM, V10 came to assist R9 to the toilet. V10 removed R9's brief which was completely saturated in urine from front to back. V10 had R9 stand and wiped his buttock region then applied his brief and pants without wiping his front peri region or offering.2.R6's Facesheet with a print date of 7/30/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, type two diabetes mellitus, polyneuropathy, and chronic kidney disease.R6's MDS dated [DATE] documented she was cognitively intact and required substantial/maximal assistance from staff for toileting hygiene and toileting transfers.R6's Care Plan revised on 4/20/25 documented she is frequently incontinent of bladder with interventions revised on 4/29/25 of, in part, for staff to change disposable briefs every 2 hours and as needed and to check her every 2 hours and as required for incontinence.On 7/28/26 at 12:27 PM, R6 stated she has been left for over an hour waiting to use the restroom and often soils herself from waiting too long. R6 stated it doesn't make her feel good. R6 stated tearfully she gets upset now about her care, she should not be treated this way after paying so much. R6 stated she just wished they had more staff so she could get to the toilet before wetting herself, it feels embarrassing, and she's not used to this.3.R3's Facesheet with a print date of 7/30/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, Alzheimer's disease, myoclonus, and depression.R3's MDS dated [DATE] documented she is rarely/never understood and that she is completely dependent on staff for assistance with all self-care and all mobility.R3's Care Plan initiated on 5/30/25 documented she had bowel/bladder incontinence with intervention of, in part, for staff to check her as required for incontinence, to wash, rinse and dry perineum, and to change clothing as needed after incontinence episodes.On 7/28/26 at 10:05 AM, V6 (R3's caregiver) stated she comes in the morning and stays until 1:00 PM to provide R3 with baths, feeding, and daily activities. V6 stated she will come in the morning and R3's briefs will be completely saturated with her linen soiled, unchanged. V6 stated there's no reason she should be left like that until she gets there.On 7/29/26 at 8:54 AM, V6 (R3's caregiver) just arrived in her room for the day and stated R3 was wet, then lifted up her sheets to show a saturated brief and turned her call light on.On 7/29/26 at 8:56 AM, V7 and V9 (CNA) came into R3's room to provide incontinence care. V7 and V9 cleaned R3 up but did not remove the soiled pad underneath her or replace it and left her lying on top of it after putting a new brief on and pants. After V7 and V9 left the room, V6 removed the dirty pad and lifted it up, the pad had a foul odor of urine coming from it with a slight urine ring.On 7/30/26 at 9:53 AM, R11 stated she is the president of the resident council and the concerns mentioned in the past three months were about waiting for long periods of time for incontinence care and the restroom.On 8/10/26 at 9:31 AM, V20 (MD) stated he expects staff to be providing timely and complete incontinent care per the facility's policy. V20 stated there is potential for psychosocial harm for feelings of helplessness and embarrassment if a resident is left waiting long periods of time in a soiled brief but it does depend on the timing and patient, such as whether they wanted to be changed.8/10/26 at 11:34 AM, V1 (administrator) stated she expects staff to replace a soiled pad with incontinent care and expects both front and back regions to be cleaned. V1 stated she expects full peri care to be offered. V1 stated there is potential for psychosocial harm with feelings of helplessness and embarrassment from being left soiled while waiting for toileting assistance if that is the way they are feeling.On 7/30/26 at 10:00 AM, V2 (director of nursing/DON) stated waiting for long periods of time for incontinence care while soiled can have the potential to cause psychosocial harm with a resident.On 7/30/26 at 11:24 AM, V18 (CNA) stated incontinent care includes cleaning front and back regions that are soiled and replacing any soiled linens, pads, or clothing. V18 stated incontinent care is supposed to be offered at least every 2 hours and as needed. V18 stated it should be timely, and residents should not have to wait soiled for long periods of time. V18 stated if she had to wait for long periods of time soiled it would make her feel upset, sad, and humiliated.The facility's Perineal Care Policy and Procedure last revised 11/2026 documented residents who require assistance from nursing staff to cleanse their perineal area will be cleansed in a manner that decreases the risk of transmission of infection and promotes skin integrity. The perineal care includes care of the external genitalia and anal area. Apply a clean brief or incontinent pad if applicable.

Based on interview and record review, the facility failed to update medication orders as ordered by a provider for 1 of 3 residents (R1) reviewed for pharmacy services/procedures/pharmacist/records in a sample of 11.Findings include:R1's Facesheet with a print date of 7/30/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, other specified disorders of bone density and structure, type two diabetes mellitus, and vitamin D deficiency.R1's Orders with a start date of 5/12/16 at 8:00 AM documented Vitamin D3 Oral Tablet (Cholecalciferol) Give 4000 unit by mouth in the morning for supplement.R1's Orders with a start date of 2/2/26 and discontinue date of 7/28/26 documented Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth in the morning for supplement. R1's Health Status Note dated 5/15/26 at 4:15 PM documented, Endo (endocrinology) called with results of density scan being osteoporosis. new orders calcium 1200 mg (milligram) dly (daily), it D3 (viamin D3) 4000 units dly, increase Januvia to 50 mg dly, discontinue Actos and start Prolia 60 mg SubQ (subcutaneous) every 6 months will make daughter aware.R1's Medication Administration Records (MARs) from May through July 2026 documented the order for Vitamin D3 Oral Tablet (Cholecalciferol) Give 4000 unit by mouth in the morning for supplement was started on 5/12/26 continued to be administered to R1.R1's MAR's from May through July 2026 documented the order for Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth in the morning for supplement was started on 2/2/26 and was administered until 7/28/26.On 7/28/26 at 8:52 AM, V4 (licensed practical nurse/LPN) went to administer R1's medications. V4 stated she didn't have the Vitamin D3 available and needed to go get it along with a new insulin pen. V4 went to medication room and could not find vitamin D3 available and reported this to V5 (restorative registered nurse/RN). V5 stated she would try to find some for her. At 9:21 AM, V5 stated she had to correct the orders for R1's vitamin D3 there were two. V4 stated V5 saw that the old order of vitamin D3 had not been discontinued back in May. V4 stated V5 is going to discontinue one of the orders and she is supposed to give R1 4,000 units. V4 stated R1's vitamin D3 had a duplicate order, and one hadn't been discontinued. V4 administered R1 her vitamin D3 at a dose of 4,000 units and discarded the remaining extra dose.On 7/29/26 at 12:02 PM, V2 (director of nursing/DON) stated V2 stated R1's Vitamin D3 was originally 2,000 units and was increased to 4,000 but whoever put in the increased dose did not update the existing order and instead created another one and did not discontinue the original one. V2 stated her expectation is that the proper dose of medications to be entered into the MAR and other orders discontinued as appropriate.On 8/10/26 at 11:34 AM, V1 (administrator) stated she expects orders to be updated as ordered by a provider and discontinued appropriately.On 8/10/26 at 9:31 AM, V20 (medical director/MD) stated he expects nurses to be putting orders in as recommended by a provider and to discontinue them appropriately as needed.The facility's Medication Administration policy dated 1/11/10 documented the objective is to provide accuracy during medication pass to assure quality care for residents.The facility's Physician Orders policy last revised on 5/2022 documented it is the policy to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility.

Based on observation, interview and record review the facility failed to label, store and secure medications for 5 of 5 residents (R11, R13, R18, R30 and R81) reviewed for medication storage in a sample list of 37.Findings include: 1. On 05/26/2026 at 10:47 AM, there was a medication cup with a white powdery substance inside that was not labeled sitting on R11's overbed table. R11 stated that the nurse last night gave it to R11 and was told it was R11's Nystatin powder (antifungal) for R11's itching. R11 continued to state that R11 was going to have the girl put it on R11 this morning. There was also a container of Flonase nasal spray on R11's over bed table. There was no pharmacy label on the Flonase and no date of when it was first accessed. The expiration date, on the bottle of Flonase, was 1/2026. R11 stated that R11 brought that with R11 from home when R11 came to the facility and that it was about empty. R11's Minimum Data Set, dated [DATE], documented that R11's cognition was intact. R11's Physicians Order Sheet, dated 5/16/2026, documents orders for Nystatin External Powder, 100000 UNIT/(Gram)GM. Apply to under breasts & axilla topically as needed for yeasty rash twice daily if needed. It also documented an order for Fluticasone Propionate Nasal Suspension 50 (micrograms) MCG/ (actuation)ACT. 2 sprays in both nostrils at bedtime for allergic rhinitis for 14 Days and 2 sprays in both nostrils every 24 hours as needed for allergic rhinitis and nasal congestion. R11's Physician's order does not document an order to self-administer medications. R11's Medication Administration Record and Treatment Administration record, dated May of 2026, does not document that these medications could be self-administered. 2. On 05/26/2026 at 10:55 AM, there was a bottle of Fungi-nail (anti-fungal nail treatment), not labeled, not dated on R13's overbed table. R13 stated that the nurses will leave R13's medication at R13's bedside and that R13 can put the nail treatment on R13's self and that's why they left it for R13 to do. R13's MDS dated , 5/1/2026 documents that R13's cognition was moderately impaired. R13's Physicians Order Sheet, dated 2/26/2026, documents an order for Fungi-Nail External Solution (Undecylenic Acid). Apply to toes topically every day shift for fungus. R13's Medication Administration Record and Treatment Administration record, dated May of 2026, does not document that these medications could be self-administered. 3. On 05/26/2026 at 11:30 AM, there was a bottle of 70% Isopropyl Alcohol (rubbing alcohol) sitting on R81's over bed table. R81 stated that R81's son brought it into the facility. R81's MDS, dated [DATE], documents that R81's cognition is severely impaired. R81's Physician's order sheet does not document an order for rubbing alcohol or its intended use. 4. On 5/27/2026 at 9:02 AM V12 prepared medications at the medication cart, collected supplies and entered a resident room, V12 left the medication cart unlocked and unattended in hallway. Nurse returned from resident room after several minutes. 5. On 5/28/2026 at 8:50 AM in the South 300 hall Medication Cart, R30's Lantus (insulin) multiuse pen was open and in use but there was no date written on the pen when it was first opened. R18's Novolin R (insulin) multiuse pen was open and in use but not dated with the date it was first opened. At this time, V12 Assistant Director of Nursing (ADON), confirmed both R30 and R18's insulin pens were opened, used and not dated. Also, in this medication cart there was a Milk of Magnesium multiuse bottle open and in use, but no date written on the bottle when it was opened. There was also a bottle of Geri-Lanta (antacid) multiuse bottle open and in use but not dated. V12 confirmed the bottles were not dated with the date that they were first opened. R18's Physician Order Sheet dated 5/2026 documents HumuLIN N Subcutaneous Suspension Inject 15 unit subcutaneously at bedtime. It also documents a diagnosis of TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA. R30's Physician Order Sheet (POS) dated 5/2026 documents Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 8 unit subcutaneously at bedtime. This POS also documents a diagnosis of TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. 6. On 5/28/2026 at 8:55 AM in the South 100 hall medication cart there were single use eye drop ampules in a compartment with no pharmacy label affixed to them. There was also a Miralax (laxative) multiuse bottle open and in use and not dated. 7. On 5/28/2026 at 9:10 AM in the North 100 hall medication cart there was a Geri-Lanta (antacid) multiuse bottle open and in use and there was no date written on the bottle when it was opened. 8. On 5/28/2026 at 9:20 AM in the [NAME] Medication Room there was a Tubersol multiuse vial opened and in use but not dated with the date it was first accessed. On 5/28/2026 at 9:25 AM V3 stated anything opened, even stock medication needs to be dated with the date that it was opened. V3 stated the TB solution is used throughout the facility and should have been dated when opened. On 05/28/2026 at 12:40 PM V22, License Practical Nurse (LPN), stated that if a resident was able to keep their medication at the bedside, there should be an order in the resident's chart that would say may keep medication at bedside. V22 continued to state that R11 does not have an order to keep R11's Flonase nor for R11's nystatin powder at the bedside. V22 stated that R81 does not have a physician's order for the rubbing alcohol that has been left at R81's bedside and that R81's family brings it in. On 05/28/2026 at 12:44 PM V28, Registered Nurse (RN), stated that V28 admitted R13 and thought that V28 had written R13's order for R13's toenail treatment for R13 to do. V28 also stated that R13 has been doing that treatment on R13's own since R13 was admitted . On 05/28/2026 at 1:21 PM V2, Director of Nurses stated that medications should not be left at the resident's bedside. The facility's policy, Self Administration of Medication Protocol, dated 10/2005, documents, The facility nursing staff is responsible for drug storage and for recording self-administration in the residents Medication Administration Record (MAR). Any medication that is being self-administered will be indicated as such on the Medication Administration Record (MAR). The facility's policy, Medication Administration, dated 1/11/2021, documents, 13. Make sure the resident takes the medication. Generally- Do not leave meds at bedside (may be exceptions after thorough assessment and care planning. The facility's policy, Storage of Medications, dated 4/17/2025, documents, A. The provider pharmacy dispenses medication in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. It continues, Expiration dating (Beyond-use dating). It continues, D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration.

Based on observation, interview, and record review, the Facility failed store and serve food and clean essential equipment (ice machine) in a manner that prevents potential contamination. This has the potential to affect all 87 residents living in the Facility.Findings include: 1. On 5/26/2026 at 9:30 AM, the dry storage room felt excessively warm and had no air flow. V9, Dietary Manager, stated it gets pretty warm in there. On 5/26/26 at 9:58 AM, the dry storage room temperature measured 92.7 degrees Fahrenheit (F) when pointing a metal infrared thermometer directly through the middle of the room. The ceiling air vent measured 83.8 degrees F with the infrared thermometer. The vent on the bottom of the freezer measured 89.0 degrees F with the infrared thermometer. In the same dry storage room, there was a rack filled with bread and a rack with boxes of apples, oranges, bananas, potatoes, and sweet potatoes. On 5/28/26 at 1:40 PM, V29, [NAME] President of Culinary Services, stated the Facility should follow Food Code for dry storage temperatures, and the range of 83 to 93 degrees Fahrenheit is too warm. 2. On 5/26/26 at 11:45 AM, V10, Cook, was serving food from the steam table. V10 had a beard on V10's chin that was approximately 1/4 inch long which was not covered by the beard net. V9 was standing at the end of the steam table and had a 2–3-inch beard which was not covered by a beard net. On 5/26/26 at 12:05 AM, V9 stated beard nets should be worn in the kitchen. 3. On 5/26/2026 at 11:10 AM ice machine on 100 hall noted to have yellow sludge at base of drain pipe. 4. On 5/27/2026 at 12:50 PM V11 Environmental Service Director stated the machines are deep cleaned every 3 months. V11 stated the sludge is not a concern due to there is no tubing that the sludge could travel up and if there was a clog they would be able to tell because water would not be draining. 5. On 5/27/2026 at 12:58pm 300 hall ice machine interior had brown speckling and debris noted on bottom edge of the inner lip of the ice chest with water dripping from inner lip onto clean ice. V11 Environmental Service Director took a paper towel and wiped off brown speckling. V11 stated brown speckling was mineral buildup and V11 stated he is not concerned with build up unless it is pink in color, pink indicates fungal growth. 6. On 5/29/2026 at 12:05 PM V1 Administrator stated the facility does not have a policy regarding ice machine cleaning or use. No policy regarding Ice machine cleaning was provided. The Facility's Personal Hygiene: Illness, Shoes, Hair Restraints Policy dated 2/2022 documents employees will use effective hair restraints such as hats, hair coverings, beards restraints and clothing that cover body hair to effectively keep their hair from contacting exposed food and clean equipment. [NAME] guards will be available to men with beards. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 5/26/26 documents there are 87 residents living in the Facility.

Based on observation, interview and record review the facility failed to follow policy and procedure for infection control practices by failing to post Enhanced Barrier Precaution signs and have Personal Protective Equipment readily available (R5), and the facility failed to obtain Urinalysis Culture results to be able to monitor, analyze and track infection rates. This has the potential effect all 87 residents.1. On 5/26/2026 at 10:30am there was no Enhanced Barrier Precautions (EBP) sign on R5's door. There was no personal protective equipment (PPE) located near R5's room. On 5/26/2025 at 3:30pm V32 Certified Nursing Assistant (CNA) entered R5's room to assist R5 into bed following dialysis. V32 did not don PPE. On 5/28/2026 at 8:30am there was now an EBP sign placed on R5's door and there was also PPE now available near R5's room. R5's Physician's orders dated 10/3/2024 documents that R5 is to be on EPB precautions. R5's care plan dated 4/30/2026 documents R5 has a diagnosis of End Stage Renal disease and that R5 receives hemodialysis three times weekly on Tuesday, Thursday and Friday mornings every week. R5's Minimum Data Set score dated 4/30/2026 documents R5 is cognitively intact. On 5/27/2026 at 11:12 am R5 stated staff does not use PPE when providing care to me(R5). On 5/27/26 at 1:00 pm, V16 Registered Nurse (RN) stated, I use PPE depending on what I am doing with (R5). On 5/27/2026 at 1:10 pm V13 CNA stated, I do not use PPE with (R5). On 5/27/2026 at 1:20pm V3 Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated, Yes, (R5) should be on EBP. (R5) had a sign. I do not know how it was removed. 2. The Facility's Infection Control Log does not list a causative organism for R83's 2/19/26 UTI (Urinary Tract Infection), for R37's 3/18/26 UTI, for R10's 3/24/26 or 4/10/26's UTI or for R69's 4/29/26 UTI. On 5/28/26 at 2:50 PM, V3, Infection Preventionist (IP), stated sometimes it is difficult to obtain urine cultures for residents from the hospital making it harder to track which organisms are in the building. V3 stated V3 cannot always get the organisms and V3 could not explain how V3 is tracking and trending without knowing which organisms are in the facility. On 5/29/26 at 9:56 AM, V1, Administrator, stated V1 expects the Facility to follow its infection control policies. The Facility's Surveillance Policy revised 4/2022 documents all residents are monitored for current infections. In addition, the monthly log contains all infections and is used for identification of underlying cause(s) of infection trends. The facility compares current infection surveillance data to past data to detect unusual or unexpected outcomes, trends, potential ineffective practices, and performance issues. This data is used to improve outcomes and enhance resident care. The Facility's Enhanced Barrier Precautions Protocol revised 4/8/24 documents, Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in educating staff, residents, and visitors on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for the resident. The Policy continues, EBP should be used for residents with indwelling medical devices including central lines. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 5/26/26 documents there are 87 residents living in the Facility.

Based on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL) assistance such as showering and nail care for 2 of 2 residents (R2 and R94) in the sample list of 37.Findings include: 1. On 5/26/2026 at 9:30 AM, R2 was lying in R2's bed with R2's left hand outside blankets contracted into a fist. R2's first and second fingernails on left hand were more than 1/2 inch in length. R2's third and fourth fingernails were not visible. R2's right hand had all five fingernails more than a half an inch in length. R2's fingernails were pale, thin and had jagged edges with dark matter noted underneath the fingernails. On 5/26/2026 at 12:52 PM, R2's fingernails were still dirty, long and uncut on both contracted hands. On 5/27/2026 at 1:20 PM, V15 Certified Nurses Assistance (CNA) confirmed R2's fingernails on both hands were still dirty, long and had jagged edges. On 5/27/2026 at 8:30 AM, V5 CNA stated R2's fingernails were cut 2 months ago, R2's nails are cut due to the risk of R2's nails cutting into his palm. V5 stated staff try and put washcloths in his hands but they hurt and he gets irritated. On 5/27/2026 at 1:00 PM, V14 Certified Occupational Assistant (COTA) stated R2's fingernails are supposed to be kept short and CNAs or nurses are to cut R2's fingernails. V14 stated it is not impossible to perform the task, and it gets done sometimes, depending on R2's behavior. V14 stated R2 is more compliant with cares with the right approach. On 5/27/2026 at 1:15 PM, V3 Assistant Director of Nursing (ADON) stated R2's fingernails should be checked weekly due to R2's contractions. V3 continued to state R2's fingernails could cut into R2's palms. V3 stated the CNA staff know to check R2's nails and if they are comfortable can cut it themselves or notify the nurse to do it. On 5/28/2026 at 3:15 PM, V2 Director of Nursing (DON) stated that if R2 allowed staff to place the washcloth that day R2's nails would have been cut that day because R2 would have allowed it to happen. V2 confirmed V2 has not seen R2's nails for several weeks due to training staff, state surveys and being kept busy. R2's care plan dated 4/16/2026 documents R2 has the potential for impaired skin integrity with the intervention of Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails trimmed and filed as needed. R2 is at risk for an Activities of Daily Living Self Care Performance Deficit related to Impaired balance and impaired cognition with the interventions of R2 is dependent on staff for personal hygiene. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. R2's Physician Order Sheets dated 5/2026 documents a diagnosis of Alzheimer's Disease, Unspecified. 2. R94's shower schedule shows that R94 is to receive a shower on Mondays and Thursdays between 2:00 PM to 10:00 PM. R94's Brief Interview for Mental Status dated 5/27/26 documents R94 has no cognitive impairment. On 5/26/26 at 1:24 PM, R94 stated R94 has not received a shower since R94's admission date on 5/23/26. R94 stated staff has not assisted R94 with oral hygiene. R94 stated R94 would like to receive a shower. On 5/27/26 at 9:02 AM, R94 stated R94 has still not yet had a shower or been offered a shower. R94 stated R94 has not been told when R94's shower days will be. R94 stated R94 would be okay with showering twice weekly. On 5/28/26 at 9:01 AM, R94 stated R94 has still not had a shower and has not seen anyone to ask for a shower. On 5/29/26 at 8:48 AM, R94 stated R94 did not receive a shower yesterday. R94 stated R94 is wanting to have a shower. R94 stated R94 has not been offered assistance with oral hygiene, peri-care, a bed bath, or any personal hygiene. On 5/29/26 at 8:56 AM, V2 Director of Nursing (DON) stated V2 would expect residents to receive a shower twice weekly. V2 stated V2 would expect staff to reapproach residents at a later time if they refuse their shower. V2 stated V2 would expect staff to offer assistance with a bed bath, perineal care, or other personal hygiene if a shower is not able to be completed. V2 stated the shower schedule can be rearranged per residents' preferences if needed. On 5/29/26 at 9:37 AM, V2 DON stated V2 is unable to provide any completed shower sheets for R94. On 5/29/26 at 9:32 AM, V1 Administrator stated the facility follows the Centers for Medicare and Medicaid Services guidelines for residents' showers since the facility does not have their own shower policy. The facility's Resident Care Policy and Procedure revised on 10/17/24 documents that personal hygiene and nail care should be provided to the residents every morning.

Based on observation, interview and record review the facility failed to provide range of motion exercises and therapeutic devices for 2 of 2 residents (R2 and R31) reviewed for positioning and mobility in the sample list of 37.1. On 5/26/2026 at 09:30 AM, R2 was lying in R2's bed with R2's hands outside of the blankets. R2 did not have a rolled washcloth in either R2's left hand or R2's right hand. On 5/26/2026 at 12:52 PM, R2 was lying in bed with no washcloths rolled up in either of R2's hands. On 5/27/2026 at 1:20 PM, V15 Certified Nurse's Assistant (CNA) was attempting to perform passive range of motion. R2 became agitated and jerked R2's hands away from V15. V15 did not attempt to reapproach. On 5/28/2026 at 10:20 AM, R2 was lying in R2's bed with R2's fisted hands on top of the blankets. R2's treatment of rolled washcloths was not in place. On 5/29/2026 at 8:51 AM, R2 was sitting upright in a reclining wheelchair with V13 Certified Nurses Assistant (CNA) transporting R2 down the hall. No washcloths were in either hands. On 5/29/2026 at 10:50 AM, R2 was lying in R2's bed with hands contracted. No washcloth was observed in either hand. On 5/27/2026 at 8:30 AM, V5 Certified Nurses Assistant (CAN) stated staff try and put washcloths in R2's hands but R2's hands hurt and R2 gets irritated. On 5/27/2026 at 11:15 AM, V13 Certified Nurses Aide (CNA) stated R2 receives passive range of motion every day but it is hard to do. V13 stated We do the bare minimum. On 5/27/2026 at 1:00 PM, V14 Certified Occupational Assistant (COTA) stated that they attempted to treat contractures with a (tapered, cone-shaped cushion) positioning device, but it kept getting lost, so it was replaced with washcloths due to expenses. V14 stated that if the resident does not have the splint (wash cloths) in place V14 will notify the CNA staff or Assistant Director of Nursing (ADON/V3) but V14 doesn't always follow up to make sure that the splint is put into place. On 5/27/2026 at 1:15 PM, V3 stated R2's splint treatment is usually in place. On 5/28/2026 at 10:05 AM, V3 stated R2's hands are so contracted that they won't get better and R2 is noncompliant with passive range of motion due to being in pain. V3 stated that when a resident is noncompliant with treatments the physician should be notified. On 5/28/2026 at 3:15 PM, V2 Director of Nursing (DON) stated that it is the expectation that staff attempt to place the washcloths in R2's palms, R2 will often refuse and have aggressive behaviors towards staff. Some staff are more successful with R2's treatment than others. V2 DON stated that when R2 refuses treatment staff are to reapproach at a later time. V2 stated that R2 has been a long-time resident at the facility and the staff know how R2 responds. On 5/29/2026 at 10:30 AM, V2 Director of Nursing stated V2 performed R2's treatment this morning. R2's care plan dated 4/16/2026 documents R2 is at risk for an Activities of Daily Living Self Care Performance Deficit related to impaired balance and impaired cognition with the interventions of PROM-PROM bilateral upper and lower extremities, 3 sets of 10 reps (repetitions) twice a day, all planes to maintain current ability of extensive assist and prevent further contraction and rolled washcloth to be placed in bilateral hands every morning. Always keep (R2) informed as to actions. Allow (R2) to assist. Wash/soak hands with soap and water and dry well before applying wash cloths. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. R2's Physician Order Sheets dated 5/2026 documents a diagnosis of Other Specified Disorders of Muscle. 2. On 5/26/26 at 10:00am R31 was up in R31's wheelchair in R31's room in front of the television. R31 has contractures to both hands, with a rolled towel in the right hand. On 5/27/2026 at 11:00am R31 was lying in a low bed with a towel rolled in R31's right hand. On 5/28/2026 12:20pm R31 was in a low bed in low position with a towel rolled in R31's right hand. After being requested to administer PROM, V13 Certified Nursing Assistant (CNA) performed passive range of motion to R31's hands. On 5/26/26 at 12:02pm V18 R31's Power of Attorney (POA), stated that R31 has been here for three to four years. V18 stated (R31) was doing therapy when (R31) admitted , but (R31) plateaued, and therapy was stopped. V18, R31's POA, stated that No one assists (R31) with range of motion at all. On 5/26/2026 at 12:20pm V13 CNA stated, I did not know we are supposed to do Range of Motion on (R31). On 5/26/2025 at 12:30pm V16 Registered Nurse (RN) stated I see the certified nursing assistants doing range of motion with (R31) sometimes. I know they put a towel in one of (R31's) hands. On 5/28/2026 at 1:35pm V30 Licensed Practical Nurse stated, I have never seen (R31) having range of motion. On 5/28/2026 at 1:40 pm V31 CNA stated, I have known (R31) a long time, and I do range of motion with (R31) when I am here. I work as needed. On 5/28/2026 at 1:42pm V18, R31's POA stated (R31)'s hands have gotten worse since (R31) admitted here three to four years ago. They were not this bad. On 5/28/26 at 1:30pm V2 Director of Nursing states (R31) could benefit from range of motion. It is in (R31's) care plan. There is no documentation record on how often (R31) receives range of motion. R31's care plan dated 4/14/2026 documents (R31) hemiplegia/hemiparesis related to Cerebral Vascular Accident. (R31) will remain free of complications or discomfort related to hemiplegia/hemiparesis through review date. (R31) will have range of motion (active or passive) with am/pm care. R31's Minimum Data Set, dated [DATE] documents (R31) has functional limitation in range of motion with upper extremities on both sides in the shoulder, elbow, wrist, and hand. Policy provided by V1 Administrator dated 1/12/11 documents Inservice shall be held at regular intervals to provide training to staff in principles of contracture treatment and prevention. Section D documents, Encouraging and assisting the resident to perform passive and active optimal joint function to prevent deformities and stimulate circulation and build endurance.

Based on interview and record review, the facility failed to evaluate for a root cause of a fall and implement fall interventions for 2 of 2 residents (R16, R55) reviewed for accidents in the sample list of 37. Findings include: 1-R16's Face Sheet documents R16 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Lack of Coordination, and Abnormalities of Gait and Mobility. R16's Minimum Data Set (MDS) dated [DATE] documented R16 was moderately cognitively impaired, ambulated with a walker, and required supervision with walking. R16's Care Plan initiated 7/3/26 documents R16 is at risk for falls. R16's Progress Note and Fall Investigation dated 1/3/26 both document R16 was found on the floor in a sitting position next to R16's bed with an intervention of Physical and Occupational therapy evaluation. R16's Progress Note dated 3/16/26 documents R16 was walking in R16's room without assistance and became unsteady. A Certified Nursing Assistant (CNA) eased R16 to the floor for safety. R16's Fall Investigation dated 5/28/26 documents R16 was ambulating in R16's room on 3/16/26 when a CNA observed R16 losing R16's balance and assisted in lowering R16 to the floor. There were no interventions listed on the investigation. R16's Care Plan does not document an intervention for R16's 3/16/26 fall. On 5/28/26 at 1:00 PM, V15, CNA, stated R16 does not have any specific fall interventions in place. On 5/28/26 at 1:20 PM, V2, Director of Nursing (DON), stated R16's 3/16/26 fall investigation was just completed today (5/28/26) because V2 was not previously made aware of R16 being lowered to the ground by staff. V2 stated the facility should be completing fall investigations in a timely manner and implementing interventions. 2. On 5/26/2026 at 11:00am R54 was stated, My(R54) roommate (R55) fell, and (R55) was on the ground for 45 minutes before staff came and got (R55) up. On 5/26/2026 at 10:55am V17, R55's caretaker stated that V17 was not aware of R55 being left on the ground at any time. On 5/26/2026 at 11:10am V16 Registered Nurse (RN) stated R55 is a fall risk, but that (R55) is easily redirected. V16 stated V16 was not aware of a fall where R55 was left on the ground for any period. On 5/26/26 at 11:15am V13 Certified Nursing Assistant (CNA) stated, I am not aware of (R55) being left on the floor at any time. On 5/26/2026 at 1:30pm V19 R55's Power of Attorney (POA) was stated that V19 was notified about one fall. V19 stated, (R55) used to fall at home a lot. On 5/28/2026 at 10:30am V25 Physical Therapy Assistant (PTA) was interviewed and stated, I do therapy with (R55). (R55) does well but (R55) is confused. On 5/28/2026 at 10:30am V25 Occupational Therapy Assistant (OTA) states I work with (R55.) V25 stated R55 was placed on therapy because of a fall on 5/25/2026. V25 stated, (R55) is doing well in therapy. On 5/28/2026 at 11:20am V27 Certified Occupational Therapy Assistant (COTA) stated, fall interventions for (R55) are a high-low bed and fall mats On 5/28/26 at 11:55am V2 Director of Nursing (DON) was interviewed about R55's falls and R55's interventions. V2 DON stated, I spoke with (V11) Maintenance Director today to make sure (R55)'s fall mats were in place from (R55)'s fall on 5/25/26. I added the intervention to the care plan today. During the dates of 5/26/2026 and 5/27/2026 multiple observations were made of R55's room and R55 had no fall mats noted at bedside. R55 did not have a concave mattress on R55's bed either. On 5/28/2026 at 8:30am there were fall mats place on each side of R55's bed, and a concave mattress had been placed on R55's bed. The facility's Incident log dated 2/26/2026-05/2026 documents R55 was noted to have a fall on 5/8/2026 at 7:15 pm and R55 had a fall on 5/25/26 at 6:30am. R55's fall scale dated 5/8/2026 documents R55's fall score as 50 indicating that R55 is a high fall risk. R55's admission assessment dated [DATE] documents that R55 requires substantial to total dependent assistance with ADL's (Activities of Daily Living). R55's Care plan dated 5/22/2026 documents I am at risk for falls r/t (related/to) weakness. R55's Brief Interview for Mental Status dated 5/8/26 documents R55 has severely impaired cognition. 5/26/26 fall intervention is documented as fall mats/concave mattress. Interventions for (R55) dated 5/28/2026 documents Physical and Occupational therapy to evaluate and treat and to provide a reacher to pick up items. The Physician's order sheet dated 5/8/2026 documents R55 has a diagnosis of Unspecified Dementia, and a History of Falling. The Facility's Fall Assessment and Management Policy revised 6/2024 documents after residents have a fall, a licensed nurse will consult with the care givers and interdisciplinary team in regard to future intervention and identification of specific risk factors.

Based on interview and record review, the facility failed to obtain urinalysis results timely for a resident symptomatic of a urinary tract infection for one (R19) of one residents reviewed for urinary tract infections in a sample list of 37.Findings include:R19's Minimum Data Set, dated [DATE] shows R19 has no cognitive impairment.On 5/28/26 at 9:32 AM, V12 Registered Nurse (RN) stated V12 called V23 Nurse Practitioner (NP) on 5/18/26 regarding R19 reporting burning with urination. V12 stated V23 ordered a urine sample to be collected at that time to check for a urinary tract infection (UTI).R19's Nursing Progress Note dated 5/18/26 documents Late Entry: (V12) called (V23). New order received for urinalysis (UA) culture and sensitivity along with a complete blood count with differential. Related to complaints of burning with urination from (R19). Writer scheduled lab to be collected on next lab day.R19's Physician Order Sheet documents an order dated 5/18/26 for a UA culture and sensitivity, to collect urine per scheduled lab day and discontinue once collected.R19's Medication Administration Note dated 5/19/26 documents every shift collect urine per scheduled lab day and discontinue once collected. Not collected. R19's Medication Administration Note dated 5/20/26 documents every shift collect urine per scheduled lab day and discontinue once collected. To be collected on Thursday for lab to pick up on Friday.R19's Medication Administration Note dated 5/23/26 documents every shift collect urine per scheduled lab day and discontinue once collected. Lab not here on Sunday.On 5/26/26 at 3:20 PM, R19 stated R19's pelvic pain, urethral pain, and burning with urination began a couple of weeks ago. R19 stated R19 does not feel that R19 is able to empty R19's bladder.On 5/26/26 at 3:29 PM, V7 Licensed Practical Nurse (LPN) stated for the past week R19 has had confusion and has been asking for R19's as needed pain medication frequently. V7 stated R19 is not taking an antibiotic at this time, that the physician is awaiting UA results prior to starting R19 on an antibiotic.On 5/27/26 at 9:04 AM, R19 stated R19 has not heard any information from the nurses regarding the results of the UA. On 5/27/26 at 11:10 AM, V7 was not able to give a definitive answer on what day and time the UA ordered on 5/18/26 was collected. V7 was not able to find any results in the computer system from this UA.On 5/27/26 at 1:33 PM, V7 stated V7 found the old UA sitting in the lab specimen fridge at the facility. V7 stated it was never picked up by the lab. V7 stated the urine had to be discarded due to sitting in the fridge for two days. V7 stated V7 obtained a new UA today via urinary straight catheter. V7 stated the UA was then driven to the lab due to the facility's contracted lab had not yet shown up today.On 5/28/26 at 9:04 AM, R19 stated R19's UTI symptoms are worsening, stating R19 has been having increased pain and burning with urination. R19 stated R19 is concerned about the worsening symptoms and wants an antibiotic to be started soon.On 5/29/26 at 8:51 AM, R19 stated R19 is feeling worse this morning. R19 stated R19 is having a more difficult time urinating due to burning and pain with urination. R19 stated R19 has not been told of R19's UA results, nor has R19 been started on an antibiotic.On 5/27/26 at 2:24 PM, V3 Assistant Director of Nursing and Infection Preventionist Nurse stated V3 would expect a urine sample to be placed as an immediate lab if the resident is symptomatic of a UTI. V3 stated if the resident's condition deteriorates, then the physician should be contacted.On 5/28/26 at 10:24 AM, V23 NP stated she would expect a UA to be collected and sent to lab on the next available lab collection day, but no later than five days after the order was originally placed. V23 stated V23 would expect the facility staff to check at least a temperature if a resident was symptomatic of a UTI.R19's Vital Signs Log shows R19's blood pressure, heart rate, and temperature were last checked on 5/6/26 and within normal limits.On 5/28/26 at 11:08 AM, V26 Chief Nursing Officer stated the facility does not have a policy relating to processing and carrying out physician orders or laboratory orders within a timely manner.

Based on observation, interview, and record review, the facility failed to follow transfer and fall prevention policies and did not provide adequate supervision for 2 of 2 (R2, R6) residents in the sample of 14. This failure resulted in R2 being forcefully lifted from the floor by V5, Certified Nursing Assistant, CNA, without the use of a gait belt or mechanical lift, and R6 sustaining a fall that resulted in a fracture.Findings include:R2's face sheet documents an admission date of 12/4/2025. Diagnosis includes Sepsis, Cerebral Infarction, Type 2 Diabetes, Dementia, Cellulitis of Buttock.R2's Minimum Data Set, MDS, documents R2 is severely cognitively impaired. R2 is dependent for mobility and transfers. Has upper and lower one-sided impairment.R2's care plan updated 12/17/2025 documents R2 is at risk for falls related to history of stroke, traumatic brain injury, history of falls, dementia, incontinence, medication use. Interventions include: 02/1/26 bed/chair alarm. On 1/5/26 cushion in reclining chair, keep within vision of staff when up in wheelchair. 12/7/25 low bed, fall mat. Always keep non-skid footwear on while up. Reclining chair for mobility. Make sure call light is always within reach. No risk of abuse documented on care plan.R2's fall assessment dated [DATE] documents R2 is at high risk for falls.On 2/6/2026 at 10:30am Surveyor observed video of incident involving R2 and V5, Certified Nursing Assistant, CNA. Video time stamped 2/1/2026 at 8:14PM, shows V5 walking into video frame and R2's arm reaching for V5. V5 picks up R2 by R2's shoulders and forcefully puts R2 on the bed. V5 then pulls on R2's right leg and shirt and straightens R2 in bed. V5 then raised R2's bed and puts pillow behind R2. During encounter R2 can be heard calling out Ouch and moaning. No gait belt, no staff assistance, no assessment, no mechanical lift, in room during transfer.R2's progress notes dated 2/1/2026 at 9:15PM documents Situation, Background, Assessment, Recommendation, SBAR, it was reported to writer that R2 rolled out of bed on to the floor. He was observed lying on fall mat next to bed. Background: R2 is on hospice. Can be restless at times and fidgets with his blankets. Alert to self only, confused per normal. Assessment (Registered Nurse)/Appearance (Licensed Practical Nurse): Range of Motion, ROM within normal limits. Neurological within normal limits. No visible injuries.R2's fall investigation dated 2/6/2026 documents R2 was observed on the floor next to his bed lying on the fall mat. Bed was in low position. R2 unable to give description. R2 assisted back to bed. Post fall assessment shows range of motion within normal limits. No signs of pain/discomfort. Head to toe assessment completed with no visible injury noted. R2 did not go to hospital.R2's abuse investigation documents on 2/2/2026 phone interview with V4, Licensed Practical Nurse, LPN, revealed that V4 was not aware that R2 had fallen. This was not reported by V5, CNA. On 2/4/2026 via phone interview with V6, CNA, documented V6 was not aware R2 had a fall and was not asked by V5 to help transfer R2. On 2/5/2025 V7, CNA, documented V7, was not aware R2 had a fall and was not asked by V5 to help transfer R2. Resident interviews documented on R2's abuse investigation documents R7, R8, R9, R10, R11, R12, R13, and R14 all deny ever being improperly transferred in facility.On 2/6/2026 at 10:30AM V8, R2's family member, stated R2 has dementia and gets out of bed. Bed is in low position. We have a video recorder in R2's room and saw on video V5 very forcefully manhandle R2 from floor to bed and forcefully reposition in bed. Stated facility terminated V5. I sent the video in with complaint. Stated R2 can be heard yelling Ouch Ouch. We also sent video to Administrator and police were notified.On 2/6/2026 V1, Administrator, stated I found out about the video on 2/2/2026 the day after it was taken. I found out about the incident from the family. V5 did not report the incident, did not report R2 fell out of bed and was on the floor, did not tell the nurse, did not follow policy and did not transfer appropriately. We started an abuse investigation and fall investigation on 2/2/2026. The Director of Nursing, DON, assessed R2. V5 was terminated on 2/3/2026 when he came in to work. V5 did not work after the video. R2 is very confused, we can't even get a Brief Interview for Mental Status, BIMS on him. Surveyor asked V1 if she thought R2 was intimated by the transfer involving V5. V1 stated I don't feel R2 has the cognition to have been intimidated. The incident was against policy and inappropriate, but I don't think V5 was trying to hurt R2. V5 had been here 3 years and never disciplined. I was shocked. The staff and residents loved him.On 2/13/2026 at 3:00PM V4, LPN, stated I was working the evening that R2 was on the floor in his room and V5, CNA, transferred R2 back to his bed without telling anyone R2 had fallen. I did not find out until a couple of days later that the incident even happened. I had never known V5 to do anything like that. I worked with V5 as a CNA before becoming a nurse and he was not one to roughly handle the residents. If a resident is on the floor the resident is not to be moved until they are assessed, vitals taken, and neuro checks started. V5 did not tell anyone R2 was on the floor.On 2/13/2026 at 11:00AM V11, Assistant Director of Nursing, ADON, denied seeing video of V5 picking R2 up off the floor. Stated I had not known V5 to ever do that. I understand R2 was assessed the next day after the video was shared, and he was not injured. I would expect any resident that is on the floor to be assessed before being transferred and for a gait belt or mechanical lift to be used.On 2/13/2026 at 1:10PM V14, Nurse Practitioner, NP, stated I am not familiar with R2 or the circumstance. If a resident was on the floor, I would expect the use of a gait belt at least and probably a mechanical lift, not pulling them up and putting them back in bed. 2.R6's face sheet documents an admission date of 10/31/2025. Diagnosis includes Senile Degeneration of Brain, Hypertensive Heart Disease with Heart Failure, Congestive Heart Failure, Atrial Fib, Metabolic Encephalopathy. R6's Minimum Data Set, MDS, dated [DATE] documents Brief Interview for Mental status, BIMS, 4. R6 requires partial/moderate assistance with mobility, transfers, and walking.R6's care plan updated 12/22/2025: I had an actual fall related to dementia, poor safety awareness. Interventions include cushion, nonskid footwear, and a clear pathway.R6's fall assessment dated [DATE] documents R6 is a high risk for falls.R6's progress note dated 11/23/2025 at 9:40AM documents Certified Nursing assistant, CNA, alerted nurse that R6 was on floor in another resident's bathroom. R6 located on the floor of the shower in room. R6's head and back against shower wall with feet pointed toward the door, right leg flexed, left leg extended. R6 was holding left shoulder with right hand. R6 was tearful and complained of pain in head, left shoulder, buttocks and right lower extremity. R6 verbalized inability to move. R6 assessed, notifications made, transfer to Emergency Department, ED. R6's progress notes dated 11/24/2025 at 10:00AM documents Situation: Interdisciplinary Team, IDT, met and reviewed. According to nurse documentation: CNA alerted nurse that R6 was on floor in another resident's bathroom. R6 located on the floor of the shower, head and back against shower wall with feet pointed toward the door, right leg flexed, left leg extended. R6 was holding left shoulder with right hand. R6 was tearful and complaining of pain in head, left shoulder, buttocks and right lower extremity. Background: R6 has history of degeneration of the brain-senile, Atrial Fib, dementia, asthma, right clavicle fracture, and prior falls. Assessment according to nurse documentation: Assessed for neurological deficits, safety ensured, CNA delegated to stay with R6, family notification, Emergency Medical Services, EMS, contacted transport, V2, Director of Nursing, DON, notified. Recommendations: 11/24/25: Will review upon return.R6's initial fall investigation dated 11/24/2025 documents (R6), with a BIMS of 4, was observed on the floor in the bathroom. (R6) was taken to the bathroom and assisted to bed approximately 20 minutes prior. R6 complained of pain to left shoulder, right lower extremity, and buttocks. R6 would not allow staff to assist her off of floor due to complaints of pain. Vital Signs, VS, 136/72, 86, 97.3, 18. Neurological checks within normal limits, WNL. Power of Attorney, POA notified and requested R6 be sent to Emergency Room, ER, due to pain. Physician notified. R6 was transferred to ER via ambulance for evaluation. Computerized Axial Tomography, CT, scan results show a nondisplaced avulsion fracture of the right ilium and a re-demonstration minimally displaced right distal clavicle fracture. R6 was admitted to the hospital for treatment of urinary tract infection, UTI and pneumonia. Fractures will not be treated operatively. Investigation initiated, final report to follow. Investigation is complete. R6 with a BIMS of 4, was observed on the floor in the bathroom. Approximately 20 minutes prior, resident was assisted to the bathroom and then bed. Call light was placed within reach. Upon assessment after fall, resident was complaining of pain to her left shoulder, lower right extremity, and buttocks. VS 136/72, 86, 97.3, 18. Resident was unable to report what she was doing at the time of the fall. POA was notified of fall and pain and requested R6 be sent to the ER for evaluation. Physician notified. R6 was transferred to ER via ambulance for evaluation. CT scan results showed a non-displaced avulsion fracture to the right ilium, and a re-demonstration minimally displaced right distal clavicle fracture. Fractures were not treated operatively. Resident was admitted overnight for treatment of pneumonia and UTI. She returned to the facility where she continues with hospice care. Care plan was reviewed and updated with new interventions. R6's computerized axial tomography, CAT, scan results dated 11/23/2025 at 10:53AM documents Bones and soft tissues. There are new calcifications that is seen anteriorly within the right iliacus (8/394). There is a peripherally enhancing fluid collection seen within this region as well measuring 1.6 cm (4/406). This extends inferiorly 4.3 cm. Findings are suspicious for avulsion fracture with associated muscle injury. No destructive osseous lesion.On 2/10/2026 at 9:30AM V1 stated she sent in a reportable on R6. R6 was very confused and a wanderer.On 2/13/2026 at 1:49PM V11 ADON, stated R6 was very much a wanderer. She would get up on her own. It didn't help to remind her to stay sitting or wait for assistance because she would not remember. We had a bucket seat and a cushion, but she was able to get up anyway.On 2/13/2026 at 9:30AM V10, CNA, stated R6 had a cushion. She would just get up and wander all the time. Everyone, even the kitchen staff, knew her and would remind her to sit down.Facility transfer policy with a revision date of 3/18/2018 states Should a resident fall to the floor, the resident will be first be assessed by a nurse. If the resident is deemed medically appropriate to transfer from the floor, a full size mechanical (Hoyer TM type) lift will be used. If the resident is not medically appropriate to transfer from the floor, emergency medical technicians will be notified and said technicians will transfer the resident.Facility fall policy with a revision date of 4/2024 states It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.

Based on interview and record review, the facility failed to answer resident's call lights to address their needs and promote resident dignity for 6 of 6 residents (R9, R16, R25, R30, R33 and R285) reviewed for dignity in the sample of 42. This failure resulted in R285 becoming incontinent and feeling humiliated. Findings include: 1. R285 was admitted on [DATE] with diagnosis of, in part, fracture of left fibula, left tibial fracture, fracture around internal prosthetic left knee joint, and retention of urine. R285's Care Plan dated has an ADL Self Care Performance Deficit requires substantial/maximal assistance from staff participation for toileting hygiene and transfers and requires substantial/maximal staff participation with personal hygiene and set up help from staff with oral care. On 3/10/25 at 12:50 PM, R285 stated she will wait a minimum of 30 minutes or more to have her call light answered. R285 stated, I've had to wait so long and accidentally soiled myself because I couldn't wait any longer. It's humiliating. The facility policy Call Light dated 8/1/05 documents it is the policy of this facility to maintain the highest quality of care for its residents. The policy documents to answer call light promptly. The policy documents if you are unable to meet resident request or need, leave call light on and obtain assistance from charge nurse. 32874 2. During the resident council meeting held on 3/12/2025 at 2:30PM, R9, R16, R25, R30, and R33 all stated call lights are not answered timely. All stated could take up to 30 minutes to get light answered. R9's Minimum Data Set (MDS) dated [DATE] documents R9 is cognitively intact. R16's MDS dated [DATE] documents R16 is cognitively intact. R25's MDS dated [DATE] documents R25 is cognitively intact. R30's MDS dated [DATE] documents R30 is cognitively intact. R33's MDS dated [DATE] documents R33 has moderate cognitive impairment. The facility resident council minutes dated 2/27/2025 documents under old business any unresolved issues since last month residents state Certified Nursing Assistants (CNAS) still take awhile to answer call lights. Resident council minutes dated 1/31/2025 documents old business any unresolved issues last month CNAs are still taking a long time to answer call lights, new business residents state the CNAs come to find out the reason the light is on and leaves without fixing the issues, residents stated CNAs are very late answering call lights at night.

Based on interview, observation, and record review, the facility failed to serve palatable food. This failure has the potential to affect all 87 residents residing in the facility. Findings include: 1.On 3/12/25 at 11:20 AM the kitchen was entered. The food thermometer was calibrated to 32 degrees. The noon meal was on the steam table. The garlic butter chicken was 151 degrees, the ground chicken was 186 degrees, the pureed chicken was 150 degrees, the whole sweet potato was 172.5 degrees, the cubed sweet potatoes was 168 degrees, the pureed sweet potato 175 degrees, the cauliflower was 176 degrees, the pureed cauliflower was 177 degrees, gravy 169 degrees, rice was 194 degrees. At 11:34 AM the kitchen service started. The first 300 hall cart went out to the hall at 11:47 AM. The second 300 hall cart went out to the hall at 11:58 AM. The 300 hall trays were all delivered at 12:20 PM. The 100 hall cart was delivered at 12:12 PM. The 100 hall trays were all delivered at 12:28 PM. The 200 hall cart was delivered at 12:14 PM. The 200 hall trays were all delivered at 12:36 PM. The dining room cart was delivered at 12:22 PM. The dining room trays were all delivered at 12:36 PM. On 3/12/25 at 12:36 PM a test tray was sampled. The chicken was 106 degrees. The chicken was dry, tough, and bland. It tasted cold. The cauliflower was 124 degrees. It tastes lukewarm. The cubed sweet potatoes were 117 degrees and they tasted warm and bland. On 3/13/25 at 9:35 AM, V1, Administrator, stated it seems like it is a staffing delivery issue of the trays and that is why the food is cold. We do not have policy on palatable food. The Resident Council Meeting Minutes, dated 9/26/24, documents, Food continue to be overcooked. The Resident Council Meeting Minutes, dated 11/27/24, documents, Residents state the food is cold. The Resident Council Meeting Minutes, dated 1/31/25, documents, Residents state the vegetables are overcooked. Residents state the noodles are overcooked. Residents state the food temperature is not consistent and is often lukewarm when they receive it. The Long Term Care Facility Application for Medicare and Medicaid, dated 3/10/25, documents the facility has 87 residents residing in the facility. 2. On 3/10/25 at 10:10 AM, R51 stated the food is Shi**y here and is usually cold. 3.On 3/11/25 at 9:10 AM, V7, Certified Nursing Assistant (CNA), stated We get a lot of the residents complaining that their food is cold, and we just heat it up for them. It's hard to keep the food warm until they get it. We don't have enough people to hand the trays out fast enough. 4. On 3/11/25 at 12:05 PM, R51's lunch tray was delivered to her room and placed on her bedside table. R51 was not in her room and was in therapy. When R51 returned, she stated her food was already cold and V7 heated it up for her. 5. On 3/11/25 at 12:08 PM, V7, CNA, was seen warming up R27's lunch plate.

Based on interview, observation, and record review, the facility failed to dry dishware before use. This failure has the potential to affect all 87 residents residing in the facility. Findings include: On 3/12/25 at 11:34 AM the kitchen service began. At 11:51 AM, the trays and the dish covers were noted to be wet. The napkin was getting wet and water drops from the dish covers were potentially dropping onto the food. V21, Dietary Aide, confirmed the trays were wet. V19, Cook, stated they probably did not get shook out enough to dry. On 3/12/25 at 1:40 PM, V1, Administrator, stated Now that I am overseeing the kitchen I have realized that I need to order more supplies because there just isn't enough time in between the meals for things to dry. On 3/13/25 at 9:35 AM, V1, stated We do not have policy on palatable food or drying dishes. The Long Term Care Facility Application for Medicare and Medicaid, dated 3/10/25, documents the facility has 87 residents residing in the facility.

Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infection for 5 of 5 residents (R20, R40, R51, R60, R185) reviewed for urinary incontinence in the sample of 42. Findings include: 1. R185's Face Sheet, print date of 3/12/25, documents R185 was admitted on [DATE] with a diagnosis of History of Falling. R185's Clinical Admission, dated 3/6/2025, documents, Mental Status: Resident is confused. Oriented to person. Confused: Chronic. Genitourinary: Ostomy (including urostomy, ileostomy, and colostomy). Urinary catheter intact. Urine amber in color. Urine retention noted. Genitourinary Note: Hospital stated resident has urinary retention. R185's Health Status Note, dated 3/9/2025 06:40, documents, Note Text: ER (emergency room ) nurse called with report. Resident is being sent back on ABT (antibiotic) for UTI (Urinary Tract Infection). On 3/10/25 at 12:09 PM, V11, Certified Nurse Aide (CNA), entered R185's room to provide care. R185 is lying in a low bed. R85 has an indwelling urinary catheter. R185's urinary drainage bag is hooked onto the bed side rail at a point that the bag is above the bladder. V11 removed R185's incontinent brief, the brief had stool smears, with a wash cloth that was moistened with peri-wash and water V11 wiped R185's pubic area and left groin, V11 rolled R185 onto her side, and with another wash cloth that was moistened with peri-wash and water, cleansed R185's rectal area and buttocks. V11 did not cleanse or spread the labia, cleanse the urethra opening, indwelling catheter tubing, or dry R185 after the care. On 3/11/25 at 2:10 PM, V11 was questioned why she did not cleanse or spread the labia or dry R185 on 3/10/25, V11 stated, because I was by myself and she is a bigger lady. On 3/13/25 at 9:18 AM, V2, Director of Nurses, stated, catheter care should be complete, spreading the labia, and cleansing the catheter tubing. The policy Catheter Care / Incontinent Care, dated 8/1/05, documents, Procedure: 5. Turn or assist resident to back lying position. 6. Expose genitalia. 7. Put on clean gloves. 8. Cleanse peri area or if appropriate. Cleanse area of insertion of catheter into meatus using clean washcloth prepared with soap and water. Cleanse downward from top to bottom giving care to cleanse the catheter when applicable. Use a clean wash cloth for each swipe down. 9. Rinse well with clean cloth. 10. Dry with clean towel. 44967 2. R51's Admission Record, undated, documents R51 was admitted to the facility on [DATE] with diagnosis of Morbid Obesity, Urinary Tract Infections (UTI), Acute Cystitis, Hydronephrosis, Anxiety Disorder, and Extended Spectrum Beta Lactamase (ESBL). R51's Care Plan, dated 1/10/25, documents R51 has a catheter related to Hydronephrosis with Renal and Ureteral Calculous Obstruction. Interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door. It continues R51 is at risk for an ADL Self Care Performance Deficit Generalized muscle weakness. R51's MDS, dated [DATE], documents R51 is cognitively intact and is dependent on staff for toileting. On 3/11/25 at 11:20 AM, V9, CNA, and V7, CNA, performed incontinent care on R51 with no Personal Protective Equipment (PPE), except gloves, while on Enhanced Barrier Precautions. Supplies brought to bedside, including a bucket of soapy water and washcloths. R51's incontinent brief was unfastened and V9 got a wet washcloth from the water and wiped R51's urinary catheter from urethra opening down the catheter, then got another wet washcloth out of the water and wiped R51's left groin, then with another wet washcloth and wiped down R51's vagina twice. R51 was rolled to her right side while V9 got wet cloth and wiped R51's left buttock and anal area. V9 placed a clean incontinence brief under R51 and rolled her to her back and the brief was fastened. There was no drying of R51, no cleaning of R51's right groin, buttock or hip, and no wiping under abdominal fold. Both CNAs used their soiled gloves to put R51's clean incontinence brief on, her pants put on, placed the full body mechanical lift device sling under her, then R51 requested to take her nightgown off and put a shirt on and both CNAs did this still with their soiled gloves on. Both CNAs doffed gloves and left the room with no hand hygiene seen done. 3. R60's Admission Record, undated, documents R60 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease, Depression, Transient Ischemic Attack (TIA)/Cerebral Vascular Infarction without residual deficits, and Falls. R60's Care Plan, dated 1/10/25, documents R60 is at risk for an Activities of Daily Living (ADL) Self Care Performance Deficit related to Parkinson's. It continues R60 has had actual falls with intervention of frequent toileting every two hours. R60's Minimum Data Set (MDS), dated [DATE], documents R60 had a moderate cognitive impairment and is dependent on staff for toileting, bathing, and transfers. On 3/11/25 at 9:25 AM, V7, Certified Nursing Assistant (CNA), assisting R60 to get out of bed and dressed. R60 had a strong smell of a bowel movement (BM) noted. V7 assisted R60 to the restroom and pivoted R60 to the toilet. Upon removing R60's incontinence brief, a large BM was seen. While R60 was finishing on the toilet, V7 had the water running in the sink with half of a towel in the sink. After R60 finished, V7 took the towel out of sink, donned gloves, and took the wet part of the towel to the toilet and wiped R60's buttock and anal area, then used the same gloves to put on a clean incontinence brief on R60 and pulled up his pants, then assisted him back to his wheelchair. V7 did not wipe the front or sides of R60 at all. V7 doffed her gloves and pulled R60 to the sink to wash his face. V7 did not do hand hygiene after doffing gloves or leaving the room. On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to provide timely and complete incontinent care, including proper hand hygiene and glove changes when soiled. 32874 4. On 03/12/25 at 8:40AM during incontinent care V16, activities assisted V14 CNA to stand R40 with use of gait belt in R40's bathroom. With R40 holding on to grab bar by stool V14 CNA removed R40's adult diaper. R40 incontinent of stool. V14, CNA with wet cloth with cleanser reached between R40's legs from the back and swiped from the front to the back. V14 did not cleanse bilateral groin or separate the labia. V14 cleansed rectal area and dried all areas. V14 did not cleanse buttocks. R40's care plan dated 10/23/2024 documents R40 at risk for ADL (Activity Daily Living) related to disease process. R40's care plan documents the intervention dated 10/23/2024 toilet use requires staff participation to use the toilet. R40's Minimum Data Set (MDS) dated [DATE] documents R40 requires supervision with toileting, and R40 is frequently incontinent of stool. 5. On 03/12/25 at 09:15 AM during incontinent care with R20 in bed on her back. V11, CNA removed adult diaper wet as verified by V11. V11 with wet wash cloths with shampoo body wash on washcloths. With soaped wet washcloth V11 wiped across R20's perineal area. V11 then cleansed bilateral groin. V11 did not separate or cleanse R20's labia. V20 did not rinse R20 prior to drying. V11, CNA then turned R2 to left side and cleaned and dried R20. R20 was not rinsed prior to drying. R20's MDS dated [DATE] documents R20 is frequently incontinent of urine R20's MDS documents R20 is dependent on staff for toileting. The facility policy Perineal Care Policy and Procedure dated, revised 11/2016 documents residents who require assistance from nursing staff to cleanse perineal area will be cleansed in a manner that decreases the risk of transmission of infection and promotes skin integrity. The policy documents perineal care includes care of the external genitalia and anal area and will be performed by a nurse or nurse's assistant. The policy documents for female genitalia- use gentle downward strokes from the front to the back of the perineum, using a clean section of the washcloth or premoistened wipe with each stroke. The policy documents if soap and water used, use clean, wet washcloth to rinse perineal area, using same motion as you did with cleansing, ensuring clean section of the washcloth or pre moistened wipe is used with each stroke. Pat dry resident's perineal area with a dry towel. Turn the resident on their side or in a position comfortable to resident to cleanse rectal area, cleanse rinse, and pat dry the anal area in the same manner you cleansed the perineal area, using strokes that work away from the urethra opening. If needed.

Based on Interview and Observation the facility failed to properly store medications for 4 of 11 residents (R27, R30, R48, R237) observed for proper medication storage in the sample of 42. The Findings Include: 1. The 300-North Hall Medication Cart was Reviewed with V4, Registered Nurse (RN). Basaglar Insulin Pen was seen in the cart and was opened with no resident label, name, or the date it was opened. On 3/10/25 at 12:15 PM, V4 stated There are only a few residents who are on that insulin, so I'm sure I can narrow it down to who's it is. The label must have fallen off. 2. On 3/10/25 at 11:00 AM, R27 was seen lying in bed with a medicine cup sitting on his bedside table with 7 pills in the cup. R27's Medication Administration Record (MAR), dated March 2025, documents R27 received the following medications on 3/10/25 at 8:00 AM: ASA 81 MG (milligram), Atorvastatin 40 MG, Cetirizine 10 MG, Famotidine 20 MG, Iron 325 MG, Folic Acid 1 MG, Lisinopril 10 MG, Metoprolol 25 MG, Magnesium Oxide 400 MG. R27's Minimum Data Set (MDS), dated [DATE], documents R27 is cognitively intact. On 3/10/25 at 12:50 PM, V4, RN, stated I always make sure the resident takes all of their meds before leaving the room. There are very few people I trust here that would take their pills if not. On 3/11/25 at 9:23 AM, V7, CNA, stated It's a common thing around here to find a cup of medications left in a resident's room for them to take. 3. On 3/11/25 at 9:20 AM, R237 had a bottle of Pepto-Bismol sitting on his dresser. R237 does not have an order for this. R237's MDS, dated [DATE], documents R237 is cognitively intact. 50908 4. R30 was admitted to the facility on [DATE] with diagnosis of, in part, Parkinson's disease, type two diabetes mellitus, and hypertension. On 3/10/25 at 10:35 AM, R30 had a cup with medications in it sitting on his bedside table. R30 stated the medications were his morning doses, the nurse usually just leaves it there for me to eventually take. 5. R48 was admitted to the facility on [DATE] with diagnosis of, in part, femur fracture, type two diabetes mellitus, and hypertension. On 3/10/25 at 10:11 AM, R48 had a cup of medications on her bedside table. R48 stated the medications were left there this morning by the nurse because she was running late. The Facility's Medication Storage Policy, dated 5/23/24, documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. The Facility's Medication Administration Policy, dated 1/11/10, documents It is the policy of this facility to accurately administer medication following physician's orders. 13. Make sure the resident takes the medication. Generally, do not leave meds at bedside (may be exceptions after thorough assessment and care planning).

Based on interview and record review, the facility failed to provide the resident with a written notice of why they were going to the hospital for 2 of 3 residents (R1, R185) reviewed for transfer/discharge notices in the sample of 42. Findings include: 1. On 3/11/25 at 9:20 AM, R1 stated the staff tell me why I am going to the hospital, but they don't give me anything in writing. They always let my family know if I am sent out to the hospital. On 3/11/25 at 10:31 AM, V28 Licensed Practical Nurse, stated the resident will get a bed hold policy. I tell the resident if they are alert and orientated why they are going out but nothing in writing. On 3/11/25 at 11:14 AM, R1's Electronic Medical Record fails to document a written notice to R1 as to why he is being sent to the hospital. R1's Nurses Note, dated 2/22/2025 14:05, documents, Note Text: EMS (Emergency Medical Services) arrived and left with resident at approximately 2:00 PM to (local hospital) ER (Emergency Room). 2. R185's Face Sheet, print date of 3/12/25, documents that R185 was admitted on [DATE]. R185's Health Status Note, dated 3/9/25, documents, Resident left with ambulance at this time. Will be taken to (local) hospital. Message was left for POA (power of attorney) upon initial time of incident. Writer will attempt to call POA again. R185's Electronic Medical Record fails to document the written notice to R185 as to why she was sent to the hospital. On 3/12/25 at 11:00 AM, V1, Administrator stated that R1 and R185 did not have a written notices as to why he was sent to the hospital. On 3/12/25 at 8:40 AM, V1 stated, I am not sure if the nurses give the resident a written reason for transfer to the hospital. I don't think we have a policy on that.

Based on interview and record review, the facility failed to provide notice regarding the bed hold policy to residents when transferred to the hospital for acute care for 2 of 3 residents (R1, R185) reviewed for notice of bed hold policy in the sample of 42. Findings include: 1. On 3/11/25 at 9:20 AM, R1 stated the staff tell me why I am going to the hospital, but they don't give me anything in writing. They always let my family know if I am sent out to the hospital. On 3/11/25 at 10:31 AM, V28 Licensed Practical Nurse, stated the resident will get a bed hold policy. On 3/11/25 at 11:14 AM, R1's Electronic Medical Record fails to document a bed hold form for R1's hospitalization on 2/22/25. R1's Nurses Note, dated 2/22/2025 14:05, documents, Note Text: EMS (Emergency Medical Services) arrived and left with resident at approximately 2:00 PM to (local hospital) ER (Emergency Room). On 3/12/25 at 11:00 AM, V1, Administrator stated that R1 did not have a bed hold for the hospital visit on 2/22/25. 2. R185's Face Sheet, undated, documents that R185 was admitted on [DATE]. R185's Health Status Note, dated 3/9/25, documents, Resident left with ambulance at this time. Will be taken to (local) hospital. Message was left for POA (power of attorney) upon initial time of incident. Writer will attempt to call POA again. R185's Electronic Medical Record fails to document a bed hold given for R185's hospital transfer. On 3/12/25 at 8:40 AM, V1 stated, The nurses should be giving a copy of the bed hold to the resident when they are sent to the hospital. If the resident is admitted to the hospital the business office manager will notify the family of the bed hold and ask if they family wants a bed hold. The IL (Illinois) Bed Hold Notification, undated, documents, 'When a resident is transferred to a hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. Such a request is a called a bed hold. It continues, The bed - hold notification will be issued at the time of transfer, and in cases of emergency transfer, notice will be given within 24 hours of leave.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for 1 of 16 residents (R185) reviewed for baseline Care Plan in the sample of 42. Findings include: R185's Face Sheet, print date of 3/12/25, documents R185 was admitted on [DATE] with a diagnosis of History of Falling. R185's Clinical Admission, dated 3/6/2025, documents, Mental Status: Resident is confused. Oriented to person. Confused: Chronic. Level of cognitive impairment: Moderate impairment (memory loss). Resident is coherent. Speech is clear. Language barrier: No Genitourinary: Ostomy (including urostomy, ileostomy, and colostomy). Urinary catheter intact. Urine amber in color. Urine retention noted. Genitourinary Note: Hospital stated resident has urinary retention. On 3/11/25 R185's Electronic Medical Record fails to document a Care Plan for R185 addressing her medical and safety needs. On 3/11/25 at 11:00 AM, V1, Administrator, stated Normally when a person is admitted , and the nurse does the Admission Assessment the computer program generates the interim Care Plan. The nurse that did (R185's) Admission Assessment did not answer the Care Plan questions so an interim Care Plan was not created. The policy Care Plan Process, dated 11/2017, documents, The Baseline Care Plan will be completed and implemented within 48 hours of admission. This Care Plan will include instructions needed to provide person centered care that meets professional standards of quality. At a minimum, the baseline care plan will address the resident's initial goals for stay, dietary, therapy and social services needs, as well as PASSAR (Preadmission Screening and Resident Review) recommendations if applicable. Necessary physician orders will be included as well.

Based on observation, interview and record review, the facility failed to have an updated resident centered Care Plan to address the current needs of the residents for 2 of 16 resident (R21, R42) reviewed for Care Plan in the sample of 42. Findings include: R21's Face Sheet, print date of 3/12/25, documents R21 was admitted on [DATE] and has a diagnosis of Dependence on Renal Dialysis. R21's Pre/ Post Dialysis Evaluation, dated 3/4/25, documents, Access site: Access site location: LUE (Left Upper Arm). R21's Care Plan, dated 9/8/23, documents, (R21) has renal failure r/t (related to) End Stage disease. Receiving hemodialysis with (Dialysis Center) on Tuesday (Tuesday), Thur (Thursday), Sat (Saturday) mornings. Interventions: Assist resident with ADL's (Activities of Daily Living) and ambulation as needed. Fluid Restriction as ordered. (1500ml (milliliters) as ordered. Give good oral hygiene. Give medications as ordered by physician. Monitor changes in mental status; Lethargy, Somnolence, Fatigue, tremors, seizures. Monitor for s/sx (signs and symptoms) of hypovolemia or hypervolemia. Monitor vital signs as ordered. Plan rest periods as needed. weight monitoring 3 x weekly. To be done at dialysis. This Care Plan fails to document R21's Let Upper Arm fistula, do not use left arm for blood pressure or blood draws. On 3/12/25 at 3:35 PM, V1, Administrator, stated R21's Dialysis Care Plan is not complete related to it does not document the fistula site and do not use left arm for blood pressures or blood draws. 2. R42's Face Sheet, print date of 3/12/25, documents R42 was admitted on [DATE] and has Hemiplegia and Hemiparesis following a stroke and Epilepsy. R42's Bed Rail Evaluation, dated 11/22/24, documents R42 has bilateral 1/2 bed rails. On 3/11/25 at 10:04 AM, R42 is in bed with 1/2 bed rails raised. V25 Certified Nurse Aide stated that R42 does try to use them when he is being turned. R42's Care Plan, dated 12/7/23, documents, (R42) is at risk for limited physical mobility r/t hemiparesis / hemiplegia. Intervention: Side Rails: 1/4 side rails, x 2 bilaterally, to promote bed maneuverability due to hemiparesis / hemiplegia. The policy Resident Assessment and Care Planning, dated 11/2017, documents, The facility must evaluate and modify, if necessary, the efficacy and appropriateness of each resident's care plan on at least a quarterly basis, and with a significant change in condition.

Based on observation, interview, and record review, the Facility failed to ensure showers, and basic grooming assistance was provided for 1 of 24 residents (R2) reviewed Activities of Daily Living (ADLs) in the sample of 42. Findings include: R2's Admission Record, undated, documents R2 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure, Chronic Kidney Disease, and Osteoarthritis. R2's Care Plan, dated 2/3/25, documents R2 scored an 11 on her BIMS (Basic Interview for Mental Status - 13-15= Intact cognitive response, 8-12= Moderate Cognitive Impairment, and 0-7= Severe Cognitive Impairment). R2 understands need for placement and can express her needs. Interventions: needs assistance with all decision making. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a moderate cognitive impairment and requires partial/moderate assistance from staff for bathing and dressing. On 3/10/25 at 10:05 AM, R2 was seen sitting on the side of her bed and appears to have greasy hair. R2 stated she has not had a shower or a bath in a long time. On 3/11/25 at 8:45 AM, R2 stated she did not get a shower last evening and is unsure when she last had a shower or bed bath. R2's hair still appears very greasy, combed, and matted. On 3/12/25 at 8:55 AM, R2 sitting in wheelchair next to her bed. R2's hair appears very greasy and combed back with flakes in her greasy hair. R2 stated the only time they wash me up is when they are cleaning me down there (pointed to groin area). R2 stated My hair needs washed, it really feels dirty, and I would feel a lot better after getting a shower. I'm not sure I can stand up to get a shower, I will probably drown. On 3/12/25 at 8:58 AM, When asked about R2 getting showers, V13, Certified Nursing Assistant (CNA), stated (R2) gets a shower on Monday and Thursday Evenings, so I would not have anything to do with it. On 3/12/25 at 9:05 AM, V12, Licensed Practical Nurse (LPN)/Wound Nurse, stated I collect the resident shower sheets from the staff and do weekly audits with them. When told that R2 has greasy hair and stated she has not had a shower in a long time, V12 stated There are no shower sheets in my binder for the month of February or March for (R2). When asked about her audits she completed, V12 stated Well, I don't want to tell you this, but it looks like (R2) has not had a shower since she's been here. I believe I even asked the CNAs for (R2's) shower sheets and they had none to give me. On 3/13/25 at 9:15 AM, V12, stated I called every CNA who was working with (R2) on the shower days and asked them why (R2) didn't get a shower and they all said they filled out a shower sheet and/or (R2) refused a shower. I had each one of them come in last night to fill out a shower sheet from that day they worked. V12 provided handwritten notes indicating R2 refused, and some shower sheets that were completed last evening (3/12/25). On 3/13/25 at 10:25 AM, V1, Administrator, stated I would expect the staff to ensure all residents are getting their showers as scheduled. I agree, if the shower sheets weren't done and (R2) has greasy hair, the showers probably weren't done. On 3/13/25 at 12:00 PM, V1, stated We have looked and cannot find any policy for showers or ADL Care of Residents.

Based on interview and record review the facility failed to ensure residents were free from sexual abuse for 1 of 6 (R5), reviewed for abuse in the sample of 6. This failure resulted in R5 experiencing two episodes of being sexually abused by R1 on 9/8/24, in which R5 was verbally heard yelling for help, stating that it hurt. The reasonable person concept can also be utilized, a reasonable person would experience fear, trauma, humiliation, should sexual abuse occur to them. The Immediate Jeopardy began on 9/8/2024 when R5 was sexually abused by R1. The abuse was witnessed by V5 (Certified Nurse Assistant, CNA). After removing R1 from the room, leaving R1 unsupervised, R1 again re-entered the room and sexually abused R5 for a second time. V1 (Administrator) was notified of the immediate jeopardy on 9/23/2024 at 2:27 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 9/24/24 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings include: On 9/20/2024 at 10:22 AM, V6 (Licensed Practical Nurse, LPN) stated she was the manager on duty and was physically in the facility on 9/8/2024 when the incident between R1 and R5 occurred. V6 stated a Certified Nursing Assistant (CNA) reported the incident to her. V6 stated it was witnessed by the CNA and reported to her that R1 was holding R5's penis. V6 stated she reported the incident to the administrator immediately. V6 stated she had not observed R1 have any inappropriate behavior recently. V6 stated there was an incident with R1 involving sexual abuse in February 2024, which was founded. V6 stated R1 was started on Provera at that time. V6 stated R1's Provera had been discontinued, but agreed R1 was started back on Provera after the recent incident with R5. On 9/20/2024 at 10:50 AM, V1 stated that based on her investigation she did substantiate the allegation of abuse involving R1 and R5 based on witnessing of actual incident and witness statements. V1 did agree that R1 did have a previous incident of abuse. On 9/20/2024 at 11:00 AM, V5 stated she was on break on 9/8/2024 and upon return she heard R5 yelling help, it hurts. V5 stated R1 had his hand under R5's sheet. V5 stated when she pulled the sheet back R1 had his hands around R5's penis. V5 stated R1 dropped R5's penis at that time. V5 stated she removed R1 from the room into the hall. V5 stated she left R1, going to report the incident to V6, who was the manager on duty. V5 stated when she returned from reporting the incident R1 was back in the room holding R5's penis a second time. R1's care plan dated 2/26/2024 documents R1 has a hyper-sexual and flirtatious behavior. R1's care plan documents the following interventions: 2/26/2024 anticipate and meet R1's needs, caregivers to provide opportunity for positive interaction, attention, stop and talk with him as passing by, if reasonable discuss behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed, md to review chart, medications, recent changes in status, diagnosis, recent labs. R5's electronic medical record documents R5 has diagnosis in part of encounter for closed fracture, with routine healing, unspecified fall, and urinary tract infection. R5's Minimum Data Set (MDS) dated [DATE] documents that R5 has severe cognitive impairment. R5's care plan dated 9/12/2024 documents R5 has impaired physical mobility. R5's care plan documents R5 is at risk for Activities of Daily Living (ADL) self-care deficit related to disease process. R5's care plan documents R5 requires mechanical lift with 2 staff for transfers. On 9/20/2024 at 10:31AM V2 Director of Nursing (DON) stated if incident involving sexual abuse would separate residents and have a visual on them. On 9/19/24 at 11:22 AM, R1 was noted to be cognitively impaired, expressing no concerns regarding abuse or memories of events that had occurred. R5 was unable to be interviewed, as he did not reside in the facility during the time of this survey. R5's Clinical Record documented his discharge from the facility on 9/12/24. The facility policy abuse prohibition dated 3/15/2018 documents all residents have the right to be free from sexual abuse. The policy documents sexual abuse is non-consensual sexual contact of any type which includes, but is not limited to sexual coercion, or sexual assault. The policy documents sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus, or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. The policy documents if the incident involves suspected abuse, the charge nurse shall assure that the suspected abuser has no further contact with the resident involved or with any other resident. The immediate jeopardy that began on 9/8/2024 was removed on 9/24/24, when the facility took the following actions to remove the immediacy: Nurse managers and Administrator interviewed all residents for abuse on 09/23/24 and 09/24/2024. No abuse was determined or reported at this time. Facility completed head to toe assessment on all residents by Nurse managers on 09/24/2024. No signs or symptoms of abuse were noted at this time. All resident charts have been reviewed on 09/24/2024 by the facility Administrator, DON, Nurse Managers and Social Service Director, including progress notes and tasks, to identify any additional resident behaviors and incidents if applicable; no residents were identified. The resident identified for exhibiting inappropriate behaviors related to the citation is in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room - interventions will remain in place as long as resident is residing in facility. Assignments of 1-1 will alternate between staff directly assigned per Administrator. Primary Care Physician reviewed chart and medications, ordered 5mg tablet of Provera daily and was initiated. Primary Care Physician requested a psychiatry consult. V16, Psychiatrist, contacted and recommended in-patient psychiatry evaluation. Facility has made several attempts to place for psychiatry evaluation without acceptance. V16 will continue to follow the resident in the facility. Facility Pharmacy consultant completed Medication Regimen Review and Chart Review. Facility sent referrals with resident's approval to multiple facilities for the resident to reside, all referrals have been declined. The facility Social Service Director reassessed the resident's PTSD Screen for DSM-5/Trauma Informed Care, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation; no significant changes were identified. Residents Identified: There was 1 male resident identified to have been directly affected by the inappropriate behavior of the male resident. The identification was reported to Administrator on 09/08/2024; full investigation was initiated including staff and resident interviews conducted by the facility Administrator. Administrator completed full body assessment of both male residents on 09/08/2024, no harm identified. All residents are at risk for being affected by this male resident's behavior; he will reside in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room; resident will remain in the private room across from the nurse's station while residing in the facility. The male resident identified to have been directly affected by the inappropriate behavior on 09/08/2024 was immediately provided a room reassignment. Resident was interviewed and assessed on 09/08/2024 immediately following occurrence by the Administrator, resident was unable to recall occurrence, he denied pain. The resident did not display any s/s of negative effects. Administrator reviewed resident's chart on 09/08/2024 and implemented monitoring resident every shift to ensure any changes in mood, activities, or ADL status would be identified and reviewed every shift by the Administrator. No changes in psychosocial well-being were identified. Resident's care plan was updated on 09/08/2024 by Administrator. Resident was reassessed on 09/11/2024 by the Social Service Director, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation completed; no significant changes were identified. Upon admission from hospital, resident had a discharge plan to return to previous facility he resided, once facility was able to accept based on bed availability, discharged from facility on 09/11/2024. Immediate Education: Regency Care - [NAME] has policy, procedures, and protocols based on current standards of practice. * V1,Administrator provided education to each department manager on 09/23/24 and 09/24/2024 regarding the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy. * Department managers V2 (Director of Nursing), V7 (Assistant Director of Nursing), V9 (Infection Preventionist), V6 (MDS Coordinator), V10 (Restorative), V11 (Social Services), V12/V13 (Environmental Services), V14 (Dietary Manager), V8 (Business Office Manager) provided education to all staff regarding the facility Abuse and Neglect Policy; disciplinary action that will result if failure to follow facility policy on 09/23/2024 and 09/24/2024. * The Director of Nursing or designee will review behavior notes and progress notes (on the clinical dashboard and 24-hour summary) of all residents to identify inappropriate behaviors and notify Administrator and reviewed at daily IDT meetings. * The Administrator updated care plan on 09/08/2024 of the resident identified for exhibiting inappropriate behaviors and staff were educated on 09/08/2024 - 09/13/2024. Care plan was reviewed and updated again on 09/23/2024. * Administrator provided education regarding the 09/23/2024 updated care plan for resident identified for exhibiting inappropriate behaviors to each department manager on 09/23/24 and 09/24/2024. * Administrator and department managers provided education to all staff of the 09/23/2024 Care Plan revisions and updates on 09/23/2024 and 09/24/2024. * Administrator provided education to all department managers on 09/09/2024 regarding resident's care plan: resident will reside in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room; resident will remain in the private room across from the nurse's station while residing in the facility. Administrator educated department managers again on 09/23/24 and 09/24/24. * 09/24/2024 The Interdisciplinary Team (IDT) has reviewed, discussed and approved the Immediate Jeopardy Removal Plan. The IDT included staff members: V1 Administrator, V2 Director of Nursing, V7 Assistant Director of Nursing, V9 Infection Preventionist, V6 MDS Coordinator, V10 Restorative, V11 Social Services, V12/V13 Environmental Services, V14 Dietary Manager, V8 Business Office Manager, V15 Medicaid Specialist/Admissions coordinator. * Administrator will monitor to ensure compliance of interventions put in place by auditing 3 X week for 4 weeks. Audits will be reviewed at nest QA meeting in October 2024.

Based on observation, interview and record review, the facility failed to protect a resident from sexual abuse for 2 of 3 residents (R1 and R2) reviewed for sexual abuse in the sample of 6. Based upon a reasonable person's concept, R2 would not have wanted sexual contact without her consent and would have experienced psychosocial harm (e.g., fear, anger, depression, anxiety and humiliation) as a result of the sexual abuse since there is an expectation that R2 would not be sexually abused in the facility. Findings include: The facility's report, Report to Illinois Department of Public Health dated [DATE] documents, Initial Report: (R1), 90 y/o (year old) male with a BIMS (Brief Interview for Mental Status) of 7 and (R2), 70 y/o female, with a BIMS of 3 observed in a sexual act in room ,d+[DATE] by staff. Staff intervened immediately and residents were separated. Upon initial interview, both parties were consenting. (R2) was assessed for injuries and none noted. After separation and assessment, (R2) attempted to seek out (R1) again. MD (Medical Doctor) and POA (Power of Attorney) for both parties and police have been notified.(R2) was sent to (local hospital) for examination. Investigation initiated. Final report to follow. On [DATE] at 9:00 AM, R2 was up in her bathroom washing her hands with stand-by assistance verbal cues from V5, Certified Nursing Assistant (CNA). After finishing, she asked, What do I do now? Where do I go? V5 continued to give her verbal cues and R2 walked back to her bed and laid down. She was able to answer short, direct questions during conversation, but was unable to recall going out to the hospital. R2's Face Sheet, printed [DATE] documents her diagnoses to include: Cirrhosis of Liver, Portal Hypertension, Esophageal Varicies without Bleeding, Type 2 Diabetes Mellitus, Gastrointestinal Hemorrhage, Muscle Weakness, Unspecified Dementia, Unsteadiness on Feet, Unspecified Abnormalities of Gait and Balance, Arteriosclerotic Heart Disease (ASHD), Gastroesophageal Reflux Disease (GERD), Major Depressive Disorder, and Acute Duodenal Ulcer with Hemorrhage. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, she is independent with bed mobility and ambulation, and frequently incontinent of urine. This assessment documents R2 did not have any behaviors at time of assessment. R2's Care Plan, initiated [DATE] documents: (R2) has a dementia diagnoses. Scored a 3 on her BIMS. Goal: (R2) will maintain current level of cognition by review date of [DATE]. Intervention for this care plan documents: (R2) required approaches that maximize involvement in daily decision making and activity. After the sexual encounter between R1 and R2 occurred, R2's Care Plan was updated with the new focus dated [DATE]: (R2) has a hyper-sexual and flirtatious behavior towards residents and staff. Goal: (R2) will have fewer episodes of hyper-sexual and/or flirtatious behaviors by review date Interventions: Assist (R2) to develop more appropriate methods of coping and interacting with staff and residents. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with her as passing by. If reasonable, discuss with (R2) her behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. (R2) is to have no male caregivers. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R2's Progress Note dated [DATE] at 11:30 PM documents, When responding to a call light pressed by ,d+[DATE], Staff observed (R1) on his knees at the bedside performing oral sex on Resident. She was holding her left leg up and laughing. Staff immediately separated them and (R1) was escorted from the room. Writer was called to the room. Resident nor (R1) was unable to tell Writer what had just happened. She only continued to laugh and run her fingers through her hair. From the hallway (R1) was yelling for cookies. Earlier today, Resident and (R1) was observed by staff attempting to kiss and hold hands in his room. They were redirected and separated at that time. (R3) (,d+[DATE]) advised Writer that at 2320, (R1) had wheeled himself into the room, began to talk to Resident and soon started to kiss her leg and private area. On [DATE] at 8:45 AM R1 was sitting in the w/c in his room. He stated, I feel good. Just keep an eye on me. I don't want anything to happen to me. R1 stated he gets along with his roommate and other residents just fine. He stated, Just keep an eye on me and make sure I do ok. R1 was unable to recall that he had a different roommate a couple days ago or any interaction between him and any female residents. R1's Face Sheet, printed [DATE], documents his diagnoses as : Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Transient Ishemic Attacks and Cerebral Infarction without Residual Deficits, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Vascular Dementia, ASHD, Insomnia, Cardiac Pacemaker, Anemia, and Hyperlipidemia. R1's MDS dated [DATE] documents he is severely cognitively impaired (BIMS 7), he is independent with bed mobility, transfers and mobility, uses both a wheel chair (w/c) and a walker, able to walk up to 50 feet. Care Plan: initiated on [DATE], after sexual encounter with R2, documents : (R1) has a hyper-sexual and flirtatious behavior. Goal: (R1) will have no evidence of behavior problems by review date. Interventions for this behavior care plan initiated [DATE]: Anticipate and meet (R1) needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him as passing by. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. R1's Care Plan was reviewed and he had no other Care Plan regarding inappropriate behaviors prior to [DATE]. R1's Progress Note dated [DATE] at 8:14 AM documents, Behavior Note: Behaviors: Very sexually aggressive to staff. Made several comments to female and male staff that he wanted to kiss it and that they would like it. Non-pharm interventions: Redirected. Writer told Resident that his comments were inappropriate and that he should not say things like that. Writer offered him cookies. Pharm interventions: Summary: Cookie distraction only effective for a short time. Sexual comments resumed. Unable to redirect at this time. R1's Progress Note dated [DATE] at 11:20 PM documents, Resident found in room [ROOM NUMBER]. He was engaged in inappropriate sexual behavior with a female Resident of that room. They were immediately separated and he was placed in 1:1 supervision at the nurse's station. On [DATE] at 8:15 AM, V3, Assistant Director of Nursing (ADON) stated they currently have an investigation going on regarding sexually inappropriate behavior between a male and female resident who were caught during a sexual act. She identified the residents as (R1) and (R2). V3 stated both of these residents have dementia and neither are alert and oriented . V3 stated according to the staff who witnessed it, neither of the residents were resisting and both were enjoying it, and R2 was giggling. V3 stated the staff who initially witnessed the incident, V9, CNA, observed (R1) in (R2's) room and he was performing oral sex on her and she was holding one of her legs up in the air. V3 stated the two residents were separated immediately and the administrator, police, MD and families were notified. V3 stated (R2) was sent to the emergency room for evaluation and she returned with no new findings. V3 stated (R2) was seeking (R1) out before she even left for the hospital. V3 stated (R2) ambulates independently and (R1) mostly uses his w/c but is able to ambulate also. V3 stated 1:1 were started immediately. V3 stated when (R2's) son was notified, he stated he is not surprised that she is the instigator. She stated (R1) does not have a POA, just an emergency contact and she just said ok when she was notified. V3 stated since the incident the residents have been kept separated. She stated a few days before the incident, (R2) was started on Trazadone due to not sleeping well . V3 stated a side effect of Trazadone in women can be increased sexual drive and they think this might be why (R2) was sexually inappropriate. V3 stated (R2) has been on 1:1, because she is ambulatory. V3 stated yesterday (R2) was very flirtatious and (R1) was not paying attention to her. V3 stated they are looking into a memory care unit for (R2) to go to. On [DATE] at 10:07 AM , V14, R2's son, during phone interview, stated he received a call Sunday night from the facility to inform him his mother (R2) and a male resident were doing something sexual in her room and she was sent to the hospital to get checked out. He stated he received a call from a nurse at the hospital who stated they didn't find anything, and then the nurse from (the facility) called and let him know she was back in the facility and they had settled her in. V14 stated (V3), ADON followed up with him by phone later and let him know a man had entered (R2's) room and his mother was participating in a sexual act and was not resistant to what was going on. V14 stated his mother has no clue what is going on and if she was in her normal state of mind she would never had participated in sexual activity with that man. He stated his father just passed away in November and (R2) does not even remember him or that he died . V14 stated his mother did not recognize him the last time he visited. He stated the facility is keeping the two of them separated. V14 stated he has not seen any sexually inappropriate behaviors from his mother before. He stated she is happy go lucky, always laughing and giggling. He stated this person is not the mother he knew. He stated it is heartbreaking because his mother would never have done this when she was in her right mind. On [DATE] at 9:40 AM V10, Licensed Practical Nurse (LPN) stated she worked the 200 hall from 7:00 PM until 11:00 PM and then picked up both 100 and 200 Halls for rest of night shift from [DATE] to [DATE]. V10 stated the CNAs on the 100 Hall, (V8) and (V9), called her to (R2's) room. She stated by the time she arrived to the room, (R1) was sitting in his w/c in the hall, and the CNAs were in (R2's) room trying to get her settled down back into bed because (R2) was trying to get up and come out into the hall. V10 stated she asked (R1) what happened and he just asked for cookies and was unable to tell her what happened. She stated the CNAs reported when they went into (R2's) room to answer the call light, (R1) was on his knees next to (R2's) bed. V10 stated up until that morning ([DATE]) the most she heard (R1) say was ,Nurse, give me some cookies. She stated on that morning, prior to this incident, around 5:00 AM, he was saying to her, Just let me lick it and you'll like it repetitively. V10 stated she tried to redirect him and he finally went to his room and went to sleep. V10 stated she returned to work at 7:00 PM and received report from the day shift nurse that (R2) was in (R1's) room and had to be redirected out of his room. She stated (V12), the day shift nurse said (R2) was leaning over (R1) at the time and close to his face, either whispering or trying to kiss him. V10 stated (R1) usually only comes out of his room occasionally to go to the nurses station or the day room, but she had never seen him go into other resident's rooms. V10 stated on the night of the incident between (R1) and (R2), (R2's) roommate, (R3) had put on the light and V10 went back in to talk to her after (R1) and (R2) were separated and (R1) removed from (R2's) room. V10 stated (R3) told her she saw (R1) come into their room, and he kissed (R2) on the leg and then started having oral sex with her. She stated she asked (R3) if she was alright and (R3) stated yes and that she thought maybe (R2) was just lonely. She stated (V3), ADON, asked her if the sexual contact between (R1) and (R2) was forced and V10 stated she informed her, No (R2) was holding her leg up during the incident. V10 stated it appeared consensual but neither (R1) or (R2) have the cognitive ability to give consent as they are both confused. On [DATE] at 10:15 AM V3, ADON, stated she was first notified of the incident between (R1) and (R2) from (V1), Administrator around 11:30 PM on Sunday night. She stated later the nurse called and told her . V3 stated she was the wound nurse prior to being ADON and had never heard (R1) make sexual comments to anyone. She stated the incident between (R1) and (R2) was consensual, but neither (R1) nor (R2) have the cognitive capacity to consent. She stated the facility does not have an assessment to determine if a resident has the ability to consent, but both (R1) and (R2) are severely cognitively impaired. The facility's policy, Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media, revised [DATE] documents, This facility, for the protection of the residents, utilizes the seven stages of the CMS STRIIPP abuse prevention protocol. These stages include: S, screening potential hires, T, training new and existing employees; R, reporting of incidents, investigations, and facility response to the result of the investigations; I, identification of possible incidents or allegations which need investigation; I, investigation of incidents and allegations; P, protection of residents during investigations; and P, Prevention policies and procedures. 1. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. 2. All residents have the right to personal privacy of not only their own physical body; but also of their personal space, including personal care, and living accommodations. 14. Sexual abuse is non-consensual sexual contact of any type which includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual coercion shall include any intentional or knowingly touching or fondling a non-consenting resident's sex organs, anus or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. 3. All staff are trained that a facility will treat all residents with respect and dignity, promote and protect the rights of all residents and recognized their individuality. 4. All staff will have training on dementia management and abuse prevention.

Based on interview, observation and record review, the facility failed to implement intervention to prevent, timely identify, and monitor pressure ulcers for 2 of 5 residents (R3, R113) reviewed for pressure ulcers in the sample of 31. This failure resulted in R113 developing an unstageable pressure ulcer to her right buttocks five days after admission. Findings include: 1. R113's Order Summary Report, dated 4/18/23, documents that R113 was admitted on [DATE] with diagnoses of a fracture of left femur, Type 2 Diabetes Mellitus and Peripheral Vascular Disease. R113's Nurse (N) Advance (Adv) -Clinical Admission Form, dated 4/13/23, documents, R113 arrived at the facility via transport another facility. The Form documented R113 used a wheelchair. It continues, Resident is alert & (and) oriented x (times) 3. Oriented to place. Oriented to time. Oriented to person. The Form documented that R113 had a pressure ulcer/injury to R113's left buttock measuring 3.2 centimeters (cm) length by 2.8 cm width. R113's N Adv - Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 4/13/23, documents, Braden Evaluation: Sensory Perception: No impairment. Moisture: Occasionally moist. Activity: Chairfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Adequate. Friction and shear: Potential problem. N Adv - BRADEN Score: 17.0. R113's Health status Note, dated 4/17/23, documents, Resident seen today in facility by (V18 Nurse Practitioner) with New orders for: Facility wound doctor to evaluate and treat for left buttocks wound - (pressure relieving) cushion on wheelchair and bed -Patient requesting bariatric bed. On 4/17/23 at 10:05 AM, R113 was lying in bed with a knee immobilizer on. R113 was on a regular mattress and has no side rails for turning and repositioning. R113 stated that she was recently admitted because she broke her femur above her below the knee amputation, she is a diabetic and goes to renal dialysis 3 times a week. R113's stated that she believes she has a wound on her buttocks. R113 stated, I think I got it here. I have been asking for a better mattress and side rails, but I haven't gotten either yet. I really want the side rails so I can turn and reposition myself. It is hard to move with this knee immobilizer on. On 4/18/23 at 8:10 AM, R113 was lying in bed. R113 has the same mattress as 4/17/23 and no side rails on her bed. R113 stated, The nurse last night found a new area on my buttocks. She called the doctor, and he wants me to have a CT (Computerized Tomography) scan. On 04/18/23 at 12:56 PM, V11, Licensed Practical Nurse (LPN), Wound Nurse, stated, She (R113) developed an in-house pressure ulcer to her right buttock., The night nurse called (V16, Physician), and he said send her to ER (emergency room ) and get a CT. I think he was half asleep because it was in the middle of the night the wound is 2 (centimeters) x (by) 2. (R113) did not want to do that. This morning I called him, and he wants an Xray to rule out osteomyelitis. I contacted our wound doctor, (V17 Wound Doctor), and got orders for a sheet of thera honey and cover with a dry dressing bid (twice a day). I looked into her history because she has been here before and last time, she had a pressure ulcer in the same spot. R113's Health Status Note, dated 4/18/23 at 06:34 AM, documents, Resident has open area to right buttocks, 3cm x 3cm, heavy dark serosanguinous drainage with foul odor noted, resident c/o (complaint of) pain 7 out of 10, notified PCP (Primary Care Provider), rcvd (received) an order to send resident to ER for CT scan and rcvd a referral order to see Wound MD for eval (evaluation) and tx (treatment), resident made aware of n.o. (new order) R113's Health Status Note, dated 4/18/23 at 09:05 AM, documents, Wound MD gave order to cleanse right upper buttock with wound wash and pat dry and then apply thera honey sheet to right upper buttock and cover with dry dressing twice daily. R113's Health Status Note, dated 4/18/23 at 2:05 PM, documents, Received call from (V18) who states no need for CT or x-ray since wound isn't open and just continue with her orders for pressure relief equipment, resident currently has air loss mattress on bed with bariatric bed and side rails. R113's Ulcer / Wound documentation, dated 4/18/23, documents that R113 has an unstageable pressure ulcer on her right buttock that measures 2 centimeters x 2 centimeters that has moderate serous drainage. On 4/18/23 at 9:00 AM, V11 Wound Nurse, entered R113's room to change R113's right buttock pressure ulcer dressing. R113 was rolled onto her left side. V11 removed the old dressing that was on the right buttock. R113 stated that removing the dressing hurt the pressure ulcer. The dressing had a moderate amount of black, brown drainage on it. The wound was the approximate size of a quarter. The peri wound was red. The wound bed was black. 2. R3's Admission Profile, print date of 4/19/23, documents that R3 was admitted on [DATE] and has diagnoses of Metabolic Encephalopathy and Epilepsy. R3's Hospice Admitting Orders, dated 4/4/23, documents admitted to hospice on 4/4/23 with severe protein malnutrition. Activity: bedrest turn every 2 hours. Skin Care Orders: Clean open areas twice daily. R3's Minimum Data Set, dated dated [DATE], documents that R3 is severely cognitively impaired and requires extensive assistance of 1 staff member for bed mobility. R3's Braden Scale for predicting pressure ulcers, dated 4/4/23, documents that R3 is at high risk of developing a pressure ulcer. R3's Hospice Nursing Initial Comprehensive Admission Assessment, dated 4/4/23, documents that R3 has a coccyx Stage 2 pressure ulcer measuring 1 cm x 1 cm x 0.1 cm with a pink bloody wound bed and a right heel pressure ulcer that is unstageable that measures 2 cm x 3 cm. R3's Ulcer / Wound documentation, dated 4/12/23, documents that R3 has an unstageable pressure ulcer to the sacrum that measures 2 cm x 2 cm. R3 Medical Record fails to document on R3's right heel pressure ulcer on 4/12/23. R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has a Stage 2 pressure ulcer to the sacrum that measures 3 cm x 2.5 cm. R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has an unstageable Pressure ulcer of the right heel measuring 3.5 cm x 4 cm, the wound bed is Necrotic tissue and that the pressure ulcer was first identified on 4/19/23. R3's Ulcer / Wound documentation, dated 4/19/23, documents that R3 has a deep tissue injury on the right lateral foot measuring 0.5 cm x 0.5 cm that was first identified on 4/19/23. R3's Physician Orders, print date 4/11/23, documents, Monitor black area of right heel start date of 4/11/23, Cleanse open area to coccyx with soap and h2o (water) or saline apply optifoam drsg (dressing) change every 5 days and PRN (as needed) when soiled or dislodge start date of 4/4/23, Resident may stay in bed and turn and reposition q (every) 2hrs (hours) start date of 4/4/23. On 4/18/23 at 3:10 PM, V11, Wound Nurse, stated, (R3) has not had her right heel measured. She got that wound while she was in the hospital, but I cannot find any documentation of that. She came back from the hospital on hospice, and they ordered just to monitor the wound. (R3's) son is a doctor and he does not want any treatment done to her pressure ulcers. On 4/19/23 at 2:10 PM, V11, stated that R3's right heel was never measured because the pressure ulcer was not put onto the 24-hour report, so I didn't know about it. Pressure ulcers should be measured every week at least. On 4/19/23 at 8:25 AM, R3 is lying on her back with the head of the bed elevated 20 degrees. R3 is wearing bilateral heel boots. The right foot is in the middle of the boot not in the heel pocket of the boot. On 4/19/23 from 8:25 AM to 11:20 AM, based on 15 minute or less interval observations R3 was not given the benefit of turning or repositioning to relieve pressure. On 4/19/23 at 11:20 AM, V21, Certified Nurse's Aide, entered R3's room to provide incontinent care. R3's incontinent brief was removed. R3's buttocks were red with crease marks on it. R3's back was red with crease marks on it also. At that time, R3 was wearing bilateral heel boots. R3's right foot was in the middle of the boot not in the heel pocket. At 11:30 AM, V11 and V12 both LPNs entered the room to change R3's sacrum pressure ulcer dressing and to exam R3's right heel. The sacrum pressure ulcer measured 3 cm x 2.5 cm. The wound bed is covered in 50% slough and the other 50% is red tissue. The pressure ulcer was cleansed with wound cleanser and a border foam dressing was applied. R3's bilateral heel boots were removed. R3's right heel has a dark black necrotic pressure ulcer measuring 3.5 cm x 4 cm. R3's right lateral foot has a pressure ulcer measuring 0.5 cm x 0.5 cm that is black and necrotic. R3's left heel has an area that is dark pink the approximate size of a quarter. R3's heel boots were reapplied. On 4/19/23 at 11:30 AM, V12, LPN, stated, I have not been here in 4 days the last time I saw her heel it was just red. It was about the same size. V12 further stated that R3's left heel is soft. On 4/19/23 at 11:30 AM, V11, LPN, stated, I have not seen her heel until now. I am going to call hospice and see about getting her a pressure relief mattress. The interventions (to prevent pressure ulcers) for her are her boots and turning and repositioning. V11 was questioned if he knew about the area on the outside of R3's right foot before it was noticed it by the surveyor, V11 stated that he did not know about it until it was pointed out. On 4/19/23 at 4:10 PM, V2, Director of Nurses and V20, Regional Nurse, both stated that they expect pressure relieving devices to be put into place for a resident at risk for pressure ulcers and used correctly, turning and repositioning should be done, measuring of the pressure ulcer should be done weekly or if there is a worsening of the pressure ulcer and no one should sustain a pressure ulcer while they are at the facility. V20 further stated that since it was known that R113 had previous pressure ulcers R113 should have had a preventative mattress and side rails to aide in repositioning as soon as possible. The policy Wound & Ulcer Policy and Procedure, dated 1/10/2018, documents, Wound & Ulcer Policy and Procedure. It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale - Ulcer risk Assessment. the resident will be assessed upon admission, once a week for four weeks, and monthly thereafter. Protocols may include any or all of the following based upon the needs and condition of the resident. Additional measures may be added at the discretion of the facility. High Risk Protocol: Residents with existing ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment Score. Daily skin checks completed by direct care staff. The Skin Observation Report may be used to communicate skin observation or changes to the nurse. Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing / relieving properties may be placed on the resident's bed and chair as indicated. Skin contact surfaces may be padded to protect boney prominences. Range of motion may be provided if clinically indicated. The resident may be placed on a turn and position schedule if clinically indicated. It continues, When a resident is found to have a wound our licensed nurse will complete ulcer, either on admission or during their stay, the following: Document assessment of the wound / ulcer in the medical record. Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed. The classification and treatment of wounds, including ulcers, will follow the wound management program protocols for the wound type / ulcer stage assessed unless otherwise specified by the physician. Document wound / ulcer treatment provisions on the treatment administrations record. It continues, Assessment of progress toward healing in completed at least weekly and the physician is notified at least monthly of progress toward healing. If there is regression, the physician is notified of the condition change.

Based on observation, interview and record review, the facility failed to monitor, provide progressive intervention, implement dietician recommendations, and encourage the resident to eat or offer substation for 1 of 6 residents (R40) reviewed for weight loss. This failure resulted in R40 having a19% weight loss in 3 months and a 23.8% weight loss in 6 months. Finding includes: R40's Care Plan, dated 09/20/2021, documented, Eating: supervision with set up/clean up assistance. R40's Minimum Data Set, dated dated [DATE], documented that R40 required supervision with 1-person physical assistance for eating. On 04/17/2023 at 12:31 PM, R40 was in bed with the head of her bed elevated and her meal tray sitting in front of her, with the lid off. On her tray was a piece of ham, not cut up, a baked sweet potato, without any butter nor was it cut up, a biscuit, not buttered or cut up and green beans. R40 had not eaten any food on the tray. R40 had some broken front teeth and 1 tooth totally intact. From 12:30 PM to 1:30 PM R40's room was under continuous observation. No staff member entered nor was any eating encouragement given. On 04/17/2023 at 01:30 PM, V13, Certified Nurse's Assistant picked up R40s tray and placed it on the hall cart. When asked how much R40 consumed of her meal, V13 stated that she only took a couple of drinks but didn't touch her food. R40's meal tray was covered with a dome and under dome was a piece of ham, not cut up, a baked sweet potato, not cut up, biscuit and green beans. On 04/19/2023 at 12:05 PM, a staff member served R40 her lunch tray. The staff member cut up R40's meat, pepper steak, buttered her biscuit and made sure all of her lids to her drinks were off. At 12:10 PM, R40 was sitting at the table and had not even took a bite of her food or a drink of any of her fluids. No staff members approached her to give her verbal cues to remind her to eat. Then at 12:15 PM, R40 was still sitting at the dining room table and had not even attempted to feed herself nor did any of the staff members assist or cue her to eat. At 12:20 PM, V13 asked R40 if she wanted to drink her milk and she told him she wanted chocolate milk. V13 went and retrieved a carton of milk for her, opened it and poured it in a cup with a handle. He then handed it to her, and she started to drink it. At 12:30 PM, R40 drank most of her chocolate milk but no staff gave her any verbal cues to eat or offer any other substations for her meal. On 04/19/2023 at 02:00 PM, R40 stated that she did not care for the lunch today when she was asked. R40's weight log documented weights on 05/12/2022 as 161.7 and on 08/08/2022 at 143.6 pounds as this was a 11.19% weight loss in three months. R40's weight log documented weights on 10/01/2022 as 158.4 and on 03/31/2023 as 120.7 pounds as this was a 23.8% weight loss in six months. R40's Dietician's Note, dated 05/23/2022 at 2:11 PM, documented, Nutrition Note Text: RD monthly weight note: Current weight is 161.7# (5/12/22). Weight is stable over the past month from 162#(4/5/22). She continues to trigger for significant wt. (weight) loss. Weight is down 11.6%(21.3#) over the past 5 months from 183#(12/8/21). BMI (Body Mass Index) is 27.8 (overweight but acceptable per age). Diet is LCS (low concentrated sweets) with thin liquids. She feeds herself. Intake has been variable lately due to AMS/confusion/hallucinations. often poor <25%. increased behaviors noted. Variable intake meal to meal with some refusals. Weight loss likely r/t (related to) confusion and hospitalization . Supplements include 60 ml (milliliters) med (medication) pass TID (three times daily) which were recently increased. Blood glucose levels have ranged 88-184mg(milligrams)/dL(deciliter) the past month. Skin: No edema noted. meds reviewed Continue to encourage adequate intake. increase supplements. liberalize diet. Monitor nutritional parameters. RD (registered dietician) f/up (follow-up) PRN (as needed). R40's Dietary note, dated 05/31/2022 at 10:27 AM, documented, Note Text: 5 day completed. (R40) is currently on a LCS (low concentrated sweets) diet with thin liquids and is receiving 60cc (cubic centimeters) med (medication) pass TID (three times daily). She consumes varies amounts of her meals but lately 0-25% with an average fluid intake of 360ml per meal sometimes more. Her current weight is 161.7 pounds with BMI of 27.8. Dietary will continue to provide ordered diet, monitor her weight, monitor her for her changing needs, and refer her to the dietitian PRN (as needed). R40's Dietician's Note, dated 08/10/2022 at 1:33 PM, documented, Nutrition Note Text: RD monthly weight note: Current weight is 143.6#(8/8/22). 146.5#(7/6/22) Weight is down 16.7% over the past month 6 months from 172.4#(2/11/22). wt. hx (weight history): 153.9#(6/9/22); 169.5#(1/20/22). Weight has continued to decline. BMI is 24.6(WNL). Intake is poor and she has been refusing to eat. Diet remains LCS with thin liquids. She feeds herself. Intake has been variable lately due to AMS/confusion/hallucinations. often poor <25%. increased behaviors noted. Variable intake meal to meal with many refusals. Weight loss likely r/t confusion and poor appetite. Supplements include 90ml med pass TID. Blood glucose levels have been acceptable most often this past month. Rec adding high protein ice cream with meals and liberalize diet to regular. Skin: No edema noted. meds reviewed Continue to encourage adequate intake. continued increased supplements. offer between meal snacks. Monitor nutritional parameters. RD f/up PRN. R40's Dietary Note, dated 10/10/2022 at 11:23 AM, documented, Dietary Note Text: Readmission completed. (R40) is currently on a cardiac diet with thin liquids. She is consuming 51-75% of her meals with an average fluid intake of 241ml-480ml per meal. Her current weight is 158.4 pounds with a BMI of 27.2. Dietary will continue to provide order diet, monitor her weight, monitor her intakes, and refer her to dietitian PRN. R40's Dieticians Note, dated 02/28/2023 at 08:30 AM, documented, Nutrition Note Text: RD Wt. (weight)/Skin Note: Stage 3 pressure injury to sacrum. Previously healed in August but has reopened per DON. Tx (Treatment) in place. Current Ht-64, Current Wt-122.2#, BMI-21.0 Noted higher wts on 1/3 and 2/1 likely scale errors. Nursing to review wt. and reweigh to confirm loss. CBW is a 12.6% loss x 5 mo. Also noted a 17.9% loss x 2 mo (months) (12/6 wt.=148.8#). Poor PO noted at many meals. Fluid changes w/ CHF (Congestive Heart Failure) and diuretic rx (medication) could also influence wt. BMI is healthy and wt within IBW range. Further wt loss not desirable for resident. Diet Rx: NAS (no added salt)/reg/thin, 60ml med pass TID. Many intakes <25%, but a few meals in 26-75% range. No chew/swallow concerns noted. 2/10 Hgb A1c 5.3. Recent D/C of DM meds and accuchecks per MD. Will cont. to monitor A1c. Recommend 30ml liquid protein AWC d/t stage 3 wound. Due to wt. loss and poor PO, suggest MD consider addition of appetite stimulant. Diet/supplements adequate to meet/exceed needs and support healing. RD prn. R40's Progress notes were reviewed and there was not documentation that R40's physician was notified of weight loss, nor was it documented about asking for an appetite stimulant. R40's Dietician Notes, dated 03/22/2023 at 12:07 PM, documented, Nutrition Note Text: RD Wt/Skin Note: Stage 3 pressure injury to sacrum. Previously healed in August but has reopened per DON. Tx in place, improving per most recent Wound MD review. Current Ht-64, Current Wt-122.8#, BMI-21.1. Per Wt Exception Summary wt loss of 22.5% from wt on 10-1-22. Wt stable x 1 mos. Poor PO noted at many meals. Fluid changes w/ CHF and diuretic rx could also influence wt. BMI is healthy and wt within IBW range. Further wt loss not desirable for resident. Diet Rx: NAS/reg/thin, 60ml med pass TID. Many intakes <25%, but a few meals in 26-75% range. No chew/swallow concerns noted. Recently began receiving 30mL Liquid PRO daily. Meds reviewed, no nutrition-related med changes since last RD review. No recent labs available to review. Diet and supplements exceed estimated needs and are appropriate to support skin healing. RD will continue to monitor and f/u PRN. On 04/19/2023 at 02:20 PM, V10, Dietary Manager stated that R40 was placed on Med Pass 3 times a day on 12/22/22 they have been trying to stabilize her weight since then. She also stated that R40's meal intake has been decreased. V10 continued to state that R40 is not one of the residents that the normally watch or assist. V10 continued to state that she reviews weights weekly looking for a 5% to 10% weight gain or weight loss and then sends a report to the nurse management team and the dietician. On 04/20/2023 at 10:00 AM, V24, Dietician, stated that nursing should have assisted R40 with her meals and that R40's weight loss has slowed down and has been minimized. On 04/20/2023 at 11:10 AM, V26, Certified Nurse Assistant (CNA) stated that it depends on R40's mood if she wants to eat or not but she likes to drink. V26 continued to state that R40 does require verbal cueing to eat her meals. On 04/20/2023 at 11:15 AM, V27, CNA, stated that R40 requires assistance with eating her meals. On 04/20/2023 at 10:05 AM V2, Director of Nurses stated that the staff should assist R40 if she is not eating or offer substitutes. V2, stated that she did not know that the Dietician recommend that R40 be on an appetite stimulant because she was not here at the facility at that time, but she will look into it. The Facility's policy, Weight Management Policy and Procedure, dated 2/2016, documented, Any resident with a significant or insidious weight change will be referred to the dietitian for assessment of condition. The dietitian will implement any necessary clinical interventions or make recommendations regarding diet and supplementation to the physician. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian.

Based on interview and record review, the facility failed to notify Adminsitrator/Director of Nursing and medical doctor, failed to document incident, failed to ensure provision of assessment, and monitoring for change of condition after a fall for 1 of 4 residents (R2) reviewed for incidents/accidents of care in the sample of 4. This failure resulted in a delay (24 hours) in treatment for a fractured femur. Finding include: On 8/9/22 at 11:30AM, V2, Director of Nursing (DON), stated R2 had a visit to see Orthopedics on 8/1/22, for preparedness of clearance for prophylactic bilateral hip pinning, due to the metastasis to both of her hips, and the greater chances of developing a left hip fracture, without having the pinning hardware to her hips. R2's Orthopedic consult note, dated 8/1/22, documented, Resident is a [AGE] year old resident with diffuse osseous metastatic disease including bilateral proximal femurs, notably to the left femoral head, bilateral iliac bones, sacrum and multiple vertebrae with plans for prophylactic pinning of bilateral hips. R2's Hospital History and Physical report, dated 8/3/22, documented, R2 presents, for altered mental status and a recent fall in bathroom found to have left femur fracture. Plan for surgical intervention. R2's Hospital History of Present Illness, dated 8/3/22, documented a Chief Complaint of, fall at nursing home yesterday. Shortening and rotation of left lower extremity, presents to the emergency department today for altered mental status and a recent fall in the bathroom found to have left femur fracture. Plan for surgical intervention. V2 Director of Nursing (DON) stated, on 8/3/22, V4 was assigned to work and cared for R2, without mention of R2's fall. On 8/3/22 late morning, R2 developed a change in condition with her respiratory status. V2 stated at that time while assisting R2 to be transported out for evaluation and treatment, R2 had stated she had fallen in the bathroom yesterday afternoon. V2 stated after R2's transport, she notified the physician, R2's family representative and requested V4 to complete the appropriate Fall Incident Forms prior to ending her work shift, R2 was delayed because R2's fall was not reported. V2 stated, R2 was admitted with a left femur fracture with plans of surgical interventions. V2 stated on 8/2/22, after V4 left her working shift at 3:00PM, there was no documentation in R2's medical records. On 8/8/22 at 2:10PM, V2, Director of Nursing (DON), stated R2 remains in the hospital due to sustaining a left femur fracture. V2 stated R2 had an increased cough, diminished lung sounds, poor oral intake, and c/o (complained of) generalized pain late morning on 8/3/22. V2 stated she was in R2's room for the preparation of R2's transport to the local hospital, when R2 stated she had fallen in the bathroom yesterday. V2 stated V4, Licensed Practical Nurse (LPN), who was providing care for R2 that day, notified R2's son (V6) of R2's transport to hospital for changes in her respiratory condition. V2 stated she was not aware of this fall, therefore she initiated the telephone call to V6 to explain that R2 had a fall on 8/2/22. V2 stated she discussed this issue of R2's fall with V4. V2 stated that V4 had told her she did not know that R2 had fallen until late the evening of 8/2/22 when V3, Certified Nurse Aide (CNA), called her at her residence because he was worried about R2's condition after her fall. V2 stated V4 did not follow facility protocol, as V4 did not complete a Fall Occurrence Report, as this includes: a set of vitals, a full skin and pain assessment and notification to R2's Physician and V6. V2 stated there was no documentation from the nurses who followed after V4's work shift from 8/2/22 through 8/3/22. V2 stated V4 was assigned to work 8/2/22 from 7:00AM to 3:00PM and returned to work on 8/3/22 for 7:00AM to 3:00PM, and still there was no documentation of R2's fall. On 8/8/22 at 2:20PM, V1, Administrator, stated the facility managers get together every morning to discuss issues, concerns and Fall reporting's and on 8/3/22, no one thing was mentioned of R2 having a fall that occurred on 8/2/22 at 1:00PM. On 8/9/22 at 10:10AM, V3, CNA, stated he was assisting R2 to the toilet on 8/2/22. V3 stated as he was standing at the bathroom doorway, watching R2 toileting, R2 had raised herself up to cleanse herself, leaned forward and fell on to the floor on her right side, did not hit her head. V3 stated this happened so fast he could not get to R2 to prevent the fall. V3 stated R2 was then assisted back onto the toilet and he called out to V4. V3 stated he explained to V4 that R2 had fallen and was assisted back onto the toilet. V3 had stated V4 came into the bathroom had done a body skin assessment and checked R2's vital signs. On 8/10/22 at 9:20AM, V4, LPN, stated that V3 reported that R2 needed assistance with toileting, with no mention of a fall. V4 stated that she entered R2's bathroom, R2 was sitting on the toilet, helped V3 clean her up from having a large bowel movement, felt her body all over for any abnormalities, R2 had stated she hurts all over, but this her normal base line every day. V4 stated the evening of 8/2/22 at around 7:00PM, V3 had called her at home, with a statement that he was concerned for R2, due to her fall she had early in the afternoon. V4 stated, she was not aware of this fall, got wrapped up in events occurring at home and did not notify the facility, the On-call nurse nor V2 of this concern. V4 continued to state, she did not complete, nor document R2's fall event, as she thought she would take care of it the next day when she came into work. On 8/9/22 at 3:50PM, V2 stated she would expect the licensed nursing staff, to document and complete the appropriate forms as required per facility policy and procedure, provide notification of an incident to the physician and family and report such incident to the Director of Nursing. The facility's Fall Assessment and Management policy and procedure, dated 4/2019, documented, Post fall assessment - immediately after a fall the resident will not be moved from their position until a licensed nurse determines it is safe to do so, A license nurse will immediately assess the resident, document a description of how the resident is observed, notify the physician, responsible party, complete a Risk Watch Occurrence Report immediately and a Licensed Nurse will continue to document post fall occurrence for 72 hours regarding the resident's status and note any change in condition. A fall occurrence will be presented and reviewed at the Quality Assurance meeting.

Based on observation, interview and record review, the facility failed to implement effective infection control procedures to prevent the spread of COVID-19 by failing to ensure accurate completion of employee screening tools to prevent employees from working while experiencing symptoms of COVID-19; failing to ensure non-vaccinated employees who report close contact with others with COVID-19 quarantine; failing to timely implement transmission based precautions for residents who were in prolonged contact with a staff member with COVID-19; and failing to ensure staff have access and utilize appropriate Personal Protective Equipment (PPE) when caring for residents who have been potentially exposed to COVID-19. These failures resulted in an Immediate Jeopardy (IJ) which began on on 4/9/21 when V7, Certified Nurse Aide (CNA), an unvaccinated CNA, worked an entire shift while experiencing symptoms of COVID-19 and exposing 14 residents (R4, R9, R10, R11, R20, R22, R27, R30, R33, R37, R39, R43, R49, R51) who reside on the 100 and 200 hallways. Four of these residents have not been fully vaccinated (R20, R30, R37, R43). This has the potential to affect all 59 residents living in the facility. The Immediate Jeopardy was identified on 4/29/21. On 4/29/21 at 2:03 PM, V1, Administrator, was notified of the of the Immediate Jeopardy. The surveyors confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 4/30/2021 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: On 4/26/21, when entered the facility V1, Administrator, stated, We have no active COVID-19 cases in the building. The red zone and yellow zones are both on the 300 hallways, there is also a green zone on the 300 hallway. The red zone is rooms 301-303, we have no positive COVID residents at the present time but those are the rooms they would be in. The yellow zone is rooms [ROOM NUMBERS]. The rest of the building is green. We did have a staff member who tested positive a couple weeks ago. The rest of the staff and residents have been tested and are negative. The census is 59. Entered the double doors leading into the 200 hallway, the dining room was to the right. 100 hallway was to the right of the nurses station, 200 hall was to the left of the nurses station. Rooms 100, 101, 102, 103, 104, 105, 106, 107, 108, 115, 116, 118 all had Droplet precaution signs on the doors. room [ROOM NUMBER] had Airborne precaution sign and door was open. Rooms 109, 111, 112, 113, 114 had Enhanced Isolation Precaution sign on their doors. room [ROOM NUMBER] had a Contact Isolation sign. On 200 hallway Rooms 201, 202, 203, 204, 205, 206, 207, 208, 209 had Droplet precaution sign on the door. On 4/26/2021 at 10:30 AM, V1 provided a typed document, dated April 26, 2021, that documents, Regency currently has no confirmed or suspected COVID residents in the facility. On 4/26/21 at 11:15 AM, when asked why all the Droplet, Airborne Isolation signs were on each resident door, V16, CNA, stated, It's just precautionary because a staff member tested positive a couple weeks ago. On 4/26/21 at 2:30 PM, when asked why the isolation signs are on every room, V15, CNA, stated, I don't think anyone is in isolation. On 4/26/21 at 2:45 PM, when asked why every door on the 100 hall and 200 hall has an isolation sign, V7, CNA, stated, I don't know why every door has an isolation sign. On 4/26/21 at 3:00 PM, when asked why all the rooms had isolation signs on the doors, V9, Licensed Practical Nurse (LPN), stated, On 100 hall a staff member was positive for COVID, it's just precautionary. (R19) is in contact isolation for [MEDICATION(S)]-Resistant Enterococcus (VRE) and we have to gown and glove, but not the other rooms. On 4/26/2021 at 3:05 PM V1, Administrator, stated that the residents on 100/200 hall were on precautions and don't require isolation. V1 stated that the residents on 300 hall in the yellow zone were on isolation. V1 stated that the residents in the yellow zone are new admissions, they are there because they have no idea what they have been exposed to, but the residents on 100/200 hall they know what the residents that live there have been exposed to. V1 stated that she would have to get the DON (Director of Nursing) to give the specifics. On 4/26/2021 at 3:10 PM V2, DON, stated that the residents on 100/200 hall are on quarantine because of a staff that tested positive for COVID. V2 stated that the staff are not using gowns and gloves when going in and providing care for residents that are under quarantine. V2 stated that she was going to place the residents on full isolation but was told by the Administrator not to. V2 stated that V7, CNA, worked on Friday (4/9/21) and became sick midway through her shift with a headache and required V8, Scheduler/Medical Records, to take her home in her car. On 4/26/2021 at 3:15 PM V2, DON, provided documentation of what the facility is using for guidelines. IDPH (Illinois Department of Public Health) PPE (Personal Protective Equipment) use in LTC (Long Term Care) when community transmission is no to minimal transmission (less than 5%). The form documents Residents in TBP (Transmission Based precautions) for suspected or Confirmed COVID: All routine care and potentially AGP (aerosol generating procedures) such as [CONDITION(S)]/[CONDITION(S)], nebulizers. No to minimal transmission outbreak: by definition one case puts a facility into outbreak see below for PPE requirements. No to Minimal Transmission Outbreak: N95 respirator required, face shield when the N95 is unavailable, eye protection-required, gowns- required, gloves required. Moderate to Substantial Transmission-Outbreak: N95 respirator required, Face shield when the N95 is unavailable, eye protection-required, gowns- required, gloves required. On 4/26/2021 at 3:30 PM, the facility provided a Midnight Census report, dated 4/9/2021, identifying 12 residents cared for by V7, CNA. Of the 12 residents identified R20 was identified as having only the 1st dose if COVID vaccine. R30, R37, and R43 were not vaccinated at all. On 4/26/2021 at 3:40 PM, V2, DON, provided V7's Current Pay Period Sheet, not dated, that documented V7 worked 2 PM to 10 PM shifts on 4/4, 4/5, 4/7, 4/8 and 4/9/2021. It also documents 4/11 felt ill. 4/12 Call off-Hospital. 4/13 LWOP (Leave without pay), 4/14 LWOP reported positive COV-2 (COVID-19 test). On 4/26/2021 at 3:45 PM V8, CNA, stated that she came in at 8:00 PM and worked at the facility on the floor until the evening shift was over around 10 PM on 4/9/2021. V8 stated that she saw V7, CNA, outside and asked her if she needed a ride. V8 stated that she gave V7 a ride around the corner and back. V8 stated that once she found out that V7 was positive she asked to be tested and notified V2, DON, that she gave V7 a ride. V8 stated that she has not been quarantined and has continued to work in the facility since being in close contact with V7. On 4/27/21 at 7:30 AM, V9 was asked why all the residents rooms now had isolation carts outside the rooms when yesterday they did not, she stated, As of late yesterday afternoon, after you and I talked we were told everyone here is in isolation and we have to wear gowns and gloves when we enter all the rooms. On 4/27/21 at 7:30 AM, V9 performed hand hygiene, put a gown on that she had gotten out of the isolation cart outside room [ROOM NUMBER] and stated, We were told we could re-use these gowns, we have to hang them up on a hook prior to leaving the room. When asked, how do you know whose gown it is, she stated, We need to put our initials on them, but I didn't have my marker in the room with me, so I'll have to initial it later. On 4/27/21 at 7:55 AM, V14, Activity Director, and V16 walked into R51's room, V16 was pushing R51 in the wheelchair, neither staff put a gown or gloves on. On 4/27/21 at 7:58 AM, V10, CNA, walked into room [ROOM NUMBER] without getting a gown or gloves from the isolation cart outside of room [ROOM NUMBER]. On 4/27/21 at 8:10 AM, V10 came out of room [ROOM NUMBER], when asked if she wore a gown while she was in the room she stated, The first time I walked in I didn't, the second time I went in I did. When asked what she did with the gown, she stated it is hanging up by the door. There was only one gown hanging at the door and it was the gown V9 had used when she went in the room earlier. I told V10, that was V9's gown, she stated, I didn't know it was (V9)'s gown. On 4/27/21 at 8:15 AM, V16, Restorative CNA, when asked if he works on all the halls in the facility, V16 stated, Yes, I'm Restorative and I go all over and help where I'm needed, When asked if he was wearing gowns and gloves in resident rooms on 4/26/21, V16 stated, No, I wasn't wearing gowns and gloves in the rooms yesterday. On 4/27/21 at 9:35 AM, during Resident Council group meeting, R13, R16, R24 and R43 all stated that they knew that a staff member had COVID. R13, R16 and R24 all stated that the staff did not wear gowns or gloves while they were in isolation and that the staff was wearing mask and eye protection. 4/27/2021 at 2:30 PM, V7, CNA, stated that she worked Friday 4/9/2021. V7 stated that she was sneezing and coughing at work. V7 stated that she filled out her own employee screening and answered no to symptoms because she thought it was her sinuses. V7 stated that she worked her entire shift. V7 stated that V8, CNA, gave her a ride to pick up her son on 4/9/2021. V7 stated that she woke up the following day and felt worse and stayed in bed most of the day. V7 stated that she lost her taste and smell on Sunday (4/11/2021). V7 stated that on Monday (4/12/2021) she and her son were sick with the same symptoms. V7 stated that the facility called and spoke with her family and was notified of her symptoms and that she was on bed rest. V7 stated that on Tuesday (4/13/2021) she and her son went to the local clinic and received a rapid COVID test that was positive and PCR (polymerase chain reaction [test]) which would come back the following day. V7 stated that she notified V8 and V2, of her rapid test results by phone around 11 AM to 12 PM (4/13/2021). V7 stated that she was told she would be on quarantine by the facility and IDPH which would start from the date of symptoms. V7 stated that she is not vaccinated, by choice. V7 stated that she had been educated on the process of the screening but put no symptoms down anyway. V7 stated that the screening is done when you first walk in the door. V7 stated that she worked on the 100/200 hall unit and was assigned to rooms 101 to 109. V7 stated they were short that evening and she had to pick up more rooms. V7 took care of 14 residents on 4/9/21 (R4, R9, R10, R11, R20, R22, R27, R30, R33, R37, R39, R43, R49, R51). V7 stated that 4/26/2021 was her first day back. V7 stated that she did not show anyone a release. V7 stated that she spoke with V8 and was told to return. V7 stated that she did not have documentation of release from isolation until she called the health department and requested it on 4/27/2021. V7 stated that no one asked her for written documentation, and she did not provide one when coming to work. V7 stated that her son was sick with COVID symptoms before she was. V7 stated that she told the facility that he was sick. V7 stated that she had to leave work early on 3/30/2021 and called off on 3/31/2021. V7 stated that her son's symptoms were fever, coughing and complaints of stomachache. On 4/28/21 at 9:52 AM, V11, Licensed Practical Nurse (LPN), Infection Preventionist, stated, We found out on Wednesday April 14th that V7 had tested positive, originally the facility was going to set up isolation but was directed from corporate not to because the staff had not been in the facility for 48 hours. V11 stated that 100/200 hall should be on isolation. V11 stated that she had not spoken to or had any contact with V7. V11 stated that she was not aware that V7 or her son had COVID symptoms and had not received any information pertaining to V7's return to the facility. V11 stated that she was aware of V8, CNA, being in close contact with V7. V11 stated that V8 should have been quarantined. The Facility's Employee Screening Prior to Clocking in to Work Form for the following date 4/9/2021 documents V7 as No to the question of new symptoms: Do you have any of the following New symptoms- shortness of breath, cough or worsening cough, sore throat, chills or shaking with chills, muscle pain, headache, loss of smell or taste, runny nose, fatigue, nausea, vomiting, or diarrhea. For the following dates: 4/12, 4/13, 4/14, 4/15, 4/16, 4/19, 4/20, 4/21, 4/22, 4/23, 4/26, and 4/27/2021, It also documents V8, CNA, as No to the question of Contact: Had close contact with someone with COVID-19 infection in the prior 14 days? On 4/29/21 at 2:50 PM, V11, Infection Preventionist, was asked who determined what isolation signs to put up and when were they put up. V11 stated, The staff randomly put up the signs, no reason as to what sign was put up. The signs were put up on Monday 4/26/21. The Droplet Precaution signs on the doors dated 2-2015, documents, In addition to standard precautions. Visitors Please Report to Nurses Station Before Entering Room. 1. Wash Your Hands. 2. Gloves Should Be Worn Whenever There is Contact With: Blood, Body Fluids, Mucous Membranes, Or Non-Intact Skin, Changed After Use, Removed After Leaving the Resident's Room and Hand Hygiene Should be Completed. 3. Gowns are Indicated if Soiling is Likely. 4. Mask is Indicated for Those Who Come Within Less than or Equal to Three Feet Of The Resident. 5. Face Shields May be Worn During Procedures, I.E. Cough Inducing. 6. Bag Linen to Prevent Contamination. 7. Discard Infectious Trash to Prevent Contamination. 8. Wash Your Hands. Droplet Precautions Everyone Must: Clean their Hands, Including Before Entering and When Leaving the Room. Make Sure Their Eyes, Nose and Mouth are Fully Covered Before Room Entry. Or Remove Face Protection Before Room Exit. The Airborne Precautions sign, not dated, documents, Airborne Precautions Everyone Must: Clean Their Hands, Including Before Entering and When Leaving the Room. Put On A Fit-tested N-95 Or Higher Level Respirator Before Room Entry. Remove Respirator After Exiting the Room and Closing the door. Door to Room Must Remain Closed. The Enhanced Barrier Precautions sign, not dated, documents, Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting, Device Care or Use: Central Line, Urinary Catheter, Feeding Tube, [CONDITION(S)]. Wound Care: any Skin Opening Requiring a Dressing. Do not wear the same gown or gloves for the care of more than one person. The Facility's COVID-19 Testing and Response policy, revised 3/22/21, documents Screen staff (includes vendors, volunteers and visitors): This includes but is not limited to screening all staff for temperatures and new symptoms (shortness of breath, cough or worsening cough, sore throat, chills or shaking with chills, muscle pain, headache {new or unusual onset not related to dietary reasons such as hunger or history of migraines, cluster, or tension headaches, or headaches typical of the person} or loss of smell or taste prior to shift. The Policy documents Follow Respiratory Protection Program and ensure staff are educated on and correctly performing hand hygiene, donning, and doffing of PPE, and using appropriate products for environmental cleansing/disinfection. Ensure PPE (personal protective equipment) supplies are easily accessible to staff when available. The Policy documents All employees should promptly notify supervisor of any symptoms of illness in themselves or individual in their care. The Policy documents Employees who are ill are to exclude themselves from work environments and are to seek the advice of their health care provider. The facility policy documented Facility has developed a plan for positive COVID-19 residents and/or PUI (Persons under investigation). Isolation plan is in place. The Policy documents Facility-associated case of COVID-19 infection in a staff member: A staff member who worked at the facility for any length of time two calendar days before the onset of symptoms (for a symptomatic person) or two calendar days before the positive sample was obtained (for an asymptomatic person) until the day that the positive staff member was excluded from work. The Centers for Disease Control (CDC) Guidelines, updated Feb. 23, 2021, for Interim Infection Prevention and Control (IPC) Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, document, The IPC recommendations described below also apply to patients who have met criteria for a 14-day quarantine based on prolonged close contact with someone with [CONDITION(S)]-CoV-2 infection. Patients in this 14-day quarantine period should be isolated in a single-person room and cared for by HCP using all PPE recommended for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. However, these patients should NOT be cohorted with patients with [CONDITION(S)]-CoV-2 infection unless they are also confirmed to have [CONDITION(S)]-CoV-2 infection through testing. This strategy maximally reduces post-quarantine transmission risks and is the strategy with the greatest collective experience at present. The Guidance documents HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The CDC website guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated Mar. 29, 2021, document, Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. The Guidance documents HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. The Guidance documents Because of the high risk of unrecognized infection among residents, a single new case of [CONDITION(S)]-CoV-2 infection in any HCP or a nursing home-onset [CONDITION(S)]-CoV-2 infection in a resident should be evaluated as a potential outbreak. The CDC Guidance documents Establish a process to ensure HCP (including consultant personnel and ancillary staff such as environmental and dietary services) entering the facility are assessed for symptoms of COVID-19 or close contact outside the facility to others with [CONDITION(S)]-CoV-2 infection and that they are practicing source control. The guidance documents Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, HCP report absence of fever and symptoms of COVID-19, absence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The guidance documents Fever can be either measured temperature > or = 100.0°F or subjective fever. People might not notice symptoms of fever at the lower temperature threshold that is used for those entering a healthcare setting, so they should be encouraged to actively take their temperature at home or have their temperature taken upon arrival. HCP who report symptoms should be excluded from work and should notify occupational health services to arrange for further evaluation. In addition, asymptomatic HCP who report close contact with others with [CONDITION(S)]-CoV-2 infection might need to be excluded from work. If HCP develop fever (Temperature > or = 100.0°F) or symptoms consistent with COVID-19 while at work they should inform their supervisor and leave the workplace.Have a plan for how to respond to HCP with [CONDITION(S)]-COV-2 infection who worked while ill (e.g., identifying exposed residents and co-workers and initiating an outbreak investigation in the unit or area of the building where they worked). The Resident Census and Conditions of Residents, CMS (Centers for Medicare and Medicaid Services) Form 672, dated 4/26/2021, documents there are 59 residents living in the facility. The Immediate Jeopardy that began on 4/9/2021 was removed on 4/30/2021 when the facility took following actions to remove the Immediacy: 1. All management re-educated on the facility's COVID-19 testing and response plan, specifically the return to work criteria, appropriate PPE usage, appropriate signs for isolation, and employee screening criteria. Completed on 4/29/2021 and ongoing. 2. Implementation of effective infection prevention and control procedures to prevent the spread of COVID-19. 3. All staff re-education on the facility's COVID-19 testing and response plan, specifically the return to work criteria, appropriate PPE usage and supply location, and employee screening criteria, Isolation protocols, and staff process of reporting symptoms immediately to the facility. Completed 4/30/2021 and ongoing. 4. Monitoring for compliance with the contingency plan. The facility Infection Prevention will monitor for return to work criteria compliance of COVID-19 positive staff, PPE supply availability, and appropriate isolation signs. This will be monitored by: a. Implementation and daily review of employee call off worksheet b. Updates to staff screening process and daily review of employee screening logs c. Twice daily checks of PPE supply on units d. Audits will be completed on daily round to ensure proper isolation signage. Ongoing.

Based on observation, interview and record review, the facility failed to provide safe transfers technique to prevent injury for 1 of 5 residents (R59) reviewed for accidents in the sample of 27. This failure resulted in R59 falling and sustaining fractures to the right tibia and fibula. Findings include: The physician's orders [REDACTED]. The Admission Nursing Assessment, dated 09/07/17, documented R59 required assistance with transfers and toileting with an assistive device. On 09/07/17, the falls risk assessment identified R59 as being a moderate risk for falls. A Occurrence report, dated 09/07/17 at 3:30 PM, documented R59 fell while being toileted. It documented R59 had fallen during a one person transfer onto the bathroom floor. It documented V22, CNA, had toileted R59 alone without a gait belt and upon standing R59's legs buckled and she fell . It documented R59 was observed by V7, Licensed Practical Nurse (LPN) lying on her back on the floor with right knee bent and right foot behind right thigh. It documented R59 stated Voiced that the girl wasn't able to hold me that my legs gave out. The immediate actions taken were for ice pack applied, pain when Range of Motion (ROM) performed and resident kept under continuous supervision. On 09/07/17 at 3:30 PM, R59's Nurse's Note documented R59 fell and complained of right knee pain. A nurse's note documented V2, Director of Nursing (DON) had massaged a small knot area in the muscle that R59 was voicing pain. It further documented knot disappeared and R59 said some relief. At 4:35 PM, a Nurse's Note documented R59 voicing pain again in right below the knee and area was swollen and Physician was called. At 5:24 PM, a nurse's note documented called physician back and waiting on call. At 5:40 PM, physician called back and said to send to emergency room . At 5:55 PM, ambulance called for transport to the hospital. At 6:26 PM, ambulance arrived and transported R59 to the hospital. At 11:30 PM, a nurse's note documented the hospital called and notified that R59 had fractured right leg. On 04/11/18 at 9:50 AM, R59 stated she was dropped on the floor by V22, CNA. R59 stated she was unable to ambulate without a lot of assist prior to coming to the facility. On 04/12/18 at 3:00 PM, V2 Director of Nursing stated R59's fall and fracture was due to poor transfer techniques and that subsequently, V22, CNA was terminated for not following facility policy regarding safe transfers. On 04/12/18 at 3:30 PM, V7, LPN stated that on 09/07/17, he was asked to come to R59's room for a fall. V7 stated that he saw R59 on the bathroom floor with the right leg bent back behind her leg with full weight on the right leg. V7 said R59 was complaining of pain at the right knee. V7 stated V22 had been transferring R59 from the toilet without a gait belt alone. V7 stated V22 should not have tried to transfer without a gait belt. The Care Plan, dated 09/08/17, documented R59 required extensive assist of two staff per full mechanical lift for transfers. On 09/19/17, the care plan documented R59 required extensive assist of two staff for transfers. On 12/19/17, the care plan documented R59 required extensive assist of two staff per sit to stand mechanical lift. On 04/13/18, the care plan documented R59 required extensive assist of two staff per full mechanical lift for transfers. The Minimum Data Set (MDS), dated [DATE], documented R59 required extensive assist of two staff for transfers with sit to stand mechanical lift and was non-ambulatory. On 04/11/18 at 3:00 PM, V15 and V16, Certified Nursing Assistants (CNA's) were completing incontinent care and a skin check for R59. When the blanket was removed off R59's legs, there were multiple (more than 10) bruises of varying colors and stage of healing. Most were on bilateral knees and shins. V15 and V16 could not say a reason for the bruising. On 04/12/18 at 2:50 PM, V10, Certified Nursing Assistant (CNA) and V21 Registered Nurse (RN) were observed during transfer and toileting for R59. R59 was up in the wheelchair and required sit to stand mechanical lift for transfers. V10 and V21 applied the lift sling around the upper back and extending up under each axilla. R59's legs were placed onto the footboard and her knees pushed closely to the pad. As V10 lifted R59 up she immediately started to cry out ouch, no no, it hurts, it hurts. When V10 was done lifting R59, her legs were not supporting any weight on the footboard and the sling was pulling up on both arms and no longer under the axilla's. R59 was in a dangling-like position during this transfer. The bruises on bilateral legs coincided with the position of her legs and the knee board of the sit to stand mechanical lift. After toileting, again R59 was transferred in the same manner with R59 crying out the entire way to the bed. When V21 was asked if R59 cried out in pain and not able to support herself during sit to stand mechanical lift was common she stated We may have to change that (transfer) again.

Based on interviews, observations and record review, the facility failed to assess/identify causative factors contributing to falls, implement interventions based on those causative factors, monitor/modify the interventions if needed and provide adequate supervision to prevent falls for 3 of 3 residents (R1, R2, and R3) reviewed for falls in the sample of 7. This failure resulted in R1 falling and sustaining a depressed fractured nasal bone on the left and R3 falling and sustaining an acute non displaced fracture of the left superior pubic ramus. Findings include: 1. R1's Admission Record documents R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/1/17 at 10:30 AM, R1 was sitting at the nurses' station in her wheelchair. Her left eyebrow area and upper cheek were bruised greenish/yellow and purple with a dressing present over her left temple area. R1 had foot pedals on with a foot buddy to prevent her feet from falling to the floor behind the pedals. R1's Minimum Data Set (MDS), dated [DATE], documents R1 to have a Brief Interview of Mental Status (BIMS) score of 11 - moderately cognitively impaired. The MDS identifies R1 requires extensive assist of one staff for transfers and mobility on and off the unit and in hallway. The MDS documents she uses a wheelchair and has balance deficits during transfers and walking being only able to stabilize with the help of staff. The MDS documents no falls prior to admission. R1's Fall assessment, dated 1/16/17, documents R1 to be at high risk for falls. An Occurrence Report, dated 2/18/17 at 7:30 AM, documents R1 planted feet as wheelchair was being moved and fell forward out of wheelchair. Resident statement at the time was I fell and hit my face. Witness statement from E3, Certified Nurse's Aide (CNA), documents Resident placed feet down and fell forward out of chair. Recommendations written in at the bottom of the first sheet documents Leg rests - with foot buddy for positioning. Injuries documented on the Report was two areas on left forehead, one measuring 4.5 centimeters (cm) by (x) 3.5cm. knot of left eyebrow and the second small 0.5 cm in length bruise to left cheek. The Report section identified as Root cause analysis is marked N/A (Not Applicable) as was conclusion and care plan update. On 2/19/17 at 18:05 (6:05 PM), an Occurrence Report documents R1 to have another fall. The Nurse's Notes on the report document At 1800 (6:00 PM) the resident began yelling help. CNA (E4) asked resident what she needed and resident stated to lay down. The Report documents E4 was wheeling resident to her room and resident put her foot down refusing for CNA to help her. Resident fell face foreward out of w/c (wheelchair) landing on her right side w/ (with) legs bent. The Report documents bruising from prior fall but that R1 had a nose bleed, Right nostril bleeding moderate amount of blood. Residents nose slightly bent towards right side. The witness statement documents E4 told writer He was taking resident to room for bed as she requested. The Report does not document leg rests with foot buddy were on R1's wheelchair at the time she fell . The report documents the facility requested a facial X-ray. The X-ray report, dated 2/19/17 documented R1 sustained a depressed fractured nasal bone on the left. R1's Care Plan, dated 1/17/17, documents R1 to be at risk for falls due to confusion and psychoactive drug use with the goal being to have no falls thru next review. Interventions include educating her and family/caregivers about safety reminders and what to do if a fall occurs, leg rest with foot buddy for positioning (added 2/20/17) and provide safe environment with even floors free from spills and/or clutter, adequate glare free lights, bed in low position at night, handrails on the walls and personal items within reach. On 3/1/17 at 11:10 AM, E2 Director of Nurses (DON) stated they identified that E4 needed additional transfer training following the incident but was unable to state why R1 did not have the foot pedals on that were recommended the day before as a result of the first fall. E2 did not realize R1's first fall occurred as she was being pushed by E3, CNA. When asked if she considered the rate at which the CNA's were pushing R1 as a factor, stated she did which resulted in her recommending E4 get additional training in transfers. E2 was unaware if R1 used her feet to propel herself prior to placement of the pedals but stated she thought she did. No revision was done to R1's care plan to reflect her dropping her feet during a wheelchair transfer when foot pedals are not in place. 2. The Admission Record for R3 documents she was admitted to the facility on [DATE] following hospitalization for a non-displaced intertrochanteric fracture of the left femur and pathological fractures in part. R3's MDS, dated [DATE], documents her to have a BIMS score of 7 - severe cognitive impairment. The Section entitled balance during transfers and walking documents she is unsteady and can only stabilize with staff assistance. R3's Care Plan, dated 12/20/16, documents R3 to be at risk for falls due to gait/balance problems and incontinence. The goal documents R3 is to be injury free from falls thru the next review on 3/29/17. The care plan reflects no falls as occurring since admission. An Occurrence Report dated 1/23/17 documents R3 was sitting in her w/c she moved forward in the seat and lunged forward gently landing on her knees she had no injury. The Witness statement documented R3 lunged forward and landed gently on her knees. The root cause analysis is documented as n/a and a recommendation for a pommel cushion was made by therapy. Progress Note, dated 2/13/17 at 1700 (5:00 PM), documented R3 was walking unassisted in her room and falling before staff could reach her. The Nurse's notes document resident was stumbling backwards. The Nurse's Note documented the Certified Nurse's Aide (CNA) and R3 fell to the floor. The Occurrence Report, dated 2/13/17, documents therapy was discontinued, root cause analysis was documented n/a with no conclusion, and none noted written for recommendations following the fall. The report includes copies of medication administration records that document on 1/18/17, R3's Paxil, Remeron and Tramadol was changed and/or discontinued. R3 sustained no injuries. There were no revisions made to the care plan following this fall. Progress note, dated 2/14/17 16:01 (4:01 PM) document resident trying to ambulate self, transfer and ambulate self without staff assistance stating I'm leaving. Progress note, dated 2/15/17 4:02 AM document resident very confused with increased behaviors in the evening and night time, difficult to redirect. The Occurrence Report, dated 2/17/17 at 2235 (10:35 PM), documents R3 was found on the floor in the bathroom following her sister's visit. It was an unwitnessed fall. The report documents R3 asking where her sister was. The recommendation written on the bottom of the report is to monitor to see for behaviors of sitting on the floor. No root cause analysis was documented and no conclusion written. No staff interviews were conducted according to the report. Progress note, dated 2/17/17 at 23:05 PM document that 15 minutes before incident, resident had come to the nursing station looking for her sister. There is no explanation as to why the intervention of monitoring sitting on the floor would have been added since she was in the bathroom and there was no indication she sat herself down or had a history of [REDACTED]. The Occurrence Report, dated 2/18/17 at 9:30 AM, documents R3 was again found on the floor in her room. The report documents R3 stated I was walking tried to leave and I'm leaving no matter what you say. The recommendation was for a perimeter mattress even though the report documents R3's lights were on, slippers on, wheelchair in use along with a low bed. The report documents no staff interviews done and no information as to where R3 was prior to the fall was recorded in the report. No root cause was identified or conclusion documented. On 2/24/17 at 10:38 AM, the Progress Note documents Quetiapine (Seroquel) 12.5 mg (milligrams) at HS (bedtime) was started for sleep, mood liability, behaviors aggression - verbal, delusions, and dementia with behaviors. At 1732 (5:32 PM) Progress notes documents R3 behaviors started at 9 this morning, Resident began standing up from w/c walking w/o (without) staff assistance and poor gait stating I'm trying to go downstairs. Resident continues to stand up from bed with staff assistance. On 2/25/17 4:07 AM, Progress note documents R3 up all night standing up from the wheelchair when it is not locked crying and being verbally abusive to staff. An Occurrence Report, dated 2/25/17 at 1800 (6:00 PM), R3 was found on the floor of her room on the left side of her bed. She was reported to be sitting on the bedside mat with her legs stretched out. The report documents resident's statement as I slid down out of bed. The report documents R3's confusion with tearfulness and difficulty redirecting. No root cause for the fall was identified and no recommendations were made or revisions made to the care plan. An Occurrence Report, dated 2/27/17, at 6:00 AM documents R3 was found in hallway on floor on her left side - resident had been sitting in her wheelchair. The report documents R3 stated I fell down with no staff interviews done. The report also documents R3 had been up all night and is tearful and confused. R3 was complaining of pain in her left leg and an x-ray was ordered upon physician notification. Root cause was documented as N/A as was conclusion. The X-ray result dated 2/27/17 documents Acute non displaced left superior pubic ramus fracture. A recommendation was written at the bottom of the report that documented Medical Workup - since more confused than baseline. On 3/1/17 at 10:36 AM, E2 stated R3 was very behavioral and continually attempted to get up. E2 stated R3 is currently on bed rest pending an appointment with the orthopedic doctor. E2 stated they have an order now for a lap belt when R3 can get up again. E2 also stated R3 appears to be calmer with the Seroquel. E2 confirmed that R3 repeatedly tried to get up unassisted and with her severe cognitive impairment, doesn't realize she is unable to ambulate without assistance and doesn't know to call for help. E2 also stated she was very behavioral and often refused redirection and assistance. E2 was asked if getting up without assistance could be the root cause of most of her falls, E2 stated she thought so given that she thinks she can walk when she can't. E2 confirmed that R3's behaviors or resisting redirection and/or repeatedly getting up unattended are not identified on her plan of care for falls preventions. R3's current care plan as of 3/3/17 documents R3 to be at risk for falls due to gait/balance problems and incontinence. The goal is to have no injury from falls by next review (3/29/17) with interventions dated 12/20/16 to educate her/family/caregivers about safety reminders and what to do if a fall occurs, and provide a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on the walls, personal items within reach. Provide reacher was added on 1/3/17, Pommel placed per therapy was added 1/24/17 and on 2/20/17, revisions added to include monitoring to see if new behavior of sitting on floor and perimeter mattress. On 2/28/17, fall mats at bedside and therapy screen for positioning in w/c was added. Repeatedly getting up unassisted was not identified as a problem nor was adding additional supervision or keeping her more within visual range added an intervention. Progressive interventions were not developed and/or added following falls on 2/13/17, or 2/25/17 in an effort to prevent R3 from continuing to get up unassisted and falling. The care plan also fails to identify R3's poor or lack of safety awareness, her repeated falls and her need for additional supervision due to this behavior. R3 was in bed on 3/1/17 at 10:00 AM sleeping. She had a scoop mattress and the bed was in low position. R3 remained in bed at lunch and again at 2pm appearing calm making no attempt to get up. The facility's policy/procedure entitled Fall Assessment, risk identification and management policy dated 3/20/12 documents It is the policy of the facility to assess each resident's fall risk on admission to help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess, and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. Procedure documents Post fall care planning will include consulting with the resident's care givers and other disciplinary team members in regards to future intervention, and resident specific risk factors. Interventions will be based on the resident assessment and the circumstances surrounding the risk for injury or actual injury or fall. 3. The Admission Record documents R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's MDS, dated [DATE], documents R2 as having severe cognitive impairment with a BIMS score of 6. The MDS identifies R2 requires extensive assist of one staff for transfer and has a balance deficit during transfers and walking that requires staff to stabilize. R2's Care Plan, dated 12/27/16 identifies R2 to be at risk for falls due to confusion, deconditioning, gait/balance problems, psychoactive drug use and unaware of safety needs. The goal is to have no injuries from falls with interventions being dated 12/27/16 Anti-rollbacks to w/c, Educate him/family and caregivers about safety reminders and what to do if a fall occurs, and provide a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on the walls, personal items within reach. On 12/29/16, fall mats beside bed was added and on 1/12/17, Drop Seat in wheelchair was added. High back w/c with pommel was added and on 1/31/17, perimeter mattress was added. An Occurrence Report, dated 1/22/17, at 1630 (4:40 PM) documents R2 tried getting out of the wheelchair to pick a shoe up and staff intervened. R2 sat back down and got up again falling to the floor. A high back w/c (wheelchair) with Pommel cushion was recommended. No staff interviews were conducted and the root cause analysis section is documented as n/a. An Occurrence Report dated 1/30/17 documents R2 fell again at 2250 (10:50 PM) when staff responded to his call light going off and found him on the floor between the beds. The report documents when asked what he was doing, R2 responded I do this every night but tonight I couldn't get back into bed. The report documents R2 to have a low bed in place. Root cause analysis is again documented n/a with no conclusion. R2 is documented as sustaining a skin tear on his left forearm. No staff interviews are documented. Recommendations written at the bottom of the report include perimeter mattress and family wants a room change. The perimeter mattress was added to the care plan. The room change was not reflected on the care plan. An Occurrence Report dated 2/3/17 at 6:30 AM documents R2 was found sitting on the floor on his bottom beside the bed. The report documents no staff interviews were done. Root Cause analysis and Conclusion was documented as n/a. Recommendations written on the report documents Keep bed in lowest position when resident is in it, continue all other current interventions. R2's Care Plan was not revised with progressive interventions to prevent potential future falls. An Occurrence Report 2/12/17 at 2100 (9:00 PM) documents R2 to have another fall. The report documents resident was found on the floor in his room sitting on his buttocks. Under resident statement, the report documents He does not have an explanation regarding what he was doing. He states 'I fell down.' Written at the bottom of the report was In bed prior - Review of prior intervention - continue all interventions at this time. No staff interviews were done, and root analysis/conclusion is marked n/a. R2's Care Plan was not revised after this fall with progressive interventions to prevent potential future falls. On 2/16/17, R2's Occurrence report documents at 1435 (2:35 PM) he was in the bathroom and was found on the floor by a unit aide. R2 had a documented 2.0 cm right elbow skin tear. Witness statement documents resident told staff that he was going home. No root cause analysis was documented as being done with no conclusion. Recommendations documented reflect Toilet diary. R2's Care Plan was not revised at this time to address R2's continued falls. On 2/27/17 , R2's Occurrence Report documents at 2045 (8:45 PM), R2 was found on the floor beside his bed. Recommendations written in on the report include F/U (follow up) urine but nothing addressing R2's repeated behaviors of getting up unassisted and falling. On 3/2/17 at 3:00 pm, E2 stated R2 is continually getting up with assistance and can be difficult to redirect. E2 stated R2 is kept at the nurses' station most of the time when he is in his wheelchair for increase visual supervision which she agreed is no reflective in his falls prevention plan. E2 stated R2 repeatedly getting up unassisted could be a causative factor in him falling and she is having a difficult time developing interventions to address this behavior since he does it often. E2 confirmed R2 requires more supervision due to him attempting to get up on his own.

Based on observation, record review and interview, the facility failed to timely identify; accurately and timely assess; turn and reposition residents; monitor for drainage and intact dressings; follow physician orders for treatment; and failed to follow intervention for prevention and promote healing of pressure sores for 6 of 8 residents (R1, R2, R3, R4, R11 and R13) reviewed for pressure sores in the sample of 16 and 1 resident (R28) in the supplemental sample. R2 developed an unstageable pressure sore in house with no treatment change on decline and was receiving incorrect treatment. R3 developed 4 unstageable pressure sores in house that were avoidable. R4 developed an unstageable in house pressure sore that facility was not aware and had a decline in a stage 4 pressure sore and failed to follow Physician orders for the treatment of [REDACTED]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/14/14 at 10PM, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate and monitor the effectiveness of the facility policies and procedures; Inservice training on turning and repositioning; pressure sore assessment; pressure sore treatment; and pressure sore prevention. Findings include: 1. R3's MDS (Minimum Data Set) of 2/8/14 documents R3 has severe cognitive impairment; requires extensive assistance of 2 or more for transfer and hygiene; extensive assistance of 1 for bed mobility; and is at risk for pressure sores. R3's Care Plan of 11/26/13 documents R3 is at risk for potential impairment to skin integrity r/t (related to) fragile skin, medication use ([MEDICATION NAME]). "She requires total assist for incontinence care, requires assistance with nutritional intake, demonstrates contracture of left hand, has had history of distal fibula fracture, requires total assist for transfers with a mechanical sling lift, is wheel chair bound, demonstrates potential risk for shearing and friction injuries and has decreased sensory perception as manifested by profound cognitive deficits and advanced dementia. Braden Scale: 12 high risk." Care Plan goal is R3 will be free from skin breakdown. It is documented under interventions, "11/04/2013 abrasion buttocks. Re-evaluate sling usage, turn reposition every 2 hours...11/26/2013 Daily skin checks with all incontinent episodes and with all showers. Report any changes to the nurse. Nursing notify MD (Medical Doctor)/POA (Power of Attorney) of any changes...11/26/2013 Keep skin clean and dry. Use lotion on dry skin. 11/26/2013 Monitor/document location, size and treatment of [REDACTED]. to MD...Resident requires pressure relieving cushion to protect the skin while up in chair. Resident requires pressure relieving/reducing mattress to protect the skin while in bed..." R3's March 2014 Physician Order Sheet, POS, documents an order to turn and reposition every 2 hours. Physician Correspondence form of 3/11/14 documents 4 cm x 2.5 cm reddened and excoriate area on left buttock as well as 2.2 x 1.3 cm area on coccyx. Areas cleansed with wound cleanser, dried and hydrocholloid protective dressing applied. Z1, R3's Physician, responded, "Do you have a decubitus ulcer protocol or P.T. (Physical Therapy) need to eval for prevention so this heals and doesn't get worse?" During a skin check on 3/11/14 at 4:35PM, E11, Certified Nurse Aide, CNA,, stated he had just given incontinent care to R3 and was going to get another CNA to assist with the mechanical lift transfer. During the skin check, R3 was observed to have dried feces smeared on her left lower buttock. E12, Licensed Practical Nurse, LPN, confirmed and washed the area with disposable wipes. R3 had an hydrocholloid dressing dated 3/11/14 on her coccyx and left upper thigh. R3 had a light brown area on her mid left outer mid foot 1 cm in diameter. E12 stated she didn't know what it was. R3 was observed every 10 to 15 minutes on 3/12/14 from 8:15AM to 2:45PM sitting up in a wheel chair with a mechanical sling under her and her legs extended out in front of her. At 8:15AM, R3 was in her wheel chair in the Dining Room waiting for breakfast. At 9:12AM, E17, CNA, started to feed R3 and R3 ate over 75% of food served. R3 was taken from the Dining Room to Activities at 9:45AM by E17. At 9:55AM, R3 was taken to the beauty shop. At 10:10AM, R3 was taken out of the beauty shop by Z3, Hairdresser, to get her hair washed and then back to the beauty shop. R3 was observed to be in the beauty shop until 11:25AM and was taken to the 100 Hall Nurses Station by the Dining Room and remained there until 12:15PM when E18, Nurse Aide, took her into the Dining Room for lunch. R3 remained up in her wheel chair in the Dining Room until 1:40PM when R3 was taken from the Dining Room by E17 still in her wheel chair by the Nurses Station. At 1:40PM, E13, LPN, was informed that R3 had been up in her wheel chair since breakfast and requested to do a skin check. At 2:03PM, E15, CNA, took R3 from the Nurses Station to her room. R3 remained up in her wheel chair in her room until 2:45PM. E13, E14, LPN's and E15, CNA transferred R3 from her wheel chair to bed using the mechanical sling lift. R3 did not have a pressure relieving cushion on her wheel chair. R3's incontinent brief was saturated with urine and had an area that was blood tinged. R3's back of thighs and buttocks were deep creased and red. R3 had hydrocholloid dressings on her coccyx and left upper thigh. E13 stated the blood was coming from a wound on R3's coccyx. E13 removed the dressing from the coccyx. R3 had 3 open pressure sores. E13 and E14 stated the open sores were from pressure. E15 was observed to give incontinent care and failed to wash all areas that were soiled with urine. E15 wiped R3's anal area with disposable wipes and then wiped the pressure sores without changing his soiled gloves. E13 and E14 identified 3 pressure sores and stated one was the size of a dime and two were the size of a nickel and stated all 3 pressure sores were stage 2. Observation showed all pressure sores were unstageable with eschar and/or slough. When asked about the dark section on the top pressure sore, E13 stated yes it was getting dark. E13 placed a new hydrocholloid dressing on the pressure sores without cleansing the pressure sores first. E15 stated R3 was already up in her wheel chair when he came on duty at 7AM and confirmed she had not been out of her wheel chair until the time of the observation. On 3/13/14 at 11:20AM, R3's Pressure Sores were assessed by E5, LPN/Wound Nurse and E2, Director of Nursing, at the request of the Surveyor. E13 also was present. R3 was laying in bed on her back and was laying on 3 quilted bed pads and a folded sheet. E5 removed the hydrocholloid dressing from R3's coccyx. The adhesive to the dressing was directly on the pressure sores and the skin pulled and R3 cried out in pain when the dressing was removed. E5 stated she had not seen the pressure sore on R3's left upper thigh and stated she had seen the coccyx that was a stage 2. E5 stated she had not measured the pressure sores and had no documentation of the areas. E5 stated it would be on the Incident Report of 3/11/14 by E24, LPN. R3 had 3 pressure sores on her coccyx. E5 measured and staged the pressure sores. Coccyx: #1 measured 2.7 x 3 x .1 cm and was identified as a stage 2. The pressure sore was observed to have yellow slough. #2 measured 1.5 cm x 1.5 cm. and staged unstageable. E5 stated it had a dark area but may be from the hydrocholloid dressing. There was eschar observed. #3 measured 2 cm x 1 cm x 0.1 cm and was identified as a stage 2. There was necrotic tissue and slough. The pressure sore on the upper left thigh measured 6 cm x 2 cm x 0.1 cm and was identified to have serosangous drainage. E5 stated the pressure sore had a black area through the middle and that part is unstageable and the rest of the pressure sore is a stage 2. E2 was asked how he would stage the pressure sores and E2 stated all the pressure sores are unstageable. On 3/13/14 at 2:50PM, E14, LPN, stated E5 did not document the measurements for R3's pressure sore and asked if the Surveyor had the measurements. At 2:45PM, E13 stated she had not contacted Z1, R3's Physician, of the 3 pressure sores observed on 3/12/14. At 4:15PM, E5 stated she did not know if Z1 had been notified of R3's pressure sores being unstageable and increased in size. On 3/14/14 at 8:40AM, Z2 (Z1's Nurse) stated they got a fax from the facility last night after the office was closed. Z2 stated Z1 was not in the office today but she had contacted Z1 that morning of the fax information. Z2 stated the fax did not identify pressure sores. Record review showed the fax "Physician Correspondence" was not in R3's medical record. At 9AM, E1, Administrator was asked where the fax could be located and he stated to check with E14 she is taking care of that. At 9:10AM, E14 stated she did not know about a fax sent to Z1's office yesterday evening. E14 looked in R3's medical record stating it should be there. E14 was unable to locate the fax in R3's medical record or at the Nurses Station where the fax machine is located. At 11:20AM, Z2 provided the above fax that documents, "In addition to the prior fax sent for wounds on coccyx and thigh I just wanted to clarify that the wound on the thigh is on the R (right) side not the L (left) side & a new area was noticed today current measurements are coccyx - top 2.7 x 3 x 1.1, (L) 1.5 x 1.5, (R) 2 x 1, (R) thigh 6 x 2 x 0.1. Serosangous drainage from area & sloughing. Any new orders?" In an interview with Z1, R3's Physician, on 3/14/14 at 11AM, Z1 stated the facility faxes concerns to her office after 5PM and no one is there to receive the fax. Z1 stated that is inappropriate. Z1 stated the facility sent another fax last night (3/13/14) after the office was closed and they did not get until this morning. They did not identify R3 as having pressure sores. The information the facility gives is incomplete. Z1 stated the first correspondence that Z1 received from the facility identified the pressure sores as being an excoriation. Z1 stated she looks at excoriation as red dried skin, not open pressure sore. Z1 stated R3 had never had a pressure sore in the past. Z1 stated R3 needs turning and repositioning and she is concerned the facility is not following her orders. Z1 stated the lack of turning and repositioning and timely incontinent care would contribute to development of pressure sores. R3 is dependent on staff for care. Z1 stated someone is wiping R3's bottom, they should have seen the pressure sores when they were red before they were open with slough. Z1 stated that putting 3 pads and a folded sheet on the pressure relieving mattress takes away from the effectiveness of the pressure relieving mattress stated it makes it into a regular mattress. Z1 stated she was concerned that the facility would put the adhesive over the pressure sores stating it had to hurt when they removed it. Z1 stated she considered this as neglect. "Very neglectful." Z1 stated she does not see patients in the Nursing Homes but planned to go to the Nursing Home today to see R3. At 1:11PM, Z1 was at the facility and stated she looked at R3's pressure ulcers. Z1 stated she had placed an order for [REDACTED]. Z1 stated they have R3's legs extended out for a [MEDICAL CONDITION] that healed a long time ago. Z1 stated R3's positioning is a problem and increases the risk of pressure sores. Z1 stated she is sending R3 to the wound clinic. 2. According to the Minimum Date Set, MDS, dated [DATE], R2 is totally dependent on staff for all activities of daily living. The MDS indicates she is frequently incontinent of bowel/bladder with no toileting plan in place. The MDS identifies no pressure ulcers present at that time. The care plan dated 3/12/14 identifies R2 to have actual skin integrity with the goal to have no skin breakdown by next review and will have no complications due to the pressure ulcer on right hip through the next review. Interventions include pressure relieving device bed and chair, padding such as pillows/sheepskin, encourage good nutrition and hydration in order to promote healthier skin, identify causative factors and eliminate/resolve where possible, keep skin clean and dry, monitor/document locations, size and treatment of [REDACTED]. The Physician's Order Sheet (POS) for March 2014 includes an order dated 11/28/13 for Butt paste to be applied to bony or reddened areas up to four times a day. There are no current labs for Protein and/or [MEDICATION NAME]. The POS also reflects orders for Health Shakes three times daily dated 12/2/09. Braden Scale for Predicting Pressure sore risk last done 6/3/13 identifies R2 as being at high risk. The facility Skin Condition Report for week 1/3/14 identifies R2 has a newly identified in house developed pressure ulcer right hip on 1/2/14 which measured 3.5cm x 1.5cm Unstageable with Eschar, hydrogel dry dressing treatment. In the documentation, there is no explanation as to why the area was not identified until it was necrotic unstageable pressure ulcer even though treatment records for January 2014 show barrier cream to be applied to bony and reddened areas four times a day prior to 1/2/14. The POS does not reflect any additional supplements and/or nutritional supports ordered to aid in wound healing. The Nurses Noted dated 1/2/14 document Hospice was called regarding the pressure ulcer when identified but nothing in regards to notifying the physician and/or representative. A dietary progress note dated 1/21/14 written by E30 Registered Dietician (RD) documents the pressure ulcer right hip as unstageable measures 5.7 cm x 4.5cm. The January 2014 TAR shows the treatment ordered daily but not initialed as done on 2/3, 2/5 or 2/11. On 1/13/14, Hospice ordered a [MEDICATION NAME] dressing to be applied and changed every three days and was only applied on 1/13/14 then discontinued. On 1/14/14, the treatment was then documented as "Cleanse with NS (Normal Saline) apply hydrogel cover with foam dressing every day and was documented thru 1/22/14. The TAR shows Solosite to wound bed and cover with foam dressing twice daily. Documentation of the treatment being done is absent on 7-3 shift for 1/23 and 1/25, 3-11 shift on 1/30 and 1/31/14. According to the weekly wound reports, the measurements remained the same until 1/16/14 when its was documented as measuring 5.7cm x 4.5 cm outer perimeter, inner 2.4cm x 1.5cm x 1, unstageable, dark purple with 100% slough. The order was changed to Santyl and foam boarder change daily. On 1/21/14, the nurses notes (no time) document that the Hospice nurse was called regarding R2's right hip wound having "extra drainage and change in color of wound". But again, no notification to the Physician and/or representative. A Physician's Progress note dated 1/31/14 documents R2's "status appears unchanged. She recently has been treated for [REDACTED]. The February weekly skin condition reports on 2/7/14 and 2/10/14, R2's right hip ulcer measured 2.8cm x 3.1 identified as necrotic unstageable. On 2/17/14, R2's pressure ulcer shows another decline measuring larger at 3cm x 3.5cm. There is no indication that the physician was notified of the decline and a different treatment was sought. On 2/27/14, the ulcer measurements remained the same but description documented necrotic moderate. The February 2014 TAR documents an order to cleanse with NS, pat dry, apply therahoney and cover with foam dressing BID (twice daily.) The treatment was not documented as done for 7-3 shift on 2/2, 2/5, 2/12, 2/23, and 2/28/14. 3-11 shift shows no treatments documented on 2/3, 2/12, 2/21, 2/23, 2/24, and 2/26/14. The Registered Dietician note dated 2/20/14 documents that R2 has an unstageable press ulcer with health shakes three times daily had no suggestions for supplements due to the wound improving. The Weekly skin report dated 3/7/14 identified R2's right hip ulcer as a stage IV measuring 3cm x 3cm x 1cm, with 20% slough and 80% granulation. The March TAR shows no treatment documented to R2's pressure ulcer on 7-3 on 3/7 shift, 3/10, 3/11 and 3/12/14. On 3/11/14 at 11:10am, R2 was laying in her bed. She had three padded incontinent briefs under her. She had a foam dressing on her right hip dated 3/11/14. She had an air cushion on her wheelchair. Her water pitcher was full of warm water and there was no straw/cup. R2 was transferred to her wheelchair and taken to lunch. No fluids were offered from her her. At lunch, she was noted to eat less than 25% taking in very little fluids. On 3/14/14 at 10am, R2 was transferred to bed by E3 and E20, CNA's. E3 stated in aninterview that R2 was up when she came in at 7am. R2 had deep white/red creases throughout her upper thighs, hips, and buttocks. She had a foam dressing on dated 3/13/14 that had visual drainage throughout the dressing. E5, LPN came in with the treatment cart. E5 removed the foam dressing exposing a packed wound underneath. The packing was pink/grey tinged drainage with no odor. E5 stated that the treatment did not call for packing and had been done wrong. E5 stated the wound was suppose to be cleansed, then have therahoney applied to the base of the wound with a foam dressing applied. E5 removed the packing exposing a golf ball size wound. The wound had slightly rolled edges, was covered with a thin film of slough. There was grey stringy tissue at 5 o'clock with dark areas surrounding it from 2 to 6 o'clock. There was no beefy red tissue. E5 changed her gloves and after putting some wound cleansing on a two 4 x 4 gauze pads, patted the base of the wound but did not cleanse the wound. She measured it for the weekly skin report at 4cm x 3cm x 1.5cm at the deep point 4 O'clock. E5 did not check for tunnelling and denied that the wound currently has any. E5 applied therahoney gel with a gauze pad and covered it with a foam dressing. On 3/14/14 following the treatment, E5 was asked why no treatment change had been done since 1/22/14 since the ulcer had showed a change and decline stated she thought it looked better since the "plug" came out. E5 stated the facility wound consultant had been in on Monday 3/10/14 and made a recommendation for the treatment to be changed to [MEDICATION NAME] but that she hadn't had time yet to contact Hospice to see if they covered that treatment or not. E5 stated she would have preferred a specific debridement agent but Hospice did not cover it. E5 was asked if she notified the physician and stated she would notify Hospice first. The weekly wound skin report includes the above measurements but fails to include any documentation about the drainage observed that saturated the packing and foam dressing. Nurses notes from 1/2/14 thru 3/14/14 fail to include any documentation of R2's pressure ulcer except the two above mentioned calls to Hospice. On 3/14/14 at 2:10pm, Z5 Certified Medical Assistant for Z6, R2's physician stated in interview that Z6 was called on 2/24/14 regarding the order for Therahoney every 3 days and that Z6 saw R2 on 2/26/14 writing a note "worsening progress with skin breakdown." When asked about the facility nurses doing R2's treatment twice daily when she had it documented as every three days, Z5 stated perhaps the order changed. Z5 was told the facility's wound consultant saw R2 on Monday 3/10 and made recommendations for a treatment change with no documentation that the physician was notified. Z5 stated the physician has had no communication from the facility or Hospice since 2/24/14. Hospice notes reviewed showed no documentation of this pressure ulcer since 2/24/14 when notes written by Z8, Hospice Nurse documented "Wound base yellow/white center, pulling away from edge (outer) - outer surrounding tissue red + intact, wound odorous" There is no measurements documented. On 3/14/14, Z7 Hospice Registered Nurse was interviewed and asked about the pressure ulcer. Z7 stated she was not aware that the facility wound consultant made recommendations for a treatment change and stated "what the wound consultant gives is just a recommendation. It's all about billing, all about medicare and what will get paid for" when asked about a treatment change. Z7 stated she wouldn't expect the home to call as they usually take care of their own wounds adding that Hospice has their own wound nurses. Z7 stated they see R2 on a weekly basis with the CNA's coming in twice weekly. Z7 stated they would expect R2 to be turned and repositioned every 2 hours and that is does concern her that R2 was up for three hours. There is no documentation including a wound assessment by Hospice since 2/24/14. On the evening of 3/14/14, the facility did a house skin sweep and remeasured R2's pressure ulcer to be different with what E5 had done earlier in the day. New measurements were recorded on the Weekly skin report as: 2.8cm x 4cm x 1.5cm, pink wound bed, low odor, serous drainage, tunneling at 4 o'clock 2.5cm in depth with slough plug noted. E5 had not identified the drainage or tunneling. According to a documentation provided by the facility dated 3/14/14, the Hospice Nurse (Z7) declined the facility wound consultants recommendations from 3/10/14 on 3/14/14, explaining to the facility that "in her opinion the wound was actually improving with the current treatment being used on" R2. Based on the wound measurements, R2's wound has shown marked deterioration as evidenced by 2.5cm of tunnelling since Hospice last assessed it on 2/24/14 3. On 03/11/14 at 10:00 AM, R4 was observed lying in bed on his back with the head of bed at a 30 degree angle with knees bent up toward his abdomen and his bottom directly on two incontinent pads. On 03/11/14 at 2:00 PM, R4 was observed in bed in the same position on his bottom. On 03/12/14 from 8:35 AM to 10:45 AM, R4 was observed sitting in a wheelchair with his lower extremities elevated approximately 30 degrees. A mechanical lift sling was under R4's buttocks. At 10:45 AM, E15 and E23 (CNA's) were observed during transfer of R4 and incontinent care. When R4 was transferred from the wheelchair to bed per mechanical lift, he had facial grimacing and moaned, as if to be in pain. The bed was observed to have two incontinent pads with a draw sheet folded into eights. E23 stated that R4 had pain in his legs, especially when wearing the heel protecting boots, because the boots are heavy. E15 stated that staff got R4 up in the wheelchair at 7:30 AM. R4 was log rolled to the right side lying position, as E15 removed the incontinent brief, a heavily soiled dressing was hanging off a large gaping open pressure ulcer located on the sacral area. R4's buttocks, scrotum, lower back and back of the thighs were all deeply reddened and heavily creased from sitting. A heavily soiled bloody, brown packed dressing the size of a 4 x 4 gauze was observed to fall out of the ulcer onto the soiled incontinent brief. E15 was observed to put the gauze back into the large ulcer and attempted to replace the adhesive part of the bandage to take hold. The adhesive did not stick. There was a small amount of feces observed at the anus and smeared into and on the dressing. E15 used wet wipes to wipe cleanse the anal area, but did not cleanse the scrotum or surrounding buttocks. No catheter care was performed. E15 then placed a new incontinent brief on and repositioned him with the head of the bed at a 30 degree angle and knees bent, essentially sitting on his buttocks. A dressing was observed on the left hip, dated 3/10, with a large brown area of drainage 3 cm in circumference. Neither CNA knew why. On 03/12/14 at 10:55 AM, E21, LPN stated that R4 was admitted with a stage IV decubitus ulcer on the coccyx and a pressure ulcer on the right heel both with daily dressing changes. E21 stated that R4 had a pressure ulcer of the left hip, but said it had healed. E21 stated that she could not do the dressing changes at this time because R4's Santyl ointment for the pressure ulcers was currently out of stock and she would have to call the physician to get a refill. E21 did not assess R4's pain level prior to performing dressing changes. On 03/12/14 at 2:00 PM, E21, LPN was observed during dressing changes for R4 on the coccyx/sacral area and right heel. E17, CNA was observed to remove the coccyx/sacral dressing while removing the incontinent brief. Two small areas between the ulcer and the anus were observed to be under the taped part, not protected by the 4 x 4 gauze. E21 stated that the areas were probably caused by the CNA's wiping during incontinent care. There was feces at the anus and smeared up into the ulcer. The ulcer was observed to be large gaping hole 8 cm x 6 cm x 3 cm with macerated rolling edges and undermining. The ulcer had a foul smell with at least four areas of black necrotic tissue measuring 2.5 cm each and 80 % slough throughout. E21 was observed to cleanse the area around the ulcer with a wet wipe then used wound cleanser spray to moisten the inside of the ulcer. E21 then gently pressed a dry 4 x 4 gauze into the ulcer and patted gently. Bloody, brown serosanguineous drainage was noted on the 4 x 4 gauze. E21 then applied a small amount of Santyl ointment to a dry 4 x 4 gauze and smear together to spread the ointment then placed in inside the ulcer. E21 then covered the ulcer with a dry 4 x 4 dressing and taped. Tape was applied over the two small areas between the anus and ulcer and were not addressed. Upon request, E21 then removed the left hip dressing, dated 03/10/14, and said that she did not know about it and other staff must of noticed it on the weekend. E21 pointed out a scarred area above the current ulcer and stated that's where the old ulcer was located and had healed. A foam bordered dressing was removed with brownish yellow drainage measuring 4 cm x 6 cm was observed. The left hip ulcer was observed to be completely covered with yellow eschar and surrounded by red swollen skin measuring 3 cm x 4 cm, depth could not be determined. E21 was observed using wound cleanser spray and pat the skin dry, then placed a small amount of Santyl ointment on a 4 x 4 gauze folded into 2 x 2 shape and an foam dressing placed on top. E21 could not determine when this ulcer was first observed by staff. E21 removed the dressing to the right inner heel ulcer. The soiled dressing was observed to with brownish yellow serosanguineous drainage. The ulcer was covered with red swollen tissue and yellow slough throughout. The ulcer was observed to have an area from 9 o'clock to 3 o'clock of denuded white skin edges. E21 stated this is caused from too much moisture. E21 was observed to spray wound cleanser onto the ulcer and pat dry, add a small amount of Santyl ointment on a cut to size 4 x 4 gauze and place onto ulcer then covered with a folded dry 4 x 4 gauze and taped. The Telephone Order (TO), dated 01/24/14, documented "change to sacral ulcer to Puracol silver hydrogel and cover with border foam. Change daily and as needed (prn)." On 03/12/14, E21, LPN stated that Santyl ointment was ordered for all ulcers. E21 was observed to apply Santyl to the sacral ulcer. However, the Treatment Record, dated March 1-31, 2014, documented daily dressing changes for the sacral ulcer was to "Apply Puracol, then [MEDICATION NAME] and cover with bordered foam to sacral ulcer every day and as needed." The treatment records for the month of February, 2014 could not be located. The treatment record documented staff initials each day during the month of March, 2014 as being done for the sacral ulcer. There were no physician's orders documented for the treatment of [REDACTED]. There were documented treatments for the month of March, 2014 for left hip pressure ulcer. There were no nurses notes that documented an assessment of initial date of when the left hip ulcer was identified. On 03/13/14 at 11:20 AM, R4 rated his pain level at a 10 on a scale of 0-10. R4 stated that the pain was in his bottom and lower back. Treatment record for March, 2014, documented R4 was given Tylenol 650 mg on 03/12/14 at 11:50 AM on 3/14/14. On 03/13/14 at 11:25 AM, E5, LPN/Wound Nurse, stated that all of R4's ulcers were currently being treated with Santyl and covered with 4 x 4 dressings. E5 further stated that the coccyx ulcer was previously changed from using a "Puracol Silver Hydrogel" type dressing and was being changed twice per day and as needed. She did not know why or when the orders had changed. However, during a dressing change on 03/13/14, E5 stated that due to the uncertainty of the undermining/tunneling and the multiple areas of necrosis and slough, the wound could be assessed as unstageable. E5 also stated that both the left hip and right heel ulcers were considered unstageable. E5 further stated that R4's ulcers of the coccyx and right heel were also being treated by the wound clinic every two weeks. She also stated that R4 was going to the wound clinic once every week, but had been recently changed to every other two weeks. On 03/14/14 at 10:55 AM, E5, LPN was observed during dressing change and measurements for R4's coccyx and right heel pressure ulcers. E5 stated that R4 was given pain medications earlier in the morning. Treatment record documented on 03/14/14 at 8:00 AM, Tylenol 650 mg was given. R4 stated his pain level was a 5/10 on the pain scale. When the covers were pulled back off of R4, R4's pants were pulled down to his knees and the urinary catheter tubing was tucked between R4's legs and wrapped around underneath the right leg. When R4's pants were removed, R4's bilateral legs were heavily creased and the buttocks and testicles were deeply reddened. The coccyx dressing was hanging on by only one side of the adhesive tape and saturated with bloody yellow/brown drainage and soiled with feces. E5 measured the coccyx wound at 6 cm x 6.7 cm x 2.5 cm. However, R4 was turned onto his right and the positioning of his buttocks was not optimal for a true measurement due to the left side of the buttocks sagging down toward the center of his body. E5 stated she could not determine the exact measurement of the undermining due to position of R4. The POS, dated March 1-31, 2014, documented R4's diagnoses, in part, as Urinary Tract Infection/Sepsis on three different hospitalization s and VRE infection, Stage II Sacral Decubitus Ulcer [MEDICAL CONDITION] infection, mild Dementia and Diabetes Mellitus. The MDS, dated [DATE], documented R4 was totally dependent on at least two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. It also documented that R4 is incontinent of bowel and bladder occasionally. However, R4 has a urinary catheter and E15 (CNA), E23 (CNA) and E21 (LPN) stated R4 is always incontinent of bowel, he does not toilet. The Care Plan, dated 02/07/14, documented R4 as being admitted with Stage IV pressure ulcer to the coccyx, unstageable to right inner heal and unstageable to left hip. On 03/12/14, E21, LPN stated that the left hip wound had healed. A scar was observed above the newly acquired hip ulcer. The Care Plan documented interventions, in part, as assess, record and monitor wound healing, report improvements and declines to the MD, requires staff assist with turning and repositioning every two hours or more often as needed, inform family/caregivers of any new area of skin breakdown, treat pain as per orders prior to treatment to ensure his comfort and treatment per order. The Admission Nursing Assessment, dated 01/08/14, documented R4 was admitted with a "8 x 5 open area" pointing to the coccyx region on the Skin Condition section of the sheet. It also documented "open area" to bilateral hips and "[MEDICAL CONDITION] to left heel" and "3 x 3 cm black area." A Wound Analysis Report (Wound Clinic), documented R4's last visit was on 03/03

Based on observation, record review and interview, the facility failed to notify the Physician and POA (Power of Attorney) of declining pressure sores for 2 of 8 residents (R3 and R4) reviewed for pressure sores, in the sample of 16. Findings include: 1: Physician Correspondence Form from the Facility dated 3/11/14 documents 4 cm x 2.5 cm reddened and excoriate area on left buttock as well as 2.2 x 1.3 cm area on coccyx. Areas cleansed with wound cleanser, dried and hydrocholloid protective dressing applied. On 3/14/14 at 8:40AM, Z2 (Z1's Nurse) stated they got a fax from the facility on the morning of 3/12/14 that was faxed the evening of 3/11/14 after the Doctor's office was closed that identified excoriation on R3's coccyx and left buttock. Z2 stated Z1 had not had any other correspondence from the facility until last night after the office was closed. Z2 stated the morning of 3/14/14, they received another fax from the facility but the fax did not identify pressure sores. Z2 stated Z1 was not in the office today but she had contacted Z1 that morning of the fax information. At 11:20AM, Z2 provided the above fax that documents, "In addition to the prior fax sent for wounds on coccyx and thigh I just wanted to clarify that the wound on the thigh is on the R (right) side not the L (left) side & a new area was noticed today current measurements are coccyx - top 2.7 x 3 x 1.1, (L) 1.5 x 1.5, (R) 2 x 1, (R) thigh 6 x 2 x 0.1. Serosangous drainage from area & sloughing. Any new orders?" This information was incorrect in that R3 was observed on 3/12/14 at 2:45PM to have a pressure sore on her left back upper thigh, not right, and pressure sores on coccyx were observed to have eschar and slough. Interview with Z1 on 3/14/14 at 11AM, Z1 stated the facility faxes concerns to her office after 5PM and no one is there to receive the fax. Z1 stated that is inappropriate. Z1 stated the facility sent another fax last night after the office was closed and they did not get until this morning. They did not identify R3 as having pressure sores. The information the facility gives is incomplete. Z1 stated the first correspondence that Z1 received from the facility identified the pressure sores as being an excoriation. Z1 stated she looks at excoriation as red dried skin, not open pressure sore. Z1 stated she does not see patients in the Nursing Homes but planned to go to the Nursing Home today to see R3. At 1:11PM, Z1 was at the facility and stated she looked at R3's pressure ulcers. Z1 stated she had placed an order for [REDACTED]. Z1 stated R3's positioning is a problem and increases the risk of pressure sores. Z1 stated she is sending R3 to the wound clinic. Interview with Z14, R3's son, on 3/14/14 at 4:30PM, Z14 stated he is R3's POA. Z14 stated the facility had called him a couple days ago and told him his mother had a wound on her buttock. The facility did not let him know she had pressure sores. Z14 stated he had talked to Z1, R3's Physician, and she told him today of R3's pressure sores. Z14 stated a Nurse called him today and he told the Nurse he had already talked to the Doctor. 2. On 03/12/13 at 11:00 AM, E21, Licensed Practical Nurse,LPN, was observed during dressing changes R4. E21 stated that for all of R4's pressure ulcers, Santyl ointment was used. E21, stated that R4's Santyl ointment was currently out, so she would have to wait to complete the dressing changes. At 2:00 PM, E21, LPN was observed to complete the dressing changes and was observed to apply Santyl ointment to all pressure ulcers. On 03/14/14 at 3:20 PM, R4 stated that he has pain every day located of his bottom and lower back. R4 also stated that he does not routinely get pain medications nor does staff ask him routinely about his pain level. The POS, dated 03/1-31/2014, documented R4 was admitted on [DATE] with a Stage IV pressure ulcer on the coccyx, unstaged bilateral heel pressure ulcers and unstaged bilateral hip pressure ulcers. The March, 2014 Treatment Record documented R4's ordered treatments for the stage IV pressure ulcer was "Apply Puracol, then [MEDICATION NAME] and cover with bordered foam to sacral ulcer every day and as needed." Initials were documented as done each day in March, 2014 except March 2, 2014. E21, LPN stated that she was told to use Santyl ointment and did not remember when this had taken place. The Regency Admission Order Sheet, dated 01/08/14, documented R4's treatment orders for the pressure ulcer of the sacral area was "Santyl with Dakins moistened dressing twice per day 0.125%." On 01/24/14, a telephone order documented sacral ulcer treatment changes to "Apply Puracol, Silver Hydrogel and cover with border foam, change daily and as needed." The March, 2014 Treatment Record documented that the "Puracol, Silver Hydrogel..." was initialed by staff as what treatment was done on the sacral pressure ulcer. A Wound Analysis Report (Wound Clinic), dated 03/03/14 documented R4's stage IV sacral pressure ulcer had declined, as well as the right heel had declined. Also, R4 was observed to have had developed a new stage III pressure ulcer of the left hip. There was no documentation of when R4's left hip pressure ulcer was identified, when the family was notified or when the physician and wound clinic was notified. There was no documentation that staff notified family, the physician or the wound clinic of R4's pain level or worsening pressure ulcers. On 03/14/14 at 12:10 PM, Z4, RN (primary physician's RN) stated that their office was not notified of R4's pressure ulcers worsening, of the newly acquired pressure ulcer or increased pain. On 03/19/14 10:00 AM, Z12, RN (Wound Clinic) stated that R4 was seen in the wound clinic on 03/17/14. Z12 stated that R4's sacral pressure ulcer and right heel pressure ulcer had both declined, and that he had developed a bone infection of the coccyx. Z12 stated that R4 had developed a newly acquired stage III left hip pressure ulcer. Z12 stated that the wound clinic was not notified of the order for dressing changes of the sacral pressure ulcer. Z12 further stated the "Puracol, Silver Hydrogel..." was not a wound [MEDICATION NAME] agent, and therefore would have aided in the decline in the sacral pressure ulcer. Z12 stated that the wound clinic would not have changed the order for using Santyl ointment, because it is a very proven wound [MEDICATION NAME] agent. On 03/18/14 at 10:30 AM, E2, DON stated that it is unclear why or who wrote the telephone order to change the sacral dressing treatment from Santyl to "Puracol, Silver Hydrogel." E2 also could not answer the reason that E21, LPN documented she used "Puracol, Silver Hydrogel," but was observed using Santyl ointment. 3. The facility's policy entitled "Resident Change of Condition Physician Notification" (undated) documents that attending Physician's, or Physician's on call will be notified of residents change in condition/health status with time of call, physician or nurse practioner or other person spoken to, reason for call and results of call received. The policy for Family/Responsibilible Party Notification documents that they will be notified if there is any change in condition or plan of care.

Based on observation, record review and interview, the facility neglected to identify, accurately assess, and monitor pressure sores; neglected to get a new treatment for [REDACTED]. This failure resulted in R2 having a decline in unstageable pressure. R3 developed 4 unavoidable pressure sores. R4 developed an unstageable pressure sore that the facility was not aware of and had a decline in a stage 4 pressure sore and developed bone infection and had severe pain. Findings include: 1. The facility's policy and procedure for the treatment and prevention of the skin breakdown, dated 2005, documents that it is the policy of the facility to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcers according to industry standards of care. The procedure of pressure ulcer preventions include identifying the risk factors, skin protection (Assess and treat incontinence), provide nutritional support including encouraging fluid intake, and nutritional/protein supplements, observe/assess/treat pain, weekly documentation with the care plan evaluated and revised as necessary based on the needs of the resident, and provide appropriate positioning among others. Under treatment, the facility is to initiate wound care protocols, implement care plan with appropriate interventions, document on weekly wound documentation along with a weekly nurses note, provide protective barriers. Documentation of the wound is to include location, size (length, width and depth), sinus tracts/tunneling, undermining, exudate (amount, color, odor and consistency), odor, wound base characteristics (necrotic tissue, slough tissue, the presence or absence of granulation tissue), wound edge characteristics (epithialization, [DIAGNOSES REDACTED], [MEDICAL CONDITION], induration, crepitus, pain, warmth, and/or maceration) and pain. The policy includes directives to offer pain medication prior to dressing changes if appropriate. Directive: if the wound has a cavity or "dead space", loosely fill all cavities without over packing. 2. R3's Minimum Data Set, MDS, of 2/8/14 documents R3 has severe cognitive impairment; requires extensive assistance of 2 or more for transfer and hygiene; extensive assistance of 1 for bed mobility; and is at risk for pressure sores. R3's Care Plan of 11/26/13 documents R3 is at risk for potential impairment to skin integrity. Care Plan documents, in part: R3 requires total assistance of staff for incontinent care, and transfers; is to have daily skin checks; turn and reposition every 2 hours; notify Physician and POA (Power of Attorney) of any changes; requires pressure relieving/reducing mattress in bed and cushion when up in chair. R3's March 2014 Physician Order Sheet, POS, documents an order to turn and reposition every 2 hours. R3's Nurses Notes of 3/11/14 at 3PM documents R3 has a 4 cm x 2.5 cm reddened excoriated area found on left buttock as well as a 2.2 cm x 1.3 cm area on the coccyx. POA and Physician Notified. On 3/11/14 at 3:45PM, R3 had an hydrocholloid dressing dated 3/11/14 on her coccyx and left upper thigh. R3 had a light brown area on her mid left outer mid foot approximately 1 cm in diameter. E12, Licensed Practical Nurse LPN, stated she didn't know what the area on the foot was. R3 was observed every 10 to 15 minutes on 3/12/14 from 8:15AM to 2:45PM to be sitting up in a wheel chair with a mechanical sling under her and her legs extended out in front of her. At 2:45PM. E13, E14, LPN's and E15, Certified Nurse Aide, CNA, transferred R3 from her wheel chair to bed using the mechanical sling lift. R3 did not have a pressure relieving mattress on her wheel chair. R3's incontinent brief was saturated with urine and had an area that was blood tinged. R3's back of thighs and buttocks were deep creased and red. R3 had hydrocholloid dressings on her coccyx and left upper thigh. E13 stated the blood was coming from a wound on her coccyx. E13 removed the dressing from the coccyx. R3 had 3 open pressure sores. E13 and E14 stated the open sores were from pressure. E15 was observed to give incontinent care and failed to wash all areas that were soiled with urine. E15 wiped R3's anal area with disposable wipes and then wiped the pressure sores without changing his soiled gloves. E13 and E14 identified 3 pressure sores and stated one was the size of a dime and two were the size of a nickel and stated all 3 pressure sores were stage 2. Observation showed all pressure sores were unstageable with eschar and/or slough. When asked about the dark section on the top pressure sore, E13 stated yes it was getting dark. E13 placed a new hydrocholloid dressing on the pressure sores without cleansing the pressure sores first. E15 stated R3 was already up in her wheel chair when he came on duty at 7AM and confirmed she had not been out of her wheel chair until now. On 3/13/14 at 11:20AM, R3's Pressure Sores were assessed by E5, LPN/Wound Nurse and E2, Director of Nursing, at the request of the Surveyor. E13, LPN, also was present. R3 was observed to be laying in bed on her back and was laying on 3 quilted bed pads and a folded sheet. E5 removed the hydrocholloid dressing from R3's coccyx. The adhesive to the dressing was directly on the pressure sores and the skin pulled and R3 cried out in pain when the dressing was removed. E5 stated she had not seen the pressure sore on R3's back of left upper thigh and stated she had seen the coccyx that was a stage 2. E5 stated she had not measured the pressure sores and had no documentation of the areas. R3 had 3 pressure sores on her coccyx. E5 measured and staged the pressure sores. Coccyx: #1 measured 2.7 x 3 x .1 cm and was identified as a stage 2. The pressure sore was observed by Surveyor to have yellow slough. #2 measured 1.5 cm x 1.5 cm. and staged unstageable. E5 stated it has a dark area but may be from the hydrocholloid dressing. Surveyor observed eschar. #3 measured 2 cm x 1 cm x 0.1 cm and was identified as a stage 2. The Surveyor observed necrotic tissue and slough. The pressure sore on the upper left thigh measured 6 cm x 2 cm x 0.1 cm and was identified to have serosangous drainage. E5 stated the pressure sore had a black area through the middle and that part is unstageable and the rest of the pressure sore is a stage 2. E2 was asked how he would stage the pressure sores and E2 stated all the pressure sores are unstageable. On 3/14/14 at 8:40AM, Z2 (Z1's Nurse) stated they got a fax from the facility last night after the office was closed. Z2 stated Z1 was not in the office today but she had contacted Z1 that morning of the fax information. Z2 stated the fax did not identify pressure sores. At 11:20AM, Z2 provided the above fax that documents, "In addition to the prior fax sent for wounds on coccyx and thigh I just wanted to clarify that the wound on the thigh is on the R (right) side not the L (left) side & a new area was noticed today current measurements are coccyx - top 2.7 x 3 x 1.1, (L) 1.5 x 1.5, (R) 2 x 1, (R) thigh 6 x 2 x 0.1. Serosangous drainage from area & sloughing. Any new orders?" The facility again neglected to inform Z1 that R3's "wounds" were pressure sores and the information given that it was the right thigh not the left was incorrect. Interview with Z1, R3's Physician, on 3/14/14 at 11AM, Z1 stated the facility faxes concerns to her office after 5PM and no one is there to receive the fax. Z1 stated that is inappropriate. Z1 stated the facility sent another fax last night after the office was closed and they did not get until this morning. The facility did not identify R3 as having pressure sores. The information the facility gives is incomplete. Z1 stated the first correspondence that Z1 received from the facility identified R3 as being an excoriation. Z1 stated she looks at excoriation as red dried skin, not open pressure sore. Z1 stated R3 had never had a pressure sore in the past. Z1 stated R3 needs turning and repositioning and she is concerned the facility is not following her orders. Z1 stated the lack of turning and repositioning and timely incontinent care would contribute to development of pressure sores. R3 is dependent on staff for care. Z1 stated someone is wiping R3's bottom, they should have seen the pressure sores when they were red before they were open with slough. Z1 stated that putting 3 pads and a folded sheet on the pressure relieving mattress takes away from the effectiveness of the pressure relieving mattress states it makes it into a regular mattress. Z1 stated she was concerned that they would put the adhesive over the pressure sores stating it had to hurt when they removed it. Z1 stated she considered this as neglect. "Very neglectful." Z1 stated she does not see patients in the Nursing Homes but planned to go to the Nursing Home today to see R3. The facility neglected to timely identify and properly assess R3's pressure sores and neglected to follow Physician orders for pressure sore prevention. The facility neglected to give accurate and timely notification of R3's pressure sores to Z1. At 1:11PM, Z1 was at the facility and confirmed R2's "wounds" were actually pressure sores and stated she had placed an order for [REDACTED]. 2. According to the MDS dated [DATE], R2 is totally dependent on staff for all activities of daily living and is severely cognitively impaired. The MDS indicates she is frequently incontinent of bowel/bladder and had no pressure ulcers present at that time. However, the care plan dated 3/12/14 identifies R2 to have actual skin integrity with the goal to have no skin breakdown by next review and will have no complications due to the pressure ulcer on right hip through the next review. Interventions include pressure relieving device bed and chair, padding such as pillows/sheepskin, encourage good nutrition and hydration in order to promote healthier skin, and Hospice care among others. The Physician's Order Sheet (POS) for March 2014 includes an order dated 11/28/11 for Butt paste to be applied to bony or reddened areas up to hour times a day. There are no current labs for Protein and/or [MEDICATION NAME]. The POS also reflects orders for Health Shakes three times daily dated 12/2/09. The facility Skin Condition Report for week 1/3/14 identifies R2 to have a newly identified in house developed pressure ulcer right hip on 1/2/14 which measured 3.5cm x 1.5cm Unstageable with Eschar at the time it was identified. There is no explanation as to why the area was not identified before it was necrotic and unstageable even though treatment records for January 2014 show barrier cream being applied to bony and reddened areas four times a day prior to 1/2/14. A dietary progress note dated 1/21/14 written by E30 Registered Dietician (RD) documents the pressure ulcer right hip as unstageable measure 5.7 cm x 4.5cm. The February weekly skin condition reports dated 2/7/14 and 2/10/14 have R2's right hip ulcer measured 2.8cm x 3.1 identified as necrotic unstageable. On 2/17/14, R2's pressure ulcer shows decline measuring larger at 3cm x 3.5cm. There is no indication that the physician was notified of the decline and the facility neglected to change the treatment until 2/27/14 when Hospice changed it. The ulcer measurements remained the same but description documented necrotic moderate. The facility nurses neglected to document treatments done consistently on the February 2014 Treatment Administration Records (TAR). The order was to cleanse with NS, pat dry, apply therahoney and cover with foam dressing BID (twice daily was documented as done. The treatment was not documented as done for 7-3 shift on 2/2, 2/5, 2/12, 2/23, and 2/28/14. 3-11 shift shows no treatments documented on 2/3, 2/12, 2/21, 2/23, 2/24, and 2/26/14. The Weekly skin report dated 3/7/14 completed by E5, Licensed Practical Nurse, identified R2's right hip ulcer as a stage IV measuring 3cm x 3cm x 1cm, with 20% slough and 80% granulation. The March TAR shows no treatment documented to R2's pressure ulcer on 7-3 on 3/7, 3/10, 3/11 and 3/12/14. On 3/14/14 at 10am, R2 was transferred to bed by E3 and E20, CNA's who stated she had been in her chair since 7am, three hours earlier. She had a foam dressing on dated 3/13/14 that had visual drainage throughout the dressing. E5, LPN came in with the treatment cart and after washing hands, donned gloves then removed the foam dressing exposing a packed wound underneath. The packing was pink/grey tinged drainage with no odor. E5 stated that the treatment did not call for packing and had been done wrong. E5 stated the wound was suppose to be cleansed, then have therahoney applied to the base of the wound with a foam dressing applied. E5 removed the packing exposing a golf ball size wound. The wound had slightly rolled edges, was covered with a thin film of slough. There was grey stringy tissue at 5 o'clock with dark areas surrounding it from 2 to 6 o'clock. There was no beefy red apparent. E5 changed her gloves and after putting some wound cleansing on a couple 4 x 4 gauze pads, patted the base of the wound but did not cleanse the wound. E5 then measured it for the weekly skin report as measuring 4cm x 3cm x 1.5cm at the deepest 4 0'clock. E5 stated no tunnelling at the time when asked. She identified no drainage. E5 then applied therahoney gel with a gauze pad and covered it with a foam dressing. On 3/14/14 following the treatment, E5 was asked why no treatment change had been done since 1/22/14 since the ulcer had showed a change and decline stated she thought it looked better since the "plug" came out. E5 stated the facility wound consultant had been in on Monday 3/10/14 and made a recommendation for the treatment to be changed to [MEDICATION NAME] but that she hadn't had time yet to contact Hospice to see if they covered that treatment or not. E5 stated she would have preferred a specific debridement agent but Hospice did not cover it. E5 was asked if she notified the physician and stated she would notify Hospice first. Nurses notes from 1/2/14 thru 3/14/14 fail to include any documentation of R2's pressure ulcer except the two above mentioned calls to Hospice. On 3/14/14 at 2:10pm, Z5 Certified Medical Assistant for Z6, R2's physician stated in interview that Z6 was called on 2/24/14 and has not been notified of any further recommendations since that time. Hospice neglected to assess/monitor and document R2's pressure ulcer since 2/24/14. Hospice documentation of this pressure ulcer had not been done since 2/24/14 when notes written by Z8, Hospice Nurse documented "Wound base yellow/white center, pulling away from edge (outer) - outer surrounding tissue red + intact, wound odorous" There is no measurements documented since then. According to a plan for corrections dated 3/14/14, Z7, Hospice nurse explained to the facility that "in her opinion the wound was actually improving with the current treatment being used on" R2. On the evening of 3/14/14, the facility did a complete house skin sweep and remeasured R2's pressure ulcer to be different with what E5 had done earlier in the day showing a markedly deterioration of the wound with tunnelling not previously identified. New measurements were recorded on the Weekly skin report as: 2.8cm x 4cm x 1.5cm, pink wound bed, low odor, serous drainage, tunneling at 4 o'clock 2.5cm in depth with slough plug noted. E5's assessment done earlier in the day neglected to identify the 2.5cm of tunnelling at 4 O'clock nor did she identified the drainage. E5, facility wound nurse neglected to accurately assess R2's pressure ulcer. 3. On 03/11/14 at 10:00 AM, R4 was observed lying in bed on his back with the head of bed at a 30 degree angle with knees bent up toward his abdomen his bottom directly on two incontinent pads. On 03/11/14 at 2:00 PM, R4 was observed in bed in the same position on his bottom. On 03/12/14 from 8:35 AM to 10:45 AM, R4 was observed sitting in a wheelchair with his lower extremities elevated approximately 30 degrees. A mechanical lift sling was under R4's buttocks. When R4 was transferred from the wheelchair to bed per mechanical lift, he had facial grimacing and moaned, as if to be in pain. E15 stated that staff got R4 up in the wheelchair at 7:30 AM. R4 was log rolled to the right side lying position, as E15 removed the incontinent brief, a heavily soiled dressing was hanging off a large gaping open pressure ulcer located on the sacral area. R4's buttocks, scrotum, lower back and back of the thighs were all deeply reddened and heavily creased from sitting. A heavily soiled bloody, brown packed dressing the size of a 4 x 4 gauze was observed to fall out of the ulcer onto the soiled incontinent brief. E15 was observed to put the gauze back into the large ulcer and attempted to replace the adhesive part of the bandage to take hold. E15 then placed a new incontinent brief on and repositioned him with the head of the bed at a 30 degree angle and knees bent, essentially sitting on his buttocks. The facility failed to assess R4 for pain control and failed to turn and reposition R4 every two hours per care planned. On 03/12/14 at 10:55 AM, E21, LPN stated that R4 was admitted with a stage IV decubitus ulcer on the coccyx and a pressure ulcer on the right heel both with daily dressing changes. E21 stated that R4 had a pressure ulcer of the left hip, but said it had healed. E21 stated that she could not do the dressing changes at this time because R4's Santyl ointment for the pressure ulcers was currently out of stock and she would have to call the physician to get a refill. E21 did not assess R4's pain level prior to performing dressing changes. The facility failed to accurately identify, assess, monitor and treat as per physician's orders for declining pressure ulcers and a newly acquired pressure ulcer. On 03/12/14 at 2:00 PM, E21, LPN was observed during dressing changes for R4 on the coccyx/sacral area and right heel. E17, CNA was observed to remove the coccyx/sacral dressing while removing the incontinent brief. Two small areas between the ulcer and the anus were observed to be under the taped part, not protected by the 4 x 4 gauze. E21 stated that the areas were probably caused by the CNA's wiping during incontinent care. There was feces at the anus and smeared up into the ulcer. The ulcer was observed to be large gaping hole approximately 8 cm x 6 cm x 3 cm with macerated rolling edges and undermining. The ulcer had a foul smell with at least four areas of black necrotic tissue measuring approximately 2.5 cm each and 80 % slough throughout. E21 was observed to cleanse the around the ulcer with a wet wipe then used wound cleanser spray to moisten the inside of the ulcer. E21 then gently pressed a dry 4 x 4 gauze into the ulcer and patted gently. Bloody, brown serosanguineous drainage was noted on the 4 x 4 gauze. E21 then applied a small amount of Santyl ointment to a dry 4 x 4 gauze and smear together to spread the ointment then placed in inside the ulcer. E21 then covered the ulcer with a dry 4 x 4 dressing and taped. Tape was applied over the two small areas between the anus and ulcer and were not addressed. Upon request, E21 then removed the left hip dressing, dated 03/10, and said that she did not know about it and other staff must of noticed it on the weekend. E21 pointed out a scarred area above the current ulcer and stated that's where the old ulcer was located and had healed. A foam bordered dressing was removed with brownish yellow drainage measuring approximately 4 cm x 6 cm was observed. The left hip ulcer was observed to be completely covered with yellow eschar and surrounded by red swollen skin measuring approximately 3 cm x 4 cm, depth could not be determined. E21 was observed using wound cleanser spray and pat dry, then placed a small amount of Santyl ointment on a 4 x 4 gauze folded into 2 x 2 shape and an foam dressing placed on top. E21 could not determine when this ulcer was first observed. The facility failed to follow physician's orders for dressing changes and failed to notify the physician and obtain orders for a newly developed pressure ulcer. The Telephone Order (TO), dated 01/24/14, documented "change to sacral ulcer to Puracol silver hydrogel and cover with border foam. Change daily and as needed (prn)." On 03/12/14, E21, LPN stated that Santyl ointment was ordered for all ulcers. E21 was observed to apply Santyl to the sacral ulcer. However, the Treatment Record, dated March 1-31, 2014, documented daily dressing changes for the sacral ulcer was to "Apply Puracol, then [MEDICATION NAME] and cover with bordered foam to sacral ulcer every day and as needed." The treatment records for the month of February, 2014 could not be located. The treatment record documented staff initials each day during the month of March, 2014 as being done for the sacral ulcer. The facility failed to follow physician's orders and notify the wound clinic of a decline in pressure ulcers and newly acquired pressure ulcer. There were no physician's orders for the newly acquired left hip pressure ulcer as of 03/16/14. There were documented treatments for the month of March, 2014 for left hip pressure ulcer. There were no nurses notes that documented an assessment of initial date of when the left hip ulcer was identified. The facility failed to accurately identify, assess and treat a newly acquired pressure ulcer, and failed to notify the physician and the wound clinic. On 03/13/14 at 11:20 AM, R4 rated his pain level at a 10 on a scale of 0-10. R4 stated that the pain was in his bottom and lower back. Treatment record for March, 2014, documented R4 was given Tylenol 650 mg on 03/12/14 at 11:50 AM. The facility failed to identify, assess and treat R4's pain and notify the physician. On 03/13/14 at 11:25 AM, E5, LPN/Wound Nurse, stated that all of R4's ulcers were currently being treated with Santyl and covered with 4 x 4 dressings. E5 further stated that the coccyx ulcer was previously changed from using a "Puracol Silver Hydrogel" type dressing and was being changed twice per day and as needed. She did not know why or when the orders had changed. However, during a dressing change on 03/13/14, E5 stated that due to the uncertainty of the undermining/tunneling and the multiple areas of necrosis and slough, the wound could be assessed as unstageable. E5 also stated that both the left hip and right heel ulcers were considered unstageable. E5 further stated that R4's ulcers of the coccyx and right heel were also being treated by the wound clinic every two weeks. She also stated that R4 was going to the wound clinic once every week, but had been recently changed to every other two weeks. The facility failed to follow physician's orders for dressing changes and failed to accurately assess, monitor and treat R4's pressure ulcers, as well as, notify the family, physician and the wound clinic of the decline in the pressure ulcers and the newly acquired pressure ulcer. On 03/14/14 at 10:55 AM, E5, LPN was observed during dressing change and measurements for R4's coccyx and right heel pressure ulcers. E5 stated that R4 was given pain medications earlier in the morning. Treatment record documented on 03/14/14 at 8:00 AM, Tylenol 650 mg was given. R4 stated his pain level was a 5/10 on the pain scale. When the covers were pulled back off of R4, R4's pants were pulled down to his knees and the urinary catheter tubing was tucked between R4's legs and wrapped around underneath the right leg. When R4's pants were removed, R4's bilateral legs were heavily creased and the buttocks and testicles were deeply reddened. The coccyx dressing was hanging on by only one side of the adhesive tape and saturated with bloody yellow/brown drainage and soiled with feces. E5 measured the coccyx wound at 6 cm x 6.7 cm x 2.5 cm. However, R4 was turned onto his right and the positioning of his buttocks was not optimal for a true measurement due to the left side of the buttocks sagging down toward the center of his body. E5 stated she could not determine the exact measurement of the undermining due to position of R4. The MDS, dated [DATE], documented R4 was totally dependent on at least two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. It also documented that R4 is incontinent of bowel and bladder occasionally. However, R4 has a urinary catheter and E15 (CNA), E23 (CNA) and E21 (LPN) stated R4 is always incontinent of bowel, he does not toilet. The Care Plan, dated 02/07/14, documented R4 as being admitted with Stage IV pressure ulcer to the coccyx, unstageable to right inner heal and unstageable to left hip. On 03/12/14, E21, LPN stated that the left hip wound had healed. A scar was observed above the newly acquired hip ulcer. The Care Plan documented interventions, in part, as assess, record and monitor wound healing, report improvements and declines to the MD, requires staff assist with turning and repositioning every two hours or more often as needed, inform family/caregivers of any new area of skin breakdown, treat pain as per orders prior to treatment to ensure his comfort and treatment per order. A Wound Analysis Report (Wound Clinic), documented R4's last visit was on 03/03/14. The report documented "pressure ulcer coccyx - measurements 8.1 cm x 5 cm x 3.2 cm with undermining 2.5 cm wound classification at Stage IV. Wound procedures - open wound/selective debridement, level non-viable tissue." The Wound Analysis Report also documented on 03/03/14 "pressure ulcer right medial foot - measurements 1.7 cm x 2.3 cm x 0.5 cm." On 03/14/14 at 10:20 AM, Z9, (daughter of R4) stated that when she spoke to the wound clinic doctor in December, 2013, he stated that the pressure ulcers were all "preventable with timely turning and repositioning." Z9 also stated she had not been made of the newly acquired left hip pressure ulcer or the decline in the coccyx ulcer from the facility as of this date. On 03/14/14 at 12:10 PM, Z4, RN (R4's primary physician's nurse), the physician's office was not notified of the declining nature of the coccyx pressure ulcer, nor a newly developed unstageable pressure ulcer to the left hip, nor any wound clinic results nor the adding of or changing in ulcer treatments. Z4 also stated that she had tried to call the facility and speak with a nurse to give orders and was told that they are at lunch and to call back in a hour. Z4 also stated that R4's physician wants aerobic cultures of all wounds, wound team to consult, current treatments, frequent repositioning every 2 hours and Tylenol 650 mg every six hours or [MEDICATION NAME] 50 mg every six hours as needed for pain. On 03/19/14 at 9:50 AM, Z12, (RN, Wound Clinic Nurse) stated that R4 had been seen on 03/17/14 at the wound clinic, she stated R4's coccyx and right heel pressure ulcers have declined and he had developed a new pressure ulcer on the left hip/trochanter. Z12 stated that the stage IV coccyx pressure ulcer most likely has a bone infection and they are awaiting aerobic culture results. Z12 stated that their recommendations are for a wound vac to be applied as soon as possible. Z12 stated that frequent turning and repositioning would prevent such decline and new developments from happening. She stated that the facility is responsible for ordering the vac and then applying it, and the wound clinic will see him in a week. Z12 confirmed that the wound clinic physician signed the order and faxed it back to the facility. The measurements taken on 03/17/14 for the coccyx pressure ulcer were 8.6 cm x 4.0 cm x 3.2 cm with undermining from 7 - 11 o'clock of 3.3 cm, stage IV with probable bone infection. Z12 stated that Santyl dressings ordered to change twice daily and as needed. Z12 also stated that the left hip/trochanter pressure ulcer is a new stage III with 100% slough measurements of 2.7 cm x 2.2 cm x 0.1 cm. Orders for the hip treatments are for Santyl ointment with a foam dressing, change daily and as needed. The right heel pressure ulcer stage III measurements of 1.4 cm x 2.1 cm x 0.3 cm. Z12 stated that the pressure ulcer treatments have not been changed from Santyl since January, 2014. She further stated that at no time did the wound clinic have ordered a Puracol Silver Gel dressing with foam border, because it does not enhance wound debridement. Z12 confirmed that the wound clinic was not aware of the change in wound treatments. The facility failed to accurately identify, assess, monitor, treat and notify family, physician and wound clinic of R4's pressure ulcers and pain control. This failure resulted in R4's Stage IV pressure ulcer of the coccyx to decline with multiple necrotic areas and bone infection, development of a new Stage III left hip pressure ulcer, a decline in a Stage III pressure ulcer of the right hip and an increase in pain that was not assessed and treated.

Based on record review, interview and observation, the facility failed to provide timely supplements, adaptive eating utensils and meal assistance/clues for 2 of 6 residents (R2, R12) reviewed for weight loss in the sample of 16. This failure resulted in R12 incurring in a unplanned significant weight loss and below desired laboratory tests. Findings include: 1. R12's Minimum Data Set (MDS), dated [DATE], documented severe cognitive impairment and supervision of setup help only with eating and fluids. R12's Care Plan, focus date 1-2-14, documented, her ideal body weight as plus/minus 125 pounds. It was also noted that she needed assistance with meals, encouragement, praise her to consume at least 50-100% of each meal offered and provide a divided plate for meals. R12's Hematology lab, dated 1-7-14, documented her hemoglobin as 10.6 gm/dl range of 12.0-16.0 gm/dl, hematocrit 32% range of 37-47%, red blood count 3.69 M/CUMM range of 4.20-5.40 M/CUMM, absolute lymphocytes 0.6 K/CUMM range of 0.9-3.0 K/CUMM, [DIAGNOSES REDACTED]as 71% range of 47-67%, lymphocytes 17% range of 25-45%, platelets 113 K/CUMM range of 140-410 K/CUMM and [MEDICATION NAME] 3.3 gm/dl range of 3.5 0 5.5 gm/dl. R12's Rehab Addendum Note, dated 1-6-14, documented R12 was issued a spoon with built up handle and was directed to scoop her food and bring it to her mouth. During observation of R12's breakfast meal on 3-12-14, R12 was served, in part, pureed meat, bread and eggs in a divided plate. A small glass of thin orange juice, two bowls of pureed fruit and a supplement cup were placed around her divided plate. R12 ate her meal with a regular soup spoon and not a spoon with a built up handle. R12 was not assisted or encouraged to eat her meal. She repeatedly dipped her soup spoon in her plate and supplemental cup and without obtaining any food and then lick the spoon. She did not drink her orange juice nor was she offered any fluids, including water, during her meal. R12 only ate bites of her breakfast meal. R12's Meal Intake Record, dated 3-2014, documented she ate only 25% of her meals on 3-7-14, 3-8-14, 3-9-14 and 3-13-14. R12's MDS, dated [DATE], documented R12's eating/drinking had declined to limited assistance of one person physical assistance. The facility's Monthly Weight Log, not dated, documented R12's weights as 87 pounds for 1-2014 and 86 pounds for 1-2014. Interview of E5, Licensed Practical Nurse (LPN), on 3-13-14 at 11:15a.m., E5 stated R12's 3-2014 weight had declined to 81 pounds. Interview of E25, Dietary Manager, on 3-14-14 at 3:05p.m., E25 said R12's five pound weight loss would be considered a significant weight loss for her. Interview of E2, Director of Nursing (DON), on 3-12-14 at 10:30a.m., E2 stated R12 was not in a restorative program but should be. 2. According to the MDS dated [DATE], R2 is totally dependent on staff for all activities of daily living including eating. The physician's orders [REDACTED]. The weekly pressure ulcer report identifies R2 to have a stage IV pressure ulcer. The care plan dated 12/18/13 includes a goal to consume 50% of each meal with interventions to encourage food and fluids at and between meals, encourage to increase food intake and substitutes dislikes for like foods among others. The monthly weight report sheet documents R2's weight in February (no day) 2014 at 117 pounds. No weights recorded for March as of 3/13/14. The dietary manager last review dated 12/18/13 documents that R2 is fed by staff, skin in intact, health shake tid, diet general puree comfort food. Dietary Progress note dated 1/21/14 written by the Registered Dietician (RD-E30) identifies R2 now with an unstageable pressure ulcer with intake less than 25% to 50%, no sugg (suggestions.) On 2/20/14, the RD documents the same information as 1/21/14 with no suggestions made. On 3/11/14 at 12:40pm, R2 was fed her pureed meal by E3, CNA. She had orange drink, mashed potatoes, meals, fruit and bread. R2 did not receive a health shake. R2 sat in her chair with her eyes shut. Occasionally E3 would touch R2's arm and ask "are you awake". At 12:51pm, E3 got up to assist another table and returned a few minutes later. R2 drank 50% of her orange drink, took bites of potatoes and meat, didn't have any peas, fruit and/or bread offered to her before staff stopped attempting to feed her. No subs were offered or attempted. No health shake was given as ordered. On 3/12/14 at breakfast meal, R2 was taken to the dining room at 8:27am. At 8:35am, E7 CNA sat down to feed R2. R2 had scrambled eggs, oatmeal, sausage, yogurt, and fruit. R2 remained with her eyes shut as E7 would occasionally shake her arm and ask her to wake up. R2 ate 75% of her fruit but none of her other foods. She drank 100% of her orange juice but none of her orange drink. E7 did not offer any oatmeal, sausage or yogurt to her as she assisted her. No health shake was given to R2 at breakfast. At 9:25am, R2 was propelled out of the dining room after having eaten only a few bites. On 3/12/14 at the noon meal, R2 was given a health shake after she ate only a few bites of meal, 75% of her ice cream and 100% of her fruit. She drank 100% of her health shake. Meal Intake Record for March 2014 show no intake recorded for breakfast and lunch 3/1-3/4 and 3/8-3/14 and no intake recorded for supper from 3/13 thru 3/17 when reviewed. For most meals, staff have documented 25% of meal and occasionally 50%. No recorded intake for dates meals were observed. In addition, there is no documentation of the health shakes ordered three times daily. On 3/14/14 at 1pm, R2's weight was requested and none was provided. E25, Dietary manager stated she did not have monthly weights for R2 yet. E3 weighed R2 in her wheelchair at 188 pounds then weighed her wheelchair at 78.5 pounds giving R2's weight at 109.5, a decrease of 7.5 pounds (6.4%) loss since recorded weight of 117 pounds in February. E25 stated they do not weigh R2 any more often than monthly and that R2 is on Hospice. 3. Residents will be weighted weekly or more often based upon ongoing assessment of nutritional intake, fluid retention, and other medical factors." 4. The facility's Restorative Programs Log, not dated and presented as the most current log, did not document R12 on the facility's Restorative Programs Log. 5. The facility's Restorative Nursing Therapy Services, dated 11-2013, documented, in part, "Policy: To provide a multifaceted program that seeks to: attain and maintain residents highest level of functioning, to maintain resident dignity or self worth. Restorative therapy is to work in conjunction with skilled therapy services and nursing services." 6. The facility's Eating/Swallowing, not dated, documented, in part, "Purpose: To promote resident independence by providing activities that improves or maintains a residents self performance in feedings one's self food and fluids or maintains resident's ability to ingest nutrition and hydration by mouth. Explain to residents using simple instructions what you want them to do. 14. Provide frequent verbal cues and hand over hand assist as needed. 16. Provide encouragement and allow the resident to do as much for themselves as they can." 7. The facility's Adaptive Equipment - Eating, dated 1-13, documented, in part, "Policy: Provide adaptive equipment to assist residents and patient at mealtimes for easier, independent eating." 9. The facility's Weight Monitoring - Nursing Services policy and procedure, not dated, documented, in part, "it is the policy of this facility to monitor residents' weights from the time of admission and to provide interdisciplinary support and/or intervention avert adverse trends.

Based on observation, record review and interview, the facility neglected to identify, assess and monitor for injury; neglected to follow Care Plan for transfer; neglected to follow physician orders [REDACTED]. These failures resulted in R2 sustaining injury of unknown origin and not receiving timely treatment after a [MEDICAL CONDITION] femoral condyle of right leg and Hemarthrosis. Findings include: Facility Policy and Procedure of 1/2013 for Reporting Abuse to the Facility Management documents in part; "It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source... to nursing supervisor, Director of Nursing and Administrator...When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident:..The state licensing/certification agency responsible for surveying/licensing there facility...The Resident's Attending Physician; and The Facility Medical Director." Facility Policy and Procedure of 1/2013 for Resident and Employee Abuse Investigations Policy documents all reports of resident injuries of unknown source shall be promptly and thoroughly investigated by the Administrator. The facility Policy and Procedure for Resident Change of Condition Physician Notification of 10/99 documents, in part: Attending physician, or physician on call, is to be notified of residents change in condition/health status...Document time of call, physician or nurse practitioner or other person spoken to, reason for call and results or orders received. Facility Fall Procedure that is undated documents, "Check resident as often as needed and chart residents condition. Charting will be done on all shifts for 72 hours." The facility undated Policy and Procedure for NEUROLOGICAL FLOW SHEET shows Nurses are to do assess motor and sensory function including moves all extremities and to document that it was done. R2's Flow Sheet shows none of the Nurses documented motor and sensory function to R2's extremities. The Policy and and Procedure documents to call the Physician if noted bluish tinge to skin. R2's Minimum Data Set (MDS) of 8/8/13, documents R2 has severe cognitive impairment and is totally dependent on 2 or more staff for transfers; has limited range of motion on both upper extremities and both lower extremities; and is unable to answer questions regarding pain. R2's most recent Care Plan of 5/4/11 documents R2 is alert with confusion at times. R2 has decreased safety awareness and poor short term memory. R2 has [DIAGNOSES REDACTED]. Undated note documents mechanical sling lift with 2 staff assist every shift. Nurses Note of 10/19/13 at 9:10PM, documents R2 was found on the floor by E8, Licensed Practical Nurse (LPN). Skin tear 1/4 cm circle noted to left elbow cleansed with normal saline and triple antibiotic ointment applied and covered with bandaid. Abrasion noted to left lateral knee with redness no swelling. R2 is alert with Dementia and when asked what happened stated "I don't know". A vital sign sheet with neuro checks initiated. Review of Nurses Notes from 10/20/13 through 10/25/13 at 4:40PM show that R2 had no signs or symptoms of injury other than a bruise on her left cheek. Nurses Notes and Neuro check flow sheet show staff did not document that R2 was assessed every shift for 72 hours as per the facility Policy and Procedures for falls. Nurses Note of 10/25/13 4:30PM, "Call received from the nurse at (Z2's (R2's Physician)) office regarding R2's bruising and swelling to R(right) knee nurse states that (R2) to be seen at prompt care or ER (emergency room ). MD (Medical Doctor) does not want X ray to be done at facility." Hospital Radiology Report of 10/25/13 documents X ray of right knee at 10PM showed, "There is a [MEDICAL CONDITION] femoral condyle. There are severe [MEDICAL CONDITION] changes within the knee. There is a hematrthrosis. There is pronounced medial soft tissue swelling and subcutaneous [MEDICAL CONDITION]. Diffuse osteopenia." Record review of facility INCIDENT/ACCIDENT LOG for October 2013 shows R2's fall on 10/19/13 was not documented on the log. Interview with E1, Administrator, on 10/26/13 at 4PM, E1 stated there was no investigation concerning R2's fall on 10/19/13. E1 stated he would expect staff to continue to monitor and assess R2 for any bruising or injury for several days following the fall. On 10/26/13 at 2PM, E2, Director of Nursing, was requested to go into R2's room for a skin check with E3 LPN. R2 was observed to be lying in a low bed with mats on the side of the bed. R2's right knee had an immoblizer on her knee. R2 had a 2 cm x 1/2 cm irregular shaped scab on her right shin below the knee. E3 opened up the stabilizer and R2 was observed with a yellow bruise covering the knee and surrounding tissue. During skin check, R2 was observed with a yellow purple bruise across her upper chest above her breast that went from her right side at the axilla area across above the breast and over into the left axilla. R2 had a bruise on the left upper arm at the same level and width as the bruise along her upper chest that was also yellowish purple. E3 stated E12, Certified Nurse Aide (CNA) had just informed her of the bruising on R2's chest that day and E3 had not had a chance to look at it and this was the first time she had seen the bruising. E3 stated the bruising did not look new. E3 was asked about the dark area on R2's cheek and E3 stated it's always been there. It's a discoloration of her skin, not a bruise. During interview with E2 on 10/26/13, E2 stated that the bruising on R2 looked like it was from a gait belt. Stating R2 is on anticoagulation therapy and would bruise easily. E2 stated that he was informed of incident of bruising on R2's knee on 10/24/13 and they got an X ray. E2 stated he was not aware of the bruising on R2's chest. E2 confirmed the bruising on R2's chest was not new. E2 stated he would have expected Nurses to do a full body assessment after finding the bruise on the right knee on 10/24/13. During interview with Z1, Facility Medical Director, on 10/26/13 at 2:45PM, Z1 stated the bruising on R2's chest was even across the upper breast and corresponds with a gait belt. Z1 stated the bruising is about 4 to 6 days old due to the yellowish purple color and appears to be uniform in size. Z1 stated probably R2 got the bruising from the force of a gait belt with someone pulling on it from her back or side. Probably 1 person and not from a fall. Z1 stated she had been unaware of the bruising on R2's chest until 10/26/13 when she went in the room at E1's, Administrator, request to evaluate R2. On 10/29/13 at 3:45PM, E7, Certified Nurse Aide (CNA), stated on 10/23/13 she had noted R2's bruised swollen knee and had concerns that R2 was in pain. E7 stated she informed E9, LPN. On 10/29/13 at 4PM, E9 stated he went down to give R2 pain medication and she refused. E9 stated he did not assess R2. On 10/29/13 at 2:20PM, E10, CNA stated on 10/24/13, she was helping E12, CNA, get R2 in bed. R2 was sluggish. Her right knee was bruised and purple on the back and yellow and green on the front, "Her knee was really swollen and hot to touch. R2 kept saying, "be careful" during the transfer. E10 stated she reported the bruised swollen knee to E3. On 10/29/13, E3 stated the first time she was told of R2's bruised knee was on 10/24/13. The right knee was bruised all the way around black and blue and swollen, hot to touch. R2 acted like it hurt when E3 moved it to look at it. E3 stated she faxed Z2, R2's Physician to let her know what was going on. E3 stated at the end of her shift she had not heard back from Z2 and told E9 that Z2 would be calling about R2's knee. E3 stated she did not do a head to toe assessment of R2. E3 was not aware of R2's previous fall. E3 stated she came on duty on 10/25/13 and noticed nothing was done with R2..E3 called and talked to Z2's Nurse who told her that Z2 did not want a portable X-ray and had given orders the previous day to send R2 out. Interview with with Z3, Z2's Nurse, on 10/30/13 at 11:30AM, Z3 stated that they had gotten a fax concerning R2's fall on 10/19/13 that documented skin tears to the elbow and shin and knee being red. Z3 stated they were informed it was the left knee, not the right. Z3 stated they got a call on 10/24/13 from the facility wanting an X ray of the right knee. Z2 order for the facility to send R2 to prompt care or the walk in ortho clinic to get an X-ray or to the emergency room if R2 was in a lot of pain. Z3 stated the facility did not follow the orders because they called again the next day on 10/25/13 again asking for an X-ray for R2's knee. Z2 again ordered R2 be sent out for right knee X-ray. Z3 stated she had talked with Z2 and Z2 stated she would have expected the facility to continue to assess and monitor R2 for injury after her fall. It's good Nursing judgement. Injury does not always show up right away after a fall especially with patients with poor communication. The facility should have been assessing for pain and injury the following days after the fall. Record review of R2's Resident Body Audit form documented by E12, CNA, on 10/24/13 documents a bed bath was given. There is no documentation of any bruising or skin tears. Skin Monitoring: Comprehensive CNA Shower Review form of 10/26/13 documented by E12, bed bath given and bruising to the chest and left upper arm yellow in color and splint on right knee. Skin Monitoring: Comprehensive CNA Shower Review form of 10/31/13 documented by E15, CNA, does not document any bruising on R2. IDPH NOTIFICATION INCIDENT INVESTIGATION REPORT of 11/1/13 documents E8 was terminated from the facility related to her improper transfer of R2 and failure to appropriately follow up with R2 after an incident/accident. E12 was terminated from the facility related to falsifying documentation on a resident skin check sheet after admitting that on 10/24/13, E12 neglected to do a bed bath on R2 and then filled out skin check sheet as if the bed bath was completed. E15 was terminated from the facility for falsifying documentation on a skin check sheet for R2 and not accurately assessing R2 for bruising or other skin conditions. R2 is being transferred at all times with assist of two with a mechanical sling lift and is being seen by therapy.

Based on observation, record review and interview, the facility failed to accurately assess and monitor for injuries 1 of 3 residents (R2) reviewed for falls in the sample of 3. This failure resulted in R2 not receiving timely treatment after a [MEDICAL CONDITION] femoral condyle of right leg and Hemarthrosis. Findings include: R2's Minimum Data Set (MDS) of 8/8/13, documents R2 has severe cognitive impairment and is totally dependent on 2 or more staff for transfers; has limited range of motion on both upper extremities and both lower extremities; and is unable to answer questions regarding pain. R2's most recent Care Plan of 5/4/11 documents R2 is alert with confusion at times. R2 has decreased safety awareness and poor short term memory. R2 has [DIAGNOSES REDACTED]. Nurses Note of 10/19/13 at 9:10PM, documents R2 was found on the floor by E8, Licensed Practical Nurse (LPN). Skin tear 1/4 cm circle noted to left elbow cleansed with normal saline and triple antibiotic ointment applied and covered with bandaid. Abrasion noted to left lateral knee with redness no swelling. R2 is alert with Dementia and when asked what happened stated "I don't know". A vital sign sheet with neuro checks initiated. The following is the documentation of all Nurses Notes from 10/20/13 through 10/25/13 at 4:40PM: 10/20/13 at 2:15AM," (R2) on FVS (full vital signs) with neuro checks. 97.8 -69-18-113/61. ( R2) resting in bed quietly. No new injury noted. Alarms in place and functioning. Bed on lowest position. Will Cont. (continue) to monitor. " 10/21/13 at 2PM. " FVS B/P (blood pressure) 102/58 P (pulse) 80 R (respiration) 20 T (temperature) 98.9 (R2) asleep in bed easily awaken alert and pleasant no sign or symptoms of injuries. Bed alarms on and in place neuro per flow sheet." 10/21/13 at 11AM. "(R2) conts FVS 98.4 - 76 - 26 (R2) shows no s/s (signs/symptoms) of distress bruise noted to (L) left cheek. Neuro WNL (within normal limits) Will cont to monitor." 10/22/13 at 2AM, "FVS B/P 108/52 P64 R 18 T 98.5 Sleeping well in bed easly awaken alert and pleasant no c/o (complaint of) pain. no signs or symptoms of injuries from fall Neuro check per flow sheet bruise to Lt (left) side cheek." 10/23/13 at 11PM, "(R2) given B12 injection R (right) quadricep. (R2) tolerated injection well." 10/25/13 4:30PM, "Call received from the nurse at (Z2's (R2's Physician)) office regarding R2's bruising and swelling to R knee nurse states that R2 to be seen at prompt care or ER (emergency room ). MD (Medical Doctor) does not want X ray to be done at facility." Hospital Radiology Report of 10/25/13 documents X ray of right knee at 10PM showed, "There is a [MEDICAL CONDITION] femoral condyle. There are severe [MEDICAL CONDITION] changes within the knee. There is a hematrthrosis. There is pronounced medial soft tissue swelling and subcutaneous [MEDICAL CONDITION]. Diffuse osteopenia." A facility report dated 10/26/13 was faxed to IDPH and document R2 was involved in a reportable incident.. Facility IDPH Notification Incident Investigation dated 10/29/13 documented that on 10/26/13 IDPH surveyor reported that R2 had bruising on her chest and arm. On 10/26/13 at 2PM, E2, Director of Nursing, was requested to go into R2's room for a skin check with E3 LPN. R2 was observed to be lying in a low bed with mats on the side of the bed. R2's right knee had an immoblizer on her right knee. R2 had a 2 cm x 1/2 cm irregular shaped scab on her right shin below the knee. E3 opened up the stabilizer and R2 was observed with a yellow bruise covering the knee and surrounding tissue. During skin check, R2 was observed with a yellow purple bruise across her upper chest above her breast that went from her right side at the axilla area across above the breast and over into the left axilla. R2 had a bruise on the left upper arm at the same level and width as the bruise along her upper chest that was also yellowish purple. The bruising 2 was 2 inches wide. E3 stated E12, Certified Nurse Aide (CNA) had just informed her of the bruising on R2's chest that day and E3 had not had a chance to look at it and this was the first time she had seen the bruising. E3 stated the bruising did not look new. During interview with E2 on 10/26/13, E2 stated that the bruising on R2 looked like it was from a gait belt. Stating R2 is on anticoagulation therapy and would bruise easily. E2 stated that he was informed of incident of bruising on R2's knee on 10/24/13 and they got an X ray. E2 stated he was not aware of the bruising on R2's chest. E2 confirmed the bruising on R2's chest was not new. E2 state he would have expected Nurses to do a full body assessment after finding the bruise on the right knee on 10/24/13. During interview with Z1, Facility Medical Director, on 10/26/13 at 2:45PM, Z1 stated she went with E1 (Administrator) to look at the bruising on R2's chest. Z1 stated the bruising was probably not from a fall. The bruising was even across the upper breast and corresponds with a gait belt. Z1 stated the bruising is about 4 to 6 days old due to the yellowish purple color and appears to be uniform in size. Z1 stated probably R2 got the bruising from the force of a gait belt with someone pulling on it from her back or side. Probably 1 person. Z1 gave a written statement that includes, in part;, "as per assessment - bruise is across chest that appears uniform across her chest width likely size of "gait belt" and also on her left arm. same direction and place on chest. Bruise could be between 4-6 days old..." Record review of facility INCIDENT/ACCIDENT LOG for October 2013 shows R2's fall on 10/19/13 was not documented on the log. Interview with E1, Administrator, on 10/26/13 at 4PM, E1 stated there was no investigation concerning R2's fall on 10/19/13. On 10/29/13 at 3:45PM, E7, Certified Nurse Aide (CNA), stated on 10/23/13 she had concerns that R2 was in pain. She just didn't seem the same. R2 was saying ouch, ouch when given care. E7 stated she noticed R2's knee, it was swollen and bruised. E7 knew R2 had fallen previously and she asked E9, LPN, if R2 could have some pain medicine. E9 told E7 he had looked in R2's medical record and stated its documented she had bruising and swelling to her knee. On 10/29/13 at 4PM, E9 stated he went down to R2's room to give her pain medication but R2 refused to take the medication. E9 stated he had already documented the medication as given, so he had to error it out on the MAR (Medication Administration Record). E9 stated he did not assess R2. Review of the MAR indicated [REDACTED]. MAR indicated [REDACTED]'s initials. On 10/29/13 at 2:20PM, E10, CNA stated on 10/24/13, she was helping E12, CNA, get R2 in bed. R2 was sluggish. Her right knee was bruised and purple on the back and yellow and green on the front, "Her knee was really swollen and hot to touch. R2 kept saying, "be careful" during the transfer. E10 stated she reported the bruised swollen knee to E3. On 10/29/13, E3 stated the first time she was told of R2's bruised knee was on 10/24/13. The right knee was bruised all the way around black and blue and swollen, hot to touch. R2 acted like it hurt when E3 moved it to look at it. E3 stated she faxed Z2, R2's Physician and to let her know what was going on. E3 stated at the end of her shift at 3:00PM, she had not heard back from Z2 and told E9 that Z2 would be calling about R2's knee. E3 stated she did not do a head to toe assessment of R2. E3 was not aware of R2's previous fall. E3 stated she came on duty on 10/25/13 and noticed nothing was done with R2..E3 called and talked to Z2's Nurse who told her that Z2 did not want a portable X-ray and had given orders the previous day to send R2 out. Interview with with Z3, Z2's Nurse, on 10/30/13 at 11:30AM, Z3 stated that they had gotten a fax concerning R2's fall on 10/19/13 that documented skin tears to the elbow and shin and knee being red. Z3 stated they were informed it was the left knee, not the right. Z3 stated they got a call on 10/24/13 from the facility wanting an X ray of the right knee. Z2 order for the facility to send R2 to prompt care or the walk in ortho clinic to get an X-ray or to the emergency room if R2 was in a lot of pain. Z3 stated the facility did not follow the orders because they called again the next day on 10/25/13 again asking for an X-ray for R2's knee. Z2 again ordered R2 be sent out for right knee X-ray. Z3 stated she had talked with Z2 and Z2 stated she would have expected the facility to continue to assess and monitor R2 for injury after her fall. It's good Nursing judgement. Injury does not always show up right away after a fall especially with patients with poor communication. The facility should have been assessing for pain and injury the following days after the fall. Record review of R2's Resident Body Audit form documented by E12, CNA, on 10/24/13 documents a bed bath was given. There is no documentation of any bruising or skin tears. Skin Monitoring: Comprehensive CNA Shower Review form of 10/26/13 documented by E12, bed bath given and bruising to the chest and left upper arm yellow in color and splint on right knee. Skin Monitoring: Comprehensive CNA Shower Review form of 10/31/13 documented by E15, CNA, does not document any bruising on R2. During interview with E1, on 10/26/13 at 4PM, E1 stated on 10/24/13, either E12 did not give R2 a bath or lied about R2's bruising on the report. On 10/29/13 at 11:30AM, E1 stated when he interviewed E5, LPN, she stated on 10/26/13 she was at the Nurses Desk when E12 turned in the bath shower report on 10/26/13 and it did not have any bruising for R2 documented on the report. E5 told E12 that R2 had bruising and a immobilizer on her knee and to go back and look at R2 and document the bruising. That when E12 turned in the report of bruising across R2's upper chest and upper left arm and on her right knee. E1 stated that E12 was terminated from employment at the facility for not doing her job and/or falsifying documents. On 10/30/13 at 4PM, E1 stated he terminated another CNA, E15, for not documenting R2's bruising on the Shower Sheet. Record review of facility undated Policy and Procedure for NEUROLOGICAL FLOW SHEET shows Nurses are to do assess motor and sensory function including moves all extremities and to document that it was done. R2's Flow Sheet shows none of the Nurses documented motor and sensory function to R2's extremities. The Policy and and Procedure documents to call the Physician if noted bluish tinge to skin. Facility Fall Procedure that is undated documents, "Check resident as often as needed and char residents condition. Charting will be done on all shifts for 72 hours." E1 stated on 10/26/13 at 4PM that he would have expected Nurses to do full body check each time they checked R2 to ensure there were no injuries.

Based on observation, interview and record review, the facility failed to use appropriate transfer technique for 2 of 3 residents (R2 and R3) who were reviewed for transfers and falls in the sample of 3. This resulted in R2 sustaining injuries of unknown origin with extensive bruising across her chest and over her left upper arm and a fracture of the right medial femoral condyle. R3 sustained 2.5 cm skin tears to her left and right elbows and on another occasion caused a 7 cm skin tear to the leg. Findings include: R2's Minimum Data Set (MDS) of 8/8/13, documents R2 has severe cognitive impairment and is totally dependent on 2 or more staff for transfers. R2's most current Care Plan documents on 7/26/12 that R2 is transferred with a mechanical sling lift. Undated note documents mechanical sling lift with 2 staff assist every shift. On 10/26/13 at 12:15PM, E3, Licensed Practical Nurse (LPN) was interviewed and stated she was caring for R2. E3 was asked if there were any bruises or injuries concerning R2. E3 stated R2 went to the hospital for an X ray the previous evening due to bruise on her right knee but had no injury. She now has a brace on her leg but not sure why. Not aware of any other bruising. On 10/26/13 at 2PM, the Surveyor requested E2, Director of Nursing, to do a skin check on R2. E2 asked E3 to help with the skin check. R2 was observed to be lying in a low bed with mats on the side of the bed. R2's right knee had an immoblizer. R2 had a 2 cm x 1/2 cm irregular shaped scab on her right shin below the knee. E3 opened up the stabilizer and R2 was observed with a yellow bruise covering the knee and surrounding tissue. During skin check, R2 was observed with a yellowish purple bruise across her upper chest above her breast that went from her right side at the axilla area across above the breast and over into the left axilla. The bruise was approximately 2 inches wide across her chest and left arm. R2 had a bruise on the left upper arm at the same level and width as the bruise along her upper chest that was also yellowish purple. E3 stated this was the first time she had seen the bruising. E3 stated the bruising did not look new. During interview with E2 on 10/26/13 at 2:15PM, E2 stated that the bruising on R2 looked like it was from a gait belt and was not new. E2 stated that he was informed of incident of bruising on R2's knee on 10/24/13 and they got an X ray. E2 stated he was not aware of the bruising on R2's chest until doing the skin check with the Surveyor. E2 stated he would have expected Nurses to do a full body assessment after finding the bruise on the right knee on 10/24/13. During interview with Z1, Facility Medical Director, on 10/26/13 at 2:45PM, Z1 stated she went with E1 (Administrator) to look at the bruising on R2's chest. Z1 stated the bruising was probably not from a fall. The bruising was even across the upper breast and corresponds with a gait belt. Z1 stated the bruising is about 4 to 6 days old due to the yellowish purple color and appears to be uniform in size. Z1 stated probably R2 got the bruising from the force of a gait belt with someone pulling on it from her back or side. Probably 1 person. Z1 gave a written statement that includes, in part;, "as per assessment - bruise is across chest that appears uniform across her chest width likely size of "gait belt" and also on her left arm. same direction and place on chest. Bruise could be between 4-6 days old..." Nurses Note of 10/19/13 at 9:10PM, documents R2 was found on the floor by E8, Licensed Practical Nurse (LPN). Skin tear 1/4 cm circle noted to left elbow cleansed with normal saline and triple antibiotic ointment applied and covered with bandaid. Abrasion noted to left lateral knee with redness no swelling. R2 is alert with Dementia and when asked what happened stated "I don't know". A vital sign sheet with neuro checks initiated. Review of R2's Nurses Notes and Shower Sheets from 10/20/13 to 10/25/13 show no documentation of R2 having any bruises, skin tears or swelling to her right knee. Resident Incident Report of 10/24/13 documents date and time of incident is unknown. Nature of injury is bruise to right knee front and back. " R2 was found with this bruising on right knee today and unsure how and when happened." It is documented Z2, R2's Physician was notified on 10/24/13 at 4:30PM. Record review of facility Incident/Accident Log for October 2013 shows on 10/24/13 bruising to R2's right knee was documented with X ray of knee. There are no Nurses Notes documented on R2 on 10/24/13 in her medical record even though she was found to have a bruised right knee and had an order for [REDACTED]. R2 is to be seen at prompt care or ER (emergency room ). Z2 does not want X ray to be done at the facility. Hospital Radiology Report of 10/25/13 documents X ray of right knee at 10PM showed, "There is a fracture of the medial femoral condyle. There are severe degenerative changes within the knee. There is a hematrthrosis. There is pronounced medial soft tissue swelling and subcutaneous edema. Diffuse osteopenia." Hospital Emergency Department after Care Instruction dated 10/25/13 documents, "Right distal femoral fracture. Ice affected area. Stay in knee immpbilizer at all times. NWB (non weight bearing) to RLE (right lower extremity). Interview with with Z3, Z2's Nurse, on 10/30/13 at 11:30AM, Z3 stated that they had gotten a fax concerning R2's fall on 10/19/13 that documented skin tears to the left elbow and abrasion to left lateral knee with redness no swelling. Z3 stated they were informed it was the left knee, not the right. Z3 stated they got a call on 10/24/13 from the facility wanting an X ray of the right knee. Z2 gave a telephone order on 10/24/13, for the facility to send R2 to prompt care or the walk in ortho clinic to get an X-ray or to the emergency room if R2 was in a lot of pain. Z3 stated the facility did not follow the orders because they called again the next day on 10/25/13 again asking for an X-ray for R2's knee. Z2 again ordered R2 be sent out for right knee X-ray. On 10/29/13, E3 stated the first time she was told of R2's bruised knee was on 10/24/13. The right knee was bruised all the way around black and blue and swollen, hot to touch. R2 acted like it hurt when E3 moved it to look at it. E3 stated she faxed Z2, R2's Physician to let her know what was going on. E3 stated it was around 2:50PM, at the end of her shift. E3 stated she told E9, LPN, that Z2 would be calling about R2's knee. E3 stated she did not do a head to toe assessment of R2. E3 stated she came on duty on 10/25/13 and noticed nothing was done with R2. E3 called and talked to Z2's Nurse who told her that Z2 did not want a portable X-ray and had given orders the previous day to send R2 out for an X ray. On 10/29/13 at 4PM E9 stated he called the ortho center on 10/24/13 but was told they couldn't do the X ray because the doctor ordering is not on staff. This is not documentated in R2's medical record and there were no further attempts to get an X ray on R2's knee.. The following staff were interviewed during the Survey about how R2 is transferred 10/26/13 at 3:30PM, E7, Certified Nurse Aide (CNA) stated she was taught that R2 is a one person transfer using a gait belt. E7 states she positions R2 at the edge of the bed and pivots her during transfer. E7 stated R2 does not stand for her during the transfer. 10/26/13 at 3:25 PM, E3 stated R2 does not bear weight, "not at all" during a transfer. R2 is a gait belt transfer with 2 people but sometimes only 1. 10/26/13 at 3:45PM, E4 (LPN), stated R2 should be a 2 person transfer. They try to use 2 people because R2 does not bear weight. Sometimes E4 will assist CNA with transfer using a gait belt. 10/29/13, at 2:20PM, E10 CNA stated she observed E12 on 10/24/13 to transfer R2 to bed by herself using a gait belt. R2's right knee was bruised - purple on the back of the knee and yellowish green on front. R2's knee was hot to touch and really swollen. E3 was informed of R2's knee. On 10/26/13 at 4PM, E1, Administrator, and E2, were informed of concern of the Surveyor that R2's Care Plan states she is to be transferred by a mechanical sling lift with 2 staff and that Surveyor had interviews that staff are using a gait belt and that R2 does not bear weight. E1 stated he would have therapy evaluate R2's transfer. On 10/30/13 at 8:15AM, Surveyor asked the facility for a list of residents who were transferred by a mechanical sling lift and if R2 was assessed for transfer by therapy a copy of the assessment was requested. The facility provided a list with only 1 mechanical sling lift being R4. 10/30/13 at 8:50AM, E13 stated he works on the same hall as R2 and there are no mechanical sling lifts on the hall. 10/30/13 at 10:23AM, E16, CNA, stated she got R2 up that morning with assistance. E16 stated they used a gait belt for the transfer. Rehabilitation Screen dated 10/30/13 by E17, Physical Therapist, documents, "Recent fall with resulting R (right) Distal Femur Fracture. Considering patient's cognitive status and non - weight bearing precautions and immobilizer on R knee/LE (lower extremity). A mechanical sling will be the safest indicated mode of transfer at this time. During interview with E17 and E18, Physical Therapy Assistant/Therapy Director on 10/30/13 at 10:45AM, E17 stated she could not screen R2 in person because she was out at the Doctor's at that time. E17 had just did the screen prior to interview. E17 stated with chart review, she determined R2 should be a mechanical sling lift for safe transfer. Both E17 and E18 stated they had not seen R2 in therapy or worked with her since 11/2012. E18 stated that on 10/29/13 she was asked to do an evaluation on R2. E18 stated they checked on R2's insurance coverage and was waiting to hear from the insurance company before doing an evaluation. On 10/30/13 at 11:00AM, E1 was informed of concern that R2 was still being transferred with a gait belt and had orders for NWB. E1 asked where the Surveyor got the orders for NWB and was told they were the discharge orders from the Emergency Department on 10/25/13. Z4's PHYSICIAN'S PROGRESS NOTES of 10-30-13 at 9:44AM, documents, in part; "If patient is going to be weight bearing at all on right leg brace should be in place." On 10/30/13, E1 stated that E17 evaluated R2 while R2 was at the Z4's office. E1 provided a telephone order of 10/30/13 that it is OK to bear weight while wearing the brace. On 10/30/13 at 12:25PM, Z5, Z4's Nurse, stated when R2 came to the appointment that morning, the staff who came with her did not know a lot about her. Did not know if R2 ambulated or was weight bearing prior to the injury of her knee. Z5 was concerned about R2's transfers and stated she would have Z5 call the Surveyor back. On 10/30/13 at 5PM, Z5 stated she had asked the care giver who was with R2 at her appointment if R2 bears weight and the care giver stated she did not know. Z5 stated that's why she wrote the above note that if R2 was going to be weight bearing at all then she needed to wear the brace. If R2 had been walking prior to the injury then it would be OK but not preferable. Z5 stated she would prefer R2 be transferred with a mechanical sling lift due to non weight bearing and R2's poor cognition. It would be safer. Z5 stated someone called from the facility to ask if R2 was OK to bear weight while wearing the brace. Z5 stated she was not informed R2 was unable to bear weight and wouldn't think they would be asking if she could bear weight if she didn't have the capability. On 10/29/13 at 9AM, E1 stated he had talked to E8, LPN about finding R2 on the floor on 10/19/13 and E8 told him she picked R2 up by herself, cradling R2 and placed her back up into her bed. Even if the bed is low it would be unlikely that E8 would be able to pick R2 up by herself. E1 stated he was still investigation. On 10/30/13 at 10AM, E1 stated he doesn't know if he'll ever get the true story of what happened. E8 states she picked R2 up and put her in bed. Can't see how she could have picked her up. E8 isn't that big and not in that great of shape. E1 stated he didn't know even if he could have picked up R2 and put her back to bed the way E8 described. E1 stated he wouldn't even have attempted it. Possible E8 is the one who caused R2's injury. May have tried to transfer R2 herself. Don't know. E5 stated E8 was acting funny that day. Not wanting any help from E5 and wanted E5 to find the CNA. E1 stated he had talked with staff and it's unlikely that R2 would have been able to get out of bed. It doesn't make sense. E1 stated E8 will be terminated from employment. R2's Care Plan documents last fall was on 11/8/12. On 10/30/13 at 4PM, E1 stated all the staff he had talked to stated they were trained to place the gait belt up under R2's armpits during transfer. E1 stated he has inserviced staff on proper gait belt transfer. IDPH NOTIFICATION INCIDENT INVESTIGATION REPORT of 11/1/13 documents E8 was terminated from the facility related to her improper transfer of R2 and failure to appropriately follow up with R2 after an incident/accident 2. Facility INCIDENT/ACCIDENT LOG documents R3 had a skin tear on her right lower elbow on 8/16/13 and a fall on 10/1/13 resulting in a 7 cm arc shaped skin tear on her left calf. R3's MDS of 8/18/13 documents R3 has severe cognitive impairment and is totally dependent on staff for transfer. R3's Care Plan of 8/21/13 documents R3 requires staff assistance with transferring, is able to weight bear, pivot , use arms to support and take two steps. Care Plan note of 8/16/13 documents Skin tear to right elbow, 2.5 cm arch shaped. Intervention is documented that staff were educated on correct transfer. Note of 10/1/13 documents Left calf skin tear 7 cm arch shaped. Intervention, "Staff education on proper transfer." Incident Report of 8/16/13 documents skin tear to right and left elbow 2.5 cm arch shaped. Cause was transfer and CNA, E19 was instructed on transferring R3. Employee Warning Notice of 8/16/13 documents 1st warning, "Failure to use appropriate transfer technique when transferring resident. Not using gait belt resulting in Fall. Taking break during meal times. gait belt provided to employee." Incident Report of 10/1/13 documents skin tear to left calf 7 cm arch shaped. "While transferring resident from w/c (wheel chair) to bed bumped residents leg on w/c causing 7.0 cm arc shaped skin tear...Reeducated CNA on proper transfer. During interview with E6, LPN on 10/29/13 at 11:50AM, E6 stated she educated E20, CNA, on proper transfer after the incident of 10/1/13. E20 was instructed to remove the wheel chair pedals from R3's wheel chair and place the wheel chair close to the bed before transfer to prevent her leg from being bumped.

Based on interview and record review the facility failed to administer medications per physician orders [REDACTED]. This failure resulted in R3 being readmitted to the hospital in acute [MEDICAL CONDITION]. Findings include; According to R3's Face Sheet, he was admitted to the facility on [DATE] at 3:30PM with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital dated 6/14/12, document that a total of 13 pages of orders were faxed to the facility of 6/14/12 at 10:35 AM. A second set of discharge orders were faxed to the facility on [DATE] at 11:19 AM. On page 5 of the discharge instructions faxed at 10:35 AM, [MEDICATION NAME] 20 mg, oral BID (twice per day), [MEDICATION NAME] Discus 250-50 1 inhalation BID, Insulin Levimir prefilled [MEDICATION NAME] 10 units subcutaneously at HS (hour of sleep) was ordred. The discharge orders faxed at 11:19 AM did not include page 5. Review of the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the admission nursing notes document that R3 had 3 plus [MEDICAL CONDITION] (extensive swelling of his lower extremities). Nurses Notes dated 6/16/12 at 0210 document that R3 had rapid shallow breathing with an increased respiratory rate of 38 breaths per minute. The physician was notified and R3 was transferred by ambulance back to the hospital and admitted with an exacerbation of [MEDICAL CONDITION]. Review of the Facility Medication Incident/Error Report dated 6/16/12 documents that E3 did not transcribe the [MEDICATION NAME] or [MEDICATION NAME] Discus to the Physicians Order sheet, and send it to the Pharmacy, which resulted in R3 not receiving the medication while in the facility. Review of the Cardiology Consultation Summary from the Hospital dated 6/19/12 completed by Z1 Medical Doctor (MD) treating R2, documents that (R3) was "readmitted to the hospital with [REDACTED]. This was ultimately attributed to a medication error. The patient had apparently not been receiving [MEDICATION NAME] at the nursing home. Once [MEDICATION NAME] was resumed the patients heart failure symptoms improved. The patients heart failure symptoms improved with appropriate diuresis, no other medications or treatments were changed." In an interview with E3 LPN, on 6/21/12 at 2:30PM, she stated, "we sometimes get multiple copies of the discharge orders from the hospital. They are usually faxed over before the Resident gets here and the resident also brings a copy of the orders with them when they get here. We review the orders, then transfer the orders over to our admission order sheet and send them to Pharmacy. In this case I did not realize the faxed orders from 6/14, were missing page 5, which included the [MEDICATION NAME], until I got a call from the emergency roiagnom on [DATE] asking when his last [MEDICATION NAME] dose was given. So he did not get the medication on Friday evening or all day Saturday." I did not look at any other copies of the discharge orders when I transferred the orders for Pharmacy. E3 confirmed that she received copies of the orders faxed at 11:19 AM, and transferred that set of orders to the "Regency Admission Order Sheet." These orders did not include the missing medications from page 5. R3 also brought copies of the discharge orders with him to the facility which were carried by hand and included all 13 pages of the orders. E3 faxed the orders to the pharmacy without noticing that page 5 was missing. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E4 LPN called the Physician to clarify insulin orders later in the day of 6/14, so the Levimir insulin missing from page 5 was added as part of the clarification of insulin orders and had been administered as ordered. .

Based on interviews, observations and record review, the facility failed to ensure that 2 (R3, R1) of 3 residents reviewed for falls were adequately assessed, and interventions were implemented and evaluated for effectiveness to prevent additional falls. The facility failed to implement a physical therapy recommendation of [DATE] for stand by assist or contact guard assist whenever up ambulating for R3. This failure resulted in R3 falling on [DATE] sustaining a head injury expiring a week later from a subdural hematoma. Findings include: 1. R3's latest Minimum Data Set ( (MDS) dated [DATE] identified her to have short/long term memory deficits with moderate cognitive impairment and exhibited wandering behaviors. The MDS indicated R3 required minimal assist of one staff for transfers, was independent in ambulation in her room and requires supervision for ambulation in corridor. The MDS also identified standing balance deficits but indicated that R3 can balance herself after standing. The Falls Risk assessment dated [DATE] identifies R3 as high risk (score 11). The care plan originally dated [DATE] identifies R3 at risk for falls due to independent ambulation, poor memory and decision making abilities and at that time, ambulated with a slow steady gait, requiring supervision, cueing and limited hands of assist with Activities of Daily Living (ADL's). The care plan identifies falls on [DATE], [DATE], [DATE], [DATE], and then none until [DATE]. Interventions include falling star program, Give 1:1 invite and monitor during groups, encourage programs of interest, Provide verbal cures or hand over hand as needed while sitting ([DATE]). Nursing Notes, on [DATE], Z3, (physician), ordered Trazodone 50mg at hs (bedtime) for Insomnia and Remeron 15mg at hs for anorexia. Z3's progress notes states "79 (year old) seeing for 1st time... Start Remeron help c depression improve appetite" and "Agitation/not sleeping @ (at) night start low dose Trazodone 50mg q (every) hs." According to Prentice Hall NURSE'S DRUG GUIDE 2009, adverse effects of Trazodone include lethargy, drowsiness, lightheadedness, insomnia, agitation, disorientation, and headaches. Adverse effects of Remeron include general/peripheral edema, somnolence, dizziness, tremor, confusion, agitation, vertigo, twitching, and nausea/vomiting along with urinary frequency. Nursing implications include "make position changes slowly especially from lying or sitting to standing, report dizziness..." An INCIDENT/ACCIDENT REPORT of [DATE] indicates the staff was assisting R3 to a wheelchair when she fell over to the floor. Intervention added was "enc (encourage)/remind to make position (Change) slowly." The RESIDENT FALL EVALUATION indicates R3 needs assistance at times with bed mobility/transfer/ambulation but does not identify which skill she needs assistance with. Another INCIDENT/ACCIDENT REPORT dated [DATE] indicates that R3 "was in hallway ambulating s (without) her walker started to get unsteady took 2 more steps and fell over." The recommendation was to have physical therapy evaluate her. A FALL RISK ASSESSMENT was not completed following this fall. According to E2, DON on [DATE] at 12pm, one should have been done with the investigation immediately after but was not. On [DATE] at 6pm, R3 fell again. The nurses notes state "was notified by CNA (Certified Nurses Aide) that "R" had fallen in SR (Sun Room). Upon arrival noted R laying in prone position. "R" c/o (complained of) neck pain. Noted copious amount of blood from unknown area @ (at) that time.... rolled noted a 4.5cm x 2.5cm x 0.4cm laceration above R (Right) eye brow...." R3 was transported to the emergency room for treatment. On [DATE] and [DATE], E3, Licensed Practical Nurse, (LPN), stated that R3's ambulation was unsteady from her admission but that she started to lean to the right after the Trazodone was started. E3 indicated R3 had also become lethargic with some leaning to the right as she walked. This was confirmed by E9 LPN on [DATE] at 3:10pm. Both E9 and E3 stated R3 would often sit at the nurses station with them so they could keep an eye on her. E3 stated R3 would be agitated when they would try to give her the walker saying it wasn't hers and that they would constantly remind her to use it. E3 described R3's gait as "shuffling" and if she sat/laid down, she would be back up right away and walking down the hall. E3 agreed that R3 had negative adverse effects from the Trazodone. E3 stated on [DATE] at 10:50am the Trazodone was reduced on [DATE] and that she noted the lethargy continued after the Trazodone was reduced and she contacted the physician to have it discontinued on [DATE]. Both E3 and E9 indicated that they were monitoring R3 at the nurses station most of the times but she would be up and walking very quickly. On [DATE] at 2pm, Z2 (R3's family representative) stated she had come into the facility on [DATE] for a quarterly care plan meeting and had noted that the Monday prior ([DATE]) her mother's speech was garbled and running together and was told her mother had been started on a new medication. Z3 stated that her mother was sleepy and when she asked the nurse about it, stated the nurse hadn't noticed the changes. Z3 said she discussed R3's decline with the E2, Director of Nursing (DON) then and was told by E2 that they would look into it and possibly request a dose reduction. On [DATE], E6, Certified Nurse Aid, (CNA), stated that when R3 first came, she walked steadily with her walker but the last month she was at the facility, had "deteriorated." E6 stated R3 didn't want to use the walker as she thought she could walk without it. E6 indicated that R3 was alert but confused, not able to use a call light. On [DATE] at 11am, E7, CNA, also said R3 was lethargic and would nap more toward the end. E7 said R3 would get up as soon as you set/laid her down and was very quick. E7 stated R3 needed constant reminders to use the walker and that she never trusted her to ambulate without it. E7 stated R3 he always told the nurses that one day R3 would fall as she was constantly getting up and down. Both E6 and E7 stated that R3 would get irritated but not agitated/aggressive when cued to use walker. The care plan includes a statement dated [DATE] indicating that R3 did not use her walker anymore, there are no new interventions added to the care plan regarding R3's need for stand by assist due to her refusal to use the wheeled walker. On [DATE] at 10:40am, E11, Care Plan Coordinator (CPC) recalled R3 well and stated that R3 constantly needed verbal cues/reminders to use her walker and then refused to use it. E11 stated that R3 was not sleeping well at night and would be "pretty tired during the day" stating that this could have possibly impacted her ambulation. E11 said R3 would get agitated if she was up walking without the walker and staff would continually remind her but couldn't identify what intervention was implemented to ensure she walked safely after she started to refuse the walker other than a physical therapy evaluation. E11 couldn't identify what intervention(s) were added that replaced the use of the walker to steady R3's gait when she started to refuse to use it. E11 stated she would have implemented alarms because the staff at least would have been alerted that R3 was up and moving so assistance could be provided but didn't because the family had refused them before. According to an ENDURANCE/FUNCTIONAL ABILITY assessment dated [DATE], R3 was placed on a bed mobility program and a "safe transfer" program by E2, Director of Nursing (DON). According to the interview with E3, LPN and E9, R3 had no problem with transferring but with actual ambulation. E2 stated, on [DATE] at 4:30pm, that she placed R3 on a transfer program as part of her falls prevention so she got up safely before she started to ambulate. However, review of her falls reports show no falls during transfer but always with ambulation. The Physical Therapy (PT) Evaluation dated [DATE] stated R3 required stand by assist-contact guard assist with supine to sit, and ambulation with safe cadence + proper technique in barrier negotiation. On [DATE] at 1:30pmn, E12 Physical Therapy Assistant (PTA) recalled R3 and when asked if she expected the facility to implement the recommendations, stated "yes, when she's up and walking around." The care plan shows no revisions added and no further assessment/evaluation done to ensure R3's safety except the PT evaluation. Interview with E2, DON, on [DATE] at 12pm confirmed that if PT determined R3 needed stand by assist to ambulate, then that assistance should have been provided to R3 every time she was up and walking. On [DATE] at 1:15pm, Z3 (Physician) stated she would expect the facility to implement any recommendations by PT "especially with a history of falls." According to E9, LPN, who responded when R3 fell on [DATE], stated she had been sitting with R3 at the nurses station just before the fall. E9 stated she got up to attend another resident leaving R3 at the nurses desk and when she returned, R3 was no longer at the desk. E9 stated a few minutes later, she was informed that R3 was on the floor in the sun room which was half way down the 200 hall. E9 stated R3's walker was not with her when she fell nor was it present in the sun room. E9 agreed R3 needed 1:1 at the time of the fall but that she needed to go to another resident so she left her alone at the desk. E9 stated she did not consider assigning a staff person to do a 1:1 or provide stand by assist with R3 at the time and that she considered that the nurses job along with responding to alarms sounding and call lights since the CNA's are busy doing other things. On [DATE] at 3:10pm E2 stated that the Trazodone had a negative effect on R3's activities of daily living including ambulation decline. E2 acknowledged the facility is a "restraint free facility" and that if she implemented restraints then she would get deficiencies for restraints instead of falls. E2 stated she did not consider 1:1's or a sitter as she didn't think she could ask the family to pay for it. E2 did state she understood the facility was responsible to meet all the needs of the residents. On [DATE] at 12pm, E2 stated that R3 had an overall decline in functional status identified on [DATE] and that her fall score also went up from an 11 on [DATE] to a 12 [DATE]. E2 confirmed the stand by assist was not added onto the care plan nor was the insomnia taken into regards with the falls assessment done [DATE] even though her fall risk increased and overall function declined. The facility's policy entitled "FALL PREVENTION PROGRAM" states all resident are assessed as being high risk for falls and individualized fall preventions will be developed for that resident with preventative measures taken whenever possible The objectives include consistently identifying and evaluating residents who fall and treat/refer for treatment appropriately, and prevent/reduce injuries related to falls among others. According to the Death Certificate, R3 expired on [DATE] with CAUSE OF DEATH due to Subdural hematoma due to fall at the nursing facility. 2. The MDS dated [DATE] identifies R1 as having short/long term memory deficits with moderate cognitive impairment. The MDS indicates R1 is not ambulatory in her room and requires extensive assist of one staff for transfers. The MDS indicates R1 is unable to stand without assist. According to the care plan dated [DATE], R1 is at risk for falls due to decline in physical abilities and bilateral lower extremety weakness indicating she needs one assist for transfers and ambulation. Interventions include encouraging to use call light, provide activities, assess for fall factors prior to falls occurring, evaluate/investigate if falls occur, every two hour toileting while awake, tab alarm in bed, sensor alarm in wheelchair, dycem to wheelchair cushion, remove from stimuli and others. The care plan also identifies numerous falls over the past six months. Observations of R1 on ,[DATE] and [DATE] show her to be sitting at the nurses station or across from the nurses station and attempting to get up unassisted setting off her alarms alerting staff in the immediate area that she is moving. However, R1 repeated attempts to get up. R1 was also observe to cry often throughout the day as she sat in her wheelchair. Review of the incident reports show numerous falls as follows: On [DATE] at 4pm, R1 slid out of her chair onto the floor. Her TABS unit was connected but not sounding due to the battery being dead. The report stated R1's right arm was caught in the wheelchair with only redness noted. On [DATE] at 2:55pm, R1, climbed out of bed and was on the floor when staff responded to the alarm sounding. Recommedation was to observe her every 30 minutes. On [DATE] at 6:45pm, R1 was found sitting on her "butt" on floor behind the nurses station with the alarm sounding. Intervention added was to remove from stimulation to decrease agitation and restlessness. On [DATE] at 3:45pm, R1 fell while attempting to stand up. She sustained a 1.5cm hematoma on her left parietal area. The alarm was sounding. The recommendation was to get a psychiatric evaluation. NO further interventions were added toward addressing her repeated attempts at self transfer. On [DATE] at 10:30am, R1 again slid out of her wheelchair when getting anxious after attempting to get up several times. There is no indication as to whether the dycem added to her care plan on [DATE] was in her wheelchair at the time or not. The recommendation was to assist to bathroom with increased restlessness and agitation. At 12:30pm on [DATE], R1 was yelling for help when staff found her on her knees beside the bed. She sustained a 1cm x .6cm skin tear to her left shin. The report indicates the TABS unit was still attached to her clothes when found. On [DATE] at 12:35pm, R1 again attempted to stand up. She missed the wheelchair and sat on the floor. The alarm was sounding. The intervention added was to ensure wheelchair brakes are locked. The facility failed to provide adequate supervision to ensure timely response to the alarm. On [DATE] at 4pm, R1 was found on the floor facing her wheelchair when staff responded to the alarm. She was reminded to not get up unassisted. Her MDS identifies short term memory deficits. On [DATE] at 3:10pm, E2 DON, stated R1 requires "lots of 1:1's". However, that is not evident in her care plan for falls prevention. According to E9 LPN on [DATE] at 3:10pm, R1 is very busy, has alarms which probably go off at least 50 times per shift. E9 described it as "constantly." E9 also said R1 requires lots of 1:1's and does not know how to use the call light. due to her cognitive impairment. Interview with R1's physician on [DATE] also indicated that 1:1's help. On [DATE] at 11am, E7 CNA stated that R1 wants to move around and will slide forward on her wheelchair. E7 described R1 as confused, unable to use the call light and that they keep her at the nurses station frequently so someone is around. On [DATE] at 9:40am, E2 DON stated she just initiated a 1:1 on [DATE] on R1 since she repeatedly attempts to get up unassisted. However, following breakfast, R1 was observed sitting in the hallway outside the dining room beside the med cart with no staff in attendance. She was out of visual range of the staff in the dining room. E2 stated the 1:1 she had was attending to another resident who also required a 1:1. An occupational therapy assessment dated [DATE] indicates R1 is unable to maintain long sits without assist and is high fall risk. Coordination is decreased. Other barriers listed include confusion, depression, with positioning needs "may need some c w/c - demonstrated increase postural lean. The evaluation indicates she is alert/oriented to self only.

Based on interview, record review and observations the facility failed to ensure that 2 (R3 and R2) of 3 residents on the sample reviewed for unnecessary drugs had adequate indications for use, adequate monitoring for adverse consequenses. This failure resulted in R3 having an overall decline in mobility including unsteady gait, leaning, and lethargy after [MEDICATION NAME] and [MEDICATION NAME] were initiated. R3's decline resulted loss of weight and falling three times with the last on 8/21/10 when she sustained a subdural hematoma. The facility failed to have justification for use of [MEDICATION NAME], failed to monitor R2 for adverse effects including lethargy and weight loss and failed to discontinue the [MEDICATION NAME] when appropriate Findings include: 1. According to R3's latest Minimum Data Set ( (MDS) dated [DATE], R3 is a [AGE] year old female admitted to the facility on [DATE]. The MDS indicates R3's behaviors as repetitive questions and wandering. On 7/22/10, Z3's (physician) progress notes shows, "79 (year old) seeing for 1st time... Start [MEDICATION NAME] help c depression improve appetite" and "Agitation/not sleeping @ (at) night start low dose [MEDICATION NAME] 50mg q (every) hs." A [MEDICAL CONDITION] DRUG assessment dated [DATE] identifies the [MEDICATION NAME] and [MEDICATION NAME] with behaviors warranting the use as "poor appetite, difficulty sleeping, wt (weight) loss, pacing, retpetitive questions." with side effects checked "no" but fails to identify when R3 began exhibiting [MEDICAL CONDITION] and how often it occurred. According to the Prentice Hall NURSE'S DRUG GUIDE 2009, [MEDICATION NAME] is a Psychotherapeutic agent - antidepressant to be used with [MEDICAL CONDITION] with or without anxiety. Adverse effects include lethargy, drowsiness, lightheadedness, [MEDICAL CONDITION], agitation, disorientation, and headaches among others. [MEDICATION NAME] is identified as a psychotherapeutic agent - antidepressant, antianxiety. Adverse effects include general/[MEDICAL CONDITION], somnolence, dizziness, tremor, confusion, agitation, [MEDICAL CONDITION], twitching, and nausea/vomiting along with urinary frequency. Nursing implications include "make position changes slowly especially from lying or sitting to standing, report dizziness..." The nurses notes dated 8/3/10 at 8:30am identify a change in R3's behaviors in that she started to "refuse" to use her walker stating that is wasn't hers and that she would just leave it in the hallway as she walk on. On 10/19/10, E3 indicated that R3 refusing the walker was a new behavior. On 8/3/10 at 9pm, the nurses notes identify R3's ambulation/gait as "unsteady". and on 8/4/10 at 8:30am, E3 wrote that R3's gait remained unsteady and she was hand fed. On 8/4/10 at 2:55pm, E3 wrote "resident lethargic Was started on [MEDICATION NAME]" On 8/4/10 at 10pm, the nurses notes identify R3 as being "lethargic this shift. Response to verbal stimuli. Was transferred into w/c d/t (due to) difficulty walking." and that she was up with one assist and hand fed supper. A backnote dated 8/4/10 at 7pm identifies increased confusion. A facsinile transmission note dated 8/4/10 states "resident was started on [MEDICATION NAME] 50mg po (by mouth) q (every) hs (bedtime) on 7/22/10. Resident more lethargic during daytime. May we try [MEDICATION NAME] 25mg po q hs?" The physician returned an order to decrease the [MEDICATION NAME] to 25mg. This was confirmed by E3 on 10/7/10 at 10:30am. On 10/ 7/10 at 10:30am, E3 stated R3's gait was unsteady since admission but had gotten worse after the initiation of the [MEDICATION NAME]/[MEDICATION NAME] but couldn't say when. On 10/7/10 at 10:30am, E3 Licensed Practical Nurse (LPN) stated she had reported R3's [MEDICAL CONDITION] to the physician based on information she received in shift report from the 11-7 nurses. E3 stated R3 would be up and down all night and then sleep into the daytime hours. E3 also stated if R3 sat/laid down, she would be back up right away and walking down the hall a minute later. A facsimile dated 8/9/10 written by E3 requests the [MEDICATION NAME] to be discontinued due to R3 being lethargic. On 10/7/10 at 10:30am, E3 confirmed that R3's appetite was good when she was admitted , but R3 lost interest in eating after a while. E3 stated that she went from feeding assist to being fed and refused to eat at times. On 10/7/10 at 3:10pm, E9, LPN, confirmed the information reported by E3. E9 stated the combination of the two drugs definately could have contributed to R3's overall decline in eating, mobility and refusals. E3 described R3's gait as "shuffling". E9 described R3 as "very fatigued, very lethargic" and having to be fed in the dining room and agreed that her gait was worse with the [MEDICATION NAME]. E9 could not find any reference in the nurses notes for 2nd shift regarding the [MEDICAL CONDITION] prior to 7/22/10. The care plane did not reflect insominia, being up at night and sleeping through the day or the weight loss. The Registered Dietician's quarterly assessment dated [DATE] identifies R3's weight loss as 11.4 pounds and is "fed by staff (started to refuse to feed self) and "closes mouth, eyes during meals, appears to sleep + chews" and "staff to feed @ meals, lost wt (weight) due to quit feeding self." The nutritional status is "overweight, but refusing to eat." According to the MAR for July 2010, R3 received her last dose of [MEDICATION NAME] on 8/9/10 but continued to receive the [MEDICATION NAME]. On 10/7/10, E6 CNA stated R3 had decline the last month she was at the facility, had "deteriorated." E6 stated R3 didn't want to use the walker as she thought she could walk without it. E6 indicated that R3 was alert but confused, not able to use a call light. E7 CNA also said R3 was lethargic and would nap more toward the end. E7 said R3 would get up as soon as you set/laid her down and was very quick. On 10/6/10 at 3:10pm, E2, Director of Nursing (DON) stated R3's ambulation skills deteriorated after the [MEDICATION NAME] and [MEDICATION NAME] was started. R3's family representative, Z2, stated that on 7/29/10 she that R3's speech had become garbled and that something was wrong. Z2 also indicated that R3 appeared listless and was confined to a wheelchair at times during visits. Z2 also indicated that she met again with E2 on 8/6/10 about discontinueing the rest of the [MEDICATION NAME] and having some physical therapy. In addtion, Z2 stated R3 continued to decline even though the medication was discontinued. R'3 anorexia was also not tracked, identified or monitored in a timely manner prior to the initiation of the [MEDICATION NAME]. According to the monthly weight sheet record for 2010, R3 went from 152.8 pounds in June to 144.3 pounds in July 2010. The Care plan dated 7/29/10 did not identify R3's anorexia prior to the [MEDICATION NAME] and [MEDICATION NAME] being added. There is no plan developed regarding R3's behaviors of getting up and down during mealtime. This was confirmed in interview with E11 Care Plan Coordinator on 10/19/10 at 10:40am. E11 stated that she remembered adding the [MEDICATION NAME]/[MEDICATION NAME] but nothing before that. On 10/19/10 at 1:15pm, Z3 Physician stated she would have expected the facility to assess for side effects stating it is "standard procedure to monitor" the effectiveness of the drug especially for the sleep pattern including side effects. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurses notes following 7/22/10 do not identify any adverse effects or whether the [MEDICATION NAME]/[MEDICATION NAME] was effective. The care plan includes a statement dated 7/29/10 that says R3 "does not use walker anymore. Becomes frustrated when staff try to remind her." Review of the INCIDENT/ACCIDENT LOG shows R3 falling on 8/2/10. On 8/14/10 at 3:15pm, the nurses notes indicate R3 fell again. On 8/21/10 at 6pm, R3 fell again and sustained a laceration measuring 4.5cm x 2.5cm x 0.4cm above her right eye brow. R3 was transported to the emergency room for treatment and diagnosed with [REDACTED]. The facility's policy on [MEDICAL CONDITION] MEDICATIONS purpose is to establish a standardized system to inform residents and/or thier responsible persons about [MEDICAL CONDITION] medications and their side effects. The policy states a resident "will not receive a [MEDICAL CONDITION] medication unless behavioral programming and/or environmental changes have failed to sufficiently modify a resident's target behavioral disturbance. A resident will not receive [MEDICAL CONDITION] medication unless such a medicaiton is needed to treat a specific condition and each [MEDICAL CONDITION] medicaiton will be given to treat clearly defined target behaviors." The policy continues to state "Consistent observation of all target behaviors will be done to assist in the assessment of the risks and benefits of [MEDICAL CONDITION] drug therapy" and "Ongoing observations for side effects of all psychotrop9ic medications will be completed. Duplicate drug therapy is discouraged." The policy indicates that for each TARGET BEHAVIOR, there will be at least one measurable target behavior identified and will be observed for every shift and documented on int he daily behaviorsl observations sheet or nurses notes along with the care plan. 2. The MDS dated [DATE] identifies R2 as having no short/long term memory deficits but decision making difficulties. The MDS indicates R2 requires only minimal assist for all aspects of mobility. The MDS identifies no mood/behaviors or psychosocial concerns but the physician's orders [REDACTED]. According to the current care plan, an intervention under adjusting to room mate issues stated "inappropriate touch of female resident." On 10/7/10, the Director of Nurses identified R3's inappropriate behaviors as targeting one female resident in particular and touching her. E2 stated that was the reason why the [MEDICATION NAME] was ordered to begin with. E2 stated that the dose was 1mg then was decreased to .5mg and then the physician refused to stop it. E2 confirmed that R2 no longer touches inappropriately. E2 was asked why interventions the facility implemented prior to starting him on [MEDICATION NAME] as there are none in the care plan. The [MEDICAL CONDITION] DRUG assessment dated [DATE] indicates inappropriate behaviors as "inappropriate touching" and presents danger to themselves or others or interferes with staff's ability to provide care but fails to specify how. Additional comments says "1/25/10 [MEDICATION NAME] (decreased) to 0.5mg". The MULTI-SYMPTOM EXAM FORM dated 1/25/10 stated R2's sexual aggression has stopped. A [MEDICAL CONDITION] DRUG assessment dated [DATE] again indicates the behavior is inappropriate touching but includes no other information. The note states the physician decline a reduction 1/25/10 and that the behavior was improved. Review of the behavioral tracking sheets show no behaviors as occurring since January 2010. On 7/22/10, the physician again refused a reduction even though R2 has had no targeted behaviors since shortly after it's initiation. In addition, there is no reference to the [MEDICATION NAME] on the pharmacy reviews since 1/8/10. On 10/6/10 at 11:22am, E3 Licensed Practical Nurse (LPN) stated it had been quite a while since R3 had sexually inappropriate behaviors. This was confirmed with E9 LPN on 10/7/10 at 3:10pm when she stated that R2 has no sexually inappropriate behaviors and stated that he has been more sleepy lately. On 11/6/10 during the lunch hour, R2 was noted to eat very little and dose throughout his entire meal leaving the majority of his food when he left the dining room. An assessment of R2's behaviors was requested and E2 was unable to provide one. E2 was also unable to provide a plan developed that including interventions addressing R2's inappropriate touching of female resident prior to the use of the [MEDICATION NAME].