Every finding on record at River Bluff Nursing Home

Based on observation, interview and record review, the facility failed to assess and monitor a resident after a significant weight loss and failed to ensure a resident's nutritional supplements were implemented after a significant weight loss. This failure resulted in the residents having continued weight loss. This applies to 2 residents (R77, R67) reviewed for weight loss in a sample of 36. The findings include: 1. R77's Face Sheet printed on 6/24/26 showed R77 was initially admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, and type 2 diabetes. R77's Weights summary showed R77's weights where: on 4/7/26 at 207.6 pounds (lbs.), on 4/21/26 at 200 lbs., on 4/28/26 at 200 lbs., on 5/1/26 at 189 lbs., on 5/16/26 at 189 lbs., on 5/26/26 at 188 lbs., on 6/17/26 157 lbs. R77's weight loss is calculated as being from 4/7/26 to 5/1/26 as an 8.7% weight loss in 24 days. From 5/26/26 to 6/17/26 as a 16.49 additional decrease in weight in 23 days. Both weight losses are examples of significant weight loss. R77's Nutritional assessment dated [DATE] showed R77 had moderate decrease in food intake and no weight loss in the last 3 months. When comparing the same 3 months to R77's weight/vitals summary R77 had a net weight loss of 9 lbs. R77's Facility assessment dated [DATE] showed R77 had a weight loss greater than 5% in the last month and was not on a physician-prescribed weight-loss regimen. R77's Mini Nutrition Progress note dated 5/16/26 showed R77 was at a risk of malnutrition. On 6/22/26 at 2:40 PM, V28 (R77 family) stated R77 has had some more medical issues over the last 6 months. V28 stated R77 does not like the eating pureed food. V25 stated R77 has been losing weight. V25 stated he noticed a few weeks ago R77's hands and face were thinner. At the Care Plan meetings, we discussed R77's weight loss. It was brought up in the last 2 weeks. V25 could not remember talking about R77 weight loss in April or May (2026). On 6/23/26 at 12:15 PM V26 Certified Nursing Assistant (CNA) stated R77 has been eating poorly off and on since R77 was put on a pureed diet. R77 does not like the pureed food. V26 stated R77 has been eating between 50-75% of her meals. On 6/23/26 at 12:30 PM, V27 Nurse Practitioner stated they had not been notified of any weight loss for R77 until V25 contacted them on 5/26/27. V27 stated they had not been contacted by the dietitian or have seen any dietary recommendations for R77. On 6/23/26at 2:00 PM, V2 Director of Nursing stated that when a resident triggers for significant weight loss we usually get a notification, and we contact the physician and the dietitian. V2 stated they did not know why R77's charting did not trigger after 5/1/26 (5.5% weight loss). On 6/24/26 at 10:30 AM, V25 Registered Nurse stated R77 has had some changes with her health over the last few months. V25 stated that when we put the weights in the computer it usually triggers a notice if there is a large weight change. V25 does not know why there was not a notice of R77 losing weight. V25 stated they were taking care of R77 on 5/26/26 when they noticed R77 looked like they had lost weight. V25 had the Certified Nursing Assistants weigh R77 three times to double check the weight. V25 stated they entered the weight on 5/26/26 as 188 lbs. V25 stated they contacted V27 Nurse Practitioner and got an order for a shake supplement. R77's medical record showed no additional monitoring of R77 weight was after 5/27/26 when the shake supplement order was placed. R77 continued to lose weight after this intervention with an additional 16.49% weight loss from 5/26/26 to 6/17/26. On 6/25/26 at 10:00 AM, V10 Dietitian stated she does dietary reviews for residents on tube feeding, new admissions, and significant weight loss. V10 stated on 6/22/26 they were informed of R77's decrease in weight and new weight done. V10 stated R77's previous weights over the last year had fluctuated around 200 lbs. V10 stated they had talked about R77 during the weekly Weight Meetings but was not reviewed for significant weight loss. The facility's Weight Monitoring Policy dated 2/3/26 showed the definition for significant weight loss is a loss of 5% change in weight in 1 month (30 days), 7.5% weight change in 3 months (90 days), and 10% weight change in 6 months (180 days). This policy also shows the physician should be notified of the weight change, and the dietitian should be consulted to assist in interventions which should be documented in the resident's chart. 2. R67's face sheet shows she has diagnoses including Alzheimer's, CHF, unspecified dementia, chronic kidney disease stage 3, unspecified protein-calorie malnutrition, and heart disease. R67's Nutrition Note dated 5/1/26 shows she has 20% weight loss in 6 months. BMI (Body Mass Index) is severely underweight. Intake variable 25%-50%. Continue remeron (appetite stimulant), ongoing supplements (mighty shakes) and recommend to start 2 cal (nutritional supplement) 60 ml (milliliters) three times a day. R67's weight report 1/2/26-124.4 lb (pounds)2/1/26- 116 lb.3/24/26- 113.3 lb.4/1/26- 101.9 lb. 5/1/26-101.5 lb. 6/1/26-102.5 lb. On 6/22/26 at 9:36 AM, R67 was in her room lying in bed. She presented with a thin appearance, sunken eyes, sunken cheekbones and bony upper extremities while eating her breakfast meal. Eggs, toast and water served but was not served her nutritional shake (mighty shake). On 6/23/26 at 8:20 AM, R67 was in her recliner chair near the nurse's station, eating breakfast. R67 was served milk, eggs and biscuit and gravy but was not served her nutritional shake. On 6/24/26 at 10:01 AM, V10 (Dietitian) said weights are reviewed weekly. If a resident has weight loss, she puts in the recommendations for supplements. R67 triggered for significant weight loss and she recommended to continue to her mighty shakes and added two Cal three times a day. She should be receiving both supplements. R67's Physician Order Sheets dated June 2026 shows orders for two Cal three times day however her orders do not include mighty shakes. R67's Medication Administration Record dated May 2026 shows on 5/6 her mighty shakes were discontinued. The facility's Weight Monitoring Policy revised 2/26 states, To monitor the weight of each resident in order to develop appropriate medical nursing, and/or dietary interventions, while maintaining the dignity of each resident.

Based on observation, interview, and record review the facility failed to ensure clean kitchen pans and boiling water used for cooking were maintained in a manner to prevent contamination and failed to ensure frozen food items were labeled and dated. This applies to all 150 residents residing in the facility. The findings include:The facility's CMS form 671 dated 6/22/26 shows a census of 150 residents. On 6/22/26 at 9:10 AM, during the initial tour of the kitchen with V17 Dietary Supervisor, the freezer contained multiple plastic bags of chicken like products with no label of what they were or a date to show how old the product was. V17 when asked how do you know what is in the bags, V17 said the cooks know what it is. At 9:32 AM, V19 Dishwasher was working on the clean side of the dishwashing machine. V19 removed brown plastic bins from the clean side and stacked them on the wet floor mats next to the dishwasher. V19 then picked up the stacked bins and stacked them inside another clean plastic bin on the shelf under the clean side of the dishwasher. A brown plastic bin was observed on the clean side of the dishwasher holding lids to resident cups. At 9:41 AM, V18 Assistant Dietary Supervisor was pureeing foods at a prep counter. V18 used a pitcher to obtain hot water from a large kettle type pot and used the water to add to the pureed foods. There were two kettle pots located under an exhaust hood. Directly above the boiling water kettle, which was steaming, water drops had collected on the exhaust hood and were observed dripping back into the hot water used for cooking. On 06/23/2026 at 11:40 AM, V17 said frozen foods should be labeled with what the contents are and the date opened, or the date the box was opened and the bag removed from the box. V17 said the brown bins are used to hold clean dishes temporarily until the dishes are put away and should not be placed on ground to prevent contamination. V17 said the drops of water dripping back into the water kettle can contaminate the water used for cooking. The facility's Food Safey Requirements Policy dated 6/3/2025 shows Contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. Food safety practices shall be followed throughout the facility's entire food handling process. All equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. Labeling, dating, and monitoring food including, but not limited to leftovers, so it is used by its use-by date.

Based on observation, interview, and record review the facility failed to ensure pureed food was of a smooth consistency was served for 4 of 4 residents (R70, R77, R110, R125) reviewed for pureed food in the sample of 36. The findings include: On 6/22/26 at 10:00 AM, V18 Assistant Dietary Supervisor was pureeing the noon meal. V18 added pizza burgers, tomato sauce, thickener and water to the puree machine. V18 ran the machine for a few minutes and then poured the pureed contents into a serving pan. The puree did not visibly appear smooth. This surveyor tasted the puree and noted small bits of meat that had to be chewed. V18 did not taste the puree and covered the pan up and put into the warmer to be served for lunch. On 6/22/26 at 12:20 PM, R110 was seating in the dining room for the noon meal. R110 took one bite of pureed pizza burger and chewed for a while before swallowing. R110 did not take another bite of the pizza burger On 6/22/26 at 12:45 PM, the pureed pizza burger was tasted by two surveyors and found to be not smooth with bits of meat that needed to be chewed. At 12:56 PM, V17 Dietary Supervisor tasted the puree and said it was not smooth and needed to be pureed longer. The facility's People Roster Report sorted by diet order dated 6/22/26 shows R70, R77, R110 and R125 are on a pureed diet. The facility's Puree Food Preparation Policy dated 6/11/26 shows Puree means that all food has been ground, pressed, and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding.

Based on observation, interview and record review the facility failed to provide a wider bed for a resident upon request. This applies to 1 of 36 residents (R78) reviewed for accommodation of needs in the sample of 36. The findings include: On 6/22/26 at 12:59 PM R78 stated that she had asked for a wider bed on admission, and no one has gotten her anything. (R78 was admitted to the facility on [DATE]). R78 stated that she fell out of bed at the hospital and now has a fear of falling out of bed. R78's Progress Notes dated 6/10/26 written by V28 (RN- Registered Nurse) state, Patient admitted yesterday afternoon from (Rehab Hospital), alert and oriented x 3. Anxious. States she is anxious because of her bed. The bed is not comfortable for her. Transferred to recliner which was also not comfortable and opted to return to bed. States she is afraid of rolling out of bed. Bed lowered all the way to floor. Patient states she has previously inadvertently rolled out of bed. Hand holds in place on either side of bed, which patient has used to reposition, however states she wishes she had full side rails. Asked for ice cream and assistance to eat it, provided. Asked several times if another bed is available. Apologized and informed her that all available beds are the same model at present. She has been calling out as well. On 6/24/26 at 9:35AM a call was placed to V28 requesting her to return the call to Surveyor. No return call was received prior to survey exit. On 6/24/2026 at 12:35 PM V1 (Administrator) stated with V2 (Director of Nursing) present, That is not true. We have some beds inhouse that the frames expand to a bariatric bed. If we do not have one available, we can order one from (DME supply company). This is the first I am hearing about this this.

Based on interview and record review the facility failed to ensure PRN (when needed) psychotropic medications had stop dates. This applies to 3 of 6 residents (R12, R13 & R113) reviewed for unnecessary medications in the sample of 36. The findings include:1. R113's June MAR (medication administration record) shows, Quetiapine fumarate (anti-psychotic) oral tablet 50 MG (milligram), give 1 tablet by mouth every 24 hours as need for agitation PRN for agitation at HS (hour of sleep). Start date: 6/5/26. There is no stop date. She has received the medication 6 times since ordered. The pharmacist's recommendation to prescriber for R113 dated 6/16/26 shows, Findings/recommendation: this resident has new order(s) or was admitted /readmitted with order(s) for QUETIAPINE 50 milligrams QHS PRN. According to federal nursing facility regulations, PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. If this is the case, the prescriber should document the rationale in the medical record and indicate their duration for the PRN order(s). There are no exclusions for Hospice or end of life care. May we discontinue the above order(s) 14 days after the start date to help the facility maintain regulatory compliance.2. R12's June MAR shows, lorazepam intensol oral concentrate 2 mg/ml (milligram/milliter), give 0.25 ml by mouth every 3 hours as needed for agitation/anxiety, restlessness, uncontrolled seizures. Start date: 5/19/26. There is no stop date.The pharmacist's recommendation to prescriber for R12 dated 6/2/26 shows, Findings/recommendation; this resident has new order(s) or was admitted /readmitted with order(s) for Lorazepam 0.5mg Q3hrs PRN. According to federal nursing facility regulations, PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. If this is the case, the prescriber should document the rationale in the medical record and indicate their duration for the PRN order(s). There are no exclusions for Hospice or end of life care. May we discontinue the above order(s) 14 days after the start date to help the facility maintain regulatory compliance.3. R13's June MAR shows, lorazepam intensol oral concentrate 2 mg/ml, give 0.25 ml by mouth every 3 hours as needed for anxiety. Start date: 5/29/26. There is no stop date. The pharmacist's recommendation to prescriber for R13 dated 6/16/26 shows, Findings/recommendation; this resident has new order(s) or was admitted /readmitted with order(s) for Lorazepam 2mg/ml-give 0.25ml Q3hrs PRN. According to federal nursing facility regulations, PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. If this is the case, the prescriber should document the rationale in the medical record and indicate their duration for the PRN order(s). There are no exclusions for Hospice or end of life care. May we discontinue the above order(s) 14 days after the start date to help the facility maintain regulatory compliance.On 6/24/26 at 11:15 AM, V2 Director of Nursing stated, all PRN antipsychotic medications have to have a stop date of no more than 14 days. The facility's use of psychotropic medications policy dated 1202026 shows, Policy: it is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the residents' medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Policy explanation and compliance guidelines: .16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical records should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no access no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on observation, interview and record review the facility failed to treat a resident experiencing a change of condition in a timely manner. The facility also failed to ensure resident's ace wraps were applied to their legs as ordered. This applies to 3 of 36 residents (R2, R23, R95) reviewed for quality of care in the sample of 36. The findings include: R2's EMR (Electronic Medical Record) shows that R2 was admitted to the facility last on 4/27/26 with diagnoses including Respiratory Failure, Pneumonia and Hypertensive Heart Disease. R2's Progress Notes dated 6/19/26 at 8:15 PM written by V26 (LPN- Licensed Practical Nurse) state, Lethargy noted. Able to arouse for brief moments at a time. Skin warm and clammy. Upper trunk and facial diaphoresis noted. Afebrile. Increased audible congestion noted with occasional moist cough. Pulse ox 88-89% with O2 @ 2L/min. via N.C. HOB (Head of Bed) elevated for the ease of breathing. PRN (As needed) nebulizer with some effectiveness noted. B/P; 88/68. RN supervisor notified and evaluated. The same Progress Notes shows that V26 attempted to contact R2's POA (Power of Attorney) at 8:50PM. Then show at 10:50PM she had still not heard back from the POA so she contacted another family member (R2's sister). It is documented that V26 will continue to follow up and call back if condition does not improve. Sister will call back facility in the early AM. Finally, at 11:15PM (3 hours after initial assessment) V26 documents, Texted (Nurse Practitioner) in regard to condition change. At 11:45PM V26 documented, Received new orders from (Nurse Practitioner) to send resident out to ER for evaluation. R2 was transported to the hospital via private ambulance company at 1:20AM (5 hours after initial assessment) on 6/20/26. R2's Progress Notes dated 6/20/26 state that R2 was admitted (to the hospital) with diagnoses including hypoxia, AMS (Altered Mental Status), sepsis and elevated troponin. (Primary marker for a heart attack but can also be triggered by other conditions like heart failure.) On 6/24/26 at 11:00AM V26 (LPN) stated, The day before (R2) had been not acting right. I work with him all the time and sometimes you just know. He was more congested, but the nebulizers were working the day before. He is usually coherent but, on the 19th, he was mumbling, and incoherent. He was more lethargic. He was awake for a moment and then he would fall back to sleep again. He was more congested and he has a history of pneumonia. He did not have a fever, but he was sweating profusely. I asked the CNAs to clean him up and dry him off and then he was wet again from sweating. His Blood Pressure was low- it is usually low, but it was lower than usual. His O2 saturation usually runs between 89 and 92%, and I could not get it past 89%. I had the RN supervisor (V27) take a look at him and she said he did not have any rhonchi or rales, but his lungs were diminished in the bases. She wanted me to get a hold of the family and see what they wanted to do. I could not get a hold of the POA, but I got a hold of the sister who didn't want to put him through that this late at night (sending him to the hospital) and said to monitor him and she would call back in the morning to check on him. His symptoms did not come on all at once. A little later I texted (one Nurse Practitioner) but I didn't get a response so I texted (the other Nurse Practitioner) and she said we would not be able to get a stat chest X-ray, so we needed to send him out. I called the sister back and told her we had an order to send him out and she agreed. The sister stated she would get ahold of the POA- (R2's niece). I was monitoring him the whole time and his symptoms did not come on all at once. I contacted the supervisor and the family and then the MD. If they are a DNR I call the family first and see what they want to do. This family is pretty involved. (Surveyor asked about admitting diagnoses) V26 was able to tell Surveyor diagnoses but stated, I am not sure I know what that means. The facility policy entitled Notification of Changes dated 4/7/26 states, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Significant change in a resident's physical, mental or psychosocial status. This may include: a. Life threatening conditions, or b. Clinical complications 2. R23's face sheet shows she has diagnoses including neuromuscular dysfunction of bladder, polyneuropathy, chronic kidney disease, personal history of urinary tract infections, and presence of urogenital implants. On 6/22/26 at 1:30 PM, V13 (Certified Nursing Assistant-CNA) transferred R23 with the mechanical stand lift from her wheelchair to her recliner. R23 was positioned in her recliner with moderate amount of edema to her lower legs. R23 stated, I don't have my wraps on my legs. V13 said she would let the nurse know. R23 said they should put my leg wraps on every day. They wraps should be placed on in the morning and removed at night. On 6/23/26 at 8:13 AM, R23 was in the main dining room sitting in her wheelchair during the breakfast meal. R23 said they never put on my leg wraps yesterday after she reported to V13 her wraps were not on. On 6/23/26 at 12:18 PM, V12 (Licensed Practical Nurse-LPN) said R23 is alert and oriented, she transfers using the mechanical stand lift. Her elastic wraps should be applied in the morning and removed at night for her edema. R23's Physician Order Sheets dated June 2026 shows orders including apply elastic wraps to both lower legs on in AM and off at bedtime for edema. 3. R95's Facility assessment dated [DATE] showed R95 is cognitively intact and does not have any behaviors with being resistive to care. On 6/22/26 at 9:15 AM, R95 was sitting in their recliner. R95'a lower extremities could be seen from knee to foot. R95's lower legs were swollen with dry, cracked, thick skin. R95's circumference of their lower leg appeared to be the same from the knee to the foot. R95's feet were swollen. 2 elastic wraps were rolled up on R95's table. On 6/22/26 at 12:30 PM, R95's elastic wraps were in the same location as before. R95 stated she did not know why the nurse did not put them on this morning. R95 stated she thought the wraps were supposed to be put on every day. She stated the morning nurse is usually the one who does it. R95 stated the staff had gotten her up before breakfast and did not put them on. R95's Physician Order Sheet printed on 6/24/26 showed R95 has an order for wraps to both lower extremities on in the morning and off at bedtime related to heart failure. On 6/22/26 at 2:00 PM, V2 Director of Nursing stated wraps should be placed on as ordered.

Based on observation, interview, and record review, the facility failed to ensure appropriate assessment, treatment and care planning for a newly acquired pressure injury and failed to implement interventions to promote healing and prevent worsening of wounds for 2 of 7 residents (R7 and R82) reviewed for pressure in the sample of 36.The findings include: 1. R7's Face Sheet printed on 6/24/26 documented R7 was admitted to the facility and has diagnoses that include hemiplegia, cerebral infarction, gastronomy and colostomy status, aphasia and dysphagia. There is no documented diagnosis for pressure injury or wound. R7's Clinical Physician Orders reviewed on 6/22/26 includes orders to monitor wound of right outer ankle/float every shift for pressure ulcer (started 2/23/26) and to cleanse and dress right outer ankle every M-W-F (Monday, Wednesday, Friday/started 6/1/26). On 6/22/26 at 11:32 AM and 6/23/26 at 2:47PM, R7 was observed in bed with right ankle lying on bed, not floated or elevated. On 6/23/26 at 12:11 PM, V31 Licensed Practical Nurse provided wound care to R7's right ankle. Foam bandage dated 6/21/26 was removed, site cleansed with wound cleanser, and a foam dressing was applied. The site was observed to have a circular, reddened wound, with a purple indentation in the center. V31 did not measure the wound during the dressing change, however stated that the wound appeared to be a Stage 1. V31 did not attempt to float or elevate R7's right ankle following the dressing change. V31 stated based on care experience with R7 and previous refusal, V31 did not attempt floating of the ankle. 06/24/2026 at 11:03 AM, V30 Assistant Director of Nursing stated V30 became aware of R7's pressure injury upon gathering surveyor requested documents. V30 stated no previous wound consult order was entered upon identification of pressure injury, which resulted in R7's wound not being assessed or treated by the wound physician. V30 stated that when a pressure injury is identified, the primary physician should be informed to place a referral to be seen by wound care physician. Subsequently, V30 stated V30 entered a wound consult order on 6/24/26. 06/24/2026 at 11:52 AM, V20 Unit Coordinator stated that V20 recently (date/time not expressed) became aware of R7's pressure injury and does not know when it was first identified. V20 stated that the facility's process for identified skin concerns is that a risk management assessment is completed, the provider is notified to implement treatment orders, referral for wound consult and the residents care plan will be updated to include pressure and interventions. In addition, V20 stated that a weekly wound observation tool would be completed by the nurse. Additionally, V20 stated that interventions are offered regardless of previous resident refusals, and refusals and attempted interventions need to be charted within the resident's medical record. R7's Clinical Physician Orders reviewed on 6/22/26 includes orders to monitor would right outer ankle/float every shift for pressure ulcer that started on 2/23/26 and to cleanse and dress right outer ankle every M-W-F (Monday, Wednesday, Friday). On 6/23/26 at 10:30 PM, the orders were updated to include float bilateral heels while in bed or apply heel boots, chart refusals. On 6/24/26, an additional order for wound consultation to evaluate and treatment including debridement if needed to right outer ankle was entered. R7's medical record was reviewed for Wound-Weekly Observation Tools and there was only one completed on 2/21/26. The tool documents that a facility acquired pressure ulcer, unstaged, was identified on 2/21/26 to R7's right outer ankle. No additional observation tools were available for review. Additionally, the record did not document R6's refusal of intervention to float ankle. R7's Skin Check's (between 2/21/26-6/21/26) were reviewed and documents a facility acquired right ankle pressure injury with no skin issue education, notification or clinical suggestions documented. R7's Care plan Report printed on 6/24/26 documents that R7 has the potential for pressure ulcer development, however, has not been updated to include the acquired pressure injury to the right ankle with goal and interventions. The facility's Pressure List Current provided on 6/23/26 did not include R7. 2.R82's face sheet shows he has diagnoses including pressure ulcer left elbow stage 3, intellectual disabilities, legal blindless, heart disease and generalized anxiety. On 6/22/26 at 12:07 PM, R82 was sitting in a chair in the hallway eating the noon meal. A round open area was visible to his left elbow without a dressing in place. At 1:24 PM, R82 was in his room lying in bed, there was no dressing to his left elbow and there were no elbow pads in place. On 6/23/26 at 9:48 AM, V14 (Certified Nursing Assistant-CNA) said R82 has a wound to his left elbow. He did have elbow pads, but she has not seen the elbow pads, and no one has told her to put on his elbow pads. On 6/23/26 at 12:18 PM, V12 (Licensed Practical Nurse-LPN) said R82 is blind, he has a wound to his left elbow and should have a dressing in place. R82's Wound Physician Note dated 6/18/26 shows a stage 3 pressure wound to the left elbow measuring 1.1 cm (centimeters) x 0.5 cm x 0.1 cm with moderate serous drainage. Treatment plan includes apply calcium alginate daily with bordered foam dressing daily. Off load wound with elbow pads. The facility's Pressure Injury Prevention and Management Policy revised 4/2026 states, The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcer/injuries.

Based on observation, interview and record review, the facility failed to ensure a residents indwelling drainage bag was positioned below the level of the bladder to prevent the backflow of urine. This applies to 1 of 6 residents (R23) reviewed for catheters in the sample of 36. The findings include: R23's face sheet shows she has diagnoses including neuromuscular dysfunction of bladder, polyneuropathy, chronic kidney disease, personal history of urinary tract infections, and presence of urogenital implants. On 6/22/26 at 1:30 PM, R23 was sitting in her wheelchair. V13 and V34 (Certified Nursing Assistant-CNA's) transferred her from her wheelchair to her recliner chair using the mechanical stand lift. R23 requesting for her leg bag to be emptied. R23's leg bag was not positioned below the level of the bladder. The drainage bag was secured to the lower thigh, overlapping the kneecap and was not positioned downward. V13 emptied the urine into the urinal and did not secure the drainage cap. Urine was dripping down R23's leg. This surveyor asked V13 to check the cap. V13 said she closed the cap then stated, Oops, I thought it was closed. On 6/23/26 at 9:48 AM, V14 (CNA) said the CNA's change the urinary drainage bag to leg bags. Leg bags should be used for residents who are ambulatory. Drainage bags should be placed below the level of the bladder for the urine to drain and to prevent infections. R23's current care plan shows she has a activity daily living deficit related to absence of balance with non-ambulatory status. Her care plan also shows she has a indwelling urinary catheter related to urinary retention. Interventions include to position catheter bag and tubing below the level of the bladder. Her care plan shows she was treated for a Urinary Tract Infection on 5/1/26. The facility's Catheter Care Policy dated It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate treatment catheter care.leg bags may be used for ambulatory residents.leg bags will be attached to the residents thigh or calf making sure to have slack on the tubing to minimize pressure and retention.

Based on observation, interview and record review the facility failed to ensure staff knew how to appropriately respond, assess and address behaviors for residents exhibiting behavioral symptoms with a diagnoses of dementia. This applies to 3 of 6 residents (R72, R75 & R113) reviewed for dementia care in the sample of 36.The findings include:1. R113's face sheet lists her diagnoses to include: dementia and agoraphobia with panic disorder. She was admitted to the facility on [DATE] from home. R113 resides on a locked memory care unit. On 6/22/26 at 12:22 PM, R113 was wandering around the unit independently with no assistive devices. She went out a door at the end of one of the hallways. The door goes to another enclosed area that goes through another door to the outside. The outside is an area enclosed with a fence and another exit door with an alarm. She was adamant about going outside. Several staff members responded to the door alarm and were trying to get her back inside. R113 refused to come back inside. After a minute or two, R113 turned around and came back inside. She was very upset and getting aggressive with staff. V8 Registered Nurse (RN) went to get V3 Licensed Practical Nurse (LPN) to give R113 medication to calm her down. V8 RN then went back to R113 and was trying to get her to calm down and come with her, while V9 Certified Nursing Assistant (CNA) had a piece of paper and pen trying to get her to come with her to write down her complaints. V3 LPN then approached and was trying to help as well. R113 was getting more frustrated and upset, yelling, I don't have to f*****g do anything! She walked to the other hall and tried to exit that door but staff (V8 RN, V9 CNA) would not let her. She just wanted to go outside. After about 5 minutes she agreed to walk to the small dining room and sat down asking for water. She calmed down and drank some water. V3 LPN got R113's PRN (when needed) medication and tried to have her take it (once she was already calmed down) but R113 refused. V3 LPN stated, they try to re-direct her otherwise they just give her PRN medication hoping the medication would calm her down. They don't usually let her go outside or walk with her even though the area is available. V9 CNA stated, R113 is always trying to get out the doors. They just let the nurse know so they can give her medication. They don't go outside with her.R113's progress notes dated 6/22/26 shows, Data: I was told that R113 was on 4 hall trying to get out of the building. We tried to redirect and get her to come back down the hall. She was yelling at staff, and we could not distinguish what she was saying during her yelling. Action: We finally got her into the tv lounge on hall 1, she sat in a recliner and calmed down a bit She did refuse her PRN medications as well. Response: She did finally calm down and was no longer being verbally aggressive toward staff. R113's progress notes dated 6/20/26, 6/16/26 & 6/13/26 shows, R113 having aggressive behaviors and exit seeking. The interventions: PRN medications. R113's care plan dated 6/7/26 shows, Focus: R113 is an elopement risk/wanderer r/t (related to) disoriented. Interventions: disguise exits: cover door knobs and handles, tape floor, distract R113 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. R113 prefers (left blank and there is nothing listed), identify R113's triggers for wandering/eloping and what de-escalates behavior.R113's care plan dated 6/18/26 shows, Focus: R113 is/has potential to be verbally aggressive r/t dementia. Interventions: Identify R113's triggers for verbal aggression. Determine what R113 behaviors is de-escalated by, When R113 becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. 2. R75's face sheet lists his diagnoses to include: dementia and anxiety disorders. On 6/22/26 at 11:28 AM, R75 was sitting in the main dining room. V8 RN was heard in a loud stern voice saying, why did you do that?, stop doing that!, Don't do that. They need all new silverware now because of him. On 6/23/26 at 8:52 AM, V8 RN stated, R75 had taken all of the silverware off of the table and was wrapping them up in a napkin, sticking them in his shirt. He has these behaviors so she took the utensils and told the unit aide to get clean ones. R75's progress notes do not show, he had this behavior on 6/22/26. On 6/24/26 at 11:15 AM, V2 Director of Nursing (DON) stated, she knows you have to talk to him calm otherwise it will work him up more. R75's care plan does not address this specific behavior however a care plan dated 2/10/26 shows, Focus: R75 can be verbally and physically sexually inappropriate at times. R75 at times has a tendency to put small items in his mouth, nursing will monitor. Interventions: If reasonable, discuss R75's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R75. 3. R72's face sheet lists his diagnoses to include: dementia. He was admitted to the facility on [DATE] from home. On 6/22/26 & 6/23/26, R72 was wheeling himself around the unit. He was alert to himself only.On 6/22/26 at 11:27 AM, V35 R72's sister stated, she came into the facility to visit her brother. When she arrived to the unit, a staff member (V4 LPN) asked who she was there to visit. She responded R72 and V4 LPN stated, Oh well thank god, he's been wandering in and out of ladies rooms and trying to take his clothes off. We had to keep the other residents safe and put him in the room with the male nurse (V5 LPN). V35 found R72 sitting with V5 LPN and was very agitated and upset. She was able to get R72 to calm down. She reported the incident and filed a grievance. She was considered that the staff didn't have the training for people with dementia and felt like they were shocked he was wandering considering he has dementia. On 6/23/26 at 12:57 PM, V7 CNA stated, she was working the same night this incident happened. R72 likes to exit seek more on the PM shift. She didn't know exactly what happened but knows he tried hitting some staff and was being aggressive. V5 LPN told him loudly that he can't do that. He took R72 to the medication room with him. The sister came in right after and was upset. V7 CNA stated, she felt staff needed more dementia training and how to approach residents having behaviors. Yelling at them, telling them not to do something doesn't work for them. They need to try to offer ice cream, take him for a walk. She thought the way V5 LPN said that to R72 just escalated things and made him worse. On 6/23/26 at 1:42 PM, V5 LPN stated, R72 was being aggressive and wandering into female resident rooms. He brought him to the medication room with him to decrease the stimuli and get some work done. He stated, he believed he told R72 not to be hitting staff. R72's reaction to that was by hitting him. The sister came in a few minutes after he got him to the medication room. The grievance form dated 6/8/26 for R72 shows, When I arrived to visit R72 in the lobby a staff member asked me who are you here to visit. I said R72. She said Oh thank god, he's been going in and out of ladies rooms. He tried taking his cloths off. We told no you can't do that but he kept doing it so we had to protect the ladies and we put him n the room with the male nurse (med (medication) room?). I found him in a w/c (wheelchair) he was very upset trying to get out. He saw me and asked me to get him out of there. He was trying to stand so I asked about his walker. Female staff said we took it away he could fall on the slippery floors and he can't be going in the ladies rooms. I asked for the walker as he was trying to stand the female staff said to R72 use both hands to push up as he was holding the w/c one hand and walker the other but he was so worked up and up se he ws saying things to her to mind her own business and leave hi alone. She then said to the other resident there something about We have to keep you all safe from people like him. We went to his room and I was able to get him calmed down after about 20 min (minutes) and of course he forget it shortly after. My concern is that he was clearing sundowning yet the staff did not seem to know how to handle it. Do they not get special training? OT me they seemed to think he was just a difficult person that they did not have the time or patience to deal with him. He is easily distracted if you are calm and talk to him. They way the female staff member talked to me was [ineligible] very excitable frustrated and one and expressive action. I do not consider it abuse but proper training is questionable.The facility's follow up letter to V35 R72's sister dated 6/11/26 shows, Dear V35, In response to your grievance of June 8, 2026 regarding a nurse's approach to R72 during a sundowning period, thank you for brining this matter our attention. You stated when you entered the unit and identified yourself, a staff person blurted out some of R72's current behaviors and how she was managing them. This included removing his walker so he couldn't get in and out of resident rooms, and telling a female that she needed to be protected form him. You mentioned that you were able to calm him after about 20 minutes, that you did not think the staff was abusing, but appeared to be lacking the proper training to manager the situation. Your grievance was founded. We are hopeful that reminders to staff will resolve this matter, but will remain watchful on all shifts. R72's progress notes dated 6/8/26 shows, Resident wandering into female peers' rooms and undressing. Looking for his wife. Redirected and assisted. Became combative with this writer and team 2 nurse. Removed from stimuli and provided support. Sister arrived and provided comfort to resident who was looking for his wife. R72's care plan dated 6/16/26 shows, Focus: R72 has a behavior problem r/t facility. Interventions: caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by, 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, minimize potential for R72's disruptive behaviors by offering tasks which divert attention, provide a program of activities that is of interest and accommodates R72's status. On 6/24/26 at 11:15 AM, V2 Director of Nursing stated, the staff should be talking to all the residents in a calm, kind and gentle way is better than scolding them and making it worse. They haven't had a unit coordinator down there for about a month and they need one. There has been a few personality difficulties with staff since. The facility's dementia care policy dated 1/20/26 shows, Policy: It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or diagnosed with dementia, to meet his or her highest practical physical, mental, and psychosocial well-being. Definition: Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with variant symptomology and rates of progression. Policy explanation and complex compliance guidelines: .Care and services will be person-centered and reflected each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being. If needed, the environment will be modified to accommodate individual resident care needs.

Based on observation, interview and record review the facility failed to administer medications as ordered. There were 40 opportunities with 2 errors resulting in a 5% error rate. This applies to 2 of 6 residents (R113 & R120) observed in the medication pass. The findings include: 1. On 6/22/26 at 12:32 PM, V3 Licensed Practical Nurse (LPN) was giving R113 a PRN (when needed) anti-psychotic medication. She stated, R113 had home medications they were using. She pulled out a bottle from a local pharmacy with R113's name on it. The medication was for Seroquel 25 mg (milligrams). V3 LPN stated, R113's orders were for 50 mg so she would give her 2 tablets. She put 2 tablets in a medication cup. It was observed there were 2 different pills in the bottle. V3 LPN said she hadn't noticed that before. 1 pill was the pill that should be in the bottle. The other pill she wasn't sure of. She pulled her phone out and googled what the tablet was. Google showed, it was a Seroquel tablet. V3 LPN, ok she would give the medication because google confirmed it was Seroquel. R113's June MAR shows, Quetiapine fumarate (anti-psychotic) oral tablet 50 MG (milligram), give 1 tablet by mouth every 24 hours as need for agitation PRN for agitation at HS (hour of sleep). 2. On 6/22/26 at 11:57 AM, V3 LPN was giving R120 her noon medications. She was asked to inform this surveyor if she had already given something or would hold any medications. She gave her a Wellbutrin 75 mg tablet, Tylenol 500 mg tablet, metformin 500 mg tablet, a senna plus tablet, tramadol 50 mg tablet and 0.25 ml (milliters) of liquid lorazepam. V3 LPN, did not say she had already given R120 any medication or that she had any other medication due at that time. R120's June MAR shows the following medications due at 12:00 PM: Tylenol 500 mg, bupropion HCI (Wellbutrin) 75 mg, lorazepam 0.25 ml, metformin 500 mg, senna plus, tramadol 50 mg, voltaren external gel 1% to bilateral knees 4 times per day. She did not apply any voltaren gel to R120's knees. On 6/23/26 at 8:56 AM, V3 LPN stated, she had already gave the volatren gel prior to doing the medication pass. The facility's Medication administration policy dated 4/16/2000 and six shows, policy explanation and compliance guidelines: 10. Ensure that the six rights of medication administration are followed: a. right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation.

Based on observation, interview and record review the facility failed to ensure medication was labeled with an open date, discarded once expired and failed to verify a resident's home medications prior to use. This applies to 3 of 6 residents (R10, R113 & R131) reviewed for medication storage in the sample of 36. The findings include:1. On [DATE] at 12:32 PM, V3 Licensed Practical Nurse (LPN) was giving R113 a PRN (when needed) anti-psychotic medication. She stated, R113 had home medications they were using. She pulled out a bottle from a local pharmacy with R113's name on it. The medication was for Seroquel 25 mg (milligram). It was observed there were 2 different pills in the bottle. V3 LPN said she hadn't noticed that before. R113's folic acid and metoprolol mediation bottles also had 2 different pills in the bottles. V3 LPN stated, she was told to use R113's home medications until they were gone. Those were the medications she was using. R113's June MAR showed, a physician order for Seroquel 50 mg PRN, folic acid 1 mg, metoprolol 50 mg. 2. R131's long acting insulin pen was opened and being used. There was no open date on the pen. The insulin pen had a dispensed date of [DATE] on it. V3 LPN stated, insulin pens are only good for 28 days, it was probably expired and should be thrown away. 3. R10's short acting insulin pen was opened and dated [DATE] (more than 28 days). V3 LPN stated, the pen was expired and should be thrown away. Nurses are supposed to label the pens when they are opened so you know how long they are good for. The pharmacies med room/nursing station inspection reports for February and March of 2026 show, concerns with meds being used within expiration dates and not being labeled with open dates. These labeling of medications policy dated [DATE] shows, Policy: All medications used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy explanation and compliance guidelines: 1. All medications will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.

Based on observation, interview, and record review, the facility failed to ensure that staff followed infection prevention and control practices, including the use of personal protective equipment and hand hygiene, to prevent cross contamination for 1 of 36 residents (R6) reviewed for infection control in the sample of 36.Findings include:R6's Care Plan Report documents R6 is on enhanced barrier precautions related to Klebsiella Pneumoniae (bacteria in urine) and to ensure extra hand hygiene and cleaning of supplies.On 6/22/2026 at 1:08 PM, an Enhanced Barrier Precaution (EBP) sign was present outside of R6's room. V32 Certified Nursing Assistant transported a cart containing resident's meal trays into R6's room. While in R6's room, V32 touched R6's pillow, sheets and bed controls without wearing personal protective equipment. V32 then picked up a towel from the floor and placed it on the cart. The cart was subsequently wheeled out of R6's room and into the common area (where unit hallways meet) of the unit. V32 then removed another resident's (R70) meal tray from the cart and delivered it to R70. No hand hygiene was observed before or after contact with R6's environment, upon exiting the resident's room, or prior to handling R70's meal tray. No sanitization of the cart was observed.On 6/22/2026 at 1:25PM, V32 Certified Nursing Assistant states not knowing why R6 was on EBP. V32 confirmed that V32 brought cart containing meal trays into R6's room, touched R6's pillow, bedding, and bed controls, picked up a towel from the floor and placed on the cart and did not perform hand hygiene prior to providing R70's meal tray from the same cart. V32 stated that the cart should have remained outside of R6's room and hand hygiene should have been performed.On 6/24/26 at 9:30AM, V33 Unit Coordinator states that carts should remain outside of resident rooms with isolation precautions, that gloves should be worn when delivering resident trays as a precaution and hand hygiene should be performed upon exiting the resident room to prevent cross contamination. V33 stated that there are designated bins in the resident rooms to place linens and towels, and the towel should not have been placed on the tray containing resident meals.The facility's Enhanced Barrier Precautions (reviewed/revised 11/4/2025) documents implementation of enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms during high contact resident care activities that include handling linens.

Based on interview and record review the facility failed to ensure a resident was offered a maintenance ambulation plan for 1 of 3 residents (R2) reviewed for maintaining mobility in the sample of 3.The findings include:On 5/26/26 at 8:56 AM, R2 said staff did not assist him to walk in the hallways on 5/17/26. R2 added he tries to walk daily to maintain his ability to walk and staff should know he needed to be walked daily. R2's Care Plan with an initiated date of 4/23/26 showed R2 had limited mobility and the goal was for a maintenance ambulation plan to maintain the ability to walk. Floor staff were to offer ambulation assistance with walking the hallway once a day for 5-7 days a week. The same care plan showed R2 refused to use his call light to be assisted with walking. On 5/26/26 at 10:52 AM, V5 (Restorative Nurse) said R2's goal was to maintain his ability to walk. V5 said on 5/17/26 staff did not offer R2 his maintenance ambulation plan. V5 said V18 (Certified Nursing Assistant - CNA) was taking care of R2 and V18 was under the assumption R2 would ask to be walked. V5 confirmed R2 will not ask to be walked. V5 reviewed R2's Maintenance Ambulation Plan Task Documentation for 5/17/26 and said it showed R2 completed the task however that documentation was not correct. V5 said that it was the expectation for the day shift CNAs to offer to walk R2 daily and that did not happen on 5/17/26. V5 added the reason there was a range of 5-7 days a week in R2's mobility care plan was to account for R2's refusal to walk at times and the maintenance ambulation plan should be offered daily. R2's Task documentation for Day Shift Staff to Offer to Walk with R2 for 5/17/26 had a check mark under not applicable. R2's Mobility Maintenance Audit documentation indicated R2 did not walk on 5/17/26. R2's Progress Notes dated 5/21/26 showed on 5/17/26 R2 did not ask to be walked therefore V18 assumed R2 did not want to walk.

Based on observation, interview and record review the facility failed to ensure medications were given as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.The findings include:R1 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to unspecified psychosis, other specified depressive episodes.R1's November 2025 Medication Administration Record (MAR) documents an order for quetiapine (an antipsychotic medication) 12.5 mg (milligrams) in the morning. The MAR shows the medication was ordered and discontinued on 11/19/25. R1's progress notes show the power of attorney did not consent to the medication. R2's admission record shows she was admitted to the facility on [DATE]. R2's order summary sheet shows a 4/17/26 order for quetiapine 12.5 mg at bedtime related to generalized anxiety disorder. Her April 2026 MAR shows she began receiving the medication on 4/17/26. None of the doses were marked as not given or medication not available.The proof of delivery slip from the pharmacy shows R2's quetiapine tablets were not delivered until 4/26/26. The facility stock supply receipt for quetiapine shows only 1 dose was taken for R2 on 4/22/26On 5/13/26 at 9:00 AM, V4 (Licensed Practical Nurse-LPN) said he found a card of quetiapine for R1 in the medication cart with a note written by V3 (Unit Coordinator/Registered Nurse-RN) to use R1s card of medication for R2 until her supply came in from pharmacy. V4 said he removed the card and attempted to locate the house supervisor. When he could not find her, he turned the card into V1 (Administrator). V4 said as a nurse you are not allowed to use other residents' medications for someone else. V4 said the quetiapine is in the stock cubex it should have been used until R2's medication card came in from the pharmacy.On 5/13/26 at 11:12 AM, V1 stated she knew nothing about the card, and referred to the director of nursing.On 5/13/26 at 10:40 AM, V3 said she did recall the incident. R2's medication was originally ordered quetiapine 25 mg, and that was the same day her husband was being buried. We had to send her out to the hospital for anxiety, and we did not know if it was the quetiapine, or everything she had going on with her family. So we stopped the medication. Then a few days later R2 was insisting the medication helped her anxiety and wanted it back, so the Nurse Practitioner re-ordered the quetiapine at 12.5 mg. V3 said We sent it in (the prescription), the insurance said they were not going to send it, so we went several days without it, and she was not doing well. So, I grabbed the card (R1's) out of the return bin, and said it could be used until hers comes in. V3 said she should not have done that and was aware it is not the protocol. V3 said she did not think about checking the cubex to see if it was in stock.On 5/13/26 at 10:10 AM, V7 (RN) said resident cards can be changed for the time of day it may be given but it is never right to change the resident. It would not meet the criteria for the 5 rights of medication administration. Right medication for the right patient. V7 said all of the medication goes into the return bin to go back to pharmacy, you cannot use it for other residents.A photograph of R1s card for quetiapine shows his name crossed out and a note written by V3 stating Dcd (discontinued) for (R1) use for (R2) until hers comes in.On 5/13/26 at 11:15 AM, V2 (Director of Nursing) said no staff had reported an incident of medication cards being used for other residents. She said medication cards should only be used for the residents they are prescribed. V2 called the pharmacy to verify when R2's medication card arrived. The card arrived on 4/26/26. V2 reviewed the cubex report to see if any doses had been signed out. She said only one dose was signed out by V4 on 4/22/26. She said the other nurses should have been getting the medication out of the cubex.The facility's 4/16/26 policy for medication administration shows, 10. Ensure that the six rights of medication administration are followed: a. right resident b. right drug c. right dose 12. Compare medication source (bubble pack) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview and record review the facility failed to ensure a residents restorative walking program was followed. This applies to 1 of 3 residents (R1) reviewed for restorative services in the sample of 5. The findings include: On 4/20/26 at 8:42 AM, R1 was in his room sitting in his recliner chair. R1 said he's supposed to get walked twice a day. V12 (Former Restorative Aide) got fired a couple of weeks ago and she had been walking with him at set times 7:00 AM and 1:30 PM. R1 said he filed a grievance on 4/14/26 about not getting his restorative walking services. R1 said on 4/11/26 and 4/12/26 he did not get walked and staff did not offer to walk him. On 4/13/26 R1 said he did not get walked twice a day. R1 said he shouldn't have to complain to get things fixed, the staff should do what they are supposed to do. On 4/20/26 at 9:32 AM, V4 (RN) said R1 is supposed to get walked twice a day. There is no set time, once in the morning and once in the afternoon. The CNAs should be walking him, and nursing should remind the CNAs to walk him. If he refuses to walk the CNA should report his refusal to nursing. On 4/20/26, V1 (Administrator) said R1 filed a complaint about not receiving his walking program. V1 said she met with R1 on 4/15/26 regarding his concern. We did have a restorative aide, (V12) that was walking with him twice a day. That staff (V12) is no longer here. She spoke with R1 and explained the floor staff would be walking with him but could no longer have a set time. On 4/20/26 at 12:53 PM, V6 (Restorative Nurse) said R1 should be walked twice a day. The floor CNAs should be walking him. R1 wants a set schedule like before but we are no longer able to provide a set time. V6 said it's up to R1 and the CNA to decide when he gets walked. It's usually sometime in the morning and afternoon. If R1 refuses his walks it should be reported to the nurse and documented. On 4/20/26 at 1:49 PM, V1 said R1 was not wanting to walk with anyone when V12 was not here. V12 left on 4/8/26, she did not follow up with the CNA's on 4/11/26 and 4/12/26 when R1 alleged he did not receive his walks. It would have been V7 (Unit Coordinator RN) to follow up with the staff. On 4/20/26 at 2:18 PM, V7 (Unit Coordinator) said R1's restorative walking was a newer grievance. Now we don't have restorative staff, and the floor staff should be walking twice a day. V7 said R1 was not scheduled to receive his restorative services every other weekend. V7 said she did not follow up with the CNA's on 4/11/26 and 4/12/26 because he was not scheduled to get walked. V10 and V11 (Both CNA's) were assigned to him that weekend. On 4/20/26 at 4:10 PM, V10 (CNA) said she doesn't know who walks the residents that are on a restorative program. She thinks restorative walks the residents but I'm not sure. V10 said I have never walked (R1). I don't know who walks him. On 4/21/26 at 10:24 AM, V11 (CNA) said she is not sure who walks residents that are on restorative. She said she is newer to the facility and still learning how things work. V11 said she did not walk R1. R1's Restorative assessment dated [DATE] shows he is on walking program. R1's Task Report provided on 4/20/26 shows R1 will walk 50 feet in hallway or as tolerated with wheeled walker and staff providing standby assist twice a day through the next review, he prefers AM and afternoon. R1's Grievance form dated 4/14/26 documents nature of complaint: walking rehab schedule not being followed. R1's attached note states, I was not walked Saturday (4/11/26 or Sunday (4/12/26) .I need to know if my talking rehab is going to be taken care of or not.V1's email response dated 4/14/26 shows she will be following up with R1's concern regarding the walking program grievance. R1's walking program will be as followed: Nursing floor staff will be ambulating with him. It should be offered two times a day, we will not be given a set time or schedule for his walking. Resident refusals will be documented in the medical record. We will offer the ability to split up walking among more than just day shift. PM's and even nights could do the early morning before the end of the shift. R1's current care plan shows he has limited mobility related to lower extremity weakness and recurring wounds. R1's restorative ambulation program shows he will walk 50 feet in the hallway with wheeled walker and staff providing stand by assist two times a day through the next review date. Interventions updated on 4/14/26 show R1's preference to be walked twice a day in the AM and afternoon. If he refuses to walk inform the charge nurse and it must be documented ask other CNA's if they can walk with him. R1's progress notes reviewed from 4/11/26 to 4/12/26 did not show R1's refusals for walking.

Based on interview and record review the facility failed to care for and transfer a resident in a safe manner to prevent a resident injury for 1 of 3 residents (R1) reviewed for resident safety and supervision in the sample of 3. This failure resulted in R1 falling while being cared for by facility staff. R1 was hospitalized due to the fall where he was diagnosed with an unstable vertebral (spine) fracture. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards in his wheelchair, just after he was transferred into the chair, by facility staff. R1 began complaining of pain to his back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. On 2/3/26, R1 was emergently transferred to a local hospital, due to his worsening back pain, where he was diagnosed with a thoracic vertebral fracture. As of 2/5/26, R1 remained hospitalized due to his injury.R1's hospital CT scan (computed tomography scan) results dated 2/3/26 showed R1 sustained an acute fracture to his eighth thoracic vertebrae due to his fall on 2/1/26. The results showed, The findings are suggestive of a hyperextension injury and is considered an unstable fracture and recommended neurosurgical consultation.On 2/5/26, R1 could not be interviewed due to being hospitalized . R1's current care plan showed R1 was cognitively impaired. R1 was at risk for falls due to his impaired cognition, obesity, and impaired balance. On 2/5/26 at 10:15 AM, V7 Certified Nursing Assistant (CNA) stated she was providing cares to R1 at the time of his fall on 2/1/26. V7 CNA stated on 2/1/26, V7 and V8 CNA used a sit-to-stand lift (mechanical lift) to transfer R1 from his bed to his wheelchair. V7 stated V8 CNA left R1's room immediately after R1 was placed in his wheelchair. R1 remained attached to the sit-to-stand lift via a strap around R1's back as he sat in his wheelchair. V7 stated as she began to unhook/disengage the back strap from the sit-to-stand machine, R1 laid back in his wheelchair, causing R1's wheelchair to flip backwards onto the floor. R1 landed directly on his back. V8 CNA stated, I was unhooking the strap from the machine. The lift strap was still behind (R1's) back. No one was holding onto (R1) or his wheelchair. I don't know what happened. He all of a sudden just flipped back. On 2/5/26 at 12:33 PM, V3 Assistant Director of Nursing (ADON) stated two facility staff are to stay with the resident until the resident is completely unhooked from the sit-to-stand lift and securely seated in a wheelchair. V3 stated one staff member is to operate the stand lift while the second staff member makes sure the wheelchair and the resident remains steady until the stand lift is completely unhooked from the resident. It's done that way for safety reasons. On 2/5/26 at 12:10 PM, V13 Nurse Practitioner stated the expectation is that residents are cared for by staff in manner to prevent resident injury. The facility's Safe Lifting and Movement of Residents, Including Mechanical Lifts policy dated 4/12/2022 showed, Purpose: In order to optimize the safety and well-being of staff and residents, and to promote quality care, this facility will assess for and provide the most appropriate technique and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decision regarding the safe lifting and moving of residents. At least two (2) CNAs are required for mechanical lift and stand lift transfers to safely move resident.

Based on interview and record review the facility failed to effectively manage and treat a resident's pain after the resident fell in the facility. The facility failed to notify the attending physician/nurse practitioner of this resident's worsening pain. These failures apply to 1 of 3 residents (R1) reviewed for pain management in the sample of 3. These failures resulted in R1 experiencing worsening, severe lower back pain caused by a thoracic vertebral (spine) fracture he sustained when he fell in the facility. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards onto the floor while seated in his wheelchair as he was being cared for by staff. R1 fell directly onto his back. R1 began complaining of pain to his lower back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. On 2/3/26, R1 was transferred to a local hospital, due to worsening back pain, where he was diagnosed with a thoracic vertebral (spine) fracture. R1's hospital CT scan (computed tomography scan) results dated 2/3/26 showed R1 sustained an acute fracture to his eighth thoracic vertebrae due to his fall on 2/1/26. The results showed, The findings are suggestive of a hyperextension injury and is considered an unstable fracture and recommended neurosurgical consultation.R1's progress notes dated 2/1/26 were reviewed. At 1:54 PM, a note showed at 6:44 AM, R1 had fallen backwards onto the floor in his wheelchair. The note showed a facility nurse practitioner was notified via phone of R1's fall. R1's nurse practitioner (NP) ordered pain medication for R1. R1's February 2026 Order Summary Report showed a physician order, dated 2/1/26, that R1 was prescribed Tramadol (pain medication) 50 mg (milligrams) every four hours as needed for pain, after his fall in the facility. The report showed R1 was also received scheduled doses of Tramadol, three times a day. The notes showed no documentation of R1 being seen or assessed by a physician or nurse practitioner on 2/1/26. R1's progress notes dated 2/2/26 were reviewed. At 10:14 AM, a note showed R1 began complaining of increased back pain with movement. The note showed R1 yells when HOB (head of bed) is elevated or lowered or when staff assist with repositioning. R1's progress notes dated 2/2/26 showed no documentation that R1's physician or nurse practitioner were notified of R1's worsening lower back pain. The notes showed no documentation of R1 being seen or assessed by a physician or nurse practitioner on 2/2/26. R1's progress notes dated 2/3/26 were reviewed. At 3:59 AM, a note showed, Resident continues to have pain in the back from fall Sunday am. Slowly turn for pericare. At 7:29 AM, a note showed, Patient received in pain. Yelling out when staff attempts to provide cares. Refused shower this morning from staff. Patient states he hurts too bad. (V13 Nurse Practitioner/NP) notified regarding patient's condition. Stated she was on the way to the facility to assess if needing to send patient to ER (emergency room). At 11:25 AM, a note showed V14 NP and V5 (R1's POA) were also notified by staff of R1's uncontrollable pain. V5 requested R1 be sent to the hospital. R1 was sent to the hospital by ambulance. On 2/5/26, R1 could not be interviewed due to being hospitalized . R1's current care plan showed R1 was cognitively impaired. R1 was at risk for falls due to his impaired cognition, obesity, and impaired balance. On 2/5/26 at 10:34 AM, V9 Licensed Practical Nurse (LPN) stated she was the nurse caring for R1 when he fell on 2/1/26. V9 stated she immediately assessed R1 after his fall. V9 stated R1 had no complaints of pain. V9 stated when she reassessed R1 later on 2/1/26, R1 began complaining of pain all over. V9 stated R1's pain was not worse with movement. V9 stated she notified the nurse practitioner of R1's pain on 2/1/26. On 2/5/26 at 10:55 AM, V10 LPN stated she cared for R1 during the day shift on 2/2/26 and 2/3/26. V10 stated on 2/2/26 R1 was in pain. He stayed in bed. He would yell if we moved him because of his pain. His pain was in his back. He refused cares because he would be in pain if we tried to move him. V10 stated she did not notify R1's physician or nurse practitioner on 2/2/26 of R1's worsening pain with movement or that he was refusing cares due to pain. V10 stated on 2/3/26, (R1) was yelling out in his room due to his pain when I arrived for my shift that morning. You could hear him down the hall. No one was even touching him. I called the nurse practitioner to have him sent to the hospital. On 2/5/26 at 2:00 PM, V11 Registered Nurse (RN) stated she cared for R1 during the night shift on 2/1/26 and 2/2/26. V11 stated R1 complained of back pain and refused cares from staff because any movement made R1's pain worse. V11 stated she never called or notified R1's physician or nurse practitioner of R1's worsening pain or that he was refusing cares due to pain. On 2/5/26 at 12:35 PM, V14 NP stated the facility notified her of R1's fall on 2/1/26. V14 stated she was told by staff that R1 did not want to go to the hospital at that time so V14 ordered an X-ray of R1's lower back and increased the frequency of R1's pain medication (Tramadol). V14 stated the facility did not notify or inform her of R1's worsening back pain on 2/1/26 or 2/2/26. V14 stated she had not seen or examined R1 from 2/1/26-2/3/26. V14 stated, I was in the facility seeing other residents on Monday (2/2/26). I don't know why they (the facility) didn't call me to let me know about his pain. I would have gone to see him then. On 2/5/26 at 12:10 PM, V13 NP stated she was notified on 2/1/26 that R1 had fallen in the facility. V13 stated the facility did not notify or inform her of R1's worsening back pain on 2/2/26. V13 stated she did not see or examine R1 on 2/1/26 or 2/2/26. V13 stated, The facility called me on Tuesday (2/3/26) morning, telling me (R1) need to be sent to the hospital due to his pain. I got to the facility to see (R1) just as the paramedics were putting him on the cot. V13 stated facility staff should have notified her or V14 NP of R1's worsening pain on 2/1/26 and 2/2/26. V13 stated had known this information, she would have come in to assess (R1). Possibly changed his pain medications or treatment.On 2/5/26 at 9:31 AM, V5 (R1's POA) stated she was notified on 2/1/26 that R1 had fallen in the facility. V5 stated on 2/1/26, They told me (R1) did fall on his back in his wheelchair. I was told he was given pain medication. V5 stated the facility did not call her again on 2/1/26 or at any time on 2/2/26 to give her an update on R1. V5 stated on the morning of 2/3/26, she received a call from facility staff stating R1 was yelling out due to his back pain. V5 stated, Had I known he was in that much pain yesterday (2/2/26), I would have sent him to the hospital then. The facility's Pain Management policy dated 4/15/25 showed, (Facility) in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. If re-assessment findings indicate pain in not adequately controlled, the pain management regimen and plan of care will be revised as indicated.

Based on interview and record review the facility failed to ensure a resident's radiology studies (X-ray) were completed as ordered for 1 of 1 residents (R1) reviewed for radiology and diagnostic services in the sample of 3.The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards onto the floor while seated in his wheelchair as he was being cared for by staff. R1 fell directly onto his back. R1 began complaining of pain to his lower back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. On 2/3/26, R1 was transferred to a local hospital, due to worsening back pain, where he was diagnosed with a thoracic vertebral (spine) fracture. R1's progress notes dated 2/1/26 were reviewed. At 1:54 PM, a note showed R1 had fallen backwards onto the floor while seated in his wheelchair. R1's nurse practitioner (NP) ordered an X-ray of R1's lower back, to be completed in the facility, due to his complaint of pain from his fall.R1's physician order dated 2/1/26 showed a radiology order for R1 to have 2-3 views of the lower lumbar (back) area related to trauma/pain.R1's progress note dated 2/2/26 at 2:03 PM, showed, X-ray tech arrived to complete X-ray. Unable to complete due to weight concerns. Stated she will have to await an additional tech with board that would hold him (R1). The notes showed the X-ray staff never returned to the facility to complete R1's X-ray. R1's progress notes dated 2/2/26 showed no documentation that R1's physician, nurse practitioner, or V5 (R1's POA) were notified that R1's X-ray was not completed. R1's progress notes dated 2/3/26 showed R1 was sent to a local hospital for an evaluation due to his worsening back pain. R1's lumbar X-ray was never completed in the facility prior to R1 being sent out to the hospital.On 2/5/26 at 10:55 AM, V10 Licensed Practical Nurse (LPN) stated she provided cares to R1 on 2/2/26. V10 stated she did not notify V5 (R1's POA), V13 Nurse Practitioner (NP), or V14 NP that R1's X-ray was not completed on 2/2/26.On 2/5/26 at 9:31 AM, V5 (R1's POA) stated the facility did not notify her until 2/3/26 that R1 had never received his lumbar X-ray. On 2/5/26 at 12:35 PM, V14 Nurse Practitioner (NP) stated facility staff did not inform her until the morning of 2/3/26, right before R1 was sent to the hospital, that R1 did not receive his X-[NAME] 2/5/26 at 12:10 PM, V13 NP stated she was notified on 2/3/26 that R1 did not receive his X-ray as ordered. V13 stated staff should have notified her on 2/2/26 that R1's back X-ray was not completed in the facility. V13 stated had known this information, she would have looked into him getting his X-ray done somewhere else. The facility's Diagnostic Testing Services policy dated 6/30/25 showed, (Facility) will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines.

Based on interview and record review the facility failed to follow their policy and procedure for bed bug prevention and management. This failure resulted in bed bugs being found in R2 and R3's shared room. This failure applies to 2 of 3 residents (R2 & R3) reviewed for bed bugs in the sample of 4.1. The Progress Notes dated 7/4/2 for R2 did not show any documentation regarding bed bugs being found in his room, and care and/or procedures done related to the bed bugs.On 7/15/25 at 9:02 AM, V1 Administrator stated if the facility suspects or see any bed bugs, they try to capture the bug for the exterminator. The exterminator is called. The room is checked. The resident is removed from the room. Everything is bagged and the room is taped off. The bathroom is taped off from the inside if it's connected to an adjacent room. V1 stated maintenance calls the exterminator; the facility uses pest control company B. The facility also uses pest control company A and they have a dog that is able to detect bed bugs in a facility. V1 stated on 4th of July she received a picture of a bed bug from V15 Nursing Supervisor. V1 stated she told V15 to remove the residents from the room, give them a shower, bag the belongings, leave the belongings in the room, keep the bug, and have maintenance seal off the room. V1 stated that families of the residents affected by the bed bugs were notified. V1 stated the facility did not send out notification to all family members of residents on the dove unit. V1 stated everything should have been documented in the residents' chart including the showers, room change, notification etc. V1 stated she told staff they were to notify the family/power of attorney about the bed bugs. On 7/15/25 at 9:19 AM, V3 Director of Nursing stated their policy after a bug is found is to call the exterminator, have the area treated, and have housekeeping do a deep cleaning after treatment. One bug was found last week then someone said they found another one. V3 stated she went to check, and she found two more bed bugs in R2's bed. V3 stated she placed the bugs in a cup, the exterminator was called, and the room was resealed. All the belongings had been bagged. Laundry and housekeeping oversaw that. V3 stated the affected residents' families were to be notified of the bed bugs and room change. On 7/15/2 at 9:34 AM, V5 Maintenance Director stated on Saturday (7/5/25) V22 maintenance employee taped the room off. V5 stated he called pest control company B on Saturday, but they don't come out on weekends. On Monday he called them again and the facility was placed on the list for treatment. On 7/15/25 at 10:02 AM, V6 Power of Attorney (POA)stated she was called by the facility and they stated R2 was moved because they were doing something to his room and that i was under maintenance. They did not notify her that there were bed bugs in his room and that was the reason for a move to a different room. V6 stated she is the power of attorney and stated that her mother did not receive a call regarding bed bugs. V6 stated when she went to see him on 7/8/25 none of his stuff had been moved to his new room. V6 stated she did not know why they did not tell her the truth and she was frustrated because she doesn't know anything.On 7/15/25 at 10:55 AM, V3 DON stated she did not know when the residents were moved. The family/POA should have been notified and it should be documented in the chart. Showers are documented on shower sheets. Staff should document what they are doing, should notify the family, tell them we are moving, and why we are moving to be transparent. Staff should and let them know how we are handling/eradicate it, and the timeframe when they can go back to their room etc. On 7/15/25 at 10:58 AM, V1 stated she talked to V10 RN because she was the nurse that documented in residents record that families were called about the room change. V10 stated she didn't tell the families because maintenance didn't have confirmation that it was a bed bug. V1 stated the facility should have called the POA/family of the residents on 7/9/25 when they had confirmation of the bed bugs. V1 stated the residents were showered on 7/4/25 and moved to a new room on 7/5/25. The Skin Check Note dated 7/5/25 at 9:22 PM for R2 showed, skin issues note small red marks noted to left lower extremity, hip, and thigh.The Communication Note dated 7/5/25 at 9:56 AM for R2 showed the power of attorney was called and notified that R2 would be moving to room [ROOM NUMBER] for maintenance. No additional Progress and/or Communication Notes were documented from 7/5/25 to the date of the survey on 7/15/25 that showed the POA was notified of the bed bugs in R2's room. R3's Progress Notes from 7/6/25 through the survey investigation date of 7/15/25 did not show the power of attorney was notified that bed bugs were found in R3's room.The Census List for R2 dated 7/15/25 showed on 7/5/25 he was moved from 395-1 to 350-1.The Face Sheet for R2 dated 7/15/25 showed diagnoses including Alzheimer's disease, hyperlipidemia, dementia, hearing loss, hypertensive heart disease, gout, osteoarthritis, and benign prostatic hyperplasia. The facility's Bed Bug Prevention and Management policy (7/8/25) showed, facility staff will implement measures to prevent, eradicate, and contain bed bugs as part of the facility's overall pest control program. 1. The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests, and prevention of recurrence. 3.e. Document in the medical record for each resident affected: Physician and family notification. Intervention and treatments. Notifications regarding any room changes. Response to treatment, and any monitoring efforts. 4. Eradication of pests: a. If a bug is found that meets the description of a bed bug, maintenance will notify pest control company for verification and eradication. B. [NAME] personal protective equipment, including gown, gloves, mask, hair, and shoe coverings. C. Check resident rooms adjacent to the room in which the bug was found. Check at night with a flashlight when bed bugs are most active. d. Tightly bag belongings, do not remove items or furniture from room. i. remove resident from room, shower, and get clothing from storage. ii. Place resident in a new room until treatment is completed. 5. Prevention of Recurrence: b. Monitor for bed bugs. Consider increase in housekeeping/cleaning efforts during this timeframe. c. Consider sealing cracks and crevices to remove hiding places. d. Follow up on treatment in the recommended timeframe. e. Maintain documentation of actions taken for treatment, eradication, and prevention.2. The Progress Noes dated 7/4/25 for R3 did not show any documentation regarding bed bugs being found in his room, and care and/or procedures done related to the bed bugs. The Skin Check Note dated 7/5/25 at 6:19 AM showed, resident had a shower today; scattered red marks noted on the top of his head, left hip, and right lower extremity.The Progress Notes/Communication Note dated 7/5/25 for R3 showed the power of attorney was called and notified that R3 would be moving to room [ROOM NUMBER] temporarily for maintenance. She advised the pacemaker (transmitter for pacemaker) was in the windowsill. This writer notified staff to move pacemaker (transmitter) to room [ROOM NUMBER]. On 7/15/25 at 11:35 AM, V7 POA stated she was not told R3 was moved because of bed bugs. V7 stated she was told they were doing some thins to his room and he would be moved back eventually. R3's Progress Notes from 7/6/25 through the survey investigation date of 7/15/25 did not show the power of attorney was notified that bed bugs were found in R3's room.The Census List for R3 dated 7/15/25 showed on 7/5/25 he was moved from 395-2 to 350-2.The Face Sheet for R3 dated 7/15/25 showed diagnoses including Alzheimer's disease, abdominal aortic aneurysm, hypercholesterolemia, cataract, anemia, macular degeneration, hypertensive and chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, sarcopenia, ataxia, cardiac pacemaker, and dementia. The Care Plan dated 6/6/25 for R3 showed he requires moderate to extensive assistance for bathing, showering, bed mobility, dressing, personal hygiene, and toilet use.The facility's Bed Bug Prevention and Management policy (7/8/25) showed, facility staff will implement measures to prevent, eradicate, and contain bed bugs as part of the facility's overall pest control program. 1. The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests, and prevention of recurrence. 3.e. Document in the medical record for each resident affected: Physician and family notification. Intervention and treatments. Notifications regarding any room changes. Response to treatment, and any monitoring efforts. 4. Eradication of pests: a. If a bug is found that meets the description of a bed bug, maintenance will notify pest control company for verification and eradication. B. [NAME] personal protective equipment, including gown, gloves, mask, hair, and shoe coverings. C. Check resident rooms adjacent to the room in which the bug was found. Check at night with a flashlight when bed bugs are most active. d. Tightly bag belongings, do not remove items or furniture from room. i. remove resident from room, shower, and get clothing from storage. ii. Place resident in a new room until treatment is completed. 5. Prevention of Recurrence: b. Monitor for bed bugs. Consider increase in housekeeping/cleaning efforts during this timeframe. c. Consider sealing cracks and crevices to remove hiding places. d. Follow up on treatment in the recommended timeframe. e. Maintain documentation of actions taken for treatment, eradication, and prevention.

Based on observation, interview, and record review the facility failed to provide timely incontinence care for one of one residents (R83) reviewed for activities of daily living in the sample of 43. Findings include: R83's face sheet printed 4/10/25 showed diagnoses including but not limited to mental disorders due to known physiological condition, chronic kidney disease stage 3, malnutrition, palliative care, insomnia, anxiety, and irritable bowel disease. R83's facility assessment dated [DATE] showed severe cognitive impairment and total to substantial staff assistance needed for toileting hygiene, personal hygiene, dressing, and transfers. The same assessment showed R83 is always incontinent of urine and bowel. The assessment showed R83 is at risk for skin breakdown. On 4/8/25 at 10:34 AM, V17 (Certified Nurse Aide) entered R83's room and said the resident was asking to be changed. V17 said she was not assigned to the hall, but answers call lights whenever she sees them on. V17 said she did not know when R83 was last checked or changed for incontinence. V17 removed R83's bed linens and said these are all wet. V17 opened R83's incontinence brief and it was completely saturated through with urine. The thick blue pad under R83 was saturated. The bed sheet under the pad had a three-foot-wide urine ring on it. The bed alarm safety pad under the sheet was completely saturated. The mattress under the alarm pad was also saturated with urine. V17 said everything is so wet with urine that she needs a complete bed change now. R83 was lightly moaning and stated she was cold and uncomfortable. R83 was questioned regarding when she was last changed and said it was long ago so she could not remember. V17 stated the aides check all incontinent residents every two hours or more. V17 said it is not appropriate that R83 is so saturated. This should have been noticed sooner. There are some newer staff and they may not know to check her often. At 10:54 AM, V4 (Registered Nurse) entered the room to provide medication. V4 said R83 just came to the unit from the other side of the building. Staff are still getting familiar with her needs. V4 said incontinent residents have the potential for the development of moisture associated skin disorders, wound development, and urinary tract infections. R83's care plan showed a focus area related to ADLs (activities of daily living) initiated dated 3/24/25. Interventions included staff to check, change and complete peri/incontinence care upon waking, before & after meals, before bed, during the nighttime bed checks, per her request, and as needed. On 4/9/25 at 2:41 PM, V3 (Director of Nurses) stated residents are at risk for skin breakdown and infections if they are left in urine. They should be checked a minimum of every two hours. It is a dignity issue too. They should be changed right away. There is no reason someone should be found soaked with urine. Staff are not checking enough if they are so wet they need a complete bed change. The facility's Activities of Daily Living policy dated 3/24/25 states under the guidelines section: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling and fracturing her left hip. The findings include: R1's Face Sheet (Admission Record) showed an admitted [DATE] with diagnoses to include dementia, depression, and left femur fracture (admitting diagnosis). R1's 3/19/24 Significant Change Assessment Minimum Data Set (MDS) showed severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. The MDS showed she was dependent upon staff for transfers from bed to chair transfers and she had not walked. The MDS showed she used a wheelchair for mobility and bed/chair alarms were used daily. R1's Progress Notes showed the following fall events: On 4/29/24 at 1:16 PM, .[R1] was laying towards her right side in front of her w/c (wheelchair) . On 4/26/24 at 4:42 PM, CNA (Certified Nursing Assistant) yelled out for help for fall resident observed on the floor sitting on the floor . On 3/29/24 at 12:25 PM, Resident in nursing station after eating lunch with husband. She attempted to stand up, w/c moved back and she slid off to the floor . On 1/17/24 at 2:00 PM, Reported to nurse that patient was observed sitting on the floor in another resident's bathroom . On 1/15/24 at 4:00 AM, Observed resident sitting on the floor in an upright position . On 1/1/24 at 3:20 AM, .observed resident sitting on floor next to floor mat with legs straight out . On 12/18/23 at 1:20 PM, Resident has been self-transferring and standing up frequently, doesn't follow directions, propelling self on w/c . resident observed on the floor . R1's 5/8/24 Event Note from 5:30 AM showed, Resident observed sitting on floor with her back against another resident w/c (wheelchair) while other resident sitting in w/c. Resident stated that she didn't hit her head. No pain noted. Resident stated that she was just getting up. House supervisor notified, resident assessed, ROM wnl (Range of Motion within normal limits) The note showed vital signs and a neurological assessment was completed. The not continued, Resident c/o (complains of) discomfort to left hip post fall . The note showed the provider was notified and an Xray was ordered. R1's 5/9/24 Left Hip Xray showed an Acute (sudden onset) acetabular and left inferior pubic ramus fractures (fractures of the pubic bone where the hip connects to the pubic bone.) . The facility's staff schedule showed V6 CNA and V4 Licensed Practical Nurse were working the third shift on 5/7/24 for R1's unit. On 5/14/24 at 11:05 AM, V6 stated he was doing rounds early morning on 5/8/24. V6 stated R1 was awake and sitting at the edge of the bed so he toileted her and got her ready for the day. V6 said, .once she's up she likes to stay up . V6 said he transferred R1 to her wheelchair and brought her out the nurses' station. V6 said he left R1 at the nurses' station and went down the hall to speak with V4. V6 said two to three minutes later he heard a resident yelling out at the nurses' station, so he investigated. V6 said R1 was sitting on the floor with her back resting on another resident's wheelchair. V6 said, There was no alarm in her wheelchair at that time. I didn't realize she was supposed to have one .Supposedly she had a chair alarm, and it was left in the recliner . V6 clarified the recliner was at the nurses' station and the night prior and the staff member who transferred R1 out of that recliner did not place the chair alarm in the wheelchair. V6 said, after the fall, R1 was transferred to the wheelchair and approximately 30 minutes later she began to complain of pain to the left hip. V6 said, The purpose of the chair alarm is to alert the staff that someone is trying to get up. It is true, a chair alarm might not prevent a fall. It might prevent a fall if we can get there quick enough. V6 stated the supervisor who responded to the fall was V11 RN. On 5/14/24 at 12:58 PM, V4 stated she was R1's third shift nurse beginning on 5/7/24. V4 stated, the morning of 5/8/24, she heard another resident yelling at the nurses' station and R1 was found sitting on the floor with her back resting against another resident's wheelchair. V4 stated R1 did not have a chair alarm in her wheelchair; it was in the recliner. V4 said, It was supposed to be in the wheelchair. When the CNA got her up, I don't think he realized it wasn't there. The purpose of the chair alarm is to alert us the resident is getting off the pad or let us know they are getting up. The chair alarm gives us a heads up that someone is trying to move just so we know if they are moving. On 5/14/24 at 11:30 AM, V11 Part-time House Supervisor stated she responded to R1's fall. V11 said, while she was filling out the fall report, .I got to the alarm part, and I asked CNA was the chair alarm sounding? Because I didn't understand what took so long for them to respond if they were responding to a resident screaming instead of the alarm and the CNA said the alarm was in the recliner. I asked was it was supposed to be in the wheelchair, and they said yes. By the time I looked at the wheelchair, they had put the alarm in the wheelchair. The purpose of the chair alarm is to let us know when someone is starting to get out of the chair. It should alarm as soon as their butt gets off that pad so we can start moving toward the resident right away. Chair alarms don't always prevent a fall, but they can give us a couple of extra seconds to respond to a resident to get them to sit back down before they fall. We generally have fewer staff on third shift, so I would say those alarms are even more important on third shift than other shifts because, if they only have two CNAs for four halls, they can't be everywhere, so it helps them to respond when a resident is getting up. On 5/14/24 at 2:06 PM, V2 Director of Nursing stated the purpose of chair alarms is to reduce the risk of falls to the resident. They help by giving the staff a heads up that the person is trying to get up and they can attempt to intervene. [R1] should have had a chair alarm that morning when she fell . On 5/14/24 at 1:14 PM, V12 Nurse Practitioner stated she was on-call when R1's Xray results became available. V12 said she does not know R1's history; however, the fractures she sustained are fractures I see after someone has a fall. On 5/14/24 at 1:20 PM, V13 Medical Director/R1's provider stated the fractures R1 sustained are .typical and most common after a fall . V13 stated R1's fractures were a result of the fall and most likely and undiagnosed condition of osteoporosis (weakening of the bones). R1's Care Plan showed, [R1] is at risk for fall r/t (related to): confusion, weakness, incontinence, Poor communication & comprehension, Impaired physical mobility, unaware of safety needs & her own risk factor, hx of fall, behavior of self-transferring without assist, aggressive behaviors towards the staff when redirected, impulsive behavior . The care plan showed the following intervention, Chair alarm when up in chair/wheelchair. Date initiated 12/15/23. R1's April and May 2024 Medication Administration Record showed pain assessments were completed every shift (every 8 hours). Except for one pain assessment in April 2024, R1 did not have documented pain during these shift assessments until after her fall on 5/8/24.

Based on observation, interview, and record review the facility failed to identify a pressure injury prior to becoming a deep tissue injury, failed to obtain treatment orders for a new pressure injury, and failed to implement pressure relieving interventions for a resident with multiple pressure injuries for 1 of 7 residents (R117) reviewed for pressure injury in the sample of 31. These failures resulted in R117 suffering a deep tissue injury to the right heel, a Stage 2 pressure injury to the right buttock, and a Stage 1 to the left lateral ankle. The findings include: R117's face sheet showed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of fracture of the right femur, weakness, polyneuropathy, heart failure, foot drop of the left and right feet, and chronic obstructive pulmonary disease. On 03/05/24 at 12:21 PM, R117 was in a wheelchair in his room. There were ace wraps to both legs and feet. R117 had black shoes on his feet and his feet were on the foot pedals. V15 Certified Nursing Assistant-CNA and V12 CNA transferred R117 from the wheelchair to bed using a mechanical lift. R117 grimaced in discomfort during the transfer and his right leg rotated internally. V12 stated he fractured his right hip about 2 months ago and doesn't think he had surgery. V12 and V15 discussed if heel boots should be on when he was in the chair or in the bed. They were uncertain. At 2:21 PM, V41, R117's son in law stated R117 fell at home on 2/4/24 and fractured his right hip. V41 stated R117 was not a candidate for surgery to repair the fracture due to the location of a plate in his leg. V41 stated R117 did not have any skin breakdown at the time of admission and cannot lift his leg. 03/06/24 12:25 PM, V2 Director of Nursing- DON stated if a new skin condition is found the nurse should obtain treatment orders and notify the provider and family. Pressure interventions should be put into place as soon as we can but getting a treatment started is more important. The provider determines if the resident is referred to wound care. It's important that interventions are in place to avoid new injury and prevent worsening of current pressure wounds. On 3/5/24, this surveyor requested to observe R117's wounds with wound rounds on 3/6/24. On 3/6/24, R117's wound round was completed when this surveyor arrived at the facility. On 3/6/24, this surveyor asked V42 wound doctor to speak with this surveyor when his rounds were done and before he left the facility. V42 left the facility without speaking to this surveyor. At 1:08 PM, V2 assisted to observe R117's right heel wound. R117 was in bed with heel boots on, and both feet resting on the mattress. The offloading pillow was on the floor. V2 asked staff why the heels were not offloaded; they responded because he was eating. R117's right lateral heel had a non-blanchable red purple irregularly shaped area approximately the size of a quarter. On 3/7/24 at 10:00 AM, V17 Unit Coordinator and V18 Registered Nurse-RN assisted to observe R117's left lateral ankle wound. R117 was in a wheelchair in his room. R117 had bilateral foam heel boots on with both feet resting on the foot pedals of the chair. There were inflatable boots with the heels open on the top shelf of the closet. V17 said those were from the hospital. R117's left foot was positioned outward allowing the left lateral ankle to rest on the heel boot. The left lateral ankle had non-blanchable red-purple area approximately the size of a dime. R117's (late entry) skin concern notes effective 3/4/24 at 1:16 PM showed discoloration to bilateral heels. This note showed to float heels when in bed, ace wraps to bilateral legs, apply in the morning and remove at night, medical doctor will be in the facility tomorrow to assess wounds and power of attorney gave consent for wound care to follow. R117's 3/4/24 wound weekly observation tool showed a right heel suspected deep tissue injury measuring 3 centimeters (cm) X 4 cm. Float heels in bed/chair, wound care to see 3/6/24. R117's wound doctor notes showed no mention of the heel wound being assessed. The note showed a Stage 1 pressure injury to the left lateral ankle measuring 2.5 X 0.6 cm and a Stage 2 pressure wound to the right upper medial buttock measuring 0.9 X 1.1 X 0.1 cm. This note showed to offload the wounds. A 3/5/24 nursing note showed the medical doctor ordered heel lift boots while in wheelchair and a wedge when in bed. R117's physician order sheet printed 3/6/24 at 1:10 AM showed orders dated 3/5/24 to float heels while in bed at all times and heel lift boots while up in wheelchair for pressure relief. An order for a gel dressing to the right upper medial buttock was ordered on 3/6/24 and to start on 3/8/24. An order for skin prep to the left lateral ankle was dated 3/6/24 and to start 3/8/24 (wound found 3/4/24). There were no treatment orders for the heel wound found 3/6/24 until 3/7/24. The facility's 4/12/2021 Pressure Ulcer Prevention Policy showed interventions necessary to maintain skin integrity or promote healing will be incorporated into the plan of care based on each resident's individual needs and risks. This policy was less than a page and a half in length. Additional pressure injury policies and/or procedures was requested twice, and none was received. The facility's 10/12/2023 Wound Treatment Management Policy showed wound treatments will be provided in accordance with physician's orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record. R117's 2/9/24 pressure injury risk assessment showed he was bedfast and completely immobile (does not make even slight changes in body or extremity position without assistance). R117's care plan showed impaired mobility related to cognitive loss, incontinence, pain, visual deficit, inconsistent motivation to participate in his care, and required hands on assist with repeated verbal directions to participate in and to complete bed mobility and repositioning. R117's care plan showed he required assistance from 2 staff members using a total mechanical lift for all transfers, was non-weight bearing and non-ambulatory. R117's 2/9/24 care plan showed a closed right hip fracture related to a fall. The 2/16/24 potential for pressure development related to decreased mobility care plan was updated 3/4/24 to show 2 new bilateral heel deep tissue injuries. Interventions dated 3/5/24 showed to apply heel lift boots and off load heels while in bed. R117's 2/15/24 facility assessment showed severe cognitive impairment and bilateral lower extremity range of motion impairment. This assessment showed dependence for toileting, bathing, lower body dressing, putting on and taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed.

Based on observation, interview, and record review the facility failed to identify decreased food intake for residents and implement interventions to prevent a significant weight loss for 2 of 6 residents (R50 & R87) reviewed for nutrition in the sample of 31. These failures resulted in a 5% weight loss in one month for R50 and R87. The findings include: 1. On 3/5/24 at 10:03 AM, R50 was in bed with the head of her bed raised. R50 had her tray table in front of her with her breakfast tray sitting on it. R50 had a sausage patty, hardboiled egg, roll, french toast, water, and chocolate milk. The french toast was cut in half and did not have any syrup on it. R50 picked up the hardboiled egg, looked at it and sat it back down on the tray table. R50 did not eat any of her breakfast. R50 was talking gibberish to herself and when asked questions. No staff were observed assisting R50 with breakfast. On 3/5/24 at 1:06 PM, R50 was sitting in her bed with the head of her bed elevated. R50 had her tray table in front of her with her lunch sitting on it. R50 had au gratin potatoes, broccoli, cake, beef a Roni, water, and juice. R50 did not eat any of her food; lunch was served at around 12:15 PM. R25 CNA (Certified Nursing Assistant) came into the room to assist R50's roommate and stated R50 hasn't been eating but will drink her fluids and then left the room. The Care Plan dated 2/7/24 for R50 showed, R50 has an ADL (activity of daily living) self-care performance deficit related to cognitive loss, episodes of impaired balance, resistive with staff during care, bi-lateral lower extremity edema, incontinence, alteration in endurance, new to facility, and requires repeated verbal directions, coaxing, encouragement and hands on assist to participate in and to complete daily care and tasks. Eating: R50 is able to feed herself after staff assist with set up of meal. Provide finger foods when R50 has difficulty using utensils. Provide milkshakes or liquid food supplements when R50 refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. R50 has potential nutritional problem. Provide, serve diet as ordered. Monitor intake and record every meal. Registered dietician to evaluate and make diet change recommendations as needed. The Nutrition/Dietary Note dated 2/15/24 for R50 showed, Diet: Regular with regular texture and thin liquids. Per Nursing notes, resident requires cues and intermittent 1:1 assist to stay on task with meals. The weights for R50 documented in the electronic medical record as of 3/6/24 showed on 2/1/24 her weight was 163. 4 pounds and on 3/1/24 her weight was 152.4 pounds. R50 had an 11-pound weight loss in one month = 6.7% weight loss. On 3/6/24 at 3:30 PM, V40 RN (Registered Nurse/Unit Coordinator) stated, significant weight changes come up in the weights section of the computer charting. V40 stated they meet every Thursday for a meeting to discuss weight changes. V40 stated she did want to get a re-weigh for R50 to see if the weight was accurate. V40 stated if there was a weight loss the doctor and power of attorney would be notified. V40 stated she would discuss the weight change with the registered dietician, and she will see the resident and make recommendations. V40 stated she believes R50's weight is accurate because she looks like she has lost some weight. Staff should be encouraging her to eat. V40 stated she thinks R50 might be needing more help and that it hasn't been brought to her attention yet by staff. V40 stated if a resident refuses to eat staff can offer a supplement, come back later, and try to get the resident to eat, and try to find out why the resident is not eating. V40 stated that no one has said anything to her about R50 not eating. On 3/7/24 at 8:37 AM, V23 CNA (Certified Nursing Assistant) stated, if the resident is not eating, we will let the nurse know. We assist if they need help eating. If not eating with assistance, then let nurse know. V23 stated she would offer the resident something else like fruit or if they can tell her what they want she will get that. V23 stated they can offer supplement shakes. V23 stated if there were a big weight change for a resident, she would let the nurse know. On 3/7/24 at 9:18 AM, V20 RD (Registered Dietician) stated she is at the facility 8 times per month so usually twice per week on Mondays and Thursdays. V20 stated she was on vacation and had V21 RD filling in for her remotely this last Monday. V20 stated she typically is the one that goes through the weights to look for weight changes. V20 stated the facility has weekly weight meetings and will bring stuff to her attention as well. V20 stated she printed off a list of residents and weight concerns from home and circled the residents that she needs reweighs on and have questions about. V20 stated she would talk to the unit coordinator to see if they thought the weights in question were legitimate or not. V20 stated V21 listed R50 as needing to be re-weighed on Monday (3/4/24) to make sure the weight was accurate. As of last night (3/6/24) she did not see that R50 had been reweighed. V20 stated typically when she asks for a reweigh, she would have to wait for the new weight to know if it is accurate before she makes recommendations. V20 stated if the reweigh is not in there then apparently nothing was done. V20 stated she would have looked through R50's notes to see if she was refusing to eat and/or not feeding herself. If R50 was not feeding herself then staff could assist her. Staff could do verbal cueing. V20 stated she would expect a note in R50's chart saying she prefers liquids over food. V20 stated if the staff know R50 is declining in eating then they should be there to assist the resident with eating and verbal cues. V20 stated R50 eating in her room alone would not be good; it would be better to be out at a table. The Nutrition/Dietary Note dated 3/7/24 at 9:49 AM for R50 showed, RD Weight Review; Principal diagnosis: unspecified dementia, severe, with other behavioral disturbances. Comfort care in place & do not hospitalize per family preference. Notified of reweigh per unit coordinator of 154.2#. Weight reflecting a significant weight loss of 5.6% (9.2 pounds) x/times 30 days. Meal intake remains variable, however, appears to have declined. Per records, resident requires cues and intermittent 1:1 assist to stay on task with meals. Noted Resident was fed per staff times 1 meal on 2/10, 2/17, 2/18, 2/29 & 3/2 per records. No labs to review. Discussed weight loss with unit coordinator and she will notify the power of attorney and primary care physician. Unit coordinator reports resident likes milk and has been taking fluids well. Will recommend supplement shakes twice a day to assist with calorie & protein needs. Monitor acceptance of supplement. Continue to cue & assist resident at meals as needed. Recommend weekly weight monitoring. Monitor intake & weight. The Face Sheet dated 3/8/24 for R50 showed medical diagnoses including unspecified dementia, severe, with other behavioral disturbance, macular degeneration, history of anxiety disorder, hypertension, unspecified psychosis, polyneuropathy, hypothyroidism, hypercholesterolemia, vitamin D deficiency, and gastroesophageal reflux disease. 2. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed on 2/1/24 his weight was 202.6 pounds and on 3/1/24 his weight was 186 pounds. R87 had a significant weight loss of 16.6 pounds in one month that equals and 8.2% weight loss. The Face Sheet dated 3/7/24 for R87 showed diagnoses including alzheimer's disease, muscle weakness, protein-calorie malnutrition, generalized arthritis, hypertension, vitamin D deficiency, mixed hyperlipidemia, bilateral hearing loss, atherosclerotic heart disease, paroxysmal atrial fibrillation, cerebrovascular disease, gastro-esophageal reflux disease, benign prostatic hyperplasia, and type 2 diabetes mellitus. The Progress Notes from 2/1/24 through 3/7/24 at 8:57 AM did not show any documentation related to R87's weight loss. The Nutrition Intake Documentation for R87 from 2/7/24 through 3/6/24 showed staff documented the resident ate 76-100% of his meals except for 3 meals where he ate 51-75%. On 3/7/24 at 8:41 AM, R22 LPN (Licensed Practical Nurse) reviewed R87's weights in the electronic medical record and stated usually when the weight loss is like R87's the dietician will come in and see the resident, have the resident re-weighed and go from there. R22 stated R87 eats really well and usually has a weight gain. R22 stated she was not aware of R87's weight loss and would have him re-weighed. On 3/7/24 at 8:59 AM, V3 RN (Registered Nurse/Unit Coordinator) stated they have meetings every week about weights. V3 stated that the dietician was on vacation. V3 reviewed R87's weight in the computer and stated he is going to have R87 re-weighed because doesn't think the weight is accurate. V3 stated R87 usually eats great and has no eating problems that he is aware of. V3 stated the dietician goes through the building. There is a meeting that the unit coordinators go to, to talk about weight losses and gains. They re-weigh residents if needed. V3 stated if the documented weight is something ridiculous then it is brought to his attention. V3 stated R87's weight loss was kind of ridiculous. The Weights and Vitals Summary Sheet dated 3/7/24 for R87 showed at 10:56 AM he was re-weighed, and his weight was 186.4 which was a 16.2-pound weight loss. This was an 8% significant weight loss in one month from his 2/1/24 weight of 202.6 pounds. The Care Plan dated 1/25/24 for R87 showed R87 is able to feed himself independently, staff assist with set up as and if needed. R87 has a potential nutritional problem related to his weight being higher than recommended for his height. Monitor intake and weight. Monitor/record/report as needed any signs/symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, and >10% in 6 months. The Nutritional Management policy (10/12/23) showed, the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Care Plan implementation: Interventions will be individualized to address specific needs of resident. Examples include but are not limited to iii. Weight related interventions; iv. Environmental interventions; vi. Physical assistance or provision of assistive devices. The physician will be notified of i. significant changes in weight, intake, or nutritional status Nutritional recommendations may be made by dietician based on resident's preferences, goals, clinical condition, or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated.

Based on observation, interview, and record review the facility failed to provide the necessary care and services for a resident with a dislocated shoulder for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. This failure resulted in resident (R1) waiting approximately 12 hours to be transferred to the hospital for acute intervention of a dislocated shoulder. The findings include: On 11/22/22 at 11:21 AM, R1 was observed in a wheelchair at the dining room table with a sling on her right shoulder. R1's right arm was immobilized by the sling. R1 stated she went to the bathroom, washed her hands, and when she came out of the bathroom, she couldn't lift her arm. R1 stated the Certified Nursing Assistant (CNA) was in there with her and nothing happened. R1 stated she didn't fall or bump anything with her arm. R1 stated Oh my God yeah was it painful, the pain was a 10. They told me I had to wait for the X-ray. I had to wait a long time. Why they didn't send me sooner is a good question. I had to wait for X-ray in all that pain. I couldn't lift my arm. On 11/22/22 at 11:45 AM, V4 CNA stated R1 was in the hall in her wheelchair and told her Oh my arm hurts. V4 stated R1 told her that her arm was out of the socket. V4 stated R1 was putting pressure on her right shoulder with her left hand to try to relieve the pain. On 11/22/22 at 12:35 PM, V6 CNA stated she took R1 to the bathroom in the morning and nothing happened out of the ordinary. V6 stated after she wiped R1, pulled up R1's pants, assisted R1 to sit and then R1 washed her own hands in the sink. V6 stated 10-15 minutes after this, R1 was complaining that her arm hurt, and she couldn't lift it. V6 stated she left at 2:00 PM and R1 was still waiting for her X-ray and kept saying she couldn't lift her arm. On 11/22/22 at 1:09 PM, V7 Registered Nurse stated R1 came out into the hallway and said she couldn't move her arm. V7 stated R1 told her this happened to her before when she lived at home. V7 state she asked the CNA what happened and was told nothing happened during care. V7 stated she did an assessment and R1 could squeeze with both hands, but when she barely touched R1's right arm, she cried out Ouch. V7 stated she was unable to do range of motion or any further assessment on R1's right arm due to pain. V7 stated she called the Nurse Practitioner (NP) and relayed her findings. V7 stated the NP ordered and X-ray of the shoulder. V7 stated she called and ordered the X-ray to be done that day. V7 stated R1 acted normal unless R1 tried to move her arm and then she had pain. V7 stated she gave R1 her morning scheduled pain medication and did give R1 Tylenol later on in the afternoon. V7 stated when she left for the day the X-ray still had not been done. V7 said R1 kept her arm by her side and was not moving it. V7 stated had R1 been screaming or looked like she was in agony, I would have sent her out. On 11/22/22 at 1:16 PM, V8 NP stated she received the call from the nurse about R1's shoulder dislocation. V8 stated the nurse did tell her about R1's history of R1's shoulder popping out, R1's pain with palpation, and that the nurse was not able to do a further assessment due to R1's pain. V8 stated she ordered a STAT X-ray to determine if the shoulder was dislocated. V8 stated she didn't receive any results from the X-ray during the rest of her shift, the next NP on call received them. V8 stated if she would have received the results, she would have sent R1 to the ER/emergency room . R1's Minimum Data Set, dated dated dated [DATE] shows R1 is cognitively intact. R1's Progress Noted dated 11/19/22: At 8:35 AM, shows resident in hallway, sitting in her wheelchair, yelling out I can't lift my right arm, nurse noted hand grasps strong and equal, attempt to check range of motion (ROM), resident yelled out when nurse held wrist, refused ROM, stated it hurt when she tries to lift her arm. No distress noted with rest, no movement to right upper extremity (RUE), resident stating my shoulder is out of socket, I have to go get it pushed back in like before at the hospital, it happened like that when I lived in town. Resident states she was in the bathroom with CNA without any problems .sat back into her wheelchair, washed her hands, came out of her room and noticed she could no longer lift her RUE. Resident denies injury .states it just happened. At 8:49 AM, shows resident states she is unable to lift RUE, has pain when she tries. Message for on call NP. Awaiting call back. At 9:03 AM, shows V8 NP returned call, reported residents' complaint, and nursing assessment to RUE. New order received, 2 view X-ray to right shoulder, portable. At 9:10 AM, shows spoke with X-ray service, set up portable X-ray for today. At 4:00 PM , shows X-ray of right shoulder taken, 2 views. Resident continues to complain of pain and inability to raise her harm. She is able to move her hand and fingers .Medication given for pain. At 6:55 PM notified family of dislocation and they want her sent to hospital for evaluation and treatment. At 8:30 PM, (approximately 12 hours after the injury was reported) shows transferred by stretcher to local hospital. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Radiology Report Shoulder Complete, Right dated 11/19/22 at 5:00 PM shows acute anterior medial dislocation involving the humeral component of the reverse total shoulder arthroplasty. On 11/22/22 at 12:48 PM, V2 Director of Nursing stated if the X-ray is taking too long, they can call back and check the status. V1 Administrator stated she was aware of R1's incident and the ordered X-ray. V1 stated I do agree, it was a long time to wait for the X-ray and they could have sent R1 out without the X-ray or an order. On 11/22/22 at 1:45 PM, R1 stated they should have sent me out to the hospital sooner, it was something else. The pain got worse thru the day. They told me I had to have an X-ray before I go. Now my arm only aches once in a while, I have to follow up with the doctor on Monday. R1's Hospital After Visit Summary dated 11/19/22 shows you were seen .shoulder injury Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER]

Complaint Investigation 89/IL 1 Based on observation, interview, and record review the facility failed to supervise a resident at high risk for falls for 1 of 6 residents (R1) reviewed for falls in the sample of 6. The facility failed to ensure fall interventions were in place for 3 of 6 residents (R2,R3, R5) reviewed for falls in the sample of 6. This failure resulted in R1 being found on floor in an unsupervised area and sustaining a [CONDITION(S)] requiring 5 staples. The findings include: 1. On 9/22/22 at 10:13 AM, R1 was sitting in her wheelchair at the nurse's station. R1 had a 4 cm laceration to the right posterior side of her head with 5 staples visible. V4 Licensed Practical Nurse (LPN) stated R1 is at high risk for falls, she is one of my star pupils, you have to watch her. R1 has Dementia and thinks she is at work and when she's done working, it's time to leave and she tries to get up. R1 will get antsy and try to stand up and with her Parkinson she is shaky. R1 has had falls the most recent was Tuesday night (9/20/22). She fell and was sent out and got 5 staples in the back of her head. R1 has a clip alarm and a sensor alarm, and we put her at the nurse's station for close monitoring. On 9/22/22 at 11:40 AM, V3 Assistant Director of Nursing (ADON) stated R1 tries to get up and down from the chair, mostly on the PM shift. V2 Director of Nursing (DON) with V3 stated R1 had a fall on 7/23/22, 8/12/22, and 9/20/22. V3 stated after R1's 7/23/22 fall, R1 already had bed/chair alarms in place, bolsters to the bed were added, toileting before bed was added, and 4 months of R1's blood pressure readings were sent to the doctor for review. V3 stated after the 8/12/22 fall, they added a tab alarm and close monitoring (keeping R1 at the nurse's station). R1's Fall Huddle shows R1 had an unwitnessed fall on 7/23/22 where R1 was found sitting on the floor in her room, a witnessed fall on 8/12/22 where R1 stood up from her wheelchair and fell , hitting her head and sustaining a Hematoma on her right forehead, and an unwitnessed fall on 9/20/22 where R1 was found on the floor at the nurse's station with a laceration to her head. R1's Fall Risk Evaluation date 8/12/22 shows R1 is at risk for falls and has intermittent confusion, 1-2 falls in the past 3 months, and has decreased muscular coordination and a balance problem while walking. R1's Care Plans shows R1 has diagnoses of history of falling, Unspecified Dementia, Psychotic disturbance, Mood disturbance, Anxiety, and Meniere's disease. The same Care Plan shows R1 is at risk for falls related to cognitive loss, impaired balance, incontinence, impaired visual status, unaware of her risk factor or safety needs, hospice care for declining condition, history of falls, and requires repeated verbal directions and hands on assist to complete bed mobility, transfers, ambulation, re-directions and locomotion. On 9/22/22 at 12:32 PM, V7 Certified Nursing Assistant (CNA) stated on 9/20/22 R1 was at the nurse's station table, herself and the nurse (V6 LPN) were sitting there charting. V7 stated R1 sometimes tries to stand up and was at the nurse's station to be watched. V7 stated she answered a call light down the hall. V7 stated a residents [CONDITION(S)] bag had broken for the second time that night and she called V6 to come to the resident's room to change it (leaving R1 alone at the nurse's station). V7 stated there was a big mess, with the [CONDITION(S)] and V6 was occupied for a long time in that resident's room. V7 stated V6 finished up and left the room and she continued to clean up the resident. V7 stated when she left the room and went to the nurse's station, R1 was on the floor and V6 was holding her head and stated he found R1 on the floor. V7 stated there was another CNA working with them (V9) but she did not see her before going to the residents room and was not sure where V9 was during that time. V7 stated neither herself nor V6 heard any alarms while in the resident's room with changing/cleaning the [CONDITION(S)]. On 9/22/22 at 1:23 PM, V9 CNA stated on 9/20/22, R1 was at the nurse's station with V7. V9 stated she informed V6 that she was going to take her break and then left the floor. V9 stated when she returned from break, R1 was bleeding, and she was told R1 had fallen. V9 stated R1 was at the nurse's station to be watched, R1 is a well-known fall risk and tries to get up. On 9/22/22 at 11:56 AM, V5 Nurse House Supervisor stated he works the PM shift and sees R1 with behaviors of standing up and R1 talks about going home. V5 stated R1 is on close monitoring which is when they try to have someone near her at all times. V5 stated he was working on 9/20/22 and was notified when R1 fell that night. V5 stated when he went down to that unit, he saw R1 with a laceration on the top right side of her head and recommended R1 be sent to the hospital. On 9/22/22 at 1:30 PM, V2 stated close monitoring is keeping the resident in common areas, nurses' station, or a high visibility area where staff are within eyesight of the resident. V2 stated R1 was on close monitoring. On 9/22/22 at 1:59 PM, V3 stated if residents are at the nurse's station for close monitoring and the staff has to step away, they should get someone to watch those residents and not leave them unattended. V3 stated it is not an ideal situation to leave the resident alone at the nurse's station with no way to call for staff assistance. R1's Progress Notes dated 9/20/22 at 8:15 PM, shows resident involved in an unwitnessed fall in the day room, hit back of her head, has a 4 cm gash that was bleeding. Resident is conscious, appears to be in pain. Sent out to the hospital. R1's After Visit Summary from the hospital dated 9/20/22 shows Reason for visit: Fall, Diagnoses: Head injury, scalp laceration, and Done Today: laceration repair staples. R1's Progress Note dated 9/21/22 at 12:05 AM, shows returned from hospital, 5 staples to posterior head. 2. On 9/22/22 at 9:05 AM, R2 was observed sitting in a reclining wheelchair in her room by herself eating breakfast. R2 had an alarm hanging on the back of the wheelchair. The cord that connects the sensor pad to the alarm was not plugged into the alarm box. R2's Minimum Data Set (MDS) dated [DATE] shows R2's cognition is moderately impaired. R2's Care Plan dated 7/22/22 shows R2 is at risk for falls related to impaired balance, impaired visual status, poor safety awareness and is dependent on staff for transfers and locomotion. This same Care Plan shows R2 has an intervention of Chair alarm when up in chair/wheelchair, staff will check placement and function. 3. On 9/22/22 at 9:12 AM, R3 was observed sitting in her wheelchair at the dining room table. R3 had an alarm on the back of her wheelchair. The cord that connects the sensor pad to the alarm was not plugged into the alarm box. R3's MDS dated [DATE] shows R3 is cognitively impaired. R3's Care Plan dated 9/8/22 shows R3 is at risk for falls related to unaware of safety needs at times, history of falls prior to admission, limited mobility, alteration in endurance, cognitive loss and requires verbal directions and hands on assist for transfers and locomotion. 4. On 9/22/22 at 10:14 AM, R5 was observed sitting in her wheelchair with a chair alarm hanging on the back of the chair. The chair alarm box was not flashing green. V4 LPN stated the chair alarms are working when the sensor pad is plugged into the box and the light is flashing green. V4 looked at R5's alarm and stated it was not working for some reason, the light is not on. R5's Care Plan shows R5 is at risk for falls related to forgetfulness, impaired balance, and requires assist from staff for mobility, transfers, and ambulation. This same Care Plan shows an intervention of a chair alarm and for staff to check placement and function each shift. The facility's Fall Reduction Program Policy shows It is the policy of this facility to have a fall reduction program that promotes the safety of residents in the facility assigned nursing personnel; are responsible for ensuring that the ongoing precautions are put in place and consistently maintained the use of alarms require on-going monitoring to determine functionality; alarms shall be checked for placement every shift and functioning to be tested .

Based on interview and record review the facility failed to ensure fall prevention interventions were implemented for a resident at risk for falls for 1 of 28 residents (R59) reviewed for safety and supervision in the sample of 28. This failure resulted in R59 falling and sustaining a fracture of her femur that required surgical repair. The findings include: R59's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired and requires extensive assistance of two persons for toilet use. R59's Fall Risk Evaluation dated 2/4/22 shows that she is at high risk for falls. R59's Incident Report dated 3/13/22 at 8:50 AM shows that she had an unwitnessed fall in the bathroom. R59's Incident Report dated 3/14/22 at 9:30 AM shows, Resident was assisted to toilet, CNA (Certified Nursing Assistant) stepped out of room for 1 min (minute), nurse heard w/c (wheelchair) moved, observed pt. (patient) sitting on floor, back resting on toilet, w/c on left side, legs extended in front of her, continues with pain the LLE (Left Lower Extremity). Denies hitting her head, resident still needing care, was barefoot, no pants or brief, CNA coming back to give care Nurse asked her if she tried to walk to her bed she stated, That's what I'm saying, help me go to bed, please, ma'am. On 5/17/22 at 2:12 PM, V13 (Licensed Practical Nurse) stated that R59 fell and sustained a fracture. Since R59 has returned to the facility, she does not want to move and requires a mechanical lift for transfers. On 5/17/22 at 2:24 PM, V14 (Restorative Nurse) stated that she is not sure what interventions were put in place after R59's fall on 3/13/22 to prevent future falls. V14 stated that if a resident has had a fall in the bathroom, the staff should not leave them alone in the bathroom in the future to prevent any future falls. V14 stated that R59 was at risk for falls before her fall on 3/13/22. V14 stated that maybe the CNA was not aware that she fell the day before in the bathroom. V14 stated that if a resident is at risk for falls and is left unsupervised in the bathroom, they could fall. On 5/18/22 at 10:35 AM, V14 stated that a person who is confused and has a history of an unsafe self-transfer should not be left in the bathroom alone. R59's left femur x-ray from 3/15/22 shows that she had an acute spiral fracture of the distal femoral shaft with proximal/medial displacement. R59's Hospital Notes dated 3/15/22 shows, [R59] is an [AGE] year-old female with Dementia-who presented to the emergency room earlier this afternoon after a fall at her nursing facility onto her left side. She was brought to the ER (emergency room ) with severe pain and unable to ambulate Assessment/Plan: Closed left distal femur fracture consulted ortho trauma surgery tentatively scheduled for 12:30 PM . R59's Physician's Notes dated 3/28/22 shows, 'A few weeks ago patient had a fall complicated by right hip/leg pain; she was sent to the ER, and she was diagnosed with right femur fracture; patient was seen by ortho, and they treated her with IMN (Intramedullary Nailing). Since coming back, patient has been sleepier, and her appetite has declined; she spends most of her time in the bed . R59's Fall Care Plan shows that she is at risk for falls related to cognitive loss, alteration in endurance, impaired balance, incontinence, weakness and closed spiral distal femur fracture with proximal medial displacement, history of falls, not always cooperative with staff, unaware of her own risk factors and is dependent on assist from staff to complete bed mobility, transfers and locomotion. No fall interventions were added to her care plan after her fall on 3/13/22. The facility's Fall Reduction Program revised on 4/12/21 shows, Safety interventions will be determined and implemented based on the assessed, individualized risks and in accordance with standards of care; interventions to be documented within the resident's care plan. Assigned nursing personnel are responsible for ensuring that the ongoing precaution(s) are put in place and consistently maintained per the individuals plan of care Attempts shall be made to implement new or modified interventions as needed to enhance safety and consistent with root cause analysis; new interventions to be communicated to the facility staff through revision of resident care plan on profile to maintain continuity of care Residents who require staff assistance will not be left alone after being assisted to bathe, shower or toilet if resident is not able to maintain proper sitting balance or determined to be at risk of unassisted transfer.

Based on observation, interview, and record review the facility failed to ensure a resident's fall interventions were in place for a resident who is a high risk for falls. This failure resulted in R1 sustaining a fall with a right elbow fracture. This applies to 1 of 4 residents (R1) reviewed for falls in the sample 7. The findings include: R1's incident report dated March 25, 2020 documents R1 was sitting upright in her wheelchair in the TV lounge room. V17 (LPN) turned away and went and into a room across from the TV lounge area .a thump was heard by V17. R1 was found lying on the floor on her left side. R1's left arm was out in front of her, her right arm was pinned under her body. Blood was rapidly pooling under her head. R1 stated, She bend over and boom. R1 sustained a laceration to the head and a right elbow fracture. On August 25, 2020 at 3:15 PM, V17 (LPN) said on March 25, 2020, R1 was in her wheelchair in the TV lounge room after the dinner meal. V17 said she gave R1 her medications and turned her back and went into another resident's room and then heard a thump. R1 was on the floor. V17 said R1 had a history of [REDACTED]. V17 said R1 was not showing signs of behaviors at this time so she did not tilt R1's wheelchair. On August 26, 2020 at 8:45 AM, V19 (Rehab Coordinator) said after a resident falls the resident's care plan is updated with new fall interventions. V19 said R1 has a history of falls and R1's care plan was updated in February after she fell out of her wheelchair. V19 said R1's care plan was updated for her reclining chair to be in a tilt position to prevent her from sliding out. V19 said she inspected R1's reclining chair after she fell on [DATE] and discovered the hydraulics' to tilt the wheelchair were not working properly. V19 said they replaced R1's wheelchair after the incident. The Physician order [REDACTED]. R1's Minimum Data Set assessment dated [DATE] shows her cognition is impaired. R1's Fall Risk assessment dated [DATE] shows she is a high risk for falls. The nurse's note on March 26, 2020 by V19 (Rehab Coordinator) documents she spoke with the unit coordinator and checking R1's wheelchair. R1's wheelchair has the ability to tilt the pelvis but there is something wrong with the chair that makes it extremely difficult to complete this. V19 informed the unit coordinator of this and also the chair needed to be replaced related to the defect. R1's care plan shows she was at risk for falls, related to incontinence, absence of balance, visual deficit, non-ambulatory status, weakness, cognitive loss and history of falls. R1's interventions include to keep her reclining chair in a tilt position while she is up in chair (created on February 4, 2020). The facility Falls and Falls Risk Management Policy with a revision date May 2020, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling, or to minimize complications from falling.

Based on interview and record review the facility failed to ensure a resident, on a mechanical soft diet, was given a sandwich prepared in the consistency to meet her needs. This failure resulted in R1 choking and her subsequent death. This failure resulted in an Immediate Jeopardy (IJ). The IJ began on (MONTH) 4, 2019 when R1 choked on a peanut butter and jelly sandwich which was not prepared to the consistency required by R1's mechanical soft diet. R1 expired prior to reaching the hospital. On (MONTH) 17, 2019 at 9:55 AM, V1 Administrator was informed of the Immediate Jeopardy regarding R1's choking incident. While the immediacy was removed on (MONTH) 17, 2019, the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of revised policies, procedures, and staff education. This applies to 1 of 3 (R1) residents reviewed for therapeutic diets in the sample of 3. The findings include: R1's Electronic Face Sheet showed [DIAGNOSES REDACTED]. R1's (MONTH) 5, 2019 MDS (Minimum Data Set) showed her to have moderate cognitive impairment and to require extensive assistance of one person for eating. R1's (MONTH) 2019 physician's orders [REDACTED].>R1's Care Plan revised on (MONTH) 5, (YEAR) showed, .Speech therapy has determined that mechanical soft is the safest consistency for her. R1's Care Plan Intervention revised on (MONTH) 11, (YEAR) showed, Provide and serve diet as ordered: CCHO/Mechanical Soft/ Thin liquids. ½ portions. R1's (MONTH) 29, (YEAR) (Approximately one year ago) Event Note from 6:40 PM showed that a family member informed a nurse that R1 was choking. The note continued, This writer responded quickly, took a few steps and observed (R1) with her hands near her throat, mouth open, and unable to breathe. Face was starting to turn red. R1 chest thrust completed and airway was cleared. Loud gasping noise when airway was cleared. Stated that she was choking on a small piece of grilled cheese and she couldn't breathe . R1's (MONTH) 30, (YEAR) Physician Communication note showed an order for [REDACTED].>R1's (MONTH) 10, (YEAR) Speech Therapy Treatment Encounter Note showed, R1 had a cough x2 during a regular solid meal and Mechanical soft solids remain most appropriate diet for (R1) at this time . R1's Speech Therapy Discharge Summary dated (MONTH) 16, (YEAR) showed the discharge reason to be: highest practical level achieved. The summary showed a LTG (long term goal): (R1) will tolerate safer and least restrictive diet to meet nutrition and hydration needs without s/sx (signs/symptoms) of aspiration. The long term goal showed that diet to be mechanical soft solids and thin liquids, no s/sx of aspiration. On (MONTH) 5, 2019, the facility reported to the Local Health Department a new choking incident and subsequent death involving R1. This incident occurred on (MONTH) 4, 2019 at approximately 6:00 PM. The facility's Follow-up report regarding the incident showed R1 began choking while eating peanut butter and jelly sandwich; the [MEDICATION NAME] maneuver removed small amounts of food; and the resident was transported to a local area hospital. The report showed R1 was pronounced dead at 6:25 PM on (MONTH) 4, 2019. The facility's investigation showed a statement from V9 CNA (Certified Nursing Assistant), which stated, I was feeding (R1). She began to choke, (I) called (the) other aide to let her know. The investigation also showed a statement from V10 CNA that she was feeding another resident and V9 was feeding R1 and R1 began to choke. On (MONTH) 14, 2019 at 2:35 PM, V10 stated, Me and V9 were feeding residents on (the memory care unit) in the bigger dining room. When I was feeding (another resident), V9 was feeding (R1) and she (R1) started choking. (R1) wasn't responding so we called (V11, Registered Nurse RN) at the nurse's station and (V6, RN). V10 said R1 lost consciousness and was lowered to the floor where abdominal thrusts were continued. V10 said, I would say peanut butter and jelly is okay for mechanical soft. It doesn't have to be altered in any way. I would have made it for her. There are some peanut butter and jelly on the line, if not, we make it. We keep peanut butter and jelly on the unit and that's how I would have made it. The peanut butter and jelly sandwiches from dietary are normal peanut butter and jelly sandwiches; they are not altered in anyway. So whether I got one off the cold line or made one, it's all the same. On (MONTH) 14, 2019 at 1:00 PM, V6 Registered Nurse said a CNA told her a resident was choking and when I got to her I asked her (R1) if she was choking and she shook her head yes. She was in a wheelchair so I put her hands on her abdomen and pushed in and up while she was in wheelchair. She lost consciousness so we lowered her to the floor, she became limp. It did not appear she was exchanging any air. V6 stated she believed peanut butter and jelly sandwiches was acceptable for residents on a mechanical soft diet and the peanut butter and jelly sandwiches that dietary brings to meals are not altered in any way. V6 stated, Following a mechanical soft diet, makes it easier for them to swallow, not following it can make it more likely for them to choke. On (MONTH) 14, 2019 at 10:04 AM, V9 stated, R1 did not want the chili served that evening. V9 said, so I got her a peanut butter and jelly sandwich. I got the peanut butter and jelly sandwich for her, I made it. I got two to three packs of jelly and I got the peanut butter out of the jar of peanut butter, it was just regular creamy peanut butter. I made the sandwich like I would for my kids. By the third bite I told the CNA (V10) I thought she (R1) was choking so I had her get the nurse. The nurses came immediately. She looked like she wasn't breathing. V9 continued, There are some premade sandwiches. There is nothing special about them, they are for the diabetics to have snacks later on in the night if they need a snack. She (R1) could eat whatever she wants. I don't know if she was mechanical soft or not, I think she was regular (diet). On (MONTH) 14, 2019 at 11:13 AM, V4 Registered Dietician stated, We have a diet manual that specifies what a mechanical diet is. V4 stated that residents on a mechanical soft diet can have a peanut butter and jelly sandwich; however, the peanut butter has to be blended with the jelly. V4 said, According to our manual making it with peanut butter then jelly on top would not meet the dietary manual standards or consistency for mechanical soft. In my opinion, peanut butter by itself, the tackiness of it, it can get balled up. When it's (peanut butter) mixed with the jelly it makes it thinner. V4 stated the staff should know the peanut butter and jelly sandwiches provided by dietary are altered but with the turnover they may not know. The CNA's should know to ask what the diet is, you should always check if you don't know. On (MONTH) 14, 2019 at 1:34 PM, V12 Dietary Manager stated, the dietary staff blend the peanut butter and jelly together and make all of the peanut butter and jelly sandwiches for that day. V12 stated the sandwiches are delivered to the units with lunch and supper. V4 said, We offer the peanut butter and jelly sandwiches as the alternate if they are on a mechanical soft diet. We make meat sandwiches as well and if the meat is not mechanically altered they should get the peanut butter and jelly. The staff should know the peanut butter and jelly sandwiches are altered. It's altered as a precaution. R1's Death Certificate shows the cause of death to be [MEDICAL CONDITION] and the date and time of death to be (MONTH) 4, 2019 at 6:27 PM. On (MONTH) 14, 2019 at 3:15 PM, V5 Family Nurse Practitioner stated, For someone with a history of choking who was seen by speech therapy and had a recommendation for mechanical soft diet, the diet is important to prevent further episodes of choking. I do expect my orders to be followed including diet orders. V5 said, I signed her (R1) death certificate. They don't want you to write choking as the cause of death you have to write what actually happened. The choking lead to her [MEDICAL CONDITION] .choking is what caused her death as far as I can tell. The facility's Long Term Care Diet Manual Edition (YEAR) for Dental Soft (Mechanical Soft) Diet showed, the Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods .This Diet may also be used by a Speech Language Pathologist in the treatment of [REDACTED].sticky .foods The policy showed, Smooth peanut butter mixed with adequate amounts of jelly, honey or syrup is allowed. Through observation, interview, and record review the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: 1. Peanut butter was removed from units. Only premixed peanut butter and jelly will be provided to units. Completed [DATE]. 2. Similar food items were also removed from units until in-servicing completed. Completed [DATE] 3. All facility staff were in-serviced on properly serving altered foods, drinks, and how to identify and kind of altered diet; such as reading type of diet on tray card, cross referencing speech therapy recommendations in a binder on each neighborhood dining room and where binders are located. Staff also in serviced on safety monitoring of dining rooms during meal times. Completed [DATE]. 4. All staff not in serviced will be removed from the schedule until education completed. Completed [DATE]. 5. Nursing staff, including all CNAs have been in-serviced on how to identify residents who have altered food and drink. Completed [DATE]. 6. On [DATE] Dietician initially conducted a mass in-service for dietary department reviewing methods of preparing all altered diets including mechanical soft and pureed diets. Ongoing in-servicing was completed by certified dietary manager. All staff no in-serviced will be removed from the schedule until education is completed. 7. Nursing staff have been in-serviced on mealtime and dining room supervision/monitoring protocols. All staff not in serviced will be removed from the schedule until education completed. Completed [DATE]. 8. Dietary staff have been in-serviced on the proper method of preparing puree and mechanical diets. All staff not in-serviced will be removed from the schedule until education completed. Completed [DATE]. 9. Binders of residents at risk for swallowing difficulties or any speech therapy recommendations have been placed in each dining room. Unit coordinator/house supervisors will be responsible to assure that binder is updated with all speech therapy recommendations. Completed [DATE]. 10. All current agency staff have been given an orientation checklist and education with the instructions for safety supervision of all dining rooms and altered consistency diets. Completed [DATE] and ongoing. 11. Future agency staff will be required to be given an orientation and checklist with instructions for safety supervision of all dining rooms and altered consistency diets. Completed [DATE]. 12. Audit of all resident diet orders has been done, confirming diet orders are consistent with physician orders. Completed [DATE]. 13. Q.A. audit sheets have been given to all department heads and being completed every shift to ensure staff understanding of dietary requirement regarding altered diets and dining room supervision. Completed [DATE] and ongoing. 14. An emergency Q.A. meeting was held with the Medical Director (via telephone), Nurse Practitioner, Administrator, DON, ADON, Unit Coordinators, Therapy Director, MDS coordinators, Restorative Nurse and Dietician to review the removal plan. Completed [DATE].

Based on observation, interview, and record review the facility failed to identify a pressure ulcer prior to a stage III, failed to consistantly follow treatments as ordered, and failed to reduce/eliminate pressure to the affected area. These failures contributed to the development and progression of a stage III pressure ulcer. (R1) The facility failed to replace a dressing on a stage IV pressure ulcer and failed to perform dressing changes as ordered by the physician. (R2) This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 4. The findings include: 1. The Minimum Data Set for R1 dated July 22, 2015, states R1 is at risk for developing pressure ulcer but does not have any pressure ulcers. The Braden scale for predicting pressure sore risk for R1 dated July 22, 2015, states R1 has a risk score of 12 which is high risk. The Braden scale for R1 dated October 21, 2015, states R1 has a score of 14 which is a moderate risk. The facility's policy and procedure for the Prevention and treatment of [REDACTED].e., pressure ulcer development), daily skin checks will be done by team leaders for residents who are moderate and high risk with documentation weekly. The dietitian will be notified upon discovery of a wound, when a wound declines unexpectedly, and if a wound is not showing progress in 2-4 weeks. The facility's Wound Weekly Observation Tool instructions state, Stage I=intact skin with non blanchable redness of a localized area usually over a bony prominence. Stage III=Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV=Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The facility's Skin/Wound Note dated August 30, 2015 states, Weekly skin check: Applied new dressing to right lower buttock to old wound site with scar tissue. On October 21, 2015 at 10:15 AM, E3 (Unit Coordinator) stated, R1's ishial wound was first noted on September 6, 2015. The facility's progress note for New Skin Concern dated September 6, 2015, states, During weekly skin check resident had an [MEDICATION NAME] on left ischium removed and pressure area found very tender to touch. Area was cleaned and measured 2 centimeters x 2 centimeters with 0.5 centimeter depth. The facility's Health Status progress note dated September 7, 2015, states R1's wound on her left lower buttock measures 3 centimeters x 2.8 centimeters. Current yellow slough is less than 25 percent of open wound space. Night nursing sent treatment order request to primary care provider. The facility's Skin/Wound progress note dated September 8, 2015, states, Wound to left ischium measures 2 centimeters x 2 centimeters with a depth of 1 centimeter. There is approximately 50 percent slough to wound bed. The facility's Wound Weekly observation tool dated September 9, 2015, states, There was not any special equipment/preventative measures in place and the resident is on turning a repositioning routine. Pressure ulcer to left ishium is a stage III acquired on September 6, 2015. Overall impression: first observation, no reference. Slough over entire wound, measurements: 2 centimeters x 2 centimeters with a depth of 0.5 centimeters. Current treatment plan: [REDACTED] R1's Physician order [REDACTED]. Cover wound with border gauze dressing. The facility's Skin/Wound progress note dated September 13, 2015, states, Measurements of left ischium noted, stage II 2 centimeters x 1.5 centimeters x 1.5 centimeters. The facility's Skin/Wound progress noted dated September 18, 2015, states, Reviewed weekly wound report and faxed to Z1 (Medical Doctor-MD) for view and possible increase in treatment. The facility's Wound Weekly observation tool dated September 18, 2015, states, Pressure ulcer to left ischium is stage III-unchanged. Special equipment/preventative measures: No answer. Resident is on turning and repositioning routine. Wound measurements: 2.1 centimeters x 1.8 centimeters, with a depth of 2.1 centimeters. There is tunneling inside the outer wound area. Current treatment plan: [REDACTED]. (alginate does not have [MEDICATION NAME] properties) The facility's Wound Weekly observation tool dated September 21, 2015, states, Pressure ulcer to left ischium is stage III and worsening. Special equipment/preventative measures: special mattress, custom wheelchair seating system, resident is on turning and repositioning routine. Length is 2.2 centimeters width is 2.3 centimeters. Tunneling at 6-8 o'clock-2.6 centimeters, 11 o'clock-1.2 centimeters, 5 o'clock-1.4 centimeters. Current treatment: pack tunnel space with alginate rope. The facility's Physician order [REDACTED]. Appointment set for October 1, 2015. The facility's Health Status progress note dated September 22, 2015, states, Had wound nurse evaluate area. Recommendation to soak packing strips in 1/4 strength wound cleanser with bleach and gently pack into wound then cover with gauze. Do treatment twice daily. The facility's Wound Weekly observation tool dated September 25, 2015, states, Left ischium pressure ulcer is worsening. Measurements: 2.5 centimeters x 2.4 centimeters with tunneling at 6-8 o'clock 2.6 centimeters, 11 o'clock 1.4 centimeters, 5 o'clock 1.7 centimeters, and 11-5 o'clock unknown depth. Wound depth obscured with visible moist necrotic tissue. The facility's Skin/Wound progress noted dated September 28, 2015, states, Wound progression is declining with increasing discoloration-advancing tunneling. Anticipating wound care clinic consult October 1, 2015. The Wound Care Clinc assessment and plan dated October 1, 2015 states, Patient with likely stage IV pressure sore by left ischium likely from sitting. Apply santyl nickel thick to left ischium wound and cover with dry dressing. Low air loss mattress and turn or roll patient every two hours. Limit wheelchair time to less than 1/2 hour at a time. R1's Physician order [REDACTED]. The facility's Wound Weekly observation tool dated October 3, 2015, states, R1's left ischium pressure ulcer is a stage III pressure ulcer which is worsening. The New Incident progress note dated October 8, 2015, states, Dressing changed to buttocks. Dressing was halfway off with foul smelling tan drainage. R1's Physician order [REDACTED]. Continue with debriement agent to left ischial wound and cover with an abdominal dressing. The Wound Center progress notes dated October 15, 2015 states, Left ischium: 3 centimeters x 3.5 centimeters with a 1 centimeter depth pressure sore noted with necrotic tissue and malodor. Wound appears to go down to muscle layer. On October 20, 2015 at 9:40 AM E5 (Licensed Practical Nurse-LPN) removed a bordered gauze dressing and then removed gauze that was packed inside of R1's wounded on her left ishium. There was a small amount of yellow drainage on the dressings. The wound was about the size of a half dollar. The wound bed was pink/red with a dime sized area of slough(dead tissue). E5 cleansed the wound then applied an enzymatic [MEDICATION NAME] agent to the tan area. E5 took a dry 4 x 4 piece of gauze and layed it over the entire wound pushing some gauze into the wound. E5 then applied a bordered gauze dressing to secure the dressing. E5 stated, I would call her wound a stage IV pressure ulcer. I wound say 1/3 of the wound bed has slough. I put a little bit of gauze inside of the wound. R1 also had 4 x 4 gauze secured with paper tape to R1's right knee which was not due to be changed. On October 21, 2015 at 2:00 PM, E4 (LPN) stated, On October 21, 2015, I cleaned R1's wound with wound cleanser, applied santyl to the slough, covered the wound with a 2 x 2 gauze, and then covered that with a 4 x 4 bordered gauze. On October 21, 2015 at 1:45 PM, Z1 (MD) stated, R1 is wheel chair bound and she goes to the wound clinic. She spends all day in the wheel chair and has not had a pressure ulcer before. I believe her pressure ulcer is a stage IV based on the wound clinic notes. Yes it is my expectation that the facility probably should identify a pressure ulcer prior to a stage III. The New Skin Concern progress note, with a late entry dated October 15, 2015, states, Noted a red spot on right inner thigh above the knee noted a stage 1 pressure ulcer measures 1 centimeter x 0.5 centimeter. Wound care called and notified if a foam dressing would be beneficial covering for this spot. They agreed and Z1 faxed an order to notify and change the foam dressing every three days and as needed. The facility's fax transmission sheet requesting an order for [REDACTED]. R1's Skin/Wound progress note dated October 18, 2015, states, Right inner knee bony prominence discoloration, [MEDICATION NAME] applied per protection. R1's treatment record for the stage 1 to her right knee states the [MEDICATION NAME] (foam dressing) was signed off on October 16, 19, and 21, 2015. R1's Skin/Wound progress note dated October 21, 2015, 12:13 AM states, Right inner knee [MEDICATION NAME] intact. Observations on October 20, 2015 and October 21, 2015 showed there was a gauze dressing secured with paper tape on R1's right knee. On October 21, 2015 at 10:15 AM, E3 (Unit Coordinator) was asked if she was aware that R1 had a gauze dressing to her right knee on October 20 and 21, 2015. E3 stated, Really? R1 shouldn't have a gauze on her right knee, it should be [MEDICATION NAME] (foam dressing). E3 removed the 4 x 4 gauze to R1's right inner knee at 10:35 AM. E4 stated, The gauze on R1's right knee may have been a temporary fix. On October 20, 2015 at 12:25 PM, R1 was sitting in the wheel chair eating lunch. At 1:00 PM R1 was sitting in her wheel chair in the dining room. At 1:10 PM R1 was sitting in her wheel chair in the dining room. At 1:22 PM R1 was in bed on her right side. On October 21, 2015 at 11:30 AM, R1was observed in her wheel chair being pushed down the hallway toward her room by E6 (Certified Nursing Assistant-CNA). 12:07 PM R1 sitting in her wheel chair in the dining room and E6 was taking lunch orders. 12:30 PM R1 was sitting in her wheel chair at the dining table with her lunch tray in front of her. 12:45 PM R1 is in the wheel chair eating lunch. 1:00 PM R1 sitting at the table in the dining room watching television. 1:05 PM E6 stated, We were getting R1's weight prior to lunch. I'll be putting R1 down any minute. She can only be up for 30 minutes. I know it has been longer but it is hard because of the feeders. R1's careplan dated September 6, 2015 states, R1 has an area on her left ischium measuring 2 centimeters x 2 centimeters and is covered with yellow slough. The care plan was revised on October 1, 2015 to state the new measurements of the ischial wound was 4 centimeters x 3 centimeters with a depth of 2 centimeters and tunneling at 6 o'clock of 3 centimeters deep. The treatment of [REDACTED]. New intervention initiated October 1, 2015 was resident to be up in wheel chair for no longer than 30 minutes at a time. Change of treatment initiated October 15, 2015: [MEDICATION NAME] dressing for protection to bony prominence inner knee. The Nutrition/Dietary note dated August 4, 2015 from the facility's dietitian states, Registered dietitian significant change assessment: Noted improvement in skin. Meal intake most meal 76-100 percent and at times less. No pressure areas at this time. There was no documentation that the dietitian was notified upon discovery of new pressure area. 2. On October 20, 2015 at 12:40 PM, R2 was observed without a dressing to the pressure ulcer on his sacrum. There was a small amount of red/yellow drainage on the pad underneath R2. E5 stated, They took off the dressing to do peri care. I don't know when they took it off. R2's pressure ulcer is a stage IV. E5 placed a chemical [MEDICATION NAME] agent plus a crushed antibiotic on the yellow tissue to R2's sacral pressure ulcer after cleansing the wound. E5 then place gauze moistened with saline in the wound bed and covered it with a 4 x 4 gauze secured with paper tape. R2's careplan dated September 9, 2014, states, Monitor dressing to sacral area to ensure it is intact and adhering. On October 20, 2015 at 1:15 PM, E3 stated, I removed R2's dressing to his sacrum at about 11:30 AM/11:45 AM. R2's Physician order [REDACTED].`wound, apply a think layer of santyl to yellow slough, apply thin layer of venelex to wound bed without slough and to skin around the wound. On October 20, 2015 at 2:45 PM, E5 stated, I only put santyl ([MEDICATION NAME] agent) and the antibiotic in R2's wound bed. I did not put venelex (promote wound healing) on it, I'm sorry. On October 20, 2015 at 3:00 PM, E2 (Director of Nursing-DON) stated, R2's dressing should be replaced as soon as possible when it is removed. We do not typically remove a dressing and leave it off. If the resident has had a bowel movement then the wound should be redressed by the nurse as soon as possible. The nurses are to follow treatment orders as prescribed by the physician.

I. Based on observation, interview and record review the facility failed to ensure that a resident was not injured while being pulled down the hall by staff in her wheelchair. This failure resulted in R2 hitting her left arm against the handrail and sustaining a left radius fracture on 2/14/12. The facility failed to transfer residents in a safe manner to prevent injury to the residents and staff. This applies to 4 of 30 residents (R2, R1, R3, R12) reviewed for safety in a sample of 30. The findings include: 1. The physician's orders [REDACTED]. The Nurse's Notes dated 2/14/12 state, "CNA reported left arm bruise. Assessed- left arm bruise from elbow to wrist- approximately 12 x 8 cm with swelling. Resident with no complaints of pain. States only a little sore. Resident states she hit it on the bed railing while trying to get up with her walker and arm slipped. Denies falling." Left Forearm Xray report dated 2/15/12 states, "There is a torus fracture in the dorsal cortex of the distal radius." On 2/29/12 at 3:45 PM, E16 (Activity Assistant) stated, "I was pushing 1 resident and pulling R2 and I got too close to the wall and she hit her arm against the wall. She said ouch and then she went to the activity and never said a word. I looked at it, I didn't see anything. I certainly didn't think anything like this happened." A written statement from E19 (CNA) dated 2/14/12, states, "I was coming up 1 hall to answer an alarm I heard R2 yelling , 'my arm, my arm- that hurts' about 8ish or soon after BINGO got done. I came out of the resident room and looked down the hall. A lot of people were coming down 1 hall. The activity's aide (E16) was bringing them back." On 2/29/12 at 1:25 PM, E19 stated that on 2/14/12 she was in a room caring for another resident and she heard R2 yell out, "Oh, my arm!". E19 stated that she reported to the nurse that R2 had hit her arm on the hand rail. 2. The physician's orders [REDACTED]. The facility Incident Report dated 7/29/11, states, "(R1) was being transferred with stand lift, R1 let go of handles and slid through belt, striking head. Complained of headache and decreased mobility of neck. Call placed to doctor. Transferred to hospital emergency department. CNA doing transfer placed on administrative leave pending investigation. " An undated, untitled , typed report by E2 (DON) states, "Follow up investigation (R1) fall from stand lift on July 29, 2011. After investigation it was determined that (CNA) transferred (R1) wrong. She had the belt too loose as evidenced by the belt on the lift measured 41 inches and the resident's waist was 37 inches. There was no give to the belt. After (CNA) pulled up (R1's) pants, the chair was not behind the resident." 3. On 2/28/12 at 8:35 AM, R3 was observed as she was transferred from the bed to the toilet using the stand lift. E10 (CNA) applied the belt around R3 and lifted R3 off the bed with the lift. The belt fit loosely around R3's waist. E10 was asked if she had ever had any trouble with the stand lift. E10 states, "Oh, I forgot to tighten it (belt). We have been educated on that." E10 then lifted R3 off of the toilet, again without tightening the belt. E10 then stated to the resident, "I'm trying to figure out where the other sling is. The one that actually fits you. This one is too big." 4. The Nurses Notes for R12 dated 11/21/11 showed, "Certified Nursing Assistant (CNA) transferred with mechanical lift and did not position correctly in wheelchair. R12 immediately slid out of wheelchair onto floor. Sitting on her butt in front of wheelchair. Denies pain, did not strike head. States she is just fine. Assist to wheelchair again with mechanical lift device and positioned in the chair correctly." On 2/29/12 at 8:00am, E11 ( Registered Nurse/Unit Coordinator) stated, "We educated the Certified Nursing Assistant (CNA) after this happened. She transferred R12 using the mechanical lift and didn't have R12 sitting far enough back in her wheelchair and she slid out onto the floor." The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/12 showed extensive assistance needed for bed mobility and transfers. R12's Physician order [REDACTED]. R12's Care Plan dated 11/8/11 and 2/7/12 showed, "I may fall because...Slide from wheelchair onto the floor.; Approach: Follow assigned transfer technique. Assess resident for injury and reposition correctly." II. Based on observation, interview and record review the facility failed to ensure the courtyard exterior door alarms were working on the B and C units in order to alert staff if a resident left the building. This applies to 3 of 30 confused residents (R4, R18, R28) in a sample of 30 and 16 confused residents (R45, R46, R49, R52, R68, R73, R74, R78, R83, R84, R122-R127) in the supplemental sample who ambulate independently. The findings include: On 2/28/12 at 8:50am during environmental tour with E13 (Maintenance Supervisor), the courtyard exit doors located at the entrances of the B and C units failed to sound when the door alarms were checked. When the "light" switch located by the door is flipped up or down the door opens automatically. The doors are recessed off of the units and are not visually controlled by staff. The alarms and a flashing light at the door alert staff that someone has gone out into the courtyard. E13 said, "The door alarms are checked weekly." E13 agreed that with the alarms not working, staff would not be aware if someone went out. The facility's list entitled "Confused residents who ambulate" dated 3/1/12 showed 19 confused residents (R4, R18, R28, R45, R46, R49, R52, R68, R73, R74, R78, R83, R84, R122-R127) who ambulate independently throughout the facility.

Based on observation, interview and record review the facility failed to reduce or eliminate pressure relief for residents at risk for skin breakdown. This failure resulted in the resident developing a Deep Tissue Injury to her coccyx that was identified on September 15, 2010. The facility failed to identify pressure ulcers prior to becoming a stage II. This applies to 6 residents in the sample with pressure ulcers. (R7, R3, R29, R1, R2) The examples include: 1. The Minimum Data Set of 12/14/2010 shows that R7 has [DIAGNOSES REDACTED]. The Braden Scale for Predicting Pressure Sore Risk shows that R7 scored an 11. (12 or less represents High Risk) R7's physician's orders [REDACTED]." The Nurse's Notes dated 9/15/10 stated, "Noted coccyx with 2 areas of purple discoloration. 0.5 cm and 2.5 cm with blister area." NN on 9/16/10 stated, "Informed by hospice CNA resident has a noted deep tissue wound to coccyx with red surrounding skin 2.7. cm x 1.5 cm. Resident placed on side to side turning schedule." On 2/8/11, R7 was observed during a bed bath. R7 had a baseball sized open are to her coccyx. The area was clean with a small amount of slough in the center of the wound. The wound had a strong unpleasant odor. On 2/7/11 at 10:45 AM and 1:45 PM and on 2/8/11 at 8:30 AM, 9:55 AM and 10:30 AM, R7 was observed laying on her back or sitting up in her bed. R7's bed had a static support mattress. On 2/8/11 at 10:10 AM, E22 (LPN) was asked if R7 was supposed to be positioned on her back. E22 stated, "I know she is repositioned every 2 hours but I don't know, I will have to check." On 2/8/11 at 4:00 PM, E2 (DON) stated, "I talked to hospice and one (pressure relieving mattress) was supposed to have been delivered in June." According to Acute and Chronic Wounds,Bryant 2007, page 135 , Suspected deep Tissue Injury- Purple or maroon localized area of discolored intact skin or fluid- filled blister due to damage of underlying soft tissue from pressure and/or shear." Page 225 states, "Because pressure is the causative factor of pressure ulcers, reduction or elimination of the interface pressure is essential." 2. On 2/9/11 at 8:30am, R29 was observed sitting in her wheelchair in her room. R29 had a cloth incontinence pad folded up on the seat of her wheelchair. R29 stated, "I have a wound on my rear end. I don't know how I got it." R29 was asked if she had any type of cushion for her wheelchair? R29 stated, "I don't have one now. I had one and it was sent to the laundry and never came back. That was about 2 weeks ago or longer." On 2/9/11 at 8:45am, E10 (Registered Nurse - RN/ Unit Coordinator) stated, "There is no reason why R29 shouldn't have a cushion in her wheelchair. I have talked to the certified nursing assistants about it. R20 had a pressure ulcer to her buttock that healed and has re-opened." The facility's Wound Report for R29 showed, "1/20/11 - Location: Left buttocks.; Type of wound: Pressure Ulcer Stage II.; Negative factors: Circulatory Insufficiency, Incontinence, Immobility & Diabetes. Length: 2.0; Width: 1.2; Depth: less than 0.1mm; Exudate: None; Granulated." No centimeters or inches were written for the length and width measurements. R29's Wound Report dated 1/26/11 showed the length of the wound to her left buttock was 2.3 and width 0.5. No centimeters or inches were written for the length and width measurements of the pressure ulcer.; Depth - less than 0.1mm; No exudate and "[MEDICATION NAME] covered." R29's Wound Report dated 2/2/11 showed the pressure ulcer to her left buttock was not open and "slightly discolored." On 2/8/10 R29's Wound report showed the pressure ulcer to her left buttock was "re-opened" and the length was 1.2, width 0.8, depth less than 0.1mm with no exudate and granulation present. The length and width measurements did not show if the measurements were in inches or centimeters. R29's Care Plan dated 2/3/11 showed, "I could be at risk for skin problems. Score 15 = moderate risk. Incontinent of urine. I sit a lot and walk some. Requests not to be turned at night.; Approach: I will be encouraged or assisted with position change. I will use my side rail to assist with position change. I will have my skin condition checked daily. If I have any red or open area it will be reported to team nurse and to the doctor if necessary. Apply barrier creams as ordered." R29's Plan of Care Card (with no date) showed, "Chair surface: cushion." The facility's policy and procedure for Pressure Sore Prevention and Treatment showed, "Policy: The facility will assess each resident for risk factors and skin breakdown and will practice preventative and treatment protocols on each resident identified as "at risk" or who has/develops a pressure sore.; Definitions: A pressure sore is a lesion caused by unrelieved pressure causing damage to the skin and underlying tissue. Stages are as follows: Stage II - Partial thickness skin loss involving epidermis, dermis or both. This stage may present clinically as an abrasion, blister or shallow crater.; Procedures: A specific protocol for each level of risk (mild, moderate, high and severe risk) will not be developed by the facility, but rather an individual plan of care addressing that person's risk factors will be developed. A history of a recently healed pressure sore will automatically place the resident at risk for the ensuing six months." R29's Minimum Data Set with an Assessment Reference Date of 1/28/11 showed a score of 14 out of 15 possible on the Brief Interview for Mental Status.; Total dependence on staff for bed mobility, dressing. toilet use, personal hygiene and bathing.; Always incontinent of urine.; Active [DIAGNOSES REDACTED]. 3. R3's Nurses Notes showed, "8/1/10 - Certified Nursing Assistant (CNA) reported fluid filled blister to left lower outer ear. Cause unknown. 1.3cm by 1.3cm area." The Wound Progress Notes for R3 showed, "8/1/10 - Fluid filled blister 1.3cm by 1.3cm to left lower outer ear. Open to ear.; 8/9/10 - Blister no longer intact.; 8/14/10 - Blister healed.; 10/18/10 Noted 1cm open area to coccyx ("crack" - open area). Doctor here and aware.; 10/24/10 - Open area to coccyx (crack) healed." On 2/10/11 at 11:00am, E2 (Director of Nurses - DON) stated, "An investigation was done regarding the fluid filled blister to R3's left ear. it was on her lower ear. we think it is from R3 rubbing her head on her bed." The Monthly Goal Charting for R3 for October 2010 showed, "Remain without skin interruption - met goal. Remain free of skin breakdown - met goal. R3's Nurses Notes dated 10/18/10 showed, "Noted 1cm "crack" open area to coccyx. Protective ointment applied." R3's Treatment Record for the month of October 2010 showed, "Monitor open 1cm "crack" open area to coccyx every shift until healed" with a start date of 10/18/10.; Nurses order: Pillow under both legs while up in wheelchair every shift." On 2/8/11 at 10:04am, E22 (CNA) stated, "I have the same residents on a daily basis 6 days a week." E22 was asked if she had ever seen a blister on R3's ear? E22 replied, "I have been with R3 since August 2010 and have never heard of one on her ear. I know of a blister to her ankle that she has. It is better now. It is drying up. It was really red (left ankle) and had a blister. I was told to not put any shoes on that touch R3's ankle." R3 was observed sitting in her wheelchair on 2/8/11 at 10:04am. R3's chin was tucked down to her chest. E22 removed R3's shoe and sock from her left foot. A dry, white circular area was observed on R3's left ankle with the tissue around the area pink. No pillow was observed under R3's legs while she was up in her wheelchair. R3's Nurses Notes dated 1/12/11 showed, "CNA reported round red area 2cm with white center 0.5cm.... Complains of tenderness to area." On 2/10 11 at 11:00am, E2 (Director of Nursing - DON) stated, "The doctor looked at her ankle and said it was a callous. R3 had high boots that she liked to wear and the doctor said for her not to wear them because they rub on the ankle." R3's Physician order [REDACTED]. The Monthly Goal Charting for R3 for June 2010 showed, "Remain without skin interruption - not met. Blister to right foot 6/22/10.; Remain free of skin breakdown - not met. Stage II to coccyx 6/16/10. The Monthly Goal Charting for R3 showed in 4/2010, R3 had "bilateral posterior ear abrasions" and in 8/2010 R3 had a "blister/scratch" to an unidentified area. The Treatment Record for R3 dated 12/1/10 through 12/31/10 showed, "Bows of eyeglasses, place wrap foam daily (start 4/20/10). Pillow under both legs while up in wheelchair (start 11/16/10). Right heel: Apply protective dressing as directed to keep shoe from rubbing (start 2/5/09) - discontinued. Both feet: Apply protectors at bedtime (start 2/6/09). May be fitted for a collar to be worn on a limited basis for watching television with visitors etc. (Verbal Atrophy, Chin on Chest Syndrome. Start 4/28/09). Skin check daily - chart weekly for high risk of skin breakdown (start 10/19/10). The scale used for Predicting Pressure Sore Risk for R3 dated 1/19/11 showed a score of 12 = high risk for pressure ulcers. R3's Minimum Data Set (MDS) with an Assessment Reference Date of 1/18/11 showed extensive assistance is needed for bed mobility and transfers. R3 is dependent on staff for dressing, eating and bathing. R3's Care Plan dated 1/26/11 showed, "1/25/10 - right buttock stage II.; Check skin daily and record as indicated. Utilize protective/pressure relieving devices as indicated...." 4. On 2/8/11 at 12:25pm, R1 was observed sitting in her wheelchair with no pressure relief device on the wheelchair. On 2/10/11 at 11:00am, E2 (Director of Nurses - DON) stated, "We don't think R1 had a pressure ulcer to her coccyx on 2/5/10 because it was healed on 2/9/11. The nurse wasn't sure if it was pressure or an abrasion so she wrote pressure. We are not disputing that R1 should have a pressure relief device to her wheelchair. R1's Care Plan says she is to have one." R1's Nurses notes dated 2/5/11 showed, "CNA noticed open area on resident during care. It is...Stage II in the coccyx area but not on the coccyx directly." R1's Care Plan dated 2/5/11 showed, "R1 is high risk for skin breakdown because of incontinence and impaired mobility.; Decubitus ulcer to coccyx, stage II.; Approach: Utilize protective/pressure relieving devices as indicated...chair cushion." R1's Physician order [REDACTED]. R1's POS dated 2/1/11 showed an order dated 10/14/10 for a thin dressing to R1's coccyx to be changed until healed. (The order showed R1 has had a pressure ulcer to the coccyx previously.) R1's MDS with an ARD of 11/9/10 showed extensive assistance needed for bed mobility and total dependence on staff for transfers, dressing, eating, hygiene and bathing. 5. A pressure ulcer scale tool for R2 dated 12/3/10 showed, "Ulcer location: Right foot tip of great toe." The Wound Report dated 12/3/10 for R2 showed, "Length 0.3cm, width 0.2cm, superficial. Small amount of [MEDICAL CONDITION] to surrounding tissue. Mild pain." A foot drawing for wound form for R2 dated 1/6/11 showed, "Cleanse right big toe with wound cleanser. Apply adhesive foam strip. Check daily...." R2's Care Plan dated 11/17/10 and 2/9/11 showed, "I develop foot complications because I have diabetes. Apply socks and comfortable fitting shoes. Monitor for [DIAGNOSES REDACTED], itching, scabbing, cracking, blistering, pain, change in temperature. Report abnormals. Diabetic shoes as ordered. Foam strip as ordered." R2's Care Plan for Skin Breakdown dated 11/17/10 and 2/9/11 showed, "I have moderate risk for skin breakdown because...my mobility is compromised. Scab to right great toe.; Approach: Check skin condition daily and record as indicated. Bilateral heel boots on at bedtime and off in the morning. Diabetic shoes as ordered. Foam strips as ordered." R2's POS dated 2/1/11 showed [DIAGNOSES REDACTED]." R2's physician progress notes [REDACTED]. Both feet show diminished circulation in the dorsalis pedis. he has a small area or early necrotic area on the right foot, particularly near the toe.; Plan: He will get diabetic shoes. If it breaks down we will give him more skin care." On 2/8/11 at 11:10am, E21 (CNA) stated, "There was a little black dot and redness to R2's toe. I told the nurse. We have been putting cream on it. R2's shoes were too small. R2's feet swell at times and would rub his toe. Once we changed shoes the spot started to go away."

Based on observation, interview and record review the facility failed to have preventative measures in place to minimize the chance of residents at low risk for pressure sores to develop/re-open multiple areas.The facility failed to identify contributing risk factors, and develop indivualized nursing interventions to address the resident skin concerns. The facility failed to ensure staff commuicate with each other regarding resident skin conditions and treatment plans, and failed to consistently document wound characteristics. As a result of this non-compliance: R64 developed 2 open areas on the coccyx/buttocks; R65 developed 2 open areas which increased in size; R1 had pressure areas re-open with increasing wound size; R60 had no treatment in place for hand wounds caused by contractures; R29 developed deep tissue injury to both heels and R62 developed open areas on both heels. This applies to 6 residents reviewed with pressure ulcers in a sample of 10 (R64, R65, R1, R60, R29, R62). The example includes: 1. The medical record documents R64 was admitted to the facility on [DATE] to recover from a fractured wrist after a fall at home. The Admission Nursing Skin assessment dated [DATE] documents R64 had a "Red Spot" over a circled area over the buttocks/coccyx area on the body chart. No additional skin assessment information regarding the skin is located in the medical record. The initial care plan dated 2/1/6/11 for R64 states, "I could be at risk for skin problems." The care plans shows R64 has a skin risk assessment score of 18 (indicates she is at low risk to develop a pressure ulcer). The care plan states R64 has a Fractured left Arm, no longer walks and has [MEDICAL CONDITION]. The care plan does not address the skin irritation on her buttocks. The nurses' notes for R64 dated 3/22/11 at 1:00 PM states, "The CNA (Certified Nursing Assistant) noticed a small open area on the coccyx. Resident was crying when I told her about the open area." The wound report dated 3/22/11 documents the type of wound as Stage II and Unstageable due to slough. According the Bryant, Acute and Chronic Wounds, 2007, Third Edition, Mosby, page 135, Stage II: Partial thickness loss the dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough in the wound bed. The care plan dated 3/23/11 states R64 has a "pressure area on the coccyx due to sitting a lot - no walking". The interventions do not address how the staff will address R64's immobility related to "sitting a lot". The nurses' notes dated 4/3/11 at 10:30 AM states, "While changing the residents dressing (on the coccyx) a small area noted to have opened up again. Measures 1/2 cm x 1/2 cm x <0.1 cm depth". On 4/4/11 at 12:10 PM, E10 (RN Unit Coordinator) stated, "R64's bottom was slightly red when she came in. I think they were using a protective cream. I will check with the CNA staff." At 12:20 PM, E10 returned and stated, "I talked to the CNA staff and now she lies down in the afternoon after the wound opened up again." On 4/5/11 at 1:15 PM, E2 (Director of Nurses - DON) stated, "R64's daughter wants her to use her motorized chair. She doesn't take naps, and is always in her chair. She sits in her chair for long periods of time." On 4/4/11 at 11:30 AM, R64 was observed in an electric chair at a table in the unit dining room. R64 was alert and responsive to talking. R64 stated she was at the facility to get therapy for her arm and was the planning to go back home to live with her daughter. 2. On 4/4/11 at 2:10 PM, R65 was observed sitting in a wheelchair at a table in the large dining room area. R65 pointed to her left foot and stated, "I don't know what caused the sore on my foot. It's pretty tender." R65 removed her shoe (beige walking shoe with velcro strap closure) and sock to show the surveyor the bandage on the heel of her foot. The Minimum Data Set of 3/4/11 shows R65 does not have any short or long term memory problems, and independently transfers herself and walks with a walker or uses a wheelchair for long distances. The MDS states R65 does not have a history of any unhealed ulcers. The skin risk assessment (measures a resident's risk to develop pressure) tool for R65 dated 3/8/11 shows a score of 20 (low risk for developing pressure ulcers). The Wound Report for R65 dated 3/18/11 documents a Stage II pressure area on the left heel measuring 0.1 cm x 0.1 cm. On 3/22/11 the form shows R65 has 2 openings on the left heel, measuring 0.8 cm x 4 cm and 2.8 cm x 1.9 cm. The wound is described as open with serous drainage, irregular moist edges. On 3/29/11 the wounds are described as, "5 cm x 5 cm resurfaced with 0.3 - 0.4 cm open areas x 5". No further description is given. On 4/4/11 at 1:50 PM, E23 (Certified Nursing Assistant - CNA) stated, "R65 is able to transfer herself and walk a few steps in her room." E23 stated, "I'm not sure what caused the sores on her heels, maybe she got blisters from her shoes." The Care Plan for R65 dated 3/19/11 states there are 2 areas open on the left heel. The precipitating factors and risk factors are not identified. The interventions on the plan are preprinted and not resident-specific to meet her needs. On 4/5/11 at 12:55 PM, E2 (Director of Nurses - DON) stated, "The reports I sent show that R65 did have open areas before. She was getting mineral cream to the heel area 2 times a day, then it opened up again. I know I talked to the nurse about getting her different shoes. I'm not sure why she has those beige shoes on again. Last night I found her new shoes way in the back of her closet, the black ones. I called the family and told them to pick up those beige ones and that I was concerned they didn't fit. It was the end of February, when the nurse when down (to the auxillary store room) to get her different shoes. R65 walks very little in her room, she spends most of her time in a wheelchair. She doesn't spend that much time in bed that's why we thought the blisters came from the shoes, but there isn't any documentation about that. I guess the nurse didn't think to chart that information about the shoes in the chart." On 4/5/11 at 1:20 PM, R65 was again observed sitting in a wheelchair at the table in the large dining room table. R65 was wearing black shoes with a black velcro closure strap. R65 stated, "These shoes feel fine, but then so did my other ones. There was one nurse here that had a problem with my other shoes and told me I couldn't wear them anymore." 3. The Physician order [REDACTED]. The Minimum (MDS) data set [DATE] documents R1 is at risk for pressure, and does not have any current unhealed or healed pressure ulcers. R1 is totally dependent on staff for toileting, personal hygiene and mobility. R1's care plan shows she has had repeated openings of the buttock and coccyx areas. On 3/18/11 the initial wound assessment states a Stage II opening was noted on the right gluteal fold, measuring 1.1 cm x 0.3 cm. On 3/23/11 the wound size increased to 1.0 cm x 0.5 cm. The care plan stated the skin condition will be checked daily and recorded as indicated. On 4/5/11 at 1:50 PM, E24 (Registered Nurse - RN) stated, "The CNA (Certified Nursing Assistants - CNA) should be checking the skin every day during cares. On shower days, the CNA fills out the shower sheet to document any skin concerns. The form is then given to the nurse for review. The nurse would assess the opening and call the physician and family, report the opening to the unit coordinator and pass it along in house report." According the Bryant, Acute and Chronic Wounds, 2007, Third Edition, Mosby, page 131, "Daily monitoring of a patient's skin may reveal a reddened area. This observation should then prompt an assessment by the appropriate staff so that additional information can be collected, interpreted and used for care plan development." 4. The Physician order [REDACTED]. The initial wound note on 3/9/11 documents a Stage III wound was found on the left hand when the splint was removed. The wound measures 2.4 cm x 1.5 cm x 0.3 cm with blooding drainage. The POS dated 3/9/11 documents to discontinue the left air hand cone splint, continue with handroll/washcloth roll to left hand and on at all times. On 3/11/11 the POS states to use a foam dressing to the left thumb, change every 3 days until healed. R60's care plan dated 3/9/11 states to use a handroll/washcloth at all times in the left hand. On 3/29/11 at 10:45 AM, R60 was observed lying in bed. Both of R60's hands were clenched shut. No handroll was in place. E12 (Unit Coordinator - RN) gently opened R60's left hand. No foam dressing was in place, the wound was uncovered. E12 stated, "I measured the wound this morning and the handroll and dressing were in place. It must have come off in the shower and the CNA reported it to the nurse." E12 approached E25 (Licensed Practical Nurse) regarding replacement of the wound dressing. E25 stated, "I was not aware the dressing had come off. The CNA just reported off to me and went to lunch. She did not say anything about it." 5. R29's April, 2011 physician's orders [REDACTED]. The same order sheet showed an order dated 3/4/11 to wear heel lift boots at all times. R29's Minimum Data Set (MDS) assessment of 1/28/11 showed that R29 was cognitively intact (summary score 14). R29 was totally dependent on one person for bed mobility, and required extensive assistance of 1 person for transfers. R29 was not ambulatory, and was dependent on one staff for dressing, toilet use, and personal hygiene. R29 had range of motion impairments that affected both of her upper extremities. R29 was always incontinent of urine and frequently incontinent of bowel. The same assessment showed that R29 had one stage II pressure ulcer. A Braden Scale (Pressure ulcer Prediction tool) dated 2/3/11 showed a score of 15. (A total score of 12 or less = high risk) Shower sheets showing R29's skin status were reviewed and showed the following: 3/14/11 documented no skin concerns. 3/22 a blister (stage II pressure ulcer, partial thickness loss of the Dermis, presenting as a shallow open ulcer, with a red/pink wound bed without slough) is identified on R29's left heel 3/18/11 documented no concerns. 4/4/11 a blister was documented on the left heel. The Wound Report dated 3/4/11 showed that R29 had a deep tissue injury of her right heel that measured 6 cm (centimeters) with a 3 cm x 4 cm black center.(completed by E2) The Wound Report dated 3/25/11 showed a 1.5 cm x 0.7 cm red area with a 1.5 cm by 0.7 cm dark center was identified on R29's right great toe. (bunion area) The same report documented deep tissue injury. R29's Nursing Notes for 3/4/11 at 4:45 AM showed " Certified Nursing Assistant (CNA) states that R29 had a sore heel. Left heel had a 6 cm circular fluid filled area, with a 3 cm x 4 cm black area in the center, heel is boggy and inflamed. 5:00 AM, applied a heel lift boot immediately when found. The Physician's Progress Notes dated 3/8/11 documented that R29 developed a left heel bulla. (blister) " The best option is pressure relief to let the area heal slowly." The Physician's Progress Notes for 2/29/11 documented that R29 also had a left heel blood bulla and right great toe bunion skin break down. "The bunion lesion is not open either and is movable with center sub-skin eschar. Hopefully, both areas will improve with pressure relief only." E2 Director of Nursing said on 4/4/11 at 2:30 PM, that she had found the area on R29's foot when she had worked the night shift on 3/4/11. E2 said that the area was fluid filled and had deep tissue injury. E2 said that sometimes R29 doesn't want to be turned and that is why she was watching her. E2 said that E7 (Assistant Director of Nursing) was going to be moving to the night shift at the end of the month so she should be able to focus on the wounds more. E2 said she did not know what caused these areas of injury to R29's foot. E2 said that R29 is to be wearing the heel lift boots at all times now. R29's Skin Risk Care Plan dated 3/3/11 did not document that R29 is non compliant with turning or positioning. Another care plan for open areas dated 2/3/11 documents that R29 had a left heel soft brown, fluid filled area . The approaches included to wear heel lift boots. On 4/4/11 at 2:15 PM, R29 was observed in her room, sitting in a recliner chair. R29 was wearing blue foam boots. R29's left heel was observed and had a brown/black discolored area on the inner aspect of the heel. On 4/5/11 at 1:45 PM, R29 was observed sitting in her recliner in her room. R29 was wearing white socks with pink slippers. R29 said " I don't have to wear the boots when I'm sitting in the chair because I'm not standing on it." E2 was interviewed on 4/5/11 at 2:15 PM and said " R29 is supposed to have her heels off loaded I will go and check." R29 returned and said " she has them back on now, they took them off because her feet hurt." Acute and Chronic Wounds, Bryant, Nix, Third Edition, Mosby 2007, pg.137. A stage II is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Suspected Deep Tissue Injury is defined as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 6. R62's April, 2011 physician's orders [REDACTED]. R62's MDS Assessment of 3/4/11 showed severe cognitive impairment (summary score of 4) R62 required extensive assistance of 2 persons for bed mobility and transfer. R62 is nonambulatory. R62 required extensive assistance of one person for dressing, toileting, and personal hygiene. The same assessment showed that R62 had one stage I pressure ulcer. R62's Braden Scale (Pressure ulcer risk assessment tool) of 3/9/11 showed a score of 13. (12 or less = high risk) R62's Treatment Administration Records showed the following: 2/2011 Right heel boot on while in bed (started 1/28) 3/2001 Right and left heel boot on while in bed. The same record showed " monitor right heel wound until healed." (3/13/11) 3/16/11 showed a left heel ulcer 1/2 cm x 1/2 cm, dark blue area. Wound Reports showed the following: Right heel 1.5. cm x 1.0 cm dated of onset 2/28/11. The entry for 3/15/11 showed that the same wound was necrotic. On 3/22/11 the wound is documented as being scabbed. On 3/28/11 the wound is documented to have slough. (devitalized tissue) On 4/2/11 the wound is described as 15% necrotic tissue, (dead tissue) 75 % slough, and 10% granulation. Wound Progress Notes for the Left heel showed: 3/22/11 1 cm x 1 cm dark purple area. 3/29/11 .03 cm x .06 cm dark area. 4/2/11 R62 complained of left heel area, shoes placed up in closet. Wound Progress Notes for the Right heel showed: 3/15/11 1.8 cm x 1.8 cm necrotic. 3/22/11 2.0 cm x 2.0 cm scabbed. 3/29/11 1.2 cm x 2.0 cm x 1 cm deep, has drainage. Pain at area.. R62's physician's orders [REDACTED]. On 4/5/11 at 2:00 PM, R62 was propelling her wheelchair in the hallway, no foot rests were on the wheelchair. She was wearing a pair of slippers and was using her feet (heels) and hands to move her wheelchair.